International Rhetoric, Domestic Evidence
Civil society reports on sexual and reproductive health provide a contrast to the claims and assurances made by the government’s report to an international human rights mechanism on its public health commitments and achievements, with information that is at gross variance to the official report. This discordance questions the credibility and accountability of the government to these international human rights processes and more so, its citizens.
The Universal Periodic Review (UPR) is an important human rights accountability mechanism established in 2006 within the United Nations’ Human Rights Council (UNHRC) through which each UN member state is subject to a peer review of its human rights situation every five years. During each review, other member states provide recommendations to the state under review. While these are not binding, if the state under review accepts a recommendation, it makes a commitment to implement it. For each review cycle, the state under review has to submit a report on the efforts made to implement the previous cycle’s recommendations. Along with this, reports are submitted by human rights institutions (in India’s case, by the National Human Rights Commission) as well as civil society organisations and coalitions.
India in UPR 3: Reports Contradicting Evidence
India’s first review under this process was held in 2008 (UPR 1), followed by a second review cycle in 2012 (UPR 2) and a third review cycle which was held recently on 4 May 2017 (UPR 3). All UPR 3 submissions were reviewed in April–May 2017, and subsequently, other member states shared their comments. The Government of India (GOI) has to respond to the concerns and comments by 21 June 2017 indicating its commitments for the next cycle. This commentary is based on a submission to the UPR 3 process by a coalition of organisations and networks to present a civil society perspective on the gains and gaps in India’s fulfilment of the sexual and reproductive health and rights (SRHR) of women and girls.
During the 2012 review (UPR 2), India received 169 recommendations of which it accepted 56. The recommendations accepted by GOI in relation to SRHR included: strengthening health systems; increasing resource allocations to the health sector; improving access to maternal health services; safe abortion services; gender-sensitive contraceptive information and services; counselling on SRHR, and reviewing laws that do not uphold gender equality. However, we find the GOI report to the UPR 3 makes several claims which are not consistent with ground realities, and we draw on our own submission to the UPR to question some of GOI’s submissions.
While reporting back in UPR 3, the GOI submission with respect to health in general and maternal health in particular, mentions that steps have been taken towards improving access to maternal health, obstetric delivery services, and sexual and reproductive health services (GOI 2017: para 105), and that the National Rural Health Mission (NRHM) has been effectively implemented. To reduce maternal and infant mortality, the GOI submission mentions an increase in allocation under the Janani Suraksha Yojana (JSY) from ₹16.06 billion in 2011–12 to ₹17.62 billion in 2013–14.
Ailing Public Health System
During UPR 2, the GOI had accepted recommendations to increase spending on health to 3% of the gross domestic product (GDP). However, as per the Economic Survey of India 2015–16, India’s public spending on the health sector overall is only 1.3% of the GDP (Ministry of Finance 2016). The vision of NRHM to strengthen and scale up the public health system remains unfulfilled, as its schemes were consistently underfunded (MoHFW 2017).1 The recent changes in the budgetary allocations for states have further impacted health service provisioning.2
The public health system in rural areas continues to be severely understaffed. The government has identified a shortfall of 81.2% of specialists at community health centres (CHCs) across rural India (Rajya Sabha Secretariat 2016). The states of Bihar, Uttar Pradesh, Jharkhand and Chhattisgarh have less than 1 skilled health personnel per 1,000 population whereas the World Health Organization (WHO) prescribes a basic threshold of 2.3 personnel per 1,000 population (Hazarika 2013). Public health infrastructure is ailing as well, with significant shortfalls in the setting up of CHCs at 32%, primary health centres (PHCs) at 22%, and health sub-centres (HSCs) at 20% (MoHFW 2015).
Poor infrastructure, absent supplies, and inadequate human resources in the public sector, compel even the poor to turn to private facilities for life-saving care. Currently, India’s health system is one of the most privatised in the world and public expenditure is one of the lowest, with only 32% of the total expenditure on healthcare being public expenditure (WHO 2014). The unregulated private sector3 offers services of questionable quality at exorbitant prices. However, both national and state governments continue to partner with the sector through public–private partnerships, ostensibly in an effort to improve availability and accessibility of health services, although there is a lack of robust evidence to support this claim (Ravindran 2011). The recent development that showcases the government’s intent is the National Health Policy (NHP), 2017 which opens the door for privatisation through its plan for “strategic purchasing” of secondary and tertiary healthcare services, leaving the public sector to provide only primary healthcare services. By implicitly putting in market-based privatised mechanisms that will make the realisation of this right impossible for its most marginalised citizens, the government has betrayed its own commitment to the right to health of its citizens.
Although the GOI reported that a cashless health insurance scheme Rashtriya Swasthya Bima Yojana (RSBY) has been implemented in order to “ameliorate vulnerabilities due to ill health” especially for those living below the poverty line and those working in the unorganised sector (GOI 2017: para 73), evidence from the field has highlighted inadequate coverage, non-availability of private providers in districts with a weak public health system, and malpractices by private players (Nandi et al 2012).
The Maternal Mortality Paradox
The GOI submits that “schemes like the JSY provide institutional delivery services to pregnant women who fall below the poverty line, so as to reduce maternal and infant mortality” (GOI 2017: para 108). The government also declares it has streamlined monetary assistance under the JSY through direct bank transfers (GOI 2017: para 108). It is undeniable that since the introduction of the JSY, there has been a steep rise in institutional deliveries from 39% in 2005–06 to 79% in 2015–16 (IIPS 2017). However, studies thus far have been unable to detect a linkage between the rise in facility births and maternal mortality reduction (Randive et al 2013).
Facility births can be expected to improve maternal health outcomes, only if in-facility care is of an acceptable standard and ensures skilled attendance at birth (Chaturvedi et al 2015). Studies by civil society networks of over 250 maternal deaths among marginalised populations in several states indicate that the basic components of maternal care such as antenatal examinations, prenatal counselling, skilled birth attendance, emergency obstetric care, and postnatal care, are unavailable for women in many parts of the country (Subha Sri and Khanna 2014; Dasgupta et al 2016). Absence of basic infrastructure in health facilities, non-availability of safe abortion services, lack of treatment for post-abortion complications, poor quality and expensive care in private facilities, and persistent underreporting of maternal deaths are major concerns. Clearly, monetary incentives under JSY are not tantamount to skilled attendance at birth or improved maternal health outcomes. In fact, the monetary incentive did not improve maternal survival for the poorest women. Comparisons of data for 2007–10 show that reduction in maternal deaths among women in the highest income groups was four times higher as compared to the poorest ones (Randive et al 2014).
The Janani Shishu Suraksha Karyakram (JSSK)4 initiated in 2011 promised cashless healthcare for maternal and child health. However, out-of-pocket health expenditure continues to remain high (Dasgupta et al 2015); an average of ₹5,544 was spent per childbirth in hospital in rural areas and ₹11,685 in urban areas (NSSO 2015). Access and utilisation of services and schemes is poor particularly among the Scheduled Castes, Scheduled Tribes, Muslim women, young women and adolescent girls (IIPS and Macro International 2009). Since the health of women who belong to marginalised communities or live in underserved areas is already compromised owing to compounded vulnerabilities, any complication during pregnancy or childbirth can cause death unless there are skilled and effective health services that respond promptly (Dasgupta et al 2016). It is also established that poor and vulnerable women are systematically deprived of antenatal and post-partum care (Subha Sri and Khanna 2014).
In India, over 90% of women workers are in the informal economy without the protection of labour welfare legislations. The Maternity Benefits Act (Amendment), 2017 recently passed in Parliament does not take into account the informal sector women workers who are denied wage compensation during maternity. A promise made in the National Food Security Act, 2013 to formulate central schemes for universal maternity benefits has not been fulfilled; the only existing scheme, the Indira Gandhi Matritva Sahyog Yojana (IGMSY)5 excludes the most vulnerable women by disqualifying anyone with more than two children. This effectively debars the poorest and those from marginalised groups including Dalits and tribals (Lingam and Yelamanchili 2011).
Sterilisations and Unsafe Abortions
India had committed to ensuring that all women would have access to sexual and reproductive health services including safe abortion services (UPR 2: Recommendation 138.153). India’s UPR 3 report, however, does not specifically report on the progress towards this recommendation. Unsafe abortions are believed to contribute to 9–13% of maternal mortalities (Srivastava et al 2013). In spite of the Medical Termination of Pregnancy (MTP) Act of 1971, the Indian Penal Code still considers abortion to be a criminal offence. More than 80% of women in the country still do not know that abortion is legal and available (Banerjee and Anderson 2012). Several medical students are either unaware about the MTP Act or have anti-abortion views (Palo et al 2015; Sjostrom et al 2014).
Misinterpretation and overzealous implementation of the Preconception Prenatal Diagnostic Techniques Act (PCPNDT), 1994 has resulted in further restriction of access to safe abortion services. The continued use of problematic terms such as “female foeticide” in government literature and reports adds further to the anti-abortion rhetoric (GOI 2017: para 111).
Ensuring access to gender-sensitive, comprehensive contraceptive services was one of the key recommendations of UPR 2 (Recommendation 138.153). However, the GOI does not specifically report on this. On paper, the GOI promises women an informed choice in the matter of reproduction, but plans and budgets actually promote female sterilisation as the predominant method (PFI et al 2014: 26). Expected Levels of Achievement (ELA) are set, which translate on the ground as targets imposed upon health managers and providers for female sterilisation, as against the purported target–free approach.
Female sterilisation is performed under extremely hazardous conditions leading to deaths, complications and illnesses as well as failure and unwanted pregnancy. When seen together with the government’s target of covering 48 million couples with family planning by 2020, a promise made to Family Planning 2020 (FP2020),6 the reduction in public health expenditure raises serious concerns about maintaining standards of quality of sexual and reproductive health services. In November 2014, following a “mass sterilisation camp” performed under shockingly negligent conditions, 13 young women in Bilaspur, Chhattisgarh lost their lives (JSA, SAMA and NAMHHR 2014). Protests by activists and legal interventions have led the Supreme Court to direct the government to stop camp-based sterilisations altogether (Devika Biswas v Union of India and Ors). However, coercive measures such as the two-child norm (by which those with more than two children are excluded from contesting elections, applying for jobs and accessing welfare benefits) continue to be invoked as in the case of Assam’s draft Population Policy (Government of Assam 2017).7
In order to address adolescent health, the government cites that the Rashtriya Kishor Swasthya Karyakram (RKSK)8 has been initiated in 2014. However, three years after the scheme was launched, Adolescent Friendly Clinics, which were to be operationalised at PHCs, CHCs and district hospitals, are not in place (SAHAJ 2017) and the programme has not been implemented in many states. The Rajiv Gandhi Scheme for Empowerment of Adolescent Girls–Sabla was launched in 2010 in 205 pilot districts, as an effort to empower adolescent girls. Despite positive evaluations (ASCI 2013), Sabla has not been upscaled across the country, as indicated by decreasing budgets of the Ministry of Women and Child Development in 2015–16. Several states have not introduced comprehensive sexuality education for adolescents and a parliamentary committee has ruled against it citing moral and cultural reasons (Rajya Sabha Committee on Petitions 2009).
As detailed above, the GoI has reported to the UN Human Rights Council that it has made progress in several of the commitments it made at UPR 2, when it had voluntarily accepted suggestions from a peer group. The civil society joint report on sexual and reproductive health provides a contrast to these claims of the government with information that is at gross variance to the official report. This discordance questions the credibility of the claims and assurances of the government’s report to an international human rights mechanism on its commitments and achievements, and brings us to question the government’s accountability to these international human rights processes. It is necessary for the people of this country and their elected representatives to be aware about the suggestions received during the UPR 3 and play the role of informed interlocutors. Although these international processes play a facilitatory role in maintaining peer pressure on member states, the Indian government’s primary accountability remains to its citizens.
Despite the progressive objectives in the NHP 2017 to achieve universal health coverage and reinforce trust in public health systems, the policy fails to recognise health as a human right, increases private sector involvement, and further delays substantive increases in public health expenditure. Given this worrying lack of commitment to guarantee the right to health, the GOI must be reminded of its constitutional obligations to protect and fulfil the human rights of its people, including their right to health, especially those most marginalised. The UPR 3 international review process, reinforced with domestic involvements, can provide it with some impetus in this direction.
1 The underfunding of the National Health Mission (NHM) should be read in the light of the draft National Health Policy’s comment that “The budget received (for the NHRM) and the expenditure … was only about 40% of what was envisaged for a full re-vitalization in the NRHM Framework.”
2 As recommended by the 14th Finance Commission, there has been an increase in the share of states in the divisible pool of central taxes from 32% to 42% every year since 2015–16. At the same time, there have been reductions in the centre’s financial assistance to states for their plan spending. Thus, the 10% points increase in the states’ share in central taxes has come at the cost of the reductions in centre’s support for a number of schemes in the social sector. Also, as recommended by the subgroup of chief ministers on restructuring centrally-sponsored schemes (CSS) constituted by the NITI Aayog, NHM now has a changed centre-state funding pattern in the ratio of 60:40 from the erstwhile 75: 25. This changed funding pattern has transferred larger responsibilities of financing some of the crucial social sector schemes like NHM to the states.
3 A heavily diluted Clinical Establishments (Registration and Regulation) Act, 2010, designed to regulate all healthcare facilities, was passed by Parliament. However, even its limited provisions have not been notified in most states.
4 JSSK launched in 2011 to provide free and cashless services to pregnant women, including normal deliveries and caesarean operations and care for the sick newborn (up to 30 days after birth), in government health institutions in both rural and urban areas, aimed at mitigating the burden of out of pocket expenses.
5 IGMSY was started more than five years ago as a “pilot” across 50-odd districts of the states and union territories. Till date, it remains as a pilot in these few districts.
6 FP2020 is a global health initiative which aims to expand access to family planning information, services and supplies to an additional 120 million women and girls in 69 of the world’s poorest countries by 2020. For more information see www.familyplanning2020.org/.
7 The recently drafted State Population Policy by the state of Assam (which has been put out by the government for comments) stipulates that those with more than two children will be ineligible for government employment and taking part in panchayat and municipal body elections.
8 RKSK includes the imparting of health education through community-based interventions, and the Scheme for Promotion of Menstrual Hygiene among adolescent girls in rural areas.
Jashodhara Dasgupta ([email protected]) works on public health rights and is with Sahayog, Lucknow; Subha Sri B ([email protected]) is with CommonHealth (The Coalition for Maternal–Neonatal Health and Safe Abortion) and Rural Women’s Social Education Centre, Tamil Nadu; Priya John ([email protected]) is with CommonHealth; Sana Contractor ([email protected]) is with the Centre for Health and Social Justice, New Delhi and the National Alliance of Maternal Health and Human Rights (NAMHHR); Renu Khanna ([email protected]) is with Sahaj, Vadodara and CommonHealth; and Sandhya Y K ([email protected]) is with Sahayog, Lucknow and NAMHHR.
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