Interventions in health and population policies- the AIDWA experience.

Ms. Sudha Sundarraman

16 Sep 2013

The All India Democratic Women’s Association, (AIDWA) which has been one of the frontline organisations in the countrywide campaign for women’s rights and women’s equality, firmly believes that the issues of women need to be addressed through multiple interventions and struggles, so as to alter oppressive power structures, in the family, in society, and in the policy framework.

In its efforts to bring about systemic changes, AIDWA has made critical policy-level interventions at every juncture. Our organization –– with a total membership of over 1.10 crores ( in 2012) –– is one of the largest women’s mass organizations, in India. A majority of our members belong to the poorest, most marginalized sections of society. First formed as a national organization in 1981, AIDWA is a an organization deeply committed to opposing gender exploitation of women on multiple levels as women, as workers, and as citizens.

AIDWA has been addressing the problems of women through multidimensional strategies including legal interventions, social reform campaigns, united actions, holding of seminars and meetings around topical issues, and also mobilized women in significant numbers around their own demands. Thousands of violence victims have been enabled to access justice through the legal aid and counseling centres set up by AIDWA. We have also consciously involved the community in support of the survivors of violence. AIDWA has been actively taking up struggles against child sexual abuse which are on the rise, and has been spearheading the resistance to casteist and conservative elements who are perpetrating crimes and killings in the name of honour.

Local units of AIDWA have initiated campaigns and activities for securing civic amenities in the neighbourhood, to improve the lives of women. This includes issues relating to water, sanitation, ration supplies, ICDS, health schemes, etc. AIDWA has been in the forefront of efforts to streamline the PDS and ensure food security through an effective delivery of entitlements. It has upheld healthrights for all, & conducted struggles to improve women’s access to health care. It has taken active part in the total literacy campaign.

AIDWA has taken up issues relating to rural women like ensuring proper implementation of NREGA, launching struggles for equal wages, minimum wages, joint ownership of land and pattas, etc. It has also organized domestic workers, home based workers, and other sections of unorganized women workers around their demands. It runs self help groups that enhance women’s collective voice, and assist in raising their conditions of existence.

AIDWA has led campaigns against the scourge of untouchability. It has brought all sections together in the fight against oppression of dalits, adivasis, minorities, and other sections which are especially disadvantaged because of their caste, class or community. It is working actively to mobilize women within communities to reform personal laws, while striving to widen the scope of secular laws. AIDWA believes in equal and democratic rights of all communities, as promised to us in the Constitution.

has intervened to protect women in situations of communal conflict, and has always stood up against communal and fundamentalist forces that seek to attack/limit women’s rights.

Thousands of AIDWA members have fought elections to panchayats and local bodies. AIDWA is actively involved in training programmes for elected members. It has been campaigning, independently and jointly, for 33% women’s representation in parliament and state assemblies.

AIDWA’s engagement with public health issues related to women:

The women’s movements in India, along with all concerned sections of the society, has been in the forefront of the struggle to achieve “ Health for All” , as defined comprehensively in the Alma Ata declaration of 1979. The All India Democratic Women’s Association(AIDWA), as an organization that fights for the equal rights of women, especially the most marginalized and underprivileged sections, has always seen woman’s right to health as inclusive of her right to reproductive health. It has been part of the joint campaigns that have taken up this issue for many years. Both with other organizations, and independently, it has been challenging the population policies that were initiated in our country, as a targeted, anti-poor, family planning approach, without addressing overall health status and development. AIDWA firmly believes that the question of population cannot be tackled in isolation, nor can “family planning” be imposed, as a top down, coercive measure. We strongly believe that the fundamental question is redistribution of resources, which is at present skewed in favour of the haves, and not population growth as is often projected. In any case, population stabilization can only occur when women choose not to have more children, and then are enabled to exercise that choice. While the government has been forced to shift its stance vis a vis coercive population policies, after the ICPD (1994) (at least in its official discourse) unfortunately, it has not been sufficiently committed to achieving the goals of universal access to health care. Over the last few decades beginning in the early eighties, an aggressive neo liberal paradigm of development, combined with a regressive and deeply entrenched patriarchal system, has led to a situation where women’s access to health care services has deteriorated. This has therefore been an important area of work for our activists.

AIDWA has been actively intervening on the issue of women’s health rights at many levels. We take up matters of policy at the national level, and also organize and mobilize women around their entitlements to health care at the local area level.

Our experience on the ground forcefully brings out the reasons why health and well being cannot be restricted to disease, drugs and doctors alone. For instance, in most of the states, AIDWA units have been waging struggles against the proliferation of liquor shops, especially near schools, bus stops, temples, crowded places etc. The exponential growth in sale of liquor which is being projected as an indicator of progress by the Government is actually a means of extracting money from the poor, who can ill afford it. And of course, morbidity, mortality, domestic violence are outcomes that impact on health status of women especially those from impoverished, economically and socially deprived families.

We emphasize, therefore, the holistic nature of health, and AIDWA has been consistently active on many of the basic factors underlying good health; food security and nutrition, universal ration at subsidized prices, right to clean water, right to free water, proper sanitation, toilets,housing - the whole gamut of social needs that improve the quality of life have been important areas of intervention.

Three relevant aspects on which AIDWA has been active, and which we will touch upon in this presentation are:

Provision of public health systems geared to improving maternal and child health needs.
Against coercive population policies and two child norm, for safe and effective contraceptive services.
Addressing the implications of declining child sex ratios.

Current Health Indicators of Women:

We all know that the official statistics on health indicators for women reveal a very grim situation.

33% of women are malnourished.
56.2% of all women and 58% of pregnant women are anaemic (as compared to 26% for men.)
The MMR stands at 213 per 1,00,000 live births. In other words: Over 60,000 women die in maternity each year.
Fifty children below the age of 5 die every half hour.

NFHS-III data for 2005-06 shows that one third of all women have lower than normal Body Mass Index. When pregnant and lactating mothers suffer from high anaemia, it is not surprising that the number of infants between 6 to 35 months who are underweight is also an alarming 79.2 per cent. Data also shows that the worst affected are tribal women, followed by Dalit women and others from the backward sections. They constitute the poorest; most deprived and exploited sections of our people. Many more figures can be cited, all of which are a combined indictment of the present system of health care in our country.

Public health systems and reproductive health care

crucial factor leading to this shocking situation is the refusal to allocate sufficient resources to the public health system. The primary health care system comprising of Primary Health Centers (PHCs), the secondary sector with Community Health Centers (CHCs) and the tertiary sector with big public hospitals is in shambles in most parts of the country. A sick person is lucky to get the treatment she needs – the respective centres often do not have beds, or drugs, or doctors, or facilities or paramedicals- as the case may be. Patients are thus often forced to resort to private clinics, which they can ill afford. The deliberate neglect of public health has been one of the core issues that AIDWA has been taking up, and we have initiated a wide variety of actions to resist privatization, and force the Government to safeguard the public health system. In Kerala, for instance, AIDWA led the movement for free services in government hospitals, and the fight against the huge outpatient charges that were levied. The struggle was partially successful. In UP, an attempt to auction off public hospitals to private health providers last year was determinedly opposed by our unit there, and we were able to stave off this attempt at blatant hand over of the public health facilities to private health providers. In Himachal Pradesh, corruption within the Rogi Kalyan Samitis was exposed, and a better system of monitoring was put in place due to our efforts.

Paltry allocation of resources

At the policy level, AIDWA has been demanding a massive infusion of funds from the central government to re-energise the public health system and create both physical and social infrastructure. The nine national women’s organizations- AIDMAM, AIDWA, AIWC, CWDS, GOS, JWP, MWF, NFIW, YWCA- have been petitioning the Government repeatedly during the budget exercise, for higher allocations. It is here that the neo-liberal ideology becomes an impediment. In 1991 when the neo-liberal policies were initiated in India, the public health expenditure to GDP was a paltry 1.3 per cent. This had come down to less than 0.9% in 2005-06. It rose marginally to about 1.04% by the end of the 11th Plan- but the first two years of the 12th Plan have seen a complete stagnation in investment. This puts us today among the lowest in the world in terms of public health expenditure to GDP. Moreover, the actual expenditure of the Ministry of Health and Family Welfare has always fallen short of the budgetary outlays by significant margins- of 9 to 18.5 per cent., and much shorter of Plan allocations- almost one third to half of the amounts envisaged.

While the NRHM was a step in the right direction, taken under the political compulsion of UPA-1, its roll out has at all times been half-hearted, and it has been considerably under-funded. As against a projected fund of 1.75 lakh crores, not more than about 60,000 crores were actually released. The latest attempt to further starve the programme, by coalescing the urban and rural health missions without an appropriate increase in funding demonstrates the policy direction of the UPA-2. AIDWA participated in the JSA convention that exposed the Planning Commission’s move to undermine the public health system by bringing in a ‘managed care’ model of health care. The corporates would provide health services, and the compensation would be provided by the Government. AIDWA held a central workshop on this issue, reported the developments to its members, and joined in the mass protest organized by JSA during the last Parliament session to protest this shift. The move was subsequently dropped.

Reproductive care – policy limitations

AIDWA has always questioned the general policy trend that reduces comprehensive primary health care needs of women to just reproductive and child health care. These get further trivialized into some elements of care in pregnancy and immunization and family planning services. What about reproductive tract infections, or infertility, or access to safe abortions? We have been asking for a life cycle approach to women’s health which requires the system to also address adolescent health care needs, the occupational hazards caused within specific work sectors, menopausal health care needs, etc. But, in reality, the elderly woman, the working woman, or the teenage girl find that the services are highly inadequate for their needs.

Since AIDWA works among the most marginalized sections, we have realized that women in tribal areas, dalit colonies, muslim habitations, are especially affected by the lack of services. Even in an urban area like Delhi, there is such a bias, which the organization has been trying to address by mobilizing the local women and demanding proper services for the more marginalized communities. The situation in rural areas is even worse.

A major lacuna is the paucity of women doctors, to examine and treat women. In most clinics, a total lack of privacy prevails. Women requiring O& G examination are forced to undergo a lot of discomfort, and indignities. In many states, AIDWA has been mobilizing women to demand that more women doctors, and nurses, be posted. Such protests have occurred in states like Orissa, Assam, Karnataka, AP, etc. In states like Kerala, & Tamil Nadu, there has been an improvement in some of the districts. At the all India level, however, the numbers are far from satisfactory. Not surprisingly, women approach the centres only as a last resort.

As women shift to private clinics due to the lack of care in the public health services, another problem is the number of caesarian sections, and hysterectomies that they are forced to undergo, whether they require it or not. The private clinics make a lot of money through this totally unethical practice. In Dausa district of Rajasthan, AIDWA organized a study, which brought out the extent to which gullible women were being systematically advised hysterectomies, and the private hospitals were making huge profits through these surgeries. There was a total collapse of the public health system in this area, forcing women to go to these hospitals.

The other issue that AIDWA has been taking up was is the rising cost of drugs, and the need to have essential medicines distributed free ( or at least at nominal cost) by the public hospitals. It is not only private medical practitioners, but also doctors within the public health system who prescribe a number of irrational, high priced drugs, which the patient cannot afford to buy. We have been asking for controls to be imposed on the prices of essential drugs. The demand for use of generic drugs has been endorsed by us. In UP, a mass protest was organized in Lucknow against the increasing cost of essential medicines, and the DM was petitioned. In Jharkhand, in the tribal district of Godda, the non availability of anti snakebite serum was taken up as an issue, after some deaths due to snakebite in the nearby villages. Many such initiatives are being taken at the local level.

Janani Suraksha Yojana

The Janani Suraksha Yojana was a new scheme of the Union Health ministry under the NRHM to give incentives for institutional deliveries, to enhance the survival rates of mother and child. Despite the problems of poor implementation, corruption, etc, it was welcomed by the poor women who were able to access the entitlements under it. In many states like Jharkhand, Odisha, MP, AP, etc, AIDWA units were active in the process of ensuring that the money reached the actual beneficiaries. The experience of our women underlined two basic flaws in the scheme. Firstly, it is restricted to over 19 year old mothers only, in many states. While it is desirable to have a situation where the consciousness of the society is raised so that children are not born to mothers below 19 years of age and that the anti child marriage legislation is implemented, the present realities are such that a large number of women between the ages of 16 to 18 do give birth to children. These mothers often do not have a choice, either in terms of their early marriage or in terms of childbirth. While initiatives to prevent child marriages and promoting later childbirth should be intensified, excluding pregnant women below 19 years from institutional deliveries is an unjust punishment to them. Secondly, the scheme is restricted to the birth of only the first two children. This is another attempt to punish the mothers for circumstances which are often beyond their control. Denying support for institutional deliveries to mothers for the birth of the third child is another unacceptable measure of population control. Such a policy victimizes women, and has been opposed by AIDWA with signed memorandums being submitted to the authorities by our delegations. We have pointed out that it is absurd, since it is precisely in these two groups that most of the maternal mortality is clustered. We have been demanding that these provisions need to be removed from the scheme if its main goal of lowering the MMR is to be achieved.

As part of the Jan Swasthya Abhiyan, AIDWA took active part in the public hearings that were organized in almost all the states, to identify the gaps in health services. An important aspect that got highlighted was the total lack of regulation of the private sector. In the National People’s Health Assembly Kolkata, 2000), a special plenary was organized by us on the issue of violence against women. AIDWA has been addressing the numerous interlinked factors that underlie violence against women, and has been emphasizing the importance of taking this up from the health angle as well.

Targeted sterilization, & Coercive population policies

Historically, the early decades after independence were characterized by a huge investment in “family planning”, with targets that had to be fulfilled, an approach which was as unsuccessful, as it was a violation of democratic rights. The 2 child norm was adopted as state policy, and all out attempts were made to enforce it. Incentives and disincentives were introduced in the public health system. Anganwadi workers and other government staff were forced to recruit a certain number of women for sterilization, failing which they were penalized. In many states, there were bizarre situations with post menopausal women being recruited, or the same woman undergoing tubectomy twice, leading to meaningless figures, and a dehumanization of the whole process! The campaign against forced sterilization of women, and the use of incentives and disincentives to push family planning were amongst the earliest interventions which brought a number of women’s organizations and health organizations together. Some partial success was achieved due to the united resistance.

Subsequently, the National Population Policy statement of 2000 had underlined the failure of targeted sterilization, and asserted commitment to the “Development is the best contraceptive” approach. Despite this, many states continue to have incentives and disincentives based on the 2 child norm. In states like Maharashtra, absurd penalties were imposed- agricultural loans were refused to families with more than 2 children, subsidized power connections were stopped. The conditionality of the 2 child norm has particularly penalised poor, dalit, tribal and backward caste women. Their right to stand for panchayat elections is subverted, as also their right to avail of certain welfare schemes. This is one of the biggest injustices that AIDWA has had to take up, in many states. After some struggles on this issue, the 2 child norm has been withdrawn in a number of states.

Our experience also showed that the 2 child norm is not only an ineffective family planning strategy, it is also a reason for the elimination of female foetuses in a big way, contributing to terribly skewed child sex ratios.

Despite all the declarations, and commitments, in effect, women in our country still do not have access to safe and effective contraception. There is a huge unmet need, which is being ignore by the Government at great peril to women’s health. The laproscopy camps in which hundreds of women are sterilized at one go are a pointer to the desperation amongst women. Unsafe abortions, and deaths are also outcomes of this lacuna. AIDWA has been insisting that safe and effective contraceptives must be introduced widely, male contraception, and vasectomies must be popularized as much safer alternatives. The responsibility for smaller families must be shared, and be more gender equal.

Another phase of activity on behalf of women’s organizations followed upon the introduction of injectable contraceptives like depo provera and net en, into our country in the early 80s. These were projected as better options to keep women’s reproduction under check. Though the Government spoke of informed consent, in fact, poor, illiterate women were targeted. The whole range of invasive contraceptives was unleashed on unsuspecting women, without concern about the effects of such drugs on undernourished women with little recourse to health services. In many states, women were being treated like guinea pigs, but were not even aware of this fact. No records were maintained , no follow up was done. Women with side effects were just left to suffer. In the quinacrine episode, a drug that was banned in many countries, was being actively propagated as an effective contraceptive. Doctors in Kolkata were prescribing it with little concern about the repercussions, or health problems of women. In the fight against the quinacrine clinical trials, AIDWA took a lead, and worked in collaboration with the CSM Dept in JNU to take up the case in the Supreme Court. While its introduction into the public health system was prevented, It was introduced into the private health sector despite widespread resistance.

The voice of women’s organizations which came together on this issue did create an impact on policy. But the aggressive liberalization drive has given a new impetus to the proliferation of clinical trials, often in a totally unethical manner. For instance, the HPV vaccine trials conducted on tribal girls in AP and Gujarat by PATH were done with the active connivance of the ICMR, without following the prescribed protocols. A so called demonstration project was actually a trial being conducted on unsuspecting, poor, tribal girls, without information being given to them or consent being obtained. The hostel warden signed on their behalf. The death of 4 tribal girls in Khammam district sparked off protests, led by AIDWA activists, who demanded immediate action. It was only after a public outcry at many levels that these trials were stopped. Recently, the Parliamentary Committee set up to enquire into this issue has found that the authorities have been guilty of allowing the trials to take place in a most unethical manner. In this era of globalization, the regulatory system is being undermined by the corporates with impunity.

AIDWA has been active with other organizations in developing an approach to issues like surrogacy, ART, etc, keeping in mind the rights of the women not to be exploited.

Declining child sex ratios and demographic change.

The aggressive “population stabilisation” programme, preceded by the family planning drive launched by successive governments have contributed to the sharp decline in child sex ratios. This is because smaller families are being propagated and popularised within a highly patriarchal and gender discriminatory social construct. Parents too now wish to have less number of children, but, the fall in growth rate of population after decades of stagnation appears to have been achieved primarily at the cost of the girl child. When parents decide to have one child, or two children, the preference is for the son- even without sex selective abortions. In a state like Punjab, it was observed during field research that families with one son prefer not to have another child at all!

Though the two child norm has been formally given up, many states continue to implement it, with incentives and disincentives still being included in different ways. Women with more than two children cannot contest panchayat elections in some states. In Maharashtra, the Cong/ NCP government has passed a law that families with more than two children will have to pay one and a half times more for irrigation water.

Modern families want at least one son, and not more than one daughter - and methods to achieve this ideal are being resorted to without compunction. Indeed, surveys have shown that higher literacy figures and economic growth provide no guarantees against the crime of sex selection. It is in urbanised, fast growing metros that sex selective abortions are gaining popularity, and acceptance. In rural areas, the girl child is neglected after birth, her health needs are not attended to, and she is allowed to die. Such is the grim reality of aversion to daughters.

Sex Selective abortions

Under the PcPNDT Act (1994) sex selection is illegal, and punishable. However, in reality sex selective abortions are being conducted with impunity. There is a well developed nexus between the medical profession, the technicians, and the large companies selling the ultra sound machines. This profitable market exists because of the unwillingness of the government to take stringent action against those violating the law.

When AIDWA did a sting operation in Pune district of Maharashtra against a leading doctor, it discovered that the Act had not even been notified in that district even ten years after the Act had been put into place! A similar lapse undermined the efficacy of the law in Haryana as well!

Collusion between the profit makers, corruption and the clout wielded by unethical and corrupt members of the medical profession (often supported by their associations) have rendered the Act toothless. Clinics get sealed due to our struggles, and then, are back in action within a short period. So-called monitoring committees at all levels are dominated by those who are being monitored and activists, experts etc are conspicuous by their absence on these committees.

The “F” forms that should be analysed and monitored to identify wrongdoers are gathering dust in office rooms.

The Central Supervisory Board set up to monitor and oversee the implementation of the PcPNDT Act did not hold a single meeting over three years. It has been reconstituted recently, in a most non transparent manner. States too are following suit, which will render these bodies ineffective once more.

The linkages with the medical service as business are becoming more advanced, with the advent of newer and newer technologies. The phenomenal expansion in ART centres indicates what a lucrative business enterprise it has become- the potential for its misuse for sex pre selection is extremely high, but there is no regulation. Thus, there is a serious lack of political will in the implementation of the PcPNDT Act by the government.

The numbers of ultra sound machines are increasing by the day, and there are now mobile clinics catering to outlying areas. Pregnant women are being subjected to a number of ultrasounds, for which there is no necessity, and indeed this can be harmful for the unborn baby, as declared by the radiologist’s association in the US. Privatisation is breeding a culture of excess screening and medical tests, a trend that is being exploited by the unscrupulous private health providers.

AIDWA held a consultation on this crucial issue, in which the participants noted that the neo liberal paradigm of development had led to devastating implications for women. They underscored the complex link between the market economy, and the erosion in women’s status. The agrarian crisis, and the consequent further devaluation of women’s work has led to her increased impoverishment and marginalisation. Unemployment and underemployment among women is high. The denial of nutrition and health care, made worse by the introduction of user fees in health institutions, the lack of a universal PDS, accompanied by a decline in the consumption of food grains, the repeated increase in prices of essential commodities, the huge increase in dowry, without property rights and asset creation for women – all these have created a matrix where the girl child is supremely unwanted. While dowry demands are escalating, property rights for girls are not implemented properly. In Haryana, the daughter who inherits property from the father is expected to sign over her share to her brothers- otherwise she is subjected to a great deal of harassment. The growing incidence of violence against women and girls transforms them into even more of a burden.

Thus, there are a plethora of factors leading to sex selective abortion, and neglect of the girl child , which have to be addressed, for the government to arrest the decline in child sex ratios.

AIDWA has taken up this issue seriously, and has launched a nation wide campaign for: stringent implementation of the PcPNDT Act; members with knowledge of the law and proven commitment to upholding the rights of girls should be appointed to the CSB and equivalent state mechanisms; swift punitive action should be taken against the offenders;the two child norm should be withdrawn with immediate effect, including all related incentives and disincentives; existing schemes for girl children must be critically examined and reformulated such that they are universal and are not linked to any kind of conditionalities and stereotypes;monitoring for proper implementation of the Act must not violate privacy rights of pregnant women; rampant privatisation of public health care should be curbed with an umbrella legislation on healthcare. AIDWA also demanded that misuse of new technologies like the Assisted Reproductive Technologies (ARTs) for sex selection should be prevented.

Conclusion

Ultimately, we cannot have a population policy that does not hinge on equity and gender justice.. Issues concerning women’s health and reproductive rights can only be part of a larger package of a health and social development policy. Twenty years after Cairo, if the commitments made there have to have meaning, it is clear that we cannot have RCH without PHC; nor indeed can we have gender-just population policies without the enabling conditions of health and overall development. AIDWA has been demanding a comprehensive legislation to safeguard public health rights to address the multiple concerns. AIDWA will continue to fight, independently, and jointly, for a holistic perspective in which reproductive rights of women form part of a larger gamut of health rights as defined in the Alma Ata declaration.

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