France carries out one more nuclear explosion in the Pacific, and there is world-wide indignant condemnation, rightly so.  Close at home, another kind of bomb ticks away, the process of implosion going on every second, minute and hour of a day.  This non-stop phenomenon - the “Population Bomb” is taking a heavy toll of the environment; and the Bomb’s direct explosive fallout, a burgeoning population growing at an average rate of 1.9% will reach a figure of 1 billion by 2000 AD making sustainable development colossal task. 

We are not insensitive to this reality.  Our own concern is genuine.  India was one of the first countries free from colonialism, to launch a family planning programme.  That it has not been successful is another matter.  The world knows it.  We are not condemned, only pitied.  Uncontrolled growth of population in l.d.c.s. has been a matter of global concern.  Aids have been coming from developed countries.  A few decades ago, China, Indonesia, were not ahead of us.  How they have gradually reached a level of `control’ and we have generally failed has been and will be a subject of study and research for years to come. 

If the projections of the UNFPA are correct, by 2035 AD India will overtake China and together will account for 60% of Asian population and 35% of global population.  The question that the world-community can legitimately ask, or we should ask ourselves is “If China and Indonesia can achieve their population goals, why can’t we”?  It is worthwhile discussing the similarities and the differences briefly and examine our own scenario in somewhat greater detail.  May be, the `Bomb’ is being defused and it will not be `apocalypse’ in 2035 or thereafter.  Let’s see the comparative positions of the countries in S/SE/East Asia regions as they were, are and projected to be:

That our neighbours Bangaldesh and Pakistan are worse off than us, is no consolation.  In fact, the political repercussions are far-reaching, if they are not able to check their growth rate.  Population grows after taking into account the birts and deaths in a year.  The births in a year are a function to female fecundity. 

The statistics on these are given at Table 2. 

The fertility rate is high where couples want children as security in old age, as helper in gathering fuelwood, drawing water from distant sources, strong desire to have sons for status and cultural reasons.  A woman tends to conceive often when offsprings die very young.  The infant mortality rate is a major determinant of number of pregnancies rather than cutlural compulsions or religious imperatives. 

There is ample evidence that a low infant mortality rate (IMR) leads to a lower fertility rate.  This is true on a global basis, as well as the Indian context. 

The IMR depends on a number of factors.  The lower IMR is associated with better access to health care particularly at pre-and post-natal stages, attendance at birth by qualified midwife/auxiliary nurse, nutrition available to mother and child, and the level of women’s literacy.  When we examine the fertility transition in the developed world, status of women - socially, economically and politically, appears to have been a major causation factor.  The empowered woman has an equal, if not more, say in planning a family and she makes the choice out of the measures available for birth control. 

The other significant factor in transition to lower fertility is the female literacy rate.  Though the definition of literacy varies from country to country, empirical evidence shows that increase in the female literacy rate invariably leads to lower fertility.  This is true even in the Indian states.  Three other Asian countries viz. Sri Lanka, Malaysia and Thailand have been included in Table 3 to show that improved female literacy rate, which is a development indicator, leads to lower fertility along with the fact that in all these countries health services would have also improved considerably due to assistance from WHO, UNICEF, the World Bank and national efforts.  Immunisation programme to protect the children from the diseases such as tuberculosis, polio, diptheria, pertussis and measles have succeeded upto 80% even in the least developed countries. 

There are vast differences in the total populations of each of the countries mentioned above.  But, by no means, population of Sri Lanka, Malaysia and Thailand is small when compared to the nations of the North.  Malaysia and Thailand have been under stable governments whereas Sri Lanka has a raging civil war with secessionist Tamils for nearly two decades.  The polity in India has been in a state of flux in the last two decades, but the administrative processes had remained unchanged.  Yet, planned family programmes, which had been worked out to great details on paper, have not been as effective as expected.  The results of the family planning and welfare programme have been at great variance from one state to other.  Some states have achieved remarkable results of East Asia/SE Asia and South Asia regions.  The state-wise fertility, IMR, literacy, health/education spending figures are given at Table 4. 

The country average of fertility is around 4.  In the populous states of U. P., Bihar and Madhya Pradesh, the per capita expenditure on education and health, is abysmally low.  The literacy level of women is pathetic.  In the state of Rajasthan, the per capita expenditure on education and health is comparable with West Bengal, Andhra Pradesh and Karnataka, but the female literacy rate is the lowest in the country and the fertility rate is well above the national average.  The reason could be deeply entrenched traditional prejudices of a staunch male-dominated society acting as a barrier. 

The need of the hour is to direct energies and resources in bringing up the literacy level of women in all the states (except Kerala), but particularly so in Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan who, between them have 40% of the total population. 

Since IMR has a significant role in bringing down the fertility rate along with increase in female literacy rate, a higher percentage of national budget must be allocated to health-care; and its delivery made effective.  Sri Lanka and Thailand spend 5.4% and 3.6% of GDP on health-care achieving IMR of 24 and 26 respectively.  Indonesia spent 2% and India1.6% on health-care with IMR of 65 & 88 respectively.  Increased outlay, all other things remaining as they are (that will be indeed a sad state of affairs), is likely to help in brining down the IMR in India along with additional benefits in the life expectancy area. 

The obvious choice of strategy is, therefore, to provide for additional funds for health-care.

China, Indonesia and India have many things in common - an important characteristic is the prevalence of corruption.  China has the distinction of being the most `corrupt’ and we follow closely in the heels of Indonesia!  In spite of being more corrupt than India, China and Indonesia have performed creditably in their population front.  It is worth its while to examine how this has happened.
 

The Chinese Story 

The ideological content of the Chinese family planning aims at realising the general strategic goal of economic development.  Family planning is not merely for the well being of an individual person or family, but more importantly is more for the prosperity of the nation and the happiness of the individual and the collective must be linked with that of the state. 

Rather a late starter in family planning, China’s journey to success has been achieved primarily through pressures applied on the population of varying degrees.  The party apparatus is able to reach the grass-roots.  Goals decided by the party are sacrosanct and they are executed with ruthless enthusiasm by the cadres.  The state raised the age of marriage.  The slogan became late marriage, late pregnancies, fewer children.  There were educate the masses on the advantages of small families.  That population control is the means to alleviate poverty, was propagated through communes and state owned enterprises to the rural, industrial and urban sectors.  People learnt to adopt contraceptive measures and responded.  The policy was implemented by provinces, prefectures and countries and each enjoyed flexibility of operation control and could make variations and exceptions. 

The policy of 1979 became somewhat draconian in that China adopted a one-child norm.  Incentives and disincentives were worked out at local levels.  There were instances of coercive enforcements including forced abortions.  Simultaneously however, vast improvements were made in health education, raising literacy levels, better delivery of mother-child health care and setting up of `technical services’ to provide consultation services to the population, free supplies of contraceptives and performance of sterilisation.  It is acknowledged worldwide that China has established an effective `Family Planning Infrastructure’.  The `barefoot’ doctors brought birth control to each individual in China from door to door on a one-to-one basis.  This required organised training of committed cadre and effective supervision.  China, like India, too set targets and managed to reach them.  It is not an uninterrupted story of success.  But, the decentralisation and flexibility were its major strengths.  The party knew how far people could be pushed and it stopped there. 

The preference for a 2-3 child family exists in the rural areas.  The one-child norms is not popular and the state, realising this, has revised the policy that gives it a more humane face. 

In China, as in India, the women do not have many choices in family planning.  The keystone of the programme is acceptance of the inexpensive steel IUD, and sterilisation (Tubule legation).  Contribution of the male towards family planning seems to be on the low side at about 16% of which 11.6% is vasectomy.  It appears that access to short-term contraceptives is not promoted to the extent that long-term methods are made available. 

The population control has proceeded side by side with all-round development.  A flexible, decentralised programme with an adequate workforce of health-education workers, and increased literacy, decreased IMR and gradual acceptance of family planning by people, at times under pressure, have all contributed to China’s success story.  No doubt, the party and the `state’ meant business and did not hesitate to adopt harsh measures. 

The ongoing economic boom will enable the state to be a better provider of services for poverty alleviation and the economically stronger population will seek a higher level of living and with further improvement of women’s education level and health care, the acceptance of a nuclear family norm is likely to be universally adopted on a voluntary basis.
 

The Indonesian Story 

Two decades ago, Indonesia and India were almost at the same point in population growth.  (Table2) The successful Indonesia effort at controlling this growth rate is in sharp contrast to the Indian experience which had a two-decade lead over Indonesia in family planning.  The pertinent question that arises is why did Indonesia succeed and India fail?

Indonesia is a country remarkable for its diversity.  It is the world’s largest archipelago with 13,667 islands stretching 5110 km from West to East and nearly 2000 km in the north-south axis.  Only 3000 islands are inhabited and more than 60 percent of all Indoneisans live on Java island.  There are more than 300 ethnic groups speaking 360 languages. 

Economic prospects were bleak in 1960s.  There were chronic inflation and balance of payments difficulty with increasing political instability.  The leadership changed in the late sixties, huge reserves of oil and LNG were discovered, explored and developed and in the mid 70s, the economy started booming.  The surplus on the b.o.p. was judiciously utilised for development of the infrastructure - roads, communications, irrigation along with ushering of the green revolution and Indonesia embarked on a planned population control programme.  The National Family Planning Coordination Board was set up with the President of the Republic as its Head.  Motivation of the population at village level, delivery of health-services, improvement in women’s literacy field, patient dialogue with the religious leaders, and involvement of leaders and administrators at all levels led to the decline of the birth-rate, IMR (Table 3) and the fertility rate.  The present trend of growth at 1.8 percent is not alarming and with an increasing GNP, and better education/health services, Indonesia may be able to reach the Net Replacement Rate in a planned manner in the next decade. 

Family planning strategy acknowledged the need for the people to have knowledge on contraceptive methods and provided one FP field worker for 2-3 villages.  In the mid-seventies, it was found that 75% or so of `eligible couples’ were aware of family planning and its advantages.  Starting with a new acceptor figure of 58,100 in 1969/70, the number of new acceptors was steadily increased to 4 million by 1981/82 exceeding the planned target by nearly 50%! 

The pattern of contraceptive use had been undergoing changes.  To begin with (1969-70), the first option of the family planning acceptors was IUD (54.7%), the pill (27.5%) and the condoms (17.8%).  In a decade, the preference changed to the pill (69.9%), followed by IUD (17.9%) condoms (7.5%), and other options (4.7%).  Sterilisation plays a minor-role-not more than 2% goes for this terminal method.  However, the use of condoms is actively promoted for prevention of AIDS. 

The success of the Indonesian story has the ingredients of political wisdom, augmenting the health and family infrastructure as the economy flourished, overcoming constraints of trained manpower, associating the village volunteers with the programme, patient dialogue with religious groups leading to approval of IUD’s by women and the tradition of mutual self-help through volunteer service. 

That the message for family planning has really gone home can be deduced from the fact
that 60 percent of family planning acceptors in Indonesia are couples who are young of age, have little education and are farmers.  And, reaching this group has the greatest demographic impact.
It is perhaps only in Indonesia that percentage of rural population practising
family planning is higher than in urban area.  The role of the village volunteers is indeed laudable.
 

The Indian Story 

It is a great irony in the history of development that India, which was the first of the newly independent states too adopted a family planning programme in the very first 5-year plan has been left way behind by China, Indonesia, Malaysia who were at the same base level of underdevelopment in the 50’s.  In the words of Pandit Nehru, “We have come to grips with this problem of population....  It does not matter how far and how much you succeed in evolving feasible, simple, and cheap methods of birth-control if the hundreds of millions of our people do not make good in other ways, economically and educationally.  In order to achieve to go hand in hand with the general economic and social advance in the country.... the movement of family planning becomes a part of the larger movement for raising the standard of living of the people”.  He knew the problem, had the wisdom to address it, but the effort remained just a statement.  Had primary education and mother and child health received the same priority as agriculture and state-run basic industries, the population story would have been different.  That, perhaps, is the wisdom of hind-sight.  The approach of limiting population by birth control proved ineffective without complementary supportive action in primary education and health care, particularly mother and child health.
 

Birth Control through Contraceptive Methods 

The decade of sixties saw the promotion of the `loop’ - I.U.D.   Initially popular, the method started losing appeal becuase the follow-up health-care was not available.  The funds for the family planning came from the GOI, and donor agencies such as USAID and Ford Foundation.  The minutest details of targets of each state got worked out at the Centre, and the funds allocated.  The states felt alienated.  The delivery system was weak and continues to remain so.  One of the achievements, however, is establishment of a vast network of nearly 1,50,000 family planning centres and sub-centres for a country with more than half a million villages.
 

Post Emergency Setback 

In the decade of seventies, for achieving targets, sterilisation strategy was adopted.  During the period of the Emergency, harsh coercive measures were adopted to forcibly sterilise men (vasectomy) and the excesses led to great resentment among the population resulting in a thorough drubbing of the Congress Party in the next general election after the Emergency.  An idea of the magnitude of the scale of sterilisation can be shown from the fact that in one year the number of cases went up from 2.7 million to 8.3 million and most of it involuntary. 

The `eligible couples’ had hardly any choice in selection of a contraceptive.  The `pill’ and the `condoms’ were not really actively promoted.  The pill, by and large, was used by urban, educated women. 

The `family planning’ issue became politically so sensitive that it was left on a very low-key for about a decade.  However, during this decade, the policy planners realised that without augmented MCH facilities, attention to immunisation and ante-natal services, family planning goals will not be reached.  Substantial increase in the outlays for health and education were necessary and an integrated effort has been going on for a decade now.
 

Causes for failure to achieve results 

No doubt, there is a vast network of family planning centres and sub-centres.  But the quality of services is ineffective the main factors being lack of adequate equipment, & indifferent atttitude towards its upkeep, supplies of contraceptives such as condoms and pills not reaching the villages, lack of proper facilities for training and retraining of staff, vacancies remaining unfilled due to administrative red-tape and a lack of sense of commitment.  Interpersonal communication skill for informing clients on choices available and their pros and cons, the benefits that accrue to couples who use contraception methods, is poor.  Furthermore, vigorous campaigns for promoting a particular method seem to make a family planning worker feel that his/her role is insignificant whereas the most effective strategy is that he/she should interact with couples on a one-basis.  There are exceptions to this dismal scenario, viz. Kerala, Mizoram and Goa.  Incidentally, these states have a large Christian population. 

The cultural barriers are very strong and difficult to penetrate.  The northern states of Uttar Pradesh, Bihar, Rajasthan, and Haryana are pre-dominantly bastions of male chauvinism.  Women live in seclusion and have little say in decisions on the size of the family and spcing.  To give in to a husband’s desire is still considered to be a great feminine virtue and woebegone is the woman who fails to give birth to a male child.  Frequent pregnancies till she produces an heis is the lot of a woman who is on the margin as a human being because she lacks education and is generally incapable of earning no more than very low wages as an unskilled labourer. 

Another disheartening aspect of family planning work is that the private doctors, hospitals have not been made to play much of a role in promoting family planning.  But there are over ten-thousand voluntary organisations, big and small, national and local, working in this area; the overall achievements are scrappy and they have not made a significant dent though the sincertiy and commitment and the desire for doing something are genuine.  In the Indian context, it appears that the task of family planning will remain a governmental responsibility.  The government, in its wisdom is concentrating on the four states of Bihar, Uttar Pradesh, Rajasthan and Madhya Pradesh where the fertility rates are much higher than the national average and these states account for 40 percent of total Indian population. 

The performance of some of the states such as Karnataka, West Bengal, Maharashtra and Gujarat could be better where cultural prejudices are not a major impediment, to expansion of literacy base, particularly of women.  From past data, it appears that in these states IMR and fertility rate have fallen and the literacy level risen with increased outlays in education and health care and therefore, the states must mobilise additional resources to at least provide more of the same thing, if not a better package.  The level of awareness is high and this should be backed up by service delivery.
 

Ongoing Scenario  

As it has been said earlier, the government of India formulates the most comprehensive plans for family planning.  There is a surfeit of experts with access to vital information-a veritable think-tank that does this job.  The implementation is required to be done at the grass-root level by workers who are unfortunately lackadaisical, uncomitted, without possessing much of interpersonal skills and knowledge base to counsel a couple with options available.  Often enough the end-result is frustrating. 

The administrative machinery talks of people’s participation, empowerment of women and improved delivery.  But all this sounds hollow in the face of overwhelming evidence of unbridled corrupton and deteriorating norms of attitude of public men and officials.  The contraceptives, counselling and clinical back-up perhaps remain in the realm of illusion; at best they may peripherally be improved.
 

Institutional Change: Women in Panchayat 

The political will is not likely to be any stronger than before.  Forces will re-align for the sake of expediency and power, and population control will be too hot a brick for handling.  And the pity of it all is that in a democratic country, the popularly elected representatives - the leaders, have lost credibility, respect and are mere influence peddlers and power brokers.  An air of despondent cynicism has become all prevading adding to the anguish of an Indian’s ingrained, unconscious acceptance of fatalism.  But, there is a significant change in this institutional democracy.  It has been taken to the grassroot in the form of `Panchayat Raj’ and it is  a wonderful thought, a great leap forward that one-third of the members of the Panchayat have to be women!  Are the women ready or equipped for this role particularly in the northern states?  Perhaps  not.  The attitude of the male in society seems to change only with education and that, too, in the face of empowered women and the process is slow.  But, it is worth its while in spending much more in women’s education to give her a sense of being human who can exercise an option and stands up to be counted.  Someday, and at not too distant a future, she will become a less `fertile’ woman than what she was to be without this elementary education.
 

Coercion, Persuasion versus Voluntarism 

When we contrast our lack of achievement with the spectacular results in China, we must remember the omnipresence and omniscience of the Communist Party and the absolute nature of its diktats.  A mix of service and coercion including forcible abortions, ensured that the party’s goals were reached.  It is not the individual who counts, it is the economic strength and ultimately through it, the power of the state that matters.  The means can justify the end. 

Let us not be unhappy that we have chosen a fumbling form of government that is inefficient and ineffective.  We get the government that we deserve that’s the privilege of free people.  While acknowledging the steady progress in population control in Indonesia, we tend to forget the miserable economic bankruptcy that it went through till the late sixties.  The benevolent autocracy rode on the wave of an economic boom-more of a serendipity phenomenon than a conscious achievement through a series of economic activities.  The exploration of oil and natural gas turned the wheel of fortune and Indonesians were lucky that the new-found wealth was used for creating an infrastructure in roads, communications, institutions and the social segments of health care and education.  We did too -- with our own resources.
 

We, the People 

We had to work hard for reaching our modest goals of development and economic growth without the benefit of a windfall.  But we have enjoyed prolonged political stability, albeit rocked by some disturbances and tremors at times and right not precariously poised.  We have the freedom of faith, expression and movement - the human rights.  The moot question is - are the freedoms relevant when the majority of the people are grossly undernourished,  live in sub-human conditions, have poor access to health care and education, are unemployed and have to be carried on the shoulders of society as deadwood.  As the affairs of the state and the norms of behaviour of public men descend to an abysmal chasm of callousness and insensitivity would we be required to call in the military to take over the reins?  Perish the thought.  The buck stops at our doorstep, the doors of `we, the people’.  It is our mindset that prevents us from doing what we are paid for.  It needs a Colossus of a leader to bring about a change in attitude, and such a leader is not on the horizon.  Therefore, we must depend on one thing that bring this about, so suggests empirical evidence - education - through the indirect subliminal route.
 

Education: The Agent for Change 

We have failed to meet the constitutional mandate of primary education for all and the total literacy remains an illusion.  Currently, elementary education and total literacy are receiving the deserved but long delayed focus.  The budgetary allocations are on the increase and the theoretical framework promotes decentralisation from the district, an initiative called the District Planning in School Education Programme, it can be expected to reach the blocks, panchayats and the people.  In four decades, large strides have been taken in the field as the following statistics show:

But, the drop-out rates are significant.  In 1988-89, it was 47% in classes I to V.  There are striking disparities in access to primary education-disparities between regions, rural and urban areas, boys and girls, the affluent and the deprived and all this is recognised in official plans.  The POA is almost perfect-all lessons of the past, local and glboal, seem to have gone into its making.  One of the strategies is `Operation Blackboard’.  The achievements of `Operation Blackboard’ appear to be impressive from the statistics given in Table 6. 

It is to be hoped that the toal outlay has not been gobbled up by administrative overheads and the usual corrupton-human greed cuts across all levels.  Even if half of the amount has been utilised for the purpose, something extra would have been achieved.  It is obvious that teachers recruited from the local areas would be more effective in communicating with the people and they need not be overqualified.  A minimum of high school with a training period of three to four months on a properly developed package covering the teaching of the three `R’s and sanitation and hygiene ought to meet the requirement of elementary schooling and here again the tilt should be in favour of women.  The empowerment of women, improved status and their acceptance for teaching girls even in the backward conservative areas, are all synergetic.  But, the big question is how do we find the woemn teachesrs  in the states where female literacy rate is low? 

`Operational Blackboard’ needs to be extended to cover all primary schools.  The outlay required may be around Rs. 2,00 crore-surely not an astronomical sum.  We are past masters at frittering away our revenue income by adopting populist welfare measures which are instances of too little, too late for the supposed beneficiaries.  One huge push is what is required rather than fragmented efforts in each social sector.  And, this additional resource can be found with a little application of political will.
 

Involve the Business/Industry 

In many countries, industry and business have become conscious of the need for working for the environment, and for participation in the social sectors.  What they offer are funds and management skills.  Indigenous Industry and business are yet to develop the perspective that a degraded environment threatens the very survival of the planet and everyone is the ultimate loser without interactive intervention for stemming the rot.  A small levy of perhaps 1% of the gross profits of the organised sector can provide the financial outlay.  But, their social responsibility must not stop there.  Let the state provide the land and facilities of road, and electricity.  For each district a LEAD `business house’ can be selected.  The resources on a realistic `per capita’ basis be made available to the business house.  It can be made to operate a social wing - the construction, classroom facilities, water, sanitation and hygiene, recruitment of teachers be all their responsibilities.  The management group has to remain autonomous, but include the representative of the panchayats and parents.  The scope can be expanded to embrace the middle school and high school in stages.  Accountability and monitoring are two important keys to success and the business knows how to implement through their management techniques.  The power of `hiring and firing’ ensures results.  `Business’ can be expected to deliver quality as well.  They need not be losers in any way.  A tax benefit of `double’ the amount that they contribute as levy can  be given to them provided they deliver.  `Business’ talks of challenges and opportunities; here is one.  All the desirable goals such as special attention to the education of adolescent girls in the age group of 12-18, population study in the curriculum, a free mid-day meal, acquisition of vocational skills can all be better achieved through the private sector. 

It will be a worthwhile experiment to call in the TATAs for work in Bihar, the Thapars in Orissa, Singhanias in U.P., Khaitans in Assam and West Bengal and Ambanis in Gujarat and Madhya Pradesh, Birlas in Rajasthan.  Will they accept the challenge or chicken out? 

A number of voluntary organisations are involved in adult literacy work.  Some have done a good job, others are not genuine.  The latter category has to be identified and weeded out.  The `good; NGOs be encouraged to expand their territory and given additional funds for carrying out this job. 

In a land of paradoxes that is India, there is a great divide between `the public/government sector and the
private sector’.  `We’ operate as a split personality in these sectors.  The private self is the hope - the beacon.
 

Family Planning Prorgamme : Call in the Private Sector 

The appraisal of the family planning programme reveals its weaknesses some of which are intractable and require awareness and attitudinal changes which do not fit into an immediate time-frame.  To cite examples, male-domination, low status of women, obsession with the desire for at least one male child, corruption and greed, and callous attitude of officials big and small, all may change in a secular period if they change at all.  Within these constraints, it is the delivery system that can be addressed.  The solution may lie in brining in the private sector particularly the drug and pharmaceutical manufacturers including MNCs to filling the gaps.  Training and retaining of staff, helping them to acquire the required degree of communication skill, the promotional campaign, the literature, provision of equipment and their maintenance, responsibility be handed over to the `Lead’ business house.  The supply of pills, condoms, IUDs, should no more be from the government stores.  The private sector should take over all this on a contractual basis.  PHCs and sub-centres can be regrouped since many do not have the staff and equipment, handed over to the private sector and the budgetary allocation on a per capita basis be placed at the disposal.  The operation of a parallel family planning programme ought to have salutary effect on the government sector. 

The charter for the private sector may promote choices other than IUDs, and sterilisation so that the family planning programme can operate without the services of a qualified doctor, but with reasonably well trained `sales persons’.  For success, the  delivery of the service has to be at the doorstep of clients at all times.
 

Promotion of the indigenous weekly pill 

India was one of the first countries to go for social marketing.  Condoms have been distributed freely for four decades now. The dependence on the success of one single contraceptive method, be it IUD or sterilization must make way for multiple choice particularly the choice of a hormonal pill.  In Indonesia the IUD was the most favoured method, but it lost ground to the pill over a period of a decade or so. 

It is amazing that one hardly notices any effort at promoting the indigenously researched successfully developed pill known as `Saheli’ or centchroman.  It would appear to be the most reasonable step to promote this pill to be taken just once a week and yet, the lack of promotional effort makes one wonder if there are inescapable and invisible compulsions to prevent this? 

In the long run, the business and industry require a stable population, raised above the poverty level, for their requirement of future work force, purchasing power for their products and services and a stable market condition.  Population dynamics are too volatile without an effective check on its spiralling upward growth.  The industry and business must intervene with their proclaimed ability to deliver because of their penchant for accountability and management expertise.  Meaningful participation in family welfare programme is investment in the future.  We talk of perspective planning all the time.  Do our industry and business have the perspective?
 

Maternal and Child Health Care 

Any visitor to a government hospital or health care centre can see for himself/herself the state of affairs.  At the best of the hospitals, even in the capital, equipment such as Cat Scan, Ultrasound do not work.  An outdoor patient may have to wait for more than a month for an ordinary X-Ray.

The general environment is of decay, neglect and indifference.  There are too many people mostly the poor and the struggling middle class who line up for free/subsidised treatment and care.  But, when we look at the numbers of facilities created, achievements appear significant.  Whatever is done seems to be too little for the burgeoning population.  The table below given an idea of the quantitative achievements in two decades.

There is a continuous effort at providing extended services as it evident from the table below:

In China, one of the facilities that has helped in reducing the IMR is the greatly enhanced presence at childbirth of a midwife/traditional  `attendant’ whose skills had been gradually built up by training.  The ANMs play a very significant role in family planning information and education and they are the backbone of the system.  India, too, has been systematically training the `Dais’ (traditional birth attendants) every year, the maximum number having been trained in 1978079 and 79-80, the numbers being 83,892 and 79,192.  In a country where numbers are at the source of many developmental problems, the quantitative increments play a role in providing a bit more of the same thing.  And, this must receive acknowledgement.  The reduction in IMR is a result of all these quantitative extensions.  If we have not reached the acceptable level of IMR of 50 or less, may be we would if the quality of service is improved and the expansion of facilities in terms of health centres and trained staff and supplies is continued. 

The crude death rate has fallen from 19 per thousand in 1971 to 9.8 in 1991 - a reflection of the expansions in the health care facilities, the birth rate from 41.2 per thousand to 28.5 in 1991.  The Infant Mortality Rate is showing a steady decline - from 79 in 1992 to 74 in 1993 - an excellent trend if it can be maintained.  Under the aegis of UNICEF great strides have been made in the immunisation of children against diptheria, tetanus, measles, polio and pertussis - 80% of the children are protected.  As regards children’s health and nutrition, a most comprehensive `Integrated Child Development Services’ is in operation covering 3157 blocks and 240 urban slums.  The beneficiary coverage is as high as 1.75 crore children and 36 crore mothers.  The scheme has made impressive improvements possible in predominantly tribal and backward areas of Andhra Pradesh, Orissa, Bihar and Madhya Pradesh.  The mid-day morning meals, if properly administered, would certainly make school attendance more attractive for the children of the poor and greatly supplement the nutrition that the parents can provide and bring up the retention rate.

Summing Up 

When the efforts at population control are appraised objectively the performance is not spectacular, but the progress over the last four decades is significant. 

Policy planning had to be done within the internal financial resources and with donor assistance which had generally some conditionalities attached.  The planners had tried various approaches within serious limitations-some met with failures, most with success.  When the performance of Kerala, Tamil Nadu, Goa and Mizoram is considered, the question that surfaces is if there is spectacular success in these pockets, perhaps the planners had not been off the mark! 

India was able to generate awareness among the people four decades ago but it has failed to deliver effective service, particularly in the more populous states. 

Voluntarism always limits state intervention to the extent of people’s cooperation, motivation and cultural prejudices.  The IUD was successful as a direct control measure, but its gradual rejection came when the after care service was not available.  For reasons not understood fully, the hormonal barrier was not promoted - a simple method that is almost universally adopted by women of developed countries. 

Sterilisation method was the strategy to achieve goals quickly and the males could be made major partners in family planning.  But, it misfired due to human failures of providers who had failed to assess the psychic barriers of the population.  This being an irreversible method, should have been left to the people to choose and not thrust upon them by letting loose health workers to `collect’ the volunteers who, of course, received an incentive payment, so did the health workers!  There were disincentives as well and the people learnt to defeat the system.  The resentment was very deep.  The congress party in the driving seat for three decades, had to suffer a humiliating defeat at the post-emergency election.  The issues became so sensitive that family planning per se was sent backstage. 

India was learning that population control through direct adoption of contraceptive measures was not to come.  Universal elementary education, total literacy and a vastly improved healthcare service centres and sub-centres providing services to mothers and children and the immunisation of the children against some of the killer diseases such as diphtheria, tetanus and pertussis to reduce the IMR which generally correlates with reduced fertility rate - all must go together. 

The financial outlays have all along been raised expanding the facilities, but the results were not as expected owing to slippages in the administrative system and the callous mind-set of the people at all levels of delivery hierarchy.  The failure is a matter of people vs. people. 

The states which are backward in female literacy, IMR, per capita expenditure health  and education and high in fertility rate have been identified and very specific action plans have been made out for these areas.        

The health-care private sector have managed to steer clear of family planning work-there is no money in it!  Now is the time to involve the private business houses to take up this challenge and show results.  Population control is everyone’s concern. 

Let us finally allow the statistics to show the trajectory over a period of a few decades.

SRS (Sample Registration System) 1993 shows a small decline in the birth rate as well as IMR which stands at 74.  Th significant improvement in the IMR in the backward states of Bihar, UP, MP, Rajasthan and Orissa in course of the last two years is a strong indicator that the integrated, holistic policy and the specific POA for these states, is working.  The IMR figures appear below:

When we look at the budgetary provisions and actual expenditure for the entire social sectors as reproduced in Table 10, the focus and thrust are obvious. 

Population control is not the ‘a priori’ requirement for human development.  They are independent and must go in tandem.  Development effort in all the social sectors such as health, education, employment, empowerment of women, provision
of better shelters, poverty alleviation may all lead towards achieving the desired stabilisation level of population that the
environment and the resource base can support.  The vast increase in outlays, by themselves, seem to be working in the right direction.

1.         Provision made at RE stage, as the schemes were launched on Oct. 2, 1993.  RE for EAS was Rs. 600 crore and Rs. 35 crore for PMRY.

2.         The momentum needs to be sustained and the next SRS 1994 will tell us the position where we are on the new road to population check.  The budget 1995-96 gives a further push to this momentum. 

The process of defusing has started and the bomb need not explode.  Doomsday prophets and Cassandra's may take a short holiday. 

The author works in the Communication Unit, Development Alternatives

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