Ensuring Sexual and Reproductive Health and Rights (SRHR) for Garment Workers through Health Insurance
Dr. Ahmed Al Kabir, President, RTM International
I believe that there are three things we can achieve from this roundtable discussion. We will address how to make workers and factory owners interested in SRHR health insurance investment, the right to information in regard to health insurance for SRHR, and finally, how we can ensure workers get access to services. A study was conducted on SRHR by the then government in Bangladesh in 2000 for health insurance by the Health Economics Unit of the Ministry of Health and Family Welfare, which detailed plans and interventions on how to roll out health insurance in Bangladesh. However, we are still in the early stages as no real developments took place in all these years.
We need to understand that SRHR is mostly a preventive health care system. There are curative aspects here for the extreme cases of those who require hospitalisation. Unfortunately, it is not considered to be a priority issue. Preventive healthcare, as well as health insurance, often falls outside the realm of top priorities.
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Ella de Voogd, First Secretary, Sexual and Reproductive Health and Rights, Education, and Gender, Embassy of the Kingdom of the Netherlands
We want to create a kind of business model regarding SRHR of garment workers through health insurance, so that it will be sustained. We do not only want to look at the government all the time but would also want to look towards the private sector and request them to take this responsibility for the development of their own country. They could contribute by investing in SRHR insurance for their workers so that they, as well as their workers, could benefit from that.
Farhtheeba Rahat Khan, Team Leader, Working with Women Project, SNV Bangladesh
The affordability of services, gender disparity, health seeking behaviour of women that is guided by their family, right information to be in place, and social and cultural taboos continue to be challenges that we face when trying to ensure SRHR.
When we started the project, we did a value chain analysis to determine how SRHR can be integrated into the garment industry. We found that there was improper management of menstruation, low use of family planning methods, and low accessibility of antenatal and postnatal care services for mothers. There is also the vulnerability of sexual harassment and the sad thing is that all of this is led by garment workers' lack of information and knowledge about SRHR.
A recent study found that 95 percent of female garment workers use dirty rags or rejected fabrics during their menstruation while 20 percent remain absent due to illnesses related to menstrual hygiene. The economic loss of absenteeism is estimate to be around $2.5 million per annum. Thus, this shows that a worker's sexual health does have an economic impact on the industry as well.
We lack the economic rationale to implement SRHR interventions on the field. When a worker is absent due to SRHR related issues, she loses her day's wage and she has to spend from her pocket to get medicines or other necessary items. This means that her income level is going down along with her productivity. This ultimately degrades her empowerment. We also need to see what the factory stands to lose when a worker is absent due to SRHR related issues; there's a loss of manpower hours, there's also the risk of the consignment being hampered, thus ultimately there is a loss of productivity as this may even delay shipments to buyers.
Factory management tend to think that workers' health or SRHR are social responsibilities. They need to be sensitised about the economic impacts of the issue. Local service providers also often don't understand how to work with factories to provide the services and products. The end result is that appropriate SRHR services are not available for garment workers.
Under SNV's project, three insurance models have been launched. Through this project, we want to create evidence of business benefit and profitability in RMG factories as a result of integrating SRHR for female workers.
When we talk about access, the picture of health insurance comes in mind. One of the business models is in association with TMSS and Progoti Life Insurance, one is with the Family Planning Association of Bangladesh and another one is with Gonosyahtha Kendra. The providers have come up with different insurance schemes.
GIZ has done a study on the willingness to pay for workers' insurance for the health economics unit of the government. The objective of this study was to understand the feasibility of rolling out health insurance in the garments sector on the basis of the willingness of workers to pay for this insurance and attitude of the garment factory management to contribute to the scheme. 84.3 percent of the respondents were willing to purchase the insurance while several garment factories were also willing to pay up to Tk 74 per month; the median was Tk 30. The majority of the workers were willing to pay around Tk 50 per month.
In the end, there are three questions that we need to ask: what strategies are required to institutionalise SRHR insurance for garment workers, who are the main stakeholders and what could their possible roles be and finally, how can the health insurance models work effectively for the betterment of the workers.
Nur Hossain Talukdar, Director General, DGFP
The Directorate of Family Planning is more than willing to help in ensuring SRHR of garments workers through insurance. Around 4000 Family Welfare Centres are in operation in different unions around Bangladesh. We try to ensure 24 hours service delivery and have special focus on adolescent health services through designated health corners. The basic difference between hospital doctors and our department is that patients go to doctors while our staff have to search for 'clients.' If we don't do that, our target audience will not take our service. We even visited garment factories and facilitated services for the women working there. In respect to family planning, we commit to supply every facility, service or product required to garment factory workers.
Syed Ahmed, Inspector General (Additional Secretary), Department of Inspection for Factories and Establishments
Insurance is not enough to cover sexual health related issues of women because if we opt for insurance, lots of questions will be raised - who will pay the premium, how will the dividends be paid to the garment workers. I believe that it the prime responsibility of garment owners to provide health facilities for their workers. Otherwise the poor workers will be unable to pay for the expenses of the treatment.
I think more should be done to aware female workers about menstrual hygiene. If owners invest money in the health sector for their workers, they will get the returns of it in due time as their workers will be healthy and productivity will increase. While the owner should take the major share of responsibility, little amount could be taken as premium from the workers.
Our department, with support from the governments of the Netherlands, Canada and the UK are also working on upgradation for factories. We have already 3,700 factories on the safety issue. We will also be revisiting our checklist for the RMG industry to include the reproductive health and rights of the women workers.
Md. Jalalul Azim, Managing Director & CEO, Pragati Life Insurance Limited
A pilot project on SRHR in Kalihati upazilla has already been launched. We should take the issue of having health insurance for RMG workers seriously as it is one of the main sectors driving growth in our country. Pragati Insurance has introduced insurance at only half a dollar per month. In this package, workers will get health insurance coverage, which includes out-patient and in-patient requirements and medications. While Tk 50 for the insurance can be paid by the workers, Tk 75 can be paid by the owner. Another unique feature of this scheme is that a single point service will also be provided. The Thengamara Mohila Sabuj Sangha (TMSS) is our partner for this project; workers can go to the nearest TMSS centre, which has a dedicated doctor who can refer them to a secondary service provider if necessary. At present, the stakeholders, be it health service providers, SNVs or insurance companies, are undertaking this project as a social responsibility not for commercial purposes. If we can make this pilot project a success and we can find the right product with the right premium, upscaling and commercialising the project further will help to make the RMG workforce feel healthy and encourage them to comply with the requirements of the stakeholder.
Tahmina Rahman, General Secretary, Bangladesh Apparels Workers Federation
Health insurance will work only if the garment workers are made aware about reproductive and sexual health. If they don't know why it is important for them to avail the health service, they will never opt for it.
Garment workers need to produce 150 to 200 pieces of clothes every hour. Because of the pressure they work under, they cannot think of proper water intake and the damage that they do to their kidneys. The workers have to struggle to meet all the expenses with their meagre salary. So in terms of paying instalments for the insurance, the owners should take the entire responsibility. Be it Tk 20 or Tk 50, it will be very hard for workers to pay the amount.
Quazi Suraiya Sultana, Executive Director, RHSTEP
Our firm works with garment workers and trains them on the way to place their demands to the management body. We also sit with the management body twice annually, and address the workers' needs and rights.
We have introduced sanitary napkins in 35 factories and the management bodies continue to make them available in the workplace. Women have become aware about how to use them. We are conducting different awareness programmes through lectures, information, brochure, and are working with some clinics where workers can get heath service at a reduced rate. We are slowly achieving our target.
Dr Syed Abdul Hamid, Associate Professor, Institute of Health Economics, University of Dhaka
While Pragati Insurance is covering the health issues, it's not clear who is looking after the reproductive health issues. As we know, insurance only covers emergencies like illness and serious injuries; reproductive components like sexual behaviour and pregnancies are part of our lifecycle that the insurance does not cover.
The second concern is if there is insurance, the type needs to be defined; whether it's voluntary or compulsory. We have ,seen that there is no success with private, voluntary insurance in developing countries. So if there is health insurance it should be compulsory, otherwise it won't be effective in our country. If it is made compulsory, we need to know who the stakeholders are. While the garment owners should be the key responsible entity, the government too should come forward as it is allocating a huge amount of the budget for social security. Finally, the remaining part will be paid by factory employees, which could be covered by the donor agencies.
Dr Nazneen Akhter, Faculty, Department of Public Health, North South University
In terms of maternal health and child heath, we have made some appreciable progress but we are behind in the gender and economic agenda.
I have two suggestions to make here. First, we need to redesign SRHR package as the reproductive service package focuses mostly on the reproductive part but when it comes to the sexual health of garment workers, it's not that extensively thought about. Sexual health has a lot of governing power over the whole body and on the total reproductive health. Thus, attention needs to be given to various issues, starting from MR to family planning. The National Contraceptive Prevalence Survey (NCPS), abortion, menstrual hygiene, gender violence - everything should be included in the package of reproductive banner.
If the psychological domain is not taken care of, the reproductive domain will be affected as well. Therefore the service should include counselling and comprehensive sexual education and mental health education. We have to think about integrated, comprehensive, friendly and rights driven services.
My second suggestion is related with financing the reproductive health services. We need to manage continuous financing. Health insurance might be a part of the solution. To make it effective we need to understand the consumers of the insurance policy as well as the owners who will implement it. In addition to that, cost sharing of the insurance money should not be a burden for the poor garments workers.
Ghulam Mustafa, Executive Director, Gonoshasthaya Kendra
After Rana Plaza tragedy, the government has taken many initiatives to ensure safety and security of the workplace but sexual and reproductive health of female garments workers remains neglected. It should be an integral part of the whole reform package. Owners and buyers needs to come forward and share the burden of financing SRHR programmes in RMG.
Engr. Md. Kawsar Ali, COO, Comfit Composite Knit Limited
In our factory, we are providing sanitary napkins to workers at Tk 16. We also share the cost of pregnancy tests and child delivery costs. We have also signed a tripartite MoU with SNV and Kumudini Hospital to provide our workers with SRHR services. These practices have been replicated by our neighbouring industries.
Dr. Jafar Ahmad Hakim, Senior Adviser, ASTHA, Swisscontact
I think the government should take the lead in financing SRH programmes in garment factories. It should be made compulsory for employers to provide SRH facilities to their workers. Workers should also share some cost of health insurance so that their ownership retain in it.
Dr. Julia Ahmed, SRHR and Gender Expert
SRHR is closely related with gender equality. Where gender discrimination exists, negligence of SRHR persists. That's why when we talk about providing SRHR services to garment factories, we also need to look at the issue of gender discrimination there. Both the garment owners and workers are not trained to speak the language of SRHR and gender. We need to breach this gap and do more training and awareness building programmes in garment factories.
In our country, we generally mix up sexual health rights with sexual intercourse. But sexual health means positive expression of one's sexuality. It is related with a person's self esteem, confidence, body image, relationship building and social role. We need to define the sexuality issue in this spirit in our training curriculum for garments.
On the question of strategy and resources, I believe that NGOs have solid experience. As far as SRHR is concerned, I would say that we are far ahead. Now it is a question of leadership. I would say that we have a leadership crisis in Bangladesh; we really need to develop good leaders at every level.
Dr Nadira Sultana, Programme Specialist, UNOPS
The health insurance model for preventive health care that is being carried out in different parts of the world is actually covered by the countries' government. The service components of SRHR must consider the life cycle approach. SRHR starts with puberty and ends with menopause. We need to bear this important fact when formulating an appropriate health insurance strategy.
Primary level of healthcare for health insurance, which is NCP, must be followed in every garment factory. While the owner should ensure this, the government is also liable to provide primary healthcare services. The government is trying to do that through community clinics and medical college hospitals. The facility needs to be reached to the garment workers. Female garment workers should be aware of their sexual and reproductive healthcare system.
Before implementing a health insurance model, we need to go through different operational research works. A feasibility study can help gather more knowledge about this. The government already has some social safety and security projects in place for rural women. This existing model can also be explored for garment workers. Lastly, proper negotiations with garment owners will help us run this project smoothly.
Irfan Hossain, Programme Officer, Population Council
I would like to use this platform to tell factory owners that we, INGOs and NGOs, are not your enemies. We are here to provide help to you. Whenever we go to the door of a factory owner, we do not get the expected cooperation from them. I just came to know from SNV's value chain analysis report that by investing one dollar for the health of factory workers, factory owners can get three dollars in return. It, in a sense, leads to increased productivity.
Dr. Matiur Rahman, Director, Health, TMSS
I think proper healthcare and ensuring SRHR is a challenge for Bangladesh. Institutionalization of SRHR services through insurance is also great challenge for us. Government offices are not committed about introducing this type of health insurance. If they are reluctant about this at a policy level, it is impossible to introduce this kind of challenge. I believe that we should reach the negotiation table with influential groups of people from government, NGOs and business sectors. If they are committed then it will be easy to introduce insurance for garments workers.
We commonly see that doctors and health professionals are not available where they are posted. We cannot deploy anyone if they are not experienced with SRHR. We need capable manpower to provide this type of service. We also need to do pilot projects which will cover two components - SRHR health services and subsidised insurance services.
Tarik Hasan Shahriar, Senior Correspondent, Daily Sun
We could try going for a minimum package scheme which could include whole health productive services, subsidised by donors or supported by NGOs. It can be a small package which with focus on important issues like menstrual hygiene and family planning. That would be less of a burden, as family planning commodities are supplied by the government. Menstrual regulation and psychosexual counseling could also be incorporated in this package for garments workers. Food security and safety is a global agenda today. The package could also include meals at a subsidizsed rate.
Suraiya Haque, Executive Director, Phulki
SRHR is carrying out awareness programmes in garments factory. We saw how the proper use of sanitary napkins changed workers' life. We did a return of investment study on garments owners and found that when they invested Tk 1, they would get Tk 13. Earlier, workers would dump their used napkins or rags in the toilet. Cleaning the clogged toilets three to four time a year would result in huge costs. This cost is now avoided because of awareness. Workers do not understand what sexual health is. This is because women issues are not considered as social issues. Woman issues are not much discussed. I have been speaking with BGMEA officials for the last ten years. When I began to speak about menstruation and menstruation hygiene, I noticed that no one would look straight at me. It is imperative that we can discuss these issues openly and without shame.
Farhtheeba Rahat Khan
When we take this project to the buyers' forum, they say that if you have sexuality in health rights and that is your brand then we cannot join you as people will say that we are doing something on sexuality. There is still taboo on this issue that will remain for another 10 to 20 years.
Operational research is important. We are thinking about how these things could be documented. When we talk about Inclusive Business, we need to identify how to create a sustainable model. Workers need to be made to understand that this is their right.
Training methodology is very important. When we started the project, the Netherlands government did a study to understand what is happening in the garments sector. Awareness programmes could be a traditional form of spreading information. Unless workers are made aware of their rights, it does not matter whether the package is affordable, qualitative or accessible.
I believe that workers should pay for their SRHR because we found in our study that if they don't pay for it, they won't feel a sense of ownership.
Mahfuz Anam, Editor, The Daily Star
Women are being neglected in so many ways. Women health and menstruation issues are neglected. The health of women garments workers is a matter of great priority. We would like this issue to reach major policymakers like the government and the BGMEA. The Daily Star is committed to helping social issues like this.
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