Mapping Community Needs

October 28, 2008 • Delhi Dynamic, Theme • Views: 1009

by Emma Sokoloff-Rubin:

Twelve women leaned over a map on the floor of a crumbling room and spoke to one another, their conversation punctuated by children’s yells in the streets and the whispers of men outside the windows.

The map was marked with squares to represent houses in the community, but this was no geography lesson. Decorating the map were bindis, indicating how many vaccinations each child in the community had received.

Women in Agra chart child vaccinations in their community. (Walton/TYG)

When women in this slum in the city of Agra began going door to door in 2006 to monitor their neighbors’ health, many residents shut the door in their faces. Now, the women share information on families in need and plan widely attended public presentations and vaccination clinics.

The women in Agra are part of the new face of public health in India, where government ministries and NGOs have begun to work together to tackle gender and healthcare inequalities. Throughout Delhi and surrounding cities, NGOs are facilitating the delivery of free health services from the government to the city’s most vulnerable: migrants, slum dwellers, and women.

The partnerships take varied forms. Bhagidari, a government program, is designed to improve social services through NGOs like New Opportunities for Women (NOW), which runs Gender Resource Centers under the direction and financial support of the government. The Urban Health Resources Center (UHRC) works to give people access to government services that already exist, and implements its own programs independently in the hopes that the government will replicate them on a larger scale. By encouraging women to care for themselves and to improve the health of their communities, these partnerships are changing the face of urban healthcare in Delhi. In the process, they are challenging traditional gender roles that keep women in the home.

Removing a Burden
Seventy-year-old Sheila Dikshit, chief minister of Delhi, has a history of fighting for women. She served on the United Nations Commission on the Status of Women in the 1980s, and in 1990 spent 23 days in jail for leading a protest against the government’s treatment of women. Today, this experience is reflected in her sharp analysis of women’s rights, along with her commitment to devising programs specifically for women.

Chief Minister Dikshit believes that in India, “a girl child is considered a burden built into the family—she is seen as an expense.” Families struggling to survive put tremendous energy into filling their daughters’ dowries. Moreover, girls who must help with housework and are not allowed to work or attend school cannot bring in the same income as their brothers. Indeed, families often abort in order to avoid having daughters altogether. According to Dikshit, “constitutional laws [in India] act very favorably towards women—but what happens on the ground is a different story.”

To mitigate the high number of abortions, the government passed legislation in 1996 prohibiting doctors from revealing the gender of unborn fetuses. But this law has been difficult to enforce, and the cultural values and economic realities that stand behind female feticide are hard to change.

Empowerment at a Distance
The government’s latest approach to improving the status of women’s health and education, the ladli program, illustrates a delivery problem that plagues most government programs: resources do not necessarily reach the people who need them most. ladli, first introduced in May 2008, has tried to challenge the notion that women are an expense by investing in each female child whose family makes under 100,000 rupees ($2,332) a year. The government makes a conditional cash transfer for each year that a girl remains in school, so that by age 18, she should have 100,000 rupees in a bank account made out in her name.

But the girls who most need the money often slip through the program’s cracks. Registration takes place in schools and public hospitals, excluding slum dwellers and recent migrants who do not make it to these places or cannot register without an official address. Even families who know about the program often choose to keep girls out of school so they can work.

The program is young, so it remains to be seen whether a bank account can change the way parents view the prospect of having daughters, and whether the girls registering for the program will control how their money is used once they reach age 18.

Beyond the Census
The UHRC has tried to address the gap between government services and the people who need them. The UHRC runs the women’s health group in Agra, which simultaneously takes on healthcare and women’s empowerment by facilitating conversations between women and their communities, NGO workers and government officials, and even government officials and the women themselves. According to the UHRC director, Dr. Siddharth Agarwal, the organization’s primary focus is urban health. But as program directors watched women become community leaders through these health programs, strengthening women’s rights became one of the UHRC’s goals.

Since setting up public health cooperatives in 100 slums in Agra, the UHRC has begun building groups in Delhi. But the population density of India’s capital has made it difficult even for UHRC to reach the people most in need of health services. According to Agarwal, for Delhi, the success enjoyed by the group in Agra “is the dream far ahead.” Gaps in Delhi’s healthcare system are not due to a lack of facilities: Delhi has more hospitals than Agra and other cities, and the government provides an increasing number of medical services free of charge. But many people do not make use of these services because they lack transportation to local hospitals, or do not know what services are available for free.

In addition, with many families moving from rural areas and settling in slums and on street corners, the population of Delhi is constantly shifting, often in ways undetectable by the city’s official census. According to a UHRC report commissioned by the city government, the slums of Delhi are growing at nearly four times the rate of the settled urban population, forcing the UHRC to work with a rapidly changing community with myriad healthcare needs.

Bridging the Gap
When local clinics fail, women suffer the most. Even in the communities of Agra, where women from the UHRC cooperative monitor the health of each pregnant woman, half of births occur at home without trained professionals, leading to high infant and maternal mortality rates. In addition to taking on the dangers associated with pregnancy and childbirth, women are usually responsible for keeping children alive and healthy.

“Women care more about their husbands or their children,” argued Rashni Singh, director of Bhagidari, “and neglect themselves. Women don’t demand help for themselves.”

The UHRC public health groups give women an official job in the community: to make healthcare demands. In the process of advocating for others, they take on new roles for themselves. They persuade their husbands to let them leave their homes to meet in spaces like the room in Agra, where 12 women collaborated despite crowds of men peering in through the windows. When women bring vaccinations and information to houses throughout the community, they enter on their own terms.

A Place Where People Will Listen
Confronting gender inequality in Delhi goes beyond addressing medical matters. At the Gender Resource Center in Hari Nagar, Delhi, five rooms are crowded into one. At the front, girls gathered around PCs, opening Microsoft Word documents or designing bright patterns on the screen. On the other side of a makeshift divider, a class in craftsmanship, a group of embroiderers, and girls braiding each others’ hair shared the space. At the back, a young woman—once one of the girls who came here after her parents prohibited her from attending school—organized information on everything from local employment opportunities to birth control and domestic violence.

The Center, run by NOW, has been a designated “Gender Resource Center” since this NGO joined forces with the government in 2006. It is one of 45 Gender Resource Centers created through Bhagidari, each run by a different NGO.

Seema Singh, who started NOW with her sister Bharti Mehrotra, knows that women come to her center for more than vocational courses and vaccination clinics. Victims of domestic violence, for example, could go directly to a police center designed especially to help them file official complaints. But many women seek counseling, not lawyers, and “they prefer to go where people listen.” Singh also helps women fill out forms to receive government services and trains local residents to go door-to-door so that community members who might not otherwise come to the Center do not need to walk there alone.

Reflecting on her decision to partner with the government, Singh said that the government offers consistent financial support that NGOs rarely enjoy. And NGOs have built credibility and infrastructure on a community level that the government has yet to establish. “Being here for 18 years makes it possible to do what we do,” she said without hesitation, describing the years it took simply to convince husbands to let their wives visit the center, or to raise issues of sex and birth control in a religious neighborhood. The medically equipped minivan that brings doctors to remote parts of the neighborhood may run on government funds, but people approach it because the van is linked to a community organization that they trust.

Sitting with the Community
When asked why the government of Delhi has decided to partner with NGOs, Minister Dikshit responded that the government lacks NGOs’ access and close relationship to the communities. “Government officials don’t like to go and sit with the community,” she explained. With Bhagadiri, they do not have to: the Gender Resource Centers bridge the gap between public health services and ordinary citizens without forcing government officials to confront their distance from their constituents.

As a result, the government devises new programs without facing the frustrations and challenges of making sure that people actually receive those programs’ services. While government-NGO partnerships improve access to services in the short term, they also allow officials to avoid what many NGO leaders consider the government’s primary responsibility to its citizens: providing services and making sure those services reach the people who need them.

For now, NGOs like NOW and the UHRC encourage ordinary people to tackle healthcare crises and gender stereotypes within their own communities. The vaccination clinics run by women in Agra do lead to higher vaccination rates among children—one of the initial goals of the program—but the founders are equally proud of the program’s contribution to the community engagement and autonomy of the women who lead the public health clinics and bring their children for free vaccines.

“Any process that affects human beings should not have a narrow goal,” UHRC director Agarwal insisted. “A human being can’t compartmentalize his life into health and sanitation.”

Pictures of Progress
The future of the public health group in Agra is uncertain. UHRC leaders hope the government will replicate their models on a larger scale, but even the Gender Resource Centers, products of official NGO-government partnerships, rely heavily on the dedication and connections of individual NGO directors.

On a local level, the Agra group’s efforts have already begun to pay off. Beaming, the women announced that not a single baby died the year after their program started, compared to six the year before. But otherwise, their success is not easily quantifiable. Nor is the extent to which the public health cooperative has changed the community.

When evaluating the effects of the program, one UHRC representative observed, “We can’t say ‘we posted five new doctors.’ That would be easy.” What is harder to measure—and perhaps also harder to replicate— is the effect of the picture books that show images of women in colorful saris weighing and vaccinating babies, resting during pregnancy, and visiting a local health center. Half of the women who carry these picture books to local homes, who sing songs about vaccinations and family planning at community gatherings and religious celebrations, cannot read or write. Yet they have managed to map out on a piece of white poster board each house in the community, returning again and again to monitor the health of families the government does not know exist.

Emma Sokoloff-Rubin is a sophomore in Timothy Dwight and an associate editor for the Globalist.

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