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Towards a New Population Policy for Uttar Pradesh_ 9-7-15 rev |
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Towards a
New Population
Policy for
Uttar Pradesh
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Towards a
New
Population
Policy for
Uttar Pradesh
Soon after the National Population Policy was announced in 2000, Uttar Pradesh
followed with its own population policy. The state policy, like the national policy,
had included goals, objectives and strategies. The UP Population Policy aimed
to improve the quality of life of the people through population stabilization and
improvement of the health status of people, particularly women and children,
which were viewed as important prerequisites for sustainable development.
Population Foundation of India (PFI) and the State Innovations in Family Planning Project Services Agency
(SIFPSA) were involved in the drafting of the Uttar Pradesh Population Policy, valid from 2000 to 2016. Now, Uttar
Pradesh has become the first state to review its population policy in a very proactive consultative manner, involving
government officers right upto the district level, service providers, policy makers, local leaders and members of the
civil society.
A mid-term review of the policy in October 2008 had shown that many of the goals for maternal and child heath,
delaying age of marriage, and meeting the unmet need for adoption of contraceptive methods could not be achieved.
However, in the sphere of antenatal care coverage and institutional deliveries the state had performed better than
the stated goals. When the UP Population Policy was adopted, Uttar Pradesh included the region, which is now the
state of Uttarakhand. Given the bifurcation of the state it was considered timely to examine the progress of the policy,
identify the gaps and determine what was needed to draft an effective policy.
The state government initiated the process of review and revision of UP’s population policy in February 2014 and
invited SIFPSA and PFI to lead the process. The two organisations have facilitated the formation of three committees
set up for policy revision – a Core Committee, a Drafting Group and a Review Committee headed by the Chief
Secretary.
Senior officers from the Department of Health and Family Welfare, the National Health Mission, leading organizations
working in the field of population, and stakeholder departments are members of the Core and Review Committees.
The drafting group will write the revised Population Policy of Uttar Pradesh after the state-level consultation in June
2015, under the chairmanship of the Chief Secretary, Government of Uttar Pradesh.
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The consultative process
Four regional consultations that culminate in a state consultation were planned for the policy review. The
aim was to bring all stakeholders on a common platform to debate, discuss and develop a policy that could
successfully overcome the challenges faced so far and meet the aspirations of the people in the state. With
this exercise, UP becomes the first state where micro action will influence macro policy.
The four regional consultations, jointly facilitated by PFI and SIFPSA, were day-long events. The events
covered the Allahabad, Jhansi, Gorakhpur and the Moradabad regions and with that the entire state.
All the consultations were facilitated by Mr B K Jain, General Manager, Research & Evaluation, SIFPSA and
Dr Sanjay Pandey, Programme Director, Population Foundation of India. Dr Meenu Sagar, Director Family
Welfare, Uttar Pradesh, discussed the National Population Policy and the current Uttar Pradesh Population
Policy outlining the need for amendments, and the desirability of linking family welfare with child health,
and the strengthening of facilities required to deliver services.
The meetings had participation by district magistrates, Chief Medical Officers and their teams down to
the district level, state government officers, political leaders, representatives of civil society organizations
and academics. Additional directors, programme managers and deputy programme managers of the district
health departments, medical superintendents of respective district hospitals, representatives from the
Integrated Child Development Services (ICDS) and the State Institute of Health and Family Welfare also
participated. Thereby, with village level representation it was ensured that rural priorities are included in the
policy.
Each of the four regional consultations was chaired by the Divisional Commissioner of the region where
these were held. The first regional consultation was held in Allahabad on August 26, 2014 and had 141
participants from 17 participating districts of Allahabad, Mirzapur, Lucknow and Varanasi divisions. .
The second regional consultation was held in Agra on September 19, 2014 and had 130 participants from 15
districts of Agra, Aligarh, Chitrakoot and Jhansi divisions.
The third regional consultation was held in Gorakhpur on October 17, 2014 and had 110 participants from
18 districts of Gorakhpur, Basti, Faizabad, Azamgarh and Devipatan divisions.
The fourth regional consultation was held in Moradabad on October 31, 2014 and had 134 participants from
24 districts of Kanpur, Saharanpur, Meerut and Moradabad divisions.
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Structure of
consultations
At each of the consultations, the first half of the day was spent on examining the objectives of the national and the
state population policies, the population trends in the state and the country as a whole, and the progress on the goals
set in the current state policy. There was special focus on the health and demographic indicators of the districts
within the region where the consultation was being held and how these compared to the rest of the state. Priority
issues were flagged for discussion by the working groups for the afternoon session.
The recommendations that emerged from the four regional consultations and the state consultation will be
incorporated in the policy draft. The draft will also include the findings of the four studies being carried out by
SIFPSA and PFI.
SIFPSA has completed the study on Barriers in adoption of family planning methods. SIFPSA has also entrusted
Population Research Centre, Lucknow, to carry out the study on Out of pocket expenditure for health seeking
behaviours in UP. PFI has completed two studies – Budget analysis of the family planning programme in Uttar Pradesh
and Policy review of the family planning programme in Uttar Pradesh. These studies will feed into the drafting of the
revised population policy.
Issues focussed on
• Even though India was the first country to start a family planning programme, we have not been able to stabilise
population growth envisioned in the policy. According to the UN State of the World Population Report, India will
be the most populous country in the world by 2028.
• The national policy set the medium term objective of attaining replacement level fertility rates across the country
by 2010, and in the long term, attain population stabilisation by 2045. The main objective of the current UP
Population Policy is to attain replacement level TFR of 2.1 by 2016. However, the total fertility rate (TFR) of UP
is 3.1 (SRS, 2013).
• To reach replacement level TFR, the use of modern contraceptives had to increase from 22 percent in 1998-99 to
52 percent in 2016. The contraceptive prevalence rate in the state as per Annual Health Survey, 2012-13 is 37.6.
• The emphasis is on a target free approach to make available modern contraceptive methods to couples and build
awareness to enable an informed choice.
• The state policy lays emphasis on maternal and child health to attain population stabilisation. The policy has
detailed strategies to achieve its objectives, with an emphasis on monitoring and evaluation.
• 50% of India’s population is below 25 years, and 65% below 35 years. In UP, the proportion of the population
below 25 years and below 35 years is 56%, and 69% respectively. The population momentum, due to the large
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base of young people in the country, is estimated to contribute to 70 percent of the population growth. This
makes it very important to focus on their special needs, which include counselling for marriage at the legal
age, counselling for delaying first pregnancy and spacing of births for better health of the mother and children,
expanding the basket of family planning methods and ensuring that services reach them.
• Total Fertility Rate ranges from a low of (2.1 Kanpur) to 5.5 (Shrawasti). (AHS, 2012)
• Fifty five percent of the girls in the state get married before 18 years of age. (DLHS 3)
• The state recorded only 0.2% vasectomy, placing the entire burden of limiting family size on women. (AHS,
2010-11)
• Fertility and contraceptive behaviour are inextricably linked to infant and child mortality. To achieve population
stabilization, there is an urgent need to reduce the infant mortality rate as well as the maternal mortality ratio.
On the other hand, family planning is a key intervention that helps lower both maternal and infant mortality.
The state has faced many challenges in population stabilisation and these were examined. It has a high population
density of 800 per sq km. There is a huge shortage of human resources including an inadequate number of doctors
serving the population (the ratio being 1:3332), health services are poor and basic family planning services do
not reach the community. Every sixth Indian is a person from UP and the state’s population of 19.95 crores (2011
Census) is equivalent to the population of Brazil, the fifth largest country in the world. Eleven districts have a TFR
of 4.1, while 46 districts have a TFR between 3.1 to 4. Only 13 districts have a TFR below 3.
Group work for strategy development
In the second half of the day, the participants were divided according to the TFR of their districts so that they could
collectively brainstorm on eight points that had been flagged for discussion. The participants were encouraged to
focus on district specific measures that can be adopted in the new policy.
The eight points for discussion:
1. Vision Statement
2. Measures to reduce TFR
3. Measures to increase CPR
4. Strategies to increase awareness for family planning
5. Measures to increase male participation
6. Increase age at marriage
7. Improve sex ratio at birth
8. Measures for strengthening the health system
The recommendations that emerged in the four workshops are grouped under the above mentioned eight categories:
1. Vision Statement
The working groups were asked to come up with a vision statement for the policy. The groups focused on a range of
issues, the underlying thought being the importance of the policy reaching all, with strengthened service delivery so
as to bring about a qualitative change in the lives of the people of the state.
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Some of the vision statements that emerged were:
• Small, empowered and happy families in a beautiful, healthy and prosperous state
• Better quality of life for people by improving their social, economic, educational and health status
• Improved quality of life for people in Uttar Pradesh attained through:
• Quality and comprehensive health and family planning services for all with special emphasis on reaching
the marginalized population and young people
• Adopting a multi sectoral approach
• An enabling environment with increased political and policy support
2. Strategies to reduce Total Fertility Rate
Legal
• Increase legal age at marriage so that early pregnancy could be avoided
Counselling services
• Health providers and community leaders to motivate people to delay age of marriage and newlyweds to delay
the birth of first child by adopting a modern contraceptive method, and counsel couples to have an adequate gap
between two pregnancies
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• Counselling services to be available at village and block level so that unwanted pregnancies can be avoided
• Hold regular counselling sessions with mothers-in-law and daughters-in-law through saas-bahu
meetings up to block level
• Place trained male and female counsellors at Primary Health Centres and Community Health Centres
Sexuality education
• Sexuality education and family planning knowledge should be imparted to adolescents
• The topic of population stabilization should be covered in text books so that awareness is created at a
young age
• Extensive IEC/BCC, family planning education should be introduced in educational institutions and
counselling at the family level
Birth and death registration
• Birth and death registration should be done at the panchayat and ward levels
3. Strategies to improve Contraceptive Prevalence Rate
Increase the basket of choice
• The basket of choice for spacing methods in the public health system should be expanded to include
new contraceptives methods like projestin only pills (POPs) and injectables.
Service delivery and contraceptive distribution
• Increase the number of family planning service delivery centres for easy access by the community
• Every facility where deliveries take place should offer counselling, postpartum IUCD (PPIUCD) and
sterilisation services
• Increase condom distribution points. Condom outlet boxes could be installed at Anganwadi Centres,
bus stands, panchayat ghar, etc
• The Anganwadi centre could be developed as a family counselling centre
Regular and adequate training for service providers
• Awareness about PPIUCD and contraceptive update training should be promoted
• All PHC, CHC doctors should be trained for minilap operations
• Quality of services should be ensured by providing regular training
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Supply chain management
• Strengthen supply chain mechanism by putting in place a system to monitor stock status on a regular
basis
• Social marketing of contraceptives should be expanded through public private partnerships (PPP)
• Increase participation of NGOs and PRIs for supply of contraceptives
• Set up contraceptive depots at the division level
• Ensure regular supply of contraceptives through ASHAs to make contraceptive pills and condoms
available at doorstep.
Counselling of eligible couples
• ASHAs should identify and maintain a list of couples in four groups for counselling – 1) newlyweds
2) couples with one child 3) with 2 children and 4) more than 2 children
• Register newlywed couples and arrange for their counselling
• Organize monthly village family planning day for rural women and ensure easy availability of all
contraceptives along with counselling.
• Focus on meeting the unmet need
• Satisfied beneficiaries of family planning methods should be encouraged to share their experience of
adopting the method. They would be the best change agents for a community.
• Follow-up of couples using spacing methods; organise husband-wife meets along the lines of saas-
bahu meets
Monitoring
• Introduce a system for third party monitoring on a periodic basis
Convergence, coordination and collaboration between departments
• The collaboration between health and other departments needs to be strengthened
• Coordination between ASHA, ANM and the anganwadi worker should be established for better
tracking of maternal and child health and counselling services for family planning
4. Strategies to increase awareness for family planning
• Community and opinion leaders should be motivated to create awareness on population issues and
advantages of a small family.
• Engage with influential stakeholders such as politicians, religious leaders, sportspersons etc. and
convince them to take on the responsibility for mass sensitization
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• Build awareness through text (sms) messages
• Work towards changing social norms around family planning. This could be done by -
• Encouraging discussions on the benefits of a small family and contraceptives at work places and resident
get-togethers during national celebrations
• Hold debates, discussions and competitions on the issue of family planning in colleges
• Engage the media for increased coverage on population issues
• Encourage religious leaders to advocate for small family norm and gender equality during religious functions
and gatherings
• Identify champions from among well recognized personalities such as actors and sportspersons to advocate
for the cause
• Identify family planning ambassadors at the gram panchayat level
• Make family planning services a topic of discussion at Village Health Sanitation and Nutrition Committee
(VHSNC) meetings
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5. Measures to increase male participation
On non scalpel vasectomy
• Create groups of males at village level to remove misconceptions and myths regarding male sterilization
• Organise meetings where satisfied non scalpel vasectomy (NSV) client share their experience
• Effectively monitor and evaluate NSV procedures
• Promote NSV through various health schemes
• Train and increase the number of NSV service providers
• Increase the number of facilities conducting NSV
• Improve counselling for NSV
• Have fixed day service for NSV
Male partnership and participation
• Make men aware of the benefits of spacing and terminal methods that can be adopted
• Increase adoption of permanent methods among men through the services of a male health worker
• Hold husband-wife meets at block and district levels
• Increase the number of male health workers, and make them responsible for promoting male involvement
in reproductive health and family planning matters
• Counsel spouse during marriage registration, during delivery (recruit male counsellors for this task) and
during ANC (spouse to accompany pregnant woman)
6. Strategies for women’s empowerment and increasing age at marriage
• Step up work on improving education status in rural areas; make education compulsory for girls
• Promote skill enhancement and financial independence for girls
• Enforce the existing law on age at marriage. Publicize the law (Prohibition of Child Marriage Act) through
extensive promotional campaigns
• Age at marriage should be increased from 18 to 21 years for females and from 21 to 23 for males.
• Parents and community elders should be oriented on the harmful consequences of early marriage and
the benefits of marrying at the legal age
• Marriage registration should be made mandatory
• Village pradhans should not issue marriage certificates for girls below 18 years of age
• Strengthen adolescent friendly health services and clinics
• Take the support of other departments – Panchayati Raj, ICDS, Social Welfare, Education, etc to promote
legal age at marriage
• Involve religious leaders
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7. Improve sex ratio at birth
Education and job opportunities
• Provide free education for girls from primary classes to college
• Provide job opportunities and security for girls
Sensitisation
• Raise awareness on social imbalance created by declining sex ratio
• Mass sensitization on sex selective abortions
• Identify role models and raise awareness regarding the value of a girl child
• Conduct gender equality programmes in educational institutes and communities
• Involve community based organisations in sensitization programmes
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Policy
• Birth registration to be made compulsory
• Strict and effective implementation of existing laws – MTP Act, PCPNDT Act, the Dowry Act
8. Measures for strengthening the health system
Enhancement of skills of service providers
• Adequate training of staff at every level on contraceptive technology updates, quality of care and the importance
of reproductive health and family planning
• Training/refresher course for medical and paramedical staff
• Put in place a system for regular supportive supervision
• Enhance the counselling skills of ASHAs and ANMs
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Improve basic health services
• Prepare detailed implementation plans for family planning at various levels from village to block and district
• Make infrastructure as per Indian Public Health Standards available at all levels
• Fill all vacant posts
• Provide fixed day services for family planning counselling at sub-centres
• Introduce mobile health services in hard-to-reach areas
• Improve living conditions for medical staff at PHCs and CHCs
• Fix responsibility at every level for quality MIS data
• Increase use of information technology
Incentives
During the course of the consultations, participants made recommendations to include a range of incentives. There
is no evidence that incentives work and incentives are also co-related to coercion, especially for the marginalized
and economically disadvantaged groups and go against the rights based and empowerment approach. Giving
incentives to the health staff should be reviewed and may not be necessary as it has been seen that in order to
achieve larger numbers, the quality of care is most often compromised. The incentives provided to health staff must
be linked to quality of care rather than achieving numbers.
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Some proposed incentives
• Couples who adopt a permanent method after two children should be given a special card that entitles them to
some facilities
• Women who maintain a three-year gap between two pregnancies should get a financial incentive. (Suggestion
was for Rs 100 per month)
• Incentive should be provided to PPIUCD beneficiaries
• Free transport service be given to those who go in for sterilisation
• Increase the incentive for sterilization. Incentive for male sterilisation to be higher than for female sterilisation
Action points and key recommendations by panellists during the course of discussions
n A counsellor should be placed in all institutions, especially those doing 100 deliveries per month.
– Mr Amit Ghosh, National Health Mission Director and Principal Secretary, Health
n Include family planning in the government’s list of 100 programmes that are monitored every month.
– Mr Pradeep Bhatnagar, Commissioner, Agra Division
n Condom vending machines should be installed in Primary and Community Health Centres.
– Dr Rakesh Raman, Additional Director, Chitrakoot
n There should be 50% reservation for women in services.
– Dr Rakesh Raman, Additional Director, Chitrakoot
n Include discussions on family size in group meetings of NABARD, NRLM and other such community based
schemes.
– Mr Ranjan Kumar, District Magistrate, Gorakhpur
n Ensure inter-departmental coordination so that all government departments are aware of the population
policy measures and use every platform to spread the message. A consultant may be put in place to achieve
this.
– Mr Ranjan Kumar, District Magistrate, Gorakhpur
n Pay attention to social factors when formulating revised population policy; focus on skill upgradation to
increase employability.
– Mr Sudhir Garg, Commissioner, Moradabad
n IEC material related to women’s health and family planning should be distributed in simple Urdu in Muslim
dominated areas.
– Maulvi Waliullah, Shahar Qazi, Gorakhpur
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“We were 10 brothers and sisters. I had four children and they have two children each. This is the result
of education. When we educate people, we will not need to spend on incentives for adopting family
planning measures.”
Mr Jagan Prasad Garg, MLA of Agra North
“The training of ASHAs and ANMs is not up to the mark. Several ANM positions are lying vacant. As
more and more ANMs retire with time, the gap will increase. An ANM is the only medically trained
person available in rural areas. Supply chain issues too need to be resolved. Senior health officials should
create an efficient feedback mechanism for the districts.”
Mr Pankaj Kumar, District Magistrate, Agra
“Agra city has 2,200 clinics, but there are no doctors or nurses beyond the city limits. Community medicine
needs to be brought back to the mainstream once more. There are no big hospitals in Iran; all health needs
are met through community clinics. Most of these clinics are in rural areas and have doctors, nurses and
medicines available there. We need to reorient the entire health structure towards community medicine.”
Mr Pradeep Bhatnagar, Commissioner, Agra Division
“There is acute lack of interdepartmental coordination at present. All government departments,
especially those dealing with community groups, must be made aware of population policy measures so
that they can spread the message at every platform.”
Mr Ranjan Kumar, District Magistrate, Gorakhpur
“All the country’s development will be reduced to nothing if we are not able to make family planning
services available to people who need them. We are failing in the area of community motivation despite the
large health apparatus and the presence of so many organisations working in the health sector. Whatever
the population policy, it must reach every person.”
Mr R.K. Ojha, Commissioner of Gorakhpur district
“Our hospitals should treat patients with more compassion. This will encourage more people to seek
the government’s services, including family planning. And as for the Muslim community, there is a
widespread lack of education. Special awareness campaigns could be carried out in slums and villages
with concentration of the minority population.”
Mr Yusuf Ansari, MLA, Moradabad
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Population Foundation of India
B-28 Qutab Institutional Area
New Delhi-1100 016, India
Telephone: + 91-11-43894100
Fax: +91-11-43894199
E-mail: info@populationfoundation.in
Website: www.populationfoundation.in
20 | Towards a New Population Policy for Uttar Pradesh
State Innovations in Family Planning Services
Project Agency (SIFPSA)
'Om Kailash Tower', 19-A, Vidhan Sabha Marg, Lucknow - 226001
(Uttar Pradesh), INDIA
E-Mail : info@sifpsa.org
Phone Numbers : ( 91 - 0522 ) 2237497, 2237498, 2237540
Fax Numbers : ( 91 - 0522 ) 2237574, 2237388
Website : www.sifpsa.org