While at Manthan, I got to work alongside Denise as she tries to measure Manthan’s impact on the communities in which it works. I was able to come along with her and conduct interviews with women from the region, in order to gain a better sense of what specific barriers are faced by women as a whole, women within their castes, and in specific areas.
While women and men suffer many of the same health issues globally, women are less likely to be financially independent, more likely to perform tremendous domestic labor (such as long journeys to fetch clean water), be domestically abused, and be discriminated against by health systems. Women who are part of a marginalized caste, from rural areas, and/or members of indigenous groups are all the more likely to experience not only disparities in health, but disparities in determinants of health such as education and labor access.[i]
Eleven of the thirteen women Denise and I have interviewed in the last week and a half have named health as a significant issue in their personal lives or within their communities. Problems include inadequate menstrual health education and resources, unsanitary and distant health centers, stigma around women’s health, inadequate health education, and a lack of competent doctors for women. Seven women also named the intersection of alcoholism and domestic violence as a significant issue, all women identified water access as a barrier, and three women mentioned taking care of severely disabled relatives. While these were rarely identified as health issues, the burden on women’s health created by domestic violence is clear–likewise the health issues around water, and the difficulty of taking care of disabled family members without adequate health care or health education.
Often, when discussing barriers to the right to health, a rubric commonly called “the AAAQ framework” is used: health facilities, goods, and services ought to be available, accessible, acceptable, and of good quality.[ii] While barriers rarely fall under only one of these evaluation factors, it can be helpful to break down issues this way in order to explain systematic failures within a health system to those who are not experiencing the issues first-hand.
- “Availability. Functioning public health and health-care facilities, goods and services, as well as programmes, have to be available in sufficient quantity within the State party.”[iii]
Within rural parts of India, health care can be accessed through India’s formal health care system, both government-run hospitals and health centers and private hospitals and clinics, and through an informal health system, such as village midwives and god-men.
A woman trying to access government health care could work through a chain starting with government-trained auxiliary nurse-midwives (ANMs), then going up to primary health centers (ideally equipped to deal with common health problems, but often lacking basic medicines and adequately trained staff), community health centers (intended to have staff with more training and a doctor, and more medications), then block hospitals or district hospitals for more serious issues requiring surgical intervention or other specialized health care.
Lower levels of the government health system frequently do not have the staff, medications, or health equipment needed to diagnose and treat health issues, and getting treatment at district hospitals requires access and funds for transportation from a village to the city of the hospital.
Informal health resources are often more accessible, and will more immediately provide diagnoses and treatment advice–though frequently inaccurate, and sometimes harmful.
Within the Sambhar Lake region, health resources tend to be technically present but functionally inaccessible or unhelpful. Manthan works to increase the training and capacities of workers in the informal health system, who tend to be more trusted by communities, as well as more likely to go to rural locations to address health issues.
Suama Daiyama is one such example. At seventy years old, she has spent more than thirty years delivering children in Kotri. She will stay with her patients throughout their labor, sleeping in the same room and preparing food for them as she keeps an eye on their progress and well-being. Because of her close ties to the communities in which she works, she is also trusted to address issues such as alcoholism and domestic violence.
Her years of experience delivering children and dealing with birth complications mean she is often more capable than government-trained ANMs, who frequently turn to her for advice. But prior to working with Manthan, she had no formal medical training, and relied on delivery methods that risked the introduction of infection and post-birth complications. Manthan, recognizing her skill as a midwife and as a change agent in communities, linked her to formal medical training through Barefoot College, where she received sanitary delivery tools, training in using them, and training in modern delivery techniques. Training midwives like Daiyama in technical skills allows midwives to combine their traditional, trust-building operational style with safer birth practices, increasing community access to quality medical care. This emphasis on combining effective traditional practices with modern technical knowledge is fundamental to Manthan’s approach.
- Health resources must be accessible: non-discriminatory towards vulnerable populations, physically accessible (“within safe physical reach for all sections of the population, especially vulnerable or marginalized groups”), affordable, and with information accessibility (access to health education and health information).[iv]
One of the clearest examples of the disconnect between available health care and accessible health care comes from the Banjaro community. A mostly nomadic group, they have a semi-permanent settlement directly next to a community health center near Roopangarh.
Talking to women of the community revealed significant accessibility issues. While the CHC is perhaps two hundred meters away, there is no doctor there and no machines available for diagnosis. Health workers from the CHC will not come into their community, especially at night. The ANM who oversees the area insists that community members walk to her house for help, a two or three kilometer walk. If women giving birth have complications, they must find a way to get to the district hospital in Kishangarh, which is financially impossible for them. Women who do go to the community health center are rarely given medical advice–many are currently suffering from a problem they call safed pani, “white water,” an irregular vaginal discharge that is often accompanied by long-term internal problems. They cannot get a diagnosis from the CHC, and do not have access to any female doctors or health workers who are trained in reproductive and sexual health.
Many rural women lack information even about their own menstrual cycles. Buaji, a Manthan staff member, remembers getting her first period and fearing that she had somehow been injured. The women in her village tended to use a single cloth as a sanitary product, which they would wash and hang to dry in dark, hidden places, such as under their beds. Bacteria breed on sanitary clothes when they are not properly washed and dried completely in the sun, and many women get infections when they menstruate.
Buaji did not learn about safe menstrual hygiene until she began working at Barefoot College. She sought as much health information as she could, and educated her own daughter about her menstrual cycle and menstrual hygiene before they had their periods, as well as teaching girls in school about safe menstruation practices.
Buaji is a living example of an effective health education technique–training and educating key community members, especially mothers, on basic health and hygiene practices enables them to be community change makers, allows them to have open and informative conversations with their children and their communities, and normalizes conversations about health, especially on topics such as menstruation that are highly stigmatized.
- “Acceptability. All health facilities, goods and services must be respectful of medical ethics and culturally appropriate, i.e. respectful of the culture of individuals, minorities, peoples and communities, sensitive to gender and life-cycle requirements, as well as being designed to respect confidentiality and improve the health status of those concerned.”[v]
Very few of our interviewees discussed the acceptability of health services, because it was so difficult to access them in the first place. But in every community where we conducted interviews, women mentioned a lack of female doctors or government health workers trained to deal with sexual and reproductive health issues when they had sought them.
And many women do not reach the point of seeking health care for these health issues. As Suraj, a teacher at Manthan’s girls’ school, informed us, women often do not feel that they can talk about “internal issues.” Openly discussing reproductive and sexual health is stigmatized, to the point that sometimes mothers and daughters do not discuss menstrual health issues. The acceptability issue many women here face is not a failure of health systems to be ethical and respectful, but the acceptability of acknowledging health issues in the first place.
- “Quality. As well as being culturally acceptable, health facilities, goods and services must also be scientifically and medically appropriate and of good quality. This requires, inter alia, skilled medical personnel, scientifically approved and unexpired drugs and hospital equipment, safe and potable water, and adequate sanitation.”[vi]
The quality issues in health care in this region are some of the biggest reasons that communities often do not trust government health care services. ANMs, such as one of our interviewees, do not always have a passion for the work. They frequently neglect their communities, refusing to visit in person, such as in the Banjaro community.
Women often want to have good medical care, such as a safe delivery in a hospital. But their experiences with government health facilities that lack medication, equipment, and trained staff either keep them from seeking health care, or push them towards private hospitals where they must pay money they do not necessarily have.
Gita, a Manthan employee who works part-time here and part-time laboring in the salt pans, barely has money to cover basic living expenses for herself, her disabled son, and his wife. But when her daughter-in-law gave birth, Gita and her family paid 5000 rupees for her to deliver in a private hospital. They feared that there would be a birth complication if they used a midwife or went to a government hospital, and that they would be blamed for the child’s death, since Gita’s daughter-in-law was having a girl.
The barriers to health for women in this area are myriad. Manthan does tremendous work to address problems with social determinants of health, to provide health education and training, and to address the gaps between the formal health system and realities on the ground, but realizing the right to health in the salt flats cannot be achieved without concerted, cross-sectoral efforts. Community voices like Gita’s, like Suama Daiyama’s, like those of the Banjaro women, need to be heard on a wider scale so activists, policymakers, health workers, and funders understand where their efforts need to be concentrated.
[i] See “The Right to Health: Fact Sheet No. 31” from the Office of the High Commissioner of Human Rights and the World Health Organization.
[iii] General Comment No. 14. It’s worth noting that this document also directly names access to safe and potable drinking water as a health availability issue.