WORKING WITH THE HUMAN RIGHTS-BASED APPROACHES FOR PREVENTION OF MATERNAL MORTALITY AND MORBIDITY IN INDIA

24TH JUNE, 2014 LODHI ROAD, MAPPLE ROOM NEW DELHI

ORGANISED BY NATIONAL ALLIANCE ON MATERNAL HEALTH AND HUMAN RIGHTS (NAMHHR)

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LIST OF CONTENT

Background Welcome and Introductions Session 1: Situation analysis of maternal health in India- an overview Session 2: Technical Guidance Note of the OHCHR Session 3: UPR Process and India’s last Report Session 4: Consolidating the discussion: Ways Forward Annexures About NAMHHR List of participants Suggestions and inputs on contents of the Situational Analysis document

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Background In spite of all the efforts made so far by the Government of India, tens of thousands of women still continue to die each year, for reasons entirely preventable given the state of India’s economic progress and the current scientific and medical knowledge available. This regrettable situation remains despite India being a destination for medical tourism, in that its tertiary care hospitals provide world-class medical care to citizens of developed as well as developing countries. The problem lies in the lack of information and data on maternal mortality and morbidity (MMM) which is disaggregated by class, religion, caste or education. Beyond the obvious bio-medical causes of maternal ill-health and death lies a whole matrix of reasons related to the social determinants of health, including the gender-unequal power relations that affect women’s health, as well as health system causes. The health system causes behind high maternal mortality in India have been reported upon by the former UN Special Rapporteur (UN SR) on the Right to Health, Prof. Paul Hunt, following his Mission to India to study maternal mortality towards the end of 2007. In his report (HRC/A/14/20, April 2010) the UN SR highlights the ‘profoundly inequitable access’ to skilled maternal care (including emergency obstetric care), given the lack of human resources in rural and disadvantaged areas (http://righttomaternalhealth.org/resource/hunt-india). He detected ‘extremely weak technical capacity for managing maternal health programmes’ and pointed to gaps in India’s current monitoring, accountability and redress mechanisms in relation to public and private sector (Human Rights Council, 2010). Hence it is clear that that maternal mortality and morbidity are problems exacerbated by inequitable circumstances. Maternal deaths in India are not inevitable, nor are they a matter of fate. These deaths are almost entirely preventable, and are not random – they are taking place selectively among certain sections of India’s population that are already vulnerable owing to social marginalization, poverty and location in the states with the poorest health services. Maternal health in India is therefore a human rights issue because the current situation is putting the well-being, health and lives of millions of women of this country at risk, and it is a violation of their constitutional rights enshrined in Articles 14, 15 (rights to equality and non-discrimination) and Article 21 (Right to Life) of the Constitution of India.

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Welcome and Introduction The workshop commenced with welcome of participants by Dr. Sandhya YK, representing NAMHHR1 it was taken forward by Adv. Anubha Rastogi, Lawyer and Human Rights activists for an official round of self introduction of the participants. Representatives of the various and leading Civil Society Organizations as well as media person, donors participated in the meeting (Refer to Annexure 2).

Anubha mentioned that NAMHHR is seeking to promote the use of HRBA for the prevention of MMM through some strategic opportunities provided through our new national government: NAMHHR intends to brief the new parliamentarians on the key aspects of maternal health and rights, as was done last time in 20092. In addition, NAMHHR is keen to use international processes of accountability: the Office of the High Commissioner for Human Rights (OHCHR) has developed a Technical Guidance Note (TG)3, and has been requesting countries to report back on how they have used it. Moreover, the mid-term review of India’s UPR-2 report to the Human 1

Refer to Annexure 1 for details about NAMHHR See Briefing Sheet and Booklet for new MPs (2009) at http://www.sahayogindia.org/advocacy-and-campaignmaterials2.html 3 Technical guidance on the application of a human rights based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality, OHCHR 2012 A/HRC/21/2 available at http://ap.ohchr.org/documents/dpage_e.aspx?si=A/HRC/21/22 2

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Rights Council is due in 2014, while the next the UPR-3 report is due in 2016, where the government is due to report back, among other issues, on its commitments to sexual and reproductive health and rights. (The opportunities for working on both are detailed in Annexure One). Therefore NAMHHR has organized this Strategy Development workshop with the following three objectives: 1. To develop a shared understanding of the relevance of using HRBA for preventing MMM 2. To brainstorm on ways of using human rights-based tools such as the Technical Guidance and the UPR process with the following possible stakeholders in India a. Health and Family Welfare department b. Parliamentary Standing Committee c. National Human Rights institutions and /or Judiciary d. Civil society and research institutions 3. To shortlist possible interventions in 2014-2015, and draw up a collective timeline

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Session 1: Situation Analysis of Maternal Health in India- An Overview Presenters: Sandhya YK and Vinita S Chair: Dr. Abhijit Das

This session began with Sandhya giving a brief introduction of why the situational analysis was undertaken. She explained that about a UN document called talked the Technical Guidance Note (TGN)4 which was launched in September 2012 by the Office of the High Commissioner on Human Rights with the primary purpose to assist policymakers in improving women’s health and rights by providing guidance on devising, implementing, and monitoring policies and programs to reduce maternal mortality and morbidity. The TGN encourages governments to design national public health strategies and programmes based on an up-to-date situational analysis of women’s sexual health and reproductive health and rights. Such a situational analysis should be informed by disaggregated data and trends focusing on groups which are marginalized. The TGN clearly mentioned that such a situational analysis should include: 4

Available at http://www2.ohchr.org/english/issues/women/docs/A.HRC.21.22_en.pdf

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 Examination of SRHR data and trends disaggregated by sex, age, caste/religion, residence, education, wealth quintile, region, etc.  Review of legal framework including laws, policies, regulations and guidelines  Assessment of institutional capacities of duty bearers and estimating needs both in terms of human, financial and other resources both in the public sector as well as in the private sector.  Analyzing whether or not universal access has been effectively ensure - in terms of antenatal care, family planning, prevention of sexually transmitted diseases including HIV, access to safe abortion, post abortion care, domestic violence, management and prevention of post partum hemorrhage, caesarian section and post partum care.  Issues around the availability of medicines including contraceptives Sandhya mentioned that NAMHHR sought to undertake this situational analysis and present the data to the government. Vinita then presented the situational analysis on the basis of the suggestions in the TGN dividing it a first section on data and situation of SRHR indicators in the country, an overview of the policies and identifying critical gaps in the existing policies, assessing the institutional capacity of duty bearers including the expenditure on public health infrastructure and human resources and an assessment of the extent of universal access to maternal health services. The presentation was followed by rich and elaborate discussions and suggestions on how this document could be enriched (Refer to Annexure 3 for list of suggestions).

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Dr. Sebanti suggested that the data present in the situation analysis could be more resent and use the most recent data from the Annual Health Survey (AHS), District level health survey-4 (DLHS). She further mentioned that the RMNCH+A which has been rolled out in different state has indicators in gap analysis and quality of services (at least for some state), this data could also be cited in the document. Smita Bajpai suggest that another source of data that could be used was the review of Janani Sishu Surakha Karyakaram (JSSK) by National Health Systems Resource Centre (NHSRC) which has data on out-of-pocket expenditure related to maternal health care and the impact of the JSSK on expenditure. Adv. Jayashree Satpute suggested that instead of using only government data sources and focusing on the numbers, studies and stories about the live experiences of the people in relation to maternal health be used, as this would clearly bring out the issues of discrimination.

The Chair suggested a different angle to carry out this situation analysis by moving beyond from the first generation disaggregation of data (first generation means age, sex, caste, religion, region, education, wealth quintile) to second generation disaggregation that is identification of discrimination. One of the important aspect in second generation disaggregation pointed out by Dr. Abhijit is understanding the distinction between ‘difficult to reach’ and ‘people whose need are not yet clear’those people who the system is not conscious of, who are ignored, denied, and discriminated. In the TGN and other international human rights frameworks around health, there is a tendency to limit themselves to a compliance to technical standard and a few laws; for instance while analyzing from the view point of AAAQ 8

framework, the while the issues of availability, accessibility and quality are addresses, the concept of acceptability is completely missing. Acceptability is rooted in autonomy, self respect, dignity, expectation and those are issues which are extremely important for the communities which are ignored, forgotten, actively discriminated and coerce.

Dr. Prakasamma suggested that since NAMHHR was undertaking this situational analysis it was essential that it be presented from a human rights based perspective, rather than just being a document of fact and figures. She questioned the conceptual framework that was used for this situational analysis and suggested that rather than only presenting data that was already available to the government, it would be more beneficial to use the principles of TGN while analyzing the data and come out with a situational analysis that was informed by a HRB perspective. Others present felt that this was a valuable suggestion and the Chair agreed that NAMHHR should use a different framework which was right based approach rather than a service based approach. He suggested that analytical framework need to consider the context of the people who are not able to articulate their own needs; hence we should move beyond the recommended parameters that have been place in the TGN. 9

The session ended by the formation of an editorial committee5 who would rework on the situational analysis document to incorporate the above suggestions and inputs. Session 2: Technical guidance Note of the Office of the High Commissioner for Human Rights (OHCHR) Presenter: Jashodhara Dasgupta (SAHAYOG) Moderator: Subrat Das (CBGA)

The session provided an overview on Technical guidance note by OHCHR. Jashodhara explained that the TGN is an UN document developed for governments on what exactly a HRBA would mean in terms of policy and planning to prevent high maternal mortality and morbidity (MMM). This was prepared with inputs from Expert Group which met in April 2012 and launched in September 2012. During its launch, it 5

Members of Editorial Committee – Dr. Abhijit Das, Dr. Prakasamma, Dr. Sebanti Ghosh, Adv. Anubha Rastogi, Adv. Sashi Bindani, Vd. Smita Bajpai

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was stated that all governments are expected to promote and implement the TGN and report back to UN Human Right Council this September. In her presentation Jashodhara explained about the following: General principles of HRBA which include:  rights-holders and their entitlements and duty-bearers and their obligations  just and effective health system by upholding the human right principles of Non-discrimination/Equality, Participation , Empowerment , Transparency and Accountability  centred around women’s rights: RBA is not about preventing illness but about promoting health and empowering women, seeing women as active agents in the society.  ensuring women’s sexual & reproductive health by using AAAQ framework of health and human right issues Planning for applying HRBA in policies and programs to prevent MMM  Need to have a national plan or strategies on health including strategy on sexual and reproductive health with the active participation of women and the organizations working in the women issues  Plan should be based on an up-to-date situational analysis, both the national and sub-national levels  It should have detail guidelines and address any barriers to access by women and girls like discrimination, social or structural barriers  Strengthen the capacity of heath work force and protection of their rights as workers  Budgeting, what to monitor and how to monitor are highlighted.  Remedies about if the rights are violated is also mentioned in the document. This presentation was followed by a rich and insightful discussion on applicability of this TG note in the Indian context. The moderator Subrat Das clarified the points of discussion that we are using the technical guidance note as a tool to achieve maternal health and rights issues but it should not be accepted uncritically. Therefore the discussion should focus on the strengths and weakness and gaps of this document.

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Strength of the document which emerged from the discussion  The principles in this TG are universal which are all about the points the meeting had been discussing at the first session like accountability, participatory, therefore it was suggested not to shy away from using this tool for HRBA in maternal health.  Besides the general principles the guideline is actually coming to points as it talks about women and reproductive rights or community or health system strengthening which is related with the betterment of health of the women.  The document can be use as an advocacy tools, it has budgeting and planning which is very practical. Therefore by using this tool, it will be easier for us to put the pressure on government to adopt HRBA in maternal health care. Gaps and weakness of the TG note  Being an international document, it has the universal approach with ‘one size fit all’ so there is lack of context specific issues 12

 It is a principle, the challenge and gap is how to use it in the Indian context given the situation of lack of health infrastructure, health personnel, geographical difficulties, situation of corruption etc.  Another gap in the document is it does not address the issue of acceptability of health services.  In terms of understanding the inadequacy in the framework of this document, there is lack of holistic approach. Focusing only on the maternal health issues might not serve the purpose unless the problems of the health system as a whole are addressed. Therefore providing and allocating adequate resources and budget for one program is not the solution.  Tools and mechanism of how the community are going to put their grievances and get the responses is lacking Other comments and suggestions

 As the documents is too long and quite repetitive, it was recommended to select only the principles and contents related to our context and health issues and develop our own document in the context of prevailing health situation and resources.  In the discussion main concern of the participants was how to use HRBA when the situation of the country in respect to infrastructures, resources and finances are not in shambles. However it was agreed upon that no matter the 13

situation is, now we need to go forward with this approach as Human rights are enshrine in our constitution and the RBA is very much within the law so we have to stand up in spite of having all these constraints.  It was pointed out that, in India health is too much of a state subject so, we need to explore how we take this to state and sub state levels  Another question raised was regarding the awareness of the existence of the TGN among the health organizations and government. It was revealed that most of the stakeholders including the MOHFW, human right activist, lawyers, had not heard of this note. A point of observation was that there might be resistance from the government in adopting an international document like the TGN  It was decided that the need of the hour was to cull out salient points from the TGN which were relevant to the Indian context and use it to advocate with the government

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Session 3: Universal Periodic Review Process Presenter: Henri Tiphagne (WGHR) Chair- Vd. Smita Bajpai (CHETNA, Gujarat)

The session began with a presentation by Henri on the UPR process and how it rolled out in the international arena. He said that UPR is a good strategy and opportunity for CSOs and people to hold their governments accountable to the recommendations that they had accepted. Therefore community of human right activists should own it and utilize its vast potential. Henri’s presentation highlighted the following points.  Definition: Cooperative mechanism and a state-driven process which reviews the fulfillment of the human rights obligations and commitments of all 192 UN Member States once every four years. It is an opportunity for the States to show actions taken to improve the situation of human right.  Objectives: Improvement of the HR situation on the ground, fulfilment of the State’s HR obligations and commitments, assessment of positive developments and challenges faced by the State, enhancement of the States’ capacity and of technical assistance, sharing of best practice among States 15

and other stakeholders, support for cooperation, cooperation and engagement with the HRC, HR bodies and OHCHR.  Basis/Principles of Review: Universality in the respect that it covers all the UN state, periodic in the sense that review happens every 4 years, participative as there is an interactive dialogue / stakeholders participation (including NGOs and NHRIs).  He explain that it is cycle which start with a national process focusing within the country. Actual review happens in working groups in Geneva during the Human Rights Council Session. After this session, written recommendations are provided by the countries of the working group and the country under review either accepts or rejects the recommendations. And ultimately formal adoption of the outcome of UPR process is made in the plenary session of the Human Rights Council. Following the completion of review, each country is supposed to begin working to address the recommendations that it has accepted. This is where the role of civil society becomes critical as it can monitor the implementation of the recommendations and make independent submissions.

Follow-up to the review

National Process Consideration and adoption of Outcome in plenary Review in the UPR WG Post session written views

 Documentation: National reports, UN compilation. Summary of stakeholder’s submissions  Modalities: Interactive dialogue in the Working groups (the review) and adoption of the Outcome in the HRC Plenary. 16

Explain the role of the WGHR in this process he explained that between the reviews the WGHR put pressure on the Ministries to ensure that they were acting on the accepted recommendations as well as drafting submissions.

Discussion on the possible collaboration with NAMHHR  The first concrete suggestion put forward by WGHR is presenting a report on the status of the recommendations made to the Indian government. He invited NAMHHR to work with WGHR to recommendations on maternal health  Bring together all the CSOs and institutions involve in health and human right work for a day or two training on UPR process.  Training program for the senior functionaries of the national human rights institutions and various ministries, in which NAMHHR can take sessions on maternal health  Organizing a briefing session for parliamentarians on the UPR process  Active participation of NAMHHR in writing annual report as well as common stakeholder report of UPR.  Meeting UN Resident Commissioner and other UN Bodies

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The session was then taken forward by the moderator, Smita Bajpai, she said that all the suggestions given above are very concrete and doable and open the session to the participants for any clarification, sharing of experiences and discussion. Discussions and Suggestions There was a suggestion that it would be valuable if not only CSOs working on health but those associated with other movements such as the Right to Food and the Right to Work also being involved in the UPR process. Another question was regarding whether there was a possibility of lobbying with countries to ensure that specific recommendations are raised. Henri explained that there was a possibility of this, but before engaging in it, the concerned CSOs needed to identify countries who were interested in the issue. Each country he said tends to focus more on certain issues and one need to identify the country interested in the specific issue and engage in lobbying with them. It was felt that since the recommendations of the UPR were binding, the UN member states took the process very seriously and therefore it made sense for CSOs to engage with the process. 18

Session 4: Consolidating the Discussion; shortlisted interventions and timeline Chair: Adv. Kamayani Bali Mahabal, Lawyer and Human right activists

Kamayani started the consolidating session saying that the workshop had a very rich and in-depth discussion. She summarized the day long discussions into following points. Situational Analysis of maternal health in India: The editorial committee would re-work on the document with a human rights based perspective. Technical guidance note: Adapt it to the Indian context and share this simpler version with relevant stakeholders such as parliamentarians, senior government functionaries, human rights institutions and CSOs. Reach out to UNFPA, NHRC, WHO whose representatives had not attended this meeting and explore the possibility of working together with them to promote the TGN. UPR process: WGHR had given some concrete suggestion to NAMHHR which would be discussed in its Steering Committee and would communicate to the WGHR. The meeting ended with a vote of thanks by the Secretariat of NAMHHR to all the participants for providing meaningful and valuable comments and suggestions which would guide the work on NAMHHR.

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Annexure 1: About NAMHHR The National Alliance for Maternal Health and Human Rights (NAMHHR) has been formed as a collaborative effort of civil society groups from different states in January 2010 during one such collaborative effort. The group agreed on the need to strengthen maternal health as an issue of women’s human rights, given the sheer scale of the problem at seventy to eighty thousand women dying each year in India of preventable causes related to maternity. The Alliance believes that strong rights-based strategies are needed to build greater accountability for the thousands of preventable deaths among women in India. The group is attempting to address the urgent need for women’s organizations, health organizations, groups working on law and human rights, and mass-based organizations to come together on this issue. Currently the NAMHHR brings together 36 member networks from 13 Indian states, organizations, and individuals guided by 6 expert advisors working with research, Right to Food, public health, right to medicines and budget accountability. The Secretariat of the Alliance is housed in SAHAYOG, Delhi and is currently being directed by a 10 member Steering Committee.

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Annexure 2: List of Participants Organization ANSWERS ASHA, West Bengal CBGA, New Delhi CHETNA, Gujarat/ Rajasthan CHSJ, New Delhi HeathWatch Forum UP HRLN Individuals (Mumbai ) Nazdeek, New Delhi/ Assam Save the Children (India)/RMNCH+A Coalition SEWA Rural, Gujarat SODA, Odisha WGHR SAHAYOG, New Delhi

Individual JNU Editor, Emzr-People USAID

Names

E- mail Id

Civil Society Organizations Dr. M. Prakasamma [email protected] Dr. Sebanti Ghosh [email protected], [email protected] Subrat Das [email protected] Sona Mitra [email protected] Vd. Smita Bajpai [email protected] Dr. Abhijit Das [email protected] Tia Farrell [email protected] Nibedita Phukan [email protected] Esha Saraswat [email protected] Awdesh Kumar [email protected] Sanjai Sharma [email protected] Adv Kamayani Bali Mahabal Adv. Anubha Rastogi Adv. Jayshree Satpute

[email protected] [email protected] [email protected]

Dr. Anuradha Jain Pankaj Shah Sashiprava Bindhani Henri Tiphagne P. Krishnamoorthy Jashodhara Dasgupta

[email protected] [email protected] [email protected], [email protected] [email protected] [email protected] [email protected]

Y K Sandhya Anaswara K Rekha Srivastava

[email protected] [email protected] [email protected] Consultants Vinita sahasranaman [email protected] [email protected] Saya Okram Media Dr. P.N. Rao [email protected] Donor Sharmila Neogi [email protected]

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Annexure 3: Suggestions and inputs on contents of the Situational Analysis document  Need of prioritizing the issues and areas instead of writing extensive report by putting everything  Question was put forward regarding the logic of using only three laws in the documents (MTP act, POSCO, Prevention of early marriage act) and suggested to look further about accessibility of pills in regards to MTP act, issues of conducting abortion by illegal personnel, maternity benefit schemes in the legal frame work  Equity focus has to be reflected in the document, in the section of RMNCH+A strategy, it was highlighted that from the policy point of view the concept of high priority district and how are we prioritizing the high priority districts needs to be accounted.  Highlight aspects on public-private partnership and schemes offer for maternal health care  Cost of care, out-of-pocket expenditure, cases of informal payment needs to be highlight in the analysis  Suggestion was given to include the new policies and initiatives which are state specific like use of misoprostrol for preventing post partum hemorrhage which has been piloted in tribal remote areas of state like Jharkhand.  Role of AYUSH doctors posted in public health institutes in maternal health care  Issues of home birth by skilled birth attendance in the notified area  It was recommended to include available cases on successful stories with good result.  Policies which are not directly related to health but affecting the health like Clinical Establishment Act.  Clear understanding of whose right we are serving as right perspective of the provider and beneficiaries are different.

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