Tuesday, August 25, 2009

Stabilising India’s Popualtion

Dr. Prema Ramachandran
Adviser, Health, Planning Commision


India, the second most populous country in the world, has no more than 2.5% of global land but is the home of 1/6th of the world's population. The prevailing high maternal, infant, childhood morbidity and mortality, low life expectancy and high fertility and associated high morbidity had been a source of concern for public health professionals right from the pre-independance period. The Bhore Committee Report (1946) which laid the foundation for health service planning in India, gave high priority to provision of maternal and child health services and improving their nutritional and health status. It is noteworthy that this report which emphasized the importance of providing integrated preventive, promotive and curative primary health care services preceded the Alma Ata declaration by over three decades. Under the Constitution of India elimination of poverty, ignorance and ill health are three important goals. Successive Five Year Plans have been providing the policy frame work and funding for planned development of nationwide health care infrastructure, manpower, drugs, devices and other essential items for improving health status of mothers and their children

In 1951, the infant republic took stock of the existing situation in the country and initiated the first Five Year Development Plan. Living in a resource poor country with high population density, the Planners recognised in the census figures of 1951, the potential threat posed by population explosion and the need to take steps to avert it. It was recognised that population stabilisation is an essential prerequisite for sustainability of development process so that the benefits of economic development result in enhancement of the well being of the people and improvement in quality of life. India became the first country in the world to formulate a National Family Planning Programme in 1952, with the objective of “reducing birth rate to the extent necessary to stabilise the population at a level consistent with requirement of national economy”. Thus, the key elements of health care to women and children and provision of contraceptive services have been the focus of India’s health services right from the time of India’s independence. Successive FiveYear Plans have been providing the policy framework and funding for planned development of nationwide health care infrastructure and manpower. The Centrally Sponsored and 100% centrally funded Family Welfare Programme provides additional infrastructure, manpower and consumables needed for improving health status of women and children and to meet all the felt needs for fertility regulation.

Achievements of the Family Welfare Programme

Basic premises of the Family Welfare Programme are:

Acceptance of FW services is voluntary
FW programme will provide :
Integrated Maternal and Child Health (MCH) & FP services
Ensure easy and convenient access to FW services free of cost
Effective IEC to improve awareness
Major Achievements of FW Programme are:

Reduction in Crude Birth Rate (CBR) from 40.8 (1951 Census) to 27.2 in 1997 (SRS 97)
Reduction in Infant Mortality Rate (IMR) from 146 in 1951 to 71 in 1997 (SRS 97),
Increase in Couple Protection Rate (CPR) from 10.4% (1970-71) to 45.4% on 31.3.1998 (Dept of Family Welfare)
The National Family Health survey (1992-93) indicated that

There is universal awareness about contraception
40.6% of currently married women use contraceptives
Wanted fertility is lower than the actual fertility
There is a large unmet need for contraception: -
11.0% for birth spacing methods and
8.5% for terminal methods
Lessons learnt during implementation of FW programme:

Governmental network provides most of the MCH and contraceptive care
Adequate financial inputs and health infrastructure are essential prerequisites for the success of the programme
Providing efficient and effective integrated MCH and contraceptive care helps in building up rapport with the families
IEC activities are powerful tools for achieving the small family norm;
The population is conservative but responsible, responsive and mature; their response is slow but rational and sustained
Population Growth

Over the last four decades there has been rapid fall in Crude Death Rate (CDR) from 25.1 in 1951 to 9.8 in 1991 and less steep decline in the Crude Birth Rate (CBR) from 40.8 in 1951 to 29.5 in 1991. As a result, the annual exponential population growth rate has been over 2% in the last three decades. During the Eighth Plan period the decline in CBR has been steeper than that in the (CDR) and consequently, the annual population growth rate has been around 1.9% during 1991-95.

The rate of decline in population growth is likely to be further accelerated during the Ninth Plan period. Though the decline in CBR and CDR has occurred in all States, the rate of decline in CBR was slower in some States like U.P. and Bihar.

There are substantial differences in CBR and IMR between States (Figure 3 and 4) and even within the same State there are substantial differences between districts .

Population Projections and their implications to FW programme

The population of the country was 846.3 million in 1991 as recorded in the census.

As per projections made in the Report of the Technical Group on Population Projections the estimated population in the census years 2001 and 2011 will be 1012.4 million and 1179 million respectively. There are major differences between states with regard to their current population size as well as their potential to contribute towards the increase in the population of the country during 1996-2016 (Figure-5,6)

The five states of Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan and Orissa, which constitute 44% of the total population of India in 1996, will constitute 48% of the total population of India in 2016 (Figure-6). These states will contribute 55% of the total increase in population of the country during the period 1996-2016 (Figure-7). The progresss in these states would determine the year and size of the population at which the country achieves population stabilisation. In all the states performance in the social and economic sector has been poor. The poor performance is the outcome of poverty, illiteracy and poor development which co-exist and reinforce each other. Urgent energetic steps are required to be initiated to assess and fully meet the unmet needs for maternal and child health (MCH) care and contraception through improvement in availability and access to family welfare services in the states of UP, MP, Rajasthan and Bihar in order to achieve a faster decline in their mortality and fertility rates. The performance of these states would determine the year and size of the population at which the country achieves population stabilisation.

Population Projection– implications to the FW Programme

There will be massive increase of population in the 15-59 age group (from 500 million to 800 million) in just twenty years (Figure). The RCH care has to provide the needed services for this rapidly growing clientele. Along with the demographic transition, there is concurrent ongoing socioeconomic, educational, information technology transition. The population in this age group will therefore have greater awareness and expectation regarding both the access to a wide spectrum of health care related services and the quality of these services. The Family Welfare Programme has to provide the wider spectrum of health care needs of this population – including maternal and child health care, contraceptive care, management of gynaecological problems, STD/RTI/HIV management and control; quality of services need also be improved. Increasing number of the population beyond 60 years would necessitate provisions for management of some of the major health problems in this age group including management of cancers.

The number of births will not alter substantially over the next two decades; this respite from increasing numbers should be utilised to provide improved access to high quality of services so that there is reduction in the current high IMR and MMR. This in turn might lead to a fall in the current high desired level of fertility. If the birth rate continues to decline at the present rate, replacement level of fertility will not be achieved till 2026. In view of the serious implications of this, efforts should be made to meet all the felt needs for contraception and achieve a more rapid decline in birth rates

Policy and strategy for achievement of rapid population stabilisation

The current high population growth rate is due to:

the large size of the population in the reproductive age-group (estimated contribution 60%);
higher fertility due to unmet need for contraception (estimated contribution 20%); and
high wanted fertility due to prevailing high IMR (estimated contribution about 20%).
Unmet needs for health and contraceptive care exist in all regions and all segments of the population irrespective of religion, caste, education and income status.

The objective of the Population policy is to achieve rapid reduction in the population growth rate by :

meeting all the felt-needs for contraception; and
reducing the infant and maternal morbidity and mortality so that there is a reduction in the desired level of fertility so that the country achieves replacement level of fertility by 2010.
The country’s medium and long term efforts will be focussed on bringing about an accelerated convergence of ongoing demographic, socio-economic, educational and information technology transitions, enable the increasingly literate and aware families to achieve their reproductive goals, and the country to achieve rapid population stabilisation, sustainable development and improvement in quality of life.

The strategies for achieving these objectives will be:

To assess the needs for reproductive and child health at PHC level and undertake area- specific micro planning; and
To provide need-based, demand-driven high quality, integrated reproductive and child health care.

The Family Welfare Programme will be directed towards:

Bridging the gaps in essential infrastructure and manpower through a flexible approach and improving operational efficiency through investment in social, behavioural and operational research
Providing additional assistance to poorly performing districts identified on the basis of the 1991 census to fill existing gaps in infrastructure and manpower.
Ensuring uninterrupted supply of essential drugs, vaccines and contraceptives, adequate in quantity and appropriate in quality.
Promoting male participation in the Planned Parenthood movement and increasing the level of acceptance of vasectomy.
Efforts will be intensified to enhance the quality and coverage of family welfare services through:

Increasing participation of general medical practitioners working in voluntary, private, joint sectors and the active cooperation of practitioners of ISM&H;
Involvement of the Panchayati Raj Institutions for ensuring inter-sectoral coordination and community participation in planning, monitoring and management;
Involvement of the industries, organised and unorganised sectors, agriculture workers and labour representatives.

Efforts are being made to provide adequate inputs to improve availability and access to services to improve performance so that the disparities between states will be narrowed. It is noteworthy that there are districts in these states where CBR and IMR are well below the national levels; steps may have to be initiated to study and replicate these success stories within each of these states so that the existing disparities between states are minimised.

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