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MATERNAL MORTALITY IN ODISHA Fact-Finding Mission to Rayagada District
14 March – 15 March 2015
March 2015 Human Rights Law Network
Reproductive Rights Initiative 576 Masjid Road, Jungpura New Delhi, India 110014
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TABLE OF CONTENTS
ACRONYMS ................................................................................................................................. 3
MAPS ............................................................................................................................................. 4
NAMES OF RELEVANT CHARACTERS ............................................................................... 7
I. INTRODUCTION................................................................................................................... 8
II. FACTS ..................................................................................................................................... 9 A. MEETING WITH VILLAGERS.................................................................................................................. 9 B. MEETING WITH ANGANWADI WORKERS ............................................................................................. 10 C. MEETING WITH DR. DALEI ................................................................................................................ 11
III. MAJOR ISSUES OF CONCERN ....................................................................................... 14 A. MULTI-LEVEL FAILURE OF ACCESS TO HEALTH CARE SCHEMES ................................................................ 14 B. CHRONIC ABSENTEEISM ................................................................................................................... 16 C. LACK OF WATER AND BASIC INFRASTRUCTURE LEADING TO VILLAGE ........................................................ 16
IV. RELEVANT BACKGROUND ............................................................................................ 16 A. MATERNAL HEALTH ......................................................................................................................... 17
1. Maternal Mortality ........................................................................................................... 18 2. Maternal Health ................................................................................................................ 19
B. HEALTH FACILITIES & MINIMUM HEALTHCARE SERVICES ....................................................................... 20 1. Anganwadi Workers .......................................................................................................... 20 2. Mobile Health Unit ........................................................................................................... 21 3. Subcentre .......................................................................................................................... 22 4. Community Health Centre (CHC) .................................................................................... 23
V. RELEVANT GUARANTEES AND GUIDELINES .......................................................... 26 A. INTERNATIONAL CONVENTIONS ......................................................................................................... 26 B. CONSTITUTIONAL GUARANTEES ......................................................................................................... 26 C. KEY CASES ...................................................................................................................................... 26 D. NATIONAL HEALTH MISSION (FORMERLY, NRHM) ............................................................................... 27
3. Janani Suraskha Yojana (JSY) .......................................................................................... 28 4. Janani Shishu Surakasha Karyakram (JSSK) ................................................................... 28
E. MAMATA SCHEME (ODISHA SPECIFIC) ................................................................................................ 29
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ACRONYMS ADMO Assistant Distrct Medical Officer ANC Antenatal Checkup ANM Auxiliary Nurse Midwife ASHA Accredited Social Health Activist AWC Anganwadi Centre AWW Anganwadi Worker AYUSH Ayurveda, Yoga, Unani, Siddha, and Homeopathy (Doctor) BPL Below Poverty Line CDMO Chief District Medical Officer CHC Community Health Centre DLHS-3 District Level Health Survey 2007–2008 HMIS Health Management Information System HPS High Performing State IFA Iron Folic Acid (tablet) IPHS Indian Public Health Standards JSSK Janani ShishuSurakashaKaryakram JSY Janani SuraskhaYojana LPS Low Performing State MBBS Bachelor of Medicine/Bachelor of Surgery MCP Mother and Child Protection (Card) MDG Millennium Development Goal MMR Maternal Mortality Rate MO Medical Officer MPW Multi-Purpose Worker NFHS-3 National Family Health Survey 2005–2006 NHM National Health Mission NRHM National Rural Health Mission OBGYN Obstetrician/Gynaecologist OT Operational Theatre PHC Primary Health Centre PPH Postpartum Haemmorhaging RKS Rogi Kalian Samiti RTI/STIs Reproductive Tract Infections and Sexually Transmitted Infections TT Tetanus Toxoid UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund VHND Village Health and Nutrition Day (“MamataDiwas”) WHO World Health Organization
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MAPS
The State of Odisha
Source: Wikimedia Commons
Districts of Odisha
Source: Wikimedia Commons
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Rayagada District, Odisha
Source: MapsofIndia.com
Village of Tentulipadar, Rayagada District, Odisha
Source: Maps.google.com
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Points of Interest on Trek to Tentulipadar
Source: Maps.google.com
Melakajuba
Road becomes impassable for Jeep Jeep
Tentulipadar
Distance of approx. 3 km.
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NAMES OF INDIVIDUALS
Title Name
Deceased Sikoka Alme
Husband Sikoka Salupu
Anganwadi Worker K. Triveni – Badabamanaguda Anganwadi Centre
Janaki Kurdia – Karnjia Anganwadi Centre
CHC Chief Medical Officer Dr. S. Dalei - Kaylansingpur
CDMO AnantPadhi -Rayagada
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I. INTRODUCTION Between 14 March and 15 March 2015, health rights activists conducted a fact-finding mission in the Rayagada District of Odisha following the death of , Sikoka Alme, who was pregnant,. The preventable deaths are due to poor provision of health services at all levels of the health care system. The purpose of the fact-finding was to ascertain possible explanations for the death. On the evening of 24 February, 2015, Alme began feeling pain in her abdomen. As the road to the closest village has no lighting and is very unstable, the family decided to travel to a health facility the next morning. On 25 February, the villagers put Alme in a dola and carried her for roughly five hours before finally reaching the CHC in Kaylansingpur. At the hospital, the medical officer declared that her condition was beyond the care they could provide. An ambulance was called, but it did not arrive for an hour and a half. Alme died of septic shock in the ambulance on the way to Rayagada. Her foetus was not saved. The fact-finding team consisted of two reporters from the local news who first broke the story, four social activists from the Human Rights Law Network, and a multi-purpose worker from the government. The team visited the woman’s village, the Anganwadi Workers (AWW) charged with her care, the attending physician and the Chief District Medical Officer. The team successfully met with the family, the AWWs and the physician at the CHC and captured the full picture of the events of Alme’s last day.
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II. FACTS
A. Meeting with Villagers
The fact-finding team encountered the same challenges women and families face in accessing basic services and facilities. The drive from Rayagada was nearly 45 km to the CHC in Kaylansingpur, another 4-5 km to the Anganwadi Workers (AWWs) in Melakajuba and another 2-3 km, walking, to the village of Tentulipadar. The path to the village is up a steep mountain on unstable and rocky ground, and the climate is hot and humid. Upon reaching the village, the team saw children and animals playing together. They were also informed that the children were suffering from a measles outbreak, and many of them have scars on their shoulders from the sickness. The team also noticed a pregnant woman lying on the ground in the shade. She was pale, with a bloated face. Alme’s husband, Salupu, sat down with the fact finding team, along with four other village men and some of the older boys. He explains that Alme was his second wife, and that he lost his first wife to tuberculosis after she delivered five children. His marriage to the Alme was brief, having only taken place in July 2014. Shortly following their marriage, Alme became pregnant for the first time.
Salupu explained that Alme had been staying with her mother in law (MIL) for the three months prior to her death, per traditional mandate. On 24 February, 2015, at approximately 6PM, Alme began to experience severe abdominal pain. At this time, Salupu walked 20 minutes walk to his mother’s house. At this time the traditional birth attendant was also called.
Soon after it was decided that Alme would require medical assistance, though unfortunately at that time it was too dark to begin the journey down to the CHC in Kalyansingpur.
House of Mother-in-Law
Village children with measles
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At approximately 6 PM on 25 February 2015, a “dola” was fashioned from a large bamboo stick and a blanket, and Alme sat in this while two males stood on either side and carried her to the CHC. They arrived to the CHC around 11 am. According to Salupu, the workers at the CHC said there was nothing that they could do for his wife. At that point, the doctors started Alme on an IV, and referred her to the District Hospital in Rayagada. The doctors dialed 108, the number for an ambulance dispatch service, but the family was told there was no vehicle that could take her to Rayagada. The family then called 102, another dispatch service for pregnant women, and the 102 workers rudely stated that no vehicle was available either. The CHC finally provided an ambulance to go to Rayagada. Unfortunately, Alme perished in the ambulance en route. After Alme passed away, the ambulance turned around, not bothering to see if a cesarean section would save the foetus. The ambulance that carries the dead is not covered by any scheme, but because Alme came from a primitive tribal group, the CHC said they would provide transportation of her body back to the village free of charge. However, the ambulance only took her body to Melakajuba before they said they would not take it any further. This incited an argument, after sometime which the authorities were called. The authorities told Salupu to take his wife and get her home. Salupu and the other villagers then had to carry Alme’s body the rest of the way up the mountain to be cremated. For the cremation ceremony, Red Cross has provided Rs. 10,000, and an additional Rs. 2,000 has been given by virtue of the Harishandra Yoshina scheme. Alme has since been cremated. No autopsy could be preformed after her death, in part because of a Dongria Kondh belief that once the deceased has been cut open, they will no longer be able to be reincarnated. Sometime after her death, an Assistant District Medical Officer (ADMO) came to visit the village. Salupu informed the ADMO that he was furious at the service that was given to his wife and stated that had an ambulance arrived on time, two precious lives could have been saved. He then demanded that he is owed 2 lakhs from the State for their part in his wife’s death.
B. Meeting with Anganwadi Workers
The Anganwadi Workers (AWWs) for Tentulipadar live in a village called Melakajuba, which is approximately 3 km away. There are two women filling the role of AWWs for this region. These women serve as the first point of contact for all pregnant women in the area. These women then refer the pregnant women on to a Mobile Health Unit (MHU) and an ASHA. Between the three of them, there should be adequate care for all expecting women. This care shall extend to getting the woman to the hospital safely when she is giving birth.
Husband, SikokaSalupu
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In addition to being the first point of contact, these AWWs are meant to make rounds of the villages in their care and to provide pregnant women with Maternal and Child Protection Cards, or “Mamata cards” and nutritional supplements during pregnancy. These supplements are given to the women to prevent anemia and other problems that may arise as a result of malnourished during pregnancy. However, the AWWs stated that they have not made these rounds for awhile, waiting instead for the villagers to approach the center for services. The AWWs stated that there are currently four pregnant women that they are aware of in their area of care.
When asked about the pregnant woman that the fact-finders had seen in Tentulipadar earlier that day, the women quickly added that to their count, stating that there were in fact five pregnant women currently in their region.
The AWWs said that they had provided the supplements and additional care to Alme, though the husband had previously insisted that no such care had been provided. When pressed further about their actions to provide Alme with proper care during her pregnancy, the AWWs merely stated that she was a drunk and acted as though taking care of her was hopeless. When asked about the pregnant woman on the ground, the AWWs said that they were also caring for her, though again, the villagers said that they had not seen anyone come to help her.
An issue of particular concern in this case was the failure to provide a Mamata card to Alme. The AWWs stated that the state does not provide an adequate stock of cards, and thus they have started making photocopies of the one they have. They then charge the villagers Rs. 20 for each one, despite the fact that Mamata cards are to be given free of charge.
Another shocking discovery during the meeting with the AWWs is their general lack of knowledge about the supplements they are providing. The women were asked about the expiry date of the supplements and they responded that they did not know. They then went in search of rations and upon their return it was discovered that there is no expiration date on them. They say that they are not informed of this information when it is distributed to them, only that they must distribute it to the women who are pregnant.
C. Meeting with Dr. Dalei
Pregnant woman in Tentulipadar
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Upon reaching the CHC, everything appeared to be closed at 3:30 PM. After some time, the fact-finding met Dr. Dalei, the doctor on duty the day of the incident. Dr. Dalei agreed to meet and discuss the events of 25 February. Dr. Dalei stated that when Alme arrived at 11:15 AM, she was already in shock, had very low fluid levels and was slightly anemic. He also noted that he had been told she had been experiencing pain since the night before; though due to the poor conditions of the road, the family had delayed bringing her down to receive help. Dr. Dalei then stated that it was evident that the CHC could not adequately treat Alme. Upon this realization, they administered antibiotics and started an IV drip, then referred her to Rayagada District Hospital. At that point, the 108 ambulance dispatcher was called and the doctor had to explain Alme’s condition over the phone for approximately 10 minutes. He explained that she was in shock, and the ambulance team asked if he meant that she had been electrically shocked. After such a long conversation, he finally told the ambulance service that there was a heart situation, and they needed to come immediately. He stated that it took approximately an hour and a half for them to get to the CHC. This is inconsistent with the postmortem report that was filed with the ADMO, which stated that it only took 40 minutes for the ambulance to arrive. Dr. Dalei stated that by the time the ambulance had arrived, it seemed evident that the deceased would not survive the trip to Rayagada DH. When asked about the condition of the foetus and if a cesarean section would have saved it, he stated that he was sure the foetus was dead, because he did not hear a foetal pulse, and did not feel any movement from the belly. Alme perished in the ambulance on the way to Rayagada at approximately 2 PM. The official cause of death was septic shock. Dr. Dalei agreed with the AWW in that the Mamata cards are not adequately provided by the state, and in this particular instance, it was fatal. He had no information on her condition or the details of her pregnancy, because Alme did not have a Mamata card. The postmortem report filed by the doctor does state however, that Alme had received multiple ANCs, though without a Mamata card, there could be no way to verify this, and the family insists that she received no care during her pregnancy. Interestingly, Dr. Dalei was under the impression that this was her third husband and that she had previously given birth to five other children, which was noted in his report. The family stated that this was her first marriage and first child.
FINDINGS
Fatal breakdown in the application of schemes intended to provide pregnant women with safe and free health care during their pregnancy.
Failure to provide antenatal care.
Lack of adequate services to primitive tribal groups living in remote regions.
Lack of oversight and punishment for services not rendered.
Failure to engage services provided through the Mobile Medical Health Initiative during pregnancy, delivery and postpartum care.
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Failure in delivery of key emergency services. (e.g. the ambulance services provided through toll free numbers 102 and 108).
Communication barrier between service providers, including AWWs and village members.
Weak referral mechanisms between service providers (e.g. lack of AWWs providing a Mamata card which would have allowed the doctor to see any critical information about her pregnancy).
Conclusion The fact-finding team was profoundly disturbed by the details surrounding the death of this woman. There is a system in place that is designed to provide adequate care for pregnant women in each of these villages, and yet they are not properly administered. This is a direct violation of multiple international agreements that India is a party to, establishing a right to survive pregnancy and childbirth. The government of India has created multiple schemes to help provide services that guarantee pregnant women that right. In this particular instance, there was a breakdown in the referral mechanisms which prevented antenatal care from being distributed, prevented the doctor from being able to understand his patient’s condition when she arrived, and a failure to get her to a hospital that could treat her in time. All of these resulted in a failure to avert a preventable maternal mortality, a violation of her right to survive pregnancy and child birth. The events of this case also constitute violations of multiple rights provided by the Constitution, including the fundamental right to health, and guaranteed access to medical services regardless of status. Every person in India is guaranteed the right to heath, regardless of his or her sex or status. There are even schemes in place to provide these services to the Scheduled Tribes by way of the AWWs, as the Scheduled Tribes may not otherwise know about such services offered. Because there was a failure of the AWWs to engage the village members, Alme especially, and the State failed to hold its employees accountable, she did not receive the care she needed to remain healthy during her pregnancy. If the assumptions about the AWWs status as Brahmins and the role that may have played in the failure to provide access to live saving medications is also true, then there is an egregious violation of the right to be from discrimination based on caste that is also provided for in the Constitution. There is fear that other women similarly situated may face the same fate if the state does not address these egregious violations. There is no group that is faultless in this case. The State has failed to provide meaningful amenities to this village, providing them with useless solar panels, when a working road would be more appropriate. The lack of oversight and accountability has created an environment rampant with failures that have finally resulted in death. The CHC and ambulance services both failed in their inability to respond quickly with services that could have saved this woman’s life. Finally, but far from least importantly, the AWWs continue to collect incentives for a job they are not doing, which could have prevented the death of this woman. The need for corrective action in this district is blatantly obvious, and needs to be taken immediately.
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III. MAJOR ISSUES OF CONCERN Based on the visits to the village, the AWWs, the CHC and the CMDO, the fact-finding team identified three major issues of concern: (A) systemic failure of access to health care schemes available to women; (B) chronic absenteeism; and (C) lack of water and basic infrastructure.
A. Multi-level Failure of Access to Health Care Schemes
Anganwadi Workers Anganwadi Workers are the first line of care for the pregnant women living in rural villages. They are required to make trips once a year to survey the families and children living in their community.1 The purpose of these trips is to register pregnancies, to provide the pregnant women with supplements, and to help get them antenatal care. The two AWWs servicing Tentulipadar and surrounding areas do not make trips to the villages under their care, they instead wait for the villagers to come to them. This creates concern for many reasons, chief among them being that if the villagers do not have prior knowledge of these services, there is no way they will know to take advantage of them. The AWWs do not have adequate records. AWWs told the fact-finding team that their region had only four pregnant women, but when the team asked about a pregnant woman in Tentulipadar, the AWWs quickly moved the total number to five. This is especially disconcerting, because one could infer that there are many more pregnant women living in this area that are currently unaccounted for living in these villages. If these aforementioned instances are not egregious enough, it was seen that the AWWs are also receiving some small, though illegal, financial compensation from the village women. The AWWs stated that they are not receiving Mamata cards from the government, and so have been making photocopies of the card that they have. The AWWs then sell those cards to the village women for Rs. 20, when the cards are meant to be provided free of charge. For those living in extreme poverty, this could create a barrier to life saving services. There are a number of potential reasons for the failure of the AWWs in this case. One possible issue may be that the instructions for AWWs are not clear for AWWs working in the community.2 Secondly, recently AWWs in Odisha have been demanding that their allowances be increased and that they receive a pension of Rs. 3,000 per month, suggesting that AWWs are currently not appropriately compensated for the work that they do.3 This could easily lead to a lack in provision of services. One final possibility is the status of the AWWs as Brahmins who have been made responsible for scheduled tribes, which may have led to refusal to administer proper care. If this
1 Roles and Responsibilities of AWWs, Ministry of Women and Child Development,
http://wcd.nic.in/Roleandresponsibilities.doc (last visited 19 Mar. 2015). 2 See id. 3 Odisha Anganwadi Workers Demand Regularization of Jobs, More Wages, The Hindu (23 Feb. 2015)
http://www.thehindu.com/news/national/other-states/odisha-anganwadi-workers-demand-regularisation-of-jobs-more-wages/article6923195.ece.
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is true, it would be in direct violation of the guidelines regarding the selection of AWWs, which specifically states“[s]pecial care should be taken in her selection so that the children of Scheduled Castes and other weaker sections of the society are ensured free access to Anganwadi.”4Alme and her village are a Scheduled Tribe, making them a “weaker section of society,” and thus any discrimination by the AWWs would be a violation of numerous rights. CHC The failure of the ambulance to go to Melakajuba and arrive in time to the CHC cost Alme nearly two and a half hours in which she could have been getting treatment at the hospital in Rayagada. The doctor admitted that the CHC could not handle the Alme’s
case and had to refer her to the hospital in Rayagada, almost 50 km away. Alme was in septic shock by the time she arrived at the CHC. The most important step in treating sepsis is aggressive and immediate treatment. Because the family did not bring her when the pain began, and because they wasted hours waiting on an ambulance that the CHC should have had on hand, her condition likely deteriorated rapidly. The CHCs should be in charge of ambulance services in their region, however, the CHC in Kaylansingpur relies on a third party based in Rayagada for ambulatory services. The family stated that both toll free numbers for this third party, 108 and 102, were called when they reached Melakajuba, and were told that no ambulance would come. This then forced the family to carry her to Kalyansingpur, costing valuable time. The doctor at the CHC in Kalyansingpur has stated that he attempted for over 10 minutes, to explain how critical the deceased’s condition was, and an
ambulance still did not arrive for over an hour and a half. If the CHC was in control of ambulatory services, as they should be, these moments would not have been wasted. There is no question that an ambulance could not make the journey to the village of Tentulipadar. However, the fact-finding team was able to drive through the village of Melakajuba with ease, suggesting that an ambulance, could, and should, have done the same. Furthermore, the CHC in Kalyansingpur is easily accessible, the road from there to Rayagada being paved the majority, if not the entire way.
4 Selection of Anganwadi Workers Under ICDS Scheme, Ministry of Women and Child Development, Letter to
Secretaries of all States/UTs dealing with ICDS Scheme (22 Sep. 2011) http://wcd.nic.in/icdsimg/icdsdtd22092011.pdf.
Path to Tentulipadar
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B. Chronic Absenteeism
While not the focus of this investigation, the fact-finding team did note difficulty in accessing medical facilities due to absence of staff . When the fact-finding team arrived at the CHC, they found it vacant and had to search to find the doctor on call. The team could not visit the ADMO in Rayagada because the facility, which is supposed to be open 24 hours a day, seven days a week, was closed. Also of note was the lack of an ASHA worker available for this region. The AWWs said that they were not even sure who the ASHA is, but know that the role has been assigned. This role is a critical link between the villagers and receiving adequate services. That there is a person assigned this role, but that they are missing and the role has not been reassigned is deeply disturbing.
C. Lack of Water and Basic Infrastructure Leading to Village
One disturbing find at the village of Tentulipadar was a lack of access to clean water. The villagers are dependent on the rains, and then take water from a nearby stream. This water is not filtered in any way. Additionally, the path leading to the village in impassable by car. This, as mentioned above, was a leading factor in the death of this woman. Because the path is unstable, and there is no way to light it at night, the villagers could not go down the mountain when the deceased initially started having problems, the night before her death. Walking to the village, the fact-finding team saw a marker stating that the State has spent a considerable amount of money on the road. Interestingly, the fact-finding team was on foot when they saw the sign, because their jeep could not make the journey to that point. What the village did have, was eight solar panels provided by the State. Two of them were attached to street lamps that no longer work because the batteries require distilled water that the villagers would have to pay for. The remaining six were sitting on the roofs of the shanties that the villagers lived in, attached to nothing. Broken solar panels did nothing to save this woman’s life, but a road certainly could have.
IV. BACKGROUND
MIL and son drinking water from stream
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The State of Odisha is located on east coast of India by the Bay of Bengal. It is divided into 30 districts. According to the 2011 Census, the State has a population of 43,228,228 people spread over 155,707 square kilometres.5 Over80.9% of Odias live in rural areas, which is significantly higher than the national average of 68.8%.6 This is significant because it is generally more difficult for people in rural areas, especially women and children, to access necessary health services. As an overall measure of health, total life expectancy in Odisha is 59.5 years (59.6 for females, 59.5 for males), which is substantially lower than the national average of 63.4 years (64.2 for females, 62.6 for males).7
A. Maternal Health in India
Every year, India has more maternal deaths than any other country in the world. With approximately 17.3% of the world’s population,8 India accounts for 19% of the world’s maternal deaths.9The most recent numbers for 2013 show that 56,000 women in India lost their lives due to pregnancy-related causes.10Moreover, India’s rate of progress in reducing these deaths lags behind that of other countries in the region.11 Right now, India is far from reaching its united Nations Millennium Development Goal (MDG) 2015 targets for reducing maternal mortality.12 Thus, thousands of Indian women continue to die needlessly from wholly preventable causes. While India has performed poorly on maternal healthcare, Odisha’s performance has been even worse. Not only is the State responsible for a disproportionate share of India’s maternal deaths,
but its progress in reducing these deaths has also been slower than the national average. As a result, the State lags behind the rest of the country in all the key maternal and child mortality indicators (i.e., maternal mortality, under-five mortality, infant mortality, and neonatal mortality). While a handful of Indian states are on track to hit at least one of their 2015 MDG targets for reducing maternal and child mortality, Odisha lags behind on all fronts.13 5 HMIS Analysis – Odisha Across Districts, Apr ’14 to Sep ’14, National Rural Health Mission (14 Nov. 2014).
Analyzing data from the 2011 Census. 6 Census of India 2011, Orissa Profile, available at http://censusindia.gov.in/2011census/censusinfo
dashboard/stock/profiles/en/IND021_Orissa.pdf; Census of India 2011, India Profile, available at http:// censusindia.gov.in/2011census/censusinfodashboard/stock/profiles/en/IND_India.pdf.
7 High Focus States – Other than NE, National Rural Health Mission (30 Sep. 2014). Analyzing data from the 2011 Census.
8 Based on 2011 figures from Census of India 2011, India Profile (calculating India’s 2011 population at 1.21
crore) and Population Reference Bureau, 2011 World Population Data Sheet, available at http:// www.prb.org/pdf11/2011population-data-sheet_eng.pdf (estimating 2011 world population at 7 crore). The highest estimate of India’s population as a percentage of world population that the authors have seen is 17.9%
from Population Reference Bureau, 2013 World Population Data Sheet, pp. 2–3, available at http://www.prb.org/pdf13/2013-population-data-sheet_eng.pdf.
9 A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health in India, Ministry Of Health and Family Welfare, pg. 4 (Jan. 2013) http://nrhm.gov.in/images/pdf/RMNCH+A/RMNCH+A_Strategy.pdf.
10 Id. 11 See WHO & UNICEF, Countdown to 2015: Maternal, Newborn & Child Survival (2010), pp. 8–9. 12 Id. 13 Government of India, Ministry of Statistics and Programme Implementation, Social Statistics Division,
Millennium Development Goals: India Country Report 2014 [hereinafter Government of India, MDGs: India Country Report 2014], pp. 57–93 & Appendix 6, pp. xxxvi–xliii (Tables 11–17),available at http://mospi.nic.in/Mospi_New/upload/mdg_2014_28jan14.pdf. (analyzing Indian States’ performance).
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Source: MDG: India Country Report 2014
1. Maternal Mortality
Every year India experiences 56,000 maternal deaths, which represents153 deaths per day, or just over six deaths per hour.14A maternal death is defined as the death of a woman while pregnant, during childbirth, or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management.15 The vast majority of maternal deaths are wholly preventable. Maternal health experts have determined that three preventable delays result in maternal death: (1) an initial delay in obtaining quality antenatal care; (2) a delay in reaching care (e.g., poor infrastructure, unavailable or costly transportation, continual referrals); and (3) a delay in receiving quality care at a medical facility (e.g., inadequate staff, facilities, supplies, hygiene). These might be considered the social and governmental causes of death, which inevitably precede the direct medical causes of death discussed next. In India, the most frequent direct medical causes of maternal death are postpartum hemorrhaging (PPH), often from lack of blood at health facilities; post-delivery infection, from lack of access to hygienic institutional delivery; and anaemia and malnourishment. The final two are caused by inadequate nutrition and significantly increase a pregnant woman’s chance of maternal death or
morbidity. Other major medical causes include high blood pressure during pregnancy (eclampsia and pre-eclampsia), unsafe abortion, obstructed labour, and infectious diseases such as malaria.
14 A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health in India, Ministry Of
Health and Family Welfare, pg. 4 (Jan. 2013) http://nrhm.gov.in/images/pdf/RMNCH+A/RMNCH+A_Strategy.pdf.
15 WHO, Maternal Mortality Ratio, http://www.who.int/healthinfo/statistics/indmaternalmortality/en/.
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In measuring maternal deaths, the most important statistical indicator is the Maternal Mortality Ratio (MMR), which estimates the number of maternal deaths per 1 lakh live births. According to WHO and three other UN agencies using 2013 statistics, India’s MMR is 190.16The MDGs require countries to reduce their MMR by 75% between 1990 and 2015.India’s 2015 MMR target is 109, but due to inadequate access to healthcare and poor quality of services, the country is only projected to achieve a MMR of 140 by 2015.India will therefore fail to hit its target by 31 lives per 100,000.17 For a country with more than 2.56 crore live births in 2012 (a number that increases every year), this failure represents at least 7900 additional maternal deaths per year in India.18 Unfortunately, Odisha’s MMR of 235 is 32% higher than the national average. Moreover, under
the MDGs, Odisha should reduce its MMR to 121 by 2015, but the State is only projected to achieve a MMR of 202, thus failing to meet its target by an even larger margin of 81 lives per 100,000.19 With the State’s 8.23 lakhs annual live births, this failure represents approximately an excess of 667 maternal deaths per year in Odisha.20
2. Maternal Health in Odisha According to the District Level Health Survey 2007–2008 (DLHS-3), more women in Odisha received antenatal checkups (ANCs) in government facilities than the national average. In Odisha, 84.0% of pregnant women having had some antenatal care, of which 58.9% used a public health facility.21Similarly, a higher percentage of pregnant women in Odisha (23.2%) had full antenatal care than the national average (18.8%).22 The DLHS-3 National Family Health Survey 2005–2006 (NFHS-3) put the rate of institutional delivery, anaemia, and contraceptive use in Odisha all below the national averages. The rate of institutional delivery in Odisha is 44.1%, also below the national average of 46.9%.23Anaemia is a blood condition caused by malnutrition that puts women at significantly higher risk for maternal death, maternal morbidity, premature delivery, and low birth weight. Odia women are much more likely to be anaemic (61.2%) than the average Indian woman (55.3%).24 As for contraceptive use among reproductive-age women (ages 15–49), only 48.2% of Odia women use any contraceptive method, and only 39.6% are using a modern method of contraception. Furthermore, the unmet need for family planning is 23.1% in Odisha, compared
16 WHO, UNICEF, UNFPA & The World Bank, Trends in Maternal Mortality: 1990–2013, p.32. 17 Government of India, MDGs: India Country Report 2014, p. 8. 18 UNICEF, India Statistics, http://www.unicef.org/infobycountry/india_statistics.html. 19 Government of India, MDGs: India Country Report 2014, Appendix 6, p. xlii (Table 16). 20 See note 9 above & accompanying text for discussion of the 8.23 lakh annual live births figure. 21 Government of India, Ministry of Health & Family Welfare, District Level Household and Facility Survey 2007–
08, April 2010 [hereinafter Government of India, DLHS-3], p. 56 (Table 4.2), available at http:// mohfw.nic.in/WriteReadData/l892s/DLHS%20III.pdf.
22 Id., p. 62 (Table 4.5B). 23 Id., p. 70 (Table 4.8). 24 Government of India, Ministry of Health & Family Welfare, National Family Health Survey 2006–2006,
[hereinafter Government of India, NFHS-3], Vol. I, p. 313 (Table 10.25), available at http://pdf.usaid.gov/ pdf_docs/PNADK385.pdf.
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with 20.5% nationally.25 These low numbers are troubling because to fully exercise their reproductive rights, women must have access to a wide range of contraceptives, information about those options, and the medical care necessary to effectively exercise their choices.
B. Health Facilities& Minimum Healthcare Services
In 2005, the Government of India launched the National Rural Health Mission (NRHM) with the goal of “improv[ing] the availability of access to quality health care by people, especially for those
residing in rural areas, the poor, women and children through equitable, affordable, accountable and effective primary healthcare.”26To this end, the NRHM sought to deliver maternal and child health services through three levels of healthcare facilities (i.e., subcentres, PHCs, and CHCs), in addition to fourth and fifth levels of facilities provided by sub-district hospitals and district hospitals. For each of the levels of facilities established under the NRHM, the NRHM Service Guarantees and Indian Public Health Standards (IPHS) Guidelines establish minimum requirements with regard to healthcare services, staffing, equipment, medicines, hygiene, and quality of care. Since 2005, the NRHM Service Guarantees have established minimum services that Subcentres and CHCs must provide. The IPHS Guidelines, first published in 2006, were updated in 2012 and are now replete with dozens of tables and annexures that clearly set forth and explain all of the services, staff, equipment, and medicines that are “essential” (as opposed to merely “desired”) for
that level of facility. As a general rule, all of the services that are deemed essential for smaller facilities are also essential for larger facilities.
1. Anganwadi Workers Anganwadi Workers (AWWs) serve as a first point of contact between villagers living in remote areas and the health care system. Per the Integrated Child Development Services (ICDS) Scheme Monitoring Manual, AWWs are the focal point of delivery of services under this scheme.27 As a part of their responsibilities, AWWs are required to organize supplementary nutrition feeding for expectant and nursing mothers.28 AWWs are also required to assist the PHC staff in the implementation of antenatal and postnatal checks. Finally, they are required to assist Accredited Social Health Activists (ASHAs) in the delivery of health care services and maintenance of ICDS records. AWWs are responsible for all data capture pertaining to services and beneficiaries. This information must be forwarded to a Child Development Project Officer (CDPO) in Monthly
25 Government of India, DLHS-3, pp. 122 (Table 6.7), 137 (Table 6.16). 26 Government of India, Ministry of Health and Family Welfare, National Rural Health Mission, Framework for
Implementation 2005–2012 [hereinafter “Government of India, NHRM 2005–2012 Framework”], p. 8. 27 Monitoring in ICDS, Ministry of Women and Child Development, pg. 1,
wcd.nic.in/icdsformat/ICDSMONITORINGMANUAL.doc, last visited 20 Mar. 2015. 28 Roles and Responsibilities of AWWs, Ministry of Women and Child Development, pg. 1,
http://wcd.nic.in/Roleandresponsibilities.doc.
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Progress Reports.29 When the AWWs go into the field they must capture data on a variety of child and maternal factors. Specifically they must record population details, births and deaths of children, maternal deaths, number of pregnant and lactating mothers, and number of “at risk”
mothers.30 AWWs must also provide a monthly summary of the supplementary services rendered to pregnant and lactating mothers.31 Finally, when an AWW learns of a pregnancy, she is required to visit that household to collect information on the mother. The AWWs are meant to be based out of an Anganwadi Centre (AWC). The population norm for setting up an AWC in a tribal or difficult area is 300-800 people.32Where there is only a population of 150-300, a Mini AWC should be established. As of September 2014, there are 72,873 sanctioned AWCs in Odisha, though only 71,306 of them are operational.33 As of March 2014, there were 70,269 AWWs providing services in Odisha, and an additional 2,906 vacant positions.34 Those AWWs were providing services to 817,509 mothers throughout the state, at an average of 11.63 mothers per AWW.35Estimates for India show that only 75% of eligible women are registered at AWCs.36 Lack of motivation of AWWs to identify and register the entire eligible population is cited as one of the primary causes of this deficiency. As recently as February 2015, AWWs in Odisha have been protesting stating that their position should be regularized, and they should receive a minimum wage salary of Rs. 15,000 per month.37 Lack of a perceived fair wage could lead to such a lack of motivation to carry out assigned tasks.
2. Mobile Health Unit Mobile Health Units (MHUs) were created with the intention to serve communities in difficult to access areas due to difficult terrain.38 They exist to provide health care to remote villages that are further than 2 km from a public health institution.39The teams are required to consist of an AYUSH doctor, a pharmacist, an ANM, an attendant and a driver. There are presently 192 Mobile Medical Vans in operation in Odisha that are mobile at least 22 days of the month.40 There are two
29 Monitoring in ICDS, Ministry of Women and Child Development, pg. 2. 30 Integrated Child Development Services (ICDS) Scheme, Ministry of Women and Child Development,
http://wcd.nic.in/icds.htm, last visited 20 Mar. 2015; Monitoring in ICDS, Ministry of Women and Child Development, pg. 6, wcd.nic.in/icdsformat/ICDSMONITORINGMANUAL.doc, last visited 20 Mar. 2015.
31 Monitoring in ICDS, Ministry of Women and Child Development, pg. 9. 32 Id. 33 High Focus States – Other than NE, National Rural Health Mission, pg. 4 (30 Sep. 2014). 34 Status Report of the ICDS - AWWs, Ministry of Women and Child Development (Mar. 2014)
http://wcd.nic.in/icds/Qpr0314forwebsite23092014/qpr0314AWWsHelpers.pdf. 35 Status Report of the ICDS – Supplementary Nutrition, Ministry of Women and Child Develoment (Mar. 2014)
http://wcd.nic.in/icds/Qpr0314forwebsite23092014/qpr0314supplementarynutrition.pdf. 36 Integrated Child Development Services (ICDS) Scheme, Ministry of Women and Child Development,
http://wcd.nic.in/icds.htm, last visited 20 Mar. 2015. 37 Odisha anganwadi workers demand regularisation of jobs, more wages, The Hindu (23 Feb. 2015)
http://www.thehindu.com/news/national/other-states/odisha-anganwadi-workers-demand-regularisation-of-jobs-more-wages/article6923195.ece.
38 Mobile Health Unit, Ministry of Health and Family Welfare, pg. 1,http://pipnrhm-mohfw.nic.in/index_files/high_focus_non_ne/Orissa/39.MHU.pdf, last visited 19 Mar. 2015.
39 Id. at pg. 2. 40 Id. at pg. 2.
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additional Mobil Medical Units operative on motorcycle for the most difficult to reach villages. They are required to visit all of the villages in their assigned block in that time period. As of February 2011, there are 17 MHUs operating in Rayagada, throughout the 11 Blocks in the district.41However, there was never a formal step taken to select the villages that belong to each Block, which has led to some infrequency in visits to the villages and duration of delivery of services.42 In Rayagada, each of the 17 MHUs is responsible for catering to an average of 206 villages every month.43 Due to the remoteness and difficulty to reach some of the villages, they are left off of the Block plan.44 Additionally, especially in Rayagada, the number of villages requiring access to an MHU is high, due to the distance of so many villages from other medical providers. This also leads to inadequate coverage by the MHU, because they have too many villages to visit. Because of this, Rayagada has devised a system whereby the MHUs visit 12 fixed points once a month and additional non-fixed points every six months. The villagers then come down to the fixed or non-fixed point and receive care as needed.
3. Subcentre
Sub Health Centres (or “Subcentre”) are an additional primary point of contact for a community with the government healthcare system. Subcentres should have at least one auxiliary nurse midwife (ANM); one Health Worker Male; four beds with mattresses; a fully equipped labour room (including labour table); a fully equipped Newborn Care Corner; various specified equipment, including for sterilization of instruments and equipment; and various supplies and medicines.45 Regarding minimum maternal health services, subcentres should provide pregnancy registration in the first trimester; at least four antenatal checkups (ANCs);minimum laboratory services; identification and prompt referral of high-risk pregnancies; iron folic acid (IFA) tablets and other services to combat anaemia; vaccinations (including TT);malaria prophylaxis in malaria epidemic zones (such as Odisha); counseling and referral for Reproductive Tract and Sexually Transmitted Infections (RTI/STIs); provision of a range of contraceptives; and information about government incentive schemes, such as NMBS, JSY, and JSSK. Minimum child health services should include essential newborn care; immunizations; Vitamin A prophylaxis; and prevention and treatment of malnutrition, anaemia, infections, diarrhoea, and other common childhood health problems. In addition to the services above, subcentres should implement national health programmes (e.g., National Vector Borne Disease Control Program, Universal Immunization Programme, Reproductive and Child Health Programme) and conduct a monthly Village Health and Nutrition Day (VHND).Patient records should be kept and maintained. Finally, A Citizen’s Charter should
41 Impact Assessment of MHUs in Orissa, Health & Family Welfare Department, pg. 25,
http://www.nrhmorissa.gov.in/writereaddata/Upload/Documents/Impact%20Assesment%20of%20of%20MHUs%20in%20Odisha.pdf, last visited 24 Mar. 2015.
42 Id. at pg. 46. 43 Id. at pg. 48. Averaging data from table with information from three Blocks. 44 Id. at 49. 45 Government of India, Ministry of Health & Family Welfare, Directorate General of Health Services, Indian Public
Health Standards (IPHS) Guidelines for Sub-Centres (Revised 2012).
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be posted that explains to patients what services are available, the quality of care to which they are entitled, how to raise complaints, and the process by which complaints will be addressed.46 Unfortunately, more than half (53.4%) of subcentres in Odisha operate without living quarters for the ANM, and of the subcentres with ANM quarters, 24.6% of ANMs are not living there. Moreover, many of the functioning subcentres lack regular access to water (34.0%) or electricity (39.7%).47 As applied to this case, there is currently no subcentre active in the territory near Tentulipadar. It is believed that the population of the region in which Tentulipadar is located is populated enough to warrant the establishment of a subcentre in Melakajuba. The addition of such a centre would greatly benefit the entire region, and would remove some of the pressures from the already inefficient AWWs.
i. ASHA Worker Accredited Social Health Activists (ASHAs) are a critical part of the National Rural Health Mission (NRHM) as they act as an interface between the villagers and the public health system.48 They also serve as a first point of contact for women and children who have a difficult time reaching major health centres. ASHAs must have knowledge and a kit to deliver first-contact care, and they are expected to be a “fountain head” of community participation. They provide minimum curative care, and make timely referrals as required. Finally, ASHAs facilitate community access to antenatal chec-ups, postnatal check-ups, supplementary nutrition and other services provided by the government. As of September 2014, there are 43,427 ASHAs in operation in Odisha.49 The number of those that are operating in the field with drug kits is approximately 42,775. Information from 2011 shows that they were operational in 52,349 villages.50
4. Community Health Centre (CHC) At the third level of care, a Community Health Centre (CHC) is the referral point for four PHCs. CHCs should have at least 30 beds and provide specialist care in the areas of obstetrics, gynaecology, pediatrics, general surgery, dental, and AYUSH medicine. The minimum staff is 46 persons, including 1 Block MO that oversees 5 specialists (i.e., general surgeon, physician, OBGYN, paediatrician, and anaesthetist); 1 dental surgeon, 2 general duty MBBS doctors, 1 AYUSHdoctor, 10 staff nurses, 2 pharmacists, 2 laboratory technicians, 1 radiographer, 1 vaccine assistant, and many other staff. In addition to all PHC infrastructure and equipment, a CHC should
46 Id., pp. 8–14, 18, 26–31, 60 (Annexure 11); Government of India, NHRM 2005–2012 Framework, Annexure II
(“Service Guarantees for Health Care”). 47 Government of India, Ministry of Health & Family Welfare, Statistics Division, Rural Health Statistics in India
2012 (May 2013) [hereinafter Government of India, Rural Health Statistics 2012], pp. 74–75, available at http://mohfw.nic.in/WriteReadData/l892s/492794502RHS%202012.pdf.
48 About Accredited Social Health Activist (AHSA), Ministry of Health & Family Welfare (2013) http://nrhm.gov.in/communitisation/asha/about-asha.html.
49 High Focus States – Other than NE, National Rural Health Mission, pg. 3 (30 Sep. 2014). 50 Evaluation Study fo National Rural Health Mission in 7 States, Programme Evaluation Organization, pg. 19
(2011) http://nrhm.gov.in/images/pdf/publication/Evaluation_study_of_NHM_in_7_States.pdf.
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have a Newborn Care Stabilization Unit, an operation theatre (OT), a blood storage facility, sterilization equipment, and emergency lighting.51 CHCs should provide all PHC healthcare services plus24/7 basic emergency surgery, emergency a large range of emergency obstetric care (including Caesarean sections), a Newborn Stabilisation Unit, safe abortion, basic ophthalmologic care, dental services (including surgery), mental healthcare, cancer screening (including PAP smears), and blood transfusions. In addition to all PHC diagnostic services, CHCs should also provide x-ray, dental x-ray, and ECG. As at the PHC level, quality of care is ensured by regular trainings and having staff follow various Standard Operating Procedures and Standard Treatment Protocols. Accountability continues to be addressed byrequiring the CHC to post the Charter of Patients’ Rights to have a functioning RKS.52 Unfortunately,only 9.5% of Odisha’s 377 CHCs have filled the four specialist positions (i.e., surgery, general medicine, OBGYN, and paediatrics), and only 15.9% have the minimum 30 beds. While all CHCs report having functional laboratories and labour rooms, 21.8% of CHCs have no functional OT, and the vast majority (88.9%) lack an x-ray machine. For newborn care, 45.9% of CHCs lack a New Born Care Corner, and 99.0% lack the required Newborn Care Stabilization Unit. Again, not a single CHC in Odisha is functioning as per IPHS norms.53
i. Ambulatory Services Per the Guidelines for Primary Health Centres, it is preferable for primary health centres (PHCs) to have their own transport capabilities.54However, in the absence of funding or other barriers to access, transport facilities can be outsourced to a third party provider. In Odisha, there is substantial reliance on third party providers of ambulatory services. The Orissa Emergency Medical Ambulance Service (OEMAS) is required to provide transportation services within 20 minutes in urban areas, and 35 minutes in the case of rural areas. It is required that there be one ambulance per 1 lakh population.55 Between all of the Odisha’s Primary Health Centres, Community Health Centres, Sub-District Hospitals and District Hospitals, there are only 351 facilities with their own ambulances.56 There are nearly twice as many ambulances available through party providers in the state. There are currently 305 102-Type ambulances, and 420 108-Type ambulances in operation.57 102-Type ambulances cater to the needs of pregnant women and children.58 These ambulances are meant to
51 Government of India, Ministry of Health & Family Welfare, Directorate General of Health Services, Indian Public
Health Standards (IPHS) Guidelines for Community Health Centres (Revised 2012). 52 Id., pp. 2, 4–8, 18; Government of India, NHRM 2005–2012 Framework, Annexure II (“Service Guarantees”). 53 Government of India, Rural Health Statistics 2012, pp. 79–80. 54 Guidelines for Primary Health Centres, Directorate General of Health Services, Ministry of Health & Family
Welfare, pg. 17 (2012) http://health.bih.nic.in/Docs/Guidelines/Guidelines-PHC-2012.pdf. 55 Outcome Budget, Department of Health & Family Welfare, pg. 40, sect. 3.5
http://www.odisha.gov.in/finance/Budgets/Outcome_Budget_2012_13/H_FW_2012_13.pdf. 56 High Focus States – Other than NE, National Rural Health Mission, pg. 10 (30 Sep. 2014). 57 Id. 58 EMRI/Patient Transport Service, Ministry of Health & Family Welfare (2013) http://nrhm.gov.in/nrhm-
components/health-systems-strengthening/emri-patient-transport-service.html.
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transfer from home to facility, inter-facility transfer, and drop back. 108-Type ambulances are for emergency transport, designed to attend to patients in critical condition.
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V. GUARANTEES AND GUIDELINES
A. International Conventions
The right to survive pregnancy and childbirth is a basic human right. Under international law, India has a duty to ensure that women and infants do not experience death or morbidity from wholly preventable causes.59This duty arises from multiple international conventions to which India is a party, and which establish the right to health, the right to reproductive autonomy, and the right to be free from degrading treatment. Relevant conventions include the International Covenant on Civil and Political Rights (ICCPR),the International Covenant on Economic Social and Cultural Rights (ICESCR), the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), and the Convention on the Rights of the Child (CRC).60
B. Constitutional Guarantees
Article 21 of the Constitution of India guarantees the right to life and personal liberty. The Hon’ble
Supreme Court has interpreted Article 21 to include numerous fundamental rights already protected under international law, including a fundamental right to health (both physical and mental)61; the right to live with dignity62; and the right to be free from torture and cruel, inhuman, or degrading treatment.63 Articles 14, 15, and 38 of the Constitution of India provide additional guarantees. Article 14 guarantees equality before the law, and the Hon’ble Supreme Court has described gender equality as one of the “most precious Fundamental Rights guaranteed by the Constitution of India.”64 Article 15 prohibits discrimination on the grounds of religion, race, caste, sex or place of birth. While the burdens of pregnancy and childbirth are inequitably borne by women, the ability to reproduce should not increase women’s chances of death, disability, or illness. Finally, Article 38 guarantees access to medical services regardless of status.
C. Key Cases
59 See generally Center for Reproductive Rights, Maternal Mortality in India: Using International and
Constitutional Law to Promote Accountability and Change, 2008, pp. 9, 27–38, available at http:// reproductiverights.org/sites/crr.civicactions.net/files/documents/MM_report_FINAL.pdf; International Initiative on Maternal Mortality and Human Rights, No More Needless Deaths: A call to action on human rights and maternal mortality (2009), available at http://righttomaternalhealth.org/resource/no-more-needless-deaths.
60 See especially ICCPR Art. 6 (right to life); ICESCR Art. 12 & CEDAW Art. 12 (right to the highest attainable standard of health, including the right to health services that are accessible and of good quality); ICESCR Art. 15 (right to enjoy the benefits of scientific progress, including in obstetrics and paediatrics).
61 In Consumer Education and Research Centre v. Union of India, [1995 SCC (3) 43]. 62 Francis Coralie Mullin v. Union Territory of Delhi &Ors., [1981 SCR (2) 6]. 63 Id. 64 Apparel Export Promotion Council v. Chopra, [AIR 1999 SC 625].
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In Francis Coralie Mullin v. Union Territory of Delhi &Ors., [1981 SCR (2) 6], the Supreme Court held that the right to live with dignity and protection against torture and cruel, inhuman or degrading treatment are implicit in Article 21 of the Indian Constitution. In Pt. Parmanand Katara v. Union of India &Ors.,[1989 SCR (3) 997], the Supreme Court held that Article 21 of the Constitution casts the obligation on the state to preserve life. In Consumer Education and Research Centre v. Union of India, [1995 SCC (3) 43], the Supreme Court held that Article 21 of the Constitution of India includes a fundamental right to health, and that this right is a “most imperative constitutional goal.” In Paschim Banga KhetMazdoor Samity v. State of West Bengal, [1996 SCC (4) 37], the Supreme Court affirmed that providing “adequate medical facilities for the people is an essential part” of
the government’s obligation to “safeguard the right to life of every person.” In PUCL v. Union of India,[1996 SCC], the Supreme Court held that all pregnant women should be paid Rs. 500 under NMBS at 8–12 weeks prior to delivery for their first two births, irrespective of the place of delivery and age. In Laxmi Mandal v. Deen Dayal Harinagar Hospital &Ors., [W.P. (C) 8853/2008], the Delhi High Court heldthat an inalienable component of the right to life is “the right to health, which would include the right to access government health facilities and receive a minimum standard of care. In particular this would include the enforcement of the reproductive rights of the mother.” In Sandesh Bansal vs. Union of India &Ors.,[W.P. (C) 9061/2008], the Indore High Court concluded that timely health care is of the essence for pregnant women to protect their fundamental rights to health and life as guaranteed under Article 21 of the Constitution of India.
D. National Health Mission (Formerly, NRHM)
In 2013, the Centre Government launched the National Health Mission (NHM) as an umbrella program with two main prongs: the National Rural Health Mission (NRHM), first launched in 2005, and the National Urban Health Mission (NUHM).65 The purpose of these schemes is to improve health infrastructure and health outcomes in India’s rural and urban areas. A major focus of the NRHM is improving maternal and infant health, which is revealed in the NRHM Service Guarantees. In addition to the Service Guarantees, the NRHM houses numerous individual benefit schemes with a more targeted focus. Individual schemes that focus on improving maternal and infant health are discussed below. They include the National Maternity Benefits Scheme (NMBS), Janani SuraskhaYojana (JSY), Janani Shishu Surakasha Karyakram (JSSK).
65 C. Maya, Draft guidelines focus on quality health care, The Hindu (19 Dec. 2013), available at
http://www.thehindu.com/todays-paper/tp-national/tp-kerala/draft-guidelines-focus-on-quality-health-care/ article5476728.ece.
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1. Janani SuraskhaYojana (JSY) Since its implementation in 2005, the JSY scheme has aimed to reduce maternal and neonatal mortality by providing women with conditional cash assistance for registering their pregnancies and choosing institutional deliveryAll women are eligible for JSY benefits, regardless of their age or number of children. As a LPS, Odisha must provide JSY benefits of Rs. 1400 for institutional deliveries in rural areas, Rs. 1000 in urban areas, Rs. 1500 for Caesarean section patients, and Rs. 500 (from NMBS funds) for home deliveries conducted by skilled birth attendants. Although women who choose to deliver in private health facilities must bear the costs themselves, they are still eligible to receive JSY benefits for having had an institutional delivery. To receive JSY benefits, women in Odisha must present a JSY Card and a referral slip from either an Accredited Social Health Activist (ASHA), Auxiliary Nurse Midwife (ANM), or Medical Officer (MO).
JSY BENEFIT FOR INSTITUTIONAL DELIVERIES (in Rupees)
Rural Urban Category of States
Assistance to mother
Assistance to ASHA
Total Assistance Mother
Assistance to ASHA
Total
LPS* 1400 600 2000 1000 400 1400 HPS** 700 600 1300 600 400 1000
* Low Performing States (LPS) include Assam, Bihar, Chhattisgarh, Jammu & Kashmir, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh, and Uttaranchal.
** High Performing States (HPS) include all states that are not LPS.
Source: Indian Ministry of Health & Family Welfare, Directive No. Z.14018/1/2012-JSY, 13 May 2013.
According to the 2011–2012 Annual Health Survey, 67.7% of new mothers in Odisha receive financial assistance for delivery under the JSY scheme, with a significant divide between rural women (70.1%) and urban women (53.2%). These numbers increase for women who undergo institutional deliveries (84.7%) and institutional deliveries in government health facilities only (95.0%), with similar gaps between women in rural and urban areas.66
2. Janani Shishu Surakasha Karyakram (JSSK) Through the NRHM, the government also coordinates the JSSK scheme, which it launched in June 2011 as a means of eliminating out-of-pocket expenses incurred by pregnant women and sick
66 Government of India, Office of the Registrar General & Census Commissioner, Vital Statistics Division, Annual
Health Survey 2011–12 Fact Sheet: Odisha [hereinafter Government of India, Annual Health Survey 2011–12 Fact Sheet: Odisha], p. 83.
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newborns, which are “without doubt, a major barrier” for pregnant women and children, many of whom “die on account of poor access to health facilities.”Therefore, the JSSK scheme provides that pregnant women seeking institutional delivery and sick newborns until 30 days after birth are entitled to absolutely free care in all government health facilities.67 JSSK services are available to all women who deliver in government health facilities, regardless of age, number of children, or economic status. These free JSSK services include delivery (including Caesarean section), medicines, consumables, essential diagnostics, blood transfusions, nutritious meals (up to 3 days for normal delivery and 7 days for Caesarean section), free transportation to and from the facility (and between facilities in cases of referral), and exemption form all user charges.68The JSSK scheme provides essentially the same free services to sick newborns that are available to pregnant women.69
E. Mamata Scheme (Odisha Specific)
The State of Odisha introduced the Mamata Scheme in September 2011.70 Mamata is a conditional electronic cash transfer maternity benefit scheme aimed at curbing the high rates of maternal and infant mortality by promoting positive child and maternal health and nutrition practices.
Mamata Installments & Conditions
First Installment (Rs.1500) – Given after completion of second trimester of pregnancy upon fulfillment of all five conditions below.
1. Pregnancy registered within six months at the AWC or Mini AWC (requires completion of 2-page English-language registration form).
2. Received at least one antenatal check-up (out of optimal 3). 3. Received IFA tablets. 4. Received at least one TT vaccination (out of optimal 2). 5. Received at least one counseling session at the AWC/Village Health and Nutrition Day
(VHND).* Second Instalment (Rs.1500) – Given after completion of three months after delivery upon fulfillment of all six conditions below.
1. Child birth is registered. 2. Child has received BCG vaccination. 3. Child has received Polio 1 and DPT-1 vaccination. 4. Child has received Polio 2 and DPT-2 vaccination.
67 Government of India, Minstry of Health & Family Welfare, Maternal Health Division, Guidelines for Janani-
Shishu Suraksha Karyakram (2011), Preface, p. 2. 68 Id., p. 4. 69 Id., p. 5. 70 Odisha Department of Women & Child Development, Directive From Commissioner-Cum-Secretary Arti Ahuja
to All Collectors, “New Conditional Cash Transfer Scheme of State Government for Mothers – Mamata” (11
Aug. 2011), http://www.wcdorissa.gov.in/download/MamataGuideline_English.pdf.
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5. Child has been weighed at least two times after birth (out of optimal 4 times including weighing at birth).
6. After delivery, mother has attended at least two IYCF counseling sessions at the AWC, VHND, or Home Visit (out of optimal 3 times).*
Third Instalment (Rs. 1000) – Given after the infant completes six months of age on fulfilment of all five conditions mentioned below.
1. Child has been exclusively breastfed for first six months.** 2. Child has been introduced to complementary foods on completion of six months.** 3. Child has received Polio 3 and DPT-3 vaccination. 4. Child has been weighed at least two times between age 3 and 6 months (out of optimal
3). 5. Mother has attended at least two IYCF counseling sessions between 3 and 6 months of
lactation at the AWC, VHND, or Home Visit (out of optimal 3).*
Fourth Instalment (Rs.1000) – Given after the infant completes nine months of age on fulfilment of all four conditions below.
1. Measles vaccine has been given before the child is one year old. 2. Vitamin A first dose has been given before the child is one year old. 3. Age specific appropriate complementary feeding has started and is continuing.** 4. Child is weighed at least two times between six months to nine months of age.
Note: Verification of a condition without an asterisk is done by MCP Card. * Verification through the Mamata Scheme Register at the AWC or Mini-AWC. ** Verification by the beneficiary.
Source: Odisha Department of Women & Child Development, Directive From Commissioner-Cum-Secretary Arti Ahuja to All Collectors,“New Conditional Cash Transfer Scheme of State Government for Mothers – Mamata,” 11 August 2011.
The targeted beneficiaries are all pregnant and lactating women ages 19 and older, who do not have paid maternity benefits through their or their husband’s employer, for their first two
livebirths. Under the Scheme, eligible women may receive a total incentive of Rs. 5000 in four instalments, subject to the fulfilment of specific conditions. Each instalment must be cleared before the next instalment may be claimed. To participate in the scheme, a pregnant woman must register with the Anganwadi Centre (AWC) to which she belongs within six months of conception. Upon registration, the Anganwadi Worker (AWW) issues the pregnant woman a Mother and Child Protection (MCP) Card, which will serve as a means of recording the beneficiary’s fulfillment with the conditions of payment. Because Mamata payments are delivered by e-transfer, women are required to open a bank account into which the funds are to be deposited. Administratively, AWWs are charged with submitting to their supervisors the names of beneficiaries entitled to Mamata payments.
