The Baby And The Bathwater

Old public campaigns, like old habits, never really go away in this country. They just have reruns. The familiar 'Hum do hamare do' slogan—relegated to the freezer six years ago after a 'forced' change of family planning policy—is all set to be revived. And this formal reversal of stance indicates a larger breach between the Indian government and global agencies on health issues.

Preceding the strategy change was a realisation that the approached favoured by the United Nations Population Fund (UNFPA)—that overall socio-economic development is key to controlling population—is seen to have failed in the Indian context. The view, placing the onus of healthcare on the government rather than on the targeted families, is also championed by ngos.

That such an approach was inapplicable here is the assessment of the National Commission on Population (NCP), a body set up in May 2000 after India crossed the billion mark. In a strategy paper on family planning submitted to the Union cabinet—Outlook is exclusively privy to it—the NCP has expressed reservations about the UNFPA-led campaign to stabilise population. Instead, it recommends a return to the proactive programme to promote the two-child norm as a national goal.

While reiterating India's commitment not to adopt any coercive measure—the slogan has a murky provenance in the forcible vasectomy programme of the mid-'70s—the paper talks of persuading all eligible couples with two or more children to undergo the terminal methods of contraception at the earliest. It also recommends giving state governments a free hand to implement suitable incentives and disincentives to promote the two-child norm.

With this, the old discussion on whether to support incentive- and disincentive-based population control—an idea the UNFPA has always strongly opposed—is back with us in all its acrimony. Back in 1996, India had been forced by mounting pressure from the UN agency and ngos to adopt the 1994 Cairo resolution which listed advocacy, quality of care and individual choice as instruments for implementing family welfare programmes.

Accordingly, a couple was given the choice of having as many children, while the government was to be entrusted with providing quality reproductive and child health care services and information about availability of various contraceptives. However, no contraception targets were set.

So, the aggressive campaign 'Hum do hamare do', that had made it to the neighbourhood public wall, gradually vanished. The sterilisation drives, riddled with stories of fudged figures and unsuccessful operations, declined and set targets were forgotten. The focus moved away from achieving targets, to controlling the population by ensuring overall development.

Six years later, the ncp has concluded that this approach didn't work. The strategy of achieving overall development is now being described as ineffective, as India grapples with poor health and family welfare services both in terms of quality and coverage.

The commission has substantiated its views with facts. According to the department of family welfare, the couple protection rate (CPR)—couples covered by various methods of contraception—has shown negligible progress. In fact, from 1997-1999 it registered a constant decline.

But UNPFA does not buy this. Says its country representative Francois M. Farah: "All it means is that services are not there (contraceptives are not available) to meet the demand. Here is a situation where people are standing at your door knocking to receive services and you are going out to look for more people to join the queue. This argument doesn't carry a lot of justification because you have a substantive and important gap in terms of meeting the unmet need.For this, the services (contraceptives) have to be made available, accessible and, more importantly, they have to be of good quality and handled by qualified staff."

Farah defends the UNPFA's stand against any incentive/disincentive-linked population stabilisation programme. "Our experience shows that it certainly doesn't help because there are a number of side-effects. For example, parents trying to get rid of the second girl child. From a developmental perspective and from a rights perspective you rather equip your people so that they can decide what is in their best interest."

Krishna Singh, member-secretary of the ncp, has a counter: "Every sector has unmet needs and the fundamental reason is population explosion. At this rate, no sector will be able to cope up with this burden. Which is why we want to promote district-level programmes of birth control with the support and involvement of communities at different levels." Adds another NCP member: "We're not promoting coercion, sterilisation or abortion. But things have swung to the other extreme where the entire family planning process has slowed down."

The reference is to the linking of human rights with the population-control programme. At the time when the target-oriented policy was in place, the UNFPA and the NGOS supported by it had described the policy as violative of the reproductive rights of individuals, especially women. But NCP experts rubbish it as a slogan raised in UNFPA-supported seminar circuits. The strategy paper reads: "It can be said that repetitive child bearing, often against their will, is an attack on the human rights of poor women in countries like India. Similarly, producing more children without being able to give them basic facilities like food, shelter, healthcare, education etc is a violation of their rights...."

The NCP has highlighted the success of the population policy of Andhra Pradesh which is target-oriented, especially for permanent contraception, and involves many individual and community-based incentives. These range from monetary incentives for sterilisation to preference being given to those who adopt family planning while extending benefits such as loans, allotment of housing sites and awarding of surplus agricultural land to the landless. Evidently, Andhra Pradesh which had a fertility rate (4) far higher in comparison to Maharashtra and Karnataka (both 3.6) in 1981, has now brought it down to 2.2.

"The problem is not numbers. You can't go out tomorrow and say whoever has three (children) must reduce them to two or whoever has one must close the tap and say they won't have any more kids. There is no quick-fix solution," says Farah.

Finally, the debate boils down to the existing socio-economic problems (which the ncp feels has worsened due to the population growth). Says Meera Shiva of Voluntary Health Association: "For poor people, kids are not just mouths to feed but also hands that work. And considering the inadequate health services, how can you promote sterilisation without ensuring that the two kids will survive." Avers Amit Sengupta of Jan Swasthya Abhiyaan, a network of 1,000 health NGOS: "By approving of disincentive measures you end up punishing the most vulnerable section of society."

Significantly, the NCP hasn't paid much heed to the unstated threat that introduction of incentives and disincentives into the family planning programme might lead to denial of foreign aid. It's pointed out that the UNFPA is supporting population-control measures in China in spite of their one-child norm. Explains Farah: "We're working in 36 counties of China and we've an understanding with the government that no coercive action is used in those counties."

The government, however, has taken note of the link between UNFPA's emphasis on spacing methods (temporary contraception) and a huge social sector market opening up in the country.Says a senior official in the Union health ministry: "A majority of spacing devices like IUDS, oral pills and condoms are manufactured by MNCS and India offers these products a huge market. That is why you've a sustained campaign opposing sterilisation and supporting spacing options."

With the cabinet considering the review of the national family welfare policy, all these issues are likely to be heatedly discussed. And if health officials are to be believed, the 'free choice' to sire as many children as you want could now have some strings attached.