Sangeeta Rege is currently Coordinator /Director at CEHAT (Centre for Enquiry Into Health and Allied Themes). CEHAT undertakes research, action advocacy and services related to operationalising Health as a human right for marginalised sections of the community. CEHAT acts as an interface between academia and progressive peoples movements.

Sangeeta’s interests include issues of gender, sexuality, violence as a health and human rights concern and justice. Through CEHAT’s work she highlights the intersections between these themes and public health policy and services, advocating for a conscious integration of the gender and sexuality lens in the healthcare sector. In the context of the current COVID-19 crisis, Sangeeta says, “ The already existing lack of an intersectional lens in the health system is exacerbated in these times. There are particular challenges for women and girls with physical, psychosocial and intellectual disabilities, persons belonging to LGB communities, and trans people, in terms of access to health care.”

Shikha Aleya (SA): A warm thank you, Sangeeta, for this interview. Please tell us a little bit about your work and some of the challenging impacts that you have identified in the context of SRHR due to the current COVID-19 crisis.

Sangeeta Rege (SR): COVID and subsequent lockdowns have forced people to stay indoors. This is a public health strategy being implemented the world over, but it does pose significant constraints to access services. These are as follows:

1. Access to contraceptives – both over the counter as well as in health settings.
2. In case of unwanted pregnancies (resulting out of rape, forced sex, consensual unprotected sex between heterosexual couples) and ability to access to MTP (Medical Termination of Pregnancy). Medical abortion prescriptions and procedures though laid down by the Government of India, particularly in the context of availability of drugs, conservative attitudes of providers so that even in the early stages of pregnancy there is a preference for surgical methods, delays from health providers leading to late stage abortions and with it the entire court / legal rigmarole.
3. Lack of access to telemedicine (telephonic services for seeking treatment) to seek sexual and reproductive health services. This is an emerging field in India and we are still learning. Young people especially adolescents fear that these services may not be confidential.
4. Redeployment and diversion of Health Care Professionals (HCP) to COVID-related duties, and lack of training of HCPs around responding to SRHR requirements during a humanitarian crisis.
5. The already existing lack of an intersectional lens in the health system is exacerbated in these times. There are particular challenges for women and girls with physical, psychosocial and intellectual disabilities, persons belonging to LGB communities and trans people in terms of access to health care.

SA: Thank you for this focused and precise identification of priority concerns. In a 2019 paper based on a study in Maharashtra on the development, implementation and testing of a gender integrated curriculum with medical students, you and your co-authors highlight multiple attitudinal challenges that were identified. Please share some of your insights with us.

SR: Medical education in India, like other parts of the world, did not take into account the social determinants of health. If they were included, they were at best relegated to community medicine in MBBS – Undergraduate (UG) medical education. The Maharashtra University of Health Sciences (MUHS) – Directorate of Medical Education and Research (DMER) Mumbai and CEHAT effort was to facilitate gender perspectives in medical education (ME) and bring about gender sensitivity amongst medical educators and students. Sex in ME is classified as a binary, based on rigid anatomical constructs of XX and XY, and any variation was considered an anomaly. Reorientation of ME enabled the ME curriculum to communicate that babies born as intersex are a variation, not an abnormality, thus moving away from the rigid binary understanding of sex. Discussions on subjects like deferring surgery, deferring the practice of assigning sex immediately on birth, counselling parents to recognise and accept intersex  children and the removal of damaging terminologies such as ‘hermaphrodite’, enabled medical students to get a nuanced understanding.

Gender and Sex are conflated in ME. Social construction related to roles that men and women are expected to play is missing in ME. Recognising Gender as being different from Sex is crucial for differential diagnosis and treatment. For example, TB can occur in both men and women, but the chances of an individual being deserted, dumped back with the parental family, of not being taken care of, is higher for women than men. So health seeking, and access to health services is also affected by gender. Integration of the gender lens was done while teaching about infections and diseases by adding case studies and exercises that would compel students to think about how gender disproportionately affects access.

While on the topic of gender in medical education (GME), we made a compelling case that gender also cannot be seen as a binary. Health concerns of transgender people had to be centre-staged. Evidence related to biases about trans people was discussed in classroom sessions and examples of good practice were shared from other countries. Examples of re conceptualising ‘Family planning services’ to contraceptive and sexual health services, asking trans people about their preference related to the gender of their doctors, discussing admission preferences and the ward where they would be comfortable – are some examples of themes that were integrated.

SA: What are the strategies you would consider for engagement at a systemic and environmental level, across education and provision of health services, that would lead to systemic change?

SR: I have listed some examples above, and the strategy that CEHAT additionally adopted was:

• To bring on board medical educators, for they are the ones to influence medical students, and not an NGO;
• Identification of gaps in curricula, done in collaboration with Medical Educators so that there is ownership of the content and it is not seen as a third party intervention;
• Develop materials that fit teaching hours because no medical college in the country will provide additional teaching hours for GENDER, and even if they do, it would become an elective that only a few students will attend and forget;
• Mainstreaming gender concerns in ME by relating it to existing medical curriculum and not creating an add-on or parallel curriculum that speaks of gender. When it’s mainstreamed the chances of it being tested are higher. For example, some questions in multiple choice questions and short answer questions would compel students to study these issues.
• Using innovative but not time-consuming methods of teaching such as case studies, quizzes, debates, which in as little as 15 minutes can grip the attention of students and impart important messages;
• Ensuring that the academic council of the DMER reviews the modules and finds it feasible for its implementation; also putting it up on their websites brings it legitimacy as part of Maharashtra ME curriculum .

The Medical Council of India, (MCI), released its revised medical curriculum for UG-MBBS – the thrust is on experiential learnings and designing of competency and skills, and less about didactic lectures. Plus Gender as a foundation course has also been introduced. Lobbying with state level DMER is the next step to ensure effective implementation. 

SA:  In a case study online describing the GME project, you have referred to the National Health Policy, (NHP) of 2017. This is the third National Health Policy, with the first having been drafted in 1983. Do you feel that over the decades, there has been any significant presence in health policy, of gender and sexuality concerns, in the context of planning and providing public health services?

SR: 2017 was the first time that the NHP made a mention of Gender as a social determinant of health. I would say there is an important opportunity therein to expand what has been done in Maharashtra to other states. There is evidence amply developed.

Allocation to Health care in the GoI budget is 1.5% of its entire budget. It is practically impossible to implement health programs effectively with such a poor budget. For the NHP to be realised, surely a larger percentage of the overall budget is required to be allocated to health. This means earmarking finance for training of medical educators, facilitating research in the area of medical science and gender, resources for monitoring of gender integration and evaluation studies for it. Unless this is done the NHP will be only on paper

Yet we see that allocation to Health is as meagre as less than 2%. Competing requirements in “Health” plus an entirely unregulated private health sector does not really enable implementation of policy .A policy has to come with a clear national plan, budget, personnel and M&E strategy.

SA: A very warm thanks, Sangeeta! A final question: what would you identify as the top three ingredients required to make the health care space a positive, sexuality affirming, inclusive and safe space in India?

SR: The top three points I’d say are:  (1) Political and administrative willingness from senior health management to recognise an intersectional approach to medical education. (2) Dedicated funds to medical colleges /department of medical education, to provide incremental trainings to medical educators to integrate gender, to enable them to carry out studies on assessing inclusion, and to equip medical students to take up thesis topics related to intersectional approaches in health care. And (3) Advocacy by champions from within the health system and medical colleges who have implemented the curriculum and brought about changes in clinical practices, for example, Miraj and Aurangabad medical colleges in Maharashtra, and doctors and nurses in Mumbai hospitals providing gender sensitive health services – they can influence others in the health system.

Cover Image: Sangeeta Rege