Mistreatment and Coercion: Unethical Sterilization in India · ObGyn Obstetrician/Gynaecologist OT Operational Theatre PIP Programme Implementation Plan ... SOP Standard Operating

Mistreatment and Coercion: Unethical Sterilization in India

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81-89479-94-6

Female sterilization in India overwhelmingly dominates the contraceptive

method mix used across the country, at a colossal 75%. In addition to this, 85% of

the family planning budget is used for promoting and implementation of female

sterilization through camps in rural India. Through these camps, women continue

to be pushed into the procedure, often with a glaring lack of informed consent.

Sterilization in India has long been used as a means of target-driven population

control, disregarding the reproductive autonomy of women in favour of curbing

population growth. Although the National Population Policy 2000 broke new

ground in prioritizing reproductive rights over population control, the existence

of sterilization camps and the rampant, disproportionate promotion of the

procedure demonstrate that implementation 18 years on remains to be fully

realized.

In 2015, the Devika Biswas v Union of India case challenged appalling sterilization

camps that were taking place across the country, rounding up poor women

and loading them like cattle into abandoned schools, sterilizing them in barbaric

and highly unsanitary conditions, without anesthesia. These camps resulted in

many deaths, and in the overwhelming majority of cases, the women did not

consent to the procedure – many of them were young and in the reproductive

age group of 18-39. In a landmark judgment, the Supreme Court outlawed the

camps and directed various states to provide compensation to the families of

the victims.

Nevertheless, sterilization in India is still problematic. Ground level health workers

are heavily incentivized to encourage women to undergo the procedure, rather

than promoting condom or oral contraceptive pill usage. Sterilization remains a

procedure that is performed at a disproportionately high rate when compared

with other nations. This book will look at sterilization through a rights-based lens, to

shed light on how sterilization has been used for years as a weapon to impede

reproductive autonomy and champion coercive population control tactics, at

the expense of women's bodies. The book also highlights the struggle through

the use of law to change the way family planning programmes especially

female sterilization was being implemented

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Human Rights Law Network’s Vision ●Toprotectfundamentalhumanrights,increaseaccesstobasicresourcesformarginalizedcommunities,andeliminatediscrimination.

●To create a justice delivery system that is accessible, accountable,transparent, and efficient and affordable, and works for theunderprivileged.

●Raisethelevelofpro-bonolegalexperienceforthepoortomaketheworkuniformlycompetentaswellascompassionate.

●Professionally train a new generation of public interest lawyers andparalegalswhoarecomfortableintheworldoflawaswellasinsocialmovements and who learn from such movements to refine legalconceptsandstrategies.

India’sFamilyPlanningProgrammeCrueltyinSterilizationCamps

©SocioLegalInformationCentre

ISBN: 81-89479-94-6

Editors: MadhulikaMasih,SaritaBarpandaandZahraWynne

Sub-Editors: LeonRauch,SangeetaBanerjee,MahimaDuggal

Design & Print:ShivamSundram

Published by:HumanRightsLawNetwork(HRLN):AdivisionofSocioLegalInformationCentre576MasjidRoad,JangpuraNewDelhi110014IndiaPh:+91-1124379855/56E-mail:[email protected]:www.hrln.org

Disclaimer: Sincewriting theoriginal report,newer informationanddatahavebeenpublishedandhaveshednew lightonfemalesterilizationprogramme inIndia,andphasingoutofsterilizationcampsinthevariousstatesofIndia.Wehavemadeaneffortandhavetriedtoupdatethepublication,butthenthereisaneedtounderstandthattherewillbegapsintheinformation.Wewouldbegratefulifyoucouldsharewithusrelevantinformationandwewillensurethatitisincorporatedinthenextpublication.

Note on Footnote and Endnote: HRLN has employed a simple and straightforward formatting style tomaximize the usability of the sources cited. Any section of this volumemay be reproduced without prior permission of the Human Rights LawNetworkwhere it is forpublic interestpurposesandcontainsappropriateacknowledgment.

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ACKNOWLEDGEMENTSGoing through theentireprocessofbringingout thisbook, thenotionthat,byourselves,wewouldhavebeeninadequatewasreaffirmed.Manyofourfriendshavehelpedusinseveralwaysintheirvariouscapacities.

WethankmembersofcivilsocietygroupsingeneralandespeciallyJashodhara Dasgupta, Advisor, Sahayog, Bijit Roy, PopulationFoundationof India (PFI)andMs.DevikaBiswas, SocialActivistwhowas thefirst to travelandhelpuswith the testimonialsontheseforced,coercivesterilizationcampswhichultimatelyleadtomortalityandmorbidityamongstwomen.Wearedeeplygratefultoourfriendsandinternswhocontributedduringthecaseandcompilationofthebook.

Finally,wewouldliketothankourcolleagueMr.ColinGonsalvesfor giving us the first thought of bringing out this book andappearingasthecounselforthepetitioner.

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TABLE OF CONTENTSIntroduction 9

History of Family Planning in India 17

Violations happening across India 30

CampcultureTargetbasedapproachLackofinformedconsentFutilityofFPIS

Fallacies With India’s Focus on Sterilization 40

Female-centricCattlecultureSterilizationdrivesNonaccesstoinformationTwochildnorm

Case Study of Two Important Supreme Court Rulings & Analysis of the Fallout of the Family Planning Programme in Recent Times 48

RamakantRaiDevikaBiswasCaseChhattisgarhMassacre

Critique of the Target-Based Approach in 135FamilyPlanning

International Law and Cases on Sterilization 145

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India’s Family Planning Programme

Findings from the Field 171

The Way Forward for India’s Sterilization Programme 246

Summary of the Judgment in WPC Devika 251Biswas v UOI 95/2012

Conclusion 254

Annexures 256

JudgmentpassedintheRamakantRaivUOI,WPC209/2003AnitaJhaCommissionReportJudgmentinthematterofDevikaBiswasvsUOI,WPC95/2012Guidelines

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ACRONyMS

ADMO AssistantDistrictMedicalOfficerANC AnteNatalCheckupANM AuxiliaryNurseMidwifeASHA AccreditedSocialHealthActivistAWC AnganwadiCentreAWW AnganwadiWorkerBPL BelowPovertyLineCDMO ChiefDistrictMedicalOfficerCEDAW TheConventionontheEliminationofallFormsof

DiscriminationDQAC DistrictQualityAssuranceCommitteeFPP FamilyPlanningProgrammeFPIS FamilyPlanningIndemnitySchemeHRLN HumanRightsLawNetworkHTTS HealthDepartmentOperated,Incentive-based,

Target-Oriented,Time-boundandSterilization-focused

IUCD IntrauterineContraceptiveDeviceICPD InternationalConferenceonPopulationand

DevelopmentIPHS IndianPublicHealthStandardINC IndianNationalCongressIEC Information,EducationandCommunicationJSSK JananiShishuSurakshyaKaryakramJSY JananiSurakshyaYojanaLPS LowPerformingStateLGBT LesbianGayBisexualTransgenderMCH MaternalandChildHealthMMR MaternalMortalityRate

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MOIC MedicalOfficerinChargeMoHFW MinistryofHealth&FamilyWelfareNHM NationalHealthMissionNRHM NationalRuralHealthMissionNFHS NationalFamilyHealthSurveyObGyn Obstetrician/GynaecologistOT OperationalTheatrePIP ProgrammeImplementationPlanPHC PrimaryHealthCentrePPH PostPartumHaemorrhageRCH ReproductiveandChildHealthSQAC StateQualityAssuranceCommitteeSOP StandardOperatingProcedureWHO WorldHealthOrganization

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1. INTRODUCTION

“My name is Saraswati Devi. I was sterilized at Kapafora camp, Bihar. I had to be hospitalized for 8 days after that. We had to spend money our own money so that I could get better. I did not know anything about operation.”

In September 2016, the Supreme Court of India directed theUnionGovernmenttoensurethediscontinuationof‘sterilizationcamps’withinthefollowingthreeyearsandtoinducethestategovernments to follow suit. It also charged the governmentto ensure proper monitoring of the programme, investigatesterilization failures, complications or deaths, and increase thecompensation amount in these cases. It further ordered theimplementation of established legal, medical and technicalstandardsforsterilization.Thesedirectivescameasaresultofa

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2012petitionfiledbyahealthactivistthroughtheHumanRightsLaw Network, the case better known as theDevika Biswas vs. Union of India.ThiswasthesecondpublicinterestlitigationfiledonthesubjectofwidespreadnegligenceandhumanrightsabusesoccurringregularlyinsterilizationcampsacrossIndia.

Newspaper reports and research by a multitude of humanrightsgroupspaintsanappallingpictureoftheconditionsunderwhich the sterilization surgeries take place. Reports assert thatthe women who were being convinced to go through thesesterilization surgeries were below 30 years of age and illiteratewith most being completely unaware of other forms of birthcontraceptives.Mostofthem,asstatedearliercouldn’tread,sotheconsentformhadn’tmadesenseandmanyhadneverevensignedoraffixedtheirthumbprintonanyform.Thecampswereset-upinmakeshiftlocations,withnogenerators,oxygencylindersorrunningwater.Theequipmentusedforthesurgerywashardlysterilized,withmanycampseven lackingproperboilers for thepurpose.Womenweremadeto layonbaremattresses for thesurgeries,withnopost-surgery recuperation facilities.Often thewomenweremadetowaituptofivehoursafterregistering,andbythetimetheyreachedtheoperatingtabletheiranaestheticwouldhavewornoff.

InplaceslikeBhubaneshwar,OdishaandFerozpur,UttarPradesh,thedoctorsconductingsurgerieswouldusebicyclepumpsinsteadofaninsufflator,tointroduceairintothewomens’abdomens(asreported by Shreelatha Menon). The doctor in Bhubaneshwarstated that he had done over 60,000 tubectomies andmanyofthemwithbicyclepumps. InKaparfora,Bihar,awomanwasoperatedupon,eventhoughshewaspregnant,andsufferedamiscarriageasaresult.

InAugust2016, thegovernment sharedwith thecourt that113womendiedaftertubectomiesin2015-2016.AccordingtofigurespresentedinParliament,1,434tubectomydeathswerereportedacrossthecountrybetween2003and2012:about150ayearorabout threeperweek.However, theofficial figuresareagrossunderestimate,andhalfof thewomenundergoing this surgerysufferlong-termcomplicationslikepain,bleedingandinfection.Oneofthelargestsingleincidentsofreporteddeathstookplace

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inNovember2014,when18womendiedatfourcampsinBilaspur,Chhattisgarh,where 137womenwent through tubectomies.Asinglesurgeonoperatedon83womenintwohours-thatmeanslessthantwominutespersurgery.

WhilethisremainsthestatusquoinrelationtotheimplementationoftheFamilyPlanningProgramme(FPP),itiscrucialtoexaminetheprocessthroughwhichthisprogramme,oneofthelargestinIndia,came intobeing. India isacountryof 1.2billionpeople,secondinpopulationonlytoChina,andlikelynotforlong1.TheIndian government struggles to meet the needs of countlesspeoplewhen itcomes tonutrition,healthcare,education,andmore. As of 2011-12, approximately 21.92% of people in Indialivedbelowthepovertyline2.Additionally,IndiaisfailingtomeetstandardssetbytheUnitedNationsMillennialGoalsforissueslikematernalmortality:

FromaMaternalMortalityRate(MMR)of437per100,000livebirthsin 1990-91, India is required to reduceMMR to109per 100,000livebirthsby2015.Between1990and2006,therehasbeensomeimprovement in theMaternalMortality Rate (MMR),which hasdeclinedto167per100,000livebirthsin2009.However,despitethis,India’sprogressonthisgoalhasbeenslowandofftrack3.

While conditions seem to be slowly improving, the vast, ever-growing population makes addressing these issues quite thechallenge. Attempts to address population concerns have awell-establishedhistoricalcontext.“In1952,Indialaunchedtheworld’s first national programme emphasizing family planningto theextentnecessary for reducingbirth rates ‘to stabilize thepopulationatalevelconsistentwiththerequirementofnationaleconomy.’”4

1 CIA World Factbook: https://www.cia.gov/library/publications/the-world-factbook/geos/in.html,Accessedon13.06.20172 Planning Commission, Government of India. 2013. “Handbook Of Statistics On IndianEconomy-Table162:NumberAndPercentageOfPopulationBelowPovertyLine”.NewDelhi:ReserveBankofIndia.3Millenium Development Goals; Eight goals for 2015;Goal4-ReduceChildMortality<http://www.in.undp.org/content/india/en/home/post-2015/mdgoverview.html>, Accessed on18.07.20174“NationalHealthMission-FamilyPlanning:Background”.2018.Nhm.Gov.In.http://nhm.gov.in/nrhm-components/rmnch-a/family-planning/background.html.

Introduction

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Indiawas,and still remains,anation that livesand thrives in itshundreds of villages, where the population boom remaineduninhibiteddespite themanynaturalandman-madesetbacksthatcameinitsway.Familyplanningwasapolicyraisedtotacklethis handicap, a possible solution to the dilemma of providingacutelyshortservicesthroughoverstretchedresourcestoanever-growingpopulation.Inotherwords,familyplanninginIndiawasmeanttorestoreasemblanceofparitybetweenthepopulationandthecapacityoftheStatetoprovideforsociety’seconomicandsocialneeds.

Familyplanningoptionsareanessentialpartofensuringahigherquality of life for the entire population. Theability to planandspacechildrenallowsfamiliestostaywithintheirmeansandhavecontrolovertheirlives.

Onewaytomeasureaccesstofamilyplanningisthroughunmetneed data. “Unmet need for family planning refers to [thepercentageof]fecundwomenwhoarenotusingcontraceptionbut who wish to postpone the next birth (spacing) or stopchildbearing altogether (limiting).”5 Ideally, unmet need forfamilyplanningwouldbeat0%andeverywomanwouldhavebodily autonomy and control over her reproductive health.Unfortunately,thisisnotthecaseinIndia.Whiletotalunmetneedforfamilyplanning in Indiavariesbystate,thenationalfigure is21%percent.6 Thenortheastern regionof India, includingstatesfromChhattisgarhtoNagaland,hasthehighest ratesofunmetneed. Rates in these areas vary from the astonishing 56.4% inSiwan,Bihartolessextremebutstilltroublingratesinthe20-30%rangeinotherpartsofBiharaswellasotherstateslikeJharkhandandChhattisgarh7.Thesenumberspaintaconcerningpictureinwhichimmensenumbersofwomendonothavebodilyautonomyorchoiceaboutif,when,andhowtheyhavechildren.

5 Ministry of Health and FamilyWelfare;National Family Health Survey-4; State Fact Sheet Bihar:<http://rchiips.org/nfhs/pdf/nfhs4/br_factsheet.pdf>Accessedon08.08.20176HealthandPopulation-PerspectivesandIssues36(1&2),26-44,2013;Regional Variations of Unmet Need of Family Planning in Rajasthan;SherinRajT,V.K.TiwariandJ.V.Singh<http://medind.nic.in/hab/t13/i1/habt13i1p26.pdf>Accessedon08.08.20177 Sheet, India Fact. “NFHS-4 (National Family Health Survey-4).” International Institute for Population Studies(2017).

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ThereasonsforsuchahighlevelofunmetneedinIndiaarelayeredandcomplex. It isevident,however,thatthegovernmentmustredistributeandallocatepublicresourcestoaddresscrucialsocialproblems,whichmaysometimes includecontrollingpopulationgrowth. Any universal strategy to encourage family planningmust necessarily include public awareness and education inordertoincreasetheuseofanddecreasethestigmaassociatedwith contraceptivemeasures. Despite government campaignsseeking to limit family size harmful perceptionsassociatedwithfamilyplanningstillremain.Itoftencontinuestobeseenassociallyunacceptable,taboo,andaninsulttotheIndianfamily.Indiaisnot unique in adopting family planning programmes, howeverIndia does stand alone in its worrying reliance on sterilizationin general, and unsafe, non-consensual female sterilization inparticular.

WHAT IS STERILIZATION?

Sterilization isatypicallypermanentprocedureusedtopreventconception.8Thesterilizationprocedureforwomeniscalledtubal ligationandinvolvesclosingshutthefallopiantubesbyavarietyofmethods,fromsilkthreadtoelectroniccoagulation.Formalepatients,theprocedureiscalledvasectomyandinvolvesseveringeachvasdeferens througha small incision in the scrotum. Theproceduresareusuallypermanent,thoughtheycansometimes,more frequently for men, be reversed. Sterilization reversal inIndia,especiallyamongthepoor,ishighlyunlikelyasthereversalprocedureshaveahighrateoffailureandareexpensive.

Sterilization procedures for women are riskier, more complex,andmoreexpensivethanformen.Despitethis, familyplanningprogramme tend to focus on women. Globally, sterilizationproceduresperformedonwomenoutnumbersthoseformen.Thisfocusonwomenforfamilyplanningingeneralandsterilizationinparticularisasymptomofpatriarchalsystems.Theonusisplacedonwomentocareforfamiliesthattheytendtohavelittlecontroloverproducing.Inaddition,notonlyisanyformofbirthcontrolstill

8Sterilization.(2015).Encyclopedia Britannica.Retrieved16February2018,fromhttps://www.britannica.com/topic/sterilization-medicine

Introduction

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stigmatizedinmanypartsoftheworldandinIndia,butalsomalesterilization isparticularly stigmatized.Whentheorizingoverwhysterilizationeffortsarefocusedonwomen,MaryHvistendahlsaid,“Thismaybebecausewomenaredeemedlesslikelytoprotest.”9

Whilesterilizationisavalidwayforpeopletochoosenottohavemorechildren,ithasalsobeenusedfordubiouspurposes,suchas itshistoricuseforeugenicpurposes.Certainconditionsweredeclared,oftenarbitrarily,as inheritableandgroupsofpeopleweresterilizedasaformofselectivebreedinginorderto“purify”thehumanrace.IntheearlytwentiethcenturytheUnitedStatesengagedineugenics-drivensterilization.IntheUS,“between1907and1939,more than30,000people in twenty-nine statesweresterilized,manyof themunknowinglyoragainst theirwill,whiletheywere incarcerated inprisonsor institutions for thementallyill.” Themost famous historical sterilization programmewas theeugenicsagendapursuedbyNaziGermanyduringtheHolocaust,inwhichanestimated300,000to400,000peopleweresterilized.“A diagnosis of ‘feeblemindedness’ provided the grounds inthemajorityofcases, followedbyschizophreniaandepilepsy.”“AlthoughtheSterilization Law sometimes functionedarbitrarily,the semblanceof legalityunderpinning itwas important to theNaziregime.”10Publicsupportwasgeneratedusingpropagandaand eugenics-based logic to fuel a legitimate, governmentinitiatedaim,whichcompletelyviolatedhumanrightsofcountlesspeople.

Today, while laws may not announce eugenic aims, hiddenagenda to dispose of “undesirables” in society can still bediscovered by looking beyond the face of the law. Whilemany population control policiesmay appear benign on theirface,upon further investigation the statedmedical reasons forsterilization and the identification of groups to which the lawapplies are revealed to be morally and legally suspect. Forexample, compulsory sterilization law laws often target LGBT+

9India’s dark history of sterilization;BBCNewsIndia;14.11.2014<http://www.bbc.com/news/world-asia-india-30040790>Accessedon08.08.201710Transgender sterilization: Sweden and Beyond;07/01/201307:55pmET|UpdatedFeb02,2016; The Huffington Post <http://www.huffingtonpost.com/entry/transgender-sterilization-sweden-and-beyond_b_3519723.html?section=india>Accessedon08.08.2017

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people, especially transgender people. In many countries, inorder to transition,a transgenderpersonmaybe facedwitha“non-choice” between sterilization and a transition procedurethatisnot legallyormedicallyrecognized.11Asaresultoftheselaws,transgenderpeoplemustgiveuptheabilitytoreproducetogainaccesstohealthcareandlegalrights.Evenstill,transgenderpersonsarerefusedaccesstothesamerangeofrightsenjoyedbycisgenderpeople.12

“We’ve learned from the emergence of fertility medicinethatrecognitionofgenderisnotcontingentonreproductivecapacity, so why is this unrelated ability brought to bearon trans people’s legal gender legitimacy? Ultimately, thisisaboutwhatsterilizationhasalwaysbeenabout:purifyinga state by punishing “others,” rendering nonconformistlivesundesirable,strippingawaytheagencyanddignityofoppressedpeoples, and sacrificing reproductive freedomsforbasicrights.”12

InIndia,state-imposedquotasresultinmanycoercedandforcedsterilizations,leadingtocountlesshumanrightsviolations.Indeed,the BBC documented India’s “dark history of state-sponsoredpopulationcontrol,oftenwitheugenicaims-targetingthepoorand underprivileged.”13 One of the darkest times in terms ofsterilization use by the governmentwas during the EmergencyPeriod of the 1970’s, which will be discussed in the followingchapter.

India’s family planning programme, especially its sterilizationinitiatives,hasfocusedexclusivelyontarget-orientedpopulationcontrolwithoutanyconsideration for the reproductive rightsofwomen.Asaresultofatarget-basedinitiativewhichignoresthematerialneedsofthepopulation,theStatemachinery,especiallyin the rural areas, neglects its obligation tomaintain women’s

11Transgender sterilization: Sweden and Beyond;07/01/201307:55pmET|UpdatedFeb02,2016; The Huffington Post <http://www.huffingtonpost.com/entry/transgender-sterilization-sweden-and-beyond_b_3519723.html?section=india>Accessedon08.08.201712ibid.13India’s dark history of sterilization;BBCNewsIndia;14.11.2014<http://www.bbc.com/news/world-asia-india-30040790>Accessedon08.08.2017

Introduction

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health and dignity. As Shree Venkatram of the PopulationFoundation of India notes, “family planning saves lives. Whenit ends up taking the lives of youngmothers, or inflicting themwithlifelongsickness,itisamonumentaltragedy.Andithasthepotentialofsettingbacktheprogrammebydecades.”14

ThepurposeofthisbookonsterilizationsinIndiaismulti-faceted.Ittracesthehistoryandevolutionoffamilyplanningandsterilizationinitiatives in India and addresses the issues that plague thisinitiative.ItattemptstoreflectonthefallacieswithinIndia’sfocuson sterilization, by delving into the two of the most importantpublic interest litigations in India involving gross violations ofhuman rights. This book sets out a family planningprogrammewhich is humane, consensual, and respects and upholds therightsdignityofallpeople,especiallythepeopleuponwhomitisimplemented.

14ShreeVenkatram,“India’s family planning must give way to proper family planning,”Accessibleat: <http://www.theguardian.com/global-development/poverty-matters/2014/nov/22/india-sterilization-camps-family-planning-tragedy>,Accessedon08.08.2017

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2. HISTORy OF FAMILy PLANNINg IN INDIA

“In this 1950 photo, a group of women sit below posters advocating family planning in a doctor’s clinic in the Indian village of Badlapur in Maharashtra.” Source: Getty Images

The concept of ‘family planning’ encompasses a couple’sconscious choice regarding family size and reproduction.However,astatecontrolledprogrammewithstructuralandpolicyinterventions, aimed specifically at lowering the society’s birth-rateamongparticular sectionsof thepopulation isa relativelynewphenomena.Itsroots lie intheperiodbetweentheendoffeudalismandthegrowthofcapitalistsocietiesthatweseetoday.

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India’sNationalFamilyWelfareProgrammewaslaunchedin1951,makingIndiaoneofthefirstcountriesintheworldtohaveanofficialprogrammeforthepurposeoffamilyplanning.Theprogrammeaimed to reduce the birth rate nationwide, thus stabilizing thepopulationatalevelconsistentwiththatrequiredforgrowthofthenationaleconomy.Sinceitslaunch,theprogrammehasbeenpursuedbytheGovernmentofIndiaasapriorityofthenationalagendaandhasbeenafullycentrallysponsoredscheme15.

gOPALASWAMI’S REPORT AND MALTHUSIAN CHECkS

The ideaofa familyplanningprogrammewasnotnew to thepolicymakers of 1950s. In fact, advocacy for a stringent birthcontrolprogrammeinIndiacanbetracedbacktoP.K.Wattal’smonograph ‘The Population Problem in India: a Census Study’,published inBombay in1916. In theyears leadingupto India’sindependence,numerousgovernmentcommissionscommentedontheclearneedforacomprehensiveapproachtobirthcontrolin thecountry.Ultimately, theNationalPlanningCommitteesetupbytheIndianNationalCongress(thenchairedbyJawaharlalNehru) institutionalized theNational FamilyWelfareProgrammein193516.

Gopalaswami’s report, based on the staggering results of thefirst post independence census, was the spark which set lightto India’seagerness to instituteapolicy tocurtail theboomingpopulation17.R.AGopalaswami,ademographerbytraining,wastheRegistrarGeneralandex-officioCensusCommissioner18.

The results he presented were stupefying in their scale. In1951, India had a population of over 365 million people and

15 National FamilyWelfare Programme < http://pbhealth.gov.in/pdf/FW.pdf> Accessed on08.08.201716 The status of family planning in India: An introduction, Family Health International India,<http://www.fhi360.org/sites/default/files/media/documents/india1-family-planning-status.pdf>Accessedon01.04.201617Galor,O.,&Weil,D.N.(1999).FromMalthusianstagnationtomoderngrowth.The American Economic Review,89(2),150-15418 The status of family planning in India: An introduction, Family Health International India,<http://www.fhi360.org/sites/default/files/media/documents/india1-family-planning-status.pdf>Accessedon01.04.2016

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a lifeexpectancyof justover35years.Only12percentof thepopulation could safely be considered literate. The averagenumberofchildrenthatawomanhadinherlifetimewassixandone-fifthofall infantsbornnever livedtoseetheirfirstbirthday.Gopalaswami predicted that India would continue to addover500,000personstotheglobaldemographicannually19.Heanticipatedthatby1981, Indiawouldboastofapopulationof520million(anumberweactuallyreachedadecadeearlier in1971).Gopalaswamiquestionedthenation’scapacitytosupportandfeedsuchanimmensepopulationwhichultimatelyleadtohis drastic recommendation of a policy ofmass sterilization tocontrolpopulationnumbers.

Mass sterilization can be categorised as a preventive checkaccordingtoMalthusianpopulationtheory.Inhistheory,Malthus20setsforthtwoformsofcheck(orcontrolmeasures)throughwhichthe rate of population growth is controlled and brought to asustainablelevel:i. ‘Positive Checks’ - This referred to anomalies which lead toprematuredeathlikewars,epidemics,starvationandsoon.

ii.‘PreventiveChecks’-Thisreferredtovoluntaryactionstakenbythepopulationtoavoidcontributingtopopulationgrowth,suchasmoral restraints, abstinence, delayedmarriage, restrictionsonmarriagebetweenpeoplebelongingtocertainsectionsofthesocietyandsoon.

Sterilization has long existed as a more permanent check onpopulationgrowth.Masssterilization,however,wasanexperimentmadeinevitablebyIndia’sloomingpopulationexplosionandtheconcernthatsuchamassivepopulationismoreofaliabilitythanadividend.

19TerrenceMcCoy,‘The forgotten roots of India’s mass sterilization program,’TheWashingtonPost 15.11.2014, <https://www.washingtonpost.com/news/morning-mix/wp/2014/11/14/the-malthusian-roots-of-indias-mass-sterilization-program/>Lastaccessedon01.04.201620ThomasRobertMalthuswasEnglishsociologistandscholarofthe18thcenturywhoiswidelycreditedwith his theoryonpopulation.His theorywasbasedon the relationshipbetweenpopulationgrowthandresources.Thebasicpremiseofhistheorywasthatpopulationgrowthalwaysrisesexponentiallyandwilleventuallyoutstripandoutgrowtheresourcesavailableforthem

History of Family Planning in India

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INITIAL ExECUTION OF THE FAMILy PLANNINg PROgRAMME

Initially,despitethegloomyoutlookofGopalaswami’sreport,theNationalPlanningCommitteeunderINCconsideredtheissueofIndia’sboomingpopulationasonethatwouldeventuallycorrectitselfthroughabasicwelfareplanandIndia’strajectoryfromadevelopingnationtoadevelopedone.TheStatebelievedthatIndiawould follow in thepathofotherdevelopednationsandseemarkedimprovementofthestandardoflivingwhichwouldcauseafallintherateofpopulationgrowth.

Hence, Jawaharlal Nehru instituted a family welfare policyunder thefirstFiveYearPlanof1952thatwas largelyclinical innature.Hesawthemassivepopulationasahurdletoagrowingsocialeconomy, familyhappinessandnationalplanningwhichcouldbesolvedthroughhisconstitutedpolicymeasures.Thefirstdecade of India’s Family Planning Programme (FPP) adoptedanalmost‘clinical’approachwherechiefemphasiswaslaidonnatural methods. Hence, it focused extensively on creation offacilities required for the implementationandexecutionof theFPP,likesettingupfamilyplanningclinics.Theprocesswasquiteslow-pacedandhalfbaked.Thisismadeclearinthefactthatameagre65lakhsofatotaloutlayof1,960crores-I.e.anegligible0.033percent-wasallocatedtoFPP.Ofthis,onlyanapproximateof15lakhswasspent21.

TheSecondFiveYearPlan(1956-61)followedasimilarapproach.Gopalaswami’sMalthusian suggestionswere largely ignoredasthenationstaterefrainedfromadoptinganaggressiveapproachto family planning in favour of expanding India’s healthcareinfrastructure.However,of themerefivecroresallotted to FPP,onlyhalfwerespentandonly411clinicsweresetupnation-wide.All failed to attract the expected number of clients. With thecountryinitsnascentyears,oneofthereasonsoftencitedasacauseforsuchabysmalresultswasdeplorableliteracyratesandseverelylackingtransportationnetworks.

21ArupMaharatna,‘India’sFamilyPlanningProgramme:AnUnpleasantEssay’,Economic and Political Weekly, Vol.37,Issue10,9thMarch2002,p.971

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The Third Five Year Plan (1961-66) attempted to correct theshortcomingsofthepreviousclinicalapproachandshiftedfocustothe‘Information-Education-Communication’(IEC)approach.Thisinvolvedhealthworkersvisitingwomenofchildbearingagestoencouragethemtolimittheirfamilysize.AsFPPexpendituresjumpedby11timesunderthisplan, itbecamean integralpartofIndia’spublichealthdepartment.Nevertheless,itsexpenditureconstituted far less than one percent of total governmentoutlays22. The IECapproachwasnot successfuland fadedoutbefore itcouldeven take root,givingway toa ‘targetbased’approach23enteredaroundsterilization.

Emergence of Sterilization as the Flagship of India’s Family Planning Programme

“Family Planning Programmes have been implemented in ways that have led to numerous human rights violations for women in India.”

22ibid.23P.VisariaandV.Chari,‘India’sPopulationPolicyandFamilyPlanningProgramme:Yesterday,Today and Tomorrow’,Do Population Policies Matter? Fertility and Politics in Egypt, India, Kenya, and Mexico, A.Jain(ed.),PopulationCouncil,NewYork,1998,p.63

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TheFourthFiveYearPlan(1966-74)sawasignificantshiftwiththegovernment adopting an aggressive target based approachto combat the rapidly rising population. This was sparkedpredominantlybytheoverwhelminganddeeplydisturbingresultsof the 1971 census. India had already crossed the 520 millionmark, whichwasGopalaswami’s predicted number for India’spopulationin1981.Moreover,statisticsshowedthatIndiawouldcontinuetoaddover10millionpeopletoitsalreadystaggeringpopulationeveryyear.

Thismarkedthebeginningof thestate-backedfamilyplanningpolicy’sevolutionintoarobust,almostmechanicalprogrammewe see today. While the State initially viewed economic andsocialdevelopmentasthebestcontraceptiveandthebiggestbulwark against rapid population growth, the Indira Ghandigovernmentoversawaradicalshifttotheright,andthepursuitofamorepermanentmethodofpopulationcontrol:sterilization.

Thehealthdepartmentsetdemographicgoalsandtargetstobeachieved.FPPbegantobeingrainedinwhatK.Srinivasannamedthe ‘HITTS’ model: health department operated, incentive-based, target-oriented, time-bound, and sterilization focused24.Annualtargets fornumberofacceptorsofcontraceptionweresetbythecentralgovernmentandtheresponsibilitytoachievethese targetswaspassedon to loweradministrativeunits suchas states, districts, primary health centres, subcenters and theirfunctionaries25.

Differentstatesuseddifferentmethodstoachievetargetsduringthecampaign:

“…toaverywidevarietyofactivitiesinvolvinginteractionofthepublic with government agencies of almost any kind. Issue oflicensesforguns,shops,canecrushersandvehicles,issueofloanofvariouskinds,registrationofland,issueofpermitsforcement,fertilisers,seeds,etc,issueofrationcards,exemptionfrompayment

24 K. Srinivasan, ‘Population Policies and Programmes since Independence’, K. Srinivasan,Demography India, Vol.27,Issue1,1998,p.625supran.5

23

ofschoolfeesorlandrevenue,supplyofcanalwater,submissionofapplication for any job, exerciseof foodcontrol regulationsagainst shopkeepers,gettingtransfers,obtainingbailandevenfacilitationofcourtcases,werelinkedupwiththeprocurementofcasesforsterilization.”

Eventually, sterilization targets were even given to teachers,with immense pressure and threats of consequences if theyfailedtomeetthesetargets, likethepressureplacedonhealthandgovernmentofficials.Itwasadrasticstepupfrompreviousgovernment efforts for sterilization, which had offered enticingincentives. It drew into question the validity of consent for theprocedure. While not physically forcing men and women toundergo sterilization, these new methods presented even lesschoiceforthosesubjectedtothem.

The decade of 1965 to 1975 witnessed the building up andconsolidationofanFPPdictatedbythe‘tyrannyoftargets’.TheoutlaysonFPPreached1.8percentduringthistimeperiod.Inanattempttoreducethebirthratefaster,thecentralgovernmentalso stepped up the incentive programme for acceptors andmotivatorsof vasectomiesand tubal ligations. Thisgave rise toorganisationofmasssterilizationcampsandleadtothe‘campbased’approach.

The camp-based approach saw its nightmarish form duringthe Emergency rule (1975-77), under Prime Minister IndiraGandhi’sgovernment.Populationcontrol featuredprominentlyin thegovernment issued twenty-point programme26. The 42ndamendmentaddedfamilyplanningtotheconcurrentlist intheIndianConstitution27.

SanjayGandhi,sonofPMIndiraGandhi,wasattheforefrontofIndia’shorrificsterilizationinitiative.Millionsofpeople,mostlymen,werecartedofftobesterilisedonbackoftrucks.Thereweremanyreportsofphysically forcedsterilizations throughraids invillages

26 Twenty Point Programme - General Knowledge Today. (2015).Gktoday.in. Retrieved 16February2018,fromhttps://www.gktoday.in/twenty-point-programme_22/27The Inevitable Billion plus: exploration, of Interconnectivites and action possibilities; deepening the debate on science, population and development;VasantGowariker;published1993


24


bypolice-accompaniedhealthandgovernmentofficials.Thosewho appeared eligible for sterilization were rounded up andsterilizedinlargegroups.Thisincludednotonlythosewhoalreadyhadchildren,butalsothosewhowerechildless,unmarriedorstillinpuberty.

It is important tonoteagain that these raidsdisproportionatelytargetedthepoor.“Theweakersectionsusuallyformedthefocusoftheraids.Personsbelongingtothemoreprosperoussectionswereletoffeventhougheminentlyeligibleforsterilization.Some,however,hadtobuytheir‘release’byprocuringsubstitutecasesfrom the poorer classes.” The deadly danger of these hastysurgerieswasexacerbatedfurtherbythecompletelackoffollow-upcareprovided.Insomevillages,peoplefledandhidinfields,sometimesforweeks,infearoftheraids.

Hence,thevoluntaryaspectofGopalaswami’sMalthusianplanseemedtohavebeenentirelyabandoned.Thestatewentfromrewardingmenwithtransistorradiosforundergoingavasectomyproceduretoaspreeofforcedsterilizations.

Millions of peoplewere sterilized in India under these coerciveandforcefulmeasuresduring,before,andaftertheEmergencyPeriod.Toputitintoperspective,itisestimatedthatover6millionpeoplewere sterilized in1976alone,more than thenumberofpeople sterilizedbyNaziGermanybefore1939.As resultof thispoliticalandadministrativepush,thenumberofsterilizationsrosefrom1.3millionin1974-75to2.6millionin1975-76andthenshotupto8.1millionin1976-77,alevelwhichhasnotbeenreachedsince.Sterilization‘quotas’leadtomanyabuses.28

In addition to the sheer number of coerced and forcedsterilizations, theway inwhich the sterilizationswereperformedwashasty,unprofessional,unsafe,andunsanitary. IthadlastingeffectsonthepublicperceptionoffamilyplanningpracticesinIndia.Theunsoundmethodsusedtoachieveridiculoussterilizationquotastarnishedthepublic’sviewofhealthworkers.Forexample,

28SoutikBiswas,“India’s dark history with Sterilization,” 14November2014<http://www.bbc.com/news/world-asia-india-30040790>Accessedon02.09.2017

25

whenin1977,fearandsuspicionledto“…massrefusaltoacceptimmunizationsfromthepublichealthinstitutions,fearingthatthesearesurreptitiouswaysofsterilizingchildren,[which]indicatesthedepthofthecrisisofconfidenceamongthecommunityaboutitshealth institutions.” The failedcampaignduring theEmergencyPeriodcontributedtostrongoppositiontofamilyplanninginIndia,whichcanstillbeseentoday.

FURTHER DOWN THE TIMELINE

Predictably,theexcessesduringEmergencygaverisetoabacklashthatresultedinthebitterlossoftheCongressGovernmentinthenextGeneralElectionandtheformationofanewgovernmentin1977.Thenewgovernmenttriedtoreducetargetsonsterilizationand relymoreon IEC, India’sFPP returnedwhen IndiraGandhiwas voted back into power in 1980: the health-based, time-bound,target-orientedFPPwasrevived.

During the 1980s, an increased number of family planningprogrammeswereimplementedthroughthestategovernmentswith financial assistance from the central government. In ruralareas,theprogrammeswerefurtherextendedthroughanetworkofprimaryhealthcentersandsubcenters.By1991,Indiahadmorethan150,000publichealthfacilitiesthroughwhichfamilyplanningprogrammeswereoffered.Fourspecialfamilyplanningprojectswere implementedunder theSeventhFive-YearPlan(1985-89).OnewastheAll-IndiaHospitalsPost-partumProgrammeatdistrictandsubdistrict-levelhospitals.Anotherprogrammeinvolvedthereorganizationofprimaryhealthcarefacilitiesinurbanslumareas,while another project reserved a specified number of hospitalbedsfortuballigationoperations.

Throughall of this, sterilization remainedaprincipalmethodofpopulationcontrol.Eventhoughthephaseofforcedsterilizationsen masse had passed, the state still continued to push andencourage thepopulation toopt for sterilizationby influencingthem with monetary provisions. However, with the horrors ofsterilizationcampsstillarecentmemory,menwouldoftenrefusetocome forward forvasectomyanddue to limitedavailabilityofspacingmethods,thetubal ligationofwomenbegantorise


26


steadily, eventually becoming the dominantmethod of familyplanning.

TheSeventhFive-YearPlan (1985-90)continued the traditionoftargetsetting,withincentivesbeingofferedtoyoungcouplestonot havemore than twochildren. Health officials cameunderseverepressurebythegovernmenttoreachsterilizationquotas,they responded in turn by pressuring women to undergo thisdrasticprocedurewith little regard to thepersonalwishesandsafetyofthepatient.Thisrepresentsaseriousabridgmentoftherightsandautonomyofthetargetedpersons.29

The InternationalConferenceonPopulationandDevelopment(ICPD)organizedby theUnitedNations in 1994, inwhich Indiaparticipated, restored some sanity to official policies andtemporarily slowed state aggression against women. Theconference concluded that, henceforth, population policiesshouldbeguidedprincipallybyconsiderationsof reproductivehealthandgenderequityratherthanbythemacro-demographicconsiderations and target-driven programmes whichunnecessarilyburdenwomenandaredrivenbythesoleconcernof fertility regulation.Asa signatory, Indiawas forced toadopttheso-calledReproductiveandChildHealth(RCH)approachtofamilyplanningandabolishtheexistingtargetbasedapproach.The targetdriven implementationof familypolicywasofficiallydiscarded in 1996 through the National Population Policy andsubsequentlyratifiedbytheparliamentin200030.

The abolishment of targets caused the prevalence of femalesterilizationtoslowdowninthelate1990s,althoughitremainedthedominantformofcontraception.Despitethis,therewasnotanoticeablechangeintheusageofIUDs,howeveruseofcondomsincreasedslightly.Ontheotherhand,theproportionofmarriedwomenwhohad reportedsterilization rose from27% in1992-93(NFHS-1)to34%in1998-99(NFHS-2)andfurtherto37%in2005-06(NFHS-3).Duringthisperiod,theproportionofmenwhoreported

29supran,p.97330 ibid.p.975

27

sterilizationfellfrom3.5%to1%.31Notonlyarewomenundergoingsterilizationinlargerproportionsbuttheyarealsodoingsoatanearlieragethanbefore.Between1992-93(NFHS-1)and2005-06(NFHS-3),themedianageofwomenwhentheyortheirhusbandsunderwent sterilizationdropped from26.6 years to 25.5 years32.Further,women’seducationissignificantlyassociatedwiththeuseofsterilizationascontraception–themoretheyearsofschooling,thelowertheoddsofoptingforsterilization33.

Nevertheless, despite official abandonment of target basedapproach, there is ample of evidence to suggest that unsaidandunspokentargetsremaintobeachievedbydoctorsontheground,ASHAworkersandothersof theirkin.Ambiguous termslike‘expectedlevelofachievement’reinforcetheideaoftargetsandincentivesatthegrassrootslevel.

Indiacarriedoutnearly4millionsterilizationsbetween2013and2014, according to official figures. Less than 100,000 of thesesurgeriesweredoneonmen.Morethan700deathswerereporteddue tobotched surgeriesbetween2009and2012. Therewere356reportedcasesofcomplicationsarisingoutofthesurgeries.Though the government has adopted a raft ofmeasures andstandards for conducting safe sterilizations, an unseemly hastetomeethighstate-mandatedquotashasoftenledtobotchedoperationsanddeaths.

China adopted institutionalized population control in the1980s,however theconditionsexperiencedby targetsof theseprogrammes did not approach the level of abuse inflicted inIndia.Therehavebeenreportsoftheappallingqualityoftuballigationformanyyearsnow,yetauthoritiesrefusetorecognizethisasanimportantreproductivehealthconcern.Thesedisreputablesurgeriescontinue,riskingthelivesofpoorwomen.

31BaliRam,‘FertilityDeclineandFamilyChangeinIndia:ADemographicPerspective’,Journal of Comparative Family Studies, Vol.43,Issue1,Jan-Feb2012,p.2332ibid33 L.K. Dwivedi, F. Ram and R.S. Reshmi, ‘An approach to understanding change incontraceptivebehaviourinIndia’,Genus, Vol.63,Issue3-4,Jul-Dec2007,p.39


28


The quality of services presented in India’s FPP has beenfar from satisfactory and has not improved over time. This isunsurprising as India’s allocation of funds for family planningservicescontinuously fallsbelow2%of thetotaldevelopmentalbudget despite seemingly high- level of official concern overrapidpopulationgrowth34.ThisisprobablywhyeventhoughtheIndiangovernmenthasonpaperaimedtoprovideachoiceofcontraceptive methods, the history of India’s FPP indicates itsfocusonpermanentmethodslikesterilization35.

Policymakershaveremainedblindtothepossibilitythataboldallocation of funds for FPP, especially if utilized towards IECandmotivationalefforts tocreateawarenessanddemand fortemporary contraceptive and spacingmethods, could createwideracceptabilityof familyplanningandsafeguardpeople’shealthandreproductiverightsthroughvoluntarycontraceptionmethods. Health officials’ ambivalence and half-heartedrecognition of the crucial importance of IEC, especially in thecontext of mass poverty and illiteracy, has beenmatched bythetypicalbureaucraticzealandpredilectiontowardsrecords,targets,numbersandincentives,therebylosingsightofthekeyfactthateffectivemotivationalanddemandcreationeffortsshouldprecedethepromotionoftheso-called‘cafeteriaapproach’totheprovisionofmoderncontraception36.

AleadingcauseofIndia’soverpopulationisahighfertilityrate.Ratherthanwaitingforeconomicdevelopmenttotakeitsslowand gradual course to curb a possible situation of populationexplosion, a well- planned and executed family planningprogramme can be the immediate answer. However, it is theapprehensionofapopulationexplosionandanirrationalurgencytocontrolthesamewhichdrivesthegovernmenttosettargetssoseverethatitresultsinanunfortunatecaseofharshbirthcontrolmeasures. This is mainly, due to the low budgetary allocation

34K.Srinivasan,‘PopulationpoliciesandfamilyplanningprogrammesinIndia:Areviewandrecommendations’,Proceedings of the fifth Dr. C. Chandrasekaran Memorial Lecture, IIPS Newsletter, Vol.47,Issue1-2,2006,pp.5-4135supran.1536supran.1,p.976

29

towards FPP, which indicates weak official willpower towardsrealizing individual families’needsandreproductiveautonomy.Asa result, thegovernment chooses to use female sterilization(whichisoftencoerciveormanipulative)astheprimarymodusoperandi to curtail population growth instead of encouragingandcreatingawarenessaboutdifferent spacingand limitationmethodsand temporary formsof contraception. It is the Statewhichthenbecomesthedecision-makingbodywhenitcomestothereproductivechoicesofacouple.

India’s FPP thus, unfortunately, remains characterized by anoverridingconcernfornumbers–asmeasuredbytherecruitmentof sterilization acceptors – frequently at the expense of higherquality,client-centeredservice37.Havingtarget-drivensterilizationastheflagshipofIndianfamilyplanningoftenresultsinahostofhumanrightsviolationsrelatingtorestrictedchoiceofmethods,lackofinformedconsent,deprivationofreproductiveautonomy,poorstandardsofhealthcareservices,unhygienicandunsanitaryconditionsat sterilizationcamps,etc.,whichwillbecovered inmoredetailinsubsequentchapters.

37M.A.Koenig,G.H.C.FooandK.Joshi,‘QualityofCareWithintheIndianFamilyWelfareProgramme:AReviewofRecentEvidence’


30


3. VIOLATIONS HAPPENINg ACROSS INDIA

“Coercive policies cannot be justified on any grounds; they violate human rights, gender justice, equity, and human dignity.” Indian FamilyWelfare Programme:AReviewofRecentEvidence’,Studies in Family Planning, Vol.31,Issue1,2000,p.12

Asthepreviouschaptershaveshown,sterilizationinIndiaisbesetwithmanyreproductivehealthrightsissuesandsocialproblemsthat are seemingly inherent in India’s family planning policiessince Independence.Thethebelief thatsterilization is thebest-suitedfamilyplanningmethodtotacklepopulationgrowthhasfar- reaching and detrimental implications. Indeed, the originsof its implementation in India is riddledwithfaultsandfallacies.

31

Indiacarriedoutnearly4millionsterilizationsbetween2013and2014, according to official figures. Less than 100,000 of thesesurgeriesweredoneonmen.Morethan700deathswerereporteddue tobotched surgeriesbetween2009and2012. Therewere356reportedcasesofcomplicationsarisingoutofthesurgeries.38

The year 2010-11 endedwith 34.9million total family planningacceptorsatnationallevelcomprisingof5.0millionSterilizations,5.6millionintrauterinedevice(IUD)insertions,16.0millioncondomusersand8.3millionO.P.usersasagainst35.6milliontotalfamilyplanningacceptorsin2009-10.Atotalof50.09Lakhsterilizationswereperformed in thecountryduring2010-11asagainst 49.98Lakhin2009-10.States/UTsviz.Assam,Bihar,Gujarat,Jharkhand,MadhyaPradesh,Orissa,Punjab,Arunachal,Manipur,Meghalaya,Nagaland, Tripura, Uttarakhand, Daman & Diu, LakshadweepandPuducherryhaveshownimprovedperformance in2010-11ascomparedto2009-10.39

Insteadof presenting sterilizationasa safealternative to otherfamily planning methods on a voluntary basis, there is anaggressivecultureofsterilizingpeopleinhordesundersubstandardconditionsinwhichasimplesurgerymayturnouttobefatalinitsconsequences.

Someof themajor issuesplaguingtheservicesof sterilization inIndiainclude:

I. Camp Culture

The horrors of the Emergency- era sterilization camps are alesson from which policymakers must learn. India has recentlydeveloped a system of administering sterilization, which Al-Jazeera has famously termed ‘camp culture’.40 To reach thecentrallydecidedgoals,peopleareoftenbrought inhordestosuchcamps.Sterilizationinthesecampshappensen masse,and

38Biswas,S.(2018). India’s dark history of sterilization.BBC News.Retrieved16February2018,fromhttp://www.bbc.com/news/world-asia-india-30040790.39FamilywelfarestatisticsinIndia2011-MinistryofHealthandFamilyWelfare,<http://mospi.nic.in/statistical-year-book-india/2011/199>accessed26.07.201740LisaLeBode,“Why Indian Women are victims of sterilization ‘Cattle Camps,”14November2014 <http://america.aljazeera.com/articles/2014/11/14/women-india-sterilization.html>,accessedon18.07.2017

Violations Happening Across India

32


tensandthousandsofpeoplearesterilizedoverthecourseofafewdays.While it is theadministration’s responsibility toensurethatsuchservicesareprovidedtosomanypeople,theirattitudeof the administration is largely careless and irresponsible, andtheyonlyremainedconcernedforthe‘numbers’,whichneedtobeattained.

Mostcampsonlyhavelimitedfacilitiesattheirdisposal,withlittleor nohelp from theadministration thesecampsmakedowiththe leastpossible requirements.Mostof thesecampsare tents,locatedinmakeshiftfacilitiessuchasschools,whichareinnowayequipped toadministerpreandpost-surgicalcare topatients,menandwomenalike.

Further,thesecampsareoftenconductedwithoutthepermissionofthestatemedicalauthorities,andinthosecaseswheretheyare sanctioned, thecampsareorganizedwithout adhering tothenecessaryrequirementsinvolvedinoperatingsuchacamp.It is also to be noted that these camps do not have qualityassurance committees, leading to unacceptable standards ofhealth,hygieneandsanitation.Theresourcesavailableforsuchprogrammes are extremely limited and the administration, byallowingthesterilizationstotakeplaceenmasse,furtherstretchestheresourcesout.Thus,duetoalackofanypost-surgicalcare,menandwomenareoftenleftbleedingafteroperations,oftencarriedoutusingold,unsterilizedinstruments.

ConsiderthecaseofAraria,Biharwhere53womenweresterilizedin a matter of mere hours in dirty, unhygienic conditions in amakeshift facility created in a school.41 Also consider the caseof West Bengal where, as mentioned in the article, ‘women[were]dumpedon[the]streetaftersterilizationdrive’.Here103women were sterilized at a disturbingly rapid rate in a ‘MegaLigationCamp’.42Themostinfamousinstanceofthecampsisin

41ShoumijitBannerjee,“Barrack-room surgeries in Bihar’s backwaters,”32January2012<http://www.thehindu.com/todays-paper/tp-opinion/barrackroom-surgery-in-bihars-backwaters/article2824008.ece>,accessed27.06.201742SoudhritiBabani,“Women dumped on field after Sterilization drive,”7February2013<http://indiatoday.intoday.in/story/women-dumped-on-field-after-sterilisation-drive/1/249324.html>,accessedon12.07.2017

33

Chhattisgarhwhere140womenweresterilizedinsimilarlydismalconditionsleadingtothedeathsofoveradozen,largelyduetosepticemia.43

The camp approach has attracted intense national andinternational condemnation for its perpetuation of genderand caste discrimination and flagrant, systemic violations ofGovernment mandated guidelines on the quality of care, asit is strongly associated with the sterilization of women. Thesepractices violate the standards for female sterilization servicesascovered in the ‘Standards for FemaleandMale SterilizationServices’ published by the Division of Research Studies andStandards, Ministry of Health and FamilyWelfare, Governmentof India inOctober2006.44Thisdocumentspecificallystatesthefollowingwithrespecttoestablishingthestandardproceduresforconductingfemalesterilizations:

Eligibilityofprovidersforperformingfemalesterilizations

Physicalrequirements

Caseselectionmethods

Clinical processes that include counselling, informed consent,preoperativeinstructions,andsurgicaltechniques.

Post-operativecare,whichalsorequiresacertificateofsterilizationtobeissuedbytheMedicalOfficer.

Despitegovernmentinitiatives,atleastonpaper,thepracticeofsterilizationiscarriedonwithoutmuchconcernforethicalvaluesorhumanlife.

Further, Human Rights Watch45 has reported that the familyplanningprogrammefocusesalmostentirelyonmarriedwomen,

43Medical Negligence, Sub-standard drugs cause Sterilization tragedy,”26August2015<http://www.firstpost.com/india/medical-negligence-sub-standard-drugs-caused-chhattisgarh-sterilisation-tragedy-panel-2409264.html>,accessedon29.08.201744MinistryofHealthandFamilyWelfare(ResearchStudiesandStandardsDivision),Governmentof India. (2018). Standards for Female and Male Sterilization Services. NewDelhi: NationalHealthMission,MinistryofHealthandFamilyWelfare.45HumanRightsWatchisanonprofit,nongovernmentalhumanrightsorganization


34


whilecompletelyneglectingthemaleresponsibilityandtheneedtoeducatetheyoungpeopleandadolescents,regardingsafesexpractices.Ithasbeenfoundthatthis‘campapproach’isnowbeingexpandedforinsertionofIUDsaswell.Further,fieldreportshaverevealedthatIUDsarebeinginsertedstealthilyafterwomengive birth in hospitals. Therefore, it is evident that the resultingdeaths,failures,complicationsandcoercioncausedbyfemalesterilizationhavegraveimplicationsforwomen’srighttolife,righttohealthandrighttoreproductivehealth.

II. Target- Based Approach

Unfortunately, despite the positive steps taken by the Statein the late90sand theparadigm shiftmarkedby theNationalPopulationPolicyof2000whicheliminatednumericaltargetsforsterilizationorthenumberofpeoplethatmustbesterilized,realityconfirmsthatdistrictandsub-districtauthoritiescontinuetoassignindividualannualtargetsforcontraceptives,withaheavyfocusonfemalesterilization.

Therefore, whilst ‘top-down’ targets have officially beeneliminated, this hasmerely been replaced by the emergenceof‘bottom-up’targetsandquotascouchedintheeuphemisticphrase,‘ExpectedLevelofAchievement’.Inpractice,State-levelauthoritiesanddistricthealthofficialscontinuetobepressuredtoachievetargetsthroughasystemoffinancialincentivesincludingmonetarypayments,orareotherwisethreatenedwithsalarycuts,negative performance assessment, suspension and dismissal.Numerous reports and studies confirm that grassroots healthworkers face immense pressure from their superiors to achievetargets.

AccordingtoHumanRightsWatch,severalhealthworkershavealleged that they were humiliated and verbally abused bytheir supervisors for not motivating enough women to acceptcontraception, threatened with salary cuts or dismissals whileothers were suspended from their jobs. Supervisors are not inregularcontactwiththelocalcommunityandhavenopersonalrelationshipwiththewomenthatthehealthworkersareseekingto motivate. They are therefore insensitive to the needs and

35

opinions of the women. The target-based system represents astate-sanctionedviolationofsexualandreproductiverights,andinevitably results in a substantial deterioration in the quality ofcare.

With high targets set for the ANMs and ASHA workers, whichotherwisemay result in them losing their jobs, their targets areusuallywomenwhohavehadtwochildrenwhoarebothmaleoratleastonethatismaleasthereisastrongson-preferenceinIndia.Thisalsoaffectsthesexratioadversely.OneASHAworkerinKhurdaregionputitthisway,“Wearerequiredtomotivateandbringincouplesforsterilization,andwetryourbesttodothis.Wedonotpersuadethoseclientswhohavedaughterstoconsiderthisoptionbutprefertofocusonthosewhohavealreadygivenbirth to boys. They aremuchmore receptive to themessage.Sometimesweevenmotivatethewoman’smother-in-lawtosendheracrossforsterilizationandsheimmediatelyagreesbecauseshe too does not want granddaughters.” (Women FeatureService).

Thenegativeimpactoftargetsonbasicreproductivehealthcareisfurtherhighlightedbythepracticethatlocalhealthworkerswilldedicatemostoftheirtimeonfulfillingtargetsandsubsequentlyspend less timeand resourcesondistributing timely supplies ofother contraceptivemethodsandonprovidingother essentialreproductivehealthservices.

III. gender- Bias

Thereisadeep-rootedgenderbiasagainstwomenwithinIndia’ssterilization programme. Instead of spending resources andenergyonmoreandeffectiveawarenessprogrammes,especiallyamongmen,thenationalandstatehealthbudgetsfocusmostlyontheadministrationofsterilizationservicestowomen.Infact,areporthadsuggestedthatvasectomies,orsterilizationsonmen,accountedforamere4%ofallsterilizationproceduresinIndia.46

46Mavalankar,Dileep;Sharma,Bharti,“The Quality of Care in Sterilization Camps: Evidence from Gujarat. : In Improving Quality of Care in India’s Family Welfare Programme“.PopulationCouncil.1999.p.293-313.ISBN0-87834-099-8


36


Further, another report suggests that less than one percent ofmenundergosterilizationprocedureswhilefouroutoftenwomenundergo tubectomy operations.47 Given that a vasectomy ismucheasierandsafertoperformthanatubectomy,thisreflectsaclearbiasagainstwomenandrepresentsadenigrationoftheirrights.

Alotofthereasoningbehindsuchbiasliesinthedefectiveideaofmanhoodandthepersistingsocialnormsofmasculinity thatfinditswaynotonlyintosociety,butalsointhepublichealthcaresystem. In a traditionally patriarchal society such as in India’s,anything that might affect any man’s masculinity or virility isconsidered taboo. For many, a man who undergoes such aprocedureisanoutcast,incapableofprocreatingchildrenwhomayextendhisline.Further,manyassociatesterilizationwithalossinsexualpotency.Thisattitudeisreadilysubscribedtobysocietywrit- largeandhaspermeated thegeneralpolicy strategiesofthehealthcaresystem.

Thisgenderbiasreflectsawidespreadbeliefthatwomencanbecoerced,orevenforcedintoasterilizationprocedure,ofwhichthey have no knowledge. Authorities believe that women areless likely tocomplainandare thereforeeasier targets for suchoperations. Accredited Social Health Activists (ASHA) workersfor instance, rarelyapproachmen toundergosuchsterilizationoperations.48

Suchabias,unconsciousornot,affectswomenwhoarepoorandunderprivilegedandwhobelongtominoritygroupsthehardestastheiraccessto information,education,and legal recourse isparticularlylimited.

IV. Lack of Informed Consent

Womenmakeeasy targets for sterilizationsbecauseauthoritiesbelievetheyare less likelytocomplainaboutsuchprocedures.

47 RakshaKumar, “India’s Lethal Contraception Culture,”8 February 2015 < http://america.aljazeera.com/multimedia/2015/2/female-sterilization-in-india.html>,accessed5.08.201748AditiMalhotra,“Why Indian Men don’t get sterilized,”13November2014<http://blogs.wsj.com/indiarealtime/2014/11/13/delhis-mega-vasectomy-camp-and-why-indian-men-dont-get-sterilized/>,accessedon3.07.2017

37

This is reinforced by a lack of information or the presence ofmisinformation related to sterilization procedures, leading tofurthercoercionandmisleadingactivity.

There have been cases where patients have been carted offfor‘minor’operations,onlytocomeoutincapableofbearingachildeveragain.49Ashealthcareserviceproviders, it isthedutyand responsibility of doctors, nurses and ASHAworkers to dulyinform suchwomen about the nature, consequences, positiveandnegativeimplicationsorsideeffectsofthesaidprocedure.Yet,asisthecasemostofthetime,theseprovidersfailtodotheirdutybysimplyskimmingthroughthedetailsoftheprocedureinarush,withoutadequatelyexplainingthemtothewomen.

Theissueisaccentuatedfurtherbythelowratesofliteracyamongrural women, who constitute the most significant populaceparticipating in thesaidsterilizationdrives.Thisdoesnot resolvethe issue even after the State hasmandatedwritten forms forconsentasmostofthesewomencan’treadorwrite.Itisthereforeleftforthesewomentotrusttheirhealthcareprovidersblindly,inanextensionofthatfaithplacedinadoctorbyhispatient.

V. Futility of Family Planning Indemnity Scheme

With sensitive operations such as a sterilization procedure, it isimportanttohavesomeformofaccountabilityagainstthosewhoareresponsibleforprovidingthesehealthcareservices.However,where suchprocedure is unsuccessful, punitiveactionsagainstsuchserviceprovidersresponsibleissorelylacking.

TheFamilyPlanningIndemnityScheme(FPIS),wasaschemetoensureaformofmonetaryrecoursetosuchafailureinsterilizationoperations.UnderNHMStateProgrammeImplementationPlans(PIPs)w.e.f.1stApril,2013,under theFamilyPlanning IndemnitySchemeithasbeendecidedthatStates/UTswouldprocessandmake payment of claims to beneficiaries of sterilization in theevent of death/ failure/complication and indemnity cover to

49 “Teen tricked Into Sterilization Surgery,”21 March 2015, <http://timesofindia.indiatimes.com/city/gurgaon/Teen-tricked-into-sterilization-surgery-was-told-it-was-vaccination-camp/articleshow/46641098.cms>,accessed3.07.2017


38


doctors/healthfacilities.ItisenvisagedthatStates/UTswouldmakesuitable budget provisions for implementation of the schemethroughtheirrespectiveProgrammeImplementationPlans(PIPs)in the relevant headunder theNationalHealthMission (NHM).TheschemeisuniformlyapplicableforallStates/UTs.

Afailure inthiscase includesdeathorpermanent injurytothepatient,aswellasacasewherea formofmonetary remain isable to procreate. For instance, under the scheme there is acompensationofRs.50,000toRs.2 lakhfordeathcausedbyasterilization procedure. Further, where a sterilization procedurehasfailed,thereisacompensationofRs30,000.

Section Coverage LimitsIA Deathfollowingsterilization(inclusive

ofdeathduringprocessofsterilizationoperation)inhospitalorwithin7daysfromthedateofdischargefromthehospital

Rs.2lakh

IB Deathfollowingsterilizationwithin8-30daysfromthedateofdischargefromthehospital

Rs.50,000/-

IC Failureofsterilization Rs30,000/-ID Costoftreatmentinhospitalandup

to60daysarisingoutofcomplicationfollowingsterilizationoperation(inclusiveofcomplicationduringprocessofsterilizationoperation)fromthedateofdischarge

ActualnotexceedingRs.25,000/

SECTIONII:EmpanelledDoctorsunderPublicandaccreditedPrivate/NgoSectorandHealthFacilitiesunderPublicandaccreditedPrivate/NgoSectorII Indemnitycoverageupto4casesof

litigationsperdoctorandperhealthfacilityinayear

UptoRs.2Lakhpercaseoflitigation

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However,theschemeitselfisbesetwithalotofproblems,whichinclude:

Patients are not made aware of and informed about theexistence of the scheme. The knowledge of those who havetheseproceduresperformedon themand theASHAworkers isrestrictedtotheamountofincentivemoneytheyareentitledtoafter such surgery,anotherexampleof theState’s failingeffortto fully inform the public. As a result, the provisions relating tothecompensationthatcanbeclaimedintheeventofadeath,failureorcomplicationsfollowingthesterilizationremainunknowntoamajorityofthepublic.

Intheeventofanycomplicationduetothesurgery,theacceptorslosetheirfaithinthegovernmenthospital’sfacilitiesandprefertoavailtheservicesataprivatehospitalwheretheythenmustshelloutexorbitantamountsofmoney.

AnotherissueisthelackofawarenessabouttheschemeamongtheGovernment officials. Health officials/service providers andASHAworkersthatareentrustedwiththeresponsibilityofcreatingawarenessaboutfamilyplanningarethemselvesunawareofthevariousfamilyplanningpoliciesofthegovernmentinplace.

EvenwhenFPISismadeknowntopeople,theentireprocessofclaiming compensation under the scheme is long-drawn andfraughtwithredtape.Theclaimprocess,despitebeinganurgentneed, is insteadmadecumbersomeanddraining for thepartyconcerned.

India’sadoptionof sterilizationhas several serious shortcomingswhichwillbeaddressedinthefollowingsection.


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4. FALLACIES WITH INDIA’S FOCUS ON STERILIZATION

“My name is Bikki Devi. I was operated in 2012 in the sterilization camp in Kaparfora Govt. School. I was not given any incentive by the government. I ended up spending from my own pocket.”

Asdiscussed inthepreviouschapters, there isnothingwrong inintroducingsterilizationprogrammesinthecountryasareliablemethod of family planning. However, while the initiatives maybe established with good intentions, their implementation isoften dramatically harmful. This may be attributable to thecomplete lackofpoliticalpoweramongst thosemostaffectedby the policies. Further, the problemswith the implementation

41

ofsterilizationinitiativesinIndiastemfromfallaciesandwrongfulmindsetsofthepeopleandthegovernment.

India’ssterilizationcampaignhasmostlyclaimedfemalevictims.That,inpart,isexplainedbythenatureofthemedicalprocedure—vasectomiesaresafer,medicalexpertssay,thantheoperationwomenundergo,whichinvolvescuttingandtyingfallopiantubesthroughakeyhole-sizedopeningintheabdomen.

Another explanation for Indian women’s victimization insterilization‘cattlecamps’liesinthesheerfigures,whichbegantoshiftradicallyinthemid-1990s.LessthanonepercentoftheIndianmalepopulationchoosestoundergothesterilizationprocedure,while nearly four out of ten women choose sterilization— thehighestpercentageintheworld,accordingtotheWorldHealthOrganization. Men’s reluctance, centered on cultural taboos,comes despitemore generous financial compensation for theprocedure: Inmoststates,menwhochoosetobesterilizedarepaidapproximatelyRs.2000/-bytheIndiangovernment.Women,ontheotherhand,typicallyreceiveRs.1400/-.

THE REALITy OF STERILIZATION PROgRAMMES IN INDIA

Thetruthofwhathappens inthenameofsterilizationhasquiteextensivelybeenexplainedinthepreviouschaptersofthisbook.Injusticeiswovenintotheimplementationofsterilizationpracticesin India, including compulsory sterilization, the continued issuessince thehorrific sterilizationcampaignof1975, theunhygienicconditions in which the operations take place, the lack ofmedicalcareincludinglackofpre-operativeandpost-operativeassistance for patients, the target-driven methods of botchedup operations, the lack of compensation for victims of failedsterilization operations, and the gross violation of human rightsthroughlackofinformedconsentandthedeprivationofchoiceforindividualsregardingtheirownbodies.

DiscussedbelowaresomeoftheissuespertainingtosterilizationsaspracticedinIndia.

Fallacies with India’s Focus on Sterilization

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THE FEMALE- CENTRIC NATURE OF STERILIZATION PROgRAMMES

India’spopulationcontrolpoliciescontinuetobewomen-centric,with female sterilizationbeing the largestmodeof interventionat 36 per cent, whilemale sterilization is amere 0.3 per cent,accordingtodatafromtheNationalFamilyHealthSurvey,2015-16.

Despite tubal ligations being riskier, more complex, and moreexpensive than vasectomies, sterilization efforts in India andaroundtheworldhaveoverwhelminglyfocusedonwomen.50InChhattisgarh,forexample,in2011-12,“1,27,114tubectomieswereperformedagainst just 6,765 vasectomies— thismeansalmost19timesasmanywomenweresterilizedasmen.”51Thetrend isthesameineverystate.AccordingtotheExecutiveDirectorofPopulationFoundationofIndia,PoonamMuttreja:

Tubectomies contribute to 38% of India’s family planningefforts while vasectomies are just 1%. There are strongsocial reasons, there is a myth that men lose their virilityor become weak after vasectomy and the governmenthas not done anything to dispel that notion. There arefewer trained people now that we have done awaywith the male health worker. We do not have targetsfor vasectomies but we have targets for tubectomies.Women undergo theprocedure in subhumanconditions.

Thistrendshowsagovernmentsupportedsystemthatplacestheburdenoffamilyplanningalmostentirelyonwomen’sshoulders.This system is accompanied by complete disregard for logicalandscientific reasons that sterilizationefforts shouldbeat leastequally,ifnotmore,focusedonmenduetothedecreasedrisks,costs,andtheeaseoftheprocedureformen.

Female sterilization remains the first choice for family planning

50LisaDeBodeon“WhyIndianwomenarevictimsofsterilization‘cattlecamps”,<http://america.aljazeera.com/articles/2014/11/14/women-india-sterilization.html>51Ghosh,A.(2014).Chhattisgarh:19timesasmanywomensterilisedasmen.The Indian Express.Retrievedfromhttp://indianexpress.com/article/india/india-others/19-times-as-ma-ny-women-sterilised-as-men-in-state/

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in India.Resultsof theNFHS-4 releasedby theUnionMinistryofHealth&FamilyWelfareconductedin2015alsorevealedthatthepercentageofmalesterilizationsurgery(vasectomy)isminuscule.

ThefemalesterilizationpercentageinAndhraPradeshstandsat68.3percentwhilemalesterilizationisbarely0.6percentwhiletheusageofpillsandcondomsremainsextremelylowat0.2percent.Thisiswhen62.9percentwomenand79.4percentmenareliterateinthestate.Karnatakarecordedahighnumberoffemalesterilizationsurgeriesat57.4percentwhilemalesterilizationwasoptedbymerely0.2percentofthosesurveyed.Only0.8percentusedpillsand1.7percentusedcondomsforspacingchildren.

ThesituationisnodifferentinTamilNaduwith55percentwomenundergoing sterilization surgery and merely 0.4 per cent menoptingforVasectomy.Pillsandcondomsareachoiceforbarely0.2percentwomen2.3percentmen.MadhyaPradeshfaresnowell,withusageofpillsat1.7percentandcondomsat4.8percent.Asmanyas 44.3percentwomenunderwent sterilizationsurgeryin2015.

ThefindingsofNFHS-4,2015-16forthirteenstates,includingAndhraPradesh, Bihar, Goa, Haryana, Karnataka, Madhya Pradesh,depictthatmarriedwomenaredevoidofusingmodernfamily-planningmethodsineightoftheFirstPhasestates/unionterritories.TamilNadualsorecordsanabysmalusageofcondomsat2.3percentandpillsat0.2percent.Femalesterilizationispreferredby55percentthough.InTelanganatoo,condomsandpillsareleastpreferred,withonly0.5percentpreferringcondomsand0.3percentbirthcontrolpills.

Figuresformalesterilizationhavebeenlowinpreviousgovernmentsurveys. NFHS-3 indicated that only 1 per cent of the currentlymarriedwomenreportedmalesterilizationasamethodoffamilyplanning.Thereporteduseofthemalesterilizationwasevenworsethan indicatedbytheNFHS-2during1998-1999.NFHS-2showedthat1.9percentmarriedwomenreportedmalesterilizationasamethodoffamilyplanningwhenalmostalltherespondents(97.4percent)wereawareofthemalesterilizationasafamilyplanningmethod.


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Whenwomenundergocompulsorysterilization,theyaremovedto sterilization camps where these procedures take place ina dangerously haphazard manner. Their treatment is oftencomparedtohowcattlearetreated,withoutmuchpropercareorcaution.Venuesofsterilizationarereferredtoas“cattlecamps”becauseoftheextremelypoortreatmentofwomenundergoingtheprocedurebyofficialsandmedicalpersonnel.

STERILIZATION DRIVES

In January 2012, the Times of India reported that theMadhyaPradesh government pressurised health workers in Indore toconduct3500proceduresinthreemonths.A16-year-oldboywhohadgonetothehospitalbecausehehadafeverwasinjectedwithsomethingthatmadehimloseconsciousnessandwhenhewokeup,hehadbeen sterilized. The statehad seta targetofsterilizing10%of thepopulation. InJabalpur, threepeoplewhohadalreadybeensterilizedin2011wereforcedagainin2012.

Sterilizationtargetsarewrappedbeneathabureaucraticveilbycallingthem“ExpectedLevelsofAchievement”.Thewomenwhoarethetargetsofthesesterilizationdrivesareeitherfromruralorsemi-ruralareasorslumsinthecitieswithASHAsandMultiPurposeHealthWorkersbeingtheirinterfacewiththehealthcenters.

TheASHAsandMultiPurposeHealthWorkersdonothaveafixedsalary systemandarepaidperdeliveryorper surgery, so theyareunderpaidandhaveuncertaintyof jobaswell. InMadhyaPradesh,workersaregiventheincentiveofwinningaNano(car)if theyget500people sterilized,a fridge for fiftypeopleandatengramgoldcoinfortwenty-fivepeople.Undertheiruncertaincircumstances, it iseasy that theyget luredbysuchoffersandmobilize women to achieve their sterilization targets withoutgiving them information of other available contraceptives.Hence,governmenthealthworkersareknowntolurepeopleforsterilization.Duetothepoorstateofgovernmenthealthfacilitiespeoplealsoprefertochoosethesecamps.

In the state of Tamil Nadu, which follows sterilization- centricfamilyplanningschemes,there isapatternofusing institutional

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deliveries to convince women to get sterilized while they arein labour. Southern states suchas Keralaand Tamil Naduareconstantlyshieldedfromcriticismandpushingfor improvementin healthcare practices as they are regarded as forward dueto good Maternal Mortality Ratio, sex ratio and Fertility Rate.However,doctorshereregularlysterilizewomenbetween18and21,which is in violationof theGovernmentof Indiaguidelines.Thestatehasmonopolyonmaternalreproductivehealthcare.Inoneinstance,awomanonlydiscoveredthatanIUDhadbeeninsertedinherafter20years.

LACk OF INFORMATION

India is a signatory of ICPD, committed to “voluntary andinformedchoiceandconsent”.Thisnecessitatesagovernmentefforttoeducateandseekthe informedconsentofallpersonssubjecttofamilyplanningschemes.Further,itistheconstitutionalright of all persons to haveaccess to sexual and reproductivehealth education and family planning information. Doctorsandnursesoftendisplayanabhorent levelofapathyandmayrefrainfromproperlycounsellingwomen.India’sfamilyplanningprogramme claims to follow a “cafeteria approach” with a“basketofchoices”.Themethod-mixinthisprogrammeincludesfive official methods — female sterilization, male sterilization,intrauterine contraceptive device (IUCD), oral contraceptives,andcondoms.HoweverfemalesterilizationandinsertionofIUCDaretheonlytwomethodspushedacrossbythestates.

Medicalhealthworkersfrequentlyuseinhumanelanguagesuchas‘wecan’tencouragethesewomen’and‘wemustdecreasethepopulation’.Saroj,aresidentofDelhi,explicitlystated,“Idon’twanttodothis”rightbeforetheprocedurebutshewasquicklyadministeredaninjectionthatrenderedherunconscious.Perhapsthis is because page 9 of the Standards for Female andMaleSterilizationServiceswhichdealswithGeneralAnesthesiastates“itmayberequired...incaseofanon-cooperativepatient”.Non-cooperative may be used synonymously with non-consensualandrobsapatientoftherighttosay‘no’.


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Additionally, the contraceptive and family planning needs ofyoungwidowsandseparatedanddivorcedwomenareignored.Contraceptiveand spacingmethodsarealsonotavailable tocouplesoutsidemarriage.In2003,India’sYouthPolicyrecognizedthat ‘information in respect of the reproductive health systemshould form part of the educational curriculum’. However, sexeducationstillremainsatopicthatistalkedaboutinwhispersinIndia.

TWO- CHILD NORM

The two-child norm is oneof India’s target-oriented, family-sizecontrolpolicies,whichencouragesparentsto limit their familiestotwochildrenandcreatesdisadvantagesforcoupleswithmorethan two children. Disadvantages include disqualification fromPanchayat council positions; denial of certain public servicesandgovernmentwelfareprogrammes, includingmaternalandchild health programmes. The two-child policy was modeledonChina’s one-child policy (1979), underwhich coupleswereforbidden from having more than one child. Politicians andleadersareexpectedtosetanexampleforothersbyadoptingthisnormthemselves,influencingthevillagestofollowsuit.Itwasbelievedthatthroughthetwo-childpolicy,thenationaltargetofreplacementlevelfertilityof2.1wouldbeachievedby2010.

Thepolicydisqualifiedanycandidatewithmorethantwochildrenfromrunningforalocal,municipal,ordistrictoffice.Governmentemployeesandlocalelectedrepresentativeswhohaveathirdchildwhileinofficewouldbeforcedtoresign.Asaresultofthepolicymanywomenwerebeencoercedintoresortingtoabortioninordertosavetheirjobsiftheyareovertheirtwo-childlimit.Inmanyplaceswhereatwo-childpolicyisineffect,maleelectedrepresentatives have abandoned or divorced their spouses inordertobeincompliancewiththepolicy.Othershavetakenasecondwifesoastobeabletohavemorechildrenandstillretaintheirgovernmentposts.

The state in India to adopt a two-child limit for governmentemployeesareAndhraPradesh,Odisha,Maharashtra,Rajasthan,Bihar, Gujarat, and Uttarakhand. Since in a country like India

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wheremeninamarriagealonedecidethenumberofchildren,many women have been forced to hide their pregnancies,registering their children under the names of their relatives orrefusingtoregisterthemaltogether,resortedtoabortiontosavetheirgovernmentposts.

The two child norm has been viewed as anti-democraticbecause it seeks toprevent people fromparticipating in localself-governanceaftertheyhavebeenelectedthroughpeople’smandate. This policy interferes with the reproductive rights ofindividuals because it prevents individuals from exercising theirrighttodecidethenumberofchildrentheychoosetohaveanddiscriminatesagainstyoungcitizens in their reproductiveprime,becauseitcreatesdistinctionbasedonnumberofchildren.

Just as sterilization should not be seenas apopulation controlmeasurealone, in a similar fashion, theaimof family planningprogrammesmustbetoenablecouplesandindividualstomakeinformedchoicesandavailabilityofsafeandeffectivemethods.The two-child norm, which is promoted as a family planningpolicy,robsanindividual’sfreedomtoreproductivechoicesandisdiscriminatoryinthatitsnon-compliancepreventsanindividualfrom participating in local self-governance and from holdinggovernmentjobs.Thisalsoleadstocomplicationssuchasforcedabortions, forced sterilization, sex-selective abortions, divorce,desertionsanddisowningofthethirdchild.Thishasanadverseeffecton the sex ratioaswell because in thewantofamalechild,moresex-selectiveabortionsarecarriedout.


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5. CASE STUDy OF TWO IMPORTANT SUPREME COURT RULINgS AND AN ANALySIS OF THE FALLOUT OF THE FPP IN RECENT TIMES

Sterilizationsurgeriesleadingtoseriousinfectionsanddeathsofyoungwomenacrossthecountry ledtothefilingofPIL intheSupremeCourtofIndia.SeveralreportsandsurveysweredoneontheappallingconditionsinGovernment-runsterilizationcentreswhereGovernmenthealthworkershadfailedtorespectbasicdignityoftheirpatients,highlightingdoctor’sfailuretoprovidecounselling towomenbeingbrought for sterilization surgeries,lackofoutliningalternativeformsofbirthcontrolorwarnaboutdangers associated with operation and health facilities thatfailedtorespectprivacyorconfidentialityofwomen.

RAMAkANT RAI VS. UNION OF INDIA, W.P (C ) NO. 209 OF 2003

The petition in this public interest litigation (PIL) case, which isknownas theRamakant Rai vs. Union of India, citedpracticesof female sterilizationby thegovernment in the States of UttarPradesh,Bihar,andMaharashtra.Eachcaseofsterilizationlackedcounsellingorinformedconsent,lackedpreandpost-operativecare, and included unhygienic and unanesthetized operatingconditions,sterilizationofminors,coercionandcruelty.

Thebasiccodeof human rights lawprotects the reproductiverightsofwomentohaveaccesstovoluntarysterilizationservicesfreeofcoercion,discrimination,andviolence.InApril2004,alegalmemorandumwas drafted based on the illegality of coercivesterilization, how it violates human rights law, and the possible

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remedialmeasure toaddress theabusesdone topoorpeoplethroughthecrimeofcompulsorysterilization.52

HumanRightsLawNetwork(HRLN)submittedthememorandumin support of its petition to the Indian SupremeCourt, allegingcoercion and abusive practices resulting from poor quality ofcareingovernment-runsterilizationcampsandfailuretocomplywithnationalguidelinesontheperformanceofsterilization,whichestablishmandatoryproceduresforobtaininginformedconsent.

InMarch 2005, the SupremeCourt ordered stategovernmentstotake immediatesteps to regulatehealth-careproviderswhoperform sterilization procedures, and to compensate womenwhosuffercomplicationsduetosubstandardpracticesandtherelativesofvictimswhodiedduetobotchedoperations.

Later, a Public Interest Litigation (PIL) was filed requesting theIndian Supreme Court to direct the Union of India (and all itssubsidiary bodies) to implement the Ministry of Health andWelfare’sGuidelinesonStandardsofFemaleSterilization,enactedin October 1999. This petition further sought compensation forvictimsofmedicalnegligenceinsterilizationprocedures,aswellasaccountabilityforviolationsoftheseguidelines.

Theobjectivebehindthispetitionwastomakeknowntheinjusticebeing done to poor and vulnerable women who underwenttheseprocedureswithoutanumberofessential rights includinginformed consent, pre-operative and post-operative care,hygienic facilities, anesthesia when appropriate, and freedomfromcoercion,cruelty,andsterilizationofminors.53Itwasfurtherassertedthatthecurrentsterilizationconditionsviolatednotonlythe guidelines, but also patients’ reproductive rights, women’srights,andhealthrightsasarticulatedininternationalinstrumentsratifiedby India, including theAlmaAltaDeclaration,CEDAW,the ICPD Programme of Action, and the Beijing Platform for

52 Ramakant Rai v. Union of India / Amici (Supreme Court of India), <http://www.reproductiverights.org/case/ramakant-rai-v-unionof-india-amici-supreme-court-of-india#>,accessedon5.08.201753 Ramakant Rai v. Union of India, W.P ( C) No 209 of 2003, <https://www.escr-net.org/caselaw/2013/ramakant-rai-v-union-india-wp-c-no-209-2003>,accessedon6.07.2017

Case Study of Two Important Supreme Court Rulings and An Analysis

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Action. The PIL further contended that the current conditionsviolatedpatient’sconstitutionalrighttohealth,whichisapartoftherighttolifeenshrinedinArticles14,15,21,and47oftheIndianConstitution.

Aninterimorder issuedbytheCourt inMarch2005pointedoutthe lack of uniformity of procedures and norms to ensure thattheguidelineswerefollowed.Thisresultedinthecasebeingleftopen.ThecourtorderedallstatesinIndiatoestablishimplementandfollowthefollowingguidelines:

1. Introduceasystemofhavinganapprovedpanelofdoctorsand limiting the persons entitled to carry on sterilizationprocedures in the State to those doctors whose namesappearonthepanel.Thepanelmaybepreparedeitheronastate-wise,District-wiseorRegion-wisebasis.ThecriteriaforincludingthenamesofthedoctorsonsuchpanelmustbelaiddownbytheUnionofIndiaasindicatedsubsequently.Until the Union of India lays down uniform qualificationcriterionfortheempanelmentofdoctors,forthetimebeingnodoctorwithoutgynecologicaltrainingforatleast5years’postdegreeexperience shouldbepermitted tocarryoutthesterilizationprogrammes.

2. TheStateGovernment shallalsoprepareandcirculateachecklist,whicheverydoctorwillberequiredtofillinbeforecarrying out sterilization procedure in respect of eachproposedpatient.Thechecklistmustcontainitemsrelatingto(a)theageofthepatient,(b)thehealthofthepatient,(c) thenumberofchildrenand(d)anyfurtherdetails thattheStateGovernmentmayrequirebasedontheguidelinescirculated by the Union of India. The doctors should bestrictlyinformedthattheyshouldnotperformanyoperationwithoutfillinginthischecklist.

3. ThestateGovernments shallalsocirculateuniformcopiesof the proforma of consent. Until the Union Governmentcertifiessuchproforma,forthetimebeing,alltheStatesshallfollowtheproformaasutilizedintheStateofU.P.

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4. Each State shall set up a Quality Assurance Committeewhichshould,asbeingfollowedbytheStateofGoa,consistof the Director of Health Services, the Health SecretaryandtheChiefMedicalOfficer, for thepurposeofnotonlyensuringthattheguidelinesarefollowedinrespectofpre-operativemeasures (forexample,bywayofpathologicaltests, etc.), but also operational facilities (for example,sufficient number of necessary equipment and asepticconditions)andpostoperativefollowups.ItshallbethedutyoftheQualityAssuranceCommitteetocollectandpublishsix-monthlyreportsofthenumberofpersonssterilizedaswellasthenumberofdeathsorcomplicationsarisingoutofthesterilization.

5. Each State shall also maintain overall statistics giving abreakdown of the number of sterilizations carried out,particularsoftheprocedurefollowed(consideringtherearedifferentmethods of sterilization), the age of the patientssterilized, the number of children of the persons sterilized,thenumberofdeathsofthepersonssterilizedeitherduringthe operation or thereafter, and the number of personsincapacitatedduetothesterilizationprogrammes.

6. TheStateGovernment shallnotonlyholdanenquiry intoeverycaseofbreachoftheUnionofIndiaguidelinesbyanydoctorororganizationbutalsotakepunitiveactionagainstthem.Asfarasthedoctorsareconcerned,theirnamesshall,pendingenquiry,be removed from the list ofempanelleddoctors.

7. The state shall also bring into effect an insurance policyaccordingtotheformatfollowedbythestateofTamilNaduuntil such time the Union of India prescribes a standardformat.TheUnionofIndiashalllaydownwithinaperiodoffourweeksfromdateuniformstandardstobefollowedbytheStateGovernmentsregardingthehealthoftheproposedpatients,theage,thenormsforcompensation,theformatofthestatistics,checklistandconsentproformaandinsurance.


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8. The Union of India shall also lay down the norms ofcompensation, which should be followed uniformly by allthe states. For the timebeinguntil theUnionGovernmentformulates the norms of compensation, the States shallfollowthepracticeoftheStateofAndhraPradeshandshallpayRs.1lakhincaseofthedeathofthepatientsterilized,Rs.30,000/- incaseof incapacityand in thecaseofpost-operativecomplications,theactualcostoftreatmentbeinglimitedtoasumofRs.20,000/-.

SIgNIFICANCE OF THE CASE:

First,thecourtissueddirectivesnotonlyfortheStateshighlightedin the petition but to the entire country. Second, the case isalso significantas theCourt underscored theneed for uniformguidelinesinperformanceofsterilizationproceduresforwomenandmen, including requirement of informed consent, punitiveaction for violations, and compensation for victims. Third, it isconsideredtobethelandmarkjudgmentforanythingregardingsterilization measures adopted in India and every case oncompulsorysterilizationsthatfollowedreferredtothiscaseasthebasisforstandardsofcareduringsterilizationprocedures.

AfterthedecisionoftheSupremeCourt,UnionofIndiapublishedthefollowingdocuments,manualsandreferencingmaterialstobeusedasguidelinesforallsterilizationproceduresthatfollowed:

“Standards for Female and Male Sterilization Services” (2006) –

The Government of India states in the manual that theDevelopment of Standards on Sterilization Services is animportant step in ensuring the provision of quality services.This document sets out the criteria for eligibility, physicalrequirements, counselling, informed consent, preoperative,postoperative, and follow-up procedures, and proceduresfor management of complications and side effects. It alsohighlightsthesalientstepsofthesurgicalproceduresandtherecommendedpracticesforinfectionprevention.

Thisprovides,interalia,fordoctorstobeputonapanel,thephysical infrastructure required, informedconsent, and that

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thewomenshouldbemarried,bebetweentheagesof22-49years,andhaveatleastonechildabovetheageof1year.This manual explains the nature of counselling that shouldtakeplace soan informeddecisioncanbemade.Womenarealsorequiredtobeinformedofalltheavailablemethodsoffamilyplanning,andthattheyhavetheoptionofrefusal.In the procedure for operations, it is inclusive of medicalexamination and monitoring after the operation. The post-operative care requires that thewomen be kept overnightatthefacility.Itisstatedthatallfailuresofcomplicationsarerequiredtobedocumented,thatcleanlinessbemaintained,andthatequipmentandsuppliesbesterilized.

Standard Operating Procedure for Sterilization Services in Camps (2008) –

The formulation of Standard Operating Procedures (SOPs)for Sterilization Camps was to ensure provision of qualityservicestotheclientsincamps.Itenvisagedthatprogrammemanagers and service providers would be encouraged totakeappropriateremedialmeasuresforensuringadherenceto standards in thecampsas laiddown in the “Manual onStandardsformaleandfemalesterilization”byGovernmentofIndia.TheStandardOperatingProcedureswouldalsoserveasaguideforplanning,implementingandmonitoringqualityof services in sterilization in a camp setting, for programmemanagers, camp managers and service providers at alllevels.Thisdocumentmayalsobefoundusefulbytheservicedeliveryorganizationsengagedinorganizationofthecamps,includingNGOs.

Thismanualextensivelyhighlightedtheoperatingproceduresto be followed in camps,which includes the camp timingsandthenumberoflaparoscopictubectomyoperationsthatcanbeperformedinoneday,andmandatesthatsterilizationcamps can be organized only at established healthcarefacilitiesaslaiddowninthestandardsofGovernmentofIndia.

The major elements included in the SOP are the range ofservicesinacamp,pre-requisitesforsterilizationcamps,roles


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and responsibilities of programme managers and serviceproviders, conduction of camps, prevention of infection(asepsisandantisepsis),andtheassuranceofqualityincampsettingandthemanagementofemergency.

Standards & Quality Assurance in Sterilization Services (2014) –

‘Standards and Quality Assurance in Sterilization Servicescoalescethefourmanuals(‘StandardsonFemaleandMalesterilization, Quality AssuranceManual, StandardOperatingProcedures’forsterilizationservicesincampsand‘FixedDayStatic’ 2008) into one without diluting any of the contentsand at the same time strengthening with new technicalknowledgeand learningfromthefieldsothattheoutcomeis a comprehensive manual which touches all aspects ofsterilizationservicesinIndiaandactasaonestopreferenceforall issuesconcerning standards,qualityassurance, skilledprovisionofservices,logisticsandsupplies,indemnitycoverageand robustmonitoringprotocols. Themanualhasalsobeenmadeuserfriendlyforalllevelsofthehealthsystem.

Thismanualensurestheprovisionofqualityservicestotheclientsbyprogrammemanagersandserviceprovidersprovidingpermanentmethodsofcontraception.Thisdocumentsetsoutthecriteriaforeligibility, physical requirements, counselling, informedconsent,pre&post-operativecare, follow-upprotocolsandproceduresformanagement of complications. It also highlights the salientpre-operative, operative and post-operative instructions of thesurgicalproceduresandtherecommendedpracticesforinfectionprevention.Italsoservesasaguideforassessingservicequalityandenableprogrammemanagers and serviceproviders bothin thepublicsectorand inaccreditedprivate/NGOfacilities toprovidequalitysterilizationservicesandtotakeremedialmeasureswhereverdeficientforensuringadherencetostandardsinservicedelivery.Inaddition,aframeworkfortheprocessofpaymentofcompensation for unforeseen situations such as complications,failures,deaths,arisingoutofsterilizationprocedureforclientsaswellasserviceproviders,hasbeenspecifiedindetail.

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The standards laiddown in thismanualapplies toboth ‘static’and‘camp’mode.Thisdocumentincludestheeligibilitycriteriaof thepatientsandhowtocarryoutcounsellingand informedconsent/choice.

“Manual for Family Planning Indemnity Scheme (FPIS) (2013)”–

The “Family Planning Indemnity Scheme” was developedwithanobjectiveof providinga framework for theprocessofpaymentofcompensationfordeath/failure/complicationscases arising out of sterilization failures for acceptors andindemnitycoverageforserviceprovidersbothinthepublicandintheaccreditedprivate/NGOfacilities.Themanualhighlightscertainpaymentsmadeby thegovernmenton sterilization,thecompensationpaidforlossofwages,transportation,diet,drugs,dressing,death,failure,etc.Themanualalsocarriestheprocedureforclaimsettlement.

UndertheFamilyPlanningIndemnityScheme,itisenvisagedthat States/UTs would make suitable budget provisions forimplementation of the scheme through their respectiveProgrammeImplementationPlans(PIPs)intherelevantheadunder the National Health Mission (NHM). The scheme isuniformlyapplicableforallStates/UTs.TheschemeprovidesacompensationofRs50,000–Rs2lakhfordeathcausedbyasterilizationprocedure.Further,whereasterilizationprocedurehasfailed,thereisacompensationofRs30,000.

“Reference Manual for Female Sterilization” (2014)

Thesemanualattemptstolaydownuniformstandardsinthesurgicaltechniquetobeadoptedbyalltrainingcentersandservicedelivery facilities. Themanualalsoaims toequip theserviceproviderstoscreenclients,counselthemondifferentmethodsofcontraception,andperformminilap tubectomyandlaparoscopictubalocclusionsafely.Themanualenablesproviders to recognize and manage potential problemsas well as provide appropriate follow-up. It also lays downuniformstandardsfortrainingacrossthecountryincorporatingmanagement aspects of conducting training in female


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sterilization, layingdowncurriculaand settingupof trainingcenters.

INFORMED CONSENT

Informedconsentinthecaseofsterilizationproceduresmaybedefinedastheprocesswherehealthcareprovidersarerequiredtodiscloseallappropriate information to thepatient regardingthe medical procedure to be undertaken. In other words,informed consent is where consent is so sought after havingprovidedsuchpatientwithallrelevantinformation,includingbutnotlimitedtofacts,details,circumstances,necessity,alternativesandcomplicationsthatmayaccompanyamedicalproceduresuchassterilization.

Informed consent implies that the information provided to theclient iscomprehensive,thattheclienthasfullyunderstoodtheinformation, and that the client freely consents to adoptinga particular method. For consent to be valid, it is the duty ofthe provider to ensure that the client understands the giveninformation.AstheDeclarationofHelsinkinotes,“afterensuringthat the subject has understood the information, thephysicianshouldthenobtainthesubject’sfreelygiveninformedconsent”.54

Informed consent originates from the legal and ethical rightthat,thepatientmustdirectwhathappenstohis/herbodyandfrom the ethical duty of the physician, doctor, or surgeon toinvolvethepatient inherhealthcare.Themost importantgoalofinformedconsentisthatthepatienthasanopportunitytobean informedparticipant inherhealthcaredecisions.Ordinarily,informed consent, regarding a sterilization procedure, wouldrequirethattheattendingdoctororsurgeoninformthepatientofthefollowing:

1. The nature and purpose of the proposed method ofsterilization

54 Touitou, Y., Portaluppi, F., Smolensky,M. H., & Rensing#, L. (2004). Ethical principles andstandardsfortheconductofhumanandanimalbiologicalrhythmresearch.Chronobiology international,21(1),161-170.

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2. Therisksandbenefitsassociatedwiththesaidmethodofsterilization

3. Alternativestosuchmethodofsterilization4. The risksandbenefitsassociatedwith thealternatives to

thesaidmethodofsterilization5. The risksandbenefitsassociatedwithnot receiving such

treatmentorsterilizationprocedure

These pre-conditions to satisfy the criteria of informed consentadditionallymayormaynotincludeanassessmentofthepatient’sunderstandingofthesaidsterilizationprocedure,includingallofitsrisksandbenefits,aswellastherisksandbenefitsassociatedwithsecondarysterilizationproceduresaswell.

INDIAN STERILIZATION SERVICES’ NOD TOWARDS INFORMED CONSENT

As Ms. Rajalakshmi and the Population Council’s Report55 oninformedconsentinIndia’scontraceptiveservicesnotes,evidenceoftheextenttowhichconsentincontraceptiveservicesinIndiais truly informed is limited. The sparse evidence available fromthe literatureonqualityofcare in reproductivehealth servicesinIndiasuggeststhatinformationprovidedtoclientsisgenerallyincompleteand superficial. Likewise,anecdotalevidence fromIndiasuggeststhatinformedconsentisoftenmisunderstoodandperceivedasamereformality,thatis,ofobtainingasignatureonaconsentformratherthananongoingprocessthattakesplacebetweentheproviderandtheclient.Evenwhereaconsentformissigned,itisnotclearwhetherprovidershavemadetheefforttoensurethattheclienthasunderstoodtheinformationprovided.

Thisisparticularlyunsettlingbecausetheproceduresofsterilization,likeVasectomyandTubectomyaresupposedtobepermanentmeasuresofcontraceptionanda failure toadequately informthepatientaboutthesaidprocedurewillleadtodistressingandunwarranted consequences for the said patient. It is therefore

55 Ram Prakash, Rajalakshmi, Indian journal of medical ethics- Reducing reproductive rights:spousal consent for abortion and sterilization,Vol.4,pp.102-3,2007


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of utmost necessity that the client must be informed aboutthe array of alternative options to sterilization, including non-terminal methods, and the comparative benefits and risks ofeachmethod,sothatshecandecidewhethershewouldliketoundergosterilizationornot.

Informed consent however, is not a concept or a procedureindependentfromanyotherarmsofthedelicateprocedure.Infact,theargumentcanbemadethatinformedconsentispartandparcelofevery stageof the sterilizationprocess. That saidprimarily, thequestionofwhatconstitutes informedconsent,orthatqueryinghowinformedconsentisadministeredandensuredisonethatarisesduringtheprocessofcounselling.

Section 1.4.1 and 2.4.1 of the Standards forMale and FemaleSterilization Services defines counselling as, “the process ofhelping clients make informed and voluntary decisions aboutfertility.”Informedconsent,ensuresthatthevolunteerorpatientsare made aware of all information regarding all proceduresinvolved,beforemakinganychoiceordecisionandistherefore,anintegralpartoftheentiresterilizationprocess.

Tocontinuequoting1.4.1oftheStandardsofMaleandFemaleSterilizationServicesinverbatim,

General counselling should be done whenever a client hasadoubt or is unable to takeadecision regarding the typeofcontraceptivemethodtobeused.However,inallcases,method-specificcounsellingmustbedone.

Thefollowingstepsmustbetakenbeforeclientssigntheconsentform:

1.4.1.1.Clientsmustbeinformedofalltheavailablemethodsof family planning and should bemade aware that for allpracticalpurposesthisoperationisapermanentone.1.4.1.2.Clientsmustmakeaninformeddecisionforsterilizationvoluntarily.1.4.1.3.Clientsmustbecounseledwhenever required in thelanguagethattheyunderstand.

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1.4.1.4. Clients should bemade to understand what wouldhappenbefore,during,andafterthesurgery,itssideeffects,andpotentialcomplications.1.4.1.5. The following features of the sterilization proceduremustbeexplainedtotheclient:• It is a permanent procedure for preventing future

pregnancies.• Itisasurgicalprocedurethathasapossibilityofcomplications,

includingfailure,requiringfurthermanagement.• Itdoesnotaffectsexualpleasure,ability,orperformance.• Itwillnotaffecttheclient’sstrengthorherabilitytoperform

normalday-to-dayfunctions.• SterilizationdoesnotprotectagainstRTIs,STIs,orHIV/AIDS.• Clientsmustbetoldthatareversalofthissurgeryispossible,

but that the reversal involves major surgery and that itssuccesscannotbeguaranteed.

1.4.1.6.Clientsmustbeencouragedtoaskquestionstoclarifytheirdoubts,ifany.

1.4.1.7. Clients must be told that they have the option ofdeciding against the procedure at any timewithout beingdeniedtheirrightstootherreproductivehealthservices.

Further,1.4.4oftheManualadditionallydoesstipulate,albeitbrieflyguidelinesrelatedtoInformedConsentregardingmaleandfemalesterilizationservices.ToquoteSection1.4.4,

1.4.4.1. Consent for sterilization operation should not beobtainedundercoercionorwhentheclientisundersedation.

1.4.4.2.Clientmustsigntheconsentformforsterilizationbeforethesurgery

Itcan thereforebe inferred that Indian sterilization servicesarenot immunetothe ideaof informedconsentandthattheveryconcept is not alien to India’s persistence with sterilization, intheoryifnotinpractice.


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THE REALITy OF INFORMED CONSENT FOR STERILIZATION

Ithasbeenprovenbythemanycasesofill-informedconsent,notonlyamongthemediabutasconcludedbyseveralindependentfact-findingmissionsaswell.Tochecktheimplementationofthisguideline andwhether the ‘informed consent’ is genuinely aninformedone,whetherthebeneficiarieshavebeencounseled,informedandmadeawareofwhat is the surgeryabout,whatwill happenpre, duringandpost op, about thecomplicationsandsideeffectsthatmayoccur,areexplainedindetail.Further,onemustalsopayattentiontothefactthat,theconsentgivenis voluntarilyorof theirownwilland isnotacoercedoneor istakenwhentheclientisundertheinfluenceofdrugsetc.andtheconsentofthatsamepersononwhomthesurgeryistobedoneistakenandnotoftheirspouse/guardianetc.

Incidents of poor counselling and sterilization camps wererecordedbyNGOsandmedia indifferentpartsofthecountry.Some arementioned below to understand the realities at thegroundlevel:

1. On23.05.2012,KolayatHospital in the stateofRajasthansterilized 72 women. The same hospital had earlierbeen reported to have sterilized another 42 women on25.04.2012.Thesesterilizations,alldoneenmassewere inviolationof theguidelineswhichprescribe that nomorethan30 sterilizationsmaybedonebya teamwith threelaparoscopes in a single day. Further, the women werenotputunderpost-operationobservationfortherequiredperiodofthreehours. Intheabsenceof recovery rooms,theywere forced to lie on the crowdedanddirty floorsofcorridorsforrecovery.Noneofthesewomenhadeverbeen counseled on any other forms of contraception.Further,over80percentof thesewomenstated tohavebeenunconsciouswhendischarged.56

2. In an incident dated 05.02.2013 in the Manikchak RuralHospital in Malda, West Bengal, 103 women were

56TheHorrorsof India’sPopulationControlProgrammes” issuedby theCaravanMagazine,Accessedon12.11.2014

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sterilized in ‘Mega Female Minilap Ligation Camp’ bythe State authorities. As per the written record, threedoctors conducted 103 Minilap operations. The hospitalwas used as amakeshift facility for the sole purpose ofsterilizationandhadacapacityofonly60bedswithdirtyandtornmattressesthustheasepticpartwascompletelyoverlooked.Thepatientsweremadetolieontheopendirtygroundsofthehospital inapainful,semi-consciousstate,attendedtoonlybyconcernfamilymembers.Therewasnoadequatecounsellingregardingwhatwillhappenbefore,during,andafterthesurgery,itssideeffects,andpotentialcomplications, including failure. The consent forms onwhichwomengavetheirconsentfortheoperationswerenottranslated inthe local languageandwere inEnglish.There were no post-operative examinations conductedor any post-operative instructions given to the women.There were no discharge cards indicating the name ofthe institution, thedateandtypeofsurgery, themethodused,andthedateandplaceoffollow-upasmandatedbyMOHFWgiventothewomenafterthesurgeries.Itwasinthisregard,thatlocalhealthofficialsacknowledgedtheappallingconditionsoftheprogrammeandnoticesweresentbytheNHRCtotheDistrictMagistrateinMaldaandthePrincipalSecretary,WestBengal.57

3. Inacontinuingtrendofmedicallaxityandnegligence,intheMandi district of Himachal Pradesh on 12.12.2014, adrunkendoctorperformedfivesterilizationsandfellasleepduringthecourseofhissixthlaparoscopictubectomyinthePrimaryHealthCareCentreinthevillageofThunag.Itwasinformedthatthedoctorhadlockedhimselfupinaroomtosleepwhileheleftthesixthpatientaftertheadministrationofanesthesia.Thedoctorinquestionwascreditedtohaveperformedhundredsofsurgeriesoverthepastfewyears.However,thesaiddoctorwaslatersuspendedanditwasfurthersuspectedhehadapreviousrecordofintoxication

57Mukherjee,A.(2013).103womensterilisedinadayatWestBengalhospital;probeordered.NDTV India.Retrievedfromhttps://www.ndtv.com/india-news/103-women-sterilised-in-a-day-at-west-bengal-hospital-probe-ordered-512610


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atworkandhadalsofallenasleepduringthecourseofaprevioussterilizationprocedure.

CRITICISM OF INDIA’S PRACTICE OF ‘INFORMED CONSENT’

India’smuchmaligned sterilizationprogrammehas, in its literalsenseandformseachoftheseduties.Additionally,itwouldseem,thatIndia’ssterilizationdrive,inspiritattheveryleast,understandswhatexactly‘informedconsent’meansandimplicates.However,it isunlikely toamount toanythingunless themanydrawbacksof it are addressed urgently. Some limitations and handicapsof India’spracticeof ‘informedconsent’ in its sterilizationdriveinclude,

1. As is requiredbytheguidelines issuedbytheApexCourtinRamakant Rai v. Union of India,volunteersmustsignaconsentformbeforegoingthroughsterilization.However,thereremainmanywhocannotreadorwriteandtherefore,the contents of the same are not understood by suchvolunteers. Further, therehavebeencaseswherehealthofficialshaverefusedtoclarifywhatwaswritteninthesameandthus,consentwasgivenwithoutanunderstandingoftheconsentform.

2. Anothercriticismisthefactthatalotoftheconsentformsgiven to volunteers before going through the operativeproceduresofthesterilizationwerenotinthelocallanguageof the community resulting which, many of whom whowereliterateintheirlocallanguagehadtogiveconsenttotheprocedurewithoutmuchclarityandunderstanding.Asisoftenthecase,ASHAworkersarelefttosigntheconsentformsonthebehalfofthevolunteers.

3. It has been reported that even where health officialand ASHA workers have informed the volunteers of thesterilization process, they aren’t informed adequately orenough.Infact,accordingtoareportbythePopulationResearchInstitute,34%(1in3)ofallwomenwhohadbeensterilized admit that they were not told that tubectomywas permanent in nature. Further, 68% of all women sosterilized were never informed about the side effects or

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possiblecomplicationsthatmayariseoutofaprocedureasdelicateas tubal ligation. There isa failure toprovidecomprehensive informationabout theprocedureand itsalternativesbyhealthcareofficials.

4. As has been exhibited by fact-finding missions acrossIndia,comprehensiveknowledgeoftheentireprocessofsterilization is still leftwantingamonghealthcareworkers.ASHAworkersoftendonotpossesscompleteinformationon the procedure. This calls for a review of the traininggonethroughbysuchworkers.

5. Sincesterilizationoftenhappensinhordesandenmasse,thereisalotofpressureonhealthcareofficialstomeetthe‘expected levelofachievements’ for theday. Thereforeoften, concerned volunteers do not always get theopportunity to properly address and clarify any doubtstheymayhave.

6. Motivating people to undergo sterilization has becomeverytarget-oriented,whichiswhytherehavebeencaseswhere ASHAworkers and other healthcare professionalshavemisinformed volunteers so that theymay undergosuchprocedures,apracticethatisalsoethicallywrong.

7. Due to theoftenpatronizingandsubservient relationshipbetween a volunteer and the doctor, volunteers oftenagreetowhateverthedoctormayrecommend,withoutseekingtoclarifyanydoubtstheymayhaveand‘trusting’their doctors. Here, such consent is not informed but isinstead,aconfirmationofthevolunteer’sconfidenceinhisdoctor.

8. Therehavealsobeencaseswherefamilymembersgaveconsentonbehalfofthevolunteer,apracticethatdoesnotconstituteinformedconsent.Healthcareofficialsmustensure that the volunteer gives suchconsent voluntarily,freeofanyinfluenceandontheirown.


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FAMILy PLANNINg INDEMNITy SCHEME (FPIS)

TheFPISwasaresultoftheculminationofeventswhichledtothePILinRamakant Rai & UP & Bihar Health Watch vs. Union of India,apetitionagainsttherampantabuseandnegligentsterilizationsofwomenincampsacrossIndia.

The Family Planning Insurance Scheme is one of the initiativeslaunchedunderdirectionfromtheHon’bleSupremeCourt,witha view todoawaywith thecomplicatedprocess ofpaymentof ex-gratia to the acceptors of sterilization for treatment ofpost-operative complications, failure of sterilization or deathattributabletotheprocedureofsterilization.TheFamilyPlanningInsuranceScheme(FPIS)wasintroducedinNovember2005withOrientalInsuranceCompany,totakecareofsuchcases.

Theschemewasfurthermodifiedinprocedurew.e.f.01-04-13to31-3-2014,andwasapartofStateProgrammeImplementationPlans (PIPs) under NRHM and renamed as Family PlanningIndemnityScheme.Theavailablebenefitsareasunder:

Eligible beneficiaries/ doctors/ health services providers:

a.AllpersonsundergoingsterilizationoperationsandsignedtheConsentFormarecoveredunderSectionIA,IB,ICandID.

b. All the Doctors/Health Facilities including Doctors/HealthFacilitiesofCentral,State,Local-SelfGovernments,otherPublicSectorsandall theAccreditedDoctors/HealthFacilitiesofNon-Government and Private Sectors rendering Family PlanningServices and conducting such operations shall be indemnifiedagainst theclaimsarisingon themoutof failureof sterilization,deathormedicalcomplication.

ThoughtheSupremeCourtrulingintheabovementionedPILwasinplace,wediscussthefalloutsofthestillhorribly implementedfamilyplanningprogrammes,especiallythesterilizationsdrivesinplaceslikeArariainBiharandChhattisgarh,whichhaveresultedinthemanyunnecessarydeaths,thesetwoplacesare justtwoexamplesofsuchpracticeswhichtakeplaceacrossthecountry.

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DEVIkA BISWAS VS UNION OF INDIA WPC 95/2012

“In clear violation of nearly all the guidelines, governmentAccredited Social Health Activist under National Rural HealthMissionworkersrecruitedbetween50and63belowpovertyline,scheduled caste and other backward class women for NGO(Jai Ambe Welfare Society) sterilization camp at GovernmentMiddleSchool,Kaparfora,onJanuary7.NeithertheNGOnorthesurgeon conducted pre-operative tests to determine suitabilityoftheenlistedwomenforsterilization,”allegedBiswas,whohailsfromArariaandclaimedtobeaneye-witness.”

BACkgROUND- ARARIA STERILIZATION CAMP

According to official figures, India carried out nearly 4 millionsterilizations during 2013-2014. More than 700 deaths werereportedduetobotchedsurgeriesbetween2009and2012with356 reported cases of complications. Though theGovernmenthas adopted standards for conducting safe sterilizations, anunseemlyhastetomeethighstate-mandatedquotashasoftenledtobotchedoperationsanddeaths.Therehavebeenpersistingreports of the horrifying quality of tubectomies but authoritiescontinue to disregard it as an important reproductive healthconcern.Oneof such similar incidents,whichcaughtmuchofmediaattentionand subsequently led to the filingof PIL,wasDevika Biswas vs Union Of India & Others(WPC 95/2012).

On thenightof 7th January2012,a singledoctor sterilized fifty-threewomenintwohourswiththehelpofunqualifiedstaff.ThecampwasorganizedatKaparforaGovernmentMiddleSchool,inArariaDistrictofBihar,whichdidnothavebasicamenitieslikerunningwaterandsterilizingequipment.

ThewomenthatwerebroughttothecampbelongedtoBelowPoverty Line (BPL), ScheduledCaste (SC)andOtherBackwardClasses(OBC).Thecampwasorganizedincompleteviolationoftheguidelineson“StandardOperatingProceduresforSterilizationServices in Camps” laid down by the Supreme Court andGovernmentofIndia.TheStateofBiharauthorizedalocalNGO“Jai AmbeWelfare Society” to organize the camp. The camp


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was conducted after school hours, when the staff had left fortheweekend.Thesurgeonperformedtheoperationsfromabout8pmto10pminunhygienicandcruelconditions.

Local inhabitants of Kaparfora and nearby villages came toknow about the sterilization camp when the women (whowereeventually sterilized)were swayedbyASHAworkers. Theywere persuaded and lured for free sterilization operation andfreemedicinebutnoneofthewomenhadanyideawhatthatactuallymeant.

WomenalongwiththeASHAsandtheirguardiansstartedpouringin from 12:00 noon. None of the women received any healthcheckupsorcounselling.Theywerenotinformedofothermethodsoffamilyplanningorofwhatwouldhappenbefore,during,andafter the surgery, its side effects, and potential complications.EyewitnessesreportthattheNGOhadmadenoarrangements.The patients were kept waiting from noon till 8:00 pm for thedoctor.Theyweregivenanesthesiaoncethedoctorhadarrivedandweretakentothemakeshiftoperatingtheatreingroupsoffourwithintenminutes.

The classroom being used for the procedures had not beencleaned; the school desks being used as operation tableswithout being disinfected; and the doctor did not change hisgloves between procedures. Operations were carried out byan all male staff in the dim bulb and torch light and no postoperativecarewasgiven.Post surgery, theyweremade to lieonstrawthattheirguardianshadarrangedfor.Asaresult,threewomenwere leftprofuselybleeding.OneofthesewomenwasadmittedtothenearbyPHCwheresheremainedforeightdays.Another woman, who was operated on despite being threemonthspregnant,miscarried justdaysafter theprocedure.Thesurgeonleftimmediately,leavingtheminthehandsofthreestaffmembersoftheNGO.All53womensufferedexcruciatingpain.Theyweregivenexpiredpainkillers forpainmanagement.Withnofurthermedicalcareavailable,theywereforcedtoseekoutprivate practitioners, incurring heavy out of pocket expenses.Exasperated by the callous attitude of the NGO workers, thepublic nabbed the three of the NGO staff and phoned to

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registertheircomplaintswithMOICandthepolice.Noneofthewomenhadreceivedanyofthepromisedcompensation.Policeinvestigationrevealedthattheschoolauthoritieshadnotbeenaskedfortheuseofthepremisesasasterilizationcamp.Mr.DilipVerma, school in charge, said that his staff had vacated thebuildingby11:30amonthedayofthecampandwereunawareof its useover theweekend. The Superintendent of Police,Mr.Lande,raidedtheNGO’sofficesandfoundforgedstamps,videosandphotographs.ThevillageMukhiyasaidthatheinquiredtheNGOstaffof“whatweretheydoingandiftheyhadanyorderwith them”. The staff informed him that they had the requiredpermissions forconductinga sterilizationcamp. TheNGOstaffalsoinformedthatsincetheydidnothavecash,theywouldbegivingfreemedicinestopeople.

Throughout India, rural women are routinely dehumanized bythe unsanitary conditions of sterilization camps. The incident inArariahighlightedthepatternofviolationsthatoccurfrequentlyin Kaparfora. The Government of India strictly prohibits thepracticeoforganizingcamps in schooland states that “undernocircumstances should SterilizationCampsbeorganized inaschoolbuilding/PanchayatBhavanoranyothersuchsetup”.

Most of the women were within the prescribed age group of22to49yearsbutseemedunderageandanemicduetotheirfrail physique and malnourishment. The doctor’s absence forpostsurgicalcasewasinviolationofthegovernmentguidelineswhichsaythat“womenwillbedischargedonlyafteraphysicalexaminationbythedoctorhasbeencompleted,iffoundtobesatisfactory after the women come back to their senses, andwhentheyhaveanattendantwiththem”.

A series of complaints were filed and they were registeredat Kursakanta Police Station on 8th January 2012 being S.DENo.135/12, 136/12, 137/12 and 144/12. State investigations intothecomplaintconcludedthatthecampwasasuccessalthoughwomenhadadmittedlybeenprovidedexpiredmedication. Infact,thePrincipalSecretaryofHealthforBihar,Mr.AmarjitSinha,theDistrictMagistrate and theCivil Surgeon issued statementsthatthecampwasconductedaccordingtotheGovernmentof


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IndiaguidelinesandpraisedtheNGOanddoctorforajobwelldone.However,investigationscarriedoutbyDevikaBiswasandjournalistFrancisElliottconcludedthatthesterilizationcampdidnotmeetanyoftherequirementslaiddownbytheCourtortheGovernmentofIndia.

Even though theMinistry of Health and FamilyWelfare clearlystatesthataclientcanonlybedischarged:“afterat least fourhoursofprocedure,whenthevitalsignsarestableandtheclientisfullyawake,haspassedurine,andcanwalk,drinkortalk.Theclienthasbeen seenandevaluatedby thedoctor.Whenevernecessary, the client should be kept overnight at the facility”;noneoftheabovementionedinstructionswerefollowed.

In consonance with the Ramakant Rai judgment, the CentreissuedguidelinesthatmustbefollowedinsterilizationproceduresalloverIndia:

a.QualityAssuranceManualforSterilizationServices(2006)b.StandardsforFemaleandMaleSterilization(2006)c. Standard Operating Procedures for Sterilization Services incamps(2008)

These give explicit instructions regarding the place wherethe camp must be conducted, the timings, the number ofproceduresasurgeonisallowedtoperforminaday,therequiredpre-operative screening tests, selection criteria of the women,steps tomaintainahygienicandsterileenvironmentandpost-operativemandates,checklists tobemaintainedand forms tobeexplainedtothewomen.

Ms.DevikaBiswas,aHealthRightsActivistsandnativeofArariafiledpublicinterestlitigationunderArticle32oftheConstitutionofIndia,relatingtoviolationofthedirectionsissuedbythisHon’bleSupreme Court in Ramakant Rai vs Union of India and Others (Writ Petition (Civil) No. 209/2003) wherein the Supreme Courtaddressedrampantforced,unsafesterilizationandtarget-drivenpracticeof‘sterilizationcamps’inIndiathathadresultedintoanincidentwhichcompletelyviolatedthewomen’srighttolife.

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Thepetitionhighlightswrongpracticesemployedbythestatetoachievesterilizationtargets,whichisdiscouragedbytheSupremeCourtandtheNationalPopulationPolicy,2000.Italsounderlineshowsterilization isviewedasa ‘populationcontrolmeasurebythehealthcarepersonnel rather thanawayof safeguardingawoman’sreproductiverights.

TESTIMONIES OF WOMEN

1. Saraswati Devi, 28 years old woman, three children- 2 girls and 1 boy.

SaraswatiDevivisited thecamponlyafterbeingmotivatedbytheASHAworkerwhohadspreadinformationaboutthecampin her village. She was aware of what sterilization meant andsinceshealreadyhadthreechildren,shewantedtoundergotheprocedure.Saraswatisaidthatshewasforcedtowaitatthecampfromnoonuntilthedoctorfinallyarrivedat8p.m.Itwasthenthatthefourwomenweregivenanesthesiaandquicklytakeninside.Saraswatiunderwenttheprocedureatapproximately8:30p.m.

Saraswatisharedthatshewasmoreor lessdrowsy,butnotfullyconscious so she did not knowwhat happened. She becameconsciousonlyaftermidnightwhen she startedcryingoutwithexcruciating pain and noticed that therewas bleeding. Therewasnobodypresentwhocouldtendtoher.Thedoctorleftthecampsoonafteroperationsataround10:30pm.TherewerethreemenleftbehindwhowerefromtheNGO.Themedicalteamleftwith the doctor. Hence, there was nomedical help availablewhenwomenstartedwakingupbleedingand inpain.Hence,shecalledherfamilywhocontactedthePHCandtookhertothehospital.

Saraswati testified that the operationswere carried out in dimlightfromatemporarygeneratorandthroughtheuseofatorch.In two hours sixtywomenwere operated upon. Saraswati wasplacedonhayonthefloorfollowingthesurgery.ShewastoldthatshewouldbegettingcashmoneyandmedicinesworthRs.600/-.Butinsteadofcashmoney,theyweregivenexpiredNimesulide,whichwasapainkiller.Saraswatihadtobeadmittedinahospitalon8thJanuaryandwasdischargedonthe15th(ofJanuary).


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2. Jitni Devi, 25 years old woman, sterilized at Araria Camp.

JitniDevihastwochildren.Shecametoknowaboutsterilizationcamp through the ASHA worker who persuaded her of theprocedurealthoughshehadnoknowledgeofsterilizationortheprocedureshewastogothrough.Althoughshewasinformedthatthecampwouldbeginby12noon,itwas9:00or10:00pmwhensheunderwenttheoperation.JitniDeviwasgivenaninjectionat8:00pm.Shewasveryscaredandkepthereyesclosed.Shehadnoideaofwhathappenedtoherorwhodidwhat.

JitniDeviwaspregnantatthetimeofsterilizationoperation.Shewas told that shewouldstillgivebirthbuta fewdaysafter theoperation,shehadamiscarriage.JitniDevididnotknowthatshewaspregnantandwasonlyinformedofherpregnancylaterbythedoctorwhoperformedthesurgery.JitniDevistatedthatshewasplacedonthehayonthefloorpostsurgeryandherpainhadbecomeunbearable.Shehasnotbeengivenanymoney.

3. A woman sterilized at the Araria Camp (name not provided)

Thiswomanhastwosonsandonedaughter.Heryoungestchildwas two years and six months old at the time of sterilizationoperation.Shewenttothecampbecauseshewaspersuadedbyahealthworkerwhotoldheraboutthesterilizationoperation.Since she had three children already, she wanted to get anoperation. She reached thecampbynoonandwaiteduntil 8pmwhenshewasgiventheanesthesia.

She testified that there was no pre-screening and after theoperation, they were not given any certificate. She, like otherwomen,wasmadetoputherthumbimprintonapaper,withoutbeinginformedthatitwasaconsentform.

Thedoctordidnotconsultwithanyofthewomen.Uponarrival,he immediatelyproceededwiththesurgeriesandhadalreadyperformed three operations within a mere 10 minutes. Thesaid woman was understandably terrified and anxious as sheunderwent a delicate procedure without the proper requiredcounselling.Shewokeupinimmensepainandrealizedthattherewasnodoctorpresentforpost-surgicalcare

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Shewas also informed that shewouldn’t get anymoney andwouldinsteadbegivenmedicine.Later,thesaidwomanhadtoseektreatmentfromaprivatedoctor.

4. Reika Devi, 32 years old woman, sterilized at the Araria Camp:

ReikaDevihasthreechildren,twogirlsandoneboy.ShecametoknowaboutcampfromanASHAworkerwhoimpelledhertocometothecamp.SinceReikaalreadyhadthreechildren,shewantedtogetanoperation.Reikareachedthecampataround5:00pmandhadanoperationat9:00 in thenight. Shearrivedlatebecause sheexpectedadelay in thecommencementoftheprocedure.Shelivedamereeightkilometresawayfromtheschoolwherethecampwasbeingheld.Thewomenwereplacedondesksfortheprocedureandmadetolieonhayafter.Reikawoke up to profuse bleeding and agonizing pain. Her clothesweresoaked inblood.Althoughthestaffwaspresent, theydidnotconsiderherconditionasseriousanddidnothingtohelpher.Thelocalsfinallycametoheraidandbandagedthewound.Shewasforcedtoseektreatmentataprivatemedicalfacility.

5. Dauchna Devi, 22 years old, woman sterilized at the Araria camp.

Althoughshedidnotwishtoundergothesterilizationprocedure,Dauchna went the camp due to pressure from her guardian.Shebecamedrowsywithanesthesiaandwasmadetolieonthefloor.However,shewasnotcompletelyunconsciousandcouldstill hearand see.DauchnaDevi shared that thewomenwereoperatedintheclothesthattheywerewearing;thedoctorhadonlyanapronandgloveson.

WhenDauchnaDeviwokeup,shehadintolerablepain.ShedidnottakethemedicinegivenbytheNGOstaffbutshetookthepainkillerathome.

OBSERVATIONS MADE By DEVIkA BISWAS

1.S.P.LandecouldassessthattheaccreditedNGOwasrunningarackettomakemoneybyusingforgeddocumentaryevidences.Hewanted theguilty tobepunished,butwasperhapsunable


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toseethattheentirehealthsystemwasfaultyandinviolationofSupremeCourtguideline.

2.AllHealthDept.personnel (frompresentno.ofKursakata,ExMOlC,DrRPraset,CSDrHusanaAraBegum,Mr.RehamPMO,Araria, Mr. Hoda Reg DP MO and ACMD and other officials)triedtodefendtheaccreditedNGOsirregularitiesbecausetheywantedtohidelapsesinthesystem.

3. The villagers and relatives of the Kaparfora stated that noadvertisement or information was given to them about thesterilizationcampbutthereisevidencethatASHAworkersluredtheeligiblecouplesforsterilizationcamp.ThevillagersquarreledwiththefiveNGOworkerstogetmedicalhelpandcompensationpackages,whichtheydidnotgive.TheyinformedthepoliceandSPLandetocouldget justice.Theydidnothowevermakeanywrittencomplaints.

4.Mostofthewomenwhoweresterilizedwerefrompoor,DalitandOBCfamilieswithsubstandardhealthconditions.Thereisadireneed for familyplanningandmarginalizedpeoplewantafree treatment facility. Theywait for sterilizationcamps for freeproceduresandsincetheyarelargelyignorantoftheirrights,theyacceptwhatever servicesandcompensation theygetwithoutquestioning.Inthisinstance,uponrealisationofthepoorqualityofservicesthroughSPLande’sinvestigation,theyreadilytestifiedtoallfact-findingteams.ObservationofProceduralViolationsthattookplace inKaparforaGovernmentMiddleSchool inthe lightof thesanction/accreditationorderof theofficeofDHS,Araria(MemoNo1165/Arariadated29.11.2011):

The following directives have to be followed compulsorily

Compliance by the organizing agency

Adherence of Governmentof India’s Quality AssuranceManualforSterilizationServices(2006) – all directives given inAnnexureC,Clause2.

Did not adhere to allguidelines.

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Availability of all physicalconditionsas perGovernmentofIndia’sStandardsforFemaleandMaleSterilizationServices.

No, it was not carried outin any government healthfacility.Rather,itwascarriedout in a school where allthese facilities were notavailable.

Camp organized at anygovernment health facility,SHC/ Additional PHC, PHC/CHC/ Referral and districthospitals.

No. It was carried in aschool,floutingtheSupremeCourt’sorder.

Camp to be organizedpreferably between 9AM to4PM.

CandidateswithASHAandguardians started pouringin from 12AM. Besidesenlistmentandgettingtheirthumb impression on blankconsent form, no healthcheckup,andinvestigationwere done with singlesterilized women. Theactualoperativeprocedurestartedatabout8PMonthearrivalofOperatingDoctor,A.K.Chowdhury.Thus, all operation carriedout under dim bulb light,andtorchlightsfrom8.00to10.00PMon7.01.2012.

Availability of fully equippedambulance for referral serviceatthecampsite.

No ambulance wasavailable.


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Discharging women only afterphysical examination by thedoctoriffoundtobesatisfactoryafter the women come backtotheir senses,andwhentheyhaveanattendantwiththem.

The doctor himself left theplace at night soon afterall operations were over,without checking anysterilized women and nogovernment health staffwas there at the campsiteatnight.

Adherence to age limit forsterilization, and carryingadvertisementforthesame.Agelimitforsterilization:Men:22yearsto60yearsWomen:22yearsto49years

Most of the women wereof the prescribed age butdue to their frail physicalframeandmalnourishment,seemed under age andanemic. ASHA workers didmobilizepeople.

The upper limit for sterilizationcases to be handled bysingle surgeon is 50. If morecases come for sterilization,the number of doctors to beincreasedaccordingly.

This norm was violated;as per the government’sown guidelines. The singlesurgeon operated 53sterilization cases in thecamp,onthatday.

Same as condition number 2,regardingOTfacilityandotherphysicalinfrastructures.

Not adhered to, as it wasa makeshift temporaryarrangement. Violation ofallhygienicconditions.

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Prior plan approval from CSoffice with copy to MOIC ofthatareaunit.

Perhaps it was done as itwas in the knowledge oftheCS.Dr.RajendraPrasad,the then MOIC, Kursakata,gaveastatementtopolicethat all operations weredone under his supervision.Even, involvement of ASHAconfirms that the healthdepartment had priorknowledgeandapproval.

The supervision of camp tobe done at the venue onthe fixed date and time bythe concerned MOIC/MO/BHM/BCM, and also supervisegivingall details ofmanpower(with name, address, anddesignation).

Though the health officialsonly accepted that alloperationtookplaceunderthedirect supervisionofDr.Rajendra Prasad, the thenMOIC, Kursakata, but theyaresilentaboutotherteammembers and about theteam of NGO involved inthework.Theirqualification,age, address, designation,notmadeavailable.

The MOIC /MO/BHM/BCM ofthe concerned area wouldverify and attest the numberof sterilization cases done asper the QAC manual (page-13) and only after doing thatwould put his or signature onthe sterilization register at thecampitself.

The health departmentcertifies that 53 sterilizationstookplaceunderthedirectsupervision of the MOIC. Itimplies that he has verifiedattestation and put hissignatureonthesterilizationregisteratthecampsite(thepublic did not see him onthe7thatthecamp).


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The accredited organizationhas to do the photography/videographofthebeneficiariesofsterilizationcampcompulsorilyandtosubmitwithinthreedaysall activity reports photocopyof the sterilization register, allphotographsandvideototheoffice

Perhaps no photographyor videograph beenconducted this time. It hasnot been confirmed fromanysource.Toshootvideosat the camp seemedviolatingprivacyofwomen.

TheconcernedMOIChave tosubmithisreportontheseconddayofthecampcertifyingthenumber of sterilized person toDHSoffice

Information could notbe obtained regardingsubmission of report.However since the thenMOICandCS,bothcertifiedthat53casesof sterilizationtook place, it implies thattheyhaveMOIC’sreportattheDHSoffice.

As per the letter number 4437dated 26.6.2007, of SHS; theregister has to be maintainedat campsite by only thegovernmentstaff.

Thepeopledidnotseeanygovernment health staff,exceptASHAhealthworkerson 7.01.2012. It was onlyafter Police intervention,people saw the MOIC, aswell as, CS, and DPM, on8.01.2012. So it is amysterywhether any governmentstaff maintained suchregisteratall.

The concerned organizationwould get Rs.1500/- persterilizationcase.

Thiscouldnotbeverified.

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All conditions are mandatoryand obligatory for adherencebytheorganization.

Underthedirectsupervisionof government officials,all main conditions wereoverlooked. Hence, thegovernment themselves,are at fault. Rather, theysuppressed facts, saying allworkwasdoneaspernorm.Thereshouldanexplanationprovided regarding whyblatant violations aretaking place all over India,particularlyinBihar.

The Supreme Court Case- Devika Biswas vs Union of India WP(C) 95 of 2012

DevikaBiswas,(MA,Econ.PGDip,PM&IR), isanativeofArariawith an extensive professional experience in the developmentand health sectors. She has worked in Uttar Pradesh, Delhi,JharkhandandBiharinhercapacityasahealthrightsactivistandhasalsobeenassociatedwiththeIntegratedChildDevelopmentSchemeinBihar.Shehaspublishedarticlesandbooksinherfieldof specialization and is a public spirited individual. Ms. Biswasfelt theneedtofileaWritPetition in thepublic interestagainstthe rampant forced and unsafe sterilizations after the Biharsterilizationcamp. Thepetition raisedconcerns regardingStategovernment’smanagement of sterilization procedures, lack ofpre-operationandpost-operativecare.Ms.Biswaswascompelledthatthispetitionshouldensurethatsterilizationsnation-wideareconductedasperthe legalnorms,propermedicalproceduresandtheprovisionsof themanualssetbytheSupremeCourtofIndia.ShealsowantedthatthevictimsinBihartoshouldreceivecompensationfortheirinjuries.

The petition highlighted that despite the extensive guidelinesanddirections issuedbytheHon’bleSupremeCourtof India in


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thematterofRamakant Rai (I) & Anr. v. Union of India & Ors58inhumanesterilizations,particularlyinruralareas,continuedwithrecklessdisregardforthelivesofpoorwomen.SterilizationsinthestateofBihar,thecasestudyinthewritpetition,showedthatthemosthorrendouspracticespersistincontemptoftheRamakantRaidirectionsandviolationofguidelines(theGovernmentofIndiapublishedaQualityAssuranceManualforSterilizationServices(in2006);StandardsforFemaleandMaleSterilization(in2006);andStandardOperatingProceduresforSterilizationServicesinCamps(in2008).

Disregardingthesestandardsandqualityassuranceguarantees,mosthealthfacilitiesdonotmeetminimumstandardsinregardto staff, services, infrastructure, equipment, drug supply, andrespectforpatient’s’rights.Sterilizationoperationscanbedonein a respectful, ethical, and healthy way under the StandardOperatingProceduresandQualityAssuranceControls.However,in complete disregard of the Supreme Court’s orders, theConstitutionofIndia,andtheSterilizationGuidelinesoutlinedbytheMinistry of Health, inhumane sterilizationswere observed inBiharandthroughoutthecountry.

The petition further covered similar violations in not only BiharandbutalsoinallotherRespondentStates(UnionofIndia,Bihar,JaiAmbeWelfareSociety,AndamanNicobarIsland,ArunachalPradesh,Assam,Punjab,Goa,Delhi,Gujarat,Haryana,HimachalPradesh, Jammu & Kashmir, Jharkhand, Karnataka, Kerala,Maharashtra,Manipur,Meghalaya,Mizoram,MadhyaPradesh,Nagaland, Orissa, Puducherry, Rajasthan, Sikkim, Tamil Nadu,Tripura,UttarPradesh,UttarakhandandWestBengal).

ThefilingofpetitionwasfollowedbyStateHealthSocietyissuingamemorandumon9thFebruarytotheCivilSurgeonineachdistrictpermittingprivatehealthfacilitiestoconductsterilizationcampsinplacesotherthanaccreditednursinghomesaslongasthereis“requisitequalityassurance.”

TheStateHealthSociety,Bihar,alsoissuedfinancialguidelines:foreachsterilizationoperation,thegovernmentwillpaythefacility

58(2009)16SCC565

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fee(Rs1350)andthemotivatorfee(Rs.150),butwillnotcoverexpenses for equipment, management, or transportation. TheempanelleddoctorwillreceiveRs.75foreachsurgery.

On 8 Feb 2012, the Civil Surgeon issued a report praising thecamp,withoneexception:theexpiredmedicines.On10January2012,thePrincipalSecretaryofHealthfortheStateGovernmentofBihar,Mr.AmarjitSinha,calledapressmeetingtodiscussthecamp.HeusedtheCivilSurgeon’sreporttodemonstratethatallsterilizationsfollowedgovernmentstandardsandguidelines.

Followinga10January2012letterfromtheDistrictMagistrateforAraria,M.Sarvaran,states:

• Under the supervisionof theKurshakantaMOIC,M.B.B.S.,Dr. Ajay Kumar Chowdhary performed sterilizations on 7January2012.

• ThesterilizationswereconductedatacampsponsoredbyanaccreditedNGO.

• Thefacilityhadadequateroomsforthecamp.• Nopatientscomplainedaboutthecamp.• FIRshavebeenlodgedwiththepolice,andaninvestigation

hascommenced.

ThewritpetitioninitiallywasconcernedwithresponsesfromUnionof India, StatesofBihar,Kerala,MadhyaPradesh,Maharashtraand Rajasthan due to incidents of mass sterilizations reportedin these states. However, numerous other allegations surfacedduringthecourseofhearing.

Themassacre in Biharwas not an isolated incident. Evidencesof similar rampant fundamental rights violation and deaths insterilization campswere submitted from states ofWest Bengal,Rajasthan, Madhya Pradesh, Kerala, and Uttar Pradesh. ThesituationinMaharashtraindistrictssuchasNagpur,ChandrapurandGardhchirolihighlightedtheplightofwomenwhowerebeingsterilizedincampswithpoorinfrastructure,unsafeandunsanitaryconditions on routinely basis. The PHCs lacked the provisionof Blood Bank, no transport facility, inadequate counselling


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for sterilization services; inadequate replacement equipment;inadequatebasicsupplies-womenandtheirfamilieshavebeenforcedtopurchasetheirownsuppliesincludingstitches.

InMadhyaPradesh, afterChiefMinister Shivraj SinghChouhandeclared 2012 as the year of family planning, some districtcollectorsseemedtohavetossedtherulebooktothewindstomeet their targets. Theofficials luredandmisguidedprotectedtribalswithdwindlingpopulation into sterilizationwithmonetarygainofRs1,100asanincentive.Twoofthesetribes,GondsandKorkus,aredesignated“primitive”,whosenumbershavedwindledby11%werenotspared.RehkaWasnik,apoor labourer’swife,amotherofsix,wasbroughttoBalaghatthedistricthospitalonFebruary9forsterilization.Shewastwelveweekspregnantwithtwin girls. Rekha died hours after she began bleeding on theoperation due to sheer negligence. Her post-mortem reportdescribed “external and internal bleeding” in her uterus frominjuriescausedbyasharpandpointedinstrumentasthecauseofherdeath.

During the course of hearing of this writ petition, allegationssurfacedwithregardtosterilizationcampsconductedinBilaspurdistrict,Chhattisgarh[between8thand10thNovember2014]andtherewerealsoconcernswith theallegationsmade in respectofthecampsconductedinthatStateaswell.[The details of the incident explained in subsequent chapters]

InadditiontothesegraveviolationsofArticle21,14,and15,DevikaBiswasdocumentednearuniversalfailuretocomplywithUnionofIndiaGuidelinesoninformedconsent,hygiene,infrastructure,orpost-operativecareduringsterilizationcamps.AdditionalaffidavitswerefiledinthispetitioninJuly2012withevidenceofcontinuingandwidespread sterilization surgery related fundamental rightsviolations. InFebruary2013, therespondentsfiledarejoinder totherespondentswhohadreplied.InMay2013,thePetitionerfiledasecondrejoindertoadditionalstatesthathadreplied.

Notice in the writ petition was issued on 2nd April 2012 andthereafterthepetitionwastakenupforactiveconsiderationonlyon30thJanuary2015whentheSocialJusticeBenchofthisCourt

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wasseizedofthismatterandaftercompletionofpleadingsandinstructionsreceivedbythelearnedAdditionalSolicitorGeneralfromtheUnionofIndia.

On30thJanuary2015, learnedAdditionalSolicitorGeneral fromthe Union of India completed the pleadings. The petitioner’scounselsuggestedforastatusupdateofimplementationofeachdirectiongiveninRamakant Rai (I) & Anr. v. Union of India & Ors withdetailsrelatedtotheimplementationoftheFamilyPlanningIndemnityScheme,2013particularlywithregardstothereleaseandutilizationoffundsunderthesaidscheme.

STATES RESPONSES REgARDINg IMPLEMENTATION OF RAMAkANT RAI gUIDELINES:

Amajority of the 37 respondentsmade submissions in reply tothe original petition.Most of the states have failed to provideconcreteevidenceanddocumentationtosupportgenericandsweeping statements that the Centre’s guidelines are beingimplemented. ThePetitionerfiledadditionaldocumentsaswellasrejoinderaffidavitsinreplytotheRespondents.

TheStateresponsescanbebroadlysummarizedasunder:

1. Union of India

UOIdidnotplaceon recordwhether Statesanddistrictswereimplementing theRamakantRaiguidelines. Itclaimed tohaveempanelleddoctors,uploadedmanualonStandardandQualityAssurance in Sterilization Services, 2014 including StandardOperatingProcedure forCamp,ReferenceManual for FemaleSterilization, 2014, Reference for Male Sterilization, 2013 andmanual for Female Planning Indemnity Scheme, 2013 on thewebsiteofMinistryofHealthandFamilyWelfare.Asperoneofthedirectionsgivenby theSupremeCourtof India (Ramakant Rai v UOI)thestategovernmentsweretocirculateuniformcopiesoftheproformaofconsent.EventhoughtheStateGovernmentagreed to have circulated uniform copies of the proforma ofconsent,therewasnomentionofcomplianceornon-complianceofguideline.Merelyissuingformsdoesnotensureimplementationandenforcementofguidelines.


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UOIstatedthataQualityAssuranceCommitteewasestablishedtoensurethatguidelinesarefollowedforpre-operativemeasures,operationalfacilities,andpost-operativefollowups.Therewasnoinformationprovided if statesweremaintainingoverall statisticsgivingabreak-upof thenumberof the sterilizationcarriedoutandparticularsoftheprocedurethatshouldbefollowed.Therewasnodatasupplied.

UnionofIndiaintheiraffidavitdidnotmakeanymentioniftherewereanyenquiriesheld intocasesofbreachbyanydoctorororganizationoranypunitiveactiontakenagainstthem.Itmerelyclaimed that the Government has carried out an audit; theaccountsareopentotheinspectionoftheCAGandtheinternalauditoftheMinistryofHealthandFamilyWelfare.Thegovernmentdidnothaveanysupportingevidencetotheirclaims.

2. Bihar

The affidavit submitted by State of Bihar confirmed a series ofviolationsofRamakantRaiguidelines.Thestatedidnotprovidea detailed list of empanelled doctors for verification or anydocumentaryevidencetoshowthatthechecklist(tofillbeforecarrying out sterilization procedure) was being used as perguideline.TheStategovernmentwasrequiredtocirculateuniformcopiesoftheproformaguidelines,whichthestatetillthatpointhadfailedtodo.TheStateofBiharclaimedtohaveestablishedafunctionalQualityAssurancecommittee,chairedbyPrincipalSecretary(Health)andGovt.ofBihar.However,itprovidedvaguedetailsregardingthefunctioningofthecommitteeinitsaffidavit,withnosubstantialevidence.Itdidnotprovideanyevidenceifthestatisticsalongwithbreak-upofthenumberofthesterilizationscarriedoutwasbeingmaintainedatstate/district/blocklevel.

The state did not provide supporting data to prove if DistrictQuality Assurance Committee was reviewing all cases andtaking necessary action against errant doctors. The State hasan operational insurance policy, in accordancewith FPIS andGovernmentofIndiaguidelines.StategovernmentofBiharhadnotsubstantiatedtheirclaimsonfollowingFPISguidelines.

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3. Andaman & Nicobar

Andaman& Nicobar (Union Territory) in its response regardingimplementation of guidelines issued by Ministry of Health andFamilywelfare claimed to haveprepareda checklist (containitemsrelatingto(a)theageofthepatient,(b)thehealthofthepatient,(c)thenumberofchildrenand(d)anyfurtherdetails)whicheverydoctorwasrequiredtofillinbeforecarryingoutsterilizationprocedure. TheUTalsoclaimed thatalldoctorswereasked tostrictlyadheretothechecklist.However,ithasnotprovidedanyevidence to back their claim of circulating uniform copies ofproformaofconsent.TheUTclaimedtohaveconstitutedStateQualityAssuranceCommitteeandthatthequalityreportswerebeingsubmittedtotheGovt.of India.Therewasnodocumentproduced to show that the Administrative Order has beenimplementedandnoneof these reportsweresubmittedtotheSupremeCourtforverification.Therewasnodocumentaryproofprovidedtoshowthatstatisticsgivingabreakupofthenumberofsterilizationcarriedoutarebeingmaintained.TheUnionTerritoryclaimed that it was conducting an enquiry into every case ofbreach,4failurecaseshavebeensubmitted,threearerejectedand1 ispendingbefore theDQAC.TheUnionTerritoryhasnotprovided,tothepetitioner,anydocumentstoverifytheirclaimofcompliancewiththisguideline.

With regardstoFamilyPlanning IndemnityScheme(FPIS)whichhas been implemented since November 2005, the UT had noevidencetoshowiffundshavebeenreleasedaspertheschemetodeservingpersons.

4. Assam

ThestateofAssamfiledanaffidavitconfirming implementationofguidelinesbyMinistryofHealthandFamilyWelfare.However,theycouldnotprovideanyprooftoshowthatdoctorshavebeenempanelledasperguideline.Thestateclaimedthatnooperationisconductedwithoutfillinginthechecklistbutnochecklistwasplacedonrecordandnodocumentaryevidencewassubmittedto show adherence to guideline. The State was supposed tomaintain statistics of number of sterilizations carried out, the


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numberofdeathofthepersonssterilizedandcomplicationsbutnodatawasgivenon thewebsiteandnoconcreteevidencewasprovidedtoshowthatthestatisticsaremaintained.

TheGovernmentofAssamdidnothaveanyprooftoshowthatdoctorswhobreachedguidelinesarebeing“obstructed”andifFPISschemewasbeingimplemented.

5. goa

The state government ofGoa also failed to provide the list ofqualified gynecologists/surgeons to perform the sterilizationoperations. Itclaimedthat thechecklist ismaintainedforeachandeverypatient.Howevertherewasnodocumentaryevidencetoshowadherence.

Thestatesaidthattheconsentformisdulysignedbythepatient/husband of the patient prior to the sterilization. This is a graveviolationasonlythepatienthastheauthoritytosigntheconsentform; thehusbandcannotdosoonherbehalf. TheHonorableSupremeCourtwasinformedthatQualityAssuranceCommitteeandDistrictQualityAssuranceCommitteewerealsoinplaceandthat thedata is uploadedondhsgoa.gov.in. But therewasnodata available to cross-check the information. Since the statewasnotmaintaininganystatistics,itcouldnotprovideinformationonpercentofdeathinthestate,whichclearlyindicatesproperstatistics,isnotmaintained.Despitesomanyviolationstherewerenocomplaintfiledagainstanydoctorwhoperformedsterilization.TheStateofGoacouldnotprovideanyevidencetocorroboratetheimplementationofFPISguideline.

6. Delhi

Delhicouldnotprovideanysatisfactoryresponsewithregardstolistofpanelofdoctors.Therewasnodocumentaryevidencetoprovethatdoctorsfilledoutchecklistsforeachpatient.Despitestate’s submissions that informed consent were taken prior toeach sterilization procedure, there was a lack of supportingdocuments for the claim. It was stated that Delhi has a StatelevelQualityAssuranceCommitteeand11DistrictLevelQualityAssurance committees but there was no documentary proof

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provided tocorroborateaforementionedclaims. Therewasnostatistics maintained and no information provided regardingservicefacilitiesandmonthlyandquarterlyreportssubmittedbydistricts. The government’s assurance that they will comply toholdenquiryincaseofbreachofguidelinescannotbetakenatfacevalue.TheUnionTerritoryhasnotprovidedanydocumentstoshowthattheFPISschemeisbeingimplemented.

7. gujarat

ThestateofGujaratmadeseveralclaimsofhavingapanelofqualifieddoctors,checklistsbeingregularlyfilled inanduniformpro forma of consent forms being available in all districtsthroughoutthestate,yetthegovernmentfailedtoprovideanyevidence to substantiate their claims. The state claimed thattherewere26DQACandoneSQACsetupinStatebutnodataprovidedtoverifythisinformation.Thestate,initsaffidavit,didnotmentionanynumbersofdeathsofthepersonduetosterilization,listofnumberofincapacitatedandthosewhoweresterilizedoraction against errant doctors has been provided. TheGujaratGovernment’s response only confirmed that the state did notadheretotheRamakantRaiguidelines.ItfailedtoimplementFPISanddidnotprovideany information regardingcompensationsunderthescheme.

8. Haryana

State of Haryana in its response stated that the Ramakant Raiguidelineswerebeingimplemented.Someoftheclaimsincludedhaving a panel of qualified doctors, proper filling of checklistbefore sterilizationprocedure,circulationuniformcopiesof thepro forma, settingupofQualityAssurancecommitteesatbothState and District level and maintaining of overall statistics.Therewasnodocumentaryevidenceprovidedby thestate tosubstantiate the claimmade by theGovernment of Haryana.TheGovernmentofHaryanadidnotprovideanyprooftoshowiftherewasanyinvestigationagainstthedoctorswhobreachedguidelinesoriftheFPISwasimplemented.


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9. Jammu & kashmir

ThestateofJammu&Kashmirdidnotprovideanydocumentaryevidence of implementation of guidelines ofMinistry of Healthand FamilyWelfare. The state stated that itwas implementingRamakantRaiguidelines suchcirculationofchecklist toall theChiefMedicalofficers,settingupofQualityAssuranceCommitteesatStateandDistrictlevelandmaintainingthestatisticsaspertheguidelines ofMOHWGovt. of India. None of the claimsmadeby the state of Jammu and Kashmir could be supported withdocumentary proof.Merementioning does not imply that theguidelinesarebeingfollowedproperly.Itwashighlyunlikelythattherewasnocaseofbreachofguidelinesorincidentwithregardtosterilizationswasreported.Therewasinformationprovidedbythestate.

10. kerala

ItclaimedtohaveintroducedthesystempanelofdoctorsandaccreditedhospitalsasperGOIguidelines.However therewasnoevidencetosupportthestatement.Thestategovt.alsofailedtoprovideany indepth information regarding implementationofRamakantRaiguidelines,usinguniformproformaofconsentor ifQAC’swere formed. TheStateofKeraladidnotprovidedanyevidence in showing real implementationofclaimsmade.Thestateclaimedtohavemaintainedoverall statisticsand it isbeingreviewedatstate,districtandblocklevelmeetingsbutnoevidencewasgiven.

11. Maharashtra

The state of Maharashtra stated in its response that thesterilizationprocedureswerebeingcarriedoutasperdirectivesoftheHon’bleSupremeCourt.TherewasnoevidenceprovidedregardingproperimplementationoftheRamakantRaiguidelines.The State government despite its claims did not provide anyevidence to prove if it circulated the checklist for sterilizationprocedures.TheQACwasestablishedatbothStateandDistrictlevelhowevertherewasnoevidenceregardingmeetingsbeingregularlyheldtoreviewqualityofsterilizationprogramme.There

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wasnodataprovidedtocorroborateclaimsmadebytheStategovernment in their response. State claimed of maintainingthe statisticsof sterilizationscarriedoutat respective institutionsrelatedtoage,numberofchildrenetc. Informationonnumberofdeathsand failureofprocedureswasnotproducedbeforethe Hon’ble Supreme Court. The state failed in providing anyverifiableevidencetoshowthatthestategovernmentisinrealityimplementingthedirectivesoftheHon’bleCourt.

12. Manipur

Thestate in itsaffidavitclaimedtohave introducedapanelofdoctors/gynecologist’ with more than 20 years of experience.Therehasbeennomentionof theDistrictPanelofdoctors,nodocumentary evidence to show that State has implementedguideline, prepared and circulated the checklist, which everydoctorbeforecarryingouttheprocedurehastofill,therewereno details provided regarding circulation of uniform copies oftheproforma.AspertheaffidavitsubmittedbystateofManipur,QACare set up both in State andDistrict. The government ofManipurhasnotfurnishedanytangibleprooftocorroboratetheirclaims,maintainingtheoverallstatisticsofthesterilizationcarriedout.Statisticshavenotbeenuploadedonthewebsite.TheStateGovernment also stated that it would follow the guidelines ofthe Union of India. This clearly indicates that the directives ofthe SupremeCourtwerenotbeing implemented. The StateofManipurdidnothaveanydataorsupportingdocumentsfortheirclaims.

13. Mizoram

The responses received from state of Mizoram were not verydifferent. The State Government did not provide any proof toshow that doctors have been empanelled as per guidelines.Merelymentioningthatguidelinesarebeingimplementedisnotsufficient.TherewasnodataprovidedtosubstantiatetheclaimmadebytheGovernmentofMizoram.ItwasmentionedbythestatethatQACcellhasbeen“implemented”.Thegovernmentcouldnotprovideanyevidencetoshowiftheyhadcompliedwiththeguidelines. Itwasstatedthatthestatehadtakenmeasures


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toensure thatall recordswerebeingmaintained. Theaffidavitfailedtoprovideanyinformationonnumberofdeathsorfailuresof sterilization. The StateGovernment ofMizoramhas failed toprovideanyevidencetocorroboratetheirclaimofimplementingtheguidelines.

14. West Bengal

ThestategovernmentofWestBengalmadeseveralclaims likeithadempanelleddistrictwisequalifieddoctors forperformingmaleand female sterilizationasper Standards for FemaleandMale Sterilization Services, issued by Government of India on2006.Therewasdocumentaryproofofwhethermedicalofficerswerefillingupchecklistsbeforeoperationorifuniformcopiesoftheproformaofconsentwerebeingmaintainedat thedistrictlevel.TheWestBengalGovernmentstatedthatQACshadbeenestablished at the State and District Levels and that the statewasmaintainingstatisticsofthenumberofsterilizationoperationcarriedout,particularsoftheprocedurefollowedwererecordedandmaintainedmonthlythroughHMIS.TheStateGovernmentdidnotprovideanydocumentaryevidencetoverifytheirclaim.TheGovernmentofWestBengalhasfailedtoproduceanyevidencetoshowifcasesofbreacharebeinginvestigated.

15. Nagaland

AspertheaffidavitsubmittedbythestateofNagaland,itwasyetto introduceasystemofhavinganapprovedpanelofdoctorsfor carrying out sterilization procedures. Nagaland responseswere ina singleword“Yes”withnodocumentaryevidence toshowcompliancewith theHon’bleCourtsdirections. The stategovernment’s response on circulation of uniformcopies of theproforma of consent is not verifiable as they have failed toproduceanydatatoshowcompliance.Thegovernmentwebsitenrhmnagaland.inhadexpiredandhencenouploadeddataorinformationregardingQACwasavailable.

16. Punjab

The state of Punjab consented to implementing orders of theHon’bleSupremeCourt.Itclaimedtohaveconstitutedapanel

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of doctors; assuring that checklists were being filled beforesterilization and circulation of consent form for SterilizationoperationsasperGovernmentofIndiaguidelines.ItalsoclaimedtohavesetupQACbothinStateandDistrictasqualityassurancemanualdictates.Therewasnoverifiabledataprovidedtoprovetheclaimsofthegovernment.IntheabsenceofanyevidenceitwasdoubtfuliftheStatewasmaintainingstatisticsofsterilizations.TheStategovernment failed toprovideanyevidence to showthat Ramakant Rai guidelines were successfully implemented.ThestateclaimedthattheFPISguidelineswereimplementedbuttherewasnoevidencetoprovethesame.

17. Rajasthan

Rajasthan also claimed to have implemented the RamakantRaiguidelinesasperGOInorms.Thestatedidnotprovideanydocumentaryevidenceofwhetheritcirculateduniformcopiesoftheproformaofconsent,datatoverifytheirclaimsofcompliancewiththetermssetoutbytheHon’blecourt.Thisstatetoodidnotprovide any concrete document stating that overall statisticswerebeingmaintainedgivingabreak-upofthenumberofthesterilization carried out, particulars of the procedure. The statealsostatedthattherewasnocaseofbreachofguidelines. It ishighlyunlikelythatnountowardincidentsoccurredinthestate.With regards to implementation of Family Planning IndemnityScheme,theStateofRajasthanprovidednoevidencetoshowthattheschemeisbeingimplementedornot.

18. Sikkim

ThisstatedidnotprovideanydocumentaryevidencerelatedtoimplementationofGOIguidelines.Itclaimedtohaveconstituteda panel of doctors, circulated uniform copies of forms andchecklistbeingfilledbeforesterilizationprocedurebuttherewassupportingdocumenttoshowifitwasbeingcarriedoutatgroundlevel.ThestateofSikkimalsorespondedinoneword“Yes”.Thisdoesnotestablishconformitytotheguidelines.TheGovernmentofSikkimhasfailedtoproduceanyevidencetoshowcasesofbreacharebeinginvestigated.


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19. Uttar Pradesh

UttarPradeshclaimsthatithasempanelledqualifieddoctorsforprovidingsterilizationservicesaspercriteriagivenbytheUnionofIndiainsterilizationmanualandtheempanelleddoctorstocarryoutsterilizationsurgeries.Therewasnoevidenceprovidedtoshowthat theguidelineswerebeingadheredto. Itassertedthat theconsentformswerebeingfilledbeforesterilizationproceduresatthefacilitylevel.ThoughtheHon’bleSupremecourtsawitfittosettheState’sConsentformasthestandardtobefollowed,thereisnoevidencetoshowcontinuedimplementationoftheguidelines.Even though thestategovt.claimed tohaveconstitutedQACat the State and the District levels, the government failed tofurnish any documents to corroborate their claims. The statedid not submit the statistics for verification. Uttar Pradesh StateGovernmentdidnotprovideanyverifiableevidencetoshowiftheguidelineswerebeingfollowed.Thestatementfromthestateregarding implementation of FPIS seemed to convey that theprocessofimplementationisstillunderway.

20. Tripura

ThestategovernmentofTripuratooclaimedtohaveimplementedtheguidelinesofGOI.Ithowever,didnotprovideanydocumentaryevidenceinsupportofitsclaims.Thestateinitsresponsesmerelymentionedtohaveapanelofdoctors,preparedchecklist,andcirculated consent forms also in Bangla language, constitutedQACatstateanddistrict level. Thisdoesnotnecessarilymeanthat theguidelinesarebeing followed.TheStateofTripurahasnodatatoshowthattheguidelineisbeingimplemented.Acopyofannexurewasnotavailableforverificationofclaimsmadebythe StateGovernment. The state could not provide any proofof maintaining overall statistics on the sterilization operationconducted by the all-public and private health institution. Thestatealsowasunabletoprovideanyinformationonconductingenquiries into cases of breach of union of India guidelines onmaleand&femalesterilizationbyanydoctorororganization.ItwasnotclearfromtheaffidavitprovidedbythestateifFPISwasimplemented.HencethestatestoodinviolationofordersoftheHon’bleCourt.

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21. Tamil Nadu

ThestateofTamilNadustatedthatapanelofdoctorswaspreparedatstateanddistrictlevelandthatonlytheempanelleddoctorscarryoutthesterilizationprocedure.Thestatedidnotprovidethenamesof thedoctors forverification. Thestatealsomentionedin theaffidavit that itwasmademandatory forall thedoctorsto fill out checklists before performing sterilization procedures.It claimed to havepreparedandcirculated thechecklist andconsent form however there was no documentary evidence.ThegovernmentofTamilNaduwaspromptinsharingregardingestablishmentofDQACandSQACand the implementationoftheguidelinesandthatreportsarebeingpublishedregularly.Thestate maintains that all the information and periodical reportsweresenttoGOIregularly.

Therewasnoperiodicalreportthatwasannexedwiththeaffidavitfor verification. Though it is true theHon’blecourt ordered theFPIS scheme tobebasedon themodel followedby the state,therewerenodocumentsprovidedtoshowthecontinuedandeffectiveimplementationofthescheme.

22. Uttarakhand

The state of Uttarakhand claimed in its affidavit that the statehasimplementedtheguidelinesbytheGovernmentofIndia.Thisincludedempanelmentofqualifieddoctorstocarryoutsterilizationoperation to ensure the safety and standard, circulation to alldistrictsacopyofchecklist tobefilledbyeverydoctorbeforecarryingoutthesterilization,circulationofuniformcopiesoftheproformaofconsent.Howevertherewasnoevidencetoverifyanyoftheinformationprovided.TheStatealsoclaimedtohaveconstituted theQAC at the State level. District level QAC hasnot been constituted and though on paper the State QualityAdministrationCommitteeexisted,therewasnoprooffurnishedtoverify itsperformance. Itwasmentioned in theaffidavit thatthestatemaintainsoverallstatisticgivingabreakupofnumberofsterilizationcarriedoutanddeathsofpersonssterilized.Thestatefailedto furbishstatus reportmentioningthedeathscausedbythemethodofprocedures.TheGovernmentofUttarakhandhas


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notgivenanyprooftoshowthatdoctorswhobreachguidelinesarebeing“obstructed”. TheStateGovernmentofUttarakhandfailed to provide any evidence to corroborate their claim ofimplementingtheguidelines.

23. Puducherry

As per the information provided by UT of Puducherry, 150doctorsentitledtocarryonsterilizationproceduresintheU.T.ofPuducherryareempanelledin44accreditedcenters.Therewasnodocumentaryevidencetoverifythequalificationofthe150doctorsempanelled. The statealsoclaimed tobeconductingpre-operative checkups as per the items included and thebasicbloodinvestigationsforeachpersonbutnodocumentaryevidencewaspresented.Itclaimedthatitgetsawrittenconsentform in both English and local language. Though it is notedthattheState is issuingtheforms inthe local languageaswell,ithas stillnot furnishedany substantialproof toverify itsclaims.QAC exists with a 9-member committee; information from thecommitteeisprovidedbutnotverifiable.Puducherrystatedthatitwasmaintainingtheoverallstatisticsgivingthebreakupnumber/proceduresofsterilizationsandnumberofpersonsincapacitatedbysterilizationprogrammes.Thestatedidnotprovideanynumberoffailures.

Asstatedintheaffidavit,sofartherewasnocaseofbreachofguidelines.UnionTerritoryofPuducherryisfollowinganinsuranceschemeasperFPISguidelines.Therewasnoevidencethatwasprovidedtoshowtheschemeisbeingimplementedaspertheguidelines.

24. Arunachal Pradesh

Arunachal Pradesh stated that it has a panel of doctors forconductingsurgeries.Thestatealsoclaimedtohaveimplementedtheguidelines.Nodocumentswereprovidedtoverifynamesornumberofdoctors. Theaffidavitmentioned that thenecessarystepssuchascirculationofchecklist,proformaofconsentwerecompleted. However simply mentioning circulation does notsuffice,nodocumentaryevidence to showactualcompliance

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was submitted to the SupremeCourt. Amere oneword replyfromthegovernmentofArunachalPradeshdoesnotsufficetoshowthattheyareconformingtotheguidelineslaiddownbythisHon’bleCourt.Thestateinitsresponseusedone-wordresponseslike“Compiled”and“Yes”.Thereweren’tanydetails regardingimplementation of the guideline. The state government wasunabletoprovidedocumentstoitsclaimofmaintainingoverallstatisticsgivingabreak-upofthenumberofthesterilizationcarriedout,particularsoftheprocedurefollowed.TheStategovernmentfurtherfailedtoprovideanyevidencetoshowifithassuccessfullyimplementedtheguidelines.ThoughttheStategovernmenthasclaimeditisfollowingthenormsrelatedtoimplementationFPIS,noevidencetosupporttheirclaimhasbeenprovided.

25. Andhra Pradesh

The government has through its affidavit claimed to haveempanelled the eligible doctors to carry out the sterilizationoperationtoensurethesafetyandstandard.AsperthedirectionofGovernmentof India,Uniformmedical records&casesheetformale/female sterilizationswereprintedandcirculated toallthefacilities,whichareprovidingsterilizationservices.TheStatehowever did not provideany documentary evidence to showthat theguideline isbeing implemented to its fullestextent.AspertheinformationQualityAssuranceCommitteesweresetupatbothStateandDistrict levelsandauditshavebeenconductedperiodically,toassessqualityoffacilities,andnumberofdeaths.Norelevantdocumentshavebeenfurnishedbythestatetoshoweitherthatthecommitteeshavebeensetuporanyauditshavebeenconducted.Separateregisteraremaintainedatthefacilitylevel andat thedistricts level to record in caseof anydeath,failure and complication are followed by the sterilization. ThestateclaimedthattheDeathAudithasbeenconductedatthefacilitylevel.Themereclaimofadeathauditbeingconductedisnotenoughtoshowanyrealimplementation.TheDistrictQualityAssurance Committee is yet to review the report and makerecommendation for corrective action. The state governmentalsocouldnotprovideanyinformationregardingimplementationofFPIS.


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26. Dadra & Nagar Haveli

TheUnionTerritorythroughitsaffidavitsubmittedthatservicesofonedoctorwerebeing undertaken for conducting sterilizationsurgeries. The usage of the services of only one doctor is aclearviolationofguidelinebythegovernment. It iscompulsoryfor patients to undergo physical examination and blood testhowever no documentary evidence was submitted to provethisassertion.Theproformaofconsentusedwasannexedintheaffidavit. But the Union Territory did not provide any evidencetobacktheirclaim. ItwasmerelymentionedthatStateQualityAssurancecommitteeandFamilyPlanningsub-committeehavebeen formedand that theunion territorymaintains theoverallstatisticsgivingbreak-upofthenumberofthesterilizationcarriedout.ThereportsarealsoprovidedtotheFamilyPlanningDivisionMoHFW,Govt.ofIndiaeveryquarterasstatedintheaffidavit.Noreportorstatisticsweresubmittedforverificationofclaims.Fromthestatement in theaffidavit it seemedto indicatethatDadar&NagarHavelihasobservednobreaches.SincetheUTdidnotprovideanyevidencetosupporttheirstatement,itcouldnotbeverified.TheUnionTerritoryhasnotprovidedanydocumentstoshowifFamilyPlanningIndemnitySchemeisbeingimplemented.

27. Chandigarh

ThegovernmentofChandigarhhadnotconstitutedapanelofdoctorsaspertheguidelines,whichwasaclearviolationoftheguidelines. ItclaimedthatasperthedirectionsoftheSupremeCourtchecklistswerecirculatedtoallthedeliverypoints.Issuingdirections does not translate to implementation. It also statedthat Quality Assurance Committee was already in place andthereportregardingthesameisforwardedtoGovt.ofIndia.Theaffidavitstatedthatprocurementprocesshasbeeninitiatedfornew equipment. There was no report submitted corroboratingthe setting up of the Qualitative Assurance committee. TheUnion Territory did not even claim that the guideline is beingimplemented. There were no clear statements if the work hasbeguninimplementingFPISguidelines.

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28. Chhattisgarh

The state of Chhattisgarh claimed that it was following theguidelinesofGOI.Therewasnoevidenceprovidedbythestateforverification.Regardingpreparingandcirculationofcompulsorychecklists for doctors, the state claimed that directions havebeen implemented.Thestatedidnot feel theneedtoprovideany documentary evidence to confirm the implementation.Regarding the proforma of consent, the State governmentclaimedthataproformawasalreadyinplacebuttheproformamentioned in theguidelines shallbecompliedwith further. Thestategovernmentdidnotprovideanydocumentstothepetitionerforscrutiny.Itsresponsesregardingimplementationofguidelinesandmaintainoverallstatisticsgivingabreak-upofthenumberofthesterilizationcarriedout,particularsoftheprocedurefollowedweregiveninoneword“Yes”,GovernmentofChhattisgarhmadenoclaimof implementationof theguidelines. TheGovernmentof Chhattisgarh did not give any proof to show that if anyinvestigationwasconductedagainstdoctorswhobreachedtheguidelines. It isunclear fromstatements ifStateofChhattisgarhwasimplementingguidelineonMaleandFemalesterilization.PostChhattisgarhsterilizationmassacre,theChhattisgarhgovernmentfiled“incomplete”affidavitoverallegedbotchedupsterilizationsurgeries at Bilaspur district in which 13 persons lost their lives.ThestatedidnotfilecertaindetailslikethenumberofFIRsfiled,progressmadeintheirinvestigationetc.arenotsubmitted.

29. Himachal Pradesh

The stateofHimachal Pradesh stated thatonlyapprovedandtrainedpanelofdoctorsarecarryingoutthesterilizationprocedures.The listofpanelofdoctorswasnotonrecordforverification. ItwasalsomentionedthatchecklisthasbeencirculatedtoalltheChiefMedicalofficersandthesechecklistsarebeingmaintainedbefore performing sterilization operations at district level.Merecirculationdoesnotamounttoimplementationoftheguidelines.Norelevantdocumentswereannexedforverification.TheStategovernment failed to produce any evidence to support theirclaimofSQACandDQACmeetingregularly,asperGovt.ofIndiaguidelines. Thedatawasunavailable to supportclaimofState


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government.Regardingtheclausethatthestatehastomaintainthe statistics bygivingabreakupof the number of sterilizationcarriedoutbydifferentmethods,thestatefailedtoprovideanydocumentaryproofforthesame.TheGovernmentofHimachalPradeshalsodidnotprovideanyevidence to show ifcasesofbreacharebeing investigated. TheStateofHimachalPradeshhasprovidednoevidencetoshowifFPISwasbeingimplemented.

30. Jharkhand

The state claimed that directions to district andGOI Standardguidelines were disseminated. There was nodocumentaryevidence of implementation. It also implied using one wordresponse “circulated” that checklist has been circulated toall districts. A mere one word reply from the government ofJharkhanddoesnotsufficetoshowthattheyareconformingtotheguidelineslaiddownbythisHon’bleCourt.Itwasmentionedthat SQAChavebeen formedbut noevidencewasprovidedto verify claims made. As per the guidelines each state is tomaintainoverallstatisticsgivingabreak-upofthenumberofthesterilizationcarriedout,particularsoftheprocedurefollowed.Thestateinitsresponsedidnotshareanyrecordsoffailuresordeathsby the procedure provided. Even though the state claimedthatit“implemented”guidelinesothatcasesofbreachcanbeinvestigatedbutmereclaimofimplementationbeingconductedis not enough to showadherence to guidelines. Therewas noevidenceprovidedregardingimplementationofFPISguidelines.

31. karnataka

ThestateofKarnatakastatedthatanapprovedpanelofdoctorispreparedatthedistrictlevel;strictadherencetothecriteriaaslaiddownbytheGOIregardingempanelmentofdoctorsisfollowed.Anyevidenceforverificationofimplementationofguidelinedidnotsupportthis.Theaffidavitstatedthatachecklistforsterilizationismaintained;proformaiscirculatedtoallthecentersconductingsterilization.Therewasnodocumentaryevidenceprovided.TheState of Karnataka has no data to show that this guideline isbeingimplemented.SQACwerenotformed.Thestateclaimed

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tohavecompiledareportbutitwasnotmadeavailable.ThefactsclaimedbytheStateofKarnatakaintheirAnnexurewerenotverifiable.Statisticsrelatedtodifferentmethodsofsterilizationaswellasdemographicprofileoftheclientismaintainedatthefacility level.Thestatemaintainstheactualnumberofdifferentsterilizationoperationsonlynotthestatisticsofhowmanydeathsarecausedfollowingprocedure.TheclaimoftheKarnatakaStategovernmentregardingimplementationcannotbeverifiedasnoevidencehasbeenprovidedtoshowany implementation.Themerementionoftheword“implemented”cannotbeacceptedasproofofanyactualimplementationbytheState.

32. Lakshadweep

The state claimed that sterilization procedures were beingperformed by gynecologists in RGSH agatti and by specialists(gynecologists) deputed to IGH by Ministry of health & FamilyWelfare. ItalsoheldthatapanelcouldnotbeimplementedinthisU.Tbecauseshortageofspecialists,sterilizationproceduresisbeingperformedonlyafterfilingthechecklist.TheproformaoftheconsentisbeingfollowedbytheUnionTerritory’sadministration.TheUnionTerritoryhasnotprovidedanyevidencetobacktheirclaim.QualityAssuranceCommitteeconstituted,guidelinesarestrictly followed Information provided by the Union territory ofLakshadweepcannotbecorroboratedasnoevidencehasbeenprovided. Theaffidavitmaintained that statistics on sterilizationprocedures are maintained and monthly report is being senttotheministry.TheReport,which isclaimedtohavebeensentto theMinistry, isnot furnished. Itwas stated thatnobreachofguidelinescamebefore theQualityAssuranceCommittee.TheUnionTerritorydidnotprovide,tothepetitioner,anydocumentstoverifytheirclaimofcompliancewiththisguideline.TheUnionTerritorydoesnotevenclaim that the FPIS scheme is inplace,whichisaclearviolationoftheorderofthisHon’bleCourt.

33. Madhya Pradesh

Theaffidavit submittedby thestateofMadhyaPradeshstatedthat empanelment of doctors approved by DQAC has beendoneatdistrict level.Butthestategovernmentdidnotprovide


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anydetailedinformationtoshowempanelment.Itwasclaimedthatall thenecessarystepssuchascirculationofchecklistandthat itwasbeingfilledbydoctorsdiligently.Merecirculatingacopyofthechecklistdoesprovethatdoctorsusethesameforallsterilization.Thethumbimpression/signatureistakenoftheclienton the proforma after explaining the surgical procedures andimplications.TheMadhyaPradeshGovernmenthasprovidednoevidence to substantiate their claim of explaining the surgicalprocedurebeforetakingthesignatureofthepatients.ThestateclaimedthatSQACandDQAChavebeenformed,howeverhalfyearlyreportswerenotbeingsubmitteddespitetheclaimsthatcommitteeswerefullyfunctional.TheStateofMadhyaPradeshhas furnished no documents to support their claims made inthe annexure. As per the guidelines the state shouldmaintainthestatisticsgivingabreakupof thenumberof thesterilizationaccording to theprocedure.MadhyaPradesh failed to furnishconcrete evidence about the statistics. In cases of breachthe enquiries were pending.The State government has failedto provide any evidence to show that they have successfullyimplementedtheguidelines.

34. Meghalaya

This state did not provide documentary evidence related toimplementationofGOIguidelines.TheaffidavitsubmittedstatedthatadistrictwiseempanelleddoctorslistswereavailableaslaiddowninQAmanualforsterilization.Namesofthelistofdoctorsnot annexed. Therewas no documentary proof annexed thatwould confirm if the state government had taken any stepsto prepare checklist, if theses checklists were being filled upproperly,ifproformaofconsentasperQualityAssuranceManualforsterilizationisutilized.TheGovernmentofMeghalayahasnotproducedanyevidencetosubstantiatetheirclaimsoffollowingthisguideline.SQACandDQAChavebeenformulated,deaths,failures and complications not published. The state failed toprovide documents to prove the compliance of the State ofMeghalayawiththeRamakantRaiguidelines.

The affidavit did not mention any information or evidence toshow that statistics are beingmaintained. The Government of

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Meghalayahasnotgivenanyproof to show thatdoctorswhobreach guidelines are being “obstructed”. No evidence hasbeen provided to show the Insurance Policy scheme is beingimplementedaspertheguidelines.

35. Odisha

The state government through its affidavit claimed to haveconstitutedadistrictwisepanelofdoctors thatcarriesout thesterilization in Odisha. The State government also stated thatit has circulated uniform copies of the pro forma guidelines,preparedandcirculatedchecklist for everydoctorperformingsterilizationanddirectedthemtofillthemupmandatorilybeforesuchprocedure.Therewasnodocumentaryevidenceprovidedwithanyoftheclaimsmade.Merecirculationandanaffirmativeresponse do not suffice as proof of the State’s action on theguideline.NodatahasbeenprovidedtosubstantiatetheclaimmadebytheGovernmentofOdisha.ThestategovernmentdidnotprovideanyverifiableevidencetoshowifbothDistrict&StateassuranceCommitteewereconstitutedandwerethefunctioningofthecommittees.Noconcreteevidenceinsupportoftheregularcollectionofinformationonnumberofpersonssterilized,numberofdeathcasesduringsterilizationoperationswasprovided.TheStategovernmenthasfailedtoprovideanyevidencetoshowifDQAChavesuccessfully investigatedalldeaths relating toanybreachofUnionofIndiaguidelines.

36. Telangana

ThestateofTelanganainitsaffidavitstatedtohavecompliedbytheorders of SupremeCourt and implemented theguidelines.Governmentclaimedtohavetakenstepslikeprintingofuniformmedical recordandcirculating it toall the facilities,whichareprovidingsterilizationservices.Thegovernmenthasnotprovidedany solid evidence to show effective implementation of thisguideline. TheQACwas set upat the StateandDistrict levels,butnodatawasprovidedtoverifyinformationprovidedbytheStategovernment.Allthedeath,failureandcomplicationarisingoutofthesterilizationareauditedbythedistrictslevelQAC.Theauditreportsarefurnishedtothestatefortakingnecessaryaction


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ontherecommendationsofthecommittee.Noproperstatisticswas furnished in supportof thestatement. ThedeathaudithasbeenconductedbytheDQACandactionisbeingtakenagainstdoctorswhobreachtheguidelines.

The claim of the Telangana State government regardingimplementation cannot be verified as no evidence has beenprovidedtoshowanyimplementation.Statementionedtohaveextended thebenefitof the scheme toall thoseaffectedanddeservingunder FPISguidelines. TheaforementionedAnnexurehasnotbeenmadeavailabletothepetitionerforverificationofclaimmadebytheStateGovernment.

37. Daman & Diu

Itwasstatedthatqualifiedgynecologistsandgeneralsurgeonshavebeenincludedinthepanelandcompetentauthorityhasapprovedthesame.Thegovernmentmentionedthatthechecklistisbeingfilledupandmaintainedbeforecarryingoutsterilizationprocedure.Thegovernmentinitsresponsestatedthatinformedconsent is being taken prior to each sterilization procedure.The Union Territory has not provided any evidence to backtheirclaims. Therewasno response fromthestategovernmentregarding establishing a Quality Assurance Committee toensurethatguidelinesarefollowedforpre-operativemeasures,operationalfacilities,andpost-operativefollowups.DamanandDiugavenoresponseregardingmaintenanceofoverallstatisticsof thenumberof the sterilizationcarriedoutandparticularsoftheprocedurefollowed.Thestategovernmentalsomaintainedsilenceonissueoftakingactionincaseofbreachbydoctors.TheFPISschemewasclearlynotimplementedtillthattimewhichwasinviolationsofordersofthisHon’bleCourt.

The Chhattisgarh Massacre

TheincidentofsterilizationmassacretookplaceinChhattisgarhon8th&10thNovember2014.ThiswasbroughttothenoticeofSupremeCourtwithregardtothesterilizationcampsconductedin Bilaspur district. The report submitted showed that as many

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as137womenweresubjected toa sterilizationprocedureand13ofthemdied.Manyotherscomplainedofproblemssuchasvomiting,difficultyinbreathing,severepainetc.Theyweretakentonearbyhospitalsanddischargedafternecessary treatment.It appeared that some women who had not undergone asterilizationprocedurealsohadsimilarcomplaintsandsomeofthemdiedtherebyincreasingthenumberofdeathstoover13.TheStateofChhattisgarhwasdirectedtosubmitsufficientparticularsanddetailswith regard to theaction taken subsequent to themishapinthesterilizationcampincludingacopyofasampleFIR,postmortemreportandchargesheetfiled,ifany.[Detailsoftheincidentanddevelopmentsdescribedinsubsequentchapters]

SUBMISSION By UNION OF INDIA

The Ministry of Health and Family Welfare of the GovernmentofIndiainitsaffidavitacceptedthatUOIreceivedacomplaintregarding sterilization camp on 7th January in Araria district ofBihar. A report received in this regard stated that Dr. AbhayKumar Chowdhary, a contract physician (who conductedsurgeriesinsterilizationcamp)atthePrimaryHealthCentrehadbeendismissedandithadfurtherbeenorderedthathemaynotbeemployedforanygovernmentworkinfuture.FirstInformationReports(FIRs)werelodgedinrespecttotheeventsof7thJanuary2012, investigations were concluded and charge sheets werebeenfiled.

The affidavit filed by Union of India affidavit in relation to theimplementationoftheFamilyPlanningIndemnityScheme,2013,claims that all States fully compliedwith the Hon’ble SupremeCourt’sorder inRamakantRaiandthatanadvisorywas issuedtoallthestatestoadheretothestandardoperatingprocedures.The Union of India in its affidavit stated that compensationschemeforAcceptorsofSterilizationwasrevisedon31stOctober2006 and improved with effect from 7th September 2007. Italso stated that public health is a “State Subject” occurring inEntry 6 of List II of the Seventh Schedule of theConstitution. IthighlightedthatGovernmentofIndiaonlyprovidessupportandfacilitates inachievinghealthwelfare schemes.Hence it is theState Government that can monitor the quality of services in


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accordancewithagreedbenchmarks.

UOIfurtherstatedthatlargefundswereapprovedandutilized(inlakhs)bytheStatesundertheFamilyPlanningIndemnityScheme2013.Inyear2013-14abudgetof15.66.69lakhswereapprovedwithanexpenditureof675.59lakhs.Similarlytheyear2014-15sawanexpenditureof828.19 lakhsby theendof3rdquarter foranapproved fundof 1485.80 lakhs. However, theUnionof India’sown expenditure data shows gaps in implementation of FPIS.Acrosstheboard,thestatesarenotspendingtheirfullbudgetforFPIS.

State / UT Particulars Approval Expenditure

2013-2014

2014-2015

2013-2014

2014-2015

AndamanandNicobar

4failurecases(3rejected,onepending)compensationpaidasperguidelines

5.00 4.80 0.00 0.00

AndhraPradeshArunachalPradeshAssamandBiharnoinformationprovidedChandigarh In2013-14,death(not

paidyet),fourfailures(paidRs.120,000)

5.00 3.80 5.00 0.00

Chhattisgarh,DadarandNagarHaveli,DamanandDiu,DelhinoinformationprovidedGoaGujarat

Nodeathsince2010.5failuresin2013/14,5failuresin2014-15

5.00 0.00 5.00 1.20

Haryana AmountapprovedunderPIPin2013-14is12.00andexpenditureincurred25.30.In2014-15amountapproved16.50,3.60extendedtillDecember14

52.50 50.00 25.86 44.30

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JammuandKashmirJharkhandKarnatakanoinformationprovided

Karnataka 65 65 63.00 21.82KeralaLakshadweepMPMaharashtraManipurMeghalayaMizoramnoinformationprovidedNagaland Stateisyettointroduce

asystemofhavingandapprovedpanelofdoctorsforsterilization

OrissanoinformationprovidedPuducherry QAClatestsixmonthly

reportnodeathorcomplications

5.00 5.00 4.50 0.00

PunjabnoinformationprovidedRajasthanSikkim

For2013-14,paidfor1367/1495failure.For2014/15,paidfor1/3complicationsand1499/1626failure

TamilNadu For2013-14,outof462claims(failure)received270paid,38rejectedand154returnedforwantofrequireddocuments.For26deathsclaimsreceived,21paid2lakh,4paid50000andonerejected.Fundspassedtovictimsisrupees13220000,balanceleftis694000.For2014-15claimprecededfor18deathsand214failure

139.14 142.97 27.0 123.25

Telangana,Tripura,UttarPradesh,WestBengalinformationnotprovided.


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UnionofIndiainitsaffidavitrefrainedfromprovidingappropriateexplanationregardingtheauditofdisbursaloftheamountsandsimplymentioned that the States and the Union Territories arerequiredtofollowthefinancialmanagementsystemandsubmitstatutoryaudit reports,utilizationcertificates,quarterlysummaryonconcurrent audits etc. It failed toprovideanyevidence toproveifanyofitwasbeingadheredto.Itwasnotclearfromtheaffidavits if theorganisations involved insterilizationhadproperaccounts,whethersanctioningauthorityandauditincludingtheComptroller and Auditor General of India had ever inspectedaccountsofanyoftheseorganisations.

Asan interimmeasure theHo’ble SupremeCourtdirected theSecretaryintheMinistryofHealthandFamilyWelfare,Governmentof India to hold a meeting with his counterparts in the Statesand Union Territories to arrive at a consensus on the effectiveimplementation of the various schemes relating to sterilization,FamilyIndemnityScheme(2013)andthedirectionsgivenbythisCourt in Ramakant Rai Vs. Union of India. The Supreme CourtdirectedtheStateforpaymentstobemadetothevictimsunderFamily Planning Indemnity Scheme. Later, the Court orderedfor bi-monthly high-level meetings with the states to inform ofguidelinesoftheGovernmentof Indiaandthepolicydecisionsthatgetmodifiedfromtimetotime.Italsoorderedforthestateto implement thedecisions taken in themeeting in theMinistryofHealthandFamilyWelfareon15thMay,2015.Thekeydecisionstakenduringthemeetingwere:

• Sterilization services must be provided in a client friendlymanner and in a safe environment after taking informedconsent.Safetyofthosewhooptforitshouldbeensured.

• A mechanism should be put in place wherein serviceprovidersormanagersarenotvictimizedorarrestedwithoutinstituting a proper enquiry by the district/State qualityassurancecommittees.

• All States to conduct workshops on quality in sterilizationservices orienting its programme managers and serviceprovidersbothattheStateanddistrictlevelontheupdated

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manuals on standards, male and female sterilization andfamilyplanningindemnityscheme.

• AllGovernmentofIndiaguidelinestobestrictlyadheredbythestates.

• Aperiodicassessmentofallthefacilitiesandfixeddaycampsby 1-2 members of the sub-committees under the StateQuality Assurance Committee/District Quality AssuranceCommitteeon implementationof the infectionpreventionprotocolsaswell as theefficacyof the servicesprovided,shouldbecarriedout(aslaiddownintheManuals).

• The issue of shortage of pool of providers for sterilizationcouldbeaddressedby resorting tocompulsory trainingofMBBSmedicalofficerswhentheyjoingovernmentservices.

• Onsite Training/mentoring be initiated by identifying highcaseload facilities (first) to undertake sterilization trainings.Thiswillensuretheserviceproviderisavailableatthefacilitytoundertaketheirprimarytaskofprovidingservicestotheclientsinadditiontoprovidetrainingtoprospectivetrainees.

• Retrainingofproviderswhoareeithershortonconfidenceorhavehighfailurerates.

• ThereshouldbemorethrustonMinilapSterilizationasitleadstofewerfailuresandcomplications.

• Thescopeofincreasingthebasketofcontraceptivechoiceslike injectables/implants and weekly pills like ‘Saheli’ beexploredurgentlytoprovidemorechoice.

• Theideaofmobileteamsorclinicaloutreachteamsneedstobeencouragedtoaddresstheissueofshortageofsurgeons.

• Every case of sterilization death must be audited as performatlaydownandreportedtotheGovernmentofIndia.

• Linelistingofdeathsandfailurestobeundertakendistrict/facilitywiseandsurgeonwise.Disbursalofclaimsfordeaths,failuresandcomplicationsshouldbecomputerized.


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• To address the issue of sterilization failures, sterilizationcertificatesshouldbeissuedafteratleastonemonthincaseoffemalesterilizationandafterthreemonthsincaseofmalesterilization.

• StatestotakeurgentstepstorejuvenatetheFamilyPlanningProgrammewiththeultimateaimofreducingthematernalandinfantmortalityandmorbidityinadditiontoachievingpopulationstabilization.

• GovernmentofIndiatoconducthighlevelmeetingliketheinstantonewithallStatestoacquaintthemwiththe latestpoliciesandprogrammesoftheGovernmentofIndiaonayearlybasis.

In compliance with directions of the Hon’ble Court, anothermeetingwasheldunderthechairmanshipofAdditionalSecretary&MissionDirector(HFW)asofficer-in-chargeduringtheperiodofleaveofSecretary(HFW),withPrincipalSecretaries(HFW),MissionDirectors (NHM), Directors (Family Welfare) and others of allstates/UTson17thNovember2015 throughvideoconferencingat Nirman Bhawan, New Delhi. Representatives of all statesandUnion Territoriesof Indiaparticipated in themeeting.UttarPradeshcouldnotattendduetoastateholidayandonaccountof the state National Informatics Centre (NIC) office beingclosed.ThefollowingkeypriorityareasweresharedwiththeStateGovernmentsandUnionTerritories:

• Uniform consent forms should be available in all facilities,whichshouldbedulyfilledin,andtheconsentoftheclientshouldbetakenpriortotheprocedureinallcases.

• StateQualityAssuranceCommittee(SQAC)/DistrictQualityAssurance Committee (DQAC) and State Indemnity SubCommittee(SISC)/District IndemnitySubCommittee(DISC)tobeconstitutedaspertheGOIguidelines.

• All the Family Planning guidelines should be printed anddisseminatedattheState/districtaswellasfacilitylevel.

• State/District level orientation of all the programme

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managersandprovidersfortheguidelinesandprotocolstobecompletedinallStates.

• Members of SQAC and DQAC should conduct periodicsupportive supervision visits as per quality protocols. Thefindingsofthesamearetobedocumentedandcorrectiveactionsshouldbetaken.

• TrainingcalendarfortrainingnewlyrecruiteddoctorsistobepreparedandupdatedineachState.

• Line listing of all the sterilization providers needs to bepreparedandperiodicallyupdatedbyallStates.

• Everydeathattributabletosterilizationshouldbeaudited.

• Sterilization certificates should be issued as per existingguidelines.

SincetheStateofUttarPradeshwasnotpresentforthehighlevelmeeting,itsuggeststhatresponsibleofficersintheStateofUttarPradeshseemtogivemoreimportancetoStateholidaysratherthanissuesrelatingtoFamilyPlanning.

ANationalSummitonFamilyPlanningwasheldon5thand6thApril 2016. The Government in addition to the new guidelinesproposed to be undertaken proposed the following practicalandpragmaticmeasures:

1. Conducting annual review workshops of the programmeinallStatesof IndiawiththeStateanddistrictprogrammemanagersandserviceproviders.

2. Monthlymonitoringofatleast2publichealthfacilitiesand1accreditedprivate/NGOfacilitybySQAC/DQAC.

3. Replacementofoperational‘Camps’byregular‘Fixeddayservices’overthenextthreeyears.

4. Further Strengthening of the State Quality AssuranceCommittee(SQAC)andDistrictQualityAssuranceCommittee(DQAC)mechanism.


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5. Close monitoring, reviewing and collection of reports ofdeaths attributable to sterilization by the Government ofIndia.

6. ConductingClient exit interviews of 10% cases as per thepreparedchecklist.

7. FeedbackfrombeneficiariesbyMaternalandChildHealthTrackingFacilitationCentre(MCTFC).

UOI informed the Supreme Court that states of Tamil Nadu,Maharashtra, Sikkim,GoaandalsoChhattisgarh havealreadyphasedouttheholdingofsterilizationcamps.Henceitproposedtophaseoutcampapproachoveraperiodofnextthreeyears.Unionof IndiaalsoclaimedtohavetakenseveralmeasuresforimprovementintheFamilyPlanningprogrammeandsterilizationprocedures.Suchas:

1. Declineindeathsfollowingsterilizationfrom140in2014-15to89in2015-16(asperdataavailableonthewebbasedHMIStill31.3.2016);

2. Declineinthenumberoffailuresfrom5928in2014-15to2093in2015-16(asperdataavailableonthewebbasedHMIStill31.3.2016);

3. Theempanelledlistofprovidersisavailableineverydistrict;

4. Surgeonsarenotperformingmorethan30casesperday;

5. Camps are being held only in public health facilities oraccreditedprivate/NGOfacilities.

6. WorkshopsrelatingtoFamilyPlanningprogrammehavebeenheldin28outof29States(ason21stJuly2016).Unfortunately,nosuchworkshopswereheldafter24thAugust2015.

7. Thenumberofdeathsattributabletosterilizationproceduresin2014-2015was140but ithascomedownin2015-2016to113.

8. In2015-2016clientsexit interviewshavebeenconductedinrespectof1,06,055persons.

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9. Monitoring and supervision of facilities by SQAC/DQAC in2015-2016inregardtopublicfacilitiesisashighas12,044andwithregardtoprivateaccreditedfacilitiesitisashighas2,984.

10.Theamountallottedforqualityimprovementwhichincludestraining, family planning equipment, other service deliveryactivities,humanresourcecost,infrastructureshare,planningand monitoring (including quality assurance) and familyplanningcommoditiesisasfollows:

year 2013-14 2014-15 2015-16AmountinCrores 1000.7 1648.07 1243.9

11.TheMinistryofHealthandFamilyWelfareoftheGovernmentof India reiterated that ithasconstantlybeenworkingandtakenadequatesteps for improvementandsuccessof theFamily Planning programme. It stated that over the yearsconsiderable amount of work has been done and is stillbeing done particularly in sterilization procedures in publicand private health facilities. While deficiencies and faultshavebeenpointedout, there hasalsobeenconsiderableimprovementinanongoingexerciseofnationalimportance.

SUBMISSION By STATE OF BIHAR

TheStateofBiharfiledtwoaffidavits-aStatusReportandWrittenSubmissions. The state also acceptedall the allegationsmadeby Devika Biswas regarding fundamental rights violation atsterilizationcampsandacceptedthatJaiAmbeyWelfareSociety(NGO)conductedasterilizationcampon7thJanuary2012.Thestateagreedthatthecampwasheldlateintheevening,whichstandsinviolationoftheordersoftheconcernedCivilSurgeon.AnFIRwas lodgedagainst theNGOforviolating thedirectivesanddistributingexpiredmedicinetothewomenwhohadbeenbrought to the camp for the purpose of sterilizing. A ChargeSheethasbeenfiledinthisregardandcognizanceofthisoffencehasalsobeen takenby the TrialCourt,but thedetailsarenotavailableonrecord.

KumarNathChoudhary,SecretaryofJaiAmbeyWelfareSociety(respondent No.4) confirmed through an affidavit filed on 14th


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January2013,thatJaiAmbeSociety(NGO)hasbeenblacklistedand that appropriate steps were being taken to compensatewomenwhohaddevelopedcomplicationsduringthesurgeries.Twochargesheetswerefiledinthisregard-KursakantaP.S.CaseNo.03/2012andCaseNo.05/2012. Three FIRswerealso lodgedagainsttheNGO,namely:

1. KursakantaP.S.CaseNo.03/2012:ChargeSheetbearingNo.23 of 2012 dated 09.03.2012 and supplementary ChargeSheetNo.167of2012dated31.12.2012havebeensubmitted.Cognizanceof theoffencehasbeen takenand thereafterRevisionApplicationNo.44/369/12hasapparentlybeenfiledby the accused persons and that is pending in the DistrictCourtinAraria

2. Kursakanta P.S. Case No.05/2012: Charge Sheet No. 24 of2012dated12.03.2012andsupplementaryChargeSheetNo.87of2013havebeensubmitted.Cognizanceoftheoffencehas been taken on 28.06.2012 and a Revision Petition hasapparentlybeenfiledbytheaccusedbearingNo.31/226/13whichispendingintheDistrictCourtinAraria.

3. Kursakanta P.S.CaseNo.14/2012: Nodetailswereprovidedwhichisamatterofconcern.

TheaffidavitalsostatedthatafterthecompletionofinquiriesbythestateofBiharintotheeventsthattookplaceon7thJanuary2012,ashowcausenoticewas issuedtotheMedicalOfficer inchargeinthePrimaryHealthCentreinBausa,Purnia,Kursakanta,ArariaandalsototheCivilSurgeon,Purnia.

SUBMISSION By STATE OF MAHARASHTRA

TheStateofMaharashtra,filedonlyoneaffidavit14thAugust2012.In its submission, it stated that the family planning programmeis beingconductedeffectively.On thecontraryDevika Biswasandotherhealthgroups submittedampleevidence todisputethis assertion. Women continue to experience fundamentalrightsviolationatsterilizationcampsinIndiaeveryday.Thiswasprovedby incidents that tookplace in sterilization camps thatwere held in Nagpur,Chandrapur andGadchiroli districts, the

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statehadaskedforadetailedfromtheCivilSurgeon,Gadchiroli,ChandrapurandNagpurDistrict.

The counsel for the petitioner submitted a report on conditionof women in sterilization camps in Maharashtra highlightingthat sterilization camps are routinely conducted in unsanitaryandunsafefacilitieswherepatientsdonothavecompletepre-operative counselling in Nagpur, Chandrapur and Gadchirolidistricts.ThestateofMaharashtrainitsaffidavitclaimedtohavetakeimmediatecorrectiveactionandinstructionswereissuedtoall theDistrictHealthOfficersandCivilSurgeons toperformthefamily planning operations as per the standards prescribedbyGovt.ofIndiainhygienicconditions.

ThestateofMaharashtradidnotprovideanyevidencedetailedreportwiththeaffidavitandalsofailedtoprovidedetailsofanyactiontakenagainstanyofficerresponsibleforthemishaporanycompensationpaidoranyfurtheractiontakeninthisregard.

SUBMISSION By STATE OF RAJASTHAN

InresponsetothereportandviolationshighlightedinthereportbyManjariandCentre forHealthandSocial Justice, the Stateof Rajasthan filed an affidavit on 23rd November 2012. It didnotcontradicttheeventsrelatingtothesterilizationprocedurescarriedoutinBundidistrict.ThestateinitsaffidavitaffirmedthatthestandardoperatingproceduresarebeingfollowedandthatthefailurerateisinconformitywiththefailurerateprescribedbytheGovernmentofIndia.

Despitethetestimoniesofseveralwomenthatwererecordedandfindingsbasedon interviewsconductedwith749women (whoweresterilized)theStateofRajasthanstatedthatthewomenwereproperlyinstructedbeforeoperationandadvisedwithrespecttoboth the sterilizationaswell aspost-sterilizationcare. The Statefurthermentionsthatcontinuouseffortsaremadebythehealthemployees“tomotivatefemalestotakeupsterilizationsurgery”.The State also submitted that it was taking sufficient steps toensure implementationof thedirections inRamakantRai (I)aswellastheguidelinesoftheGovernmentofIndia.


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SUBMISSION By STATE OF CHHATTISgARH

TheStateofChhattisgarhconfirmedthatsterilizationcampswereorganizedinSakrivillageofBilaspurdistricton8thNovember2014and inGorela, PendraandMarwahi in Bilaspurdistrict on 10thNovember 2014. There were 137 operations that were carriedout after which several women ended up with severe healthcomplications.Consequently,allofthemwereadmittedinnearbyhospitalsfortreatment.Unfortunately,13womendied.Apart137,fivemorepeoplehaddiedduetoconsumptionofCiprocin500tablet.Hencebringthetotalnumberofdeathto18.

Departmentalactionformedicalnegligencewastakenagainstthe doctors who were involved in sterilization surgeries at thecamp.Twoofthemhavebeendismissedfromservicewhiletwoothershavebeensuspendedpendingadepartmentalenquiry.The Licensing Authority has also been suspended. The stategovernment claimed that Rs. 4 lakhs compensationwasgiventothefamiliesof thosewhodiedandRs.50,000/-wasgiventothosewhoweredischargedfrommedicalinstitutions.Asclaimedby the state government, the children of the deceased havebeenadoptedbytheStateGovernment.Thesechildrenwouldbeprovidedfreeeducationandhealthcaretilltheyare18yearsofage.TheStateGovernmenthasalsoputinanamountofRs.threelakhinafixeddepositforchildrenofthepersonswhodiedinthetragedy.Thechildrenwouldbeentitledtotheamountonattainingtheageof18years.

The state submitted that a one person Judicial Commission ofInquiry headed by a retired District Judge Ms. Anita Jha wassetup.Thiscommissionprobeintothecasualtyof13womeningovernment-run sterilization camps in Chhattisgarh’s Bilaspurdistrict and cited the administration of substandard poisonousdrugsandmedicalnegligenceasthecausesofdeath.ThereportgivenbytheMs.AnitaJhaCommissionhasbeenacceptedbytheStateGovernmenton10thAugust2015.Thereportwaslikelytobeconsideredby the StateCabinetwithin twoweeksof itssubmission.

AchargesheetNo.19/2015dated15thFebruary2015hasbeenfiledintheCourtofJudicialMagistrate,FirstClassatBilaspuragainstDr.R.K.Gupta,RameshMahawar,SumitMahawar(manufacturers

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ofCiprocin500tablets),RajeshKhare,RakeshKhareandManishKhare(suppliersofCiprocin500tablets).RakeshKhareandManishKharehavesincebeendeclaredproclaimedoffendersandtheirpropertyattachedandarewardfortheirarrestandinformationoftheirwhereaboutshasalsobeenannounced.

In order to prevent the recurrence of such an incident,Chhattisgarh has phased out sterilization camps and begunplacinggreater emphasis on spacingmeasures. The statealsoencouragedvasectomyforgenderequity.AnadvisoryhasbeenissuedthatCiprocin500shouldnotbeconsumedandeffortsarebeingmadetoeducatepeopleabouttheimportance,benefits,methods andavailability of services in health facilities. Amassawarenesscampaignhasalsobeenlaunchedandseveralotherproactivemeasureshavebeentaken.TheStateofChhattisgarhhasreactedpositivelytothetragedyandhasnotsoughttohideinconvenientfactsunderthecarpet.

SUBMISSION By STATE OF kERALA

TheStateofKeralainitsaffidavitstatedthathasfileda‘StatementofFacts’throughaletterdated15thMarch2013.Aspertheletter,campsinKeralawereconductedonlyinwell-equippedcentres(usuallyinfirstreferralunitsandabovehospitals),whichcomprisedof proper operation theatre facility, lab facility, and referralfacility. The state further stated that sterilizationproceduresarecarriedoutinhygienic,wellequippedhospitalsunderthecontrolandsupervisionofqualifiedempanelleddoctors.

As per the affidavit filed by State of Kerala on 1st July 2013, itreiteratedthat:

“[The]tribalpopulationofKeralaStateisaccordedspecialconsiderationforitsdealingmembers.ThereisnocompulsionofpromotionofsterilizationaspartofGovernmentpolicy.Atthe same time family planning services are not denied tothis segmentof thepopulation ifdemanded. FeltneedofthecommunityisassessedbytheHealthWorkerandvariousoptions are put before them explaining the merits anddemerits of eachmethod and encouragingmaking rightchoice.”


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The Statement of Facts could not be put on record becausetherewasnoevidenceprovidedand itwasnotannexedwiththeaffidavit.ThestatealsodidnotdenyanyofthesubmissionsthatweremadeinthePILfiledbyDevikaBiswas.

SUBMISSION By STATE OF MADHyA PRADESH

TheStateofMadhyaPradeshfiledonlyoneaffidaviton7thAugust2013. The state did not deny any allegationsmadebyDevikaBiswas.Thestateinitsaffidavitstatedthatsterilizationoperationswerecarriedoutonlyafterwomenmadean informedchoiceand gave consent. The State further submitted that the stateGovernment has issued instructions for taking due precautionsfor sterilization operations. The State Government has formedQualityAssuranceCommitteeineachDistrictoftheState,whichisheadedbytheChiefMedical,andHealthOfficerofthedistrict.ThefunctionoftheQualityAssuranceCommitteewastoreviewall types of caseswhere there is some complication and takenecessarystepstorectifythesame.Yet,thestatedidnotdenyanyeventsinBalaghatdistrict.

DEVIkA BISWAS SUBMISSION

Devika Biswas has pointed out that the entire Family PlanningProgrammefocusesonfemalesterilization,aswashighlightedinaffidavitsfiled.Targetsaresetbythestateforfemalesterilizationand the National Health Mission Project Implementation Planallocates 85% of the family planning budget exclusively tofemalesterilization.AsperthestatisticsprovidedbytheMinistryofHealthandFamilyWelfareoftheGovernmentofIndia,97.4%ofallsterilizationproceduresduring2012-13wereofwomen.Thishasgoneup to 98.1% for 2014-15. Theaffidavits filedby StateslikeMadhyaPradesh,AndhraPradeshandGoaconfirmedtheallegationsmadebyDevikaBiswas.Whatwasequallyworrisomeinthefactsubmittedbystateswasthatnumberofmenseekingsterilizationisverylow.

As per the data releasedby theMinistry of Health and FamilyWelfare during the period 2010-13, at least 363 people havediedasa result of sterilizationprocedures. Thereareequally a

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largenumberofproceduresthathavefailedandsurgeriesthathave led to severecomplicationswith respect topersonswhounderwentasterilizationprocedure.ThishasresultedinpaymentofcompensationofatleastRs.50crores.

Lack of proper implementation of the various processesand guidelines issued by the Government of India has led todeathsofwomenacross thecountry.Hencemere issuanceofguidelinesbytheGovernmentofIndiadoesnotguaranteetheirimplementation.ItwasalsopointedoutthatdespitetheHon’bleSupremeCourt’sorder, the listofempanelleddoctorsstill isnotreadily available; consent forms are not available in the locallanguageexceptintheUnionTerritoryofPuducherry;unrealistictargetsandpressurefromtheauthoritiesforcontraceptivewithaheavyfocusonfemalesterilizationhasresultedinnon-consensualandforcedsterilizations.Someyoungpersonshavebeensterilizedtomeettargetsandbyandlargeilliteratepersonsaresterilized.DevikaBiswasisopposedtosettingoftargets,butunfortunatelyStateGovernmentsandUnionTerritoriesarestill setting informaltargetsforsterilization.

TheQualityAssuranceCommittees(QACs)attheStateandtheDistrict Quality AssuranceCommittees (DQAC) levels needs tobe strengthened to ensure that the standards for female andmale sterilizationas laiddownby theGovernmentof Indiaarebeingfollowedinrespectofpreoperativemeasures,operationalfacilities and post-operative follows ups and aremonitored bythe Quality Assurance Committees formed at the State levelundertheChairmanshipofthePrincipalDirectorandtheDistrictCollectorattheDistrictlevel.DevikaBiswaspointedoutthatthevital information is not available on thewebsite of theMinistryof Health and Family Welfare. This included the details of theconstitutionofQACsandDQACs,thestepsanddecisionstakenortheminutesoftheirmeetingsorreportssubmittedbythem.Henceit is of utmost importance that there is transparency regardingexistinginstitutionseffectivelyandefficientlyfunctioning.

Inadequate monitoring mechanism of sterilization camps andfacilitieswasproved through incidents thatwerebrought forthduring the hearing. Essential standards as prescribed for the


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serviceswerecompromisedandtherewasnomonitoringdonein the sterilization camps and health centres, to ensure qualityservices. In all the camps accountability measures were notfoundtobeinplaceandtherightsofthousandsofwomenwhoundergosterilizationprocedureswereviolated. It isnotenoughfor theGovernmentof India to showthat it ismerelyplayingasupportiveandfacilitativerolesincethecampaignisanationalcampaignandif it isnotproperly implemented, itmerely leadsto passing the buck with the State Government blaming theGovernmentofIndiaandviceversa.

With sensitive operations such as a sterilization procedure, it isimportant for there to be some formof accountability againstthosewhoareresponsibleforprovidingthesehealthcareservices.It is unclear even after submissions if disbursements in case ofdeath,failure,complicationetc.aremadeavailableanywhere.Thereisnoindicationofthenumberofclaimsfiled,thenumberof claims rejected and the reasons for the rejection and theamountprovidedtoeachsuccessfulclaimant.ItisobservedthatspecialistswhoareconversantwiththeSchemearenotavailableatsterilizationcampsandhealthcentrestoexplaintheSchemeindetailsothatthereisnodifficultyorcomplicationfacedintheeventofanunfortunatemishap.Thedeathauditsarecompletelymissing inevery instanceeventhoughit isarequirementunderthescheme.

In most of the camps it was observed that people seekingsterilization have not been guided or provided with correctinformationthathas ledto lackofawarenessamongstwomenabouttheprocedure.Infact,allinformationthatisdisseminatedwith regard to the sterilization procedure should be madeavailableinthelocallanguageatallGovernmenthealthfacilitiesandaccreditedprivatefacilities.

The petition encouraged the Government of India to look atthequalityofcaremadeavailabletopersonspostasterilizationprocedure.AsisclearfromvariousdocumentsonrecordincludingtheMs.AnitaJhaCommissionReport,after-carefacilitiesintermsofcounselling,assistance,follow-upetc.aretotallyabsent.

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CHHATTISgARH MASSACRE

“Chaiti Bai, a Baiga — aprotectedtribewassickwithjaundice and the mitanintold her that she could goto the Community HealthCenter for treatment. Themitanin never mentionedsterilization or familyplanning. Chaiti Bai diedafteroperation.Shewasjust

22yearsoldandamotheroftwochildren.”

Themajor fallacies of the sterilization programme of India arerevealed through the Chhattisgarh sterilization massacre thatshooktheentirestateandincitednationwideprotestsagainstthefamilyplanningprogrammeofIndia.

Themass sterilization camp in Chhattisgarh in November 2014resultedintragicdeathsofthe13womenwhowereintheir20sand30s.While13died,morethan70womenwereleftincriticalconditionfollowingproceduresoflaparoscopicsterilization.TheyhadtobehospitalizedatApolloHospital,Bilaspur. This incidentwas one that raised grave questions once again about thecalloustreatmentgiventowomen,aswellastheclearviolationsofethicalandqualitynormsinthehealthcaresystem.Inseveralinterviewswiththewomenandtheirfamilymembers,theysharedneverendingtalesofunsafe,unhygienicconditionsatthecampandthecarelesswaythesterilizationswereconductedresultingindeathsandmorbiditiesamongthewomen.

On 08.11.2014, a single doctor performed sterilization surgerieson83womeninNemiChandTrustPrivateHospitalinSakritown(Takhatpur District). It was an abandoned private charitableHospitalandResearchCentrelocated6kilometersfromBilaspurcity.Thehospitalhadbeenshuthenceitwasnotcleanedforlongandwasstinking.Therewerenoplans,initiallytoconductcampatSakrihoweveritwasdeliberatelychangedbecauseitwaseasiertobringmorewomen for operation in this area. Similar camps


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were organised on 10.11.2014 in PHC/CHC at Gorela, PendraandMarwahblocks,Chhattisgarhwhereinhumanesterilizationscontinuedwith reckless disregard for the lives of poorwomen.Nearly140womenwerebroughttothesecampsforsterilization.Thelargestofthesecampsfor83womenwasconductedwithinashortspanof3-4hours.

This unnecessary loss of life took place as the Government ofChhattisgarh, inordertofulfillthe‘numbers’ inthistarget-driveninitiativeofcurbingpopulation,providedincentivestothepoorfamilies tomake theirwomenundergo sterilizationprocedures.As it has been reported, none of the women had ever beencounseledaboutsterilization.Theywerenotmadetounderstandwhatwouldhappenbefore,during,andafterthesurgery,itssideeffects,andpotentialcomplications.Theydidnotknowanythingabout theconsent forms that theyweremade to signon. Thewomen after going through surgeries, done using the samelaparoscope, weremade to lie on dirtymattresses placed onthefloor. Some reportshave stated thatwomenwerepaid fortheoperation.However,theyhavedifferedonhowmucheachonewaspaidwithsomesayingtheamountwasRs.1400/-,whileothershavesaiditwasRs.600/-.

As per the Anita JhaCommission’s Report, evidence from thevictimsandtheirfamilies,CMHO,BMO,civilsocietygroupshaveclearlyrevealedtheviolationsoftheguidelineslaiddownbytheHon’bleSupremeCourtinRamakantRaivs.UnionofIndia&Ors.andguidelineslaiddownbyMinistryofHealthandFamilyWelfareinStandardOperatingProcedureforSterilizationServices(2006,2008) leading to thedeathof 13women,and serious illnessofmanymore.

Itshouldalsobenotedthatthewomenwhowereselectedwerenotselectedatrandom.TheverybasisoftheIndiansocietywhichisdefinedbydiscriminationatall levelscanalsobeseeninthewomenwhowereforcedtogothroughthisprocedure,onlytobeaddedtothenumbersofthistargetdrivenprogramme.AmongstthewomenwhodiedmanybelongedtotheDalit,Adivasi/Tribaland OBC (Other Backward Classes) communities. Most of thefamilieswerelandlessandtheirmainsourceofincomewasdaily-

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wagework.Manywomenwho lost their lives had up to threechildren. Some of them, with infants as small as three monthsold, had undergone the sterilization surgeries. A woman fromBaigaProtectedTribalCommunitywasbroughttothecamponpretextoftreatmentforweaknessbutwassterilizedinstead.Shelike theotherwomenwasoperateduponand leftonmattressunconscious.Thewomandiedleavingbehindsmallchildren.

The Chhattisgarh Government attempted to wash off itsresponsibilityforthedeathsofthepoorwomenwhowerekilled.Itstatedthat,“theemergingevidenceshowsthattheimmediatecauseofthedeathscouldbeeitherpolluteddrugsorsepsisfromrustyor infected instrumentsusedduring the surgery. Thedrugsadministeredapparentlyshowedtracesoftoxicsubstances.”Thesterilization camps in the HealthMinister, Amar Agarwal’s ownconstituency(oneofthemashortdistancefromhisownhome)hadabysmalstandardsofbasichygiene. ItwasfoundthattheOperationsweredoneonthefloor,withlackofproperamenitieswomenwerepiledontobeds,rustyandinfectedinstrumentswereused. Thedoctor (sincearrested)performed83operations in5hours.TheStateGovernmentmustsquarelyacceptresponsibilityforthetarget-drivenandincentive-drivenapproach.

With pressure building up from themedia andwomen’s rightsgroup, the then Chief Minister of Chhattisgarh, Raman Singhstatedthatitwasaseriousmatterofnegligenceandthatitwasunfortunate. Further,when theattempts to cover up the grossmismanagement of the sterilization camp, completely failedthe surgeon, who had been previously honored by the StateGovernmentforthe‘distinction’ofconductingthe‘maximumnumberof sterilizations’,Dr R. K.Guptawas suspendedon thecharges of negligence. He along with a doctor who had notrainingorexperiencehadperformed the ill- fatedprocedure,whichresultedinthedeathofthirteenwomen.

There were also reports of the women having fallen ill afterconsuming Ciprofloxacin tablets that were provided to themfollowing the surgeries at theCamp. State officials initially saidthat theybelieved that thewomen hadcontracted infectionsbecauseofthepoorconditionsinthecamp.Itwasalsosuspected


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that theCiprofloxacin tabletsgiven to thewomenpost-surgerywere contaminated with zinc phosphide, a rat poison. ThePolice detained Ramesh Mahawar and Sumit Mahawar –fatherandson,who runMahawarPharmaceuticalsPvt.Ltd.;aChhattisgarhbasedPharmaceuticalsCompany,whichsuppliedtheCiprofloxacin.Whilethepostmortemreportshavebeenkeptunderwraps, it iswidelybelieved that thecauseofdeathwasduetosepticemia.

ThecampswereincontemptoftwoofSupremeCourtordersinthemattersofRamakantRaivsGovt.ofIndia,2005,and“DevikaBiswasVsGovt.ofIndia,2012”whereSCorderedrestrictionsonsterilizationprocedures.Thecasesmandatethat“amaximumof30operationscanbeconductedinoneday,withtwodifferentsurgeries only in a government controlled facility.” In addition,“onedoctorcannotconductmorethan10sterilizationsinaday.“Despitethis,Dr.Guptaperformed83surgeriesinabout5hours,aclearviolationthatapparentlywasnotoutofthenorm.

Reportsofdoctorsperformingover theacceptablenumberofsurgeriesinadayabound:

Health workers in Gujarat told Human Rights Watch thatbetween40and150womenaresterilizedinweeklycampsin their district. Dr. Abhijit Das from the Centre for Healthand Social Justice, a leading Delhi-based health rightsorganization, told Human Rights Watch that he found atleastonegynecologistinMadhyaPradeshstateconducting250to300sterilizationsonsomedays.

In one state, a study found that the state’s approach tofemale sterilization forceddoctors in thepublichospital tocommitsomuchstafftimetosterilizationcampsthatotherbasicreproductivehealthcaresuffered.Acivilsocietyteamthat investigated maternal deaths in Barwani district ofMadhya Pradesh state found that the senior gynecologistfrom the district hospitalwas absent four days in aweek,performingsterilizationsincamps.

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Policereportedthatthelocationoftheprocedureswasdirtyandwiththespeedoftheoperations,therewascertainlynotenoughtimetochangebloodysheets.Thecleanlinessoftheinstrumentsisquestionableatbest.Dr.Guptawasquotedsaying,“theyaredippedinspiritafteranoperationandthenreused.IfIfeelitisnotworkingwellIchangeit.Idoabout10operationswiththesameknife.Towelclipsarealsoreusedafterbeingdippedinspirit.”Dr.Guptaalsosaidthedirtyconditionsoftheabandonedhospitalwere “normal”, sparking serious concern for conditions aroundIndia.

Additionally,post-operativeprocedureswerenotfollowed,asthewomenreceivedvirtuallynofollow-upcare,asisreportedlytheroutineforsterilizationproceduresinpracticeacrossthecountry.Adoctorcaringforthewomenwithcomplicationsreported,“Theydischargedthemimmediately”.Iftheyhadvisitedthesewomenaftertheoperation,thetragedycouldhavebeenaverted.Thepatientscameontheirownonlyaftertheirrelativesrealizedthattheyhadbecomeserious.

It should be noted that the incentives which are provided bythe state, encourages, and often even forces doctors intocommittingthesegrossviolationsofcourtorders,regulations,andhumanrights.ThestateofChhattisgarhclaimedthatthetainteddrugsresultedinthewomen’sdeaths.However,manyprominentforensicexperts,doctors,andactivistshavearticulatedthedrugstoryinaredherring,meanttodistractfromcrucialshortcomingsinhealthservicesdelivery,grossneglectforhygieneandinfectionprevention,and rampantundignified treatment. Theseabusivecamps continue undeterred without meaning accountabilitymeasuresfromtheSupremeCourt.

The drugs cannot be solely responsible for the women’sdeaths.First,asforensicexpertstatedinthePopulationFoundationofIndiareport,anadulthumanwouldhavetotakeaverylargequantityofratpoisontoactuallydie.Thereportstated:

“Furtheraccording to forensicmedicineand toxicologyexpertanadultmaleneedtoconsume5gmofzincphosphidetodie.Foraverageadultwomenthiswouldbe4.5gm.Thisifconsumed


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inonegoorslowlyoveraperiodwherebuyitgetdepositedinthebody.Thecontaminatedmedicineswereof500mgof theantibiotic.Eventhoughitisimpossiblebutforthesakeofargumentifweassumethattheentire500mgwaszincphosphideawomanwould need to consume a minimum of 9 tablet to make thepoisonfatal,whichwasnotthecasewiththewomenwhodied.Soitiscompletelythatzincphosphideinthemedicinescouldnothavebeenthemajorcauseofthesedeath,evenifweacceptthattheycouldhavebeenoneofthecauses.”

TheDown toEartharticleexplains that soonafter the incident,drug samples from the spot were sent to 4 Laboratories-Governmentandprivate-todeterminethecauseofdeathsandillness.ThelistincludestheCentralDrugLaboratory,Kolkata;TheNationalInstituteofImmunology,Delhi;SriramInstituteofIndustrialResearch,Delhi;andQualichemLaboratories,Nagpur. All fourlaboratoryreportsstatedthatthemedicinesused inoperationsweresubstandard.

Down to Earth reports, “The National Institute of Immunology,Delhishowsthatafteradministeringveryhighdoseofthecrossin500(500mg/facts,orthesamedosagegiventoadulthumans)theanimalsufferedfromacutetoxicshockanddied.Apublichealth expert on condition of anonymity says such high dosescanbefatalforanimals. Itwaspointedoutthatthewomenatthecampdidnotconsumesuchhighdoses.

The state also tested viscera or organs of 5 of the deceasedwomen and found no rat poison in their bodies. ForensicexpertatLadyHardingeMedicalCollegeDelhi,BLChaudharytoldDown To Earth, “viscera report is the finalword in forensicscienceininvestigationsofdeath.Thestateforensiclaboratoryreports suggest the deaths occurred due to infection causedbyunhygienicconditionsandmedicalpracticesatthecamp”.Interestingly,thegovernmentdidnotsendviscerasampleforthewomenwhosepostmortemreportlists“shockduetosepticemia”asthecauseofdeath.Septicemiaisabloodinfectioncausedbyunhygienicoperatingconditions.

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Moreoverifalargebatchofbasicantibioticwassocontaminatedastocausedeath,manymorewomenatthecampwouldhavediedandmanymorepeople in theareawouldhavesuffered.MoreoverpoorqualitydrugsdonotcountforthedeathofChaitibywhodiedafterundergoingsterilizationatasimilarmasscampon10thNovember2014daysafterthemajorcamp.

InApril2015theCollisionagainstCoercivethePopulationPolicyandtheNationalAllianceforMaternalHealthandHumanRightsorganisedacampaign todocument the realityat theCamppostChhattisgarh.Theteamsobserved6campswhereatotalof59womenunderwentsterilizationinUttarPradeshfromJanuarytoMarch2015.Thereporthighlightsthefollowingmajorfindings:

1.Noneofthewomenreceiveddischargesliporsterilizationcertificate

2.NoneofthewomenreceivedcounsellingaboutSideEffectsassociatedwithsterilization

3.Noneofthewomenreceivedinformationaboutthefamilyplanningindemnityscheme

4.InallcampHealthcareworkersfailedtoreadthecontentsoftheconsentform

5.Noneofthewomenreceivedslipsorreportsregardingthemedicaltesttheyunderwent

6. Inthecampsdoctorsused just2Levelscopestooperateonmorethan30women(soprequiresthreelaparoscopes)

7.Twocampscontinuedafter4p.m.inviolationofsop

8.UnhygienicconditionsatStreetdogsatthecamp

9.Noattentiontopostsurgerycare

AtKarviPublicHealthCentretheoperationtookplaceinthedeliveryroomeventhoughthefacilitydoeshaveaseparateoperationtheatre. The medical professional completely disregarded thewomen’s dignity andprivacyother peopleWalked inandoutoftheroomduringsurgeryanddeliveriescontinuedsidebyside


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sterilizationsurgeries.Thefacilitydidnothavearecoveryspace;“aftertheoperationwomenlaydownontheverandahonredcolourthickclothes.”Thestraydogsroamedfreely.

At the Pahari Community Health Centre camp 35 womenunderwentsterilization.Noneofthewomenreceivedcounsellingand Information about the family planning indemnity scheme.Theoperationtheatrewasnothygienicandthedoctoroperatedonthreewomensimultaneously.AfterthesurgerynoHospitalstaffcametocheckonthewomen’sstatus.

The violations inChhattisgarh neverwould havecome to lighthavesomanywomennotdiedatonce,drawingattentiontotheincident.Itisimportanttonote,however,thatthiswasnotaone-time,unusualevent.ConditionsforsterilizationandimplementationofsterilizationinitiativesacrossIndiaarelacedwithdanger,whichisdisproportionatelytargetedatpoorwomen.

THE JUDICIAL COMMISSION REPORT- MS. ANITA JHA

PostChhattisgarh sterilizationmassacre, the StateGovernmentconstitutedsingle-membercommissiontoprobethedeathsof13womenfollowingthesterilizationsurgeriesBilaspurdistrictthathasstatedthat“seriousnegligence”anduseof“substandard”and“poison-laced”medicinesledtothetragicincident.

The enquiry by the state government on the given incidentrequiredtheconstitutionofacommittee,whichwouldinvestigateintothefollowing:

1.Were StandardOperatingProcedures (SOP’s henceforth)followedinconductingthesterilizationcamps?

2.Identificationofgaps,whichleadtotheoccurrenceoftheincident?

3.Werestandardmedicinesusedinthecamps?4.Identificationofindividualsresponsiblefortheincident?5. Identification of ways to prevent such incidents from

occurringinfuture?6. Suggestions for a gender equity approach on family

planningpracticesinthestateofChhattisgarh?

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7. Identification of other issues of public importanceapplicable to the incidentas foundduring thecourseoftheinvestigationprocedure?

Asper theAnita JhaCommission’s Report, it isan indisputablefactthaton8thNovember2014campswereorganizedinNemiChand Trust Private Hospital in Sakri town (Takhatpur District)and similar camps were organised on 10th November 2014 inPHC/CHCatGorela,PendraandMarwahblocks,Chhattisgarhwhere inhumane sterilizationscontinuedwith recklessdisregardforthelivesofpoorwomen.Evidencefromthevictimsandtheirfamilies,CMHO, BMO,civil societygroups has clearly revealedtheviolationsoftheguidelineslaiddownbytheHon’bleSupremeCourt inRamakantRaivs.Unionof India&Ors.andguidelineslaiddownbyMinistryofHealthandFamilyWelfare inStandardOperating Procedure for Sterilization Services (2006, 2008). 83women were sterilized on 8th November 2014 out of which 13women died during the treatment. Other women were lateradmitted in Bilaspur Apollo Hospital due to serious illness. Thesterilization camps maintained a target-based approach tosterilization.

A single doctor performed sterilization surgeries on 83 women.Thesewomenwhowere not providedwith any information orcounsellingwereprimarilymotivatedbyASHAworkers.A lotofwomen coming to the camp did not know about sterilization.Hence some women thought they were going to be treatedfor weakness. The consent form was not read out to women,thefloorsandbathroomsweredirtyandstinking.Soonaftertheoperation,womenwereaskedtogohome.Theywerenotissuedanycertificateorgivenaftercareservices.Womenweregivenmedicines,whichfurthercausedproblemslikevomiting.

Members of the families of thesewomen later stated that thesurgeryofthewomenhadbeencompletedwithin2-4minutes.Aftersurgerytheywerelaidonfloormattresses.Thefloorwasnotcleaned.Thewomenwerethendischargedin20-30minutesafteroperation.Sterilizationcertificateswerenotprovided.


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BaigaProtectedTribalCommunity-HusbandofChaitaBaistatedunder oath that they did not want a sterilization operation.ChaitaBaiwasweak,henceusetostayunwell.ASHAworkertoldthemthatChaitaBaicouldgettreatmentforweaknessbutdidnotinformherthatshewasgoingtogetChitaBaisterilized.HerhusbandonlycametoknowaboutChaitaBai’ssterilizationafterhiswifehadbeenoperateduponandwaslyingunconscious.Thecouplewasnotgivenanycertificate,reportsoftestsconductedormoney. Theyweregiven two stripes of ciprocin 500mgandI-Brufin400mg.Hiswifediedthenextdayaftertaking2-3dosesofmedicine.

Operationsweredonewiththehelpofatraineedoctor.Therewasjustone laparoscopemachineused tooperateon83women.Asper theRamakantRaiguidelines,no ruleswere followed formaintainingachecklistand standardconsent form,Pro-forma,wasnotfollowedinboththecamps.Therewereseriesofviolations,whichledtodeathsofinnocentandmarginalizedwomen.

The Standard Procedures Were Not Followed in ConductingCamps

1. Dr. Rishi Kumar Bhange, CMHO Bilaspur stated underoath that for conducting such sterilization camps anadministrative committee is set up which comprises ofthe District Collector, MVO, and Nodal officers amongotherspecialist.Thecommitteehastoinspecttheprivatehospitalbeforegivingtheirapprovalforanycamptobeconducted on private hospital premises. The committeehadnotrecommendedthisprivatehospital,andwasnotawarethatacampwillbeconductedhencetherewasnoinspectionthatwasdone.

2.AcalendarispreparedontherequisitionofFamilyPlanningOfficer for each block of district for the purpose ofconductingmonthlycamps.Asperthiscalendaracampwas to be organized in Kota block. In Sakri (TakhatpurBlock)therewasnoplanoforganizingcampon6thand8thNovember2014.IfthereisanycorrectionrequiredindateandaddressthenBlockmedicalofficereitherinwritingor

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through personal meeting can request the DHO for thesame.A localmeetingwasconductedon3rdNovember2014,whereDr.Ari(DistFamilyPlanningOfficer)sharedthatacamphastobeorganizedon8thNovemberatPendari.Hewas not physically present at themeeting.Membersofthemeetingdecided(aftertalkingtoDr.Arionphone)toconductcampatPendari.Dr.Bhangeinhisstatementstated that there was no such permission granted toconductacampatNemiChadHospital.

3.Dr.Tiwari(BMO)hasstatedunderoaththatnocampwasplanned for Sakri (Pendari)on8thor 10thNovember2014(page23,point36)and thathehadnot informedCMOaboutthechangeinwritingorthroughanyothermeans.

4.Theoriginalplanasperthecalendarwastoconducthealthcamp at Kota on the 8th November 2014. However, theplanswerechangedwithoutinformingCMO.Dr.Khetrapalconducted the health camp in CHC in Ratanpur on 8thNovember2014becausetherewerenotenoughwomeninKota.TheCMOwasinformedaboutthischangeofplan.

5. Dr. Saxena (CMO) stated that Nemi Chand hospitalwas non functional before 8th November and was notrecommended for organizing any camp in 2014. Alsoothercommitteemembersandofficialshadnotgivenanyrecommendationforthesame.NemiChandTrustHospitalwasnotgivenanyrecognitionformaternalhealthcampsin2014.

6.AsstatedinthereportthataccordingtoMoHFW“undernocircumstances should sterilizationcampsbeorganized inaschoolbuilding/publicPanchayatBhawanoranyothersuchsetup.CampsshouldbealwaysorganizedeitheratCHCsorPHCs.

7. AsperDr. Tiwari-Hehasconductedmanysimilarcampssince 2006 where more than 30 women in each campweresterilized. In2014,throughaletterfromCMOoffice,a targetof2100womenhadtobemet.Aspermeetingon3rdNovember, itwasestimatedthatapproximately40


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womenwouldcometothecamp.Dr.TiwarialsoconveyedthistoDr.Guptaonthedayofthecamp(overthephone,inmorning)

8. Dr. Dhurve (Camp Incharge) shared that Dr. Tiwari hadinformedhimof thecamp tobeorganizedon8thon7thitself. Hence, when Dr. Dhurve reached the venue on8that10am, registrationswerebeingcarriedoutat thattime.TheOTwaslockedhencehedidnotinspect.

9.Dr.Gupta(surgeon)wasaccompaniedbyafemaletraineedoctor(fortraining)whowasnotfromBilaspur.RamakantRaiGuidelinesviolated,thetraineedoctorassistedintheoperations.

10. As per Saxena, Dr.Guptawas not given anywritten orverbal instructions for camp on 8th November 2014 atNemichand. Dr. Saxena admitted that the surgeries atNemiChandhospitalweredonewithoutthepermissionofChiefMedicalOfficer.

11.HealsostatedthatBMOsentonlyonedoctortothiscampwhere83womenweresterilized.Theyhavenoinfoaboutthenumberof laparoscopymachinesused for surgeries,whichisaclearviolationofSupremeCourtguidelines.

12.Onanaveragetimespentoneachsurgeries is from10-12minutes(i.e.only30surgeriescouldhavebeenpossiblefrom2-7Pm)Butatotalof83surgeriesweredoneinsameperiod.Hence3-4minuteswerespentoneachoperation.

13. Dr. Dhurve did not fulfill duties of a campmanager Dr.Dhruve stated that he did not sign the list ofmedicinesrequiredforthecamp.Alsothesurgicalglovesorderedforthesurgerieswereonly35innumbers.

14. Dr. Dhurve also first stated that the certificate after theinspectionofarrangementsforcampisnotrequired.Yet,he submitted a certificate for the same (which he hassignedhimself)afteramonthofthecamp.Thecertificateismadeon8thDec2014.His justification is that theCMO

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officeaskedacopyof thecertificateandtheclerkwholatertookhissignatureonitpreparedthesaidcertificate.ItisevidentthatthecertificatesubmittedbyDr.Dhurveisonfalsefacts.

15.Beforeandaftertheoperation,thepatientsweremadetoliedownonmattressesonfloor.Lateronmorebedsheetswerebrought fromSakri tenthouseonce thenumberofpatientsincreased.Itishighlydoubtfulthatthesheetsfromtenthousewouldbesterilized.

16.Asper Ramakant Rai guidelines, no ruleswere followedformaintaining a checklist. Checklist (with seven points)required complete information of the male/femalebeneficiarybutitwasfilledasmereformalitywithoutnameofsurgeonandsealofconcerneddoctor.

17.StandardconsentformProformawasnotfollowedinboththecamps.Thecasecardofwomenwhoweresterilizedwasnotfilledproperlyandthestandardprocedureswerenotfollowedwhichresultedinsymptomsofinfections.

18. Medicine given to the patient after the surgery wereciprocin500andI-brufin400whichresultedindeathsandcomplications like vomiting, weakness after taking 2-3dosesofmedicines.

Some concerns of Chhattisgarh groups regarding the Judicial Commission and its report:

TheJudicialCommissionReportcompiledtestimoniesofwomenandfamilymembersofthosewhowereaffectedduesterilizationcamps. Thecommissiondidnotcommenton the statusof theaffectedwomenandtheir families, thestatusofcompensationand other services that the Government had announced forthem. The findings of the judicial commission were mostly ontheanticipatedlinesasstategovernmentthatthedeathswerecausedduetodistributionofsubstandardandpoisonousdrugsandmedicalnegligence.Thisishighlydebatable.


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Ms. Anita Jha’s appointment to the one person JudicialCommission raised some questions. Her recommendations on‘rewarding’ government and private sector employees, whoadopt family planningmethods, reflect her lack of knowledgeand understanding on the current debates and discussionsaroundreproductiverightsandcoercivepopulationpolicies.

Theway the Judicial Commission conducted the investigationwashighlydebatableandquestionable.Thecommissionmadenoattempttoreachouttotheaffectedwomenandtheirfamilies.AssharedbyalocalfieldworkerfromBilaspurdistrictonconditionofanonymity,“thecommissionhaspublishednotices inHindi inthelocalnewspaperstoinformthepublicabouttheprocedureforfilingtheaffidavit,buthowdotheyexpectilliteratepeopleinvillages toaccess this information?” Theaffected familieswereexpectedtoreadtheadvertisementoftheJudicialCommissioninthenewspaper(publishedon19thNovember2014)andtravelfrom20to100kmstoBilaspurtosubmittheiraffidavitsbeforethedeadlineof8thDecember2014.

Thefamilieswillingtofileaffidavitswerenotprovidedanysupportor given any legal advice. As per the stock taking report, thedeadlineforfilingaffidavitswasrevisedfrom8thDecemberto6thJanuary2015attheinsistenceofcivilsocietygroupsandbecauseveryfewaffidavitshadbeensubmitted.Attheendoftheseconddeadline, theCommission sent letters to the affectedwomen,askingallofthemtocomeonthelastdate,i.e.6thJanuary2015.ThewomenandtheirfamiliestravelledfromthedifferentblocksbutoncetheyreachedBilaspur,theyreceivednohelp.Theyhadtobearall theexpensesof travelandmakingof theaffidavits.Finallyaproportionofaffectedpersonscouldfile theaffidavitswithhelpfromlegalgroups likesKanooniMargdarshanKendra,HRLNandJanhit.

Thecommission’sreportstatedthatnegligenceinfollowingthestandard operating procedure (SOP) for holding tubectomycampsandsubstandardmedicinesledtotheincident.Dr.SuryaPrakash Dhaneria tested by commission of inquiry, ProfessorandHeadofDepartment,DepartmentofPharmacology,AIIMSRaipur,hasoathfullystatedthatonlyonechemicalCiprofloxacin

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ispresentinpowderforminCiprocintablet.Thereisnoadverseeffectofthesechemicalsonhumanbody.

All reports, including thepostmortem report,viscera report, thehistopathologicalreport,allpointouttothefactthatthesurgerieswhich were performed in the camp were done in completeviolationoftheguidelinesandinstructionsoftheHon’bleSupremeCourt.Thesurgerieswereperformedinamannerandinunhygienicconditions thatmadethewomensusceptible to infectionsandthe deaths were not due drugs which were administered, asthesamedrugshadbeenused inothercamps. Basedonthefacts and evidences gathered from the camp, the report ofthecommissionclearlyshowsthatstandardguidelineswerenotfollowedandmandatoryrequirementswereviolatedasaresultofwhichwomenwereinfected.Thecommissionheldthefollowingresponsibleforthetragedyandsuggestedforactionstobetakenagainstthem:

• TheBlockMedicalOfficer–Takhatpur,• On-dutycampmanageratTakhatpur• SurgeonperformingthesurgeryatTakhatpur• BlockMedicalOfficer–Gaurella• MedicalOfficer-CHCTakhatpur• MahavarPharmaPvtLtd,Khamadih,Raipur,TechnicalLab

andPharmaPvtLtd,HaridwarUttarakhand• KavitaPharma,Tifra,Bilaspur• MembersofDistrictDrugPurchaseCommitteeBilaspur• Members of District/ State Drug Purchase Committee

(whicheverwasinvolvedinpurchasingthedrug.• TheLicensingAuthorityandDrugOfficer.

The Judicial Commission in its recommendations to the HealthandFamilyWelfareDepartmentsuggestedthatsurgeriesshouldbedoneinadherencetothestandardsinpublichospitals.Italsosuggestedthatprivatehospitalscouldbeusedforholdingcampsonly under special circumstances in agreement at high-levelcommittee at state level consisting of Director Health, District


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Magistrate,CMHOandCivilSurgeon.Thehospitalchosenbyahighlevelcommitteeshouldbeone,whichhasbeenperformingsuch surgeriesat least since the last fiveyears. Thecommissionexpressedtheneedforawarenessprogrammesrelatedtofamilyplanning.Thegovernmentshouldmandatorilyinvolvedrugandpharmaceutical companies’ operation in CG in sterilizationcampsthroughcorporatesocialresponsibility.

Twopointsshouldbekeptinmindwhenpurchasingmedicinesfordistributioninsterilizationcamps–

1. For transparency inbuyingemergencymedicinesbythepurchasecommittee,thedecisiontakenbythecommitteeandthedecision-makingprocessshouldberatifiedbythegovernment.

2. It is important that the inspection of medicines is donebefore distribution and hence it is important to have agovernmentlaboratoryinthestateitselfforsuchpurpose.Suchalaboratoryshouldbesetupinthestateimmediately

ThecommissionrequestedanassurancethattheMitanins(ASHAworkers)whosesupportissoughtforsterilizationhavefinishedtheir14throundoftraining,whichfocusesonFamilyPlanningServices.HencethereviewoftheactivitiesofmitaninsshouldbedonebyBMO.

ThereshouldbeanintroductionofaMitanKarykraminthelinesofMitaninKaryakramtoencouragementotakepartinsterilizationactivities can lead to gender equality in Family Planningprogramme.

Suggestion towork towardsgenderequality in FamilyPlanningprogrammes.

InFPP,targetsshouldbekeptregardinggenderequality.Extensivecampaigningandawarenessshouldbedonebymenabouttheoptionsofcontraceptivesavailableformen.

Those employed in private sector should be given incentivesin terms of salary for contraception. This will bring parity ingovernmentandprivatesectorpolicies.

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Involvementofadministrationand society is expected throughproperimplementationandfollow-upofprogrammesmeantforgenderequality,Empowermentofwomenshouldbeundertakenso that theycanmake informedchoicesabout theoptionsofcontraceptionavailabletothem.

THE CASE AgAINST DR R.k. gUPTA

Twoyearsafter13womendiedand severalothers impaired inbotched sterilization camp, the Chhattisgarh High Court onTechnicalgroundsacquittedDr.R.KGupta.

Thesurgeonaccusedofusingthesamegloves,syringesandsutureson all the eighty- three women, and causing life-threateninginfections,wasacquittedaftertheprosecutionarguedthattheinvestigation did not have the State government’s sanction,necessarytoprosecuteapublicservant.

Dr.Guptawasarrestedandreleasedonbailtwenty-sevendaysaftertheincident.

AstheAnitaJhaJudicialEnquiryCommissionreporthasclearlypointedout:“Itisevidentfromthefactsthatinthecampsorganizedon8.11.2014and10.11.2014therewasabreachintheimportantnecessities hence the standardoperatingprocedurewere notfollowed.Asa resultofwhich the symptomsof infectionswerefoundinpost-operativefemalebeneficiaries”.Itfurtherstates:“Onthebackgroundofdeliberationof investigationpointnumber1to3,investigationcommitteehasfoundfollowingpersonsguilty/responsible,functionary,during08and10November,2014:-4.1FornotfollowingstandardproceduresandformedicalnegligencebyimmediatefunctionaryBlockMedicalOfficer,TakhatpurandsurgeonwhoconductedsurgeryintubectomycampatSakriandGaurella.(Surgerieswerecompletedbythesamesurgeoninthebothcamps)”.

Thedecisioncameasashocktomanywhofeltthatjusticehadbeendeniedtothebereavedfamiliesofthose13youngwomenwhodiedinBilaspurdistrict,themanymorewomenwhosufferedseriousillnessinhospitalsandthemanysmallchildrendeprivedof


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theirmothers’care.However,theHon’bleCourt inits judgmenthas stated that “the Respondent State shall be free to takeprevioussanctionoftheStateGovt.inthisregardifitstilldesirestoprosecutethepetitionerandintheeventofobtainingsanction,they would be at liberty to further prosecute the petitioner. Itismadeclear that thisCourthasnotgivenanyopinionon themeritsofthecaseastheprosecutioncasewasnotsustainableonthepreliminaryobjectionitselfandthemeritsofthecaseisstillleftopentobeconsideredandadjudicateduponatasubsequentappropriatestageifthesituationsoarises”....

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6. Critique of the Target- Based Approach in Family Planning

gENESIS AND ABANDONMENT OF THE TARgET- BASED APPROACH

According to projections made by various institutions, India’stotal fertility rate is likely to fall somewhere between 1.85 and2.50 by 2020 and 2025.59 However, in the early 20th century,the fertility rate in India was approximately 6.0, threateningeconomic development and raising concerns aboutthe ability of the Government to feed the population.6061TheCentral government considered it impractical to passivelywait for improvements in development and education todecreasefertilityrates,andinsteadintroducedmethod-specificcontraceptivetargetsforeachStateinthe1960s.Sterilizationwasheavily promoted, as it is a provider-dependent option that isrelativelycost-efficientwhencomparedtootheruser-controlledoptions such as condoms and OCPs. State targets for eachcontraceptive were set based on certain demographic goalsderived from national data such as the census, and pressuresto achieve these targets were filtered down to the lowestadministrativelevels.Failuretoachievetargetsatgrassrootslevelsresultedinpunitivemeasuressuchasthesuspensionofsalariesforthecommunity-basedhealthworkersinvolved.

Theadministrativepreoccupationwithmeetingcentrallydecidedtargets eventually became unsustainable. The achievement

59BaliRam,‘FertilitydeclineandFamilyChangeinIndia:ADemographicPerspective’(2012)43(1)JournalofComparativeFamilyStudies11,31.60Ram,aboven1,12;PeterJ.Donaldson,‘TheeliminationofcontraceptiveacceptortargetsandtheevolutionofpopulationpolicyinIndia’(2002)56PopulationStudies97,98.61NationalHealthMission,MinistryofHealthandFamilyWelfare,FamilyPlanning:Background(2 February 2015) <http://nrhm.gov.in/nrhm-components/rmnch-a/family-planning/background.html>.

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of targets became an end in itself, and health workers wereencouraged to engage in unethical practices and outrightcoercioninordertoachievedemographictargets,resultinginacorrespondingdeteriorationinthequalityofservicesandclientsatisfaction. Furthermore, the use of centralized planning andtargetsettingfromthetophinderedinnovationandflexibility inthe Family Planning Programme toadequately respond to theneedsofthecommunity,adverselyimpactingthereproductivehealth situation. Therefore, in 1996, the Central governmentinitiatedasignificantparadigmshift,whicheliminatednumericaltargets.

The National Population Policy of 2000 advocated a holistic,multi-sectoral approach towards population stabilization.Numerical targets for specific contraceptive methods wereabolished; instead, Statesweredirected toachieveanationalaverage total fertility rate (TFR) of 2.1 by the year 2010.62Thistarget-freeapproachwasknown,asthecommunityneedsassessment approach. Under this decentralized approach,grassroots workers such as Auxiliary NurseMidwives (ANM) aregiventhediscretiontoassesstherealneedsandpreferencesoffamilyplanningserviceswithin the localcommunityandtousethisinformationtodeveloptheirowntargets.

63THE CURRENT SITUATION

In 2003-05, the fertility rate was at or below the replacementlevel (i.e. the total fertility rates of 2.1 children per woman) inseveral states, includingPunjab,Delhi, KeralaandKarnataka.64 However, even in states where the replacement fertility levelhasbeenachieved,forexample,inTamilNadu,Stateauthoritiescontinue to pursue female sterilization as a key contraceptivemethod.”65

62SuneelaGargandRiteshSingh,‘Needfor integrationofgenderequity infamilyplanningservices’(2014)140(1)IndianJournalofMedicalResearch147.63Donaldson,aboven2,99.64Ram,aboven1,13.65 Human Rights Watch, India: Target-Driven Sterilization Harming Women (12 July 2012)<https://www.hrw.org/news/2012/07/12/india-target-driven-sterilization-harming-women>.

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Despite theoptimismandpotential for change ingovernmentpolicytocatalyzeamajorshiftinthedeliveryoffamilyplanningservices,areportontheuseoftargetsbyHumanRightsWatchconfirmsthatdistrictandsub-districtauthoritiescontinuetoassignindividualyearly targets forcontraceptives,withaheavy focusonfemalesterilization.

Therefore, whilst ‘top-down targets have officially beeneliminated,thishasmerelybeenreplacedbytheemergenceof‘bottom-up’ targets66 and quotas couched in the euphemisticphrase,‘ExpectedLevelofAchievement’.Inpractice,State-levelauthoritiesanddistricthealthofficialscontinuetobepressuredtoachievetargetsthroughasystemoffinancialincentivesincludingmonetarypayments,orareotherwisethreatenedwithsalarycuts,negative performance assessment, suspension and dismissal.Numerous reports and studies confirm that grassroots healthworkers face immense pressure from their superiors to achievetargets.

In a report published by Human Rights Watch, several healthworkersallegedthattheywerehumiliatedandorallyabusedbytheir supervisors for not motivating enough women to acceptcontraception, while others were suspended from their jobs.67Supervisorsarenotinregularcontactwiththelocalcommunityandhavenopersonalrelationshipwiththewomenthatthehealthworkersareseekingtomotivate.Theyarethereforeinsensitivetotheneedsandopinionsofthewomen;tothem,achievingtargetsismerelyagameofnumbers.

The various State Governments are also complicit in thecontinued coercion, albeit through indirect means by wayof various government programmes and policies, whichrequire people to accept various forms of contraception,most notably sterilization, in order to receive benefits. Forexample, health insurance will only be provided to poorfamilies if they undergo sterilization after two children.68Furthermore, ‘girl child promotion’ programmes have beeninitiatedinfiveIndianstates,whichprovidemonetarybenefitsto

66Donaldson,aboven2,107.67HumanRightsWatch,aboven8.68KeyaAchara,‘SterilizationinIndia’(2001)279(1626)ContemporaryReview26.

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parentsofgirls,withafinalcashbenefit if shereachestheageof18unmarried.However,thereceiptofbenefitsandmonetarypayments is contingent upon couples producing a sterilizationcertificate.69

ARE TARgETS NECESSARy?

Theproponentsofthetarget-basedapproachassertthattargetsact as a crucial guiding posting order to effectively plan andorient family planning services, and are useful for estimatingsupplies and budgets, and for assigning staff.70 Targets havebeen considered an essential tool tomeasure the functioningand efficacy of family planning programmes as progress canbe judgedby the extent towhich the targets are achieved.71Furthermore, a fear persists amongst senior health workersand programme administrators that, without targets, lowerlevelworkers ‘wouldhavenomotivation togetanyone tousecontraception.’72

ANALySIS OF THE IMPLICATIONS OF TARgETS

Thetarget-basedsystemrepresentsastate-sanctionedviolationof sexual and reproductive rights, including the right to makeinformed reproductive choices, and inevitably results in asubstantialdeteriorationinthequalityofcare.

This deterioration can be attributed to healthcare providersignoring the needs and preferences of individual clients andinstead engaging in unethical practices such as the provisionof incomplete, inaccurate or otherwise biased information.Mosthealthworkersare likelytopromotepermanent,provider-controlledmethodssuchassterilizationratherthanuser-controlledoptionssuchasthepill,73motivatedbyself-interestandtheneed

69HumanRightsWatch,aboven8.70MJohnson-Samuel,MLingarajuandPPrabhuswamy,‘HasAbolitionofTargetsImprovedtheQualityofFamilyPlanningandHealthServices?ASurveyinKarnataka’(2000)2(1)JournalofHealthManagement99,100.71LeelaVisaria,ShireenJejeebhoyandTomMerrick,‘FromFamilyPlanningtoReproductiveHealth:ChallengesFacingIndia’(1999)25InternationalFamilyPlanningPerspectives.72Donaldson,aboven2,107.73RuthSimmonsandLauraGhiron,‘FamilyPlanningTargetsandQualityofServices:Workers’PerspectivesandDilemmas’(1999)1(2)JournalofHealthManagement277,279.

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tofulfillsterilizationandIUDtargets.Inseekingtoachievetargets,healthworkers routinely provide prejudiced information and insomecircumstances,outright liesare told towomen regardingthesideeffectsofcertaincontraceptivemethodstopresentanoptionasmorefavorable.Forexample,healthworkershavebeenreportedtohavetoldwomenthatinjectablecontraceptivesare‘likelytomakethebloodimpure’inordertomaketheCopper-Tseemlikeabetteroption.74

Women living in rural areas are particularly susceptible to thisdistortionofinformationbecauseoflowliteracyandeducationallevels.Thispracticeoughttobeviewedasunlawfuldiscrimination,violating thenon-discriminationprovisions underArticles 14, 15,and 16 of the IndianConstitution. This endemicmisinformationis responsible for the negation of the right to make informedreproductive choices and nullifies the exercise of sexual andreproductiveautonomy,violatingseverallegalrightsflowingfromtherighttolifeenshrinedinArticle21oftheConstitution.

Eveninsituationswherehealthworkersarecognizantofaclient’sindividual situation and needs, there is often limited possibilityto appropriately respond because of the time and resourceconstraints imposed by the preoccupation with meetingformalizedtargets.75Healthworkers frequently forego importantprocesses such as screening clients for contraindications, andare likely to recommend inappropriatecontraceptivemethodswithout first properly examining the physical condition of theclientintheirattemptstoachievenumericaltargets.Infact,theresultsofarecentstudywhichcomparedthehealthoutcomesofwomeninatarget-orientedfamilyplanningregimewithwomenwho were not subject to such targets demonstrated that asignificantlyhigherincidenceofsideeffectswasreportedwhennumerical targetswere inplace.76Thus, targetscanbeseen tojeopardize thehealthoutcomesof individualsbyplacing thematunnecessaryriskofinfectionandothercomplicationsastheyarecoercedintoaparticularformofcontraceptiontheyneitherneednordesire.

74Ibid28175Johnson-Samuel,LingarajuandPrabhuswamy,aboven14,103.76Ibid


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The target-based approach is therefore in violation of thebroadprotectionsprovidedunderArticle21oftheConstitution,guaranteeing the right to lifeand the right to livewithdignity.TheIndianSupremeCourtinBandhua Mukti Morcha v. Union of India and Ors [AIR 1984 SC 802]heldthatthisencompassestherighttohealth,andinparticularincludestheenforcementofthereproductiverightsofwomen.77

The right to health is also adversely impacted because of thetendencytoutilizethecampapproachinordertoprovidemassfamily planning services to people living in interior areas, andto conveniently fulfill contraceptive targets. Such camps areorganizedroutinely.Forexample,atotalof438femalesterilizationcamps were proposed for the years 2015-2016 in the state ofUttarakhand,whichworksoutto6campsperblockperyearforfourhigh-focusdistricts,and2campsperdistrictpermonth forthe remainingdistricts.78Analysisof theNHMBudgetSheetalsoreveals a heavy bias towards sterilization as the main form ofcontraception encouragedby the State. In 2015-16, 81.46%ofthetotalbudgetallocatedforfamilyplanningserviceswastobeusedinassociationwiththeprovisionofterminalmethodssuchassterilization,whereasamere0.09%wasallocatedforalternativespacingmethods.79

Thecampapproachisheavilyassociatedwiththesterilizationofwomen,whereithasattractedintensenationalandinternationalcondemnation for its perpetuation of gender and castediscrimination and flagrant, systemic violations of Governmentmandated guidelines on the quality of care, including thenegationofinformedfreechoiceandpersistenceofsubstandardconditionsatcampfacilities.

Therefore, this focus on sterilization camps as ameans to fulfillsterilization targets is a violation of the right to livewith dignityand the right to freedom from torture and cruel, inhuman ordegradingtreatment,whichis implicit inArticle21oftheIndian

77PaschimBangaKhetMazdoorSamityv.StateofWestBengal,[1996SCC(4)37].78UttarakhandState,NHMBudgetSheet2015-16.79Ibid.

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Constitution.80 Additionally, it was found that certain stateapproachestofemalesterilization‘forceddoctors inthepublichospitaltocommitsomuchstafftimetosterilizationcampsthatother basic reproductive health care suffered’. A civil societyteam that investigated maternal deaths in Barwani district ofMadhyaPradesh state found that the seniorgynecologist fromthedistricthospitalwasabsentfourdays inaweek,performingsterilizationsincamps.81

The negative impact of targets on basic reproductive healthcareisfurtherhighlightedbythefactthatlocalhealthworkerswilldedicatemostoftheirtimeonfulfillingtargetsandsubsequentlyspendlesstimeondistributingtimelysuppliesofothercontraceptivemethods. Furthermore,whenhealthcareworkersareburdenedbyfulfillingsettargets,theaveragetimeandattentiongiventoexistingpatientsisreduced,andlesstimeisavailabletofocusonotherimportantreproductiveandmaternalhealthissues.

Astudyconductedin2000highlightedthatfewerwomenreceivedproperantenatalcarewhilehealthworkerswereseekingtofulfilltargets.Forexample,84%ofwomenreceivedtetanusinjectionsduring the target-oriented regime, while up to 96% receivedinjections after the targets were lifted.82 Only 24% of mothershadtheirbabiesweighedduringthetarget-orientedregime;thisincreasedto37%after targetswereremoved.8347%ofmotherswereadvisedaboutbreastfeedingduringtarget-orientedregime;incontrast,67%wereadvisedaboutthebenefitsofbreastfeedingaftertargetslifted.84Therefore,targetsareclearlyseentohaveanimpactontheprovisionofotheressentialhealthcareservicesinfurtherviolationoftherighttohealth.

THE WAy FORWARD

The above cost-benefit analysis of the justifications for thecontinueduseofnumerical targetsascompared to theharms

80Ibid.81HumanRightsWatch,aboven8.82Johnson-Samuel,LingarajuandPrabhuswamy,aboven14,108.83Ibid110.84Ibid.


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thatareperpetuatedthroughthepreoccupationwithachievingthosetargetsmilitatesagainsttheircontinueduse.Suchflagranthuman rights violations cannot be justified in the name ofcontrollingpopulationgrowth.Instead,governmentpolicyshouldfocusonaddressingtheunderlyingcausesofhighfertilityratesinIndia.EvidenceshowsthatthedrivingforcesofhighfertilityratesinIndiaareattributedtosocialfactors.‘Nationalandinternationalexperience’ clearly indicates that family size is dependent onnon-demographicfactors’.85

One of these factors is the age at marriage and subsequentchildbearing. Traditional Indian norms sanction early anduniversalmarriage.Inmanypartsofthecountry,earlymarriagecontinues to be prevalent. According to theNFHS-3 (2005-06),47.4%ofwomeninIndiaweremarriedbytheageof18.Severesocialstigmaisattachedtochildlessness;thisappliestobothlow-fertilityandhigh-fertilityregionsinIndia.86In2003-05,two-fifthsofallmarriedwomenaged20-24hadalreadygivenbirthtoachild.About97%ofallmarriedwomenhadgivenbirthbytheirearly30s.87Thesestatisticsdemonstratethatmanypeoplemarryearly,andstartchildbearingearly–usuallywithin twoyearsofmarriage,88

and therefore have a much longer window of childbearing.Whilstlegislativemeasureshavebeenenactedtopreventearlymarriage such as the Prohibition ofChildMarriageAct (2006),which imposes monetary sanctions and jail terms for thoseinvolvedinfacilitatingmarriagesunderthelegalage,theselawsare largely ineffective inmodifying customs and tradition andfacilitatingattitudinalchange.

Another reason for high fertility rates in India is the preferenceformalechildren,whichpervadeevery sectionof society; richand poor, less educated and highly educated, urban andrural. Despite significant modernization and socio- economicdevelopment, male preference has not weakened. Sons arecontinued to be seen the only security for poor parents in old

85Achara,aboven12,27.86Ram,aboven1,19.87Ibid18.88Ibid32.

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age, and women face intense family pressure to bear sons.89Many couples give birth to many children in pursuit of malechildren.Even incaseswhena son isborn,couplesareunsurewhetherhewill survivetoadulthood,giventhehigh infantandchildmortalityratesinIndia.

The2011Census shows that39outofevery1000childrenborndiedbeforereachingtheirfirstbirthday.Therefore,‘thereisampleevidence that theexperiencewith, or fear of infant andchildmortalityleadsparentstohaveadditionalchildrenby‘replacing’those who have already died or as an ‘insurance’ againstexpected deaths. Many couples produce a larger number ofchildren, expecting that at least one of them will be able toprovideeconomicsupportintheiroldage’.90

Therefore,themosteffectiveapproachthatdoesnotcompromisefundamental human rights is through the adoption of non-coercivemeasuressuchasthepromotionofeducationforgirls,whichhasbeenlinkedtodelayedageofmarriageandimprovedsocioeconomic conditions and employment opportunities.Evidence from low-fertility states such as Kerala supports thenotionthat‘higherlevelsofautonomyandabettersocialpositionforwomen…have led to increased femaleutilizationofhealthservicesandcontraception,higher levelsof femaleeducation,andlateragesofmarriageandfirstbirth’.91

Thegovernmentmust alsodomore toaddress the high infantand child mortality rates. Evidence also exists which supports‘greaterinvestmentinwomen’seducation[as]amorepragmaticapproachintermsofthereductionininfantandchildmortalityasitisthebetter-informedmotherswhoaremorelikelytosavetheirchildrenfromdiseasesanddeath’.92Finally,thereisalsoapressingneed to address India’s lack of social security for the elderly.Whilst IndiacreatedaNationalPolicy forOlderPersons in1999andpassedtheMaintenanceandWelfareofParentsandSenior

89Achara,aboven12,27.90Ram,aboven1,25.91TrinaVithayathil,‘PathwaystoLowFertilityinIndia’(2013)9(3)AsianPopulationStudies301,304.92Ram,aboven1,34.


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CitizensAct,2007, littlehasbeendonetoimplementthepolicyand law.93This failureof theCentralGovernment to implementsocial security programmes has been a major deterrent tocontraceptiveuse.

Therefore,theaboveoptionsrepresentperhapsbetteralternativesthan the current coercive regime of achieving contraceptivetargetsinfamilyplanning.

93HumanRightsWatch,aboven8.

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7. INTERNATIONAL LAW AND CASES ON STERILIZATION

According to theWHO, women in many regions of the worldcontinuetosufferfromforcedsterilization.Thepeoplemostoftensubjected to these abusive practices are women, especiallythose living in poverty, women living with HIV, women withdisabilities, minority and indigenous women, and transgenderandintersexpersons.“Eliminatingforced,coerciveandotherwiseinvoluntary sterilization”, a statement released by several UNagencies,describesthehistoryofthispractice, including itsuseasamethodofmassbirthcontrol in the latterhalfof the20thcenturyincontraventionoffundamentalhumanrightsprinciplesofautonomyanddignity.

Theagencies,includingtheUNOfficeoftheHighCommissionerforHumanRights,haveproducedtheresearchintheformofastatementforgeneralreleasetoaddweighttocallsforStatestoacttoeliminateinvoluntarysterilization.Whileacknowledgingthat“sterilizationisoneofthemostwidelyusedformsofcontraceptionin theworld”, the statement reaffirms that itmustonlybeusedwith the“full, freeand informed”consentof thoseundergoingtheprocedure.TheUNagenciesofferasetofguidingprinciplesforsterilizationprocedures,principalamongwhichisautonomy-therespectfordignityandthephysicalandmental integrityofeachpersonexpressedthroughfull,freeandinformeddecision-making.Peopleshouldbeabletochooseandrefusesterilization,the statement says. Inaddition to theUNHumanRightsOffice,UNWomen,theJointUNProgrammeonHIVandAIDS(UNAIDS),theUnitedNationsDevelopmentProgramme(UNDP),theUnitedNationsPopulationFund(UNFPA), theUnitedNationsChildren’sFund (UNICEF) and the World Health Organization (WHO) allcontributedtothestatement

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Following are some of the international convention andconferenceplanofactionwhichfocusonfamilyplanningandensuringadequatehealthcareservicewithoutanydiscrimination:

A. INTERNATIONAL COVENANT ON CIVIL AND POLITICAL RIgHTS (ICCPR):

ICCPRwasadoptedbyUNGeneralAssembly in1966,with theidealof freehumanbeingsenjoyingcivilandpolitical freedomandfreedomfromfearandwant.Thiscanonlybeachievedinconditionswhereeveryonemayenjoyhiscivilandpoliticalrights,aswell as his economic, social and cultural rights. India beingsignatorytothecovenantisobligatedtofollowthelawsofICCPR.Article7oftheICCPRstates-

‘Nooneshallbesubjected to tortureor tocruel, inhumanordegradingtreatmentorpunishment.Inparticular,nooneshall be subjectedwithout his free consent tomedical orscientificexperimentation.’

Hence,without informedconsentwomencannotundergoanysterilization procedure. India’s system of sterilization camps isdeliberate and pervasive. According to the report SterilizationCamps in India (2015): Population Research Institute, ‘India’ssystematic sterilization of women en masse, without informedconsent,andindangerousconditionsdemandsourattention.’

B. CONVENTION ON THE ELIMINATION OF ALL FORMS OF DISCRIMINATION AgAINST WOMEN (CEDAW):

CEDAWwasadoptedbyUNGeneralAssemblyonDecember18,1979and it focusesonwomen’s rightsandwomen’s issue. Theconvention focuses forensuringadequatewomenhealthcareandservices.

1. Article10oftheconvention,thestateisrequiredtoensureeducation for women as well as access to informationrelatingtothehealthandwellbeingoffamilies,includinginformationandadviceonfamilyplanning.

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2. UnderArt12,thestatemustensureappropriatehealthcareservicesforwomen,includingfamilyplanningservices.

3. UnderArticle 16, the state shall ensure thatwomencanfreelyandresponsiblydecideonnumberandspacingoftheirchildrenandhaveaccesstoinformation,educationandthenecessarymeanstoenablethemtoexercisetheserights.

C. COMMITTEE ON ECONOMIC, SOCIAL AND CULTURAL RIgHTS (CESCR):

CESCR is the body of 18 independent experts that monitorsimplementation of the International Covenant on Economic,Social and Cultural Rights (ICESCR) by its state parties. TheCommitteewasestablishedunderECOSOCResolution1985/17of28May 1985 to carry out themonitoring functionsassigned tothe UnitedNations Economicand SocialCouncil (ECOSOC) inPartIVoftheCovenant.

Article102,Article12.1-“TheStatesPartiestothepresentCovenantrecognizetherightofeveryonetotheenjoymentofthehighestattainablestandardofphysicalandmentalhealth”.

D. INTERNATIONAL CONFERENCE ON POPULATION DEVELOPMENT (ICPD):

TheUnitedNationscoordinatedanInternationalConferenceonPopulationandDevelopment (ICPD) inCairo, Egypt from5–13September1994.ItsresultingProgrammeofActionisthesteeringdocumentfortheUnitedNationsPopulationFund(UNFPA).Theprogramme highlights the importance of universal access tohealth-careservicesincludingfamilyplanningandsexualhealth.

Principle 8 declares-

“Statesshouldtakeallappropriatemeasurestoensure,onabasisofequalityofmenandwomen,universalaccesstohealth-careservices, including those related to reproductive health care,whichincludesfamilyplanningandsexualhealth.Reproductivehealth-care programmes should provide the widest range ofserviceswithoutanyformofcoercion.”

International Law and Cases on Sterilization

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E. FOURTH WORLD CONFERENCE ON WOMEN (FWCW):

FWCWwasorganisedbyUNwomenwithanagendaforwomen’sempowermentandconsideredthekeyglobalpolicydocumenton gender equality. It sets strategic objectives andactions fortheadvancementofwomenand theachievementofgenderequalityin12criticalareasofconcern.

Paragraph89-”Womenhavetherighttotheenjoymentofthehighest attainable standard of physical and mental health....Health isastateofcompletephysical,mental,andsocialwell-being and not merely the absence of disease or infirmity....”),Paragraph92,Paragraph267

Paragraph 223 -”The Fourth World Conference on Womenreaffirms that reproductive rights rest on the recognitionof thebasic right of all couples and individuals to decide freely andresponsiblythenumber,spacing,andtimingoftheirchildrenandtohavetheinformationandmeanstodoso.”

Case Law on Sterilization Decided by International CourtsCase Name: A.S. v. Hungary, Communication No. 4/2004Forum: UN Committee on the Elimination of Discrimination

Against WomenDate of Ruling: August 29, 2006

Summary:

Upongoingintolabor,Ms.A.S.,amemberoftheRomacommunity,neededanemergencyCesarean section. Immediatelybeforethe surgery, a doctor asked Ms. A.S. to sign consent formson which the doctor had hand-written a statement that Ms.A.S. consented to a sterilization procedure. Ms. A.S. did notunderstand the statement or that she had been sterilized untilaftertheoperationtookplace.Herclaimofcivilrightsviolationsandnegligentsterilizationwasrejectedatthelocallevel. InhercommunicationtotheCEDAWCommittee,itfoundthattheMs.A.S.exhaustedherdomesticremediesbecauseunderHungarianlawshewasunabletoappealthisdecisiontotheConstitutionalCourtgiventhenatureandfactsofhercase.Hungarywasfound

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tohaveviolatedMs.A.S.’srightsto(1)fullyinformedconsenttomedicalprocedures;(2)righttoinformationonfamilyplanning;(3) right toappropriate services in connectionwithpregnancyandthepost-natalperiod;and(4)righttodeterminethenumberand spacingofherchildren,underArticles 10(h), 12and16(1)(e)oftheConventionontheEliminationofDiscriminationAgainstWomen. The Committee also found that the communicationwas admissible, even though the operation occurred beforetheOptionalProtocolentered into force forHungary,becausesterilizationwasacontinuous injury,andbecause sterilization ispermanent, irreversible(despitethestate’sclaims)andsuccessofreversalislow.

ENFORCEMENT OF THE DECISION AND OUTCOMES:

The Committee recommended that Hungary compensateMs. A.S. and takemeasures tomake sure health officials giveinformation to patients and obtain informed consent. In 2008,HungaryamendedthePublicHealthActtoensurethatwomenreceived proper information regarding sterilization procedures.Finally, inFebruary2009theMinistryofSocialAffairsandLabourannouncedthattheywillcompensateMs.A.S.accordingtotheCommittee’srecommendations.

SIgNIFICANCE OF THE CASE:

Thisisalandmarkdecision,inwhichforthefirsttimeaninternationalbodyheldastateresponsibleforfailingtoprovideawomanwithnecessary informationandobtain full consent for reproductivehealth procedures. This decision establishes that obligations toensurewomen’shumanrightsrequirethattheymustbeprovidedwith acceptable reproductive health services, specificallyrequiringfreeandinformedconsenttoasterilizationprocedure.This decisionwasan important step inaddressing the systemicdiscrimination against Romani women in Central and EasternEurope; however, governments in the region remain highlyreluctanttoacknowledgemarginalizationanddiscriminationofRomanipeoples.


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1. E vs. Eve, [1986] 2 SCR 388 Forum: Supreme Court of CanadaDate of Judgment: 10-23-1986Summary:

Mrs. E was the mother of Eve, who was intellectually anddevelopmentallydisabled (IDD).When Eve turned twenty-one,shewas sent toa school for i adultswhohave IDD inanothercommunity.At this school,Evestruckupaclosefriendshipwithamalestudent:infact,theytalkedofmarriage.HetoohasIDD,thoughsomewhatlesssothanEve.ThesituationnaturallytroubledMrs.E.,EvewasattractedandattractivetomenandMrs.E.fearedshemightquitepossiblyandinnocentlybecomepregnant.Mrs.E.wasconcernedabouttheemotionaleffectthatapregnancyandsubsequentbirthmighthaveonherdaughter.Eve,shefelt,couldnotadequatelycopewiththedutiesofamotherandtheresponsibilitywouldfallonMrs.E.Thiswouldunderstandablycausehergreatdifficulty; she isawidowandwas thenapproachingsixty.ThatiswhyshedecidedEveshouldbesterilized.

Mrs.E.appliedtotheSupremeCourtofPrinceEdwardIslandforpermissiontogiveconsenttothesterilizationofEve.Theapplicationsought: (1) a declaration that Eve was mentally incompetentpursuanttotheMental Health Act;(2)theappointmentofMrs.E.ascommitteeofEve;and(3)anauthorizationforEve’sundergoingatuballigation.Theapplicationforauthorizationtosterilizewasdenied,andanappealtotheSupremeCourtofPrinceEdwardIsland,in banco (inthebench),waslaunched.AnorderwasthenmadeappointingtheOfficialTrusteeasGuardianad litemforEve.Theappealwasallowed.TheCourtorderedthatEvebemadeawardoftheCourtpursuanttotheMedical HealthActsolelytopermittheexerciseoftheparens patriaejurisdictiontoauthorizethesterilization,andthatthemethodofsterilizationbedeterminedby theCourt following further submissions.Ahysterectomywaslater authorized. But Eve’s ad litem guardian filed an appealagainsttheauthorizationforhysterectomyattheSupremeCourtofCanada.

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Judgment:

It was held that the appeal should be allowed. The Mental Health Actdidnotadvancerespondent›scase.ThisActprovidesa procedure for declaring mental incompetence, at least forproperty owners. Its ambit is unclear and it would take muchstronger language to empower a committee to authorize thesterilizationofapersonfornontherapeuticpurposes.TheHospital Management Regulations were equally inapplicable. They arenotaimedatdefiningtherightsofindividuals.

The parens patriae jurisdiction for the care of the mentallyincompetentisvestedintheprovincialsuperiorcourts.Itsexerciseis founded on necessity the need to act for the protection ofthosewhocannotcareforthemselves.Thejurisdictionisbroad.Its scope cannot be defined. It applies to many and variedsituations,andacourtcanactnotonlyifinjuryhasoccurredbutalsoifitisapprehended.Thejurisdictioniscarefullyguardedandthecourtswillnotassumethatithasbeenremovedbylegislation.

Whilethescopeoftheparens patriaejurisdictionisunlimited,thejurisdictionmustnonethelessbeexercisedinaccordancewithitsunderlyingprinciple.Thediscretiongivenunderthisjurisdictionistobeexercisedforthebenefitofthepersoninneedofprotectionandnotforthebenefitofothers.Itmustatalltimesbeexercisedwith great caution, a caution that must increase with theseriousnessofthematter.This isparticularlyso incaseswhereacourtmightbetemptedtoactbecausefailuretoactwouldriskimposinganobviouslyheavyburdenonanotherperson.

Sterilization should never be authorized for non -therapeuticpurposesundertheparens patriae jurisdiction.Intheabsenceoftheaffectedperson’sconsent,itcanneverbesafelydeterminedthat it is for thebenefitof thatperson.Thegrave intrusiononaperson’s rightsandtheensuingphysicaldamageoutweighthehighlyquestionableadvantagesthatcanresultfromit.Thecourt,therefore,lacksjurisdictioninsuchacase.

The court’s function to protect those unable to take care ofthemselves must not be transformed so as to create a duty


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obligingtheCourt,atthebehestofathirdparty,tomakeachoicebetweentwoallegedconstitutionalrightsthattoprocreateandthatnottoprocreatesimplybecausetheindividualisunabletomakethatchoice.Therewasnoevidencetoindicatethatfailureto perform the operation would have any detrimental effecton Eve’s physical or mental health. Further, since the parens patriajurisdictionisconfinedtodoingwhatisforthebenefitandprotectionofthedisabledperson,itcannotbeusedforMrs.E.’sbenefit.

Cases involving applications for sterilization for therapeuticreasonsmaygiverisetotheissuesoftheburdenofproofrequiredtowarrantanorderforsterilizationandoftheprecautionsjudgesshould take with these applications in the interests of justice.Since,barringemergencysituations,asurgicalprocedurewithoutconsentconstitutesbattery,theonusofprovingtheneedfortheprocedureliesonthoseseekingtohaveitperformed.Theburdenof proof, though a civil one,must be commensurate with theseriousnessofthemeasureproposed.Acourtinconductingtheseproceduresmustproceedwithextremecautionandthementallyincompetentpersonmusthaveindependentrepresentation.

2. V.C. Versus Slovakia, 18968/07 Forum: European Court of Human RightsDate of Judgment: 08-11-2011Summary & Judgment:

Theapplicant is a Romawomanwhowas sterilizedduring thedeliveryofhersecondchildviaCaesareansectionon23August2000.UnderArticlethreeoftheEuropeanConventiononHumanRights(hereinafterreferredtoastheConvention)theapplicantcomplained that she had been subjected to inhuman anddegradingtreatmentonaccountofhersterilizationwithoutherfull and informed consent, and that the authorities had failedtocarryoutathorough,fairandeffectiveinvestigationintothecircumstances surrounding her sterilization. She also claimedthat her Romaethnicity – clearly stated in hermedical record–hadplayedadecisive role inher sterilization. Theapplicant’ssterilization has had serious medical and psychological after-

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effects. Shehasbeen treatedbyapsychiatrist since2008andcontinuestosufferfromthefactthatshewassterilized.ShehasalsobeensterilizedbytheRomacommunity.UnderArticle8oftheConventiontheapplicantcomplainedthather righttorespectforherprivateandfamilylifehadbeenviolatedasaresultofhersterilizationwithouther fulland informedconsent.UnderArticle12oftheConventiontheapplicantcomplainedthatherrighttofoundafamilyhadbeenbreachedonaccountofhersterilizationwithoutherfullandinformedconsent.ShealsocomplainedunderArticles13and14.

TheCourtnotedthatsterilizationamountedtoamajorinterferencewithaperson’sreproductivehealthstatusand,involvingmanifoldaspectsofpersonalintegrity,requiredinformedconsentwhenthepatientwasanadultofsoundmind.However,fromthedocumentssubmitted,theapplicanthadapparentlynotbeenfullyinformedaboutthestatusofherhealth,theproposedsterilizationand/orits alternatives. The applicant’s sterilization, as well as the wayinwhichshehadbeenrequestedtoagreetoit,mustthereforehavemadeherfeelfear,anguishandinferiority.Theapplicant’ssterilizationhadbeeninviolationofArticle3.TherehadbeennoviolationofArticlethreeasconcernedtheapplicant’sallegationthattheinvestigationintohersterilizationhadbeeninadequate.Given itsearlierfindingofaviolationofArticle3, theCourtdidnot consider it necessary to examine separately under Article8 whether the applicant’s sterilization had breached her rightto respect for her private and family life. It nevertheless foundthat Slovakia had failed to fulfill its obligation under Article 8to respect private and family life in that it did not ensure thatparticularattentionwaspaid to the reproductivehealthof theapplicantasaRoma. Therehad thereforebeena violationofArticle8concerningthelackof legalsafeguardsatthetimeofthe applicant’s sterilization giving special consideration to herreproductivehealthasaRoma.TheCourtfoundthattherehadbeennoviolationofArticle13.Itheldthattherewasnoneedtoexamineseparatelytheapplicant’scomplaintsunderArticles12and14.

Article 3: No one shall be subjected to torture or to inhuman or degrading treatment or punishment.


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Article8:1) Everyone has the right to respect for his private and family life, ...

2)Thereshallbenointerferencebyapublicauthoritywiththeexerciseofthisrightexceptsuchasisinaccordancewith the lawand is necessary in a democratic societyin the interestsofnational security,public safetyor theeconomicwell-beingof thecountry, for thepreventionofdisorderorcrime,fortheprotectionofhealthormorals,orfortheprotectionoftherightsandfreedomsofothers.

Article12:Men and women of marriageable age have the right to marry and to found a family, according to the national laws governing the exercise of this right.

Article13: Everyone whose rights and freedoms as set forth in [the] Convention are violated shall have an effective remedy before a national authority notwithstanding that the violation has been committed by persons acting in an official capacity.

Article 14: The enjoyment of the rights and freedoms set forth in [the] Convention shall be secured without discrimination on any ground such as sex, race, colour, language, religion, political or other opinion, national or social origin, association with a national minority, property, birth or other status.

Held by The Court:

1. Holds unanimously that there has been a substantiveviolationofArticlethreeoftheConvention;

2. Holds unanimously that there has been no proceduralviolationofArticlethreeoftheConvention;

3. HoldsunanimouslythattherehasbeenaviolationofArticle8oftheConvention;

4. Holds unanimously that it is not necessary to examineseparatelythecomplaintunderArticle12ofthe Convention;

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5. Holds unanimously that there has been no violation ofArticle13oftheConvention;

6. Holdsbysixvotestoonethataseparateexaminationofthe complaint under Article 14 of theConvention is notcalledfor;

7. Holdsunanimously(a)that the respondent State is to pay the applicant,

within three months from the date on which thejudgment becomes final in accordance with Article44 § 2 of the Convention, the following amounts:

• EUR 31,000 (thirty-one thousand Euros), plus any taxthatmaybechargeable,inrespectofnon-pecuniarydamage;

• EUR12,000(twelvethousandEuros),plusanytaxthatmaybe chargeable to theapplicant, in respect ofcostsandexpenses;

(b)that from the expiry of the above-mentioned threemonthsuntilsettlementsimpleinterestshallbepayableontheaboveamountsatarateequaltothemarginallending rate of the European Central Bank duringthe default period plus three percentage points;

4. Concern raised by the Human Rights Committee through its Concluding Observations on the Fourth Report of Slovakia regarding the implementation of provisions of the UN International Covenant on Civil and Political Rights:

Sterilization of Roma Women:

Para26:TheCommitteeisconcernedthattheStatepartyhasstillnotacknowledgedresponsibilityforthepastpracticeofforcedsterilizationofRomawomenorprovidedcompensation for thevictims,exceptinonecase.

Para 27: The State party should: (a) establish an independentbodytoinvestigatethefullextentofthepracticeofsterilizationwithout informed consent and to provide financial and other


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reparation to the victims; (b) provide ongoing training forhealthcarepersonnelonhowtoensurethatinformedconsentisobtained;and(c)monitorhealth-careproviders’implementationoflegislationoninformedconsentinsituationsofsterilizationandensurethatappropriatesanctionsareappliedifbreachesoccur.

5. Joelle gauer and Others Versus France, 61521/08

The case was brought before the European Court of HumanRights andconcerns fivedisabledwomenwhowere forcefullysterilized, which according to them was a violation of Articlesthree(freedomfromtortureorinhumanordegradingtreatmentor punishment), Article 6 (right to a fair trial), Article 8 (right torespectforprivateandfamilylife),Article12(righttomarryandtofoundafamily),andArticle14(righttonon-discriminationintheenjoymentof protected rights and freedoms) of the EuropeanConventiononHumanRights.ThiscasewasfiledafterfiledafternoremedywasprovidedtothewomeninthedomesticcourtsofFrance.

In this case, a document containing Written Comments wassubmitted to the court jointly by five organizations, viz. CentreForReproductiveRights,EuropeanDisabilityForum,InternationalCentre for the Legal Protection of Human Rights (INTERIGHTS),InternationalDisabilityAllianceandMentalDisabilityAdvocacyCentre.Thesecommentscontainedinsightsonhowandwhyareforcedsterilizationsareaviolationofaperson’srightssettingforthinternationalhumanrightsandmedicalstandards,withfocusontheviolationoftherightsofdisabledwomen.

In the written comments, reference was made to a previousjudgment of the Court wherein it had held that a guardian’splacementofapersonwhohasamentaldisabilityandhasbeendeprivedofhislegalcapacityinapsychiatrichospitalsolelybasedontheguardian’sbeliefthatthepersonrequireshospitalization,againsttheperson’swillandintheabsenceofajudicialreview,violatesArticle5oftheConvention.InitsShtukaturovjudgment,the Court recognized that the will of a person placed underguardianshiphadtobetakenintoconsiderationwhenarestrictionona right as fundamental as the right to liberty is concerned.

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21Insodoing,theCourtrecognizedthatapersonwhoselegalcapacity has been formally restricted may retain capacitytomakemedical andotherdecisions rather thanhaving suchdecisionsmadebythirdparties.

TheprovisionsoftheUnitedNationsConventiononRightsofPersonswithDisabilities(hereinafterreferredtoasCRPD)werefrequentlyreferred to. Article 12 of the CRPDmandates States Parties torecognise thatpersonswithdisabilitiesenjoy legalcapacityonanequalbasiswithothers. Thismeans thatan individual’s righttodecision-makingshouldnotbereplacedbydecision-makingofathirdparty,butthateachindividualwithoutexceptionhastherighttomaketheirownchoicesandtodirecttheirownlives,whetherinrelationtolivingarrangements,medicaltreatment,orfamilyrelationships.Article12iscentraltotheCRPDbecausetheexercise of legal capacity affects somany other fundamentalrights.

Internationalstandardsexplicitlyendorsetheprincipleofinformedconsentasfundamentaltotheexerciseofone’sindividualhumanrights.Informedconsent,whichincludestherighttoinformation,isparticularlycriticaltothelife-alteringprocedureofsterilizationwhich seriously impacts uponan individual’s human rights. TheCommittee on Elimination of Discrimination Against Women(hereinafter referred to as CEDAW Committee) has expressedconcernaboutforcedsterilizationsthatresultfromthelackoffulland informedconsent. In itsGeneralRecommendation24, theCEDAWCommitteeexplainsthat“acceptableservicesarethosethat are delivered in a way that ensures that a woman givesher fully informedconsent, respectsherdignity,guaranteesherconfidentialityandissensitivetoherneedsandperspectives.”

TheCommitteeontheRightsofPersonswithDisabilities(hereinafterthe CRPD Committee‟) specifically recommended that states“incorporateintothelawtheabolitionofsurgeryandtreatmentwithoutthefullandinformedconsentofthepatient,andensurethatnationallawespeciallyrespectswomen’srightsunderarticle23and25oftheConvention.”WorldHealthOrganisation(WHO)clearly states in its Declaration on the Promotion of Patients


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Rights in Europe94 that “the informed consent of the patient isaprerequisite for anymedical intervention.”Also, InternationalFederationofGynaecologyandObstetrics’(FIGO)guidelinesonfemalecontraceptive sterilization stress that surgical sterilizationmustbeprecededby“thepatient’s informedandfreelygivenconsent.” The FIGOguidelinesnote that “medicalpractitionersmustrecognisethat,underhumanrightsprovisionsandtheirownprofessional codes of conduct, it is unethical and in violationofhuman rights for them toperformprocedures forpreventionoffuturepregnancyonwomenwhohavenotfreelyrequestedsuchprocedures,orwhohavenotpreviouslygiventheirfreeandinformedconsent.”

The United Nations Special Rapporteur on the Right to Healthemphasised that Stateshaveanobligation to respect,protectandfulfilltherighttohealthofallindividuals,includingthosewithmentaldisabilities.Herecognisedthat“forcedsterilizations,rapeandother formsof sexual violence,whichwomenwithmentaldisabilitiesarevulnerableto,areinherentlyinconsistentwiththeirsexualandreproductivehealthrightsandfreedoms.”TheSpecialRapporteuralsostressedthat“consenttotreatmentisoneofthemostimportanthumanrightsissuesrelatingtomentaldisability,”andaccordingly “it isespecially important that theproceduralsafeguards protecting the right to informed consent are bothwatertightandstrictlyapplied.”

The Council of Europe’s Convention on Human Rights andBiomedicine obligates the medical provider to give eachpatient objective and comprehensive information about hisor her contemplated treatment, including its purpose, nature,consequencesandrisks,inordertoenablethepatienttomakean informed decision. The FIGO guidelines specify that thephysicianwhoperformsthesterilizationisresponsibleforensuringthatawomanhasbeencounseledregardingrisks,benefits,andalternativestosterilization.Womenmustbemadeawareofandhave the opportunity to consider alternatives to sterilization,particularlyfamilyplanningmethodsthatarereversible.Surgical

94 A Declaration on Patient’s Rights in Europe; < http://www.who.int/genomics/public/eu_declaration1994.pdf>Accessedon23.08.2017

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sterilizationisrecognizedasapermanentcontraceptivemethodby international medical bodies, and while surgery to reversesterilizationexists,suchproceduresarecostly,notwidelyavailableandhavealowsuccessrate.TheFIGOalsolaysoutinformationthatmustbeconveyedduringcounselling,includingthatsterilizationisintendedtobepermanent;thatlifecircumstancesmaychangeasaresultoftheprocedure;andthatapersonmaylaterregrether state of sterility. The FIGO also emphasizes that “informedconsentisnotasignaturebutaprocessofcommunicationandinteraction.”

Inorder foran individual togivefulland informedconsent, theinformationcommunicatedshouldbeprovidedinamannerthatis understandable to her. The WHO explains that “informationmustbecommunicatedtothepatientinawayappropriatetothe latter’s capacity for understanding, minimizing the use ofunfamiliar technical terminology. If thepatientdoesnot speakthe common language, some form of interpreting should beavailable.”TheCRPDrecognizesthat“communicationincludeslanguages,displayof text,Braille, tactilecommunication, largeprint, accessible multimedia as well as written, audio, plain-language, human-reader and augmentative and alternativemodes, means and formats of communication, includingaccessible information and communication technology.”The FIGO Guidelines Regarding Informed Consent specificallynote that the difficulty or time consuming nature of providingsuch information, forexample, topatientswhohavehad“littleeducation,”doesnotabsolvemedicalprovidersfromstrivingtofulfillthecriteriaforinformedconsent.

TheCEDAWCommitteewhich,inastatementonviolenceagainstwomen,statedthat“compulsorysterilization...adverselyaffectswomen’sphysicalandmentalhealth…

TheWHOinarecentreport(WorldReportonDisability)reliedonstandards setout in theCRPD in relation tonondiscrimination,andreiteratedtherightofpersonswithdisabilitiestoretaintheirfertility and exercise their legal capacity inmaking healthcaredecisions, including sexual and reproductive decisions. Thereport specifically states that “the presence of a particular


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health condition is not sufficient to determine capacity. Theassumptionthatpeoplewithcertainconditionslackcapacityisunacceptable,accordingtoArticle12oftheCRPD.”Thereportnotes“therearemanycasesofinvoluntarysterilizationbeingusedtorestrictthefertilityofsomepeoplewithadisability,particularlythose with an intellectual disability, almost always women….Involuntary sterilization of persons with disabilities is contrary tointernational human rights standards. Persons with disabilitiesshould haveaccess to voluntary sterilizationonanequalbasiswithothers.” Italso stated that legal frameworksand reportingandenforcementmechanisms,shouldbeputinplace“toensurethat,wheneversterilizationisrequested,therightsofpersonswithdisabilities[shouldbe]alwaysrespectedaboveothercompetinginterests.”

6. F.S. Versus Chile, Report No. 52/14, Petition No. 112/09Forum: Inter-American Commission on Human RightsSummary:

F.S., a young woman from a rural town in Chile, was forciblysterilizedwithoutherknowledgeorconsentwhenshewasjust20yearsoldbecausesheisHIVpositive.

Duringthefirst trimesterofherpregnancy,F.S. learnedthatshewas HIV positive through a routine pre-natal test. Despite herinitialdismayandfearonreceivingthisnews,F.S.wasrelievedtolearnthattherewasagoodchancethatherchildwouldbebornhealthyandHIVnegative—theriskofmother-to-childtransmissionislessthan2%whennecessaryprecautionsaretaken.Throughouther pregnancy, F.S. took all the necessary steps to carry toterma healthychild, seeking regular prenatal care, accessingantiretroviraltherapy,anddeliveringthroughacaesarean.

In November 2002, F.S. checked into the Hospital of Curicó,thepublichospitalwherehercaesareandeliverywasgoing totake place. The night before the operation, though, shewentinto labor,and shortlyaftermidnight, F.S.wasbrought into theoperatingroomandadministeredanaesthesia.F.S.sleptthroughtheprocedure,awakingonlytolearnthatshehadgivenbirthtoaboy.Thefollowingmorning,F.S.awoketolearnthathersonwas

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bornhealthyandHIVnegative.Butthenshereceivedashockingblow—theoperatingsurgeonhaddecidedtosurgicallysterilizeherduringthedeliverywithoutherknowledgeandwithouteverdiscussingsterilizationwithher,andsheandherhusbandwouldnotbeabletohaveanymorechildrentogether.F.S.continuesto suffer the physical and psychological harms of this forciblesterilization.

Overtime,F.S.learnedthatthedoctor’sactionsviolatedChileanlawandherrights.InMarch2007,tovindicateherrightsandtopreventotherwomenfromexperiencingthesameabuseshehadsuffered, F.S. filed a complaint against the operating surgeon.The complaint sought criminal sanctions against the surgeonand financial indemnification.Apolice investigationconfirmedthat F.S. had not given written consent for the sterilization asrequiredbyChileanlaw,butthePublicProsecutorcarriedoutasubstandardinvestigationintoF.S.’scomplaint.ThesurgicalteamgavecontradictorytestimonyeitherthatF.S.hadrequestedthesterilizationor that the surgeonasked if shewouldbe sterilizedandsheassented,andthenursethatcompletedF.S.’smedicalchartsaidthatshedidnotrecallanyrequestforsterilization.

Ignoring these glaring discrepancies in the testimonies of themedicalteam,F.S.’sowntestimonythatshehadneverconsented—verballyorotherwise—tobesterilized,andChileanlawrequiringwritten consent, the Public Prosecutor recommended that thecase be dismissed, saying that F.S. had verbally consented tothe sterilization. The trial court followed the Public Prosecutor’srecommendationanddismissed thecase. F.S.andher lawyersappealed this decision, but the appellate court upheld thedismissal,leavingF.S.withoutanyredressfortheirreparableharmthatshesuffered.

OnFebruary3,2009,theCentreforReproductiveRightsandVIVOPOSITIVO, a Chilean nongovernmental organization, broughtF.S.’s case to the Inter-AmericanCommissiononHumanRights(Inter-American Commission). The case is the first internationalhumanrightscasetoaddressthesexualandreproductiverightsofwomenlivingwithHIVandtoseekgovernmentaccountabilityfortheseviolations.


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Status: The Inter-American Convention on Human Rights hasdeclaredthecaseasadmissible.

7. Maria Mamerita Mestanza Chavez Vs. Peru, Report No. 71/03, Petition No. 12.191Forum: Inter-American Commission on Human RightsSummary:

In a petition lodged with the Inter-American Commissionon Human Rights on June 15, 1999, the nongovernmentalorganizations Office for the Defence of Women’s Rights(DEMUS),theLatinAmericanandCaribbeanCommitteefortheDefenceofWomen’sRights(CLADEM),andtheAsociaciónProDerechosHumanos [Association forHumanRights] (APRODEH),whichsubsequentlyaccreditedasco-petitionerstheCenterforReproductiveLawandPolicy(CRLP)andtheCentreforJusticeandInternationalLaw(CEJIL),allegedthattheRepublicofPeruviolated the human rights of Ms. María Mamérita MestanzaChávez,byforcedsterilizationthatultimatelycausedherdeath.

Ms.MaríaMaméritaMestanzaisjustoneamongalargenumberof cases of women affected by a massive, compulsory, andsystematic government policy to stress sterilization as ameansforrapidlyalteringthereproductivebehaviourofthepopulation,especiallypoor, Indian,and ruralwomen. Theynoted that theOmbudsman had received several complaints on this matter,andthatbetweenNovember1996andNovember1998CLADEMhaddocumented243casesofhuman rightsviolations throughtheperformanceofbirthcontrolsurgeryinPeru.

ThepetitionersstatedthatMs.MaríaMaméritaMestanza,aruralwomanabout33yearsoldandmotherof sevenchildren,waspressured to accept sterilization starting in 1996 by the HealthCenter of Encañada District. She and her husband JacintoSalazar Suárezwere subjected to various forms of harassment,including several visits inwhichhealthpersonnel threatened toreportherandMr.SalazarSuárez to thepolice,and told themthatthegovernmenthadapprovedalawrequiringanyonewhohadmorethanfivechildrentopayafineandgotojail.

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Theystatethatfinally,undercoercion,Ms.Mestanzaagreedtohave tubal ligation surgery. The procedure was performed onMarch27,1998attheCajamarcaRegionalHospital,withoutanypre-surgerymedicalexamination.Ms.Mestanzawasreleasedthenext day,March 28, 1998, although she had serious symptomsincluding nausea and sharp headaches. In the following daysMr.JacintoSalazarreportedtopersonnelofLaEncañadaHealthCenteronMs.Mestanza’scondition,whichworseneddaily,andwastoldbythemthatthiswasduetopost-operativeeffectsoftheanaesthesia.

Ms.MestranzaChavezdiedathomeonApril5,1998,andthatthedeathcertificatespecifieda“sepsis”asthedirectcauseofdeathandbilateraltubalblockageasaprecedentcause.TheyreportthatafewdayslateradoctorfromtheHealthCentreofferedasumofmoneytoMr.JacintoSalazarinanefforttoputanendtothematter.

On April 15, 1998 Mr. Jacinto Salazar filed charges with theProvisional Combined Prosecutor of Baños del Inca againstMartínOrmeñoGutiérrez,ChiefofLaEncañadaHealthCenter,inconnectionwiththedeathofMs.Mestanza,forcrimesagainstlife, body, and health, in premeditated homicide (first degreemurder).TheyaddthatonMay15,1998thisProvincialProsecutorindicted Mr. Ormeño Gutiérrez and others before the localProvincial Judge, who on June 4, 1998 ruled that there wereinsufficientgroundstoprosecute.ThisdecisionwasconfirmedonJuly 1, 1998by theCircuitCriminalCourt, soonDecember 16,1998theProvincialProsecutororderedthecasedismissed.

Status:OnMarch2,2001during the110th regular sessionof theIACHR a Preliminary Agreement for Friendly Settlement wasreached.Thefinalfriendlysettlementwassignedon26thAugust,2003.Thetermsofthefriendlysettlementare:

1)Recognition: In thatagreement thePeruvianStateadmittedinternational responsibility for the factsdescribedandpledgedto take steps for material and moral reparation of the harmdone and to initiate a thorough investigation and trial of theperpetratorsandtakestepstopreventtherecurrenceofsimilarincidentsinthefuture.


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2) Investigation and Punishment: The Peruvian State promisestomakea thorough investigationof the factsandapply legalpunishments to any person determined to have participatedin them, as either planner, perpetrator, accessory, or in othercapacity,eveniftheybecivilianormilitaryofficialsoremployeesofthegovernment.

In this regard, thePeruvian Statepledges tocarryout administrative and criminal investigations intotheattackson thepersonal liberty, life,body,andhealthofthevictim,andtopunish:

a.Thoseresponsiblefortheactsofpressuringthe consent of Ms. María MaméritaMestanzaCháveztosubmittotuballigation.b.ThehealthpersonnelwhoignoredtheneedforurgentcareforMs.Mestanzaafterhersurgery.c. Those responsible for the death ofMs. María Mamérita Mestanza Chávez.d.Thedoctorswhogavemoneytothespouseof the deceased woman in an attempt tocover up the circumstances of her demise.e. The Investigative Commission, namedby Cajamara Sub-Region IV of theHealth Ministry, which questionablyexonerated the health personnel fromresponsibility for Ms. Mestanza’s death.

Apartfromtheadministrativeandcriminalpenalties,the Peruvian state pledges to report any ethicalviolationstotheappropriateprofessionalassociationso that it can apply sanctions to the medicalpersonnel involved in theseacts,asprovided in itsstatutes.

In addition, the State pledges to conductadministrative and criminal investigations into theconductofagentsoftheOfficeofPublicProsecutionandthejudicialbranchwhofailedtotakeactionto

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clarifythefactsallegedbyMs.MaméritaMestanza’swidower.

Indemnification:

Monetary Compensation:

a) Moral damages: The Peruvian State awards one-timecompensationtoeachofthebeneficiariesoftenthousandU.S.dollars ($10,000.00) for reparation of moral injury, which totalseighty thousand U.S. dollars ($80,000.00). Beneficiaries are thehusbandandsevenchildrenofMaríaMaméritaMestanza.

TheStatewilldeposittheamountduetheminorsinatrustaccountinaccordancewiththebesttermsavailableundersoundbankingpractice. Arrangements will be made jointly with the SalazarMestanzafamily’slegalrepresentatives.

b)Corollarydamages: Injurycausedasadirectconsequenceoftheeventgivingrisetotheclaimconsistsofexpensesincurredbythefamilyasadirectresultoftheacts.Theseexpenseswereincurredtofileandfollow-upcriminalchargeswiththeOfficeofPublicProsecutionsforaggravatedhomicideofMaríaMaméritaMestanza, as well as the costs of Ms. Mestanza’s funeral andburial.TheamountexpendedforthesepurposesistwothousandU.S.dollars($2,000.00),whichthePeruvianStateshallpaytothebeneficiaries.

Indemnification from those criminally responsible for the Acts:

The Agreement for Peaceful Settlement does not include thebeneficiary’s’ right to damages from all those responsible forviolation of Ms. María Mamérita Mestanza’s human rights, asdeterminedbyacompetentcourtinaccordancewithArticle92ofthePeruvianPenalCode,arightwhich is recognizedbythePeruvianState.Thisagreementexpresslywaivesanyotherclaimby the beneficiaries against the Peruvian State as responsibleparty,aco-defendant,orinanyothercapacity.


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6)RightofRecovery:

The Peruvian State reserves the right of recovery against allpersonsfoundtoberesponsibleinthiscasethroughthedefinitivesentenceofacompetentnationaltribunal,inaccordancewithcurrentdomesticlaw.

7)Taxexemption,compliance,andlatepenalty:

The damages awarded by the Peruvian State shall not besubjecttopaymentofanypresentorfuturetax,assessment,orfee,and shall bepaidno later than sixmonthsafter the Inter-AmericanCommissiononHumanRightshassentnotificationofthisagreement’sratification,afterwhichtheStateshallpaythemaximumlatefeeandinterestrequiredorpermittedbydomesticlegislation.

Medical Payments:

The Peruvian State promises to make a one-time payment tothe beneficiaries of seven thousand U.S. dollars ($7,000.00) forpsychologicalrehabilitationtreatmenttheyrequireasaresultofthedeathofMaríaMaméritaMestanzaChávez.Thatsumshallbepaid in trust toapublicorprivate institution,designatedasthetrustee,whichwilladministertheresourcesspentonprovidingpsychologicalcareneededby thebeneficiaries. The institutionwill be chosen jointly by the State and representatives of theSalazarMestanzafamily,withsupportfromtheNationalHumanRightsCoordination,DEMUS,APRODEH, and theArchbishopofCajamarca.ExpensesforlegalestablishmentofthetrustshallbepaidbythePeruvianState.

Inaddition,thePeruvianStatepromisestogivethehusbandandchildrenofMaríaMaméritaMestanzaChávezpermanenthealthinsurancewiththeMinistryofHealthorothercompetententity.The surviving spouse’s health insurance will be permanent, aswill thatof thechildrenuntil theyhavetheirownpublicand/orprivatecoverage.

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Education Payments:

The Peruvian State promises to give the victim’s children freeprimaryandsecondaryeducationinpublicschools.Thevictim’schildrenwill receivetuition-freeuniversityeducationforasingledegreeatstateschools,providedtheyqualifyforadmission.

Other Payments:

The Peruvian State agrees tomake an additional payment oftwenty thousandU.S.dollars ($20,000.00) toMr. JacintoSalazarSuáreztobuylandorahouseinthenameofthechildrenhehadwithMs.MaríaMaméritaMestanza.WithinoneyearofthedateofthisagreementMr.SalazarSuárezmustregisterthepurchasebydeliveringthedeedtotheExecutiveSecretariatoftheNationalHumanRightsCounciloftheMinistryofJustice.Furthermore,Mr.SalazarSuárezagreesnottosellorleasethepropertypurchaseduntiltheyoungestofhischildrenisoflegalage,unlessauthorizedbythecourt.

Peru’sNationalCoordinatorofHumanRightswillberesponsibleforthenecessaryfollow-uptoensurecompliancewiththeprovisionsofthisclause.

Changes in laws and public policies on reproductive health and family planning:

ThePeruvianStatepledgestochange lawsandpublicpolicieson reproductive health and family planning, eliminating anydiscriminatoryapproachandrespectingwomen’sautonomy.

The Peruvian State also promises to adopt and implementrecommendationsmadebytheOmbudsmanconcerningpublicpolicies on reproductive health and family planning, amongwhicharethefollowing:

A. Penalties for human rights violations and reparation for victims

1. ConductajudicialreviewofallcriminalcasesonviolationsofhumanrightscommittedintheexecutionoftheNationalProgrammeofReproductiveHealthandFamilyPlanning,


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to break out and duly punish the perpetrators, requiringthemtopaytheappropriatecivildamages,includingtheStateifitisdeterminedtohavesomeresponsibilityfortheactsthatgaverisetothecriminalcases.

2. Review the administrative proceedings initiated by thevictims and/or their familymembers, linked to the casesin the previous paragraph, which are pending or haveconcluded concerning denunciations of human rightsviolations.

B. Methods for monitoring and guaranteeing respect for human rights of health service clients

1. Adoptdrasticmeasuresagainst those responsible for thedeficientpre-surgeryevaluationofwomenwhoundergosterilization, including healthprofessionals in someof thecountry’shealthcenters.AlthoughtherulesoftheFamilyPlanningProgrammerequirethisevaluation,itisnotbeingdone.

2. Continuouslyconducttrainingcoursesforhealthpersonnelinreproductiverights,violenceagainstwomen,domesticviolence,humanrights,andgenderequity,incoordinationwith civil society organizations that specialize in thesetopics.

3. Adopt the necessary administrative measures so thatthat rulesestablished forensuring respect for the rightofinformed consent are scrupulously followed by healthpersonnel.

4. Guarantee that thecenters thatoffer sterilizationsurgeryhaveproperconditionsrequiredbystandardsoftheFamilyPlanningProgramme.

5. Takestrictmeasurestoensurethatthecompulsoryreflectionperiodof72hoursisfaithfullyanduniversallyhonored.

6. Take drastic action against those responsible for forcedsterilizationwithoutconsent.

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7. Implement a mechanism or channels for efficient andexpeditious receipt and processing of denunciations ofviolationof human rights in the health establishments, inordertopreventorredressinjurycaused.

Constitution of India and Case Law

TheConstitutionofIndiaguaranteestheRighttoLife(Article21)and the Right to Equality (Article 15). The Supreme Court hasdetermined that the Right to Life includes the Right to Health(See Pashim Banga KhetMazdoor Samiti, 1996 4 SCC 37), theRight todignity,and theRight tobe free fromcruel, inhuman,anddegradingtreatment(FrancisCoralieMullinv.Administrator,Union Territory of Delhi &Ors.). Some of the fundamental rightwhichfocusesonhealthofwomenarediscussedbelow:

1. Right to access contraceptive information and services. Article 21 guarantees Right to Life. In Suchita Srivastava vs. Chandigarh Administration AIR 2010 SC 235) holding that: “Thewoman’srighttomakereproductivechoicesisalsoadimensionofpersonallibertyasunderstoodunderArticle21oftheConstitutionofIndia.Itisimportanttorecognizethatreproductivechoicescanbeexercisedtoprocreateaswellastoabstainfromprocreating.”

2. Right to be free from discrimination based on sexArticles14,15,21givespeoplethefundamentalrightstofreefromanyformofdiscriminationbasedonsexbutIndia’sfamilyplanningpolicytargetsonlywomentocontroltheboomingpopulation.

3. Right to dignitySuchita Srivastava vs. Chandigarh Administration (AIR 2010 SC 235)holdingthat:thecrucialconsiderationisthatthewoman’sright to privacy, dignity, bodily integrity should be respected.This means that there should be no restriction whatsoever ontheexerciseofreproductivechoicessuchasawoman’srighttorefuseparticipationinsexualactivityoralternativelytoinsistenceonuseofcontraceptivemethods.Furthermore,womenarealsofreetochoosebirthcontrolmethods.”


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4. Ramakant Rai v. Union of India, W.P ( C) No 209 of 2003, Supreme Court of India, 12/06/2007)

APublicInterestLitigation(PIL)wasfiledbythepetitionerfortheimplementationoftheMinistryofHealthandWelfare’sGuidelinesonStandardsof FemaleSterilization,enacted inOctober1999.Thepetitionfurthersoughtcompensationforvictimsofmedicalnegligence in sterilizationprocedures,aswellasaccountabilityforviolationsoftheguidelines.

5. Devika Biswas vs Union of India (WP (c) 95/2012):OnSeptember,2016theSupremeCourtorderedabanonmasssterilizationcampsinIndiawithinthreeyears.‘’Thepublicinterestlitigation was filed after 53 women underwent sterilization inunsanitaryconditionsinKaparfora, inArariadistrictofBihar.Theprocedurewasconductedinaschool,incompleteviolationoftheguidelinesforfemalesterilizationlaiddownbytheSupremeCourtandtheGovernmentof India.Thejudgmentdirectsthecentraland state governments to stop all camp-based sterilizationswithinthreeyearsandinsteadstrengthenhealthfacilitiessothattheyareable toprovide this facility. The judgmentalsodirectsgovernmentstonotseteveninformaltargets,compellinghealthworkerstoundertake“whatwouldamounttoaforcedornon-consensualsterilization”.

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Findings from the Field

8. FINDINgS FROM THE FIELD

Human Rights Law Network (HRLN) carried out fact findings along with a team of activists and lawyers in different states of India. In this section, fact findings from the states of Rajasthan, Chhattisgarh, Uttarakhand, Madhya Pradesh and Delhi carried out between January 2012 - July 2017 have been complied with the objective of investigating and documenting case studies of women who have undergone sterilization. The fact-finding missions revealed numerous parallels across health facilities and similarities in women’s experiences in accessing the health system. Lawyers and social activists visited sterilization camps throughout rural areas and interviewed various doctors, nurses, hospital staff, patients and families in order to assess the nature and conditions of the sterilization camps; assess whether the guidelines for sterilization were being followed by surgeons and other health workers; assess the patient’s level of understanding of the inherent risks of the surgery; examine why women were choosing to undergo sterilization; and finally assess the camps and facilities where women were undergoing sterilization.

1. FACT-FINDINg MISSION TO RAJASTHAN (SIkAR, BHILWADA, MADHOPURA)

DATE OF VISIT: 12th till the 14th of February 2017STATE PROFILE: RAJASTHAN

ThestateofRajasthanhasthemostcomprehensiveimplementationoffamilyplanningpoliciesandsterilizationcampsinthecountry.Everyyear,Rajasthanconductssterilizationofoverthreelakhmenandwomen,oftenofferingNanocarsandfreegasconnectionsasincentive.Thestategovernmenthasbeenpromotingsterilizationas the best family planning method for years.Just in the lastthreeyears,RajasthanhasendeduppayingoverRs10croreas

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compensation for failed sterilization procedures, according toanRTI(righttoinformation)requestfiledbyaresidentofJaipur,YadunathDashanan.

The Government of Rajasthan has also employed a seriesof policies that are highly coercive, policies that incentivisesterilizationthroughofferingwomenwhogothroughsterilizationprizessuchasmotorcycles,televisionsets,andevenachancetowinacar.95Althoughsuchprogrammesarenolongerconducted,cash incentives for sterilization remain, with women receiving1400rupeesforundergoingtheprocedure.ASHAworkersarealsoincentivisedtoencouragetheirpatientstoundergosterilization,but receive no incentives for promoting other forms of familyplanning like spacingmethods. The structures and schemes inplace are coercive measures that encourage impoverishedwomentoundergopotentiallydangerousandharmfulsurgerieswithpermanenteffects.

FOCUS AND METHODOLOgy

AnRTIwasfiledinstateofRajasthantotheDistrictMedicalOfficerrequestingtheauthoritiestosharethecalendarpreparedforthepurposeofconductingsterilizationmonthlycamps.

Ateamof lawyersandsocialactivistsvisitedvarioussterilizationcampsthroughoutruralareasofRajasthan.Theteaminterviewedseveral doctors, nurses, hospital staff members, patients andfamilies in order to assess the nature and conditions of thesterilizationcamps.

THE FACT-FINDINg INVESTIgATION5.1 CAMP VISIT 1-SHRI kHATUSHyAMJI COMMUNITy HEALTH CENTRETheteamvisitedCommunityHealthCentreatShriKhatushyamjion12/02/2017toobservethesterilizationcampandthehealthcareprovider’s adherence to Hon’ble Supreme Court’s recentjudgmentpassedinthematterofDevikaBiswasvUOIregardingthe violation of standard operating procedures (SOP) in mass

95BritishBroadcastingCompanyNews,Delhi,WhydoIndianwomengotosterilizationcamps?11/11/2014http://www.bbc.com/news/world-asia-india-29999883

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sterilizationcamps.TheteamarrivedattheCHCat10:00amandobservedthatwomenhadalreadystartedcomingin-mostwithgeneralhealthissues,andveryfewforthesterilizationoperation.

The doctor (general physician) onduty informed the team that thecamp usually starts after the doctorhas arrived, which is after 12:30 or1:00 pm. He also stated that thereare no gynaecologists in the CHC,Khatushyamji, Rajasthan. 19 womenbetween the ages of 20-30 yearswere registered for the camps.They had been motivated by theirlocal ASHA workers to undergo theprocedure, who accompaniedthem to the camps along with theirfamilymembers. A sticker carryinganumber was pasted on the back ofthe women’s hands to keep count.RepresentativesfromFoundationforResearchinHealthSystems,anNGO, filledup forms for thewomenwithbasic information,leavingseveralsectionsincomplete.Womenwerethensentforbloodandbloodpressuretests.Howeverminimalcounsellingwasobserved.Moreover,physicalexaminationofwomenwasmerelyaformality,asitwascompletedwithinseconds.

Oneof the teammemberswas invitedtoobserve thecounsellingsessions. TheNGO representative spoke positivelyabout sterilization, thus promotingit. It was unclear if the women hadbeen informed about the risks of theprocedure, and they did not appearto be giving informed consent asmandated by the guidelines. ThehospitalstaffandNGOteamappearedtoconsiderattendanceatthecampasanindicationofthepatient’sconsenttosterilization. The camp was scheduled

THECHCATKHATUSHAMJI

WOMENLYINGONFLOORAFTERGIVENANESTHESIA

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tooccur from12:30pm-3:00pm,with theNGOoperatingteamarriving shortly before this. The fact finding teamwas informedthattheprocedurewouldtake4to5minutes,withthewomenremainingforobservationaftertheprocedurefor1-2hours.Thisisfarlessthanthegovernmentmandated4hoursofpoststerilizationobservation.17women,outofthe19registered,wereoperatedon.Onewomanwasdeniedtheprocedureasshetestedpositiveonapregnancytest,andtheotherwasdeniedduetoproblemswithherappendixandtheassociatedriskofthesurgery.

The women received anaesthesia viainjection from an anaesthetist. Following theanaesthetic, women were left to lie on thefloor of a roomwith their bodies completelycovered by a blanket. The women wereleft unattended, as the doctors took breaksto allow the anaesthetic to take effect forapproximately 45 minutes. An activist fromthe team was invited to observe several ofthe procedures by the surgeon. The activistwas informedbythedoctorthathechangesglovesfrequently,whichhedemonstrated.Toprove thatcleanlinesswasmaintained in theoperating theatre, NGO workers attempted

tocoverwallsof theoperating theatrewitha sheet;displayedequipment neatly and used separate colour coordinateddustbins.However,notmuchattentionwaspaidwhenitcametochangingbloodstainedsheetsonoperationtable.

Even though the team was previously informed that therewere three laproscopes available, it was difficult to assess iflaparoscopeswerechanged/disinfectedbetweenprocedures.Following surgery, thewomenwere taken viawheelchair to award for post-operation monitoring. The team observed thatthewomenwereprovidedwithbedsintheward.Theteamwasinformed that the women would make their own way home.Therewasnoambulance facilityavailable to take thewomenhome,thuscausingthemoutofpocketexpenditures.Thepatientsinterviewedstatedthattheywerenotawareoftheirentitlementtotransportationfromthefacilitytotheirhomesundersterilization

WOMENBEINGCARRIEDBACKTOWARDAFTEROPERATION

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guidelines.AdoctorfromFRHS,alocalNGO,informedtheteamthat theoperationusually tookaround4 to 5minutesand thewhole process takes around 2 hours (pre-operation and post-operation).

TheMedicalSuperintendent(MS)ofCHCatKhatushyamjisharedwiththeteamthattheCHCinquestionisaFirstReferralunit(FRU)with a provision of 50 beds. In Sikar (within 8 Blocks) there areapproximately33CHCs,99PCHs,and624sub-centres.AsthereisnogynaecologistpresentinthisCHC,thegovt.engagedFRHStoorganizesterilizationcamps.Femalepatientsweregiven INR1400/-whereasmalepatientswegivenINR2000/-forNoScalpelVasectomy(NSV)asincentiveseitherthroughchequeorcash.

Regarding meeting the targets, the team was informed thatthe Anganwadi workers and ASHA workers monitor women,especiallythosewhoarepregnant.Theyencouragewomentogetsterilizationoperationsdoneaftertwochildren.Healthworkersinformedtheteamthatmobilizingwomenandconvincingthemtoundergoasterilizationprocedurewasabigchallenge.

CAMP VISIT 2 – PALSANA COMMUNITy HEALTH CENTRE

TheteamvisitedthecommunityhealthcentreatPalsanaonthe12/02/2017. The teamspoke toVinod,a LowerDivisionalClerk,and Sheesh Ramji, who was part of themale nursing staff. These individuals werethe only ones present atCHCat the timeof visit. They informed the team that thecamphadoccurredthedaybeforei.e.onthe11/02/2017(Saturday).Thewomenhadarrived for registration and counselling at9:00am.Sevenwomenwereregisteredforsterilizationsurgeries.Theteamresponsibleforconductingoperationsarrivedby11:00amand consisted of government employees.During registration and counselling, aphysicalcheck-upisperformed,andbeforetheoperationthewomen’sbloodpressureischeckedagain.Thewomen receive sedation via injection and are then left for 30

OPERATIONTHEATER

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minutestoallowtheoperationtooccur.Itisunclearwhatlevelofsupervisionthewomenaregivenduringthisperiodandwhethertheyhaveaccesstobedsinthehospital.Thestaffinformedtheteamthattheoperationtakes10-15minutes,andthewomenareleftformonitoringfor1-2hours.Thissuggeststhatthewomenarenotreceivingthemandated4hoursofpostoperationmonitoring.

Thewomenwere alsomonitored by a different doctor as theoperationteamleftshortlyaftertheoperationswascompleted.Womenwererequiredtofindtheirowntransporthome,inviolationoftheguidelines,andwereprovidedwithpost-operationtablets.The teamwas informed that the patient receives 1400 rupeesfor undergoing sterilization. The ASHA workers also received150 rupees for every patient they counselled and referred forsterilizationandanaddedINR1000/-bonusifthepatientalreadyhadtwochildren.

CAMP VISIT THREE – gULABPURA COMMUNITy HEALTH CENTRE

HRLN’s team of lawyers and social activists visited GulabpuraCommunityHealthCentreonthe13/02/2017as thesterilizationcamp was underway. The CHC hada facility of 50 beds witha provision of one general physician (MBBS Doctor) and noGynaecologists,Paediatricians,ENTspecialists,orEyespecialists.Severalwomenwerepresentforsterilization,someofwhomhadbeenpresentattheCHCsince7am.Thewomen’sfirstpointofcontactinthehospitalwasforregistration,whichlargelyconsistedoffillinginthe(selective)relevantdocumentation.Thenursefillinguptheformsaskedveryfewandspecificquestionsonmenstrualcycle,numberofchildren,casteetc.Theregistrationswerebeingcarried out in an extremely small roommeant for conductingECGtests.ItservedmultiplepurposeswithmalepatientsreceivingECGswhilethenursekeptfillinguptheformasthewomenpouredin.Hence,therewasnoprivacyforthewomentoopenlydiscusstheir sexualhealthor toaskanyquestions that theymayhavehad.Outoftenregisteredcases,onewasrejectedbecausethepatient’spregnancytestwaspositive.

Additionally, the team also observed that no counselling wasprovidedtowomen.Therewasnodiscussionwithwomenabout

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the associated risks of the surgery or thenecessarypostoperationproceduresandcare.Itwasnotevidentthatthethresholdof informedconsentwas beingmet. Theteamwasinformedthatsterilizationcampswere conducted every Monday withan average of 10-12 procedures beingconducted. A male nurse mentionedthat themaximumnumberofpatientsatasterilizationcampwas20,whileanotherdoctor at the CHC stated that theremaybeupto30womenatacamp.Thefact finding teamwas informed that themedicalteam(whichincludedasurgeon,anurseandsupportingstaff fromBhilwadaDistrictHospital)conducted the sterilizationcamps.Thedoctorkeptinquiringabouttheno.ofwomenwhohadcomeforoperation.Theseriousnessoffillinguptheformscanbeassessedfromthefactthenurseaskedsocialactiviststofilluptheformswhenshehadtoleaveherdeskforafewminutes.

The doctor and his team arrived at 12:22 pm and did quickphysicalexamination,spendingmerelyafewsecondsoneachpatient.Subsequently,womenproceededto theOTwhere theywere injectedwithanaesthetics. It was unclear if therewasadedicatedanaesthetist for this task, oriftheanaestheticwasbeingadministeredby the surgeon or a member of thesupportstaff.Theoperationsbeganat1:15and by 1:50 seven women had alreadyundergone the procedure. Thus, thedoctorspentanaverageof5minutesoneachpatient.However,whenthemedicalteamwas interviewedafterthesurgeries,thedoctorstatedthathespent10minutesoneach sterilizationprocedure. The stafffurther stated that patients remained atthefacilityuntileveningforpost-operativeobservation; however the surgeon andhis team left shortlyaftercompleting the

ASHA’SANDMEDICALSTAFFGETTINGTHEIRCLIENTSREGISTERED.

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surgeries.Other staffat theCHCasserted thatonaverage thewomenremainedforobservationforonlytwohours,ratherthanthemandated4hoursofobservation.Womenwerenotgivenhospitalgownsfortheoperationsandremainedintheirpersonalclothes.After surgery, thewomenwere taken to femalewardswith theaid ofwheelchairs andplacedonbeds for recovery.TheCHCstaffstatedthatwomenusedtheirownmeanstotravelhomeastherewasnoambulancefacilityavailable.

The fact-finding team identified a complete lack of hygienicpractices and general hygienewithin the hospital. Bed sheetsthatthewomenwereprovidedforrecoveryappeareduncleanand unhygienic. The staff used the sameneedle to administeranaesthetictoall thewomen,cleaning itviatheuseofboilingwaterfor1-2minutes.Asourcewhowishedtoremainanonymousinformedthefact-findingteamthat thesurgeonusedonlyonelaparoscope and that it required 3-4 minutes cleaning withdisinfectant solution. However, according toguidelines, propercleaning of laparoscopes requires 20-30 minutes of cleaning.In order to adhere to these guidelines and perform multiplesterilizations continuously, at least 4 laparoscopes are requiredwithrotationalcleaningoftheinstruments.

Thefact-dingingteamreportedthatthehospitalwasdirty,withuncleanfloorsandbeds.Ithadopenspacesthatwereexposedtotheelements.Theteamobservedastraydogwalkingthroughthehospitalandneartheentranceoftheoperatingtheatreandwomen’swards.

The fact finding team was informed that for every sterilizationprocedure conducted, a surgeon gets paid INR 100, agynaecologist gets INR 50 and an anaesthetist gets INR 50 ascash incentives. The surgeon also informed HRLN’s team thattheQuality Assurance CommitteeMeetings are held in Jaipurregularly where cases of failure have been brought up andstudied. The doctor said that rate of failure is approximately 4casesofevery1000cases inan idealcondition. In suchcases,thereexistsaprovisiontoprovideINR30,000tothevictim(underFPIS).Adistrictlevelcommitteehasbeensetuptofollowupthecaseandrecordthereasonforfailure.

5.5 CAMP VISIT 4 – SHRIMADHOPUR COMMUNITy HEALTH CENTREThe team visited a sterilization campat Shrimadhopur on 14/02/201, andinterviewedthedoctors,nurse,healthcareworkersandASHAworkers.ThehospitalMSanda seniorDoctorwere relativelywillingtotalkaboutthesterilizationcampafteraninitial inquiry regarding the team’smotivefortheinterviews.

A health care provider shared that sixwomen and one man had registeredfor sterilization and NSV proceduresrespectively and their counselling hadalreadybeenby RFHS teammember. However, pre-operationcounselling,asobservedby the team,amounted to littlemorethanregistration.Thewomendidnotappeartobeinformedabouttheinherentrisksoftheprocedure,andmanywerenotawareofthecontentsofthedocumentsthattheyweresigning.Thenursesstated that theyperformed10minutecounselling sessionswiththewomen.Itwasunclearwhetherthistimeconsistedofmerelyfillingouttheformsandbookletsorifitalsoincludeddiscussionsofsterilizationalternatives,risksoftheoperationandinstructionsonpost-operativecare.Thehealthcareproviderstatedthatshediscussedtherisksassociatedwiththeoperationaswellaswhatfoodthewomenshouldeatafterthesurgery,howeverthiswasnotobservedbytheteam.

INTERVIEW WITH THE LAB TECHNICIAN/ANAESTHETISTTheteamwas informedthattherewasnoanaesthetist in the area. Instead of aqualifieddoctor,thelabtechnicianfortheCHC had undertaken the duties of ananaesthesiologistafterundergoinga shorttwomonthcourseinthesubject.Duringthecourse of interaction with the Labtechnician, the team observed that thetechnicianwasveryrudeanddisrespectful

Women made to lie on floor after anaesthesia was administered

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5.5 CAMP VISIT 4 – SHRIMADHOPUR COMMUNITy HEALTH CENTREThe team visited a sterilization campat Shrimadhopur on 14/02/201, andinterviewedthedoctors,nurse,healthcareworkersandASHAworkers.ThehospitalMSanda seniorDoctorwere relativelywillingtotalkaboutthesterilizationcampafteraninitial inquiry regarding the team’smotivefortheinterviews.

A health care provider shared that sixwomen and one man had registeredfor sterilization and NSV proceduresrespectively and their counselling hadalreadybeenby RFHS teammember. However, pre-operationcounselling,asobservedby the team,amounted to littlemorethanregistration.Thewomendidnotappeartobeinformedabouttheinherentrisksoftheprocedure,andmanywerenotawareofthecontentsofthedocumentsthattheyweresigning.Thenursesstated that theyperformed10minutecounselling sessionswiththewomen.Itwasunclearwhetherthistimeconsistedofmerelyfillingouttheformsandbookletsorifitalsoincludeddiscussionsofsterilizationalternatives,risksoftheoperationandinstructionsonpost-operativecare.Thehealthcareproviderstatedthatshediscussedtherisksassociatedwiththeoperationaswellaswhatfoodthewomenshouldeatafterthesurgery,howeverthiswasnotobservedbytheteam.

INTERVIEW WITH THE LAB TECHNICIAN/ANAESTHETISTTheteamwas informedthattherewasnoanaesthetist in the area. Instead of aqualifieddoctor,thelabtechnicianfortheCHC had undertaken the duties of ananaesthesiologistafterundergoinga shorttwomonthcourseinthesubject.Duringthecourse of interaction with the Labtechnician, the team observed that thetechnicianwasveryrudeanddisrespectful

Women made to lie on floor after anaesthesia was administered

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towardswomen.Womenwereforcedtolieonthe floor after anaesthesiawas administeredand no beds were made available for theiruse. The Lab technician was harsh towardsASHAworkersaswell. Shegotoffendedandscolded ASHA workers for talking amongstthemselves.Shealsodidnotallowwomentotalk and instructed them to lie downquietly.The labtechnician informedthat thewomenreceivedminimalpre-operation labtestsandcheck-ups. The lab technician/ anaesthetistspoke negatively about women from

marginalisedcommunitiesastheylayonthefloor.

The doctor informed the fact-finding team that the averageoperation timewas between 5 and 7minutes.Itwas not clearhow long thewomen remained forpost-operationalcareaftertheprocedure.

INTERVIEW WITH THE DOCTOR AND ASHA WORkERS

TheASHAworkersandnursesdiscussed themotivationsbehindwomen opting for sterilization procedures. They consideredmonetary incentive a significant driving force. ASHA workerscounselledwomen and attempted to convincewomen themthatasterilizationoperationaftertwochildrenwasbestfortheirphysicalhealthandfinancialstatus.Theyemphasisedthatfamilies

would be able to give greater support totheir children, in terms of education andjobopportunities, if they limitednumberofchildren to two. The teamnoticed severalboxesofcondoms inthecounsellingroomwhichread“forhomedeliverybyASHA(Govtof India Supply).” These boxes appearedfull and it remained unclear whether theASHA workers and nurses were discussingalternativemethodsofcontraceptionwiththe women. It should also be noted thatthere are greater incentives for the ASHAworkerstocounselthesewomentoreceive

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sterilization than any other forms of contraception. Althoughtherearesignificantcashbonusesforcounsellingwomentobesterilized,ASHAsreceivenosimilarbonusforadvisingalternativemeansofcontraception.Forinstance,theASHAworkersreceivenofinancialbenefitforhandingoutofcondoms,andthiswouldlikelyrequireahigherlevelofcontinuedworkfortheASHAworkeras compared thework required in counselling and supportingwomenforsterilization.

On being asked how targets were set,the health worker informed the teamthat 1%of thepopulation inanareawasconsidered the target for sterilization. TheASHAworkersstatedthattheyhadatargetof counselling 12 women per month. IncaseswhereanASHAwasunabletomeetthe target, theywere scolded and yelledat inmeetings. An ASHA also shared thatdoctorsandMSarealso required tobringincasesforsterilization.TheyfrequentlyaskASHA workers to convince more womenfor the procedure, to add them to theirnumbersandaccomplish their set targets.ThisputsextrapressureonASHAs.AnASHAworkeraddedthatshesometimeshadto requestherhusbandtotalktomentoconvincetheirwivestoundergothesterilizationprocedure.

AWWsandASHAworkersundergospecialtrainingregardinghowtomotivatewomenforsterilization,althoughtheycontinuetofinditchallenging.Malemembersofafamilyareusuallyreluctanttodiscuss the issueastheybelieve itaffects theirmasculinity. Theydownrightrefusetoundergotheprocedureastheythinkitmakesthemunfitforwork.

OBSERVATIONS

The operation of sterilization camps in Rajasthan presentssignificant health risks to women who attend them. All of thecampsattendedbytheteamsfailedtomeetseveralrequirements

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outlinedbytheMinistryofHealthandFamilyWelfareasthebasicstandards in the administration of sterilization services. Failuretomeetthesestandardslimitsthecapacityofwomentomakeinformed choices about their sexual health, creates significanthealthrisksandmaycauselastingharmordeath.

The sterilization standards outline that women must receivecounselling before undergoing the procedure through camps.Thepurposeofthiscounsellingistoallowwomentomake“wellinformed,wellconsideredandvoluntarydecisionsaboutfertilityand to choose a contraceptive method.”96 This requires thatwomenbemadeawareofalternativemeansofcontraception,thepotentialrisksandcomplicationsoftheprocedure,andthepermanency of the procedure. Only through explaining theseelements of the procedure can an individual give informedconsent to the surgery. While the team observed counsellingsessionsoccurringatallthecamps,thestandardsforcounsellingwerenotbeingmet.Thecounsellingsessionsamountedto littlemorethanthefillingoutofthenecessaryformsanddocuments.Many of the women were not made aware of the inherentrisks of theprocedure, aswell as the necessarypost-operativeprocedures. When the risk of infection and complication is sosignificant,duetothesubstandardhygieneandconditionsofthehospital,thefailuretoinformwomenofoperativerisksismoresoalarming.Most importantly,womenwerenotcounselledaboutthe alternatives to sterilization, such as the use of condoms orcopper t’s.Rather thanprovidingthenecessary information forwomen to give informed consent to the procedure, many ofASHAworkersandotherhealthprofessionalsappearedtoemploycoercivemeasuresinfavourofsterilization.TheincentivebasedsystemforASHAworkersrewardsthemforencouragingwomentobecomesterilized,whileprovidingnosimilarfinancialincentivefor the promotion and use of other forms of contraception.Furthermore,someASHAworkersspokento indicatedthattheyreceived significant financial bonuses when they encouragedwomenwhohadalreadyhad2childrentoreceivesterilization.

96MinistryofHealth&FamilyWelfare,Standards & Quality Assurance in Sterilization Services, November2014.

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The same financial incentives exist for women to undergo thesterilizationprocedureandserveasimilarcoercivepurpose.

There was an overwhelming overrepresentationofwomenatthesterilizationcamps.Inallcampsvisitedbytheteam,onlyonecontainedasinglemalepatientreceivingsterilization,and itwasunclearwhetherhewent through with the procedure. Existingtaboosandculturalpracticesplacetherisksof sterilizations camps disproportionatelyupon women. While the government hasintroduced higher financial incentives formalesterilizationthanforfemalesterilization,this has had limited effect. Health workersthemselves perpetuate these taboos,with ASHA workers seemingly counsellingin favour of female sterilization over malesterilization. Greater education, government incentives andlegislation are required to reduce the disparity betweenmaleandfemalesterilization.

Themedical standards of sterilization camps continually failedto meet required guidelines. Following the administration ofanaesthetic,womenatallthecampswereleftunattendedandunmonitoredbythedoctororanaesthesiologist,withsomelyingonthefloor.Thisisindirectcontraventionofsterilizationstandardswhich state that the “clientmust bemonitored and attendedtoafter theparenteraladministration.”97 Theguidelinesoutlinethattheanaestheticshouldtakeeffectwithin4-5minutes iftheprescribeddrug isusedand isproperlyadministered.However,severalofthedoctorsspokentostatedthattheanaesthetictookbetween30 to45minutes to takeeffect. This suggests that theanaesthetistswerenotusingtheappropriateanaestheticfortheprocedureasmandatedbygovernmentstandards.Furthermore,at one of the camps visited, the anaesthetic was not beingadministeredbyamedicalanaesthetist.Insteadalabtechnician


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with 2-3 months of anaesthetic training was responsible foradministeringthemedicine.

Sterilization camps and community health centres alsodemonstratedadisregardforbasichygiene,withpatientsbeingsubject tounhygienicconditions thatplace their healthat risk.The team observed bedding and linen that was often soiled,unhygienic and not changed between different patients. Thissignificantlyraisesthepost-operationrisksthatthewomenface,like the risksof infectionandcontagiousdiseases. Theuseandcleaning of medical instruments at the campwas also belowstandard. The required standards mandate the cleaning oflaparoscopes via initial decontamination with a swab soakedin a spirit and then the use of High Level Disinfection (HLD) orwhere possible sterilization. This process can vary between 20-30minutesand this necessitates that surgeons haveaccess tomultiple laparoscopes in order conduct multiple sterilizationsin shortperiodsof timeasoccurs in thecamps.While someofthecamps visited hadaccess tomultiple laparoscopes,manyofthecampsonlyhadaccessto1or2 laparoscopes.Thusthespeedandvolumeofthesterilizationsatthesecampsindicatesthatlaparoscopeswerenotbeingcleanedappropriatelyputtingpatientsatasignificantriskofinfection.Theteamalsowitnessedonehospitalthathadastraydogroamingthroughoutthehospitalandneartheoperatingroomwherethesterilizationsweretakingplace.TheCommunityHealthCentresvisitedtobytheteamdidnotrepresentsuitablelocationsforenmassesterilizationstotakeplace,lackingthenecessaryfacilitiesandequipmenttoensurethatsafeandhygienicoperationswereconducted.

Thepost-operativeprocedureswerealsofoundtobelackingatall thecampsvisitedby the teams. Thegovernment standardsoutlinethatwomenmust remainforpost-operativeobservationin the hospital and must only be discharged “after at least 4hours of procedure, when the vital signs are stable and theclient if fully awake, has passed urine and can talk, drink andwalk.”98 Thestandardsalsooutline that theclientmustbeseen


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andevaluatedbyahealthcareproviderbeforedischargeandwherevernecessary theclient shouldbe keptovernightat thefacility.Noneofthesepost-operativestandardswerereachedintheanyof thesterilizationcampsattendedtoby theteam.Allthehealthprofessionals spoken tomentioned that thewomenremained for observation for 1-2 hours, with some stating thatthe women remain till evening without providing a specifictimeframe.Severalofthecampsvisitedalsohadsurgeonsleavealmostimmediatelyaftersurgery,withotherdoctorsattheCHCthusbeingresponsibleforthemonitoringofthewomen.Allofthecampsobservedtookthewomenfromtheoperationroomtothewardsviawheelchairs,andprovidedwomenwithbeds for therecoveryprocess.

All the camps attended failed to provide women withtransportationtoandfromthesterilizationcamp.Allthewomeninterviewedhadmadetheirownwaytoandfromthesterilizationcampwith the assistance of their family. None of the womeninterviewedwereawareoftheirrighttorequestanambulanceservicefortransportation.ManyoftheCHCsdidnotappeartohave active or functional ambulance services. This limits theircapacitytoofferthismandatedservicetothepatientsaswellasprovidegeneralmedicalservicestotheregion.

The promotion of sterilization camps in Rajasthan greatlyendangers women who may choose to or be coerced intoundergoing these procedures. Sterilization camps providewomenwithaccess toaformofcontraceptiveservicefor freeand incentivize them for doing so. However, the practice ofconductingtheseformsofsurgeryenmasseplacesthehealthofthesewomenatriskinfavourofcostandtimeefficiency.ThesecampsarealsocomprisedentirelyofBPLandSTwomenwhichsuggeststhatthemostvulnerablesectionsofIndiansocietyarebecoming subject to the grievous health risks associated withsterilizationcampsandbeingsterilizedatdisproportionateratesincomparisontothewiderIndianpopulation.

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2. FACT-FINDINg MISSION TO UTTARAkHAND, CHAMPAWAT AND PITHORAgARH, DATE OF VISIT: 23RD JAN-28 JAN, 2016

Family Planning and Population Control in India

India’s public sector family planning programme claims toprovidea‘cafeteriaapproach’99witha‘basketofchoices’.Fiveofficial contraceptivemethods are providedat different levelsof the public health system, including spacing methods suchas oral contraceptive pills (OCPs), intra-uterine devices (IUDs)andcondoms;and limitingmethods suchasmaleand femalesterilization.100 However, the use of modern spacing methodsisminimal. In 2005-2006, it accounted formerely 10.1%of totalcontraceptive use.101 Furthermore, negligible male interactionand engagement with family planning is widespread. In 2005-2006,only9.1%ofmarriedcouplesusedmalemethodsorcouple-dependentcontraceptivemethods.102

99Acafeteriaapproachisindividualizedplansallowedbyemployerstoaccommodateemployeespreferencesforbenefits.100Ibid.101 Saroj Pachauri, ‘Priority strategies for India’s family planning programme’ (2014) 140(1)Indian Journal of Medical Research137; India,Mumbai: IIPS;2007. International Institute forPopulationSciences(IIPS)andMacro International.NationalFamilyHealthSurvey(NFHS-3),2005-06.102 India,Mumbai: IIPS;2007. International Institute forPopulationSciences(IIPS)andMacroInternational.NationalFamilyHealthSurvey(NFHS-3),2005-06.

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Female sterilization is aggressively promoted by the statethrough centrally-decided numerical targets despite India’scommitmentatthe1994InternationalConferenceonPopulationandDevelopment toadopta ‘target-free’approach to familyplanning.

Research Methodology

AteamofactivistandlawyersvisitedtwodistrictofUttarakhand,ChampawatandPithoragarh, from23rdJan-28thJan2016withthe objective of evaluating sterilization services and lookingat thegaps in implementationof standardsandguidelines forqualitycareandservices.ThemappingofthedistrictisbasedonthedataofAnnualHealthSurveywhichhighlightedthefactthatusageofsterilizationasspacingmethodishighestinChampawatandPithoragarhascompared tootherdistrictofUttarakhand.Thisresearchisbasedonsecondarydatalikecensus,DistrictLevelHouseholdSurveyReport,governmentreportsandprimarydatabasedonhousehold surveys in 15 villagesofChampawatandPitthoragarhvillage.

STATE PROFILE OF UTTARAkHAND:

Table: 1: State Profile

S.No. Background CharacteristicsStateNumber

1 GeographicArea(inSq.kms) 53,484sq.kms2 Number of blocks 953 Size of Villages (2011 Census)

Numberofvillages 168261-500 13460(80%)501-2000 2679(17%)2001-5000 426(2.7%)5000+ NIL

4 Number of towns 31

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5 Total Population (2011) 1,01,16,752Male 5,154,178Female 4,962,574

6 Sex Ratio (F/M*1000)PopulationSexRatio 963ChildSexRatio 886

7 Decadal growth rate 19.178 Density- per sq. km. 1899 Literacy Rate (+6 Pop) 79.63%

Male 88.33%Female 70.70%

10 SC/ST populationSC 15.17%ST 2.56%

3. Champawat district profile

Thedistrict ofChampawatwasestablished in 1997. It currentlyranks12thintermsofpopulationsize,withatotalpopulationof259,648.103DecadalpopulationgrowthinChampawat(15.63%)islowerthanthegrowthrateofthestate(18.81%).104ChampawatisoneoftheleasturbanizeddistrictsinUttarakhand;only14.77%of the population resides in urban areas. The following tablecontainskeyhealth indicators in thedistrictofChampawat,ascomparedtostateandnationalaverages:

Table 2: Health indicator 2012-13INDICATOR CHAMPAWAT UTTARAkHAND INDIACrudeBirthRate 16.9 18.0 21.8TotalFertilityRate 2.0 2.1 2.4CrudeDeathRate 5.6 6.1 7.1InfantMortalityRate 34 32 44

103GovernmentofIndia,Census2011.104GovernmentofIndia,Census2011.

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MaternalMortalityRate

182 292 212

SexRatio(per1000) 980 963 940Maleliteracyrate%) 91.61 88.33 82.14Femaleliteracyrate(%)

68.05 70.70 65.46

Sources:AHS2012-13,Census2011,SRS2012

4. PITHORAgARH DISTRICT PROFILE:

ThedistrictofPithoragarhwasconstitutedin1960.Itistheeastern-most district in Uttarakhand and currently ranks 8th in terms ofpopulation size,with a total population of 483 439.105 Decadalpopulation growth in Pithoragarh (4.58%) is lower than thegrowthrateofthestate(18.81%).106Pithoragarhisoneoftheleasturbanizeddistricts inUttarakhand;only14.4%of thepopulationresides in urbanareas. The following tablecontains key healthindicatorsinthedistrictofPithoragarh,ascomparedtostateandnationalaverages:

Table 3: Health Indicators 2012-13

INDICATOR CHAMPAWAT UTTARAkHAND INDIACrudeBirthRate 15.4 18.0 21.8TotalFertilityRate 1.7 2.1 2.4CrudeDeathRate 6.2 6.1 7.1InfantMortalityRate 23 32 44MaternalMortalityRate 182 292 212SexRatio(per1000) 767 963 940Maleliteracyrate(%) 96.8 88.33 82.14Femaleliteracyrate(%) 78.9 70.70 65.46Sources:AHS2012-13,Census2011,SRS2012

105GovernmentofIndia,Census2011.106GovernmentofIndia,Census2011.

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Status of Family Planning Programme in the State:

Allthemoderncontraceptivemethodsareavailableinthestate.The following graph analysis highlights the usage of differentspacingmethodsinthestatefrom2010-2015:

graph 1: Status of family planning in the state

Thus,fromtheabovetableitisclearthatusageofcondomsandIUCDarecommonmechanismsforfamilyplanningmechanisminthestate.Womenalsoundergosterilizationprocessbutitislessascomparedtousageofotherfamilyplanningprocess.Further,thegraphshowsthatnumberofsterilizationusageisconstantsince2010.

InthestateofUttarakhand,atotalof438femalesterilizationcampswere proposed for the years 2015-2016.107 The Uttarakhandstategovernmentopenlystatesthatitneedstoconduct48,000additionalsterilizationsannuallytomeetitsfertilitytargets.108.

• UsageofcontraceptivemethodsinChampawat:

Thedisproportionate relianceupon female sterilizationand thelimitedaccesstoalternativecontraceptivemethodsisillustratedinthefollowingtableonfamilyplanningpracticesinChampawat.

107UttarakhandStatePIP2014-2015.108Ibid.

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Table 5: Family planning practice in ChampawatINDICATOR CHAMPAWAT UTTARAkHAND INDIAAnymodernmethodofcontraception(%)

67.6 62.7 47.1

Femalesterilization(%) 46.8 27.6 34.0Malesterilization(%) 0.7 1.3 1.0CopperT/IUD(%) 0.2 0.9 1.9OCP(%) 4.2 4.9 4.2Condom(%) 15.6 18.7 5.9Emergencycontraceptionpill(%)

0.0 0.7 0.6

Totalunmetneedforfamilyplanning(%)

15.8 15.3 21.3

Source:AHS2012-13,DLHS-32007-08

Thus, from theabove table it is clear that among themoderncontraceptives usages, theusageof female sterilization is highwith46.8%.

• UsageofcontraceptivemethodsinPithoragarh:

ThefollowingtableonFamilyPlanningpracticesinPithoragarh.

Table 6: Family Planning practices in PithoragarhINDICATOR PITHORAgARH UTTARAkHAND INDIAAnymodernmethodofcontraception(%)

72.2 62.7 47.1

Femalesterilization(%) 52.4 27.6 34.0Malesterilization(%) 1.3 1.3 1.0CopperT/IUD(%) 0.4 0.9 1.9OCP(%) 2.7 4.9 4.2Condom(%) 15.3 18.7 5.9Emergencycontraceptionpill(%)

0.1 0.7 0.6

Totalunmetneedforfamilyplanning(%)

13.3 15.3 21.3

Source:AHS2012-13,DLHS-32007-08

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Findings:

The fact- finding mission revealed numerous parallels acrossthehealth facilitiesandsimilaritiesacrosswomen’sexperiencesin accessing the health system. Each hospital appearedunderstaffed, and had infrastructure in need of urgentupgrading. Public amenities and washrooms were unhygienic,as were the wards where women stayed. Women commonlyreportedreceivingincompleteinformationregardingsterilization,and a lack of access and information regarding alternativecontraceptivemethodsavailable.

Thefollowingsectiondetailstheresultsofthefact-findingmission,beforeextractingkeyissuesofconcernasidentifiedbytheteam.The report finally concludeswith recommendations to improvethe quality of care with regard to sterilization services. TheserecommendationsarenotconfinedtothestateofUttarakhand,but apply to sterilization and the provision of family planningserviceswithinIndiaingeneral.

• Interviewswithwomen:

1. SunitaMehra,25year,ismarriedforfiveyearsandhastwochildren,aboyandagirl.HerhusbandworkswithITBP(Indo-TibetanBorderpolice)postedoutsideUttarakhand.Whileinterviewingher, itcame into light thatshewasplanningtoundergosterilizationinafewmonths.Whenaskedwhyshe is opting for this permanent method of sterilization,her answer reflected that all she wants is ‘permanentmethods’.Butshewasnotawareofthecomplicationsofthesterilization.Shewaswelleducatedbutitseemedthatthedecisionofsterilizationwas influencedbyher in-laws.Onfurtherquestioning,theotherthingthatcameintolightwas that she‘wants’anotherdaughter,butat thesametime,shecannotexpressherwant(fortheobviousreasonthat her economic conditions did not allow it and herfamily’sviewthatshewasalreadyamothertoaboyandagirlandhencehadnoneedofathirdchild).

2. RaniDevi,a34yearoldwomanhasthreechildren:aboyandtwogirls.Herhusbandownsashopintheirvillage.She

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underwent sterilization in 2014, although the procedurefailed.Shewassentbackaftertheoperationafterbeingtold that the procedure had been successful. However,after threemonths, she realized that shehadconceivedandwascarryingthreemontholdfoetus.Shewentbackto the hospital where she underwent the surgery, triedtalking to thedoctorsandasking for compensation,butthehospitalauthoritiesgavenoresponse.Shefurtherwenttohigherauthoritiesandfiledacaseagainstthehospitalforbeingcarelesstowardsher.ThegovernmentawardedheracompensationofRs.35,000.Sheisnowsufferingfrombackpain.

3. Soni Devi, 25 years old, had 2 children. She went forsterilization on 25 Jan, 2016 but was disappointed. Thedoctorsspent15minutestryingtofindtherightnervetobeoperatedon,butfailed.Shewasgivenhighdosesofanti-bioticandinjectionswhichkeptherdrowsyandnauseatedforthenexttwodays.Thedoctorssentherbackandaskedhertoreturnthefollowingweekfortheprocedure.Whileatthehospital,SoniDeviwasnotprovidedabedaftertheattemptattheprocedureandwasmadelieonthefloor.Moreover,thefailureinconductingasuccessfulprocedurenotonlydelayedheroperationbutalsokepther inbed,whichaffectedherhouseholdchoresandshecouldnotevenlookafterherchildren.SoniDeviwasaccompaniedonly by theASHAworker of her village. Hence, not onlywasshewasforcedtotravel120kmsonherownexpenseforforthefailedsurgery,butshealsosufferedterriblyfromfever,nauseaandsevereabdominalpain.

4. PariDevi,25yearsofage,alsounderwenttheprocedureat LohaghatCHCon25th Jan, 2016. Though shedidnotfaceanycomplicationswithheroperationandreceivedtheincentivethatshewasentitledto,shewascompletelyunaware of complications and risks associated with thesterilization procedure. The local ASHA workers signedher consent form at the hospital. Her interview clearlyindicatedthatthesterilizationoperationhadaffectedhermental health poorly. She confirmed that her husband

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wasunawarethatshehadundergonetheprocedureasheworkedaway fromhome, inacity. Shealreadyhadthreekids -twogirlsandaboy.Alhough shedidnot saymuch regardingher feelings for sterilizationasamethodofcontraception, itwasevidentthattheprocedurehadbeenconductedagainstherchoice.

5. SoniDevi,a24yearoldwoman,hastwochildren-aboyand a girl. She never received any formal educationandwasmarriedasachild,at theearlyageof 16. Sheunderwent the sterilizationprocedureaweekbeforeherinterview with the team and was in the hospital for herfollow-up.Sheconfirmedthatheroperationwentwellandthatshehadreceivedtheincentivethatshewasentitledto. However, her interview revealed that Soni Devi wascompletelyunawareofothermethodsofcontraception.Shechosesterilizationsimplybecausesheandherhusbandcouldnotaffordtobringupanymorechildren,consideringthatherhusbandisadailywagelabourer.Sheaddedthata ‘woman ishelplesswhenherhusband isathomeandcannottakeriskeverytimesoitshouldbebetterifwegetridofitonceandforall’.

6. ParvatiDevi, 26yearsofage,gotmarriedat theageof20.Shedeliveredherthirdchildwhichwas‘finally’aboy.WhenshevisitedtheLohaghatCHCforherdelivery,doctorsreferred her to the Pithoragarh hospital during labour.AccordingtoParvatiDevi,thedoctorsmishandledherbyinsertinghandinhervaginatocheckherprogress,duetowhichshehadvaginaltractpuffinessandswelling.Thishadactuallyincreasedherpainanddoctorscouldnothandleherdeliveryanymore lateras theyarenotequipped forit.ShethencametoPithoragarh in the labourpainonly,travelling75kms.Hereinthishospitalthedoctorstreatedherwellandweregivenfullmedicationsandpropercare.Further, she underwent sterilization in 2014 because shedeliveredbabyboyandnowshewantpermanentsolution.Shewas not aware of the process and complication ofsterilization.

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7. NandaDevi,aged22years,hasthreechildren.HerhusbandisadailywageearnerandworksinDelhi.Sheliveswithhermother-in-lawsandchildren. Sheopted for a sterilizationprocedure due to the cash assistance programme. Shewas not aware of the complications involved with theprocedure.

• Visits tohospital facilitiesand interactionwithhealthcareproviders:

Champawat District Hospital

The fact-finding team first visitedChampawat District Hospital,established in 2010. The hospitaldoes not have its own ambulanceservice; the only functionalambulance service in the district isthegovernmentserviceof108.Thereisalsonofunctionalbloodbank.

Uponentry,thefact-findingteamfirstnoticed that it was extremely busy,with a lot of patients. Although wewere told that the staff included12nurses, twogynaecologistsandonepediatrician, the only healthcareworkersthatcouldbeseenattendingthe patients were two nurses, onedispensary worker, the CMO anda singledoctor.Asa result,manypeoplewere forced towaitlongtimesbeforetheywereseen.Althoughthehospitalbuildingitselfwaswell-lit and spacious, therewere inadequate seatingarrangementsoutsidetheconsultationrooms.Furthermore,therewasa lackofprivacyas thedoorswerenotclosed,andotherpatientswouldwaitinthesameroomorjustoutside.

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Therewerenumerouspostersonmotherandchildcare,preventionofHIV/AIDS,the importanceof institutionaldeliveryandthe‘benefits’ofsterilizationonthewalls of the hospital. However, theywere placed upstairs and it seemedunlikelythattheywouldbeseenbythewomen and ‘couples’ for whom theyweretargeted.

After making enquiries, the teamdiscovered that the two permanentgynaecologistswereon leave; in theirplaceasinglegynaecologistwithonlyayear’sexperiencewaslookingafterallthegynaecologypatients.Furthermore,wewereinformedthatthenurseswereresponsible for delivering babies; the

gynaecologists were either hesitant or absent. The team wasabletowitnessthisfirst-handastheyobservedanurseassistingapregnantwomaninlabour.Thelabourroomitselfwasspaciousandcontainedallthenecessaryinstrumentsaswellasmedicinesrequiredatthetimeofdelivery.Theteamobservedafunctionalautoclaveandnoticedtheboilingofinstruments.However,basichygiene standards were otherwise not observed; there werebloodstainsonthefloors,pillowcasesandlinens;medicalwasteincludingblood-stainedgauzewereleftonatrayonthesideoftheroom;andthefloorsandlowerpartofthewallswerecoveredingrimeanddirt.

Failuretomaintainbasicsanitaryconditionswasalsoevident inthewashrooms,whichwereverydirtyandfoulsmelling.Therewasalargepuddleofdarkwateronthefloor,andthetapsandlightswerenotworking.Thesinkwascloggedandfilledwithrubbish.

Interview with ASHA worker at Champawat district hospital

WeinterviewedoneASHAworkerofthevillagewhobelongstothisvillageonly.Thefollowingfactscameupontalkingtoher:

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• The averageage ofwomenwho undergo sterilization isbetween22-25yearsofage.

• She has motivated women to use copper-T also in hervillage.

• Theaveragenumberofchildrenwiththewomanwhohasdecidedtoundergosterilizationistwo.

• There have been instances where women have threechildrenonlybecauseofthewant/desireofamalechild.

• Onbeingasked how theymotivatewomen to undergosterilization,sheindicatedthatASHAworkersdonotneedto go to women, they come themselves to the ASHAworkers thatnowtheywant togofor sterilizationas theynowhavetwoorthreekids.AccordingtotheASHAworker,womenarenoweducatedandareawarethatsterilizationisrequiredbecausetheireconomicconditionsdonotallowthem to raisemore than twoor atmost threechildren.Whereas, women say that they have been informed ofsterilization camp that have held in the district hospitaland ‘they have to come’. ASHAworkers are also givenincentivesbasedonthenumberofwomentheybringtohospitalforsterilization.

• According to her,womengenerally don’t go for follow-upsbecausethehospitalisnearly60kmsawayandtheycannotaffordtovisititfrequently.Hence,theirstitchesarealsobeingcutinthevillageonlybytheANMortheASHAworkerherself.

• Shesaidthatduringherthreedaytrainingperiodsheonlyreceives100/-whichincludestravel.

INTERVIEW WITH CMO –CHAMPAWAT DISTRICT HOSPITAL

The fact-finding team spoke to theCMOin his office. We were told that the mostcommon health issues faced by womenand children in the area are infection,malnutrition and anaemia. The womenpatientsaremotivatedandbrought inby

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ASHAworkerswhohavetrainedatnearbyPHCsandCHCs.EachASHAreceivedRs.1000foreachpersonbroughtinforsterilization;however, the motivation fee has recently been reduced toRs. 500. He reported that 90% of sterilization procedures wereperformedonwomen;menwereunwillingtoundergovasectomyandall prior attempts tomotivatemen have failed. TheCMOfurthertoldusthatthenormaltrendnowistotargetwomenafterthe birth of their first child, whereas before women were onlyapproachedaftergivingbirthto2-3children.TheCMOdeniedthatanysterilizationsurgerieswereperformedongirlsagedlessthan18years.ChampawatDistrictHospitalhasonlyoneFamilyWelfareCounsellorservingthedistrictwho is responsiblefor thecounselling ofwomenandensuring they know their rights, thepermanencyof sterilizationand its risksandbenefits. TheCMOalso toldus thatmostpatientsand familieswereawareof theservices and benefits provided by the hospital as mandatedbytheGovernmentSchemes,however, theyhadnomeanstocontactwomen living in interiorareasas theywereover20kmaway.

Lohagat CHC The fact-finding team next visited

LohagatCHC,whichwaslocatedinthetown centre. This CHC is a 30 beddedhospital.AstheonlyCHCforthedistrictsofChampawatandPithoragarh,itservesastheprimehealthcentreforvillagesasfar as 62km away. The hospital hasrecentlybeenundertakenintoapublic-privatepartnership.

Thehospitalwasemptywhenwearrived; theteamfoundonlyonewomanmoppingthefloorwithabucketofgreywater.Wewereinformedthatthesterilizationcampheldthatdaywasover– theoperating surgeonandmedical staffandall thewomenhadreturnedhome.Aftersomeenquiries,theteamdiscoveredthat a total of 30-40womenwere operated on that day. Thewomenwere fromthevillageofMadlak located100kmaway,

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ontheborderofNepal.AllwomencametotheCHCbytheirowntransportwhichcostthematotalofRs.400/-.

TheconditionsatLohagatCHCwereabysmal.Theentirebuildingwas inwantof repairandgeneralmaintenance.A largepackofstraydogswasfoundbehindthemainbuilding.Therewasnowastedisposalmechanism.Allwastewasdumpedinanareajustbehindthehospital.

Moreover, thewashroomswereextremelyunhygienic.Thetapswerebrokenand the sinkswerecloggedwithdirt. It is unclearwhentheurinalswerelastcleaned;athicklayerofgrimealongthe lower part of the walls and floor was clearly visible. Urinecoveredthefloor.

Uponfurtherexploration,thefact-findingteamfoundevidenceofcompletedisregardforasepsisandinfectioncontrolmeasures,indirectviolationoftheIndianPublicHealthStandards(IPHS).Bedsheetswerefilthyandhadnoticeablebloodstainsandrubbish.Thefloorswerefilthyandliquidspillsnotcleaned.Thedoorinoneof the operating theatreswas broken; the bottom third of thedoorwascoveredinathicklayerofblackmould.

Pithoragarh district hospital

The fact-finding team visited PithoragarhDistrict Hospital. There is an altogetherdifferent building for women only andtherefore separate male and femalewards.

Upon entry, the fact-finding teamimmediatelynoticeditwasfarbusierthanthe previous health facilities that hadbeen visited. There were many womenandchildrenstandingwhilewaitingtoseethe gynaecologist. Others were forcedto sit outside on the dirt floors. Inside theconsultation room, there was an evidentlack of privacy. The team observed one

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womanbeingexaminedbythedoctorwhilealonglineofpatientsstoodnearbyandwatched.

During the visit, the fact-finding team found various postersplacedinsideandontheouterwallsofthebuildingonJSY,AIDScontrol, breast feeding, post-natal care and antenatal care.Some of these posters were in Hindi, however, some posters,including those on breastfeeding and feminine hygiene, werewritteninEnglishonlyandthereforeinaccessibletowomenfromlesseducatedbackgrounds.

Overall, the hygiene and sanitation levels of the hospital wasconcerning.Thefact-findingteamwasabletolocatethedeliveryandlabourrooms,whereitwasobservedthattheinfrastructurewasdeficient.Thesmallroomhad2-3bedssqueezedin,thefloorsweredirtyandoverall, theroomdidnotsmellclean.Awomanwasmoaning inpain fora fewminutes in the roomnextdoor,beforeadoctorcametoherassistance.

Thewashroomswere inagrosslyunhygienic state.Adirtymopwasleftontopofthecistern,drippinggreycolouredwaterontothefloor.Thebucketfilledwithmurkywaterwasleftinthetoilet.Thetiledwallswerecoveredindirt,andtherewasurineontheground.

Observations:

1. Camp Site and client load: Fromthefindingsitwasobservedthat the timing of sterilization was from 2:00 pm-4:00 pm.Butaccording toSOP,camptiming“shouldpreferablybebetween9amand4pm”. Thus,within the spanof2hours,they have operated 40women thatmean per operationtheyspend3-5minutes.Thisclearlyshowstheviolationoftheguidelines.

2. Physical requirements for female sterilization: There wasno provision of drinking waterat Lohghat CHC. There is ageneratorforelectricitybackupsbutit’snotfunctionalsince6months.

3. ThebathroomsandsterilizationroomswerenotcleanedatPithoragarhdistricthospitals,LohghatCHCandChampawat

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Districthospitals.Thefactfindingteamnoticedbloodstainsonthebedsheets.

4. AtLohaghatCHC,due to shortageofbeds,womenweremadetoliedownonthefloorwithoutanymattresses,beforeandaftertheoperations.Moreover,inpeakwinter,hospitalauthoritiesdidnotprovideblanketstothewomen, insteadaskingthemtocarrytheirownblankets.

5. ThereisnoproperwastedisposalmechanismattheLohghatCHC.Allthewasteisdisposedinanopenareajustbehindthehospital building. Furthermore, women interviewed by theteamstatedthatsincehealthcentresdonothavehygieneandcleanenvironmenttheydon’tfeelcomfortabletogetadmittedatthehospitals.

6. Counselling:109 Before the operation women should becounselled for sterilization. From thecase studies it isclearthatallinterviewedwomenwerenotawareoftheavailablemethods of family planning but they opt for sterilizationbecause it’sapermanentmethodandmoreoverwomengets paid for it. Women are not aware of the potentialcomplicationandsideeffects. This shows that thehospitalauthority failed to giveproper counselling towomenandinsteadtheymotivatethewomeninordertofulfillthetargets.

7. Failure in Clinical assessment: Outof10interviewedwomen,8 women reported that medical history and physicalexaminationwerenotrecordedpriortotheirsurgeries.Onlythelaboratoryexaminations,includingbloodandurine,wereconducted.Thisshowspoorqualityofcareatthecamps.Inmanycases,womenwerenotgiventhoroughpost-operativeinstructionsotherthantorestandtakemedicinesprovided.This is insufficientandbelowtheminimum levelmandatedby the Government of India Sterilization Standards. Forexample,therewasnoinformationonwhattodotopreventinfection, or who to contact for help if needed. Womenwerealsodischarged fromhospitalmerely onehouraftertheiroperation,despitethe requirementthat theymaybedischarged after a minimum of four hours and only after

109ibid

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evaluationbyadoctor.Thesefactorstogethercontributetogreater levelsofunnecessary infectionandcomplications,which could otherwise be easily avoided. This violates awoman’s right to health (Constitution of India Article 21;ICESCRArticle12).

8. Informed consent: Women are not provided with thecomplete information necessary to make an informeddecisiontoundergosterilization.Althoughthepermanencyof sterilization was understood, many women could notname any alternative contraceptivemethods, or the risksassociatedwiththeprocedure inbreachof theStandardsfor Female andMale Sterilization (2006). In fact, formanywomen the local ASHA worker was their only source ofinformation. This may partially be due to the resourceconstraintsidentifiedaboveregardingavailablecounsellors.However,inthemajorityofinstancestheprovisionofpartialor incorrect information is directly related to the incentivebased target driven approach to family planning whichforceshealthworkers towithhold information thatmaybeprejudicial to their own self-interests. Additionally, consentformswerenotexplainedtowomenintheirownlanguage,and in onecase thenurse signedonbehalf of awomanwithoutaskingforanyfurtherinformation.

9. This is a violation of the right to access contraceptiveinformationandservices,therighttoinformedconsentandtherighttobodilyintegrity(ConstitutionofIndia,Article21;CEDAWArticle16).

10. Follow up visits: Afterthesurgery,womenarekeptonlyanhourforobservationsasreportedbytheASHAworkerandinterviewedwomen.WomenfromMadlakvillageinformedtheteamsthatitwillbedifficultforthemtovisittheLohoghatCHC for follow up check ups since transport services arenotavailableandLohaghatCHCis70kmsfromthevillage.Also, therearenoPHCs in thevillageandsowomenmustvisit local ‘quack’doctors in thevillage for followupvisits.Outof10interviewedwomen,5womencomplainedaboutcomplicationslikenausea,abdominalpain,backpainandabdominalswelling.

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11. Under-resourced public sector: Manyofthehospitalsvisitedhad problems with staff shortages. For example; there isonlyoneFamilyWelfareCounsellingservicefortheentiretyof Champawat. In many of the facilities, the number ofpatientsexceededthenumberofavailablenurses.Thiswasthecasealsoforthosehealthcarefacilitiesthathadenteredinto public-private agreements. Lack of skilled staff hasseriousimplicationsforthelevelofqualityofcarethatcanbeprovided toeach individualpatient,and shortcutsarecommonlytakentokeepupwithworkflows.

12. Lack of access to contraceptives: Research shows thatfinancial barriers exclude poor and uneducated womenfromaccessingmoderncontraceptivemethods.Thepublichealthsectorismandatedtoprovidemoderncontraceptivesincluding sterilization services free of cost.110 However,governmentdatashowsthat10%ofwomenhadtopaytoaccess sterilization services in thepublic sector,while 32%hadtopaytoaccessIUD,24%hadtopayfortheOCPand30%hadtopayforcondoms.111Manywomeninterviewedreported that they did not have access to alternativecontraceptives either because they were not providedwith information about the alternative methods availableorbecausetheASHAworkerdidnothaveanystock.Theseparticularlyaffectedwomenfromruralareas,astheASHAworker fromPithoragarhconfirmedthatwomen in thecityareasmostlyusedtheCopper-T,andthatmenfromtheseareasusedcondoms.

FACT-FINDINg MISSION T SATNA AND kHANDWA DISTRICT, MADHyA PRADESH Date of Visit: 5th January 14thof January 2016

Background

From 5th- 8th January and 11th- 14th January 2016, the teaminvestigatedtheconditionsof sterilizationcamps in twodistricts

110TiagodeOliveira,DiasandPadmadas,aboven10,8.111 India,Mumbai: IIPS;2007. International Institute forPopulationSciences(IIPS)andMacroInternational.NationalFamilyHealthSurvey(NFHS-3),2005-06.

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of Madhya Pradesh. The team interviewed ASHA and ARSHworkers,doctorsatcampsandhospitals,subcentres,assistants,pharmacists andwomenwho underwent sterilization surgeries.TheteamalsovisitedtwocampseachinthedistrictsofSatnainMadhyaPradesh.

Health indicators in Madhya Pradesh

TotalAHS 2103

UrbanAHS 2013

Urban Poor (NFHS three reanalysis)

InfantMortalityRate 62(2013) 47 78.4

Neo-NatalMortalityRate 42(2103) 30 54.8

Under-fiveMortalityRate 83(2013) 57 97.9TotalFertilityRate 3.1(2011) 2.4 3.7FullImmunization(percentage)

54.9(2011) 64.9 54

NumberofSAMchildrenidentified(ICDSdata)

187599(2012)

- -

AnnualBloodExaminationRate(ABER)formalaria

13.55 NA NA

AnnualParasiteIndex(API) 1.23 NA NA

DengueCaseFatalityRate 0(2011) NA NA

AnnualNewSmearPositivecasedetectionrate

5708 NA NA

Treatmentsuccessrateamongnewsmearpositivecases

5459 NA NA

LeprosyPrevalenceRate 0.66(2010-11)

NA NA

No.ofoutbreaksreportedunderIDSPinpastyear

213(2011) NA NA

Source:NATIONALURBANHEALTHMISSIONPIP2015-16-MADHYAPRADESH

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Coercive Policies in Madhya Pradesh

The aggressive sterilization policies of India are apparent inMadhya Pradesh. The Government of Madhya Pradesh hasapproveda38%increaseinthenumberofsterilizationcampsinMadhyaPradeshaccordingtothe2015-16budgetproposals,ascomparedto2014-15.Thegovernmenthasgonetogreatlengthstopromotefemalesterilizationthroughincentives.Asrecentlyas2011,MadhyaPradeshofferedTataNanocarsformotivating500peopletoundergosterilizationprocedures.112Furthermore,in2008,MadhyaPradeshoffereda “guns for vasectomy”programme,wheregunpermitswerepromisedinexchangeforavasectomy,113whileatthesametimemakingclaimsthat itwasnotusinganycoercivemeasuresortargetsinits’sterilizationpolicies.

Furthermore,thegovernmentofMadhyaPradeshhasapprovedabudgetfororganising6,200campsintheruralareasofthestate,withtheaimofconductingatotalof186,000femalesterilizations.Thisdirectlydefiestheirpubliclystatedpolicyofnotusingtargets,which lead to coercive behavior by state officials. Femalesterilization is currently themostpopular formofcontraceptionin Madhya Pradesh. 45% of women have been sterilizedaccording to the District Level Household & Facility Survey. Allother formsof contraception (IUDs, condoms,male sterilizationand pill) combined only equaled 11% of the family planningmethodsused.Hence,femalesterilizationisthedominantformofcontraceptionandisdoneinatargetedandcoercivemannerbythegovernmentofMadhyaPradesh.

Interviews and visits:

1. Interaction with women who were sterilized:

i. Free and informed consent?

112ShubhamGhosh,MP: Win a Nano by sending 500 people to sterilization camp!,OneIndia,3/18/2013,http://www.oneindia.com/2013/03/18/mp-win-nano-by-sending-500-people-to-sterilization-camp-1174182.html.113HTBhopalCorrespondent,Go for vasectomy, get a gun licence,HindustanTimes,2/4/08,http://www.hindustantimes.com/bhopal/go-for-vasectomy-get-a-gun-licence/article1-295124.aspx.

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Twenty-eightwomenwereinterviewedofwhichnineteenwerehousewives and the rest worked as agricultural labourers. Thewomen belonged to poor families with small monthly incomeand often did not earn themselves. The Rs. 1400/- given towomenasan incentive for sterilization is aclear indicator thatthe consent is “bought” and not obtained freely. There is nocounselling provided to thewomen. None of thewomen hadanypersonalconsultationwithaqualifieddoctor.Mostwomen(apartfromthreewomen,twoofwhowereoperatedonbythesamedoctor) did not even know the nameor qualificationofthedoctoroperating them.Womensimplyput their trust in thedoctorswithoutprovidingan informedconsent for the surgery,particularlyinthegivenconditions.Manywomenadmittedthattheconsent formswerenot in their local languagebecauseofwhich theydidnot follow them.Manyconsent formswere leftincompleteeventhoughdoctorsproceededwiththeprocedure.

ii. Pre-operational care

Ofalltheinterviewedwomen,onlyonehadreceivedthefullpre-operationalcheck-upinaccordancewiththeguidelines.Nineofthemdidnotevenhavetetanusimmunization.

iii. Post-operational care

There were only two women who had received the requiredexit check up. Therewas only onewomanwho had receivedinformationaboutfollow-upcare.Onlyonewomanhadreceivedfreetransporttohome.Somewomeninformedthefact-findingteam that they only received Rs. 600/- while others said thattheyhadreceivedRs.1300/-.Somedidnotevenreceivepropermedications. All women interviewed were asked to go backhomewithin1.5hoursofthesurgery,contrarytoguidelineswhichrequirepatientstobekeptunderobservationpostoperationforatleast4hours.

iv. Maximum number of operated women by one single doctor

Sixwomen,interviewedon8thJanuary2016,informedtheteamthat45to50womenhadundergonesterilizationon12thDecember

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2015attheMundaiCHCbyasingledoctor.Thewomendidnotknowanythingaboutthenumberoflaparoscopesused.

Awomanaddedthaton20thDecember2015,inacampatPHCMoondi,around30-35womenwereoperated.Anotherinformedthat 200 women were operated at the same time when sheunderwenttheprocedure.However,shedidnotwanttoprovideuswiththeinformationaboutwhenandwherethishappened.

2. Interviews of Asha workers

25%ofthe13interviewedAshaworkerswerenotawareofmajorhealthissuesconcerningwomenandwhattheyshouldcounselwomenabout.Oftheinterviewedworkers,halfincludedmenintheirfamilyplanningcounsellingsessions,61%werenotprovidedwithenoughASHAKitsasprescribedbythegovernmentand90%hadnoclearororganisedformofmethodologywhenitcametocounsellingwomenandrecommendingformsofcontraceptiontotheirclients.25%ofASHAworkerstalkedaboutmeetingtargetsforsterilizationandthecorrespondingincentivesofRs.200/-.

3. Interviews with the Doctors:

a. District Khandwa,CHCMundai, Dr. Gagan BMOandDr.Themerse,surgeon.

b. DistrictKhandwa,PHCSulgawn,Dr.SunilRomdeasMMBSandDr.Rehmann,surgeon

Sincedoctorsdidnothavemuchtimetospare,theinteractionwiththedoctorswasveryfocusedondurationofanoperationandthenumberofoperatedwomenbyasingledoctor.

As per MoHFW guidelines and quality assurance committeerecommendations, “doctors are allowed to conduct only 30operationsinadaytomaintainqualityandavoidanydeathorcomplications”.

DrSunilsharedthatheperforms15-70sterilizationssurgeriesadayinacamp.Healsosharedthatonesurgerylastsfor3-5minutes.Additionally,Dr.Themere informedthatheneeded3-5minutesforeachpatientandthathewouldperform30to100sterilizations

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in a day. The same statementwas given byDr. Rehmann. Dr.ThemereandDr.Rehmannaddedthattheycouldperformthesurgerieswithoutanyassistance.

4. Camp Visits:

a) Visit at Satna District PHC Camp kulgadhi- Block Unchehera

Dr. K.L. Nandio, the surgeon who was supposed to performthe sterilization operations, arrived late for the camp. Patientswere waiting outside, in an open ground. Most women wereaccompanied by their kids; some aged less than a year andbreastfeeding.Anassistantsittingoutsidewasfillingtheformsfor“freeinformedconsent”.Theconsentformswerenotbeingfilledinproperlyandwerehence incomplete.Thesurgeon informedthathespent1to2minutesoneachsurgery.Further,herevealedwithpridethathehadonceoperated262womeninasingledayandhadalreadyoperatedaround88000womeninhislife.

Regarding the operation apparatus, there were only 2laparoscopes.Onthedayofthecamp18womenweresterilizedwith 1.5 hours. So intentionally thedoctor ignored theneed todisinfect the laparoscope and breached the guidelines withregardstoqualityofcare,women’shealthandsanitaryconditions.

AsurgeongetsRs.75/-foreveryprocedureperformed.Surgeonsaremoreconcentratedonmaximisingtheirearningsandhenceconductasmanyproceduresaspossible ina shortamountoftime.This practice leaves more room for negligence, causinginfections and jeopardising women’s lives. On inquiring aboutthepost-operativecare,theteamwastoldthatallpatientswerekeptfor4hoursafterthesurgeryandweregivenenoughtimetorecuperate.Onfurtherquestioning,thesurgeonexcusedhimselftostartthecamp.Itwasabout3:15pm.Therewasnoanesthetistavailable.

Thewomenweregivenlocalanesthesiabyamedicalassistant,whohadnoqualificationtoadministeritandweremadetolieonthefloor.InsidetheOT,therewasjustoneoperationtablewhichseemedunhygienic. The toiletswere inpoorconditionanddidnotevenhavethebasicfacilityforwashinghands.

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b) Satna District CHC Camp Nagaur- Block Unchehara

Thecampstartedat2pm;thesurgeriesbeganat2:15pmandwerefinishedby3.40pm.Therewerenostretcherstomovethepatients.Patientswerepaidcompensationbuttheyhadtospendoutof theirpockets for the transportback,and in somecasesevento reachthecamp.Oneof thepatient’s relatives sharedthatthestaffhadtoldthemthattheincentiveofRs.1400wouldinclude the transportation cost as well. Family members werewaitingoutsidethecamptopickupthepatients.Conditionsweresopoor that therewasnoarrangement forwater. Thedoctor,aftercompletingsurgeriesinlessthan1.5hours,hadalreadyleftby3:40pm.Sevenwomenwerestill in theunhygienicrecoveryroom.Therewasnomonitoringintherecoveryroomatall.Thewomen were manually being carried like sacks of vegetablespost-surgery. Therewas noprovisionofbedsormattresses; thepatientswere left to lieon the floorwithoutanydisinfectionorproperhygiene.

Onexploringthehospital, itwasfoundthattheroomadjacenttothepostoprecoveryroomwasadilapidatedroomwithmanydecrepitbedframesandthreadbaremattressesjustlyingthere.Despitetheavailabilityofbedframes,thestaffdidnotbothertomaintainthem.

Withinintenminutesoftheoperation,allwomenbeganreturninghome in delirious states; unable to standor evenwalk; and inself-hired private transport despite multiple idle ambulancesbeingavailable.Whenquestionedaboutthis,theadministrativewomantoldtheteamthattherewerenodriversavailableandhencetheambulanceswillnotply.

The team saw five of seven women, very weak, going homewithoutanypost- operational informationorcaregiven. Thesewomendid not receiveanyexit checkupor transport facility.Thebathroomswerefoundtobehighlydirtyandunhygienicandwereinnoconditiontobeofanyuse,therewasnowashbasin,orwaterpressure.Theoperationtheatrewasunhygienicaswell.Twopatientswerestillrestinginthemakeshiftrecoveryroomwithoutmonitoring.Aftertalkingtosomeofthepeopleaccompanyingthepatients,theteamleftforthePHCatKulgadhi.

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2nd Visit at Satna District PHC Camp kulgadhi- Block Unchehera

Onrevisitingthecampataround5pm,theteamdiscoveredthatthiscampwasalsocomingtoanend.Oftheinitial18patientswhowerepresentat3:15,only threewere left in the recovery roomandonewasbeingtransportedbackhomeonthebackseatofabicycle.

In less thanoneandahalfhours,all theoperationshadbeencompleted and the patients dispatched. The operationsof eighteen women had been conducted with only twolaparoscopes,withinaspanofanhour.Yet;thedoctorsreportedthat thedisinfection timeof instrumentswas thirtyminutesafterevery operation. The disinfectant used is called Cidex OPA.Again,itseemedthatthecampstaffwasnotevenawareoftheconcept of post-op care.Of the last threepatients left at thecamp,nonewasgivenanysortofattentionandanyformofpostoperationalcheckuporfollowup-information.Thewomenleftinadeliriousstate,unabletotalkandinneedofassistancetowalk.

Breaches of the guidelines Observed:

1. Thedoctoratthefirstcampwaslateanddidnotabidebytheguidelinestostartthecampontime.

2. Thesurgerieswerecarriedout inunhygienicsetupandnopostoperativecarewasprovidedtowomen.

3. Inbothcampsthesurgeonshadalreadyleftandnopersonfromthestaffgaveanyaftercareandmonitoringofwomen.Nobody monitored them, nobody checked vital signs asrequired and nobody gave them follow up instructionsbeforethewomenleft.

4. Therewere only two laparoscopes whichwere not beingdisinfected after each operation. None of the womenweregivenanytransportfacility.Therewasnoanaesthetistavailableatboththecamps.

5. At the hospital in Chimtipurt, only one laparoscope wasavailableeven though20-30womenareoperatedat the

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campmonthly.Thesurgeonoftenoperatesinmorecamps(sometimes 4–5 a day). No register is maintained in caseof deaths (he estimated 1 or 2 deaths a year caused bysterilization) nor is pre-operational check up list availablethere. Thewomen get only Rs. 600, and the AshaworkerRs.200asincentive.Thehospitaldidnothaveadoctorforthepastthreeyears. It lackedfacilities likephone, internetaccessandemergencyvehicle.Therewasonlyonedistricthospital, at a distance of 30 kms. On Sunday, only onepersonwsavailable.Thestaffhadnocapacitytoreachouttopeople invillages. Thepharmacistcouldnotprovideuswithanyfurtherinformationaboutpost-opcare.

6. ANMShivkaliDhurveatJunaPaniandhercolleaguesharedthattherewasagovernmentaltargetforsterilizationwhichneeded to be fulfilled. Both ANMs tried to convincemenas well because they considered male sterilization a lesscomplicated procedure. Men did not often participatein thesemeetings; they feared losing theirmanhoodaftersterilization. If a couple did not have a male child, thentheywere recommended towait foranotherchildbeforeundergoingtheprocedure.

7. ARSH worker Arti Dube at District Hospital Chhindwarainformedthat1%ofwomenbetween16and18yearsgetsterilizedwhentheyhavemorethantwochildren.Shealsosharedthattherewasaweekly(everyWednesday)campwhere30to40surgerieswereperformedbysingledoctor.The samedoctorworked in 4-5 camps, sometimes in oneday.Theteamwastoldthatafterapproximatelythreehoursaftertheoperationthewomenweresenthome.Thedistricthospitalwasnotcleanandsmelledrevolting.TheteamwasshowntheOT,wherearecentlyoperateduteruswithcancerremainedonthefloorformorethanhalfanhourwhiletheteamspokewiththeARSHworker.

8. Youngpeoplebetween13and24hadnoclearideaaboutthereproductiveprocess,HIV,howtoprotectpregnancyoranyformsofexistingcontraception.

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Conclusion

There has been complete violation of guidelines regardingunhygienicpractices,numbersofwomenbeingoperated-onbyonesingledoctor,lackofpre-andpost-operationalcheck-up.Allsterilizationincampshappensasmassproceduresinunhygieniccircumstances. The camp ideology concentrates on highestandallegedlycheapestpossibilityofbirthcontrol.Thereareveryfewcasesofmale sterilization. The targetand incentivebasedapproachofthegovernmentcomesatthecostofhealthandlifeofwomenandinviolationoftheirrighttoleadalifewithdignity.

3. FACT-FINDINg MISSION TO SONIA VIHAR, DELHI, Date of Visit: 27th November 2014The reproductive rights team of HRLN conducted fact findinginSoniaVihar,Delhitogetacquaintedwiththegroundrealitiesof sterilization in Delhi. A list of all thewomenwho underwenttubectomywassoughtundertheRighttoInformationAct,2005.The list also included those whose tubectomy operations hadresultedinfailure/complication/death.Theobjectivewastofindoutwhetherthesewomenhadreceivedpropertreatment,careandwhethertheywereawareoftheFamilyPlanningIndemnityScheme to compensate women and families in the event ofcomplications,failures,anddeaths.Theaddresslistprovidedbythegovernmentdidnotgivealltheinformation.Inmanycasestheaddresseswerenottakendownproperly,andhencecouldnotbeverified.

CASES OF LACk OF INFORMED CHOICE AND INFORMED CONSENT AND SHEER NEgLIgENCE

1. Story of kailash Devi, Sonia Vihar, New DelhiAge: 28 yearsNumber of Children: 04Date of Sterilization: 10.9.2014

ReproductiveHistory:Mrs.KailashDevi lives inSoniaVihar,NewDelhiwithherhusbandandfourchildren;threeboyswhoareten,fiveandsevenyearsofageandonegirlwhoistwomonthsold.

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Documents Available: Kailash Devi had her ultrasound reportwithher,aswellasJugpraveshandGuruTegBahadurhospitaltreatmentdocuments. Shewasasked tocollect thecertificateafteronemonthshecouldnotgo.

Dischargeslipdated22/9/2014mentionedtuballigation.

Case Story:

WhenKailashDeviwassterilized,shedidnothaveanyintentionofundergoingtubectomy.Asperhospitalrecords,herLMPwason1/12/2013andEDDwason8/9/2014.ShevisitedJagPrakashhospital because her delivery date had passed without anylabourpains.KailashDeviwas told togetacaesareansectionsincethefoetusweighed4kg.

AftershewastakeninforthesurgeryatGTBhospital,herhusbandwasaskedforpermissiontoconducttubectomybuthewasnotgiven sufficient time to consider this decision.Doctors told himthat since the couple already had three living children (twodaughters and a son) andwere now having their fourth childthroughacaesareansection, therewasa risk toKailashDevi’slife.Hewasgivenonlytenminutestodecideandsigntheconsentform. Worried that his wife, who had already undergone fivepregnanciesandhadanabortiononce,wouldnotsurviveanotherpregnancy,hegaveconsent for theprocedure impulsively.Hedid not know anything about the procedure, its repercussionsandmost importantly itspermanentnature,exceptforthefactthatitwasamethodofbirthcontrol.Nobodyexplainedorreadouttheconsentformtohim.WhileKailashDeviwasinlaborshewasasked to sign theconsent formwhich shedid,mistaking itastheconsentforthecaesareanprocedure.Shesaidthatshewouldnothaveagreedtoundergotubectomyifsheknewaboutit.ShewasadmittedtoGTBhospitalon10September2014forherdelivery;immediatelyafterwhichthetubectomywasperformed.Theywerefalselyinformedinanultrasoundreportthatthebaby’sweightwasmorethanfourkgsandthatshewouldhavetoundergoaC-SectionDelivery. Theywere later informedbyhospital staffthat the ultrasound report,which leads toa caesarian sectionandultimatelyatubectomy,wasincorrect.

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ThiswasacaseofsheernegligenceandviolationofMs.KailashDevi’shealthrights.Neitherthehospitalnorthelocaldispensarywhereshewentforcheck-upduringherpregnancyconductedanyprior testsonher to see if shewas suitable for tubectomy.KailashDevididnotgetasterilizationcertificate.

Fortunately, she did not experience any sort of side effectsor complications from the procedure. However she had noinformationaboutthefamilyplanningindemnityschemewhichbenefitswomenwhose tubectomy fails orbecomes subject tocomplications.Norepresentativeofthehospitalorthegovernmenthas informed her about the same. Conducting tubectomywithoutgettinghervoluntaryconsent isagrossviolationofherhumanrights.

2. Mrs. Mamta Rajan Age: 28 yearsTotal living children: 3Case story:Mamtahas twoboysagedeightand sevenyears respectivelyandagirloftwoyearsandsixmonthsofage.Herhusbandworksinanothercity.Shewasawareofandhadbeenusingcontraceptiveslikeoralpillsandcondomsbefore shechosesterilization. Inhercase, these methods failed and she got pregnant. However,shedidnotrealisethisandcontinuedtotakethepillsaswellasotherharmfulfooditems,resultinginamiscarriageat4months.Perturbedbythis,shedecidedtoundergotubectomy.

She received adeqaute information regarding the procedureand signed the consent form being fully aware that it is apermanentcontraceptive.Shewasgiveninformationregardingitsadvantages,disadvantagesandalternativesavailablebythedoctor.Shechosetohavethesurgerydonebecauseshefeltthattheothermethodswerenotreliableandshedidnotwantsuchanincidenttohappenagain.However,shewasinitiallyinterestedingettingaCopper-T.UponvisitingthegovernmentdispensaryinSoniaViharforthispurpose,shewastoldthatshewouldhavetowaitforatleastsixmonthsasthefacilitywasnotavailableatthemomentandshethoughtitunwisetowaitforthatlong.

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Thereafter, she had the surgery done inMarch 2014 at ArunaAsafAliHospital.Shewasrequitedwiththefacilitiesinthehospitalas itwascleanand the staffwerecourteous. Theyconductedapregnancy test andcheckedherbloodpressurebefore thesurgery and she was made to feel comfortable enough toask questions about the procedure. She did not receive anyinstructionsonpost-operativecareexceptaprescriptionforthemedicines.Thedoctorexaminedherbeforedischargeand shecommutedtoandfromthehospitalinherownvehicle.Shewasgiven Rs. 400/-after the surgery as incentive and a certificateshowingthatshehasundergonetubectomy.

Hercasewasdifferentfromtheotherwomeninthatshegavefullconsent to theprocedurebutshedevelopedsideeffects fromthesurgery.Herskinpeeledoffneartheareawherethesurgerywas done. She went back to the hospital and they gave hermedicinesbuttheyhadnoeffect.ShewasalsotheonlywomanwhowasawareofFPIS.However,herinformationcamefromhermother-anAnganwadiworker-andnotthehospitalshevisited.Mamtadidnot try toavailcompensation forhercomplicationbecausethetraveltothehospitalwasmoreexpensive.Herfriendhadpreviouslytriedtoavailcompensationforafailedtubectomybutdid not receive theamount shewasentitled to in spiteoftryingforalongtime.ThisonlyservedtodiscourageMamtafromfollowingthesamepath.

Uponbeingaskedheropinionofmenundergoingvasectomyasitismuchlesscomplicated,shesaidthatshewouldnotwantherhusband to undergo it becausepeople in her neighbourhoodlooked down upon sterilized men. Un-flattering rumours werespreadaboutthefamily,thushighlightingthestigmathatprevailsinoursocietywhenitcomestomalesterilization.Educationandinformationarecrucial inchangingthismindset,withoutwhichgenderdisparityinsterilizationwillpersist.

TheFPIS,inpractice,containsmultipledeficiencies.Itsexistenceis notwidely known bymedical facilities, doctors, other familyplanningmedicalworkers,orwomenwhoundergothesterilizationprocedure.Additionally,womenarenotconsultedprior to theprocedureandmanycannotnamealternativemethodsofbirth

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controlavailable,indicatinglackofinformedconsent.Althoughsomesigntheconsentform,theydonotknowwhatitcontainsnoraretheyawareofthecomplicationsthatcouldariseasaresultoftheprocedure.Manydonotspeaktothedoctorpriortothesurgeryandarenotgivenanypost-operativeinstructions.Inmanycases,patientsarenotgivenacopyoftheconsentformandarenotgivenproofofsterilizationaftertheprocedureisconducted.ManyASHAworkersarealsounawareoftheexistenceoftheFPIS.

3. Mrs. SapnaAge: 33 yearsTotal living children: 2 (younger child is 2 months old) Sapna,ahomemaker,isagraduateandmotheroftwoboyswhoareagedfiveyearsandtwomonthsrespectively.Sheunderwenttubectomy right after the delivery of her second child at GTBHospital.Shechosesterilizationasshefeltthatwithcopper-Tandoral pills there was a higher chance of failure and she wouldrathernottaketherisk.

She was told about the procedure by the ASHAworker. Eventhoughshewasawareaboutothermethodsofcontraception,she had never used any of thembefore the surgery. Shewasadmittedtothehospitalwithoutanypriorteststodeterminethesuitabilityofthemethod.Shesignedtheconsentformwhichshereadandclearlyunderstood.Sherecoveredonabedafterthesurgeryandwasexaminedbythedoctorsinaroomfullofotherwomenwhichdidnotoffermuchprivacytothepatientstoaskpersonalquestions regardingtheirhealth.Thiscoupledwiththefactthatshewasfrightenedrenderedherunabletofreelyinteractwithherdoctor.Shealsohadtodealwitharudelybehavedstaff.

Thedoctorsexaminedthestitchesbeforeherdischargefromthehospitalandgaveherawrittenprescriptionofthemedicinestobe taken forpost-operative recovery. Shewasnot informedofwhen she could resume sexual intercourse or given any otherinstructions to be followed. However, she was asked to returntothehospitalforaroutinecheck-upafteramonth,whichshehadnotdoneasof the timeof the interview. She travelled tothehospitalandback inanautorickshawandspentRs.200 in

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the process. Shewas not given any incentives for undergoingthe surgerynordid she receive themoney shewasentitled tounder theJSYbecauseshedidnothaveabankaccount.Shehasnot receivedanydocumentationevidencing the fact thatshehasundergonetubectomy.OnbeingaskedabouttheFamilyPlanningIndemnityScheme,neithershenortherestofherfamilywasawareofthesame.

4. FACT-FINDINg MISSION AT BILASPUR DISTRICT, CHHATTISgARH, DATE OF VISIT: 14-18 NOVEMBER 20141. Introduction

On8November2014,asterilizationcampresultedin15deathsinTakhatpurBlockofSakri,BilaspurDistrict;Chhattisgarh.On10November2014doctorsconductedsterilizationcampsinGaurellaBlockatGaurella,Marwahi,andPendra.OnewomandiedasaresultoftheGaurellacamp.SomewomenremainedhospitalizedincriticalconditionatApolloHospital,Bilaspur.ThegovernmentissuedRs.4lakhtothefamiliesofthedeceasedandpromisedtoprovidehealthcareandeducationtotheirchildren.

JournalistsfromIndiaandacrosstheworldreportedthegruesomedetails:asingledoctoroperatedon83womeninjustafewhours;thehospital,whichisusuallyclosed,wasfilthy;womenrecoveredfromthesurgeryonthefloor;andallparties,thedoctor,fieldlevelhealthworkers(Mitanins)andthewomenreceivedanincentivepayment.16youngwomenwhoattendedthiscampexpectingasimpleproceduretocontroltheirfertilitydiedasaresultoftheirundignified,unsafe,andunethicaltreatment.

TheGovernmentofChhattisgarhandmediaoutletsreleasedthefollowinglistofdeaths:

Name Age Caste Village Children1.Janaki 24 SC Chichirda 32.Chaiti 22 ST Dhanauli 23.Ranjita 25 SC Nirtu 34.Shivkumari 27 OBC Ganiyari 35.Dularin 24 OBC Lokhandi 2

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Name Age Caste Village Children6.Nembai 37 SC Ghuru 57.Chandrakali 22 OBC Bharari 38.Rekha 24 SC Amsena 29.Dipti 28 OBC Dighora 310.Phool 28 OBC Amsena 311.Neera 30 Vindhasar12.Pushpa 25 ST Nachuwa13.Sunita 25 OBC Ghutku

Methodology

On14November2014,areproductiverightsactivistfromtheDelhibased Human Rights Network traveled to Bilaspur to conducta fact-findingwith two local lawyers. The fact-finding had twoprimarygoals:

1. TodeterminewhetherthesterilizationcampheldatSakriinNovember2014violatedwomen’sfundamentalrights;

2. Todeterminewhetherthiscamprepresentsasinglecaseofmedicalnegligenceorwhetherthecampispartofalargerstatefailuretoensurewomen’sreproductiverights.

At hospitals, the team spoke with 14 women from campsthroughout Bilaspur, including six women from the Sakri campthat resulted in 13 deaths. At Apollo Hospital, the team spokewithhospitaladministrators.Invillages,theteammetwithfamilymembers of the deceased, the Panch and/or Sarpanch, themitanins,andwomeninthecommunity.

This report outlines findings from the field; major fundamentalrightsviolations;statefailurestocomplywiththeSupremeCourt’sRamakant Rai orders;statefailurestoensurecompliancewiththeStandardOperatingProceduresforSterilizationServices(Ministryof Health and Family Welfare, 2008); women’s experiences atsterilizationcampsinBilaspurDistrict;interviewswithfamiliesofthedeceased;observationsfromfacilitiesandinterviewswithhealthworkers,andrecommendations.

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Ultimately,thisreportconcludesthatChhattisgarh’sill-equippedpublic health system coupledwith the state’s relentless pursuitof family planning targets creates an environment wheredeathbecomes inevitable. This report recommends immediateimprovementsinqualityofcare;acompleteendtothetarget-basedapproach to familyplanning;accountability forflagrantviolationsofGovernmentofIndiaandSupremeCourtguidelines;andjusticeforgravefundamentalrightsviolations.

2. Health Indicators and Family Planning in Chhattisgarh

The2011CensusrecordsChhattisgarh’spopulationas2.55crorewithlargepopulationsfromdiversetribes.Chhattisgarhisonethepooreststates inIndiawithabout49.4%ofthepopulationlivingbelowthepovertyline.TheMultidimensionalPovertyIndex,whichmeasuresmorethanmereincome,findsthat69.7%ofthestate’spopulationfallsbelowthepovertyline.

Health indicators,Chhattisgarh (District LevelHousehold Survey2007-2008,unlessotherwiseindicated)

Health Indicator Chhattisgarh IndiaTotalFertilityRate 2.7(SampleRegistration

System,SRS,2011)2.4(SRS,2011)

SexRatio 964women/1000men(2011census)

940/1000(2011census)

Anemiainmarriedwomen15-49

56.2% 56%(NationalFamilyHealthSurvey2005)

InfantMortalityRate

48deaths/1000livebirths.(SRS2011).113/1000forteenagemothers.

44(SRS,2011)

ChildMarriage 45.2%ofwomenage20-24marriedbefore18.

43%ofmarriedwomenage20-24marriedbefore18.

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Health Indicator Chhattisgarh IndiaMaternalMortalityRatio

260(SampleRegistrationSystem(SRS)Bulletin,2011)

212(SRS2011)

WomenwhohadfullANC

13.7% 18.8%

WomenwhoreceivedJSYbenefit

9.3% 13.3%

InstitutionalDelivery 34.9%ofmarriedwomenhavehadaninstitutionaldelivery.(AnnualHealthSurvey,2011-2012)

47%

MarriedWomenUsingContraception

49.7% 54%

MarriedWomenUsingModernMethods

47.1% 47.1%

MarriedWomenUsingSterilizationasContraception

41.3% 34%

MarriedMenUsingVasectomy

1.8% 1.0%

MarriedWomenUsingIUDasContraception

0.6% 1.9%

MarriedCouplesUsingCondomasContraception

1.6% 5.9%

Unmetneedforcontraception

20.9% 21.3%

Chhattisgarh has failed tocomplywithminimumpublic healthinfrastructure, staffing, and services guarantees under theNational Health Mission. The state lacks 45 Community Health

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Centres (CHC), 302 Primary Health Centre (PHC) doctors, 131CHCobstetriciansandgynecologists,130pediatriciansatCHCs,525 total CHC specialists, 293 CHC and PHC pharmacists, 460PHCandCHC laboratory technicians,and1246PHCandCHCnurses.Hence,thestate’shealthcareinfrastructurefallsshortoftheminimumgovernmentprescribedstandards.

3. Failure to Comply with Supreme Court orders in Ramakant vs. Union of India & Ors.

Thefact-findingteamrecordedacompletefailuretoimplementtheSupremeCourt’s2005sterilizationcamporders:

ORDER COMPLIANCE1.Limitedpanelofdoctorsauthorizedtocarryoutsterilizationprocedures.

•Onlythreelaparoscopicsurgeonsinthedistrict.Noinformationonempanelment.•ThenumberofcampsplannedinChhattisgarh’shealthbudgetfor2014-2015greatlysurpassesthenumberofqualifiedphysicians.

2.Checkliststocompleteforeachpatientwithhealthinformationandbiodata.

•Noneofthewomensawhospitalstaffcompletingachecklist.•Theamountoftimeperpatientmakesitimpossibletothoroughlycompletethechecklistforeachpatient.•Tribalwomenwhoshouldnotbesterilizedunderwenttheprocedure.

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3.Consentforms. •Thecampstaffdidnotgivewomentimetoreadtheform.•Campstaffdidnotreadorexplaintheformtowomenwhocannotread/write.•Somepatientssignedblanksheetsofpaper.•Womendidnothaveadequatecounsellingtomakeaninformeddecisionregardingsterilization.

4.EstablishaQualityAssuranceCommittee.

•DistrictQualityAssuranceCommitteeestablishedmonthsbeforethecamp,butnotfunctional.

5.Maintainstatisticsontheageandnumberofchildrenandonsterilizationinjuriesanddeaths.

•Informationisnotavailable.

6.Holdinquiriesintoguidelinebreachesandtakepunitiveaction.

•Thefact-findingteamuncoveredapatternofguidelinebreaches(e.g.,acampwith100womeninJuly2014).Noinvestigationoraccountabilitystepstaken.•Evenhere,theDQAChasnotlaunchedtheinvestigation,itistheHighCourtandtheHealthMinistry.•QualityAssurancereportnevercompletedinthisDistrict.

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7.Createaninsurancepolicy.

•Statehasaninsurancescheme,butcampstaffdidnotinformasinglewomanaboutthepolicyorhowtoaccessit.•Notasinglewomanreceivedanyproofofsterilization–anecessarycomponentforaccessingcompensation.•Womendidnotknowthedoctor’sname.Doctor’ssignatureisnecessaryforaccessingtheinsurancescheme.

4. Overwhelming Failure to Follow the Standard Operating Procedures for Sterilization Services in Camps (SOP, Ministry of Health & Family Welfare, March 2008)

TheteaminterviewedwomenfromtheSakri,Gaurella,Marwahi,andPendraCamps,familiesofthedeceasedandgovernmenthealthworkers.These interviewsshowthatthesterilizationteamacted with complete disregard for the Sterilization Services inCampsSOP.Thefollowingtableoutlinesthecountlessinfractions:

5. Major Fundamental Rights Violations

The fact-finding teamuncovered evidence of grave violationsof fundamental rights at sterilization camps in Bilaspur District.AspertheGovernmentofIndiaschemesincludingtheNationalHealthMission,guaranteesinformationandaccesstoa“basket”ofcontraceptivechoices.Additionally,theConstitutionof IndiaguaranteestheRighttoLife(Article21)andtheRighttoEquality(Article15).TheSupremeCourthasdeterminedthattherighttolifeincludestherighttohealth(SeePashim Banga Khet Mazdoor Samiti,19964SCC37), therighttodignity,andtheRighttobefreefromcruel,inhumane,anddegradingtreatment(SeeFrancis Coralie Mullin v. Administrator, Union Territory of Delhi & Ors.).

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Additionally, sterilization camps in Bilaspur District violate theGovernment of India’s international obligations under theInternational Covenant on Civil and Political Rights (ICCPR),International Covenant on Economic, Social, and CulturalRights (ICESCR), the Convention on the Elimination of RacialDiscrimination(CERD),andtheConventionontheEliminationofallformsofDiscriminationagainstWomen(CEDAW).

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Right Obligation Brief Description of Violation(s)Righttoaccesscontraceptiveinformationandservices.

•ConstitutionofIndia,Article21(SeeSuchita Srivastava vs. Chandigarh Administration AIR2010SC235)holdingthat:“Thewoman’srighttomakereproductivechoicesisalsoadimensionofpersonallibertyasunderstoodunderArticle21oftheConstitutionofIndia.Itisimportanttorecognizethatreproductivechoicescanbeexercisedtoprocreateaswellastoabstainfromprocreating.”•CEDAW,Article12:1.StatesPartiesshalltakeallappropriatemeasurestoeliminatediscriminationagainstwomeninthefieldofhealthcareinordertoensure,onabasisofequalityofmenandwomen,accesstohealthcareservices,includingthoserelatedtofamilyplanning.•CEDAW,Article16.1.StatesPartiesshalltakeallappropriatemeasurestoeliminatediscriminationagainstwomeninallmattersrelatingtomarriageandfamilyrelationsandinparticularshallensure,onabasisofequalityofmenandwomen:(e)thesamerightstodecidefreelyandresponsiblyonthenumberandspacingoftheirchildrenandtohaveaccesstotheinformation,educationandmeanstoenablethemtoexercisetheserights.

•TheStatehasfailedtoensurethatwomenhaveaccesstocontraceptiveinformationandservices.•TheState’sProjectImplementationPlansdemonstrateaclearcommitmenttotargetsforfemalesterilization.Targetsforaspecificformofcontraceptionensureaproviderbiasandeliminatetruefreechoice.•Chhattisgarhreportsanunmetneedforcontraceptionat20%andBilaspur’sunmetneedisat29&.•Intervieweesneverreceivedcounsellingoncontraceptiveoptions.•Intervieweesdidnotknowwheretoaccessinformationorservicesfornon-permanentformsofcontraception.•Mitaninsdonotreceivein-depthtrainingonnon-permanentformsofcontraception.Thestatetrainsfieldlevelhealthworkers“toconvince”womentoundergosterilization.•Campsillustratetheinadequateaccesstocontraceptiveinformationandservices;womencannotavailofserviceswhenandwheretheywant,theyhavetowaitforacamp,whichmayonlytakeplaceonceortwiceayear.

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Right Obligation Brief Description of Violation(s)2.RighttoinformedconsentandRighttobodilyintegrity.

•ConstitutionofIndia,Article21.•CEDAW,Article16.

•Withoutadequateaccesstocontraceptiveinformationandservices,womencannotcontrolwhentheybecomepregnant.•Womendidnotreceivecounsellingonthesterilizationprocedure(whatwouldhappen,possiblerisks,sideeffects,etc.)•Womendidnothavetimetoreadtheconsentform.•Noonereadorexplainedtheconsentformtowomenwhocannotread/write.•Husbandssignedsomeconsentforms.•Mostfamiliesofthedeceaseddidnotreceiveanyrecords–post-mortems,deathcertificates.

3.Righttobefreefromdiscriminationbasedonsex.

•Constitution,Articles14,15,21.•CEDAW.

•Statefamilyplanningpolicytargetswomen.Sterilizedwomencomprise41.3%ofmoderncontraceptiveusersinChhattisgarh;sterilizedmencomprisejust1.8%.•Womencomprise97%ofallsterilizationsurgeriesinIndia.•InadequateprimaryandmaternalhealthserviceshaveresultedinanunacceptablenumberofmaternaldeathsinChhattisgarh.

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Right Obligation Brief Description of Violation(s)4.Righttobefreefromdiscriminationbasedoncaste.

•ConstitutionofIndia,Article15•ConventionontheEliminationofRacialDiscrimination(CERD),Article1,definingracialdiscriminationas“anydistinction,exclusion,restrictionorpreferencebasedon…descent,ornationalorethnicoriginwhichhasthepurposeoreffectofnullifyingorimpairingthe…enjoymentorexercise,onanequalfooting,offundamentalfreedomsinthepolitical,economic,social,culturaloranyotherfieldofpubliclife.

•Sterilizationcampstargetmarginalizedwomenwhohavelimitedoptionsforcontraception.•Thegovernmentprovideddatafor13deceasedwomen–4womenfromSC;6womenfromOBC;2fromST;1unknown.

5.Righttodignity.

•ConstitutionofIndia,Article21.•CEDAW,Article16.•ConstitutionofIndia,Article21(SeeSuchita Srivastava vs. Chandigarh Administration AIR2010SC235)holdingthat:thecrucialconsiderationisthatthewoman’srighttoprivacy,dignity,bodilyintegrityshouldberespected.Thismeansthatthereshouldbenorestrictionwhatsoeverontheexerciseofreproductivechoicessuchasawoman’srighttorefuseparticipationinsexualactivityoralternativelytoinsistenceonuseofcontraceptivemethods.Furthermore,womenarealsofreetochoosebirthcontrolmethods.”

•Norespectforpatientconfidentialityorprivacy.•Operationsconductedinassemblylinefashion.

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Right Obligation Brief Description of Violation(s)6.Righttobefreefromcruel,inhumanordegradingtreatment.

•ConstitutionofIndia,Article21 (Francis Coralie Mullin v. Administrator, Union Territory of Delhi & Ors.).•ICCPR,Article7(SeeGeneralCommentNo.7:Article7“clearlyprotectsnotonlypersonsarrestedorimprisoned,butalsopupilsandpatientsineducationalandmedicalinstitutions.”

•Womenrecoveronthefloor.•Twominutespersurgery.•Noattentiontoinfectionprevention.•Non-consensualmedicalproceduresamounttoinhumananddegradingtreatment.

7.Righttohealth. •ConstitutionofIndia,Article21.•ICESCRArticle12(Guaranteeingtherighttothehighestattainablestandardofhealthandavailable,accessible,acceptable,qualityhealthservices).•CEDAW,Article12.•CEDAW,Article16.

•Inadequateprimaryhealthservices–lessthan40%ofwomendeliverininstitutions.•Healthservicesarenotavailableoraccessible:Womencannotavailofsterilizationwhentheywant,theyhavetowaitforacamp;BilaspurDistrictHospitalisthreehoursfromsomevillages;Facilitiesandhealthworkersdonothaveavailablestocksorinformationonnon-permanentformsofcontraception.•Completedisregardforqualityandacceptablebasiccarepracticesincludinginfectionprevention,patientconfidentiality,surgicalbestpractices,post-operativeinstructions.

8.Righttolife. •ConstitutionofIndia,Article21.

•16deathsasaresultofunsafeandunethicalsterilization.

6. Women’s Experiences at Sterilization Camps in Bilaspur

Interviews with women create an indisputable pattern ofwomen’s rights violations in Bilaspur. Interviews with womenabout sterilization camps consistently revealed poor accessto primary health services, woefully inadequate access tocontraceptive services and information, insufficient informedconsent procedures, negligent and harmful surgical practicesand infection prevention, failure to provide post-operativeinstructions,andundignifiedtreatment.

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1. Name: Manisa; Age: 25; Number/Age of Children: three (Ages 5 years, three years, and 6 months); Camp: Sakri; Interviewed at District Hospital.

Manisa’s husband works as a daily laborer. Although she hadfullantenatalcareduringeachpregnancy,sheneverreceivedfamilyplanningcounselling.Daysbeforethecamp,hermitanincame toherhouseand toldherabout thecamp. Themitaninonlytoldherthatthesurgerywould“stopchildren”andthatsheshouldavoideatingonthemorningoftheprocedure.

Manisa,herhusband,andthemitanintravelled30minutestothecamp.Shereceivedaconsentform,butshedidnothavetimetoreadit.InviolationoftheMinistryofHealthandFamilyWelfareGuidelines, noonecounseledManisaaboutcontraceptivesortheprocedureaftershereachedthefacility.Healthworkerstookbloodandurine samplesandconductedaphysicalexam.Noone toldherwhatwere the tests regardingorwhat the resultswere.Shereceivedfive injections, two ineacharmandone intheabdomen.Shereceivedtheseshotswhileonabedwithfourother women. Then she became drowsy. Male health workersliftedherontoatableforthesurgery.Sheneversawthedoctor.After,themalehealthworkersputheronanotherbedforstitchesandthenmovedhertothefloor.Shestayedinthesameclothingthroughout the procedure and never saw anyone wash theirhands.Shewasinexcruciatingpain.

Afterthirtyminutes,shereceivedRs.600andtwopills.Anursetoldhertotakethepillswithfood.Shedidnotreceiveanyadditionalpost-operative instructions, warnings and proof of sterilizationor documentation on the Family Planning Insurance Scheme.ManisapaidRs.150/-foranautohome.ShevomitedaftertakingthemedicinesandthemitaninbroughthertotheDistrictHospital.Afterafewdaysinthehospital,shefeelsfineandisreadytogohome.Noonehasdiscussedcompensationwithher.Shedoesnotknowwhenshecangohome.

2. Name: Sobha; Age 20; Number/Age of Children: 3(Ages 2 years, 1 year and 6 months); Camp: Pendra; Interviewed at District Hospital.

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Sobhamarriedat19andduringherpregnancies,shereceivedantenatal care at her local Anganwadi Centre. She chose todeliverathomewith thehelpof theMitaninbecause shewasafraid togo to thehospital. Shedidnot receiveJSYpaymentsfor either delivery. She never received counselling on spacingmethodsorfamilyplanning.

A week before the camp, the mitanin told her about thesterilizationsurgery.Sobhacouldnotexplainthesurgery;sheonlyknewthatitwouldpermanentlypreventpregnancy.At3pmonthedayofthecamp,Sobhaandhermother-in-lawwalkedtothehospitalwithfivewomenfromthevillage.Sheknowshowtoreadandwrite,butshedidnotreadtheconsentformbeforesigningit.Next,shehadaurineandbloodtestandinjections.Thensheonlyrememberswakinguponthefloor.Shedidnotreceiveanypost-operativeinstructionsoracertificateshowingthatshehadbeensterilized.ShereceivedRs.500/-andwenthomeinanambulance.Shehadaslightfever,butnoadditionalpost-operativeissues.

3. Name: Rambati; Age 25; Number/Age of Children: 4 (Ages 7 years, 6 years, two years, 9 months); Camp: Pendra; Interview at District Hospital.

Rambati married at age 14 and received Antenatal Care atthe localAnganwadiCentreduringallofherpregnancies.Shedeliveredeachchildat thePHCand receivedherentitlementcash under the JSY scheme. She never received counsellingon contraceptives during her pregnancies or after delivery. Aweekbeforethecamp,themitanincametoherhouseandtoldherthat ifshedidnotwantmorechildrenshecouldgofortheupcoming camp.On the day of the camp, Rambati traveled2kms inanautowithhermother, themitanin,andthreeotherwomen from the village. Rambatidoesnot knowhow to readorwrite,soshedidnot readtheconsent form.Noonereadorexplained the form to her. Ramnati does not know anythingaboutthesterilizationprocedure,sheonlyunderstandsthatshewill never have children again. She provided urine and bloodfor testing.She then receivedfive injectionsandbegan to feeldrowsy.Whenshewokeupshewasonthefloorandhadaslightpaininherstomach.Shereceivedherstitchesonthefloor.Shedidnotreceivepost-operativeinstructionsorproofofsterilization.

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ShereceivedRs.600/-andmedicines.ShepaidRs.100/-foranautohome.Shetookthemedicines,butshedidnotexperiencesideeffects.Shefeltveryscaredduringthecamp,andthewholeexperiencehasmadeitdifficultforhertotrustdoctors.

4. Name: kumal; Age: 23; Number/Age of Children: 2 (Ages three years and three months); Camp: Marwahi; Interview at District Hospital.

Kumal receivedantenatalcareat theAnganwadiCentreandshedeliveredbothchildrenathomewithhelpfromthemitanin.She never received counselling regarding contraception. Aweekbefore thecamp, she tookherchildren for immunizationand the local health workers told her about the upcomingcamp. Theonly thing sheknowsabout theprocedure is that itpreventspregnancy.On thedayof thecamp, she traveled tothe campwith twowomen from her village. She cannot readandwrite,soshedidnotunderstandtheconsentform.Noonereadorexplainedtheformtoher.Shegaveurineandbloodfortesting.Whenshewokeupafterthesurgery,shewasonthefloor.She did not receive documentation of her sterilization or post-operativecare instructions.ThehospitalstaffgaveherRs.600/-andprescribedtwomedicines.ShetraveledhomeinacarforRs.200/-.

5. Name: Marti; Age 26; Number/Age of Children: 2 (Ages 4 years and 2 years); Camp: Pendra; Interview at District Hospital.

Marti delivered both children at Pendra Hospital where shereceivedherRs.1400/- incentiveJSYpayment.Themitanintoldheraboutsterilization–theonlythingMartiknewaboutsterilizationisthatitstopsconceptionofchildren.Shecouldnotnamenon-permanentformsofcontraception.Martidoesnotknowhowtoreadorwrite–sheputherthumbimpressiononaform,butnoonereadittoherorexplainedthecontents.Shehadbloodandurinetestsandreceivedfiveinjections.Sheremembersthatthesurgerylastedlessthanfiveminutes.Whenshewokeupafterthesurgery,shewasonthefloor.Shedidnotreceivedocumentationofhersterilization.ThehospitalstaffdidtellhernottobatheposttheprocedureandgaveherRs.600/-andtwomedicines.

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6. Name: gauri; Age 25; Number/Age of Children: 3 (Ages 7 years, 3 years, and 2 months); Camp: Sakri; Interview at District Hospital.

ThemitanintoldGauriaboutthecampthreemonthsinadvance.Onthedayofthecamp,Gauri,afamilymember,andthemitanintravelled to the campand reached thereat noon. She neversawaconsent form.Shecouldnotexplain theprocedureandhadnocounsellingaboutthesurgery.Thecampstafftestedherurineandbloodandthengaveherfiveanaesthetic injections.She received the injectionsalongwith fourotherwomenonabed.However,itispossiblethattheanaesthesiawasincorrectlyadministered as she remembers a cut being made and thedoctor “pulling somethingout of her” during the surgery.Aftertheoperation,malehealthworkersplacedheronanotherbedwhereshereceivedherstitches.Thehealthworkersmovedhertothefloorforrecovery.Shedidnotreceiveproofofsterilizationorpost-operativeinstructions.ShetookanautohomeforRs.100.Shetookthemedicinesanddidnotexperiencesideeffects.ThemitanintookhertotheDistrictHospitalpergovernmentorders.

7. Name: Reena; Age: 22; Number/Age of Children: 2 (Ages 2 years and 3 months); Camp: Sakri; Interviewed at CIMS.

ReenareceivedAntenatalCareatherlocalAnganwadiCentrefor both pregnancies, but she never received counsellingregardingcontraception.Shedeliveredataprivatehospital inKorba,whereshelives.ShetraveledtoBilaspurforthesterilizationsurgery and to be with her mother. She did not receive anyinformationorcounsellingabout sterilizationprior to thecamp.Theonly thing she knewabout sterilizationwas that itpreventspregnancy.Eightpeoplefromhervillagetraveledtothecampintwocars,eachpersonhadtopayRs.200/-fortheday.Theyreachedthecampat12:30.Shedid seeandsign theconsentform, but she did not have time to read it. The hospital staffconductedaphysicalexamandtestedherbloodandurineandaskedhertositonthefloor.Whenitwasherturn,shelayonabedwithmanywomenandreceivedfiveinjections.Afterthesurgery,shereceivedmedicinesfromthehospitalstaff.However,shetookthemedicineonceshe reachedhomeandvomited.Although

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shefeltfine,themitaninbroughthertothehospitalonceotherwomen at the camp began facing gross complications anddied.Reena’shusbandisatraditionaldoctorwhotoldthefact-findingthatthecampconditionsconstituteunsafeandunethicalmedicalpractice.

8. Name: Shree kumari; Age: 22 years;Number/Age of Children: 3 (Ages 7 years, 3 years and 2 months); Camp: Sakri; Interviewed at CIMS

Shree Kumari had antenatal care for all her pregnancies anddeliveredallthreechildrenathomewiththehelpofa‘dai’.Unlikeother women the team interviewed, she did have counsellingon alternate and non-permanent forms of contraception. Shetookoralcontraceptives forayear,butshediscontinuedthembecausepeopleinthevillagetoldherthatthepillsmightharmher.Herneighboursandthe localmitaninadvisedher thatsheshouldundergotheprocedure.Shestoppedtakingthepillsanddecidedtohaveathirdchildbeforeundergoingsterilization“incase something happened to the other children.” Themitanintoldheraboutthesurgeryafewdayspriortothecamp.Shehadwanted toundergo sterilizationafter her thirddelivery,but shehadtowaitforthecampseason.

On thedayof thecamp, shebookedanauto for theday forRs. 500/-. She traveled to the campwith hermother and twowomenfromhervillage.Whenshereachedthecamp,shefilledout theconsent formand thehealthworkersaskedher to signit. However, the workers were in such a rush that she did nothavetimetoread it.Thestaffcheckedherbloodpressure,herblood,andherurine.Theydidnotshowherthetestresults.Shetoldtheteamthatthecampstaffshouldhavetoldthewomeniftheywerenothealthyenoughtoundergosurgery.Thehealthworkersaskedthewomentoliedownonabedandtheygaveeachwomanfiveinjections.ShreeKumareewokeupduringthesurgeryandscreamedinpain.Thedoctorgaveheralightslaptocalmherdown.Afterthesurgery,malehealthworkersshiftedhertoanotherbedforherstitches.Aftertenminutesonthefloor,thestaffgavehertwomedicines,oneto“drythewound”andoneforpain.ShereceivedRs.600/-andtooktheautohomewithout

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anyproofofsterilization.Shetookthemedicinewithfoodanddidnotexperiencesideeffects.

9. Name: Santoshi; Age 23; Number/Age of Children: 3 (Ages 4 years, 2 years, and 3 months); Camp: Sakri; Interviewed at CIMS.

SantoshihadantenatalcheckupsatherlocalAnganwadiCentreanddeliveredeachchildathomewith thehelpofaDai. Themitanintoldheraboutoralcontraceptivepills,butsheandherhusbandneverreallydiscussedpreventingpregnancysoshedidnotfeelcomfortabletakingthepillswithouthisknowledge.Afterherthirdchild,Santoshiwantedtohaveasterilizationsurgerytopreventfuturepregnancies.Shedidnotunderstandthespecificsofsterilization,onlythatitpreventspregnancy.Onthedayofthecamp,SantoshiandthreewomenfromthevillagetraveledtothecampforRs.100/-each.Theyeachquicklysignedaformandahealthworkerrecordedthenumberofchildreneachwomanhad.Next,shehadabloodpressure,urine,andbloodtests.Thehealthworkers asked her to lie down in a bedwith four otherwomen and a nurse gave each woman five injections. Otherwomenbecamedizzyandfellasleep,butSantoshiwasawakethroughout theoperation. Thedoctormovedquicklybetweentwobedswhereheconductedthesurgeries.Eventuallyshewokeuponaplasticsheetonthefloor.ShereceivedRs.600/-andahealthworkertoldhertogohome,eat,andtaketwomedicines.Whenshereachedhomeshefeltsickandchosenottotakethemedicine.Thenextdayshetookthemedicinesandfeltfine.Afterotherwomenatthecampdied,themitaninbroughthertoCIMS.Asa resultof thisexperience, she feels terrifiedofdoctorsandhospitals.

10. Name: Sukhvaiya; Age: unknown; Number/Age of Children: 5 (Ages 14 months to 1 month); Camp: gaurella; Interviewed at CIMS.

Sukhvaiyaisatribalwoman.Sheheardaboutthiscampfromadoctor.Sheneverreceivedantenatalcareduringherpregnanciesanddeliveredallfivechildrenathome.Sheisnotfamiliarwithanyformsofnon-permanentcontraceptives.Shehashadvery little

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interactionwithformaldoctorsorthepublichealthsystem.Whenshereachedthecamp,sheputherthumbprintonaform,butshedoesnotknowthecontentsoftheform.Shedoesnotunderstandanythingaboutthesurgery.Sheonly rememberswakinguponthefloor.Shedidnotreceiveanincentivepayment.Themitaninhadarranged fora jeep to takeher home. She vomitedaftershe took themedicinesand themitanin tookher to thedistricthospital.

11. Name: Mankuuwa; Age 35; Number/Age of Children: 5 (Ages ranging from 17 years to 2 years); Camp: gaurella; Interviewed at CIMS.

MankuuwahadAntenatalCareattheAnganwadiCentreforallfivepregnanciesanddeliveredathomeeachtime.Shecouldnotnamespacingmethods.Shewas feelingunwellandcouldnothavean indepthconversationwith the fact-finding team.Whenshereachedthecamp,sheputherthumbimpressiononaform,althoughshedidnotknowthecontentsoftheform.Afterthesurgery,shewokeuponthefloor.ShereceivedRs.500/-asincentiveandhadtopayRs.100/-fortransportationtoandfromthecamp.Shedidnot receivepost-operativecare instructionsordocumentationprovingthatshehadundergonesterilization.When she reached home, she took themedicine and startingvomitingafterthethirddose.ShetraveledtoCIMSforcare.

12. Name: Neepa; Age 22; Number/Age of Children: 2 (Ages three years and three months); Camp: Sakri; Interviewed at CIMs.

Neepahadantenatalcheck-upsattheAnganwadiCentreduringbothpregnanciesanddeliveredathomewiththehelpofaDaiandamitanin.Shedidreceivecounsellingonspacingmethods,includingthecopper-T.Shewantedtohavetwochildrenandthenhavethesurgery.Shedidnotreceivecounsellingforsterilization;sheonlyknowsthatthesurgerypreventspregnancy.

Onthedayofthecamp,shetraveledtothehospitalinanautowithfourpeoplefromthevillage.Neepasignedaconsentform,althoughshedidnotreadit.Afterthis,shehadabloodtestanda urine test. She told the fact-finding team that she trusts the

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mitaninwith everything related to her healthcare and shedidnot feel comfortable asking questions about the tests. She feltpainduringtheoperationandremembersmalehealthworkersmoving her to the floor for her stitches. Ten to fifteenminutesafterthesurgery,shewokeuponthefloorsurroundedbyotherwomen.ShereceivedRs.600/-andtwomedicines.Shedidnotreceiveanydocumentationofthesterilizationorpost-operativeinstructions.Whenshereachedhomeshetookthemedicineshewasgivenwith foodand felt fine initially.However, she startedvomitingabout24hourslater(on9thNovember)andwenttothehospital for treatment on 10th November. Neepa informed theteamthatshefeltbetternowandwishedtoreturnhome.

13. Name: Chandrika; Age 22; Number/Age of Children: 4 (Ages 10 years, 6 years, three years, and 2 months); Camp: Sakri; Interviewed at CIMS.

ChandrikahadAntenatalCareatherlocalAnganwadiCentre,but she never received counselling or information aboutcontraception.Shedeliveredathomewithhelpfromhermother.Themitanin told her about sterilization fifteen days before thecamp, but she did not receive any information about theprocedure. She traveledanhour to thecamp inanautowithfivepeoplefromthevillage–othercouplesandthemitanin.Shereceivedaconsentform.However,shedoesnotknowhowtoreadorwriteandnooneexplainedthecontentsofformtoher.Next,thehealthworkerstestedherblood,bloodpressure,andurine.Anursegaveherfiveinjections.Duringthesurgery,sheremembersseeing something “pulledout”of herbody. Themedical teamchattedwithChandrikaduring the surgery todistracther fromthe pain. After, male health workers transferred her to a bedforstitches.About30minutes later,shewokeuponthefloor inpain.AhealthworkergaveherhusbandtwomedicinesandRs.600/-. Shedidnot receivedocumentationof the sterilizationorpost-operative instructions.When she reachedhome, she tookthemedicinewithtoastandteaandfeltfine.Shevomitedonce,on theway to thehospital,after theStateGovernmentcalledallcamppatientsinfortreatment.Shefeelshealthynowandislookingforwardtoreturninghome.

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7. Interviews with families of the deceased

1. gunyari Village. Deceased: Shivkumari, aged 27. 3 children, ages 4 years, three years, 6 months. Husband: Bahorik. Camp: Sakri

The mitanin told Shivkumari about the sterilization camp onseveraloccasions,butneverdiscussednon-permanentformsofcontraceptionwiththefamily.AfewdaysbeforethecampinSakri,themitanincametoherhometoencouragehertoparticipate.Shivkumari and her mother went to the camp together. Theyreached home around 8pm. Shivkumari felt tired post surgery,but shedidnot vomitorcomplainofgreatpain. She took themedicineat9pmandbeganvomitingat11pm.Inthemorning,shewenttothegovernmenthospital(PHC).ThePHCreferredhertoCIMSwhichinturnreferredhertotheprivatehospital,Apollo.The family reached Apollo around 9pm. Shivkumari died dayslateratApolloon12November2014.Thefamilydidnotreceiveacopyofthedeathcertificateoranofficialcauseofdeath.ThefamilyreceivedacheckforRs.2lakhandthefamilytoldtheteamthattheywouldreceiveanadditionalRs.2lakh.Bahorikdoesnothaveabankaccount.Helivesinajointfamilyandhisrelativeswillbeabletoassistincaringforthethreechildren.

TheteamalsometwithShivkumari’ssister-in-law.Sheis24yearsoldandhas threechildrenofagesfiveyears, threeyears,andeight months. She delivered two children in the hospital andreceivedherincentivepaymentsundertheJSYscheme.

Shivkumari never received counselling or information aboutcontraceptivesduringherantenatalcarecheck-upsordeliveries.ShewenttoasterilizationcampinJulyorAugust2014.Themitanintold her about the camp, where over one hundred womenturnedupforsurgery.Shesignedhernametotheconsentform,but shedidnot know thecontentsof the form. Shehadbasictestsandreceivedherfiveaesthesiashotswhilelyingonthefloor.Sheremembers“everything”fromthesurgeryincludingthatshesawthedoctor“pullssomethingout”andthatthewholesurgerylasted five minutes. When she woke up after the surgery shewas inextremepainandrecoveringonthefloor.Shereceived

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twomedicinesandRs.500/-asinincentivepayment.Sheneverreceived any post-operative instructions, information on theFamilyPlanningInsuranceSchemeorproofofsterilization.

2. Dhanauli Village. Deceased: Chaiti Bai, aged 22. Two children, ages 6 years and 7 months. Husband: Budh Singh. Camp: gaurella.

ChaitiBailivesthreehoursfromtheDistrictHospital.Shedeliveredherfirstchildathomeandhersecondatthehospital,forwhichshe receivedRs.1400/-under theJSYscheme.Shedidnotuseanycontraceptionbetweenpregnancies.Thefact-findingteaminterviewedherfamilyincludingherhusbandandsisterandsomeneighbours.Onthedayofthecamp,ChaitiBai’shusband,BudhSingh,wentintothefieldtoworkwhenthemitanincametothehousetospeakwithChaitiBai.Themitaninhadneverbeentotheirhomebefore.ChaitiBaihadbeensickwithjaundiceforamonthand themitanin told her that shecouldgo to theCommunityHealth Centre for treatment. The mitanin never mentionedsterilizationorfamilyplanningduringthisvisit.

Chaiti Bai, her husband,and themitanin travelled to theCHCtogether in an auto, bearing out-of-pocket expenditure. Theyreached theHospital at 3pm.Chaiti Bai’s husband receivedablankformtosign.Bothcouldreadandwrite,buttherewasnotextontheconsentform.Hesignedtheformforhertreatment,without understanding that his wife was going to be sterilized.Afterhesignedtheformhehadtowaitoutsidewithotherfamilymembers.A fewhours later, themitanan toldhim togo insideandretrievehiswife.Hewent intoaroomwithwomenalloverthefloor.Hiswifewassemi-conscious.Ahealthworkergavehimsomemedicineandtoldhimtogiveherthemedicineswithfood.Hedidnotreceiveadditionalinstructions,proofofsterilization,oranincentivepayment.

After the surgery, Chaiti Bai stayed with her mother. She hadtea,biscuits,andthemedicinearound10pm.Inthemorningshetookthemedicinesagainandherhusbandmadesureshefeltwellbeforehewent towork. Thenextday she returnedhomeandbytheeveningshebeganvomiting.Thefollowingdayshe

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wenttotheCommunityHealthCentrewhereshehadanIVdrip.ShelostconsciousnessandthedoctorreferredhertotheDistrictHospital in Bilaspur (a three hour drive). They reached Bilaspurthatevening.Intheambulance,ChaitiBaiwokeupandstartedcomplainingaboutchestpains.Shortlythereafter,stillenroutetoBilaspur,ChaitiBaidied.BudhSinghreceivedacheckforRs.2lakhfromthegovernment,buthedoesnothaveabankaccount.Hedoesnothavefamilymemberstohelphimwithhischildren.HeearnsonlyRs.60-70aday.Hewantsjusticeforhiswife’slifeandasecurefutureforhischildren.

3. Lokhandi Village. Deceased: Dularin, aged 24. Two children, ages 4 years and 2 months. Husband: Dinesh. Camp: Sakri.

Dularinhadantenatalcarecheckupsduringbothpregnanciesand delivered both children at home. Two weeks before thecamp,themitanincameandtoldwomenathervillageaboutthecamp.She informedthemthat itwasbest tohaveasmallfamily.Onthedayofthecamp,womenfromthevillagetravelledtothecampintwoautos.EachpersonpaidRs.100/-.Whentheyreached thecamp,amale healthworker filledout a consentformforthehusbandandwifetosign.NeitherDularinnorDineshknewhow to readorwrite, but they knew itwas some sort ofconsentform.Dularin’shusbandwaitedoutsideforsixhours.Hethoughtthefacilitywasfilthyandworriedabouthiswife’ssafety.He told the team, “Therewere no facilities for thewomen, noplacefor themtositor liedown”.Fivehours laterhetooktheirbabyintothehospitalsoDularincouldbreastfeed.Shewalkedtotheauto,buthesawmalehealthworkerscarryingotherwomentotheautos.Hereceivedoneweek’sworthofmedicineandahealthworkertoldhimtogivehermedicineinthemorningandatnight.Hedidnotreceiveproofofsterilizationoradditionalpost-operativeinstructions.

Themitanin visitedDularin at homeandgave her tablets. Shedidnotexperienceanysideeffectsfortwodaysafterwhichshestartedvomiting.Onthemorningof10November,shewenttoCIMS.ThatnighttheSarPanchreceivedamessagetosendallwomenfromthecamptoCIMS.DularinlefttheICUatCIMSforaprivatehospital,Kims,whereshelaterdied.CIMSconducteda

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post-mortem,butthefamilyneverreceivedacauseofdeathoradeathcertificate.Politicianshavevisitedthefamilyandpromisedtocare forDularin’s children. Fivewomen from LokhandiwerestillatApolloHospitalinseriousconditionwhentheteamvisitedDularin’sfamily.

4. Chichirda Village. Deceased: Janaki, aged 24. Three children: ages 7 years, three years, and nine months. Camp: Sakri.

Janakiwasthefirstwomantodieasaresultoftheunsafeandunethical sterilizationcamp in Sakri. Both sheandherhusbandworkas labourers. Theybelong to ScheduledCaste. The teamspokewithJanaki’smother, family,neighbours,and thevillagePanch.Janakiwasa24yearoldmotherofthreechildrenagedsevenyears,threeyearsandninemonths.Shehadheardaboutthecampjustdaysbefore.Themitanindidnotprovidedetailedcounselling about the surgery; she only told her that doctorsadvisedwomen to have this surgery “once you have enoughchildren”.Janakitravelledtothecampwithherhusbandonhismotorcycleand themitantinand Janaki’smother travelledbyauto.Theyreachedthefacilityatnoon.Janaki’smotherdoesnotknowifshereadtheconsentform.Thegovernmenthealthworkerstookher for tests,butnooneexplained the testsor the results.Shewasinsidethefacilityfortwohours.Janakiwasunconsciousonthefloorwhenhermothersawherafterthesurgery.AnursegaveJanaki’smothermedicinebutdidnotprovidesterilizationdocumentationoradditional instructions. They receivedRs.600andspentRs.300foranautototheirvillage.

They reached home at 7pm on 8 November 2014 (Saturday)evening.Janakifeltdizzyandnauseatedaftershereachedhome.Shefeltworsethenextevening.Onthemorningof10November,herfamilycalleda108ambulanceandtravelledtotheDistrictHospital.Thehospitalputheronadripandshediedat8:30amonthe10th.TheHospitalwantedtodoapost-morteminvestigation.Janaki’smotherdisagreedandaskedthem,“whywouldyoucutheropenwhenyouknowshediedbecauseofthesurgery?”Butthehospital insistedandperformedthepost-mortemaround10am.Atnoon,otherwomenfromthesamecampstartingarrivingat the district hospital. The family received a death certificate

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and left theHospitalat 2pm. Theyhave receivedRs. 4 lakhascompensation.Hermothertoldtheteamthatshehaslostfaithinpublichospitals:“Theykilledmydaughter,nowIwon’tgoagain.”

5. ghuru Village. Deceased: Neem Bai, aged 37. Five children, ages 18, 14, 10, 8, and 3 months. Camp: Sakri.

NeemBaiwenttothecampwiththemitanan.TheteamcouldonlyspeaktoNeemBai’sbrother,andhedidnothavefulldetailsof thecamp.Hetoldtheteamthatafter thecamp,NeemBaifeltveryweak.Twowomenhadtocarryherintothehouseafterthecamp.Shetookhermedicinesasprescribedwithsometeaand bread.OnMonday (10November), themitanan came tothehouseandgaveheraninjection.Shetookhernextdoseofmedicine and immediately started vomiting. The family calledthe 108ambulanceandanauto. Theautoarrivedbefore theambulanceandby the time they finally reachedCIMS,NeemBaiwasunconscious.ShediedaboutanhourlaterintheICU.ThefamilyreceivedtwochecksforRs.2lakhs.

6. Nirtu Village. Deceased: Ranjita, aged 25. Three children, ages 7, 3, and 2 months. Husband: Santosh. Camp: Skri

ThemitanincametoRanjita’shomeafewdaysbeforethecamp.ShetoldRanjitathatsheshouldattendthecampbecauseshealreadyhadthreechildren.Ranjitaleftforthecampwithfourotherwomen fromthevillage inanautopayingRs.200/-per family.BothRanjitaandherhusband,Santosh,signedaconsentform,butneitherofthemhadtimetoreadtheform.Santoshwaitedoutsidefortwo-threehours.Thedoctorcampat3:30andlater,hesawtheworkersatthecampplacingwomenonthefloorforrecovery.WhenSantoshwentintothehospitaltocollectRanjita,shewas in pain. She received Rs. 600/- andmedicines but nopost-operativeinstructionsoracertificateprovinghersterilization.TheyleftthecampwhenRanjitaregainedconsciousness.

They reachedhomeat 7:30pmand she took the tablets andvomitedjusttenminutesafter.Shecontinuedtovomitandcalledthedoctorhomethenextmorning.Whenshecontinuedtovomitfor another 48 hours, the doctor called the 108 ambulance.

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RanjitadiedonthewaytotheCIMS.ThefamilyreceivedacheckforRs.2lakh,buttheydonothaveabankaccount.

8. Facilities & Health Workers

1. CHC gaurella:

This Community HealthCentre conducts camps twice aweektomeet itsgoalof800femalesterilizationsperyear.Thefacilityconditionsareextremelyunhygienic.InviolationofIndianPublicHealthStandards,thefacilitydoesnothavespecialistsorabloodstorageunit.

Thebedsinthematernitywarddonothavesheets.EveryMondayandThursdayabout10-20womenvisittheCHCforsterilization.AsurgeonandanOT technician travel to the facility toconducttheoperations.Thedoctorsatthefacilitytrytoplacewomenonbedsforrecovery,butifmorethaneightwomenshowupforthecamps-whichisalmostalwaysthecase-theyhavetorecoveron the floor. Everymonth, at least two or threewomen returnto the facilitywithproblems related to their sterilization surgery.ChaitiBaidiedafterundergoingsterilizationatthisfacility.AfterthecampshecametotheCHCvomitingandshowingsignsofshock.ThedoctorattheCHCreferredhertotheDistrictHospital,overthreehoursaway.Shediedintheambulanceonthewaytothecamp.

Thefacilityusuallyreachesabout60-70%ofthetargetsterilizations.When they do not meet the target, the doctors receive areprimandfromtheseniorsandashowcausenotice.

2. Nemichand Jain Hospital and Research Centre

Thishospital,where the sterilizationcampon8November2014tookplace,hasnotbeenregularlyusedasamedicalfacilityforyears.Communitymembersreportthatthegovernmentusesthefacilityforsterilizationcampseveryfewyears.Otherwise,it isanabandonedbuilding.Thefacilitydoesnothaveregularcleaning.

Authorities sealed theOT,but the fact-finding teamcouldseetheopenroomwherethewomenrecoveredthroughthedoors;

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theroomdidnothavebeds.Oldequipment,pilesofwaste,andrustingfurniturelitteredthehallsofthefacility.TheHospitaldoesnothaveemergencyequipment.

3. Mitanin, Chichirda Village.

ThisMitanandidnotwanttogivetheteamhernamebecauselocalofficialshavetoldhernottospeakwithoutsiders.Shegivesinfants polio drops and takes women for antenatal checkups.Her seniors have told her to tell women that small families arebest.Shedoesnothaveaccesstocondomsormala-D.Peopleare afraid that these non-permanent forms of contraceptiondamagetheuterus.Themitananalsohadasterilizationsurgeryinsimilarconditions.Shetoldtheteamthatitiscompletelynormaltoconductsomanysurgeriesinasinglecamp.Ifwomenaskheraboutsterilizationnow,shewillsendthemtothedistricthospital.Shewillneversendawomantoasterilizationcampagain.

4. Mitanin, Lokhandi Village

TheMitaninhashadmuch trainingon familyplanning,but shedoesnotknowaboutnon-permanentformsofcontraception.Inherwork, sheworksmostly togetwomenaccess toAntenatalCareandsafedeliveryservices. Ifawomanhasthreechildren,themitanin will tell them to undergo sterilization. She says theconditions“arealwaysthesame”.Afterthiscamp,shereceivedmedicines for thewomen.When thewomen started vomiting,shecalledtheANM,whocametothevillageandcheckedthewomen’sbloodpressure.FivewomenfromthisvillageendedupatApolloHospitalincriticalcondition.

5. Mitanin, Chorbati Village

On1stNovemberahigh-levelgovernmentofficialheldameetingwithmitaninswhere he told them that they shouldeachbringthreewomeninforthenextsterilizationcampsotheycouldmeettheir1 lakhsterilization target.Themitaninbrought fourwomenin for the surgery. She does not have any information on theprocedureand shehasnever received trainingoncounsellingwomen.Onceawomanhas twochildren, themitantin tries to“forcethem”togoforsterilization.Ofthefourwomenshebrought

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forthesurgery,threeareincriticalconditionatApollo.Shetoldtheteamthatthesamebadconditionsexistatallcamps.Afterthisexperience,shestatedthatshewillneverbringawomantoasterilizationcampagain.

Recommendations

In the wake of this tragedy, the fact-finding team urges theSupremeCourtofIndiatopassthefollowingorders:

1. Ensure access to justice for all women who have sufferedfundamental rights violations at camps in Bilaspur. Womenshould receive compensation for undignified and unsafemedical care. Provide all women with documentation ofsterilization, information on the Family Planning IndemnityScheme,andinstructionsforaccessingfree,qualitymedicalcareforfuturepotentialmedicalcomplications.

2. Ensure access to justice for families of the deceased. Inadditiontofinancialcompensation,theStateshouldensurealong-termcareplanforthechildren,employmentguaranteesfortheparentsorprimarycaregivers,andaccesstoadequatenutrition,especiallyforinfants.

3. Ensure transparency during all investigations and JudicialInquiryCommissioninvestigation.PostfindingsontheStateNHMwebsite.Createpostsforthreecivilsocietyrepresentativesontheinvestigationteam.TheUnionofIndiashouldalsoprovideamemberfortheinvestigationteam.

4. End sterilization camps. All public facilities with operatingfacilities, sufficient beds, adequate staff, appropriateequipment,andexemplaryhygienestandardscanconductfixedday sterilization services. TheState shouldprovide freetransportation to fixed day services where maximum 30womenwillundergosterilizationpertheStandardOperatingProcedure.TheChiefMedicalOfficerwillobserveallfixeddaysterilization services to ensure compliance with SterilizationGuidelinesandrespectforfundamentalrights.

5. Endinherentlycoerciveandineffectivesterilizationtargets.

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6. ImmediatelyestablishaQualityAssuranceCommitteeattheStateandDistrict Levels. TheDQACmustundertakeQualityAssurancemeasuresoutlinedinMinistryofHealthandFamilyWelfare guidelines, take action for those responsible forguidelinebreaches,andreportregularlytotheStateQAC.

7. Rolloutastate-widetrainingprogrammeformitaninsandallfacility staffonallcontraceptives,counselling, theStandardOperatingProceduresforSterilizationServices,andwomen’sentitlements under the National Health Mission, FamilyPlanningIndemnityScheme,andConstitutionofIndia.Involvecivil society members including representatives from thePopulationFoundationofIndia(PFI)andNationalAllianceforMaternalHealthandHumanRights(NAMHHR)inthistraining.

8. Createposters in local languagesoutlining theguidelines inthe Standard Operating Procedure for Sterilization Servicesandposttheseinallgovernmenthealthfacilities.ThepostersshouldincludeafreenumbertotheDQACthatwomen,healthstaff or familymembers cancall or SMS to report guidelinebreaches.

9. Immediately fulfil the posts for specialists, especiallygynaecologists and obstetricians and nurses throughoutChhattisgarh.

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9. The Way Forward for India’s Sterilization Programme

Ashasbeenestablished,sterilizationinIndiaisamajorissueandoften there is a complete lack of oversight and responsibilityamong those who are charged with providing these services,including the State and other healthcare professionals. India’sfamily planning programme has unwisely placed sterilizationat the centre of population control measures. Callousness,negligence,andapathyhasledtothispolicyresultinginseveralhuman rights abuses and the deaths of many women. If thegovernmentcontinuestopromotesterilizationitmustbeensuredthattheseproceduresaresafe,consensual,upholdthedignityofthepatient,anddonottargetcertaingroups.

Unfortunately,however,thedeplorableconditionsexistingpriortotheorderoftheApexCourtintheaforementionedcasecontinuetoprevailtoday.EvidenceoftragediesinBiharandChhattisgarh,merelytwoexamplesinacatalogueofothertragedies,confirmtheassertionthattheState’sbarbaricandinhumanepracticeofenforcedsterilizationcontinuestoviolateeveryreproductiverightofmenandwomen.Theconstitutionof Indiabarsendangeredtribes such as Baiga Tribe from undergoing family planningmeasures. This has forced women from these communities totravel todifferentstatefor illegalsterilizationoutofdesperationwhentheyenduphavinglargefamiliesthattheycannotsupport.Sterilizationcanbea viable, valuableoption if it ismade safeandnon-coercive,providingqualityservicesandupholdingthedignityofwomen.

Sterilizationmaybeasolutiontoaboomingpopulationgrowth,butitisadrasticone,asolutionthatmustbedrivenbyinformedchoice rather than calculated coercion and targeting. Evenwhere it isdoneonpeoplewhowillinglycome forward for the

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The Way Forward for India’s Sterilization Program

procedure,sterilizationhasbeenknowntobedoneinthepoorestofconditions,endangeringthelifeandhealthofoneandall.

Illegal sterilization surgeries continued to be conducted in thevarious states and Union Territories of India in unhygienic andunethicalconditionsevenaftertheorderoftheSupremeCourtdated 1.1.2005 in thecaseofRamakant Rai vs Union of India.In response to thisviolationof fundamental rightsprotectedbyArticle21,Article14andArticle15of theConstitutionof India,Human Rights LawNetwork andDevika Biswas sought specificdirectionsfromtheSupremeCourt.

1. The system of ‘sterilization camps’ should be struck down.Delicateproceduressuchastubectomyandvasectomymustnotbeconducted inmakeshift facilities setup in schoolsorabandonedhospitals.Itshouldonlybeallowedinaccreditedmedical health care centers. Also, the persisting culture ofsterilizing people en masse should be avoided to keep areasonableworkloadontheserviceproviders.

2. TheState should take responsibility for theexistenceof low-level targets set by medical authorities at the state anddistrictlevel.TheStateshouldalsodeclaresterilizationtargetsas inherentlycoerciveandinviolationoftherightstobodilyintegrity,individualautonomyandhealth.

3. AllStatesandUnionTerritoriesshouldimplementinletterandspirit Standard Operating Procedures for Female andMaleSterilization (2006),QualityAssuranceManual for SterilizationServices(2006),StandardOperatingProceduresforSterilizationServices inCamps(2008) issuedbytheGovernmentof IndiaafterthedecisionofthisCourtinRamakantRai’scaseinorderto ensure that poor women in rural areas are treated withrespectanddignitywhentheyundergosterilizationoperations;

4. QualityAssuranceCommitteesshouldbesetupatStateanddistrictlevelstoensurethatthebasicstandardsofhygieneandmedicalproprietyaremaintainedwhereversuchsterilizationservices are being provided. This will help strengthen theimplementation and monitoring of the family planningprogramme.

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5. Ensure that women are made aware, in a language thatthey clearly understand, of all available methods of familyplanning,of thefact thatsterilization ispermanentandthatwomenunderstandwhathappensbefore,during,andafterthe surgery, its side effects, and potential complications,includingfailure.

6. Ensurethatwomenmakeaninformeddecisionforsterilizationvoluntarily,areencouragedtoaskquestionsandaretoldthattheyhavetheoptionofdecidingagainsttheprocedureatanytimewithoutbeingdenied their rightsorother reproductivehealthservices.

7. Ensure that all pre- procedure clinical assessments as persection1.4.2,includingdemographicinformationisrecorded,each patient’s medical history is taken and that everywoman has physical examination including blood pressure,pulse, pelvic examination, and laboratory examinations forhemoglobin,sugar,aluminumandpregnancy.

8. Ensurethatconsentisnotobtainedundercoercionorwhenthe client is under sedation, and that the client signs thesterilizationconsentformbeforethesurgery.

9. Ensure that all sterilization camps are organized only inestablishedHealthCareFacilities-eitherCHCsorPHCs.Andthateachsurgeonisrestrictedtoconductingamaximumof30 laparoscopic tubectomies, 30 vasectomies or 30minilaptubectomiesor50surgeriesperdaywithadditionalsurgeons,supportstaff,instruments,equipment,andsupplies.

10.Surgeons and gynecologists should verify that each clienthas been adequately counseled and screened, by fillingoutachecklistbeforeconducting theprocedure. Requisiteequipment, instrumentsand supplies, aswell as emergencyandsurgicalproceduresshouldbeprovided.Post-operativeinstructionsontherecordsofallcasesshouldbedocumented.

11.Ensure that all post- operative procedures are followed, inparticulartheclientismonitored,theclientisonlydischargedat least4hoursaftertheprocedurewhenthevitalsignsarestableandtheclientisfullyaware,haspassedurineandcanwalk,drinkandtalk,andtheclienthasbeenevaluatedbyadoctor.

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The Way Forward for India’s Sterilization Program

12.ThestateshouldalsoensurethatASHAworkersfollowupwithclients48hoursafter surgeryandwomenshould report toahealthfacilityaftersevendaystohavetheirstitchesremoved.

13.To have increased and active involvement of civil societymembers by including civil society members in the StateQuality Assurance Committee for monitoring and trainingmechanism.

14.Thestateshouldpublicizeonradioandtelevisionthecontentof the orders passed by the Supreme Court in RamakantRai case and information about family planning insuranceschemes. Further, the medical authorities should providedocumentationofsterilizationproceduresdonetothefamiliesofthedeceasedoranyoneincapacitatedbytheprocedure.

15.The focusof familyplanning in India shouldbebroadened.Thebudgetsforsterilizationservicesshouldbecutandinsteadmust be pooled in a larger campaign for spreading familyplanningawareness inthesociety,especiallyamongstmen.Peopleshouldbemadeawareofalternativefamilyplanningoptions.

16.ThestateshouldbedirectedtoprovideRs.1lakhcompensationto the 68 surviving women who underwent sterilization atSakrion8thNovember2014andthe53womenwhosurvivedsterilizationatGaurella,MarvahiandPendraon10November2014.

17.TheStateshoulddevelopalongtermcareplanforthechildrenof the sixteen deceased women and any other womenwho die as a result of these camps including employmentguarantees for the primary caregivers, access to long termadequatenutrition,freehealthservices,andeducationuptocollegeforthechildren.

18.Thestateshouldrolloutastate-widetrainingprogrammesformitanins,ASHAsandotherfacilitystaffonallcontraceptives,counselling, the Standard Operating Procedures forSterilizationServices,Women’sentitlementsundertheNationalHealthMission, the Family Planning Indemnity Scheme, andthe judgmentsof theCourts of India,and in these trainingsto consult and involve civil society members including

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representativesfromthePopulationFoundationofIndia(PFI)andNationalAllianceforMaternalHealthandHumanRights(NAMHHR).

It is important that ministry of health and family welfarebe encouraged, to promote gender equity in the family-planningprogrammespointingtowardstheintroductionandavailability of a greater number of contraceptive choicesforbothmenandwomenandgreaterparticipationofcivilsociety organizations in delivering quality family-planningservices. Family planning is not just about women but alsoaboutmenandtheneedfor their increased involvement inthefamilyplanning.Itmustbehighlightedinourprogrammesthatthesterilizationprogrammecannotbeprimarilytargetedtowardswomenbutmustalsoactivelyincludemen.

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10. SUMMARy OF THE JUDgMENT

In Devika Biswas Vs Union of India114 the honorable SupremeCourtof Indiapassedamuch-awaited landmark judgmentonthe14thSeptember2016.The judgmentconcludedafive-yearlongfightagainstthemasssterilizationdrives.Thejudgmentnotedthatevidenceofpoorqualityofcareduringsterilizationcampsleadingtodeathsinseveralcaseshasbeenreportedfromotherstates includingChhattisgarh, Uttar Pradesh, Kerala, Rajasthan,MadhyaPradeshandMaharashtraduringthecourseofhearing.

Thecivilsocietyorganizationshavewelcomedthejudgmentasitcallsforstrengtheningofhealthsystem,toimprovethequalityof careof the Family Planningprogrammeandaccountabilityofgovernment.TheSupremeCourtrecognizeddeaths,failures,complications and coercion as a result of female sterilizationhaveimplicationsforwomen’sRightstolife.

1. Thejudgmentdirectsthegovernmenttophaseoutcampapproach in next three years and instead strengthenhealthfacilitiesforbetterservices.

2. Coercive methods are not justified and are not eveneffective in meeting the goals of population control.Improved access, education and empowerment shouldbetheaim.

3. OneofthefundamentalerrorspointedoutbytheSupremeCourtwasthatUnionofIndiainmanyofitaffidavitsstressedthat“implementationofsterilizationprogrammeisastateconcern”asitispublichealth”issueaspertheEntry6ofListIIintheSeventhSchedule(theStateList)oftheConstitution.However the Union of India completely overlookedthe more appropriate Entry 20A in the Concurrent List,

114DevikaBiswasVsUnionofIndiaandOthers(WritPetition(Civil)No95of2012)

Summary of the Judgment

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“Population Control and Family Planning” (Constitution(Forty-second)AmendmentAct,1976).AspointedoutbytheSupremeCourt,populationcontrolandfamilyplanninghasbeenanationalcampaignovermanydecades.TheUnionof Indiahas takengreat interest inpromotingandhas spent largeamountsofpublic fundsencouraging it.Hence,theSupremeCourtorderedthatUOIshouldtreatthe sterilizationprogrammeasapublichealth issue,andnot leave it to the stategovernments. Thecourtpointedout that thegovernmentof theUnionof Indiamust takeownership of the family planning programme, whichis included in ‘Concurrent List’ of the Constitution. Theresponsibilityofsuccessandfailureofthefamilyplanningmust rest squarelyon the shouldersofUOIand itcannot‘passthebuck’tothestategovernment.

4. The judgment confirms the allegations that theoverwhelmingnumberofsterilizationproceduresistargetedtowardswomenandthereisvirtuallynoattentionpaidtomalesterilization.

5. Contents of the checklist should be explained to theproposedpatientinalanguagethatheorsheunderstandsand the proposedpatient should also be explained theimpactandconsequencesof the sterilizationproceduretoavoid‘incentivizedconsent’.

6. StateGovernmentandUnionTerritorytoensurethattargetsarenotfixedforhealthworkerswhichamounttoaforcedornon-consensualsterilization.

7. Quality Assurance Committees at the State and DistrictLevelshouldpublishdetailsofcommitteemembersonthewebsiteoftheMinistryofHealthandFamilyWelfareaswellasthecorrespondingMinistryorDepartmentofeachStateGovernmentandeachUnionTerritory,inabi-annualreportcontaining the number of persons sterilized, the numberof deaths or complications arising out of the sterilizationprocedure, non-statistical information in the form of a

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reportcardindicatingthemeetingsheld,decisionstaken,workdoneandtheachievementsoftheyearetc.

8. Regular audits to be conducted of failures and deathsandAnnualReportsoftheQualityAssuranceCommitteesmustincludedetailsofsuchauditsheldandremedialstepstaken.ThefirstAnnualReportsshouldbepublishedbeforeMarch312017.

9. The quantum of compensation fixed under the FamilyPlanningIndemnityScheme(FPIS)deservestobeincreasedsubstantiallyandtheGovernmentof IndiaandtheStateGovernmentthereofmustequallysharetheburden.

10.The SupremeCourt declared it to bemore than a pity,foracountry tonothaveanyhealthpolicy. ThedraftofaNationalHealthPolicy,2015wasputuponthewebsiteon the Ministry of Health and Family Welfare of theGovernment of India in December 2014 for comments,suggestionsandfeedbackbutevenaftermorethanoneandahalfyears,thewebsiteofthesaidMinistryshowsthattheNationalHealthPolicyhasnotbeenfinalized.HencethecourtdirectedUnionof India to finalize theNationalHealth Policyonorbefore 31stDecember 2016 keepingissuesofgenderequityinmind.

Summary of the Judgment

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11. CONCLUSION

The Indian Government’s efforts toward population controlthroughsterilizationsareill-informedandbaseduponapatriarchalstructurewhichdoesnottakeintoaccountimportantintersectionsofgender,socio-economicstatus,orgeographicallocation(ruralorurban)ofthepeopleuponwhichthepoliciesareimplemented.BymappingthecoursethroughwhichtheFPPinIndiacameintobeing,onecanseethat ithas its roots intheMalthusiantheoryof population growth and control. Many countries includingthecountryitoriginatedin,havenegatedthetheoryandhavegoneforamorehumanisticapproachtowardsfamilyplanning,focusingmoreoneducationand spreadof information,aswehave seen in the chapter dealing with international rules andregulations regarding sterilizationand familyplanning. Inpolicyandinpractice,sterilizationeffortstargetpoorwomenforunsafeprocedures, rarely with informed consent. Unable to makedecisiononherown,withlittleornocontroloverherbody.Policymakersseeherastheveryreasonofpopulationgrowth.Further,herstatusintheIndiansocietymakeshertheperfectscapegoatfor the vertically implemented family planning programme,which is solely focusedon sterilizationgiving littleweight to theabilityofwomentouseotherformsofcontraception. Incentiveschemesforsterilizationalsotargetpoorwomen,givingthemlittlechoicewhentheymustchoosebetweensterilizationandsurvivalofthemselvesandtheirfamily.

TheIndiangovernmentmustmoveawayfromitscurrentquota-basedsystem,whichincentivizeshasty,unsafesterilizationsliketheonesthatkilledsomanywomeninChhattisgarh.Thegovernmentshouldinsteadfocusonprovidingwomenandmenaroundthecountrywithafullrangeofsafecontraceptionchoices,includingbutcertainly not limited to sterilization. Thegovernment shouldrework the incentive scheme so that it encourages bothmenandwomentopartakeinfamilyplanning.Anyincentivescheme

musttakeintoaccountthedesperationofmany,especiallypoor,women.Measuresshouldalsobetakentoeliminatequotas forsterilization, which encourage coercion and force to be usedagainstdisadvantagedpeoplebyhealthworkers.Thiswillhavethe additional, indirect effect of improving damaged relationsbetweenhealthworkersandpatients.

Empoweringwomentochoose ifandwhentohavechildren isessential toaddressingsocial issues thatplague India.Coupledwithincreasedawarenessandeducation,thegovernmentmustaddressmanyissuesarisingundertheblanketofoverpopulationsuchashighratesofpovertyandmaternaldeaths. Ithasbeenshownthatimprovingliteracyrates,forexample,reducesfertilityrates.115 Further as many field reports have shown, any suchprogrammerequiresintegrationfromthegrassrootslevel.ASHAworkersandANMsmustbetrainedproperlyandnotkeptintheconstant threat of losing their jobs due to unreached targets.Severaldiscreteissuesmustbeaddressed,suchastheprovisionofappropriatetechnology inordertopreventtheunnecessarydeathsandhealthissuescausedbyusingout-datedandunsafeinstruments,includingbicyclepumps.

The Indian government should work to improve educationregardingfamilyplanningandfamilyplanningresourcesaswellasimprovingrelationsbetweenhealthcare/familyplanningprovidersandtheirclientele. Inaddition,campaignstodestigmatizeandeducate thepeople of India about family planning should beaccompaniedbyacknowledgementofthepatriarchalsystem,which places the onus of childcare and domestic activity onwomen. The Indian government should address the fact thatwomenaresterilized,often-inunhygienicandunsafeconditions,somuchmoreoftenthanmen.Thegovernmentoughttolaunchcampaigns combatting harmful gender roles and challengesystemsofinequalityinIndia.Untilthesechangesoccur,womenwillcontinuetosufferatthehandsoftheverygovernmentthatismeanttoprotectthem.Thesehorrendousviolationsoftherightsofwomenmustend.

115How Female Literacy Affects Fertility: The Case of India.(1990).East West Center.Retrieved16February2018,fromhttps://www.eastwestcenter.org/fileadmin/stored/pdfs/p&p015.pdf

Conclusion

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12. ANNExURES

SUPREME COURT OF INDIA

RECORDOFPROCEEDINGS

WritPetition(Civil)No.209/2003

RAMAKANTRAI&ANR. Petitioner(s)

VERSUS

UNIONOFINDIA&ORS. Respondent(s)

Date:01.03.2005

CORUM:

HON’BLEMRS.JUSTICERUMAPAL

HON’BLEMR.JUSTICEARIJITPASAYAT

HON’BLEMR.JUSTICEC.K.THAKKER

UPONhearingcounseltheCourtmadethefollowing

ORDER

Several states have filed affidavits setting out the steps takenby them to regulate sterilizationprocedureswith regard to themaleandfemalepatientsintheirrespectivestates.However,itisapparentthatthereisnouniformitywithregardtotheproceduresnorthenormsfollowedforensuringthattheguidelineslaiddownbytheUnionofIndiainthisregardarebeingfollowed.Takingthebestofwhatisbeingfollowedbysomestates,wedirectthattheStatesshall:

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Annexures

1. Introduceasystemofhavinganapprovedpanelofdoctorsand limiting the persons entitled to carry on sterilizationprocedures in the State to those doctors whose namesappear on thepanel. Thepanelmaybeprepared state-wise, District-wise or Region-wise basis. The criteria forincludingthenamesofthedoctorsonsuchpanelmustbelaiddownbytheUnionofIndiaasindicatedsubsequently.Until the Union of India lays down uniform qualificationcriterionfortheempanelmentofdoctors,forthetimebeingnodoctorwithoutgynecologicaltrainingforatleast5yearspostdegreeexperience shouldbepermitted tocarryoutthesterilizationprogrammes.

2. The StateGovernment shall also prepare and circulate achecklistwhicheverydoctorwillberequiredtofillinbeforecarrying out sterilization procedure in respect of eachproposedpatient.Thechecklistmustcontainitemsrelatingto(a)theageofthepatient,(b)thehealthofthepatient,(c)thenumberofchildrenand(d)anyfurtherdetailsthattheStateGovernmentmayrequireonthebasisoftheguidelinescirculated by the Union of India. The doctors should bestrictlyinformedthattheyshouldnotperformanyoperationwithoutfillinginthischecklist

3. ThestateGovernmentsshallalsocirculateuniformcopiesoftheproformaofconsent.UntiltheUnionGovernmentcertifiessuchproforma,forthetimebeing,theproformaasutilizedintheStateofU.P.,shallbefollowedbyalltheStates;and

4. Each States shall set up a Quality Assurance Committeewhichshould,asbeingfollowedbytheStateofGoa,consistof the Director of Health Services, the Health Secretaryand theChiefMedicalofficer, for thepurposeofnotonlyensuringthattheguidelinesarefollowedinrespectofpre-operativemeasures (forexample,bywayofpathologicaltests, etc.), operational facilities (for example, sufficientnumber of necessary equipment and aseptic conditions)and postoperative follow ups. It shall be the duty of theQuality Assurance Committee to collect and publish sixmonthly reportsof thenumberofpersons sterilizedaswell

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asthenumberofdeathsorcomplicationsarisingoutofthesterilization.

5. EachStateshallalsomaintainoverallstatisticsgivingabreakupofthenumberofthesterilizationscarriedout,particularsoftheprocedurefollowed(sincewearegiventounderstandthattherearedifferentmethodsofsterilization),theageofthepatientssterilized,thenumberofchildrenofthepersonssterilized,thenumberofdeathsofthepersonssterilizedeitherduringtheoperationorthereafterwhichisrelatabletothesterilization, and the number of persons incapacitated byreasonofthesterilizationprogrammes.

6. The StateGovernment shall not only hold an enquiry intoeverycaseofbreachoftheUnionofIndiaguidelinesbyanydoctorororganizationbutalsotakepunitiveactionagainstthem.Asfarasthedoctorsareconcerned,theirnamesshall,pendingenquiry,be removed from the list ofempanelleddoctors.

7. The state shall also bring into effect an insurance policyaccordingtotheformatfollowedbythestateofTamilNaduuntil such time the Union of India prescribes a standardformat.

8. TheUnionofIndiashalllaydownwithinaperiodoffourweeksfrom date uniform standards to be followed by the StateGovernments with regard to the health of the proposedpatients,theage,thenormsforcompensation,theformatofthestatistics,checklistandconsentproformaandinsurance.

9. The Union of India shall also lay down the norms ofcompensation which should be followed uniformly by allthe states. For the timebeinguntil theUnionGovernmentformulates the norms of compensation, the States shallfollowthepracticeoftheStateofAndhraPradeshandshallpayRs.1lakhincaseofthedeathofthepatientsterilized,Rs.30.000/-incaseofincapacityandinthecaseofpost–operativecomplications,theactualcostoftreatmentbeinglimitedtoasumofRs.20,000/-.

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Annexures

AlltheStateshaverespondedexcepttheStateofJammuandKashmir.NeedlesstosaythattheStateofJammuandKashmirwillalsofollowthisorder.

Let thematterbeplacedeightweeks laterbywhich time theUnionGovernmentandStateGovernmentsshould indicatethestepstakenbythemincomplianceofthisorder.

USHABHADWAJ MADHUSAXENA

COURTMASTER

SUBMISSIONS OF THE PETITION IN DEVIkA BISWAS CASE (WRIT PETITION (C) NO: 95 OF 2012)

The Petitioner Described

1. ThePetitioner,DevikaBiswas,(MA,Econ.PGDip,PM&IR)isanativeofArariaandhasextensiveprofessionalexperiencein thedevelopmentandhealth sectors.Asahealth rightsactivistsshehasworkedinUttarPradesh,Delhi,Jharkhand,and Bihar. After she conducted a fact findingmission onsterilizationsinhernativedistrictofAraria,shefeltcompelledtofilethispetitiontoensurethatsterilizationsnation-wideareconductedasperthelegalnormsandtoseethatthevictimsinBiharreceivecompensationfortheirinjuries.

The Petition Summarized

2. In the Petition the fact finding report prepared by thepetitioner and by Mr. Francis Elliot of The Times, London,annexedatpage169onwardsreportsthemannerinwhich61womenweresterilizedon2.1.12undertorchlightatnighton the school desks. (15 onwards). The guidelines allowonly 30women tobe sterilizedwith three laparoscopes inaday.Theschoolwasusedwithoutauthorisation.AnNGOJai AmbeWelfare Society (R-4) was given a contract bytheState toperform the sterilizations. Atpage173of thePetition, it is stated that each operation was done withinaboutthreeminutes.Apregnantwomanwasalsosterilized.They fell unconscious. Someof thewomenwereprofusely

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bleeding.Thesurgeon left theplacewith theNGOstaff. Itissaidatpage174thatFIRswerelodgedattheKisrakantaPoliceStation.Noactionwastaken.Itisstatedatpage174onwards that themedicines used hadpassed their expirydates.

3. Despite this, government officials maintained that therewerenolapsesatall.(156,166,176).

4. Thefactfindingreportgivesdetailsofthestatementsmadebymembersofthepublic.(180onwards)Thepublic(about100localinhabitantsofKaparforaandnearbyvillages)gaveoralwitness toMr.Elliotand thePetitioner that theycametoknowaboutthesterilizationcamponlywhenthewomansterilized,motivatedbyallASHAworkersstartedpouring inthegovernmentmiddle schoolcampusofKaparfora,andtheorganizingaccreditedNGOworkerswereenlistingtheminthenoonof7.1.2012.

5. Thepresentmukhiyawantedtoknowfromthemthepackageofcompensation,thecandidateswouldreceivefromthemandtheysaidthatitisgoingtobefreemedicine.Forthefirsttime,thecashcompensationwasnotgiven,hence,publicwantedtoseetheofficeorderinthisregard.

6. According to thepublic,noarrangementsweremadebytheNGO. Thepaddy-strawwasbroughtby theguardiansof sterilized persons for night stay for their wards. Theoperation room (one of the classrooms) was not clean;the school desks (high benches) were used as operationtableswithoutanydisinfectedcovers.Noarrangementsforcandidates’disinfectionofclothes,orrunningwateroranyotherarrangements forpre-operativecounselling,physicalcheckup or any test took place. All women were givenanesthesia(byinjection)justbeforetheywerebroughtintheoperationroombytheuntrainedNGOyouths.Fourwomenwereoperatedin10minutestimeandthenextfourwomenwere sent in. No change of gloves by the doctor and alloperationstookplaceindimbulb lightandtorch light.Nopost-operative carewas given to thewomen. All womenstartedcryinginpainandsomewerebleeding.Buttheso-

261

Annexures

called doctor who came in same vehicle left the placeimmediatelyaftercompleting53operationswithoutvisitinganysterilizedwomen.TherewerethesesterilizedwomenleftatthecampinthecareofNGOworkerswhodidnotpayanyattentiontothecriesofwomeninthenight.

7. TheschoolAuthority:Theschoolincharge,Mr.DilipVermaandother teachers told thatnobodyasked forpermissionto use the school building for sterilization camp purposes.The roomwhere theoperation tookplaceandwhere thewomenspentthenightwerenotlocked.ItbeingaSaturday,theschoolstafflefttheschoolby11:30,sotheydonotknowabouttheincident.

8. Thestatementsofthesterilizedwomenwererecordedandissetoutatpage183onwardstotheeffectthattheywerenot counseled, they were not medically examined, thatthumbimpressionwastakenonablankconsentform,theyweremadetoliedownbleedingonthefloor,thenextdaytheywenttoprivatedoctorstoremovethestitches,andapregnantwomanwassterilized.Interviewswiththesterilizedwomenaresetoutfrompage191onwards.

Similar report regarding sterilizations in Maharashtra, Rajasthan, MP

9. AsimilarfactfindingreportdonebyagroupfromMaharashtratogether with photographs regarding the unhygienicconditionsunderwhichwomenwerebeingsterilizedinutterdisregardoftheRamakantRaiguidelinesistobefoundfrompage 203 onwards. The Rajasthan report is at pages 112onwardsandtheMPreportisatpage221onwards.

Reliefs sought in the petition

a. Issue amandamus or any other appropriatewrit order ordirection establishing a committee such as the NationalAllianceforMaternalHealthandHumanRights(describedin page 40). To investigate and submit a report within12 weeks regarding the facts stated in this petition andrecommendationsforadditionalguidelinesifnecessary.

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b. Issue an order awrit ofmandamus directing the State ofBihar to initiate departmental proceedings against theGovernmentofficials involvedinthesterilizationcampandthegrantingofpermissiontotheNGO(RespondentNo.4)tocarryoutsterilization.

c. Issue an order a writ ofmandamus directing the state ofBihartofileastatusreportinthiscourtregardingthecriminalproceedings instituted against the Government officialsand theNGO(RespondentNo.4)and thereafter, tomakeappropriateordersforthespeedytrialoftheoffenders.IssueanorderawritofmandamusdirectingthestateofBihartoderegister and debar the Respondent No.4 from carryingoutanypublichealthactivitiesincludingsterilization.

d. Issueanorderawritofmandamusdirectingalltherespondentsstates to, in all cases obtain the informed consent of thepatients in themannerprescribed inguidelines for femaleandmalesterilization(2006).

e. IssueanorderawritofmandamusdirectingalltheRespondentStatestofilethestatusreportontheimplementationofthiscourt’s directions in Ramakant Rai’s case as well as theGuidelines for FemaleandMale Sterilization (2006)and toensurethatboththeseguidelinesareadheredtothroughoutthecountry.

f. ForanorderdirectingpaymentofRs5lakhscompensationforeachofthe53womenwhoweresterilizedon7January2012 at Kaparfora Government Middle School, Jai Ambewelfaresocietysterilizationcamp.

No action taken by State of Bihar

10. Eventilltodaynoofficialhasbeenpunisheddepartmentally,nocriminalproceedingshasbeen instituted, theNGOhasbeen debarred but no action has been taken against itsmembersandnocompensationhasbeenpaid.

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Annexures

Post Ramakant Rai (I)

11. After the decision of the Supreme Court, Union of Indiapublished “Standards for Female and Male SterilizationServices(2006)atpage49ofthepetition,StandardOperatingProcedureforSterilizationServicesinCamps(2008)atpage142ofthecounteraffidavitofUnionofIndiadated13.4.15,Standards&QualityAssuranceinSterilizationServices(2014)page189of thecounteraffidavitofUnionof Indiadated13.4.15 and the “Manual for Family Planning IndemnityScheme”(2013)(Annexure42oftheofthecounteraffidavitofUnionofIndiadated13.4.15),andthe“ReferenceManualforFemaleSterilization(2014)”atAnnexure40of theof thecounteraffidavitofUnionofIndiadated13.4.15.

Standards for Female and MaleSterilization Services (2006)

12. Petitioner has annexed this Government of India manualat page 49 onwards. Thismanualwaspreparedafter thedecision in Ramakant Rai case. It provides, inter alia, forqualified doctors to be put on a panel (53), the physicalinfrastructure required(53,86), informedconsent (54),andthat thewomenshouldbemarried,bebetweentheagesof22–49yearsandhaveatleastonechildabovetheageof1year.Themanualsetsoutthenatureofcounsellingthatshouldbedonesothataninformeddecisioncanbemade.Inparticular,womenarerequiredtobeinformedofalltheavailable methods of family planning (55) and that theyhavetheoptionofrefusal(56).Theprocedureforsterilizationoperations is set out at page 57 onwards. This includesmedicalexaminationandmonitoringaftertheoperation(63onwards).Thepostoperativecarerequiresthatthewomanbekeptovernightatthefacility(67onwards).Itisstatedthatallfailuresofcomplicationsarerequiredtobedocumented(72)andthatcleanlinessbemaintained(73onwards),andthatsterilizationbedoneofneedles,linenetc.(80onwards).

Standard Operating Procedure for Sterilization Services in Camps (2008)

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13. This document lays down extensively the operatingprocedures to be followed in camps which includes thatcamptimingsshouldbebetween9amand4pm(151),that30 laparoscopic tubectomyoperations canbedone in aday for a team with three laparoscopes (151), and thatsterilization camps can be organized “only at establishedhealthcare facilitiesas laiddown in the standardsofGoI”(151). The required staff, the equipment, instruments andsuppliesand required the laboratory tests tobedonearesetout frompages150onwards. The responsibilitiesof theofficialsandotherscarryingouttheactivitiesaresetoutfrompages157onwards.Preventionof infection is setout frompage165onwards.Assuranceofqualityissetoutfrompage171onwards.Managementofemergencyissetoutatpage179onwards.

Standards & Quality Assurance in Sterilization Services (2014)

14. Thisdocumentissetoutatpage189ofthecounteraffidavitofUnionofIndiadated13.4.15.Theeligibilitycriteriaissetoutatinternalpage5andis,interalia,asunder:

“Clientshouldbemarried.Femaleclientsshouldbeabovetheageof22yearsandbelowtheageof49years.Thecoupleshouldhaveatleast1childwhoseageisabove1year.”

15. Counselling and informed consent/choice is set out atinternalpage6onwardsandis,interalia,asunder:

Thefollowingstepsshouldbeensuredbeforetheclientsignstheconsentform:

a)Clientshavebeencounselledwherever required in thelanguagetheyunderstand.b)Clientshavebeeninformedofalltheavailablemethodsoffamilyplanningandprocedures.c) Clients have been made to understand what mayhappenbefore,duringandafterthesurgery,itssideeffectsandpotentialcomplications.

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Annexures

d)Clientshavemadean informeddecision for sterilizationvoluntarily

Informed Choice and Informed Consent (Section 1.5 of Standards in Sterilization Services, 2014)

16. The concepts of informed choice and informed consentare related but quite different in their intent. The purposeof informedchoice is toensure thatallclientschoose thebest option/s for their health care needs after getting fullinformation about all available options. Informed consentmeansthataclientunderstandsthesurgicalprocedureandotheroptionsandthendecidestoreceivethecare.

17. Itissetoutinthestandardsthatpriortosurgerythemedicalhistoryoftheclientsshouldbestudied,physicalexaminationandlaboratoryinvestigationsshouldbedoneassetoutfrompage9onwards.

18. From internal page 13 onwards it is stated that clientmonitoriesmustbearoutinepractice,medicalrecordsaretobemaintainedandpost-operativecaredone.Conditionsare laid down for when it is appropriate to discharge apatientandthatwhenevernecessarytheclientshouldbekeptovernightat the facility, shouldbeaccompaniedbyanadultwhilereturninghomeandthosemedicinesshouldbe provided. Post-operative care is set out frompage 15onwards.Adischargecardhastobegivengivingfulldetailsof the institutionand the surgery performed togetherwiththepost-operativeinstructions.Acertificateofsterilizationistobegiven. Thisdocumentalsoprovides for treatmentofcomplicationsandsideeffectsaswellasfailureofoperationleading to pregnancy. Quality assurance is described atpage45onwards.Inparticular,qualityassurancecommitteesare required to be formed at the State and District levelto ensure that standards are followed (internal page 46onwards).Atthestatelevelthereare10membersandatthe district level there are 9 members. These committeesarerequiredtomonitor/reviewthequalityofthesterilizationactivities and to make reports as well as to adjudicateclaimsforcompensationundertheNationalFamilyPlanning

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Indemnity Scheme in cases of deaths, complications andfailures. Thesequalityassurancecommitteesare tochecktherecordsofthefacilityaswellastheclients,theinformedconsent forms and other records and make reports ofmonitoringvisits.Clientexitinterviewsaretobeconducted(internalpage51onwards).Detailedreportsofthedeathsare tobedone. Thedeathaudit report is tobepreparedandreviewedbythequalityassurancecommittee.Similarlyreportsoncomplicationsandfailuresaretobereportedandreviewed.

Manual for Family Planning Indemnity Scheme (2013)

19. This is to be found at page 192 onwards of the counteraffidavitofUnionofIndiadated13.4.15.Certainpaymentsaremadebygovernmentonsterilization.Compensation ispaid for lossofwages, transportation,diet,drugs,dressingetc.Certainpaymentsaremadefordeath,failureetc.Theprocedureforclaimsettlementissetoutatinternalpage11onwards.

Reply of the UOI in affidavit dated 13.4.15Regarding compliance with the Ramakant Rai (I) guidelines

20. AperusaloftheaffidavitshowsthatalltheStates/UTshavereportedtotheUOIfullcompliancewiththeRamakantRai(I)Guidelines.However,nodetailsareprovidedatall.Apartfromcrypticreportingthattheguidelinesarebeingfollowedtherearenoannexuresandnodetailsgiven.ItisalsoclearthatUOIhasnotbothered toverifyor spotcheckeven ina limitedmannercomplianceregardingasingleguidelineeveninasinglestate.

Continuing reports of Sterilization deaths and complications

21. On 23.05.2012, Kolayat Hospital in the state of Rajasthansterilized 72 women. The same hospital had earlier beenreportedtohavesterilizedanother42womenon25.04.2012.Thesesterilizations,alldoneenmassewereinviolationoftheguidelineswhichprescribethatnomorethan30sterilizationsmaybedonebyateamwiththreelaparoscopesinasingle

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day. Further,post-surgery, thewomenwerenotputunderobservation for the required period of three hours. In theabsenceofrecoveryrooms,theywereforcedtolieonthecrowdedanddirtyfloorsofcorridors for recovery.Noneofthesewomenhadeverbeencounseledonanyotherformsofcontraception.Further,over80percentofthesewomenstatedtohavebeenunconsciouswhendischarged. (“TheHorrorsofIndia’sPopulationControlProgrammes”issuedbytheCaravanMagazinedated12.11.2014).

22. Inanincidentdated05.02.2013intheManikchakRuralHospitalinMalda,WestBengal,103womenweresterilizedin‘MegaFemaleMinilapLigationCamp’bytheStateauthorities.Asperthewrittenrecord,threedoctorsconducted103Minilapoperations.

23. The hospital was used as a makeshift facility for the solepurpose of sterilization and had a capacity of only 60beds with dirty and torn mattresses thus the aseptic partwas completely overlooked. The patients were made tolie on the open dirty grounds of the hospital in a painful,semi-conscious state, attended to only by concern familymembers. There was no adequate counselling regardingwhatwill happenbefore,during,andafter the surgery, itssideeffects,andpotentialcomplications, including failure.TheconsentformsonwhichwomengavetheirconsentfortheoperationswerenottranslatedinthelocallanguageandwereinEnglish.Therewerenopost-operativeexaminationsconductedoranypost-operative instructionsgiven to thewomen.Therewerenodischargecardsindicatingthenameoftheinstitution,thedateandtypeofsurgery,themethodused,andthedateandplaceoffollow-upasmandatedbyMOHFWgiventothewomenafterthesurgeries.

24. Itwasinthisregard,thatlocalhealthofficialsacknowledgedtheappallingconditionsoftheprogrammeandnoticesweresentbytheNHRCtotheDistrictMagistrateinMaldaandthePrincipalSecretary,WestBengal.(“103WomensterilizedinadayatWestBengal;probeordered”issuedbyNDTVdated08.02.2013”).

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25. On07.11.2013,ayoungmanwastakentoalocalCommunityHealthandWelfareCentreinRajasthanwhenhecomplainedofabdominalpain.Thepublichealthworkersperformedanon-consensualvasectomyontheyoungman.Thisinstanceof sterilizationona27yearoldman,where thecomplaintwassolelywithregardtoabdominalpain,isreflectiveoftheattitudeofhealthworkerstoforciblyandwithoutproperandinformed consent, carryout sterilizations on many haplesspeople.(AnnexureA-5ofOriginalPetition).

26. InJalandhar,Punjabonthe25thofJuly,2013,awomandiedduringasterilizationoperationataTubectomycamp.Thecampwasorganizedat theBadapindVillageCommunityHealthCentre. The victim, hailing fromUttar Pradeshdieddue to severe internalbleedingcausedbynegligentandinadequate operative care provided by the surgeons onduty.An inquirywasherein instituted,withoutanypunitiveactionbeingtakenagainstthesurgeons,aswasrequiredbyaguidelineinRamakantRaiandcompensationamountingtoRs2,00,000wasdisbursedtothehusbandofthedeceased(Womandiesduring sterilizationoperation, probeorderedissuedbyIndiaTVdated25.07.2013).

27. On 22.11.2013, another tragic victim of India’s recklesssterilizationplancametothefore.AtacampattendedbydozensofyoungandoldwomeninBargarh,Odisha,oneofthem,ShantiMahanandpassedawayduetoshockcausedby excessive bleeding. In the said case, the doctors hadreportedly carelessly severed one of Shanti’s veins duringher laparoscopic Tubectomy. There were no adequateemergency care services available at the camp whichwaswhyshecouldn’tbetreatedon-site.(AnnexureA-6ofOriginalPetition).

28. In November 2014, one of the worst tragedies in India’shistorywithsterilizationdrivesbefellthestateofChhattisgarh.On08.11.2014,Dr. R.KGuptaperformed140 laparoscopictubectomiesintheBilaspurDistrictoftheState,including83whichhehadcompletedwithinaperiodof sixhours. Twodayslater,amajorityofthemfellillandweresubsequently

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admitted to nearby hospitals. By the 13th however, 13women, some with babies as young as 14 months, diedas a result of this Tubectomy and further seventy womenremainedinhospitalwithseriouscomplications.

29. Thepreliminaryreportonthedeaths,mostlywomenfrompoorfamilies,wasattributedtoeithersepticemiaorperitonitis.Thesaid programmebreached numerous guidelines owing totheno.ofsuchprocedurestobeconducted.Theevidenceshows the use of unsterilizedmedical instruments, spuriousmedicines,lackofpreandpost-opexaminationcoercioninadmissionandlackofinformedconsentonthepartofthepatients. It is safe to say thatalmostall thewomen’s rightto life, dignity, health and the various reproductive rightsstoodviolated.Ithadalsobeenperhapsrightlysuspected,that thedoctorswere underpressure tomeet the targetssetbytheprogramme.Itwaslaterheldandacknowledgedby a Judicial Commission in December 2015 that ‘severenegligence’ on the part of the authorities, especiallypertaining to the Standard Operating Procedures, was afatalfactorinthedeathsofthe13womeninBilaspurdistrictofChhattisgarh (Annexure1,Application for impleadmentoftheStateofChhattisgarhfiledbythePetitioner,I.ANo.4of2014on25.11.2014)

30. InashockingincidentthatwasreportedintheAnguldistrictof Odisha, a sterilization camp in Banarpal village led byDr. Mahesh Prasad Rout on 01.12.2014 used a bicyclepumptosubstituteforstandardmedicalinstrumentsduringlaparoscopictubectomies.Onquestioning,headmittedtohavingusedandhavingknowledgeofbicyclepumpsbeingusedforyearsinruralcamps,wheremodern-dayequipmentwas unavailable. Here, the pump was used in place ofan insufflator, usedprimarily to regulateairpressure in theabdomen of a woman during a sterilization procedure.Further,Dr.Routclaims thathehasbeencommended forthealmost60,000tubectomieshehasperformedinthepasttenyears(AnnexureA-10ofI.ANo.6of2015)

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31. Inacontinuing trendofmedical laxityandnegligence, inthe Mandi district of Himachal Pradesh on 12.12.2014, adrunkendoctorperformedfivesterilizationsandfellasleepduringthecourseofhissixthlaparoscopictubectomyinthePrimaryHealthCareCentreinthevillageofThunag.Itwasinformedthatthedoctorhadlockedhimselfupinaroomtosleepwhileheleftthesixthpatientaftertheadministrationofanesthesia.Thedoctorinquestionwascreditedtohaveperformed hundreds of surgeries over the past few years.However, the saiddoctorwas later suspendedand itwasfurthersuspectedhehadapreviousrecordof intoxicationatworkandhadalso fallenasleepduringthecourseofaprevious sterilization procedure (Annexure 11, I.A No. 6 of2015)

32. A case that significantly shed light on the failing andinadequatestateofIndia’sfamilyplanning,andspecificallyits sterilization programmes, 40 women were sterilizedin Jharkhand at a state-run health clinic on 09.01.2015.However,themostdisturbingpartofthereportisthefactthatallthesesurgeriesandoperationswereconductedinpitch-dark,theonlylightcomingfromasingletorchusedduringthesaidoperations.Itwasclaimedthattorchlightwasusedasthefacilitywasoutofpowerthatnight,adecisionthatseverelyriskedthelivesofthesewomen.Further,aftersuchsterilization,thewomenweremadetositandlieoutsideinthecorridorswithoutanypost-opmedicalcare,ortheuseofblanketsandstretchers(AnnexureA-12,I.ANo.6of2015)

33. A similar shocking incident was recorded in Azamgarh inthemonthofFebruary2015where60womenweresterilizedwithin 4.5 hours under amobile and torch light since theelectricpowerwasbeingusedtocoolthemobilevaccines.Theoperationswerecarriedoutintheevening,inunsanitaryandinhumaneconditionsinthehospitalwhichlackedevenbasic infrastructure and facilities like beds. A number ofwomenoperated for sterilizationwere left unattendedonthehospitalfloorincoldweather(“InAzamgarhfiftywomensterilized in torch,mobile light in four hours flat” issued byTwocircles.netdated14.03.2015”)

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34. Inyetanotherinstanceofimproprietyinsterilizationinitiativesin India, a 15-year old boy was tricked into having avasectomydone.On22.11.2015onpretextofavaccinationcamp,aboy,adaily-wageworker,hadbeenpromiseda‘freevaccination’byanASHAworker.Theboywasaskedto lie about his age and marital status at the local civilhospital in Gurgaon. The doctor in question didn’t objectorquestionhis claimsas thenorms required. TheboywaslaterpaidasumofRs1,100forhaving‘volunteered’fortheprocedure,evenashehadbeentrickedintoavasectomyinsteadofavaccinationashewaspromised(“Teentrickedintosterilizationsurgery,wastolditwasvaccinationcamp”issuedbyTimesofIndiadated21.03.2015”)

35. Another shocking incident to come to light, as many as14womenwereoperatedand laparoscopic tubectomiesperformed on by nurses, instead of trained, professionaldoctors and surgeons as was necessitated on 23.12.2015.Theseproceduresweresoconductedaspartofamedicalcamp organized by the Health authorities in Pitthorgarh,Uttarakhand. By the useof untrainednurses todo suchacomplexmedical procedure, the authorities hadabettedthe risk to the lives of these 14 women and later, theUttarakhand Human Rights Commission rightly demandedthattheDistrictMagistrateinstituteaninquiryintothematter(Timesof India report “Inquiryonmedicalcampasnursesperformedsurgeries”).

36. Under Family Planning Programme, within 17 days, threewomendiedafterundergoingsterilizationinthreedifferentdistricts namely Seedhi, Umariya and Anupur in MadhyaPradesh.ThecampsviolatedtheguidelinesoftheMinistryofHealthandFamilyWelfare’sStandardOperatingProcedures.

37. InChandiyaCHC, District Umariya, a 26 year oldwomannamed Rekha Kaul, W/O Kumahre Kaul was sterilized on19thDecember 2015. Rekhadevelopedcomplicationson24thDecember2015andwasreferredtoDistricthospitalinUmariya.Rehkadiedduring treatmenton25thDecember2015. The post Mortem report states that the woman’sintestinesweresticking.

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38. In district Seedhi, village Meera Khaddi, a young womannamed Kiran Singh, aged 26 years, W/O Pushpraj Singhunderwent sterilization on 23rd December 2015 at PHC,Danha Vikaskhand Rampur Naikin. The surgery wasconducted byDr. Deepa Rani Israni (Gynecologist). KiranwasreferredtoMedicalCollegeinReevabutshediedontheway toMedical College. The CMHO at Seedhi, in hisreporttoJointDirectorstatedthatthewoman’sfamilyhasbeencompensatedwithRs.50,000/-.

39. In Anupur, a similar case of negligence came into lightwhenawomandiedafterhersterilizationinacamp.Soonafter operation the woman developed complications,complained of pain in her stomach and her conditiondeteriorated.ShewasreferredtoDistrictHospitalatAnupur.Thewomandiedduringtreatment.

40. Inall the threedeaths, the familiesof thedeceasedhavebeencompensatedwithRs.50,000/-withapromiseof1.5lakhtobegivenlater.However,itisaclearcaseofmedicalnegligence, yet no action has been taken against thedoctorsinvolvedintheoperation.

41. InDecember,2015theTimesofIndiareportedthatadoctorinIndoreconducted196sterilizationssurgeriesinonedayonDecember12,2015toachievehistargetinPunsablockofKhandwaDistrict.TheactwasinclearviolationofguidelinesofMinistryofHealthandFamilyWelfare.Dr.DCMahadik,agovernmentdoctorwhoperformedsurgeries inPunsatoldTimesofIndia,“Youcannotquestionthecapabilityofdoctorsworking 24/7 forpatients.Givenachance, I am ready toconduct 1,000 surgeries” (Times of India report “In a day,Indoredoctorconducts196sterilizations”dated17.12.2015).

42. In May, 2015 the Times of India reported that six doctorswere in the dock in Chhattisgarh as they achieved only11 percent of their targets of conducting 8,300 cataractsurgeriesduring the last fiscal year,whichcontradicts thatthe state government does not fix targets for surgeries fordoctors. Director Health Services (DHS) R Prasanna said

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the targets, under theNational health scheme in 2014-15,hadnotbeenmetbythedoctorsdespitethefactthatallfacilities were available in district hospital (Times of Indiareport,“SixdoctorsindockfornotmeetingsurgerytargetsinChhattisgarh”dated17.05.2016).

43. In December, 2015, Uttar Pradesh, the Deccan Chroniclereported that a doctor allegedly carried out sterilizationsurgerieson27womeninanhourataprimaryhealthcentrewithoutproperarrangements inplace (DeccanChroniclereport “Doctor performs 27 sterilization surgeries in just 60minutes”dated05.03.2015).

44. TheIndianExpressreportedthatwithinaweekofChhattisgarhSterilizationmassacre,26womenweresterilizedinonehouratacampinBilaspur.Onewomandied(TheIndianExpressreport“Chhattisgarhsterilizationtragedy:Despitedeaths,26moretubectomiesweredoneinonehourinanothercamp”dated13.11.2014).

45. TheHindustanTimes,2014reportedthatlessthantwoweeksaftertheChhattisgarhcamp,132womenweresterilizedin5hoursatnight inacampinMadhyaPradesh.Thecamplackedstretchersandbeds(HindustanTimesreport“MadhyaPradesh: 132 women sterilized in 5 hours in Chhatarpur”dated19.11.).

46. AsreportedbyTimesNewsNetworks(TNN)inlateDecember,awomanatacampinOrissahadheresophagusslashedduringasterilizationprocedure(TimesNewsNetworks(TNN)report “Orissa Doctor ‘cuts’ woman’s food pipe” dated05.01.2015).

47. TimesofIndiareportedinearlyJanuary,2015that45womenweresterilizedatacampinUttarPradesh;thecampofficialsleft the women on the floor after the surgery (TimesofIndia report“Nobedforwomenundergoingsterilization inAzamgarh”dated03.01.2015).

48. In January,2015,DeccanHerald reported that73womenweresterilizedinfourhoursinacampinUttarPradesh.The

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womenwerenotgivenbedsaftertheprocedure,butwereleftonthefloor(DeccanHeraldreport“73womensterilizedin4hoursinVaranasi”dated31.01.2015).

NgO reports

49. Inseveralfact-findingmissionstoplaceslikeBundidistrictofRajasthan (2012) (AnnexureP-5ofOriginalPetition),Arariadistrict of Bihar (February and May-June 2012) (AnnexureP-15 of Original Petition and Annexure P-3 of Rejoinder),Asansol(January2013)(AnnexureR-16oftheStatusReportsubmitted with Original Petition) &Malda (February 2013)(AnnexureR-17oftheStatusReportsubmittedwithOriginalPetition)inWestBengalandChhattisgarh(November,2014)conductedby theHumanRightsLawNetwork themanyStatesofIndia,violationoftheguidelinesgivenbytheCourtwasuniformlyobserved.Someobservationssomadeduringthecourseofsuchfact-findingsinclude,asignificantnumberof women attending such sterilization camps were notcounseledonthepermanencyofasterilizationprocedureoranyside-effectsthatmayaccruefromthem.Infact,thereisagenerallackofawarenessandinformationwithregardtoalternativeformsofcontraception.

50. Most of these procedures were performed by a singlesurgeonwithout the assistance of nurses or technicians inunsanitary,unhygienicmakeshiftfacilitiesthatwerefarfromadequate,withinsufficientmedicalsuppliesandnoprovisionfordrinkingwateroremergencyservices.

51. Women were not being screened for pre-op illnesses orimmunizations and post-operative care was virtually non-existent.Preliminarymedical tests suchasUrineandBloodtestswere performedon only fewwomenpresent for thesterilizationprogrammeandeveninsuchcases,thereportswereoftenwithheldfromthem.

52. Further, a camp observation report was conducted bytheCoalitionagainstCoercivePopulationPoliciesandtheNational HealthAlliance forMaternal Health inApril 2015,inthestateofUttarPradesh(AnnexureA-4ofStatusReport

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submittedonbehalfofPetitioner inMay,2015). This reportwas based on observations made at government-heldcampsinChitrakoot,AzamgarhandMirzapur.Thefollowingobservationswerethusmade(a)poorcounsellingandlackofdocumentationwasprominentinallcamps.(b)Consentformswerenotreadinlocallanguagesandnowomanwasinformedofthecompensationscheme,asagainstthefailureofsterilization.

53. In all the camps, none of the women were provideddischarge slips or sterilization certificates, nor was anyoneprovidedwithtestreportsthattheyhadundergonebeforetheprocedureofsterilization.

54. Incampsheld inChitrakoot, therewasno separate roomforwomenaftersterilizationandwereaccommodatedontheverandahof thehospital. Further, no serviceprovidersbothered to check upwith the patients and provide anypost-opcare.

Robbed off choice and dignity: Indian Women dead after mass sterilizationReport by a Multi-organisational team1.12.14

55. Amulti-organizationalfactfindingteamtravelledtoBilaspuronNovember19-20,2014toassess thedeathof16youngwomenandthecriticalconditionofseveralothersfollowingtheir tubectomyat a sterilization campat BilaspurDistrict,Chhattisgarh.

56. Thewomenstartedregisteringfor thecampfrom10:30amand registrationcontinueduntil 1:30pm. The LaparoscopicSurgeonstartedthesterilizationproceduresat3:30pmandcontinuedtill5:00pm.Atotalof83womenwereoperatedoninaboutoneandahalfhours,whichamountstoadurationofonetooneandahalfminutepersurgery.

57. Aspertheinformationprovided,noneofthestaffchangedtheir hand gloves in between the procedures. The sameinjection needle, syringe, and suture needle were used

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for all the cases, neither of those was sterilized. Only onelaparoscope was used for all the 83 surgeries, while theMinistry of Health and FamilyWelfare guidelines prescribethreeforamaximumof30patients.Thatonelaparoscopewascleanedonlybydipping it intoabig traycontainingwarmwaterandbetadinebeforeeachprocedure.

58. The surgeon performed each procedure without anyadherence of the Infection Prevention practices andQualityofCareprocedures.TheLaparoscopicsurgeondidnotcheckanywomenbeforeorafter theprocedureandproceededtoblindlyputhissignatureonthepatient’scasesheets.

59. At the camps there was also a complete apathy for thedignity of women. The women were operated on in anassembly line fashion, with a male ward boy positioningthemforsurgeryinthelithotomypositionandcarryingthemtothemattressafterwards.Theyhadnobedstolieon,andweresenthomealmost immediatelyafter thesurgerywithutterdisregardfortheirhealth.

60. The officials revealed that some of the women startedshowing discomfort and symptoms including, vomiting,breathingproblemsandabdominalpain.Thesewomenfirstcontacted their community healthworkers, someof themwere given an antiemetic drug, but when their vomitingdidnotstop,thewomenweretakentothedistricthospitalwhereverylowbloodpressurewasrecordedonallofthem.

61. Atthebeginningthreewomenwenttothedistricthospital,outofwhichtwodied.Withinaspanof12-24hoursamajorityof the sterilized women became grievously ill developingcomplicationsandsomediedduetoirreversibleshock.

62. IftheprotocolssetbytheGovernmentofIndiaweretobefollowed, for a camp of 83 patients, three teams wouldberequired.Eachteamwouldconstitutethreestaff in theoperating room,one laparoscopy surgeon,oneoperationtheatreassistantandonenurse.Incontrastthestaffinvolved

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inthecampwasonlyfourmedicalofficers,twostaffnursesandtwoauxiliarynursemidwivesintotal.

63. In response toaqueryby the teamabout the fumigationproceduresfollowed,thereplywas,“Yes, itwasdone.Thesweepercleanedthewallswithamop.”

64. Contradictory statementson the responsibility for selectionof campsites, with block level officials claiming that thedecisionwas taken entirely by the ChiefMedical Officersandthedistrictofficialssayingtheselectionsweredoneontheadviceof theBlockMedicalOfficers.A typicalblamegamerevealing that therewasnoactualplanning. (Page20)

65. Furthermore, it was revealed that there were only threelaparoscopicsurgeonsfortheentirestatewhenthenumbershouldhavebeenaround85. Theofficialsall agreed thatthestandardsadheredtointhecampswereverypoorandno guidelines were actually followed. The District QualityAssuranceCommitteewasformedonlyafewmonthsagoandhadyettoactuallybeginfunctioning.

66. NoneofthestaffmetbytheteamhadanyknowledgeoftheStandardOperating Procedures for Sterilization in Camps,theGuidelinesforLaparoscopicProcedureandtheQualityAssuranceManual.

67. One of the workers revealed that an IntrauterineContraceptive Device was inserted post-delivery, withoutthepriorconsentofthewoman.Thewomanwasonlylaterinformed,whichisagrossviolationofherrights.

68. Analyzing theexpenditureon familyplanning, it ispointedout that for theyear2013-14, India spentRs. 396.97croreson female sterilization programmes, which constitutes 85percent of the total expenditure for all sterilizations donein the country. The amount spent as compensation wastwoandhalftimesthetotalgrantsgiventoPrimaryHealthCentre’sforinfrastructurestrengthening.Atotalof39,23,945female sterilizationswere performed in 2013-14,with 1,142

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inChhattisgarh.Outofthe15.59crorerupeesspentbythestate on sterilization, 13.09 crores were spent on women,thus female sterilization constituted 85% of total FamilyPlanning Expenditure.Out of the 13.9 crore rupees spent,Rs.12.67croreswas spentoncompensationandonly 0.42croresonthecampsthemselves(Page26).(AnnexureA-2,ApplicationforDirections,2014)

CAMP OF WRONgS A Fact Finding Report on Sterilization Deaths in BilaspurSama Resource group for Women and HealthJan Swasthya AbhiyanNational Alliance for Maternal Health and Human Rights

69. Percentage of female sterilization in the year 2012-2013was97.4%whilepercentageofmalesterilizationhasbeendecliningandisjust1.1%asperthereportsofFamilyPlanningandPopulationcontrolinIndia.Targetfor2015-16was10000for male sterilizations and 175000 for female sterilizations.(Annexure7 I.A6of2015Applicationforpermissiontofindadditionaldocumentsdated16/01/2015,NamaharReport)

70. Thisreflectsthedisproportionateemphasisonsterilizationsforwomen.Thesetargetsinthecontextofshortageofspecialistsinthehealthsystem,impliesenormouspressuretomeetthetargets in the given time. Camp approach provision forsterilization services raises doubts about daily conduct ofsterilizationsattheDistricthospitalandattheCHC.

71. Mitanins are the frontline health workers who provideprovision of health information and form a link betweencommunitiesandthehealthsystem.Theyaregivenincentivesformotivatingwomenforsterilizations

72. Mitanins get upsetandworried thatpeoplewouldblamethem as they are the ones who motivate women forsterilization.

73. The issues behind so many deaths of women due tosterilization includeswhetherthe location issterilizedornotortheinfrastructureoftheplaceisproperenoughwherethe

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procedurescouldbeconducted.Surgerieswereconductedinmerelyintwoandahalfhourwhichhasseriousimplicationsforthemaintenanceanduseofsterileequipment,instrumentsandotherreusableitems.Thepost-operativeareamustberestricted to prevent post-operative infections, which wasoverlooked.Dischargeofthewomenwithinanhourortwoof thesurgeries is responsible formanyof them losingtheirlives.Seriousnessofthissurgery–requiringskills,highqualitysterilizedequipment,adequatetimeandhighstandardsofsanitationandhygieneisroutinelyundermined,placingthewomenundergoingtheproceduresinprecarioussituations.Negligenceatvariouslevelsledtothesafetyandwell-beingof the people attending the camps grossly compromisedandrighttohealthhasbeenviolated.

HUMAN RIgHTS LAW NETWORk FACT FINDINg REPORT, SONIA VIHAR, DELHI (Annexure, A-8, I.A No. 5 6 of 2015: Application for permission to file additional documents dated 16.01.2015)

74. ThegroundrealityoffemalesterilizationinDelhiwassubmittedthrough additional documents filed by the petitioner on28/1/2015.FromthefactfindingconductedbyHumanRightsLawNetworkinSoniaVihar,Delhi,itisevidentthat,womenarenotprovidedfullandinformedconsent.Itwasseenthattheaddresslistprovidedbythegovernmentwasfaultytheaddresseswerenottakendownproperly.AshaworkerswerealsonotawareoftheFPISScheme

75. Kailash Devi of Sonia Vihar, Delhi was sterilized after herhusband impulsively provided consent on her behalf.The husbandwas worried that his wife, who had alreadyundergone 5 pregnancies and an abortion once, wouldnot survive another pregnancy. The husband was notmadeawareof theprocedure, its repercussionsandmostimportantlyitspermanentnature.Nobodyexplainedorreadouttheconsentformtohim.WhileKailashDeviwasinlabor,shewasaskedtosigntheconsentform.Shemisunderstoodittobeconsentforcesareansurgerywithoutbeingawarethatitwasforthepurposeofthesterilization.Thisisacaseof

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negligenceandviolationofthehealthrightsofMrs.KailashDevi.Neitherthehospitalnorthelocaldispensarywhereshewent for check-up during her pregnancy conducted anypriortestsonhertoseeifsheissuitablefortubectomy.Shewasgivenmedicinesbutshewasnotgivenanyotherinstructions.Neitherdidshereceiveanyincentive,compensationorJSYmoney,norwasshegivenanydocumentshowingthatshehasundergonetubectomy.

76. It was observed that there had been some aspects ofdefaultinthemannerofconductingthewholeprocedure.NoneofthewomenwhounderwentsterilizationinthiscampreceivedanymoneyunderFPIS,eitherbecausetheywerenotawareorbecausetheprocessitselfistoocumbersomeand there is no initiative on the part of the authorities toensure implementation of guidelines. Lack of informationand improper procedure for conducting the sterilizationsmakesitadangerousoptionforwomentoutilizethismethodoffamilyplanning.

HUMAN RIgHTS LAW NETWORk FACT FINDINg REPORT, MADHyA PRADESH (JANUARy - 2016)

77. Between5thto8thand11thto14thJanuary2016,ateamof social activist and researcher from Human Rights LawNetworkandpartnerorganisationsconductedafactfindingin districts ofMadhya Pradesh. The team investigated thesituationofsterilizationcamps,withregardtoadherenceof,qualityassurance for sterilization services (2006), standardsfor male/female sterilization (2008) and SOP (2008) byinterviewing the ASHA, doctors at camps and hospitals,sub centres, assistants, pharmacists andwomenwho hadundergonetheprocedure.Theteamalsovisited2campsinthedistrictofSatnainMadhyaPradesh.

a) SatnaDistrictPHCcampKulgadhi-BlockUnchehera

b) SatnaDistrictCHCcampNagaur-BlockUnchehara

78. Theteamwitnessedclearviolationoftheguidelines issuedbytheHon’bleSupremeCourtinRamakantRaivs.Unionof

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India&Ors.AndguidelineslaydownbyMinistryofHealthandFamilyWelfare.Itwasdiscoveredthatsterilizationscontinuewithapathyforthelivesofpoorwomen.

79. The sterilization camps continued to flout basic norms ofmedical ethics, maintained a target based approach tosterilizationandbreachedalmostallof theguidelines. Thefacts in Madhya Pradesh illustrate the callous attitude ofMedicalOfficerslikeDr.K.LNandio,thesurgeonatPHCCamp,SatnaDistrictKulgadhi-BlockUncheherawhoinformedtheteam,thathecancompleteanoperationwithin2minutes.Onfurtherenquiry,herevealedwithpridethathehadonceoperated262womeninasingleday.

80. All women, except one, that were interviewed had notbeen provided any counselling on sterilization, potentialcomplications,failure,sideeffectsormandatorypre-surgeryhealthscreenings.SterilizationswerecarriedoutinCHCsandPHCs,whichwerehighlyunhygienicandunsafe.

81. The report demonstrates that informed consent and carewereignored.Therewasn’tanyuniformmethodfollowedtogive incentives towomen, some receivedRs.1400/-, somereceived1300/-andothersgotonly600/-.Theconsentformswerenotavailableinthelocallanguage;

82. None of thewomen had receivedpost-operational care,exitcheck-up, informationabout follow-upcareorpropermedication.Allwomenthatwereinterviewedwereaskedtogobackhomewithin1.5hoursofsterilizationsurgery.

83. Six women were interviewed on 8th January 2016 whoinformedthat45to50womenwereoperatedon12thDec2015inCHCMundaibyasingledoctor.Thewomendidnotknowanythingaboutthenumberoflaparoscopesused.

84. Onewomanalsosharedthaton20thDecember2015,inacampatPHCMoondi,around30-35womenwereoperated.Onewomaninformedtheteamthat200otherwomenwereoperatedatthesametimewithher.

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85. 25%ofthe13interviewedASHAworkerswerenotawareofmajorhealth issuesandwhat should theycounselwomenonand25%talkedaboutthetargetsforsterilizationandthattheyreceiveanincentiveofRs.200persurgery.

86. Situation at the camps: Both the camps started late.An assistant at Satna District PHC camp Kulgadhi-BlockUncheherafilledtheformsof“freeandinformedconsent”onbehalfofthewomen.Theconsentformswereincomplete.18womenweresterilizedwithin1.5hours.

87. SinceasurgeongetsRs.75/-peroperation,theconcentrationis more on making money, this practice leaves room forinfections,negligenceandjeopardizingwomen’slives.

88. At both the camps, there was no post-operative careprovided to women, there were no anesthesiologistsavailable, most of the staff seemed unaware of post-operativecare. Thepatientsweremanuallybeingcarriedlike sacksofvegetablespost-surgery,made to lieonfloor.Therewerenobedsorevenmattresses.

89. Thetoiletswereinafilthycondition,noambulanceservicewasprovidedandsterilizedwomenhadnootheroptionbuttogobackhomeontheirown.Onewomanwasevenseentravelingonabicyclepost-operation.Womenwereleftonthedirtyfloorwithoutanydisinfectionorproperhygiene.

90. On11thJanuary2016,atthehospitalinChimtipur,theleadingpharmacist informed that there is only one laparoscopeavailable while monthly 20-30 women in a camp aresterilized.Thesurgeonoperatesinmanycamps(sometimes4–5aday).Thereisnoregistermaintainedfordeaths.Nopre-operationalcheck-uplistisavailable.

HUMAN RIgHTS LAW NETWORk FACT FINDINg UTTARAkHAND (JANUARy - 2016)

91. In Uttarakhand, service utilization or acceptance is verylowfordifferentaspectsofhealthcare.Therearesignificantdifferencesinthetrendofserviceutilizationoracceptancebetweenurbanandruralareas.

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Annexures

92. Further,therearealargenumberofvacanciesinthevariousGovernment health facilities. Appointments of personnelon contractual basis have not succeeded in filling thegapeffectively. The lackof trainedpersonnel impacts theutilizationanddemandofservices.

93. Each hospital was understaffed, and had infrastructure inneedofurgentupgrade.Publicamenitiesandwashroomswere unhygienic, as were the wards where womenstayed.Womencommonly reported receiving incompleteinformationregardingsterilization,andalackofaccessandinformationregardingalternativecontraceptivemethods.

94. The fact-finding team first visited Champawat DistrictHospital.Thisfacilitywasopenedin2010.TheHospitaldoesnothave itsownambulanceservice; theonlyambulancethatworksinthewholeofdistrictisthegovernment’sserviceof“108”.Therewasalsonofunctionalbloodbank.

95. Twoofthepermanentgynecologistswereonleave;intheirplaceasinglegynecologistwithonlyayear’sexperiencewaslookingafterallthepatients.Furthermore,wewereinformedthatthenurseswereresponsiblefordeliveringbabies.Basichygienestandardswereotherwisenotobserved;therewereblood stainson the floors,pillowcasesand linens;medicalwasteincludingblood-stainedgauzewereleftonatrayonthe sideof the room;and thefloorsand lowerpartof thewallswerecoveredingrimeanddirt.

96. Thewashroomswereverydirtyandfoulsmelling.Therewasalargepuddleofdarkwateronthefloor,andthetapsandlightswerenotworking.Thesinkwascloggedandfilledwithrubbish.

97. Thefact-findingteamnextvisitedLohagatCHC,whichwaslocatedinthetowncentre.TheCHCis30beddedhospitals.LohaghatCHCistheonlyCHCforthedistrictsofChampawatandPithoragarh,andservesastheprimehealthcentreforvillagesasfaras62kmaway.Thehospitalhasrecentlybeenundertakenintoapublic-privatepartnership.

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98. Aftersomeenquiries,itwasdiscoveredthatatotalof30-40womenwereoperatedonthatday.ThewomenwerefromthevillageofMadlaklocatedontheborderofNepalover100kmaway.AllthewomencametotheCHCbytheirowntransportwhichcostthemtotalRs.400/-.

99. TheconditionsatLohagatCHCwereabysmal.Alargepackofstraydogswasfoundbehindthemainbuilding.Therewasnowastedisposalmechanism.Thewastewasdumpedinanareajustbehindthehospital.

100. Thewashroomswereextremelyunhygienic. The tapswerebrokenand the sinkswerecloggedwithdirt. It is unclearwhen theurinalswere lastcleaned;a thick layerofgrimealongthelowerpartofthewallsandfloorwasclearlyvisible.Urinecoveredthefloor.

101.Upon further exploration, the fact-finding team foundevidence of complete disregard for asepsis and infectioncontrol measures, in direct violation of the Indian PublicHealthStandards(IPHS).

102. ThePithoragarhDistrictHospitalhasadifferentbuildingforwomenandthereforeseparatemaleandfemalewards.

103. Insidetheconsultationroom,therewasanevident lackofprivacy. The hygiene and sanitation levels of the hospitalwasconcerning.Thewashroomswere inaterriblestateofcleanliness.

104. Further, in an interviewwith womenwho had undergonesterilizationinthePithoragarh,Chamapawatdistricthospitaland Lohaghat CHC, informed us that since the healthcentresdonothavehygieneandcleanenvironmenttheydon’tfeelcomfortabletogetadmittedatthehospitals.Thefollowing failures were observed in the implementation oftheguidelines

105.Allinterviewedwomenwereawareoftheavailablemethodsoffamilyplanningbuttheyoptforsterilizationbecauseit’sapermanentmethodandmoreoverwomengetpaid for it.

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Buttheyarenotawareofthepotentialcomplicationsanditssideeffects.Thishospitalauthorityhasfailedtogivepropercounsellingtowomenandinsteadmotivatesthewomentooptforsterilizationinordertofulfillthetargets.

106.Outof10interviewedwomen,8womenreportedthatbeforethesurgerymedicalhistoryandphysicalexaminationwerenot recorded. Only the laboratory examination includingbloodandurinewasexamined.Thisshowspoorqualityofcareatthecamps.

107. In many cases, women were not given thorough post-operativeinstructionsotherthantorestandtakemedicinesprovided.Thisviolatesawoman’srighttohealth(ConstitutionofIndiaArticle21;ICESCRArticle12).

108. Inthemajorityofinstancestheprovisionofpartialorincorrectinformationisdirectlyrelatedtotheincentive-based,target-driven approach to family planning which forces healthworkers towithhold information thatmaybeprejudicial totheirownself-interests.Additionally,consentformswerenotexplainedtowomenintheirownlanguage,andinonecasethenursesignedonbehalfofawomanwithoutanyfurtherinformation.

109.Research shows that financial barriers exclude poor anduneducatedwomenfromaccessingmoderncontraceptivemethods.10%ofwomenhadtopaytoaccesssterilizationservicesinthepublicsector,while32%hadtopaytoaccessIUD,24%hadtopay for theOCPand30%hadtopay forcondoms.

THE CHHATTISgARH INCIDENT

110.Chhattisgarh’s entire family planning programme focusesonfemalesterilization. TheNationalHealthMissionProjectImplementationPlan(PIP)setstargetsforfemalesterilizationandallocates85%ofthefamilyplanningbudgetexclusivelyforfemalesterilization.TheAnnualHealthSurvey2012-2013showsthatBilaspurdistricthasa29.7%unmetneedforfamilyplanningservices,whichmeansthatalmost30%ofmarried

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womeninBilaspurdistrictofChhattisgarhwhowanttopreventpregnancydonothaveaccesstocontraceptives. Insteadofstrengtheningfacilities,counsellingcapabilities,women’sunderstandingandeducationofaccesstodifferentspacingmethod(copper–T,oralpills,condoms),theGovernmentofChhattisgarhpursuesthesterilizationtargetsthroughcamps.(I.ANo.5of2014ApplicationforDirectionspageno.3).

111.On 8 November 2014, 83 women underwent sterilizationthrough laparoscopic Tubectomy at Nemichand JainHospital and ResearchCentre, Takhatpur Block, Sakri. Thiswas an unused hospital without beds, regular cleaningservicesandemergencyservices.AsofDecember2014,13womenhavediedasaresultoftreatmentatthiscamp.(I.ANo.5of2014ApplicationforDirectionspageno.4).

112.On 10 November 2014, the government held camps inGuarellablockat threePHC sites-Guarella,MarwahiandPendrawere23,16and15womenunderwent sterilization(total54).(I.ANo.5of2014ApplicationforDirectionspageno.4)OnewomandiedasaresultofthesterilizationcampinGaurella.

113. Immediately following thenewsof thedeaths inBilaspur itwaswidelyreportedinthenewspaperandlocaladvocatesaswellasexpertsfromotherpartsofthecountryconductedfactfindings.Theseteamsmetwithwomensterilisedatthefour camps, families of the deceased, field level healthworkers (Mitanins) inspected government health facilitiesandvisitedthesiteofthe8November2014camp.

114.AllthefactfindingsregardingtheChhattisgarhincidentshowthatnopanelofdoctorsexistedasrequiredbytheRamakantRai Guidelines. There was admittedly a huge shortage ofdoctors to perform sterilizations. Medical investigationsprior to operationswere not done. Informed consentwasnot taken. Thumb impressions were taken mechanicallysometimesonblankpaper.Thewomenwerenotcounselednorinformedaboutpossiblecomplications,theirrighttopostoperative care and of other methods of family planning.

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Annexures

The Quality Assurance Committees were not functioning.ThestandardssetbyUOIofdoing30sterilizations inadayifthreelaparoscopeswereavailablewereoftenbreachedwith100womenfoundinacampinJuly2013.Womenwereputon thefloorafter theoperation. Thewomenwerenotmadeawareof the insuranceschemes. (I.ANo.5of2014ApplicationforDirectionspageno.5)

115. Experts from a multi organizational team with membersfromPopulationFoundationofIndia,ParivarSevaSansthan,Family Planning Association of India and CommonHealthalsoundertookafactfindinginthewakeofthesterilization.(‘RobbedofChoiceandDignity:IndianWomenDeadafterMass Sterilization Camps in Bilaspur District, Chhattisgarhdated1ofDecember2014).

116. The facts inboth the reportsuncoverwidespreadflagrantandnegligentfailurestocomplywiththeStandardOperatingProcedure forSterilizationServices issuedby theMinistryofHealthandFamilyWelfare2008.

117. Thesedocumentsshowthatwomenwererarelycounseledandthathealthworkerswere inserting IUCD’s immediatelypost delivery without consent. Tests required to be donein accordance with the standards (blood, urine, sugaretc.) were not done. Despite the Government of Indialayingdown standards that sterilization ought to bedoneonly inPHCs,CHCsandgovernmenthospitals, sterilizationscontinued to be done in non functional facilities whichwereunusedandfilthy,wheretherewasnoprivacyforthewomen,whereinfrastructureandequipmentdidnotexisttohandleemergenciesandwherepostoperativecarewasnotprovided.Thepracticeofusingasinglelaparoscopewithoutproper sterilization and sometimes even using the sameneedlewasobserved.Women’sclothingwasnotchanged.The staff did not use surgical gowns. The linen was dirty.The state and district quality assurance committees werenonfunctional. (I.A No.5 of 2014 Application for Directionspageno.18)

288


ANITA JHA REPORT (August 2015)Judicial Investigation Report: State of Chhattisgarh

• 8.11.14,NemichandTrustHospitalSakriTown,Bilaspurdistrict,• Noconsenttakenfromthewomen18,19,65,66,70,73,77

onwards,145,146• Utterlyfilthyconditions18,20,74,80• Breachofguidelinesand standardoperatingprocedures

22,26,35,36,44,48,51• Targetsforsterilizationwereissuedbythecentralgovernment

45,46,149• Onlyafewminutesforeachsurgery50-52,58• Traineedoctorpresent52• Glovesnotchanged53• Negligence,dirtyfloorsanddirtysheets54• Checklistkeptblankonhealthindicators60,64• Drugs.Spurious?119,120,121,122,123,124,133onwards• Postmortemreport135• DrugPurchaseCommittee• Deathsduetoinfectionanddrugs• Guiltynamed36,44,45,141• Recommendations143• QualityAssuranceCommittee149• FailureofInsuranceScheme148,149

118.DirectionsSoughtbythePetitionerdated8.5.14

a. Foradeclaration that sterilizationsurgeriesconducted inthevariousstatesandUnionTerritoriesofIndiaevenafterthe order of the Supreme Court dated 1.1.2005 in thecaseofRamakantRaivsUnionofIndia,havebeendonein unhygienic and unethical conditions which representafundamental rightsviolationunderArticle21,Article14andArticle15oftheConstitutionofIndia.

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Annexures

b. For an order directing all States and Union Territories toimplementinletterandspiritStandardOperatingProceduresforFemaleandMaleSterilization(2006)(Petitionpage49-103), Quality Assurance Manual for Sterilization Services(2006), Standard Operating Procedures for SterilizationServicesinCamps(2008)issuedbytheGovernmentofIndiaafterthedecisionofthisCourt inRamakantRai’scase inordertoensurethatpoorwomeninruralareasaretreatedwith respect anddignitywhen they undergo sterilizationoperations;andinparticular:

1. TheStatesshallestablishQualityAssuranceCommittees(QAC) and facility-level Quality Circles that will meeteverythreemonthstoconductaMedicalAuditofallthatdeathsrelatedtosterilization,tocollectallinformationonhospitalizationsrelatedtosterilization,toprocesscasesoffailure,complicationrequiringhospitalization,anddeathsfollowingsterilizations,toensurefacilitiesmeetthestandardoperatingguidelines,andtomakeminutesofthemeetingssignedbythosepresent.

2. Ensure that women aremade aware, in a languagethat theyclearlyunderstand,ofallavailablemethodsoffamilyplanning,ofthefactthatsterilization ispermanentand that women understand what happens before,during,andafterthesurgery,itssideeffects,andpotentialcomplications,includingfailure.

3. Ensure that women make an informed decision forsterilization voluntarily, are encouraged to ask questionsandaretoldthattheyhavetheoptionofdecidingagainsttheprocedureatanytimewithoutbeingdeniedtheirrightsorotherreproductivehealthservices

4. Ensure that all pre procedure clinical assessments asper section 1.4.2, including demographic informationis recorded, eachpatient’smedical history is takenandthat every woman has physical examination includingbloodpressure,pulse,pelvicexamination,andlaboratoryexaminations for hemoglobin, sugar, aluminum andpregnancy.

290


5. Ensurethatconsent isnotobtainedundercoercionorwhentheclientisundersedation,andthattheclientsignsthesterilizationconsentformbeforethesurgery.

6. Ensurethatallsterilizationcampsareorganizedonlyinestablished Health Care Facilities- either CHCs or PHCs.(section2.1ofSOP).

7. Ensurethatspacehasareceptionarea,waitingarea,privatecounsellingarea, laboratory,clinicalexaminationroom, pre-operative preparation room, hand washingarea, sterilization room, isolated operation theatre withadequatelighting,aspaciousandwellventilatedrecoveryroomwithbedsadequatetoilets,andanofficearea.

8. Ensurethateachsurgeonisrestrictedtoconductingamaximumof30laparoscopytubectomies,30vasectomiesor30minilaptubectomies(section2.2)or50surgeriesperday with additional surgeons, support staff, instruments,equipment,andsupplies(section2.2).

9. Ensure thatall sterilizationcamps takeplacebetween9amand4pm(section2.3).

10. Ensure that all sterilization camps are adequatelystaffedwiththestaffassetoutinsection4(a).

11. EnsurethatANMsprovidecounsellingforalltheclients,ensure documentation of informed consent, ensuresufficient material including linen, instruments, ensureemergency equipment confirms the pre procedure ofclients,andmonitorclientsduringtheprocedureandassistinpost-operativecare.

12. Ensurethatthesurgeon/gynecologistverifiesthateachclient has been adequately counseled and screened,fill a checklist before conducting the procedure, ensurerequisite equipment/instruments and supplies, ensuresemergency and surgical procedures, documents post-operative instructions on the records of all cases, thus apost-operativecheckup,anddealswithemergencies.

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Annexures

13. Ensurethatall sterilizationcampsstaffadherestothemandatory infection prevention procedure laid out insection5.Inparticular,allstaffshouldwashtheirhands,weargloves maintain methods o9f environmental cleanliness;ensure the proper processing of instruments and otheritemsandfollowproperwastedisposalpractices.

14. Ensurethatallpost-operativeproceduresinsection1.5arefollowed,inparticulartheclientismonitored,theclientis only discharged at least 4 hours after the procedurewhenthevitalsignsarestableandtheclientisfullyaware,has passed urineandcanwalk, drink and talk, and theclienthasbeenevaluatedbyadoctor.Theclientmustbeaccompaniedbytheresponsibleadultwhilegoinghomeandanymedicinesmustbeprescribedasnecessary.

c. Ensure thatASHAworkers follow upwith clients 48 hoursaftersurgeryandwomenshouldreporttoahealthfacilityaftersevendaystohavetheirstitchesremoved.

d. For an order directing all states and Union territories toensurethatthevillagehealthandsanitationcommittees,the PHC monitoring and planning committees, theblock monitoring and planning committees, the districthealth monitoring and planning committees, and thestate health and monitoring committee, a monitor allsterilizationcampsoperatingwithintheirjurisdiction,ensurefull compliance with standard operating procedure forfemaleandmale sterilization (2006), Standards&QualityAssurance in Sterilization Services (2014) and StandardOperating procedures for sterilization services on camps(2008)andmaintainawrittenrecordofthesaidmonitoringand inspectionsduly signedby themembersof the saidcommittee.

e. Foranorderdirectingall statesandUTs to inductonthedistricthealthmonitoringandplanningcommitteesaswellas the statehealthplanningcommitteesandmonitoringcommittees, as well as the sterilization District QualityAssuranceCommittees,and theStateQualityAssurance

292


Committees a nominee of the National Alliance forMaternalHealthandHumanRights.

f. For an order directing the establishment of a CourtcommissionheadedbyMr.A.R.Nanda,retiredSecretary,health and family welfare, GOI and retired executivedirectororthePopulationFoundationofIndia,whoshallbepermittedtoputtogetherateamofCo-Commissionersfromthestates/UTswhoareeminenthealthexpertstomonitorthe implementation of the guidelines of government ofIndiaandtheordersofthisHon’bleCourt.

g. ForanorderdirectingtheRespondentstopublishinstatelanguagesasummaryoftheguidelinesoftheGovernmentofIndiaabovementionedandtheorderofSupremeCourtdated1.1.2005 inRamakantRai’sCaseaswellasorderspassedinthismatterandtohavesaidorderspastedonallPHCs,CHCsandDistricthospitalsthroughoutthestate.

h. For an order directing the Respondents to publicize onradioandtelevisionthesubstanceoftheorderspassedbytheSupremeCourtinRamakantRai’scase,theorderinthiscaseandinformationaboutthefamilyplanninginsurancescheme.

i ForanorderdirectingtheRespondentNo.2(StateofBihar)toprovide5lakhincompensationtothewomensterilizedattheKaparforaSterilizationcampinArariadistrict,Bihar.

j. For an order to the Respondents to review and updateStatelistofempanelleddoctorsasdirectedinRamakantRai’scase

119.DirectionsSoughtbythePetitionerregardingChhattisgarh

I.A. 5 dated 3.12.14

1. For an order of this Court directing the State to provideRs.1 lakhcompensationtothe68survivingwomenwhounderwent sterilization at Sakri on 8th November 2014

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Annexures

andthe53womenwhosurvivedsterilizationatGaurella,MarvahiandPendraon10November2014.

2. For an order of this Court directing the state to providethe families of the deceased and all surviving womenwithdocumentationoftheirsterilizationsurgeryalongwithinformationabouttheFamilyPlanningInsuranceSchemeandguidelines/schemesforaccessingfreemedicalcareforfuturecomplications.

3. For an order to the State to develop a long term careplanforthechildrenofthe16deceasedwomenandanyotherwomenwhodieasaresultofthesecampsincludingemploymentguaranteesfortheprimarycaregivers,accesstolongtermadequatenutrition,freehealthservices,andeducationuptocollegeforthechildren.

4. For an order of this Court directing an independentinquirybyseniorrespectedpersonsintothefactstatedinthis application and to ascertain the criminal and otherculpabilitiesofthepersonsconcerned.

5. For an order prohibiting sterilization operations in campsoranyotherplaceotherthanCommunityHealthCentres,hospitalsandclinicswithoperatingtheatres,sufficientbeds,adequate staff, appropriate equipment, and exemplaryhygienestandardswithfixeddaysterilizationservices.

6. For an order directing all States and Union Territories toprovidefreetransportationtosterilizationservices.

7. ForanordertoallstatesandUTstoadheretothemaximumof 30womenperday inaccordancewith the StandardOperatingProcedureand toensure that the seniormostofficer of the establishment is specifically instructed tosupervisetheoperationsandassumeresponsibility.

8. For an order to declare sterilization targets inherentlycoerciveand in violationof the rights tobodily integrity,individualautonomyandhealth.

294


9. ForanordertotheRespondentstoimmediatelyestablishaQualityAssuranceCommitteeattheStateandDistrictLevelsinaccordancewiththeRamakantRai[WP(C)209/2003]orderandtoensurethattheyfunctioninaccordancewiththeguidelinesfiledwiththepetition.

10. Foranorder to theRespondents to roll outa state-widetrainingprogrammesformitanins,ASHAsandotherfacilitystaff on all contraceptives, counselling, the StandardOperating Procedures for Sterilization Services, Women’sentitlementsundertheNationalHealthMission,theFamilyPlanning Indemnity Scheme, and the judgments of theCourtsofIndia,andinthesetrainingstoconsultandinvolvecivil societymembers including representatives from thePopulationFoundationofIndia(PFI)andNationalAllianceforMaternalHealthandHumanRights(NAMHHR).

11. For an order to the Respondents to create posters inlocal languages outlining the guidelines in the StandardOperating Procedure for Sterilization Services and posttheseinallgovernmenthealthfacilities,andtomakethemavailablefreetothepublicwithinformationregardingtheraisingofgrievances.

12. ForanorderdirectingtheRespondentstoimmediatelyfillallsanctionedpostsforspecialists,especiallygynaecologistsandobstetriciansandnurses.

13. For directions to the Respondents in terms ofrecommendationsoutlinedonpages161to168ofAnnexureA-2,RobbedofChoiceandDignity:IndianWomenDeadafterMassSterilization:SituationalAssessmentofSterilizationCampsinBilaspurDistrict,Chhattisgarh.

ADDITIONAL AFFIDAVIT WAS FILED ON BEHALF OF THE PETITIONER FOR THE CIVIL SOCIETy ORgANISATIONS TO BE CO-OPTED AS MEMBER OF STATE QUALITy ASSURANCE COMMITTEE FOR MONITORINg AND TRAININg MECHANISM.

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Annexures

Thenamesthatweresuggestedon20thdayofApril2016were:

State Name Mail Id Org

Delhi Mr.ARNanda [email protected]

FormerSecretaryMoHFW–proposedCommissioner

Delhi Dr.AbhijitDas [email protected],MemberAGCA(NHM)

Delhi SarojiniN.B. Sama.genderhealth.org (SAMA)MemberMSG

Delhi JashodharaDasgupta

[email protected]

SAHAYOG&NationalAllianceforMaternalHealth&HumanRights,formermemberHLEGonUHC

Delhi DrAparajitaGogoi [email protected]

CentreforCatalyzingChange

Delhi DrLeilaVarkey [email protected]

Delhi Mr.GopiGopalakrishnan [email protected] WorldHealth

Partners

Delhi DrVijayAruldas [email protected] AGCAmember

Delhi MsPoonamMuttreja

[email protected]

PopulationFoundationofIndia

Delhi JayashreeSatpute [email protected] NAZDEEK

Bihar SandeepKumarOjha [email protected]


Bihar Dr.Shakeel [email protected] CHARM

Bihar DevikaBiswas [email protected] HealthWatchForum,Bihar

Maharashtra DrAbhayShukla [email protected] SATHI-CEHAT

296



Maharashtra AdvAnubhaRastogi - TLC,Mumbai

Maharashtra DrRaniBang - SEARCH,Mumbai

Maharashtra Dr.ArunGadre [email protected] SATHI,Pune

AndhraPradesh

DrMPrakasamma [email protected]

AcademyofNursingStudies(ANSWERS)

Assam JennyLiang [email protected] TheAnt,Chirang

Gujarat MsInduCapoor [email protected] CHETNA

Gujarat RenuKhanna [email protected] SAHAJ

Gujarat NeetaHardiker [email protected] ANANDI

Gujarat MsMiraiChatterjee

[email protected] SEWA

Odisha DrNabinKumarPati [email protected] Paulfoundation

Odisha DrSaraswatiSwain

[email protected];[email protected]

SecretaryGeneral,NIAHRD

Odisha GourangaMohapatra - JanSwasthya

Abhiyan

Jharkhand Mr.SanjayKumarPaul [email protected]


Rajasthan MsSmitaBajpai [email protected] CHETNA

Rajasthan DrSharadIyengar

[email protected] ARTH

Rajasthan NarendraGupta [email protected] PRAYAS

Rajasthan MamtaJaitly [email protected] VIVIDHAUttarPradesh

SangeetaMaurya

[email protected]

SAHAYOG,Lucknow

UttarPradesh AdvUrmila -

IBTEDASevaSansthan,Chitrakoot

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Annexures


UttarPradesh

RajdevChaturvedi [email protected]

GrameenPurnarnirmanSansthan,Azamgarh

Uttarakhand SunitaShahi [email protected] PRAYAS,Nainital

Uttarakhand KanchanBhandari

[email protected] VIMARSH,Nainital

Jharkhand KalyaniMeena [email protected] PreranaBharti

Jharkhand MurariChowdhury [email protected] NEEDS

Jharkhand Dr.PKTripathy [email protected] EKJUT

MadhyaPradesh SmritiShukla [email protected] SATHIYAWelfare

Society

HimachalPradesh

SubhashMendhapurkar [email protected] SUTRA

Chhattisgarh Dr.YogeshJain [email protected] JanSwasthyaSahyogBilaspur

Chhattisgarh SulakshanaNandi [email protected] PHRN

WestBengal SujoyRoy [email protected] ChildinneedInstitute

WestBengal Dr.RajatDas [email protected] ASHA

WestBengal AnchitaGhatak [email protected],ASocietyforEmpowermentofWomen

Punjab DrManmeetKaur [email protected]

IndianPublicHealthAssociation,Chandigarh

Karnataka DrThelmaNarayan [email protected] CommunityHealth

Cell

Karnataka Dr.AkhilaVasan(KJC) - KJC

Karnataka Dr.ThelmaNarayan [email protected] SOCHARA

Karnataka DrHSudarshan [email protected] KarunaTrust

298


State Name Mail Id OrgTelengana&Andhra

VeenaShatrugna [email protected] ANVESHI

TamilNadu Dr.SubhashreeB - CommonHealth

TamilNadu Dr.SubhasriB [email protected] RUWSEC

TamilNadu AmeerKhan [email protected] SOCHARA

Kerala AleyammaVijayan [email protected] SAKHI

ANITA JHA -JUDICIAL COMMISSION REPORT

IN THE SUPREME COURT OF INDIACIVIL ORIgINAL JURISDICTION

WRIT PETITION (CIVIL) NO. 95 OF 2012

Devika Biswas … Petitionerversus

Union of India & Ors. …. Respondents

J U D g M E N TMadan B. Lokur, J.

1. This public interest petition raises very important issuesconcerningtheentirerangeofconductandmanagement,under the auspices of State Governments, of sterilizationprocedures wherein women and occasionally men aresterilizedincampsorinaccreditedcentres.Theissuesraisedalso includepre-operationproceduresandpost-operativecareorlackofit.Asterilizationsurgerydoesnotappeartobecomplicatedandyetseveraldeathshavetakenplaceacrossthecountryovertheyears.Undoubtedly,thisneedslooking into by the Government of India and the StateGovernments and remedial and corrective steps need to

299

Annexures

betaken.Personswhoarenegligentintheperformanceoftheirdutiesmustbeheldaccountableandthevictimsandtheirfamilyprovidedfor.Itistimethatwomenandmenaretreatedwithrespectanddignityandnotasmerestatisticsinthesterilizationprogramme.

2. The petitioner Devika Biswas is a public spirited individualofArariadistrict inBihar. She isahealth rightsactivistwithextensive professional experience in the developmentandhealthsectors.ShehasworkedinUttarPradesh,Delhi,Jharkhand and Bihar in her capacity as a health rightsactivist. Shehasalsobeenassociatedwith the IntegratedChild Development Scheme in Bihar and has publishedarticlesandbooksinherfieldofspecialization.

3. Sometime in 2005 the issue of sterilization procedures forfemalesandmalesunderthePopulationControlandFamilyPlanning programme or the Public Health programme oftheGovernmentofIndiacameupforconsiderationbeforethisCourt inapetition filedbyRamakantRai. Thepetitionwas substantially decidedby thisCourt on 1stMarch 2005bypassingseveraldirections.ThedirectionsarereportedasRamakant Rai (I) & Anr. v. Union of India & Ors.116

4. PursuanttothedirectionsgivenbythisCourt,theGovernmentofIndiapublishedaQualityAssuranceManualforSterilizationServices(in2006);StandardsforFemaleandMaleSterilization(in2006);andStandardOperatingProceduresforSterilizationServices inCamps(in2008). Thesemanuals really formtheproceduralandsubstantivebasisforconductingsterilizationproceduresbothoffemalesandmalesinthecountryunderthepopulationcontroland familyplanningprogrammeorthepublichealthprogramme.

5. 5.What seems tohaveprovokedDevika Biswas in filingawritpetitionunderArticle32oftheConstitutioninthisCourtisthaton7thJanuary2012asmanyas53womenunderwenta sterilization procedure in a camp in highly unsanitary

116(2009)16SCC565

300


conditions in Kaparfora Government Middle School,Kursakanta,ArariadistrictinBiharbetween8pmand10pmthroughasinglesurgeon. Infact,someofthebroadissuesconcerningthesterilizationcampheldon7thJanuary2012asfoundoninvestigationbyDevikaBiswas,includedanabsenceofpre-operativetestsonthewomenorproposedpatients;theywerenotgivenanycounsellingofanykindatall;theyhad no idea about the potential dangers and outcomesof the sterilization procedure; the sterilization procedureswere carried out in a school and not in a governmenthospitaloraprivateaccreditedhospital;runningwaterwasnot available at the site; the sterilization procedureswerecarriedoutundertorchlightwiththewomenbeingplacedonaschooldesk; thesurgeondidnothaveanyglovesorat leastdidnotchange theglovesavailablewithhim;noemergencyarrangementsweremadeetc.etc.Essentially,the entire campwas conducted in unsanitary conditions,inanunprofessionalandunethicalmanner.What isworseis that the camp was conducted under the auspices ofanNGOcalledJaiAmbeyWelfareSocietywhohadbeengrantedaccreditationbytheDistrictHealthSocietyonlyafewmonthsearlierthatison29thNovember,2011apparentlywithoutfollowinganyformalandtransparentprocedure.

6. Asaresultofthesterilizationcamp,manywomenwhowereoperateduponunderwent tremendousphysicalpainandanguish and were traumatized. Consequently, a series ofcomplaintswerefiledandtheywereregisteredatKursakantaPolice Station on 8th January 2012 being S.DE No.135/12,136/12,137/12and144/12.SomeofthesecomplaintswereinquiredintobytheStateauthoritiesanditwasfoundthatthesterilizationcampwasasuccessexceptthatanexpiredmedicinehadbeengiventothewomen.Ontheotherhand,thestudyandtheinvestigationscarriedoutbyDevikaBiswasalongwitha journalistcalledFrancisElliottconcludedthatthesterilizationcampdidnotmeetanyoftherequirementslaiddownbythisCourtorbytheGovernmentofIndiaandthatthiswasconfirmedbythewomenwhowereoperateduponaswellastheirrelatives.

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7. Devika Biswas then felt compelled to file a public interestlitigationinthisCourttoensurethatsterilizationproceduresnationwideareconducted inaccordancewithacceptedlegal norms, medical procedures and the provisions ofthemanuals and that thosewomen andmenwho sufferdue to the failure or complications in implementing thenorms, procedures and provisions are given adequatecompensation.ThatisreallythecoreissueraisedbyDevikaBiswasandthatsuchinstancesarenotrepeated.

8. In this context, Devika Biswas says in herwrit petition thaton9thFebruary2008theStateHealthSocietyinBiharissuedamemorandumtotheCivilSurgeon ineachdistrict intheState. The result of thismemorandumwas that sterilizationprocedurescouldnowbeconductedinaccreditedprivatehealth facilities also in a campmode. Thememorandumalsomentionedthat theStateGovernmentwouldprovidefunds to the private facilities and the motivators as pertheGovernmentof Indianorms forconductingsterilizationprocedures. However it was made clear that extra fundsfor campmanagement, transportation etc.would not beprovided by the Government to the accredited privatefacilities.

9. This was followed by another memorandum dated 9thFebruary2009regardingsterilizationprocedurescarriedoutatgovernment institutionsbyempanelledprivatedoctors.ThememorandumissuedbytheStateHealthSocietyofBihartotheCivilSurgeoninalldistrictsstatedthatanempanelledprivatedoctormightalsobepermittedtocarryout familyplanningsterilizationprocedures ingovernment institutions.TheQualityAssuranceCommitteeofthedistrictwasentitledto employ private doctors including contractual doctorswhose term had expired for carrying out the sterilizationprocedures.

10. ThepetitionfiledbyDevikaBiswasgoesontosaythatin2010aNonGovernmentalOrganization(NGO)calledtheCentreforHealthandSocialJusticereleasedareportconcerningthequalityofcareandconsequencesoffemalesterilization

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proceduresinBundidistrictofRajasthanin2009-10.Accordingto the report 749 women (mainly underprivileged) weresterilizedatPublicHealthCentres,CommunityHealthCentresorCamps.Researcherswhofoundthatasignificantnumberof themwerenotcounseledabout thepermanentnatureof thesterilizationprocedureandalmost88%of themtoldthe researchers that theydid not receiveany informationabout potential complications, failures or side effects ofthe sterilization procedure interviewed them. The reportindicated that while the internationally accepted failurerateis0.5%thefailurerateinBundidistrictinRajasthanwas2.5%thatis5timestheacceptableinternationalstandard.

11. Similarly,inFebruary2012aFactFindingMissionbyasocialactivist reportedthat sterilizationprocedurescarriedout inthreedistricts inMaharashtra, that is,Nagpur,ChandrapurandGadchirolifoundthatsterilizationcampswereroutinelyconductedinunsanitaryandunsafefacilities.

12. Again in February 2012 a sterilization camp in MadhyaPradesh was conducted in Balaghat district withoutfollowinganyoftheestablishedproceduresandtribalswerelured into sterilization camps bymotivatorswho collectedasubstantially largeamountoverandabovethefinancialnormsfixedbytheGovernmentofIndia.

13. In Kerala also a similar story was repeated in July 2011highlightingthatsterilizationprocedureswerenotconductedinaccordancewith theprescribed requirementsof lawortheprocedures laiddownby theGovernmentof India. Inparagraph40ofthewritpetition,DevikaBiswassubmits“InJuly 2011, a local journalist inWayanad and theChief oftheKattunayakantribe,whoservesasthePresidentofthePrimitiveTribalAssociation,metwithhealthworkersinKerala.They shared storiesofmenandwomenwhowere toldbythe government health workers that it was compulsoryto undergo sterilization. The Chief is concerned aboutgovernmentcoercionandcompulsioninsterilizationanditseffectonthetribe’spopulation.”

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14. In this background, Devika Biswas prayed for a series ofdirections including setting upacommittee to investigatethefactsrelatingtothesterilizationcampheldon7thJanuary2012andtoinitiatedepartmentalandcriminalproceedingsagainst thosewhowere involved in the sterilizationcamp.It is also prayed that the guidelines given in themanualspreparedbytheGovernmentofIndiashouldbescrupulouslyadheredtosothatsuchincidentsdonotrecurinanypartofthecountryandiftheydo,additionalcompensationshouldbepaidtothewomenindistress.

15. In this writ petition, we are primarily concerned with theaffidavitsof theUnionof India, the Statesof Bihar, Kerala,Madhya Pradesh, Maharashtra and Rajasthan sinceallegations have been made in respect of sterilizationcampsheldintheseStatesonly.However,duringthecourseof hearing of this writ petition, allegations surfaced withregard to sterilizationcampsconducted inBilaspurdistrict,Chhattisgarh[between8thand10thNovember2014]andsowearealsoconcernedwiththeallegationsmadeinrespectofthecampsconductedinthatStateaswell.

16. Whatwasbroughttoournoticewithregardtothesterilizationcampsconducted inBilaspurdistrictwas thatasmanyas137womenweresubjectedtoasterilizationprocedureandunfortunately13ofthemdied.Manyotherscomplainedofproblemssuchasvomiting,difficultyinbreathing,severepainetc. Theywere taken to nearby hospitals anddischargedafternecessary treatment. Itappeared that somewomenwhohadnotundergoneasterilizationprocedurealsohadsimilarcomplaintsandsomeofthemdiedtherebyincreasingthenumberofdeaths toover13.Undoubtedly, thiswasamatterofgreatconcernbrought toournoticeduring thependencyofthewritpetition.

Orders passed by this Court

17. Notice in thewritpetitionwas issuedon2ndApril2012andthereafterthepetitionwastakenupforactiveconsiderationonlyon30thJanuary2015whentheSocialJusticeBenchof

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this Court was seized of this matter and after completionof pleadings and instructions received by the learnedAdditionalSolicitorGeneralfromtheUnionofIndia.

18. On30thJanuary2015afterhearinglearnedcounsel,arequestwasmadebyustothelearnedSolicitorGeneraltoensurethatachartbepreparedgivingthestatusofimplementationofeachdirectiongivenin

RamakantRai (I).Detailswith regard to the implementationofthe Family Planning Indemnity Scheme, 2013were also soughtparticularly with regard to the release and utilization of fundsunderthesaidScheme.

19. During the hearing, the events in Bilaspur, Chhattisgarh(mentionedabove)alsocameupforconsiderationandsothe State of Chhattisgarhwas required to file an affidavitstating the steps taken to ameliorate the conditions ofthepersonswhohadfacedthe recent tragedy.TheStateGovernmentwasalsorequiredtoindicatetheactiontakenagainst thedoctors involvedand steps taken to educatethe people in Chhattisgarh with regard to the sterilizationprocedureanditsimpact.

20. Thepetitionwasthentakenupforconsiderationon20thMarch2015whenitwasnotedthateventhoughChhattisgarhhadfiledanaffidavitdated19thFebruary2015,ithadnotgivensufficient particulars anddetailswith regard to the actiontaken subsequent to themishap in the sterilization camp.Chhattisgarh was therefore required to file a proper anddetailed affidavit including a copy of a sample FIR, postmortemreportandchargesheetfiled,ifany.

21. With regard to an affidavit filed by the Union of India inrelation to the implementation of the Family PlanningIndemnity Scheme, 2013 itwas noted that themanner ofutilizationof fundswasnot indicated. The learnedSolicitorGeneral assured this Court that full details in this regardwouldbefurnishedandalsoanauditwouldbeconductedtoensurethatthefundsareutilizedforthepurposeforwhichtheyhavebeengivenby theGovernmentof India to the

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State Governments. Unfortunately, these details have notyetbeenfurnishedandwehaveonlythefiguresgivingthebudgetapprovedaswellastheexpenditureincurredbytheStateGovernmentsandUnionTerritories.

22. On17thApril 2015 thewritpetitionwasagain takenup forconsiderationandas an interimmeasure the Secretary intheMinistryofHealthandFamilyWelfareoftheGovernmentofIndiawasdirectedtoholdameetingwithhiscounterpartsintheStatesandtheUnionTerritoriestoarriveataconsensuson the effective implementation of the various schemesrelating to sterilization [of females andmales], the FamilyPlanningIndemnityScheme,2013andthedirectionsgiveninRamakantRai(I).

23. 23.ChhattisgarhwasalsorequiredtofileaStatusReportontheprogressmadebyaCommission set upby it (theMs.Anita Jha Commission) to look into the tragedy that hadoccurredinthesterilizationcampsheldinBilaspur.

24. The learned Advocate General appearing for the StateofChhattisgarhstatedthathewould look intothe issueoftakingactionagainstthemanufacturerofthedrugusedinthesterilizationcampsandthefeasibilityoffilingachargesheetagainsttheoffendersandtostepupeffortstoarrestthe absconding persons or if necessary to declare themproclaimedoffenders.

25. In the hearing on 14th August 2015 it was noted that theSecretary in theMinistryofHealthandFamilyWelfarehadheldameeting,asearlierdirected,on15thMay2015.Itwasnotedthatoneofthesuggestionsgiveninthatmeetingwasthatsimilarhigh-levelmeetingsshouldbeconductedeverysixmonths.Accordingly,weexpectedtheSecretary intheMinistryofHealthand FamilyWelfare toconducta similarmeetingaftersixmonthsthatisonorabout15thNovember2015.

26. AsfarasChhattisgarhisconcerned,itwasnotedthatithadfiledanaffidavitandthelearnedAdvocateGeneralstated

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thattheMs.AnitaJhaCommissionsubmitteditsreporton10thAugust2015andthatthereportwaslikelytobeconsideredbytheStateCabinetinthenextcoupleofweeks.

27. ThelearnedAdvocateGeneralinformedusthattwochargesheetshadbeenfiled inconnectionwith thetragedyandthat no FIR was pending investigation. He further statedthatsomescientificreportswereexpectedfromaForensicScience Laboratory and a supplementary charge sheetwouldbefiled,ifnecessary,immediatelythereafter.

28. Withregardtotwoabscondingpersonsconcernedwiththetragedy, it was stated by the learned AdvocateGeneralthattheyhadbeendeclaredproclaimedoffendersandarewardhadalsobeenannouncedfortheirwhereabouts.

29. Inthehearingon4thDecember2015wewereinformedthatthereportgivenbyMs.AnitaJhahadsincebeenacceptedby the State Cabinet. Subsequently, on 29th March 2016wewereinformedthatanActionTakenReportontheMs.AnitaJhaCommissionReporthadbeenplacedbeforetheLegislativeAssembly.

30. Since the proceedings in this case were not adversarialin nature we requested the learned Additional SolicitorGeneral appearing in the matter as well as the learnedSenior Counsel to sit down and give suggestions on howto implementtheStandardOperatingProceduresandtheGuidelineslaiddownbytheUnionofIndiainthematterofsterilizationprocedures.

31. On 4th August 2016 when we heard the writ petition, wewereinformedthatameetingwasinfactheldbetweenthelearnedAdditionalSolicitorGeneral,learnedSeniorCounselforDevikaBiswasandofficialsoftheMinistryofHealthandFamily Welfare of the Government of India and that anaffidavit in this regardhadalsobeenfiled.Wethenheardlearnedcounselforthepartiesandreservedjudgment.

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Affidavits filed by the Union of India

32. TheMinistryofHealthandFamilyWelfareoftheGovernmentof India have filed asmany as 10 (ten) affidavits. It is notnecessarytotraverseeachofthemindetail.However, it isnecessary tohighlight thebroad submissionsmade. Theseare:

i. ItisadmittedthattheUnionofIndiareceivedacomplaintwithregardtothesterilizationcampheldon7thJanuary2012andareporthadbeencalledforinthisregard.AreporthassincebeenreceivedfromtheconcernedauthoritiesintheStateofBiharandDr.AbhayKumarChowdhary,acontractphysicianat thePrimaryHealthCentrehadsincebeendismissedandit had furtherbeenordered that hemaynotbeemployedin any government work in future. First Information Reports(FIRs)werelodgedinrespectoftheeventsof7thJanuary2012,investigationshaveconcludedandchargesheetsfiled.

ii. TheGovernmentof Indiahaspublished severalManuals fortheguidanceoftheStateGovernmentsandUnionTerritoriesin respect of sterilization procedures and conducting suchcamps.Theseare:

a. StandardsforFemaleandMaleSterilization,2006;

b. QualityAssuranceManualforSterilizationServices,2006;

c. StandardOperating Procedures for Sterilization Services inCamps,2008;

d. FixedDayStaticApproachforSterilizationServices,2008;

e. FamilyPlanningInsuranceScheme;

f. CompensationSchemeforAcceptorsofSterilization(revisedon 31st October 2006 and improved with effect from 7thSeptember2007);

g. Standards and Quality assurance in Sterilization Services,2014includingStandardOperatingProcedureforcamps;

h. ReferencemanualforFemaleSterilization,2014;

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i. ReferenceManualforMaleSterilization,2013;

j. Manual for Family Planning Indemnity Scheme, 2013(updatedin2016)

k. FrequentlyAskedQuestions,2016.

iii. PublicHealthisaStatesubjectoccurringinEntry6ofListIIoftheSeventhScheduleoftheConstitution.TheGovernmentofIndiaonlyplaysasupportiveandfacilitativeroleinachievinghealthwelfare schemes and it is essentially the StateGovernmentthatisinthebestpositiontomonitorthequalityofservicesinaccordancewithagreedbenchmarks.

iv. Thefollowingfundshavebeenapprovedandutilized(inlakhs)by theStatesunder theFamilyPlanning Indemnity Scheme,2013:

Approval E x p e n d i t u r e Approval Expenditure2013-14 2013-14 2014-15 2014-15(tillend

of3rdquarter)1566.69 675.59 1485.80 828.19

AtthisstageitmaybementionedthatthecoverageundertheFamilyPlanningIndemnitySchemeisasfollows:

Section Coverage Limits1. Deathfollowingsterilization(inclusive

ofdeathduringprocessofsterilizationoperation)inhospitalorwithin7daysfromthedateofdischargefromthehospital

Rs.2lakh

2. Deathfollowingsterilizationwithin8-30daysfromthedateofdischargefromthehospital

Rs.50,000/-

3. Failureofsterilization Rs.30,000/-

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Section Coverage Limits4. Costoftreatmentinthehospitaland

upto60daysarisingoutofcomplicationfollowingsterilizationoperation(inclusiveofcomplicationduringprocessofsterilizationoperation)fromthedateofdischarge

ActualnotexceedingRs.25,000/-

5. Indemnityperdoctor/healthfacilitiesbutnotmorethan4inayear

UptoRs.2lakhperclaim

TheUnionofIndiahasgivennoclear-cutanswerregardingauditofdisbursaloftheamounts,excepttosaythattheStatesandtheUnionTerritoriesarerequiredtofollowthefinancialmanagementsystemandarerequiredtosubmitstatutoryauditreports,utilizationcertificates,quarterlysummaryonconcurrentauditsetc.WhetherthisisbeingadheredtobytheStatesandtheUnionTerritoriesisnotmentioned. It isalsonotclearwhethertheaccountsof thevarious organizations involved in sterilization procedures are infactopenfor inspectionbythesanctioningauthorityandauditincludingtheComptrollerandAuditorGeneralofIndiaandtheinternalauditoftheMinistryofHealthandFamilyWelfareoftheGovernmentofIndia.

iv. TheUnionofIndiahasissuedanadvisorytoalltheStatesandUnionTerritorieson30thDecember2014toadheretothestandardoperatingproceduresatalllevelstopreventand preempt incidents that might adversely affect thehealthofclientsduetosterilizationprocedures.

v.Inthehighlevelmeetingheldon15thMay2015(pursuanttoorderspassedby thisCourt) the following keyactionpointswereagreedupon:

a. Sterilization servicesmustbeprovided inaclient friendlymannerinaconduciveenvironmentaftertakinginformedconsent.Safetyofthosewhooptforitshouldbeensured.

b. Amechanismisput inplacewhereinserviceprovidersormanagersarenotvictimizedorarrestedwithoutinstitutinga proper enquiry by the district/State quality assurancecommittees.

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c. All States toconductworkshopsonquality in sterilizationservices orienting its programme managers and serviceprovidersbothattheStateanddistrictlevelontheupdatedmanualsonstandards,maleandfemalesterilizationandfamilyplanningindemnityscheme.

d. AllGovernmentof Indiaguidelines tobestrictlyadheredbytheStates.

e. A periodic assessment of all the facilities and fixed daycampsby1-2membersofthesub-committeesundertheSQAC/DQACs[StateQualityAssuranceCommittee/DistrictQualityAssuranceCommittee]on implementationof theinfectionpreventionprotocolsaswellastheefficacyoftheservicesprovided,shouldbecarriedout(as laiddownintheManuals).

f. The issue of shortageof pool of providers for sterilizationcouldbeaddressedbyresortingtocompulsorytrainingofMBBSmedicalofficerswhentheyjoingovernmentservice.

g. Onsite Training/mentoring is initiated by identifying highcaseloadfacilities(first)toundertakesterilizationtrainings.This will ensure the service provider is available at thefacilitytoundertaketheirprimarytaskofprovidingservicestotheclientsinadditiontoprovidetrainingtoprospectivetrainees.

h. Retrainingofproviderswhoareeithershortonconfidenceorhavehighfailurerates.

i. There should bemore thrust onMinilap Sterilization as itleadstofewerfailuresandcomplications.

j. The scope of increasing the basket of contraceptivechoices like injectables/implants and weekly pills like‘Saheli’isexploredurgentlytoprovidemorechoice.

k. Theideaofmobileteamsorclinicaloutreachteamsneedsto be encouraged to address the issue of shortage ofsurgeons.

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l. Every caseof sterilizationdeathmust beauditedas performat laid down and reported to the Government ofIndia.

m. Linelistingofdeathsandfailurestobeundertakendistrict/facilitywiseandsurgeonwise.Disbursalofclaimsfordeaths,failuresandcomplicationsshouldbecomputerized.

n. To address the issue of sterilization failures, sterilizationcertificates should be issuedafter at least onemonth incaseoffemalesterilizationandafterthreemonthsincaseofmalesterilization.

o. States to take urgent steps to rejuvenate the FamilyPlanningProgrammewiththeultimateaimofreducingthematernalandinfantmortalityandmorbidityinadditiontoachievingpopulationstabilization

p. GovernmentofIndiatoconducthighlevelmeetingliketheinstantonewithallStatestoacquaintthemwiththelatestpoliciesandprogrammesoftheGovernmentofIndiaonayearlybasis.

(vi)Inthehighlevelmeetingheldon17thNovember2015(pursuanttoorderspassedbythisCourt)thefollowingkeypriorityareasweresharedwiththeStateGovernmentsandUnionTerritories:

a. Uniformconsentformsshouldbeavailable inall facilities,whichshouldbedulyfilledin,andtheconsentoftheclientshouldbetakenpriortotheprocedureinallcases.

b. StateQualityAssuranceCommittee(SQAC)/DistrictQualityAssuranceCommittee (DQAC) and State Indemnity SubCommittee(SISC)/DistrictIndemnitySubCommittee(DISC)tobeconstitutedaspertheGOIguidelines.

c. All the Family Planningguidelines shouldbeprintedanddisseminatedattheState/districtaswellasfacilitylevel.

d. State/District level orientation of all the programmemanagersandprovidersfortheguidelinesandprotocolstobecompletedinallStates.

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e. Members of SQAC and DQAC should conduct periodicsupportive supervision visits as per quality protocols. Thefindingsofthesamearetobedocumentedandcorrectiveactionsshouldbetaken.

f. TrainingcalendarfortrainingnewlyrecruiteddoctorsistobepreparedandupdatedineachState.

g. Line listing of all the sterilization providers needs to bepreparedandperiodicallyupdatedbyallStates.

h. Everydeathattributabletosterilizationshouldbeaudited.

i. Sterilization certificates should be issued as per existingguidelines.

Theaforesaidmeetingwasheldthroughvideo-conferencing.TherepresentativeofUttarPradeshcouldnotattendduetoaStateholidayandsincetheofficeoftheNationalInformaticsCentreintheStatewasclosed.Itmaybementionedthatthisissomewhatoddand suggests that responsibleofficers in the StateofUttarPradeshseemtogivemoreimportancetoStateholidaysratherthanissuesrelatingtoFamilyPlanning.Thisismostunfortunate,tosaytheleast.

(vii)ANationalSummitonFamilyPlanningwasheldon5thand6thApril2016.AsaresultofseveralworkshopsandsummitsheldfromtimetotimeonissuesrelatingtofamilyplanningandthedirectionsgivenbytheCourtfromtimetotimethefollowingpractical and pragmatic measures were proposed by theGovernmentinadditiontothenewguidelinesproposedtobeundertaken:

a. Conductingannual reviewworkshopsof theprogrammeinallStatesofIndiawiththeStateanddistrictprogrammemanagersandserviceproviders.

b. Monthlymonitoringofatleast2publichealthfacilitiesand1accreditedprivate/NGOfacilitybySQAC/DQAC.

c. Replacement of operational ‘Camps’ by regular ‘Fixeddayservices’overthenextthreeyears.

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d. Further Strengthening of the State Quality AssuranceCommittee (SQAC) and District Quality AssuranceCommittee(DQAC)mechanism.

e. Closemonitoring, reviewing and collection of reports ofdeathsattributable to sterilizationby theGovernmentofIndia.

f. ConductingClientexit interviewsof10%casesasperthepreparedchecklist.

g. FeedbackfrombeneficiariesbyMaternalandChildHealthTrackingFacilitationCentre(MCTFC).

viii.Our country has adopted a comprehensive RMNCH+A(Reproductive, Maternal, Neonatal, Child and AdolescentHealth)strategyunderwhichtheFamilyPlanningprogrammeis being emphasized to promote reproductive health andreducematernal,infantandchildmortalityandmorbidity.

ix. The States of Tamil Nadu, Maharashtra, Sikkim and Goahavealreadyphasedout theholdingof sterilizationcamps.During the course of submissions we were informed by thelearnedAdvocateGeneral forChhattisgarh that that Statehasalsophasedoutsuchcamps.AsfarastheUnionofIndiaisconcerned, itproposes toensure thephasingoutof suchcampsoverthenextthreeyears.

(x)SeveralimprovementshavebeenmadeintheFamilyPlanningprogrammeandsterilizationprocedures.Theyare:

a. Declineindeathsfollowingsterilizationfrom140in2014-15to89in2015-16(asperdataavailableonthewebbasedHMIStill31.3.2016);

b. Decline in thenumberof failures from5928 in2014-15 to2093in2015-16(asperdataavailableonthewebbasedHMIStill31.3.2016);

c. Theempanelledlistofprovidersisavailableineverydistrict;

d. Surgeonsarenotperformingmorethan30casesperday;

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e. Camps are being held only in public health facilities oraccreditedprivate/NGOfacilities.

f. Workshops relating to Family Planning programme havebeen held in 28 out of 29 States (as on 21st July, 2016).Unfortunately, no such workshops were held after 24thAugust2015.

g. Thenumberofdeathsattributabletosterilizationproceduresin2014-2015was140butithascomedownin2015-2016to113.

h. In2015-2016clientsexit interviewshavebeenconductedinrespectof1,06,055persons.

i. MonitoringandsupervisionoffacilitiesbySQAC/DQACin2015-2016inregardtopublicfacilities isashighas12,044andwithregardtoprivateaccreditedfacilitiesitisashighas2,984.

j. Theamountallottedforqualityimprovementwhichincludestraining,familyplanningequipment,otherservicedeliveryactivities, human resource cost, infrastructure share,planningandmonitoring(includingqualityassurance)andfamilyplanningcommoditiesisasfollows:

year 2013-14 2014-15 2015-16AmountinCrores 1000.7 1648.07 1243.9

ThesumandsubstanceoftheaffidavitsisthatitisnotasiftheMinistryofHealthandFamilyWelfareoftheGovernmentofIndiaissittingidleandnottakingadequateinterestinthesuccessoftheFamilyPlanningprogrammeandparticularly in sterilizationproceduresin public and private health facilities. While deficiencies andfaultshavebeenpointedout,therehasalsobeenconsiderableimprovementinanongoingexerciseofnationalimportance.

AffidavitsfiledbytheStateofBihar

33. TheStateofBiharhasfiledtwoaffidavits,aStatusReportandWrittenSubmissions.

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34. ThebroadallegationsmadebyDevikaBiswashavebeenacceptedandit isacceptedthatasterilizationcampwasconducted by Jai Ambey Welfare Society (NGO) late intheeveningof 7th January 2012 in violationof theordersof the concernedCivil Surgeon. An FIR has been lodgedagainsttheNGOnotonlyforviolatingthedirectivesbutalsofordistributingexpiredmedicinetothebeneficiariesofthefamilyplanningcamp.

35. It isfurtherstatedthattheNGOhassincebeenblacklistedand steps have been taken for giving compensation tosome of the women who had developed complicationsduringthesurgeries.

36. The blacklisting is confirmed by respondent No. 4, that is,Kumar Nath Choudhary, Secretary of Jai Ambey WelfareSocietywhofiledanaffidaviton14thJanuary2013inwhichitisstatedthathueandcrywasmadeaboutthesterilizationcamp by anti-social elements and as a result three FIRs,namely,KursakantaP.S.CaseNo.03/2012,CaseNo.05/2012andCaseNo.14/2012havebeenlodgedagainsttheNGO.

37. TwochargesheetshavebeenfiledinrespectofKursakantaP.S.CaseNo.03/2012andCaseNo.05/2012.

38. AsregardsKursakantaP.S.CaseNo.03/2012,ChargeSheetbearingNo.23of2012dated09.03.2012andsupplementaryChargeSheetNo.167of2012dated31.12.2012havebeensubmitted.CognizanceoftheoffencehasbeentakenandthereafterRevisionApplicationNo.44/369/12hasapparentlybeenfiledbytheaccusedpersonsandthatispendingintheDistrictCourtinAraria.

39. AsregardsKursakantaP.S.CaseNo.05/2012,ChargeSheetNo. of 2012 dated 12.03.2012 and supplementaryChargeSheetNo.87of2013havebeensubmitted.Cognizanceoftheoffencehasbeen takenon28.06.2012andaRevisionPetitionhasapparentlybeenfiledbytheaccusedbearingNo.31/226/13whichispendingintheDistrictCourtinAraria.

40. As regardsKursakantaP.S.CaseNo.14/2012 isconcerned,thedetailsarenotavailableonrecord.

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41. WehavealsobeentoldthatanFIRhasbeenfiledagainsttheNGOJayAmbeyWelfareSocietyfordistributingexpiredmedicinestothebeneficiariesoftheFamilyPlanningcampheldon7thJanuary2012.AChargeSheethasbeenfiledinthisregardandcognizanceofthisoffencehasalsobeentakenbytheTrialCourt,butagainthedetailsarenotavailable.

42. It is also admitted by the State of Bihar that inquiries intotheeventsthattookplaceon7thJanuary2012havebeenconcluded and show cause notices have been issued totheMedicalOfficerinchargeinthePrimaryHealthCentreinBausa,PurniaaswellasKursakanta,ArariaandalsototheCivilSurgeon,Purnia.

43. 43.ThatthesituationinBiharhasnotimprovedisclearfromthe fact that in Sarandistrict theaccreditationofGunjanMaternity and Surgical Clinic at Chhapra to conductsterilizationprocedureswascancelledon4thMarch2012,justafewmonthsaftertheincidentinArariadistrict.

Affidavit filed by the State of Kerala

44. TheStateofKeralahasfiledaStatementofFacts througha letterdated15thMarch2013. The Statementof Facts isnotaccompaniedbyanaffidavitandthefirstpageoftheStatementofFactsisnotontherecordofthiscase.However,theletterstates,interalia,that“InKeralasterilizationcampsare conducted only in well equipped centres (usually infirst referral units and above hospitals) where there areoperation theatre facility, lab facility, referral facilityare inplace.”Itisalsostated“sterilizationproceduresarecarriedout in hygienic,well equippedhospitals under thecontroland supervision of qualified empanelled doctors.” This isreiterated in an affidavit dated 1st July 2013 filed by theStateofKerala.

45. Inresponsetothesubmissionmadeinthewritpetition,theStateofKeralastatesinparagraph11ofitsaffidavit:

“[The]tribalpopulationofKeralaStateisaccordedspecialconsiderationforitsdealingmembers.There

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isnocompulsionofpromotionofsterilizationaspartof Government policy. At the same time familyplanning services are not denied to this segmentof the population if demanded. Felt need of thecommunity is assessed by the Health Worker andvarious options are put before them explainingthe merits and demerits of each method andencouragingtomakerightchoice.”

There is thereforenospecificdenialof thesubmissionmadebyDevikaBiswasinherwritpetition.

Affidavit filed by the State of Madhya Pradesh

46. The State ofMadhya Pradesh has filed only one affidavitdated7thAugust2013andtheallegationsmadebyDevikaBiswashavenotbeendeniedinthataffidavit.

47. However, the State of Madhya Pradesh denies coercivesterilizationsandasserts that sterilization isundertakenonlyafter informed consent of the patient. The State furthersubmits:

“The State Government has issued instructions fortaking due precautions for sterilization operations.TheStateGovernmenthasformedQualityAssuranceCommittee in each District of the State, which isheadedby theChiefMedical, andHealthOfficerofthedistrict.ThefunctionoftheQualityAssuranceCommitteeistoreviewalltypesofcaseswherethereis somecomplicationand takenecessary steps torectifythesame.”

ThereisnospecificdenialoftheeventsinBalaghatdistrict.

Affidavit filed by the State of Maharashtra

48. TheStateofMaharashtrahasfiledonlyoneaffidavitdated14thAugust2012inwhichitisgenerallystatedthatthefamilyplanningprogrammeisbeingconductedsatisfactorilyanda large number of statistics have been given in support

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of this submission. However,with regard to the sterilizationcampheldinNagpur,ChandrapurandGadchirolidistrictsitisstatedasfollows:

“It is respectfullysubmittedthat inthelightoffactssubmittedinthePetitionbythePetitioner,detailedreport has been called from the Civil Surgeon,Gadchiroli,ChandrapurandNagpurDistrictwhichis marked and annexed as Annexure-1. However,keeping in view the gravity of such instancesreported, State has taken immediate correctiveactionandinstructionshavealreadybeenissuedtoall theDistrictHealthOfficersandCivilSurgeonstoperform the familyplanningoperationsasper thestandardsprescribedbyGovt.of India inhygienicconditions.”

Nodetailed report has beenannexedand no further affidavitwasfiledbytheStateofMaharashtraregardinganyactiontakenagainstanyofficerresponsibleforthemishap,anycompensationpaidoranyfurtheractiontakeninthisregard.

Affidavit filed by the State of Rajasthan

49. TheStateofRajasthaninitsaffidavitfiledon23rdNovember2012 does not specifically contradict the contents of thereport relating to thesterilizationprocedurescarriedout inBundi district but only affirms that the standard operatingprocedures are being followed and that the failure rateis in conformity with the failure rate prescribed by theGovernmentofIndia.

50. TheStateofRajasthanmaintainsthattheproposedpatientsaresufficientlyinstructedandadvisedwithrespecttoboththe sterilization itself as well as post-sterilization care. TheState further mentions that continuous efforts are madeby thehealthemployees“tomotivate females to takeupsterilization surgery”. The failure rate at Bundi district “is inconformitytothefailurerateprescribedbytheGovernmentof India”.TheStatesubmitsthatsufficientstepshavebeen

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takenforimplementationofthedirectionsinRamakantRai(I)aswellastheguidelinesoftheGovernmentofIndia.

Affidavits filed by the State of Chhattisgarh

51. The State of Chhattisgarh has taken up the issue ofmismanagementofthesterilizationcampsinBilaspurdistrictwithduepromptitudeandseriousnessandhasfileddetailedaffidavitsthatnotonlyspecifytheameliorativestepstakenbutalsothepreventivestepsagainstrecurrenceofasimilartragedy.

52. Chhattisgarh has confirmed that sterilization camps wereorganizedinSakrivillageofBilaspurdistricton8thNovember2014 and in Gorela, Pendra and Marwahi in Bilaspurdistricton10thNovember2014. Inall 137operationswereconductedandmanyofthoseoperateduponcomplainedofvomiting,painanddifficultyinbreathing.Consequently,allofthemwereadmittedinnearbyhospitalsfortreatment.Unfortunately,13deathstookplacedespitereliefmeasuresincluding bringing in a teamof doctors from theAll IndiaInstituteofMedicalSciencesinNewDelhi.

53. Apart from these 137 persons, 37 persons who were notoperateduponalsohad similarcomplaintsand5 (five)ofthemdiedtherebybringingthetotalnumberofdeathsto18.Itappearsthatthecauseofdeathofthese5(five)personswasnotrelatedtothesterilizationprocedurebutwasduetoconsumptionofCiprocin500tablet.

54. Bywayofmonetarycompensation,theStateGovernmenthasgivenRs.4lakhstothefamiliesofthosewhodiedandRs. 50,000/- to those who were discharged from medicalinstitutions.ThechildrenofthedeceasedhavebeenadoptedbytheStateGovernmentwhichhastakentheresponsibilityofprovidingthemfreeeducationandhealthcaretill theyare18yearsofage.TheStateGovernmenthasalsoput inanamountofRs.threelakhinafixeddepositforchildrenofthepersonswhodiedinthetragedy.Thechildrenwouldbeentitledtotheamountonattainingtheageof18years.

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55. Departmental action has been takenagainst the doctorsinvolved in the sterilization camps. Two of them havebeen dismissed from service while two others have beensuspendedpendingadepartmentalenquiry.TheLicensingAuthorityhasalsobeensuspended.

56. A Judicial Commission of Inquiry headed by a retiredDistrict JudgeMs.Anita Jhawas setup togive its findingson the criminal culpability and accountability of thepersonsconcerned.The reportgivenby theMs.AnitaJhaCommissionhasbeenacceptedbytheStateGovernmentandalsoactedupon.

57. CriminalproceedingsintheformofChargeSheetNo.19/2015dated 15th February 2015 has been filed in the Court ofJudicial Magistrate, First Class at Bilaspur against Dr. R.K.Gupta,RameshMahawar,SumitMahawar(manufacturersof Ciprocin 500 tablets), Rajesh Khare, Rakesh Khare andManishKhare(suppliersofCiprocin500tablets).RakeshKhareandManish Kharehave sincebeendeclaredproclaimedoffendersandtheirpropertyattachedandarewardfortheirarrestand informationof theirwhereaboutshasalsobeenannounced.

58. As regards measures taken to prevent the recurrence ofsuchan incident,Chhattisgarhhasbegunplacinggreateremphasisonspacingmeasures,whichwillbemoreeffectiveinpopulationcontrol.Greateremphasisisbeingplacedonvasectomyforgenderequity.AnadvisoryhasbeenissuedthatCiprocin500shouldnotbeconsumedandeffortsarebeing made to educate people about the importance,benefits, methods and availability of services in healthfacilities. A mass awareness campaign has also beenlaunchedandseveralotherproactivemeasureshavebeentaken.

59. Allinall,theStateofChhattisgarhhasreactedpositivelytothetragedyandhasnotsoughttohideinconvenientfactsunderthecarpet.

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Further submissions of Devika Biswas

60. 60.DevikaBiswashaspointedout invariousaffidavitsfiledduringthependencyofthiswritpetitionthatthecampaignforsterilizationiseffectivelyarelentlesscampaignforfemalesterilization. The web portal of the Ministry of Health andFamilyWelfareoftheGovernmentofIndiaprovidesstatisticsonthenumberofsterilizationproceduresconductedinthecountry for 2012-13. The portal indicates that 97.4% of allsterilizationprocedures during this periodwereofwomen.Devika Biswas alleges that the entire family planningprogrammeofChhattisgarh focuseson femalesterilizationandtheNationalHealthMissionProjectImplementationPlansetstargetsforfemalesterilizationandallocates85%ofthefamilyplanningbudgetexclusivelytofemalesterilization.

61. More or less confirming the allegations made by DevikaBiswas, the affidavits filed by Madhya Pradesh, erstwhileAndhra Pradesh and Goa reflect the fact that theoverwhelmingnumberofsterilizationproceduresistargetedtowardswomenand there is virtuallynoattentionpaid tomalesterilization.

62. DevikaBiswashasalsopointedout thatdata releasedbytheMinistryofHealthandFamilyWelfareduringtheperiod2010-13showsthatatleast363peoplehavediedasaresultof sterilization procedures, a very large number of suchprocedureshave failedand that therehavebeen severecomplicationsinrespectofseveralpersonswhounderwenta sterilization procedure. This has resulted in payment ofcompensationofatleastRs.50crores.

63. 63.TheprincipalproblempointedoutbyDevikaBiswasiswithregardtotheimplementationofthevariousprocessesandguidelinesissuedbytheGovernmentofIndiafromtimetotime.MereissuanceofguidelinesbytheGovernmentofIndiadoesnotguaranteetheirimplementation.Itispointedout(forexample)thatthelistofempanelleddoctorsisnotreadily available; consent forms are not available in thelocallanguageexceptintheUnionTerritoryofPuducherry;

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unrealistictargetshavebeensetforsterilizationprocedureswiththeresultthatnon-consensualandforcedsterilizationsare taking place, including of persons who are physicallyor mentally challenged. Some young persons have beensterilizedtomeettargetsandbyandlargeilliteratepersonsaresterilized.DevikaBiswasisopposedtosettingoftargetsandsaysthatshehasthesupportoftheGovernmentofIndiain this regard, but unfortunately State Governments andUnionTerritoriesarestillsettinginformaltargetsforsterilization.

64. 64.Itisfurtherpointedoutthatthereisinadequatemonitoringof sterilization camps and facilities. There is little or nomonitoringinmostcampsandhealthcentres,accountabilitymeasures are not in placeand the rights of thousands ofwomenwhoundergosterilizationproceduresareviolated.ItisnotenoughfortheGovernmentofIndiatoshowthatitismerelyplayingasupportiveandfacilitativerolesincethecampaign isanationalcampaignand if it is notproperlyimplemented, itmerely leads topassingthebuckwith theStateGovernment blaming theGovernment of India andviceversa.

65. The strengthening of the Quality Assurance Committees(QAC) and the District Quality Assurance Committees(DQAC) is crucial to the success of a family-planningprogrammeofwhich sterilizationprocedures is oneof theelements. Details of the constitution ofQACs andDQACsarenotavailableonthewebsiteoftheMinistryofHealthandFamilyWelfare.Thereisalsonoindicationofthestepsanddecisionstakenbythemortheminutesoftheirmeetingsorreportssubmittedbythem.Inotherwords,vitalinformationissimplynotavailable.DevikaBiswasdoubtswhethertheseCommitteesmeetona regularbasisalthough itwouldbeappropriateforthemtohaveat leastquarterlymeetingsifnotmeetingseverysixmonths.

66. According to her, unless these existing institutions functioneffectivelyandefficientlyoraremadetofunctioneffectivelyandefficiently,itisveryunlikelythatanymeaningfulprogresswill be made in the family planning programme of the

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Governmentof India, ofwhich sterilization is an importantcomponent.

67. With regard to theFamilyPlanning IndemnityScheme, it ispointed out that regular reviews are not carried out; theutilizationof fundsmadeavailableunder the Schemearemere figures since the details of disbursements in case ofdeath, failure, complication etc. are simply not availableanywhere. There is no indication of the number of claimsfiled, the number of claims rejected and the reasons fortherejectionandtheamountprovidedtoeachsuccessfulclaimant.TheSchemerequiresadeathaudittobecarriedout but that is more or lessmissing in every instance. It isstatedthatspecialistswhoareconversantwiththeSchemearenotavailableatsterilizationcampsandhealthcentrestoexplaintheSchemeindetailsothatthereisnodifficultyor complication faced in the event of an unfortunatemishap.Itshouldbethedutyofsuchaspecialisttoensurethat each person proceeding to undergo a sterilizationprocedurehasacopyofalltherequireddocumentssothatthereisnodifficultyfacedlateron.Thiswillalsoensurethateachpersongivesan informedconsent to the sterilizationprocedure in a language that he or she understands. Infact,all informationthat isdisseminatedwithregardtothesterilizationprocedureshouldbemadeavailableinthelocallanguageatallGovernmenthealthfacilitiesandaccreditedprivatefacilities.

68. It is high time, according to Devika Biswas, for theGovernmentof India to lookat thequality of caremadeavailable to persons post a sterilization procedure. As isclear fromvariousdocumentson record including theMs.AnitaJhaCommissionReport,after-carefacilitiesintermsofcounselling,assistance,follow-upetc.aretotallyabsent.

Is it a public health issue?

69. 69.ThefundamentalerrorthattheUnionofIndiaismaking(andithasrepeatedthatinitsaffidavits)isbyassertingthattheeffectiveimplementationofthesterilizationprogramme

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istheconcernofeachStatesinceitisa“Publichealth”issuecovered by Entry 6 of List II in the Seventh Schedule (theStateList)of theConstitution.Apart fromthe fact that thevariousentries intheSeventhSchedulerelateto legislativepower,theerrormadebytheUnionofIndiaisincompletelyoverlooking themoreappropriate Entry in theConcurrentListthatisEntry20Awhichis“PopulationControlandFamilyPlanning”.ThiswasinsertedbytheConstitution(Forty-second)Amendment Act, 1976. If the sterilization programme isintendedforpopulationcontrolandfamilyplanning(whichitundoubtedlyis)thereisnoearthlyreasonwhytheUnionofIndiashouldrefertoandrelyonEntry6oftheStateListandignoreEntry20Aof theConcurrent List. Populationcontrolandfamilyplanninghasbeenandisanationalcampaignoverthelastsomanydecades.Therefore,theresponsibilityforthesuccessorfailureofthepopulationcontrolandfamilyplanning programme (of which sterilization procedure isan integralpart)mustrestsquarelyontheshouldersoftheUnion of India. It is for this reason that the Union of Indiahasbeen taking somuch interest inpromoting it andhasspenthugeamountsover theyears inencouraging it. It isratherunfortunatethattheUnionofIndiaisnowtreatingthesterilizationprogrammeasaPublicHealthissueandmakingit the concern of the StateGovernment. This is simply notpermissibleandappearstobeacaseofpassingthebuck.

70. 70.As regardsEntry20Aof theConcurrentList, theJusticeSarkaria Commission had this to say in Chapter II titledLegislativeRelationsinparagraph2.21.08:

“OnlyoneStateGovernmenthassuggestedthatthisEntryshouldbetransferredtotheStateList.Accordingto them family planning facilities should be anintegralpartofthehealthfacilities,whichisaStatesubject and the present dichotomy between thetwo facilities, hampers their adequate integration.Populationcontrol and familyplanningarea vitalpart of the national effort at development. ThisEntrywasinsertedbytheForty-secondAmendmentto the Constitution recognising the importance of

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this matter. It is well known that a significant partof the fruits of development is neutralised by thehigh growth in population. With more mouths tofeed, fewersavingareavailablefordevelopment.Largeadditiontothepopulationhas its impactoneveryaspectofthenation’s life.Manyoftheillsofthe societycanbe tracedback to largenumberswhoare unable to finda rewardingemployment.It is necessary to recognise this inter-dependencebetweenfamilyplanningandothersectors.Weare,therefore,of theviewthatPopulationControlandFamilyPlanning isamatterofnational importanceand of common concern of the Union and theStates.”

Notwithstanding the view of that one State Government, theUnionofIndiadidnottransferEntry20AtotheStateList,therebymakingitsintentionsquiteclearandobvious.

71. 71.WhentheUnionofIndiaformulatesschemesofnationalimportancesuchasfamilyplanning,theirimplementationisundoubtedly dependent on the StateGovernments sincethey have the requisite mechanism for implementing theschemes and can also take into account the needs thatareparticulartotheStateanditspeople.Inthismanner,thecooperationoftheUnionofIndiaandallStateGovernmentsisindispensabletothesuccessofsuchnationalprogrammes.AdvertingtotheprovisionsoftheConstitutionthatallowforsuchcoordinationbetweentheUnionandStates,theJusticeSarkaria Commission held that these provisions are notrepugnanttobutinsteadfurthertheprincipleoffederalism.

72. In the samemanner, it is imperative forboth theUnionofIndia and the State Governments to implement schemesannouncedbytheUnionofIndiainamannerthatrespectsthefundamental rightsof thebeneficiariesof thescheme.Giventhestructureofcooperativefederalism,theUnionofIndiacannotconfineitsobligationtomereenactmentofaschemewithoutensuringitsrealizationandimplementation.

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73. Apart from anything else, by not giving the sterilizationprogramme the importance it deserves (apart from othermethods of population control and family planning) andtrying to pass the buck to the State Governments, theUnionof India isattemptingtofindanexcuse for failure initsdutyofeffectivelymonitoringaprogrammeofnationalimportance.Thisgameofpassingtheparcelandtreatinganationalprogrammeasapublichealthissuehastostopandsomebodymust takeownershipof the PopulationControlandFamilyPlanningprogramme.

Draft National Health Policy

74. Tocompoundtheproblemanditismuchmorethanapity;ourcountrydoesnotseemtohaveanyhealthpolicy.Thedraft ofaNationalHealth Policy, 2015wasput upon thewebsiteontheMinistryofHealthandFamilyWelfareoftheGovernment of India in December 2014 for comments,suggestions and feedbackbut evenaftermore thanoneandahalfyears,thewebsiteofthesaidMinistryshowsthattheNationalHealthPolicyhasnotbeenfinalized.

75. ThedraftNationalHealthPolicystatesthatitsprimaryaimisto“…inform,clarify,strengthenandprioritizetheroleoftheGovernmentinshapinghealthsysteminallitsdimensions…”The draft recognizes the correlation between health anddevelopmentandalsorecognizesthehighinequityinaccesstohealthcare.

76. Withrespecttosterilization,itstatesthatsterilizationrelateddeathsareadirectconsequenceofpoorhealthcarequalityandisapreventabletragedy.Italsorecognizesthatfemalesterilizationsaresafestifperformedinanoperationtheatre,whichisfunctionalthroughouttheyearand,byaprofessionalteamwithsupportsystems,whichareinconstantuse.Campmode for such operations itself becomes a reason forunsatisfactoryquality.MoremonetaryandhumanresourceinvestmentisrequiredfortheNationalRuralHealthMission.

77. Increase in the proportion ofmale sterilization in the totalsterilizationsfromtheexisting5%toatleast30%isstatedtobe

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anotherpolicyimperativeunderthehealthpolicy.Coercivemethods are not justified and are not even effective inmeetingthegoalsofpopulationcontrol.Improvedaccess,educationandempowermentshouldbetheaim.

78. 78. Under the head of ‘Governance’ the draft NationalHealthPolicystates:

“One of the most important strengths and at thesame time challenges of governance in health isthe distribution of responsibility andaccountabilitybetweentheCenterandtheStates.ThoughhealthisaStatesubject,theCenterhasaccountabilitytoParliamentforcentralfunding–whichisabout36%ofallpublichealthexpenditureandinsomestatesover50%.Furtherithasitsobligationsunderanumberofinternationalconventionsandtreatiesthatisapartyto.Further,diseasecontrolandfamilyplanningarein theConcurrent list and thesecouldbedefinedverywidely.FinallythoughStateownershiphasbeenused by some states to become domain leadersandmarchahead setting theexample for others,the Center has a responsibility to correct unevendevelopment and provide more resources wherevulnerabilityismore.”

Surely, someone shouldbeconcerned thatwedonothaveanational health policy or is it that we do not need a nationalhealthpolicyandadhocmeasuresaregoodenough?

Female versus male sterilization

79. Aperusalof thevariousaffidavitson record indicates thatthesterilizationprogrammeisvirtuallyarelentlesscampaignforfemalesterilization.ThisismoreorlessconfirmedfromthefiguresavailableonthewebsiteoftheMinistryofHealthandFamilyWelfareof theGovernmentof Indiawhich indicatethefollowing:

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yEAR 2013 2014Femalesterilizations 1,57,431 1,49,262Malesterilizations 8130 5085Totalsterilizations 1,65,561 1,54,347%Femalesterilizations 95.09% 96.7%%Malesterilizations 4.91% 3.29%

80. 80.Theissueofmaleversusfemalesterilizationswasdebatedanddiscussedduringthecourseofthehearingsanditwasconcededby all the learnedcounsel that the sterilizationprogrammecannotbetargetedprimarily towardswomenbutmustalsoactivelyincludethesterilizationofmenaswell.Itappearstous,withoutgoingintothemeritsanddemeritsof the incentives given for undergoing the sterilizationprocedure, the documents on record indicate that theincentive given to males for undergoing a sterilizationprocedureislessthanitisforfemalesandthatmayperhapsbeoneofthereasonswhythepercentageofmalesbeingsterilizedissoremarkablylowascomparedtofemales.Thisis anarea that theUnionof Indiamustaddress itself to, ifnothingelsethenatleastforreasonsofgenderequity.

Right to life

81. 81. The manner in which sterilization procedures havereportedly been carried out endanger two importantcomponents of the right to life under Article 21 of theConstitution–therighttohealthandthereproductiverightsofaperson.

(i)Righttohealth

82. 82.ItiswellestablishedthattherighttolifeunderArticle21oftheConstitutionincludestherighttoleadadignifiedandmeaningfullifeandtherighttohealthisanintegralfacetofthis right. InC.E.S.C. LimitedandOrs. v. SubhashChandraBoseandOrsdealingwith the right tohealthofworkers, itwasnoted that the right tohealthmustbeconsideredanaspect of social justice informedby not only Article 21 of

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the Constitution, but also the Directive Principles of StatePolicyandinternationalcovenantstowhichIndiaisaparty.Similarly, the bare minimum obligations of the State toensurethepreservationoftherighttolifeandhealthwereenunciatedinPaschimBangaKhetMazdoorSamityv.StateofW.B.

83. In Bandhua Mukti Morcha v. Union of India & Others thisCourtunderlinedtheobligationoftheStatetoensurethatthefundamentalrightsofweakersectionsofsocietyarenotexploitedowingtotheirpositioninsociety.

84. Thattherighttohealthisanintegralpartoftherighttolifedoesnotneedanyrepetition.

(ii)Righttoreproductivehealth

85. 85.Over time, therehasbeen recognitionof theneed torespectandprotectthereproductiverightsandreproductivehealthofaperson.Reproductivehealthhasbeendefinedas“thecapabilitytoreproduceandthefreedomtomakeinformed, free and responsible decisions. It also includesaccess to a range of reproductive health information,goods, facilities and services to enable individuals tomake informed, freeand responsibledecisionsabout theirreproductive behaviour.” The Committee on Economic,SocialandCulturalRightsinGeneralCommentno.22ontheRighttoSexualandReproductiveHealthunderArticle12oftheInternationalCovenantonEconomic,SocialandCulturalRightsobservedthat“Therighttosexualandreproductivehealth is an integral part of the right of everyone to thehighestattainablephysicalandmentalhealth.”

86. 86.ThisCourtrecognizedreproductiverightsasanaspectofpersonallibertyunderArticle21oftheConstitutioninSuchitaSrivastava v. Chandigarh Administration. The freedom toexercisethesereproductiverightswouldincludetherighttomakeachoiceregardingsterilizationonthebasisofinformedconsent and free fromany formof coercion. The issue ofinformed consent in respect of sterilization programmeswas considered by the Committee on the Elimination of

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DiscriminationAgainstWomeninA.S.v.Hungary ,wheretheCommitteefoundHungarytohaveviolatedArticles10(h),12and16,paragraph1(e)oftheConventionontheEliminationofDiscriminationAgainstWomenbyperformingasterilizationoperationonA.S.whileshewasbroughtinforacaesareanbymaking her sign a consent form that she did not fullyunderstand.TheCommitteefoundthatitwasnotplausibletoholdthat,inthebriefperiodof17minutescommencingfromheradmissioninthehospitaltothecompletionofthesurgicalprocedures,thatthehospitalpersonnelprovidedherwithsufficientcounsellingandinformationaboutsterilization,aswellasalternatives,risksandbenefits,toensurethatshecouldmakeawell-consideredandvoluntarydecisiontobesterilized.TheCommitteeheld:

“Compulsory sterilization ... adversely affectswomen’sphysicalandmentalhealth,andinfringesthe rightofwomentodecideon thenumberandspacing of their children.” The sterilization surgerywasperformedon theauthorwithout her full andinformed consent and must be considered tohave permanently deprived her of her naturalreproductivecapacity.”

87. Itisnecessarytore-considertheimpactthosepoliciessuchasthesettingofinformaltargetsandprovisionofincentivesbytheGovernmentcanhaveonthereproductivefreedomsof themostvulnerablegroupsof societywhoseeconomicandsocialconditionsleavethemwithnomeaningfulchoicein thematter andalso render them the easiest targets ofcoercion.

Article12:1.StatesPartiesshalltakeallappropriatemeasurestoeliminatediscriminationagainstwomeninthefieldofhealthcareinorder toensure, onabasis of equality ofmenandwomen,accesstohealthcareservices,includingthoserelatedtofamilyplanning.

2. Notwithstanding the provisions of paragraph I of this article,States Parties shall ensure to women appropriate services in

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connection with pregnancy, confinement and the post- natalperiod, granting free services where necessary, as well asadequatenutritionduringpregnancyandlactation.

Article16:1.StatesPartiesshalltakeallappropriatemeasurestoeliminatediscriminationagainstwomeninallmattersrelatingtomarriageand family relationsand inparticular shallensure,onabasisofequalityofmenandwomen- (e)Thesamerights todecidefreelyandresponsiblyonthenumberandspacingoftheirchildrenandtohaveaccesstotheinformation,educationandmeanstoenablethemtoexercisetheserights;

ThecasesofPaschimBangaKhetMazdoorSamityandBandhuaMukti Morcha have emphasized that the State’s obligation inrespectof fundamental rightsmustextendtoensuring that therightsoftheweakersectionsofthecommunityarenotexploitedbyvirtueof theirposition. Thus, thepoliciesof theGovernmentmust notmirror the systemicdiscriminationprevalent in societybutmustbeaimedatremedyingthisdiscriminationandensuringsubstantiveequality.Inthisregard,itisnecessarythatthepoliciesand incentive schemes are made gender neutral and theunnecessaryfocusonfemalesterilizationisdiscontinued.

Supplementary directions

88. Onthebasisofthesubmissionsbeforeus,wehavehighlightedsomekeyissuesthatneedactiveconsideration.Inaddition,ourattentionwasrepeatedlydrawntotheguidelinesgivenby this Court in Ramakant Rai (I) andwhile it is generallythecaseof theUnionof Indiaandall the States that theguidelinesarebeingfollowed,wefindthatatleastinrespectofsomeofthem,there isstillmuchmorethatneedstobedonefortheireffectiveimplementationnotonlyinletterbutalsoinspirit.Somefine-tuningisalsonecessaryinviewofthepassageof time, change in circumstances and the needtouse technology to theoptimum.Accordingly,wefind itnecessarytoissuethefollowingsupplementarydirections:

1.TheState-wise,district-wiseor region-wisepanelofdoctorsapprovedforcarryingout thesterilizationprocedure,must

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beaccessiblethroughthewebsiteoftheMinistryofHealthand Family Welfare of the Government of India as wellthe corresponding Ministry or Department of each StateGovernmentandeachUnionTerritory.Thelistshouldcontainallnecessaryparticularsofeachdoctorandnotmerelythenameanddesignation.Thisexerciseshouldbecompletedonorbefore31st

December, 2016and thereafter the listbeupdatedeveryquarterthatisby31stMarch,30thJune,30thSeptemberand31stDecemberofeveryyear.

2. The contents of the checklist prepared pursuant to thedirections given in Ramakant Rai (I) should be explainedto the proposed patient in a language that he or sheunderstands and the proposed patient should also beexplainedtheimpactandconsequencesofthesterilizationprocedure. Thiscanbeachievedby (a)ensuring that thechecklist is inthe local languageoftheState;(b) itshouldcontainacertificatedulysignedbytheconcerneddoctorthattheproposedpatienthasbeenexplainedthecontentsofthechecklistandhasunderstood itscontentsaswellastheimpactandconsequencesofthesterilizationprocedure;(c) in addition to the certificate given by the doctor, thechecklistmustalsocontainacertificategivenbyatrainedcounselor(whomayormaynotbeanASHAworker)tothesameeffectasthecertificategivenbythedoctor.Thiswillensure that the proposed patient has given an informedconsentforundergoingthesterilizationprocedureandnotanincentivizedconsent.

Sufficientbreathingtimeofaboutanhourorsoshouldbegiventoaproposedpatientsothatintheeventheorshehasa second thought; time isavailable forachangeofmind.

Thechecklistpreparedpursuant tothedirectiongiven inRamakantRai (I)with theaforesaidmodifications shouldbepreparedinthelocalorregionallanguageonorbefore31stDecember2016.

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3.The Quality Assurance Committee (QAC) as well as theDistrict Quality Assurance Committee (DQAC) has beensetup ineveryStateandDistrict in termsof thedirectionsgiveninRamakantRai(I).However,itisonlythedesignationof itsmembers thathasbeenmadeavailable. ThedetailsandnecessaryparticularsofeachmemberoftheQACandDQACshouldbeaccessiblefromthewebsiteoftheMinistryof Healthand FamilyWelfare of theGovernment of Indiaaswell thecorrespondingMinistryorDepartmentofeachState Government and each Union Territory on or before31stDecember,2016andthereafterupdatedeveryquarter.

4.InadditiontothesixmonthlyreportsrequiredtobepublishedbytheQACcontainingofthenumberofpersonssterilizedaswellasthe

Number of deaths or complications arising out of thesterilization procedure, as already directed in RamakantRai (I), the QAC must publish an Annual Report (on thewebsiteoftheMinistryofHealthandFamilyWelfareoftheGovernmentof Indiaaswell thecorrespondingMinistryorDepartment of each State Government and each UnionTerritory) containing not only the statistical information asearlier directed, but also non-statistical information in theformofareportcardindicatingthemeetingsheld,decisionstaken,workdoneandtheachievementsoftheyearetc.Thiswillhaveasignificantmonitoringandsupervisoryimpactonthesterilizationprogrammeandwillalsoensure theactiveinvolvementofallthemembersoftheQACandtheDQAC.

ThefirstsuchAnnualReportcoveringthecalendaryear2016shouldbepublishedonthewebsitesmentionedaboveonorbefore31stMarch,2017.

5.Asmanyas363deathshavetakenplaceduetosterilizationproceduresduring2010-2013.Thisisahighfigure.Duringthisperiod,morethanRs.50croreshasbeendisbursedtowardscompensation in cases of death. Apart from steps takenbyBiharandChhattisgarhduringthependencyofthewritpetition tomitigatethesufferingsof thepatients,wehave

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notbeentoldofanydeathauditconductedbyanyStateGovernmentorUnionTerritoryinrespectofanypatient,norhave we been informed of any steps taken against anydoctororanybodyelseinvolvedinthesterilizationprocedurethathasresultedinthedeathofapatientoranyfailureorany other complication connected with the sterilizationprocedure. There isaneed for transparencycoupledwithaccountability and the death of a patient should not betreatedasaone-offaberration.Therefore,itisdirectedthattheAnnualReportpreparedbytheQACmustindicatethedetailsofallinquiriesheldandremedialstepstaken.

6.With regard to the implementationof the Family PlanningIndemnity Scheme (FPIS), there does not seem to be anydefinitive informationwith regard to thenumberofclaimsfiled, theclaimsacceptedand inwhichcategory (death,failure,complicationetc.),claimspending(andsincewhen)andclaimsrejectedandthereasonsforrejection.TheQACisdirectedtoincludethisinformationintheAnnualReportandtheMinistryofHealthandFamilyWelfareoftheGovernmentof India as well as the State Governments should makethis information accessible on the website, including thequantumofcompensationpaidundereachcategoryandtothenumberofpersons.

We have mentioned above that the learned SolicitorGeneralhadassureduson20thMarch2015thatfulldetailsof the fundsutilizedunder theFPISwouldbe furnishedbutthatinformationhasnotbeengivenasyet,necessitatingthedirectionthatwehavepassed.

InadditiontothedirectionrelatingtotheFPIS, theMinistryof Healthand FamilyWelfare shouldconductanaudit toensure that the funds given by the Government of Indiahavebeenutilizedforthepurposeforwhichtheyweregivenfortheperiodfrom2013-14onwards.

7.The quantum of compensation fixed under the FamilyPlanningIndemnityScheme(FPIS)deservestobeincreasedsubstantiallyandtheburdenthereofmustbeequallyshared

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bytheGovernmentofIndiaandtheStateGovernment.TheStateofChhattisgarhhasshownthewayinthisregardanditwouldbeappropriateifothersfollowthelead.Everydeathorfailureorcomplicationrelatedtothesterilizationprocedureis a setback not only to the patient and his or her familybutalso in the implementationof thenationalcampaign.Wedeclinetofixthequantumofcompensationbutwouldsuggest,followingtheexampleoftheStateofChhattisgarh,thattheamountshouldbedoubledandsharedequally.

1.The Union of India is directed to persuade the StateGovernmentstohaltthesystemofholdingsterilizationcampsashasbeendonebyatleastfourStatesacrossthecountry.Inanyevent, theUnionof India shouldadhere to its viewthat sterilization campswill be stoppedwithin a period ofthreeyears.Inouropinion,thiswillnecessitatesimultaneousstrengtheningofthePrimaryHealthCarecentresacrossthecountrybothintermsofinfrastructureandotherwisesothathealthcareismadeavailabletoallpersons.ThesignificanceofhavingwellequippedPrimaryHealthCentresacrossthecountry certainly cannot be over-emphasized. Therefore,wedirecttheUnionofIndiatopayattentiontothisaswell,sinceitisabsolutelyimportantthatallcitizensofourcountryhaveaccesstoprimaryhealthcare.

9.The Union of India should make efforts to ensure thatsterilizationcampsarediscontinuedasearlyaspossiblebutinanycasewithinthetimeframealreadyfixedandadvertedto above. The Union of India and the StateGovernmentsmustsimultaneouslyensurethatPrimaryHealthCentresarestrengthened

10. Although the Union of India has stated that no targetshavebeenfixed for the implementationof the sterilizationprogramme, itappears that there isan informal systemoffixing targets.We leave it to the good sense of the eachStateGovernmentandUnion Territory toensure that suchtargetsarenotfixedsothathealthworkersandothersdonotcompelpersonstoundergowhatwouldamounttoaforcedornonconsensualsterilizationmerelytoachievethetarget.

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11.Thedecisionstakeninthehighlevelmeetingsheldon15thMay2015and17thNovember2015aswellastheNationalSummiton Family Planningheldon5thand6thApril 2016should be scrupulously implemented by the Ministry ofHealthandFamilyWelfareoftheGovernmentofIndia.Thesaid Ministry should also ensure effective implementationofthedecisionstakenkeepinginmindthatthesterilizationprogrammeisapartofanationalcampaign.

12.TheUnionofIndiaisdirectedtoensurestrictadherencetothe guidelines and standard operating procedures in thevariousmanuals issuedby it. TheSterilizationprogramme isnotonlyaPublicHealthissuebutalsoanationalcampaignfor Population Control and Family Planning. The Union ofIndia has overarching responsibility for the success of thecampaignanditcannotshifttheburdenofimplementationentirelyon theStateGovernmentsandUnionTerritoriesonthegroundthatitisonlyapublichealthissue.AstheJusticeSarkariaCommissionput it “PopulationControlandFamilyPlanningisamatterofnationalimportanceandofcommonconcernoftheUnionandtheStates.”

13. We are pained to note the extremely casual manner inwhich some of the States have responded to this publicinterestpetition.WhatstandsoutistheresponseoftheStatesofMadhyaPradesh,Maharashtra,RajasthanandKeralainrespectofwhichStatesallegationsweremadeconcerningmismanagementinatleastonesterilizationcamp.Noneofthese States have given any acceptable response to theallegationsandwehavenooptionbuttoassumethatthecampsthathavebeenreferredtointhewritpetitionweremismanaged as alleged by Devika Biswas. However, thematter should notendhere.Wedirect theRegistry of thisCourt to transmit acopyof this judgment to theRegistrarGeneraloftheHighCourtintheStatesofMadhyaPradesh,Maharashtra,RajasthanandKeralaforbeingplacedbeforetheChief Justiceof theHighCourt.We request theChiefJustice to initiate a suo moto public interest petition toconsidertheallegationsmadebyDevikaBiswasinrespectofthesterilizationcamp(s)heldintheseStates(theallegations

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nothavingbeenspecificallydenied)andanyothersimilarlaxityor unfortunatemishap thatmightbebrought to thenotice of theCourt andpass appropriate orders thereon.WealsodirecttheRegistryofthisCourttotransmitacopyofthisjudgmenttotheRegistrarGeneralofthePatnaHighCourt for being placed before the Chief Justice of theHighCourt.WerequesttheChiefJusticetoensurespeedycompletionof the investigationsandproceedings relatingtothemishapon7thJanuary2012 inthesterilizationcampinKaparforaGovernmentMiddleSchool,Kursakanta,ArariadistrictaswellasthemishapinChhaprainSarandistrictthatledtocancellationoftheaccreditationofGunjanMaternityandSurgicalClinicon24thMarch2012.

14. The State of Chhattisgarh is directed to implement therecommendationsgivenintheMs.AnitaJhaReportattheearliestandwithallsincerity.

15.WehavealreadyexpressedoursadnessatthefactthattheNationalHealthPolicyhasnotyetbeenfinalizeddespitethepassageofmorethanoneandahalfyears.WedirecttheUnionofIndiatotakeadecisiononorbefore31stDecember2016 onwhether it would like to frame a National HealthPolicyornot. IncasetheUnionofIndiathinks itworthwhileto have a National Health Policy, it should take steps toannounceitattheearliestandkeepissuesofgenderequityinmindaswell.

Conclusion

89.Withtheabovesupplementarydirections,thewritpetitionisdisposedof.WemustrecordourappreciationfortheeffortsputinbyDevikaBiswasinbringingthisvitalissuetothenoticeofthisCourtandtoallthelearnedcounselandconcernedofficersoftheMinistryofHealthandFamilyWelfareoftheGovernmentofIndiainnottreatingthepublicinterestlitigationasanadversarialproceeding but as a collaborative effort to find a remedy tosomeproblemsandimprovethewellbeingofthecitizensofthecountry.

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(MadanB.Lokur)

NewDelhi;(UdayUmeshLalit)September14,2016

gUIDELINES

STANDARDS FOR FEMALE AND MALE STERILIZATION SERVICES (2006)

INPUTS

1. Eligibility of Providers for Performing Female Sterilization

Service Basic Qualification Requirement of Provider

MinilapService TrainedMBBSdoctorlaparoscopicsterilization

DGO,MD(Obst.&Gynae.),MS(Surgery)(trainedinlaparoscopicsterilization)

2. Thestateshouldconstituteadistrict-wisepanelofdoctorsforperformingsterilizationoperationsingovernmentinstitutionsandaccredited private/NGOcentres based on the above criteria.Only thosedoctorswhosenamesappearon thepanel shouldbeentitledtocarryoutsterilizationoperationsinthegovernmentand/orgovernment-accreditedinstitutions.Thepanelshouldbeupdatedquarterly.

1.2. Physical Requirements

PhysicalRequirementsforFemaleSterilization

Sr.No Item Requirements1 Facilities Well-ventilated,fly-proofroomwith

concrete/tiledfloor,whichcanbecleanedthoroughlyRunningwatersupplythroughtaporbucketwithtapElectricitysupplywithastandbygeneratorandotherlightsource

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Sr.No Item Requirements2 Space

RequiredAreaforreceptionWaitingareaCounsellingareawhichoffersprivacyandensuresavoidanceofanyinterruptionslaboratorywithfacilitiesforblood&urineexaminationClinicalexaminationroomforinitialassessmentandfollowupPreoperativepreparationroomfortrimmingofhair,washing,changingofclothesandpremedicationHandwashingareaneartheOTforscrubbingSterilizationroom,neartheOT,forautoclaving,washingandcleaningequipment,preparationofsterilepacksOperationtheatre:shouldbeisolatedandawayfromthegeneralthoroughfareoftheclinic,itshouldbelargeenoughtoallowoperatingstafftomovefreelyandtoaccommodateallthenecessaryequipment.Lightingshouldbeadequate.Recoveryroom:mustbespaciousandwellventilated,numberofbedswillbedeterminedbytheavailablespace,shouldbeadjacenttotheOT.Adequatenumberoftoilets:sufficientnumberofsanitarytypetoiletswithrunningwaterfortheclientsandthestaff.StorageareaOfficeareaforkeepingrecords

3EquipmentandSupplies

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Sr.No Item Requirements3A Examination

RoomRequirements

ExaminationtableFootstoolBloodpressureapparatusThermometerStethoscopeExaminationlightWeighingscaleInstrumentforpelvicexamination

3B Laboratory HaemoglobinometerandaccessoriesApparatustoestimatealbuminandsugarinurineReagents

3C SterilizationRoom

AutoclaveBoilerSurgicaldrumsSSTrayGlutaraldehydesolution2%

3D CleaningRoom

HandbrushesUtilityglovesBasinsDetergentsChlorinesolution0.5%

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Sr.No Item Requirements3E Operation

TheatreOperatingtablecapableofTrendelenburgpositionStep-upstoolSpotlightinOTInstrumenttrolleyMinilaparotomykitlaparoscopykitBloodpressureinstrumentStethoscopeSyringewithneedlesEmergencyequipmentanddrugsRoomheaterIvstandWastebasket,storagecabinet,buckets,basinsfordecontaminationBoxforusedlinenPuncture-proofboxforneedles

3F RecoveryRoom

Patient’scotwithmattress,sheet,pillow,pillowcover,andblanketsBloodpressureinstrumentStethoscopeThermometersIvstandEmergencyequipmentanddrugsasperlist

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Sr.No Item Requirements4 Equipment

andSuppliesStethoscopeBloodpressureinstrumentOralairwaysguedelsize3,4,5Nasopharyngealairwayssize6,6.5,7.0SuctionmachinewithtubingandtwostrapsAmbubagwithmasksize3,4,5TubingandoxygennippleOxygencylinderwithreducingvalveandflowmetreBlanketGauzepiecesKidneytrayTorchSyringesandneedles,includingbutterflysets,IVcannulaIntravenousinfusionsetsandfluidsSterilelaparotomyinstrumentsEndotrachaeltubesize6,6.5,7,7.5,8.0laryngealmaskairwaysize3,4,5CombitubeCricothyroidectomyset

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Sr.No Item Requirements5 Essential

DrugsInjectionAdrenalineInjectionAtropineInjectionDiazepamInjectionDeriphyllineInjectionPhysostigmineInjectionXylocardInjectionHydrocortisone(Dexamethasone)InjectionPheniramineMaleateInjectionPromethazineInjectionPentazocineInjectionRanitidineInjectionMetoclopramideInjectionCalciumGluconate/CalciumChlorideInjectionSodiumBicarbonate(7.5%)InjectionDopamineInjectionMephenteramineInjectionFrusemideInjectionMethergineInjectionOxytocinWater-solublejellyElectrodejellyIVfluidsRingerlactate0.9%sodiumchloride(normalsaline)5%DextroseHetaStarch(HES6%)Glucose25%

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1.3 Case Selection

(Self-declarationbytheclientwillbethebasisforcompilingthisinformation.)

1.3.1.Clientsshouldbemarried(includingever-married).1.3.2.Femaleclientsshouldbebelowtheageof49yearsand

abovetheageof22years.1.3.3. The couple should have at least one child whose age

is above one year unless the sterilization is medicallyindicated.

1.3.4.Clientsortheirspouses/partnersmustnothaveundergonesterilizationinthepast(notapplicableincasesoffailureofprevioussterilization).

1.3.5.Clientsmustbeinasoundstateofmindsoastounderstandthefullimplicationsofsterilization.

1.3.6.Mentallyillclientsmustbecertifiedbyapsychiatrist,andastatementshouldbegivenbythe legalguardian/spouseregardingthesoundnessoftheclient’sstateofmind.

PROCESSES

1.4. Clinical Processes

Preparation for surgery includes counselling, preoperativeassessment, preoperative instructions, review of the surgicalprocedure,andpost-operativecare.Itisessentialtoensurethattheconsentforsurgeryisvoluntaryandwell informed,andthattheclientisphysicallyfitforthesurgery.Preoperativeassessmentsalso provide an opportunity for overall health screening andtreatmentofRTIs/STIs.

1.4.1. Counselling

Counsellingistheprocessofhelpingclientsmakeinformedandvoluntary decisions about fertility. General counselling shouldbedonewheneveraclienthasadoubtor isunabletotakeadecisionregardingthetypeofcontraceptivemethodtobeused.However,inallcases,method-specificcounsellingmustbedone.

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Thefollowingstepsmustbetakenbeforeclientssigntheconsentform:

1.4.1.1.Clientsmustbeinformedofalltheavailablemethodsoffamilyplanningandshouldbemadeawarethatforallpracticalpurposesthisoperationisapermanentone.

1.4.1.2. Clientsmustmake an informeddecision for sterilizationvoluntarily.

1.4.1.3. Clients must be counselled whenever required in thelanguagethattheyunderstand.

1.4.1.4.Clientsshouldbemadetounderstandwhatwillhappenbefore,during,andafterthesurgery,itssideeffects,andpotentialcomplications.

1.4.1.5.Thefollowingfeaturesofthesterilizationproceduremustbeexplainedtotheclient:

• It is a permanent procedure for preventing futurepregnancies.

• It is a surgical procedure that has a possibility ofcomplications, including failure, requiring furthermanagement

• Itdoesnotaffectsexualpleasure,ability,orperformance.It will not affect the client’s strength or her ability toperform normal day-to-day functions. Sterilization doesnot protect against RTIs, STIs, or HIv/AIDS. Clients mustbetoldthatareversalofthissurgeryispossible,butthatthe reversal involvesmajor surgeryand that its successcannotbeguaranteed.

1.4.1.6. Clientsmust be encouraged to ask questions to clarifytheirdoubts,ifany.

1.4.1.7.Clientsmustbetoldthattheyhavetheoptionofdecidingagainsttheprocedureatanytimewithoutbeingdeniedtheirrightstootherreproductivehealthservices.

1.4.3. Timing of the Surgery

ProcedureIntervalsterilizationshouldbeperformedwithin7daysofthemenstrualperiod(inthefollicularphaseofthemenstrual

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cycle). Post-partum sterilization should be done after 24 hoursupto7daysofdelivery.Sterilizationwithmedicalterminationofpregnancy (MTP) canbeperformedconcurrently. Sterilizationfollowing spontaneous abortion can be performed providedtheclientfulfilsthemedicaleligibilitycriteria.Laparoscopictuballigation shouldnotbedoneconcurrentlywith second-trimesterabortionandinthepostpartumperiod.

1.4.4. Informed Consent

1.4.4.1.Consentforsterilizationoperationshouldnotbeobtainedundercoercionorwhentheclientisundersedation.

1.4.4.2.Clientmust sign theconsent form for sterilizationbeforethesurgery.Theconsentofthespouseisnotrequiredforsterilization.

Post-operative Care

a. Theclientismonitoredasdescribedin1.4.7.c(iii)b. Theclientmaybedischargedwhenthefollowingconditions

aremet:• Afteratleast4hoursofprocedure,whenthevitalsignsare

stableandtheclientisfullyawake,haspassedurine,andcanwalk,drinkortalk.

• Theclient hasbeen seenandevaluatedby thedoctor.Whenevernecessary,theclientshouldbekeptovernightatthefacility.

c.Theclientmustbeaccompaniedbyaresponsibleadultwhilegoinghome.

d.Analgesics,antibiotics,andothermedicinesmaybeprovidedand/orprescribedasrequired.

1.5.1. Post-operative and Follow-up Instructions

Theclientistobeprovidedwithadischargecardindicatingthenameoftheinstitution,thedateandtypeofsurgery,themethodused, and the date and place of follow-up (Annexure ). Bothwrittenandverbalpost-operativeinstructionsmustbeprovidedinthelocallanguage.

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Annexures

Theclientmustbeadvisedto:• Returnhomeandrestfortheremainderoftheday.• Resumeonlylightworkafter48hoursandgraduallyreturnto

fullactivitybytwoweeksfollowingsurgery.• Usemedicinesasinstructed.• Resumenormaldietassoonaspossible.• Keeptheincisionareacleananddry.Donotdisturboropen

thedressing.• Bathe after 24 hours following the surgery. If the dressing

becomeswet,itshouldbechangedsothattheincisionareaiskeptdryuntilthestitchesareremoved.

• In the case of interval sterilization, the client may haveintercourse one week after surgery, or whenever she feelscomfortable. Sterilization procedures do not interfere withsexualpleasure,abilityorperformance.Theclientmustreporttothedoctoror theclinic if there isexcessivepain, fainting,fever,bleedingorpusdischargefromtheincision,oriftheclienthasnotpassedurine,notpassedflatus,andfeelsbloatingoftheabdomen. Follow-upcontactwithall tubectomyclientsathomebythefemalehealthworkerinagovernmenthealthinstitution or reporting by the client to the clinic should beestablishedwithin48hoursof surgery. The second follow-upshould be done on the seventh post-operative day for theremoval of stitches and post-operative check-up. A pelvicexamination may be done, if indicated. The third follow-upshouldbedoneafteronemonthorafter theclient’sfirstmenstrualperiod,whicheverisearlier.Theclientmustreturntotheclinicifthereisamissedperiod/suspectedpregnancywithintwoweeksofthemissedperiod. Ifshehasmissedherperiodorisexperiencinganymenstrualabnormality,shemustbe examined to rule out pregnancy. Instructions should begivenonwheretogofor routineandemergencyfollow-up.Iftheclienthasanyquestions,sheshouldcontactthehealthpersonnelordoctoratanytime.

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1.5.2. Certificate of Sterilization

A certificate of sterilization should be issued after one monthof thesurgeryorafter thefirstmenstrualperiodbytheMedicalOfficerofthefacility.

2. STANDARD OPERATINg PROCEDURE FOR STERILIZATION SERVICES IN CAMPS (2008)

1. CounsellingCounsellingistheprocessofhelpingclientsmakesinformedandvoluntarydecisionsabouttheirfertility.Methodspecificcounsellingshouldbedonewheneveraclient isunabletotakeadecisionorhasadoubtregardingthetypeofcontraceptivemethodtobeused. Inthecaseofclients foundeligibleforsterilizationthefollowingstepsshouldbetakenbeforeshe/hesignstheconsentformforsterilization:

• Clientsmustbe informedofall theavailablemethodsoffamily planning and should bemade aware that for allpracticalpurposes,sterilizationisapermanentone.

• Clients must make an informed decision for sterilizationvoluntarily.

• Clientsmustbecounseledinthelanguagethattheyclearlyunderstand.

• Clients shouldbemadetounderstandwhatwillhappenbefore,during,andafterthesurgery, itssideeffects,andpotentialcomplications,includingfailure

In situations where the camp is providing other FP methods,methodspecificcounsellingshouldalsobeprovided.2. Camp TimingsCamptimingsshouldpreferablybebetween9a.m.and4p.m.

3. Probable Client Load Estimation of likely number of clients to turn up for accessingserviceswillhelpindeterminingnumberofteams.Formaintainingquality service, each surgeon should restrict to conducting amaximumof:

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Annexures

• 30 laparoscopic tubectomy (for 1 team with threelaparoscopes)or

• 30vasectomy(NSVorconventional)or• 30minilaptubectomycases.

*Withadditionalsurgeons,supportstaff,instruments,equipmentandsupplies,thenumberofproceduresperteammayincreaseproportionately.However,themaximumnumberofproceduresthatareperformedbyateaminadayshouldnotexceed50.

ROLES AND RESPONSIBILITIES OF PROgRAMME MANAgERS AND SERVICE PROVIDERS1. Pre-camp Activities (beginning of the year)

A.Districtchiefmedicalofficer• Toupdatethelistofempanelledsurgeonsandcirculatetoallcampmanagers

• Tonotify/designatecampmanagersatthefacilitieslikelytoorganizesterilizationcampsduringtheyear

• ToorganizeavailabilityoffundsfromRCH2programmeatthefacilitylevel

• ToconstituteteamsforcampsinconsultationwithI/CDistricthospital/FRUsfromwheretheprovidersaregoingtobesenttocamps.

B.DistrictnodalofficerforFP(ADHO,DyCMHO,DPMorothers)• Develop block-wise quarterly camp calendar specifyingdateandsiteinconsultationwithcampin-charge• To ensure communication to the operating teams inadvance

• To keep readya list of standby staff soas tomeetanycontingencyrequirements

• Tokeepastockofequipmentsuchaslaparoscopes/NSVequipmentreadyandalsoarrangeforAMC/repairs

• Toensurethatallnecessarysuppliesrequiredforthecampsaremadeavailable inadequatequantitiesbeforethecommencementofthecamp

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• To ensure that adequate funds are available with thecampmanagerfordisbursementasincentives.

C.Campmanager/sub-districthospital/FRU/CHC/PHC(campsite)• To coordinate the team activities with the district nodalofficer

• Toarrangefortherequiredfundsfororganizingthecamps• Toensureavailabilityofthelocalteammembers• Toensureavailability of equipment, instrumentsandothersuppliesforeachcamp

• To ensure intense IEC activities regarding the camp in hisareaincoordinationwiththeDistrictauthorities.

3. STANDARDS & QUALITy ASSURANCE IN STERILIZATION SERVICES (2014)

1.3. Eligibility Criteria for Case Selection(Self-declarationbytheclientwillbethebasisforcompilingthisinformation. No eligible client should Standards in SterilizationServices,2014bedeniedfamilyplanningservices)1.3.1.Clientsshouldbeevermarried.1.3.2.Femaleclients shouldbeabovetheageof22yearsand

belowtheageof49years.1.3.3.Maleclientsshouldbeabovetheageof22yearsandbelow

theageof60years.1.3.4. Thecouple shouldhaveat leastonechild,whoseage is

aboveoneyearunlessthesterilizationismedicallyindicated.1.3.5.Clientsortheirspouses/partnersmustnothaveundergone

sterilizationinthepast(notapplicableincasesoffailureofprevioussterilization).

1.3.6.Clientsmustbeinasoundstateofmindsoastounderstandthefullimplicationsofsterilization.

1.3.7.Mentallychallengedclientsmustbecertifiedbyapsychiatristandastatementshouldbetakenfromthelegalguardian/spouse regarding the soundness of the client’s state ofmind.

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Annexures

1.4 Counselling

Counselling in familyplanning is theprocessof facilitatingandenabling clients to make well informed, well considered andvoluntarydecisionsaboutfertilityandtochooseacontraceptivemethod.Counsellingisaclientcenteredapproachthatinvolvescommunicationbetweenaserviceprovider/counsellorandclient.Counsellingenables the serviceprovider tounderstandclient’sperception,attitudes,values,beliefs,familyplanningneedsandpreferencesandaccordingly thecounselorcanguideher/himtowardsdecisionmaking.Theprovider/counselorshouldbenon-judgmental. Privacy (auditory and visual) and confidentialityshouldbemaintainedduringtheprocessofcounselling.Clients may not have complete information about sterilizationand itseffectwhich is furthercompoundedbymisconceptionsand concerns. These should be dispelled by providing correctinformation.

1.4.1GeneralCounselling:Shouldbedoneforalltheclientsseeking familyplanning services. Themainaimofgeneralcounselling is toprovide informedchoice toenable themto take a decision regarding the type of contraceptivemethodtobeused.However, inallcasesmethod-specificcounsellingonthechosenmethodmustbedone.

1.4.2 Method Specific Counselling: During counselling forsterilization, use of simplified schematic diagrams can behelpful(refertodiagramsin‘ReferenceManualforFemaleSterilization(2014)’)

Thefollowingstepsshouldbeensuredbeforetheclientsignstheconsentform:

A. Clients have been counselled wherever required in thelanguagetheyunderstand.

B. Clientshavebeen informedofall theavailablemethodsoffamilyplanningandprocedures.

C. Clients havebeenmade tounderstandwhatmayhappenbefore, during and after the surgery, its side effects andpotentialcomplications

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D. Clients have made an informed decision for sterilizationvoluntarily.

E. Thefollowingfeaturesofthesterilizationprocedureshouldbeexplainedtotheclient:

• It is a permanent procedure for preventing futurepregnancies.

• Itisasurgicalprocedurethathasapossibilityofcomplications,includingfailure,requiringfurthermanagement.

• Itdoesnotaffectsexualpleasure,abilityorperformance.

• Itwill notaffect theclient’s strengthorability toperformnormalday-to-dayfunctions.

• After vasectomy, it is necessary to use a backupcontraceptive method until azoospermia is achieved(usuallythistakesthreemonths).

• SterilizationdoesnotprotectagainstRTIs,STIsandHIV/AIDS.

• A reversal of the surgery is possible but the reversalinvolvesamajorsurgerythesuccessofwhichcannotbeguaranteed.viii)Intheunlikelyeventofanycomplication/failure/death there isa redressalmechanismavailable intheformofindemnitycoverage.

1.4.3Follow-upCounselling:The informationprovidedaftertheprocedureisreinforced.Serviceprovidersneedtolistenattentivelyandbepreparedtoanswerquestionstheclientmayhaveandaddressproblemsshe/hehasexperiencedafterundergoingtheprocedure.Thishelpstheclientcopewithcommonproblemsorsideeffects.

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FemaleSterilization:Adviseclienttoreturntothefacilityifthereis any missed period/no periods, with in 2 weeks to rule outpregnancy.Male Sterilization : Advise client to return to the facility afterthreemonthsforsemenexaminationtoseeifazoospermiahasbeenachieved.Ifsemenstillshowsspermreturntofacilityeverymonthtill6months.

1.5 Informed Choice and Informed Consent

The concepts of informed choice and informed consent arerelatedbutquitedifferentintheirintent.Thepurposeofinformedchoice is toensure thatallclientschoose thebestoption/s fortheir health care needs after getting full information aboutall available options. Informed consent means that a clientunderstandsthesurgicalprocedureandotheroptionsandthendecidestoreceivethecare.However, informedconsentalonedoesnotconstituteinformedchoice.

Theconsentofthepartnerisnotrequiredforsterilization.Howeverthepartnershouldbeencouragedtocomeforcounselling.

1.5.1 Documentation of Informed Consent

The client’s signature or putting her thumb impression on aninformedconsentformisthelegalauthorizationforthesterilizationprocedure tobeperformed.Theclientmustalways signorputher/histhumbimpressionontheconsentform.Incaseofthumbimpressiona signatureofawitness (anypersonnotassociatedwith the service facility and chosen by the client) is a must(Annexure1).

Consentforsterilizationshouldnotbeobtainedwhenphysicaloremotionalfactorsmaycompromiseaclient’sabilitytomakeacarefullyconsidereddecisionaboutcontraception

4. MANUAL FOR FAMILy PLANNINg INDEMNITy SCHEME (2013)

OPERATIONAL PROCEDURE FOR CLAIM SETTLEMENT FROM 1-4-2013:

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SECTION I

8.1 CLAIMS PROCEDURE:

1. OnreceiptoftheinformationofanyclaimfromtheacceptorofSterilizationunderSection-I,thebeneficiary,throughtheirdesignatedhospital anddoctors, shall immediately fill upclaimform.(AnnexureI)

2. If such covered cause is detected “during examinationof theacceptor inhealth facility”, thehealth facility shallensuretogettheclaimformfilledfromthebeneficiaryonthespotwithoutlossoftime.Thehealthfacilityshallforwardtheclaimpapersalongwithnecessarydocuments to thedesignatedofficerofthedistrict.

3. Onreceivingtheclaimpapers,properacknowledgementmustbemadebythedesignateddistrictofficialbyputtingthe stamp on all documents, for further processing andpaymentoftheclaims.Basedonthefollowingdocuments,claims shallbeprocessedby thedesignateddistrict levelofficerunderdifferentsectionsofthescheme.(AnnexureIII)

4. TheclaimsprocessingunderSection-Ideath,complicationsandfailuresfollowingsterilizationoperationwillcontinuetobeprocessedbytheDistrictQualityAssuranceCommittee(DQAC)andputuptoSQAC.TheSQACcouldperformtherolehencecarriedoutbytheInsuranceCompanyintermsofscrutinizingthedocumentsandcallingforanynewandrelevantmaterialmissingfromtherecommendationoftheDQAC. The SQACwould thus reviewevery singlecase inthe stateand recommend releaseof funds to thedistrictwhereverapplicable.(AnnexureXI)

5. For thepurposeofverificationandmedicalevaluationoftheclaimlodgedbythebeneficiary,theStateGovernmenthas formed/shall form the Quality Assurance Committee(QAC) and for all purposes the authority shall be withCMO/CDMO/CMHO/CDHMO/DMO/DHO/ Joint Directordesignatedfor thispurposeatdistrict leveldesignatedbyrespectiveStates/UTs.

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6. The“ClaimFormcumMedicalCertificate” inoriginaldulycompleted in all respects by the beneficiary submittedthrough their designated hospital and doctors shall beauthenticated by the CMO/ CDMO/CMHO/ CDHMO/DMO/DHO/Joint Director designated for this purpose atdistrictlevel.(AnnexureI)

7. Duly completed “Claim Form cum Medical Certificate”alongwithdocumentsasspecifiedbelowshallbethebasisoflodgingclaimsunderSection-Iofthescheme.The“ClaimFormcumMedicalCertificate”shallbedulycompletedinallrespectsbythebeneficiaryandshallbeauthenticatedby the CMO/ CDMO/ CMHO/ CDHMO/DMO/DHO/JointDirectordesignatedforthispurposeatdistrictlevel.

8. TheclaimsprocessingshallbedecentralizedatStateleveland District level, along with the required documents asspecifiedbelow,preferablywithin30daysfromthedateofdetectionofthecoveredcauseisdocumentedunderthescheme.

9. StipulatedtimelimitforsettlementofclaimsunderSection-Ioftheschemewouldbe15workingdaysincaseofdeathand21daysincaseofothers,aftersubmissionofallrequireddocuments.

8.1.1 DEATH FOLLOWINg STERILIZATION (SECTION-I -A & I-B):

a) IncaseofclaimsfordeathoftheacceptorunderSection-Ifollowingsterilizationoperation(inclusiveofdeathduringprocessofsterilizationoperation),copyofdeathcertificate issuedbyhospital/municipalityoranyotherauthoritydesignatedandcopyofProofofPreandPostOperativeProcedure/DischargeCertificate duly attested by the convener of QAC/CMO/CDMO/CMHO/CDHMO/DMO/DHO/JointDirectordesignatedforthispurposeatdistrictlevel.(AnnexureVI)

b) Claims under Section-1-A death following Sterilization(inclusive of death during process of sterilization operation)in hospital orwithin 7 days from thedateof discharge fromthehospitalandunderSection-1-BDeathfollowingsterilization

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within8-30daysfromthedateofdischargefromthehospital)shallbepaidequally in favourof the spouseandunmarrieddependent children whose names are appearing in theConsentForm/ClaimForm.Incaseofnospouse,thepaymentshall be made to the unmarried dependent children. StateHealthSociety/DistrictHealthSocietyunderSection-I-AwillfirstreimburseRs50,000/-toRKSofthedistrict,incasethisamountispaidbyRKSasex-gratiaandthebalanceamountwillbepaidtoothereligiblemembersofthedeceased.(AnnexureVII)

c) IntheeventofdeathasperSection-I-Aabove,theStateHealthSociety/DistrictHealthSocietywouldbepayingtothefirstkinof thedeceased if,deathof theacceptorhas takenplace following sterilization(inclusiveofdeathduringprocessofsterilizationoperation),duringhospitalizationorwithin the7daysfromthedischargeofthehospital.

Ifdependentchildrenareminor,thepaymentshallbemadeby theDistrict Health Society in the nameofminor children.Thecheques,inthiscasewouldbeissuedbytheDistrictHealthSociety in the name of minor beneficiary with the followingendorsement(overleaf);

“Amount to be deposited as FDR in the name of minor Sh /ku ................. till the minor attains the maturity. No premature payment of FDR is allowed. Quarterly interest may be paid to the guardian”.

Incase, therearenosurvivingspouse/unmarrieddependentchildren, theclaimshall thenbepayabletothe legalheirofthe deceased acceptor subject to production of legal heircertificate.

DOCUMENTSREQUIRED FOLLOWINGSTERILIZATION (SECTION-I-A&I-B):

a. ClaimFormcumMedicalCertificateinoriginaldulysignedand stamped by the convener of QAC/CMO/CDMO/CMHO/CDHMO/DMO/DHO/JointDirectordesignatedforthispurposeatdistrictlevel.(AnnexureI)

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b. Copy of Consent Form duly attested by the convenerof QAC/CMO/CDMO/CMHO/ CDHMO/DMO/DHO/JointDirectordesignatedfor thispurposeatdistrict level.(AnnexureII)

c. Copy of Sterilization Certificate duly attested by theconvener of QAC/CMO/CDMO/CMHO/ CDHMO/DMO/DHO/JointDirectordesignated for thispurposeatdistrictlevel..(AnnexureIV)

d. Copy of Proof of Post Operative Procedure/DischargeCertificate duly attested by the convener of QAC/CMO/CDMO/ CMHO/CDHMO/DMO/DHO/Joint Directordesignatedforthispurposeatdistrictlevel.

e. CopyofDeathcertificate issuedbyHospital/MunicipalityorauthoritydesignateddulyattestedbytheconvenerofQAC/ CMO/CDMO/ CMHO/ CDHMO/DMO/DHO/JointDirectordesignatedforthispurposeatdistrictlevel.

FAILURE OF STERILIZATION (SECTION-I-C)

The claims under Section-I-C (Failure of Sterilization) & I-D[(Complication following Sterilization operation (inclusive ofcomplicationduringprocessof sterilizationoperation)] shall bepaidinthenameofbeneficiary.

In case of amale beneficiarywho has undergone sterilizationoperationandmotility is noticed in the semen test reportafterthree months of sterilization operation; the designated districtlevel officer shall process and provide compensation to thepersonhavingundergonesterilizationasperthelimitspecifiedinSectionICoftheschedule.

DOCUMENTSREQUIREDFORFAILUREOFSTERILIZATION(SECTION-I-C):

a) ClaimFormcumMedicalCertificateinoriginaldulysignedand stamped by the convener of QAC/CMO/CDMO/CMHO/ DMO/ DHO/Joint Director designated for thispurposeatdistrictlevel.(AnnexureI)

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b) Copy of Consent Form duly attested by the convenerof QAC/CMO/CDMO/CMHO/CDHMO/ DMO/DHO/JointDirectordesignatedfor thispurposeatdistrict level.(AnnexureII)

c) Copy of Sterilization Certificate duly attested by theconvener of QAC/CMO/CDMO/CMHO/ CDHMO/DMO/DHO/JointDirectordesignatedforthispurposeatdistrictlevel.(AnnexureIV)

d) CopyofanyofthefollowingDiagnosticReportsconfirmingfailure of sterilization duly attested by the convener ofQAC/CMO/CDMO/CMHO/ CDHMO/ DMO/DHO/JointDirectordesignatedforthispurposeatdistrictlevel.


European Union

IND

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9 788189 479947

ISBN

81-89479-94-6

Female sterilization in India overwhelmingly dominates the contraceptive

method mix used across the country, at a colossal 75%. In addition to this, 85% of

the family planning budget is used for promoting and implementation of female

sterilization through camps in rural India. Through these camps, women continue

to be pushed into the procedure, often with a glaring lack of informed consent.

Sterilization in India has long been used as a means of target-driven population

control, disregarding the reproductive autonomy of women in favour of curbing

population growth. Although the National Population Policy 2000 broke new

ground in prioritizing reproductive rights over population control, the existence

of sterilization camps and the rampant, disproportionate promotion of the

procedure demonstrate that implementation 18 years on remains to be fully

realized.

In 2015, the Devika Biswas v Union of India case challenged appalling sterilization

camps that were taking place across the country, rounding up poor women

and loading them like cattle into abandoned schools, sterilizing them in barbaric

and highly unsanitary conditions, without anesthesia. These camps resulted in

many deaths, and in the overwhelming majority of cases, the women did not

consent to the procedure – many of them were young and in the reproductive

age group of 18-39. In a landmark judgment, the Supreme Court outlawed the

camps and directed various states to provide compensation to the families of

the victims.

Nevertheless, sterilization in India is still problematic. Ground level health workers

are heavily incentivized to encourage women to undergo the procedure, rather

than promoting condom or oral contraceptive pill usage. Sterilization remains a

procedure that is performed at a disproportionately high rate when compared

with other nations. This book will look at sterilization through a rights-based lens, to

shed light on how sterilization has been used for years as a weapon to impede

reproductive autonomy and champion coercive population control tactics, at

the expense of women's bodies. The book also highlights the struggle through

the use of law to change the way family planning programmes especially

female sterilization was being implemented

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