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Gender matters
‘The empowerment and autonomy of women and the improvement of their political, social, economic and health status is a highly important end in itself. In addition, it is essential for the achievement of sustainable development. The full participation and partnership of both women and men is required in productive and reproductive life, including shared responsibilities for the care and nurturing of children and maintenance of the household. The power relations that impede women’s attainment of healthy and fulfilling lives operate at many levels of society, from the most personal to the highly public… Achieving change requires policy and programme actions that improve women’s access to secure livelihoods and economic resources, alleviate their extreme responsibilities with regard to housework, remove legal impediments to their participation in public life, and raise social awareness through effective programmes of education and mass communication… [para 4.1, Chapter IV on Gender Equality, Equity and Empowerment of Women, Program of Action (POA), International Conference on Population and Development (ICPD), 1994.] THE ICPD Programme of Action has been hailed as a path-breaking document in many respects, foremost being its radical paradigmatic shift from demographic imperatives to qualitative aspects – among which, empowerment and rights of women, gender equality and equity play a major role.1 This document is in many ways symbolic of the victory of the international women’s movement, especially in mainstreaming a highly contentious and contested international document with a feminist language of gender justice and rights.2 Having mainstreamed and institutionalized gender language and policy intent, the aftermath of Cairo (and Beijing in 1995)3 presents a serious challenge to feminists, gender policy advocates and activists. The challenge is on two fronts. One, to ensure that the gains made in these international conferences are not lost in the country contexts whenever policies and programmes are designed. Two, if policies do incorporate a gender language, in being ever watchful that they are not operationalised in a diluted and depoliticized form. However, playing the faithful watchdog role has been fraught with complications and problems, as the language of gender has been subject to a free-play of dilution or ‘rhetorification’, to coin a new word. Given the handful of women (and men) in India who subscribe to a feminist political content in gender discourse, the task is daunting as the mechanisms for monitoring and ensuring accountability remain poor. The challenge is especially acute in the new millennium as gender sensitive language is becoming politically correct (or incorrect) and (un)fashionable in policy circles and documents. And there remain many new, static and conservative interpretations to ‘gender ideologies’. Post-Cairo, India was one of the few countries to incorporate some elements of the ICPD-POA. In 1996-97, India experimented by first removing targets and then designing the Community Needs Assessment Approach (CNAA) which envisaged a bottom-up and decentralized planning of health and reproductive needs within the community. The Reproductive and Child Health (RCH) approach followed, which brought into its ambit a
lifecycle approach and expanded the state services beyond maternity and child health to include
SEMINAR, Vol# 511, Beyond Numbers, March-01 gynecological morbidities including STD/AIDS. It has a section on ‘gender sensitivity’ which purports to provide good quality care, male participation in family planning, focusing on reproductive tract infections, keeping clinics open at times suitable for women, training in gender sensitivity for service providers and involving elected women members and clients for monitoring4 (MOHFW, 1997). In the year 2000, the Indian National Population Policy (NPP 2000) and the state population policy documents were released. Some of these policy documents have attempted to incorporate the language of gender equity and women’s empowerment in their goals or objectives and/or strategies. How are these policy intentions supported by concrete strategies for action? To what extents do these policies genuinely engender equity and justice for women? This paper will focus on gender implications of the state and national population policies. First, a framework for analysis will be outlined followed by a brief history of population policy in India. This will be followed by a description of the macro-environment within which these policies are located in India. Next, the population policies, in terms of their gender implications will be outlined, followed by conclusions. In India, in matters of fertility decisions, multiple forms of power converge on women and
several actors mediate control over women’s bodies. They include the husband, the family, the
community in some instances (when religion comes into the picture) and the state. One location
is the family where gender and other social hierarchies play a role. In the Indian socio-cultural
context, women do not make isolated individual decisions about their fertility. Men and elderly
women play a critical role in deciding the number and the preferred sex of the children.
Outside the household, in the ‘public’ sphere, the thrust of health and population (control) policies dictate the options and choices available to women for accessing services. Pro-natalist regimes encourage women’s fertility in some countries of Asia, notably Japan, Singapore and Malaysia. Here a denial or restriction in the supply of birth control methods is actively engineered by the state.5 Anti-natalist countries like India discourage fertility and gear their health and family services towards this end. The quality of women’s relationship with their partners also plays a role in negotiating fertility. At times, however, women subvert family decisions by adopting contraceptives surreptitiously. This is where the family planning services have a critical role in provisioning of safe, affordable and effective contraceptives. Thus the state has the ability to either enable or disable women in control over their bodies and their fertility. In addressing or confronting the state for access to safe and effective contraceptives, the human
rights framework is a powerful instrument to ensure women’s access to health and reproductive
decisions. The state, including the Indian state, is obliged to respect, promote, protect and fulfil
women’s right to self-determination by most international human rights conventions and treaties.
However, when the state supersedes women’s/men’s right to decide the number of children in
the interest of the ‘socially desirable goal’ of population control/stabilization, women/men’s right
to birth control gets compromised. This is precisely where the ICPD-POA document’s
SEMINAR, Vol# 511, Beyond Numbers, March-01 delineation of rights, especially reproductive health and rights in the specific context of population policy, is relevant (see Chapter 7, articles 7.2, 7.3, 7.4). Starting with the WHO definitions of reproductive and sexual health,6 this chapter defines reproductive rights as the right to make reproduction decisions free of discrimination, coercion and violence. It defines government duty to base all policies and programmes including family planning programmes on these rights, and to promote equitable gender relations. The chapter states that reproductive health services (including sexual health and family planning) should be linked to the primary health care system, and should include making abortion safe (where it is not against the law), treating reproductive tract infections, sexually transmitted diseases and infertility, in addition to maternal and child health services plus counselling men and youth for responsible sexual behaviour. The chapter supports decentralization of services, improvement of quality in the family planning programmes, and strongly argues against any form of coercion in family planning programmes including targets, quotas, incentives and disincentives. It calls upon civil society to monitor programmes and put in place systems to detect and control abuse. The chapter has a strong section on the health needs of adolescents. However, reproductive health and rights have come under heavy criticism as being western, in
sharp contrast to eastern/southern cultural traditions. Further, they are construed as
individualistic, androcentric, abstract and universalist (see Sen and Batliwala, 2000). The ethical
principles of reproductive rights as delineated by Correa and Petchesky (1994) – bodily integrity,
personhood, equality and diversity7 – help transcend these criticisms by making them applicable
across cultural, socio-economic and political contexts.
In India too, the concept of reproductive rights is poorly understood. Further, other social, economic and civic rights like right to livelihood, safe drinking water, sanitation and general health care are juxtaposed as meriting more importance and attention than reproductive rights. A popular critique in India (among some progressive women’s groups as well) is that reproductive rights reduce women’s identity to their uterus and reproductive organs, diminish their value as persons, and ignore other health and survival needs. The difficulty of translating reproductive rights in local languages is a another critique against this concept. However, such challenges for translating feminist concepts are not new. Take for instance, the
concept of gender. The word for sex and gender is the same – linga – which is also another word
for the ‘phallus’. In Malyalam, sex gets translated as linga, and gender becomes linga-padavi.
Retranslated into English, literally, this could mean ‘phallus’ for sex and ‘phallus status’ for
gender, ironically giving a centrality to the phallus as an important feminist concept. Yet, these
concepts are not rejected but used creatively by feminists, underlining the political significance
of creating a new language.8
Notwithstanding the above critique of reproductive rights, their conceptualization by feminist scholars9 as well as the delineation out-lined in ICPD-POA, underscores the relevance of reproductive rights in the Indian context. However, it needs to be emphasized that reproductive SEMINAR, Vol# 511, Beyond Numbers, March-01 rights are not ‘stand-alone’ or isolated rights, but intimately and intricately connected to other social, economic, civil and political rights of men and women – with special rights for women for the biological (and social) onus and burdens for reproduction that women bear in the context of gender power relations. It is a powerful feminist political strategy to use reproductive rights as a struggle-concept in the context of gender subordination and coercive target oriented population policies. And to ensure that it does not get smothered and lost in the arti-culation of other equally important rights which encompass basic needs. The diversity and complexity of women’s lives across their different identities and socio-political locations in India makes it difficult (and unjust) to indulge in an exercise of hierarchy of rights, and privilege some rights over others. Depending on a woman’s specific life-context, different kinds of rights assume importance at different time points to enable her to lead a fulfilling life. Asserting rights as an individual or collectively through institutions (like unions, women’s groups) then becomes an important and strategic instrument for women to negotiate with the state and affect or alter policy in the process. To understand such shifts in policy dynamics, I will adapt Mackintosh (1992) who distinguished
between two models of development policy – policy as prescription and policy as process. These
connote a static and dynamic concept of policy respectively. Policy as prescription is just that –
what the government/state prescribes for achieving policy objectives and goals and is based on a
set of assumptions that the state is inherently benevolent and knows what is best for its citizens.
Policy as process seeks to explain how different institutions and actors who are involved, or
affected by the policy, take a proactive stance in challenging policy. In the process, they end up
forcing changes, making alterations or modifications in the way policy is operationalised.
The interaction between the prescription and the process is forever dynamic, where the state tries its best to subvert efforts it perceives as contrary to its objectives. This is where coercion, disincentives and incentives come into play in population policies and attempt to put a brake on the process of individual self-determination. It is also buttressed by restricting options in the design and quality of health care provided to the people and by promoting specific types of contraceptives. However, women’s groups protesting against dangerous and harmful contraceptives in India
have amply demonstrated that there are niches and spaces within the political system to put
brakes on policy. For example, the ban on contraceptives like Net-en and Quinacrine is a case in
point. The ban was affected entirely through action and protests by women’s groups. In 1985, the
Stree Shakti Sanghatna and in 1998, the All India Democratic Women’s Association (AIDWA)
SEMINAR, Vol# 511, Beyond Numbers, March-01 initiated a public interest litigation against the State of India challenging Net-en trials and sterilization through injecting Quinacrine, a malarial drug into women’s reproductive system. These efforts have effectively stymied the efforts to introduce these contraceptives in the state family planning services. Population policy in the last 50 years continues as a struggle between prescription and process. In this paper, I make a distinction between analyzing policy per se and policy document. The former is a larger exercise, which includes analyzing the intent on paper and the translation of policy action at the ground level, which can be done when the policy has been implemented over a period of time. The latter, however, remains a document-analysis when the policy is released to the public. Here, the goals and themes of the policy are analyzed in tandem with the strategies stated on paper to operationalise these – to see how they contradict/conflict or reinforce/enable each other. This is best done in the historical context of previous policy formulation and translation that been in operation over the decades. Population policy in India lends itself to such a historical and contemporary analysis, having been in existence for half a century since 1952. When India launched its family planning programme in 1952, it was primarily initiated with a laudable goal of ‘nation-building’. The policy to begin with was relatively benign.10 The family planning programme was first and foremost embraced by men, keen to contribute to India’s development with a personal and patriotic fervor by adopting a small family norm. In fact, educated young men, post-independence, were highly motivated by leaders who believed that India’s progress lay in curtailing its population size. Vasectomy and condoms dominated the programme and many men voluntarily and willingly
adopted both. Men in the 1950s and early ’60s aptly termed this as recreation without
procreation.11 While diaphragms for women were also available, they lay mostly unused as men
took the initiative.12 It was not until the mid ’60s when Lippe’s loop, an intra-uterine device
(IUD) was introduced, did women come into the picture to adopt it as a spacing method, despite
many attendant problems. The ’60s was also a period when the oral pill emerged as a popular
contraceptive in the West. It journeyed to India not long after, and was officially introduced into
the family planning programme. By this time, however, the unstated goal of population policy
moved to solving India’s food crisis and poverty by reducing the number of people.
By the mid ’70s, with the availability of condoms and vasectomy for men and the oral pill and
Copper-T, a new IUD for women, an uneven balance was achieved in terms of ‘choice’ and
options available for men and women. It was uneven because women’s contraceptives were
invasive in nature compared to those for men. While condoms were non-invasive in the broadest
SEMINAR, Vol# 511, Beyond Numbers, March-01 sense of the term, Copper-T by its constant presence in the uterus led to reproductive morbidity and discomfort in the form of excessive bleeding during periods for many women. Further, it was provider controlled as a woman’s decision to terminate this method needed support from medical practitioners who in the prevailing policy climate could very well refuse. The pill though invasive in terms of its side effects for some women – manifested by mood swings, depression, nausea and other morbidities – was user controlled in the sense that women could stop using the pill in case they so decided. The contrast in terms of side effects and invasiveness of the contraceptives available for men and women by mid ’70s was very sharp. It was around this time that the first ever Statement of National Population Policy was announced in 1976, and incentives and disincentives became a policy strategy. Coinciding with the now infamous years of the Emergency and forced vasectomies that toppled the government, the 1976 population policy was buried forever. A year later, in 1977, a new policy statement on family welfare emerged.13 The rapid changes and turnarounds in population policy within a short span of one year during this period are reflective of policy as process through the political clout of Indian men. The change in nomenclature from family planning to family welfare was deliberate. Massive
human rights violations during vasectomies had marked the term family planning with a
scandalous and negative connotation. After 25 years, family planning became family welfare, but
it was like old wine in new bottle. The only difference being that women became the prime
targets for India’s population control programme facilitated by the merging of maternal and child
health with family welfare. Women who went for post-natal check ups or abortions, were arm-
twisted into accepting methods like IUDs, pills or sterilization, depending on the number of
children and surviving sons, by health workers, whose career and promotions depended on the
number of ‘cases’ they could mobilize for family planning. Thus women’s right to birth control
got hijacked by the state’s agenda of population control, now euphemistically called family
In 1983, the National Health Policy emphasized the need for ‘securing small family through
voluntary efforts
and moving towards the goal of population stabilization’ (emphasis added). The
Parliament voiced the need for a separate national population policy while adopting the health
policy. In the absence of a clear-cut population policy, the strategies of incentives and
disincentives became the norm accompanied by an aggressive drive to enrol women for
sterilizations. In 1991, the National Development Council committee on population brought out
its report. But it remained on paper. It was only on the eve of the International Conference on
Population and Development, 1994, held in Cairo that the exercise of a draft National Population
SEMINAR, Vol# 511, Beyond Numbers, March-01 Policy under the chairmanship of M.S. Swaminathan was conducted. Opposition from women’s organizations to parts of the draft and a concern within government circles about setting up a powerful Population Commission with financial and administrative controls resulted in the document not being formalized (see HealthWatch, 2000). This brief detour into the chequered history of India’s population policy highlights the
* One, the Indian population policy is based on an assumption that state intervention is necessary to influence and control individual behaviour and action to meet socially desirable goals like population stabilization. * Two, population policy in India has thus far, essentially been a population control policy with a smattering of development objectives thrown in – like access to education and health – more in an instrumentalist fashion. * Three, the prerogative of the state over citizens in deciding the number of children is buttressed by a range of incentives and disincentives to discipline and control fertility (and sexuality) and guide the design and financial allocation of health care systems in the public hospital. Health care providers end up becoming the conduits for implementing such draconian policy, severely compromising genuine health care needs of the people and quality of care. * Four, post the vasectomy scandal, women form the prime targets for population control and the contraceptives available in the family welfare programme are women-centred. They have progressively moved from user controlled ones like oral pills to provider controlled like IUD or terminal methods like sterilizations. Trials on long acting hormonal contraceptives have been conducted on women flouting all ethical norms of informed choice and consent; examples being injectibles like Depo Provera and Net-en, or implants like Norplant. The macro environment in which the new population policies are being introduced needs
mention at this point. More than 10 years of structural adjustment programmes have contributed
to a growing poverty and erosion of livelihoods of the poor, not the least due to alienation of land
as a result of large development projects and moves towards privatization of common property
resources. Rising unemployment and decline in food security, privatization of services coupled
with cutbacks in the thin and shrinking welfare measures has meant that the lives of poor,
especially the lower caste and tribal women, are under severe stress. Under conditions of
deteriorating poverty women bear the worst brunt, given gender bias in allocation of meager
SEMINAR, Vol# 511, Beyond Numbers, March-01 resources in households and women’s reduced access to health and education (see Sen, et al., 2000). In this bleak scenario of struggle for survival, the decade of the ’90s also witnessed certain positive developments for women at the policy, legislative, judicial and programme levels: * The entry of women into the panchayati raj institutions in the urban and rural areas following the 73rd and 74th amendments to the country’s Constitution. * The setting up of the national and state women’s commissions for dealing with situations that constitute violations of women’s human rights. * The Supreme Court ruling concerning sexual harassment of women in the workplace. * The directive banning Quinacrine (as a chemical method for female sterilization) by the Supreme Court. * The District Primary Education Programme that encourages education of the girl child, plus other measures like mid day meal scheme and free schooling for girl children. The ’90s also witnessed a strengthening and broad-basing of movements by the tribals, dalits,
fish workers, farmers and women and many diverse initiatives to demand rights and
accountability from the system, emphasizing the significance of policy as process in articulating
development policy. On the whole, the overall environment is disabling at one level while
enabling counterpoints at another.
The National Population Policy was introduced in February 2000. It combines some elements of the RCH and outlines 11 strategic themes.14 For each of these, ‘operational strategies’ are outlined. Broadly, the thrust of NPP 2000 is in the right direction in recognizing ‘.the most effective development policies are those which are socially just and focus on the well-being of all people.’ As far as gender concerns go, the section on ‘empowering women for improved health and nutrition’, focuses on some critical needs like drinking water, fuel, fodder, child care centres, and access to primary health care with an overwhelming focus on obstetric care. Sexually transmitted diseases also find mention along with reproductive tract infections (RTIs). The primary emphasis and approach of the policy is on women as wives and mothers. SEMINAR, Vol# 511, Beyond Numbers, March-01 Adolescents are mentioned only cursorily, though in another section on ‘under-served
population groups’ a subsection is devoted to adolescents, but the focus is on nutrition,
prevention of child marriage and a general mention of information, education and counselling
services, without mentioning the specific needs of adolescent boys and girls. For example, there
is no mention of gynaecological services for adolescent girls among whom menstrual morbidity
is a common complaint. Neither do post-menopausal women find a place in the policy, despite
growing statistics of the prevalence of reproductive cancers. The much acclaimed life-cycle
approach of the RCH is absent.
The strategies for men’s cooperation and enabling them to take responsibility for their fertility is touched upon only sketchily. The main concern is to motivate men to adopt contraceptives, especially popularizing the NSV – no scalpel vasectomy – and small family norm, being a responsible husband (taking care of wives during pregnancy) and a responsible father. Strategic issues of gender equality are missed out as men ar SEMINAR, Vol# 511, Beyond Numbers, March-01



Bibliografia 6 Abikoff, H. (1985). Efficacy of cognitive training intervention in hyperactive children: Acritical review. Clinical Psychology Review, 5, 479-512. Abikoff, H. & Gittelman, R. (1985). The normalizing effects of methylphenidate on theclassroom behavior of ADDH children. Journal of Abnormal Child Psychology, 13,33-44. Abikoff, H., Gittelman-Klein, R. & Klein,

Microsoft word - appendix_26_medical memorandum for isu events

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