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ICPD in India

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ICPD in India

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India and ICPD: Reproductive Health Beyond 2014

Background

The International Conference on Population and Development (ICPD) held in Cairo in 1994 was a turning

point in the history of global women’s rights, health and development. For the first time, 179 countries

came together to forge a consensus on a new approach to global health challenges. The event in Cairo

called for a comprehensive approach which recognized that economic, social and environmental progress

are critical and inter-related elements of an overall effort to improve the quality of people’s lives and

achieve sustainable development. Most importantly, ICPD represented a shift towards a rights based

approach which held that if people’s needs for family planning and reproductive healthcare are met, along

with other basic health and education needs, then population stabilization will be achieved naturally, not as

a matter of control or coercion. This approach put gender equality and women’s empowerment at the

centre of population and development strategies and policies and highlighted key concepts like quality of

care, male involvement and informed choice, which had been previously neglected by programs driven by

the narrow goal of limiting numbers.

ICPD Programme of Action

The ICPD Programme of Action (PoA) lays out recommendations and commitments agreed to by 179

countries at the International Conference on Population and Development held in Cairo in 1994. The PoA

set out to:

Provide universal access to family planning and sexual and reproductive health services and

reproductive rights;

Deliver gender equality, empowerment of women and equal access to education for girls;

Address the individual, social and economic impact of urbanization and migration;

Support sustainable development and address environmental issues associated with population

changes.i

The benchmarks added at the ICPD+5 reviews in 1999 in New York went on to inform the eight Millennium

Development Goals (MDGs).

ICPD in India

India was the first country in the world to launch a national family planning programme in 1951, aimed at

improving the health of mothers and children.ii However, with growing concerns about the rising population

and its negative impact on social and economic development the Third Five-Year Plan marked a move from

a women and child welfare approach to one of population control and stabilization.iii This was also the

period in which time bound and method specific targets were introduced.iv As is well known the target-

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oriented approach became highly coercive during the Emergency period (1975-1977). Given India’s history

of family planning, the rights based ICPD approach represented an immense ideological change.

After ICPD, the shift in the development paradigm translated into major changes in India’s population and

health policies. In 1996 for instance, the government took the radical decision of abolishing centrally

determined family planning targets and replacing it with a Target-Free Approach, based on decentralized

planning. This was further revised as the Community Needs Assessment approach in 1997 to better

address client’s needs.v Since 1994, India has developed many policies and schemes across sectors

which address several critical reproductive rights issues including policies on health, youth and women.

Many of these follow the ICPD principles in some measure.

The Reproductive and Child Health Programme (RCH-I), which was launched in 1997 promoted

comprehensive and integrated health services, including safe motherhood, child survival, abortion,

prevention and management of reproductive tract infections and sexually transmitted infections. It also

expanded services to underserved populations in remote areas, adolescents and urban slum

communities.vi Building on the ICPD Programme of Action, RCH-I attempted to also involve multiple

stakeholders including civil society, the private sector, Panchayati Raj institutions (PRIs).vii In an appraisal

of the programme, the World Bank identified RCH-I as having addressed women’s issues by improving

quality of care, increasing the numbers of female health care workers at the primary healthcare (PHC)

level, encouraging male involvement and addressing the needs of neglected populations.viii In 2000 the

National Population Policy was adopted by the Government of India and a National Population Commission

set up to guide the translation of the policy into programmes. The policy clearly focused on meeting unmet

demand for family planning and integrating reproductive health services. It also linked population issues to

sustainable economic growth and the environment as the ICPD meeting had envisaged. This was a huge

departure from the previous National Population Policy (1976) which had called for a “frontal attack on the

problems of population”!ix Most importantly, the policy followed a rights based approach and included key

reproductive health issues such as maternal mortality, services for adolescents and a target-free approach.

Another key policy drafted in the post-ICPD era was the National Health Policy (2002) which emphasized

equitable access to healthcare and primary care. In addition, it highlighted the need for funding for

women’s health. In 2005 the Government of India launched the Reproductive and Child Health Programme

Phase II (RCH-II). As in the first phase, the programme continued to prioritise the lifecycle approach and

emphasized quality of care and informed choice. RCH-II also focused on community monitoring

mechanisms, district level planning and Community Needs Assessments (CNAs).x Alongside RCH-II, the

government also launched its most ambitious programme in 2005, the National Rural Health Mission

(NRHM) for improving healthcare delivery across rural areas. The aim of the program was to create and

maintain integrated health care services for rural populations, particularly for the most vulnerable, by

strengthening health infrastructure at every level and improving human resources in the health system. A

key initiative was the creation of the community level Accredited Social Health Activist (ASHA) worker, who

are responsible for the distribution of oral contraceptive pills (OCPs) and condoms.

In early 2013 the government developed a strategy document on Reproductive, Maternal, Newborn, Child

Health and Adolescents (RMNCH+A). This new approach, emphasizes a lifecycle approach to women and

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child health, provides a comprehensive methodology to improving child survival and safe motherhood and

guidance to implement this approach in the second phase of NRHM (2012-2017).xi

Challenges

As evident from the discussion above, over the last two decades India has incorporated many of the

principles of ICPD into a range of policies, acts and laws. However, in spite of progressive policies and

schemes progress continues to be slow and there are key gaps that will require urgent attention before

India will be able to meet the ICPD targets. In spite of a stated Target-Free Approach in the National

Population Policy this does not always translate into state policies and the implementation of RCH

programmes.xii A number of the policies and strategies adopted at the state level are in direct opposition to

the principles of equity and informed choice. Several states have open or hidden incentives and targets.

Policies have in practice not led to changes in mindset or social norms at the state and district levels.

Despite an emphasis on decentralization, state-level adoption and ownership of the RCH program was low

leading to problems at the community and district level.xiii Initial implementation was plagued by issues of

insufficient capacity building, lack of trained staff, and a lack of clarity on the role of civil society.xiv At the

national level, the different aspects of reproductive health have met with varying success. While there have

been significant declines in Total Fertility Rate (TFR), Maternal Mortality Rate (MMR) and Infant Mortality

Rate (IMR), the unmet need for contraception (especially spacing) remains very high and maternal

morbidity is not highlighted. India has neither achieved any of its own national goals as set out in the

National Population Policy, nor is it projected to meet its global MDG or ICPD targets by 2015. The issues

of sex ratio and age at marriage, both critical for India, have shown little to no progress. In fact in the two

decades since ICPD, the sex ratio has declined significantly as evident in the 2001 and 2011 Census.

Key Issues in Family Planning and Reproductive Health in India beyond 2014

Given the complexity of reproductive health issues and the size and diversity of the population in India,

many reasons may account for this slow progress. Recently, in India’s ICPD post 2014 questionnaire

submitted to UNFPA, the government highlighted two issues as “most relevant regarding sexual and

reproductive health and reproductive rights that are anticipated to receive further public policy priority for

the next five to ten years”:

1. Unmet need for family planning

2. Quality of reproductive health servicesxv

Other issues that need to be addressed include promoting adolescent friendly health services, increasing

the age at marriage, preventing sex selection, community action and engagement and the promotion of

partnerships to address the reproductive rights and sexual health agenda.

1. Family Planning

Currently unmet need for family planning in India is 13%, however the unmet need for spacing methods is

highest (25%) among the youngest age group (15-19 years).xvi And yet, contraceptives available in the

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public health system are limited to methods that do not always meet the needs of these groups, such as the

Intra-Uterine Contraceptive Device (IUCD), Oral Contraceptive Pills (OCPs), condoms and sterilization.

Female sterilization continues to be the most commonly used method and Cash-incentives and targets

result in sterilization being promoted above all methods. Moreover, male involvement in family planning is

almost non-existent with vasectomies accounting for only 1% of all sterilizations in the country. The healthy

timing and spacing of birth is an issue of great concern, currently the average birth interval is 31.1

months.xvii More than half of all births occur before the optimal interval. While the NRHM promotes spacing

methods; other than IUCDs, the implementation is limited. Informed choice and quality of care continue to

be an issue with the National Family and Health Survey (NFHS-III) reporting that only one third of women

were aware of the side effects of the method they were currently using and only 28% aware of methods of

contraception other than the one they were using.xviii Supplies of contraceptives and supply chain

management continue to be inconsistent. A review of the NRHM in 2009 stated that stock outs and delays

were common due to slow progress on systems for procurement and logistics.xix

2. Adolescent Health

Delaying age at marriage and age at first pregnancy are critical in India, where about 46% of all women are

married before the legal age of marriagexx, one in six women aged 15-19 have begun childbearing and 50%

of maternal deaths among girls in the same age group are due to unsafe abortions.xxi Studies show that a

large number of risk factors for poor reproductive and child health are rooted in adolescence and yet only

15% of youth receive any education on sex or family planning.xxii Moreover, counseling services are yet to

target youth, whether married or unmarried.

3. Community Involvement

Although the NRHM has clearly made community based monitoring and planning (CBMP) part of its

implementation framework, reviews indicate that many of these local committees are unaware of their

function. The 6th Common Review Mission Report indicates that although PRI, village and local

participation seems to have improved in CBMP areas, district and block level participation has not

increased.xxiii There is now an increased commitment in the MoHFW to scale up CBMP in a systematic

manner in the next phase of NRHM across all states in the country. This provides an immense opportunity

to develop and strengthen on health and its determinants.xxiv

4. Partnerships

ICPD emphasized the need for a consultative and multi-stakeholder process to promote the PoA.

However, civil society involvement diminished soon after the initial conference. Moreover, the lack of a

consultative process between the central and state governments resulted in the slow progress of both RCH

I & II and even the NRHM.xxv The RCH I programme used NGOs as implementation agencies and brought

in the larger and better known NGOs as coordinators thereby creating a hierarchy among them.

Participation now meant involvement only in processes and programmes rather than in policy and

planningxxvi. There need to be agreement on mechanisms for broader civil society and community

participation in policy planning and evaluation including draft policies circulated in print and electronic

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media for comments, and public hearings. Political parties and Members of Parliament can play a major

role in promoting reproductive health and family planning at the national and district level and putting ICPD

back onto the national agenda.

Recommendations:

Provide voluntary and comprehensive family planning services.

Widen the range of contraceptive options in the public sector to include spacing methods such as

Progestin only pills Pills (POPs), hormonal IUDs, injectables and implants.

Counseling for contraceptives should be based on the couples’ need. Hence schemes and

incentives to frontline workers must ensure equal emphasis on spacing and sterilization to avoid a

bias in counseling.

Ensure the quality and accessibility of family planning and reproductive health services

Ensure the availability of all modern methods at the local level by strengthening supply chain

management systems

Provide adequate and well trained family planning counselors to ensure comprehensive information

and services are offered to all.

Emphasize the role of men and women in planning families and promote services and counseling

catering to men and boys.

Promote a multi-pronged approach to sex selection, which takes into account women’s rights, the

influence of class, caste, religion and other individual and group identities

Provide comprehensive sexual and reproductive health information and services catering to adolescents

Information should be provided regardless of marital status and in language that is both

comprehensible and age-appropriate.

Comprehensive sexuality education should be combined with life-skills education and youth

development programmes which help create opportunities and build skills.

Create adolescent friendly yet private and safe spaces within existing primary health care centers

that are easily accessible for all youth.

Ensure adequate legal provisions to safeguard the rights of adolescents

Strengthen existing legislation on child marriage by declaring all child marriages as null and void..

Scale up innovative and successful models for preventing child marriage and keeping girls in school.

Involve communities in planning and monitoring reproductive health services

Promote interventions that engage communities to change social norms like age at marriage and

girl’s education.

Empower communities to monitor and plan for better quality health services

Put in place effective grievance redressal mechanisms to improve accountability

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i UNFPA Overview of ICPD, UNFPA website, www.unfpa.org/public/icpd

ii Visaria, L. (2000) ‘From contraceptive targets to informed choice: The Indian experience.’ In Women’s

Reproductive Health in India ed. R. Ramasubban & S.J. Jejeebhoy, New Delhi: Rawat Publications; 331-382.

iii Visaria, P. and V. Chari. 1998. “India’s population policy and family planning programme: Yesterday, today and

tomorrow,” in Do Population Policies Matter? Fertility and Politics in Egypt, India, Kenya and Mexico, ed. A. Jain.

New York: Population Council, pp. 53–112

iv Santhya, KG. (2003) Changing Family Planning Scenario in India: An Overview of Recent Evidence. New Delhi:

Population Council, South & East Asia Regional Working Papers, No. 17

v Santhya (2003)

vi Ministry of Health and Family Welfare (MOHFW). 1997. Reproductive and Child Health Programme: Schemes for

Implementation. New Delhi: MOHFW, Government of India

vii Ministry of Health and Family Welfare (MOHFW). 1997.

viii World Bank. 1997. Project Appraisal Document: India Reproductive and Child Health Project. World Bank

Population and Human Resources Division, South Asia Country Department II, Report No. 16393-IN. Washington,

DC: The World Bank.

ix Srinivasan, K (1998) “Population policies and programmes since independence: A saga of great expectations and

poor performance,” Demography India 27(1):1-22.

x Ministry of Health and Family Welfare (2009) Reproductive and Child Health Programme-II Midterm Review Draft

Aide Memoire (Version 6 May 2009). New Delhi: MOHFW, Government of India.

xi Ministry of Health and Family Welfare (2013) A Strategic Approach to Reproductive, Maternal, Newborn, Child

and Adolescent Health (RMNCH+A) in India New Delhi: MOHFW, Government of India.

xii Department of Family Welfare (1997) Reproductive and Child Health Programme: Schemes for Implementation

New Delhi: MOHFW, Government of India.

xiii Donor Coordination Division (2006) Reproductive & Child Health Programme Phase II, 2nd Joint Review Mission,

Aide Memoire New Delhi: MOHFW, Government of India.

xiv World Bank (2005) Implementation Completion Report: On a Credit in the amount of SDR 179.5 million to India

for a Reproductive and Child Health Project. Report No: 30479-IN. Washington DC: World Bank.

xv Government of India (2013) Global Survey ICPD Beyond 2014 Country Questionnaire.

http://www.mohfw.nic.in/WriteReadData/1892s/ICPD%20beyond%202014%20Questionnaire%20-%20English-

20715848.doc

xvi International Institute for Population Sciences (IIPS) and Macro International (2007) National Family Health

Survey (NFHS-III), 2005-06: India: Volume 1 Mumbai: IIPS.

xvii IIPS (2007)

xviii IIPS (2007)

xix Government of India (2012) 6th Common Review Mission Report, New Delhi: Ministry of Health and Family

Welfare

xx IIPS (2007)

xxi Centre for Development and Population Activities (CEDPA) (2001) Adolescent Girls in India Choose A Better

Future: Impact Assessment as cited in Centre for Reproductive Rights (2008) Maternal Mortality in India New York:

Centre for Reproductive Rights.

xxii International Institute for Population Sciences (IIPS) and Population Council (2007) Youth in India: Situation and

Needs 2006-2007. Mumbai: IIPS & New Delhi: Population Council.

xxiii Ministry of Health and Family Welfare (2012) 6th Common Review Mission Report New Delhi: MOHFW,

Government of India

xxiv Government of India, Centre for Health and Social Justice (CHSJ) & Population Foundation of India (PFI) (2010)

Reviving Hopes, Realising Rights: A Report of the First Phase of Community Monitoring under NRHM. New Delhi

xxv MOHFW (2012)

xxvi Arrow, Monitoring ten years of ICPD implementation, the way forward to 2015, Asia Country Reports