The United Progressive Alliance government's new "sterilisation-centric" approach to family planning, with a big role for the private sector and resumption of targets and incentives, runs counter to the letter and spirit of the National Population Policy.
THE mandarins in the Ministry of Health and Family Welfare of the United Progressive Alliance (UPA) government have come out with a proposal that is bound to attract attention for all the wrong reasons. Their singular obsession with population stabilisation, a commitment the UPA articulated in the Common Minimum Programme (CMP), has finally taken shape in the form of a strategy paper for family planning.
What has emerged is a sharply targeted programme with a "sterilisation-centric" approach. It proposes some 50 lakh sterilisations a year in the next four years in the five "high-fertility" States of Uttar Pradesh, Jharkhand, Bihar, Madhya Pradesh and Rajasthan. This goes far beyond the current national levels. At present 48 lakh sterilisations a year are reported from all over the country, of which only around 13 lakhs are from these five States (classified in the CMP as the "high-order birth States" where families have more than two children). A much greater role is envisaged for the private sector without a corresponding level of accountability. The scope of the programme, the strategy paper says, will be increased to add another 150 high-fertility districts to "really tackle the unwanted births all across the country".
The new strategy has almost the same thrust that was seen in a previous strategy paper called "Reproductive and Child Health - II" prepared by the Health Ministry but under a different government. The thrust, as far as family planning is concerned, remains very much the same. Very little, in fact nothing of the "development" part of addressing the unmet need for contraception has been considered.
Even if a paradigm shift was made at the 1994 International Conference on Population and Development (ICPD) in Cairo to integrate population and development strategies, 10 years down the line no such shift is visible as far as Indian health planners are concerned. In fact, it hardly reflects any of the concerns mooted by health activists.
At the outset, the strategy justifies itself as having the CMP mandate, which stated that "the UPA government is committed to replicating all over the country the success that some southern and other States have had in the family planning programme. A sharply targeted Population Control Programme will be launched in the 150-odd high fertility districts". The thrust areas in these districts are family planning, immunisation and safe delivery. The emphasis clearly is on family planning as stated in the strategy paper itself. Letters have been sent to Chief Ministers, Health Secretaries and District Collectors of the States chosen for the programme for "bringing back the district administration into the family planning programme".
Semantically, there appears to be a reversal from the usage of the term "population stabilisation" to the more direct phrase "population control". The Ministry is perhaps oblivious that all countries, including India, abandoned the term population control, in 1994 when the ICPD Plan of Action was adopted. The rationale was that population "control" ran counter to the individual's right to take informed decisions about his or her own life and the lives of their children. It was also seen as being biased against women as it viewed them as only procreating and reproducing individuals, whose excessive fertility ought to be controlled. On the other hand, population stabilisation is viewed as something that enables individuals and couples to plan their families by providing them adequate information and quality health services so that there is zero population growth. But even if appropriate terms are used, they are meaningless if not applied correctly.
Going beyond semantics, a closer look at the strategy reveals that first it is to be implemented in the five Empowered Action Group States of Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan and Jharkhand. Although initially the plan was to take up only 150 districts, the Ministry felt that it would be administratively inconvenient to limit the initiatives to select districts in a State. So under the new strategy all the 209 districts in the "CMP States" will be covered.
How does the strategy work? A revised compensation package for sterilisation to cover the costs of the procedures in public and private health facilities; a professional indemnity insurance cover for doctors conducting sterilisation operations against legal and financial costs of possible consumer cases; partnerships with the private sector through accreditation; and suitable higher payment to doctors nearer to basic market costs are envisaged to attain the goals in the "CMP districts".
The tilt is clearly towards roping in the private sector. Consider this. A package of around Rs.1,200 for sterilisation in a private nursing home and Rs.600 in public health facilities, inclusive of transactional costs and expenses on travel and food is expected to "energise the demand and supply chain in family planning". In addition, banks will be approached to offer a special loan package of Rs.5 lakhs to Rs.10 lakhs to accredited doctors in the CMP districts to improve infrastructure and equipment. It is strange that the government in a welfare State, should facilitate the profit-minded private sector with funds to provide family planning services. In fact, it has been worked out that an accredited clinic will earn at least Rs.25,000 to Rs.30,000 extra a month and so be in a position to repay the loan.
Citing the case of Tamil Nadu, the strategy paper says: "In spite of a well-functioning governmental system and low levels of fertility, 35 per cent of all sterilisation in the State are at accredited private clinics." Is the government not aware that it is not a "pull" factor that operates here but the "push" factor. It is primarily the quick delivery of services, not necessarily the best, that attracts people to the private sector. The time saved as well as the fewer bureaucratic norms and the overall attitude of the health professionals often push the clients towards the private sector, despite the costs involved. With an overburdened public system, what the government should be doing ideally is to create more health infrastructure than building a case for private sector involvement.
Then there is a fall back on the much looked down upon system of incentives and disincentives. The strategy paper proposes increasing the number of institutional deliveries to bring down the high maternal mortality rate in these districts as well as prevent female foeticide. Raising consciousness for the girl child is proposed to be done through a discriminatory system of incentives. Under a scheme called the Janani Suraksha Yojana, below poverty line (BPL) mothers would get Rs.1,000 for a girl child and Rs.400 for a male child if they delivered in a health institution. Although it is meant to discourage son preference, pitting one gender against the other is in bad taste. The root causes of son preference, the socio-cultural factors, are not addressed.
Moving on, the scheme provides for transport assistance up to Rs.150 and incentive to the dais (midwives) at Rs.200/Rs.150 for female/male child for appropriate ante-natal and post-natal care and referral for institutional delivery. But the high point of this scheme is that it "aims at adoption of tubectomy by the women after the delivery". Evidently, no tubectomies, no incentives. Notably, the entire burden of contraception is being placed on women. As it is of the total number of sterilisations, only two per cent are undertaken on men. And most women who go in for sterilisation do so after having three or more children, that too at an age when they are not likely to bear any more children.
WHAT does the National Population Policy (NPP), which the strategy has selectively quoted, say about incentives and disincentives? The NPP, in principle, is opposed to incentives and disincentives for promoting contraception. It favours a more open information, awareness and empowerment approach, strengthening the options of informed choice. Most incentives are linked to undergoing sterilisation after two children, which is almost similar to promoting a two-child norm in a less coercive way. The impact of such an incentive, it is felt, could promote sex-selective abortions and pressure women to undergo sterilisations.
The Ministry is keen to achieve the targets set in the NPP, one of which is to achieve a National Total Fertility Rate (TFR) of 2.1 by 2010. (The TFR is the average number of children a woman bears in her reproductive life. The current rate is 3.2.) According to the strategy paper, it would take another 35 years for the population to stabilise at the expected level of 160 crores. Current trends indicate that if the present pace of reduction in growth rate continues, the TFR of 2.1 may be attained by 2016 and the population may touch 180 crores before stabilising. The strategy, if adopted, will prevent at least 40 crores additional births by 2045.
The NPP, considered a blueprint for population and development programmes, affirmed India's commitment to the ICPD agenda. The overriding concern of NPP 2000 is economic and social development to "improve the quality of lives that people lead, ... to provide them with opportunities and choices to become productive assets in society". While the basic thrust is on providing quality health services and supplies, information and counselling, an additional objective is to provide a basket of contraceptive choices to enable people to make informed decisions. The long-term objective is to achieve a stable population consistent with "sustainable economic growth, social development and environmental protection". Do these themes echo anywhere in the strategy paper? They do not.
Instead the role of the private sector in service delivery is being lauded. The example of Tamil Nadu is cited. Of the four lakh sterilisations reported every year, 1.5 lakh procedures are carried out in the private sector. In Andhra Pradesh, according to the strategy paper, the "spectacular success in bringing down the growth rate of population in the last decade has been possible, despite the low levels of literacy, due to the involvement of the private sector and self-help groups, provision of insurance cover to family planning acceptors, and a higher compensation package for sterilisation in the State." In fact, in Andhra Pradesh, as in Madhya Pradesh, Uttar Pradesh, Haryana, Rajasthan and Orissa disincentives that are not in harmony with the spirit of the NPP operate.
Commenting on the strategy paper, Gita Sen, founder-member of a global network of feminists from South countries called DAWN (Development Alternatives for Women of a New Era), says that without a serious plan for strengthening institutions, upgrading human resource and mobilising and educating the community, the strategy with its top-down approach, resumption of targets and incentives, is likely to recreate the distortions that existed in the Family Welfare programme prior to 1996 and lend itself to abuses of individual rights.
A founder-trustee of Healthwatch Trust, India, a national network on monitoring Reproductive Rights, Sen says there is no discussion on how quality will be improved or standards enforced in either private or public facilities. The indemnity insurance cover for providers has the potential for the violation of medical ethics and human rights since, far from ensuring quality or standards, the government is set to shield abuse and malpractice. Sen is also critical of the emphasis on institutional delivery without any measures for building up or strengthening existing institutions (private or public) to support safe delivery.
Jashodhara Das of the Healthwatch Uttar Pradesh Group told Frontline: "We fear for the quality of care in this approach, since our experience in Uttar Pradesh shows that a targeted population programme leads to many shortcuts in sterilisation operations on women, sometimes with life-threatening or fatal consequences. Women have died due to poor screening (despite having contraindications), lack of emergency care arrangements (even oxygen or ambulances) and gross medical negligence (slicing open the aorta) by doctors. They are compelled to choose sterilisation as the method of contraception in the absence of information or services regarding other safe methods. This coercion is compounded by the fact that women are forced to sign on a form absolving the surgeon and other personnel of all responsibility if the operation is not successful or leads to death. As such, the targeted population control approach is biased against women's health and rights."
The government seems largely impervious to suggestions and constructive criticism. On the occasion of the release of the United Nations Population Fund's "State of the World Population Report, 2004" Union Minister for Health and Family Welfare, Anbumani Ramdoss, while answering queries, said that the government was not going to coerce anybody to adopt the two-child norm. P.K. Hota, Secretary, Family Welfare, clarified that the issue (of the two-child norm) was "in Parliament", whatever that meant, and that there was no confusion that a new paradigm had been adopted. The new approach should have been: "Take care of the people and the people will take care of themselves." The government's paradigm may be in consonance with the CMP, but it is a far cry from the principles that emerged not only from the ICPD, but also those in the NPP.
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