She woke up and thought “What have they done to me?”. The ambulance left her where the road ends, 30 minutes from her home in the Andes of Peru.  She walked, recently operated, to reach home. This the story of Demetria one of the women subject to compulsory sterilization within the framework of public policy of health implemented in the government of Alberto Fujimori.

Public policies are used as a tool to improve social welfare. These policies are designed to achieve an objective that seeks to address the necessity of the population or to promote behaviours in order to benefit citizens and society. However, poorly designed public policy can have the opposite impact.

Public policy design and formulation faces vast challenges, such feature often intensified by the political and social reality of countries. In Peru, complex problems such as extreme poverty make this situation evident because of lack of access to basic health, education, water and sanitation services. The diffusion and introduction of public policy, moreover, deal with the limitation generated by the remote geographical location of poorer populations. Cultural patterns also make it difficult to introduce public interventions.

In the period of 1995-2000, the Reproductive Health and Family Planning Program was employed in Peru, which sought to promote women’s sexual and reproductive rights.

The program was to allow the poorest women to access free reproductive health services. It provided all available contraceptive methods. Yet, it became controversial for one particular method: Voluntary Surgical Contraception commonly called sterilization. The program was accused of being a public policy of mass forced sterilization, which led to its cancellation and would subsequently reach even international legal bodies.

The rapid growth of the world’s population became an international concern after World War II and was the design and implementation of family planning programs in response. These were strongly promoted and represented an important social experiment, based on the posed negative relation between the growth of population and economic growth.

On the other hand, the increase in the number of unsafe abortions and high rates of maternal mortality led Latin-American governments to assess the possibility of implementing such programs in order to improve health indicators. However, they encountered strong resistance both in the Catholic Church and in conservative sectors of society. In this context, public policies on reproductive health and family planning have proved to be very sensitive and generate intense debates that rarely consider women’s right to freely decide on their fertility.

In the Peruvian case, among the specific programs designed by the new National Population Program, special priority was given to “Reproductive Health and Family Planning” and to “Decentralization of Population Policy”. In the latter case, the emphasis was set on the rural areas of the Peruvian jungle and the Andes region. According to the program, women in rural areas maintain their reproductive patterns at high levels compared to the metropolitan area. Regarding the priority assigned to decentralization, its strategy is inspired by the need to give priority to low-income groups of people, such as women from the urban-marginal and rural sectors. and young people from these same sectors.

In an attempt to reduce poverty the situation turned obscure. During the 1990s, more than 314,605 women were sterilized. A medical procedure that permanently affects fertility without the consent of the victim. They all shared characteristics in common, they were indigenous and had a low level of income. Less than 10% were voluntary interventions. The majority were indigenous, Quechua-speaking and illiterate women. Some were taken by force to the clinics and tied to a bed. Others were manipulated with food or even threatened with being arrested. The sterilization was also presented as a requirement to access social programs, infrastructure or government support.

The administration of Fujimori was accused of a crime against humanity and sexual against the most marginalized sectors and indigenous populations.  Some claims that the programme was an eugenic action against the minorities and tried to eradicate the indigenous population instead of reducing poverty.

Developing countries, like Peru, present serious institutional deficiency and weak processes in training and particularly in the implementation of public policies. A combination of both, weak institutions and inefficient execution of public policy bring what is known as the perverse effect. The perverse effect is an unforeseen negative consequence of an action or policy that produces exactly the opposite to the intended effect.

Good intentions in the design of public policy are not enough.