Several Indian states have already achieved a Total Fertility Rate (TFR) between 2.1 and 3, and fertility continues to decline across the country. Why then is India's current population growth rate still a cause for concern?
For one thing, a sizeable percentage of the population is in the reproductive age group. And the biggest challenge is to provide this group with an integrated package of reproductive health services that include the promotion of safe motherhood and child survival, nutritional services for vulnerable groups, services for the prevention and management of reproductive tract infections (RTIs) and sexually transmitted diseases, the education of girls and empowerment of women.
Demographers and reproductive health specialists argue that good quality contraceptive services cannot be provided without addressing related reproductive health needs. Long years of experience have shown that contraceptive acceptance and their continued use hinge on ensuring safe and good quality services.
Take RTIs. In India, RTIs are widely prevalent among women; their management is important, therefore, to relieve women from the pain and suffering it causes, and to ensure that contraceptive methods can be provided safely and effectively. If untreated, RTIs can cause serious complications such as sterility, pelvic inflammatory disease, stillbirth and abortions, observes Dr Saroj Pachauri of the Population Council, an international NGO which promotes reproductive health issues. "The fear of sterility and delayed childbearing have been major barriers to contraceptive acceptance and so the thrust must be on integrated services," says Pachauri.
Official data concedes that the unmet need for contraception and the perceived need for high fertility (because of the prevailing high infant mortality rate) are other reasons for population growth. The goal of population stabilization can be achieved only when child survival issues, maternal health issues and contraception issues are addressed simultaneously and effectively, states the Economic Survey 2002-2003 recently brought out by the Ministry of Finance and Company Affairs.
The Economic Survey also says that actual success in containing the growth of population depends on publicly stated support by community leaders; the resources available for the Family Welfare program; efficiency and accountability in the state health system; and women's education and status in the family. The Survey notes that all these inputs have so far not been available to the required extent for the Family Welfare program, thereby not allowing the best possible benefits to be achieved.
According to the Census of India, the population of India as on March 1, 2001 was 1,027 million - with males at 531 million and females at 496 million. In the year 2000, the Indian National Population Policy (NPP 2000) and state population policy documents were released. According to researchers and experts, some of these documents have attempted to incorporate the language of gender equity and women's empowerment in their goals or objectives. But, they say, an overriding obsession with demographic goals is clearly visible in the policy.
Despite the fact that the NPP preamble speaks of the wellbeing of people, and of a comprehensive and broad-based approach being necessary, the strategies proposed by the NPP remain techno-centric, demographically-oriented, and fragmentary. There are also clear contradictions: on the one hand, the NPP calls for a target-free approach and on the other, it projects various targets for 2010 and a stable population by 2045.
Given the fact that India has drastically reduced investments in sectors that critically affect health - such as the food security system, education and transportation services - how far can such policies be supported by concrete strategies for action? The public sector, instead of servicing the needy and the poorest of the poor, has abdicated its responsibility and literally handed over the health sector to private parties, claims Dr Nina Puri, President of the Delhi-based Family Planning Association of India (FPAI).
In her opinion, moving the NPP 2000 strategies from paper into action is where the government exposes its Achilles' heel. "The infrastructure for providing health services just does not exist," laments Puri. "As much as 20 to 30 per cent of primary health centers are not in operation and in many others, doctors and other staff are not available."
Dr Puri is also concerned about the coercive and incentives-oriented element creeping back into some state population policies. She comes down heavily on states like Maharashtra and Madhya Pradesh that are reverting to the old "two-child" mantra.
Other measures which effectively curtail women's empowerment are laws enacted by states like Rajasthan, Punjab and Haryana that disqualify elected members of panchayats if they have a third child. Studies have shown that women bear the brunt of such laws.
While the debate on population control measures and their impact on the health of women rages on, linking the population control program with the democratization of grassroots governance raises doubts about a state's seriousness in seeing women play an active role in local administration, adds Puri.
In reiterated official jargon, the Economic Survey says the Tenth Five-Year Plan proposes to fully meet all the felt needs for family welfare services and enable families to achieve their reproductive goals with a paradigm shift from demographic targets to a client-oriented approach. In March 2001, an Empowered Action Group (EAG) was constituted in the Ministry of Health and Family Welfare with the purpose of assisting states with weak socio-demographic indicators to attain the goals listed in the NPP.
In the first instance, the states of Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan, Orissa, Jharkhand, Uttaranchal and Chhattisgarh have been chosen for focused attention. However, the activities of the EAG in these states remain unclear. Dr Puri, who is also a member of the National Commission on Population, is not aware if any meeting of the EAG has taken place recently. "The last meeting I attended was in December 2001", she says.
The history of India's population policy clearly illustrates that prescriptive policies can be exploitative and open to misuse by individuals in authority. The need today is to evolve a human rights framework incorporating reproductive rights as a part of a package of other rights that improve women's options for self determination and ensure their access to good quality, affordable and women-specific health care services.