Theoretical perspective
Historically, evolution of Family planning program in India from the immediate post-independence period was with the target of reducing birth rate and its consequences in the country. The proponents of Malthusian and neo-Malthusian theories in India influenced the policy makers during the initial days to take firm steps towards population control. The objective of the program in kerala too did not transcend beyond mere control over number of births and certain medical aspects of giving birth of a baby to a broader meaning of ‘planning a family’ keeping the inviolability of parenthood and other human values and needs. The program also concentrated more on the medical aspects of reproductive health, its consequences on economy, sustainability of other national programs and development of the nation as compared globally. The Kerala State policy driven by the Family planning program of the country also focused on the need for bringing down the population within a stipulated frame of time and this targeted program had specific indicators for outcome. Financial and other incentives for acceptors of family planning and health workers led to coercion to accept contraceptive measures. There are also instances of pressure tactics by the program on the health workers, even though not as bad as it happened in early days, to coerce people to undergo even a terminal contraception without adequate provision with information. Following the International Conference on Population and Development at Cairo in 1994, there was a shift of approach to a “Rights based”. However, though it reflected in the National Population Policy 2000, such recommendations remain un-implemented at large. Since the worth of the program was measured and determined only by its consequence without incorporating the social determinants, the state policy driven by the national program is Utilitarian in nature.
Benefits for Acceptors of Family Planning
Apart from the benefits for the nation as a whole, the following are the benefits for individual acceptor of family planning program –
Direct Benefits
• Reduced burden of repeated child bearing for women would help women to be in better health
• Enough spacing between children so that care of the mother and child is possible
• Terminal contraceptive measures prevent further pregnancies and associated morbidities which is of special mention in case of those women at risk
• Availability of safe Abortion locally and legally
• Sex Selective Abortions could be prevented if enforced properly
• Youth could also meet their sexual and reproductive needs
• Measures to plan and control family size is made available to women
• Reducing death of infant or mother
Indirect Benefits
• Reduced Reproductive Morbidity of both Men and Women
• Sexually transmitted diseases including HIV could be prevented
• Reduced instances of catastrophic expenses pushing to further poverty
• Early detection of treatable conditions preventing a larger burden
• High risk maternal and child care has started getting attention
• There is an opportunity to demand for sexual and reproductive rights as well as empowerment of women
Cost to the Acceptors
Direct costs:
• Hospitalization cost
• Cost of stay, medicines and materials
• Cost of transport to and from the institution in that case.
• Fee to be paid to birth attendants, nursing or for doctor if needed
Indirect costs:
• Productivity loss
• Wages lost during the period
• Time Costs incurred for tubectomy (takes upto 5 days hospitalization and upto 1 month of moderate rest at home) is much more than vasectomy (usually does not require hospitalization or rest)
• Wages lost by care takers or that has to be paid for bystanders
• During instances of hospitalization, such as in case of tubectomy, there is a cost to take care of children and other dependents at home.
• Cost of re-canalisation if at a future period in time, due to some reason the couple opts for another child.
• Loss of social/ family role for the period of hospitalisation and recuperation.
• Blame for failures usually on the women and she will have to bear the extra burden of maintaining family size.
• Value of the child unborn, following a terminal contraceptive measure such as Tubectomy or Vasectomy cannot be quantified if recanalisation fails.
• Risk of women being blamed of infidelity and resultant marital discord following failure of male contraception. This can happen when proper awareness of chance of pregnancy is given and if necessary care is not taken immediately after vasectomy.
Means to mitigate problems associated with the Costs
Ministry of Health and Family Welfare has introduced a Family Planning Insurance Scheme since 1981 and presently implemented through ICICI Lombard General Insurance Company to compensate the acceptors of sterilization for loss of wages. Central Government, under this scheme release fund to the state Government at a fixed rate such as Rs. 1100/- per Tubectomy, Rs. 600/- per Vasectomy, Rs 20 per IUCD Insertion etc. The package may vary from high focus states to low focus states. In addition to cash compensation for lost wages, food, medicines and materials etc, provisions are made to make a payment of ex-gratia to the acceptor of sterilization or nominee in case of an adverse event as follows. Rs. 200,000/- per case of death within 7 days of discharge, Rs. 50,000/- in case of death between 8 – 30 days of sterilisation, Rs. 25,000/- in case of failure of sterilization, and Rs. 25,000/- towards cost of treatment of serious post operative complication. Indemnity insurance of Rs. 200,000/- per case per doctor / facility but not more than 4 cases in a year is also provided in the program. However, there is a ceiling for the insurance company of Rs. 9 Crore to be paid in a year under each section. The amounts provided for sterilization would not be sufficient to meet all the costs of undergoing the procedure. It is unfortunate that there is no means at present to mitigate the costs involved in seeking Family Planning services. Medicines such as contraceptive pills and materials such as condoms and IUCDs are provided free of cost. Yet another fact to be noticed is that not all of the opportunity costs and incidental costs in terms of money and time are fully compensated.
Rights Provided within the program: Even though, the program highlights some of the rights, they are not fully fulfilled. However, these are,
• Right for controlling fertility
• Right for deciding size of the family
• Right to give proper care for family, especially children and spacing between two births
Rights being violated in the program
• Right to Reproduce: Even though, every individual has the right to take part in the process of reproduction, the Universal Declaration of Human Rights (UDHR), does not include the right to reproduce. It only declares that all humans “have the right to marry and to found a family” and that “motherhood and childhood are entitled to special care and assistance. The United Nations document that specifically upholds women’s right is the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), and it mandates reproductive freedom. Article 16(e) states that women and men must have the “same rights to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise their rights.” The clause of equal right is often violated as women has to compromise on the choices of contraception and the brunt of controlling family size is on her. Negotiating power of women is also pretty less in most of the Indian societies. There are also moves in different parts of the country to penalize couples and their children for not abiding to the norms prescribed by the Government.
• Right of women to decide on fertility is challenged by coercion and forceful tubectomy that is conducted as a ritual along with the delivery of second baby.
• As a result of lack of efforts from the health systems to create awareness about the effectiveness and ease of vasectomy, Tubectomy is preferred by men and the family where a comparatively more risky procedure is imposed on the weaker sex.
• Right to choose from available options is often hampered due to lack of availability or an overt projection of one method and lack of research and innovations in the field.
• Right of informed choice is violated because no information is provided on alternative choices.
• Right to refuse a method for women is usually denied as it would be the family or male partner who decides the method of contraception and size of family and the spacing.
• Coercion exists on grounds of incentives or penalties that take away the right to freedom of choice. Such exploitations exist to the extent that vasectomies are done on persons who are alcohol intoxicated by paying those incentives to consume more.
• Family planning programs also fail to maintain and promote existing families as it excludes the role and existence of members in a family as they become old. Programs view family’s function as just for taking generations forward and forget the values and positive transactions that are possible between generations. Encouraging such positive transactions may prove to be a better resource to foster identities and family values that is essential in care of older population and in bringing up of an ethically bound generation.
• Sexual self-determination of a woman forms an integral part of her dignity as a human being. Population policies and population control programs often are insensitive to this right and consider these “bodies” as mere instruments for procreation and hence consider that it could be easily manipulated to attain population control without providing provisions for respecting the identity.
Historically, evolution of Family planning program in India from the immediate post-independence period was with the target of reducing birth rate and its consequences in the country. The proponents of Malthusian and neo-Malthusian theories in India influenced the policy makers during the initial days to take firm steps towards population control. The objective of the program in kerala too did not transcend beyond mere control over number of births and certain medical aspects of giving birth of a baby to a broader meaning of ‘planning a family’ keeping the inviolability of parenthood and other human values and needs. The program also concentrated more on the medical aspects of reproductive health, its consequences on economy, sustainability of other national programs and development of the nation as compared globally. The Kerala State policy driven by the Family planning program of the country also focused on the need for bringing down the population within a stipulated frame of time and this targeted program had specific indicators for outcome. Financial and other incentives for acceptors of family planning and health workers led to coercion to accept contraceptive measures. There are also instances of pressure tactics by the program on the health workers, even though not as bad as it happened in early days, to coerce people to undergo even a terminal contraception without adequate provision with information. Following the International Conference on Population and Development at Cairo in 1994, there was a shift of approach to a “Rights based”. However, though it reflected in the National Population Policy 2000, such recommendations remain un-implemented at large. Since the worth of the program was measured and determined only by its consequence without incorporating the social determinants, the state policy driven by the national program is Utilitarian in nature.
Benefits for Acceptors of Family Planning
Apart from the benefits for the nation as a whole, the following are the benefits for individual acceptor of family planning program –
Direct Benefits
• Reduced burden of repeated child bearing for women would help women to be in better health
• Enough spacing between children so that care of the mother and child is possible
• Terminal contraceptive measures prevent further pregnancies and associated morbidities which is of special mention in case of those women at risk
• Availability of safe Abortion locally and legally
• Sex Selective Abortions could be prevented if enforced properly
• Youth could also meet their sexual and reproductive needs
• Measures to plan and control family size is made available to women
• Reducing death of infant or mother
Indirect Benefits
• Reduced Reproductive Morbidity of both Men and Women
• Sexually transmitted diseases including HIV could be prevented
• Reduced instances of catastrophic expenses pushing to further poverty
• Early detection of treatable conditions preventing a larger burden
• High risk maternal and child care has started getting attention
• There is an opportunity to demand for sexual and reproductive rights as well as empowerment of women
Cost to the Acceptors
Direct costs:
• Hospitalization cost
• Cost of stay, medicines and materials
• Cost of transport to and from the institution in that case.
• Fee to be paid to birth attendants, nursing or for doctor if needed
Indirect costs:
• Productivity loss
• Wages lost during the period
• Time Costs incurred for tubectomy (takes upto 5 days hospitalization and upto 1 month of moderate rest at home) is much more than vasectomy (usually does not require hospitalization or rest)
• Wages lost by care takers or that has to be paid for bystanders
• During instances of hospitalization, such as in case of tubectomy, there is a cost to take care of children and other dependents at home.
• Cost of re-canalisation if at a future period in time, due to some reason the couple opts for another child.
• Loss of social/ family role for the period of hospitalisation and recuperation.
• Blame for failures usually on the women and she will have to bear the extra burden of maintaining family size.
• Value of the child unborn, following a terminal contraceptive measure such as Tubectomy or Vasectomy cannot be quantified if recanalisation fails.
• Risk of women being blamed of infidelity and resultant marital discord following failure of male contraception. This can happen when proper awareness of chance of pregnancy is given and if necessary care is not taken immediately after vasectomy.
Means to mitigate problems associated with the Costs
Ministry of Health and Family Welfare has introduced a Family Planning Insurance Scheme since 1981 and presently implemented through ICICI Lombard General Insurance Company to compensate the acceptors of sterilization for loss of wages. Central Government, under this scheme release fund to the state Government at a fixed rate such as Rs. 1100/- per Tubectomy, Rs. 600/- per Vasectomy, Rs 20 per IUCD Insertion etc. The package may vary from high focus states to low focus states. In addition to cash compensation for lost wages, food, medicines and materials etc, provisions are made to make a payment of ex-gratia to the acceptor of sterilization or nominee in case of an adverse event as follows. Rs. 200,000/- per case of death within 7 days of discharge, Rs. 50,000/- in case of death between 8 – 30 days of sterilisation, Rs. 25,000/- in case of failure of sterilization, and Rs. 25,000/- towards cost of treatment of serious post operative complication. Indemnity insurance of Rs. 200,000/- per case per doctor / facility but not more than 4 cases in a year is also provided in the program. However, there is a ceiling for the insurance company of Rs. 9 Crore to be paid in a year under each section. The amounts provided for sterilization would not be sufficient to meet all the costs of undergoing the procedure. It is unfortunate that there is no means at present to mitigate the costs involved in seeking Family Planning services. Medicines such as contraceptive pills and materials such as condoms and IUCDs are provided free of cost. Yet another fact to be noticed is that not all of the opportunity costs and incidental costs in terms of money and time are fully compensated.
Rights Provided within the program: Even though, the program highlights some of the rights, they are not fully fulfilled. However, these are,
• Right for controlling fertility
• Right for deciding size of the family
• Right to give proper care for family, especially children and spacing between two births
Rights being violated in the program
• Right to Reproduce: Even though, every individual has the right to take part in the process of reproduction, the Universal Declaration of Human Rights (UDHR), does not include the right to reproduce. It only declares that all humans “have the right to marry and to found a family” and that “motherhood and childhood are entitled to special care and assistance. The United Nations document that specifically upholds women’s right is the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), and it mandates reproductive freedom. Article 16(e) states that women and men must have the “same rights to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise their rights.” The clause of equal right is often violated as women has to compromise on the choices of contraception and the brunt of controlling family size is on her. Negotiating power of women is also pretty less in most of the Indian societies. There are also moves in different parts of the country to penalize couples and their children for not abiding to the norms prescribed by the Government.
• Right of women to decide on fertility is challenged by coercion and forceful tubectomy that is conducted as a ritual along with the delivery of second baby.
• As a result of lack of efforts from the health systems to create awareness about the effectiveness and ease of vasectomy, Tubectomy is preferred by men and the family where a comparatively more risky procedure is imposed on the weaker sex.
• Right to choose from available options is often hampered due to lack of availability or an overt projection of one method and lack of research and innovations in the field.
• Right of informed choice is violated because no information is provided on alternative choices.
• Right to refuse a method for women is usually denied as it would be the family or male partner who decides the method of contraception and size of family and the spacing.
• Coercion exists on grounds of incentives or penalties that take away the right to freedom of choice. Such exploitations exist to the extent that vasectomies are done on persons who are alcohol intoxicated by paying those incentives to consume more.
• Family planning programs also fail to maintain and promote existing families as it excludes the role and existence of members in a family as they become old. Programs view family’s function as just for taking generations forward and forget the values and positive transactions that are possible between generations. Encouraging such positive transactions may prove to be a better resource to foster identities and family values that is essential in care of older population and in bringing up of an ethically bound generation.
• Sexual self-determination of a woman forms an integral part of her dignity as a human being. Population policies and population control programs often are insensitive to this right and consider these “bodies” as mere instruments for procreation and hence consider that it could be easily manipulated to attain population control without providing provisions for respecting the identity.
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