Women's empowerment and health ()

Women?s empowerment & health A comparison study       in cooperation with CARPED                                 Hyderabad, July 2004 Kitty van Kessel Introduction     What people can positively achieve is influenced by economic opportunities, political liberties, social powers, and the enabling conditions of good health, basic education, and the encouragement and cultivation of initiatives (Sen, 1999). The institutional arrangements for these opportunities are also influenced by the exercise of people?s freedoms, through the liberty to participate in social choice and in the making of public decisions that impel the progress of these opportunities. Economic unfreedom can breed social unfreedom, just as social or political unfreedom can also foster economic unfreedom.   Sen (1999) distinguishes five distinct types of freedom. These include (1) political freedoms, (2) economic facilities, (3) social opportunities, (4) transparency guarantees and (5) protective security.   In this report attention is paid to the freedoms of women. To be precise, to their empowerment and health rights. In chapter 1 women?s empowerment is taken into account, including some examples of activities of different NGO?s in Hyderabad. Chapter 2 talks about health issues and here special attention is paid to family planning. A conclusion and some recommendations are formulated in chapter 3.     Chapter 1 Women?s empowerment   ?1.1 Women?s agency and social change No longer the passive recipients of welfare-enhancing help, women are increasingly seen, by men as well as women, as active agents of change: the dynamic promoters of social transformations that can alter the lives of both women and men.   Empirical work in recent years has brought out very clearly how the relative respect and regard for women?s well-being is strongly influenced by such variables as women?s ability to earn an independent income, to find employment outside the home, to have ownership rights and to have literacy and be educated participants in decisions within and outside the family. Indeed, even the survival disadvantage of women compared with men in developing countries seems to go down sharply ? and may even get eliminated ? as progress is made in these agency aspects.   Freedom in one area (that of being able to work outside the household) seems to help to foster freedom in others (in enhancing freedom from hunger, illness and relative deprivation). There is also considerable evidence that fertility rates tend to go down with greater empowerment of women. For example, in a comparative study of nearly 300 districts within India, it emerges that women?s education and women?s empowerment are the two most important influences in reducing fertility rates.   There is considerable evidence that women?s education and literacy tend to reduce the mortality rates of children. The influence works through many channels, but perhaps most immediately, it works through the importance that mothers typically attach to the welfare of the children, and the opportunity the mothers have, when their agency is respected and empowered, to influence family decisions in that direction. Similarly, women?s empowerment appears to have a strong influence in reducing the much observed gender bias in survival (particularly against young girls).   The powerful effect of female literacy contrasts with the comparatively ineffective roles of, say, male literacy or general poverty reduction as instruments of child mortality reduction.   There is a close connection to women?s well being and women?s agency in bringing about a change in the fertility pattern. Thus it is not surprising that reductions in birthrates have often followed the enhancement of women?s status and power.   There is plenty of evidence that when women get the opportunities that are typically the preserve of men, they are no less successful in making use of these facilities that men have claimed to be their own over the centuries.   The economic participation of women is, thus, both a reward on its own (with associated reduction of gender bias in the treatment of women in family decisions), and a major influence for social change in general.   Indeed, the empowerment of women is one of the central issues in the process of development for many countries in the world today. The factors involved include women?s education, their ownership pattern, their employment opportunities and the workings of the labor market. But going beyond these rather ?classical? variables, they include also the nature of the employment arrangements, attitudes of the family and of the society at large towards women?s economic activities, and the economic and social circumstances that encourage or resist change in these attitudes.   The extensive reach of women?s agency is one of the more neglected areas of development studies, and most urgently in need of correction. Nothing, arguably, is as important today in the political economy of development as an adequate recognition of political, economic and social participation and leadership of women.     ?1.2 Imam-e-Zamana Mission (IZM) IZM?s activities are concentrated mainly in slums close to Charminar (like Moula-Ali). In this paragraph, Girls Vocational Training Centers (GVTC) and Women?s Welfare Scheme (WWS) are discussed.   ?1.2.1 Girls Vocational Training Centers (GVTC) Girls and Boys Vocational Centers were established by IZM with the objective of providing vocational training to the dropouts and over-aged boys and girls from the lower strata of society. These children were deprived of their basic education due to financial and other constraints. Vocational training is given to boys and girls in order to enable them to earn their livelihood and hence to not be dependent on others.   IZM has started 3 GVTC and at all these centers an 8 months certificate course in fashion designing and tailoring is conducted. With this certificate it is easier for the girls to obtain a job outside if need be. IZM has 100 girls at the 3 centers doing this course. She also has short courses like beautician course, mehendi designing etc.   ?1.2.2 Women?s Welfare Scheme (WWS) A garment production unit was started to fruitfully employ the girls who are trained at GVTC. The present strength of the unit is 42 and IZM has 42 sewing machines, a pico machine and an embroidery machine. The uniforms of the school children sponsored by IZM are sewn at this production unit. Besides uniforms the production unit sews night suits and other garments designed within the center. Girls who finished their education in GVTC work in the school and earn their own money! Most of the girls are not married. If they are married and have children, in most cases the grandmothers take care of the children.     ?1.3 UNICEF UNICEF has several activities concerning women?s empowerment. Some are discussed below.   ?1.3.1 Improving the relevance of curriculum UNICEF believes that if education is seen as relevant to the daily struggle for survival, poor women will reach out and also send their daughters to school. Ensuring universal schooling has to necessarily engage with the predicament of older girls who have never been to school. Mahila Samakhya ? Education for Women?s Equality Programme ? did precisely this by organizing condensed residential educational programmes ? Mahila Shikshan Kendras (MSKs) ? for older out-of-school girls in rural areas.   MSK in Banda, a district in Uttar Pradesh for example, started with the support of a NGO, Nirantar ? Centre for Women and Education. A team from Nirantar interacted with Mahila Samakhya to establish a residential education programme. The programme?s objective was to develop a locally relevant curricula, based on understanding the aspirations and needs of the students, to ensure the acquisition of learning competencies comparable to the formal system. It also included the building in activities and programmes to enhance self-confidence, and enable teachers to acquire and develop their own capabilities.   The Nirantar team worked with teachers, who are called 'saheli (girl friend)', sahayogini (village level animators) and students to develop relevant teaching and learning materials that the latter could understand and identify with. This intensive process took almost a year. Continuous interaction with the sahelis, students and experts helped to develop teaching aids, experiment kids and songs. Skits, plays and games were all part of the strategy. Balancing the needs of women learners to learn mainstream standardized Hindi and also recognize the importance of reinforcing ?Bundeli (the local dialect)? demanded extensive research and training. Nirantar drew upon educationists to develop appropriate lessons and materials.   When the first batch of girls graduated in 1995, they celebrated by riding bicycles around the campus and on the streets. Many adolescent girls opted to move into the formal school. As the girls went back to the villages, the demand for enrolment increased even more. Five years later, this centre continues to attract rural women and girls. The demand is so overwhelming that there are long waiting lists of girls wanting to acquire education. Scaling up the initiative would definitely accelerate the move towards universalizing elementary education for all.   ?1.3.2 Empowering women for local governance Promoting decentralized educational planning offers excellent opportunities for women to participate more meaningfully in local governance as well as in demanding quality education for their daughters as a right.   With her experience as a homemaker and a farmer, ?Prime Minister? Munni Devi efficiently conducts a session of ?Mahila Sansad (women?s parliament)' under a banyan tree in Meetou Village, some 65 kilometers from Lucknow, the capital of Uttar Pradesh, India?s most populated state. The preliminaries over, she quickly launches into the discussion of the day ? how to dissuade villagers from withdrawing their daughters from the village school. After initial hesitation, the 50-odd members open up to a lively debate. The women?s parliament is a vital part of the Maa-Beti Mela (mother-daughter fair), conceived under the District Primary Education Programme (DPEP) for the state.   With more girls than boys dropping out of schools due to social, economic and domestic reasons, DPEP incorporates strategies to create an environment that enables women to demand education for themselves and their daughters. The idea is not merely to make children go to school, but to ensure they stay on and learn. The Maa-Beti Mela is an effective mechanism for appealing to communities where parents shy away from sending their daughters to regular schools.   Organized by the ?panchayat (village counsel)?, the aim of the fair is to promote girls? education by empowering their mothers ? a major step towards changing the rigid views on women?s role in a patriarchal society. During the meetings, the men are also made to understand why the State is so backward. The outcomes are encouraging. Those who earlier said that it was a matter of pride that their women remained within the four walls of the home, now welcome the women?s parliament. ?None of my 4 daughters went to school, but I have ensured that my grand-daughters are educated? says 78-year-old Pyare Lal of Samad Kheda Village.   Panchayats are playing an increasingly important role in bringing about attitudinal change in the villages. Hari Prasad, President of the Village Education Committee and village head of the Narayanpur Gram Sabha explains that they ?rely on a lot of feedback and suggestions from the womenfolk.? This is where the ?Prime Minister? plays a vital role. She relays to the Committee the recommendations from mothers and daughters in the villages of Uttar Pradesh. Increasing such participation by women is virtually necessary for overcoming barriers to universalizing girls education.     ?1.4 Indo-German Social Service Society (IGSSS) IGSSS is a development (funding) organization, which strives for more human social order based on the principle of justice, equity and freedom in solidarity with the poor and vulnerable sections of society such as dalits, tribals, women and children. She realizes this by supporting sustainable programmes and initiatives, which are relevant and innovative. IGSSS achieves her objectives through dedicated and professional teams in partnership with like-minded organizations and individuals. She endeavors to continuously enhance the capacity of her human resources in terms of integrity, competence, attitude and orientation. In this report, special attention is paid to IGSSS?s National Integrated Empowerment Programme (NIEP).   ?1.4.1 National Integrated Empowerment Programme (NIEP) NIEP aims at integrated impact of IGSSS efforts for the empowerment of marginalized communities. Her activities are threefold: spontaneous projects, process based (long term) projects and Development Support Activities (DSA). A)    Spontaneous projects These projects are those, which are spontaneous, creative and innovative development initiatives by Indian NGOs. These may not be strictly within the priority geographical areas and issues and the long-term process based approach. However, encouraging them will be necessary as they may provide useful leanings to other development agents. The local conditions may demand that the development efforts should have such a nature. Moreover, they may have the potential to grow into long-term development processes. B)     Process based (long term) projects These projects are the backbone of the National Integrated Empowerment Programme. These are the long-term development and empowerment process focus on specific issues with adequate people?s participation. Tribals, dalits, women and economically weaker sections are the main focus of this programme. Women?s empowerment and gender justice are being specially promoted. C)    Development Support Activities (DSA) The objective of DSA (formerly Development Support Fund) is to enhance the capacity of NGOs and Community Based Organisations (CBOs) in order to make them competent to implement and facilitate various developmental processes. DSA aim has been to build alliances through networking and initiating joint action programmes with other like-minded organizations. One unique feature of the programme was the availability of fellowships and in-house training for NGO workers and students, who were interested in the development field so that they could sharpen their skills, enhance their knowledge and gain expertise. All the activities were based on the needs assessment and action plans prepared by the various officers of IGSSS across the country. ?1.4.2 Example: Social Economic and Education Development Society (SEEDS), Jamshedpur It was in May 2002 that SEEDS, a voluntary organization working amongst tribals in East Singhbhum, Jharkhand, started off on a unique venture to empower adolescent girls through literacy and education. Initially it was not an easy task to get the girls to come to the center for two hours a day. While the girls were most excited, it was their parents who were reluctant. Nor was it easy to get eight suitable women teachers.   The centers, sans books, are now focal points for the 160 young tribal and poor girls. The flexi timings ensure regular attendance and the girls devise their own lessons revolving around themselves, their family, society and environment. Discussions and analysis of crucial issues result in framing the main theme of lesson including numbers and maths. Thus learning takes place in a very contextual manner. The best part of the participatory classes is that every lesson designed includes a section on possible action and steps to be taken for a better life.   The first lesson was designed on gender and highlighted the imbalance between the work they do and those, which their brothers do, or between the workload of their mother and father. The main word, which they have deducted from this analysis, is ?inequality?. The action planned included sharing of the girl?s workload by the brothers!   In South Andhra Pradesh, under NIEP the interventions were aimed at ensuring livelihood security for dalit, tribal and other marginalized communities. The projects primarily focused on: ?     Promotion of alternate income generation to women groups through capacity building and micro credit activities, ?     Promotion of primary education among children, ?     Access to better health care, ?     Capacity building of the community on alternate farming systems, ?     Energy conservation and natural resource management.   Chapter 2 Women?s health   ?2.1 Family planning Considering family planning, we have to distinguish between changes in the number of children desired by a family despite unchanged preferences, because of the influence of changing costs and benefits, and shifts in such preferences as a result of social change, such as modification of acceptable communal norms, and greater weighting of the interests of women in the aggregate objectives of the family.   There is also the simple issue of availability of birth control facilities and the dissemination of knowledge and technology in this field. Despite some early skepticism on this subject, it is now reasonably clear that knowledge and practical affordability do make a difference to the family?s fertility behavior in countries with high birthrate and scarce family control facilities.   One line of analysis that has emerged very powerfully in recent years gives the empowerment of women a pivotal role in the decisions of families and in the genesis of communal norms. However, so far as historical data are concerned, since these different variables tend to move together, it is not easy to separate out the effects of economic growth from those of social changes.   The only variables that are seen to have a statistically significant effect on fertility are female literacy and female labor force participation. The importance of women?s agency emerges forcefully, especially in comparison with the weaker effects of the variables relating to economic development. Going by this analysis, economic development may be far from ?the best contraceptive?, but social development ? especially the women?s education and employment ? can be very effective indeed.   There are, in fact, many different ways in which school education may enhance a young woman?s decisional power within the family: through its effect on her social standing, her ability to be independent, her power to articulate, her knowledge of the outside world, her skill in influencing group decisions and so on. Tamil Nadu has had an active, but cooperative, family planning program, and it could use for this purpose a comparatively good position in terms of social achievements within India: one of the highest literacy rates among the major Indian states, high female participation in gainful employment, and relatively low infant mortality.   While Kerala and Tamil Nadu have radically reduced fertility rates, other states in the so-called northern heartland (such as Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan) have much lower levels of education, especially female education, and of general health care. These states all have high fertility rates. This is in spite of a persistent tendency in those states to use heavy-handed methods of family planning, including some coercion (in contrast with the more voluntary and collaborative approach used in Kerala and Tamil Nadu). The regional contrasts within India strongly argue for voluntarism (based, inter alia, on the active and educated participation of women), as opposed to coercion.     ?2.2 Imam-e-Zamana Mission (IZM) IZM provides medical assistance to its beneficiaries. The major ailments during April 2000 ? March 2002 were cardiac problems (20 cases), orthopedic problems (16 cases), surgery (piles, hernia, appendicitis & cleft lip, 14 cases), gynecological problems (11 cases) and general ailments (anemia, hepatitis B, asthma, etc, 10 cases).   The doctor in the clinic of Mouli-Ali said that deworming, malnutrition, skin infections, anemia, malaria, diarrhea and heat problems are the most common diseases in the slums. Around 40 people visit the clinic every day: 40% children, 30% men and 30% women, of all religions. IZM has funded two hospitals, one in Mouli-Ali and one in another developed slum.   IZM organizes once per two months a health camp for 100 ? 150 women per camp. Professional people teach about good nutrition for women and children. Once a week a doctor visits every school and examines all the children over there. Sick children are reported to IZM and eventually treated in Charminar general hospital or one of the two slum hospitals. If an adult gets ill, he or she comes to IZM and is eventually sent to one of the hospitals.   Till now IZM has also organized two dental camps for the children in schools.   Funds from medical organizations sponsor the medical assistance, surgery and treatment for both women and men, so for them it is mainly for free. IZM guides the people to governmental hospitals if needed. The Gandhi hospital in Hyderabad is a sponsor of IZM. Medicines are not for free; patients have to pay Rs 10,- for medicine every visit.   At the moment IZM pays a lot of attention to family planning. It is part of the education programme for the children (boys and girls!), because education is believed to be the first step toward equal rights. If both men and women have jobs, in the long run equal rights will be accepted.     ?2.3 UNICEF: the Rajasthan experience Alwar district in Rajasthan is characterized by extremely poor environmental conditions. It has witnessed a large number of children dying of diarrhea and parasitic diseases due to this reason. The schools in the districts had no provision for safe drinking water or sanitary toilets. If they existed, the children were not aware of hygienic practices to avoid falling ill. The situation is also believed to have affected enrolment and retention, of girls in particular, in primary schools.   In January 2000, UNICEF partnered with the Rajasthan Council of Primary Education (RCPE) and Centre for Development Communication and Studies (CDECS) to support a School Health and Sanitation Programme (SHSP) as a pilot project under the District Primary Education Programme (DPEP). The project?s objective was to educate children, who in turn would educate their families and community on the importance of sanitation. The idea was to focus on the concept of ?sanitation scouts? to spread the message of health and sanitation.   The project was implemented under the guidance of a core group, which included member representatives from National Programmes (Sarva Shiksha Abhiyan and DPEP), elected representatives, UNICEF, and with assistance from a committed state project coordinator and other staff. The objectives of the programme were to generate hygiene awareness amongst schoolteachers and children and introduce behavioral changes in hygiene and health-related practices as part of the curriculum. The programme was directed to create an environment in schools that would help sustain the attendance of girls and promote optimum use of resources towards better health, greater outreach and sustainability. The focus was also on spreading the project message from child to parent and then to the community.   The health package promoted under the project consisted of 7 components: safe handling of drinking water, disposal of waste water, disposal of human excreta, garbage disposal, home and food hygiene, personal hygiene and village cleanliness. In order to implement the package, some prerequisites were ensured, such as the formation of School Management Committees in each school for intervention and ensuring facilities like hand pumps and toilet.   The implementation of the package was through capacity building of teachers, headmasters and resource center facilitators in order to sensitize them to the issue and on the objectives of the project. The teachers in turn trained the school management committees with an emphasis on participatory learning and the future course of action.   Another strategy adopted was to train a total of 1500 children, 15 from each project school, as ?sanitation scouts? who would create awareness in the community on diseases, personal hygiene, maintenance of hand pumps and hardware in the scout camps organized in schools. They also imparted orientation in classes and enacted dramas, conducted workshops and held exhibitions on the issues.   Further, under the guidance of a trained teacher and resource person, each scout was entrusted with the responsibility to ensure that the project components were followed at school, monitor personal hygiene of students and conduct surveys related to the project. Solutions to practical problems such as maintenance of toilets and scarcity of water were sought through children participation and innovative rainwater harvesting techniques in schools.   The School Health and Sanitation Programme is a true instance of child participation, involving children as the agents of change. Children have successfully carried the messages to the community and facilitated the change in attitudes and mindsets of people. However, it needs to be remembered that this kind of education and communication has to be continuous and ongoing, as change is gradual and the actual adoption of practices can be slow. ?2.4 Family Planning Association of India (FPAI) FPAI addresses a wide spectrum of issues - from sexual and reproductive health, including family planning, women and child health to gender and reproductive rights. It works in close partnership with community groups, opinion leaders and local NGOs and the government to enhance the position of women, promote equality among boys and girls and prepare youth for responsible parenthood.   Furthermore, FPAI enables men and women to form local voluntary groups to initiate action for the betterment of their communities. This trail-blazing community approach has resulted improved health and standard of living; better decision-making powers and self-reliance. FPAI is nationally present in 38 cities, 40 towns and 10,408 villages. It is one of the oldest and largest NGOs in India. The head office is established in Bombay. In this paragraph, two of their most innovative activities are discussed.   ?2.4.1 Empowering communities to fulfill their reproductive health needs "Parivar Pragati Pariyojana" (Small Family by Choice Project) is a model of empowering communities to realize and fulfill their reproductive health needs and development goals. Initiated in 1995, it operates in three underserved districts of Madhya Pradesh - Bhopal, Sagar, Vidisha and more recently, in the neighboring district of Raisen. The Project plans to accelerate the adoption of the small family norm among the 6.19 million people living in 5,330 villages and 29 towns, which it serves.   The project won several awards such as the IPPF Global Vision 2000 Award, Commonwealth Award for Excellence and was selected as one of the world's outstanding sustainable development projects, exhibited at EXPO-2000 held in Hannover, Germany.   ?2.4.2 Empowering women to exercise their rights and make decisions ?        Tonk Project The women's Empowerment and Reproductive Health Initiatives Project in Tonk district of Rajasthan was launched in 1998. It covers a 7,27,000-population spread across 720 villages, 5 cities and 7 towns. It endeavors to empower women and girls to become self-reliant; active decision-makers; improve immunization coverage of expectant mothers; and bring high quality sexual and reproductive health including family planning service to the people. The Project has set a new trend in promoting family planning acceptance among men, resulting in a dramatic rise in vasectomies.   FPAI Services FPAIs 127 service outlets provide quality family planning and other reproductive health services that are affordable and accessible. Working in conjunction with private practitioners, hospitals, other NGOs and governmental agencies in their operational areas, FPAI aims at reaching the maximum number of people effectively. Services include contraception, safe abortions, safe motherhood and child survival, male reproductive health, adolescent sexual and reproductive health, infertility counseling and HIV/AIDS prevention and counseling.     ?2.5 Dangoria Charitable Trust (DCT) The Dangoria Hospital for women and children at Narsapur- Medak District, A.P. (which was taken over by the Dangoria Charitable Trust (DCT) a year after its establishment) celebrated its silver jubilee on January 1st 2004. This hospital provides highly subsidized medical care and serves the population in the entire district of Medak. Since 1994, DCT has been involved in extension training activities in the areas of health, nutrition, sanitation, non-formal education, and more recently vocational training, in the surrounding villages. A tailoring and embroidery training centre for adolescent girls and women has been started as well. Food processing and training centre was established last year and a separate society `Mahila Udyog? has been formed to facilitate marketing of the products produced by the women in the food processing centre. The idea is to evolve models for improving health, food & nutrition and environmental security, and empower the community to solve its problems. In this paragraph, special attention is paid to hospital-based activities, Women Health and Nutrition Entrepreneurs and Mobilisers (HNEMs), DAI-training and to Water Health and Sanitation (WHS).     ?2.5.1 Hospital-based activities Reproductive Health Care. A medical team from the Dangoria Hospital for women and children, Hyderabad visits the hospital at Narsapur on Tuesdays and Fridays. Besides running the out patient clinics for women and children, family planning and other gynecological surgeries are performed. From April 2003 to March 2004 over 1000 new antenatal cases were registered. 497 deliveries (including 79 caesarean sections), 74 tubectomies, 13 hysterectomies and 17 other surgeries like MTP, laprotomy and perineoraphy were performed.   ?        Child Health Care A paediatric out patient clinic is conducted on every Tuesday. Immunisation is done. Mothers are advised on maternal and child health during these clinics.   ?        Laboratory Services A trained technician who accompanies the medical team does simple laboratory investigations like urine and blood testing.   ?        Ambulance service The State Bank of Hyderabad, through the good offices of Concern India, Hyderabad donated an ambulance to DCT. The ambulance has facilitated the task of transporting serious cases to Hyderabad for timely treatment.   ?2.5.2 Women Health and Nutrition Entrepreneurs and Mobilisers (HNEMs) and DAI-training DCT is trying to develop strategies for health, food & nutrition and environment security in the villages of Narsapur mandal with the participation of women and children. The HNEM-project is a model for health care delivery, which is being tried since six years. This project was initiated in 1998. DCT has trained 5 women, one each from 5 non-ICDS villages, as HNEMs. The HNEMs have been functioning as advisors to the community, particularly the women, in health, nutrition, sanitation etc. They register all pregnant women; ensure antenatal check-up, compliance with iron folic acid tablet taking etc. They also treat minor ailments and the community pays them for their service. Records of deaths with age and cause, and births with birth weight (where possible) are maintained. `DAIs?, (Traditional Birth Attendants), are also being trained so that the two women can work in tandem.   The strategy is being assessed both in terms of process and outcome. With regard to the process, the community is aware of the HNEMs and has accepted them. They have reconciled to the fact that the HNEMs will not give injections or dispense free drugs. One of the HNEMS also conducts deliveries. Since the community is reluctant to pay for more expensive drugs, sometimes the HNEMs write the prescription and ask the patients to buy the drugs. The HNEMs do keep minor drugs and dispense them against payment, and some times free. No money is charged for consultation and advice or for measurement of temperature and blood pressure. At risk cases are referred. First aid is given for minor injuries.   ?2.5.3 Water Health and Sanitation (WHS) DCT was part of All India Coordinated Project (AICP) on Water Health and Sanitation. The objective of this project is to develop a model for disposal of liquid and solid waste and to augment the availability of safe drinking water. Two villages, Ramchandrapur and Avancha, were included in this project. Women are the major stakeholders and are trained in maintenance of the structures. Men are encouraged to help.   ?        Waste Water Disposal A model for wastewater disposal consisting of a partitioned sedimentation tub and soakage pit has been developed. The model is very effective in removing stagnant water. A total of 37 structures have been constructed. Where the available space was inadequate, the wastewater from households is diverted to open drains via `nani? traps through sedimentation tanks. In three houses the wastewater along with spill water is diverted into household gardens. These strategies have eliminated stagnant water from the villages, improving the surrounding. The villagers particularly women are very happy and say that the mosquito problem is reduced. Despite heavy monsoon last year, the system has worked efficiently except in couple of sites where there is black soil.   ?        Solid Waste Disposal For disposal of solid waste, particularly plastics, paper, glass etc., bins made from cement well rings has been installed. Organic waste is converted into manure.   ?        School Sanitation In both the villages, the village schools have been provided with a block of 2-3 latrines, a bore well with soakage pit for removing spill water, and a roof water harvesting structure. While the latrine and the bore wells are very useful, the roof water harvesting structure has limited use, because the villagers empty the tank as soon as it is filled by rainwater, defeating the purpose of storing it for the drier season. Each school has been provided a garbage-disposal bin, so that the children learn good habits. The soakage pit to remove the spill water from the school bore well had to be modified because the spill water generated exceeded the capacity of the soakage pit.   ?        Village Latrines Interested households are given latrines at a subsidised rate, the subsidy being almost 70%. Total of 13 individual latrines was constructed. Some households have constructed latrines with government aid.   ?        Training Women in Hand Pump Repair In this project, 7 women were trained for a period of 1 month in hand pump repair. Two of them are actively taking up repair work in their own and surrounding villages and are paid Rs 100,- per hand pump repaired. Their acceptance by the community is increasing and during the year they could repair 20 pumps.   To examine the impact of the WHS-project on women's knowledge and family health, the Knowledge Attitude Practice (KAP)-survey among women stakeholders was done prior to initiating the project and repeated at the end of the project. Remarkable improvement in the women?s understanding of the link between diseases like diarrhoea, malaria etc. and lack of sanitation was seen. While initially only 6.8% women expressed satisfaction with the system of waste disposal in the village, at the end of the project 100% were satisfied. Household morbidity survey in mothers with preschool children was done through family health cards. The incidence of diarrhoeas was highest in monsoon and lowest during summer. Compared to November 2002 (prior to the project), the incidence of diarrhoeas was lower in November 2003, suggesting positive impact of sanitation improvement on morbidity. Chapter 3 Conclusion and recommendations   ?3.1 Conclusion The magnitude of the population problem is often somewhat exaggerated, but nevertheless there are good grounds for looking for ways and means of reducing fertility rates in most developing countries. The approach that seems to deserve particular attention involves a close connection between public policies that enhance gender equity and the freedom of women (particularly education, health care and job opportunities for women) and individual responsibility of the family (through the decisional power of potential parents, particularly the mothers). The effectiveness of this route lies in the close linkage between young women?s well being and their agency.   Reducing fertility is important not only because of its consequences for economic prosperity, but also because of the impact of high fertility in diminishing the freedom of people ? particularly of young women ? to live the kind of lives they have reason to value. In fact, the lives that are most battered by the frequent bearing and rearing of children are those of young women who are reduced to being progeny-generating machines in many countries in the contemporary world. That ?equilibrium? persists partly because of the low decisional power of young women in the family and also because of unexamined traditions that make frequent childbearing the uncritically accepted practice (as was the case even in Europe until the last century) ? no injustice being seen there. The promotion of female literacy, of female work opportunities and of free, open and informed public discussion can bring about radical changes in the understanding of justice and injustice.   ?3.2 Recommendations for CARPED It speaks for itself that CARPED has to promote female literacy and work opportunities for women to increase their empowerment. Group meetings of small number of people with similar background (like age, sex or status like ?mothers? or ?pregnant women?) are extremely useful in discussing health aspects in detail. It is also recommended to invite local leaders or active members of the health forums (consisting of educated youth, local medical practitioners) to facilitate the group meetings. Kala jatha by ANM?s can be used for general issues in large groups. To achieve an awareness level as high as possible, full involvement of the local staff and prompt financial assistance from the authorities is required. Furthermore, cooperation with other organizations is highly recommended. This comparison study showed that different NGO?s, funding organizations and trusts in (the direct environment of) Hyderabad have comparable activities (CARPED and DCT are both working in Medak district!) and I think it a good idea if they initiate projects together, share information and analysis results. Such initiatives prevent double work and can save high amounts of money and time for all participants. And the different organizations might learn a lot from each others working methods and processes as well!   However, everyone has to keep in mind that a radical change in the (health) rights of women is only possible on the long term? Literature   Sen, A. (1999), ?Development as freedom?