VHAI -WAH WORKSHOP ON TOWARDS COMPREHENSIVE WOMEN'S HEALTH POLICIES AND PROGRAMMES AT BANGALORE 6TH TO 9TH OCT.

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Title: VHAI -WAH WORKSHOP ON TOWARDS COMPREHENSIVE WOMEN'S HEALTH POLICIES AND PROGRAMMES AT BANGALORE 6TH TO 9TH OCT.
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PRESIDENTIAL ADDRESS

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OF

Sliri Dalit Ezhilnialai

Union Minister of State for Health and Family Welfare
Government of India

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At the
Western Regional
Health Minister's Conference
22-23, September, 1998

ahmedabad

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PRESIDENTIAL ADDRESS OF SHRI DALIT EZHILMALAI,
HON'BLE UNION MINISTER OF STATE FOR
HEALTH & FAMILY WELFARE
AT THE WESTERN REGIONAL
HEALTH MINISTERS' CONFERENCE
AT
AHEMDABAD ON SEPTEMBER 22-23, 1998

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Hon'ble Health Ministers, Union Secretaries of Health,
Family Welfare and Indian Systems of Medicine and
Homeopathy, State Health Secretaries, Officers and friends.

It gives me great pleasure to be amongst you at the
Western Regional Health Ministers' Conference being held here
to deliberate on issues relating to health care in this region.
We have already held three such regional conferences for the
southern, north eastern and northen regions. I am glad to state
that we had meaningful discussions at these Conferences on
! vital issues concerning health, family welfare and 1SM&H
j sectors which have helped us to arrive at a consensus on
i matters relating to the implementation of various national
programmes.
Western Region has two industrially advanced States of
Maharashtra and Gujarat and at the same time there are States
like Madhya Pradesh and Rajasthan with a pre-ponderence of
rural areas. Gujarat and Goa have reduced their annual
exponential growth rate of population. Gujarat, Maharashtra,
Goa and Daman & Diu have female literacy rate higher than the
national average. The Crude Death Rate (CDR) is highest in
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Madhya Pradesh followed by Dadra & Nagar Haveli, Rajasthan
and Daman <Sc Diu. In this Region Goa has achieved the lowest
CDR. Again in the case of Infant Mortality Rate, while Goa's
performance is excellent, Madhya Pradesh has the highest IMR
as compared to the national average. All the States and UTs of
the Region have an adverse sex ratio.

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As you are aware, tire Government of India had adopted
the National Health Policy in 1983 which sought to provide
universal, comprehensive^ public health services focusing on
nutrition, supply of quality food and drugs, occupational health
services, potable water supply and sanitation. While we were
able to make progress in some of these sectors, due to various
reasons we were not able to achieve the NHP targets fully and
a lot more remains to be done. Wide disparities across states,
between rural and urban, developed and backward areas
continue to persist. Unless we substantially reduce these
disparities, we will not be able to build up the health of the
country in the ensuing millennium. Therefore the major
challenge before us today, as policy makers, is to reduce these
disparities, improve access and ensure greater equity amongst
and within States. This will not be possible unless we formulate
policies and implement programmes that specifically address
the problems being faced by the people particularly those living
in remote and far flung areas where transport and
communication bottlenecks exist making the delivery of health
services more difficult.
Over the last 15 years since the National Health
Policy was adopted, there have been fresh developments
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in the health sector, global as well as national, giving rise
to new priorities and concerns necessitating attention. A
note on the agenda has already been circulated for initiating
discussions on those vital issues which would help us to
formulate a revised National Health Policy. I am sure that
the deliberations in this conference would bring forth

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innovative and positive ideas based on the ground realities and
inter-State priorities.
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Population containment is a major thrust area in our
programmes. The National Health Policy has set the goal of
achieving a birth rate of 21 per thousand, death rate of 9 per
thousand and infant mortality rate of less than 60 per thousand
live births by the year 2000 A.D. The performance in these three
crucial variables shows a mixed picture in tills region. The
birth rate ranges from 14.4 in Goa to 32.40 in Rajasthan. The
infant mortality rate ranges from 15 in Goa to 97 in Madhya
Pradesh. The States like Gujarat with a birth rate of 25.7,
Maharashtra with 23.4 and Daman & Diu with 21.6 are very
close to achieving the goal which we have set before us.
However, Madhya Pradesh and Rajasthan have to go a long
way m reaching the set level. I would urge the Health Ministers
o these States to vigorously pursue the population control
programme so that the people of these States could be benefited
rom the various developmental programmes.
Another programme which is important is the Universal
Immunisation Programme which we have been implementing
for more than a decade. I am happy to note that in the area of
immunisation, the States in this Region have implemented the
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Pulse-Polio Programme very efficiently. However, the coverage
is still less than 100% of the target group. In terms of absolute
numbers about 80 lakh children have been left uncovered. I urge
the State Health Ministers of this Region to identify pockets and
communities of low coverage in their States and intensify efforts
to achieve 100% coverage. We are also concerned about the
reported decline in the coverage of routine immunisations in the
States of this Region. There has been a decline in some States of
this Region in the coverage of DPT, OPV and Measles
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Immunization in recent years. I would like to request the Stale
Health Ministers and Secretaries to take note of this decline and
take remedial action.
Hon'ble Health Ministers are aware that the focus of the
Family Welfare Programme has now shifted from quantity to
quality of services. It is our firm belief that improvement in

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quality will lead to greater acceptance of Family Planning. The
Reproductive and Child Health Programme launched recently
has an ambitious agenda. The success of the RCH would
greatly depend on local planning of service requirements. We
expect the States to come up with specific schemes as per
guidelines. Preparation of such specific schemes would require

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serious involvement of service delivery personnel. They would
also require consultation with community leaders. Effective
implementation of the RCH schemes would not only improve
the availability of services, but increase access to facilities like
essential and emergency obstetric care, screening of RTI/STD
etc. Particular stress also needs to be given for evolving efficient
logisbc system for storing and reaching various medicines and
contraceptives supplied by the Government of India.
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You are aware about the efforts being made by the
Department of Health to improve the efficacy and coverage of
various National Health Programmes for combating
communicable and non-communicable diseases. Tuberculosis
is a major problem in Western States and about 9.03 lakh cases
of T.B. are detected and put on treatment every year under the
National Tuberculosis Control Programme. The threat of H1VT.B. co-infection and the emergence of drug resistance had
added a sense of urgency necessitating vigorous implementation
of the T.B. Programmes. The funding pattern of T.B. drugs to the
States has now been changed from 50:50 to 100% Central
funding. To achieve a cure rate of 85%, the revised National
Tuberculosis Control Programme with World Bank Assistance is
being implemented in 102 districts in a phased manner. These
include 19 districts in Gujarat, 4 in Rajasthan and 5 Districts in
Madhya Pradesh. Since the States are now not required Jo spend
for purchase of anti-TB drugs, I urge upon the State Health
Ministers of this Region to establish TB centres in all Districts of
their States and also strengthen infrastructure so tliat the benefits
of the programme would be available to the whole population
of the Region.
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Incidence of Leprosy has already come down from 57 per
ten thousand in 1981 to 5.3 in 1998. In the Western Region about
45041 confirmed cases have been identified. Out of these, over
46% of the cases are in Maharashtra followed by over 45% in
Madhya Pradesh. In this Region, the Modified Leprosy
Eradication Campaign is being implemented in all the States
except in Rajasthan. Funds have been sanctioned to Rajasthan
for implementation of the programme in the State. Most of the
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States in the Western Region are not submitting to the Ministry
the necessary utilisation certificates and other audited statements
of expenditure. Unless these certificates are received, we may
not be in a position to release the grants in time. I would
therefore request the State Governments to furnish these
certificates to the Centre in time. I would also suggest that the
programme should be reviewed at the Secretary level once in
three months and at the District level each month.

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There were major outbreaks of malaria in Gujarat and
Goa recently. The malaria situation in Goa is heading from
epidemic to hyperendemic levels. This should serve as a
warning to other States as

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uncontrolled

urbanisation/

developmental projects with large population movements is
likely to create malariogenic conditions which may take
epidemic proportions. Such problems can be solved by having
in-built anti-malaria components within the developmental
projects and enforcing appropriate bye-laws. Of late outbreaks
of Dengue/DHF have been reported in several parts of the
country. Like Delhi, the states of Maharashtra and Rajasthan also
recorded cases and deaths due to dengue. The State Health
Authorities are, therefore, requested to prepare a contingency
plan to face any outbreak situations of Dengue/DHF. In view
of

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the

similarity

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ecological,

meteorological

and

epidemiological conditions pertaining to the transmission and
also due to the frequent inter-State population movements, there
is a need for frequent exchange of information on malaria and
other vector borne diseases in border areas of the concerned
States and exchange visits of State Programme Officers which
will help in coordinating the anti- vector borne disease activities.
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It is also important to carry out spray operations along the inter
state borders in the concerned States. Gujarat, Madhya Pradesh,
Maharashtra and Rajashtan are included under the Enhanced
Malaria Control Project with World Bank assistance. Under
this Project hard core tribal dominated districts and towns have
been targetted and 58 districts and 9 towns fall in tills region.
Additional inputs will be given to these project areas for
intensification of anti-malaria activities. The concerned States
should formulate or revise their District Implementation Plan in
time so as to facilitate effective implementation of the project.
The review of the epidemiological situation of the
disease in the Western States reveals that there is an increasing
trend of HIV infection in all the States and UTs but in
Maharashtra and Gujarat a sharp increase has been observed
The recently conducted National Sentinel Surveillance report
indicates that HIV prevalence among STD clinic attenders is as
high as 26.8% in Maharashtra, 15.7% in Goa and 12.3% in
Gujarat. It reflects not only the rising trend of infection in high
risks groups but also percolation of infection into low risk
groups like mothers attending ante-natal clinics. The rates are
highest in Maharashtra (2.4%) followed by Goa (0.68%) and
Gujarat (0.52%),..Thus .there is. a.need for. expeditious and
concerted efforts to slow down the transmission of HIV infection
in high risk groups as well as in general population. Some of
e ey areas which require special attention relate to expansion
o coverage of activities, directing programme resources to those
who are most vulnerable to HIV infection, inter-sectoral
collaboration, enlisting the participation of NGOs, the private
sectors, the community and individuals, social mobilisation in
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the .field,, of, blood donation, training of all categories of
health workers,..treatment of HIV related illnesses without
stigma<!ands,discrimination, registration of State AIDS
Societies.for^expeditious flow of funds to the States and
District-Units; and above all creating an enabling environment
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facets of-the programme which are being given a thrust.
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these strategies. :

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Prevalence of cataract blindness is relatively lower in the
States of Maharashtra and Gujarat than the national average. It
is a matter .of concern in case of Rajasthan which has much
r higher rate of prevalence of 2.24% against the national average
'of 1.49%. Madhya I^radesh and Goa also have higher prevalence
rates. In this region nearly 4.12 million people are estimated to
be blind and nearly 4.6 lakh people need cataract operations.
’ -l-'i' I ” ^Maharashtra, Rajasthan and Madhya Pradesh have been
included in the World Bank Assisted Cataract Blindness Control
^Project as these States have prevalence rates higher than the
>-.; : 5 National average. There is a need to enhance eye surgeries in
fixed facilities rather than through surgical eye camps as fixed
j facilities provide better quality of services and help establish
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•'institutional system for eye care for ensuring sustainability.
.
District level action plans need to be drawn up so that the State
Governments, NGOs and private sectors co- ordinate and co
operate at all levels and help enhance coverage and provide
comprehensive eye care to the affected people. Further, the
programmes need to be systematically monitored to ensure
quality control.

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The National Iodine Deficiency Disorder Control
Programme is another important programme initiated by
the Central Government with a view to bring down the
prevalence of IDD below 10% in endemic districts of the

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country by 2000 A.D. and to prevent iodine deficiency
disorders. IDD monitoring laboratories should be set up
by the State Governments of Goa, Madhya Pradesh, Rajasthan
and UT of Dadra & Nagar Haveli. Monthly progress reports
on IDD Programme activities including salt analysis results
should be submitted to the Centre regularly by the State
Governments of Goa, Madhya Pradesh, Rajasthan and UT of
Daman & Dm. I would like to appeal to all the States in the
region to promote the use of iodated salt to create awareness
about the importance of consumption of iodated salt particularly
in remote rural areas and urban slums.
In the held of Medical Education it is seen that
mere increase in the number of medical colleges has not
helped in achieving the desired goals. Efforts made by
the State Governments all over the country in making rural

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services compulsory for Government doctors have yielded
mixed results. We need to ensure continuous availability
of graduate doctors and specialists in rural areas for
which an appropriate mechanism needs to be built in the
scheme of Medical Education. It is Imperative that we ensure
that the doctors who have received subsidised medical
education are made to serve for a few years in the rural and
remote areas where large segments of our rural people reside.
Intensified efforts are called for to have an adequate number of
doctors and paramedics so that necessary health care and
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referral services could be provided to the people in close
proximity.

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India is one of the few countries fortunate to have its
own indigenous systems of medicine, established thousands
of years ago. Today we have about 6.00 lakh practitioners of
Indian Systems of Medicines & Homeopathy with a fairly
good network of dispensaries, hospitals, teaching institutions
and drug manufacturers. While there are enough
educational institutions, they are lacking in basic
infrastructure and manpower facilities. Their standards are
grossly below acceptable level. These institutions have
remained underprovided. The Central Government has a
scheme to provide grant-in-aid for the development of
under-graduate and post-graduate colleges. The State
Governments need to provide bigger contribution in
provi ing funds to these colleges so as to bring them to
tie minimum level laid down by the Central Council of
ndian Medicine. The State Governments may take initiatives
to set up model regional institutions in these systems which
will -act as centres of excellence in teaching and research.

of substandard drugs. There ic
IS an urgent need for large scale
cultivation of medicinal plants
and herbs and to standardise
agro-techniques for ;growing these plants. The State
Governments need to take an initiative i
. - in establishing large
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'Vanaspati Van' in denuded forest areas for cultivation of
medicinal plants. There is also need for in situ conservation of
medicinal plants by setting apart large forest areas where
extraction of medicinal plants are not permitted.

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I am constrained to state that the primary health care
infrastructure continues to be a weak link in the health
care delivery system of the Western Region. The major
problems in this regard are the large vacancies in the posts of
Male Health Workers, Lab-technicians and non-availability
of doctors in the PHCs and the short fall in the number of
sub-centres, PHCs and CHCs as per the population norms.
Rajasthan tops in respect of vacancy of MHW which is
currently estimated to be 5865 followed by Gujarat with 3019.
The situation in Madhya Pradesh and Maharashtra is also not
satisfactory. There are big short falls of laboratory technicians
and nurses/mid-wives in the case of Gujarat, Madhya Pradesh,
Maharashtra and Rajasthan. As regards the short fall in the
health infrastructure, Maharashtra is still short of 808 Sub
Centres, 61 PHCs and 135 CHCs. In the case of Madhya
Pradesh, the short fall in respect of Sub-Centre is estimated to
be 184, PHCs 206 and CHCs 307. In view of the problems of
infrastructual gaps the Government of India has converted the
earlier Minimum Needs Programme into the Basic Minimum
Needs Programme under which additional Central assistance
would be available for implementation of several basic
minimum services including Primary Health Care. I appeal to
all the States in this region to utilise this opportunity to invest
additional resources for bridging the infrastructural gaps in
the primary health care network.
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Objectives
The basic objectives of “HealthWatch” are:

i To translate the ICPD Programme of
Action for the national context by defining
priorities for public policies and action, and
the mechanisms for their implementation;

L i To engage in a process of constructive
but critical dialogue with the government at
multiple levels; and to lobby for a shift in
the government’s Family Welfare
Programmes from provider-driven to
people-based programmes;

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To explore mechanisms to link repro
ductive health services to strengthen
public and primary health care, and related
aspects of development, especially educa
tion and women’s economic, political and
social empowerment; in particular to advo
cate restructuring government programmes
based on the vibrant NGO experiences in
this area;
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To provide a forum for effective
networking among like-minded NGO’s to
make progress on the above objectives;

To provide a forum for continuous
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exchange of information and sharing of
ideas and experiences among NGOs them
selves.

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For further information or any comments
and suggestions, please write to:

HealthWatch
C/o Gujarat Institute of
Development Research
Near Gota Char Rasta
Gota 382 481, Ahmedabad (India)
Phone : 079-474809-10
Fax : 079-474811

HE

a Net

HealthWatch,
a Network for Action and Research
on Women’s Health

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background
Our Constitution guarantees each citizen
the right to life which includes effective
provision for work, food security; protecting
access of poor people to resources such as
land, forests, and water; safe, green, pollu
tion-free environment; safe drinking water
and adequate sanitation; adequate shelter
and the right to health. The state must
allocate adequate resources and design
supportive policies to provide these basic
needs to all people.

At a meeting of NGO s, held in Ahmedabad
on December 1-2, 1994, it was decided to
form a network to explore the feasible
approaches to move forward from the
Programme of Action adopted
at the International
Conference on Population and
Development (ICPD) in Cairo
in September 1994. We
visualized “HealthWatch” as
a vehicle to increase the
attention paid to women’s
health needs and concerns .
in public debate and
| 'A
In
fact,
a |
national policy.
series of meetings and
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workshops which had
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begun during the
L Hr
? preparations for ICPD
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focussed on defining and
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clarifying women’s health
issues, particularly
reproductive health and
rights, had prepared the
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basis on which like-minded
NGOs can work together,
and begin a process of
constructive dialogue with
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the government on policy
and programme directions.

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The Constitution also
guarantees non-discrimi
nation on the grounds of
sex; yet biases against
women are rampant in
every aspect and
stratum of society. It
is therefore the
responsibility of the
state, as articulated
in the Directive
Principles, to
undertake strong
measures to remove
all forms of discrimi
nation against women,
and protect their
human rights.

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In our country,
women’s ill-health is
mainly caused by
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poverty, clas
gender discr
be the basis

However, wo
ceived adeq
resources or
programmes
to be change

The internat
debates that
the context o
provide a us
take-off poin
such a trans
The ICPD’s
Programme
Action which
agreed to in
by India, alo
the large ma
other countr
central impo
women’s rep
health and r
women’s em
and to the im
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policy enviro
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This is the b
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formed.

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The Status of Rural Women in Karnataka Study
A Summary Report of the Preliminary Findings
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September 1997

Women’s Policy Research and Advocacy Unit
National Institute of Advanced Studies
Indian Institute of Science Campus
Bangalore - 560 012

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The National institute of Advanced Studies
The National Institute of Advanced Studies (NIAS) was the brain child of the late Mr
J.RD Tata. It was established in 1988 with Dr. Raja Ramanna (former head of the
Atomic Energy Department and the Bhabha Atomic Research Centre) as the Founder
Director Dr Roddam Narasimha is the current director of NIAS.
The philosophy behind the establishment of the Institute was that in an age of scientific
renaissance, with the explosion of information in all fields of knowledge, there is a need to
integrate this information and examine the challenges posed to the nation by the historical,
social, cultural, political and economic context in which these changes are occurring.
There is a need for multi-disciplinary approaches to the critical issues confronting the
country, to inform both policy and action.

The Women’s Policy Research and Advocacy Unit
As an institution committed to examining some of the critical development issues of the
country, NIAS realised the need to include gender issues as one of its major areas of
inquiry. Thus, the Women’s Policy Research and Advocacy (WOPRA) Unit was set up by
NIAS in August 1994, with an initial grant from the 1 ord Foundation. The first major
project that WOPRA has undertaken, is the Status of Rural Women in Karnataka (SWRK)
project. Prof. M. N. Srinivas and Prof. Ravi L. Kapur, senior professors of NIAS are
consultants to the project. Maj Gen Paul (Retd), the Controller of NIAS, provides
administrative support to the Unit. The primary objectives of the Unit are
•

To study the impact of public policies and programmes aimed at gender justice,
particularly the rights guaranteed to women through the Indian Constitution aYid the
international human rights conventions and other agreements to which Injdia is a
signatory, and

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To advocate changes in policy and implementation to facilitate the assertidn of the
rights of women, particularly from the poorest sections.

WOPRA initiated a large scale study of rural women in Karnataka in August 1994. In
addition to the research study, the WOPRA team has been actively engaged-in advocacy
for women’s rights at, local, national, and international levels. We have pursued our
advocacy objectives through five strategies.
•
•
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Training and gender sensitization of grassroots activists/NGOs and bureaucrats,
Membership of advisory groups and expeil committees,
Participation in workshops, conferences, meetings, collaborations,
Participation in and supporting the work ol various networks and organisations
addressing the needs of women,
Research and writing on gender issues to generate debate, disseminate information,
and promote gender justice
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A Study of the Status of Rural Women in Karnataka
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Why the Study

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The WOPRA Unit was conceived to do advocacy for bringing about positive changes in
women’s lives based on a systematic study of women. Today, advocacy for changes - in
law, government policy, etc - has acquired the status of an art and a skill. Often, the
experiences of individual NGOs / grassroots groups are dismissed as “exceptions” and are
not given due weightage in the making of plans or policies. It is being realised that one of
the most important requirements for effective advocacy, is actual data or information
collected and compiled systematically. It is against this background that WOPRA
undertook a study of the status of women, in rural Karnataka (hereafter, SRWK). The
broad objectives of the study were as follows:
•
•
•

Study the status of women in Karnataka,
Focus mainly on those areas where not much is known, and even less, is systematically
documented,
Use the study as an advocacy tool to change policy, provide information to panchayats
for their planning, help NGOs evolve new strategies etc.,.
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Who did the Study

The study is an outcome of the partnership between the WOPRA Unit1 and non
governmental organisations2 from representative regions of Karnataka. We feel, in
retrospect, that the partnership was successful in generating quality data despite the large
scale of the study. It has also strengthened the much needed links between research and
field insights.

Scope of the Study
The process of the study took around three years from September 1994 to July 1997, It
included a review of existing literature, developing a conceptual framework, formulating a
sensitive tool that could capture gaps identified in existing research and designing an
innovative methodology for collecting data and preparation of the preliminary report.
Given the limitation of time, money and human resources (the team consisted of 4 women
only), it was felt that we should focus initially on the needs and problems of rural women.
Also, we realised that the conceptual framework and the questionnaire, we had developed,
were inadequate to meaningfully capture the status of urban women
The team that did the SRWK Study comprised Srilatha Baliiwala, Fellow of NIAS, Anita
Gurumurthy and Anitha B K. Research Associates at the WOPRA Unit, and Chandana Wali, the Project
Assistant.
WOPRA collaborated with GRAMA from Chitradurga; Gram Vikas and REACH from Kolar,
and Mahila Samakhya - a quasi- government programme, in Bijapur and Raichur.
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I he study icsliicted its focus to a sample ol cvcr-married women in the reproductive age
gioup, that is, between 18 to 40 years of age Women in this age group have the least
autonomy and face the greatest constraints in securing their rights and so become most
relevant to a study on status.
Rather than doing a systematic sampling of women from different strata scattered
throughout a district, we selected either one large or two small villages, which mirror the
socio-economic and demographic profile of the district, and carried out a complete village
census.

Key fen iAle
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Data was collected from 6 representative districts - Kolar, Chitradurga, Bijapur, Raichur,
Dakshina Kannada and Kodagu, and approximately 200 households in each district. In
each household, one ever-married woman and her husband was interviewed. Where the
husband was absent, either the brother, father, brother-in-law, or the father-in-law, who
the woman identified as the key male member, became the male respondent for that
household. A total 1171 households were canvassed Adult male members were not
present in 68 households. Therefore, there were 1171 women respondents and 1103 male
respondents in the study
I he study used the interview method for data collection. The questionnaire used for the
a nnirtzxP
interview
anH included
innlnrlA/t Hata
r,
was PAfnnrphpnQIVA
dimensions
interview was
data z^n
on tlizi
the variousrl«»-*
of status.
comprehensive and

Questions were designed to elicit both factual and opinion-based information. All
questions were pre-coded to ensure data validity. Data on 200 items was collected.
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Defining Status : The Conceptual Framework

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While trying to unpack the notion of status, we encountered one central problem:
conventional research, including women's studies research does not appear to have clearly
defined or disaggregated the term "status". Like the term empowerment, it is one of those
rather vague, loosely used terms
Further, most of the analyses of women's status based on official data are limited by the
inherent gender blindness of formal information systems - for instance, official data on
work participation is useful to determine the number of women in the labour force, but
tells us nothing about the control women from the labour force have, over their income.
Also, official sources often tend to conflate women's status with their education and health
status, which although fundamental, are not sufficient indicators of women’s status.
Healthy, educated and even earning women, are not necessarily free from gender
discrimination and subordination
A framework to study women’s status has to follow from a clear understanding of gender
equality. Studying women’s status means a sensitive diagnosis of the nature of gender
subordination through the study of gender relations in a specific context. It also means the
application of measures derived from a clearly articulated goal of equality, to that context.
i

i
3

t

,

We understand that women's powerlessness stems from the lack of resources - human,
material, and intangible3. When we examine gender relations as power relations4, it is
evident that men are favoured by the rules of the institutions within which gender
relations occur and that they enjoy and exercise power in commanding these resources.
Gender inequality is therefore an outcome of asymmetry in power; where men are in a
T
position of privilege and women of subordination
!

For women, the absence of power has meant the lack of access to and contiiol over
resources, a coercive gender division of labour, a devaluation of their work, lack, of
control over their own self - skills, labour, mobility, sexuality, time, and fertility. Their
powerlessness is expressed in male violence against women, sexual exploitation that »
erodes all human dignity and a very acute experience of vulnerability.
The transformation for gender equality based on the human rights framework requires
the redistribution of power for promoting women’s strategic gender interests. Such a
transformation involves a set of enabling policies and conditions created by the state that
facilitate the reallocation and redistribution of resources. It focuses on increasing women's
access to and control over the entire gamut of resources that confer power at individual,
household and societal levels. It entails the loss of men’s traditional power no doubt, but it
certainly does not envisage the abnegation of men’s autonomy.
Thus, the study of women’s relative access to and control over resources is a useful
method of comparing women's position with that of men, and is also a reflection of
changes in both ideology and the institutions and structures which mediate such access
and control. As indices of gender equality, the terms ‘access’ and ‘control’ serve as
sensitive indices to capture women's autonomy and status.
But what do ‘access’ and ‘control’ mean? In the context of material, human and
intangible resources, access refers to the opportunity or the de facto rights available to use
the resource. For instance, do women get an opportunity to take a loan or go to a health
centre for treatment? If they do, they can be said to have access to these resources.
Control is a much more complex term and needs to be understood within the notion of
shared power and on-going negotiation. Control over a resource is the bargaining power
to define or determine the use of that resource.
The WOPR.A Unit based the SRWK framework, on a model developed by a researcher,
Ranjani Murthy, which examines women's status through the prism of access and control.

See Kabeer. Naila and Subrahmanian Ramya, “Institutions, Relations and Outcomes: Framework
and Tools for Gender-Aware Planning", Discussion Paper 357, Institute of Development Studies,
University of Sussex, Brighton. September 1996.
4

Ibid
4

1 he modified framework uses the following components as benchmarks to study women's
status vis-a-vis men's:
•
•
•
•
•
•
•
•

Access to and control over private assets and resources
Access to public resources
Control over labour and income
Control over their body - sexuality, reproduction, and physical security
Control over physical mobility
Access to and control over political spaces
Access to and control over intangible resources - information, influence, political
clout etc.
Position in law and their access to legal structures and redressal.

We realise that in reality, women's actual experiences cannot be compartmentalised.
I hcreforc, no single index can be construed as being independent of the other.

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I Highlights of the Study *
Demographic Profile of Households
1 he households covered by the SR WK study shows the increasing nuclearisation of rural
families. The average household size in the study was 6.4 and the mean number of children
was 3 per household All women in the sample were in the reproductive age-group, that
is, between 18 to 40 years. The majority of the men, about 70%, were in the 31 to 50 age
group. T he distribution of surveyed respondents by religion mirrors the distribution for the
state. Over 90% of the respondents were Hindus (including scheduled castes and tribes),
about 7% Muslims, and just under 2% Christians. Reporting of annual household income
indicates that more than 50% of the households wereTeTow the current poverty line of
Rs. 11,800. Moreover, around 25% of the households reported Rs. 5000 or less as their
annual income which places them in acute poverty. The data on caste distribution was still
being compiled during the preparation of this document and is hence not available at this
stage.
The following are some of the key findings of the study, presented under thq different
indices discussed earlier.
,
Access to and Control over Private Assets and Resources

i
i

Land

Me

•

71% of the households surveyed in the study, reported owning land.

•

In 81% of these households owning land, the title deeds were in the names of men.
In contrast, only 12% of the land was owned by women.

•

A disaggregation by type of land shows that the proportion of barren land held by
women, is more than double the proportion of any other type of land owned. The
study shows that as much as 27 % of barren land while only 11% of all rainfed land,
11% of plantation and 10% of irrigated land, are owned by women.

I.

T

le

Housing
•

88% of the households reported owning a house. An overwhelming 885, that is,
80.38% of the 1101 houses owned belong to men and just 158, that is, 14.38%, to
\
women members of the family.
ln

The WOPRA. team is thankful to Dr A.R. Vasavi, Fellow; Sociology Unit, and Hcad-in-chargc,
WOPRA. NIAS, for her suggestions and editorial comments in preparing this document.
6

Perceived Control over Household /Assets
ve/'nairHztr

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•

A relatively small proportion of men (27 % for land and 18% for houses) and women
(4 % for land and 3 % for houses) respondents reported that they can independently
pledge or sell immovable assets such as land and house. However, of those who feel
they can, men clearly predominate.
A higher percentage of male respondents (41%) as compared to female
respondents (17 %) feel that they can independently dispose livestock. Interestingly,
thcjKoportion of men claiming the right to liquidate "wife’s jewellery” is almost equal
Ii'
[ Xto that of women reporting such independence with respect to their own jewellery.

I

Food
Nearly three-fourth of the stud} population do not experience insecurity^jn relation to
food, despite the poverty of at least half of the surveyed households. A large majority,
-—- over 80% reported consuming at least three meals a day,. Given conditions of overall me
adequacy of household food supply, there does not appear to be a strong bias against
women’s access to food, in terms of number of meals consumed per day.
•

) I

•

Gender differences appear in the consumption of more expensive or luxury food
items like fruit, eggs, meat, poultry and fish where more men report weekly
consumption. Under each of these items, there were 7% more men than womdh, who
r
reported weekly consumption
I

•

Sharp differences appear in the reporting of perso n/s sacrificing in the event of'a food
crisis. While 79% women respondents report taking exclusive responsibility*during
i
such food shortages, only 12% of the male respondents say that they singularly
----------absorb the crisis.

•

A majority of men and women arc of the opinion that men require more food.
Further, more women (71%) than men (54%) endorse this view. Such a bias reflects
the greater internalisation by women of the ideology of women's subordination.

•

24% women and 15% men reported that obtaining two square meals a day was
difficult when they did not have work The difference in reporting suggests that in a
quarter of all households, it is women's income that takes care of the family food
, ______—-

•

fhe absence of employment security affects the food security of at least one-fourth
of the women in the sample Coupled with women's internalisation of the belief that
men need more food, the non-availability of wage labour is likely to severely affect at
least a quarter of the women

7

,

Access to Public Resources
Survival Needs
•

86% women reported that their water source is located within the village. Although
this figure indicates that access to water per se may not be a serious problem foi a
majority ofthe women, 22% reported that the source they access for drinking water
is an open well, river or stream - sources that are relatively unsafe.

•

Only 18% ofthe households probably from higher income categories, have control
over their water source. 28 % report having to depend on sources owned by landlords
or private sources, and the rest on sources under the control of the government or
the gram panchayat For 8 % of the women, dependence on other sources has meant
enduring harassment meted out by the private owners ot the water source.
f

•

An intriguing part of the data in this section is the discrepancy in the reporting about
who takes responsibility in fetching water for the household While 54% of thp men
report that they fetch water everyday, only 2% ofthe women say their husband docs
so! On the other hand, only 18% ofthe men say their wife performs this daily chore,,
compared to 87 % of women reporting “self”. Considering the data from several field
studies, and common observation in rural areas, it would appear that the men have
quite deliberately over-reported their role and under-reported their wife's role.

Y7

Cooking Fuel
•

83% ofthe households rely on bio-mass cooking fuels like fire-wood, dung-cakes
and crop wastes, proven to be hazardous and having a detrimental impact on the
health of women, who almost exclusively shoulder the responsibility of cooking.

•

Only, 34 (2.9%) of the households reported owning the fuel-efficient and smokeless
nAstra Olef\ stoves. This finding reveals the complete failure of the government to
disseminate basic technology that has the potential to alleviate problems that adversely
affect women's health

Toilets
Only 16% of all households reported having access to toilets. Of the women
respondents who had no access to toilets 73% reported that they would like to have
this facility in or near the house, whereas only 59% of the men not having access to a
toilet, showed such a preference The difference, though not dramatic, suggests that
women, by virtue of their gender, perceive a greater need for having toilets closer to
the house than do men.
7

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Health
Sex Ratio
•

The sex-ratio for the entire study population, computed on the basis of the total
number of members for all households, is 969:1000, almost identical to the
Karnataka state 199) Census figure When computed separately for adults and
children, the sex ratio reveals a disturbing trend. The adult (aged above 14 years)
sex ratio is 1001 1000 but the child sex ratio is a shocking 922 1000, Thd exact
reasons for this phenomenon, has to be determined through further analysis.
——

■

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Reporting of Illnesses
•

i,

Far more women (76 %) than men (51%) reported having suffered any illness, in' the
previous year.

Treatment Expenditure
•

Gender differentials in accessing treatment and in the type of source sought for
treatment, are negligible, but surface clearly in treatment expenditure. Across all
categories of treatment expenditure - from consultation fees, to medicines,
transport, and diet - the number of women reduces more dramatically, as cost
increases. For instance, 84 men reported having spent greater than Rs. 500 towards
medical fees whereas only 49 women report the same.

Reproductive Health
•

A shocking 26 % (310) of the women respondents reported suffering from
reproductive system ailments One-fourth of these women, had not taken any
treatment.

•
*

Of the 1033 women who had delivered at least one child, around two-thirds (63%)
had delivered the last child at home, not assisted by any trained attendant The high
percentage of home-based deliveries, is a reflection of the poor response of heaTtlT"
services to women's reproductive health needs

•

An incredible 1 in 5 women reported having lost at least one child before it reached
the age of 5.

Education
•

Education data shows predictable gender differences and follows trends available in
existing literature. 59% of male respondents and 37 % women reported having
attended school.

9

k

•

Contrary to official statistics which claim a gross enrollment ratio of over 100%, the
study data for enrollment computed on the basis of all children in the households
surveyed, shows that only 69% girls and 74 % boys below age 15 attended school.

•

Only a dismal 8 % of the study population - both male and female, reported having
attended adult literacy classes.

Aspirations for Children’s Education
•

An equal percentage (43 %) of male and female respondents agree that girls must
complete their matriculation A large percentage of respondents - 46% women and 36
% men, believe that boys should study "as much as they want". But the most telling
gender difference in perceptions of the desirable level of education is that almost
twice as many women respondents (25 %) as men (13%) think girls should study "as
much as they want". Women ieveal greater aspirations for their children's education in
general, and for their daughters' education in particular, than do men.
r

Credit
i

•

One-fifth (249) of the w omen respondents and nearly half (517) of all mdle
respondents had accessed credit from different sources.
I

•

While men had primarily accessed formal institutions like banks, followed by large,1
farmers, women had depended mainly on NGO based credit programmes, and then on
banks.
.

.......

............. -

'•

" ”

•

Banks and large farmers - sources that require collateral - constituted 70 % of all
sources accessed by men, and 4 1% of all sources that women had approached.

•

Banks alone were 42% of all sources that men had accessed and 24% of all sources
that women had accessed But this 24 % for women, must be placed in the context of
the fact that these women arFTTkelyld have been beneficiaries of government
schemes that lend exclusively to women through lead banks and do not require
collateral.

Control over Labour and Income
•

On an average, the mean number of occupations per respondent, (including home
based productive work - cultivation on own farm and farm-based activities,
sheep/goat rearing, poultry, sericulture, traditional family occupation etc.), is just a
little over 2 per head.

io

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Cultivation
•

An equal number of men and women, around 55%, had been engaged in cultivation.
Census data for Karnataka and India, shows greater participation of women in
marginal work (less than or equal to 180 days a ycar),and of men in main work (more
than 180 days a year) in cultivation. However, in a significant departure from these
statistics, work participation data for cultivation in the study, shows equal
parficipation of men and women, in both main and marginal categories, because the
study used a more gender sensitive definition of work and methods of data collection.

Agricultural Wage Labour
•

Although only 29% of the study households were landless, 35% of the male and 41%
of the female respondents were engaged in agricultural wage labour. This data
reinforces the national trend of small and marginal fanners and subsistence cultivators
having to supplement their meager income by selling their labour to other farmers.

Dairy
•

The study clearly demonstrates the ’’femaleness” of dairying - 43% of the women, and
3 1% of the men were engaged in dairying The qualitative data collected in the study,
shows that men were predominantly involved in marketing and women in the day to
day work of feeding and caring for animals, and milking, which are an extension of
women's domestic work. Data on poultry also reveals the same pattern.

•

The proportion of unremunerated production work, including both waged and
homestead-based work, was much greater for women than for men. Only 64% of all
productive work done by women yielded income, whereas 86% of the productive
work done by men yielded income.

Control over Income
•

1 he study generated data on the control over individual and household income.
70% of the earning women in our study reported handing over their wages to another
household member, as against 20% of die male earners. 60% of the women, in fact,
handed over their earnings to then husband The right to retain income in one's own
hand gives at least a notional or symbolic control over one's earning even if it is going
to be largely spent on the family

•

Nearly two-thirds of the male respondents as against one-fifth of the female
respondents reported that they participate in the purchasing of household needs, a task
Or
that may be said to vest reasonable degree of control over household income
C hcx'et
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4

•

Another indicator - retention of own earnings for personal use, also indicates that
women have a lesser degree of control over their income. 32% of the male earners
and double the proportion of female earners, that is, 67 % reported retaining nothing
out of their income for personal use.

Control over the Body and Sexuality
Age at Marriage
•

34% of the women in the sample reported being married before menarche, but only a
negligible 3% of the women, said they would choose the option of a pre-menarche
marriage for their daughter, if left to themselves.

•

Although 52 % of the women respondents had married before the age of 16, only
23% opined that they would get their daughters married at this age, an encouraging
trend In fact 30% of the men chose the option of getting their daughters married
before age 16.

Dowry
•

The data strongly supports oui initial hypothesis that the custom of dowry has
increased over generations, probably penetrating communities that did not practice
dowry before.
-1% of the women reported that dowry had been paid during their mother's
marriage - (55% reported that dowry had not been paid, 3% reported bride-price,
and 41% said "don't know").
-17% reported that dowry had been paid for their own marriage, (83% reported
not paying);
-31% reported having paid dowry for their daughter's marriage and ,

r

t

-64% said that they anticipate that dowry will have to be paid for the marriage of
j
their unmarried daughter/s!
Child-bearing Decision
•

/-Aox

Women's participation in decision-making about child-bearing, integral to Sexual
rights, was much lower than men's 1001 women and 95° men answered the question
pertaining to decision-making about the total number of children they should have.
Only a fifth of these women and 61% of these men reported having participated in the
decision

A o /eCo
12

e: H

Contraception and Birth Control
•

Awaieness about permancnl methods ol birth control, especially about tubectomy,
was higher than about temporary methods Onlv 24% women and 38% men were
aware ol condoms, whereas 80% men and 80 ? o women were aware of tubectomy and
'
65% of both men and women, of vasectomy

•

A surprisingly large percentage of respondents, about one-fifth, had heard of
injections for birth control, indicating that hormonal contraception, (not considered /
safe), has probably penetrated rural Karnataka.

•

A vast majority ot men and women believe that contraception affects- men's health
and work capacity, a wide-spread myth, that contradicts medical evidence. Such
opinions are inimical to women's sexual rights, and women end up having to bear
complete responsibility for birth control 40% of the female respondents in the study
had undergone tubectomy; barely 1% men had undergone vasectomy.

he
Violence
The total number of instances of violence reported by women was 289, and the total
reported by men, 181 This difference is clearly because of the unique experiences of
violence and harassment that women endure within the marital family as well as in
relation to their gender-specific roles Out of the 289 instances reported by women,
115 were in relation to quarrels with the husband / his family, dowry demands,
suspicion of infidelity, and childlessness.
With respect to wife-beating, although a majority (70%) of the women, think it is the
husband’s right, only a minority (27%) reported actually having been beaten by their
husband Interestingly, 381 men acknowledged beating their wife but only 312 women
reported being beaten. Going by male reporting, this means about one in every three
married women experiences domestic violence at least occasionally

Control over Mobility
•

1 he data shows that the critical difference between women and men is not so much
their right to go freely to places related to their productive or subsistence work, but
to those locations and services which determine their access to various public
resources.

•

For instance, 72% women had never visited the school and 40 % had never visited the
panchayat office, whereas the corresponding figures for men is less than half the
women's figures, that is, 3 1% for school and 15% for the panchayat office.

13

•

25% women reported having visited the panchayat office with a male escort and
another 25%, alone This mobility to the panchayat office is likely to have been
induced by the numerous schemes which have beneficiary quotas for women, the
reservation of seats for women in panchayats, as well as the presence of NGOs which
promote women's interaction with local government bodies.

•

That women's mobility is inversely related to distance comes out clearly in the mobility
data. 66% of the women had not visited a health clinic (usually located in larger
villages), 52% had not been to the taluk headquarters, and 73% had not visited
the district headquarters The corresponding percentages for men were, 14% , 30%
and 36% respectively.

Access to and Control over Political Spaces
•

Voter participation was high (over 90%) and did not show any gender differentials.

•

Data shows clear gender differentials in elections contested; we find women only
contested gram panchayat elections (30 men and 15 women), whereas even if an
insignificant number, some men in the study sample had contested elections in a
range of other bodies such as taluk (3) and zilla (1) panchayats, cooperatives (10) etc.
Women are conspicuous by their near absence in higher level political bodies, a sad
' truth which i$ vahd f°r the state legislature and the parliament.

•

As regards membership and participation in other community organisations with mass
base like farmers sanghas, youth groups, caste organisations, we find women largely
confined to women’s organisations. For example, 26 men reported being members of
political parties and 68 of caste or tribal organisations but the respective figures for
women's membership were only 3 and 35. 168 women reported being members of
mahila sanghas.
r

Access to Legal Structures and Redressal
•

I
f

There was a significant gender difference in awareness about the "injustices" faced tyy
women In fact, this difference could be traced entirely to the gender difference in •
reporting of women's problems within the "private" sphere. Out of the total 3838
female and 2408 male responses about injustices that women face, 2733 responses of
women and 1340 responses of male respondents were about those occurring within
the realm of the household, such as dowry harassment, wife beating, bigamy,
harassment for childlessness, harassment for not giving birth to a son, etc. There
was no gender difference in the awareness about injustices such as eve-teasing, rape,
lack of education, etc , that is i: justices occurring in the "public" sphere. Women may
have found it easier to recount many more instances of home-based injustices, than
those which are systemic and located farther from their immediate reality; men, on the
other hand, seem more oblivious to women's problems within the home.

14

•

1 lowever, only a minuscule proportion of women respondents (145), reported actually
experiencing any injustice A majority of these women, recounted experiences based
within the home . Ironically, most of these women (131) said they had approached
family elders for redressal, although it was the family which had been the actual site of
violence for a majority. A significant number of women (52), almost a third of the
women reporting personal experience of injustice had also approached the nyay
panchayat - a public forum Although the Nyay panchayat may not be the first choice
for women, (only 6% of all women in the sample said they would go to the nyay
panchayat first in the event of any injustice), when actually confronted with a problem,
many had sought "public" redressa’. Further analysis will reveal if these women are
part of grassroots organisations

•

The data on whom women should approach for redressal also corroborates the reality
and clearly upholds the norm that women should seek redressal for their grievances
within the family Not only 78 % of the women but also 56% of the men in the sample
endorse this view point Further, when asked about who they would personally
prefer to approach if they faced an injustice, only 25% men chose the family!

•

More (61 out of 111) men and fewer (41 out of 145) women respondents had
approached the police for redressal. 45 men and 19 women had gone to the court - a
costlier option.

Conciusions
At this preliminary stage, we have been able to share only a percentage analysis of the
findings Although preliminary, the findings indicate definite trends about the status of
rural women in absolute terms as well as in relation to their men.
In a study like this, there is bound to be a tension between how women, the subjects of the
inquiry, perceive their own status, how men define women's status in relation to their own
and how the external researcher defines the parameters constituting high or low status. We
find a resolution of this definitional tension in the adoption of the human rights framework
by feminists in their struggles for equity and justice. Such a framework, not c>nly vests in
women, all fundamental rights (thus far denied to them), that must accrue to^them as
human beings but also, recognises the specific interests of women, arising out of their
gender.
i

This study therefore looked at women's status through the concept of autonomy, and used
broad indices concerning access to and control over private and public resources and
spaces, and the body as benchmarks It also examined the mechanisms available to women
for seeking justice and how sensitive these structures are to women's interests.

etc

2

7

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The study data shows that women have very little control over private assets - thdy lack
control over immovable assets such as land and house. Laws of inheritance biased on
patriliny ensure the perpetuation of patriarchy, through the material dependence of
women on men In India, laws do not confer on married women, an equal right of
ownership to the matrimonial home. In any case, marriage marks the separation of the
woman from the natal home, and cultural norms expect her to relinquish any rights she/
may have hitherto enjoyed over the assets of the natal home. The absence of material'
assets converts into a crisis when women are confronted with violence and harassment in
the marital home
.
157 women in the study, that is, over 13% have identified the husband and his family as
the key perpetrators of the violence they have experienced. Obviously, for these women,
there is no escaping this violence Two other findings that concern women’s safety, reveal
disturbing trends and deserve to be mentioned. One is about the difference in age-specific
sex ratio; while the ratio for the adult population (1 5 years and above) in the study is
1001:1000, for the 0 to 14 age group it is a shocking 922:1000. The second finding is
about the inter-generational increase in the practice of dowry. The ground reality is thus a
sad commentary of the degeneration of women’s position which ironically, seems to be a
consequence of material development . Both these findings need to be explored further.
Data on perceptions about status shows that most (85%) women in the study believe that
men must be treated with more respect than women, an indication of the deep penetration
of patriarchal ideology into their consciousness The higher status that women accord to
men is true also within the marital relationship In fact, this perceived inferiority of women
is captured in the responses of the 25% women who report that single women - widows,
divorced and separated women - are not "respected by the community". 25% women also
feel that their "respect" ( a proxy for status) is derived from the status of their men. Out of
the total 1171 women, as many as 5.4% women were single. Within patriarchal contexts,
assetlessness would aggravate the loss of status suffered by these single women , who may
find it difficult to negotiate their position within and outside the household, in the absence
of their husband - the reference point of their status and identity.

Data on women's access to public resources such as water, fuel, health, education, and
credit reveals the inability of the state in breaking gendered barriers impeding women's
access to resources. Our data on gross enrollment contradicts the claims of the state; in
the area of rural energy the state's abdication in disseminating women-friendly technology
is evident; women's health is a low priority for the state as it is for the household - a
shoclcihgly Tfiuge percentage of women report having delivered without the assistance of
trained personnel; women's access to formal credit is still low and where women have
access to schemes that advance credit for livestock or sericulture, research from many
states suggests that these schemes end up adding to the already over-burdened work-day
of women, all in the guise of adding to family income The strategies of the state in
promoting women's access to public resources requires to be reviewed so that the state
can become a true enabler of women's empowerment
The findings under the section on work and income, indicate high participation of women
in productive work, and the mobilisation by the household of women's labour for not only

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waged work but also home-based productive work that is non-waged - both,
indispensable to the survival of the household economy. Such appropriation is obviously
not restricted to income generation but is also for unpaid productive work to which
income can be imputed, and most importantly, for sustenance, if we assume that domestic
work is women's responsibility fhus, the question of whether women have control over
their labour becomes quite misplaced, in an arrangement where women's labour is
appropriated by the household.
I he indices that measure women's autonomy in relation to their body go closest to the
issue of power and gender The study looked at women's control over their labour,
mobility, fertility, and bodily integrity The findings under each of these areas highlight the
powerful role of the strongly internalised belief-systems of a patriarchal cultunp. They also
point to the prominent role played by the family in general, and he husband in particular^
in regulating and controlling women's sexuality. The result of such control - reflected '
clearly in the low percentages of women reporting participation n child-bearing decisions,
or visiting the district headquarters and the high percentage of w omen reporting-very low
age at marriage and the high percentage of men and women reporting that men have a
right to beat their wife, - is women's lack of autonomy in relation to their body and
sexuality The immurement of women through cultural beliefs directly prevents their
access to intangible resources, discussed in the section on the conceptual framework of the
study.
It follows naturally that when women's reality and rights are mediated by the family, it is
the family that they perceive as most appropriate for seeking justice Women's lack of
assets and their restricted mobility also negates the possibility of their pursuing justice
through mechanisms that involve money and travel. However, in the final analysis,
struggles for real equality in gender relations demand that the private be made public.
Interestingly, the higher stakes that women have in social transformation for gender
equality is demonstrated by the high proportion of women who ha* accessed public fora
for redressal Out of the 145 women who had experienced injustice ■>, 52 had approached
the nyay panchayat, 41 had gone to the police and 19 to the court lor redressal. It is not
clear from the analysis at this stage whether all instances where women approached the
public fora challenged traditional gender relations However, the fa t that women were
able to move beyond the family when faced with a problem, is in itself a positive indicator,
given that deep-rooted notions of honour are associated with family affairs.
Women's political participation is critical because, ultimately, the liberation of women
from their subordination is a political task, and cannot be truly achieved until women
become a force to contend with in the political sphere It is clear from the data in the study
that reservation of seats for women in the state legislature and the parliament will be a
good beginning
A more complex picture of women’s status will emerge w ith a deeper analysis of the data.
Cross-tabulations, correlations and factor-analysis w ill allow for the inter-play of gender
with class, caste and region The broad quantitative data base of this study has to be
supported with nuances from qualitative studies.

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transformatory strategies. Undoubtedly, we have a vibrant and growing womens ,
movement in India. But if this study is any indication of women's or even men p feminist
consciousness, the task ahead is formidable Strategies are needed not only to support ;
those closer to the goal of gender equality, but to carry the vast majority resigned to,
status quo, towards this elusive goal

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I General Information

IF YOU WOULD LIKE TO PRESENT A PAPER at the conference, please send a half
page abstract [250 words] of your paper to:
a) The relevant sub-theme coordinator (addresses can be found below each sub-theme abstract)
b) SONIA BATHLA, Centre for Women’s Development Studies, 25, Bhai Vir Singh Marg,
New Delhi 1 10 001, Fax: 01 1 3346044, email: cwdslib@sansad.nic.in
To participate in the Conference you must become a member of IAWS if you are not
already one. IAWS Membership Forms can be found in thishreeh £. These must be duly
filled and mailed along with a Demand Draft drawn^i'n'lavour of “Indian Association for
Women’s Studies” payable at Mumbai, to Divya Pandey (address on form).\
[DEADLINE FOR PAPER ABSTRACTS; 15 NOVEMBER,/1999 |
Completed Conference Registration Forms along with Demand Draft drawn in favour of
Indian Association for Women’s Studies, payable\t Hyderabad to be sent to:
KALPANA KANNABIRAN, Organising Secretar^lx^TCWS^address on
form).
|PEADLINE FOR REGISTRATION: 5 DECEMBER, 1999~]
Registration fee for outstation participants is Rs. 500/-

j

Registration fee for local participants is Rs. 200/- /
Registration fee after Deadline is^Rs^bOO/^.-U^^
Please Note:
•

Please ensure that all payments are made through Demand Drafts and accompanied by
completed forms.

•

Accommodation cannot be guaranteed for participants registering on the spot. Limited
accommodation will be made available on first-come first-served basis.

•

IAWS Membership to be sent to Mumbai.

•

Conference Registration to be sent to Hyderabad.

THE VENUE:
NISIET is located beside Yousufguda Police Lines about 5-6 kms from the Airpiiort and Begumpet
Railway Station. It is easily accessible from Hyderabad and Secunderabad Railway Stati<ions. Participants
will be accommodated in Guest Houses within a 5 km radius from NISIET.
Registration Counter at the Conference site will open at 10 A. M. on 7 January, 2000.

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IXth
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Steering Committee
Va.sa.nth Kannabiran, Co-chair
Vina Mazumdar, Co-chair
Chandana Khan, I.A.S., Secretary, Women Development, Child Welfare and Disabled Welfare
Department, Govt, ofAndhra Pradesh.
N. Gopi, Vice-Chancellor, Potti Sreera.mulu Telugu University
Jeelani Bano, Eminent Writer
S. V Prabhath, I.A.S, Principal Director, National Institute ofSmall Industry Extension Training
T L. Sankar, I.A.S. [Retd], Principal, Administrative Staff College of India
Shamim Jairajpuri, Vice-Chancellor, Maulana Azad National Urdu University
Susie Tharu, Professor, Deptt. ofEnglish, Central Institute ofEnglish and Foreign Languages
P. Rama Rao, Vice-Chancellor, University of Hyderabad
Ranbir Singh, Director, National Academy of Legal Studies and Research University
Volga, Eminent Writer

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Organising Committee
Kalpana Kannabiran, Organising Secretary
N. Beena, Convenor
Aloka Parasher-Sen, Professor & Head, Deptt. ofHistory, University ofHyderabad
Amita Dhanda, Professor ofLaw, National Academy ofLegal Studies and Research University
Kancha Ilaiah, Reader, Deptt. ofPolitical Science, Osmania University
S. Jaya, Coordinator, Anveshi Research Centre for Womens Studies
C. Mrinalini, Asst. Professor, Deptt. of Comparative Studies, Potti Sreeramulu Telugu University
Rama Melkote, Professor, Deptt. ofPolitical Science, Osmania University
C. Rani, Faculty Member, National Institute ofSmall Industry Extension Training
Rehana Sultana, Programme cum Field Officer, Maulana Azad National Urdu University
Sharada Israel, Executive Director, YWCA, Secunderabad
Sheela Prasad, Reader, Centrefor Regional Studies, University ofHyderabad

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IXth National Conference on
Women’s Studies

8-1 I January, 2000
Organised by
Indian Association for Women’s Studies

at
National Institute for Small Industry Extension Training
Yousufguda [beside Police Lines], Hyderabad

Conference Coordination
Asmita Resource Centre for Women

LAWS and IX Conference Secretariat
Asmita Resource Centre for Women
10-3-96, Plot 283, 4th Floor, Street 6, Teachers’ Colony, East Marredpalli
Secunderabad-500 026, A. P., India
Tel: 91 40 7733251, 7733229 • Telefax: 91 40 7733745
Email: asmita@hdl.vsnl.net.in

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National Conference on
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Womens Perspectives on Public Policy

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Programme of Plenaries

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Sub Themes

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Pre Conference Workshop

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Stri Vividha

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Conference Schedule

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Conference Registration Form

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LAWS Membership Form

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General Information

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Women’s Perspectives on
Public Policy

Women’s Studies

Evolving an Agenda for Action into
the Next Millennium

As we step into the next millennium, a much-needed exercise is an assessment of
trends in public policies, past and present (continued or changed) and their impact on
women across the country.
During the last few decades we have been preoccupied with development and economic
policies in view of the deteriorating economic conditions for a major section of women. In
the field of laws, personal laws and rape laws have dominated our attention to the exclusion
of other aspects of our legal discourse. Public policies on health care and health services
have been another area of critical concern. All these have a history behind them. Historically,
public policies in India have paid scant attention to regional diversities or regional histories.
Be they programmes of poverty alleviation, developmental thrusts, tackling dowry, age at
marriage, or violence or scores of other such issues - there are built in biases that demand
exposition to uncover their ideological underpinnings.
The primary objective of the IX National Conference is a critical assessment of public
policy, historical and contemporary, in shaping women’s lives and setting an agenda for the
next millennium. The conference will attempt to identify the sectoral priorities that have
emerged in each region, their dynamics and their linkages with mainstream priorities viz.,
employment, health, violence, environment, communalism, family, political representation
and right to resources including property. The plenaries and sub themes will explore major
shifts in priorities, perspectives and will attempt to understand, and foreground unexplored
areas and successful or unsuccessful strategies.
In more recent times, policy initiatives have induced some concrete structural changes.
To cite a few: reforms in law and legal processes, institutional reform in policing, constitution
of women’s commissions at the state and national level and gender sensitizing programmes
for policy makers and the bureaucracy. Simultaneously, women’s collective action through
literacy, self help or anti liquor movements have induced changes in public policy.
The IAWS hopes that the IX National Conference will provide the space for women
from different parts of the country to come together and discuss ongoing areas of concern
as well as of those that have hitherto been underrepresented or unexplored.

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|Pr6gramme| of
^Plenarie/
Invited Speakers

.. Nirmala Buch ..
.. Imrana Qadeer ..
.. Sunila Abeysekera ..
.. Murli Desai ..

.. Nirmala Banerjee ..
.. Jarjum Ere ..
.. Hameeda Hossain ..
.. Mahmood Mamdani ..
.. Kameshwari Jandhyala ..
.. Ariindhati Roy ..
.. Anveshi Law Committee ..

.. Manisha Gupte ..
.. Uma Chakravarci ..
.. Sathyamala ..
.. Saheli ..
.. Forum for Women’s Health ..
.. Pradnya Lokhande ..
.. Volga ..
.. Mridula Garg ..
.. Veena Shatrughna ..

.. Ritu Menon ..
.. Pushpa Bhave ..
.. Meenakshi Mukherjee ..
.. Maithreyi Krishna Raj ..

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IXth National Conference on
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Women’s Perspectives on
Public Policy:
Incomplete or Lost Agenda?

Fifty two years is not a small period for initiating progress. The promises enshrined
in the Constitution and the vision of women’s full emancipation will not be realised unless
once again we gear ourselves to intervene more forcefully in the polity and public policy.
By public policy we do not mean only policy documents actually released from time to time
by the government in power but by all public agencies in all sectors of life - in institutions
and their functioning, in the prioritisation in the allocation of resources, in the modus of
implementation in addition to policy directives, explicit or implicit.
Women’s concern with the economy has been consistent. Before Independence, the
Sub-Committee of the National Committee for Planning had published an exhaustive blue
print, radical in thrust for bringing about equality for women in free India entitled ‘Women’s
Role in Planned Economy’.

Yet, many indicators including that of the UNDP Gender

Development Index demonstrate on many fronts, the jettisoning of these views and the cost
to women of this neglect. It took twenty-five years before the shift away from women as
‘weaker section’ in need of welfare took place. This recognition has been partial with women
still seen as merely a segment of the family-household.
In education, instead of strengthening the mainstream system and making it deliver to
fulfil its mandate for ensuring full, free, primary education to all, alternate agencies have
been mooted. While these are commendable they also raise certain basic questions. Why
do girls and women deserve only ‘non formal education with a ragbag of micro programmes?
The 1986 New Education Policy raised a lot of hopes for the first time but as yet there is
no evidence that this too will not remain on paper.

Populist measures like free education

till college level for girls in some states make no sense because this kind of across-the-board
measure ignores the deep class, caste, regional disparities and the specific hurdles that beset
girls’ education.

The women’s movement has not paid enough attention to mainstream

education for freeing the curriculum, educational establishments and men students from
patriarchal overload.
On the economic front, the first alarm bell was sounded by the NCWS report in 1974,
Towards Equality that showed women’s employment going down in several sectors especially
in the manufacturing and mining sectors. There have been several interventions since then
by women’s movement: the incorporation of a special chapter on women for the first time
in the Sixth Plan; identification of intra household inequalities and discriminations through

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solid research; exposing the biases in data that make women workers invisible; research
documenting the negative or non-effects of many programmes in agriculture and small/
cottage industry; and finally ‘Development Alternatives for Women in the 80s’ that was
produced after national and regional level consultations across the country.

The

Shram

Shakti: National Report on Self Employed Women and the report of two labour commissions
are confined to the archives. Riding on the back of this severe backlog of neglect, has come
‘liberalisation’ and the cutting down of public supports for women and opening the gates
to competition and international trade. Women’s foothold in the organised industry is now
even more precarious under flexibilisation and casualisation while their fate in the unorganised
sector is worse than before.
The family as a sacrosanct and benign refuge, a basic foundation that glues society,
has come under assault with exposure of the less than idyllic picture of the family.

Much

legal reform has been attempted in this sphere but communalisation of issues has precluded
thoroughgoing reform that will grant women true citizen rights and release them from the
thrall of personal laws.
This plenary will address all important policy initiatives in the last few decades population, health, legal reform, labour policy, and others while giving a more detailed
treatment to economy, education and family as fundamental structures that need drastic
reform. It will evaluate polices as well as women’s responses.

'Coordinator. Maithreyi Krishna Raj,[plat 53-58, Jeevan Bima Nagar, A6/3, Borivili (W),
Mumbai-400 103, Phone: 022 8930131, email: kraj@bom5.vsnl.net.in
4

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Tribal Issues and the
Women’s Movement

National Conference on
Women’s Studies

Class, caste and community are now acknowledged as significant markers for women.
However, the issue of tribal identity has not yet impacted on the theorisation undertaken
by the women’s movement. The category of the tribal is located at a node that is, in ways
defined by the state, simultaneously both legitimate and illegitimate. This location in fact
throws up a number of questions for the theorisation of gender. We therefore hope that the
plenary focus on the tribal issue would reopen for critical evaluation the manner in which
the women’s movement has thus far conceptualised gender.
While anthropologists, scholars and activist groups have been debating the definition
of the "tribe”, the “tribal,” or the “adivasi" the state has drafted several policies that would
impact on them. The seeming clarity of the state’s vision in relation to the tribals is in
contrast with the analytical confusion faced by theorists as well as activists. We therefore
feel that an important outcome of engaging with the tribal policy as formulated by the state
would be the recognition of the rationale that the state employs - its ways of identifying,
naming and addressing subject populations.
An understanding of the state’s rationality is of immense importance to the women’s
movement, especially since it would enable it to review its position vis-a-vis issues of
modernity and development. The face of modernity and development that the tribals have
seen has invariably been detrimental to them. The large-scale displacement of the tribals
from the site of the Sardar Sarovar Project in Gujarat, the exposure to nuclear radiation due
to Uranium mining in Jaduguda in Bihar or the recurrent epidemics of malaria and gastro
enteritis in tribal areas of Andhra Pradesh are some examples that come to mind when one
seeks to trace the trajectory of what developmental projects have done for tribals. The
question of statist modernisation therefore acquires obviously disturbing dimensions when
the issue of tribals is thus centred.
In bringing up these issues, the point being emphasised here is also that tribals have
so far been absent from the feminist imaginary. An attention to their situation would
necessarily put entirely different light on various issues that are being discussed today
within the women’s movement. Issues regarded as ipso facto progressive or regressive would
then need to be re-evaluated. Some of the impasses faced by the women’s movement, for
instance, in relation to the question of personal laws or in relation to gender representation
at different fora, would assume different kinds of significance in the context of how the

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notion of gender relations, rights, agency and empowerment is conceived of within these
systems. The anthropological discourse around the tribal “customary law” for instance has
ranged from representing it on the one hand as most egalitarian to characterising it as
immensely oppressive on the other. It therefore becomes important for women’s studies to
engage with these issues in order to get a more nuanced sense of these concepts which can
then be used to influence policy decisions.
Another point of significance in relation to the tribal issues lies in rhe manner in which
they are written into historical narratives. Recent scholarship has shown how the “tribal
uprisings” are always treated as adjuncts to the main narrative of Indian nationalism. This
in turn has had implications for the manner in which notions of Indian identity and citizenship
are predominantly conceived. In its attempt to interrogate hegemonic notions of “national
identity” and “Indian identity”, the women’s movement needs to engage with the situation
of the tribals as well.
The plenary will focus on
• anthropological writing:;s on tribal societies and their impact on state initiatives
• customary laws of tribal communities
• tribal identities/national identities: the case of the North-East
• modernisation, the market economy and tribal life
• tribals in India: pre-modern or modern?
Through these broad areas, the plenary will therefore seek to address through the tribal
situation issues that are of significance to the women’s movement.

^Coordinator: Rekha Pappu,|Anveshi Research Centre for Women’s Studies, OUB 1,
Osmania

University

Campus,

email: anveshi@hd 1 .vsnl.net.in

6

Hyderabad-500

007,

Phone:

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Foregrounding Women's
Health Agenda

The crucial role of public policies in ensuring survival and welfare of people is well
recognised. As we await the new millennium, a thorough critique of health and population
policies along with many other policies is most appropriate as women face their consequences
in a peculiar and gender-specific way. An urgent need for such an exercise emerges in the
light of two developments of this decade. Firstly, onslaught of globalisation, best manifested
in privatisation, cuts in resources to the social sector, shrinking employment and dwindling
food security. Secondly, the much touted

paradigm shift’ in family planning policies

wherein ‘reproductive health’ is fast replacing ‘women’s health’. Both these developments
are hitting women the hardest.
While accepting Bhore Committee’s recommendations that health care services be the
responsibility of State and comprehensive health care be available to people irrespective of
their ability to pay for the same, in reality State health services for poor are dismal. Statistics
clearly indicate the urban, anti-poor bias of health care services. The emphasis is on the
private health sector that operates without any legal or State control. Women are the worst
sufferers due to the prevalent anti-women bias present in private as well as public health
sectors. Both these sectors view women only as mothers and therefore consider their health
only in terms of their wombs. While the private sector profits on their motherhood, the
public health sector’s major concern is to prevent women from becoming mothers! Thus,
historically, all health programmes designed specifically for women have been related to
MCH (maternal and child health), contraception, child survival, safe motherhood etc. Even
this narrow approach has failed in providing services related to safe pregnancy, maternity,
and contraception to majority women. Little else is available to women to address their '
general and gender-specific health care needs. This neglect has accentuated the disastrous
impact of capitalist patriarchal development process. Various indices underline the poor
health status of Indian women. Women suffer in dual ways as they are primary producers
of life as well. The basic issue in the present period is one of survival which is under threat.
Survival today cannot mean mere biological existence but must also include human dignity
and cultural freedoms and accomplishments.
The last few decades have also seen women being targeted for population control. It
is important to note that the budgetary financial allocation for family planning programmes
is steadily increasing in the last few years even when the government is asked to cut down

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expenditure on health by the IMF and the World Bank. The thrust is on the long-acting,
provider-controlled, hazardous contraceptives for women. The disturbing trends are trials of
contraceptive methods like anti-fertility vaccines and Norplant, a hormonal implant, the
permission to market Depo Provera, a hormonal injectible.

More and more NGOs are

involved in these programmes. This plenary will
•

Present a spectrum of macro and micro issues in areas of health and population control

•

Provide critique of Health and Population control

•

Initiate debate on alternative approaches

•

Identify critical issues to set an agenda for action

•

Share insights and dilemmas of feminist health initiatives and campaigns.

\Coordinator. Forum for Womens Health,! c/o Jaya Velankar, A201, Govind Gopal Society,
Ashok Nagar Cross Road # 1, Kandivli (East), Mumbai-400 101, Phone: 022 8843776,
Fax: 022 8871559, email: greenppk@bom4.vsnl.net.in
8

Wesegyatfoni Policies
and the ^Women’s
MovementHH

IXth National Conference on
Wo men’si Studies

The policy of reservations in institutions of the state has invariably and repeatedly
been a contentious subject in the political history of twentieth century India.

The very

recent debates around the demand for the reservation of one-third seats in Parliament and
State Assemblies for women is but the most recent illustration of the range of issues that
are thrown up at different levels, whenever the need for a policy of reservations has been
raised.

In spite of this long and conflicted history, however, documentation of earlier

controversies (such as the correspondence and debates over reserved seats for women during
British colonial rule in the 1920s and 30s) is extremely sparse. The relationships between
the demand for women’s education as a principal tool of social reform, on the one hand,
and the subsequent history of reservations in education (such as the Constitutional guarantee
of proportional reservations for Scheduled Castes and Tribes, and reservations for Backward
Classes in different regions of the country) has also not received any sustained attention.
Even the current debate over the 8T' Amendment Bill has been stifled because of the
perceived urgency to try and get the Bill passed as quickly as possible.
We therefore view this panel as a valuable opportunity for discussion and awarenessra ising for all of us in the field of women’s studies. We hope to address some of the major

issues involved in this particular policy measure such as:
•

The nature of the discrimination and oppression that this policy seeks to redress

•

The different spheres of public life where reservation policies have been adopted

•

Critical distinctions between colonial and post-independence policies, as well as

•

The ambiguous relationship between the women’s movement and other social

the distinctiveness of the last decade of the 1990s
movements over this issue

\Coordinator: Mary E. John7|Centre for Women’s Development Studies, 25, Bhai Vir Singh
Marg, New Delhi 110 001, Phone: 011 3345530. Fax: 011 3346044, email: cwdslib@sansad.nic.in

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Censorshipi and

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Freedom of Expression
For the last half century freedom of expression has been a right enshrined in the Indian Constitution,
but observed more in the breach. Human rights movements have focussed on the infringements
of this right by the state; but civil society institutions have also been sites of censorship and
silencing. While people’s movements have been vehicles of resistance, they have also tended to
subvert women’s rights through the patriarchal bias of their politics.

In the new millennium

women have a pressing need to counter this trend to define and abridge rights and interests
according to the political needs of the moment. Issues of censorship in relation to the family,
community, violence and peace need to be explored and addressed.
Freedom of expression today is under far more threat than ever before. On the one hand
there is the state and its reluctance to provide information, which itself makes for a censorship
of thought and discussion. On the other, how docs the state intervene and protect the right to
freedom of expression when it is curtailed by right-wing or militant groups? What forms of
expression does the State protect, and what forms docs it deny or worse, allow to be destroyed?
To look at the freedoms that different groups of citizens have sought in specific historic contexts
and to trace the forces that come into play to promote or prohibit that right, would be useful
at this juncture. How do formal and informal, but nonetheless, powerful, censorships come into
play with converging or conflicting interests? What is the nature and agenda of gender-based,
caste-based and identity-based censorship? How does language itself censor? What are the issues
that havt been raised through various periods through different movements? How has the state
responded in terms of protecting or suppressing human rights in the context of rape, violence,
homosexuality, minority and dalit issues? Given the range of concerns that emerge, how do we
understand the context, mobilization and responses in terms of policy.
How does freedom of expression operate in relation to the film media? To the electronic
media?

How does one view the glamorisation of violence and sadomasochistic sex through

highly advanced and sophisticated technology that operates at subliminal levels? What does “free
choice” imply for a passive audience?
This plenary will attempt to raise these questions and open up these contentious areas for discussion.
\Coordinator : Vasanth KannabiranJ Asmita Resource Centre for Women 10-3-96,
Plot

283,

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email: asmita@hdl.vsnl.net.in

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Secunderabad

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Telefax:

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Closing Plenary

MADHURI SHAH
MEMORIAL LECTURE
BY
ARUNDHATI ROY

SOUTH ASIAN PANEL
J

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HAMEEDA HOSSAIN, Bangladesh
SUNILA ABEYSEKERA, Sri Lanka

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National Conference on
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co BWilizinj for Change:
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Possibilities and

Challenges

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This sub-theme focuses on the mobilization of marginalised women in urban and rural
contexts.

Our main aim is to look at innovative strategies for empowerment, development

(JO and change through the eyes of the women who are involved in such initiatives. Through
this process we try to critically assess the potential of women’s collectives to address issues
and agenda involved in development and social change.
Of central importance to us are the enabling structure and processes of mobilization,
the emerging agendas of women and marginalised groups, and the ability of women’s collectives
to create an identity and space for themselves which can help sustain action and change.
Among the main concerns addressed by women presenters are: the demand for rights
to sustainable livelihood and a healthy and educated life, an end to violence against women
and children, the ways and means to influence local self-governance and ensure accountability
of governmental systems and services.
As a beginning orientation for our learnings, we will use the experiences of grassroots
peoples and the Henry Martyn Institute (HMI), which works with urban woman in the
bastis of Hyderabad; Mahila Samakhya, which runs a government-funded initiative to mobilize
women for education and empowerment in over seven thousand villages; and Astha, which
helps to catalyze and support people’s movements in both urban and rural contexts in
Rajasthan. Brief presentations on people’s initiatives associated with these three organizations
will help to highlight both encouraging stories of positive change, as well as challenges
inherent in mobilization activities at grassroots levels. We are particularly concerned with
organizational and justice issues which arise when working for women’s empowerment.
A critical study of women’s work as mobilizers and mobilized gives us insights into the
invitations, dilemmas and contradictions of practical initiatives for social change.

Our

collective reflections also provide an occasion to better understand the possibilities and
problems of integrating and mainstreaming gender concerns, as well as forming more effective
short and long-term public policies.

[Coordinators: Diane D* Souza] and|~Kameshwari Jandhyala, | Henry Martyn Institute,
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IXth National Conference on
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in Panchayats
Role of State and Civil Society to
Strengthsien Women's Emerging Leadership a

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Rural women have come a long way in their representation in the institutions of local

1 ) governance since the beginning of this century when even the request for constituting a village
GO panchayat could be made by 20 adult male residents. For decades thereafter, they could only have
a token presence of one or two coopted/nominated members. The 73rd Constitutional Amendment
in 1993 became a watershed when it mandated their one-third minimum representation in these
bodies.

The elections after this amendment have brought women across caste, tribe, class and

regions in critical numbers and, most importantly, not only as members but also as chairpersons.
What is the experience of these women? What are their supports and constraints? How has the
state supported them in their new public role? What is their impact on these institutions and how
has their role impacted on their own
aspirations, confidence and attitudes.
<
Womens entry in panchayats has been preceded and accompaincd by various myths about
their passivity and disinterest in politics, only well to do and upper strata women coming through
reservations, their political connectivity - only kinswomen of earlier pradhans and powerful political
leaders entering panchayats and, lastly, that all these women are only proxy, namesake members.
Data from ongoing studies in different parts of the country question these myths and document
womens awareness levels, participation in panchayats, their confidence levels and new political
aspirations.

Noting the beginnings of the empowering process, it also notes the resistance of

patriarchal structures and the back lash and counter forces trying to discredit the experiment.
The sub theme seeks to share women’s experiences especially in states which are generally
dismissed for exhibiting backwardness on most of the indicators of social development.

It also

seeks to explore the role of the state and various actors in the civil society in strengthening women’s
emerging leadership at the grassroots level. It hopes to contribute to the current debate on the
need, nature and justification of mandated reservation of women in the political sphere and how
best they can use their new political space.
The sub theme will focus on successful and innovative coping strategies and the role played
by various social institutions and women’s collectives, with special emphasis on
alternative models of womens coalitions, networks, information systems, which include
women in panchayats as well as other women, appropriate for different times and places;
emerging success cases of the supponing role of the state and other actors in strengthening
women’s capacities to cope with and build on their new roles.
[Coordinators-. Nirmala Buch] and|c. P. Sujaya, Centre for Womens Development Studies, 25, Bhai
Vir Singh Marg; New Delhi 110 001, Ph.: 011 3345530, Fax: 011 3346044, email: cwdslib@sansad.nic.in

13

*1

GO [Engendering!

New and Emerging
Community
and
^^Responsibilities in Natural
Resource Management

£ ■Easnsn Rights

lEflil National Conference on
Women ’s Studies

PQ The tnterhnkages between gendered power relations and natural resource management have been recognised
y activists, researchers and policy-makers, but are as yet insufficiently concretised. This task has become
CO urgent as people’s local livelihood strategies and development choices are being swiftly transformed by
then own changing perceptions, national policy interventions and global trends. Access to, control and
use of natural resources are determined by gender, class, caste, and ethnicity - a dynamic process which
is constantly being negotiated and contested. As producers, consumers, conservers and distributors of
natural resources, women’s rights to resource use and responsibilities for resource management are
shnnlcing tn some respects, expanding in others - affected by multifarious factors such as the seasonality,
margmahry or productivity of the resource; new spaces emerging from social movements for the assertion
o commumty/group rights; the positive/ negative impact of state policies; and the creation of new
rights as in wasteland and watershed development programmes. This sub rheme, therefore, seeks to
focus on key aspects of the new spaces, and emerging community rights and responsibilities, in natural
resource management. Location-specific presentations, which document the process of gendered interventions
would be welcome, particularly from the north-eastern, arid and coastal regions of the country, with
special emphasis on any or some of the following aspects:
’

Establishing the linkages between gender and natural resource management - through empirical
case studies of changing livelihood strategies of specific nomadic, hill, forest,

wetland,

grassland, coastal and island-dwelling groups or communities.
Integrating gender analysis into community-level natural resource r
management projects - through
documenting recent or on-going field experiences of the problems, conflicts and solutions
at
the planning, data-gathering, technological intervention, and impact evaluation stages.
Assessing the impact of changes in resource management policies and practices on gender relations through analyses related to the procurement, use, conservation and development of natural resources (such
as non-tlmber forest produce, aquatic-marine resources), at both the household and the community levels.
Identifyrng customary and new institutional and legal mechanisms for gendered benefitsharmg - through examples relating to the use of natural resources, both within households,
and between communities and local and outside institutions/agencies.
It rs expected that the exchange of experiences through the presentations and discussions
would help to refine field-level methodologies and to suggest critical action points for policy
interventions, at the local, State or central levels.
[Coordinators-. Sumi Krishj^] ancl|_Narayan Banerjee) Centre for Womens Development Studies, 25,

14

Bhai Vir Singh Marg, New Delhi 110 001, Ph.: 011 3345530, Fax: 011 3346044, email: cwdshblSsansad.n’ic.m

oo
W

Meeting•!|the Evolutionary,
and Ethical Needs of
Cultural_____
Communities
N

3^

Feminist Critique of the Gap

f—i

between Food and Nutrition

National Conference on
Women’s) Studies

pq Thjs sub theme will seek to critique the current food policies arising out of economic liberalization

!

from the standpoint of women. It is premised on the belief that women in traditional societies had
G/0 a close relationship with food and were involved in its various stages of growth (from sowing food crops
to its harvesting, threshing, storing and preservation), and its preparation for consumption.

The

growing commercialization of food, promoted by the government food policies, are not only usurping
womens traditional areas of control, but are also alienating communities from their cultural moorings.
The roots of this alienation can be traced to the reductionist world-view, which since the
16,h century, has coloured the growth of scientific and technological knowledge. The corollary of
such a world-view is the prevailing conceptual dualism of mind/body, nature/culture and man/
woman in scientific knowledge. Feminist scholarship has increasingly questioned this mechanistic
construction of the human body (seen as comprising, like the automobile, various body parts) and
the separation of the human physical self from his/her mental, emotional, cultural and spiritual
potential and needs. They contend that this model of the human body has generated a fractured
image of food and nutrition, which has led to short-sighted food policies. The much celebrated
Green Revolution, has failed to wipe out hunger and has threatened the future food security of
the world.

An equally dangerous fall-out of the use of hybrid seeds, pesticides and artificial

fertilizers/feeds as well as irradiation of fruits and vegetables (supposedly to increase shelf life of
foods) is their impact on the nutrition. The recent outbreak of the Mad Cow disease in Great
Britain is only one manifestation of the reductionist view of food and nutrition.
In the current climate of global economics motivated by the profits that would accrue to them,
supranational corporations are promoting foods that, on the one hand, have no nutritional content,
and on the other are alien to indigenous cultures. The process, not only fails to meet the evolutionary
and cultural needs of the people, but is also robbing women of their access to and control over foods.
Deprived of their productive roles, women are increasingly undervalued and objectified. The trend
is also exacerbated through the promotion of crop mono-culture and controls over food resources
through the patenting of seeds and other natural resources.
From a holistic understanding of the human identity (i.e., an understanding of the human being
!ing
a5 eing closely connected with his/her environment) this sub theme questions the very premise on which
generadon and the
the current food policies
buiIt
highJigbK the
of
which surp^es research findings that contradict rhe generally accepted paradigms of scientific knowledge
Po°nacha.|Research Centre for Women's Studies,
400
Vitha‘daS Vi<lyaVihar’ JuhU CampUS' Juhu Road>
400 049. Phone: 022 6128462/Ext. 227, 297, Fax: 022 6161001, email: rcWssndt@bom3 vsnl net in

15

CO

Policy and Peopl e
PublicJ

National Conference on
Women's! Studies

in Prostitution and
MSex^Workl

PQ

The concept of the debauched, debased and deviant woman has always governed public opinion on
women in prostitution. Women have therefore been policed, coerced and raided, to be rescued, reformed
and rehabilitated by a society that would “like to order and control their life styles”, regulate or abolish
prostitution. In recent years, the discourse around prostitution has changed and is now couched in the
language of human rights. Feminists, theorists and prostitutes’ rights activists are involved in unraveling
the complex and complicated world of sexual autonomy, free choice, sexual exploitation and the agency
versus victim debates. This discourse has helped in that it has shifted the focus from blaming the woman
and her sexual preference to a continuum ranging from the ‘beneficial exploitation of the institution of
prostitution’ to the ‘inherent victimisation of the woman in prostitution’.
It is apparent that while the “prostitution question” will continue to be debated and arguments for
and against, whether voluntary/forced, ‘agency’/victim, trafFicked/socialised, legal/criminal, sexual slavery/
sexual autonomy, exploited/liberated, will continue to occupy theorists, activists, and governments, prostitution
as experienced by the women themselves is not given the kind of recognition it deserves in these debates.
The discourse unfortunately does not recognise the day-to-day struggles much less the strength of
a minority community comprising mainly of women who face the brutal and criminalised world they
inhabit. It is a struggle that is fortified by a socialisation that encourages and strengthens their ability to
deal with a hostile and violent environment. A community that has repeatedly scorned the anempts of
mainstream patriarchal society to control, regulate and abolish the institution of prostitution. It is a
community that is fighting for a voice in all the debates. In India, as in most countries of South Asia,
legislation on prostitution connects prostitution with trafficking. The Immoral Trafficking Prevention
Act, 1986 believes that women in prostitution and sex work, are victims of pimps, brothel owners and
madams and therefore need to be rescued and prostitution regulated. Prostitution is believed to be
‘commercialised vice’ and is viewed as synonymous to ‘immoral trafficking’. In fact that prostitution is but
one site for trafficking is not acknowledged. All women trafficked are not only for ‘the purpose of
prostitution’, and not all women in prostitution and sex work are in the trade due to being trafficked into
it. There is a need to define trafficking as separate from prostitution and sex work. Women in prostitution
and sex work constitute a community that bears and will continue to bear the greatest impact of the HIV
epidemic in India. Communities of women in prostitution and sex work continue to suffer high levels
of infection and re-infection. HIV may infect the children they bear. Apart from the stigma already
attached to their work, society has further marginalised them as core transmitters of HIV infection. It
fails to recognise that they are but links in the broad networks of heterosexual transmission of HIV
The sub- theme will cover various issues concerning prostitution and sex work and will address the
problem from the standpoint of • Laws that affect people in prostitution and sex work. • Trafficking as
separate from prostitution and sex work. • HFV/ AIDS and women in prostitution and sex work.
| Coordinator. Meena Saraswathi Seshu,|B-ll Akshay Apartments, Chintamaninagar, Sangli-416 416,

16

Telefax: 0233 311644, email: meenaseshu@yahoo.com

uo Gender, Conflict and
N
Political Violence

CQ

IXth National Conference on
Women’s Studies

The point of departure for this discussion is the increasing conflict and violence that women have
had to face in India - and indeed in South Asia -in recent years. This has important implications both
for public policy and development because its impact can be felt in economic, political and social
structures and on questions of governance. India is not a region of conflict in the same way as countries
like Guatemala, Liberia, Kosovo might be said to be. However, the increasing instances of conflict that
have taken place in the country in the past several years are disturbing enough to warrant serious
attention. They draw our attention to several important aspects: we can no longer be complacent about
the general non-violence” and “peaceableness” of India; we must face up to the very real possibility of
the increase and escalation of the kinds of conflict we have been seeing; we need to carefully examine
the increasing militarization of our society, and how this both creates and results in further conflict. The
question of gender is central to all these discussions.
The kinds of conflicts we plan to focus on in these discussions include: political and military
conflict such as we see in Kashmir and the North East and most recently in Kargil; ethnic/religious/
communal conflict such as has been visible in different parts of India in recent years; ongoing caste
conflict and persistent attacks on dalits and minority groups. Our attempt in the discussions will be
to examine the complexity of violence that marks our society today and to examine also the continuum
of violence whereby political violence can escalate into armed conflict and vice versa. Further, to ask
how these affect the daily lives of ordinary people, and particularly the most vulnerable sections of
society such as women and children. The vast amount of work on political violence has mainly focused
on violence and conflict as primarily male domains, and has seen it as being carried out by men on
male armed forces, guerrillas and other perpetrators of violence.
These discussions will therefore examine the following questions: How do women in particular
experience different kinds of conflict ? How do women participate in and internalise the ideologies of
conflict ? What are the States responses to womens needs in times of conflict - e.g. what is the law
on compensation, on loss of life and limb, on damage to womens health etc in times of conflict ? What
are the implications of increasing militarization for women? What are the implications of increasing
militancy for women - how do women get drawn into the ideologies of militants, of the right wing,
or the private armies and of “military” like groups such as the Bajrang Dal and others. How do they
come to serve as couriers/ messengers etc for the army and security forces in times of conflict. What
are the circumstances that push women to these steps, and what is it that draws them to such ideologies;
what, in addition, are the implications of such involvement for their lives.
The sub theme will focus not only on women as victims of conflict but also as its agents, and
to look at the role women have played as peace makers, as well as examine the quality of that peace,
its sustainability, its fragility and its importance for women.
Coordinator'. Urvashi Butalia, [Kali for Women, B 1/8, Hauz Khas, New Delhi-110 016
Telefax: 011 6864497, email: kaliw@del2.vsnl.net.in

17

E22 National Conference on

Women
N ^Business
CZ^

Womens Studies

w
X
The slow but steady in
increase in the position of women in Small Scale Sector in the Indian
J—economy would be attributed to policy initiatives taken by the Government. It is increasingly being
GO realised by decision-makers that wide spread poverty and stunted development cannot be tackled
without providing adequate opportunities for productive employment of women. The Government
conferring statutory status to the National Commission on Women, the reservation of a certain
percentage of seats for women in local self government bodies and institutions of higher learning create
avenues for bringing women into the mainstream.
During the Seventh Five Year plan an integrated multidisciplinary approach was adopted covering
employment, education, health and other related aspects on areas of interest to women.
The Government as part of its planning policy from the Fifth Plan period onwards has been
giving preferential treatment to women in finding them employment in the organised sector as also
in encouraging, equipping and facilitating them to become entrepreneurs. The measures taken include
announcing special schemes for women entrepreneurs, preference in allocation of sheds in industrial
estates, financial assistance, exclusive industrial estates for women and encouraging them through the
institution of awards for entrepreneurs.

Financial institutions and other development agencies have

taken a cue from the Government and are supplementing their efforts.
Despite the encouragement given by Government and other developmental agencies the progress
of entrepreneurship development among women in India has not been satisfactory. There is no dearth
of programmes favouring women but unfortunately the policies could not integrate women into the
mainstream of society mainly because of lacunae in the implementation process. In recent years it has
become increasingly evident that women still lag behind a great deal both in availing of the benefits
of developmental programmes due to several socio-cultural political blocks and the impassivity of the
implementing system.
This sub theme will examine
ine policy initiatives, entrepreneurship modules and the organisational
support available in fostering women empowerment through enterprise development, while focussing
on the role of governmental and non governmental agencies in strengthening women.

{Coordinator: C. Rani, [National Institute of Small Industry Extension Training, Yousufguda
Hyderabad-500 045, Phone: 040 3608577, Fax: 3608547, email: nisiet@hdl.vsnl.net.in

18

■

Against
Women

IXth National Conference on
Women's Studies

uq

H
pq

Violence against women is today, as a direct result of the Beijing Conference, assuming
centre-stage as a serious development and human rights issue within the national and

09 international arenas. The need to develop new and innovative strategies to ensure the elimination
of violence in the new millennium, is being recognised increasingly. In India, the women’s
movement has been able to consistently push the issue of violence on the national agenda.
The activism of women’s organizations has been instrumental in both enhancing the
understanding of violence against women and in generating innovative responses to the
issue. This in turn has not only resulted in amendments in law, setting up of shelter homes
and counseling services, but also community responses such as neighborhood watches, women’s
courts and social boycotts. Although much ground has been covered, we need to take a
reflective look at existing data sets on violence, what has been accomplished and what more
needs to be done to achieve the elimination of violence against women.

I

This sub-theme aims to address some critical concerns, like the cultural and regional
variations in violence against women, if any, norms of acceptable behaviour in public and
private spheres, the relationship between domestic and state violence to state a few.
The documentation of violence by institutional systems like police, courts, hospitals
and NGOs is very important. This sub theme proposes to pinpoint the specific problems
faced in this area. These responses of the state and NGOs to the issue of violence have to
be evaluated in terms of their strength and lacunae. Our focus has to be on strengthening
the legal responses alongwith seeking community participation. Since violence is a critical
development issue, the sub theme plans to highlight the interconnections between violence
and development and the impact of economic restructuring on violence against women.
Finally the sub theme will also raise the question of how violence against women is
being re-viewed as a human rights violation within India, the issues around sexual exploitation
of girl children with respect to trafficking and trends pertinent to South Asia.

Coordinators: Nata Duwury, Anuradha Rajan [and |Seema Sakhare, |International Centre
for Research on Women, F 81 East of Kailash, New Delhi 110 065, Telefax: 011 6283933,
email: icrw@ndf.vsnl.net.in

19

r

PRE CONFERENCE WORKSHOP

Information Dimensions for

E33I! National Conference on

Women’s

Women's Studies

An Agenda For The Future
7th January, 2000, Hyderabad

The Centre for Womens Development Studies in collaboration with the Indian Association for Women's
Studies is organizing a one day workshop on “Information Dimensions for Women's Studies: An agenda
for the fitture" to be held on

January 2000 at Hyderabad. The workshop will be a pre-conference

feature to the IX National Conference of Womens Studies organised by IAWS from 8-1 l‘h January 2000.
There is growing recognition at the international, regional and national levels of the critical role
of information for women’s studies research, action, advocacy and policy planning. Such information
is being generated continuously from

a variety of sources. There is constant flow of information

coming out from various levels of intra-governmental and governmental agencies, research and academic
institutions, women's organizations and also a number of commercial publishing houses.
The task of collecting, preserving, processing and disseminating this plethora of information in
its myriad forms is undertaken by Libraries, Information and Documentation Centres, Archives and
Museums. The inter disciplinary and cross sectoral nature of women’s studies, the varying needs of user
groups in different environment, the diffused nature of information available, the multiplicity of format
in which it is found makes the task of these agencies a difficult and complex one.
The one day workshop aims to highlight the role of Libraries/ Information/ Documentation
Centres/ Archives and Museums in providing information inputs for womens studies. The workshop
will also focus on the role of information networks and the use of traditional and new information
technologies for collecting, processing and disseminating the information. It would also try to assess
what has been achieved in the last few decades, analyzing the gaps and planning future strategies to
ensure equity of access to information.
The workshop provides an ideal opponunity to bring together on one platform the diverse
perspectives from womens libraries, archives, museums and information and documentation centres to
strengthen our understanding of this highly evolving area of womens studies information.
The workshop will consist of panel discussion invited talks and paper presentations. It would be
limited to 30-35 panicipants. Papers are invited on the above mentioned issues. Only selected papers
will be presented at the workshop due to time constraint. However, the Centre plans to bring out the
proceedings of this workshop where the other papers would be incorporated.
Last date for receiving the abstract (250 words) is

October 1999. Final papers are to be sent by 30* November 1999.

Travel grants will be made available to the paper presenters.

{Coordinator: Anju Vyas,|Centre for Womens Development

20

Studies, 25, Bhai Vir Singh Marg, Cole
Market, New Delhi 110 001, Phone 011 3366930, Fax: 91-11-3346044 email: cwdslib@alpha.nic.in

'

Stri Vividha

-

[ESQ National Conference on
Women’s Studies

Countless groups across the country are working to enhance the lives of women. Some of these efforts are experimental,
some quite fully viable and now working their way into mainstream. Some of these activities concern themselves with
education and communication, others seek means of livelihood for women; but all work within a framework of
panicipative, sustainable and equitable ways of living.
At the 9th National Conference of Womens Saidies to be held in Hyderabad in January 2000 we will have
a development resource fair called Stri Vividha celebrating the vitality of such alternative efforts centred around
women. While the conference would concentrate on academic discourses and debates around the theme of womens
perspectives on public policy, Stri Vividha could bring these issues into the public arena by making a popular event
of it. In other words, the fair hopes to be a bridge between the city of Hyderabad and the Conference, a unique
cultural event attracting a section of people who would not otherwise attend the conference.
Proposed features of the event
•

a mcla, an open platform exhibiting and selling womens literaoirc and products made by them. (As important
as the display of the exhibits would be the interaction between visitors and panicipants which would forge
new partnerships, encourage alternatives to prevalent forms of marketing, give crafr producers an insight into
buyers demands and stimulate creative exchanges);

•
•
•

a photo-documentary exhibition on women workers;
a festival of documentary films on womens issues;
a platform cafTheta - an interactive refreshment comer which would encourage interaction between the
conference delegates, fair participants and the people of the city. It could provide informal space for book
hunches, debates and impromptu cultural shows by fair participants;

•

a publication/a handbook on laws concerning women workers. This could include programmes and policies

on women workers as well as a directory of agencies and government schemes applicable to women workers.
Those of you who had been to Pune in 1998 would remember our previous Stri Vividha. We would like to
have your suggestions on organisations which could be invited to participate in the fair. Both producers of literature
and other resource materials and producers of craft and food items are welcome.
We would also invite your suggestions for the festival of documentary films on womens issues. A selection
committee for these films is being formed, and after inviting entries, they will review the films and put the
programme together. If you are planning book launches, public debates, press statements or would like to put on
informal cultural shows during the conference, do remember you have a stage at the Platform CafTheta. Please book
with us in advance, for we would seek press coverage of your event The cafTheta would expect heavy traffic between
6 and 8 p.m. daily. January 8-11 comes within Ramzan, so a daily iftar spread of fruit chants, halim, kebabs and
so on would be an added attraction.
As with all such events, regrettably, space is limited, and we will have to select a representative list out of
your suggestions. The final list of invitees should represent both a regional balance as well as a range of activities
and products. Please write with your suggestions to Devasmita Menon at Comet Media Foundation,
Topiwala Lane School, Lamington Road, Mumbai 400 007, Phone: 022 3869052, Fax: 022 3870901,
email- admin@comet.ilbom.emet.in giving names and addresses of likely organisations, and the names of key persons there.

21

s,
Conference; Schedule

I CT fl National Conference on
Wjomen^sl Studies

i .

1
Day I

8 January, 2000

9.30 - 10.15

Welcome Address
Vasanth Kannabiran, Asmita Resource Centre for Women
Vina Mazumdar, President Indian Association for Women’s Studies

10.30 - 1.30

Panel I: Women’s Perspectives on Public Policy

2.30 - 5.30

Sub Themes I

Day II

9 January, 2000

9.30 - 12.30

: Panel II: Tribal Issues and the Women’s Movement

2.00 - 5.00

: Panel III: Moving Beyond Wombs

Day III

10 January, 2000

9.30 - 12.30

: Panel IV: Reservations Policies and the Women’s Movement

2.00 - 5.00

: Sub Themes II

5.40 - 7.30

: Annual General Body Meeting of the Indian Association for Women’s Studies

Day IV

: 11 January, 2000

9.30 - 12.30

: Panel V: Censorship and Silence

1.30 - 2.30

: Madhuri Shah Memorial Lecture

2.30 - 4.00

: South Asian Panel

4.30 - 5.30

: Sub Theme Reports
: Vote of Thanks

22

1

I

Indian |Association for
9 Women’s Studies
Executive Committee 1998-2000

Vina Mazumdar

President

Rama Melkote

Vice President

Kalpana Kannabiran

General Secretary

Divya Pandey

Treasurer

Bina Srinivasan

Joint Secretary

Gcctanjali Gangoli

Editor

Members:

■3

• Bina Agarwal
• Chhaya Datar
• Jayshree Vencatesan
• Maithreyi Krishna Raj
• Nandini Upreti

•I
i

• Nirmala Banerjee
• Pam Rajput
• Rohini Gawankar

I

• Seema Sakhare

I

• Vatika Sibal

i

.S'
Towards Comprehensive Women’s Health Policies and Programmes”
Workshop 6-9, October, 1998 at ECC, Bangalore

Sr. Eliza Kuppozhackel
; Medical Mission Sisters, USHUS
Collectorate P.O.
Kottayam - 686002
Kerala

T.S.M. CAN BE
CLASSIFIED AS
• Drug Therapy
• Drugless
Therapy
DRUGLESS
DRUG THERAPY
Drugs are used for
No Drug but use
T reatment
Touch / Pressure
eg:
and other gadgets
• Alopathy
for Healing.
• Ayurveda
• Unani
• Siddha
• Homoeopathy

I

Some of the Therapies practised
in India are:
Accupressure
Accupunture
Belly Pressure
Diet Therapy
Hand & Food
Reflexology
Heat Therapy
Herbal Medicine
ICN/SPS
Jin shindo
Kalari
Magneto Therapy
Marma Chikilsa

Massage
Moksa
Naturopathy
Oriental Medicine
Polarity Therapy
Pranic Healing
Reiki
Sujok
Yoga Therapy
Zone Therapy
etc.,etc

Herbs for Morning sickness
1. Corrianda

- Soak 1/2 tsp in 1/2 glass water overnight
and drink that water in the morning.

2. Lemon Seeds ■ Grind and mix with water or honey
and take.
3. Tamarind

a) Tender leaves dried in the shade powder and keep
Take one pinch when ever nausea or
vomiting sensation occurs.

b)Tender leaves can be eaten fresh.
India has rich variety of herbal home remedies.Tribal
medicine has effective remedies for birth control,
fertility & General health.These need to be identified,
learned and promoted in health care approach.

Herbal Medicine
Grandma’s Remedies |Diet Therapy

-1

- Herbs used as food and
medicine.
- Traditional single therapy
for various ailments.
- Special herbs traditionally
proven for its effectiveness
available for women and
Health.

Examples :
1. Hibiscus Flower (red-Five petal flower)
rich in iron and B complex

For general Health,
Anemia,Uterine problems ,
Fertility,Menustral pai
ain,
Irregularity etc. (not to be used
during pregnancy)

2.

good for anemia.
good tonic for pregnant women.

Goosberry Tonic -

*")

DRUGLESS THERAPIES

)

Basic Principle :

Body has its own healing power.
Healing happens from within.
A holistic approach to the whole
person.
Vital energy/life force Balancing / Harmonising for total health - well being.
Yin & Yang Balance
Less side effects.
Leads to promotion of health.
Works on 3 levels :
Cure -Prevention -Promotion.

Dnigless Therapy Types
•

Using Touch /Pressure

•

No touch - works on energy level.
Bio plasmic body / Aura
eg:- Pranic Healing

I

Drugless Therapy ; Application in W & H.
- Can be learned by anyone with average intelligence
- Can be practised in simple settings Home , Community centre, Clinic
- It requires no technology
- Can be made easily available in the villages and
rural areas
- Practitioners can be trained by NGO’s having
knowledge & experience
- In Kerala 10000 people trained in Pranic Healing
-75 Pranic Healing clinics all over Kerala
- More than 20 trainers available for training
- One year Diploma course conducted for training
healers
- These can be employed in W & H programmes.
- In schools teachers trained in P.H.treat children/girls
for Head ache,giddiness, stomach problem,
cold & cough,fever,dysmenorhea,fainting etc.
- If more lady teachers are trained in this they can heal
the health problems related to adolescent girls in the
school.

PRANIC HEALING
Pranic Healing Foundation of Kerala has experience of training people at all
levels irrespective of caste, creed and class. It has appeal to all classes - high,
middle and poor. Majority use it for self healing and healing their immediate
family. Therefore, dependency on drugs for even simple ailments is brought
down.

People in office, work place, neighbourhood are helped by service minded people
sharing their gift of healing.
In one village health workers and other selected men and women from the village
were given training. Some of them became experts and were called even at
night to help relieve asthma attacks and so on.
The training given to one tribal group proved very effective and hey became good
healers.
There are successful stories by healers of treating several chronic ailments like
Asthma, Artheritis, skin diseases, heart problem, diabetes, infertility, menstrual
problems and disorders, urinary tract infection, eye problem, hearing problem etc.
etc.

II has also been successfully applied in several cases of cuts, wunds, bums,
bleeding, insect-bites and even snake bites.
Illness in children can be easily be treated by Pranic Healing.

heal,ng techniques which are becoming popular At th
work out mechanisims for supervision and effe r
and use it for seif heip and beiplng others

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• - women in the deprived sections still remain . the challenges can he distinctly described asi

' arising out a( two set al conditions. ?)n the lirst set o( conditions the ch/Me.nyc.s spring hompauerlq . landlessness, paar livinq conditions o( themltan crowded dwetUnqs and the hhe.

he second set al challr’-nqes have leen pcrpetiuitcd by the very pwcess al development .
^bhe modern pa radiynv al ‘de^uclopment has hq and la rye heen anti -women besides also betny

anti-poor and anti-e-iudroiunent. daod seenrity at the household level and nutritional status'
are two sides ol the same' coin. cA broad delinitron al load seeurtUj will include not merely

consumption ol load but lood production as a sautc.c of livelihood acid a balance tie tweenmcf zkct (a rces and nuhlic policy. Auriher load security means
protcctiiry the natural resources that cantubuie to the production a,J load.

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resources Uze latul ULGtez and (uadiw-i&ibf tfiat-

i/ie- basic- needs a/ people-

FOOD SECURITY7- PRIMARY7 AND SECONDARY
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/and\ entitlement/ and not

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micro environments (ai' theii (ood needs'.

3

T)t has fleen estimated in absolute tczms that the guantities al load culled outof the-(azests and
common p-zopezlg zesanzeos/ is upto i0% az so of the total load consumed hg the paoz/ zuzai

hiausehalds. Tt is also well known that apazt (zam tzaditionai zales. latest loads au^
exteivsiALebj used ta p to aide' load cone-zed dating pcziads al extzeme stzess and at times al
ienzpazaiq scazcAity auet/coztain pazls a^ the/geaz. sdnu-tatta designates this as htidging
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una wufafife.

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la sedloads like' cezeals and pufses a ze' a aai la Ide Izamthe timeal hautest l^aiuzazu^uht),

they diAiensitii al load is'auailaAfe/ in the- lawn al q teens, in the ensuzijzq peziad. 11 lang/
pezeruzi-als stazt qieldinq duzinq/ the- zains/. "Xohe dependence an tu&ez&i& zeleuant duzinq- the
seasons uthen cezeals zeseyutetis low. do he.' neigh toming latests a teas also pzooeta lo a son zee
al food like potatoes, suiee-tpotatoes and lamhaa sfzaats. ^It is appazent that luhat the- mazket

has to allez thent lac may- al load is' ne ut little' and that too anfg lo t/ a lew months in a geau
^hhus it is maze than afuians that women s zale in ensuung load seeuzitg is ctucial and the
key- to it lies in the' consenaati-aiv al common pzapezlg zesouzces.

THE ECONOMICS OF FOOD PRODUCTION - A POST LIBERATION
SCENARIO
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HD GENDER CONCERNS
I

OctotDber-1998

Women’s Health and Development Resource Centre

Chaltanyofl

CHETNA

“WOMEN’S
HEALTH
CONCERNS:” CHETNA’s
and Programmes

AND
GENDER
Prospects, Policies

Ms, Jyoti Gade and CH ETNA Team

OCTOBER, 1998

Paper presented during a workshop on “Towards Comprehensive Women’s
Health Policies and Programmes” held between October 6-9, 1998 in Banglore,
India, organised by Volantary Health Association of India (VHAI), New Delhi &
Women And Health (WAH!) network, Sponsored by The German Foundation
for International Development (DSE), Germany.

CHETNA

WOMEN’S rHEALTH
---------- AND GENDER CONCERNS:”
CH El NA s Prospects, Policies & Programmes

ABOUT CHETNA:
Cm
aWare"ess’. in several Indian languages is an acronym for
.11 i j Health Education, Training and Nutrition Awareness. CHETNA was
established in 1980 as a project to improve the impact of supplementary feeding
cwtx ZT
W°men 3nd chlldren’ in the state of Gujarat, India. Since then8
NA has been actively involved in addressing women ’s health and development
appr°ach Particu]arly in the states of Gujarat and
Rajasthak

^omen and children, so
their families and communities health.
A the procef. Of imPlementing its health and development programmes,
HETNA i ecognised that gender discrimination is one of the important determinants of
women s low health status. Therefore, understanding and addressing the implications of
gender relations and enlisting the participation of men and the community is central to
its ettorts in enhancing women’s health and development.

Presently in its analysis and approach, CHETNA considers the totality of the political
economic and social factors that shape women’s enviomment particularly, which affect
women s ability to control and improve their health status.

2. NEED FOR GENDER INTEGRATION IN WOMEN AND
HEALTH PROGRAMMES OF CHETNA.
Historical Perspective:
Integrated Nutrition and Health Action Programme (INHAP): 1980-84

CHETNA started its activities with a project entitled INHAP in 1980 whose purpose
was to improve and assess the impact of supplementary feeding programmes in 100
villages all over in Gujarat the project was managed by Government of Gujarat with
support from CARE. This was project aimed at pregnant women and children under six
years of age through the Supplementary Nutrition Programme (SNP). The project taught
us that the mere provision of supplementary feeding is not enough to improve the
nutritional status of pregnant & lactating women and children. Awareness raislhg of
family members and communities along with their active participation was found to be a
crucial aspect. The project also illustrated that, the programme should be implemented
in an integrated manner including appropriate control of mfectious diseases an
educational component and other support services such as emergency transportation,
and the provision of creches (for under three) etc. At present these needs such as
support services are classified under ^Practical Gender Needs’.

■

!

Child Survival Programme : 1984-1990

Based on the above experiences a ‘Child :survival’ programme was planned and
implemented. In this programme local women (most of themi non-literate and semi- ' |
literate daughter-in-law’s) were trained as health workers with the help of local NGOs.
The aim of the programme was to empower local health workers (from village
families) to enhance access and control of primary health care and promotion of
nutrition and health education at the village level in order to improve the health status of
women and children.

During the trainings within a short period, we realised that the training of local women
as health workers alone may not be adequate because they do not have decision making
power at the family nor at the community level. Therefore, the messages given by
them are not considered for implementation. For e.g. during pregnancy, a mother-inlaw decides what and how much should be eaten by the daughter-in-law who does not
have any say m such-aspects. Similarly at the village level most of the families are
extended families, where the final decision is made by mother-in-laws and men of the
families. Therefore, the participation of all family members particularly the decision
makers is very important for effective results. Also the importance of enhancing

I

health worker’s confidence and status to have decision making power in their own
lives and have equal partnership in family decisions was realised.
During the trainings it was also recognised that severe anemia and complications
during pregnancy is not merely due to pregnancy but she is already anemic since
childhood and severity become more during pregnancy due to the increased need for
iron. And it is a result of compounded discrimination of girl child from birth to
adulthood, therefore when an undernourished and anemic girl becomes pregnant, she
becomes severely anemic and hence complications arise due to this situation. Therefore
taking action only during pregnancy will not solve the problems, therefore health
services (both preventive and curative) should be provided from birth onwards in all the
stages of life cycle.

Age specific mortality is higher among girls compared to boys up to the age thirty:
Registrar General India, Sample Registration System, 1992.
In India eighty eight percent of pregnant women aged 15-49 are
anemic: Human Development Report, UNDP, 1995

This and several such incidences inspired us to seriously consider including socio
cultural aspects, apart from technical issues related to nutrition in our programmes and
trainings. We initiated a discussion on the impact of socio-cultural factors on women’s
health in CHETNA’s activities, which are now well accepted in the name of
GENDER’.

i

I

3. WEAVING GENDER INTO WOMEN AND HEALTH
PROGRAMMES OF CHETNA:
After realising the need for gender integration to improve women’s health,
efforts were made at different levels and in different ways. Capacity
building of our own team on conceptual clarity and strategies to integrate
gender in ongoing programmes was the beginning of this effort.

•3

j
■

3.1 Initiation of Women’s Awareness Generation Camps:
To strengthen socio- cultural and economic aspects of women CHETNA organised
several ’Women ’s Awareness Generation Camps’ during the course of the programme.

I
!
[

Other issues that were discussed included information and linkages for income
generation activities. Issues such as’Dakan ’1 (witch) were addressed.
Meetings with men and mother-in-laws were conducted in addition elder women were
encouraged to become presidents of Mahila Mandals, so that health and gender
messages could be accepted and implemented for pregnant women.
Based on the success of these camps, several demands were received for their
replication. However, due to the constraint of not being able to reach out to each village
of project areas, CHETNA initiated Organisers Training’ where health workers were
trained to broaden their role enabling them to organise such camps and effectively
follow-up on the same in their respective areas.

3.2 Organisational evaluation:

■

■

In 1990, CHETNA underwent an organisational evaluation facilitated by
the Society for Participatory Research in Asia (PRIA), New Delhi. Based
on the lessons learned from this CHETNA shifted their approach from
‘ MOTHER AND CHILD HEALTH ’ to ‘WOMEN AND CHILD
HEALTH’ (in the life cycle).
3.3 Capacity Building of CHETNA team on Gender Concept:
Meanwhile at CHETNA, clarity on gender concepts and planning was built including
its practical implication at the community level on various aspects of women’s health.
As a result, CHETNA trainers own capacities were developed on gender issues
including.................................................................................................................................
concepts, analysis, planning, monitoring (gender indicators), and evaluation.
One of the teams senior members was also specially deputed to a master’s degree
course in Women and Development at the Institute of Social Studies, The Hague,

1 Dakan: Generally in villages widows and infertile women are considered bad women and blamed as ’Dakan’. They
are not allowed to go to any celebrations. ?It is also considered that her evil eye is bad/harmful for infants and young
children and therefore she is not allowed to visit in any family of the x illage. Even her own family members disregard

I

I

Netherlands. Other team members also participated in short term courses organised by
FAO/Jagori, New Delhi and other workshops organised for experience sharing.

3.4 Building
activities:

of CHETNA’s Vision,

Mission,

strategy,

CHETNA’s
gender integrated vision and mission for women’s health and
development was developed by the team members.

\ ision. CHETNA envisages an egalitarian and just society where empowered women
and children live healthy and happy lives.

.^sion/ Goal: To enhance women’s health status by empowering them to gain
control over their own health and development.

Strategy’: To support GOs, NGOs and other autonomous agencies that work in the
states of Gujarat, Rajasthan and Madhya Pradesh (M. P), India, by strengthening their
capacities to implement and manage effective health and development programmes for
women and children.

Activities: Activities focus on awareness raising and sensitising, capacity building of
organisations, documenting experiences, developing/disseminating education/ training
material, networking and advocating on issues concerning children and women.
I

ay gender is weaved in all our activities.

3.4 Gender training plays and important role: Gender training at various levels is
an important aspect in order to integrate gender at the programme level. CHETNA
builds capacities of middle level workers including supervisors. However for training
to lead to change, it has been realised that if leaders must be sensitised to gender
concepts, so that middle level workers can understand and implement the concepts in
their own organisations or at the community level.
Gender Sensitisation Trainings for Leaders:

CHETNA builds capacities of middle level workers including supervisors, however it
has been realised that if leaders are not sensitised to gender concepts, middle level
workers can not implement the concept and understanding at their own
organisation/community level. Two days module has been developed for leaders which

starts from a macro perspective and moves to the micro level. Status of women, men in
Rajasthan, Gujarat, India, It’s reasons, concept of gender, patriarchy, importance of
gender planning and action from self, organisation and community at large.

t

Gender Development Training for Second Line Leaders and Middle Level
Workers:
Middle level workers from the same NGOs are trained and equipped to plan health |
programmes from a gender perspective. Some of CHETNA ’s training reports give an
in depth discussion on this. The basic aim is towards building an egalitarian society
where both women .and men have equal opportunities, power -sharing and choices in
life. However women are more discriminated against in the Indian patriarchal society,
therefore most efforts and activities are aimed to empower women in order to lucre
their bargaining power. A six to eight day module has been developed. The module ;
starts with self reflection of gender and moves to gender concepts and relations,
patriarchal structure, empowerment and planning of health programmes with a gender
perspective. Gender sensitive women’s health planning is done in of life cycle approach 1
(before birth, childhood, adolescent, adult and after 45 years of age) .One example is
given from a planning framework developed by CHETNA team members and ■
participants..

I

The following issues are taken into consideration while planning. Gender issues, >
concerns and reasons, area of action (self/family, community, own organisation, media,
education and govemment/politics level), desired outcome from strategic planning,
priority actions to be taken and resources required for implementation. Generally
changes (gender integration) are suggested within existing/ongoing program.

I

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Desired outcome priority actions :t

tegS action against
P— ah senior citizens to

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Sc’ &tag feasibility, resources required, skill and tune requtred drsctisses rn
detail.
I

Gender sensitisation training for ntiddie ievei workers and their fantiiy nte^
As already mentioned gender change

"XbeT^facilitate this

realised the need to have /°™n0" “"^“"Zrnodels for then own organ,sattons j

p * **

members waS!

organised.
3.5 Participation

as Resource Persons and Experience Sharing:

r>

' ' ; meeting to share its gender
CHETNA frequently participates in seminars, workshops
mid its ideology at the state, national and
and women’s health training experiences
international level.
(
„ person to deve.op Gender^
ln this regard during December 1993, a
rates of infant morbidity and m0^
for identlfying and
NGOs to enhance women s hea°
workshop was orgamsed by OXFAM ,
solLltlons for the same and I
d
for capacity building of!
addressing women’s heaith concerns^^U
finally to formulate a gender ba.
resource persons who integrated the |

^eo^^r^hX-doie for «ter —.
Similarly OXFAM, U.K. had..M
current priority ;■
?s”Cdev”lopment practitioners. A CHETNA team member actively!
^Gender Strategy’ through health |
participated in this meeting to share views on — education.

Before birth of a girl child:

Gender issue: Sex determination (if foetus is female, it being aborted)
Health Concerns due to above gender issue: Lower sex ratio of women, violation of
human rights, complications may arise due to abortion, unsafe abortions and emotional
stress to women due to abortion.
Reasons for practising the gender issue: Lower social status of female, social
practices such as dowry, parents cannot stay at daughters home in old age (patrilocal
and patriarchal families), myths such as if last rites are performed by a son person
goes to heaven, son continues family line.
Who perpatuate these practices: Mother-in-laws, husbands, mothers themselves,
religious leaders.
W ho perform sex determination test and abortions: Doctors, nurses, Traditional
Birth Attendant
Area of Action:

Self
Even if I already have
a daughter I will not go
for sex determination
testing during next
pregnancy

Family

Community

I will try to convince
Awareness of legal strategy for
and influence family
ban of sex determination,
members to stop this practice. Punishement if this practise
is followed including for
Try to create awareness
TBA.
among them

Changes in attitudes/practices are needed in the following institutions/peoples:
Doctors/lNurses: Enhance awareness of existing legal bill against sex determination.
Social awareness to discourage this practice.
Media : Information on sex determination bill, programmes which enhance women
status and equality, articles in newspapers.
Education : Text books emphasizing equal importance of girl and boy, status of girl
child and women.
Government/ Political parties : State security for old people, awareness campain to
enhance women’s status and existing of legal bill against sex determination.

CHETNA was an active team member for developing a Resource Kit on Womencentered and Gender- sensitive Experiences: Changing our Perspectives, Policies and
Programmes on Women’s Health in Asia and the Pacific it was specifically aimed to
share experiences, lessons learned and contained practical tools on the “how” aspects
of changing population, health and family planning policies and programmes to become
more women-centered and gender sensitive and to encourage the full implementation of
the International Conference on Population and Development (ICPD) Programme of
Action (POA), Cairo 1994 and the fourth World Conference on Women (FWCW),
Platform for Action (PFA) Beijing, 1995.

5 Documentation and Dissemination of Experience: CHETNA conducts
training mainly in the states of Gujarat and Rajasthan and some international invitations
are also accepted. In order to share CHETNA’s experiences, learning and ideas widely.
CHETNA document and disseminates experiences in regional (Gujarati), national
(Hindi) and English language. Recently CHETNA ‘s documentation centre has been
reclassified by the 'Akshara System’ a feminist system of clssification appropriate for
women needs.

Reports: Gender concerns and planning reports have been documented and widely
circulated. CHETNA has a documentation center and separate classification on gender.
Bibliography of reference material on gender is also available.
3.7 Reference material: CHETNA is actively involved in the preparation of
"erence material especially in the regional language. At present most of the gender
material is available in English. CHETNA adopts the same in regional languages. A
status paper on women and men (Gujarat, Rajasthan, India), A status paper on women
and men (South Asia), and a Gender and Development manual are some of the
examples.
A manual on gender sensitive indicators is developed for reproductive health
programmes in India. This manual has been developed to assist the health functionaries,
including programme manager, health policy makers and those influencing health
policy and programmes, in measuring how well gender concerns are being integrated
into their health programmes.
3.8 Publications: CHETNA tries to integrate gender aspects in all its publications.
There are some publications specifically emphasizing on gender aspects. Some of the
material developed were, ' A set of gender and health pamphlets’, Poster on the eve of
International Women’s day, a set of flash cards.

F

3.9 Research: CHETNA has recently undertaken to conduct a research study in
Women and Health (WAH!) training.

3.10 Collaboration with Other Organisations and Networks: It is

necessary to work with networks for the broader impact. CHETNA was active team
member to develop a Resource Kit on women- centered and Gender sensitive
experiences: Changing our perspective, policies and programmes on women's health in
Asia and the Pacific specifically aimed to share experiences, lessons learned ad
containing practical tools on the “how” aspect of changing population,^ health and
family planning policies and programmes to become more ’women-centered’ and gender
sensitive

CHETNA is also an active member of 'Health Watch' whose aim is to
promote and advocate gender sensitive women’s health policies
particularly reproductive health.
3.11 Advocacy: CHETNA is actively involved at the policy level to advocate
gender issues. For e. g. CHETNA is involved at NGO level to recommend and include
women’s concerns for a draft policy on women’s empowerment. Also CHETNA
participated in pre-Beijing meetings in an NGO forum to draft a United Nations
Platform for Action. In various workshops and forums CHETNA makes special eft^rts
to advocate women’s health from a gender, holistic, integrated and realistic peispecuve.
I

3.12 Special Efforts: Convention for Elimination of discrimination Against Women;
(CEDAW) is a United Nations forum where efforts wree made to eliminate all
discrimination against women legally and socially. The Indian Government has also •
ratified the CEDAW. However not much active action has been taken as yet on the <
same. Indian NGOs decided to prepare an alternative report to highlight discrimination
against women in all spheres of women’s lives. CHETNA was actively involved in
compilation of Discrimination in Primary Health Care (Article 12).

4. SYNTHESIZING CHETNA’ s LEARNING
WAH! TRIANGLE:

THROUGH

Over the years CHETNA team members have made efforts to develop a
gender and health perspective. Which would be more clear with this figure
which was developed by WAH! network members. CHETNA is a active
member of this network and secretariat for the western region of India.
WAH! triangle
VIOLENCE
/ Sexual \
z''j exploitation
.
\ + abuse /

Culture
|
+ Religion K
n Zd o w r V/X /

Population
Control

foeticide \
Vetc. A

I
f Over
exploitation \
and
I
abuse for /
\fertilirv/\

OVER
WORK

Ck
m

"O

•53

/
/ Woik>
/
outside
home
/Child
house
bearing
work
+ rearing
“T
' unequal
(general)
distribution
< of work .

CONTROL
OVER
WOMEN

4"'

Z

Medical
abuse
or
neglect

2-

Health
System (s)

LAb A^
/

food \
taboos '

S mating
last N least

UNDER
NUTRITION

New
b'con oinic
Policy

Price
Ki.se

WAH! stands for Women and Health which is a multi-national programme
for comprehensive, gender sensitive, sustainable primary health care for all
with special emphasis on women and girl children and all other
disadvantaged persons, throughout the life-cycle. Gender is one of the key
components of the WAH! training.

I

5. LEARNINGS:
To emphasize learning from gender integration efforts is a key issue recommended for

gender sensitive women’s health policies.
Gender relations can not be seen in isolation: Gender differences varies according to
class caste ace of women, marital status, single women, widow, non-fertile women,
mother of a son position of women such as mother-in-law and daughter-in-law etc.
religion, geographical region, generations etc. Therefore centralised strategies may not
be effective. Specific strategies for the specific condition/situation will have to be
developed and implemented.

" r a pirl child starts even befoi
Life Cycle Approach: Gender inequalities regarding
birth and continues throughout the life cycle. Therefore it is necessary to address the
women’s health programme using a life cycle approach.
Gender change is a process: Gender cannot be implemented in one’s personal life
through a single event workshop or training. It needs self modeling and time o
internalise learning. Frequent orientation is required for it to bec0™e * pr^n
Programme implementation and training is only an intervention to start the thinking
process which may provocative participants to take action for change to achieve tie
objective of humanity and equality. Frequent orientation through workshops, tiaimngs,
seminars, conferences and educational material may enhance this process.
It is a slow process : Some Indian socio-cultural practices which result in unequal
power relations particularly related to decision making and resource sharing are deep ;
rooted in households for many years. Historically not a single example can be seen .
where power relations are changed within a short duration. Therefore the process to ;
change these power relations among men and women, class, caste, may be very s ow 1
and one needs patience to understand this process.
It is a multi dimension process : Questioning of self is very important and frequent
orientation through workshops, trainings, seminars, conferences, educational material
means integration is necessary by various ways to enhance this process.
■

I

Starting from self : The experiences of CHETNA team members for more than a |
decade of integrating gender, clearly indicates that since gender is a socio-culture
construct it should start from one self and one’s family. This is the most difficult atspect

to put into practice.

1

Strategic Involvement of men: Gender applies to both women and men .
At present, decisions are laying with men and this has direct implication on women's
health, for example whom to approach during illness and how many children should be
bom. Therefore at least at the initial stages it is wise to involve men and other decision
makers of the family (mother-in-laws) and community members
(eg. sarpanch) to enlist their support.
Sexual Division of Labour: Gender operates as an organising principle in society
through the sexual division of labour, whereby men and women are allocated different
es, responsibilities and activities based on societal ideas of capabilities and
appropriateness. Although both men and women can be involved in productive and
reproductive activities, reproductive or household maintenance activities are largely the
responsibility of women. Due to the double burden of work effects can be seen on
women's physical and mental health, which we have already seen in the WAH!
triangle.
Household as the basic Unit: It was learned that women have less access than men to
three key groups of resources - economic, political and time, all of which are required
to achieve development. Women also have limited access to the returns and benefits of
these resources. This differential access limits women’s ability to participate in and
benefit from project activity. Access to all three groups of resources must be considered
in programmes that aim to involve and benefit women.

osition and Conditions: It is necessary to address both the day-to-day condition of
women’s lives and this will improve access to health care and enhance women s
capacitv to make decisions for their own health, reproduction and position .
Needs Patience: Trainers and programme implementers need patience to listen to
concerns especially from men they should also have a clear understanding in order to
explain reasons to them logically.

Gender is not a blue print concept, it is a social concept where people understand
reflect and analyse their experiences of life/work. Therefore during the implementation
of a women’s health programme thedmplementors needs patience to listen to concerns,
especially from the men of the community, and men involved at the programme level.

6. RECOMMENDATIONS:
To make the women’s health programme gender sensitive and more meaningful
CHETNA suggests following recommendations from their learning to strengthen
existing programmes and to plan new policies and programmes.
Holistic Perspective: Policies and programmes should be implemented in a holistic
nature. It should consider the totality of social, economic and political life in analysing
the forces which affect women’s health. The programmes should examine and
addressed social attitudes, behaviour and practices which affect both the productive
work and reproductive work of women, less food intake, physical and mental violence
and its impact on health conducive work, environment and sharing tliis work by other
family members, provision of support services, empowerment of women.. It she d
also address the relations of power and dominance at the household, community,
organizations.
Addressing Gender Relations: Programmes/Policies should not focus only on women,
but on the relationship between women and men, powerful women and powerless 1
women, because understanding this structure and dynamics is crucial for progress.
These relations may be different according to region, caste, class, age and marital
status of women. Therefore participation of men in women’s health programmes is a
key component.
Household as the basic unit: The programmes should recognise that the household is
the basic unit of social organisation. This would help to clarify gender relations, the
decisi s.
sexual division of labour, reproductive
and health care
Dynamics and relations within the household have a major impact especially on
women’s reproductive health.
Women’s health programme should be process oriented rather than event
oriented: As we have experienced, gender change is a very slow process therefore the
programme should be strategically planned and they should be process oriented.

Addressing to various social institutions: Institutions of society such as family,
education, knowledge systems, legal systems, media, political and government t
infrastructures, economics institutions, religions are patriarchal institutions which:
provoke gender inequalities need to be addressed simaltenously.
|

For e.g. Media always encourages oral pills rather than condoms. Religion increases the
importance of a son which results in too many too close pregnancies which result in
poor health. Most government policies and programmes encourage women as
mothers ’ ’Single’ and Non-fertile’ women do not have much place in these policies
and programmes.
Gender sensitisation of all actors of society: These include ->

Programme Level: Starting from policy makers to programme planners, managers,
middle level workers to grass root level workers is necessary.
Institutions level: Doctors, religious leaders, advocates, media people, politicians,
reaucrats, business men and women, corporate sector, pharmacist, all the
functionaries of government departments e.g. health, women, environment, education
social development etc.
Community Level: Teacher, Traditional Birth Attendant, witch doctor, sarpanch, and
panachyat members, community leaders, Anganwadi Workers, Health Workers,
youth/adolescent, children, other influential members of the community.
Family Level: Men (husband, father, brother, brother-in law). Women (wife, motherin-law, daughter-in-law, sister-in-law, sister), children (daughters, sons).

Active Partnership of GO, NGOs, Corporate sector and Women’s Health
movement, reserchers, academicians: Since all of these have the same vision and
’"'ssion of a happy and healthy community, it is necessary to come together to speed
up the process of empowerment, so that women can have control on themselves, their
families and communities health. Active partnership from planning to implementation,
process monitoring and evaluation is needed.
Srategic planning/methods to address gender concerns: As already mentioned,our
ultimate goal should be happy and healthy women, men, families and communities. At
the initial stage, it may be advisable to start meeting/discussions separately with
women, because from our experiences, initially women do not speak in-front of men
(they are not even ready to remove their ’Purdah’ (veil) especially if older men of the
family and community are sitting with them. After raising their confidence, they
themselves would be come ready to talk in-front of men.
Effective Information System: For an empowerment process, it is necessary to
provide correct infonnation at an appropriate time and in an acceptable manner. For this
purpose, information systems should be strengthened so that people can receive the

6

medias: Appropriate need based, and field tested IEC material plays an important role
in addressing gender concerns. It was learned that modem technology sue as
electronics media has not yet reached remote areas, nor are technicians availab e in
case of technical failure. Kits on issues such as anemia, gender and health pamphlets
posters, flash cards are found more useful flexible and effective and people can control
their use as well.

minimum content in big letter size.
Gender Integration in all Policies/programmes: As we have seen since all social |
institutions reflect women’s health and lives, it is necessary to integrate gender besides J
health policies, such as policies on agricultural, nutrition, economic, environment etc. |
Gender Sensitive Indicators : To monitor gender integration and its impact it is«
important to develop gender sensitive indicators in programmes.
Decentralised planning and decisions: Since gender is not a blue print and

tl

universal all over India, specific differences due to class, caste, age marital status,!
mother of a son etc it is necessary to have planning at the panchayat level to address |
these specific needs.
Conclusion :

" : women’s health. Therefore it is
Gender construction and relations directly affect
absolutel? necessary to have gender sensitive policies and programmes to empower
women so that they become capable of gaining control over their own, their families
and communities levels.

LINKAGES OF WOMEN'S HEALTH AND GENDER

Gender Issues

Impact on Health

Before Birth

Sex determination
(If foetus is female
it being aborted)

Lower sex ratio
Violation of human rights
Complication to women
due to abortion & mental
shock

Early Childhood

Discontinuation of
breast milk in early
months

Lower nutrition status
(undernutrition)

Child-Hood
(1-K ''ears)

Discrimination in food Lower nutrition &
& health care service health status
Complications due to
Responsibility of
lack of health care
house hold work &
services
child care

Adolescent
(W-19 age)

Disturbed mental
No information on
status. Anemia &
menstruation.
weekness. Too early
Early Marrige
too close pregnancies
Lack of decision
power to get pregnant RTI & prok pse
of uterus, STDs
Abortion

Age

Responsibility of
household work
Adult
(20-45 age)

Emotional & Physical
distarbance
Less access to
health care services High maternal, Morbidiy,
Overburden of social communicable diseases
rate
reproduction &
Weekness emotional
community work
disbalance
Eat last and least
Lower nutritional status
Can not talk of own
Heavy bleeding,
sexuak needs
harmonal disturbances
contraception is
& side effects
only women’s
responsibility

Violence

Reasons
Lower social status of women
Dowery
Parents cannot go and stay
with daughters in old age
If last rights performed by son
goes to heaven
Son continues family I line
If breast milk stopped chances
of pregnancy will increased to
produce son
Secondary status of g» irl child
Socially girls are responsible to
help household work.
Preference to give all the contort
food, best health care to son
due to patriarchal society.
Lack of awareness due to socio
cultural practices & beliefs(about
own anatomy & physiology of
own body)
Lack of control over own body,
life.
Lack of decision making power
Lack of economic empowerment
Poor socio-eonomic status
No security
Lack of decision power
Lack of facilities at household/
work place e.g. Kitchen, toilets
In policy/programmes women
is seen only; pregnant and
lactating mother.
Lack of economic, social &
political power.

To understand the impact of gender issues on women's health (in a life cycle), . Such analysis was critically
understand and developed among the CHETNA Team.

’

i

References :
♦CHETNA Folder
*WAH!-Women and Health Training Programme, India
♦Family and Community Participation for Women and Child development at Village
level in respect to Nutrition Promotion CHETNA’s Experiences
-Ms.Indu Capoor,Ms.Jyoti Gade and CHETNA Team
♦Gender initiattives/activities of CHETNA - paper presented: Gender workshop
at the U P. Academy of Administration, U.P. Government, Nainita
♦Gender TOT - October 9-11, 1996 CHETNA, FAO, SWDF, Dahod
♦ Report of Women and Health (WAH!) Western Region Training Programme phase -1, February to March 8, 1997.
♦ Report of Women and Health programme (WAH!) Western Regional Training Programme
WAH! Phase-II, May 27-June 27, 1997
*WAH! Western region Training Programme (Phase-Ill) September 17-October, 18, 1997
♦Forgotten Wealth, Women’s Health! (A paper presented in National Seminar on “Women and Social
Development” on 17-18, February, 1998, organised by Faculty of Social work. The M.S. University,
Fatehgunj, Vadodara-390002. -Ms.Indu capoor, Ms.Jyoti Gade and CHETNA Team
♦Beginning to change
Gender relation in India (Gujarat, rajasthan)
Towards better gender understanding effectiveness of gender sensitivity training of CHETNA’s
Women and Health Training (WAH!) programme.
♦Experiences of Gender Trainings: CHETNA - Paper presented in South Asian Workshop of Gender
Trainers from April 16 to 21, 1998.
♦ A manual on Gender sensitive indicators (for Reproductive Health Programmes in
United
Nations Population Fund (UNFPA) Developed by CHETNA
April 1998.

India For

♦Status of women and men in Gujarat, Rajasthan, India, Compilation of Statistics by Harvard Graphs
by CHETNA Team.

1

Towards Comprehensive Women’s Health Policies &
Programmes”
STATUS OF WOMEN’S HEALTH : BIHAR

Sr. Elise Mary
Sacred Heart - Bettiah
Bihar
From experience of patriarchal family the men are supreme. They may pretend
all they like that it is not they who want dowry, it is their wives (the mother-in-law);
or that it is they who want to kill the girl babies, it is their wives. But the fact
remains that it is the men who have the power, even within the families. If the
husband was to say to his mother “my wife should not be ill-treated”, there is no
way the mother-in-law can continue to subject her to repeated ill-treatment.
Similarly if the husband (or the father-in-law) was to say “I don’t want my baby
daughter (or grand daughter) to be killed”, who will dare to kill her ? But in my
experience with female infanticide, the men never killed a baby girl themselves.
They hide themselves from the crimes I
I think it is time Indian men take a stand on dowry, on female foeticide, on all the
violence on women and girl children. It is time to stop to perpetuating the myth
"women are women's own enemies’. They may appear to be; but there are
several reasons for this. The mother-in-law has not had an education she has
no cash In income in her hands, no 'job', her marriage has been bad, she has not
had a companionship with her husband; her only real 'meaning' in life is through
her son, so she remains very possessive.
In a survey in Bihar of 100 educated and working mothers-in-law (e.g. teachers)
and 100 illiterate mothers-in-law had very good relationships with their montherin-law; 98 of the illiterate mothers-in-law daughters-in-law talked of substantial illtreatment.

STATUS OF WOMEN
Health status will also depend on the general status of women in the society.
They are discriminated in rearing education, employment, wages and health care.
Social and sexual violence make them vulnerable. They should be given their
share and place in society so that they can make their own decision about family
planning choice, health, vocation etc. In Kerala an economically poor state, the
status of women and their health is beat due to socio political awareness there
Decisions are made on women’s Ihealth in the patriarchal system and by men in
the primary health care delivery system,

And women's health depends on girl

children’s’ and adolescent girls’ health”.
“She becomes adolescent and young woman, she cannot decide how many
children she should have without this information and knowledge.”
“The next part of the net is poverty; without livelihood skill-training, income
generation and employment -generation, poverty leads to malnutrition. Land is
not owned by the majority, there is no political will to implement equity
considerations. Poverty leads to more ill-health.”
EDUCATION
The overall literacy rate of Bihar has increased from 19.9 per cent in 1971 to 25
per cent in 1981 and 38.54 per cent in 1991. Even then it is one of the lowest in
the country. Female literacy is far below that of the male.
Education for girls and women has never figured as a priority for many people in
the State of Bihar. Overall literacy levels, current enrolment rates and male
female disparities continue at levels far worse than the averages for India.
Female rates extremely low.

Literacy (Above 7 years)
Female

1981

1991

All India

29.8

38.54

Bihar

16.5

23.1

The average female literacy rate is 23.1 per cent in 1991 (GOI, Registrar
General, 1991) having increased from 12.2 per cent in 1971 and 17 per cent in
1981. Not only is the literacy level considerably lower in Bihar, but also the pace
of change is slower than in the rest of India.
One probable reason particularly for girls not going to school or for their rapid
dropout relate to women’s overall status in society which allows little value to be
attached to educating girls. Socially conservative parents do not want to send
their daughters to schools staffed by male teachers and as girls approach
menarche they are withdrawn from school and they are married.
The percentage of female teachers in Bihar (18 per cent) is far below the all India
figure of 30.56 per cent. The share of teachers belonging to Scheduled Castes
and Tribes - in primary and upper primary schools - is also far less than their
proportion in the population.
The poor performance in the educational field is partly due to poor allocation of
resources to education, which is one of the lowest in the country. Of this about
85 per cent goes to the payment of salaries and allowances; the amount left for
development of the quality of education is very little.
"Why should I waste my time and money on sending my daughters to school
where she will learn nothing of use? What does the Hindi alphabet mean to her?

Too much of schooling will only give girls big ideas and then they will be beaten
up by their husbands or be abused by their in-laws."
SOCIAL FACTORS
One important social factor affecting participation in education is early marriage.
Through girls now marry at an average age of 17, pre-pubertal and child
marriages are not uncommon.
Parent’s willingness to send girls to school depended on whether certain facilities
are available such as more girls’ school, more women teachers and nearness of
schools to their homes, better transport and toilet facilities. While the latest
government document states that 95 per cent of the population is within a
kilometer of a primary school is concerned, the same document admits the lack
of vital facilities in schools such as potable water, buildings, blackboard and so on
the document further noted that though the rural sector caters to a much larger
segment of the population relatively, expenditure on this sector is comparatively
much lower than the money spent on urban schools. The question of facilities
acquire particular important in rural areas as it is linked to the urgent need to
reach out to village girls.
NUTRITION
Based on the investigators’ observation, it is found that the nutritional deprivation
suffered by young mothers are acute and range of infancy to pregnancy. The
infant mortality rate which is quite high in the study areas conforms that due to
nutritional deprivation, female child morbidity is very high.
If we glance at the nutritional programmes, they are aimed at pregnant and
lactating women. But what about the nutritional deprivation suffered by girls and
women? Undernounshment may not lead to death but there is increasing
evidence that undernourished children will grow to adulthood stunted physically
and mentally. The undernourished mother will give birth to a premature child in
birth weight, length and maturity.

AGE AT MARRIAGE
Marriag(e is considered an essential requirement of the social and cultural life of
an individual in India. Unlike in western societies, where marriage is considered
contractual arrangement between husband and wife, in India it is considered to
be a sacred life - bond and brings together two families in a close relationship.
The marriage of the daughter at young age either immediately before or after
menarche is considered an important duty of parents. Child marriages are widely
practiced in sizeable numbers in Bihar. As such, age at marriage and
percentages married among the different age groups among females influence to
a considerable extent the levels and trends of fertility.
The present mean age at marriage is 18.66 years for girls, which is just about the
level at which the period of optimum safety for reproductive activity commences;
but there is no cause for complacency on this score.
In the state of Bihar proportion of those married in the age group 15-19 remain as
high as 64.06 or roughly 2 out of 3 girls in the 15-19 age group. This mean age
of marriage in state of Bihar is only 17 per cent. In Bihar it is rate for the girl in
her teens to remain unmarried.
Early marriage for girls are sought to preserve the chastity of the girls and
secondly to ensure their subordination to the bride-groom’s family.
The mean age at marriage for females as per the 1991 census (Bihar) is 17
which is lower than the national average which is 18.32. The study findings also
show that adolescent marriages are common in this place. 13.42 per cent of the
girls are even before completing 12 years, next 30 per cent are married within the
age group of 16-20 years. A big proportion of women in the age group of 12-16
are married and they constitute 55 per cent. The custom of early marriage
insured that the girls learned the tradition of the new family, and transferred
loyalties to the new home.

AGE OF PREGNANCY
The age at marriage determines the age first pregnancy. The data show that
63 per cent get their first pregnancy as early as 16 years, A substantial 60
percent of the women have entered the childbearing role between the age of 17years. The women entering the child bearing role has almost declined as
they are entering 26 years and onwards.
e changing patterns of economic development have placed a heavy burden on
women which has been reflected in their health status. The marginalisation of
armers, landlessness, forced migration (temporary and permanent) have
undoubtedly affected women’s health and nutritional status.
Women are working in industries like tobacco, biri-making, textiles, garments fish
processing, agnculture, pesticide application fertilizer application, spice growing
and processing, )ute growing and processing, seri culture, bambo work, betel leaf
growing etc. In all these industries they toil long hours at low-paid, unskilled jobs
Hence there are health problems related to the work-place, hazards of pollutants
on women who work during childhood, adolescence, pregnancy and lactation that
can be dangerous both to the women and the foetus. There is very little
information about the safety levels of these harmful substance and more often
the damage done Includes TB, allergies, abortion, bronchial disorders, death of
unborn child, anaemia, toxicity, disfiguration etc. Hence women have been
exposed to new kinds of health hazards.
Women perform a lot of other activities that are energy consumlng-cooking
collecting fuel, fetching water, looking after cattle and other animals, unpaid work
on the family farm or in family craft and child care. Calorie needs for women are
calculated without regard to actual work burdens of women, but even these
norms are not generally fulfilled for women end girls as they eat considerably less
than their requirements. Malnutrition aggravates diseases, increases risk of
infections and reduces resistance to various diseases. Yet ironically women do
not ever consider themselves ill.

SON PREFERENCE
On examination as to the sej of the child preferred their strong desire to have at
least two to three male children. This further reinstates the fact that rural
households child bearing has continued mercilessly until one or two male children
are born as per their desire. This means that couples would wait even if they
have a string of five, six, even seven or more daughters first. On the other hand
to identify even one home which has as many sons and a youngest daughter
whose late arrival has been the reason for repeated pregnancies and with those
birth child bearing comes to an end.
Number of children desired and their preferred sex composition is a reflection of
women's status or the extent of gender inequality. The kinship structure
prevalent in this region lays great value on reproduction in general and sons in
particular.
Base line studies in Bihar report family size desires of between 3.5 and 4
children, of these, about 3.5 must be a son.
In the patriarchal family structure of this region an important means through
which a young women achieves prestige or recognition in her husband’s home is
based on her fertility in general and the birth of a son or two in particular
Preference for the male child is not an exception to the state of Bihar. Several
studies have come out with findings that almost all societies value sons more
than daughters and exhibit son preference or preference for the male child. Son
preference is both a cause and a consequence of the low status of women

It is

a consequence because it arises as a result of women being considered as
Playing only unimportant roles and thus being valued less and a cause because
this undervaluation in tun has led to lower investment in females as a result of
which they are able to play a peripheral role in society-causing a further lowering
of their status.

XT findln’? dearty show ,ha'sons are preferred due to the fo"°w'n9
Religious, economic, old age security and insurance against risk have figured
prominently ,n the demand for children particularly male children. Each of the
a ove reasons can be seen from a conceptual frame work. They theory of
emands for children explains that children in general have economic value to
he rura hounds. They serve the househo.ds In two ways. One is that they
can be directly productive themselves or indirectly contribute to the economic
productive process or replace the cost of getting extra domestic help for this
economically non-productive work. Children win also have greater economic
va ue in a labour market which is segmented by age and sex. For instance in
ultures where women are banned from some kinds of economic adivities-the
our of children, especially sons, has an additional value and could theoretically

chiid Zb

Th Wan,'n9 m°re Chi'dren' F°r ,he

35 3 Wh°le ,ha '*-1 °f

PrinCiP'9
chiidren b"
eCOn0m'C “"“utlons of
children to be greater in Bihar because child schooiing rates are reiatively ,ow
GENDER DISCRIMINATION
in the patrilineal fami.y - a son - Is looked upon as the natural successor
dauahteT 7 T °',h6 ,ami'y' A
to be a poo °IS

,0 Cha"9e

'S
IOya"ieS

,hr°U9h hiS son-

=

marria9e 3

Str°n9 prefere"“
for a son has oT o'
or
has to be understood in terms of three institutions interlinked famiiy V
dowry, property and religion.

“a"On

i,S °ri8ln ‘n ,h9 $°C“

'amity

discrimination and sex inequality starts early in a girl's life. Since she has to
eave her father, house where she
»ned by someone and her master controlled her life. Gender discrimination is
rooted in the feudal society.
Girls are not treated equally with boys in the family”.

“They are abused and neglected.”
■While girls become III or sick - they are avoided by the family membj,
rs - doctor
and medicines are not given quickly or not given at all.”
Girls in our society are considered
- barbaric and heinous crimes

a liability. So female infanticide and foeticide

are on the increase in our society.

MATERNAL MORTALITY (MMR) and sex ratio
he maternal situation in Bihar as well as in India is very gloomy. The MMR
which was 400-500 per 1,00.000 live birth in 1976, is still almost the some even
a er more than two decades. The current MMR of Bihar is 470 against the
national average of 453. About 25% of ail the death of women in child bearing
age in deveioping countries are due to compiiations of pregnancy and deHvery in
contrast to 1 % ,n USA. About 16000 maternal death occur in Bihar every year
while in India it is 1,25.000. The most common cause of these deaths are -

'

^ffheae 23%, anaemia 20%, abortion, toxemia and puerperal sepsis Unless
MMR is lowered, their health status can not improve.
In Bihar institutional delivery ir
in rural areas is only 9.5%, though delivery by
trained personnel is 13.5%. There i
is very little facility for referral services to
complicated case in Bihar.
faZ The
“

on?

°n

*
B'har' deC"n9

3S
de“de ,0 de“de

-"-I
-3 91, in

991 census, whereas It was 879 in UP, Kerala is oniy state in the countiy where
it is more than male i.e. 1036.

ANTE NATAL CARE (ANC)
MCH programme was started in the first five 1-----year plan for care of maternal and
child health. In recent years attention has been f.
. .ocused on them under the DIP

They are abused and neglected.”
"While girts become ill or sick - they are avoided by the family members - doctor
and medicines are not given quickly or not given at all.”
Girls in our society are considered a liability. So female infanticide and foeticide
arbanc and heinous crimes are on the increase in our society.

maternal mortality (MMR) and sex ratio
he maternal situation in Bihar as well as in India is very gloomy. The MMR
which was 400-500 per 1,00.000 live birth in 1976, is still almost the some even
= er more than two decades. The current MMR of Bihar is 470 against the
nal average of 453. About 25% of all the death of women in child bearing
age in devetoping countries are due to compi.ations of pregnancy and deHvery in
contrast to 1% m USA. About 16000 maternal death occur in Bihar every year
while in India it is 1,25,000. The most common cause of these deaths are mmTT 23%' anaemia 20%' ab°rt'°n',0Xemia an<i puerpera'

'

Unless

MMR is lowered, their health status can not improve.
In Bihar institutional delivery in rural areas is only 9.5%, though delivery by
trained personnel is 13.5%. There is very littie faculty for referral services to
complicated case in Bihar.
Sex ratio is dependent on

the health care services, as well as social and cultural

factors. The sex ration in Bihar is decling from decade to decade and was 911 in
1991 census, whereas it was 879
• in UP, Kerala is only state in the country where
it is more than male i.e. 1036.

ANTE NATAL CARE (ANC)
MCH programme was started in the first five year plan for care of maternal and
child health. In recent years attention has been focused on them under the UIP,

CSSM and RCH. Unfortunately, even after four and half decades, there is little
improvement In their health, though survival chances of children has much
improved due to decline in vaccine preventable diseases. A look al NFHS data
reveals that during 1989-90, 62% of prignant women did not get the ANC
services, 17% did not know about availability of such services and 58% did not
think it necessary meaning there by 75% of women were not educated about the
necessity and availability of these service. How such situation can prevent
complication of pregnancy and delivery particularly anaemia, bleeding,toxaemia
and even of mother and new born baby,
IMMUNISATION
TT2 immunization In Bihar during 1989-90 to 1993-94 has been only 40-60
though national average have been much higher (70-90%), but according to
NFHS it is just 30% in Bihar. The alarming situation is that even this has shown
decline in recent years and during 1996-97 it was only 33% after implementation
of TFA.
Position of child immunization was better (80-100%) during 1989-90 as per govt
report, by the NFHS report reveal that only 10.7% children got all the vaccine and
/o did not get in Bihar. The national average data is much better However
■f we take into account also the potency of vaccine, which is sometime doubtful ’
due to cold chain failure and whether all doses were given in due time the
effective impact may still go down. The performance of 1996-97, has also shown
decline (50-top78%) after TFA was introduced.
FAMILY PLANNING
Performance of Bihar has been much lower than the national average, though
tubectomy sti" forms 83-94% of iota! steriteation. During 1996-97, steri.ization
declined to lowest of 27-39% and IUD 38-1% Bihar.

UNMET NEEDS
»

According to NFHS, 25% of currently married women in Bihar had on unmet need
for family planning. That is they are not using contraception even though they do
not want any more child or they want to wait at least two years before having next
issue. On the whole unmet need for spacing 14%) I is slightly higher than unmet
need for limiting methods (11 %) with the lower performance now, the unmet need
is likely to increase.
HOW PRIMARY HEALTH CENTRES ARE FUNCTIONS?
About 2/3rd of total PHC and HSC have no govt, building (1985) in Bihar and are
functioning either in private houses or on paper only. During my recent visit to a
PHC about 25 km from Patna, it was found that PHC is still functioning in old
dilapidated Board building, though a new operation theatre has been added.
Only one medical officer was available in OPD out of four Mos, who arrange their
OPD on rotation so that others are free on rest of days. Visit to sub centre is
occasional. 50% of sub centres are supposed to functions without ANM male
Health workers are even much less as state govt, has not sanctioned their post
after 1.4.81 In a survey ORG found that in same PHCs MO are available for a
few houses only. With such a state of affair of infrastructure and man power
functioning hoe quality service can be expected and thus demand generation for
quality service appears to be irrelevant. To sum up it will not be exaggeration to
say that environment for implementation of RCH is rather lacking in Bihar.

ECC, Bangalore
Oct, 7, 1998

i

Annual Report 1997

I

I

DSE in Brief

he German Foundation for International Development
< DSE) provides a forum for development policy dialo
gue and offers initial and advanced training of specia
lists and executive personnel from developing and transition
al countries. In addition, it supports experts of German
technical and cultural cooperation, and their families, in their
preparation for assignments in de\eloping countries (see
p. 20). and maintains the largest documentation and infor
mation centre on development cooperation issues in
Germany (see p. 44).
Conferences, meetings, seminars and training courses sup
port projects which serve economic, social, and ccologicall\ compatible development, thus contributing to an effective,
sustainable and wide-ranging development.
The DSE cooperates with partners al home and abroad. A
considerable number of the programmes lake place in devel
oping and transitional countries, and the rest in Germany.
Since I960 the DSE has given advanced professional trai
ning to more than I5().()()() decision-makers, specialists and
executive personnel from over 150 countries. Every year
approximately 10.000 participants take part in the DSE's dia
logue and training programmes.
The DSE contributes to development cooperation on the
basis of the guidelines of the German Federal Government's
development policy. The German Foundation is funded by
the Federal Ministry for Economic Cooperation and
Development (BMZ). Some of its programmes, however, are
Financed by other donors (e.g. other Federal ministries, the
Federal States, the European Union).
Additionally, the Federal Slates of Baden-Wiirttemberg,
Bavaria. Berlin. North-Rhine/Westphalia. Saxony and
Saxony-Anhalt provide conference and training centres and
buildings. Since its foundation in 1959 the DSE has been
jointly financed by the Federal Government and the Federal
States. This corresponds to the German Foundation's decen
tralized structure with specialized departments (centres) and
conference centres in a number of Federal Slates. The seat of
the Foundation is Bonn. The Executive Office, the
Development Policy Forum, (he Print Media Programme, the
Central Administration, and three centres arc located in
Berlin. Other locations are Bad Honnef, Feldafing,
Zschorlau. Magdeburg, and Mannheim.

I
DSE
R5/9

I

I

DSE Instruments
The DSE’s advanced training events arc planned together
with partner institutions in the developing and transitional
countries and. when they lake place on-site, arc also imple
mented with them. The events include:
• Short-term programmes lasting up to three months in
Germany or abroad, e.g. seminars and training courses lor
middle management specialists and multipliers, interna
tional meetings and expert discussions lor high-ranking
executives and political decision makers. The pro
grammes also include the secondment oi programme
officers to support advanced training institutions in devel
oping countries or scholarships lor congress trips to lake
part in the North-South exchange of views.

I

; at
■

• Long-term programmes lasting between three and 24
months in Germany and developing countries. These pro
grammes with their focus on practical professional
advanced training are offered as part of the Federal
government’s scholarship programme, and in direct
aareemcnl with professional institutions ol the partner
countries, to specialists and executives in the
government and non-government sectors.
The short-term and long-term programmes are offered
both as project-related and non-projccl measures.
Combinations of programmes from the short-term and
long-term areas, mutually agreed with partner institutions
and covering a time-scale of several years, are called pro
gramme packages. This bundling of different DSE instru
ments enables a systematic contribution to organizational
and human resource development in particular. Programme
packages are eminently suitable to support structural change
and to achieve the sustainability and broad impact of DSE
work. Examples of programme packages are:

.1

11
i

• Promotion of local government in Chile and the
Philippines
• Training programme for regional planning and project
management in Indonesia
• Advanced training of leaching staff for the public health
sector in Tanzania
So-called follow-up contact measures with former
participants of DSE programmes serve the exchange of
views and the updating of professional knowledge. The DSE
thereby also promotes the sustainability and broad impact of
its events.

I

Public Health Promotion Centre (ZG) ■” Berlin

he Public Health Promotion Centre (ZG) is the young
est work unit of the German Foundation for
International Development (DSE). It was founded in
1991 alter the DSE look over the support programmes for
scholarship holders from the former GDR.
The ZG collaborates with governmental and non-govern
mental organizations in the countries of the South in the
planning, implementation and evaluation of its programmes.
The leading partners arc primarily public health services and
the training and advanced training institutes used by them. In
Germany, the ZG works closely with the Institute of Tropical
Hygiene and Public Health (1TH0G) in Heidelberg, the
Health Department of the German Agency for Technical
Cooperation (GTZ). the Berlin Senate Health Ad
ministration. and the Land Institute of Tropical Medicine in
Berlin. Other partners are professional German institutes in
the field of public health and/or tropical medicine. At
international level the ZG has working contacts with
UN agencies and the leading European institutes for
public health in the tropics.

i

p

sures are complementary to the own efforts of the partner
countries and the activities undertaken in German and inter
national development cooperation. The following pro
gramme approaches are applied to attain the objective:
• Presentation of basic experience and problem-solving
approaches in the introduction of the PHC concept. Both
South-South dialogue and South-North dialogue are
strengthened in conferences and seminars.
• Improvement of the organizational and management skills
of leading health officers at district level and other health
service providers (e.g. women’s organizations) through
the development of standardized model training courses
which can be tailored to national or regional needs as
required.
• Advanced training in basic curative health care techniques
(e.g. district surgery), support for effective - in develop
mental terms - professional integration of medical staff
trained in Germany in the health services of the devel-

PSi
w

The ZG has a harmonized set of programme instru
ments available for each area of its work. They include:

• Dialogue events
• Training courses
• Long-term scholarships

1

11V?'■'

The notification of ZG events is undertaken by invi
tations for applications through the German diplomatic
missions in the partner countries. The selection of the
participants is coordinated with the partner organiza
tions.

Objectives

¥h

'1

It-

7/
■<

■

. .............. 4||

H
ifr

The staff of the ZG

rjphe work of the ZG is based on the concept of Primary
JL Health Care (PHC) which was formulated at the World
Health Conference in Alma Ata in 1978 and adopted by all
member states of the World Health Organization (WHO).
This concept covers health-promoting services, prevention
and rehabilitation and the treatment of diseases.
The objective of ZG work is to assist the developing coun
tries in the implementation of the PHC concept. ZG mea-

oping countries (physicians programme).
• Promotion of human resource planning, development and
management in agencies responsible for health care in the |
developing countries.
■

Target groups
r | ''he advanced training courses of the ZG are particularly B''
addressed to:
• Decision makers in the field of primary health care who

h'

deal with the preparation of basic and wide-ranging con
cepts (e.g. health ministries, planning ministries, finance
ministries, provincial administrations, organizations
financing sickness insurance and health care)
• Staff in the technical and administrative departments of
training institutes in the health sector
• Members of the district management teams and the
structures above them at province level
• Persons responsible for personnel planning and develop
ment in health offices and other health care agencies
• Organizations working with municipalities, enterprises,
patient and user groups and consumers in issues related to
health
In order to improve the contribution of women in keeping
with their key role in the health sector, the programme part
ners are requested to give more consideration to women in
the selection of participants and the design of programmes.

Priority work areas
nphe ZG works in two sections: Section 81, "Basic issues
X of health policy", organizes seminars and international
conferences. It is also responsible for the implementation of
the physicians programme. The Section has the following
work areas:

• Financing of public health, local financing, user parlicipa
lion and health insurance systems
• Drug policy and drug control
• Professional integration through the physicians
programme
• Promotion of local experts

Section 82, "Primary health care", deals with the model
development and implementation of advanced training
schemes at district level. As many countries are introducing
decentralization of tasks and decision-making powers in the
health sector, personnel management and human resource
development are gaining importance. The Section has the
following work areas:
• Planning, management and financing of PHC at district
level
• Training and advanced training of trainers for medical
personnel
• Curative services in the district hospital
• Rehabilitation and orthopaedic techniques
• Reproductive health
• Promotion of non-governmental organizations in health
care, particularly women's organizations in the health
sector

InternationalDialogue
on the Financing of Health Care
The Example of Germany
Dr. Walter Seidel, Director of the Public Health Promotion Centre

German public health in the discussion process
There is a widespread malaise in the German public on the
situation of the public health system and its reforms. Various
catchwords, most of them with a negative connotation, are
an expression of this, e.g. cost explosion, lack of efficiency,
little transparency, hightech machine-dominated medicine,
etc. This basic pessimistic attitude often goes hand in hand
with the assumption that little can be learned from the
German public health system, and certainly not by develop
ing countries.

In contrast to the criticism voiced by the German public,
there is the basically positive assessment by German profes
sionals from highly different cireles and disciplines, and the
growing interest of international experts. In particular, the
more economically advanced developing countries are in
terested in the experience of how the typical world wide
problems of health insurance and health care delivery plus
their financing are solved - or not solved - in Germany.

Public Health Promotion Centre (ZG) - Berlin

I
I

ii

'I

Interest of the developing countries

Necessity for dialogue: central topics

The interest shown by public health experts and politicians
from developing countries in the German public health
system touches various aspects:

For several years the term "health sector reform" in interna
tional debate has contained very different concepts in rela
tion to very different problems:

• The combination of private and public providers which
are financed by statutory state-regulated but non-govern
mental health insurance schemes ("Bismarck model") is
an attractive alternative to the purely government-run
and financing models
health care delivery
("Beveridge-System" in the United Kingdom) and the
mostly private delivery and financing models found
elsewhere (e.g. USA).

• Firstly, rigid monopolist state structures have to be broken
through the introduction of more competition between
public and private service providers and more choice for
the users.

• In a comparison of industrialized countries the German
per capita expenditure on public health lies somewhere
between that of the USA and the United Kingdom.
Foreign observers feel that this could eventually be an
acceptable compromise - also in terms of costs - between
the two opposite systems.
• The pluralist structure of the German public health system
means, on the. one hand, that single powerful interest
groups cannot get control easily, but it also means that
reforms take quite some time. A review of such a system
ofchecks and balances can give ideas and suggestions for
alternative structures in the developing countrfes.
• The development of the rates of contribution for statutory
health insurance since 1950 illustrates both the long term
rising trends (1950: 6% - 1995: 13.2%) and the efforts to
stabilize the level of contribution (whereby the percentage
share of health expenditure in the GNP remained constant
during this period): Every downturn of the curve or every
check in the rise reflects the application of a reform
measure.

™« W or . per—y ongoipp Pe.np

„n.

measures and to
develop assessment elements and criteria for the reform
measures to be introduced in a given country.

• Secondly, an attempt is made to influence uncontrolled de
facto privatization of collapsed public health services
through regulatory intervention and the organized efforts
of local authorities, and to make them more effective and
socially just.

• Additional sources of financing have to be opened through
the introduction offees for health services. These fees will
be settled either through direct payments by the users or
through newly established health insurance schemes or a
combination of both forms.
• In many reform projects an attempt is made to exploit
rationalization reserves in the public health sector: some
examples are essential drugs policy, evidence based
medicine and better links between outpatients and therapy.
• Another internationally often discussed problem for
which no satisfactory solutions have been found either in
the industrialized nations or in the developing countries, is
the participation of the users in the design of the health
services. The ways and means of achieving this are the
subject of international dialogue on further reform
endeavours.
This short outline shows the similarities in the structure of

all differences in concrete application. Against this back-di-

useful to conduct an international dialogue which can lead to
enhanced knowledge of possible solutions for all concerned.

—-J,

The Public Health Promotion Centre has developed a type
of programme which enables a structured dialogue - with
many references to the German situation - between partici
pants from the developing countries and German experts.
The participants of the ZG programmes particularly appre
ciated the critical frankness with which German public
health professionals discussed the problems of their system.
As an example of how similar the structures of the prob
lems are, we will - on the basis of reports from ZG-participants - give a brief outline of the situation in two developing
countries, Viet Nam and Colombia:

-I

The aim of dialogue and exchange of experience
When assessing reform measures and their momentum, it is
relatively easy for experts from developing countries and
their German counterparts to get a consensus on their funda
mental objectives:
• improvement of the quality of health services (defined as
effectiveness and user satisfaction).
• improvement of efficiency, and
• securing socially just access to health services ("equity").

Which insurance system, which payments system, v u
_____________________ ______
principle of o^
nizing services and
financing, what type
Viet Nam
of user representation,
how much competi
It Tiet Nam, with a per capita GNP of USS 240 (1995) continues to be one of the least developed
V countries. Up to 1989 health services were provided through a delivery system financed and
tion and how much
regulation or stan
organized by the state which envisaged free access for all inhabitants. Later, low user fees were introdardization is optimal
; duced which did not cover the costs, and in 1992 first steps were taken to set up a health insurance
in the given local and
system. Already three years after the introduction of this system, this health insurance covered some
historical situation 7 million persons (equivalent to about 10% of the population). The target is to extend this system to
the task of finding
cover the entire population. A special problem arises from the groups of small farmers who make up
answers to all these
about 80% of the population of Viet Nam. Some forms of voluntary insurance are being developed
questions is a com
in pilot projects for this population (if we recall, the German farmers were fully integrated in the stat
plex and time-con
utory health insurance only in the 1970s, that is, almost a century after the start of the Bismarck
suming process. The
reforms). Top-ranking staff members of the Vietnamese Ministry of Health and the health insurance
organizations who are familiar with the above-mentioned pilot projects, participated in the ZG’s dia- i experience gained by
the ZG shows that it
logue programmes.
can
be
acceler
ated and intensi !
structuied
through
_________________________________________________________________ —_ --------exchange of experi-1
ence and international
Colombia
dialogue - with case
studies - between
/Colombia was able to start the reform of its public health system on a considerably better econoprofessionals from
x^mic basis (per capita GNP in 1995: USS 1,910). "From subsidization of supply to subsidization
different continents.
of demand" - this was the motto under which the Colombian Parliament adopted a law in 1993 con
All persons involved
taining the provisions for the introduction of a health insurance system, with fundamental aims simi
in this process believe
lar to those of the Vietnamese reforms. Persons employed in the formal sector are compulsorily inthis dialogue is an
' sured, those in the informal sector and unemployed persons can, within the framework of the state
important contribu
* social Welfare system, get themselves classified as needy persons and thus acquire eligibility for state
tion to their own know
subsidies or a full refund of their health insurance contributions. There are considerable local dif
ledge-gathering and
ferences in the insurance protection coverage rate (between 15 and 50%). One must wait and see how
decision-making ac
long the state can continue paying subsidies at this level, if claims for further subsidies continue to
tivities.
be made at the present rate. Within the framework of its management training the ZG supports the
health services in two provinces in their transition from public budget financing to performanceoriented financing via health insurance schemes.
_______________________

Draft

Management Constraints for Operationalization of Reproductive
Health Programme Interventions in PHC System in India

by Dr. Dileep V. Mavalankar MD, Dr. P. H.
Indian Institute of Management Ahmedabad, 380015
Email: dileep@iimalid.emet.in

iI •

1

After International Conference on Population and Development (ICPD) at Cairo most family planning
programmes are moving towards reproductive health approach. A package of reproductive health
services has been recommenced for India1, which is shown in table 1. Government of India is also
planning a major project to reorient the family planning programme towards reproductive health under
a new programme called Reproductive and Child Health (RCH) programme with the assistance of the
World Bank2. In India tills programme will have to be implemented like other national health
programmes through the primary health care (PHC) system. The weaknesses and strengths of the PHC
system including the managerial capacity will have important bearing on the degree of success of the
programme. For example the Tuberculosis control programme which is integrated in to the PHC
system has suffered due to weakness of the PHC system3.
Strategic management approach mandates that formulation of new strategy should take in to account
strength and weakness of the organisation and opportunities and threats in the environment. Hence it is
very important to understand the strengths and weaknesses of the PHC system and to design the RCH
interventions taking these into consideration. In an earlier paper we have discussed how the strengths
and weakness of the PHC system will affect the delivery of Emergency Obstetric Care (EOC) in India,
which is a recommended approach for Safe Motherhood component of RCH package4. This paper
focuses on constraints which may hamper operationalisation of RCH interventions through the PHC
system.
Table 1: Recommended Package for Reproductive Health Services for India.
1

Prevention and management of unwanted pregnancy**

2

Services to promote safe motherhood**

3

Services to promote child survival**

4

Nutritional services for vulnerable groups * *

5

Prevention and treatment of RTI and STD**

6

Prevention and treatment of Gynaecological problems

7

Screening and treatment for breast cancer

8

Reproductive services for adolescents**

9

Health, sexuality and gender information, education and counselling**

10 Establishment of effective referral system**
* * Indicates that these services are part of an minimal or essential Reproductive Services Package.

The PHC system in India has several strengths and advantages which we fully recognise, but these are
not discussed here as the central focus of the paper is on constraints of the PHC system. The paper is
based on our personal observations of PHCs in some Indian states, in-depth studies of some PHCs
which we have done in one state, discussions with PHC and district level staff, reports of other studies
in the on PHCs in the country and discussion with other researchers. Given the diversity of India some
2

of our observations may not be applicable through out the country, but most would represent the
reality in many parts of the country with variation in degree from place to place.
Major constraints faced by the RH programme can be classified in to following broad categories.
1. Human Resource Management related problems.
2. Poor access and quality of services
3. Weak support service systems.
4. Weak and centralised monitoring and supervision.
5. Inadequate and in-operational service Infrastructure.
6. Poor demand for services
7. Weak management of services.
We discuss the constraints of the PHC system and suggest some possible solutions below.
1. Human Resource Management related problems
Non-availability of doctors in the new PHCs:
The PHC system is facing shortage of doctors for quite sometime. In Gujarat about 20 % of PHC
medical officers posts are vacant at any time1. Study from UP shows that in 1990 40% of PHC medical
officers' posts and 42% of specialists posts were vacant5. The shortage of doctors is likely to be more
in states where private practice is not allowed in the government system, making government service
much less attractive for the doctors. Tliis problem was exacerbated after mid 1980s when the number
of PHCs was increased almost three folds by bringing down the norm for PHCs from 1 for 100,000
population to 1 for 30,000 population, with a view to increase access to health services in rural areas.
Even when the doctor's post is filled at the PHCs in this new set up, they may not be available for about
30-40% of the days in a year due to official leave available to them2. There is no provision of having
reserve doctors to look after the PHC when PHC doctor is on leave. On top of this doctor may not be
available at the PHC for another 10-20% of the time because he is busy with meetings. Sterilisation
camps, training, special campaigns and other administrative work. This means that in the new PHC the
i

Recent efforst made by Gujarat government to recruit new
doctors has decreased the level of vacancies in PHC. But without
a long term strategy to combat this problem it is not sure if
this improvement will last long or not.
2 Government doctors in Gujarat get following holidays in one year.
52 Sundays, 18 Government/public holidays, 30 earned leaves, 17
casual leaves, 10 sick leaves. This adds to 127 i.e. 34.8% of days
in an year. Saturdays are half days hence to this we should add 26
days which makes it 153 days which is 41.9% of days of the year are
holidays.
3

posted doctor may not be available for almost 50?/o of the time. This situation is aptly described by one
health secretary from a state. She said, “ our PHCs are manned by ghosts! The staff is there but not
there”6 Lack of availability of the doctor becomes a major issue in the new PHCs as the new PHCs
has only one doctor instead of 2-3 in the old Block level PHCs. Under the old PHC pattern there are 23 doctors; hence in spite of lot of officials leaves and holidays the possibility of finding at least one
doctor at the PHC at any time was quite high.
The second major factor in the non-availability of the doctors is the fact that in the new PHCs most
doctors do not stay at the PHC village. The old PHCs were located at sub-district towns which were
somewhat larger and the PHCs had quarters for the doctors to stay, and the village where PHC was
located had some basic civic amenities so that doctor’s family also can feel comfortable and children's
education does not suffer a lot. While the new PHCs, which were opened with a norm of one for
30,000 population are located in very small villages with population of 3-6,000, with very little civic
amenities. These PHCs also do not have quarters or if quarters are there they are of very poor quality
due to poor quality of construction and lack of maintenance. All these factors lead to the situation
where most doctors do not stay at the new PHC or within the new PHC village. In many districts
wliich have large cities in them, PHC doctors prefer to live in the city and commute to and from the
PHCs rather than living at the PHC head quarter village. For example out of some 48 PHCs in
Ahmedabad district only at 3 PHCs the doctors stay at the PHC village. Even though this may be an
extreme case, situation may be similar in districts where cities are located. Recent study by Indian
Council of Medical Research (ICMR) covering 23 districts in 14 states showed that only 57% of the
doctors of 473 PHCs sampled were staying at the PHC village7. When doctors do not stay at the PHC
village they have to travel by public transport which is not vary reliable. This makes the availability of
the doctor at the PHC very uncertain and limited to only few hours of the day as they have to arrange
their schedule depending on the bus timings. Some doctors even do not go to the PHC regularly and
still on paper they are posted at the PHC. In extreme case doctors go to the PHC only a few days in a
month, while the other PHC staff' manages rest of the show on paper.
Lack of Interest in the PHC work by doctors:
The irregularity of doctors is compounded by and is caused by lack of interest in PHC work by the
doctors. Many doctors are not interested in PHC as a career they see it as a stepping stone to more
lucrative and satisfying private practice or job in a hospital in urban area. Hence they are not eager to
develop the activities of the PHC or to do innovative things to improve the PHC functioning. Lack of
training and orientation of young doctors towards community medicine, preventive medicine and
public health make them less suitable for duty in PHC. Without orientation training or apprenticeship in
PHC they feel like fish out of water when they are posted as in charge of the PHC immediately after
graduation from an urban medical collage. In the states where private practice is allowed by the
government doctors, most of their attention is devoted to their own practice as it directly pays them in
addition of the government salary. Such private practice may also reduce the time and attention they
give to patients in the PHC. The target oriented Family Planning programme did further damage by
evaluating the work of the PHC based on only the number of sterilisations performed. As long as the
sterilisation targets were achieve the supervisor did not bother to see what else was happening at the
PHC. The PHC supervisors have tolerated less than optimal work by the doctors and hence an
4

atmosphere of acceptance of poor work culture has developed with in the PHC system thus further
supporting such dysfunctional and unaccountable work patterns in the PHCs.
When the doctor is not available the rest of the PHC clinic almost stops functioning as no one else in
the PHC including the pharmacist or the trained nurses or ANMs are officially allowed to examine
patients independently and prescribe scheduled medicines even for common illnesses. Unofficially they
do it, but then they are always afraid that if some thing goes wrong they will be in difficulty.
Non availability of para-medical staff at village level:
Many of the things said regarding doctors also apply to the paramedical staff Most of them also do not
stay at the PHC villages. The ICMR study referred above also showed that 52% of ANMs do not stay
at the Sub-Centre village8. They have to commute thus their time in the field is very limited. Some
studies show that on an average out of the working day of 8 hours paramedical staff of the PHC are
available for 3-4 hours at their place of work. On many days the workers do not go to the allotted
village due to several reasons. Even when they go to the villages many do not systematically visit all the
houses. There is no preplanning of what activities have to be done during the home visiting. Due to this
haphazard way of working it is very difficult for community to contact the workers when need arises.
In such situations one cannot expect to treat RCH problems unless availability of doctor is ensured
and/or para-medical staff arc allowed to use required basic drugs for treating these problems. When
the doctor is not regular or not available at the PHC for adequate duration, he looses control and
authority over his other staff. Hence such doctor can not get work done from their subordinate staff.
The supervision becomes weak and extension activities become irregular and haphazard. In such
situation it is difficult to imagine how new RCH interventions will be implemented. Hence regular
availability of doctors is essential for success of RCH programme. In area where this is not possible the
health workers should be thoroughly trained and empowered to provide a minimum package of RCH
services.
Male Doctors at PHCs:
Most PHCs have male doctors. Given the socio-cultural set up in many parts of the country it is
difficult to expect that women will come forward for reproductive health problems to a male doctor.
One of the important contributing factors to the "culture of silence" regarding reproductive problems
among women is lack of availability of gender sensitive health services for women. Currently even
males from the community do not seem to be coming to PHCs for STD or RTI or other reproductive
problems. This means that even at PHC level a female health provider (generally ANM of Health
Visitor) has to be trained to examine and identify RTls and other reproductive health problems among
female clients. And they should be allowed to manage the patient independently or in consultation with
the doctor if present. Secondly as far as possible a second doctor who is a female should be appointed
at the PHCs. In Sanand Taluka of Alimedabad district, we have experimented with provision of female
gynaecologist once a month at the PHC. This has yield good results in terms of access and utilisation of
Reproductive Health services by women. In UP under the USAID project they have made
arrangements for a visiting lady doctor every week at each PHC. The response to this seems to be
5

good. With proper gender sensitive manners, with a female attendant and adequate privacy even a male
doctors may be acceptable in many areas for women's examination if arrangements are not possible for
women doctors. A well trained nurse as discussed above can also help over come barrier posed by
males doctors at PHC level for examination of female clients.

Inadequate Training Management:
Training has never been a priority in the health department. Most state governments did not develop
any training infrastructure for in-services training and tended to depend on centrally funded training
institutions. For a long time it was assumed that basic training is enough for health workers to do their
job effectively. In-service training were only conducted when any new programme was introduced such
as immunisation or ORS. Unfortunately there is no systematic periodical appraisal of workers
capabilities and skills. Our recent experience in parts of two districts show that workers level of
knowledge and skill is very inadequate. Many wrong notions are common in the workers and many a
times they don't know the right techniques for various simple clinical procedures such as making ORS,
testing urine for protein, diagnosis of ARI.
Given the health department's track record on providing effective training to the health workers for
health interventions it is likely that radical reorganisation of the training set up will be required for
training health workers for RH problems. Most training in health department has been theoretical and
classroom based. For example training done for the Child Survival and Sale Motherhood (CSSM)
programme. In this training majority of the time was spent in reading the modules. Secondly this
training combined 11 intervention elements into 5 day training thus giving very little time to each topic.
After the training the required supplies and drugs did not arrive in the workers hands for 6 to 12
months. As a result of all of this even today many workers we have interviewed are not clear about
simple things like management of diarrhoea and pneumonia9. Fortunately World Bank assisted India
Population Projects and other Area Projects have done many useful things to improve training set up in
the government. For the first time State Level Training Institutes are being developed. The training
system will have to change from class room lectures by guest faculty to field oriented and clinical
training to address reproductive health problems. In-service training for clinical skills have been focused
so far on sterilisation. It did not cover basic gynaecological, obstetrical and neonatal health skills. The
current pattern of one month's tubal ligation training should be modified to include basic obstetric,
gynaecological and neonatal work. This will require at least three to six months time in a high case load
situation so that each person get to practice the clinical skills. This could be done by broadening the
skills training being planned under the CSSM programme10 to cover all the RH interventions.
Unfortunately in the CSSM programme the clinical skills training was very delayed and perhaps not
given high priority, this should be guarded against in the RCH programme. More and more centres at
the district level have to be recognised for clinical training besides the Medical collages as in the latter
many a times trainees from the PFIC system do not get priority as the residents and interns are also
sharing the case load.
Second problem of training has been that it has not been linked to the actual work performance of the
workers. It is not reinforced by their supervisors in the field and required support materials are not
provided to the PHC staff to practice what they have been taught. Many of these things happened in
6

the immunisation programme but did not happen in the CSSM programme leading to deterioration of
skills and knowledge of the workers. The training has to be reinforced periodically by the supervisors
and supported by required medicines and supplies. Unless this is done training alone will not produce
results. Training has to be followed up with a supervisory system which will ensure positive and
negative feedback for the workers so that they are motivated to identify and treat more cases of RH
problems. Non-monetary incentive have to be built into practice of what has been learnt in training.
Training should be follow up with systems development and problem solving.
Besides training there are several areas of HRM that need to change in the government system. The
selection, promotion and transfer policies have to be made more linked to qualification, commitment
and performance rather than political connections, ability to pay or caste. Each employee should have
reasonable promotional avenues and opportunities for self development. This should be linked to
rigorous monitoring of performance in all spheres of work rather than the current system of measuring
perfonnance only for sterilisation. Cunent emphasis on targets for sterilisation must give way to
measure work along many dimensions. Rewarding those who perform must be the centre piece of the
HRM policy. Unless there changes are made it is unlikely that RH programme can be implemented
successfully.

2. Poor Access and Quality of Services:
Worker-Community Contact Weak :
One of the key factors for success of the family planning programme in Bangladesh has been close
contact between the FP worker and the community 11. Unfortunately in spite of substantial FP and
health infrastructure in rural areas regular contact between the worker and the community seems to be
low. This is due to the fact that most workers are not resident in their area of work, lack of adequate
micro-level planing, supervision and monitoring as well as due to over emphasis on sterilisation and
immunisation. In most places workers do not seem to visit clients homes regularly. In the hay days of
malaria control programme the malaria workers were going house to house according to Time Place
Movement ( fPM) schedule which was a well worked out system of house visiting on a periodic basis.
With Multipurpose Health Worker Scheme starting in mid 1970s and over emphasis on family
planning, the TPM schedule got neglected. For the Female workers (ANMs) no such detailed
programme of house visiting seem to be in force. They have to visit villages allotted to them on a fixed
day of the week. But there is no detailed plan of house visiting. Due to lack of any such plan of
activities during the field visit the house visiting by AMNs becomes random and haphazard. Our field
observations in a few PHCs indicate the female workers do not visit each household regularly. They
spend most of the time in the village at few houses where they have friends or where they get better
reception. Because of pressure to get sterilisation cases they do visit house were there are potential
sterilisation clients.

Post project studies after the India Population project in UP showed that only 15% of eligible couples
were contacted by the health workers 12. Recent survey done in 11 districts of UP have shown that only
7-16% of couples are visited by health workers in last 3 months13. On the other hand 80% of the
7

households were visited by any health worker in past 3 months as reported in a base line survey in 5
districts of Gujarat 4. National Family Health Survey data showed that only a small percent of pregnant
women got a home visit by any health worker for ANC during the 9 month of pregnancy. Ideally each
couple should have been visited by both the male and female workers once in every 15 days i.e. in three
months the couple should be visited six times by the male and female workers. During the nine months
of pregnancy each women should receive at least 3-4 visit by the ANM. This shows the gap between
the planning and what is actually happening in the field and that there are wide variation in coverage of
extension work. At such a low level of contact with the community it is very difficult to imagine any
rapport building or effective service delivery. In many villages we work in, the people don’t know who
the male and female health workers for their village are.
Given this scenario of lack of contact and rapport between the government health functionary and the
community, the community currently does not see government health worker as a source of treatment
for health problems except perhaps for family planning and malaria. In this situation it is difficult to
imagine that the community will readily come forward for treatment of reproductive problems from
such workers or health centres. The first step will have to be developing close rapport with the
community through regular and reliable contact between the community and the health providers at the
village level and PHC level.
Deteriorating Technical Competence and Level of Clinical Practice:
The technical competence and clinical practice at PHCs has deteriorated substantially over time. The
current practice at PFIC is limited only to symptomatic treatment without arriving at a clinical diagnosis
based on proper examination. Most doctors in PHCs do not take adequate clinical history and conduct
proper physical examination. Our recent visits to PHCs showed that many PHCs even do not have
standard set of instalments for basic clinical examination. Simple and essential things like torch,
spatula, thermometer, blood pressure measuring instrument, stethoscope are not found in many PHCs.
Situational Analysis done in two districts of UP by Population Council showed that 20 to 45% of the
PHCs did not have basic instruments such as stethoscope or BP instalments15. Situation at the sub
centre level is even worse. Situational analysis study in 2 districts of UP bears this out. Availability of
the instalments does not mean that it is used. Many times instalments are available but generally locked
up in the cupboards, or are not functioning or of very poor quality. For example the data from ICMR
study of 23 districts showed that even when facilities were available woman’s weight was taken in 68%
of cases, foetal heart sounds were listened in 57% of cases, BP was measured in 37% of cases, urine
was examined in 37% of cases and haemoglobin was measured in 31% of cases for pregnant women16.
In surgical contraceptive procedures as female sterilisation the quality of care is poor as reported by us
from Gujarat , and by Townsend, Khan and Gupta from UP 18, by Laxmi and Barge from Madhya
Pradesh 19
The clinical knowledge of the doctors also leaves lot to be desired. There is not regular updating of the
technical knowledge of the doctors or the health staff. Irrational prescribing is not uncommon. Recent
review of drugs procured by one district showed some irrational medications indicating that not much
attention is paid to updating the drug list at the district and state level. Currently district or state level
supervisors are not taking any interest in the clinical side of the PHC practice. They concentrate their
8

attention on monitoring of the sterilisation and other targets. In this situation introduction of RCH
programme will need thorough reorientation of the doctors and para-medical staff and improvement of
their clinical skills and prescribing practices. We feel that each doctor in the PHC system should spend
at least 15 days per year in a higher level of facility to update clinical skills and knowledge. Every 5
years each doctor should spend 1-2 months to upgrade the clinical skills and every 10 years each
doctor should spend 3-4 months in upgrading clinical skills. Before each promotion each staff member
should go for in services training at an appropriate training centre as is the system in the Indian Armed
Forces. Besides this supervisors will also have to introduce regular auditing of clinical practice at the
PHC level. Only such attention to clinical practice will help implement the RCH programme effectively.
Lack of Privacy and Confidentiality:
In the current PHC set up hardly any attention is given to ensure privacy and confidentiality of the
clients. The usual scene at the PHC is that two or three patients are present in the doctors room when
he is examining one case. Proper screens are not used to ensure privacy while doing physical
examination. At sterilisation camps the level of privacy needed is more as exposure of private parts is
required during the preparation and operation. Our observations at the sterilisation camps in Gujarat
have highlighted this problem of privacy 20. Situational Analysis study of PHCs in two districts in UP
showed that auditory privacy was available in only 46% of PHCs and visual privacy was available in
64% of PHCs in Sitapur district while both these numbers were 42 % in Agra district21 . Unfortunately,
PHC staff is insensitive to this aspect of quality of care. Confidential counselling hardly ever takes place
in the PHC system. One of the important reasons for people to seek private care especially for abortion
is due to lack of privacy and confidentiality in the government system 22.
Given such environment maintenance of confidentiality cannot be expected unless special attention is
given to it. These factors will act as barriers to the use of RH services at the PHC level as
confidentiality and privacy are very important for delivery of RH services which by its nature are
sensitive matter in any society. Sincere efforts are needed to sensitise the staff to these issues and
systems need to be developed to ensure privacy and confidentiality at each step. Privacy and
confidentiality should be incorporated into each training and should be part of supervisory checklists at
all levels in RCH programme.
Weak Information, Counselling and Communication process:
At various levels in the PHC system the information giving, counselling and communication process
arc quite weak. Situational analysis in two districts of UP referred above indicated that information
provision to even acceptors of family planning methods is not adequate. Other studies also have
pointed out this weakness. For example the four state study by UPS showed that only 22 to 40% of
ANMs reported that they would discuss with the client how to use the oral pill if the client showed
willingness to use the pill23. NFHS has shown that even in 1992-3 only 58 to 66% of women in
reproductive age knew about various spacing methods24. Further analysis of the NFHS data showed
that only about 45 % know about all the four methods of FP available in Indian programme. This
indicates low level of communication even for family planning in the community. This is because
communication skills are not taught in the basic training of any category of staff including the doctors.
9

Secondly the programme does not place importance on this and hence the workers do not think that
talking to the patient or client and explaining them the procedures for various services is part of their
job. Our participant observations at several PHCs, camps and immunisation or ANC clinics showed
that there is hardly any communication with the clients. Communications is limited to the bear
minimum necessary related to the services given. Even proper instructions are not given regarding how
to take the medicines, when to co- 1 ck, what is wrong or what is done to the client. Workers and
doctors we have talked to do not scu any need for such communication! ICMR study in 23 districts
showed that only 21% received information about other methods and 26% were told about advantages
and disadvantages and 31% received advice on how to use the method at the time of accepting the
method 25. This clearly shows the weakness of information giving process in the FP services.
The family planing programme has used incentives and targets rather than communications to motivate
their clients and workers. The Block Extension Educator and the District Extension Educator which
are the key posts for ensuring communications have become more of clerks or assistants to the medical
officers to do administrative work rather than communication and extension work. Communication
work becomes more difficult as the workers timings (Sam to 4 pm) coincide with the daily work
timings of the community especially the males. There is hardly any communication activities happening
late in the evening or night when the community has spare time. Field experience shows that not much
regular communication efforts goes on even though on paper reported activities may look impressive.
The communication aids used like posters, pamphlets etc. also have several technical problems besides
being unattractive and in inadequate in quantity.
As communication and counselling skills play a very important role in RH approach it would be
essential that these skills be developed at various levels so that they can support the activities for RH.
All the staff including doctors have to be trained and motivated to practice good interpersonal
communication and counselling with the clients. This will help improve the image of the PHC to a great
extent. This will be a difficult and long term process as teaching communications skills is more difficult
than teaching technical skills. Secondly regular field level monitoring will be needed to ensure that
communications for RH continue in a systematic way. This can be done if at the state level and district
level qualified and dynamic persons are in charge of communication and health education activities.
Communication should be integral part of service delivery process and should be included in the quality
standards as well as monitoring indicators.
Poor Image of the PHC in the Community and gross under utilisation of PHC services:
Due to over emphasis on preventive programmes, especially family planning, the PHC’s curative role
has been neglected and weakened. There is no monitoring of how many patients come to the PHC and
for what diseases. The health statistics reports published by the ministry do not include these data.
Currently PHCs are seen by the community only as a place for sterilisation, immunisation and malaria
treatment. Because of various problems in the PHC system including non-availability of doctors and
medicines, poor quality of services and indifferent human interaction, they have lost credibility in the
community. Baseline surveys from 11 districts in UP show that only 5-27% of the households reported
that they always prefer government health services, while 30 to 76% prefer private health care
services26. There is increasing competition from the private sector in many area of the country. With
10

improvement in transportation the access to private care in towns and cities has also improved
substantially in most part of the country. This has led to further under utilisation of health services
especially those not located at strategic locations. Data from baseline surveys done by ORG in 15
PHCs of 5 districts of Gujarat in 1990 showed that on an average each primary health centre clinic
treats about 24 cases per day which is a small number given the fact that each case takes only 2-3
minutes. This study also showed poor use of the indoor facilities27. Data from all PHCs in Gujarat
showed that on an average each PFIC treats 20 cases in a day28.
Recent Multi Indicator Cluster Surveys done by Centre for Operations Research and Training for
UNICEF in six districts of Gujarat show that 54-80% of people went to private doctors for treatment
of diarrhoea while health worker have treated only 1.6-16% of diarrhoea cases and government
doctors have treated 13-39% of cases in different districts29. NFHS data shows that substantially small
proportion of diarrhoea and cough with fever were treated by government health facility30. An all India
household survey of medical care done by National Council of Applied Economic Research (NCAER)
in 1990 showed that out of all illness episodes where medical care was sought in last two weeks, only
8% went to PFICs, while 28% went to government hospitals and 43% went to private sector31. In a
baseline survey done by ORG referred above, in Gujarat only 13 % of families reported exclusive
dependence on PHC system for treatment. Majority of people tended to seek medical treatment from
private sector.
Most sub-centres do not have a building and sub-centres clinics are not held regularly and are not well
attended. Data from recent surveys done in UP cited above, show wide variation in percentage of
households reporting visit to a PHC or sub-centre in last 3 months. This figure varies from low of 6%
to high of 59%. Attendance at sub-centre clinics is also very low. Only small proportion of deliveries
are conducted by the para-medical workers. NFHS data shows that only 12.6% of deliveries are
conducted by health workers32. Most workers do not have training and required equipment and
supplies to properly examine a patient and treat common illnesses. For example most ANMs did not
have BP instalments till very recently and many still don't have it. On the other hand even when nice
equipment are provided they are seldom used by the staff We have seen several PHCs and CHCs
where new equipment are found unopened even after months or years of receipt.
This clearly shows how poor is the contribution of PHC system to curative care. Looking at what kind
of cases come to the PHC it is very clear that reproductive problems forms a very small part of it if at
all. All this indicates that there is an urgent need to refocus PHC work on curative care and establish its
credibility in the community. Only then one can expect that people will come to PHCs for STD/RTI,
maternal care and other reproductive diseases.
3. Weak Support Service Systems:
Weak Referral System:
The referral system in the PHC is currently ad hoc and un-systematic. There are no referral slips or
records of referred cases. The referral facilities also do not inform the referring PHC about the follow
up actions needed in each case. Referred cases do not get any special care or preference at the referral
11

centre. Each level of the PI IC system functions almost independently, even administratively they fall
under different set ups. For example in Gujarat the PHCs and Sub-centres are under district Panchayats
with Chief District Health Officer and the District Development Officer being in charge, while the
Community Health Centre (CHC) and above are under state government with Regional Deputy
Director and Additional Director of Medical Services as the administrative heads. The PHCs are under
the Director in charge of public health services while the, CI ICs are under Director of Medical services
and medical collages are under the Director of medical education. Many times the head of these
divisions within the health department do not get along well with each other and hence can not forge
proper co-ordination and co-operation at the top level which percolates to the lower levels. This
situation has added to the deterioration in the image of the PHC system. Many RH services require
referral to higher levels, for example surgical treatment, management of infertility etc.
Given the present situation it would be difficult to visualise that for RII problems treatment will be
offered through proper referral in the PHC system. The programme will have to develop adequate
referral mechanism especially to ensure that contacts of the case are traced and treated simultaneously
for STDs and RTIs and higher level of care is available when ever needed. This will mean development
of a functioning referral chain. One of the reasons that clients go to private sector is that there the
informal referral chains are well developed due to monetary interests. This gives clients faith in the
private system.
Weak Laboratory Services at PHC and CHC:
Laboratory services at PHCs are currently very weak, primitive or non-existent. Lab technician’s posts
are vacant in many PHCs and where filled the scope of their of work is limited only to blood tests for
malaria, sputum for TB and urine sugar and albumen and some time routine tests like haemoglobin.
Even urine microscopy is not done at many places due to lack of simple instruments like centrifuge.
Many PHC laboratories do not have even basic furniture, washing facilities and autoclaving
arrangements. The maintenance of laboratory equipment is also lacking and hence instruments once out
of order remain unrepaired for many months or years thus making laboratory dysfunctional. Given this
situation substantial inputs will be required in the laboratories along with training of laboratory
technicians to ensure that basic tests required for RH diagnosis are available at PHC level. Condition of
CHC and district hospital labs may not be very different. Generally lab tests needed to diagnose STDs,
HIV, cause of infertility and menstrual disturbances, PAP smear for cancer of cervix are not available
at most CHC and even at many district level hospitals. People have to go all the way to medical collage
for such tests. Hence these labs will also have to be upgraded to do basic and more sophisticated work
for detecting RTIs and other RH problems that arc referred to higher level.
Poor Epidemiological and Microbiological Services:
As the incidence and prevalence of RTIs and other reproductive problems vary a lot from place to
place , it is very important to have adequate epidemiological information on these problems at local
level. Even now at district and state level epidemiological and microbiological services are very poorly
developed. This was highlighted during the recent Plague epidemic34. Virological services are almost
12

non-existent in most parts of the country. The district health organisation has only one post of epidemic
health officer who is having only a basic medical qualification without any special training in
epidemiology. Even at state level there are very few trained epidemiologist in the health department. As
discussed previously the lab services at CHC and district level are weak. In effect district health
organisation in most districts do not have any laboratory set up under its control. The district hospital
laboratory is only for clinical lab work. Microbiological work or histopathology work is generally not
available in the CHC or district level. None of the National Level Research institutions have focused on
RH problems with exception of family planning.
Epidemiological and microbiological services are essential for accurate diagnosis of RTIs and for
working out their epidemiology of RH problems in the community. Unless these services are improved
it would not be possible to direct the RH intervention in a scientifically appropriate way. For example,
periodic testing at sensitivity of organisms is essential to provide optimal drug therapy for RTI and
STD. Standardised clinical and epidemiological definitions of various RH problems are urgently
needed. Using different criteria for diagnosis of various RTI can give wide variation in their prevalence
as shown by Bulut et al 35. Hence local epidemiological understanding of women's health and neonatal
health problems is essential to the development of appropriate strategy to tackle them. Building up
epidemiological and microbiological services will be important first step in dealing with RH problems.
Better linkages of health department and the medical collages where these services are potentially
available and could be developed will be useful. Unfortunately no national level thinking seems to be
going on in this direction.

4. Weak and centralised monitoring and supervision:
Difficulty in Monitoring RH interventions:
Management of RH programme is difficult as it has many different interventions as shown in table 1
and the demand for RH services will vary from PHC to PHC based on prevalence of various RH
problems including RTI/STD and community's health care seeking behaviour. In some RH
interventions such as safe motherhood or immunisation one can set a norm for services provision based
on estimated birth rate, but for other problems such as RTI/STD or menstrual problems no norms can
be set centrally on expected cases to be treated in each PHC. This means that a new monitoring system
will have to be developed for measuring the performance for RH interventions at the PHC level. Such
monitoring system will have to link up with reward system to ensure that the workers are motivated to
take care of RH problems. A target based approach which has been used for family planning
programme so far will have to be replaced. At the central government level efforts are on to develop an
alternative way to monitor the programme without the use of targets36. Unfortunately these systems
are yet not tested in the field. Hence urgent efforts are needed to develop and field test feasible
approaches to replace target based approaches.
As quality of care including information and client perspective are also important aspect of RH,
indicators to measure them will have to be developed and used in monitoring the programme. Secondly
given the limited capacity of the health system to collect, analyse and use information in a meaningfill
way any new system of monitoring will have to be very simple and straight forward. Today's public
13

health system works under lot of political interference, the new monitoring system will have to
circumvent these problems in order to be effective. Developing such a system will be a important
managerial challenge for the RH programme.

5. Inadequate and in-operational Service Infrastructure:
Poor buildings, eqiiipment^n^ipnlies:
The PHC infrastructure including buildings, equipment, transport and supplies are generally in a poor
shape due to lack of maintenance and timely replacements. This is due to inadequate finances, diversion
and wastage of available resources and lack of interest and initiative of the PHC medical officers and
their higher level managers. An extensive study of PHCs done by ICMR in 1987-89 has showed that
PHCs were deficient in many of the basic requirements37. Things do not seemed to have changed much
since that study except that in some PHCs and CHCs new equipment have been supplied under the
CSSM programme and some new buildings are constructed under various Areas Projects which are
supported by bilateral donors. Our recent visits to many PHCs showed that the basic equipment at
PHC are not available or old, not working and often kept in an unclean condition. Recent situational
analysis done by Population council in two districts of UP also show that almost half of the PHCs and
SCs do not have basic equipment or equipment are not working38. Except for cold chain equipment,
no system of repair and maintenance is developed for any other equipment in the PHCs. Non-working
equipment provides the unwilling doctors a good excuse for not doing work related to that area of
health care and the supervisors also do not take serious notice of such non-functioning equipment or
doctors. The audit and accounts system too does not calculate costs of down time of equipment due to
non-repair and the consequent indirect cost and suffering imposed on the clients. Purchase of poor
quality, substandard and unnecessary equipment due to vested interest and corruption also contributes
to this problem.
One of the main problems is that the construction and repair of buildings of the PHC system is under
the Public Works Department (PWD) of the state governments which are famous for their inefficiency,
poor quality of work and corruption. This affects the quality of PHC building construction and
maintenance. Poorly constructed and maintained buildings provide reason for doctors not to stay in
them or not to do surgeries and procedure in them.
The situation of supplies of medicines and contraceptives is also a problem. The ICMR study and the
situational analysis done by Population Council have shown substantial supply problems at the PHC
and SC level. Many PHCs and SCs do not have essential medications for RH problems and
contraceptives. Even simple things like Iron and Folic acid tablets are in short supply at times.
Along with shortage of equipment and buildings there are also surplus and unused equipment and
buildings bought or constructed under various schemes and donor assisted projects. Each new project
adds new set of instruments and at times buildings without assessing the location-specific need and
potential for use given the local circumstances. Such facilities and assets are later not used at all or not
14

..

fully used. We have seen stoie rooms of many PI ICs which are full of expensive but unused ecjuipment
fioni several projects gathering dust. Many a times location of buildings are not strategically chosen
and hence their functionality suffers a lot. It is reported that in Gujarat about 200 PI ICs get less than 5
patients pci day. Several CIICs arc underused because of locational problems. Unused or under used
buildings and staff are one of the greatest sources of wastage in the Health department which is not
accounted for. There is not “asset-productivity” audit in the health department.
Because of various infrastructural, supply related reasons as well as lack of training and motivation,
various levels of the PHC system are not fully functional. For example many SCs and do not provide
basic delivery services, many PHCs do not provide sterilisation, MR, MTP and delivery services, many
CHCs don’t provide Essential Obstetric Care services. Situational Analysis study in Agra and Sitapur
districts of UP showed that only 16 and 23% of PHCs offered sterilisation while only 9% and 26% of
PHCs offered MTP services. Unfortunately there is no monitoring at district, state or national level of
the functional status of the, SCs, PHCs and CHC/FRUs. The most glaring example of this is that even
after the completion of the World Bank assisted CSSM project (in which one of the main safe
motherhood intervention was to offer Emergency Obstetric services through First Referral Units at
CIIC level) there is no clear idea about how many planned FRUs are actually functional in the
country39.
Given this situation the RH programme will have to ensure that equipment are properly maintained and
infrastructure is in a reasonably functional and in clean condition so that clients would like to come to
the health centre. Standards for quality and adequacy of physical facility will have to be developed and
adhered to provide good quality RH care. This may mean setting up separate maintenance systems for
buildings and equipment. Diverting some funds from constiuction of new PHC and subcenter buildings
to maintenance of existing infrastructure would be more cost effective. Before buying new equipment
the existing equipment should be inventoried and repaired and redistributed to make optimal use of it.
Only after this the missing equipment should be allowed to be purchased. For this to happen the
purchasing has to be done at a local level and has to be tied up with decentralised planning.

6. Poor demand for liealtli services:
Low Community Demand for PHC services :
Given the problems with the PHC system and its poor image the community does not perceive it to be
a preferred place for curative care. Hence many people are using private health care providers for
treatment of health problems. The overall demand from the community of services of the PHCs is low.
Studies done by UNICEF, NCAER and Population Council cited above indicate that majority of the
people prefer private care. Secondly many RH problems such as leucorrhea and menstrual problem are
seen by women as inevitable and they continue to suffer in silence. The cultural factors also contribute
to this low demand for gynaecological health problems. Given this situation lot of effort will have to be
devoted to generating community demand and increasing community awareness regarding RH services
at PHCs. Unfortunately till the services availability and quality does not improve the demand
generation may prove to be counter productive and frustrating to the staff and community alike. Our
experience with RH services camps and similar experiences from other NGOs indicate that if
15

reasonable services are provided for RH problems with proper communication to the community
women will come in large numbers to take advantage of these services. Thus supply of gender sensitive
and effective services activates potential demand.

1. Weak management of services:
Lack of Commitment and Accountability in the PHC Staff:
Of late the levels of commitment and accountability to work in the PHC has been deteriorating. Many
PHCs and SCs do not start working at 8.30 which is the stipulated time, as staff comes late, usually by
1-3 hours, partly because they do not stay in the PHC or SC village and partly because there is no
monitoring. Absence from work, not going to the field area, poor quality of services, etc. are quite
common in the PHC system. The field work is also not systematically planned and happens in a
haphazard way. Bringing cases to sterilisation camps or motivational visit to a potential sterilisation
client dominates all other activities and takes precedence on them as well as provides an ready excuse
for not following the schedule if work. There are very few individuals in the PHC system who are
willing to try out new or innovative activities to improve the services. The common complaint of
everybody is that they are over burdened by work even though studies of time use of PHC workers
have shown substantial proportion of time is used in unproductive activities such as travel, records and
personal work40 41 . The work output of the PHC also indicates gross under-utilisation of staff and
PHC services at many places. The supervisors are not able to enforce a highly productive work culture
and at times encourage the lax attitude and complacency due to their own shortcoming or irregularities.
When medical officers arc not attending to the Pl IC regularly on time or if they arc doing illegal private
practice they loose control over the field level staff. Most supervisory visits and meetings of district
level officers ai'e meant to check on the target achievement and to motivate the staff by threatening
them if targets are not achieved. They never bother to check or ensure quality of service or solve
genuine problems of the workers. Accountability is further weakened because of inability of the district
and state levels health managers to take action against erring workers due. to their political connections
and pressure from local politicians. For example punitive transfers and non-payment of salaries are
frequently cancelled under political pressure. It is frequently reported that local politicians often protect
erring employees at the expense of damaging the accountability in the whole system and putting the
public at risk. This demotivates the few who are committed.
Given the situation one can expect that introduction of RH interventions may meet with substantial
resistance and inertia from the staff and supervisors as they will have to change their old ways of
working to become more responsive to the need of the clients. Thus changing the work culture must be
the first step along with inducing reasonable level of accountability in the system. Community pressure
along with administrative accountability will be needed to implement RH programme in its true spirit.
Ineffective and Bureaucratic Management Processes:
Most of the PHC managers including doctors are not at all trained in management. Just one year
diploma in Public Health besides basic medical qualification is enough to reach to top position in some
of the state health departments in others even that is not required and a clinical specialist can also
16

become head of the public health services without any further management or public health training. At
central level the Director General of Health Services does not require any public health or management
training. A pure clinician such as an orthopaedic surgeon can become and has become Director General
of Health Services at central level having the responsibility for the whole countries health systems.
Secondly the at the central level all the technical positions are stalled only by officers of the Central
Government Health Services. Thus these officers do not have first had management experience of any
state government mn PHC systems. Their only exposure is in the CGHS which only covers the
employees of central government and some small union territories. Various government rules and
regulations along with centralisation of power in the department limits the scope of effective
management at the peripheral levels. Promotion by seniority rather than ability and skills puts the oldest
person at the top rather than the most capable or innovative and dynamic persons. All this is
compounded by archaic hierarchical style of management where the boss is always right. There is
hardly any team spirit. In such environment innovations and participatory management can not be
expected. RCH programme focuses on decentralised management which will need substantial change
in the way the programmes have been managed so far.
Quality has never been on the agenda of any governmental department in India and health department
is no exception. I here is no management recognition that quality is important. This can serve as a great
barrier to RH approach where quality and client satisfaction are paramount. Supply and logistics an
important management function is also weak in the PHC system. Target oriented approach has further
damaged the effectiveness of the management. Political interference, corruption, lack of accountability
and other social cancers have not spared the management system of the health programmes. In this
situation if the RCH programme has to succeed the PHC management has to be rebuild with effective
management training, decentralisation and alteration in the monitoring and evaluation as well as the
reward systems.

Conclusions and Recommendations:
It is obvious from the discussion above that the PHC system in India is facing may constraints which
will limit the effectiveness of the RH interventions. Given these constraints of the PHC system
introduction of RH interventions will have to be done very cautiously and after addressing some of the
key systemic problems discussed above. We see three broad and interlinked strategies which may be
needed to promote RH interventions.
Firstly, improvement of overall management functions to ensure availability of doctors and para-medics
and improve their commitment to 1<11 programme. The management intervention should also help
reduce the barriers to provision of quality care and support the functionaries. This would mean solving
some ot the genuine problems of the employees and the system, overcoming infrastructural problems,
ensuring supplies and logistics to encourage delivery of quality service.
The second strategy will have to address itself to improving clinic based and community based practice
at PHCs and sub-centres. This will include retraining of the staff'and motivating as well as monitoring
their process of service delivery to ensure compliance with good clinical practice in diagnosing and
17

treating RH problems as well as effective extension work. For this training and supervision system has
to be reworked. Training has to be continuous and skill building type rather than didactic. Super vision
has to ensure good clinical and field practice. It is vital to clearly specify what RH service will be
offered at which level and further specify the timing and quality of services. And finally set up
monitoring system to ensure that the services are accessible and of high quality and are used.
Lastly, adequate efforts will be needed to generate demand in the community so that community
members seek treatment from the PHC set up. This should go pari pasu with improving quality of PHC
services. The community efforts will also have to be directed to changing behaviour so as to reduce
risk of STD/RTI and AIDS and seeking early treatment for various RH problems. The community
efforts also should focus on creating pressure for perfonnance on the health system to deliver the
services due to the community. For this effective communication using multiple media will be required
to reach the community.
Such three pronged strategy will help operationalize the RH interventions through PHC system in
India. Unless these changes are made the constraints of the PHC system will grossly limit the
effectiveness of the RH interventions, as has happened in the CSSM programme, and the large
investments being made in the programme will not yield commensurate results.

References:
1. Pachauri. S. Reproductive Health
working paper. 1995.

Package.

Population Council

2.World Bank,
Reorienting India’s Family Planning
Towards Reproductive and Child Health approach. 1995.

Programme:

3. Banerjee D. World Health Forum.
4. Mavalankar. DV. Can PHC system in India delivery emergency
obstetric care?
Indian Institute of Management Working Paper.
1994 .
5. Premi MK. Family Planning and MCH in Uttar Pradesh, (A review of
studies) The Population Council. Asia and near east operations
research and technical assistance project. 1994. PP.63.
. Health Secretary of a state made this comment during a
Seminar organised to facilitate dialogue between Inadian and
Chineses family planning officials. Jaipur 19th March 1998.
A base line survey of reproductive health care services in 23
districs (14 states) India. Indian Council of Medical Research,
New Delhi. August 1997.
8 . ICMR Op Cit (7).
18

9. Personal observations of the training and discussion with PHC
staff and health officials.
10.
and Safe Motherhood Programme:
National
Child Survival
Integrated clinical skills course for physicians. ARI, Diarrhoeal
diseases, essential newborn care. MCH Division, Dept,
Dept. of Family
Welfare, Ministry of Health and family welfare. Govt, of India.
. Haider SJ, Islam N, Saleh SN. Profile of health worker
visitation. In Extended Analysis of Bangladesh Demographic and
Health Survey 1993-94. Ed. Kantner A, Al-Sabir A, Chakraborty N.
National Institute of Population Research and Training & EastWest Center, Dec. 1996. P. 118-135.
12. Population Centre (1994): Fertility and family planing in rural
areas: A post project survey in the areas of first India Population
Project, Report series. Lucknow: As cited in Premi 1995. P.64.
13. Based on compilation of data from 11 reports of "District level
baseline survey of family planning programme in Uttar pradesh",
SIFPSA, Lucknow, The population council, India, VIMARSH, New Delhi.
1995.
14. Report on baseline survey in Gujarat. Vol. IV. (executive
summary) draft report. A study sponsored by govt, of India and
Govt, of Gujarat. Operations Research Group, Baroda 1992. P. 19.
15

. Situational analysis of family welfare programme in UP: Agra
and Sitapur districts. Council for Social Development and
Population Council, New Delhi. 1995.
16 . ICMR study Op Cit.
1 . Mavalankar DV, Sharma B. The quality of care in
sterilization camps: Evidence from Gujarat. Chapter 14. In.
Forthcoming book. Quality of care in Family Welfare in India. Ed.
Koenig M.
18

. Townsend JW, Khan ME, Gupta RB. The quality of care in
sterilization camps of Uttar Pradesh. Chapter 15 In. Forthcoming
book. Quality of care in Family Welfare in India. Ed. Koenig M.
19

Lakshmi R. Barge S. Quality fo services at laparoscopic camp
in Madhya Pradesh. Chapter 13. In. Forthcoming book. Quality of
care in Family Welfare in India. Ed. Koenig M.
20. Mavalankar DV. Sharma B. Quality of care in Sterilization Camps
in Gujarat. Paper presented at workshop on "Quality of services in
the Indian Family Welfare Programme" held in Bangalore, May 24-26
1995, Sponsored by Population Council.
19

21

. Situational Analysis study. Population Council Op cit.

22. ICMR study cited in. Chabra R, Nuna SC. Abortion in India: an
overview. P. 34-35.
23

. Verma RK, fRoy TK. Assessing the quality of family planning
service providers in four Indian states. Chapter 9.. In.
Forthcoming book. Quality of care in Family Welfare in India. Ed.
Koenig M.
24. National Family Health Survey 1992-3 India. International
Institute of Population Science, Bombay, August 1995. P.132.
25

. ICMR study 1997. Op cit.
26. compilation of district level surveys referred above.

27. Report on baseline survey in Gujarat: Vol IV: Draft report: A
study sponsored by govt, of Indian and Govt, of Gujarat. Operations
Research Group, Baroda. 1992. P. 32.
28

. Information obtained from Directorate of Health and Family
Welfare, Government of Gujarat. 1997.
29. Multi Indicator Cluster Survey: Summary of Six Districts.
Centre for Operations Research and Training, Baroda, India, page 5.
30

. NFHS India report. UPS Bombay. 1992-3.
31. Household Survey of Medical Care. National Council of Applied
Economic Research. New Delhi. June 1992. P. 41.
32. India: National Family Health Survey 1992-93.
Institute of Population Sciences, Bombay. P.xxxi.

International

33. Luthra UK et. al. Reproductive tract infections in India: The
need for comprehensive reproductive health policy and programs. In:
Reproductive Tract Infections: Global impact and priorities for
women's reproductive health. Ed. Germain A. et al. PP.317-342.
34. Mehta NR, Desai PK, Pathak KJ, Mavalankar DV, Raval V. Report
of Expert Committee Appointed by Government of Gujarat to
Investigate Suspected Plague Epidemic In Surat City during Sep.Oct. Gujarat Government 1994.
35. Bulut A. Yolsa N. Filippi V. Graham W. In search of truth:
Comparing alternative sources of information on reproductive tract
infection. Reproductive Health Matters. No. 6. 1995. P. 31-9.

20

36

. Mannual on Target Free Approach to Family Welfare.
Government of India. 1996. New Delhi.
37. Evaluation of Quality of Family Welfare Services at Primary
Health Centre Level. ICMR Task Force Study. Indian Council of
Medical Research, New Delhi. 1991.
38. Situation analysis of family welfare program in Uttar Pradesh:
Sitapur: Final Report: India. The population Council. Asia & near
east operations research and technical assistance project. December
1995.
39

. World Bank, CSSM completion report. 1997. New Delhi.
40. Basu Ghosh. Primary Health Ch re Time Management in Rural South
India. Journal Of Health Management. &(2) July-Dec. 1994. p. 25-52.

41. Field report on task analysis study of the multipurpose health
worker and supervisor in relation to community and health
organization in Orissa. Orissa Implementing Consultancy Group. May
1995.

21

VHAI, WAHJ& DSE
TOWARDS COMPREHENSIVE WOMEN'S HEALTH POLICIES & PROGRAMMES
WORKSHOP 6-9 OCTOBER, 1998 AT E.C.C, BANGALORE.

Health Scenario at the Turn of the Century
Shanti Ghosh
In 1977, the Thirtieth World Healthy Assembly passed a historic resolution
committing WHO and its Member States to achieving by the year 2000, a level of health
for everyone that would permit them, to lead socially and economically productive lives.
Towards achieving that, the declaration of Alma Ata in 1978, called on all governments
to formulate national policies, strategies and plans of' action, to launch and sustain
primary health care, as part of a comprehensive national health system and in
coordination with other sectors, leading to Health for All by the year 2000. With only 2
more years to go, the problems of primary health care delivery in India are as formidable
as ever. WHO realising the impossibility of achieving this goal, has now shifted it to
2020.

The rural health infrastructure suffers from many inadequacies, which is partly
due to poor training, inadequate supervision,

and indifferent attitude of the health

personnel, and partly due to lack of mobility, inadequate supply of drugs and equipment.
Besides there is not enough awareness of preventive and promotive health among the
health personnel and the community, with the result that only about 50% women receive
any prenatal care or iron tablets for anaemia and 70-80% are delivered at home by
unskilled persons, contributing to the high maternal mortality as well as a high neonatal
mortality. In a large country like India, there are vast regional differences and the worst
scenario is in the large states of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh.
India's maternal mortality estimated around 400-500 per 100,000 live births is fifty times

1

higher than that of many developed countries and six times higher than that of Sri Lanka.
On the whole access of women to health care is poor. This is due to lack of awareness,
their poor status in the household, lack of initiative, lack of time and empathy and the
working hours of the health services. Besides there are very few women doctors, whom
the women would prefer to consult. They mostly suffer from chronic reproductive tract
infections, problems associated with pregnancy, anaemia, backache etc.

There is an increasing disenchantment concerning health and health services
among all segments of our society. The poor who have so far accepted illness and death
are now beginning to demand care during illness. Poorest 40% of rural householdsrspend
on an average Rs. 131/- for an illness episode when receiving care from government
doctors and Rs. 157/- when purchasing care from private doctors (42nd round of the
National Sample Survey (NSS) 1986-87)l. Medical care cost is only next to dowry as a
cause of rural indebtedness. Several reports have assessed that 7-9% of income is spent
on health care, which is often of poor quality, and the "doctors” usually untrained.

Cost and the burden of treatment are closely related to access to health care and
are among the highest in those states where public health infrastructure is least
developed. This fact applies equally to government and to private institutions. Where
public health infrastructure is well developed, not only is treatment cost in government
hospitals low but same is true for private hospitals. This is clearly demonstrated by the
Kerala situation. In all states with the exclusion of Kerala, rural patients pay more for
health care and bear a higher burden for treatment. This is due to sparse distribution of

2

health care facilities in rural areas^The Kerala situation demonstrates that if primary
health care is readily accessible to rural population, then even the cost of out-patient
treatment can be minimal. The high out patient treatment cost for the rural population in
the backward states clearly indicates the failure to deliver primary health care.

The investment in health is very small. The most persistent declining trend has
been on expenditure for hospitals and dispensaries during the last decade, counter
balanced by the phenomenal expansion of private hospitals. Health care expenditure has
not kept pace with increase in government expenditure. For the eighth five year plan, the
total outlay was Rs. 434100 crores of which Rs. 7582 crores was for health and Rs. 6500
crores was for family welfare - total 3.25%. WHO recommends about 5%. The estimates
for the Ninth Plan are only marginally higher.

The goals and targets of the eighth plan (1992-97) emphasised the human face of
economic reforms. However, social sector expenditure did not reflect this concern. The
budgetary allocations for education, public health and water supply family welfare,
housing, urban development labour, social security and welfare by the Centre and States
together remained almost stable at about 5.8% of GDP and about 21% of total
government outlay. Much of this is used up by salaries and buildings, leaving little for
new investments, human resource capacity building and other inputs for improving the
quality of life.

3

Mortality Rates

Even though infant mortality rates (IMR) still remain high, these have been
steadily falling, but the decline varies greatly from one state to another. IMR which was
110 in 1981 has come down to 72. More than 50% of this takes place in the first month
of life (neonatal) which is due to inadequate services for prenatal, natal and neonatal care.
Childhood mortality too is declining (1993 figure is 23.7) and here there is considerable
disparity between male and female deaths, female mortality being higher from one year
onwards. As a matter of fact, female mortality is higher till 35 years of age due to
discrimination against the girl child and due to causes related to reproduction.

There are vast urban and rural differences, which are due to poor access to health
care, lack of knowledge and information and paucity of economic resources. Age at
marriage too is significantly associated with high birth rate and high death rate.
9

According to the National Family Health Survey , children bom to teenage mothers were
40% more likely to die in their first year than those bom to women in their twenties and
yet early marriage is a common phenomenon in several states. Four large Indian states,
Uttar Pradesh, Madhya Pradesh, Rajasthan and Bihar contribute most to mortality. Table
1, 2 and 3 show the health indicators, death rates by gender and relationship between
birth rate, infant mortality rate and age at marriage.

4

Table 1: HEALTH INDICATORS
Birth rate
Death rate
TFR
IMR
Life expectancy
Source - World Bank, 1995
SRA -1996

1996
27.40
8.90
3.50
72.00
60.00

1981
37.20
15.00
4.50
110.00
50.50

1951-61
41.70
22.80
5.97
146.00
41.30

Table 2 : ESTIMA TED A GE SPECIFIC DEA TH RATE BY GENDER
Age (years)

Male

Female

0-4
5-9
10-14
15-19
20-24
25-29
30-34

26

28

2.4

3.0

1.4
1.7
2.4
2.7
3.2

1.5
2.5
3.2
3.0
3.2

s'

Table 3 : RELA TION BETWEEN BIR THRA TEf IMR AND AGE AT MARRIA GE
BR
IMR
Mean age at
State
effective marriage
17.3
13
224
Kerala
32.1
72
19.0
Bihar
32.4
97
18.4
Madhya Pradesh
32.3
86
18.3
Rajasthan
34.0
85
19.3
Uttar Pradesh
19.2
54
20.3
Tamil Nadu
27.4
72
19.5
India
SRS- 1996

5

f.

Major causes of deaths
Apart from the high neonatal death rate, the other major causes of deaths are acute
respiratory infections (ARI) and diarrhoeal diseases, even through diarrhoea management
programme has been in operation for several decades and ARI programme for about two
decades. The key message that diarrhoea needs replacement of fluids and not drugs is
beginning to be accepted, even though a vast number of anti-diarrhoeal drugs still
continue to be prescribed and parents spend a great deal of money buying these.

The standard treatment regime for ARI, Cotrimexazole is also supposed to be
available at all outlets of health services - rural as well as urban, and yet due to lack of
awareness and lack of timely access, infants and young children continue to die of this
■

condition. The number of deaths due to these two conditions is dilficult to assess, but
could be around 3 million per year.

Universal immunization programme
One of the more important area of success in health delivery system is the
immunization programme which was started in a mission mode by Rajiv Gandhi , the
then Prime Minister of India, and where coverage overall had reached almost 80%, even
though children with complete immunization with all vaccines are only about 35-40%.
Two doses of tetanus toxoid to the pregnant women have helped to reduce the incidence
of neonatal tetanus to a much lower level than hitherto. Now India has launched a pulse
polio programme for elimination of polio, in which two doses of the vaccine, a month

6

apart, are given to every child under 3 years (now increased to 5 years) on two fixed days
throughout the country. The programme needs an efficient surveillance system, which at
present is lacking. For how many years the programme will have to be carried out, is
difficult to say even though the slogan adopted is - Polio free India by the 2000. One
hundred and forty five countries are polio free according to WHO, 1996. According to
government sources, the number of polio cases in 1996 was 1005, compared to 3428 in
1995. However, there are indications that immunization rates for various other vaccines
have shown a downward trend, which could have serious consequences.

Child Survival and Safe Motherhood programme covered the whole country
during the Eighth Five Year Plan which gave some boost to MCH. Now it has been
replaced by Reproductive and Child health (RCH) programme in which women’s health
gets much more attention. There has been a paradigm shift in the family planning
programme also with abolition of targets and the programme emanating from the
grassroots and making various contraceptives available for spacing. However, this is
easier said than done and needs a tremendous amount of organization, training and
supervision. Central to all this is community involvement and participation, so it is not
surprising that family planning activities go on much the same as hitherto. The targets are
there, the camps are there, but there is a little more client friendly atmosphere and some
evidence of spacing methods. The clients are nearly all women. So nothing much seems
to have changed.

7

Too early, too frequent and too many
India’s population in 1996 was estimated to be 953 million (1996 UN estimate)
which is 16 percent of the world population and has more than doubled in the past three
decades. The population had remained stable in the first half of the century, which has
been attributed to frequent famines and epidemics. India has a young population - 36.3
percent of the population is between 0-14 years. The mean age at marriage of females is
presently 19.6 for India as a whole, but is much lower than that in several states. The
reproductive pattern can be summarised as - too early, too frequent, and too many. One
third babies have a birth

weight less than 2500 g (low birth weight) Early marriage and

repeated pregnancies take their toll and about 20,000 deaths are attributed to abortion
because of lack of access to contraceptives and inadequate facilities for medical
termination of pregnancy (MTP) even though the Act came into force in 1971 and was a
landmark of social legislation. NFHS has estimated that there is 30% unmet needs for
contraception. Sex ratio is unfavourable to females - 927 females per 1000 males (1991)
with a higher female mortality from the first month of life till about 35 years of age. This
indicates discrimination against the females, and a high death toll because of causes
related to reproduction. The maternal mortality rate is estimated to be 437 per 100,000
live births according to NFHS, but in some areas it could be even twice as much.

There is increasing evidence of foetal sex determination with a view to aborting
the female foetus inspite of laws against it. A recent report from Haryana highlights the
widespread prevalence in that state (Eco. And Political Weekly, 1998).

8

Female

infanticide too is reported from a few states. Son preference is a very deep-rooted
phenomenon in most of the country and many rural families would like to have two sons!

Widespread malnutrition
Malnutrition is common among all population groups but is more significant and
serious in women of child bearing

and young children. Maximum

malnutrition

is

between 6 months and two years in every state - only the extent varies2’3’4,

According to the National Nutrition Monitoring Bureau, Hyderabad (1988-90)5
only 10% children had normal nutrition, while 8.7% were severely malnourished. The
situation was a little better than what it was ten years ealier6. According to the
countrywide National Family Health Survey (1992-93)2, stunting rates are 52% while
wasting rates are 17.5%.

It can be estimated that there are 60 million malnourished children under four, of
which nearly 60% live in the five states of Uttar Pradesh, Bihar, West Bengal, Madhya
Pradesh and Maharashtra. Two out of three preschoolers are severely or moderately
malnourished. Malnutrition is contributory to almost half the deaths under 5 years of age.

The risk of death for common childhood diseases is doubled for a mildly
malnourished child, tripled for a moderately malnourished child, and may be as high as
7

eight times for a severely malnourished child .

9

WHO estimates that malnutrition was associated with over half of all deaths in the
developing countries in 1995. Besides research indicates a link between malnutrition in
early life including the period of fetal growth and the development later in life of chronic
conditions like coronary heart disease, diabetes and high blood pressure, giving the
countries in which malnutrition is already a major problem new cause for concern8.

However, there seems to be light at the end of the tunnel. Nutritional status seems
to be improving a little and even prevalence of low birth weight babies seems to be
declining a little (Sachdev H.P.S., unpublished data).

Reports from Tamil Nadu9 suggest an improvement in the nutritional level with
51.8% normal, 27.6% stunted and 9.9% wasted, and one should make an indepth study of
the contributory factors.

Feeding and Caring
Breastfeeding is a fundamental right of the child. It is the perfect food and even
the malnourished mothers are able to produce sufficient amount for the baby. It costs
nothing, it is a source of bonding between the mother and the baby and prevents the baby
from infections. Several studies have shown a high incidence of diarrhoeal and
respiratory infections in non-breastfeeding babies. Exclusive breastfeeding for 5-6
months is what the baby needs before going on to home cooked semisolid foods10. The
economic value of breast milk has been estimated to be approximately Rs. 6000 crores
per year.

10

However, apart from lack of family support to the. breastfeeding young mother in
the case of nuclear families, their availability for breastfeeding is also questionable when
they are working. They try and cope by breastfeeding in the morning, evenings and
through the night. However, the feeding of semi-solid family food is left to someone else,
a granny if she is lucky, but often to a young girl who in the bargain misses out on her
schooling and a carefree childhood.

How is this young child to be cared for ? A working mother is a reality and a
necessity in our socio-economic milieu. A majority, almost 80% are in the un-organized
sector and are not entitled to any maternity leave. They do take some time off depending
on the needs of the child and their need to earn money to sustain their families. There is
very little provision for child care. In this context the traditional custom among some
communities of the pregnant woman going to her maternal home towards the end of
pregnancy and staying there for a variable period after the birth of the baby is extremely
helpful both for the health of the mother and the baby.

For the organized sector, there has been some improvement. Maternity leave has
been increased from 3 months to 4-1/2 months (only for two pregnancies) and there is a
paternity leave for 15 days as well.

Integrated Child Development Services (ICDS) programme, which will soon
cover the whole country, has no provision for child care either. One can consider a

11

convergence between ICDS and some of the women’s development programmes such as
DWCRA, TRYSM, Indira Avas Yojana and many others, where women could bring their
young children with them and they could be looked after by some of the women who
could be trained as child care workers and earn some money. The ICDS programme
could provide overall support.

The creche as it is generally understood is a very expensive venture, and unless
managed properly, can lead to infections with further deterioration of the nutritional
status. However, with mothers present in the child care centres described above, the
situation would be far better and breastfeeding could go on. This will also release the
older sibling from child care responsibilities, and she could go to school. ICDS could
then become a real nutrition and child development programme as it was envisaged.

At present, there is nothing in it in practical terms for children upto 3 years except
some food distribution. For older children there is some provision for child development
activities. Some studies have shown better psycho-social development in these children.
However, there is ample scope for improving these activities.

Several evaluations have shown no difference between the nutritional status of
children in ICDS and non-ICDS blocks11. If ICDS has to make a difference to the
nutritional status of children, it will h^ave to concentrate on children under 3 years, not at
the anganwadi but in their homes. Active participation of the community, which is sorely
lacking at present, is of paramount importance. Vibrant women’s groups could contribute

12

a great deal to various activities connected with ICDS and in empowering the
community.

ICDS is considered the prestigious child development programme. Out of a
budget^Rs. 847 crores for the department of women and child for 1996-97, as much as
Rs. 682 crores was allocated for ICDS.

Accesses to adequate food and to health care are among the universally accepted
human rights. While infant and under five mortality has registered a considerable fall (72
and 35 respectively) it is still much too high. Several studies have shown a higher
prevalence of malnutrition among the girls and higher mortality among them. There is
cultural and social bias and their access to healthcare is poorer as compared to the boys.
There is discrimination regarding food at the household level. NFHS data shows that a
higher proportion of girls are severely malnourished in 11 of the 14 large states.

Shiv Kumar12 has studied the Gender related Development Index (GDI) in the
various states of India. Whereas India as a whole ranks 99th out of 130 countries on the
GDI, there are only 13 countries in the world that record a lower GDI than Uttar Pradesh
and Bihar. Kerala has done well on the GDI and ranks seventy third in the world along
with China. As against an HDI (Human Development Index) value of 0.423 India's GDI
value is 0.388. The two would have been the same if there had been perfect equality
between women and men in the formation of human capabilities, fhe extent ol disparity
varies across the states. The lowest differential is found in Himachal Pradesh,

13

Maharashtra and Kerala and the highest in Haryana and Punjab, two states noted for their
high per capita incomes but extremely adverse female-to-male ratios.

Anaemia is widely prevalent among all age groups and is particularly serious
problem among pregnant women. It is responsible for 20% of maternal deaths.
Government has had an anaemia management programme for more than twenty years,
but it has not made any dent on the problem13. The supply of iron tablets is erratic and
their consumption by pregnant women is also irregular. Besides, the short period for
which a pregnant woman is being treated is not enough to make any impact.

Several studies have now shown a high incidence of anaemia among the
adolescent girls14. These anemic girls are tomorrow's mothers, and with early marriage
and repeated pregnancies, the chances of any improvement in anaemia are practically nil.
Anaemic mothers are more likely to give birth to babies under 2.5 kg. In whom the death
rates are higher and growth is also compromised.

There are hardly any services aimed at the adolescents - be they related to health,
education, awareness etc. Frequent suggestions have been made to include the adolescent
girls in the anaemia management group. Various studies have shown that it is possible to
do that. Besides for reducing low birth weight, one has to focus on the health and
nutrition of young girls before they become pregnant - in other words, health care during
adolescence.

14

Directive Principals of State Policy have wide provisions for women and children.
National Policy for Children was pronounced in 1974, which was a follow up on the
Directive Principals and the United Nations Declaration of the Rights of the Child, 1959.
The National Children’s Board was set up in 1974 and reconstituted in 1981 under the
Chairmanship of the Prime Minister. However, it has not met for a decade or more.
Convention of the Rights of the Child was adopted by the UN General Assembly in 1989.
India ratified it in 1992. However, the situation of children leaves much to be desired
with poor access to education and to health care not to speak of millions who labour for
long hours under difficult and even dangerous environment. This requires not only laws
(which are usually flouted) but concern and activism on the part of others, who have all
the advantages.

According to Mahatma Gandhi, the test of human rights and human dignity was
when the last among the least were empowered to realize them first. Among these the
most defenseless and the most voiceless are the children, and even among them, the girl
children.

15

REFERENCES

1. National Sample Survey, 42nd Round, 1986-1987.
2. National Family Health Survey 1992-93.

International Institute for Population

Sciences, Bombay 1994.
3. Reddy V, Pralhad Rao N, Sastry G, Kashinath K. Nutritional Trends in India,
National Institute of Nutrition, Hyderabad, 1993.
4. Gillespie S. Child Nutrition in India. Finding from the National Family Health Survey
(1992-93), NFIBull 1996:17( 1 ):5-8.
. 5. National Nutrition Monitoring Bureau. Report of Repeat Survey (1988-90). National
Institute of Nutrition, Hyderabad 1991.
6. National Nutrition Monitoring Bureau. Report for the year 1979. National Institute of
Nutrition, Hyderabad, 1980
7. Pelletier DL, Frangillo EA and Habioht JP. Epidemiological evidence for a
potentiating effect of malnutrition on child mortality. American J of Public Health
1993:83.
8. Barker DGP. Mothers, babies and diseases in later life. BMJ Publishing Group,
London 1994.
9. Abel Rajaratnam, Sampath Kumar V. Tamil Nadu Nutritional Survey comparing

children aged 0-3 years with the NCHS/CDC reference population. Indian J Pediatr
1998;65:565-572.
10. Ghosh S. Nutrition and Child Care. Jaypee Brothers, New Delhi 1997.

16

£

*

11. Ghosh S. Integrated Child Development Sciences Programmes - Need for Reappraisal
Ind. Pediatr 1997;34:911-918.
12. Shiv Kumar AK. Gender, Equality and Political Participation: Implications for Good
Health in Women's Health Public Policy and Community Action Edited by Swapna
Mukhopadhyay. Published by Manohar, 1998.
13. Indian Council of Medical Research. Evaluation of the National Nutritional Anaemic
Prophylaxis Programme - an ICMR Task Force Study, New Delhi. Indian Council of
Medical Research, 1989.
14. Kanani S. Combating anaemia in adolescent girls, Mothers and Children. 1994
Vol.l3,No.l.

l

i

17

CONCEPTUAL FRAMEWORK FOR ASSESSING WOMEN’S HEALTH NEEDS
Thelma Narayan*
Introduction
It is now more widely accepted that during the past few decades the
health system in India, in its planning and health careservices, has viewed
the health needs of women primarily in terms of their child bearing or
reproductive function,

^st health programmes for ’women have focussed on

family planning and mother and child health services.

The main interest

seems to have been to evolve methods by which the reproductive function
of women could be controlled, so as to serve the needs of the nation, of
^ven child
survival strategies were evolved to ensure that the small family norm was
society, of demography, of the child or perhaps the family.
acceptable to people.

There is probably a consensus among people oriented

health workers that this has been a narrow and limited view concerning
women* s health.
It does not take into consideration sufficiently the
personhood and the wholeness of women.
There is also a growing and anxious realization that this approach has
not even been able to serve the purpose for which it was intended, namely
of population

control.

However in the process of evolving alternative

approaches, the basic assumptions concerning the position of women in Indi;
society and their resultant health status, on which the earlier approach
rested, have not been challenged or cuestioned by the health system.
Therefore, the same philosophy, with the same underlying goals have been
repackaged or extended to cover more than just the child bearing age group
of women.

They now also cover the girl child and the adolescent girl, with

the hope that these efforts would bear fruit during the crucial child
bearing or motherhood period.

International public health experts and

agencies have also floated various package deals like GOBI-FFF and Safe
Motherhood, which again are narrower and more verticalised. versions of the
earlier Mother and Child Health Services.
The other cause for deep concern in India has been the declining sex
ratio as is revealed by the decennial census, ever since the turn of ••2
*Comniunity Health Cell, Society for Community Health Awareness, Research
and Action, 326, V Main, I Block, Koramangala, Bangalore - 560 034o
Prepared for the Workshop on Women’s Health conducted at the Child-In-Need
Institute (CINI), West Bengal on the 23rd and 24th of April 1993.

2.

the century.

Levels of other indicators regarding the health status of

women like the Maternal Mortality Rate, levels of anemia and malnutrition
etc., are also unacceptably high.

This has occured inspite of at least

four decades of planned health interventions through an expanding health
infrastructure.

It has occured even though there has been an overall

slow improvement in other health indicators of the population in general.
There is therefore, clearly a need for a “rethink” and for evolving new
approaches.
Redefining health needs of women
If new policies, strategies and approaches for the improvement of the
health of women in India have to be developed, there is a need to under
stand and define anew what the health needs of women are.

A few ideas are

being raised in this regard.
A woman is a

persnm situated in society and her health tjas to be

viewed with an integrated wholistic approach.

Several non-medical, societal

socio-economic/ political and cultural factors determine her health status.
Using the WHO definition of health itself, there is a need to include the
physical,

social, emotional and intellectual (mental) and spiritual aspects

in understanding the health status and needs of women, when evolving health
strategies.
When considering physical health, while her reproductive system does
influence the functioning of her body and may be a cause for ill health,
women also suffer from morbidity and mortality resulting from disease in
any or all the other systems as well. Availability and access to good
basic and comprehensive health services is therefore essential,
a
There is also/close interplay of all the aspects of health mentioned
in the WHO definition.

The most crucial fact, cutting across class lines

is that being ‘woman1 straightaway categorises all women to an inferior,
unimportant social status in India.

When considering the sizeable prop

ortion of women (30-40% by official estimates) living below the poverty
line, their health and social status is far worse than others and would
derive from the following life scenario,

Being poor they are likely to

have a large number of live, stillborn and aborted children, They are
also susceptible to a variety of physical sicknesses, most of which are
preventable.

They undertake exhausting work at home in poor environmental

conditions.

At work too they have the dirtiest, most tiring jobs with

inadequate remuneration and rest.

They have lower levels of literacy and

less access to existing health services.

Life in this situation also makes

for a poor self-image, low self esteem, lack of self confidence and to
unrecognised emotional problems during the several episodes of life crises
that are experienced.
Viewing women, particularly poor women, surviving in an inhuman situ
ation, primarily in terms of their reproductive function, therefore does
tnem no justice, and not surprisingly, does not meet the targets set by
the health system,, and even much less caters to their total health care
needs. There is evidence infact that this targetted approach with the
indiscriminate and unscientific use of numerous family planning procedures,
are an added iatrogenic cause of ill-health for women living under these
iverse circumstances.
'Wherefore it is imperative that the health needs of women should be
viewed from a broader and a more humane perspective.
★ Her value os
a human oerson of dignity and worth needs to be

emphasised,
This is to be de-linked to reproduction or production
of any tyre. This crucial aspect* is not measurable or quantifiable.
★
Her total health needs in the context of her circumstances should
be considered.
* Positive indicators of physical, emotional, intellectual and social
health need to be used.

★

Periods of life crisis in womens1 lives are to be recognised.

This

method can build on the strengths and infrastructure of the MCH
approach and extend not only to the girl child and adolescent but
also to the postchild bearing period.
Indicators to assess health/disease
The assessment or the measurement of the health status of women is an
important yardstick for us to know where we are in our efforts to promote .
the health of women.
It helps us to make a situation analysis, to measure
also the
and also
the extent of the oroblem, and
the effectiveness of strategies used.
4

4.
Commonly used health indicators most often give us information about
levels of disease and death among the population.

These are a result of

general living conditions, access to health services etc., which are thus
inairectly indicated. The sex specific Crude Death Rates, sex differentials
in Infant Mortality Rates, Maternal Mortality Rates etc., based on studies
of sample populations, are well known indicators of deaths occuring in
different groups of the population.
also reflects the overall health
women live.

Life expectancy

at birth or at 1 year

status and conditions under which people/

The sex ratio is the number of women per 1000 men and its

trend over the decades speaks volumes to us of the situation of women in
the country.

If one could disaggregate and study these rates by geogr

aphical region, by urban/rural/tribal location, and by class and caste,
enormous differences would be revealed. It is necessary to do this if
the health stetusof those in greatest need has to be recocnised/assesed
and also for the monitoring and evaluation of health and related strategies
that are employed.
Inspite of certain limitations and cautions that are necessary when
undertaking such an exercise, comparison of rates between Districts, States,
South asian Countries, Asian Countries, developing countries and developed
countries are useful. Some indices from South Asian countries are given
below to illustrate the differences revealed by such comparison.
Country

Maternal Deaths

Female Life

per 1,00,000

Expectancy

Proportion of
Births attended by

(Years)

Trained Staff

Live Births
. Agghanistan
2. Bangladesh

690

42.0

8%

600

50.4

Co-'

3. Bhutan

1710

47.1

4. India
5. Nepal

360
830

6. Maldives

400

57.9
50.3
61.0

7%
3 3%
6%
25%

7. Pakistan

400-600

56.5

24%

8. Sri Lanka

60

72.5

87%

Source; 2
..♦5

5.
Information regarding sickness (morbidity rates) among women are more
hard to come by at the national or State level.
community based epidemiological data.

This is even more true of

Studies of nutritional levels reveal

that levels of malnutrition among girls/women continue to be high though
there may be a gradually declining trend. Studies by the National Nutrition
Monitoring Bureau showed no evidence of improved height and weight among
girls from 1955 to 1979.

One third of babies born are low Ipirth weight

(less than 2.5 KG), which results from poor maternal nutrition,

Other

studies reveal inadequate calorie and micronutrient intake.
Community based studies by Rani Bang, et al., have found that the
prevalence of Reproductive Tract Infections (RTI) are very high.

Contra

ceptive use in the presence of RTIs have been found to aggravate the
problem.

Occunational or workplace related health oroblems of women in

the tobacco industry, among tea pickers and in a host of cottage industries
in the unorganised sector also reveal high sickness rates.

Hazardous effect

of rollutants on women during childhood, adolescence, precnancy and lacta
tion also heed to be studied.

A study by Sathyamala, et al., found that

the toxic gases at Bhopal adversely affected reproductive health and reprcductive outcome in Ehooal. We have an indication about the extent of
violence against women in Indian Society from the media, and from the
experience of grours working with women. A few studies regarding mental
health indicate a higher proportion of suicides and suicidal attempts
among women than among men.
It is necessary to integrate and pool all available data concerning
the different aspects of health of women to get a composite understanding
of the situation.

This needs constant updating and continuing studies.

When putting different studies together^ it is also important to keep in
mind that there rnay be differences in concepts and definitions used and
in the methods employed.
Need for new indicators
While accepting that having some indicators, however imperfect, are
better than none, health workers/activists have been feeling the need for
indicators that could gauge decision making opportunities and capacities of
women, their levels of participation in health and societal life, their
. ..6

6.
;•

levels of autonomy, their role in provision of health care in the family,
their levels of knowledge and practice of traditional methods and systems
of healing among others.

There is much scope for further work in this.

Indicators of health related issues
These include figures regarding levels of literacy (formal, non-formal],
income/wages, percentage below the poverty line, employment/unemployment,
participation in different sectors of the workforce, purchasing capacity,
housing, food intake, access to safe water and sanitation.

These are also

crucial factors that impinge on the health status of 'women o
Health care indicators
These would indicate access to primary and secondary health care,
distance to nearest health facility etc.
tilisation (of services) rates and coverage rates are available for some
services eg., immunization coverage and immunization status. The proportion of births attended by trained personnel
The need for measurement and assessment

z also a useful indice.
of effectiveness and utili

sation of services is illustrated by a few examoles.

A snudy of in and out

patient records showed that for every 3 men who utilised medical services
only 1 woman did so.

Male staffing of facilities was a deterrent to

utilization (Ref. Health Status of Indian People, 1968., Foundation for
Research in Community Health)
Another recent study by the Paediatric Department of Maulana Azad
Medical College in 150 slums, covering 22,181 households in the capital
city of Delhi found the following:
* 45% mothers did net avail of antenatal services
*

16% had the optimal'

four antenatal checks

★ 12% smoked even during pregnancy

Awareness regarding health, nutrition, and awareness of
possible complications during pregnancy was poor
51% received iron and folic acid tablets
63% mothers were immunized with tetanus toxoid.
* 82% delivered at home, untrained birth attendants
conducted me
deliveries.
Sources 3

. . .7

7.

I
Caution in the use of indicators

When using any health indicators, it is important to keep in mind the
methods of data collection and quality of data before deriving conclusions
from them.

Questions should be raised regarding methods of sampling used

viz.,£re they representative of the population.

Are findings from one or

two studies conducted in relatively defined geographical areas being
extrapolated or generalised to the entire population.

There is thus a

need for a critical appraisal of any data and. rates.

It is also important

to keep in mind that the health situation ir. the community is dynamic and
changes continuously as a result of several factors.
all that easy to draw cause and effect conclusions
intervention and possible health outcome.

It may also not be
a particular health

The role of other factors that

could cause a bias or be confounding will have to be considered.

However/

‘nspite of all the above there is scope to build further and not to just
abandon what we already have o
we look at new perspectives emerging in health/ new indicators
need to be developed.
as

References
1. M.Han-inond and J Geor, 19 86
Measuring Community Health - Workshop 1
Oxford University Press.
2. KIMFIT (National Immunization Mission Feedback Information and
Technical Update ), 1992/
Ministry of Health & Family Welfare/ GOI/ New Delhi,
Issue No. 24, June 1992.
3. Puri R.K. and Sachadev H.P.S./ 1992,
MCH Services in Delhi Slums
KFI Bulletin, April 1992, Vol. 13, No. 2.
4. Shatrugna V. (undated)
Women and Health/ Current Information Series 2
Research Unit or. ’Women* s Studies, SM
SH DT Womens University.
5. World Bank, 1991
Gender and Poverty in India - A World Bank Country study.
1818 H Street,
Street/ N.W. , Washington D.C., 20433,
The World Bank, 1S18

U.S.A.

will

b; ^13
TOWARDS COMPREHENSIVE WOMEN’S HEALTH POLICIES & PROGRAMMES
WORKS1IKOP 6-9 OCTOBER/ 1998 AT E.C.C, BANGALORE.
*

Role of T-S.M in Women1 s health, with a special reference to FLO H.
Traditional systems of Health Care flow through two distinct but
symbiotically nourishing streams, an oral streams and a codefied
one.
The local Health traditions or the Lok Swasthya Paramparas are the
oral traditions born out of experiences of thousands of commnities
A
of different geographical zones and cultural backgrounds over
thousands of years. This system is basically eco-specific and
local need based, depending on the immediately available local
resources 5uch as flora fauna and minerals.
This is spread across the country over six lakhs of villages
carried down by common house wives, village dais bone
and other local practitioners and some religious institutions
and healers.
The codefied streams which are documented in thousands of
manuscripts are represented by Ayurveda, Siddha, Unani and
Tibetan.
The unifying factor of these written traditions are the underly
ing unique basic principles and world view which forms the corner
stone of this science.
The codefied and oral traditions have been in interaction over the
years and many practical aspects of written traditions are drawn
out of the experiences of the oral traditions. And the oral
traditions when validated can be seen as based on the foundational
principle of the written tradition such as Ushna Sheets Vata etc.
o<TSM as a whole is basically^science born out of experience and
based on universal principles.
The world view of TSM is that the whole world including living
beings and inert substances are made of FIVE ELEMENTS which through
their infinite and reversible permutation combinations create
different objects of diverse characters. Thus we see in everythings which has an existence in consciousness having the presence
of these five elements namely

2
Prithwi (Solidity principle)
AP (Fluidity principle)
Thejas (Heat principle)
Vayu (Principle of movement)
Akash (Ether or principle of space)
In the living beings these principles are further grouped into the
three functional units called VHATHA, PITHA AND KAPHA.
VATHA is formed by the predominance of Vayu + Akasha elements with
other 3 principles in lesser percentage
PITHA is formed out of more of Agni + less jala and other 3 elements
still in lesser quantity.
KAPHA is formed out of the combinations of Prithvi + jala with ot^er
3 elements with lesser volume. Thus the Fanja Mha Boodhas are
re-classified in the living being as Vatha, Pitha and Kapha.
The role of the physician or the healer is to observe the changes
or vitiation of these 3 e.ements in the body either alone or in
combination and provide such materials from the outer universe to
the body so as to bring in back the lost equilibrium.
The only contribution of the healer in this action is the processing
of such outside substance into an easily assumables form by the body.
To be precise the healer chooses and advises such deeds (Karma)
life style (Pathya) and medications (Oushadhi) which can be
assumulated by the body when it is in a de-ranged condition.
To bring back its homestatsis or internal environment<»
It is with this view point Acharya Vagbhada described everything
in the universe as medicinal (Jagathyevamanoushadham Navadyat) so
if properly understood in the right perspective TSM can do a great
deal in preventive, promotive and curative aspects of health care.
In TSM women’s health comes under separate branch along with
paediatrics. Women's health is giving so much of importance in
TSM that the whole life cycle is very beautifully drawn in the
Samhabidas.
BALA, THARUNI, KANYA, YOUVANA, PROUDHA, MATHYAMA AND VRUDHA are the
seven stages in chronological order in women’s life.

•?>In Bala Avasta also it is further divided into KSHEERADA, KSHEERANNADA
and ANNADA, which marks the culmination of infancy.
Women’s health in adult life is elaborately dealt along the following
lines:
1. Problems of primary and secondary reporductive organs
2. Reproductive tract infection
3. Diseases of uterus during menstrual period and after menopause
4. elements to be remembered for suitability of bride and bridegrooms
5. Compatability for marriage
6< Methods of making marital life enjoyable by right choice Ahar
and Vihar
7. Diet during different age, season and occasion - for example:
a.
b.
c.
d.
e.
f.

during menstruation
during early stages of pregnancy
after delivery
during breast feeding
during menopause AND
during old age

Subtle and detailed descriptions of women's health needs and disease
management with minute details are explained in TSM. The whole
concept of ante-natal care where the mother is given the utmost
importance not only for physical and physiological needs, but for
her psychological and spiritual wellbeing is a notable area in
Ayurveda.
Apart from the detailed life cycle approach of health and disease, the
cosmetology for women is an unexplored area in TSM.
From skin care to hair care, from maintaining the body form and shape
to keeping all the organs of the body with optimum functional level
is another unique aspect of TSM.
The permutation combination of plants and other materials give
infinite choices to the healer .
from within or without to chose
the appropriate materials at the right time.

-• >r

Indian medical professionals have a great deal to contribute
to women's health by exploring the fullest potential of TSM.
They can bring out effective and safe materials and methods
which can be used by our healers and health managers of today
so that Traditional wisdom can be rediscovered by rural women
who have in recent decades been stripped off all their natural
healing powers curiously enough in the name of 'Science and
Modernity’.

Vd. G.G. Gangadharan
Executive Director
LSPSS, Coimbatore, India.

7^

•'•••I V

■

Organising Poor Women for Health A Note

,

.t

„ . ,

c= = = ==: = = = =s =s S3 =3 ss s= =s = = =3 c= =x =a tn = = = = as = = =b s= =: = = s= = = = = = == = = =n ex = ss = ss =: s= as = x= = =a so =s = = ss sc===a

Mirai Chatterjee
General Secretary, SEWA
October, 1998.

SEWA has been organising poor, Self-employed women for full
employment
and self reliance for over two decades. In the course ofour work y there
have been several experiences concerning poor women's health.
Women often say:
"Our health is our only wealth"
"As
long as we are healthy we can work. And as long as we get work
survive".

we

SEWA Bank's experience and data reveal that mortality and morbidity of
a Women and/or Family member is the Number One Stress event
in
her
life.
It is a major cause for non-payment of
installments
daily
for
loans taken out, and for indebtedness.

fact, in 1977 when SEWA Bank reviewed the loan performance <of
In
its
depositors,
we found that of 500 women who were defaulters, the ma j or
cause was sickness of the loanee, inability to work and earn and
hence
inability to repay the loan taken. Of these 500 women 20 women had died
- the predominant cause of death being childbirth. This finding
forced
us to start up our work for Maternity Benefits, Safe Child - Birth and
Health in general.
Another concern which is uppermost in women's minds vis-a-vis health is
the escalating costs of health expenditure. Our members routinely spend
between Rs.500/- and Rs.800 on hea1th-related expenditures. The major
increase in cost is due to rapidly increasing drug costs. The cost of
life-saving Rifampicin, for example, an anti-T.B. drug, went up three
times in one year alone (in 1996)!

In sum„we learne/d that:
a)

Women in the informal sector do work that is physically demanding,
often with harmful substances. They work long hours
in
positions
that harm various parts of their body. Pregnant and feeding mothers
often work in circumstances that lead to miscarraige or affect
the
health of the child. Occupationa1 hea1 th is a major issue for poor
women.

b) Their health affects their work. Work in the informal
sector is
mainly manual, and productivity depends on a body in peak
physical
Unfortunately, because of poor nutrition, lack
condition.
of care
pregnancy and childbirth, living in unsanitary conditions
during
and
lack of access to health care, most women are in poor
physical
(and often mental) health. This causes a fall in
productivity and
income,
leading into a vicious cycle of deteriorating
health and
increasing poverty. Access to Social Security is essential for
poor
women.

----h—

above,
then,
Given
the
following basic approach:
a)Al 1

SEWA developed

its

hea1th

team

with

the

health services/care should be need-based and demand driven.

b)All health care should strengthen women's quest for Full Employment &
Self Reliance (SEWA's goals).
hea1th/primary
health care approach
c)A
community
with
within the health sector and
in tegrated
both
activities.
d)Women
should
be developed as health providers,
existing knowledge and skills.

and
ho1 istic
other economic

bui1 ding

on

thei r

e)All health services should be provided in a manner which
contributes
•from
to long-term se1f-re1iance (both cash and in kind contributions
women are encouraged).
f)Initial curative care to be slowly augmented by health education,
the latter to be emphasized.
g)Strong
referral
care by coordination and
col 1aboration
government and pro-poor, affordable private health care.

with

and
both

h)Rational, generic drug therapy.

and
i)Combine grass roots action with policy action at State, national
pro—poor,
international
level policy action for more pro-women and
appropriate health policies and resources allocations.

Some examples of heal th action at SEWA
neighbourhoods)
1.Organized
local women (from villages and poor urban
often dais^to be^ "barefoot doctors" for their own communities, These
with
women then formed their own health workers and dai cooperatives
4 such cooperatives are active at present.
In an
SEWA's
support,
and
prone
districts
drought (Banaskantha
additional
two
Surendranagar) dais have been organised into exising district - level
women's associations which are part of SEWA movement.
the
has an elected executive committee which
run
Each cooperative
the
and plans and manages all the health activities for
cooperative
from
concerned.
They generate revenues in
various ways:
district
and
women,
fees
from employers, from government, through training
drugs shops.
2.Heal th insurance has been organized for SEWA members with the support
32,000 women have paid premium
which
for coverage
SEWA Bank.
of
includes matenity benefits, reproductive health, occupational health,
health

problems of older women and

for common and serious

Each woman receives coverage upto Rs.

d i senses.

1200 per annum.

provides
3.'Shakti
Packet'
programme
is run by village women
and
foodgrains and essential food items to women in two desert districts
at present.

ensure that poor women and their
families obtain
"Shakti
Packets"
and
good quantity and quality food items and hence proper nutrition,
at
affordable prices at their very doorsteps.

in Ahmedabad have
amenities in 11 poor urban neighbourhoods Ahmedabad
4)Basic
Muncipal
by col laborating with the called
provided
been
"Parivartan"
.
(AMC) in a unique joint programme
Corporation
poor
and
families
AMC ---------r-local Corporate bodies
"Parivartan" j
r-..
Under
basic
health-enhancing
themselves
contribute towards provision of
toilet,"gutter connections, garbage disposal, street
services: water,
?
paving roads and by -• lanes and lands raping
lighting,
and leveling and growingj shade trees). Individual
families
ditches <_-- manaqed by SEWA Bank which also provides them with loans
which also
finances are manageo y SEWA Bank
deposits to the AMC when
substantial
AMC when
substantial
the families
and only releases
t-ground work ((laying of pipes etc.) is completed.
providing
to poor
activity found
11 has also
the counters'
prices to be the lowest in the market,
forced nearby chemist shops to revise their exorbitant rates.

5)3

£ipm

round -the-clock drugs counters have been run by women,

4 new drugs counters are being developed, one
At present,
rural members.
will be in a taluka town, serving our

of

which

What we have learned ^a sunimary_
without
and
income security nor Full Employment and Self-Reliance.
-- j measure of work security
2)When women organize for and obtain some
security and health care.
they seek and demand health
I-their
integral part of
3)Reproductive health is viewed by women as an
not
is
their health
health.
Seoaratinq this aspect of
Separating
overal1
useful to women.
neglected aspect of women 's health and
4)Occupationa1 health is a very
and have some impact.
yet one where it is difficult to intervene,
because
This is
si tuation where
i a
a)Women are afraid of losing their employment in
tobacco
of
case
the
(as in
(as
t..
al ternative employment is scarce
heal th
and hence are not eager to take up oc c u pa t i on a 1
workers),
activities.
processes and
require major changes in work
b)Saf e workplaces often
do not want to
substitution of toxic substances which employers women have weak
And
saying they are 'expensive .
undertake ,
bargaining power as few unions exist.
and
* > be technical
^Occupational health
health interventions often need to
the
from
with and learning
scientists with an interest in working
i
poor are hard to come by.
SHhere is a tremendous hunger among women and men to learn about their
learn and need
their
bodies and
They are very ready to
I--their health.
information
"
simple,
understandable
and appropriate health
information that is both useful and empowering.

6)Health care/services can be a source of employment,
especially self
poor
employment for
women. For example, they can become health
educators and charge fees they/ can earn
from their midwives services
and by sale of drugs.
Cooperatives of
health providers
economically viable organisations.

like

dais

can

be

acLive

and

7) Decentralization
of health services and delegation of the
to
• latter
women's
groups
and
organisations
(unions,
Marii la
manda1s
cooperatvies and
producer‘s groups) is a;» effective way
to reach
heal th care to the poorest
populations. It is the ideal
a1ternative
to both government and
private health care which are both
general 1y
neither pro-poor not women — centred.

a strong <-8)Combining
grass roots base with policy action can
hel p
develop health policies
-co and programmes
reflect the health
that
priorities of
poor women.
Policy ac tion
may
be undertaken at
district, state national and internationa1
levels. For example SEWA'*
long standing demand for identity cards
and hence recognition of dais
has been accepted by the Gujarat
--- c government ■ ’various plans to involve
these local
women health care -givers
in
primary health care
activities are being worked out.
Perhaps most
important what we have learned in all
these years is
the importance of organising —i.e. when women workers
come
together in
a group
around r~
’
common interests
including
their own
heal th,
they
become a powerful force for
change. Change in their iown
1 i ves <,
own communities and the world
their
beyond
,
i their villages, It is they who
will
to ensure their
lead
own
their
and
families overa11
heal th and
wel 1 ~ beingu

TOWARDS COMPREHENSIVE WOMEN'S HEALTH POLICIES& PROGRAMMES
WORKSHOP 6-9 OCTOBER, 1998 AT E.C.C, BANGALORE.

d

b

JRe PR ODJxenVE

HEALTH PROMOTION AMONG WOMEN

5^7/7 ez1

CPresenfecf
By

Mrs.J.p.Saulina Arnold, JVIA., JVISW (IASA)
Executive Secretary
Tamil Nadu Voluntary Health Association
18, Appadurai Main Street, Ayanavaram, Chennai - 23.

At the
K/&R.XSHOP
I o)^AA.X>3

Com pct: H-e/usr

1+^A-t.ru FbA-ief£S
At

£c c

■1

/3

HEALTH PROMOTION AMONG WOMEN

In this country, which is called Bharath, the Baratha Matha is the mother of all and all
important issues is given to goddesses (not god the male) - Education to Saraswathi,
wealth to Lakshmi and power to Kali. God created male and female in His Image and left
the work of production and rule the world to them says the Bible.

Production and

protection has been left to Sivan (Male) and Sakti (Female) equally that one cannot exist
without the other says Indian religion. But all are only religious attribution and in reality
the daughters of mother India lack education - as there are more illiterate (61%) than
literate (39%) - women have low status, no rights on wealth or power over their own
body leave alone their family. In this situation this paper is to present women’s agenda
for health. It is not sure if the agenda is for the women to follow, or the policy makers
(mostly men) to follow. In this paper the presenter is trying to depict the situation of
women, the health status of women, issues blocking their health and development and
ways to improve the situation through health promotion activities.

Fifty years after independence it is not sure if the health situation is more improved than
science and technology. The population has been doubled, literacy rate has improved and
mortality rate reduced considerably. But still the following data show the health situation
of people. There are still many illiterate, specially among women. There are about 32
crores living under poverty line.

INDIA - FACT SHEET (1991)

SI.No.

I.

Particulars

Population Total

India

84.6 Crores

Sex Ratio per 1000 Male
II

III

929

Literacy Rate
Male

64.13%

Female

39.29%

People living below Poverty line
Percentage

35.97

No. of people

32 Crores

IV

Maternal Mortality Rate

570

V

Infant Mortality Rate

110

VI

Mean age at marriage

15 years

The status and situation of women has to be understood on these issues-declining sex
ratio and gender inequality, the burden on women, reproductive health and morbidity,
adolescent health, etc.
DECLINING SEX RATIO

India is one of the few countries, where since the turn of century the sex ratio of women
to 1000 male is steadily declining from 972 in 1901 to 929 in 1991.

Sex Ratio Tamil Nadu & India

975
972
970
965
960
955
950
945
940
935
930
925
1900

1920

Years

1901

1921

1941

1961

1981

1991

972

955

945

941

934

929

India

955

5
934
1940

1960

2000

1980

This key indicator of the low status of girls and women in the society is further supported
by the reversal of the Infant Mortality Rate (IMR) between boys and girls.

1980 -

Male

96

Female 90

1986 -

Male

74

Female 86

The unfavourable status of women in India affects the health status of women and their
girls both directly and indirectly. "Son preference" and gender disparity in household has
its own ill effect on the growth of the girl child. Due to these the number of girls outside
education system is more, more girls who have to work at home, (and also study if they

are sent to school); Besides girls eat last and least amount of nutritious food; the social
norms both in the natal home and in the home where she is given in marriage, gives her
least priority for her health or status. This treatment and trend is more now than ever
before.

Increasing "dowry" problems, ill-treatment and death are seen even among

educated. Due to this gender discrimination, violence against women is increasing.
”In India more than 5000 women are killed each year due to dowry”

- UNICEF

Wife beating is very normal, when most of the countries has brought legislation against
Domestic Violence, Marital rape. Sexual harassment and female genital mutilation, India
has not included these in its legislation. Not that there is no policy or legislation in India.
Since British time many legislations were enacted but they have not been implemented
due to the strong male dominant world. Women groups need to know about these and
try to implement.

Even educated people see only the visible - educated middle class women - and forget
about the women. Invisible - 60 - 70% women in rural and urban slums.

HEALTH STATUS

According to the World Bank, about one third of the disease burden in developing
country is of women between 15 to 44 years of age. It is linked with pregnancy, child
birth, abortion and Reproductive Tract Infection, STDs/HIV/AIDS.

India’s maternal mortality ratio is fifty times higher than that of many developed
countries and six times higher than that of Sri Lanka. The generally poor nutritional

status of girls and women plays a major role in this. Malnourished women give birth to
low-birth weight baby and if it is a girl the vicious cycle continues.

Most of the burden of health care falls on women. Nearly all family planning methods
are for women creating more problems.

While the data given below shows those

recorded there are thousands who do not seek medical help from trained professionals.
There are many mis-conceptions that prevent women from seeking health services.

DISEASE DATA

Sl.No.

Particulars

1.

CRUDE DEATH RATE

2.

Life Expectancy at Birth

3.

DISEASES (in 1000s)

Both

Female

Male

10

10

55.4

55.7

2,87,902

1,42,308

1,45,594

Tuberculosis

13,794

8,748

5,046

STDs

5,566

1,871

3,695

Respiratory Infection

34,251

16,059

18,192

Maternal conditions

7,409

7,409

- Infection

1,256

1,256

- Abortion

1,600

1,600

- Obstructed labour

1,503

1,503

- Haemorrhage

846

846

Non communicable

83,437

10

42,071

41,366

-Source - World Bank Publication 1995
BURDEN ON WOMEN

Women who is not given power or education is expected to take care of the whole family,
irrespective of whether the husband earns and gives money, whether there is fuel or
provisions for the family.

Rural Energy Consumption %
Kerosene

7.1

Log, twigs & charcoal

51.6

Dung

21

Crop waste (Hay)

16

- The Second India - World Resources Institute

These data shows that 89% of energy is non commercial - have to be collected, saved by
women. Their time and energy has to be spent for this. These energy, specially with
smoke are very hazardous for women.

Some studys said a women inhales about 40

cigarettes smoke while working in the kitchen. Kerosene and other commercial energy
are not accessible to women. It is also said that with less and less common land for
women, to collect twigs and cow dung her task is harder.

Poverty: - in India with less social security the individual households have to look for
their own survival - that means all in the family have to work. So no time for education
or upgradation. Lack of income produces malnutrition, low productive people and in turn
they give birth to similar persons which perpetuate poverty. Inspite of development the
people under poverty line remain the same.

This cycle has to be broken through

education and empowerment. At present urbanisation and urban poverty have increased.
There are many cities with more than one lakh population.

The local authorities for

example, Channai with only 174 Sq.Km has 50 Lakhs population and has a density of

21,111 persons per one Sq. Km. Growth of this scale has put enormous pressure on
urban infrastructure and administration. So women are more burdened.

Families have less and less social support and that also is a problem for women. Increase
in urban poverty affects mostly women and children. There are not many who work for
these groups.
•

Poverty with illiteracy, unemployment and low status drive many women to sell sex
for survival. This makes them more vulnerable for STDs and even HIV/AIDS.

•

Basic amenities-water and sanitation is lacking in many places.

That affects the

health of women. There is an urgent need to provide these.

ADOLESCENT HEALTH

It is estimated that 19 crore adolescents (aged 10-19) are in India with nearly half of them
being girls. Many of them are not studying but working. In India in many states girls are
married in this stage. Also women commence sexual activity at an early age and become
more vulnerable due to their already under-nourished status.

Inspite of conservative

attitudes there are more and more unmarried adolescent girls getting pregnant and restore
to unethical and dangerous methods to abort the child. Lack of education, sex education,
modern mass media all lead to this situation. There are evidences to show that RTIs and
STIs are in young girls also. But no measures have been taken to educate them properly.
Even the lesson added in 10th standard text is only an academic exercise and makes no
change in their lives. There are more semi educated girls now, without jobs, than ever
before. That leads to problem. Only planned intervention for them can promote health.

HEALTH SERVICES
One of the most neglected areas for women in India is lack of access to health services.
There are blocks at every steps.

In the family

- they have to get permission, money
- they need a support to go with them

In the health centre there are not - many Lady Doctors,
- basic health facilities
- encouragement
- besides distance, unsuitable OP timing also contribute to their misery.

Besides these the medical personnel in many places do not understand the plight of
women and blame them for the same.

Their attitude prevent women from going to

treatment.

Creating awareness among health personnel could be one solution for this.

AGENDA FOR WOMEN

In this background if we have to give women's group an agenda to improve women's
health, the following steps have to be taken on all the above issues.

a) Awareness for women's group leaders
b) Documentation of information
c) Awareness to women and community
d) Promotion of Reproductive Health
e) Socio-economic programmes
only step by step changes could be brought and little drops of water make an ocean.

ci) Awareness for women leaders
The Voluntary organisations and the Government need to plan strategies to equip women
leaders with knowledge and skill.
b) Documentation
In India most of the data pertaining to women’s development are not available. To create
awareness as well as to see the progress in each area, data have to be collected regularly
on the following issues:
no. of women in the area
•

no. of women in reproductive age

•

no. of girls - adolescent

•

their status / health problem, etc.

These data could be used in participatory methods to create awareness.

c) Promotion of Reproductive Health

To reduce Maternal Mortality Rate and Infant Mortality Rate as well as to have healthy
life the people in this age group (14-40) need to be concentrated on and, activities to be
planned for the improvement of

•

Nutritional status of women

•

Adolescent girls health - education on sexual health

•

Follow-up of Family Planning

•

Prevent abortions through education and support

•

Education on RTI/STI and prevention methods

•

Promote health seeking behaviour and referral

•

Promote Breast Feeding hrough family support

•

Education on Sexuality and gender and sexual health

•

Community mobilization and education for reproductive health

Provide basic amenities - Toilet / bathroom in public places for women with the help of
local Panchayats.

Motivate women groups for action to promote women's status.
(I) Socio-economic programme

Women Sangams need to be strengthened to mobilise local resources. There are many
schemes by Government for women's group for self employment, cooperatives etc.
Women should participate in Panchayat and mobilise resources for their development.
Women should be organised to empower them.

ILLITERACY

ILLITERACY

SEX
STATE

RATIO

FEMALE

1991

INDIA
DELHi

“Up
BIHAR

Tvip
RAJASTHAN
ORISSA

KARNATAKA
TAMIL NADU

MIZORAM
KERALA

927
827
879
911
931
910
971
960
~9Tr
974
955
1036

WOMEN

60.71
33.01
74.69
77.11
71.15
79.56
65.32
55.66
67.28
48.67
21.04
13.83

SCHEDULE

SCHEDULE

CASTE

TRIB

76.24
56.18
89.31
92.93
81.89
91.69
79.26
74.05
79.08
65.11
18.75
25.69

91.81
80.14
85.25
89.27
95.58
89.79
76.43
91.32
79.77
21.03
48.93

FEMALE ILLITERACY’ BY AGE

AGE

RURAL

URBAN

35+

85.98

53.37

25-34

73.45

36.08

20-24

66.01

27.05

NEED ADULT LITERACY PROGRAMME & FIEALTH EDUCATION ACTIVITIES

PRESENT HEALTH PROMOTION ACTIVITIES

By Govt. / NGO / Health Workers

FOR LITERATE

Poster / Booklets / Handbills

FOR GENERAL

MASS MEDIA

TV

VIDEO

HOW MANY
PERCENT ARE
COVERED ?

FOLK MEDIA

Through Govt./NGO

Only in very few

selected area

LITERACY PROGRAMME
BUT HOW MANY

IS SUPPOSED TO BE IN ALL AREA

ATTEND ?

HOW MANY HAVE TIME TO
EDUCA TIVE PROGRAMME

REALLY SIT AND LISTEN TO

Mostly they want only Entertainment - not Education
WAY OUT
When do women seek advice?
When they have a problem
Whom do they approach?
THE VILLAGE HEALTH INFORMANT

HEALTH WORKERS

HEALTH PROMOTION AMONG WOMEN

HEALTH PROMOTION through

Health Education "I Individual / women groups
Health activities

i

TNVHA'S EXPERIENCE IN HEALTH PROMOTION AMONG WOMEN

TNVHA had collaborated with Government to promote specific health action among
women.
SOME SALIENT FEATURES

1991-97

PVOH-II USAID Govt, of India, Health & Family Welfare
Department

A. PROJECT THROUGH - LA Y FIRST AIDERS
COORDINATION BETWEEN

•

Govt. - NGO (TNVHA)

.

NGO (TNVHA) - NGO (Members)

•

NGO (Members) - GRASSROOT LEVEL WORKER (LFAs)

1200 LFAs of 129 NGOs were trained
TWO MONTHS TRAINING ON PRIMARY HEALTH CARE
Follow up 4 years
They were

=> First Health informant

=> Counsellors
=> Health providers
=> Even Researchers

=> SOME CONTESTED & WON
Posts in Local Body Election

I

1996-97 Operational Research on Reproductive Tract Infection (RTI)

These LFAs were involved.

Trainings
Health Camps
Focus Group Discussions
Individual Interviews

OUTCOME OF THESE

'SILENCE OF WOMEN' WAS BROKEN

WOMEN GOT AWARENESS
WOMEN TALKED OPENLY
CLARIFIED DOUBTS ABOUT THEIR REPRODUCTIVE HEALTH

ONLY PROBLEM is for Treatment Not many Health centres were
available for women

TRAINING of Girls from SC/Backward community

TN

MCH & FIRST AID
30,000 girls

TARGET
AGE

:

15-25 years

Girls trained so far 19,000 (app.)
OUTCOME

:

The girls are active
0

SOME BECAME HEALTH WORKER

0

They have become an informant in their habitat

Plan to make them a link between SC Community and Govt, facilities.

THESE ARE SOME WAYS THE WOMEN COULD BE INVOLVED FOR HEALTH
PROMOTION OF WOMEN

CONCLUSION
Women's power need to be re-kindled. Let us to women to show the way for other
women. But at the same time men need to extend their support and help in this aspect to
have a lasting change in the society. Only health education and health promotion can do
this. This can be achieved if all get together and work.

REFERENCE

1. 'The Progress of Nation 1997', UNICEF. New York
2. "Improving women's Health in India", World Bank 1996. USA
3. Pachauri, Saroj ’’Defining A Reproductive Health Package tor India" - A proposed
Frame Work, 1995. The population council, New Delhi. India
4. Jejeebhoy, Shireen J. "Adolescent Sexual and Reproductive Behaviour", International
Centre for Research on Women (ICRW) 1996.
*****

TOWARDS COMPREJ
SIVE WOMEN'S HEALTH POLICIES &
'OGRAMMES
WORKSHKOP o-9 OCTOBER, 1998 AT E.C.C, BANGALORE.

RANKING OF SEVERITY DONE BY RESPONDENTS WITH
VAGINAL DISCHARGES

Very Severe

87%
90%

75%
J

80%

i 1 Pus like Discharge

70%
60%
50% •

40%
30%

J Mucus Discharge

50%

I
Yim

; J Blood Stained Disc

J Green or Yellow C

] Discharge with Itch

20%

~~] Watery Discharge

10%

| Curdy Discharge

0%
Very Severe (%)

Severe
35%
30%

31%
(

31%
25%

25%

25%

QJ Pus like Discha

.7

25%
20%

_] Mucus Dischar
.

.

J Blood Stained
-

15%

'■

•:,

Green or Yello

■

%

10%

m V.

5%

)

0%

Severe (%)

] Discharge with

] Watery Dischar

Not Severe

i

4
00

90%
80%.

I

70%
60%
50%
40%
30%

ID

cd
co

|

| Pus like Discharge

[~] Mucus Discharge

Blood Stained Discha

□ Green or Yellow Colo

5?
to

co

a

20%

I

10%

|~"| Discharge with Itchin
|

| Watery Discharge

O Curdy Discharge

0%-

Not Severe (%)

PERCEIVED CAUSES & EFFECTS OF OTHER SYMPTO
GYNAECOLOGICAL MORBIDITY
SL. NO.

1.
2.
3.

4.
5.

6.

SYMPTOMS
Vaginal Ulcers

CAUSES
Promiscuous Behaviour*

It will get
automatic
Swellings on the
Promiscuous Behaviour
It will bec
groin_____________ Evil Eye *________________ if not trea
Boils on the genitals Promiscuous behaviour,
It is a ver
Evil Eye, Heat, Food Allergy It should
immediat
Genital warts
Do not know
It is like a
the body.
Excessive bleeding
Insertion of IUD
It will be a
Tubectomy
is sprinkle
Evil Spirit *
is tied by
Threat, Weakness, Heat
It will lead
Weaknes
Lower abdominal
Tubectomy, Weakness &
It will be a
pain
Heat

CAUSES

NATURE OF VAGINAL

R

DISCHARGE
Watery

Body Heat

♦ Women

♦ Husban

Curdy

♦ Alcohol

Mucus
Weakness

♦ Poor Nu

Tubectomy

♦ Side Ef

Copper-T

♦ Weaken

♦ Cutting
Purulent (Pus)

Most Commonly

Blood

Due to Promiscuous

Foul Smelling

Behaviour

Yellow

• Most of the respondents have this kind of perception. Hence they
tubectomy.
___________

ACCESSIBILITY & UTILISATION OF HEALTH CARE SERVI

SI.
No.

1.
2.
3.
4.
5.
6.
7.

8.
9.
10
11.
12.
13.
14.

Health Care Services

Traditional Birth Attendant
Traditional Healer________________
Manthrik Healer (Faith healer)______
VHN I Health Workers_____________
Private Practitioner (Indian Medicine)
Private Practitioner (Allopathic)_____
Private Practitioner (Quacks)_______
Sub Centre______________________
Primary Health Centre_____________
Dispensaries (Private)_____________
Dispensaries (NGO)_______________
Hospitals (Private)________________
Government Hospital______________
Teaching Hospital

Average
distance from
village

Very
frequently

1 kms.
1-10 kms.
1-5 kms.
1-5 kms.
3 - 5 kms.
5-10 kms
1-5 kms.
3 - 5 kms.
5 - 30 kms.
5 - 20 kms.
5-20 kms.
10-20 kms.
15 - 30 kms.
20 - 50 km.

70
60
52

%

85
40
35
50
12
12
15
38
20
30
15

rv-

ANNEX

BASIC INDICATORS OF MOST POPULOUS TWO COUNTRIES
China

India

/. Population

1088.4

815.6

2. Area (thousands of Sq.km)

9561

3288

3. Average annual rate of inflation %

4.9

7.4

4. Life expectancy at birth (years)

70

58

5. Adult Illiteracy - Total

31

57

45

71

6. Crude birth rate /1000 population

21

32

7. Crude death rate /1000 population

7

11

8. Women of childbearing age as % of population

55

49

74

35

10. Babies with low birth weight (%)

6

30

//.Infant Mortality Rate (per 1000 live births)

31

97

/2.Percentage of urban population

50

27

/3.Risk of dying by age five

40

120

30

118

44

500

124

81

Indicators

- Female

9. Married women of child bearing age using

contraception (%) including men

- Male
Female

/-/.Maternal Mortality Rate

(per 1,00,000 live births)
75.EnroIement in primary school (%)

Source : World Development Report 1990 - Poverty :World Bank

Women and Health
Programme

Voluntary Health
Association of India
BY COURIER

September 21,

PR:DSE:

1998

h

Sub:

— 6th to 9th Oct.
VHAI-WAH! Workshop at Bangaloe
A

'98

Dear
□u must be aware of the WAH! initiative in training in women s
at regional levels having taken place in the south under
nealth
the coordination of
AIKYA and the western region
under the
VHAI to complement the efforts of gender
coordination of CHETNA.
the
training
in
sensitive
taken
women's
has
health,
onal
Nati
responsibility
to organise Preparatory Workshops and
"Tawards
Policy
Seminar related to Women's Health titled
C o th p r & h a n s i y e

Homeri ' s

H & a 11 h Policies

ari d

Programmes".

This

is just to inform you about the dates of the Preparatory
letter
workshop which have been fixed for 6th-9th October i.e. three and
half
a days in Bangalore at:
(ECO,
Ecumenical Christian Centre
Bangalore-560
066;
Whitef i eld ,
8452270, 8453158.
8452653,
Phones: (080)
we decided
In view of optimization of time, energy and cost,
after discussion with the WAN! core group to have the two
As you are aware the WAN!
Preparatory workshops combined as one.
of
the
host
The local
initiative has been supported by DSE.
i s Ms.
workshop in Bangalore will be AIKYA and the contact person
(VHA
of
Neerjakshi
of
Karnataka
VHA
and Ms.
Philomena 1Vincent
Street
,
2nd
Cross,
Gurumurthy
Raj
ini
Nil aya. No.60,
Karnataka,
Phone:
Ramakri shna Mutt Road Cross, Ulsoor, Bangalore 560 008
080-5546606) .
While we
we would
would like to invite many outstanding health personnel
the
who have
have contributed to womenrs health, we are limiting
number to those whose contribution to the process of compehensive
women's health policies and pogramme planning would be valuable.
We would hope to see experiences of the NGOs woking
in women's
health especially those from the South shared with those' working
on policies and programmes.

_2

Voluntary Health Association of India
Tong Swasthya Bhawan, 40 Institutional Area, South of l.l.T., New Delhi - 110 016

2

Thi s
You are cordially invited to participate in this workshop,
is to request you to kindly participate from 6th to 9th
1etter
1etter
'98 in the above workshop in Bangalore. A formal
October
is co—
enclosed.
This workshop
is being enclosed,
with the programme
organised by VHAI-WAH!.
Pl ease
I will be grateful if you can confirm your partici pation■
kindly note down the phone numbers, fax number and the Emai 1
A IKY A
number of VHAI and the dates in your diary and Address of
is :

Ms. Philomena Vincent, !Di rector,
AIKYA, 377, 42nd Cross,, Sth Block,
Jayanagar,
Bangalore-560 082,
Phone:

080-8432363;

Fax : 080-6643276.

With warm regards.
Yours sincerely.

Dr. Mira Shiva
H.O.D. Public Policy, VHAI &
Coordinator VHAI-WAH! Policy Wokshop

Encls: Object!ves
Programme.

pr .

HI

Voluntary Health
Association of India

Women and Health
Programme

/7

Objectives of the workshop
(
1

to analyse selected national policies and programmes affecting women's health from the
perspective of comprehensive health care, so as to :

i’)
c)

2.

Identify priority areas of concern & intervention
Areas of neglect and gaps
Give suggestions for strengthening women's health and ^vomen's perspective in all
policies

p
and need to be supported and those that are
Identify factors that are health promoting
detrimental to women's health that need to be resisted.

Share WAI I's experience in training and perspective building in women's health.

(

4.

To focus indepth on policy and program aspects of Reproductive & Child Health in the context
of women's health and comprehensive integrated primary health care.

5.

To bring together select persons, activity involved in women's health program at grass roots,
to look at RCH and women's health to share experience of collaboration and problems in
implementation.

6.

I'Jaboralion of recommendations
- how to incorporate women's health concerns in national health policies
- how to include traditional knowledge systems in sustainable health care programmes
- how to organize training to improve women's health care and
how to improve cooperation between government and NGOs health programmes

Voluntary Health Association of India

--- * .L_ C M FT I S "T I & M
IH C O M E: M I C2
WHITEFIELD, BANGALORE - 560 066

GENERAL

INFORMATION

Whitefield is* 19 kms from Bangalore city and the Ecumenical Christian Centre
minute walk from the Whitefield Dus Stand, There are signboards
is a twenty
I
showing the way to the Centre.
The Centre is about 3 kms from the Whitefield Railway Station.
Buses take about 45 minutes from Bangalore to Whitefield and may be boarded at
any of the following three bus stands!

4

Majestic Bus Stand
COpp. City Rly Stnl

Bus Nos. 315 B, 333 E, 334

Shivajinagar Bus Stand
Cl Km. from Cantt.Rly Stnl

Bus Nos. 320, 331, 331 E, 339, 339 E

City Market

Bus Nos. 322, 324, 324 A, 326, 326E

Autorikshaw fare from the City to ECC may cost Rs. 100 to Rs.120.
F rom Whitefield to ECC is Rs.15/a private
Delegates engaging a taxi, autorikshaw or coming from the City by Turning left
rtuvi^u
vu,
Whitefield
Road.
~
vehicle are advised to take the Airport, HAL
just after Whitefield junction and driving past, ECC signboards will lead you
1/2 kms- from
to the Centre, which is about 1 1.--- the Whitefield Junction.
Hence bring

Please note that you may not get porter facilities at Whitefield.
only a small travel bag which you can carry.
Accommodati on

On arrival at the Campus, look for directions at the Office Building,
enquire at the security room or off ice.
single/double room with
Your stay will be arranged in one of the hostels in a
will
have to collect hot
attached toilet and shower facilities. Delegates
water from the common washroom in the building.
Please note that a mattress, a pillow, sheets, a blanket and
provided for each resident.

Food
Vegetarian and non

vegetarian food is served.

Tel ephone
Std Code 090
. .
Nos. 9452653, 9452270, 9453159 (During office hours only)
Weekdays 9.30 a.m to 1.00 p.m
2.00 to 5.00 p.m
Saturdays 9.30 a.m to 1.00 p.m

Fax:

91

090 - 9452653

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To U L»

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AIP- PoR T-

WHITErj E Lt>
RLV station

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TC^JARDS CTr’FSEFEb’SIVE Urt-OrS HEALTH POLICIES & FSC^AibtES
WORKSHOP* 6-9 OCTOBER 1998, EAMGALCFE
October 6, 1V98

9. 30 a., m.

Registration
Welcome &
Opening Remarks

VHAI
Al ok: Mukhopadhyay
Executive Di recter, VHAI.

WAH! Secretariat - Indu Lapeer
DSE - Erika Fink
10.00 a.m—10.15 a.m

Objective o+ the workshop

10.15 a.m—10.45 a. m

Introduction

10.45 a.m—11.00 a.m

TEA BREAK

11.00 a.nr-12.30 p.m

Panel Di scussi on
Review of Health F'olicy &
FY-ogramme in the context
of women's health.

Dr. Imrana Qadeer - JNU
Dr. Shanti Ghosh
Dr. Sudarshan, VGKK

12.30 p.nr-01.45 p.m

Role of TSM in National
Health Policy.

Darshan Shankar — FFLHT
Dr. Saraswati Swain, NIAHRD

01.45 p.m—02.30 p.m

LUNCH

02.30 p.m-03.45 p.m

Role of TSM in RCH
women’s heal th.

Dr. Mira Shiva, VHAI

Philomena - AIKYA/Shodhini
Sister Eliza

Smita Bajpai - Chetna
Dr. Hari Jchn - Deen Bandhu
Vd. Gangadharan - LSFSS
Dr. Manjunath
03.45 p.m—04.15 p.m

Discussion

04.15 p.m—©5.15 p.m

bender Sensitive Initiative
in women's health.

05.15 p.m-05.30 p.m

Di scussi on

Planish a Bupte - Masum
Dr. Srinivas Murthy - NIMHANS
Laxmi Lingam - TISS

LctobET 7, 1995

09.30 a-nr-ll-OS a.m

National Policy toi- women
£< major policies affecting

Dr. Sari a Gopalan
Dr. Mira Shiva

.omen ' s heal th.
Economic Policy SAP
Impact on UJomen's Health.

Geeta Sen

i E-cu.ssi on
1.00 a.nr-12.30 p.m

RCH Policy & Programme
components.

2.30 p.m-01.30 p.m

Di scLission

1.30 p.m-02.30 p.m

LUNCH

2.30 p.m—04.00 P-m

Panel Di scussi cn
.CH & TEA
ajor components, Analysis,
status & trends.

04.00 p.m-04.15 p-m
04.15 p.fTr-05.30 p.m

Daleep Mav lank ar
Daisy Dharamraj

Abhijeet - Sahayog
Vi ml a Ramchandr an -

Rajasthan.

Saul ma Arnold - VHA, TN.
Indu Capoor — Chetna, Gujarat.

TEA ?«: Discussion.
Conprehensi ve vsrxneTi' s heal th
health programme as part of
primary health care.

Opportunities -3: Limitations
of collaborating with Govt.
Froqramme
Schemes for
wcmen.

Dr. Mabel Arole - CRH3’, Jamkhed
Dr. Hari John - Deen Bandhu
Dr. Lata Desai - Sewa Rural

Mirai Chatterjee - SEWA Ahmedaba
Dr. Sudarshan - ^O:-K experience
Shobha Shah - Sewa Rural experie
Er. Mabel Arole
Sr. Elise - Sacred Heart

October 8, 1998
09.IZS3 a.m-10.30 a.m

Nutrition Policy
Food Security
WccTien ' s Nut r i t i on al St at us
Priority Policy Loncerns
Strategy ter action.

Cr. Veena Shatrughan — NIN
Er. Manaja Ram Prasad - Coco
Shobha Raghuram

10.30 a.m—11.45 a.m

The WAH initiative in
Training ter v*jQmen s health
WAH! Perspecti ve
DEE'S Role in WAH!
Southern Region WAH!
Western Region

Dr. Mira Sadgopal

11.45 a.m-12.00 noon

Women's Heal th
Need assessment
Maharashtra WAH!

- hFC

Erika Fink - CEE
Philomena — AlkYA/Kumar
Pallavi/Indu - Chetna
Mira Sadgopal
Dr. Kaushal ya Devi

Women's Health.

12.00

12.30 p.m

Di scussi on

12.30 p.m-01.30 p.m

Gender Sensitive
Training -For RCH &
women 's health.

01.30 p.m-02.30 p.m

LUNCH

02.30 p.m-03.30 p.m

Sub theme & group discussion
1) Regional Diversity ot
women's health needs.
2) UJornen and work and
occupational health hazards.
3) Strategies to integrate TEH
i n RCH 2*: Women ' s Heal th.
4) Developing indicators 2<
parameters ter comprehensive
sustainable RCH & Uksmen
Health Policy & programme
women's health i ndex.

03.30 p.m—04.15 p.m

Present at ion of sub themes

Philomena - Mahila Samakhya
Jashodhara - Sahayog
Shumita Ghose - Ayard/Urmul
Jyoti Gade - Chetna

Shumita uhose
Abhi jeet
Mirai Chatterjee
Laxmi Lingam
Philomena
Smita Bajpai
Renu Khanna
Daleep Mavlan kar

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Tong Swasthya Bhawan, 40 Institutional Area, South of I.I.T., New Delhi-110 016, INDIA.
Phone: 6518071-72, 6965871,6962953 Fax: 011-6853708 Grams: VOLHEALTH N.D.-l 6 E-mail: VHAI@del2.vsnl.net.in
Donations exempted fpm IT under Section 80-G of IT Act 1961. Also exempted U/S 10(23C) IV as applicable to institutions of importance throughout India
■*.

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Voluntary Health Association of India

?s'/

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Tong Swasthya Bhawan, 40 Institutional Area, South of I.I.T., New Delhi-110 016, INDIA.
Phone: 6518071-72, 6965871,6962953 Fax: 011-6853708 Grams: VOLHEALTH N.D.-l 6 E-mail: VHAI@del2.vsnl.net.in
Donations exempted from IT under Section 80-G of IT Act 1961. Also exempted U/S10(23C) IV as applicable to institutions of importance throughout India

T

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