Mumbai: “If the pandemic has taught us one big lesson, it is to strengthen our public health system,” said Poonam Mutterja, executive director of the Population Foundation of India (PFI), a New-Delhi based NGO. “We have to invest more in our public health system, not just in terms of finances but in human resources,” she explained.
In the eight months of the COVID-19 lockdown, women’s reproductive and mental health was impacted as was their access to education. Muttreja spoke about how India could have used its grassroots health workers to provide these services door-to-door, the urgent need to invest more in India’s public health system and using innovative techniques to make sure women and children get access to health and education.
Edited excerpts from the interview:
We are now eight months into COVID-19 and some form of lockdown or the other. This has had a tremendous impact on homes, particularly on women, both in rural and urban India. What is your takeaway?
First of all, all the essential services that women use much more because of their reproductive, sexual and other aspects of their biology have been completely neglected. The demand for family planning services has gone down. Women are scared to go to health facilities but the facilities are also not providing help to women on, say contraception. This means India is going to have 26 million couples who are going to go through a pregnancy, without planning for it.
Second, women are the ones responsible for a child’s health--immunisation, for instance. Immunisation rates went down by close to 25%. The burden of work in the households, whether urban or rural, increased dramatically because husbands, parents, in-laws, children were at home, and women had to fetch more food, fuel and water for the family. Third, violence against women and girls increased because women were locked in the house with the perpetrators of violence. And a lot of the frustration, I am afraid, that men have, came out on both women and young girls. They were the victims and they could not go anywhere to report given the lockdown, and they could not even move out to deflect the situation. Often, women go to their parents’ house, or friend’s house, or neighbourhood, but in this situation they were in captivity with their perpetrators.
Fifth, because girls began to do a lot more work at home, they are the ones who got the least, even when there was education online. It was the girls who suffered more because of the order of priority of even using smartphones, leave alone connectivity to the Internet, which is: father, then son, then mother, then daughter. So girls had very little access; only 11% of the girls across the country had any access at all. We did some studies and found that 80% of the young girls we interviewed in Bihar said they experienced tremendous anxiety throughout the lockdown and needed support. Young girls are worried about two things that always happen when there are pandemics or disasters, which is that girls drop out of school and there is early and forced marriage. There are also reports of slavery, selling young girls into the flesh trade and so on. So the story for girls is all this existed even before--family planning is a challenge, reproductive health, maternal health, immunisation is a challenge. But all these silent factors got exacerbated. It got much worse for the women and girls than the men.
When cooking [for the family] under resource constraints--where people have lost their jobs, where there is insecurity about jobs--the burden falls on the women to feed [everyone]; always women eat the last and the least. And here, it was even meagre eating. I would like to say that not only did their biological factors fail them, but in terms of mental well being, in terms of physical well being, and their sexual and reproductive right, which is access to family planning.
And finally access to abortion. In India, there are 16 million abortions every year. There were no abortion services available. The private sector also failed the women--even [among] the poor, we know that almost 65% of the [health] expenditure is on the private sector. The private sector almost closed down in small towns and villages. So, the situation for women in the pandemic requires serious attention and we need a post-COVID response that looks at women and girls. Also, we need to put in mechanisms in place--what do women do when they experience violence even under normal circumstances? But let our post-COVID response at least be a serious response to women’s and girls’ realities.
You talked about the girl child, for example, dropping out of school or pushed into marriage. This is one kind of problem. The biological, reproductive issues you talked about is another kind. Mental health is the third kind. The violence that they face at the hands of the spouses and other family members is the fourth kind. Each of them is critical and deserves a proper response, but is there a way to prioritise or distribute the responses in a manner that is more efficient and effective?
I would like to say that we prioritise health first, because we are already in a pandemic, which makes them more vulnerable. Pregnant women are more vulnerable; we do not know the impact on children. We have to create special facilities. Just like, let us say, Max [hospital] has a COVID-19 facility hospital and non-COVID facility hospital. We need to separate the services--we need COVID facilities and non-COVID facilities even in the rural areas. We need to strengthen our public health system. Countries that have done well, developed or developing, or emerging economies, are the ones that had strong public health systems. Even the most developed countries that did not have strong public health systems did not do well on COVID. Our public health system is already in the ICU, we need to lift it up. We need to strengthen our public health system and we need to pay greater attention to women because of their biological and special needs. [We need to] ensure that family planning services are available not just in public health facilities. We should have a partnership. This is one place where I encourage partnership with the private sector.
Sixty percent of the girls cannot afford sanitary pads, they get free sanitary pads in schools. Now the schools closed, but what stopped the education system from distributing them at their home or using ASHA [accredited social health activists] or ANM [auxiliary nurse and midwives], the anganwadi worker? We have 3.3 million frontline health workers who could have been used well, who could have been paid well to give these services. We could have had distribution of not just contraceptives but also of sanitary pads for the girls, across to their homes or ration shops. Fortunately, we have many infrastructures for distribution, and that could have been put to good use.
Finally, I think this digital divide that we have, where people in the rural areas and poor kids have a much bigger divide in terms of educational attainment--it has been a wasted year. It has been a year of anxiety for people. Why can we not have facilities where, at social distance, we have children coming to school, especially in those districts where there has never been a COVID-19 case? In so many tribal areas, we have had not a single case of COVID. The most backward areas actually have the least COVID. We should put the DM [district magistrate] in charge. They have a more important role to play than the PM [prime minister] at the district level. They could have taken a call--where is it that we can provide what facilities? Where there is no COVID, could we experiment with schools? Ten children going, even once a week, would be great for their mental health. Extraordinary times require extraordinary solutions. Young kids, even one day a week, going to school would really keep their mental well-being in a better situation.
This is time for innovation and NGOs [non-governmental organisations] are doing huge innovations across the country. Instead of the government dumping them after they did the [COVID-19] relief and making laws which are going to make them more dysfunctional, this is the time for the government to take advantage and use the NGO sector’s commitment, innovation to work across the country.
You spoke about the challenge faced within homes. First was violence, the second was access to a mobile phone and therefore to information, entertainment and so on. How do you feel that these two could be addressed from a policy framework and maybe, as you said, the solution lies more in a decentralised approach rather than a federal structure where you push everything down?
Everyone may not have a phone. While I do want to see the digital divide narrowing, everyone in India, except the homeless, has television. We have the government's own channel Doordarshan, where the quality has quite improved today. Gone are the days when we were growing up and we saw those very boring programmes. I am quite impressed with the kinds of things that are happening on Doordarshan. There are great anchors and all kinds of things are happening. So why could we not educate children [using TV]? You choose Monday for class 2, Tuesday for class 3 and do some education which cuts across three years and four years. There are methodologies. So television was a missed opportunity in terms of digital.
Why can we not also use the cell phone for messaging on behaviour change and health education, including on ending violence? People do need to be reminded--I am sorry but again, I am not anti-men; but the way we have brought up our men is so bad that we need to help them now to be less violent, less patriarchal. They have the phone. Can we not send good messages--convincing and powerful [on the cell phone]?
India is home to the best film industry. The film industry came out in a big way to do fundraisers, concerts and so on. Why could we not use this opportunity for messaging...they were all free. Our experience with some of the celebrities was they gave us more time during the lockdown than any other time. So we could have used them to make short films, with good messaging. People are sitting at home, there are thousands of film makers. Forget the Bollywood industry. We were doing it in our own small way. PFI is a small NGO. We made 700 short films and programmes for ‘My Gaon’ website, and for states across India. We, who are not producers or great production houses. Why could we not ask? The government can pool-in, request different channels to do their own programmes.
You believe that approach will work to some extent. It is not going to solve the whole problem, but it can help?
It will not solve the whole problem. Let me give you an example. Entertainment education is the new mantra for changing social norms and behaviour across the world. Soul City in South Africa, for 20 years, has had a programme. There was a perception in South Africa that half the young population will be wiped out because of risky sexual behaviour and HIV-AIDS as a result. This entertainment education...we all take inspiration from Soul City. Sexual behaviour is the most difficult behaviour to change and they changed it in 20 years.
In Brazil, fertility rates came down from six [children] per woman to three per woman in five years, when there was entertainment education in the favelas [slums].
In India, we had this programme called Hum Rahi that Ashok Kumar did 25 years ago. PFI did something called Mein Kuch Bhi Kar Sakti Hoon, which Feroz Abbas Khan had directed. When we evaluated it, we did not believe the impact: 8% women said they plucked the courage, after seeing 52 episodes, to negotiate contraceptives with husbands. And normally in India, in an average patriarchal conservative household, which is most households, the women do not dare to discuss family planning and contraception with their husbands. 20% of men and women, after seeing 56 of our episodes, said it was not right to beat their partners or get beaten by their spouses. This is huge. We had to get an international evaluator to India, to evaluate whether our evaluation was right. The impact was tremendous.
During COVID time, our feedback on our own behaviour change communication was that the impact was much bigger because the people were anxious, wanted well being, and they were watching more TV than they normally did.
Whether it is gender or climate change, the power of communication is something that can definitely be far more.
What has happened is that because of the power of communication, people have access to information. They know how the better half lives. So people are more ready for a change. It is not that we are making good programmes and that is the only reason people are changing. We have to use and bring out the aspirations of the people which have already changed. So we have to play with the aspirations to create a bigger change and that potential exists today more than ever.
As you look ahead, how do you see us, as a country, converging on bringing more awareness, and therefore improvement, in gender equality, gender lifestyle and gender empowerment from a workforce point of view?
One is, we have to invest more in behaviour change communication. And we have to understand the science and art and run with it. It is cost effective when you do it at scale.
Number two, violence is a huge issue, not just for mental health, but it leads to many negative externalities and consequences. Violence must become a public health issue. It is not a public health issue now. Today, a doctor looks away when he realises that a woman is being beaten even when he or she examines them. A child is sexually abused, a doctor looks away.
Third, we need to invest more money on public health. If the pandemic has taught us one big lesson, it is to strengthen our public health system and spend more money. We have to invest more in our public health system, not just in terms of finances but in human resources and a very good management approach. We cannot have governance failures and now we realise that it is a life and death issue not just for the poor, but the rich too.
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