Asha says she didn’t even tell her husband that she was going to get sterilised. The 29-year-old domestic worker from the busy New Delhi suburb of Noida says she knew her husband and family would disapprove of her having the procedure. But she says that with the couple already struggling to feed the three children they have, she just didn’t understand why they wanted her to have another baby.
‘I never understood it,’ she whispers conspiratorially, even though we’re alone. ‘But my family said “What if your sons die? You’ll be left with nothing.” I heard this a lot.’
Asha is a resident of Uttar Pradesh, India’s most populous state with a population of 190 million and growing. With a total fertility rate of 3.8 (TFR being the average number of children a woman bears during her lifetime), the state is a perfect example of everything that’s wrong with India’s health infrastructure. It’s also an unlikely place for Asha’s ‘no more kids’ resolve.
As well as a high fertility rate, Uttar Pradesh has a worryingly high infant mortality rate of 67 per 1000 live births (twice the rate of the Maldives and more than 10 times that of the United States). It’s figures such as these that encourage families like Asha’s to want more children, to in effect hedge against possible future losses.
‘It’s the biggest bottleneck for family planning, the defining disincentive for small families,’ says Poonam Muttreja, executive director of the Population Foundation of India, a leading non-profit that’s based in New Delhi.
Under the guidance of Indian Health Minister Ghulam Nabi Azad, who seems to have brought to the role a genuine enthusiasm for reform, India has in recent months shown a delayed but welcome focus on the challenge of stabilizing the population.
Still, it’s a complex and emotive issue. To begin with, the sheer scale of the task of managing population growth in a country that now has 17 percent of the world’s population is extremely daunting. The task has been complicated over the years by the changing perceptions of population and family planning.
From the 1960s through much of the 1980s, the country’s rapidly growing population was considered a major obstacle toward equitable development, with India’s population growing from 360 million in 1951 to 1.02 billion in 2001. But in the post-liberalisation years of the early 1990s, the steady supply of human resources and a young population was instead hailed as a key strength in an otherwise greying global economy.
Not surprisingly, the truth lies somewhere in between. And, encouragingly, a balanced discourse seems finally to be taking place that recognises the urgent need to manage this precious resource or else risk this demographic dividend becoming a demographic disaster.
India’s current population stands at a little over 1.2 billion people, making it the second most populous nation after China. But according to US Census Bureau projections, India will pass China’s population by 2025. The problem is, if India stays on its current course, the surge won’t end there.
Azad is under no illusions over how difficult it will be for India to correct course, and says he believes it will be ‘extremely difficult’ for India to achieve the 2045 population stabilisation targets stipulated in the National Population Policy (NPP) 2000.
The NPP 2000 had advocated better family planning and an improved health care infrastructure across India to help meet its mid-term objective of achieving a TFR of 2.1 by 2010. The national rate currently stands at 2.8.
At a recent meeting of the National Commission on Population chaired by Prime Minister Manmohan Singh, Azad pushed the deadline back to 2070. By then, if current trends continue, there would be 1.7 billion Indians.
‘Our family planning programme has been buried for years,’ Muttreja says, adding the neglect seems particularly unfortunate considering India was the first country to launch a national family planning programme back in 1952.
A lack of political will is said to be one of the main problems in trying to tackle the issue, something that can be traced back to the disastrous political backlash against the dire approach of a 1970s family-planning campaign that relied on ‘forced’ sterilisations. Launched in April 1976 by Sanjay Gandhi, Prime Minister Indira Gandhi’s younger son, the infamous campaign pressured thousands of men and women into undergoing vasectomy procedures and tubal ligation, sometimes for money.
‘Family planning has been mired in myths, misconceptions and mismanagement ever since,’ says Muttreja. ‘We need to create awareness that there’s no need to resort to coercion. There are multiple temporary methods available.’
But Prof. Irudaya Rajan of the Centre for Development Studies is more upbeat. Rajan says that although many have advocated more coercive measures such as those adopted by China with its one-child policy, India has remained ‘liberal’ in its population policies. ‘Look at Kerala. It has managed what China did without coercion,’ Rajan says.
In 1979, China had a TFR of 2.8, which dropped to 2.0 in 1991. In contrast, Kerala’s TFR of 3.0 plunged to 1.8 in 1991. The state of Tamil Nadu has seen an even more dramatic fall, from a TFR from 3.5 in 1979 to 2.2 in 1991.
The change in Tamil Nadu came despite it suffering many of the ills that plague numerous Indian states—high infant mortality rates and a cultural preference for male children. But this southern state has demonstrated how a holistic approach that takes into account women’s education, food security, nutritional health, hygiene and institutional deliveries can have a significant impact.
The 2005 National Rural Health Mission (NRHM), a national effort at ensuring effective healthcare through intervention at the individual, household, community and most critically, at the health system levels, has also had some effect. ‘It has brought in synergy in our health care delivery,’ says Parul Sharma, programme manager for the Population Fund of India’s various projects across India. ‘Family planning begins with good health care.’
But some regions will be much more challenging than others. Azad noted that while there has been a declining trend in fertility rates in 14 States, northern and central parts of the country continued to have persistently high TFRs ranging anywhere from 3 to 3.9.
One problem is that at the state and district level, authorities still talk about sterilisation targets, said one government doctor in Bihar who asked not to be named. This is despite the fact that greatly improved and highly effective contraceptive options like oral pills and injectables are now more readily available. India’s slowness in this area contrasts with neighbours Bangladesh, Nepal and Sri Lanka—all of whom record 10 percent of total contraception used to be in the form of injectables.
‘On the national policy level there’s now correct thinking,’ Muttreja says. ‘But it hasn’t percolated down to the states. This is on top of poor governance and poor delivery of services.’
According to Muttreja, lack of awareness over the issue isn’t the only problem in trying to boost contraceptive use. She says that numerous studies have shown that although up to 97 percent of women are aware of at least one or more kinds of contraceptive methods, they still don’t use them. ‘Family planning initiatives must attack social mindsets and talk to the gatekeepers of women’s sexuality as well,’ she says.
Rajan agrees. ‘There needs to be equal participation in family planning by men,’ he argues. ‘That’s just as important as educating women and reducing infant mortality.’