Population : Background & Perspective

 By Sandhya Srinivasan

The world has a population of 6 billion. India alone has a population of 1 billion. Despite the fact that India was the first country in the world to have a population policy. But is this mammoth population really cause for alarm? It could be more important to understand the factors that led to this population explosion and the complex links between population growth rates and levels of development. And to acknowledge that India is in the midst of a demographic transition, with fertility rates definitely declining, though not as fast as was expected.

The problem / How things have changed / History of India's population programme / Reproductive and child health programme / National population policy / Census 2001 / Population and development / Skewed sex ratio / Contraceptive technologies

WHAT'S THE POPULATION 'PROBLEM' ALL ABOUT?

In the year 2000, much was made of the fact that as the world's population reached six billion, India's share was a massive one billion. As one writer noted, alarm bells were sounded the world over that the first country in the world to have a population policy had failed miserably in the effort. However, demographers have pointed out that there is really no reason to panic. "This hue and cry is intended to put the clock back and will lead us to the same family planning trap from which we are struggling to emerge," says Dr Ravi Verma, reader and head of the department of extension studies, International Institute of Population Studies, Mumbai.

India is in the middle of what demographers describe as the 'demographic transition'. It has moved from a situation of high birthrate and high deathrate to an intermediary stage of high birthrate and low deathrate, but is yet to reach a point of stability, with a low birthrate and a low deathrate. This intermediary period will naturally see high rates of population growth.

Demographers note that the latest census figures show that India has entered the phase of a declining fertility rate, though the actual decline may be less than what was targeted in the preceding years.

HOW THINGS HAVE CHANGED IN THE LAST 50 YEARS

India's population policy has been guided by the perception that a growing population is a serious impediment to development efforts. This concern goes back to India's independence in 1947. At the time, census figures showed a Crude Birth Rate (CBR) of over 45/1,000 population -- every year, over 45 children were born for every 1,000 people. The Total Fertility Rate (TFR), an estimate of how many children a woman would have in her lifetime, was 6.

At the time, the government set a target to bring the CBR down to 27/1,000 by 1990, and to 21/1,000 by the year 2000, with a target total fertility rate of 2.1 or replacement fertility.

Fifty years later, the CBR had dropped, but not as much as had been hoped. In 1990, it was 30.2/1,000, and according to the latest figures, it is a little over 25 per 1,000 population.

The TFR fell from over 6.0 in the 1940s to 3.6 in 1991, and most recently to 3.1.

Some reasons why we haven't reached the goals set in 1947:

a.  The focus on family planning ignored other influences on the birthrate: Public health specialists Mohan Rao and Devaki Jain note that a population policy is more than just family planning. There are "macro-economic forces shaping the enabling conditions necessary for health and family planning". In reference to the National Population Policy, 2000, they ask, "How are issues of livelihood, poverty, inequality, hunger and ill health reflected in the NPP?"

b.  Better health: People lived longer because of improved nutrition, and the deathrate declined faster than the birthrate did. Life expectancy at birth rose from 32 in 1947 to 63 in 1998. The Infant Mortality Rate fell from 200/1,000 live births in the mid-1940s to 72/1,000 in 1998.

c.   A high infant mortality rate: Even though the IMR has almost halved in 50 years, it is still significantly higher than in developed countries, as well as in countries like Sri Lanka, Cuba and China. Many couples have large families as insurance against multiple infant and child deaths.

d. Some states did better than others: The success of states such as Kerala and Tamil Nadu, where fertility has dropped sharply (TFR 1.8, or below replacement level, in Kerala, and 2.2 in Tamil Nadu) was countered by the high growth rates in states such as Uttar Pradesh (TFR 5.1), Madhya Pradesh, Rajasthan (4.6) and Bihar (4.4).

e.  A built-in momentum: Thirty-six per cent of the population is in the reproductive age group. That proportion will go up before it comes down. Even if these men and women have very small families, the sheer numbers of the next generation will result in a further swelling of the population before it starts shrinking in future generations.

f.  Unmet need for contraception: The National Population Policy 2000 notes that only 44 per cent of India's 168 million couples in the reproductive age group use effective contraception. A large proportion of the remaining couples may want contraception, but do not have access to it. Reproductive health and basic health infrastructure and services often do not reach the villages.

g.  Early marriage: One in two girls marry before they turn 18, which is the minimum legal age of marriage. Many of them start childbearing almost immediately, with second and third children following at intervals of less than 24 months -- which in turn reduces each child's chances of survival.

A BRIEF HISTORY OF INDIA'S POPULATION PROGRAMME: 1947-1997

A. India was the first country in the world with a population policy. Though the actual policy was first formulated only in 1976, the subject was discussed in various reports on the health services and taken up in the First Five Year Plan in 1952. When India became independent, population growth was seen as a major impediment to the country's socio-economic development -- and population 'control' was seen as integral to the development process. Population growth was seen as an urgent problem related to economic development with limited resources. While an improved standard of living would eventually lead to a reduction in the birthrate, this would take time, and meanwhile, it was felt, this high birthrate would retard development. At the same time, family planning would benefit both individual families as well as women's health. (This tone continues even today. The National Population Policy 2000 notes: "Stabilising population is an essential requirement for promoting sustainable development with more equitable distribution.")

B. In 1952, a sub-committee appointed by the Planning Commission asked the government to provide sterilisation facilities and contraceptive advice through existing health services, in order to limit family size, and also institute studies on population. While one committee member felt a government birth control programme should provide birth control appliances and literature free of charge at every health centre, the dominant view resisted efforts to promote birth control actively.

C. The findings of the 1961 Census suggested that providing limited services was an inadequate strategy. The population had grown from 361.09 million to 439.23 million in the decade since the previous census -- a growth of 21.64 per cent compared to earlier decennial changes between 11 and 14.22 per cent.

D. By this time, the Mysore Population Study, looking at factors influencing family size preference, had identified some areas in which the programme was going wrong. Some of the findings: people had large families partly because they wanted sons; education was a factor in family size; and few couples practised family planning.

E. In 1964, the Reorganised Family Planning Programme recognised that people's decisions on reproduction are influenced by many social, educational, health, economic, religious and cultural factors. It spoke of people's participation in formulating and implementing a policy the benefits of which would go to them.

F. Unfortunately, these ideas remained on paper, says Dr Ravi Verma of the IIPS. "The panic caused by the 1961 census findings, a new health minister who not only supported birth control but sterilisation in particular, and a swing towards technological solutions -- all these resulted in a target-oriented, technocratic programme with little interest in people's real needs." The 'population control' programme began in earnest.

G. The Reorganised Family Planning Programme ended up focussing on programmes for IUD insertion and sterilisation camps. Work was determined by abstracts set by the ministry. In 1966, the health minister announced annual targets of 6 million IUCD insertions (20/1,000 population in the urban areas and 10/1,000 in the rural areas) and 1.23 million sterilisations (or 2.5/1,000 population). Health workers were given incentives to meet targets, and 'disincentives' or punishments if they failed. The targets were not for staff, materials or quality of services, but for contraceptive cover, notes Dr Verma. This focus on sterilisation and IUCDs has been at the cost of quality care and informed consent. Surveys have shown that one in four women who undergo sterilisation suffer long-term complications in silence. (Sterilisation -- mostly done through government services -- accounts for the vast majority of contraception use in India. Sterilisation accounts for more than 75 per cent of total contraception in India, with female sterilisation accounting for almost 95 per cent of all sterilisations. Eighty-two per cent of sterilised women had never used any other method of contraception before being sterilised.)

H. In the Fourth Five-Year Plan (1969-1974), a target of 14.9 million sterilisations was expected to bring the CBR down from 39/1,000 to 25/1,000 within 10-12 years.

I. Coercion, always a part of the family planning programme at some level, became formalised with the use of incentives, and later with harsher measures. At the 1974 International Conference on Population and Development in Bucharest, the Indian government coined the famous slogan: "Development is the best contraceptive", telling the world to stop forcing population control and to give money for development. The government came home only to do exactly the opposite!

J. The Emergency, 1975-76, took coercion to new heights as slumdwellers were rounded up and sterilised. In 1976-77 an all-time high of 8.26 million sterilisations were performed, mostly on men.

K. In 1976, the first National Population Policy talked of integrating family planning with general health care, of maternal and child health, the influence of female education, employment and age of marriage on family size, the effect of a high infant mortality rate, and so on. 1977 saw the Policy Statement on the Family Welfare Programme. Both statements were tabled in parliament, but were not discussed or adopted.

L.
In the 1970s, after the forced sterilisations brought the government down, the programme just made a switch -- to female sterilisations. Doctors vied with each other to set records in laparoscopic sterilisation camps. Vasectomies were forgotten: today, most medical officers are not trained in vasectomies.

M. The National Health Policy of 1983 emphasised the need for "securing the small family norm through voluntary efforts and moving towards the goal of population stabilisation".

N. In 1991, the Report of the National Development Council Committee on Population proposed the formulation of a National Population Policy with a long-term and holistic view of development, population growth and environmental protection. The policy was to suggest policies and guidelines for the formulation of programmes, with a monitoring mechanism.

O. In 1993, the Swaminathan Committee, an expert group headed by Dr M S Swaminathan, presented a draft population policy. It called for a move away from the target approach and against incentives. In fact, in 1992-93, extra incentives were removed (only loss of wages was compensated). This draft foreshadowed many of the ideas expressed at the International Conference on Population and Development at Cairo, Egypt, in 1994.

P. The 1994 International Conference on Population and Development in Cairo has been described as a historic meeting where pressure from international women's health organisations managed to shift the meeting's agenda from population control to reproductive health. The Programme of Action in Cairo looked at population control as a by-product of a general people-oriented health programme, not an end in itself. Though the Cairo document was silent about how to generate resources, operationalise the programme and several other practical issues, it was unambiguous in its intentions and recommendations. Most important, it was signed by all participating countries.

Q. Others have argued that the 'reproductive health' of the 1994 ICPD is nothing more than the same population control programme: old wine in new bottles. And the Reproductive and Child Health Programme, launched with much fanfare in India in 1997, has generally provided only contraceptive services. Secondly, 'top-down' targets (assigned to health workers, for the number of IUCD insertions or sterilisations each year) have been replaced by 'estimated levels of achievement' (ELAs), the health worker's estimates of the community's 'unmet need for contraception' -- based on a survey of families in the area. However, these may not represent people's own perception of their needs. Also, the pressure to achieve these new ELAs remains.

R. The draft National Population Policy, first seen by the cabinet in October 1997, underwent a number of revisions based on the comments of a cross-section of academics, public health specialists, demographers, social scientists, and women's representatives before being placed before the cabinet in the year 2000.

S. Following the announcement of a National Population Policy, a number of states are coming out with their own policies.

THE REPRODUCTIVE AND CHILD HEALTH PROGRAMME

The RCH Programme was launched in India on October 15, 1997, though it is yet to be implemented in all parts of the country. The earlier programme was target-oriented, focussed on women in the reproductive age-group, and catered only to their family planning and maternal and child health needs. The RCH programme was meant to provide high quality, integrated, client-centred services based on people's needs and the local demand, and at all stages of the life cycle.

In fact RCH services are essentially the same as the earlier services: maternal and child health, birth control and abortion, with the addition of treating reproductive infections and providing adolescent health services.

THE NATIONAL POPULATION POLICY, 2000

The NPP 2000's stated goal is to achieve net replacement levels by 2010, by meeting people's 'reproductive and child health needs'. The government plans to work with the private sector and voluntary organisations to establish a health infrastructure and provide a package of contraception, maternal and child health services. This approach is to result in population stabilisation (Total Fertility Rate of 2.1) by the year 2045 -- a population 'consistent with sustainable development'.

The NPP 'affirms commitment of the 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'.

It aims at developing an infrastructure for the RCH package, providing and ensuring education till age 14; reducing infant mortality to below 30/1,000 live births and maternal mortality to below 100/100,000 live births; universal immunisation, delayed marriage, institutional or supervised deliveries; 100 per cent registration of births, deaths, marriage and pregnancy; tackling communicable diseases, integrating Indian systems of medicine in these services, reaching out to households, promoting the small family norm, and linking family planning to other social sector programmes.

A National Commission on Population to guide all efforts is to be presided over by the prime minister, with the chief ministers of all states and UTs, and central ministers of the department of family welfare as well as other concerned departments (such as women and child development, education, social justice and empowerment, rural development, environment and forests) as well as demographers, public health professionals and non-governmental organisations.

Funding will be a priority: "All efforts at population stabilisation, will be adequately funded in view of their critical importance to national development."

A number of 'promotional and motivational measures' are described: rewarding panchayats for exemplary performance in achieving 'small family norms', low IMRs, high schooling… cash incentives with the birth of girls (the first two children), for women who have their first child after the age of 19, for couples getting sterilised after two children. States with high birth rates are penalised by freezing the number of representatives to the central legislative assembly, on the basis of population at 1971 census levels, until 2026.

Following the publication of the National Population Policy, a number of states have come out -- or are coming out -- with their own population policies.

INDIAN CENSUS DATA FOR 2001

The Indian Census is a massive, countrywide operation which takes place every 10 years. Information gathered in the census and other regular data collection programmes is meant to guide the government's policies. The 2001 Census (http://www.censusindia.net) has just been completed this March. We have some statistics:

As of March 2001, the total population of India was a little over 1 billion -- 1,027,015,247 to be exact (531,277,078; female: 495,738,169).
Of this number, 157,863,145 are children up to the age of six years (81,911,041 males and 75,952,104 females).
A little over 65 per cent of the population is literate (75.85 per cent of males, and 54.16 per cent of females)

Demographers, or students of population, have various indicators with which to measure a population's change and to make predictions of future population change. Some of these figures for India are given below:

Crude Birth Rate (annual number of births per 1,000 total population) 27.00
Crude Death Rate (annual number of deaths per 1,000 total population) 9.00
Infant Mortality Rate: Seventy-two out of every 1,000 babies born die before their first birthday. Seven per cent (72/1,000) of newborn infants perish within a year of birth, because of low birth weight, pre-maturity, malnutrition, diarrhoeal diseases, acute respiratory infections and malnutrition. Compare this to the IMRs in Sri Lanka (18/1,000) and China (41/1,000 Moreover, in India, there are more female deaths (rural or urban areas) in the age group of 0-14 than elsewhere. Although the IMR has decreased from 146 per 1000 births in 1951 to 72 per 1000 births (1997) and the sex differentials are narrowing, there are wide inter-state differences.
Life expectancy: The average person can expect to live up to the age of 62.
Rate of natural increase (birth rate minus death rate, expressed as a percentage) 1.80
Total Fertility Rate (average number of children born to a woman during her lifetime) 3.30 Only nine states or union territories in the country have a TFR less than or equal to the desired 2.1: Eleven have a total fertility rate of more than 2.1 but less than 3.0. At least 12 have a total fertility rate of 3.0 or over.
Eighteen per cent of births are to teenage women aged between 15 and 19
Forty-nine per cent of women give birth for the first time by age 20.
The average age at first marriage (or informal union) is 20.
Forty-three per cent of married women are using modern methods of contraception.
Females in secondary school/100 males: 65

Age composition: The age structure of a given population influences its future growth. The younger the population is overall, the larger the proportion of people in the reproductive age group, which means the greater number of babies born even if each couple has only one or two children.

The current age distribution of the population is as follows: a little more than 34 per cent are under the age of 15 years; 58 per cent are between 15 and 59, and 7 per cent are over the age of 60. By the year 2016, it is expected that there will be fewer people under the age of 15 (28 per cent), more between the ages of 15 and 59 (nearly 64 per cent), and slightly more above the age of 60 (nearly 9 per cent).

On the basis of such statistics, the Indian Planning Commission's Technical Group on Population Projections predicted in the National Population Policy (2000) that India's population would be 1.012 billion in March 2001, going up to 1.179 billion and 1.264 billion in March 2011 and 2016 respectively.

Additionally, the Population Reference Bureau have predicted that India will have a population of 1.363 million by the year 2025, and 1.628 million by the year 2050 (www.prb.org/pubs/wpds2000).

THE ISSUES

1. Are we in a crisis?
Many demographers don't think so. "India is in a state of rapid fertility transition with the pace of decline having accelerated in recent years," states the United Nations Population Fund 1997 report on India.

Birthrates are declining all over India, though in varying degrees. And they are beginning to decline faster than the death rate goes down -- so we are slowly but surely moving towards replacement fertility.

2. Is population growth at the root of our development problems?
It is argued that communities swamped with the burden of providing for large families will not be able to move forward. But it has been demonstrated that as communities become confident that their children will survive till adulthood, and as they become financially stable and able to control their destinies, they decide to have fewer children. But the motivating factors are less likely to be aggressive family planning programmes, or incentives and 'disincentives'. They are more likely to be a complex of enabling conditions -- work, food, health and associated services. The Indian government's health expenditure (as a proportion of its GNP) is one of the lowest in the world. And within this meagre amount, more than 60 per cent is spent on the family planning programme.

It is also argued that a growing population poses a threat to limited resources, that at the current rate of growth all our forests will disappear, our water supplies be exhausted, the hole in the ozone layer expanded and so on. But the fact is that a small percentage of the world's population consumes the vast majority of resources.

3. Coercion
The use of 'incentives', 'disincentives' and other forms of coercion is one of the most controversial aspects of India's population programme.

Alternative suggestions from the NPP

Measures to 'motivate' poor couples to marry late, have children late, and get sterilised after the birth of the second child.

Suggestions from state policies

Writes public health specialist Mohan Rao, "The fact that structural adjustment policies have led to the collapse of a weak and underfunded public healthcare system, and that these same policies have also led to an increase of infant mortality rates in 10 of the 15 major states of the country, do not seem to concern our policy-makers. So single-minded are they in their short-sighted policies that they do not realise the appalling fact that it is the fearsome pursuit of family planning programmes that has led to the distrust of the health system among the poor."

4. Sex ratio

The government's push for a small family together with an unethical medical profession has combined to further distort a sex ratio skewed against the girl-child.

The (female to male) sex ratio has been steadily declining: From 972 (for every 1000 boys) in 1901 to 927 in 1991. The preference for sons has led to discrimination against the girl-child and lower female literacy, sex-selective abortion, higher mortality levels for females in all age groups up to the age of 45. The latest census shows a slight overall improvement in the sex ratio to 933. Unfortunately, this is offset by a worsening of the sex ratio of children up to the age of six. Demographer Malini Karkal points out that women are genetically stronger than men are, for which reason most populations have more women than men. Yet the sex ratio for children up to the age of six has gone down from 962 girls per 1000 boys in 1981, to 945 in 1991, to 927 in 2001. The sharpest declines in sex ratio for the child population are reported from Himachal Pradesh, Punjab, Haryana, Gujarat, Uttaranchal, Maharashtra and Chandigarh, where abortions of female foetuses are known to be widely practised.

The overall rise in the sex ratio is due to the improvement in the survival chances of older women. (http://www.censusindia.net/maps/sexratio.html)

5. The role of the medical profession

"If we don't do the test, they'll only go somewhere else."… "Isn't it better to abort a female foetus than kill an infant girl?" "We're only supporting the couple and helping the family planning programme." Such statements have routinely been made by doctors.

The medical profession has long promoted prenatal sex detection and sex selective abortion -- diagnostic centres have mushroomed even in rural areas. In the 1980s, women's and health groups launched a campaign against this practice, and managed to get legislation passed restricting prenatal diagnostic techniques to registered centres, for use only when indicated. The Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act was passed in Maharashtra in the late-1980s, and at the central level in 1994. However, the law was observed more in the breach.

Prenatal sex-determination tests including the use of ultrasound technology continue to be carried out by doctors using compact machines. Women pay about Rs 500 (US$11) for ultrasound tests and Rs 2,000 rupees for an abortion. Various groups campaign against sex-selective abortions but the 1994 law is weak, with prosecutions for those undergoing sex-determination tests unlikely. In some areas within India ultrasound tests are openly advertised.

The collusion of the medical profession with an aggressive population control programme has resulted in a gross imbalance in the sex ratio.

The Supreme Court of India recently ordered the government to implement the law against prenatal sex detection and sex selective abortion.

6. Contraceptive technologies

Women's groups assert that they advocate family planning, in the interests of the poor and women, based on voluntary choice. Women have the right to decide the number of children they want and access to safe and affordable contraception which they can control.

However, the population programme has encouraged research into potentially hazardous, long-acting, provider-controlled, contraceptives targeting women. Injectable contraceptives and subdermal implants could cause irreversible damage to the health of women and their children. Women's groups note that these drugs are being approved by Indian drug regulatory authorities without the mandatory trials.

Indeed, many feel that the family planning programme shows little evidence of concern for the poor women it is supposed to serve.