issue 176 - October 1987
two ways to plan a population programme
START WITH THE POPULATION
'Progress should be measured in the only terms which ultimately matter - births averted'
Dr RT Ravenholt, ex-Head of Population, USAID
SIX STEPS TO COERCION
Set up a target
Setting definite population targets often means that more wide-ranging efforts to improve health and wellbeing are neglected. In INDONESIA 95% of women know about family planning, but less than 25% have ever heard of immunization or oral rehydration, both vital aids to preventing child deaths.
'When you've got targets and incentives it just becomes a family
planning programme and not much more than that'
Tricia Parker, Oxfam Bangladesh
'Here the only things not lacking are contraceptives I have sent many letters reporting a
shortage of supplies and the only thing they ever send are contraceptives'
Doctor, Dominican Republic
Choose your weapon
Target-oriented programmes tend to concentrate on a small number of permanent or semi-permanent methods (sterilization or IUD) to minimize dropout rates. In CHINA where 49% of contraceptors use the IUD, a new type of IUD has been introduced recently which cannot be removed by the woman. It has to be extracted by a trained person with a metal hook.
'It is clear that political-administrative elites and not the masses of
acceptors are deciding on the technology to be used'
USAID Evaluation Report, 1979
'Women always ask for a good contraceptive because they really need one.
But the family planning worker pushes only those which have a target'
UBING Bangladesh, 1987
Cut costs to the bone
Providing proper counselling and screening costs money. When reduction of birth rates is the main aim, these 'luxuries' are often dispensed with. A study in COLOMBIA found that an integrated service with proper medical back-up cost four times as much per person-year of protection as a straight female sterilization drive and led to a wide-ranging cost-cutting exercise. A subsequent independent study found that 7% of women in COLOMBIA 8% in INDIA and 11% in GHANA regretted being sterilized or felt unsure about it
'Family planning programs are less costly than conventional development projects
successful projects of this kind will yield very high economic returns'
Robert McNamara, ex-President, World Bank
Informing people of the availability of services is necessary. But trying to persuade ('educate', 'motivate') them to use family planning demonstrates an unwillingness to understand why people have children in the first place. This means that those underlying factors are unlikely ever to be tackled and people will come to distrust a government that disregards their needs.
'The women said "If the children are small their mortality is so high that we do not dare to stop childbirth?" When we asked "Would you consider sterilization if no money was given?'; 13 out of 18 said "No"'
UBING Bangladesh, 1988
Possible complications and side-effects are ignored or minimized in a target-oriented programme because it is more important to add to the numbers of acceptors than to help women make an informed choice about contraception. In BANGLADESH and MEXICO, for example, people are often not told that sterilization is permanent. Recent US studies of the IUD warn that it should never be used on women who intend to have children because of the danger of permanent sterility.
'We don't tell them of the major side-effects for fear of losing them'
Field worker, Kenya
Force as a last resort
When all else fails and people are still not coming forward in sufficient numbers to meet the targets, then persuasion escalates into coercion. This generates further distrust and resistance which is, in turn, met with further coercion, culminating in gross abuses such as those during the 1975-to-1977 State of Emergency in INDIA In the last half of 1976 over 6.5 million people were sterilized - a rate four times that in any previous period
'Coercion? Perhaps But coercion in a good cause'
'Overt violence or other potentially injurious coercion is not to be
used before non injurious coercion has been exhausted'
Bernard Berelson (ex-President of the Population council) and Jonathan Lieberson
'Human Rights is not the overriding issue in the population field'
Dr van Arendonk, UNFPA Bangladesh
'If you have the operation you will get a sari and money'
I had been working as a dai (midwife) for the Government since 1974, but I resigned when they stopped paying my salary and only paid me if I brought in patients to be sterilized. Now I work for the Family Planning Association because they pay a salary as well as a bonus for each sterilization. I don't bring in people who want IUD any more because I don't get paid for them now.
I have to motivate people by telling them 'More children - more problem. How much land do you have? If you have more children you will not live well.' Then I say: 'If you have the sterilizatlon operation you will get a sari and money.' I was told to promise them wheat as well. But some of them were angry when they were not given the wheat. They said they would not let me beck into the village until I got them a ration card and some wheat. But I have no power to do that. So far I have referred 125 women and 15 men for family planning. It is difficult to motivate men for vasectomy. But in the poorest families both husband and wife have been sterilized to get the money and food. Once 75 people were operated in one day. It was during the floods in 1984 when lots of people lost their crepe and there was no work for them. They attracted the people by offering wheat and money. Two of the patients were widows. They didn't need the operation but they needed the food. The health worker told me to keep quiet about it.
'I did not agree but she would not leave me alone'
My husband is a day labourer. I'm 18 years old and we have two children. A woman from the Government told me: 'You have two children. You must have the operation.' I did not agree, but she would not leave me alone. She kept on promising wheat, sari, ration card. Then she took me to the centre by saying that she had asked the permission of my husband and he had given permission. But actually he did not know. When he came to the centre I was already inside the operating room. Then they said I have to be operated because I am already ready and my name is on the list.'
Interview by UBING, Bangladesh
START WITH THE PEOPLE
'A woman who wants family planning can have it. But we don't think it is a top priority. We don't think poverty will end by ending the poor'
Orlando Rizzo, Director of Health, Nicaragua
5 BILLION POPULATION PLANS
Every person is different and each has her or his optimal strategy for survival. For some the best strategy is nine children; for others it may be one or two. The only humane population programme is one that expands people's opportunities so that large families are no longer necessary for survival. And that means understanding and respecting the reasons why people have children.
WHY PEOPLE HAVE CHILDREN
1. LOW STATUS OF WOMEN: Where husband and in-laws want many children, a wife may not dare to object
2. NEEDS OF TODAY: Children help with work and provide status and love for their parents.
3. FEAR OF TOMORROW: Children are many parents' only source of security in old age.
4. LACK OF CONTRACEPTION: The family planning clinic may be too far away, the services too expensive or scarce, or even prohibited.
5. FEAR OF INFERTI LITY: Where children are needed fear of infertility can lead to early, frequent childbearing.
6. FEAR OF CHILDREN DYING: In the Sahel a woman must have ten children to be 95% certain of a surviving adult son.
7. CONTRACEPTIVE SIDE EFFECTS: Unless these are clearly explained women may avoid contraception unless they are really desperate.
'We always begin with the needs that the group identifies'
When we go to a new group we always begin with a meeting with the women to see what they want. They might decide they want to learn how to read, that they want information about birth control, or advice about getting rid of a caique (local boss). We always begin with the needs that the group identifies and then discuss with them how these needs relate to what we call our four analytical cornerstones - four issues which represent the oppression of women.
The first is the role of women as housewives and mothers and the devaluation of domestic work, how this creates a self-image of being someone who has to be provided for. The second is women as workers. Women workers do not receive a fair wage because their earnings are considered a complementary salary. The third issue is sexuality: women are not subjects in the decisions affecting their bodies. They cannot make free decisions about motherhood or their sexual partnership with a man. The fourth issue is women's lack of control in their own political process. We believe that the analysis of these four cornerstones can help women transform themselves into subjects of their own reality.
For birth control it's no different. We always start from the experiences of the women. We realize, for instance, that there is no 'ideal' method of birth control and that people's decisions about it can change at anytime. The most important aspect of this work has been to give women the information they need to choose the method they prefer. A woman who has access to this information can start to take decisions about motherhood and her own sexuality. But the decision to become a mother is tied to many other factors: to better salaries, to deeper changes.
The Government sees population growth as an evil force. But we question whether this factor is the cause of our 'underdevelopment'. We see population growth as only one aspect of our reality. But the Government is only interested in statistics. We in CIDHAL, as feminists, are also concerned about the person. We believe that women are capable of deciding what is best for them.
Of course not all family planning programmes culminate in sterilization at gunpoint But if you concentrate on population first and people second, people will always tend to be sacrificed to the programme. Periodically abuses appear and the system is tinkered with. But the approach itself is never questioned, so the abuses simply resurface later in a new guise. In INDIA for instance, despite the sterilization scandals of the 1970s, there are now new reports of widespread sterilization abuse in Gujerat (using famine relief as an 'incentive') and Rajasthan (using promises of employment as an 'incentive' for tribal women).
...of a bad programme
1. Incentives to staff or clients
2. Emphasis on sterilization or IUD
3. Use of targets
4. Special cadre of family planning workers different from or paid more than general health staff
... of a good programme
1. Full integration with health programmes
2. Wide choice of contraceptives
3. Counselling , screening and follow-up
4. Treatment and prevention of infertility