A Paradigm Shift

Author(s): Amit Sen Gupta
Date Published: July 15, 2006
Source: Political Environments #4, Fall 1996

A significant shift in India's Family Welfare programme has gone largely unnoticed. After decades of devising various family planning targets, as well as strategies to meet such targets, the programme has suddenly decided to go "target-free". Interestingly, this volte face comes in the wake of recommendations to drop targets by a World Bank document of June 1995. Probably, not so surprising given the fact that major policy decisions in key sectors are taken today only after their "clearance" from foreign donor agencies. Thus, while the target oriented approach has invited criticisms from diverse quarters within the country for more than twenty years, the government has chosen to act only when called upon to do so by the World Bank.

Targets in the Family Planning Programme in India have, for decades, been a major obsession. From the village patwari and school-teacher, to almost all Government functionaries working in rural areas - virtually no one was immune to the demands of meeting FP targets. Not surprising, considering the popular perception which links all social, political and economic ills of the country to its increasing population. Consequently, policy makers and planners in India have consistently treated the country's population "problem" as its favourite "whipping boy". From the programme's inception in 1952, family planning targets have licensed the use of coercive measures to ensure contraceptive use. Promotions, postings and transfers of functionaries have hinged around fulfillment of targets related to contraceptive use. Down the years, the contraceptive methods to be propagated have changed - from Intra Uterine Devices (IUDs) till the 1960s, to vasectomy in the 1970s and finally to tubectomy and injectable contraceptives in the 1980s and 90s. What has remained constant is the single-minded devotion to fixing targets and ensuring that these are met. The high noon of the target fetish of the programme was seen in the days of the Emergency between 1975 and 1977, and contributed in no small measure to the downfall of the then Congress Government. Yet, even this experience resulted only in cosmetic changes to the target-oriented approach. Probably the only lasting change was in nomenclature - the Family Planning Programme being renamed the Family Welfare Programme.

A dispassionate assessment of the programme in its four- and half-decades of existence raises many interesting issues. Today acceptors of contraception constitute just 43 percent of couples in the child-bearing age group. Even this is likely to be a major overestimation, linked to over reporting - a bane of the target oriented approach - and to the fact that a large part of this figure is made up by tubectomies conducted on women towards the fag end of their reproductive life. Indirect evidence too indicates that the programme can hardly be held responsible for the few success stories in family planning in the country - Kerala and Tamil Nadu. Kerala's success in achieving results comparable to the developed world - vis-à-vis both demographic and health indicators - has been widely attributed to factors such as high minimum wages, land reforms, high literacy rates and access to universal health care. Much of Tamil Nadu's success in pegging down birth rates in recent years is being attributed to improved child survival due to the massive state-wide feeding programme for undernourished children. Both experiences strengthen the maxim that "development is the best contraceptive".

Experiences within, as well as outside the country, show that a reduction in population growth rates follows overall socio-economic development. Except in conditions of war and famine they seldom precede such development. Yet this has largely been ignored in our planning process, possibly as it prevents our planners from blaming the country's tardy development rates on the pressures posed by population increase. As a result family planning strategies have tended to be paternalistic, prescriptive and coercive. The principal belief underlying these strategies is that the poor breed prodigiously and it is the nation's duty to cap their unbridled fertility. Thus programmes are aimed at the poorest sections, and more specifically at women. Tubectomy rates in the country are 50 to 100 times higher than vasectomy rates, though the latter is a far simpler and safer procedure. Hormonal methods aimed at women find precedence over propagation of condoms, in spite of widespread reports that the former are associated with a large number of health hazards. In this whole process the supposed beneficiary - the impoverished rural woman - has virtually no choice. She is at the receiving end of technologies which the state or society believe are necessary. Such programmes are inappropriate not only because they victimise women, but also because they do not work.

These strategies have undermined the effectiveness of the general health care infrastructure as well as the faith that women have in this infrastructure to address their real concerns. Most programmes have tended to view women as assembly line appendages required to produce babies. Thus a woman's health becomes important only when she is pregnant or lactating. But in India 65 percent of deaths in women are due to infection related causes and only 2.5 percent of deaths are related to childbirth. Even among women in the reproductive age group only 12.5 percent of deaths are due to childbirth associated causes.
It is in this context that the new shift in population policies needs to be viewed. A target free approach is indeed a welcome change. Unfortunately the World Bank's concern regarding the target free approach to family planning does not emanate from any of the concerns cited above. Rather it is a reflection of the Bank's impatience with the alleged slow progress of Third World nations in controlling population growth. Population policies funded or dictated by the North, look for numbers as the ultimate bottom-line, not at esoteric statistics of empowerment and development.

This agenda on population control, flows from fears in the developed countries of North America and Europe that the resources of the planet will not be able to keep pace with the current rate of consumption. We are being made to believe that large population growth rates in the South are responsible. Yet the hidden agenda is related to the fact that the developed world is unable or even unwilling to curb consumption. Each child born in North America consumes as much energy as 3 Japanese, 6 Mexicans, 12 Chinese, 33 Indians, 147 Bangladeshis, 281 Tanzanians or 422 Ethiopians. Yet we are told that the poor nations of the Third World are the culprits who must listen to the voice of reason emanating from the corridors of power in Europe and America. Coercion does not stop here. Third World nations, eager to implement population policies, pass on the burden of these programmes to the poorest sections. All part of the familiar argument that the poor 'breed' too fast and that is the root cause of their poverty. Finally, the ultimate victims (not beneficiaries) of population programmes are poor illiterate women. Thus a bulk of strategies for population control target women. This completes the chain of coercion - from the global North to the underdeveloped nations of the South, from the governments of these nations to the poorest communities, and ultimately women in these communities.

In the same breath that the new policy talks about the target-free approach, it talks of a new Reproductive and Child Health (RCH) package, which shall replace earlier mechanisms. The essential coercive content of the family planning programme has, thus, been kept intact. As the name itself suggests, the concerns are with reproduction and not health. The gaze of the programme is still firmly fixed at women as targets.

Nomenclature notwithstanding, the new policy carries within it the basic core of earlier policies, which made them unacceptable to large sections of women in this country. Women need access to family planning services because of their own health needs. But such access has to ensure that women have a choice and that women are in a position to make decisions. In order for a policy to center-stage women's concerns and needs, it should revolve around a package that addresses women's health in all its dimensions and not just their wombs. Women need access to contraceptive methods and information about their effects on their bodies. For this to happen contraception must form part of a comprehensive health package.

A few districts in the country have already embraced the target free approach. But such an approach, unless it is willing to shed the paternalistic baggage of earlier policies, is likely to flounder. Already doubts are being expressed by administrators about the feasibility of the new approach. Evidently, the notion that population growth can be arrested only by forcing people to adopt technologies decided upon by a few wise men is current among a lot of programme implementors. In the absence of unambiguous signals from the top, the estimated 250,000 personnel involved in family planning activities will find it difficult to internalise even the limited shift in emphasis that is being proposed. Complaints from the field suggest that even today workers have to function with targets. In fact, in some states, these lower level workers complain that no one has officially informed them that targets are no more.