In September 2016, the Supreme Court of India directed state governments to upload, on the websites of their family planning departments, audit reports of deaths following sterilisation and the status of claims filed under the Family Planning Indemnity Scheme. The Court was disposing of a writ petition filed by social worker Devika Biswas and others, calling for action against lapses in government sterilisation camps. In the year since that order, no state or union territory has filed complete reports and fully complied with the directive.
As per government data, around 40 lakh sterilisation surgeries are conducted in India every year. In more than 97% of cases in India, it is the woman who faces the scalpel, though male sterilisation is both safer and cheaper. In the last five years, 1,000 women have died following sterilisation. Many more have faced post-operative complications. The fact that an apparently healthy woman dies or becomes ill following a short preventive procedure, is unacceptable.
Several studies from different parts of the country have reported the appalling conditions under which sterilisation camps are conducted – no pre-operative check-ups, poor infection-control, weak or no anaesthetisation, performance of large number of procedures by a single or a handful of doctors in a short time, and sub-optimal post-operative and follow-up care. There have also been reports of coercion during so-called counselling and the absence of any effort to get informed consent from the person being operated on. Most, if not all, deaths and complications from sterilisation surgeries are a result of utter negligence of the healthcare delivery system.
Evolution of sterilisation guidelines
The government has had standard guidelines for sterilisation services at least since 1989, and has updated them periodically. But these guidelines have not been implemented.
In 2003, lawyer Ramakant Rai and others filed a public interest litigation in the Supreme Court demanding that states governments be directed to comply with the latest standards for sterilisation surgeries. In 2005, the Court ordered the Union government to update its norms and standards for sterilisation, and ordered state and union territories to implement them: a panel of doctors authorised to conduct sterilisations. The Court ordered that state governments have a checklist to be filled by the operating doctor for each case, a proforma for taking consent, a Quality Assurance Committee to ensure compliance with Union government guidelines in pre-operative, operative and post-operative care, publication of statistics on the number of sterilisations, deaths, complications and failures, inquiry into every case of breach of guidelines, and action against the doctors or organisations responsible, and an insurance policy to pay compensation for complication or death following sterilisation or failure of the procedure itself.
Following the Supreme Court order, the guidelines were revised in 2006 and again in 2014. Under the guidelines, a doctor could conduct a maximum of 30 sterilisations in a day. The government also introduced the National Family Planning Insurance Scheme later modified as the Family Planning Indemnity Scheme.
But little changed.
The Araria and Bilaspur cases
In 2012, gross negligence was observed at a sterilisation camp in Araria district of Bihar. This was the case that social worker Biswas took up in her PIL at the Supreme Court. She reported that 53 women were operated on by a single surgeon at the camp during late evening hours on classroom desks under torch light in a school building that lacked even running water facility. Many of the women operated on in the camp underwent tremendous physical pain. Biswas also cited cases of negligence from the states of Rajasthan, Maharashtra, Madhya Pradesh and Kerala. In November 2015, even as the Court was hearing arguments in this PIL, 13 women died following sterilisation surgeries at camps in Bilaspur district of Chhattisgarh.
On September 14, 2016, while disposing of the Devika Biswas case, the Court ordered both union and state health departments to post details of doctors approved for performing sterilisation, and details of members of state and district-level Quality Assurance Committees on the union and state health ministry websites by December 31, 2016, to be updated every quarter. The Court also ordered state Quality Assurance Committees to prepare annual reports on the number of sterilisations, deaths, complications and failures. The reports were also to have details of enquiries held on deaths following sterilisation and the follow-up steps taken, and the status of claims filed under the Family Planning Indemnity Scheme. The Annual Reports for the financial year 2016-’17 were be uploaded on state websites by March 31, 2017. Moreover, the Court directed the health ministry to ensure that states do away with camp approach by 2019 and stop all targets for sterilisation programmes at any level, even informally.
Evaluating compliance
Towards compliance with the Devika Biswas order, the Union health ministry created a webpage with space for states to upload documents. However, as of July 2017, not a single state or union territory had uploaded all the documents required as per the Supreme Court’s directives. Only 24 out of 36 states and union territories have published some information related to sterilisation. The links provided by 28 states work but those provided by eight states are either dead or broken. The links provided by four states go to their respective health department websites, which do not contain any family planning-related data.
Maharashtra, Nagaland and Meghalaya have not uploaded their latest annual reports and Nagaland has not updated data since 2014. None of the states or union territories have uploaded death audit reports of all the deaths following sterilisation surgeries while only two states have uploaded any death audit reports at all.
Nine women died following sterilisation in Uttarakhand, but not a single death has been investigated.
Out of 1,748 fresh claims filed in the year 2016-’17, 61 were related to complication, 18 related to death and 1,669 were of failure in sterilisation. Apart from these claims, there were 581 pending claims from the previous year, of which 11 were cases of death and 570 were of sterilisation failure.
There are 125 claims that remain pending – three cases of complications following surgery, six cases of death and 116 of sterilisation failure.
The rate of rejections of claims is also very high. An analysis of 1,204 claims filed in 2016-’17 and earlier shows that 636 claims were rejected against 568 claims that have been paid.
From the limited data on the website, it is also clear that the rules are not being followed. For instance, in Punjab, in five cases post-sterilisation death, the victims’ families were paid Rs 7 lakh instead of Rs 10 lakh as stated in the Family Planning Indemnity Scheme guidelines. In Tamil Nadu, death audits were not performed in three cases and action has not been taken in four deaths.
Finally, an analysis of five years’ data shows that while there was a gradual decrease in number of deaths following sterilisation, in the last year the number of deaths has increased by 32%. Whether this reflects a true increase or is due to under-reporting of deaths in previous years is not known. According to data on the website from the Health Management Information System, only 10 women died in Chhattisgarh in 2014-’15. But we know that at least 13 women died in a single camp in Chhattisgarh, in November 2014 – a number recorded in the Supreme Court proceedings in the Devika Biswas case.
Little change
Despite the Supreme Court’s 2016 directives, there was a mere 5% decrease in the number of sterilisations conducted last year. Most states still follow a target driven approach and none of them have outlined strategies for phasing out sterilisation camps.
The Supreme Court’s order was intended to open to the family planning programme to public scrutiny, to hold government authorities accountable. The mere necessity of publishing data should prompt states to ensure the safety of women undergoing sterilisation. Many states have found a way around this by simply not following the orders of the Court.