Skewed priorities

The draft document on Reproductive Health and Family Planning, prepared by the Department of Family Welfare, focusses only on family planning and ignores the larger issues of reproductive and child health.

in New Delhi

ON July 16, Deputy Prime Minister L.K. Advani told newspersons that the Bharatiya Janata Party-led National Democratic Alliance (NDA) government was considering legislation to bring about population control. An integral part of the legislation, he said, would be the strict imposition of the two-child norm to the extent that it would make ineligible anyone with more than two children for contesting elections or applying for government jobs. That this was not an off-the-cuff comment became evident two days later, when BJP president M. Venkaiah Naidu, while spelling out the agenda before the party's National Executive meeting in Raipur, called upon the government to take some decisive steps to curb the burgeoning of population.

Obviously, there is a concerted move in the BJP to revert to methods of population control other than those recommended by the government's National Population Policy (NPP), 2000. The NPP had cautioned against the use of incentives and disincentives, including barring people from contesting elections, as methods to control population growth. It had also proscribed the "target-oriented" approach of the past.

In fact, the BJP's line of thought is articulated well in a recent document that ostensibly deals with Reproductive and Child Health (RCH) issues. Prepared by the Department of Family Welfare (DoFW) in the Ministry of Health and Family Welfare (MoHFW), the draft document is titled "Reproductive and Child Health II and Family Planning - Program Implementation Plan". It spells out RCH and family planning programmes, which are in consonance with the Tenth Plan goals, millennium development goals as well as immediate and medium-term goals of NPP, 2000.

But there is more to the draft document than meets the eye. The greater objective of the document seems to be to increase the visibility of the population stabilisation programme - the sanitised term used to denote population control - rather than a composite, holistic RCH programme. Explaining the rationale for increasing such visibility, the document notes: "The inverted red-triangle, the eye-catching logo of the Indian family programme of yesteryear has slowly faded from public memory. There is an urgent need to bring back the visibility to the population stabilisation programme. The paradigm shift in the programme calls for a new but simple logo." The idea, obviously, is to take matters beyond changing the logo.

A senior bureaucrat, formerly associated with the Health Ministry, observed that it seemed as if the Community Needs Assessment (CNA) approach - a pivotal feature of RCH-I, which was a client-centric approach - had been sidelined. To treat family planning as a separate entity reflected the fact that the policy-makers had an incomplete understanding of RCH, he said. More dangerously, he felt, this could create confusion in the minds of the service providers. The CNA approach was basically one where the needs of the community, and not those of the government, were given priority. This entailed going beyond the nominal approach to "community needs"; RCH-I reflected a broader understanding of what reproductive rights ought to be - including concepts pertaining to the dignity of women, quality of care, planning and participation by the community, with emphasis on the demand side. The current draft document is tilted more towards the supply side.

On June 6, 2003, the Secretary, DoFW, held a meeting with non-governmental organisations (NGOs) concerned with gender and reproductive health issues, to discuss the draft document. Not surprisingly, the participants expressed many reservations, especially about the report's obsession with family planning rather than with the entire gamut of RCH issues. Alarm signals went out when it was noticed that family planning and RCH had been clubbed together in RCH-II, unlike in RCH-I.

The RCH programme was meant to be a holistic one, and family planning only one of its many features. The programme itself was inspired by the International Conference on Population and Development in Cairo. A good part of the programme gets foreign aid, with the World Bank being one of its major external funding agencies.

Some gender and health activists who were present at the meeting voiced their strong disapproval at the absence of a holistic approach - the life-cycle one - in the document. They argued that RCH was not only about population stabilisation, maternal health and neonatal and postnatal care but about the entire life-cycle of a woman, beginning from puberty to menopause. It was argued that the reproductive health of even those sections of women who did not opt for pregnancy and motherhood ought to be taken into consideration. It was felt that the document was based on the old Maternal and Child Health (MCH) model rather than on RCH.

There is a distinct gender bias as well. An example of this is the generous offer of a "basket of contraceptives", most of which are directed once again at women. It says that injectibles and implants, which are not currently offered under the programme, must be introduced as early as possible. It further suggests that female condoms too would be "a welcome addition to the programme". But women's organisations and NGOs in the health sector have had serious reservations about the introduction of injectibles and implants, especially because there is hardly any system in place to deal with the complications they would cause. It also raises the question of rational use of drugs.

Renu Khanna, founder-director of Sahaj, a Vadodra-based organisation dealing with gender, health and rights issues, said that reproductive health was inherently a rights-based concept and that some of the NGOs could not understand the continuous use of the term family planning to refer to a contraceptive programme. This presupposed that only married couples required contraceptives. She said that a rights-based approach essentially recognised that contraceptives were also required by unmarried people.

Subhash Mendhapurkar, director of Sutra, a Himachal Pradesh-based NGO, says: "We welcome the reduction in infant mortality rates and maternal mortality rates but when you talk about a reduction in TFR, we need to look at the Census 2001 (provisional) data which clearly show that the States which have a TFR of less than 3 have the worst girl-child ratios. So the question is whether we want a low TFR at the cost of the girl child. The RCH-II is completely silent on this question. The document doesn't speak about the challenges ahead. It goes back to the MCH-centric approach, which everyone seems to be comfortable with." Mendhapurkar added that the RCH-I had laid great emphasis on the life-cycle approach.

But what is more galling is RCH-II's recommendation to increase the involvement of the private sector in the delivery of family planning services, especially in areas where the public sector is weak. It singles out large parts of the Empowered Action Group (EAG) States - Bihar, Rajasthan, Madhya Pradesh, Orissa, Uttar Pradesh, Chhattisgarh, Jharkhand and Uttaranchal - as well as inner-city slum areas, where private sector interventions will be required. The EAG States are those where population stabilisation has been slower as compared to the rest of the country.

"Female sterilisation," the document notes, "has been the mainstay of the Indian family planning programme." It states that "a high level of infant and child mortality and strong preference for sons in the EAG States deter women from accepting a terminal method of contraception early". The document offers a wide range of contraceptive methods, mainly for women. There are some cosmetic references to increasing "male involvement" and adoption of the non-scalpel vasectomy method.

The document states that private medical practitioners provide more than two-thirds of all health care in India. But the relevant question is whether in a country like India, where rural and urban indebtedness and poverty are high, a case for further private sector involvement in place of vigorous public sector intervention is justified. Making a case for the private sector, the document states: "In rural areas, they are more respected and accessible than government grassroot workers."

Another disturbing feature of the RCH-II document was the emphasis given to social marketing and the involvement of Rural Health Practitioners (RHPs). The document has recommended that injectibles and other contraceptives be given to RHPs for a nominal charge, which they could provide to their patients. According to the National and Family Health Survey data, less than 10 per cent of rural women said that an auxiliary nurse midwife (ANM) visited them during a year.

RHPs, according to the document, constitute a large pool of formally or informally qualified persons who meet the day-to-day healthcare needs of rural folks. In addition to them, male health workers and ANMs are supposed to supply the contraceptives to RHPs and maintain an account of the same. The document suggested that the distribution network be entrusted to NGOs wherever the government machinery was weak.

There are certain unwarranted inferences too. For instance, on the subject of expanding the choice of contraceptives and making a case for reversible contraception methods, the document states: "The Hindu-Muslim difference in fertility and use of contraception has become a major political issue in India. Partly the difference stems from the religious objections for the use of sterilisation among Muslims." It is no secret that the BJP and its ideological allies have time and again raised this baseless bogey. But it is surprising that a government document should succumb to this kind of propaganda.

The overall thrust of the document should have been on setting up more healthcare infrastructure for the majority of the population. But this is hardly a priority in the document. The document may have lamented about the lack of primary health centres and community health centres, lack of staff, poor doctor-patient ratio and so on but refrains from making quality of care and access its central concern.

The redeeming features of the document include sections on urban health, tribal health and adolescent health. But the basic approach in all these is the same.

Mira Shiva, Director of the Department on Women, Health and Development and Rational Drug Use at the Voluntary Health Association of India, feels that the socio-economic determinants of RCH have not been addressed in the document. There should have been more involvement from other Ministries in formulating RCH-II, she felt.

By and large, the document is perceived to have been drafted by people with a Malthusian mindset. There is hardly any reference to female foeticide or even the alarming decline in the sex ratio. The document has made a departure from the "development is the best pill" approach. Prasanna Hota, Secretary, Family Welfare, told Frontline that the document was not yet finalised. The document hopefully will redeem itself and encourage more decentralised participation, entail a client-centric and a rights-based approach and inject renewed interventions from the public sector. It is of crucial importance that it does so because being a national document, it is bound to be emulated by State governments as well.