REPORT ON POPULATION ISSUES AND WOMEN'S HEALTH A NEW APPROACH
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REPORT ON
POPULATION ISSUES AND WOMEN'S HEALTH
A NEW APPROACH
VOICES
Population Issues and Women’s Health: A New Approach
Report of the Health Watch Karnataka-Andhra Pradesh regional workshop
June 28-29, 1996
Organized by VOICES, Bangalore & the Indian Institute of Health and Family
Welfare, Hyderabad
Prepared by Sunccia Krishnan for Health Watch
Summary
This report describes the proceedings of the Andhra Pradesh-Karnataka workshop held at
the Indian Institute of Health and Family Welfare, Hyderabad between June 28 and 29, 1996, the
first in a series of regional workshops being organized by Health Watch to generate discussion on
the Government of India’s new health and family welfare program The primary aim of the
workshop was to examine and document NGO experiences in women’s health in order to draw
relevant lessons for the delivery of government health services. Participants included NGO
representatives, government officials, and academics
During the presentations and discussion, a number of key themes emerged. First, there
was overwhelming agreement regarding the importance of the involvement of women’s groups in
the planning, implementation, monitoring, and evaluation of the new health and family welfare
program. NGO experiences indicate that women’s groups can play a critical role in ensuring the
delivery of high quality services. However, careful attention must be paid to issues such as how
these groups are formed, who will be responsible for their formation, and the groups’ rights and
responsibilities. Drawing upon the experiences of NGOs and the Government of Andhra Pradesh
(which is conducting pilot projects of the new health and family welfare approach), strategies to
form and activate women’s groups, and to involve women’s groups in the process of planning,
implementation and evaluation were outlined The need for documentation of these experiences
was stressed Second, participants emphasized the need to disseminate information on the new
health and family welfare approach to all levels of the government and to the public. Channels of
communication must be established, and should include mechanisms by which the perceptions of
communities and government health functionaries will be recorded and taken into account. Third,
the importance of formulating systematic implementation guidelines, and testing these guidelines
through pilot projects during a defined time period was stressed Evaluation and process
documentation of these pilot projects are vital and can play a crucial role in tailoring programmes
to local needs Finally, it is hoped that the process of planning and implementation of the targetfree approach will be open and responsive to feedback from advocates of women’s health like the
Health Watch
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5
Introduction
The International Conference on Population and Development (ICPD) marked a
significant shift in the Government of India’s (GOI) conceptualization of population issues and
policies GOTs official position paper at Cairo revealed a shift from a population control strategy
to a more holistic, quality-driven reproductive health approach As a first step in this direction, it
decided to remove method-specific targets in its family planning programme in select districts
across the country Subsequently, it decided to eliminate targets completely on April I, 1996.
During the early months of 1996, GOI convened a task force to develop alternative performance
indicators (in place of targets), and began developing a comprehensive health program in the spirit
of the reproductive health approach (the Reproductive and Child Health programme).
In order to generate public discussion on the new health and family welfare program, GOI
invited Health Watch to organize a series of regional workshops. Health Watch, an informal
network of researchers, non-governmental organizations (NGOs), and policy analysts interested in
health who came together during the pre-Cairo period, was formally launched in December 1994.
Its primary objective is to be an advocate for women's health, specifically, to try to ensure that
government programmes are responsive to women's health needs and are accountable to women.
Health Watch has interfaced with GOI on the issue of the new reproductive health programme as
a way of achieving its larger objective
Focus of the regional workshops
Health Watch will be organizing eight regional workshops during the latter half of 1996,
the Karnataka-Andhra Pradesh meeting is the first in this series The focus of these workshops is
as follows:
1
to examine & document NGO experiences in women’s health in order to draw relevant
lessons for the delivery of government health services, experiences on involving women in
planning, implementing and monitoring programmes will be highlighted,
2. to study the ground-level implications of the ‘Target-free Approach” (TF) and the
Reproductive and Child Health (RCH) programme from women’s perspectives,
3. to examine & evaluate the new performance indicators developed by GOI, particularly those
in the Manual on the Target-free Approach,
4
to develop a concrete response to the challenges, strengths and limitations posed by GOI’s
shift in population policy and health care delivery, particularly with regard to the process of
planning, implementation, monitoring and ensuring accountability,
5. to expand & strengthen the Health Watch network, and formulate region-specific plans of
action for advocacy at the state level.
2
Making the transition from target-centered to target-free programmes: experiences of
Andhra Pradesh
Based on inaugural address by Ms. Rachel Chatterjee
Secretary, Health and Family Welfare, Andhra Pradesh
Ms Chatterjee’s inaugural address focused on AP’s experiences in implementing the
Target-Free and RCH programmes Her introductory remarks highlighted India’s pioneering
efforts in family planning (FP). India took the lead at the first International Population Conference
in advocating an integrated approach to FP, one which involved a broad range of contraceptive
methods, and was based on community participation. India had also linked FP to broader issues of
poverty and gender discrimination Thus, placing individuals at the center of FP activities, as was
stressed at the Cairo conference, was consistent with GOI’s efforts Since the ICPD, there has
been a marked shift in focus from FP to reproductive health; FP is now viewed as one intervention
among many others through which women can fulfill their reproductive rights The key policy
implication of this shift is that programmes which were once based on demographic targets will
now be based on clients’ needs and desires. However, this does not imply that slowing population
. growth has ceased to be a goal, rather, it implies that the design and management of FP
programmes will now be oriented towards satisfying clients
According to Ms. Chatterjee, the TF/RCH Approach has four primary characteristics
•
it is client centered & moves away from targets;
•
it expands choice by broadening the range of safe methods of contraception provided,
and by introducing reproductive health services;
•
it emphasizes quality of services and management of programmes,
•
it builds partnerships with the community
She went on to outline AP’s experiences in implementing the above
Needfor a formal system of implementation and monitoring
The testing of TF in Tamil Nadu and Kerala revealed that eliminating targets does not
compromise the goals of the FP programme. In fact, it has been observed that if the need for
fertility control is met adequately, demand for such services increases In Andhra Pradesh (AP),
.
the National Family Health Survey indicated that there is considerable unmet need for fertility
control AP decided to initiate TF one vear prior to its official launching in April 1996 A State FP
Action Programme was formed, but its track record indicates that when a new approach is
implemented in the field, a critical prerequisite is the presence of a formal implementation system
which includes dissemination of the philosophy of the programme, training, advocacy for
providers, and alternative performance indicators. In the absence of a formal system, it will revert
either to the old “number-oriented" system or to a “work-free system
AP has attempted to develop a formal implementation system A workshop attenaed by all
health and family welfare frinctionaries was organized to outline an action plan and to discuss
performance indicators. A second workshop was conducted to discuss objective methods of
programme evaluation These indicators and methods are currently being field-tested
3
*
Need for broadening the range of services
In AP, 95% of contraceptive services provided are sterilizations; 95% of these are for
women. The need for birth spacing methods is critical. Temporary methods such as hormonal
contraceptives (implants), though controversial due to the potential for abuse and questionable
safety when follow-up is inadequate, must be further investigated. AP is planning to introduce
reproductive heal ih services at the primary health center (PHC) and sub-centre levels.
Need for improving quality of services
A core issue facing TF/RCH programmes is the need to improve skills, knowledge,
aptitude, and motivation levels of providers. If the quality of RCH services are improved, need for
these services will decline (due to decreased morbidity); if quality of FP counseling improves, the
demand for FP will increase. Thus, accountability of government health functionaries and
programmes to clients is central. In AP, training programmes are underway for health providers
which include a module on attitudes and behaviour, and a module on RCH (including counseling,
diagnostic and treatment skills).
Need for building partnerships with the community
Involvement of the community in planning, implementation, monitoring and evaluation is
essential. The 73rd Amendment to the Constitution made this programme a people’s programme.
FP and RCH are linked to deep cultural and social issues, and are dependent upon community
demand, in order to be successful, they must involve people
Need to involve women
There is currently an enormous opportunity to involve women since they comprise a third
of elected members of panchayats. AP has also witnessed strong women’s movements The
government is building on these strengths to highlight the responsibility and authority of women,
and to motivate women to take ownership of health programmes Women’s groups are the focal
point of delivery of RCH, and women’s leadership can be crucial in ensuring the delivery of
quality services. A module for DWCRA groups has been developed to encourage them to be
leaders in this social programme
Involving women’s groups in ensuring the accountability of field health workers such as
auxiliary nurse midwives (ANMs) is currently being tested in two districts in AP over a one year
period. At baseline, neither of the two pilot project areas had strong, functioning women’s
groups, the pilot projects had to develop them In each village, women’s groups will record
ANMs’ visits, and review them in monthly meetings. Based on this, they will decide the ANM s
salary. In an ideal situation, health workers’ salaries would be given by village groups/committees
However, this would depend on the existence of a sound partnership between the government and
local groups.
Women’s groups will also be trained to ensure that local health services meet women’s
needs. They will:
• maintain a register of services provided by ANMs and other health personnel,
•
inform the District Medical Officer of problems.
i
•
visit and observe the activities of Anganwadi workers and dais, and fill checklists once
in six months,
f
function as partners with government village workers such as ANMs and Anganwadi
teachers,
•
administer village referral funds for emergencies, the AP State government has
sanctioned, on a pilot basis, a sum of Rs. 5000 per village to be administered by village
groups.
II
Problems with implementation
The AP pilot projects have just begun. Thus, results are not as yet available However, one
problem has been encountered thus far. It is clear that if women’s groups are motivated, they can
ensure accountability of government health services The key question is how can women s
groups be motivated? NGOs have to facilitate this process. In the Shamirpet pilot project, it was
found that women’s groups could not function on their own, a local NGO has been providing
them training on managing their activities
A key part of the pilot study experience is the documentation of the process and outcome >
of the projects. In order to guide the implementation of the TF/RCH programme in AP as well as
in other parts of the country, process documentation and dissemination are critical
5
Session I
New directions in Family Welfare
Presentation I: Women advocating change: lessons from experience1
Based on presentation by Vimala Ramachandran
Health Watch
Although GOI statements outside the country since the 1950s have been radical, there has
been a significant gap between policy statements and ground level reality The most visible gap
has been in the family welfare sector: despite radical policy statements on the link between
population and development, the FP programme in India has been anti-people There have been
many attempts to bridge the gap between policy and implementation. Efforts to make government
programmes more sensitive to people’s needs have been made by pressure groups such as
women’s organizations. There have been two kinds of experiences:
•
the Development of Women and Children in Rural Areas (DWCRA) & Integrated
Child Development Services (ICDS) experiences in which the programmes were
conceptualized by individuals who were not involved in implementation,
•
the Women’s Development Programme (WDP), Rajasthan & Mahila Samakhya (MS)
experiences in which the same actors were involved in the conceptualization and
implementation of programmes
In the latter case, there has been an emphasis on an organic link between those who develop and
those who implement programmes.
Health Watch’s activities are based on an understanding of the need for an organic link
between the multiple stages of policy planning and implementation In the context of GOFs
TF/RCH programme, there are three potential functions that Health Watch can perform
First, Health Watch may function as a sounding boardfor the government on the
implementation of the TF approach However, GOI will ultimately decide whether to incorporat
or ignore its comments and recommendations There have been primarily two reactions to this
scenario. Some dismiss such efforts as being fruitless, others see this as an opportunity to keep
informed about and to inform the process of implementation Members of Health Watch subscribe
to the latter view point. Health Watch workshops are intended to keep a dialogue open with the
government, to keep pressure on the government to be cognizant of and responsive to women s
needs; to communicate with those in the government, the medical establishment, and donor
agencies who are also concerned with women s health
Second, Health Watch may use the opportunity afforded by the RCH programme which
has been introduced in select districts to promote a woman-centeredfocus in existing health
services. There is a shortage of individuals to help the government design this programme at the
district level which the government is aware of and wanting to address However, as in the past,
participation in the design stage may not be linked to participation in implementation
Third, Health Watch may perform an advocacy role Many politicians, and members of
the media and the general public have not thought deeply about population issues; many advocate
1 Sec also paper in Appendix
6
FP and target-oriented programmes There is considerable propaganda about the “population
explosion” and its implications for development. Therefore, the overall mind-set must be changed
“Women advocating change” implies strategic planing: there is a need for radical protest as well
as dialogue with representatives of the status quo Individual women and women s groups need to
realize their strategic roles in this spectrum of activities Neither ends of the spectrum will be able
to accomplish change on their own
Presentation IT: The “target-free” approach: potential and challenges
Dr. M. Prakashamma
I1HFW
Dr. Prakashamma’s presentation discussed the potentials and challenges of the TF
approach from several perspectives She noted that, while the process of change in FP and health
is a welcome one, it should not result in complacency given the long history of nomenclatural
changes in government programmes without accompanying changes in the field. However, the
current change has opened up a range of potentials and challenges for health personnel, women,
NGOs and the government
petition tmd role of health workers
Dr. Prakashamma highlighted the enormous unused potential of grassroots health workers
in India. She lamented the transformation of the auxiliary nurse-midwife (ANM) from “one among
women” itl the 1950s to an “insipid character who can talk only about cases” in the 1990s The
“case” (a potential candidate for family planning) has come to dominate their thoughts, stories and
dreams I he challenge facing the ANM today is the transformation of this mind-set from a case
centered to a holistic, gender-sensitive, and quality-oriented one She must become an advocate
for women and children The ANM’s strength and potential is that she is a woman of the village,
she can identify with other women.
The IIHFW has been attempting to change ANMs’ mind-sets from a case chaser to a
counselor. However, there has been little time. The TF programme began on April 1, 1996, the
past three months have been characterized by utter confusion for ANMs. Many are unaware of
the changes that have and are happening. In one of AP’s pilot projects, IIHFW staff spoke with
village leaders and health workers about how the process of alienation experienced by ANMs can
be reversed. Many health workers were pessimistic One said
"Our history is in their hands. AH will collapse.
Many felt that the new programme was placing a great deal of responsibility on grassroots health
workers, responsibility that no one else is willing to shoulder Furthermore, attention has primarily
focused on women health workers. The role of male workers is unclear. Will the new programme
further alienate male health workers? Clearly, the role and accountability of all grassroots health
workers need to be considered
The role of women
Past experience indicates that merely renaming programmes as “target-free” and RCH will
not impact women The challenges facing women (and women’s health activists) include:
7
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•
.
recovering women's knowledge about women’s health Many potentially beneficial traditional
practices have been replaced by the biomedical system Women’s health centres need to be
established to document women’s knowledge and practices
understanding women’s health There has been extremely little research on women’s health
other than those aspects related to fertility and contraception.
The role of NGOs
Many NGOs have moved away from mainstream family welfare activities. Given the
current changes in the government’s approach, the potential and challenge facing them is whether
they will be willing to contribute to the process of change.
The role of the government
The challenge facing the government is the realization and acceptance of the problems
facing the current health and family welfare approach as well as the translation of these into
appropriate action The government needs to ensure that all its functionaries understand the
philosophy of the new programme An additional critical issue facing the government is the
development of new quality and performance indicators.
Presentation III: Elements of a woman-sensitive and holistic health care system
Dr S P. Tekur
Community Health Cell, Bangalore
Dr Tekur’s presentation highlighted the elements underlying a “woman-sensitive and
“holistic” health care system. Holism, according to him, does not just comprise of a senes of
components (such as maternal and child health + child survival and safe motherhood + . . .), does
not solely entail looking at an issue from a number of angles, is not just being open, unbiased, and
pragmatic Rather, holism involves having a broad understanding ofpoverty, disadvantage, and
well-being.
Developing a woman-sensitive health care system does not have to be justified on
philosophical, scientific or political grounds Being woman-sensitive is being practical Women
have been neglected. The value systems they represent are eroding, and the health-carer in every
family is being handicapped
Women’s health status is determined by a number of complex, intertwined factors:
biological, social, economic, and cultural. It is known that women have better survival at birth,
and have fewer manifestations of stress-related diseases. However, during their reproductive
years, women suffer from anaemia, protein-energy malnutrition, damages to the reproductive
tract, and depression They are at higher risk per exposure to STDs such as HIV and HPV (which
is a putative cause of cervical cancer. After menopause, women have higher morbidity due to
stress than men of the same age. However, more data are required to truly understand women s
health status There have been few studies which have focused on women other than as mothers.
Women face social, economic and cultural disadvantages which also adversely affect their
health They get lower wages, are forced to do arduous work; have multiple roles and
responsibilities, and face hazardous working conditions within the home and without.
8
Furthermore, many do not have control over decision-making (regarding education, marriage,
children
) Many women are exposed to abuse and discrimination. Health care services are
provided within the same ethos
Functionaries of the government health care system may feel that they cannot tackle such a
broad range of issues, and that tackling these issues is not their responsibility. However, if the
government health system takes a life cycle approach, it has the potential to make a difference.
Issues that need to be addressed include those during:
•
infancy & childhood such as sex selection & discriminatory child care,
•
adolescence such as family life education, prevention of early marriage, child bearing
& discriminatory child care, prevention & treatment of anaemia & malnutrition,
•
reproductive years such as address issues indicated above, focus on pregnancy-related
& gynaecological problems;
•
post-reproductive years such as address all health problems on top priority basis,
particularly, malnutrition, osteoporosis, osteoarthritis, central vascular and central
nervous diseases and gynaecological cancers
Additional issues that the health care system can address are.
•
gender-based violence during all phases of the life cycle,
•
depression,
•
disability,
•
lack of decision-making power,
•
hazards of work at home, in occupational settings, and in the environment.
Women can provide clues as to how these issues may be tackled. They have stressed the
need for education: education of policy-makers, service providers, men and other women. There
is a need for investment in women’s education, specifically health education. Women s access to
health services needs to be improved, and their needs must be addressed. Thus, provider
competence, informed choice, continuity of care, and privacy must be ensured. During the entire
process of building a holistic, woman-centered health care system, women must be consulted
Moreover, all members of the community need to be involved in this process in order to establish
credence to women’s needs
t
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Discussion Notes
Session I
Discussion at the close of the first session entitled, “New directions in family welfare,”
revealed a broad consensus on the importance of the involvement of women’s groups in planning,
implementation, monitoring, and evaluation of the TF/RCH programme, and the need for
information dissemination and process documentation
A participant suggested the use of participatory rural appraisal (PRA) techniques at the
panchayat level to help formulate the programme in partnership with local leaders. Others stressed
that women’s groups should be actively involved
The need for dissemination of information regarding the new programme to bureaucrats,
health workers, and the public was raised by a number of participants. It was suggested that the
development of a mechanism for the transfer of such information should be top priority since not
even all senior government officials appeared* to *be aware of the new TF/RCH programme. A
with government functionaries at
participant from AP noted that official meetings were underway
i
many levels
There was also some discussion of the definition of “quality service or quality approach
in the government’s Manual on the Target Free Approach. Mechanisms that may be employed to
ensure high quality services as outlined in the Manual were critically evaluated. Participants noted
that clarifications were required in two cases. First, the Manual s mechanisms foi improving
quality of equipment and infrastructure was found to be weak as they consist of ascertaining
whether facilities are available rather than their quality. In addition to identifying whether
equipment and infrastructure are available, it is felt that their quality should also be evaluated.
Secondly, the Manual suggests that quality will be improved through the involvement of the
community While participants commended the fact that community involvement has been
explicitly recognized, they felt that the nature of this involvement must be specified in more detail.
In addition, it was felt that women’s groups could play a key role.
Additional points raised during discussion included the importance of advocacy at the level
of donor agencies (in order to ensure the appropriate allocation and disbursement of donor agency
funds, they need to understand the ground reality), and the issue of State culpability (the
greatest changes are called for at the level of grassroots workers and voluntary organizations
while individuals at the top of the governmental hierarchy remain untouched). A number of
questions regarding the nature of the role of women’s groups, NGOs, and the government were
identified for further discussion in working groups (see reports below).
10
Session II
Making government services accountable to women: lessons from the field
Presentation I: Mahila Samakhya, Karnataka
Representatives of field organizations involved with women presented their work, and its
relevance to the implementation of the target-free approach Ms. Gouri from the Mahila
Samakhya (MS) programme in Karnataka was the first speaker MS is active in five districts
(approximately 250 villages) in Karnataka, and focuses on increasing women’s literacy levels. The
programme emphasizes development, health, and political issues. They have nearly 6000 women
members, most of whom belong to the backward castes
In order to encourage women to participate in MS, a number of methods were used.
Street plays were conducted, anganwadi workers were recruited to help launch the total literacy
campaign Needs assessments were conducted among women to identify issues of concern to
them Bv focusing on these issues, women would be encouraged to participate
Village leaders were identified, and given leadership training. These leaders and local
women were made aware of government schemes and facilities For example, the local primary
health centre in one area was charging for its services Women were told that these services
should be free, and consequently they demanded that no fees should be collected. Thus, MS
groups have been able to demand accountability of government health services
Discussion Notes
Discussion of the presentation highlighted the use of role plays and dramas as methods to
encourage participation and to provide information on issues such as the advantages of a small
family and contraceptive choice Ms. Gouri noted that members of MS were actively involved
in the provision of FP services by, for example, helping ANMs and dais counsel women about
contraceptive choice As a result of the MS programme, substantial improvements in the
quality of services delivered by ANMs and PHC doctors have been observed. Noted Ms.
Gouri. “Five vears ago there were no doctors at the PHC, now, at least the doctors are
present ” In addition, there has been an improvement in the quality of communication between
.ANMs and women
Presentation II: Deccan Development Society, Hyderabad
Ms Rukmini Rao, in her introduction to the work of the DDS, noted that women fail to
utilize government health services not because of lack of demand for services, but because of their
poor quality In fact, poor women spend a considerable amount of resources on good quality care.
Ms Rao described the range of activities that NGOs have been involved in to promote health and
to ensure the accountability of government health services. They include:
•
raising awareness regarding prevention and treatment of diseases
•
supplementing government services
•
providing low cost drugs
•
demanding reproductive rights
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highlighting problems with the government health infrastructure in local areas, and agitating
for change along with local women
The DDS is active in 70 villages in Karnataka, its health programme focuses on
reproductive health. DDS works with women’s sanghas (groups) and trained dais They identify
local practices, and assess their effectiveness The most effective methods are promoted DDS'
experiences indicates that, for successful health care delivery, the most crucial components are a
strong grassroots health worker and a well functioning referral system DDS has accomplished
this by, first, establishing links between ANMs, dais, and women’s sanghas ( woman to woman
links), and second, establishing links between communities, primary health centres, and hospitals.
The former ensures first level preventive and curative care, and the latter ensures higher levels of
care
Discussion Notes
Discussion focused on the potential of women’s groups in implementation and evaluation
of government health programmes, and on the need for male accountability. Ms. Rao pointed out
many village-level women’s groups which are supposed to be functioning in fact are not doing so.
DDS has been successful by training and bringing together DWCRA leaders.
Dr Prakashamma also echoed the fact that many village-level women’s groups are not
functional She noted that making these groups functional is a long process; it requires continuous
interaction The AP government’s Shamirpet pilot project has been able to create a functional
sangha This has involved using existing groups and strengthening them (by first focusing on
members’ most immediate interests - be it health or otherwise); this appears to be the most
efficient strategy The Shamirpet women’s groups are now assessing health services by using an
assessment form prepared by the Institute for Health and Family Welfare, these forms are
discussed at monthly group meetings
One participant (Ms Prabeen Singh) raised the issue of male accountability:
Why is it that only women have to help women9 Why is it that the issue of male
accountability (at the policy level or at the level of bureaucrats or NGOs ) is seldom
raised9 Women will not be able to make significant gains without male support, men must
also become responsible for women’s health
Ms Rao responded that DDS has realized the need for men to take responsibility For example,
when women in sanghas discussed various contraceptive options, they concluded that the Nirodh
is the safest DDS makes Nirodhs available to women, and women are demanding it. Thus,
although men are not directly dealt with, they are being reached indirectly through women
members
Prof Gita Sen noted that reproductive health has been part of a larger set of issues
encompassed by “reproductive and sexual rights” which focus on changing gender relations.
Thus, both men and women are involved. This has not been highlighted, largely because of the
struggle to ensure that women’s needs are met. In the case of government health services, we
have been struggling to ensure that they are providing immunizations, diagnosing and treating
reproductive tract infections, and so on Making them address men, and involving men may be a
secondary issue However, we do need to focus on rights and responsibilities more clearly.
12
Presentation HI: Gramya, Hyderabad
Ms Jamuna, as a consultant, has visited over 70 NGOs implementing family welfare
programmes In her presentation, she summarized their experiences, and the results of her
interactions with them
Women .s groups
The Andhra Pradesh Government was interested in forming women’s health groups,
Mahila Swasthya Sanghs (MSS) Rather than forming new groups, NGO experiences indicate that
one can work with existing groups such as the DWCRA groups In fact DWCRA groups could
become MSS
Strategy of implementation
The primary approach that NGOs have taken is intersectoral NGO experiences suggest
that programmes of the Departments of Rural Development, Health, and Education should be
coordinated at the village level
Training
In the initiative that Ms Jamuna was involved in, NGOs did not have a training budget.
Funds for training were provided by women s groups, they took up education activities (for
adolescent girls, for health etc ). A training module has been developed for them which addresses
issues of gender and development The module attempts to give DWCRA leaders several methods
which they can use to inform other women.
District level health educators have also been trained The key is to provide a holistic
picture of issues, and thus to enable women and men to easily incorporate them into their lives.
One training session was held for policy officials and implementers. However, there was some
resistance from these officials who claimed that the training material was “feminist.” Also, while
the ideological basis of programmes may be conveyed, translating them into action plans may be
extremely difficult (or implementers may be resistant) Women’s activism may be critical in these
situations
Lessons from AT
The importance of activism and its impact on policy implementation are manifest in two
examples of people’s mobilization in Andhra The first is the anti-arrack movement in Nellur
which was spearheaded by women The second is the formation of mothers’ school committees in
Adilabad district in which mothers organized to demand that schools function.
The key lesison from the above two experiences is the need to politicize issues which may
not initially be perceived as being political. Without political action, change will not occur.
The other key ingredient for implementing change is the dissemination of information.
Information must be available with village-level government functionaries and with community
members This in turn is linked to the functioning of village institutions such as the primary health
centre, and to the availability of information through mass media Once information is available,
demand for health services will increase.
13
\ >
Presentation IV: Vivekananda Girijana Kalyana Kendra, Karnataka
VGKK s experiences with working with a tribal community in Karnataka were presented
by Dr M Roopa Dr Roopa noted that one of the strongest features of VGKK’s work in this
community was its exploration and use of traditional health practices. The NGO has conducted
extensive research on traditional herbal medicines, and promotes their use. VGKK has now taken
over two PHCs in their coverage area, and has hired staff from the community to run them Thus,
strong collaborations with the community are another key feature of the NGO’s approach.
Drawing upon her experiences as a government physician and as an NGO activist, Dr.
Roopa made the following recommendations for the implementation of the TF approach:
•
family welfare and health need to be implemented in an integrated fashion,
•
health problems such as cervical cancer and tuberculosis should not be neglected in
favour of family planning,
•
referral services, particularly for emergencies, should be ensured,
•
a people-oriented approach needs to dominate, many women, for example, are
unwilling to undergo an internal examination because of lack of infontiatioti regarding
what the process entails - information, informed consent, informed choices need to be
central to health service delivery,
•
gender-sensitive indicators of health need to be used in place of targets for programme
monitoring and evaluation
Discussion Notes
A major topic of discussion was the role of NGOs vis-a-vis the government Questions
that were raised included should NGOs set up parallel structures as in health? what ends do these
parallel structures serve9 should NGOs limit themselves to monitor government activities or
should they take over the government’s responsibilities (such as by running PHCs)? There
appeared to be a number of different opinions. Some felt that NGOs should in fact only act as
people’s advocates (monitoring activities and demanding change) while others felt that NGOs
may be able to demonstrate how services can be provided to suit people’s needs.
Prof Gita Sen suggested that there may be two conditions in which NGO take-over of
government services may be legitimate The first is when an existing well established organization
does so as a way of strengthening its own activities and as a way of taking services to a level that
does not currently exist The second is when NGOs can demonstrate how services can be
provided to a community which hitherto had been underserved (or ignored). In the latter case, the
NG<' acts as a model for translation, and clear steps for translation need to be specified. This
issue has not until now been framed in these terms by the government
Ms Vimala Ramachandran noted that the government sees NGOs primarily as service
providers, not as partners or as pioneers of new approaches NGOs will have to respond to this
view. However, there is a "mixed wicket”: many NGOs are willing to be service providers.
Ms Rukmini Rao argued that NGOs have always been service providers. The difference
now is that NGOs are now a means of "social privatization.” They present an avenue by which the
14
government can abdicate its responsibilities. In this scenario, NGOs have to exercise extreme
caution
Session III
Summary review of the Ministry’s “Manual on Target free Approach”
Dr Gita Sen
IIM, Bangalore
Discussion Notes
A significant part of the discussion on the Manual centered on the AP government’s
experiences in implementing a number of TF/RCH pilot projects, valuable lessons have been learnt
on the formation and training of women’s groups and on the development of management
information systems Additional issues raised during discussion include the need to furthei
develop the conceptualization of reproductive health within the RCH approach, and the need to
put in place specific and direct links with women and communities to determine needs
Experiences from Andhra Pradesh
Dr Prakashamma described the process of forming women’s groups in the AP TF/RC H
pilot projects At first, ANMs and male health workers were asked to form these groups At a
village meeting it became apparent that village members did not approve of the individuals
identified by health worker Thus, a grama darshan (village procession) was held to announce the
formation of a women’s group on health, followed by a grama sabha At this village meeting,
individuals volunteered to be a part of the committee As a result of this process, a group which
was locally acceptable was formed
Ms Chatterjee, Secretary of Health and Family Welfare, reported that the AP government
was working with NGOs to train these women’s groups on issues related to the TF/RC H
approach, a module has been prepared for DWCRA members and ANMs on health issues
However, she stressed, the government system alone cannot conduct training programmes NGOs
will have to play a key role in training, motivating and sustaining women s groups during the
initial period
In response to participants’ call for mechanisms of information dissemination and
feedback, Ms Chatterjee noted that the AP government was developmg an miormauon system to
collect and analyze data from health programmes Data will be analyzed at the district level, am
relevant information will be intimated to the concerned personnel
Echoing participants’ views, Ms Chatterjee stated that the Manual is a draft document
whose performance will have to be tested The Manual should be modified over time depending
on its performance In fact, the AP government has already made some changes to its ^^1
based on regional requirements For example, the AP PHC plan .s slightly different rom the~o
recommended by GO1, it focuses on specifics such as electricity and water supply the H
All levels of the health system have been informed of the new plan, and its experimental sta us
l acunae in the / raining Manual
Participants felt that the RCH approach was based on a weak conceptualization oi
centre, PHC etc ) must be meticulously outlined and addressed
15
It was noted during the discussion that although in the preparation of the PHC. family
welfare and health care plan meetings are to be organized with panchayat members, primary
school teachers, etc., specific provisions for a direct dialogue with community members to assess
perceived needs during planning and implementation is absent in the Manual Participants agreed
that this is a crucial part of the process of planning Likewise, it was felt that the monitoring and
evaluation components should include a mechanism for community feedback
A key ingredient to the success of the new programme will be the level of motivat ion and
skill of the staff of the government health infrastructure Participants stressed the need to ensure
quality of care by developing training materials for PHC staff which includes practical experience,
motivational and attitude change sessions. One participant stated that ‘‘reproductive health and
rights” should not be treated as mere vocabulary, communication of the concepts underlying the
term is essential
a
Session IV
Recommendations of working groups
Four working groups were formed on the second day of the workshop one discussing the
“Manual on the target-free approach”, one discussing the relationship between NGOs and the
governtpept^and tyvo discussing the role of women’s groups in ensuring accountability of
government programmes. The following are some of their conclusions and recommendations
Group I: Feedback on the “Manual on the target-free approach in family welfare
programme”
Focus ofManual
A key component of the Manual is its introduction; it should contain the essence of the mission at
hand First, the group felt that a mission statement or preamble should be included which states
the principles on which the TF approach is built The statement should reflect the role of the
Manual. For example, it may read as follows
Keeping in mind the change in approach, and keeping doors open for discussion and
further change, this manual may be treated as guidelines which may need to be utilized and
modified based on local conditions
Second the group felt that the Manual should be revised to highlight the centrality of women’s
health rights; thus, the focus should be shifted from one of achieving demographic goals to one of
bettering the lives of women and men
Implementation ofManual
Several steps need to be taken to implement the Manual They include
•
awareness creation among government officials and the community about the nature
and use of the Manual;
•
widespread dissemination of the Manual;
•
community-level workshops on the use of the Manual (and also to collect feedback),
•
translation of the Manual into local languages,
•
preparation of local models of components of implementation system (filled forms,
clear instructions for activities involved, guidelines for the formation of community
groups),
•
concretization of community participation, and training of women's groups.
•
outline of method for selection of community members who will be assessing health
workers’ activities and performance.
•
outline of methods used to assess PHC activities (such as participatory rural appraisal),
•
development of a feedback system on the Manual.
•
formation of technical groups to formulate detailed formats for quality assessment
/7
In addition, it was felt that the manual should be made more user friendly
Group II: The relationship between NGOs and the government
The aim of Group II was to critically examine the relationship between NGOs and the
government, and their respective roles and responsibilities in the implementation of the TF
programme Group II began by exploring the history of NGOs The group brought attention to
the fact that the focus of voluntarism has shifted from charity to welfare to development, that
historically NGOs acted as catalysts for change and worked for change as partners of the people.
In more recent times, a split has occurred between NGOs and voluntary organizations in part due
to the influx of funds to NGOs from the government and other external sources; the latter are
thought to be more representative of the spirit of earlier times
The group went on to discuss whether voluntary organizations can be partners of the
government It was felt that being partners with the government was made difficult by the rigidity
and in-built inequalities that characterize the government bureaucracy. Furthermore there is now
the danger that the government will use voluntary organizations as a means of privatizing their
responsibilities
What is the role of voluntary organizations9 The group identified the following:
•
as a catalyst for social change one which brings the voice of the people to the government.,
•
as a partner of the people in the planning, implementation, monitoring, and evaluation of
people-supported programmes,
•
as a liaison between the people and the government to foster mutual understanding.
Finally, voluntary organizations are accountable to the people
Groups III & IV: The role of women’s groups in the TF approach
These groups discussed the role of women’s groups in the TF approach. The
overwhelming consensus of participants at the workshop was that, in order for women s needs to
be recognized and met adequately, women’s groups will have to play a key role in the target-free
programme
In this context, four key questions were identified
1
How will women’s groups be formed, and who will be responsible for their formation?
\. hat are the pre-requisites for a well-functioning women’s group?
3
What are the rights and responsibilities of these women s groups9
4
What sorts of linkages between women’s groups , health workers and officials will have to be
developed9
First, given that women’s groups are integral to government health and family welfare
policy formulation and implementation, a key question that policy makers will have to address is
how these groups will be formed, and who will be responsible for their formation. It was
19
suggested that the group may be one which already exists in the community such as a DWCRA or
MS group; Ms. Vimala Ramachandran suggested that an alternative was to form a village
women’s forum which came together specifically to address the TF/RCH programme This would
not be a group as such, but an issue-based forum consisting of interested individuals This issue
based forum or group would be intimately involved in local-level planning, implementation, and
monitoring of the programme
Second, pre-requisites for a well-fiinctioning women's group will have to be carefully
identified The group suggested that the following two issues would be important
•
conceptual understanding of issues which may be fostered through training sessions.
•
availability of resources including a place to meet and funds for emergencies
A third issue is the rights and responsibilities of this group/forum What resources will
they have at their disposal9 How will they be involved in planning, implementation, monitoring,
and evaluation9 It is imperative that the government delineates their rights and responsibilities in
detail, and in consultation with women themselves
Fourth, the linkages between women’s groups, health workers and officials in the health
care delivery system need to be established Will women’s groups have some control over the
salaries of health functionaries9 Will village groups have recourse to higher officials such as the
District Collector in the face of an unresponsive health worker9 Lastly, what is the locus standi oi
the group? Participants felt that these issues must be resolved as soon as possible
Conclusion
A number of vitally important issues related to the planning, implementation, and
monitoring of the Target-free family welfare programme were raised during the two-day APKarnataka regional workshop First, participants overwhelming agreed that women’s groups must
play a key role in the formulation and implementation process if the programme is indeed "client
centered” Questions that will have to be answered collectively, by the government and NGOs.
include how women’s groups will be formed and by whom, how the effective functioning of
women’s groups can be promoted and maintained, what the groups’ rights and responsibilities
are, and how the groups will be linked to health workers and government officials Experiences
of the AP government from its TF pilot projects and from NGOs such as the DDS offer answers
to a number of these questions, and should be examined carefully Second, participants also
stressed the need to develop an effective communication system to ensure the dissemination of
information to individuals at all levels of the government system as well as to the public, in
addition, feedback loops need to established so that information does not travel unidirectionally
Third, it was felt that pilot projects need to be conducted over a defined time period (such as one
year) in different areas in order to test the performance of the implementation manual under
different conditions It is critical that these pilots are extensively documented, and that the process
documentation is widely distributed Fourth, there was an overall consensus that the Manual be
treated as a draft document, one which can evolve and be modified over time
3A
S3 VOICES
POPULATION ISSUES AND WOMEN'S HEALTH I A NEW APPROACH
June 28 - 29, 1996 at Hyderabad
PROGRAMME
June 28
9:00
10:00
WeIcome
Inaugural ion
Secretary
Health and Family Welfare,
Andhra Pradesh
Mode rators:
Ms. Sucharita S Eashwar
VOICES, Bangalore
Dr. M Prakashamma
Indian Institute of Health and Family
Welfare,
Hyderabad
10:00
10:30 Coffee break
10:30
1-00
New directions in family welfare
Moderator: Dr Gita Sen
I IM Bang a lore
The "target-free" approach:
potential and challenges
Dr M Prakashamma
Women advocating change:
lessons from experience
Ms Vimala Ramachandran
NFI, New Delhi
Elements of a woman-sensitive and
holistic healthcare system
Discussion
1 :00
2:00
LUNCH
Dr S P Tekur
Community Health Cell
Bangalore
sa voices
June 28
2:00 - 5:30
Making government health services
accountable to women s
Lessons from the field
Moderators: Dr. Dara Amar
St . John's Medical College
Bang a lore
Dr . M Prakashamma
Ms. Gouri R
Mahila Samakhya, Karnataka
Ms. Rukmini Rao
Deccan Development Society
Hyde rab ad
Dr. M Roop a
Vivekananda Girijana
Kalyana Kendra, Karnataka
Ms. Jamuna
Gramya, Hyderabad
Discussion
June 29
Summary review of the Ministry's
‘•Manual on Target Free Approach”
9:00
10:00
10:00
10:30 Formation of working groups on
methods and mechanisms to make the
government programme more accountable
to women
Moderator: Dr. Shobha Raghuram
HIVOS, Bangalore
10:30
1 :00
1 :00
02:00
2:00 - 5:00
Working groups
LUNCH
Presentation and review of working
group recommendations
Conelus ion
/or librarY
£o (
and
I J oocu^NTAnoN )
UN'1
>-*
Dr. Gita Sen
Workshop on Population Issues and Women’s Health : A New Approach
I1HFW, Hyderabad
List of participants
Name
■ '?
7
Telephone No.
Fax No.
Dr. Gita Sen
Indian institute of Management
Bannerghatta Road
Bangalore 560 076
080-6632450
6644050
Ms. Sandhya Rao
Parivar Seva Sanstha
2 and 2/1, AMM Towers
DN No.53, Hosur Road
Bangalore 560 027
080-2214270
080-2214270
Ms Gangamma
Mahila Samakhya Karnataka
3308, 13th Main, Sth Cross
HAL II Stage
Bangalore 560 008
080-5277471
5262988
Ms. Subhadra Venkatappa
Family Planning Association of India
375, 1st Cross, 9th Main
Judges Colony, R T Nagar
Bangalore 560032
080-3434818
3338755
Ms. Neerajakshi
Voluntary Health Association of India
Rajani Nilaya, 60 R K Mutt Road
3rd Cross, Ulsoor, Bangalore 560 008
080-5546606
■)
Name
Telephone No
Fax No
DR M Antony David
Head-Dept, of Community Health
Catholic Health Association of India
P B 2126, Gunrock Enclave
Secunderabad 500003, A.P
040-848293
848457
811982
S P Doss
Head-Dept, of Community Health
Catholic Health Association of India
P B 2126, Gunrock Enclave
Secunderabad 500003, A.P
040-848293
848457
811982
*
Dr. Nandini Gandhi
President,
Family planning Association
Hyderabad.
Mr. B. Nageswaia Rao
'Sravanti Association
32-1-50 KVRSwamy Road
Rajahmundry 533101, A.P.
Mr. M. Subba Rao
Director
MASSES
Velayanandapuram
Gudur 524101, A.P.
0883-61139
51206
08624-51285
Mr. C H Sundera Rao
President
Nidubrolu 522124
Ponnur Mandal
Guntur Dist., A.P.
lI
.{B'Ji 'I/irl
Name
Telephone No
Fax No
Ms. Sucharita S Eashwar
Executive Director
VOICES
P B 4610, 59 Millers Road, Benson Town
Bangalore 560 046
080-5546564
563017
569261
Ms. Sangeeta Cavale
Programme Executive
VOICES
P B 4610, 59 Miller Road, Benson Town
Bangalore 560 046
080-5546564
569261
Mr. Azmathullah
Manager
VOICES
P B 4610, 59 Miller Road, Benson Town
Bangalore 560 046
080-5546564
563017
Ms. Suneeta Krishnan
SFA Alpine Court
2-B Cross, 7th Main
Koramangala 1 st Block
Bangalore 560034
5538205
Ms. Gouri R
Mahila Samakhya Dist Implementation Unit
Sangamesh Building, Viveknagar
Near Ibrahimpur
Basavana Bagewadi Road
Bijapur 586 101
08352-22086
Dr. Dara Amar
Professor and Head Dept, ofCommunity Health
St. John’s Medical College
Bangalore 560034
5530724, Ext 413,
Ms. Mani Makalai
Institute of Social Studies Trust
‘Sreeshyla’, No.42, 4th Temple Street
15th Cross, Malleswaram
Bangalore 560003
3340315
563017
569261
5531786
Name
Telephone No
Fax No
Mrs Rachel Chatterjee
Secretary Health and Family Welfare
.Andhra Pradesh
Dr. V . Rukmini Rao
Secretary, Deccan Development Society
A-6, Meera Apartments
Bashirbagh
Hyderabad 560 029
040-231260
Dr. K. Rajashekhar
HERSELF Society
Shyam Nagar
Nandyal
Kurnool, A.P.
08514-44056
Mr. D Srinivasu
Regional Coordinator
AWARE
5-9-24/78 Lake Hill Road
Hyderabad 500463
040-236311
Mrs. Sumabala,
ASMITHA
House No.45, Road No.2
West Maredpally, Secunderabad. 500 026 A.P.
803745
G. Vijaya Lakshmi
ASMITHA
House No.45, Road No.2
West Maredpally, Secunderabad. 500 026 A.P
803745
232867
231260
Name
Telephone No
Mrs Prabheen Singh
A 10/3, Vasant Vihar
New Delhi 110054
6874320
Mr. Vinod
Community health Worker
Janadaya, Konapurpet, Mauvi
Raichur, 584123, Karnataka
53534
Mr. 4^vaji
Sangamitra Service Society
Vijayawada 520007, A. P
554002
554374
Mr. N. S. Chandrasekhar
Creator's Charitable Organization
78-8-4 Gandhipuram - 3
Rajarryindry 533 103, A.P.
76710
Mrs J. Kausalya
Villages on Partnership
Teacher's Colony
H-No 8-5-20B/1
Mahboobnagar, A.P
42058
Mrs N. Shanti
Mahila abhyudaya Seva Samstha
F-l, Shirdi Appartments, Rajabhavan road
Somajiguda, Hyderabad
3325630
Fax No
Name
Teiphone No
Fax No
Dr. J. C. Mahanty )
IIHFW, Vengalraonagar
Hyedrabad.
3810416
3812816
.
Dr. M. Prakasamma
IIHFW, Vengalraonagar
Hyderabad.
Dr. V. Umadevi
IIHFW, Vengalrao nagar
Mr. T. Dass
Women's Development Society
43972
6-88-34/1
Boregaon, Nizamabad, A.P
Dr. S Balavenkataiah
Kurnool Dist Rural Devlopment Society
13, Raghunath Complex
Kallur, Kurnool, A.P
26882
Mr. K. Sivakumar
MASS,Paddapalli
Karimnagar, A.P.
08452-64353
Mrs P. Jamuna
Gramya
1-16-79/3 Sainagar Colony
Alwal, Secunderabad
862007
.1
Name
Telephone No
Mr. Gurudatt Prasad
ACTION
Krishna Sadam
Dr. Med Ranga Prasada Rao Gardens
Hukimpet
Rajmundry 533103
0883-61442
Fax No
Dr. V. Janardhan Rao
Health Director
WDT Hospital
Kalyandurg 515761
Anathpur
Ms. Mrudala
State Programmer
Andhra Pradesh Mahila Samitha Society
Plot No. 8, Aparajitha Housing Colony
Vidyadaya School Lane
Ameerpet
Hyderabad 500016, A.P.
Mrs. Sarah Kamala
Andhra Pradesh Academy of Rural Devolopment
Govt of A.P.
Rajendra Nagar, Hyderabad 500 030
245337
245959
Mrs. Sushila Ramidamy
Academy for Nursing Studies ,
Nagarjuna Nagar
Ameerpet,Hyderabad
c M /)
241228
Mrs Vimala Ramachandran
XC-1 Sah Vikas,68 I P. Extn
Delhi 110092
■
.
2432770
2432949
257005
Fax No
Name
i Telephone No. ---
Dr S P Tekur
Community Health Cell
367, 1st Main, 1st Block
J K Sandra
Bangalore 560 034
;O8O-5531518
Dr. Pankaj Mehta
52, NGEF Layout, 1st Main Road
Sanjaynagar
Bangalore 560 094
! 080-3364615
3365948
Ms. K R Sreevidya
Institute of Social Studies Trust
Sreeshlya” No.42, 4th Temple Street
15th Cross, Malleswaram
Bangalore 560 003
080-3340315
080-3311764
Dr. Shobha Raghuram
HIVOS
India Regional Office
Flat No.402, Eden Park
20 Vittal Mallya Road
Bangalore 560 001
080-2210514
2270367
080-2270367
Ms. C S Veeramatha
Institute for Social and Economic Change
Population Research Centre
Nagarbhavi Post
Bangalore 560 072
080-3355519
Dr Vijaylakshmi Hebbare
Indian Society of Health Administrator
104 (15/37), Cambridge Road Cross
Ulsoor, Bangalore 560 008
080-5574297
080-3334896
2 96
Telephone No
Name
Dr. R Radha
Research Officer
State Family Welfare Bureau
Directorate of Health and Family
Welfare Services
Ananda Rao Circle
Bangalore 560 009
080-2870224
2870205
Dr. M Roopa
’ Consultant
Vivekananda Girijana Kalyana Kendra
BR Hills 571 441
Yelandur Taluk
Mysore Dist., Karnataka.
08224-8425
Ms. Dhanalakshmi
MYRADA
Post Box No. 5
Challakere 577 522
Chitradurga Dist.
08195-2243
Sr. Maria Rose
‘Janodaya’
Good Shepherd Sisters
Manvi - 584 123
Raichur Dist., Karnataka.
08538-53534
Ms. Poornima
Health Coordinator
Stuuraksfefc
c< c c c
'
Jalahalli, Deodurg Taluk
Raichur 584 116, Karnataka
55223
56063
Ms. Emelda Rani
Family Planning Project Director
Hope Foundation BangaloreP B 3828
080-5588819
Fax No
080-2870224
5288819
- Media
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