K. Srinivasan*
India is the first country, ever to launch an official national programme of family planning , as a part of its first five-year development plan (1951-56),with the objective of reducing its birth rate to levels commensurate with its developmental aspirations. Its strategy of implementation changed over the years, starting with the “clinic approach” during 1951-1961, “ extension education approach” during 1962-69, “HITTS approach” ( health system based incentive driven time- bound target –oriented schemes)which was largely camp approach to conduct vasectomies during 1969-75, and the “coercive approach” during 1975-77 implemented during the national emergency. Vasectomy, male sterilization, was the main contraceptive method, promoted during these 25 years. About 20 million vasectomies were done in India during this period, highest number of sterilizations in the world.
Post emergency, in 1977, the family planning programme suffered a serious set serious set back and vasectomy was considered as a symbol of state despotism and authoritarianism. The number of vasectomy acceptors declined sharply and the family planning needs of the people were largely met through tubectomy, the female sterilization. The “Recoil and Recovery phase” of the programme during 1977- 82 was slow but steady rising trend of tubectomy operations indicating the felt demand for limitation of family size by the married women. The targets set for acceptors were lower and the population goal was shifted to net reproduction rate of 1 (or replacement level of fertility of TFR of 2.1) setting goals for simultaneous reductions in infant and child mortality levels along with fertility levels.
In this context, came in the recommendations of the International Conference on Population and development (ICPD) convened by the United Nations at Mexico and this conference was dominated by women’s groups and human rights activists who held the view that national programme of family planning should not be an instrument used by the state to achieve any pre set fertility goals since the burden of achieving these goals fell disproportionately on women suffering the consequences of sterilizations and use of various chemical contraceptives, The Programme of Action formulated at the end of the Conference and for which India is a signatory, postulated that population policies should be viewed as an integral part of programmes for women’s development, women’s rights, women’s reproductive health, poverty alleviation and sustainable development. They argued that, henceforth, population policies should not be viewed with the sole concern of reductions in fertility rates considered desirable by planners and demographers, but by considerations of reproductive health, reproductive rights and gender equity. It was argued that developmental programmes, which are not engendered, are not only sustainable but also endangered. The Programme of Action adopted by the ICPD recommends a set of qualitative and quantitative development goals. They are: sustained economic growth in the context of sustainable development; education, especially for girls; gender equity, equality and empowerment of women; infant, child and maternal mortality reduction; and the provision of universal access to reproductive health services, including family planning and sexual health. The RCH approach came to the dominant approach in India since 1995 abolishing all family planning acceptor targets, the target –free approach ( TFA) and the contraceptive services provided based on the Community Needs Assessment Approach( CNA) . The TFA- CNN method is the dominant approach prevailing at present in many states. Integration of various services at the grass root level was the sine-qua-non of the programme.
Simultaneously, in 1992 the constitutional amendments 72 and 73 were passed by the Parliament and enactments of Panchayat Raj and Nagar Palika Acts set in motion the process of democratic decentralization. These acts ushered in a three-tier system of political governance in the country, central government, state government and the panchayats in the rural areas and the Nagar palikas in the urban areas upto the district level, by which constitutionally the powers, responsibilities and resources are to be shared by these three-tiers of elected bodies. The primary health care including family planning, primary education and provision of certain basic amenities to the people such as drinking water and roads became the responsibility of the panchayats. Another notable feature of this Act is the reservation of one third of the seats in Panchayats for women members. Thus at the grass root level the women are politically empowered by this act, on all decision making issues pertaining to social development including family planning. This is great leap forward for the Indian democracy and empowerment of women. The process of this demographic decentralization is still going on with varying speed and intensity in different states. Generally, the states are reluctant to share their powers and resources with the elected bodies of the panchayats. In some states, even the elections to the panchayats are yet to take place. Decentralization of services in the health and family planning fields became the mantra.
The policies overarching the present implementation of family welfare programmes are three: the National Population Policy -2000( NPP), the National Health Policy formulated in 2002 ( NHP) and the National Rural Health Mission launched in 2005 (NRHM). The first two policies have both quantitative and qualitative out put targets without outlining how these targets are to be achieved and what inputs are needed and how they are to be utilized. NRHM has not only laid out the desired output goals but also the input goals and strategies.
Decentralization, integration and convergence of services are the buzz words going around all the health and family planning programmes in the country. District level RCH societies have been constituted in almost all the districts and central funds for the health and RCH programmes are directly routed through these societies. There has been considerable increase in the resources ploughed into the health and family welfare programmes since 1995, especially after 2005 with the introduction of NRHM and spent through these societies.
However, a recent analysis of data collected in the national Family Health Surveys 1, 2 and 3 conducted during 1992-92, 1998-99 and 2005-06 reveals that the pace of annual progress after 1998 during the RCH phase of the programme, in 24 out 29 indicators of reproductive and child health ( such as child immunizations) is slower than in the pre-RCH phase. If adjusted for higher expenditures incurred in the RCH programmes after 1998, these differences become sharper. Similarly there appears to enormous wastage in the condoms distributed by government sources, as free supplies, falsely over-reporting the users and condoms used in the free distribution system. Decentralization and integration of health care services may not be effective unless monitored centrally and backed by full time health (medical/paramedical) professionals at the delivery level. The extent to which the community level personnel ( the Anganwadi workers and Ashas and Ushas ) will be useful in the programme is really limited.
Fertility, infant and child mortality levels in many parts of the country remain very high and in states of Bihar, Chattisgarh, , Jharkhand, Orissa, Madhya Pradesh, Rajasthan and Uttar Pradesh ( with about 400 million people) and so is high levels of malnutrition of women and children. The recent World Bank study ranks this area in terms of its high levels of mortality and nutritional deficiency worse than many countries of sub-saharan Africa. On the other hand the southern and Western states of Kerala , Karnataka, Tamil Nadu , Gujarat and Maharashtra enjoy a high level of social and economic development partly fuelled by the demographic dividends of their rapid fertility declines during the past two decades. Many of the goals set in NPP-2000 and NHP-2002 such as reaching the IMR of 30 by 2010 have not been realized and IMR of 30 at the national can be expected to be reached not earlier than 2020 , if the present trends of decline continue. In 2008 the IMR ranged from 12 in Kerala to 70 in Madhya Pradesh and 67 in Uttar Pradesh. The policies do not seem to be working as expected in these states.
There is a need to revisit the population and health policies particularly with reference to these seven states. The following recommendations are worth considering.
1) The program placed total emphasis on sterilisation as the major method of family planning from the very beginning, vasectomy until 1977 and tubectomy thereafter. Quality of services offered in this regard was far from satisfactory and has not improved over time. Sterilization is as dominant a method of family planning in Andhra Pradesh, Kerala and Tamil Nadu with below replacement fertility levels as in Uttar Pradesh and Bihar with TFR above 4. Spacing methods should become the major methods of contraception for attracting young couples, if demographic transition is to be sustained.
Specific policy and programme measures are needed.
2) One way to start the process is to stop forthwith any incentives offered to sterilizations, to doctors, institutions and individuals. This can be achieved in two phases; first in those states, which have already achieved low fertility as Kerala, Andhra Pradesh and Tamil Nadu, and then in a phased manner to the other states. The money saved from incentives should be used to improve the quality of services. This suggestion is worth serious eration.
3) We should revert back to the clinic approach with which we started the family planning programme in the first two five year plans. Family planning clinics, providing good quality contraceptive services including induced abortion on medical grounds, should be set up in every block and the services there should be freely available for any couple below the poverty line asking for such services. Others above the poverty line should be asked to pay at subsidized rates. In the high fertility states there may be a need to continue with subsidies for all types of contraceptive services and in the setting up of these clinics by qualified NGOs, but there is no need for subsidy in states where the fertility levels are already low.
4) Family planning clinics, recommended above, should not be a part of of the health system and if agreed upon can be considered a part of the Department of women and Child Welfare. The possibility of setting up a separate national corporation to establish and run these clinics can also be considered. Family planning should not erode into public health programmes. In my view integrating them with primary health care has slowed down the health care services especially maternal and childcare services and is beginning to harm both.The design and construction of such clinics should be done by professional and should carry the same insignia throughout the country. With our economy galloping at top gear , it will be a wise investment to establish these clinics across the country. They should operate independently as clinics under a private agency or a governmental agency.
The time and resources of the existing maternal and child health programme personnel should not be wasted any more to motivation of cases for family planning and they should be asked to concentrate on their maternal and child care duties.
It is time to de-link the family planning from regular maternal and child health activities which have suffered so far.
*Summary of Public Lecture delivered by the author in Bangalore under the auspices of Bangalore University and Institute for Social and Economic Change, Bangalore on 30 July 2010.