Growing concerns

A group of women with their infants outside a primary health centre. The population control programme will be launched in the 150-odd high-fertility districts. - K.N. CHARI

The special population stabilisation programme envisaged in the Common Minimum Programme of the United Progressive Alliance government raises several concerns, particularly gender-related ones.

THE latest "sharply targeted population control" strategy specified in the Common Minimum Progamme of the United Progressive Alliance (UPA) government has caused dismay among women's activists and those with a perspective on public health.

The concerns raised by the Left women's organisations and the Jan Swasthya Abhiyan, a broad front comprising health and women's groups, are twofold. One, the inclusion of the term "population stabilisation" in the document under the section titled "Women and Children" presupposes that the responsibility for fertility control lies solely with women, bringing back memories of a certain document on Reproductive and Child Health introduced by the previous National Democratic Alliance government, which talked extensively of targeted population control programmes. That such a concept contradicts the spirit of the first International Conference on Population and Development (ICPD) - held in Cairo in 1994, as also the National Population Policy (NPP) 2000, is another matter altogether. The second concern is that the clubbing of population stabilisation with the policy on women and children means that any programme to check the burgeoning population problem will be targeted at women only.

Gender concerns apart, it is wondered if such a programme is really needed, especially when fertility levels are on the decline.

(This has been one of the primary findings of Census 2001, the final results of which were put together in July.) But for a bureaucracy and a polity historically preoccupied with the concept of "unmet needs" (as envisaged in the NPP) only in terms of contraceptive choices and not life choices, the inclusion of such a programme seemed inevitable.

The CMP says: "The UPA government is committed to replicating all over the country the successes that some southern States have had in family planning. A sharply targeted population control programme will be launched in the 150-odd high-fertility districts. The UPA government recognises that States that achieve success in family planning cannot be penalised." Ironically, the next sentence talks about protecting the rights of children, elimination of child labour, ensuring facilities and extending special care to the girl child. There is no mention of the two-child norm that is prevalent in several States where women panchayat members and leaders have been deprived of certain privileges for having more than two children. Above all, there is complete silence on the skewed child sex ratio, a phenomenon reported in Census 2001. There are indications that the situation is no better despite the strict enforcement of the Pre-Natal Diagnostic Techniques (PNDT) Act. Preliminary results derived after monitoring the sex ratio at birth have shown that the male-female gap continues to be wide.

The Ministry of Health and Family Welfare has decided to take the CMP's commitment to its logical conclusion. It has announced targeted population control programmes, which will effectively begin in October, in 170 "high-order birth" districts across five States - Uttar Pradesh, Bihar, Jharkhand, Madhya Pradesh and Rajasthan - where the average number of children born is more than two per family.

The target is to achieve a Total Fertility Rate (TFR - the total number of children a woman has in a lifetime) of 2.1 from the current 3.4. The ideal of course is Kerala where the TFR is 1.8. In 2001, the previous government constituted an Empowered Action Group (EAG) in the Health Ministry and prepared area-specific programmes, with special emphasis on eight States (Bihar, Madhya Pradhesh, Rajasthan, Orissa, Chhattisgarh, Uttaranchal, Jharkhand and Uttar Pradesh that contribute to 45 per cent of the population boom of the country) that have been lagging behind in checking population growth. Special developmental measures, especially in the area of reproductive and child health, were envisaged for these socio-demographically backward States, called EAG States.

Secretary for Family Welfare P.K. Hota told Frontline that special efforts would be made to "unlock the potential of the private sector in family planning services". The experience of some southern States showed that private clinics accredited to the government were successfully conducting tubectomies. The main objective was to use the unutilised private sector in achieving the targets, he said. The officer said that women in the Below Poverty Line category would be given Rs.1,000 to meet the costs. This was apparently to compensate the loss in wage labour. Asked about the accountability of the private sector in the matter, Hota clarified that the Chief Medical Officer would supervise the work. Also, to prevent losses, the services of management professionals would be sought for better financial management. According to him, the best aspect of this scheme is that the Ministry can handle the programme well within its budget. In reply to a question, he wondered why there should be "any resistance". Hota denied that targets were being formulated, but added that there were "expectations". He said that they were "giving information and access". Targets, he said, would have been an issue in the public sector.

The private-public sector partnership was mooted in the NPP 2000 and reiterated in a document on Reproductive and Child Health (RCH) programme but was construed as a ploy by the government to withdraw from providing services and make the private sector fill the void. The partnerships have been tried out in other developing countries. The services included social marketing programmes sponsored by certain donors and subsidised private investments to distribute contraceptive methods. In many countries, fees were introduced for previously free services. But this somewhat reduced the spirit of free and quality health care as clients were expected to pay for these services. The bottom line, according to A.R. Nanda, former Secretary, Department of Family Welfare and now Executive Director of Population Foundation of India (PFI), is that whatever way it is done, the rules of the game, that is quality care, have to be followed. Nanda, who also served as the former Registrar-General and Census Commissioner of India, says that there has to be an inter-sectoral approach. The programme should also aim at reducing the infant mortality rate, the maternal mortality rate and anaemia among women. Nanda feels that the government should offer terminal methods of contraception as a last resort. "In my experience, we have seen women in their early twenties getting sterilised. The method should be reversible," he says.

Nanda, who has studied the Chinese experience, said that a lot was being said about the one-child norm and the harm it caused. "What is not said is that in the first 30 years after the Revolution, the Chinese gave equitable access to health and education to their people, which we did not do." By 1978, the fertility [rate in China] came down from 6 to 2.6. The obsession with numbers started only after 1979 when hinese demographers trained in the West also began talking the language of the "yellow peril".

Population is an asset, not a liability, says Nanda. Population stabilisation should essentially mean a stabilisation in the quality of life and not just numbers. The two-child norm is applicable in seven States, including those where the child-sex ratio is low. These are Haryana, Madhya Pradesh, Rajasthan, Himachal Pradesh, Delhi, Andhra Pradesh and Orissa. Nanda said that the overemphasis on sterilisation and targets had done the greatest harm to the Public Health System and women's health. The TFR, which was 6, has now come down to 2.8. Nanda believes that it has been partly due to government interventions and partly due to people's own understanding. "Will any rich person allow his wife or daughter to undergo tubectomy or sterilisation?" he asks. There is an anti-poor bias in sterilisation, he said.

Suman Parashar, Joint Director in the RGI's office, gives an interesting statistic. She says that 39 per cent of married couples do not even have a room for themselves. "Where will couples get the space for family planning when there is no privacy?" she asks. Suman Parashar, who also looks at the gender dimension in the Census, wondered if the goal of population stabilisation was feasible in the absence of a complete birth and death registration system. "In any event, stabilisation should not come at the cost of the girl child," she says emphatically.

It is going be a decade since the historic ICPD in Cairo and a lot of introspection is going on on the development models, which have only exacerbated inequalities of every kind, including sex ratios. Governments are yet to be convinced of "development being the best pill", and getting rid of the syndrome of "Targetitis", a term coined by Nanda. The NPP had recommended encouraging the small family norm and not the two-child norm. It had advised against using incentives or disincentives to promote a small family size.

In fact, former Union Health Minister Shatrughan Sinha had written to the Andhra Pradesh and Haryana governments asking them to move away from the two-child norm. But evidently, the plea, which was propelled by a campaign against the two-child norm, went unheard. A recent survey of the impact of the two-child norm in Madhya Pradesh, conducted by SAMA, an organisation specialising in women's health, and the Madhya Pradesh unit of the Bharat Gyan Vigyan Samiti, showed that several women sarpanchs were asked to quit their posts for having more than two children. The Madhya Pradesh Population Policy 2000 made persons having more than two children after January 26, 2001, ineligible for contesting elections to panchayati raj institutions. More than 145 panchayat representatives were interviewed and women, especially from the marginalised groups, seemed to have suffered the consequences of the policy.

If the UPA is committed to improving the social indices of development in the country, it has to begin with a serious reversal of policies.