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BUENOS AIRES, ARGENTINA – The morning light floods through the windows of an old building in the original core of Buenos Aires, Argentina’s capital. Instructors in the spacious learning center teach students skills to preserve the city’s architectural heritage. In one of the classrooms, students model clay figures of various shapes and sizes.
One of the students, Jorge Vázquez, 47, is studying ornamentation, the art of decorating statues in plazas and gardens. His specialty is one of several available to students at the Escuela Taller del Casco Histórico, a free city government school that teaches architecture and remodeling in the Casco Histórico, the city’s historic center.
Using a fine-tipped wire modeling tool, he puts the finishing touches on a series of interlaced petals and leaves he is making for his class. Bending over his work, he seems oblivious to his classmates’ comments and movements.
Vázquez is learning to model ceramic copies of figures that decorate gardens and outdoor spaces so he can restore original figures in need of repair. In learning the art of restoration, he strives to get into the skin of a project’s original creator.
“It is not easy,” Vázquez says. “You have to get into the eyes of the person who made the original piece, adapt yourself to that, and not allow yourself to get carried away by the personal desire to create.”
Although Vázquez has made ceramic figures for more than two decades, this is the first time he has undertaken such training. A doorman at a primary school, Vázquez appreciates the free opportunity to refine the skills he uses in his avocation.
A public school with the capacity to enroll 195 students, the Escuela Taller del Casco Histórico teaches techniques for conserving and restoring the cultural heritage, which includes buildings, outdoor structures and sculptures, in Buenos Aires’ historic center. Last year, the school first offered a two-year training program through which students will graduate with the title of technical assistant at the end of 2014.
It is the only free school in the city that specializes in this type of training. It accepts anyone 18 or older who is interested in the subject.
Located in San Telmo, the city’s oldest neighborhood, the school has operated for 14 years. The Escuela Taller is under Buenos Aires’ General Directorate of the Historic Center, a Ministry of Culture office tasked with protecting and maintaining the area’s cultural identity and architectural heritage.
The Casco Histórico comprises the 222 blocks of the city’s original urban nucleus, says Vivian Fernández, an architect and coordinator of the General Directorate of the Historic Center.
During the 19th century, Argentine architects designed many finely ornamented and elegantly decorated Italian- and French-style buildings in the Casco Histórico, Fernández says. The city’s authorities, many of them European immigrants, sought to transform Buenos Aires into one of the world’s great metropolises.
The center features emblems of Argentine culture, including the Casa Rosada, the seat of the national government; the Catedral Primada de Buenos Aires, the country’s principal Catholic church; and notable palaces, cafes and bars.
“This is part of what we are as a city,” Fernández says. “Every sign of a building, every corner, is talking to us about a story. That is to say, it is the physical part of a story that can be told again. Therefore, it is heritage.”
The school formed in the midst of a construction boom in 2002, a year marked by a depression where a loss of confidence in the banking system prompted heavy investment in real estate development. That year, private developers began demolishing old buildings to make room for new ones.
That trend alarmed preservationists, says Aquilino González Podestá, an architect who specializes in the conservation and restoration of architectural heritage.
The school has functioned for more than a decade as a workshop where students could come and go, says the school’s coordinator, Marino Santa María, who specializes in plastic art.
With the new two-year training, students can graduate with a specialty in woodworking, ornamentation or sgraffito, a style of decoration where parts of a surface layer are cut away to expose a different-colored ground. They can also train to become luthiers – makers of stringed instruments. All students receive theoretical training to learn to value patrimonial assets.
BAMENDA, CAMEROON – Excitement filled the air as residents of Bamenda, the capital of Cameroon’s Northwest region, awaited the national football team’s matches in the 2014 FIFA World Cup in Brazil this month.
Whistling and hooting rose from the streets on June 13, the day of the team’s first match in the competition underway in Brazil. Hundreds of residents donned jerseys featuring the colors of the national flag – green, red and yellow.
In the city’s main market, a group of men and women sporting Cameroon jerseys moved from shop to shop, whistling, singing, shouting and clapping. Merchants and shoppers cheered them on. A member of the group wore a lion’s head mask in honor of the football team, which is nicknamed the Indomitable Lions.
Cameroonian flags hung from every corner of the market and decorated motorbikes zooming through it. Hawkers moved from street to street, selling flags and caps featuring the flag’s colors.
Rene Ngang, an Anglophone merchant in Bamenda market and a die-hard fan of the Indomitable Lions, says he plans to watch World Cup competition from start to finish.
“l have to close my shop most of the time for about a month,” says Ngang, who sells electronics. “I don’t want to miss any of the matches, especially Cameroon matches – not even for a second.”
Watching the Indomitable Lions play is the only thing that makes Ngang feel like a Cameroonian, he says.
At other times, Ngang feels like a foreigner in his own country because Anglophones are hardly involved in governance, he says. Francophones dominate the government, including the National Assembly, Cameroon’s parliament, he says.
Cameroonians elect their representatives to parliament. Anglophones, being a minority, elect fewer members of the National Assembly than Francophones.
The nation’s president is Francophone. Although the prime minister is Anglophone, Francophones hold most other top government positions.
That makes Ngang feel like an outsider, he says. The only exception is when the national team takes the field.
“When Cameroon is playing, I throw away all my annoyance towards the government and focus on the love I have for Cameroon through the Lions,” he says.
English-speaking Cameroonians – who occupy the Northwest and Southwest regions of the country – do not get opportunities equal to those of the citizens living in the nation’s eight Francophone regions, Ngang says.
Ngang, who graduated from college eight years ago with a degree in sociology, has yet to find a job. The dominance of the French language in Cameroon is partly to blame for his joblessness, he says.
Cameroon is bilingual, but since there are more Francophones than Anglophones, French is the country’s dominant language.
Twice Ngang was invited to interview for jobs in private companies in Francophone Cameroon, and he was disappointed to find that both were conducted in French, he says. Unable to speak French, he missed both opportunities.
The companies’ failure to level the field by interviewing all candidates in their native languages is a form of discrimination, he says. But football relieves his frustration.
“With the state of things in the country, my patriotism is dying,” Ngang says. “My spirit of patriotism unconsciously comes alive when Cameroon’s Indomitable Lions are playing.”
Cameroon’s minority English-speakers say the World Cup conjures a rare patriotism amid the discrimination they typically feel by the government and French-speaking citizens. Francophones get most of the government jobs, and development is skewed toward Francophone regions, Anglophones say.
Francophones point out that language can be a barrier for all citizens but acknowledge that Anglophones face more obstacles. Officials say some marginalization of Anglophone citizens may occur but that the government strives to ensure regional balance in its programs.
This year’s World Cup marks Cameroon’s sixth appearance in the competition’s 84-year history. In 1990, Cameroon became the first African team to reach the quarterfinals.
Cameroon has lost to all three of its 2014 World Cup opponents – Mexico, Croatia and Brazil.
Anglophone Cameroon comprises just over 16 percent of the country’s population, according to 2010 data from Cameroon’s National Institute of Statistics.
Agnes Tangie, an Anglophone and head of the history department at the Government Bilingual High School in Bafut, a town in the Northwest region, says Cameroon’s colonial history caused the chasm between the nation’s Anglophone and Francophone citizens.
Britain and France jointly assumed rule of Cameroon in 1916. Britain administered its territory in English, and France administered its much larger territory in French.
The Francophone and Anglophone regions unified after Cameroon gained independence in 1960. Francophones have dominated government and private sector offices since unification, Tangie says.
The minority Anglophones felt like strangers in a foreign country whenever they traveled to French-speaking regions, she says.
Ngang has lost hope of finding a government job and now focuses on his business, he says.
French-speaking candidates are better able to pass the “concour,” an exam people take when seeking admission to training institutions or applying for public service positions, so they get most of the jobs, Ngang says.
He has taken the exam twice and failed, he says. The second time, he passed the written part but failed the oral part as it was conducted in French.
Many Anglophones meet the same fate when taking the exam, he says.
“You drop your application, they hire a Francophone instead,” he says. “You write a concour, and the Francophones carry the day.”
Although government officials have stressed in TV speeches their commitment to ensuring that all regions get an equal share of national resources and opportunities, the government does not carry out that policy, Ngang says.
The government concentrates development projects in Francophone regions, he says. Those regions have the best roads, airports and learning institutions, while the Anglophone regions have poor roads and a run-down airport.
At the time of unification, the Southwest region’s airport, Tiko Airport, was one of the nation’s best, he says. Since the government opened airports in Yaoundé and Douala, cities in Francophone Cameroon, it has fallen into poor condition.
The Northwest region did not have a university until the government opened the University of Bamenda two years ago after Anglophones pushed for its establishment, Ngang says.
“I wish the government took regional balance seriously so there is equitable development in the country,” he says. “I do not hate my French brothers and sisters. I hate the system. I hate the state of things. I hate anyone who is promoting marginalization and discrimination.”
Charity Nebare, an economist working with the divisional delegation of the Ministry of Social Affairs in Donga-Mantung, a division in the Northwest region, affirms Ngang’s insistence that Anglophone regions have received less than their share of development resources.
Road infrastructure is poor, she says. She cites the border town of Bakassi in the Southwest region, which has no asphalt roads even though the area is a source of crude oil.
The Cameroonian Constitution states that all citizens have equal rights and obligations and that the state has a duty to ensure the protection of minorities.
However, development is not the sole responsibility of the central government, Nebare says. Mayors and members of parliament who receive funds for micro-projects should spend it carefully to benefit the people.
Driscol Eyong, an Anglophone taxi driver in Bamenda, also cites discrimination from French-speaking citizens. He feels like a foreigner whenever he travels to Francophone Cameroon, he says.
“It is difficult to go to Yaoundé, Douala or any other French-speaking region because they regard Anglophones as fools,” he says. “Francophones even change the word ‘Anglophone’ to ‘Anglofools.’ I once went to Yaoundé, and as I was asking for directions to a certain office, residents mocked me because I was speaking in English.”
JHOR MAHANKAL, NEPAL – 4 a.m.
Gauri Dulal leaves her house of mud and stone, carrying a small lamp into the predawn darkness.
Dulal, 44, heads toward a public tap shared by 10 families for her morning bath. She walks along the narrow road, passing other stone houses that stand silent at this early hour in Jhor Mahankal village development committee in the Kathmandu district of central Nepal.
As she nears the tap, she sees two other women bathing in darkness. They too are menstruating.
“The people in the village know that the menstruating women use the tap in the morning time, and they do not come to the tap in the morning unless it is very urgent,” Dulal says. “They do not want the menstruating women to touch their water.”
Nepalese Hindus believe water touched by a menstruating woman is impure and must be thrown out, she says.
On days when Dulal is not menstruating, she refrains from going to the tap in the morning to avoid the menstruating women.
Throughout Nepal, women share a common bond during their menstrual periods. For four days every month, the cultural customs of their communities and limited access to feminine hygiene products dictate the way they live, work, eat and sleep.
Hindu tradition deems things touched by menstruating women impure, says Pramod Bardhan Kaudinnyayan, a professor at Valmeeki Vidyapeeth, a college in Kathmandu, Nepal’s capital, specializing in Sanskrit education. Hindu families observe this tradition despite their increasingly modern lifestyles.
“The Hindu sacred writings state that women, during their menstruation, are considered to be impure for three days,” Kaudinnyayan says. “But in practice, most families keep women separate for four days.”
Nearly 82 percent of the population practices Hinduism, according to the National Population and Housing Census 2011 by the Central Bureau of Statistics.
After bathing this morning, Dulal quickly washes the cloth pads she used the day before and tucks them under her washed clothes so that nobody will see them. She has made several pads from two old saris, which she washes and reuses until they are too old and must be thrown away.
Dulal learned about sanitary pads from a college friend of her daughter’s, she says. But she has never used them.
“They are too expensive, and I do not know how to use them,” she says.
Menstruation is a taboo subject that is not discussed openly, so many women remain ignorant about innovations like sanitary pads and continue in the traditional ways of their mothers and grandmothers, Kaudinnyayan says. Further, sanitary pads are too expensive for poor women in rural areas, who do not earn an income and must rely on male family members for money.
A pack of eight sanitary pads costs at least 40 rupees (42 cents). This is a considerable sum in Nepal, where almost a quarter of the population lives on less than the equivalent of $1.25 a day.
Dulal begins doing outdoor chores. She is not allowed to work in the house during menstruation.
She does not mind being excluded from the housework, but sometimes her daughters, who are in their early 20s, rebel and ask her why they must follow these customs, she says. She responds that they cannot question the traditional ways.
When Dulal finishes cleaning the cattle shed, she feeds the animals, making sure she stays away from family members and neighbors.
“If others touch me during my periods, I will commit sin,” Dulal says. “The gods will be angry.”
If a woman fails to follow the traditions of untouchability during menstruation, her departed soul will not rest in heaven, Dulal says.
“It is believed in Hinduism that if a woman touches someone during menstruation, then she has to do a puja [prayer ritual] and also fast for one day to be cleansed,” she says.
About 200 kilometers (124 miles) away in Chhorepatan, a small town in Kaski district, Jyoti Subedi awakes to the sound of her mother-in-law softly chanting the morning puja to the gods at the little shrine in the family’s home.
Subedi usually performs the ritual offering of water, flowers, rice grains, tika powder and light to the Hindu gods for the family. But today, because Subedi is menstruating, her mother-in-law performs the ritual.
“In our culture, when we are menstruating, we do not touch shrines,” she says. “This is what we have been taught, and this is what I believe.”
Subedi, 18, is the mother of a 1-year-old girl. She and her husband, a salesman in the nearby tourist city of Pokhara, live with his parents in Nepal’s Western region.
Although many of these restrictions are common throughout the country, women living in the western regions of Nepal face harsher conditions, says Himalaya Panthi, social development manager at Nepal Water for Health, an organization working for clean drinking water and sanitation in Nepal.
In accordance with a custom known as “chaupadi,” menstruating women in these areas must leave their houses and live in cattle sheds or small huts that lack proper lighting and ventilation.
The custom stems from a superstition that something bad will happen to a woman’s family if she stays in the home during menstruation, Kaudinnyayan says. The folk belief is not grounded in Hindu scriptures.
Subedi’s in-laws are understanding and do not strictly enforce the rules, she says.
“We do follow our customs, but they are lenient too,” she says. “They don’t ask me to sleep outside the house. When I am menstruating, they don’t give me much work and allow me to rest. I am lucky that way.”
As Subedi has no household chores to do in the morning, she decides to sleep a little longer.
“I have time to rest and relax, which is good,” she says with a smile.
She makes herself more comfortable on the thin bedding she has put down on the floor of a special bedroom she uses during her menstrual period. On other days, she sleeps in a bedroom with her husband on a mattress in a wooden bed.
Dulal drinks a cup of hot tea after her morning chores in Jhor Mahankal and then goes out into her vegetable field. She inspects the potato plants, which will soon be ready to harvest, and prepares the soil for the mustard seeds she will sow next week.
When she works in the field while menstruating, she manages the menstrual flow with the cloth pads, she says.
“Since my first periods, I have used a piece of old sari as a pad, and I tuck it inside my petticoat,” she says.
She then begins the hourlong trek to the forest to collect firewood.
Dulal usually uses one cloth pad for an entire day, and sometimes blood leaks onto her clothing. She does not change the pad during the day because she is embarrassed to bring extra ones to the forest and fields, where there may be men and there are no bathrooms. She cannot go to the public tap to wash during the day, and she does not have a private tap at home.
Sometimes the rough sari fabric cuts into Dulal’s skin and causes pain in her genitals, she says. Sometimes she experiences itching and swelling.
“I frequently have these problems, but I haven’t gone for a checkup,” she says.
Traveling to a hospital is costly, and Dulal does not think her discomfort and pain require medical attention, she says. She has not heard of any infections or diseases caused by poor hygiene during menstruation.
Pema Lakhe, deputy executive director of Nepal Fertility Care Center, an organization in Kathmandu that provides sexual and reproductive health education and services, says a lack of pads and clean cloths during menstruation can cause health problems.
“Women have no knowledge regarding menstruation at all,” she says. “The lack of cleanliness during menstruation can lead to uterine infection and pelvic inflammatory diseases.”
There is no data available on the number of women who contract these infections and diseases as a result of unhygienic menstrual practices, Lakhe says.
MEXICO CITY, MEXICO – At 15, María Isabel Ibarra Hernández is pregnant with her second child.
She was 13 when she first became pregnant. At the time, she had been dating her baby’s father for nine months and living with him for four months, she says.
This morning, María Isabel is visiting the Community Health Center in the Hank González neighborhood of Ecatepec de Morelos municipality in Mexico state.
Teenagers carry nearly one-fifth of the pregnancies in Mexico state, according to the National Institute of Geography and Statistics. More than 40 percent of the residents of Ecatepec – which adjoins Mexico City, the nation’s capital – are poor, according to the Municipal System of Statistical and Geographical Information.
The weekly workshop for pregnant teenagers is part of Holistic Care for the Teenage Mother, a program managed by Mexico’s National System for the Integral Development of the Family.
The program operates in neighborhoods that account for most of Ecatepec’s teenage pregnancies, says Tania Pelcastre Ángel, who runs the system’s office in the municipality.
This is María Isabel’s first time at the workshop. She knew nothing about preventing pregnancy before she got pregnant because she left school after the second grade and had never been to the health center, she says.
María Isabel would have preferred to wait for motherhood, but her boyfriend was eager to have a child, she says. She asked him to wait until she had her “quinceañera” party, a celebration that marks the transition of a 15-year-old girl into adulthood. But they did not use protection.
“The truth is that I did fall in love with my husband,” she says. “He used to ask me for a child, and I gave it to him.”
María Isabel and her boyfriend, the father of both of her children, fought constantly and are separated. Now living with her parents, she says all she wants to do is to support her children.
She plans to look for a stable job after her second child is born. Meanwhile, she sells merchandise in subway cars.
Aiming to reduce unplanned teen pregnancies, the Mexican government has promoted prevention for three years. But critics says its campaigns target teenagers who can control their sex lives without taking into account how marginalization, gender violence, and access to sex education and contraception affect other teens. Although the government has also implemented actions to guarantee teenagers access to contraception, reproductive rights activists say access will not reduce the pregnancy rate unless programs ensure that teens obtain contraceptives and learn to use them effectively. Furthermore, sex education should go beyond providing information and promote sexual and reproductive rights, activists say.
Although the country’s overall fertility rate fell between 1999 and 2013, the fertility rate among 15- to 19-year-olds increased from 64 to 66 births per every 1,000 teens, according to the National Institute of Geography and Statistics.
More than 40 percent of pregnancies among 15- to 19-year-olds are not planned or desired, according to the National Population Council.
The Mexican government has focused on teenage sexual and reproductive health only in the past few years, according to the council. In 2011 and 2013, the council and the Ministry of Health launched campaigns aimed at helping 15- to 19-year-olds avoid unplanned pregnancies and sexually transmitted diseases.
The campaigns strive to empower teenagers to assume responsibility for sexual decisions, says Rufino Luna Gordillo, deputy director general of sexual and reproductive health for the National Center of Gender Equity and Reproductive Health, which is under the Ministry of Health.
“If you take the responsibility to initiate an active sexual life, there [is] the responsibility of protection for themselves, including for their partner,” he says. “The idea is to empower these teens that if they can make this decision, they must also decide to protect themselves.”
Marisol, 17, a participant in the Holistic Care program in Ecatepec’s San Agustín neighborhood, agrees that teens must protect themselves. Marisol, who is nine months pregnant, requests partial anonymity for fear of being stigmatized.
“You have the responsibility,” she says. “You know what you want for your future. I think it would be an issue in which each person would know how to take care of themselves.”
Isabel Fulda, executive analyst of Grupo de Información en Reproducción Elegida, which means “information group for reproductive choice,” an organization that promotes and defends women’s reproductive rights, criticizes the government for promulgating the idea that teenagers alone are responsible for unplanned pregnancies.
“The idea is always: The youth get pregnant because they do not take care of themselves,” Fulda says. “But in reality, the responsibility there is the state’s, and the large number of teen pregnancies that there are, are the product of structural problems and deficiencies that the state should cover.”
The government must address social factors that contribute to teenage pregnancies, including poverty, social inequality, discrimination, gender violence, and a lack of access to contraception and sex education, Fulda says.
Marisol says she left school because of family problems and moved in with her boyfriend. They had been living together for two months when she became pregnant.
Marisol says she got pregnant because she was not careful with contraceptives. She had previously used the calendar method, in which a woman tracks her menstrual cycle and refrains from sex while ovulating, but abandoned it when she started living with her boyfriend. They sometimes used a condom.
Although 90 percent of young people ages 12 to 19 have at least heard about contraceptive methods, only about 33 percent of sexually active females and 15 percent of sexually active males used protection in their first sexual encounters, according to the 2012 National Health and Nutrition Survey.
Further, 36 percent of sexually active teens have never used contraception, according to the National Population Council.
KULGAM, INDIAN-ADMINISTERED KASHMIR – Dawn had just broken on a cool November morning in Malwan, a village in Kulgam district. Meema Ganaie, 35, recounts how she struggled up the muddy, unpaved roads filled with large potholes when she was nine months pregnant with her first child.
Walking slowly, she and her husband made the 10-kilometer (6-mile) journey by foot to the District Hospital Kulgam in Kulgam town because they could not find any transportation at that hour.
“When I reached the hospital, I had no strength even to talk,” Ganaie says. “I was almost out of breath.”
In the maternity ward, Ganaie saw that two or three patients shared a single bed, she says.
Nurses performed a routine checkup, asking Ganaie about her pain and checking her blood pressure, she says. They then told her she was not in labor and had more time for her delivery. They asked her to go home and return the next day for a blood test.
“I wept on the floor of the hospital,” she says. “But the staff didn’t pay any heed to my pain despite many requests.”
At home that night in 2011, Ganaie began to suffer severe pain, she says. Her mother-in-law asked the village midwife to visit. Within 30 minutes after the pain began, Ganaie gave birth to a baby boy.
“Both my baby and I were fine,” she says. “There were no complications after my delivery.”
Enlisting the village midwife saved the family the cost of traveling to Kulgam town, says Taja Begum, 68, Ganaie’s mother-in-law. The birth occurred at night, so public transportation was not available and the family would have had to hire a vehicle.
“We are poor people,” Begum says. “The government doesn’t provide us free transport.”
Ganaie is now pregnant with her second child. She does not see any benefit to delivering at the hospital, she says.
“I have a bitter experience of hospital care when I was pregnant with my first baby,” she says. “I gave my first delivery at home. It was normal. I don’t want again to beg in front of the hospital staff for help.”
When contacted about Ganaie’s experience, officials at the District Hospital Kulgam said they were not aware of the incident because they had not received a formal complaint and could give no details.
“I have no idea about this case,” Dr. Showkat Ali Looloo, chief medical officer of the hospital, says in a phone interview.
The federal and state governments have funded an agency to improve rural health care for nearly a decade. But the quality of health services in rural areas of the Kashmir Valley remains poor and difficult to access. The system lacks enough hospitals, clinics, medical staff and equipment, health care workers say. Officials and doctors also allege funding delays and misuse, although higher-level officials deny that criticism. The government is beginning to address the system’s shortcomings by building more hospitals in rural areas and hiring more medical personnel, officials say.
The Kashmir Valley, which has a population of 7 million, is one of three regions in Jammu and Kashmir state, the portion of Kashmir administered by India.
Each of the 10 districts in the Kashmir Valley has a district hospital, Dr. Saleem-ur-Rehman, director of health services for Indian-administered Kashmir, says in a telephone interview. The district hospital in Ganderbal district is still under construction.
Saleem-ur-Rehman’s department works under the Department of Health and Family Welfare of Jammu and Kashmir state. It is the primary government agency responsible for implementing national and state health programs in Indian-administered Kashmir.
In addition to the district hospitals, there are seven government-run specialization hospitals in the Kashmir Valley, Saleem-ur-Rehman says. These hospitals specialize in secondary, tertiary and pediatric care; orthopedic treatments; psychiatry; chest diseases; and obstetrics and gynecology. All are located in Srinagar, the state summer capital.
“The health sector in Kashmir is engaged in providing health care and medical facilities to the masses,” Saleem-ur-Rehman says in a phone interview.
Seventeen of the 23 villages in the Kashmir Valley identified by the government as “backward,” or underdeveloped, are in Kulgam district. The public health facilities in Kulgam district consist of one district general hospital, three subdistrict health centers, 27 primary health care centers and 90 subcenters.
The Indian government has established a separate agency to improve health care services in rural areas throughout the country. It launched the National Rural Health Mission nationwide in India in April 2005 and in Jammu and Kashmir state in December 2005.
“It is aimed at improving the access of rural people, especially women and children,” says Dr. Mushtaq Ahmad Dar, divisional nodal officer of the program’s Kashmir division. “The poor population should be able to have equitable, effective and accountable primary health care.”
The program acts as a mediator between the state health department and the rural population to improve the services and infrastructure of rural health services, Dar says.
The Indian government provides 90 percent of the National Rural Health Mission’s budget, he says. The Jammu and Kashmir state government provides the rest.
The state has used 9.87 billion rupees ($166 million) of the 10.49 billion rupees (roughly $177 million) the federal government allocated it through the program in 2005, Dar says. The central government has not yet disbursed funds for the new fiscal year, which are dependent on its performance evaluation of the agency that is in progress.
Kulgam district received 34 million rupees ($580,000) and spent 31 million rupees ($520,000) in the 2013-2014 fiscal year, which concluded in March, Dar says. The district spent those funds mainly on construction and the Janani Shishu Suraksha Karyakaram, or Reproductive and Child Health Program, an incentive program that targets pregnant women in rural areas.
Under this program, in addition to the free medical care at the hospital, a pregnant woman receives free food for up to three days for a vaginal delivery and up to seven for a cesarean section. She also receives 1,400 rupees ($23) to cover her travel expenses.
In 2012, 84,307 pregnant women and 14,796 newborns benefited from the program, Saleem-ur-Rehman says. From January to October 2013, 61,956 pregnant women and 15,079 newborns received medical attention under the program.
Another important aspect of the National Rural Health Mission program is the Accredited Social Health Activist program, under which a woman chosen by each village serves as a community liaison to the public health system. These women, known as ASHA workers, raise awareness of health services available in their villages, accompany pregnant women to the hospital, and encourage villagers to use government health services.
To date, the state government has engaged 10,779 ASHA workers to promote maternal health services in Jammu and Kashmir, Dar says. Workers receive 600 rupees ($10) for each pregnant woman they lead to hospital health services, including prenatal clinics and delivery.
But pregnant women say the quality of medical care at government hospitals is poor. Some women have paid heavily for failures in the health care system.
“I still remember the day of Nov. 28, 2012, when my cousin, who was pregnant, died due to negligence of doctors in our district hospital,” says Huzaifa Mir, of Malwan. Her cousin, Sheeraza Bi, was 28.
Early that morning, Mir and other family members took Bi to District Hospital Kulgam when she complained of labor pain, Mir says. They placed Bi on a makeshift wooden stretcher and carried her on their shoulders for nearly 10 kilometers (6 miles).
“When she reached the hospital, doctors delayed her treatment for almost nine hours,” Mir says.
When the doctors checked Bi, they found that the fetus had died in her womb, Mir says. Doctors told the family to take Bi to the Maternity and Childcare Hospital nearly 22 kilometers (13 miles) away.
The doctors did this because they realized Bi’s condition was serious and did not want to be held responsible for her death at the District Hospital Kulgam, Mir alleges.
“On our way to the hospital, we lost our daughter,” Mir says, speaking of her cousin’s death as analogous to a family losing a daughter.
Looloo, the only hospital official authorized to speak to the news media, says in a phone interview that he does not have any information on this case and cannot comment. Bi’s family did not file an official complaint with the hospital.
Misra Hussain, 24, says hospital services have to improve.
Hussain, of Malwan, is eight months pregnant with her first child and has decided she will not deliver at District Hospital Kulgam. She plans to give birth at home with the help of her mother and the village midwife. She is due in mid- to late June.
In March, an ASHA worker in Hussain’s village persuaded her to go to the hospital for a prenatal checkup, and the visit was distressing, she says. She had to wait in long lines.
The doctor was rude, which shocked and embarrassed Hussain, she says. This made her doubt doctors would care for her well during her delivery.
“The doctor who did my checkup told me everything is normal,” Hussain says, “and when I asked her about the next visit, she got angry and shouted at me to come when I am in labor, and then moved on to the next patient.”
Hussain’s mother, Jalla Begum, accompanied her on the visit.
"I don't want my daughter to deliver her baby at this facility,” Begum says. “The home deliveries are tension-free, and traditionally women get all the care by just being at home. The hospital deliveries are full of problems. There is no good care available at our district hospital. Our roads are mostly not in good condition, and it’s very difficult to reach the hospital.”
The hospital is working to improve the conditions, Looloo says. But he cannot comment on Hussain’s experience as he has no information about it.
“We are trying our level best to utilize the NRHM benefits to benefit more and more women under the scheme,” Looloo says. “We make sure all the incentives for both ASHA workers as well as pregnant ladies are disbursed on time through checks. There is always room for improvement, and we are working hard to fill all the gaps."
Dr. Nelofar Jan, a gynecologist, worked in various public district hospitals for more than 15 years before retiring from government service in September 2013. She now runs a private practice in Srinagar but regularly visits rural areas as part of her consultation work.
She has seen firsthand the suffering of pregnant women in rural areas of Kashmir Valley, she says. Many of them cannot reach a hospital in an emergency or access health care during pregnancy or when they deliver.
Most women in rural areas deliver at home because their villages lack medical facilities and they cannot afford transportation to distant hospitals. Further, rural roads in Kashmir Valley are impassable during winter and heavy rains.
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