1.INTRODUCTION

The subject matter of this project is: Progress of Family Planning Till the Eleventh Five Year Plan and Suggested Programs during the 11th Plan. The reasons for selecting this topic, the objectives and the methodology undertaken for this project are mentioned below:

REASONS

Population concerns have a long history in India. Until 1920, India's population had been growing very slowly owing to the heavy toll from famines, epidemics, and wars. According to census reports, the population of the country within its present geographical boundaries actually declined between l911 and 1921, from 252.1 to 251.3 million because of the high mortality inflicted by the influenza pandemic of l918-19. It is estimated that about 5 percent of the country's population - some 13 million persons - died in that epidemic. The population has increased steadily since l921, largely because of epidemic and famine control measures undertaken simultaneously with sanitation programmes by the provincial governments. Hence 1921 is considered as the demographic divide in India.

This trend was reflected in the coming years as well. The measures to control population were limited. They aimed on a provincial control of population rather than national control. However the trigger for specific policy and action at the national level came after the Bengal Famine in which 1.5million people died during 1943-1944.The report of the Bengal Famine Inquiry Committee constituted by the Government of India which submitted its report in l945 contained a chapter on the potential dangers to the economy and life of people arising out of rapid population growth, especially a population living in abject poverty and deprived of the bare necessities of life. Similarly, the Health Survey and Development Committee popularly called, the Bhore Committee, which was set up in l943 to make an assessment of the health conditions in India submitted its report in l946 and recommended a suitable health infrastructure for the country. It also stressed the need for a national programme of family planning for improving the health status of population. The reports of these two committees, the Bengal Famine Enquiry Committee and the Bhore Committee, one for sheer survival and the other for an improvement on the health of the population, paved the way for the Government of India to adopt a National Programme of Family Planning after attaining its political independence in l947

India became the first third world country to initiate a state-sponsored family planning program in 1951 to control its high population growth rate. Since its inception in 1951 the family planning program has passed through several ups and downs. A number of times population policies, goals, programs have been set up and management processes have been changed and revised. Now, into its 58th year it is important to know the achievements in the Family Planning Programme as well as the suggested programs in the present plan. Hence the writer has selected this topic.

OBJECTIVES:

This project is aimed at the following objectives:

  1. To understand the nature of family planning programmes in India
  2. To appreciate the achievements of Family Planning Programme in India till the 11th Five Year Plan

  3. To understand the suggested programs under the 11th Five Year Plan regarding Family Planning

  4. To analyse the suggested programs and examine their feasibility

  5. To understand the problems in the Family Planning Programme and the solutions suggested there under.

METHODOLOGY

The writer will be working on secondary data from reliable sources, preferably the original programmes drafted under the Five Year Plans, Official data from the Ministry of Health, Government of India, which gives a detailed report on the statistical data on various aspects of population and the facts and figures of the National Commission on Population. The writer will also be referring to scholarly articles, books and other works for knowing the views on the subject and other relevant data. A detailed lists of such works referred are provided in the Bibliography.

2.THE PROGRAMME OF FAMILY PLANNING

The policy of Family Planning was adopted by the Government in 1952. The aim of this policy was to reduce birth rates among the population. This was to be done through voluntary measures such as encouraging people to follow birth control measures or late marriages etc. and secondly by massive education programmes to achieve the objective. It was stated in the First Five Year Plan: “The rapid increase in population and the consequent pressure on the limited resources available have bought to the forefront the urgency of the problems of the family planning. All progress in this field depends first on creating a sufficiently strong motivation in favour of family planning in the minds of the people and next on providing the necessary advice and service based on acceptable efficient, harmless and economic methods.” With this view, the following objectives were set out in the First Five Year Plan as follows:

  1. To obtain an accurate picture of the factors which contribute rapid increase of population
  2. To gain fuller understanding of human fertility and the means of regulating it;
  3. To device speedy ways of education of the public
  4. To make family planning advice and service an integral part of the services in hospitals and health centres.

To implement the above objectives, the Family Planning Research and Program Committee was appointed. The Committee in turn set up two sub-committees, one socio-economic and cultural studies and other on biological and qualitative aspects of population.

After reviewing the progress made during the First Five Year Plan and in order to develop the continuous study of population problems on systematic lines, a national program with four main components was initiated in the Second Five Year Plan. They are:

  1. Education to create the background of contraceptive acceptance
  2. Service through rural and urban centres, including provision of sterilization facilities
  3. Training of personnel
  4. Research

A standing committee for coordination of population and vital statistics, consisting of representatives of ministries concerned, the Indian Statistical Institute and High Level Planning Boards were established both at the Centre and the States. The three Annual Plans (1966-1969) focused on population control programmes. This has been the cardinal feature of all Five Year Plans, starting from the Third to the Seventh. Consequently various schemes and methods for achieving the population control policies were spelt out.

The population policies formulated, and the national programmes of family planning implemented after independence went through a number of changes both in the intensity and modus operandi; can conveniently be classified into six phases as follows:

  1. Clinic Approach (1951-61);
  2. Extension Education Approach low intensity HITTS i.e. Health department operated, Incentive based, Target-oriented, Time-bound and Sterilization-focused programme model (1962-69);
  3. High intensity HITTS Approach (1969-76);
  4. Coercive approach (1976-77);
  5. Recoil and recovery Phase (1977-94); and
  6. Reproductive and Child Health Approach (since 1995)

These phases may be discussed in brief as follows:

1.The Clinical Approach (1951-1961)

This approach was prevalent in the first two five year plans. As an important component of the developmental strategy it sought to reduce the birth rates to the extent necessary to stabilize the population at a level consistent with the requirements of the national economy. A number of family planning clinics were opened throughout the country and it was assumed that there was already a strong desire to space and limit family size among the couples and if contraceptive services such as condoms, diaphragm and jelly, and vasectomy for men were offered in a clinic setting, it would be sufficient to reduce the birth rate. The first Five Year Plan of the country allocated a sum of Rs. 6. 5 million for this purpose, but most of it remained unspent.The main work during this period related to the establishment of family planning services, and to provide public education and the training of personnel. Some of the significant moves of the government during this period towards family planning programs were to set up, among others, a Contraceptive Testing Laboratory (now the Institute for Research in Reproduction) and a Central Family Planning Demographic and Training Research Center (currently known as the International Institute for Population Studies). In 1959, the government declared its support for all methods of family limitation including sterilization. The clinic approach was extended during the second plan period, 1956-61, increasing the number of clinics from 147 to 4165. The expenditure also increased further from 6.5 million in the First Plan to 21.6 million in the second.

2.Extension Education Approach low intensity HITTS model (1962-1969)

However the 1961 census showed a continued rise in the population growth rate and an increase in the fertility levels. As a reaction, for the first time in the country, a demographic goal was set in 1962, to reach a crude birth of 25 by 1972. Since then reduction in fertility levels was the sole objective of the Indian population policy until the early eighties. In this model, incentives were offered to those who accepted vasectomy and intra-uterine devices. The approach became more grass root in the sense that the family planning workers were asked to make house to house visits to motivate couples to accept family planning methods. This phase thus marked the beginning of the long spell of the controversial vasectomy program.

Another major development in this period was that in the center, a separate department of family planning was set up and the departments of health in the states were renamed, over time as Departments of Health and Family Planning. Family planning programme was fully funded from the central funds with methods of functioning formulated by them. With the setting up of demographic goals, state by- state, district-by-district, for the programme, achievement of these goals was made the responsibility of the health departments through recruitment of a targeted number of contraceptive acceptors. The programme became entrenched in a HITTS model: i.e., Health department operated, Incentive based, Target-oriented,

Time-bound and Sterilization-focused programme.The year 1962 was the beginning of the HITTS approach, which lasted until 1977 with varying degrees of emphasis on each of its components of involvement of health functionaries, change of incentives, targets and the time frame for achievement of targets. Vasectomy came to be regarded as the main point for fertility regulation.

Despite looking good on paper, the program failed on account of unrealistic targets. The target thus required revision. Consequently a new approach was formulated.

3.High intensity HITTS Approach (1969-1976)

The Extension Education Approach could not meet the expected targets. Sample surveys done in the late ‘sixties in different parts of the country revealed that the birth rate was not declining but on the other hand was even rising in some areas. There was frustration building up in many quarters that the population growth rates were not declining and the 1971 census confirmed these fears. High population growth was considered as one of the key factors responsible for retarding the economic development of the country in spite of increased investments in the five-year plans. So the new approach was formulated.

Vasectomy camps were organized as part of this approach. However, apart from the involvement of health officials, police and revenue officials were also involved giving a coercive nature to the programme. The socio-political conditions forced for a change in this approach in the mid of 1970s.

4.Coercive approach (1976-77)

This approach was during the Emergency era from 1975-1977. The rights of the individuals were suppressed. The Government at the centre assumed authoritarian powers over the individuals and the State Government. For the first time a National Population Policy was formulated and adopted by the Parliament in April 1976 which called for a ‘frontal attack on the problems of population' and which inspired the state governments to ‘pass suitable legislation to make family planning compulsory for citizens' and to stop child bearing after three children, if the ‘state so desires'. The legal minimum age of marriage was increased from 15 to 18 years for females and 18 to 21 years for males. A long-term demographic goal was adopted by the country to reduce the Net Reproduction Rate (NRR) to one, Total Fertility Rate (TFR) to 2.3 and the crude birth rate to 21 by 2000. The publication of this population policy greatly helped to highlight and increase family planning activities in general. At the same time, the government also enunciated a 20-point program for its socio-economic development where the promotion of Family Planning programs has been one of its objectives.

Many other measures were introduced such as stipulations to government officials in the health and revenue departments to recruit given numbers of vasectomies from their areas of operation, failing which punishments were to be meted out to them. Various coercive tactics were used to control the fertility levels, mainly though increased number of vasectomies.

The incentive payments to acceptors was substantially increased and related on a sliding scale to the number of living children a couple had at the time of accepting sterilization.

Innovative political and fiscal incentives were offered by center to the state governments to implement the family planning programme very seriously. Laws, which made it compulsory for couples to stop reproduction after two or three children, were beginning to be drafted and placed before state legislatures in Maharashtra and other states for enactment.

Forceful sterilization was conducted in Bihar and Uttar Pradesh. These excesses were brought to light after the Emergency and there was massive public agitation against it. For e.g. the number of sterilizations done in India during April 1976 to March 1977 was 8.26 million, more than the total number done in the previous five years and more than the number done in any other country in the world until that time.

5.Recoil and Recovery Phase (1977-1994)

The strong impetus and vigor that the program had acquired was marred by overkill in some places, mostly in Northern India. The outcry raised by politicians and others politicized the program as an election issue and it became a major cause for the ruling party losing the election. After the Emergency, the first non-Congress government came into power. The new government changed the name of ‘family planning' to ‘family welfare', reduced the targets on sterilization and chose to achieve demographic change through a programme of education and motivation. This new policy was hardly any di仔erent from the previous one, except putting extra emphasis on a purely voluntary basis. In spite of its efforts, the program was not able to pick up momentum till the end of the seventies. Consequently, the percentage of couples protected, which had risen to 23. 5 per cent in 1976-77 fell to 22.4 per cent in 1978-79 and to 22. 3 percent in the following year. In 1980-81 it again reached 23. 7 percent (estimates based on the 1981 Census).

A judicial commission was appointed to enquire into the wrong doings during the emergency period including forced sterilizations. Consequently, the family planning program almost collapsed and less than a million sterilizations (one-eighth of the previous year was performed during 1977-78). A revised Population Policy adopted in l977 was totally against compulsory sterilization and legislation of any kind towards that end and stated that compulsion in the area of family welfare must be ruled out for all times to come and “Our approach is educational and wholly voluntary”. The 1977 policy was welcomed as a type of liberation for the expression of individual opinions and attitudes on family size and freedom of choice of contraceptive methods to be used by couples. The new government enacted into law the proposal by the earlier government, the policy of raising the minimum age at marriage of 18 for girls and 21 for boys which came into operation in October 1978. This laxity was responsible for the increasing population. The change of government again in January l980 marked a turning point and helped to restore the family planning programme garbed as family welfare programme.

The emphasis on sterilizations continued though on a voluntary nature. The Sixth (1980-85), Seventh (1985-90) and the Eighth plans (1990-95) viewed demographic goals from a wider perspective. It was realized that a desired birth rate could not be achieved without concomitant improvements in the conditions of the standard of living, especially infant and child mortality. During the revised sixth Five Year Plan, l980-85, a Working Group of Population Policy was set up by the Planning Commission to formulate long-term policy goals and programme targets for family welfare programmes. The long term demographic goals were revised in terms of achieving Net Reproduction Rate (NRR-1) by the year l996 for the country as a whole on an average, and by the year 2001 in all the states. Targets were redefined and the policy, which aimed to achieve a NRR of unity by the year 2000 shifted to 2006-2011. The National Health policy of 1983 emphasized the need for "realizing the small family norm through voluntary efforts and moving towards the goal of population stabilization" and reiterated India's commitment to attain a status of ‘Health For All' by 2000 A.D.

These goals are yet to be realized. These goals were translated into achieving a crude birth rate of 21, a crude death rate of nine, infant mortality rate of 60, expectancy of life at birth of 64 years and contraceptive prevalence rate 60 percent among eligible couples by modern methods of family planning to be achieved in all the states by the year 2000. The health-based, time-bound target-oriented family planning programme was revived with reduced emphasis on sterilization and greater emphasis on spacing methods and on child survival programmes. However, the post-emergency collapse of the family planning programme could never be revived fully in the subsequent years, especially in terms of acceptance of vasectomy by men, as a good method of family planning.

6.Reproductive and Child Health Approach (Since 1995)

This approach came in the middle of the Eighth Five Year Plan (1992-1997). There are many reasons responsible for this approach. Some of the major ones are as follows:

1. Firstly

, the passing of 73rd and 74th constitutional amendments and enactments of Panchayat Raj and Nagar Palika Acts setting in motion the process of democratic decentralization. The primary health care including family planning, primary education and provision of certain basic amenities to the people such as drinking water and roads became the responsibility of the panchayat's.This democratic decentralization infringed the powers of state government to impose any strong family planning programme through its Primary Health Centers and Sub-Centers.

2. Secondly

, the organized intensification and expansion of the women's movements within the country and outside, questioned the policies and directions of the government with regard to role of governments on their reproductive rights, and the organized national family planning programmes in which women had to shoulder major responsibilities for fertility regulation and demographic transition. Setting up fertility goals and related family planning targets by the governments were considered as an infringement on human rights, women's rights and especially on their reproductive rights. All family planning were ultimately targeting woman, for e.g. preponderance of female sterilizations as the dominant method of family planning in the country, was regarded as an infringement on their fundamental right. Thus family planning programme landed itself in a dilemma where it could neither achieve its demographic goals of low fertility and population stabilization nor withdraw from such a programme in the context of a continuing rise in the yearly additions to its population.

3.Thirdly

, the economic liberalization of the Indian economy and the society had its impact on the population policies and programs in the country. The launch of the National Family Health Survey program in 1991-92 was one step in this regard.

4. Fourthly,

the International Conference on Population and Development (ICPD) at Cairo in 1994 also played a significant role in the New Population Policy. The Programme of Action formulated at the end of the Conference and for which India is a signatory, postulated that population policies should be viewed as an integral part of programmes for women's development, women's rights, women's reproductive health, poverty alleviation and sustainable development. They argued that, henceforth, population policies should not be viewed with the sole concern of reductions in fertility rates considered desirable by planners and demographers, but by considerations of reproductive health, reproductive rights and gender equity. The Government of India, which was a signatory to ICPD Programme of Action, promptly followed up on the recommendations by abolishing the acceptor based family planning targets since April 1995, in the country as a whole.

5. Fifthly,

The Government of India appointed in July 1993 an Expert Group chaired by Dr. M.S. Swaminathan, an eminent agricultural scientist, for drafting a National Population Policy. The Expert Group submitted its report in May 1994. This report contains some basic directional shifts in the goals of population stabilization programs, organizational modifications at various levels and setting up of new institutions, for effective programme implementation. It has also a number of popular clichés such as it is ” pro-nature, pro poor and pro-women “ in its direction and thrust that the population program should move from negative to positive goals: that population growth is depleting non-renewable natural resources, especially the underground water at an exponential pace and if not checked in time, can lead to serious deficiencies of water in the country; it is assumed that development that is not equitable is not sustainable; and that gender equity is essential for development and is an integral component of development itself. Only broad goals were set for achieving reductions in selected demographic parameters by the year 2010, such as in the TFR values from the existing level to 2.1, IMR to less than 30, maternal mortality rate to less than 100 per 100,000 live births, negligible incidence of marriage below age 18 for girls, and rapid improvements on a number of other social indicators such as female education, abolition of child labour, and accessible quality primary health care. The further deliberation on this report led to the drafting of the National Population Policy of 2000.

Since 1997, officially, the Reproductive Health Approach has been adopted as the national policy of the Government of India. The official RCH programmes include the conventional maternal and child health services including immunization of children, contraceptive services to couples, treatment of reproductive tract infections (RTIs) and sexually transmitted diseases, provision of reproductive health education and services for adolescent boys and girls, and screening of women near menopausal age for cervical and uterine cancer and treatment, if were required. The budget required for these additional services, intended to be covered under reproductive health are quite high, but only about the same amount allocated in the earlier years for the programme has been allocated. It was feared that the emphasis on contraceptive services would get diluted when budgets are not adequately increased to cover the wider goals of RCH programmes. Population concerns go beyond reproductive health, though the latter is an important contributing factor for population stabilization.

3.THE RECENT POLICIES

At present three policies exist in the country that has direct impact on population issues and availability of family planning services. They are:

  1. National Population Policy 2000 (NPP 2000),
  2. National Health Policy (NHP 2002)
  3. National Rural Health Mission (NRHM 2005)

These policies need to be understood so as to appreciate the suggested programs on family planning in the 11th Five Year Plan.

1.National Population Policy

National Population Policy was announced in February 2000, after almost 6 years of preparation and discussion. Since 1994, after ICPD, innumerable discussions were held on the appropriate population policy by various committees set up by the Planning Commission for a revised population policy for the country. The two important demographic goals of the National Population Policy (2000) are: achieving the population replacement level (TFR 2.1) by 2010 and a stable population by 2045. The National Population Policy envisages the following socio-demographic goals to be achieved by 2010.

  1. Address the unmet needs for basic reproductive and child health services, supplies and infrastructure.
  2. Make school education up to age 14 free and compulsory, and reduce dropouts at primary and secondary school levels to below 20 percent for both boys and girls.
  3. Reduce infant mortality rate to below 30 per 1000 live births.
  4. Reduce maternal mortality ratio to below 100 per 100,000 live births.
  5. Achieve universal immunization of children against all vaccine preventable diseases.
  6. Promote delayed marriage for girls, not earlier than age 18 and preferably after 20 years of age.
  7. Achieve 80 percent institutional deliveries and 100 percent deliveries by trained persons.
  8. Achieve universal access to information/counseling, and services for fertility regulation and contraception with a wide basket of choices.
  9. Achieve 100 percent registration of births, deaths, marriage and pregnancy.
  10. Contain the spread of Acquired Immunodeficiency Syndrome (AIDS), and promote greater integration between the management of reproductive tract infections (RTIs) and sexually transmitted infections (STIs) and the National AIDS Control Organization.
  11. Prevent and control communicable diseases
  12. Integrate Indian Systems of Medicine (ISM) in the provision of reproductive and child health services, and in reaching out to households.
  13. Promote vigorously the small family norm to achieve replacement levels of TFR.
  14. Bring about convergence in implementation of related social sector programmes so that family welfare becomes a people-centered programme.

The National Population Policy, 2000 affirms the commitment of government towards voluntary and informed choice and consent of citizens while availing of reproductive health care services, and continuation of the target free approach in administering family planning services. The NPP 2000 provides a policy framework for advancing goals and prioritizing strategies during the next decade, to meet the reproductive and child health needs of the people of India, and to achieve net replacement levels (TFR) by 2010. It is based upon the need to simultaneously address issues of child survival, maternal health, and contraception, while increasing outreach and coverage of a comprehensive package of reproductive and child health services by government, industry and the voluntary non-government sector, working in partnership.

2.National Health Policy

The setting down of NHP-2002 was based on an objective assessment of the quality and efficiency of the existing public health machinery in the field.. For the outdoor medical facilities in existence, funding is generally insufficient; the presence of medical and para-medical personnel is often much less than that required by prescribed norms; the availability of consumables is frequently negligible; the equipment in many public hospitals is often obsolescent and unusable; and, the buildings are in a dilapidated state. In the indoor treatment facilities, again, the equipment is often obsolescent; the availability of essential drugs is minimal; the capacity of the facilities is grossly inadequate, which leads to over-crowding, and consequentially to a steep deterioration in the quality of the services. As a result of such inadequate public health facilities, this policy was formulated.

The main objective of this policy is to achieve an acceptable standard of good health amongst the general population of the country. The approach would be to increase access to the decentralized public health system by establishing new infrastructure in deficient areas, and by upgrading the infrastructure in the existing institutions. Overriding importance would be given to ensuring a more equitable access to health services across the social and geographical expanse of the country. Emphasis will be given to increasing the aggregate public health investment through a substantially increased contribution by the Central Government. It is expected that this initiative will strengthen the capacity of the public health administration at the State level to render effective service delivery. The contribution of the private sector in providing health services would be much enhanced, particularly for the population group which can afford to pay for services. Primacy will be given to preventive and first-line curative initiatives at the primary health level through increased sectoral share of allocation. Emphasis will be laid on rational use of drugs within the allopathic system. Increased access to tried and tested systems of traditional medicine will be ensured. Within these broad objectives, NHP-2002 aims at the following goals:

Eradicate Polio and Yaws

2005

Eliminate Leprosy

2005

Eliminate Kala Azar

2010

Eliminate Lymphatic Filariasis

2015

Achieve Zero level growth of HIV/AIDS

2007

Reduce Mortality by 50% on account of TB, Malaria and Other Vector and Water Borne diseases

2010

Reduce Prevalence of Blindness to 0.5%

2010

Reduce IMR to 30/1000 And MMR to 100/Lakh

2010

Increase utilization of public health facilities from current Level of 20 % to75%

2010

Establish an integrated system of surveillance, National Health Accounts and Health Statistics.

2005

Increase health expenditure by Government as a % of GDP from the existing 0.9 % to 2.0%

2010

Increase share of Central grants to Constitute at least 25% of total health spending

2010

Increase State Sector Health spending from 5.5% to 7% of the budget

Further increase to 8%

2005

2010

However, the sad part of the policy was that it did not receive much attention and consequently it was deemed to be a failure.

3.National Rural Health Mission

The National Rural Health Mission 2005 was launched by the Hon'ble Prime Minister Manmohan Singh is a departure from the earlier policy and plan documents in two aspects. First, it takes the programme in a “Mission Mode” probably encouraged by the success of the earlier missions such as the Technology Mission. Secondly, more importantly, it is not obsessed by the desired goals of impact but rather it focuses on inputs, strategies and programmes to be done, and leaves the ultimate impact as an outcome of what is done. This is a more realistic approach for the improvement of the health of the people. Thus, its major thrust is on health. The Mission adopts an approach emphasizing on health and determinants of good health such as segments of nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming the Indian systems of medicine to facilitate health care. The Plan of Action includes increasing public expenditure on health, reducing regional imbalance in health infrastructure, pooling resources, integration of organizational structures etc. Its main goals are as follows:

  1. Reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR)
  2. Universal access to public health services such as Women's health, child health, water, sanitation & hygiene, immunization, and Nutrition.
  3. Prevention and control of communicable and non-communicable diseases, including locally endemic diseases
  4. Access to integrated comprehensive primary healthcare
  5. Population stabilization, gender and demographic balance.
  6. Revitalize local health traditions and mainstream Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy (AYUSH)
  7. Promotion of healthy life styles.

Unlike the National Health Policy of 2002, this programme has been well received. Funds have been adequately provided for this program by the Central government from time to time.

4.SUGGESTED PROGRAMS IN THE ELEVENTH FIVE YEAR PLAN

India is in the middle of demographic transition. Both fertility and mortality have started declining throughout the country, though the pace and magnitude of the decline varies considerably across the states. Like many countries of the world, the onset of mortality decline preceded the onset of fertility decline by few decades. The country has witnessed significant improvements in demographic and health indicators since Independence. But an accurate assessment of India's demographic achievements is hampered by data deficiencies, particularly for the period before the 1970s.The official estimates of fertility and mortality levels at the time of independence are believed to be gross underestimates. Nonetheless, even they suggest significant achievements in this field. The crude birth rate, which was officially put at 42 per 1,000 in 1951-61, has declined to 24 in 2004, as per the estimates. Life Expectancy has doubled from 32 to 64 in the period of 1951 to 2004. Infant Mortality Rate has come down from about 150 in 1951 to 58 by 2004. It is in light of these demographic achievements and the policies mentioned earlier, the family planning chapter in the Eleventh Five Year Plan was drafted.

In this context, the Working Group on Population Stabilization for the Eleventh Plan (2007-2012) was constituted by Planning Commission under the chairmanship of Secretary, Health & Family Welfare. The Group has the following functions:

  1. Review the current demographic projections for the 11th Plan and beyond: the time by which the country's population is likely to stabilize; and to review the goals indicated in the National Population Policy (NPP), 2000.
  2. Suggest strategy for achieving population stabilization as early as possible keeping in view the current mortality, fertility & couple protection rates in different states; fixation of state wise goals for the 11th Plan & individual years for birth rate, IMR, couple protection rates, immunization, antenatal, intra partum, neonatal & child health care, etc.
  3. Assess the current status and future requirements (short, medium & long-term) of demographic, bio-medical, social and behavioural research aimed at meeting the felt needs for health care of women and children, adolescents and aged during the 11th Plan.
  4. >
  5. Project financial implications for implementation of family welfare programme during 11th Plan including the plan and non-plan requirements; and the Centre- State participation in the funding.
  6. To deliberate and give recommendations on any other matter relevant to the

The emphasis is on health and its related aspects and hence thrust has been to National Rural Health Mission. Equal importance is also given to National Population Policy (NPP). The expected level of achievement is as follows:

  1. Although the actual impact of the forgoing strategies to reach population stabilization is difficult to predict, if effectively perused, they should able to bring down the birth rate faster than what is projected by the Technical Group on Population Projections.

  2. Through these measures, it is anticipated that Total Fertility Rate (TFR) would reach replacement if not by 2010, by 2015 - roughly by five years earlier than that projected by the Technical Group.
  3. By the end of the Eleventh plan, at the all-India level, crude birth rate (CBR) is expected decline from 24 in 2004 to 19.
  4. Couple Protection Rate (CPR) to increase from 53 percent in 2002-04 to 64 percent. It is expected that the increase in CPR would result from reducing the unmet need for contraception by half, i.e., from 21 percent to 11 percent.
  5. Universal access to public health services such as women's health, child health, water, sanitation & hygiene, immunization and nutrition.
  6. Prevention and control of communicable & non-communicable diseases, including locally endemic diseases.
  7. Access to integrate comprehensive primary health care.
  8. Apart from the achievement of these statistical targets, emphasize is also on the statistical targets sought to be achieved by the National Population Policy and National Health Mission.

POPULATION PROJECTION

The Technical Group on Population Projections set up by the National Commission on Population has come out with population projections for India and states. As per this report, India's population is expected to reach 1.2 billion by 2011 and 1.4 billion by 2006. According to this projection, population would grow by 1.4 percent during the Eleventh Five-Year Plan period, more precisely during 2006-11. Even by 2021-26, the population is expected to have a growth rate of 0.9 percent. An important assumption underlying this projection is that the total fertility rate would reach replacement level approximately 2.1 only by 2021. The reason behind this gloomy expectation is the slow pace of fertility transition in several large, north Indian states. In fact, according the Technical Group, Total Fertility Rate would not reach the replacement level in some of these states even by 2031. Although the Technical Group did not carry forward the projection till the date of stabilization, the projected delay in reaching the replacement-level fertility would imply that India's population would not stabilize before 2060, and until population size nears 1.7 billion.

To conclude, the following recommendations were made by the Working Group on Population Stabilisation:

  1. Despite five decades of effort to promote the use of family planning methods, a large percentage of couples report unmet need for contraception. If this unmet need could be met, population stabilization goal would be achieved. Even meeting half of the unmet need could make significant dent on the birth rate. ANMs and ASHAs could be asked to identify the couples with unmet need in their area, and address their concerns. As more than half of the unmet need is for limiting family size, meeting the unmet need would call for significant expansion of sterilization services, especially in the large north Indian states, although the NHRM launched by the Government of India acknowledged this issue.
  2. India's Family Welfare programme placed heavy emphasize on sterilization as the major method of family planning. Many other Asian countries started their family planning programmes with spacing methods and then gradually introduced sterilization. Providing sterilization services requires well-trained medical personnel and well-equipped facilities. A permanent method may not be preferred when levels of infant and child mortality are high, or because of religious beliefs. Therefore, sterilization should be the last resort than the first one in the contraceptive choices given to the public. So there is a need to expand the range of choices of contraceptives as well as to improve the quality of services provided to couples, both in rural and urban areas.
  3. There is an urgent need to restructure the existing PHCs and SCs. Does it make sense to have the same number of ANMs per population in every state, given that birth-rates differ considerably from state to state? Whether the Government has the capacity and funds to adequately maintain and to operate the current level of infrastructure? How best we can attract qualified doctors to government health care institutions in rural areas. Answers to such persisting questions should be immediately found within the framework of NHRM. Some successful experiments made to address these concerns should be carefully looked into for implementation at a wider scale.
  4. There is a need for specially focusing on poorly performing districts based on the available data from the DLHS and Facility Surveys. To bridge the gap in essential health infrastructure and manpower, state should have a more flexible approach. Care should be taken to ensure the uninterrupted supply of essential drugs, vaccines and contraceptives of required quality and quantity to all the CHCs, PHCs and SCs.
  5. The Panchayati Raj Institutions should play a bigger role in the supervision and monitoring of PHCs. In most states the PRI involvement is not very effective mainly because the health management committees are not functioning or not representing the poor. Even when the health committees are active they have no authority over medical and paramedical personnel. In many cases, there is the need to develop better co-ordination mechanism between local self governments and health care institutions. It is necessary to orient the PRI members about their roles and responsibilities in providing better public health services as well as the need for assigning top priority to health issues among the activities of the PRIs. Although the NRHM Framework for implementation approved by the Union Cabinet specifically addresses this issue, the challenge lies in its implementation.
  6. Concerted efforts are necessary to improve the coverage and quality of registration of births, deaths, marriages and pregnancies. A motivated ANM, Anganwadi Worker or ASHA can play an important role in this regard. The responsibility of ensuring the complete registration can be entrusted to the local bodies with clear-cut guidelines.
  7. Strict enforcement of the Child Marriage Restraint Act, 1976, implying prevention of marriages of girls and boys below the legally permissible ages of
  8. 1. 18 and 21, respectively, would facilitate not only reduction of high risk teenage pregnancies but also help in human resource development amongst these younger girls and boys during their formative years towards improvement in the quality of life in the long run. The Group recommends a national campaign against Child Marriages, sex selection against the girl child & for promoting institutional delivery by the Central & State Governments.

  9. Focused attention on antenatal and institutional delivery care would help towards reduction in neo-natal component of infant mortality as well as maternal mortality, which in turn has externalities towards better acceptance of the family welfare program interventions and thus accelerate the process of fertility transition and population stabilization.
  10. To improve the operational efficiency of the programmes, the Health
  11. 2. Management Information System (HMIS) needs to be strengthened. The timely and accurate information gives the health managers the ability to monitor inputs and outputs of the system and help them to assess the costs and returns from various procedures. In many cases, measuring performance and distributing that information will automatically provide certain incentives for the service providers to perform.

  12. The success of the Family Welfare Programme depends to a great extent on the personnel working in various institutions. Regular in-service training to enhance their knowledge and skills and to familiarize them with the new programmes should become a part of regular activity of the health department. They should also be in a position to develop local level health plans taking into account the health conditions of the people and their requirements.
  13. It is important to periodically assess the utilization of health services and customer satisfaction. Regular surveys, both for clients as well as for health care providers are to be undertaken. The findings from these periodic surveys should provide feedback to the health department as well as to the local bodies.

These recommendations have accordingly been incorporated in the 11th Five Year Plan and are in motion.

5.CONCLUSION

India's successive five-year plans have provided the policy framework and funding for the development of nationwide health care infrastructure and manpower. In

1951, India became the first country in the world to launch a family planning programme to check the population growth. Since then, the family planning programme in India has undergone variety of forms. The passive, clinic-based approach of the 1950s, gave way to a more proactive, extension approach in the early 1960s. The late 1960s saw the emergence of a "time-bound", “target-oriented" approach with a massive effort to promote the use of IUDs and condoms. This was followed by even more forceful "camp approach" to promote male sterilization in the 1970s. The excesses of these campaigns lead to a severe backlash from which it took years for the programme to recover. After re-christened as Family Welfare Programme in 1978, maternal and child health services began to receive greater attention under the programme's plan of action. The centrally funded programme has been providing the states additional infrastructure, manpower and consumables needed for the delivery of services. In the 1990s, Government of India began to reorient the programme in the light of changing economic context and subsequent to international concern of population increase.

Despite five decades of effort to promote the use of family planning methods, a large percentage of couples report unmet need for contraception. If this unmet need could be met, population stabilization goal would be achieved. Even meeting half of the unmet need could make significant dent on the birth rate. India's Family Welfare programme placed heavy emphasize on sterilization as the major method of family planning. Many other Asian countries started their family planning programmes with spacing methods and then gradually introduced sterilization. Providing sterilization services requires well-trained medical personnel and well-equipped facilities. A permanent method may not be preferred when levels of infant and child mortality are high, or because of religious beliefs. Therefore, sterilization should be the last resort than the first one in the contraceptive choices given to the public. So there is a need to expand the range of choices of contraceptives as well as to improve the quality of services provided to couples, both in rural and urban areas. There is an urgent need to restructure the existing PHCs and SCs. The success of the Family Welfare Programme depends to a great extent on the personnel working in various institutions and the stricter implementation of associated programs.

The future course of fertility transition in the country, no doubt, may depend on the performance of the four large Hindi speaking northern states of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh (inclusive of three newly formed states of Jharkhand, Chhattisgarh and Uttaranchal) as these states together account for nearly 40 percent of the country's total population. These states lag behind considerably on various social and economic development indicators, and as a consequence not only is the rate of fertility relatively higher in these states, but the changes in these states also appear to be at a slower pace. This has drawn special attention from social scientists, policy makers and planners of the country and other international agencies.

Many of the goals set have not been achieved on time. For example the goal of 30 births per 1000 has not yet reached and it still continues to be 32 per thousand. This is because of socio-economic and religious factors, which the government is unable to pierce through. Family control programmes cannot succeed by governmental methods alone but by educating the people about the advantages of having small families. It is on these aspects that family planning programmes focus more into so as to achieve the demographic goals.

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