A video report on the milk bank at Mumbai’s Lokmanya Tilak Municipal General Hospital, popularly known as Sion Hospital. It gets donations from nearly 40 mothers every day and the milk benefits 3,000 babies every year. According to doctors, breastfeeding within the first hour of birth is one of the measures to fight infant mortality.
This report was aired on NDTV’s Every Life Counts campaign, supported by the Gates Foundation
“Back home in Ghazni, I never used to cook. It was only after I moved to Delhi six years ago that I made my first biryani,” says Farhat. A single mother, she moved to India from Afghanistan in 2010 when the Taliban killed her husband, an Afghan Army officer.
She is a member of Ilham, a catering service that serves traditional Afghani dishes to people in Delhi. Ilham, which means “positive” in the Dari language, was launched in late 2015 by the UN refugee agency, UNHCR, and its partner Access. The initiative brings together seven women, all refugees from conflict-torn Afghanistan.
“There are too many restrictions on women there,” says Farhat, who tried to support herself and her six-year-old son with odd jobs after her husband’s death. “Neighbours started calling me a bad woman for leaving the house and I was afraid of attracting the Taliban’s attention. So I left for India.”
There are nearly 11,000 Afghan refugees registered with the UNHCR in India, mainly living in Delhi and bordering areas. The influx began in 1979 after the Soviets invaded Kabul and continued through the fall of the Taliban regime. The early refugees were mainly Hindus and Sikhs but with the security situation getting worse, more ethnic Afghans are coming in.
Historically too, India has been a favoured destination for Afghan traders or Kabuliwalas, who would travel across the mountains to sell spices, dry fruits and attars (perfumes), an association that has been immortalised in many Bollywood films and works of literature, including a popular short story, Kabuliwala, by Nobel Laureate Rabindranath Tagore.
“India is also an obvious choice because the government allows UNHCR mandate refugees to apply for long-term visas that regularises their stay and enhances employment opportunities and enables easier access to higher education,” says Shuchita Mehta, a spokesperson at UNHCR India.
As of August 2015, there were a total of 27,000 refugees in India registered with the UNHCR. The total refugee population across the country runs into well over 200,000. India’s liberal approach towards asylum seekers attracts large numbers but there is no specific policy or legal framework regarding refugees. The country has not ratified the 1951 convention on refugees.
Refugees registered with the UNHCR find it easier to get long-term visas and work permits. They are entitled to free education in government-run schools and free healthcare. Others face a miserable existence, confined to illegal settlements, where access to water and electricity is irregular.
Finding a steady, well-paid job is hard too. Zameera, a schoolteacher in Afghanistan, had to work as a domestic help in Delhi for years before she became a part of Ilham. “It was a struggle to communicate as I could not speak English or Hindi. I had five children to feed and educate so I was desperate,” she says.
She lives in Lajpat Nagar, home to a large number of Afghan refugees. The community is concentrated in small pockets in parts of Delhi, the ghettoisation preferable to living in a mixed colony where they stand out, their accents and clothes regarded with open curiosity, and occasionally some hostility.
“There is an urgent need for sensitisation programmes,” says Aditi Sabbarwal, project manager at Access. “People have no idea what they are fleeing from, their back stories, so there is a perception among some that they are freeloaders. The government should conduct awareness campaigns so people come to know what’s going on in their countries.” She points to stray comments on Ilham’s Facebook page pointing to the turmoil in Europe over the refugee crises and making the case that India should not take in outsiders.
The idea of starting a catering initiative was born after hours of talks between Access and the Afghan women enlisted with them. “People in Delhi are open to trying out different cuisines but there were very few that served Afghan food,” says Sabbarwal. “So we decided to try some dishes out at a fair last winter. We were sold out in less than an hour. We realised that starting this on a larger scale could guarantee them fixed employment and financial independence.”
The range of dishes is limited but great effort is taken to source the original ingredients to ensure authenticity. The American embassy in New Delhi is among their most regular customers.
The women cook the dishes at their homes and deliver to the designated pick-up centres. Given the growing demand, there are plans to set up a community kitchen.
“We make a profit of Rs 3,000-4,000 a month, which is much more than what we earned working odd jobs,” says Qadria, who left Herat in west Afghanistan six years ago after she was lashed in public for not covering her face properly.
“The orders are growing everyday and the money is good,” says Qadria. “I am able to pay my daughters’ school fees and buy them what they want. I feel happy when I see them enjoy the freedom I never had in Afghanistan.”
Ziyagul, the most vocal of the group, who has dreams of starting her own restaurant, says: “I feel so happy that I am able to share some of my culture with people here. When customers praise my dishes, I feel so confident. I realise that I am as capable and independent as any man!”
Some names have been changed to protect the women.
mMitra, started in Mumbai slums with the support of the civic body, is a free mobile voice call service that gives information on preventive care and simple interventions to reduce maternal and infant deaths. It is given in the language of the user’s choice and sent weekly or twice a week. Launched in 2014, it reaches over 5 lakh women in slums in Mumbai city, up to its far suburbs.
Domestic violence accounts for five in 10 of reported crimes against women in India. Many cases go undocumented, nearly 7 out of 10 women have suffered some form of domestic violence. Domestic violence is linked to posttraumatic stress disorder, gastrointestinal infections, suicide, chronic pain, and increased risk of unintended pregnancy, which, in turn, compromises maternal, infant and child health. The Little Sister’s Project, an initiative that works among victims of domestic violence in Mumbai, has 160 local women to identify and report incidents of gender violence using Android smartphones and an app called EyeWatch.
This documentary was done for the NDTV-Gates Foundation campaign, Every Life Counts. To watch click here
A two-year-old app is helping women in Asia’s largest slum, Dharavi, to stand up against domestic violence. The Little Sister app, working in 3 languages, is helping women report instances, however small, and get help.
Home to a population of over one million, Mumbai’s Dharavi sees many such cases, say the women who are part of the initiative started in 2014 by a non-profit, SNEHA – the Society for Nutrition, Education and Health Action.
“Physical abuse and sexual violence is most common,” said Rashida, a sangini or worker in Little Sister.
Violence against women is listed as one of the top 10 reasons of death for women and domestic violence, also known as intimate partner violence, accounts for five in 10 reported crimes against women in India. Even so, many cases go undocumented, and various studies show nearly seven out of 10 women in India have suffered some form of domestic violence.
A report released last year by Population Reference Bureau, a Washington DC-based think-tank, said India — along with Nepal, Pakistan and Sri Lanka – shows a very high rate of violence, with one in three women reporting sexual and/or physical violence, mainly from a partner.
One of the many reasons why domestic violence goes unreported is because it has cultural sanction. “Everyone, including the mother-in-law, thinks the man has rights over the woman’s bodies, regardless of her feelings,” said Rashida.
“We recently counselled a woman who had been beaten by her husband for 22 years, right through their marriage,” added Saira Shaikh, another Little Sister sangini. “She kept thinking it was OK because her husband was providing for the family.”
Married twice, Rashida was abused both times. She finally found the courage to walk out when she nearly died after consuming poison in a fit of despair. “While in hospital I realised that by suffering violence, I was damaging my children.”
These are not easy decisions for any woman, especially those who are poor, uneducated and lack family support.
This is where the app greatly helps, believes Rashida – its biggest advantage being that women can express their pain in safety and secrecy, until they are ready to speak out.
Registering instances on the app gets immediate response.
Depending on what she wishes, the sanginis contact her and provide counselling. In case of physical violence, they can even contact the police and hold family counselling sessions.
“The project was designed to mitigate under-reporting of violence by providing a tool for women to record instances,” said programme coordinator Damini Mohan. “Most cases are reported to authorities as a last resort, when the violence has severely escalated. It helps us capture instances of violence at an early stage and helps us prevent its escalation.”
Since it was launched in June 2014, Little Sister has recorded 1,062 cases of domestic violence, compared to 200 cases recorded in 2013-2014.
While there are laws against domestic violence, what is not widely understood at the policy level are the health consequences, doctors say.
Women who suffer domestic violence are twice as likely to suffer from depression and about 50% more likely to become HIV positive. Other outcomes are post-traumatic stress disorder, gastrointestinal infections, suicide, and chronic pain. It is also linked with higher risk of unintended pregnancy that compromises maternal, infant and child health.
“Whenever there is violence, physical or otherwise, the physical impact shows up in the form of scars but the impact, internally, is 25% more,” said Praful Kamble of SNEHA. “There is depression, a sense of shock and a major impact on children who witness it. Even verbal abuse can affect pregnancy outcomes.”
This article was published on the NDTV website. To view the video report click here
From April this year, injectable contraceptives will be available in district hospitals across India.
At the recently held International Conference on Family Planning in Bali, top health ministry officials from India said that they were determined to meet their stated target of providing 48 million women with access to contraceptives by the year 2020.
In 2012, at the London Summit on Family Planning, India had pledged to commit almost $2 billion dollars until 2020. As a result, today more women and girls have access to family planning. In 2013 alone, three million additional women and girls in India were equipped with the tools and the information needed to choose a modern contraception method.
To fulfil this goal of 48 million, the government will increase the basket of contraceptive choices offered to women, and promote spacing between births. Apart from injectables, this will include Centchroman, a non-steroidal agent, and POPs or progesterone only pills.
Centchroman, marketed as Saheli, is a once-a-week oral contraceptive that acts on the hormones produced in the body, especially progesterone. POPs thicken the mucus in the cervix, stopping the sperm from reaching the egg.
“We are determined that no woman should be left behind and no partner be left behind,” said C.K Mishra, Mission Director, National Health Mission.
Phase 1 results from the fourth National Family Health Survey or NFHS-4 for 2015-16 that covered 13 States and two Union Territories are quite promising with total fertility rates or the average number of children per woman dropping considerably, ranging from 1.2 in Sikkim to 3.4 in Bihar.
All states in this phase, except Bihar, Madhya Pradesh and Meghalaya have either achieved or maintained replacement level of fertility and this is a major achievement in the past decade.
However, what remains problematic is the female sterilisation rate, which at 34% is very high. Health officials hope to bring down the numbers by offering more contraceptive choices and improving service delivery.
“All along there has been greater emphasis on terminal methods of family planning and we have not given spacing the attention needed,” said Mishra. “The goal ahead is to focus on adequate spacing”.
Also of concern is the total unmet need for contraception in India, which at 21.3% is the highest in the world. Bringing down the unmet need was a key Millennium Development Goals target that India was unable to meet.
A high unmet need for contraception translates into a high number of unintended pregnancies and has tremendous health implications. India accounts for 19% of the world’s maternal deaths and meeting the need for contraception is critical to saving lives.
“Today more girls and women have access to contraception but we are still 10 million behind in terms of what the figure should be,” said Chris Elias, president of the Global Development Program, Bill & Melinda Gates Foundation, while speaking to a group of journalists on the sidelines of ICFP 2016.
Last November, the Gates Foundation had announced that it would invest an additional US$120 million in FP programs over the next three years to meet the Family Planning 2020 goal of giving 120 million additional women and girls’ access to contraceptives.
“If there is spacing, half of the lives lost would be saved. Women should be able to decide when they should have babies,” believes Elias.
Health ministry officials in India seem to be moving forward in the right direction. However, there is quite some distance to travel before the revised plans are implemented, cautions Poonam Muttreja, Executive Director, Population Foundation of India.
“Apart from issues like inadequate budget allocation, the bigger challenge India faces is wide disparities and inequities in women’s access to healthcare and family planning. Access to health services still depends upon where one lives, how educated one is, and economic and social status”, says Muttreja.
Clearly, the approach will have to go beyond simply making these choices available at various health centres. “It is not just about making the full range of methods available,” says Elias. “Women have to be empowered to make those choices”.
Every morning I would take a broom and tin plate to the homes of the upper caste thakurs to pick up their faeces. I would collect the waste in a cane basket and later throw it in a dumping ground outside the village.”
As you watch a confident Ranikumari Khokar educate a group of boys and girls on how to file a police case, it is hard to imagine that this 21-year-old spent most of her adolescence working as a scavenger.
Today she is a “barefoot lawyer”, an initiative started by Jan Sahas, an NGO that has been campaigning against the practice of manual scavenging for 12 years. Since the launch of the programme in 2014, 800 girls and young women have been trained in the states of Madhya Pradesh and Rajasthan.
A caste-based role, manual scavenging condemns mostly women to clean excreta from dry latrines with their hands and carry it on their heads to dumps. Men from the community clean open gutters and sewerage lines, often with no protective gear.
Derogatorily called bhangis, which means “broken identity,” most of the scavengers are dalits, ranked lowest in the caste system and expected to carry out tasks regarded as beneath the dignity of those higher up in the hierarchy.
“We were looked down upon by the villagers,” recalls Ranikumari. “They would never walk with us. At the village well, we were made to wait at a distance until everyone else had filled up.”
Even worse was the discrimination in school. “The teachers would call us bhangans [children ofbhangis] and expect us to clean the toilets and the classrooms. We sat apart from everyone else and were never given a chance to participate in school functions,” adds Ranikumari.
Caste-based discrimination or untouchability was banned in India in 1955 and down the decades several policy measures have been announced to end the inhumane custom of manual scavenging. Article 17 of the country’s constitution clearly abolishes the practice, while the 1993 Dry Toilets Prohibition Act forbids the employment of manual scavengers.
But none of these policies have been effective because manual scavenging was categorised as a health and sanitation issue, a responsibility implemented by state governments. Many states like Delhi and Rajasthan did not even bring the policy into force, and those states that did showed little will to enforce it on the ground. People remained unaware they had the right to refuse this role. The few who dared to came under intense social pressure, and received no support from local government officials. They risked violence and eviction.
The International Dalit Solidarity Network, which works towards ending caste-based discrimination, estimates that there are about 1.3 million manual scavengers in India, most of them women. These women are victims twice over: looked down upon by the upper castes and discriminated against within their homes.
“People from my village would walk far away from us as if we gave out a smell they could not bear,” says Mayu, a resident of Sava village, Rajasthan. “We were made to draw water from a well in which dead animals and birds were found and if anyone gave us any food, it would be thrown in our direction. Even my husband would tell me to bathe many times because I was cleaning other peoples’ shit although he had no problem eating the rotis I brought home.”
It was these attitudes that Jan Sahas had to battle when it started its campaign in 2003.
“They were socialised to believe that they have to be low caste,” says Aashif Shaikh, the founder of Jan Sahas. “They would tell us ‘this work has been given to us by god and we are at an advantage as we get food’. The reality was that they were being treated worse than animals.” Because they were rarely paid in cash, they were dependent on the upper castes for the basics – food, clothing and shelter.
Jan Sahas started working in two villages in Rajasthan. It would take nearly two years before they were able to convince the community to put down their brooms. The gamechangers were the children, especially girls.
“The girls were determined to end the practice,” says Shaikh. “They were deeply unhappy about the discrimination they faced in schools so we would make them speak at our meetings.”
But there was fierce resistance from the upper castes; some Dalit homes were even burned down. The local police refused to act and it was only after district level officials intervened that action was taken.
Since 2003, Jan Sahas claims to have liberated more than 21,000 women in Madhya Pradesh, Bihar and Rajasthan. These women have become ambassadors for the movement and it was their countrywide agitation in 2013 that led to the Indian parliament enacting a new, stronger law against manual scavenging.
Those who employ manual scavengers face a one-year prison term and a fine of 50,000 rupees (over £500). For repeated violations, the prison term is two years and a fine of 100,000 rupees (£1,000).
Stronger penalties apart, the Prohibition of Employment as Manual Scavengers and their Rehabilitation Act, 2013 makes it mandatory to rehabilitate rescued manual scavengers. They now get 40,000 rupees (over £400) as compensation from the government and get trained for alternative employment.
Many women now work in government-funded construction projects and small factories. Others have enrolled in community initiatives started by NGOs that offer training in skills like tailoring and embroidery.
Changing minds, however, remains a challenge as caste-based discrimination is still deeply entrenched in Indian society.
“You can change your religion in India but you cannot change your caste,” says Shaikh. “You hear of people converting to another religion but their caste remains the same, and this is true for even Muslims and Sikhs although neither religion has the caste system. Even politics runs on the basis of caste.”
The way forward, activists believe, is to educate the younger generation, who are open to change. The barefoot lawyers initiative, which trains men and women from all communities, is a step in that direction.
“I go to different villages and educate the youth about laws relating to caste discrimination, sexual assault and rape,” says Ranikumari. “I even speak to school authorities if I hear complaints of discrimination. As a child I could not speak up for myself but now I have a voice.”
At the recent International Conference on Family Planning, Indian health ministry officials committed to make available better quality family planning services and expanding contraceptive choices. How much of that will translate into action will depend on the money allocated to health care in this budget.
India has promised to meet the FP2020 goal of providing 48 million additional women and girls in the country with access to modern contraceptives by 2020. Family Planning 2020 is a global partnership that is working with governments, civil society, donors and the private sector to enable 120 million women and girls to decide for themselves, whether, when, and how many children they want.
Reaching 48 million, however, seems like a tall order. India spends just 1.3% of the GDP on health care, which is lower than other countries. China, for instance, spends 2.8% and South Africa 4.1%. Budget 2014-15 saw an 87% drop in funds allocated to family welfare and this was reduced even further by 34% in 2015-16.
The low priority is baffling given that India has among the worst maternal and infant mortality rates in the world. The role family planning plays in achieving broader development goals, including poverty reduction has been well documented.
Population Foundation of India figures show that 46% couples in India do not practise family planning, About 21% of births every year are unplanned, due to lack of access to contraceptives. The cost of unplanned children, according to a PFI study ranges from 2% of state GDP in Tamil Nadu to 14% in Bihar.
In this context, the Health Ministry’s decision to introduce injectable contraceptives in government health centres is a welcome move. The decision was pending for nearly 15 years due to protests from many women’s rights groups. It also plans to promote spacing methods and improve quality of care.
“Meeting the FP2020 goal would need an investment of approximately Rs 13500 crore over seven years (2014 to 2020)”, points out Poonam Muttreja, Executive Director, Population Foundation of India. An additional Rs 11,150 crore would be needed over the next four years, which is Rs 2800 crore per year, adds Muttreja.
Supplying injectables alone will not is be enough say experts. The government needs to rethink its approach towards family planning.
“If you are talking of FP2020 goals, a lot depends on involving men”, says Ashok Dyalchand, Director, Institute of Health Management in Pachod, Maharashtra. “Not enough has been done to involve men and you have a significant proportion of women using contraception without their husbands’ knowledge.”
“The emphasis has been largely on methods for women historically”, adds Muttreja. “The public health system, FP programmes and communication strategies have to change to encourage male engagement”.
For decades India has depended on female sterilization as a means of contraception. It conducts the highest number of tubal ligations – nearly five million in a year. Data from the first phase of the National Family Health Survey (NFHS-4) shows that female sterilisation accounts for 34% of modern contraceptive methods, while less than 1% men go for a vasectomy
One of the main reasons for the low prevalence are the many myths and misconceptions relating to vasectomy says Emily Jane Sullivan from the London School of Hygiene and Tropical Medicines.
“A tubal ligation is a more complicated, costly, and risky procedure than vasectomy”, says Sullivan. “However, in India, more than 1 in 3 women choose to have a tubal ligation while only 1 in 100 men choose to have a vasectomy.”
Countries like Bhutan, Brazil, Nepal, and Rwanda have countered these myths effectively through campaigns that frame men who choose vasectomy as responsible and caring towards their families.
“There is an opportunity for these countries to share their ‘lessons learned’ with other national family planning programs that are looking to thoughtfully, ethically, and effectively promote vasectomy”, says Sullivan.
India needs to look at similar approaches instead of simply adding more to the basket of choices say experts.
“The only addition to the basket is injectables. We do not have male contraceptives. I am in favour of injectables but whether diligence will go into administering it in the government sector is a concern. There is also the question of a strong provider preference towards tubectomies”, cautions Dyalchand.
For decades India has followed a targets and incentives based approach towards family planning. Achieving the FP2020 goal involves a shift away from that. It is not just about technical solutions or contraception, but also about women’s agency, choice, quality of reproductive health services and dignity.
Thie article was published in The Indian Express here.