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Advocacy Papers Population Issues |
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Advocacy Papers ON
pOPULATION
iSSUES
Population Foundation of India
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Compiled By:
Sona Sharma
Chandni Malik
Nihar Ranjan Mishra
Assisted By:
Shailendar Singh Negi
Jolly Jose
© Population Foundation of India, 2010
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Contents
1. Introduction
2. Overview
3. Compilation of already published papers
....
5-7
.... 8-30
Papers:
i.Obsolescence and Anachronism of Population Control: From Demography to
Demology. Demography India vol. 33, No. 1 (2004), pp 1 – 12: A R Nanda
ii. Population Scenario of India and National Population Policy: An Overview: Almas Ali
iii. Population Policy: An Overview: A R Nanda
iv. Population and Development: Myths and Realities,
NFI Bulletin, January 2004: Almas Ali
v. Women and National Population Policy: Almas Ali
vi.The National Population Policy, 2000 – what can it achieve realistically?: A R Nanda
vii. Changing Sex Ratio and its implications: A R Nanda
....31-94
.... 33-43
.... 44-59
.... 60-64
.... 65-70
.... 71-76
.... 77-87
.... 88-94
Books/Journals/Papers/Articles for Further Reading
Annexures:
(A) Presentations:
i. Political environment impacting maternal mortality and
young people’s reproductive health
ii.Evolution of India’s Family Planning Programme and the National Population Policy
iii. National Population Policy, 2000 & State Population Policies
iv. Investing in Young People’s Health: Issues and Challenges
v. Building Supportive Environment for Improved Quality of Care (QoC)
through Advocacy Initiatives: An Overview
vi. Primary Health Care Key to Population Stabilization
vii. Advocacy Initiatives on the theme of “Missing Girls”
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95
.... 97-142
.... 99-102
.... 103-112
.... 113-117
.... 118-122
.... 123-127
.... 128-139
.... 140-142
(B) Compilation of supporting documents
i.Letter from the Union Health Minister to State Governments regarding
two child norm and incentives/disincentives
ii.Letter from PFI to Heads of Political Parties to incorporate Critical Population
and Health Issues in Election Manifesto
iii.Letter to Prime Minister from Avabai B Wadia, Member, Governing Board, PFI
iv. Statement of Concern on the Proposed Rural Health Care Mission
.... 143-155
.... 145-147
.... 148-149
.... 150-151
.... 152-155
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Introduction
Population Foundation of India (PFI) is a national non-government organization
working on population issues. The Foundation considers rights-based approach and
gender sensitivity as cross cutting in all its programmes and activities. The Foundation
recognizes the importance of family planning as also the need for repositioning family
planning in the present context to increase its acceptability and effectiveness. Further,
the issues of women’s empowerment, gender equity and equality, missing girls, quality of
care, informed and expanded contraceptive choices and the needs of young people have
been identified as major thematic areas of PFI.
This publication is an
attempt to document
Foundation’s approach
and advocacy efforts
through compilation
of advocacy papers
The issues surrounding India’s population are increasingly stirring public debate and
discussion. Advocacy on core aspects crucial to population stabilization being a strategic
focus, the Foundation is playing an important role in continuing the informed debate on
the same.
published and
presented at various
forums over the last
In simple terms advocacy means “promotion of open dialogue, frank discussions and few years.
informed public debate – ultimately influencing public opinion on a particular issue (in
this case “the issue of population stabilization”) on a sustainable basis through various audience
and channels.” To bring about a desirable, internalized and sustainable social change in the
present context, advocacy has become the most appropriate approach and a meaningful strategic
tool. Identification of key stakeholders, significant information, relevant data and empirical facts
and figures are the key components of successful advocacy.
This publication is an attempt to document Foundation’s approach and advocacy efforts
through compilation of advocacy papers published and presented at various forums over the last
few years. PFI has felt the need to bring out such a compilation by putting together the existing
and available advocacy materials produced by the Foundation from time to time, and from other
sources. As PFI celebrates 40 years of relentless work on the issue of population stabilization, it is
an opportune time and an appropriate occasion to bring out this publication.
While the emphasis of issues within the papers varies depending on the occasion of advocacy
and the stakeholders targeted, there is bound to be an overlap in the underlying approach in these
materials.The most important objective of bringing out this volume is to compile the relevant advocacy
perspectives at one place.
This compilation is more relevant because for most people, the word “population problem”
is invariably associated with galloping numbers for which the poor, those belonging to backward
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social groups including religious minority groups are held responsible. Even now, the attitude of
the elite and middle class remains one of a forceful and targeted family planning programme. For
decades, in the rush to lower birth rates and the rate of population growth, we disregarded the
merit for a more humane empowerment and balanced approach to population issues, to favour
an authoritarian approach.
The International Conference on Population and Development (ICPD) held in Cairo in 1994
looked at the “whole question of population” anew from the aspect of sustainable development,
reproductive health and reproductive rights. While the new language of rights and choice has
gained greater acceptance among policymakers and programme implementers, just beneath the
surface of new labels persists the old fear of galloping numbers. This fear is based on lack of
understanding about the built-in ‘population momentum’ in India’s population due to its young
age structure.
Despite clear evidence about the “population momentum”, there is still a reliance on the old
argument that only “control approaches” with targets and incentives and disincentives will work
in bringing down the numbers to a manageable level. Given the implications of the population
momentum, to impose, for example, a “two child norm” (as in some state population policies
which are framed in the old population control mindset) may simply be barking up the wrong tree.
This may be neither relevant nor particularly effective in bringing down the growth rate, and is
definitely counter-productive.
Unfortunately, even today there are lots of myths and misconceptions surrounding population
issues. These misconceptions need to be demystified so as to pave the way for relevant and effective
policies and strategies. The advocacy papers compiled in this volume are an attempt towards the
same.
A paradigm shift has taken place in the language used in the policy and programme documents,
but it will take a long time to bring about a real paradigm shift in thinking. There are still some
diehard “population control” exponents among politicians, bureaucrats, demographers and some
sections of the elite, who have not reconciled to the paradigm shift and who feel more comfortable
with an authoritarian policy regime of quantitative targets for the sake of achieving soft and quick-
fix options. They often deride the “target free” approach as one which leads to complete
Unfortunately, even lack of accountability and lack of quick and visible results on the ground. Such mindset
today there are
is prominent among the present generation of bureaucrats and scholars, who have been
trained and oriented in neo-Malthusian studies of population.
lots of myths and Against this backdrop, serious advocacy efforts are required on a sustained basis
misconceptions in order to change attitudes and mindsets. This publication is intended as a tool for
surrounding population advocacy. It is a conscious attempt to continue informed public dialogue and debate
among policymakers including elected representatives at various levels i.e. national -
issues. These Members of Parliament (MPs), States - Legislative bodies (MLAs), District/sub districts
misconceptions need - Panchayat and urban municipal bodies (PRIs of three tier system and ward members),
to be demystified so
as to pave the way for
relevant and effective
planners, administrators, judiciary, media and civil society organizations (NGOs, CBOs
and activists).
The compilation of supporting documents in this publication holds a lot of relevance
in our times. The first is a letter from the Union Health Minister to State Governments
policies and strategies. in July 2002. This letter was written by Mr. Shatrughan Sinha, the Union Minister of
p o p u l a t i o n f o u n d a t i o n o f in d ia
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Health and Family Welfare, to various heads of State Governments urging them not to introduce
the two child norm because some State Governments were in the process of making policies that
were contradicting the spirit of the National Population Policy. The Minister proactively took this
step that was instrumental in upholding the values of the National Population Policy. The second
letter is one written from PFI to Heads of Political Parties in February 2004 to incorporate Critical
Population and Health Issues in Election Manifesto. It urged leaders of political parties to recognize
the close linkages between sustainable development and population stabilization as well as follow
non- coercive, rights based and gender sensitive approach for population stabilization. The third
letter was written to the Prime Minister from Avabai B Wadia, Member, Governing Board, PFI in the
context of the UPA Government introducing the Common Minimum Programme (CMP) in 2004.
They wanted to launch a mission focusing on high fertility districts, but with an approach of the old
mind set. The essence of the message was that family planning cannot be a stand-alone concept
and has to be integrated with the larger issue of health and better quality of life. The Statement of
concern that follows the above was again part of the advocacy efforts of PFI and other civil society
organizations, to make sure that the proposed National Rural Health Mission (NRHM) stays in line
with the spirit of the NPP. These advocacy efforts went a long way in shaping up NRHM, the way
it stands today.
Through this publication it is hoped that the debate on the issue of population will be
better informed – moving away from the extremes of doomsday scenarios on the one hand and
a negation of the problem on the other. It is not as if population growth is not an important
development concern. The important point is to view the issue in a larger historical and socio-
economic perspective and understand the factors that propel change.
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Overview
Changes in Population Thinking
Over the last half century there have been many changes in the thinking on population issues.
At the outset it would be worthwhile to trace the history of the population debate spanning over
the last five decades.
From mid 1950 onwards, as a result of a rapid fall in death rates, there were unprecedented
high levels of natural growth. This sudden decline in death rates (mortality) was primarily the
result of achievements in the economically advanced countries and the unexpectedly low cost of
applying the benefits of modern medicine and replicating them in developing countries. Knowledge
acquired in curbing the spread of killer diseases and epidemics was transferred to the developing
countries whose natural growth rate was near stagnant, which was a reflection of high mortality
and high fertility. While the death rate fell drastically, fertility and reproduction maintained their
high levels (i.e. birth rates remained high) which resulted in unprecedented high levels of natural
growth of population.
It was this concern of “excessive demographic increase” (then declared as population explosion
– a term extensively used in the mid 1960s and in the deliberations of the Club of Rome) and
its social, economic and geo-political ramifications that impelled and triggered the international
community to focus on slowing down population growth by implementing what was
Knowledge acquired then called “Population Control” or “Family Planning Programmes”. This was perhaps a
in curbing the spread
of killer diseases
and epidemics was
transferred to the
spontaneous and logical response on the part of international community trying to curb
the increase in number from a “purely quantitative perspective”.
As discussed in the first paper titled “Obsolescence and Anachronism of Population
Control: From Demography to Demology” by Mr. A.R Nanda, this panic like Neo-
Malthusian environment/situation continued in the 1960s, 1970s and throughout
developing countries the 1980s. Even in 1987, when the world’s population crossed five billion mark, the
whose natural growth
alarm then was the rapidly increasing numbers and it was this concern which led to the
observance of World Population Day. The thought on population was primarily concerned
rate was near stagnant, with numbers. Increasing numbers were looked at with fright. It was this fear that formed
which was a reflection the central/core idea of the population programmes those days. The focus was mostly
on “Population” and not “People”. These programmes did not look at the “Human
of high mortality and Development” as the need of the hour, but instead targeted “Women” whose fertility
high fertility. needed to be controlled. The word “Control” best represented the situation.
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International Conference on Population & Development
(ICPD), 1994 - A Watershed in the History of Population
Thinking
It is since 1994, after the International Conference on Population and Development
(ICPD) at Cairo, Egypt, that there has been a dramatic change in thinking on population
issues. In fact ICPD was a Watershed in the history of thinking on population issues.
Indeed, it would not be an exaggeration to suggest that ICPD was a sort of a New
World Population Order. It brought about a significant shift in frameworks, strategies
and approaches relating to population and public policy issues.
At the ICPD it was
recognized that merely
focusing on reducing
numbers will not lead
to better quality of life
for the poor or better
health for women.
The ICPD represented a “quantum leap” for population and development policies as it involved
a paradigm shift from the earlier emphasis on Population Control and Demography to Sustainable
Development and recognition of the need for Reproductive Health (RH) and Reproductive Rights (RR),
addressing the “Life Cycle Approach”. It became clear that population was no longer about numbers,
figures and statistics but about people and improving their quality of life. It was also agreed that no
method specific targets imposed from above, no force, no coercion, no incentives and disincentives are
required, because incentives and disincentives are either coercive or ultimately tend to be coercive and
are in fact counter productive. Coercion infringes upon human rights and inhibits human development.
The ICPD Programme of Action (PoA) placed “individuals” in the center of development with a focus
on building pillars of “Human Development, Human Rights, Gender Equity and Equality”.
As discussed in the second paper titled “Population Scenario of India and National Population
Policy: An overview” by Almas Ali, the central theme of the ICPD was to forge a balance between
population, sustained economic growth and sustainable development. The objective of the
agreement reached at the Cairo Conference was to raise the quality of life and enhance well-being
and to promote human development. The Programme of Action (PoA) rightly emphasized the
need to integrate population concerns fully into development strategies and planning, taking into
account the inter-relationship of population issues with goals of poverty eradication, food security,
adequate shelter, employment and basic services (like health and education) for all.
At the ICPD it was recognized that merely focusing on reducing numbers will not lead to better
quality of life for the poor or better health for women. It was also agreed that trying to reduce
numbers through discrimination, force, coercion or violence is a violation of human rights.
Two fundamental changes have occurred in recent times in conceptualizing and implementing
Population Policies. First is to ensure that Population Policies and Programmes address the
root causes of high fertility such as persistent gender disparities in access to education, health,
employment and other productive resources. The second is to expand the existing Family Welfare
Programme beyond contraceptive delivery to include a range of Reproductive Health Services with
a greater emphasis on quality of care and individual’s right.
Now the focus has become broader and more holistic. Earlier, Total Fertility Rate (TFR) and
Contraceptive Prevalence Rate (CPR) used to be the fixation of most population programmes
as they also served as indicators of success. ICPD replaced them with Quality of Care, Informed
Choice, Gender factor, Women’s Empowerment and Accessibility to a whole gamut of reproductive
health services.
The ICPD for the first time looked at the whole question of population anew and was in fact a
milestone in the history of population and development as well as the history of women’s rights.
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It placed women’s equity and equality at the centre stage and introduced the importance of rights
based programming.
This change in thinking, concept and understanding naturally implied a logical change in
policies and strategies. Many countries had taken steps to integrate population concerns with their
development strategies. In 2000, India announced its National Population Policy (NPP) which takes
its basic philosophy from the ICPD-PoA and focuses on improving quality of life as the means to
achieve population stabilization.
The ICPD has been instrumental in forwarding the notion that the concept of reproductive
health care encompasses more than just family planning services. Moreover, it declares that
reproductive health and reproductive rights cannot be realized without a concomitant fulfillment
of women’s human rights. The other ideas mainstreamed by the ICPD are that both the sets of
rights are interlinked and must be advocated in tandem and that empowering women is crucial to
successful population and development programmes.
The reference to reproductive health and rights within the debate on population and
development that have occurred post-ICPD underscores its influence on subsequent conferences
and international documents. The strength of the ICPD’s reproductive health approach can also be
found in the 2000 Millennium Development Declaration, which, however, pays significant attention
to highlighting selective issues of reproductive health.
Moving on from the changes in thinking related to population, another issue that warrants
discussion in this light is the theory of demographic transition.
Exploding the Myth of Population Explosion
In the last five decades, India’s population has increased from 36 crores in 1951 to over 102
crores in 2001. The growth of India’s population is often seen as an “uncontrolled explosion” and
has been identified as a significant hindrance for country’s progress and development.
It has to be understood that population growth occurs naturally and has taken place everywhere
in all the regions of the world and India is not an exception to this transition. In order to understand
this in a correct perspective, the theory of demographic transition is presented below:
Three Stages of Demographic Evolution
• First stage is High Birth Rate and High Death Rates (high balance)
• Second (intermediate) stage is High Birth Rate and Low Death Rate (high
rate of natural increase), and
•Third stage is Low Birth Rate and Low Death Rate (low balance)
The first stage of the demographic transition is when high birth rate and high fertility is
accompanied by high death rate. In the second stage, high birth rate and high fertility continues.
However, a few factors lead to a steep fall in the mortality rate resulting in a high natural growth.
With the advancement of economic and material progress, education, women’s empowerment and
availability of contraceptives, birth rate starts declining slowly at first. Rapidly thereafter a stage
is reached, where the birth and death rates are equal once again, i.e. low balance. This cycle of
changes, which occurs in any population, is known as demographic transition.
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Population Growth of India at a Glance, 1901-2001
YearsTotal
AbsoluteDecadal
Average
Phase of Demographic
Population Increase Growth
AnnualTransition
(in crores) (in crores) RateExponential
Growth Rate
1901-1951 23 - 36
13
-
-
Stagnant population
1951 1961 36 - 44
8
+21.6%
1.96%
Rapid high growth
1961-1971
1971-1981
1981-1991
44 - 55
55 - 68
68- 84
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+24.8%
2.22%
13
+24.6%
2.20%
16
+23.9%
2.14%
Rapid high growth with
definite sign of fertility
decline
1991-2001 84 -102
18
+21.3%
1.93%
Source: Census of India
As discussed in detail in Almas Ali’s paper titled “Population and Development: Myths and
Realities” published in the Nutrition Foundation of India (NFI) bulletin, January 2004,in India
around independence, death rate started declining rapidly while birth rate continued to be high.
This led to a rapid growth in population.
The table above shows that although there is absolute increase in population after 1981, the
population growth rate (both decadal growth rate and average annual exponential growth rate)
has reduced considerably. In fact, the decadal growth during 1991-2001 registered the sharpest
decline since independence. This means that in India, population growth rate has definitely been
declining steadily over the last two decades. Moreover, the Total Fertility Rate (the average number
of live births a woman would have in her life as she passes through her child bearing years) which
was as high as six or more in 1951 has come down to 3.2 in 2001 and 2.7 in 2007 (SRS). Despite
the fact that couples now have fewer children than earlier, the overall growth in numbers still
appears high because of “Population Momentum”. Past trends in fertility and mortality from 1951
to 1981 have shaped the population structure in such a way that there is tremendous in-built
growth potential resulting in the ‘bulge’ in the proportion of people in prime reproductive age.
In short, India has high proportion of young persons (about 60%), who are in reproductive age
group or will soon be so. Even if this group produces fewer children per couple there will still be a
quantum increase in numbers because the number of reproductive couples is high. This tendency
of growth is termed as “Population Momentum” in demographic literature.
India with its large proportion of young persons will take some time before the results of
declining fertility start showing explicitly. Put simply, this decline does not look very rapid because
India is like a fast moving express train whose brakes have just been applied, but since it is very
heavy and moving very fast, it will take some time to come to a complete halt. The important thing
is to note that the brakes have been applied as evident from the declining fertility and decadal
growth rates.
Evolution of the Family Planning Programme and Population
Related Policies in India
The evolution of population stabilization efforts in India by government goes back to the onset
of five year development plans in 1951-52. The Government of India launched the world’s first
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ever and largest population “programme” in the form of the National Family Planning Programme,
which emphasized ‘family planning’ to the extent necessary for reducing birth rates to stabilize the
population at a level consistent with the requirement of national economy. In the 1950s, it was
largely an urban clinic-based programme, then in the 1960s, it became rural in its focus and more
community oriented in its approach. In 1966, several important developments concerning the Family
Planning Programme took place. A full fledged department of Family Planning was established
within the Ministry of Health. The programme was made ‘centrally-sponsored’; financial incentives
were introduced for sterilization acceptors; and sterilization was made target-oriented. In 1976,
the government announced a National Population Policy Statement. The compulsory and coercive
nature of the programme during 1975 and 1976 made it highly unpopular. A damage control
exercise began by re-christening Family Planning as Family Welfare with voluntary acceptance of
contraceptive targets without any coercion as the key strategy and again a policy statement was
announced in June 1977. The policy statements of both 1976 and 1977 were laid on the table of
the houses of the Parliament, but never discussed or adopted.
While adopting the National Health Policy of 1983, the Parliament emphasized the need for a
separate national population policy. The Karunakaran Committee set up by National Development
Council (NDC) in 1991 missed the wood for the trees by emphasizing on disincentives around
two-child norm in the form of disqualification for MPs, MLAs and other elected representatives.
A Constitution Amendment Bill was introduced in Rajya Sabha thereafter, and is pending for
consideration even now. Some State Governments have gone ahead with legislations on the same
measures for Panchayati Raj and urban local bodies. It is well-known that such measures for
population stabilization alienate the poor, marginalized and women from political empowerment
and are counter-productive.
In 1993, the Government appointed Dr. M S Swaminathan as Chairman of an Expert Group
to draft a Population Policy. The expert group prepared a draft Population Policy in 1994, which
contained many positive and innovative recommendations. It called for a radical shift to a policy
that would be “pro-poor, pro-woman, and pro-nature”, and argued for a more bottom up and
needs-based approach. This draft Population Policy was submitted to Prime Minister in 1994, was
subsequently tabled in Parliament, but could not be passed. Again in 1997, an attempt was made
by the United Front Government to table and get the Population Policy passed; however, it could
The Group of not be done.
Ministers finalized
Another round of consultation was held during 1998 and a fresh draft policy was
prepared in March 1999. The central government asked a Group of Ministers to examine
the draft population the draft policy. The Group of Ministers finalized the draft population policy in November
policy in November
1999. A fresh draft was
submitted thereafter
1999. A fresh draft was submitted thereafter and the Government of India adopted the
National Population Policy in February 2000.
Major milestones in the Evolution of India’s Family Planning Programme since
independence are as follows:
and the Government • In 1952, the First Five Year Plan document noted the “urgency of the problems of
of India adopted the family planning and population control” and advocated a reduction in the birth rate
National Population to stabilize population at a level consistent with the needs of the economy.
Policy in February
•
In 1956, the Second Five Year Plan proposed expansion of family planning clinics
in both the rural and urban areas and recommended a more or less autonomous
2000. Central Family Planning Board, with similar state level boards.
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• In 1961, the Third Five Year Plan envisaged the provision of sterilization facilities In 1996, a Target Free
in district hospitals, sub-divisional hospitals and primary health centers as part of
the family planning programme. The state of Maharashtra organized “Sterilization
regime started and
Camps” in rural areas.
Reproductive and Child
• In 1963, the Director of Family Planning proposed a shift from the clinic approach Health Programme
to a community extension approach to be implemented by auxiliary nurse midwives from 1998.
(one per 10,000 population) located in PHCs. Other proposals include: (a) a goal of
lowering birth rate from an estimated 40 to 25 by 1973; and (b) a cafeteria approach to the
provision of contraceptive methods, with an emphasis on free choice.
• In 1965, the Intra Uterine Device (IUD) was introduced in the Indian Family Planning
Programme.
• In 1966, a full-fledged Department of Family Planning was set up in the Ministry of Health.
Condoms began to be distributed through the established channels of leading distributors of
consumer goods. Targets were set for contraceptives.
• In 1976, during emergency, the Congress Government under Smt. Indira Gandhi formulated a
Population Policy (in a form of Policy Statement) which became counter-productive because of
a clause, which permitted States to go for Compulsory Sterilization.
• In 1977, a revised Population Policy Statement was tabled in Parliament by the Janata
Government. It emphasized the voluntary nature of the “Family Planning” programme. The
term “Family Welfare” replaced Family Planning.
• In 1983, National Health Policy was announced in which mention was made in passing of the
Population and Family Welfare Programmes.
• In 1991, Congress Government under Shri Narasimha Rao appointed a Committee headed by
Shri K Karunakaran, which submitted a report to the National Development Council in 1993,
which pleaded for a National Population Policy.
• In 1993, the same Government appointed Dr. M S Swaminathan as Chairman of the Expert
Group to draft a Population Policy. The draft Population Policy was submitted to the Prime
Minister in 1994, was subsequently tabled in Parliament but could not be passed.
• In 1996, a Target Free regime started and Reproductive and Child Health Programme from 1998.
• In 1997, an attempt was made by the United Front Government under Shri I K Gujaral to table
and get the Population Policy passed; however, it could not be done.
• In 1999, the BJP Government under Shri A B Vajpayee asked a Group of Ministers to examine the
draft Policy prepared by the Department of Family Welfare, Ministry of Health & Family Welfare.
• In 2000, the Government of India announced the National Population Policy (NPP), 2000
National Population Policy (NPP), 2000
The National Population Policy, 2000 (NPP, 2000) takes its basic philosophy from ICPD PoA
and from the concerns of women’s organizations in the country thereby taking into consideration
the changing understanding on population, reproductive health, equity and rights. With the shift in
international perspective influenced by the ICPD, the government reflected its change of approach
in the NPP, 2000 by eliminating the use of contraceptive targets. The NPP is a historic document
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and a significant step forward in the right direction with a more reasoned and balanced view of
the issue of population. It reflects a shift from the earlier demographically driven, target oriented
policies to one that addresses special concerns of reproductive health. The NPP is an affirmation
and articulation of India’s commitment to the ICPD agenda and forms the blueprint for population
and development related programmes in the country. The NPP, 2000 is also a significant move
towards a humane and effective development policy aimed at improving the overall quality of life
by promoting better awareness of and access to health care options with a focus on women. It is
in fact the first big step in the country’s effort to look at population issues from the perspective
of social development and is the reference point for India’s current rights based approach to the
subject. The same has been discussed in greater detail in A.R Nanda’s paper “Population Policy: An
overview”, that was delivered at the People’s Tribunal on ‘Coercive Population Policies and Two-
Child Norm’ at New Delhi in 2004.
The ICPD PoA strategy focuses on meeting the health needs of individuals rather than achieving
demographic targets. In keeping with this, the NPP, 2000 consistently avoids the word ’population
control’ and talks instead of ’population stabilization’ despite widespread and entrenched convictions
about the ’population explosion’ in India. This is a courageous stance in consonance with the current
understanding of demographic momentum in India, which indicates clearly that the need of the hour
is not coercion and control, but information and services for family planning and reproductive health
with quality of care. Thus, it does away with the fruitless baggage of targets and coercion.
The NPP is gender sensitive and incorporates a comprehensive holistic approach to health
and education needs of women, female adolescents and girl child. It also seeks to address the
constraints to accessibility of services due to heavily populated geographical areas and diverse
socio-cultural patterns in the population. Almas Ali’s paper titled “Women and National Population
Policy” explores this aspect in greater detail. This was delivered at the refresher course on Gender
studies at Academic Staff College, Jamia Millia Islamia on 14th February, 2006.
For the first time, a policy on population talks of universal education, RCH, delaying marriage,
counseling, control of communicable diseases, decentralized planning, quality of health care
services, adolescents, ageing, safe abortion and sex selective abortion - a pioneer in many respects.
The NPP, 2000 is The NPP, 2000 starts with a premise that ’the overriding objective of economic and social
also a significant development is to improve the quality of life of people, to enhance their well-being and
to provide them with opportunities and choices to become productive assets in society.’
move towards a It also states in no uncertain terms that stabilizing population is not merely a question
humane and effective of making reproductive health services available, accessible and affordable, but also
increasing the coverage and outreach of primary and secondary education, extending
development policy basic amenities like sanitation, safe drinking water, housing and empowering women
aimed at improving the with enhanced access to education and employment.
overall quality of life Objectives, Goals and Strategic Themes of NPP, 2000
by promoting better Objectives
awareness of and
access to health care
options with a focus on
women.
• Immediate objective - To address the unmet needs for contraception, health
care infrastructure and health personnel and to provide integrated service delivery
of basic reproductive and child health care.
• Medium term objective - To bring the TFR to replacement level by 2010, through
vigorous implementation of inter-sectoral operational strategies.
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• Long term objective - To achieve a stable population by 2045, at a level consistent
with the requirements of sustainable economic growth, social development and
environmental protection.
National Socio - Demographic Goals
In pursuance of these objectives, the NPP, 2000 has formulated 14 National Socio-
Demographic Goals to be achieved in each case by 2010.
• Address the unmet needs for basic reproductive and child health services, supplies
and infrastructure.
In pursuance of these
objectives, the NPP,
2000 has formulated
14 National Socio-
Demographic Goals to
be achieved in each
case by 2010.
• Make school education up to age 14 free and compulsory for both boys and girls and reduce
dropouts at the primary and secondary school levels to below 20 percent.
• Reduce infant mortality to below 30 per 1000 live births.
• Reduce maternal mortality ratio to below 100 per 100,000 live births.
• Achieve universal immunization of children against all vaccine preventable diseases.
• Promote delayed marriages for girls, not earlier than age18 and preferably after 20 years of
age.
• Achieve 80 percent institutional deliveries and 100 percent deliveries by trained persons.
• Achieve universal access to information / counseling and services for fertility regulation and
contraception with a wide basket of choices.
• Achieve 100 percent registration of births, deaths, marriage and pregnancy.
• Contain the spread of Acquired Immuno Deficiency Syndrome (AIDS) and promote greater
integration between the management of reproductive tract infections (RTI) and sexually
transmitted infections (STI).
• Prevent and control of communicable diseases.
• Integrate Indian Systems of Medicine (ISM) in the provision of reproductive and child health
services and in reaching out to households.
• Promote vigorously the small family norm to achieve replacement level of TFR.
• Bring about convergence in implementation of related social sector programmes so that family
welfare becomes a people centered programme.
Strategic Themes
The NPP, 2000 has identified 12 strategic themes for successful implementation of the policy.
These are:
•Decentralized planning and programme implementation.
• Convergence of service delivery at the village levels.
•Empowering women for improved health and nutrition.
• Child health and survival.
• Meeting the unmet needs for family welfare services.
•Under-served population groups: urban slums, adolescents, tribals, displaced and migrants.
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•Diverse health care providers.
• Collaboration with and commitments from NGOs and private sector.
• Mainstreaming Indian Systems of Medicine and Homeopathy.
• Contraceptive technology and research on reproductive and child health.
• Providing for the older population.
• Information, Education and Communication.
The above strategic themes reflect the spirit and language of the principles agreed upon in ICPD
Plan of Action and we see that the themes are deeply influenced by the ICPD-PoA. Decentralization
of planning and programme implementation, convergence of service delivery at community levels,
women’s empowerment for improved health and nutrition, child health and survival, meeting the
unmet needs for all family welfare services, emphasis on under-served population groups including
adolescents, are some of the commonalities. While operationalizing the thematic strategies,
reproductive rights, gender equity and quality of care need to be addressed as the cross-cutting
concerns.
The strategic theme of inter-sectoral convergence, which is meant to be an acclaimed feature
of the NPP, can be successfully implemented only when respective Ministries and departments
get clear guidelines and mechanisms for delivery of the required services such as primary and
secondary education, housing, sanitation, drinking water etc, with organic links established with
reproductive health on the ground.
A 100-point Action Plan has been suggested in the Policy document to be pursued as ‘National
Movement’ through a ‘multi-sectoral endeavour, requiring constant and effective dialogue among
a diversity of stakeholders, and coordination at all levels of the government and society’. Spread of
literacy and education and women’s participation in the paid work force together with a ’steady,
equitable improvement in family incomes’ have been recognized as important as equitable access,
quality and affordable reproductive and child health services aimed at population stabilization.
More detailed analysis of the Population Policy, 2000 can be found in the paper titled “the National
The strategic theme Population Policy, 2000 – what can it achieve realistically?” by A.R. Nanda.
of inter-sectoral
convergence, which
is meant to be an
acclaimed feature
of the NPP, can
be successfully
implemented only
when respective
Ministries and
departments get clear
guidelines
State Population Policies and the Two Child Norm
Several State Governments have already formulated their state specific population
policies (and some others have initiated action for developing their population policies).
There is a distinct difference in tone and attitude between the NPP and some of the state
population policies. Some of the state policies reflect the neo-Malthusian “population
control” mindset viewing population growth as a human crisis and are more upfront in
methods of achieving demographic goals through a series of incentives and disincentives,
and short-cut vertical programmes and strategies.
There is enough data and documentation to establish that disincentives tend to
be coercive. It has also been noticed that the disincentives always hit the poor and
underprivileged, especially those who belong to scheduled castes and tribes and backward
classes. Till the large unmet needs of these socially backward groups for health and family
welfare services are met, proposing any punitive measures is clearly irrational. Similarly,
a “two child norm” conditional for welfare measures deprives these sections for whom
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these schemes are meant. The disincentives are also anti-women since women in our “Two Child Norm” has
country do not enjoy the freedom to decide how many children they would like to bear.
Although almost all the state policies use the term “target-free”, many recommend
clear incentives and disincentives. When the policy translates into programme
implementation, it has negative implications on the idea of informed choices, individual
the potential to cause
immense harm to
women’s health in the
decision making and results in violation of human dignity, especially of women. Thus,
these state policies violate the spirit of the NPP.
This shows lack of common understanding on the part of some state governments
and consequently their differential commitment to ensuring choice-based decision
existing social situation
where son preference
is high and women’s
making. Clearly, there is a need to intensify efforts to bridge this gap in understanding status is low.
among the stakeholders and to develop a consensus on the processes to be adopted to
reach the goals. One has to be careful in choosing words because it can be interpreted differently
(for example the confusion between the small family norm and two-child norm).
The primary theme running through the NPP is provision of quality services and supplies
promoting a basket of choices. People must be free and enabled to access quality health care,
make informed choice and adopt measures for fertility regulation best suited to them. It is in this
spirit that the NPP advocates a small family norm. Nowhere does the policy advocate for two child
norm. However, it is unfortunate and some times even disturbing to note that while talking about
NPP the small family norm is often misinterpreted as two child norm (which has a definite coercive
connotation). Two child norm implies that the state promotes two children per family and has a
system of incentives and disincentives/punishments for achieving it.
Moreover, in view of the vast disparities among the states, there is a need to form a body to receive
feedback and help the states in taking corrective action. In fact in early 2002, the Department of
Family Welfare, Govt. of India had urged the state governments not to introduce coercive methods in
their population policies and constituted a national level resource committee to bring about common
approach in the state population policies while keeping the general principles and the conceptual
framework of the NPP in mind.The National Resource Committee (NRC) was expected to play a catalytic
role in a meaningful way using a collaborative and consultative process in the formulation of new state
population policies and to undertake a review of state policies to bring them in line with NPP.
Two Child Norm Policy - Implications & Consequences
(A) “Two Child Norm” has the potential to cause immense harm to women’s health in
the existing social situation where son preference is high and women’s status is low. One of
the important risks includes increase in sex selective abortions and consequent reduction in the
number of girl children.
This happened in China when the Government declared in 1979 that no couple should have
more than one child. The “One Child Policy” in China appears to have created more societal
and family problems like skewed sex ratio, female infanticide and foeticide, rather than helping in
smooth stabilizing of population. There are thus, lessons to be learnt from the Chinese experience
in governance. We tend to misrepresent the Chinese story, whenever we compare the Indian
situation for advocating coercive policy like ’Two Child Norm’ and the concomitant regime of
incentive and disincentives to solve our population problem quickly.
Several State Governments had enacted legislation to enforce ‘two child norm’ as a general
disqualification clause in election to Panchayati Raj Institutions and urban local bodies. This was
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after the Supreme Court made some observations in respect of the two-child norm in Javed v/s State
of Haryana. The apex court acted on the presumption that the two-child norm was incorporated in
the National Population Policy, 2000. Nothing could be further from the truth.
The two child norm came in by a side wind. Persons who were disqualified from contesting
Panchayat elections in Haryana filed a petition in the Supreme Court impugning the constitutionality
of the state notification laying down the norm. In these proceedings, the Union Government
appears to have given the apex court the impression that the two-child norm was indeed part
of the NPP. The Court relied on an obsolete “Club of Rome” framework and characterized “the
torrential increase in the population… as more dangerous than a hydrogen bomb”. It quoted with
approval two obscure writers on the subject who said that “the rate of population growth has not
moved a bit from 1979”. In fact, India has experienced the sharpest fall in decadal growth from
23.81% in 1991 to 21.34% in 2001, the lowest population growth rate since independence.
As already stated, many states have enacted legislations that barring women with more than
two children from contesting election to PRIs, introduced with the avowed intention of controlling
family size and stabilizing population growth. The two-child norm has become a cause of anxiety
for human rights activists and women’s organizations. The measure is seen as being implemented
in an environment, where women and the marginalized do not have adequate access to health.
It results in infringement of reproductive rights, as it tends to penalize women, who anyway have
little control over reproductive decision making. It has been noticed that this law hits the poor and
the backward section of the society.
An exploratory study on ‘Panchayati Raj and Two Child Norm: Implications and Consequences’
was taken up by Mahila Chetna Manch in the states of Andhra Pradesh, Haryana, Madhya Pradesh,
Orissa and Rajasthan. This study found that its implementation is discriminatory to women and
disadvantaged sections of the society. The study also found that information on the law has
not been disseminated properly. Most people charged with violating the law found out about
its existence only when they filed their nominations or were sent notices. The study also clearly
revealed that the economically and socially vulnerable sections are most affected by this legislation
which is often misused to settle political scores or prevent the under privileged from getting into
positions of power. While the law had had little impact on reproductive choices or in motivating
people to have small families, it has become a tool in the hands of opposing factions to deny
power to a rival. As in all power struggles, it is the marginalized and the poor who have
Several State suffered. It has thus, become a source of harassment for the already disadvantaged.
The study also found that there is no evidence that the law has persuaded Panchayat
Governments had Members to adopt a small family or others to follow their example. People do not decide
enacted legislation to have fewer children because the Sarpanch has a small family.
to enforce ‘two child
norm’ as a general
disqualification
clause in election
to Panchayati Raj
Institutions and urban
local bodies.
In the states where these laws have been imposed scores of cases have been
documented, where women have been deserted or forced to undergo sex selective
abortions. Children have also been abandoned or given up for adoption. In general, such
a norm provides an impetus for an increase in sex-selective abortions worsening the
already existing dismal child sex ratio in the country.
The good news is that the ‘Two Child Norm’ in the states of Himachal Pradesh,
Haryana and Madhya Pradesh has been withdrawn and it was indeed a wise decision. This
was possible due to very intensive advocacy efforts from the civil society organizations
and activists with the support and backing of PFI.
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Current Population Scenario and Demographic Achievements
According to 2001 Census, India’s population was 1,028,737,436 (102.9 crores). Viewed
globally, India constitutes 16.9% of world’s population and 2.4% of the global land area. Currently
(2009) India’s population is estimated at about 117 crores.
India has made considerable progress with respect to improving the health of the people over
the last thirty seven years (from 1971 to 2008), which is reflected the improvements in some of
the demographic indicators presented below:
India’s Demographic Achievement (1971-2008)
Parameters
1971 1981 1991 2001
Current (2008)
CBR
43.5 38.0 35.0 28.2 22.8 (SRS 2008)
TFR
6.5
5.4
4.6 3.5 2.7 (SRS 2007)
CDR
21.3 16.0 13.6 9.3 7.4 (SRS 2008)
IMR
129 110
73
66 53 (SRS 2008)
Life expectancy at birth (male)
Life expectancy at birth (Fe-
male)
CPR
44.0 50.0
43.0 49.0
10.4 22.8
55.5 60.8 62.6 (RGI, 2002-06)
56.0 62.3 64.2 (RGI, 2002-06)
44.1 48.2 56.3 (NFHS-3 2005-2006)
Parameters
Fertility
CBR
TFR
Contraceptive Use
CPR
Death Rate
CDR
Infant Mortality
IMR
1971
43.5
6.5
10.4
21.3
129
Years
Current (2008)
22.8 (SRS 2008)
2.7 (SRS 2007)
56.3 (NFHS-3)
(2005-06)
7.4 (SRS 2008)
53 (SRS 2008)
The Crude Birth Rate (CBR) has declined from 43.5 in 1971 to 22.8 in 2008 as per the latest
SRS bulletin published in October 2009. The Total Fertility Rate (TFR) has come down from 6.5
in 1971 to 2.6 in 2007. The Crude Death Rate (CDR) has also declined from 21.3 in 1971 to 7.4
in 2008. The Infant Mortality Rate (IMR), which was 129, has declined to 53 during the same
period. The Contraceptive Prevalence Rate (CPR) increased from a meagre 10.4 to 56.3 in 2005-
* In India the need for a dependable demographic data was felt soon after independence. The Registration of Births and Deaths
started on voluntary basis and there was no uniformity in statistical returns resulting in both under-registration and incomplete
coverage. In order to unify these civil registration activities, the Registration of Births and Deaths Act, 1969 was enacted. Despite
having the registration of births and deaths compulsory, the level of registration of births and deaths under the Act continued to be far
from satisfactory in most of the states. With a view to generate reliable and continuous data on mortality and fertility indicators, the
office of the RGI initiated the scheme of Sample Registration of Births and Deaths in India, popularly known as Sample Registration
System (SRS) in 1964 – 65 on a pilot basis and on full scale from 1969-70. Based on the dual record system, the SRS has been providing
reliable estimates of mortality and fertility on a regular basis from 1971 onwards. The SRS data is considered to be the most reliable at
the national level to be compared among the states at different points of time.
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06 (NFHS-3). Despite this overall improvement in health and demographic indicators, inequity in
health exists and persists.
For a mind prone to generalizations India can prove to be a notorious quicksand and national
averages can be quite misleading, because broad aggregates mask the large disparities and
variations, which exist between geographical regions, among states, within states and among
districts.
Yes - India is a country of striking demographic diversity. In fact substantial differences are
visible among states in achievement of basic demographic indices. This has led to significant
disparity in current population size and the potential to influence India’s population increase
in future. There is already a ’North-South Demographic Divide’. All the Southern states namely,
Kerala, Tamil Nadu, Andhra Pradesh and Karnataka are doing well in reduction of fertility, whereas
in the four large northern states namely, Bihar, Uttar Pradesh, Madhya Pradesh and Rajasthan
growth rates continue to be high. Thus, the crux of India’s population problem lies in these four
states. These states have high fertility rates, low literacy rates and low health indicators with high
infant mortality and high maternal mortality. These states account for nearly 40% of the country’s
population and will contribute well over 50% of growth in the coming decades. The performance
and the demographic outcomes of these states will determine the time and the size of population
at which India will achieve population stabilization.
Year by which Replacement Level of Fertility
(Total Fertility of 2.1) will be achieved
India and Major States
Year by which projected TFR will be 2.1
India
2015
Andhra Pradesh
Achieved in 2002
Assam
2019
Bihar
2021
Chhattisgarh
2022
Delhi
Achieved in 2001
Gujarat
2012
Haryana
2012
Himachal Pradesh
Achieved in 2002
Jammu & Kashmir
NA
Jharkhand
2018
Karnataka
Achieved in 2005
Kerala
Achieved in 1998
Madhya Pradesh
2025
Maharashtra
2009
Orissa
2010
Punjab
Achieved in 2006
Rajasthan
2021
Uttar Pradesh
2027
Uttarakhand
2022
Tamil Nadu
West Bengal
Achieved in 2000
Achieved in 2003
North East (Excl. Assam)
Achieved in 2005
Source: the Technical Group on Population Projections by the Office of the RGI, 2006
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It may be noted from the projections that India’s population will reach replacement All the Southern states
levels of TFR 2.1 in the year 2015, while some of the large northern states namely, Uttar
Pradesh, Rajasthan, Bihar and Madhya Pradesh will reach that level after 2021, in fact, namely, Kerala, Tamil
UP will reach only in 2027.
Nadu, Andhra Pradesh
The reasons for extremely slow progress in population stabilization in these states
and poor performance in provision of RCH services are complex and deep rooted. On
and Karnataka are
the one hand, high rates of poverty, illiteracy & low autonomy of women lead to poor doing well in reduction
knowledge and low demand for RCH services. On the other hand, poor infrastructure
and not so efficient governance compound the problem. Bridging the gap would require
of fertility.
public awareness, sensitizing administrators and encouraging meaningful community involvement
in the delivery of health and family planning services of quality.
The major challenge for the states of UP, Rajasthan, Bihar and MP is to achieve population
stabilization. In these states more efforts need to be done to address the unmet need and stabilize
the population to earn benefits from the demographic dividend. The British Parliamentarians’
report on ‘Return of the Growth Factor: Its Impact on Millennium Development Goals’ is all the
more relevant in the context of these states.
Key Issues related to Population Stabilization
i. Age at marriage
Marriage is a universal phenomenon in India. Nationally 21.5% of women aged 20-24
are married below 18 years as per the NFHS-3, 2005-2006. According to the same source, the
percentage of married women in the same age group is more than 50% in the states of Jharkhand
(61.2), Bihar (60.3), Rajasthan (57.1), Andhra Pradesh (54.7), West Bengal (53.3), Madhya Pradesh
(53.0), Uttar Pradesh (53.0), and Chhattisgarh (51.8) as compared to Goa (11.7) and Himachal
Pradesh (12.3). The mean age at marriage for females has increased steadily over time in India.
Legislation, advocacy and socio-economic changes are possibly leading to this positive trend.
However, in large parts of India, the female age at marriage is low relative to the legal minimum
age of 18 years. There are massive state and district level variations. Inter-district and inter-regional
variations are found due to differential development of various districts and areas of the state.
According to the Child Marriage Restraint Act, 1978, the minimum legal age at marriage in
India is 18 years for women and 21 years for men. A large majority of women are not aware of the
legal minimum age at marriage and child marriages continue to take place in large numbers.
Age at marriage has far reaching consequences on fertility rates, child bearing and other health
issues such as infant and maternal mortality. Menarche or the onset of menstruation cycle constitutes
the land mark for female entry into the institution of marriage. Women are pressurized to bear children
soon after their marriage in order to prove their fertility and worth. Hence, adolescent marriage becomes
synonymous with adolescent child bearing. Early marriages have adverse effect on the health of the
mother and child. The high rates of maternal, neo-natal, infant and child deaths are clearly associated
with early marriages. The ignorance of these critical issues may explain in some part the failure of
public and government in honouring the implementation of the minimum age of marriage laws.
For population stabilization, one of the important factors is raising the age at marriage/
cohabitation especially for girls. The strongest impact of this can come through increasing years of
schooling for girls. At the national level, the age at marriage is likely to be increased by a further rise
in female education. Population momentum can be curtailed in part by investing on adolescents
with emphasis on raising girl’s social and economic prospects and enhancing their self esteem.
ii. Maternal Mortality Ratio
Maternal Mortality Ratio (MMR) is defined as the number of maternal deaths (during pregnancy,
childbirths and puerperal period) per 100,000 live births. India, which contains about 16% of the
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world’s population, accounts for nearly 20% of maternal deaths as per the latest estimates of
maternal mortality ratio by RGI, 2004-06. MMR for India stands at 254 per 1,00,000 live births.
At the one end of the spectrum are the states like Assam (480) followed by Uttar Pradesh (440),
Rajasthan (388), MP (335), Bihar (312) and Orissa (303), which have high MMR while at the other
end of the spectrum are states like Kerala (95), Tamil Nadu (111), Maharashtra (130) and Gujarat
(160), which have comparatively lower MMR.
•Three mothers die for every 1000 live births each year in India. There are vast regional and
rural-urban differences.
•Every five minutes a woman dies as a result of complication attributable to pregnancy and child birth.
• It is estimated that for each woman who dies as many as 30 other women develop chronic and
debilitating conditions, which seriously affect the quality of life.
Nearly 7 million induced abortions take place annually in India. For each legal abortion, it
is estimated that another 10 illegal abortions take place, but go unrecorded. Nearly 12% of all
maternal deaths are attributable to abortion related complications. Anaemia is the underlying
cause for 20%, toxemia for 13%, puerperal sepsis for 13% and bleeding during pregnancy for
23% of maternal deaths.
Maternal mortality is usually high in those states, where fertility is high, because there women
are having frequent pregnancies. Maternal mortality is also high in those states, where children are
born to very young women and to women, who have multiple and closely spaced pregnancies.
The lack of male participation results in poor utilization of pre/ante-natal and post natal services
by pregnant women. Several reports indicate that men do not give much importance to the health
problems of women especially during pregnancy and child births. Either they are unaware of the
importance of seeking preventive care or they are simply indifferent.
Women need support in obtaining access to essential obstetric care. Raising awareness of the
need for women to reach emergency obstetric care without delay if complication arises during
pregnancy is crucial. Studies have shown that in 25% of maternal deaths, family members were not
aware of the seriousness of women’s condition and took no action towards obtaining assistance.
iii. Infant Mortality Rate
Infant Mortality Rate (IMR) is one of the most sensitive indicators of health and development
and is expressed as number of infant deaths (below 1 year of age) per 1000 live births. As per the
latest available SRS 2008 data, the IMR for India stands at 53 (58 Rural and 36 Urban) per 1000
live births. IMR continues to be high in states like Madhya Pradesh (70), Orissa (69), Uttar Pradesh
(67), Assam (64), Rajasthan (63), Meghalaya (58), Chhattisgarh (57), Bihar (56) and Haryana (54),
which are above the national average. The states with the lowest IMR are Goa (10) and Kerala (12).
Access to family welfare services and contraceptive care is also a critical determinant of
A large majority of infant mortality and birth rate.
women are not aware
of the legal minimum
age at marriage
and child marriages
continue to take place
in large numbers.
For the states which have higher IMR, there should be focused, area specific
interventions to reduce IMR, 100 percent recording of births & deaths and strengthening
of essential new born care at the district and sub-district levels, particularly home based
and community based care.
iv. Child Sex Ratio: Issue of Missing Girls
While there is marginal improvement in overall sex ratio i.e. from 927 in 1991 to 933
in the Census 2001, what is the most alarming is the decline of Child Sex Ratio (CSR) i.e
the sex ratio of children in the age group of 0-6 years. The child sex ratio shows a negative
trend and it causes serious concerns not only to demographers but also to policymakers
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and planners. The decline is not only from the previous Census, but is continuous from 1961
onwards. But, a matter of grave concern is the quantum decline in the last two decades.
Child Sex Ratio Since 1961
Sl. Nos.
1
2
3
4
5
Years
1961
1971
1981
1991
2001
Child Sex Ratio
976
964
962
945
927
Census 2001 showed a decline of 18 points from 945 in 1991 to 927. The declining of child sex
ratio is so wide spread that out of the 28 States and 7 Union Territories, only one State namely, Kerala
(2 points increases) and Union Territories namely, Lakshadweep (18 points increases) and Pondicherry
(4 points increases) appear to be free from this socially harmful and degrading phenomenon.
Child Sex Ratio in the States and Union Territories (1991-2001)
xxx
Sl. Nos.
States
0-6 Sex
Ratio
1991
2001
Absolute Change
India
945
927
-18
1
Punjab
875
798
-77
2
Haryana
879
819
-60
3
Himachal Pradesh
951
896
-55
4
Chandigarh
899
845
-54
5
Delhi
915
868
-47
6
Gujarat
928
883
-45
7
Uttaranchal
949
908
-41
8
D&N Haveli
1013
979
-34
9
Maharashtra
946
913
-33
10
Daman & Diu
958
926
-32
11
Nagaland
993
964
-29
12
Goa
964
938
-26
13
Arunachal Pradesh
982
964
-18
14
Manipur
974
957
-17
15
A & N Island
973
957
-16
16
Orissa
967
953
-14
17
Jharkhand
979
965
-14
18
Andhra Pradesh
975
961
-14
19
Karnataka
960
946
-14
20
Meghalaya
986
973
-13
21
Bihar
953
942
-11
22
Uttar Pradesh
927
916
-11
23
Assam
975
965
-10
24
Madhya Pradesh
941
932
-9
25
Chhattisgarh
984
975
-9
26
Rajasthan
916
909
-7
27
West Bengal
967
960
-7
28
Tamil Nadu
948
942
-6
29
Mizoram
969
964
-5
30
Sikkim
965
963
-2
31
Tripura
967
966
-1
32
Kerala
958
960
2
33
Pondicherry
963
967
4
34
Lakshadweep
941
959
18
35
J&K
NA
941
NA
Source: Census 2001
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The States and Union Territories that have shown large declines in child sex ratio are Punjab
(-77), Haryana (-60), Himachal Pradesh (-55), Gujarat (-45), Chandigarh (-54), and Delhi (-47),
in spite of being economically developed with high female literacy rates. There are 122 districts
spread over 14 states which have CSR less than 900.
As can be seen from the paper titled “Changing Sex Ratio and Its Implications” presented at the
Symposium on Nutrition in Developmental Transition, in November 2005 at the India International
Centre by A.R. Nanda, several questions have been raised with regard to trends in child sex ratio in
the last decade. The indications are that this alarming trend is due to large scale practice of female
foeticide. Female foeticide or sex selective abortion is the elimination of the female foetus in the
womb itself after prenatal sex determination thus avoiding the birth of girls.
The decline in child sex ratio may be due to different factors such as neglect of female children
resulting in their higher mortality at younger ages, female infanticide and female foeticide. High
incidence of induced abortion and the sharp decline in the child sex ratio in the last decade clearly
proves the practice of female foeticide.
Factors Responsible for Female Foeticide
•The obsession to have a son
•Discrimination against the girl child
• Socio-economic and physical insecurity of women
•The evil of dowry prevalent in our society
•The worry about getting girls married as there is the stigma attached to being an unmarried
woman
•Easily accessible and affordable procedure for sex determination during pregnancy
• Failure of medical ethics
•The two child norm policy of certain state governments
The Implications of Declining of Sex Ratio in the Population
There are various socio-economic and health implications of declining sex ratio:
•Decreasing number of females in the society is likely to increase the sex related crimes against
women.
The decline in child
sex ratio may be due to
different factors such
as neglect of female
children resulting in
their higher mortality
at younger ages,
female infanticide and
female foeticide.
• It will lead to increase of social problems like rape, abduction, bride selling, forced
polyandry etc. Reports are already trickling in about how unemployed young men
in Haryana find it difficult to get married. In Dang district of Rajasthan, there was a
report of eight brothers marrying one woman. This is not only a social problem but
also unethical.
•There will be increase of prostitution, sexual exploitation and STD and HIV/ AIDS.
•This imbalance will not only lead to increase the crime against women but will also
cause for various physical, physiological and psychological disorders particularly
among women.
•The health of the woman is affected, as she is forced to go for repeated pregnancies
and abortions.
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v. Adolescent/Young People’s Reproductive Health
In the past women
India is at a stage of demographic transition and is indeed in the midst of a process, were seen as the main
where it faces the ‘window of opportunity’ to avail the demographic dividend. During
the first three decades of post independence development while the mortality rates fell party in procreation
significantly, the fertility rate remained more or less stagnant and this increased the
population of young people including adolescents significantly.
Adolescents in the age group of 10-19 constitute about a fifth (23%) of India’s
population. There are about 331 million (33.1 crores) young people (in the age group 10
to 24 years) in India, representing little less than one third of the total population. This
adding to population.
Thus almost all family
planning strategies
have hitherto focused
group is the largest generation of young people India ever had and ever will have.
on women as targets of
India is set to emerge as a regional (or even global) power in the not too distant contraceptives.
future. The demographic advantage or dividend to be derived from the age structure of
the population, is traced to the fact that India is (and perhaps will remain for some time) one of the
youngest countries in the world. Therefore, in our country investing in young people equitably in
their education, nutrition, skill, employment and health, assumes urgency and importance. Clearly,
a failure to do so will have long term repercussions on individual life, health systems, security,
demography, economy and development.
Recognizing adolescents/young people as a distinct group with their own unique needs and
concerns, issues related to them can not be ignored in the policies and programmes of population
stabilization. What happens in the future depends to a large extent on the decisions taken by the
adolescents, as they enter the reproductive years. Reproductive health, in particular, represents
the most critical area given a situation where there is strong son preference, incidence of early
marriage and high rates of maternal mortality.
The needs of adolescents/young people including improvement in health status, protection
from unwanted pregnancies and sexually transmitted diseases (STDs) have not been sufficiently
addressed in the past. Improvements in the health status of adolescent girls have an intergenerational
impact. It reduces the risk of low birth weight and minimizes neo-natal mortality. Their special
requirements comprise information, counseling, population education, accessible, friendly and
affordable reproductive health services, food supplements and nutritional services. Programmes
should encourage delayed marriage and child- bearing and education of adolescents about the
risk of unprotected sex.
vi. Male Participation
In the past women were seen as the main party in procreation adding to population.Thus almost
all family planning strategies have hitherto focused on women as targets of contraceptives. While
Contraceptive Prevalence Rate (CPR) has consistently increased over the years, the proportion of
male sterilization acceptors has progressively declined.
Men’s involvement is placed within the wider context of gender equity. The active cooperation
and participation of men is vital for programme acceptance. Their involvement is not limited to
use of condom or vasectomy, but is also called for in planning families, supporting contraceptive
use, helping pregnant women stay healthy, arranging skilled care during delivery, helping after the
baby is born and finally being a responsible father.
There is now a greater recognition that men make decisions that affect women’s reproductive
health as well as their own. Men are involved in reproductive health through their multiple roles as
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sexual partners, husbands, fathers, household members, community members etc. The lack of male
participation results in poor utilization of prenatal, natal and postnatal services by pregnant women.
vii.Quality of Care
Along with accessibility and availability of services, provision of quality of care is recognized as a
priority area in RCH/FP programme. Good quality of care creates demand from clients and ensures
satisfied clients, who in turn come back for services. Quality services are commonly accepted as
services that meet the needs of clients. While the client perspective focuses on individuals, the
provider and managerial perspectives are equally important. Access to quality reproductive health
services should also be seen within the framework of reproductive rights.
In addition to equipping and strengthening the services at various levels, the Government has
piloted interventions on quality of care. MoHFW with support of UNFPA has developed a nine-element
framework for ‘quality of care’, which is used as a guideline for monitoring quality of care. Five of
these elements could be applied in a generic manner to any reproductive health service. The remaining
four elements are to be best applied individually to each reproductive health service such as family
planning, maternal health and HIV/AIDS prevention, which are characterized as service elements.
Reproductive Health Programme Quality Framework
Generic Elements
1. Service environment
2. Client provider interaction
3. Informed decision making
4. Integration of services
5. Women’s participation in management
Service-specific elements
1. Access to services
2.Equipment and supplies
3. Professional standard and technical competence
4. Continuity of care
Way Forward
Population stabilization, therefore, has to be looked at in the context of wider socio- economic
development. There exists a strong linkage between social development, health status and the
Population population stabilization. The issue of population stabilization is not a technical issue with
technical quick-fix solutions. The answer does not lie in pushing sterilizations and chasing
stabilization, therefore, targets in the conventional mode. For population stabilization, it is important to improve
has to be looked at in
the context of wider
socio- economic
people’s access, particularly women’s access to quality health care. The contraceptive mix
needs to be enlarged and expanded. It has been well established that the obvious route
to population stabilization is through social development, women’s empowerment and
through greater gender equality.
development. There
exists a strong
linkage between
social development,
health status and
the population
stabilization.
The single most important factor that can smoothen population momentum is raising
the age at marriage/ cohabitation and increasing the interval between marriage and
the first pregnancy especially for girls. The strongest impact of this can come through
increasing years of schooling for girls. Therefore, population momentum can only be
eased out significantly by policies that encourage women to delay child bearing as this
stretches out the time between generations.
Population momentum can also be smoothened in part, by investing on adolescents
with emphasis on raising social and economic prospects for girls and enhancing their
self-esteem. Measures that would accomplish this include:
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• Promoting valued role for women apart from motherhood
• Increasing young women’s access to education, income, work and financial credit
• Providing young women and men with information about reproductive and marital rights,
health and sexuality and extending their access to appropriate services.
• Fostering equality between young women and men and improving their perceptions of marital
responsibility.
Historically, India’s population stabilization efforts have centered around family planning,
with a focus on fertility reduction. Such narrow vertical programmes, often limited to achieving
numbers, are not the answer for India’s population stabilization.
We need to tackle the issue of population stabilization in a holistic way. Family planning
programmes cannot be addressed in isolation.
Holistic Framework
Overall-Socio-Economic Development
Health
Education
Nutrition/food & security
Employment
Poverty alleviation
Comprehensive Primary Health Care
Broader Context of Reproductive Health and Rights
Positioning Family Planning
Family Planning has to be re-positioned in the broader context of Reproductive Health and
Reproductive Rights. In fact, it has to be placed and positioned in the context of Comprehensive
Primary Health Care.
The most important aspect of Primary Health Care is its ‘all-inclusive equity-oriented approach’.
Primary health care was and still is a potentially revolutionary concept, which looks beyond the
customary, conventional and traditional boundaries of curative and preventive medicine and tries to
address up-front the underlying social causes of poverty, deprivation, discrimination, food security,
hunger and poor health. This is, in fact, a holistic concept and is guided by five principles, namely,
(i) equitable distribution, (ii) multi-sectoral approach, (iii) utilization of appropriate technology; (iv)
focus on prevention, and (v) community participation and involvement.
It is, therefore, suggested that the family planning programmes should form an integral
part of the comprehensive primary health care and need to be based on “Community Needs
Assessment” with participatory planning at different tiers of Panchayati Raj system starting from
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the Gram Sabha upwards rather than the method specific contraceptive targets being imposed from
the above. Micro planning with community needs assessment can help to identify and address the
local problems through more acceptable strategies. The gender concerns and the women’s health
concerns could be better taken care of in such a decentralized approach.
Various studies have brought out the importance of decentralized planning and programme
intervention more specifically at the district level. With 73rd and 74th Amendment of Constitution,
district has become the focus of planning and programme interventions.
Community Needs Assessment (CNA) was and still is the hallmark of the NPP based on
the changed philosophy i.e shift from target based “top-down” approach to community needs
based “bottom-up” approach.
In this new approach, which focuses on decentralization and people’s participation, elected
representatives at all levels have a crucial role to play, since elected representatives are in touch
with people and are aware of their needs, aspirations, strengths and attitudes. The following are
some of the key roles:
• Political will and public opinion are important preconditions for sustained advocacy on issues
related to population and development. Elected representatives can provide leadership in
acknowledging the existence of the issues.
•Discussing the issues in meetings, formal and informal, including public meetings, committee
meetings and party meetings. Utilizing the feedback received during such meetings in the
process of policy formulation and programme development.
• Sharing views and perceptions with other representatives to identify common concerns as well
as differences.
• Mentioning key issues in party programmes and election manifestoes.
Various studies
have brought out
the importance of
decentralized planning
and programme
•Discussing these issues with international, national and regional organizations in
order to convey people’s views and perceptions.
•Ensuring partnership and coordination among government and non-government
organizations in policy formulation and programme implementation.
• Monitoring the progress of the programmes; while numerical achievements are
important, emphasis should be on qualitative aspects.
intervention more
specifically at the
district level. With 73rd
and 74th Amendment
of Constitution,
district becomes the
focus of planning
and programme
interventions.
CNA should also assess the community perception of ‘Quality of Care’ and practical
indicators for quality of care should be developed. In this exercise, it is vital to install a
good Health Management Information System (HMIS) for improving the effectiveness of
the programme; there will also be emphasis on complete registration of births, marriages,
pregnancies and deaths. Against this backdrop, CNA should be viewed as an important
health sector reform initiative and not merely a reporting system.
The need is for greater social investment, wider socio-economic development,
strengthening the public health system and improved governance in order to achieve
population stabilization.
Social investments help reach the goal of slower population growth. Strategies for
achieving population stabilization should include improving socio-economic indicators
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such as addressing the needs for maternal care; child health and contraceptive services;
education of girls; ensuring minimum age at marriage of girls; reducing infant mortality
and MMR through better health care and immunization; and nutrition support to women
and children.
There is a need to focus on reducing IMR and MMR. Verbal autopsy audit of all such
deaths would help understand the leading causes of such events for taking necessary
action. The participation of various community based organizations, Non-Governmental
Organizations and local experts should be encouraged during the audit.
The twin issues of gender and equity should be overarching in all the strategies being
formulated. In this context, there is a need to promote male participation and promotion
of methods for regulation of male fertility, both temporary as well as permanent, through
good quality health care delivery system.
There is a need to
focus on reducing
IMR and MMR. Verbal
autopsy audit of all
such deaths would
help understand the
leading causes of
such events for taking
necessary action.
“Population stabilization is not merely about numbers; it has to be looked at in the context
of wider socio-economic development. It does not matter if in the process we don’t stabilize by
2045 (as indicated in National Population Policy 2000), it could be achieved by 2060 or 2070.
But, what is of greater concern is how we approach the issue of population stabilization. It should
be a gender balanced and rights based approach rather than top down authoritarian approach.”
(Nanda A R: Seminar: Beyond Numbers, 511 March 2002 (Full Journal).
Since 2005, the National Rural Health Mission (NRHM) is being implemented in the country
• NRHM appears to have brought back the primacy of the Alma Ata declaration and comprehensive
Primary Health Care.
• NRHM provides a platform for:
n Fostering inter-sectoral co-ordination
nDecentralized planning and implementation
n Strengthening of Primary Health Care
n Involving communities in monitoring services and convergence at the village level.
All of these have a potential to contribute towards achieving the socio-demographic goals of
the National Population Policy for population stabilization.
The concept of Primary Health Care as advocated in the Alma Ata declaration – with its
emphasis on equity and strong people’s participation addressing the underlying social, economic
and political causes of poor health, is as valid and relevant today as it was 32 years ago – and is
even more urgently needed now. People say that primary health care has been tried and failed.
In fact, in our country it has never been tried in its true spirit and in the comprehensive form as
advocated at the Alma Ata.
Considering that the NPP is a progressive and people centered policy document, there is a need
to follow it as a blue print to be communicated to all stakeholders and much more systematic and
evidence-based advocacy efforts have to be mounted by advocates, who have fully internalized
the paradigm shift.
While NRHM is an opportunity for systemic reforms and developing convergence mechanism
for achieving the socio-demographic goals of the nation, it is essential to remind ourselves that the
essence of the NPP is empowerment of people and it needs to be pursued as a national movement.
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“In the new millennium, nations are judged by the well-being of their peoples; by levels of
health, nutrition and education; by the civil and political liberties enjoyed by their citizens; by the
protection guaranteed to children and by provisions made for the vulnerable and the disadvantaged.
The vast numbers of the people of India can be its greatest asset if they are provided with the
means to lead healthy and economically productive lives” - National Population Policy, 2000.
The population of India could be its biggest asset, if appropriate policies and programmes are
formulated and implemented with people’s participation. We can reap the demographic dividend,
as we stabilize the population over the next 50 years.
“The myth of overpopulation is destructive because it prevents constructive thinking and
action on reproductive issues. Instead of clarifying our understanding of these issues, it
obfuscates our vision and limits our ability to see the real problems and final workable
solutions. Worst of all, it breeds racism and turns women’s bodies into a political
battlefield. It is philosophy based on fear, not on understanding”. - Betsy Hartmann,
Reproductive Rights and Wrong: The Global Politics of Population Control (From Sanjam
Ahluwalia; Reproductive Restraints: Birth Control in India, 1877-1947, Year 2008)
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Papers
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Obsolescence and Anachronism
of Population Control:
From Demography to Demology**
A.R. Nanda
I am grateful for the privilege of delivering a lecture in memory of Dr. George B. Simmons, whose
advocacy of the effectiveness and efficiency of organized family planning programme interventions
for fertility reduction, particularly in the context of India and Bangladesh is well-recognized. He
gave very distinct direction to the qualitative aspects of population studies in the 1970’s and 80’s,
and influenced in no small measure the contemporary demographers in India and abroad.
On this occasion, I would like to name a few of his works, which have influenced policy and
programmatic changes in Governments and international/bilateral funding agencies. These are:
1. Measures of Efficiency for Family Planning Evaluation (1979).
2.The Determinants of Family Planning Acceptance in Rural Uttar Pradesh (1979).
3. Post-Neonatal Mortality in Rural India: Implications of an Economic Model (1982).
4.On the Institutional Analysis of Population Programme (1983).
5. Family Planning Programmes in “World Population and U.S. Policy: The Choices Ahead” – edited
by Jane Menken (1986).
6.Organizing for Effective Family Planning Programme (1987).
7. Reflection on the Future of Family Planning (1988).
8. Family Planning and Development: Issues in Inter-agency Co-ordination in Uttar Pradesh (1988).
9.The Policy Implications of the Relationship between Fertility and Socio-economic Status (1988).
10. Cost Effectiveness Analysis of Family Planning Programmes in Rural Bangladesh: Evidence from
Matlab (along with other authors), (1991).
11. Supply and Demand, not Supply versus Demand: Appropriate Theory for the Study of Effects of
Family Planning Programmes on Fertility (1992).
12.Techniques for Improving Client Relations in Family Planning Programmes (1992).
E��x�e�c�u�t�i�v�e��D�i�re��c�to��r,�P��o�p�u�l�a�t�i�o�n��F�o�u�n��d�a�t�io��n��o�f�I�n�d��ia�,��2�8�B��, �Q�u��ta��b��In�s�t�i�t�u�t�io�n��a�l�A��re��a�,�N��e�w��D��e�l�h�i-�1��1�0��0�1��6�.
** George B Simmons Memorial Oration delivered on the occasion of the Annual Conference of the Indian Association for the Study of
Population (IASP) on February 9, 2004 at Annamalai University, Annamalai Nagar, Tamil Nadu.
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George Simmons, who was Professor and Chair, Department of Population Planning and
International Health in the University of Michigan, Ann Arbor had made India, and particularly
U.P. his area of research for almost two decades, in association with some of India’s eminent
population scientists. Based on his studies in Bangladesh and India, he recommended, inter
alia, exploring “alternative approaches to delivering health and family planning service… In the
hopes of finding more effective, more efficient, or more administratively feasible intervention”.
He suggested the national programmes to “expand to include a variety of reversible methods in
addition to terminal ones without incurring a significant rise in the cost per contraceptive year”.
He had the intellectual honesty to admit “considerably more needs to be learned about the costs
and effectiveness of health and family planning interventions. A concerted effort to incorporate
such issues in the design of programmes and evaluation would benefit policy makers and planners
in the allocation of scarce resources aimed at reducing fertility and mortality in rural Bangladesh
and elsewhere in the developing world…”.
George Simmons could not live to see the crystallization of the new concerns around population
issues leading to the paradigm shift in ICPD 1994, and the Programme of Action on population and
development. Family Planning Programme interventions have now become an integral part of the
Reproductive and Child Health in India. This alternative approach is planned to be demand-driven,
client centered, need based and gender-sensitive at each community level aimed at more efficient
and effective service provision. The earlier authoritarian contraception target from above has
been replaced with a new regime of target-free C.N.A. approach of service delivery. The National
Population Policy, 2000 has recognized the value of the paradigm shift, and “efficiency and cost
effectiveness” – which were the prime concerns of George Simmons – are to be measured against
new indicators of quality of care, gender-sensitivity, and reproductive rights, rather than the sole
indicator of contraceptive prevalence and narrow demographic targets. The close involvement
of the community and the local self-governing bodies in planning, designing, monitoring and
evaluating calls for new instruments and mechanism of management of demand and supply of
products and services for achieving responsive, socially audited and result-oriented population-
development outcomes in the short, medium and long run. Population studies and research have
been attuned to adopt more inter-disciplinary approach to cater to the new scenario.
Before I discuss the implementability, feasibility and future prospects of the new RCH regime
post-ICPD in India and elsewhere, I deem it proper to dwell at some length on the experiences,
perspectives and thinkings on population issues during the last 100 years or so globally as well
as in India, and the rationale behind the evolution of stand-alone “population control” mind set
leading to unintended negative consequences.
The foundation seed, as you all know, was a super classic “An Essay on the Principle of
Population” written by Malthus in 1798. David Ricardo, the father of modern Economics, is
credited with bringing Malthus’s population theory into that structure, but in such a
The National simplified version as to promote a misconception on the Essay’s actual content. In
Population Policy, 2000
has recognized the
value of the paradigm
the words of Peterson (1979), Malthus’s “central ideas are often misunderstood even
by professional demographers”. Neo-malthusians in 20th century claimed a “different
half-truth – that Malthus’s theory of fertility differed from theirs only in that he did not
approve of contraception”.
shift, and “efficiency The general relationship among eugenics, demography, and population control
and cost effectiveness” in the last one hundred years centered round the politics of population growth.
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Institutionalization of linkages internationally ensued in 1900, when the first in a series
of international population conferences started. As the international movement for birth/
population control began soon after the World War I ended, led by a Nurse, Margaret
Sanger, the population scientists (economists, eugenists, demographers, geneticists,
doctors and sociologists) liked to take political positions, while attempting to make the
study of population a true science. For most of them it was all about “control”. The
central question of how to reconcile “individual rights” with “social responsibility” in
the realm of population policy was often posed during the inter - war period in terms
of “whether a new birth control movement could unite with the gathering force of
eugencies”.
It may be pertinent to recall the world view of population in 1920 by a Harvard Ph.D.
named Stoddard, who referred to “overcrowded colored homelands from where would
come the outward thrust of surplus colored men” (1920). He blamed the white men as
“responsible for their own demise, since they had reduced famine and disease and had
thus removed checks to population increase among non-whites….”.
Economists like Harold
Wright warned that
population trends
“may, if they are not
modified, destroy
western civilization in
a few years” and urged
for “a world policy in
regard to population
problems”
It is interesting to find reverberations of this argument in the international debate about
population trends for many decades. Economists like Harold Wright warned that population
trends “may, if they are not modified, destroy western civilization in a few years” and urged for “a
world policy in regard to population problems” (Wright, 1923).
Demographers, Carr-Saunders (1926), Cox (1926) and Blacker (1926), held the same phobia
of “Yellow peril” behind their plea for population control. This was at a time when the population
growth rates in Japan, India and other countries in Asia and Africa were less compared to those in
the countries of Europe, and “the broad based public health campaigns had barely begun in these
countries”. East, in his book ‘Mankind at the Crossroads’, claimed that “English brains have made
a new India in 50 years. Famine-stricken, pestilence-smitten, cobra-bitten India has been given a
new lease of life. ..”. India started being a “focus of international birth control efforts” from the
1920s and ‘30s.
In the sixth international Neo-Malthusian and Birth Control Conference held in New York in
1925, an Indian representative, Taraknath Das, countered the “Yellow peril”, with evidences for
the “white peril”, and while endorsing the dissemination of “birth control”, emphasized that “it
has to be only a part of a programme that aimed at poverty, poor health and ignorance, that were
the root causes of India’s population problem. He looked at birth control within a broader health
and social development perspective to “afford greater freedom to women and greater opportunity
for real education”. A demographer, Louis Dublin warned against disregard of “the permanent
interests of the state” by promoting birth control. He cautioned on the issue of contraceptive
safety and reliability. The issue of “control of fertility” remained unresolved “how to be controlled,
by whom, and for what purposes”.
The tendency to go for a policy of “compulsory birth control” persisted from 1927 World
Population Conference at Geneva through the discussion in later conferences in the decades of
1930s, ‘50s, ‘60s and ‘70s. The tendency for such coercive policy and strategy was reflected in
China going for ‘one-child policy’ from 1979, and in India during 1976-77. It is well realized
by now that such tendency smack of an alarmist, racialist and over-simplistic view of a complex
personal and societal issue which needs to be perceived with utmost circumspection, care and
empathy.
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Population control has been a central concern of population scientists and activists throughout
the 20th century. In its negative and over-simplistic sense, it has remained an obsession among
many elites in different walks of life – be it academics, doctors, businessmen, political leaders and
bureaucrats. Even in the pre-independent India, from the likes of P.K. Wattal, B.T. Ranadive and
Radhakamal Mukherjee with their publications in the 1930s (some demographers subscribe to
similar views even today), to the likes of politicians. Imam Hossain introducing a resolution in the
Council of State in 1935 for taking steps to check the increase in population (the same tendency
and mind set with M.P.s coming up with 15-20 resolutions for compulsory birth control in every
parliament session even today), to the likes of bureaucrats, Megan and Leonard Rogers (longtime
health advisor to the India office) saying that he might have been “better employed in finding a
lethal gas which might put the excess population (of India) out of its misery”, the Malthusian/Neo-
Malthusian mind set of the elites (in a negative sense) has, by and large, shaped the attitude of
authoritarianism of the higher and middle class in India on the population issue over last 70 years.
It was Radhakamal Mukherjee who convened the first Indian Population Conference in Lucknow
in 1936. He also headed the sub-committee on population of the “National Planning Committee”
of the Indian National Congress in the 1930s.
Thanks to the spiritual and humanitarian visionary and Father of the Nation, Mahatma Gandhi,
and the visionary leader and first Prime Minister, Jawaharlal Nehru, such inhuman, negative, anti-
poor and anti-women tendencies and narrow approaches to population control did not form the
cornerstone of the policies of population and family planning, when India introduced the official
family planning programme as a part of the 5-year development plans from 1951.
Mahatma Gandhi had assessed and felt the pulse of the masses as no other leader or elitist
had done. The encounters of two ladies of world “birth control” movement, How-Martyn and
Margaret Sanger with Gandhi in the 1930s are well known. It is a pity that many Neo-Malthusian
scholars and stand-alone family planning activists accuse Gandhiji of his negative attitude to
population issue. From the records of Margaret Sanger’s encounter with him, it is very clear that
Gandhi had a clear vision that Indians should have smaller, but healthier families. He had agreed
Nehru’s ideas on that uncontrolled reproduction was a social problem. He was a strong advocate for
gender justice and women’s empowerment for enabling women to take decisions on
population control child bearing and to negotiate with their husbands to observe abstinence. It is well-
were based on
liberalism and creation
of an enabling
environment for
known that Gandhi believed in “Gram Swaraj” – the rule of the village community, by
the community, for the community.
Nehru’s ideas on population control were based on liberalism and creation of an
enabling environment for choices, as would be evident from his ‘Autobiography’ written
in 1940s. Some scholars term his attitude as one of ‘ambivalence’.
choices, as would The post-World War II international movement for population control and family
be evident from his
‘Autobiography’
written in 1940s.
planning had its ideological foundations on the negotiations and lack of unanimity in the
events of the first 5 decades of the 20th century. Demographers, birth control proponents
and other population activists shifted their attention from the poor and ethnic minorities
in their own societies and countries to the relative growth of poor and underdeveloped
Some scholars term countries. In the 1950s and ‘60s, U.S. Government was persuaded by population activists
to assert leadership over the international campaign. The cold war in international
his attitude as one of politics bolstered by the study and interpretation of the demographic trends engendered
‘ambivalence’. the fear of the “population bomb” and “population explosion” on the same pedestal
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of anxiety as the nuclear war. Doomsdayers like Paul Ehrlich cemented international One of the direct
fears of population explosion in India and China, and the threat to security of U.S.A. The
international politics of population took on a confrontational turn. Professor W. Brand’s
outcomes and fallouts
report on the world population problem “skillfully utilized a scientific cloak to faithfully of the international
serve the aggressive policy of the imperialists” in the international conference on and U.S. policy and
Population Problems in 1959. A Neo-Malthusian twist was given to the issue by arguing
that backwardness, poverty, unemployment and all other hardships in poor countries strategy in the 1950s
were only due to “over-population”, and hence, birth must be controlled first. The State and ‘60s in India was
Department of the U.S. Government’s report on “The Growth Trend and the Problems of
World Population” of 23rd July, 1959 was influenced by the Brand’s report.
The Neo-Malthusian view of economic development argued that over population
is a cause of poverty, rather than a result of poverty. This argument was based on the
the system of “family
planning targets”
initiated in 1966.
assumption that poor and underdeveloped countries and particularly lower class communities
therein are “to blame for their unfettered fertility, which leads to their poverty. Their fertility,
therefore, must be controlled to ensure greater economic prosperity for the families of the poor,
for their nations, and for the world as a whole, since the large poor populations in the third world
are considered a drain on the world’s resources”. “The Club of Rome” Report, 1972 (Limits to
Growth), and even the “Global 2000 Report to the President, 1980” in USA continued the Neo-
Malthusian stance.
The Marxists considered the Neo-Malthusian view as “reactionary”. Other anti-Neo-Malthusians
and liberalists like E.Dupreel, the Belgian sociologist and Julian Simon became the exponents of a
saner and more rational view of population. Many economists dismissed the ‘Club of Rome’ Report
and the Club of Rome itself turned around completely 4 years later, and as much as said: “We were
telling you lies before to shake you up”. Simon (1981) remarked “People with a lot of education tend
to lack respect for the capacity of people who are poor and have had less education, to cope, and
may therefore worry that they won’t be able to handle their problems in their parts of the world”.
One of the direct outcomes and fallouts of the international and U.S. policy and strategy in the
1950s and ‘60s in India was the system of “family planning targets” initiated in 1966. After the
slow phase-by-phase introduction of a “clinical” approach (with equal reliance on conventional
and natural methods like ‘rhythm’ and non-invasive methods, particularly for woman) and an
“extension” plus IEC approach, an aggressive method-specific targeting and new invasive method
for women (like IUD) were taken up. The National Family Planning Programme was incorporated
within the MCH system where MCH workers were given targets to motivate a particular number
of men and women to “accept” different kinds of contraceptives month-by-month. A system of
rewards and penalties, and competitions was build-in for State Governments, Hospitals, Districts
and MCH workers. To quote Hollan (2003):
“The implementation of these policies was a response to increasing pressure by international
(lending/donor) organizations (World Bank, USAID and Ford Foundation) to step up population
control programmes as a condition for economic development….”
The evolution of population stabilization efforts in India by government goes back to the
onset of five year development plans in 1951-52. A national programme was launched which
emphasized ‘family planning’ to the extent necessary for reducing birth rates to stabilize the
population at a level consistent with the requirement of national economy. A clinic-based
approach with equal emphasis on natural method like rhythm as on some contraceptives was
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taken cautiously, along with awareness building and research on new contraceptives and their
acceptability. A Family Planning Research and Programme Committee was constituted, which in its
first meeting at Bombay in July 1953 took quite a comprehensive and broader view of the family
planning. To quote their report:
“The committee emphasized that the family planning programme should not be conceived of in
the narrow sense of birth control or merely of spacing of the birth of children. The purpose of
Family Planning was to promote, as far as possible, the growth of the family as a unit of society,
in a manner designed to facilitate the fulfillment of those conditions which were necessary for the
welfare of the unit from the social, economic and cultural points of view. The functions of a Family
Planning Centre would include sex education, marriage counseling, marriage hygiene, the spacing
of children, and advice on such other measures (including on infertility) as necessary to promote
welfare of the families”.
Around the same period in China, the new Communist Government under Mao Tsetung looked
at population basically as an asset, and took many benign measures of social development which
brought in more equitable access to basic health, education, assets (including revolutionary re-
distribution of land) and income over next 20 years. The concept of family planning services that
China followed was in tune with what the Bombay family planning research and programme
committee had conceptualized.
Instead of a top-down prescriptive target approach, China went in for a localized community
approach. The Cultural Revolution made the bureaucrats and service providers more responsive
and accountable to the local party hierarchies, the communes and the Production Brigades, and
purged them of their elitist-intellectual hatred or indifference for the peasants. They became more
alert to the needs of the communities and were responsible to meet these needs in an equitable
manner. Such a style of governance brought in quick results in all indicators of social development
including women’s status; and the fertility rate came down very sharply by 1970s. The perception
of the families and that of the state converged, when it came to acceptance of a small family norm.
Only with the contagion of western education, the threat perception of growing numbers took deep
roots in the mindset of some Chinese scholars, and leaders, and they advocated many restrictive
population policies like the ‘One-child policy’ which appears to have created more societal and
family problems like skewed sex ratio, female infanticide and foeticide, rather than helping in smooth
stabilization of population. There are thus lessons to be learnt from the Chinese experience in
governance. We tend to misrepresent the Chinese story, whenever we compare the Indian situation
for advocating coercive policies like “Two-child norm” and the concomitment regime of incentives
and disincentives to solve our population problem quickly.
It is a pity that our bureaucrats, advisors, planners and policymakers paid a lip service to the rational
and sane advice of the Family Planning Research and Programme Committee in 1953, and
The evolution of instead, adopted disjointed, verticalised and top-down contraceptive programmes with targets
population stabilization of sterilization. A Department of Family Planning was created in the Health Ministry in 1966;
efforts in India by
the programme was made ‘Centrally-sponsored’; financial incentives were introduced for
sterilization acceptors; and sterilization was made target-oriented. Although the programme
government goes back was integrated with maternal and child health during the Fourth Plan (1969-74), and further
to the onset of five with health and nutrition in the Fifth Plan (1974-79) with creation of multi-purpose workers,
introduction of mass motivational efforts and population education, the primary objective
year development was to achieve targets of male and female sterilization imposed from above. The compulsory
plans in 1951-52. and coercive nature of the programme during 1975 and 1976 made it highly unpopular.
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Anandhi (1994) has referred to the fears of population explosion in which “women
are viewed as the bearers of bodies to be counted”. This view of women is inherent in
the concept of “Modern Population Control”, wherein women participating in targeted
population control are parts of this “embodied modernity”.
The western countries
came out with very
generous support
Bose (1988) has clearly brought out that family planning is not likely to succeed in for programmes
a scenario where “the demographers tend to get stuck in decimal points, while family “spreading the
planning administrators are obsessed with targets and achievements”. He has very
aptly observed: “India’s family planning programme has become increasingly vertical, message that a small
bureaucratic and dehumanized, where people do not count. Only the number of
sterilization cases matter. And all this has happened in the face of the professed policy
of making family planning a ‘peoples’ movement….”.
Historically, one can see the origin of what Horn (1994) terms “the notion of the
family was the key to
prosperity and personal
fulfillment”
reproductive population as a positivistic, quantifiable and malleable object of governance” as a
distinctive view of modernity in 19th century Europe, but the means of constructing and fashioning
the given population through ‘population control’ or ‘family planning’ varied greatly across time
and space over last 200 years.
The drive to reduce population growth and size through stand-alone family planning initiatives
in India, with the technical and financial back-up from U.S and international bodies became a
paramount concern; but its “impact on the experience of the poor and marginalized” has, more
often than not, been negative, disastrous and inhuman.
It will not be out of place here to recall the interesting debate between demographers Donald
J. Bogue and Amy Ong Tsui on one side, and Paul Demeny on the other, during 1978 and 1979.
Dr. Donald J Bogue was one of the first demographers to predict “the end of the population
explosion” in 1967. The prediction was based on the theory that “heroic efforts by Governments,
involving the exercise of political and administrative muscle, may hold out greater with a more
ominous programmatic promise”.
Paul Demeny in a commentary on this prediction and the theory underlying therein said “….But
the belief that achievement of zero population growth can be expected as a natural consequence
of increased availability and perfection of birth control methods is naive in the extreme or banks
unwisely on sheer good luck”.
As I have told earlier, the 1960’s and ‘70s can be considered as “the heyday of the international
campaign” to control population growth, particularly in poor and developing countries. The
western countries came out with very generous support for programmes “spreading the message
that a small family was the key to prosperity and personal fulfillment” (Connelly, Unpublished).
The cause was discredited for various reasons, like:
(i) Failure of early fertility limitation,
(ii) Coercive measures,
(iii) Prediction or prophesy of gloom and doom of “global famine” not coming true, and
(iv) Internal divisions and external oppositions in the family planning coalition from “new
powerful constituencies” like environmentalists and feminists.
The conflicting perceptions in the 1970s and ‘80s over the global politics of population (e.g.
Bucharest and Medico Official Population Conferences) are well-known. As families grew smaller
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in the 1980s and ‘90s, in every region of the world, below-replacement level and new pandemics
like HIV/AIDS raised the phenomenon of population decline. The population control activists and
scholars have either given up or been more discreet or muted in using languages of “population
bomb”, “population explosion” and “population control” in favour of the languages of
“population and development”, “population stabilization”, “gender equity, equality and justice”,
“quality of care”, “reproductive rights” and promotion of “women’s sexual rights and health”,
among others.
The paradigm shift with ICPD, 1994 gave a new, but more realistic dimension to the resolution
of population problem in all circumstances.
It has been realized that “target” approach to reducing population has been ineffective, and
has to be rejected straightaway. Governments in many countries are moving away from narrow
demographic approaches to population issues towards a focus on issues of “gender inequality”
and lack of “reproductive rights and choices” as key factors contributing to the problems of
population growth.
The Government of India’s family planning programme was being criticized by NGOs, women’s
groups and rights-based scholars for its lack of concerns and sensitivity over human rights and
dignity abuses associated with the target approach. The feminist organizations started a systematic
campaign against human rights abuses associated with the Norplant and Depo-provera.
In view of these concerns and the sustained campaigns, and on India signing the ICPD
Programme of Action in 1994, Government abolished the system of targets and the “target-free”
reproductive and child health care approach was accepted from 1997-1998 onwards. As stated
earlier, the RCH approach (further backed up by a solid national policy on population in 2000) has
opened a new vista with “a decentralized planning approach” and a more comprehensive and
holistic vision of “women’s health” throughout the life cycle. Goals are to be set primarily at the
district level, based on the work plans of local communities prepared with a CNA approach. Family
planning/contraceptive targets for specified numbers of acceptors are to be replaced by targets
which could serve as indicators of the “Quality of health care needed and provided”.
The Government of
India’s family planning
programme was being
criticized by NGOs,
women’s groups and
rights-based scholars
for its lack of concerns
and sensitivity
over human rights
There are some diehard ‘population control’ exponents among politicians,
bureaucrats, demographers and other sections of the elite, who have not reconciled to
the paradigm shift, and who feel more comfortable with an authoritarian policy regime of
quantitative targetists, for the sake of achieving soft and quick-fix options (either in field
implementation or research studies). They often deride the “target free” approach as one
which leads to complete lack of accountability and lack of quick and visible results on the
ground (as reflected in the administrative reports). Such mind set is understandable in
as much as most of the present generation of senior politicians, bureaucrats and scholars
have been trained and oriented in Neo-Malthusian studies of population and have been
players in or witness to implementation of MCH policies, which “throughout India have
been dominated by Family Planning and driven by numerical targets for so long that it
will take time for a fundamental reorientation to transpire…. It is yet to take deep roots
in peoples’ minds….” (Hollen, 2003).
and dignity abuses
associated with the
target approach.
To allay the fears of these “population control” exponents of the loss of the CPR,
it can be said that the rates of contraception “acceptors” have continued to rise in a
target-free environment, since many women “have begun to voluntarily opt for family
planning”, particularly in South Indian states.
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A comparison of data of NFHS-I (1992-93) with the data of NFHS-II (1989-99)
reveals an 18 percent increase in contraceptive prevalence during 6 and a half years in
the 1990s. A preliminary comparison of data from the RCH Survey I (19989-99) and the
first phase of the RCH Survey II (2002), reflecting changes after the introduction of the
CNAA and RCH Program, also indicates an increase in contraceptive use in all the major
states, particularly U.P., M.P. and Himachal Pradesh (Santhya, 2003).
The operationalisation
of the new Population
Policy and the RCH
strategy has not yet
To quote Santhya (2003) “Early assessments of the impact of the new policy and been taken up with
programme initiatives suggest some improvement in overall indicators such as CPR
and the magnitude of the unmet need for contraception. However, underlying issues
sincerity in many
including limited contraceptive choice, poor quality of services, restricted access, gender districts.
inequalities and lack of male involvement continue to plague the programme”. Lacunae
like low level of ownership of and commitment to RCH at the state level and weak programme
management at the district level, particularly in the EAG states, and inadequate decentralization
of processes remain.”
It may be clarified that “the vital discourses” of the new policy like: (i) Participatory planning,
(ii) Target free, (iii) Life Cycle, and (iv) Social health, are to quote Hollan “not merely top-down
instruments of propaganda, but, in fact, have long been brewing at the local level, as evidenced
by the local critiques of earlier policies pursued since the 1960s”.
Therefore, “regardless of whether or not the Governments involved are now capable of and
committed to implementing a policy that reflects a fundamental reorientation towards women’s
health” and reproductive rights, “the rhetoric of the policy resonates the local concerns of the
women who are the recipients of health services”.
A symposium on population planning and advocacy held towards the end of 2001 discussed on
the contemporary population issues in India post-ICPD and post-National Population Policy, 2000.
The incongruities in state population policies vis-à-vis the NPP and ICPD were brought out in sharp
focus. The symposium papers have been published in a special issue (Beyond Numbers) of ‘Seminar’
(511, March 2002). To quote Visaria and Ramachandran (2002) in this issue, “The challenge before all
the players in this field is to frame population and development issues in the larger context of gender
justice and women’s autonomy”. To quote Sen and Iyer (2002): “….given the crucial importance
of the population momentum and unwanted fertility in the country, incentives and disincentives
to pressure people to want fewer children may simply be barking up the wrong tree. They may be
neither relevant nor particularly effective in bringing down the growth rate of population”.
The operationalisation of the new Population Policy and the RCH strategy has not yet been
taken up with sincerity in many districts. Some State Governments simply linked together pre-
existing Family Planning, Child survival and Safe motherhood, RTI, STD and abortion services;
and “Family Planning remained the dominant force in the equation”. The numerical Family
Planning targets from above have not been completely given up. They call this as “expected level
of achievement” – an euphemism for “top-down targets”. The instructions and directions from
some State Governments and the conflicting and ambivalent approach of National Population
Commission and Government of India, complicate the situation further.
The increase in female literacy, women’s increasing role at Panchayati Raj institutions, formation
of consortia and watch-dog institutions of NGOs – CBOs – SHGs – Gender – Rights activists
will ensure commitment to active participation in and better implementation of the target-free
Reproductive Health and Population Policy and strategy at the community level. Deviation from
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and distortion of the basic norms of the new strategy should not be allowed in any circumstances.
The National and State Human Rights and Women’s Commissions have to play very vital role in
this respect. Much more systematic and evidence-based advocacy efforts have to be mounted
by advocates and researchers who have fully internalized the paradigm shift, and the elite target
audience at different levels has to be educated and influenced to stay on course. This is the key
challenge facing us.
Finally, a word about research. Demographic research has taken rather a limited perspective
in its study of differences among communities divided on racial, caste, tribal and class lines. This
is truer of fertility and family formation research. Sociological differentials like essentialism,
assimilationism and racial/caste and class stratification are to be studied. Same is true of the
gender issues. In this connection, I would like to quote Mc Daniel: “Like much demographic
research, fertility and family formation research has taken a limited perspective in its study of racial
differences” (Mc Daniel, 1986).
Secondly, I would like to re-iterate what Greenhalgh (1995) observed:
“A political economy of fertility is a multi-leveled field of enquiry. It combines societal structure and
individual agency, both of which generally escape the demographer’s attention, and draws on both
quantitative and qualitative research methods and materials… The objective is to understand how
institutions and behaviour evolved and how its constitutive elements relate to each other…”.
I would suggest we need more inter-disciplinary research on the population issues that
confront us today. The demographers and socio-cultural anthropologists have to reach out to
each other, much more than ever before. “It is well-known by now that quantitative data and
analysis at micro-level, along with ethnographic research, can give more compelling explanations
of population phenomena like female infanticide and foeticide”, as a fall-out of fertility transition
and one or two-child norm policies in China and India. I need not have to tell this audience
that John Caldwell and Geoffrey McNicoll have shown and emphasized the merits, nuances and
limitations of these micro-approaches to demographic research.
To quote Greenhalgh (1995) again “An over reliance on quantitative research has constrained
our understanding of the full complexity and context of fertility; it has also provided a powerful
tool to uncover injustice, as in the case of China’s skewed male-female ratios”.
Much more systematic
and evidence-based
advocacy efforts
have to be mounted
Similarly I would refer to Rachel Snow’s caution that “while reliability was often
the overriding criterion of those who direct contraceptive research, focus groups across
cultures show it is a major concern for many poor women as well. Privileging ‘user
control’ regardless of the social context in which contraceptives are actually used might
discourage the development of technologies like injectables, and thus deprive some
women of the only means to limit their fertility without fear of retaliation” (Connelly,
Unpublished).
by advocates and
researchers who have
fully internalized the
paradigm shift.
Earlier anthropological approaches to reproduction tended to focus on how reproductive
practices and beliefs reflected social and cultural systems. Scholars now argue that
anthropology can benefit from viewing ‘reproduction’ itself as a key site for understanding
the ways in which “people reconceptualise and reorganize the world in which they live”.
This is a “processual view of culture-in-the-making”. Cross-cutting issues of equity,
entitlement, living standards and rights could be captured more succinctly, in order to
provide more meaningful policy prescriptions on population-development-environment.
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Time has come for broadening ‘Demography’ in to what I term as ‘Demology’ in the interest of
attuning research to the needs of the hour – to help in better understanding of people constituting
population.
References
Anandhi, S., 1994, Population Policy and Politics of Reproductive Rights, In: S. Anandhi (ed.), Population Policy and
Reproductive Rights, Madras Initiatives on Women in Development.
Blacker, C.P., 1926, Birth Control and the State: A Plea and Forecast.
Bose, Ashish, 1988, From Population to People – Vol. I. B.R. Publishing Corporation, New Delhi.
Carr-Sunders, A.M., 1926, Population.
Connelly, Mathew, Population Control is History: New Perspectives on the International Campaign to Limit Population
Growth, CSSH, (unpublished).
Cox, Harold, 1926, The Problem o Population.
Demeny, Paul, 1979, Notes and Commentary. Population and Development Review, 5 (1).
Govt. of India, 2000, National Population Policy-2000. Department of Family Welfare, Ministry of Health and Family
Welfare.
Greenhalgh, Susan, 1995, Anthropology Theroizes Reproduction: Integrating Practice with Political-economic and
Feminist Perspectives. In : Situating Fertility: Anthropology and Demographic Inquiry, Cambridge University Press, New
York.
Hollan, Cecilia Van, 2003, Birth on the Threshold – Child Birth and Modernity in South India. University of California
Press.
Horn, G. David, 1994, Social Bodies: Science, Reproduction and Italian Modernity. Princeton University Press, J.J.
ICPD-POA, 1994, Programme of Action adopted at the International Conference on Population and Development, Cairo,
Sept. 1994, UNFPA.
Mr. Daniel, Antonio, 1996, Fertility and Racial Stratification. Population and Development Review, A supplement, 22.
Peterson, William, 1979, From Malthus. Oxford University Press.
Santhya, K.G. 2003, Changing family planning scenario in India: An overview of recent evidence. Regional Working
Paper No. 17, Population Council.
Sen, Gita and Aditi, Iyer, 2002.Incentives and Disincentives: Necessary, Effective, Just? In: Beyond Numbers, Seminar
No.511.
Simon, Julian, 1981, The Ultimate Resource. Princeton University Press.
Simon, Julian, 1981, Is there an Answer to Malthus? Broadcast interview, October, 1981.
Stoddard, Lothrop, 1920, The Rising Tide of Color Against White World – Supremacy. Charles Saibners’ Sons, New York.
Tsui, Amy Ong and Bogue. Donald J., 1967, Declining World Fertility: Trends, causes and implications, Population
Bullettin, 33 (4)
Visaria, Leela and Ramachandan, Vimla, 2002, The Problem in: Beyond Numbers, Seminar, No. 511.
Wright, Harold, 1923, Population. Cambridge University Press.
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Population Scenario of India and
National Population Policy:
An Overview**
DR ALMAS ALI*
Current thinking on Population Issues
In the last half century there have been many changes in the thinking on Population Issues.
Let us begin by having a quick look at the history of Population debate spanning over last five
decades.
From the mid 1950s onwards, as a result of rapid fall in death rates there was an unprecedented
high levels of natural growth. It was this concern of excessive demographic increase (which was
then qualified as “Population Explosion” – the term extensively used in the mid – 1960s in the
deliberations of Club de Rome) and its social, economic and perhaps geo-political ramifications
that impelled the international community to focus on slowing down population growth by
implementing what was then called “Population Control”or “Family Planning Programmes.” The
The reality was that
reality was that excessive growth was taking place in the poorest and least developed
countries and was adversely affecting their capacity to cope with their development
excessive growth requirements. The excessive demographic growth coupled with traditional, inefficient
was taking place in and poorly yielding means of production put a lot of pressure on available resources
and meant an obvious dwindling in depletion of the provision of basic social services
the poorest and least like education, health, nutrition, housing, water and sanitation. The most spontaneous
developed countries
and was adversely
affecting their
and “logical” response then on the part of the international community was to try to
curb the increase in number from a purely quantitative perspective.
This panic like neo-Malthusian environment continued in the 1960s, 1970s and
throughout 1980s. Even in 1987 July 11th, when the world population crossed five
capacity to cope with billion, the alarm then was the rapidly increasing number and it was this concern which
their development
led to the observance of World Population Day. The thought on Population was primarily
concerned with numbers. Increasing numbers were looked at with fright, as if a swarm
requirements. of people growing at an unregulated pace would one day overwhelm the planet,
* Senior Advisor, Population Foundation of India, New Delhi.
**This paper was delivered as a key note address at the 9th International Conference on “Issues of Population
stabilization and development” organized by the Council of Cultural Growth & Cultural Relations, Orissa in February
2002 and published in the volume ”Population stabilization and development”, 2002
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consume its resources, lay it bare and bring the planet to its destruction. It was this fear The central theme
that formed the central idea of the Population Programmes. The focus was mostly on
“Population” not “People”. These programmes did not look at “human development” of the ICPD was
as the need of the hour, but instead looked at women whose fertility needed to be to forge a balance
controlled. The word “Control” best represented the situation. Thus the central concern
was “Population Control.” That is why the Population Programmes were focused only between population,
on sterilization and not other health needs of the people.
sustained economic
This international perspective was also reflected in our national policies and
programmes upto mid 1970s, when during the Emergency, the Family Planning Programme
growth and sustainable
received a set back in India due to rigid implementation of a target based approach. In development.
India, the political and human wounds of the “Population Control” measures during
emergency over 25 years ago, are still to heal. From late 1970s, to mid 1980s, there was a lull and
from late 1980s, we revisited the population debate again from the same old perspective.
It is only since 1994, after the International Conference on Population and Development
(ICPD) at Cairo, Egypt, that there has been a dramatic change in thinking on population issues.
In fact, ICPD was a watershed in the history of thinking on population issues. It brought about
a significant shift in frameworks, strategies and approaches relating to population and public
policy issues.
The ICPD represented a “quantum leap” for population and development policies as it
involved a paradigm shift from the previous emphasis on ‘Demography and Population Control
to Sustainable Development’ and recognition of the need for Comprehensive Reproductive
Health Care and Reproductive Rights. It became clear that population was no longer about
numbers, figures and statistics but about people and their quality of life. That for such a
quality development to occur population progrmmes should be development oriented, human
rights-based, inclusive and participatory and should involve the people of concern in the
whole process of defining problems, deriving strategies, implementing programmes and
evaluating outcomes. It was also agreed that no force, no coercion, no incentives and disincentives
are required, because incentives and disincentives are either coercive or ultimately tend to be
coercive and are in fact counter productive. Coercion infringes upon human rights and inhibits
human development. The ICPD Programme of Action (PoA) placed “individuals” in the center of
development with a focus on building pillars of “human rights, gender equity and equality.”
The central theme of the ICPD was to forge a balance between population, sustained
economic growth and sustainable development. The objective of the agreement reached at the
Cairo Conference was to raise the quality of life and enhance well-being and to promote human
development. The Programme of Action (PoA) rightly emphasized the need to integrate population
concerns fully into development strategies and planning, taking into account the inter-relationship
of Population issues with goals of poverty eradication, food security, adequate shelter, employment
and basic services (like health and education) for all.
Two fundamental changes have occurred in recent times in conceptualizing and implementing
Population Policies. First is to ensure that Population Policies and Programmes address the
root causes of high fertility such as persistent gender disparities in access to education, health,
employment and other productive resources. The second is to expand existing Family Welfare
Programmes beyond contraceptive delivery to include a range of Reproductive Health Services
with a greater emphasis on quality of care and individual’s right.
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Now the focus has become broader and holistic and different in nature. Earlier, Total Fertility
Rate (TFR) and Contraceptive Prevalence Rate (CPR) used to be the fixation of most population
programmes as they also served as indicators of success. ICPD replaced them with quality of care,
informed choice, gender factor, women’s empowerment and accessibility to a whole gamut of
reproductive heath services.
We no longer use words like “Population Control” or “Population Explosion” as these words
have a negative connotation.
The natural fallout of the ICPD was commitment by the countries around the world to implement
Reproductive Health Approach. India has broadened the scope of Reproductive Health by adding a
distinct component of Child Health also, hence the nomenclature “Reproductive and Child Health
– popularly known as RCH.”
In this paper, we will also be dealing in detail the current status of RCH Programme in
India. However, we feel it would be better to give an overview of current population situation
(Demographic Scenario of India) before we proceed to deal with RCH. Therefore, what follows
next is a brief over-view of the current population situation in India.
Population Scenario of India
India possesses only 2.4 percent of the world’s land area but has 16.7 percent of its population
and is the second most populous country in the world after China. While the global population has
increased nearly three-fold during the twentieth century (1901-2000) from 2 billion to 6 billion,
the population of India increased nearly five times in the same period. In 1901 the country’s
population within its present boundaries was only 238.4 million and has increased by slightly over
660 million in the past 100 years. Out of this increase, 84% has occurred during the second half
of the century i.e. 1951-2000 and only 16% was added during the first half.
According to the Census of India, 2001, the population of India on March 1, 2001 stood
at 1,027,015,247 (i.e. 1027 million or over one billion and twenty seven million) comprising
531,277,078 males (over 5312 million) and 495,738,169 (over 4957 million) females. Based
on these figures, sex ratio (number of females per 1000 males) is 933 (as against 927 in 1991)
and the density of population per sq.km. is 324 (as against 274 in 1991) i.e. there are now 50
more people in every sq.km. of the country. The overall decadal population growth rate has come
down by 2.52 percent (i.e. from 23.86 in 1991 to 21.34 in 2001), the sharpest fall ever in decadal
population growth and the average annual exponential growth rate of population has gone down
to 1.93% in 2001 from a level of 2.14% in 1991. In fact this is the lowest population growth rate
experienced by the country since independence.
India is following the demographic transition pattern of all developing countries from initial
levels of “high birth rate – high death rate” to the intermediate transition stage of “high birth rate
– low death rate” which manifests in high rates of population growth, before graduating to “low
birth rate – low death rate.” The current high population growth rate in some parts of the country
is due to:
•The large size of the population in the reproductive age group (estimated contribution 60%)
• Higher fertility due to unmet need for contraception (estimated contribution 20%)
• High wanted fertility due to prevailing high Infant Mortality Rate (IMR) (estimated contribution
about 20%)
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A look at the Census figures of the last four decades indicates a perceptible decline in recent
years, in the growth rate of the population.
Growth of Population in India
CENSUS
Decadal Growth Rate (%)
Average Exponential Growth
(%)
1961-1971
24.80
2.20
1971-1981
24.66
2.22
1981-1991
23.86
2.14
1991-2001
21.34
1.93
In 1952, India was the first country in the world to launch a national programme emphasizing
fertility regulation to the extent necessary for reducing birth rates “to stabilize the population at a
level consistent with the requirement of national economy.” Half a century after formulating the
National Family Welfare Programme, India’s demographic achievement is:
India’s Demographic Progress
Indicators
1951
1981
1991
Current
1. CBR
40.8
33.9
29.5
25.8 (SRS 2000)
2. CDR
25.1
12.5
9.8
8.5 (SRS 2000)
3. TFR
6.0
4.5
3.6
2.9
4. CPR
10.4
22.8
44.1
48.6
5. IMR
146
110
80
68
Although there has been significant improvement in the socio-demographic indicators, there
remain wide inter-state, male-female and rural-urban disparities in outcomes and impacts. These
differences stem largely from poverty, illiteracy and inadequate access to health and family
welfare services, which co-exist and reinforce each other. In many parts the widespread health
infrastructure is not always responsive. Empirical studies suggest that overall governance issues
are crucial in explaining the striking diversity between States in demographic and health indicators,
especially those relating to the enhancement of access and availability of health care products
and services, the actual quality of the services reaching household levels, levels of education and
micro-insurance of segments of population below poverty line to meet emergent expenditures
towards ill health.
Atleast nine States and Union territories had already achieved replacement levels of fertility
by the year i.e. total fertility rate of 2.1 in Goa, Kerala, Nagaland, Delhi, Tamil Nadu, Pondicherry,
Andaman and Nicobar Islands, Chandigarh and Mizoram. Eleven States and Union territories
are making steady progress and gaining ground in terms of outreach and coverage of basic and
essential reproductive health care. These are Sikkim,West Bengal, Maharashtra, Karnataka, Punjab,
Andhra Pradesh, Manipur, Himachal Pradesh, Daman & Diu, Arunachal Pradesh and Lakshadweep.
However, there are eight States i.e. Uttar Pradesh, Bihar, Madhya Pradesh, Rajasthan, Orissa,
Uttaranchal, Jharkhand and Chhattisgarh, which currently constitute nearly 44 percent of the total
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population (projected to be 48 percent of the total population in 2016) whose socio-demographic
indices need significant improvement. Demographic outcomes in these States would determine
the timing and size of the population at which India achieves population stabilization.
Basic Demographic Indicators in India: At a Glance
INDICATORS
• Geographical Area (In sq. kms)
3131866
• Number of Districts
593
Census Provisional (2001)
• Population
Total
Males
Females
1027015
531277
495738
• Decadal Growth Rate
1981-91
1991-2001
Change in %age decadal growth rate
23.35
21.34
-2.52
• Annual Average Exponential Growth Rate
1981-91
1991-2001
Change in %age exponential growth rate
2.14
1.193
-0.21
Child population (in 000s) in age group 0-6 years
Persons
Males
Females
157863
(15.42%)
81911
(15.47%)
75952
(15.36%)
• Density of population (per sq. kms)
1991
274
2001
324
Difference
+50
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INDICATORS
• Sex-ratio (Females/100 males)
• Sex-ratio (in 0-6 age group)
• Literacy rate (%)
Gap in literacy rate
Gap in literacy rate
1991
2001
Difference
1991
2001
Difference
1991:
Males
Females
2001:
Persons
Males
Females
Decadal difference (1991-2001) in literacy rate
927
933
+6
945
927
-18
64.13
39.28
24.85
65.38
75.96
54.28
21.68
Males
Females
Key indicators based on RHS-RCH Survey (1998-99)
• % of girls marrying below 18 years of age
• % of births of order 3 and above
• CPR
• % of pregnant woman with any AC
• % of Safe Delivery
• % of children with full immunization
Mortality and Fertility Data based on (Latest SRS-1999): SRS Bulletin April
2001
• Birth Rate
Total
Rural
Urban
• Death Rate
Total
Rural
Urban
• Infant Mortality Rate
Total
Rural
Urban
11.83
15.00
36.8
45.8
48.1
67.2
41.9
53.3
26.1 [25.8–SRS 2000]
27.6
20.8
8.7 [8.5–SRS 2000]
9.4
6.3
70 [68 – SRS 2000]
75
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Based on (SRS Statistical Report 1998, RGI, 2001)
• Child (Below 5 years) mortality rate
• Neo-natal mortality rate
• Early neo-natal mortality rate
• Late neo-natal mortality rate
• Post neo-natal mortality rate
• Peri-natal mortality rate
• Still birth rate
• Total Fertility Rate (TFR)
• General Fertility Rate
• Age Specific Fertility Rate (ASFR)
Age group:
15-19
20-24
25-29
30-34
35-39
40-44
45-49
Gross Reproduction Rate (GPR)
Data on Human Development and Related Indicators
Based on Population Foundation of India (PFI) Data 1997
Human Development Index
Gender Health Index
Reproductive Health Index
22
45
34
11
27
42
9
3.2
106.5
54.0
220.3
182.9
104.2
54.3
25.0
9.0
1.5
37
57
43
Reproductive and Child Health (RCH) Programme in India
One of the key changes that have occurred in the RCH strategy is that it is a client centred, demand
driven, quality service approach as opposed to previous provider-centric target-based approach.
The new approach implied a paradigm shift where the National Family Welfare Programme has
undertaken a change from a narrow segregated approach in Family Welfare and Mother and Child
Health Services to that of an integrated approach in Reproductive and Child Health (RCH Approach).
One of the key changes
that have occurred in
the RCH strategy is that
RCH takes up a Life-cycle approach in addressing the issues of Women and Child Health
from birth to death i.e. from womb to tomb or from creation to cremation.
Soon after the Cairo conference (September, 1994), the Government of India
set in motion a process to translate ICPD Programme of Action (PoA) within the
it is a client centred, national context. In November, 1994, a joint mission of Government of India
demand driven, quality
and World Bank was set up to take up a sectoral review. In 1995, the World
Bank submitted the report entitled “India’s Family Welfare Programme: towards
service approach as Reproductive and Child Health Approach.” The Government of India decided to adopt
opposed to previous the policy and as a first step, in April 1996, removed method-specific contraceptive
provider-centric target-
targets nationwide (Target Free Approach – TFA). This was an essential pre-requisite
for translating the ICPD agenda in India. On October 15, 1997, Reproductive and Child
based approach. Health (RCH) programme was formally launched by the Government of India.
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Three documents shaped the content of the RCH Programme in India – the Broad recognition of
ICPD – PoA which provided an overarching frame work of Reproductive Health
and Reproductive Rights and the World bank publications “India’s Family Welfare
what is needed in
Programme: towards Reproductive and Child Health Approach” (World Bank 1995) order to move the
and “Improving Women’s Health in India” (World Bank 1996.) These documents set population agenda
the stage for a debate on the content of the Reproductive Health Programme and
encouraged planners, administrators and women’s health advocates to take a serious forward has become
look at the operational details of the concept that was agreed to. Besides the Government part of the official
of India, the World Bank, alongside UNFPA, European Commission and DFID emerged as
key players in setting the RCH agenda in the country.
The period between abolishing methods specific target in April 1996 and the formal
announcement of the RCH Programme 1997 witnessed a range of interesting activities.
language of policy
statements and
programme documents
Social demographers, health administrators, family planning organizations and women’s in our country.
health activists got involved in developing indicators and service protocols for Target Free
Approach. The Target Free Approach (TFA) Manual, later known as Community Needs Assessment
(CNA) Approach was a result of these initiatives. The contents of the Manual for CNA was
revised to actually base calculations of requirement of the community through a participatory and
consultative process with the community.
As mentioned above the period after ICPD has seen significant changes in the population
field in the country. Most important is the paradigm for thinking about the population policies
including language and concepts which has shifted away from numbers per se to issues related to
Reproductive Health. Broad recognition of what is needed in order to move the population agenda
forward has become part of the official language of policy statements and programme documents
in our country.
At the policy level this includes the enunciation of the Population Policy statement – the
National Population Policy (NPP 2000) which asserts the centrality of human development, gender
equality and equity, adolescent reproductive health and rights, among other issues to stabilizing
the country population. In the last section of the paper we would be dealing in detail about the
National Population Policy.
At the programme level the last few years have seen the evolution of broad approach of
Reproductive and Child Health involving new training, more decentralization, Community Needs
Assessment (CNA) attempts to improve infrastructure and logistics, and new partnerships with
NGOs and the private sector. We have also witnessed some innovative programmes for women’s
empowerment and rights, a renewed recognition of the role of men, and new attention to
adolescents.
RCH –Programme Strategy includes the following:
• Community participation in planning for services and prioritizing
• Client centered approach to service provision
•Upgraded facilities and improved training
•Emphasis on quality of care
• Absence of contraceptive targets and incentives
• Making services gender sensitive
• Multi-sectoral approach in implementing and monitoring services.
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Components/Elements of RCH
Essential components/elements of RCH are:
• Services to promote Safe Motherhood (Services for Pregnant Women and Lactating
mothers)
• Services to promote Child Survival (services for new born, infants and children)
• Prevention and management of unwanted pregnancy (promoting use of Contraceptive methods
among eligible couples for advocating healthy family life and responsible parenting) as well
as focus on reproductive health services for adolescents (services for adolescent girls with
emphasis on counseling on Family Life Education – FLE)
• Prevention and treatment of Reproductive Tract Infections (RTIs) and Sexually Transmitted Diseases
(STDs) (Services for women – Awareness generation and counseling about RTIs/STD/HIV/AIDS)
• Health, Sexuality and Gender-information, education and counseling.
RCH Programme
As mentioned earlier the Government of India formally announced the RCH Programme on
15th October, 1997.
Reproductive and Child health Programme continues fertility regulation, safe motherhood,
child survival, RTI/STI interventions. The programme is primarily implemented through the Primary
health care infrastructure. The overall goals of the programme are to reduce maternal and infant
mortality, morbidity and unwanted fertility and to contribute towards stabilization of population.
The programme aims to:
• Provide need-based, client centered, demand driven, high quality and integrated RCH services;
• Maximize coverage by improving accessibility especially for women, adolescent, socio-
economically backward groups, tribals, slum dwellers, with a view to promoting equity;
• Withdraw financial incentives to health providers with an objective of improving quality of care
as the incentive for utilization of services;
• Introduce a package for essential reproductive health care that includes family planning, safe
motherhood and child survival and management of RTI/STI;
•Directly finance States through the Standing Committee for Voluntary Action (SCOVA) in order
to minimize delays in implementation due to budgetary constraints;
The overall goals of
the programme are
to reduce maternal
and infant mortality,
morbidity and
unwanted fertility
and to contribute
towards stabilization of
population.
• Involve NGOs and private sector in the delivery of services; IEC/Advocacy in the Public
Sector; and
• Involve practitioners of the Indian System of Medicine (ISM) in the delivery of RCH
services to improve access to services, especially in rural and tribal areas and to
include ISM Medicines under the programme.
•The RCH package announced by the Government included the following:
• Maternal and Child health care
- 100% immunization against 6 VPD
-Elimination of neonatal tetanus and reduction of measles
- Control of diarrhea and respiratory infections
- Prophylaxis against anaemia and blindness
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-Essential obstetric care at all PHCs and EOC at 1748 identified CHCs
The RCH initiative
- Promotion of institutional deliveries
merged existing Child
• Increased access to contraceptive care
• Safe management of unwanted pregnancies; MTP facilities in all PHCs
• Nutritional services to vulnerable groups
• Prevention and treatment of RTI/STD
- Clinics to control RTI and STDs in 230 districts, in addition to 300
Survival and Safe
Motherhood (CSSM)
programme and Family
Planning Programmes
districts otherwise covered as well as in selected FRUs
and added a few
• Reproductive health services for adolescents
specific components.
• Prevention and treatment of gynecological problems; and screening and treatment of
cancer, especially that of uterine cervix and breast
• IEC for above
The RCH initiative merged existing Child Survival and Safe Motherhood (CSSM) programme,
Mother and Child Health (MCH) and Family Planning (FP) Programmes and added a few specific
components like Reproductive Tract Infection (RTI) Screening, Lab Technicians training.
The RCH Programme has been extended to all the districts of the country and is currently in
the 5th year of implementation. Besides implementing and strengthening the various activities/
interventions of the programme, efforts have been made to provide quality services to those pockets
which have been neglected so far, example tribal populations, urban slum dwellers, migrant and
displaced population. Focused attention is being paid to the initiatives of Dai training, Border
District Cluster Project, RCH Camps and RCH Outreach Services including neo-natal care. In
addition, a new project viz: Immunization Strengthening Project has been negotiated with the
World Bank and E C assisted Sector Investment Programme (SIP) has started functioning.
Findings from the RCH Household Survey Data
STATE
All India
% of births of order
3+ in the last 3 years
45.8
% use of contraception
among currently married
women
43.2
Andhra Pradesh
28.9
56.4
Assam
39.8
30.4
Bihar
57.8
21.0
Gujarat
37.2
50.8
Haryana
40.0
51.8
Karnataka
27.8
56.2
Kerala
17.9
57.9
Madhya Pradesh
45.2
45.3
Maharashtra
34.7
57.7
Orissa
46.0
38.1
Punjab
36.0
53.1
Rajasthan
51.2
35.4
Tamil Nadu
23.1
49.8
Uttar Pradesh
59.8
22.8
West Bengal
36.4
47.0
Total unmet need
for contraception
27.3
17.2
38.6
46.9
25.4
20.0
18.1
17.1
27.2
22.4
24.1
14.3
32.3
21.6
41.2
14.0
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Findings from the RCH Household Survey Data
STATE
% of pregnant women
who received any ANC
% of safe
delivery
All India
67.2
41.9
Andhra Pradesh
95.3
63.2
Assam
63.6
38.6
Bihar
30.9
18.4
Gujarat
80.3
51.6
Haryana
70.0
33.0
Karnataka
89.3
62.3
Kerala
99.5
97.1
Madhya Pradesh
58.8
30.2
Maharashtra
89.4
57.2
Orissa
79.2
31.6
Punjab
84.6
55.5
Rajasthan
52.4
32.3
Tamil Nadu
98.1
80.2
Uttar Pradesh
46.7
21.9
West Bengal
87.6
47.1
Trends in Total Fertility Rate (TFR)
% of full immunization among
children ages 12-23 months
53.3
72.8
50.6
16.8
49.8
66.6
64.9
80.3
47.3
77.7
54.9
71.6
29.8
89.5
41.7
50.3
Trends in Total Fertility Rate (TFR)
STATES
All India
Rural
NFHS-I 1992- NFHS-II 1998-
93
99
3.67
3.07
Andhra Pradesh
2.67
2.32
Assam
3.86
2.39
Bihar
4.14
3.59
Gujarat
3.17
3.03
Haryana
3.07
2.18
Karnataka
3.08
2.25
Kerala
2.09
2.07
Madhya Pradesh
4.11
3.56
Maharashtra
3.12
2.74
Orissa
3.00
2.5
Punjab
3.09
2.42
Rajasthan
3.87
4.06
Tamil Nadu
2.54
2.23
Uttar Pradesh
5.19
4.31
West Bengal
3.25
2.49
Urban
NFHS I 1992-
93
NFHS II 1998-99
2.27
2.27
2.35
2.07
2.53
1.50
3.25
2.75
2.65
2.33
3.14
2.24
2.38
1.89
2.38
1.89
3.27
2.61
2.54
2.24
2.53
2.19
2.48
1.79
2.77
2.98
2.36
2.11
3.58
2.88
2.14
1.69
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Key RCH Indicators at Two Points of Time (NFHS-I and NFHS-II)
INDICATORS
NFHS – I
(1992-93)
1. Female literacy
43.3
2. Percentage of girls married below 18
54.2
NFHS – II
(1998-99)
51.4
50.0
3. Children fully immunized (%)
(BCG, Polio 3, DPT 3, Measles)
3 (a) Coverage of individual antigens
BCG
Polio 3
DPT
Measles
62.2
72.0
53.4
63.0
51.7
55.0
42.2
51.0
4. Infant Mortality Rate
78.5
67.6
5. Three or more ante natal check up for women
44.0
65.3
6. Two or more doses of TT
55.0
67.0
7. Iron Folic Acid supplementation
52.0
58.0
8. % Safe Delivery
34.2
42.3
9. % of births of order 3 and above
48.5
45.2
10. Contraceptive Prevalence Rate
40.6
48.2
11. Sterilization
31.0
36.0
12. Spacing methods (modern) spacing methods (traditional)
6.0
4.0
7.0
5.0
13. Total Fertility Rate
3.4
2.9
14. % of women with any anaemia
NA
52.0
15. % of children with any anaemia
NA
74.2
The National Population Policy (NPP), 2000
The Government of India released the National Population Policy in February 2000 to articulate
its agenda on stabilizing the country’s population. The policy document begins with the statement
that “the over-riding objective of economic and social development is to improve the quality of
lives that people lead to enhance their well being and to provide them with opportunities and
choices to become productive assets in society”. The National Population Policy has three clearly
articulated objectives. The immediate objective is to address the unmet needs of contraception,
health infrastructure and trained health care personnel and to provide integrated service delivery
for basic Reproductive and Child Health (RCH). The medium term objective is to bring the total
fertility rate (TFR) to replacement levels by 2010 through vigorous implementation of the inter/multi
sectoral operational strategies. The long term objective is to achieve a stable population (population
stabilization) by 2045, at a level consistent with the requirements of sustainable economic growth,
social development and environmental protection.
In pursuance of these objectives, 14 National Socio-Demographic Goals for 2010 are formulated,
whose achievements are to be facilitated with the pursuit of 12 strategic themes, 16 promotional
and motivational measures for adoption of the small family norms and 102 operational strategies
or in all over 120 interventions. The 14 National Socio-Demographic Goals are the following:
i) Address the unmet needs for basic RCH supplies and infrastructure
ii) Make school education upto age 14 free and compulsory and reduce dropouts to below 20%
at primary/secondary school levels for both boys and girls
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iii) Reduce infant mortality below 30/1000 LBs
iv) Reduce maternal mortality below 100/100,000 LBs
v) Achieve universal immunization against all vaccine preventable diseases
vi) Promote delayed marriage for girls, not earlier than 18, and preferably after 20 years
of age
vii) Achieve 80% institutional deliveries and 100% deliveries by trained persons
viii) Achieve universal access to information, counseling and services for fertility regulation
ix) Achieve 100% registration of births, deaths, marriage and pregnancy
x) Contain the spread of HIV/AIDS and promote greater integration between management of
RTI (Reproductive Tract Infections) and STI (Sexually Transmitted Infections) and the National
AIDS Control Programme (NACO)
xi) Prevention and control of communicable diseases
xii) Integrate Indian Systems of Medicine in the provision of RCH services and reaching out to
households
xiii) Promote small family norm to achieve replacement levels of TFR
xiv) Bring about convergence in the implementation of related social sector programme so that
the family welfare becomes a people centered programme.
The 12 strategic themes are the following:
i)Decentralized planning and programme implementation
ii) Convergence of service delivery at village levels
iii)Empowering women for improved health nutrition
iv) Child health and survival
v) Meeting the unmet needs for family welfare services
vi)Under served population groups:
a)Urban slums
b)Tribal communities, Hill areas/migrant population
c) Adolescents
Bring about d) Increased participation of men in planned parenthood/involvement of men
convergence in the vii)Diverse health care providers
implementation of
related social sector
programme so that the
viii) Collaboration with and commitments from the Non-Government Organizations
and private sector (Public-Private Partnership i.e. PPP)
ix) Mainstreaming Indian Systems of Medicine and Homeopathy (ISM &H)
family welfare becomes x) Contraceptive technology and research on Reproductive and Child Health (RCH)
a people centered xi) Providing for the older population/elderly
programme. xii) Information, Education and Communication (IEC)
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The National Population Policy is gender sensitive and incorporates a comprehensive
and holistic approach to health and education needs of women, female adolescents
and the girl child. It also specifically seeks to address the constraints to accessibility to
services which arise due to a heavily populated geographical area and diverse socio-
cultural patterns in the population.
Stabilizing population is not merely a question of making Reproductive Health Services
accessible and affordable, but also of increasing the coverage and outreach of primary
and secondary education, extending basic amenities like sanitation, safe drinking water
and housing, empowering women with enhanced access to education and employment
and providing roads, transportation and communication. The NPP 2000 affirms the
commitment of Government towards:
•Voluntary and informed consent as the basis for availing of Family Planning Services
• A Target Free Approach in administering the Family Planning Services
A primary objective
running through the
National Population
Policy 2000 is provision
for quality services and
supplies, information
and counseling,
besides arrangement of
the basket of choices of
contraceptives.
• Improving the Health and Nutrition Status of Women
• Implementing Child Survival initiatives to bring about reductions in infant and child morbidity
and mortality
•Decentralization of planning and implementation which will promote need based demand driven,
area/location-specific, integrated and high quality Reproductive and Child Health Care services
• Addressing adolescent health related issues, ageing and HIV/AIDS.
Out of the 12 strategic themes already mentioned, the four Core themes that drive the NPP
2000 are:
• Addressing the unmet needs
•Decentralization and convergence in implementation with all other relevant social sectors
• Commitments from and collaboration with the Government Sector and Private Corporate
Sector (Public-Private-Partnership-PPP), to augment the pool of diverse health care providers
• Mainstreaming the Indian Systems of Medicine
The National Population Policy stresses the need for decentralized planning, the empowerment
of women for population stabilization, child health and survival, collaboration with the voluntary
and NGO sector, and encouragement of research in contraceptive technology.
A primary objective running through the National Population Policy 2000 is provision for quality
services and supplies, information and counseling, besides arrangement of the basket of choices
of contraceptives. People must be free and enabled to access quality health care, make informed
choices and adopt methods for fertility regulation best suited to them. It is in this spirit that the
NPP 2000 speaks of the small family norm. The National Population Policy does not envisage
any individual incentives and disincentives, which tend to become coercive. Instead the NPP
2000 envisages 16 promotional measures that may facilitate implementation of the appropriate
interventions at community levels.
As mentioned earlier, the NPP has identified the immediate objectives as meeting the unmet
needs for contraception, health care infrastructure and trained health personnel and to provide
integrated service delivery with the following interventions:
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• Strengthen Community Health Centres (CHCs), Primary Health Centres (PHCs) and Sub-
centres
• Augment skills of health personnel and health care providers
• Bring about convergence in the implementation of the related social sector programme
• Integrate package of essential services at village and household levels by extending basic
reproductive and child health care through mobile clinics and counseling services
•Explore the possibility of accrediting private Medical Practitioners and assigning them to
defined beneficiary groups to provide these services and revive the system of licensed medical
practitioners who could provide specified clinical services.
Important Initaitives Since Adoption of Npp, 2000
Maternal Health
• Promoting 24 hour delivery service at PHC/CHC
• Contractual appointment of additional ANMs, Staff Nurses and Laboratory Technicians
• Providing referral transport to indigent families for obstetrics emergencies
•Training of Traditional Birth Attendants (DAI)
• Reproductive and Child Health (RCH) Camps for improving access to services of Specialists like
Gynecologists and Pediatricians
• Providing safe motherhood consultants in PHCs/CHCs and sub-district hospital
• Providing private Anesthetists for attending to emergency obstetric cases at FRUs
•Training programme for doctors for providing anesthesia
•Development of cadres of community based nurse-midwives
• Integrated financial envelop for providing flexibility to better performing states to enable them
to design package of interventions of address problems of maternal health care.
Child Health
• Immunization strengthening activities
•Operationalization of district new-born care
• Home-based neo-natal care
• RCH-out-reach services for a remote and comparatively weaker districts and urban slums
• Border district cluster strategy
• Integrated management of childhood diseases
• Setting up of adolescent health clinics.
Contraception
• Increased choice of contraceptives
•Development of emergency contraceptives
• Community based social marketing of contraceptives.
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Involvement of NGOs
•Enhancing Public Private Partnership
• Innovative initiatives on gender sensitive issues e.g. female foeticide.
The objective of the
EAG is to enhance
and accelerate
Strengthening Primary Health Care
the performance
• Providing additional funds for strengthening sub-centres
and facilitate the
• Providing delivery kits & essential drugs.
preparation of area-
The National Population Policy (NPP), 2000 prompted setting up of a National specific programmes
Commission on Population (NCP). The NCP is presided over by the Prime Minister, with
the Central Ministers in-charge of concerned Ministries/Departments, the Chief Ministers in States that have
of all States and UTs, reputed demographers, public health professionals and NGOs as
members. The Commission is to oversee the implementation of the National Population
Policy. The NCP in its first meeting announced the formation of an Empowered Action
Group (EAG) to focus on States that have below average socio-demographic indices.
been lagging behind in
containing population
growth to manageable
An Empowered Action Group has been constituted in the Ministry of Health and Family limits.
Welfare, Government of India, comprising of 28 members under the chairmanship of the
Minister of Health and Family Welfare. The objective of the EAG is to enhance and accelerate the
performance and facilitate the preparation of area-specific programmes in States that have been
lagging behind in containing population growth to manageable limits. The States which are the
focus of attention of the EAG are the so-called eight weak States in terms of socio-demographic
indicators viz., (1) Uttar Pradesh, (2) Bihar, (3) Madhya Pradesh, (4) Rajasthan, (5) Orissa, (6)
Uttaranchal, (7) Jharkhand, and (8) Chhattisgarh.
There is a compelling need to take the National Population Policy forward by drawing up on
State Specific Population Policies within the framework of NPP 2000. Some States have formulated
Population Policies which are framed in the old Population Control mind-set and have set targets
for lowering fertility within a specified time-frame. The driving force in some of these policies
are demographic targets, population control objectives and disincentives and do not reflect the
major paradigm shift in thinking on population issues. Fortunately, not all States appear to be
supporting such draconian approaches. The Central Government has urged the State Governments
not to introduce coercive methods in their population policies. The need of the hour is that the
State Governments should formulate their State Specific Population Policies which should be in
consonance with the ICPD-PoA and NPP 2000, while taking into account local priority issues of
the State.
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Population Policy: An Overview
A R Nanda
…………. I had a long stint in the government. When I speak on the population policy, I have
little trepidation because I know that the policy, which has been framed, is at best – a compromise.
A compromise between what the people perceive as their needs and what the government in its
wisdom perceives, as a requirements, to meet those needs.
Government of India formulated the ‘National Population Policy’. It was laid before the
Parliament, was discussed at length, and it is supposed to have the consensus of all political
parties, which were at the national scene at that time. Before this policy was formally announced,
it had the necessary consultation with the experts and various state governments. Thus, this policy
seems to have gone through an evolutionary process.
The evolution of population stabilization efforts in India by government goes back to the onset
of five year development plans in 1951-52. The first such policy was launched in the form of a
Programme in the year 1952, which was called as the ‘National Family Planning Programme’
and henceforth India became the first country to officially declare a National Family Planning
Programme. In fact, China that went through the Communist Revolution in 1950s, borrowed a
few things from our Programme, but they administered it in a different manner under the Maoist
era. They adopted an equitable social development approach to tackle their population problem.
They started with the premise that – ‘population is our biggest asset’ and took many benign
measures of social development. So they looked at their people, even if they were many, as an
asset, whereas in India we started looking at our people, right from the year 1952, as liability. And
this remains the basic difference between the approaches adopted by these two countries.
We all talk about emulating the Chinese model. They in fact have solved their population problem,
but they did not solve it through ‘one-child norm’. One-child norm came much later in the year 1979
and China, between the years 1949 to 1979, followed an equitable, social development approach
If we really want to – a people’s approach. But in India we seem to have lost that opportunity. If we really
want to emulate China, we must follow their social developmental approach, which they
emulate China, we adopted to stabilize their population. India is a democratic country. So our approach has
must follow their to be slightly different and well within the democratic four walls.
social developmental
approach, which they
adopted to stabilize
their population.
In India, an apex committee known as ‘Family Planning Research and Programme
Committee’ was set up which sat for its first meeting at Bombay in July 1953. It took
quite a comprehensive and broader view of the family planning issue. It suggested
that family planning should not be conceived of in the narrow sense of birth control
or merely of spacing of the birth of children and we must adopt a holistic approach
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towards the problem. It vouched for opening Family Planning centers at different
places for sex education, marriage counseling, marriage hygiene, planned parenthood
and many other things including infertility issues, because fertility is as much an issue
as fertility control. Keeping all this in view, the committee gave its recommendations
The Chinese are
reviewing their policy
and looking at the
in the year 1953.
possibility of having
China took due note of these recommendations and started looking at the basic a law against sex
needs of the people such as marriage counseling and many other things, other than
pure contraceptive measures. Thus, People’s needs and state’s needs converged and
determination.
as a result of this a cultural revolution got initiated in which academicians, bureaucrats and
service providers were asked to go and work with the peasants. We never had any such thing
conceptualized and being implemented in India. So the path, which China took, was more
suitable to look into the basic needs of the masses, and they witnessed a tremendous rise in
women empowerment, equitable access to health, education and income. All this had a direct
effect on the fertility rate, and as a result the birth rate fell down sharply by 1979. Thus, it’s
clearly visible that the basic concept of family planning services that China followed was in tune
with what the Bombay meeting has envisaged.
In the year 1979 when Mao Tsetung was out from the Chinese scene, there came a paradigm
shift in their approach. With the contagion of western education, the threat perception of
growing numbers took deep roots in the mindset of some Chinese scholars and leaders. Some
people who went to US to pursue higher education backed the idea that China needs to control
its population and they advocated many restrictive population policies like the ‘One-Child policy’
and this development marked and brought about a paradigm shift in their whole approach
towards population control. The results were disastrous which created more societal and family
problems like skewed sex ratio, increased crime against women, female infanticide and foeticide,
rather than helping in smooth stabilization of population. And now the Chinese are reviewing
their policy and looking at the possibility of having a law against sex determination.
There are thus lessons to be learnt from the Chinese experience in governance. We tend
to misrepresent the Chinese story, whenever we compare the Indian situation for advocating
coercive population policies like the ‘Two-Child Norm’ and the concomitant regime of incentives
and disincentives to solve our population problem quickly.
It’s a pity that our policy makers and bureaucrats paid a lip service to the rational and sane
advice of the Family Planning Research and Programme Committee and instead, adopted a
top-down contraceptive programme with targets of sterilization. A separate Department of
Family Planning was created in the Health Ministry and a centrally sponsored ‘target oriented’
programme was launched from 1966 providing for financial incentives for sterilization acceptors.
Although later on, the programme was integrated with maternal and child health and further
with health and nutrition, the primary objective was to achieve targets of male and female
sterilization. All this has done more harm than good.
The various Committees formed before and after independence have clearly emphasized on
adopting a comprehensive approach of primary health care, with no compromises to be made in
this regard. The perception of the families and that of the state must converge, when it comes
to acceptance of a small family norm. Peoples’ needs must be understood and addressed in
a holistic manner and they will voluntarily accept family planning. But unfortunately, we are
again coming back to targets.
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National Population Policy 2000
With this scenario, I will now place the National Population Policy 2000. There are seven state
policies which are not in tune with the NPP. These states have introduced various incentives and
disincentives in their respective policies which are not in tune with the NPP. Hence by and large,
their approach is different from what the national population policy envisages.
National Population Policy is the affirmation and articulation of India’s commitment to
International Conferences on Population and Development agenda. It forms the blue-print for
Population and Development Programmes in the Country. The Cairo conference, wherein for the
first time a consensus among many countries including India was reached at, was a remarkable
development in many ways. The ICPD, 1994 successfully adopted a Programme of Action,
which constituted a paradigm shift in thinking and action on population issues globally and in
each participating country’s context including India. Though India is yet to fully incorporate the
provisions of this convention in its domestic laws, but by virtue of their country being a signatory
to this international convention, the civil society has a moral right to ask the government not to
deviate from its commitment to ICPD agenda.
The National Population Policy, which was formulated and announced in February 2000, is
the first ever comprehensive and holistic population policy of the country. The NPP envisages
overall economic and social development as the goal to improve the quality of life of the
people, to enhance their well being and to provide them with opportunities and choices with
a comprehensive, holistic and multi-sectoral agenda for ‘population stabilization.’ It envisions
population stabilization as a function of accessible and affordable reproductive health; increased
coverage and outreach of primary and secondary education; assured availability of basic amenities
like sanitation, safe drinking water and housing; women empowerment with enhanced access
to education and employment; and infrastructural development like roads and communication.
Thus, it promotes a more open information, awareness, empowerment and development based
approach and sums up ‘population stabilization’ as a multi sectoral endeavour. In principle, it
unequivocally rejects the targets and the incentive/disincentive approaches and provides for a
Target-Free Approach (TFA).
The NPP is gender sensitive and incorporates a comprehensive holistic approach to health and
education needs of women, female adolescents and girl child. A primary theme running through
the NPP is provision of quality services and supplies and arrangement of a basket of choices i.e.
people must be free and enabled to access quality health care, make informed choice and adopt
measures for fertility regulation best suited to them.
Objectives of the NPP
A primary theme
running through the
NPP is provision
of quality services
and supplies and
arrangement of a
basket of choices
The immediate objective of NPP is to address the unmet needs of contraception,
health infrastructure, and trained health care personnel and to provide integrated service
delivery for basic reproductive and child health care. Its mid term objective is to bring the
Total Fertility Rates (TFR) to replacement levels country-wide, by 2010 through vigorous
implementation of multi-sectoral operational strategies. And its long term objective
includes bringing about population stabilization by 2045, consistent with the requirements
of sustainable economic growth, social development, and environmental protection.
It envisions achieving universal access to information, counseling and services
for fertility regulation; 100% registration of births, deaths, marriages and pregnancy;
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containing the spread of HIV and promote better integration with the National AIDS
Control Organization (NACO); managing reproductive tract infections (RTI) and sexually
transmitted infections (STI); mainstreaming Indian systems of medicine; promoting
‘small-family norm’ to achieve replacement levels of total fertility rate (Small-family norm
is not two-child or one-child norm but could be anywhere between having one to five
children. It depends on the necessity, needs and requirement of a family); and to bring
about convergence in the implementation of related social sector programmes so that
family welfare becomes a ‘people centered programme.’
As far as contraceptive
technology and
research on
reproductive and child
health is concerned,
we have excellent
Strategic Themes
research going on and
The implementation of the strategies and Action Plan of the NPP requires a
transformation in the mindset and style of functioning of the bureaucrats, technocrats
and service-providers vis-à-vis the approach to population issues, accountability, planning,
monitoring and coordination. The most important strategy is decentralized planning and
programme implementation. In India, we have more than 620 districts, around 6,38,000
villages and 4000 cities and towns. Under the decentralized planning and programme
some of the products
have already been
released into the
market.
implementation there will be a separate annual plan for every village, every ward of a city/town,
wherein the health service people, ICDS and others will work together. There will be a house-to-
house survey of each family. During these social audits, they will assess the specific needs and
requirements of each family – relating to infertility, death due to diseases and other problems and
the contraceptive requirement best suited to them. All the plannings for effective implementation at
the community level will be done by the elected representatives of panchayats/gramsabhas (PRIs) of
that village and they will ensure a proper assessment of the needs for health, education, nutrition,
reproductive health and family planning within that village. This plan is known as ‘Community needs
assessment’ through participatory methods.
Such holistic plan for health, population and social development is to be prepared for each
village and each ward. And the district plans, state plans and the central plan should be based on
the community level plans reflecting the perceived needs of each family and each community.
Even under the current CMP, if the sharply targeted population control measures remain and we
supplant them further with village/ward/town specific community plans and don’t impose a target
set by either the central or state or local government, it will become a ‘people’s programme.’
Apart from decentralized planning and implementation, other important strategies involve
convergence of service delivery at village levels; empowering women for improved Health and
nutrition; Child survival and Child health; meeting the unmet needs for family welfare services;
special strategy for under-served population groups, namely, urban slums, tribal communities, hill-
area population and displaced and migrant populations; adolescents; increased participation of
men in planned parenthood; diverse health care providers; collaboration with and commitments
from NGOs and the private sector; mainstreaming Indian systems of Medicine and Homeopathy;
contraceptive technology and research on reproductive and child health; providing for the older
population; assuring information, education and communication.
As far as contraceptive technology and research on reproductive and child health is concerned,
we have excellent research going on and some of the products have already been released into
the market. The non-hormonal male contraceptive known as ‘RISUG’ is a good example of the
ingenuity of Indian scientists. There are many other such products like ‘Saheli’ etc., which are
again non-hormonal and thus safe from the health stand point for women.
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Providing for the older population is one of the immediate concern areas. The Census has just
brought out that 7.6% of our population is in the age group of 60 years and above. It clearly
indicates that out of the 100 crores, roughly around 8 crore people are in this age bracket. The
average life span has increased due to direct intervention of modern science and technology and
people are living longer particularly, widowed women. We have to look after them.
……… I apologize if I have cast out some aspersions, but since I was part of the government
and have seen the functioning from very close quarters, I know that we had many failings. But
I am happy to see that the present CMP has brought out an excellent blue print for effective
implementation of policies, barring that particular sentence which talks about population. I am
hopeful that the Tribunal will take a view on that and would suggest the government not to go
in for a strategy which will kill the comprehensive Primary Health Care approach. Anything that
has to be strategized has to be within People’s Health Mandate. Only then could the efforts at
population stabilization proceed on a smooth course, and would turn into a people’s movement
producing desired results.
(This write-up is based on the Expert Address delivered by the author at the People’s Tribunal
on ‘Coercive Population Policies and Two-Child Norm’, at New Delhi in 2004.)
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Population and Development:
Myths and Realities*
Almas Ali
During the last five decades India’s population increased from 360 million in 1951 (around
the time of Independence) to over 1,020 million in 2001. This growth in India’s population has
become a source of concern for everyone - politicians, public leaders, administrators, bureaucrats,
development planners, public health experts, demographers, social scientists, researchers and
the common man. It is often being stated that uncontrolled population explosion is responsible
for holding up India’s progress and economic growth and acts as a significant hindrance to the
country’s development.
The important question therefore, that demands an answer is: is India currently going through
a “Population Explosion”? This question admits of the simple answer - definitely NOT. In order to
justify this answer some basic issues need to be considered.
Population growth: Population growth occurs naturally and has taken place everywhere in all
regions of the world and India is no exception. In order to understand this in its correct perspective,
there is a need to understand the concept of demographic transition. The theory of demographic
transition is usually presented in terms of three stages of demographic evolution:
• First stage of high birth rates and high death rates (high balance),
• Second (intermediate) stage of high birth rates and low death rates (high rate of natural
increase), and
•Third stage of low birth rates and low death rates (low balance).
With the advancement of economic and material progress, education, women’s empowerment
and availability of contraceptives, birth rates start declining slowly at first and rapidly thereafter,
and soon a stage is reached (that is, the third stage) where birth and death rates are equal
once again (low balance). This cycle of changes, which occurs in any population, is known as
demographic transition. The second (intermediate) stage of development is characterised by high
rates of natural increase as a result of faster decline in death rates (mortality) with birth rates
maintaining their initial high levels.
In the second half of the 20th century, the world witnessed an unprecedented growth rate. The
world’s population doubled from 3 to 6 billion in less than 40 years between 1960 and 1999. It
* This paper was published in NFI Bulletin Volume 25 Number 1, January 2004.
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increased from 5 to 6 billion in just 12 years (from 1987 to 1999) while it had taken four times as
many years to double from 1.5 to 3 billion and nearly a millennium to reach the first billion. What
triggered this growth in the second half of 20th century starting from 1950 onwards, shortly after
the Second World War, was the rapid and steep fall in the death rates. This sudden decline in death
rates (mortality) was primarily the result of advances in health technology (including the discovery
of antibiotics), and public health interventions. Knowledge acquired in curbing the spread of killer
diseases and epidemics was transferred to the developing countries whose natural growth rate
was governed by high mortality and high fertility. As a result, the death rates fell drastically, while
fertility and birth rates maintained their high levels. This resulted in an unprecedented high level
of natural growth.
India was no exception to this phenomenon: with sharp declines in death rates brought about
by advances in health technology, while birth rates continued to remain high. India had also
witnessed a phase of rapid growth in population from 1951 to 1981.
This concern of excessive demographic increase and its social, economic and, perhaps, geo-
political ramifications triggered and impelled the international community to focus on slowing
down the population growth by implementing what was then called population control or family
planning programmes. During the mid-1960s in the deliberations of Club de Rome the Malthusian
inspired-term “population explosion” was coined. However, this term is no longer used as it has a
negative connotation.
Table : Population growth trends from 1951-2001
Years
Total
Absolute
population increase in
in crores crores
1901-1951 23-44
13
Decadal
Growth
rate
-
Average Phase of demographic
annual
transition
exponential
growth rate
-
Near stagnant population
1951-61 36-44
8
+ 21.6 % 1.96 %
High growth
1961-71 44-55
11
+ 24.8 % 2.22 %
Rapid High growth
1971-81 55-68
13
+ 24.6 % 2.20 %
1981-91 68-84
16
+ 23.9 % 2.14 %
High growth with definite
1991-2001 84-102
18
+ 21.3
1.93 %
signs of fertility decline
It will be seen from the above Table that the total population of India which was little over 360
million in 1951 grew to about 440 million in 1961 and to about 550 million in 1971. During the
decade 1951-61 absolute increase in population was about 80 million, the decadal growth rate
was 21.6 per cent and average annual exponential growth rate was 1.96. The period between
1961-71 recorded the highest ever-decadal growth rate of 24.8per cent with a corresponding
average annual exponential growth rate of 2.22 with an absolute increase of about 110 million. The
period between 1971 and 1981 recorded a marginal decrease in decadal growth rate from 24.8 per
cent in 1961-71 to 24.6 per cent in 1971-81. The decadal growth rate declined from 24.6 per cent
in 1971-81 to 21.3 per cent in 1991-2001; so did the average annual exponential growth rate from
2.20 to 1.93. We are, therefore, now actually witnessing a progressive decline in fertility.
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Myths and Realities
Some myths and realities with respect to India’s population growth now need to be
considered.
Myth: India is currently going through a “population explosion”.
Reality: In fact, India’s population growth rate has been declining steadily over the last two
decades since 1981.
•The decadal growth rate during 1991-01 represents the sharpest decline since Independence
(even less than +21.6 per cent during 1951-61).
•The average Annual Exponential Growth rate is also declining, that is, 1971-81: 2.20 per cent;
1981-91:2.14 per cent; 1991-2001: 1.93 per cent.
In fact, this indicator is also the lowest since Independence (even less than 1.96, during 1951-61).
• Fertility has also declined. Total Fertility Rate (TFR), that is, the average number of children a
woman would have, has come down from six in 1951 to 3.2 in 2001. Now couples have fewer
children and opt for smaller families.
• For the first time in the 2001 Census, the proportion of children under six years has also come
down - a clear indication of the fertility decline. If this is the case, why is the overall population
growth in India still apparently high?
Population numbers are growing because of what is called “Population Momentum”. Past
trends in fertility and mortality (high fertility and low mortality) from 1951 to 1981, had shaped
the population age structure in such a way that there is a tremendous in-built growth potential
which has resulted in the “bulge” in the proportion of young people in the prime reproductive
ages. Moreover, improvement in general mortality conditions in the aged population and increase
in life expectancy has helped to accelerate in-built growth. In short, India has a high proportion of
young persons (over 60 per cent) who are in the reproductive age group or will soon be so. Even
if this group produces fewer numbers of children (just two or even one) per couple the “quantum
increase” in numbers will be high because the number of reproductive couples is high. Again, we
should remember that the “quantum increase in numbers” will continue to be high for some more
time (that is, 20-30 years) because of the phenomenon of “Population Momentum”. India, with
its large proportion of young persons, will take some time before the results of declining fertility
start showing explicitly.
Myth: India’s population is growing because uneducated rural poor families have more
children now than they had 50 years ago, while the educated urban middle class has controlled
its family size.
Reality: The fact is that family size and number of children across all population groups, poor
or middle class, rural or urban is declining. Both rural and urban people have roughly 44 per cent
fewer children compared to a few years ago. Comparison between urban and rural TFR shows that
while urban women now have 1.7 children less, the rural women have 2.1 children less than they
had 30 years ago (TFR: rural 5.6, urban 4.1 in 1970 and rural 3.5, urban 2.4 in 1999).
Myth: Poor people have more children because they do not appreciate the benefits of family
planning.
Reality: The poor often have large unmet needs for contraception. In some poorer states
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unmet needs for contraception are as high as 25 per cent. The desire for family planning has
increased in poor families.
Myth: Since India’s Independence, population growth has overtaken food production.
Reality: Food production since Independence has also increased over four times (from 50
million metric tonnes in 1951 to over 200 million metric tonnes in 2001), while population growth
has been a little less than three times (from 36 crores in 1951 to 102 crores in 2001).
Myth: India’s large population is the real reason for high levels of poverty, low per capita
income and slow economic growth.
Reality: A country is not poor because it has too many people. By rapidly lowering birth rates
and reducing fertility we cannot eliminate poverty and improve standards of living. Bangladesh,
for instance, reduced its TFR rather dramatically from almost 7(6.8) to 3.1 during 1975-98, but this
has not alleviated poverty. In Kerala and Tamil Nadu, the TFR is below replacement level and yet we
cannot say that there is no poverty in these states. China has a much larger population and its per
capita income is almost twice that of India. Again, if we compare with China, between 1975-95,
China’s per capita GNP grew annually by almost 8 per cent while India’s grew only by 3per cent
during the same period.
The stark reality is that income levels and growth depend on how well the state treats its
people, how well it invests in its people, in their education, health, nutrition and their well-being
to improve their quality of life. On the contrary, the state’s failure to provide basic services such as
health, education, etc, is attributed again to population growth and large population size.
Myth: There is a real shortfall of resources due to the large population.
Reality: The fact is that India has sufficient resources but it is the skewed distribution system
which has caused gross inequalities.
Myth: Natural resources are getting depleted because of high population growth of the poor.
Reality: Natural resource depletion depends on two factors: the number of consumers, and
the rate and pattern of consumption. If everyone consumes the same quantity of natural resources
then the total use or exploitation of natural resources would depend on numbers only. And the
poor being more in number would cause greater damage. But the consumption rates of rich
individuals/countries are far higher than that of poor, be it food or natural resources such as water,
petroleum, forest produce etc. The richest 20 per cent consume up to 70 per cent of the world’s
resources, while the poorest 20 per cent hardly get 10 per cent. It is estimated that a child born to
a rich family consumes 30 to 50 times more resources than a child born to a poor family. So who
is really degrading the environment? Not the poor, of course.
Myth: The quickest results in speeding population stabilisation can be achieved through a
coercive/authoritarian approach like China’s One Child Policy or imposing a two-child norm.
Reality: While it is true that China has brought down its population growth rate remarkably,
even more remarkable drops in the growth rate occurred in Kerala over the same period (China’s
TFR 2.8 in 1979 dropped to 2.0 in 1991, while Kerala’s TFR of 3.0 in 1979 dropped to 1.8 in
1991) and that too without any coercion. Also, much of the growth rate reduction in China took
place between 1970 and 1979, before the introduction of the One Child Policy. The decline in
China’s growth rate has its roots in increasing education access, improvement in economy and in
the status of women which took place after the Communist Revolution and before the One Child
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Policy was introduced. And so, it is not entirely clear how much of China’s fertility decline can be
actually attributed to the One Child Policy alone.
Myth: Economic prosperity is the only way to population stabilisation.
Reality: Kerala, for instance, does not have a very strong economy, but it enjoys the best
development indicators and has gone much below the replacement level TFR and stabilised the
population. The same is the case with Tamil Nadu. Haryana, on the other hand, has a much better
economy but lies far behind in matters of social development and population stabilization.
Myth: Low population density ensures economic progress and states with high density of
population are poorer.
Reality: States with low density such as Rajasthan are very poor, while high density states
such as Karnataka are economically better off. So, no direct relationship can be drawn between
population density and economic progress.
Myth: India’s cities are more crowded now because of increasing birth rates in the slums.
Reality: This is not true. Birth rates have declined both in villages and slums as well. The
growth of slums has no doubt increased, but this is a result of wrong economic policies.
Myth: The two-child norm is not only useful from a population and development point of view
but is also good for women’s health.
Reality: The two-child norm has to be understood in the context of son preference, a common
feature of Indian society. If the Government imposes a two-child norm, there will be widespread
sex-selection and sex-selective abortion of the female foetus resulting in increased abortion-
related health risks for women.
Myth: Checking population growth is the main objective of India’s National Population
Policy.
Reality: In fact, the over-riding concern of the National Population Policy is economic and
social development, to improve the quality of lives people lead, to enhance their well-being and to
provide them with opportunities and choices to become productive assets in society. This is possible
by providing quality health services and supplies, information and counseling. In addition, arrange
for a basket of contraceptive choices to enable people to make informed choices and access
quality health care services. The National Population Policy’s long-term objective is to achieve a
stable population which is consistent with “sustainable economic growth, social development and
environmental protection”.
Population stabilisation is not a technical problem requiring a technical solution. The answer
does not lie in pushing sterilisations and chasing targets. For population stabilisation, it is important
to improve people’s access, particularly women’s access, to quality health care. Women must have
access to both essential and emergency obstetric care. The contraceptive mix needs to be enlarged
and expanded. There is also a need to revitalise community-based health initiatives.
We are now discovering that the obvious route to population stabilisation is through social
development, through women’s empowerment, through greater gender equality. Women’s
empowerment is critical to human development.We also know that there exists a direct relationship
between infant mortality and fertility. Reducing IMR and child mortality are, therefore, important
to reduce population growth and ultimately stabilise population. Interventions for improving
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child survival are well known. They are the following: better education, improved access to quality
health care, better nutrition, better employment opportunities, higher earnings, safe drinking
water and better sanitation, etc. Interestingly enough, these are the very same interventions which
are also required for empowering women, improving the quality of life and for stabilising the
population.
Curbing population growth cannot be a goal in itself. It is only a means to development. If
development can help in stabilising the population, truly that is a much better and superior solution
to one where population growth is curbed in the hope that development will automatically follow.
Therefore, improvement of health and nutrition, on the other hand, can be an end itself and will
lead to population stabilisation. Surely, this is a better approach. This has been accepted in principle
in the National Population Policy (NPP) 2009. It believes that people are the most valuable and
precious resource of our country and the common agenda of both population stabilisation and
development is the well-being of the people. Unless the mindset of people who matter changes,
the NPP will remain in paper and cannot be implemented in its true spirit. It is high time, that we
stop counting people and instead start counting on people. Public action is required to expand
people’s capabilities, to enlarge opportunities and choices, to invest on social sectors such as
education, health, nutrition, etc, and to promote women’s empowerment. The simple mantra of
population stabilisation is “take care of the people and population will take care of itself”.
References
1. Population growth and demographic transition- fact sheet in “Population Stabilsation and Sustainable development:
Media brief”: Department of Family Welfare, MoH&FW, GOI and UNFPA, New Delhi, 2002.
2. Francois., M. Farah: From Maternal and Child Health (MCH) to Reproductive Health (RH) - Beyond the Semantics,
Mimeographed August, 2002 (unpublished).
3. Ali, Almas: Population scenario of India and National Population Policy: An overview in the book Population
Stabilisation. Ed G.Patnayak, The Universe: International Cultural Society, Cuttack, 2002
4. Nanda, A.R.: Not just a numbers game. 511, Seminar, March, 2002.
5. Census of India 2001: “Provisional totals: Paper 1 of 2001” Registrar General and Census Commissioner, India, New
Delhi, 2001.
6. Population, Myths and Misconception, Department of Family Welfare, MoH&FW, GOI & UNFPA, New Delhi, 2002.
7. Population: Questions and Answers: Department of Family Welfare, MoH&FW, GOI & UNFPA, New Delhi, 2002.
8. Ali, Almas: Background note on “Two Child Norm and Realities of Population Stabilisation” - prepared for the
MoHFW, GOI Mimeographed, September 2002 (unpublished).
9. National Population Policy: Ministry of Health and Family Welfare, Government of India, New Delhi, 2000.
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Women and
National Population Policy
Almas Ali
Women’s heath for long was only important as far as her child-bearing capacities
were concerned, and thus there was a focus on maternal health. The whole concept of
reproductive health emerged as a departure from this narrow approach. There has been a
growing understanding that the subordinate status of women in society deeply influences
The gender difference
between men and
women affect their
their health status. In many societies the principal responsibility of women is restricted health in different
to childbearing, and this is at the expense of economic, social and political participation
in the family or community. This over-emphasis on the biological aspect has led to such ways. At one level
situations as early marriage and repeated child-bearing and its attendant complications. these differences
Son preference, another strong trait of Indian society has led to the heinous practice of
sex-selective abortion and repeated abortions and its attendant complications.
Women’s workload in many places is considered minimal, but a careful daily analysis
reveals that women hardly have a moment to spare in the course of the entire day while
lead to difference in
the incidence and
prevalence of ill health.
men are entitled to their share of relaxation after a days hard work. Women’s subordinate status
has also led her to be an easy target of family planning programmes in our country with the bulk of
sterilizations being tubal ligation operations. To add to the situation described above women have
very little autonomy to decide what they should do for keeping healthy. Many women’s reproductive
health issues, which are related to her genitals are considered dirty and shameful and hence women
not only feel uncomfortable in openly discussing their problems, but they refuse treatment from
male medical providers. Medical providers, themselves are products of the society in which they live
and thus carry with them the usual social and cultural biases regarding women and their abilities.
The gender difference between men and women affect their health in different ways. At
one level these differences lead to difference in the incidence and prevalence of ill health. They
also manifest in the response of the family and community towards the person, response of the
individual to her/his own health condition, in the accessibility and availability of treatment and
health services and finally at the level of health outcomes.
Despite the socially prescribed, acknowledged and encouraged difference in the status of
women and men, the principles of universal human rights, as well as the Indian Constitution
upholds the equality of women and men. Gender equality is thus an ideal that is not only universal
Lecture delivered on Women and National Population Policy in India, - at the first three week refresher course in Gender studies at
Academic Staff College, Jamia Millia Islamia on 14th February 2006.
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but also constitutionally and legally binding in India. It is important to note that gender equality
and human rights are two of the core principles of the reproductive health approach.
Sources of Health Related Rights
Indian Constitution – Article 14, 15, 16, 21, 39, 42, 47
Indian Laws – Selections of the IPC, Child Marriage Restraint Act, MTP Act, PNDT Act
etc.
Policies – National Population Policy, National Policy on the Empowerment of Women,
National health Policy, National Youth Policy etc…
Programs – RCH Programme, other national programmes
International Law and Agreements – Rights to Health – The International Covenant on
Economic, Social and Cultural Rights (ICESCR), The Convention on the Elimination of All
Forms of Discrimination Against Women, (CEDAW), and The International Conference on
Population and Development – Programme of Action, (ICPD-PoA).
In India, Women have been the central targets of the Family Planning Programmes from the late
1960s and yet their reproductive health needs were neither acknowledged as a Policy Concern
nor set within an overall integrated approach to their health.
It was only after
•Vienna conference on Human Rights, 1993
• International Conference on Population & Development
(ICPD), 1994 and
• 4th World Conference on Women, Beijing, 1995,
That the health sector in India witnessed a paradigm shift in the sense of Locating Health
within a comprehensive framework of
• Poverty reduction
• Women’s empowerment
• Reduced social inequalities
•Economic growth and women’s rights to better health, choice and safetly in reproduction.
Family Planning concerns were expanded into broader reproductive health care.
The paradigm shift in the National Population Policy is in line with ICPD ethos of meeting
reproductive health needs of individuals and couples.
It is important to
note that gender
equality and human
rights are two of the
core principles of the
reproductive health
approach.
The International Conference on Population and Development (ICPD) was a milestone
in the history of population and development as well as the history of women’s rights.
It heralded a paradigm shift in the approach to population and development, placed
women’s equity and equality centre stage and introduced the importance of rights based
programming.
The ICPD has been instrumental in forwarding the notion that population and
development programmes recognize that the concept of reproductive health care
encompasses more than just family planning services. Moreover, it declares that
reproductive health and reproductive rights cannot be realized without a concomitant
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fulfillment of women’s human rights. That both sets of rights are interlinked and
must be advocated in tandem and that empowering woman is crucial to successful
population and development programmes are ideas mainstreamed by the ICPD.
ICPD - PoA is a shift in policy focus away from “population control” rationales and
objectives in favour of women’s reproductive health and rights within a broad primary
health care context.
With the shift
in International
perspective influenced
by the ICPD, the
government reflected
Drawing from the ICPD – PoA, the most positive feature of the NPP is that it resolutely
affirms the commitment of government towards “voluntary and informed choice and
consent of citizens while availing of reproductive health care services, and continuation of
the target free approach in administering family planning services”. These commitments
for human rights and the freedom and dignity of women were translated into a non-
targeted family welfare programme, which rightly abjures incentives and disincentives.
its change of approach
in the NPP, 2000 by
eliminating the use of
targets.
The National Population Policy, 2000 (NPP, 2000), takes its basic philosophy from ICPD PoA
and from the concerns of women’s organizations in the country thereby taking into consideration
the changing understanding on population, reproductive health, equity and rights. With the
shift in International perspective influenced by the ICPD, the government reflected its change
of approach in the NPP, 2000 by eliminating the use of targets. It is a significant step forward
and reflects a shift from the earlier demographically driven, target oriented policies to one
that addresses special concerns of reproductive health. The NPP is in fact an affirmation and
articulation of India’s commitment to the ICPD agenda, and forms the blueprint for population
and development related programmes in the country. The NPP, 2000 is also a significant move
towards a humane and effective development policy aimed at improving the overall quality
of life by promoting better awareness of and access to health care options with a focus on
women. It is in fact the first big step in the country’s effort to look at population issues from
the perspective of social development and is the reference point for India’s current rights based
approach to the subject.
The NPP is gender sensitive and incorporates a comprehensive holistic approach to health and
education needs of women, female adolescents and girl child.
The National Population Policy: An Overview
The NPP, 2000 starts with a premise that “the overriding objective of economic and social
development is to improve the quality of life of people, to enhance their well-being and to
provide them with opportunities and choices to become productive assets in society.” It also
states in no uncertain terms that stabilizing population is not merely a question of making
reproductive health services available, accessible and affordable, but also increasing the
coverage and outreach of primary and secondary education, extending basic amenities like
sanitation, safe drinking water, housing and empowering women with enhanced access to
education and employment. It very clearly recognizes the close inter-relationship and two-way
linkage between population stabilization and socio-economic development and enunciated
goals and strategies – both social and demographic – which would have to be simultaneously
pursued in a synergistic manner.
The NPP, 2000 provides a policy framework for advancing goals and prioritizing strategies to
meet the reproductive and child health needs of the people of India.
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Objectives
The immediate objective of the NPP, 2000 is to address the unmet needs for contraception,
health care infrastructure, and health personnel, and to provide integrated service delivery for basic
reproductive and child health care. The medium term objective is to bring the TFR to replacement
levels by 2010, through vigorous implementation of inter-sectoral operational strategies. The
long term objective is to achieve a stable population by 2045, at a level consistent with the
requirements of sustainable economic growth, social development, and environmental protection
In pursuance of these objectives, the following National Socio-Demographic Goals to be
achieved in each case by 2010 are formulated:
National Socio-Demographic Goals for 2010
1. Address the unmet needs for basic reproductive and child health services, supplies and
infrastructure.
2. Make school education up to age 14 free and compulsory, and reduce drop outs at primary and
secondary school levels to below 20 percent for both boys and girls.
3. Reduce infant mortality rate to below 30 per 1000 live births.
4. Reduce maternal mortality ratio to below 100 per 100,000 live births.
5. Achieve universal immunization of children against all vaccine preventable diseases.
6. Promote delayed marriage for girls, not earlier than age 18 and preferably after 20 years of
age.
7. Achieve 80% institutional deliveries and 100% deliveries by trained persons.
8. Achieve universal access to information/counseling, and services for fertility regulation and
contraception with a wide basket of choices.
9. Achieve 100% registration of births, deaths, marriages and pregnancies
10. Contain the spread of Acquired Immunodeficiency Syndrome (AIDS), and promote greater
integration between the management of reproductive tract infections (RTI) and sexually
transmitted infections (STI) and the National AIDS Control Organizations.
11. Prevent and control communicable diseases.
12. Integrate Indian Systems of medicine (ISM) in the provision of reproductive and child health
services, and in reaching out to households.
13. Promote vigorously small family norm to achieve replacement levels of TFR.
14. Bring about convergences in implementation of related social sector programmes so that family
welfare becomes a people centered programme.
Strategic Themes
We identify 12 strategic themes which must be simultaneously pursued in “stand alone” or
inter-sectoral programmes in order to achieve the national socio-demographic goals for 2010.
These are presented below:
1.Decentralized planning and programme implementation.
2. Convergence of service delivery at village levels.
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3. Empowering women for improved health and nutrition.
The situation of
4. Child health and survival.
5. Meeting the unmet needs for family welfare services.
6.Under-served population groups:
•Urban slums;
•Tribal communities, hill area population and displaced and migrant populations;
• Adolescents;
• Increased participation of men in planned parenthood
7.Diverse health care providers.
8. Collaboration with and commitments from non-government organizations and the
private sector.
women in terms of
their condition and
position needs to be
understood in the
larger socio-economic,
cultural and political
framework of the
country.
9. Mainstreaming Indian Systems of Medicine and Homeopathy.
10. Contraceptive technology and research on reproductive and child health.
11. Providing for the older population.
12. Information, Education and Communication.
One of the 12 strategic themes which the NPP identifies is Empowering Women for
Improved Health and Nutrition. The NPP has spelt out the following issues.
•The complex socio-cultural determinants of women’s health and nutrition have cumulative
effects over a life time and the fact that interventions for improving women’s health and
nutrition are critical for poverty reduction.
• Impaired health and nutrition of women is compounded by early childbearing and consequent
risk of serious pregnancy related complications and women’s risks for pre-mature death and
disability during their reproductive years.
• High maternal mortality recognized not merely as a health disadvantage but as a matter of
social injustice.
• Women’s health and nutrition problem can largely be prevented through low cost interventions
designed for low income settings.
• Involvement of voluntary / NGO sector and private sector in areas of basic reproductive and
child health care, basic education etc.
The situation of women in terms of their condition and position needs to be understood in
the larger socio-economic, cultural and political framework of the country. Three main factors
which have contributed to the dis-empowerment of women and particularly of poor women
are: a) a culture built on patriarchy, discriminatory notions of social hierarchy and division of
labour that adversely affects women, b) an unequal distribution and control over resources with
women having very limited access when compared with men and c) systemic barriers at various levels
that restrict women’s access, participation and decision making powers in economic, political and legal
structures. Efforts to promote women’s empowerment must, therefore, address all these three issues.
Poverty in general, and extreme poverty in particular, has a significant gender dimension. Studies
reveal that (i) the percentage of adult women below the poverty line exceeds the percentage
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of adult men below the poverty line, both in rural and urban areas and (ii) in both urban and
rural areas, disadvantaged groups of women from Scheduled Castes and Tribes constitute a high
proportion of the poor.
The National Population Policy has identified the following operational strategies for achieving
the goal of empowering women
• Creating an enabling environment for women to benefit from products and services disseminated
under RCH programme.
• Building partnerships with other programmes – convergence with programmes relating to
women of other Ministries/ Departments like WCD, Panchayati Raj, Rural Development etc.
• As a measure to empower women, open more child care centres in rural areas and urban
slums, where a women worker may leave her children in responsible hands.
• Priority to be given to energy saving devices, improving access to drinking water, provision of
sanitation facilities etc. – which will empower households, in particular women.
• Improvement of health management at all levels – district, sub-district, panchayat.
• Improvement in technical skills for maternal and child health care providers by:
n Strengthening skills of health personnel/ health provider through on the job training in
management in of obstetric and neo natal emergencies
n Monitoring of performance and health care services at each level by using the maternal and
child health local area monitoring systems such as coverage of ante-natal visits, deliveries
assisted by trained health care personnel and post-natal visits, among other indicators.
n Support community activities such as dissemination of IEC materials like leaflets, posters
and promotion of folk media to promote healthy mother messages along with good
management practices to ensure safe motherhood, including early recognition of danger
signs.
nExpand the availability of safe abortion care.
Unless the women are empowered to be part of the decision-making process in the family, the
community and the society, overall goal of the Population Policy to improve the quality of lives will
remain unfulfilled.
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The National Population Policy, 2000–
what can it achieve realistically
A R Nanda
“In the new millennium, nations are judged by the well-being of their peoples; by levels of
health, nutrition and education; by the civil and political liberties enjoyed by their citizens;
by the protection guaranteed to children and by provisions made for the vulnerable and
the disadvantaged. The vast numbers of the people of India can be its greatest asset if they
are provided with the means to lead healthy and economically productive lives” - National
Population Policy, 2000.
The Alma-Ata
declaration which
received full
commitment from the
In 1978, a potential breakthrough in global health rights took place at an international Indian Government,
conference organized by the World Health Organization (WHO) and the United Nations
Children’s Fund (UNICEF) in Alma Ata. The fundamentals of the approach of Alma Ata
declaration is in fact in tune with, India’s vision of 1938 of entrusting “people’s health
in people’s hand” as advocated by the National Planning Committee during the anti-
called for a
convergence of trends
in thinking in relation
colonial struggle. It was a path-breaking endogenous thinking in public health. The most to health, health care
important aspect of Primary Health Care as proposed at Alma Ata was its all inclusive
equity-oriented approach. The notion of access to Health for All as envisaged in the Alma and development.
Ata declaration had its reflection in the National Health Policy, 1983. The concept of Primary Health
Care “was a potentially revolutionary concept that looked far beyond the customary boundaries
of curative and preventive medicine and tried to address the underlying social causes of poverty,
hunger and poor health.” (AbouZahr.C 1999)
Primary Health Care guided by five principles: equitable distribution, community involvement,
focus on prevention, appropriate technology and a multi-sectoral approach: was grounded in a broad
theory of development that rejected economic modernization as the only path to well being and
placed good health firmly at the centre of economic growth, equity and productive nexus. It was also
guided by a desire to improve equity in access to health care and to achieve gender equality and right
to good health.
The Alma-Ata declaration which received full commitment from the Indian Government,
called for a convergence of trends in thinking in relation to health, health care and development.
“This declaration was important in proposing a broad and consistent philosophy towards a
strategy secured in the Primary Health Care Approach” (Nanda. A.R. & Ali.A.2006). It outlined
the necessary shifts in strategic thinking and planning - renewing relationship between health
service professionals and members of the community. “Of central importance was equity as a
component to health. Equity was defined as equal health, meaning - equal access to health care,
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equal utilization of health care and equal access to health care according to need.” (Nanda. A.R.
& Ali.A.2006)
The comprehensive approach to Primary Health Care with its emphasis on equity and its call
for a model of socio-economic development conducive to Health For All was “quickly undermined
by the experts at the John Hopkins School of Public Health as early as 1979, who claimed that it
was too complex and too costly. Instead, they advocated selective Primary Health Care focusing
on a few “cost effective”, top-down technological fixes targeting high risk groups” (Werner. D
2003) Thus, the Primary Health Care Approach was compromised by the adoption of selective
interventions that attempted to bring technological fixes to health problems without addressing
the underlying imbalances which create the problems in the first place.
Again in 1994, the International Conference on Population and Development (ICPD), Cairo,
represented in a way the same kind of challenge to the established way of doing things as did
Alma Ata way back in 1978.
Many of the core concepts of Alma Ata again reappeared in its new avatar in the Programme of
Action (PoA) of ICPD, Chapter - VIII of which starts with a discussion on Primary Health Care. Since
1994 after the ICPD – PoA, there has been strong commitment to provide Primary Health Care for
all in line with the Declaration of Alma Ata. This new paradigm reflects a conceptual linking of the
discourse on human rights with that on health. It proposed a radical shift away from technology
– based, top-down approaches to programme planning from below. This commitment was guided
by desire to improve equity in access to healthcare, to achieve gender equality and reproductive
rights.
The International Conference on Population and Development (ICPD) was a milestone in
the history of population and development as well as the history of women’s rights. It heralded
a paradigm shift in the approach to population and development, placed women’s equity and
equality centre stage and introduced the importance of rights based programming.
The ICPD has been instrumental in forwarding the notion that population and development
programmes recognize that the concept of reproductive health care encompasses more than just
family planning services. Moreover, it declares that reproductive health and reproductive rights
cannot be realized without a concomitant fulfillment of women’s human rights. That both sets of
rights are interlinked and must be advocated in tandem and that empowering woman is crucial to
successful population and development programmes are ideas mainstreamed by the ICPD.
The International
Conference on
Population and
Development (ICPD)
was a milestone in the
history of population
and development as
well as the history of
women’s rights.
The reference to reproductive health and rights within the debates on population
and development that have occurred post-ICPD underscore its influence on subsequent
conferences and international documents. The strength of the ICPD’s reproductive health
approach can also be found in the 2000 Millennium Development Declaration, which
however, pays significant attention to highlighting selective issues of reproductive
health.
Although the National Population Policy (NPP), 2000 doesn’t explicitly talk about
reproductive rights, India’s commitment to ICPD declaration and the Plan of Action (PoA)
indicates the willingness on part of the government to look at Reproductive Health
from the perspective of individual’s right to access health information and services and
individual decision making based on informed choice. It is true that nowhere in the
NPP there is mention of reproductive rights or human rights; but when it comes to
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reproductive health, the ICPD-PoA has clearly identified a number of areas where these
rights are translated into information, education, services, and counseling in issues such
as family planning, ante-natal care, safe delivery, post-natal care, infertility, abortion,
RTIs/ STIs, including AIDS (ICPD - PoA, 1994). In discussing the unmet Reproductive
Health needs of different population, the PoA recognizes vulnerable and marginalized
groups as women, girls, adolescents, and elderly.
ICPD - PoA is a shift in policy focus away from “population control” rationales and
objectives in favour of women’s reproductive health and rights within a broad primary
health care context.
The compulsory and
coercive nature of
the family planning
programme during
1975 and 1976 made it
highly unpopular
Drawing from the ICPD – PoA, the most positive feature of the NPP is that it resolutely affirms
the commitment of government towards “voluntary and informed choice and consent of citizens
while availing of reproductive health care services, and continuation of the target free approach
in administering family planning services”(NPP, 2000). “These commitments for human rights and
the freedom and dignity of women were translated into a non-targeted family welfare programme,
which rightly abjured incentives and disincentives” (Rao.M 2002).
The evolution of population stabilization efforts in India by government goes back to the onset
of five-year development plans in 1951-52. The Government of India launched the world’s first
ever and largest population “programme” in the form of the National Family Planning Programme.,
which emphasized ‘family planning’ to the extent necessary for reducing birth rates to stabilize
the population at a level consistent with the requirement of national economy. In 1950s it “was
largely an urban clinic-based programme, then it became in the 1960s, rural in its focus and more
community oriented in its approach” (Sen.G 2000). In 1966, several important developments
concerning the Family Planning Programme took place.A full fledged department of Family Planning
was established within the Ministry of Health. The programme was made ‘centrally-sponsored’;
financial incentives were introduced for sterilization acceptors; and sterilization was made target-
oriented (Nanda.A.R.2004). In 1976, the government announced a National Population Policy
Statement. The compulsory and coercive nature of the family planning programme during 1975
and 1976 made it highly unpopular (Nanda.A.R.2004). A damage control exercise began by re-
christening Family Planning as Family Welfare with voluntary acceptance of contraceptive targets
without any coercion as the key strategy and again a policy statement was announced in June
1977. The policy statements of both 1976 and 1977 were laid on the table of the house of the
parliament, but never discussed or adopted.
While adopting the National Health Policy of 1983, Parliament emphasized the need for a
separate national population policy. The Karunakaran Committee set up by NDC in 1991 missed
the wood for the tree by emphasizing on disincentives around two-child norm in the form of
disqualification for MPs, MLAs and other elected representatives. A Constitution Amendment
Bill was introduced in Rajya Sabha thereafter, and is pending for consideration even now. Some
state governments have gone in for legislations on the same measure for Panchayati Raj and
urban local bodies. It is well-known that such measures for population stabilization alienate the
poor, marginalized and women from political empowerment, and are counter-productive (Nanda.
A.R.2004).
In 1993, the Government appointed Dr. M S Swaminathan as Chairman of an Expert Group
to draft a Population Policy. The expert group prepared a draft Population Policy in 1994, which
contained many positive and innovative recommendations. “It called for a radical shift to a policy
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that would be “pro-poor, pro-woman, and pro-nature”, and argued for a more bottom up and
needs-based approach” (Sen.G 2000). This draft Population Policy was submitted to Prime Minister
in 1994, was subsequently tabled in Parliament, but could not be passed. Again in 1997, an
attempt was made by the United Front Government to table and get the Population Policy passed;
however, it could not be done.
Another round of consultation was held during 1998, and another draft policy was prepared in
March 1999 and the government asked a Group of Ministers to examine the Policy draft. The Group
of Ministers finalized a draft population policy in November 1999. A fresh draft was submitted
thereafter and the Government of India adopted the National Population Policy in February 2000.
The National Population Policy, 2000 (NPP, 2000) takes its basic philosophy from
ICPD – PoA and from the concerns of women’s organization in the country thereby taking into
consideration the changing understanding on population, reproductive health, equity and rights.
With the shift in International perspective influenced by the ICPD, the government reflected its
change of approach in the NPP, 2000 by eliminating the use of targets. It is a significant step
forward and reflects a shift from the earlier demographically driven, target oriented policies to
one that addresses special concerns of reproductive health. The NPP is in fact an affirmation and
articulation of India’s commitment to the ICPD agenda, and forms the blueprint for population
and development related programmes in the country. The NPP, 2000 is also a significant move
towards a humane and effective development policy aimed at improving the overall quality
of life by promoting better awareness of and access to health care options with a focus on
women. It is in fact the first big step in the country’s effort to look at population issues from the
perspective of social development and is the reference point for India’s current rights based
approach to the subject.
The new strategy of the ICPD – PoA focuses on meeting the health needs of individual women
and men rather than on achieving demographic targets. In keeping with this, the NPP, 2000
consistently avoids the word “population control” and talks instead of “population stabilization”
despite widespread and entrenched convictions about the “Population explosion” in India. This is
a courageous stance in consonance with the current understanding of “demographic momentum”
in India, which indicates clearly that “the need of the hour is not coercion and control, but
information and services for family planning” (Dasgupta.J 2004). Thus, it does away with the
“fruitless baggage of targets and coercion.”
The NPP is gender sensitive and incorporates a comprehensive holistic approach to health and
education needs of women, female adolescents and girl child.
For the first time, a policy on population talks of universal education, Reproductive and
The new strategy of Child Health (RCH), delaying marriage, counseling, control of communicable diseases,
the ICPD – PoA focuses
decentralized planning, quality of health care services, adolescents and ageing - a
pioneer in many terms.
on meeting the health The NPP, 2000 starts with a premise that “the overriding objective of economic and
needs of individual social development is to improve the quality of life of people, to enhance their well-
women and men rather being and to provide them with opportunities and choices to become productive assets
in society.” It also states in no uncertain terms that stabilizing population is not merely
than on achieving a question of making reproductive health services available, accessible and affordable,
demographic targets. but also increasing the coverage and outreach of primary and secondary education,
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extending basic amenities like sanitation, safe drinking water, housing and empowering
women with enhanced access to education and employment. It very clearly recognizes
the close inter-relationship and two-way linkage between population stabilization and
socio-economic development and enunciated goals and strategies – both social and
demographic – which would have to be simultaneously pursued in a synergistic manner.
The NPP, 2000 provides a policy framework for advancing goals and prioritizing
strategies to meet the reproductive and child health needs of the people of India. The
immediate objective of the NPP, 2000 is to address the unmet needs for contraception,
health care infrastructure, and health personnel, and to provide integrated service
delivery for basic reproductive and child health care. The medium term objective is to
bring the TFR to replacement levels by 2010, through vigorous implementation of inter-
sectoral operational strategies. The long term objective is to achieve a stable population
by 2045, at a level consistent with the requirements of sustainable economic growth,
social development, and environmental protection.
In pursuance of these objectives, the following national socio-demographic goals to
be achieved in each case by 2010 were formulated:
The long term
objective is to achieve
a stable population
by 2045, at a level
consistent with
the requirements
of sustainable
economic growth,
social development,
and environmental
protection.
1. Address the unmet needs for basic reproductive and child health services, supplies and
infrastructure.
2. Make school education up to age 14 free and compulsory, and reduce drops out at primary and
secondary school levels to below 20 percent for both boys and girls.
3. Reduce infant mortality rate to below 30 per 1000 live births.
4. Reduce maternal mortality ratio to below 100 per 100,000 live births.
5. Achieve universal immunization of children against all vaccine preventable diseases.
6. Promote delayed marriage for girls, not earlier than age 18 and preferably after 20 years of
age.
7. Achieve 80% institutional deliveries and 100% deliveries by trained persons.
9. Achieve universal access to information/counseling, and services for fertility regulation and
contraception with a wide basket of choices.
9. Achieve 100% registration of births, deaths, marriages and pregnancies.
10. Contain the spread of Acquired Immunodeficiency Syndrome (AIDS, and promote greater
integration between the management of reproductive tract infections (RTI) and sexually
transmitted infections (STI) and the National AIDS Control Organizations.
11. Prevent and control communicable diseases.
12. Integrate Indian Systems of Medicine (ISM) in the provision of reproductive and child health
services, and in reaching out to households.
13. Promote vigorously small family norm to achieve replacement levels of TFR.
14. Bring about convergences in implementation of related social sector programmes so that
family welfare becomes a people centered programme.
In order to initiate our discourse on what the NPP can realistically achieve, we should take
into account all socio-demographic goals it has laid out without giving particular emphasis to any
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one. However, in practice, the emphasis is being laid towards achieving the replacement levels
of TFR 2.1 by 2010 without linking it with other socio-demographic goals (like reduction of IMR
& MMR, 100 percent registration of births, deaths etc., delaying age at marriage etc), and this
becomes really a matter of grave concern. Do we afford to forego or underplay all other goals and
concentrate on fertility reduction alone? Answers to these questions are important to decide our
approach and consequently our course of action in future.
To achieve the national socio-demographic goals by 2010, the following 12 strategic themes
were identified:
1.Decentralized planning and programme implementation.
2. Convergence of service delivery at village levels.
3.Empowering women for improved health and nutrition.
4. Child health and survival.
5. Meeting the unmet needs for family welfare services.
6.Under-served population groups:
a)Urban slums;
b)Tribal communities, hill area population and displaced and migrant populations;
c) Adolescents;
d) Increased participation of men in planned parenthood.
7.Diverse health care providers.
8. Collaboration with and commitments from non-government organizations and the private
sector.
9. Mainstreaming Indian Systems of Medicine and Homeopathy.
10. Contraceptive technology and research on reproductive and child health.
11. Providing for the older population.
12. Information, Education and Communication
The above strategic themes reflect the spirit and language of the principles agreed upon in ICPD
The Policy pays and the Plan of Action and we see that the themes are deeply influenced by the ICPD-
meticulous attention to
PoA. Decentralization of planning and programme implementation, convergence of service
delivery at community levels, women’s empowerment for improved health and nutrition,
the need for increasing child health and survival, meeting the unmet needs for all family welfare services, emphasis
attention to delivery
on under-served population groups including adolescents, are some of the commonalities.
While operationalising the thematic strategies, reproductive rights, gender equity and
of health services and quality of care need to be addressed as the cross-cutting concerns.
its convergence with
other services or basic
amenities and the need
for increasing finances
for this.
The Policy pays meticulous attention to the need for increasing attention to delivery
of health services and its convergence with other services or basic amenities and the
need for increasing finances for this. Very significantly it also accepts and promotes the
idea of devolving power, to deliver and manage (and hold accountable), to the local self
government institutions.The policy’s promotion of decentralised planning - a constitutional
strategy for local governance - as crucial for its effective implementation, provides scope
for direct advocacy at grassroots. Its recognition of Panchayati Raj institutions as the key
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forums or instruments for design, development and implementation of the Policy at the Most of the state
ground level offers scope and opportunities for people to demand their entitlements and
make informed choices about family size.
The strategic theme of inter-sectoral convergence which is meant to be an acclaimed
feature of the NPP, can be successfully implemented only when respective ministries and
policies reflect neo-
malthusian the
“population control”
departments get clear guidelines and mechanisms for delivery of the required services mindset viewing
such as primary and secondary education, housing, sanitation, drinking water etc, with
organic link established with reproductive health on the ground.
population growth as
A 100-point Action Plan has been suggested in the Policy document to be pursued a human crisis and
“as a national movement” through a “multi-sectoral endeavour, requiring constant and are more upfront in
effective dialogue among a diversity of stakeholders, and coordination at all levels of the methods of achieving
government and society”. Spread of literacy and education and women’s participation in
the paid work force together with a “steady, equitable improvement in family incomes” demographic goals
have been recognized as important as equitable access, quality and affordable reproductive and
child health services aimed at population stabilization. (Nanda.A.R.2004).
Several State Governments have already formulated their state specific population policies
(and some others have initiated action for developing their population policies). There is a distinct
difference in tone and attitude between the NPP and the state population policies. Most of the
state policies reflect neo-malthusian the “population control” mindset viewing population growth
as a human crisis and are more upfront in methods of achieving demographic goals through a
series of incentives and disincentives, and short-cut verticalized programmes and strategies.
There is enough data and documentation to establish that disincentives tend to be coercive.
It has also been noticed that the disincentives always hit the poor and down trodden especially
those who belong to scheduled castes and tribes and backward classes much harder than the
privileged section of the society. Till the large unmet needs of these socially backward groups
for health and family welfare services are met, proposing any punitive measures is clearly
irrational. Similarly working a “two child norm” conditional for welfare measures deprives
these very sections for whom these schemes are meant. The disincentives are also anti-women
since women in our country do not enjoy the freedom to decide how many children they would
like to bear.
Some of the state policies bar women with-more than two children from contesting elections
to PRIs. Debarring such women from contesting elections or from public employment opportunities
makes a mockery of policies to empower women. Further, it will provide and impetus for sex-
selective abortions and female feoticide, worsening the already deplorable child sex ratio in some
parts of the country.
Although almost all the state policies use the term “target-free”, many recommend clear
incentives and disincentives. When the policy translates into programme implementation, it has
negative implications on the idea of informed choices, individual decision making and results in
violation of human dignity, especially of women. Thus, these state policies violate the letter and
spirit of the NPP.
This shows lack of common understanding on the part of some state governments and
consequently their differential commitment to ensuring choice-based decision making. Clearly,
there is a need to intensify efforts to bridge this gap in understanding among the stakeholders and
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to develop a consensus on the processes to be adopted to reach the goals. One has to be careful in
choosing the words because it can be interpreted differently (confusion between the “small family
norm” and “two-child norm”).
A primary theme running through the NPP is provision of quality services and supplies and
arrangement of a basket of choices. People must be free and enabled to access quality health
care, make informed choice and adopt measures for fertility regulation best suited to them. It is in
this sprit that the NPP advocates a small family norm. Nowhere does the policy advocate for “two
child norm”. However, it is unfortunate and some times even disturbing to note that while talking
about NPP “small family norm” is often misinterpreted as “two child norm” (which has a definite
coercive connotation). “Two child norm” implies that the state promotes two children per family
and has a system of incentives and disincentives/punishments for achieving it. A “two child norm”
has the potential to cause immense harm to women’s health in existing social situation where son
preference is high and women’s status is very low (Nanda.A.R.2004a).
Moreover, since the disparities among the states are out and clear, there is a need to form
a body to receive the feedback and help the states in taking corrective action. In fact in early
2002, the Department of family welfare, Govt. of India had urged the state governments not to
introduce coercive methods in their population policies and constituted a national level resource
committee to bring about common approach in the state population policies while keeping the
general principles and the conceptual framework of the NPP in mind. The NRC was expected to
play a catalytic role in a truly meaningful way using a collaborative and consultative process in the
formulation of new state population policies and to undertake a review of state policies, which had
included coercive measures and disincentives to bring them in line with NPP.
Though the paradigm shift has taken place in the language used in the policy and programme
documents but it seems it will take a long time to bring about a real paradigm shift in thinking.
There are still some diehard “population control” exponents among politicians, bureaucrats,
demographers and other sections of the elite, who have “not reconciled to the paradigm shift,
and who feel more comfortable with an authoritarian policy regime of quantitative targets for
the sake of achieving soft and quick-fix options. They often deride the “target free” approach as
one which leads to complete lack of accountability and lack of quick and visible results on the
ground. Such mind set is understandable in as much as most of the present generation of senior
politicians, bureaucrats and scholars have been trained and oriented in neo-malthusian studies of
population.” (Nanda.A.R.2004 b).
A “two child norm”
has the potential to
cause immense harm
Considering that the NPP is a progressive, people centered policy document, the need
to follow it as a blue print must be communicated to all stakeholders and a much more
systematic and evidence-based advocacy efforts have to be mounted by advocates who
have fully internalized the paradigm shift.
to women’s health in
existing social situation
where son preference
is high and women’s
status is very low
Following a rights and equity based approach is as challenging as bringing the TFR
levels to the replacement level of 2.1. Implementation of NPP therefore involves the task
of ‘meeting the desired goals’ by ‘following the desired process’. Some of the challenges
are:
The governance for implementing the strategies and programmes/Action Plan of the
NPP need to be suffused with a transformation of the conventional mindset and style of
functioning of the bureaucrats, technocrats and service providers vis-à-vis the approach
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to population issues, accountability, planning, monitoring, coordination and synergy
– vertical as well as horizontal.
The key challenge facing us, therefore, is how to position family planning and
population programmes in the wider canvas of primary health care.
All those who have worked for the cause of health and family planning understand
that family planning is not an isolated programme, but has to be part of a comprehensive
primary health care within the overall gamut of social development.
The key challenge
facing us, therefore,
is how to position
family planning
and population
programmes in the
Overall-Socio-Economic Development
Health
Education
Nutrition/food & security
Employment
Poverty alleviation
wider canvas of
primary health care
Comprehensive Primary Health Care
Broader Context of Reproductive Health and Rights
Positioning Family Planning
Family Planning (FP) has to be positioned in the broader context of Reproductive Health (RH)
and Reproductive Rights (RR) and again, Reproductive Health (RH) and Reproductive Rights (RR)
have to be viewed in the context of Comprehensive Primary Health Care – which is still viewed as
a revolutionary concept that looks far beyond the customary boundaries of curative and preventive
medicine and tries to address the underlying causes of poverty, hunger/food-security and poor
health. The social and developmental issues including poverty issues need to be tackled in a
comprehensive and holistic manner rather than targeting population control/family planning on a
stand - alone basis.
It is, therefore, suggested that family planning and other population stabilization programmes
should form an integral part of the comprehensive primary health care programmes and need to
be based on “community needs assessment” which should be the starting point in any exercise of
planning and designing of programme implementation.
Imposing arbitrary targets of contraception reflects a ‘top-down’ approach, which goes
against decentralized planing and service delivery and denies people the right to informed choice.
Therefore, the authoritarian top-down target settings and bureaucratic monitoring of targets
need to be replaced with work-plans based on Community Needs Assessment Approach (CNAA)
with the active participation of PRIs, urban local bodies and community-based organizations
like self-help groups, particularly of women. Such holistic plan for health, population and social
development is to be prepared for each of the 6,40,000 villages and each ward of 6,000 urban
areas. The district plans, state plans and the Central plan should be based on the community level
plans reflecting the perceived needs of each family, and each community. Implementation of the
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work plans for each community should be monitored by the elected members of the ward of the
panchayat/urban body with technical and financial assistance from government – NGOs - private
sector, and all elements of ‘social audit’ built into this. Micro planning with community needs
assessment can help to identify and address the local problems through more acceptable strategies.
The gender concerns and the womens’ health concerns could be better taken care of in such a
decentralized approach. The twin issues of gender and equity should be over-arching while
implementing the NPP.
Quality of Care (QoC) should be an important issue to ensure mass appeal of the programme
so that people utilize the facilities, assured of the quality in response to their felt need. Thus, in the
planning stage itself certain minimum and practical indicators of QoC should be incorporated. This
will simplify the implementation and monitoring of the up gradation of rural health infrastructure,
at the same time guiding what basic minimum is needed for a good quality health service delivery
system. QoC indicators would be the main items to be monitored rather than the quantitative
targets per se through PRIs and other social audit organizations.
It is vital to install a good MIS for improving the effectiveness of the programme. The emphasis
on complete registration of births, marriages, pregnancies and deaths, shall inform the planners of
the current and the future status of the population and help at various stages of the programme.
The two key issues enunciated as strategic themes in the NPP are reducing IMR and MMR.
The verbal autopsy audit of all such deaths should be done so as to understand the leading
causes of such events and to take necessary action. The participation of various community based
organizations, Non-Governmental Organizations and local experts should be encouraged during
the audit.
The above suggestions are in line with India’s larger commitment to the Alma Ata declaration
and the ICPD. Locating the Family Planning Programme in the Reproductive Health and Rights
perspective, as a component of the comprehensive Primary Health Care, shall improve the overall
socio economic development of the country.
During the meeting of the National Commission on Population on 23rd July 2005, Dr.
Manmohan Singh, Prime Minister of India said, “We must not mistake population stabilization
to be population control. There is widespread consensus that population stabilization entails a
The emphasis on
complete registration
of births, marriages,
holistic, comprehensive approach towards education and health care, particularly of our
women and children, investment in comprehensive health care, coupled with a wider
development policy addressing the educational and economic needs of our population
together with raising the social status of our women must be the key to any population
pregnancies and stabilization strategy.” (Singh. M 2005)
deaths, shall inform
the planners of the
current and the
He further expressed that the National Rural Heath Mission (NRHM), which
will function on the basis of a decentralized district plan for health care, will ensure
stakeholder’s participation, enhanced investments and proper prioritization. It will
provide accessible, affordable, accountable, effective and reliable primary health care to
future status of the
population and help at
various stages of the
the poor and vulnerable sections of the population so as to achieve the goals of National
Population Policy and National Health Policy (Singh. M 2005).
The concept of Primary Health Care as advocated in the Alma Ata declaration – with
its emphasis on equity and strong people’s participation addressing the underlying
programme. social, economic and political causes of poor health – is as valid today as it was 28 years
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ago, and is even more urgently needed now. Some say that primary health care has been
tried and failed. In fact, in our country it has never been tried in its true spirit, in the
comprehensive form as advocated at the Alma Ata.
The National Rural Health Mission (NRHM), 2005 appears to have brought back
the primacy of Alma Ata declaration and comprehensive primary health care. It provides
a platform to foster the desired inter-sectoral co-ordination. It has created space for
decentralized planning and implementation, strengthening of primary health care,
involving communities in monitoring of services and convergence at the village level,
all of which have a potential to contribute towards the socio-demographic goals set in
the NPP. In order to utilize this opportunity to the fullest, it is all the more important to
generate awareness at all levels about the goals and approach of NPP.
The National Rural
Health Mission
(NRHM), 2005 appears
to have brought back
the primacy of Alma
Ata declaration and
comprehensive primary
health care.
While NRHM is an opportunity for systemic reforms and developing convergence mechanism
for achieving the socio-demographic goals of this nation, it is essential to remind ourselves that
the essence of NPP is empowerment of people and that it needs to be pursued as a national
movement.
References
1. National Population Policy (2000) - Ministry of Health and Family Welfare (MoHFW), Government of India.
2. AbouZahr.C (1999) - Some thoughts on ICPD+5, Policy and Practice, Bulletin of the World Health Organization,
1999,77 (9).
3. Nanda. A.R. & Ali. A. (2006) - Health Sector: Issues and Challenges, India Social Development Report, Council for
Social Development.
4. Werner. D (2003) - the Alma Ata Declaration and the goal of ‘Health for All’, 25 years later: keeping the dream alive,
Health for the Millions, Vol. 30 No. 4 & 5, Voluntary Health Association of India.
5. ICPD-PoA (1994) - Programme of Action of the International Conference on Population and Development, Cairo,
Egypt, Sept. 5-13, 1994.
6. Rao. M (2002) - Population Policy - A Voice of Sanity, Frontline, Vol. 19-Issue 19, Sept.14-27, 2002.
7. Sen.G (2000) - India’s National Population Policy 2000: A Comment, POPULI - September 2000.
8.Dasgupta. J 2004 - National Population Policy 2000: A Critique. A paper presented at the Seminar on the New
Paradigm of Development and Sex Selection, August 2004.
9. Nanda. A.R. (2004) - Convocation Address delivered at the 46th Convocation of the International Institute of
Population Sciences, Mumbai, May 8, 2004.
10. ------------(2004a) - National Population Policy: Small Family Norm and Sex Selection. A paper presented at the
Seminar on the New Paradigm of Development and Sex Selection, August 2004.
11. ------------(2004b) - Obsolescence and Anachronism of Population Control: From Demography to Demology,
Demography India, Vol. 33, No. 1, 2004.
12. Singh. M (2005) - PM’s Speech on National Commission on Population Meet, July 23, 2005.
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Changing Sex Ratio And
It’s Implications*
A R Nanda
Introduction
One of the current demographic issues in India that is of serious concern is the declining female
sex ratio. India holds a dismal record of being one of the few countries in the world where the sex ratio
continues to be highly unfair to women. As is well known by now, the number of females is constantly
decreasing across the country and the 2001 census data clearly shows that in several parts of India
the sex ratio, especially in the age group 0-6 is unacceptably low. Attempts have been made by several
scholars to study the causes and consequences of this phenomenon. Amongst these, Prof. Amartya Sen
was the first one to coin the term “Missing Women” in mid eighties and to set the stage for scholarly
discourse on this issue.
Sex ratio defined as the number of females per 1000 males in the population, is an important
social indicator to measure the extent of prevailing equity between males and females in a society.
It is mainly the outcome of the interplay of the sex differentials in mortality, sex selective migration,
sex ratio at birth and at times the sex differential in population enumeration.
Table 1: Sex Ratio in India 1901-2001
Year
Sex ratio
(Females per 1000 males)
1901
972
1911
964
1921
955
1931
950
1941
945
1951
946
1961
941
1971
930
1981
934
1991
927
2001
933
Decadal Variation
-8
-11
-5
-5
+1
-5
-11
-4
-7
+6
Source : Census of India, 2001
* Paper Presented at the Symposium on Nutrition in Developmental Transition, Organised by NFI, IIC, New Delhi
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Table 1 presents the trends in sex ratio in India since 1901. The sex ratio in the country had
always remained unfavorable to females. Moreover, barring some hiccups, it has shown a long
term declining trend. In the beginning of the 20th century, the sex ratio in the colonial India was
972 females per 1000 males, it declined by -8, -11, -5, and -5 points in 1911, 1921, 1931 and
1941 respectively. During 1951 census it improved by +1 point. During 1961, 1971, 1981 and
1991 it declined by -5, -11, -4 and -7 points respectively. During the period between 1961-71, the
country saw one of the sharpest decline of 11 points in the sex ratio.
Table 2: Sex Ratio (female per 1,000 males) : 1901-2001
Sl. India/ State/
Census year
No. Union territory* 1901 1911 1921 1931 1941 1951 1961 1971 1981 1991 2001
INDIA 1,2,3
972 964 955 950 945 946 941 930 934 927 933
1 J & K2
882 876 870 865 869 873 878 878 892 896 900
2 H.P 3
884 889 890 897 890 912 938 958 973 976 970
3 Punjab
832 780 799 815 836 844 854 865 879 882 874
4 Chandigarh *
771 720 743 751 763 781 652 749 769 790 773
5 Uttaranchal
918 907 916 913 907 940 947 940 936 936 964
6 Haryana
867 835 844 844 869 871 868 867 870 865 861
7 Delhi *
862 793 733 722 715 768 785 801 808 827 821
8 Rajasthan
905 908 896 907 906 921 908 911 919 910 922
9 Uttar Pradesh
938 916 908 903 907 908 907 876 882 876 898
10 Bihar
1,061 1,051 1,020 995 1,002 1,000 1,005 957 948 907 921
11 Sikkim
916 951 970 967 920 907 904 863 835 878 875
12 Arunachal Pradesh4
NA NA NA NA NA NA 894 861 862 859 901
13 Nagaland
973 993 992 997 1,021 999 933 871 863 886 909
14 Manipur
1,037 1,029 1,041 1,065 1,055 1,036 1,015 980 971 958 978
15 Mizoram
1,113 1,120 1,109 1,102 1,069 1,041 1,009 946 919 921 938
16 Tripura
874 885 885 885 886 904 932 943 946 945 950
17 Meghalaya
1,036 1,013 1,000 971 966 949 937 942 954 955 975
18 Assam
919 915 896 874 875 868 869 896 910 923 932
19 West Bengal
945 925 905 890 852 865 878 891 911 917 934
20 Jharkhand
1,032 1,021 1,002 989 978 961 960 945 940 922 941
21 Orissa
1,037 1,056 1,086 1,067 1,053 1,022 1,001 988 981 971 972
22 Chhatisgarh
1,046 1,039 1,041 1,043 1,032 1,024 1,008 998 996 985 990
23 M.P
972 967 949 947 946 945 932 920 921 912 920
24 Gujarat 3
954 946 944 945 941 952 940 934 942 934 921
25 Daman & Diu *
995 1,040 1,143 1,088 1,080 1,125 1,169 1,099 1,062 969 709
26 D & N Haveli *
960 967 940 911 925 946 963 1,007 974 952 811
27 Maharashtra
978 966 950 947 949 941 936 930 937 934 922
28 Andhra Pradesh
985 992 993 987 980 986 981 977 975 972 978
29 Karnataka
983 981 969 965 960 966 959 957 963 960 964
30 Goa
1,091 1,108 1,120 1,088 1,084 1,128 1,066 981 975 967 960
31 Lakshadweep *
1,063 987 1,027 994 1,018 1,043 1,020 978 975 943 947
32 Kerala
1,004 1,008 1,011 1,022 1,027 1,028 1,022 1,016 1,032 1,036 1,058
33 Tamil Nadu
1,044 1,042 1,029 1,027 1,012 1,007 992 978 977 974 986
34 Pondicherry *
NA 1,058 1,053 NA NA 1,030 1,013 989 985 979 1,001
35 A & N Island. *
318 352 303 495 574 625 617 644 760 818 846
Source : Census of India, 2001
1. For working out the sex ratio of India and Assam for 1981, interpolated figures for Assam have been used.
2. For working out the sex ratio of India and Jammu and Kashmir for 1991, interpolated figures for Jammu and Kashmir have been used.
3. For working out the sex ratio of India, Gujarat and Himachal Pradesh for 2001, estimated figures for affected areas of Gujarat and
Himachal Pradesh have been used.
4. The sex ratio for Arunachal Pradesh is not available for the years 1901-1951 and for Pondicherry it is not available for the years
1901, 1931 and 1941
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The table 2 gives the trends in sex ratio for past hundred years in respect of all the states and
Union Territories, except Arunachal Pradesh, for which data is not available for 1991 to 1951.
In 1901, there were as many as eleven States and Union territories that had sex ratio of more
than unity. Amongh these, except Kerala all other States and Uniion territories have shown a
downward trend. Although the sex ratio in Punjab has been consistently low, it has shown a long-
term upward trend and has not contributed to the overall deterioration in sex ratio of the country.
In Rajasthan, the sex ratio kept fluctuating in a narrow band and always remained at a low level.
Haryana, Andhra Pradesh and Karnataka are the States where the sex ratio has remained more or
less stagnant. In West Bengal the sex ratio declined sharply from 1901 to 1941 and then made a
gradual turnaround on an upward path to reach 934 in 2001.
The sex ratio of Indian population has always been of topical interest for the demographers,
social scientists, women’s groups, research scholars and various planners and policy makers. Why
is it that India has such uneven composition of population as compared to most of the developed
countries in the world? Several reasons are adduced to explain the consistently low level of sex
ratio and their further decline in the country. Some of the important reasons commonly put forward
are listed below:
• Neglect of the girl child resulting in their higher mortality at younger ages
• High maternal mortality
• Sex selective female abortions
• Female infanticide
• Change in sex ratio at birth
The declining female sex ratio has been a matter of concern for several years but it is the 2001
census that set the alarm bells ringing when the data clearly showed that in several parts of the
country especially in the age group 0-6 female sex ratio is unacceptably low. The data showed
alarming decline in some states and districts.
Child Sex Ratio (CSR)
While the improvement in overall sex ratio is noticed in the census 2001 what is most alarming
is the decline in the Child Sex Ratio (CSR), i.e the sex ratio of children in the age group of 0-6
years.
The sex ratio of Indian population has always
been of topical interest for the demographers,
social scientists, women’s groups, research
scholars and various planners and policy
makers.
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Table 3: Child Sex Ratio (0-6 Years) India
Sl. No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
State
India
Punjab
Haryana
Himachal Pradesh
Chandigarh
Delhi
Gujarat
Uttaranchal
D&N Haveli
Maharashtra
Daman & Diu
Nagaland
Goa
Arunachal Pradesh
Manipur
A & N Island
Orissa
Jharkhand
Andhra Pradesh
Karnataka
Meghalaya
Bihar
Uttar Pradesh
Assam
Madhya Pradesh
Chhattisgarh
Rajasthan
West Bengal
Tamil Nadu
Mizoram
Sikkim
Tripura
Kerala
Pondichery
Lakshadweep
J&K
0-6 Sex Ratio
1991
2001
945
927
875
798
879
819
951
896
899
845
915
868
928
883
949
908
1013
979
946
913
958
926
993
964
964
938
982
964
974
957
973
957
967
953
979
965
975
961
960
946
986
973
953
942
927
916
975
965
941
932
984
975
916
909
967
960
948
942
969
964
965
963
967
966
958
960
963
967
941
959
NA
941
Source : Census of India 2001, Primary Census Abstract, RGI
Absolute Change
-18
-77
-60
-55
-54
-47
-45
-41
-34
-33
-32
-29
-26
-18
-17
-16
-14
-14
-14
-14
-13
-11
-11
-10
-9
-9
-7
-7
-6
-5
-2
-1
2
4
18
NA
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Census 2001 showed a decline of 18 points from 945 in 1991 to 927. The decline of child sex
ratio is so wide spread that out of the 28 States and 7 Union Territories, only one State namely
Kerala (2 points increase) and two Union Territories namely Lakshadweep (18 points increase) and
Pondicherry (4 points increase) are free from this socially harmful and degrading phenomenon.
The States and Union Territories that have shown large declines in child sex ratio are Punjab
(-77), Haryana (-60), Himachal Pradesh (-55), Gujarat (-45), Chandigarh (-54) and Delhi (-47)
though they are economically quite developed with high female literacy rates. There are 122
districts spread over 14 states having CSR less than 900.
Several questions have been raised with regard to trends in child sex ratio in the last decade.
The indications are that this alarming trend is due to large scale practice of female foeticide.
Female foeticide or sex selective abortion is the elimination of the female foetus in the womb itself.
The decline in child sex ratio may be due to different factors such as neglect of female children
resulting in their higher mortality at younger ages, female infanticide and female foeticide. Female
foeticide refers to a practice where the female foetuses are selectively eliminated after prenatal sex
determination thus avoiding the birth of girls.
The factors responsible for female foeticide are:
Obsession to have a son
Discrimination against the girl child
Socio-economic and physical insecurity of women
Evil of dowry prevalent in our society
Worry about getting girls married as there is the stigma attached to being an unmarried
women
Easily accessible and affordable procedure for sex determination during pregnancy
Failure of medical ethics
The two child norm policy of certain state governments.
As seen from the above, one of the important factors responsible for female foeticide is the
“Two Child Norm” policy adopted by certain state governments.
Implications
Declining sex ratio is expected to have several implications. Broadly these implications can be
classified under two heads namely sociological and economic. Under each head several questions
have been raised which need thorough discussion. These are:
a. Sociological Implications:
Institutions which are expected to be influenced due to declining sex ratio are primarily family
and marriage as well as status and rights of women. In addition to these, violence against
women and trafficking may be the most probable outcomes of decreasing female sex ratio.
i) Consequences on the status of women within the family and community.
The primary issue that needs attention will be the consequences on women’s lives. As the
number of women decrease, will women be considered special and their value increase?
Will women-deficient communities “buy/obtain” from other communities and thus reduce
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women into tradable commodities? Will women from the non-affluent communities become
primary victims of such a trend?
ii) Impact on the institution of family
Will the role of men and women in families change? Will women be further restricted to their
domestic roles? Will some of the support to family like caring for the children, sick, elderly
etc. have to obtained from outside of the family on payment?
iii) Change in the institution of marriage
Will the decreasing number of women lead to increase in polyandry marriages? What would be the
implication of such a change for women? Would it lower the status of women further and reduce
their rights relating to inheritance, property, education, religion, decision making in the family.
iv) Health related issues due to changing pattern of family and marriage
Will the changes in the family and marriage result in loss of reproductive rights of women?
Since the women may be confined to the domestic sphere with limited access to economic
resource, will their access to health get further reduced? Will adoption and choice of
contraception become an impossibility to sexually transmitted diseases and HIV/AIDS, which
in turn may result in increased morbidity and mortality amongst women?
v) Increase in violence against women and violence due to rights over women
If elimination of girls becomes a widely accepted norm will infanticide and neglect of female children
increase?Will other forms of violence like rape increase?Will individual men or communities in general
fight over the right of women, as women become rare but essentially needed “resources”?
vi) Impact on trafficking in women and girls
Since women are essential for running of the household and also for contributing to the
household economy, will there be increase in trafficking of women and girls for domestic work,
as labour in the informal, household economic activities and also to service needs of men?
b. Economic Implications:
All over the world and also in India, women’s contribution to the economy has been well
recognized. In the context of India’s developing economy, what would be the consequences
of reduction in the number of women on the country’s growth and development?
i) Impact on the economy at the household and the macro levels, in the context of reducing
numbers of women and lesser avenues available to them for capability development
With higher marriage rate for women and higher involvement of women in their reproductive
roles, would it lead to reduced outside labour market participation. If so, how does this
impact on women’s economic status and empowerment as well as economics of women
dominated industries, including agriculture? Or would it only impact on those cultures that
have traditionally been known as “plough cultures” with little or no role for women in
agriculture? Would the reduced economic value of the girl child, in general exacerbate the
situation by further decline in sex ratios?
ii)Economic consequences of women’s migration for marriage to a women deficit region
How do these consequences play out for both the women surplus and the women deficit
regions? Does it change micro-economic of dowry/bride price? Does marriage of girls remain
a liability in both kinds of regions and does this in turn influence the sex ratios?
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iii.Extent of economic loss of the country
Most of the countries in the region are undergoing rapid social and economic change. Can the loss
to the country’s economy be calculated, if women’s participation in economic activities reduce?
iv.Extent of economic loss to the family
With the reducing number of women in the family, will the families have to buy services from
outside for normal household activities like care of the elderly etc. what will be the impact of
such increased expenses on the family income and savings?
Population Foundation of India’s Focus on Critical Issues of Population and Development:
A fundamental change which has occurred in recent times in conceptualizing and implementing
Population Policies and Programmes is to ensure that these Policies and Programmes address the
root cause of high fertility such as persistent gender disparities in access to education, food &
nutrition, health, employment and other productive resources. Therefore, the focus of PFI is to
reduce the gender disparity and gender gap.
One of the cruelest forms of gender disparity is the phenomenon of sex selection and Pre-Birth
Elimination of Females (PBEF)/Female Foeticide. The theme of ‘Missing Girls’ captures the foremost
concern of population and development issues, namely declining child sex ratio, sex selection, sex
selective abortion (female foeticide/PBEF) gender & equity concerns.
PFI’S Advocacy Initiatives on “Missing Girls”
PFI identified the issue of ‘Missing Girls’ as one of the priority areas for advocacy. In 2003,
PFI initiated with the help of Plan International, India State-level advocacy on the issue of ‘Sex
Selection and Pre-Birth Elimination of Females’ in eleven states namely Delhi, Andhra Pradesh,
Uttar Pradesh, Uttaranchal, Gujarat, Haryana, Punjab, Himachal Pradesh, Orissa, Maharashtra and
Rajasthan. key Stakeholders for the advocacy efforts were MLAs and corporate leaders. In Delhi
and Andhra Pradesh the stakeholders were widened to include media, medical professionals, and
school teachers. To have a meaningful impact, it was realized that there was an urgent need to
take advocacy activities down to district and sub district levels, to widen the stakeholders at these
levels and add new initiatives to the campaign.
In 2004, PFI in association with UNFPA had launched an advocacy campaign at the district
and block levels in seven states – PFI tied up with state level NGOs in the state to carry out
various advocacy activities. The states and the NGOs identified were: Punjab – VHAP, Haryana
– FPAI, Maharashtra – Cehat, Gujarat – Chetna, Rajasthan – Prayas, Himachal Pradesh – Sutra
, Delhi – CWDS. Various Advocacy initiatives like Campaigns, Rallies, Focus Group Discussions,
Workshops/Seminars were entrusted to the NGOs to carry out in specific locations.
The campaign tried to communicate the following issues to the stakeholders: What will happen
to families if girls would be missing in such a rapid way; Legal literacy; PNDT vis-a-vis MTP;
illegality of sex selection and legality of safe abortion; positive value of girl child/women; gender
discrimination – violation of rights; dowry is illegal and women have an equal right to property.
The theme of Missing Girls is really an interface between population & development and
gender. It should be looked in a wider perspective covering sex ratio & sex selection issues in a
broader Gender and Reproductive Health (RH) framework.
It is a frightful scenario and there is an urgent need to correct the sex imbalance at this stage,
before it becomes too late.
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Books/Journals/
Papers/Articles for
Further Reading
i. From Population Control to reproductive health, Malthusian arithmetic: Mohan Rao
ii. Coercion versus empowerment: Mohan Rao
iii. Beyond Numbers, 511 March 2002 (Full Journal): Seminar
iv. Population Policy: Authoritarianism versus Cooperation, International Lecture Series
on Population Issues: The John D and Catherine T. MacAurthor Foundation, August 17, 1995:
Amartya Sen
v. Many faces of gender inequality, The Frontline, volume 18-issue -22, October 27 - November,
2001: Amartya Sen
vi.Two Child Norm is plainly unfair, it is anti-women, anti-poor, anti-rural folk: Mohini Giri
vii. Fear of the poor, The Hindu, Wednesday, May 23, 2001: Mohan Rao
viii.Fatal Misconception, The Struggle to Control World Population, 2008: Mathew O Connelly
ix. Reproductive Restraints, Birth Control in India, 2008: Sanjam Alhuwalia
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annexures
Presentations
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POLITICAL ENVIRONMENT
IMPACTING MATERNAL MORTALITY AND
YOUNG PEOPLE’S REPRODUCTIVE HEALTH
By
A R Nanda
Executive Director
Population Foundation of India
Second Round Table Discussion on Maternal Mortality and
Young People’s Reproductive Health
Organized by
MacArthur Foundation
December 8, 2003
India Habitat Centre, New Delhi
Why Focus on Maternal Mortality and
Young People’s Reproductive Health
Maternal Mortality
•Discrepancy between developed and developing countries is much greater for maternal
deaths than for most other health problems
• More than one quarter of deaths among women in developing countries
n 1% of deaths among women in developing countries
n In India although MMR has been declining in 468 in 1980 to 407 in 1998 it is still very
high
• MMR is higher in states having poor health infrastructure and services
• For every woman who dies during child birth about 20 survive with complications
• Abortion is a significant cause for maternal death
Young People’s Reproductive Health
•The World has now the largest group of adolescents in history – some 85% living in
developing countries.
• Adolescents constitute about a fifth (23%) of India’s population.
• Increasingly, adolescents are exposed to non-pregnancy related reproductive heath
disorders such as STDs and RTIs.
• Adolescent fertility poses serious concern in India – about 19% of total fertility has taken
among 15-19 age group.
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• Pre-pregnancy anaemic status of adolescent girls is crucial and has long term
intergenerational consequences.
•Violence against women and girls in general, and domestic violence in particular is a
growing phenomena.
• Adolescent girls are definitely the more disadvantaged, through boys also suffer abuse.
•Dowry killing as a form of violence is rising. Young brides are the most vulnerable due
to their age disadvantages.
Policy Initiatives and Major programmes
• Goal of reducing maternal deaths reaffirmed at major international conferences.
n World Summit for Children, New York, 1990
n ICPD, Cairo, 1994
n Fourth World Conference on Women, Beijing, 1995
n Millennium Development Goals at the Millennium Summit, 2000
• ICPD + 5 reaffirms the commitment to reduce maternal mortality as a health sector
priority
• ICPD Programme of Action explicitly recognized the reproductive health needs of
adolescents as a distinct group, clearly advocates for the provision of services.
• “Maternal mortality is not merely a health disadvantage, it is a matter of social
injustice”… National Population Policy, 2000
• NPP-2000 includes maternal deaths as one of the priority issues to be addressed and
targets to reduce MMR to below 100 per 100,000 by 2010.
• Strengthening the referral network in management of obstetric and neo-natal
complications.
• Strengthening various levels of health centers to provide obstetric and neo-natal care.
•Establishing rigorous problem identification mechanisms through maternal and peri-
natal audit, from village level upwards.
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•Ensuring adequate transportation for women with complications
• NPP – 2000 recognized that the needs of adolescents have not been addressed in the
past. It recommends programmes – to encourage delayed marriage and child bearing.
nEducation of adolescents about the risk of unprotected sex
n RCH services for adolescent boys and girls
n Food supplements and nutritional services through ICDS.
nTenth plan gives priority to reduction of maternal mortality by operationalizing
n Universal screening of all pregnant women
n Identification of women with complications
n Referral to appropriate care centre
n Prevention and management of anaemia
•Tenth Plan reaffirms the life cycle approach for betterment of the adolescents.
•The World Bank mission to review RCH programme in 2003 recognize the importance of
24 hour delivery service and essential obstetric care in reducing maternal mortality but
finds operationalizing the FRU has been difficult due to
n Human resource shortages
n Lack of referral transport
n Absence of blood banking facilities
n Lack of effective BCC interventions
•This review mission agrees
•The key staff need to be placed prior to identifying FRUs
n Contracting private nursing homes/hospitals to provide emergency obstetric care
where public sector FRUs are absent or poorly utilized
n Ensuring access to good quality safe abortion services
Policy Issues and Political Environment
•Lack of baseline information related to awareness and perception of political leaders on
the issues related to Maternal Morality and Young People’s reproductive health
•Difficulties in mapping MMR - data scattered and inadequate
• National Population Policy 2000 – Excellent policy frame work
•Operationalization of recommendations NPP w.r.t maternal mortality is poor
nDeviations from national policy
nTrend towards population control – likely to further deteriorate maternal health and
young people’s Reproductive Health and Rights
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• Private members’ bills introduced in Parliament.
nDemand compulsory sterilization in case of couples with two or more children.
n Prescribes strong incentives and disincentives such as disqualification from contesting
election and reduced access to PDS, education, jobs etc.
• Such bills appear to be generating pressure on government either to enact its own
legislation or at least take a position on the subject.
• Change of political leadership in major states – possible impact on maternal mortality
and young people’s reproductive health, unless sustained advocacy is taken up.
• 33% reservation in Panchayats and growing number of women chief ministers – how
effective can they be?
• Is private sector involvement the answer – need for a legislative framework to ensure
quality assurance.
Need for Advocacy
• Political will is an important precondition for sustained campaign on issues related to
maternal mortality and young people’s reproductive health.
•The elected representatives can provide leadership in acknowledging the existence of
the problem, to speak out on it and implement policies to correct it.
•Discussing maternal mortality and young people’s reproductive health as a human right
and development issues and not purely as women’s issue.
• Sharing views and perceptions with major political parties to identify common concerns
as well as differences. Mentioning the issue in party programmes and election
manifestoes.
• Political consensus on issues related to maternal mortality and adolescent reproductive
health and strong commitment for taking effective steps required to be advocated.
• Necessity of a strong campaign including sensitization and education of parliamentarians
to change the mindset.
• Questions in parliament and state legislatures have to be strategically framed to
influence government to react. To raise questions they need to be equipped with facts
and figures.
• Advocacy efforts more on women, elected representatives who could act as pressure
groups.
• Need for networking/alliance among likeminded rights based civil society organizations
and individuals.
• Need for alliance with political leadership and the media.
• NGOs and civil society groups need to be become very proactive.
• Health and social audit to be introduced.
• National Youth Policy to reflect the concerns of the adolescent reproductive health and
rights.
Thank You !!!
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Evolution of India’s Family Planning Programme
and the National Population Policy
Dr. Almas Ali
Senior Advisor, PFI
Symposium on Reproductive Health:
A Life Cycle Approach,
at Karachi,
September 20 – 21, 2004
• In 1952, India was the first country in the world to launch a national programme,
emphasizing family planning to the extent necessary for reducing birth rates “to stabilise
the population level consistent with requirement of the national economy”
• Since then the Indian Family Planning Programme has gone through several changes
- at times it has been integrated with different programmes like the minimum needs
programme. Maternal and Child Health (MCH) and Child Survival and Safe Motherhood
(CSSM). However, the goal of the Family Planning Programme has been reducing the
birth rate and the rate of population growth by the introduction (since the mid 60s) of
method-specific family planning targets to achieve these goals.
Major Milestones in Evolution of India’s FP Programmes
• 1952 The Fist Five Year Plan document noted the “urgency of the problems of family
planning and population control’ and advocated a reduction in the birth rate to stabilize
population at a level consistent with the needs of the economy.
• 1956 The Second Five Year Plan proposed expansion of family planning clinics in both
rural and urban areas and recommended a more or less autonomous Central Family
Planning Board, with similar state level boards.
• 1961 The Third Five Year Plan envisaged the provision of sterilization facilities in district
hospitals, sub-divisional hospitals and primary health centers as a part of the family
planning programme. Maharashtra state organized “Sterilization Camps” in rural areas.
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• 1963 The Director of Family Planning proposed a shift from the clinic approach to a
community extension approach to be implemented by auxiliary nurse midwives (one per
10, 000 population) located in PHCs. Other proposals include: (a) a goal of lowering
the birth rate from an estimated 40 to 25 by 1973; and (b) a cafeteria approach to the
provision of contraceptive methods, with an emphasis on free choice.
• 1965 The Intra Uterine Device (IUD) was introduced in the Indian Family Planning
Programme.
• 1966 A full-fledged Department of Family Planning was set up in the Ministry of Health.
Condoms began to be distributed through the established channels of leading distributors
of consumer goods.
• In 1976, during emergency, the Congress Government under Smt. Indira Gandhi formulated
a Population Policy (in a form of Policy Statement) which become counter-productive
because of a clause, which permitted States to go for Compulsory Sterilization.
• In 1977, A revised population policy statement was tabled in Parliament by the Janata
Government. It emphasized the voluntary nature of the “Family Planning” programme.
The term “Family Welfare” replaced Family Planning.
• In 1983 National Health Policy was announced in which mention was made in passing
about Population and Family Welfare Programmes.
• In 1991, Congress Government under Shri Narasimha Rao appointed a Committee
headed by Shri K Karunakaran, which submitted a report to the National Development
Council in 1993 in which it pleaded for National Population Policy.
• In 1993, the same Government appointed Dr. M S Swaminathan as Chairman of an
Expert Group of draft a Population Policy. The draft Population Policy was submitted to
the then P M in 1994, which was subsequently tabled in Parliament but could not be
passed.
• Again in 1997, an Attempt was made by the United Front Government under Shri I K
Gujaral to table and get the Population Policy passed, however, it could not be done.
• In 1999 the BJP Government under Shri A B Vajpayee asked a Group of Ministers to
examine the Policy draft prepared by the Department of Family Welfare, Ministry of
Health & Family Welfare.
In 2000, the Government of India announced the National Population Policy (NPP),
2000
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India’s Demographic Achievement
Parameter
1951
1981
1991
Current
NPP – Goals for 2010
Population (in million)
361
483
846
1028
1107
(2001 Census)
1111
Current (estimate)
Crude Birth Rate (per 1000 population)
40.8
33.9
29.5
25.0
21
(SRS)
(SRS)
(SRS 2000)
Total Fertility Rate
6
4.5
3.6
2.9
2.1
(SRS)
(SRS)
(NFHS 98-99)
Maternal Mortality Ratio (per 100, 000 live births)
NA
NA
437
407
100
(92-93)
-1998
Infant Mortality Rate (per 1000 live births)
146
110
80
63
Below 30
(1951-61)
(SRS)
(SRS)
(SRS-2002)
Literacy Rate
Persons
18.33
43.57
52.21
65.38
Males
27.16
56.38
64.13
75.85
Females
8.86
29.76
39.29
54.16
Contraceptive Prevalence Rate %
10.4
22.8
44.1
48.2To meet all needs
-1971
(NFHS- 98-99)
Full Immunization of infants
56%
100%
(from 6 vaccine preventable diseases)
ANC checkup (3 visits)
43.80%
100%
Institutional Deliveries
34%
80%
Growth of Population in India
Census YearDecadal Growth Percent
(percent)
Average Exponential Growth
1971
24.80
2.20
1981
24.66
2.22
1991
23.86
2.14
2001
21.34
1.93
Average Exponential Growth Rate
2.25%
2.20%
2.15%
2.10%
2.05%
2.00%
1.95%
1.90%
1.85%
1.80%
1.75%
2.20%
2.22%
2.14%
1.96%
1.93%
1951-61 1961-71 1971-81 1981-91 1991-01
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Reasons for High Population Growth
Population growth in India continues to be high on account of
•Large size of the population in the reproductive age – group (estimated contribution
over 60%)
• Higher Fertility due to unmet need for contraception (estimated contribution 20%)
• High wanted fertility due to the high IMR (estimated contribution 20%)
•Over 50% of girls marry below the age of 18, the minimum legal age of marriage,
resulting in a typical reproductive pattern of “too early” too frequent, too many”
Reproductive and Child Health (RCH)
Programme - 1997
• Adopting the Principles of ICPD Plan of Action, India introduced the RH agenda through
RCH Programmes.
•Target free approach and provision of wide range of Reproductive and Child Health
Services were the cardinal features.
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Reproductive and Child Health (RCH) Programme
RCH Package - I
• Maternal and child health care
• 100% immunisation against 6 VPD
•Elimination of neonatal tetanus, reduction of measles
• Control of diarrhoea and respiratory infections
• Prophylaxis against anaemia and blindness
•Essential obstetric care at all PHCs, EOC at 1748 identified CHCs
• Promotion of institutional deliveries
• Increased access to contraceptive care
• Safe management to unwanted pregnancies
• MTP facilities in all PHCs.
RCH Package - 2
Nutritional Services to Vulnerable Groups;
• Prevention and treatment of RTI/STD
• Clinics to control RTI and STDs in 230 districts, in addition to 300 districts otherwise
covered as well as in selected FRUs
• Reproductive health services for adolescents
• Prevention and treatment of gynaecological problems, and Screening and treatment of
cancers especially that of uterine cervix and breast
• IEC for above.
NATIONAL POPULATION POLICY
India 2000
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VISION STATEMENT
Development Aims to…
• Improve the quality of lives people lead
• Provide them with opportunities and choice with a comprehensive, holistic and mulit-
sectoral agenda for population stabilisation.
Stabilising Population is a function of
• Making reproductive health accessible and affordable
• Increasing the coverage and outreach of primary and secondary education
•Extending basic amenities like sanitation, safe drinking water and housing;
•Empowering women with enhanced access to education and employment;
• Providing roads and communication
OBJECTIVES
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Immediate Objective
•To address the unmet needs of contraception, health infrastructure, and trained health care
personnel;
•To provide integrated service delivery for basic reproductive and child health care.
Medium Term Objective
•To bring the total Fertility Rates to replacement levels country-wide, by 2010.
•Through vigorous implementation of multi-sectoral operational strategies
Long term objective
•To bring about population stabilistion by 2045
• Consistent with the requirements of sustainable economic growth, social development,
and environmental protection.
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National Socio-Demographic Goals 2010
• Address the unmet needs for basic RCH, supplies and infrastructure.
• Make school education up to age 14 free and compulsory and reduce drop-outs to
below 20% at primary/secondary school levels for both boys & girls.
• Reduce infant mortality below 30 per 1000 live births.
• Reduce maternal mortality below 100 per 100,000 live births
• Achieve universal immunisation against all vaccine preventable diseases.
• Promote delayed marriage for girls, not earlier than 18, and preferably after 20 years of
age.
• Achieve 80% institutional deliveries and 100% deliveries by trained persons.
• Achieve universal access to information, counseling, and services for fertility regulation.
• Achieve 100% registration of births, deaths, marriage, and pregnancy.
• Contain the spread of HIV/ AIDS and promote greater integration with the National AIDS
Control Organisation in managing the RTI and the STI.
• prevent/ control communicable diseases.
• Integrate Indian Systems of Medicine in the provision of RCH services, and in reaching
out to households.
• Promote the small family norm to achieve replacements levels of TFR.
• Bring about convergence in the implementation of related social sector programmes, so
that family welfare becomes a people centred programme.
STRATEGIC THEMES
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1.Decentralized planning and programme implementation
2. Convergence of Service delivery at village levels
3.Empowering women for improved Health and Nutrition
4. Child Survival and Child Health
5. Meeting the unmet needs for family welfare services
6.Under-served population groups:
a.Urban slums;
b,Tribal communities, hill area population and displaced and migrant populations;
c. Adolescents;
d. Increased participation of men in planned parenthood .
7.Diverse health care providers
8. Collaboration with and commitments from non-government organizations and the private
sector
9. Mainstreaming Indian Systems of Medicine and Homeopathy
10. Contraceptive technology and research on reproductive and child health
11. Providing for the older population
12. Information, Education and Communication
•The NPP is gender sensitive and incorporates a comprehensive holistic approach to
health and education needs of women, female adolescents and girl child.
• A primary theme running through the NPP is provision of quality services and supplies
and arrangement of a basket of choices. People must be free and enable to access
quality health care, make informed choice and adopt measures for fertility regulation
best suited to them.
• Substantial differences are visible between states in the achievement of basic
demographic indices. This has led to significant disparity in current population size and
the potential to influence population increase. There are wide inter-state, male-female
and rural-urban disparities in outcomes and impacts. These differences stem largely from
poverty, illiteracy, and inadequate access to health and family welfare services, which
co-exist and reinforce each other.
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•The 5 States of Bihar, Rajasthan, Madhya Pradesh, Uttar Pradesh, Rajasthan and
Orissa will constitute 55% of the increase in numbers projected up to 2016.
• An Empowered Action Group (EAG) has been constituted to design and formulate
need based programmes in the 8 socio demographically vulnerable and backward
states.
• Population stabilization is not just about number but is about balanced development
which should be looked in the context of wider and broader socio economic development.
However, the time has come to stop counting people and instead start counting on
people. In short the moral of the story is if we take care of people, population will take
care of itself.
THANK YOU
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National Population Policy, 2000 and
State Population Policies
Dr. Almas Ali
Senior Advisor, PFI
National Consultation and Laws, Policies and Rights in the Context of the
Reproductive Health and Population Stabilisation
September 25-26, 2004
India Habitat Centre, New Delhi
• Brief History of Population Debate
• ICPD, 1994 – Watershed in the history of population thinking
• Myth about Population Growth
• National Population Policy
• State Population Policies
Stages of Demographic Evolution
• First stage - high birth rate – high death rate- high balance
• Second state – high birth rate – low death rate – high natural growth
•Third Stage – low birth rate- low death rate – low balance
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114
Population of India at a Glance
YearsTotal
Population in
Crs.
1901-1951
23-36
1951-1961
36-44
1961-1971
44-55
1971-1981
55-68
1981-1991
68-84
1991-2000 84-202
AbsoluteDecadal Average Annual Phase of Demographic
increase
GrowthExponentialTransition
(in Crs.)
Rate
Growth Rate
13
—
—
Near stagnant population
8
+21.6
1.96
High Growth
11
+24.8
2.22
Rapid High Growth
13
+24.6
2.20
16
+23.9
2.14
High growth with define
18
+2.13
1.93
signs of fertility decline
India’s Demographic Achievement
Parameter
1951
1981
1991
Current
NPP – Goals for 2010
Population (in million)
361
483
846
1028
1107
(2001 Census)
1111
Current (estimate)
Crude Birth Rate (per 1000 population)
40.8
33.9
29.5
25.0
21
(SRS)
(SRS)
(SRS 2000)
Total Fertility Rate
6
4.5
3.6
2.9
2.1
(SRS)
(SRS)
(NFHS 98-99)
Maternal Mortality Ratio (per 100, 000 live births)
NA
NA
437
407
100
(92-93)
-1998
Infant Mortality Rate (per 1000 live births)
146
110
80
63
Below 30
(1951-61)
(SRS)
(SRS)
(SRS-2002)
Literacy Rate
Persons
18.33
43.57
52.21
65.38
Males
27.16
56.38
64.13
75.85
Females
8.86
29.76
39.29
54.16
Contraceptive Prevalence Rate %
10.4
22.8
44.1
48.2To meet all needs
-1971
(NFHS- 98-99)
Full Immunization of infants
56%
100%
(from 6 vaccine preventable diseases)
ANC checkup (3 visits)
43.80%
100%
Institutional Deliveries
34%
80%
Fertility
Contraceptive Use
Infant Mortality
Death Rate
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Reasons for High Population Growth
Population growth in India continues to be high on account of
•Large size of the population in the reproductive age – group (estimated contribution
over 60%)
• Higher Fertility due to unmet need for contraception (estimated contribution 20%)
• High wanted fertility due to the high IMR (estimated contribution 20%)
STATE POPULATION POLICIES :
CONCERNS
A number of State Governments have announced or are in the process of formulating
their State Population Policies. The idea of a State Population Policy was infact to identify
and address priority issues pertinent to the specific State within a broad framework of the
National Population Policy keeping the letter and spirit of the PoA, ICPD intact.
State level Population Policies present a very mixed picture in their espousal in incentives
and disincentives. Not all state policies do this, but some clearly do.
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•Unfortunately some States have formulated State Population Policies which are framed
in the old population control mindset and have set targets for lowering fertility within a
specified time frame.
•The driving force in some of these states policies are
n demographic targets,
n population control objectives and
n disincentives, despite the fact that the Po, ICPD to which India is a signatory and NPP
2000 strongly rejects such an approach
Their implications for equity and social justice are highly questionable.
• Whatever may be the reason, the unfortunate fact is that some of these State Population
Policy documents are innocent (ignorant) of any reflection of the major paradigm shift
that population policy has undergone both globally and nationally, because either they
are unaware of the ICPD paradigm shift (which is indeed difficult to believe in this age of
information technology) or the “old population control mindset” is so ingrained which is
still very hard to discard.
• Given the crucial importance of Population Momentum (which in a way assures
further population growth in near future, no matter we introduce “two-child”/ even
“one-child” norm and unwanted fertility in our country to impose a “two-child”/ one-
child” norm to pressurize people to go for less than two children may simply be barking
up the wrong tree. This may be neither relevant nor particularly effective in bringing
down the growth rate.
•The single most important factor that can reduce momentum is raising the age at
marriage/ cohabitation specially for girls. The strongest impact of this can come through
increasing years of schooling for girls. Therefore, population momentum can only be
eased out significantly by policies that encourage women to delay child bearing as this
stretches out the time between generations.
• Recently announced Common Minimum Programme (CMP) of the UPA Government is a
very progressive document but among its provisions is a line “A sharply targeted population
control programme will be launched in the 150-odd high-fertility districts” which again is
a reflection of a mindset which believes there is a big population problem.
• It is indeed a little worrying trend because at a time when the Reproductive and Child
Health (RCH) Programme is recording significant structural and long term impact, the
Indian experience does not warrant a shift back from the social development approach.
There appears to be a very thin dividing line between awareness creation, gentle
persuasion, voluntary decision and of course force/coercion.
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• If this approach is not handled properly, it will ultimately end up in a situation leading
to “two child” norm and the chances of widespread sex pre selection and sex-selective
abortions of the female foetus leading to distorted sex ratio in 0-6 years child population.
The other probable fall out of this focused campaign mode approach may be that the
health functionaries might be pre-occupied again with family planning goals/targets
and terminal contraception (citing as voluntary adoption), neglecting services related to
women’s health and quality of care, the two cardinal features of Reproductive and Child
Health (RCH).
THANK YOU
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Investing in Young People’s Health:
Issues and Challenges
A. R. Nanda
Executive Director
Population Foundation of India, New Delhi
Adolescents, Youth, Young People
• Adolescents 10-19 yrs of age (early 10-14 yrs, late – 15 to 19 yrs)
•Youth: 15 to 24 yrs
•Young People: 10-24 yrs
World Population Report 2003
The National Youth Policy of India recognizes people in the age group of 13 to 35 yrs.
Why Talk about Young People?
Globally
• Nearly half of the population is of people under 25 yrs
• Almost 22.5% of young people live on less than USD 1 a day
• Half of all new HIV infections occur in people aged 15-24 yrs
•Unmet need for contraception is highest among adolescent women
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Why Talk about Young People?
India
• 33 percent of married women are in the age group 15-19
• 28% of adolescents in the age group 10-19 are illiterate
• Just 10% of the married adolescents in the age group 15-19 use any method of
contraception (NFHS II)
Young People Face a World of Challenges
•Lack of education and other life opportunities
• Poverty, unemployment, indebtedness
• Fast changes in trade and economic trends, nature of work, required skills
•Urbanization, migration, trafficking, wars, insurgency, physical/sexual violence, substance
abuse
• Poor health and nutritional status
• High incidence of reproductive and sexual health problems and emerging epidemics,
especially HIV/AIDS
Health Risks and Consequences
Early Pregnancy
• Higher health risks, increased morbidity/mortality, reduced opportunities for education
and gainful employment
• Higher cost on health care, reduced quality human resource, reduced prospects of poverty
reduction and increased gender disparities
Slow progress in desirable demographic outcomes
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Unwanted Pregnancy
• Abortion (often unsafe), larger family size than intended, reduced chances for
development, violation of basic reproductive rights.
•Lesser investment on children’s development and increased gender inequalities
Poor quality of life, especially for women and children
Sexual Abuse and Violence
• Physical and psychology trauma, inability to have trusting relations, higher vulnerability
for further abuse and violence.
• Persistent violation of human rights and values, increased unwanted pregnancy/unsafe
abortion/STI/HIV/AIDS, reduced opportunity for education and employment, increased
crime.
Slow progress against critical health problems such as HIV/AIDS
Health Risks and Consequences
Sexually Transmitted Diseases and HIV/AIDS
• Increased reproductive morbidity, infertility, increased poverty, stigma and discrimination,
premature death.
•Loss of productive workforce, high cost of healthcare and social security for the affected/
infected.
Social and economic systems disrupted
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PFI’s Efforts
• National and state level advocacy consultations involving young people.
• Supporting the “Alliance for Young People: Towards a Healthy Future”. Promising
practices are being documented.
• Inputs on health component in the Action Plan for the National Youth Policy.
•Undertaking advocacy on ASRH issues in Bihar and Jharkhand for building a
positive environment on these issues and mainstreaming them within the available
opportunities.
•Technical support for developing State Youth Policy for Jharkhand.
A Positive Environment Prevails……
• ASRH has been recognized as an important component of national health programmes
(RCH II, ICDS).
• ASRH issues in action plan of the National Youth Policy.
•Diverse set of organizations (research, technical support, advocacy, CBOs, donors etc.)
working on this issue.
• Increasing evidence and documentation of promising practices.
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Our Investments Need to Address
•The most vulnerable (such as poor, girls, out of school)
•The root causes: education, employment, lack of health facility, age at marriage
•Direct involvement of young people in programmes
• Both service delivery and information/counseling services
• Convergence of essential services for empowering young people
•Linking evidence to policy advocacy.
Thank You
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Building Supportive Environment for
Improved Quality of Care (QoC)
through Advocacy Initiatives: An Overview
Dr. Almas Ali
Senior Advisor, PFI
Consultation on Quality of Care in Reproductive Health Programmes
7th July, 2005
India International Centre, New Delhi
BACKGROUND
• ICPD, 1994 – milestone in the history of population and development as well as history
of women’s rights.
n It heralded paradigm shift in approach to population and development
n Placed women’s equity and equality center stage
n Introduced importance of rights based programming
• A fundamental change which has occurred in recent times in conceptualizing and
implementing Population Policies and Programmes is to expand existing Family Welfare
Programmes beyond contraceptive delivery to include a range of Reproductive Health
Services with a greater emphasis on “Quality of Care” and individual’s right.
• Quality of Care (QoC) has emerged as a critical element of reproductive health
programmes.
•Emphasis on QoC was made explicit at the ICPD Cario 1994.
• High quality of care ensures that client receives the care that they deserve.
• Providing high quality care also makes sense for services providers, since improving basic
standards of care attracts:
n More clients
n Reduces per capita costs of services
nEnsures sustainability.
• Access to quality reproductive health services should also be seen within the framework
of reproductive rights.
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•UNFPA has developed a reproductive Health Quality Framework which includes nine
elements.
n Five are applicable in all situations
n While four are specific to different reproductive health conditions.
n An important feature of this framework is the inclusion of client’s participation
in management decisions which goes well beyond the concept of client provider
interaction.
Reproductive Health Programme
Quality Framework
Generic elements
(common to all RH Services)
Service- specific elements
(Specific to each RH Services)
Service environment
Access to services
Client provider interaction Equipment and supplies
Informed decision making
Professional standard and technical competence
Integration of services
Professional standard and technical competence’
Continuity of care’
Women’s participation in management
• What this framework implies is that the generic elements have to be improved and
ensured in all service environments while equipment, supplies, technical competence
will depend upon the level of service and as well as the reproductive health condition for
which services are being provided
• ICPD Programme of Action (PoA) affirms that all public and private health programmes
including family planning must improve quality of care.
•Unfortunately, QoC of reproductive health services continues to be poor in many places
in our country, despite many efforts to improve them.
• It is in this context that Advocacy assumes a major role
• Population Foundation of India (PFI) with the help of UNFPA and Ministry of Health
Family Welfare, Government of India, under Country Programme 6 (CP6) had initiated
issue-based advocacy for strengthening Quality of Care of reproductive health services
in 2004.
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Objectives
The broad objective was to build supportive policy and programme environment for improved
quality of care through advocacy initiatives.
The specific objectives were
•To orient and sensitize various stake-holders like policy makers, programme functionaries,
public-private health care providers, NGOs, PRIs and women’s groups on quality of care.
•To present an overview of the quality of care with special reference to RCH services
(supply side) and experiences on mobilization for quality of care (demand side) in India
during post Cairo period.
•Documentation and dissemination of lessons learnt and best practices.
•To recommend effective approaches for achieving improvements in quality of health care
and their sustainability.
Under this project four advocacy workshops were organized with the help of local NGOs at
:
nLucknow – Sahyog
n Jaipur - Prayas
n Bhubaneshwar - BGVS
n Ranchi – PFI, Yarsh Project, Jharkhand
• Representatives from the government, civil society, medical college, media, local NGOs,
attended the workshop.
Some Insights from these Workshops
• A critical reason for under utilisation of services is that clients perceive the quality
of services to be poor to merit use.
• Perception quality influences client’s decision regarding utilisation and non-
utilisation of a specific service from a particular source.
•Lack of basic facilities at the health care institutions (e.g water supply, cleanliness,
availability of toilets, electricity etc.) affects client’s satisfaction.
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• Inadequate attention for privacy remains a major concern.
• Another key component affecting quality is the attitude of the service providers.
• Major reasons for not accepting contraception includes fear of side effects, limited access
& lack of knowledge about contraceptives.
• Informed decision making a hallmark of quality is seriously compromised in such
situation.
• In view of incidences of method related complications continuity of care is an important
quality element.
• Continuity of care is also crucial in terms of ANC, Natal and post-partum care, child
survival/ health services and RTI management.
• Non-availability of essential package of service in absence of a referral linkage, dissuade
clients from seeking services from the public systems.
Each workshop came out with various recommendations which was discussed at a
National Dissemination Meeting on 17th December 2004 at PFI.
Discussions at this Meeting Highlighted the Following Issues
• Social audit has to emerge as one key activities to ensure quality of care.
•Efforts to outline technical standards, client’s rights and citizens charter by IPPF can form
templates for designing these in India.
•Efforts need to be directed at increasing the capacity of providers.
•Emphasis on population will continue to undermine efforts to provide quality services.
• Advocacy on Quality of Care should be one of the most important strategies in the
future
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An Advocacy Handbook on Quality of
Care has been prepared and published in
both English and Hindi and was released
in that meeting.
Way Forward
•Various promising developments at the policy and programme level are encouraging.
•The challenge to shift the programme from merely increasing coverage to quality is
however, formidable.
•Effective advocacy is required with various stakeholders like Policy makers, Media, NGOs,
PRIs, Gram Panchayats, Mahila Mandals , SHGs etc.
• Advocacy efforts at various levels would help generate an understanding of the issue,
recognizing the importance of it and acting positively to address the same.
•This consultation is an attempt to carry forward the advocacy efforts on Quality of Care,
which we initiated last year.
THANK YOU
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Primary Health Care
Key to Population Stabilisation
Dr. Almas Ali
Senior Advisor, PFI
National Conference on Health Reforms and Social Sciences:
Challenges Ahead
18th March 2006
NIHFW, New Delhi
Linkage between–
n Social Development
n Health Status
n Population Stabilization
• Many Changes in Thinking on Population Issues
• Brief History of Population Debate
• ICPD, 1994 – Watershed in the History of Population Thinking
• Myth about Population Growth
• National Population Policy
• Primary Health Care – Key to Population Stabilization
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ICPD 1994 - was a milestone in the history of population and development as well as
history of women’s rights.
n It heralded paradigm shift in approach to population and development
n Placed women’s equity and equality center stage
n Introduced importance of rights based programming
• Two fundamental changes which have occurred in recent times in conceptualizing and
implementing Population Policies and Programmes are :
One
• To ensure that these Policies and Programmes address the root cause of high fertility
such as persistent gender disparities in access to education, food & nutrition, health,
employment and other productive resources.
•One of the cruelest forms of gender disparity is the phenomenon of sex selection and
Pre-Birth Elimination of Females (PBEF).
•The theme of ‘Missing Girl’ is an interface between population and gender.
• It captures foremost concern of population and development issue, namely
nDeclining child sex ratio,
n Sex selection,
n Sex selective abortion (Female foeticide/PBEF)
n Gender and equity concern.
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Two
• Is to expand existing Family Welfare Programmes beyond contraceptive delivery
to include a range of Reproductive Health Services with a greater emphasis on
“Quality of Care” and individual’s right.
• Quality of Care (QoC) has emerged as a critical element of reproductive health
programmes.
•Emphasis on QoC was made explicit at the ICPD Cario 1994.
Stages of Demographic Evolution
First stage – High Birth Rates – High Death Rates – High Balance
Second stage – High Birth Rates – Low Death Rates – High Natural Growth
Third stage – Low Birth Rates – Low Death Rates – Low Balance
Myth
India is currently going through a “Population Explosion”
Reality
Infact, India’s population growth rate has been declining steadily over the last
two decades since 1981.
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Population of India at a Glance
YearsTotal
Population in
Crs.
1901-1951
23-36
1951-1961
36-44
1961-1971
44-55
1971-1981
55-68
1981-1991
68-84
1991-2001 84-102
AbsoluteDecadal Average Annual Phase of Demographic
increase
GrowthExponentialTransition
(in Crs.)
Rate
Growth Rate
13
—
—
Near stagnant population
8
+21.6
1.96
High Growth
11
+24.8
2.22
Rapid High Growth
13
+24.6
2.20
16
+23.9
2.14
High growth with define
18
+2.13
1.93
signs of fertility decline
Decadal Growth Rate is Declining
1971-81
1981-91
1991-2001
24.6%
23.9%
21.3%
Infact recent, decadal growth rate during 1991-2001 is the sharpest decline since
independence (even less than 21.6% during 1951-61)
Average Annual Exponential Growth Rate is Declining
1971-81
2.20%
1981-91
2.14%
1991-2001
1.93%
Average Annual Exponential Growth is also the lowest since independence
(even less than 1.96%, which was during 1951-61)
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• Fertility has also declined. Total Fertility Rate (TFR) i.e. the average number of children a
woman would have, has come down from 6 in 1951 to less than 3.
• Now couples have fewer children and opt for smaller families.
• For the first time in 2001 Census - the proportion of children under 6 years has also
come down – a clear indication of the fertility decline.
If this is so Then why overall growth in India still appears to be high?
•Yes the numbers are growing because what is called “Population Momentum”
n Past Trends in fertility and mortality (high fertility low mortality) from 1951-81, has
shaped the population age structure in such a way that there is “bulge” in the
proportion of young people in the reproductive ages.
nThis tendency of growth is termed as population momentum.
• In short, India is high proportion of Young Persons (over 60%) who are in reproductive
age group or will so be so.
•Even if this group produces fewer number of children (just two or even one) per couple
the “Quantum increase” is high because the number of reproductive couples is high.
• Quantum increase in number will continue to be high for some more time (20-30 years)
because of phenomenon of Population momentum
•The single most important factor that can reduce momentum is raising the age at
marriage/ cohabitation specially for girls. The strongest impact of this can come through
increasing years of schooling for girls. Therefore, population momentum can only be
eased out significantly by policies that encourage women to delay child bearing as this
stretches out the time between generations.
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India’s Demographic Achievement
Parameter
1951
1981
1991
Current
NPP – Goals for 2010
Population (in million)
361
483
846
1028
1107
(2001 Census)
1111
Current (estimate)
Crude Birth Rate (per 1000 population)
40.8
33.9
29.5
25.0
21
(SRS)
(SRS)
(SRS 2000)
Total Fertility Rate
6
4.5
3.6
2.9
2.1
(SRS)
(SRS)
(NFHS 98-99)
Maternal Mortality Ratio (per 100, 000 live births)
NA
NA
437
407
100
(92-93)
-1998
Infant Mortality Rate (per 1000 live births)
146
110
80
63
Below 30
(1951-61)
(SRS)
(SRS)
(SRS-2002)
Literacy Rate
Persons
18.33
43.57
52.21
65.38
Males
27.16
56.38
64.13
75.85
Females
8.86
29.76
39.29
54.16
Contraceptive Prevalence Rate %
10.4
22.8
44.1
48.2To meet all needs
-1971
(NFHS- 98-99)
Full Immunization of infants
56%
100%
(from 6 vaccine preventable diseases)
ANC checkup (3 visits)
43.80%
100%
Institutional Deliveries
34%
80%
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Fertility
Contraceptive use
Infant Mortality
Death Rate
Reasons for High Population Growth
Population growth in India continues to be high on account of
•Large size of the population in the reproductive age – group (estimated contribution
over 60%)
• Higher Fertility due to unmet need for contraception (estimated contribution 20%)
• High wanted fertility due to the high IMR (estimated contribution 20%)
National Population Policy (NPP), 2000
• NPP is an affirmation and articulation of India’s commitment to ICPD Agenda.
• It forms the Blue-print for Population and Development Programmes in the Country.
• It favours a more open
n Information
n Awareness and
nEmpowerment Approach
• It infact sums up “Population Stabilisation” as a “Multi Sectoral” Endeavour.
• In principle, it is against incentive/disincentives.
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•The NPP is gender sensitive and incorporates a comprehensive holistic approach to
health and education needs of women, female adolescents and girl child.
• A primary theme running through the NPP is provision of quality services and supplies
an arrangement of a basket of choices. People must be free and enable to access quality
health care, make informed choice and adopt measures for fertility regulation best suited
to them.
National Population Policy (NPP), 2000
• Vision
• Objectives
• Socio-demographic Goals - 14
• Strategic Themes – 12
National Socio-Demographic Goals 2010
• Address the unmet needs for basic RCH, supplies and infrastructure.
• Make school education up to age 14 free and compulsory and reduce drop-outs to
below 20% at primary/secondary school levels for both boys & girls.
• Reduce infant mortality below 30 per 1000 live births.
• Reduce maternal mortality below 100 per 100,000 live births.
• Achieve universal immunisation against all vaccine preventable diseases.
• promote delayed marriage for girls, not earlier than 18, and preferably after 20 years of
age.
• Achieve 80% institutional deliveries and 100% deliveries by trained persons.
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• Achieve universal access to information, counseling, and services for fertility regulation.
• Achieve 100% registration of births, deaths, marriage, and pregnancy.
• Contain the spread of HIV/ AIDS and promote greater integration with the National AIDS
Control Organisation in managing the RTI and the STI.
• Prevent/control communicable diseases.
• Integrate Indian Systems of Medicine in the provision of RCH services, and in reaching
out to households.
• Promote the small family norm to achieve replacements levels of TFR.
• Bring about convergence in the implementation of related social sector programmes, so
that family welfare becomes a people centred programme.
Strategic Themes
1. Decentralized planning and programme implementation.
2. Convergence of Service delivery at village levels.
3. Empowering women for improved Health and Nutrition.
4. Child Survival and Child Health.
5. Meeting the unmet needs for family welfare services.
6. Under-served population groups:
a.Urban slums;
b,Tribal communities, hill area population and displaced and migrant populations;
c. Adolescents;
d. Increased participation of men in planned parenthood.
7.Diverse health care providers.
8. Collaboration with and commitments from non-government organizations and the
private
sector.
9. Mainstreaming Indian Systems of Medicine and Homeopathy.
10. Contraceptive technology and research on reproductive and child health.
11. Providing for the older population.
12. Information, Education and Communication.
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There exists a linkage between Social Development, Health Status and Population
Stablisation.
The Issue of Population Stablisation is not a technical issue that has a technical quick fix
solution. The answer does not lie in pushing sterilization and chasing targets. For population
stabilization it is important to improve people’s access particularly women’s access to quality
health care.
• Women must have access to essential and emergency obstetric care.
• Contraceptive mix needs to be enlarged and expanded.
• Need to revitalize community based health initiatives.
Obvious route to population stabilization is through social development
through women’s empowerment through greater gender equality. Women’s
empowerment is critical to human development.
Key Challenges in Implementation of NPP, 2000
• Following a rights and equity based approach is as challenging as bringing the fertility levels
to the desired 2.1. Implementation of NPP therefore puts forth the dual task of ‘meeting the
desired goals’ by ‘following the desired process’. Some of the key challenges are:
• Implementation of action plan of NPP needs to be suffused with a transformation of the
conventional mindset and style of functioning of the people working with the system.
• Generate debate and discussion in order to develop consensus among various
stakeholders about the human centred approach towards population and development.
• Setting up the mechanism to monitor the implementation, interstate variations and
suggest corrective action.
• Strengthening primary health care system and making FP/RH services part of
comprehensive health care package.
The key challenge facing us, therefore, is how to position family planning and population
programmes in the wider canvas of primary health care.
Overall-Socio-Economic Development
Health
Education
Nutrition/food & security
Employment
Poverty alleviation
Comprehensive Primary Health Care
Broader Context of Reproductive Health and Rights
Positioning Family Planning
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Five Principles of Primary Health Care
1. Equitable Distribution
2. Community Involvement
3. Focus on Prevention
4. Appropriate Technology
5. Multi-sectoral Approach
Eight Essential Elements of Primary Health Care
E -Education about Prevailing Health Problems – How to prevent and control them.
L -Locally endemic diseases – Prevention and control.
E -Expended Programme of Immunization (now/UIP-Universal Immunization
Programme).
M - Maternal and child health care including family welfare/planning.
E -Essential drugs provision.
N - Nutrition and food supply.
T -Treatment of common diseases / minor ailments.
S - Safe water supply and basic sanitation.
Seven Supporting Activities for Primary Health Care
S - Sectoral Collaboration (intra and inter).
U -Utilization of appropriate technology for health.
P - Participation from community.
P - Provision of resources.
O -Organization and management development.
R - Research (Action/Operation).
T -Training and Manpower Development.
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• Strengthening community needs assessment beyond FP including other health issues.
•Ensuring community participation in monitoring of health services (social audit of
services)
•Developing practical indicators for assuring Quality of Care (QoC)
Opportunities for Achieving NPP Goals
through Necessary Convergence
• NRHM appears to have brought back the primacy of Alma Ata declaration and
comprehensive Primary Health Care.
• NRHM provides a platform for:
n Fostering inter-sectoral co-ordination.
nDecentralized planning and implementation.
n Strengthening of Primary Health Care.
n Involving communities in monitoring services and convergence at the village level.
All of these have a potential to contribute towards
achieving socio-demographic goals of the NPP.
While NRHM is an opportunity for systemic reforms and
developing convergence mechanism for achieving the socio-
demographic goals of this nation, it is essential to remind
ourselves that the essence of NPP is empowerment of people
and that it needs to be pursued as a national movement.
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“In the new millennium, nations are judged by the well-being of
their peoples; by levels of health, nutrition and education; by the
civil and political liberties enjoyed by their citizens; by the protection
guaranteed to children and by provisions made for the vulnerable and
the disadvantaged. The vast numbers of the people of India can be its
greatest asset if they are provided with the means to lead healthy and
economically productive lives”
– National Population Policy, 2000
Curbing population growth cannot be a goal in itself. It is only a
means to development. If development can help in stabilising the
population, truly that is a much better and superior solution to one
where population growth is curbed in the hope that development will
automatically follow. Therefore, improvement of health and nutrition,
on the other hand, can be an end itself and will lead to population
stabilization. Surely, this is a better approach.
It is high time, that we stop counting people and instead start
counting on people. Public action is required to expand people’s
capabilities, to enlarge opportunities and choices, to invest on
social sectors such as education, health, nutrition, etc, and to
promote women’s empowerment. The simple mantra of
population stabilisation is
“take care of the people and population
will take care of itself.”
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Advocacy Initiatives on the theme of
“Missing Girls”: An Overview
Dr. Almas Ali
Senior Advisor, PFI
Consultation on “Missing Girls”
7th July, 2005
India International Centre, New Delhi
Background
• ICPD, 1994 – milestone in the history of population and development as well as history
of women’s rights.
n It heralded paradigm shift in approach to population and development
n Placed women’s equity and equality center stage
n Introduced importance of rights based programming
• A fundamental change which has occurred in recent times in conceptualizing and
implementing Population Policies and Programmes is to ensure that these Policies and
Programmes address the root cause of high fertility such as persistent gender disparities in
access to education, food & nutrition, health, employment and other productive resources.
•Therefore, the focus of PFI is to reduce the gender disparity and gender gap.
•One of the cruelest forms of gender disparity is the phenomenon of sex selection and
Pre-Birth Elimination of Females (PBEF).
•The theme of ‘Missing Girl’ is an interface between population and gender.
• It captures foremost concern of population and development issue, namely –
nDeclining child sex ratio,
n Sex selection,
n Sex selective abortion (Female foeticide/ PBEF),
n Gender & equity concern.
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• PFI identified the issue of ‘Missing Girl’ as one of the priority areas of Advocacy.
• In 2003, PFI initiated with the help of Plan International, India State-level advocacy on
the issue of Sex Selection and Pre-Birth Elimination of Females in eleven states namely
Delhi, Andhra Pradesh, Uttar Pradesh, Uttaranchal, Gujarat, Haryana, Punjab, Himachal
Pradesh, Orissa, Maharashtra and Rajasthan.
• Stakeholders – MLAs and corporate leaders.
• In Delhi and Andhra Pradesh the stakeholders were widen to media, medical professionals,
and school teachers.
•To have a meaningful impact it was realized to take advocacy activities down to district
and sub district levels.
•To widen the stakeholder at the district and sub district levels.
• Increase the type of activities at various levels.
• In 2004, PFI in association with UNFPA had launched an advocacy campaign at the
district and block level in seven states – PFI tied up with state level NGOs in the state to
carry out various advocacy activities. The states and the NGOs identified were:
n Punjab - VHAP
n Haryana - FPAI
n Maharashtra - Cehat
n Gujarat - Chetna
n Rajasthan – Prayas
n Himachal Pradesh - Sutra
nDelhi - CWDS
•Various Advocacy initiatives like
n Campaign
n Rallies
n Focus Group Discussions
n Workshops/ Seminars were entrusted to above NGOs to carry out in specific locations.
•The campaign tried to communicate the following issues to the stakeholders
(Civil Society at large)
n What will happen to families if girls would be missing in such a rapid way
nLegal literacy – PNDT vis-a-vis MTP – illegality of sex selection and legality of safe abortion
n Positive value of girl child / women
n Gender discrimination – violation of right
nDowry is illegal and women have an equal right to property.
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Advocacy activities on “Missing Girls” has clearly brought out from last year’s experience
the following:
•The theme of Missing Girls is really an interface between population & development and gender.
• It should be looked in a wider perspective covering sex ratio & sex selection issues in a
broader gender and Reproductive Health (RH) framework.
•The correctness of the idea (abortion is legal should be communicated. Distinction
between PNDT act and MTP act needs to be clearly shown in the campaign in future.
•There must be continued contact with community and with grassroot people.
nThe campaign should be sustained for a longer period of time.
n It is an opportune time to focus on translating Advocacy into Action.
nThis should be done meaningfully forging linkages between local NGOs/ CBOs and
Appropriate Authorities.
• In today’s consultation we would share the experiences of our partner NGOs and
come out with concrete strategies to take forward the advocacy campaign on “Missing
Girls”.
THANK YOU
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Compilation of
Supporting Documents
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February 13, 2004
Dear* Sonia ji
Very soon your party will come out with your election manifesto for the forthcoming
parliamentary elections. We in the Population Foundation of India (PFI), which has been in the
forefront of advocacy on Population and Development issues over last three decades, like to submit
for your kind consideration the following for inclusion in your party manifesto.
In fact, the initiatives for a new National Population Policy was taken by the Congress
Government in the early 1990s when they appointed an expert group under the chairmanship of Dr.
M S Swaminathan, to draft a National Population Policy. The report produced by the Swaminathan
Committee was remarkable for it’s time, being written as it was in the year 1993 (a year before
the International Conference on Population and Development (ICPD), Cairo 1994). It called for a
radical shift to a policy that would be “pro-poor”, “pro-women”, and “pro-nature” and argued for
a bottom-up and needs based approach. The National Population Policy, 2000 has in fact largely
adopted the sprit of this report.
We believe that under your able leadership the country will move to greater heights if the
following commitment is made in your election manifesto.
Mission Statement
“Our party is committed to develop a new generation for the new millennia, which
belongs to India and other developing countries. This ancient country at this moment of
history is very young and youthful. This youthful population is the creator of our National
Wealth, and therefore, it needs to be adequately equipped with health, education, technology
and skills. Towards this, it is our commitment to deploy more resources to make every
Indian - man or woman, a nation builder. This is possible when we achieve the miracle of
sustainable development & demographic transition, the signs of which have already taken deep
roots in the country.”
The priority issues we promise to address are:
• Recognition of close linkages between sustainable development and population stabilization.
•Link population programmes with other development initiatives like health, education, nutrition
and poverty alleviation programmes.
• Follow a non- coercive, rights based and gender sensitive approach for population
stabilization.
* Similar letters were sent to Heads of all political parties
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• Create an enabling environment for the poor and marginalized to have a small but a happy
and healthy family by choice and not through coercion, incentives and dis-incentives and not
through imposition of two child norm from above.
• We do not believe in targets for family planning to be imposed from above.
• Improve health and family planning services for the poor by addressing issues of access and
quality.
•Design and plan health, population and social development programmes for local communities
(each village and each ward of an urban area) based on the felt needs of the community and
by the community itself.
• Self Help Groups (SHGs), Panchayat Raj Institutions (PRIs) and Community Based Organizations
(CBOs) to be involved in planning, implementation and monitoring of programmes.
• Focus on adolescent and youth (10-24 years) to make them healthy and productive through
gender - sensitive and value - based Family Life Education including on sexual and reproductive
health.
• Convert 1.07 billion people into productive assets of society to make India into a
developed country – a vibrant economy and society.
We shall be grateful if you could kindly consider the above suggestions for inclusion in your
party’s election manifesto.
With kind regards,
Yours sincerely,
A. R. Nanda
Ms Sonia Gandhi
President
Indian National Congress
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June 2, 2004
Dear Mr. Prime Minister,
May I be permitted to offer you my sincere congratulations on assuming the high office of
Prime Minister of India to lead the country on its march to progress. There could not have been
a better choice and I need hardly say that you have the utmost goodwill and support of millions
behind you in your endeavours.
I would also like to say how deeply proud and grateful we are to the true daughter of India,
Sonia Gandhi, for her profound dedication, wisdom and political sagacity in serving the country.
I am now writing in my personal capacity in connection with the Common Minimum Programme
just issued by your Government. It briefly covers a vast area of work. In it under the caption of
Women and Children it states that “The UPA government is committed to replicating all over the
country the success that some southern and other states have had in family planning. A sharply
targeted population control programme will be launched in the 150-odd high-fertility districts.
The UPA government recognizes that states that achieve success in family planning cannot be
penalized.”
It is good to note that family planning has been listed among other important measures and that
the successes in some southern and other States have been noted. But I must confess that the language
“a sharply targeted population control programme” is somewhat disturbing. This
sentence is strongly reminiscent of the past where “targets” and “control” have shown their
inadequacy at best, and their coercive nature at worst, in promoting, such a sensitive, intimately
human programme as family planning.
Experience gained over the years has outdated this approach and language, and it is the
“human face” (which you yourself have so rightly emphasized) that must be highlighted as the
right of all persons to get accurate information, and the means and quality services, to practice
family planning by exercising their own informed choice. Also, those of us who have worked in
this field for many years strongly uphold the fact that family planning is not an isolated programme
but is a part of a constellation of measures including safe motherhood, infant and child survival,
education for all, valuing the girl child, women’s skills training and empowerment and meeting the
needs of adolescents on the one hand, and infrastructural programmes like water, sanitation, roads,
electricity and village betterment on the other. Population and development are thus inextricably
interlinked and measures to advance them also need to be promoted on a broad horizontal front.
It is fitting that, as the CMP indicates, the programme will strongly focus on the 150-odd high
fertility districts. But these are precisely the districts where maternal and infant mortality is very
high and there are huge lacunae in education, in women’s status and rights, and in economic
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and social development and all these social and developmental indices need to be tackled in a
holistic, inter-related manner, rather than “targeting” family planning. Also, these are the very
districts which are lacking in voluntary organizations and people’s participation is low. Self-help
groups and other types of voluntary efforts need to be actively encouraged and supported in these
areas.
I do hope that in terms of practical implementation, your Government will give all of us a fresh
impetus, and encourage a “human face” in the different aspects of the programme in an effective
manner, to bring to the people a greater access to information and quality services on various
health aspects including family planning, which they can value and in which they can participate.
The National Population Policy 2000 has provided a comprehensive overview of an integrated
programme and given useful leads as to the nature and the process of the programme.
In conclusion, may I say that I have been a volunteer worker in this field of family planning and
population concerns (now known as a programme for Reproductive and Child Health) for over 50
years, being a founder-member of the Family Planning Association of India and the International
Planned Parenthood Federation, and having worked closely with Government. Hence my continuing
deep interest in and endeavours to help in making a success of this national programme.
Thanking you and with renewed sincere congratulations and good wishes,
Yours sincerely,
Avabai B. Wadia
President Emeritus, FPAI
Patron, IPPF
Hon’ble Dr. Man Mohan Singh
Prime Minister of India
South Block
New Delhi 110011
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STATEMENT OF CONCERN
ON THE PPROPOSED
RURAL HEALTH CARE MISSION (2004)
Introduction
• We believe that any Health Programme has to have strong links with the Panchayati Raj
System.
• We believe that any program has to be in the context of Comprehensive Primary Health Care
within which RCH is one of the components.
•The rural health care mission should not become yet another vertical programme. It needs
intra-sectoral coordination and needs to be implemented with inter-sectoral linkages.
• We believe that Health for All can only be achieved in the context of overall development.
The Rural Health Care Mission: Some Observations
•The mission for rural health care, in its draft, emphasizes the lack of horizontal connections
between several vertical programmes in the country; but in the implementation strategy this
has been overlooked and reads like an isolated vertical programme, focusing on population
control.
• We reiterate that it has to include the whole country. It should not be on the basis of TFR, but
on the basis of a composite index that could capture social and human development.
• We support the concept of ASHA - based on all our field experience in rural, urban and tribal
areas.
• We are concerned that this programme should not become a mere strategy for ‘population
control.’
• A comprehensively trained worker will be a major asset to the community and Panchayati
Raj.
•Training has to be district specific - the NIOS and distance education mode only provides a
universal quality assurance.
•Village health worker scheme cannot be implemented without also strengthening the public
health care system at all levels.
• Re-orientation of training and regulation of the other existing health personnel needs to be
simultaneously addressed.
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• Regulation of the private sector at all levels across all systems of medicine is required.
Our Recommendation
• Community health workers should be predominantly women. And should be recognized as an
asset to the community.
•The most optimal process of selection is one that is a facilitated process by the community.
•There should be continuing training and support.
•The worker should be paid by and accountable to the community.
•The implementation at all levels will be through partnership with PRIs/CBOs/Govt. This
approach has been borne out by several large scale experiences across the country.
We strongly emphasize that such a program should not be rushed through. This program needs
further meaningful consultations with state governments and civil society. As it has been put in
the public domain, there is need for time for a meaningful public debate.
Signed
Dr. N H Antia,
Director, Foundation for Research in Community Health, Pune & Chairperson Jan Swasthya
Abhiyan.
Dr. Thelma Narayan,
Co-orddinator, Community Health Cell, Bangalore.
Dr. Sundararaman,
Director, State Health Resource Centre, Chhattisgarh.
Dr. Almas Ali,
Senior Advisor, PFI, New Delhi.
Dr. Rama Baru,
Associate Professor, Centre of Social Medicine and Community Health, JNU, New Delhi.
Dr. Mittal Shah,
Health Coordinator, SEWA, Ahmedabad.
Dr. Rakhal Gaitonde,
Research Officer, Foundation for Research in Community Health, Ralegan, Siddhi.
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DISCUSSION NOTE ON THE
COMMUNITY HEALTH WORKER
IN THE RURAL HEALTH MISSION –
28TH NOVEMBER 2004
This meeting was in continuation of our earlier discussions on the Rural Health Mission in your
office on 21st October 2004 and your subsequent request to devise a structure for implementation
of a Community Health Worker scheme for the Mission. The larger concerns regarding the Mission
and its scope have been articulated in the Note as presented at the aforesaid Meeting (Statement
of concerned dated 21st October 2004 attached).
Principles:
As health is a holistic and multidimensional concept, the principles on which the National
Health Mission shall be conceived are:
•That Comprehensive Primary Health Care remains the key strategy of which RCH is one of the
components.
•That comprehensive approach facilitates better inter-sectoral coordination and integration with
developmental efforts.
•That Panchayati Raj and Women and Child Development Ministries are amongst the key
ministries that must have adequate ownership over the mission.
•The community health worker is a basic element of primary level care supported by an effective
public health system.
• Monitoring and regulation of the private sector at all levels needs to be addressed.
• Any effort at grassroots level planning and community participation will present a plurality of
problems and solutions.
Processes for developing Community Health Workers:
• Community Health Workers should be predominantly women who after training will be a
permanent asset to their communities.
•The most optimal process of selection is one which is facilitated by the community itself.
•Training should not be a one-time effort but a continuing process. The training should ensure
minimum quality with contents addressing health rights and health /gender equity issues.
•The workers must be accountable to their community.
• Strategies for supporting the health worker will not be through user fees.Alternative mechanisms
for supporting the health worker would be evolved by the community.
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•The implementation at all levels will be through partnerships with PRIs/civil society organizations
and existing government institutions. This approach has been borne out by several large-scale
experiences across the country.
•The programme would be phased appropriately so that definite outcomes are visible at the
national level within a period of five years.
Structure
In order to achieve the desired goal, the structure proposed by the Group is as follows:
•The National Steering Committee comprised of officials from the officials representing the
Ministry of Health & Family Welfare, Ministry of Women and Child Development, the Ministry of
Panchayati Raj and the Prime Minister’s Office as well as the representatives of health-rights
based networks who have been actively engaged in promoting community centered public
health systems or other community-based organizations working in allied fields.
•This committee should be empowered to plan strategies as well as approve specific proposals,
coordinate and oversee the implementation of the various aspects of the Rural/National Health
Mission.
• A National Resource and Training Centre chaired by the Director, Foundation for Research in
Community Health who is also the chairperson of the People’s Health Movement (JSA) would
be constituted to act as an additional technical capacity to the Secretariat of the National
Steering Committee for assisting in the following functions:
• Identification of civil society partners at the State and district levels.
•Training of the community health workers in collaboration with existing institutions of the
government.
•Enhancing capabilities at the State level especially of the civil society partners for assisting
state governments in planning and implementation of all the objectives of the Mission.
• Monitoring programme implementation at the different levels.
•The National Resource Centre with full time professionals will be guided by a National Advisory
Committee whose members should have a track record of health rights work for at least a decade.
Additionally, this Committee would be empowered to independently induct for a specified period
any professional who may be appropriate for the issues at hand from time to time.
India is fortunate enough to have a large number of dedicated community based organizations
who can partner this programme through out the country.
N H Antia
FRCS,FACS (Hon.)
Director, FRCH
Persons who attended the meeting
Dr. N H Antia, FRCH, Pune
Mr. A.R Nanda, PFI, New Delhi
Dr. T Sundararaman, Jt. Convenor, JSA
Dr. H Sudarshan, BR Hills, Karnataka
Ms Mittal Shah, SEWA, Gujarat
Dr. Nerges Mistry, FRCH, Pune,
Dr. Vikram Gupta, PFI, New Delhi
Dr. Rama Baru, JNU, New Delhi.
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