Integrating strategies to address gender inequity and change harmful gender norms is an increasingly important component of HIV programs. However, gender integration among programs targeting most-at-risk populations (MARPs) is much less prevalent. This case study (one of nine in a series) reviews how SANGRAM, a women-led network of collective empowerment groups in India, is developing and administering projects that promote and protect the rights—and health—of MARPs.
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By Nandita Kapadia Kundu
Engaging Communities in India to Demand their Rights
It is August 15th, India’s Independence Day and a festive holiday nationwide. In the town of Miraj, Maharashtra, 25-year-old sex worker Gangowa Kamble is in her one-room tenement with her children and her new malak (lover). Vinay, her 5-year-old son, is playing with 18-month-old Bhumika. But Gangowa’s malak is irritated by the antics of the energetic Vinay and tells him to sit quietly instead of jumping and running around the room. Vinay continues jumping and playing. Suddenly, the malak takes a big serving spoon, heats it on the tawa (flat pan), and burns the boy’s face, arms, right leg, and foot with the hot spoon.
Vinay’s screams of pain echo through the lane as the malak walks out of Gangowa’s home. Within minutes, the news of little Vinay’s mistreatment has spread, and representatives of the local sex workers’ collective Veshya Anyay Mukti Parishad (VAMP; Sex Workers Collective Against Injustice) swing into action. As Vinay is rushed to the hospital, a police complaint is filed against Gangowa’s malak, who is arrested and jailed. VAMP makes arrangements to keep Vinay in the nearby town of Nippani, at Mitra, which is a hostel for the children of sex workers.
VAMP, Mitra, and the network of sex workers who came to the aid of Gangowa and her son are all part of a network of self-help collectives that grew out of Sampada Grameen Mahila Sanstha (SANGRAM(1); Rural Women’s Organization). Launched in 1992 as a grassroots peer education program for sex workers, SANGRAM has worked with VAMP to develop and administer a series of self-help organizations for most-at-risk populations (MARPs) in west-central India. SANGRAM/VAMP’s rights-based approach has helped these marginalized groups to help one another and protect their rights to live and work in safety, prevent exposure to HIV and other sexually transmitted infections (STIs), avoid violence, and increase access to services.
It’s My Adhikar (Right)!…sex workers demand rights.
Disclaimer: The author's views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
HIV prevalence and MARPs: According to a 2006 survey, India’s HIV prevalence is about 2.5 million, or 0.28 percent of the general population (IIPS and Macro International 2007). The epidemic is geographically concentrated, with 89 percent of cases occurring in 6 of India’s 28 states (Maharashtra, Andhra Pradesh, Karnataka, Tamil Nadu, Arunachal Pradesh Nagaland, and Manipur; Saidel et al. 2008). Prevalence is further concentrated among MARPs: for example, in Maharashtra, HIV prevalence is 24.4 percent among people who inject drugs, 11.8 percent among men who have sex with men (MSM), and 17.1 percent among female sex workers (FSWs; AVERT 2007). A 2006 biobehavioral survey of about 100,000 FSWs and 4,597 MSM in four high-prevalence states showed an average HIV prevalence of 14.5 percent among FSWs (Ramesh et al. 2008). The MSM survey indicated that HIV prevalence was 18.1 percent in hijras, 15.9 percent in bisexual men, 13.5 percent in kothis, 7.6 percent in panthis,(2) and 10.5 percent in men who reported both receptive and insertive anal sex (Brahmam et al. 2008).
Numerous behavioral factors increase health risks for MARPs. The biobehavioral survey showed low condom use (less than 49 percent) with regular partners and more than 80 percent with paying commercial partners. A large proportion (43 percent) of MSM sampled had also had sex with a female partner in the past three months (Brahmam et al. 2008). The linkages between physical violence and risk of HIV are well established in the Indian context. A study conducted in the state of Andhra Pradesh found that almost 26 percent of sex workers had experienced at least one episode of physical violence in the past year. Experiencing violence was associated with much lower likelihood of condom use (Beattie et al. 2010). These findings suggest significant potential for the further spread of HIV within and beyond high-risk groups.
Women’s rights also remain a major challenge in India, where men are still seen as the only decision makers. Women have limited access to resources and are frequently subjected to violence. FSWs are doubly challenged, as women and as a socially marginalized group. They have limited access to social safety networks, such as police protection, when they experience violence either at home or during the course of their work—in fact, they may endure further violence at the hands of the police.
Legislative environment: Sex work is legal in India, though solicitation in public places and running a brothel are illegal. Deeply rooted patriarchal traditions censure the sex worker, not his or her male clients. The majority of sex workers take up the work because of dire economic need (Ramesh et al. 2010; Reed, Gupta, and Biradavolu 2010). Sex workers (female, male, and transgender) have long suffered low status and social discrimination (Blankenship et al. 2008).
The Indian Penal Code, until recently, criminalized same-sex activities, and MSM lived under the constant threat of police harassment. This law was revoked in 2009, and there were celebrations by MSM groups all over India.
Evidence exists within the Indian context of the impact of peer-led interventions on condom use and reduced incidence of STIs in FSW (Reza-Paula et al. 2008). The impact of a sex worker collective on reduction in HIV prevalence in Sonagachi has also been demonstrated (Jana et al. 2004; Cohen 2004). However, there is little documentation on the impact that a rights-centered approach can have on the lives of MARPs and their families in other locations in India.
SANGRAM, established in 1992 in Sangli, Maharashtra, has grown into a series of collective empowerment groups for stigmatized communities (sex workers, MSM, and transgender individuals) in six districts of southern Maharashtra and northern Karnataka. SANGRAM is unique in being a women-led, rights-based group that seeks to change community norms and tackle gender inequities at the grassroots level. These inequities include gender-based violence (GBV), access to resources, and rights in terms of protection, property, and power. SANGRAM also works at a deeper level by addressing male norms.
SANGRAM is a registered nonprofit organization with seven board members, all women who live in and around the city of Sangli, and 83 staff members. As SANGRAM grew, a range of donors approached the organization, which is currently funded by the Bill & Melinda Gates Foundation, the Netherlands-based Humanistic Institute for Development Cooperation, and the Ford Foundation. SANGRAM’s primary focus is working with marginalized groups to prevent GBV and HIV and to provide care and support for group members who are in need. The nongovernmental organization’s (NGO’s) activities build on the concept of asserting rights and the core tenet that communities have the ability to find their own solutions. Central SANGRAM principles include 1) involving sex workers in program design, implementation, and leadership; 2) creating a sense of community to facilitate collaboration; and (3) working to eliminate the stigma and discrimination associated with sex work.
SANGRAM’s first efforts focused on empowering FSWs to protect themselves and avoid contracting HIV by using condoms. Gokulnagar, Sangli’s red-light district, was a volatile environment where fights over clients, drunken brawls, thugs, and police raids were daily realities. Initially, women in Gokulnagar viewed SANGRAM’s efforts with mistrust and cynicism. Thus SANGRAM’s first goal was to build trust through empathy and respect.
The next step was to begin building communities based on common interests and needs. SANGRAM established a peer education program that was both targeted at and carried out by sex workers, who promoted condom use among other sex workers while continuing with their own dhandha (sex work). They did not insist on 100 percent condom use, but used a rights approach that assumed that sex workers feel it is in their best interest to protect themselves. By focusing on empowering women to meet their own needs, the peer educators helped to establish condom use as a norm in Gokulnagar.
BOX 1. COMMUNICATION: SANGRAM'S NETWORK OF SUPPORT
The cell phone is a primary means for ensuring support for members of the SANGRAM collectives. Sex workers who are having trouble with the police call a VAMP board member, who arranges for their release. Sex workers routinely call or visit one another, or visit the local VAMP office, for help with family problems or difficulties with rent, or to organize schedules to help a member who needs food or medical supplies. After Gangowa’s malak burned her son, for example, fellow VAMP members used their cell phones to arrange for the man’s arrest and provide help for Gangowa’s family.
Genesis of VAMP: Within a few years of becoming peer educators, brothel-based sex workers began to discuss the need to have their own organization. The sex workers’ collective, VAMP, was born in 1996. Originally centered on preventing HIV, VAMP later changed its name to convey “freedom from injustice” as its focus spread to include issues at the very core of gender inequities: violations of human rights, including GBV directed against sex workers. Peer educators worked first with women in the two main red-light areas of Gokulnagar, providing information and condoms. VAMP next turned its attention to street- and home-based sex workers. It took some time to win the confidence of streetbased workers. “Trust is key,” says Kamalabai Pani, vice president of VAMP. “You have to help. You have to get immersed in their problems… They are harassed by goondas (thugs) and the police. We [secure the release of] at least one or two street-based sex workers from police custody every week. Now the women say to the police, ‘You have no right to hit us; you cannot use any type of violence against us.’” The peer outreach program covers six districts with a total of 5,000 sex workers and distributes approximately 470,000 condoms every month.
VAMP is now a registered sex workers’ collective with about 5,000 informal members and a staff of 127, several of whom are the children of sex workers. Any sex worker can join, free of charge, and use the information and services that VAMP provides.
VAMP’s advocacy and support for members helped to increase sex workers’ access to public services. There was a time, for example, when sex workers were not allowed to enter the police station to file a complaint against any act of GBV or other injustices. Now the police regularly register complaints from sex workers. After VAMP worked with the police and malaks, or clients, anecdotal evidence suggested that violence against sex workers was beginning to abate. Sex workers have also become leaders in Sangli’s HIV prevention efforts.
The collective provides a community safety net that helps other members through difficulties while benefiting the collective as a whole (see Box 1). For example, when a sex worker died and left her 10-year-old son destitute, VAMP members repaired the woman’s home and rented it out; the monthly rent provided income to raise and educate the child. For members living with HIV, other VAMP members provide food, help in obtaining medical care, and assist with children. They also often contribute money toward the marriage expenses of the children of impoverished sex workers; some members have been able to convince family members to accept the daughters of sex workers as brides for their sons.
Today, SANGRAM and VAMP work in tandem. VAMP’s role is to manage all peer interventions within the sex worker community; peer educators stock condoms and provide noncoercive information and references on preventing HIV and obtaining HIV testing. SANGRAM provides administrative support and collaboration as required, has helped to develop VAMP’s administrative capacity, and has trained the adult children of two sex workers to manage administration and accounts. SANGRAM/ VAMP have gone on to establish and help to build a number of collectives that address human rights, HIV prevention and care, and prevention of GBV within a range of communities, including not only sex workers but the general population (see Table 1).
SANGRAM’s Process for Initiating Programs
SANGRAM’s programs seek to enable collective transformation—a change occurring to or within a group of persons that is sustainable at the individual, group, and systemic levels. SANGRAM bases the process of transformation on a set of 10 rights-based steps or principles that create a cycle of further transformation; the process depends on local contexts, and the steps may not always follow the chronological order described as follows.
Steps 1 and 2. Build trust through empathy and respect: The separate but intertwined processes of 1) building trust and 2) showing empathy and respect are crucial for working with marginalized groups and communities. Shabana Khazi, General Secretary of VAMP, describes the process of building trust as, “First, understand our dukh (sorrow). Don’t humiliate us.” It was important to the members of VAMP that SANGRAM accepted the sex workers’ issues and never tried to dissuade them from sex work. Approaching an individual or a community requires empathy and respect. However, showing empathy and respect does not always lead to trust. A VAMP member recalled that she had to go with a client, proving that she, too, was a sex worker, before the street-based sex workers would accept her as a peer educator. Building trust takes time—from several months to a year—but time must be invested to build the foundation for the subsequent steps.
Step 3. Develop peer-led initiatives: SANGRAM’s philosophy centers around the belief that marginalized communities carry their own solutions within themselves; hence the NGO’s goal to build the capacity of the communities to develop peer-led solutions. Some peer leaders are volunteers (village peers), whereas peers in sex worker communities are paid as SANGRAM employees. SANGRAM provides the initial training, and training updates take place through weekly meetings to discuss events and concerns.
Step 4. Let the group reach “readiness”: SANGRAM leaders advise organizers against rushing to establish a collective. Groups will express a need to organize themselves when they are ready.
Step 5. Establish the collective: Once the group is ready to form a collective, the next step is to establish and formally register the collective or organization; subsequently, members need to work out the organization’s goals and governance strategies. The organization is led by a board of respected leaders chosen by their peers.
Step 6. Respond to local needs: A factor in SANGRAM’s success has been flexibility—the ability to respond to local needs, including those outside program parameters, while moving toward program objectives. For example, after a riot broke out during a community festival, SANGRAM organized a three-day youth conference that discussed the need for community harmony in the face of unrest.
Step 7. Focus on rights: SANGRAM’s experience is that the rights-centered framework enables the transformation of communities—the right to work and live free of discrimination, inequality, and violence.
Step 8. Speak the language of rights: New collectives go through a learning process as the group takes shape. Typically, members of a new collective have a limited understanding of what a rights-centered approach means. Later, they come to understand how to demand their rights, and finally, the language of rights becomes part of the daily vocabulary of the members of the collective.
Step 9. Venture into new territories: The development of the collective is an enormous confidence building exercise for all members. As the organization gains strength, and its members begin to experience benefits and see how their situation improves, collectives may begin to see new focus areas.
Step 10. Strengthen the collective: SANGRAM has played a crucial role in strengthening the collective. The relationship between SANGRAM and VAMP is symbiotic. As VAMP gets stronger, SANGRAM works to further strengthen VAMP’s organizational capacity at all levels.
|VAMP—HIV prevention, care, and support for sex workers||Covers more than 5,000 sex workers in five states, 470,000 condoms are distributed monthly, and provides care and support for sex workers with HIV.||127|
|The "District Campaign"||Program for HIV prevention and reduction of GBV for the general population in 713 villages; also includes an education program on adolescent sexuality and health rights.||51|
|Muskan, a program for MSM, transgender, and bisexual men||Provides STI/HIV information, health services at a drop-in center, and referral services for HIV testing and STI treatment to a government hospital for MSM, including bisexual men.||19|
|Mitra Home||A home for children of sex workers from five states.||Included in District Campaign|
|Center for Advocacy on Stigma and Marginalization (CASAM), a center for rights-based advocacy||A library of resources on sex workers; produces monographs and papers on issues related to human rights and sex work.||7|
|Sangli Talkies, a community video unit||An initiative by adult children of sex workers; they produce documentaries that highlight issues of discrimination.||7|
|SANGRAM Plus||For the general population, provides 25 support groups for people living with HIV in Sangli district, has 463 members, and provides antiretroviral therapy, care, and support.||Included in District Campaign|
FIGURE 1. DEVELOPMENT OF VAMP
Click here for a larger image.
Based on these principles, SANGRAM and VAMP have established a number of programs to address issues within, and beyond, the sex worker community. Figure 1 shows the development of VAMP’s programs from peer education and support to programs for the general population.
District Campaign: In 1997, while continuing its peer education among sex workers, VAMP decided to initiate an HIV prevention program for married women and unmarried adolescents in the 713 villages in Sangli district. This campaign implemented a broad range of outreach activities (see Table 2) focused on preventing HIV, reducing violence, and preserving the rights of marginalized groups. The campaign’s main audiences were village women, government health workers, and adolescents. Here, too, the model used was a peer-led effort and maitrins (women volunteers) were selected in villages. About 3,490 maitrins received one-day training on HIV prevention and GBV. The maitrins provide home visits to people living with HIV and to families where there are HIV-affected orphans. SANGRAM/VAMP teams also inform the maitrins of any cases of violence or gender injustice; teams intervened in several instances where women whose spouses have died of HIV-related disease were denied their property rights.3
Adolescent sexuality program: Another program in the district campaign is a sex education curriculum for adolescent girls and boys in 314 high schools and colleges in Sangli district. SANGRAM’s training on sexuality covers reproductive and sexual health and conveys an attitude of acceptance toward nontraditional sexual lifestyles.
SANGRAM Plus: The district campaign team also promoted the rights of people living with HIV to health care. SANGRAM Plus organized 25 support groups for people living with HIV throughout the Sangli district, providing the 463 participants with antiretroviral therapy (ART), care, and support. A representative of SANGRAM/VAMP also works in 53 of the district’s 59 government primary health centers, where health services and medicines are provided free of cost. Because not all villagers are aware of this free service, the campaign team worked with the district-level Panchayat Samiti (local self-government committee) to put notices in every primary health center indicating that treatment at these centers is free and advising clients to contact the Panchayat Samiti in the event of violations. VAMP/SANGRAM has placed a social worker at the main government hospital to ensure that its community members, people living with HIV, and people referred throughout the district receive health services with a humane approach.
Mitra Hostel: The children of sex workers and those affected by HIV face difficult lives. For example, 1,255 children in Sangli were orphaned due to HIV. Some can live with families; finding solutions for others is more complex. In 2009, SANGRAM/VAMP established a home for the children of sex workers. The Mitra Hostel hosts 34 children who were chosen by VAMP members based on need. Eligible children include orphans and those with single mothers who lack the support systems to care for the child, are alcohol-dependent, or are too ill to care for their children. Each sex worker in the collective donates two weeks of her time annually to the hostel.
Muskan: In 2000, a group of men approached SANGRAM to discuss starting a program for MSM, including male sex workers, kothis, hijras, and bisexual men. This led to the establishment of Muskan (Smile), which uses a rights-centered approach to provide support for MSM and promote the prevention of HIV and violence. Lack of family support at home is a key issue for MSM, who often are beaten, isolated, and ostracized. Muskan provides support to men who have left their homes and provides safe spaces where MSM can be themselves, discuss their problems, and, importantly, celebrate events and festivals in a community. The group provides outreach to over 1,000 MSM and transgender individuals through 18 peer educators. Muskan also provides home-based care to MSM who are living with HIV, promotes consistent condom use through a network of peers, and advocates at the Sangli hospital to reduce stigma against MSM. Muskan also addresses the issue of violence among MSM. “If we hear a complaint that a kothi is being harassed, we act immediately,” says Rao Sahib of Muskan. VAMP has placed a social worker at the Sangli Civil hospital, and there are anecdotal reports of a change in attitude of the hospital staff toward sex workers, MSM, and transgender people.
The Center for Advocacy on Stigma and Marginalization (CASAM): In 2006, SANGRAM established an advocacy center, CASAM, to document lessons learned from community-based initiatives with broad implications for marginalized populations at the national and international levels. CASAM produces monographs and papers on issues related to human rights and sex work. SANGRAM has published 19 case studies of sex workers’ children in Brothel Born and Bred: Children of Sex Workers Speak,(4) which describes the discrimination that these children faced, how they overcame it, and their acceptance of their mothers as sex workers. Beyond the Sangli district, CASAM also promotes the idea of sex work as “work” and seeks to de-link sex work from trafficking. SANGRAM also works with several other Indian sex work collectives, the Asia Pacific Network of Sex Workers, and the Global Network of Sexwork Projects.
Sangli Talkies: In a recent development, SANGRAM initiated “Sangli Talkies,” a community video project carried out by the children of sex workers. A recording unit enables them to make short films describing the grassroots perspective on various issues. Five films were made in 2009 and 2010, including documentaries on school dropouts among the children of sex workers(5); the annual festival celebrating Yellamma (a goddess worshiped by many sex workers); and the street workers’ annual program on Babasaheb Ambedkar Jayanti, architect of the Indian constitution and a noted leader of the dalits (the lowest of India’s castes). Point of View, a Mumbai based non-profit organization, documented SANGRAM’s work in 1998 and 2006.
Other activities: SANGRAM organizes several annual programs and festivals, including those documented in the Sangli Talkies, a youth festival, and an event for International Women’s Day. The organization also responds to community emergencies. For example, it established a community kitchen for inhabitants of Gokulnagar in 2005, when parts of the Sangli district were submerged following a major flood.
|Condoms distributed (general population)||39,300|
|Sexuality education in schools||17,337 girls, 23,604 boys|
|Domestic violence cases||145|
|Group meetings||2,364 meetings attended by 15,516 people|
|Referral for HIV testing||616|
|Follow-up visits for people living with HIV||9,692|
|New HIV outreach||210 total (120 females, 87 males, 23 children)|
|Street plays on HIV||106 plays attended by 13,550 people|
|Women's day program||1,500 attendees|
What Worked Well
The rights-based approach for community self-advocacy: SANGRAM’s empowerment of marginalized communities has had a significant positive impact on members of the various collectives that it formed or helped develop. SANGRAM/VAMP has had a transformational affect on individuals, families, and communities. The empowerment brought about through the rights-based approach and the participation of marginalized groups has helped these groups build their capacity for leadership and develop strategies to demand their basic rights and address such barriers as gender discrimination, prejudice, mistrust, and pity. Subsequently, the sex workers’ collective in Sangli extended help to communities that once marginalized and mistreated them. As a result, VAMP’s leadership role has grown in the general community. Several VAMP representatives have been nominated to serve on local ward committees and on committees of national and international sex workers’ collectives.
Recognition of sex work as a profession: The sex workers who serve as peer educators and officers of VAMP—including women, MSM, and transgender sex workers—reported that they were comfortable introducing themselves as “sex workers.” Sex workers are better able to negotiate condom use, and sex with a condom has become the norm in Sangli’s red-light district. However, condom use with malaks is still inconsistent.
Advocating for sustainable improvements in health services: SANGRAM’s advocacy led to construction of a new facility in the government district hospital and ensured that citizens, including the poorest, receive the services to which they have a right.
Sustaining the SANGRAM/VAMP partnership: SANGRAM’s leadership has sustained the partnership with VAMP. However, without SANGRAM’s funding and fundraising expertise, VAMP would face sustainability challenges.
Absence of rigorous monitoring and evaluation: SANGRAM does not conduct routine monitoring, and its work has not been systematically evaluated. The absence of rigorous documentation of specific benchmarks for achievements limits the potential for existing SANGRAM/VAMP initiatives and creates an obstacle for donors who want to understand, adapt, or support the approaches that have worked for SANGRAM.
Need for tighter focus: SANGRAM’s district campaign has become very diffuse and needs a sharper focus to capitalize on and continue the momentum built at the grassroots level since 1998.
Continuing violence and harassment: Sex workers report that violence from clients has diminished, but both sex workers and MSM continue to experience violence. Police continue to arrest and harass street-based and MSM sex workers, though they are less likely to be abused once detained. There is a need to examine and develop interventions for the community and cultural attitudes that condone the mistreatment of marginalized men and women.
Achieving full participation: The words “participation,” “community mobilization,” and “empowerment” have often been used in HIV prevention programs. The challenge remains: how to move from rhetoric to real participation and empowerment of MARPs.
Providing a model for partnership: The SANGRAM/VAMP model, as well as the other collectives nurtured by SANGRAM, offers a new type of partnership in which the older organization nurtures the newer one.
Replication through engagement: The SANGRAM philosophy is to engage communities in addressing the conditions that disempower them. These groups can then use the principles and processes established by SANGRAM to target the goals they seek.
SANGRAM’s work over 20 years represents a work in progress, and should continue to evolve in order to reflect the changing reality of sex workers’ lives. The next challenge will be to define the linkages between the rights-based approach and the elimination of gender-based inequities. VAMP highlights the enormous potential that exists in marginalized groups and, with outside funding support, could be a capacity building resource to other organizations in the global south.
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Sincere and heartfelt thanks to the SANGRAM/VAMP/Muskan teams and their communities. Specifically, thanks to Meena Seshu (General Secretary, SANGRAM); Kamlabai Pani, Shabana Qazi, Durga Poojari, Laxmi Shinde, and Bhimawa Gollar (VAMP office bearers); Shanitlal (administrator); Raju Naik (coordinator); Kavita Raut and Priya Kamble (sex workers, Gokulnagar); Sudhir (coordinator, Muskan); Rao Saheb, Pandurang, Asif Shaikh, Swapnil, Sachin Kadam, Rafique, Chandrakant Patil, Sambhaji, Devdas, and Mohan (Muskan team); Vinayak Kulkarni, Vijay Kamble, Kalappa Shivasane, Sachin AIwale, Mahesh Manoj, and Sunil Terkale (adult children of sex workers); Sushila Kunde, Sunita More, and Yashodha (district campaign); Lata Podar, Vaishali Shinkole, Sangeeta Date, Akka tai Ganpati More, and Anita Mohite (SANGRAM Plus); Sheetal Pratap (Finance Director & Board Member). Thanks also to the PEPFAR Gender Technical Working Group for their support and careful review of this case study.
Kundu, Nandita Kapadia. 2011. SANGRAM’s Collectives: Engaging Communities in India to Demand their Rights. Case Study Series. Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.