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 Twenty years on and targets remain in all but name, say doctors,
healthcare workers and family planning experts, meaning that,
although below peak numbers, more than four million people underwent
surgery in 2013-14.
In recent years, the vast majority have been women.
The risks the campaign poses were highlighted this month when more
than a dozen women died after having a tubectomy at two
sterilization "camps" in the state of Chhattisgarh.
Ongoing investigations point to contaminated drugs given to the
women as a possible cause of death, but a dirty operating room and
operations performed in a matter of minutes raised new questions
about the program's efficacy and safety.
"Targets may have been removed, but the target mindset remains,"
said Poonam Muttreja, executive director of the Population
Foundation of India NGO.
Wary of a ballooning population, India launched a family planning
program to slow population growth in the 1950s.
As the campaign went into overdrive, some seven million men had
vasectomies between April 1976 and January 1977, according to the
Centre for Health and Social Justice in New Delhi.
Today, tubectomies on women are by far the most common form of birth
control in India, and India's fertility rate, or the average number
of children a woman has in her lifetime, has fallen from 3.6 in 1991
to 2.4 in 2012.
But it has failed to reach the desired "replacement" level of 2.1,
and India, with a population of around 1.2 billion, is set to
overtake China as the world's largest nation by around 2028,
according to the United Nations.
At a recent sterilization "camp" in the eastern state of Odisha,
operations went on apace, seemingly impervious to negative publicity
after the deaths next door in Chhattisgarh.
A doctor and five assistants from a nearby hospital worked flat out,
performing 13 tubectomies in about an hour at the facility in Baruan
village.
After her surgery, 35-year-old patient Renubala Ojha was guided
outside by a health worker who settled her onto a dirty rug to
recover. Nearby, empty water bottles, used tobacco pouches and piles
of cow dung littered the ground.
TARGETS OR "UNMET NEEDS"?
Sabitri Sethi, the health worker, said her supervisor had instructed
her to bring at least two women to the camp.
Some 80 percent of Odisha's family planning budget under the
National Health Mission was set aside for sterilization activity
this year, including holding camps and paying compensation, a state
health official familiar with the plan said.
He added that Odisha, which accounts for some 3.4 percent of India's
population, is prepared to carry out sterilizations on as many as
20,000 men and 160,000 women this year.
The Health Ministry is adamant such numbers are not targets, and
that state budget figures for the national program are expressions
of "unmet need" for such services.
Critics say the distinction is misleading, because any objective
puts pressure on healthcare workers and lands too many women in
"camps" where dozens are operated on in a few hours.
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"I have done 90 surgeries in a day," one doctor at the Chhattisgarh
Institute of Medical Sciences admitted. "If I had said no, the
government would have sacked me."
Officials in New Delhi add that, in addition to ditching targets,
the government has promoted alternative options, including condoms
and intrauterine contraceptives, to reduce the number of people
having surgery.
Sterilizations dropped from well over five million in 2010-11 to
over four million in 2013-14.
Critics counter that a payments-driven system continues to push more
people to choose sterilization over other options.
At the Odisha clinic, Ojha received 600 rupees ($9.70) after her
surgery, a significant sum in a country where hundreds of millions
of people live on less than $2 a day.
Sethi, the healthcare worker, said she would also receive money for
each woman she brought, but she did not say how much.
The Odisha state government pays 75 rupees ($1.20) to doctors for
each surgery, 25 rupees to the anesthetist, 15 to the staff nurse
and attendant, and 10 to other staff.
POOR PUNISHED?
Advocates of a shift away from sterilization say the system
penalizes the poor.
"The poor are being seen as irresponsible breeders ... who need to
be permanently dealt with," said Abhijit Das, director of the Centre
for Health and Social Justice.
Without better education for health workers and a more readily
available selection of contraceptive choices, women will keep going
to potentially dangerous camps, Das added.
And entrenched social attitudes will likely remain.
Many men think vasectomies threaten their virility, placing the
burden on women. Of couples in India who use modern contraception,
two percent of men were sterilized compared to 74 percent of women,
U.N. data show.
(Additional reporting by Aditya Kalra in Bilaspur and Krista Mahr in
New Delhi; Writing by Krista Mahr; Editing by Mike Collett-White)
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