The Daughter Disadvantage – Is Beti Bachao Beti Padhao Changing mindsets at all?

Data from the Civil Registration System (CRS), appears to indicate that there is a substantial decline in the sex ratio at birth. The ratio has fallen from 898 in 2013 to 887 in 2014; see http://www.thehindu.com/todays-paper/Sex-ratio-at-birth-on-the-decline/article16728001.ece. The decline has been sharp since 2011 when the figure was 909[1]. The states of Manipur, Rajasthan and Tamil Nadu have witnessed a decrease in the sex ratio.

Evidently, the decline appears to worsening over the years and the practice of discrimination against girls appears to be seeping into communities – even those, which were not known to have had strong patriarchal ideology.

A key lesson learnt as a part of the efforts addressing sex ratio and sex selection is that “in the long run, sex selection needs to be become the community’s own concern so that it endeavors to find local solutions. In the process, the long-held patriarchal beliefs and expectations that discriminate against daughters can be obliterated and the value of girls upheld” (see http://india.unfpa.org/sites/asiapacific/files/pub-pdf/UNFPA_EA_GHRC_India.pdf)

Our team at Development Solutions has been part of assignments that have evaluated efforts of the civil society and community in addressing this issue. We have evaluated interventions in Rajasthan, Punjab, Haryana and Himachal Pradesh. Our evaluations found that while involving the community certainly brought dividends; it also came with its share of challenges. Awareness on the issue had increased as a result of community involvement. However, interestingly, the awareness often led to denial of the issue. Many said that it does not occur in their community. Given the denial, it becomes difficult to discuss the issue of sex selection. Overcoming this denial is important to move forward. The other risk in involving the community is that on occasions, some of the members who are involved by the civil society perceive their role as one of surveillance. This has an impact on the autonomy of women and their rights.

It is also seen that efforts do not sustain beyond the project period. There is little effort by the projects to create community institutions that would take this process forward. In addition, these efforts often remain as small islands of community efforts- without adequate linkages to the health department, Panchayat and other stakeholders. There is still lot of effort needed for it to become “community’s own concern”.

Given the poor implementation of Government programs and declining involvement of the civil society and the community; sex ratio is expected to decline much faster in the next few years. There needs to a comprehensive effort towards addressing issues of women, more so aspects of education, employment and security. “Beti Bachao, Beti Padhao” needs to be more than a just a slogan!

[1] There also appears to be discrepancy in the data – while CRS 2011, indicates Sex Ratio at Birth at 909, Census 2011 indicates a figure of 919.

Facility Based maternal care – lacking respect and interpersonal care

Disrespectful intrapartum care during facility-based delivery in sub-Saharan Africa: A qualitative systematic review and thematic synthesis of women’s perceptions and experience – http://www.sciencedirect.com/science/article/pii/S0277953616305469

This article in the sub Saharan African context analyses the model of maternity care that is increasingly institution centred rather than women centred. Women’s experiences at institutions indicate that institutions and care providers tend to maintain power and control by situating birth as a medical event by focusing on the technical elements of care, including controlling bodies and knowledge. Global policies are pushing for facility based care, putting service providers and women between medical based care as compared to the traditional psycho emotional care provided by mid-wives.

The study though based in Africa is indicative of the issues in Indian context too, especially with the push from the NRHM (National Rural Health Mission) /NHM (National Health Mission) for institutional delivery. Field work in Jharkhand, done as a part of a fellowship on maternal health by the team at Development solutions also indicates that the push for institutional delivery, often dehumanizes women. The study in Jharkhand analysing the factors that influence access to care during pregnancy and child birth, reveals that given a choice, most women would prefer not to access Government facilities. Women are often treated with disrespect and lack the care and emotional support needed during delivery; and available in traditional home based delivery and care systems. While the need for a safe delivery and the merit in institution based care, is understood; the lack of adequate interpersonal care and support is a deterrent. The main reason why women accessed the Government facilities was owing to the Janani Suraksha Yojna (JSY) incentive. Those who could afford to, accessed good private hospitals, where they felt the quality of care is much better; else they preferred to call qualified doctors and nurses at home for delivery.

Hysterctomy – Addressing the stigma of menstruation

Hysterectomy is a big business in many private hospitals in India. There are ample reports and newspaper articles on this issue. Several media and newspapers including #The Hindu ,  #Times of India, #Guardian and #BBC have reported on how some of the private health care providers have been exploiting and profiting from it (See http://www.theguardian.com/society/sarah-boseley-global-health/2013/feb/07/india-healthcare?; http://www.bbc.com/news/magazine-21297606). In fact, it is according to one site a health tourism issue too (https://www.health-tourism.com/hysterectomy/india/).

Clearly, hysterectomy is not indicated in many cases. An Audit of Indications, Complications and Justification of Hysterectomies at a Teaching Hospital in India concluded benignly “With the emergence of many conservative approaches to deal with benign gynecological conditions, it is prudent to discuss available options with the patient before taking a direct decision of surgically removing her uterus.” Studies published in the International Journal of Reproductive Medicine (Volume 2014 (2014), Article ID 279273, 6 pages http://dx.doi.org/10.1155/2014/279273) have also clearly indicated that the state and private sector sponsored insurance schemes have actually driven this market of “uterus chopping” in many states (See-http://www.hrln.org/hrln/images/stories/pdf/national-consultation-on-understanding-the-reasons-for-rising-numbers-of-hysterectomies-in-india.pdfhttp://www.slideshare.net/LifecareCentre/how-to-decrease-hysterectomy-rate-in-india-25506955; http://www.hrpub.org/download/201309/ijrh.2013.010110.pdf). Consequently, some of the states such as Andhra Pradesh and Karnataka have tweaked their insurance policies to disallow hysterectomy.

Apart from the fact that many private health providers use this to make a quick buck, the market for this is also driven by how menstruation is viewed and how it impacts many women. Often, women are isolated during the menstrual period and many view the menstrual blood as unclean. This is still predominant in many rural parts of the country. Hence, some women as soon as they have completed their reproductive responsibility of bearing children and ensuring a family; undergo hysterectomy. This puts an end to their isolation every month. Worse, as the report in #The Hindu reported on May 22, 2016 (http://www.thehindu.com/news/national/other-states/poverty-superstition-take-their-toll-on-sangola-womens-health/article8631138.ece) in  drought stricken Maharashtra, women undergo hysterectomy as they often migrate for work to sugarcane fields and roadwork. The periods impact their migration and hence their earnings. Young girls too seem to opting for this with many ill effects to their health.  Costs associated with hysterectomy have  also pushed many into poverty.

While addressing poverty is certainly necessary, it is also imperative that our education helps to dispel the stigma about menstruation and enables both women and men to treat this as a natural phenomenon in life of  women.

Swachh Dilli Door Ast!

The Swachh Bharat Abhiyan launched last year by the Prime Minister is the new mantra of cleanliness (https://swachhbharat.mygov.in/). A very welcome initiative; much has already been written about the campaign. While some have examined why the program is struggling[1]; others have tried to understand the sanitation behaviour in rural north India and the reasons why many do not use toilets even if they are constructed[2].

We however, want to focus on the abysmal state of many of the poorer and neglected localities in Delhi. The filth, stench, dirt and poor sanitation in many of these localities left us wondering about the efforts over the last so many years in Delhi.

During an assignment we did in Delhi in 2014, we got the opportunity to visit the many galis nooks and crannies in Chandni chowk, Nabi Karim (Near railway station), Gandhi Nagar, and Madanpur Khadar among others. While as always it was a pleasure interacting with the residents in these locations, one of the things most strikingly common in all these locations that just could not be ignored was – the sheer filth and dirt!!!

A narrow lane in Okhla, with the rain the stench from the drain below us was unbearable!

A narrow lane in Okhla, with the rain the stench from the drain below us was unbearable!

Between 2 lanes of houses – In Madanpur Khadar

Between 2 lanes of houses – In Madanpur Khadar

While we walked through these lanes, the first instinct was to cover our face! Think of it … so many people live in these places day in and out!

The civic conditions are abysmal.  Many of these locations are resettlement colonies, where people from across slums in Delhi have been moved. While building these settlements, no care has been taken to ensure proper roads, space, sewage and drainage. Open drains flow alongside houses, many of which are used for defecation as well. There are no public garbage dumps and no systems of waste collection. Public toilets are few and far and there is no regular water supply. In focus group discussions with women in Madanpur Khadar, they pointed out ‘that while the authorities had built public toilets, there were very few compared to the number of residents. In addition, despite having to pay for use, they were extremely dirty.’ Some also felt that Rs.1, 2 and 5 levied as fee for use was very high. For a family of 5 with each member bathing once and using the toilet; the average per day cost was anything above Rs 25; a huge cost indeed for many of poorer households. Hence, many resorted to open defecation.

We got Stuck with a Bullock on the way out!!

We got Stuck with a Bullock on the way out!!

There is no regular water supply in these areas. In many locations, water tankers are sent by the authorities. There are no fixed times and days of water supply; also several residents complain of muddy water in the public supplies. As a result many households purchase water commercially, for drinking and cooking, adding to their costs.

In the absence of regular water, no space for toilets to be constructed within houses, unhygienic community toilets, which also entail considerable expenses to use; more investment in toilet construction may not lead to any perceptible improvement. Perhaps, a comprehensive approach under the Swacch Bharat Abhiyan, which addresses aspects of housing, provision of water, roads, waste disposal systems and toilet construction, is the way forward; at least in these localities in Delhi.

[1] see http://www.livemint.com/Opinion/b6XOmxNBkTr5MtjvgMoGyH/Like-its-predecessors-Modis-sanitation-programme-is-strugg.html?facet=print

[2] See Coffey D; et, al (2015); Culture and the Health Transition: Understanding sanitation behaviour in rural north India; Working Paper, International Growth Centre. (www.theigc.org)

Differently abled & Access to Education: Is enough being done?

We, at Development Solutions, are undertaking an assignment with SCORE Foundation, to enable skilling and employment of visually challenged persons across the country[1]. For the assignment, we were examining the data on population, school enrolment, education levels and employment among differently abled persons.

A recent article in ‘The Hindu’ reported a reduction in the enrolment of differently abled students in higher education, compared to last year. A survey by the National Centre for Promotion of Employment for Disabled People (NCPEDP) indicated that of the total students, only 0.56 percent are differently abled. The Government has stipulated a minimum quota of 3 percent seats for differently abled persons in higher education.

This low enrolment in the higher education didn’t seem surprising! We came across similar statistics while analysing drop-out rates among visually challenged persons.

While the Census 2011 reports 55 percent literacy among differently abled persons; we found an entirely different picture from the District Information System for Education (DISE) data.

The DISE provides data on enrolment by type of disability up-to class 8. Using this, we approximated the enrolment and drop out from class 10 to 12, among visually challenged persons. This analysis was done for 8 states including Bihar, Jharkhand, West Bengal, UP and MP. Our analysis found that a staggering 69 percent students drop out from class 10 to 12. In other words, many differently abled children drop out just before finishing their schooling.

The DISE data for elementary education also reveals that in 2013-14, only 1.3 percent of the total children were differently abled in primary education (class I -V); and only 1.2 percent in upper primary (class VI – VIII). Specifically in Government schools, the enrolment has been less than 1 percent for over a decade. The situation is particularly severe in states such as UP, Bihar, MP and Rajasthan, who despite having a greater number of differently abled children, have poor school enrolment.

Despite the Right to Education (RTE) Act, which guarantees ‘free and compulsory education’ for all between the ages of 6 – 14 years, the enrolment of the differently abled children has remained consistently low. Interestingly, from the DISE data, it appears that the enrolment of differently abled students has actually gone down since the introduction of RTE from 1,384,116 children in 2008-09 to 831,497 children in 2011-12.

The low enrolment and low retention of the differently abled children appears to signal the failure of the efforts to mainstream these children. People we spoke to said that as the children go to higher classes, access to schools becomes an issue. In addition, many of them face neglect and discrimination from fellow students and teachers in schools.

Unschooled, unskilled, many are entirely dependent on the support of their family and relatives. Many of the differently abled are thus denied a dignified life.

There have been various efforts both by the Government and the civil society to address the needs of the differently abled. It appears that these efforts are not adequate. What could be the newer ways to ensure that the differently abled are part of the mainstream, in schools and in employment? ….. We hope to explore some of these aspects as we go along.

[1] SCORE Foundation is a not for profit organisation that has for over 12 years been working with and for visually challenged persons in India.