“A maternal death is the ultimate event that is a result of a complexity of human dynamics and the measures in which problems are dealt with…a maternal death is not due to medical conditions alone, but due to the distance between services and the needy clients, social inequalities and dynamics.
Maternal Mortality is not a human rights violation that occurs in isolation; rather it is the culmination of a multitude of rights denial encompassing poverty, illiteracy, malnutrition, child marriage and discrimination faced by marginalized and vulnerable groups.”
M. Prakashamma, ANSWERS
April 11, 2011
NGO Partners' Forum - PMNCH in Delhi
NGOs were the majority of the participants at the Forum, and were very much engaged in the Forum itself as well as the pre-Forum events and meetings. On Nov. 12 there was an NGO constituency group meeting where 80-90 participants discussed the UN Secretary-General’s Global Strategy for Women’s and Children’s Health, launched in September at the MDG Summit. Participants reviewed the commitments organizations have made to the Global Strategy and discussed how to move those commitments forward and generate new ones. Key outcomes included recommendations on how the NGO Constituency might help to implement and/or monitor the fulfillment of Global Strategy commitments.
An NGO Statement was developed over the course of the Forum and presented during the final session, highlighting commitments related to advocacy, education, accountability and implementation. NGOs commended Secretary General Ban Ki-Moon’s on-going leadership via the Global Strategy and called for the meaningful engagement of civil society representatives in all mechanisms and structures established for the achievement of the Strategy’s aims, including an accountability framework. Moving forward, the NGO community will develop platforms and mechanisms that will enable NGOs to work – individually, collectively, and with partners – to contribute to the implementation and monitoring of the Global Strategy.
Two of the current NGO reps (BRAC and Family Care International) will be rotating off the PMNCH Board at the end of 2011. Elections will be held shortly, so keep an eye out – we will be asking for nominations for new representatives, according to criteria approved by the Board.
Ann M. Starrs
President
Family Care International
588 Broadway, Suite 503
An NGO Statement was developed over the course of the Forum and presented during the final session, highlighting commitments related to advocacy, education, accountability and implementation. NGOs commended Secretary General Ban Ki-Moon’s on-going leadership via the Global Strategy and called for the meaningful engagement of civil society representatives in all mechanisms and structures established for the achievement of the Strategy’s aims, including an accountability framework. Moving forward, the NGO community will develop platforms and mechanisms that will enable NGOs to work – individually, collectively, and with partners – to contribute to the implementation and monitoring of the Global Strategy.
Two of the current NGO reps (BRAC and Family Care International) will be rotating off the PMNCH Board at the end of 2011. Elections will be held shortly, so keep an eye out – we will be asking for nominations for new representatives, according to criteria approved by the Board.
Ann M. Starrs
President
Family Care International
588 Broadway, Suite 503
Presentation of the UN-SR report before the Planning Commission on 23rd August 2010
The Planning Commission organized a meeting on the Report of the Mission to India of UN Special Rapporteur on the Right to Health; and Ms Jashodhara Dasgupta, SAHAYOG was invited to make a presentation. This opportunity was used to also share the Recommendations from civil society during the Public Dialogue on the UN SR-RH report organized by the NAMHHR on 13th August. (For the a list of the Recommendations, see here:
http://www.sahayogindia.org/media/13%20Aug%20Public%20Dialogue/namhhr%2010_9_10,%20final%203_30%20pm.pdf)
Present at the meeting were three Members of the Planning Commission (Syeda Hameed, Arun Maira and Dr.Narendra Jadhav); as well as senior representatives of NHRC, NCW and MWCD. However inspite of being invited, there was no representative from the Ministry of Health and Family Welfare present at this meeting.
In the discussion following the presentation of the UN SR report, Mr Maira was more concerned about the challenges in implementation, and did not think that a body reporting to the PM's office or to the legislature would actually be able to make the health system accountable. He preferred a more decentralized approach to accountability. Dr. Narendra Jadhav was not convinced that posting fresh medical graduates to rural areas would work - he said this had been tried earlier but there was no verification that the doctors actually went there. Abhijit Das highlighted the Human Rights dimensions of the sheer scale of deaths and serious illnesses faced by women as a result of this lack of accountability of health systems. The National Human Rights Commission officer mentioned that the NHRC was having a meeting of its Core Group to deliberate on the UN-SR report.
There was no time to formally present the CS recommendations from 13th, and print copies were handed around. However, the Members did look at them and refer to them.
http://www.sahayogindia.org/media/13%20Aug%20Public%20Dialogue/namhhr%2010_9_10,%20final%203_30%20pm.pdf)
Present at the meeting were three Members of the Planning Commission (Syeda Hameed, Arun Maira and Dr.Narendra Jadhav); as well as senior representatives of NHRC, NCW and MWCD. However inspite of being invited, there was no representative from the Ministry of Health and Family Welfare present at this meeting.
In the discussion following the presentation of the UN SR report, Mr Maira was more concerned about the challenges in implementation, and did not think that a body reporting to the PM's office or to the legislature would actually be able to make the health system accountable. He preferred a more decentralized approach to accountability. Dr. Narendra Jadhav was not convinced that posting fresh medical graduates to rural areas would work - he said this had been tried earlier but there was no verification that the doctors actually went there. Abhijit Das highlighted the Human Rights dimensions of the sheer scale of deaths and serious illnesses faced by women as a result of this lack of accountability of health systems. The National Human Rights Commission officer mentioned that the NHRC was having a meeting of its Core Group to deliberate on the UN-SR report.
There was no time to formally present the CS recommendations from 13th, and print copies were handed around. However, the Members did look at them and refer to them.
Public Dialogue on the Report of the Mission to India of UN Special Rapporteur on the Right to Health, 13 August, 2010, New Delhi
The public dialogue, organized by the NAMHHR, was held on 13th August 2010 in New Delhi. This dialogue was an attempt to highlight the fact that India needs far more rigorous mechanisms for accountability regarding the unacceptably high rates of preventable maternal deaths still occurring in this country; especially since India is capable of simultaneously providing global class health care.
The current UN Special Rapporteur on the Right to Health, Mr Anand Grover, graced the event and spoke on the issue of International Accountability with regard to the right to maternal health. Professor Gita Sen, IIM Bangalore and Brinda Karat, Honourable Member of Parliamentary Standing Committee, distinguished speakers at the event, added to the discussion with their important recommendations and support. Eminent chairs for the various sessions included Dr. Syeda Hameed (Honourable member of the Planning Commission); Mr P.C. Sharma (National Human Rights Commission); Mr. A. R. Nanda (Population Foundation of India); Ms Poonam Muttreja (MacArthur Foundation). Distinguished persons like Renu Khanna, (Commonhealth); Professor Dileep Mavalankar (IIM Ahmedabad); Dr. Abhay Shukla (SATHI-CEHAT); Dr. Nirmala Nair (EKJUT); Jashodhara Dasgupta (SAHAYOG); Dr. Abhijit Das (Centre for Health and Social Justice); Trisha Agarwal (Centre for Budget and Governance Accountability) presented on various aspects of the UN SR-RH Report. Seventy five participants from six states representing various civil society organizations participated in this dialogue. (For presentations and other details, see here: http://www.sahayogindia.org/pages/programmes/maternal-health-and-rights/events.php)
The former UN Special Rapporteur on the Right to Health (UN SR-RH), Paul Hunt came to India on a mission in 2007 to understand the steps taken by the government regarding maternal mortality. The report provides a right-to-health analysis of the serious issue of preventable maternal deaths in India. The report has been recently tabled at the UN Human Rights Council in Geneva, where the current UN SR-RH Anand Grover presented it. The Government of India has taken cognizance of it and provided a response in the Council.
This dialogue was a first step by the alliance in wide dissemination of the UN-SR-RH report. The report is available on the University of Essex website within the list (3rd bullet)(http://www.essex.ac.uk/human_rights_centre/research/rth/index.aspx)This UN report is supported by a Supplementary Note which provides some additional background information, and outlines a right-to-health approach to maternal mortality.
To sum up, the dialogue brought forth some key suggestions to be taken forward. It was decided that one of the immediate areas of work to be taken up is long term sustained advocacy with parliamentarians on the issue. Moreover, the Planning Commission has invited Ms. Jashodhara Dasgupta to make a presentation on the Report of the Mission to India of UN Special Rapporteur on the Right to Health on 23rd August where we plan to present the recommendations that came up at the Public Dialogue. The Planning Commission has invited the MoHFW for this presentation.
The current UN Special Rapporteur on the Right to Health, Mr Anand Grover, graced the event and spoke on the issue of International Accountability with regard to the right to maternal health. Professor Gita Sen, IIM Bangalore and Brinda Karat, Honourable Member of Parliamentary Standing Committee, distinguished speakers at the event, added to the discussion with their important recommendations and support. Eminent chairs for the various sessions included Dr. Syeda Hameed (Honourable member of the Planning Commission); Mr P.C. Sharma (National Human Rights Commission); Mr. A. R. Nanda (Population Foundation of India); Ms Poonam Muttreja (MacArthur Foundation). Distinguished persons like Renu Khanna, (Commonhealth); Professor Dileep Mavalankar (IIM Ahmedabad); Dr. Abhay Shukla (SATHI-CEHAT); Dr. Nirmala Nair (EKJUT); Jashodhara Dasgupta (SAHAYOG); Dr. Abhijit Das (Centre for Health and Social Justice); Trisha Agarwal (Centre for Budget and Governance Accountability) presented on various aspects of the UN SR-RH Report. Seventy five participants from six states representing various civil society organizations participated in this dialogue. (For presentations and other details, see here: http://www.sahayogindia.org/pages/programmes/maternal-health-and-rights/events.php)
The former UN Special Rapporteur on the Right to Health (UN SR-RH), Paul Hunt came to India on a mission in 2007 to understand the steps taken by the government regarding maternal mortality. The report provides a right-to-health analysis of the serious issue of preventable maternal deaths in India. The report has been recently tabled at the UN Human Rights Council in Geneva, where the current UN SR-RH Anand Grover presented it. The Government of India has taken cognizance of it and provided a response in the Council.
This dialogue was a first step by the alliance in wide dissemination of the UN-SR-RH report. The report is available on the University of Essex website within the list (3rd bullet)(http://www.essex.ac.uk/human_rights_centre/research/rth/index.aspx)This UN report is supported by a Supplementary Note which provides some additional background information, and outlines a right-to-health approach to maternal mortality.
To sum up, the dialogue brought forth some key suggestions to be taken forward. It was decided that one of the immediate areas of work to be taken up is long term sustained advocacy with parliamentarians on the issue. Moreover, the Planning Commission has invited Ms. Jashodhara Dasgupta to make a presentation on the Report of the Mission to India of UN Special Rapporteur on the Right to Health on 23rd August where we plan to present the recommendations that came up at the Public Dialogue. The Planning Commission has invited the MoHFW for this presentation.
A discussion on the Indira Gandhi Matriva Sahyog Yojana (IGMSY)
A discussion on the Indira Gandhi Matriva Sahyog Yojana was organized by the NAMHHR on the 25th February 2011. A panel consisting of various speakers critically analyzed the Scheme from various perspectives. Ms. Dipa Sinha (Commissioners to the Supreme Court) presented a brief outline of the Scheme. Critically analysing the scheme from the nutritional perspective, she said that the IGMSY was the first such scheme centred round maternity entitlements, however the serious flaw in the scheme was that it saw maternity benefit not as a ‘right’ but as an ‘incentive’ for ‘right behaviour’. Besides, the other problem with the scheme was the insufficient amount of money given to the beneficiaries which was not linked to wages. She also feared that this scheme could be seen as a pilot for Conditional Cash Transfers (CCTs).
Prof. Imrana Quadeer provided a health systems perspective to the analysis of the Scheme. She held that while analysing the IGMSY; it is necessary to situate it in the scheme of larger things. Looking back at history, a shift in vision is clearly discernable- earlier health was a service, but now it has become a commodity. The present policy and planning of our government has led to an erosion of what had been created by post independence India. She mentioned that it was necessary for us to stress that the primary responsibility of the state was to provide free quality health care. In conclusion she reiterated that we must first ensure that basic infrastructure exists, basic services are insured and then providing people with short term benefits such as the IGMSY would be welcome.
Ms. Sandhya Mishra (Sikhar Prasthan Sansthan) critiqued the scheme from the informal worker’s perspective. She began by saying that the conditionalities in the scheme had ignored the patriarchal nature of Indian society. In a country where women had no control over their reproductive decisions and marriage, barring under 19 year women and women with more than two children was unfair. She also mentioned that rolling out of the scheme through the ICDS was highly problematic since there were many Dalit colonies where Anganwadi centres did not exist. The push for six months exclusive breastfeeding without making provisions for enabling conditions and a mother friendly work place would deprive poor informal sector women workers the benefits of the scheme.
Dr. Evangeline Dutta (CMAI) critiqued the scheme from the ASHA perspective. She began by saying that the entire ASHA system was incentive driven; this she claimed had resulted in an erosion of the basic value of community health workers. The consequence was that community health workers were slowly becoming an extension of a small bureaucracy. The government, she held, was doing its best to commodify the provisioning of services by health workers. The huge amount of corruption and competition in the system was only going to intensify with this scheme and so would the confusion in the minds of the people and the community health workers regarding their responsibilities.
The Anganwadi workers perspective was given by All India Federation of Anganwadi Workers and Helpers. The concerns expressed by the Federation in regard to the IGMSY, was that it would increase the burden of the already burdened Anganwadi Workers (AWW) and Helpers. The proposed incentive that was to be given to the AWW was critized as being too small and too late. Instead it was suggested that the Scheme be rolled out through the ASHAs and the government concentrate on strengthening the AWW system.
An outline of the budgetary allocations of the Scheme was given by Ms. Trisha (CGBA). She shared that the IGMSY scheme hoped to cover a target population of 13.80 lakh women in the first year. The budgetary allocations for the scheme are Rs.390 crore and Rs.610 crore for 2010-11 and 2011-12 respectively. She went on to say that as the money would be transferred to the beneficiary’s bank accounts this could create a problem as most rural women did not have accounts. She went on to point out that while as a special intervention, two additional staff would be provided in District ICDS Cell, there was to be no increase in the number of frontline workers.
The presentations were followed by an enriching discussion wherein it was decided to take the following strategic position:
• The scheme is eroding the entire system
• It will result in the loss of credibility of the health system and the government
• We must use this as an opportunity to state what we want form the women’s point of view
• Stress on the strengthening of the health system
• Push for a holistic view of health
• Create an enabling environment for women
The discussion ended with a set of asks being outlined which would be placed before the Planning Commission:
1. The existing health system must be strengthened
2. Question how the health system will support the woman’s wellbeing
3. We want this scheme to be a maternity benefit scheme and not a wage compensation
4. Simplify the disbursement pattern
5. Remove all conditionalities
6. What is the evaluation framework of the scheme
7. What is the accountability mechanism of the scheme
8. Incorporate the learnings from the JSY scheme into the IGMSY
9. Increase AWW and ANM services
Prof. Imrana Quadeer provided a health systems perspective to the analysis of the Scheme. She held that while analysing the IGMSY; it is necessary to situate it in the scheme of larger things. Looking back at history, a shift in vision is clearly discernable- earlier health was a service, but now it has become a commodity. The present policy and planning of our government has led to an erosion of what had been created by post independence India. She mentioned that it was necessary for us to stress that the primary responsibility of the state was to provide free quality health care. In conclusion she reiterated that we must first ensure that basic infrastructure exists, basic services are insured and then providing people with short term benefits such as the IGMSY would be welcome.
Ms. Sandhya Mishra (Sikhar Prasthan Sansthan) critiqued the scheme from the informal worker’s perspective. She began by saying that the conditionalities in the scheme had ignored the patriarchal nature of Indian society. In a country where women had no control over their reproductive decisions and marriage, barring under 19 year women and women with more than two children was unfair. She also mentioned that rolling out of the scheme through the ICDS was highly problematic since there were many Dalit colonies where Anganwadi centres did not exist. The push for six months exclusive breastfeeding without making provisions for enabling conditions and a mother friendly work place would deprive poor informal sector women workers the benefits of the scheme.
Dr. Evangeline Dutta (CMAI) critiqued the scheme from the ASHA perspective. She began by saying that the entire ASHA system was incentive driven; this she claimed had resulted in an erosion of the basic value of community health workers. The consequence was that community health workers were slowly becoming an extension of a small bureaucracy. The government, she held, was doing its best to commodify the provisioning of services by health workers. The huge amount of corruption and competition in the system was only going to intensify with this scheme and so would the confusion in the minds of the people and the community health workers regarding their responsibilities.
The Anganwadi workers perspective was given by All India Federation of Anganwadi Workers and Helpers. The concerns expressed by the Federation in regard to the IGMSY, was that it would increase the burden of the already burdened Anganwadi Workers (AWW) and Helpers. The proposed incentive that was to be given to the AWW was critized as being too small and too late. Instead it was suggested that the Scheme be rolled out through the ASHAs and the government concentrate on strengthening the AWW system.
An outline of the budgetary allocations of the Scheme was given by Ms. Trisha (CGBA). She shared that the IGMSY scheme hoped to cover a target population of 13.80 lakh women in the first year. The budgetary allocations for the scheme are Rs.390 crore and Rs.610 crore for 2010-11 and 2011-12 respectively. She went on to say that as the money would be transferred to the beneficiary’s bank accounts this could create a problem as most rural women did not have accounts. She went on to point out that while as a special intervention, two additional staff would be provided in District ICDS Cell, there was to be no increase in the number of frontline workers.
The presentations were followed by an enriching discussion wherein it was decided to take the following strategic position:
• The scheme is eroding the entire system
• It will result in the loss of credibility of the health system and the government
• We must use this as an opportunity to state what we want form the women’s point of view
• Stress on the strengthening of the health system
• Push for a holistic view of health
• Create an enabling environment for women
The discussion ended with a set of asks being outlined which would be placed before the Planning Commission:
1. The existing health system must be strengthened
2. Question how the health system will support the woman’s wellbeing
3. We want this scheme to be a maternity benefit scheme and not a wage compensation
4. Simplify the disbursement pattern
5. Remove all conditionalities
6. What is the evaluation framework of the scheme
7. What is the accountability mechanism of the scheme
8. Incorporate the learnings from the JSY scheme into the IGMSY
9. Increase AWW and ANM services
Barwani Maternal Deaths
Barwani district located in south-west of Madhya Pradesh has a population of 10, 81.039 of which 7,24,735 or 67% belong to Schedule Tribes. (2001 census). The terrain of the district is hilly and dry, with frequent droughts. Agriculture and labour work are the primary occupations of a large percentage of the district’s population. Barwani has been identified by the Government of Madhya Pradesh as one of ten districts with very poor indicators, low population density and weak infrastructure, in need of special attention. According to the Madhya Pradesh Human Development Report 2007, the district has the second lowest Human Development Index amongst all districts of Madhya Pradesh. This report also gives the MMR figures for the district based on 2002 data as 905 per 1,00,000 live births (SRS, 2003).
In the District Hospital, Barwani between April to November 2010 there had been 25 maternal deaths, 9 of which occurred in the month of November 2010 alone. Incidentally, none of the CEmONCs in Barwani District conduct cesareans or manage complicated deliveries; only 1.5% of births are delivered by cesarean section, suggesting that many women who need this life saving service are not receiving it. The draft study report on JSY evaluation in Barwani District conducted by National Health Systems Resource Centre (NHSRC) mentions that only 1.9% of estimated pregnancy related complications in the district are being managed in the District hospital. Given the topography, there have been instances where women in labour have travelled upto 100 kms from their villages to seek treatment in Barwani District Hospital, only to be referred to Indore Medical College Hospital, located another 150 kms away - this despite the fact that District Hospitals are supposed to be dealing with such cases.
The point of contention is not merely about general deficiencies in infrastructure, but also the negligent and careless attitude doctors in the District Hospital and poor management by senior officials, which has resulted in local people being put through derogatory treatment, harassment and even in death. A rally was held on 28th December to protest against this extreme callousness and ill-treatment regularly meted out to women in pregnancy and labour by the public health system, and particularly the District Hospital. Nearly a thousand people from far-flung adivasi villages of the district demonstrated under the banner of Jagrit Adivasi Dalit Sangathan (JADS), a mass organization active in this area for more than a decade now. Contrary to expectations that some corrective action would be taken by the District authorities, what came as a rude shock was the arrest warrant issued by the district administration against the leaders of JADS and 200 people who participated in this protest.
The National Alliance for Maternal Health and Human Rights decided to undertake advocacy on this issue and made submissions to the National Human Rights Commission (NHRC), Planning Commission, Department of Women and Child, the Chairperson of the Parliamentary Standing Committee (H&FW) and NRHM Mission Director, Madhya Pradesh. We have to date received positive responses from the NHRC, Parliamentary Standing Committee and the Mission Director. The NHRC has issued notices to the District Magistrate, SSP of Barwani and CMO of Barwani District Hospital and demanded a report within four weeks. The Parliamentary Standing Committee has requested for a submission of all related reports to be placed before them for their consideration. Further the NAMHHR co-organized a meeting entitled ‘Civil society Action on Maternal Health: A Strategic Meeting’ on the 1st March where the findings of the three member fact finding team consisting of civil society activist were shared. During the course of this meeting the future course of action to be taken was also charted.
In the District Hospital, Barwani between April to November 2010 there had been 25 maternal deaths, 9 of which occurred in the month of November 2010 alone. Incidentally, none of the CEmONCs in Barwani District conduct cesareans or manage complicated deliveries; only 1.5% of births are delivered by cesarean section, suggesting that many women who need this life saving service are not receiving it. The draft study report on JSY evaluation in Barwani District conducted by National Health Systems Resource Centre (NHSRC) mentions that only 1.9% of estimated pregnancy related complications in the district are being managed in the District hospital. Given the topography, there have been instances where women in labour have travelled upto 100 kms from their villages to seek treatment in Barwani District Hospital, only to be referred to Indore Medical College Hospital, located another 150 kms away - this despite the fact that District Hospitals are supposed to be dealing with such cases.
The point of contention is not merely about general deficiencies in infrastructure, but also the negligent and careless attitude doctors in the District Hospital and poor management by senior officials, which has resulted in local people being put through derogatory treatment, harassment and even in death. A rally was held on 28th December to protest against this extreme callousness and ill-treatment regularly meted out to women in pregnancy and labour by the public health system, and particularly the District Hospital. Nearly a thousand people from far-flung adivasi villages of the district demonstrated under the banner of Jagrit Adivasi Dalit Sangathan (JADS), a mass organization active in this area for more than a decade now. Contrary to expectations that some corrective action would be taken by the District authorities, what came as a rude shock was the arrest warrant issued by the district administration against the leaders of JADS and 200 people who participated in this protest.
The National Alliance for Maternal Health and Human Rights decided to undertake advocacy on this issue and made submissions to the National Human Rights Commission (NHRC), Planning Commission, Department of Women and Child, the Chairperson of the Parliamentary Standing Committee (H&FW) and NRHM Mission Director, Madhya Pradesh. We have to date received positive responses from the NHRC, Parliamentary Standing Committee and the Mission Director. The NHRC has issued notices to the District Magistrate, SSP of Barwani and CMO of Barwani District Hospital and demanded a report within four weeks. The Parliamentary Standing Committee has requested for a submission of all related reports to be placed before them for their consideration. Further the NAMHHR co-organized a meeting entitled ‘Civil society Action on Maternal Health: A Strategic Meeting’ on the 1st March where the findings of the three member fact finding team consisting of civil society activist were shared. During the course of this meeting the future course of action to be taken was also charted.
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