INTRODUCTION

This illustration represents WHRAP logo which is drawn like a female body.

About Women's Health and Rights Advocacy Partnership — South Asia

The Women's Health and Rights Advocacy Partnership (WHRAP)-South Asia positions itself as an international partnership with a regional voice. The partnership brings together women-led organisations and other civil society actors for evidence based advocacy on sexual and reproductive health and rights (SRHR). Over the last 13 years, WHRAP-South Asia has facilitated and contributed to processes aimed at improving the quality of life of marginalised women in Bangladesh, India, Nepal and Pakistan through empowerment, strengthening civil society engagement and public support leading to better accountability for health governance.

In South Asia, social determinants such as poverty, educational status, food and nutrition and water and sanitation affect health outcomes. Discrimination and inequalities based on gender, caste, class, religion, disability, age and geographical location entrenched in society and institutions adversely impact access of rights including the enjoyment of the highest attainable standard of physical and mental health. In this context, WHRAP-South Asia's rights-based approach includes the recognition that marginalised women in South Asia are rights-holders vis-à-vis the duty-bearers, the state authorities represented by government officials, health care providers, representatives of health facility based oversight mechanisms (OMs)¹ and human rights guardian institutions (GIs).² WHRAP-South Asia employs an approach whereby evidence is gathered locally and transformed into local, national, regional and international advocacy initiatives.

WHRAP-South Asia is implemented as a partnership programme between five leading national women's organisations including Beyond Beijing Committee (BBC) in Nepal, Naripokkho in Bangladesh, Shirkat Gah in Pakistan, Centre for Health Education, Training and Nutrition Awareness (CHETNA) and SAHAYOG in India as national partners; their selected community-based partners that work directly with the women on the ground; and the Asian Pacific Resource and Research Centre for Women (ARROW) as its regional partner. The programme has been carried out in cooperation with and funded by the Danish Family Planning Association (DFPA).

WHRAP-South Asia began as a project in 2003. Currently in its fourth phase, it aims to promote marginalised women's SRHR. It calls for a context- specific and rights-based continuum of quality care (CQC) for women's reproductive health in South Asia which spans across a woman's life-cycle – before and during pregnancy to postpartum/post-abortion and menopause – and across various locations, for example, the home, community and health facilities.3 CQC is crucial in order to reduce adolescent, maternal, newborn, and child mortality and morbidity and improve women's SRHR.

Learn More about us at: www.arrow.org.my

ABOUT STORIES of CHANGE

Over the years, WHRAP-South Asia has contributed to various changes that brought about positive impact to the lives of women in general and marginalised women in particular. WHRAP-South Asia implements a complex modality where advocacy is at various levels – at the community, sub-national, national and international, and by various actors – women, CBOs, civil society groups and health alliances, media, national, regional and international partners and allies.

Over the course of 13 years, through WRHAP-South Asia's strategic interventions, women in the implementation areas are able to articulate their needs and demands for quality sexual and reproductive health services and seek improvement in the quality of health services provided. The community and national partners have garnered more support for their issues with other civil society groups and health alliances as well as media. In the implementation areas, community-based partners have reactivated and improved the functioning of various OMs where now they are taking up issues related to women's health in their regular discussions and actions. At the national level, through concerted advocacy there have been positive commitments and responses from GIs towards the improvement of women's health and rights. At the regional and international levels, CQC issues have been raised as the missing component in the current global SRHR and health strategies and commitments.

With this publication, WHRAP-South Asia documents the types of changes that are brought about as a result of its implementation in Bangladesh, India, Nepal and Pakistan.

These stories of change evolved through a process which was jointly decided by the partners. A format was designed where the partners narrated and wrote these stories at a write-shop organized by ARROW in Colombo, Sri Lanka from 17-20 May 2015. The write-shop allowed the partners an opportunity to qualitatively analyse the results they had achieved over the years.

This publication begins with the stories of brave women and men who found their voices to articulate SRHR concerns in their area. This is followed by stories of allies who have championed WHRAP issues. Subsequently there are stories to highlight the change brought about by community mobilisation towards effective functioning of OMs and of GIs taking note of grave SRHR violations. Finally, it documents examples of effective use of the evidence gathered at the local level for international advocacy.

Altogether, the nine stories, two from each of the countries, and one from the regional partner, ARROW, have captured not only the changes and successes but also the processes that have led to the successes which WHRAP-South Asia has been instrumental in. Generating such stories are imperative in order to have evidence to support the advocacy and strengthen the visibility of WHRAP-South Asia.

First, She Changed Herself

Overcoming Abortion Stigma

Story by
Ruby Shakya

Written by
Anju Shreshta

Location
Nepal

Partner Organisation
Beyond Beijing Committee

CQC Framework Highlight
Safe abortion services should be readily available and affordable to all women. This means that services should be available at all levels of health facilities which should be equipped with counseling services for safe abortion and use of contraception to prevent unwanted pregnancy.

Katahari is a village in Morang District located in the Koshi Zone of southeastern Nepal. It is situated in a semi-urban area and is inhabited by people from various caste groups. Shanti Chaudhary who is 41 years old now, was living with her happy family in Katahari. She had two sons and a daughter. She was a member of the community and used to take a lead role in its activities despite not being able to read and write.

Shanti's 20-year-old son, her eldest, married a 19-year-old girl. They were young and planning to continue their studies in order to establish their careers, and had no plans of having children. But after one year of their marriage her daughter-in-law got pregnant accidentally and the couple decided to have an abortion without consulting their parents. After a few days Shanti got to know about the abortion. The news stunned her as she was scared of being discriminated by the community, which stigmatised abortion. She believed that abortion was a sin and was against their cultural and societal norms. She had basic knowledge about contraception but did not know that abortion is legal in Nepal.

After a few days Shanti met Anita, a district focal person for the WHRAP-South Asia initiative in Nepal, who was seeking a community leader from her village. Anita proposed Shanti be the village focal person in the district as part of WHRAP-South Asia to advocate on sexual and reproductive health and rights (SRHR) in their village. Shanti agreed and as a consequence got opportunities to participate in capacity building trainings, meetings, and dialogues on issues related to SRHR. Working with WHRAP-South Asia made her aware that abortion is a choice and a woman's right. Now she regrets her initial reaction and behavior towards her son and daughter-in-law when she got to know about their abortion.

The Bold One!

How one woman stepped beyond the traditional boundaries to make health services more accessible for her community

Story by
Sajida Parveen

Written by
Y.K. Sandhya

Location
Pakistan

Partner Organisation
Shirkat Gah

CQC Framework Highlight
Free screening with full quality, antenatal routine care/services and services for postpartum/post abortion complications. This should also be provided for screening of other situations such as violence, malaria, uterine prolapse, blood grouping, HIV, Sickle Cell anaemia, etc.

Located in the Sheikhupura district of Pakistan is a village called Shamkey, home to about 3,000 people. In this village, like in many areas of Pakistan, women and girls are given differential treatment when compared to men and boys. Girls are usually discriminated against in terms of food and are given much less to eat both in quantity and quality, which often leads to health complications during pregnancy due to malnutrition.

Living in Shamkey in a joint family home is Shazia Imran, 28, a mother of two. Like most women and girls in the village, Shazia's access to basic health services was limited due to the restrictions on her mobility. Shazia's life would have probably continued in that same manner if it was not for her meeting the staff of Shirkat Gah and their partner Nai Umeed who are implementing the WHRAP-South Asia initiative.

In September 2014, Nai Umeed launched a local initiative to work on maternal health issues among vulnerable and poor households using a framework that employed community champions in order to enable a sustainable community accountability model. The idea was to train the champions on issues related to maternal and reproductive health and provide them with the opportunity to build strong links with various health facilities and government functionaries, such as the Lady Health Visitor, Lady Health Workers, and the Vaccinator, in order to facilitate women's access to maternal health services. They would also be linked with the Secretary of the Union Council to facilitate birth, marriage and death registrations.

During her initial visits to the village, Venus realised that birth registrations were not being done.1 Previously, there was a government post of a Chowkidar (gatekeeper or watchman), who was responsible for recording the names of the children and submitting it to the office of the Union Council for registration. However, for reasons unknown, this was no longer happening and the onus of registering births lay with the people.

Shazia, despite being educated up to the tenth standard, and married to a government employee, was not aware of the importance of birth registrations and as such did not register her children's birth. Nai Umeed, during the course of their meetings with the champions, aside from discussing the concept of quality health care for women, also raised the issue of lack of birth registration in the village. They explained the importance of registration to the women and encouraged the champions to list all the children in their muhallas (communities) and submit it to the office of the Secretary of the Union Council. Shazia now spearheads a birth registration campaign, and over a short span of six months, compiled a list of all the children in her muhalla who had not been registered. In one of her visits to the office of the Union Council, she suggested that registrations would be easier if they could send a mobile van to the villages. The Council accepted the suggestion and plan to buy a van for this purpose.

Over several interactions through Nai Umeed, Shazia has built a strong relationship with a Female Welfare Worker (FWW) from the Population Department who is trained in various family planning methods. Shazia would take her village women to consult the FWW for family planning services and other reproductive health issues, and if required, the women would be referred to the gynaecologist. The women learned that a referral from the FWW meant that the treatments would be faster and better than when they sought services on their own. This encouraged them to use public health facilities more than ever before. She also convinced reluctant mothers to vaccinate their children by addressing their fears related to vaccinations.

Making News Matter

Using media to hold local authorities accountable for reproductive health

Story by
Ahmed Raza Khan

Written by
Sangeeta Maurya

Location
Pakistan

Partner Organisation
Shirkat Gah

CQC Framework Highlight
Respecting a woman's dignity, right to privacy and sensitivity to her needs and perspectives is paramount at all times. This includes the provision of safe abortion services, contraception, counselling and media reporting. In addition, attention should be given to the special needs of poor, adolescents and other vulnerable and marginalised women.

Sajjad Ahmed Jan, 45, lives in Charsadda district in the province of Khyber Pakhtunkhwa (KPK), Pakistan. He has been a news editor at a local newspaper, Charsadda News, for the last seven years. However, he admitted, “like other news reporters and news editors in the area, I too had no knowledge and awareness about women's reproductive health or rights. Like other parts of Pakistan, in my area too, the custom is that women are not allowed to go outside. In this situation, it's very difficult — especially for men, to talk about women's reproductive health and rights. This is even more difficult in Khyber Pakhtunkhwa (KPK) as majority of the people are still very conservative.”

In 2014, Sajjad, along with some other media members, participated in a workshop on reproductive health (RH) organised by the Shirkat Gah Women's Resource Centre. During the orientation, he watched a documentary called Mumtaz Bach Sakati Thi (Mumtaz could have been saved). Watching this film shook him deeply and for the first time, he realised the poor state of women's health in his region. He felt it was a serious and flagrant issue and decided to work on it.

Sajjad explains further, “In our area, people refuse the Polio vaccination because they think that in the guise of the Polio vaccine, western countries were trying to control the fertility of the people. In such a situation, it is very difficult to write about family planning and other RH issues of women. There is also the possibility of threat. Despite this and because it is such a very serious issue, I decided to work on it.”

After returning from the session and exposure visit, Sajjad wrote several articles on anaemia, family planning, early marriage, and on the use of the Khyber Pakhtunkhwa Right to Information (RTI) Act.1 “After getting an orientation on the RTI process, I have realised its power and have used it to file an RTI to get details of health budgets. When I get the replies, I plan to use the information to write articles on the gaps and raise questions to make duty bearers accountable,” he says. Motivated by conversations with Sajjad, two of his friends have also filed RTIs. These were published not only by his newspaper, but by other local newspapers too.

He also found out that in the district hospital, women were not treated with dignity. So he discussed it with the duty bearers and lodged a complaint with the District Complaint Cell. Since Sajjad was well known and had good relations with the official within the Complaint Cell as a journalist, immediate action was taken against the concerned staff. Now the behaviour of the staff has improved towards the people, especially women.

Aside from being involved in improving the situation, Sajjad has also played a significant role in motivating the grassroots local champion² under the WHRAP-South Asia project. For instance, in the Basic Health Unit (BHU), staff members were charging illegal informal fees for pregnancy test services. Sajjad used his influence as a journalist to help the local champion lodge a complaint with the district complaint cell, resulting in the termination of the norm of charging these illegal informal fees.

At a more personal level, Sajjad says he now discusses reproductive health issues with his wife and motivates her to share her knowledge with other women. Additionally, he has shared all his newfound knowledge with his friends and colleagues and encourages them to use it for the benefit of the women in their area.

Bringing the Good Doctor Back

Advocacy to ensure the provision of comprehensive abortion services

Story by
Anju Shreshta

Written by
Ruby Shakya

Location
Nepal

Partner Organisation
Beyond Beijing Committee

CQC Framework Highlights
Guarantee women's safety in child birth whether in facility – based or home delivery. Having broad-based health care providers, such as Auxillary Nurse Midwives (ANM), Trained Birth Attendants (TBA), community midwives etc., is important. This should also be backed by emergency transport especially for complicated cases.

Manahari is a beautiful village in Makwanpur district of southern Nepal. The village includes people of various cultures and religions with different lifestyles. They are fortunate enough to have drinking water, electricity, mobile towers, cable services, and a primary health centre available in their village.

In the primary health centre (PHC), they also have comprehensive abortion services (CAS), which started in 2009. However, due to the stigma and discrimination attached to abortion in the society, as well as low awareness on availability of services, only two to three women access these services in a month. The fear of being disclosed forces women to seek backstreet abortion services. Due to under utilization of abortion services provided at the health centre, it is less prioritised even by trained health personnel. Anita's story below illustrates this:

“Anita, a 32-year-old woman has four children – two sons and two daughters – all born at home. When she learnt that she was pregnant again, she decided to have an abortion as she did not want to have more children. She was unaware of the services offered in the primary health centre, so she went to a village sudeni (a traditional birth attendant) to have an abortion. Soon after the procedure, Anita experienced heavy bleeding. She was first taken to the nearest primary health centre, but due to their lack of services, she was referred to a district hospital. She died during the transfer. “

Making Change Happen, One Village at a Time

Advocacy to hold village committees accountable for women's health and rights

Story by
Naresh Madawat

Written by
Smita Bajpai

Location
India

Partner Organisation
CHETNA

CQC Framework Highlights
Open the healthcare systems to continuous public/community monitoring. Social reviews, as part of a regulatory mechanism, must ensure the accountability of all duty bearers involved.

After working in a programme for improvement in the public education system in the state of Rajasthan for eight years, I started Shrusti in 1999. It was intended as a space to independently implement my ideas and to fulfil my desire for interacting with the rural communities of the Jhadol Block in the Udaipur district of the state of Rajasthan, India. We started focussing on education and then moved on to address other issues, such as livelihood and health.

In 2013, one of my team members asked me to join Rajasthan White Ribbon Alliance for Safe Motherhood (SUMA) anchored by CHETNA, which is a network working for the reduction of maternal and newborn mortality in the state of Rajasthan. Realising the importance of this issue, we joined SUMA and participated in the trainings which were organised to build our capacities.

To begin with, we held discussions with women's groups in five villages to learn about their experiences of accessing maternal health services from the public health system. Women from interior villages shared that they were not treated properly, they were not respected, they had to make several visits, and not all women got all of the benefits and services that they are entitled to. Each woman had a different story to tell.

In order to collect better evidence for advocacy, we carried out an assessment of the services provided by the public health facilities, using tools provided by CHETNA. Although there were some challenges, such as understanding difficult technical terms and uncooperative government authorities, we were able to complete the assessment. We understood the roles that the Village Health Sanitation and Nutrition Committees (VHSNC), facility-based committees, the Anganwadi (crèche) worker (AWW) of the Integrated Child Development Scheme (ICDS) which is India's Supplementary Nutrition Project, and the Auxiliary Nurse Midwife (ANM) at the sub-centre, were supposed to provide for quality services. Additionally, the assessment allowed us to see which areas needed work, and motivated us to work on them.

We shared the Citizens' Report Card with key decision makers from the Gram Panchayats, (Local Self Government Bodies), the Health Department, and the members of the facility-based committee–Rajasthan Medicare Relief Society (RMRS),1 to which mixed responses were received. While some appreciated the initiative, others found loopholes. The Chief Medical Officer of Jhadol Block dismissed the issue right away. Though we were disappointed with his reaction, we did not lose hope. We approached the Sarpanch (head) of Madla Gram Panchayat, who was more compassionate and agreed to bring this matter up at the upcoming Gram Sabha.

Though this sounded hopeful, we were unsure of our next step and how to proceed with it as we had never made proposals at the Gram Sabhas. The training organised by CHETNA helped us gain clarity on the Panchayat system and ways to present proposals at Gram Sabhas. The discussions made us more hopeful about potential positive results as a result of advocacy at the Gram Sabhas. The training ended with a plan to engage with the upcoming Gram Sabhas. People from the community were motivated to participate in Gram Sabhas to support our call.

We were pleasantly surprised when our proposal to fill up the vacant post of the Anganwadi worker resulted in the selection of a worker on the spot. The Gram Sabha also resolved to take action on the two other issues we proposed.

Health and Happiness Across River Islands

Holding authorities accountable for quality health services

Story by
Monirujjaman Heru

Written by
Samia Afrin

Location
Bangladesh

Partner Organisation
Naripokkho

CQC Framework Highlight
CQC monitoring systems must include continuous tracking of services for vulnerable groups including migrants, internally displaced, persons with disabilities, socially excluded, people living with HIV and women. Their access to SRH information and services including EmOC and referrals must also be tracked.

Sangkalpa Trust is a community-based organisation (CBO) of Naripokkho that is working as part of the WHRAP-South Asia initiative toward decreasing maternal death and is advocating for Continuum of Quality Care (CQC)¹ in Bangladesh. As part of this project, Sangkalpa Trust formed the Right to Health Alliance,² and its members visited five chor³ areas in the Barguna and Patuakhali districts of Barisal Division in December 2014 to learn about the standards of living of the people there and their access to health services.

During this visit, the alliance members saw that these chors are situated 20-30 km from the mainland and there is no other communication or transportation system from a chor to the mainland or to other chors aside from boats, and these are also poorly available. There are 3,000-10,000 people living in each chor, but most of them are illiterate due to inadequate access to education. There is only one educational institution, a primary school, in a chor. There is little opportunity of employment; most people sustain themselves by farming and fishing. For this reason, their monthly income is less than BDT 5,000 (USD 65) and their standard of living is very low.

Early marriage is a common reality within the chors. Often, parents marry off their daughters when they are between 10 and 14 years old. As a result, they become pregnant as adolescents, and suffer poor maternal health and complications, particularly as there is insufficient access to government health services in the chors. Due to a government mandate, there is only one community clinic in one chor, usually in those with a population of more than 6,000, and these clinics are only open for two to three days per month. Many smaller and more remote islands with lower populations are denied basic health services. People have very little idea about maternal health services and many pregnant women often take medicines from quacks and religious charlatans. There is no primary and emergency health services for women to depend on. Therefore, maternal death and child death rates are higher than mainland.4 Moreover, there is no health facility in chor areas.

During the visit, alliance members collected crucial information about health service systems in the chor areas, made a report on the basis of that information, and presented and discussed it in the alliance meeting to develop a plan for advocating with local authorities to improve the situation.

This picture shows a trip of Sangkalpa Trust staff members over river islands in Bangladesh.

Sangkalpa Trust staff travelling to river isalnds. Source: Naripokkho

This picture shows a member from Right to Health Alliance service, talking with a Chor resident in Bangladesh, for gathering information on Maternal Health.

An alliance member collecting information of MH in the Chor. Source: G M Badal

Will the Real Member of Parliament Stand Up?

Community organisation holds an elected representative accountable for quality health services to his electorate

Story by
Samia Afrin

Narrated by
Monirujjaman Heru

Location
Bangladesh

Partner Organisation
Naripokkho

CQC Framework Highlight
Establish a well thought-out functioning grievance redress mechanism with adequate participation/inclusion of nonsystem people at the grassroots level which addresses grievances in a timely manner. The action taken should be monitored. Existing mechanisms should be activated and empowered which should include an element of capacity enhancement of the officials/members of the grievance redress committee.

Sangkalpa Trust, a community-based organisation (CBO) of Naripokkho, has been working since 2003 with the Women's Health and Rights Advocacy Partnership — South Asia initiative in order to ensure the accountability of service providers in Patharghata Upzila¹, in Barguna district of Barisal Division. It monitors services provided at government health facilities and advocates for quality health services through the activation of Hospital Management Committees (HMC)². Sangkalpa Trust is also a member of the HMC of the Patharghata Upzila.

According to current government orders in Bangladesh, an HMC is to be headed by the local Member of Parliament (MP). Similarly, the Upzila Health and Family Planning Officer (UH&FPO) is the member secretary for HMC. According to government rules, HMC meetings should be held monthly in order to discuss issues related to the quality of health care services in hospitals, and to find ways to address the issues that require approval of a local M P. In 2014, Sangkalpa Trust found out that the HMC in Pathorghata Upzila Health Complex has not met in more than two years. This was because of the very infrequent visit of the MP in the Upzila due to his busy work schedule. The absence of HMC meetings led to a deterioration in accountability mechanisms and services in the health complex. Doctors were not available even during the time of their duty, patients were charged illegal fees, the quality of the medicines and other services were compromised, and there was lack of running water in the health facility. In addition, the security at the hospital was poor, and failed to deter loitering drug abusers, who discouraged patients' use of the facilities.

Through an initiative of the Executive Director at Sangkalpa Trust, these issues were discussed at the Right to Health Alliance3 meetings. The members of the alliance decided to reach out to the MP to inform him of the situation and to stress the importance of activating the HMC. The alliance members met with the MP who made several promises but did not keep his word. Despite this, Sangkalpa Trust proactively put the agenda together. Unfortunately, the agenda was dismissed by the secretary of the committee, who failed to show up at a meeting that the MP did attend due to a fear that they would be held accountable for irregularities in the health complex. However, the health alliance under the leadership of Sangkalpa Trust did not give up, and continued lobbying with the MP and with the Upzila Executive Officer and Upzila Health and Family Planning Officer (UH&FPO).

This picture shows a meeting of Hospital Management Committee members in Bangladesh.

HMC Meeting in Pathaoghata Upzila Health Complex. Source: Mirza Khaled

Finally, after a year of advocacy, the MP was convinced and assured that he would call for a meeting during his next visit. He called for the first HMC meeting in more than three years on 19 March 2015. The issues that were identified through the monitoring of the facility by Sangkalpa Trust and the alliance were discussed. When the importance of regularity of the HMC meeting was brought up, the MP affirmed it, and said that in his absence, the co-chairperson would chair the meeting.

Following the meeting, actions were taken in order to improve services at the health complex. These included the following: reduced absenteeism and frequent transfers of medical officers, increased visits by doctors, the organisation of health education for out-patient department (OPD) patients, increased OPD usage, a reduction in the demands for informal payments, improved sanitation, a regular water supply, and improved security at the campus. Moreover, the Committee members are now more proactive in identifying problems and taking measures to solve them.

These changes would not have materialised if not for the perseverance and commitment of Sangkalpa Trust and members of the Right to Health Alliance.

Digging Deep, Reaching High

Civil Society gathers evidence of SRHR violations to hold the government accountable

Story by
Y. K. Sandhya

Written by
Sajida Parveen

Location
India

Partner Organisation
SAHAYOG

CQC Framework Highlights
Contraceptive services must equally focus on men with a specific emphasis on temporary methods as opposed to permanent methods. Public dialogues must be organised which bring the public health functionaries/providers, local self-government representatives and the users in a multi–stakeholder dialogue. This should also allow health providers space to discuss the challenges they face.

Implementation of the Family Planning Programme in India began several decades ago in 1952,¹ when the growing population was often dubbed as a bomb that was about to explode. The national government believed that if population growth was not controlled, economic development would remain elusive. As a definite way of controlling population growth, targets were set in each state regarding the number of men and women to sterilise.² It should be noted that female sterilisation, a terminal method, has for decades, remained the mainstay of the national family planning programme. Although the programme talks about offering a basket of choices, modern spacing methods (IUCD, oral contraceptives, and condoms) account for a very small fraction of contraceptive use.

Sterilisation services are provided not just in hospital facilities but also in camps that are organised by the government and sometimes with the support of NGOs. A number of women are called for sterilisation in the camps. In many of these camps, doctors perform a large number of sterilisation operations in conditions that do not follow the standard quality norms mandated by the Supreme Court of India, which has led to the death and morbidity of many women. Furthermore, although mandated, it is very difficult for the affected women or the families of the dead women to receive the compensation they are entitled to.

SAHAYOG and other members of the Health Watch Forum (HWF) have observed several sterilisations camps and conducted case documentations of sterilisation failures and deaths. Based on them, in 2003, the HWF filed a public interest litigation (PIL) case³ in the Supreme Court, wherein it cited data from the States of Uttar Pradesh, Bihar, and Maharashtra, that provided evidence on government practices regarding female sterilisation. These included lack of counseling or informed consent, lack of pre- and postoperative care, and performing sterilisation in unhygienic and un-anesthetised operating conditions. The judgment was clear. The Supreme Court recognised the problem and formulated a set of guidelines that are required to be followed.

Connecting Local and Global Accountability

Accountability for Women's SRHR at the International Level: WHRAP-South Asia Strategies

Story by
Nalini Singh

Location
Malaysia

Partner Organisation
ARROW

CQC Framework Highlights
States have an obligation to fulfill their international commitments as signatories. They should provide quality healthcare services for all. Sustained investment in strengthening the health system must happen under government supervision and management.

This picture shows a moment of merriment, enjoyed by CBO members at a meeting in Malaysia, where representatives have gathered from National, Regional and International organisations.

Respresentatives from CBOs, National, Regional and International partners of WHRAP at a partners meeting held in 2015. Source: ARROW

Investment in building a strong Asia Pacific partnership for advocacy on SRHR was a strong collective call at an ARROW Regional Partners Meeting in 2001. This partnership would strengthen the linkages between the local, national and international advocacy so that the impact and efforts to influence policy and programme change is increased.

In moving this call forward, WHRAP began as a programme for ARROW in 2003. A new approach was needed as identified by ARROW and partners to ensure that SRHR remains a priority agenda for governments in the region as well as donors. The implementation of the Millennium Development Goals (MDGs) recognized improvement of reproductive health as part of the larger poverty eradication strategy but within its limited framework. Many of the policies driven by agencies and donors to reduce the maternal mortality ratio focused narrowly on institutional deliveries. However, these failed to recognize the context marginalised women are in. In the four WHRAP-South Asia countries, home deliveries are a reality.

As an international partnership with a regional and local voice, WHRAP-South Asia has been able to leverage spaces at the regional and international levels so that partners are able to present their evidence and positions in these spaces. ARROW also has been at the centre of developing the position paper on a Context-specific Rights-based Continuum of Quality Care (CQC) for Women's Reproductive Health in South Asia. This has enabled partners to move towards common and unifying advocacy goal despite addressing diverse populations and issues in each country. This position has formed a framework for WHRAP-South Asia's national and CBOs partners for their interventions. It has been translated and widely disseminated. It has also been the basis of submissions to the WHO Commission on Information and Accountability for women's and children's health through its Independent Expert Review Group.1

In recent years, ARROW has been able to raise joint positions through organizing regional advocacy dialogues, events and by engaging in key regional and international processes. One such highlight was the organisation of the Regional Advocacy Dialogue in 2012 on “Advancing Accountability: Raising the Issue of Maternal Deaths in South Asia” in New Delhi, India. This brought together 18 regional and national stakeholders, including representatives from WHO-SEARO, UNFPA, WRAP-South Asia partners and others to assess maternal health policies and their impact on the lives of marginalised women. It highlighted and addressed the gaps in care and services. The participants agreed on WHRAP-South Asia's CQC advocacy agenda and reflected on the need for broader alliance building for the partnership. The then ‘UN Special Rapporteur on the Right of Everyone for the Enjoyment of the Highest Attainable Standard of Physical and Mental Health’, Anand Grover, who also joined the meeting, suggested use of the mechanism's complaints protocol for violation of rights.

Similarly, in 2014 ARROW/WHRAP-South Asia received support from a broader base of civil society for the CQC position. More than 50 representatives from 38 different CSOs in Asia Pacific deliberated and produced ‘the call for action towards context specific rights-based continuum of quality care.2 The call was formulated in the context of the new Sustainable Development Goals (SDGs) which were being decided and strategies for ending preventable maternal mortality were being finalised by WHO and other agencies. It reiterated that the ground level realities should be taken into account so that the final goals and strategies are reflective of the needs of, and can bring about real changes for, all women, particularly marginalized women.

In 2015 ARROW/DFPA/WHRAP-South Asia, organised a side event at the July session of Intergovernmental Negotiations (IGN) on the SDGs at the UN headquarters in New York. It was organised in collaboration with the DFPA, United Nations Non-Governmental Liaison Service (UN NGLS), AIDS Accountability International (Africa focus), and with official support from the government of Nepal. The side event showcased the lived realities of girls and women in South Asia. It provided an analysis of the region's persistent reproductive health challenges, 15 years after MDG implementation by highlighting the contextual differences, lack of accountability at the local level and the need to focus on quality health care especially on SRHR. The participants who included several member state representatives including Nepal and Denmark, staff of various UN agencies and other CSO representatives were presented with evidence that argued for the CQC approach. Representing WHRAP-South Asia's first-ever engagement at the UNHQ, the event proved to be an opportunity to forge relationships and strengthen support for our advocacy. Participants agreed that the CQC call was timely and was missing from the ongoing SDGs discussions.

With this sustained engagement as a partnership, we hope to ensure that the forthcoming global accountability framework recognises the urgent need for context-specific continuum of quality care for all women.

Notes

1  Oversight Mechanisms refer to Hospital Management Committees that have the function of supervising the management of hospital finances, approving hospital budgets, monitoring the performance of hospitals against the budgets, etc. Nepal — Health Facility Management Committees (HFMC); Bangladesh -Union Parishad Standing Committee, Health and Family Planning Committee, Union & Divisional Level Hospital Management Committee; India — Rogi Kalyan Samiti (Patient Welfare Committee), Facility-based Planning and Monitoring Committee; and Pakistan — Oversight Committee on Health and Population.

2  This includes various UN Human Rights Accountability Mechanisms such as the Universal Period Review process, CEDAW reporting, UN Special Rapporteur mechanisms, national human rights institutions, etc.

3  More about Continuum of Quality Care (CQC) can be found at http://arrow.org.my/wp-content/uploads/2015/04/Fulfilling-Womens-Right-to-Continuum-of-Quality-Care_Advocacy-Brief_2014.pdf).

1  In Pakistan, registering births remains a challenge and this poses many administrative problems including difficulties to track age of marriage, as it is not possible to ascertain whether girls are marrying before the legal age of 16 for females in the absence of a birth certificate.

1  The act was signed into law on November 4, 2013, and provides citizens “the right to access to information in all matters of public importance,” including public documents and records. Khyber Pakhtunkhwa Government website, accessed November 30, 2015, http://www.khyberpakhtunkhwa.gov.pk/Rti-updated.pdf

2  Champions are local community activist. Most of the champions are between the age of 22-35 years. Shirkat Gah identified these champions with the help of local CBO United Youth Welfare organization Charsadda. Now these champions are trained to conduct community sessions, identify local RH issues, share with media and coordinate with district complaint cell Charsadda.

1  Since November 1995, the government of Rajasthan has created RMRS, a society aimed to provide various diagnostic and treatment facilities at nominal cost to general patients and free of cost to below poverty line (BPL) and dependent patients. Source: http://medicaleducation.rajasthan.gov.in/ajmer/RMS.asp

1  CQC is a context specific and rights-based approach that will ensure Continuum of Quality Care across a woman's lifecycle, including adolescence, pregnancy, postpartum/post-abortion, and menopause.

2  The Right to Alliance was formed in 2014. It was an initiative taken by Executive Director of Sangkalpa Trust according to the guidance of Naripokkho for proper implementation of the WHRAP project.

3  Chor or alluvion is an area in the midst of a river that is formed by the accumulation of alluvium through river flow. There are many chors in the project implementation area and five were visited in 2014.

4  The following statistics also reflect the same. According to the Bangladesh Maternal Mortality Survey (BMMS) 2010, the Maternal Mortality Rate (MMR) is 194 per 100,000 live births in Bangladesh and the divisional MMR for Baraisal is 168. However, in 2012 Naripokkho-WHRAP found that the MMR is 231 in 111 union of Barisal Division and those unions have several Chors as Barisal is surrounding by many rivers.

1  Upzila refers to a sub-district.

2  The Hospital Management Committees (HMCs) were formed by the Ministry of Health and Family Welfare to monitor the work of the Upzila, District and Divisional level hospitals. There are 21 members at the Upzila level. The Chairperson and the Co-Chair of the HMC are the local Member of Parliament and Chair of the elected Upzila Parishad respectively. Other members include the hospital staff, women leaders, government officials, local journalists, and local NGOs.

3  The Right to Health Alliance was formed in 2014. It was an initiative taken by Sangkalpa Trust with the guidance of Naripokkho for proper implementation of WHRAP project.

1  In 1952, India launched the world's first national programme emphasising family planning to the extent necessary for reducing birth rates “to stabilise the population at a level consistent with the requirement of national economy.”

2  India has had a long and somewhat turbulent history with regard to family planning. It has, over the years, adopted a number of different approaches, including a coercive target approach, a policy articulating a reproductive health and rights paradigm, contraceptive-specific incentives, and a family planning camp approach, among others.

3  In collaboration with the Human Rights Law Network and the Centre for Reproductive Rights.

1  http://www.who.int/woman_child_accountability/ierg/en/

2  http://arrow.org.my/wp-content/uploads/2015/04/Continuum-of-Quality-Care_Call-for-Action_2014.pdf