Community Health Workers- change agents and mobilisers

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The American Public Health Association defines a community worker as: “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery”. Non-profits working towards improvement of vulnerable population rely on the work of these individuals, to achieve the organization’s mission.

Community health workers (CHW) are therefore fundamental for implementing field-level programming by engaging the community and the beneficiaries through participatory efforts. Carrying out initial work in the community through surveys, house-listing, community mapping, corner meetings, micro-planning etc. are crucial tasks in establishing first contact with the community. Initial community engagement activities carried by CHW(s) include identification of eligible beneficiaries, enrolling them for the sessions, services and trainings. They also mobilize community to participate in group education events and campaigns. Carrying out interventions in the community through group formation, group/community meetings, counselling, information sharing, capacity building, paying home visits, conducting growth monitoring health camps and vociferously following up with individual cases are significant activities carried by them. An important skill that they have mastered over their engagement with the community is customizing the information delivery based on the requirements of the beneficiary. Case management and referrals are other vital tasks carried by them to reach out to the beneficiaries.

A critical area of SNEHA’s research involved analyzing the motivations of these frontline workers, to both take up as well as sustain in this challenging role. As such, a study was created in order to gain insight into the perception of roles and responsibilities by CHWs as well as motivations and challenges they faced. The study comprised of in-depth interviews of the health workers from four NGOs namely: SNEHA, Apnalaya, Foundation for Mother and Child and Shelter Associates, to tap into areas, from background information and training, to personal and organizational factors.

Many themes emerged as to why CHWs decided to join the non-profit sector to begin with. Narratives expressed a desire to contribute to purposeful work, as well as to increase one’s knowledge base from a personal growth perspective. Others expressed support from supervisors as contributing factors to making the decision to join the organization. Another narrative offered willingness to try out work in a new field, and an opportunity to return to the workforce following marriage and motherhood as motivation behind initial association.

Community Health Workers also reported having a positive impact on beneficiaries who engage with trained staff during a critical phase in their growth and development. This, CHWs stated, gave rise to a capacity for self-reflection, increase in knowledge and discernible behavior modification, promotion of healthy relationships through candid conversations between beneficiaries and their parents, and added value through incentivized vocational courses, such as computer literacy and English speaking for beneficiaries. Most importantly, confidence and a personal connection and rapport is built in beneficiaries, and changes seen in youth that push forward that they will go on to produce an equitable society free from gender based or domestic violence.

As for their perceived role, many CHWs believe they served as teachers as well as resource personnel. However, they also believed their responsibilities and scope of influence transcended programming and campaign initiatives. They served as confidants and guides to youth and adolescents by providing them with a safe space, to share their experiences and voice their opinions.

Self-reported characteristics of an ideal CHW included: a strong work ethic, exceptional communication skills, and the ability to generate goodwill through intensive rapport-building efforts in communities. Many front line workers left feeling their own exposure to topics during training left them having not only gained knowledge but also triggering introspection and empowerment within them themselves.

Most CHWs reported having a positive and supportive environment at work and were well satisfied with provisions offered by the organization, including training, timely salaries, flexibility with schedules, as well as staff support and real time feedback.

As for challenges that arose within their work, CHWs expressed the need to juggle multiple responsibilities, thus risking being overstretched. Financial situations also posed a challenge, as did organizational factors.

Perhaps one of the most moving aspects of the study was the participants’ personal account on the changes they had witnessed within themselves, having been part of the organization. While their role was believed to be multifaceted to include serving as a teacher, confidant and guide to the beneficiaries, a significant element that emerged from their personal journey with the NGO was their own process of self-reflection. This manifested in an internalization of knowledge within participants such that through their evolving understanding of themes, empowerment emerged. Affection and respect for working with interacting with children arose as well, contributing to a positive learning environment. Participants also expressed an increase in topical knowledge; skill based competencies, as well as improvements in communication skills and self-confidence. Most importantly, participants saw themselves community resources persons, with one expressing the view of being a change agents, with the ability to empower people in the community.

 

A step towards empowerment and leadership- Our Sanginis

 

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Our Sanginis at the Godrej India Culture Lab conference. Photo courtesy: Godrej India Culture Lab (Link: https://www.facebook.com/IndiaCultureLab/?fref=ts)

 

 

Godrej India Culture Lab is a Mumbai-based experimental space that brings together ideas and people together to explore what it means to be Indian. It held a two-day conference, ‘We the Nation: Micro-narratives of change’ on June 30th and July 1st, in Mumbai. The conference, showcased organisations that are documenting the rapid changes taking place in India today, through talks, panel discussions and exhibitions. It featured noted journalist, P. Sainath, who spoke about the work he is doing through People’s Archive of Rural India (PARI), Video Volunteers, a Goa-based organisation that empowers marginalised communities to tell their stories, Digital Desh Drive, an annual report that explores how non-metros are using the internet, Khabar Lahariya, a community-run newspaper published by rural women; amongst other path-breaking and inspiring organisations.

SNEHA’s sanginis (women volunteers from the community) attached to our Prevention of Violence against Women and Children program, who identify and map cases of domestic violence, refer cases to our crisis centre for legal aid or intervention and hold community meetings to discuss gender norms, had the opportunity to attend the the conference and participate in a panel discussion. They were accompanied by Meera Sai, Program Coordinator of the Little Sister project  that uses mobile technology to track and report instances of domestic violence in Dharavi.

This was an opportunity for our Sanginis to share their experience in using mobile technology to address the pervasive issue of domestic violence in slum communities. The audience was intrigued to know how Shehzadi, one of our sanginis, who hails from the muslim community, is challenging gender norms. Shehzadi has been part of SNEHA’s efforts in preventing domestic violence for over a decade now. Nikita, another Sangini, shared about how SNEHA has played a pivotal role in shaping her thoughts – ‘Not being educated or not being able to converse in English has not stopped me from being confident,’ she said while telling a tale about how she fought with her family and supported her daughter to pursue higher studies.

For our sanginis, who work on challenging patriarchy and social norms everyday, the conference was a validation of their inspiring work as well as an incredible platform to share their stories. Empowering women and developing grassroots’ leaders is the core of our work in preventing gender violence and platforms like these, are where we want our sanginis to be!

 

 

How a Community Worker has the power to help vulnerable women make better health choices

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“Health cannot be bought at the supermarket. You have to invest in health. You have to get kids into schooling. You have to train health staff. You have to educate the population.” – Dr. Hans Rosling, Swedish Global Health Scientist

Mumbai is a truly fascinating location for a case study in Maternal Health due to the large number of coexistent inequalities when it comes to women’s health. The city boasts of world-class health facilities, yet struggles with equitable health distribution for a majority of its citizens. The country’s second largest city has a population of approximately 12.4 million, more than half of whom live in informal settlements (colloquially known as slums).  Some numbing statistics include: Only about one-fifth of dwellings in informal settlements have a private toilet, only 31% of residents have completed 10 years of education, and the total fertility rate is below the replacement threshold at 1.9. The 40% slum dwelling population, including the often-discounted migrant populations, are often shortcharged by the quality of public health services. One of the major reasons for the lack of accessed care is that awareness, uptake and knowledge levels among many of the users of public health services typically tends to be low, especially, in informal settlements in urban areas. Female literacy is only 54%, and women lack the autonomy to make decisions, that affect their own bodies. On the supply side, quality of health services tend to be sporadic and inconsistent.

As part of my research thesis field work, I spent the Summer of 2016 working with a Mumbai-based non-profit, Society for Nutrition, Education and Health Action (SNEHA) that believes in investing in women’ health in vulnerable urban slum communities in four large women’s health areas, Maternal and Newborn Health, Child Health and Nutrition, Sexual and Reproductive Health and Prevention of Violence against Women and Children. In SNEHA, I spent most of my time understanding how they work through their community staff, known as Community Organisers, to motivate and educate their beneficiaries (typically residents of vulnerable pockets in poor urban communities) and nudge them towards better care-seeking behaviour.

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Community organizers hired by SNEHA are members of the community who are trained to provide education to expectant mothers in the area through door-to-door educational interventional programs. Community Organisers also work with health systems, by training, up-grading and building capacity of health workers attached to these systems.

Through my field work, it became abundantly clear that maternal education programs in urban Mumbai work due to the close relationships that are forged between the Community Organizers who work intimately with beneficiaries from vulnerable communities. While studying the various forms of beneficiary compliance and behaviour change, I was able to track that the relationship between the community organizer and the mother was the main determinant in the level of compliance. Even in the least compliant measure of cultural compliance where mothers are expected to follow medical instructions instead of harmful cultural practices, mothers with the most visits from a community organizer were most likely to follow instructions that most mothers in that cultural climate would not. To improve compliance, SNEHA would have to increase the number of times the community organizer meets the mother, and start the antenatal care as early as possible.

The public health system has a negative perception among its users. Previous experiences including long wait-times, lack of required resources, bad behavior by staff and unnecessary referrals, further adds to these perceptions. This prevents pregnant women from seeking regular antenatal care and seek follow-up visits. One of the ways we could prevent loss of follow-up is to enable Community Organisers to accompany pregnant women for their antenatal check-ups. This could start a smooth initiation into the antenatal care process. SNEHA already works with the public health system and intervenes, setting up and managing referral works while working with health posts so that they can handle basic antenatal check-ups. Another intervention mode could include training public health staff in soft skills including patient interacting, communication and information sharing.

Maternal deaths are preventable. Safe motherhood can be achieved as a goal with access to quality institutional care for mothers with complications during pregnancy. Availability and accessibility of skilled birth attendants, basic and comprehensive emergency obstetric care, around the time of birth is also critical. A large proportion of newborn illnesses and deaths can also be prevented using simple, low-cost interventions during delivery and during the week following birth partum, provided both in the facility and at home (where currently 50 per cent of newborn deaths occur). SNEHA’s community workers achieve these aims by their relentless efforts to educate the most affected populations. Education improves health, while health improves learning potential. Education and health complement, enhance and support each other; together, they serve to improve quality of life for women and children in developing countries.

By Shikha Chandarana

Shikha is an undergraduate student in Brandeis University, US. She was a research intern at SNEHA in 2016.

All opinions recorded here are of the author and don’t necessarily reflect SNEHA’s views and opinions at all times.

Not a ‘private matter’

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By Rahul Thekdi

An abundant amount of written content, a robust set of laws and several promising media campaigns have all been unable to combat the problem of domestic violence at its root cause. Mostly shrugged off as a ‘private matter’ by men, the victims who in most cases are women, are yet to speak openly about the ill treatment faced by them behind closed doors.

The social evil, which affects both rich and poor equally, has denied many women the basic human values of respect and freedom of individuality thus restricting them to caged framework of conduct laid out by the society. Not only do these women succumb to physical injuries but also face long lasting negative impact on their mental health as a direct consequence of the abuse.

Women who are victims of domestic violence are more vulnerable to depression and anxiety among other psychological consequences. Domestic violence is also associated with a thread of fatal consequences such as chronic pain disorder, sexually transmitted infections including HIV, unwanted pregnancy, miscarriage, complications during pregnancy which may also lead to substance abuse and suicide.

There have been relatively very few studies in India throwing light on the men’s perceptions as to why they inflict violence on their spouses. In this backdrop, to engage men in bringing a positive change in their behavior towards nonviolence, a study conducted by SNEHA in which it interviewed 13 male participants revealed that primary cause of violence lies in the notion of male superiority and authority over his spouse’s conduct. The deeply ingrained patriarchal social system is to be blamed; it creates a permissive environment for spousal abuse.

In order to sooth the male ego, any act of disobedience or mistake by the woman, form the basis of his right to use force in order maintain his dominance within his marriage.

Another very important parameter is societal pressure, which causes instances of abuse by men so as to keep intact their image in the society. Men justify these acts by simply labeling it as social norm and any act of outsider’s/natal family’s intervention or contact with the police is considered as a threat to the marriage.

The study found out that a section of these men who accepted the blame cited stress and frustration as the primary reason to resort to violence. In fact, according to the study, men who undergo stress are more likely to be abusive than those who do not undergo stress. Stress is caused mainly due to economic hardships, difficulty of coping with urban lifestyle and lack of personal space. The study found that men hesitate to share any of these stressors with their friends or family for fear of being labeled ‘weak’.

The need for the hour is to break the societal barriers and create an environment for men to openly discuss their problems. Counseling these men to help stop the violent behavior and build a nature of acceptance rather than denial is the key. This could only be done through opening up and letting the partners share their feelings and as an intervention, provide a helping hand through effective communication, self-control, anger and stress management workshops.

Simply labeling the men as violent partners is not the answer to solve the problem; an intervention is required to bring about an effective communication model and to provide them a platform to voice their concerns which will in turn help change their outlook towards domestic violence.

What needs to be understood are the reasons for the aggressive nature and their source of frustration in order to deconstruct their existing concept of masculinity.

These angels live on the ground – A Women’s Day Special

Ten years ago, Archana Ramesh Mahapade, 50, was out on a fund collection drive when she saw a large group of women.

“When I saw the line and the women waiting patiently, I became curious. I joined them and found out that interviews were being conducted for the position of a community worker at SNEHA. I was selected and that is how my journey began.”

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Archana Ramesh Mahapade, Community Organizer, SNEHA

It is community workers like Archana that help drive the impact of SNEHA, Society for Education, Nutrition and Health Action, an organization that for many decades now, has been working towards improving the health of women and children in slum communities.

SNEHA’s community centres in the vulnerable areas are key to driving the program. The community organizers are drawn from the community itself, and their ease and familiarity with the local population makes them an invaluable asset.

However, as Anupama points out, the familiarity does not guarantee that their presence or advice is always accepted.

“When we first tell people about SNEHA and the work we do, many look tense and turn away. Some women even shout at us and we do feel bad. But we always come back the next day. Eventually their attitudes change when they realize that we are there for good, and not just for a day.”

Once the ice is broken, it takes a few more sessions before they start talking about their lives. “Initially, when we ask them about family planning methods, they are not honest. They say everything is good but as we probe further, we get to know about the situation at home, the pressures they face.”

Building this intimacy is critical given the many levels of SNEHA’s intervention. It goes beyond maternal and newborn health to child nutrition, and sexual and reproductive health, issues that girls and women have never been encouraged to think about. SNEHA offers crisis intervention, counseling, medical and legal help to survivors of violence. It also works on prevention in communities and enables government systems to respond in an effective and sensitive manner.

Access into the homes and lives of women here is vital,  and the community organizers enable that.

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Saira Shaikh, CO, Govandi

“The women in my area come to the city after marriage and they are lonely and unaware”, says Saira Shaikh, 38, a community organizer at Shivaji Nagar in Govandi. Govandi, one of Mumbai’s largest urban settlements, is home to a large population of migrants, who depend on odd jobs to make a living.

“They face violence at home and have no one to turn to,” adds Shaikh. “The violence is made worse by the low unemployment levels. The husbands spend the daily wages on other women or on drinking. We give these women strength by telling them to come forward and seek help so they can start providing for themselves and their kids. We also encourage them to stand up to their husband. Over a period of time, they start to listen and assert themselves. “

Often it can take as long as two years for behaviour change to set in.

Saira brings up the case of a woman in Shivaji Nagar who was pregnant with her fifth child. Her hemoglobin count was just 7.6 and she was always complaining of feeling dizzy and weak.

“The husband would shout at her for being lazy and as we started visiting her we realized that she hadn’t even registered her name at the local hospital”, says Saira. “This was because her husband would not give her money even to go to the hospital. She was a victim of domestic violence. Her husband would even shout at us when we paid a visit. ”

Saira finally took the help of a senior SNEHA staff member to convince the husband. “We were very patient and calm but it still took three months to get him to agree to a hospital delivery. In the meantime, we took the help of the local municipal health staff and started giving her injections and monitored her diet closely. Because she had little money, we encouraged her to eat dates, which are cheap but high in nutrition. She was able to have a healthy baby. “

The episode offers a glimpse into the level of focus and dedication that the community organizers bring to the job.

“In my experience, women and children’s health is an issue everywhere, “ says Archana. “The kids are weak but the mothers don’t think anything is wrong because they compare them with other kids in the neighborhood. They don’t realize that their child has not met important growth indicators. “

Given the sensitivity of such matters, I ask Archana how she speaks to the mothers without making them feel inadequate.

“When we talk to the women, we ask them what the kids eat and the answer almost always is – “I cook but he doesn’t eat what I make”. Then we ask if the kids have been given pocket money that day. The mother realizes that the child has spent the money on buying snacks, and does not want to eat what is cooked at home. We get the mothers to stop doing that. We also show them ways to cook such that the food is to the child’s taste. Like to partially fry an egg and add the roti so the child gets protein and carbohydrates. We have been able to encourage all the women to breastfeed, which was not the practice earlier.”

Ask Archana what difference being a community organizer has made, and her face lights up.

“I am so proud to be a CO. I have helped women who have suffered multiple miscarriages, deliver healthy babies. I have also been able to help couples conceive by telling them about ovulation. The money may not be much but the satisfaction is huge. It has helped to build ties within the community. Now when I don’t go to the community even for a day or two, the women tell me you haven’t come for so many days,” laughs Archana.

Why Family Planning must be key priority in Budget 2017

Just this month, a woman died and five others were critical after a surgery at a family planning health camp in Maharashtra’s Yavatmal district went horribly wrong.

The woman who died was just 36 years old. The death, according to reports, occurred because the government doctor at the Primary Health Centre cut the intestine instead of the fallopian tube while operating on her.

The tragedy brings home the critical gaps in India’s family planning programs especially in large parts of rural India. Given this, it is important that the government prioritizes family planning in the upcoming Budget to ensure that young couples are offered information about, and given access to FP options.

In 2015, the Health Ministry announced some welcome measures in this regard, like expanding the basket of contraceptive choices and ensuring their availability in district hospitals. There are now three spacing methods of contraception in the government FP program – Centchroman, Progestin Only Pills, and injectable contraceptive – offering greater choice and independence to users.

But India is still way short of the commitments it has made under FP2020. At the 2012 London summit, the country had promised to provide FP services to an extra 48 million new users by 2020.

The progress report in 2015-16 shows just how far we are from that goal. Less than eight million extra users have been catered to until July 2016. To meet the targeted numbers, the government has to allocate more resources towards meeting the FP needs of the population.

Census 2011 showed that over 10 crore girls in India get married before they are 18 years old. Young couples, across communities, come under great pressure to have a baby within a year of marriage. Many of them want to delay babies but don’t have the information or access to do so.

Expanding contraceptive choices for men and women while important is not sufficient by itself. They have to be empowered about exercising these choices and this has to be done through sustained community awareness campaigns by the government, civil society and other stakeholders. This needs extra staff on the ground and therefore more funds. The budgetary allocations to health and FP need to be substantially hiked.

India spends just 1.3% of its GDP on healthcare, a figure far lower than countries like Bangladesh, Brazil, Russia and China. Even Afghanistan and Nepal allocate more. Budget 2017 needs to address this shortfall.

Unsafe abortion – A major risk in India

Just how grave a threat unsafe abortion is for women is brought home in the data that 10 women die everyday in India. The country sees over 65 lakh pregnancy terminations every year. Unsafe abortion ranks as the third leading cause of maternal deaths in India. Hence access to safe abortion methods is critical to prevent these deaths.

In this context, the US President Donald Trump’s decision to bring back the Mexico City Policy, popularly called the Global Gag Rule, has major implications for women around the world, including India.

The Mexico City Policy is a US government policy that requires foreign NGOs to certify that they will not “perform or actively promote abortion as a method of family planning” with non-US funds as a condition for receiving US global family planning assistance. As of January 23, 2017, this includes any other US global health assistance, including HIV and maternal and child health (MCH).

The rule is a dangerous move against reproductive rights, as organizations will now have to choose between receiving American foreign assistance funds and providing comprehensive care. It dictates to foreign NGOs not just how American aid is to be used but also lays down that they must not spend their own money on providing abortion, and abortion-related services.

Poor or no access to contraception and safe abortion is a major public health crisis for women in the poor countries. The Global Gag Rule puts them in more danger as it puts them at risk of unsafe abortions.  The policy change will lead to the withdrawal of aid set aside for contraceptive access as well as comprehensive abortion care worldwide.

Once again politics has prevailed, and with the stroke of a pen powerful men have decided the reproductive rights of millions of women across the gobe.This is a move that affect women’s health and endangers their rights and independence. And the impact is widespread and damaging as it is well documented that giving women control over their reproductive health, improves not just the health outcomes of mothers and children but is key to economic progress.

Innovative approaches to tackling malnutrition

The malnutrition-related deaths of nearly 600 children barely 100 kilometres from Mumbai in 2016 underlines the critical need for various stakeholders to come together to find ways to bring about behaviour change, and ensure that benefits charted out under various government schemes actually get to those who most need them.

The fact is that children do not die of malnutrition but of causes due to malnutrition. Stunting is a better indicator of malnutrition and according to studies 51% of children and adults among tribal populations in Maharashtra are undernourished and stunted. This is a significant figure and one that has not shown sufficient improvement in the last few years.

Across India, the occurrence of wasting among children is serious. Even within the limits of the financial capital Mumbai, NFHS-IV shows that one-fifth of children under the age of five years suffer from wasting. This is very serious indeed given the associated risks of disease, even death, among children who are very underweight.

Since 2011, a program introduced and managed by SNEHA and CRY has shown the way forward when it comes to tackling urban malnutrition, especially wasting. Over a period of two years, the percentage of wasting in children reduced sharply from 18% to 12% in the slums of Mankhurd, Govandi and Kurla situated in the suburbs of Mumbai. SNEHA’s intervention in child health and nutrition in Dharavi showed equally encouraging signs – a fall of wasting from 18% to 13%.

The percentage of children who received full immunization rose from 66% to 73% in the three areas mentioned earlier. There were also other positive changes, like rise in hospital deliveries (12 up to 15%), adoption of family planning methods (34% up to 59%) and a dramatic drop in pregnancies among women below the age of 20 years. (17% up to 4%).

The changes took place because of a sustained merging across different sectors at the community level to enhance child under-nutrition. This was backed up with enabling behaviour change through home visits, one on one counseling, awareness campaigns, and community meetings. This led to greater adoption of FP methods, immunization and better nutrition practices.

Urban malnutrition is a challenge not just peculiar to world cities like Mumbai. Tackling it requires innovative and creative approaches that take the community’s needs and pressures into account. The program by SNEHA and CRY offer a window into an approach that could show results in many parts of India to reduce malnutrition rates.

 

 

 

Ehsaas: Making Boys Part of the Solution

It is now widely recognized that improving the status of women has to involve boys and men. As much as girls, boys too are trapped in stereotypes and they need to recognize and value the importance of building equal and healthy relationships.

Unequal power not only suppresses women and girls, but also oppresses men and boys. Apart from the pressure of being the economic provider, rigid gender roles also limit men’s cultural experience. There is the pressure to appear virile and strong at the cost of suppressing emotions.

Since 2013, SNEHA’s Ehsaas program has been working among adolescents in Mumbai’s slum communities towards breaking these stereotypes. Through a mix of street plays and community sessions with adolescents and their families, gender stereotypes are questioned and challenged.

“The attitude has been to look at boys as problems”, says Neeta Karandikar, associate program director, Ehsaas. “This is especially the case after the Nirbhaya and Shakti Mills incident in Mumbai where the accused were from the slum areas. Boys from poorer communities were seen as problems. But we have to recognize the challenges they deal with”.

Traditional patriarchal attitudes, believes Karandikar, not only oppress women but act as traps for boys and men. By highlighting norms that allow boys to play while girls do hosuehold chores, Ehsaas encourages youngsters to question prevailing mindsets.

“My sisters would eat only after the men of the house would finish their meals”, says Shahid Shaikh, a peer educator with Ehsaas. ‘I never questioned that. It was after I joined the program that I realized how wrong this was and I now make sure they eat with everyone else”.

For decades, gender equality was considered a woman’s issue. Now, there is a realization that the role of men and boys in challenging and changing unequal power relations is critical. There is a stronger focus on the positive role men and boys can play in promoting women’s empowerment in the home, community, and  workplace.

To know more about Ehsaas, read this NDTV report 

Giving Girls a Voice

Just how distant a dream going to school remains for girls in India is borne out in the new data on female literacy.

According to this study, the proportion of girls who finished five years of primary school in India is 48%, which is far lower than Nepal (92%), Pakistan (74%) and Bangladesh (54%). The data also shows that only 15% of Indian women who studied till Class II can read a sentence.

Gender, location and poverty remain such huge barriers for a majority of girls in India today. The bias against educating girls keeps them vulnerable to female infanticide, early marriage, gender violence, and sex trafficking.

This can only change when education comes to be seen as a vital necessity for everyone, regardless of gender, rather than an advantage that only the privileged have.

Investing in every girl’s education has to be seen as critical for social and economic development, for lifting households out of poverty.

Educating girls is necessary to reduce the number of child marriages, which remain high in large parts of India even today despite being against the law. Studies show that women who get a secondary school education are 92% less likely to be forced into an early marriage. This in turn makes them vulnerable to early pregnancies, domestic violence, HIV and depression.

Education also has a direct link to lower maternal and infant mortality rates. It helps build awareness about better hygiene, vaccinations and nutrition. It enables more informed choices on matters like family planning and employment. Studies show that women who have had the opportunities to go to school are two times more likely to send their own kids to school.

All of which make compelling arguments to ensure we do more to send every girl in India to school.

 

 

 

Child marriages & impact on mental health

The impact of early marriage on the reproductive health of women has been well documented, but the effect on mental health often gets overlooked. Child brides often find themselves struggling to cope with anxiety and depression and find little sympathy or support in their marital home.

A sociological study done by the University of Calicut among 600 women who had married before the legal age found that most of them were in conflict with their husbands and other members of the marital home. They were under pressure to take over the household chores and produce a child early.

Any assertion of right or voicing an opinion was treated as a challenge and often met with ridicule, even physical abuse.

A new India wide study by the Delhi-based SAMA Resource Group for Women and Health is also examining the wider impact of early marriage on a woman’s health. Early findings of the report say that when girls are forced to leave school and marry, they experience a loss of mobility. The immediate result is a loss of companionship as they are no longer free to meet their friends. This is a major cause for distress.

Every aspect of their lives comes under close watch – from what they wear to whom they speak to – so there is a constant feeling of apprehension that they might break the rules.

Any sign of sadness or unduly quiet behaviour is regarded as proper and hence gets ignored. It is only when the signs of mental health become very obvious that outside help is sought and this is not professional help, but from traditional faith healers.

“Whenever there is physical violence, it shows up in scars”, says Praful Kamble, Program Officer of SNEHA’s Little Sisters program which has been working towards bringing addressing domestic violence issues in Mumbai’s Dharavi area. “But the impact on the mind is 25% more. There is depression and a sense of shock. And when there is negative support from the family, the woman feels even more isolated.”

Geeta (name changed) experienced verbal violence from her in laws and husband, as her son was constantly ill. Even her sisters-in-law did not support her. One day she threw kerosene on herself and set herself on fire.

“I did it out of despair”, she says. “Caring for a sick child was stressful as it is and then to be constantly blamed for it was a miserable feeling. I was worried for my child and had no idea where to seek help.”

There are multiple linkages between early marriage and health. Mental health is a key one, and needs greater focus in India’s programs and policies.

 

Let’s Talk About Periods

She may have missed out on a medal but Chinese swimming star Fu Yuanhui is being hailed as a champion back home and around the world for breaking the taboo that comes attached with periods in sports.

Fu attributed her team’s failure to make it to the top three in the 4x100m medley relay to the fact that she started her periods a day before the event, a remark that the Chinese media was quick to praise, given the silence that surrounds menstruation. Soon athletes and activists around the world picked followed suit.

Across the world, and more so in countries like China and India, there are a deep-rooted cultural resistance, even stigma, attached to periods. There is indignity and even a certain revulsion attached to it, which prevents open discussion. Which makes statements like Fu’s, or American musician Kiran Gandhi who ran the 2015 London Marathon while she had her periods, welcome.

For those who might think them over the top, consider this. Menstruation remains a major barrier to achieving gender equality in many parts of the world today.

Adolescent girls in developing countries miss five days of school in a month due to lack of access to sanitary pads and hygienic toilets in schools. This makes them fall back in education.

Menstruating women in countries like Nepal and India are seen as impure and a sign of bad luck. They are made to sleep outside their homes and eat out of different utensils.

If talking about periods openly and scientifically can help end this damage of a million lives, then by all means let us all start.

Time to End the Shame Around Breastfeeding

Last week, protests were witnessed across Argentina by groups of women who breastfed their babies in public. They were agitating against the police’s move to throw out a mother from a square in Buenos Aires for nursing her infant in public.

Carrying signboards that said, “Nursing is not up for discussion” and “My breasts, My rights”, over 500 women took to the streets in different parts of the country demanding respect for mother’s rights.

Breastfeeding is a simple, no-cost intervention that boosts the health of children and women substantially, in rich and poor countries. Yet there is little awareness about this. And as we get set to observe World Breastfeeding Week (August 1-7) around the world, experts are calling for programs that encourage ideal breastfeeding practices.

Studies in The Lancet point out that increasing breastfeeding to optimum levels could save over 800, 000 lives every year, most of them children under six months. Also, nearly half of all diarrheal diseases and one-third of respiratory infections in children in low- and middle-income countries could be prevented.

Babies who get no breast milk at all are seven times more likely to die from infections than those who get some in their first six months.

Children who are breastfed also do better at intelligence tests, are less likely to be overweight and less likely to get diabetes later in life. The benefits to mothers are also huge. They show lower risk of developing breast and ovarian cancers.

The awareness is especially abysmal in low-income countries, like India. And it does not help that the government has not aggressively promoted breastfeeding. The focus on bringing down maternal and child deaths has been heavily directed towards promoting institutional deliveries, antenatal check-ups and neonatal care.

There are many barriers that come in the way of early breastfeeding in India and this helps explain why signs of childhood malnutrition like stunting (45%) and wasting (20%), that depend significantly on early breastfeeding, remain high.

According to studies, only one in four mothers are able to start breastfeeding within one hour of giving birth and less than half of all mothers are able to exclusively breastfeed their babies for the first six months after birth.

Supportive health-care systems, workplace interventions, counseling and educational programs are needed to improve breastfeeding. The government’s recent moves to bring changes to the Maternity Benefit Act of 1961 are welcome steps.

There is also a need to break the wider social shame that exists around breastfeeding in public, something the UN has also acknowledged by backing the social trend of belfies – mothers sharing pictures of themselves breastfeeding. It is a welcome step towards ending that stigma and spreading the word about the importance of a mother’s milk.

 

 

 

Pregnancy prevention is still a woman’s problem

An RTI report has uncovered that a total of 26 women died while undergoing sterilization in Mumbai over the past five years, ten in 2015 alone. They went through a tubectomy, which has been the mainstay of India’s family planning program since Independence, a method that the government has promoted as safe, reliable and effective.

Yet time and time again, come reminders like this one of how perilous the procedure can be, especially when the women have persistent and deep-rooted health problems. The most heartrending was the aftermath of a government sterilization camp in Bilaspur, Chhatisgarh in 2014. Thirteen women died and over 120 left with serious health problems after the procedures were botched up due to poisonous medicines and medical negligence.

Be it a rural health camp or a thriving metropolis like Mumbai which reportedly has better access to healthcare, the point is that female sterilization is fraught with risk and there has to be a move away from pushing this. Since April this year, the Ministry of Health has finally introduced the much talked about basket of choices in family planning methods across district hospitals, an acknowledgement that a move away from female sterilization is long overdue.

However, making those choices available is a challenge, especially in rural areas. Making sure that stocks of contraceptives are made available at hospitals and primary health centres is just one part of the challenge. Creating awareness and counseling is also an important aspect.

These are demands that cannot be met adequately given the huge shortage of health workers and doctors across urban and rural areas. The main reason why sterilization continues to be used so widely is because it is a gunshot intervention. It requires no follow up, any check ups or counseling over a period of time, which makes it a popular choice with the medical staff.

The same BMC data for Mumbai also tells an interesting story. Between April 2015 to March 2016, 18,910 women in Mumbai underwent a tubectomy, as opposed to just 810 men who opted for vasectomies in the same period. This is despite considerable evidence that vasectomies are less invasive and require less post surgery care.

All this points to how women are so disempowered when it comes to childbirth. She has no say on when, or how many children to have; yet when it comes to preventing a pregnancy, it remains entirely her problem.

“Vasectomy and safe family planning methods need to be aggressively promoted if we care about women’s health”, says Dr Vijaya Sherbet, a gynecologist at Bengaluru’s Columbia Asia Hospital. “That sense of empathy, of political will has been largely missing.”

Signs of a change are evident. Tubectomy rates are down and doctors at government hospitals are promoting alternate FP methods. But this is in Mumbai, the financial capital. Rural India, or even the outskirts of Mumbai city offer an entirely new set of challenges.

 

 

An app that is saving women’s lives in Dharavi

One of the most positive fallouts of the rapid mobile phone penetration in India has been the impact on education and health in rural India. These are parts of the country that have been left out of the benefits of the economic boom and progress seen in urban parts, either due to poor infrastructure or lack of political will. Be it apps that provide health updates or learning tips, start ups are coming up with creative, innovative ways to reach a constituency that was regarded as difficult to access for the longest time.

One such initiative that has received much attention, and for the right reasons, is SNEHA’s Little Sister project that deals with the sensitive subject of domestic violence. DV is rampant in India but has never been given the attention it needs given the scale as most women do not report it. Many of them don’t even see it as an issue as a nationwide survey in 2013 found out. Over 50% of women said it was justified on many counts.

Apart from being a human rights issue, DV is also a health issue. It impacts women’s health in a myriad ways – from causing Post Traumatic Stress Disorder to depression and even affecting maternal health outcomes. Also think of the impact on a child who watches his mother get verbally abused or physically beaten up? You are looking at a generation that will grow up to be either abusers or victims of abuse.

SNEHA’s Little Sister app works by offering women in Dharavi a safe space to seek help. It is private, non intrusive and effective. Most victims of DV are not looking to walk out when they seek help. Often they want a shoulder to cry on before deciding what to do next. Little Sister does just that. It allows the woman to set the pace. Its the comfort of reaching out to someone who you do not have to see again if you don’t wish to and who will not judge you, or your situation.

To find out more about the Little Sister project click here. There is a video link about the project as well. 

 

 

 

Making girls count: Why open data matters in gender development

“Closing the gender gap is not possible without closing the data gap.” – Melinda Gates

One of the key announcements to emerge from the ongoing Women Deliver 2016 at Copenhagen is the launch of a new data and research partnership to monitor and drive progress on gender targets outlined in the Sustainable Development Goals.

Key to meeting these new gender targets is reliable and up to date information on women and girls to help ensure transparency, accountability and citizen engagement. In most countries, this data is largely missing or incomplete, be it on child marriages, dowry deaths, domestic violence, the wages women are paid, or why and how many girls are dropping out of schools. Having the data helps set concrete plans and goals and hold governments accountable.

This is especially critical in these times given the global financial crisis, natural disasters and widespread political instability. Take climate change related disasters for instance. There is evidence to show that every such crisis affects men and women differently. This is especially the case in developing countries where women face greater risks to life and health due to social structures. However the lack of adequate data to support this differentiated impact means they don’t get taken into account at the policy level.

“Making all girls visible in statistics is a critical first step towards holding governments to account and implementing the girl-focused global goals”, believes Anne-Birgitte Albrectsen. CEO of Plan International, which is one of the groups leading the joint research initiative. Progress on gender equality goals are slow because there are no numbers to track it. “We do not adequately measure the number of girls who leave school due to marriage, pregnancy, or sexual violence, simply the number in school. Millions of girls are left invisible”, adds Albrectsen.

This invisibility supports the attitude that girls and women simply do not count. Having hard numbers for where they live, what they go through and what they want will help bring down that wall.

 

Maternal deaths in Mumbai down but there are areas of concern

 

The recent data released by the Brihanmumbai Municipal Corporation showing a drop in maternal deaths in Mumbai is good news. According to the report, maternal deaths in the city fell to 311 in 2015-16. This is welcome given that the figures on this front have seen a steady rise over the last few decades, except for 2013-14.

One of the main factors is that anaemia, which has been the single largest contributor to the high maternal deaths, has seen a major fall. According to the report, anaemia is behind less than 2% of the maternal deaths in 2015-16. Until a few years ago the figure was as high as 25%. This shows that interventions by the BMC alongwith various organizations like SNEHA in slums have paid off. There is greater awareness about the importance of taking folic acid tablets, calcium and iron from the early stages of pregnancy.

As women I spoke to in Dharavi point out, they would rarely remember to take these supplements during pregnancy. And even when they did, they had no idea how to. They would simply club them together.

“Now I am aware that I have to space them out through the day so they are effective,” says Vandana, who is pregnant with her second child. “These are things that I learned from counselors who visit the area”.

Another positive is that the fight against tuberculosis is showing results. It contributed to 6% of maternal deaths in 2015-16 compared to 11% in 2015-16. Proof that DOT centres in the slums and awareness campaigns by the BMC is paying off.

However, what is worrying is the threat posed by poor sanitation and hygiene. The BMC data shows that a majority of maternal deaths are due to hepatitis – both A and E. Both strains are directly attributed to poor hygiene and the lack of clean water. Around 14% of the deaths in 2015-16 were due to hepatitis.

Experts say the figures highlights the lack of clean water in the slums, Most of the slums, especially in the tertiary areas like Govandi, rely on water from tankers. Lack of safe water is a major risk factor during and post pregnancy.

Apart from ensuring clean water supply, there is also a need to strongly promote better hygiene and sanitation practices like boiling water, washing hands and using public toilets to reduce infections. The solutions are many and entirely in our hands. Like the fight against anaemia, this too is a battle that can be won.

 

Water crisis has links to women’s rights & economic progress

Just how grave the water shortage in India is brought out in IndiaSpend’s latest report, which says that India is facing the worst crisis in a decade, with the shortage likely to create drought-like conditions in many parts of the country.

We are already seeing the worst of it in many regions. Farmers in Bengaluru led a protest over water scarcity that lasted days. The water crisis in Karnataka is affecting Tamil Nadu and Andhra Pradesh, which are among the states that will be worst hit this year.

The impact of this scarcity will be felt most by women and children, especially girls, on every count, be it health, education or nutrition.

In Bundelkhand, Uttar Pradesh, the acute drought has led to an alarming drop in nutrition levels. 86% homes have cut down on dal intake, while 84% have cut down on milk for their children.

The threat of food scarcity is not limited to Uttar Pradesh alone given that there is not enough water to irrigate farmlands. So we are looking at a potential food shortage across the country.

Clean water affects education. It helps keeps children in schools. This is especially true of girls because in rural India, the task of fetching water still remains the primary responsibility of women. Families in Marathwada, in rural Maharashtra, which is facing severe water scarcity, are pulling their children out of school so they can help fetch water.

Perhaps the biggest concern is the impact on health. The acute shortage of safe, drinking water will lead to a spiralling of diseases like diarrhoea. There are over 300,000 diarrhoea-related deaths in the world every year. 45% of them are from India.

Access to clean water is not just a supply and demand issue. It has links to women’s rights, maternal and infant health and overall economic progress. Its time we looked at water from a larger perspective rather than battling it from season to season.

 

Quiltessentially SNEHA – Threads that bind and empower

As you walk into the exhibition of Quiltessentially SNEHA, the thought that strikes you is how the sea of rich patterns and intricate weaves is such a powerful expression of SNEHA’s work; conveying both the range of its outreach work and the ties it builds in the communities it works in.

Quiltessentially SNEHA, the livelihood project started in 2009 by the Society for Nutrition, Education and Health Action, aims to equip women in slums with various skills that will strengthen them financially

“I was supervising a tailoring class for adolescent girls and women and that’s when the idea came about. We thought why not start a small unit that makes patchwork quilts”, says Naina Fernandez, project director.

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Naina Fernandez, Project Director & Seema Singh, Volunteer

Initially she relied on fabrics donated by clothing and furnishing stores that usually have large swatches left over.

“We taught the women basic stitching skills and we had some sewing machines and we were set to start”, she says.

The women would put the pieces together guided by creative inputs from Fernandez.

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This is how it all started, with patchwork quilts

Some families took a little convincing at the start.

“There was this young girl who was really talented but in the early stages, the earnings weren’t that good”, says Fernandez. “Her family pulled her out because they felt she was better off working as a domestic help. I stepped in and insisted that she had a gift and they should not stop her from coming to the center”.

From quilts, the range of products has expanded way beyond to dupattas, bathroom mats, bedspreads and cushion covers. And then there are the small and thoughtful items like pouches for sanitary pads, an idea that Fernandez says came from school-going adolescent girls that SNEHA works with.

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Pouches for sanitary pads

The designs are never repeated so each product is unique. The demand for the products is huge, especially among corporate houses.

The project employs about 40 girls and women, with 13-15 working on a shift basis. The timings are flexible as many have young children or elderly in-laws to look after. On an average, each person earns upwards of Rs 5000 a month.

Income that Manali, one of the earliest members, says comes in handy, especially when finances run low.

“My husband is a BEST driver and he earns decently but we used to feel the pinch when my children needed books or clothes. Now I contribute and ease the financial burden which makes me feel great”, says Manali. “I am able to support my family”.

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Manali (right), among the early members

Above all, the project offers a safe space for women to get together and bond over shared experiences and issues.

“We stitch together, we share, laugh, chat, give each other advice and in the process feel lighter”, says one of the project members.

 

“I can often hear them giggling loudly as they work” laughs Fernandez. “People in the nearby units tell me these people make such a racket. So I know they are in a happy space.”

 

 

How Climate Change Impacts Women More

Amidst the stream of news reports on the severe drought across India, here is one that didn’t make it to primetime.

It’s the story of Yogita Ashok Desai from Maharashtra’s Beed district who died of a heat stroke. The 12-year-old was dehydrated and collapsed after her fifth trip to the village hand-pump to fetch water. Just last month,  a 10-year-old girl from Pimpalgaon village, also in Beed district, died after she fell into a well while trying to draw water.Both girls had been pulled out of school to help their families cope with the severe water scarcity.

The reasons for the worsening drought are many; many of them manmade like the indiscriminate digging of borewells and the cultivation of water guzzling crops. Decisions that women had little to do with. excluded as they are from choices relating to irrigation systems or what crops to grow. However, they are facing the worst impact.

A recent World Bank report, Shock Waves – Managing the Impacts of Climate Change on Poverty, highlights how ending poverty and addressing climate change is key to achieving sustainable global development. Addressing climate change is critical as it directly impacts availability of food and heightens health risks.

Most vulnerable are the poor and marginalized, and within that group, women and children. There are various studies that show that women, especially in developing countries like India, suffer the impacts of natural disasters and climate change more due to cultural norms.

In rural areas, women rarely work and are economically dependent on their husbands for survival. Faced with a severe drought, men have the resources and the independence to find ways to adapt. Women are denied those options.

Faced with a shortage of food, women place their husbands’ and sons’ needs above theirs or their daughters’, making them vulnerable to diseases.

Faced with income or food crunch, girls’ get hit the hardest. They get pulled out of school and are expected to help with the household chores. Their nutrition and health gets neglected. Climate change also affects availability of water. Women and girls’ are expected to fetch water for the family, often traveling long distances to do so.

As Rachel Yavinsky points out in her 2012 study, their secondary role and lack of decision-making power severely limits women’s ability to adapt to climate change.

“Without participation by women, programs to replace traditional crops with those better suited to the changing environment might focus only on the needs of men’s fields and not address the problems women face with household gardens’, says Yavinsky.

She points to various studies that demonstrate how women can be effective agents of adapting to climate change if equipped with information and power. In Bangladesh, for instance, women farmers switched to raising ducks because they kept losing their chickens to frequent floods.

Empowering women, especially rural women, is necessary to address climate change effectively. Climate change will affect all os us, most of all women, and unless we empower them, building a sustainable future will remain a distant dream.

International Day for Maternal Rights – Time to Act

This week the world marked the second International Day for Maternal Health and Rights. High time the world paid attention to maternal health given that even today, in circa 2016, a woman dies in childbirth every two minutes. Clearly there is a need to promote and set up a comprehensive and rights-based approach to maternal health.

These rights are abused in many different ways, be it in terms of lack of access to quality health care during pregnancy, lack of information on birth control and availability of methods, or the abuse and disrespect that women are subject to during pregnancy and childbirth in hospitals and primary health centres.

Applying a human rights-based approach requires policy makers and health care providers to see women not as clients or patients or victims, but as those whose rights should be maintained and upheld in the context of health care.

It’s an approach that has been missing in the Indian government’s single-minded focus on increasing institutional deliveries. Broader sexual and reproductive health issues like access to safe abortion, setting up of adolescent friendly services, access to pap smears and mammograms, and promoting gender equity in family planning have been mostly neglected.

While nationwide surveys may show the maternal deaths rate declining, the statistics bury some hard realities. Anemia, which has a direct bearing on maternal health, continues to affect over 55% of Indian women. The poor and the marginalized face discrimination from healthcare providers. Caste continues to dictate access to immunization and other factors that help determine safer pregnancies.

These are factors that cannot be addressed by simply increasing the number of hospitals, healthcare providers or contraceptive choices. While structural changes like building stronger health systems makes a difference, maternal mortality is closely linked to development and cultural factors that are harder to change. Parts of the bigger picture may have shown some improvement, but what is missing is a rights based approach.

People, Planet, Prosperity & Peace – How gender equality is critical to achieving these goals

Today is International Women’s Day, and the theme of 2016 is Gender Equality. The theme was set by UN Women, the United Nations organization dedicated to women’s empowerment, within the context of the new Sustainable Development Goals for 2030. The SDGs, which follow the Millennium Development Goals, cover 17 goals across four categories – people, planet, prosperity, and peace. For progress on each of these goals girls and women have to be empowered.

Think about it. Women’s roles are varied – they are breadwinners, farmers, teachers, businesswomen, mothers; they contribute to their homes, the community and the economy in multiple ways. Because they are at the forefront, they are often more affected than men by factors like climate change, revolutions, economic crises and poor health care. Hence, their assistance and direction is needed to achieve the SDGs.

Take SDG 1, which is bringing an end to poverty. This can be achieved only when there is no gender-based discrimination. Gender inequality denies women basic rights and opportunities for wellbeing.

If a woman is not given access to the same wages and services as men, she will remain deprived. For instance compared to male farmers, women farmers have less access to seeds, credit and technology. This in turn feeds into SDG#3, which aims to ensure health lives. Food security affects nutrition, and if women are not healthy, their babies will be malnourished.

The links to empowering women are not always so direct. Ensuring water availability for example benefits men and women. But the fact is that it is women who spend hours everyday collecting and transporting water that the family needs. Also it is lack of water that leads to girls dropping out of school when they start menstruating, a factor that comes in the way of a gender equal world.

“Gender equality is advanced when girls can stay in school because they are able to delay marriage and childbearing”, says Ellen Starbird, Director, USAID office of Population and Reproductive Health, “and when they are empowered to make healthy reproductive decisions and exercise their reproductive rights. Constructive engagement of boys and men to change gender norms must also be part of these efforts. “