Health policy rethink

April 4, 2014 at 1:08 PM | Posted in Demography, Fertility, Family planning, Population, Gender/Women's Rights | Leave a comment
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deccan logoThe challenge is to contrast the cost with the advantages of introducing strategies that could transform lakhs of lives.

Whatever may be the complexion of the next government, three areas of health policy require urgent rethinking. All three depend upon changing human behaviour which is often a bigger challenge than finding resources. But given the dramatic extent to which a few initiatives can better lives and reduce investments on health, the implication of continuing to function incrementally needs examination.

First there is the issue of fertility and here one refers to quality, not numbers. Fortunately by now, nearly half the country has achieved replacement levels of fertility. But Uttar Pradesh and Bihar, which together account for a third of the country’s annual 27 million births, would need another 15 years to reach there. And while the picture is somewhat better in Madhya Pradesh, Rajasthan, Jharkhand and Chattisgarh, these states too will need another decade to contain fertility.Pushing up the first birth to after the mother is 20 can bring a 50 per cent reduction in maternal mortality. It will allow the mother-to-be to overcome malnutrition and anaemia which predispose her to birth underweight, malnourished and sickly children. The expectation that trickle-down from economic growth will percolate and boost their health is unlikely, given fresh health findings.

A recently published Lancet survey which covered 36 low and middle income countries has shown that economic growth (GDP) makes little difference to child under-nutrition. That is precisely why demographers and economists need to demonstrate the implications of allowing generations of children to be born too early, only to become victims of malnutrition, infirmity and even stunting, wasting and poor mental development.

But this is far from easy. Rural mindsets favour early marriage and childbearing soon thereafter. To some extent mandatory registration of marriages will oblige more and more families to wait until a girl is 18 years of age. Although a welcome development, it will not address the issue of malnutrition and anaemia which afflict adolescent girls, leaving them in poor shape to bear healthy children.

Apart from the need to encourage postponement of the first childbirth to after 20, there is also a need to focus on spacing between children. WHO studies show that in rural areas, mortality is highest among infants born within a year, and the risks are progressively lower when followed by a gap of two, three and four years. Every encouragement needs to be given to spacing between children by persuading women at risk and their well-wishers to understand the need for longer birth intervals. Condoms and pills are known to have too many imponderables and when overall contraceptive use is less than 19 per cent among 15 to 24-year-olds, alternatives must be accessible.

Space births

In China, 40 per cent of the contraception is managed through IUDs (intrauterine device.) In Bangladesh, Indonesia, Iran and Sri Lanka the use of IUDs and injectables – both for spacing and limiting births – helped lower fertility years ago. In India, female sterilisation still accounts for 72 per cent of all contraceptive methods although it is an outmoded strategy. No other country promotes it so widely. The economic gains from widening newer contraceptive use among adolescent and young women needs to be calculated and tools that are reliable and trouble-free offered to them. The second policy area which needs urgent attention is the high incidence of oral cancer. The Union health ministry statistics show that 50 per cent of cancers among men and 25 per cent of cancers among women are related to tobacco use.

According to ICMR, the direct and indirect costs of three major tobacco related diseases – cardiovascular disease, cancer and chronic lung disease total 25 per cent of all public spending. Deaths caused by tobacco use are responsible for more fatalities than those caused by HIV/AIDS, TB and malaria combined. Although excise duties on smoked tobacco have increased, they do not affect the unbridled consumption of non-smoking tobacco – a huge contributor to oral cancer. The ultimate solution lies in phasing out tobacco cultivation. But unless the costs of cancer treatment are juxtaposed in economic terms with the “gains” from tobacco cultivation, including the employment it generates, the agriculture and labour ministries and tobacco growing states will evade conversion to alternative crops.

The third policy area relates to the growing incidence of hypertension, heart disease and diabetes which are ballooning in urban areas. Much of this has to do with high salt, fat and sugar intake, besides sedentary lifestyles. Occasional awareness campaigns and admonitions from doctors are not capable of commanding the lifestyle changes needed on a massive scale. Disincentives, higher duties and health warnings on product labels have succeeded substantially elsewhere in the world. We have to calculate the dangers of soft handling because society will pay the price.

Who should do it? Discouraging early wedlock and pregnancy will only be pushed by health bureaucracies, if chief ministers champion the need to lower fertility and thereby promote women’s and children’s health. Phasing out tobacco cultivation will need sustained leadership from a prime minister who alone can drive three powerful but reluctant ministries- finance, agriculture and labour to understand the urgency to depart from tobacco cultivation.

Finally, meddling with the consumer’s right to satiate his palate will be considered political hara-kiri. Yet finance and health ministries in progressive countries are helping citizens to alter life-styles. The challenge is even greater among Indians who value extra-fattening foodstuffs as a mark of big-heartedness. Surely, a combination of public health researchers and micro economists can contrast the cost of doing business as usual with the advantages of introducing strategies that could transform lakhs of lives. And at nominal cost.

India’s high fertility: The myths and the reality

March 6, 2014 at 10:35 AM | Posted in Demography, Fertility, Family planning, Population | 2 Comments
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This article attempts to uncover widespread assumptions about women’s fertility, contraception and the role that religion plays in birth control. The good news is that 44 per cent of the population living in 21 states and UTs has already achieved replacement levels of fertility. Kerala and Tamil Nadu achieved this more than a score of years ago.


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Population stabilisation efforts in the rest of the country are of relatively recent origin but none-the-less commendable. The added good news is that the increase in contraceptive prevalence has been larger and faster among illiterate and uneducated women than those with schooling.

According to the International Institute of Population Sciences (EPW Arokiasamy 2009), more than two fifths of the reduction in Total Fertility Rate country-wide is attributable to illiterate women. The study calls it “remarkable demographic behaviour which has given significant direct health benefits to women and children — almost equal to what educational improvement has done for progress in human development.”

Now some disappointments: States which continue to lag behind are the same — Bihar, Uttar Pradesh, Madhya Pradesh, Jharkhand, Chattisgarh and Rajasthan — some 284 problem districts account for nearly half India’s population and 60 per cent of the yearly births countrywide.

Among 18 to 24-year-old couples the contraceptive prevalence rate is not even 19 per cent. In many districts it is as low as 10 per cent. According to NFHS -3 and the latest Annual Health Survey, in Bihar more than half the women in the child bearing group are not using any family planning method.

Ideally one should wait for the unravelling of the 2011 Census data and the results of NFHS- 4 to see the extent of improvement but both reports are expected only in a year or two.

Even so, lessons that existing reports provide will only get updated — certainly not set aside.

In India, female sterilization continues to be the most dominant method of birth control even though women overwhelmingly favour non-invasive options. In the absence of tools that do not depend on partner-co-operation (condoms) or adherence to rigid regimens (pills), a poor woman confronts the prospect of an unwanted pregnancies every month, until somebody agrees to escort her for an operation. The policy question is whether by facilitating more acceptable birth control options one can accelerate fertility regulation and in the process improve health outcomes for women (and newborns).

That brings one to a widespread myth relating to the practice of contraception by religion. Professor P.M. Kulkarni at JNU who has researched differentials in population growth among Hindus and Muslims (using NFHS data) says that all religious communities have experienced substantial fertility decline and contraceptive practice has been well accepted by all. Within religious faiths, 85 per cent of Hindu women would like to limit the family to two children whereas in the case of Muslim women, the figure is 66 per cent.
Even so, fertility levels among the poor, be it Hindus or Muslims are not so widely different and have in fact narrowed considerably.

The difference in births boils down to less than one child per woman.

“This,” says Kulkarni “belies the general belief that Muslim women are barred from using contraceptives.”

The belief that religion and religious fiats discourage contraception among Muslims is not borne out by statistics.

An even more significant aspect of his analysis of NFHS data shows that the unmet need for family planning is one and a half times more among Muslim women than Hindu women.

In terms of contraceptive use, Muslim women’s use of the pill is almost twice that of Hindu women and the use of IUD is also higher compared to Hindu women. Two things can be concluded: First that among the rural poor, the difference in fertility between Hindus and Muslims is not as marked as is usually supposed.

Second: there is a perceptible difference in the preferred method of contraception: Muslim women seem to be more open to the use of it.

This leads one to ask what might be the trends in Muslim dominated countries like Bangladesh, Indonesia and Iran which have achieved high levels of contraceptive use.

According to the UN Economic & Social Affairs Population Division’s Contraceptive Use by Method (2012,) in Bangladesh the use of the pill is more than 25 per cent. Women also use IUDs and injectables in sizeable measure. In the case of Indonesia injectables are the preferred choice, followed by pill use. The use of condoms is comparatively small. Iranian women seem to rely hugely on the pill but they also use IUDs in high proportion.

To sum up, the focus of the reproductive health programme has appropriately been on the laggard districts — mostly in the Hindi belt. But reduction in fertility has to be pursued by meeting the unmet demand for specific contraceptive choices and not by depending predominantly on sterilizing women. This requires three approaches: first by encouraging spacing among 18 to 24-year-olds; second improving access to contraceptive choices for women who are averse to sterilization. Finally what other countries have done to great advantage needs a re-look. In China, 40 per cent of the women rely on IUCDs. In India more and more women with children have begun opting for IUDs but access needs to increase manifold because the device gives a 3 to 10 year protection against pregnancy and can be reversed at will. Finally, latest research on the safety of injectables needs to be investigated afresh, looking at international best practices.

Instead of lamenting over irresponsible parenthood, the focus needs to target the unmet needs of specific population cohorts to empower women with what they need the most — liberty to decide when to have the next child or not to have one. Without being subjected to an operation.

Religion is not the issue-women’s freedom to decide about pregnancy and childbirth is.

India’s Health-Issues and Challenges

October 3, 2012 at 4:56 PM | Posted in Demography, Fertility, Family planning, Population | 2 Comments
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Lead Article

October 2012

Public health is squarely a state responsibility and particularly so in a developing country. It has to go hand-in-hand with sanitation, drinking water, health education and disease prevention.

The challenges facing India’s health sector are mammoth. They will only multiply in the years ahead. Surprisingly many of the challenges are neither a result of the paucity of resources nor of technical capacity. These hurdles exist because of a perception that the possible solutions may find disfavour with voters or influential power groups.

The first malady has been the utter neglect of population stabilisation in states where it matters the most.

The second is the monopoly that an elitist medical hierarchy has exercised for over 60 years on health manpower planning. The result has given a system where high-tech speciality services are valued and remunerated far higher than the delivery of public health services. The latter ironically touches the lives of millions.

Related to this is the third big challenge — how to make sure that doctors serve the growing needs of the public sector when the working conditions are rotten, plagued by overcrowding, meagre infrastructure and a virtual absence of rewards and punishments.

Divergent Attitudes to Birth Control.

In the aftermath of the 1975 Emergency and the odium of forced sterilisations, the emphasis on population control shrivelled in most of North India. While countries like Korea and Iran which then had fertility rates far higher than ours, embraced the joys of planned parenthood, India dodged the subject. In 1994 the country adopted a target free policy and the states were encouraged to implement a “cafeteria approach” while supplying contraceptives.

However the southern states of Kerala and Tamil Nadu unlike the rest of the country went full force to make family planning their top-most priority. No matter which party came to power, political support was there in abundance. In the mid- eighties the programme was spearheaded by no less than the state Chief Secretary of Tamil Nadu, Mr.T V Anthony, (nick-named Tubectomy-Vasectomy Anthony )which speaks for itself. With enthusiastic politicians, civil servants and doctors joining hands, Kerala and Tamil Nadu reduced fertility rates to equalise European levels. That was more than 20 years ago. Meanwhile, North India (where most of the emergency driven sterilisations had taken place) recoiled from the very mention of family planning- a mind-set that persists even to this day.

The Challenge of Reducing Maternal and Infant Mortality

There is a clear correlation between the health of the mother and maternal and infant mortality. In the northern states more than 60% of the girls and boys (respectively) are married well before the legal ages of 18 and 21. The repercussions of early pregnancy and child birth have not even dawned on the pair when they wed. The first child arrives within the year when most adolescent girls are malnourished, anaemic and poorly educated. With no planned spacing between the births, another child is born before the young mother has rebuilt her strength or given sufficient nutrition and mothercare to the first born. These are among the main causes of high deaths of young women and infants. The chart and tables below clearly show the regional difference in maternal, infant and child mortality. Narrowing the gaps poses one of the biggest health challenges.

Regional Variations: Maternal Mortality Ratio* (MMR)

Extract from – Special Bulletin (June, 2011) on Maternal Mortality in India 2007-09 (Sample Registration System) Office of Registrar General, India
*MMR: Maternal deaths per 1,00,000 live births

The regional variations in the deaths of mothers in the states of Uttar Pradesh, Bihar, Jharkhand, Madhya Pradesh, Chattisgarh, Odisha, Rajasthan and Assam show that the percentage of maternal deaths is 6 times higher than in the Southern states.

Source: Special Bulletin on Maternal Mortality in India 2007-09 (SRS, 2011) Office of Registrar General, India and Unicef SOWC, 2011

Taken together the EAG States and Assam account for 62% of the maternal deaths. Schemes for nutrition, supplementary feeding, literacy, the right to education and health care remain hollow expressions without any meaning as long as women (and chiefly adolescents) have no control over pregnancy. Unlike other South and South East Asian countries the use of IUD and injectibles has not taken off in India -nor are these the thrust areas for family planning anywhere in the country. Although long term, reversible methods of preventing pregnancy are available, young mothers and children continue to suffer or die. The challenge lies in bringing the issue to centre –stage and not wait for incremental improvements to take place in the fullness of time. The charts below show the colossal difference that has been achieved by the southern states that invested heavily in family planning (albeit through the adoption of terminal methods like sterilisation which can be avoided today.)

Source: Registrar General of India, Ministry of Home Affairs (SRS, 2011)

Source: Registrar General of India, Ministry of Home Affairs (SRS, 2011)

Health Management and Manpower Planning

The second challenge relates to a obsession for exclusivity that has consumed the medical sector for too long. The Councils that regulate education and register the practitioners (Medical Council of India (MCI), Dental Council, Pharmacy Council, Nursing Council) were established with laudable goals- to elect a cross section of doctors and other health professionals democratically and to entrust to them the responsibility for designing and executing professional corses. It was expected that the country’s needs for professional health manpower would be met both qualitatively and quantitatively. But because the Councils were constituted through a political process of elections, the baggage of money, patronage and quid pro quos became a predictable accessory. Today, gaining entry to professional colleges has become highly commercialised-ultimately reflecting in the aspirations of the health fraternity to reap back benefits from huge investments incurred. As the quest to produce specialists and super specialists grows, the production of qualified technical manpower has declined severely creating a mis-match which cannot be corrected by people who work in silos and lack the understanding and vision to think of the country’s health needs in totality.

The Challenge of Establishing NCHRH.

The neglect of public health is one of the fallouts of the elitism that has pervaded medical education. Whereas cities and towns at least have alternatives available- at a price- epidemics and acute illnesses that occur in rural areas often leave people in the hands of fate. The erstwhile elected MCI had relegated public health to the lowest rung of the health hierarchy and the doctors that once decimated dreaded diseases like malaria and smallpox are not to be found. The complement of technical staff, nurses, pharmacists, dentists, lab technicians and operation theatre staff are all in short supply outside the urban areas as the bodies that register them do not work in tandem. More importantly no Council has a stake in health care of any particular state- leave alone the country.

The proposal to set up a National Council for Human Resources in Health (NCHRH), far from being a bureaucratic response was a well thought out strategy having its roots in the recommendations of independent think tanks and expert committees. The rationale for setting up such an umbrella body was to see that the goals of health manpower planning, the prescription of standards, the establishment of accreditation mechanisms and preservation of ethical standards were served in a co-ordinated way, on the lines of structures that operate successfully in other countries.

The Indian Medical Association in particular and doctors in general have been arguing against the need for such a body because they perceive it as a threat to their autonomy and a camouflage for political and bureaucratic meddling. The fact that health manpower planning was simply ignored, that there was a complete lack of coordination between the councils and most important of all the fact that public health had become a low priority have been overlooked in the fire and fury of opposing the NCHRH concept tooth and nail. The challenge today is how to ensure that the health sector produces adequate professionals as required for the primary, secondary and tertiary sectors, both for the public as well as the private sector health facilities. If the NCHRH Bill before the Standing Committee of Parliament does not see light of day, the resurrection of the superseded scam-ridden MCI is a foregone conclusion.

The Challenge of Allopathy and AYUSH.

Public health cannot be run on contract basis and much less be farmed out to private insurance companies and HMOs (Health Management Organisations) as a recent report on Universal Health Coverage seems to suggest. Public health is squarely a state responsibility and particularly so in a developing country. It has to go hand-in-hand with sanitation, drinking water, health education and disease prevention. The National Rural Health Mission (NRHM) which is a public-sector programme has registered an encouraging impact in even the most intractable regions of the country. A UNFPA study has shown that nearly three quarters of all births in Madhya Pradesh and Odisha had been conducted in a regular health facility. The percentage of institutional deliveries in Rajasthan, Bihar in Uttar Pradesh was lower but even so, accounted for almost half the deliveries conducted in those states. Indeed these achievements are immense.

Having said this, institutional deliveries alone cannot be the answer to all the problems that beset the rural health sector. A visit to any interior block or taluka in the Hindi belt states shows that most primary health centres beyond urban limits are bereft of doctors, except sporadically. Some state governments have taken to posting contractual AYUSH doctors engaged under NRHM to man the primary health centres. These doctors dispense allopathic drugs, prescribe and administer IV fluids, injections and life-saving drugs, assisted by AYUSH pharmacists and nursing orderlies. This reality must be confronted. If an AYUSH is doctor has been entrusted with the responsibility of running a primary health centre, and found in shape to handle the national programmes, the controversy over what AYUSH doctors can and cannot do must be settled. The trend of AYUSH doctors working in as registrars and second level physicians in private sector hospitals, clinics, and nursing homes is wide-spread in states like Uttar Pradesh, Maharashtra, and Punjab; so also in Delhi and Mumbai. The challenge lies in understanding what can be changed and what cannot be changed, without getting intimidated by protests from Medical Associations that will always protect their turf to retain primacy.

The Challenge of Retaining Doctors.

The most important concern by far is to decide what kind of medical and public health cover is necessary and feasible to be given to people living beyond the bigger towns and cities. If all general duty doctors are making a beeline for post graduation- failing which opting for management, administration and even banking jobs (because cities are better places to live in,) the facts must be faced. Pursuing post-graduation, migrating abroad and prospecting for jobs outside the medical sector cannot be stopped by any Government. But fixed term requirements to stay bonded to the public sector can certainly be insisted upon for state sponsored medical graduates. But equally the working conditions, facilities and remuneration of such doctors should be respectable. In the state of Jammu & Kashmir the compensation given for working in more difficult areas has been graded. Such practical solutions can greatly bolster doctor retention.

At the end of the day, the challenges of the health sector can only be met if doctors, essential drugs and supporting staff are available in the health facilities. The biggest transformation will come if wriggling out of postings and manipulating things through political patrons stops. The doctors will fall in line only if postings are notified through a transparent and fair process and no exceptions whatsoever are allowed. Only the state Chief Ministers and Health Ministers can make this happen. But will they?

Census and sensibility

February 13, 2011 at 7:44 PM | Posted in Bureaucracy, Governance and Sarkar, Demography, Fertility, Family planning, Population | Leave a comment
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By Shailaja Chandra

In a country with a population of over 1 billion, not even a fraction of people is aware of the gigantic story which the forthcoming census can reveal. For the average Indian, the census is just another event—an eager enumerator’s home visit in February, followed by a flash of newspaper headlines in March.

The number game: Officials sorting data from the census form

Although a mind-boggling mass of data is generated by the census, its availability is limited to what the Registrar General of India (RGI) decides to reveal. Even after the data is released at the national level, it takes years for the district data to be published. The release of district data for 2001 came only in 2007. An interesting finding popped up from the data pertaining to Delhi—nearly 40 per cent of the population lived in one room; virtually every household owned a television set but a quarter of the families still had no toilet in their homes. Published six years after the census, no one gave it another glance.

There can be no better tool for meaningful planning than the census. But the delay in the release of disaggregated data causes it to lose relevance. Besides, most officials are ill-equipped to capture and project data that can raise uncomfortable questions. There is, therefore, a pressing need to package the census results in a way that they add meaning and content to planning.

Some nationwide surveys, despite covering not even 1 per cent of what the census encompasses, carry enormous weight because their results are easy to decipher. For instance, the National Family Health Survey [NFHS-3 (2005-06)], providing state-level estimates primarily on women’s health and the District Level Health Survey [DLHS-3 (2007-08)], focusing on women’s reproductive health indicators, are used extensively not just by academics but by health planners, the media and NGOs. Comparative charts and colourful maps are used to flag the high or low rankings on all indicators, making it easy to understand.

The census data is unfortunately difficult to chew and digest and remains coddled in the presentations of research institutions, think tanks and demography seminars. It does not throw up questions, debate or excitement within civil society when it contains information down to every household.

The census exercise is something of a miracle considering the rudimentary set-up of the RGI’s office, which operates from World War II barracks on Mansingh Road in Delhi. But no taxi or scooter driver has ever heard of it.

In countries like the UK, the policy mandates that census data should be accessible and free. There is no such law in India and the RGI’s office sells CDs for 0400 only through designated offices. How much better would it be if they could be distributed across colleges, secondary schools and libraries. A film on national television should broadcast how custom-built maps, graphs and charts can be shaped.

In 2007, the National Population Stabilisation Fund called Jansankhya Sthirata Kosh (JSK) put up PDF maps of every district on the internet, displaying district health facilities superimposed on GIS maps. Overnight, it was possible to see the clustering of primary health centres and sub-centres in different talukas. Even the distance of every village from the nearest health facility could be viewed easily. Based wholly on census data, it was executed with the help of the National Informatics Centre in just four months.

As Prabhat Jha, a leading Canadian public health researcher who works with the RGI’s office, puts it, “The Reserve Bank of India represents India’s monetary policy. The census is no less—it represents India’s central bank for social policy.”

The author was the first executive director of the National Population Stabilisation Fund, Government of India.

Power to the People: Indicators for Accountability

January 3, 2011 at 7:02 AM | Posted in Bureaucracy, Governance and Sarkar, Demography, Fertility, Family planning, Population | 10 Comments
OECD Publication

Statistics, Knowledge and Policy 2007: Measuring and Fostering the Progress of Societies

OECD Publication

Chapter 9

Author Shailaja Chandra was the Executive Director of the National Population Stabilisation Fund from 2006 to 2009 and is presently writing a Report for the Ministry of Health& Family Welfare on the benefits that the public has received through the Indian Systems of Medicine.

Abstract

Shailaja Chandra’s PowerPoint presentation in OECD World forum, Instanbul, Turkey from 27-30 June 2007

In this article I define what constitutes indicators and information in the context of civil society and participatory democracy. The first part describes how a government-citizen partnership called Bhagidari coupled with the Delhi Right to Information Act 2001 empowered the citizenry of New Delhi, the capital of India and promoted a climate of responsible response to civic challenges. The paper describes how the power of information could alter citizen’s lives and give them a public voice.

The second part of the article explores how in nearly half the 600 districts in India, the amalgamation of GIS maps and census data has enabled disparities and inequities in the provision of health services to be placed in the public domain, in a visual, easily downloadable fashion. This internet based indicator tool is aimed at enhancing the understanding of all stakeholders viz., the affected public, media, academic bodies and non-governmental organisations to enable them to use the information to bring about change.As the mapping exercise represents almost 94% of a country of 1.2 billion people, the visual data depiction is expected to widen understanding about the extent of inequity that exists between even contiguous districts and provides a tool to increase public accountability..

Section I

Participatory Democracy: How Indicators Gave Power to the People

Statistical data, surveys, projections, extrapolations, portrayal of inequities through inter and intra regional mapping, are all vitally important as indicators. But these cannot be easily understood or visualised by lay people and because of this it inhibits their participation in demanding greater attention to be paid by governments.Generally international organisations, national Governments and statistical organisations provide the status of developments and the result of analysis through the release of reports, political speeches, press releases, seminars and discussions in which improvements (or lack of them) are projected. Couched in economic jargon and statistical terms they do not create an impact on the wider general public, because in their very nature such reports do not appear to relate directly to community or individual concerns. Instead such data becomes of use only to planners and academics working in specific sectors. This has the shortcoming of presenting a misleading picture unless the historical background and context is understood. The general public is not well versed in appreciating the nuances of academic reports,much less using the information to demand better performance.

Against these presumptions, Section I of this paper expounds on three important developments which took place in New Delhi, the capital of India, which depict how indicators and information empowered the public to hold government departments and even the political executive accountable.

Delhi is mega-city with a population of more than 16 million. Since, the city is divided into 7 parliamentary seats, 70 assembly constituencies and 272 municipal wards, political conflict and contending priorities are inherent in the situation. Being the seat of the central and state governments and with three levels of political representation, with16 National newspapers published from the city and over forty TV channels devoted to its affairs, it is a daunting situation for both political and administrative management. Arriving at a consensus is extremely difficult while pursuing government policies in the absence of public participation a one-sided affair. An unforeseen backlash can occur at any time, caused by public perception about the bona-fides of the leadership which can derail even good projects and schemes.

Since the political colour of the Members of Parliament, Members of Legislative Assembly and Municipal Councilors in New Delhi is generally different, the Government of Delhi needed to identify a way of involving the public directly, to create an understanding about who was responsible for what aspect of governance and service delivery. The government also realized the importance of giving the public a route to measure the responsiveness of the government to their concerns. Educating and involving the public was therefore of paramount importance for which they had to be first equipped with facts and data, information about processes, reporting levels and where the responsibility for action finally lay. Likewise localized information on the performance of electricity and water utilities, schools, hospitals and dispensaries, municipal services, upkeep of roads, parks etc. had to be placed in the public domain to evoke interest and involvement of citizens.

Bhagidari: A Government Citizen Partnership

Bhagidari in Hindi literally means partnership. This is an example how people’s power catapulted over 3 levels of political representation and was responsible for the creation of more than 1800 Resident Welfare Associations in New Delhi in a span of 3 years from the year 2000. The movement grew in strength as the public became aware of the systems and processes through which Government organisations could be accessed and also became conversant with how the provision of services could be demanded, as due. Collaboration with the citizenry was fundamental to address the existing and future issues affecting the quality of life of people. Thus the partnership was of mutual interest.

The Bhagidari process began with the organisation of large group meetings with a wide range of stake-holders namely resident’s welfare associations, market associations, school standards committees, environment groups. Such meetings were first organised at the district and sub-district levels as citizen’s day-to-day problems are generally localized. At the Apex level, meetings were organised by rotation, district wise every 2 months for 3 days at a time, in a large hall where 36 tables were occupied by 12 persons at each table ; 6 government representatives and 6 resident’s representatives on each roundtable. During the 3 day conclave, representatives on each table were give an opportunity to exchange lists of deficiencies and to listen to the response of the government offiials about the methodology of resolving civic problems. By the third day the macro picture emerged and senior officers of the government joined the meeting and responded to the main issues. This exposed the Residents Welfare Committee representatives to the working of the government departments and also gave them information about the intra-colony status of services, the intra-district funding available, future priorities, programmes on the anvil and the basis on which decisions had been taken.

In response the citizen’s representatives could differ with the organisation, question arbitrary decisions and also highlight instances of pick-and-choose and favoritism they had come across. They could raise issues of immediate concern to the neighbourhood and expect a positive response in the presence of senior officials.

The Bhagidari movement used newspapers, documentation, reports, awards and incentives and introduced systems for sharing lessons from failures and successes as instruments for generating momentum, expanding the support base and encouraging collaboration. The movement has now covered more than 3 million people and has helped create a network of associations which represent a large spectrum of citizens needs. Although they have no elected status, the Resident Welfare Associations have gained prominence and credibility because of their numbers and ability to leverage attention.From early initiatives which were localised, the movement spread to include more important subjects like electricity and water distribution, solid waste management. It jolted the ordinary citizen out from a state of helplessness to which he had become a accustomed and created a public awakening that public services that needed to be demanded and obtained through collective action and effective interface with Government agencies. The fulcrum on which this movement rested was the provision of information which led to empowerment.

The Bhagidari initiative received the United Nations public service award for improving transparency, accountability and responsiveness in the public service categories in 2005.

Human Development Report for Delhi

When the Bhagidari movement was in full swing it was decided to collect information for a Human Development Report (HDR) for Delhi city (the first city HDR in the world). An independent survey was commissioned which extended over 14 000 households in Delhi in 2003-04. The respondents were asked to provide their assessment of twelve different services which included education, health, water supply, power supply, sanitation, roads, transport, environment, livelihood and housing. the security of women and overall perception of governance also featured in the survey. The methodology of the survey gave due weightage to residents of eleven types of colonies which exist in the city ranging from posh up market colonies to slum clusters from rural and urban villages to the old walled city of Delhi, from Government housing, to self-promoted colonies on private land. The respondents had to comment on the performance of various sectors in terms of services offered to residents and also identify the most pressing problems that needed attention. While 82% of the residents wished to continue living in the city, their main complaints related to water supply, garbage disposal, traffic, high levels of crime and public transportation deficiencies. The collection of these indicators and zone wise display of survey results gave credibility to the process and provided a direct voice to the citizens in an organised way. It also provided a basis for making demands and holding the political representatives as well as the bureaucracy accountable. The Report was prepared by academics and experts in operational research which underscored objectivity of approach and the reliability about the results projected in the HDR. The results of the surveys are available on the website http://data.undp.org.in/shdr/delhi/completereport.pdf.

The HDR survey results gave further credibility to the Bhagidari initiative and increased public participation.

The Right to Information Act in Delhi

Side by side, the Delhi Right to Information Act was introduced in 2001 which further gave people the right to ask questions about governance, systems, processes and decisions. The introduction of the Right to Information law coupled with the Bhagidari movement brought to the fore the reluctance within the bureaucracy to open its files and system of working to public scrutiny. Since the Act allowed citizens to inspect public records, documents and works and even take samples of work, NGOs in particular became quick to use the legislation in creative ways. Data on the public distribution system, the food stock position in warehouses and its distribution showed that there was large scale diversion of essential commodities. The Indian Express group of newspapers conducted a series of camps along with a local Non-government organisation based upon the information received. The Right to Information Act created an enabling environment because people were empowered to expose wrong doing and keep public servants under check and accountable. It gave people the direct authority to question what Government organisations were expected to achieve and why there was an apparent shortfall in the outcomes.

Table  Status of Applications received under

 the Delhi Right to Information Act, 2001 and Disposed off Upto September, 2007)

Number of Applications

Information

 

Received

Disposed Off

Given

Not Given

Total

11 557

11 036

10 067

969

Source : Department of Administrative Reforms, Government of National Capital Territory of Delhi.

How Giving Information can also Derail Decisions

The Bhagidari movement and the avenue of Right to Information worked as a bulwark for participatory democracy. The government in power was re-elected on the strength of giving the public a meaningful place in governance, but the outcomes have to be viewed in totality.

The Government had privatised electricity at a distribution end by 2002. The expectation was that this would improve efficiency. In 2005 when the public realised that electricity meters being supplied through private companies were running fast, and the electricity bills were spiraling, they rejected the electronic meters and began questioning the privatisation process itself. Using the platform of Bhagidari and by demanding information under the Right to Information Act, non-government organisations used the information made available under the Act, to motivate the media and the public to raise issues which forced the government to abandon the proposed privatisation of water distribution in the city. Information relating to power privatisation was used to draw attention to how expensive the decision to privatise water distribution could eventually become, thereby using the power of information to forestall a government decision that had already been taken. By exposing the inter and intra-city inequities in the supply of water and the government’s intention to hand over the problem to private distributors an uproar was created, and later snowballed, involving the media, academic bodies and NGOs. The result has been that the privatisation of water has been put off indefinitely because of people’s capacity to impede the process, backed by data that exposed who was to gain through the privatisation of water. This too was an outcome of the power gained by people under Bhagidari and the Right to Information Act.

Comment

For participatory democracy to be sustainable, there is no doubt the power has ultimately to be exercised through the ballot. Information can imbue a non-elected groups with temporary power and authority to question government policies, schemes and the covert intentions behind certain policies. The dilemma is that while civil society can exert a counterveiling pressure on the domination of the state and an exploitative market, once it begins to exercise authority it can also challenge democratically established institutions. If the arbitration of what is right and wrong, important or unimportant, cost effective or sustainable, is to be determined by the public at large, it could have consequences on long term sustainability. Such civil society movements though powerful, have not been tested in the history of democratic countries. Never-the-less the power of information can make authoritarian systems accountable which point is underscored through the preceding examples

Section II

Enhancing Accountability through G. I. S. Mapping and Census Data

Population growth is one of India’s biggest challenges. India is a second most populous country in the world sustaining almost 16% of the world population on 2.4% of the land surface. The population of Indian states can be compared to the population of many countries. Unlike Europe and North-America, Australia, New Zealand, Japan, Thailand and Korea, India has the distinction of having an enormous growth of a young population for the next few decades. In comparative terms India is facing fewer challenges of dealing with an ageing population that many countries in the world face today. It can look forward to high productivity on account of a high proportion of the population belonging to the young cohort. By 2026, the population of India will rise by 371 million and share of 15-59 age group would be 64%. However, this cannot be an asset unless social indices like health, education, drinking water, sanitation improve side-by-side.

It was therefore felt that the provision of localised indicators and information could highlight larger issues and motivate Government authorities, the media and Non-Governmental Organisations to understand the bigger picture and what lies in store. There is every need to project statistical data in simple visual ways to empower the public. One of the most effective ways is to display inter and intra regional disparities is through maps, graphs and charts in a way that can create direct interest at a local level.

Drawing Attention to Disparity – The Power of Comparative Analysis

India is divided into 28 States administered by elected governments and 7 Union Territories (administered through the Central Government). In an effort to provide information to the public, the National Population Stabilisation Fund of India (called Jansankhya Sthirata Kosh (JSK) in Hindi), prepared State Level Health Facility maps for 19 states.. As this article gets posted on the blog, all rural districts in the whole country have been covered and the PDF maps can be easily downloaded from JSK’s website.

;Figure 1 gives the picture in respect of just one state of India (Orissa) in terms of spatial distribution of Primary Health Centres.

Spatial Distribution of PHC’s in Orissa

Figure

From the state map one can move to the district map and view the picture of each district, its sub-divisions and the population of every village along with its distance from the nearest primary health centre. The maps highlight inequities in health facility coverage down to every village to enable resources to be targeted to underserved areas. The national, state district and other roads further exhibit the proximity not only to Primary Health Centre but also to surface communication in general. All this can be viewed alongwith rank of every district on JSK’s website (www.jsk.gov.in).

The maps are an amalgamation of census data and GIS mapping and they depict not only the disparities in access to health facilities in respect of every sub-division of the districts but also provide information on the distance people have to travel to reach a health facility. This information was sent on CD to the senior most administrator of each district (called Collector or District Magistrate), the Chairman of the District Development Committee, the member of the Legislative Assembly among others to familiarise them with the extent of prevailing inequity .

Figure 2 Health Facilities in District Malkangiri, Orissa

The information highlights the inter and intra district differences and disparities in coverage by health facilities. The census data has been used to show the distance of a village from a primary health centre alongwith the population of each village living 5 kms. away, 5-10 Kms and more than 10 Kms. away from the health facilities. The GIS mapping has been used to display the clustering of health facilities and the presence of large underserved areas. The map shown in Figure 9.2 indicates the clustering of facilities in Malkangiri District of Orissa State. The Distance chart at Figure 9.3 shows the distance to be traveled to reach a Primary Health Centre represents just one sub-division (taluka) out of eight sub-divisions of that particular district. There are 600 districts in the whole

country.

Table 9.1 State – Orrisa: District – Malkangiri: Range from PHC’s

State – Orrisa: District – Malkangiri: Range from PHC’s

Table Indices Covered in Study “Ranking and Mapping of Districts” for Composite Ranking and Composite Index

Source: Ranking and Mapping of Districts, IIPS 2006.

In 2006, the International Institute for Population Sciences India released a report titled “Ranking and Mapping of Districts – Based on Socio-economic and Demographic Indicators”. The Report had given a composite Ranking to every district (Table ). This information was converted into bar charts and the ranking based of the district in terms of the composite index was made available for scrutiny on the CD sent to the districts. The bar-charts shown in Figure 9.3 and 9.4 indicate the difference between the best performing and a lowest performing district within the same state. This is something people can relate to and raise questions about.

Figure 9.3 Best Performing District of the State according to the Composite Index: District of Indore (State – Madhya Pradesh)

Source: Ranking and Mapping of Districts. IIPS 2006 and DLHS-RCH State and Nutritional Report, 2006.

*IIPS: International Institute for Population Sciences, Deonar, Mumbai, is an autonomous insititution under the administrative control of the Ministry of Health and Family Welfare. Government of India. It Offers academic courses in the area of population studies.

Figure 9.4 Lowest Performing District of the State according to the Composite Index : Distric of Sidhi (State – Madhya Pradesh)

Source: Ranking and Mapping of Districts. IIPS 2006 and DLHS-RCH State and Nutritional Report, 2006.

*IIPS: International Institute for Population Sciences, Deonar, Mumbai, is an autonomous insititution under the administrative control of the Ministry of Health and Family Welfare. Government of India. It Offers academic courses in the area of population studies.

The National Population Stabilisation Fund has placed all this data on its website http://jsk.gov.in which can be accessed by public representatives, administrators, media and research bodies. The organisation has publicised the availability of this information through national newspapers and magazines so that a wider group of stakeholders can access it. An average of 100-150 persons a day access the website every working day.

The point to be underscored is that until now the availability of the data on health and social indices as well as the resident population was merely seen as statistical inputs. These have now been converted into visual form and made easily accessible on the website. This is expected to empower the public to question why the inter-district and intra district indices show so much variation and why availability of health services and accompanying health indices are better in certain districts as compared to others. It is expected that in planning new health facilities the underserved areas will now get prominence.

Conclusion

It can be concluded that indicators and information can be used to empower the public to hold their policy makers accountable. Were it not for access to information and indicators, the Bhagidari initiative may not have been able to gain the leverage it gained in the context of empowering citizens of New Delhi.

It is also expected that the exercise undertaken by the National Population

Stabilisation Fund of India (called Jansankhya Sthirata Kosh in Hindi) to provide inter-state and intra-state, inter-district and intra district variations which highlight underserved districts, sub-districts and villages will lead to questions about low performance. Both the political executive as well as civil servants would be answerable for allowing apparent inequity to continue. It would necessarily require infusion of funds for upgrading facilities and services since disparities would be evident down to every village. Since data as compiled by national organisations like the Survey of India and the Registrar General of India has been used, complaints that it has been selectively compiled to credit or discredit any particular segment would not hold true.

Although such data has been available for decades, the difference now is that technology has enabled it to be displayed in visual form capable of being down loaded and lending itself to analysis even by a layperson. By improving access to information, leaders can keep themselves abreast of developments and have a basis to profess how they are promoting the quality of citizens life and how progress can be measured.

The process would also help international donors and external agencies to evaluate where critical gaps exist. The data can be used to focus on under-served areas so enabling the funding to be targeted properly.

Notes

1.

The exercise includes a population of 960 million (out of a total of 1.2 billion) from the States of Bihar,Chhatisgarh, Jharkhand, Orissa, Madhya Pradesh, Rajasthan, Uttar Pradesh, Uttarakhand, Haryana, Jammu & Kashmir, Punjab, West Bengal, Goa, Gujarat, Maharashtra, Andhra Pradesh, Karnataka, Kerala and Tamil Nadu covering 482 districts, 4 645 sub-division and 579 779 villages in India.

Ten States have been omitted because village boundary data is presently not available with the Survey of India. The excluded states constitute 111 districts and a population of 68 million which is relatively small (6% only), given the size of the country.

Accordingly almost 94% of a large country of 1.2 billion people has been covered through JSK’s exercise,

giving a visual idea of the location of health facilities, alo

References

Annual Report of Public Grievances Commission, Government of National Capital Territory of Delhi .

Bhagidari Cell, Office of the Chief Minister, Government of National Capital Territory of Delhi.

Delhi Human Development Report 2006: Partnership for Progress, Oxford University Press, New Delhi, 2006

International Institute for Population Sciences, Nutritional Status of Children and Prevalence of Anaemia among Children, Adolescent Girls and Pregnant women, International Institute for Population Sciences, Mumbai, 2006

National Informatics Centre, Ministry of Communications and Information Technology, Department of Information Technology, Government of India

National Population Stabilisation Fund, Ministry of Health & Family Welfare, Government of India.

Ram, F and Chander Shekhar, Ranking and Mapping of Districts: Based on Socio-economic and Demographic Indicators, International Institute for Population Sciences, Mumbai, 2006

Registrar General of India, Census Volumes, Census of India 2001, New Delhi

Survey of India and Registrar General of India data

World Bank, Reforming Public Services in India: Drawing Lessons from Success, 2006

Managing change in India

October 4, 2010 at 10:42 AM | Posted in Demography, Fertility, Family planning, Population, Gender/Women's Rights | Leave a comment
Tags: ,

Measuring progress and societal changes
from global project to stiglitz report
How to go beyond MDGS
OECD World Forum Busan 2009: workshop

Population Stabilisation – Issues and Concerns

May 11, 2010 at 12:47 PM | Posted in Demography, Fertility, Family planning, Population | 2 Comments
Tags: , , , , , ,

India’s population growth rate has been declining over the years but the overall population will continue to grow as more than half the people are in the reproductive age group and more will join this group each year

IND1A S 2001 census puts the country’s population at over I billion, In the next twenty years India will be the most populous nation in the world overtaking even China. The population of India’s a states is comparable to large countries.

India has grappled with the issue of population stabilisation* for over 60 years. Although stabilisation was projected to take place by 2045, the performance of several states indicates that this will shoot past this forecast with serious implications for sustainable development. On the positive side India has the benefit of a young population and it can expect high levels of productivity and lower levels of dependency. even as the developed world is confronted by the prospect of aging and low fertility. While India’s youth could be a huge asset it could also be a dangerous liability, because unless the population is healthy it will pull hack development.

In the next 16 years, the bulk of the population growth will take place in Uttar Pradesh, Utrarakhand. Bihar. Jharkhand, Madhya Pradesh, Chhattisgarh and Rajasthan-accounting for more than 50% of the growth. In contrast the Southern states will add only 13% to the total population growth.

Fertility Pattern among Different States -The Challenge Ahead:

The Total Fertility Rate (TFR) signifies the average number of children a woman will produce in her childbearing years. Alok Ranjan Chaurasia and S. Gulati in “India the State of Population 2007” have divided the country into three groups.

1. In the first group there are the Hindi belt States and some north-eastern states like Manipur and Meghalaya. Together they will account for more than half the population growth in the country by 2026. In these States. lowering fertility will be very difficult as the majority of couples use no contraception.

2. In the second group, stand States like Maharastra, West Bengal, Gujarat, Haryana and Orissa, which have achieve the two child goal.

3. The third group of States comprises Andhra Pradesh, Goa, Hirnachal Pradesh, Karnataka, Kerala. Punjab and Tarmil Nadu. These States will account for hardly 15 per cent of the population growth by 2026 and have already achieved replacement levels of fertility with two children per woman.

Enforcement of the legal age of marriage — The Challenge ahead:

Marriage take place very early particularly in rural India. Later marriages will do more to stabilise India’s population momentum than any other measure. In rural areas 60 to 70% of the women are married by 18 particularly in states like Bihar, Jharkhand. Rajasthan. Uttar Pradesh and Madhya Pradesh. The percentages are as low as 20% among rural girls of Kerala and Himachal Pradesh where girls continue to study and get married at a later age. This shows that over time, change is possible but the challenge lies in focusing on the age of marriage which has a direct relationship with the mother’s and child’s health.

Very early child bearing and an absence of spacing increase risks to mother and child. Teenage pregnancies are the cause of a high number of maternal deaths. Repeated pregnancies increase the risk of death and disability to both mother and child.

Apart from the Hindi belt states., Andhra Pradesh and West Bengal also stand out as examples of states where the marriages before the legal age are unusually high. The Jansankhya Sthirata Kosh, (JSK) also called the National Population Stabilisation Fund has started implementing a strategy in districts where the prevaicnce of the practice of early marriages is exceptionally high by giving awards and financial rewards for girls to marry after 19, where the first birth this when the girl’s 21 years old and the second after she is 24 years old. These are all responsible parenting practices. Role models from the community have been showcased at public functions emphasizing why it is necessary for the girl to be in good health at the time of pregnancy and childbirth.

To give a positive example, Himachal Pradesh placed strong emphasis on the enforcement of the legal age of marriage and simultaneously encouraged girls to stay in school. It has the lowcst percentage of boys and girls married before the legal age. School retention is also far higher than the rest of the country with (be exception of Kerala. That is the model that would work in the northern states but ii requires a new focus which is completely absent at present.

  • Need of Registration of Marriage –
  • Legal and Social aspect: The only way that this can he enforced is by making the registration of marriages compulsory and at that time documentary proof of to be shown about the age of the girl and boy.

    The Supreme Court order: On 25th October 2007 the Apex Court directed that all marriages should be registered. It was reiterated by the Supreme Court that marriage should be compulsorily registered ‘sin respect of persons who are citizens of India even if they belong to various religions.’

    The Rajya Sabha Committee on Petitions recently in its Hundred and Thirty-Fifth Report 2009 on Introduction of Sex Education in Schools included the following recommendation:

    “Students should be made aware qf the marriageable age which is 21 years in the case of boys and 18 in the case of girls…. . Students should also be made aware that child marriage is illegal and is injurious i’o the health of the girl child”


    Major factors that impact on population stabilisation:

    Three factors impact upon population growth and are intrinsically linked, The first is maternal mortality which refers to a woman’s death linked to pregnancy having a direct impact upon population stabilisation because that determines how far a newborn child will receive care during infancy. If mothers die, children are bound to be neglected. Therefore institutional deliveries are being given a lot of emphasis. The good news is that there has been a huge response to the Governments Janani Suraksha Yojana (JSY) and the number of women who have availed of hospital delivery facilities has increased from 29 lakhs to 73 lakhs during 2007-08. Unless maternal mortality reduces it would be difficult to ensure child survival. This leads to a vicious cycle of having several children to compensate for the ones that die.


    Maternal Mortality (MMR) – The Challenges Ahead: Within the country there are huge disparities in maternal mortality. The latest figures show a huge improvement over the past. All- India MMR having fallen from 301 in 200 l-0.3 to 254 in 2004-05.

    Although the southern states of Tamil Nadu and Kerala have fared comparatively well, still, their maternal mortality levels are far higher than those of neighboring Sri Lanka and China.


    The positive development is that hospital deliveries have increased by more than 40% in the Hindi belt states which are now poised to register lower MMR. That in turn wifl impact very positively on population siabilisation as both mother and children will receive institutional care, also essential to deal with obstetric complications.

    Infant Mortality – The Challenges Ahead:

    High Infant Mortality Rate (JMR) is the second significant factor that impacts on population stabilization, as parents continue to have several children because they know that some will die. Infant deaths refer to children who die before reaching their first birthday. Among infant deaths, IMR is higher in rural areas and excessively so when the mother’s age is less than 20. If the birth interval is less than two years the IMR escalates hugely. The challenge lies in reducing infant mortality and for that two critical factors are the mother’s indifferent health and lack of spacing between children.


    Family planning – challenges in meeting the unmet demand for contraception :

    The third aspect is improving access to contraceptive products and services. More than half India’s population is in the reproductive age group and only half are using contraceptives. In this we are far behind neighbouring countries like Indonesia. Sri Lanka and Thailand. Sterilisation is the most common method of limiting families but nearly 96% of all sterilisations were until recently carried out only on women with hardly 1% on men.

    In the last two years numerous steps have been taken to offer a range of contraceptives and to upgrade the skills of the medical and paramedical workers responsible for providing family planning services. Fixed day services are being widely publicised and there is a revival of interest in male sterilisation. Compensation money for undergoing sterilisation operations has also been increased and private providers have been encouraged to join in family planning activities with a tee for procedures carried out.

    As a result of these initiatives, vasectomies (male sterilization) have registered a huge increase which had been declining up to 2007. The increase was 84% increase last year and this year it has crossed 24% increase in the first six months of the year.

    Overall the total sterilization figures (male and female) have gone up significantly. In the entire 1-Hindi belt States except Madhya Pradesh and Chhattisgarh the performance has increased appreciably over the last three years. This is a reversal of past trends and the emphasis on family planning given by these states is a very positive sign.

    Conclusion

    India’s population growth rate has been declining over the years but the overall population will continue to grow as more than half the people are in the reproductive age group and more will join this group each year. With only half of them using contraceptives, it may take several decades more to achieve the goal of achieving planned families which is a necessary requirement for sustainability.

    India’s maternal and infant mortality levels are very high and repeated childbirths are seen as an insurance against multiple infant and child deaths. Vast numbers of people cannot avail of services even when they are available, due to problems of knowledge and access.

    The progress in the last two years has been remarkable, which gives the hope that the importance of population stabilization has been recognized by people themselves. This has now to be sustained and accelerated particularly in the Hindi belt states where fertility Levels are very high. Many of the factors that impact upon population momentum are cultural in nature. Attitudes to early marriages, expectations about early childbearing, and disregard for the need for spacing between children need to be altered. Low female literacy impacts adversely on safe motherhood and the maternal care that their children receive. Additionally a strong son preference leads to negative feelings towards girls and results in pre-natal sex determination and elimination of the female foetus.

    All these issues require that civil society fully understands the importance of driving change. Within civil society, political representatives, the media and religious leaders can play the most influential role.

    Women as brood mares

    May 5, 2010 at 6:33 AM | Posted in Demography, Fertility, Family planning, Population | Leave a comment

    How fair is it that men are never targeted to accept blame for the unwanted pregnancies that occur year after year? Must women continue to suffer for policy failure?

    Last month I was in Ghadchiroli district. It ranks last among Maharashtra’s 35 districts on a combination of social indices. Synonymous with remoteness, surrounded by forests and inhabited by tribal people, a health worker was to show me how neonatal care had improved survival rates of infants. I asked her how many people used contraceptives. She told me straightaway, no one did. Women went in for tubal ligation as soon as they had two children.

    Visits to see newborn babies ensued. Entering a shack, I noticed an infant clinging onto his grandfather. Inside the house an emaciated woman, removed a dirty cloth from a tiny mound on the floor to reveal a shrivelled neonate underneath. As soon as she lifted the cloth, swarms of flies settled on the baby’s face. She had delivered the second baby within a year of the first. She herself was no more than 18 and a bag of bones, her eyes devoid of emotion, and her lips a straight line.

    Ghadchiroli is ranked at the 345th position out of the 593 districts surveyed by the International Institute of Population Studies (IIPS). Not bad compared with hundreds of lower ranking districts in the country. At least they had access to sterilisation services.

    The percentage of women having three or more children is a direct measure of fertility. The larger that percentage, the weaker the impact of the family planning programme. As can be expected, the worst hundred districts in the country according to the IIPS study done belong to Bihar, Jharkhand, Madhya Pradesh, Rajasthan, Uttar Pradesh and some North-Eastern States where between 50 per cent and 60 per cent of women beget three, four and even more children.

    India was the first country to launch a Government family planning programme in 1952. Due to mismanagement, forced sterilisations and chasing fictitious targets, the programme received an unsavoury reputation it just cannot discard although decades have gone by.

    Post-1994, Cairo and ICPD, Governments the world over supported by international organisations and NGOs ushered in a new reproductive child health approach. Today, people who talk of population control and explosion are considered barbaric. In the name of giving “reproductive choices” to women and offering “a cafeteria approach”, the old targets, incentives and disincentives have been struck off the strategy list. Rightly so, if one goes back to the horrors of family planning excesses, but wrongly so if there is no cafeteria, no coffee (read condoms), IUDs or oral pills to make that choice.

    The emergency contraception pill, the most needed of all, is unheard of in most of the country. The social marketing approach can deliver up to a point – no more.

    So steeped is our present culture in the soft new approach that we refuse to face the fact that of the 26 million babies born each year, some 40 per cent are underweight, underdeveloped, often stunted and incapable of later imbibing even elementary education, leave alone become productive citizens. Infant and under five mortality continues to be extremely high, mainly because family planning is denied the thrust it badly needs.

    While tender talk about quality issues and women’s rights is well intentioned, how can we enable severely anaemic women not to have to produce unwanted babies and face repeated pregnancies? How can one prevent men from forcing pregnancies? How can one stop adding generations of unhealthy children if there is no insistence on increasing the age of marriage, spacing and male sterilisation?

    How fair is it that 98 per cent of all sterilisations performed in the country are on women? How fair is it that men are never targeted to accept blame for the unwanted pregnancies that occur year after year?

    The unmet need for contraception continues to be displayed in colourful computer generated bar charts at all population conferences. But who is going to fill that unmet need and how? To provide access to contraceptives more than a modicum of sustained service delivery is essential. A large percentage of villages, particularly in the northern States, are more than 10 km away from a primary health centre (even if such outfits are functional). How do women living there protect themselves from unwanted pregnancies?

    Some right thinking industries and tea estates have tried to help and ended up complaining how their efforts to sensitise men to stop child marriages, early marriages, several marriages and multiple partners and to explain how all such behaviour is self-damaging, falls on “deaf ears”. Government schemes, letters, meetings, monitoring supplies and disposal will continue, as it must. But at the end of the day if women are still forced to bear children they do not want, at the cost of their own physical health, what could be a greater denial of a human right?

    It is time that spacing and male sterilisation were resolutely brought back on the front line. Lest the next generations require more hospitals than schools to attend to the abysmal levels of anaemia among women, and the resultant wasting and stunting of children, accompanied by high levels of under-five mortality. This beckons a deliberate restoration of family planning services to prevent unwanted pregnancies.

    Sugar-coated lie

    May 2, 2010 at 10:54 AM | Posted in Demography, Fertility, Family planning, Population | Leave a comment

    The so-called ‘demographic dividend’ is so much bunkum and no more. Limited access to education and healthcare among young men and women has left them with no awareness about family planning and HIV/AIDS. A demographic disaster is in the making

    An excellent report by the International Institute of Population Sciences, Mumbai, has demolished the ‘demographic dividend’ theory; one which has been urban India’s euphoric rejoinder to stave off any concerns about the questionable social health of Indian youth. The report points in no uncertain terms to a demographic disaster taking place, having “squandered” the potential that could have given that dividend.

    Titled A Profile of Youth in India the report is a State-wide study and systematically captures the urban-rural split, as well as the male-female disparities in education and reproductive health among adolescents and the youth — a huge segment of India’s population. The report has to be taken seriously because it was published by a Government organisation under the aegis of the Ministry of Health and Family Welfare. The image of an exuberant youth, educated and resilient, has been shattered through this report. Here are some of the highlights:

    A significant proportion of the youth were found to have received little education. Many were illiterate and several were burdened with onerous familial responsibilities. The enormous lack of education that prevailed among the female and rural youth left no opportunity for them to contribute to development or the tremendous challenge of nation building. A third of the females and only two out of every five men were found to have completed 10 years of schooling. Only two out of five adolescents were found actually attending school, leaving the rest of them destined to join the ranks of the uneducated and unemployable. One out of five teenage girls possessed no education, with one in three Muslim girls falling into this category.

    The report found every third adolescent girl to be married. The element of gauna was found to be fractional, so negating the theory that child marriages were only symbolic. Early marriages consummated well before the legal minimum age of marriage had negated efforts to reach the goals of the national youth policy.

    Limited use of contraception for spacing, and an over-reliance on traditional methods persisted after decades of chasing the family planning programme. Among the youth the unmet need for family planning soared. What did these young, married women know? Not even a fifth of the 20 to 24year-olds knew about the fertile days within the menstrual cycle; adolescent girls knew far less. Knowledge among boys was virtually non-existent. Yet the rhythm method continued to be the most preferred form of family planning despite knowledge about the menstrual cycle being so poor. For all the work that the State AIDS Societies claimed to have done, and all the money that they had exhausted, only 20 per cent of the female youth had comprehensive knowledge about the routes of transmission and prevention of HIV/AIDS infection. In several States only half such women had even heard
    about AIDS.

    Undernutrition and anaemia continued to be very high among adolescents and the youth, doubling health risks for pregnant and breast-feeding women, as well as their infants. Large-scale use of tobacco and alcohol prevailed among very young adolescents with negative health fallouts over a lifetime. A high prevalence of domestic violence existed and the social norms inherited by the youth still justified wife beating.

    Obviously, several Government programmes despite incremental improvements are haemorrhaging badly at places. The claims made by the National Literacy Mission, the Sarva Shiksha Abhiyan and the ICDS programmes are clearly either coloured or false. Unfortunately, the report has no silver lining. The report has not spared either the outcomes of the family planning programme or the national AIDS control programme. At one level it is highly satisfactory that the present dispensation believes in transparency and has not pushed these facts under the carpet. On the other, it is disheartening to find that there are no outcries from the State Governments that ought to have either felt ashamed of their failure or combative if they did not subscribe to the findings. Instead a climate of ‘business as usual’ prevails and one can wager that none of the people in charge of youth affairs, woman and child development, education, literacy, or the prevention of AIDS and premature marriages have looked at the report.

    Clearly, all the hard work is not reaching the most vulnerable people of this country. There is absolutely no case for more Government; we need smarter Government. While that exploration should take priority, for starters, the demographic dividend theory should be dumped publicly, because it is just a sugar-coated lie.

    No merit in early marriage

    May 2, 2010 at 10:12 AM | Posted in Demography, Fertility, Family planning, Population | Leave a comment

    Government must adopt a policy of incentives and disincentives to prevent teenaged girls from being forced into marriage and early motherhood. This will not only help reduce India’s alarming maternal and infant mortality rates but also stabilise its population

    Union Minister for Health and Family Welfare Ghulam Nabi Azad was speaking on July 11, the World Population Day. As a part of the programme, villagers from some of the poorest districts in India were felicitated, simply for having done the right thing voluntarily: A daughter’s marriage at 19, the first child born two years later (instead of the habitual nine months) and the next arriving after an interval of more than three years, followed by sterilisation by one parent.

    With two-thirds of girls in more than half the country married by their mid-teens, and producing several children thereafter, these award-winning couples had broken stereotypes, big time. News of their awards had already created huge excitement back home in their districts.

    After the awards were handed out, there came the Health Minister’s observation that no reward ought to be given to people who only abide by the law. Awards should only be given for marrying after 25 or even later, he said. Indeed, if the Minister could offer incentives to the poor to delay marriages, it could be revolutionary. Let us for a minute look at the sheer force of the numbers.

    Each year half of all the children born in India are born in only eight States. Rest of the country accounts for less than half the residual annual births. Therefore, concentrating on this group of eight prolific States makes perfect sense. Hypothetically speaking, if all teenage marriages in these eight States could be postponed, each year 18 lakh girls would get a chance to lead improved lives, instead of being thrust with premature cohabitation and child-bearing. And if perchance their marriages could be further delayed until they became 25, a fifth of the total births in the country could be delayed each year in eight States alone.

    Before a controversy about feasibility erupts, the article only seeks to highlight how many girls can benefit by delaying their marriages. Admittedly, no Government has the right to order the timing of nuptials or births. But certainly a progressive Government can and should encourage, and even induce, poor people to postpone marriages (read child-bearing) for the sake of women and children’s health. It is very much the responsibility of Governments to make Herculean efforts to reduce maternal and infant mortality. And when teenage fertility is one of the fundamental reasons for the high level of pregnancy related deaths, this factor has to be confronted. Any measure that helps postpone early marriages should be unabashedly argued for as a public health strategy. Stated this way, it does not amount to governmental interference in family life.

    What are the risks of early marriages? First, the opportunity to educate girls is aborted. Second, pregnancy starts when the girl is not capable of recognising its early symptoms, so endangering her own health and that of the unborn child by neglecting ante-natal care. Anemic and underdeveloped girl/mothers tend to produce underweight, malnourished children with poor chances of survival and growth. Infants born to 15 to 19-year-olds are nearly 80 per cent more likely to die during the first year of life than infants born to mothers who are 20 to 29-year-old. Delaying a woman’s first birth can reduce infant mortality of first born children by up to 30 per cent. When all this is widely known to health professionals, why should it be ignored to let century-old traditions to hold sway?

    The solution really lies in compensating and rewarding delayed marriages. Imagine if every woman belonging to the lowest wealth quintile or possessing no education (virtually interchangeable) were to be given a National Rural Employment Guarantee kind of inducement, simply for staying unmarried until she is 19. Additionally, if the amount was to increase with each passing year that she remains unmarried until she is 24, the investment would lead to much happier and healthier outcomes for millions of poor women and children. In the name of public health, a National Rural Postponement of Marriage Scheme should be introduced which would do more for safe motherhood and child survival than all the tried and (failed) models we have seen so far.

    Side by side Government must stop giving cash compensation for institutional deliveries to women, unless they are 19-year-old at the time of delivery. Everyone knows that today the age of the mother coming for delivery is never questioned because of the uproar it causes on grounds of discrimination. But if women start receiving greater benefits for staying unmarried the hullabaloo would fast subside.

    This article is not intended to open a Pandora’s Box of crazy ideas; rather to highlight where the epicentre of the population problem lies. If the honourable Health Minister could use his immense political acumen to influence the Chief Ministers of the Hindi belt States to make his idea of a marriage after 25 a reward winning event for the poorest families, he could achieve what none of his predecessors have pulled off in 60 years.

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