1: Regional overview.

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1

INTRODUCTION

The challenges of sexual and reproductive health and rights in South Asia are embedded within the complex matrix of poverty, disparities and traditionalism. In spite of considerable economic progress, South Asia also records some of the highest levels of absolute poverty in the world. Technological and material advancement have not enabled social change, especially in the area of gender norms.

This stark reality comes home when looking closely at the issue of maternal mortality. South Asia is one of the regions in the world which has had a consistently high ratio of maternal mortality. In 2004, India (with an estimated 136,000 maternal deaths annually) and Pakistan (with an estimated 26,000 maternal deaths annually) were among the three countries, which experience the highest number of maternal deaths in the world according to the World Health Organisation. In that year, this region, overall, recorded a maternal mortality rate of approximately 500 per 100,000 live births, which is among the highest in the world.

Although the millennium development goals call for a reduction of maternal mortality ratio by three quarters and the ICPD Programme for Action also call for a halving of the 1990 maternal mortality levels by 2000 and a reduction to half of those levels by 2015, South Asia does not seem to be on target to achieve all of these goals.

The maternal mortality rates in the table below show the progress of the countries in the region towards these goals.

The ICPD Programme for Action also identified the areas of action in order to achieve this goal:

* Narrowing disparities within countries between socio-economic, geographical and ethnic groups;

* Expanding the provision of maternal and child health services in the context of primary health;

* Increasing emphasis on the management of high risk pregnancies;

* Meeting nutritional needs of childbearing women;

* Dealing with the health impact of unsafe abortion and reducing the recourse to abortion through expanded and improved family planning services;

* Providing information on reproductive health services; including family planning services

* Encouraging men to share the responsibility for sexual and reproductive health.

There are many key reasons for the high rates of maternal mortality. One reason is the fact that a majority of childbirths are still attended by unskilled birth attendants. Another reason is that anemia is a widespread problem among women of reproductive age. A third reason is that abortion services and treatment for complications from abortion are prohibited because abortion laws are restrictive and abortion facilities are not easily accessible. Thus, women seeking abortion are often compelled to use the services of illegal, untrained providers and delay seeking treatment for abortion complications. It is estimated that nearly 7.2 million unsafe abortions take place in this region each year. (1)

Bangladesh permits abortion only for saving the life of the woman and Pakistan, additionally, to preserve the health of the women. India, too does not recognise a 'right to abortion, but does provide for abortion for reasons such as failure of contraception, pregnancy as a consequence of rape and for eugenic reasons. Nepal, which hitherto, penalised women who opted for abortion with incarceration, now has one of the most liberal laws for permitting abortion. (2)

A distinctive feature of South Asia's young population is that they marry young: both boys and girls marry at a relatively young age and a large proportion of girls marry before they reach adulthood. Early marriage is followed by early childbirth, which poses a risk to the life of the mother and child. Moreover, the tradition of early marriage denies, particularly girls, the opportunity for education and gainful employment, which are crucial inputs for autonomy as well as for positive health-seeking behaviour. The gender divide is quite sharp in some respects, especially with reference to economic activity and higher education. South Asia is still far from the goal of achieving universal literacy as evidenced from youth literacy rates, which indicate that 30-45% of the youth (15-24 years) continue to be illiterate. Women continue to face obstacles in seeking employment, as can be seen by the fact that only about half as many women are engaged in paid work as compared to men While female employment is high in Bangladesh and Nepal, where women workers were 76% and 67% of the total number of male workers, in India, there were only half as many women in the workforce as men. The proportion was lowest in Pakistan, where women workers were 44% as a percent of men workers. (3)

Consequently, women are dependent on their husbands and families, not merely for economic survival, but also for mobility and access to healthcare facilities. Seclusion and segregation based on gender is practiced widely in this region, either overtly through the tradition of purdah or more subtly through the exclusion of women from public spaces and institutions. These norms affect younger women more deeply, because these norms are quite consciously constructed in order to control women's sexuality and rights. As a consequence, care seeking for illness, childbirth, contraception and abortion are all mediated by the husband and the marital family. In addition, South Asia's version of patriarchy also shapes the behaviour and attitudes of other institutions other than the family, like educational and healthcare services, which further constrain women's autonomy.

1.1 A critical analysis of the SRHR policies in the region

In general, all the countries have had a history of family welfare programmes, with a limited focus on MCH and family planning. Population control was a dominant concern in the entire region, which resulted in most of the countries having a tradition of population policies outlined. As part of the general development discourse of the 1950-80s era, controlling population growth was seen as a high priority concern. Most of the countries mentioned in this report have had national programmes for promoting family planning. Dependence on external aid was also a contributory factor in the thrust towards aggressive population control policies, which were considered as a necessity by the donor countries. However, this legacy was to prove a hindrance in the later years, when attempts were made to integrate these separate family planning services and institutions within the larger healthcare framework. The existence of separate departments, with separate funding, infrastructure and, most importantly, bureaucracy led to a vested interest in sustaining the independent existence of family planning programmes.

The ICPD (1994) was a landmark event, which led to positive changes in national policies in almost all countries. There was a categorical consensus on the need to integrate the various components of reproductive health into a single entity. A perspective of rights (with its concomitant freedoms for people) was propounded to replace the target-oriented demographic approach.

In Bangladesh, the Health and Population Sector Programme was instituted in 1997 and included integration of health and family welfare as well as decentralisation of Essential Package of services, and improvement of quality. However, as a lot of the efforts were devoted towards administrative and structural reorganisation, with little improvement in health indicators. Consequently, the programme was reorganised as Health, Nutrition and Population Sector Program (HNPSP). The second phase i.e. from 2003 to 2006 has seen a strategic policy shift that separates health and family planning services from an earlier effort to integrate them.

In India, the family welfare programme was changed to the Reproductive and Child Health (RCH) programme, which has been implemented since 1997, which clearly states that reproductive health services are a right of people. The most important element of the programme was the integration of the MCH and family planning activities, along with some elements of treatment of Reproductive Tract infections and adolescent health. (1) However, the most important objective of the RCH 1 was changing the perspective of the health system to view reproductive health holistically, rather than focussing narrowly on fertility reduction. While the policies changed substantially on paper, this process was, by and large, unsuccessful in changing mindsets, as can be evidenced in the return of coercive measures and incentives and disincentives in the population policies of several state governments.

Nepal too was influenced by the ICPD. Efforts were made to integrate reproductive health in development, to improve access to quality reproductive health services, empower women, increase literacy status and promote higher levels of income. Adolescent sexual and reproductive health was also recently included in the reproductive health programme. In 2002, as a result of the sustained advocacy campaign of women's groups, the law on abortion was changed. Prior to this, women in Nepal were incarcerated for abortion. Almost 20% of all imprisoned women in Nepal were either accused or convicted of attempting or conducting abortion. The parliament overwhelmingly voted to make abortion legal for any reason up to 12 weeks. Following this, the Department of Health Services has set up a task force to convert this legal right into a reality. This requires setting up standards for delivery of services, training of providers, registration and monitoring of services. (4)

Pakistan's population programme began in 1953 and the first official population policy was introduced in the mid sixties. The program has been characterised by the demographic objectives of reducing the population and fertility growth rates. Initially it solely addressed women and failed in reaching its objectives. ICPD marked a turning point in the country's approach to population, moving it from the narrow family planning framework to a more integrated health and reproductive health programme. The immediate impact was the modification of policy (Eight Five Year Plan, 1993-1998). National Health, Population and HIV/AIDS policies were formulated (the latest in 2002, 2001, and 2000 respectively), with emphasis on a broader-based RH approach, maternal and child health care, rural outreach and improved service delivery. Greater coordination between the Ministry of Family Planning and Health ensued and joint designing of a Reproductive Health Package by the two ministries was undertaken. (1)

However, in the late 90s and 2000, there has been an increasing dependence on external aid for funding health programmes. Typically, this aid is targeted towards some disease or theme, which leads to distortions and fragmentation with the healthcare delivery system. For e.g. HIV/AIDS which receives substantial funding has remained, for the most part, separated from the RCH programmes, although the two issues are intrinsically linked.

South Asia has also experienced considerable economic development (at least, in certain parts), which has in turn led to the development of a substantial private sector in health care. Voluntary organisations and people's movements have also been active and have had mixed results in influencing government policy.

1.2 National and local budget allocations for SRHR

In all the countries surveyed, there is no specific budget allocation for reproductive health. There was also no information about funding allocation specifically for safe motherhood programmes. The expenditure on health as a percent of GDP ranged from 2 to 6 %. The lowest being in Bangladesh and Pakistan and the highest in India and in Nepal. However, this statistic in itself is not indicative of either adequacy or effectiveness of healthcare provisioning. In all the countries, private expenditure on health far outstripped the government's expenditure on health.

1.3 Tables showing overall key development indicators for gender and health in South Asia

Table 1
MATERNAL MORTALITY RATES PER 100,000 LIVE BIRTHS SOUTH ASIA

             1995 (HDR)   2000 (HDR)   2007 (HDR)     National
Country      (1980-92)    (1990-98)    (1990-2005)   Statistics

Nepal           830          540           540        281 (a)
Pakistan        500           --           530        350 (b)
Bangladesh      600          440           320        322 (c)
India           460          410           540        300 (d)

Source: (a): Nepal DHS 2006. (b): Pakistan social and living
standards measurement 2004-2005, (c): Maternal Health Services
and Maternal Mortality Survay 2001BDHS 2004, (d): SRS1997-2003

Table 2
GENDER DEVELOPMENT INDEX

            Bangladesh   India   Nepal   Pakistan

GDI value     0.514      0.586   0.511    0.508
Rank           105        98      106      107

Source: Human Development Report 2005

Table 3 Youth Literacy Rate

YOUTH LITERACY RATE (10-24 years)
Figures in Percent

             Year   1980   1985   1990   2004

PAKISTAN            37.4   41.4          53.9
BANGLADESH          35.7   38.4    42    49.7
INDIA               55.3    60    64.3   76.4
NEPAL               32.9   39.5   46.6   70.1

Source: http://globalis.gvu.unu.edu/indicator_
detail.cfm?Country=PK&IndicatorID=41

Source: UN Common Database; Unesco

Table 4

                                Pakistan   Bangladesh   India   Nepal

Secondary Enrolment for girls      19          47        40      43
Secondary Enrolment for boys       29          45        57      58

Gross enrolment ratio indicate the number of female students
enrolled in a level in the education system per 100 females in
the appropriate age group. They do not correct for individuals
who are older than the level-appropriate age.

Source: UNFPA, State of World Population 2003

Table 5
FEMALE ECONOMIC ACTIVITY (AGE 15 AND ABOVE)

              BANGLADESH   INDIA   NEPAL   PAKISTAN

Total FWPR       66.5      42.5    56.9      36.7
Year             2003      2003    2003      2003
As % Of Men       76        50      67        44
Year             2003      2003    2003      2003

Source: Human Development Report; 2005

1.4 List of international and regional conventions and agreements that the sub region is party to that are related to SRHR.

Box 1

CONVENTIONS/            PAKISTAN                INDIA
AGREEMENTS

CEDAW (Convention on    1996                    1993
the Elimination of All
Forms of                Reservations:           Reservations
Discrimination Against                          Article 29
Women)                  "The Government of the
                        Islamic Republic of     Declarations:
                        Pakistan declares that
                        it does not consider    "i) With regard to
                        itself bound by         articles 5 (a) and 16
                        paragraph 1 of article  (1) of the Convention
                        29 of the Convention."  on the Elimination of
                                                All Forms of
                        Declaration:            Discrimination Against
                                                Women, the Government
                        "The accession by       of the Republic of
                        [the] Government of     India declares that it
                        the Islamic Republic    shall abide by and
                        of Pakistan to the      ensure these
                        [said Convention] is    provisions in
                        subject to the          conformity with its
                        provisions of the       policy of non-
                        Constitution of the     interference in the
                        Islamic Republic of     personal affairs of
                        Pakistan."              any Community without
                                                its initiative and
                                                consent.

                                                "ii) With regard to
                                                article 16 (2) of the
                                                Convention on the
                                                Elimination of All
                                                Forms of
                                                Discrimination Against
                                                Women, the Government
                                                of the Republic of
                                                India declares that
                                                though in principle it
                                                fully supports the
                                                principle of
                                                compulsory
                                                registration of
                                                marriages, it is not
                                                practical in a vast
                                                country like India
                                                with its variety of
                                                customs, religions and
                                                level of literacy."

Optional Protocol for   Not signed              Not Signed
the Convention for
Elimination of All
Forms of
Discrimination
Against Women

Convention on the       1990                    1993
Rights of the Child
(Children s Rights                              India
Convention)
                                                Declaration:

                                                While fully
                                                subscribing to the
                                                objectives and
                                                purposes of the
                                                Convention, realising
                                                that certain of the
                                                rights of child,
                                                namely those
                                                pertaining to the
                                                economic, social and
                                                cultural rights can
                                                only be progressively
                                                implemented in the
                                                developing countries,
                                                subject to the extent
                                                of available resources
                                                and within the
                                                framework of
                                                international
                                                co-operation;
                                                recognizing that the
                                                child has to be
                                                protected from
                                                exploitation of all
                                                forms including
                                                economic exploitation;
                                                noting that for
                                                several reasons
                                                children of different
                                                ages do work in India;
                                                having prescribed
                                                minimum ages for
                                                employment in
                                                hazardous occupations
                                                and in certain other
                                                areas; having made
                                                regulatory provisions
                                                regarding hours and
                                                conditions of
                                                employment; and being
                                                aware that it is not
                                                practical immediately
                                                to prescribe minimum
                                                ages for admission to
                                                each and every area of
                                                employment in
                                                India--the Government
                                                of India undertakes to
                                                take measures to
                                                progressively
                                                implement the
                                                provisions of article
                                                32, particularly
                                                paragraph 2 (a), in
                                                accordance with its
                                                national legislation
                                                and relevant
                                                international
                                                instruments to which
                                                it is a State Party."

Optional Protocols to   Not ratified            2005
the Convention on the
Rights of Child
Prostitution and Child
Pornography, and
regarding Children
in armed conflict

International           1994                    1994
Conference on
Population and
Development

Beijing Declaration     1995                    1995
and Platform For
Action                  Para 97 & 232 (f)
                        relating to sexual
                        and reproductive
                        health issues (1)

United Nations          2000                    2000
Millennium Declaration

SAARC Convention        2002                    2002
on Preventing and
Combating Trafficking
in women and Children

CONVENTIONS/            BANGLADESH              NEPAL
AGREEMENTS

CEDAW (Convention on    1984                    1991
the Elimination of All
Forms of                Reservations            (No reservations)
Discrimination Against
Women)                  The Government of the
                        People's Republic of
                        Bangladesh does not
                        consider as binding
                        upon itself the
                        provisions of article
                        2, [...] as they
                        conflict with Sharia
                        law based on Holy
                        Quran and Sunna."

Optional Protocol for   Signed and Ratified 6   Signed on 18 December
the Convention for      September 2000          2001, but not ratified
Elimination of All
Forms of
Discrimination
Against Women

Convention on the       1990                    1990
Rights of the Child
(Children s Rights      Bangladesh              (No reservations)
Convention)
                        Reservations:

                        "[The Government of
                        Bangladesh] ratifies
                        the Convention with a
                        reservation to article
                        14, paragraph 1.
                        "Also article 21 would
                        apply subject to the
                        existing laws and
                        practices in
                        Bangladesh."

Optional Protocols to   2002                    2006
the Convention on the
Rights of Child
Prostitution and Child
Pornography, and
regarding Children
in armed conflict

International           1994                    1994
Conference on
Population and
Development

Beijing Declaration     1995                    1995
and Platform For
Action

United Nations          2000                    2000
Millennium Declaration

SAARC Convention        2002                    2002
on Preventing and
Combating Trafficking
in women and Children

2

THE BURDEN OF MATERNAL MORTALITY AND BARRIERS TO SAFE MOTHERHOOD

2.1 Extent of maternal mortality

Maternal mortality continues to be a very serious problem in the area. While it is difficult to estimate the trends in maternal mortality due to absence of reliable data, it is quite clear that the reduction in maternal mortality has been very marginal (Table 1). Bangladesh, inspite of high levels of poverty and low development has, in fact, been able to make much better progress in this regard than the other countries in this region. Given the fact that the age at marriage and first birth is very low in this region, the risk of maternal death continues to be high. Overall, the maternal mortality rate in this region in between 500-600 deaths per 100,000 live births as of which year.

2.2 Causes of maternal mortality

Maternal mortality is a complex phenomenon, influenced by a range of social, cultural and economic factors. A review of the causes of death reveals that direct causes such as post-partum hemorrhage, sepsis and abortion contribute significantly to maternal deaths. In India, the leading causes of death were hemorrhage, sepsis and abortion complications. Data from Nepal indicates a similar pattern with direct causes accounting for 70% of all maternal deaths, of which post-partum hemorrhage, obstructed labour, pre-eclampsia / eclampsia, puerperal sepsis, abortion complications and ante-partum hemorrhage were listed as causes of death. In Bangladesh, the reported leading causes of death were hemorrhage (both antepartum and post-partum), eclampsia, obstructed or prologed labour and abortion complications. In Pakistan too, the reported leading causes of maternal death include hemorrhage, eclampsia, sepsis, obstructed labour and abortion complications. Nonetheless, it is important to remember that under-reporting of maternal deaths and the absence of an effective mechanism to collect information could mean that several deaths that result from indirect causes are not reported. There are few studies specifically conducted on this subject in this region. However, such studies do indicate that the indirect causes such as injury, violence and infections (especially malaria and T.B.) are responsible for a substantial number of deaths. Estimates from Bangladesh suggest that 14% of pregnant women's death as associated with injury and violence. Moreover, it is important to analyse the factors that can are responsible for the occurrence of maternal deaths. The absence of trained attendants at birth, lack of referral facilities and unavailability of emergency obstetric services are a common factor in all countries reviewed in this report. The data shows that only about 1/5th of the births in each of the countries was attended by a skilled attendant. (Table 6) Even in India, which has a much better infrastructure and long history of medical education, less than half the births are attended by skilled provider.

Quite predictably therefore, the rate of institutional delivery is low in all the countries. (Table 7) Less than 10 percent of the births in Bangladesh and Nepal took place in institutions, whereas less than a quarter in Pakistan and about one third of the births in India were in institutions. While institutional delivery is not in itself a requisite for reducing risk of maternal mortality, in this region, it is an important indicator. Referral systems are weak, transportation (especially in remote areas) is often unavailable and there are several bureaucratic hurdles, which inhibit speedy hospitalization of women when they are in crisis.

Apart from institutional delivery, antenatal and postnatal care plays an important part in influencing mortality and morbidity trends. In this region, we find that less than half the women receive any antenatal care from a trained provider. Moreover, the pattern of antenatal reveals strong co-relations with the class and demographic background of women. Women experiencing a first pregnancy are more likely to receive care as compared to women with later births. urban women are much more likely to receive antenatal care as compared to rural women and well-to-do women are much more likely to receive care than poorer women. literate vs. non literatre While emergency obstetric care is an important factor in preventing maternal mortality, access to antenatal care can help to pre-empt problems that could put women's lives at risk and it also contributes to better maternal health. (See Table 8)

The South Asian region has had a long history of state run family planning programmes. India, Pakistan and Bangladesh had initiated family planning programmes in the 1950s. While the programmes have had mixed success, they have often had the tendency to lapse into a web of

incentives and disincentives in order to aggressively promote family limitation. Following the ICPD Cairo Conference, there was official repudiation of any kind of coercive measures to promote family planning, the focus shifting towards comprehensive reproductive health. It has also been the experience of the region that fertility decline is very closely linked to women's development. Thus, intra-country comparisons do show co-relation with education and class. The fertility was recorded to be highest in Pakistan, although as noted before, the teenaged pregnancies are relatively less common there and the age at first birth is higher. However, even in Pakistan, the fertility rate has shown considerable decline from the very high levels prevailing before the nineties. The fertility rate was lowest in India, having declined to less than 3. Bangladesh was not far behind.

The accessibility of the family planning programme is measured through the contraceptive prevalence rate, which has a established link to decline in fertility. However, these figures indicate that less than half of the couples in the reproductive age are using contraception. Most studies indicate that knowledge about contraception is quite high in the region. However, the constraints on use are related to unavailability, unsuitability and the unhelpful attitude of the healthcare providers, and attitudes towards young people using contraception (in particular those yet to have children or sons). (See Table 9)

One of the most important influences on fertility is the perception of child survival. Being uncertain about the survival of their offspring is an important reason for couples articulating a need to have more children.

2.3 Policy environment in South Asia

While there is a widespread recognition that safe motherhood is an important and urgent need, there is a lack of a coordinated effort to meet the challenge. In Bangladesh, in recent years, considerable progress has been made in reducing maternal mortality and morbidity, a maternal health strategy was formulated in 2001, which included the elements of antenatal care, safe delivery with provision of emergency obstetric services, neonatal care, postnatal care, prevention of unsafe abortion and management of complications and family planning services. In August 2000, the government has approved a new National Health Policy, which foresaw the development of a modern, client responsive, efficient health service involving non governmental and as well as government providers. However, despite having a good policy, the implementation of the policy recommendations is found to be lacking, which gives rise to the high number of maternal deaths. In India, all matters related to SHRH are covered by the National Population Policy, the latest of which was formulated in 2000. In terms of implementation, the RCH (Reproductive and Child Health) Programme is the key medium for improving maternal health. Currently, it is in its second phase. Recently, the National Rural Health Mission has been launched to cover the least developed districts of the country and improve the health situation. The Policy has set long-term and short-term goals, including the reduction of maternal mortality rate to 100 per 100,000 live births by 2010. In keeping with the times, the policy highlights the increasing role of the private health sector in secondary and tertiary level care and speaks of the need for statutory licensing, regulation and monitoring to ensure minimum but adequate standards of diagnostic centers. However, in practice, there is no comprehensive provision of services for maternal health and ad hoc measures are the norm. Thus, a pregnant women receives medical care through health services run by the department of health, nutrition supplementation is the task of the ICDS programme, which is run by the women and child development department, whereas the monetary benefit (which is quite minimal and linked to several conditionalities) is usually disbursed by the district administration. Ironically, this scheme deliberately leaves out the most vulnerable mothers, those under the age of 19 years and those who already have three children are ineligible.

In Pakistan, there is no specific RH and SRH policy. In 1998-99, the Ministry of Health and Ministry of Population Welfare jointly introduced the RH package that comprises of nine components including STIs/RTIs, reproductive cancer, male involvement, gender equity and equality, prevention and treatment for HIV/AIDS, Maternal and neonatal health, and EmOC. However, for sexually transmitted illnesses, RR and SR remain unaddressed in the RH Package.

Pakistan's Ninth Five Year Plan (1998-2003) focuses on rural outreach and improved service delivery in a broader reproductive health approach with emphasis on mother and childcare as its stated objective.

In Nepal too, there is no specific policy on sexual and reproductive health. The policies and programmes developed by the government for safe motherhood, family planning, young people, abortion, and so on are fundamentally need-based and service-oriented. As with the other countries in the region, these policies do not integrate a human rights perspective and therefore fail to address the socio-economic, socio-cultural and socio-political factors that are at the root of high maternal mortality and morbidity.

This lack of perspective is most apparent when we consider the fact that all these countries have been unable to create the enabling conditions for good maternal health. For example, all the countries have enacted a minimum age at marriage for women as well as men. However, large proportions of young people (especially young women) are actually married below that age.

The policy towards abortion in most of these countries is liberal in word, but restrictive in practice. India has quite a liberal law vis-a-vis abortion, allowing women to seek abortion services even for contraception failure. Although Bangladesh has a restrictive policy on abortion, menstrual regulation is widely practiced. Nepal has the most liberal law on abortion but this has only been of recent. However, the general picture reveals that safe and legal abortions were generally inaccessible to women in these countries, forcing them to seek services from untrained providers at the risk of their health.

2.4 Provision of services

The situation with regard to provision of services was varied in the region. None of the countries reviewed provided healthcare services as a right. Also, none of the countries had a system of comprehensive social insurance. The state was the largest provider of free or subsidised health services, along with voluntary organisations. The development of the healthcare system was quite ad-hoc, especially in countries dependent largely on external aid for funding. Existing social disparities were more or less replicated within the health system, with poorer classes and regions having less access. The most developed health system was in India, which has a huge network of primary care centres and referral centres. It also had a large pool of trained medical personnel. However, inspite of this, the quality of services was poor and there were problems of accessibility. Rampant absenteeism, vacancies and shortage of drugs and equipment plagued the system. A similar situation was to be found in Pakistan, although here the physical infrastructure was more limited. Nonetheless the problems cited above were an important obstacle in the delivery of care. In both these countries, there was a highly developed private sector, which provided a substantial proportion of first contact care. In both these countries, rural-urban differentials were quite large. The ratio of doctors to population in rural areas is six times lower than that of urban areas in India (5). The largely elite medical fraternity is reluctant to work in rural areas. Services were understaffed and underfunded, resulting in poor quality services. While even the situation of antenatal care is itself far from satisfactory, delivery, post-partum care and abortion services, which require 24 hour care (emergency obstetric care) was largely unavailable in the rural areas. The health system was relatively less developed in Nepal, with less than half of the required centres being able to provide comprehensive emergency obstetric care and less than 1/10th of the required centres being equipped to provide basic emergency obstetric services. Moreover, the hilly terrain of large parts of Nepal and current environment of conflict put more obstacles in the way of accessing emergency care during childbirth. The absence of effective local government also meant that execution of plans and implementation of programmes was affected deeply. This created a complex matrix of issues within the health sector; including lack of resources, poor quality and badly maintained buildings, insufficient and inappropriate staffing, lack of professional support for staff, vicious cycle of low staff morale and poor quality of care, and mismanagement.

Bangladesh had a much more developed healthcare system inspite of its poverty and low development status. This is partly due to the presence of large voluntary organisations which have created a healthcare system parallel to the government. Considering the high number of maternal death in 3rd trimester the government has put special emphasis on Emergency Obstetric Care (EmOC). The goal is to provide basic emergency obstetric care in all centres at the Primary and Secondary Care level and comprehensive emergency obstetric care at all hospitals at the district level. More than half the district hospitals and all the teaching hospitals in the country were providing comprehensive emergency obstetric care services. Of the institutional deliveries, 64.62 % are conducted by government facilities and the rest by private clinics The private clinics providing comprehensive EmOC services on payment are highly concentrated in big cities of four divisions: Dhaka, Chittagong, Rajshahi and Khulna.

With support from uNFPA, uNICEF and AMDD, the government has increased the number of functioning comprehensive EmOC facility from 45 in 2000 to 70 in 2002. It also has been installed and incorporated life saving equipment, as well as standardised list of EmOC equipment and supplies in UHC and district hospitals on pilot basis.

2.5 Recommendations

Recommendations were largely related to four aspects--law and policy formulation, service provision, community mobilisation and research and documentation.

As regard law and policy formulations, the recommendations were that an awareness of the importance of SRHR issues should be built among policy-makers and bureaucrats. In all the countries, the lax implementation of social legislations (such as those relating to child marriage) was the norm and needed to be addressed. Moreover, regulations and laws were required for improving access to services and regulating their quality (for e.g. rules enforcing minimum standards of care for certain medical procedures). A clear area where more progressive legislation was required was in the area of abortion, which was either entirely illegal or available under very restrictive conditions. Other protective legislations, such as Maternity Benefit, were rendered more or less irrelevant due to the existing economic conditions, where the vast majority of women workers were in the unorganised sector. Hence, it was important to introduce more comprehensive measures, which would ensure universal coverage. In terms of policy, the recommendations were that it should have a clear rights-based approach, outlining the rights of the people and the obligations of the state, which would help to end the ad-hocism with which programmes were currently being implemented. Policy should also take into specific regional differences and plans should be formulated in accordance to their specific needs.

In terms of service provision, reforms were recommended at both the primary care and emergency care levels. It was recommended that the coverage of the public health measures be increased by including traditional birth attendants and unqualified practitioners, who are currently providing a large proportion of the first contact care in the rural areas. It was recommended that greater emphasis should be placed on preventive measures contributing to better maternal health--through greater health education and information dissemination as well as better nutrition for mothers and infants. At the same time, up gradation of secondary and tertiary care facilities was recommended to provide effective emergency obstetric care. This required ensuring 24 hour availability of staff, special training to staff to deal with emergencies, make provisions for equipment, drugs and other supplies, e.g. blood. Moreover, greater monitoring and public accountability of services was recommended--to root out malpractices such as absenteeism and illegal private practice, corruption and pilferage from the public healthcare system as well as the private sector.

More active mobilisation of the community was seen as necessary to increase awareness about the problem of maternal morbidity and mortality. Greater public monitoring of health services would improve quality and access of services. Both public action and social action were seen as being necessary - in the form of setting up of effective redressal mechanisms and at the same time, action against providers indulging in malpractice as well as provoking greater public debate on the issue through the use of media and the arts.

Finally, greater emphasis on research, both into the exploration of the issue (its epidemiological and social aspects) as well as evaluation of interventions was recommended. It was noted that up-to-date and complete information on maternal deaths was woefully lacking and presented an important problem is assessing the situation and planning of interventions. Regular review and social audit of maternal deaths would deepen understanding about maternal mortality and morbidity.

3

CHALLENGES TO MEETING YOUNG PEOPLE'S HEALTH NEEDS

3.1 Situational analysis with facts and figures

As with many countries, which have only recently undergone demographic transition, the countries being reviewed have a largely young population. About one third of the entire population is in the age group between 10-24 years. About 23% of the population in each of the countries is adolescent.

South Asia clearly has a very low age at marriage of both girls and boys. Although legislation exists in all the countries, stipulating a minimum age at marriage, several adolescents (especially girls) are married before they attain adulthood. The latest available statistics for the minimum age at marriage shows that the mean age at marriage is particularly low in Nepal and Bangladesh. According to the Bangladesh Demographic Health Survey 2004, more than half of all women aged 20-49 years of age were married before their 15th birthday. While girls are married early, there is also a considerable age gap between the spouses. The law itself sometimes stipulates different minimum legal ages at marriage (without the consent of parents) for girls and boys: 18 for girls and 21 for boys in India and Bangladesh; 16 for girls and 18 for boys in Pakistan; and 20 for both boys and girls in Nepal. In contrast to the other countries, Pakistan has a much higher age at marriage, with the mean age at marriage being 22.1 years for girls. Early marriage has several implications for girls. It curtails the opportunities for higher education, the experience of employment and restricts personal freedom. Early marriage is usually followed by early pregnancy. This is particularly so, in view of the fact that boys are generally older than girls at the time of marriage and sexual activity is initiated almost immediately, often at the behest of the male partner.

The age at first pregnancy in the region was around 18-19 years of age. Again, the exception being Pakistan, which reported that the median age at first pregnancy

for women between 25-45 years was 21.3 years. Each of the other countries reported that one third to one fifth of teenage girls had already experienced a pregnancy. Early pregnancy poses several risks for women. Apart from the risk of higher infant and maternal mortality, young women have very little control over their sexuality. They are unable to use contraception, and also access healthcare in case of problems. Moreover, they are emotionally unprepared for motherhood, which is thrust upon them. Thus, early childbearing has significant health and social consequences for women.

While the use of contraception is rising in all these countries, among the young married, the use among young married women is very limited, which is demonstrated by the fertility rate among adolescents. (See Table 11)

It is widely believed that the expansion of basic education raises the age at marriage at the societal level. By making education universal and compulsory, the social norm related to the ideal age at marriage can be changed. However, we find that the achievement in terms of even spreading literacy among the youth has been very disappointing. (Table 2) While nearly half of the youth in Bangladesh were illiterate, even in India, nearly one fourth of the youth population was illiterate. Moreover, there existed considerable disparity between the genders, with the expansion of literacy being much more rapid among males than females.

The lack of access to education itself constitutes a violation of human rights because it limits the opportunities for self-development and reduces the girls' ability to control various aspects of their lives. Illiteracy reduces freedom for girls, compelling them to be dependent on others for fulfilling their needs, as they are unable (or presumed to be unable) to make decisions for themselves. Moreover, inspite of the growth of the electronic media, literacy is also an important determinant of access to information on health and sexuality. Schooling itself is an important component of this because it provides the opportunity to access scientific information about health (within the limits imposed by state policy) from reliable sources such as teachers and textbooks. The peer group of those who are in school is also likely to be more progressive than those who are not. Although, data from the UN common database indicates that even among the girls currently between 6-14 years, schooling is far from being the norm.

3.2 Maternal health and maternal mortality among young people

Information on the use of maternal health services by adolescents reveals that there are large gaps in information and access. A study in Pakistan revealed that a large portion of the married female adolescents are unaware of the need for antenatal checkup, post natal care services, number of tetanus toxoid doses required for first pregnancy and through out life, emergency preparedness for delivery, and danger of performing abortion by untrained person.

Similarly, the findings of a study in Nepal conducted by the EU/UNFPA and UPSU/Valley Research Group in 2004 on Knowledge, Attitude and Behavior on SRH of adolescent and youth in 19 districts revealed that young people do not have adequate knowledge on menstruation cycle, first sex and its consequences and pregnancy. Only 17% had correct knowledge about SRH, more males (23%) than females (13%). (6)

Maternal mortality as well as infant mortality is significantly higher among young mothers than women of 20-29 years because of their biological susceptibility as well as the lack of adequate social support mechanism. (7) The demographic and health survey in Nepal (2001) reports that the infant mortality rate among children born to mother under 20 years of age was 134 per 1000 live births (for a ten year period preceding the survey) as compared to 98 for women between 20 and 29 years. Such differentials are also seen in the other countries in the region. The demographic health surveys report that there is no difference in the extent of care provided to adolescent women during pregnancy (15-19 years) as compared to older women. Similarly, their access to institutional delivery and trained attendance at birth is also similar. In fact, meta-analysis of demographic health survey data worldwide even indicates that adolescents are less likely to receive care during childbearing than older women.

3.3 Policy environment in South Asia

The realisation that adolescents and young people have special health needs and constitute a specific group is very recent. Moreover, policy making in this region has yet to integrate this new understanding. Generally, adolescent girls are treated as a sub set of women and the maternal health and reproductive programmes. Adolescent boys and male youth are absent from policy. Generally, the concern for adolescents is limited to a statement of the intention of addressing their problems, which is not necessarily accompanied with the provision of actual services. In many countries, policies related to education, employment and vocational training are often divorced completely from health and population policies. Thus, the various linkages between socio-economic development and better health are not taken into account.

In view of this, most policies related to adolescent or youth health are primarily focussed on information provision.

3.4 Provision of services

As stated above, service provision to adolescents is primarily focussed on imparting information and even this is mainly focussed on married adolescents. However, the actual problems even in imparting information are considerable. Firstly, policy-makers and educationists are, in general, reluctant to address issues related to sexuality and reproductive health in education curriculum. Several studies reveal that even when particular subjects and modules are incorporated in the curriculum, teachers are ill-equipped, reluctant and embarrassed to deal with the subject matter in the schools. A study in Nepal reports that the public school teachers responded that they were not able to teach the subject because the students were from the same community and they felt embarrassed; the girl students abstained from those classes because the public schools are co-education schools; the teachers have had no training and there was no monitoring of teachers doing this job. Moreover, such programmes do not even reach the large majority of adolescents, who are outside the formal education network. NGOs have tried to bridge the gap, by providing community based or non-institutional services. For example, in Pakistan, the Family Planning Association of Pakistan has been involved in work with youth for several years, and currently conducts a Girl Child project in addition to its work with male youth under which it offers guidance to adolescent girls, life skills training and RH education.

In most instances, sex or health education is provided in the context of HIV/AIDS programmes, which focus primarily on risk reduction and are not necessarily adequate to provide detailed and culture-specific information on sexuality. The few service-based interventions include the provision of iron supplementation through the integrated child development service (ICDS) in India, as well as the establishment of adolescent friendly clinics and hospitals in which country. However, the latter are largely small demonstration experiments, which do not cover any significant part of the population. One of the primary challenges of providing services to adolescents is to select the most appropriate way to reach the huge number of adolescents and youth to provide them with reproductive health services due to the wide diversity in their social and cultural situations (married and unmarried, school-going and non school-going, rural and urban). The large majority of adolescents seek services (in whatever limited way that they are able to) from the general health system. Hence, it is very important to orient these services to be sensitive to the specific needs of the adolescents. In the absence of such services, it has been observed that adolescents seek care from unqualified providers.

3.5 Recommendations

In all countries, the concern for adolescents' health issues does not have a rights-based focus. They do not take into account their specific needs and ensure that they have a voice in such initiatives. It is important to link specific programmes for reproductive health with other initiatives (related to education, employment, etc.) which are working for their overall development. More research needs to be conducted in this area to understand the specific problems of the adolescents and young people and devise appropriate strategies for delivering services to them .

Especially, health services providers and institutions need to be trained to be sensitive to the needs and rights of the adolescents and youth. Particularly, with relation to issues perceived to be moral problems, (pre-marital sex, abortion, contraception, STIs), providers need to be trained and sensitized to be sensitive to the adolescents. More participation of young people is required to ensure that services for them are appropriate, effective and empowering. Particular attention must be paid to the needs of those adolescents, who belong to the marginalised groups.

4

ASSESSING THE IMPACT OF HEALTH SECTOR REFORMS ON WOMEN'S HEALTH AND RIGHTS

Improving efficiency and service coverage as well as recovering costs has been a dominant thrust in healthcare reform process in this region. However, this is not to deny that there is an urgent need to reorganise services in order to improve both access and quality of care. Some common features of supply side reforms in these countries include decentralisation, private-public partnerships, use of cost-effectiveness for priority setting, targeted interventions, streamlining management and reducing bureaucratic hurdles. In some countries, attempts were made to unify family planning services and general health services. Efforts were also made to devolve powers (for taking find-allocation decision, procuring equipment and supplies, etc) to institutions at the district level--either the local governance institutions (Pakistan, Nepal, a few states in India) or district level administration (most states of India, Bangladesh). Funding for specific programmes has increased due to inputs from multilateral and bilateral agencies. However, the impact of vertical funding on the public health sector needs to be closely monitored and evaluated.

There is some early evidence (from Rajasthan, India) that the imposition of user charges and, particularly, in the case of obstetric care, the use of disincentives have had particularly adverse effects. An important change has been the recognition of the need for community involvement in the planning process. Thus, a process of developing local plans prior to central plan formation has been instituted. The success of this process has been variable depending on the level of community awareness, effective lobbying and the participation of advocacy groups.

In Bangladesh, it was noted that in the first phase of health sector reforms, a substantial amount of project aid was spent for consultancy services.

In Nepal, it was noted that within the health sector reform process there were large gaps with regards to services for young people and services to deal with violence against women.

4.1 An analysis of budget allocations

The data on health expenditure indicates that health forms a very small part of the total economy. Information for 1998-2002 shows that there has been no significant change in the health sector as a proportion of the total GDP. (See Table 12)

However, it is quite clear that each of the countries

allocates 3-7 percent of the total government outlay for health. (See Table 13)

Another important question relates to the sustainability of health finance allocation. If a substantial part of the increase (in real terms) in health expenditure is on account of grants received from external agencies for specific programmes on the basis of the health sector reform process, is this sustainable in the long run?

4.2 Impact on SRHR service provision

Since the health sector reform process is still in its early stages in the four countries, the full impact of the process cannot be fully gauged. The process seems to have had noticeable difficulties in both Bangladesh and India. For example in Bangladesh, the series of reform initiatives undertaken had limited success due to different factors. Some of these limitations are as follows:

* There was recognition of the need for, and commitment in principle, to the importance of gender equity in health sector programmes. But implementation of policies and plans was limited due to weak institutional mechanisms, capacity building initiatives and leadership.

* Overall, public spending on health has remained low and scarcity of resources remained. At the same time, HPSP could not disburse all the funds available. In this regard, delayed World Bank fund disbursement mechanism was acute.

* Development partners' coordination, even though improved, remained too much World Bank-dominated.

* Ineffective unification, long-lasting conflicts between FP and Health cadres, inefficient efforts on management information system (MIS), BCC, procurement of medicine and logistics, hospital improvement initiative, planning process, halting of satellite clinics and home visitation have resulted in curving down the quantity and quality of RHservices rendering from different tiers of the health service delivery chain.

* Insufficient attention has been paid to the supply side barriers faced by the vulnerable population. These are: unofficial fees, erratic drug supplies, absenteeism, and negative attitude of the service providers.

* Social marketing initiatives have mainly concentrated on promotion of contraception and condoms, and not on comprehensive maternal health or youth SRH services.

* The weak decentralisation process has severely endangered the local health services. In conservative areas, decentralisation can even be counter-productive.

* It allowed cost recovery by local governments and explored cost-recovery for public services.

Gender discrimination is a universal phenomenon, which takes different cultural forms.

On the other hand, in Pakistan, the early, general, impression is that devolution has resulted in resources being better utilised and both services and access to services has improved in some areas. There still needs to be close monitoring to evaluate the results of the health sector reform process.

4.4 Impact on women and young people's access to services

In most countries, improving access of services to women and young people has been a stated objective of the reforms process. The thrust towards strengthening primary care services has led to improvements in access in specific areas such as family planning services and immunisation. However, regional differences are observed even with respect to such programmes. There has been considerably less success in improving access to more capital intensive services such as emergency obstetric care, institutional delivery and safe abortion.

In the case of young people, as stated earlier, the service provisioning has been largely in terms of information sharing, primarily through HIV/AIDS control programmes. RH services are limited to specific measures, for e.g. the supplementation of iron-folic acid for girls in India. There is no holistic programme for providing healthcare, counseling and education to young people through the formal health system. In particular, there are gaps in provision of sexual health services for boys and girls, information and resources for birth spacing for young married adolescents, abortion services and prevention of HIV/AIDS.

5

GENDER AND SOCIO-CULTURAL OBSTACLES TO IMPROVING SRHR IN SOUTH ASIA

5.1 Cultural factors

The countries being reviewed in the South Asian region have a different socio-political context, but are culturally quite closely linked. Gender discrimination is a universal phenomenon, which takes different cultural forms. In this region, particularly, it takes the form of son preference and, in some cases, neglect of daughters. It would be fallacious to regard this kind of society as being uniformly and unchangingly hostile to the welfare of women. However, it is true that several traditional practices which severely limit women's freedom and opportunities continue to prevail. Segregation based on sex is prevalent in different forms in the region. While in the Muslim countries, it takes the overt form of purdah (veiling), it also exists in the non-Muslim regions in different forms, in particular amongst the upper caste Hindus. Thus, it should be properly regarded as a cultural, rather than religious tradition.

This kind of social system has several consequences for women. Firstly, it limits the opportunity for schooling for adolescent girls in the absence of girls-only schools. While many girls are taken out of school, those who continue face discouragement and discrimination because of their smaller numbers. Moreover, segregation usually limits women's opportunities to go into public spaces and institutions. Segregation may impede women from seeking employment and proscribe the type of employment they seek. Segregation also affects the way in women seek and access healthcare and service providers.

Women are also fairly unequal within their households. This results in discriminatory practice in the distribution of food, low expenditure on women and girls' personal needs, and the lack of bargaining power within the household. As a consequence, health needs of women are often left unattended due to the fact that they are not valued members of the household. However, it is also important to remember that poverty is a very important underlying factor, which is at the root of women's ill-health and lack of access to care.

Apart from the structural problems of patriarchy and poverty, there are also specific taboos, cultural practices and beliefs that are particularly harmful to women. For e.g. the restrictions of food, which are practiced during menstruation, pregnancy and lactation, often lead to undernourishment. Women's reproductive needs in particular get neglected because of a strong taboo on discussing any matter related to sexuality or reproduction. Thus, girls and women do not reveal even menstrual problems, when they visit a doctor or a health worker. Other problems related to pregnancy, breast-feeding, sexual health and menopause are much more difficult to discuss, even though they may be posing life-threatening risk. This problem is compounded by the unavailability of female staff at the healthcare facilities.

5.2 The role of religious factions

In many of the countries being reviewed, there is a dual legal system. There is the constitutional law, which is the result of the modern process of state building, the customary/personal law, which is based on religious texts, scriptures or maxims. While in India, there is a single legal system which deliberates on both aspects of the law and passes judgments . In other countries, such as Pakistan, there is a separate Sharia court, which has the final authority with regard to customary law. In a majority of the states, the constitutional law guarantees gender equality. However, even in the constitutional law framework, there are gender differences in the actual exercise of the legal framework. The customary law, in general, does not accept gender equality even as a principle and largely reflects the patriarchal structure of South Asian society.

In most of the legal systems, women have unequal rights to inheritance, termination of marriage, minimum age of marriage, and natural guardianship of children. Polygamy is allowed in some personal laws, and there are grossly inadequate provisions for women's financial security after divorce.

Child marriage is a serious issue in almost all the countries, except Pakistan, and the practice is diminishing. Although there exists legislation stipulating the minimum age at marriage, the violation of this law is hardly penalised. Thus, even though census after census reveals that a large number of under-aged persons are married, there are hardly any cases being heard in the courts under this law.

Another blatant violation of the law is with regard to sex selection. It is widely understood that the continual decline in the juvenile sex ratios in India (in many states, there are less than 900 girls per 1000 boys) is a result of sex selection. The widespread use of ultrasonography to determine the sex of the foetus and followed by medical termination of pregnancy, in case the foetus is female, has actually altered the demographic profiles of certain states in India.

5.3 Economic and Social factors

Widespread poverty, especially in the rural areas, is a common feature of all the countries being reviewed. Thus, the study of the healthcare situation cannot be divorced from the study of poverty and underdevelopment in this region. Poverty, under-nutrition, lack of education, employment in the informal sector, lack of social security network and violence form a cycle of related deprivations that determine women's health. Apart from the overall situation of poverty, we find that it also has a gendered dimension--with the presence of substantial disparity between men and women. For e.g. women's opportunity to seeking employment is quite limited. (See Table 18) The lowest workforce participation rate was found in Pakistan and the highest in Bangladesh. In urban areas, women work largely in the unorganised sector where they do not have any social protection. Moreover, many of them are employed in hazardous industries such as leather tanning, chemicals and scrap recycling. Even in other industries, such as garments manufacturing (which is a very large sector in all the countries being studied) and handicrafts, few, if any, safety precautions, are taken to protect workers. Most urban women workers, like their rural counterparts, do not have access to maternity leave or benefit. Even where schemes exist for providing such benefits (as in India, the National Maternity Benefit Scheme has been launched), the utilisation of the benefits is very low.

Poverty can also be exacerbated by other physical and social obstacles. Villages in the hilly terrains of Nepal are very isolated and women and children find it particularly difficult to access distant health facilities. In times of crisis, such as obstructed labour, it is often physically difficult to transport the women to a hospital for safe delivery.

5.4 Political factors

In several parts of the region, for e.g. in Nepal, northeast India, Kashmir and border areas of Bangladesh, conflict (internal and external) has a very strong effect on women's health. Violence against women by armed forces or those in opposition to the state is quite common, leading to rapes, unwanted pregnancies and considerable trauma. Even routine care is affected due to blockages, curfew, military presence and destruction of health infrastructure and absence of health personnel. This leads to scarcity of information and services, destruction of service delivery centers, absence of service providers, etc.

Moreover, in addition to men and adolescent boys, increasingly women, and particularly adolescent girls are being directly affected by the conflict.

This element of mass conflict is an added dimension to the more pervasive problem of gender-based individual violence, both within the home as well as the community. This includes marital violence, honour killings, and retribution during family feuds, all of which target women as the victims. Violence against women both in the family and the community has been aggravated in the absence of law or administrative measures to protect them.

One more gender-based violation that takes place quite commonly in this area is trafficking and forced prostitution. Often, there is a cross-border trade in human beings and young girls constitute a substantial number in this trade. This trade is particularly active between Nepal and India, with many young Nepali girls being trafficked to small and large cities in India.

6

MOBILISING FOR CHANGE

Based on above recommendations, what specifically can be changed in the near future (a short, critical, realistic and do-able list) including regional advocacy priorities on safe motherhood and young people's SRHR for South Asia.

Enabling factors within country context in South Asia--women-friendly laws, policy makers, civil society, media

6.1 Enabling factors within country context

Enabling factors within country context in South Asia--women-friendly laws, policy makers, civil society, media

All the countries being reviewed are signatories of the CEDAW convention and have also formally adopted the approach mooted at the International Conference of Population and Development (ICPD) held in Cairo in 1994. As a result, national policies on population, maternal health and family welfare did see substantial changes and the adoption of a broader approach to reproductive health is in evidence. While in actual implementation, there has been uneven progress, a new generation of policy makers, health providers and planners, has emerged, which understands the concept of reproductive health.

In all the countries reviewed, there have been recent campaigns for political democracy in different forms. This has had the effect of revitalising civil society institutions such as the press and popular media, voluntary organisations. In particular, some countries have reported that the removal of state monopoly of media has helped to bring out many issues related to women's health to the fore.

NGO experiments were seen generally to have provided an impetus to promoting reproductive health. With their innovative methods, social commitment and proximity to the community, they have provided successful models for service delivery as well as acted as advocates for the reproductive rights of women and young people. In some countries, the intervention of the UN agencies was seen as an important component for enhancing the quality of training, policy making and service delivery as well as introducing the concept of modern management (through better monitoring and evaluation mechanisms and evidence based interventions).

Part of the political change process has been the growing awareness of rights. Women activists, human rights and legal aid organisations have voiced public concerns on gender issues and have supported different initiatives for adoption of a rights agenda. These organisations are an important link to ensure that the state's commitment to implementation of the UN instruments, for e.g. (CEDAW), is actually operationalised. Their contribution has been vital in ensuring that the national laws are changed so that they are in consonance with the spirit and letter of the international law.

In many of the countries reviewed above, violence against women and girls (trafficking, sexual abuse, domestic violence) have become important matters of public debate.

Some of the countries have also passed laws with regards to these issues. Other measures taken include the setting up of complaint cells in police stations for women, setting up of all-women police stations, establishments of crisis centres and shelters--both by the government and NGOs for women facing violence. Apart from the legal system, in India as well as Pakistan, experiments have been tried to locate these centres outside police stations--in hospitals.

Girls' education has received more attention in some countries, with the institution of incentives and subsidies for girls both at the primary and secondary levels. Other innovations include provision of childcare facilities so that older girls can come to school, appointment of female teachers, especially in the elementary education. Apart from specific interventions for girls, life-skills training and health and sexuality education for young people in general is gaining more acceptance in state policy and will gradually become institutionalized. The effect of these interventions will take time to emerge. However, they represent an important step in increasing women's and young people's empowerment and enhancing their health.

As outlined above, the greater integration of countries into the international community has created a space for local organisations to demand accountability from national government vis-a-vis protection, promotion and respect for the rights of women and young people using international instruments and agreements.

An active judiciary is seen as an important influence in Bangladesh and India because they have been proactive in using their authority to compel governments to take action on several issues--such as sex selective abortions, child-marriage, violence against women, child abuse, etc. Even statutory bodies such as the National Human Rights Commission in India have taken an interest in the issues related to the right to health and tried to create moral pressure on governments to act in order to prevent maternal and infant deaths.

The emergence of non governmental organisations as a legitimate 'third party' in all discussions and deliberations related to the policy making has strengthened the voice of the community. The emphasis on community participation in planning and implementation of health programmes has become an accepted norm and has created spaces for voicing concerns, expressing views and influencing the direction of change. However, this is not to claim that all programmes are completely democratic in their outlook.

'Gender' as a concern has gained acceptance in almost all circles. Hence, there have been proactive attempts to review existing curricula and revising them to make them more gender sensitive. This holds the possibility that the successive generations of people, professionals and leaders will be much more aware and sensitive than at present.

Institutional and state support for education, training and awareness generation for health will greatly increase the access of programmes for the marginalised groups. One can hope that greater co-operation with NGOs will ensure that successful innovations are scaled up (although they may not be in their current form) within the larger state systems so that it increases the reach of services.

6.2 Recommendations:

The recommendations emerging from all the countries can be categorized into the following

6.2.1 Law and Policy reform to remove some of the broader constraining factors

One of the important lacunae observed in many of the countries reviewed related to the registration of births and marriages. These are important to ensure the observance of the law regarding child marriage and also for protection the rights of women in marriage.

In all the countries being reviewed, there were specific laws (both customary as well as constitutional) which were discriminatory to women. These related to marriage, inheritance, divorce, adultery, rape and domestic violence. All such laws should be amended or repealed in order to protect women's rights.

A need was also felt to enact a law to ensure the reservation of quotas for women in jobs as well as political institutions. This has been a contentious issue in several countries even where the concept of gender based reservation is accepted in principle.

Adoption of youth friendly policies--which reaffirm young people's rights to education, decision-making, access to information and services are a crucial step in ensuring their health.

Legislation to provide for safe and legal abortion is necessary in some countries such as Pakistan and Bangladesh. Equally important was legislation for providing and implementing maternity benefit and leave to women workers in both the unorganised as well as the farm sector.

6.2.3 Restructuring of services and systems

A universal recommendation was for the merging of health and family welfare/population welfare departments for effective formulation and implementation of policies to include maternal mortality, unsafe abortion, sexual health and rights, bodily rights and adolescent SRH with a focus on a life cycle approach to women's health.

Gender--based barriers like those which hinder institutional delivery for high-risk mothers, the reluctance of women to seek care from male personnel, the stigma attached to seeking care for non-maternity related reproductive health concerns need to be addressed and services restructured accordingly. While there may be a long-term objective of bringing about cultural change, in the immediate context, specific provisions will be re required to ensure that women and girls have access to care.

Better regulation of the health services is needed in both the public and the private sector. This relates to the provision of services, manufacture, sale and supply of drugs and equipment, training and competence of health personnel as well as medical research.

Existing services, particularly referral centres, need to be strengthened in order to ensure that they are adequately equipped and staffed to handle complex maternal health emergencies

Training curriculum for health personnel should include interpersonal skills development, to enable better and fruitful interaction with women during counseling and consultation.

Incorporate adolescent friendly health service corner in the existing public and private Health facilities at all levels. Provide adolescent RH and life skills education as well as counseling for parents, teachers and service providers on how to address adolescents in respect of SRH issues

Decentralisation to local level institutions to launch programs directly or indirectly related with the women's health and education will improve the accessibility of programmes as well as allow for more flexibility which will improve the 'fit' between people's needs and the nature of service provision.

6.2.4 Community Mobilisation

Provide formal and informal education to both in-school and out of school adolescent boys and girls, which will empower them to make more informed decisions in aspects of their life and also lead to greater personal and community development.

There needs to be greater awareness among the people about sexual and reproductive health issues so that there is more emphasis on them in local and national government. Likewise, specific groups, such as women elected members, members of women's self-help groups, etc. need to be specifically trained to increase their involvement as a pressure group in improving health.

While the overall health situation is not satisfactory, there needs to be a special focus on health care for the disadvantaged and marginalised groups especially those belonging to the rural, tribal and remote areas.

Greater cooperation between the public sector, private sector, non-governmental organisations, community based organisations and civil society can improve the overall health system and ensure the accountability of all players involved.

6.2.5 Effective implementation, monitoring and evaluation

There is a great need to document best practices in the different areas of maternal health and young people's health.

There is very little accurate data on issues such as maternal mortality and morbidity, abortion and infant deaths, violence against women which obscures the magnitude of the problem and, does not allow for proper planning. A systematic process for data gathering on a continuous basis needs to be developed.

Effective methods of monitoring and evaluation (including participatory monitoring) need to be evolved so that an evidence base is created for upscaling successful interventions as well as improving existing interventions in general.

REFERENCES

International Institute of Population Sciences and ORC Macro. 2000. National Family Health Survey--2; 1998-99; IIPS; Mumbai

Mari Bhat P.N.2002.Levels and Differentials in Maternal Mortality in Rural India: New Evidence from Sisterhood Data; Working Paper Series No. 87; National Council of Applied Economic Research; New Delhi 

Mathur. S et al. 2003. Too young to Wed, The Lives, Rights and Health of Young Married Girls; International Centre for Research on Women; New Delhi

Ministry of Health [Nepal], New ERA, and ORC Macro. 2002. Nepal Demographic and Health Survey 2001; Calverton, Maryland, USA.

National Institute of Population Research and Training (NIPORT) et al. 1994. Bangladesh Demographic and Health Survey 1993-94; Dhaka.

National Institute of Population Studies et al. 1992. Pakistan Demographic and Health Survey 1990-91; Islamabad

National Institute of Population Studies, Ministry of Population and Welfare. 2001. Pakistan Reproductive Health and Family Planning Survey 2000-01; Islamabad

Policy Research Unit (PRU), Ministry of Health and Family Welfare, Government of Peoples Republic of Bangladesh, Health Systems Development Programme. 2002-03. Bangladesh Maternal Health Review; Dhaka.

United Nations Development Programme.2005. Human Development Report 2005, New York 

World Bank; World Development Indicators available at www.worldbank.org/data.

World Health Organisation. 2004. Maternal Mortality Estimates in 2000; Geneva.

ENDNOTES

(1) Ahman, Elisabeth and Iqbal Shah. "Unsafe abortion: Worldwide estimates for 2000." Reproductive Health Matters. Volume 10, Number 19. May 2002.

(2) Ibid

(3) United Nations Development Programme (UNDP), 2005. Human Development Report 2005

(4) Family Care International Inc., 2005. Saving Women's Lives: The Health Impact of Unsafe Abortion.

(5) CEHAT, Policy Brief, undated 

(6) EU/UNFPA; UPSU/Valley Research Group. 2004. Study on Knowledge, Attitude and Behaviour on Knowledge, Attitude and Behavior on SRH of adolescent and youth . Kathmandu, Nepal: EU; UNFPA; UPSU; Valley Research Group.

(7) Mathur S et al. 2003. Too Young to Wed. Washington, DC: International Center for Research on Women.

Table 6

                     SKILLED ATTENDANCE AT BIRTH

       Bangladesh       India         Nepal       Pakistan

           9.5          34.2           7.4          18.8
Year    1994 (a)     1992-93 (b)    1991 (a)      1991 (a)
          13.2          42.3           18            23
       2003-04 (c)   1998-99 (b)   2003-04 (d)    2001 (a)

Sources: (a): World Development Indicators; National Family
Health Survey 1992-93, (b): National Family Health Survey 1998-99.
(c): Bangladesh Demographic and Health Survey 2003-04. (d): Nepal
Demographic and Health Survey 2003-04

Table 7

                    INSTITUTIONAL DELIVERY
                (AS PERCENT OF ALL LIVE BIRTHS)

         Bangladesh    India     Nepal     Pakistan

                       25.5                   15

Year                  1992-93               1990-91
Source                 NFHS               ICPD report

            4.1        33.6

Year      1996-97     1998-99
Source      BDHS      NFHS-2

            7.6

Year     1999-2000
Source

            9.3                   9.6         23

Year        2004                2003-04      2004
Source                            DHS

Sources: Nepal Demographic and Health Survey 2003-04
National Family Health Survey 1992-93
National Family Health Survey 1998-99
Pakistan ICPD Report

Table 8

% OF WOMEN RECEIVING ANTENATAL CARE (ANY VISIT)

Bangladesh     India     Nepal    Pakistan

39             49.2               25.5

1999-00        1992-93            1990-91
World health   NFHS               Pakistan Family
report; 2005                      Health Survey

26.3                     48.6     36

1996-97                  2001     1996-97
BDHS                     NDHS     WORLD
                                  HEALTH REPORT

33.4           65        49

1999-00        1998-99   2001
BDHS           NFHS      WORLD
                         HEALTH
                         REPORT

48.7

2004
BDHS

Sources: Sources; Nepal Demographic and Health Survey 2003-04
National Family Health Survey 1992-93
National Family Health Survey 1998-99

World Health Report

Table 9
CONTRACEPTIVE PREVALENCE RATE

Bangladesh   India   Nepal   Pakistan

54           47      39      28

Source: World Development Indicators 2003

Table 10

ADOLESCENT POPULATION (10-19 YEARS) AS PROPORTION OF
TOTAL POPULATION

         Bangladesh   India    Nepal    Pakistan

           23.62       22.8    23.54      22.7

Year        2001       2001     2001      1998
Source     Census     Census   Census    Census

YOUTH POPULATION (10-24 YEARS) AS PROPORTION OF THE
TOTAL POPULATION

           32.49        30      30.9

Year        2001       2001     1996
source     Census     Census    NDHS

Table 11

BIRTHS PER 1000 (15-19 YEARS)

Bangladesh   India   Nepal   Pakistan

119          98      109     60

Source: world Development Indicators 2003

Table 12

HEALTH AS % OF GDP

             1998   1999   2000   2001   2002

Bangladesh   3.1    3.2    3.2    3.2    3.1
India        5.2    5.7    6.3    6.1    6.1
Nepal        5.1    4.8    4.7    4.9    5.2
Pakistan     3.5    3.6    3.3    3.2    3.2

Source: The World Health Report; 2005; 'Making every
Mother and Child Count'; World Health Organisation; 2005

Table 13
GOVT. HEALTH EXP AS % OF TOTAL GOVT. EXPENDITURE

             1998   1999   2000   2001   2002

Bangladesh   5.4    4.7    4.3    4.7    4.4
India        5.2    4.8    4.6    4.4    4.4
Nepal         7     5.9    5.6    6.2    7.5
Pakistan     4.2    3.7    3.3    3.5    3.2

Source: The World Health Report; 2005; 'Making every
Mother and Child Count'; World Health Organisation; 2005

Table 14
POPULATION AND DEVELOPMENT & ECONOMIC-SOCIAL-
CULTURAL-POLITICAL CONTEXT

INDICATORS-BANGLADESH

Indicator                   1995    2000    2007

Gross Domestic Product      1,230   1,361   2,053
Per Capita

Total expenditure on          3      3.1     3.1
health as percentage of
GDP

General sector exp. on      31.6    26.5    36.8
health as percentage of
total health expenditure

Private sector exp. on      68.4    73.5    63.2
health as percentage of
total health expenditure

Table 15
POPULATION AND DEVELOPMENT & ECONOMIC-SOCIAL-
CULTURA-POLITICAL CONTEXT.

                              INDICATORS-INDIA

Indicator                  1995    2000    2005/08

Gross Domestic Product     1,230   2,077    3,452
Per Capita

Total expenditure on        4.1     4.3      4.9
health as percentage of
GDP

General sector exp. on     26.3    22.2     19.6
health as percentage of
total health expenditure

Private sector exp. on     73.7    77.8     80.4
health as percentage of
total health expenditure

Table 16
POPULATION AND DEVELOPMENT & ECONOMIC-
SOCIAL-CULTURAL-POLITICAL CONTEXT.

                               INDICATORS-NEPAL

Indicator                  1995    2000    2005/08

Gross Domestic Product      --     1,157    1,550
Per Capita

Total expenditure on        5.3     5.4      5.7
health as percentage of
GDP

Generals ector exp. on     26.5    24.9     30.5
health as percentage of
total health expenditure

Private sector exp. on     73.5    75.1     69.5
health as percentage of
total health expenditure

Table 17
POPULATION AND DEVELOPMENT & ECONOMIC-SOCIAL-
CULTURAL-POLITICAL CONTEXT.

                              INDICATORS-PAKISTAN

Indicator                  1995    2000    2005/08

Gross Domestic Product     2,890   1,715    2,370
Per Capita

Total expenditure on        2.4     2.5      2.0
health as percentage of
GDP

General sector exp. on     26.3    20.0     16.44
health as percentage of
total health expenditure

Private sector exp. on     73.7    80.0     83.6
health as percentage of
total health expenditure

Table 18

FEMALE ECONOMIC ACTIVITY (AGE 15 AND ABOVE)

BANGLADESH   INDIA   NEPAL   PAKISTAN

66.5         42.5    56.9      36.7

FEMALE WORKERS AS % OF MEN

76            50      67        44

Source: Human Development Report 2005