Laxmi Mandal & Ors. v Deen Dayal Harinagar Hostpial & Ors., W.P.(C) 8853/2008
India, High Court of Delhi

Laxmi Mandal & Ors. v Deen Dayal Harinagar Hostpial & Ors., W.P.(C) 8853/2008

DATE 04-06-2010DOWNLOAD LEGAL DECISION

Judges:

S Muralidhar

S Muralidhar

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Topics:

Maternal Health

Related standards:

Constitution of India (India) Article 21. Protection of life and personal liberty

RELATED STANDARDS

Constitution of India (India) Article 21. Protection of life and personal liberty

No person shall be deprived of his life or personal liberty except according to procedure established by law.

WHY IT MATTERS:

High Courts are the highest ranking state courts in India. High Courts function as constitutional courts. Their decisions are mandatory for all the lower courts of that state.

This decision sets an important precedent in relation to the right to safe motherhood in a context of high maternal mortality rates. The Court emphasised the indivisibility of civil rights and social and economic rights. Further it consistently underlined the indivisibility of basic human rights and particularly highlighted the interrelatedness of the rights to life, health and food. It stated that the inalienable right to health is inherent in the right to life and observance of this right is the means of enforcing the right to life.

Additionally, it is worth noting that the Court relied extensively on international law and documents combined with national jurisprudence to support its findings.

The Laxmi case is the result of a public interest litigation promoted by the organization Human Rights Law Network (HRLN) as part of their advocacy initiative for reproductive rights in India.

The New Delhi High Court recognized a constitutionally and internationally protected right to maternal healthcare and ordered compensation for rights violations experienced by two impoverished women and their babies during and related to childbirth. Both cases, the Court found, were essentially about the protection and enforcement of the basic, fundamental and human right to life under the Constitution and the two inalienable survival rights that form part of the right to life: the right to health, in particular reproductive rights of the mother, and the right to food.
Government Schemes
The Government of India had introduced a cluster of schemes aimed at reducing infant and maternal mortality and in particular schemes addressed at benefitting mothers below the poverty line during their pregnancies and thereafter. The Supreme Court of India had, in 2001, recognised the interrelatedness of the schemes and made certain mandamus orders in relation to the schemes (People’s Union for Civil Liberties v Union of India, Writ Petition No. 196 of 2001, 28 November 2001, hereinafter PUCL Case). It had thereafter time and time again emphasised the importance of the effective implementation of these schemes meant for the poor.

First Petition on behalf of Shanti Devi and Archana
Shanti Devi, an Indian woman living below the poverty line, died as a result of being refused adequate maternal healthcare, despite the fact that she qualified for the free services under the existing state-sponsored schemes. Ms. Devi was generally of poor health and suffered from anaemia and tuberculosis. Two of her four previous pregnancies had resulted in the death of the foetus or the child. In 2008 during her fifth pregnancy, Ms. Devi was forced to carry a dead foetus in her womb for five days after being denied medical treatment at several hospitals because her husband did not have an appropriate medical card to prove she was below the poverty line. The Court had intervened at this point in 2009 and ordered that she be admitted and treated free of cost. The following year Ms. Devi became pregnant for the sixth time and died after giving birth to a premature baby, Archana, delivered at home without the attendance of a skilled birth attendant. The Court made a series of order to ensure the care of Archana and ordered a maternal audit of her death. The audit highlighted serious shortcomings in her care. On foot of this, the Court found that the direct cause of her death was extensive haemorrhage (PPH) with retained placenta. However, it continued that there were many indirect and contributing factors to her death broadly including her dismal socio-economic status which denied access to needed resources and services, and her poor health condition which is a culmination of anaemia, tuberculosis and repeated unsafe pregnancies.

Second Petition on behalf of Fatema and Alisha
Fatema, a poor uneducated woman suffering from epilepsy fits, was homeless and living under a tree. Her husband abandoned her after she became pregnant. She attended at a maternity home in her area inquiring about vaccinations and benefits available under the public health programmes but received no response or assistance from the authorities. In June 2009, she delivered her child, Alisha, under a tree, in full public view, without access to skilled health care and medical guidance. Despite informing the maternity home no visit was made by the staff. The Court had intervened in January 2010 to make various orders, including the provision of a medical card, medical assistance to both mother and child, the payment of the appropriate cash benefits available under the appropriate government schemes. They sought compensation, proper implementation of the schemes and the provision of nutrition to Fatema and her daughter.

Right to health and reproductive rights
The Court noted that the two petitions were essentially about the protection and enforcement of the basic, fundamental and human right to life under article 21 of the Constitution and highlighted the indivisibility of basic human rights as enshrined in the Constitution. Both cases concerned the “two inalienable survival rights that form part of the right to life.” The first, the right to health, includes the right to access and receive a minimum standard of treatment and care in public health facilities and in particular includes the enforcement of the reproductive rights of the mother and the right to nutrition and medical care of the newly born child and continuously thereafter until the age of about six years. The second right, the right to food, is seen as integral to the right to life and health. Both rights call for immediate protection and enforcement in the context of the poor.

The right to health as an inalienable component of the right to life was reiterated by the Court and noted as consistent with international human rights law. In an extensive analysis of international human rights law, the Court pointed to article 25 of the Universal Declaration of Human Rights, which it noted as having the force of customary international law. The Court thereafter referred to the International Covenant on Economic, Social and Cultural Rights (ICESCR) as spelling out in greater detail the various facets of the broad right to health. It further cited three paragraphs from General Comment No. 14 of 2000 of the Committee on Economic Social and Cultural Rights as explaining the scope of the aforementioned rights. Those paragraphs refer, broadly to the right to control one’s health and body, including sexual and reproductive freedom, outlines the underlying determinants of the right to health and notes that the reduction of infant mortality requires measures to improve child and maternal health and sexual and reproductive health services, including access to family planning, pre and post natal care, emergency obstetric services and access to information, as well as to resources necessary to act on that information.

It continued its examination of international law with the Convention on the Elimination of Discrimination Against Women (CEDAW) citing in full articles 12 and 14 which detail the obligation of States to eliminate discrimination against women in the field of health care in order to ensure access to health care services and family planning and highlights the particular problems faced by rural women and outlines obligations of the State. Thereafter it referred to the Convention on the Rights of the Child (CRC) articles 24 and 27 outlining States’ progressively realizable obligations, inter alia, to ensure the highest attainable standard of health for every child.

Referring again to the PUCL case the Court stated that in effect the Supreme Court had in that case spelt out what the “minimum core” of the right to health and food is and also spelt out, in line with international human rights law, the “obligations of conduct” and the “obligations of result” of the Union of India and States. Recognizing the indivisibility of civil rights and social and economic rights the Supreme Court made them enforceable via a “continuing mandamus” which mandate the High Courts are obligated to carry forth.

Merits
The Court noted that both cases pointed to the complete failure of the implementation of the schemes. Neither woman received attention or care in the critical weeks preceding the expected dates of delivery and both were deprived of accessing minimum health care at homes and public health institutions. Shanti, during her lifetime, did not get the benefit offered under two of the schemes which is a “major failure which aggravated the causes that ultimately led to her death.” Fatema did finally receive benefits under the schemes but only after the intervention of the courts. The Court noted that it was well possible that without its intervention both mother and baby might have been denied benefits which could have caused irreparable injury and possibly loss of life.

With regard to public health it held that “no woman, more so a pregnant woman should be denied the facility of treatment at any stage irrespective of her social and economic background.” This it stated, is the primary function in public health services: “[t]his is where the inalienable right to health which is so inherent in the right to life gets enforced.” There cannot be a situation where a pregnant woman in need of care is turned away from a public health facility only on the basis that she has not been able to demonstrate her eligibility status: that she is below the poverty line. The approach of the Government, according to the Court, should be to ensure that as many people as possible get covered by the scheme not insisting on such documentation as they appeared to be doing. This “onerous burden” to prove that they are persons in need of urgent medical assistance constitutes a major barrier to their availing of services.

Government Misuse Argument
As well as a variety of fact based objections, the government had argued, inter alia, that there was an apprehension that the benefit under the scheme would be misused. The Court found this argument to be misplaced, noting that given the status of the facilities available in public hospitals and primary health centres across the country, it was very unlikely that any person who could otherwise afford health care was going to misuse those facilities.

With regard to Shanti’s “clearly avoidable” maternal death, the Court made a series of orders benefitting her daughter and family including the refund of monies paid for treatment which should have been free, the cash benefits available under the various schemes, the provision of the appropriate cards to Archana’s family so that she may avail of benefits, as well as a fixed amount of compensation to be paid by the State to Shanti’s husband, her two sons and her Archana each. Significantly, it recognised Shanti as a “primary bread winner” under the scheme thus entitling her husband and children to a further lump sum.

With regard to Fatema and Alisha, the Court ordered that Fatema and Alisha receive all appropriate benefits under the various schemes, including basic food stuffs and provided a scheme and location for Fatema to receive treatment and be monitored regarding her epilepsy. For the violation of the fundamental rights of Fatema by being compelled to give birth to Alisha under a tree the Court awarded her a lump sum.

Additionally the Court detailed various shortcomings of the relevant schemes and stated that the present case afforded to the Central and State governments an opportunity to put in place corrective measures. Finally, it made specific directions in relation to the organisation and implementation of the schemes which it deemed necessary to ensure that the benefits contained therein are not denied to the beneficiaries and that assistance is provided promptly and at the nearest accessible point.

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