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Showing posts with label Public Health. Show all posts
Showing posts with label Public Health. Show all posts

Tuesday, November 12, 2024

Go deeper: Editorial on research flagging 82 Indian districts on unwanted pregnancy list

 

This makes it evident that demographic signifiers like higher income & education & better access to healthcare need not always secure women’s lives, choices or right over their bodies.


The findings of a study, the first-ever district-level examination of unintended pregnancies from nationwide data, have been revealing and significant. Published in the journal, BMC Pregnancy and Childbirth, the research has revealed that as many as 82 districts of India have a rate of unwanted pregnancies that is higher than the national average. Three of Bengal’s districts — Birbhum, Malda and North Dinajpur — figure among these hot spots, as do 30 districts in Bihar, 14 in Uttar Pradesh, 8 in Madhya Pradesh, 6 in Delhi, 4 in Haryana and 3 each in Uttarakhand and Himachal Pradesh. The regional variations throw up intriguing questions. India’s northern states, known for their combination of low literacy — Bihar’s literacy rate is 61.7% while Uttar Pradesh’s is 73% — conservative social norms, and lower individual agency for women, offer a potent cocktail of social factors that often leads to unwanted pregnancies. But Kerala and Delhi, educated, urban, economic hubs, that were expected to buck such regressive trends, also found themselves amidst the geographical clusters that have a rate of unintended pregnancies higher than the national average. This makes it evident that demographic signifiers like higher income and education and better access to healthcare need not always secure women’s lives, choices or their right over their bodies. The cultural preference for a male child remains a formidable opponent to the forces of progress even in urbanised geographies that are relatively affluent. Given the pervasive culture of violence against women, it is also worth asking whether women whose pregnancies are the result of sexual assault and other crimes receive the same kind of access to healthcare and support as their peers.

The data collated from this study also have uses other than challenging — dismantling — prevalent assumptions. For instance, the information that has been unearthed could help policy zero in on areas where the use of contraception is low and then resolve the problem. Equally important is the data’s potential to identify future courses of further research. The fact that as many as eight out of Kerala’s 14 districts show a high propensity of unintended pregnancies should lead to follow-up queries about why a state with the best maternal and childcare indices has failed to check undesirable conceptions. Resources and manpower should not be constraints for future research projects in this direction: the answers would have a bearing on national welfare.

Source: The Telegraph, 7/11/24

Tuesday, June 13, 2023

Ignoring Red Lines: Violence Against Health Care in Conflict 2022

 A report titled “Ignoring Red Lines: Violence Against Health Care in Conflict 2022” was released recently by the Safeguarding Health in Conflict Coalition (SHCC). It revealed that the incidence of violence against healthcare workers in Mali increased by more than two-fold in 2022 in comparison to the previous year, 2021. A staggering total of 46 such incidents were identified, highlighting the heightened risks faced by those on the front lines of medical services.

lobal Insights: A Wider Perspective on Violence in Conflict Zones

The SHCC’s report extended beyond Mali, documenting 1,989 attacks and threats against healthcare facilities and personnel across 32 countries and territories plagued by armed conflict and political instability in 2022. Among these nations, Ukraine and Myanmar reported the highest number of attacks on healthcare infrastructure and personnel, underscoring the dire situation faced by healthcare workers worldwide.

Trends and Challenges: Understanding the Impact

According to the report, there was an overall increase in reported incidents of violence against healthcare in conflict zones in 2022 compared to 2021. While violence decreased in some regions like the Central African Republic, Ethiopia, and Syria, it rose in countries across West and Central Africa, including Mali. This highlights the complex challenges faced by healthcare workers in regions grappling with ongoing conflicts and instability.

Mali’s Troubled Regions: Kidnappings and Looting

The Mopti region in Mali witnessed a distressing number of health worker kidnappings, with at least 26 healthcare professionals abducted in 11 incidents while traveling to or from work, non-profit bases, or remote areas to provide vital healthcare services. Additionally, regions such as Gao, Mopti, Sikasso, and Tombouctou experienced frequent looting of essential medicine supplies and equipment. Armed groups targeted health centers and communities, exacerbating the limited availability of healthcare services in these areas.

Consequences on Research and Activities

The impact of violence against health workers extends beyond immediate risks and physical harm. The SHCC report highlighted how international non-profit organizations suspended planned activities, including crucial research and health surveys aimed at identifying disease prevalence. The difficulties in conducting research and surveys due to violence not only hinder public health policies but also impede the provision of targeted healthcare services to vulnerable populations.

Monday, February 20, 2023

How is Assam faring on the TB eradication front?

 “My husband is a buddhu [illiterate],” 41-year-old Anita Bodo says through her tears. When she was diagnosed with tuberculosis in early 2021, her husband was thrown out of his job and he in turn nearly abandoned her. Such is the stigma of TB among the tribal people of Baksa district in north-western Assam that a patient and even his family face exclusion and loss of livelihood.

Baksa, one of the four districts of the Bodoland Territorial Autonomous District (since renamed as the Bodoland Territorial Region) formed in 2003 after the signing of the historic Bodoland Territorial Council accord, is home to a diverse group of people including Bodos, Nepalis, Bengalis, Adivasis working in tea gardens, Assamese, and Rajbongshis. The majority of them are poor and work as daily wage labourers, making them one of the most vulnerable populations.

As in other rural parts of the country, the lack of awareness and fear of contagion leads to the isolation of patients in their homes. Coughing up blood terrifies communities that are all too familiar with the symptoms of the illness. Most people are simply unaware that the disease ceases to be infectious after two weeks of treatment. Though there have not been many deaths, the stigma surrounding TB is enormous.

Social disease

As a result, tuberculosis has become a social disease. Apart from the physical seclusion of patients, families often keep separate utensils for them. Women are subjected to more stigma and discrimination than men. Anita battled the disease for a year with the help of her children and now wants to help others who are suffering from the social and physical impacts of TB.

When Frontline met her, she had cycled several kilometres from her village in Geruapara to the Adalbari State Dispensary to attend a tuberculosis care and support group meeting. She was joined by Bhabananda Das, 42, who lost his job after being diagnosed with TB. In his village of Athiyabari, seven persons contracted it simultaneously. “Because of the stigma people hid the fact that they had contracted the disease, which led to its rapid spread,” he said. According to the National TB Prevalence Survey, 2019-2021, as many as 312 per 100,000 population in India is afflicted with TB. In Assam, the figures are 217 per 100,000 population. “Our goal is to reduce the TB infection rate to 44 per lakh population by 2025 under the ongoing NTEP [National Tuberculosis Elimination Programme],” says Dr Avijit Basu, Joint Director and State TB Officer, Department of Health Services, Government of Assam.

The NTEP aims to eradicate TB in India by 2025. The Sustainable Development Goals of the United Nations call for the elimination of the global TB epidemic by 2035.

According to the WHO, India accounts for roughly one-fourth of the world’s TB burden. Close to 50,000 people die of the disease every year in India, where at the same time about a million cases are missed every year, says Dr Palash Talukdar, WHO Consultant, NTEP, Assam. Active testing is a key challenge in detecting TB. Community engagement at the grassroots level is one of the ways the government and NGOs are trying to accelerate the process of TB eradication. In order to reach out to people in their communities, TB champions such as Anita Bodo and Bhabananda Das use tools provided by Lakhya Jyoti Bhuyan, Prasenjit Das, and Dinesh Talukdar, foot soldiers of the Karnataka Health Promotion Trust (KHPT), an NGO that works on TB, adolescent health, maternal neonatal and child health, and primary healthcare. They identify a TB Buddy, who can be a caregiver or community member to provide support during each stage of the treatment. One of their objectives is to reduce the psychosocial impact of TB on patients by effecting behavioural changes.

Arjun Narzary, who works with the Inland Water Transport department in Guwahati, was fortunate to have a government job. He was granted medical leave for the period of treatment and has rejoined duty.

E-rickshaw driver Phukan Basumatary has made it his life’s mission to spread awareness about the disease. He travels from village to village, blaring instructional audio content about TB from his vehicle. He has defied the stigma of remaining silent about the disease by shouting it out from his rickshaw.

Controlling it

KHPT’s Breaking the Barriers project (2020-2024), supported by USAID, is in line with India’s National Strategic Plan for TB elimination. “Elimination does not mean there will be zero cases of TB but that the disease will be under control. By 2025, our aim is to minimise the TB caseload,” says Dr Avijit Basu.

In Baramchari, a picturesque little village in Baksa, dozens of women finish their daily chores to settle under a canopy of trees to discuss how to combat the monster of TB. Members of a self-help group, they say that detection has gone up ever since their group got actively engaged with TB awareness. “We have so far detected four cases of TB in our villages. We make sure that there is no ostracisation of patients. We have more TB cases because of a lack of testing. People here work hard as daily wage labourers and can seldom afford nutritious food. And then they also drink the local liquor. A combination of these factors compromises their immunity and they get TB,” says Reena Rabha of Lokpala village, a leader of the group.

Apart from the tribal community of Baksa, the tea garden workers of Dibrugarh, mining populations, industrial workers, and urban migrants are among the most vulnerable groups. Urban migrants are vulnerable primarily because of their unhygienic living conditions, tobacco use, and a lack of proper nutrition. Suman Phukan, a community coordinator with the KHPT, works with such groups in Guwahati and the Kamrup Metropolitan district. She is the first point of contact for the Bihari and Muslim migrant labourers who live in the Sitlabari Railway Colony slum.

She tells the story of Sunil Peshwan, who was diagnosed with pulmonary TB for the third time at the age of 28. After his wife left him, Sunil had no one to look after him and he discontinued his medication. Members of the local Gajraj club volunteered to look after him, but when it became too much for them, they admitted him to a hospital. Sunil ran away from there.

When the club members tried to get re-admit him, the hospital authorities refused, citing the lack of a primary care giver. When Suman learned of Sunil’s deteriorating condition, she had him admitted to a Missionaries of Charity home, which had a TB unit on its premises. When Frontline met Sunil on the day of his release from the centre, he had lost a lot of weight, but had recovered and was willing to take care of himself.

Another vulnerable area identified by the KHPT is the localities around the famous Kamakhya temple in Guwahati. Members of two self-help groups, Muktinath and Kuhipat, have prioritised TB detection in this area.

Only time will tell whether these efforts by communities, governments and NGOs will be successful in eliminating TB. In her landmark book Phantom Plague: How Tuberculosis Shaped History, Vidya Krishnan sounds a word of caution. Narrating the history of TB from the days of the vampire panics that led to Bram Stoker’s Gothic horror novel Dracula to the discovery of modern medicine and penicillin, Vidya asks readers to be cautious about reducing the stories of patients to mere numbers and targets. She emphasises the links between social inequalities and disease and how sometimes urban building laws can act as institutionalised incubators of deadly drug-resistant bacteria.

She writes, “No amount of aid is going to save us from ever-evolving pathogens unless we fix the superstructures of global health at their structural root. TB and humans have evolved hand in hand. During the course of this relationship, the bacteria has learned from us more than we have from it. One bad decision at a time, the global TB pandemic has been socially constructed by us—humans who are reliably small-minded, casteist, and racist every time we face a pathogen that is highly unpredictable, mutating and thriving. The fundamental question here is not whether the pathogen will prevail. It is whether individual decency—that encourages us to fight for the right to health and the right to dignity for the poor and vulnerable—will prevail. There lies our salvation. No one is safe until everyone is.”


DIVYA TRIVEDISource: FRONTLINE.THEHINDU.COM, 22/06/22

Friday, September 23, 2022

Noncommunicable diseases caused 66% deaths in India in 2019: WHO

 Every year 17 million people under the age of 70 die of NCDs – one every two seconds, and 86% of them live in low and middle-income countries (LMICs), WHO said


Noncommunicable diseases (NCDs) – chief among them, cardiovascular diseases (heart disease and stroke), cancer, diabetes and chronic respiratory diseases – along with mental health, cause nearly three-quarters of deaths in the world, according to a report by the World Health Organization (WHO).

Every year 17 million people under the age of 70 die of NCDs – one every two seconds, and 86% of them live in low and middle-income countries (LMICs), WHO said in its report titled ‘Invisible numbers: The true extent of noncommunicable diseases and what to do about them’.

“NCDs are noncommunicable diseases, which include some of the world’s biggest killers: cardiovascular diseases (heart disease and stroke), cancer, diabetes and chronic respiratory
diseases,” it said.

41 million deaths

In India, according to the report, over 60.46 lakh people died due to NCDs in 2019 and the percentage of total deaths due to NCDs was 66%. And, the probability of 30-year-old-people in the country who would die before their 70th birthday due to NCDs is 22% while it is 18% at the global level. The four major NCDs – cardiovascular diseases (heart disease and stroke), cancer, diabetes and chronic respiratory diseases – along with mental health, account for a very high proportion of deaths and ill health. In total, 41 million people – 74% of all deaths – die of an NCD each year, according to the report

“Most of these premature deaths are preventable. NCDs affect all countries and regions, but by far the largest burden falls on low- and middle-income countries, which account for 86% of these premature deaths. The COVID-19 pandemic took an especially heavy toll on people living with NCDs, highlighting how these diseases undermine the very foundations of good health,” Dr. Tedros Adhanom Ghebreyesus, WHO’s Director-General, said in the report.

“This report is a reminder of the true scale of the threat posed by NCDs and their risk factors… The clock is ticking towards the 2030 deadline for achieving the Sustainable Development Goal target to reduce premature mortality from NCDs by one third. Currently, we are far off track… NCDs are everyone’s business. Working together, we can build a healthier, safer and fairer world for all,” he added.

Relatively small additional investments in NCD prevention and treatment could make a big difference long before 2030: spending an additional $18 billion per year across all LMICs could generate net economic benefits of $ 2.7 trillion over the next seven years. This is an investment, not simply a cost, with the benefits of action going far beyond health, the report said.

Many of these early deaths are not inevitable. Addressing major risk factors that can lead to them – tobacco use, unhealthy diet, harmful use of alcohol, physical inactivity and air pollution – could prevent or delay significant ill health and a large number of deaths from many NCDs, it added.

According to WHO, millions of people – especially in lower-income settings – cannot access the prevention, treatment and care that could prevent or delay NCDs and their consequences. This huge inequity undermines the human right of everyone, in all countries, to the best available standard of health.

Four major NCDs

Cardiovascular diseases (CVDs) affect the heart and blood vessels and are the cause of more deaths globally than any other disease. CVDs account for one in three deaths – 17.9 million people a year, and 86% of CVD deaths could have been prevented or delayed by eliminating risks to health through prevention and treatment, as per the report. Cancer is a disease in which abnormal cells are rapidly created and spread out of control to affect other parts of the body. One in six deaths – 9.3 million people a year are due to cancer, and 44% of cancer deaths could have been prevented or delayed by eliminating risks to health, WHO said.

Chronic respiratory diseases: The most common chronic respiratory diseases are asthma and chronic obstructive pulmonary disease (COPD). COPD is the third leading cause of death worldwide with one in 13 deaths (4.1 million people a year), and WHO said 70% of chronic respiratory disease deaths could have been prevented or delayed by eliminating risks to health.

Diabetes occurs either when the pancreas does not produce enough of the hormone insulin (type 1 diabetes) or when the body cannot effectively use the insulin it produces (type 2 diabetes). One in 28 deaths (2 million people a year) is due to diabetes and as WHO, more than 95% of diabetes cases globally are of type 2 diabetes.

COVID-19 and NCDs

COVID-19 highlighted the links between NCDs and infectious diseases, with serious impacts on NCD care. In the early months of the pandemic, 75% of countries reported disruption to essential NCD services because of lockdown restrictions and channelling of resources, including cancellation of elective care, reductions in screening and redeployment of staff, the report said.

Also during the pandemic, exposure to NCD risk factors changed. Public health measures such as lockdowns often led to less physical activity, and economic insecurity meant many people could not afford to eat a healthy diet.

People living with NCDs are at greater risk of becoming seriously ill from COVID-19. Current evidence suggests, for example, that people with obesity or diabetes have a greater chance of being hospitalised or dying from COVID-19; people with coronary artery disease and COPD are also at higher risk of severe outcomes; and smoking increases the chance of dying from COVID-19.

This implies that protecting people from NCDs and their risk factors will also build resilience to other health conditions, including infectious diseases, minimising the health and economic consequences of future epidemics, the report said.

Noting that too many people are getting sick and dying from NCDs that could have been avoided, WHO warned that inaction on NCDs is not an option for any government that cares about its people or its economy.

“Countries have the power to turn the tide on NCDs. This requires a few ingredients – political will, right policies and interventions, stronger health care delivery and protection for the vulnerable,” it said.

Source: The Federal, 23/09/22

Tuesday, May 24, 2022

Who are ASHA workers, the women healthcare volunteers honoured by WHO?

 The World Health Organisation has recognised the country’s 10.4 lakh ASHA (Accredited Social Health Activist) workers as ‘Global Health Leaders’ for their efforts in connecting the community to the government’s health programmes.

While congratulatory messages have since poured in from the Prime Minister and the Health Minister among others, the women health volunteers continue to fight for higher remuneration, regular jobs, and even health benefits.While intermittent protests have been going on in several states, thousands of ASHAs from across the country took to the streets in September last year to fight for their demands.

Who are ASHA workers?

ASHA workers are volunteers from within the community who are trained to provide information and aid people in accessing benefits of various healthcare schemes of the government.hey act as a bridge connecting marginalised communities with facilities such as primary health centres, sub-centres and district hospitals.

The role of these community health volunteers under the National Rural Health Mission (NRHM) was first established in 2005.

ASHAs are primarily married, widowed, or divorced women between the ages of 25 and 45 years from within the community. They must have good communication and leadership skills; should be literate with formal education up to Class 8, as per the programme guidelines.

How many ASHAs are there across the country?

The aim is to have one ASHA for every 1,000 persons or per habitation in hilly, tribal or other sparsely populated areas.

There are around 10.4 lakh ASHA workers across the country, with the largest workforces in states with high populations – Uttar Pradesh (1.63 lakh), Bihar (89,437), and Madhya Pradesh (77,531). Goa is the only state with no such workers, as per the latest National Health Mission data available from September 2019.

What do ASHA workers do?

They go door-to-door in their designated areas creating awareness about basic nutrition, hygiene practices, and the health services available. They focus primarily on ensuring that women undergo ante-natal check-up, maintain nutrition during pregnancy, deliver at a healthcare facility, and provide post-birth training on breast-feeding and complementary nutrition of children. They also counsel women about contraceptives and sexually transmitted infections.

ASHA workers are also tasked with ensuring and motivating children to get immunised. Other than mother and child care, ASHA workers also provide medicines daily to TB patients under directly observed treatment of the national programme. They are also tasked with screening for infections like malaria during the season. They also provide basic medicines and therapies to people under their jurisdiction such as oral rehydration solution, chloroquine for malaria, iron folic acid tablets to prevent anaemia, and contraceptive pills.

“Now, we also get people tested and get their reports for non-communicable diseases. On top of that ASHA workers were given so much work during the pandemic. We are no longer volunteers,” said Ismat Arra Khatun, an ASHA worker from West Bengal and general secretary of the Scheme Workers Federation of India that led the national protest.

The health volunteers are also tasked with informing their respective primary health centre about any births 

How did the ASHA network help in pandemic response?

ASHA workers were a key part of the government’s pandemic response, with most states using the network for screening people in containment zones, getting them tested, and taking them to quarantine centres or help with home quarantine.

“During the first year of the pandemic, when everyone was scared of the infection, we had to go door-to-door and check people for Covid-19 symptoms. Those who had fever or cough had to be tested. Then, we had to inform the authorities and help the people reach the quarantine centres. We also faced a lot of harassment because there was so much stigma about the infection that people did not want to let us in,” said Ismat Khatun.

Kavita Singh from Delhi, a former ASHA worker and a member of Scheme Workers Federation of India, added, “We had to go to households with confirmed Covid-19 cases and explain the quarantine procedure. We had to provide them with medicines and pulse-oximeters. All of this on top of our routine work.”

With the vaccination drive for Covid-19 beginning in January last year, they have also been tasked with motivating people to get their shots and collect data on how many people are yet to get vaccinated.or deaths in their designated areas. 

How much are ASHA workers paid?

Since they are considered “volunteers”, governments are not obligated to pay them a salary. And, most states don’t. Their income depends on incentives under various schemes that are provided when they, for example, ensure an institutional delivery or when they get a child immunised. All this adds up to only between Rs 6,000 to Rs 8,000 a month.

“Her work would be so tailored that it does not interfere with her normal livelihood,” the National Health Mission states. However, with outreach of most health programmes depending on them, that is not the case.

“Even if we work 24 hours, we will not be able to complete all the tasks. And, we do not get any benefits like pension or health insurance. If WHO recognises our role, if the government can call us veerangna (hero), shower us with flowers, why can’t they pay us fairly for all the work that we do,” said Ismat.

For quite some time now, ASHA workers have been demanding that they be made permanent employees of the government and provided benefits.

“If not that, they should at least fix our core incentives so that we get paid at least Rs 3,000 a month no matter what. All the work is graded 0 to 12 and if I do not get at least 6 points, I get paid only Rs 500 instead of Rs 3,000. I do not get points, even if a woman goes back to her home town to deliver the baby,” said Kavita.

She said that Covid-19 pushed them to their limits.“During Covid-19, we were only being paid Rs 1,000 for all of the additional work. Since the incentive stopped in March this year, half of the ASHA workers in Delhi decided not to participate in Covid-19 vaccination related activities,” added Kavita.

Written by Anonna Dutt 

Source: Indian Express, 24/05/22


ASHA: A successful public health experiment rooted in the village community

 

It is a programme that has done well across the country. As skill sets improved, recognition and respect for the ASHA went up. In a way, it became a programme that allowed a local woman to develop into a skilled health worker.

The World Health Organisation (WHO) has recognized the contribution of India’s 1 million Accredited Social Health Activists (ASHAs) during the Covid-19 pandemic. It is acknowledged that ASHAs facilitate linking households to health facilities, and play pivotal roles in house-to-house surveys, vaccination, public health and Reproductive and Child Health measures.

In many states, ASHAs are involved in national health programmes, and in the response to a range of communicable and non-communicable diseases. They get performance-based payments, not a fixed salary like government servants. There have been agitations demanding employee status for ASHA workers. The idea of performance-based payments was never to pay them a paltry sum — the compensation was expected to be substantial.

The ASHA programme was based on Chhattisgarh’s successful Mitanin programme, in which a Community Worker looks after 50 households. The ASHA was to be a local resident, looking after 200 households. The programme had a very robust thrust on the stage-wise development of capacity in selected areas of public health. Dr T Sundararaman and Dr Rajani Ved among others provided a lot of support to this process. Many states tried to incrementally develop the ASHA from a Community Worker to a Community Health Worker, and even to an Auxiliary Nurse Midwife (ANM)/ General Nurse and Midwife (GNM), or a Public Health Nurse.

Important public policy and public management lessons emerge out of the successful experiment with Community Workers who were not the last rung of the government system — rather, they were of the community, and were paid for the services they rendered. The idea was to make her a part of the village community rather than a government employee.

Over 98 per cent ASHAs belong to the village where they reside, and know every household. Their selection involved the community and key resource persons. Educational qualification was a consideration. With newly acquired skills in health care and the ability to connect households to health facilities, she was able to secure benefits for households. She was like a demand-side functionary, reaching patients to facilities, providing health services nearer home.

The Expert

Amarjeet Sinha is a retired civil servant who was associated with the design and capacity-building thrust of the ASHA programme for more than five years.

Building of a cadre

It is a programme that has done well across the country. As skill sets improved, recognition and respect for the ASHA went up. In a way, it became a programme that allowed a local woman to develop into a skilled health worker.

The ASHAs faced a range of challenges: Where to stay in a hospital? How to manage mobility? How to tackle safety issues? The solutions were found in a partnership among frontline workers, panchayat functionaries, and community workers. This process, along with the strengthening of the public infrastructure for health with flexible financing and innovations under the Health Mission and Health and Wellness Centres, led to increased footfall in government facilities. Accountability increased; there would be protests if a facility did not extend quality services.

The Community Worker added value to this process. Incentives for institutional deliveries and the setting up of emergency ambulance services like 108, 102, etc. across most states built pressure on public institutions and improved the mobility of ASHAs. Overall, it created a new cadre of incrementally skilled local workers who were paid based on performance. The ASHAs were respected as they brought basic health services to the doorstep of households.

Issue of compensation

There have been challenges with regard to the performance-based compensation. In many states, the payout is low, and often delayed. The original idea was never to deny the ASHA a compensation that could be even better than a salary — it was only to prevent “governmentalisation”, and promote “communitisation” by making her accountable to the people she served.

There were serious debates in the Mission Steering Group, and the late Raghuvansh Prasad Singh made a very passionate plea for a fixed honorarium to ASHAs. Dr Abhay Bang and others wanted the community character to remain, and made an equally strong plea for skill and capacity development of Community Workers. Some states incentivised ASHAs to move up the human resource/ skilling ladder by becoming ANMs/ GNMs and even Staff Nurses after preferential admission to such courses.

The important public policy lessons are the need to incrementally develop a local worker keeping accountability with the community, make performance-based payments, and provide a demand-side push with simultaneous augmentation of services in public systems. The system can sustain and grow only if the compensation is adequate, and the ASHA continues to enjoy the confidence of the community.

Debate over status

There is a strong argument to grant permanence to some of these positions with a reasonable compensation as sustaining motivation. The incremental development of a local resident woman is an important factor in human resource engagement in community-linked sectors. This should apply to other field functionaries such as ANMs, GNMs, Public Health Nurses as well.

It is equally important to ensure that compensation for performance is timely and adequate. Ideally, an ASHA should be able to make more than the salary of a government employee, with opportunities for moving up the skill ladder in the formal primary health care system as an ANM/ GNM or a Public Health Nurse. Upgrading skill sets and providing easy access to credit and finance will ensure a sustainable opportunity to earn a respectable living while serving the community. Strengthening access to health insurance, credit for consumption and livelihood needs at reasonable rates, and coverage under pro-poor public welfare programmes will contribute to ASHAs emerging as even stronger agents of change.

Written by Amarjeet Sinha

Source: Indian Express, 24/05/22

Wednesday, November 10, 2021

Unequal access to toilets remains a worry, and is central to global feminist movement

 

Inadequate toilet accommodations reflect society’s bias against women in the workplace and public spaces and reinforce the notion that women belong at home


Kalpana Narvekar lives in a ramshackle slum, encroached across two office buildings in Mumbai’s commercial Fort district. The nearest public toilet is well over 15 minutes away by foot. Navrekar and her three young children either walk to the public toilet or relieve themselves on the side of the road, which is often the case. For her sons, this usually isn’t a problem but for Navrekar and her daughter, every time they need to use the toilet, they risk exposing themselves to strangers. In one particularly troubling incident, her daughter, who was suffering from diarrhoea, could not hold it long enough to find a secluded spot. As a result, she was forced to defecate near a busy road and was verbally abused by several motorists who were mostly men.

Lack of access to public toilets is a wide-spread problem in India. For women, whose bodies are particularly objectified, this poses massive ramifications in terms of safety, comfort, and health. Compounding the problem, public infrastructure is designed to cater to men. A report in 2012 found that there are almost twice as many public toilets for men than there are for women in Mumbai. Additionally, the toilets that do exist, lack proper hygiene standards and are often unsafe. A 2017 study by ActionAid India found that 35 per cent of the 229 toilets surveyed in Delhi did not have a separate section for women, 53 per cent did not have running water and 45 per cent did not have mechanisms to lock the door from inside.

Globally as well, the issue of unequal toilet access has a special place in the feminist movement. In 2012, women in China protested against the lack of public toilets for women by using men’s lavatories. In America, advocacy has resulted in legislation that mandates building standards which prioritise women’s restrooms, and laws that prohibit commercial spaces from failing to provide adequate facilities for women. The so-called potty parity movement is not a critical component of the feminist movements today, however, it is a topic worthy of consideration given the significant ramifications of une

How it works

Studies have shown that women take, on average, twice as long to use the restroom as men. These studies consider only the time used to urinate and don’t factor in the use of a bathroom as a social space. According to John Banzhaf, a law professor at George Washington University and the ‘father of potty parity,’ there are a number of factors that contribute to this divide. For men, using the toilet usually involves zipping down their pants and peeing into a urinal. In contrast, women have to unbutton their clothing, pull down their pants and make contact with the toilet seat whenever they pee. One in four women are also menstruating at any given point, which increases bathroom time due to the need to use and dispose of sanitary products. Additionally, two groups that take longer on average to pee include children and the elderly. Given that women are often responsible for childcare, and that there are more older women than men, this also contributes to the problem. Perhaps most importantly, urinals take up less space than cubicles, so men’s restrooms tend to accommodate more people at a time.

Speaking with indianexpress.com, Banzhaf states that having to use the restroom is an “immutable problem,” and therefore, denying women the same provisions as men violate their right to equality enshrined by law. Having to wait longer to use the restroom, or not having access to one at all, can cause a myriad of problems. Banzhaf notes that women often suffer from medical issues for having to hold in their pee and have fewer opportunities to network and socialise at public gatherings. Referring to the constraints as a “urinary leash,” Banzhaf argues that for many women, the lack of access to toilet can be a deterrent from straying too far away from home.

Additionally, for women in male dominated fields like construction and agricultural work, lack of toilet access can even prevent them from working. In 2004, Danish Khan, a Mumbai-based reporter, surveyed a number of public toilets in the city’s railway stations. He found that most toilets were closed due to clogged drains and some stations lacked facilities for women altogether. This in turn, he asserts, disincentives women from using public transportation, and limits their ability to work.

Kathreyn Anthony, a professor of architecture at the University of Illinois, who spoke with indianexpress.com, argues in a seminal paper on potty parity, that long lines for women’s restrooms can also have commercial implications especially at venues like sporting stadiums and concert halls when the demand for toilets peak at particular times. “Rather than face a long wait,” says Anthony, “women feel compelled to curtail or avoid liquid intake” which means they’re less likely to purchase concessions than men. The lack of availability and cost of sanitary products similarly hinder their ability to access and enjoy public spaces. Pregnant women and women with UTIs who find it harder to hold in their pee are also disproportionately affected.

While it is impossible to measure the economic and social costs of unequal access, Anthony does point to several scenarios that highlight the need for potty parity. She notes that in New York, several female taxi drivers quit their jobs because of a lack of public toilets while male drivers often just peed in a jar under their seat. Additionally, Anthony argues that while men can use unhygienic toilets, women, who have to touch the seat while peeing, face particular health risks from doing so. She also mentions that paid toilets, which have now been discontinued in the US, discriminate against women because men can use urinals for free and can pee in open spaces. In India, paid toilets still exist.

The impure woman

Despite the fact that toilets play a significant role in our lives, historically, very little consideration has been given to female restrooms. According to Harvey Molotch, a Distinguished Professor at NYU, who spoke with indianexpress.com, this is because women are associated with “purity and cleanliness.” People don’t like to think of women using the toilet, which in turn, stigmatises the issue. The lack of discussion around women’s toilets means that in terms of policy, very little is done. According to Molotch, women are considered to be guardians of the home, and few public spaces were designed to accommodate their needs. Since 1857, the American Institute of Architects has had 97 presidents, of which, only five have been women. Lack of representation of women in architecture and construction reflects the lack of priority given to their sanitation needs equal toilet access.

Until very recently, workplaces dominated by men failed to include provisions for women.In fact, it took until 2011 for female Representatives to get their own toilets in the US House. Up till then, they were forced to use the same toilets reserved for the general population. Given that men can, and do, pee on walls, legislators who tend to be overwhelmingly male, don’t consider potty parity to be a prevalent topic. According to Molotch, the lack of action can be attributed to the fact that potty parity is both a women’s issue and one that is greatly stigmatised. “It’s what you would call a double whammy of prejudice,” he says.

Despite that, there has been progress. Banzhaf notes that over the last few decades, things have improved in the US. Now, 20 out of 50 states have potty parity legislation. However, that too comes with its drawbacks. For one, the legislation only applies to new buildings which means that existing establishments like courthouses and factories have to either break down men’s toilets and replace them with facilities for women, or disincentives women from accessing those spaces.

The former comes at a great cost which would have to be borne by the establishment. According to Molotch, there are “built in efficiencies” when it comes to existing buildings as it is difficult to repurpose hardware to convert men’s facilities into those suited for women. Anthony further argues that toilet parity is “really a controversy over economic resources.” She writes that “in the employment context, the concern is over who will bear the cost of incorporating women in the workforce” and outside the workplace, “the concern is who will bear how much cost in the public arena.”

In terms of the latter, there are historical incidents in which women have been unfairly targeted in order to meet toilet standards enshrined by law. Anthony references one such incident in her paper. In it, a Texas based company operated a factory with only one toilet for 80 workers, 95 per cent of whom were female. Instead of constructing more toilets in line with official regulations, the company fired twenty female workers. Thus, the laws, while being a step in the right direction, can be difficult to implement and/or come with trade-offs for both men and women.

What can be done

As stated previously, there are laws in the US which require new buildings to have two bathrooms for women for every one bathroom for men. In venues that accommodate large crowds, certain states have even mandated a 3:1 ratio. However, Banzhaf argues that while that legislation is useful to an extent, it doesn’t address the needs of existing structures. Pointing to changes made by his own University, he details three strategies that could be implemented instead to enable equal waiting times.

The first involves making men’s toilets unisex, so that women can either use a designated women’s restroom (where they may feel safer) or choose to share facilities with men. According to Banzhaf, most of his female students don’t have a problem with sharing a space with the opposite gender, however, he does acknowledge that the same may not be the case with other demographics, particularly the elderly.

The second option is to have unisex, single seater toilets like the ones you find on airplanes. This would eliminate the need for men and women to share a common space at the same time, but like the prospect of building more toilets, would be costly and take up a lot of acreage. Toilet design would have to be prioritised by architects and engineers in order for this to be feasible on a large scale and unfortunately, as Molotch notes, the people responsible for designing and maintaining these spaces often consider toilets only as an afterthought.

The third initiative involves constructing flexible bathrooms in places like concert halls or sporting arenas. Banzhaf states that there is evidence that different events attract different genders. For example, a stadium hosting a football match might see a lot of male fans on that day. If they were to host a gymnastics event the next day, they would then be more likely to witness an influx of women. Building toilets that are flexible would allow stadiums to convert them for men’s and women’s use respectively, on days where there is high demand for one or the other.

The quality of restrooms is also important, and Anthony argues that much more can be done with female restrooms in order to make them safer, more accessible, and better suited to women’s needs. She suggests employing more bathroom attendants so that women feel safer and also makes a case for female urinals so that more women can be accommodated at any single point of time. According to Anthony, menstrual products should be available in women’s restrooms so that women aren’t forced to run back home or risk soiling their pants in the event that they are unprepared for the onset of their period. Period tracking apps like Oky can also enable women to be better prepared in situations where restrooms don’t sell sanitary products. The menstrual cup, she adds, is another solution as it eliminates the need to dispose of pads or tampons and lasts almost twice as long as a standard large tampon thus reducing the need to change it frequently.

However, in countries like India where there is a stigma against unisex toilets and where menstrual products are not easily available, more creative solutions need to be found. Molotch suggests that India can reimagine entrances to bathrooms so that they are both visible from a distance and yet private enough to ensure safety and discretion. He says that in societies where caste differences are prominent, separate entrances can also be designed for different functions. For this, he provides the analogy of hotels. “When you enter the hotel as a guest, you have this large lavish door welcoming you whereas staff usually enter from a separate, more discreet door,” he says. If toilets were designed like hotels, people from different backgrounds can enter separately but ultimately share the same space.

India has made significant strides in improving sanitation measures. The Swachh Bharat campaign is actively promoting the construction of more toilets and better maintenance standards for existing ones. According to the Swachh Bharat website, the program has resulted in the construction of over 106 million toilets taking India’s rural sanitation coverage up from 39% seven years ago to 100% now. According to a study by the World Health Organization, the Swachh Bharat Mission in rural India was expected to prevent over 300,000 deaths from diarrhoea and malnutrition between 2014 and 2019. Coming at a cost of $14 billion, this campaign has produced tremendous results although the official statistics ought to be taken with a grain of salt.

Despite this progress, there is still a lot to be done. Outside of commercial establishments there are still far too few public toilets and given that restaurants and bars only allow customers use of their facilities, many poor people still face barriers to entry. In cities, public toilets for women are often overcrowded and lack basic hygiene standards. Having two toilets for women for every one toilet for men would help mitigate the problem. However, given that stalls take up more space than urinals and women take longer to pee, doubling the number of bathrooms alone may be insufficient.

Inadequate accommodations reflect society’s bias against women in the workplace and public spaces and reinforce the notion that women belong at home. Potty parity is an issue that people rarely discuss, and many feel uncomfortable with. However, unequal access represents a form of discrimination and should be addressed meaningfully at every level. Hopefully a combination of policy and investment will mean that by the time Navrekar’s daughter has children of her own, she won’t have to worry about their health and safety every time nature calls.

Written by Mira Patel


Source: Indian Express, 9/11/21


Thursday, September 30, 2021

Recognising the role of health in India’s social and economic growth

 Focus on a system that responds to the capacity of the State and other stakeholders in the immediate-term, while building on such capacity in the longer term. Better responsiveness to the needs of citizens can drive trust between citizens and the State.

As India begins marking its 75th year of Independence, it is an appropriate time to take stock of the priority we have accorded to our biggest resource — human capital. Today, India has the largest population of young people; an enviable resource that can move India on to a stronger economic path. Research has highlighted the links between building human capital (through nutrition, health, and education) and growth. And yet, data on nutrition, health, and education suggests that the value of this resource has not been recognised.

When we focus on health, there has been progress, but India remains well below peer countries — and where it needs to be — in terms of the well being of citizens. This stems from multiple reasons.

One, it is not clear if national and political incentives to improve health have been clear to leaders. There are two aspects to this. The first is linked to the limited attention to the links between health and human capital, and growth promotion — a case that positions health not merely as a welfare issue, but as an influencer of India’s growth.

The second is the limited attention to the impact of health care on poverty. Health-related expenditures are estimated to push 3.5% of the population below the poverty line; with those already below the poverty line pushed only deeper. Anirudh Krishna’s research across four continents found health-related expenses to be the prime reason for households descending into poverty and that millions of households live “one illness away” from poverty.

Political incentives could also be a factor of “credit”, and in India’s federal system, a lack of clarity in “credit” from the improved health care services may further diffuse political incentives. Reforming the health care system may also be viewed as too long-term an agenda, and, therefore, not conducive to immediate political gains. Additionally, the pathways at different governance and administrative levels are often not evident, constraining political interest from relevant leaders. Two, the absence of health as an electoral demand dilutes its political salience. Data from multiple CSDS Lokniti polls has highlighted that health figures low among voter priorities. The middle-class has exited from the use of public services, and increasingly, the poor are moving in the same direction.

It is, therefore, not surprising that the health sector has one of the lowest public investments at 1.3% of the Gross Domestic Product, with a disproportionate use of private services, and 64% of health care expenditure being out of pocket at the point of service.

However, leaders have sought political legitimacy through attention to targeted sectors and the initiation of reforms. Regime shifts in several countries such as Turkey, Indonesia, and Brazil saw leaders prioritising health to establish credibility with the voter base and reaping electoral benefits. Well implemented reforms fuelled citizen expectations, leading to demand, and creating the space for further reform. India has not witnessed too many examples of this.

State capacity is a central variable in the cycle of well-implemented reforms, tangible benefits, a social compact between the government and its citizens, and electoral gains. The absence of this confidence in capacity will likely lead to a clientelist model of delivering services, rather than a systems approach.

What is the path that India should take? One, focus on a system that responds to the capacity of the State and other stakeholders in the immediate-term, while building on such capacity in the longer-term. Better responsiveness to the needs of citizens can drive trust between citizens and the State. And do this while highlighting the role of health in a nation’s journey, and building citizens’ understanding of the primacy of health and its impact on their economic status.

A lot more needs to be done to identify paths to reform, through a combination of public and private provisions, with the State as a regulator. This can offer a coherent response to constraints and political benefits at the national, state and sub-state levels.

Sandhya Venkateswaran is member, Lancet Citizens Commission on Reimagining India’s Health System and Centre for Social and Economic Progress.

Source: Hindustan Times, 29/09/21

Tuesday, December 29, 2020

We must realise global health requires a coordinated effort

 

To reap the benefits of globalisation, to ensure an equal world, global health must be central to international collaboration. It determines social and economic development for all. And peace is the logical result.

The ongoing pandemic, with over 79 million people infected and 1.7 million lives lost, has become the most destructive infectious disease outbreak in recent human history with unprecedented human, social and economic costs. Countries are struggling to respond to new infections and virus mutations through a mix of containment measures- periodic lockdowns, domestic and international border-sealing and available, limited medical solutions.
International trade and domestic economies were the first to take a hit. By the end of the second quarter, international trade was almost one-fifth less compared to second quarter of 2019. As 2020 closes out and vaccines are getting emergency use approvals, the Covid-19 shock is expected to cause a seven to nine per cent fall in global trade.
Countries that were growing economically pre-pandemic, are now witnessing worrying trends. For instance, pre-Covid, unemployment in the United States (US) was at a half-century low but by the second quarter of 2020, its Gross Domestic Product (GDP) plunged by nearly 31.4% - a record held previously only by the Great Depression. In the United Kingdom (UK), unemployment hit a three-year high and over 800,000 people lost their jobs. Emerging and fledgling economies like India and South Africa are also experiencing historic contractions.
But the impact of Covid-19 isn’t limited to economics and trade. It has magnified fault-lines, exacerbated inequities and inequalities and resulted in shadow pandemics such as mental health crises, violence against women, and disruptions in critical health services, possibly reversing recent improvements. It has forced hundreds of thousands of skilled and unskilled workers out of jobs and is expected to push an estimated 88-115 million into extreme poverty. Countries, rich and poor, have been affected by an economic emergency. Several low- and middle-income countries, battling existing political instability and conflict, coupled with weak health systems infrastructure have borne the worst of this impact. The pandemic has underscored that the world needs to rethink policies and programmes to bring back some semblance of equality and stability in societies. It needs to view global health as a security issue.
For too long, the concept of security has assumed an anthropomorphised ‘other’ - an ‘us’ seeking existential security from another state or organisation. Here, state security is threatened in physical or cyber battle by potentially rational or irrational actors, who driven by distrust or ambition or power dynamics, launch threats to a state’s security. While these can be checked with negotiation, mediation and arbitration, or destruction, i.e. war; in case of disease, such an understanding is limited. Disease, and resulting hunger and poverty can cause destabilisation, political unrest, civil disorder, and international conflict– all of which threaten international peace and security. Covid-19 has also shattered the illusion of international collaboration. In the last two decades, these have emphasised good health and well-being, especially through the Millennium Development Goals and Sustainable Development Goals. But in the wake of Covid-19, countries that could launch a coordinated effort to check the impact of the pandemic have resorted to inward-looking policies. Ending the pandemic must be a global goal and a critical determinant of foreign policy, trade, and economic co-operation.

Protectionism, isolationism, as seen through vaccine nationalism has reversed the efforts of international bodies and platforms to place health at the centre of the global development agenda. Coalition for Epidemic Preparedness Innovations (CEPI), Gavi, the Vaccine Alliance; and the World Health Organization are working with governments and vaccine manufacturers to expedite vaccine research and ensure that the vaccine, when available, is accessible to all. But to ensure success wealthier countries must join hands and lend their support so that all countries can roll-out the vaccine, almost in parallel.

As we see the light at the end of the tunnel, as vaccines get rolled out across the world, we need to collectively recognise that global health determines economic trajectories and requires a coordinated, concerted effort. To reap the benefits of globalisation, to ensure an equal world, global health must be central to international collaboration. It determines social and economic development for all. And peace is the logical result.

Anjali Nayyar is executive vice-president, Global Health Strategies

Source: Hindustan Times, 29/12/20