Truth be told, the philosophy of population control in India still rests on four basic assumptions: One, unregulated population growth is a ticking bomb threatening our overall development. Two, India’s poor have more children than they can afford, so they must be coerced to accept sterilisation as their best option for controlling the size of their family. Three, with sufficient funding, well-trained teams and new technology, sterilisation that involves surgical procedures may safely be carried out in the remotest parts of the country by holding special camps periodically, even if the area lacks basic healthcare facilities. And four, given the urgency of the situation, promotion of irreversible sterilisation must take precedence over all other reversible options and, occasionally, health and safety concerns of the target group.
The National Population Policy, 2000, had strongly advocated doing away with “targets” and emphasised voluntary and informed choice in family planning. The Union health ministry has since issued several handbooks for health workers, which clearly spell out the new focus on individual wellbeing. The brochures also urge health workers to follow proper pre- and post-op procedures and maintain clean and safe facilities where sterilisations are carried out. And the Supreme Court has also ruled that no more than 30 surgeries can be performed in a day by a team led by two doctors. But four decades after Delhi’s infamous Turkman Gate disaster, the same troublesome family planning philosophy based on monetary compensation has resurfaced. Five to six million women are sterilised each year in India. Government data, usually known for underplaying bad news, reveals that botched up operations have killed 707 women between 2009 and 2012.
The key component of all health services under the National Rural Health Mission, the prime “motivator” for sterilisation camps, is the ASHA (accredited social health activist), a locally recruited woman. Preferably literate, she is trained to service her community, particularly women and children, and help them get access to health services. It is notable that the ASHA is not paid a regular salary. But for motivating and accompanying women to sterilisation camps, she receives a “performance-based incentive” — Rs 150 per “case”. The amount, one learns, was recently increased. The doctor, anaesthetist and nurses are all paid cash incentives. It is not hard to see how this may be a big “motivator” for the medical teams, which are in such a hurry to perform a record number of sterilisations that they forego basic safety norms. The doctor supervising the nefarious Chhattisgarh camp was allegedly awarded Rs 50,000 for the record number of surgeries he performed in a day. But obviously, nothing was spent on the creation or maintenance of medical facilities for patients.
Vasectomies are considered infinitely less risky than tubectomies, but men, wary of “losing” their maleness, remain a minuscule proportion of the adults coming to sterilisation camps. The burden for limiting births all over India falls on women. Though, when they do undergo sterilisation, men are given more compensation than women. In UP, for example, men get Rs 1,500 for a vasectomy, whereas women get only Rs 1,000 for a tubectomy. Though, in the Kushinagar episode, many women said they were given only Rs 500. Some are reported to have received only five kg of rice and five eggs.
Two years ago, an investigation by the advisory group on community action constituted by the health ministry had visited a camp in Barwani, MP. Its report revealed the sorry state of reproductive health services and lack of attention on quality pre- and post-operative care. The group found that the performance of health officials is mostly measured in terms of targets achieved, rather than the quality of care. Officials become the scapegoats each time rural sterilisation camps cause deaths. State governments routinely palm off the entire blame on officials they label negligent or overzealous. The media also accepts this theory. But on closer examination, the basic problem is with the four assumptions about the poor this article started with.
No one will deny that there is huge unmet demand for family planning in India. Nor that handing money to poor patients for food and lost workdays is not a bad idea. But what the poor really want is access to basic healthcare, education and other opportunities. There is certainly a place for sterilisation as a method of limiting the size of families, but the poor also have to be given other options. When they do opt for a terminal method like sterilisation, the procedure must be carried out without pressure and with the full knowledge and consent of the patient, under safe circumstances. Only then can sterilisation be considered a powerful tool for reproductive freedom. In the wrong hands, guided by the wrong set of priorities, sterilisation, particularly of women, will remain an immoral and intrusive act of physical violence against a human being.
The writer is a Delhi-based journalist and former chairperson of Prasar Bharati