Transcript Against the Tide - Population Leadership Program

3rd Asia Pacific Conference on Reproductive and Sexual Health 2005
Against the Tide
Advocacy for Informed Choice and
Quality of Care in Population
Policies and Programs in India
Satellite Session : Policy Advocacy for Reproductive and Sexual Health
History and Context
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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
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
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
Results ( decline in growth rates) were not
commensurate with reported target achievement
No formal population policy existed prior to 2000.
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
ICPD at 10 – Review of
Achievements ( Government)
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Abolition of contraceptive target regime and movement
towards decentralized, client- centered reproductive
health approach
Formulation of a National Population Policy that aims at
achieving population stabilization
Establishment of a National Commission on Population
A comprehensive reproductive child health programme
Legislative measures to ensure gender equity, equality
and empowerment of women
Reform based programme management to increase the
accountability of all levels
Integration of HIV/AIDS programme with RCH
Area of Concern – Population
Control mindset
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Two child norm
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Incentives and Disincentives
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Incentives – Additional development benefits, Gold Chains , Gun
licenses
Disincentives – no irrigation supply, no development assistance
Targets and Punishments for Health Providers
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State Population Policies
State Local Government laws ( despite 73rd Amendment)
Supreme Court Judgement
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 )
Area of Concern
Lack of informed Choice
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Unmet need – high in many states (upto 25%) Wanted
TFR – 2.1; actual TFR – 2.85
Some State Population Policies – Population Control
focussed
Disincentives exist in many states – participation in PRI,
participation in Govt. development schemes
Program emphasises – Female Sterilisation Review Study findings
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Community lacked knowledge and awareness about side effects and
contraindications
Doctors and nurses considered women’s complaints as misconceptions
Increase in demand but supply often short and low quality
Providers using client segmentation approach
Men are hardly approached
Female Sterilisation predominates
Year
Sterilisation
IUD
Oral Pill
Condom
Total
1994-95
13.5 (96 .9%)
19.8
52.3
14.4
8,339,000
1995-96
13.1 (97.2%)
20.4
51.4
15.1
8,235,000
1996-97
12.1 (98.1%)
17.7
53.8
16.4
7,303,000
1997-98
12.6 (98.3%)
18.4
50.0
19.0
7,940,000
1998-99
12.1 (97.6%)
17.5
50.3
20.0
7,976,000
1999- 2000 12.5 (98.1%)
16.9
49.4
21.1
8,530,000
2000- 01*
12.9 (97.7%)
16.6
49.7
20.8
8,518,000
2001- 02*
12.8 (97.7%)
16.8
47.2
23.3
8,723,000
Pill – 2.1 %; IUD – 1.6 %; Condom – 3.1 %; F Sterilisation – 34.2%
Area of Concern
Poor quality of services
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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
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.
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
( From CAG Performance Audit of National FW Prog. 2001)
Review of QoC
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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
Demands for money
Surgical negligence ; no provision for following up
failures ( expected rate 0.5% actual rate much higher)
Apathy in cases of re-conception
Providers not aware of quality parameters
( DFiD GoI sponsored review
and HW UP Bihar study)
QoC at Sterilisation Camps
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OT tables makeshift. Pre and post operative areas
inadequate.
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.
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.
Laparscopic ligation completed in 2 to 5 minutes per case
No pre operative or post operative monitoring.
( HW UP, Bihar Study 2002)
Policy level Advocacy
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Building Evidence – Case Work, Newspaper clippings, Studies,
Locating Government reports – CAG, SIFPSA etc.
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
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
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
Public Hearings – State level, National level, Independent Tribunals,
with NCW and NHRC
Complaint / Litigation – Petition to NHRC, PIL in Supreme Court;
Community level advocacy
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Awareness raising on the issue among NGOs
Awareness raising among communities
Case work with those who have suffered
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 local representative and groups to
write to politicians
Opportunities and Challenges
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Progressive National
Population Policy
Change in National
Government
Spaces for Civil Society
Data about decline in sex ratio
in low fertility states
Understanding on ‘population
momentum’ has increased
Supreme Court sympathetic to
women’s health issues
Young persons – seen as a
economic resource
Media highlighting violations
and coercion
Trust among civil society and
International agencies
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Population Control mindset still
predominates
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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
Indemnify individual doctors
without compromising quality
Coordination with PRI based
organisations is low
Results at the policy level
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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
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
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.
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
Way forward
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Focus on state level advocacy action to remove
discriminatory laws in line with NPP and 73rd
Amendment
Coordinate with organisations working on strengthening
local governance and community development
Ensure compliance to Supreme Court guidelines on
quality of care
Work with health department identify strategies to
address unmet needs
Work with medical profession to ensure quality
compliance and indemnification of individual doctors
Strengthen community advocacy
Assist those who have suffered to get compensation
Partners in Change
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Community Based Organisations
Women’s Groups and Health rights Groups
Large NGOs and Institutions
Networks
Individual activists and academics
International Organisations and donors
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
Thank You