COMMENTARY
International Rhetoric,
Domestic Evidence
Government Claims on Health
Inconsistent with Reality
Jashodhara Dasgupta, Subha Sri B, Priya John, Sana Contractor,
Renu Khanna, Sandhya Y K
Civil society reports on sexual
and reproductive health provide a
contrast to the claims and
assurances made by the
governments report to an
international human rights
mechanism on its public health
commitments and achievements,
with information that is at gross
variance to the official report.
This discordance questions the
credibility and accountability of
the government to these
international human rights
processes and more so,
its citizens.
Jashodhara Dasgupta (jasho_dg2006@yahoo.
com) works on public health rights and is with
Sahayog, Lucknow; Subha Sri B (subhasrib@
gmail.com) is with CommonHealth (The
Coalition for MaternalNeonatal Health
and Safe Abortion) and Rural Womens
Social Education Centre, Tamil Nadu;
Priya John (pria.john1@gmail.com) is with
CommonHealth; Sana Contractor (sana@
chsj.org) is with the Centre for Health and
Social Justice, New Delhi and the National
Alliance of Maternal Health and Human Rights
(NAMHHR); Renu Khanna (renu.cmnhsa@
gmail.com) is with Sahaj, Vadodara and
CommonHealth; and Sandhya Y K (sandhya@
sahayogindia.org) is with Sahayog, Lucknow
and NAMHHR.
Economic & Political Weekly EPW JUNE 17, 2017
T
he Universal Periodic Review (UPR)
is an important human rights
accountability mechanism estab-
lished in 2006 within the United Nations
Human Rights Council (UNHRC) through
which each UN member state is subject
to a peer review of its human rights situ-
ation every five years. During each review,
other member states provide recommen-
dations to the state under review. While
these are not binding, if the state under
review accepts a recommendation, it
makes a commitment to implement it. For
each review cycle, the state under review
has to submit a report on the efforts made
to implement the previous cycles recom-
mendations. Along with this, reports are
submitted by human rights institutions
(in Indias case, by the National Human
Rights Commission) as well as civil society
organisations and coalitions.
India in UPR 3: Reports
Contradicting Evidence
Indias first review under this process was
held in 2008 (UPR 1), followed by a second
review cycle in 2012 (UPR 2) and a third
review cycle which was held recently on 4
May 2017 (UPR 3). All UPR 3 submissions
were reviewed in AprilMay 2017, and
subsequently, other member states shared
their comments. The Government of India
(GOI) has to respond to the concerns and
comments by 21 June 2017 indicating its
commitments for the next cycle. This
commentary is based on a submission to
the UPR 3 process by a coalition of
organisations and networks to present a
vol lIi no 24
civil society perspective on the gains
and gaps in Indias fulfilment of the sex-
ual and reproductive health and rights
(SRHR) of women and girls.
During the 2012 review (UPR 2), India
received 169 recommendations of which
it accepted 56. The recommendations
accepted by GOI in relation to SRHR
included: strengthening health systems;
increasing resource allocations to the
health sector; improving access to mat-
ernal health services; safe abortion ser-
vices; gender-sensitive contraceptive inf-
ormation and services; counselling on
SRHR, and reviewing laws that do not
uphold gender equality. However, we
find the GOI report to the UPR 3 makes
several claims which are not consistent
with ground realities, and we draw on
our own submission to the UPR to ques-
tion some of GOIs submissions.
While reporting back in UPR 3, the
GOI submission with respect to health in
general and maternal health in particular,
mentions that steps have been taken to-
wards improving access to maternal
health, obstetric delivery services, and
sexual and reproductive health services
(GOI 2017: para 105), and that the
National Rural Health Mission (NRHM)
has been effectively implemented. To
reduce maternal and infant mortality,
the GOI submission mentions an increase
in allocation under the Janani Suraksha
Yojana (JSY) from `16.06 billion in 2011
12 to `17.62 billion in 201314.
Ailing Public Health System
During UPR 2, the GOI had accepted rec-
ommendations to increase spending on
health to 3% of the gross domestic prod-
uct (GDP). However, as per the Economic
Survey of India 201516, Indias public
spending on the health sector overall is
only 1.3% of the GDP (Ministry of Finance
2016). The vision of NRHM to strengthen
and scale up the public health system re-
mains unfulfilled, as its schemes were
consistently underfunded (MoHFW 2017).1
The recent changes in the budgetary
21
COMMENTARY
allocations for states have further im-
pacted health service provisioning.2
The public health system in rural areas
continues to be severely understaffed.
The government has identified a short-
fall of 81.2% of specialists at community
health centres (CHCs) across rural India
(Rajya Sabha Secretariat 2016). The
states of Bihar, Uttar Pradesh, Jharkhand
and Chhattisgarh have less than 1 skilled
health personnel per 1,000 population
whereas the World Health Organization
(WHO) prescribes a basic threshold of 2.3
personnel per 1,000 population (Hazarika
2013). Public health infrastructure is ail-
ing as well, with significant shortfalls in
the setting up of CHCs at 32%, primary
health centres (PHCs) at 22%, and health
sub-centres (HSCs) at 20% (MoHFW 2015).
Poor infrastructure, absent supplies,
and inadequate human resources in the
public sector, compel even the poor to
turn to private facilities for life-saving
care. Currently, Indias health system is
one of the most privatised in the world
and public expenditure is one of the low-
est, with only 32% of the total expendi-
ture on healthcare being public expendi-
ture (WHO 2014). The unregulated pri-
vate sector3 offers services of questio-
nable quality at exorbitant prices. How-
ever, both national and state govern-
ments continue to partner with the sec-
tor through publicprivate partnerships,
ostensibly in an effort to improve availa-
bility and accessibility of health services,
although there is a lack of robust evi-
dence to support this claim (Ravindran
2011). The recent development that show-
cases the governments intent is the
National Health Policy (NHP), 2017 which
opens the door for privatisation through
its plan for strategic purchasing of sec-
ondary and tertiary healthcare services,
leaving the public sector to provide only
primary healthcare services. By implic-
itly putting in market-based privatised
mechanisms that will make the realisa-
tion of this right impossible for its most
marginalised citizens, the government
has betrayed its own commitment to the
right to health of its citizens.
Although the GOI reported that a cash-
less health insurance scheme Rashtriya
Swasthya Bima Yojana (RSBY) has been
implemented in order to ameliorate
22
vulnerabilities due to ill health especially
for those living below the poverty line
and those working in the unorganised
sector (GOI 2017: para 73), evidence
from the field has highlighted inade-
quate coverage, non-availability of pri-
vate providers in districts with a weak
public health system, and malpractices
by private players (Nandi et al 2012).
The Maternal Mortality Paradox
The GOI submits that schemes like the JSY
provide institutional delivery services to
pregnant women who fall below the
poverty line, so as to reduce maternal and
infant mortality (GOI 2017: para 108). The
government also declares it has stream-
lined monetary assistance under the JSY
through direct bank transfers (GOI 2017:
para 108). It is undeniable that since the
introduction of the JSY, there has been a
steep rise in institutional deliveries from
39% in 200506 to 79% in 201516 (IIPS
2017). However, studies thus far have
been unable to detect a linkage between
the rise in facility births and maternal
mortality reduction (Randive et al 2013).
Facility births can be expected to im-
prove maternal health outcomes, only if
in-facility care is of an acceptable standard
and ensures skilled attendance at birth
(Chaturvedi et al 2015). Studies by civil
society networks of over 250 maternal
deaths among marginalised populations
in several states indicate that the basic
components of maternal care such as an-
tenatal examinations, prenatal counsel-
ling, skilled birth attendance, emergen-
cy obstetric care, and postnatal care, are
unavailable for women in many parts of
the country (Subha Sri and Khanna
2014; Dasgupta et al 2016). Absence of
basic infrastructure in health facilities,
non-availability of safe abortion services,
lack of treatment for post-abortion com-
plications, poor quality and expensive
care in private facilities, and persistent
underreporting of maternal deaths are
major concerns. Clearly, monetary incen-
tives under JSY are not tantamount to
skilled attendance at birth or improved
maternal health outcomes. In fact, the
monetary incentive did not improve
maternal survival for the poorest women.
Comparisons of data for 200710 show
that reduction in maternal deaths among
JUNE 17, 2017
women in the highest income groups
was four times higher as compared to the
poorest ones (Randive et al 2014).
The Janani Shishu Suraksha Karyakram
(JSSK)4 initiated in 2011 promised cashless
healthcare for maternal and child health.
However, out-of-pocket health expendi-
ture continues to remain high (Dasgupta
et al 2015); an average of `5,544 was
spent per childbirth in hospital in rural ar-
eas and `11,685 in urban areas (NSSO
2015). Access and utilisation of services
and schemes is poor particularly among
the Scheduled Castes, Scheduled Tribes,
Muslim women, young women and ado-
lescent girls (IIPS and Macro Interna-
tional 2009). Since the health of women
who belong to marginalised communi-
ties or live in underserved areas is al-
ready compromised owing to com-
pounded vulnerabilities, any complica-
tion during pregnancy or childbirth can
cause death unless there are skilled and
effective health services that respond
promptly (Dasgupta et al 2016). It is also
established that poor and vulnerable
women are systematically deprived of
antenatal and post-partum care (Subha
Sri and Khanna 2014).
In India, over 90% of women workers
are in the informal economy without the
protection of labour welfare legislations.
The Maternity Benefits Act (Amendment),
2017 recently passed in Parliament does
not take into account the informal sector
women workers who are denied wage
compensation during maternity. A prom-
ise made in the National Food Security
Act, 2013 to formulate central schemes for
universal maternity benefits has not been
fulfilled; the only existing scheme, the
Indira Gandhi Matritva Sahyog Yojana
(IGMSY)5 excludes the most vulnerable
women by disqualifying anyone with
more than two children. This effectively
debars the poorest and those from mar-
ginalised groups including Dalits and
tribals (Lingam and Yelamanchili 2011).
Sterilisations and
Unsafe Abortions
India had committed to ensuring that all
women would have access to sexual and
reproductive health services including
safe abortion services (UPR 2: Recom-
mendation 138.153). Indias UPR 3 report,
vol lIi no 24 EPW Economic & Political Weekly

however, does not specifically report on
the progress towards this recommenda-
tion. Unsafe abortions are believed to
contribute to 913% of maternal mortali-
ties (Srivastava et al 2013). In spite of the
Medical Termination of Pregnancy (MTP)
Act of 1971, the Indian Penal Code still
considers abortion to be a criminal offence.
More than 80% of women in the country
still do not know that abortion is legal and
available (Banerjee and Anderson 2012).
Several medical students are either una-
ware about the MTP Act or have anti-
abortion views (Palo et al 2015; Sjostrom
et al 2014).
Misinterpretation and overzealous im-
plementation of the Preconception Pre-
natal Diagnostic Techniques Act (PCPNDT),
1994 has resulted in further restriction of
access to safe abortion services. The con-
tinued use of problematic terms such as
female foeticide in government litera-
ture and reports adds further to the anti-
abortion rhetoric (GOI 2017: para 111).
Ensuring access to gender-sensitive,
comprehensive contraceptive services was
one of the key recommendations of UPR 2
(Recommendation 138.153). However, the
GOI does not specifically report on this.
On paper, the GOI promises women an
informed choice in the matter of repro-
duction, but plans and budgets actually
promote female sterilisation as the pre-
dominant method (PFI et al 2014: 26).
Expected Levels of Achievement (ELA)
are set, which translate on the ground
as targets imposed upon health manag-
ers and providers for female sterilisa-
tion, as against the purported target
free approach.
Female sterilisation is performed under
extremely hazardous conditions leading
to deaths, complications and illnesses as
well as failure and unwanted pregnancy.
When seen together with the govern-
ments target of covering 48 million cou-
ples with family planning by 2020, a
promise made to Family Planning 2020
(FP2020),6 the reduction in public health
expenditure raises serious concerns
about maintaining standards of quality
of sexual and reproductive health ser-
vices. In November 2014, following a
mass sterilisation camp performed
under shockingly negligent conditions, 13
young women in Bilaspur, Chhattisgarh
Economic & Political Weekly EPW JUNE 17, 2017
lost their lives (JSA, SAMA and NAMHHR
2014). Protests by activists and legal inter-
ventions have led the Supreme Court to
direct the government to stop camp-based
sterilisations altogether (Devika Biswas
v Union of India and Ors). However, coer-
cive measures such as the two-child norm
(by which those with more than two chil-
dren are excluded from contesting elec-
tions, applying for jobs and accessing
welfare benefits) continue to be invoked
as in the case of Assams draft Population
Policy (Government of Assam 2017).7
In order to address adolescent health,
the government cites that the Rashtriya
Kishor Swasthya Karyakram (RKSK)8 has
been initiated in 2014. However, three
years after the scheme was launched,
Adolescent Friendly Clinics, which were
to be operationalised at PHCs, CHCs and
district hospitals, are not in place (SAHAJ
2017) and the programme has not been
implemented in many states. The Rajiv
Gandhi Scheme for Empowerment of
Adolescent GirlsSabla was launched in
2010 in 205 pilot districts, as an effort to
empower adolescent girls. Despite posi-
tive evaluations (ASCI 2013), Sabla has
not been upscaled across the country, as
indicated by decreasing budgets of the
Ministry of Women and Child Develop-
ment in 201516. Several states have not
introduced comprehensive sexuality edu-
cation for adolescents and a parliamen-
tary committee has ruled against it cit-
ing moral and cultural reasons (Rajya
Sabha Committee on Petitions 2009).
Conclusions
As detailed above, the GoI has reported
to the UN Human Rights Council that it
has made progress in several of the com-
mitments it made at UPR 2, when it had
voluntarily accepted suggestions from a
peer group. The civil society joint report
on sexual and reproductive health pro-
vides a contrast to these claims of the
government with information that is at
gross variance to the official report. This
discordance questions the credibility of
the claims and assurances of the govern-
ments report to an international human
rights mechanism on its commitments and
achievements, and brings us to question
the governments accountability to these
international human rights processes. It is
vol lIi no 24
COMMENTARY
necessary for the people of this country
and their elected representatives to be
aware about the suggestions received dur-
ing the UPR 3 and play the role of informed
interlocutors. Although these international
processes play a facilitatory role in main-
taining peer pressure on member states,
the Indian governments primary account-
ability remains to its citizens.
Despite the progressive objectives in
the NHP 2017 to achieve universal health
coverage and reinforce trust in public
health systems, the policy fails to recog-
nise health as a human right, increases
private sector involvement, and further
delays substantive increases in public
health expenditure. Given this worrying
lack of commitment to guarantee the right
to health, the GOI must be reminded of
its constitutional obligations to protect
and fulfil the human rights of its people,
including their right to health, especially
those most marginalised. The UPR 3 in-
ternational review process, reinforced
with domestic involvements, can provide
it with some impetus in this direction.
Notes
1 The underfunding of the National Health Mission
(NHM) should be read in the light of the draft
National Health Policys comment that The
budget received (for the NHRM) and the expend-
iture was only about 40% of what was envis-
aged for a full re-vitalization in the NRHM
Framework.
2 As recommended by the 14th Finance Commis-
sion, there has been an increase in the share of
states in the divisible pool of central taxes from
32% to 42% every year since 201516. At the same
time, there have been reductions in the centres
financial assistance to states for their plan
spending. Thus, the 10% points increase in the
states share in central taxes has come at the
cost of the reductions in centres support for a
number of schemes in the social sector. Also, as
recommended by the subgroup of chief ministers
on restructuring centrally-sponsored schemes
(CSS) constituted by the NITI Aayog, NHM now
has a changed centre-state funding pattern in
the ratio of 60:40 from the erstwhile 75: 25. This
changed funding pattern has transferred larger
responsibilities of financing some of the crucial
social sector schemes like NHM to the states.
3 A heavily diluted Clinical Establishments (Regis-
tration and Regulation) Act, 2010, designed to
regulate all healthcare facilities, was passed by
Parliament. However, even its limited provi-
sions have not been notified in most states.
4 JSSK launched in 2011 to provide free and cash-
less services to pregnant women, including
normal deliveries and caesarean operations
and care for the sick newborn (up to 30 days
after birth), in government health institutions
in both rural and urban areas, aimed at miti-
gating the burden of out of pocket expenses.
5 IGMSY was started more than five years ago as
a pilot across 50-odd districts of the states
and union territories. Till date, it remains as a
pilot in these few districts.
23
COMMENTARY
6 FP2020 is a global health initiative which aims
to expand access to family planning informa-
tion, services and supplies to an additional 120
million women and girls in 69 of the worlds
poorest countries by 2020. For more information
see www.familyplanning2020.org/.
7 The recently drafted State Population Policy by
the state of Assam (which has been put out by the
government for comments) stipulates that those
with more than two children will be ineligible
for government employment and taking part in
panchayat and municipal body elections.
8 RKSK includes the imparting of health educa-
tion through community-based interventions,
and the Scheme for Promotion of Menstrual
Hygiene among adolescent girls in rural areas.
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