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The classic Catch 22-- population control or development?

By Nalini Bhanot and Laxmi Murthy

Indian planners, like their counterparts in the rest of the world, were influenced by Malthus and started out by laying heavy stress on population control. India was the first country in the world to set up an official family planning programme. For several decades, the reasoning was that population growth was bound to adversely affect the rate of economic growth and standard of living of people. Since Independence , the government tried a variety of approaches to bring down the birth rate in the country -- clinic approach, extension approach, target approach, multi-sectoral approach. However, these strategies for population reduction did not bear expected results despite crores upon crores of rupees being pumped into the programme. For instance, a target was set to reduce the birth rate to 25/1,000 by 1973. This birth rate was achieved only in 2002!

Reasons for failure

For most of its history, the family planning programme treated people as numbers which had to be reduced at any cost. Living conditions, health needs, social relations between communities and between men and women were largely ignored. Some of the significant and controversial features of the programme have been:

1 Incentives and disincentives: Carrot and stick

In the early-1960s, the government introduced financial incentives for acceptors of family planning as well as for staff. Money, loans, subsidies, blankets, inclusion in food for work programmes, were some of the incentives offered to acceptors of family planning. Health staff, together with a 'motivator', was also rewarded with money, prizes, promotions and good postings.

It is important to note that disincentives were suggested as early as 1961 by the Mudaliar Committee. The measures suggested included graded tax penalties, withdrawal of maternity benefits and limitation of certain government services such as free education to three children per family. Thus, long before the newly-introduced family planning programme had been given a chance to work, coercive measures were recommended to tackle what, in the West, was being perceived as a population 'bomb' in Third World countries, posing a threat to themselves and the entire world.

Disincentives included denying government jobs, denying benefits of the public distribution system (which entitled the poor to subsidised food), disqualification from participation in local government, requirement of a sterilisation certificate before grant of government permits, rural credit, and even fertiliser, denial of school admission to children of parents with more than three offspring, offering re-housing after slum clearance only to those who accepted sterilisation, etc. In some places, police detachments were employed to obtain motivated clients for sterilisation.

Disincentives to staff have included withholding pay and promotion, punishment postings, and so on.

For almost 40 years, from the early-1960s to 2000, these incentives and disincentives created havoc. Staff spent much more time on family planning activities than on health because of the incentives. Records were falsified, a brand new form of corruption came into being, and women were coerced by staff, husbands or relatives into undergoing sterilisations in unsafe conditions. The scheme was offensive in itself as it took advantage of the economic and social vulnerability of the poor without doing anything to improve their lot in life.

2 Target approach: Missing the mark

Also introduced in the 1960s, the target approach meant that each health functionary had to motivate and get a given number of acceptors for each method of family planning. In reality, this meant getting a certain number of women to accept sterilisation or get an IUCD (intra-uterine contraceptive device) inserted.

Village-level health workers have a lot of work to do aside from motivating women for family planning. They have to visit 50 or more households per day, and visit all the houses in the area assigned to them at least once a month. They have to ensure that children are immunised, women receive necessary care during pregnancy, give health education, treat minor ailments and, apart from all this, spend a lot of time keeping records. The pressure of fulfilling targets, more so with incentives and disincentives being applied, led to an overall deterioration of all services provided by these workers.

As Dr Mohan Rao points out: "In 1966-67, over 900,000 women were fitted with IUCDs. In the following year, the number declined to 669,000 in spite of the best efforts, on the part of health workers, and from then on the decline was quite drastic." Mohan Rao attributes the reasons for the failure of the IUCD programme not so much to the technology of the contraceptive, but to the inability of the system to screen suitable women and provide guidance, counselling and follow-up. It was also undoubtedly related to the targets that placed a premium on numbers.

3 Women bear the brunt : Promoting the use of hazardous contraceptives

When the family planning programme started, the contraceptives offered to couples (read women) were the diaphragm, jelly and the rhythm method. Sterilisation was added to the programme in 1959. The IUCD and the oral pill were introduced in the mid-'60s. In 1972, the abortion law was liberalised, re-named 'medical termination of pregnancy', and abortion was also considered a way of reducing births.

With the exception of sterilisation, which is a permanent method of family planning, all the others were methods that enabled couples to increase the birth interval between children (spacing methods). However, the most significant feature of these contraceptives was that they were user-controlled - a woman could decide whether and when to use the contraceptive. If she was unhappy with it, she could stop using it.

But when fertility rates did not decline as anticipated, the government started introducing long-acting contraceptives (whose effects lasted for several months, even years), for example injectables and implants. These methods were provider-controlled in that women could not start and stop using them at will. For instance, injectables had to be given by a trained doctor or nurse every two to three months. Once injected, the woman had to bear the consequences of the injectable as long as its effects lasted, that is, two to three months. There was nothing anybody could do to 'remove' it earlier.

Similarly, implants need to be inserted by a trained doctor and are effective for a period of two to five years. Removal of the implant also has to be done by a trained doctor.

There were several problems in using such contraceptives, but in their eagerness to control numbers the government still went ahead with them.

  • Oral pills, injectables, implants and the newer IUDs (intra-uterine devices) contain hormones that can have several side-effects. Safe use requires careful screening of potential users, and careful monitoring of side-effects. For example, oral pills have been widely used in the US for more than 40 years. Different combinations of hormone pills are available there and are prescribed according to which combination is most suited to a woman. Despite this long use, oral pills are still not sold over the counter at drug stores. A doctor's prescription is required to purchase them. In contrast, in India, the same combination of oral pills is distributed to everybody; they are even sold at paan shops and by petty shopkeepers.
  • Injectable contraceptives have a tremendous potential for abuse because an injection can be given to a woman without her realising that she is being given a contraceptive. This is more so in a target-oriented family planning programme.
  • Implants are expensive, and though the government bears the cost of providing the implant to the woman, the experience of women in several countries, including India , shows that medical personnel are very reluctant to remove the implant at a woman's request, even if she is having medical problems. To remove it before its effective lifespan would be a waste of money, so women are "persuaded" to continue with it for some more time.

4 Laying greater stress on family planning than on health

Over 70% of our population still lives in rural areas. The government did set up a system of primary health centres and sub-centres to serve the rural population. However, instead of evolving a health structure with a rural focus, largely dependent on paramedical personnel, what emerged was a doctor-based, urban-biased healthcare system. These developments did not take place by chance, rather they reflected the priorities of our planners, and the distortions set in from the First Five-Year Plan itself.

Over the years, several policy documents pointed out the extreme inadequacy of the healthcare system. Some even argued that "the existing exotic, top-down, elite-oriented, urban-biased, centralised and bureaucratic system which overemphasises curative aspects, large urban hospitals, doctors and drugs should be replaced by an alternative model".

Unfortunately, the situation did not change much even after decades. The National Health Policy 2002 accepted that "the morbidity and mortality levels in the country are still unacceptably high... an indication of the limited success of the public health system".

Ignoring the health needs of people in favour of pushing family planning meant that:

  • Child deaths remained high. Women continued to have more children than they needed in the hope that some would survive.
  • Hazardous contraceptives were pushed on women who were not always healthy to begin with, leading to many more complications and side-effects.
  • The health staff and health centres, particularly in rural areas, were ill-equipped to counsel, screen and monitor the health of women using contraceptives.
  •   Ultimately, the bad experiences of a few women led others to reject contraceptives as well.

5 Ignoring the gender issue

Excepting the short period of the Emergency, when male sterilisation was aggressively pushed, the rest of the time women have been the focus of the family planning programme. Aside from sterilisation, the condom has been the only other method available for men.

The very first surveys had indicated that women wanted fewer children than they actually produced. However, the focus on women rather than couples ignored the reality in which women live.

Ours is a male-dominated or patriarchal society, in which the status of women is subordinate to that of men. All major decisions are expected to be made by the eldest male in the family (the patriarch). This includes the decision on the number of children to have. Even if women want to use a contraceptive, they can be pressured by their husbands or in-laws to produce more children.

Being a predominantly agricultural society, great importance is given to a woman's fertility and her ability to produce sons -"†sons who will work on the land and inherit it, sons who will perform religious duties including the last rites of the patriarch, sons who will look after the parents in their old age. Daughters are viewed more as a burden, since they will marry and go away to their matrimonial home. Even today, women can be deserted or divorced if they cannot bear children. They do not have the legal right to inherit land. Given this emphasis on fertility and the need to produce sons, women do not stop reproducing until they have had the desired number of sons and are sure they will survive.

While there is a paucity of doctors in rural areas, there is an even greater paucity of women doctors. Women are extremely reluctant to be examined by male doctors and discuss issues of menstruation or gynaecological problems with them. This is a constraint particularly with the use of IUCDs.

Women are often victims of violence and rape within the family and outside. This is just one of the reasons why girls are married off at a young age. Girls are not encouraged to study and so their literacy levels are lower compared to boys. Women are also economically disadvantaged. Household labour carries no monetary value. Even for agricultural and other labour in the unorganised sector, women are paid a lower wage than men for doing the same work. For example, according to the Alternative Economic Survey 2006, men get paid a daily wage of Rs 76.5 for ploughing while women get only Rs 38.52; men get Rs 95 for well-digging, women get only Rs 51. Whatever income women do earn is controlled by in-laws or husbands.

For all these reasons, women are educationally, socially, economically and legally at a disadvantage. Little wonder then that they do not have the power to decide how many children to have.

Why do women's groups oppose long-acting hormonal contraceptives?

Women's groups the world over have been opposing long-acting, hormonal, invasive contraceptives. What is it that makes these contraceptives so unsuitable for women, especially in the Third World?

  • They are invasive. In addition to the reproductive organs, they affect several vital organs in the body -- the brain, the liver, the heart, etc.
  • They are dangerous. They have several side-effects, such as menstrual disturbances, headaches, fatigue, depression, and possible hazards like the formation of blood clots, cardiovascular problems, osteoporosis (thinning of the bones) and the risk of cancer.
  •   They are long-acting. The effects of these contraceptives cannot be withdrawn before a given period of time, even if a woman experiences a serious problem.
  •   Return of fertility is not assured. Although these methods are promoted as spacing methods, that is, to ensure a gap between one child and the next, many women experience delays or difficulty in conceiving.
  • The risks to breast-feeding infants cannot be satisfactorily ruled out. This is a grave concern, since a majority of women users will be breast-feeding.
  •   Risks to children conceived by accident, or conceived before the effects of the drug have worn off, have not been satisfactorily assessed.
  • They are provider-controlled, which means that a village health worker, doctor or paramedic is needed to administer the contraceptive, and, in the case of implants, even remove it.
  • Inadequate healthcare infrastructure to rule out contraindications, monitor the woman during use, respond to life-threatening emergencies like allergic shock or pregnancy outside the uterus.
  • Unethical testing, f rom lack of informed consent to outright coercion.
  • Potential for abuse with indiscriminate use in the population control programme, with misinformation, lack of informed consent and 'persuasion' through incentives.
  • No protection against HIV/AIDS.

Profit-making by pharmaceutical companies takes precedence over women's health. In the rush to win over the market, especially Third World governments, research norms are violated and ethics take a back seat in the race to complete trials, get approval and make money.

Source: Saheli: 25 Years of Continuity and Change, 2006

6 Ignoring the democratic rights of people

The Constitution of India grants to all its citizens, men, women and children, irrespective of caste, class and religion, the right to a life of dignity. Life in this context means not just an animal existence, but one that includes mental, physical and spiritual wellbeing. While the family planning programme in India started out respecting the dignity of people, when the desired reduction in birth rates did not take place it progressively started treating people as numbers.

The worst and most traumatic period was in 1976-77 when a state of Emergency was declared in the country. This meant that all democratic processes were put aside and the rights of people to oppose the government were taken away. A national target of 4.3 million sterilisations for the period April 1976 to March 1977 was announced. Unlike at other times, male sterilisation was the main focus, probably because it was a simpler and faster procedure than female sterilisation and the target set was high. The brunt of this sterilisation drive was borne by the poor, illiterate lower castes, scheduled castes and Muslims.

Describing the fear and resentment these moves generated among people, Dr Mohan Rao writes: "In many rural areas of Haryana, Rajasthan and Uttar Pradesh, there were reports of people attacking or fleeing from official vehicles that were suspected to be involved in the family planning campaign. At other places, people avoided health centres for fear of being nabbed for sterilisation. At still other places, people refused vaccinations fearing it was for purposes of sterilisation. Those forced to undergo sterilisations included bachelors, persons with no children, old persons, patients in hospitals, inmates of jails and night shelters, and pavement-dwellers. There were also riots resulting in police firings and deaths."

Sterilisation itself took a ghastly toll: 1,774 deaths were reported, according to Government of India figures. This is undoubtedly the largest ever loss of life in the history of a 'welfare' programme. Indeed, it would not be an exaggeration to state that the scars of the family planning programme of the Emergency period persist as they bludgeoned the credibility of the healthcare system.

Demographer Ashish Bose estimates that what he calls the 'Sanjay Effect' -- a combination of 'coercion, cruelty, corruption and cooked figures' -- accounted for 7 million forced sterilisations.

Even after the Emergency was lifted, apathy and indifference to people has been a hallmark of the family planning programme. Study after study reveals the dissatisfaction felt by women. This is clearly highlighted by a study in Uttar Pradesh where only 45% of those who had accepted sterilisation and 38% of those who had accepted IUCD said they would recommend it to others. This study was done in 1993-94, more than 30 years after the family planning programme started!

A quick guide to contraceptive methods

IUCD: Intra-uterine contraceptive device. A small device that is inserted into a woman's uterus though her vagina.

Oral pill: Contraceptives in the form of a tablet which contains hormones. Depending on the hormones they contain, a woman has to take a pill each day either for 21 days or for 28 days.

Injectables: Contraceptives in the form of an injection which contains hormones. Depending on the hormones they contain, a woman has to be given an injection every two or three months.

Implants: Small matchstick-sized rods containing hormones are inserted under the skin in the upper arm through a minor surgery. Depending on the hormones they contain and the number of rods, one implant is effective for two or more years.

Sterilisation (female): A small surgical procedure to tie up a woman's fallopian tubes (the tubes that carry the eggs from the ovary to the uterus). This used to be the most commonly used method -- newer methods of sterilisation have since been developed.

Sterilisation (male): A small surgical procedure to tie up a man's tubes (the tubes that carry sperm from the testes to the penis).

Barrier methods: Condoms -- both male and female; diaphragms (cup-shaped synthetic rubber device a woman can place inside her vagina to cover her cervix); spermicidal jellies (which chemically destroy sperm).

InfoChange News & Features, March 2007