Read Part I of this report here.
USAID TIED TO “RESULTS”
The OECD report also elucidates how USAID encouraged India's sterilization quota system to develop by carefully financing its activities in India. It used a unique mechanism known as “performance based disbursement (PBD”) in which the dollar value was attached to “a set of targeted results” agreed upon between USAID and SIFPSA. “The targets for achievement were set at an achievable yet ambitious level to emphasize the focus on achieving results,” according to the OECD.
Of course, on the surface it looked as though population targets were being dropped. As USAID noted to PRI this week, US law forbids funding them. The 1999 Tiarht Amendment prohibits the U.S. Agency for International Development (USAID) from funding any family-planning program that has targets or quotas, is coercive, has financial or other incentives or involves non-consensual experimentation. If any of these requirements is violated or a “pattern or practice of violations” emerges, the administrator of USAID has 60 days to submit a report of findings and remedies to the Committee on International Relations and the Committee on Appropriations of the House of Representatives and the Committee on Foreign Affairs.
It was damaging for India to keep quotas in the open after all the bad publicity China's One Child Policy was eliciting in the 90s anyway, so in 1996 India adopted a “Target-Free Approach” to family planning. But recent investigations by human rights activists in India have found that population targets and sterilization quotas are still routine and widespread. “Every state sets targets in its annual health plan for female sterilization, male sterilization, insertion of IUDs, and distribution of contraceptive pills,” says a 2012 report from Human Rights Watch (HRW) based on interviews with 50 Indian health workers. “A central government body, the National Project Coordination Committee, reviews these targets and allocates funds for family planning in every state.”
And the funds, at least in part, are coming from USAID. A 2014 report of the Health Policy Project, a five-year cooperative agreement funded by USAID in 2010 and implemented by Futures Group, Futures Institute CEDDPA and others, details how funds to India’s National Rural Health Mission in the state of Uttarakhand are dispersed through a labyrinth of implementing District Health Societies and their underling organizations and how “RCH Flexipool funds are used for reproductive and child health programming, which includes maternal health, child health, family planning, JSY, RCH camps, and compensation for sterilisation.”
State family planners, working to ensure that the people sending the cash are pleased, can get draconian to meet their quotas.
“They shout at those who have not fulfilled their targets during meetings. It’s humiliating,” one worker told HRW. “They say, “If others can achieve the target, why can’t you? You must know some women? You must have relatives or some contacts after working in the villages? Use them and get women operated [sterilized].”
“In much of the country, authorities aggressively pursue targets, especially for female sterilization, by threatening health workers with salary cuts or dismissals,” the HRW report adds. “As a result, some health workers pressure women to undergo sterilization without providing sufficient information, either about possible complications, its irreversibility, or safer sex practices after the procedure.”
“I have to keep going to women’s houses,” one worker explained. “Sometimes in one week I go 10 times to one woman’s house.”
It's also why at financial year end or when new budgets are being written, sterilization targets can suddenly swell in India. Dr. Abhijit Das from the Centre for Health and Social Justice, told HRW investigators, that in Bihar state for example, fewer than 150,000 sterilization operations were “achieved” in 2005-2006 but that target for 2011-2012 was set at 650,000—nearly a four-fold increase. Similarly, the state of Madhya Pradesh set a target of 700,000 sterilizations, doubling what was achieved in earlier years.
SIFPSA’s “target-free” policies were simply a bugbear that family planners had to work around, while still playing the numbers game. SIFPSA's website describes how it “kick-started the government sterilization programme after setbacks due to the introduction of the target-free approach and expanded services provided in camps by funding 60,148 integrated RCH camps in 33 districts of [Uttar Pradesh] and 5 districts of Uttranchal.”
And there is no sign of India retreating from its population control objectives. A press release issued last month by the Government of India’s Ministry of Health and Family Welfare details new “schemes and awareness campaigns” by the government “to stabilize the population of the country.” These include a new emphasis on “post partum sterilization,” a “compensation scheme for sterilisation acceptors” which has been “enhanced for 11 high focus states with high TFR,” a National Family Planning Indemnity Scheme which protects “providers and accredited institutions “against litigation in the event of death or complications following sterilizations.
It also describes how the government made World Population Day a mandatory celebration in 2013, which is marked by “Mobilization Fortnight” and “Population Stabilization Fortnight” government funded campaigns marked by increased population control activity including camps.
RESURRECTION OF THE IUD
Clearly, India's sterilization camps are a public relations nightmare for health officials and any foreigners even remotely involved. It's not likely the way most American elite designers and “innovators” of the programs envisioned their population control being executed. But it is the reality.
Another new population stabilization “scheme” listed by the GOI is an “emphasis” on resurrecting hormonal and copper IUDs, intrauterine devices that are surgically implanted in the uterus to prevent conception for up to five years.
IUDs fell out of fashion in the US in the 1980s after as many as 200,000 American women testified they were injured by the notorious Dalkon Shield—and their market has never really recovered. Given the complications associated with IUDs from displacement (one 2014 study describes their migration to the peritoneal cavity is a known complication and they have even been found to migrate to the intestine), and expulsion to perforation of the uterus and infection,it's hard not to wonder why a development agency would choose it for a country where women are dying from filthy sterilizations. It also is known to cause heavy bleeding in some women which would be a particular problem among Indian women, more than half of whom (56%) HRLN reports are anemic.
But in the mid 2000s USAID started looking for more ways to reduce fertility in the developing world and The Contraceptive and Reproductive Health Technologies Research and Utilization (CRTU), a five-year (2005-2010) agreement with Durham, NC based Family Health International (now FHI360) resulted. FHI started working in a number of countries including India through its Ministry of Health and Family Welfare (MoHFW), the Population Council, the Indian Council of Medical Research, the Constella Futures Group, SIFPSA and, of course, the government of India's most populous state, Uttar Pradesh, towards supporting the “revitalization” of family planning, “especially the IUD.”
In 2007, USAID sponsored a symposium with FHI360, about developing a “comprehensive strategy for IUD repositioning.” Dr L.B. Prasad, the director general of India's MOHFW once again highlighted the growing population of India. He said that “limiting methods” of contraception (ie., sterilization) were not so acceptable as they once were and that they wouldn't really affect population growth enough since sterilizing couples had already had all the children they want. In order to really get numbers down, he said, they needed “birth spacing” and the Copper T380A IUD was the answer to be “promoted by changing the mindsets and attitudes of people and providers.”
This explains why currently at all of SIFPSA/ USAID/India affiliates’ websites, including those belonging to Jhpiego at Johns Hopkins University and Engender Health include copious documentation about the benefits and need for promoting social awareness and acceptance of Long Acting Reversible Contraceptives (LARCs)s like the IUD; and strategizing about social marketing and social franchising to “create a market” and “increase demand” for the devices. Once again, advertising agencies and media are enlisted, providers are being trained in the technicalities, and community workers deployed en masse to bring women into hospitals for safe, clean deliveries where they can have IUDs inserted within 10 minutes of delivery.
A study published in October 2014 in the Journal of Obstetrics and Gynecology of India says that post partum insertion of a copper IUD is “safe and effective” and “cash incentives to the accepter, motivator and of course provider would bring about a substantial progress in the PPIUCD use in developing countries like India.”
USAID seem to have been well ahead of that trend. One USAID/INDIA Innovations in Family Planning Services Final Evaluation Report from May 2013 discusses the implementation of a compensation scheme for IUDs and sterilizations, without any mention of the Tiahrt Amendment. “Janani Suraksha Yojana (JSY), a safe motherhood intervention under the NRHM [National Rural Health Mission], is being implemented with the objective of reducing maternal and neonatal mortality by promoting institutional delivery among poor pregnant women.”
“The success of the scheme is determined by the increase in institutional delivery among poor families,” explains the report. “All mothers irrespective of age, birth order, or income group (BPL & APL) will get cash assistance of Rs 1400 in a lump sum at the time of delivery. ASHAs [Accredited Social Health Activists] receive Rs 600 for accompanying a rural delivery and Rs 200 for an urban delivery.” The USAID document says that sterilization is equally rewarded under the scheme with 600 rupees for a tubectomy and 1,100 rupees for vasectomy. 
Of course, there is no guarantee that IUD provision in India will be any safer, cleaner or more ethical than the sterilization camps were meant to be. HRW interviewed health workers who said India is already implementing the “camp approach” to IUDs. One doctor in Tamil Nadu said camps in her district insert IUDs in 30 to 35 women a day and activists are documenting cases of women having the devices inserted without consent and refused their requests to have them removed.
USAID said last week that it no longer supports its SIFPSA offspring. There are new strategies in play and private sector funding and corporate profiteering are playing a greater role today, although there is considerable overlap between all these agencies. Rajeev Shah, the Administrator of USAID's $22 billion annual budget, for instance, spent years in leadership positions at the Bill and Melinda Gates Foundation before he launched his government career.
Melinda Gates appears now to be leading the charge for IUD programs for India and the rest of the developing world. Her foundation website says it gave $3 million last year to Jhpiego Corporation to “provide support to the Family Planning Division, MoHFW, Government of India, as [it] takes leadership and management in providing voluntary, high-quality FP services in India with a special focus on the six high TFR [total fertility rate] states of UP, Bihar, Jharkhand, Rajasthan, Madhya Pradesh and Chhattisgarh. She awarded another $5 million to Cambridge, MA based Abt Associates, a favorite of USAID, to promote a “basket of contraceptives including injectable contraceptives” to couples in Bihar and Uttar Pradesh. And she gave FHI360—a group that has been working in India over the past two decades—$3 million for a multi-center study on IUDs.
While Gates has distanced herself from population control, Gates' family planning ties are hard to disentangle from their population control roots. Her foundation awarded $15 million this year, for example, to “promote accountability” of family planning programming in India and other countries to Johns Hopkins University—a group that has been among those at the helm in India under IFPS for the past decades while women suffered the most barbarous sterilization abuses. But the Gates Foundation declined to answer PRI’s questions about its programs in India.
Some might consider the USAID/Gates “technological” approach to family planning amidst the deeply entrenched cultural context of India naïve. The question remains whether IUDs, latex rubber gloves for sterilizations and US-sponsored free condoms for men will do anything to truly help women in the country where they are still tortured to death in witchhunts, half are married before age 18 and millions of baby girls are killed by infanticide. Indeed, the USAID approach—increasing Western pharmaceutical and device consumption and reducing by sterilization the number of babies born to Indian women—population control by definition—seems only to have added to the exploitation and suffering of India’s women. Already more than 20 years of history of US underwriting of this population control tyranny is documented in tedious government and NGO policy reports. The reality is told in heartbreaking detail by human rights activists, by the women themselves, and by their surviving families and children. America must now decide whether it wants that legacy to continue.
India: Target-Driven Sterilization Harming Women, 12 July, 2012. http://www.hrw.org/news/2012/07/12/india-target-driven-sterilization-harming-women
Effectiveness of Fund Allocation and Spending for the National Rural Health Mission in Uttarakhand, India Block and Facility Report, March 2014, The Policy Project. http://www.healthpolicyproject.com/pubs/377_UttarakhandPhaseFINAL.pdf
SIFPSA website. http://www.sifpsa.org/ifps_project/key_achievements.htm
“Population Stabilization.” Press Release of the Government of India Ministry of Health and Family Welfare, 05 December, 2014. http://pib.nic.in/newsite/PrintRelease.aspx?relid=112699
Laparoscopic removal of migrated intrauterine device embedded in intestine.” Journal of the Society of Laparoendoscopic Surgeons, July 2014. http://www.ncbi.nlm.nih.gov/pubmed/25419105
Fact-Finding Report on Sterilization, Access to Contraceptive Information and Services, and Women’s Health in Bilaspur District, Chhattisgarh 14-18 November 2014,” Human Rights Law Network
Symposium to Develop a Comprehensive Strategy for IUD Repositioning, Report of FHI 360, 03 March , 2008. http://www.fhi360.org/sites/default/files/media/documents/Symposium%20to%20Develop%20a%20Comprehensive%20Strategy%20for%20IUD%20Repositioning.pd
Evaluation of Safety, Efficacy, and Expulsion of Post-Placental and Intra-Cesarean Insertion of Intrauterine Contraceptive Devices (PPIUCD).”Mishra S. Journal of Obstetrics and Gynecology of India. October, 2014.http://www.ncbi.nlm.nih.gov/pubmed/25368457
EVALUATION: USAID/India Innovations in Family Planning Services Project Final Evaluation Report, May 2013. http://pdf.usaid.gov/pdf_docs/PA00JQ4B.pd
See No. 1.
Gates Foundation website. http://www.gatesfoundation.org/How-We-Work/Quick-Links/Grants-Database/Grants/2013/11/OPP1084386
Gates Foundation website. http://www.gatesfoundation.org/How-We-Work/Quick-Links/Grants-Database/Grants/2013/10/OPP1084463
Gates Foundation website. http://www.gatesfoundation.org/How-We-Work/Quick-Links/Grants-Database/G...
Gates Foundation website. http://www.gatesfoundation.org/How-We-Work/Quick-Links/Grants-Database/Grants/2013/04/OPP1079004
210 women tortured to death for 'witchcraft' in Chhattisgarh, many await justice.”The Times of India, 06 December, 2014. http://timesofindia.indiatimes.com/india/210-women-tortured-to-death-for-witchcraft-in-Chhattisgarh-many-await-justice/articleshow/45397113.cms
See No. 6.
Reprinted with permission from Population Research Institute.