The Billion Plus blitzkrieg

But of all the dichotomies and contradictions that have marked family welfare administration in India, there was none quite as misguided as the skewed emphasis on family planningat the expense of people8217;s health. Mohan Rao, a community health sociologist, in a recent book he edited, Disinvesting in Health Sage Publications, painstakingly documents this tragic trajectory. It all began in 1952, with a modest budget of Rs 64 lakh being earmarked for family planning. In the Second Five Year Plan, family planning accounted for Rs 5 crore, while health received Rs 225 crore.

What followed was a sharp increase in the family planning budget accompanied by a relative stagnation in the health budget. The Third Five Year Plan had family planning accounting for Rs 30 crore and health for Rs 342 crore. By the Fourth Five Year Plan, the outlay for family planning had jumped to Rs 315 crore, while health had an outlay of just Rs 433.5 crore. By the Fifth Five Year Plan, the rhetoric had changed a bit. The Plan document now spoke of the need to integrate 8220;minimum public health facilities8221; with family planning and nutrition for vulnerable groups. But, despite these brave words, familyplanning accounted for Rs 516 crore of the outlay, while health got Rs 797 crore.

The Sixth Five Year Plan acknowledged that 8220;high morbidity and mortality rates8221; were responsible for the desire for more children, but having stated the problem the planners didn8217;t bother to address it. Family planning now accounted for Rs 1010 crore, while health received Rs 1,821 crore. By the Seventh Five Year Plan came around, even the pretence of emphasising health concerns was given up, with the outlays for family planning and health almost on a par 8212; at Rs 3,256 crore and Rs 3,392 crore respectively.

So what did all this money earmarked for family planning really achieve? The mid-term appraisal of the Seventh Plan acknowledged that 47 per cent of the total decline in birthrates from 1961 to 1981, had taken place due to the rise in the age of marriage. As Rao points out, technological solutions to the problem of galloping numbers could never be sustained. The craze for promoting intrauterine contraceptive devicesled to an estimated 900,000 women being given such aids in 1966-67. By the next year, the number had declined to 669,000 and kept slipping thereafter. Similarly, sterilisations peaked in 1972-73, with an estimated 3.1 million people undergoing the operation. By the next year, the figure had dropped to 0.94 million and the negative impact of the forced sterilisations mindlessly performed during the emergency is being felt to this day.

While the crores spent on controlling the population had a less than salutary effect, the money not spent on health has also had its own implications. NCAER8217;s India Human Development Report highlights how both the crude death rates and crude birth rates complement each other, with both phenomena being closely related to the level of household income. Crude birth rates and crude death rates decline as household income increases. The Report also reiterates the well-documented fact that among the poorest communities the belief that the more the children, the better, still persistsafter decades of the State peddling the small family norm.

The women of the poorest segment are more likely to have larger families and less likely to have access to ante-natal care 8212; about 60 per cent of total births in rural India were attended by untrained personnel. Their children, not surprisingly, were more likely to die of diarrhoea 8212; diarrhoeal diseases accounting for the majority of child deaths in the country. Similarly, only about 50 per cent of children of rural India were fully immunised. These are the communities that have fallen through the health delivery net, they8217;ve escaped the politeness of terms like 8220;reproductive and child health8221;.

In a meeting last month in Delhi, a group of ministers and population experts took stock of the draft national population policy. The big question was whether incentives and disincentives could be made to work. That was when T.V. Anthony, a former secretary of health and family welfare, Tamil Nadu, spoke. He first confessed to his own change of mindsetas an administrator. At one stage of his career, he was so convinced about the efficacy of sterilisations that he began to be known as Tubectomy Vasectomy Anthony8217;. But, as he explained, it was only when the state8217;s family planning programme assumed a health and social welfare dimension did it really begin to produce results. Right through the 1980s, the midday meal and childcare programmes in Tamil Nadu came to be considered as worthy of administrative attention as the dispensing of contraceptives.

There was also an attempt to revitalise the rural health delivery system, by focussing on both maternal and child mortality. Health workers were despatched to the farthest corners of the state to attend to the health needs of otherwise marginalised communities. Something happened in the process, as Anthony explained. People, especially women, came of their own volition for contraceptive information and care. Today, the great majority of children in Tamil Nadu are immunised and it has one of the lowest fertilityrates among Indian states. It was not Anthony8217;s tubectomies and vasectomies that performed this miracle, but a sane, holistic, human welfare approach coupled with administrative will.

In the excitement of turning a billion, Indian administrators may, once again, be tempted to ignore the demographic lessons learnt so painfully over so many years and come up with quickfix solutions to arrest 8220;population growth8221;. This will be the biggest danger that lies ahead. Family welfare programmes in this country must be human welfare programmes if they are to be effective.