In my last blog post, I gave a pretty one sided account of the lack of motivation and commitment of some of the Indian health professionals. I stand by my assessment that there are some who are more concerned about padding their pockets or reducing hours on duty than saving a life. I recognize, however, that these health workers are not operating in a vacuum, and instead, their behaviors and attitudes are largely shaped by underlying policies and systems.
Let me talk about my experience with family planning policy in Rajasthan…
To give a brief (and incomplete) background, India’s national family planning policy dates back to the early fifties when it was the first country to establish a population stabilization program. During the ’70s and ’80s, family planning was primarily seen as a means towards controlling population growth and thus relied on the institutionalization of targets for contraceptive use. As many of you may know, this came to a disasterous climax during the state of emergency in ’75 when Indira and Sanjay Gandhi imposed a forced sterilization campaign targeting men who had had two children (7.8 million between April 1976 and January 1977), which contributed to her party losing badly at the election polls. After the 1994 International Conference on Population and Development, India pledged to promote a policy grounded in informed choice, ensuring that women and men would be provided with comprehensive counseling and services that supported them in determining what method (if any) befit their needs. During 2004, there was a reversal in philosophy as the government again became paranoid about India’s demographic status, allowing for the reintroduction of targets in Rajasthan, coined “estimated levels of achievement (ELA).” Although it remains unclear to what extent this euphemism is formal or secret, the degree to which it is facilitating violations of women’s reproductive rights is incontrovertible.
During the last couple of months, I have been interviewing women to investigate their experience learning about, accessing, and using contraception through both public and private health systems. To complement the client perspective, I have also been conducting interviews to better understand government and ARTH employed health workers’ views and practices regarding contraception and family planning counseling. Granted the number of interviewees is small (15), they have exposed me to the insidiousness of estimated levels of achievement (ELA) and given me a much more nuanced understanding of the context in which providers’ behaviors and attitudes are generated. For example, I learned from an Auxiliary Nurse Midwife (ANM) that her annual contraceptive ELAs/targets are:
– 55 male condoms
– 100 oral pills
– 25 IUDs
– 30 sterilization
She explained that the government really only wants half of these quotas to be fulfilled by the end of the year, but is adamant about achieving the target for sterilization above all. If she fails to motivate at least 15 women to get a sterilization, the government imposes a salary freeze. ASHAs and AWWs must also convince 14 and 2 women, respectively, per year to have an operation, and suffer reprimand from their supervisors if they come up short.
This ELA/target policy has extremely perverse implications. First, it is motivating government workers to deliberately distort the information presented during their counseling sessions. I learned from one of ARTH’s Village Health Workers that some ASHAs tell women that oral pills cause tumors, so instead they should choose to get sterilized. When such pressure exists, it is not unlikely that it would affect ASHAs’ and Auxiliary Nurse Midwives’ (ANMs) willingness to provide correct information to dispel widespread myths and misconceptions about short-term methods, such as that Depo-provera (DMPA) injection causes blindness and IUDs can kill both the woman (from puncturing her lung after floating around in the body) and the man (from the string puncturing the penis during sex), and to explain that some of the negative symptoms (excessive bleeding, spotting, amenorrhea, etc.) are often temporary. When I asked providers if they think any types of contraception are harmful, the majority mentioned IUDs, DMPA, and mala-D for various reasons, while none suggested sterilization despite the known potential complications from a surgical procedure. It seems as if providers’ sterilization blinders are only serving to exacerbate confusion over what are the actual benefits and associated risks of each method, leading to reductions in contraceptive uptake and overall health-seeking behavior.
Second, ELA cause government workers to chase women who have two or more children to advocate them to get sterilized, leaving those with fewer children without any opportunity to access reversible methods. The obvious problem is that this excludes a cohort of women early in their reproductive lives from using contraception. This predisposes them to either having an unwanted pregnancy and/or birth too soon after their previous child, both of which open up the Pandora’s Box of potential problems: delivery complications from births too close together, complications from abortion (unsafe abortion is attributed to 10% maternal death in India), exacerbating anemia (anemia contributes to 20-40% of maternal death in India), mental stress of caring for another young child, greater economic constraints… not to mention it being a direct violation of her right to decide when to have a child.
However, it even prevents women who no longer want children from using a method of family planning. ARTH conducted research which revealed that women who have completed their families are unwilling to get sterilization either for fear of the side effects or concern about the survival of existing children. One ASHA said that when these women are told repeatedly by government workers to have the operation, they end up losing trust in the health system – both public and ARTH’s – and rejecting contraception altogether.
Thid, this policy is undermining collaboration between public and private service delivery systems to the detriment of poor, marginalized, women who have no other health information and service outlets. One of ARTH’s senior field staff members disclosed that ANMs are hostile towards ARTH’s village health workers because they perceive ARTH as competing to reach women with contraception. ARTH is a strong proponent of providing women with education and services that match their needs based on where they are in their life cycle. ARTH has been a pioneer of expanding contraceptive method mix, which is correlated to an increase in contraceptive usage; during the ‘90s, ARTH introduced a newer, safer, and more effective version of the copper-T (IUD) in its catchement area, after which the government scaled it up nationally. ARTH also provides the injectable, DMPA, which the government does not offer due to pressure from a lobby group against progesterone contraception. Because ANMs are under such intense pressure to promote sterilization and to a lesser extent IUDs, many see ARTH’s efforts as directly undermining their work. Therefore, some refuse to work with ARTH’s staff or refer women to access ARTH’s services, which are unquestionably the best quality in the area. One ANM went so far as to suggest that sterilization could be promoted by reducing access to IUD and safe abortion services.
I do not mean to paint the picture that government health workers are sinister. They are just like you and I, trying to make ends meet and fulfill the responsibilities given to them. Unfortunately, their agendas are held hostage to a higher-level policy framework that prevents them from wholly focusing on promoting wellbeing. Interestingly, many of those whom I have interviewed said that what they enjoy least about their job is… promoting sterilization! Some acknowledged that sterilization is an effective policy for population control, but they do not want to have targets (or they should at least be reduced). It is unclear whether their issue is based on repulsion to the policy’s implications on women’s reproductive choice, or if it stems more from the inconvenience of running around trying to convince women of something they are either not interested in or afraid of. Regardless, it reflects that this policy is not serving the demands and needs of either providers or the women they are supposed to serve.
Rajasthan’s family planning policy must no longer pay lip-service to women’s reproductive rights. As 2015 approaches, the deadline for the Millennium Development Goals, India’s commitment to fulfilling MDG 5b (universal access to reproductive health – which is actually the most off-track of all MDGs) remains tenuous. Granted there have been improvements facilitated by the first and second phases of the Reproductive and Child Health scheme and the National Rural Health Mission – total fertility rate fell from 4 in 1990 to 2.7 in 2009 while the contraceptive prevalence rate increased from 35% in 1997 to 54% in 2009 (although three fourths are from sterilization) – the overwhelming focus on limiting family size through sterilization, as stipulated through the ELA/target policy, needs to be abandoned. Many countries have demonstrated that family planning programs modeled on reproductive choice instead of coercion does lead to reductions in fertility and maternal mortality rates, as well as myriad other positive economic and social outcomes. As I have learned, providers are poised to take this approach, just as long as the government stops dragging its feet and learns to trust the judgement of its own people.
With over half of India’s 1.1 billion population under 25, it is imperative that family planning policy support women and men in PLANNING their families, not solely in ending them. If India is indeed a democracy, the government has the responsibility to listen to and accommodate the needs of both its own employees (ANMs, ASHAs, AWWs), civil society, and the very people that provide the foundation of future growth, development, and prosperity – young women.