| BARUAN, India
BARUAN, India India officially abandoned targets for its mass sterilization program in the 1990s, accepting they had put undue pressure on people to undergo surgery and failed to curb population growth sufficiently.
Twenty years on and targets remain in all but name, say doctors, healthcare workers and family planning experts, meaning that, although below peak numbers, more than four million people underwent surgery in 2013-14.
In recent years, the vast majority have been women.
The risks the campaign poses were highlighted this month when more than a dozen women died after having a tubectomy at two sterilization "camps" in the state of Chhattisgarh.
Ongoing investigations point to contaminated drugs given to the women as a possible cause of death, but a dirty operating room and operations performed in a matter of minutes raised new questions about the program's efficacy and safety.
"Targets may have been removed, but the target mindset remains," said Poonam Muttreja, executive director of the Population Foundation of India NGO.
Wary of a ballooning population, India launched a family planning program to slow population growth in the 1950s.
As the campaign went into overdrive, some seven million men had vasectomies between April 1976 and January 1977, according to the Centre for Health and Social Justice in New Delhi.
Today, tubectomies on women are by far the most common form of birth control in India, and India's fertility rate, or the average number of children a woman has in her lifetime, has fallen from 3.6 in 1991 to 2.4 in 2012.
But it has failed to reach the desired "replacement" level of 2.1, and India, with a population of around 1.2 billion, is set to overtake China as the world's largest nation by around 2028, according to the United Nations.
At a recent sterilization "camp" in the eastern state of Odisha, operations went on apace, seemingly impervious to negative publicity after the deaths next door in Chhattisgarh.
A doctor and five assistants from a nearby hospital worked flat out, performing 13 tubectomies in about an hour at the facility in Baruan village.
After her surgery, 35-year-old patient Renubala Ojha was guided outside by a health worker who settled her onto a dirty rug to recover. Nearby, empty water bottles, used tobacco pouches and piles of cow dung littered the ground.
TARGETS OR "UNMET NEEDS"?
Sabitri Sethi, the health worker, said her supervisor had instructed her to bring at least two women to the camp.
Some 80 percent of Odisha's family planning budget under the National Health Mission was set aside for sterilization activity this year, including holding camps and paying compensation, a state health official familiar with the plan said.
He added that Odisha, which accounts for some 3.4 percent of India's population, is prepared to carry out sterilizations on as many as 20,000 men and 160,000 women this year.
The Health Ministry is adamant such numbers are not targets, and that state budget figures for the national program are expressions of "unmet need" for such services.
Critics say the distinction is misleading, because any objective puts pressure on healthcare workers and lands too many women in "camps" where dozens are operated on in a few hours.
"I have done 90 surgeries in a day," one doctor at the Chhattisgarh Institute of Medical Sciences admitted. "If I had said no, the government would have sacked me."
Officials in New Delhi add that, in addition to ditching targets, the government has promoted alternative options, including condoms and intrauterine contraceptives, to reduce the number of people having surgery.
Sterilizations dropped from well over five million in 2010-11 to over four million in 2013-14.
Critics counter that a payments-driven system continues to push more people to choose sterilization over other options.
At the Odisha clinic, Ojha received 600 rupees ($9.70) after her surgery, a significant sum in a country where hundreds of millions of people live on less than $2 a day.
Sethi, the healthcare worker, said she would also receive money for each woman she brought, but she did not say how much.
The Odisha state government pays 75 rupees ($1.20) to doctors for each surgery, 25 rupees to the anesthetist, 15 to the staff nurse and attendant, and 10 to other staff.
Advocates of a shift away from sterilization say the system penalizes the poor.
"The poor are being seen as irresponsible breeders ... who need to be permanently dealt with," said Abhijit Das, director of the Centre for Health and Social Justice.
Without better education for health workers and a more readily available selection of contraceptive choices, women will keep going to potentially dangerous camps, Das added.
And entrenched social attitudes will likely remain.
Many men think vasectomies threaten their virility, placing the burden on women. Of couples in India who use modern contraception, two percent of men were sterilized compared to 74 percent of women, U.N. data show.
(Additional reporting by Aditya Kalra in Bilaspur and Krista Mahr in New Delhi; Writing by Krista Mahr; Editing by Mike Collett-White)