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Indian Journal of Gender Studies

http://ijg.sagepub.com Sculpting Population Policies: Some Issues

Mohan Rao and Devaki Jain Indian Journal of Gender Studies 2003; 10; 77 DOI: 10.1177/097152150301000105 The online version of this article can be found at: http://ijg.sagepub.com/cgi/content/abstract/10/1/77

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Sculpting Population
Some Issues



The Singamma Sreenivasan Foundation, Bangalore, and the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, had organised a Colloquium on Population Policies in Bangalore on 19 and 20 November 2000. Comprising academics, policy makers and activists from the southern states, this Colloquium yielded a rich corpus of ideas on issues related to health and population. In order to disseminate these further, to stimulate informed opinion and a wider public debate, and indeed to influence policy makers at the Centre, a Second Colloquium on Population Policies was organised in New Delhi on 21 and 22 April 2001. In addition to academics and activists from the health movement, the Colloquium also involved a wide range of womens groups, especially those seriously involved in health and population issues and dalit groups. This paper summarises the main threads of the discussion at the Colloquium. Briefly describing the National Population Policy 2000, the paper analyses the population policies of five Indian states that were the focus of the discussions at this Colloquium. Following this is a summary of the extraordinarily rich discussions that ensued.

The National

Population Policy 2000

In February 2000 the Government of India released the National Population Policy (NPP) document (Government of India 2000). While this document has many weaknesses, it made an explicit commitment to voluntary and informed choice and consent of

Acknowledgement: We are grateful to the Ministry of Health and Family Welfare for making this Colloquium possible with utterly no interference. We are also grateful to our colleagues and students for their assistance.

Mohan Rao is at the Centre of Social Medicine and Community Health, School of Social Sceinces, Jawaharlal Nehru University, New Delhi 110 067. E-mail: mohanrao@bol.net.in. Devaki Jain is at Thrangavana, D5 12th Main, RMV Extension, Bangalore 560 080. E-mail: lcjain@bgl.vsnl.net.in.

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citizens while availing of Reproductive and Child Health (RCH) services and continuation of the target free approach in administering family planning services. The NPP also acknowledges a need to simultaneously address issues of child survival, maternal health and contraception, while increasing outreach and coverage of a comprehensive package of RCH services by government, industry and voluntary NGO sectors working in partnership. The NPP lists its objectives in terms of three time frames: its immediate objective is to address unmet needs for contraception, health care infrastructure and health personnel, and to provide integrated service delivery for basic reproductive and child health. The medium-term objective is to bring the total fertility rate (TFR) back to replacement level by 2010 through vigorous implementation of inter-sectoral operational strategies. The long-term objective is to achieve a stable population by 2045, at a level consistent with the requirements of sustainable economic growth, social development and environmental protection. In pursuance of these objectives, the NPP lists 14 sociodemographic goals to be achieved at an all-India level by 2010. These include addressing the unmet need for basic RCH services, supplies and infrastructure, increasing access to schooling, reduction in infant mortality rates (IMR) and maternal mortality ratios (MMR), universalisation of immunisation, delayed marriage for girls, universalising the number of deliveries by trained personnel and increasing the number of institutional deliveries, achieving a delayed average age at marriage for girls, increased access to information and counselling, universal registration of vital events, control of communicable diseases, convergence of RCH programmes and Indian systems of medicine and homeopathy (ISMH), and convergence of different social sector programmes. The NPP stresses the need for decentralised planning, the empowerment of wolnen for population stabilisation, child health and survival, collaboration with the voluntary and NGO sector, and encouragement of research in contraceptive technology. In order to promote the policy, it lists a number of measures. These include rewarding of pccnchayats and zilla pnrislzads for exemplary performance in family welfare and maternity benefits for mothers who give birth to their first child after the age of 19. Also, a familywelfare-linked social insurance is to be given to couples below the poverty line with two or less children who undergo sterilisatior.

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The government proposes to reward couples who marry after the legal age, register their marriage, have their first child after the age of 21, accept the small-family norm and adopt a terminal method after the birth of their second child. It is also proposed to have a revolving fund for income-generating activities by villagelevel self-help groups that provide community health care services, the establishment of creches and childcare centres in rural areas and urban slums, a wide choice of contraceptives, facilities for safe and legal abortion, and vocational training for girls. One of the central features of the policy is a commitment to a target-free approach and a refusal to use disincentives or coercion in order to achieve the demographic goals set by the state. The NPP also stresses the need for involvement of local bodies at the lowest level-that is, the panchayati raj institutions (PRIs)-in the achievement of the goals that make for population stabilisation. It suggests the devolution not only of rights, responsibilities and powers to the PRIs, but also of funds and resource generation. This latter is extremely critical in order for decision making to be truly decentralised. In doing so, the NPP attempts to extend the scope of population policy to a broader notion of democracy and welfare. At the same time several state governments also announced population policies of their own. The next section summarises these

Uttar Pradesh The population policy of Uttar Pradesh links the growth of population to pressure on natural resources, and declares the inability of the state and its government to improve the quality of life of the people in the face of this growth in population pressure (Government of Uttar Pradesh 2000). It mentions the need to address issues of gender and child development in the attempt to stabilise population growth. The following are its specific objectives:
1. The need to reduce TFR from 4.3 in 1997 to 2.6 in 2011-16. 2. Proportionate increases in use of contraceptive methods by increasing demand for the same.



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3. Increase in average age of the mother at the birth of her first child. 4. Reduction in unmet need for both spacing and terminal methods. 5. Reduction in MMR from 707/1,000,000 live births in 1997 to 394 in 2010 to below 250 in 2016. 6. Reduction in infant mortality from 85/1,000 live births in 1997 to 73 in 2010 and 67 in 2016. 7. Reduction in incidence of sexually-transmitted diseases (STDs) and reproductive tract infections (RTIs). 8. Increased awareness of AIDS.

The strategies to be adopted to improve RCH include raising the average age of effective marriage, introducing and focusing on adult education, empowerment of women, and enhancing the involvement both of the private and voluntary/NGO sector and the role of PRIs. The policy lists a number of incentives and disincentives to achieve its objectives, which include some of the following:

Disqualification of persons who marry before the legal age from eligibility for government jobs. 2. Performance-based disbursement of 10 per cent of the total financial resources for PRIs. Panchayats that perform well in the provision of RCH services will be rewarded. While the total transfer of funds will amount to only 4 per cent of state revenue, the PRIs are to be entirely responsible for advocacy, identification of contraceptive needs and recording of vital events. 3. The performance of medical officers and health workers is to be based on their performance in the RCH programme. While ostensibly this would mean more efficient RCH services, it would perhaps place extreme pressure on health workers to reach targets with regard to limiting of family size. Also, linking performance appraisal of individuals to performance in RCH would probably result in lopsided health services provision, leading to an overemphasis on family planning and a neglect of other aspects of primary health care, such as control of communicable diseases.

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The document also calls for an active dialogue with the GOI [Government of India] for wider availability of injectables and other new technologies through private, commercial and government channels in the state. The state thus intends to actively push the introduction of these newer technologies. Finally, the explicit commitment to charging user fees, ostensibly to improve the quality of services, will place a further burden on the poor to pay for the entire gamut of health services. The decision of the government to disallow those who marry before the legal age and who have more than two children from government service will adversely affect women, who may have no say in their age at marriage. In this case, even the implementation of 33 per cent reservation for women in elected bodies and employment will not necessarily result in greater gender equity, except in a narrow sense for some sections of women.

Madhya Pradesh
The population policy of Madhya Pradesh stresses the need to curb high fertility and mortality, which impinge upon the quality of life, and the balance between population, resources and the environment (Government of Madhya Pradesh 2000). The policy document mentions the process of democratic decentralisation under way in the state and speaks of the need to change the thrust of family welfare from female sterilisation to include raising the age at marriage for women, provision of RCH services, universalisation of education and empowerment of women. The specific objectives of the MP policy include:
1. 2. 3.

Reducing total fertility rates from 4 in 1997 to 2.1 in 2011. Increasing contraceptive usage and sterilisation services. Increasing the age of the mother at the birth of her first child

from 16 years in 1997 to 20 years in 2011. 4. Reduction in MMR from 498 to 220 between 1997 and 2011 through greater registration of pregnant women, increase in proportions of institutional and trained deliveries, and pregnancy testing centres.
5. Reduction in IMR through increase in immunisation, use of oral rehydration solution (ORS) therapies for diahorrea in

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rural areas, reduction in incidence of acute respiratory infections (ARls), and coverage of pregnant women and children with vitamin A and iron and folic acid (IFA) tablets. 6. Increased levels of HIV testing. 7. Services for infertile couples. 8. Universalising access to primary education by 2005, with a goal of ensuring that 30 per cent of girls in the age group of
14 to 15 years in 2005 would complete elementary education.

The strategies advocated by the policy document include the need to involve PRIs, and to empower women in the endeavour to reach population stabilisation. A number of initiatives are suggested, such as:
1. 2.


Making men realise their responsibility to empower women. Strengthening local womens groups. Reducing the burden of housework and drudgery on women by providing cooking gas connections and electricity to rural
households. Reservation of 30 per cent of government jobs for women.


However, the MP These include:



also has

number of disincentives.




Debarring of persons who marry before the legal age from seeking government employment. Debarring persons who have more than two children from contesting panchayat elections. The provision of rural development schemes in villages will depend upon the level of family planning performance by panchayats. The flow of resources to PRIs is also to be linked to performance in RCH. While there is no specific commitment to increasing devolution and control of resources to PRIs, these institutions are to be made responsible for the implementation of the RCH programme. Performance by panchayats in family planning is also to be linked to the starting of income-generating schemes for


poverty alleviation programmes.

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The population policy of Rajasthan, like those of Madhya Pradesh and Uttar Pradesh, also links deceleration in the population growth rate to sustainable development (Government of Rajasthan 1999). It mentions the need to reduce infant mortality, gender discrimination and undernutrition, and to increase household security. With regard to its specific objectives, it mentions:
1. The need to increase the median age at marriage for girls from 15 in 1993 to 19 by 2010 through education and increas-

ing awareness.
2. Increase institutional deliveries from 8 per cent in 1995 to 35 per cent by 2016, and assistance by trained persons in child delivery from 35 per cent in 1995 to 75 per cent in 2010. 3. Educate all women in the reproductive age group about antenatal services, and on establishing linkages between female health workers, anganwadi workers and trained dais at the village level. 4. Improved child health is to be achieved through assuring better-quality ARI care, strengthening links between Integrated Child Development Scheme (ICDS) and health workers, and coverage of all children for immunisation and vitamin A dosage.
to operational strategies, it mentions the need to encourage men to use low-cost sterilisation services, and recognises of the sterilisation and spacing methods need to be that



quality improved. While the thrust of the policy is on provision of RCH services, improvement of management of service delivery systems, encouraging involvement of PRIs, NGOs, the private sector and cooperatives, and on information, education and communication (IEC) are also prominent.
There are, however, a number of incentives and disincentives mentioned that include the debarring of persons with two or more children from contesting elections. It is also mentioned that the same provisions can be considered for other elected bodies like cooperative institutions and as a service condition for state government employees. The policy also states that the legal provisions

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barring people with more than two children from election to panchayats and municipal bodies is a testimony of the firm political will and commitment to population control. The policy is cautious on the question of introducing new reproductive technologies, although the policy draft mentions that new contraceptive methods, as and when approved by the GOI, will be introduced to make new technology accessible. Finally, it mentions the need to address issues of infertility, RTIs and female literacy.

The population policy of Maharashtra begins with a statement of the need to bring down the rate of population growth (Government of Maharashtra 2000). Its specific objectives include:
1. 2. 3. 4.

Reducing TFR to 2.1 by 2004. Reducing crude birth rate (CBR) to 18 by 2004. Reducing IMR to 25 by 2004. Reducing neonatal mortality to 2 by 2004.

The policy extract lists a number of measures in order to achieve these objectives. These include:
1. The



5. 6.

provision of subsidies and perquisites to government employees is to be linked to acceptance of the small family norm or permanent methods of family planning by couples. Service in government jobs is also to be dependent on the acceptance of the small-family norm. Provision of village health schemes will also be linked to the performance of panchayats in the RCH programme. Assessment of medical officers will depend upon their level of performance in the RCH programme. Persons having two or more children will be debarred from contesting panchayat elections. Other schemes include cash incentives to couples undergoing sterilisation after the birth of one or more daughters, training of dais, strict enforcement of the Child Marriage Restraint Act and the ban on prenatal sex determination testing. Also, womens self-help groups are to be set up at the village level.
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Funding of PRIs will depend upon performance in the RCH


The policy makes no provision for the representation of women or other bodies. It also does not mention the devolution of resources or decision-making powers to PRIs.
in elected

Andhra Pradesh The Andhra Pradesh

population policy links population stabilisation to improvements in standards of living and quality of life of the people (Government of Andhra Pradesh 1997). It states:
Production of food may not keep pace with growing population pressure on land and other facilities will increase further, resulting in social tension and violence ... housing in both rural and urban areas will become a serious problem ... there will be an increase in unemployment ... there will be serious pressure on the countrys natural resources causing deforestation, desertification and more natural calamities.

The demographic goals as stated in the policy include:

1. Reduction of natural growth rate from 1.44 in 1996 to 0.80 in 2010 and 0.70 by 2020. 2. Reduction in CBR from 22.7 in 1996 to 15.0 by 2010 and 13.0 by 2020. 3. Reduction in crude death rate (CDR) from 8.3 in 1996 to 7.0 in 2010 and 6.0 in 2020. 4. Reduction in IMR from 66.0 in 1996 to 30.0 in 2010 and 15.0 in 2020. 5. Reduction in MMR from 3.8 in 1996 to 1.2 in 2010 and 0.5 in 2020. 6. Reduction in TFR from 2.7 in 1996 to 1.5 in 2020. 7. Increase in couple protection rate from 48.8 per cent in 1996 to 70 per cent in 2010 and 75 per cent in 2020.


objectives are to be attained by:

terminal methods and male

1. The

promotion of spacing, contraceptive methods.

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2. 3. 4. 5. 6. 7.

Increasing the coverage of pregnant women for tetanus toxoid (TT) inoculation and provision of IFA tablets. Increasing the number of trained and institutional deliveries. Strengthening of referral systems and equity in accessibility
of services.

Eradicating polio, measles and neonatal tetanus by 1998. Reducing diahorreal deaths, deaths due to ARIs and incidence of low-birth-weight babies. Increasing female literacy levels, increasing the median age at marriage for girls, and reduction in severe and moderate

malnutrition among children. 8. Reduction in the incidence of child labour.

The policy lists a number of operational strategies relating to the promotion of terminal and spacing methods, ensuring safe deliveries as well as safe abortions, prevention and management of RTIs and STDs, increasing the average age at marriage of girls, and increasing female literacy and child survival. It also mentions a role for NGOs and the private sector in social marketing of contraceptives and delivery of health care. The document explicitly lists a number of incentives to be used in the achievement of its objectives. These include the following:
1. At the

community level, performance in RCH and rates of couple protection will determine the construction of school buildings, public works and funding for rural development

2. Performance in RCH is also to be made the criterion for full coverage under programmes like the Training of Rural Youth for Self Employment (TRYSEM), Weaker Section Housing Scheme and Low Cost Sanitation Scheme. 3. Funding for programmes under the Development of Women and Children in Rural Areas (DWCRA) and other social groups will be dependent on RCH performance. 4. At the individual level, cash prizes will be awarded to couples adopting terminal methods of family planning. 5. Allotment of surplus agricultural land, housing sites, as well as benefits under the Integrated Rural Development Programme (IRDP), Scheduled Caste Action Plan and Backward

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Class Action Plan well be given in preference to acceptors of terminal methods of contraception. 6. Special health insurance schemes will be provided to acceptors of terminal methods of family planning. 7. Educational concessions, subsidies and promotions as well as government jobs will be restricted to those who accept the

small-family norm.

8. Cash awards on the basis of performance will be given to service providers. 9. An award of Rs. 10,000 each will be given to three couples to be selected from every district on the basis of a lucky dip from the following categories: (a) three couples per district with two-girl children adopting permanent methods of family planning; (b) three couples per district with one child adopting permanent methods; and (c) three couples per district with two or less children adopting vasectomy.

policy document mentions the need for involvement of peoples representatives, religious leaders, professional social bodies, professionals, chambers of industry and commerce, youth,
film actors and actresses. While it underscores the delegation of rights to PRIS, there are no provisions for delegation or devolution of resources to the panchayats.
women, and


need for

To summarise, the National Population Policy lays the groundwork for a policy of population stabilisation based on the premise that the provision of health, safety, security and protection of vulnerable groups is a precondition for population stability. It also affirms the need for a policy based on the ethics of informed choice and consent. In doing so, it eschews any measure that would be ethically hazardous or coercive. However, the state policies all suggest some measure of disincentives in order to achieve their


Macro Issues

Welcoming the participants, K.R. Nayar reasserted the need to put forward a public health approach to population policy rather than one merely demographic. The issue would include then the quality of the lives of people rather than merely numbers, issues of
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availability, access, quality and equity in health care and mechanisms, including issues of decentralisation. Devaki Jain initiated the discussions and summarised the issues emerging out of the earlier Colloquium. The NPP merited what she described as qualified support with reservations about some of its features. At the same time concern was expressed about state population policies. There was consensus that an alternative population policy framework is crucial. This would hinge on social security and social justice for the poor and disadvantaged. It was necessary to have a wider public health orientation rather than be narrowly focused on RCH. There was also a concern about macroeconomic policies and a call for greater public investment in social sector development. An implementation mechanism for quality health services also called into play the elected system of government at the local level, namely, the PRIs. Public policy, it was agreed, had to go beyond family planning to area development, to food and employment policy, and to social infrastructure. In addition, family planning must cease to attempt to reduce fertility within existing gender roles and power structures but should instead change them. Tracing the many threads that went into making a comprehensive population policy over time, she noted that the Expert Group on Population Policy (Government of India 1993) had unanimously recommended the scrapping of all targets, incentives and disincentives, including, significantly, legal conditionalities such as making individual or institutional benefits dependent on fertility control. A very significant recommendation at the structural level was to merge the family welfare department with that of health. She argued that what was necessary now was to work out the essential elements of a social justice approach to the issue. It is widely recognisea that health and population are governed by larger socio-economic issues, indeed, determined by them. Way back in 1980 the Working Group on Population Policy, for instance, recognised that population and development are two sides of the same coin (Government of India 1980); and that if fertility levels are to decrease, attention will have to be given to increasing incomes, employment, food security and so on. These in turn would induce declines in infant and child mortality, even as they generate an increasing demand for family planning services. What have
the macroeconomic reforms of the 1990s then meant for these critical determinants of health? Jayati Ghosh observed that over

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the last three decades the rate of growth of GDP rose from around 3.5 per cent or less during the 1970s to 5 per cent during the early 1980s and more than 7 per cent during the late 1980s, before decelerating to around 6.5 per cent during the first half of the 1990s and less than 6 per cent during the late 1990s. The recent fall in growth rates is only a continuation of this decelerating trend. It is now being increasingly admitted that there are real and systemic problems in the economy. The spluttering of growth has occurred not despite but because of the reform process, especially because of its impact on reduced public investment and lower effective demand from the mass of people in the country. The National Sample Surveys (NSS) 55th Round (carried out over 1999-2000), along with the latest census data, reveal a sharp, and even startling, decrease in the rate of employment generation. There is very significant deceleration for both rural and urban areas, with the annual rate of growth of rural employment falling to as low as 0.86 per cent over the period 1993-94 to 1999-2000. This is not only less than one-third the rate of the previous period 1987-88 to 1993-94, it is also less than half the projected rate of growth of the labour force in the same period. In fact, this is the lowest rate of growth of rural employment in post-independence India. The second striking fact about the Indian economy today is the combination of huge excess holding of foodgrain stocks with the presence of about 350 million people living in absolute poverty (that is, with estimated consumption inadequate to meet minimum survival food requirements). Fiscal policies have also ensured a doubling of the price of foodgrain for above-poverty-line households over a 15-month period, while for the below-poverty-line households the price has increased by 80 per cent. This is a double tragedy, because millions starve as food goes waste in public godowns, and also because the government is effectively wasting an opportunity to do something about the low employment opportunities currently prevailing. These have obviously serious implications for health and population. It is also frequently stated that we do not have resources for additional public expenditure on health. This is a completely mistaken argument on at least three grounds. First, even with the existing expenditure of the government, there is scope for shifting out of areas such as nuclear weaponisation (which is largely unproductive, hugely expensive and dangerous), which the government

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is currently involved in funding, into provision of improved preventive and curative health facilities for all citizens. It has been estimated that the cost of one nuclear warhead would amount to more than the annual cost of primary health centres in every village and urban settlement in the country. Second, one reason why expenditure cuts are being introduced is because successive governments have been progressively less able to raise taxes, such that the tax to GDP ratio of the central government has fallen from more than 13 per cent in 1980-81 to 9 per cent in 2000-2001. This amounts to a loss of 4 per cent of GDP in foregone tax revenue. This is actually more than three times the entire expenditure on medical, public health, family welfare and sanitation by central and state governments combined, which was only 1.4 per cent of GDP in 2000-2001. Third, even if such expenditure on more and improved health services cannot be financed out of more taxes because of poor political will, there is still a strong economic case for financing such expenditures out of borrowing, as long as the social rate of return on such investment is higher than the rate of interest on government borrowing. Given the high social returns on better health of our citizenry, this is surely the case. Therefore, the low public expenditure on health cannot be justified or excused on any economic grounds; it reflects entirely political decisions, which imply very different priorities of the government. Noting that social security is essential for fertility decline, K. Seeta Prabhu argued that it was necessary to distinguish between the various connotations of the term. The human resource development paradigm is governed by the view that human beings constitute a means to higher productivity and income levels in the economy. In this paradigm it is assumed that individuals invest in themselves through education, health and nutrition in expectation of higher earnings. Hence, investment in these areas is largely left to the private domain. However, since education, health and nutrition are considered merit goods, the government does assume a role in ensuring minimum levels of consumption of these goods, but as a facilitator not a provider. In sharp contrast to this viewpoint is that of human development, wherein human beings are considered ends in themselves. The provision of social security in this paradigm extends to the enhancement of capabilities. In this view, further, the provision of minimum levels of health, education and nutrition constitute inalienable human rights, which in turn implies

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dominant role for the government. This is especially the case for countries characterised by pervasive poverty, poor employment conditions, high rates of illiteracy and human deprivation. It is thus evident that it is only within the latter framework that countries like India can conceptualise a population policy. Padmini Swaminathan, noting that health issues of particular concern to the poor were visibly absent in the NPP, argued that two fundamental features relating to security were food and employment security. Under the Minimum Wages Act of 1948, in order for minimum wages to be fixed, the employment or industrial activity had to be included in the Schedule of Employment. This only covered a small proportion of the workforce, varying widely between states, and left the large unorganised sector outside its purview. Further, norms or criteria for arriving at the minimum wage have proved intractable given the lack of political commitment. The calorie norm, itself highly inadequate, has been lowered over time. According to the 1993-94 Round of the NSS, about 80 per cent of the rural population and 70 per cent of the urban population had caloric intakes below the recommended minimum. The poorest 30 per cent of Indias population consumed on average fewer than 1,700 calories per day, while the poorest 10 per cent consumed less than 1,300 calories per day, endangering survival. Given these features, any social policy should ensure employment, wage and food security, exploiting potential synergies among them. It is only on this basis that policy issues of health and population can be meaningfully considered. Disaggregated health and fertility data by caste and class is unfortunately not routinely generated in India. S.K. Thorat argued that the impact of macroeconomic policies on the health and wellbeing of Scheduled Castes and Scheduled Tribes (SC/STs) had unfortunately not been studied. The National Family Health Survey (NFHS) does provide some insights, revealing that they are significantly at a disadvantage compared to the other sections of the population. The data indicates a relationship between levels of living, literacy, access to health, and health and demographic indicators. Thus, poor health conditions among these populations is a reflection of poor socio-economic conditions. Noting that 60 per cent of the Scheduled Castes are wage labourers with high levels of unemployment and underemployment, issues of access to employment and wages become critical for health. Macroeconomic

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policies, including low levels of public investments during the reform period, hit these populations especially hard. Indeed,
privatisation may well be considered a method of de-reservation, albeit indirect. Similarly, privatisation and NGO-isation of social services will curtail access to services for SC/STs. What is equally worrying is the package of incentives and disincentives in the population policies. A range of anti-poverty and welfare measures is linked to performance in family planning, thus further reducing the impact of these already inadequate programmes on poverty levels among vulnerable populations of SC/STs. During the ensuing discussions concerns were expressed that the population policy seemed preoccupied with controlling numbers of people rather than providing for their well-being. Questions were also raised about the changing role of the state in the m.acroeconomy. Can such a retreating state provide a coherent population policy, central to which is social security? Indeed, do we need a population policy in the absence of policies for employment and food security and health? We need a social policy, not a sectoral policy, one that sees people as an end and not as a means to economic growth. Such a policy should place the social sector at the heart of its strategies for nation building, not as a residual sector. Issues of equity and justice must be abiding concerns.
Health and


Mohan Rao noted that the world has never before been as rich as it is today. Between 1960 and 2000 the net world product had increased more than eight times. Yet over the same period inequalities within and between countries had substantially widened. In 1960 the 20 per cent of the worlds population in the richest countries commanded 34 times the resources of the poorest 20 per cent; today they command 74 times more. The richest 20 per cent command 83 per cent of global resources, while the poorest 20 per cent command merely 1.5 per cent. Accompanying the widening of global disparities in income, particularly marked since the onset of neoliberal economic policies, is a widening of the global health gap. There is a net transfer of the order of 80 billion dollars from the countries of the South to those of the North. Clearly, then, the issue of population control in Third World countries was a red herring.

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No population policy can be dissociated from the macroeconomic issues of health, employment, incomes and food. Yet it is poignant that India discusses a population policy divorced from many of these concerns; indeed, in the absence of a health policy. Further, the reproductive health approach had very little epidemiological basis: among females within the reproductive age group, mortality due to causes related to reproduction accounted for merely 12 per cent. Communicable disease mortality vastly exceeds deaths due to maternal mortality. The epidemiological priorities in India continue to remain diseases of poverty and hunger. In this context not to have a universal comprehensive and free primary health care (PHC) approach was not merely epidemiologically misplaced, but also more expensive in the long run. In the short term it led to a transfer of resources to funding agencies with no substantial change in the morbidity and mortality profile. It is for this reason above all that our population control policies have

repeatedly run aground. Substantiating this, Ritu Priya drew attention to the fact that while IMR had declined, although even this was stagnating during the reform period, the nutritional status of the population had not substantially improved. Increase in food prices, increasing casualisation of labour, insecurity and instability of employment, and cuts in the public distribution system have all contributed to microfamines in a number of states across the country, pushing more
and more households under the poverty line. This indicated aneed for rethinking the structure of delivery of public health, even as it indicated the need for understanding what constitutes primary health care. Despite the recognition of the failures of vertical programmes, these have continued. An integrated approach would comprise satisfaction of basic needs, provision of medical care and preventive services including contraception, relating these with dignity to the felt needs of people. However, felt needs seem to assume importance only in the context of the NPP but not in the provision of health care. Further, the disjunction between preventive and curative medicine, the former within the ambit of the government while the latter is in that of the private sector, is a theoretical red herring. The function of public health is to alleviate peoples suffering; in order to do so, peoples perceptions and felt needs should form the beginning.

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Alpana Sagar, based on her study of a slum in New Delhi, critiqued the RCH approach. Although the NPP recognised the importance of socio-economic factors, the solution offered to the problems of womens health rested merely in the technical domain. The morbidity profile of women indicated that their health problems were rooted in their living and working conditions, and
thus the poverty that haunted the lives of the poor. An RCH

approach, by focusing on the reproductive lives of women alone,

thus misses the woods for the trees. For instance, the kind of

employment available was extremely critical to womens health, whether pregnant or not. Now, data indicated that working in poor and underpaid jobs increased the prevalence of pre-term deliveries. Women sought contraception, but poor quality medical services, the lack of safe contraceptives, lack of security in old age and hence the need for sons, and the insecurity of childrens lives all worked against this. Under such conditions, the RCH approach merely touched the tip of the iceberg of womens ill-health. Ravi Duggal noted that international influence had entrenched population concerns into policy in India, with health policy being guided by population control goals. This had profoundly weakened the credibility of the public health system. As a result, even the poor are increasingly forced into the private health sector. There is a very clear dichotomy between the public and private health sectors, a division of labour. The private sector has monopolised ambulatory curative care and the public sector preventive services. Increasingly, even hospital care is shifting towards the private sector. As a consequence, out-of-pocket expenditure is increasingly emerging as a cause of peoples indebtedness. Further, private medical care is often of questionable quality, with professional organisations showing themselves unable or unwilling to ensure basic medical ethics in practice. Public policy has supported and subsidised the growth of the for-profit sector. It is, therefore, regrettable that the NPP visualises a greater role for the private sector in health care. The public health paradigm of moving away from comprehensive care to selective care has created conditions for an increase in the share of the private sector, while public health services themselves have become deficient or discredited. A carefully structured mix of the private and public with a monopoly funding agency should perhaps be considered with a variety of methods by which funds could be raised for this purpose.
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The NPP and the state population policies carved out an increasing role for NGOs in the delivery of health and family planning services. Rama Baru noted that NGOs had made a singular contribution in a variety of issues and debates by raising critical issues and providing alternative models. However, from a public health perspective, the policy prescription of increasing the role of NGOs led to certain concerns. There is a plurality of NGOs, scattered all over the country, with a variety of ideologies guiding them. Are they meant to supplement or supplant the state? If they are implementing state policies, does this diminish .the role of NGOs as independent actors? Will this lead to a dilution of their role as conscience keepers of the community and as voices of dissent? Will they then continue to make innovative contributions? Funding from the state, and indeed from international donors, has meant that priorities of NGOs have shifted. This is brought out by the fact that many NGOs in health care shifted from PHC to RCH over the last few years. The close association with state policies also leads to a weeding out of NGOs that are opposed to some elements of state policies. Increasingly, then, only those NGOs willing to be co-opted will find space in policy discourse. Public health implies a total population perspective. Given that NGOs are small and scattered, their services are neither universally available nor accessible. Far too little thought has been given to the capacity of NGOs to deliver services. While the public health sector is critiqued for poor quality of services, lack of follow-up and referral, such issues also dog NGOs in health care. Finally, questions about the accountability of NGOs have not been adequately posed. This is especially striking when issues of monitoring and regulation of medical care and public health research have assumed such importance. The issue of the use of quinacrine for female sterilisation is one example; that of other contraceptive technologies is yet to be adequately addressed. While the public health system has to be critiqued and improved, questions need also to be raised about the scale and the economics of subsidising NGOs, given all the above concerns. Baru also noted that there is very little empirical data to substantiate the argument that the NGO sector is necessarily more efficient than the public sector. Given these issues, she called for a public health approach that takes a population perspective, is concerned with issues of universality and equity, and above all highlights the central role of the state.

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Thelma Narain also drew attention to the essential approaches of public health. It concerns the entire population and comprises a comprehensive mix of services, with the choice of technology being guided by social considerations. These call for the central role of the state and of planning, especially if, as in poor countries like India, health services have the function-as they must-of a concern for the issue of equity. Reviewing the state of public health indices-the high prevalence of infectious diseases and of malnutrition-she argued that primary health care can be the only rational agenda for a pro-poor health policy. The health care system is in shambles. The task is thus to refurbish this system with a clear of priorities, with a focus on issues in quality of care. While PRIs should be partners in all policies, including health, we should not at the same time be sanguine about their role. There is a role for larger bodies involved in issues of comprehensive planning. Water supply, sanitation, food and so forth are clearly the states responsibility. Activists must cajole, coax and challenge the state to meet its mandate. Karnataka had shown remarkable initiatives by setting up a task force on health with the involvement of a wide range of actors, including NGOs that have been active in health and are critical. The task force report takes an integrated and comprehensive view. How it is to be translated remains to be seen. Nevertheless, people cannot continue to critique policy from the safety of the sidelines; it is essential to get involved in the process. During the ensuing discussions there was consensus that population and health have to be integrated; that public health could not be expected to be better given the appalling levels of investment, among the lowest in the world. It was felt that policies of privatisation and NGO-isation could not be expected to deliver health care to the entire population, and that the state alone could provide universal and comprehensive primary health care. Chairing the session, Imrana Qadeer observed that there is currently, as evidenced in the NPP, a tendency to equate PHC with primarylevel care. This is utterly unacceptable. PHC includes all the components identified at the Alma Ata declaration that India is committed to. It is only within this framework that a reproductive health package can be meaningful. There was also consensus that in addition to reinforcing the commitment of the state to provide universal health care, there is equally a need to monitor and regulate the private sector.

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Critiques of State Population Policies

Subhashini Ali of the All India Democratic Womens Association (AIDWA) presented a critique of the population policy of Uttar Pradesh. She observed that the policy was marked by rhetoric about gender justice and choice that was completely unrelated to the situation on the ground. Uttar Pradesh had not only one of the worst health indices in the country, but the public health system had completely collapsed. This had in fact reduced options for women seeking health care for themselves and their families. Indeed, it was poignant that new goddesses were now being evoked to protect the lives of children. Instead of strengthening health services, they are being privatised or handed over to NGOs. In the political economy of UP this had proved to be yet another avenue for corruption. Further, NGOs have been using injectables and implants, not mandated by the centre, while some good NGOs had their workers arrested under the National Security Act. The whole system of disincentives and incentives was anti-dalit, antiminorities and anti-women, in keeping with the larger ideologies of the state government. With the state cutting down on employment opportunities available to women-posts of teachers and anxiliary nurse midwives (ANMs) were not being filled, training of nurses suspended-and winding down such welfare measures as were available, what gender-just policies of empowering women did the policy envisage? What remains is a target-obsessed public health care system, the commitments of the NPP notwithstanding. Jaya Velankar of the Forum for Womens Health, Mumbai, presented the Maharashtra Population Policy. She observed that India is supposed to have moved out of the paradigm of targets after the ICPD at Cairo. This was simply not true. While the NPP does not specify that the two-child norm is a national objective, the Maharashtra government, in an undemocratic government order that was not discussed in the Assembly, did so. Widespread protests led to the withdrawal of this order, but the state policy is committed to the two-child norm nevetheless. The package of incentives and disincentives includes linking the performance of health workers to the attainment of family welfare goals and funds for panchayats for a range of welfare schemes for the weaker sections are similarly linked to performance in family planning. This draconian package is nothing but coercive. While Maharashtra was the first state to

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pass the Pre-Natal Diagnostic Techniques (PNDT) (Regulation and Prevention of Misuse) Act in April 1988, the state has witnessed a sharp decline in juvenile sex ratios as per the 2001 Census. This could only be attributed to coercive family planning policies. Male

responsibility does not figure in the policy document, which is not to say that men must be coerced. But the whole approach, including the arrest of child brides, violated the letter and spirit of
the ICPD.

Aparna Sahay of the State Womens Commission, Rajasthan, noted that Rajasthan had poor health infrastructure, poor health indices, a high prevalence of undernutrition and levels of anaemia, high IMR, low age at marriage and a high TFR, embedded in a

profoundly feudal patriarchal culture. Levels of education and employment among women were low. The Rajasthan government had prepared a widely discussed and comprehensive draft population policy. A task force comprising social scientists, demographers, health managers, and feminists and NGO activists had, after widespread consultations, refined this document. But what finally appeared was a demographically-driven, unyielding and static policy with little resemblance to that prepared by the task
force. Indeed, the final document has been described as of the government, by the government and for the government. It does not reflect the rights perspective of the earlier policy. Instead, it is a utilitarian approach, with women the means to demographic ends. Sanghamitra Acharya argued that any population policy should have as its goal the well-being of people. Although this is the stated aim of the Madhya Pradesh governments policy, there is a disjunction between its framework and recommendations. It must not be forgotten that MP, as one of the members of the BIMARU group of states, has a long way to go in achieving a health transition. Yet by setting a target of a replacement level fertility by the year 2011, health and demographic transitions are sought to be brought in through generating contraceptive acceptance among women. The question of course is, do we have the necessary enabling conditions in the state? The package of incentives and disincentives is deeply anti-poor, anti-women and, above all, anti-democratic. Andhra Pradesh has, given the age structure of the population, among other factors, achieved a remarkable decline in birth rate in an astonishingly short period. Leela Sami observed that despite this, the package of incentives and disincentives announced in its

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policy is truly mind-boggling. A range of welfare measures is to be withdrawn from people with more than two children, while among the incentives is a lottery scheme in each district to reward couples sterilised after two children. Health care workers are to be rewarded on the basis of performance in family planning. For a state which is considered to be extraordinarily techno-savvy, it is surprising that no planner has heard of the paradigm shift after Cairo. There are certain common threads running through the policies. Ghanshyam Shah, chairing the session, noted that there is a mismatch between the policy framework and recommendations in all of them. All the policies are anti-poor and anti-democratic. All of them assume that poor people do not know what is good for them, and, moreover, are irrational and will only respond to coercive


Societys Responses

Landless agricultural labourers constitute the single largest category of the population in rural areas. They are overwhelmingly dalits. M. Thangaraj noted that NFHS data makes abundantly clear that dalits suffer a disproportionate load of infant and child deaths compared to other castes. They also have a disproportionately huge load of undernutrition. This is not surprising, as the NSS data indicates, that their per capita expenditure is also the lowest. It is thus surprising that the NPP and state population policies prescribe norms as if health and fertility are merely geographical entities and not socially determined. The whole package of incentives and disincentives thus are anti-dalit, by making the woefully inadequate welfare schemes for this most deprived community in the country contingent on family size norms. The states priorities are amply indicated by the fact that while minimum wages are not implemented, the small-family norm is. Indeed, Tamil Nadu, which does not yet have a state population policy, has nevertheless linked the agricultural labourers insurance scheme to the twochild norm. Issues of old-age security, illness security and unemployment benefits are all necessary elements of a population policy if it is to be described as pro-poor. That the population policies are upper-caste documents is also evident from the fact that it is assumed that rural populations are

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homogenous, casteless and classless. The implementation of the family planning programme, linked to financial assistance to PRIs, could have dire implications for dalits since by and large these bodies are dominated by the upper castes. The victimisation of dalits under the family planning programme would then have state
sanction. Activists from womens groups are frequently chided that they never find anything positive about state policies on population. The question should in fact be posed to the state, which in its discourse on population and development imbricates and seeks to

control the womb. Economics, demography and health are invoked in this disciplining of female sexuality by the state. What is left unexamined in this discourse is the issue of consumption of resources and power in relation to the control of resources. Navsharan Singh argued that it is in this context that activists from womens group analyse the issue of population policy. Global population discourse creates insecurity bred by neo-eugenic and anti-immigration fears. Third World states transform this insecurity into a threat against the existing social and economic order that apparently threatens development. Technology, including reproductive technology, is moulded by this overarching ideology. While women want safe, effective and user-controlled technologies, the state in its desire for control and discipline seeks providercontrolled technology, regardless of the harm to womens health. Can hormonal contraceptives be considered in the absence of reliable and good medical services? Can sex-selective technologies be uncoupled from patriarchy? Is the two-child norm, then, an invitation to female foeticide? These questions are seldom posed in demographic and development discourse that must be challenged, and indeed is challenged by the feminist movement. Amit Sengupta shared the concerns of the All India Peoples Science Movement. The first concern relates to the gender implications of family planning and population policies. Although said to be gender sensitive and framed in the discourse of rights, fieldlevel experience indicates that it victimises powerless women. Second, that the overriding concern with the issue of numbers sorely undermines issues in health. The single most important reason women in rural areas give for avoiding the public health _ system is its preoccupation with targets in family planning. This is reflected at higher levels in budgetary allocations also: viz hile

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reforms have meant that all social sector expenditures have declined, that devoted to family planning has not. Indeed, the family planning programme reduces peoples access to health and health services. The third concern with the policy is that it reflects the chain of coercion that commences with the elite of the First World, placing the burden of guilt for the problems of the world on the poor of the South. Without questioning this uiiderstanding, indeed, sharing in it, the elite of the countries of the South form the next link in the chain of coercion, passing the responsibility on to poor families. Within poor families, it is women who are made the victims. A whole range of health groups share these concerns as reflected in the National Health Charter drafted at the National Health Assembly at Kolkota in December 2000. Sengupta also regretted that NGOs today are the carriers of coercive population

Vandana Prasad on behalf of the Forum for Creches and Child Care Services (FORCES), an all-India network of organisations working on maternity and child care policy issues, noted that the government had not signed the Maternity Protection Convention of the International Labour Organisation. Maternity entitlements, essential to the survival of the young child and the health of the mother, had to be seen in the context of the current economic scenario. The number of women in the unorganised sector was increasing rapidly and one-third of the households in the country were female headed. Thus, the rights of women were integrally linked to the rights of the child. She noted that population policies were historically linked to racial discrimination in developed countries. For exam.ple, the motherhood endowment campaign of the 1920s in England was sponsored by the Eugenics Society to maintain the purity the white race. Similarly, the avoidance of universal maternity benefits in the USA were linked to fears of a burgeoning black population. In India the NPP links the issue to the two-child norm. Thus, the fight for maternity entitlements is closely linked to the fight against the two-child norm, indeed, any scheme of disincentives that penalises women and children. Those concerned with the rights of children should be concerned with the rights of a third child who will be victimised by state policies. Feminist discourse, however, seems to neglect the rights of children. Based on fieldwork in both rural and urban settings, Sabiha Hussain raised the following questions: Is the NPP gender just? Is

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it anti-minorities? A comparative study among Hindus and Muslims in these settings revealed that while there were some differences in the way poor women from these communities perceived the programme, there were overwhelming similarities. Given their poor state of health and the appalling state of health services, women from both communities sought better health care; they also sought access to contraceptive services. But the target-oriented, sterilisation-focused programme did not meet these needs of women in both communities. Yet it is asserted that Muslim women are against family planning. What some Muslim women are against is terminal methods. The urban study revealed that 74 per cent used spacing methods and 17 per cent had accepted sterilisation. The level of the former was higher than among comparable Hindus, while the latter was lower. But by emphasising terminal methods, the NPP bypasses the needs of Muslims. Indeed, the study revealed that, given the lack of safe and effective temporary methods, the rate of abortion among Muslims was higher than among Hindus. Respondents from both communities repeatedly asked what moral right a government that does not provide health services has to insist on family planning acceptance. Above all, what united women from both communities was their low health and socio-economic status. Indu Agnihotri said the All-India Democratic Womens Association (AIDWA) understanding of the issue of population and development led to certain fundamental disagreements with the perspective of the NPP and the state population policies. They fall in the format of UN documents that assume that we do indeed live in one world, shared equally and that there is only one way forward economically. Since historical memories are extraordinarily short, there is no questioning of this assumption. Is the world committed to sustainable development? What does it mean? That some countries exploit all the resources of the world while

others have to cut down on their consumption and population? Within the country also the document has certain unstated assumptions. Indeed, central to this assumption is the definition not only of a nation but of a citizen. That is to say, a good citizen is one who has only two children. The NPP and state policies have to be resolutely opposed on the ground that they compromise citizenship rights. If today they can be compromised on the basis of fecundity, tomorrow it could be on the basis of religion. Indeed, she pointed

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out, that the Rashtriya Swamsewak Sangh (RSS) was currently in the midst of a campaign that the Hindu family size is declining and that this decline must be stopped. What is the common sense that these documents propagate? That a class that appropriates the resources of a country can impose a norm for those who create surplus? It is thus anti-women, anti-dalit and anti-poor; all these sections will be labelled anti-national, too. On the other hand, when the state itself is withdrawing from essential sectors, both of production and of social security, when as a result the health system is crumbling, what does the operational part of the NPP portend? What common grounds do these documents provide to womens groups to constructively engage in dialogue? The lives of dalit women are overwhelmed with pain and suffering. Both class and patriarchy make people blind to this reality. Sulabha Patole, who works with dalit women, characterised the population policies, both at the centre and the states, as anti-women and anti-dalit. Dalit women and other lower-class women needed to have more children, both as sources of income and security, and as insurance against their deaths. Given this reality, how can there be a uniform norm of two children that talks of voluntary decisions and choice? Dalit women have no choices about work, about wages, about hunger and yet are supposed to choose about contraception, ignoring the demands of the family. The entire weight of the system falls on dalit families, and within them on dalit women. While education is supposed to empower them, how many of them have access to education? And what sort of education ? Issues of gender, class and caste do not configure in our system of education. Mary John argued that the swift swing of dominant economic opinion from state-led planning to market-oriented globalisation unexpectedly demonstrated the decisive importance of both ideologies and the middle classes, both relatively neglected in research. Even in the hardest of social sciences and economics, policy orientations are significantly under-determined by data. In the case of population issues, it becomes particularly salient to understand ideological regimes and the forces shaping them. Increasingly in the 1990s, the middle classes perceived the population problem to be at the heart of all problems in our country: the poor, not poverty, must be reduced. Freshly carved in this ideol ogy are women, minorities and lower castes. These spawn a range

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of myths, only some of which are explicitly acknowledged. In addition to lower-caste promiscuity are images of backward and antimodern religious groups swamping the nation. The elite fraction of the middle classes specialises in the production of these ideologies, while the mass of middle classes consumes them. The urgent question today is to critique these constructions of ideologies by investigating the multiple ideological axes of the population question, to widen the circle of people to draw into our struggle. The Joint Womens Programme (JWP) works on issues of womens empowerment ir several states of the country. The JWP has also participated in policy discussions on issues related to population and womens health. It is one of the all-India womens organisations involved in agitation against inclusion of harmful, provider-controlled contraceptives in the national family welfare programme. On behalf of the JWP, Madhu Joshi said their field experience had shown them that women wanted fewer children and smaller families. But the need for security in old age meant that they sought sons. Given prevailing levels of mortality, a twochild norm was unthinkable for them. They have a host of health problems, reproductive ones being some of them. The government, however, focuses on reproductive health, including AIDS, to the exclusion of other health problems. Similarly, they express a need for safe temporary methods of contraception, which again is not available. Women have no choices, no rights in any sphere. If the language of rights is to be meaningful to women, the first that has to be emphasised is the right to food. Amarjit Kaur from the National Federation of Indian Women (NFIW) drew attention to the need to link issues in population to wider macroeconomic concerns. What direction was the economy taking? Was it towards the fulfilment of the needs of the majority? What was happening to structures of employment, wages, food security, etc.? What is happening to the social sectors? It is in this context that policies relevant to women can be meaningful; if not it is merely rhetoric. When employment opportunities are shrinking, when women in the new industrial zones are not allowed to unionise and demand minimum wages, when deprivation forces many women to seek employment in these sectors, where is the question of womens empowerment? Similarly, in the agricultural sector there has been no diversification of employment opportunities for women. Since the launch of the structural adjustment

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programme women are being pushed back into agrarian servitude. The state is withdrawing from social sector commitments. The ICDS scheme is being dismantled, the public distribution system is being dismantled, ANM training programmes are being shut down, education is being increasingly privatised. Can the NPP be divorced from health policy and education policy? Why is elementary education now being played off against tertiary education? Curative care against preventive care? The irony is that government documents borrow the language of progressive womens groups, but not their content or context. All policies of coercion, of incentives and disincentives, of the two-child norm, of linking development schemes and welfare schemes to family planning, must be

resolutely rejected. Malini Bhattacharya from the Paschim Banga Ganatantrik Mahila Samiti compared the NPP to the Draft Report prepared in 1993 that had aroused a great deal of debate. Although the Report of the Expert Committee, popularly known as the Swaminathan Committee, had several problems, there were well-argued reasons for the Committee to suggest drastic structural changes. This included merging the department of family welfare with that of
health so that issues of health would retain their focus. Since this has not been done, and the NPP argues for doubling finances to family welfare, does this mean a further dilution of commitment to health? The Expert Group specifically highlighted the issue of safety of contraceptives. This is weak in the NPP, which is equally fuzzy about different methods to be adopted in different regions and among different population groups. The NPP places excessive emphasis on abortion. While the MTP Act is progressive, abortion cannot be a method of family planning. There is thus a need for safer and more effective temporary methods, and not just longacting hormonal contraceptives. Bhattacharya argued that decentralisation means different things to different people. Indeed, today, under globalisation when economic power is increasingly centralised, decentralisation has emerged as a mantra for every conceivable programme. What are the contours envisaged in the NPP? After all, even privatisation is a form of decentralisation. She strongly urged the need for a national group to monitor the implementation of the programme, with special reference to violation of norms and ethics.

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On behalf of the Voluntary Health Association of India (VHAI), Mira Shiva argued that population policies cannot have any package of incentives and disincentives. There is also a need for integration of health and family welfare, and to broaden the concept of reproductive health. Given the lack of availability of basic health care in the country, a scenario that has worsened over recent years, strengthening basic health care and making it accessible should be the priority. The changed paradigm in population that the policy avers can be made visible if the Population Commission is renamed Population and Social Development Commission and


given a broader mandate.

Justice Sujatha Manohar of the National Human Rights Com-

congratulated the organisers for the vibrant and rich meeting. The strength of democracy is based on the strength of a vibrant civil society, she said. This is especially important in issues of population when, as the experience of the Emergency indicates, concern for the general good replaced concern for the individual. The NPP has to reflect an individuals right to life. An individuals rights should not be compromised by national goals. Some elements of the NPP and some of the state policies are not human rights friendly. Individuals have to have the necessary enabling conditions to make choices. If the government imposes policies that violate human rights, they will only rebound on the policies. Meenaksi Dutta Ghosh from the Ministry of Health argued that the issue is of actualising the NPP. In this context she called for the need to rid people of superstition by behaviour modification to encourage the adoption of new practices. In other words to create a countrywide demand, while the government dealt with supplyside issues. The government has performed a sterling role in providing a large network of health institutions. But for a complex variety of reasons beyond the scope of the Ministry of Health, the system was largely dysfunctional. We therefore need to put in place a countrywide consortium of the private-voluntary-NGOcommunity and public sector. This consortium should begin to market the concept of behaviour change and also the product. This experiment has been successful in Tamil Nadu where 22 industrial

houses have taken over many PHCs for management. The infrastructure of 137,000 SHCs, 25,000 PHCs and 4,000 community health centres (CHCs) must be galvanised in this manner. The community will have a stake in this system, thus

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assuring accountability. It is necessary to consider the issue of social franchising in public health. If Kentucky Fried Chicken (KFC) can do it in the remotest village of Punjab, the government can put in
monitor the system. and Indonesia have initiated this scheme. Bangladesh successfully these should be a and IEC stark Backing strong programme. Together, these initiatives will ensure that demand is generated and met. A.R. Nanda, Secretary, Family Welfare, Ministry of Health and Family Welfare, said that his participation in the meeting had been a rich learning experience. He unequivocally stated that the ministry appreciated the need for a rights approach in framing the NPP This was to override any demographic goal. If the TFR of 2.1 was not reached by 2010, the world would not come to an end. The aim, therefore, has been to emphasise issues of the quality of life of the people. Indeed, he went so far as to say that terms such as population explosion or population control are anathema. He urged that members of civil society should carry this forward as non-negotiable. Some motivational measures are causing concern as they are considered coercive. The ministry is open to suggestions, he said. Any use of coercive methods or disincentives should be highlighted. The challenge is to ensure that concerns for public health, womens health, convergence of social security and welfare measures, and so on obtain consensus in legislatures and gram panchayats, where, he pointed out, other activists, demographers and academics with contrary views also found a voice. These are people who seek a quick-fix solution to problems, but the ministry does not want an anti-poor policy; the focus is on womens health and the health of the child. But we do have to remember resource constraints and the limitation of health outreach, he said. In view of the limitations in some states, the centre was considering handing over some health institutions to vibrant NGOs. This could not be construed as a shirking of responsibilities. The ministry was aware that PRIs and other village-level institutions were the best means to bring about a change in the quality of life of the people through a synergy of initiatives. It is well recognised that civil society organisations could play a critical role in this process. Family planning is in the Concurrent List and the centre does indeed play a role. There is no move for the centre to shirk its

system to accredit the franchisee and thus

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responsibilities towards the provision of health care. The ministry is more than willing to listen and to be corrected. Shabana Azmi, as chair of the session, asked if a population policy by definition was coercive. Do we then need a social policy? She cautioned that playing an adversarial role may not always provide the dividends activists looked forward to. It is necessary
to be aware of the real situation. While everyone would like to increase health budgets and cut down on defence spending, in the real world there are other considerations, other viewpoints held by other people. China has a huge defence budget, but also has resources for education and health. It is important to ask the question about where we go from where we are. Not wanting to sound like a spokesperson of the government, she nevertheless felt the need for people to come up with doable and constructive suggestions.

Justice and Ethics

A.K. Shiva Kumar in his paper noted that there is widespread belief in the myth that India is a poor country because of its large and growing population. The fact of the matter is that population size is not associated with economic prosperity in any predictable manner. Citing a large body of empirical evidence, he argued that it is simply not true that Indias growing population is the reason why the economy is growing slowly. The overpowering influence of these myths all too frequently leads to policy prescriptions that are coercive or authoritarian. Citing 10 good reasons why India should stay clear of such policies, Shiva Kumar noted that what is needed for population stabilisation is not merely more investible resources, but getting priorities right to address issues of human development. Penalties and disincentives are unnecessary because people do want fewer children, but they lack the necessary conditions to realise this aim. They are also unfair and inequitable in terms of how they affect different groups within society. The proposal to bar people with more than two children from contesting elections is thus clearly biased against rural poor and tribal populations, against less-educated persons, against women, against those belonging to the Scheduled Castes and Other Backward Classes, and others denied opportunities. Imposing disincentives thus has little ethical or moral basis. Indeed, some state governments moves such as debarring the third child onwards from education

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and health facilities clearly violate the Convention of the Rights of the Child that India has ratified. Amita Dhanda observed that we have a Constitution that guarantees right to life, equality and liberty. We also have a set of Directive Principles that are not justiciable. It is in the context of these principles that the NPP must be examined. The basic thrust of the policy appears to be one of reducing numbers, doing away with some people as redundant. Does this violate the right to life and liberty? Human rights stress the inviolability of the human being. It is an unequivocal acceptance of this inviolability that gives worth to a number of rights, which are the non-negotiables of human dignity. The NPP, supposedly framed in the language of rights, should be expected to be in consonance with these rights and not in derogation of them. In the post-Emergency period the tide turned with the judiciary becoming increasingly activist. The tide appears to have turned again in the light of several recent judicial decisions. She argued that people should not be sanguine about the judiciary, remembering that the judiciary, too, comprises people with ideologies and prejudices. In other words, we cannot depend on the judiciary alone to set right the various social problems in our country, or indeed what we see as wrong policies. Instead, the fight must be political. A human rights lawyer, Saumya Uma, noted that India is a signatory to a number of international conventions. These commitments, she argued, could be fruitfully utilised to strengthen democratic spaces within the country. The questions to be posed are: Are there contradictions between Indias commitments at international fora and state policies? Are these policies in consonance with the Constitution ? Are there contradictions between the stated policies and the obligations of the government as interpreted by the Supreme Court in a series of case laws? India is a signatory to the Universal Declaration of Human Rights, Covenants on Economic, Cultural and Social Rights, Covenants on Civil and Political Rights, Convention on the Rights of the Child, and the Convention on Elimination of Discrimination against Women (CEDAW). These, along with the Constitution, have been used by the Supreme Court to interpret a range of rights of the people and the obligations of the government. For example, in the Bishaka case, the Supreme Court drew strength from CEDAW to point to the governments responsibility to prevent sexual harassment of women at the workplace.

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Although the concept of social justice is a fundamental principle of the Constitution, it is increasingly being sidelined by the state. The Supreme Court case laws have argued that the right to life includes the right to life with dignity, right to equality and nondiscrimination. It could, therefore, be argued that population policies contradict these pronouncements of the Supreme Court. If the population policy violates human dignity, reducing people to numbers, it violates a Fundamental Right. The Right to Health is part of the Right to Life. The state has an obligation to provide health services. The UP State Population Policy thus appears to violate this. The Right to Privacy includes childbearing and motherhood. This has been elevated to the level of Right to Life, a Fundamental Right. It could be argued that coercive population norms violate this right. Similarly, state policies that link fertility norms to access to government jobs, as in the case of UP, clearly violate the Right to Livelihood. Thus, any critique of policies to widen democratic spaces should include the language of rights. Commitment to, promotion of and respect for human rights is non-negotiable. Bhagwan Das argued that the Preamble of the Constitution is the spirit of the Constitution. It is in the light of the Preamble that everything else in the Constitution is to be interpreted. The Preamble promises justice, social, economic and political; liberty of thought, expression, belief, faith and worship; equality of status and opportunity, assuring the dignity of the individual, and the unity and integrity of the nation. Fundamental Rights have a bearing on health and population: Article 39 is concerned with adequate means of livelihood, Article 43 is concerned with living wages and Article 47 with raising the level of nutrition and public health. The 42nd Amendment to the Constitution deals with family planning and population control. It is to be recalled that Dr. Ambedkar, one of the visionary framers of the Constitution, took up the cause of family planning, despite conservative opinion to the contrary, as early as 1929. At a 1942 womens conference he argued the need for family planning to protect womens health. The communalisation of censuses is not something new. The British counting of religious heads brought in communal considerations, leading ultimately to the partition of the nation on religious lines. Thus, politics and censuses are linked in manners not always so evident. Since 1951 the censuses have not been entirely honest in the counting of SCs and STs. Should these marginal people move
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livelihood, they cease to be counted as SCs and STs since these communities are defined by the states. They then cease to be eligible for reservations that are enshrined in the Constitution despite protests from the upper-caste communities. The NPP in effect achieves the same de-reservation by linking welfare schemes to family size norms. The tragedy is that Members of Parliament, even the sizable numbers holding reserved seats, do not represent the marginal communities but the dominant ones. Had this not been the case, the NPP could not have been passed in Parliament. Participants felt that the Right to Food should also be a Fundamental Right. It is sobering that today the Public Interest Litigation, which at a point in time was considered a solution to many problems of justice, is being viewed cautiously in the light of the Narmada judgement. Indeed, it was pointed out that the Rajasthan High Court had upheld the constitutional validity of the two-child norm as an eligibility criterion for contesting panchayat elections. While some participants felt that this needed to be challenged in the Supreme Court, others felt that there should be political mobilisation on the issue. It was also pointed out that there was an apprehension that under the present dispensation the Constitution itself is under threat.

out of a state in search of

Panchayati Raj Institutions

area where the Banavasi Seva Ashram look upon children as a gift to be enjoyed, as a source of joy and security in old age. Neera from the Banavasi Seva Ashram said that people ask her how two children are enough. What is the guarantee that children will survive? They say that only people with secure, permanent jobs and pensions want two children. Further, there are no jobs even for educated people. When a factory comes up, who gets the jobs there? It is not adivasis, but people from outside. In the area of their work, electricity is generated for Delhi while the villagers get displaced. Even those who are not displaced do not get electricity; they make do with kerosene lamps. The people need health centres that work, schools that work and, above all, jobs. The reason things do not work, that ANMs do not visit villages, that there is no follow-up after sterilisation, that there are no medicines in PHCs, that there

In the adivasi-dominated


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teachers in schools, is that people at the top do not care. The panchayati raj institutions have made a bit of difference, especially to women. It has empowered them. But there is a need for training and there is a need for devolution of power. Only then can there be accountability. What people want is control over their own jal, jameen aur jungle (water, land and forest). Shashi Yadav, a zilla parishad member from Haryana, argued that health and population are not priorities for panchayats. A person raising the issue of family planning is unlikely to win elections.
are no

Issues of water and sanitation are issues that concern women, not men. Panchayats are dominated by men who want roads and buildings, things that are visible. The PHC in their panchayat has been lying vacant for 10 years. There are no medicines in the government health system. Urban hospitals are only for the elite, for VIPs and politicians, not for the common people. Contraception is unsafe and supplies are irregular; MTP is not available free of cost in government institutions. So how can we talk of issues in population ? Tubectomy gives women freedom over their sexuality. This is why men oppose it. The values that govern are still feudal and patriarchal, and these first need to be opposed. The health care system will definitely improve if PRIs are given more powers and finances. But training and sensitisation of elected womens representatives are essential if they are to be empowered. Ghanshyam Shah argued that it is necessary to distinguish between the different votaries of decentralisation. The decentralisation of Gandhis dreams was to provide power to people with a decentralised economy with its heart in the village. The decentralisation of the World Bank is to be implemented within a centralised economy with major economic decisions being made in Washington. It is also important to be aware that a village is not a self-sufficient republic. Nor is it a homogenous community. The cautionary note introduced by Ambedkar into the discourse, therefore, is still relevant, with a larger framework to provide protection to minorities and the poor. When many states have not implemented the recommendations of the State Finance Committees to devolve finances to PRIs, how can they be expected to perform? A review of all discourse on decentralisation revealed that there was hardly any concern for the social sectors. The experience of Social Justice Committees (SJC) set up statutorily in Gujarat since 1976 is sobering. These are institutions at all

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levels, comprising SCs and STs, formed to protect the weaker sec-

empowered to veto panchayat decisions perceived to be their interests. A study in 1995 revealed that atrocities against dalits had increased over the period, but not one SJC had against even passed a resolution against this. What this reveals is the need for a larger process of politicisation that would strengthen these sections of the population and at the same time make these institutions

tions and


with regard to the NPP, what stands out, perhaps inadvertently,

is that the changed paradigm is not visible. PRIs have not been involved in planning, but are meant to implement it, although neither resources nor power is devolved on to them. What also stands out is that PRIs are to be assessed for their performance in family planning. If the ministry or the Population Commission is seriously concerned about correcting this image, what should be done is to send an unequivocal message that coercion under the programme, violating Fundamental Rights, is a cognisable offence. Similarly, awards for panchayats achieving family planning targets should be abolished; instead, they should be given to panchayats that provide safe drinking water, adequate coverage under PDS and bring down the IMR. Devaki Jain argued that an institutional framework is crucial for grounding any policy, be it benign or virulent. All too often while financial adequacies are emphasised, quite correctly, institutional adequacies are forgotten. Where PRIs are concerned, it seems to be something nobody wants: MPs, MLAs, bureaucrats, functionaries or donors. Academics do not support the scheme since they believe that the centre can be more radical than the

Where chief ministers of states have supported the scheme, they refer to an alternative structure of district governance that is not elected. Donors such as the World Bank do not really support the scheme since by and large they believe that it is inefficient and time consuming, as indeed democracy is. Usually, PRIs are supported only by residual arguments, namely, that there is no other option. It is thus necessary to highlight the positive arguments: that we need to set up this institutional framework to respond to Indias diversity, to press for equity, to have development involving the people.

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One reason for the neglect of PRIs is precisely the role advocated in policy documents for involving NGOs. But institutions like PRIs, trade unions and cooperatives are vibrant and democratic bodies. These can be supported by mahila samakhyas, NGOS, etc., without diminishing their central role. The 11 th Finance Commission has given us a sterling gift in recommending devolution of funds to these local bodies. Thus, democratic proximate governance should be supported. This is the level at which programmes, including health and family welfare, should be initiated and policy debates commenced. On behalf of the Population Commissions, Krishna Singh congratulated the participants for the breadth and richness of the discussions. Many of the concerns expressed were also shared by the government: that the health system is not working, that education has not reached marginalised communities, that inequalities are not being reduced, that women need empowerment, and so on. But no one begins with a clean slate, a tabula rasa. Aware that things are not perfect, equally aware that we have as a nation travelled a long distance, the agenda is to head towards where we want to take our country and how. One unmistakable fact is that demographic transition is under way and the Population Commission seeks to hasten this for the benefit of the poor and marginal communities. The Population Commission is not, however, an implementing body. It is a body meant to monitor and guide. It works through forging partnerships and consensus. Today, the states are increasingly asserting themselves, and the dictats of the centre will not carry unless there is dialogue to learn and support each other. The Population Commission is open to learning and

Plan of Action
There was consensus among the participants that it was necessary to initiate steps to ensure that the concerns expressed at the Colloquium would reach policy makers and the public, and mobilise strong support at all levels. At the heart of these concerns certain policy initiatives are non-negotiables. These include all policies of incentives and disincentives. Coercion in the programme, including any violation of human rights, must be made a cognisable offence. There is no scope for a two-child norm, or
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any such norm, in a pro-poor, gender-friendly population policy. The discrimination embedded in this norm is against the poor and the Scheduled Castes and Scheduled Tribes. These incentives and disincentives, which are hidden in the NPP, are more explicit and made worse in the population policies of various states. Since family planning is on the Concurrent List, the centre can play a pro-active role, influencing states to withdraw all such policy initiatives. Linking family planning performance to assessment of health workers and other such measures are explicit moves to bring targets into the programme. Similarly, moves to link funds to PRIs with family planning performance would not only be a hidden form of coercion, but would violate the important principles of decentralised democracy. Some other ideas seen as providing inputs to policy makers were that the Population Commission needs to look at itself as the Population and Social Development Commission, a name that had been considered by the Swaminthan Committee, to indicate its wider concerns with social sector development. Similarly, at the level of the states, a similar broadening of terms of reference needs to be advocated. There is a need for the Commission to broaden its ambit and constitute working groups on the following themes directly relevant to a pro-poor and gender-friendly population policy:

Working Group


Reproductive Technologies

and Sex

2. 3. 4. 5. 6. 7. 8. 9.

Working Group on Violation of Human Rights and Coercion. Working Group on Provision of Health and Social Security
for Scheduled Castes and Scheduled Tribes. Working Group on Ethics of Contraceptive Research. Working Group on Preparation of Textbooks and Training Material, and Advertisements. Working Group on Maternity Entitlements, Creches and Child Care. Working Group on Monitoring NGOs and the Private Sector. Working Group on Empowerment of Women. Working Group on Food Security.


If population policies are to be considered gender friendly, there no scope for the inclusion of long-acting, provider-controlled

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hormonal contraceptives into the programme. It is necessary that women are not visualised as merely breeders, mothers or sex objects. It is necessary that the Population Commission and its working groups be more widely accountable. People should be informed of the concerns and discussions in these groups. The Colloquium also decided that it was important to reach out to the media with the suggestions, as well as to the Human Rights Commission and Members of Parliament. It is necessary to organise similar dialogues and efforts to expand the knowledge base and advocacy focus at the state level, especially in states that have introduced coercive population policies. If the ministry and the Population Commission are keen on increasing the visibility of a changed paradigm, moving beyond population control, the issues of rights should be in the foreground of their concerns, suggestions and recommendations.

Government of Andhra Pradesh. 1997. Andhra Pradesh State Population Policy: A Statement and a Strategy. Hyderabad: Department of Medical, Health and Family Welfare. Government of India. 1980. Report of the Working Group on Population Policy. New Delhi: Ministry of Health and Family Welfare. 1993. Draft National Population Policy. New Delhi: Ministry of Health and Family Welfare. 2000. National Population Policy 2000. New Delhi: Ministry of Health and Family Welfare. Government of Madhya Pradesh. 2000. Population Policy of Madhya Pradesh. Bhopal: Department of Health and Family Welfare. Government of Maharashtra. 2000. Maharashtra State Population Policy: An Extract. Mumbai: Department of Health and Family Welfare. Government of Rajasthan. 1999. Population Policy of Rajasthan. Jaipur: Department of Family Welfare. Covernment of Uttar Pradesh. 2000. Population Policy of Uttar Pradesh. Lucknow: Department of Health and Family Welfare.
—. —.

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