The recent announcement that a National Population Policy (1) was approved by the Union cabinet provides an opportunity to examine the approach to the ‘population problem’, and its relevance to the ethical choices available to medical professionals.

The Indian programme

In his essay on the population programme, Mohan Rao describes the steady increase, over the years, in spending for family planning as opposed to public health, as “Family planning came to dominate concerns in the field of health and contoured the directions of health policy.” This money was spent aggressively promoting the ‘technological fix’ of the moment – first IUDs, then vasectomies, and, after the Emergency, tubectomies — through targets and camps. The latest is the range of provider-controlled hormonal contraceptives. Coercion reached new heights during the Emergency with targets for health workers, incentives and disincentives and forced sterilisations, often with legal sanction.

Such efforts had no effect on population growth since “the solution lies not in contraceptive technology but in attempts to deal with the problems of ill-heath and disease in the country, the heavy load of infant and child mortality, the lack of changes in the structures of employment, the pervasive lack of health and educational facilities…” (2)

There is little evidence of a real shift in perspective over the years. And though contraceptive-specific targets have been officially dropped after the post-Cairo ‘paradigm shift’ from population control to reproductive health, there is little doubt that the programme continues to focus on providing family planning to the exclusion of other services. At the same time, the government has been abdicating its responsibility to provide basic health services, to voluntary organisations and the private sector. ‘Liberalisation’ policies have increased the burden on the poor,worsening their health status, and that of their children.

The National Population Policy

The National Population Policy (NPP) hopes to address the unmet need for contraception, and provide health infrastructure, personnel and integrated service delivery for basic reproductive and child health, bring the total fertility rate to replacement level by 2010, and achieve a stable population by 2045. Besides more general directives such as making school education free and compulsory and promoting delayed marriage for girls, the policy advocates an “integrated package of essential services”, which seems to consist of providing contraceptives, treating some reproductive infections and implementing some communicable disease programmes. Shortfalls in the government’s services are to be made up by involving the voluntary and private sectors.

Many of the NPP’s recommendations are uncontroversial on paper, and seem to be aimed at providing people more services. However, the proposed incentives to poor couples for sterilisation, and rewards to local bodies for their performance, could encourage coercion. Women’s organisations have also asked how the ‘intersectoral approach’ will be implemented, and whether contraceptive technology and research will focus on safe and women-controlled products (3).

Most important, perhaps, is the fact that the NPP does not seriously address the conditions which produce illhealth. Without significant change at this level, family planning will remain a low priority for the poor.

Coercion

When there is no serious effort to address the basic problems which give rise to poverty, the ‘population issue’ will continue to be seen as a matter of reducing numbers, and coercive measures are easily discussed and promoted. Various states and the central government have introduced (or are discussing or have discussed) laws to ban people with more than two children from contesting elections, even denying couples with more than two children ration cards, bank loans and enrollment in government housing schemes (4, 5). The Maharashtra government’s recently announced population policy reportedly plans to offer couples monetary incentives if they accept sterilisation after the birth of one or two daughters (with no son). It would also deny government subsidies and benefits to couples with more than two children (6).

The population policy and medical professionals

Coercion is easily approved of by medical professionals who are too busy to understand or sympathise with the various pressures faced by poor patients. Some doctors have publicly called for compulsory sterilisation of women with two children. Many justify inserting an IUD or conducting a tubectomy without proper informed consent. All this is justified in the name of the ‘population problem’, or the woman’s health. Contraceptives and sterilisation are offered to women — even forced upon them — without complete information, or even proper care.

The ethical doctor provides patients the information and care that they seek — not what the doctor believes is in their best interest.