Communications
An open letter on Population Policy from HealthWatch to N. Shanmugham, Honourable Minister, Health and Family Welfare, Government of India, New Delhi.
Dear Shri Shanmugham, We, the members of the HealthWatch Steering Committee, wish to share with you our responses to the summary version of the National Population Policy (NPP) 2000. The policy statement has been keenly awaited in part because of a concern that it might contain electoral or other disincentives. Such disincentives, we feared, would once again open up a Pandora’s box of ethically questionable practices that the Government of India (in a remarkable consensus with other members of the United Nations) firmly repudiated in 1994 at the International Conference on Population and Development in Cairo. A reading of the short summary of NPP 2000 indicates there is little to fear in this regard. The opening sentence of the summary clearly and unambiguously states ‘that the most effective development policies are those which are socially just and focus on the well-being of all people.’
This approach continues in the next paragraph which achieves a balance between the government’s stated goal of stabilising population growth and the need to make reproductive health care accessible and affordable to all, increase access to education, extend basic amenities such as safe water and sanitation, and empower women and increase their employment opportunities. Furthermore, the immediate objective of the NPP is clearly stated to be addressing existing and unmet needs for contraception, health infrastructure and personnel, and integrating the service delivery for basic reproductive and child health care. Insofar as ‘unmet need’ is meant to focus on providing good quality, safe and effective family planning services to meet people’s own child-bearing aspirations, we feel this approach is laudable. The Ministry of Health and Family Welfare deserves to be congratulated for foregrounding an ethical approach at the very front of the document, and for side-stepping the pressures to bring in electoral or other disincentives which would only serve to distance ordinary people from the policy. We hope also that the NPP will be linked to a comprehensive health policy in an effective manner.
There is need, however, for a stronger emphasis than at present in the NPP’s ‘strategic themes’ (for which operational strategies will be developed) on the following central issues: promotion of gender equality and equity in programmes and through sensitisation of communities (especially men and boys); strengthening the quality of family planning and health services on a priority basis; ensuring serious implementation of a participatory approach based on community needs assessment; and training and motivating service personnel and their supervisors at all levels towards ensuring gender equity and service quality improvements.
We are also concerned about the following:
* That while the NPP’s focus on a more inter-sectoral approach is valuable, a much stronger institutional mechanism is needed to ensure this; rather than a ‘coordination cell’ being located within the Planning Commission, it needs to be located in the Cabinet itself. It must have a clear and time-bound mandate to evolve workable procedures and operational guidelines, and to ensure that such coordination actually occurs; without this we are afraid coordination between key sectors will remain an unfulfilled dream.
* That collaboration between NGOs and government take the form of genuine and mutually respectful partnerships that can develop innovative combinations of the creativity of NGOs, commitment and accountability of service providers, with the scope and reach of government services.
* That increasing institutional deliveries rapidly is neither feasible nor desirable unless their quality and access can be dramatically improved; feedback from the ground-level strongly suggests that refocusing on strengthening the capacity of traditional birth attendants and Auxiliary Nurse Midwives (ANMs) to provide safe services will be much more in line with ground realities and also with women’s preferences.
* That emphasising the ‘diversity of health care providers’, while useful in principle, should not lead to an uncontrolled legitimisation of the large numbers of questionable health providers especially in the rural areas; the focus should rather be on providing workable incentives for trained health providers as has been done in some of the states.
* That contraceptive technology and research give strong priority to women-controlled and safe methods.
So far as institutional structures are concerned, we believe it is essential that national and state-level commissions and especially the Technology Mission within the Department of Family Welfare include those from within and outside government who are clearly committed to and knowledgeable about women’s health needs and women’s empowerment.
Finally, we strongly feel that in order for the NPP to genuinely become a people’s and particularly women’s policy, it needs to move in a direction where people appreciate and respond to its goals and methods without a need for either disincentives or incentives. While many of the specific ‘promotional and motivational measures’ are unobjectionable, we are seriously concerned about the following:
* That rewarding panchayats and zilla parishads for exemplary performance should not translate into ground-level coercion of (especially) poor women towards unwanted and unsafe sterilisations or IUD insertions. It is essential to have clear guidelines on how these rewards should work, and an inclusion of criteria that are focused on improving the health care access and health status of poor women and girls, as well as women’s empowerment.
* That the ethics of rewarding those ‘below the poverty line’, whether through health insurance or any other way provided they accept sterilisation, is highly questionable and runs counter to much of the spirit of NPP 2000. Poor people and especially poor women and girls need access to safe and good quality health services on a priority basis. Placing conditionalities on this not only opens a dangerous door to potentially coercive practices at the ground-level, but reinforces a mind set among providers and politicians that poor people deserve nothing better. We strongly believe that these measures should be dropped from the policy.
Considering the national importance of the
policy, we are sharing this letter with a wider audience.
Sincerely,
HealthWatch Trust – Steering Committee
Indu Capoor, Centre for Health Education, Training and Nutrition Awareness, Ahmedabad;
Mirai Chatterji, Self Employed Women’s Association, Ahmedabad; Jashodhara Dasgupta, Sahayog, Almora; K. Pappu, Child-in-Need Institute, Calcutta; M. Prakasamma, Academy of Nursing Studies, Hyderabad; Martha Pushparani, Initiatives: Women and Development, Chennai; Nina Puri, Family Planning Association of India, New Delhi; Radhika Ramasubban, SOCTEC, Mumbai;
Vimala Ramachandran, Educational Resource Unit, Jaipur; Gita Sen, Indian Institute of Management, Bangalore; H. Sudarshan, Vivekananda Girijana Kalyana Kendra, Mysore; Ravi Verma, International Institute of Population Studies, Mumbai;
Leela Visaria, Coordinator, HealthWatch.
B 10 Vivekanand Marg,
Jaipur 302001
26 February 2000
Remembering Dr Mabelle Arole (1935-1999)
THE name of Mabelle Arole conjures up contrasting images – a physically frail lady with an iron determination. She was truly a people’s person, one who believed and demonstrated that health for all could indeed become a reality if only the professionals allowed it to be so. She saw the spirit of a wick lamp which could transfer its light to another lamp, in ordinary, humble and illiterate village women; and she set out to educate, empower and build this belief into a reservoir of sustainable community based primary health care programme in one of the poorest parts of India between 1970 to 1999 with enormous trust and confidence.
I had the privilege of meeting her in August 1998 when we visited CRHP, Jamkhed, as part of a delegation of officials from Rajasthan involved in the Reproductive and Child Health programme. For five days we experienced an enormous vision turning into reality which has transformed the lives of 250,000 poor and marginalized people in and around Jamkhed. Although still poor and with meager resources, these people have created for themselves caring and sharing communities ensuring an improved quality of life. Infant mortality, a reliable health indicator, has been reduced from 176 to 19 per 1000 births; birth rates have fallen from 40 to 20 per 1000 population. The guidance and inspiration for this pioneering work by CRHP was provided by Mabelle Arole.
When we visited Jamkhed, she was on leave from her assignment as advisor to the Unicef South Asia office in Nepal, still recuperating from her massive illness. Despite her fragile health, she accompanied us to the project areas, and with great patience helped us understand the concept and processes required in people’s empowerment through participation in their own health matters. The needs assessment, constant review and monitoring is done by the villagers themselves, especially women.
Mabelle Arole was born in a family of Methodist Christians on 26 December 1935 as Mabelle Kamala Rajappan, in Jabalpur, Madhya Pradesh. It was her father, Rajappan D. Imanual, a professor of New Testament Greek at the Theological Seminary, who introduced her to Rajnikant Arole, a fellow student at CMC, Vellore. In him she found a willing partner to share her aspirations and hopes. They married in 1960 shortly after completing their internship, and thus began their journey on an unchartered humanitarian path. While attempting to sensitise health promoters and the community to radical and pertinent issues in health and culture, they empowered and gave recognition to women and deprived groups. As a result of their efforts, scores of women have come forward and acquired knowledge and skills, not only in health matters but organizational aspects too. Today, they are participating in national and international forums as trainers and role models, as competent educationists, communicators and social workers. Mabelle Arole, together with her husband Rajnikant, demonstrated that health can be an entry point into socio-economic development. They worked closely with government health programmes in the area, particularly in family planning, immunization, leprosy, and tuberculosis identification and care. CRHP has trained hundreds of government PHC doctors, nurses and matrons, as well as medical and paramedical students.
Mabelle Arole’s passing away is a terrible personal loss not only to her husband and children, Shobha and Ravi, but to the medical fraternity, paramedics and above all to thousands of those who formed her team. Together they went beyond simply improving health conditions for the most deprived and poor. Her gentle and timely stimulation facilitating social change has turned social inequalities upside down. Her school of public health in Jamkhed imparts training about field realities discovered with communities, which is the ultimate truth.
At a time when authentic role models are desperately needed, Mabelle Arole will be greately missed. Inspite of the enormous achievements and honours such as the Padma Bhushan in 1991 and Ramon Magsaysay Award in 1979, she never lost her humility. The best homage that we can pay her is to keep the wick lamp alight, so that her glory never fades away.
Aparna Sahay
Jaipur
