WP(C) No. 36271 of 2016 (Suo Motu)

## **IN THE HIGH COURT OF KERALA AT ERNAKULAM** ## **PRESENT** **THE HONOURABLE THE CHIEF JUSTICE MR.S.MANIKUMAR** ## **&** ## **THE HONOURABLE MR.JUSTICE MURALI PURUSHOTHAMAN** **TUESDAY, THE 21[ST] DAY OF FEBRUARY 2023 / 2ND PHALGUNA, 1944** ## **WP(C) NO. 36271 OF 2016** ## **PETITIONER:** **SUO MOTU BY ADV ...** ## **RESPONDENTS:** - **1 THE STATE OF KERALA REPRESENTED BY THE CHIEF SECRETARY TO GOVERNMENT THIRUVANANTHAPURAM** - **2 THE STATE OF KERALA REPRESENTED BY THE SECRETARY TO GOVERNMENT, HEALTH AND FAMILY WELFARE DEPARTMENT, THIRUVANANTHAPURAM** - **3 THE STATE OF KERALA REPRESENTED BY THE SECRETARY TO GOVERNMENT , SCHEDULED TRIBES DEVELOPMENT DEPARTMENT, THIRUVANANTHAPURAM** - **4 THE DISTRICT COLLECTOR WAYANAD** - **5 THE DISTRICT MEDICAL OFFICER WAYANAD BY ADVS. SENIOR GOVERNMENT PLEADER SRI.TEK CHAND V.** **THIS WRIT PETITION (CIVIL) HAVING COME UP FOR ADMISSION ON 21.02.2023, THE COURT ON THE SAME DAY DELIVERED THE FOLLOWING:** **WP(C) NO. 36271 OF 2016 ..2..** ## **JUDGMENT** ## **MURALI PURUSHOTHAMAN, J.** This writ petition is registered suo motu as per the direction of the Hon'ble Supreme Court in judgment dated 14.09.2016 in W.P.(C) No.95 of 2012 (Devika Biswas _v_ . Union of India and Others) for remedial action against unprofessional sterilization procedures conducted in Kerala. 2. Writ Petition (C) No.95/2012 was filed before the Hon'ble Supreme Court on 07.01.2012 by one Devika Biswas in the light of a sterilization camp conducted under the auspices of an NGO called Jai Ambey Welfare Society. In the said camp, 53 women underwent a sterilization procedure through a single surgery in highly unsanitary conditions flouting the norms and procedure laid out in the Quality Assurance Manual for Sterilization Services (in 2006) and resulting in tremendous physical pain and trauma. In the writ petition, at paragraph 40, **WP(C) NO. 36271 OF 2016 ..3..** reference was also made about an incident in Wayanad district in Kerala in July 2011 among Kattunayakan tribe. 3. The Hon'ble Supreme Court disposed of the writ petition as per Judgement dated 14.09.2016 with supplementary directions contained in paragraph 88. In paragraph 88.13, it is stated that none of the States have given acceptable response to the allegations made by the petitioner therein. Therefore, the Hon'ble Chief Justice of the High Courts of Madhya Pradesh, Maharashtra, Rajasthan and Kerala, were requested to initiate Suo Motu public interest petition to consider the allegations made by the petitioner in respect of sterilization camps held in these States. This Suo Motu writ petition was registered under the aforementioned background. 4. A counter affidavit is filed by the 2[nd] respondent denying the allegations levelled in paragraph 40 of the writ petition filed by Devika Biswas. Paragraph Nos.4 to 9 of the counter affidavit are extracted hereunder: **WP(C) NO. 36271 OF 2016 ..4..** “4. It is respectfully submitted that at the outset, the allegation levelled in paragraph 40 of the writ petition filed by Devika Biswas is stoutly denied. No such incident as averred in the writ petition had taken place. There is absolutely no compulsive/forced/coercive sterilization of kattunayikan tribals; for that matter any other tribals or any other section of the community either at Wayanad or any other parts of the State. 5. In Kerala sterilization procedures are carried out by doctors with Gynaecological degree having undergone laparoscopic sterilization training. There is a panel of doctors in every district to perform sterilization camps and 4-5 master trainers in every district to the Gynaecologists. 6. The Government of Kerala has prepared a check list and circulated to all institutions which were filled before carrying out sterilization procedures in respect of each proposed patient. In this check list all criteria stipulated are included on the basis of guidelines Issued by the Government of India. Strict direction are given to doctors not to perform any operation without filling the check list. The Government has also circulated copies **WP(C) NO. 36271 OF 2016 ..5..** of the performance consent. The proforma is to be duly filled before performing the sterilization operation. 7. Further, the Government had set up Quality Assurance Committee in the State constituting of the Director of Health Services. The Director of Medical Education, Senior Gynaecologists. NSV Surgeon. Additional DHS(FW). Deputy DHS (FW). Deputy Director (Nursing) and Law Officer. In the district level too, Quality Assurance Committees are constituted with District Medical Officer of Health. RCH Officer, Gynaecologist. Anaesthetist, NSV Surgeon representative from Nursing cadre and legal representative. The committee will review all cases once in three months and also discuss the failure cases eligible for compensation and complications following sterilization. Uniform standards are followed with regard to the health of proposed patient, the age, norms of compensation and the format of sterilization, check list, consent proforma and insurance.. 8. It is humbly submitted that there is no compulsory sterilizations carried out by the Government. It is unethical and improper to thrust compulsion to perform sterilization. No **WP(C) NO. 36271 OF 2016 ..6..** compulsion can be thrusted upon any individual to do anything which is not obliged to do. The Government have neither violated any rights of any individual and have made any compulsion in respect of the sterilization procedures. It is reiterated that Government has never implemented forced sterilization procedures nor any instructions have been issued to the 5[th] respondent to perform compulsory sterilization. Copies of the proforma of Consent are being issued to all persons before sterilization. The clients who approach for sterilization are educated and proper counselling have been given to them before and after the procedure. The manuals, the drug hygienic standards and modern equipments are provided for such sterilization. 9. The sterilization camps are conducted only in well equipped centre (usually in first referral units and above hospitals) where there are operation theatre facility, lab facility, referral facility are in place. The persons who indents to performs sterilization operation are examined by a doctor for medical fitness and essential investigations are done (example Urine test, Blood Hb etc) the institution level. All staff including Surgeon, Staff Nurse, **WP(C) NO. 36271 OF 2016 ..7..** Laboratory Technician, ANM, Nursing Assistant are well qualified and trained performing these procedures.” 5. In the counter affidavit, reference is made to W.P(C) No.15139 of 2012 filed by the Kerala Prarthana Gotra Sangham, Wayanad. In the said writ petition, the prayer sought for _inter-alia_ was for a direction to the respondent to conduct an investigation into the incidents of forced/coerced sterilization in colonies. This Court, as per judgment dated 08.01.2020, disposed of the above writ petition on the basis of the counter affidavit filed by the 5[th] respondent, the District Medical Officer, Wayanad, and expressing satisfaction with the measures taken by the respondents. 6. In the said writ petition, the respondents denied forced sterilization and narrated the steps taken towards the health of tribals and other benefits extended to them. It is apposite to extract the counter affidavit filed by the **WP(C) NO. 36271 OF 2016 ..8..** District Medical Officer, Wayanad in W.P.(C) No.15139 of 2012, which reads thus: “1. I am the District Medical Officer, Mananthavady and the 3[rd] respondent in the above Writ Petition. I am conversant with the facts of the above case as disclosed from the official records. All the allegations and averments contained in the Writ Petition except those that are specifically admitted hereunder are denied. 2. It is respectfully submitted that I am not aware of the existence of the organisation referred to in Para-I of the above Writ Petition. At any point of time any of the office bearers of the above organisation contacted the department on any matter connected to the complaint under consideration. Several organizations of tribal community, including that of Primitive Tribe Group (PTG} are working closely with this department to improve the health status of tribal people. However, the aforesaid organization has so far not approached the department for any matter connected with **WP(C) NO. 36271 OF 2016 ..9..** health care of the tribes nor has the department been informed of their activities. It is further submitted that there is no forced st rilization of any community in Wayanad District. The allegations contrary to the same are totally false and baseless and hence denied. 3. It is respectfully submitted that this department is not aware of the strength or activities of the so called organisation as contended by the petitioner in Para 2 of the writ petition. It is further submitted that the population policy is implemented in a planned and organized manner. It is not being implemented in a mindless manner as alleged by the petitioner. The crux of the population policy rests on the reproductive rights for couples, of which right to regulation of pregnancy (through spacing methods or permanent sterilization) is a right of every couple / woman. Even though it is a fact that the population of some tribal groups are reducing as per statistics, the Govt. has no policy of denying the rights for regulation of number of children to couple, **WP(C) NO. 36271 OF 2016 ..10..** to increase population of some groups. It is the individual / couples right to decide how many children they should have and the department cannot dictate that they will be provided family pl,anning services only after they produce a particular number of children, just because they belong to a particular caste. It is the right of every couple and the department cannot deny the services to their any group, whether population is increasing or decreasing. 4. It is submitted that the allegation contained in Para-3 of the above Writ Petition that at least 40 men, many of them from Primitive Tribal Groups,(PTGs) were subjected to forced and/or coerced sterilization procedures at Bathery Taluk Hospital in Wayanad is totally baseless and hence denied. On the other hand all sterilizations are being done with proper informed consent. In case of PTG, special care is taken in the form of passing on information and getting the opinion of the tribal promoters and the Tribal Extension Officer of the concerned locality before **WP(C) NO. 36271 OF 2016 ..11..** ## sterilization is being done. 5. In response to the contentions contained in Para 4, it is submitted that the media report relied on by the petitioner is factually incorrect. The media report cannot be relied on as proof as they are often exaggerated version. Just because more numbers of sterilization cases were being done the same does not mean that forced sterlization is happening. Training camps are conducted in which more doctors participate and as a result more cases could be done. But each case is done only after observing all necessary precautions and after obtaining consent from the persons concerned. 6. It is submitted that this respondent has no information regarding the fact finding mission referred to by the petitioner in para-5 of the above writ petition. In fact no such fact finding mission has ever approached the department to get the correct facts of any case which alleged to have happened. This department was never approached in this issue by any such fact **WP(C) NO. 36271 OF 2016 ..12..** finding group of the said organisation. The standards as prescribed in Exhibit P-2 are meticulously being followed in all sterilization operations and allegations contrary to the same are false and hence denied. 7. In response to the contention in para 6 of the above writ petition that sterilization camps are being generally held at the Community Health Centres and that most of the patients are adivasis and due to the incentive. are made as financial They defacto target is not true and hence denied. On the other hand camps are being conducted in Community Health Centres ( CHCs) in order to make services available closer to homes and also to provide better services since over crowded major hospitals cannot bear the load without affecting quality of service. CHCs have all facilities for conducting sterilization operations as prescribed under the standards of sterilisation. Number off tribals in such camps are higher because due to anaemia during pregnancy, they cannot undergo post **WP(C) NO. 36271 OF 2016 ..13..** partum sterilisation (PPS) immediately after delivery and the only option left for them.is to approach such camps. Non -tribal women are generally not anaemic and so get the service of PPS available to them. It is further submitted that neither any extra incentive is given to tribal's to promote sterilization or any financial incentives is being provided to promote sterilization. A meagre amount of Rs. 250/- for APL and Rs. 600/- for BPL categories is being provided to compensate for loss of wages in cases of female sterilization. For shifting the onus of sterilization from female to male, the compensation. provided for male sterilization is set at a higher rate of Rs. 1100/- . This compensation for loss of wages is being provided to all clients irrespective of the community to which they belong. No special financial incentive is being provided to tribal communities. Besides proper and special care is being taken in the case of Tribal Community and in case of PTG, the Tribal Officer is duly informed and their concurrence is obtained before conducting **WP(C) NO. 36271 OF 2016 ..14..** sterilization. Higher compensation for loss wage is being given to all men irrespective of caste to increase proportion of male sterilization over female sterilization, in light of the department and government policy of being gender sensitive, 8. It is submitted that the allegation regarding forced sterilization mentioned in para-8 is absolutely false and hence denied. Forced sterilization has never been carried out, and on the other hand sterilisation is being done after getting voluntary consent. All information regarding benefits and risks of all sterilization procedures, various methods available and comparison of different methods is given to all clients including tribal clients. Special care is taken to provide information to tribal clients in the language they can comprehend. All allegations contrary to the same is false. 9. It is submitted that the allegation of lack of consultation and non-application of mind mentioned in Pra-9 is false and hence denied. **WP(C) NO. 36271 OF 2016 ..15..** 10. It is submitted that the allegation in para 10 that unprofessional and unskilled manner of sterilization resulted in several health complications to the patients is not true and hence denied. The further allegation regarding procedure lapses in conducting serilization which eventually lead to the death of patient is not factually correct. To our knowledge, no death has occurred in 2010 related to the sterilization operation. 11. It is submitted that the allegation in para 11 is also factually incorrect and hence denied. 12. It is submitted that the allegations contained in para-12 of the writ petition is factually incorrect and hence denied. The clients normally approach for sterilization operation because they do not want any more children. The only permanent effect of this operation is that they cannot conceive anot er child. There is no other permanent side effect on the individual. Since the client's intention itself is to limit family size in the first instance, it cannot be said that ## **WP(C) NO. 36271 OF 2016 ..16..** they do not understand the permanent effects of sterilization. In spite of this, the field staff provide necessary counselling to all acceptors of sterilization - providing them all information regarding the procedures and the risks and benefits involved. It is submitted that alll sterilization operations are being done in operation theatres, wherein only staff with proper authorization and in proper sterile clothing are permitted to enter. Maximum possible privacy and confidentiality is provided to all clients irrespective of the community to which they belong. In any institution, the operation theatre is the place wherein the maximum privacy is available and the allegation that there is no privacy in an operation theatre can only be termed as a wild imagination. It is submitted that several number of persons may be present in the pre and post operative areas, where it is impossible by any standards to provide separate rooms for each individual. Even in these areas, any procedure including injections are given **WP(C) NO. 36271 OF 2016 ..17..** only after providing proper privacy by using screens.. 13. It is submitted that the contention in Para -13, 14, 15 and 16 are not fully correct. This department as well as the Government under various beneficial schemes and projects are providing facilities for the uplifting and betterment of PTGs. The Government are implementing schemes and programmes for the proper education, health, food, land and shelter to the tribal community at large. The allegation contrary to the same are false and hence denied. 14. It is submitted that the allegation raised by the petitioner in para 17 that the Government have failed to provide STs full access to health, nutritional, and educational entitlements and has further endangered their lives and livelihood by implementing an irrational, coercive population control policy is false and hence denied. Since independence, the Government of India has introduced policies and which determine its programmes priorities on health. Population control has **WP(C) NO. 36271 OF 2016 ..18..** been at the core of these programmes since at least from 1950's. The focus of these policies has been to target permanent forms of contraception, such as sterilization programs, rather than developing a comprehensive and acceptable family planning policy. Tribal community has been provided with all facilities in Government Hospitals free of cost and all possible care is being taken in case of Tribal Group and BPL categories. 15. It is submitted that the contentions contained in Para-18 is not fully correct. The Total Fertility Rate (TFR) is a criterion for the community as a whole and not for individuals. The fact that Kerala has a low TFR is not sufficient or justifiable reason to deny services of family planning to any section of the society or to any individual. 16. In response to the contentions in Para19, it is submitted that Maternal mortality is 3 - 4 times higher among tribal groups than among non tribals. One major cause of maternal death is repeated pregnancies. Family planning is one of the most **WP(C) NO. 36271 OF 2016 ..19..** successful strategies to prevent such maternal deaths. 17. In response to the contentions contained in Para -20, it is submitted that population policy is not made blindly applicable in case of tribal, instead of family planning services are provided with utmost sensitivity to the needs of individuals and the status of the community. No targets are set for family planning. The need is assessed by a community needs assessment approach by the grass root level workers and then communicated to higher authorities. There is no process of target setting from the side of the department. As stated above the needs are assessed by the grass root workers in consultation with the local people, through a household survey as well as consultation with local community leaders through a consultative process. 18. It is submitted that the contention in para-21 is not true and hence denied. No financial incentive is being provided to promote sterilization. A meagre amount of Rs. 250/- each for APL and Rs. 600/- each **WP(C) NO. 36271 OF 2016 ..20..** for BPL categories are being provided to compensate for loss of wages in cases of female sterilization. As mentioned earlier for shifting the onus of sterilization from female to male, the compensation provided for male sterilization is set at a higher rate of Rs. 1100/- . This compensation for loss of wages is being provided to all clients irrespective of the community to which they belong. No special financial incentive is being provided to tribal communities. Besides, in case of Tribals, normally female sterilization is recommended for mothers having at least 3 children and mothers having minimum 2 children are subjected to sterilization only if they insist specifically for the same. 19. In response to the contention in para 22 it is submitted that the NRHM norms are only guidelines and they are not mandatory obligations. They are standards which the government has decided to strive to achieve through NRHM in the period till 2017. However, it is not a mandatory or legal obligation. But the department is making all **WP(C) NO. 36271 OF 2016 ..21..** efforts to achieve the idealistic standards set up under NRHM. 20. It is submitted that the contentions contained in Para-23 of the above Writ Petition is not fully correct. The approach of meeting unmet needs, providing choice and quality services and increasing male participation is in tune with the role of a government in a democratic country. It is a well recognized methodology followed by the best countries in the world. Efforts to increase male participation is a result of the increased sensitivity of the government towards the hardships of the women in the community and the need for a gender sensitive policy. This approach of meeting unmet needs, providing choice and quality services and increasing male participation is in tune with the role of a government in a democratic country. It is a well recognized methodology followed by the best countries in the world. Efforts to increase male participation is a result of the increased sensitivity of the government towards the hardships of the women in the community **WP(C) NO. 36271 OF 2016 ..22..** and the need for a gender sensitive policy. One of the main reasons behind the above approach is that female sterilization is a major surgery and it needs hospitalization for minimum 5 days and rest for at least one month. But Male Sterilization (NSV) is a minor procedure with no stitches. If needs only local anesthesia and no hospitalization. The patient can go for routine work next day onwards. So Government is promoting male sterilization and providing extra incentive to shift sterilization from female to male to ensure male participation in family planning. Subjecting woman to a major surgery when man can be sterilized through a very minor procedure is highly antiwomen'. So Government is trying to increase male participation in sterilization. 21. It is submitted that the contention of the petitioner in para 25 that State Government has still employing a quantity system is not fully correct. At the same time it is a fact that no programme can go on without setting up goals. Target and have to be viewed as goals different **WP(C) NO. 36271 OF 2016 ..23..** entities. Under the RCH programme, all goals for the next year are set at the local grass root level through consultations with the local community. This planning is needed for allocation of resources needed to provide quality services - including infrastructure, medicines, equipments, manpower and compensation for loss of wages. The state level PIP produced is the consolidation of all goals set by the respective communities against which performance of the workers are reviewed. In tune with the ICPD, the govt has done away with the system of setting targets for lower units. The targets claimed by the petitioner are just numbers arrived at to plan performance in the next year and there is no compulsion / incentive / disincentive for attaining / not attaining targets, since the goals are set by assessing the needs of the local community and not at district/ state _I_ national level. 22. In response to the contentions in Para 26 of the above writ petition, it is submitted that the chart actually supports **WP(C) NO. 36271 OF 2016 ..24..** the stand of the department. The first item, shown in the chart is institutional delivery. It is to be noted that no government would be under the impression that they can set targets for deliveries. This actually shows that the numbers shown are actual numbers of expected deliveries based on the assessment at the community level and not some target set by the government and imposed on the workers / community. It also shows that there is no extra stress placed by the govt on sterilization of tribes. The government does not even set separate goals on community wise. The allegation contrary to the same are false and hence denied. 23. It is submitted that the vacancy position referred to in Pra-27 of are not related to Wayanad since Wayanad does not have the claimed 197 Community Health Centres. The vacancies if any do not affect the quality of sterilization services provided, because of the fact that only qualified doctors are permitted to perform the various sterilization procedures. **WP(C) NO. 36271 OF 2016 ..25..** 24. It is respectfully submitted that the contentions in Para 28 of the above Writ Petition is not factually correct. The contention of the petitioner regarding staff unavailability etc. are not true. Minimum required staff are available. so far as the Wayanad District is concerned and the procedures and programmes are not affected. 25. The contentions of the petitioner in Para-29 of the above writ petition are not factually incorrect and the same would shows the total lack of knowledge of the petitioner regarding various sterilization procedures. He is making baseless allegations without properly understanding the minimum basics of the surgical procedures involved. Non scalpel vasectomy is not performed by gynaecologists. It is done by doctors specially trained in the procedure. No doctor, even if he / she is a surgeon / gynaecologist / any other specialist, is permitted to undertake no scalpel vasectomy unless and until they have **WP(C) NO. 36271 OF 2016 ..26..** undergone special NSV training as per norms. All are existing gynaecologists trained in emergency obstetric care as part of their PG course in Obstetrics. Emergency Obstetric care is not something which is given as a special training, but an integral part of postgraduate training in OBG. Without learning this, they cannot be qualified as a gynaecologist. Hence saying that only one gynaecologist is trained in emergency obstetric care shows the total lack of awareness of the petitioner in this regard. None of the constra,ints cited by the petitioner has ever resulted in any decrease in quality of services provided by the hospitals. Such things can happen occasionally in situations of developing countries like India. But all measures are taken to ensure that best possible quality of services are provided. No organisation has done any proper survey of the institutions in a scientific manner. 26. In response to the contentions and allegations in Para -31 of the above writ petition it is submitted that the petitioner's **WP(C) NO. 36271 OF 2016 ..27..** claim about Kalpetta Government Hospital is totally false and unfounded. In fact the hospital has a gynaecologist (2 at some points of time), blood storage unit, operation theatre and all related facilities. PHCs are not equipped with labour rooms because it is not needed in our society , where women prefer to deliver at the highest possible facility under care of a gynaecologist. No one prefers to deliver in PHCs. PHCs are envisaged to provide preventive services as well as primary care. The petitioner has no locus standi to say that pregnant women should be made to deliver in PHCs against their will. When there are no deliveries taking place, it will be a total waste to have incubators etc in a PHC.None of the institutions in Wayanad lack water supply. Sub centres have all facilities for the allotted work, they being staffed by a public health nurse, the functions are mainly related to prevention of diseases and care of pregnant women and children, for which all facilities exist in all 204 such centres. There is no shortage **WP(C) NO. 36271 OF 2016 ..28..** of IFA, condoms or other medicines needed for routine functioning of sub centre as alleged by the petitioner. 27. It is submitted that the petitioner is attempting to raise wild allegations to the effect that the department is not having any facility at all to conduct sterilization. In fact all surgeries are being done with total aseptic precautions in sufficiently equipped operation theatre by qualified expert trained doctors. By levelling such baseless allegations the petitioner is ,only aiming to demoralize the staff members, who are providing the best possible services to the community, with special care to the tribal community members. 28. It is submitted that none of the grounds raised in the above Writ Petition are legally sustainable. As stated earlier no forced sterilization is being carried out. All cases are being done after obtaining informed consent on proper counselling. Special care is being taken in case of tribal community. In case of PTG, the tribal officer is informed and their concurrence is also **WP(C) NO. 36271 OF 2016 ..29..** taken. All facilities are provided wherein sterilization is being conducted (both male and female sterilization) following the recommendation and guidelines issued by the Govt. of India in the standards for male / female sterilization. All procedures are carried out respecting the human rights of the clients. It is to be noted that uncontrolled fertility has a highly negative impact on the already poor health status of the tribal women. It is submitted that the only promotion being done by the government is to shift the onus of sterilization from the female to male by promoting male sterilization. The reason being that male sterilization (No Scalpel Vasectomy) is a very minor procedure and it does not need hospitalization / rest while female sterilization is a major surgical procedure needing a minimum of 5 days hospitalization and one month rest. 29. It is submitted that the Government does not set targets for sterilization. Goals are set based on a detailed 'Community Needs Assessment' (CNA). It involves a **WP(C) NO. 36271 OF 2016 ..30..** very detailed process of evaluation of previous 3 years performance, discussions with leaders on community community preferences and sample household survey to assess the needs of the community. Based on this assessment of the community's need of sterilization, goals are set at the sub centre level. These goals are used only for the purpose of planning service provision and are in no way treated as compulsory targets that are to be achieved. The goals are used purely to decide what sort of services are to be provided and where. No coercive measures are being used to promote sterilization. All cases being done after proper informed consent giving chance for free choice. No financial incentives are being provided to promote sterilization. 30. It is respectfully submitted that all norms set by the State and Central Governments are strictly followed in Wayanad district. No instances of violation of norms have been reported nor have any complaints been received at the District ## **WP(C) NO. 36271 OF 2016 ..31..** Medical Office (Health) Wayanad. The complainant organization also has not preferred any complaint in this regard. All information regarding benefits and risks of all sterilization procedures, various methods available and comparison of different methods are given to all clients including tribal clients. Since the cliants intention itself is to limit family size in the first instance, it cannot be said that they do not understand the permanent effects of sterilization. In spite of this, the field staffs provide necessary counselling to all acceptors of sterilization - providing them with all information regarding the procedures to be followed and the risks and benefits involved. All the surgical procedures are being done by qualified expert and specially trained doctors and staffs. Laparoscopic sterilization is done by a trained team of Gynaecologist and supporting staff, trained at recognized institutions for laparoscopic surgery. **NSV is** done by doctors trained specially for NSV as per norms for male sterilization by **WP(C) NO. 36271 OF 2016 ..32..** Gol. Even surgeons, with post graduate qualification in Surgery Other surgeries are not permitted to do NSV unless they are trained specially in NSV as per norms The allegation that doctors are not there to attend the case is totally false and baseless .Sterilization operations can only be done by trained specialists. Even MBBS doctors are not posted for sterilization operations. Only trained specialists are posted in all cases. It is impossible to do these surgeries without the presence of a doctor. Even by the maximum stretch of imagination, it cannot be construed that a non-doctor can attempt such a surgery. All sterilization operations are done in operation theatres, where only staff with proper authorization and in proper sterile clothing is permitted to enter. Maximum possible privacy and confidentiality is provided to all clients irrespective of the community to which they belong. In any institution, the operation theatre is the place wherein a patient gets the maximum privacy and the allegation contrary to the **WP(C) NO. 36271 OF 2016 ..33..** ## same is incorrect. Only one client is placed on an operation table and if there are more than one operation table in a theatre, a screen is provided between the tables. One operation table can only hold one person. Maximum number of tables in operation theatres in any institution in Wayanad is 2 and hence alleging that ten or more people are subjected to surgery at a time in the same room is totally false and hence denied. More number of persons may be present in the pre and post operative areas, where it is impossible by any standards to provide separate rooms for each individual. Even in these areas, any procedure including injections are given only after proper privacy providing screens etc. 31. It is submitted that sterilization operations do not have any such side effects as alleged by the petitioner. Female sterilization procedure needs hospitalization for 5- 7 days and rest for one month, while male sterilization does not need hospitalization and they can go for **WP(C) NO. 36271 OF 2016 ..34..** their routine job from the second day onwards. No financial incentives are being provided to promote sterilization. For shifting the onus of sterilization from female to male, the compensation for loss of wages is being provided to all clients irrespective of the community to which they belong. No special financial incentive is being provided to tribal communities. If at all this meager amount of compensation for wages lost is considered as an incentive, it is due to the fact that the tribal community do not have access to regular income. This has nothing to do with the health department. The department is providing the same compensation for all clients irrespective of their tribal / nontribal status, as per guidelines of the Gol. The Gol guidelines on sterilization procedures takes into account all international treaties and covenants in this regard. 32. It is respectfully submitted that good reproductive health is defined by the World Health Organization as "A state in which **WP(C) NO. 36271 OF 2016 ..35..** people have the ability to reproduce and regulate their fertility, women are able to go through pregnancy and child birth safely, the outcome of pregnancy is successful in terms of maternal and infant survival and well being, and couples are able to have sexual relations free of the fear of pregnancy and of contracting diseases." The government has consistently provided all aspects of reproductive health to all communities, family planning being only one small part of the reproductive health services being provided under the umbrella of services provided by the State and Central Government.. Other services include infertility treatment facilities, spacing methods (temporary methods like condoms, oral pills, intra uterine devices, etc) facilities for diagnosis treatment and prevention of reproductive tract infections and sexually transmitted infections. All such services are provided free of cost in government health facilities The govt has never promoted a single method alone. The family planning services **WP(C) NO. 36271 OF 2016 ..36..** are being provided through a 'cafeteria' approach, wherein a basket of services are made available to the client and the client is provided necessary counseling which helps them to choose a method best suitable for them. For example the different family planning methods provided to clients in Wayanad District during the period from March to September 2012 are as follows: **==> picture [299 x 120] intentionally omitted <==** From the above statistics, it is very clear that the Govt is pro'(iding a range of family planning services, of which permanent sterilization is only a small part (27%). 33. It is submitted that earlier all facilities where sterilization is being conducted (both male and female sterilization) have all facilities as recommended in the guidelines issued by the Govt. of India in the standards for male _I_ female sterilization. All facilities where sterilization is being conducted (both **WP(C) NO. 36271 OF 2016 ..37..** male and female sterilization) have sufficient qualified personnel as recommended in the guidelines issued by the Govt. of India in the standards for male _I_ female sterilization. It is this same unmet need that the govt is trying to address through its family welfare programme. No numerical targets are set by govt. the numbers shown by the petitioner are goals calculated at grass root level to plan performance and resource allocation for each year. A Government cannot be expected to allocate resources without any idea of the needs for the coming year. These numbers need only be seen in that perceptive. 34. It is submitted that all range of service have been provided by department. Records can clearly prove that adivasis are provided all options as per their wish and no particular method is imposed on them. As mentioned earlier the average number of children a tribal women has before she opts for permanent sterilization is always more than that of a non tribal women. This would clearly proves that tribal's are **WP(C) NO. 36271 OF 2016 ..38..** not targeted. Majority of sterilisations are carried out on non tribal's as can be shown by the data of each year. 35. It is respectfully submitted that one major cause 9f maternal and infant deaths is multiparity (more number fo deliveries) and hence sterilisation is actually in a way protecting the women and children from further morbidity and death. Health facilities are available to all people, with special care being given to tribal people. In Wayanad , tribal people are scattered over the whole district. There is no area where tribals are concentrated, hence it is wrong to say that tribal areas do not have health care facilities, because 238 facilities across the district cater to the whole population including the tribals. Tribals receive special care and attention in all institutions. 36. It is submitted that sterilization is done in the interest of the health of the mother, who is very weak due to poor nutrition in the tribal community and therefore cannot withstand repeated pregnancies. There is no denial of healthcare, The petitioner is **WP(C) NO. 36271 OF 2016 ..39..** making wild allegations to demoralize the whole system and the workers. He has failed to highlight specific issues of denial of care, nor has he / his organization given any complaints to the department authorities regarding any such issue, which would show that he has no genuine grievance. 37. It is submitted that sterilization is not mandatory. No Surgeon has ever stated that sterilizations are mandatory. Allegations contrary to the same was false and hence denied. If the petitioner was really interested in the welfare of the tribals, they should have brought any case of such issues to the notice of the department authorities and tried for a solution. The very fact that they have approached the department would expose the lack of bonafide and the hollowness of his contentions.. It is submitted that the only positive discrimination by which they are provided all facilities from the health institutions, even facilities not available to other communities are provided to them - completely free treatment and care and medicines. Even for **WP(C) NO. 36271 OF 2016 ..40..** procedures others have to pay but it is provided free of cost to them. 38. It is submitted that limiting family size is fundamental right of every individual. A person from a tribal community cannot be denied that right by virtue of their belonging to a primitive tribal group. The Government cannot deny the right for family planning to any individual from any community on the contention that the number of members in the community is low. Government has a legal obligation to treat each individual equally and hence clients from all communities need to be provided with such facilities in an equitable manner. 39. It is submitted that the petitioner is trying to make out that sterilization has some serious side effects and it harms the body, while the truth is just the opposite. Sterilization prevents further pregnancies - thereby s,:1ying the woman from risks of repeated pregnancies. Studies have shown that majority of deaths and complication during pregnancy and child birth in Wayanad are among tribal women and that their poor **WP(C) NO. 36271 OF 2016 ..41..** socio-economic status and poor nutrition has a large role to play in this. Repeated pregnancies can have serious harmful effects on the life and health of tribal women, especially since their general health and nutritional status is poor. Hence, preventing repeated pregnancies in tribal women is in the interest of their own safety and better health. It is submitted that the above writ petition is filed without any bonafide and no public interest involved and the petitioner has no locus standi to file the above writ petition styled as Public Interest Litigation. Hence it is humbly submitted that this Hon'ble Court may be pleased to dismiss the above writ petition with cost.” We are of the view that, the issues raised in this Suo Motu writ petition have been elaborately dealt with in the counter affidavit filed by the District Medical Officer, Wayanad and endorsed in the judgment dated 08.01.2020 in W.P.(C) No.15139 of 2012. We are satisfied with the **WP(C) NO. 36271 OF 2016 ..42..** measures taken by the respondents for the sterilization procedures narrated in the counter affidavit filed by the 2[nd] respondent. Accordingly, this suo motu writ petition is closed. **Sd/S.MANIKUMAR CHIEF JUSTICE** **Sd/MURALI PURUSHOTHAMAN JUDGE** SBxxxx