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Ensuring Quality of Care in Reproductive Health %28English%29 |
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Ensuring Quality of Care in
Reproductive Health
An Advocacy Handbook
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Ensuring Quality of Care in Reproductive Health
An Advocacy Handbook
Population Foundation of India
8-28, Qutab Institutional Area, Tara Crescent
New Delhi, 110016, India
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Population Foundation of India
B-28, Qutab Institutional Area, Tara Crescent
New Delhi, 110016, India
Cover Design & Layout
Ayan Chakravarty
Photo Credit & Information Resources
• KRITI Resource Centre, Lucknow
• Healthwatch Uttar Pradesh-Bihar
Printed at
Creative Printers, Lucknow
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Tools and Strategies for Effective Advocacy
• Printed Material
• Media advocacy
• Internet based advocacy
• Public Hearing and Tribunals
• Community monitoring
1. Fact Sheets
• Unsafe Motherhood
• Abortion
• Family Planning - Sterilisation
2. Advocacy Frameworks
• Constitution of India
• Policies - NPP, NHP, NPEW
• National Policies
• National Health Policy
• Indian Laws
• International Law -ICESCR, CEOAW
• International Convenant on Economic Social and Cultural Rights
• International Agreements - ICPO, FWCW
• Fourth World Conference on Women
3. Quality of Care Frameworks
• QoC Parameters - Maternal Health
• QoC Parameters - Female Sterilisation Operations
• QoC Parameters - Medical Termination of Pregnancy
• List of Reproductive Health
• Patients Rights
• Patients Responsibilities
• Needs of Service Providers
• Consumer Rights
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The Reproductive Health approach has emerged as the approach of choice in addressing women's
health, family planning and reproductive health issues. The unique features of this approach is that it
no longer considers women as passive mothers whose health is only of interest when they bear
babies or when they become 'eligible' for family planning. Gender equality, human rights, increased
range and quality of services, voluntary and informed choice, prevention and control of abuse by
program managers and women's participation in management decision making have become integral
features of this new approach.
The Family Planning programme in India has for long been driven by the twin imperatives of maternal
health and family planning leaving a large number of women's health issues including many
reproductive health issues unaddressed. However after the International Confefence,onPopulation
and Development held at Cairo in 1994, India has been .in theforefrontm inCOlPQrating changes in
the way the Family Planning programmes have been conceptualised and delivered. Key changes
were the abolition 'of contraceptive targets, adoption of the Community Needs AssessmentApproach
and the Reproductive and Child Health programme.
These changes in approach have been reflected in changes in the quality and nature of services
available to women in some places, but this has not been uniform across the country. Quality of care
of reproductive health services continues to poor in many places despite many efforts to improve
them. It is in this context that advocacy assumes a major role. Advocacy can be seen as efforts by
women and community members themselves to strengthen demand for quality services. It is a tool
of community empowerment where communities realise their own needs and on the basis of knowledge
about existing provisions they are enabled to demand for services. This kind of advocacy leads to
many benefits. It has the potential for putting in place joint assessment of community needs,
collaborative planning for health related interventions as well as setting up forums for monitoring
quality of services. Seen in another way it helps grass roots democracy and citizen participation
which is a long cherished dream for our country.
Population Foundation of India has been involved in advocacy for strengthening Quality of Care of
Reproductive Health services and this Handbook has been prepared with the expectation that it will
strengthen advocacy efforts all over the country. The Handbook has been divided into two sections.
The first section provides a theoretical overview of reproductive health and rights, quality of care and
advocacy, while the second section provides evidence and frameworks and tools for advocacy.
The preparation of this advocacy Handbook would not have been possible without the support of Mr
A.R.Nanda who has been a very strong votary for Reproductive Health related advocacy. Dr Almas
Ali and Dr Lalitendu Jagdeb provided constructive feedback. Finally this advocacy Handbook draws
upon the inspiration and support of all colleagues from Kriti Resource Centre, Centre for Social
Justice and Healthwatch UP Bihar.
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Health programmes for women have traditionally been limited to two kinds of services - family planning
and maternal health. While maternal health is an important issue of concern and women do have
contraceptive needs, this approach ignores the other health concerns of women, notably the
reproductive health concerns like reproductive tract infections, prolapse of the uterus, infertility or
cancer cervix, which do not find place in other national public health programmes. The traditional
approach also ignores women's socio-economic reality and compulsions, and how these impact
women's health status. These limitations and a new understanding of women's health led to women's
health researchers and activists all over the world demanding for greater focus on women's health
and development. The global emergence of HIV/AIDS and other Sexually Transmitted Infections
also brought the attention to reproductive and sexual health.
As a result of this increasing understanding of the multiple dimensions and the complex nature of
women's reproductive health problems, the concept of reproductive health was adopted at the
International Conference on Population and Development (ICPD) at Cairo in 1994. India was one of
the 179 countries which were signatories to the ICPD Program of Action (PoA).
Reproductive health is a state of complete physical, mental, and social well-being and not
merely the absence of disease or infirmity, in all matters relating to the reproductive system.
It implies .....
• a satisfying and safe sex life
• the capability to reproduce, and right to decide if, when and how often
• to be informed and to have access to safe, effective, affordable and acceptable methods
of FP
• safe pregnancy, child birth, and a healthy infant
• methods, techniques and services that contribute to reproductive health and well-being
by preventing and solving reproductive health problems
• sexual health which is not merely related to care and counselling but the enhancement
of life and personal relationships
• a life cycle approach
As a result of ICPD PoA the focus of family planning programs shifted from fulfillment of national
demographic goals to fulfillment of reproductive goals of individuals and couples. The changes in
the conceptualization and delivery of reproductive health services that were proposed at the Cairo
Conference, were based upon the overall principles which gUide the ICPD PoA. The respect for
human rights, the concern for gender equality and equity and the need for universal access to services
which enable the enjoyment of the highest quality of physical and mental health were now the key
guiding principles for service delivery. In concrete terms these translated into the following
• Voluntary and Informed Choice
• Addressing unmet needs
• Improve range and quality of services available
• Removal of Demographic goals and targets
• Increased participation of men
• Women's Participation in management
• Prevention and control of abuse by program managers and providers
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The decade of the 1990's was marked by many
changes in the way the National Family Welfare
programme was designed and delivered. Following the
ICPD the Government of India introduced a number of
changes, though the process of change had begun
earlier. In April 1996 the Target Free Approach (TFA)
was announced, doing away with method specific
contraceptive targets which had become a major
controversial component of the programme. In 1998
the government started the Reproductive and Child
Health programme with financial assistance of the
World Bank. In 1999 the TFA was renamed the
Community Needs Assessment Approach ( CNAA)
emphasizing the need to engage in bottom up
community based planning. The National Population
Policy was adopted in 2000 and this policy lays down
the blue print population and development programmes
in India.
A new approach to Family Welfare called the
Reproductive and Child Health (RCH) programme was
formally adopted in October 1997 and the RCH
programme document acknowledged that "it is the
legitimate right of the citizens to be able to experience
sound Reproductive and Child Health" and promised
that "the services to be provided will be client centred,
demand driven, high quality and based on the needs
of the community. The RCH program drew part of its
inspiration from the ICPD and incorporated the
treatment of reproductive tract infections (RTI) and
sexually transmitted diseases (STD, adolescent health,
IEC for sexuality and gender within the ambit of its
activities.
The RCH programme was started with a 250 million
US dollar assistance from the World Band and aimed
to improve the performance of the Family Welfare
programme through four objectives. Three of these
objectives pertained to provision of services -
• improvement in quality, coverage and effectiveness
of services,
• increase the scope and range of services offered
under the family welfare programme and
• increasing the access to RH services.
The fourth objective pertained to strengthening
management and institutional strengthening.
Some of the key features of the new programme which
go beyond the mere incorporation of the earlier
programme components are described as follows:
• Integration of fertility regulation services, maternal
and child health services with reproductive health
services for women and men
Changes in Approach and Delivery of
Family Welfare Programme
1991-92 - Removal of targets in Tamil Nadu
1992- Eighth Five Year Plan - calls for review
of targets
1992-93 - Child Survival and Safe
Motherhood Program
1994 - ICPD , Cairo
1995 - Removal of targets in 1 or 2 districts
in all states
1996 - TFA announced
1997 - RCH programme launched
1998 - TFA re-christened as the Community
Needs Assessment Approach (CNAA)
2000- National Population Policy announced
Range of Services provided under RCH
program
Antenatal care
• Registration of pregnancies
• At least 3 antenatal visits
• Iron prophylaxis
• Detection and treatment of anaemia
• Referral/management
pregnant women
Natal care
of high risk
• Delivery by trained personnel
• Increase in institutional delivery
Post natal care
• 3 post natal visits
• Monitoring and care of the newborn
• Referral/management
new born
Provision of care
pregnancies
of the high risk
for unwanted
• Referral and management of unwanted
pregnancies through MTP and safe
abortion
Identification and management of RTI/STI
Child health
• Immunisation against 6 diseases
• Vitamin A and iron prophylaxis
• Management of pneumonia
• Management of acute diarrhea
Contraceptive Services
• Providing sterilization, IUD, oral pills and
condoms
Recording morbidity and mortality
• Incidence of
vaccine preventable diseases
Pneumonia
Acute diarrhea
RTI/STI
• Numbers of maternal and child deaths
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• Client centred, demand driven, high quality services
• Upgradation of facilities for improving quality of services and variety of interventions, with focus
on MTP services, IUD insertion and counselling
• Improve access by decentralizing services and outreach
• Reaching services to special vulnerable groups like urban slums, tribal populations and slums.
In order to reach the appropriate services to the appropriate clients and to focus on the districts with
poorer RCH status, all the districts were divided into A, Band C categories with a different mix of
services for each category. The RCH programme also proposed larger roles for NGOs, for the
practitioners of Indian Systems of Medicine and the Panchayati Raj System.
The first phase of the RCH programme is now nearly over and the second phase called RCH 2 is
being planned and negotiated.
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Quality of Care in Reproductive Health
The health care provider is supposed to provide technically appropriate health care to the patient. To
ensure that the patient receives appropriate care the system of health care delivery is divided into
specialities and there is supposed to be an arrangement of referrals that ensures that the person
with a particular kind of problem reach a particular practitioner. The provider is supposed to be the
expert and his/her advice and treatment reflects this expertise. The more qualified the provider, the
more up-to-date the investigations and drugs the more high quality it is supposed to be. However
most patients know, that at times the treatment from two doctors with the same professional degree,
is slightly different. The doctors use their own judgement to make what they feel is the most appropriate
treatment. How can the patient then case be sure which of these treatments is of better? Is the
doctor who has a better bedside manner better? Is the doctor who has a more well equipped clinic
better? Or is the doctor who prescribes more tests and gives more drugs better? The basic question
is how do we judge between different kinds of healthcare services? Understanding quality of care is
one way in which we can make such a jUdgement, and as managers, providers or clients we can
make choices about what kind of service to provide or use.
There are a number of definitions of quality of care and some of these are given below.
~ Quality of care is the degree to which health services for individuals and populations increase
the likelihood of desired health outcomes and are consistent with current professional knowledge.
( Institute of Medicine 1990)
~ Quality of care can be defined by the way the clients are treated by the system, or the actual
process of care-giving, and by the focus on the client's or user's perspectives of services (Hull,
1994).
~ The degree of match between the client's view of the performance of the services and the service
providers view determines clients satisfaction (Ishikawa, 1985)
~ Quality of care is
Doing the right thing
Doing tl;lings right
Doing things at the right time
Doing things with the right attitude (Abou-Zahr, 1994)
From the different definitions given about it is clear that providers attitude towards the client, the
clients satisfaction and perspective, as well as technical appropriateness and the desired health
outcomes are important components of quality. Other important aspects of quality especially in a
community health care setting are management issues like access, training, infrastructure.
Over the years there has emerged some form of consensus regarding what constitutes quality of
care of health services however this consensus is strictly from the provider's perspective. Different
frameworks have been proposed to define quality of care the most notable among them in the context
of Family Planning programmes being the one proposed by Judith Bruce (1990) which incorporates
six elements. These include
(1) Choice of methods
(2) Information given to users
(3) Technical competence
(4) Interpersonal relations
(5) Mechanisms to encourage continuity
(6) Appropriate constellations of services
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The Judith Bruce formulation is a very robust definition and has been applied to measure quality of
services for a long time. However in recent years the increasing focus of 'elient's perspectives has
led to the addition of other components to this framework. UNFPA has developed a reproductive
health quality framework which includes nine elements. Of these nine elements five are applicable in
all situations while four are specific to the different reproductive health conditions. An important
feature of this framework in the inclusion of. client's participation in mana~... ment decisions which
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goes well beyond the concept of client provider interaction. This framawOr,~ is given be.low
~ GENERIC ELEMENTS (common to all RH services)
~ Service environment
~ Client provider interaction
~ Informed decision making
~ Integration of services
~ Women's participation in management
~ SERVICE SPECIFIC ELEMENTS (specific to each RH service)
~ Access to services
~ Equipment and supplies
~ Professional standards and technical competence
~ Continuity of care
What this framework implies is that the generic elements have to be improved and ensured in all
service environments while equipment, supplies, technical competence will depend upon the level of
service as well as the reproductive health condition for which services are being provided. Thus at
the Sub Centre the ANM will provide a different level of service while at the Disfrict Hospital the
specialist will provide another. Similarly for the same RH condition (for example obstructed labour)
will be dealt differently at the PHC (with referral) compared to the Emergency Obstetric Care Centre
(with Caesarian section).
A different way of approaching quality is to incorporate the gender and rights perspective within it.
The Government of India has through the adoption of a series of progressive measures accepted
this perspective and is also incorporating this perspective into programs and policies. The ratification
of the Convention on Elimination of All forms of Discrimination Against Women ( CEDAW) in 1993
and the adoption of the National Policy on the Empowerment of Women 2001 are steps in this
direction. When viewed from a gender and rights perspective the concept of quality of care is expanded
to include the following principles:
1. Advancing gender equality and equity and the empowerment of women, the elimination of all
kinds of violence against women and ensuring women's ability to control their own fertility
are cornerstones of population and development-related programmes.
2. It is the state's (country's) responsibility to take all appropriate measures to ensure, on a
basis of equality of men and women, universal access to health-care services, including
those related to reproductive health care.
3. The client has a set of rights which must be satisfied by the provider ( and ensured by the
state) . These include the right to receiving information, access to services, and choice, as
well as safety, the right to privacy, confidentiality, maintenance of dignity, comfort, continuity,
and expression of opinion.
4. The providers also have a set of rights and needs which m'ust be satisfied for them to provide
services effectively. These include the rights to receive training, support, guidance, supplies,
backup, feedback, respect as well as self-expression.
A composite and comprehensive way of looking at Quality of Care is to consider factors at three
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points in time· upstream at systems ( structures and capacities); at the time of client- provider
interactions ( procedures and performance); and beyond at outcomes. The different factors which
contribute to quality of ewe are indicated in the table below.
Structures/capacity
Policy intention
Program design
Laws, regulation and
licensing
Training of providers and
competence
All the above include gender
and rights perspective
Protocols and standards
Service infrastructure and
access
MIS
Supplies and logistics
Client (especially women's)
participation in management
decision-making
Processes/Performance
Diagnostic and therapeutic
appropriateness
Timeliness of care
Integration
Continuity of care
Interpersonal aspects
Involving clients in decision
making
Attending to client comforts
- cleanliness, privacy,
confidentiality etc.
Special provisions for
women and their needs
Outcomes
Therapeutic outcome
Unintended outcomes
Client awareness and
knowledge
Fulfillment of client expecta-
tions
Client satisfaction
Client behaviour
Opportunity for feedback
(especially for women's
opinion)
Women's expectations of quality can be influenced by a number of factors. These can range from
their socio-economic background to their prior experience with the health services. A study in rural
Maharashtra identified 21 community defined parameters of quality health services. It was found that
women had different expectations for different
situations. Thus while adequate staff to clean up, round
the clock service and nearby services were essential
parameters for obstetric care these were not important
for other conditions. For abortion within marriage no
requirement for husbands signature and qUick service
emerged as the top priority while confidentiality and
discrete locations were the most important for
abortions outside marriage. However for general
Haryana - Women complained of harsh
mouthed ANM. "It is alright if medicines are not
available, but at least she can speak sweetly".
Uttaranchal - Women did not feel confident
to approach the PHC staff who shouted and
scolded them if they forgot to take oral pills.
health problems the doctors attention and round the Orissa - Women in urban slums preferred to
clock service was considered most important.
visit private doctors because government
doctors were not sympathetic to their problems.
Women often have their own local terms to define and
describe their reproductive health problems. Women
can also have perceptions which are at variance with
that of accepted bio-medical wisdom. More than one
study has found that women expect to be treated
courteously by providers. However many studies also
Mumbai - "When you slept with your man, you
enjoyed no! Now you are screaming" women
abused during childbirth.
Andhra Pradesh - "These women don't have
akkal (brains) about what is normal. They come
for any complaint" Gynaecologist from
Osmanabad about women with white
report that this is often not the case. Demands for discharge.
money, physical and verbal abuse have been reported
in studies from different states.
(From: Shalini Bharat ( 2003) , Social
Assessment of Reproductive and Child Health
Women's sexual and reproductive reality changes as Programme: A Study in 5 Indian States
they advance from menarche through marriage and MoHFW, DFID, New Delhi)
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into old age. The strictly bio-medical background of all family welfare department frontline functionaries
including the ANMs and doctors precludes a nuanced social understanding of women's health vis a
vis their social position. This can become a serious impediment in understanding women's perceptions
and in delivering quality services.
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Reproductive Health, Gender and Reproductive Rights
Women's health for long was only important as far as her child-bearing capacities were concerned,
and thus there was a focus on maternal health. The whole concept of reproductive health emerged
as a departure from this narrow approach. There has been a growing understanding that the
subordinate status of women in society deeply influences their health status. In many societies the
principal responsibility of women in is restricted to childbearing, and this is at the expense of economic,
social and political participation in the family or community. This over-emphasis on one biological
aspect has led to such situations as early marriage and repeated child-bearing and its attendant
complications. Son preference, another strong trait of Indian society has led to the heinous practice
of sex-selective abortion and repeated abortions and its attendant complications. Women's workload
in many places is considered minimal, but a careful daily analysis reveals that women hardly have a
moment to spClre in the course of the entire day while men are entitled to their share of relaxation
after a days hard work. Women's subordinate status has also led her to be an easy target of family
planning programmes in our country with the bulk of sterilisations being tubal ligation operations. To
add to the situation described above women have very little autonomy to decide what they should do
for keeping healthy. Many women's reproductive health issues, which are related to her genitals are
considered dirty and shameful and hence women not only feel uncomfortable in openly discussing
their problems, but they refuse treatment from male medical providers. Medical providers, themselves
are products of the society in which they live and thus carry with them the usual social and cultural
biases regarding women and their abilities. The gender differences between men and women affect
their health in different ways At one level these differences lead to differences in the incidence and
prevalence of ill health. They also manifest in the response of the family and community towards the
person, response of the individual to her/his own health condition, in the accessibility and availability
of treatment and health services and finally at the level of health outcomes.
Despite the socially prescribed, acknowledged and encouraged differences in the status of women
and men, the principles of universal human rights, as well as the Indian constitution upholds the
equality of women and men. Gender equality is thus an ideal that is not only universal but also
constitutionally and legally binding in India. It is important to note that gender equality and human
rights are two of the core principles of the reproductive health approach.
The ICPD PoA pefines reproductive rights as those which embrace certain human rights that are
already recognized in natiollal laws, international human rights documents and other relevant UN
consensus documents. These rights includes the right of all couples and individuals to decide freely
and responsibly the number, spacing and timing of their children and to have the information and
means to do so, and the right to attain the highest standard of sexual and reproductive health. They
also include the right of all to make decisions concerning reproduction free of discrimination, coercion
and violence. Reproductive rights also include mutually respectful and equitable gender relations.
1. The Right to Life, Liberty, and Security
2. The Right to Health, Reproductive Health, and Family Planning
3. The Right to Decide the Number and Spacing of Children
4. The Right to Consent to Marriage and to Equality in Marriage
5. The Right to Privacy
6. The Right to be Free From Discrimination on Specified Grounds
7. The Right to be Free From Practices that Harm Women and Girls
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8. The Right to Not be Subjected to Torture or Other Cruel, Inhuman, or Degrading Treatment
or Punishment
9. The Right to be Free from Sexual Violence
10. The Right to Enjoy Scientific Progress and to Consent to Experimentation
The Right to Life, Liberty, and Security - The right to life is related to risks of maternal mortality in
pregnancy and childbirth and in cases of unsafe abortion. The right to liberty and security should be
invoked to protect women currently at risk from or subject to forced pregnancy, sterilization or abortion.
The Universal Declaration - Article 3
The Civil And Political Rights Covenant - Article 6. 1
The Children's Rights Convention - Article 6. 1 Article 6.2
The Right to Health, Reproductive Health, and Family Planning - It is necessary for enabling all
persons to access health care including reproductive health care and family planning services that
are accessible, affordable, acceptable and convenient to all users.
The Economic, Social, And Cultural Rights Covenant - Article 10.2, Article 12.1, Article 12.2
CEDAW - Article 10 (H), Article 12.2, Article 14.2
The Children's Rights Convention - Article 24. 1, Article 24.2
The Convention Against Racial Discrimination - Article 5
The Right to Decide the Number and Spacing of Children- This right is necessary for couples to
decide the number of children they will have as well as protect them from pressure and coercion of
population control measures.
The Right to Consent to Marriage and to Equality in Marriage - This right is necessary to protect
women from forced marriage. It is also protects women from discriminatory treatment within marriage.
The Universal Declaration - Article 16.1, Article 16.2
The Economic, Social, And Cultural Rights Covenant
Covenant - Article 23.2, Article 23.3, Article 23.4
CEDA W - Article 16.1, Article 16.2
- Article
10.1, The Civil And Political
Rights
The Right to Privacy- This is necessary to protect the right of all clients of sexual and reproductive
health care information, education and services to a degree of privacy, and to confidentiality with
regard to personal information given to service providers.
The Civil And Political Rights Covenant - Article 17. 1, Article 17.2
The Children's Rights Convention - Article 16.1, Article 16.2
The Right to be Free from Discrimination on Specified Grounds - The right to equality and
freedom from discrimination is applied to protect the right of all people, regardless of race, colour,
sex, sexual orientation, marital status, family position, age, language, religion, political or other opinion,
or other status, to equal access to information, education and services related to development, and
to sexual and reproductive health. Equality also relates to gender equality and the need for special
provisions for women.
The Universal Declaration - Article 2
The Economic, Social, And Cultural Rights Covenant - Article 2.2
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The Civil And Political Rights Covenant - Article 2. 1
CEDA W - Article 1, Article 3 Article 11.2
The Children's Rights Convention - Article 1, Article 2.1, Article 2.2, Article 5
The Right to be Free from' Practices that Harm Women and Girls - This right protects women
and girls from various harmful practices which could be discrimination around care and nutrition, to
such practices as the 'dayan pratha' ( witch hunting) or 'devdasl system of temple prostitutes.
CEDAW - Article 2 (f), Article 5 (a)
The Children's Rights Convention - Article 24.3
The Right to Not be SUbjected to Torture or Other Cruel, Inhuman, or Degrading Treatment or
Punishment - This right protects women from such treatment at home, in the community and even
within state systems like police stations, educational institutions and hospitals and medical camps.
The Universal Declaration - Article 5
The Civil And Political Rights Covenant - Article 7
The Torture Convention - Article 1
The Children's Rights Convention - Article 37 (A)
The Right to be Free from Sexual Violence - This right protects women from all forms of sexual
violence at different stages of life.
CEDA W - Article 5 (A), Article 6.
The Children's Rights Convention - Article 19. 1, Article 34
The Rome Statute Of The Ice - Article 7.1
The Right to Enjoy Scientific Progress and to Consent to Experimentation- This right is
necessary both for making available to women all forms of new treatment and drugs and contraceptives
as well as protect them from unethical medical experiments.
The Economic, Social, And Cultural Rights Covenant - Article 15. 1
The Civil And Political Rights Covenant - Article 7
Treaties and Conventions referred to above are as follows
The Universal Declaration of Human Rights
The International on Civil and Political Rights
The Convention on the Rights of the Child
The International Covenant on Economic, Social and Cultural Rights
The Convention on the Elimination of All Forms of Discrimination against Women
The International Convention on the Elimination of All Forms of Racial Discrimination
The Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment
The Rome Statute of the International Criminal Court
(Adapted from Reproductive Rights are Human Rights - Center for Reproductive Rights, New
York)
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The emergence of the rights approach - Equal human rights for all human beings is not only a
principle of international human rights but a core principle of the Indian Constitution. Since the Second
World War the international commlJnity has been concerned about protecting human rights of all
individuals. This concern was reflected in the formulation of the UN Declaration of Universal Human
Rights in 1948. Around the same time the Indian Constitution articulated the same concern through
Article 14 and 15. The right to health was articulated in the international arena through the International
Covenant of Economic, Social and Cultural Rights while the Indian Constitution included the Directive
Principles to address the issue. Article 42 specifically includes maternity related relief and benefits.
The human rights conference organized in Teheran in 1968 came up with a formulation of a right of
individuals and couples to freely and responsibly decide the number and spacing of their children. In
1979 the United Nations adopted CEDAW (Convention for Elimination of All forms of Discrimination
Against Women) accepting the need for states to make special provisions for women.
Sources of health related rights
Indian Constitution - Article 14, 15,16, 21, 39, 42,
47
Indian Laws - Sections of the IPC, Child Marriage
Restraint Act, MTP Act, PNOT Act etc.
Policies - National Population Policy, National Policy
on the Empowerment of Women, National Health
Policy, National Youth Policy etc ..
Programs - RCH programme, Other national
In the 1990's a number of significant changes
took place in the international arena which
changed the way of looking at development.
The concept of human development was
adopted by the United Nations Development
Programme with the annual publication of the
World Development Report from 1992
onwards. The concept of Human
Development was a significant departure
programmes
International Law and Agreements - Right to Health
( ICESCR), CEOAW, ICPO PoA.
from the earlier economic development
approach which was only concerned with the
economic productivity and aggregate income
of nations. It included educational
achievements and health attainments within the ambit of development. In 1993 the Vienna human
rights conference was organized and right to development was also included in the list of human
rights. Out of the 1994 Cairo conference on population and development evolved a clearer and more
precise definition of reproductive rights. The Fourth World Conference on Women organized at Beijing
in 1995 tabled the agenda for women's empowerment. All these changes were possible because of
struggles of many national and international movements spearheaded by women's rights and human
rights activists on the one hand and the willingness of governments to sit together and negotiate a
common agenda.
A consensus definition of the rights approach may be found with the UN Commission on Human
Rights which defines it as "an integration of the norms and standards contained in the wealth of
international treaties and declarations into the plans, policies and processes of developmenf'. To
this one may add the component of legislation, because without appropriate legislation, the rights
approach loo~es teeth in ensuring justice in the case of rights violations and mandating.the state to
ensure enabling conditions to enjoy the rights.
India has one of the most progressive constitutions in the world incorporating many of the features of
the rights approach within its framework. There are many appropriate laws in the penal code. The
changes in international understanding that took place in the 1990's were also readily endorsed by
the Indian Government by the formulation of National Policies and programmes meant to translate
these principles into action. The Target Free and Community Needs Assessment Approach, the
Reproductive and Child Health Programme, the National Population Policy (2000), the National Policy
on the Empowerment of Women (2001) and the National Health Policy (2002) are testimony to the
states commitment. At the same time redressal mechanisms like the National Human Rights
Commission and the National Commission on Women were also set up to safe guard human rights.
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The Indian legislative and courts too have adopted a pro-human/women's rights approach. The Pre
Natal Diagnostic Techniques Act ( 1996), the Vishakha judgement ( 1997) are some examples of this
change in approach.
The rights approach in reproductive health - Reproductive health, especially that of women is
area shrouded with ignorance, shame, silence and mystery. At the same time it is one area where
there are large number of societal expectations and prescriptions, at least in traditional societies like
India. Menarche, menstruation, pregnancy, childbirth, the number and sex of children are all issues
which guided by societal norms. Many of these have specific practices around them. With societal
expectations and norms on the one side and woman's own needs and desires on the other,
reproductive health becomes one of the most contested area of 'rights'. Who will decide whether or
not to marry? Who will decide the age at marriage? Who will decide whether to have children or not?
Who will decide the number and spacing of children? Who will decide whether to wait for a son or
not? Who will decide whether to use contraceptive? Who will decide whether to carry a pregnancy or
abort it? These and many similar questions form the crux of reproductive rights.
However reproductive rights are not limited to these decisions alone. The ability of an individual to
make these decisions depends upon the amount of information that is available to make these
decisions. Informed choice, a key element of reproductive rights, is the outcome of the possession of
adequate knowledge and information, the ability to make abiding decisions, and having access to
the appropriate services that are needed. The role of the state or the government in providing the
knOWledge/information as well as ensuring the services is key to the enjoyment of reproductive
rights. At the same time the state also has a responsibility to ensure that women are able to make
decisions in the context of their reproductive lives, which in actual practice are curtailed by family
members and societal norms. Thus education of family members, making legislation to prevent
discriminatory practices is also a role of the state. The Child Marriage Restraint Act, the Pre-Natal
Diagnostic Techniques Act have to been seen in this light.
Pregnancy, childbirth and the post partum period are one of the riskiest stages of a woman's life.
Every year over one and a quarter lakh Indian women lose their lives to pregnancy. This preventable
death can be interpreted in human rights terms and right to life can be seen extended to include the
reproductive right of mothers to go safely through pregnancy and childbirth. However this right has
not been explicitly guaranteed though as mentioned earlier the Indian Constitution does mention
maternity related benefits.
Globally abortion is one of the most contested are of reproductive rights. However in India the Medical
Termination of Pregnancy Act allows for the termination of pregnancy in a wide variety of conditions,
while setting standards for care. It is unfortunate that many people including doctors, have used this
provision of law to selectively eliminate the female foetus. The sustained people's movement and the
willingness of the legislative and judiciary enabled the framing of the PNDT Act and the subsequent
court orders to ensure its speedy and effective implementation.
Contraception and family planning, the two terms appear synonymous in many circumstances.
However, in the implementation of family planning programs one of the main difference that has
emerged over the years is that family planning is seen as a national agenda while contraception is an
individual practice, both aimed an reducing the number of pregnancies. The emergency period in
India is well known for the forced sterilsation campaigns and over 11 million sterilization operations
were conducted in two years, a statistic which has not been exceeded even though the base population
now is far higher. What this incidence highlights is the close relationship between population policies
and programs and human rights violations. Even though the Supreme Court has held the government
liable in cases of failure of sterilsation operations ( Santara vs State of Haryana) there is little
documentation available about the number of failures that take place each year ( international estimates
of failure are 0.5%) . Besides this there is a large national debate on the issue of incentives and
disincentives and its impact on the autonomy of clients and the quality of services.
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Framework for a rights approach in reproductive health in India - Implementing a rights approach
in reproductive health is a multidisciplinary initiative requiring a knowledge and appreciation of technical
health issues. policy and programme provisions and legal positions around different reproductive
health areas. The table below provides a summary of how these three areas interact
Technical Health
Understanding
Ante Natal Care
Care during delivery
Reproductive Tract Infections
Abortion etc.
Causative factors.' bio-
medical and socia-cultural
Investigation and treatment
Drugs
Preventive and promotive
measures
Quality of Care
Policy and Program
Provisions
• Community
Needs
Assessment Approach
• Reproductive and Child
Health Program
• Other National Health
Programs
• National Aids Control
Progamme
National Population Policy
•• National
Policy
on
Empowerment of Women
•••
National Youth Policy
National Health Policy
National Drug Policy
etc.
Legal Position
• Indian Constitutional
provisions
• Child Marriage Restraint
Act
•••
MTP Act
PNDT Act
Medical Negligence related
sections of the IPC
• Informed consent related
sections of the IPC
• Consumer Protection Act
and so on
The following is a list of activities that may be undertaken to claim a health related right. These
activities are ideally undertaken by the community whose rights are being violated or those who are
health advocates. These activities may be classified as - Identifying the Rights Violation, Creating a
Rights Awareness and Claiming the Right
A. Creating a Rights Awareness
1. Preparing citizens charter of rights
2. Increasing/sharing knowledge of state mandated health programmes
3. Increasing/sharing knowledge of rights and responsibilities
4. Increasing the strength of the community by making collectives
5. Making alliances and finding allies
6. Training of health providers and managers in the rights approach
7. Training of community leaders in the rights approach
and services
B. Identifying the Rights in relation to health problems in the community
1. Identifying the health problems of the community
2. Research and analysis of population and health related data ego Census, NFHS etc.
3. Preparing the list of rights that are violated in terms of each health problem
C. Claiming a Right
1. Creating forums for dialogue between community members/leaders and service providers
for sharing problems and making plans, and monitoring programmes
2. Creating an administrative grievance redressal mechanism for community to make complaints
to senior officials
3. Filing complaints/cases in the police station by community members
4. Making demands at the collectorate or CMOs office by sending deputations; or meeting
local MP, MLA.
5. Filing cases in a court of law.
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Advocating for Reproductive Health
Advocacy is an important component of the rights based approach. Policy or public advocacy is
different from legal advocacy in the sense that it does not necessarily involve courts or the judicial
system. However it is closely concerned with the rights of the underprivileged or the marginalised.
Public or policy advocacy involves the creation of public pressure for influencing policy formulation,
programme implementation in the interest of the poor, underprivileged or the marginalised. Such
advocacy efforts are usually directed towards those groups
or individuals who are in decision making positions and could
What Advocacy is not
include policy makers, legislators, senior program managers
Extension of services
and so on. The advocacy initiatives can be taken by the
Health education
affected groups themselves or by other members of civil
Advice or counseling
Providing information
society who are concerned. Advocacy thus links grassroots
services
activism to macro level policy action. Advocacy activities are _ IEC
non-violent and usually involve democratic spaces for debate, _ Skill training
discussion, protest and civil disobedience. The objec;tive of
advocacy is to ultimately increase the participation of the Advocacy is not a replacement for
underprivileged groups in decision making processes which I.-
any of the above either!
---J
affect their own lives. In a democratic country like India,
advocacy can be seen as a process aiming at improving citizenship of the poor and backward groups.
Women are among the most underprivileged of all groups.
Advocacy is - A value driven political process, embedded in the respect for human rights
Advocacy involves - Deliberate, planned and organised action
Advocacy aims - To effectively influence public policies and get them implemented
In order to - Advance social justice and human rights
Make the governance accountable and transparent
Policy Advocacy
Bringing about policy change through
_ Creating policy where they are needed and none exist
_ Reforming ineffective and harmful policies
_ Improving policy implementation
This may involve dialbgue, negotiation, protests or confrontation
India is a socialist, secular and democratic country where every individual born regardless of age,
sex, religion, caste place of residence, educational status is a citizen, and after attaining majority has
the right to participate in selecting the governments. The governments, which are elected by the
people are meant to serve the interests of the citizens and the Constitution of India has made express
commitments to serving the needs of all persons to secure social, economic and political justice for
all.
However a large portion of the population, notably women continue to live their lives without dignity,
and have to face numerous privations - social, economic and political. In the realm of health care,
women have special health needs, however despite the focus of maternal health services since
independence maternal mortality figures remain unacceptably high. Sub centres are often closed;
women doctors ctte not available at the Primary Health Centre; Emergency Obstetric Care services
are still not available at all First Referral Units; and the result is that there is very little health service
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available for women. This is despite the fact that over the last six to eight year's new policies and
programmes have been designed and implemented. It is in the interests of the women that the policy
makers and programme planners become aware of grass-roots reality. It is in the interest of achieving
the very laudable programme objectives and outputs that women become involved in monitoring the
programmes that are supposed to be providing them valuable and much needed services. The
process of informing policy programme planners about the grass roots reality and the experiences of
women so that programme forumlation and implementation can be done in the interest of women
needs advocacy. The process of getting women to become parties in the programme formulation
and monitoring process involves advocacy. The process of increasing grass roots democracy and
citizenship includes advocacy.
Developing an advocacy strategy requires systematic preparation and action. It is necessary but not
enough to have a clearly important issue, the vision and motivation to change things and the enthusiasm
to jump into action. Building an argument, developing consensus, working with coalitions are important
constituents of an advocacy strategy. Some of the key steps that need to be followed in developing
an advocacy strategy are described briefly.
Identifying the issue - Clearly this is the most important step in the whole sequence. The biggest or
the most obvious problem need not necessarily best issue for advocacy. There should be some
potential and space for change within the existing legal, policy or programme framework around this
issue. And the advocacy efforts can be focused utilizing these spaces for bringing about changes
policies, or in programme implementation, or in increasing people's awareness on their rights and
entitlements. As discussed earlier advocacy is often done on issues whish may not affect the advocate
directly, and the advocate may be acting in the interest of an affected group- in the case of reproductive
health it could be poor, rural women. Does the issue resonate with this affected group? Is this an
issue of common concern across castes and for all communities? At the same time the advocates
need to identify their own strengths and the capacities and limitations of their constituents and partners.
Identification of the issue also includes analysis of opportunities and barriers in advocating on the
particular issue.
Clarifying the issue - engaging in research - Once the broad issue has been decided it is necessary
to gather information and evidence on two'irrfportant aspects. These may broadly be called
Frameworks and Experiences. Frameworks relates to the existing legal, policy and programme
provisions. These need to be analysed to understand the potentials as well as their inherent flaws. In
the realm of experience there is need to collect evidence of women's own experiences. This may be
done by collecting information from secondary sources which can include studies and reports, and
even newspaper reports. At the same time the advocates can also engage in collecting evidence
through conducting small surveys, opinion polls or documenting case-studies.
Building consensus and coalitions - Advocacy can rarely be done alone. One of the key
responsibilities of the advocate is perhaps to obtain a mandate from the very people whose cause
she/he is taking forward. Thus building a partnership with the affected is an important step in the
process. But this alone is not enough, other important constituents in an advocacy strategy include
members of the media, NGOs concerned with the issue, academics, public personalities who can
endorse the demand, health groups, legal and so on. The objective of coalition building is not only to
engage more constituencies around to issue and build broader consensus and political support
around the issue but also to increase resources within the group.
In the process of coalition building the main issue should remain clearly in focus and not get diluted.
However together with this process there needs to be consensus built on the specifics- viz. what will
be the position of the group on the issue, what are the various outcomes that are desired, who will
take what roles and so on. During these discussions the various people involved should discuss
An Advocacy Handbook
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which are the non-negotiables, what is the common minimum understanding and what are the areas
of compromise.
Identifying Allies
• Which other groups and organisations are working on the issue?
• Are there any pre-existing networks working on the broad issue?
• What are their stands, approach to the problem? How similar or dissimilar is
it?
• What are the relative strengths of these organisations and networks?
• Can we contribute to their processes and activities, do they need our
contributions?
• What are the advantages and disadvantages of working together with these
groups and networks?
Developing Key Advocacy Messages - Advocacy involves the careful identification of an important
issue of concern and then collecting data and evidence around the issue. Once adequate data has
been collected, and compared against what situation should actually exist - a few key action I decision
areas emerge. For example if maternal mortality is high, the careful examination of evidence and
experience may reveal that there most child births take place at home and there are no trained birth
attendants in the rural areas. On the other hand the examination of evidence may reveal that when
there are complications the community chooses to visit the informal and private practitioners because
the government facilities are not close by or do not have the appropriate facilities. In the first case the
advocacy could be for increasing the training of community chosen birth attendants as skilled
attendants. In the second the advocacy could be for increasing and improving emergency obstetric
care. Often however both are necessary. But the point that is being made is that the key action point!
s or advocacy message/s must be identified and developed. The advocacy activities then focus on
getting these messages across to the relevant authorities (people in decision making positions) so
the required action may be taken.
Identifying Audiences for Advocacy - Continuing the examples provided above it may be seen
that the decision to trained skill birth attendants may lie with the district authorities - the Chief Medical
Officer, the concerned Deputy CMO or the District RCH Officer. In that case the advocacy efforts
may be directed at these individuals. If however the decision for upgrading a PHC to a First Referral
Unit lies with the state government, then the advocacy can be directed towards the Secretary Health
and Family Welfare or the Director Family Welfare. In both cases the advocacy may also be directed
towards the local MLA and MP as well. In the case of district level decision making advocacy may
also be directed towards the District Collector/ Magistrate and the President of the Zilla Panchayat
especially in places where panchayats are active. Thus the same advocacy message may be directed
at different audiences, each of whom may influence the final decision maker/so
• Identifying the main constitutional and responsibilities of the government and
existing legal frameworks
• Identifyingthe root causes of the issue under consideration eg, maternal mortality;
and the persons who are affected
• Identifying the key actors - individuals and institutions involved in the issue - in
creating the problem or who are mandated in solving the issue
• Understanding the roles played by the key actors and how decision making is
distributed within them
• Understanding how policies and programmes get made and by whom
• Understanding the current social and political context - local, national and
international.
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Preparing a plan of action - Advocacy is a deliberate and planned process, however it is a dynamic
process as well. What this means that advocacy related action moves through stages. These stages
are not water-tight and do not always progress in the forward direction. In the course of an advocacy
action, there may be backward movement as well, and it is necessary for the advocates and leaders
of the process to identify this. Some advocates divide it into five stages which are:
• Issue Identification
• Developing Solutions
• Building Political Support
• Engaging In Policy Action
• Evaluation
Others have identified these stages as
• Gathering Policy and Political Information
• Assessing risks and potentials
• Building strategic relationships
• Engaging in the advocacy initiative
• Evaluation
Using Data and Research in Advocacy - Data and research playa crucial role in both in identifying
the core advocacy issue as well as identifying possible solutions to the issue at hand. For example
the Juvenile Sex Ratio ( proportion of girls for one thousand boys) is a statistic that was never
seriously considered in our country. However office of the Registrar General of India has built up a
strong movement across the country based on this figure. The fact that son preference was leading
to sex-preselection and elimination of females was known and public movements had led to the
enactment of the PreNatal Diagnostic Techniques Act 1996. However the systematic dissemination
of the Juvenile Sex Ratio across states and districts has been successful in building a movement
around the issue of Sex Pre Selection and Son Preference. Similarly data from the National Family
Health Surveys, the District Household Surveyor the Census can be used to identify and give
substance to important issues we know exist on the ground. Smaller scientific studies, both quantitative
and qualitative, may be conducted to highlight and substantiate issues that we believe need to be
addressed through our experiences on the ground.
Data and research can also be used in identifying and creating solutions Grass roots interventions
implemented by different groups can be carefully be carefully documented to identify key issues
which led to their success. Research methodology plays a crucial role in substantiating claims with
empirical evidence otherwise these claims run the risk of being dismissed as being anecdotal.
Research findings and data, both for highlighting an issue or to provide alternative solutions needs to
be presented in a conclusive, crisp and easily understood manner to the policy makers the advocates
wish to influence. This manner of presentation is substantially different from a research presentation
because more often than not a policy maker is not a researcher and may not understand the subtle
huances of research methodology. However most policy makers are keen to understand problems
and solutions, if not from a rights perspective but because they wish to be effective managers.
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Preparing for Advocacy Action
Media Advocacy
Using the print media - Press release; Media advisory, letters to the editor, writing Op- Fd
pieces, inviting media persons to events, exclusive stories etc.
Electronic Media - radio and television- Media coverage to events, human interest stories,
participating in discussions and talk shows etc.
Public Education
Public meetings and film shows, Signature campaigns, Wall writing, Posters, Street Plays
and other popular or folk media etc.
Preparing reports, briefing kits, booklets, fact sheets and other written material
Opinion polls and focus groups
Dialogue and Negotiation
Individual meetings and face to face interaction
Consultations
Written memoranda
Policy/ Programme Monitoring
Facility visit
Interviews with clients and community
Implementation mapping
Social Audit
Legislative Advocacy
Meeting with leaders of political parties, preparing and presenting briefing kits
Asking politicians to put up questions before the legislative assembly/ parliament
Meeting with leaders of political parties around their election manifestos
Meeting and briefing politicians associated with committees associated with the legislature
or during a law making process
Legal Advocacy
Filing cases around cases of individual violation of rights in the court of law
Filing Public Interest Litigation in State High Court or Supreme Court
Public Hearing, Tribunals and Commissions
Internet based Advocacy
Email based mass mailing, action alerts
Email based signature campaigns
Building issue specific websites and portals
Direct Action
Protest March and Rally
Sit-in and Demonstrations
Hunger strikes
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Advocacy involves working with different constituencies and the effective advocate needs to be
comfortable dealing with the policy/decision makers as well with marginalised groups. The advocate
also needs to be competent in dealing with larger civil society because civil society individuals and
institutions can become part of the larger coalitions. Advocacy also requires diverse skills. It requires
the capability to make meaning out or research and data; it requires the sensitivity to understand and
empathise with the situation of the marginalised. An advocate needs to be a skillful negotiator at
some times and tenacious street fighter at others. It is difficult to find all the skills and competencies
required for effective advocate in the same individual, and so effective advocacy is often built on
complementing qualities and skills. The list of qualities and skill sets required for effective advocacy
are given below.
People centred communIcation skills
• Ability to identify different actors and groups concerned with an issue
• To be able relate to others at a human level; empathy and sensitivity to the reality of people
facing adversity
• Ability to motivate and inspire others; respect others feelings and emotions
• Able to differentiate between peoples apparent actions and value systems
• Non discrimination on any grounds such as caste, class, sex, religion etc.
• Conscious of one's own privileges and ability to empathise with others vulnerabilities
• Ability to make and sustain relationships
Personal capacities and skills
• Self motivated, keen to learn about new issues and ideas and relate them to social, economic
and political reality
• Clarity on position on the relevant issues based on clearly articulated values and evidence
• Ability to anticipate challenges as well as opportunities
• Resourcefulness and confidence
• Ability to strategise, plan and evaluate
• Ability to listen and communicate clearly
• Ability to work with others
Networking Skills
• Ability to do political mapping of actors to identify potential allies and adversaries
• Openness to new ideas, flexibility, accomodating without compromising core values
• Ability to articulate positions and take decisions
• Teamwork, sharing of responsibilities and decision making
• Respect and value for others contributions
• Transparency between affiliates
• Ability to deal with adversity, and creative crisis management
Practical Skills
• Analytical skills
• Documentation skills
• Writing skills - ability to write press releases, briefs, pamphlets etc.
• Performing skills - singing, theatre, elocution etc.
• Communication skills - oratory, succinctness, poise etc.
• Event management skills - organise meetings, consultations, demonstrations etc.
Ethical Values
• Collective decision making
• Conformity between thoughts, words and action
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Advocacy is an act of creating pressure on the policy/ decision maker so that decision making
is not only in the interests of the marginalised but that marginalised themselves get a greater
role in decision making. In order to get the decision makers listen to the arguments and
messages it is necessary to ensure their credibility. Credibility can be ensured through
Expert credibility - The arguments and messages can be made by recognised experts in the
field who act officially as spokespersons or indirectly as supporters.
Institutional credibility - Advocacy efforts gain credibility when arguments and messages
are based on data from recognised institutions. The advocacy on missing girl child in India is
associated with the Census, which has immense institutional credibility.
Celebrity endorsement- This is a tactic often used in advocacy campaign to gain supporters.
An advocacy campaign against violence against women used the cricketer Sachin Tendulkar's
message for speaking out against violence.
Grassroots mobilisation- This provides strong credibility to any advocacy effort as the affected
themselves are at the forefront of advocacy. However even such advocacy must be backed by
evidence and clear advocacy messages.
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Advocacy related publications are very useful for generalised public education and can also be
targetted for specific audiences. These publications allow the advocacy issue to be presented as
briefly or as elaborately as desired and can thus be in different formats. In a country like India where
the internet still does not reach all people the printed format has an additional advantage. A variety of
publications that are used in advocacy are described below.
Flyers - Flyers are one-page information sheets which briefly describe the what/why/who /where/
when of advocacy issues, activities and/or events. They are very inexpensive ways of getting the
message out to the public. Flyers are best used for notifying the public about an upcoming meeting
or event.
Pamphlets - These are more elaborate than flyers, with more attention to both form and content.
Pamphlets can be used to introduce the advocacy effort describing the essence of the advocacy
campaign, highlighting the main issues, the solutions as well people who are involved in it. Thus
pamphlets should remain relevant for longer periods of time as well. Advances in computer-based
desktop publication have made the production of attractive pamphlets easier.
Booklets - As the name implies these are small books and usually contain a wealth of information
on the issue of concern. Booklets cover different aspects of the advocacy issue and should be well
researched. Because booklets usually contain more substantive documentation and research, they
can be used to establish greater credibility and visibility with the media, scholars, educators, and
other advocates.
.
Newsletters -Newsletters are useful in providing periodic updates to supporters as well as inform
interested persons about the activities of the advocacy campaign or organisation. Newspapers can
printed and mailed though e-newsletters are also becoming common. The most important aspect of
a newsletter is that it should be published regularly, which makes it the strength and the weakness of
the format. Newsletters provide progressive and up-to-date information however they also require
resources especially in terms of human resources and time and on an on-going basis. Newsletters
can include articles, interviews, news and reports and can also announce forthcoming events.
Fact sheets - Fact sheets are one or two page summaries of relevant information about the advocacy
issue. This could include state-wise data on a subject that can be extracted from large surveys. It
could include summaries of qualitative research studies and also have short quotes from newspaper
reports. They are extremely efficient ways to impart information to the public, the media, or policy
makers because they sum up the issues succinctly. When preparing a fact sheets it is necessary to
use the most current data available. In order to add credibility to a fact sheet the sources should be
mentioned as an endnote or footnote. Fact sheets may need to be updated from time to time.
Briefing kits - These are a collection of documents intended to provided a variety of information on
the advocacy issue. Briefing kits can be thematic or event specific. Thus a particular press conference
may require the preparation of a event specific media briefing kit. This kit would ideally include the
press release for the event, a short summary of the research report which is to be shared (if that is
the case); a brief biography of the celebrity speaker ( if a celebrity is addressing the press conference)
and so on. In addition the kit should also include copies of the advocacy related pamphlets, latest
edition of the newsletter and any fact sheets. This comprehensive packet of information is supposed
to provide additional background material as well respond to queries that the media person may
have in preparing the story.
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Thematic briefing kits are different in the sense that they are more deliberately prepared and can be
used generically. Thematic briefing kits can include fact sheets, position papers, summaries of reports
and studies, calls for action and so on. Thematic briefing kits can be aimed at policy makers as well
as potential supporters. They should include all necessary information that helps in conveying the
advocacy messages, identifying the issues, justifying the positions and providing solutions in easily
understood language.
The media- both print and electronic, are powerful channels for communicating an advocacy message
to the government and to policy makers. It is also an important tool for public education on the issue
of concern. Effective use of the media can result in increasing the visibility and credibility of the issue
being advocated. Sometimes it may even so happen that when an issue is getting consistently
highlighted by the media, the policy makers start taking action without beingcdirectly persuaded to do
so. Institutions like the National Human Rights Commission and the National Women's Commission
and their state counterparts are mandated to take suo mota ( on their own) action and in cases of
rights violations ask the government authorities to provide explanation, relief and compensation.
These commission can and do take such suo moto action on the basis of media reports.
Despite the powerful and beneficial role that can be played by the media, media advocacy is better
not left to chance. The advocacy plan should include a deliberate plan for media advocacy. If this is
not done, there are risks that the reportage on the issue can do more harm than good. It is useful to
remember that the media can sensationalise an issue and this may not be useful from an advocacy
point of view. In addition to this the media often has the dominant perspective on an issue ( which is
seldom rights based) and this may reflect in their coverage. Some strategies and activities that may
be used for effective media advocacy are given below.
Identify Media persons and develop contacts- A useful first step is to follow reportage on health
related issues in the local newspapers and journals. This can lead to the identification of specific
media persons who are report on these issues. Once these media persons are identified it can be
useful to get in touch with them, provide them with information about the advocacy issue and key
messages by inviting them to events, providing them with press releases, briefing kits, human interest
stories and so on. Media persons especially those associated with daily publications need information
on a very regular basis, and would like to be in touch with reliable and credible sources. It is necessary
to build a relationship of respect and mutuality with some media persons.
Press releases - Press releases are concise news items describing an event or issue of significance.
They are the easiest way to get in touch with the media, and when there is a good relationship with
the media persons they start looking forward to such press releases, because it gives them a news
item without having to work too hard to get it. However it is important to realise that press releases
should be prepared for newsworthy items and not all activities undertaken as part of advocacy. Too
many press releases may lead to their devaluation. Press releases may be prepared for events, in
response to news and events relating to the issue of concern, release of a research report, on
anniversaries and commemorative days and so on. When preparing press releases it is necessary
to be careful about the newspaper deadlines.
Press Conference - A press conferences is organised when the information that has to be shared
is 'very significant'. Thus a press conference can be organised to share information about the issue
like the release of a report or even to respond to some government announcement or a judgement
from the Supreme Court or if there is a celebrity who is willing to endorse the issue. However while a
press conference allows for greater interaction with members of the media, leading to greater
elabQr,ption of the issue and hopefully a better articulated news item, it can also lead to problems if
the preparations are inadequate and questions posed by the media cannot be handled with appropriate
data and consistent messages. It is useful to prepare printed handouts and briefing kits for the media
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persons, and also have space for one to one interaction between the spokesperson and any media
person who would wish to do so. Preparation is paramount in a press conference.
Letters to the editor - Writing letters to the editor is one way of using the media for advocacy.
However it is difficult to plan and execute to perfection because the final publishing of the letter is in
the hands of the editorial staff. To improve the chances of letter to get published it helps if they are
clear, precise and short. It is useful to respond to articles and features that have raised issues
similar to or affect the advocacy issue in question. These responses need to be sent in quickly in
order to keep them relevant as far as the publication is concerned. Adding your organisation's name
and your position within it (to your name) may increase the possibility of the letter getting published.
Writing Opinion pieces - Newspaper carry opinion pieces on their editorial pages. These opinion
pieces or Op-eds, as they are called are often written by experts or well known personalities rather
than journalists. If the advocacy effort you are involved with 11asbeen able to gather the support of
acknowledged subject matter experts, it may useful to ask them to write a short opinion piece on the
issue. The opinion piece should simple language to explain the problem, have clear messages and
then provide specific solutions. Alternatively op-ed articles may be placed with development feature
services.
Working with the Electronic Media - There are some similarities in working with the print and
electronic media with one big difference. The electronic media - in most cases the news channels
require images and 'sound bites'. This characteristic of the electronic media can be used to advantage
with careful planning and preparation. As with the print media the electronic media should be invited
to press conferences and other events and they may prepare a brief news-item on the issue. With
regional and state specific news channels coming up it may be easier to get coverage. However with
a smaller coverage the reach of the advocacy message may also get reduced. With human interest
stories the electronic media has the advantage of relaying the image and the voice of the persons
involved into thousands of homes. At press conferences articulate spokespersons can deliver
creatively crafted messages which can become 'sound bites'. Giving individual interviews are another
method of reaching out through the electronic media. Here again the spokesperson needs to articulate
the message very clearly and in the shortest possible time. After editing only a few seconds of the
interview will possibly get broadcast. While replying to a question it is useful to weave in the question
within the answer otherwise the answer loses context and this may happen during the editing process.
The internet has emerged as a very powerful medium of communication and it is but natural that it
should be used for advocacy as well. It can be used very effectively in advocacy initiatives in a
number of ways.
Email action alerts or mass mailing - It can help relay information to many people very fast and
with very little expenditure on printing and postage.
E groups and Iist-servs - It can create a virtual community of like minded persons who may be
located at great distances from each other. However people need to keep posting to the egroup to
keep the discussions alive.
E-newsletter and updates - These help in sharing information about an issue among those who
choose to remain informed. It can be a valupble tool for public education.
Internet based signature campaigns - There are specialised websites which allow the creating of
internet based signature campaigns. Once the appeal has been created the link needs to be forwarded
to as many people as possible. Once the signatures have been obtained they need to be forwarded
to the person/s to whom the appeal is address through email, fax or by post.
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Websites-Increasinglyall kinds of organisations are setting up websites as a mechanism of informing
others about their products and services. Advocacy efforts can also use websites to inform the
visitor about the issues and concerns around which the advocacy is being done. While for-profit
entities have different and often intrusive ways of directing traffic to their websites, advocacy groups
face the challenge of getting the casual browser to visit the website and then keep their interest. One
way forward is to design interactive websites and building links with similar websites as well.
Overall the Internet can be seen as an important medium for advocacy out because it is
• fast and two-way
• easy to update
• relatively low cost
• worldwide reach
However the advocate should remember two important considerations when using this method.
Firstly not everyone in India either has or is familiar with the use of the internet. There are many
senior policy makers who get their secretaries to respond and key in their emails. At the same time
others may not have access to the internet despite the high levels of cyber penetration that has been
achieved in the country. The second consideration is that with people who are familiar with email,
there is an information overload, thus important messages may get ignored or deleted. Thus in most
places the internet is best use as an additional/complementary advocacy tool or strategy.
Public Hearings and Public Tribunals are public fora for sharing rights violations. In a Public Hearing
the rights violations are usually shared in front of an official panel of empowered officials like the
National Human Rights Commission and its state counterparts or the National Commission of Women
and its state counterparts. The Hearing is a quasi-judicial proceeding in which the members of the
panel provide instructions and directions to the responsible officials to take administrative action to
rectify the situation. In the case of a Public Tribunal the panel is not official, however in order to give
the panel credibility it usually comprises of eminent citizens. The panel hears the testimonies and
experiences of the persons whose rights have been violated and then makes its recommendations
and observations which are usually directed towards the state agencies responsible for action on the
subject. The National Human Rights Commission and the National Commission on Women have
started a process of hearings and consultations on health and reproductive health in different parts
of the country.
Documentation - It is essential to prepare carefully before organising a public hearing or tribunal.
The first step is to strengthen a coalition of partners who will be participating in the event. It is also
necessary to prepare detailed documentation of rights violations which take place. It is necessary to
highlight the common kinds of violations which take place routinely rather than exceptional cases
which can be easily explained away. The documentation of cases could comprise of oral record of
experiences substantiated by documentary evidence like Outpatient department tickets, indoor
records, sterilisation certificates, discharge certificates. In recording the experiences it is necessary
to record the specific instances where the required services were either absent, or denied or provided
in a substantially inadequate manner. Even though the testimonies from victims and survivors makes
the core of a public hearing or tribunal it is often not possible to provide them justice through this
mechanism. The persons making testimonies should be prepared for this. Secondary evidence on
the issue is also useful for example failure rate of sterilisation operation in a district, total number of
maternal deaths in a block over a certain period of time.
The Hearing I Tribunal Panel- The panel is a very important of the Hearing or Tribunal. In case of
an official body like the Human Rights Commission, the official nature of the body gives it credibility,
however in the case of a non-official Tribunal the panel has to be chosen with care. The panel should
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comprise of eminent citizens who need not be experts on the subject, but who should be known for
their social concern. The Panel members should be willing to make clear and unequivocal statements
based on their observations during the panel.
Public Officials - All public officials involved in the issue should be invited to the Public Hearing or
Tribunal. In case of official hearings the public officials like the Collector or the Chief Medical Officer
may attend the meeting but in other cases they may not. In order to ensure their presence at these
events it may be necessary to make extra efforts. Public officials should be allowed to respond to the
points raised by the panel and in the testimonies. However they should not be allowed to cross-
examine the testimonies.
Media Relations - It is always useful to make careful preparations for involving the media at public
hearings/ tribunals. This enables the experiences shared during the event to be circulated widely.
The Panel could address a press conference in the course of the event.
Conducting a Public Hearing or Tribunal - The outline of a public hearing or tribunal is provided
here. The actual even could begin with the organisers explaining the objective and structure of the
programme. This can be followed by the oral testimonies of the cases where rights denial and violations
took place. In cases where the aggrieved person or the relatives want their names to be kept
confidential or the organisers feel that revealing the identity of the aggrieved person could jeopardize
him or her the names and village should not be revealed. After the cases of denial are presented, the
report based on the secondary data or survey findings, about the availability and status of health
services can be presented. Then the Government Officials should be asked to respond to the issues
and concerns raised during the testimonies and the presentation. In the end, the panel should give
their comments. A press conference can follow the event.
Community Monitoring is an advocacy strategy which strengthens the community in understanding
their rights, map how many of their rights and entitlements they are presently receiving and then
prepare a plan of action for claiming these rights. The process of community monitoring is usually
intensive, but it can be seen as a very effective and sustainable way of grassroots based advocacy.
Community mobilisation - This is the first and most important step of community monitoring.
Today large number of community based groups are being formed as part of different programmes
especially self help groups.These groups may also be strengthened for community monitoring, utilising
the steps mentioned below. One important point that needs consideration is that these groups should
not only be self interest groups but should be interested in community development as well.
Community capacity building - These community groups need to be provided information about
their rights and entitlements vis a vis the health system. This includes knowledge of the government
programmes around maternal health, child health, contraceptives as well as the minimum service
quality that has been promised as part of these programmes. This is different from the usual health
education process in which the focus of the educational intervention is different steps that need to be
taken by the community. The training of community should also extend to understanding the current
health problems of the community and the availability of services both at the community and referral
levels. Community level documentation is an output of this process. This process is similar to the
Community Needs Assessment process which is already part of the reproductive and child health
programme.
Meetings with the Health Providers - Once the community leadership is aware of the different
aspects of the health services that they need and what is available to them today it will be possible
for them to discuss these with their health providers, It may be necessary to build relationship with
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th(:)local Multipurposg Hgalth Workgr as wgll as thg Mgdical Officgr of thg local PHC for this purposg.
The community leadership can approach the MO or the CMO and share their problems. In case
these officials are willing to acknowledge their communities own concerns it will be possible to proceed
to the stage of Interface described below. In case this is not possible it may be necessary to organise
public meetings and public tribunals at a later stage.
Interface with service providers - Once a bridge has been built with the health service providers
there can be a sharing of concerns, problems and plans. This can lead to a preriodic review of
activities at the Sub-Centre and PHC level. Sub-Centre review and planning meetings could take
place monthly while PHC level meetings could be organised quarterly. Mutually agreed upon quality
of care checklists could be the basis for monitoring the service provision and service uptake 'from
both sides. These activities can strengthen the Community Needs Assessment Approach which is
already part of the Reproductive and Child Health programme.
Public Meetings - In case the health providers are unwilling to accept the feedback and concern of
the community, the community may decide to organise public meetings at the block and district
levels. The community can share their experiences and concerns at these meetings. Government
officials, Panchayat members, local dignitaries, media persons can be invited to these meetings.
These meeting can serve the dual purpose of sharing concerns with a larger group of citizens as well
as create some pressure on the health care delivery system to listen to the concerns and delivery
accordingly.
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Section Two
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• Nearly 600,000 women die due to complications from pregnancy and child birth
every year. Of these 99 percent occur in developing countries
• India has the largest number of maternal deaths - over 125,000 every year
• For every woman who dies, 30 develop life-long illnesses and injuries related to
pregnancy and childbirth
• Nearly one in seven women develop life threatening complications during
pregnancy in India
• Less than 50% women in India have a skilled attendant at the time of delivery
• Every 5 minutes, one woman somewhere in India dies from complications of childbearing
• 15 percent of all pregnant women in India develop life-threatening complications
• 65 percent of deliveries occur at home
• Only 41 percent of women have a skilled birth attendant at the time of delivery
• 60 percent of all maternal deaths occur after delivery but only 1 in 6 women receive postnatal
care
• The risk of maternal death is one in 37 in India while it is one in 230 in neighboring Sri Lanka
compared to one in 5000 ;n Singapore and one in 7300 in Norway.
• With 16% of the world's population, India accounts for over 20% of the world's maternal deaths.
• The maternal mortality ratio, defined as the number of maternal deaths per 100,000 live births, is
incredibly high at 408 per 100,000 live births for the country (GOI 1997), which is unacceptable
when compared to current indices elsewhere in Asia.
• All of these estimates imply that more than 125,000 women in India die every year from causes
related to pregnancy and childbirth.
Sri Lanka China
30
115
Thailand
200
Pakistan
340
Indonesia
390
India
437
Bangladesh
850
Nepal
1500
The majority of births (65 percent) in India
take place at home (in some areas it is
almost 92 percent), and a large proportion
are assisted by unskilled personnel. In
such situations, women who experience
life-threatening complications may never
receive the required life-saving
emergency services because of what are
now called the "four delays". These
delays can result in maternal mortality or
From the Report of Comptroller and Auditor
General, Gol in 2001
Details of Institutional deliveries were not available
except in 3 states
24 hour delivery services not available in 8 states/
UTs and in 92 units in UP
Availability of essential obstetric care drugs and
equipment for care of new born very, low
FRUs not fully operational due to lack of specialist
staff, infrastructure, equipment and medicines.
All FRUs in MP and 118 FRUs in UP lacked blood
transfusion facilities
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Delay 2: Delay in deciding to seek care (inaccessible health facility, fear of costs, lack of resources
to pay for services, supplies and medicines)
in Delay 3: Delay reaching the health facility (no transport available, unaware of appropriate
referral facility)
Delay 4: Delay in receiving adequate treatment once a woman has arrived at the health facility
(health facility not adequately equipped, lack of trained personnel, emergency medicines, blood).
Social Factors
• Poverty
• Female illiteracy, and low social status of
women
• Early marriage and pregnancy
• Pregnancy in adolescence
• Lack of support from the male partner
• Malnutrition
• Harmful traditional practices
Leading to
• Lack of antenatal care or presence of
skilled attendant during delivery
• Failure to perceive severity of illness
• Failure to recognize complications
• Lack of preparedness
to handle
emergencies
Service delivery Factors
During Pregnancy and delivery
• Lack of outreach services
• Lack of adequate number of trained personnel
• Lack of available transportation
• Uncaring attitude ot providers,
• Shortages of supplies, basic equipment,blood
etc
• Non-availability of healthcare personnel
• Poor skills of health care providers
During other times
• Lack of acceptable contraceptive
• Focus on permanent methods
• Irregular contraceptive supplies
services
A maternal death is the 'death of a woman while pregnant or within 42 days of termination (via
delivery, miscarriage or abortion) of pregnancy, irrespective of the duration and the site of the
pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not
from accidental or incidental causes.
The direct causes of maternal mortality include
• Sepsis.
'
• Hemorrhage (severe bleeding)
• Complications resulting from unsafe abortion
• Prolonged or obstructed labor
• Hypertensive disorders of pregnancy (eclampsia or pre-eclamsia)
Indirect causes of deaths are due to conditions that in association with pregnancy hasten the fatal
outcome-for instance anaemia, malaria, hepatitis and increasingly AIDS.
When do maternal deaths occur?
• 20 percent of maternal deaths occur 7 days after delivery
• 50 percent of deaths occur within the first 24 hours after delivery
• 25 percent occur during pregnancy
• 5 percent 2-6 weeks after delivery
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A large majority of maternal deaths in India are distributed among the so-called BIMARU states, later
called the EAG states by the Department of Family Welfare. Some of the main reasons behind the
high maternal death in these states today is related to the quality of care available at the time of
delivery. Despite the focus on maternal health over the last fifty years or more the proportion of
women receiving comprehensive antenatal care is abysmally low. An overwhelming number of
deliveries take place at homes and in the care of untrained supervisors. The training of traditional
birth attendants has been going on sporadically in the Government sector but the fact that the process
of delivery is enmeshed in cultural and caste considerations has not been considered. In many north
Indian states the cord cutting is done by the designated Traditional Birth Attendant (TBA) community
known popularly as 'dai' but these women who belong to the lower castes have little to no role in the
actual delivery of the baby. The focus on antenatal care has also detracted from the role of life-
saving support during the process of delivery. The CSSM program started the focus on First Referral
Units (FRUs), however in the ten years since the concept was launched, the name of the location
where a Caesarian section can be performed has gone through a number of incarnations ( emergency
obstetric care (EmOC), basic emergency·obstetric care (BEmOC)) without ensuring the availability
of a surgeon, anaesthetist and blood transfusion facilities at all locations.
Over the decade a one point agenda appears to have emerged as the answer to high maternal
deaths and that is institutional deliveries. Studies have shown that roughly sixth of all deliveries can
develop complications and need expert supervision and care. This means that all deliveries do not
need to come to institutions but there needs to be a very effective system of screening before the
onset or during labour and a efficient means of referral. Today if all women from the villages of the
EAG states started approaching their local PHC
Table 4: Maternal Health care in some of the
EAG states
for delivery services they would most probably be
faced with absent doctors, unavailable beds,
UP MP Bihar Orissa dysfunctional labour-rooms, no ambulance facility
MMR
Complete
ANC
Institutional
delivery
Births w/out
health
707
4.4
15.5
77.6
498
10.9
20.1
70.3
452
6.4
14.6
76.6
367
21.4
22.6
66.6
for referral to the Emergency Obstetric Care if
necessary. There would be no guarantee that the
designated EmOC would be functional and the
district hospitals could well be overflowing with
patients leading to two mothers to a bed.
proffesional
However the situation in other states is not so
Post natal
7.2
10
10
19.2
care in home
deliverv
From NFHS 2 1998 -99 and SRS 98
dismal. Antenatal care and institutional deliveries
are increasingly becoming common in many states
particularly in the south. Reviewing the quality of
care it is evident that while there have been some
provisions made within the framework of policies
and programs there has a huge failure in large tracts of the country in proViding infrastructure,
maintaining supplies, providing competent personnel and in such a situation it would be unrealistic of
expect much in terms of diagnostic and therapeutic appropriateness. The mortality figures speak
volumes about the very poor outcomes of the maternal health services.
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• Unsafe abortion is one of the most important reasons for maternal deaths.
• Worldwide of the 210 million pregnancy outcomes each year 46 million or 21.9% are
estimated to be induced abortions.
• 20 million unsafe abortions that take place each year, nearly 90 percent are in the
developing world and one-third occur in southern Asia alone.
• 13 percent of maternal mortality worldwide is due to unsafe abortions.
• There are 4 formal (medically qualified though not necessarily certified) abortion facilities
available for per 100,000 populations in India.
• The Medical Termination of Pregnancy Act (MTP Act), which legalized abortion, has been
around for 33 years but only 24 percent private abortion facilities are legalized or certified in
the country.
• Of all the formal abortion providers only 55 percent are gynaecologists and 64 percent of the
facilities have at least one female provider.
• Each of these facilities average 120 abortions per year and this adds up to 4.8 million (one
third in public facilities) abortions being handled in formal abortion facilities per year.
• Public investment in abortion services is grossly inadequate. Only 25 percent of abortion
facilities in the formal sector are public facilities, 87 percent controlled by the private sector
• Provision of safe abortion services to women who need it is not part of the provisions of the
UP State Population policy 2000.
• UP has the highest estimated rate of abortion in the country. Over 20 lakh abortions take
place in the state of Uttar Pradesh every year of which about 60 percent are induced.
Complications from abortion are responsible for 15-30 percent of all maternal" deaths in the
state. Serious complications of unsafe abortion include infection, bleeding and injuries to the
reproductive tract.
• The difference of abortion rate across rural and urban area as well across classes and social
groups in both states significantly different - in urban areas abortion rates were nearly twice
than that in rural areas (more so in Maharashtra) and amongst classes and social groups,
those better off had much higher rates than those economically and socially disadvantaged
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• In Maharashtra and Tamil Nadu less than one-fifth abortions take place in government health
center.
• There is considerable variation across states -Rajasthan and Uttar Pradesh where access
to formal providers is very limited comparison to Maharashtra, Karnataka, Haryana and
Delhi
• In India, present MTP services are inadequate and unequally distributed.
• There are over 22,010 PHCs; 2,662 CHCs and 13,692 Hospitals in 1997, all of which are
eligible under the MTP Act to offer MTP facilities. Of these only 8,891 (23.2%) have been
approved MTP institutions in 1996-97
• These institutions conduct, on an average, 61 legal induced abortions every year
• Only one-quarter of PHCs in Uttar Pradesh and Maharashtra provide abortion services, in
Gujarat and TamilNadu, it is one-third and two-third.
• Where CHCs are concerned, about 59% in Uttar Pradesh, 78% in Gujarat, 89% in Maharashtra
and 95% (CHCs and Sub district hospitals together) in Tamil Nadu provide abortion care
services.
• There is a wide gap between the number of MTPs and the estimated number of abortions
which means that a large number of abortions being provided without being recorded
• A large number of abortions are conducted by private practitioners who are not certified
under the MTP act
• The estimated ratio of illegal to legal abortions ranges between 3 to 1 and 8 to 1.
Incidence of induced abortion
• A community based study conducted in 1998 in Marathwada region of Maharashtra, records
33.4 abortion per 1000 live births
• Studies conducted at Gandhigram near Madras, observed that among 100 contraception,
25 terminate as abortion (10 natural and 15 induced).
• About 10% of the induced abortions are preceded by sex selection tests.
• In Maharashtra, one in every six pregnancy terminations among married women are sex
selective
Abortion related mortality and morbidity
• Globally, about 20% of total maternal mortality are related to abortion
• As per the GOI official records, the share of abortion related maternal mortality for rural India
in 1995 = 17.6%
• 12-20 percent of the maternal deaths in India's are contributed by septic abortions due to
unsafe due to unsafe abortion practices.
• In India around 15000-20000 abortions related deaths are reported each year.
Causes of Abortion
• Limiting the family size is the main reason for abortion
• Non-use of contraception rather than contraceptive failure
• Misconception about contraceptive method (condom, oral pills and IUD)
• Fear about its side-effect on health
• Pain and discomfort with use of contraceptives
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• Irregular supply of contrac~ptive
• Problems with obtaining permission for using contraceptives from husband
• Sex pre selection
Traditional methods
Vaginal herbs, roots
Other vaginal foreign bodies
Oral drugs and potions
Massage
Heat Application
Modern Methods
Suction Evacuation
Dilatation and Curettage
Intra amniotic drugs
Extra amniotic drugs
Abortion pill
Hysterotomy ( Surgery)
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Family Planning Services
(with special reference to Female Sterilisation)
• The term Family Planning is most commonly used in India to describe tubectomy or
female sterilisation
• Female sterilisation is the most widely used form of contraception with over 75% share
among all contraceptives
• Over 45 lakh female sterilisation operations are conducted in India every year
• Female sterilisation operation requires major abdominal surgery
.:. Of the 180 million eligible couples in the country 73 million couples are covered by sterilisation
(31.03.2003 MoHFW)
.:. NFHS-II indicates that nearly one-half of currently married women using some method of
contraception in 1998-99 .
•:. Contraceptive prevalence varies widely among the states, from less than 30 per cent in Meghalaya,
Bihar and Uttar Pradesh to more than 60 per cent in Delhi, Haryana, Himachal Pradesh, Punjab,
West Bengal, Maharashtra and Kerala
.:. Contraceptive prevalence differs among the states, there has been an overall increase in
contraceptive use in almost all states during the 1990s .
•:. Sterilisation is the most commonly used modern contraceptive (80 %) followed by condoms
(7%), pills (5%) and IUD (4%) .
•:. Female sterilsation is 20 times more common than male sterilisation in couples who practice
contraception.
• Male sterilisation is not common all over India, only 2 percent of sterilized (NFHS-II)
• In Uttar Pradesh in 2002-03, only 1,112 men underwent sterilisation as against 3,94,267
women (%).
• 16 percent of currently married women in India have an unmetneed for FP
• It is highest (27 percent) among women below age 20
• Althrough currently use of contraception has increased and the extent of unmet need has declined
in most of the state in India, especially in the four large states of Uttar Pradesh, Bihar, Madhya
Pradesh, and Maharashtra, as well as in Orissa. (NFHS-II)
Levels of contraceptive failure vary widely by method, as well as by personal and background
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Research in the US shows that failure rates of contraceptives are higher among the poor and socially
disadvantaged groups
The research indicates that factors associated with failure can be grouped into three categories:
user characteristics, method-related factors, and provider or system factors.
Method of
Birth Control
Condoms: Male
IUD - Copper T
The Combination Pill
Sterilization: Female
Sterilization: Male
Withdrawal
Nothing
Typical Use
% pregnancy
14
0.8
5
0.5
0.15
19
85
Perfect Use
% pregnancy
3
0.6
0.1
0.5
0.10
4
85
(Based On: Contraceptive Technology: Seventeenth Revised Edition. Hatcher RA, Trussell J,
Stewart F, Cates W, Stewart GK, Kowal D, Guest F, New York NY: Irvington Publishers, 1998.)
Female sterilisation is supposed to have a failure rate of 1 in 200 but a study done in 1999 in five
districts of Uttar Pradesh came up with a much higher figure of 4.7% or nearly I in 20.
Year State
1994 Gujarat
10 camps
275 women
7 camps
82 women
3 Camps
30 women
10 Camps
253 women
Description
OT temporary in some places, lighting and ventilation poor. Lack of
cleanliness. No facility for scrubbing hands, equipment old and in poor
condition. Emergency medicines lacking.
Women not given OT clothes. Embarrassing exposure of clients
Instrument sterilization inadequate.
No post operative follow up.
Camps organized in school buildings. Makeshift OT in most places. OT
had cobweb and dust on the walls. Gloves not changed after each operation.
Outreach camps had no electricity and had to draw electricity from Jeep
batteries for operating the laparoscope. Lamps and candles used for lighting.
In all five camps number of providers outnumbered clients.
Clients had to wait for 4 or 5 hours before doctors came.
No stretchers to remove post operative patients.
OT facility depended on whether the camp was conducted in a PHC, CHC
or Post partum centre. OT facilities at the PHC were inadequate.
No pre-operatiave information or support provided to clients
Time between pre-operative medication and sterilization hurried.
In adequate time given for sterilization of laparoscope
OT tables makeshift. Pre and post operative areas inadequate. Only one
location had all recommended back up facilities.
Clients not provided with OT clothes. Surgeon and assistant had clean OT
clothes in 2 places.
Infiltration anaesthesia given along with premedication outside the OT at
variable interval before surgery
Bicycle pump and bulb of BP instrument used for pumping air into the
abdomen for laparoscopy.
Laparscopic ligation completed in 2 to 5 minutes per case
No pre operative or post operative monitoring.
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• The overwhelming proportion of tubectomy is a manifestation of the gender imbalance in the
programme.
• Only 9 states and UTs reported cases of failure of sterilization .No investigations were carried
out to ascertain the causes.
• The performance of the sterilization programme declined or remained static after adopted Target
Free Approach.
• Condoms and oral pills were not distributed according to norms. There was a shortage of supply
of condoms and oral pills.
• Beneficiary assessment revealed that a large number of acceptors of temporary methods were
getting their supplies from shops.
• Tubal rings supplied to three states was sub- standard
Client Provider Interactions - Informed choice, availability of contraceptives, technically competent
providers, are important parameters of quality where contraceptive services are concerned. A five
state study commissioned by the Ministry of Health and Family Welfare in 2003 provides evidence
that things are far from satisfactory. Tubectomy continues to be the most prevalent method for
contraception. Even the more progressive women in the community lacked knowledge and awareness
about side effects and contraindications of different methods. Doctors and nurses considered women's
complaints as misconceptions and dismissed them. While the government was the main source for
contraceptive commodities, the community needed to supplement this supply from pharmacies
because of the short supply and low quality. The study also found that there is now a demand for
these services and women are asking their health workers about supply of contraceptives. Instead of
providing information about all available contraceptives and leaving the choice up to their clients the
study found that health providers have now started using the 'client segmentation approach' to
determine which contraceptive is appropriate for whom.
.
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WE, THE PEOPLE OF INDIA, having solemnly resolved to constitute India into a SOVEREIGN
SOCIALIST SECULAR DEMOCRATIC REPUBLIC and to secure to all its citizens:
JUSTICE, social, economic and political;
LIBERTY of thought, expression, belief, faith and worship;
EQUALITY of status and of opportunity; and to promote among them all
FRATERNITY assuring" the dignity of the individual and the unity and integrity of the Nation;
IN OUR CONSTITUENT ASSEMBLY this twenty-sixth day of November, 1949, do HEREBY ADOPT,
ENACT AND GIVE TO OURSELVES THIS CONSTITUTION.
Article 14 Equality before law
The State shall not deny to any person equality before the law or the equal protection of the laws
within the territory of India.
Article 15 Prohibition of discrimination on grounds of religion, race, caste, sex or place of
birth
Article 21 Protection of life and personal liberty
No person shall be deprived of his life or personal liberty except according to procedure established
by law.
Article 37 Application of the principles contained in this Part
The provisions contained in this Part shall not be enforced by any court, but the principles therein laid
down are nevertheless fundamental in the governance of the country and it shall be the duty of the
State to apply these principles in making laws.
(1) The State shall strive to promote the welfare of the people by securing and protecting as effectively
as it may a social order in which justice, social, economic and political, shall inform all the institutions
of the national life.
(2) The State shall, in particular, strive to mini mise the inequalities in income, and endeavour to
eliminate Inequalities in status, facilities and opportunities, not only amongst individuals but also
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Article 39 Certain principles of policy to be followed by the State
The State shall, in particular, direct its policy towards securing -
(a) that the cltizen, men and women equally, have the right to an adequate means of livelihood;
(c) that the operation of the economic system does not result in the concentration of wealth and
means of production to the common detriment;
Article 47 Duty of the State to raise the level of nutrition and the standard of living and to
improve public health
Article 51A Fundan\\ental duties
It shall be the dUty of every citizen of India -
(e) to promote harmony and the spirit of common brotherhood amongst all the people of India
transcending religious, linguistic and regional or sectional diversities; to renounce practices derogatory
to the dignity of women;
(f) to value and preserve the rich heritage of our composite culture;
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1. The overriding objective of economic and social development is to improve the quality of lives that
people lead, to enhance their well-being, and to provide them with opportunities and choices to
become productive assets in society.
5. Stabilising population is an essential requirement for promoting sustainable development with
more equitable distribution. However, it is as much a function of making reproductive health care
accessible and affordable for all, as of increasing the provision and outreach of primary and secondary
education, extending basic amenities including sanitation, safe drinking water and housing, besides
empowering women and enhancing their employment opportunities, and providing transport and
communications.
6. The National Population Policy, 2000 (NPP 2000) affirms the commitment of government towards
voluntary and informed choice and consent of citizens while availing of reproductive health care
services, and continuation of the target free approach in administering family planning services .....
7. The immediate objective of the NPP 2000 is to address the unmet needs for contraception, health
care infrastructure, and health personnel, and to provide integrated service delivery for basic
reproductive and child health care. The medium-term objective is to bring the TFR to replacement
levels by 2010, through vigorous implementation of inter-sectoral operational strategies. The long-
term objective is to achieve a stable population by 2045, at a level consistent with the requirements
of sustainable economic growth, social development, and environmental protection.
(1) Address the unmet needs for basic reproductive and child health services, supplies
and infrastructure.
(2) Make school education up to age 14 free and compulsory, and reduce drop outs
at primary and secondary school levels to below 20 percent for both boys and girls.
(3) Reduce infant mortality rate to below 30 per 1000 live births.
(4) Reduce maternal mortality ratio to below 100 per 100,000 live births.
(5) Achieve universal immunization of children against all vaccine preventable diseases.
(6) Promote delayed marriage for girls, not earlier than age 18 and preferably after 20 years of age
(7) Achieve 80 percent institutional deliveries and 100 percent deliveries by trained persons.
(8) Achieve universal access to information/counseling, and services for fertility regulation and
contraception with a wide basket of choices.
(9) Achieve 100 per cent registration of births, deaths, marriage and pregnancy.
(10) Contain the spread of Acquired Immunodeficiency Syndrome (AIDS), and promote
greater integration between the management of reproductive tract infections (RTI) and sexually
transmitted infections (STI) and the National AIDS Control Organisation.
(11) Prevent and control communicable diseases.
(12) Integrate Indian Systems of Medicine (ISM) in the provision of reproductive and
Ensuring Quality of Care in Reproductive Health
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child health services, and in reaching out to households.
(13) Promote vigorously the small family norm to achieve replacement levels of TFR.
(14) Bring about convergence in implementation of related social sector programs so.
10. We identify 12 strategic themes which must be simultaneously pursued in "stand alone" or inter-
sectoral programmes in order to achieve the national socio-demographic goals for 2010.
(i)
Decentralised Planning and Programme Implementation
(ii)
Convergence of Service Delivery at Village Levels
(iii)
Empowering Women for Improved Health and Nutrition
(iv)
Child Health and Survival
(v)
Meeting the Unmet Needs for Family Welfare Services
(vi)
Under-Served Population Groups
(a) Urban Slums
(b) Tribal Communities. Hill Area Populations and Displaced and Migrant Populations
(c) Adolescents
(d) Increased Participation of Men in Planned Parenthood
(Vii) Diverse Health Care Providers
(viii) Collaboration With and Commitments from r'-lon-Government Organisations and the Private
Sector
(ix)
Mainstreaming Indian Systems cf Medicine and Homeopathy
(x)
Contraceptive Technology and r~esearch on Reproductive and Child Health
(xi)
Providing for the Older Population
(xii) Information, Education, and Communication
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1.1 The principle of gender equality is enshrined in the Indian Constitution in its Preamble, Fundamental
Rights, Fundamental Duties and Directive Principles. The Constitution not only grants equality to
women, but also empowers the State to adopt measures of positive discrimination in favour of women.
1.3 India has also ratified various international conventions and human rights instruments committing
to secure equal rights of women. Key among them is the ratification of the Convention on Elimination
of All Forms of Discrimination Against Women (CEDAW) in 1993.
1.7 However, there still exists a wide gap between the goals enunciated in the Constitution, legislation,
policies, plans, programmes, and related mechanisms on the one hand and the situational reality of
the status of women in India, on the other. ..
1.8 Gender disparity manifests itself in various forms, the most obvious being the trend of continuously
declining female ratio in the population in the last few decades. Social stereotyping and violence at
the domestic and societal levels are some of the other manifestations. Discrimination against girl
children, adolescent girls and women persists in parts of the country.
-:'
1.9 The underlying causes of gender inequality are related to social and economic structure, which is
based on informal and formal norms, and practices.
1.11 The goal of this Policy is to bring about the advancement, development and empowerment of
women. The Policy will be widely disseminated so as to encourage active participation of all
stakeholders for achieving its goals. Specifically, the objectives of this Policy include
(i) Creating an environment through positive economic and social policies for full
development of women to enable them to realize their full potential
(ii) The de-jure and de-facto enjoyment of all human rights and fundamental freedom
by women on equal basis with men in all spheres - political, economic, social, cultural
and civil
(iii) Equal access to participation and decision making of women in social, political
and economic life of the nation
(iv) Equal access to women to health care, quality education at all levels, career and
vocational guidance, employment, equal remuneration, occupational health and
safety, social security and public office etc.
(v) Strengthening legal systems aimed at elimination of all forms of discrimination
against women
(vi) Changing societal attitudes and community practices by active participation and
involvement of both men and women.
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(viii) Elimination of discrimination and all forms of violence against women and the
girl child; and
(ix) Building and strengthening partnerships with civil society, particularly women's
organizations.
Decision Making
3.1 Women's equality in power sharing and active participation in decision making, including decision
making in political process at all levels will be ensured for the achievement of the goals of
empowerment. ... Affirmative action such as reservations/quotas, including in high 3r It: gislative bodies,
will be considered whenever necessary on a time bound basis. Women-frienjly pErsonnel policies
will also be drawn up to encourage women to participate effectively in the de 1~lormental process.
Mainstreaming a Gender Perspective in the Development Process
4.1 Policies, programmes and systems will be established to ensure mainstreaming of women's
perspectives in all developmental processes, as catalysts, participants and recipients ....
Education
6.1 Equal access to education for women and girls will be ensured. Special measures will be taken
to eliminate discrimination, universalize education, eradicate illiteracy, create a gender-sensitive
educational system, increase enrolment and retention rates of girls and improve the quality of education
to facilitate life-long learning as well as development of occupation/vocation/technical skills by
women .....
Health
6.2 A holistic approach to women's health which includes both nutrition and health services will be
adopted and special attention will be given to the needs of women and the girl at all stages of the life
cycle. The reduction of infant mortality and maternal mortality, which are sensitive indicators of human
development, is a priority concern. This policy reiterates the national demographic goals for Infant
Mortality Rate (IMR), Maternal Mortality Rate (MMR) set out in the National Population Policy 2000.
Women should have access to comprehensive, affordable and quality health care. Measures will be
adopted that take into account the reproductive rights of women to enable them to exercise informed
choices, their vulnerability to sexual and health problems together with endemic, infectious and
communicable diseases such as malaria, TB, and water borne diseases as well as hypertension and
cardio-pulmonary diseases. The social, developmental and health consequences of HIV/AIDS and
other sexually transmitted diseases will be tackled from a gender perspective.
6.3 To effectively meet problems of infant and maternal mortality, and early marriage the availability
of good and accurate data at micro level on deaths, birth and marriages is required. Strict
implementation of registration of births and deaths would be ensured and registration of marriages
would be made compulsory.
6.4 In accordance with the commitment of the National Population Policy (2000) to population
stabilization, this Policy recognizes the critical need of men and women to have access to safe,
effective and affordable methods of family planning of their choice and the need to suitably address
the issues of early marriages and spacing of children. Interventions such as spread of education,
compulsory registration of marriage and special programmes like BSY should impact on delaying the
age of marriage so that by 2010 child marriages are eliminated.
6.5 Women's traditional knowledge about health care and nutrition will be recognized through proper
documentation and its use will be encouraged. The use of Iridian and alternative systems of medicine
will be enhanced within the framework of overall health infrastructure available for women.
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Nutrition
6.6 In view of the high risk of malnutrition and disease that women face at all the three critical stages
viz., infancy and childhood, adolescent and reproductive phase, focussed attention would be paid to
meeting the nutritional needs of women at all stages of the life cycle. This is also important in view of
the critical link between the health of adolescent girls, pregnant and lactating women with the health
of infant and young children. Special efforts will be made to tackle the problem of macro and micro
nutrient deficiencies especially amongst pregnant and lactating women as it leads to various diseases
and disabilities.
6.7 Intra-household discrimination in nutritional matters vis-a.-vis girls and women will be sought to
be ended through appropriate strategies. Widespread use of nutrition education would be made to
address the issues of intra-household imbalances in nutrition and the special needs of pregnant and
lactating women. Women's participation will also be ensured in the planning, superintendence and
delivery of the system.
Drinking Water and Sanitation
6.8 Special attention will be given to the needs of women in the provision of safe drinking water,
sewage disposal, toilet facilities and sanitation within accessible reach of households, especially in
rural areas and urban slums. Women's participation will be ensured in the planning, delivery and
maintenance of such services.
Violence against women
7.1 All forms of violence against women, physical and mental, whether at domestic or societal levels,
including those arising from customs, traditions or accepted practices shall be dealt with effectively
with a view to eliminate its incidence. Institutions and mechanisms/schemes for assistance will be
created and strengthened for prevention of such violence , including sexual harassment at work
place and customs like dowry; for the rehabilitation of the victims of violence and for taking effective
action against the perpetrators of such violence. A special emphasis will also be laid on programmes
and measures to deal with trafficking in women and girls.
14.1 Training of personnel of executive, legislative and judicial wings of the State, with a special
focus on policy and programme framers, implementation and development agencies, law enforcement
machinery and the judiciary, as well as non-governmental organizations will be undertaken. Other
measures will include:
(a) Promoting societal awareness to gender issues and women's human
rights.
(b) Review of curriculum and educational materials to include gender
education and human rights issues
(e) Removal of all references derogatory to the dignity of women from all
public documents and legal instruments.
(d) Use of different forms of mass media to communicate social messages
relating to women's equality and empowerment.
Panchayati Raj Institutions
15.1 The 73rd and 74th Amendments (1993) to the Indian Constitution have served as a breakthrough
towards ensuring equal access and increased participation in political power structure for women.
The PRls will playa central role in the process of enhancing women's participation in public life. The
PRls and the local self Governments will be actively involved in the implementation and execution of
the National Policy for Women at the grassroots level.
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Partnership with the voluntary sector organizations
16.1 The involvement of voluntary organizations, associations, federations, trade unions, non-
governmental organizations, women's organizations, as well as institutions dealing with education,
training and research will be ensured in the formulation, implementation, monitoring and review of all
policies and programmes affecting women. Towards this end, they will be provided with appropriate
support related to resources and capacity building and facilitated to participate actively in the process
of the empowerment of women.
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1.4 While noting that the public health initiatives over the years have contributed significantly to the
improvement of these health indicators, it is to be acknowledged that public health indicators / disease-
burden statistics are the outcome of several complementary initiatives under the wider umbrella of
the developmental sector, covering Rural Development, Agriculture, Food Production, Sanitation,
Drinking Water Supply, Education, etc. Despite the impressive public health gains as revealed in the
statistics in Box-I, there is no gainsaying the fact that the morbidity and mortality levels in the country
are still unacceptably high. These unsatisfactory health indices are, in turn, an indication of the
limited success of the public health system in meeting the preventive and curative requirements of
the general population.
1.7 Another area of grave concern in the public health domain is the persistent incidence of macro
and micro nutrient deficiencies, especially among women and children. In the vulnerable sub-category
of women and the girl child, this has the multiplier effect through the birth of low birth weight babies
and serious ramifications of the consequential mental and physical retarded growth
3.1 The main objective of this policy is to achieve an acceptable standard of good health amongst the
general population of the country. The approach would be to increase access to the decentralized
public health system by establishing new infrastructure in deficient areas, and by upgrading the
infrastructure in the existing institutions. Overriding importance would be given to ensuring a more
equitable access to health services across the social and geographical expanse of the country.
Emphasis will be given to increasing the aggregate public health investment through a substantially
increased contribution by the Central Government.
4.1 FINANCIAL RESOURCES
4.1.1 The paucity of public health investment is a stark reality. Given the extremely difficult fiscal
position of the State Governments, the Central Government will have to playa key role in augmenting
public health investments. Taking into account the gap in health care facilities, it is planned, under
the policy to increase health sector expenditure to 6 percent of GDP, with 2 percent of GDP being
contributed as public health investment, by the year 2010.
4.2 EQUITY
4.2.1 To meet the objective of reducing various types of inequities and imbalances - inter-regional;
across the rural - urban divide; and between economic classes - the most cost-effective method
would be to increase the sectoral outlay in the primary health sector.
4.6 ROLE OF LOCAL SELF-GOVERNMENT INSTITUTIONS
4.6.1 NHP-20021ays great emphasis upon the implementation of pUblic health programmes through
local self-government institutions. The structure of the national disease control programmes will
have specific components for implementation through such entities. The Policy urges all State
Governments to consider decentralizing the implementation of the programmes to such Institutions
by 2005. In order to achieve this, financial incentives, over and above the resources normatively
allocated for disease control programmes, will be provided by the Central Government.
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4.7 NORMS FOR HEALTH CARE PERSONNEL
4.7.1 Minimal statutory norms for the deployment of doctors and nurses in medical institutions need
to be introduced urgently under the provisions of the Indian Medical Council Act and Indian Nursing
Council Act, respectively. These norms can be progressively reviewed and made more stringent as
the medical institutions improve their capacity for meeting better normative standar-ds.
4.11 USE OF GENERIC DRUGS AND VACCINES
4.11 .1.1 This Policy emphasizes the need for basing treatment regimens, in both the public and
private domain, on a limited number of essential drugs of a generic nature. This is a pre-requisite for
cost-effective public health care. In the public health system, this would be enforced by prohibiting
the use of proprietary drugs, except in special circumstances.
4.17 THE ROLE OF CIVIL SOCIETY
4.17.1 NHP-2002 recognizes the significant contribution made by NGOs and other institutions of the
civil society in making available health services to the community. In order to utilize their high
motivational skills on an increasing scale, this Policy envisages that the disease control programmes
should earmark not less than 10% of the bUdget in respect of identified programme components, to
be exclusively implemented through these institutions.
4.20 WOMEN'S HEALTH
4.20.1 NHP-2002 envisages the identification of specific programmes targeted at women's health.
The Policy notes that women, along with other under-privileged groups, are significantly handicapped
due to a disproportionately low access to health care. The various Policy recommendations of NHP-
2002, in regard to the expansion of primary health sector infrastructure, will facilitate the increased
access of women to basic health care. The Policy commits the highest priority of the Central
Government to the funding of the identified programmes relating to woman's health. Also, the policy
recognizes the need to review the staffing norms of the public health administration to meet the
specific requirements of women in a more comprehensive manner.
4.21 MEDICAL ETHICS
4.21.1.1 NHP - 2002 envisages that, in order to ensure that the common patient is not subjected to
irrational or profit-driven medical regimens, a contemporary code of ethics be notified and rigorously
implemented by the Medical Council of India.
5.3 One nagging imperative, which has influenced every aspect of this Policy, is the need to ensure
that 'equity' in the health sector stands as an independent goal. In any future evaluation of its success
or failure, NHP-2002 would wish to be measured against this equity norm, rather than any other
aggregated financial norm for the health sector. Consistent with the primacy given to 'equity', a
marked emphasis has been provided in the policy for expanding and improving the primary health
facilities, including the new concept of the provisioning of essential drugs through Central funding.
The Policy also commits the Central Government to an increased under-writing of the resources for
meeting the minimum health needs of the people.
5.6 Any expectation of a significant improvement in the quality of health services, and the consequential
improved health status of the citizenry, would depend not only on increased financial and material
inputs, but also on a more empathetic and committed attitude in the service providers, whether in the
private or public sectors. In some measure, this optimistic policy document is based on the
understanding that the citizenry is increasingly demanding more by way of quality in health services,
and the health delivery system, particularly in the public sector, is being pressed to respond. In this
backdrop, it needs to be recognized that any policy in the social sector is critically dependent on the
service providers treating their responsibility not as a commercial activity, but as a service, albeit a
paid one. In the area of public health, an improved standard of governance is a prerequisite for the
success of any health policy.
An Advocacy Handbook
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176
177
191 ,192,193,194,195
197
202
204
299,300,302,303
304 A
312,313,314,315,316
319,320,321,322,323
351,352,353,
375,376
Description
These sections provide legal protection to doctors for acts done in good
faith and with regard to consent. It also defines that consent given fear
or misconception it will not count as consent.
Omitting to give information when legally bound to do so
Furnishing false information
Providing false evidence or fabricating false evidence.
Issuing or signing false certificates
Not informing the police when bound to do so
Destroying documents to prevent it being used as evidence
These sections deal with homicide and murder
Causing death by negligence
These sections deal with criminal abortion
These sections deal with causing hurt and grievous hurt
These sections deal with assault
Laws dealing with rape, including rape in a government institution,
including a hospital
• The Consumer Protection Act 1986
• The Indian Medical Council (Amendment) Act, 2001
• Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act
2002
• Medical Termination of Pregnancy (Amendment) Act, 2002
• Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002.
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The International Convention on the Elimination of All Forms of
Discrimination against Women (CEDA\\V)
Article I
For the purposes of the present Convention, the term "discrimination against women" shall
mean any distinction, exclusion or restriction made on the basis of sex which has the effect
or purpose of impairing or nullifying the recognition, enjoyment or exercise by women,
irrespective of their marital status, on a basis of equality of men and women, of human rights
and fundamental freedoms in the political, economic, social, cultural, civil or any other field.
Article 2
States Parties condemn discrimination against women in all its forms, agree to pursue by all
appropriate means and without delay a policy of eliminating discrimination against women
and, to this end, undertake:
(a) To embody the principle of the equality of men and women in their national
constitutions or other appropriate legislation if not yet incorporated therein and to
ensure, through law and other appropriate means, the practical realization of this
principle;
(b) To adopt appropriate legislative and other measures, including sanctions where
appropriate, prohibiting all discrimination against women;
(c) To establish legal protection of the rights of women on an equal basis with men
and to ensure through competent national tribunals and other public institutions the
effective protection of women against any act of discrimination;
(d) To refrain from engaging in any act or practice of discrimination against women
and to ensure that public authorities and institutions shall act in conformity with this
obligation;
(e) To take all appropriate measures to eliminate discrimination against women by
any person, organization or enterprise;
(f) To take all appropriate measures, including legislation, to modify or abolish existing
laws, regulations, customs and practices which constitute discrimination
women;
(g) To repeal all national penal provisions which constitute discrimination
women.
Article 3
against
against
States Parties shall take in all fields, in particular in the political, social, economic and cultural
fields, all appropriate measures, including legislation, to en sure the full development and
advancement of women, for the purpose of guaranteeing them the exercise and enjoyment
of human rights and fundamental freedoms on a basis of equality with men.
Article 4
1. Adoption by States Parties of temporary special measures aimed at accelerating de facto
equality between men and women shall not be considered discrimination as defined in the
present Convention, but shall in no way entail as a consequence the maintenance of unequal·
or separate standards; these measures shall be discontinued when the objectives of equality
of opportunity and treatment have been achieved.
2. Adoption by States Parties of special measures, including those measures contained in
the present Convention, aimed at protecting maternity shall not be considered discriminatory.
Article 5
States Parties shall take all appropriate measures:
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(a) To modify the social and cultural patterns of conduct of men and women, with a
view to achieving the elimination of prejudices and customary and all other practices
which are based on the idea of the inferiority or the superiority of either of the sexes
or on stereotyped roles for men and women;
(b) To ensure that family education includes a proper understanding of maternity as
a social function and the recognition of the common responsibility of men and women
in the upbringing and development of their children, it being understood that the
interest of the children is the primordial consideration in all cases.
Article 7
States Parties shall take all appropriate measures to eliminate discrimination against women
in the political and public life of the country and, in particular, shall ensure to women, on
equal terms with men, the right:
(a) To vote in all elections and public referenda and to be eligible for election to all
publicly elected bodies;
(b) To participate in the formulation of government policy and the implementation
thereof and to hold public office and perform all public functions at all levels of
government;
(c) To participate in non-governmental organizations and associations concerned
with the public and political life of the country.
Article 10
States Parties shall take all appropriate measures to eliminate discrimination against women
in order to ensure to them equal rights with men in the field of education and in particular to
ensure, on a basis of equality of men and women:
Article 11
1. States Parties shall take all appropriate measures to eliminate discrimination against
women in the field of employment in order to ensure, on a basis of equality of men and
women, the same rights. in particular:
2. In order to prevent discrimination against women on the grounds of marriage or maternity
and to ensure their effective right to work, States Parties shall take appropriate measures:
Article 12
1. States Parties shall take all appropriate measures to eliminate discrimination against
women in the field of health care in order to ensure, on a basis of equality of men and
women, access to health care services, including those related to family planning.
2. Notwithstanding the provisions of paragraph I of this article, States Parties shall ensure to
women appropriate services in connection with pregnancy, confinement and the post-natal
period, granting free services where necessary, as well as adequate nutrition during pregnancy
and lactation.
Article 15
1. States Parties shall accord to women equality with men before the law.
Article 16
1. States Parties shall take all appropriate measures to eliminate discrimination against
women in all matters relating to marriage and family relations and in particular shall ensure,
on a basis of equality of men and women:
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(a) The same n\\:lht to enter into marriage;
(b) The same right freely to choose a spouse and to enter into marriage only with
their free and full consent;
2. The betrothal and the marriage of a child shall have no legal effect, and all necessary action,
including legislation, shall be taken to specify a minimum age for marriage and to make the
registration of marriages in an official registry compulsory.
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International Covenant on Economic, Social and Cultural Rights
Article 12
1. The States Parties to the present Covenant recognize the right of everyone to the enjoyment
of the highest attainable standard of physical and mental health.
2. The steps to be taken by the States Parties to the present Covenant to achieve the full
realization of this right shall include those necessary for:
(a) The provision for the reduction of the stillbirth-rate and of infant mortality and for
the healthy development of the child;
(c) The prevention, treatment and control of epidemic, endemic, occupational and
other diseases;
(d) The creation of conditions which would assure to all medical service and medical
attention in the event of sickness.
General Comment No. 14 (2000)
The right to the highest attainable standard of health
(article 12 of the International Covenant on Economic, Social and Cultural Rights)
8. The right to health is not to be understood as a right to be healthy. The right to health contains both
freedoms and entitlements. The freedoms include the right to control one's health and body, including
sexual and reproductive freedom, and the right to be free from interference, such as the right to be
free from torture, non-consensual medical treatment and experimentation. By contrast, the entitlements
include the right to a system of health protection which provides equality of opportunity for people to
enjoy the highest attainable level of health.
11. The Committee interprets the right to health, as defined in article 12.1, as an inclusive right
extending not only to timely and appropriate health care but also to the underlying determinants of
health, such as access to safe and potable water and adequate sanitation, an adequate supply of
safe food, nutrition and housing, healthy occupational and environmental conditions, and access to
health-related education and information, including on sexual and reproductive health. A further
important aspect is the participation of the population in all health-related decision-making at the
community, national and international levels.
12. The right to health in all its forms and at all levels contains the follOWing interrelated and essential
elements, the precise application of which will depend on the conditions prevailing in a particular
State party:
(a) Availability. Functioning public health and health-care facilities, goods and services, as well as
programmes, have to be available in sufficient quantity within the State party.
(b) Accessibility. Health facilities, goods and services have to be accessible to everyone without
discrimination, within the jurisdiction of the State party. Accessibility has four overlapping dimensions:
c) Acceptability. All health facilities, goods and services must be respectful of medical ethics and
culturally appropriate, i.e. respectful of the culture of individuals, minorities, peoples and communities,
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sensitive to gender and life-cycle requirements, as well as being designed to respect confidentiality
and improve the health status of those concerned.
(d) Quality. As well as being culturally acceptable, health facilities, goods and services must also be
scientifically and medically appropriate and of good quality. This requires, inter alia, skilled medical
personnel, scientifically approved and unexpired drugs and hospital equipment, safe and potable
water, and adequate sanitation.
Article 12.2 (a). The right to maternal, child and reproductive health
14. 'The provision for the reduction of the stillbirth rate and of infant mortality and for the healthy
development of the child" may be understood as requiring measures to improve child and maternal
health, sexual and reproductive health services, including access to family planning, pre- and post-
natal care, emergency obstetric services and access to information, as well as to resources necessary
to act on that information.
Article 12.2 (c). The right to prevention, treatment and control of diseases
16. "The prevention, treatment and control of epidemic, endemic, occupational and other diseases"
(art. 12.2 (c)) requires the establishment of prevention and education programmes for behaviour-
related health concerns such as sexually transmitted diseases, in particular HIV/AIDS, and those
adversely affecting sexual and reproductive health, and the promotion of social determinants of good
health, such as environmental safety, education, economic development and gender equity.
Non-discrimination and equal treatment
18. By virtue of article 2.2 and article 3, the Covenant proscribes any discrimination in access to
health care and underlying determinants of health, as well as to means and entitlements for their
procurement, on the grounds of race, colour, sex, language, religion, political or other opinion, national
or social origin, property, birth, physical or mental disability, health status (including HIV/AIDS), sexual
orientation and civil, political, social or other status, which has the intention or effect of nullifying or
impairing the equal enjoyment or exercise of the right to health.
19. With respect to the right to health, equality of access to health care and health services has to be
emphasized. States have a special obligation to provide those who do not have sufficient means with
the necessary health insurance and health-care facilities, and to prevent any discrimination on
internationally prohibited grounds in the provision of health care and health services, especially with
respect to the core obligations of the right to health.
Gender perspective
20. The Committee recommends that States integrate a gender perspective in their health-related
policies, planning, programmes and research in order to promote better health for both women and
men. A gender-based approach recognizes that biological and socio-cultural factors playa significant
role in influencing the health of men and women. The disaggregation of health and socio-economic
data according to sex is essential for identifying and remedying inequalities in health.
Women and the right to health
21. To eliminate discrimination against women, there is a need to develop and implement a
comprehensive national strategy for promoting women's right to health throughout their life span.
Such a strategy should include interventions aimed at the prevention and treatment of diseases
affecting women, as well as policies to provide access to a full range of high quality and affordable
health care, including sexual and reproductive services. A major goal should be reducing women's
health risks, particularly lowering rates of maternal mortality and protecting women from domestic
violence.
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30. While the Covenant provides for progressive realization and acknowledges the constraints due
to the limits of available resources, it also imposes on States parties various obligations which are of
immediate effect. States parties have immediate obligations in relation to the right to health, such as
the guarantee that the right will be exercised without discrimination of any kind (art. 2.2) and the
obligation to take steps (art. 2.1) towards the full realization of article 12. Such steps must be deliberate,
concrete and targeted towards the full realization of the right to health.
33. The right to health, like all human rights, imposes three types or levels of obligations on States
parties: the obligations to respect, protect and fulfil. In turn, the obligation to fulfil contains obligations
to facilitate, provide and promote. The obligation to respect requires States to refrain from interfering
directly or indirectly with the enjoyment of the right to health. The obligation to protect requires States
to take measures that prevent third parties from interfering with article 12 guarantees. Finally, the
obligation to fulfil requires States to adopt appropriate legislative, administrative, budgetary, judicial,
promotional and other measures towards the full realization of the right to health.
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Introduction
The International Conference on Population and Development ((CPO) was held in Cairo, Egypt, from
5 to 13 September 1994. Delegations from 179 States took part in negotiations to finalize a Programme
of Action on population and development for the next 20 years.
The Programme of Action includes goals in regard to education, especially for girls, and for the
further reduction of infant, child and maternal mortality levels. It also addresses issues relating to
population, the environment and consumption patterns; the family; internal and international migration;
prevention and control of the HIV/AIDS pandemic; information, education and communication; and
technology, research and development.
Chapter 2, Principles
The set of fifteen principles contained in this chapter provides a careful balance between the recognition
of individual human rights and the right to development of nations. The wording of most principles is
directly derived from agreed international language from relevant international declarations,
conventions and covenants.
According to the principles, advancing gender equality and equity and the empowerment of women,
the elimination of all kinds of violence against women and ensuring women's ability to control their
own fertility are cornerstones of population and development-related programmes. In addition, States
should take all appropriate measures to ensure, on a basis of equality of men and women, universal
access to health-care services, including those related to reproductive health care, which includes
family planning and sexual health. The principles reaffirm the basic right of all couples and individuals
to decide freely and responsibly the number and spacing of their children and to have the information,
education and means to do so.
Chapter 3, Interrelationships
Sustainable Development
between Population, Sustained Economic Growth and
A. Integrating population and development strategies. There is general agreement that persistent
widespread poverty and serious social and gender inequities have significant influences on, and are
in turn influenced by, demographic factors such as population growth, structure and distribution.
There is also general agreement that unsustainable consumption and production patterns are
contributing to the unsustainable use of natural resources and to environmental degradation.
B. Population, sustained economic growth and poverty. Efforts to slow population growth, reduce
poverty, achieve economic progress, improve environmental protection and reduce unsustainable
consumption and production patterns are mutually reinforcing. Sustained economic growth within
the context of sustainable development is essential to eradicate poverty.
Eliminating all forms of discrimination against women is thus a prerequisite for eradicating poverty,
promoting sustained economic growth, ensuring quality family planning and reproductive healtn
services, and achieving balance between population and available resources.
C. Population and environment. Meeting the basic needs of growing populations is dependent on a
healthy environment. Such needs must be addressed when developing comprehensive policies for
sustainable development. The aim of section C is twofold: (a) to ensure that population, environmental
and poverty-eradication factors are integrated into sustainable development policies, plans and
programmes; and (b) to reduce both unsustainable consumption and production patterns
An Advocacy Handbook
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Chapter IV, Gender Equality, Equity and Empowerment of Women
A. Empowerment and status of women. The empowerment of women and improvement of their
status are important ends in themselves and are essential for the achievement of sustainable
development.
B. The girl child. The objectives are to eliminate all forms of discrimination against the girl child, to
eliminate the root causes of son preference, to increase public awareness of the value of the girl
child and to strengthen her self-esteem.
C. Male responsibilities and participation. Men playa key role in bringing about gender equality
since, in most societies, they exercise preponderant power in nearly every sphere of life. The objective
is to promote gender equality and to encourage and enable men to take responsibility for their sexual
and reproductive behaviour and their social and family roles.
Chapter VII, Reproductive Rights and Reproductive Health
A. Reproductive rights and reproductive health. Reproductive health is a state of complete physical,
mental and social well-being in all matters relating to the reproductive system and to its functions and
processes. It implies that people have the capability to reproduce and the freedom to decide if, when
and how often to do so. Reproductive rights embrace certain human rights that are already recognized
in national laws, international human rights documents and other relevant UN consensus documents.
These rights rest on the recognition of the basic right of all couples and individuals to decide freely
and responsibly the number, spacing and timing of their children and to have the information and
means to do so, and the right to attain the highest standard of sexual and reproductive health. They
also include the right of all to make decisions concerning reproduction free of discrimination, coercion
and violence. Full attention should be given to promoting mutually respectful and equitable gender
relations and particularly to meeting the educational and service needs of adolescents to enable
them to deal in a positive and responsible way with their sexuality.
B. Family planning. Actions are recommended to help couples and individuals meet their reproductive
goals; to prevent unwanted pregnancies and reduce the incidence of high-risk pregnancies and
morbidity and mortality; to make quality services affordable, acceptable and accessible to all who
need and want them; to improve the quality of advice, information, education, communication,
counselling and services; to increase the participation and sharing of responsibility of men in the
actual practice of family planning; and to promote breast-feeding to enhance birth spacing.
C. STDs and HIV prevention. Section C recommends actions designed to prevent, reduce the incidence
of and provide treatment for STDs, including HIV/AIDS, and the complications of STDs such as
infertility.
D. Human sexuality and gender relations. The objective is twofold: to promote the adequate
development of responsible sexuality that permits relations of equity and mutual respect between
the genders; and to ensure that women and men have access to information, education and services
needed to achieve good sexual health and exercise their reproductive rights and responsibilities.
E. Adolescents. Adolescent sexual and reproductive health issues, including unwanted pregnancy,
unsafe abortion (as defined by the World Health Organization), andSTDs and HIV/AIDS, are
addressed through the promotion of responsible and healthy reproductive and sexual behaviour,
including voluntary abstinence, and the provision of appropriate services and counselling specifically
suitable for that age group.
Chapter VIII, Health, Morbidity and Mortality
A. Primary health care and the health-care sector. Section A recommends actions to increase the
Ensuring Quality of Care in Reproductive Health
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accessibility, availability, acceptability and affordability of health-care services and facilities, and to
increase the healthy life-span and improve the quality of life of all people, as well as to reduce the
disparities in life expectancy between and within countries. All countries should make access to
basic health care and health promotion the central strategies for reducing mortality and morbidity.
B. Child survival and health. The mortality of children under age 5 varies significantly between and
within countries and regions. Poverty, malnutrition, a decline in breast-feeding, and inadequacy or
lack of sanitation and health facilities are all associated with high infant and child mortality.
C. Women's health and safe motherhood. Complications related to pregnancy and childbirth are
among the leading causes of mortality for women of reproductive age in many parts of the developing
world, resulting in the death of about half a million women each year, 99 per cent of them in developing
countries.
A. National policies and plans of action. Where leadership is strongly committed to economic growth,
human resource development, genderequality and equity and meeting the health and in particular
the reproductive health needs of the population, countries have been able to mobilize sustained
national commitment to make population and development programmes successful. Recognition
is given to the need to involve intended beneficiaries in the design and subsequent implementation
of population-related policies, plans, programmes and projects. Non-governmental organizations
and the private sector are acknowledged as partners in national policies and programmes.
The primary objective of this chapter is to promote an effective partnership between Governments,
non-governmental organizations, local community groups and the private sector in the discussion
and decisions on the design, implementation, coordination, monitoring and evaluation of programmes
relating to population, development and environment. Governments and intergovernmental
organizations should integrate NGOs and local community groups into their decision-making and
facilitate the contribution that NGOs can make towards finding solutions to population and development
concerns and, in particular, to ensure the implementation of the Programme of Action.
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Excerpts
Mission Statement
1. The Platform for Action is an agenda for women's empowerment.
3. The Platform for Action emphasizes that women share common concerns that can be addressed
only by working together and in partnership with men towards the common goal of gender equality
around the world. It respects and values the full diversity of women's situations and conditions and
recognizes that some women face particular barriers to their empowerment.
5. The success of the Platform for Action will require a strong commitment on the part of Governments,
international organizations and institutions at all levels.
21. Women are key contributors to the economy and to combating poverty through both remunerated
and unremunerated work at home, in the community and in the workplace. Growing numbers of
women have achieved economic independence through gainful employment.
Critical Areas 0,1 Concern
41. The advancement of women and the achievement of equality between women and men are a
matter of human rights and a condition for social justice and should not be seen in isolation as a
women's issue. They are the only way to build a sustainable, just and developed society. Empowerment
of women and equality between women and men are prerequisites for achieving political, social,
economic, cultural and environmental security among all peoples.
To this end, Governments, the international community and civil society, including non-governmental
organizations and the private sector, are called upon to take strategic action in the following critical
areas of concern:
• The persistent and increasing burden of poverty on women
• Inequalities and inadequacies in and unequal access to education and training
• Inequalities and inadequacies in and unequal access to health care and related services
• Violence against women
• The effects of armed or other kinds of conflict on women, including those living under foreign
occupation
• Inequality in economic structures and policies, in all forms of productive activities and in
access to resources
• Inequality between men and women in the sharing of power and decision-making at all
levels
• Insufficient mechanisms at all levels to promote the advancement of women
• Lack of respect for and inadequate promotion and protection of the human rights of women
• Stereotyping of women and inequality in women's access to and participation in all
communication systems, especially in the media
• Gender inequalities in the management of natural resources and in the safeguarding of the
environment
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c. Women and Health
89. Women have the right to the enjoyment of the highest attainable standard of physical and
mental health .... Women's health involves their emotional, social and physical well-being
and is determined by the social, political and economic context of their lives, as well as by
biology.
90. Women have different and unequal access to and use of basic health resources, ... Women
also have different and unequal opportunities for the protection, promotion and maintenance
of their health. In many developing countries, the lack of emergency obstetric services ....
Health policies and programmes often perpetuate gender stereotypes and fail to consider
socio-economic disparities .... Women's health is also affected by gender bias in the health
system and by the provision of inadequate and inappropriate medical services to women.
91. In many countries, especially developing countries, in particular the least developed countries,
a decrease in public health spending and, in some cases, structural adjustment, contribute
to the deterioration of public health systems ...
92. Women's right to the enjoyment of the highest standard of health must be secured throughout
the whole life cycle in equality with men ..... Good health is essential to leading a productive
and fUlfilling life, and the right of all women to control all aspects of their health, in particular
their own fertility, is basic to their empowerment.
93. Discrimination against girls, often resulting from son preference, in access to nutrition and
health-care services endangers their current and future health and well-being. Conditions
that force girls into early marriage, pregnancy and child-bearing and SUbject them to harmful
practices, such as female genital mutilation, pose grave health risks .....
94. Reproductive health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity, in all matters relating to the reproductive system
and to its functions and processes. Reproductive health therefore implies that people are
able to have a satisfying and safe sex life and that they have the capability to reproduce and
the freedom to decide if, when and how often to do so .... It also includes sexual health, the
purpose of which is the enhancement of life and personal relations, and not merely counselling
and care related to reproduction and sexually transmitted diseases.
96. The human rights of women include their right to have control over and decide freely and
responsibly on matters related to their sexuality, including sexual and reproductive health,
free of coercion, discrimination and violence. Equal relationships between women and men
in matters of sexual relations and reproduction, including full respect for the integrity of the
person, require mutual respect, consent and shared responsibility for sexual behaviour and
its consequences ..
99. Sexual and gender-based violence, inclUding physical and psychological abuse, trafficking
in women and girls, and otherforms of abuse and sexual exploitation place girls and women
at high risk of physical and mental trauma, disease and unwanted pregnancy. Such situations
often deter women from using health and other services.
Strategic objective C.t.
Increase women's access throughout the life cycle to appropriate, affordable and quality health care,
information and related services
Strategic objective C.2.
Strengthen preventive programmes that promote women's health
Strategic objective C.3.
Undertake gender-sensitive initiatives that address sexually transmitted diseases, HIV/AIDS, and
sexual and reproductive health issues
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Strategic objective C.4.
Promote research and disseminate information on women's health
Strategic objective C.5.
Increase resources and monitor follow-up for women's health
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Antenatal care
• Registration of pregnancies
• At least 3 antenatal visits
• Iron prophylaxis
• Detection and treatment of anaemia
• Referral/management of high risk pregnant women
Natal care
• Delivery by trained personnel
• Increase in institutional delivery
Post natal care
• 3 post natal visits
• Monitoring and care of the newborn
• Referral/management of the high risk new born
Components of an Antenatal Check up
1. History taking - menstrual history, past obstetric history, contraceptive history, history of the
present pregnancy etc.
2. Physical examination - height, weight, blood pressure, anaemia, jaundice, oedema etc.
3. Abdominal examination - height of the uterus, position of the foetal head, foetal heart sounds
etc.
4. Investigations - Hemoglobin estimation, urine examination for proteins
Counseling during Pregnancy should deal with
1. Diet - including fresh green leafy vegetables, avoid alcohol and smoking
2. Rest - At least two hours in the afternoon, avoid lifting heavy weights
3. Preparation for childbirth
4. Danger signs and need for referral
5. Information about referral transport related support
6. Information about National Maternity Benefit Scheme
7. Need for contraception after delivery
Medication
1. 100 tablets of Iron and folic acid to be taken daily for three months
2. Two doses of tetanus toxoid to be taken one month apart, the second dose at least one month
before pregnancy,
3. Avoid all unecessary medicines.
These services are to be provided by the Multipurpose Health Worker Female either at the Subcentre
or through home visits.
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1. History taking "7 Whendid the pains start, how frequent and for how long do the pains last
2. Examination - Position of the head of the baby, foetal heart rate.
3. Having the mother lie down in a clean place on a clean sheet
4. Internal examination ( only by a provider trained to do so) - Extent of opening of the cervix,
extent of rounding of cervix ( effacement). i
5. Washing hands, removing rings and bangles, using sterile gloves for internal examination.
6. Supporting the mother, talking to her gently - allow her to scream
7. Back massage, massage her thighs, allow her to squat,
8. Use the disposable delivery kit if it is available
9. Cutting the cord after tying it at both sides with a boiled blade
10. Tying the cord with boiled pieces of thread
11. Receiving the baby with soft clean cloth.
12. Putting the baby immediately to the breast or ask the mother to roll her nipples.
13. Waiting for the placenta to separate and then gently nudge it out without pulling hard, or pressing
the abdomen
14. Check the placenta to see whether it is complete
15. Check the abdomen whether the uterus is firmly contracted.
1. Give injections to speed up labour
2. Apply pressure to the abdomen
3. Push anything in the vagina
4. Scold or hit the mother
5. Pull out the baby
6. Apply pressure on the abdomen to pull out the placenta
The Multipurpose Health Worker Female has to visit all women who have delivered babies as soon
as they come to know and definitely within the first week., She has to make three visits in the first six
weeks and the services she is supposed to provide include thefolJowing.
History taking
1. Date, time and place of birth
2. Who was the birth attendant and whether the Disposal Delivery Pack was used
3. Any problems faced by the mother after delivery.
4. Enquire about bleeding, fever, urination
5. Enquire about the baby, its feeding habits
Examine
1. Mother - Temperature, Breasts, Position of the uterus, Genital area
2. Baby - check for congenital abnormalities, weigh the baby, note weight in a card
Counseling
1. Immunisation for the baby, inform them of the dates
2. Breast feeding and diet
3. Sex and Cqntraception
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Quality of Care Parameters - Female Sterilisation Operations
• Clients must be married; male clients should ideally be below 60 and female clients between 22
and 45; number of children is not a necessary criterion;
• Clients must be informed of all available methods of family planning;
• Clients must make an informed decision for sterilisation voluhtarily;
• Clients must understand the full implications of sterilisation;
• Clients must be counselled in the language they understand; and they should be made to
understand what will happen before, during and after the surgery, its side effects or potential
complications;
• Consent should not be obtained under physical or mental stress.
• There should be a separate counselling room which offers privacy and ensures avoidance of
any interruptions
• Laparoscopic sterilisation can only be performed by either a gynaecologist with DGO/MD/MS or
a surgeon with MS degree and trained in laparoscopy.
• A careful clinical assessment of the clients should be made to ensure fitness and in certain
conditions which require the doctors to be cautious, delay surgery, refer or counsel the patient
for alternatives
• Clinical assessment must include detailed medical history, physical examination, laboratory
examination which includes hemoglobin estimation, urine analysis for sugar and albumin and
other tests if necessary
• The operating surgeon must verify eligibility, informed consent, and confirm fitness
• Sterilisation with MTP is not to be done in camp conditions
• Premedication must be given at least 30 minutes before, if given intramuscularly
• Local anaesthetic is to be infiltrated on the OT table
• Medical records are to be maintained relating to vital signs
• Pre, intra and post operative monitoring is to done with pulse, respiration and blood pressure
records every 15 minutes and in case of post operative monitoring upto one hour.
• In laparoscopy the patient must not be elevated in excess of 15 degrees and in case of vasovagal
attack it must be immediately made horizontal
• Slow insufflation and gradual desufflation and peumoperitoneum should be done with air and
preferably with carbon dioxide with pressure not exceeding 20mm or 1 litre
• Communication must be maintained with the client throughout the procedure
• Discharge is to done after at least 4 hours and the client must be provided with a discharge card
with details and instructions provided in the local language.
• Facility shall have concrete or tile floor and must have running water, have electricity supply with
standby generator
• There must be separate space for reception and registration, waiting area, counselling room,
pre-operative waiting area for clients, pre-oprative room for part preparation and changing of
clients clothes into OT clothes and conducting laboratory tests, hand washing area ,operation
theatre, post operative recovery room/ward.
• The operation theatre must be isolated and fitted with flyproof netting. It should be large for free
movement, and be easy to enter and leave, it must have adequate light and locked when not in
use
• Preoperative assessment is extremely important in mobile settings, and final selection must be
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done by the operating surgeon
• Mobile sterilisation services should be offered in places which have an OT and in no circumstances
should it be conducted in a school building or a panchayat bhawan.
• No clinical training should be conducted during any mobile sterilisation programme
• Mobile sterilisation services should be conducted preferably between 11 am and 3 pm and the
optimum number of cases to be operated by one team in one day is twenty.
• All staff of the mobile team must be skilled in emergency resuscitation measures and necessary
emergency equipment must available
• Facility must exist to transfer the client to a higher centre to handle an emergency
• MTP should not be performed during mobile services
• The client's history of cuts and wounds for the month preceding surgery should be evaluated.
They should preferably change into theatre clothes and if not feasible wear clean clothes
• All personnel must change into theatre clothes. Movement in the OT should be minimal. Ideally
the surgeon and his/her assistant should scrub thoroughly between each procedure and if not
feasible should do a three minute scrub or alcoholic glycerine rub every hour or after 5 cases.
• After preparation of the operative site, it should be covered by a surgical drape
• Gloves should be changed after every case
• All instruments should decontaminated immediately after use and cleaned and properly sterilised
• Laparoscopes must be wiped with an alcohol soaked cloth after use, dissembled, washed, put in
a basin of Cidex for 20 minutes and rinsed twice with sterile water to remove all traces of
disinfectant
• Proper waste disposal includes burying or burning waste. Burning is preferred and it should be
done in an incinerator or closed drum as opposed to open burning. Waste should not be left in
an open pit.
(From - Standards for Male and Female Stei"i1isation, Division of Research studies & standards,
Department of Family Welfare, Ministry of Health and Family Welfare, Government of India, October
1999)
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Quality of Care Parameters '- Medical Termination of Pregnancy
Who can terminate a pregnancy - A pregnancy may be terminated by a registered medical
practitioner, -
(a) Where the length of the pregnancy does not exceed twelve weeks if such medical practitioner is,
or
'
(b) Where the length of the pregnancy exceeds twelve weeks but does not exceed twenty weeks, if
not less than two registered medical practitioner are of opinion, formed in good faith, that-
When can the pregnancy be terminated
(i) the continuance of the pregnancy would involve a risk to the life of the pregnant woman or of grave
injury to her physical or mental health; or
(ii) there is a substantial risk that if the child were born, it would suffer from such physical or mental
abnormalities to be seriously handicapped.
Explanation 1- Where any pregnancy is alleged by the pregnant woman to have been caused by
rape, the anguish caused by such pregnancy shall be presumed to constitute a grave injury to the
mental health of the pregnant woman.
Explanation 2 - Where any pregnancy occurs as a result of failure of any device or method used by
any married woman or her husband for the purpose of limiting the number of children, the anguish
caused by such unwanted pregnancy may be resumed to constitute a grave injury to the mental
health of the pregnant woman.
(3) In determining whether the continuance of a pregnancy would involve such risk of injury tp the
health as is mentioned in sub-section (2), account may be taken of the pregnant women's actual or
reasonable foreseeable environment.
(4) (a) No pregnancy of a woman, who has not attained the age of eighteen years, or, who, having
attained the age of eighteen years, is a mentally ill person, shall be terminated except with the
consent in writing of her guardian.
(b) Save as otherwise provided in clause (a), no pregna(1cy shall be terminated except with the
consent of the pregnant woman.
Place where pregnancy may be terminated - No termination of pregnanqy shall be made in
accordance with this Act at any place other than -
(a) a hospital established or maintained by Government, or
(b) a place for the time being approved fqr the purpose of this Act by Government or a District Level
Committee constituted by that Government with the Chief Medical Officer or District Health Officer
as the Chairperson of the said Committee: Provided that the District Level Committee shall consist
of not less than three and not more than five members including the Chairperson, as the Government
may specify from time to time.
Exceptions - The above provisions which relate to the length of the pregnancy and the opinion of
not less than two registered medical practitioners, shall not apply to the termination of a pregnancy
by a registered medical practitioner in a case where he is of opinion, formed in good faith, that he
termination of such pregnancy is immediately necessary to save the life of the pregnant woman.
Punishment-The termination of pregnancy by a person who is not a registered medical practitioner
shall be an offence punishable with rigorous imprisonment for a term which shall not be less than two
years but which may extend to seven years. Whoever terminates any pregnancy in a place other
than that mentioned above, shall be punishable with rigorous imprisonment for a term which shall not
be less than two years but which may extend to seven years.
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• Ante natal, and post natal check up and advice
• Safe Delivery
• Immunisation for children and pregnant women
• Iron and folic acid tablets for anaemia
• Contraceptives - Condoms, IUD and Oral pills
• Follow up after sterilisation operation
• Referral for Reproductive Tract Infections and Sexually Transmitted Infections
• Weight monitoring of children under 5 years of age
• Oral Rehydration Therapy
• Treatment for Acute Respiratory Tract Infection
• Treatment for minor ailments
• Referral for all health conditions
• Counselling services for
Breast feeding, infant feeding and malnutrtion
Adolescents
Family Planning
Reproductive tract infections
• All services available at the Sub Centre
• Curative services
• Laboratory services
• Pharmacy with essential drugs
• Treatment for reproductive tract infections
• Services for male and female sterilisation
• Referral to higher medical centres
• Medico legal services
• All services available at the PHC
• Safe abortion services
• Basic Emergency Obstetric Care
• Specialist services - paediatrics, obstetrics and gyaecology, surgery.
• All services available at the CHC
• Blood Bank
• Comprehensive Emergency Obstetric Care
• STI Clinic
• Infertility services
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4. Right to basic health care, expensive life-saving treatment and emergency services at hospitals
irrespective of ability to pay.
5. Right to easy access to adequate and appropriate health services that are effective and sensitive
to the community's needs.
6. Right to expect prompt treatment within available resources in an emergency irrespective of
client's ability to pay, during working hours of the primary and secondary health care facilities
and at all times in casualty departments of secondary and tertiary hospitals.
8. Right to health system that anticipates major health hazards, takes appropriate actions to prevent
them and, in unfortunate instances, is fully equipped to act effectively to control the damage
caused by health disasters.
10. Right to be transferred to another health care establishment only after an explanation of the
need for transfer and after the other establishment has accepted the patient.
11. Right to seek second opinion about disease/treatment, etc. (There was discussion among
members about whom to approach for a second opinion. Some members felt that for MCGM,
second opinions should be sought from teaching hospitals* (this was not fully accepted in the
earlier meetings).
13. Right to refuse participation in human experimentation or research projects affecting their care
or treatment.
14. Right to information on causes, diagnosis, treatment, medicines and preventive measures for a
particular condition.
15. Right to information about expected outcomes, side effects, after effects, chances of success,
cost and availability of prescribed medication.
16. Right to obtain all the relevant information about the professionals involved in patient care, for
example availability/timing.
17. Right to know what hospital rules and regulations apply to him /her as patient and the facilities
obtainable to the patient (applicable to primary facilities - in terms of user fees, referral, etc.).
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(Compiled from: Pondicherry Declaration on Health Rights and Responsibilities; Manual of Patients
by ACASHj People's Health Charter for Gujarat; Final Draft of People's Health Charter - Quoted
from Tools From Paving The Way: A Toolkit For RCH Published by Women Centred Health
Project) .
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8.4 Page 74 |
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1. To provide accurate and complete information about their condition as required by the health
provider.
2. To be punctual for appointments at clinic/hospital/dispensary for treat~ent.
7. To take the necessary preventive measures in case of infectious diseases as per the doctor's
instructions.
10. To keep the present doctor informed if patient wants to change the doctor or line of treatment, or
change to another system of healing.
12. To know and understand the purpose and cost of any proposed investigation/procedure/treatment
before deciding to accept it.
(Compiled from: Pondicherry Declaration on' Health Rights and Responsibilities; Manual of Patients
by ACASH; People's Health Charter for Gujarat; Final Draft of People's Health Charter - Quoted
from Tools From Paving The Way: A Toolkit For RCH Published by Women Centred Health
Project)
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Needs of Service providers
• Training
Knowledge
Skills - Technical, Communication, Understanding
Community needs assessment
Implications of treatment decisions
• Information and Update
Latest technical findings
Work of colleagues and professionals
• Supplies
Essential drugs and equipment
Contraceptives
Educational material
• Support
Need to know- they are part of a broader organized structure
From health-seeker, colleagues, seniors, managers, community, elected representatives
• Safety
Medical- infections, and other occupational hazards
Social security
• Respect
To know that they have the respect and understanding of health-seekers, colleagues, f eniors,
managers, community, elected representatives
• Encouragement
Good practices to be shared
Appropriate environment- provisions in service rules, provisions
Active exchange at different levels-better participatory management decisions and service
delivery.
• Opportunities and capacity building
Provisions for reaching highest possible level
Personal and professional capacity building
Feedback
( Adapted from the framework developed in Quality Of Care in Sexual And Reproductive Health
Services: A Pilot Intervention In Bawal Block, District Rewari, Haryana)
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The Consumer Protection Act 1986 covers medical services and gives the patient /client consumer
rights.
Rights of the consumers include
(a) the right to be protected against the marketing of goods and services which are hazardous to life
and property;
(b) the right to be informed about the quality, quantity, potency, purity, standard and price of goods or
services, as the case may be so as to protect the consumer against unfair trade practices;
(c) the right to be assured, wherever possible, access to a variety of goods and services at competitive
prices;
(d) the right to be heard and to be assured that consumer's interests will receive due consideration at
appropriate forums;
(e) the right to seek redressal against unfair trade practices or restrictive trade practices or
unscrupulous exploitation of con-sumers; and
(f) the right to consumer education.
Medical Care is a Service - A medical service falls under the purview the Consumer Protection Act
in the following cases:
• Service rendered to a patient by a medical practitioner by way of consultation, diagnosis
and treatment, both medicinal and surgical, except where the doctor provides service free of
charge to every patient
• Service rendered at a non-Government hospital/Nursing home where charges arE!required
to be paid by some person and free services given to others.
• Service rendered at a Government hospital/health center/dispensary where some persons
are provided services on payment of charges and others provided services free of charge
• Service provided by a medical practitioner or hospital/nursing home and the charges are
paid by the insurance company
• Wher the employer bears the expenses of medical treatment of an employee and his family
members
Deficiency in service - Means any fault, imperfection, shortcoming or inadequacy in the quality,
nature and manner of performance which is required to be maintained by or under any law. Or such
an undertaking for performing a service was given by a person.
Complaint - A complaint may be filed by the followil}g
• A consumer
• Any voluntary consumer association registered under the Companies Act 1956
• The Central Government or any State Government
• One or more consumers where there are numerous consumers.
District Consumer Disputes Redressal Forums - At the lowest level are the District Forums and
these are established in each District and have jurisdiction to entertain complaints where the value of
goods or services and the compensation if any, claimed does not exceed Rs.5,OO,OOO(five lakhs),
and a complaint can be filed in a District Forum within the local limits of which
a. the opposite party resides or
b. carries on his business or works for gain or
c. where the cause of action arises.
State Consumer Disputes RedressaJ Commission - The State Consumer Disputes Redress
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Commission is established in each state and:these have jurisdiction to entertain complaints where
the value of goods or services and the compensation if any, claimed exceeds Rs.5,OO,OOO(five
lakhs)but does not exceed Rs.20,OO,OOO(twenty lakhs).
National Cdm;Uin~r DIsputes Redressal Commission -The National Consumer Disputes Redressal
Commission has jurisdiction to entertain complaints where the value of the goods or services and
compensation if any claimed exceeds Rs.20,00,000 (twenty lakhs).
Provision for appeal ~Appeal against the decision of the district forum can be filed before the state
commission, from the state commission before the national commission and from the national
commission to the Supreme Court The time limit within which the appeal should be filed is 30 days
from the date of the decision in all cases.
Duties of a doctor - Duties which a doctor owes to his patient are
• A duty of care in deciding whether to undertake the case,
• A duty of care in deciding what treatment to give.
• A duty of care in the administration of that treatment.
A breach of any of these duties gives a right of action for negligence to the patient.