📰 Killing the licence: On NGOs and funding
The Government must give a more transparent account of its actions against NGOs
•If the past few years of enhanced measures against non-governmental organisations (NGOs) operating in India had not put enough of a squeeze on them, then the Ministry of Home Affairs’s long-drawn-out process of scrutinising their foreign-funding licences by year-end is sure to do so. Close on the heels of the news that the Missionaries of Charity group had been denied a renewal of its licence under the Foreign Contribution (Regulation) Act, 2010 (amended in 2020), comes the revelation that more than four-fifths of the applications of the 22,000-plus NGOs that have sought renewal have yet to be scrutinised. Unless the Government extends the deadline by midnight, all of them stand to lose their ability to access international funding in the new year. As experts have explained, the NGOs have to prove not only that the source of funding and their usage of the funds is appropriate but also establish that their work does not qualify as harmful to “public interest” or “national security” — ambiguous terms that are left to MHA officials to define. So, as many as 2,000 NGOs under scrutiny may be denied a renewal of their FCRA licence as the Missionaries of Charity and its roughly 200 homes around the country have been in this round.
•Contrary to the Government’s defence that it is only following accounting and audit procedures, it seems clear that organisations that have particularly faced the Modi government’s ire are those that work in specific “sensitive areas”: pollution and climate change issues, human rights, child labour and human slavery, health and religious NGOs, particularly Christian and Islamic charities. Prominent names among nearly 20,000 NGOs to have lost their foreign-funding licences since 2014 include Amnesty International, Greenpeace India, People’s Watch, European Climate Foundation, Compassion International and the Gates Foundation-backed Public Health Foundation of India. If the Government has ample evidence to prove that Indians are better off without the work of these internationally renowned organisations, then it has yet to show it. It is time the Government gives a more transparent account of its actions against NGOs, which at present appear to mirror those in China and Russia which have used their NGO laws to shut down dissent and criticism. The actions in India over “foreign hand” concerns seem more hypocritical given the relative ease with which political parties are able to access foreign funds for their campaigns through electoral bonds, under the same FCRA that seeks to restrict funds to NGOs. At a time when India is facing the crippling effects of the COVID-19 pandemic and a long-term economic crisis, the Government’s moves that have resulted in an estimated 30% drop in international non-profit contributions, only hurt the poorest and most vulnerable recipients of philanthropic efforts, particularly those by NGOs working in areas where government aid fails to reach.
Its fifth edition has encouraging news but addressing discriminatory social norms must remain top priority
•The health system in India has been facing unprecedented stress during the COVID-19 pandemic which includes the looming Omicron threat now on the horizon. Against this backdrop, the recently released fifth edition of the National Family Health Survey (NFHS)-5 brings some positive news. NFHS-5, which presents a bird’s eye view of the state of the nation’s health and related development indicators, looks encouraging on several fronts: population growth is stabilising, family planning services have improved, and health systems are delivering better.
•However, it also highlights the need for further improvement to address gender-based violence and harmful practices against women and girls, such as child marriage and gender-biased sex selection. These have been exacerbated by discriminatory social norms and practices hindering the achievement of the Sustainable Development Goals (SDG) 2030 Agenda and India’s development goals.
Population is stabilising
•The good news is that India’s population growth appears to be stabilising. The Total Fertility Rate — the average number of children born per woman — has declined from 2.2 to 2.0 at the national level. A total of 31 States and Union Territories (constituting 69.7% of the country’s population) have achieved fertility rates below the replacement level of 2.1.
•The main reasons for decline in fertility include: Increase in adoption of modern family planning methods (from 47.8% in 2015-16 to 56.5% in 2019-21) and a reduction in unmet need for family planning by 4% points over the same period. This indicates significant improvements in access to family planning related information and services.
•Increased reach of the health system to more non-user couples with information about family planning (from 18% in 2015-16 to 24% in 2019-21). Further, 62% of current users have received information about the side-effects of contraceptives — a crucial indicator of the improved quality of family planning services.
•Significant improvements in female literacy, with 41% women having received 10 or more years of schooling (compared to 36% in 2015-16). Girls who study longer have fewer children, and are also more likely to delay marriage and find employment. In other Asian countries too, fertility decline has taken place alongside notable improvements in access to quality education, especially girls’ education.
Improved health delivery
•Maternal health services are steadily improving. Antenatal care in the first trimester has increased by 11.4% points (from 2015-16 to 2019-21) to reach 70%; the recommended four antenatal care check-ups have increased by 7% points to reach 58.1% and postnatal care visits have gone up by 15.6% points to reach 78%. Institutional births were accessed by 88.6% of women in 2019-21, marking an increase of 9.8% points from 2015-16. There has also been an increase in institutional deliveries in public health facilities (52.1% to 61.9%), demonstrating an improvement in quality of services.
•The survey indicates a worrisome figure of 11% of pregnant women who were still either unreached by a skilled birth attendant or not accessing institutional facilities. Further analysis reveals an institutional delivery rate of under 70% in 49 districts of India. Over two-thirds (69%) of these districts are from five States (Nagaland, Bihar, Meghalaya, Jharkhand and Uttar Pradesh), indicating the need for an area-specific approach to improving maternal health services. Teenage pregnancy has declined marginally by 1% point, and 7.9% of women in the age group of 15-19 years who were already mothers or pregnant at the time of the survey. This highlights the need to invest in comprehensive sexuality education as a key component of life-skills education for both in school and out-of-school adolescents, and ensuring access to quality sexual and reproductive health services for them. A very small segment of the population is currently accessing the full range of sexual and reproductive health services such as screening tests for cervical cancer (1.9%) and breast examinations (0.9%). These services should be included while expanding the basket of reproductive health services.
Discriminatory social norms
•Evidence indicates significant progress where women have the right to bodily autonomy and integrity, and the ability to take decisions about their lives. It is heartening to see that the proportion of women (aged 15-24 years) who use menstrual hygiene products has increased by almost 20% points between 2015-16 and 2019-21 and currently stands at 77.3%. The proportion of women who have their own bank accounts has gone up by 25.6% points over the same time period to reach 78.6%. Around 54% of women have their own mobile phones and about one in three women have used the Internet. This, coupled with the increase in the proportion of women with more than 10 years of schooling, lays the building blocks for women’s empowerment. In the next few years, the combination of mobile technology, banking, education and women’s economic empowerment will be significant drivers to address informal discriminatory norms.
•To empower women and ensure gender justice, it is imperative to address harmful practices, such as child marriage and gender-biased sex selection. The prevalence of child marriage has gone down marginally from 26.8% in 2015-16 to 23.3% in 2019-21. Similarly, sex ratio at birth has shown slight improvement (from 919 to 929 over the same time period). One in three women continue to face violence from their spouse. Hence, there is a need to enhance the value of women and girls by working on transforming unequal power relations, structural inequalities and discriminatory norms, attitudes and behaviours.
Promote gender-equal values
•Women’s participation in the economy continues to remain low (only 25.6% women engaged in paid work, a meagre increase of 0.8% point). Women still bear a disproportionate burden of unpaid domestic and care work, hindering their ability to access gainful employment. This points to the need for engaging with men and boys, particularly in their formative years, to promote positive masculinities and gender-equal values.
•The pace of progress between one NFHS and the next should be accelerated by devising targeted strategies based on specific indicators and regions that are currently lagging. Convergence among multiple stakeholders is critical to bring about the desired change. Together, we must challenge discriminatory social norms that drive gender-based violence and harmful practices, and empower women to exercise agency and autonomy in all spheres of life. Women and girls having agency and bodily autonomy is not only the foundation for a better future; it is a fundamental human right.
📰 Should vaccination be made mandatory?
While some rules can be enforced to ensure coverage, it is important to focus on awareness
•It is going to be almost a year since vaccination against COVID-19 was rolled out in India for the adult population. In the midst of this massive drive, there have been numerous challenges including vaccine hesitancy and shortage in supplies. The latest issue is that some States have come up with their own strategies to ensure wider vaccination coverage — such as by making vaccination mandatory for entry into public places and workplaces — even though the Central Government has maintained that vaccination is voluntary. In a conversation moderated by Serena Josephine M., K. Kolandaswamy and G.R. Ravindranath discuss whether vaccination should be made mandatory. Edited excerpts:
What is your assessment of India’s overall vaccination performance so far? During the initial days, there was vaccine hesitancy and there were supply issues. Do you think we could have done better in terms of creating awareness among the people?
•K. Kolandaswamy: I think the COVID-19 vaccination programme is going on well. These are new vaccines, and perhaps for the first time, the whole population is getting vaccinated in such a short duration. The issues in vaccine supplies and logistics have been rectified now. The vaccination drive was done in a phased manner. We started with healthcare workers, frontline workers, then persons aged 60 years and above, then persons aged 45-plus with co-morbidities, and finally, persons above 18 years. There is reasonable vaccination coverage across the country. I think more than 142 crore doses have been administered in India, of which 8.2 crore doses have been administered in Tamil Nadu. But the last mile reach has become a challenge, particularly among the 50-plus population who have either received the first dose but are reluctant to get their second dose or have not received even their first dose yet. It is important to reach out to people who are still reluctant to get vaccinated. I feel we need to intensify efforts to educate people and take other approaches to reach out to them. We can enforce legal measures as well.
•G.R. Ravindranath: Not only awareness, but also factors such as availability, accessibility and acceptability are important. We had problems with all these factors in the initial stages. There was vaccine hesitancy initially.
•Compared to some developed countries, India’s vaccination coverage is poor. Many countries are moving towards booster doses, but we have not completed vaccination of all the eligible persons with even the first dose of the vaccine. Almost 23% of healthcare and frontline workers are yet to get their second dose in India. This is a huge crisis in public health as they will have to treat patients in case of a third wave. Even in Tamil Nadu, one crore eligible persons are yet to take the first dose, while 93 lakh are due/overdue for their second dose. Governments should have promoted scientific awareness and ensured accessibility. So, we have a lot more to do. Anti-vaxxers are actively spreading a lot of rumours, pseudoscience and unscientific information. Rumours are spread on social media and through WhatsApp. So, we have a big task at hand. The government should make vaccination a people’s movement by involving people from all walks of life.
Is it feasible to make vaccination mandatory? Historically, have governments made any vaccination programme mandatory? Some States are aiming at 100% coverage. Is this possible?
•K. Kolandaswamy: Yes, it is feasible. I can claim to have the right to not get vaccinated but others are at risk of getting infected by me. So, my right ends when someone else’s right starts. Rather than the individual’s right, the community’s right, safety and health are top priority. In a classic example, smallpox, a dreaded disease, was eradicated by making vaccination compulsory from 1965 to 1975. Across the country, COVID-19 has been declared a notifiable disease under different Acts of the States or the Epidemic Diseases Act. In Tamil Nadu, the State government declared it a notifiable disease under the Tamil Nadu Public Health Act of 1939. So, local health authorities have the power to make vaccination mandatory under Section 76. If anyone seeks exemption, they will have to approach the Judicial Magistrate. They cannot refuse to get vaccinated unless on acceptable medical grounds; unless vaccination could endanger their lives, which is very rare. So, enforcing legal measures to make people get vaccinated is highly feasible.
•G.R. Ravindranath: It is possible to achieve 100% vaccination by intensifying campaigns, promoting vaccination and putting indirect pressure on the people. Some cities have already achieved 100% coverage (first dose). We have to study such models. The Nilgiris district model in Tamil Nadu is one. Many countries have made vaccination compulsory. Tamil Nadu has made vaccination mandatory for entry into public places.
•The rights of an individual can be curtailed for the rights of the community. During a pandemic, we have to look at the community’s rights. But we ought to come up with counter campaigns against anti-vaxxers who are spreading several rumours such as ‘vaccines could produce infertility’ or ‘vaccines could alter the DNA in the body’. We need to educate people about the importance of getting vaccinated — we need to tell them that it is a powerful weapon against the pandemic and will prevent severe disease, hospitalisation and death. A vaccine not only protects the individual but also safeguards others. Vaccination has brought in several changes in our lives. It has eradicated smallpox. Polio should be eradicated soon. Millions of children have been protected due to vaccination.
The Central government has maintained that vaccination is voluntary, while noting that any misconceived doubts could result in vaccine hesitancy. Do you think governments have created adequate awareness on vaccines and their possible adverse effects? There are still some who fear vaccines. Has enough trust been built among the people?
•K. Kolandaswamy: The vaccination coverage achieved so far would not have been possible but for the education, awareness and trust built among people. At the same time, we should further educate people in a very focussed manner. Governments and health departments are taking adequate measures but we can still list out these population sub-groups and take up targeted efforts to create awareness. We need to focus on educating people and make sure that 100% immunisation is achieved. This may take a little more time. In public health, we believe in the education and service approach much more than the legal approach. At the same time, legal measures could be used appropriately — by restricting entry, incentives or disincentives — to convince people to get vaccinated. Rumour-mongering groups and anti-vaccine lobbies must be dealt with seriously, and legal action should be taken against them.
•G.R. Ravindranath: Steps to create awareness have been taken by governments but they are inadequate. There should be innovative and creative advertisements in the media to draw people towards vaccination. We can take up door-to-door campaigns with local groups. In some districts, they have achieved complete vaccination by involving local people for campaigns. Panchayat leaders, ward members and women from self-help groups should be first made aware and then educate the public. We have to make a lot of effort to promote vaccines. There are aggressive campaigns against vaccines. We have to rely on science.
Let’s look at vaccine equity and access. Has vaccination reached even the remotest villages in the country?
•K. Kolandaswamy: Yes. We have come across several video clippings of healthcare workers travelling to inaccessible and remote places such as hillocks and forest areas. Initially, we had issues in the availability of vaccines and logistics. These issues have been solved gradually. Accessibility and availability have been fully addressed. Now the real challenge is to reach the reluctant population.
•G.R. Ravindranath: Eligible persons should be vaccinated by the middle of next year. For this, vaccine equity is very important. Many Western and developed countries have more vaccines than they require and are wasting/stockpiling vaccines, while low-economic countries do not have sufficient vaccines. In fact, only less than 20% have been vaccinated in low-economic countries. This is a huge problem and will create a lot of new strains or variants in the future. This is why the World Health Organization has stated that instead of giving booster shots to all, we must provide two doses of vaccines to all the eligible people across the world. Developed countries have a big role to play. They should understand their responsibilities and the problems faced by developing and low-economic countries. The COVAX programme should be respected. All countries producing adequate vaccines must supply them to the COVAX programme of the WHO. India has a lot of manufacturing capacity. So, the government should take measures, and also involve public sector companies in vaccine production.
Do you think there is transparency on reporting adverse events following immunisation in the country?
•K. Kolandaswamy: Reporting of adverse events is systematically done at the primary, sub-centre, block and district levels. There are various committees that include specialists who go through the reports. I strongly believe that adverse events following immunisation are reported in a transparent manner. There is no need for any doubt on the reporting of adverse events following immunisation and the safety of vaccines. People who have any fears can get vaccinated in a larger facility where there are many doctors and emergency services.
What should be the way ahead in promoting vaccination among people?
•G.R. Ravindranath: Governments should come up with advertisements on television or newspapers. There should be adequate stock of vaccines, while newer vaccines should be introduced. We should vaccinate children, while booster doses should be administered to the eligible population. We must increase vaccine production and supply for poor countries to end the pandemic. Governments should provide incentives for people who get vaccinated. Building the confidence of people is very important.
•K. Kolandaswamy: The focus should be on educating people by involving doctors, community influencers such as religious leaders, political leaders, panchayat leaders and other influential groups, frontline and healthcare workers. I think we can promote vaccines by putting social and legal pressure on the reluctant population and taking stringent action against anti-vaxxers. If full vaccination is achieved in the next few months, and we consider vaccinating children, the overall incidence of COVID-19 will come down.
