#India- How to get justice from errant service or goods providers ? #mustshare #RTI


RAJ PRADHAN | 01/04/2013 12:50 PM | Moneylife.com 

Redressal of consumer complaints can entail approaching the insurance ombudsman, the consumer courts and even taking help of social media, RTI and police complaints. There are options available today to build pressure on errant service or goods providers so that they do the needful

 

A letter from Mohan Siroya, chairperson of the Consumer Complaints Cell, gives three examples of consumer power success using the help of the insurance ombudsman, Right to Information (RTI), social media activism and police complaints. Today, justice will be served if you are persistent in your efforts to pursue the errant service or goods provider. Aconsumer court may not be able to help in the absence of the postal address, but alternate means exists.
Case 1: A senior citizen was hospitalized in Seven Hills Hospital, Mumbai. New India Assurance Company refused to pay the claim of Rs12,148 submitted in August 2010. It argued about the lack of the original hospital bill/receipt, even though the insured provided documentary proof of having submitted the same. The insurer wrote a letter to the hospital asking for certain documents, including the hospital bill. It was but natural for the hospital to write the word ‘Duplicate’ on the bill as the original was already issued at the time of discharge. The insurer refused to accept this and declined to reimburse the claimed amount.
In the complaint to the insurance ombudsman, there was a claim of not only the claim amount but also‘compensation’ for undue delay in not settling/refusing to settle the claim on a flimsy or false ground and deliberate “mental torture” caused to a senior citizen. The ombudsman passed an award granting not only of the claimed amount, but also a penalty of Rs2,000, directly favouring the complainant in settlement within three working days, failing which  a fine of Rs500 would be payable  by the company for each day of delay. Usually, the ombudsman does not levy penalty, but it did in this case on the insurance company for wrongful delay and refusal.

Case 2: A consumer had purchased two heaters, which were offered cheap on the Deal92.com website as an online transaction. The online payment was made through a credit card. When the consumer received the ordered goods they were found in broken and in non-usable condition. The consumer protested on the only ‘email’ address available demanding either the replacement of goods or refund of entire paid amount. There was no response even after reminders. The National Consumer Helpline was unable to take the complaint for redressal in absence of any postal address of Deal92.com. Mr Siroya took recourse of putting this complaint on social networking websites. That defiled their name and potential customers were cautioned. The aggrieved consumer was also advised to raise a formal dispute to deny the payment made to the online merchant and treat it as a fraudulent transaction. This was done and a temporary credit was given in his account. This was further refurbished, when a complaint was filed with the cyber cell regarding this online fraud and praying to ban the seller’s website. That made Deal92.com to act. They refunded the entire amount to the same credit card account.

Case 3:  As a consumer activist, Mohan Siroya had filed a case at the MIDC police station for having received a threat on his mobile in May 2010, “threatening me to stop lodging complaints against the companies for Consumer Cause and Protection”. This particular case he was referring for the company “Fedders Lloyd” against which a complaint was sent by him to the then Union minister for civil supplies and consumer protection, Sharad Pawar. Another non-cognisable (NC) complaint was filed by him in the MIDC police station against a firm called “Modern Tech Services” for having failed to give the contracted service for second year of the contract. Mr Siroya tried to contact the firm’s office and proprietor but all the listed phones were not working/not in existence. A written notice was sent by Mr Siroya to the postal address printed in the contract/letter head. It transpired that now in that premises some other business, by some other party, was carried out. Mr Siroya filed a complaint of cheating and fraud for having failed to give the contracted service or refund of 50% of paid amount against the firm, whose address was now ‘Unknown’.
The police was requested to find out the person in whose account the cheque/ money was paid and his whereabouts. Mr Siroya made an application under RTI to know the progress. It came in mere two words “Under Investigation”. He then appealed to the First Appellate Authority (FAA) for specific “status/progress” of investigations made, besides complaint of delay in providing information. The FAA also simply ordered “As earlier informed Under Investigation”. The order reached Mr Siroya beyond 45 days of appeal date, thus another violation of the Act without giving any reasons for delay.
Mr Siroya went in for a second appeal to the SCIC (State Chief Information Commissioner), who within five months, heard his appeal. On the eve of hearing date, a police constable personally came to his home to deliver a letter that said, “In first NC, the police filed a case against one Mr Gupta under Section 504, 506 of IPC.” The second NC complaint against Modern Tech Services was of civil nature and I should go to the civil/consumer court,” Mr Siroya said.
In the hearing, the SCIC upheld delays under the Act and also for suppressing the available investigation progress/report on record. The Authority also agreed with the interpretation that in absence of a party whose whereabouts are unknown, is covered under ‘Fraud’ and thus the police is supposed to take cognisance of the same.
The SCIC further gave two specific directions—to summon the SPIO (State Public Information Officer) in person to explain “Why penalty under Section19 (8) (g) and Section 20 (1) should not be levied on him”, failing which orders will be passed under Section 20 (2)”. “Another landmark relief for me was that the concerned offices should furnish me an opportunity to inspect the information so far available on record on all such files free of charge. After two days, police started investigating about the address of the payee through the banking channels,” Mr Siroya stated.
The police machinery worked overtime, gave Mr Siroya updated information in both the cases, one through the CBI, as Fedders Lloyd Co was from Delhi. The other one they traced through the banking channel in Mumbai and made him to refund Rs1,000 in cash.

When High Court Judges usurp land meant for the homeless, where do the homeless seek justice?


Faiza Khan, Khar East Andolan

Posted on May 6, 2012

When you ask about the court cases in Golibar now, the residents will wrly reply with the famous Hindi film dailogue. “Tareek pe tareek! Tareek pe tareek! “. The hearing on this Monday, the 7th of May, will be 20 months since the Golibar criminal case has been in the Mumbai High Court. In 2009, builder Shivalik Ventures had faked signatures of residents of Ganesh Krupa Society (GKS) in Golibar to claim the 70% consent it needed to redevelop the Golibar slum. On that list of signatories was Sulochana Pawar who had died four years before she allegedly gave her consent. Going by the rules of the SRA, this should have, at the very least, led to the ouster of Shivalik Ventures from this redevelopment project.

Instead, the then Slum Rehabilitation Authority(SRA) chief, Mr. S. Zende (remember this name, it’ll come up again later!) asks the residents of GKS to settle for a compromise. The police had been even more nonchalant and refused to investigate the case until the Court directed them to do so. Once on it, they were so baffled by this seemingly obvious case of fraud that for 20 months, they’ve been seeking extension after extension to complete their investigation. The Court has been very obliging. Meanwhile MHADA’s demolition squads, with police protection continue to break people’s homes.

So the government is clearly not on their side, specially after it backtracked on the GRs last year. The police never was. Their only hope of any justice was in the Courts. Until the Nyay Sagar scam came to light.

Akankhsha tai and other women from Ganesh Krupa are huddled around a copy of Janta ka Aaina, a community newspaper. They burst into cackling laughter. “Yeh toh apna Chandrachud hai!“(This is our Chandrachud!). Apna Chandrachud is Justice Chandrachud of the Mumbai High Court who has been hearing the matter of the Golibar GR case in the High Court. Now he’s on the frontpage, accused in a major land scam, along with Justice Khanvilkar who is hearing the Golibar criminal case (of the forged signatures). There are 13 other Judges and ex-Judges accused.
Nyay Sagar and Siddhant are two multi-storeyed buildings built on a plot of government land that was reserved for the homeless. The judges of the High Court led by then Justice Rebello (now Chief Justice of the Allahabad High Court) formed Nyay Sagar Co-operative Housing Society in 2001 and in collusion with Vilasrao Deshmukh  de-reserved all but 10% of this land and appropriated it for themselves. This change in the Development Plan of this plot, Survey No 341 (Part) CTS No 629 from being reserved for the homless to Residential was facilitated by some very senior bureaucrats, including Mr. Zende (the SRA chief who asked residents of GKS to settle for a compromise). What is shocking though is that the land was handed over to Nyay Sagar CHS much before it was de-reserved.

View Larger Map

Even the de-reserving was a sham. Once it is decided that the reservation of a piece of land is to be changed, there is a notification which is open to the public for 30 days in case they have objections. This notification was made public on 16.6.2004 but just six days later, on 22.6.2004 ,the status of the land was modified. The Ghar Bachao Ghar Banao Andolan has filed a complaint with the Anti Corruption Bureau asking them to file an FIR.

Akanksha tai laughs when she reads the buildings are called Nyay Sagar (meaning Ocean of Justice) and Siddhanth (Principles). But then she asks soberly, “Now where are we to seek justice?”

THE WALL OF SHAME

THE ACCUSED IN THE CASE
1. Shri Vilas Rao Deshmukh, the then Chief Minister,
2. Shri Sangeetrao, the then Collector Mumbai Suburb,
3. Shri SS Zende, the then later Collector Mumbai Suburb,
4. Shri RC Joshi, Principal Secretary, Department of Revenue,
5. Shri Ramanand Tiwari, the then P. Secretary UDD,
6. Other Unknown Govt. Official/s.
7. Justice V C Daga,
8. Justice A M Khanwilkar,
9. Justice B R Gavai,
10. Justice S M Ghodeshwar,
11. Justice S Radhakrishnan,
12. Justice S A Bobde,
13. Justice P V Kakade,
14. Justice R Lodha,
15. Justice G D Patil,
16. Justice F I Rebello,
17. Justice D K Deshmukh,
18. Justice D B Bhosale,
19. Justice D G Karnik,
20. Justice J P Devdhar,
21. Justice DY Chandrachud


A letter from Justice Rebello to ex-CM Vilasrao Deshmukh misusing his official letterhead for a non-official matter
More documents will be made public soon.

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The Midwives Service Scheme in Nigeria


  • Seye Abimbola1*, Ugo Okoli1, Olalekan Olubajo1,Mohammed J. Abdullahi1, Muhammad A. Pate2,3

1 National Primary Health Care Development Agency, Abuja, Nigeria2Federal Ministry of Health, Abuja, Nigeria, 3 Duke Global Health Institute, Durham, North Carolina, United States of America

Citation: Abimbola S, Okoli U, Olubajo O, Abdullahi MJ, Pate MA (2012) The Midwives Service Scheme in Nigeria. PLoS Med 9(5): e1001211. doi:10.1371/journal.pmed.1001211

Published: May 1, 2012

Abbreviations: ANC, antenatal care; LGA, local government area; MMR, maternal mortality ratio; MNCH, maternal, newborn and child health; MSS, Midwives Service Scheme; NC, north central; NE, northeast; NMR, neonatal mortality ratio; NW, northwest; PHC, primary health care; SE, southeast; SS, south south; SW, southwest; WDC, Ward Development Committee

* E-mail: seyeabimbola@hotmail.com

Summary Points

  • Maternal, newborn, and child health indices in Nigeria vary widely across geopolitical zones and between urban and rural areas, mostly due to variations in the availability of skilled attendance at birth.
  • To improve these indices, the Midwives Service Scheme (MSS) in Nigeria engaged newly graduated, unemployed, and retired midwives to work temporarily in rural areas.
  • The midwives are posted for 1 year to selected primary care facilities linked through a cluster model in which four such facilities with the capacity to provide basic essential obstetric care are clustered around a secondary care facility with the capacity to provide comprehensive emergency obstetric care.
  • The outcome of the MSS 1 year on has been an uneven improvement in maternal, newborn, and child health indices in the six geopolitical zones of Nigeria.
  • Major challenges include retention, availability and training of midwives, and varying levels of commitment from state and local governments across the country, and despite the availability of skilled birth attendants at MSS facilities, women still deliver at home in some parts of the country.

Introduction

Nigeria, with more than 140 million people, including 31 million women of childbearing age and 28 million children under the age of five, is by far the most populous African country. However, the maternal mortality ratio (MMR) in Nigeria is 545/100,000 live births, as only one in three births in Nigeria is attended by skilled personnel, less than 20% of children are fully immunised at age one, and 36% of pregnant women do not receive antenatal care (ANC) [1]. Thus, strengthening these services is an urgent imperative.

Midwives Service Scheme: The Rationale

The slow rate of progress in Nigeria makes the Millennium Development Goals (MDGs) targets unachievable using current strategies alone [2]. Health indices in Nigeria vary widely across geopolitical zones (See Box 1) and socioeconomic groups [3]. The northeast (NE) zone has the highest MMR: 1,549/100,000 live births compared to 165/100,000 live births in the southwest (SW). There are also urban and rural variations with MMR of 351/100,000 live births in urban areas compared to 828/100,000 in rural areas. The under-5 mortality rate of 171/1,000 live births also varies between the lowest (219/1,000 live births) and highest (87/1,000 live births) wealth quintiles. This pattern is replicated in other indices of childhood mortality. Maternal, neonatal, and child mortality rates in Nigeria are highest in the NE and northwest (NW) zones and lowest in the southeast (SE) and SW [1]. However, although the rates are lower in the SE and SW, indices in these regions still fall short of global development targets.

Box 1. The Political Organisation of Nigeria

Nigeria is divided into 36 states and one Federal Capital Territory (FCT), which are further sub-divided into 774 local government areas (LGAs). There are six geopolitical zones in Nigeria: north central (six states and the FCT), northeast (six states), northwest (seven states), southeast (five states), south south (six states), and southwest (six states).

These variations in health indices are influenced by the presence of tertiary hospitals, social amenities, and a population that can afford to pay for health services that in turn attract highly skilled health workers [4]. Therefore, in much of rural Nigeria, beyond issues of access, there are inadequate human resources for providing 24-hour health services in primary health care (PHC) facilities [5]. Nigeria faces a crisis in human resources for health (HRH) in the form of health worker shortages, requiring an immediate and significant increase in the number of health workers [6], or in the meantime a strategic redistribution of health workers to grossly underserved rural areas (See Box 2).

Box 2. The Political Economy of Health Care in Nigeria

Health services in Nigeria mirror political organisation. The federal government is responsible for tertiary care, state governments for secondary care, and the local governments (LGs) run primary care. Health financing is tied to the flow of funds from the federation account, which are shared between levels of government according to an allocation formula that keeps about half of funds at the federal level, the 36 states share a quarter, and the other quarter is distributed to the LGs. These resources are not sectorally earmarked and the states and LGs are not constitutionally required to provide budget and expenditure reports to the federal government. This results in poor coordination and integration between levels of care, giving rise to a weak and disorganised health system with widely varying patterns of outcomes. The MSS is an unprecedented emergency stop gap collaborative effort among the three tiers of government to improve maternal and child health indices in rural Nigeria.

Efforts to better reach underserved communities have been on task shifting to community health workers (CHWs) [7]. While task shifting has offered a cost-effective expansion of the overall HRH pool, skilled attendance at birth is essential to reducing the burden of maternal mortality [8]. The shortage of skilled birth attendants in rural Nigeria impacts negatively on utilisation of services by women in these areas [5]. Launched in December 2009 , the Midwives Service Scheme (MSS) was set up to address the HRH needs in rural primary care, based on the evidence that when the number of midwives increases, utilisation of services increases, women’s satisfaction with care improves, and maternal and newborn mortality decrease [8],[9]. To do this, three categories of midwives were recruited as part of the MSS: the newly graduated, the unemployed, and the retired. They are posted for 1 year (renewable subject to satisfactory performance) to selected PHCs in rural communities.

Midwives Service Scheme: The Structure

The facilities selected for the MSS were linked in an effective two-way referral system through a cluster model in which four PHC facilities with the capacity to provide basic essential obstetric care were clustered around a general hospital with the capacity to provide comprehensive emergency obstetric care. There were 815 participating health facilities: 652 PHC facilities and 163 general hospitals. Each PHC facility has four midwives to ensure 24-hour provision of skilled birth attendance at all times, as well as other maternal and child health services.

MSS Geographical Distribution

The number of facilities in each of the six geopolitical zones was selected on the basis of maternal mortality burden. Nigeria was divided into three zones (Figure 1) according to MMR: very high MMR (NE and NW), high MMR (north central [NC] and south south [SS]), and moderate MMR (SE and SW). NE and NW have six clusters per state, SS and NC have four clusters per state, and SW and SE have three clusters per state. The project currently serves an estimated aggregate of 15 million people in Nigeria.

thumbnailFigure 1. The states of Nigeria and their MMR categories.

Red (northeast and northwest), very high MMR; yellow (north central and south south), high MMR; green (southeast and southwest), moderately high MMR.

doi:10.1371/journal.pmed.1001211.g001

Selection of MSS Facilities

Participating PHC facilities and general hospitals were selected based on rigorous criteria. Selected PHC facilities are in hard-to-reach areas or among underserved populations with a population of 10,000 to 30,000 people. The PHC facilities have potable water supply and offer 24-hour basic health services with minimum equipment including blood pressure apparatus, weighing scale, and basic laboratory diagnostic facilities for malaria and anaemia. Selected general hospitals provide basic services including ANC, child delivery, postnatal care, and family planning; comprehensive emergency obstetrics care and prevention of mother-to-child transmission of HIV (PMTCT) services; administration of antibiotics and intravenous fluids; and treatment of pre-eclampsia. The general hospitals have at least 12 maternity bed spaces, a functioning operating room, blood bank, and stand-by alternative power supply.

Midwives Service Scheme: The Process

Recruitment

The midwives under the scheme are selected with adherence to the International Confederation of Midwives (ICM) global standards for midwifery education [10]. The minimum entry level of students for midwifery education is completion of secondary education, and the minimum duration of A-Level-entry midwifery education is 3 years and 18 months for post-nursing midwifery education. The maximum age limit for recruitment is 60 years. Following an initial nationwide recruitment exercise, 2,488 (instead of the expected 2,608) successful midwives were deployed to 652 designated PHCs in the 36 states and Federal Capital Territory (FCT) on the scheme—45% of them are unemployed midwives recruited to the scheme, 44% are basic midwives during their mandatory pre-registration community service year, and 11% of them are retired midwives.

Continuing Medical Education (CME)

To enhance the quality of their services, midwives are trained quarterly in life saving skills (LSS) and integrated management of childhood illness (IMCI). The competency-based training sessions are conducted at schools of midwifery in each state. The trainings run for 6 consecutive days and the class size varies from 24 to 32 people. The training programme involves interactive theoretical and illustrative lectures with skills demonstration and practical sessions. There are initial practical sessions on dummies, then on consenting patients in the wards towards the end of the course. Participants partake in a course review and tests to assess the effectiveness of the training.

There are no defined entry criteria for the CME, as recruitment into MSS is an ongoing process to cope with the challenge of attrition. Thus, all recruited midwives are eligible for participation in both training programmes.

Political, Financial, and Community Commitment

Given the high level of fragmentation in the governance of the Nigerian health system (see Box 2), a crucial initiative of the MSS programme was for state and local governments to sign a memorandum of understanding with the federal government agency responsible for PHC in Nigeria, the National Primary Health Care Development Agency (NPHCDA), which is also the implementing agency for MSS. The state governments are expected to match with N20,000, the N30,000 monthly remuneration paid to the midwives by the federal government through NPHCDA.

In addition to the monthly stipend, the federal government provided basic health insurance coverage for all the midwives, provided midwifery kits for each of the participating PHC facilities and each midwife, and supplied a personal health record booklet, basic maternal and child health equipment, drugs, registers, and monitoring tools. The federal government funds the CME and provides technical support to the states and local government areas (LGAs) on the implementation, supervision, monitoring, and evaluation of MSS.

The state governments support the use of general hospitals as referral facilities for the MSS by upgrading the hospitals to provide comprehensive emergency obstetric and newborn care, including basic equipment and supplies such as drugs and other consumables, ambulance services, steady electricity and potable water supply, stationery, and security for health workers and equipment. The state governments also monitor and supervise the programme within their jurisdiction and coordinate the provision by LGAs of free decent accommodation in the host communities and at least N10,000 supplementary allowances for the midwives.

For each PHC facility, a ward development committee (WDC) made up of influential people in the community is established to enhance community participation and ownership and to promote demand for services. The WDCs meet monthly to discuss health and other developmental issues in the community under the supportive supervision of the LGAs. During the monthly WDC meetings, the midwives address any concerns of the community and brief the community on their work within the month, including their challenges. The WDCs in turn provide support to the midwives by ensuring their security and accommodation. While they do not routinely provide direct financial support for women seeking care, the WDCs support the transportation of pregnant women and neonates in cases of emergency. In addition to their clinical duties, the midwives serve as change agents in the target communities by working with WDCs to mobilise the people for health action and promoting women and child health care and home visits. Training for these roles is part of the basic midwifery training, and the midwives are involved in the creation of the WDCs.

Midwives Service Scheme: The Outcome

Monitoring and Evaluation Platform

MSS implementation was preceded by establishing key baseline maternal, newborn, and child health (MNCH) indicators to define goals and provide a clear framework for future evaluation. There was a nationwide survey conducted at all the facilities (primary and secondary) and communities where the intervention was located. Table 1 shows the seven core indicators of progress in the MSS, nationwide data from the Nigeria Demographic and Health Survey (NDHS) 2008, baseline data from the MSS primary care facilities, and the gains that the scheme hopes to achieve by 2015. Even though facility-based data are expected to reflect better indices, the baseline survey shows that MSS target areas are worse off compared to the national average (data from Nigerian Demographic and Health Survey 2008) even though the national data is population based.

thumbnailTable 1. MSS core indicators and projected outcome, with data comparing 2008 NDHS with MSS facility baseline data.

doi:10.1371/journal.pmed.1001211.t001

Impact of the MSS

Figures 25 show MNCH indicators for the six zones comparing data from mid to the end of 2009 and mid to the end of 2010. The gains of MSS have not been even across geopolitical zones, although it shows an overall improvement in the MNCH indices.

thumbnailFigure 2. MSS facility-based maternal mortality ratios comparing July–December 2009 with July–December 2010.

NE, northeast; NW, northwest; NC, north central; SS, south south; SE, southeast; SW, southwest; MSS, Midwives Service Scheme.

doi:10.1371/journal.pmed.1001211.g002

thumbnailFigure 3. MSS facility-based neonatal mortality ratio comparing July–December 2009 with July–December 2010.

NE, northeast; NW, northwest; NC, north central; SS, south south; SE, southeast; SW, southwest; MSS, Midwives Service Scheme.

doi:10.1371/journal.pmed.1001211.g003

thumbnailFigure 4. MSS facility-based maternal health indicators comparing July–December 2009 with July–December 2010.

ANC, antenatal care; TT, tetanus toxoid; FP, family planning.

doi:10.1371/journal.pmed.1001211.g004

thumbnailFigure 5. MSS facility-based maternal health indicators percentage increase from July–December 2009 to July–December 2010.

ANC, antenatal care; TT, tetanus toxoid; FP, family planning.

doi:10.1371/journal.pmed.1001211.g005

The facility-based MMR in the same period in 2010 was 572 compared to 789 per 100,000 live births for the same period in 2009. However, facilities in the NE and SE did not show a decrease in MMR when compared to 2009. The facility-based neonatal mortality ratio (NMR) in the same period in 2010 was 9.3 per 1,000 compared to 10.97 per 1,000 live births for the same period in 2009. Facilities in the NE, NW, and SW did not show a decrease in NMR when compared to 2009. The maternal health indicators show a general overall improvement over baseline: family planning visits, pregnant women with new ANC visits and those with at least four ANC visits, facility-based deliveries, and the number of women receiving two or more doses of tetanus vaccine.

The lack of improvement in MMR and/or NMR in specific zones may be due to an increase in the proportion of high risk deliveries in the MSS PHC facilities. As shown in Figure 4, the majority of the women who attend facilities ANC still deliver at home. The additional deliveries in MSS facilities are likely to be among women with high risk pregnancy who present too late for life saving interventions in pregnancy or the neonatal period. We hope that the continued presence of skilled birth attendants in the communities will ensure positive behaviour change, especially in seeking early and routine interventions from the PHC facilities.

These data provide useful information on the progress of MSS 1 year from establishment. There have been overall improvements in the provision of MNCH services in rural areas that usually lack skilled birth attendants such as midwives. The data also provide a powerful tool for advocacy to support the scheme particularly in the NE zone where the gains have been limited.

Midwives Service Scheme: The Challenges Top

  • The project is currently funded from the debt relief granted to the Nigerian government by the Paris Club. The greatest threat to MSS is the uncertainty about continued funding beyond the 3-yearcommitment from the grant. However, the National Health Bill passed in 2011 promises to further provide secure funds for the administration of PHC in Nigeria [11]. The state governments are encouraged to be fully involved in MSS programmes, as the plan is for them to gradually take over the scheme in their respective states.
  • Implementation of the memorandum of understanding signed with state and local governments is a persisting problem. This mainly involves provision of accommodation for the MSS midwives and irregular or delayed salary payment by state and local governments. Regular monitoring of the PHC facilities and midwives by field agents from the NPHCDA serves to coerce the state and local governments into fulfilling their roles.
  • Availability of qualified midwives poses a challenge to the success of the scheme particularly in the areas of most need: the NE and NW. Ongoing recruitment and deployment of midwives to these areas are strategies employed to overcome this problem.
  • Retention of midwives in the scheme is one of the major challenges. Most of the newly graduated midwives (44% of MSS midwives) are young, single, or newly married; a particularly mobile cohort who tend to return to their home zones (usually southern zones) after the completion of their 1-year mandatory pre-registration participation in the MSS. However, another set of newly graduated midwives replace the ones who leave at the end of the 1-year mandatory pre-registration programme.
  • Inadequate social amenities, language barriers between the midwives and the local community, and working in hard-to-reach rural areas are some of the factors responsible for attrition. Strategies and incentives used to overcome this include attractive pay package and provision of ambulances, accommodations, and health insurance coverage for the midwives. Some hard-to-reach areas in the northern zones (NC, NE, and NW) were further provided with an additional 1,000 CHWs. Two CHWs were deployed to each facility and they provide support and complement the work of the midwives. They are also encouraged to spend time within the community to identify women and children who need care and refer appropriately. There is a long-term plan to identify and train locals to become midwives who will then work within their own communities. There are also ongoing discussions around providing supervised home delivery as part of the MSS in order to better reach women, especially in northern Nigeria, who present for ANC, but choose to deliver at home for sociocultural reasons.
  • Current training of the midwives focuses mainly on LSS and IMCI. However, there is a need to also train them on other various critical aspects of health care such as PMTCT, family planning, and information and communications technology (ICT) skills. There is also a need for capacity building of the PHC team beyond just midwives.

Conclusion

The MSS strategy of the Nigerian government recognises that strategically redistributing and improving the skill set of existing cadres of health workers is achievable on a large scale. The initiative potentially serves as a model for other developing countries within and outside sub-Saharan Africa who may need to redistribute their health workforce to reduce the inequities that exist among geographical zones and between urban and rural areas.

Author Contributions

Wrote the first draft of the manuscript: SA UO. Contributed to the writing of the manuscript: SA UO OO MJA MAP. ICMJE criteria for authorship read and met: SA UO OO MJA MAP. Agree with manuscript results and conclusions: SA UO OO MJA MAP.

References Top

  1. National Population Commission (NPC) (2009) ICF Macro. Nigeria demographic and health survey 2008. Abuja, Nigeria: National Population Commission and ICF Macro.
  2. Overseas Development Institute (2010) Millennium Development Goals (MDG) report card: measuring progress across countries. Available: http://www.odi.org.uk/resources/download/5027.pdf. Accessed 22 March 2012.
  3. Harrison KA (1997) Maternal mortality in Nigeria: the real issues. Afr J Reprod Health 1(1): 7–13.FIND THIS ARTICLE ONLINE
  4. WHO (2006) Working together for health: the World Health Report 2006. Available:http://www.who.int/whr/2006/whr06_en.pdf. Accessed 22 March 2012.
  5. Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha MK, et al. (2006) Going to scale with professional skilled care. Lancet 368(9544): 1377–1386. FIND THIS ARTICLE ONLINE
  6. WHO/UNAIDS/PEPFAR (2008) Task shifting: global recommendations and guidelines. Geneva: WHO. Available: http://www.who.int/healthsystems/task_shifting/en/index.html. Accessed 22 March 2012.
  7. Samb B, Celletti F, Holloway J, Van Damme W, De Cock KM, et al. (2007) Rapid expansion of the health workforce in response to the HIV epidemic. N Engl J Med 357(24): 2510–2514. FIND THIS ARTICLE ONLINE
  8. Campbell OM, Graham WJ (2006) Strategies for reducing maternal mortality: getting on with what works. Lancet 368(9543): 1284–1299. FIND THIS ARTICLE ONLINE
  9. Betran AP, Wojdyla D, Posner SF, Gulmezoglu AM (2005) National estimates for maternal mortality: an analysis based on the WHO systematic review of maternal mortality and morbidity. BMC Public Health 5: 131. FIND THIS ARTICLE ONLINE
  10. International Confederation of Midwives (ICM) (2010) Global standards for midwifery education. Available: http://www.unfpa.org/sowmy/resources/docs/standards/en/R427_ICM_2011_Global_Standards_for_Midwifery_Education_2010_ENG.pdf. Accessed 22 March 2012.
  11. Federal Government of Nigeria (2011) National health bill 2011. Available:http://www.herfon.org/docs/Harmonised-NATIONAL-HEALTH-BILL-2011%20doc.pdf. Accessed 22 March 2012.

The Word on Women – Forced sterilization and the Millennium Development Goals


 

By Widney Brown

Two reports by the BCC this month raise the spectre that the United Nations Millennium Development Goals which include reducing maternal mortality and ensuring environmental sustainability may actually be undermining women’s sexual and reproductive rights.

The BBC has reported on the UK government’s Department for International Development is funding a program of forced sterilization of both men and women in India.

As happens all too often, poor tribal women seem to be particularly targeted for the forced sterilization.

And if being sterilized against your will is not bad enough, there are also reports of long term suffering because the procedures were botched.

The BBC also ran a shocking exposé on allegations of forced sterilization of women in Uzbekistan. In the report, an unnamed government official made the link between reducing fertility rates and the MDGs.

Since the world’s population topped 7 billion people toward the end of 2011, the language of “population control” has increasing crept back into the discourse. Implicit in the concept is a focus on preventing poor people from having a lot of children, echoing the ideas promoted by Thomas Malthus, a British clergy and economist in the late 1700s.

There is no question that an increase in the number of people in the world has a negative impact on the environment and biodiversity. However, returning to the draconian measures of forced sterilization undermines fundamental principles of human rights and ignores what we have learned about how to lower fertility rates without resorting to force.

Amnesty International has long warned the international community of the dangers of defining quantitative development goals without a strong normative human rights framework.

Public health logic may hold that reducing fertility rates leads to slower population growth and lowers maternal mortality rates. But forced sterilization violates the principle that men and women have a right to make independent choices regarding the number and spacing of their children without discrimination, coercion and violence.

Study after study demonstrates that empowering women through ensuring access to education, promoting women’s economic independence, and providing women access to comprehensive contraceptive and other health services reduces fertility rates and leads to better public health results. Where women are able to decide independently when, how often, with whom, and with what frequency to have children, the consequence is more often than not only do maternal and infant mortality rates go down, so too do fertility rates.

To be clear, forced sterilization is in and of itself a violation of human rights. It is the type of violation that has long term consequences for individuals and society. Perhaps most immediate is its destruction of the bond of trust between patient and medical service provider. When that bond is broken, women are less apt to see critical pre and post-natal care when they are pregnant.

There is speculation that the report by the BBC on Uzbekistan may mask another issue: women seeking sterilization but not informing their families because they will be ostracized for not wanting to have more children. But this alternative narrative underscores the importance of promoting women’s rights and gender equality to ensure that women and their partners can freely exercise their reproductive rights. Women who feel their only control over their fertility is to be secretly sterilized are clearly not able to make their own decisions.

Regardless of which explanation is correct in Uzbekistan, it highlights the integral connection between promoting women’s rights and gender equality and reduced fertility rates. Like Uzbekistan, India has a long way to go toward demonstrating its commitment to women’s rights and gender equality.

Rejecting forced sterilization policies does not leave governments’ with no alternatives. They can ensure that young people have access to comprehensive sex education and contraceptive services. They can discourage early marriage and promote education at the secondary and tertiary level paying particular attention to why women and girls often drop out of school.

Anti-natalist policies adopted by governments should not be discriminatory or undermine people’s fundamental rights.

The international community needs to pay heed to stories like these on India and Uzbekistan which so clearly illustrate how agreeing the Millennium Development Goals without ensuring a human rights framework for the goals, contribute to undermining women’s rights.

People living in poverty can be empowered through direct engagement in identifying the problems, defining and implementing solutions, and in evaluating the effectiveness of those solutions, thus promoting the sustainability of progress.

When the international community convenes in the next couple of years to decide a post 2015 development strategy, it is important that it take on board the dangers of promoting quantitative goals while ignoring the importance of human rights in empowering people living in poverty.

Without a human rights framework, people become the objects of government policies and practices, rather than empowered, unique, and autonomous rights holders. Development practices designed with normative human rights standards in mind enable people living in poverty to be the subjects actively working their way out of poverty.

Read Article here

Where Is the Anti-Choice Outcry Over North Carolina’s Forced Sterilization of Women of Color?



January 27, 2012 |

A task force in North Carolina recently ruled that survivors of that state’s eugenics program should be paid $50,000 each in financial compensation. Eugenics is often defined as the science of “improving” a human population by controlled breeding to increase the occurrence of “desirable” heritable characteristics. The practice of eugenics was not limited to Nazi Germany nor is it a well kept secret that’s been waiting to be discovered by organizations opposed to reproductive justice.

In America, state governments set up eugenics boards that determined the reproductive future of thousands. I grew up listening to my maternal Grandmother, a Mississippi native, warn against trusting doctors and passing along lessons she learned from other poor women of color who went into a hospital to give birth only to later find out that they were given a Mississippi Appendectomy without their consent. The horrific legacy of these state eugenics boards is one of the reasons why I embrace the reproductive justice framework advocating for the right to have children, not have children, and to parent children in safe and healthy environments.

From the early 1900s up until the 1970’s, over 30 states had formal eugenics programs. These programs enforced compulsory sterilization of individuals deemed to be “unfit” and “promiscuous.” States sterilized people that were disabled, poor, people of color, and immigrants. North Carolina had a particularly aggressive program that was alone in allowing social workers to select people for sterilization based on IQ tests. To date, only seven states have formally apologized for eugenics programs and no state has paid money to survivors. Although a task force appointed by the Governor in North Carolina ruled in favor of payment to survivors, their recommendations are now in the hands of state legislators.

Too often eugenics is looked on as a shameful part of German history and many Americans are unaware of the history of eugenics in this country. I’m reminded of the warning that those who cannot learn from history are doomed to repeat it. No, I’m not about to repeat black genocide claims that modern health care centers use contraception as a weapon or the ‘easily debunked if folks just used Google Maps’conspiracy theory about abortion clinics being located in predominately black neighborhoods. I’m referring to the history of government taking control over people’s reproductive future and how that component of the history of eugenics and is very present today. While those opposed to reproductive justice appropriate the language of Civil Rights to perpetuate bizarre anti-knowledge theories about dangerous black women and how we are the greatest threat to the newly identified species of “black child,” states that actually ran eugenics programs and sterilized thousands of people get little to no attention and all too often as not held accountable for those actions.

As for the doomed to repeat it part, many of those same states continue to seek dominion over women through everything from state mandated vaginal penetration of women seeking abortion services to a record number of restrictions hindering access to reproductive health care. States are gaining more control over people’s reproductive health care decisions and some organizations have even tried to get states to seize total control.

On the most basic level, the history of state eugenics boards is about the survivors. Their stories tell the tale of the damage wrought when government policy is used as a weapon to control the masses. Clearly that’s not a tale anti-choice folks opposed to reproductive justice are interested in making a flashy YouTube video about, because the sound of their silence on the news out of North Carolina has been deafening. With the exception of a few articles that chose to launch into another rant about Planned Parenthood rather than demand support for North Carolina’s survivors and a call for justice for victims of the other 30+ state eugenics programs, those who are usually eager to toss the accusation of eugenics out appear to be uninspired by cases of actual eugenics in America.

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