Target Or A Target-Free Approach?

Inspite of India being a signatory to International Conference on Population Development, targeted approach to population control exists across states, allege NGOs. Also the guidelines laid down by the Ministry of Health and Family Welfare for conducting sterlisation operations are clearly flouted by government-sponsored sterlisation camps and PHCs. Falaknaaz Syed gets the other side of the story.

Recently, the government of Maharashtra announced that the two-child norm will be extended to state government employees. Women organisations and trade unions in the State have formed a coalition to oppose the coercive population policies enforced by the State. A convention on the two child norm is to take place in Mumbai on the 17th of this month. NGOs argue that inspite of India being a signatory to ICPD (International Conference on Population Development), targeted approach to population control exists across states. Women are soft targets in the attempt to stabilise population by the district and state health machinery. A case in point are the state sponsored sterilisation camps and PHCs which clearly flout the guidelines laid down by the Ministry of Health and Family Welfare (1999), for conducting sterilisation operations.

What is ICPD?

In September 1994, 179 countries including India adopted a landmark 20-year programme of Action at the International Conference on Population and Development (ICPD) in Cairo. Nations signatory to ICPD promised to pursue population as an integral part of the development agenda and to adopt a "Target Free Approach" (TFA).

India adopted a system of decentralised participatory planning across states from 1st April 1996. TFA was renamed as the "Community Needs Assessment Approach" in 1997 that is formulating plans in consultation with the community at the grassroot level. The National Population Policy 2000 also clearly set out the demographic goals of the country, which are to be achieved within the framework of gender equity and social development.

However, 10 years down the line, surveys of NGOs and health associations reveal that in a desperate need to achieve population stabilisation, every state has a target for sterilisation. Coercive methods used earlier have evolved to state-sponsored incentives for those who undergo sterilisation and disincentives for those who do not follow the two-child norm. 'Expected level of achievement', another form of target is given to Primary Health Centres (PHCs), Community Health Centres (CHCs), municipal and public hospitals for motivating people to undergo sterilisation. Besides, the quality of care given at state sponsored sterilisation camps in rural areas is way under.

Around 4.6 million tubectomies are performed in India and over 85.3 per cent of all persons who have adopted this method of contraception have availed the service from government facilities. Also the proportion of contraception adopters using female sterilisation is an overwhelming 98 per cent of all sterilisations each year and roughly 62 per cent of all contraceptive users.

Scene in Maharashtra

Every year around 6.5 lakh sterilisations are performed on women in Maharashtra. During the last year, this figure crossed seven lakh. Every year there are around 35 tubectomy related officially recorded deaths. Achieving sterilisation goals are the central focus of the health services workers.

For instance, Population Policy for Maharashtra, declared on 8th March 2000, links the concept of two-child norm to eligibility of the family to more than 50 social security schemes related to agriculture and education. (See Table for details of the Policy).

Some findings of Jan Arogya Abhiyan, a Maharashtra based NGO on facilities at the sterilisation camps

• All the camps reports recorded a lack of basic amenities such as electricity, toilets, running water, etc
• In many PHCs operation theatres did not exist.
• Postoperative care for tubectomies is completely absent. Very often, women are brought in for the operation by the PHC jeep, but expected to make their own way back home.
• Forms of consent were not properly filled in any of the camps. The norms for laproscopic tubectomies say that women below the age of 20 should not be sterilised. After speaking to the women it was found that though there were women aged 17 and 18 but their ages were written as 22 or 23.
• Other norms of not operating on woman within six weeks after the delivery (for laparoscopy) were violated as some women with children barely 15 days old were being operated upon.

Comments Audrey Fernandes of Tathapi, a Pune based NGO, "We studied 17 sterilisation camps and found that targeted approach still exists. The new word that has been coined is 'Expected Level of Achievement' though in practical purposes, it remains a target. In Pune district, we saw operations being conducted on benches. We have submitted these facts to the National Human Rights Commission."

"We studied 17 sterilisation camps and found that targeted approach still exists. In Pune district, we saw operations being conducted on benches. We have submitted these facts to the National Human Rights Commission" - Audrey Fernandes, Tathapi, a Pune based NGO	"Around 60 per cent of women in UP are anaemic and therefore not fit for operation and so should be rejected. But in our survey we found that not a single case for sterilisation had been rejected" - Ramakant Rai, Activist of Health Watch, a network of 55 NGOs

Says Dr Rani Abhay Bang, Co-director of SEARCH, an NGO working towards reproductive health of women in Gadchiroli district of Maharashtra, "No doubt, quality of care in these camps is poor. The failure rate is quite high. But D section of the consent form clearly mentions that 'I know this operation can fail and I won't hold any doctor responsible for the failure.' This is wrong. Most women are illiterate and the literate ones are never explained the contents of the consent form. So when there is a failure of tubectomy or vasectomy operation, the patients are not cared for. There is no informed consent. Though women who undergo a tubectomy should be given a certificate, nearly 99 percent of these who come to me after these operations have not been handed their case papers by the doctor. After SC's recent Judgement, these camps have not started in large numbers."

When asked about the Expected Level of Achievement in Pune, Dr CG Yeole Vani, Additional Director, Arogya Seva Kutumb Kalyan, said, "The expected level of achievement this year is 7,50,000. Couples are motivated by workers to undergo sterilisation operation. Every year more than 90 per cent of our target is achieved. Since PHCs are not equipped to perform laparascopic sterilisation, so minilapratomy is mostly performed."

When asked who sets the Expected Level of Achievement, Dr Vani replied, "Targets are set by field workers, district level officers who along with Auxiliary Nurses and Midwives (ANMs) do a survey and submit the Expected Level of Achievement to their respective District Health Officer."

Says Anand Pawar of Tathapi, involved on men's project, "We found Non Sceptical Vasectomies (NSV) being performed in Pune districts. That is many a times, health assistants and health supervisors had mobilised people who were around 50-55 years of age, out of their reproductive age. Thus showing their zeal to show that targets have been met."

Scene in Uttar Pradesh

Uttar Pradesh, one of the most populous state in the country has a Population Policy 2000 similar to that of Maharashtra. It has an extensive family planning programme, which receives support from USAID and World Bank. Tubal ligation continues to be the most widely used contraceptive in the state and over 4,50,000 tubal ligations are performed each year. The sterilisation programme is worst in UP. A study of laparoscopic sterilisation failure rate conducted by the State Innovations in Family Planning Services Agency [SIFPSA 1999] concluded that the failure rate is 4.7 per cent. The study also reports that half (50.5 per cent) of the women suffered post-operative complications.

In order to understand the extent to which the standard practices recommended by the Department of Family Welfare were being followed, a study was conducted by health advocacy network, Healthwatch UP, Bihar, on 10 reproductive and child health (RCH) camps in Uttar Pradesh between December 2002 and February 2003. The study revealed shocking facts. (See Box below on findings of Healthwatch Survey)

Based on these findings, Health Watch, a network of 55 NGOs, filed a Public Interest Litigation (PIL) asking for recording of adverse effects with compensation for failures, deaths, complications and strict compliance of quality standards. In March this year, Supreme Court passed an interim order supporting the claim of Healthwatch UP Bihar.

The interim order states that- ‘No doctor without gynaecological training for at least five years post degree experience should be permitted to carry out the sterilisation programme. The woman should be insured for one lakh before operation. The State government has to pay Rs one lakh in case of death of the person sterilised. Incase of any incapacitation, Rs 30,000 of compensation should be given.’ The Supreme Court also asked the Union Government to formulate uniform qualification criterion for empanelment of doctors within four weeks.

Rues Ramakant Rai activist of Health Watch, "Incapacitation has not been defined by the State. Also incapacitation is not explained to the people who undergo sterilisation. So, there is a chance of corruption. It is eight months now since the interim order was passed but there has been no implementation regarding it in States such as Bihar, Jharkhand, Uttaranchal, Uttar Pradesh, and Rajasthan. These States have submitted false affidavits and we have found that doctors not in the panel are performing the operation even now. The government of India's 'Guidelines on quality of care for sterilisation operation 1999' have not even been circulated among health officers."

Asked what the guidelines contain, Rai said, "Before the operation, blood, sugar, urine, albumin test should be performed. Around 60 per cent of women in UP are anaemic and therefore not fit for operation and so should be rejected. But in our survey we found that not a single case for sterilisation had been rejected. The Guidelines states that after 7 days, the state should send ANM to the woman's house for cutting the stitches. If the woman comes to the hospital, then the hospital should do it for free. But we found 18 cases where doctors had charged Rs 200-400. Incase of complications, treatment was taken from the private doctor and so no compensation was given to the woman for complication. If the operation has failed, then re-cannalisation should be done but is not being done."

“Also after ICPD, government ordered that no woman should be targeted for population control programme but in the subsequent years 1997, 98, 99 the sterilisation rate of women was 95.5 per cent while males were only 4.5 per cent. Even now the scene is similar. In UP every district is targeted. Director General Health and Family Welfare sets these targets. They are then passed to Chief Medical Officer and then passed to medical officer in charge of PHCs and CHCs," says Rai.

Doctors differ on failure rate and targeted approach

Differs Dr Sarita Bhalerao working in Bandra Babha, a municipal Hospital, Mumbai, "In municipal hospital latest equipment and medicines are available so there are no failures. Also we are not given any targets though we used to be given targets around 7-8 years back."

Dr Asha Dalal, Prof and Head of obstetrics and gynaecology department, BYL Nair Hospital and TN Medical College, Mumbai said "We need a strong sterilisation programme. A few years ago, targets were set but is not so now. Today we don't have a target oriented approach and there is no force. But we do set numbers and do motivate women to undergo tubectomies. We counsel women in the antenatal period only if she has one or two children to undergo a tubectomy and we inform them that the procedure is irreversible. Women who have delivered their first child are motivated to adopt safe contraception."

When asked about State incentives, Dr Dalal said, "There are various State incentives such as Rs 50,000 if she has two children and undergoes a tubectomy. But there are few takers, as most want a son. "

When asked about failure rate, Dr Dalal said, "Failure is part and parcel of any procedure. A failure rate of 0.5 to 1 percent is acceptable. We have to ensure that the complication rate comes down. Last year there were not even 6 deaths for sterilisation. "

Says Dr Duru Shah, President Elect of Federation of Obstetricians and Gynaecological Society Of India (FOGSI), "With the new law in place, if the tubectomy or vasectomy fails, then the doctor has to bear the burden of looking after the child till he reaches 18 years of age as it is an unwanted pregnancy. So doctors are careful and do not take the assistance of junior doctors. But I agree that cases performed in camps are more."

Observes Dr Mandakini Megh, Deputy Director, Family Welfare Department, Maharashtra, "It was observed that quality of care administered in camps were bad and so the Supreme Court has given directives to the States. I am optimistic that in five years time, we will see dramatic improvement."

falak@expresshealthcaremgmt.com