1. Against the Tide Advocacy for Informed Choice and Quality of Care in Population Policies and Programs in India 3 rd Asia Pacific Conference on Reproductive and Sexual Health 2005 Satellite Session : Policy Advocacy for Reproductive and Sexual Health

2. History and Context Concern for growing population has been a historical and continues to be the most development concern Concern for growing population has been a historical and continues to be the most development concern India started the world’s first family planning program in 1951- 52 India started the world’s first family planning program in 1951- 52 Method specific targets have been the main stay of family planning program since the mid 1960’s Method specific targets have been the main stay of family planning program since the mid 1960’s India raised the slogan of ‘Development is the best contraceptive’ at Bucharest 1974 India raised the slogan of ‘Development is the best contraceptive’ at Bucharest 1974 There was forced sterilisation on men during the Emergency in 1975 -77 There was forced sterilisation on men during the Emergency in 1975 -77 Tubectomy emerged as the mainstay of the contraceptive in the 1980’s with method specific targets Tubectomy emerged as the mainstay of the contraceptive in the 1980’s with method specific targets Results ( decline in growth rates) were not commensurate with reported target achievement Results ( decline in growth rates) were not commensurate with reported target achievement No formal population policy existed prior to 2000. No formal population policy existed prior to 2000.

3. Changes in Population Policies and Programs around ICPD 1991-92 - Removal of targets in Tamil Nadu 1992- Eighth Five Year Plan – calls for review of targets 1992-93 - Child Survival and Safe Motherhood Program 1994 – ICPD, Cairo 1995 – Removal of targets in 1 or 2 districts in all states 1996 – TFA announced 1998 – RCH programme launched 1999 – TFA re-christened as the Community Needs Assessment Approach (CNAA) 2000- National Population Policy announced 2005 – RCH 2 and National Rural Health Mission

4. ICPD at 10 – Review of Achievements ( Government) 1. Abolition of contraceptive target regime and movement towards decentralized, client- centered reproductive health approach 2. Formulation of a National Population Policy that aims at achieving population stabilization 3. Establishment of a National Commission on Population 4. A comprehensive reproductive child health programme 5. Legislative measures to ensure gender equity, equality and empowerment of women 6. Reform based programme management to increase the accountability of all levels 7. Integration of HIV/AIDS programme with RCH

5. Area of Concern – Population Control mindset Two child norm Two child norm State Population Policies State Population Policies State Local Government laws ( despite 73 rd Amendment) State Local Government laws ( despite 73 rd Amendment) Supreme Court Judgement Supreme Court Judgement Incentives and Disincentives Incentives and Disincentives Incentives – Additional development benefits, Gold Chains, Gun licenses Incentives – Additional development benefits, Gold Chains, Gun licenses Disincentives – no irrigation supply, no development assistance Disincentives – no irrigation supply, no development assistance Targets and Punishments for Health Providers Targets and Punishments for Health Providers No concern for Quality of Care No concern for Quality of Care Population Control as a development strategy resurfaced before and after last general elections. Included in the agenda for governance ( CMP ) Population Control as a development strategy resurfaced before and after last general elections. Included in the agenda for governance ( CMP )

6. Area of Concern Lack of informed Choice Unmet need – high in many states (upto 25%) Wanted TFR – 2.1; actual TFR – 2.85 Unmet need – high in many states (upto 25%) Wanted TFR – 2.1; actual TFR – 2.85 Some State Population Policies – Population Control focussed Some State Population Policies – Population Control focussed Disincentives exist in many states – participation in PRI, participation in Govt. development schemes Disincentives exist in many states – participation in PRI, participation in Govt. development schemes Program emphasises – Female Sterilisation - Program emphasises – Female Sterilisation - Review Study findings Review Study findings Community lacked knowledge and awareness about side effects and contraindications Community lacked knowledge and awareness about side effects and contraindications Doctors and nurses considered women’s complaints as misconceptions Doctors and nurses considered women’s complaints as misconceptions Increase in demand but supply often short and low quality Increase in demand but supply often short and low quality Providers using client segmentation approach Providers using client segmentation approach Men are hardly approached Men are hardly approached

7. Female Sterilisation predominates YearSterilisationIUD Oral Pill CondomTotal 1994-95 13.5 (96.9%) 19.852.314.48,339,000 1995-96 13.1 (97.2%) 20.451.415.18,235,000 1996-97 12.1 (98.1%) 17.753.816.47,303,000 1997-98 12.6 (98.3%) 18.450.019.07,940,000 1998-99 12.1 (97.6%) 17.550.320.07,976,000 1999- 2000 12.5 (98.1%) 16.949.421.18,530,000 2000- 01* 12.9 (97.7%) 16.649.720.88,518,000 2001- 02* 12.8 (97.7%) 16.847.223.38,723,000 Pill – 2.1 %; IUD – 1.6 %; Condom – 3.1 %; F Sterilisation – 34.2%

8. Area of Concern Poor quality of services The overwhelming proportion of tubectomy is a manifestation of the gender imbalance in the programme. The overwhelming proportion of tubectomy is a manifestation of the gender imbalance in the programme. Only 9 states and UTs reported cases of failure of sterilization.Total number of Failures reported less than 800 Only 9 states and UTs reported cases of failure of sterilization.Total number of Failures reported less than 800 No investigations were carried out to ascertain the causes. No investigations were carried out to ascertain the causes. Condoms and oral pills were not distributed according to norms. There was a shortage of supply of condoms and oral pills. Condoms and oral pills were not distributed according to norms. There was a shortage of supply of condoms and oral pills. Beneficiary assessment revealed that a large number of acceptors of temporary methods were getting their supplies from shops. Beneficiary assessment revealed that a large number of acceptors of temporary methods were getting their supplies from shops. Tubal rings supplied to three states was sub- standard Tubal rings supplied to three states was sub- standard ( From CAG Performance Audit of National FW Prog. 2001)

9. Review of QoC Standards for sterilisation camps introduced ( 1999) but no change in the way camps are conducted Standards for sterilisation camps introduced ( 1999) but no change in the way camps are conducted Women expect to be treated courteously but are scolded, physical and verbal abuse Women expect to be treated courteously but are scolded, physical and verbal abuse Demands for money Demands for money Surgical negligence ; no provision for following up failures ( expected rate 0.5% actual rate much higher) Surgical negligence ; no provision for following up failures ( expected rate 0.5% actual rate much higher) Apathy in cases of re-conception Apathy in cases of re-conception Providers not aware of quality parameters Providers not aware of quality parameters ( DFiD GoI sponsored review and HW UP Bihar study) and HW UP Bihar study)

10. QoC at Sterilisation Camps OT tables makeshift. Pre and post operative areas inadequate. OT tables makeshift. Pre and post operative areas inadequate. Only one location had all recommended back up facilities. Only one location had all recommended back up facilities. Clients not provided with OT clothes. Surgeon and assistant had clean OT clothes in 2 places. Clients not provided with OT clothes. Surgeon and assistant had clean OT clothes in 2 places. Infiltration anaesthesia given along with premedication outside the OT at variable interval before surgery Infiltration anaesthesia given along with premedication outside the OT at variable interval before surgery Bicycle pump and bulb of BP instrument used for pumping air into the abdomen for laparoscopy. Bicycle pump and bulb of BP instrument used for pumping air into the abdomen for laparoscopy. Laparscopic ligation completed in 2 to 5 minutes per case Laparscopic ligation completed in 2 to 5 minutes per case No pre operative or post operative monitoring. No pre operative or post operative monitoring. ( HW UP, Bihar Study 2002)

11. Policy level Advocacy Building Evidence – Case Work, Newspaper clippings, Studies, Locating Government reports – CAG, SIFPSA etc. Building Evidence – Case Work, Newspaper clippings, Studies, Locating Government reports – CAG, SIFPSA etc. Repackage data – Briefing sheets, Report cards, Articles in the press Repackage data – Briefing sheets, Report cards, Articles in the press Vigilance and sharing information – UP Pop Control Bill, Rajasthan Population Strategy, CMP, A.K.Haritash Case Vigilance and sharing information – UP Pop Control Bill, Rajasthan Population Strategy, CMP, A.K.Haritash Case Generating Consensus/ Common purpose – Women’s groups, Health rights groups, human rights groups, academics, UN bodies, International groups Generating Consensus/ Common purpose – Women’s groups, Health rights groups, human rights groups, academics, UN bodies, International groups Sensitising the Guardians and duty bearers- legislative advocacy, NHRC colloquium, awareness training of legislators, policy makers and health providers Sensitising the Guardians and duty bearers- legislative advocacy, NHRC colloquium, awareness training of legislators, policy makers and health providers Representations to ruling party political leaders, ministers, senior bureaucrats Representations to ruling party political leaders, ministers, senior bureaucrats Media Advocacy – at the local, state and national levels, popular writing by academics and activists, press events Media Advocacy – at the local, state and national levels, popular writing by academics and activists, press events Public Hearings – State level, National level, Independent Tribunals, with NCW and NHRC Public Hearings – State level, National level, Independent Tribunals, with NCW and NHRC Complaint / Litigation – Petition to NHRC, PIL in Supreme Court; Complaint / Litigation – Petition to NHRC, PIL in Supreme Court;

12. Community level advocacy Awareness raising on the issue among NGOs Awareness raising on the issue among NGOs Awareness raising among communities Awareness raising among communities Case work with those who have suffered Case work with those who have suffered Empower those who have suffered to make public statements Empower those who have suffered to make public statements Encourage and support community members and leaders especially women to address the media, policy makers Encourage and support community members and leaders especially women to address the media, policy makers Encourage local representative and groups to write to politicians Encourage local representative and groups to write to politicians

13. Opportunities and Challenges Progressive National Population Policy Progressive National Population Policy Change in National Government Change in National Government Spaces for Civil Society Spaces for Civil Society Data about decline in sex ratio in low fertility states Data about decline in sex ratio in low fertility states Understanding on ‘population momentum’ has increased Understanding on ‘population momentum’ has increased Supreme Court sympathetic to women’s health issues Supreme Court sympathetic to women’s health issues Young persons – seen as a economic resource Young persons – seen as a economic resource Media highlighting violations and coercion Media highlighting violations and coercion Trust among civil society and International agencies Trust among civil society and International agencies Population Control mindset still predominates Population Control mindset still predominates Supreme Court still not convinced on population control– Two child norm – two judgements, one pending case Large number of bureaucrats and health workers still not convinced State level policies and programmes include targets and coercion New two child norm based discriminatory laws being considered in two states How to ensure access to services without compromising quality How to ensure access to services without compromising quality Indemnify individual doctors without compromising quality Indemnify individual doctors without compromising quality Coordination with PRI based organisations is low Coordination with PRI based organisations is low

14. Results at the policy level While ‘language’ the Government’s agenda for governance (CMP) has not officially changed it has been repeatedly been clarified – Prime Minister, Health Minister While ‘language’ the Government’s agenda for governance (CMP) has not officially changed it has been repeatedly been clarified – Prime Minister, Health Minister ‘CMP Strategy’ has metamorphosed into National Rural Health Mission ‘CMP Strategy’ has metamorphosed into National Rural Health Mission Prime Minister has made explicit mention of ‘incentive is coercion’ – in July 2005 Prime Minister has made explicit mention of ‘incentive is coercion’ – in July 2005 Minister of Local Government has written to all State Governments asking them to change law on local coercive state laws Minister of Local Government has written to all State Governments asking them to change law on local coercive state laws Government of India in its submission to the Delhi High Court ( Feb 2005) has explicitly mentioned that Population Control or mandatory norms are not part of its policy Government of India in its submission to the Delhi High Court ( Feb 2005) has explicitly mentioned that Population Control or mandatory norms are not part of its policy Supreme Court has issued guidelines for quality adherence and compensations for adverse outcome. These are being incorporated into the National Family Planning program in all states. Supreme Court has issued guidelines for quality adherence and compensations for adverse outcome. These are being incorporated into the National Family Planning program in all states. Failures, complications and deaths from FP operations will be documented systematically for the first time Failures, complications and deaths from FP operations will be documented systematically for the first time One State ( H.P) has repealed its Local Government law to remove disqualification One State ( H.P) has repealed its Local Government law to remove disqualification

15. Way forward Focus on state level advocacy action to remove discriminatory laws in line with NPP and 73 rd Amendment Focus on state level advocacy action to remove discriminatory laws in line with NPP and 73 rd Amendment Coordinate with organisations working on strengthening local governance and community development Coordinate with organisations working on strengthening local governance and community development Ensure compliance to Supreme Court guidelines on quality of care Ensure compliance to Supreme Court guidelines on quality of care Work with health department identify strategies to address unmet needs Work with health department identify strategies to address unmet needs Work with medical profession to ensure quality compliance and indemnification of individual doctors Work with medical profession to ensure quality compliance and indemnification of individual doctors Strengthen community advocacy Strengthen community advocacy Assist those who have suffered to get compensation Assist those who have suffered to get compensation

16. Partners in Change Community Based Organisations Community Based Organisations Women’s Groups and Health rights Groups Women’s Groups and Health rights Groups Large NGOs and Institutions Large NGOs and Institutions Networks Networks Individual activists and academics Individual activists and academics International Organisations and donors International Organisations and donors Government functionaries – legislative, executive (ministers, bureaucrats, service providers), judiciary (including guardianship organisations) Government functionaries – legislative, executive (ministers, bureaucrats, service providers), judiciary (including guardianship organisations) Women and men from the community who have suffered or have been bereaved Women and men from the community who have suffered or have been bereaved Thank You