India is supposed to be pursuing an internationally-agreed target-free approach to promoting women's reproductive health and rights. But on the ground targets rule supreme.
Whether in scorching summer or chilly winter, Usayini remains a quiet spot of a village in the north Indian state of Uttar Pradesh.
So quiet in fact that even its fortnightly health camps make no news, as I found out during the course of several visits to the village. The reason quickly became clear: the camps – run by the state government, executed by the district administration and funded by the United States government's overseas aid department – has a single focus: to sterilise women. Few want to talk about it, and most women stay away.
The overt aim of the camps, implemented by a USAID-funded project called State Innovations in Family Planning Services Project Agency (SIFPSA), is to make healthcare accessible to women and children.
But it ends up offering women sterilization in the guise of reproductive health services. Each camp has about 30 health workers, called Auxiliary Nurse Midwives or ANMs, attached to it. Each ANM is told to fetch 'cases' – a euphemism for women who are 'willing' to be sterilised – often on the threat of loss of pay or even their job.
The midwives – stationed in every village in this vast and populous state of 171 million – are responsible for guiding women through pre-natal and post-natal stages, immunisation, and family planning. What they end up doing flies in the face of India's official policy of a target-free approach to family planning – announced soon after the 1994 UN International Conference on Population and Development (ICPD) in Cairo.
ICPD was supposed to have marked a change in the controversial history of India's attempts to bring down the rate of its population growth. Belief in a targeted approach in the mid-1970s led the then Prime Minister Indira Gandhi to enforce sterilisation and vasectomy on poor masses across the country – a draconian move that contributed to the ouster of her government at elections.
But just two years before ICPD, India and USAID signed a deal under which USAID pledged $325 million to "reorient and revitalise" family planning services in Uttar Pradesh – India's largest state and a development blackspot. The aim was to bring down the state's fertility rate (number of children per family) from a high 5.4 to 4 at the end of the 10-year project (the current national fertility rate is 2.58); to increase the use of contraceptives from 35 to 50 per cent, increase the number of births receiving ante-natal care from 30 to 40 per cent, and increase the number of deliveries assisted by a doctor, nurse or midwife from 17 to 30 per cent.
At Usayini, I decide to accompany the camp in-charge, Dr M L Mishra. The first 'patient' arrived at around 1 pm – Guddi, a 27-year-old mother of six children, was accompanied by her local midwife. From behind the folds of the sari that covered half her face she said she had come for sterilisation.
Then came the second – a 26-year-old mother of four. And so on. Through the day I counted 18 'cases' – all came for sterilisation, all egged on by a midwife.
But for the 28 midwives attached to the Usayini health centre, which organises the fortnightly camps, it was a bad day – because each midwife had been set a target of three 'cases' per camp. At the very least they were expected to bring one each. To turn up empty-handed was to invite the wrath of officials.
"Why don't you simply come here and collect your salaries?" one official hectored the cowering midwives.
Another senior district-level official, who arrived later that day, reprimanded the midwives for being "inefficient" and bringing only 18 cases. There was no talk of the women's health – in spite of the fact that they had an average of five to six children each and unknown numbers of abortions. None of them had seen a doctor during pregnancy or even been given a simple tetanus injection. They were not aware of iron or vitamin pills. And no one was telling them.
The midwives were a tense lot. They conceded they were obsessed with getting cases. "That's all we think about day and night," they told me.
They also admitted not encouraging women to go in for other birth control options, such as intra uterine devices (IUD) or the pill. "If we promote Copper T [an IUD], how would we get enough women for sterilisations?" a midwife called Radha asked.
I put that question to Anjali Gule, one of four gynaecologists at the district hospital. She said that the poorly-equipped camps cannot offer anything other than sterilization. And it was not humanly possible to do anything else when sterilizations were the priority. "The numbers could be anything – but we have to do them," doctors said.
The only woman to attend the Usayini camp for reasons other than sterilization was Mumtaz, a 30-year-old mother of nine who had been suffering from severe stomach cramps since a miscarriage a month ago. But no one examined her and her midwife could not muster up the courage to press her case. Finally, a male physician prescribed her some antibiotics and anti-fungal medicines without an examination.
The midwife advised Mumtaz to visit the district hospital but she said she had no money left to go anywhere. "They [the hospital] charge six rupees [$0.1]," said Mumtaz who had already paid a similar amount to travel to Usayini from her village.
Aradhana Johri, former director of SIFPSA in the state capital until some months ago, tried to justify the emphasis on sterilisations: "From the options like condoms etc, available to agencies to choose from, we went in for sterilisation. And ANMs are also provided with IUDs and pills. If they don't supply them it is because they are a bunch of lazy women who do not do their job."
Every midwife has about 400 women of reproductive age under her, said Johri. "So is it too much to expect three cases from her every fortnight?"
In the southern state of Andhra Pradesh the annual sterilisation figure is 900,000, she informed me, whereas in Uttar Pradesh – which is double in size – the number in 2000 was 400,000. "Target-free means no work," she concluded.
Johri's successor, Kapil Dev, said, "We don't have a targeted approach. Yes, we have targets for a year if you wish to use that word. But that is merely another expression for achievement levels." Dev has a new successor this month.
About the neglect of the reproductive health goals – such as pre-natal and ante-natal care, nutrition, and other contraceptive options – the district SIFPSA-in-charge C K Mishra was blunt: "We have to meet targets as USAID funds are given on the basis of the sterilisation targets achieved."
Rajendra Mishra, director in charge of SIFPSA in the federal health ministry, brushed aside all criticism. Had there been a targeted approach for 10 years, Uttar Pradesh would have been another Kerala, he asserted, in a reference to the Indian state that has become a byword for Third World development. But Kerala, he forgot to mention, is also where women enjoy the highest health and literacy status in India and live the longest – unburdened by targeted sterilisation.
In the national capital New Delhi, the USAID spokesman for the SIFPSA project, Randy Kolstad, also denied pursuing targets. "I have issues with calling it a targeted approach," he said. As for penalties to pressure midwives to get sterilisation cases for camps, he said: "There could be situations where service providers have chosen not to work."
"We pay attention to the entire reproductive health needs of the couple. Sterilisation is a predominant method of family planning," he added.
The SIFPSA project had planning levels, but that was not the same as a targeted approach, Kolstad maintained: "We may say we intend to distribute 100 million condoms in a year and similarly with sterilisations."
To poor women brought to the Usayini camp, these are perhaps no more than semantics. Indian women have been here before.
Sreelatha Menon is principal correspondent with The Indian Express newspaper in New Delhi and writes on health and development. This report follows her investigative studies as part of a Panos media fellowship on reproductive health and rights.