The next time you hear a knock on your door, it may turn out to be your friendly local health worker with a choice of contraceptives for you. And who will you have to thank for that? None else than health and family welfare minister Ghulam Nabi Azad, whose innovations in the field of population are matchless. Well, don't hold your breath just yet, this is one scheme that Azad has mooted though it would be a safe bet that not too many health workers will be turning up at people's doorsteps just yet.
Some years ago, population was a subject quite close to the hearts of the political class, though not always in a positive sense. There were two points of view, both not very well nuanced. One was that our population would bring us demographic dividends owing to the large youth component. The other was that the numbers were a drag and that people must be stopped from breeding like rabbits. The Planning Commission has a wonderful roadmap for population in the Eleventh Plan (2007-2012) which lays down in great detail all the problems and solutions. It makes for riveting reading and it would be clear except to the most cloth-eared that if implemented we would be home free.
But as always, the proof the policy is in the implementation. Azad a career politician is not really interested in the nuts and bolts of population, except to say that the total fertility rate (TFR), that is live births per woman fell by 19% in the last decade. Nothing to cheer about Azad, the TFR has only fallen from 3.2 in 2000 to 2.5 in 2010. But the health minister says that he will achieve population stabilisation through people's cooperation and not through legislation. Not so fast, please.
But, herein lies the rub. We have no concept of eliciting people's cooperation in any family planning programme. Has the government ever got around to asking people what they think of family planning, how they would like to go about it, what they think is the optimum family size, whether they are open to the idea of sterilisation, whether they have access to any family planning method? If it has, then it must be a fairly well kept secret.
What we do know is that 60 years after family planning was mooted as a policy, officialdom is still quite fond of sterilisation camps, especially for women. Of course, these are not compulsory but there is an element of coercion in the incentives and in some cases disincentives on offer. The first question we must ask is why this emphasis on women. After all they are not reproducing in isolation. These camps are run in an assembly line fashion and the woman is rarely given pre- or post-operative care. This is not a dangerous procedure but still certain precautions have to be taken. The fact that it is seen as irreversible means that there is pressure on the woman to have as many children as her husband or family wants before going in for sterilisation. This actually works against the stabilisation goal.
A major lacuna in our family planning programmes and policies is the lack of involvement of men. It is no secret that in a majority of Indian families, it is the man who determines the family size and the number of sons he should have. It is almost always pressure from a husband and in-laws that compels women to produce children until the desired number of sons are born. Yet, men have never been the target of population stabilisation policies. They are referred to in passing but the physical burden of family planning is on the woman.
There is no reason why the majority of health workers in the field should be women. When it comes to dispensing a cocktail of contraceptives, it would be far more effective if there were male health workers who could engage with men. In a largely conservative society, it is impractical to expect women health workers to discuss contraception and spacing with men, especially in the rural areas. In many places, far from reaching contraceptives at one's doorstep, there are large swathes of populations which have never seen a contraceptive. There are also large numbers of people living in remote areas where it is again impractical for women workers to reach.
What we need is a proper mapping and survey of areas which most need reproductive health services and then target those areas. For a start, Azad could get his officials to try and get public health clinics up and running. They are either shut or grossly inadequate in most rural areas.
Getting people's cooperation is all very fine, but it is not a very clever idea to bypass legislation as a method to achieve population stabilisation. The Child Marriage Restraint Act, 1976 could well work to ensure that early marriages don't take place. A small 2.5 year increase in first birth reduces the population momentum by 21%. Most of all, the language which the government uses to convince people to have smaller families must change. No one is going to connect when you go to them and tell them to have smaller families so that we can achieve population stabilisation. No, sensitised health workers have to tell people what's in it for them. Smaller families mean the resources will go further, the woman's health is not endangered and more attention will be paid to the children, thereby safeguarding their health and education.
If Azad can get the moribund public healthcare system going, then taking care of population stabilisation should be a breeze. The target for population stabilisation was 2045. It has now been revised to 2060. All the plans and proposals are there. It just needs to be delivered if not on your doorstep, at least within easy reach. Maybe the recent attempts by our MPs to fund innovations through their local area development assistance schemes could include a helping hand for the health minister.