Listening to Marginalised Women to Get to the Root of India’s Health Crises

10th February, 2022.      //   Health  // 

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The Leave No One Behind (LNOB) India Coalition’s 100 Hotspots project has been highlighted by the UN as an SDG Good Practice. Recently the project conducted community consultations to understand the impact of COVID-19 on five marginalised groups in India: sex workers, single women, Chudihara Muslims, the Sahariya tribal group, and the Pahari Korwa tribal group.

The consultations underscored the need for the Indian government to urgently prioritize the needs of marginalised communities and to follow the policy recommendations identified by the communities themselves, if it is truly committed to leave no one behind in its implementation of the Sustainable Development Goals (SDGs).  Without understanding the stories told by sex workers, the ambition set in SDG 3 will simply flop.

Iniya, age 53, lives in Madhya Pradesh State in central India. She lost both of her parents to COVID-19-related complications. Two weeks later, her husband of 36 years also succumbed to the virus. She herself barely survived a terrible COVID-19 infection.Iniya is a member of the Sahariya tribe, and the COVID-19 pandemic has taken a particularly severe toll on her people. Thousands of lives have been lost.

The Sahariya are a forest-dwelling tribe of over 600,000 people, among the most marginalised groups in India. They are classified by the national government as a Particularly Vulnerable Tribal Group, considered one of the country’s most disadvantaged and vulnerable populations. Iniya is a composite character based on multiple members of the Sahariya community.

The Indian government has developed initiatives targeted at reaching and supporting the Sahariya community, but the initiatives have failed to adequately connect with the community. In the absence of up-to-date disaggregated data, government programmes are not able to account for the unique circumstances and needs of the Sahariya, nor to effectively address the tribe’s challenges in accessing health care and other vital public services.

The LNOB Coalition in India, led by Wada Na Todo Abhiyan, a platform that brings together 4,000+ civil society organisations across the country, knows that the best way to improve the lives and livelihoods of marginalised communities is to speak directly with their members. WNTA trains members of marginalised communities to collect and generate data on their priority concerns, helping to inform effective public policies and services that leave no one behind.

“As we carefully listen to the voices of erstwhile invisible or hard-to-reach women, we’re convinced that widows and female sex workers, in fact all marginalised groups, have knowledge over what needs to be fixed first,” said Annie Namala, Convenor of Wada Na Todo Abhiyan. “The marginalised groups are bringing alternative evidence-based and geography-focused data for the localisation of SDGs.”

Barriers to health care

Living in remote rural areas, the physical distance to health care facilities is a principal barrier for members of the Sahariya tribe to access urgent medical care in the best of times, let alone during a global health crisis that has resulted in the reallocation of already scarce resources across India.

In community consultations in Madhya Pradesh State, members of the Sahariya tribal group like Iniya voiced particular concern about the lack of access to health care. The nearest government hospital is 30 kilometres away; an insurmountable distance for those without any means of public transportation or the money to pay for private transport.

With an average household income of just above Rs. 2500 per month (USD 33), members of the Sahariya community here live well below the poverty line. This leaves most medical care out of reach. According to community representatives, maternal mortality and tuberculosis infection are common, and have worsened during the pandemic. With low literacy rates in the community, misinformation about COVID-19 has spread easily, and personal protective equipment such as masks and sanitizers has been out of reach for many.

Lost livelihoods mean lost health care

Sex work remains a socially stigmatized profession in India, and sex workers have been hit particularly hard by the COVID-19 pandemic, both through loss of livelihood and because they have been excluded from most government relief efforts for other vulnerable populations.

The LNOB Coalition collected primary data from 100 sex worker households in Maharashtra and Telangana States as part of its first 100 Hotspots study in December 2019. Since then, the coalition has held follow-up consultations in the past year to understand the specific impacts of COVID-19 on sex workers and their families. The consultations confirmed that since the beginning of the pandemic, sex workers have experienced limited to no business, especially during complete lockdown.

The resulting loss of income has not only limited sex workers’ access to health care, but also destroyed their livelihoods. Outside of pandemic conditions, surveyed sex worker households already spent more than 40% of their average annual income on health care expenses. With business evaporating during the pandemic, sex workers struggled to pay for essentials such as food and housing.

Access to medical care has also declined as the government has reallocated resources. With COVID-19 stretching the state healthcare system thin, resources and medical personnel previously dedicated to sexual and reproductive health are not readily available.

For sex workers, this has led to impossible choices. Mobility constraints during the lockdown in addition to supply shortages restricted access to contraceptives, making sex workers more vulnerable to sexually transmitted infections. Moreover, dwindling incomes and the absence of alternative employment compel them to accept whatever work comes their way, including engaging in unsafe sex for much lower wages.

Because of the severe impact of the pandemic on sex workers’ lives, mental health concerns are also on the rise. According to the LNOB Coalition, “closure of government health facilities and limited access to counselling services increased incidences of depression and suicide in the community.”

The National Network of Sex Workers has been at the forefront of organizing immediate support and relief for sex workers during the COVID-19 pandemic in the absence of government action, but it is not enough. The LNOB Coalition calls on state governments to create facilities managed by government functionaries and trained community volunteers for the community to access medication, COVID-19 vaccines, nutritious food, and other urgent needs.

Building forward towards localised action on SDGs

“Without understanding the stories told by sex workers, the ambition set in SDG 3 to realise healthy lives and promotion of well-being for all at all ages, will simply flop,” says Namala.

Still, Namala is hopeful that the National Institution for the Transformation of India (NITI Aayog), the body of the union government responsible for SDGs coordination and reporting, will follow suit and recognise the voice and agency of people like Iniya and the sex workers that shared their concerns.

She adds that at the end of the day, “without attaining health rights, progress in many of the SDGs will be rolled back by the stress of the coronavirus pandemic.”

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