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Pandemic Setbacks, Sexual And Reproductive Health

Neeta Misra leads Policy Matters; a global initiative focused on economic recovery from COVID-19, centering on the economy, people, and vulnerable communities. In this edition, she speaks with Vivek Divan and Gargi Mishra from the Center for Health Equity, Law and Policy on Sexual and Reproductive Health and Rights (SRHR)

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Tell us a little bit about your organization and the work you do? 
The Centre for Health Equity, Law and Policy (C-HELP) is an initiative of the Indian Law Society, Pune. It uses the law as a critical tool for advancing and improving health delivery, access and outcomes. At the Centre, we believe that law can be used to enable rights-based change in relation to ‘health’ in all its dimensions. Our work is underscored by a commitment to the right to health and well-being for all, as enshrined in the Indian Constitution and India’s international obligations. Decades of experience in responding to the HIV/AIDS epidemic has strengthened our belief in the vital importance of rights-based law and policy in effective health planning and delivery that is alive to the needs of the vulnerable and marginalised. 

C-HELP undertakes research, advocacy, education, empowerment and literacy on the law, develops and disseminates knowledge products (such as, provides advisory services, and convenes forums to foster interdisciplinary thinking on health issues. 

Who are the most vulnerable within Sexual and Reproductive Health and Rights (SRHR) in India? 
Vulnerability in SRHR access and outcomes in India is a function of income, age, geographical locations, caste, sexual and gender orientation, occupation, disabilities and ethnicity. Adolescents, poor girls and women, those living in remote, hilly, or difficult terrains, LGBTQ (lesbian, gay, bisexual, transgender and queer) persons, sex workers, and persons with disabilities face greater hurdles in accessing quality and safe sexual and reproductive health services, facilities, goods and information. Women in prisons, trafficked persons, and women and girls living in conflict areas are subjected to violence and coercion, putting their sexual and reproductive health at risk.  

Laws act as barriers to SRHR, such as the criminalisation of consensual sex between adolescents and mandatory reporting of sexual offenses under the Protection of Children from Sexual Offences Act 2012 (POCSO). This discourages adolescents from seeking sexual and reproductive health information and services and puts them at greater risk of having unsafe sex, contracting sexually transmitted infections (STIs), and having unplanned pregnancies and unsafe abortions. 

Societal stigma, and harassment and insensitive treatment by healthcare professionals hinder transgender, intersex and other queer persons from accessing health services. They are also subjected to non-consensual and abusive medical procedures such as “conversion therapy”, forced medical examinations, and forced “corrective” surgeries. Sex workers face discrimination and humiliation that discourages them from accessing vital SRHR services. While the Immoral Traffic (Prevention) Act 1956 does not prohibit sex work per se it criminalises aspects of sex work, such as solicitation and living on the earnings of such work, arming police with wide powers of detention and arrest. It casts sex work beyond the pale of legality and renders sex workers vulnerable to criminal prosecution and police intimidation. This hinders sex workers’ free access to health services and increases their risk of being subjected to sexual violence and contracting HIV and other STIs, while at the same time being unable to use the law for their protection. 

Due to the patchy health infrastructure in the country, which is in any event concentrated more in urban areas, SRHR services including maternal health services are often out of reach for women living in rural and remote areas. Persons with disabilities are subjected to stereotyping, stigma and coercive medical practices such as hysterectomies which severely limit their sexual and reproductive health and rights.  

How has COVID-19 impacted (SRHR) in India? 
The COVID-19 pandemic severely strained the under-resourced and inadequately prepared health system in India. In the initial scramble to respond to the crisis, attention and healthcare personnel were diverted away from existing health concerns, including sexual and reproductive health.  

Lockdowns and unavailability of transport negatively impacted women’s access and uptake of contraception and abortion services, resulting in unintended pregnancies and unsafe abortions. It became even more difficult for women to access health services safely and privately, exacerbating the lack of agency over their reproductive choices. The COVID-19 response disrupted routine ante-natal check-ups and immunizations, increasing the risks of maternal and child mortality and morbidities. Women in labour struggled to find admission in hospitals, being turned away or facing delayed care due to unavailability of beds and ambulances, lack of COVID-19 obstetric wards, or insistence on COVID-19 tests. In some cases, the fear and stigma of COVID-19 discouraged pregnant women and their families from accessing hospitals. In Meghalaya alone, this resulted in the deaths of 877 new-borns and 61 mothers. In other cases, women were forced to deliver on the streets or rely on untrained midwives.  

The lockdowns, and consequent unemployment, confinement, and lack of access to social networks and services, also resulted in an increase in cases of intimate partner violence and forced and early marriages. Indeed, this also increased the risk of rape and unwanted pregnancies.  While data is sparse, it has been observed that queer persons faced greater domestic violence, surveillance, and harassment during the lockdown. The pandemic worsened discrimination faced by transgender persons in healthcare facilities and disrupted their access to therapies required for gender transitioning and for HIV/AIDS treatment. Sex workers faced a loss of livelihood and disruptions in their access to HIV/AIDS treatment and SRHR services, including family planning services. 

What are the policy implications? 
The right to health, which includes sexual and reproductive health, is an integral part of the right to life guaranteed under our Constitution, and the obligations of the State extend to maintenance and improvement of public health and providing adequate medical facilities. The government is obliged to take steps to fully realise the right to health in all its dimensions, and this includes adopting laws and policies that ensure equal access to health care and related services.  

India should guarantee universal and equitable access without discrimination to good quality and affordable SRHR information, services and facilities, with a particular focus on women and men from marginalised and vulnerable groups and contexts, and trans and intersex persons. Indeed, with a big push towards universal health coverage in India these critical aspects of SRHR must be at the heart of a fair and non-discriminatory health system. 

Laws, policies and programmes on SRHR should be formulated and implemented through a participatory process of community empowerment and mobilisation as this would ensure that policies are sensitive, supportive and responsive to the needs of users. Meaningful participation of vulnerable and marginalised groups is crucial for this.  

A few specific aspects include: laws and policies that criminalise or hinder access to SRHR services, such as mandatory reporting under POCSO and criminalising aspects of sex work, should be amended or repealed. Use of telehealth services should be encouraged to increase access to medical abortion and contraception, while ensuring privacy and confidentiality. Healthcare providers should be trained, including with appropriate changes in medical education, to provide respectful and quality SRHR services for all. All persons should also have access to comprehensive education on sexual and reproductive health that is evidence-based and scientific. 

Tell us about the Lancet Commission that you are a part of? 
The Lancet Citizens’ Commission on Reimagining India’s Health System is an endeavour to lay out the roadmap for achieving universal health coverage (UHC) for India in the coming decade. The Commission is expected to formulate ways to achieve a resilient health system in India that is comprehensive, equitable, accountable, inclusive, of good quality and accessible to all citizens. 

C-HELP has been tasked by the Commission to examine law and policy dimensions related to UHC. The scope of the investigation is multi-fold, encompassing the groundings of Indian law and policy in rights-based paradigms, right to health jurisprudence, implementation of social justice and other health sector legislations in India, and the law and policy implications on a rapidly evolving technology and health environment. 

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