बुधवार, 3 अगस्त 2022

Jan Swasthya Abhiyan NCC meeting minutes

 

Jan Swasthya Abhiyan

NCC meeting minutes

Date: 14-15 May 2022

Venue: P. Ramamurty Bhawan, 20 Pushp Vihar, Sector VI,

M.V. Road, Saket, New Delhi-110 0017

 

A.    Introductory session: Moderators - Chhaya Pachauli and Abhay Shukla

The introductory session began with welcoming the participants, followed by a round of introductions by all participants (List of participants present in person and online in Annexure 3 – To be Added). An overview of the objectives of the NCC meeting and agenda (Annexure 1) were presented.

 

Drawing attention to the larger context in the country especially the situation of health,  the relevance of JSA was reiterated. Acknowledging that there exist internal organisational challenges, the objective would be to have a constructive discussion based on the agenda.

 

-         Participants were then requested to reflect briefly (2 minutes each) on the question–   In your opinion what is one area of strength, and one area needing improvement, regarding JSA’s organisational functioning?

-         The participants articulated the strengths  of JSA including

o   its rich diversity (geographical as well as diversity of organisations working on a range of issues) since its inception;

o   the ability to work together with such diversity;

o   the nimbleness of the organisation to respond to issues; 

o   the solidarity  and commitment of JSA members;

o   JSA’s unique position within social movements and the ability to raise issues that other movements do not;  

o   JSA’s politics of health – the robust understanding and analysis of health, health sector. It’s critical role in  contributing to immediate, emerging issues and concerns around health, and ability to influence policies. 

 

-         In terms of areas for improvement / strengthening, participants flagged some suggestions:

o   Transparency and accountability to be strengthened within the  organisation;

o   The involvement of grassroots movements and engagement with other movements need to be expanded;  

o   Pursue more effective means of campaigning, update the themes and demands of campaigns particularly in light of the evolving landscape of healthcare

o   Important that any differences are resolved through discussion and spaces for their resolution are created;

o   Strengthen the ability to collectivise JSA’s strength to respond  to challenges around us.

The session was concluded reiterating the need to resolve differences in a comradely manner- the need to move ahead with differences and beyond temporary setbacks.

There is need for balance – the bringing together and addressing various sensitivities, stepping back from situations of disrespect is key. Amit Sengupta was acknowledged for having done this extremely well.

Transperant and evidence based approach and analysis for any discourse shall be encouraged

B.    Revisiting and revamping JSA organisational framework at national level: Moderators-  Anant Phadke and Renu Khanna

The background and session objectives were shared by the moderators.

Following a meeting on 28 July 2021 meeting, a working group was constituted to update existing notes on orgnaisation.

The working group examined various previous NCC and other relevant meetings’ minutes – the Nagpur 2014 that exhaustively discussed organisational issues, Delhi 2019. Five members of the working group (Renu, Indranil, Richa, Amulya and Sanjeev Sinha) were involved -  two drafts were developed and shared. The team could not reach to a unanimously agreed note.

Abhay has worked to reconcile the similarities and differences of these two notes in which Sunder and others gave comments based on which the discussion was oriented.- there were agreements on most points, two or three issues need discussion and resolution.

It was agreed to build on what the NCC agrees  upon through the current discussion, not minding the differences existing earlier. Any issues which were not discussed or remained unresolved earlier can be noted and built on in the future.

 

Some ground rules for the discussion were suggested:

·         Not going into what happened in the past / avoid going into the process but to make suggestions base don past experiences[1].

·         Feel free to express but at the same time do not deviate too much. Else, moderators shall intervene and there should be no hard feelings. 

·         Focus should be on principle differences and not on personal differences.

 

Abhay Shukla presented the comparison table that had been shared previously with the NCC (Annexures)

Roughly 9 points where there is very little difference; there are some areas where one draft has given new / additional points. Two sections have some significant differences and five sections no major differences but requires clarity.

 

Individual person in NCC is complex. Many members were part of organisations and moved on but continued to be part of the NCC. 

 

1.       JSA NCC – structure, roles

-       National Co-convenors should be elected by NCC and ensuring diversity - regional and others.

-       Equitable representation of National networks should be allowed to have larger representation.

-       The idea is to have representation from all organisations and there should be equal weightage for each.

-       Need to reach out to the other constituencies. Mass organisations should be contacted and JSA should develop solidarity and coordination with other likeminded organisation.

-       Academic institutions should contacted to part of JSA.

-       Need to differentiate the role of health organisations and other national networks.

-       Need to have all national networks and to give space to them in NCC.

-       Responsibility of NCC should be to strengthen State units, ensure democratic functioning at all levels.

-       Mechanism or process of exit from NCC is needed

 

Key decisions / follow ups

-       All state groups, networks to be represented by two members in the NCC.

-       All networks and states to be represented.

-       Role of National Co-convenors in the NCC needs to be discussed for clarity. 

-       Individuals cannot be part of NCC unless part of the  state JSA and the state recommends - either organisational or state.

-       NCC should be the decision making body of JSA and the national secretariat shall be the implementing body.

-       Thematic group has been made few years back which should be strengthening.

 

2.      National secretariat

 

Suggestions and discussion points

-       Historical context of the JSA Secretariat was presented to situate the current discussion.  

o   National secretariat started in 2003 to coordinate various activities. Since then an organisation was involved which hosted it. First it was hosted by Sathi in Maharashtra, then MP was involved. Then it shifted to Delhi with three organisations working and one hosting it. There were also some semi-formal arrangements for funds. In 2018 there were 6 organisations (SATHI, Sama, Sochara, Sahyog, Prayas, and PHRN) Some Delhi based, some from outside.

-       The functionality of the Secretariat flagged as a concern.

-       Clarity regarding composition – is it organisational hosting or it’s individuals involved in the secretariat. This will be discussed further.

-       Is a full time functional secretariat required ( mentioned by both drafts). How to do this to be discussed subsequently.

-       Need to change the current structure of secretariat, Governability as a principle – Secretariat should be of a viable size.

-       We need dedicated time for some people- we need to think of ways to support that.

-       A full time Secretariat, it has to be hosted with an organisation which has a bank account which can also be financial host organisation. 

-       Positions in the Secretariat should be rotated in every three years.

-       Secretariat should be built around a set of people- who are willing to function and give time- whether part time or full time.

-       Stable funding should be explored and in its absence functionality could suffer.  Overall it’s a complex problem.

-       Team spirit is key. The secretariat team put together in 2018 did not work cohesively.

-       Suggested 3-4 organisations, willing to work for next 1-2 years to take responsibility.

-       The criteria should be who can contribute rather than the number.

-       Suggested 6 domains: Logistic and coordination, communication role of the network, playing a role as a consensus builder. There is need to develop criteria.

-       Some roles that were played need to be acknowledged – gaps to be kept in mind moving ahead.

-       The sect team should come to the NCC with the proposal.

-       3-4 organisations should host the secretariat and the current (at the moment no host organisation exist for JSA) ones should be given priority. 

-       Representation of young people is crucial the constituent organisations and states should explore how to work and engage with younger people; treat people in the organisations who are JSA members.

-       There are different communication platforms - JSA NCC, social media, JSA website etc. To be discussed.

-       Actual composition of the Secretariat to be discussed and decided on Day 2 by lunchtime. 

 

Broad principles identified for Secretariat functioning that emerged:

-       The Secretariat needs to be differentiated clearly from the NCC. The Secretariat functioning- role should be purely secretarial, not leadership. This is not agreeable. Secretariat members cannot be leaders but converted to clerks- is a wrong idea.

-       Secretariat positions are responsibilities and painstaking rather than power/authority.

-       Functioning of the secretariat has to be equitable. To work as a team, hierarchy is a hinderance.

-       Concern that some states have more members to NCC and some have none to be checked.

-       NCC list has undergone revisions undertaken by the Secretariat – to be shared.

 

 

DAY 2 / 15 May 2022

 

-       Brief reiteration of points from Day 1.

-       NCC as decision making body and secretariat as facilitating body.  Why repeat?

-       Importance of creating diversity within structures – creating equitable spaces in every body of JSA.

-       Agenda ahead to look at co convenors, that ties up with National Secretariat and NCC. What does it mean?

 

 

3.      Revisiting the role, structure of national co convenors

 

Key discussions and suggestions

-       JSA doesn’t have a national convenor for a decade and should not be reintroduced. There are only co-convenors.

-       States and networks equal ratio within co-convenors

-       National co-convenors – it was decided to go with 20 persons and should not go over and below that unless there is a valid reason. 

-       At least one third of national convenors or co-conveners should be changed – so that there is change but also with continuity.

-       National Co-convenors expected to play a role nationally beyond the state. Earlier 4-5 co-convenors assigned to coordinate activities in 3 states each – as a concept it was sound, worked in a variable way.

-       In 2014 – Nagpur meeting number increased to 18 / 20. Co-convenors remained active in their states but many of them did not move beyond, and some became inactive.

-       National co-convenorship is a responsibility at the national level – hence roles clarity is very important.

-       It’s a leadership position; there is need to groom younger / new people. It’s a leadership responsibility position and a space requiring mentorship  by those moving out.

-       Need to look at which positions vacant and fill positions.

-       Number of positions to be as minimal as possible would be desirable. NCC and co-convenors guide the Secretariat.

-       Younger people taking initiative but not involved in decision making should be corrected. (Overriding NCC and Secretariat?)  

-       Clarity in roles and linkages between the NCC, co-convenors and secretariat is required to minimise overlaps and improve functioning. What are the overlaps of convenors and secretariat, the thematic groups?

Responsibilities of the various tasks of the Co-convenors

o   Help JSA in arriving at crucial decisions and taking policy positions;

o   Lead JSA in various activities;

o   Coordinate with at least three state chapters and facilitate the activities; and

o   Convene at least one thematic group;

o   Guide the secretariat;

o   Represent JSA at various fora;

o   Coordinate with various networks to strengthen alliances and movements;

o   Draft various JSA publications including statements, manifestos, position papers, press release etc.

o   Report back to the NCC from states/networks and report about national activities/plans to states/networks

o   Other tasks entrusted by the NCC. 

 

Key decisions / conclusions/follow ups

-       Co-convenors is a good layer to have between NCC and secretariat.

-       Number not defined but thematic and regional representation with other diversity is necessary.

-       Need to look at each task and responsibility of all the layers being created – if overall it is facilitative, minimise overlap and spell out discrete functions.

-       Vision building decision making – NCC is the larger decision making body, co-convenors is the vehicle and secretariat should be logistics, coordination but also substantive along with the national co-convenors.

-       Internal review/ reflection to see who is transitioning out and who can be part – task remains and how and by when this can be done.

-       Pending: Who will be part of the secretariat, Who will be co-convenors?

-       Decision whether or not a secretariat coordinator is required should be the decision of the hosting organisations. The latter should propose to the NCC once discussed / decided.

 

C.      JSA position on taking institutional funding: Moderators - Sarojini and Ameer

Moderators provided a preamble to this discussion (refer – Sarojini’s note sent by email).  The note is based on revisiting previous discussions and minutes including her experience.

-       Funding is a larger and more complex issue but need to locate it in a context.

-       Discussion on funding and NGO isation – voluntarism, etc. are critical as is the understanding of privilege of investing time and implications for exclusion however strong the commitment.

-       For example, National Health Assembly (NHA) resources mobilised from institutional funding sources but also individual funds. Also, large amount of voluntarism.

-       Sources of funding is important – CSR? Gates? Etc. NGOs are also thinking / reflecting on this. Many of us / NGOs have contributed to JSA.

-       Differentiation is necessary between government, Indian philanthropic and foreign funding.

-       Institutional funding - position regarding funding from government which is not always pro people flagged. (is there any instance of accepting anti-people projects by any JSA constituent)

-       Principles, guidelines required regarding institutional funding – to have clarity on  political and practical questions. Keeping the situation in JSA as well as the larger political situation.

-       Membership funds, crowdfunding as alternatives to be considered.

-       Constituent organisations not to take foreign funds in the name of JSA. JSA members that are receiving foreign funds – if conflict of interest is found, then JSA should take a position on that.

-       Funding (other than foreign fund) / or not taking funds by JSA should be decided on a case to case basis.

-       Transparency is critical in this discussion - NCC meeting should have a dedicated session on funding, finances, etc.

-       Impact of any kind of funding on the voluntary part of organisation must be understood. Example of JAA perceived as NGO despite voluntarism.

-       Starting point of the discussion should be to identify what activities need resources, at national but also state levels.

o   Ongoing coordination at national level (sect) or state level needs dedicated human resources.

o   Resources have broadly been raised in four ways

§  Voluntary contribution by participants

§  Voluntary contribution by organisers – from our own pocket contribute (must be increased as much as possible)

§  Organizational voluntarism – organisations say office available, person will give human time (grey area – going on – haven’t discussed- some concerns. Large organization can contribute more time and person – must do as per the JSA mandate and not the priority of the organization) transparency

§  Institutional funding – guidelines to be discussed.

-       Reference to Anant’s note –Annexures 4 

o   All JSA work should be based on the analysis, understanding, ideas coming from JSA’s analysis, charter or activities, ideas suggested by JSA activists and not emerge from some funding source, funded project.

o   In all JSA work, the financial contributions should start from our internal resources, like savings from income generated from previous activities, voluntary contribution from our own pockets as individuals (in proportion to our individual resources, affordability), voluntary contribution from our organizations, from friends, supporters of JSA, people’s movements etc.

o   An estimate should be made about shortfall if any and decision be made whether or not to seek supplementary institutional funding for a big activity.

o   Routine activity should primarily be a self-funded one. If supplementary institutional funding is to be sought for some big programme, the decisions about acceptability of the source, the amount, the modality, accounting, transparency etc. should be made democratically, keeping in mind the basic JSA-framework.

o   There is an issue of overlap between JSA activities and project-activities by one or more constituent NGOs in JSA. Both constituent NGOs in JSA and state/national JSA should take care that such overlap, collaboration is avoided when possible and when it happens, attempts be made to catalyze voluntary inputs into JSA and that there is no erosion of voluntary resources, voluntary spirit in JSA. 

o   As regards reporting of such funded activity to the funder, voluntary activities either by JSA or any other voluntary group should not be included by the NGO in the report to the funder. There is a need to assure all the concerned that in case of such overlap between JSA activities and NGO-project, such reporting does not occur. Towards this end, in the spirit of transparency, the constituent NGO should send a copy of it’s project-report for the funder, to the JSA secretariat. 

o   Unless due precautions are taken, institutionally funding works like a steroid medication inpatients, there is temporary improvement but continues dependence is created.

-       Voluntarism is deficient – how can this be concretely overcome; ways to strengthen voluntarism must be deliberated.

o   There are advantages of voluntary work but limitations vis-a-vis accountability. It is important to involve students, young people and other activist and poster voluntarism.

 

 

Key decisions / follow ups

-       JSA is not taking foreign funding. Constituent organisations, therefore, should not receive foreign funds in the name of JSA.

A group to review and revise the draft note by Anant Phadke by 15 June 2022: Anant Phadke, Chaya Pachauli, Amulya, Abhay Shukla

 

2. Future representation from India region in PHM Global-Steering Committee; use of PHM funds for activities in India; clarifying relationship between JSA and PHM global

-       Moderators provided the background about PHM, reasons for why JSA is part of the PHM and JSA contribution to PHM. India is considered a region by PHM.

o   Amit Sengupta’s contribution to PHM was acknowledged.  

o   PHM secretariat located in India for a long time, hosted by Sama.

o   All the work of the PHM secretariat – was supported by the PHM fund.

o   Some PHM secretariat members contributed time also to JSA.

 

-       The PHM Steering Council  – each region has representatives to the PHM SC.  It is the decision making body of the PHM and for  governance.  

o   Representatives can be part of the SC – for three years followed by another three years.

o   Whether one or two representatives is a decision of the region.  No SC members are funded.

o   For many years Dr Ekbal was the representative to SC. After the South African PHA, Sarojini was representative to SC.

o   Current representatives are Amulya and Sulakshana, which was decided by JSA some time before  2018 December at Savar.

o   Following detailed deliberation, the meeting decided that Amulya and Sulakshana to continue.

o   Existing representatives should be more proactive and interactive.

o   Representation to the SC – the work is not to be underestimated; Globally it takes time to understand the context; two terms allows this.

o   Others who want to be part of SC in future – should get engaged in PHM processes – start contributing.

o   Ways of mentoring the next representatives to be discussed.

o   Perhaps identify 3-4 potential people – how they can be engaged till then – when opportunity emerges.

o   Towards more clarity about the role - sharing by the current representatives is important.  

 

 

-       Relationship between PHM and JSA needs strengthening.

o   Some from JSA are engaged with PHM global and others are not which is creating a dichotomy.

o   Articulation, communication is minimal currently and is to be improved.

o   Clarity on Annual report to PHM provided. Annual report to represent what different countries / regions are doing / able to do, to share experiences towards solidarity.

o   Annual report to be shared in JSA before sending to PHM.

o   Caution – recruited people to PHM work –  expectation that they should work here not agreeable. Done earlier but not recommended.

o   EACT – funding clarified. Concern about EACT report’s inclusion of  reporting of the communications and statements by AIDAN ( flagged by Malini Aisola) to be addressed. Future of the report?

o   Other issues related to EACT were also raised by members. There should be transparency in funding of PHM and its implications for  JSA activities.

o   Concerns for JSA India vis-a-vis substantial funds for PHM from OSF and Ford Foundation were flagged. It was clarified that PHM funders are beyond OSF and Ford; moreover, given JSA’s decision against taking foreign funding, this concern is not relevant.

 

Key decisions / follow ups

-       Till NCC decides on criteria or any other newer dimensions, current representatives – Sulakshana Nandi and Amulya to continue for the next term.

-       In the organisational document, revision suggested that NCC will recommend, not secretariat.

-       Criteria for PHM SC representation to be developed.

-       Within next 6 months or next NCC to identify – proactively ensure interaction and dissemination about PHM.

-       Annual report of JSA should be sent to JSA NCC and thereafter to PHM.

-       Regarding IPHU, Global Health watch,  WHO Watch, concerns raised about opaque processes. Suggestion to defer to a group that decides on all of these issues – to assess current process and what needs to be revised, to which NCC can inform / input. This is a very confusing and meaning less and the sentences are not completed.

-       It was decided in interface between JSA and PHM global will be organised by the representation of steering council and old steering council members.

 

Decisions / follow ups based on previous discussion:

-       Group to review the NCC list and co-convenors (Raman, Sanjeev, Ameer, Renu) by 1 June 2022.

o   Define criteria and requirements – overall review of co-convenor group and functions of the co-convening group, to be submitted to NCC

o   Followed by individual review of  co-convenors

 

-       Secretariat –which are these organisations should be finalised after talking to some groups.

o   Process to be carried out by a group (Indranil, Chaya, Sarojini, Amulya and Abhay) – by 15 June. Roles and responsibilities to be clearly communicated to organisations.

o   About secretariat coordination – host organisations to decide – and propose to the NCC for its inputs. Timeline for this to be decided.

 

-       Organisational document finalisation based on inputs received by Richa, Prasanna and Deepa / end of May 2022.

-       An NCC ( online) proposed within a month to move forward on key pending decisions/tasks.

 

 

D.    JSA national level activity planning: moderators - Maimoona Mollah and Gouranga

 

Decided that every state will send a written report of state JSA activities within the next 15 days to be compiled and shared. The session focused on planning action / activity / campaign at the national level.

 

Suggestions and discussion on issues and possible activities / campaign nationally were shared by participants, drawing on previous experiences.

 

Strategies / action points that emerged from the discussion:

-       National level campaign on right to health – announce this on 15 August 2022. Campaign declaration to be done on in states , at district level, sub district level.

-       Campaign can be continued through till April 2023.

-       Reach out to communities as a main objective.

-       Mass signature campaign

-       Preparation of series of leaflets towards building understanding on the issues to be raised – simple attractive one page leaflet.

-       Evidence collection  formats / tools for data / information collection to be developed.

-        Generate testimonies, case studies, and conduct of rapid surveys.

-       National convention will be held; location for convening be decided.

-       Memorandums to MP, MLAs, policy dialogues during the parliamentary sessions.

-       Preparation of slogans and dissemination (CITU comrades can assist)

-       One or more workshops as required in early July to concretise the  plan.

-       A campaign on access to drugs at national and state level was also discussed based on Dr Eqbals note on drug price.

 

Issues / themes flagged in the discussion

-       Rights to health and health care

-       Social determinants of health

-       Gender

-       Attack on women’s rights, minority rights

-       Drug pricing / access to medicines

-       Privatisation / PPP

-       Health Insurance / AB

-       Climate crisis

-       Health right bill

-       New policy developments by Niti Ayog to be understood / watched

 

 

            Concluding remarks by Amitava and expression of thanks to various persons / teams that contributed to the meeting - coordinated / organised the meeting, moderators, rapporteurs,  etc. Participants thanked Amitava and colleagues in CITU for making available Rammurthy Bhavan for this JSA NCC meeting.

ANNEXURES

 

ANNEXURE 1.

 

Draft proposed agenda for JSA NCC meeting – 14 and 15 May 2022, New Delhi

14th May

Time

Session

Moderator(s)

10.30 am – 12.00 pm

E.     Introductory session

Round of personal introductions by all participants

Overview of objectives of this NCC meeting and flow of agenda (by moderator)

Brief reflection by participants (2 minutes each) on the following question–

·         In your opinion what is one area of strength,and one area needing improvement, regarding JSA’s organisational functioning?

Chhaya Pachauli and Abhay Shukla

12.00 – 1.30 pm

F.     Revisiting and revamping JSA organisational framework at national level

Review of the major decisions taken in the last JSA NCC meeting (27 April 2021). Brief recounting of various organisational processes and efforts carried out within JSA at national level during the last one year.

Sharing of process, discussion and attempt to reach agreement regardingdocument on organisational framework for JSA – including reporting of discussions in sub-group, circulation of two drafts, comparative analysis of drafts, proposal for resolving areas of difference and synergising the two drafts.

Key aspects of revisiting and strengthening JSA organisational framework:

·   Overall review of functioning of NCC and National secretariat

·   Clarifying the role and responsibilities of NCC members

·   Clarifying role and composition of National secretariat

·   Revisiting role and responsibilities of National co-convenors

·    Decision making processes in JSA at national level

·    Overall measures for JSA movement strengthening

Anant Phadke and Renu Khanna

1.30 – 2.30 pm

Lunch

 

2.30 to 5.00 pm

B.    Session B (Revisiting and revamping JSA organisational framework at national level) continued

Anant Phadke and Renu Khanna

5.00 to 6.00 pm

G.    Session on key decisions and areas of debate requiring clarification

·         JSA position on taking institutional funding

·         Future representation from India region in PHM Global-Steering Committee; clarifying relationship between JSA and PHM global

·         Issues related to JSA and the PHM-organised EACT project

Ameer and Sarojini

15th May              

Time

Session

Moderator(s)

10 – 11.30 am

Session C (key decisions and areas of debate requiring clarification) continued.

Recap of organisational decisions which have been taken in the meeting.

Ameer and Sarojini

11.30 – 1.30 pm

H.   JSA national level activity planning

·         Brief reporting of state level activities since last NCC meeting (7-8 mins per state)

Gouranga and Maimoona Mollah

1.30 -2.30 pm

Lunch

 

2.30 – 5.00 pm

D.   JSA national level activity planning (contd.)

·      Overview of health policy and movement related challenges in present scenario

·      Response on urgent issues (e.g. drug price rise issue) and major recent policy developments (Right to health policy / acts drafted in few states, digital health policy, accelerated moves for healthcare privatisation etc.)

·      Planning for development of JSA strategy during the COVID recovery and post-COVID situation – key areas requiring emphasis such as Public Health system expansion, Private sector regulation, Post Covid situation interventions –identifying sub-groups / persons who will draft specific thematic drafts / action proposals on such areas in coming period. Emphasis will be on future programmes and campaigns for JSA movement strengthening.

Gouranga and Maimoona Mollah

5.00 – 5.30 pm

Summing up of all decisions taken, plan for follow up of all decisions taken in this NCC meeting, and tentative plan for next NCC meeting

Amitava Guha

Note: Scope of the discussion need not be limited to the points outlined, whichever relevant issues are felt important for meeting the objectives of the session, will be taken for discussion based on consensus.

Venue: P. Ramamurty Bhawan

              20 Pushp Vihar

              Sector VI, M.V. Road, Saket, 

              New Delhi-110 0017

 

(Those who would avail Metro Rail, may get down at Malviya Nagar Metro rail station (not at Saket Metro station) and exit through the gate showing Max Hospital. Take bus going to Saket Court. Get down at Singhania Hospital Stop. Cross the road and take left road where Andhra School is situated. Opposite to this is P.R. Bhawan.)

 

 

 


 

Annexure 2: Comparison of JSA organisational notes – 15 Nov. and 16 Nov. 2021 drafts

Sections / topics

Sections from 15 Nov draft (15ND)

Sections from 16 Nov draft (16ND)

Comments

1. Background

The Jan Swasthya Abhiyan (JSA) was formed in 2001, with the coming together of 18 national networks that had organised activities across the country in 2000, in the lead up to the First Global Peoples Health Assembly, in Dhaka, in December 2000. The JSA forms the Indian regional circle of the global People’s Health Movement (PHM). At present it is one of the major national platforms that co-ordinates activities and actions on health and health care across the country. The JSA, today, is constituted of by 21 national networks and organisations and state level JSA. The constituents include a range of organisations, networks, NGOs, trade unions working in the area of health, IP issues, food security and nutrition, gender and health, environment, peoples’ science, occupational health to name a few (Annexure 1 is the list of constituents).

JSA was formed in 2001 and in first of its meeting decided to a minimum organizational shape to function and lead health movement in India in the context of large participation in the first Health Assembly at Kolkata and subsequently in the first PHA held at Dhaka. Sometime later, in a meeting at Delhi a decision to form JSA Secretariat was formed though no criteria or clear definition could be thought of then. Som­etime later, when JSA was provided fund from Dorabji Tata Trust, core functioning was conducted by Sathi-SEHAT from Pune. Later this functioning was shifted to Bhopal MPVS.

At the stage of emergence of any structure it remains quite dispersed and no defined structure can be formed, but when 18 years have gone by and the organization enriched with three National Assemblies when more than 100 organizations represented and many individuals have assembled under JSA, a better structural definition could help functioning in somewhat systematic and organized manner.

Points in both drafts are complementary and could be combined. There is no discordance.

 

Some factual additions / corrections are required for the 16ND – for example JSA national secretariat was formed in JSA NCC meeting held in April 2003; the first secretariat was hosted by SATHI-CEHAT with support from two Delhi based JSA national organisers, without any institutional funding from mid-2003 to Nov. 2005. After this DTT funds became available, and based on decision in JSA NCC these were used to support some JSA activities including People’s Rural Health Watch, various preparatory meetings for NHA-II, and national secretariat.

2. Structures / processes mentioned

In addition, the organisational structure of JSA consists of - 

a. Co Convenors/Joint National Convenors     

b. State Chapters/State Committees

c. National Secretariat

d. NCC

e. Thematic Groups

 

1.   Membership in JSA

2.  Organization

3.  JSA National Co-ordination Committee (JSA-NCC)

4.  JSA Secretariat

5.  JSA Advisory council

6.  National Health Assembly

7. JSA Statements

8.. Financial resource

9.Annual report

10. Representation in committees.

Based on the final set of issues that are covered in the JSA organisational document, relevant points can be combined from both drafts.

3. Principles based on minutes of earlier JSA meetings

Nagpur and Delhi Meetings’ Minutes –Summary

The Nagpur JSA NCC Meeting held in 2014, was an important meeting where it was decided to formulate and circulate a set of ‘Guiding Principles’ for JSA.  The suggested principles were arrived at after considerable discussions among the members. Some of the core principles include -

1.         JSA state units should be organised in a spirit that respects diversity and differences.  JSA units should be inclusive, constantly attempting to enlarge the involvement of different groups, organisations and movements

2.        ‘Open Functioning’ should be encouraged as an organizational principle, ensuring that all JSA meetings are ‘open’ meetings that do not keep out people associated with the JSA even if they are not part of the formal structures.

3.        All JSA state units should have Multiple Convenors representing the diversity in the state JSA platform

4.       Responsibilities, Accountability & Mandate of Secretariat and Convenors will need to be clearly defined.

5.        Organising principles should include some rules regarding periodicity of meetings of the state coordinating body, circulation of decisions and minutes.

6.       There should be some principles that would be followed regarding rotation of the State Secretariat hosting responsibility as well as for convenors and co-convenors. A suggested principle could be that the state Secretariat and co-convenors should rotate every two terms of 2-3 years.

 

In 2018, at the Delhi NCC Meeting, it was acknowledged that JSA structure lacked mechanisms to engage with various student groups and younger people in a systematic manner. It was decided that a student and youth subcommittee of JSA should be formed to involve students and youth and coordinate their activities. The sub-committee should be represented in the JSA NCC. This sub-committee would coordinate the involvement of students and youth in thematic working groups and state JSA units.

 

The main points of these meetings have been incorporated in the present note.

Not mentioned

Principles mentioned in 15ND provide some overall background and can be considered for inclusion in the final document.

4. Background regarding present JSA organisational note (2021)

In a joint meeting of the current National Secretariat and the NCC co-convenors, held on July 28, 2021, a committee was formed to brainstorm and come up with a draft organizational note. In the light of the discussions held in the previous NCC meetings and the decisions taken therein, this draft note was prepared.

 

The core objectives of this document are to provide guidance on structure and functions of Jan Swasthya Abhiyan (JSA) and serve as a guideline. This document would be discussed in the joint meeting of the co-convenors and national secretariat and placed to the NCC for discussion and ratification. Any further amendment to the document would need consent from majority of the NCC members.

Not mentioned

Background mentioned in 15 Nov draft can be included in the covering email when the document is circulated to JSA NCC, to provide clarity.

5. JSA Membership procedure

Who could be a member of JSA? There is no formal membership process of JSA. Organisations, networks, groups who are part of the National Coordination Committee of JSA and their members are part of JSA. Additionally individuals who subscribe to JSA Manifesto and pledge to work to strengthen Peoples’ Health Movement/JSA would be a member of JSA. Members shall be preferably affiliated to the state chapters and national organisations/ Networks of JSA.

Members shall be from state level organizations and they would be registered with state JSA. These organization members could be the state branch or associate of national networks or organizations which are specific to that state. Each organization shall send one or two members to the state JSA Co-ordination Committee. Those health activists or intellectuals who can function as resource persons can also be coopted as member but not be more than one third of the regular members, JSA State co-ordination Committee will also form a core team and thematic sub committees.

Organisational membership for state JSA units is emphasised in 16ND, with space for individual resource persons upto 1/3 of regular members. 15ND also mentions option of individual members. Points from both drafts can be combined.

6. JSA Membership principles

Core working principles of JSA members: Every member of JSA and the NCC would endorse the JSA Manifesto and Charter; should uphold values and principles enshrined under Indian constitution. JSA members should uphold collective interest of JSA beyond individual interests; should follow a democratic, inclusive and participatory approach in all her/his acts, statements, gestures; should treat every other member of JSA with dignity and respect; the acts and statements should be in consonance with and uphold the principles of solidarity, non-discrimination, mutual respect; with the goal to strengthen the movement. The JSA members must put their best efforts to prevent any lobbying or spread of misinformation towards any fellow members or organisation; should actively promote and practice a culture of debate and discussion, respecting the boundaries of mutual respect and the right to dissent. JSA has developed as a collective with no hierarchy inherent in the structure. The members should follow the principle and not engage in any practice that establishes or pushes for any sort of hierarchy among the members. 

"Organization: Those who accept JSA health Manifesto and are participating to the state and national programmed of JSA but not merely involved in charitable work shall be considered as organization."

15ND proposes more detailed working principles for JSA members. While these are useful, since some new points are being suggested these would need to be discussed in JSA NCC and then based on agreement, points may be appropriately included.

7. JSA National Coordination Committee -composition and meetings

JSA NCC would consist of representatives from National Organisations; networks; representatives from state JSA chapters, members of the National Secretariat, National Co-convenors. NCC would also have representatives from the working groups nominated by the working groups.

Each state would elect a maximum of three members for representation in JSA NCC. National organizations shall nominate two representatives to JSA NCC and national networks should have three members nominated. NCC shall also include individuals, groups from among the fellow travelers to participate in a specific NCC meetings. All the founding members of JSA NCC, ex-national Co-convenors would be permanently invited members of the NCC as advisors.

 

JSA NCC shall meet twice in a year at least, either through online mode or physically, with preference given to at least one physical meeting, subject to availability of resources.

Each state will elect two members and another alternate member for representation in JSA NCC from their state conference to be held at least once in two years. In this conference/assembly the state will request at least one member of the JSA Secretariat to attend. In states where there is no state organization has been formed through state conference/assembly, JSA- NCC would form an ad-hoc team  who would contact all active state organizations and people involved in health movement for a first state JSA conference/assembly and form elected set up through the state conference/assembly. National organizations shall send one member from them as member of JSA NCC. JSA NCC shall meet twice in a year.

Regarding membership in JSA NCC, 15ND outlines representation from state JSA chapters (maximum of 3), similarly 16ND mentions two members + one alternate member. 16ND also mentions about ad hoc team in states which do not have a formed state JSA unit and details process for formation of state JSA unit after state conference.

 

15ND also mentions about other types of representation in NCC besides from state units (National resource organisations, National networks, National co-convenors, Thematic working groups). There is also mention of invitees. These forms of participation are mostly based on earlier discussions in JSA, but need ratification by JSA NCC.

8. Functions of the JSA NCC

JSA NCC would take major decisions regarding the activities of JSA:

·            Undertake necessary actions to carry forward the JSA activities and vision; including issuing statements, organize campaigns

·            Form the National Secretariat and provide necessary directions to the Secretariat; review and oversee its functioning;

·            Facilitate formation and functioning of JSA state chapters;

·            Finalise all national level publications of JSA

·            Coordinate with other organisations and movements to strengthen JSA’s vision;

·            Recommend India’s representative/s in the PHM international Steering Committee

·            Respond to any health emergencies;

·            Review the functioning of existing thematic groups and activate and expand the groups

·            Periodically review the functioning of the National Co-convenors

·            Every three years, there should be a review in the representation to NCC from the State Committee, with at least one new member.

·            Review of NCC’s own functioning once in two years.

Not separately mentioned

15ND lays down in detail functions of JSA NCC, which would be relevant for inclusion in the final document, based on ratification by JSA NCC.

9. Selection and characteristics of National Co-convenors

There will also be around ten national co-conveners elected by the NCC from among the members who have been active in JSA for last at least three- four years. The Co-convenors would hold position up to a maximum of six years.  The National Co-convenors would appropriately represent the gender, caste, religious and other social diversities of the country- would have at least half of its members as women and significant section from among deprived social groups. At least forty percent of the National Co-convenors should be below the age of 45 years, with a maximum age limit of 65 years. Existing National Co-convenors who have been there for more than ten years or have crossed 65 years would relinquish their position, but continue as advisors.

There shall be a national Convener from the JSA Secretariat to be decided by the JSA Secretariat and can continue up to three terms maximum. There will also be five to seven national co-conveners selected by JSA Secretariat who would function up to three years but cannot continue more than three consecutive terms.

 

JSA NCC members

The selection of joint convenors should be done through State convention and based on the recommendation of State units all names of Joint convenor should be endorsed by National assembly.

 

 

There are divergences between both drafts on selection and characteristics of National Co-convenors. For example, 15ND states that they would be selected by JSA NCC, while 16ND states that these would be selected by JSA secretariat. 15ND specifies criteria such as gender and social background, and age limits for co-convenors.

There is another section in 16ND (highlighted) which states that selection of joint convenors should be done through State convention and State units – this needs clarification.

These points would need to be discussed in JSA NCC to arrive at consensus.

10. Functions of the National Co-convenors

Responsibilities of the various tasks of the Co-convenors would be to

·         Help JSA in arriving at crucial decisions and taking policy positions;

·         Lead JSA in various activities;

·         Coordinate with at least three state chapters and facilitate the activities; and

·         Convene at least one thematic group;

·         Guide the secretariat;

·         Represent JSA at various fora;

·         Coordinate with various networks to strengthen alliances and movements;

·         Draft various JSA publications including statements, manifestos, position papers, press release etc.

·         Report back to the NCC from states/networks and report about national activities/plans to states/networks

·         Other tasks entrusted by the NCC. 

Not specifically mentioned

15ND lays down in detail functions of National co-convenors, which would be relevant for inclusion in the final document, based on ratification by JSA NCC.

11. Composition and procedural issues related to JSA National Secretariat

JSA Secretariat which will be selected by JSA NCC, shall be responsible for day-to-day activities of the JSA. Once formed, the JSA Secretariat would continue up to three years, after which NCC would review the work and rotate the Secretariat if necessary.

JSA NCC shall decide on the size, composition and location of the National Secretariat. The members of the JSA Secretariat may or may not be full time functionaries of JSA. Apart from members of national organisations and networks, the Secretariat should involve young volunteers periodically. Immediate attention would be paid to generate resources to run a full-time functioning National Secretariat.

JSA Secretariat which will be selected by JSA NCC, shall be responsible for day today activities of the organization. Once formed, the JSA Secretariat would continue up to three years.

Meanwhile after the state JSA Co-ordination Committee conference is

completed, the JSA Secretariat shall be formed within a year after state conference is completed.

JSA NCC shall decide number and persons for formation of the Secretariat. JSA Secretariat, apart from urgent situation shall meet once in three months (quarterly) in a year. The member of the JSA Secretariat may or may not be full time functionary of JSA. A team of full time JSA functionaries shall be created to run the national center.

The national seceteriate should functional as rotational basis and every three to five years the host organization should be changed.

Both drafts mention many similar points related to formation and composition of the JSA national secretariat, which can be combined.

 

Some points in 16ND (highlighted) are not clear and need to be clarified.

12. Roles of National secretariat

As mentioned above, the National Secretariat is a body responsible for executing the plans and agenda of the JSA NCC. The Secretariat would work according to the guidance provided by the NCC.

·         Shall be responsible for day-to-day activities of the JSA

·         Bring out various communications, statements;

·         Manage social media and web content; organize press conferences;

·         Ensure regular meetings of the NCC;

·         Organize various events, coordinate campaigns and movements,

·         Facilitate state level actions and help in the functioning of state chapters;

·         Organize thematic group meetings

·         It would also inform the NCC about various key issues and seek guidance.

·         The Secretariat would meet at least once a month virtually and

·         Would conduct a joint meeting of the National Co-convenors and Secretariat at least a month before the NCC. The Co-convenors and the secretariat should meet at least once in four months. 

Not detailed.

15ND proposes details regarding the role of National secretariat which appear relevant, and may be included in the final document based on ratification by JSA NCC.

 

13. Convener of the National Secretariat

There shall be a Convener of the National Secretariat to be elected by the JSA NCC who would continue up to three maximum years. The responsibility of regular convening of National Secretariat; coordination among secretariat members, Co-convenors would rest on the Convenor.

There shall be a national Convener from the JSA Secretariat to be decided by the JSA Secretariat and can continue up to three terms maximum.

Points are largely similar, both drafts can be combined.

15ND proposes continuation for three years at maximum, while 16ND proposes three terms, what is meant by ‘terms’ is not clear and needs to be specified.

14. JSA Advisory council

Not mentioned

JSA Advisory council:

JSA Secretariat shall select not more than one third of the members of its Secretariat certain individuals who do not belong to any organization but are contributing to movement. This Advisory council shall be invited to participate to JSA Secretariat meetings in alternate JSA Secretariat meetings. They may also be included in sub- committees or event wise groups, if formed in pursuance to programme or in representing JSA in national meetings/seminars or meetings with government and other authorities.

16ND proposes JSA advisory council to participate in alternate JSA secretariat meetings. Since this would be a new body which has not been discussed in detail in JSA NCC, this requires decision in JSA NCC.

15. Composition of JSA state chapters and JSA State committees

JSA State Chapters: JSA state chapters shall comprise of state representatives from national organisations, networks, state level member organisations and individuals who endorse JSA Manifesto.

 

JSA State Committees (SC): The SC would be elected from the members present in the General Body Meeting of the State chapter. There would be efforts to have at least a third of the total members present in the state GBM. The tenure of the SC would be maximum of three years. Members of the SC would hold the position for two terms at the maximum and every new SC would have at least a third of the new members.

 

The SC would elect two-three state conveners and JSA NCC representatives.

 

The membership of JSA SC would appropriately represent the gender, caste, religious, linguistic and other social diversities. SC would have at least half of its members as women in the SC and significant section among deprived social groups. Special efforts would be undertaken to include a third of the members below 35 years of age. All members above 65 years of age would be relieved from SC responsibilities but would continue to be part of JSA state chapter as members and advisors. 

 

In states where there is no state chapter formally established through state  conference/assembly,  JSA-NCC  would  form  a   committee, who would contact all active state organisations and people involved in health movement for a first state JSA conference/assembly.

Not dealt with in detail.

 

One related process (mentioned above in section 7) is as follows:

 

In states where there is no state organization has been formed through state conference/assembly, JSA- NCC would form an ad-hoc team who would contact all active state organizations and people involved in health movement for a first state JSA conference/assembly and form elected set up through the state conference/assembly.

15ND proposes certain details regarding composition of JSA state chapters which appear relevant, and may be included in the final document based on ratification by JSA NCC.

 

Regarding formation of JSA state units in newer states, both drafts suggest a similar process, can be finalised.

 

16. Functions of the JSA State Committee

 

·         Coordination with NCC, state level campaigns/ actions;

·         Organizing regular meetings of the members (at least twice a year);

·         Formation and functioning of state working groups;

·         Liaison with other state level networks and campaigns;

·         Disseminate national level publications in local language;

·         Develop state specific campaigns materials;

·         Regular reporting of the national level activities at the state level and vice-versa.

·         The state convenors and NCC representatives would be responsible for regular functioning of  SC; coordinate with the NCC and catalyzing state level thematic groups;

·         All efforts should be made to rotate and handover state coordination and such efforts should be reported to the NCC

 

Not dealt with

15ND proposes details regarding the functions of JSA state committee which appear relevant, and may be included in the final document based on ratification by JSA NCC.

 

17. National Health Assembly

NHA shall be held once in four years. The NCC would decide date, venue of the NCC; form organizing committees taking help from the National Secretariat to organize the Assembly. Every state chapter would have State Assemblies before the national assembly.

 

NHA shall be held once in three years. JSA Secretariat shall prepare, programme of NHA including agenda, topics of plenary and sub-plenary; workshops, etc. JSA Secretariat in consultation with JSA NCC shall also prepare names of facilitators/moderators of each meetings/workshop.

 

It was decided in NCC that every three years we will do National assembly and the tenure of all functionary should be three years. However, state can select the representing for two consecutive terms.

Both drafts mention similar points and can be combined. Whether NHA is held after 3 years or 4 years in any particular situation, could be decided based on practical considerations at that time.

 

One point from 16ND (highlighted) needs clarification).

 

 

18. JSA Statements

Any member of the NCC can propose for JSA to undertake a statement on a relevant issue, which should be seconded by at least one tenth of members of the NCC. If there are clearly articulated opposition to the statement proposal, NCC shall take the final call for appropriate action based on democratic and collective functioning. The task of coordinating the drafting of the statement would rest on the National Secretariat, who would set up a team to draft statement.

 

Any proposal to bring out joint statement(s) with other organisations/ campaigns networks and member organisations should be ratified by at least one tenth of the members of the NCC. In case JSA is asked to sign any joint statement issued by other fellow organisations/ individuals, it needs to be ratified by the NCC. The NCC should be provided at least 24 hours to respond. 

 

Statements, which are state specific should be developed by the SC; National Secretariat to be kept in the loop.

 

The NCC should be provided at least forty eight hours to respond to any statement, unless there are clearly justified emergencies.

All the statements should be released by Secteriate and not directly by NCC. Based on the suggestions and endorsement of NCC the secteriate can release the statement.

 

In all the states there are state level coordination team which works depending upon the state level situation and activeness of State units. Any Statements which are related to State specific issue   should be finalized in consultation with State JSA units and if required released by JSA National secteriate.

If any Statements with is jointly prepared the background of organization should be done by State and national JSA   Secteriat. One third members endorsement of the Secretariat should be compulsory for releasing any statements unless it's not an emergency situation.

All the statements should be released in the name of JSA and for joint statement on specific issue in which the network organization has expertise or long experience joint statements can be released.

While endorsing any statement, it should be measured how much responsibility are expected to bestow on JSA.

Points in both drafts are overlapping, however some points in 16ND need clarification or better drafting (highlighted). Based on such clarifications, both drafts can be combined and finalised through ratification by JSA NCC.

19. Representation of JSA in other forums / events

Any NCC member, member of SC, National Co-convenor and National Secretariat member, if invited to address a public event should inform JSA NCC/ respective state chapter if she/he is representing JSA. Needless to say, every member is free to attend any event on her/ his individual capacity.

 

However, any statement/ declaration signed on behalf of JSA, as part of the event should be endorsed by the NCC.

 

On urgent occasions like Govt. meetings which usually provide a short notice, National Secretariat should be consulted by email.

 

Co-organizer of events: Whenever JSA is co-organizing any event, the Secretariat has to seek permission from the NCC.

All names of such representation should be endorsed by NCC.

 

15ND proposes details regarding procedure for representation of JSA in other forums / events. There is no substantial divergence between the drafts. Points from 15ND may be included in the final document based on ratification by JSA NCC.

 

20. JSA related financial resources and funding

As discussed in the previous NCC meetings (Refer to Nagpur 2014, 2011, 2007 minutes) JSA NCC may take efforts to raise resources for running of the secretariat. A committee of five persons from NCC should review any proposal of project funding which furthers the vision and mission of JSA. Based on the recommendations of the committee JSA NCC should take the final decision.

JSA should make a dedicate team for rising financial resources which can be only India funds and largely individual and membership contribution. All state chapter can contribute Rs. two thousand to Rs,10 thousand yearly depending upon the members of State. All Network organizations can also contribute fixed yearly contribution. This amount can be Rs. two thousand to Rs.10 or more.

As JSA members individually can contribute Rs.500 Rs. to Rs 5000/ yearly

 

Organizational funds

JSA can only take organized Indian funds of required but for specific activities or campaign. The day-to-day secretariat related functions shall be managed by resources generated by its own and should not depend upon external funding.

If any network organization is taking funds in the name of JSA it should be discussed in NCC.

16ND mentions suggested amounts for State, Network and Individual contributions. These can be discussed in JSA NCC and finalised by consensus.

Both documents have a difference on the acceptable source of resources for running the Secretariat – 16ND states that this should be internally generated and no external funding be sought for secretariat functioning, while 15ND suggests that efforts be taken for raising resources for the secretariat. This issue needs discussion in JSA NCC.

21. JSA representation in PHM, and use of PHM funds for activities in India

 

Not mentioned.

Secretariat shall recommend name/s from the Convener and Co-conveners for representation in the Steering Committee of international PHM.

 

PHM takes organized funding for JSA from donor agencies which have no controversy. Any funds which PHM is taking and if it's going to route or used for India specific activities it should be discussed and approve by JSA NCC. All the annual reports and financial report of PHM should be shared to JSA NCC.

16ND proposes principles to be followed regarding use of PHM funds for activities in India, which would be associated with JSA in some form. These principles may be ratified in JSA NCC and included in final document.

22. Annual report from JSA to PHM

 

Not mentioned.

Every year the donor organization require report from PHM and JSA India has also been sending annual report to PHM. All annual reports should be discussed and endorsed by JSA NCC

16ND proposes that annual reports regarding JSA activities from JSA to PHM should be discussed in JSA NCC. This  basic procedural step may be ratified in JSA NCC and included in final document.

23. Thematic groups

Thematic groups play a very critical role in the functioning of JSA. The NCC would review the functioning of existing thematic groups, if required form new groups; entrust the Secretariat and Co-convenors to form the groups from among the members of JSA working across various states, national organisations, networks and other individuals who are contributing to the respective fields.

 

Some thematic areas that were identified and groups formed are –

 

a. Strengthening, Expanding and Reorienting the Public health system (including health workforce)

b. Privatisation and PPPs (including Insurance schemes)

c. Pvt. Sector Regulation and Patients’ Rights

d. Gender and Health - Maternal Health, SRHR, Violence, etc.

e. Access to Drugs, Devices and Diagnostics: Free Drugs, DPCO, Clinical Trials

f. Public Services and Social Determinants

Functions of the thematic groups:

·         The Thematic Group would function as policy watches, help JSA NCC to take position on policy issues;

·         Help National Secretariat to bring out statements, position papers; campaign materials;

·         Organize thematic campaigns, events and training.

·         One member from the National Secretariat/ National Co-convenor would coordinate the Thematic Group.

·         There would be representation at the NCC from each Thematic Group, selected from among the members.  

Not mentioned.

15ND proposes details regarding Thematic groups which are an important aspect of JSA functioning.

Points from 15ND may be included in the final document based on ratification by JSA NCC.

24. Specific Internal Committees

Internal Committees on gender sensitization and prevention of sexual harassment; internal complaint committees: JSA NCC should set up these committees to prevent sexual harassment and look after various forms of discrimination practiced within JSA and its activities.

Not mentioned.

15ND mentions formation of certain new committees to prevent sexual harassment and discrimination within JSA. While these are in line with JSA principles, being a new set of bodies not discussed earlier, these will need discussion in JSA NCC.

25. Youth sub-committee

JSA Youth Sub-committee: A special sub-committee should formed in line with the 2018 NCC meeting recommendation, who should be represented in the NCC.

Not mentioned.

15ND mentions need for Youth sub-committee which had been planned in JSA NCC meeting in 2018. Being based on existing NCC decision this could be included in the final document.

 

 

 

Annexure 4-

Institutional Funding and JSA: Proposed Guidelines

Anant Phadke 

 

The tradition

I think, right from the inception of the JSA, a certain perspective about institutional funding and JSA work has been understood and agreed upon, without explicit discussing about it. This is because we, the founding members of JSA and those in the NCC mostly come from some background in Peoples’ Movements and want to contribute voluntarily to build JSA as a movement. Many NGOs and persons who are part of JSA have been routinely receiving foreign/Indian funds for their respective NGOs and have also been voluntarily contributing to JSA by working for JSA beyond office hours. Some NGOs have also been using some of their organizational resources like computers, office space, some administrative help etc. on a voluntary basis. (“Organizational voluntarism”). Such organizational voluntarism is I think welcomed in JSA and in my view does not require a discussion. It is also widely understood in JSA that some NGOs can do some pro-people survey work or some educational or some  constructive work which can be helpful to the cause of the ordinary people and such work can also facilitate the work of JSA. However, JSA’s work is quite different from NGO work; it is that of a people’s movement and voluntarism is the principal strength of any movement.

In the past, Institutional funding has been taken for some JSA-work as such like the National Health Assembly-II or for catalyzing submissions to NHRC on violations of health rights.  Based on a consensus decision, such funding may be received through contracts with some JSA-linked individuals or be received by some JSA-linked NGO for JSA work. While accepting such funds, it was understood that care should be taken that this would catalyze voluntary inputs in JSA to enhance it’s work as that of a coalition of volunteers. It is necessary that this tradition, understanding is formally noted, endorsed, modified (if necessary) by the current the NCC.

There is some apprehension that perhaps currently there is no clarity about this issue across all JSA activists and hence there is a need to reaffirm this broad perspective. There is also a need to lay broad guidelines for accepting institutional funding if any for JSA work. The overall care to be taken is –JSA should be strengthened as a movement and it should acquire an image as a coalition of volunteers for People’s Health Movement and not more of an NGO conglomeration; that the distinction between voluntary and professional work is not blurred. Towards this end, I would suggest the following draft guidelines for consideration –

 

Proposed draft guidelines

1)            All JSA work should be based on the analysis, understanding, ideas coming from JSA’s analysis, charter or activities, ideas suggested by JSA activists and not emerge from some funding source, funded project.

2)            In all JSA work, the financial contributions should start from our internal resources, like savings from income generated from previous activities, voluntary contribution from our own pockets as individuals (in proportion to our individual resources, affordability), voluntary contribution from our organizations, from friends, supporters of JSA, people’s movements etc etc. An estimate should be made about shortfall if any and decision be made whether or not to seek supplementary institutional funding for a big activity. Routine activity should primarily be a self-funded one. If supplementary institutional funding is to be sought for some big programme, the decisions about acceptability of the source, the amount, the modality, accounting, transparency etc. should be made democratically, keeping in mind the basic JSA-framework.

3)            There is an issue of overlap between JSA activities and project-activities by one or more constituent NGOs in JSA. Both constituent NGOs in JSA and state/national JSA should take care that such overlap, collaboration is avoided when possible and when it happens, attempts be made to catalyze voluntary inputs into JSA and that there is no erosion of voluntary resources, voluntary spirit in JSA. 

4)            As regards reporting of such funded activity to the funder, voluntary activities either by JSA or any other voluntary group should not be included by the NGO in the report to the funder. There is a need to assure all the concerned that in case of such overlap between JSA activities and NGO-project, such reporting does not occur. Towards this end, in the spirit of transparency, the constituent NGO should send a copy of it’s project-report for the funder, to the JSA secretariat. 

********************

Rapporteurs Team

Richa, Prasanna, Indranil, Amulya, Deepa and Rakesh.



[1]  As one of the moderators I had appealed that let us not get into what happened in the past as regards some controversial issues but suggest what needs to be done in the future, keeping in mind what has happened in the past 

 

NFHS --5

 GENDER ISSUES IN HEALTH IN HARYANA

Dr. R.S. Dahiya
Ex. Sr.Prof, PGIMS, Rohtak. 

     It is a well established fact the biologically women are a stronger sex. In societies where women and men are treated equally, women outlive men and there are more women than men in adult populations. More girls die during course of pregnancy in our country. Naturally there are106 boys for 100 girls at birth as the more boys die in infancy& ratio is balanced. The unequal status, unequal access to resources and lack of decision making power experienced by girls and women because of their gender would result in disadvantages in health. These disadvantages include a higher likelihood of exposure to health, greater susceptibility to adverse health consequences as a result of the exposure, and a lower probability of receiving timely, appropriate and adequate health care. 

It is widely acknowledged on the bases of studies done in diverse settings, that inequalities in health across population groups arise largely as a consequence of differences in social and economic status and differential access to power and resources.. The heaviest burden of ill health is borne by those who are most deprived, not just economically, but also in terms of capabilities such as literacy levels and access to information. In the words of Noble Laureate Amartya Sen, India, with its present population of 1 billion has to account for some 25 million missing women.
       On the top of that in a modern world of today this discrimination has not allowed a gender sensitive language to develop. There is mankind but no woman kind; there is house wife but no house husband; there is house mother but no house father; kitchen maid is there but no kitchen man. The unmarried woman crosses the threshold from bachelor girl to spinster to old maid but the unmarried man is always bachelor.
        Discrimination means ‘treating one or more members of a specified group unfairly as compared with other people.’ A convention on this issue was held on the elimination of ACI forms of discrimination against woman (CEDAW) by the United Nations in 1979. The gender discrimination in that convention was defined as:
“any distinction, exclusion or restriction made on the basis of sex which has the effect or purpose of impairing or nullifying the recognition, enjoyment or exercise by women, irrespective of their material status, on a basis of equality of men and women, of human rights and fundamental freedoms in the political, economic, social, cultural, civil or any other field”. This gender discrimination emanates from an ideology that favours men and boys and undervalues women and girls. It is perhaps one of the most widespread and pervasive forms of discrimination. Measures of gender empowerment measure (GEM) show that there is gender discrimination worldwide. In many countries, especially from the developing world, a much larger proportion of women than men are illiterate. World wide women occupy only 26.1 % of parliament seats. Practically in all countries, developing as well as industrialized, women’s participation in the labour market is lower than that of men, women are paid less for equal work and work many more hours doing unpaid labour as compared to men. The most blatant expression of discrimination against female is the practice of sex determination in the womb and then selective sex abortion. Modern technology has now come to the aid of perpetuating culture of discrimination This  resulted in a decline in the proportion of females as compared to males in Haryana in past years op opand many other states of India. 
    Overall, more females die during pregnancy than do males. So that's why there's an excess number of males at birth,” said Orzack, who has published research on this issue.24-Jan-2019
After birth more male children die .
       Director Neerja Sekhar while sharing the details of provisional census data maintained the co-relation between literacy rate and sex ratio suggested inverse relationship, however the exact relation would be deduced after final data has been compiled.
   There were 18.02 lakh boys under the age of 6 in Haryana; the number of girls in the same age group was 14.95 lakh. (2011 census)
       The highest sex ratio was observed in Mewat at 907, followed by Fatehabad at 902, as per Census 2011.
According to the Census of 2021,
Child sex ratio (0-6 Age Group) of Haryana is 902 females per 1000 males.
Sex Ratio in Haryana
According to last Census of India in 2011, Haryana has the lowest sex ratio (834 females) in India. The state is known all over India for female feticide. However, with Government schemes and initiatives, the sex ratio in Haryana has started to show an upward movement. The state recorded a child sex ratio (0-6 age group) of over 900 for the first time in December, 2015. This is the first time since 2011 that Haryana sex ratio crossed the 900 mark. 
The highest sex ratio was observed in Mewat at 907, followed by Fatehabad at 902, as per Census 2011.
Haryana’s gender ratio was 903 (2016) according to state’s health department.  .
According to the Census of 2021,
Child sex ratio (0-6 Age Group) of Haryana is 902 females per 1000 males.
        Haryana’s skewed sex ratio reflects in adoption data too.
Providing specific details about adoption applications received from Haryana, CARA’s central public information officer said the current waiting list for adoption of female children in Haryana is 367 and the waiting list for the adoption of male child in Haryana is 886. 

    The gender discrimination has got its roots in our older cultural practices and way of living also, of course it has got a material base. The cultural practices of Haryana have a gender bias. At the time of birth of a boy, it is celebrated by beating a ‘Thali’ whereas the birth of a girl is mourned (matka phorna) in one way or the other; at the time of delivery, if a child is male, the mother will be given 10Kg ghee (do dhari ghee) and if a child is female, the mother will be given 5 Kg ghee; the sixth day (chhath) of a male child will be celebrated; the namkaran sanskar will be done if the child is male; the girls are not allowed to fire the funeral of the family members some where as the can burn mounds of wood in chulha at home . As the number of woman is going down in Haryana, they are becoming more insecure in the society. The violence in home and outside has increased in Haryana and is affecting the health of women adversely. The news papers carry many news items daily in this regard. Health department Haryana also behaves as the whole society behaves on the gender issues. The number of gynecologists in govt. hospitals is very meager compounding the women’s health still further.
         Rape cases up as Haryana sees sharp rise in crimes against women. The data shows there were 944 rape cases in 2014, 839 in 2015, 802 in 2016, 955 in 2017, 1178 in 2018, 1360 in 2019, 1211 in 2020 and 1546 in 2021.
(04-Mar-2022 https://www.dailypioneer.com › rap...)
The number of dowry deaths from the period of January 1 to July 11, a total of 13 deaths have been recorded, in 2022 whereas, this number stood at 4 in 2021.(9 deaths more)
(24-Jul-2022 https://www.tribuneindia.com › news)
    
      Haryana is infamous for crimes against women and its share in sexual crimes in India is 2.4 per cent, more than Punjab and Himachal. Around 32 per cent women are victims of spousal violence. Besides, 88 cases of child sex abuse, and 93 cases of rape had been registered every month since 2015.
(04-Aug-2018 https://www.tribuneindia.com › news)
      The unregistered cases are many more. This indicates that the price of women or the importance of woman has not increased by the decrease of their number as conceived by many people in Haryana. 
   Similarly if there is some increase , even then the atrocities on women are not coming down. Violence affects the health of women in many ways.
       Even today women have to go through many struggles, small and big. Women have achieved this day on the strength of their struggles and on this occasion women should fight against discrimination, injustice and all kinds of oppression. 

  Because even today, no value is assessed for the work done by women, whereas money has to be paid in the market for the same work. Women themselves are also unable to register their work which they should get done. He told that women have more stamina than men and they raise their children even in very bad conditions. 

 .      Think of a situation that in a dream when a man had to go through the trouble of getting pregnant and giving birth to a child. That's when she felt the pain of labor. That's why men should also realize that women have to go through a lot of hardships while giving birth to a child and men can never bear those pains. But unfortunately, the whole process of producing and raising a child is never recorded as a big task.
     Women need justice, respect and equality the most, that is why they have to struggle again and again. Whereas there is no difference between male and female except physical structure. But even then, women do not get all the opportunities that they deserve.
           The other thing which is happening in most of the villages of Haryana is that the number of unmarried males is increasing. Beyond 30 years of age, many males can be seen without marriage in each village. Unemployment is increasing amongst boys and girls both .Also there seems to be increasing trend of impotency in males because of multiple factors. The purchase of bridegrooms is becoming an accepted cultural practice in most of the villages. All these factors are adding the miseries of the women in Haryana. Side by side son preference and the under-valuation of daughter manifests itself in discriminatory practices against daughters such as well being, including, premature and preventable death of female child.
The data from the National Family Health Survey – 5 and NFHS 4



The data from the National Family Health Survey 5 and 4 indicates that
    Infant and Child Mortality  Rates(per1000 live births )
Neonate Mortality Rate..NNMR.. ..21.6
Infantil Mortality Rate(IMR)..33.3
NFHS 4..32.8
Under Five Mortality Rate(U5MR)..38.7
Children under 5 years who are stunted (height for age)%..27.5
Children under 5 years who are wasted (weight for height)%..11.5
Children under 5 years who are severely wasted (weight for height)%..4.4
Children under 5 years who are underweight (weight for age)%..21.5
Children under 5 years who are over weight (weight for height)%..3.3
Anaemia among children 
Children age 6-59 months who are anaemic ( less than 11 g/dl)%..70.4
NFHS4..71.7
NFHS 5 data revealed stunting, wasting , under weighting, adequate diet and anaemia as 27.5%,11.5%,21.5%,11.8% and 70.4% as compared to NFHS4 34.0%,21.2%,29.4%,7.5% and 71.7%
     Anaemia is very high almost same as in earlier survey. Diet intake has improved by 4.3 % but still very low percentage .  
V . Gupta et all have found in their study that stunting and underweight were more prevalent amongst girls.
.     The median duration of breast feeding for girls has been slightly lower than the median duration of breast feeding for boys . 

.    This deprivation in childhood contributes to substantial proportions of women being malnourished and stunted as adults. 
Pregnant women age 15--49 years who are anaemic ( Hb less than 11gm) are 56.5 % whereas they were 55% in NFHS 4. 
It has increased in last five years or so . All women age 15-19 years 62.3 % where as 29.9 % men of this age are anaemic. Clear gender hisse here.
For a significant proportion of adolescent Indian girls, an early marriage followed soon after by a pregnancy is the norm. 
    About 25 per cent of women aged 18-29 and 15 per cent of men aged 21-29 got married before reaching the minimum legal age of marriage, according to the latest National Family Health Survey (NFHS) conducted between 2019-21. 
    The women have no say on sexuality and reproduction. Child bearing in adolescence affects women adversely in many ways; socially, economically, psychologically and physically. It truncates their education, limits their income-earning opportunities and burdens them with responsibilities at an age when they aught to be exploring life. In developing countries, early childhood bearing carries a greater relative risk of dying in pregnancy and delivery as compared to woman in the 20-24 age .  
India’s maternal mortality rat
 (MMR) improved to 103 for the period 2017-19, but the ratio has worsened in states such as West Bengal, Haryana, Uttarakhand and Chhattisgarh, according to official data just released.
It is very unfortunate that our legal system has not been able to remove the existing social biases. Despite the constitutional guarantee of equality between men and women the law implementing agencies failed in their execution. That is the reason the women also often lack the authority to make their health care decisions for themselves. Though half a century has elapsed after framing of constitution, our social customs have not changed to match the spirit of the constitution. Still customary laws and traditions are given perferance over constitutional commitment in combination with patriarchal norms that deny women the right to make decisions regarding their sexuality , reproduction and health. Women are exposed to avoidable risks of morbidity and mortality in Haryana. 

Dr. R.S.Dahiya
Ex Senior Professor,
PGIMS, Rohtak.

मंगलवार, 5 मार्च 2019

FEMALE FOETICIDE IN HARYANA

George, Sabu M. and Dahiya, Ranbir S. Female Foeticide in rural Haryana.
Economic and Political Weekly.33(32); August 8-14, 1998. p.2191-2198.
Female Foeticide in Rural Haryana
Sabu M. George
Ranbir S. Dahiya
Female foeticide over the last 15 years distorted sex ratios as birth in several Asian
countries. Foetal sex determination clinics have been established in India over the last 20
years in northern and western cities. Presented here is the outcome of an intensive study
of the abuse of prenatal diagnostic techniques for sex selection in the a rural population of
13,000 in Rohtak district. Parents tend to be calculative in choosing the sex of the next
child and the decision is based on the birth order, sex sequence of previous children and
number of sons. Transfer of reproductive technology to India is resulting in
reinforcement of patriarchal values as professional medical organizations seem to be
indifferent to ethical misconduct.
I
Introduction
STRONG preference for sons over daughters exists in the Indian subcontinent,
east Asia, north Africa and west Asia unlike in the western countries
[Muthurayappa et al 1997, Lancet 1990, Okun 1996]. People realise smaller family
sizes with relatively greater number of sons by abuse of medical technologies.
Pregnancies are planned by resorting to 'differential contraception' -
contraception is used based on the number of surviving sons irrespective of
family size [Okun 1996]. Following conception, foetal sex is determined by
prenatal diagnostic techniques after which female foetuses are aborted [Park and
Cho 1995. Arora 1996].
China adopted a 'one child family' norm in 1979 and the phenomenon of millions
of 'missing girls' was recognised by early 1990s [Coake and Banister 1994].
Female foeticide was a major cause of this imbalance. As fertility declined
rapidly in east Asian countries (South Korea, Taiwan, Hong Kong), selective
abortion of female foetuses increased, leading to rising sex ratios at birth (SRB)
(male/female) over the last 10 years [Park and Cho 1995].
In India the population sex ratio which was 1.03 in 1901 census rose relatively
consistently to 1.08 in 1991 [National Commission for Women 1994]. Indian
medical researchers who pioneered amniocentesis in 1975 said that it would
assist those Indian women who keep on reproducing just to have a son; although
this may not be acceptable to 'persons in the west' [Verma et al 1975]. Since then
the contribution of sex determination tests (SDD to the rising sex ratio has been
2
vigorously debated [Lancet 1983, Chhachhi and Satyamala 1983, Kumar 1994].
While urban feminists demanded legislation against SDT, several social scientists
felt that SDT had little impact on sex ratio [Forum against Sex Determination and
Sex Preselection 1993, Rajan et al 1992].
According to the 1991 census, 15 of the 20 districts with the highest child (0 to 6
years) sex ratios were in the states of Haryana and Punjab in northwest India. A
well known demographer suggested that the distortions in child sex ratios in the
northwestern region for the last 100 years could be due to biological peculiarity
of these women to have a highly distorted sex ratio at birth, in favour of boys
[Premi 1994]! However, UNICEF argued that "female foeticide is reported to be a
cause for adverse sex ratios in some Indian districts in the 1991 census" [UNICEF
1994]. Therefore. we selected villages from one such district in this region to
investigate if indeed SDT were being performed and if so, to measure its impact
on sex ratios. We examined the role of doctors, and also considered the
contributions of contraception and of the social practice of female infanticide in
skewing sex ratios.
II
Subjects and Methods
Geographical Location and Background
This study was initiated in June 1996 in six villages of Rohtak district in Haryana.
Haryana was part of the composite Punjab state till 1966. This region witnessed
tremendous economic progress over the last 30 years due to 'green revolution'
[Singh 1997]. Haryana's per capita income is among the highest and fastest
growing in the country [UNDP 1997]. Consequently income poverty reduced by
more than 50 per cent. But the Anthropological Survey of India reports that the
status of women in Haryana continues to be bad.
Haryana Vigyan Manch (HVM) has been active in promoting literacy. It worked
with the district administration (1991-95) and succeeded in enrolling 1.15 lakh
illiterates in the literacy campaign. Ninety per cent of the neo-literates and their
instructors were women. HVM provided medical relief during floods and
epidemics. It organised successful public campaigns in Rohtak to get clinics to
remove advertisements promoting foetal sex determination [Chowdhry 1994].
After literacy efforts, more villagers started coming to the Medical College
Hospital where the second author works.
3
Selection of Study Villages
Following completion of the literacy endeavour in 1995, HVM undertook a
survey in 36 villages where there was good community participation. This was
motivated by the impression of the literacy activists that in some villages about
half of the pregnancies were terminated after SDT because the foetus was female.
As the enumeration was done by the village activists only limited information on
children was elicited. Demographic data such as birth order of children, timing
of pregnancy outcomes; and assessment of the completeness of the survey were
not available from this attempt. This field research is therefore a systematic effort
to follow up on indications of rampant female foeticide.
Given the sensitive nature of induced abortions and that it is a criminal offence to
do SDT we could not undertake a truly random survey of women in the district.
We wanted to obtain reliable information on deliberate termination of female
foetuses and neglect of girls from the women themselves. Our attempt was to
identify villages where there was greatest likelihood that communities would
trust our intentions given our past social commitments. An open dialogue on
SDT is possible only when women could confide about such matters without fear
of being victimised. Therefore, we chose to select villages where we had the most
respected women literacy activists. These women have developed excellent
rapport in their villages. Some of these empowered women later got elected as
members and even chiefs of village panchayats. The study villages were
identified by asking the three district literacy women co-ordinators who
independently ranked the women activists present in the 36 villages. The six
study villages lie in blocks of Rohtak out of the total 12 blocks. On completion of
the study, this district (original Rohtak) was subdivided into Rohtak and Jaghar
districts. Today, our study villages lie in both the new districts.
III
Methodology
Discussions with medical practitioners and others
First we interviewed leading obstetricians, medical practitioners of SDT in
Rohtak and women doctors of departments of obstetrics and gynecology (OG)
and radiology of the Post Graduate Institute of Medical Sciences (locally called
Medical College Hospital and henceforth referred to as MCH). We ascertained
their perceptions and involvement in SDT. The role of ultrasound scans in
antenatal care was ascertained. They were asked if SDT could result in raising
the status of women . We met with about I 50 village level literacy activists in
Jind district along with a senior medical officer to be informed of SDT practices.
Jind is adjacent to Rohtak and has the highest sex ratio in Haryana state.
4
Interviews with individual study women
To reduce recall errors. we confined interviews to women who experienced a
pregnancy outcome in the last five years rather than to all village women. There
were 1.022 eligible women. The criterion of using pregnancy outcome in the last
five years included almost all outcomes in the study villages in the recent past, as
the average interval between successive births in Haryana is 28 months [NFHS
1993]. Our sampling excluded just four women who had a previous pregnancy
outcome and were currently pregnant. They were excluded as they experienced
no outcome in the last five years. The entire history of pregnancies of study
women is necessary for us to understand family building strategies and to obtain
accurate birth orders of recently born children.
Women were interviewed at their homes in the presence of the local woman
activist. Pregnancy history was elicited from each study woman, beginning with
the last outcome. This demographic method is known to produce excellent
results with minimal loss of information. We asked very few questions in order
not to be suspected by the community as accomplices of the health department.
From our decades of contact with rural women, we knew that any suspicion of
being associated with the coercive 'family planning' programme would make
women unwilling to reveal sensitive aspects of their reproductive history. We
deliberately avoided asking individual women whether they went for SDT as we
did not want to make women feel guilty for not bearing the desired number of
sons. Rural men blame women for not producing enough sons. Some husbands
married a second time because the first wife did not bear a son.
Of these interviews 98.9 per cent were conducted by trained local women. Nearly
50 per cent of the interviews in each of the six villages were conducted by the
same interviewer. No study woman refused to co-operate for individual
interviews.
Validation of information
We obtained government sources of information on vital events to validate the
reported information on deaths. We independently contacted the anganwadi
worker (AWW), the female health worker (FHW) and the chowkidar
(functionary reporting to police). As complete records were available only for
recent years we had to limit validation to past five years. AWW and the
chowkidar were resident in the village but FHW resided in Rohtak town. We
went back to the study women in case of any discrepancy between the
information they reported and the official records.
5
Dialogue with the communities
We shared the findings with village women in 22 group meetings. On an average
20 women attended these sessions in each hamlet. We sought their explanation
for any observed gender imbalances. We asked about discrimination against
girls. In areas where there was no distortion of SRB, we enquired if the practice
of female foeticide was prevalent.
Outcomes
In the course of field work. qualitative information and sociological data related
to the practice of female foeticide were obtained. These strengthen some of the
findings presented like caste differentials in foeticide. They also throw light on
the fact that foeticide is not an isolated phenomenon but one of several ways
patriarchy demeans women; others being violence against women [Jejeebhoy
and Cook 1997], anti-women inheritance practices. customary marriage
conventions which result in a significant proportion of women being married
before 18 years, and coercion of widows to undergo levirate marriages facilitated
by state administrative directives. However, for brevity, only data on sex ratio
distortions and information related to abuse of medical technology by doctors
are presented here.
In this paper we do no consider sophisticated reproductive technologies such as
X- Y sperm selection or pre-implentational genetic diagnosis (PGD) which enable
families to choose the sex of the child without having to resort to abortion
[Ramsay 1993. Parikh 1998]. In X-Y separation, male sperms are separated and
are used to fertilise the egg. In PGD the pre-embryos are sexed for the selective
destruction of the female pre-embryo (female embryocide). As the validity of
these methods appears to be uncertain outside the research labs which
developed them. Also these very expensive methods are available at present only
in a handful of clinics in a few cities.
6
Table 1 Characteristics of Study Families
(N=1017)
Characteristics Variable Values
Wife: Mean age 25
Husband: Mean Age 25
Children: Mean no 2.60
Sons: Mean no 1.28
Demographic
Abortion (%) 10.3
Wife Husband
Illiterate 41.0 9.3
Primary and neoliterate 7.0 3.4
5-10 years of school 47.2 68.9
11-12 years of school 5.6 12.3
Educational
College 1.7 6.1
Harijan 23.6
Artisan and minor 10.6
Brahmin 4.3
Social (Per Cent)
Cast
Jat and yadav 51.5
Second Marriage Husband 3.4
Wife 1.2
Table 2: Percent Women Sterlized by Numer of Survivin Children vs Number
of Surviving Sons
No. of Surviving Sons Families
(N)
0 1 2 3 4
0 0 27
1 0 3 258
2 2 14 51 336
3 0 36 76 78 246
4 0 20 71 44 0 102
5 0 30 42 100 0 25
No. of
Surviving
Children
6+ 0 20 33 100 50 19
7
IV
Results
Virtually all (99.5 percent) study women were interviewed and 94 per cent of the
respondents were mothers themselves. The social, demographic and educational
characteristics of families of these women are described in Table I. The duration
of cohabitation after marriage ranged from one year to 30years (mean = 8.7).
Thirteen women had children who were already married. Jats and yadavs are the
cultivating castes who own most of the land. Harijans are the poorest section in
this agrarian society; and are primarily labourers of the landowning castes. There
is gross disparity between the educational status of men and women.
The pregnancy outcomes reported by the women were 2,642 live borns, 48 still
births and 272 abortions (243 spontaneous and 29 induced). Of liveborns 66.5 per
cent were of orders 1 and 2; only 1.4 per cent of children were of orders greater
than 6. There were thrice as many families having more than two surviving girls
as those having more than two sons (110 vs 37 respectively). The study women
had a maximum of five liveborn sons whilst the maximum number of liveborn
daughters was nine. Just 14 per cent of families account for 34 per cent of girls
while having only 21 per cent of boys. Over 48 per cent of mothers who reported
deaths in the cohort born in the past five years were not captured by the
government workers. The official records revealed that only two mothers had
not reported the deaths (one female each) of their children to us. Subsequently
both mothers confirmed that the deaths did occur.
The onus of contraception was almost entirely on women. Tubal ligation
(sterilisation) was virtually the only form of contraception used (270 women vs
one man). The percentage of sterilised women increased as they had more
surviving sons (Table 2). Such a strong rising trend was not evident with
increasing number of girls. Just one mother got sterilised with no surviving boys
while 69 mothers who had no surviving daughters got sterilised. Furthermore,
the family size and sex composition of the surviving children of women who
were pregnant (N= 129) at the time of interview indicated that the rates of
pregnancy were higher among women who had relatively less number of
surviving sons than daughters. Within each family size, the current rate of
pregnancy were five to six times higher for mothers who had no sons as
compared to mothers who had several sons.
A manifestation of intense son preference in a population is that for a given
family size the sex ratio of the last born child will be greater than 1.06 (i e,
skewed towards male). This is demonstrated by using the 'gender preference
indicators', family size sex ratio (FSSR) and the sex ratio of the last born child
(LCSR). Family size refers to the total number of children liveborn. Table 3
8
indicates the sex ratio for each family size. The FSSR monotonously declines as
the family size increases from one to ten. While the LCSR is generally more
elevated than that of the FSSR. Both FSSR and LCSR are much higher for
completed (sterilised) families (Table 4) with the exception of birth orders greater
than five where due to small sample sizes the ratios are not stable.
A different strategy which some parents adopt to limit family size of surviving
children and to eventually have the desired number of sons is female infanticide
[George et al 1992]. Direct infanticide refers to killing of infant usually
immediately after birth. Indirect infanticide is death caused a little after birth,
due to deliberate neglect. This could be by inadequate child care, or by poor food
related practices or health related neglect.
Of the 2,642 Iiveborns, 2,327 children were still surviving at the time of the
interviews (Tables 5 and 6). We confine detailed examination of mortality to the
cohort born in last five years as the recall errors are minimal for recent events
and also because records for validation from official sources were only available
for this period. Further, this cohort represents virtually the total population of
preschool children in the villages. For this cohort, both sex ratio at birth (SRB)
and sex ratio of surviving children at the time of survey are 1.20. Mortality data
suggests that there is no excess girl mortality in the early neonatal or late
neonatal phase (Table 6). But there appears to be excess girl mortality in the postneonatal
phase and girls are at risk of significantly greater mortality after the first
year of life. Ethnographic information indicates the existence of direct female
infanticide in the study villages and 41 percent of the female early neonatal
deaths are due to direct female infanticide. Excess female mortality in the
postneonatal and later childhood suggest the occurrence of indirect female
infanticide.
Disaggregation by caste indicates that there is no excess post-neonatal girl
mortality in harijans but exists among the upper castes. Another indicator of
deliberate discrimination against girls is the survival of liveborns in twin pairs.
The women reported that 16 twin pairs were born alive (23f+9m). The mortality
of the females was higher than that of males (57 per cent vs 44 per cent). One
manifestation of discrimination against girls is- the observation that the
interbirth interval between successive liveborn children is shorter if the
preceding child is female. This observation has been reported from Haryana state
also [NFHS 1993]. We found greater discrimination in upper castes as compared
to harijans (difference is 48 days vs 29 days).
Demographers consider the SRB of children born in last five years as the most
sensitive index of current gender imbalance at birth in the society. Table 7
suggests that SRB for all birth order for recently born children are masculine
9
including the first birth order. The SRB for harijans (lowest caste) was 1.02; whilst
among upper castes it was 1.27. The SRB of upper caste children rose from 1.26 to
1.89 as birth order went up from 1 to 5 (above 5 numbers are too small and
therefore the ratio not dependable). A similar rising trend was not seen in
harijans. The SRB kept increasing over the last five years among upper castes. It
increased from 1.15 to 1.42 from the first 2.5 years to the last 2.5 years. In fact, in
the last year, the SRB was as high as 1.80. Apart from birth order the sex
composition of the preceding born children seems to be an important
determinant of the sex of the next child (Table 8) in the upper castes. Within each
birth order, sex ratio of the next child increases as the number of preceding girls
increases. (We stopped at order 5 as there are very few children to fill the
increasing m/f combinations). For each birth order, generally the ratio is often
closer to the natural sex ratio (1.06) when the preceding number of male children
is the highest. For families with no boys the SRB of the next child increased from
1.47 to 2.50 as the preceding number of girls went up from one to four.
Table 3: FSSR and LCSR for all Families
Family Size Liveborn
M F FSSR LCSR
1 134 95 1.41 1.40
2 359 259 1.39 1.33
3 352 347 1.01 1.49
4 233 303 0.77 1.48
5 120 165 0.73 2.39
6 45 63 0.71 1.43
7 36 55 0.66 1.50
8 17 31 0.55 0.50
9 3 15 0.20 0.0
10 1 9 0.11 0.0
Total 1300 1342 0.97 1.44
10
Table 4: FSSR and LCSR from Sterlized Families
Family Size Liveborn
M F FSSR LCSR
1 3 0 * *
2 115 21 5.48 5.60
3 193 116 1.22 2.25
4 116 116 1.00 2.93
5 50 60 0.83 5.00
6 21 27 0.78 1.00
7 14 14 1.00 1.00
8+ 3 16 0.19 0.0
Total 515 376 1.37 2.91
Note: * Ratio could not be calculated as denominator is 0
We presented the results of individual women interviews at discussions held in
the hamlets. There was universal awareness of SDT and most knew where to go
for the tests and abortions. In upper caste hamlets there was open admission of
the widespread practice of female foeticide. In a few places the women blamed
doctors who are doing this for money. Some women complained that their
families' first concern following pregnancy is to put pressure on them to
determine the sex. If it is a boy then only the need for ‘ante-natal care is raised. In
harijan areas where the distortions in sex ratios were less- table 7), there were
denials about the practice.
From our dialogue with Rohtak doctors the following emerged: ultrasonography
is abused for sexing foetuses. More doctors are buying ultrasound machines and
some are taking it in cars to villages. The only difference after the national law
banning the test was passed in 1994 was that cost of the test doubled (now about
900 rupees). Almost everybody including women MCR doctors felt that selective
abortion of female foetuses would increase the status of women. They were
unanimous in the positive role of ultrasound in normal pregnancies. The only
dispute between the radiologists and the obstetricians of MCH was on the issue
who was most competent to do the scanning! Ultrasound is used in the MCH for
routine confirmation of pregnancy as problems were experienced in getting kits
for the urine test. Neither does the MCH reveal the sex of the foetus nor conduct
sex selective abortions. Following popularity of sex selective abortions, the OG
department decided a few years ago not to train their postgraduates to do mid
trimester abortion as it was felt that students would later be practising female
foeticide. However, they were forced to rescind the policy after two years when
they started getting referrals of botched abortions from their alumni. This
decision was reversed in the interests of the lives of mothers.
11
Jind activists told us about the widespread practice of female foeticide. Despite
Jind being one of the most backward districts in Haryana, ultrasonography, a
modern technology, is extensively abused.
V
Discussion
Families continued to have children till they had adequate number of surviving
sons. Consequently small families had more sons while large families had more
daughters. That family size is inversely related to the FSSR suggests differential
stopping by contraception (Table 3). It appears that most women want to have at
least two sons. When two surviving sons are ensured nearly 50 per cent of
women use sterilisation (Table 2). There is some evidence that with two sons and
one daughter nearly 75 per cent of women use sterilisation. Our findings about
completed families (sterilised women) are consistent with that reported for India
[Arnold 1996]. Sex ratio of surviving children of sterilised couples are
significantly higher than that for couples not using any contraception (1.25 vs
O.97). The marginal excess of girls in our total study children (1342 f vs 1300 m)
is itself a reflection of intense son preference. Our sample consists of all women
in the villages who had a pregnancy outcome in the last five years and the study
children comprise all their children; and this included some mothers who were
desperate for sons; for instance, seven were willing to have six to nine girls just to
have one or two sons.
It is imperative to examine the role of female infanticide as it was prevalent
earlier in this region [Chowdhry 1994]. There have also reports of its persistence
in the contemporary times [Kakar 1980]. Though direct infanticide has been
known for centuries, systematic investigation of the phenomenon is recent
[George el al 1992, George 1997]. We have an estimate only from Tamil Nadu
state, where direct female infanticide accounted for 8 to 10 percent of all infant
deaths in 1995 [Athreya and Chunkath 1997]. Direct infanticide affects just 0.99
per cent of our liveborn females and therefore can account for only a fraction of
the observed genderimbalance in surviving preschool children. The existence of
indirect female infanticide in our area is consistent with the finding of excess girl
mortality in Haryana state [NFHS 1993]. The deaths were disproportionately
high among higher birth order children. This pattern has been reported from
many parts of the subcontinent [Das Gupta 1996]. There is no known biomedical
reason to explain the observed higher risk of mortality for females born in a twin
pair. Village women rationalised the excess mortality of females by saying that
mothers can take care of only one child. Such unspoken social sanction for severe
neglect of females within a twin pair has been witnessed in south India by the
first author and also reported by others [Miller 1985]. The interbirth interval after
a girl is shorter because girls are breast-fed for a lesser period than boys (19 per
12
cent less; from state data [NFHS 1993]). After consideration of mortality
experiences we conclude that past mortality of girls cannot explain the
masculinity in sex ratios of surviving children (the higher post-neonatal girl
mortality is offset by higher early neonatal boy mortality).
Table 5: Sex Specific Survival of Liveborns by Birth Cohorts
Survivors Birth Dead Total Liveborn
Cohorts M F M F M F
< 5 years 787 654 66 54 853 708
>= 5
years
358 528 89 106 447 634
Total 1145 1182 155 160 1300 1342
Table 6: Sex Specific Death Rates by Age at Death
Sex\Age at Death Rates
Death dates 0 to < 7 7 to < 28 28 to < 365 365
M 3.99 0.70 2.58 0.47
F 2.40 0.71 2.97 1.55
Total Dead
(N)
51 11 43 15
Table 7: SRB by Birth Order and By Caste
Caste/ Birth Sex Ratios at Birth
Order 1 2 3 4 5 6+
Total Total
(N)
Upper Castes 1.26 1.19 1.34 1.25 1.89 1.25 1.27 1169
Harijan 1.15 1.04 0.77 1.15 1.09 1.06 1.02 392
All Castes 1.24 1.16 1.16 1.22 1.59 1.14 1.20 1561
13
Table 8: Upper Castes SRB by Birth Order vs Preceding Number of Children
by Sex
Proceeding Number of
Children by Sex
Birth Order
Males Females N SRB
1 0 0 364 1.26
2 1 0 189 1.01
0 1 175 1.47
2 0 29 0.93
1 1 139 1.32
3
0 2 72 1.57
3 0 2 1.00
2 1 20 0.25
1 2 69 2.25
4
0 3 26 1.60
4 0 1 *
3 1 5 1.50
2 2 17 1.13
1 3 22 2.67
5
0 4 7 2.50
Note: * There was no girl in this group and therefore the ratio cannot be calculated.
However, mortality data provides corroborative evidence for deliberate
discrimination against girls. Demographically, SRB will not be affected by
differential contraception but the sex ratio of the last born child will be higher
than normal [Coale and Banister 1994]. LCSR is masculine because women who
have not had enough sons continue to bear children until they have the right
number of boys when they undergo sterilisation. The observed sex imbalance in
children born over past five years in 'upper castes' can only be due to selective
abortions of female foetuses as we have ruled out other causes. Further, in group
discussions upper caste women confirmed that abortions of female foetuses were
taking place. The rising trend of SRB over the past five years suggests an
increasing incidence of female foeticide in the villages. That increasing numbers
of boys are being born over recent years is evident from sex differentials in
chronological age of liveborn children. Among upper castes, boys are
significantly younger than girls by 66 days (N= 1169, p=0.03) while the difference
in harijans is only 39 days, which is not statistically significant (N=392).
A sex ratio of 1.27 suggests that 16.8 per cent of female foetuses have been
aborted among upper castes in the last five years (taking 'normal' SRB as 1.06).
This is an underestimate of the current rate of sex selective abortions. Firstly, we
have downplayed the dramatic rise in SRB by averaging over five years (last
14
year: 1.80 vs 5 years= 1.27). Secondly, sex determination is done by poorly
trained ultrasound imagers. Just as in other nonwestern countries a majority of
Indian imagers have inadequate training [Mindel 1997]. In fact there is no formal
certification of ultrasound imagers in India. One way women respond to this
uncertainty is that they go for scanning only at the end of the second trimester
(instead of 16 to 18 weeks). Despite this, we are not certain that the sensitivity of
sex determination is over 90 per cent for boys. Thus in the desperation for sons,
some male foetuses would have likely been aborted inadvertently. Our doubts
are based on errors highlighted in the media [Lancet 1983, Kakadkar 1997],
literature [Booth et al 1997] and from dialogue with imaging experts. Therefore,
the real rates of induced abortions for sex selection are likely to be higher than
our estimate.
That female foeticide is occurring in many cities of India is well known [Miller
1985, Booth et al 1997, Kishwar 1995]. The following observations from urban/
clinic studies are consistent with our findings: (1) SRB increases with birth order;
(2) families with only daughters are more likely to practice female foeticide. The
latter is evident from our finding that the highest distortion of SRB is among
families with no sons (Table 8). A significant outcome from our study is that
certain rural families are unable to tolerate even the first child to be a female and
therefore will abort it. Our finding contradicts Das Gupta and Visaria' s claim
that women are unlikely to use SDT for the first pregnancy [Das Gupta and
Visaria 1996]. Their reasoning is based on the fact that deliberate girl child
neglect often spares the first girl. This extrapolation of human behaviour from
female infanticide to female foeticide is fallacious. As a Lancet editorial argued,
new technology will create new problems for the society [Lancet 1974]. The
evidence from Delhi [Khanna 1997] as well as South Korea are also supportive of
our observation [Park and Cho 1995, Leete 1996]. Our data indicates that the
proportion of families aborting female foetuses in the first pregnancy has been
increasing over the past five years.
The increased popularity of female foeticide reported by doctors in Rohtak
district is consistent with the finding that over a period of two decades the SRB
of children born in MCH. Rohtak has become pronouncedly masculine (SRB for
the years 1993-95 is 1.25, N=12,166 births). Distorted SRB have been reported
from other hospitals in this region [Booth et a.l 1994, Das Gupta and Visaria
1996]. A part of the increase may reflect discrimination against girls following
foetal sex determination in place of birth. Male babies may be given the privilege
of safer hospital deliveries while for females delivery at home in the village is
considered adequate. The SRB of institutional deliveries in India, predominantly
an urban sample, increased from 1.06 to 1.12 over the period 1949-58 to 1981-91
[National Commission for Women 1994]. Note that the latter estimate is based on
6 million live births.
15
The existence of relatively greater gender equality in harijan castes has been
reported from south India [George et aI1994]. This is because the only economic
asset harijans have is their labour so women are seen as productive members of
the family. Therefore harijans had no excess postneonatal girl mortality, or
longer interbirth interval after a girl, or more favourable SRB as compared to
upper castes. This does not imply that harijans do not express sex preference.
They do practice differential contraception like the upper castes. But their
intensity of preference for boys is lower. The overall LCSR is 1.05 for harijansas
against 1.59 for upper castes. Further for almost every birth order the LCSR is
less distorted for harijans. Note that sex selective abortion can also raise the
LCSR like differential contraception. As couples who have girls continue to abort
female foetuses until they have the right number of boys at which point they
cease childbearing. Our ethnographic information that female foeticide is much
less among harijans is consistent with the demographic data presented.
This comprehensive enquiry provides incontrovertible evidence of the practice of
female foeticide in a rural population. Both in medical anthropology and
anthropological demography meticulous micro level studies with people's
participation have become a standard research methodology. We have not
captured female foeticide at an individual level, which is most unlikely given the
criminality of the act, the collusion of medical professionals and cultural
sensitivity. However women collectively accepted the widespread extent of the
practice in their villages. Our field research which has an ethnographic
component complements district level census data. In matters like son preference
which' is intensifying, information from large surveys becomes outdated soon.
Consequently village studies need to be routinely carried out to understand the
trends and determinants of gender inequity in every district.
Our research has a major limitation. We have not explored the significant health
hazards of repeated late mid trimester abortions for women. The villagers
reported that abortions are usually done in unregistered village clinics
[Chowdhry 1994]. Further, maternal depletion following abortions in an
environment of extensive iron deficiency could have additional adverse
consequences for women's health.
The Rohtak district overall sex ratio is 1.18 while for Haryana it is 1.16 as per the
1991 census. The sex ratio of surviving children for both Haryana and Rohtak is
1.14. Our villages are better off than the average Rohtak village as far as women's
status is concerned based on the intimate knowledge of the second author of the
district. Also our selection criterion identifies the more liberal villages. The
emergence of women leaders in our villages is significant in that it has occurred
in one of the most conservative regions of India where women have led very
16
secluded lives . We therefore believe that the sex ratio of surviving children in
the district is likely to be at least as masculine as in the study villages. The sex
ratio of surviving pre school children in a December 1997 survey of randomly
selected households of rural Haryana (total population= 10,000) was found to be
1.18 [Kumar 1998]. Furthermore, sex ratios from Sample Registration Surveys
and indirect estimates from 1981 & 1991 censuses; all are supportive of such
elevated child sex ratios and sex ratios at birth for Haryana [Sudha and Rajan
1998, Mari Bhat 1998]. Thus these data along with our knowledge of the
extensive spread of SDT clinics all over Haryana in the mid to late 1980s suggests
that the findings from our study villages have relevance for the state.
We are not implying that the rates of female foeticide elsewhere in rural India are
as high as in Haryana. There has been a tradition of fierce patriarchy in this
region as in some other parts of north India [Dreze and Sen 1996]. Women have
long suffered patriarchal practices as female infanticide, child marriage,
seclusion, dowry, levirate and polygamy. Not surprisingly, Haryana state has the
highest overall sex ratio, the highest sex ratio at birth, the highest excess female
child mortality and the lowest divorce rate for women in the country [NFHS
1993. GOI 1997]. SDT clinics have been functioning in Haryana towns for about
15 years. Mobile SDT clinics have been visiting many Haryana villages for over
seven years [Chowdhry 1994]. The dramatic drop in fertility in Haryana over the
period 1971-91 has been associated with increased use of SDT. The total fertility
rate in rural Haryana in 1971 was 7.15 children per woman; which was the
highest in India then, dropped to 4.17 by 1991 [Krishnaji and James 1998]. In
patriarchal cultures, son preference intensifies in the transition period when
fertiliity is declining [Das Gupta and Visaria 1996].
We selected villages in this region as we wanted to highlight the imbalance that
could take place in case the same intensity of sex selective abortion were to take
place elsewhere in India. There is no reliable data for the incidence of female
foeticide but the Central Committee on Sex Determination described it as an
epidemic across the length and breadth of the country [National Commission for
Women 1994]. A rough estimate of female foeticide and direct infanticide
together obtained by indirect demographic techniques on census data is 1.2
million 'missing girls' in India during 1981-91 [DasGupta and Mari Bhal 1997]. If
we attribute all the 'missing girls' to foeticide this would amount to less than 1
per cent of female births. But the first author acknowledged that most of the
selective abortions occurred during the second half of the decade and predicted
that "we should expect to see more of it ill 1991-2001" [Weiss 1996]. Therefore the
1 per cent figure should be cautiously interpreted as there had been an explosion
of SDT clinics in a few places from the late 1980s and In most parts of the country
by early to mid 1990s. The access for rural populations enhanced substantially
after sophisticated ultrasound machines became widely available in India from
17
early 1990s. Historically, the east Asian experience suggests that it takes less than
a decade of spread of clinics for a dramatic rise in SRB to occur. Yet another
comparative study of the 1981 and 1991 Indian censuses with a different
methodology revealed that there has been a marked shift towards excess
masculinity of SRB in 1991 in northwest and in north India with the exception of
rural areas of Bihar and UP [Sudha and Rajan 1998]. These authors attribute this
shift to female foeticide. Further, our greatest concern is that female foeticide is
becoming popular even in south India where status of women has been
historically much better. As late as 1987 there were virtually no SDT clinics in the
south as opposed to north and west India. But over the last two to five years in
southern states of Tamil Nadu and Andhra Pradesh, clinics have started
mushrooming in small towns and even in semi-urban areas. We are aware from
13 years of field work in Tamil Nadu that rural women are increasingly resorting
to SDT in recent years. Though the present level of incidence may not result in a
serious distortion of SRB at the state level, the trends observed in northwest India
and elsewhere indicate that it is just a matter of time before the distortions
become evident in population data, unless these states immediately take
determined action to prevent emergence of more SDT clinics and the abuse of
these tests.
Advances in medical technology for sexing foetuses have made SDT more
convenient and less risky for Indian women over the last two decades. Initially
chorionic villus biopsy and amniocentesis were the techniques used.
Ultrasonography has become the most widely used method of sex determination
from the early 1990s. Besides being non- invasive, it also require no laboratory
set up. Following adoption of economic liberalisation policies by India in 1991,
several multinational companies have entered the domestic ultrasound market.
Some have even begun to manufacture the equipment in India. Increased
competition has led to the appearance of lower priced portable models, flexible
credit and dependable service for the customer. Doctors motivated in part by
multinational marketing muscle and considerable financial gains are increasingly
investing in ultrasound scanners. In South Korea and China, domestic
production of ultrasound machines facilitated increased utilisation of SDT [Cho
and Hong 1995].
The general lack of gender sensitivity of Indian doctors and other professionals
contributed to the popularisation of SDT. Just as in China, the first use of SDT in
India was in a Government. institution. These researchers advocated the use of
amniocentesis for sexing foetuses and claimed that in the foreseeable future sex
selective abortions will not result in increasing the number of males [Verma et al
1975]. There are doctors who wanted the government to promote STD to reduce
population growth [Lancet 1983]. Many gynaecologists see female foeticide as a
medical solution to son preference and find nothing unethical in it [Lancet 1983].
18
Some economists argued that SDT would result in better status of women based
on 'supply and demand' logic. Ignoring that cultural practices as son preference
are not predictable by economic principles [Arora 1996]. For over two decades,
medical abortions (MTP) were promoted by the Indian government to reduce
fertility. Also traditional methods of abortion, though unsafe are still used to
space and limit family size in rural India. Like traditional Chinese and Japanese
societies, rural Indians have beliefs and methods which supposedly determine
the sex of the foetus [Kakar 1980, Khanna 1997]. There is no evidence to suggest
that these are sensitive enough to distort sex ratios. But they are accepted on
'faith' and too often abortion follows when the prediction is female. Given all
this, the widespread acceptance of modern methods of sex determination and
selective abortion of female foetuses in parts of India should not have been a
surprise.
Some professionals hope that the national law (1994) against SDT will prevent
female foeticide. The experience of Maharashtra state law (1988)does not give
much ground for optimism. Before the legislation in Bombay city alone the
number of STD clinics went up from 10 to 248 (during 1982-87). After the
legislation the practice just went underground. Over the last 10 years not even
one doctor has been penalised for breaking the law [Kakodkar 1997]. Some
women activists argue that lobbying for gender just laws is not worthwhile as
the state would not implement them [Kishwar 1995. Menon 1993]. This cynicism
is not warranted as the state itself has an obligation to set desirable ethical
standards. The profound inaction of Indian Medical Association, Medical
Council of India (MCI) on SDT by doctors for 20 years despite representations is
proof of gross professional indifference to gender equity [Lancet 1983, Kokodkar
1997, Mazumdar 1992]. However, recently the National Human Rights
Commission (NHRC) asked MCI to take cognisance of the law. Following which
the MCI decided to amend the code of medical ethics in order to initiate
disciplinary proceedings against errant doctors [National Human Rights
Commission 1996].
Health workers did not have proper records of births and deaths as they seldom
visited villages in Haryana though their salaries are six times higher than that of
AWW. A similar finding on vital events was reported from another district. The
FHW had no records of births in some villages and in most villages the FHW
were not even familiar with the women in their villages though they have been
working there for over three years.
The coverage of antenatal services is poor. Though Haryana is economically
prosperous and rural people have access to health facilities about 70 per cent of
deliveries are conducted at home by untrained workers [Das Gupta 1990,
Jejeebhoy 1997]. Infant and child mortality is unacceptably high as compared to
19
the poor southern states. A reduction in this mortality will likely reduce the
gender disparity in post-neonatal mortality rates. Unfortunately, the entire focus
of the health system is on fertility reduction. Till last year this was based on an
elaborate system of targets for government workers, money for acceptors and
incentives for health staff and even coercion of women [Bose 1996, Kumar 1997].
This led to widespread falsification of data and corruption [Bose 1996] and
alienated the health system from people. The contraceptive burden is almost
entirely on women. The government claims that there is a change in approach
from the old method-specific contraceptive targets to client centred performance
goals [Kumar 1997]. However, Rohtak FHW report that unofficial targets still
remain though monetary incentives have been withdrawn.
Dreze and Sen (1996) have pointed out that the persistence of gender inequality
and female deprivation are among India's most serious social failures and few
other regions in the world have achieved so little in promoting gender justice. To
raise the status of women it is imperative for the state to be aggressive about
reducing existing gender disparities in education, economic opportunities,
inheritance laws, property rights and political power. One step in the right
direction is the Indian prime minister's 'girl child scheme' announced in August
1997, whereby two infant girls of every poor family will receive monetary
incentives till they become adults [TOI 1997]. This will promote fertility
reduction with gender equity. Further, public action has to challenge the many
ways patriarchy demeans women. Men have to accept responsibility for
contraception. Doctor and professional medical organisations by far have been
indifferent to such gender concerns. Ethical medical practice is imperative for
enforcement of the 1994 law against prenatal sexing of foetuses [Kakodkar 1997,
Dickens 1986]. Medical education has to inculcate gender sensitivity in students.
The focus of the health department has to change from forcing contraception on
women to enhancing women's health and reducing the gender disparities at
birth and in child survival. Otherwise the incidence of female foeticide will
increase. Women's health will be the first' casualty. The acceleration of the
increasing SRB will lead to disastrous social consequences for the well being of
our women and our society.
[The effort of Yeshwanti and other women interviewers arc much appreciated.
We most gratefully acknowledge the assistance of the village women literacy
activists, some of whom spent several months with us in the field. We thank the
Rohtak district leaders of Health Workers' Union and the Chowkidars' Union for
taking the trouble to visit the study villages. The co-operation received from the
village anganwadi workers. chowkidars and female health workers are
acknowledged. The generosity of over 20 people in Haryana Vigyan Manch who
patiently assisted our work for 18 months is appreciated. We also thank A S
Sharif. S Clark, T J John, M Bhat. V Patel. P and L Visarias, L Caleb, S Almroth. C
20
R Soman and R Palmer (DEC) for their contributions. This field study was
supported in part by the State Resource Centre, Haryana; Pondicherry Science
Forum and Bharat Gyan Vlgyan Samlti, New Delhi].