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The Return of Population Control: Incentives, Targets and the Backlash against Cairo
by Betsy Hartmann
Editors Note: Worldwide political upheaval, financial crisis, and urgency around climate change inspire hope for radical change and reform in some, while others see an opportunity for a return to the old days of coercive population policies. In the latest issue of DifferenTakes, PopDev director and longtime international womens health activist Betsy Hartmann calls on the reproductive health community to stand strong against incentive programs in family planning, long proven to be harmful to women and to the cause of reproductive freedom. Co-editors Katie McKay Bryson and Betsy Hartmann

In January, the U.S. Agency for International Development (USAID) sent out an electronic bulletin about strengthening family planning services with performance-based incentives. These include reducing financial barriers for voluntary sterilization through compensation payments to clients.1 The use of such incentives in the population field raises troubling ethical concerns. Paying

poor people to be sterilized or to use a certain form of contraception distorts the whole notion of reproductive choice. Topping up the salaries of poorly-paid health workers on the basis of their ability to meet sterilization and contraceptive quotas or targets does the same. Sterilization, for example, should be one option among many and not promoted over other methods, especially given its permanence. USAIDs bulletin, and the longer report on which it is based, represent a potential backslide away from reproductive health and freedom toward the top-down population control programs of the past. It is time to take action before history repeats itself. Lest we forget that history, recall the experience of Bangladesh. In the mid-1980s, Bangladeshs then martial law government instituted a crash program to reduce the countrys birth rates. In addition to enhancing incentive payments for sterilization, it introduced punitive measures against family planning and health personnel who failed to meet monthly sterilization quotas. Abuse was rampant. In the flood season of 1984, for example, relief workers uncovered a pattern of destitute women being denied food aid unless they agreed to be sterilized.2

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CLPP Hampshire College Amherst, MA 01002 413.559.5506 http://popdev.hampshire.edu Opinions expressed in this publication are those of the individual authors unless otherwise specified.

The governments policies did not occur in a vacuum. In 1983 major donor agencies, including USAID, the World Bank, and the UN Fund for Population Activities (UNFPA), put pressure on Bangladesh to achieve a drastic reduction in birth rates, primarily through sterilization incentives. Despite a law prohibiting the use of American funds for incentive payments, USAID financed 85 percent of the Bangladesh programs incentive costs. It got around the law by calling the incentives compensation payments. Sterilization acceptors received a cash payment equivalent to several weeks of wages and a new sari for women or sarong for men at a time when many villagers only owned one piece of clothing. Doctors, clinic staff, health workers, traditional midwives and even members of the public received a fee for each client they referred or motivated to be sterilized. As a result, the whole health care system was skewed toward sterilization and access to temporary methods of contraception was severely curtailed. Sterilization rates rose especially high in the lean season before the harvest when peasants were desperate for cash to buy food. 3 What happened in Bangladesh in the 1980s was nothing out of the ordinary. It was old-school population control with its typical callous disregard for poor womens health and rights in the war to reduce their fertility. Fortunately, by the end of that decade an international campaign against the incentives managed to stop the worst of the sterilization excesses in Bangladesh. At the same time, womens health and reproductive rights activists were organizing across the globe to reform population policy, and achieving a number of successes, particularly at the 1994 UN population conference in Cairo. The Cairo Plan of Action, endorsed by most of the worlds governments, came out against the use of coercion and incentives and disincentives in family planning programs and instead called for the provision of broader, voluntary reproductive health services. Although the Cairo agreement provided important tools for feminist reform of the family planning field, it did not go far enough in challenging population control. It left intact the assumption that population growth is a major cause of poverty, political instability and environmental degradation, thus obscuring the role of powerful corporate, military and government interests. Importantly, while it discouraged contraceptive acceptance targets at the local level, it endorsed national-level targets to reduce population growth by a certain percentage in a specified period of time.4 Several years after the Cairo reforms, the Fujimori dictatorship in Peru followed in Bangladeshs footsteps,

launching a crash program to reduce birth rates from 3.2 births per woman in 1996 to 2.5 by 2000. While USAID noted the challenges of meeting such a target in a quality way, it was still willing to fund the Peruvian program.5 In 1997 Fujimori began a brutal mass sterilization campaign primarily targeting indigenous Quechua women. Over two hundred thousand women were sterilized, many against their will, or without prior knowledge of the operation, as is documented in Mathilde Damoisels recent documentary, A Womans Womb.6 Although USAID was not directly involved, its acquiescence to the governments unrealistic demographic targets and its failure to monitor the program helped set the stage for abuse. In the wake of the Peruvian scandal, Congress approved the Tiahrt amendment in the 1999 Foreign Operations Appropriations Act. Among other stipulations, the amendment directs that in family planning (FP) projects supported by US government funds: service providers and referral agents cannot implement or be subject to quotas relating to numbers of births, FP acceptors, or acceptors of a particular methods; there be no incentives to individuals in exchange for becoming acceptors or program personnel for achieving targets or quotas for numbers of births, acceptors, or acceptors of a particular FP method.7 Why then, after ample documentation of the harm caused by such incentives, is USAID considering reintroducing compensation payments for sterilization and other problematic incentive schemes? The answer is twofold. First, performance-based incentives, commonly called pay-for-performance (P4P), refer to the current trend in international health and development programs to reward people and providers with money or goods for achieving performance targets. In the case of childhood immunization, for example, P4P programs might pay parents for bringing their children to be vaccinated and providers if they reach their quota of children immunized. USAID appears worried that if it doesnt embrace P4P, family planning may decline in perceived importance as other health activities are increasingly incentivized. Second, the reconsideration of incentives reflects a backlash against the Cairo reforms. For the more hardline proponents of population control, driving birth rates down still remains a higher priority than providing a broad array of reproductive health services

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or empowering women. The Cairo approach is too slow for their certainty that population growth is a primary cause of social and environmental ills. These proponents want immediate, quantifiable results, especially in countries where birth rates remain relatively high such as those in sub-Saharan Africa.

program in India, which pays sterilization incentives to clients, community health workers and doctors, with the scale of fees rising in low-performing states. Moreover, the report tries to rewrite history by claiming that compensation payments in Bangladesh did not promote reliance on sterilization.11

USAID funds a diversity of programs, some more atUSAIDs drive to reinstitute incentives is taking place at a tentive to reproductive health and rights than others. time of great global uncertainty. Elites in many counThe current foray into incentives may well represent an tries are looking for scapegoats for the financial crisis, attempt by population hardliners within the agency to climate change, and widespread political upheaval. In gain the upper hand over feminist reformers.8 To give the media, as well as many policy circles, blaming overthe agency its due, it has acknowledged population, and hence the fertility some of the potential pitfalls of family of poor women, especially women planning incentives, such as coercive of color, is back in vogue. NeolibIn the media, as behavior by managers and providers. eralisms vicious assault on social well as many policy In the case of compensation payments, welfare has also intensified the view USAID recognizes that, without clear of poor people as unworthy burdens circles, blaming communication, clients may incorrectly on the state, economy and society. overpopulation, interpret the offer to cover transporThe political mood is turning toward and hence the tation costs to access counseling or a re-embrace of population control. fertility of poor specific services (e.g., voluntary sterilizawomen, especially tion) as payment to accept a method. If there is a proverbial canary in the Yet the agency still asserts that these coal mine, it is increasing reports women of color, is pitfalls can be overcome with smart of the forced sterilization of HIVback in vogue. design, and ongoing monitoring and positive women, who are among the assessment.9 most vulnerable to social and medical oppression. According to Lydia No amount of smart design or monitoring can correct guterman of the Open Society Foundations, Commuan approach that is fundamentally flawed. To pay, presnity-led documentation efforts in Chile, the Dominican sure or force poor people to make certain reproductive republic, Mexico, Namibia, South Africa, and Venezuela decisions over others is a violation of human rights. A as well as anecdotal reports from countries in Eastern careful reading of the longer USAID-commissioned reAfrica, Central America, and Southeast Asia indicate port, Performance-Based Incentives: Ensuring Voluntarism that the forced sterilization of HIV-positive women is an in Family Planning Initiatives, sheds unsettling light on increasingly global abuse.12 the agencys motives. While the report is produced by a consulting firm, Abt Associates, Inc., and bears the proOptimistically, one can view USAIDs recent publications viso that the authors views do not necessarily reflect on incentives as a sort of trial balloon sent up to gauge the views of USAID, it is published with the agencys the reaction of the reproductive health community. If imprint and is clearly the source for its January bulletin.10 that is the case, the sooner its popped, the better. More What is most striking about the report is its failure to pessimistically, it represents a calculated decision to criticize current incentive schemes financed by other undermine the Cairo reforms and reinstitute population agencies that would clearly violate the Tiahrt amendcontrol as a central motive and tool of family planning ment. For example, the report speaks positively of programs. If that is true, a broad, global mobilization Burundi, where health centers receive fees based on of reproductive health and rights advocates will be new family planning acceptors and for the insertion of urgently required. IUDs and implants, thus skewing contraceptive distribution toward long-acting, provider-controlled methods We can draw an important lesson from the past by over pills or condoms. It also offers no critique of Congo, recognizing that, if the reproductive health community where a European Union-funded project pays health does not quickly seize the moral high ground on the incenters fees on the basis of the number of sterilizations, centive issue, the anti-abortion movement will surely try IUDs and implants they provide. Nor does it question to do so for their own narrow purposes. They were quick the approach of the National rural Health Mission to latch on to the Bangladesh and Peruvian sterilization

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scandals, for example. More recently, anti-abortion groups have been the most vocal source of public outrage regarding reports that the authoritarian rwandan government intends to sterilize 700,000 men in the next three years in order to reduce population growth.13 USAID will be playing with fire if it seeks to circumvent the Tiahrt amendment: giving further ammunition to the anti-abortion movement could set funding and support for international reproductive health back severely. The days ahead are critical. The reproductive health community must put pressure on USAID and other international agencies not to embrace incentives. It is also important to monitor and resist the activities of private organizations such as Project Prevention. Supported by right-wing, eugenicist interests, Project Prevention pays poor people with drug addiction problems in the U.S. and U.K. to be sterilized or use long-term contraception. It has recently expanded into Kenya where it is paying HIV-positive women a $40 incentive to get an IUD

inserted, despite evidence that this may be detrimental to their health compared with other contraceptive measures. The rapid mobilization of HIV/AIDS and reproductive rights activists against Project Prevention serves as a positive example of what can be done.14 The time to act against the reinstitution of population control incentives is now.

about the author

Betsy Hartmann is the director of the Population and Development Program and Professor of Development Studies at Hampshire College. A longstanding activist in the international womens health movement, she is the author of Reproductive Rights and Wrongs: The Global Politics of Population Control (South End Press, 1995) and other non-fiction and fiction books. read more at http://www.BetsyHartmann.com

Notes
1. USAID, Strengthening Voluntary Family Planning Services with Performance-Based Incentives: Potentials and Pitfalls, Repositioning in Action, E-Bulletin, January 2011. See Betsy Hartmann, Reproductive Rights and Wrongs: The Global Politics of Population Control (Boston: South End Press, 1995) for an analysis of the Bangladesh sterilization program and other incentive schemes. Also see Matthew Connelly, Fatal Misconception: The Struggle to Control World Population (Cambridge: Harvard University Press, 2008) for more on the history of population control. Hartmann, ibid. See Betsy Hartmann, The Changing Faces of Population Control, in Jael Silliman and Anannya Bhattacharjee, eds., Policing the National Body: Race, Gender and Criminalization (Boston: South End Press, 2002). USAID, Coverage with Quality, Limited Scope Grant Agreement 527-0375, signed in Lima, Peru, September 26, 1996, p. 4. See Latin American and Caribbean Committee for the Defense of Womens rights (CLADEM), Center for reproductive Law and Policy (CrLP), and Estudio para la Defensa de los Derechos de la Mujer, Womens Sexual and Reproductive Rights in Peru: A Shadow Report (New York: CrLP, 1998) and the recent documentary on Peru by Mathilde Damoisel, A Womans Womb, now available to watch for free on http://www. cultureunplugged.com/play/4623/A-Woman-s-Womb USAID, guidance for Implementing the Tiahrt requirements for Voluntary Family Planning Projects, April 1999, http:// www.usaid.gov/our_work/global_health/pop/tiahrtqa.pdf The different motives for USAID family planning funding are evident in the agencys descriptions of its priorities. For example, it allocates resources on the basis of a strategic budgeting model that includes factors of unmet need, highrisk births, contraceptive use, and population pressures on land and water resources. http://www.usaid.gov/our_work/ global_health/pop/countries/index.html 12. 9. USAID, Strengthening Voluntary Family Planning Services with Performance-Based Incentives: Potentials and Pitfalls, Repositioning in Action, E-Bulletin, January 2011. USAID, Performance-Based Incentives: Ensuring Voluntarism in Family Planning Initiatives, September 2010, http://www. healthsystems2020.org/content/resource/detail/2686/ In regard to Bangladesh, the report claims that there is little evidence supporting the concern that such compensation schemes have promoted reliance on sterilization, and cites a 1992 study that shows a steady decline in sterilization rates despite the persistence of incentives. What it fails to note is that as the result of the international campaign against sterilization abuse in Bangladesh and pressure from more progressive international donors, the government finally began to offer poor women more access to temporary contraceptive methods which helps explain the decline in sterilization. Lydia guterman, Women in Namibia Fight Back against Forced Sterilization, November 22, 2010, http://blog.soros. org/2010/11/women-in-namibia-fight-back-against-forcedsterilization/ Edwin Musoni, 700,000 men expected to undergo vasectomy, The New Times, Feb. 2, 2011, http://www. newtimes.co.rw/print.php?issue=14524&print&article=3795 8. The anti-abortion Population research Institute has been one of the first to respond to the news, http://www.pop.org/ content/rwanda-sterilize-700000-men-pri-pledges-worktirelessly-against-it Brett Davidson & Lydia guterman, Whats Wrong with Paying Women to Use Long-Term Birth Control?, February 21, 2011, http://blog.soros.org/2011/02/whats-wrong-withpaying-women-to-use-long-term-birth-control/ ; see also, Susana Snchez, The Problem with Project Prevention: Opposing reproductive Coercion, March 29, 2011, http:// popdev.hampshire.edu/blog/post/the-problem-with-projectprevention

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