India’s decades-old family planning programme has seen many ups and downs. While it is seen as being ahead of similar programmes in several developing countries, maternal mortality continues to be an area of concern. The US based global organisation working on reproductive health, EngenderHealth, focuses on a rights-based healthcare programme that puts women’s needs, values and right to choose first. “When you provide women access, they have hope. Where there’s hope, there are dreams,” asserted Ulla Muller, president and CEO, EngenderHealth, in an interview with Asha Ramachandran.
With 11 April observed as National Safe Motherhood Day, Muller spoke about the need to ensure women get access to a choice of birth control methods in order to decrease India’s maternal death toll. EngenderHealth has been working for almost 20 years in various projects in Bihar, Rajasthan and Gujarat to improve maternal health services. The non-government organisation targets young people through innovative strategies, as they receive no sexual or reproductive health education.
The inspirational part, said Muller, is the extent that women will go to get their right to hope that contraceptives bring. “Women support each other, help each other, are each other’s backs. This is forgotten in developed countries,” she mused. Excerpts:
Q: In your opinion, is India’s family planning programme headed in the right direction?
A: India is more advanced than many countries such as Bangladesh and Philippines. India is on the right track. It has demonstrated this. There are a lot of lessons to be learnt from India. There is a huge opportunity here. We want to make sure that we continue to make promises to women. In EngenderHealth we will keep those promises. By 2020 we will reach 18 million women globally. We will see what the strategy in India is.
Q: How is EngenderHealth’s work different from other international NGOs working with India’s family planning programme?
A: EngenderHealth works with women and girls. We work with state governments. We first approach the Centre and then the states. Our experience in India has been that both the Centre and the states are very open. Government is keen to open (its programme) on method mix. India is advanced, and understandably, on contraceptive methods.
Q: India is planning to introduce injectables in its basket of contraceptives, which is strongly objected to by health activists. Your views.
A: The more choice offered to women, the better. The product (injectables) is very safe. It’s very well-established. It is the safest form of medical intervention. There’s a lot of speculation. But it’s power dynamics. Moreover, it’s very risky to remove IUDs (intrauterine devices). Very often the decision (to remove IUDs) is due to what the man thinks.
Q: What steps have been taken to empower women to access health services, particularly family planning? Also, what is your opinion on abortion?
A: The biggest driver behind maternal mortality is unsafe abortion. If a woman wants it (abortion), she will find it. It is better to give her that choice and also the full range of contraception methods. Maybe in India, the challenge is that women are not decision-makers. The question is how to change gender dynamics and women’s right to control. Because of power and gender dynamics, women don’t make decisions.
In EngenderedHealth we use the counseling model. We need to change women’s decision-making right. It doesn’t matter if a woman wants more children, that’s her choice, though not many women would want more children. We must have a conversation with the women. Moreover, we must train providers.
At the community level, we engage with men also but not to make decisions for women. We work with the community ~ have them in and decide what and how to do it, and then monitor it. Above all, we need to do it “with” women. Women need us to open the door and then they will do it themselves.
Q: Could you elaborate upon the training programme?
A: In the last two years, we have trained 1,100 providers ~ given them on-the-job training. We not only train but we also do necessary follow-up. It is a continuous cycle. We have an obligation as an organisation to go back and look at the tools that we developed. Inclusion and participation are important.
At the same time, we ensure that there is no provider bias, where the provider decides ~ that shouldn’t happen. It is a big challenge as the providers are from the same community. We have to recognise change-makers. We also have to ensure that providers do not give advice out of malice. We need to build on good intentions and allow women to make the choice. It is critical that we start from a positive platform.
We are more than eager to train. We are doing it in Bihar, Uttar Pradesh, Rajasthan and Uttar Pradesh. We go in, set up training centres ~ district training centres and PHCs ~ and hand them over to government or the ministry. An exit strategy is very important. The EngenderHealth model is based on strengthening the government system. We don’t build infrastructure. Government should be able to take over. It works only if the other half takes the right decisions. Therefore, there’s a strong focus on women.
Q: Sensitising men has been seen as an important component of the success of health services, especially reproductive. What is your opinion on this?
A: Wouldn’t it be amazing if we could count fertility rate for men? We need to leverage more on vasectomy. But where men father children, why shouldn’t they support them? It is inherently wrong putting responsibility on women. If men understood this well, it will make an impact. It doesn’t mean we don’t work with men. But it’s important that men understand. Accountability and responsibility towards children by men, even if outside marriage, is important.
Q: How will the US Global Gag Rule impact Engender Health’s work in India? Has it also affected women’s access to medical aid?
A: The US is not the biggest donor ~ significant but not the biggest. Europe has stepped up its funding. So have private funding bodies, including She Decides, LAD (large anonymous donors) and Gates Foundation. She Decides would give an additional amount of around 200 million dollars (globally) while LADs would give an additional 50 million dollars.
We see a global trend on pushing back what’s happening in the US. We are thus seeing a way out to balance the US cut-backs. We are even supported by African ministers ~ there is no money but political support. That’s an important and strong message.
Q: What then is your vision for the programme, especially in India?
A: They will be challenging times. We will not be silenced. We are in a position where constitutionally women have a right and will claim their right to it. Women’s right is a constant process and if they don’t defend it, they will lose it.
If women are cut out of reproductive health, they are cut off from right to social and health benefits. Girls in school, when they get pregnant, are denied education and also other rights ~ because they were denied right to contraceptives in the first place.
It is difficult for us to get into schools. Teachers are uncomfortable to talk about reproductive rights. They need to allow in professionals, who know how to train. One is often in denial mode about children having sex, as it’s natural.