Describe the national family planning programme and population policy of India.

Evolution and Structure of the Programme

• The clinic approach (1952 to 1961) — services provided at clinics, on the assumption that people wanting contraception would come for it
• It failed because the assumption was wrong — in a largely illiterate rural population with no felt need and no awareness, people did not come
• The extension approach (from 1963) — recognising that services must be taken to the people, with education, motivation and outreach through field workers
• The camp approach and mass campaigns followed, achieving high numbers but at the cost of quality and follow-up
• 1966 — a separate department of family planning
• 1976 — the national population policy and the emergency, during which coercive mass sterilisation with quotas produced millions of procedures and a lasting public distrust
• 1977 — renaming to family welfare, a deliberate signal that the programme would be voluntary and integrated with health rather than a numerical exercise
• 1996 — abolition of method-specific targets, replaced by the target-free approach and then community needs assessment, in which the local worker assesses local need rather than receiving a quota from above
• 1997 to 2005 — RCH-I and RCH-II, integrating family planning within reproductive and child health
• 2005 onward — the national rural health mission and subsequently RMNCH+A
• The present programme — mission parivar VIKAS, focused on high-fertility districts in the states contributing most to population growth
• Its components — expanding the basket of choice; improving access through home delivery of contraceptives by the ASHA; SAAS BAHU sammelan, which brings mothers-in-law and daughters-in-law together — a design recognising that the mother-in-law frequently controls a young woman’s reproductive decisions in an Indian household; NAYI PAHEL kits for newly married couples; and sarathi vans for communication
• Expansion of the contraceptive basket is the most substantial recent change — the addition of injectable DMPA (Antara) and centchroman (Chhaya) to the existing condoms, pills, IUCD and sterilisation
• The rationale is that a programme offering few methods effectively offers sterilisation or nothing, which cannot meet the needs of young couples wanting to space
• Other current elements — postpartum and post-abortion family planning, using the contact a woman has already made; fixed-day static services; the ASHA as a depot holder and home deliverer; compensation for sterilisation and the family planning indemnity scheme; and quality assurance committees at state and district level
• Postpartum family planning deserves emphasis, because with institutional delivery now high, the postpartum contact is the single largest missed opportunity in the programme

Population Policy, Incentives and Assessment

• The national population policy 2000 is the governing document, with its immediate, medium-term and long-term objectives and its socio-demographic goals
• Its central principle is voluntary and informed choice, with continuation of the target-free approach and a specific rejection of coercion
• The question of incentives and disincentives is genuinely contested and should be presented as such rather than settled:
• The arguments for — compensation for wage loss and travel is a matter of equity rather than of inducement; and incentives accelerate uptake among those already inclined
• The arguments against — a payment that is large relative to a poor person’s income compromises the voluntariness of consent; incentives to motivators create pressure and misinformation; and they distort the choice toward the incentivised method
• Disincentives are more objectionable still — measures such as debarring those with more than two children from local elections or public employment, or withholding welfare benefits
• The objections to a two-child norm enforced by penalty are substantial and should be stated — it penalises the child for the parents’ decision; it falls hardest on the poor, the illiterate and marginalised groups who have least access to contraception; it has been shown to increase sex-selective abortion, since a couple restricted to two children will ensure a son; it encourages concealment and desertion of children; and it is unnecessary, since fertility has fallen to replacement without it
• That final argument is the strongest — the states with the lowest fertility achieved it through education, child survival and service access, not through penalties
• Evaluation of the programme uses several indicators:
• Couple protection rate (CPR) — the percentage of eligible couples effectively protected against childbirth by one or another approved method
• An eligible couple is a currently married couple with the wife of reproductive age, conventionally 15 to 45; there are roughly 150 to 180 eligible couples per 1000 population
• A couple protection rate of about 60% is regarded as necessary to approach replacement fertility
• Its limitation should be given — it counts sterilisations cumulatively and therefore keeps rising even if no new spacing services are provided, and it says nothing about whether the method was chosen or about the quality of care
• Contraceptive prevalence rate, the method mix, unmet need, and the total fertility rate are the other measures, with unmet need being the most honest single indicator of whether services are meeting people’s own intentions
• The method mix is itself diagnostic — a mix dominated by sterilisation indicates that spacing services are failing, whatever the total prevalence
• The achievements of the programme, fairly stated — a fall in the total fertility rate from about six to replacement level; a large rise in contraceptive prevalence; a falling birth rate and decadal growth rate; and widespread awareness of family planning
• The continuing weaknesses — excessive dependence on female sterilisation; negligible male participation; a narrow method mix in practice, whatever the official basket; unmet need for spacing among young women; quality of counselling and follow-up; the legacy of distrust from the coercive period; and wide inter-state disparity
• The conclusion that the evidence supports — the programme succeeded where it stopped being a population control programme and became a health and rights programme; and the remaining task is quality and choice rather than numbers
• Few methods means sterilisation or nothing, which is why expanding the basket matters more than raising any single figure
• A sterilisation-dominated method mix diagnoses failure of spacing services, whatever the total prevalence
• The two-child norm increases sex selection, since a couple restricted to two will ensure that one is a son
• Penalties fall hardest on those with least access to contraception, which inverts the intended effect
• Fertility reached replacement without penalties, which is the strongest argument against the two-child norm
• The clinic approach failed on a false assumption, that people wanting contraception would come and ask for it
• Targets were abolished because they distort, favouring the method that meets the quota over the one the couple needs
• Community needs assessment replaced the quota, with the local worker assessing need rather than receiving a number
• Saas Bahu Sammelan recognises who decides, since the mother-in-law frequently controls a young woman reproductive choices
• Postpartum contact is the largest missed opportunity, now that institutional delivery is high
• Couple protection rate keeps rising by itself, since sterilisations are counted cumulatively whatever else happens
• About sixty per cent protection approaches replacement, which is the figure conventionally quoted
• Eligible couples number about a hundred and fifty to a hundred and eighty per thousand population
• Unmet need is the most honest indicator, measuring whether services meet what people themselves intend
• Large payments compromise voluntary consent where they are substantial relative to a poor person income
• Incentives to motivators create pressure and misinformation, which is a separate objection from incentives to acceptors
• Present the incentive question as contested rather than settled, since there are real arguments on both sides
• Male participation remains negligible, which is the single clearest failure of the Indian programme
• Mission Parivar Vikas targets high-fertility districts rather than spreading effort uniformly across the country
• The ASHA delivers contraceptives at home, which removes the need for a facility visit and improves continuation
• Renaming to family welfare signalled the change after the Emergency, and was deliberate rather than cosmetic
• The programme succeeded when it became a health programme rather than a population control exercise