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Lessons from Bilaspur -Gita Sen
-The Indian Express

The aftermath of the terrible deaths of women who underwent sterilisation surgeries in Bilaspur in Chhattisgarh has been full of stories about what actually happened. Spurious drugs and an overenthusiastic doctor who cut corners on ensuring quality vie for immediate blame. Beyond these, many have spoken about pervasive biases of gender and caste that wreak havoc on the lives of poor women, and also of family planning policies and programmes that appear to have gone back to the bad old days of the Emergency. Each of these explanations has more than a grain of truth.

Reports in the press (‘Pharma firm was blacklisted 2 yrs ago, govt still bought drugs from it', IE, November 15) about the so-called factory of Mahawar Pharma in Raipur (from which the government sourced the antibiotics now suspected to be spurious and of poor quality), point to a repackaging outfit that had been reported, as far back as 2012, by the health minister to the state legislative assembly as selling spurious drugs. Curiously, the state drugs controller gave the firm a "good medical practice" certificate last year, a required quality assurance for the government to buy its drugs again. What, if any, changes the company had made in the interim in its production practices and quality standards, are unknown.

The state government's immediate response to the deaths was to offer compensation to the bereaved families, and to suspend the director of health services, the state family planning nodal officer, the block medical officer in Takhatpur, the operating surgeon, and the Bilaspur CMHO. Partial responsibility seems to lie at the door of both the doctor and other suspended authorities. A single surgeon conducting over 80 surgeries in a private hospital in the space of four to five hours is in complete violation of Supreme Court orders (Devika Biswas vs Govt of India, 2012, and Ramakant Rai vs Govt of India, 2005). One surgeon is not supposed to do more than 10 sterilisations in a day, and overall no more than 30 operations should be done in a day, with two separate laparoscopes and only in government facilities. But is this all? While compensation is needed, many women's groups and other civil society organisations have raised multiple questions about the deep and serious malaise in the country's family planning policy and programme. The troubled history of the programme began when it went from a clinic-based approach in the 1950s to a vertical programme by the late-1960s, separated from health, and focused on contraceptive method-specific targets.

Targets, disincentives and incentives for health providers and other government functionaries created distortions, including serious challenges of coercion, poor quality and lack of accountability. While the period of the Emergency is notorious for the forced sterilisation of men, in fact, the family planning programme both before and since has overwhelmingly focused on female sterilisation. All this appeared set for a major change when the government committed itself to implement a new national population policy in 2000 that turned away from coercive population control, removed targets from the family planning programme, and called for an approach focused on promoting health and protecting and fulfilling human rights, especially of girls and women. This was greeted with approval from women's organisations, other civil society organisations and many demographers and population scientists.

However, proponents of family-planning-as-population-control said India's fertility rate would spiral out of control, as would population growth, if targets were removed. In fact, the birth rate has continued to fall all over the country. A large number of states are already at or below replacement level fertility. Demographic projections about population growth by the year 2100 tell us that only around 6 per cent of that growth will come from women wanting more than two children. About 24 per cent will be due to the fact that people don't have access to quality contraceptives or because the government's family planning programmes are of poor quality or coercive. The rest, nearly 70 per cent, will come from the phenomenon of population momentum, that is, the extent to which a population will continue to grow because of a young-age structure, even if its overall birth rate falls to replacement level. Even in states like Chhattisgarh, Bihar or Uttar Pradesh, momentum will contribute over half of the total population growth.

If population momentum is the main contributor to growth, we ought to pay greater policy attention to reducing it. Indeed, the best ways to reduce momentum are by better birth-spacing methods or by raising the age at which young women marry and begin child-bearing. This approach would meet the needs of health and choice and protect and fulfil women's human rights while reducing population growth without coercion.

Because the family planning programme's policymakers and implementers changed from those who had been responsible for the more enlightened national population policy of 2000 to others who did not fully understand or accept the health needs or human rights of poor Dalit, lower-caste and tribal women, targets and coercion began to seep back into the programme after a brief period of experimentation with the target-free approach. First, targets came back in the guise of expected levels of achievement. Then sterilisation camps returned in recent years with their doubtful quality, poor follow-up and assembly-line approach to sterilising women.

Despite some pilot programmes to improve the quality of services, the family planning programme overall has never focused on meeting quality standards. The result - the Bilaspur deaths. Many fear that more Bilaspurs are waiting to happen, especially in areas where poor women live. Even in new government initiatives, such as the one to introduce post-partum IUDs, there is little sign of serious attention to ensuring quality or non-coercion at a time when a woman is likely to be at her most vulnerable, immediately after giving birth.

In 1991, Deepa Dhanraj's film Something Like a War graphically documented the failure of India's family planning programme to respect women's most basic reproductive rights. The film features a doctor, rather like the one reported from Bilaspur, who boasts of the large number of assembly-line sterilisations he has performed. Apparently, this war on the country's poor women hasn't ended.

Bilaspur is both shameful and inexcusable. The health ministry should immediately remove targets, disincentives and incentives, and any form of coercion in family planning, and stop the camp approach to sterilisation. More positively, it should take the needed steps in a time-bound manner to bring quality, choice and reproductive rights into the programme. Agencies such as the WHO and UNFPA have both the capacity and the responsibility to support the government to do so.

The writer is a retired professor of the Centre for Public Policy, IIM Bangalore