• A majority of the registered pregnant women did not use the health centres for institutional deliveries. This was particularly so in the States lagging on health and development parameters due to lack of planning in micro birth plan entrusted to the Accredited Social Health Activist (ASHA) and the Auxiliary Nurse Midwives (ANMs)

• Facilities were inadequate and there was a shortage of supporting staff and doctors at the health centres.

• The District Level Household and Facility Survey-III (2007-08) indicated that the percentage of institutional deliveries was 47 against the National Rural Health Mission target of 100 per cent institutional deliveries by 2012.

• More than 50 per cent of pregnant women in seven States and 20 to 50 per cent in nine States did not receive the full dose of iron and folic acid tablets due to delays and shortfalls in supply.

Report of the Comptroller and Auditor General of India, 2009

The Comptroller and Auditor General (CAG) has criticized the National Rural Health Mission (NRHM) for problems in implementation of the Janani Suraksha Yojana – maternity benefit scheme. In its latest report, the CAG pointed out that in addition to the above, the national targets for progress in human development goals and health indicators such as Infant Mortality and Maternal Mortality Rates were fixed by the Ministry of Health and Family Welfare but there was no attempt to ensure that individual State targets matched national targets or that these were achievable.

These are serious allegations considering that NHRM is the flagship program of the government. India is lagging behind in terms of basic indicators of health such as rates of infant and maternal mortality. While increasing institutional deliveries was envisaged as a way to risk mitigation, the fissures in the system ensure that this becomes difficult to achieve. Indeed there is no point in institutional deliveries if the institutions lack basic facilities. There is also a strong lobby that proposes strengthening of the community based systems such as training of the Traditional Birth Attendants (TBA) as a way to ensure safe deliveries. It is also argues that cash transfer is the only motivation that brings women to the institutions that are also ill-equipped to handle complicated cases. The cash transfer also has little meaning in the absence of adequate pre-natal and post natal care and support.

Child birth, one of the most natural human processes is at the crux of development. In order to ensure the safety of mother and infant, it is important to undertake multi-pronged programs to enhance quality and outreach of pre natal and post natal care along with complete immunization, access to adequate and nutritious food, clean water and proper sanitation facilities, etc. This is the minimum basic that we have to ensure for the mothers and their children, failing which no program can address the problems of Infant and maternal mortality.

Any understanding of disability remains incomplete until the gender dimension of the issue is well understood. Given that disability receives little attention from mainstream development agenda, the gender aspects of the issues are often ignore. However, awareness about how disability impacts the lives of men and women differently, can help design programs that are better tuned to the realities of the people that are often markedly different.

For example, National Sample Survey (NSS) 58^th round illustrate that accidents and injuries have some role in around 18 percent of all disabilities. There are, however, major gender differences in the source of such injuries. For males, over 35 percent of these injuries are at the place of work, while for women, the overwhelming proportion – 60 percent - are at home.

There is also a marked difference in intra-household attitudes and community views vis a vis men and women, especially with regard to violence against women with disabilities. This is a subject on which little quantitative research has been done to date in India. However, a 2005 study by an NGO Swabhiman from Orissa indicates that women with disabilities were subject to significant domestic abuse and sexual abuse, and that the situation was sharply worse for women with mental impairments relative to women with other types of disabilities. The findings for rape are the most shocking, with fully one quarter of women with mental disabilities reporting having been raped (with the large majority carried out by family members), and almost 13 percent of women with locomotor, visual and hearing disabilities. In only a small share of cases did the women report the abuse to her family, and in the vast majority of those cases the reaction of the family was either not to listen or to pretend nothing had happened. (Cited in: India: From Commitments to Outcomes, World Bank, 2007)

Similarly, analyzing marriage and widowhood rates, NSS data indicate that women with disabilities have much higher rates of widowhood than women without disabilities in both urban and rural areas – in both cases around four times the non-Women With Disabilities (WWD) rate. Conversely, the proportion of WWD who are currently married is much lower than non-disabled women. The explanation for such differential rates can most likely be found in the common practice of marrying of women with disabilities to men much older than themselves – men who are unable to find more “marketable” brides. (Source: India: from Commitments to Outcomes, World Bank, 2007).

These factors demonstrate that with the same kind and extent of disabilities, men and women often have different life situations that need to be understood and reflected in the programs designed and implemented. In addition, there are other intersectionalities like economic class, education levels etc, that need to be factored in to make the gender aspect of disability clearly spelt out and addressed.

Do the existing policies and programs adequately capture the gender dimension of disability?

Women and children are often in great danger in the place where they should be safest-within their family

At least one out of every three women around the world has been beaten, coerced into sex, or otherwise abused in her lifetime. The abuser is usually someone known to the victim. Yet, while violence against women and girls is a universal problem of epidemic proportions, both the sufferings of the victims often remain invisible. Fear and shame continue to prevent many women from speaking out, and data collected is often insufficient and inconsistent.

A UNICEF study carried out across various nations and cultures (including India) has established close correlation between domestic violence and suicide in India. Suicide is 12 times as likely to have been attempted by a woman who has been abused than by one who has not. In a more focused study undertaken by UNICEF in Uttar Pradesh, up to 45% of married men acknowledged physically abusing their wives. (Source: http://www.unicef-irc.org/publications/pdf/digest6e.pdf). Another UN study in India, indicates that 14 wives are murdered by their husbands’ family every day. (Source: http://www.un.org/events/tenstories/06/story.asp?storyID=1800).

A World Bank report estimated that violence against women was as serious a cause of death and incapacity among women of reproductive age as cancer, and a greater cause of ill-health, than traffic accidents and malaria combined.

Most police, prosecutors, magistrates, judges and doctors adhere to traditional values that support the family as an institution and the dominance of the male party within it. Given this, there is a great deal of reluctance to ‘criminalize’ wife battering. There is a sense that domestic violence is a crime between those who are linked by bonds of intimacy. The question of intimacy, i.e. whether wife-battering should be treated as an ordinary crime or whether there should be an emphasis on counseling and mediation, poses a major dilemma for policy makers.

Women’s organizations have provided leadership in boosting the visibility of violence against women; giving victim-survivors a voice; providing support to victims of violence; and forcing governments and the international community to take action. From local, collective action, women have transformed their struggle against violence into a global campaign. However, much remains to be done. It is a social problem that happens behind the closed doors. And yet, the most critical challenge is to open the doors and develop a mechanism for strong negative sanction. It is important to bring together the important stakeholders- the police, the law makers, the state and the civil society on a common platform to articulate a shared vision to protect women from violence and empower her to take action. Once that is clear, the message of zero tolerance has to be articulated across all levels of enforcement. The message is loud and clear- it is no longer personal.

What actions should be taken to combat domestic violence?

• Even though India has legally abolished the institution of dowry, more than 5,000 women are killed annually by their husbands and in-laws. An average of five women in a day are burned, and many more cases go unreported.

• In Bangladesh, it is estimated that there are over 200 acid attacks each year.

• More than 50 countries allow marriage at 16 or below with parental consent. Early marriage leads to childhood/ teenage pregnancy, and can expose the girl to HIV/AIDS and other sexually transmitted diseases.

• In several countries in the world including , women are killed in order to uphold the “honour” of the family.

Source: Innocenti Digest, 2000, UNICEF

Gender Based Violence against women is a manifestation of historically unequal power relations between men and women.

Women are inflicted to the various forms of gender based violence across age- from prior to birth till old age. Pre-birth, the unborn baby is at risk of sex-selective abortion. Their mothers are vulnerable to battering during pregnancy that impacts their birth outcomes. During infancy, the infants are vulnerable to female infanticide and other physical abuse. During girlhood, there are risks of being married as a child and of female genital mutilation in addition to physical, sexual and psychological abuse. The girls are also at risk of incest, child prostitution and pornography.

During adolescence, there is an increased risk of trafficking for commercial sexual exploitation and/ labour, courtship violence (e.g. acid throwing and date rape) etc. Adulthood is characterized by coerced sex, sexual abuse in the workplace, rape, sexual harassment, forced prostitution and pornography, trafficking in women, partner violence, marital rape, dowry abuse and murders, partner homicide, psychological abuse, etc.

Among elderly women, there are incidences of forced “suicide” or homicide of widows for economic reasons; physical and psychological abuse. In many rural areas, elderly women are killed, often with social sanction, on the suspicion of practicing witchcraft.

Gender based violence is one of the most pervasive of human rights violations. Violence against women is present in every country, cutting across boundaries of culture, class, education, income, ethnicity and age. Even though most societies proscribe violence against women, the reality is that violations against women’s human rights are often sanctioned under the garb of cultural practices and norms, or through misinterpretation of religious tenets. Moreover, when the violation takes place within the home, as is very often the case, the abuse is effectively condoned by the tacit silence and the passivity displayed by the state and the law-enforcing machinery. (http://www.unicef-irc.org/publications/pdf/digest6e.pdf).

Given this, it is important to address the issue at all levels of society and its institutions. One of the first steps is to recognize that while making laws is an important first step, enforcement will remain the crux of the problem unless it is backed up by strong negative social sanction. Sensitizing the enforcement agencies about the issue is another critical issue that the state and the civil society has to deal with.

What measures can be taken to ensure that the law is enforced effectively?

• Essentially all (99%) of the half a million maternal deaths every year occur in developing countries.
• Breast cancer is the leading cancer killer among women aged 20–59 years in high-income countries.
• Globally, cardiovascular disease, often thought to be a “male” problem, is the leading killer of women.
• Tobacco use is a growing threat among young women,
• Mortality rates during pregnancy and childbirth remain high in developing countries.

Source: WHO, 2009

Despite considerable progress in the past decades, societies continue to fail to meet the health care needs of women at key moments of their lives, particularly in their adolescent years and in older age. Given this, there is an urgent action both within the health sector and beyond to improve the health and lives of girls and women, from birth to older age.

The distinct roles and behaviors of men and women in a given culture, dictated by that culture’s gender norms and values, give rise to gender differences. Gender norms and values, however, also give rise to gender inequalities - that is, differences between men and women which systematically empower one group to the detriment of the other. The fact that, throughout the world, women on average have lower cash incomes than men is an example of a gender inequality.

Both gender differences and gender inequalities can give rise to inequities between men and women in health status and access to health care. For example: women cannot receive needed health care because norms in her community prevent her from traveling alone to a clinic, or showing her to a male doctor. Again, a married woman is often at risk of HIV because society is tolerant of her husband’s promiscuity. In each of these cases, gender norms and values, and resulting behaviours, are negatively affecting health. In fact, the gender picture in a given time and place can be one of the major obstacles - sometimes the single most important obstacle - standing between men and women and the achievement of well-being.

Thus, social factors combine to create a lower quality of life for women. Unequal access to information, care and basic health practices further increases the health risks for women. It is therefore crucial to increase awareness of the role of gender norms, values, and inequality in perpetuating disease, disability, and death, and to promote societal change with a view to eliminating gender as a barrier to good health.

How can gender and health be better reflected in actions to promote health seeking behaviour?

• First, certain regions of South Asia, particularly a band running through Pakistan and northern India, consistently have among the worst indicators of gender disparity in the world
• Second, the variations in gender disparity within India are as large as those across countries.
• Third, there is no correlation between average income and gender disparity in the sample, either across nations or within India.
• Girls are significantly less likely to receive treatment for common childhood illnesses in South Asia
• The female disadvantage in educational enrollment for ages 11 to 15 is high in South Asia much like the disadvantage in western and central African countries

Gender disparity in South Asia, World Bank, 1998

Yes, the data is more than a decade old. But the worst part is that not much has changed since then. A recently published UNDP Asia Pacific Human Development Report reiterated the same points. Women from South Asia continue to lag behind the world average in terms of literacy rates and labour force participation and have higher rates of Maternal Mortality and malnutrition prevalence. The proportion of women in labour force is 36 percent, compared to 60percent in Sub- Saharan Africa. China and India together account for nearly a 100 million missing women estimated to have died from discriminatory treatment in healthcare, nutrition access or neglect or because they were never born as female fetuses are aborted.

Given that South Asia accounts for almost a quarter of world’s population and within the region India accounts for 73 percent of the population, the magnitude of the problem can be well-understood.

This also reiterates the much repeated contention that high GDP does not automatically deliver human development. It needs more focused and deliberate public policy interventions. On the other hand, estimates suggest that if the work participation rate of women in improved, the GDP gets a 2-4 percent boost in countries like India.

The present scenario looks bleak and disappointing. We are talking of half the population of the country- a country with a woman as the President and another woman as the most important leader of the ruling party and also listed as one of the most powerful women in the world. While these are realities, the reality that the more things change, the more they remain the same seems to be the case here.

We also seem to know the answers, improved access to basic services like health, education and nutrition, increased empowerment at the grass root level, enhanced socio –political representation. However, we are so poor at delivering that changes are far too little.

How can the status of women in South Asia change?

Now that the Women’s Bill has been passed in the Rajya Sabha, there is a need to introspect on some of the inherent flaws.

To begin with, rotating constituencies has its own set of implications. The lure of re-election keeps the politicians connected to his/her constituency. While there are many examples of neglect, there are quite a few where the elected representatives nurse their constituency for a variety of reasons- as a reward to the voters for re-election, for demonstration effect almost in a feudal fashion, as a means to maintain the stronghold over the constituency and consolidate chances for further electoral advantages, etc. Given that the women’s bill will somewhat upset this scenario, there might be fall outs for which we need to be prepared.

The most important task is to translate this piece of legislature into an instrument of empowerment. We have a long history of egalitarian laws. The Constitution and a multitude of laws already provide for gender equality. However, other than some occasional landmark judgments and sensational cases, they have not been able to bring forth social justice or change social attitudes towards women or in any way improve the quality of life for most of the women. Given this, it is important to see ways in which the women legislators, mostly constituting an elite and enlightened upper crust, can change the grassroots reality.

Also, what are our expectations from the reservations for women? Affirmative Action, in the form of reservations for 60 years for Dalits and tribals have created a small but significant creamy layer, but failed to end discrimination. Are we looking at some kind of trickle down effect or do we want something more. The time to articulate that in clear terms is here.

Talking about the creamy layer, women politicians in India come with that baggage facilitated by the feudalism and dynastic nature of politics. In fact being a woman in a/ from a political family can accentuate chances of leadership more than anything else giving an advantage over males. Forget representation, forget connectedness with the masses, forget grass root experience- these women are born to lead and to rule. Needless to say, reservations only help them.

The whole argument is not to discredit the bill, but to caution against thinking of it as a panacea for addressing women’s issues. Gender issues are deeply entrenched in the mindsets and operate behind closed doors. Unless these doors are opened, empowerment will remain the private property of a few. We can hope that there is more strategy thinking that goes into making these reservations work for women- for the most vulnerable and the least vocal.

What can be done to make the reservations for women, actually work to the advantage of women?