V. Improving Accountability:  Reforming Grievance and Redress Mechanisms and Creating Emergency Response Systems

Establishing an Emergency Helpline

To protect the health of pregnant women and prevent maternal deaths and injury, it is important that authorities take steps to avert possible maternal deaths once they are alerted that such risks are present.

One such step is establishing an emergency response system which can make prompt interventions when authorities learn that a pregnant woman is facing barriers to care. Where delays in care are due to lack of communication or coordination between health facilities or due to demands for informal monetary payments, discriminatory treatment, or similar factors, the authorities should be notified and be in a position to intervene and take corrective measures.

Newspaper reports from Uttar Pradesh suggest that in the few cases where activists or journalists were able to bring to the attention of district medical authorities cases of denial of health care to pregnant women, authorities intervened to ensure that the women were provided immediate medical attention. The authorities should ensure that this intervention capacity is replicated on a permanent stand-by basis. One format that this could take is the creation of an emergency helpline under the control of district-level authorities who have the power to intervene and make decisions. As a prominent human rights lawyer from Allahabad, K. K. Roy, pointed out, while remedies such as public interest litigation and complaints to state human rights commissions are important, "they are like a fire brigade-they fix the problem after the fire breaks out." Continuing this analogy, he said, "the fire should be prevented."[363] 

Role for an Ombudsman's Office

An emergency response system should be supplemented by a facility-level or regional investigative authority such as an ombudsman. The ombudsman would inquire into complaints about the women's treatment or denial of care in health facilities irrespective of whether it results in a death or disability. The reasons may include corruption, discriminatory or abusive treatment, lack of facilities, and so on. For example, a pregnant woman may have complaints about abusive treatment at the time of delivery-beating, pinching, name-calling-even though she delivered safely. Following such a complaint, the ombudsman should look into the facts, and recommend remedies for the patient concerned, including compensation where appropriate, as well as other recommendations to improve delivery of health services.

Absence of accessible, independent, and transparent redress mechanisms contributes to patient frustrations, which at times boil over.  One health worker said,

Why do people gherao [surround] the hospital? They have no one who listens to them. If they had someone who could make arrangements for them and understand their problems, then maybe they would not have to come to the streets.[364]

Doctors, staff nurses, and health workers consistently reported to Human Rights Watch that even in cases where they were not able to provide appropriate assistance because of non-availability of drugs, the required expertise, or facilities, "patients did not understand," leading to confrontations between health staff and relatives, or gheraos [protests in which angry family members and others surround the hospital]. This has further exacerbated the problem of access to timely and appropriate care for pregnant women because doctors and nurses have become increasingly reluctant to admit patients presenting what they perceive as "risky cases."[365]

Ruth Daniel, president of the Uttar Pradesh Nurses Association, explained how the lack of a complaints procedure coupled with a poor ratio of staff nurses to patients caused a lot of patient-nurse conflict. She said, "There are a number of cases where our nurses get suspended, dismissed, [have] gone to jail .... I have nurses who are beaten and are scared to work."[366]

Problems with Existing Complaints Mechanisms

Women's Poor Awareness of Entitlements

Poor awareness of services offered under government schemes is the first barrier to making a complaint.[367] On paper, the NRHM provides a host of service guarantees, but these are seldom effectively communicated to pregnant women in rural areas. For example, even though community health centers visited by Human Rights Watch had big painted walls providing some information about the JSY and the duties of the ASHAs in Hindi, most families, especially pregnant women, were unaware of their entitlements under the JSY or the NRHM service guarantees. They only seemed aware of the 1400 rupees (US$28) cash incentive that would be given to them for a facility-based delivery. Almost all poor women reported paying money in government facilities despite being entitled to free antenatal, intra-natal, and postnatal care under the NRHM.[368] Several women including ASHAs reported that staff nurses in government hospitals had demanded money for the delivery, refusing to hand over the delivered baby unless money was paid to them.[369]

The government should consider disseminating information about NRHM entitlements in a manner that can be understood and utilized by women from vulnerable communities with little or no formal education.

Poor Access to Grievance Redressal Procedures

Even women who are aware of their entitlements and feel aggrieved by the treatment meted out to them in health facilities can find they have no way of registering and processing complaints. Government officials gave Human Rights Watch conflicting accounts of procedures for grievance redressal. Some stated that women could make complaints to superintendents or medical officers in charge of hospitals, while others stated that district chief medical officers could receive complaints.[370] One gynecologist in a district hospital claimed that there was a complaints box where women could drop their complaints. But when Human Rights Watch asked her for more details about the types of complaints, processes to deal with them, and their outcomes, she conceded that no one had actually used the complaints box.[371]

A senior official stated that the government had also formed a grievance redressal cell which had received many complaints forwarded by the districts, but was unable to give further details about protocols to deal with such grievances in a timely manner, or the outcomes of grievances filed with the cell. [372]

Under the NRHM, Patient Welfare Committees (Rogi Kalyan Samitis or RKS) at government health facilities are primarily seen as "management" committees that are supposed to function as a "nongovernmental organization."[373]  They have been assigned the task of "ensuring accountability of the public health providers," and establishing a system of public grievance redressal at facility level.[374] Medical officers heading the executive bodies of RKS with whom Human Rights Watch spoke were not aware of any of these powers. Women and health workers, including staff nurses and doctors in hospitals, did not know about any grievance redressal powers of the RKS.[375] For instance, one woman in a group said,

We don't know where to go and complain about anything ...We have no information about it [Rogi Kalyan Samiti]. And we will go there and make complaints only if someone goes along with us. How can we go alone and complain there?[376]

Other existing mechanisms such as filing complaints before chief medical officers, state or national human rights commissions, the national Women's Rights Commission, and filing petitions before the High Court or consumer courts are important avenues. But they are not easily accessible to rural women and do not provide timely remedies.Similarly, public interest petitions filed in the Uttar Pradesh High Court in 2006 and early 2009 about maternal health in Uttar Pradesh are still pending. According to K. K. Roy, the lawyer representing the petitioners in the four cases, no substantive orders had been passed providing any relief to the petitioners at this writing.

Many rural women report that they are too scared to complain against doctors or nurses even when they feel that they had experienced some injustice. They fear reprisals by medical officers and health workers. In the few instances that Human Rights Watch was able to document complaints filed by women before the High Court or the State Commission for Scheduled Castes and Scheduled Tribes, activists helping with the complaints said that the doctors or health workers concerned had pressured the women or their families to withdraw the complaint.[377]

Salenta's case is illustrative of the difficulties faced by women from vulnerable communities in pursuing complaints. Salenta, a Dalit woman, delivered in a primary health facility without adequate attention of the health staff in February 2007 and was discharged. After returning home, she complained of severe pain and urinary incontinence. She got no follow-up free postnatal care as guaranteed under the NRHM. Instead, with the help of local activists, she went to different public and private health facilities for treatment and was finally admitted for surgery for obstetric fistula in February 2008. She incurred about 50,000 rupees (US$1000) in medical expenses. During this period, Salenta approached several district, state, and national authorities for redress. Not only did her complaints go unheard but they were also met with threats from at least one district health official. According to SAHAYOG, a prominent Lucknow-based nongovernmental organization that provided her with support to seek redress, a district health official "abused them [Salenta and her family] and accused them of daring to complain to higher authorities. He demanded that they state in writing that they had not gone for an institutional delivery."[378] Salenta's case is now pending before the High Court in Allahabad.[379]

Most women we spoke with, many of whom are illiterate, say that they cannot exercise existing grievance options without support to file and process their complaints.[380] Filing complaints before courts and human rights commissions requires multiple visits by family members to testify before such bodies. Activists from SAHAYOG, who have assisted many pregnant women in seeking justice when they are denied health care, felt that a lack of adequate resources to follow-up complaints is a significant obstacle.[381] "Most of these women come from really poor families living on daily wages," said Shakuntala Joshi of SAHAYOG. "So how do you expect that these people can keep coming before these bodies to tell their story?"

The Need to Follow-Through in Response to Grievances

Even when women successfully lodge their complaints, there is evidence to suggest that no official inquiry or follow-up action ensues or that such steps are significantly delayed. In addition to Salenta's case described above, Human Rights Watch traced a woman who had made a written complaint before the chief medical officer of Chitrakoot district. Saroj, belonging to a Dalit community, filed a complaint in 2008 regarding a failed sterilization surgery. When interviewed by Human Rights Watch in March 2009, she had still not obtained any form of remedy.[382]

Another district official said that about five or six women had made written complaints earlier this year around April to the office of the Unnao district chief medical officer. They claimed that health facility staff had demanded money at the time of delivery or had taken money from their JSY payments. But no inquiry or further action was initiated by the Unnao chief medical officer. One district official who spoke with Human Rights Watch believed that because the complaints lodged were against doctors and would be considered by the Chief Medical Officer, also a medical doctor, the complaints would effectively be ignored. He proposed that a better structure would be to submit complaints to a committee under the district magistrate.[383]

In the relatively few instances in which the Uttar Pradesh health officials initiated action against medical staff, there is evidence to suggest that they did very little beyond suspending or transferring frontline medical staff, primarily auxiliary nurse-midwives, staff nurses, and doctors.[384]

Human Rights Watch requested a senior Uttar Pradesh health official to provide a list of staff nurses who were suspended in order to interview them, but the Uttar Pradesh government would not provide such a list, despite our assurances to respect the confidentiality and privacy of the nurses and patients involved.[385] Human Rights Watch also filed applications under the Right to Information Act, 2005, seeking information about such complaints, their investigation, and outcomes. At the writing of this report the applications are still pending.[386] 

In one case in 2008 where a pregnant woman was referred out of a community health center and delivered on the road, a staff nurse at the health facility was suspended. Human Rights Watch was able to trace the nurse. "I was not even on duty when it all happened," she claimed. "In fact I was the one who took her [the mother] back inside after she had delivered on the road, helped her when she was delivering the placenta, and cleaned her," she said.[387]

Reflecting on her experiences after working at the community health center for two years, the staff nurse said that in her community health center, there had been at least two controversial cases where women were referred to a Lucknow hospital in 2009. In one case the pregnant woman delivered on the road. In another, she died. In both cases the media played a critical role in highlighting the problems, forcing the state to respond. According to the staff nurse, the problem was primarily one of referral transport to take women to the Lucknow hospital. The government had conducted inquiries, suspending individual staff nurses, but had not come to any definite conclusions. Expressing her frustration that the problem remained unresolved, she said, "If something goes wrong nurses get into trouble ... Suspending me or another nurse will not solve the transport problem here."[388]

A senior state health official claimed that inquiries were also conducted in five or six cases where staff nurses had sought money from patients in government health facilities and some had been suspended.[389] These inquiries were conducted "mostly to save ourselves [government officials]," she said.

State responsibility for maternal deaths and complaints regarding denial of appropriate health care for reasons such as corruption, non-supply of essential drugs, and discriminatory or abusive treatment, rests primarily with the district health authorities and health facility superintendents who are in charge of planning, oversight, and implementation of maternal healthcare programs. Hence, any inquiry into a complaint should also examine possible failures in planning and oversight at the district and sub-district levels. For instance, where a doctor reports for duty at a primary health center for less than the stipulated duty hours for more than six months, and this comes to light in the context of a maternal death, the serious lapse in regular oversight by district health authorities should also be taken into consideration while apportioning individual responsibility.[390]