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Diagnostic Study Tamil Nadu |
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Diagnostic Study
of
Population Growth,
Family Planning
and
Development, 1971-81
Tamil Nadu
THE FAMILY PLANNING FOUNDATION
198, GOLF LINKS, NEW DELHI-UOO03
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DIAGNOSTIC STUDY OF
POPULATION GROWTH, FAMILY PLANNING
AND DEVELOPMENT IN ORISSA, 1971-81
y ~ ~AMAlJHADRAN
THE FAMILY PLANNING FOUNDATION
198, GOLF LINKS, NEW DELHI-llOOO3
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The Family Planning Foundation as a funding and promoting
organisation has selectively addressed itself to diagnostic research
on major population issues. As soon as the 1981 census results
were published, the Governing Board of the Foundation expressed
the need to find out why the population growth rates varied
considerably among the states and bring out the programme and
policy implications. In operationalising this suggestion, it was
felt that in view of the significance of the study and the need
to have a high level liaison with the states, the Foundation should
direc.:tly undertake the study. For this purpose the Foundation
invited Mr V K Ramabhadran to undertake the study.
The study covers 5 states with different demographic and
economic settings-Gujarat, Orissa, Rajasthan, Tamil Nadu and
Uttar Pradesh. T~is Brochu~~~~
the main findings ang
recommendations in respect of ~."This
would, we hope1
stimulate an informed discussion on the Status of Population in.
Tamil Nadu and pave the way for a more vigorous and effective
action programme in family welfare.
The Foundation would like to place on record its deep
appreciation for the willing cooperation of the state governments1
particularly of the Departments of He~l~h an~ Family Planning.
New Delhi
f~brllaI?'1, 19~?
J C KAVOORI
~~ecutive Director
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1. The decennial Census of India has always been regarded both
as an evaluator of past population policies and indicator of future
policy requirements. The Census of 1981 has performed a similar
role by disclosing a decadal growth of 25.00 per cent in 1971-81
compared with 24.80 in 1961-71. The reaction to the Census
disclosure has been somewhat mixed:
Some relieved that the momentum of population growth (as
a legacy of high fertility in the past) has been contained;
Some anxious that the expected decline in growth rate (as a
result of the family planning programme) has not taken
place.
2. While the above is the picture at the national level, behind
the 'static' decadal growth rate of population at the national
level, the picture is highly variegated at the state level. An
important feature brought Ol;~ by the 1981 Census is that the
problem of rapid population growth in India is essentially a
regional problem. Among the 14 major States of India (with a
population of 10 million and above excluding Assam), the growth
rate in 1971-81 has varied from 17.50 in Tamil Nadu to 32.97 in
Rajasthan.
3. This project entitled "Diagnostic Study of Population Growth
Family Planning and Development in 1971-81 in Tamil Nadu" is
a part of the five-state study project (which includes Gujarat,
Orissa, Rajasthan, Tamil Nadu and Uttar Pradesh). The
,project has its genesis in the disclosure by the 1981 Census of a
constant growth rate at the national level, but a highly variable
growth rate at state level. The principal objective of this study is to
identify the causes responsible for such variation in 'demographic
behaviour against the background of both the family plannirlg
programme input (which is a centrally supported -sehen'te" on a
uniform b,asis) and the social setting in different states (which
depends mainly on state policy and initiatives in development)
as well the likely synergism between these two factors. Thes~
diagnostic exercises do not aim at establishing hypotheses or
quantitative relationships nor are they expected to lead to
instantaneous solutions to problems. But it is hoped they
would expand understandin~ of the probleJJ1s and the pott;:ntial
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4. The diagnostic study adopts the framework:
Knowledge
(based on
available
information)
") Understanding
rL_ ..-+(based on interaction
with programme
J officials)
I Action
rL_--+ (based on
findings of
J the study)
The study has utilised not only the data available in various
publications and its analysis, but based on the analysis, a set
of structured questions were framed for three core levels of
leadership in the family planning programme: political level
(Heaith Minister), executive level (Commissioner/Secretary) and
professional level (Director of Family Welfare). The structured
questions, its replies and the subseq!1ent interview have vastly
improved the information base and have imparted a realism to
the exercise.
5. The main findings of the study are presented in the brochure
under four headings:
The Demographic Scene;
The Social Setting;
The Development Scenario;
Family Planning Performance.
Based on the findings, a set of forty-two Recommendations has
been developed, which it is hoped, would be seriously considered
both by the State and the Central Governments. Copies of the
Main Report have already been sent to the Programme leaders in
the State and the ("'entre.
6. The project has been funded by the Family Planning
Foundation (FPF). Though FPF has normally a funding and
promoting role, in the case of this particular project the FPF
undertook also the implementation in view of the significance of
the study for the programme and the need to have a high level
liaison with the States in securing the project objectives. The
'f\\-tudy is not an end in itself. Based on the study, a series of
, follow-up meetings are proposed with the leadership in Popu-
lation and Development in each State to translate the favourable
experience and lessons from one state to another with a view to
push up the programme performance, particularly in poor-
performance States.
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The Detnographic Scene
- The decadal population growth of Tamil Nadu in 1971-81
which was 17.50 has two features:
i) It is the lowest growth rate among all the States in
India;
if) It is substantially lower than the growth rate of Tamil
Nadu in the decade 1961-71.
- The population processes of fertility, mortality and migration
have different types of influences on these two trends. The
first due to levels and differentials in fertility and mortality
and the second due to trend in fertility. The lowest growth
rate in Tamil Nadu among States has been attained because
fertility level in Tamil Nadu in 1971-81 is lower than in many
Northern States, while the mortality level is relatively higher
than in Haryana, Kerala, Karnataka, Maharashtra and Punjab.
The drop in growth rate in Tamil Nadu compared with 1961-
71 particularly in rural areas is due to the declining trend in
fertility in 1971-81.
.- The fertility and mortality levels were respectively 31.3 and
14.5 in 1971 and 27.7 and 11.4 in 1981. Thus in absolute terms
fertility declined by 3.6 units and mortality by 3.1 units or an
annual rate of decline of 0.36 in birth rate and 0.31 in death
rate during the decade 1971-81.
- The population growth rate has declined in both the rural and
urban areas of Tamil Nadu in 1971-81 compared with 1961-71
while at the national level urban growth rate has increased
continuously.
- The rural growth rate declined from 16.35 per cent ill 1961-71
to 12.65 in 1971-81 i.e. by 23 per cent while the urban growth
rate declined by 28 per cent.
- There was a net out-migration of 0.33 per cent from rural
areas of Tamil Nadu and in-migration of 1.08 per cent into
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urban areas of the State in 1971-81. However, for the state as
a whole, there has been net out-migration of 0.35 per ccnt
of males ancl 0.05 per cent of females by place of birth during
1971-81.
While the decline in rural growth rate in 1971-81 could be
attributed to a decline in fertility and out-migration, the
decline in urban growth rate is probably due to the 'vertical
pattern' of urbanisation in Tamil Nadu when all the accretion
to urban population took place only in Class I and II cities.
One possible reason for a tardy decline in urban fertility could
be the lack of concern of the slum population in adopting
family planning against the background of their life style,
infant mortality etc.
In Tamil Nadu nearly two-thirds of fertility is contributed by
women below 30 years of age. Also the proportion of births
of higher birth orders (fourth and above) constituted 35.4 per
cent in rural areas and 30.0 per cent in urban areas. There is
a rapid decline in fertility in age group 25-29 and above which
indicates a definite trend in fertility planning.
According to 1981 Census the average number of children
born for women in the age group 45-49 was 4. IO in rural areas
and 4.36 in urban areas. Fertility moderation in rural areas
appears to be more successful than in the urban areas of
Tamil Nadu.
It is anomalous that urban fertility is high despite a couple
protection rate of 51.2 per cent in urban areas compared with
17.6 in rural areas. Ihis could either mean that the family
planning programme in the urban areas is not properly target-
ted or that natural methods of contraception supplemented
the official family planning programme in the rural areas.
This calls for a detailed study.
Infant mortality in Tamil Nadu is higher than in Karnataka,
and nearly double that in Kerala. However, there was a
decline in the late 70s.
- There are sharp ru.ral-urban differentials in infant mortality
rate with an average rural rate of 120 per thousand live births
in 1971-81 compared with 72 in urban areas.
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The mean age at marriage of females in Tamil Nadu has
increased from 19.6 in 1971 to 20.3 in 1981.
The proportion of married women in the age group 15-19 was
22.8 per cent in 1981 against the national proportion of 43.5.
- In Tamil Nadu a sizeable number of marriages do not have
religious ceremonies and are solemnised in the presence of
political leaders who speak on that occasion about small
families.
The sex-ratio (females per 1000 males) is consistently higher
than the national ratio.
Literacy in Tamil Nadu has always been higher than at the
national level. Rural female literacy was 25 per cent in 1981
compared with 18 per cent for India and 63 per cent in
Kerala.
Percentage of attendance at educational institution was the
second highest in Tamil Nadu (59.3 per cent) with Kerala
(75.1 per cent) in the lead and the national average at 38.5 per
cent.
- Work participation in Tamil Nadu has always been higher
than the national level. In particular, female work-participa-
tion increased from 15 per cent in 1971 to 25 per cent in
1981.
A disquieting feature of work-participation in Tamil Nadu is
child labour, which is a symptom of poverty.
There has been no change in occupational structure of Tamil
Nadu with the share of agricultural workers remainin~
stationary at about 61 per cent since 1961.
On the other hand, there has been an unfavourable shift
within agriculture from 'cultivators to agriculturallaboqr'. The
worst affected are female workers of whom 48 per cent wer€!
agricultural labourers in 1981 compared with 29 per cent in
1961. Such a shift has implications for fertility.
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~- Though son-preference index in Tamil Nadu (11.5) is lower
than in many States in the North (Rajasthan 31.3), the son-
preference attitude generally exists which coupled with the
higher infant mortality among males constitutes an unfavour-
able climate for vigorous family planning.
An Old Age Pension Scheme has been launched by Govern-
ment as a social security measure.
- To make women self-reliant, there are a number of Mathar-
sangams (informal Women's Association at the grass-roots
level). They have a potential but many of them need to be
energised.
- The statutory reservation of 15 per cent of Panchayat
Chairmanship for women and the setting up of the Tamil
Nadu Corporation for Development of Women are illustrative
of the State Government's interest in raising the status of
women.
- The per capita income of Tamil Nadu (Rs. 632 in 1981 at
1970-71 prices) remained below the national average (Rs. 700)
and was about half that of Punjab (Rs. 1,367).
- The State Domestic Product grew by less than 3 per cent
annually in the decade 1971-81.
- The economy was characterised by poor agricultural growth
(occasioned mostly by monsoon failure and partly by structu-
ral factors) and by low industrial investment.
- The low economic status and the poor impact of development
of Tamil Nadu is reflected in two widely recognized para-
meters: poverty and unemployment.
Over 52 per cent of the people of Tamil Nadu were below the
poverty line in 1977-78. The unemployment rate in 1972-73
was over 12 per cent compared with 8.3 per cent at all-India
level.
Though the development scenario in 1971-81 was rather bleak
some efforts to orient development towards population is in
evidence. Su?stantial step-up in outlay and expenditure on
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health care and family welfare, drinking water, rural roads
and rural electrification and village and small scale industries
was reported in 1980-81.
Rural roads and rural electrification have provided a strong
infrastructure. The length of motorable roads was above
53,000 Kms in 1980-81. Rural electrification covers almost all
the villages.
- The expenditure on population-oriented development was
nearly one-quarter of the total plan expenditure in 1980-81.
- Tamil Nadu is one of the states which had a head-start in
family planning with emphasis on sterilisation and an accept-
ance rate of 36 per 1000 population in 1973 which has risen to
68 per thousand in 1981.
The percentage of eligible couples protected through steri-
lisation has increased from 15.9 in 1973 to 26.4 in 1981 (the
overall protection has increased from 17.3 to 27.6).
Spacing methods were in low-key throughout the decade
1971-81 hardly accounting for 2 per cent of couple protection.
During the decade there were 2.3 million acceptors of
sterilisation while spacing methods accounted for 1.2 million.
In contrast, at the national level there were 25 million
acceptors of sterilisation while 36 million accepted spacing
methods.
The sterilisation programme which slumped in 1977-78 has
been rebuilt and the percentage achievement of target was al-
ways higher than all-India percentage.
The contraceptive mix in Tamil Nadu in 1971-81 with 'high
priority' for sterilisation and directed towards younger women
was a major factor in fertility decline.
One definite trend noticed in sterilisation acceptance in Tamil
Nadu, in common with the rest of India is the switch over
from male sterilisation in the first half of 1971-8J to female
sterilisation in the second half with 1977 being the transition
year. The vasectomy camps, the emergency syndrome in the
first half of thd the decade and emergence of the Japaroscopic
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technique inthe second half of the decade seem to be the
main factors influencing the change.
The laparoscopic camps have established credibility among
the rural folk through proper screening, post-operative care
and follow-up.
There has been an urban bias in the promotion of family
planning in 197HH with a couple protection rate of 51.2 per
cent among urban couple compared with 17.6 per cent among
. rural couple. Sterilisation acceptors accounted for the bulk
(48.4 per cent) among the urban couple.
- The 'contraception style' in Tamil Nadu is to go in for terminal
methods after having 2 or 3 children. 63 per cent of tubec-
tomy acceptors had less than :I children in 1980-81. In 1981,
the average number of living children was 3.4 for tubectomy
acceptors in Tamil Nadu compared with 3.7 at all-India level.
The IUD acceptance in Tamil Nadu gave only a marginal
protection to less than one per cent of the eligible couples.
The acceptance despite increase in targets is plateauing at
35,000.
The performance under other spacing methods (conventional
contraceptives and oral pills) has been poor. Not only were
achievements much lower than the target, but the percentage
achievement has been declining since 1978-79.
i) the attitude of the people to go straightaway for terminal
methods after 2 and 3 children ;
ii)staff deficiencies in contraceptive distribution;
iii) fear of side-effects.
- The family planning programme in Tamil Nadu has had a
definite impact in rural areas as the total fertility has declined
.. from 4.4 in 1971.to 3.5 in 1978 but in urban areas there is
hardly any impact.
""- Also there is a definite decline in age-specific marital fertility
at all ages above 20 in rural areas while the decline is margi-
nal in urban areas.
Though there has been an impact on fertility, there has not
been any significant improvement in quality in 1971-81 in
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terms of decline in age (30 for tubectomy) and in p'arity (i4
for tubectomy).
Political commitment across party lines is one of the strengths
of the family planning programme in Tamil Nadu. The
Cabinet Sub-committee with the Chief Minister as Chairman
and, the State Family Welfare Board with the Health
Minister as Chairman and members also drawn from the
political parties and the monitoring:)f the programme at the
level of the Chief Secretary show the high level concern for
the programme.
The District Collector is virtually the driving force and dis~
tricts which do not fulfil the proportionate target in any
month are pulled up by the Chief Secretary. This way defi-
ciencies are not allowed to accumulate.
In the target approach, the targets are distributed down the
line upto the individual functionary. The 'Athoor Experience'
of area approach and 'joint team action' have yet to be
applied on a large scale.
In Tamil Nadu it is the Health Care based approach to family
planning and motivation for family planning is done along.
with extension of health services.
- The immunisation status is quite high (82 per cent in rural
area for children below 1 year in 1978) and the medical atten~
tion at birth increased from 29 per cent in 1972 to nearly 50
per cent in 1978.
People's parti,:,ipation through voluntary organisation, Pan-
chayat Unions and the informal Women's organisations
(Mahalir Mandram) is an encouraging feature in Tamil
Nadu.
Tamil Nadu is one of the States which has involved the
voluntary organisations years bJck in the family planning
programme in and 1981-82 they accounted for nearly a quarter
of the sterilisation. The voluntary organisations assist the
programme through the urban family welfare centres and
mini-health centres.
- The co-operatives, which is another source of institutional
strength in Tamil Nadu could playa n'ore effective and direct
role in promoting family planning.
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'- The 'Athoor experience' of the Gandhigram Institute, has
shown that with the existing infrastructure under the PHC
it is possible to improve the family planning-programme in
rural areaS. Application of these wholesome experiences over
wider areas has not been seriously attempted by the State
Government so far.
The diagnosis indicates the strength and weakness of the family
planning programme in Tamil Nadu as listed below:
A. Programme Factors (or direct inputs)
1. A head-start in family planning.
2. Health care base (and hence credibility of the pro-
gramme).
3. Effective district leadership and organisations.
4. Strict pursuit of targets and their distribution down the
line.
5. High level monitoring (and prompt instructions to poor
performance districts).
6. Camp approach (to make up for shortfall in pro-rata
achievement).
7. Availability of laparoscopic technique.
B. Non-Programme Factors (or environmental variables):
1. Sustained political commitment across party lines.
2. Spread of literacy and publi~ awareness.
3. Strong infrastructure support in rural areas. (particularly
rural roads, rural electrification which has improved the
accessibility of the services).
4. Population-oriented development (accounting for 25 per
cent of total plan expenditure).
5. Status of women and higher age at marriage.
6. Involvement of Panchayat Unions.
7. Support of voluntary organisations.
8. Additional incentives by the State Government.
Impedilnents :
1. Poverty.
2. Unemployment.
3. Low agricultural productivity and economic stagnation.
4. Urban slum syndrome.
5. The 'contraception style' to go in for sterilisation after
completing a small family of 2 or 3 children, thus limiting
the scope for promoting spacing methods.
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6. Side-effects, cumbersome procedure and requirement of
female service providers of spacing methods.
7. High infant mortality with slightly higher risk for male
infants
8. Lack of unified approach to Health and Family Wel-
fare because of multiplicity of Health Directorate at the
State Headquarters and the concomitant problems of
co-ordination at the district level.
9. Limited enthusiasm of the medical profession towards
the family planning programme which is considered
'extr.aneous' to their academic attainments.
10. Non-implementation of the Village Health Guide scheme
which could constitute an important local link between
the people and the programme.
1. In c.-:;nformitywith the national demographic goal of NRR=1
by 2000 AD, Tamil Nadu is required to achieve this goal by
1991 which implies that the birth rate has to be reduced
to 21 and death rate to 9 from the 1980-82 levels of 27.1
and 11.4 per thousand respectively. At the rate of annual
decline of 0.36 in birth rate and 0.31 in death rate recorded
in the decade 197I-81, reduction in death rate to the
prescribed level could be achieved even earlier but the required
decline in birth rate would call for a more vigorous and Widespread
family planning programme directed towards the younger couples
and further raise in age at marriage.*
2. The low population growth rate in Tamil Nadu in 1971-81 is
characterised by a decline both in the rural growth rate and in the
urban growth rate. But, while there is net out-migration from
rural areas to the extent of 3.3 per thousand, there is net in-
migration in the urban areas of 11 per thousand. Also urban
growth is a vertical phenomena with Class I and II cities
accounting for the entire urban growth. Keeping in view the 'slum
situation' likely to arise from such an urban growth, there is
need to adopt a definite policy regarding spatial distribution of
population in Tamil Nadu so as to (a) contain the rural-urban
migration through measures to improve agricultural productivity
and (b) to reduce the growth of Class I and II cities by
promoting the growth of Class III to VI cities through
• In general an increase in age at marriage reduces the proportion
married and the number of couples exposed to the risk of pregnancy.
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specially designed economic programmes and 'growth centre
techniques' .
3. The family planning programme in Tamil Nadu now almost
exclusively concentrates on sterilisation and spacing methods do
not account for even 5 per cent of couple protection. To the
extent that the 'contraception style' of the people is to go in
straight-away for terminal methods after 2 or 3 children, the
sterilisation programme in Tamil Nadu could continue to have
a focus for some more time in rural India, but with reduced targets.
Also in extending th~ sterilisation programme in rural areas it
would be advantageous to introduce the mini-lap technique in
which Orissa has specialised. A team of doctors could be sent to
Orissa for training under Dr Mrs B B lena, Director of Health and
Family Welfare who has played a pioneering role in developing the
Mini-lap technique.
4. At the same time, promotion of spacing methods on a large
scale is a historical need and corrective; in particular major
thrusts through spacing methods is called for in urban areas and
districts where the contraception rate has reached the level of 40
per cent and above through sterilisation.
5. Successful family planning in Tamil Nadu in the ensuing
years with adequate emphasis on spacing methods requires
a caring and con tinuous service to the acceptors. It is
doubtful whether the present structure of an officially led
motivation and delivery system can handle a widespread
and effective spacing services. A combination of measures is
called for:
a) Reorient the functionaries in the programme at all levels
so as to bring in more human values in the programme.
b) Introduce among functionaries more social workers.
c) Utilise voluntary institutions, co-operatives and all the
informal local level organisations in recruiting clients
and supplying contraceptives adopting either the
community-based distribution system or social marketing
techniques.
d) Constantly monitor the demand and supply situation
in order to ensure a demand-supply equilibrium at
micro level to avoid frustration among genuine users, on
the one hand and avoid accumulation of un utili sed stocks,
on the other.
6. Infant mortality in Tamil Nadu is rather on the high side.
Since spacing methods have both health and survival benefits,
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there is a further justification for promoting spacing methods on
a large scale in any package of measures designed to control infant
mortality in Tamil Nadu.
7. Though there is a visible orientation of development towards
the needs of population in Tamil Nadu in the form of drinking
water, rural roads, rural electrification etc., there is no conscious
large scale effort on the part of State Government to combine
family planning with development approaches at the grass-roots
level. The high level of poverty could continue to be an impedi-
ment to the programme. It is to be recognised that poor do not
readily accept the family planning. With mal-nutrition, illiteracy,
ill health and oppression, the poor particularly in the rural
areas are left with very little control over their own
lives and circumstances and they are virtually alienated
from the very idea of 'planning". If progress in health
education and in economic activity is reached to them unhindered,
it would help create a sense of mastery over their destiny and
the idea of family planning would then be welcomed as another
opportunity to control their own lives. Family planning.
does not rank high among the hierarchy of felt-needs and it
therefore requires meaningful entry points through income
generating schemes particularly for women, creation of community
assets etc.
8. Family planning programme needs a social change which!
cannot be brought about by service-oriented functionaries. A
good deal of social counselling would be required in promoting
spacing methods not only for initial acceptaI)ce, but for counti~
nuation. There is scope for appointment of a cadre of social
workers through the voluntary organisations.
9. Family planning cannot continue to be a successful programme
unless it acquires an evenness. The adhocism, spurts in efforts,
periodic campaigns and camps to fulfil targets are far from an
approach to build a contracepting society. For this, more deter-
mined efforts are necessary to change the value system particu-
larly in the rural areas and urban slums and make family planning
a way of life of individual couples and not entirely a response to
external motivation. To ensure an expanding demand for family
planning services, relevant social and economic programmes
directed towards communities have to be combined with a 'team
approach' involving para-medicals and social workers to convince
the people about the benefits of limiting their family and the
availability of services for that purpose.
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10. Since the family planning programme is hundred per ~ cent
centrally funded and the targets are also set by the centre for
each method, the programme is more regarded as a central
programme which the states merely carry out. In order to
enhance the sense of involvement of the state, it is desirable
that the Centre indicates to the states what the level of couple
protection is to be for different years consistent with the national
demographic goal and suggest to the states to take over the
responsibility of working out realistically the targets under
different methods as well as the financial requirements [or the
programme. In this process, the states in turn could built up
their target profile on the basis of district-wise exercise in target
which would be in line with the couple protection level in each
state and the general demographic and economic characteristics.
The district administration in Tamil Nadu has shown considerable
initiative in implementing the programme and it is expected that
they could perform an equally efficient role in proposing a
realistic and appropriate targets under different methods for
each district.
11. To be effective, family planning approaches need to be
tailored to specific audiences. In the rural areas, we could divide
according to the identifiable homogeneous groups such as occu-
pational life styles (such as agricultural labour and marginal
farmers, fishermen), women's group illiterates etc. Community
organisations that cater to the needs of these sub-groups, could
be identified and utilised as channels for family planning promo-
tion. In the segmented approach to the family planning, the
urban slums need a different startegy as they are far from a
concept of good living though they may have amenities like fridge
and TV in their dwellings.
12. Though the District Collector's leadership qualities have
helped the programme (particularly the sterilisation camps) it
would be desirable to improve the political backing for the
programme at the district lev~l. One district may be allocated
to each Minister in the State who could in turn constitute an All
Party Family Planning Implementation
Committee for the
districts. Also the MLAs of the area could be directly involved
in the programme by organising 'Prestige Camps' in their name,
not necessarily for sterilisation, but for rendering immunisation
services and counselling about family planning methods as well
as distribution of contraceptives, insertion of IUD etc. Such
multi-purpose Prestige Camps are reported to have worked
successfully in Gujarat.
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13. There is a strong case for demedicalising spacing methods so
that IUDs could be introduced through LHV or ANM.
14. A mong the spacing methods available at pr~seDt in the
delivery system, IUD requires an intensive promotion. In order
to sustain a high continuation rate as well as a follow-up of the
acceptors of spacing methods (IUD, Oral pills), periodic incen-
tives in cash may be deposited into the beneficiary al::count so
as to em;ure a continuous watch on the non-pregnancy status of
the beneficiary as well as higher continuation rate.
15. The clinical services for those motivated and the camp
approach for those with lower level of motivation have served
the community in providing sterilisation service through the
medical profession. But family planning has now to move to
spacing methods, wherein the non-phisicians (particularly
indigenous medical practitioners) ha'-e a role to play. The tradi-
tional medical practitioners could not only make the family
planning services accessible but also acceptable to the people
and what is more important, the programme would be made
more sentitive and responsive to local values and individual
needs.
16. Though there is need to demedicalise family planning
services, it does not imply that the programme could do without
the medical profession. Indeed, a medical back-up to the
programme is probably the best method of imparting credibility
to the programme and the medical profession has therefore, both
a promotive and creative role in the programme. There is,
therefore, a need actually for a deeper professional involvement
of the doctors in the programme. A part of the observed super-
ficial involvement of the medical profession at present, is
probably due to the medical profession not being exposed to the
full dimension of the population problem, the social aspects of
family planning and the eontraceptive techniques available for
this purpose. Unless the basis for a redical change in their
attitude and their response is laid during their academic career,
the commitment to family planning cannot be internalised and
the doctors would still regard family planning as an activity
extraneous to their academic up-bringing. There is, therefore,
a strong case for imparting more knowledge and expertise on
family planning to the upcoming generation of doctors during
their academic career by suitably modifying the medical
curriculum. We have still not addressed ourselves adequately
to the long-term man-power problems in family planning and it
is only through the strengthening of their academic training that
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the doctors could be expected to render professionalised family
planning services in the way they are now rendering curative
services. (Books such as 'Practice of Fertility Control'-A
Comprehensive Text Book by S K Chaudhuri and others, Current
Book Publishers would be useful in modifying the curriculum).
17. The Medical Officer of the PHC has several responsibilities
now under the integrated programme of health and family
welfare. Several types of records at the PHC level are to be
maintained for follow-up of cases and for monitoring the
progress. The MOPHC needs to have adequate management
skill to handle the multifarious functions of the PHCs and also
impart a systems approach to identifying and solving
problems through a Management Information System. All these
point to the needs for imparting techno-managerial or micro-
manag~rial training to the MOPHC, with more emphasis on
management practice and not theory.
18. Promotion of family planning would require good deal of
extension work. At present, the Block Extension Educator (BEE) is
meant for this work, but is not made fully responsible for extension
activities. He is used for purposes such as stocking of contracep-
tives, arranging sterilisation comps etc. and has little contact
with the individual households and community for spreading the
message of family planning and for providing to the Programme
Managers a feed-back on the s!atus of the programme. One of
the reasons for the BEE thus becoming dysfunctional is his
method of recruitment, lack of career opportunities and above
all, the lack of extension training techniques itself. BEE needs
to be trained in family planning communication and he should
be called upon to train oth ers through training and visit systems
as used in agricultural extension. It is to be emphasized that the
stage of self-interest of clients in family planning is still a long
way off and extension is therefore an essential gap-filling role to
be performed.
19. The Orientation Training Camps need to be followed-up
systematically to derive the advantage of their 'ripple effect' in
promoting family planning through the opinion leaders.
20. The institutional support to family planning in Tamil Nadu is
in the form of the co-operative sectors and the voluntary organi-
sations. Though the voluntary organisations are being used in
implementing the programme, the co-operalive sector is utilised
only marginally by way of imparting population education to the
co-operative trainees. Because of the widespread co-operativ~
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movement in Tamil Nadu, it would be particulary important to
utilise co-operatives as outlet channels for distribution of con·
traceptives by designing social marketing techniques.
21. The corporate sector as well as the trade unions do not seem
to be fully involved in the programme. Tripartite Committees
comprising labour, employer and government could be set up for
major industrial establishments while the trade unions could be
approached through suitable incentive scheme to promote family
planning generally among their members. Indeed the full potential
of cooperatives, the Corporate sector and the trade unions in
internalising the family planning programme~both from the
demand and supply angles-need to be utilised.
22. The Matharsangams (Mahilir Mandrams or Mother's Club)
which are informal local level organisations of women, particu-
larly in rural areas appear to be useful instruments for mobilising
women and thus promote contraception. A programme of energis-
ing the large number of Matharsangams which have become
defunct may be undertaken as recommended by the Gandhigram
Institute of Rural Health & Family Welfare.
23. The' Athoor Experiences' of the Gandhigram Institute need
to be replicated over a wider area by the Government of Tamil
Nadu in collaboration with the Institute as there are several
wholesome features in it that could improve the family planning
programme even within the constraints of the Government
machinery.
24. The studies and surveys that are considered necessary for
making the family planning programme in Tamil Nadu more
relevant and responsive to the realities in the field are listed
below:
i) Is urbanisation in Tamil Nadu declining and why is the
pattern of urbanisation vertical? (Paragraph 23-24)
ii) Why was agricultural productivity low in 1971-81 and
has it led to the out-migration from rural areas? (para
26) What are the reasons for decline in 'cultivators' and
increase in 'agriculturallabourers'?
iii) Why is it that there has been no sharp decline in fertility
in urban areas (as in rural areas) during 1971·81 despite
a high couple protection rate of 51.2 per cent in urban
areas (compared with 17.6 per cent in rural areas),
particularly when sterilisation contrIbuted to 48.4 per
cent of couple protection? (Paragraph 33)
iv) What are tDe demographic features and life style of the
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'slum population' and are they responsible for high
fertility, high IMR and low family planning acceptance?
What has been the impact of slum improvement in
Madras on family planning promotion? (Paragraph 33)
v) Why is the infant mortality higher among male infants in
Tal1}ilNadu? (Paragraph 41)
vi) Prevalence ef teenage pregnancies (Paragraph 47).
vii) Prevalence of child-labour (Paragraph 53)
viii) Continued poverty of a large segment of population is
an impediment to family planning promotion. To what
extent has Tamil Nadu progressed towards its VI Plan
objective of reducing the percentage of people below
the poverty line to 40 by March 1985.
ix) Tamil Nadu has an impressive record of infrastructure
development in 1971-81 in the form of rural mads and
rural electrification. What bas been the precise effect of
these factors on family planning acceptance.
x) Evaluation of tbe impact of the Chief Minister's Mid-
day Meal Scheme which has a high priority in plan
allocation.
xi) The 'contraception style' in Tamil Nadu is to go in
straightaway for terminal methods after 2 or 3 cbildren.
In this approach, are these children being spaced in a
manner that mother's health and child care are not
affected? It would be useful to study the 1;>irthi~terval~
among sterilisation acceptor~.