In the summer of 2011, India’s National Population Stabilization Fund (Fund) instituted a new scheme in Jhunjhunu, Rajasthan, a rural town west of New Delhi, offering incentives for area residents who agreed to undergo sterilization surgery. Government health officials created a sweepstakes program, entering those who agree to be sterilized into a drawing to win a TV, mini car, or food processor. This scheme represents one of a pattern of programs designed to help India meet its Millennium Development Goal of reducing its birth rate to two children per mother by 2015. While the program does perform some vasectomies, incentive programs in rural communities disproportionately affect women: according to the most recent National Family Health Survey, 37 percent of Indian women have been surgically sterilized, as compared to one percent of men who have had vasectomies. The use of incentivizing, and often coercive, practices by government health officials compromise the quality of medical care in an attempt to encourage women, mostly from rural areas, to undergo this dangerous procedure, often without informed consent, proper health care, or family planning information. By creating programs that decrease women’s access to quality health care and family planning information, India is in violation of Articles 12, 14, and 16 of the Convention on the Elimination of Discrimination Against Women’s (CEDAW).
This is not the first time the Indian government has resorted to coercive measures to curb population growth. Incentive-based sterilization programs were popular with the Indian government from the 1950s until the mid-1970s but disappeared after Indira Gandhi’s 19-month emergency suspension of the Constitution from 1975 to 1977. During this time, Prime Minister Gandhi’s son, Sanjay, began a policy of forcible sterilization in an attempt to curb the growing Indian population. When emergency law was lifted, Sanjay’s program stopped, and incentivized sterilization programs fell out of favor. However, in recent years, as India’s population has reached 1.2 billion and is expected to surpass China in 2030, the federal government’s Family Welfare Program returned to the practice of incentivizing sterilization among men and women in rural areas.
Unlike previous programs, the most recent scheme was the first to outsource surgeries to private clinics. In an attempt to meet its goal of 30,000 sterilizations over a period of three months, the Fund offered private clinics about $308.00 per surgery and an additional $10.00 per case if a single clinic performed more than thirty operations a day. By offering such incentives to the private sector, the Indian government encourages clinics to “cut corners,” says Abhijit Das of Health Watch Uttar Pradesh. In 2005, the Indian Supreme Court issued a protocol for minimum quality and safety standards for sterilization clinics; however, no monitoring or enforcement mechanisms are in place to regulate surgery camps in rural areas. Utilizing the private sector also puts more pressure on women to undergo the operation because clinics have no monetary interest in obtaining informed consent, in providing women with alternative contraceptive options, or in explaining the risks associated with the procedure. Das says sterilization is the number one contraceptive method offered in India and that one quarter of people in a recent survey did not even know about other options (37 percent of Indian women have been sterilized, three percent use the pill, and five percent use condoms). Additionally, under incentive-based sterilization programs, women face an increased risk of medical complications because clinics do not provide the level of care necessary to ensure proper health, and women often decide to have children at a younger age and get sterilized between the ages of 22 and 23. At this age, women are more vulnerable to gynecological problems and are four times more likely to need a hysterectomy later in life.
CEDAW’s Article 12 requires that state parties take active measures to eliminate health care discrimination against women. The article specifically provides for access to services, “including those related to family planning.” Article 14 highlights the specific discrimination rural women face, requiring States to ensure that rural women have “access to adequate health care facilities, including information, counseling, and services in family planning.” Article 16 (1)(e) focuses on the disparity of power between spouses, requiring women to have equal rights to choose the number and spacing of children and to be provided with the information necessary to make informed family planning choices.
Incentive-based programs violate women’s access to information and adequate health services by placing them in a position in which they are not empowered to make informed family planning decisions. As currently implemented, the Fund’s incentivized sterilization schemes greatly limit women’s legally protected choice and oppress, instead of promote, their equal rights and advancement. Private individuals, who profit from women’s lack of information, are able to coerce women into getting the surgery before they have considered other options. The provisions in Articles 12, 14, and 16 require India, as a party to CEDAW, to take active steps to ensure women are provided equal access to health care services and adequate information, regardless of where they live, how much money they have, or whether the country desires to meet its Millennium Development Goals. The first step toward meeting this international obligation is to provide comprehensive information about different forms of contraceptives available, the risks and benefits of each, and about women’s protected right to choose the size and spacing of their individual families.