State Consultation On

State Consultation on

Sexual & Reproductive Health and Rights

- Call for Action!!!

Hotel Janki Vatika, Raigarh (Chhatisgarh)

17th & 18th of September, 2016

Organized by:

Prayas and Human Rights Law Network

Index

1. Background………………………………………………………………………….2 2. Objectives and Outcomes of Consultation……………………………………...3 3. Agenda of the Consultation……………………………………………………….4 4. Consultation- Day 1………………………………………………………………...4 i) Session 1: Inaugural Session………………………………………………4 a. Welcome………………………………………………………………….4 b. Inaugural Address...…………………………………………………….5 ii) Session 2: Introductory Session…………………………………………..5 a. Understanding Sexual And Reproductive Health Rights.………….5 iii) Session 3: Child Marriage and PCMA Act………………………………7 iv) Session 4: Entitlements of Pregnant Women……………………………9 5. Consultation- Day 2……………………………………………………………….11 i) Session 1: PIL………………………………………………………………11 ii) Photographs of Consultation…………………………………………….13

Background In continuation with the ongoing process of holding consultations in different districts of each state of the project on Expanding Sexual and Reproductive Health Rights Using Law, the first consultation of Chhattisgarh on Women Health and Reproductive Rights and Services was organized in Jodhpur. Many participants who couldn’t be a part of Bharatpur because of the large distance could participate in Jodhpur as their work area is in and around Jodhpur district.

The World Health Organization defines sexual health as: "Sexual health is a state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. So the sexual health rights are the type of human rights includes the right of women to have freely control over in making decisions concerning their own sexuality, including their own sexual and reproductive health without coercion, violence or discrimination. Similarly, reproductive health addresses the reproductive processes, functions and system at all stages of life. It implies that people are able to have a responsible, satisfying and safer sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. So, Reproductive rights are legal rights and freedoms relating to reproduction and reproductive health. The World Health Organization defines reproductive rights as: Reproductive rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. They also include the right of all to make decisions concerning reproduction free of discrimination, coercion and violence.

It is estimated that 1 in 3 deaths related to pregnancy and childbirth could be avoided if all women had access to health care and contraceptive services, including information, counselling, and services. Unfortunately, the unmet need for contraception, defined as the number of married women aged 15 – 49 who do not use contraception even though they wish to delay the birth of their next child or wish to prevent pregnancy altogether, is reported at 28 million, or 10 per cent of the global unmet need. The National Family

Health Survey reports that of all married women age 15-49 in India, just 1.7% use IUDs (intrauterine device), 3.1% use the birth control pill, and 5.2% use condoms. Female sterilization remains the only available option for millions of women throughout India – 37.3% of all married women age 15-49 have had a permanent sterilization surgery in India. Inadequate access to contraceptive information and services constitutes a violation of the rights to life, health, dignity, and equality enshrined in the Constitution of India. Child Marriage is still rampant in some parts of Rajasthan and because of this, a child loses her or his childhood and this leads to gross violation of sexual and reproductive health rights. It is imperative to come together and seriously talk about finding strategies to abolish this practice. Using Public Interest Litigation to fight against child marriage can be one of the strategies. The prevalence of this evil in India of 2015 is a reflection of the deep misogyny harboured by our culture and religious practices. In order to control women’s sexuality, production and reproduction, the strategy to claim women’s bodies at very young ages was evolved. Caste endogamy (maintaining the ‘purity’ of one’s line) too is maintained through this practice, as explained by Babasaheb Ambedkar in various anti-caste writings.

Given the context, it was imperative to hold a two day consultation to intervene and ensure the proper implementation of government schemes and also to bring in additional provisions required to bring about desirable changes.

Objectives of the Consultation

 Bring together health activists, Dalit groups, women organizations, persons with

disabilities, geographically specific marginalized groups, doctors, lawyers,

students, representatives from the government, service providers and media

 Gain basic knowledge on human rights

 Be able to identify sexual and reproductive rights issues

 Link sexual and reproductive rights issues to everyday work

 Understand roles health workers play in relation to sexual and reproductive

health rights

 Disseminate information about the project and activities

 Devise future action plan with timeline to implement the strategies and conceive ideas to enhance sharing among the organizations about the developments in their work area

The participants will be able to build their capacities around:

. Promoting reproductive health rights in development policies and

programmes

. Monitoring of reproductive health services

. Advocating on key focus areas and influence key policy processes

. Act as a source of information and guidance on reproductive health rights,

policy and practice

. To disseminate information about the project and activities

. Using the law as a tool for change.

Consultation- Day 1

Session 1: Inaugural Session

Welcome Mr. Degree Prasad Chouhan, belonging to the Adivasi movement in Chhattisgarh welcomed all the participants and began with the introduction round. The participants belonged to myriad backgrounds and movements such as working with adolescent health and focusing on sexual and reproductive health rights. There were organizations that work for livelihood of people in tribal and rural areas, Dalit groups, organizations working with Mitanins (ASHA workers of Chhattisgarh). Women from Panchayati Raj, teachers, medical students, nurse, women organizations, human rights lawyers, organization promoting sports for the lower castes, etc were also a part of the two day consultation.

Inaugural Address Ms. Rajni Soren from HRLN (Human Rights Law Network) gave the inaugural address. She talked about the organization. HRLN is an organization of lawyers and social workers. It carries out various interventions to work towards providing justice to people. She explained the objectives of the two day consultation. There will be discussion on various cases and a plan of action will be sought thereafter to tackle the issues and find solutions. Discussions on various cases that we see from Bilaspur will also be discussed in detail. Health is a burning issue today. Recently we saw a case where due to lack of ambulance, a husband had to carry his wife’s dead body for 12 kilometres. Such incidents tell us one thing. The status of health services is very low in our state. Chhattisgarh is the second state in India that has the least number of doctors and it falls way behind as far as providing quality health care is concerned. This is all the more reason to carry out litigation in the state to increase the accessibility to quality health care especially when it comes to sexual and reproductive health rights of people.

Session 2: Introductory Session

Understanding Sexual and Reproductive Health Rights Mr. Amarnath Pandey welcomed all the participants and shared his happiness to see a large amount of participation at the consultation. The organizations working in the health sector has a close relationship with the government health facilities. It is very easy for the rich elite to access various health services of top notch quality at the five star hospitals because they can afford the expensive health facilities. But people belonging to the lower strata of the society cannot afford good quality services as these are very expensive. Therefore, they are dependant largely of the health services provided by the government health facilities. We see a large number of people, especially in rural and tribal areas relying on quacks because they have immense faith on them and they don’t have to spend a huge amount to get treatment. Faith healers are very popular among the population. Health is a right given to us by our constitution. Today we have provisions for protecting cows and there are strict monitoring systems and punishment is meted out without delay. But it is sad to see that no such extreme measures are taken to penalize or punish those who violate patient rights. We cannot ignore the steps taken by the government to control the population of India. It is again sad to see that the onus of controlling the population lies

largely on women. Everything is target based today. Therefore there is a lot of pressure of carrying out female sterilization operation in large numbers. We also find that doctors prescribe unnecessary medicines that lead to a huge out of pocket expenditure.

Ms. Chhaya Pachauli from Prayas discussed about Sexual Rights and explained how these rights are different than Reproductive Rights and why working on both these rights is essential. Sexual right of a person means the right to choose independently our partner with whom one will establish a sexual relationship and the freedom to carry out sexual activity and that our full consent to indulge in any sexual activity is given to the partner before having sex. When child marriages take place, it violates the rights of both the girl and the boy to choose their partner. In almost all the cases, both the girl and the boy are coaxed into getting married and they forcefully establish a sexual relationship. This also leads to early pregnancy which further leads to higher rates of maternal death and infant deaths. When we talk about reproductive health, we usually think that it starts right from the time when a female conceives a child in her womb. But reproductive health begins from the time when girls attain puberty and start menstruating. The girl enters the reproductive age at menarche. We have various health systems of the government that are brilliant on papers but there is poor implementation. The reproductive health facilities that a primary health centre and a community health centre are supposed to provide is not seen at grassroots. In most cases the pregnant woman is referred to the district hospital. This leads to a large patient load on the district hospital. This in turn also caters to a poor delivery of health services. For a pregnant woman living in the remote villages of any district, it is a huge task to travel to the district hospital. Though there is an ambulance service in place but we see many cases where the ambulances either arrive very late or do not come at all. Instead of making institutional delivery easier for women and safer, it becomes more dangerous to her health due to the negligence by the service providers. In our patriarchal society, we find that women do not enjoy their reproductive rights. It is not just the right to have safe delivery, but a woman also has the right to decide whether to become pregnant or not. Such right is snatched away from her. Reproductive rights also include whether to keep the foetus in the womb or not, or the space between two children and the age at which a woman becomes pregnant. She is robbed off all these rights to decide for her body. The decision to choose the number of children the woman wishes to reproduce is also snatched away. The family’s greed to have a boy leads to reproduction of a number of children until they have a boy. In many cases the girls are killed before she is born or right after she is born. The woman is unable to decide for her own whether to keep

the child or not. Those women who decide to go against her family face brutality from them. Hence in most cases she remains quiet. Such practices take place also because there is acceptance in the society. The government’s decision to control the population has been harming the health of women since years. The only sure shot formula adopted by the each government has been brainwashing women to carry out sterilization operation. Due to a target based approach this has been harming women as in most cases we find failure of sterilization or even death after sterilization. The government has failed to provide access to various other options of contraception and men are not made aware of the methods that they can adopt easily to control pregnancy of their partners. As organizations working for the health rights of people, our demand is simple. We want not just increase in the accessibility to health care services, but increase in the quality of health care services that can be accessed by the people as reasonable rates. Today, we spend about 70% of our income for availing health services and this is a huge amount. Many people are indebted for life because they are unable to afford the expensive treatment which are not available at the government hospitals and for which they loan money from the market and local money lenders. People get stuck in a vicious cycle. Carrying out litigation in cases of gross violations of health rights help us in challenging the government and after filing Public Interest Litigations and Writ petitions we may get good orders that help us further in carrying out interventions at grassroots.

Session 3: Child Marriage and PCMA Act

Mr. Daya Das from the organization SROUT talked about the issue of child marriage that still prevails in our country. The organization SROUT works for women and children. Chhattisgarh did not have Childline till last year. And not the whole of Chhattisgarh has the services of Childline and SROUT played a huge role in making this possible. The organization has been successful in stopping 33 child marriages so far. Mr. Daya discussed how they get information about these incidents. He revealed that only those people who have something against the particular family reports the child marriage taking place at their house. They inform not because they are really concerned about the children getting married, but they want the family to get into trouble because of enmity between the two families. They have not received a single phone call from a really concerned person who is witnessing a child marriage and is absolutely against it. It is quite disheartening to see that even today, in the year 2016, after 70 years of independence we have failed to provide a childhood to these children who are forced

into marriage. Child marriage leads to negative effects on the physical, emotional and mental wellbeing of a child. It also leads to increase in infant mortality rate and maternal mortality rate as at a very tender age a girl becomes pregnant. This is another leading cause of malnutrition in children. He shared that it has been seen that wherever there is lack of education, incidence of child marriage is maximum. But this point was challenged as many shared that it is the “educated” lot who allow these marriages to take place, be it the police of the area, or any government official. So we cannot blame illiteracy entirely. The so called educated people need more education as they are the ones in power to stop this from happening still they let child marriages happen.

Ms. Samishti from Human Rights Law network discussed about the Sharda Act and PCMA, that is, Prohibition of Child Marriage Act. PCMA is a better act than Sharda Act because now under PCMA, everyone will be punished, who is a part of child marriage and not just the parents. It is a stricter law with stricter punishments. Every district has been appointed with a Child Marriage Protection Officer (CMPO) under the PCMA Act. Ideally every district should have a CMPO Officer but after carrying out various fact findings in the state of Chhattisgarh by HRLN, it was found that many districts do not have CMPOs. There is still a need to find cases of child marriage and punish the perpetrator of this heinous crime. We must prohibit this practice completely and not just prevent it.

One of the members of the audience raised a question that to what extent the age of a boy is taken into consideration? If a boy is 19 years old which is below the age of 21, that is also considered child marriage, hence why don’t people focus on the problems faced by the boy? Ms. Chhaya from Prayas responded by saying that we do not find a lot of cases where the boy is younger and the girl is well above her marriageable age. In all the cases of child marriage, the girl is always below the age of 18 and she is the one who faces the maximum brunt because it is the girl who becomes pregnant and she leaves her house at a tender age and bear sexual harassment from the other male members of the family. We also find cases of underage girls married to middle aged and old men and they are practically raped as their consent is not taken before establishing a sexual relation with them by their husbands. And while fighting against child marriage, even the boy’s age is taken into consideration.

Ms. Samishti further discussed about the reasons of prevalence of child marriage even today. In many cases it was found that the opportunities of pursuing education is

minimum for the lower income groups and that also indirectly forces the parents to start looking for a boy to get their girl married off. In our male dominant society, even today girls are seen as a burden and the parents are relived only when marry her off. Still the career or education of a girl is not given as importance as it is in case of a boy.

Session 4: Entitlements of Pregnant women

Mr. Shyam Sundar from Lok Shakti in Raigarh began with asking a question that why the health services aren’t services reaching us even today? We have the Mitanin programme in place but the implementation is very poor. One Panchayat has one Mitanin (ASHA worker), therefore one ASHA worker has to cater to approximately 50 families. Despite the programmes like JSSK and JSY, we are failing to ensure a safe delivery and reduce maternal mortality rate in our state. After these programmes have begun, some improvement is seen as far as infant mortality rate is concerned. But still we haven’t reached the target of reducinf IMR and MMR. This can only be achieved through Mitanins and when we look at the working conditions and the amount they receivea s their remuneration or incentive, we cannot say that it is enough for them to give out good results.

Mr. Akhiram from Pahadi Korba Mahapanchayat Sangathan, Sarbhuja shared that doctors and nurses have a very bad attitude towards the children who have been married, especially girls. He shared a case of a 14 year old girl who was pregnant and she went to a hospital. She had to wait for four hours for someone to check her up. Her condition was worsening every minute but after waiting for four hours, she just received a referral slip. No one checked her. The girl died on her way to another district Ambikapur where she was given the referral slip for. It is saddening to see that for simple procedures and check-ups patients are sent away to other hospitals.

Dr. Prabir from State Health Resource Centre commenced the discussion by asking the participants that how many kinds of doctors and staff should be present at a CHC? After the discussion these were given by the participants- BMO, gynecologist, ANM, Nurse, Midwife, Pediatrician, Surgeon (especially to carry out c-section for pregnant women) and anesthetist. He further asked how many doctors are found at a CHC usually. Most people responded by saying that surgeons are seldom found at a CHC.

They usually see an MBBS doctor present and a nurse and other helpers. Gynecologists are also not seen at a CHC. It was also shared by one of the participants that in most of the hospitals, they do not provide all the medicine that they are supposed to provide as mandated by the government. Because of such unavailability, patients have to buy medicines from outside that are branded and expensive. In Chhattisgarh, a provision of smart cards is available that compulsorily needs to be allotted to everyone. But presently, many people have not been able to get the smart cards made which is leading to further problems of accessing free services from the government hospitals. One of the Mitanins shared that the amunt they receive as their incentive is very low. It was promised to them that they will receive Rupees 1500/- but they haven’t received it yet. This particular Mitanin belonged to Pamgarh Chapa district. Another Mitanin shared that district hospitals do not have oxygen cylinders. She was talking about Raigarh Medical College Hospital especially. It is of utter shame that a hospital at the level of a medical college doesn’t have oxygen cylinder. One of the cases of this district hospital was shared by an activist from the participants. A rape victim was pregnant and she approached the district hospital of Raigarh to get an abortion done. They refused her to get any check up done saying that do not have facilities to carry out an abortion. At a district level, if hospitals fail to carry out such procedures, how can we expect them to tackle more complicated cases? The victim had to approach a private hospital but even at the hospital she couldn’t get her abortion done. The law says that abortion cannot be carried out after five months but in her case she hasn’t reached that level still the hospital refused to carry out abortion for her. She is not married and in our society unmarried pregnant women are not given any respect. It is going to be extremely difficult for her to lead her life with a new born and no support from her family as well as the society. One of the participants from Jaspur shared that their district hospital is huge. They treat leprosy patients and they have a fully functional ICU as well. But even their hospital does not have abortion services. Three nursing schools send their students for training at the hospital, yet they do not have the provision of abortion services. This is astonishing because this means that many women are denied the right to abort a child and to avail this service they will have to approach a private hospital which in turn will lead to a higher expenditure by the patients. How do we then try to reduce the out of pocket expenditure by the people on health?

Consultation: Day 2

Session 1: Public Interest Litigation

Advocate Rajni Soren from Human Rights Network began the session on Public Interest Litigation by first discussing about the condition of health facilities and how will litigation improve the situation. She talked about the famous case of sterilization in Bilaspur where more than 60 women died. After this incident, sterilization operation at government hospitals has almost stopped. Now in one month, only 20 women are sterilized. It has been observed that women are going to Odisha to avail the services of sterilization. From the participants, one of them shared that in Janjgir district, at block level, sterilization procedure does not take place at all. At district hospitals, 5-6 women are able to avail this service. They carry out the procedure manually and not using technology. Those couples who aspire to get sterilized are counseled by the Mitanin to use condoms as most couples are not able to access this service. They are also counseled to get use Mala D and Copper T. In many cases the ANM puts Copper T right after the delivery without even taking consent from the woman who just delivered. It was shared by many others that they find an apathetic behavior of the nurses and the hospital staff towards pregnant women. The nurses and hospital staff have a very rude behavior towards the Mitanin as well.

Dr. Prabir was of the view that our Government should encourage using of Copper T more and if it is administered successfully there will be no need for sterilization operation. Copper T gives good results provided that it is inserted properly. Indian government only sanctions Copper T that is meant for 10 years. We find a lot of cases where doctors insert Copper T right after delivery without even taking consent from the patient. We see that about 1400 women die per 1 lakh women while delivering and most deaths take place due to excessive bleeding. Mothers are constantly referred from one health centre to another. We do not find blood banks evenly distributed across the length and breadth of Chhatisgarh. There are total 27 districts in Chhatisgarh and total 56 blood banks but we find that about 14 districts do not have blood banks. This is a serious issue. When operations take place in hospitals where blood bank facility is not available, it proves to be dangerous and fatal for most cases. We must pressurize the

government to ensure that blood bank facilities are available in all the districts across Chhatisgarh.

Ms. Rajni talked about the importance of filing PIL in such cases. There is hope of receiving good orders from the court after filing PILs. She explained the basic concept of the emergence of PIL, due to bad economic situations poor’s were not getting justice, so PIL has emerged. She described the three ways for filing a PIL- through a letter writ; Supreme Court can take Suo-moto decision to file a PIL; and it can be filed by any social organization. She explained that a PIL is filed for- no personal interest, not harming any community/any group, not sponsored should only file on the basis of facts, should not take one’s side in group fight, also, it is mandatory to mention from where the money has come for filing the PIL. She further explained in the brief about the procedure for filing the PIL that it can be filed independently in the high court without a lawyer. English is not mandatory to file a PIL. Details are required about an individual or society if involved and also the list of aim and object of the society is required. It should have details about the incident or the issue. There must be a fact finding report of the incident, that newspaper’s fact and reality are same or different etc. She concluded by giving some experiences of the PIL hearings, that when students file PIL, they can debate in detail with the magistrate compared to a lawyer because students are generally unaware and unfamiliar with the Judges. He shared that since last few years we were getting a good response from the court when we file PIL through students. But at the end, he recommended and motivated all the social workers that the real victory of the PIL will be on that day when a social worker will herself/ himself will file a PIL independently.

Thereafter during open session participants shared various incidents of maternal death, sterilization failure, inadequacy in government hospitals, etc. And with this, the two day consultation came to an end with a vote of thanks given by Ms. Rajni Soren and Mr. Degree Prasad Chouhan.

Photographs of Consultation