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A troubling move

Print edition : Jun 08, 2002

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A yet-to-be-released strategy paper from the National Commission on Population rejects the "development is the best pill" approach, seemingly reversing the goals set in the National Population Policy.

A PROPOSAL originating from the National Commission on Population (NCP) to reorient demographic goals and the population policy has surprised government and non-government circles. The proposal, which is contained in a strategy paper, calls for a realistic assessment of the demographic situation in the major States and the scenario for the next 25 years. The kind of review it suggests harks back to the approach that has been criticised and discarded over the years, it is pointed out.

No one claims authorship of the paper and it has not been officially released. Even some senior officials in the Health Ministry have no clue about it. Meenakshi Datta Ghosh, Joint Secretary (Policy) in the Department of Family Welfare, when told about it, said she was "certainly amazed" and added that she did not know how authentic it was. It reached certain sections of the media even before NCP members had access to it. Some members' queries about the paper evoked ambiguous replies from the NCP secretariat. The replies, however, indicated that a rethink is taking place at least in some circles in the NCP and the Planning Commission, on the premises of which are located the NCP's offices.

In essence, the paper rejects the "development is the best pill" approach and aggressively promotes the two-child norm, recommending, among other things, incentives and disincentives. Several States already have mechanisms such as debarring violators of the two-child norm from government jobs and denying them the right to contest local level elections. But it is feared that a Central body recommending similar measures would send alarming signals. The NCP is a statutory body with the Prime Minister as chairperson and the Deputy Chairman of the Planning Commission as vice-chairperson. Chief Ministers, Union Ministers concerned, representatives of political parties and non-governmental organisations, mediapersons and specialists are members of the Commission.

The NCP's paper has emerged at a time when the latest Census report has brought out an alarming trend in the matter of the juvenile sex ratio. Imposing a two-child norm with incentives and disincentives can only play havoc in a situation where son-preference is a dominant phenomenon.

The paper is critical of the approach advocated by the International Conference on Population and Development (ICPD), held in Cairo in 1994, that left the choice about the number of children to individuals and stressed on advocacy and the quality of health care services. The Indian government adopted the spirit of the approach and reiterated its commitment to voluntary and informed choice and consent of citizens. It also decided to continue with the target-free approach in the administration of family planning services.

In contrast, the strategy paper argues that the "development approach" has ignored the fact that uncontrolled population is the main reason for the poor quality and coverage of health and family welfare services and the inability to provide other basic necessities in countries such as India. The principles of advocacy, quality of health care services and the right of individual choice, it says, may be relevant for developed countries where population size is not a problem and the health infrastructure is well established. Therefore, instead of demanding more budgetary allocations for and the expansion of facilities in the social sector, the NCP takes the line that the problem lies in the numbers.

It says that the quality and coverage of health and family welfare services remain very poor in most regions of the country. Shortage of doctors and auxiliary nurse midwives, and of contraceptives and drugs, of sub-centres, primary health centres and community health centres, and poor maintenance of infrastructure are cited. The continuous increase in population, it argues, has defeated attempts to cover these gaps. With no major expansion of infrastructural facilities taking place as envisaged in the Tenth Plan and the demand for health care increasing, the goal of making available the kind of quality care envisaged by the ICPD is unrealistic, the paper says. There is a need to break the vicious cycle of an ever increasing number of people chasing limited resources. This, the paper says, has increased the relevance of the "contraception is the best development" approach.

This approach, however, reverses not only what the National Population Policy (NPP) says but also what women's movements and their supporters in the health sector have been arguing for even before the ICPD proposals came up. The views contained in the paper are similar to those of NCP member-secretary Krishna Singh, who says that restrategisation is necessary to meet the goals of the NPP. A change in strategy, it is argued, is very much a part of the NCP's mandate to review, monitor and give directions for the implementation of the population policy. However, the paper's suggestions and Krishna Singh's arguments contradict the spirit of the NPP. The NPP, which was announced in 2000, was the outcome of years of discussions about the nature of the demographic goals that a country like India should have.

The NPP, while stating that stabilising the population was essential to promote sustainable development with a more equitable distribution, says that this is as much a task of making reproductive health care accessible and affordable to all as of increasing the provision and reach of primary and secondary education, extending basic amenities including sanitation, safe drinking water and housing, besides empowering women and enhancing their employment opportunities and providing transport and communications.

The immediate objective of the NPP is to meet the unmet needs of contraception, health care infrastructure and health personnel and to provide integrated service delivery for basic reproductive and child health care. Its medium-term goal is to bring the total fertility rate (TFR) to replacement levels, that is 2.1, by 2010 through the vigorous implementation of inter-sectoral operational strategies. (TFR indicates the number of children a woman would have during her lifetime if she were to experience the fertility rates of the period at each age. The NPP set this target by taking into account the adverse sex ratio at birth and the high maternal mortality rate that prevail now.) Its long-term objective is to stabilise the population at a level consistent with the requirements of sustainable economic growth, social development and environmental protection by 2045. A set of national socio-demographic goals for 2010 have also been laid down in the NPP to meet these objectives.

The NCP's proposal argues that achieving the NPP's medium-term target of a TFR of 2.1 at the earliest is of paramount importance to meet the overriding objective of economic and social development. It says: "A significant decline in the fertility rate even below the replacement level in the major States can greatly facilitate the country emerging as a major economic power in the next 25 years or so... But failure to control population growth will act as the main hurdle in this direction." The replacement level fertility is said to occur when the combination of fertility and mortality lead to a net reproduction rate (NRR) of one. The NRR also indicates the average number of girls that would be born to a birth cohort of women during their lifetime if they experience a fixed pattern of age-specific fertility and mortality.

THE NCP's paper suggests that as against the NPP's target of a TFR of 2.1 by 2010, the adoption of the two-child norm as the national objective may lead to a net reduction in the population of the country in the long run. Evidently, the NCP proposal does not take into account the sex ratio while pleading for a two-child norm as the national objective. The NPP advocates the "small family norm" but refrains from setting a national goal.

To substantiate its basic premises, the NCP's paper states that the NCP members, during their field visits to high-fertility States, observed that there was no visible improvement in the quality and availability of health care and family welfare services in rural areas and urban slums "because of the new approach adopted since 1996". Adoption of family planning methods was left to the free choice of individuals and couples, and doctors and others in the area of health care did not take up any canvassing to encourage couples either to adopt family planning methods or to undergo terminal methods (in the case of couples with two or more children), it says. The number of sterilisation procedures conducted had come down drastically in the high-fertility States of Madhya Pradesh, Bihar, Uttar Pradesh and Rajasthan. Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu performed well in this area.

The strategy paper strongly advocates terminal methods of contraception as compared to the spacing method. It says that since the adoption of the target-free approach in 1996 the advocacy and promotion of terminal methods have received a setback in the high-fertility States. A nationally accepted family size, promoted by an efficient family planning programme and linked to a well-designed scheme of incentives and disincentives, can bring down fertility rates quickly, it states.

The population policy of Andhra Pradesh receives special mention in the paper for having set predetermined targets, especially for terminal methods of contraception. There are several community-based and individual incentives in the State, which is said to have achieved a breakthrough on the population front although it does not have a good record in the matters of female literacy or the age of marriage for girls.

The paper suggests various measures to restrategise the family planning programme. The measures are:

* Declaration of the two-child norm as a national goal and its active promotion by all concerned;

* Implementation of a pro-active family planning programme without any coercion with the primary objective of promoting the two-child norm. The duties and responsibilities of health and family planning functionaries involved in this include advocating and promoting the two-child norm and persuading eligible couples with two or more children to undergo the terminal methods of contraception at the earliest;

* Implementation of suitable schemes of incentives and disincentives by State governments to promote the two-child norm as per local needs and the creation of a district population stabilisation fund, to be operated by a district level family welfare society, to generate additional resources at the local level to implement family planning programmes.

The paper is highly critical of the United Nations Fund for Population Activities (UNFPA) and non-governmental organisations supported by it. In India, the paper says, these agencies support the human rights debate relating to incentives and disincentives associated with family planning. According to the paper, this debate ignores the fact that the main reason for the poor quality and coverage of health and family welfare services in developing countries like India is the burgeoning population. It says: "The serious implications of the population explosion for providing quality health care and the need for effective intervention to control population growth is never brought up for consideration in the seminar circuits supported by the UNFPA."

This opinion reflects a mindset focussed on controlling numbers at any cost and the targeting of the UNFPA seems misplaced. Much before the UNFPA adopted this approach, leading women's organisations in the country, which are not supported by the UNFPA, and those involved in public health issues had voiced their apprehensions about setting targets and resorting to coercion in the matter of family planning. They had stressed that among other empowering measures, an enabling environment of equitable development and access to social infrastructure would have a positive impact on checking population growth.

Krishna Singh told Frontline that the Commission is seeking to find ways to implement only proposals that are in conformity with the NPP. According to her, the process of rethinking had been going on for one and a half years and discussions had been on with experts and in steering groups. The proposal would be circulated among the members soon and then forwarded to the Union Cabinet. K.C. Pant, the vice-chairperson of the NCP, would call a meeting of States to discuss this issue.

Krishna Singh said: "If we don't start thinking now, we will never reach where we want to reach. The government has announced some targets for reducing the infant mortality rate as well as for meeting the unmet needs of family planning. All these prescriptions have to be implemented and operationalised. National level prescriptions have no meaning unless they are attuned to State and district level conditions. Without getting moralistic, it should be acknowledged that there are a vast number of people who don't even have the basic necessities of life. It is true that development is the best contraceptive. But the effort has to be translated into action. A certain pace of activity is already on in the country with or without family planning."

Krishna Singh, a senior officer of the Indian Administrative Service, said that one should not make too much noise about women's rights. Women's empowerment would take place only when the burden on the infrastructure was reduced, she said. "We must be clear about whose rights we are talking about. Most women have no choice on many other fronts. The question of choice cannot just be restricted to one thing," she said. The Andhra Pradesh model, according to her, was a successful one. All development benefits had been linked to family planning there. Asked about the disincentive that barred persons with more than two children from contesting local body elections, Krishna Singh said: "What major rights get violated if someone else gets elected?" On the impact of restrategisation on the skewed sex ratio, she said that the problem of sex ratio would not get solved by people having more children. Krishna Singh and Joint Secretary V. Asokan both said that the State governments should not see the NCP's recommendations as an order but as suggestions made in their interest.

Most NCP members are in the dark about the plan to restrategise demographic goals. One of them, Imrana Qadeer, Professor at the Centre for Social Medicine and Community Health at Jawaharlal Nehru University, told Frontline that she wrote to the NCP asking for a copy of the document and got a vague reply. "There has been no formal communication regarding any such document... To the best of my knowledge, the Member Secretary has been keen on inter-sectoral development. There is also no data that refute the present strategy. Unless we improve basic services, how can we say that the strategy has failed?" Qadeer said that NCP members during their visits to high-fertility States noted the virtual absence of services and this figured in their discussions. However, it is the content of the proposal that has come under close scrutiny by the individuals concerned as it is a blueprint of all that was rejected in the early 1990s.

A senior official in the Ministry of Health and Family Welfare said that the NCP had endorsed the population policy in its first meeting and therefore the restrategisation move had come as a big surprise. Achieving a TFR of 2.1 by 2010 cannot be done by sterilisations alone. "Population stabilisation can never be a numbers game. Setting targets from above has been historically counter-productive. The moment we return to targets, the quality of care suffers and this will further affect the sex ratio," said the official. He explained that the moment a norm was set it was followed by incentives, disincentives and targets from above. There were some basic factors that were non-negotiable, including providing quality care and informed choice to the people. "A target-free approach never meant lack of accountability and governance. What should be striven for is a self-imposed target by the community for the community," said the official. Infrastructural gaps were a reality and that only meant that more investment and better utilisation were required, he said.

The official explained that the population growth momentum could be eased significantly by policies that encourage women to delay childbearing. Over 50 per cent of Indian women in the age bracket of 20-24 are married before the age of 18. The proportion was higher in Bihar, Rajasthan and Uttar Pradesh. A further rise in the age of marriage at the national level can be achieved by increasing the level of female education. Investing in adolescents, with an emphasis on raising the economic and social prospects of girls and enhancing their self-esteem, could be other ways of curtailing the population momentum.

According to the official, the two National Family Health Surveys had found an overall increase in the acceptance of contraception. The permanent method of female sterilisation formed the mainstay of the contraception programme, he said. A rapid decline in the birth rate and the fertility rate neither eliminated poverty nor improved standards of living. Bangladesh, the official said, had reduced its TFR from 6.8 to 3.1 during 1975-1998 but this had not alleviated poverty. China, with a much larger population than India, had a per capita income almost twice that of India. It was not India's large population that was responsible for the slow growth of the economy, he said.

AT a press conference in New Delhi on May 27, representatives of 17 organisations, including women's groups and health forums, protested against the "two-child norm" suggested by the strategy paper and population control strategies adopted by various State governments employing disincentives. The organisations included the All India Democratic Women's Association, the National Federation of Indian Women, the Joint Women's Programme, the Centre for Women's Development Studies, the Young Women's Christian Association, the Centre of Social Medicine and Community Health, which is part of Jawaharlal Nehru University, the Centre for Health and Allied Themes, the Delhi Science Forum, the Medicos Friends Circle, the Forum for Creches and Child Care Services and the Jan Swasthya Abhiyan.

These organisations urged the National Human Rights Commission to ensure that the steps proposed in the strategy paper and the Uttar Pradesh Population Bill are not incorporated in the NPP. The U.P. Bill lists several disincentives and incentives. For instance, it disqualifies persons who marry before the legally prescribed age of marriage from taking up government jobs. Similar disincentives already exist in Madhya Pradesh, Rajasthan, Maharashtra and Andhra Pradesh.

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