‘Population explosion is not a concern now’

Interview with Prof. T.V. Sekher, head of the Department of Family and Generations at the International Institute for Population Sciences (IIPS).

Prof. T.V. Sekher.

Prof. T.V. Sekher has authored and edited 10 books and published more than 100 research articles in national and international journals. He was a Fulbright-Nehru Senior Fellow at Cornell University in 2016-17. In an email interview with Frontline , Prof. Sekher reviewed some of the important findings of the National Family Health Survey (NFHS-5). (The NFHS is the most thorough survey on health and nutrition indicators of India’s citizens and the second phase of NFHS-5, conducted in 2019-21, was released on November 24, 2021.) Excerpts:

What has been the importance and relevance of the NFHS for Indian citizens and the government’s planning of health programmes over the years?

Since 1992-93, the NFHS has provided various health, nutrition, family welfare and social indicators at regular intervals, which has helped us to have an independent assessment of programme-related efficacy. Being a part of the worldwide Demographic Health Surveys (DHS) conducted regularly in a large number of countries, the NFHS serves as a mirror of India’s achievements and concerns in maternal and child health when compared with other countries. The five rounds of the NFHS over the last three decades have facilitated an understanding of the demographic and health changes that have taken place in a vast and diverse country like India. No other survey in India apart from the NFHS has attracted the equal attention of policy makers and researchers. It is a major exercise as it surveys some 6,40,000 households to produce comparable indicators for more than 700 districts of the country on various aspects of antenatal care, institutional delivery, child immunisation, malnourishment, age at marriage, fertility, contraception, sexual behaviour, gender-based violence, women’s empowerment, and access and utilisation of health-care services.

The incorporation of modern technology and other innovations in survey methodology have helped the NFHS generate data of acceptable quality, but there is still scope for enhancing its value and standards.

How significant is the achievement of the replacement level fertility (i.e., a total fertility rate of 2.0 per woman) for the country as a whole?

It is a well-documented fact that between 1970 and 2020, fertility declined in every country in the world, and India is no exception. The fertility transition is in the expected direction and most countries, including those in Asia, have experienced a decline in fertility rates. With the rise in the number of women getting access to education, thereby increasing their participation in the labour force, and amid universal knowledge of family planning methods and increasing contraceptive prevalence, families prefer to have fewer children.

Studies have also shown that the increasing cost of education of children is also compelling many parents to restrict the number of children to one or two. The percentage of couples deliberately opting to have only one child has gone up considerably in urban India. In a city like Kolkata, it is close to 25 per cent, as per NFHS-4. The proportion of single-child families is higher among urban, educated and employed women.

Since the fertility levels have gone down below the replacement level in the country in a majority of States, “population explosion” is not a concern now. This also shows that there is no need for population policies insisting on two-child norms, through either incentives or penalties. Although NFHS-5 indicates that India has achieved replacement level fertility, the unmet need for contraception (though marginally reduced) is still high in many States (for instance, it is 13 per cent in Uttar Pradesh), and this is where the government should focus its energies now. More concerted efforts are required to provide access and availability to quality contraceptive services in States such as Bihar, U.P., Rajasthan and Madhya Pradesh. At the same time, there is an emerging concern in many States and communities on the long-term implications of lower fertility. This can be seen in the southern States that were the front-runners in the fertility transition starting in the early 1980s. Recently, the Catholic church in Kerala offered many incentives such as free education and job opportunities for families having a greater number of children.

Perusing the NFHS data, what has been the country’s single greatest gain in the health sector over the past decade?

In my view, the most remarkable achievement of our health system in the last decade is that 90 per cent of births are happening in health facilities. The figure was only 39 per cent in 2005-06 (NFHS-3). Conditional cash transfer schemes such as Janani Suraksha Yojana (JSY) have played a major role in bringing more women, particularly in rural areas, to the hospital for child birth. This has also helped in bringing down infant and maternal mortality considerably.

Despite the introduction of many policies and programmes aimed at increasing the marriage age among women, there has been very slow change in this regard. How do you see this aspect?

Age at marriage is still a major concern. Nearly one-fourth of women in India still get married before 18. This is despite a significant improvement in girls’ education and implementation of many governmental schemes (for instance, the Laadli Laxmi Schemes in many States) wherein financial incentives are provided to girls to get married only after they turn 18. Many sociocultural norms prevalent among certain communities result in early marriages and consequent teenage pregnancies.

Child marriage has severe repercussions for girls as it affects their personal freedom, education, and expectations in life and leads to discrimination and violence. All of a sudden, the imposition of a marriage partner upon a girl child means that her childhood is cut short and her fundamental rights are compromised. But what is not noticed in the debate on age at marriage in India is the fact that a significant proportion of men are also getting married before attaining the legally prescribed minimum age at marriage of 21.

According to NFHS-5, it is 18 per cent for India and 23 per cent for Uttar Pradesh. Research in India has been largely oriented towards understanding the causes and consequences of early marriage among girls while ignoring the condition of the large number of “child grooms”.

There are many “hotspots” in India where early marriage of boys is an accepted norm. In such regions, raising the age at marriage for boys will automatically raise the age at marriage for girls (as the preference and traditional practice of Indian men is to marry women younger than them). Early marriage of boys, often without their consent and against their wishes, forces many boys to drop out of schools and take up menial jobs to support their wives and children. If we have to tackle the problem of “child brides” in India, we can no longer ignore the presence of “child grooms”. It is high time we realise that early marriage is an issue of not only girls but also boys in many regions of rural India.

How do you evaluate the gender empowerment indicators as shown by NFHS-5 when compared with previous NFHS rounds?

Although there is an improvement compared to earlier surveys, a large gap continues to exist between men and women in terms of owning properties, operating bank accounts or having mobile phones, showing that patriarchal norms are still prevalent. Unless and until daughters also inherit parental property and have financial independence, their ability to negotiate in household decision-making processes will be affected.

Also, according to NFHS-5, nearly one-third of women have experienced spousal violence. Awareness programmes and legal remedies are necessary to address the discrimination women face at different stages of their life (childhood, adolescence, motherhood and old age).

One of the areas of concern in NFHS-5 is the poor nutritional indicators of women and children, which has been pointed out by many analysts. How do you look at this important issue?

The discrimination one faces in childhood, manifesting in lack of medical care, nutrition, and education, continues into adulthood as well in many ways. However, it is very crucial to examine why, despite a large number of food supplementation programmes, anaemia among children and women is not showing any improvement at all. Nearly half of all pregnant women are anaemic, despite many large-scale incentive schemes such as the Pradhan Mantri Matru Vandana Yojana (PMMVY). It is possible that although women and children are given food through the Integrated Child Development Services (ICDS) and school mid-day meal programmes, the nutritious value is not given importance while deciding the menu.

In general, the economic condition of most Indian households has not shown any improvement during the last decade or has worsened; this might have also resulted in households spending less resources on food and nutrition. It is also a fact that remarkable progress in some of these indicators cannot be possible within a short time. The reason for this persisting malnourishment needs to be researched further.

Women’s access to health care is restricted for various reasons such as distance to health care facilities, lack of male support in making use of health services, and financial factors. Many women also ignore their own health problems while remaining concerned with the health conditions of their children. Improving health insurance coverage, which is low as shown by NFHS-5, is crucial in enhancing women’s utilisation of health-care services.

NFHS-5 says that women outnumber men in India. What is your opinion about this finding?

Sections of the media have wrongly interpreted this finding. What is given in the NFHS fact sheet is the sex ratio of the people living in the surveyed households. The NFHS is a household survey and large numbers of people living in institutions or homeless populations are not considered in the survey. Please wait for the next Census to give us an accurate data on sex ratio. I do not see the possibility of women outnumbering men in India any time in the near future.