Not just a numbers game

A.R. NANDA

THERE is a need to continue an informed debate on the issues of population and bring these issues in right perspective to the notice of policy-makers at various levels viz., the Parliament, state legislative bodies, panchayats and urban municipal bodies.

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 the mid 1950s onwards, as a result of a rapid fall in death rates, there were unprecedented high levels of natural growth. It was this concern about excessive demographic increase (then qualified as population explosion – a term extensively used in the mid 1960s in the deliberations of the Club of Rome) and its social and economic ramifications that impelled the international community to focus on curbing population growth by implementing population control or the family planning programmes.

This panic like neo-Malthusian environment continued in the 1960s and 1970s. The thinking on population was primarily concerned with numbers which were increasingly looked at with horror and this fear defined the central core of the population programme. The focus was mostly on ‘population’ not ‘people’. These programmes did not look at human development as the need of the hour, but instead looked at women whose fertility needed to be controlled.

This international perspective was also reflected in our national policies and programmes upto the mid-’70s, when during the Emergency the family planning programme received a setback in India due to rigid implementation of a target based approach. From the late 1970s to mid 1980s there was a lull and from then on we seem to have revisited the population debate from the same old perspective.

 

 

The International Conference on Population and Development (ICPD), Cairo was in many ways 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. It 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. It was also agreed that no force, no coercion, no incentives and disincentives were required. Such measures are either coercive or ultimately tend to be coercive, and are in fact counterproductive. Coercion infringes upon human rights and inhibits human development. The ICPD Programme of Action (PoA) placed individuals at the centre of development with a focus on building pillars of human rights, gender equity and equality. The natural fallout of the ICPD was a commitment by India – a signatory to the Cairo Declaration – to implement the reproductive health approach. In fact, India broadened the scope of reproductive health by adding a distinct component of child health, hence the nomenclature ‘Reproductive and Child Health’, popularly known as RCH.

A key change that has occurred in the RCH strategy is that it is a client-centred, demand-driven, quality service approach as opposed to the previous provider-centric target-based approach. The RCH agenda is a new and holistic one based on the life cycle approach which addresses and covers all aspects of women’s health from birth to death. We have come away from targeted approach to one based on assessment of the community’s felt needs, popularly known as the community needs assessment (CNA) approach.

 

 

The central theme of 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 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 education and health) for all.

Post the ICPD 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 health services. India’s commitment to ICPD principles and recommendations of the PoA was further affirmed when India released its National Population Policy (NPP) in February 2000 which asserts the centrality of human development, gender equality and equity, adolescent reproductive health and rights among other issues to stabilizing the country’s population.

The National Population Policy (NPP), 2000 begins with the statement that ‘the over-riding objective of economic and social development is to improve quality of life that people lead, to enhance their well-being and to provide them with opportunities and choices to become productive assets in society.’ The NPP is gender sensitive and incorporates a comprehensive and holistic approach to health and education needs of women, adolescents and the girl child. It also specifically seeks to address the constraints to accessibility to services which arise due to heavily populated geographical areas and diverse socio-cultural patterns in population.

 

 

The NPP also states that ‘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 of education and employment.’ The NPP 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.

* 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 twelve strategic themes, the four core themes that drive the NPP are:

* Addressing unmet needs.

* Decentralization and convergence in implementation with all other relevant social sectors.

* Commitments from and collaboration with the NGO sector and private/corporate sector (public-private partnership – PPP) to augment the pool of diverse health care providers.

* Mainstreaming the Indian system of medicines.

 

 

A primary objective running through the National Population Policy, 2000 is the provision for quality services and supplies, information and counselling, 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 NPP does not envisage any individual incentives and disincentives which could tend to become coercive. Instead, it envisages 16 promotional measures that may facilitate implementation of the appropriate interventions at community levels.

Inspite of the ICPD agenda and the adoption of a National Population Policy which have made radical departure from the old approach, the population debate in India remains constrained by fears of a population explosion. This was highlighted by a small yet vocal group of demographers and population experts. Unfortunately, this fear of a population explosion/population scare continues to haunt not only demographers and population experts, but also the educated elite, the bureaucracy and political leaders. It is in this context that there is a need to understand and address these fears through an informed debate on population issues in a right perspective.

 

 

A number of state governments have announced or are in the process of formulating their state population policies. Some of the state population policies do not reflect the major paradigm shift in thinking on population issues that has taken place globally; they have incorporated disincentives in their policy, despite the fact that PoA, ICPD (to which India is a signatory) and NPP, 2000 rejects such an approach.

The debate that is now under-way in the states and also at the Centre reflects these contradictions and conflicts. However, it is important to continue the debate because this is the essence of a democratic decision-making process. Looking at the results of the debates initiated by different bodies and NGOs, there appears to be a consensus of opinion in some states, however slow the process may be.

The central government has urged the state governments not to introduce coercive methods in their population policies. The focus, therefore, should be on providing affordable and sustainable preventive, promotive and curative health care services and bringing about a change in the behaviour of service providers both public and private. The NGOs and civil society must play an important role in ensuring that state policies on population do not slip into a ‘control mode’ once again.

The debate on incentives/disincentives could be conducted in the overarching framework of human rights, constitutional rights and people’s access to health care services. Further research and analysis is needed on the impact of incentives and disincentives. There is also a need to translate the population momentum theory in a manner that is easily understood by and is convincing for political leaders and others.

There is a need to have an effective synergy between different policies like the National Population Policy 2000, National Health Policy 1983 and Draft NHP 2001/2002, National Policy for Empowerment of Women 2001, National Policy on Older Persons 1999, and National Policy on Youth 1988 and 2000.

There is also a need to initiate inter-departmental consultations to highlight the importance of post-primary education for girls as an important step to not only delay the age at marriage, but to enable them to make informed choices.

 

 

Forging linkages between the public distribution system and excess food stocks to the nutrition status of women and children need to explored. The existing self-help groups (SHGs) could play a pivotal role in strengthening the linkages and in realization of the RCH goals by building bridges between the community and health care providers.

Translating the population policy into concrete programmes and ensuring existing programmes (like RCH initiatives) reflect the overall goal of the policy, is an important area of action. To this end various aspects of population policy need to be written in a simple and understandable language.

Direct dissemination and advocacy material should be translated in local/vernacular languages to ensure large scale dissemination at all levels – state, district, panchayat.

However, not all the ingredients of RCH have received equal focus. The areas like adolescent reproductive health, male responsibility and gender equity have received much less attention and urgently need to be addressed in a comprehensive manner, both in the 10th Plan and RCH phase-II.

Population stabilization is not just about numbers but about balanced development. The most striking result of the Census 2001 shows that there is a sharp decline of 18 percentage points in the child sex ratio (0-6 age group) from 945 to 927 during 1991-2001, which is a matter of serious concern. What is intriguing about the figures is that the fall in the child sex ratio is much higher in the economically developed states of Punjab (-82), Haryana (-59), Gujarat (-50), Maharashtra (-29) and Delhi (-50) along with the union territory of Chandigarh (-54). This is perhaps a consequence of the inhuman practice of female foeticide.

The unholy alliance between tradition (son preference) and technology (ultrasound) is playing havoc in the so-called developed states. This basically boils down to the misuse of advanced pre-natal sex detection technology (despite the PNDT Act against sex determination) by unscrupulous doctors to facilitate female foeticide through induced abortions. If we allow things to carry on this way, sex imbalances generated in the juvenile age group will be sustained for a longer duration and have a cascading effect on the country’s sex-ratio in the coming years.

As mentioned above, 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; it could be achieved by 2050 or 2060. But what is of greater concern is how we approach the issue of population stabilization.