File photo of a female sterilization camp. Photo: Reuters
- India has adopted the “cafeteria approach” for its family welfare program, in which couples have several options to choose from depending on their needs.
- This policy has been truer on paper than on the ground, where policy design often overlooks the socio-cultural context in which ‘street bureaucrats’ operate.
- Based on conversations with ASHA workers, the authors discuss some of the ways decisions become biased in favor of female rather than male sterilization.
According to recent estimates from the Fifth National Family Health Survey (NFHS-5), the use of family planning methods in India increased from 53.5% in 2015-2016 to 66.7% in 2019-2020. A 25% increase in five years in this regard is remarkable.
Access to family planning methods, or contraception, helps reduce maternal and child mortality by ensuring adequate spacing between births, the absence of unwanted pregnancies and reducing the risk of pregnancy complications. The outcome measure for the success of this program is considered to be the total fertility rate (TSF).
Figure 1 illustrates a sharply declining TFR trend from 1998-1999 to 2019-2020, which is desirable from a population control perspective. But are we on the right track?
India has adopted the “cafeteria approach” to its family welfare program, where couples are given several options depending on their needs and requirements – at least on paper.
“Family planning” ideally involves informed and voluntary decisions by individuals to manage the size of their family based on their preferences and the resources available to them. However, the terms “family planning” and “female sterilization” are often used interchangeably – which in itself ridicules the concept of choice as it relates to women.
Furthermore, a breakdown of the use of different family planning methods shows that female sterilization remains the most common method of contraception: 38% of women aged 15 to 49 report using this method in NFHS-5.
Female sterilization is a permanent method of contraception. A 2003 study who analyzed patterns of use of this method found that half of Indian women were sterilized by the age of 35 and most of them were sterilized between the ages of 20 and 35. method”, especially men from lower socio-economic strata. This forces women to opt for permanent sterilization.
Studies have also related sterilization at risk of menstrual dysfunction later in life. So, in the basket of all choices, female sterilization may not be the best one. However, policy makers have considered that India has had access to such a “basket”, in the “cafeteria approach”, since the 1980s.
Policy outcomes are driven by policy design elements and effective implementation. The effectiveness of implementation largely depends on the “street-level bureaucrats”, that is, the civil servants who mediate the relationship between the state and the citizens.
Michael Lipsky introduced the term “street-level bureaucrats” in 1980 to refer to front-line public workers who interact directly with people and often enjoy a substantial level of discretion in the performance of their duties.
Now, given one of Main tasks accredited social health activists aka ASHA workers under the Child Reproductive Health Program is to provide family planning counseling, we can safely assume that they also put implement the “cafeteria” approach.
We argue here that implementing the “cafeteria approach” in a way that is true to its spirit depends largely on the attitude, behavior, and discretion of counselors and family planning advocates on the field – who are the ASHA workers and auxiliary nurse midwives (ANM) . Our arguments here are drawn from conversations with ASHA workers in Haryana, Uttar Pradesh and Gujarat.
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Context of decisions
India was the first country in the world to launch a family planning program, in 1952. Over the past six decades, this program has evolved in its approach and design. It was started as a clinical program and was quickly replaced with a focus on community education and promotion of small family standards. Then, for a brief two-year period in the early 1970s, the government took a coercive approach and was criticized for it.
In 1977 the government renamed the program to focus on family welfare and the “cafeteria approach” was followed. The couples received multiple choice: female sterilization, male sterilization, intrauterine contraceptive devices, oral contraceptives and condoms. This program has also been integrated into the “Reproductive and child health” programme.
The government’s efforts toward birth control have been laudable, but at the same time they seem to ignore the sociocultural contexts at play when couples decide which method to adopt and when. Family planning counsellors, ASHA workers, and ANMs are mostly women and therefore typically target other women in their work.
According to NFHS-4 data, three out of eight men think contraception is a woman’s business; maybe that’s why only 0.3% of couples in India have opted for male sterilization. Some ASHA workers in Haryana also told us that they think female sterilization is the best option – especially after the birth of a male child – because it is a one-time event. which excludes the need to visit health centers again and again and because the government incites it.
Some ASHA workers also said, “We distribute condoms to women in the community, but these women are helpless and fail to convince their husbands, and then we have to deal with their unwanted pregnancies, that too in a secret way. “.
The contexts in which ‘street bureaucrats’ operate are an important factor influencing policy implementation. Their own choices, their understanding of the best contraceptive methods, and prevailing social and gender norms affect their ability to disseminate information to a target group. At its simplest, they tend to influence women’s decisions by emphasizing which methods they feel are better or more appropriate.
ASHA workers are usually part of the same community of people they work with, and in order for them to truly implement the “cafeteria approach,” they will need to understand the importance of presenting to the women they work with. engage in different choices, to be aware of the short and long term implications of different choices, and to involve the men of each family in their conversations.
Vanita Singh is Assistant Professor of Public Policy at Vijay Patil School of Management, DY Patil University, Navi Mumbai. Shobha Kumari and Pratima are pursuing a master’s degree in public health at the Tata Institute of Social Sciences, Mumbai.