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Executive Summary

India was 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 stabilize the population at a level consistent with requirement of national economy". Health care of women and children and provision of contraceptive services has been the focus of India’s health programme. Successive Five Year Plans have been providing the policy framework and funding for planned development of nationwide health care infrastructure and manpower for provision of health care services.

The technological advances and improved quality and coverage of health care resulted in a rapid fall in Crude Death Rate (CDR) from 25.1 in 1951 to 9.8 in 1991. In contrast, the reduction in Crude Birth Rate (CBR) has been less steep, declining 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 period between 1971-1991. India while celebrating its golden Jubilee of Independence in 1997 made a commitment to accelerate the process of population stabilization.

India had already become, by then, a signatory to the Programme of Action (PoA) of International Conference on Population and Development (ICPD) held in Cairo in 1994. The ICPD was the key international event in which the relationship between population and development was articulated. The central theme of the ICPD was to forge a balance between population, sustained economic growth and sustainable development. The objective of the agreement reached at the Conference was to raise the quality of life and the well-being of human beings and to promote human development. The PoA emphasised the need to integrate population concerns fully into development strategies and planning, taking into account the interrelationship of population issues with the goals of poverty eradication, food security, adequate shelter, employment and basic services for all.

The period after ICPD has seen significant changes in the population field in the country. Most importantly the paradigm for thinking about population policies, including language and concept, has shifted away from numbers per se to issues related to reproductive health. Broad recognition of what is needed in order to move the population agenda forward has become part of the official language of policy statements and programme documents in India.

India’s erstwhile programme of Child Survival and Safe Motherhood was broadened and replaced by a new holistic programme of Reproductive and Child Health (RCH), in October 1997. This Programme aimed at providing integrated health and family welfare services to meet the felt needs for health care of women and children with a life-cycle approach. The essential components undertaken for nation wide implementation include: -

 Prevention and management of unwanted pregnancy  Services to promote safe motherhood  Services to promote child survival  Prevention and treatment of RTI/STI

1 Under the RCH Programme need based training, more decentralization, Community Needs Assessment, attempts to improve infrastructure and logistics, and new partnership with NGOs and private sector have been initiated. Some innovative programmes for women’s empowerment and rights, a renewed recognition of the role of men, and new attention to adolescents have also been witnessed. Efforts were made to provide adequate inputs to improve availability and access RCH services and to improve performance especially in the states/districts where access to RCH services is sub optimal. Attempts to reduce disparities between States/districts and achieve tangible improvement in the indices by replication of better performing districts were encouraged.   Current Population Situation

 As per Census of India 2001, India’s population on March 1, 2001 was 1027 million. Viewed globally, India constitutes 16.87% of the World Population  The current high population growth rate in some parts of the country is due to: o The large size of the population in the reproductive age group (estimated contribution 60%) o Higher fertility due to unmet need for contraception (estimated contribution 20%) o High wanted fertility due to prevailing high Infant Mortality Rate (IMR) (estimated contribution about 20%)

India’s Demographic progress : Parameter 1951 1981 1991 Current NPP-Goals for 2010 1. Population(in million) 361 683 846 1027 1107 2. Crude Birth Rate 40.8 33.9 29.5 25.8 21 (Per 1000 population) (SRS) (SRS) (SRS 2000) 3 Total Fertility Rate 6.0 4.5 3.6 2.9(NFHS 2.1 (SRS) (SRS) 1998-99) 4. Maternal Mortality N.A. N.A 437 407 100 Ratio)(Per 100,000 live births) (1992 (1998) -93) 5. Infant Mortality 146 110 80 68 Below 30 Rate (Per 1000 live births) (1951-61) (SRS) (SRS) (SRS 2000) 6. Literacy Rate (Persons) 18.33 43.57 52.21 65.38 (Male) 27.16 56.38 64.13 75.85 (Female) 8.86 29.76 39.29 54.16 7. Couple protection 10.4 22.8 44.1 48.2 To meet all Rate (%) (1971) (NFHS 98 Needs -99) 8 Full Immunisation of 56% 100% infants (from 6 vaccine preventable diseases) 9. ANC checkup (3 visits) 43.8% 100% 8 Institutional Deliveries 34% 80% 

2  National Population Policy  Government of India adopted the National Population Policy in February 2000. The overriding objective is economic and social development and to improve the quality of lives that people lead, to enhance their well-being, and to provide them with opportunities and choices to become productive assets in society. It is an articulation of India’s commitment to the ICPD agenda as applied to the country, and forms the blue print for population and development related programmes in the country. Further, the Policy 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. A cross cutting issue is the provision of quality services and supplies, information and counselling, besides arrangement of basket of choices of contraceptives, in order to enable people make informed choices and enable them to access quality of health care services.

The NPP 2000 provides a Policy framework for advancing goals and prioritising 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 of 2.1) 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 comprehensive package of reproductive and child health services by Government, industry and the voluntary/non government sector working in partnership. The schemes/programmes have been undertaken to implement the strategic themes listed in the population policy for achieving the immediate objective of meeting the unmet needs for contraception, health care infrastructure and trained health personnel and to provide integrated service delivery for basic reproductive and child health care. Some of the major socio-demographic goals to be achieved by 2010, which will lead to stable population by 2045, are: -

1. To meet the demands in full for basic reproductive and child health services, supplies and infrastructure. 2. Reducing infant mortality rate to below 30 per 1000 live births 3. Reducing maternal mortality to below 100 per one lakh live births 4. Achieving universal immunization of children against all vaccine preventable diseases 5. Achieving 80% institutional deliveries and 100% deliveries by trained persons 6. Increasing use of contraceptives with a wide basket of choices 7. Achieving 100% registration of births, deaths, marriages and pregnancies 8. Integrating Indian system of medicines in providing reproductive and child health services 9. Promoting small family norm to achieve replacement levels of fertility by 2010 10. Making school education up to age 14 free and compulsory and reduce drop out at primary and secondary school levels. 11. Promoting delayed marriage for girls 12. Bringing about convergences in implementation of related social sector programmes so that family welfare becomes a people’s centered programme

3 In order to achieve, the above national socio-demographic goals by 2010 the following 12 strategic themes have been identified. These are:

1) Decentralized planning and program implementation. 2) Convergence of service delivery at village levels. 3) Empowering women for improved health and nutrition. 4) Child Survival and Child Health. 5) Meeting the unmet needs for family welfare services. 6) Under-served population groups:

a) Urban slums; b) Tribal communities, hill area population and displaced and migrant populations; c) Adolescents; d) Increased participation of men in planned parenthood.

7) Diverse health care providers. 8) Collaboration with and commitments from non-government organizations and the private sector. 9) Mainstreaming Indian Systems of Medicine and Homeopathy. 10) Contraceptive technology and research on reproductive and child health. 11) Providing for the Older Population. 12) Information, Education and Communication.

The NPP is gender sensitive and incorporates a comprehensive and holistic approach to health and education needs of women, female adolescents and girl child. It also seeks to address the constraints to accessibility to service due to heavily populated geographical areas and diverse socio-cultural patterns in the population. A primary theme running through the NPP is provision of quality services and supplies and arrangement of a basket of choices. People must be free and enabled to access quality health care, make informed choices and adopt measures for fertility regulation best suited to them. It is in this spirit that the NPP advocates a small family norm.

Population stabilization efforts are a matter of priority for the government. This is reflected in the fact that Prime Minister of India heads the National Commission on Population (NCP), which was constituted on 11th May 2000. The Commission is to review, monitor and give direction for implementation of the National Population Policy with a view to achieve the goals set in the Population Policy.

Substantial differences are visible between states in the achievement of basic demographic indices. This has led to significant disparity in current population size and the potential to influence population increase. There are wide inter-state, male-female and rural-urban disparities in outcomes and impacts. These differences stem largely from poverty, illiteracy, and inadequate access to health and family welfare services, which co-exist and reinforce each other.

4 The States of Tamil Nadu, Kerala, Goa, Nagaland, Delhi, Pondicherry, A&N Islands, Chandigarh, Mizoram have already achieved replacement levels of fertility (total fertility rate of 2.1)

Karnataka, Andhra Pradesh, West Bengal, Maharashtra, Punjab, Himachal Pradesh, Manipur, Arunachal Pradesh, Lakshwadweep, Daman and Diu and Sikkim have total fertility rate of more than 2.1 but less than 3.0.

Uttar Pradesh, Madhya Pradesh, Bihar, Rajasthan, Orissa, Assam, Haryana, Gujarat, Tripura, Meghalaya, Jammu & Kashmir, Dadra and Nagar Haveli have total fertility rate of over 3. Demographic outcomes in these States will determine the timing and size of population at which India achieves population stabilisation.

Several states have demonstrated that the steep reduction in mortality and fertility envisaged in the NPP 2000 are technically feasible with in the existing infrastructure and manpower. All efforts are being made to enhance resources, provide essential supplies, improve efficiency and ensure accountability - especially in the states where performance of socio demographic indicators is currently sub- optimal - so that there is tangible improvement in the performance. An Empowered Action Group (EAG) has been constituted to design and formulate programmes in terms of geographic and thematic areas with a special focus on the needs and to facilitate capacity building in these states.

While according priority to population stabilisation efforts, the Govt. of India has increased budgetary allocations by over 300% during the last ten years. The allocation for the current year is $1000 million. This includes resources flowing in from external partners e.g. World Bank, European Commission, USAID, UNFPA, DFID, UNICEF, JICA,WHO, DANIDA and GTZ. The assistance from these partners has been to the extent of 26%. In order to further augment the resource position, the Prime Minister has constituted National Population Stabilisation Fund (NPSF), which aims at inviting contributions from individuals, voluntary, non-Govt. Organisations, industry and corporate Sector.

Other initiatives at the policy level have been National Nutrition Policy, 1993, National Policy for Youth, 2001, National Policy for Older Persons, 2000, National Policy for Empowerment of Women, 2001, National Health Policy, 2002 and National HIV/AIDS Policy, 2002.

India has a sizeable population living below poverty line. Poverty reduction is, therefore, a foremost priority for the government and the focus of a diverse mix of programmes aimed at meeting the specific needs of different population segments. The anti-poverty programme is distinctly in favour of women, particularly in the form of Self Help Groups (SHGs). The constitutional amendments, which were introduced in 1992, have resulted in decentralisation of powers and functions. The Panchayat Raj Institutions (PRIs) or local self government systems, in which a minimum of 33% representation, for women is provided for by statutory provision, forms the bedrock of India’s rural development and poverty alleviation efforts as also empowerment of women. The urban poverty alleviation programme is also centred around local

5 communities. It is a matter of gratification that the figure for people Below Poverty Line (BPL) has declined from 36% in 1993-94 to about 23% by 1999-2000.

Poverty is not only a matter of low productivity and income of the economically active members in the family, but in a large extent the result of a large proportion of economically dependant numbers in the family. A latter initiation of reproductive activity and lower fertility are likely to result in a higher educational attainment, higher chances for the women to enter the former labour market and less family constraints to remain economically active most of the time, with evident positive consequences in terms of reducing the intra-household dependency ratio, increasing productivity and raising the family per capita income.

The most relevant components in the NPP as far as poverty eradication is concerned are:

 Maternal and child health: since maternal mortality and child/infant mortality is higher among the poor, the programme to reduce MMR and IMR is specially targeted towards this sector.  Meeting unmet needs: A significant number of unwanted pregnancies are among the poor women.  Adolescent reproductive health: reaching adolescents is a priority objective of NPP because of high incidence of early pregnancy. The Policy objective is to increase the age at marriage and first pregnancy to over 18 years. This is to be accomplished through information dissemination and counseling of reproductive health and fertility.

India has already in place the National Population Policy (NPP) aimed at reducing fertility in the framework of a comprehensive and a holistic strategy to stabilize population, which – if successfully implemented in all its fronts – can be expected to make an important contribution to alleviate and eventually eradicate poverty.

The Indian national experience demonstrates that investments in the fields which are important to eradication of poverty, such as basic education, primary health care, sanitation, drinking water, housing, adequate food supply & nutrition and infrastructure are essential for achieving the objectives of population stabilisation and sustainable development. Surely, the national experience will enrich the understanding of the inter related issues of population, poverty and sustainable development.

6 Section 1. Overview of the population and development situation and prospects, with special attention to poverty

Demographic Transition and Population Situation

India continues to be in the middle of its demographic transition. For the country as a whole the crude death rate has been declining since 1921 but decline in crude birth rate has been with a considerable lag and remarkably slow, beginning only after 1941. The gap between the fertility and mortality has resulted in rapid growth in India’s population over the last five decades.

India’s population numbered 238 million in 1901, doubled in 60 years to 439 million in 1961, doubled again, this time in only 30 years to reach 846 million by 1991. The Census 2001 reveals that the population has reached 1027 million on 1st March 2001. There has been an increase of nearly 181 million in the decade of 90’s alone. The annual average growth in population has been declining since 1971. It was 2.26% in the period 1971-81, 2.13% in the period 1981-91 and has declined to 1.93% in 1991-2001.Though, there is a visible reduction in the growth rate and it now seems to be on a decline, the future pace of deceleration in fertility and mortality is by no means certain. Much of this uncertainty comes from the fact that there are considerable differences in fertility across states and while there are states that have already attained replacement level of fertility or are close to attaining it, five states, viz. Uttar Pradesh, Madhya Pradesh, Bihar, Rajasthan and Orissa accounting for nearly 40% of country’s population in 2001, will contribute well over 50% of the population growth in the next decade. The performance of these States will determine the time and the magnitude at which the country’s population stabilizes.

Three factors, namely, a large segment of the population in the reproductive age group (estimated contribution 60%), high fertility due to considerable unmet need for contraception (estimated contribution 20%) and high desired level of fertility due to prevailing high IMRs (estimated contribution about 20%) have been found to influence the population momentum and, hence, its current growth rate.

As against the replacement level of fertility, that is corresponding to a TFR of 2.1, the TFR in India at national level was 4.5 in 1980-82, 3.7 in 1990-92, declining to 3.4 in 1995-97 and 2.9 in 1998-99. There are however large inter-state differences in TFR. The States of Tamil Nadu, Kerala, Goa, Nagaland, Delhi, Pondicherry, A&N Islands, Chandigarh, Mizoram have already achieved replacement levels of fertility (total fertility rate of 2.1).

Karnataka, Andhra Pradesh, West Bengal, Maharashtra, Punjab, Himachal Pradesh, Manipur, Arunachal Pradesh, Lakshwadweep, Daman and Diu and Sikkim have total fertility rate of more than 2.1 but less than 3.0.

Uttar Pradesh, Madhya Pradesh, Bihar, Rajasthan, Orissa, Assam, Haryana, Gujarat, Tripura, Meghalaya, J& K, Dadra & Nagar Haveli have total fertility rate of over 3.

7 Development situation – Sustainable Human Development

There is today, a broad based consensus to view human development in terms of, at least, three critical dimensions of well-being. These are related to longevity – the ability to lead long and healthy life, education – the ability to read write and acquire knowledge and command over resources – and the ability to enjoy a decent standard of living and have a socially meaningful life.

In India, overall, human development as reflected in the Human Development Index (HDI) has improved significantly between 1980 and 2001. At the national level, during the 80’s the index has improved by nearly 26% and by another 24% during the 90’s. There has been an improvement both in rural as well as in urban areas. Though the rural –urban gap in the level of human development continues to be significant, it has declined during the period. Inequalities across States on the HDI are less than the income inequality as reflected in the per capita state domestic product.

At the state level, there are wide disparities in the level of human development. In the early 80’s states like Bihar, UP, MP, Rajasthan and Orissa had HDI close to just half that of Kerala’s. The situation has improved since then. Besides, Kerala, among the major states Punjab, Tamil Nadu, Maharashtra and Haryana have done well on the HDI. In general, HDI is better in small states and \Union Territories. In terms of the pace of development Tamil Nadu, Rajasthan, Madhya Pradesh, West Bengal and Bihar improved their HDI significantly in the 80’s. However, in the 90’s the momentum was maintained from among these States only in case of Rajasthan, Madhya Pradesh and Uttar Pradesh.

It turns out that economically less developed States are also the States with low HDI. Similarly, the economically better off States are also the ones with relatively better performance on HDI. However, the relation between the HDI and level of development does not show any correspondence among the middle-income states in the country. In this category of States, some states like Kerala have high attainments on HDI, at the same time, there are states like Andhra Pradesh or even West Bengal where HDI values are not as high.

Incidence of Poverty – Income Poverty and Human Poverty

Poverty is a state of deprivation. In absolute terms it reflects the inability of an individual to satisfy certain basic minimum needs for a sustained, healthy and reasonably productive living. The Planning Commission of India has been estimating the Head Count Ratio of the poor at state level, separately for rural and urban areas for over three decades. It currently uses a minimum consumption expenditure, anchored in an average (food ) energy adequacy norm of 2400 and 2100 kilo calories per capita per day to define state specific poverty lines for rural and urban areas. These poverty lines are then applied on the NSSOs’ household consumer expenditure distribution to estimate the proportion and number of poor at state level.

At the national level, the incidence of poverty on the Head Count Ratio declined from 44.48% in 1983 to 26.10% in 1999-2000. It was a decline of nearly 8.5 percentage points in the ten years period between 1983-94 followed by a further decline of nearly 10 percentage points

8 in the period between 1993-94 and 1999-2000. In absolute terms, the number of poor declined from about 323 million in 1983 to 260 million in 1999-2000. The decline has not been uniform either across states or across rural and urban areas. While the proportion of poor in the rural areas declined from 45.65 percent in 1983 to 27.09 percent in 1999-2000 the decline in urban areas has been from 40.79 percent to 23.62 percent during this period.

At state level, among the major states, Orissa, Bihar, West Bengal and Tamil Nadu had more than 50% of their population below the poverty line in 1983. By 1999-2000, while Tamil Nadu and West Bengal have reduced their poverty ratios by nearly half, Orissa and Bihar continued to be the two poorest States with poverty ratio of 47 and 43% respectively. Among others, Jammu and Kashmir, Haryana, Gujarat, Punjab, Andhra Pradesh, Maharashtra and Karnataka have also succeeded in significantly reducing the incidence of poverty. Rural Orissa and rural Bihar continued to be the poorest among rural areas both in 1983 as well as in 1999- 2000. In Urban areas, the poorest three states in 1983 were Madhya Pradesh, Uttar Pradesh and Orissa where as in 1993 it was Orissa, followed by Madhya Pradesh and Bihar.

In recent years, poverty is viewed not only in terms of lack of adequate income but a state of deprivation spanning the social, economic and political context of the people that prevents their effective participation as equals in the development process. Human Poverty Index (HPI) capturing the state of the deprived in the society, have been estimated for the early 80’s and early 90’s for all the States both for rural and urban areas. In India the HPI has declined considerably during the 80’s. The decline was from 47% in the early 80’s to about 39% in the early 90’s. The decline has been marginally more in rural areas in comparison to urban areas resulting in narrowing down of rural, urban gap. At the national level, the magnitude of human poverty on HPI and the Planning Commissions Head Count Ratio anchored in a food adequacy norm are comparable. However, in terms of rural and urban incidence, as well as at State level there are considerable variations. The rural urban ratio for the proportion of the poor on the HPI is nearly twice as high as that on the Head Count Ratio on poverty. The inter-state differences in human poverty are quite striking. It was in the range of 55-60 percent in the early 80’s for the worse off states namely, Orissa, Bihar, Arunachal Pradesh, Assam and Uttar Pradesh and between 32-35% in the better off States like Kerala Punjab and Himachal Pradesh. It was only smaller predominantly urban areas of Delhi and Chandigarh that had an HPI in the range of 17-20 percent. The magnitude of HPI in early 90’s had declined in all the States. The decline in HPI was significant in case of Himachal Pradesh, Tamil Nadu, Maharasthra, Jammu and Kashmir, Karnataka and Kerala. In case of Bihar, Uttar Pradesh and Rajasthan the decline was only marginal.

Future trends in the context of globalisation :

Globalisation tends to impact on different countries in different ways. However in terms of its social impact, increased globalisation tends to compound existing inequalities, vulnerabilities, social exclusion and social problems in general. In a country like India, where levels of social inequality and poverty are already stark, new emerging forms of inequality due to globalisation may lead to unsustainable levels of marginalization, vulnerability and poverty. Globalisation facilitates a shift from state control to free markets which in turn will increase

9 category of people who will be at risk of becoming socially excluded and will be caught up in the cycles of poverty, while some others can move in and out of conditions of poverty, depending on availability of resources to sustain life.

Globalisation will create definite winners and losers. Individuals and social groupings who are able to market their skills and abilities in the context of a global market place may potentially reap benefits from the process. Existing inequalities will also impact on the ability of people to respond to these opportunities and pressures. Potential winners will include the urban-based middle class from all segments of the population. Also potentially included the workers with sought after skills, university graduates (IT skills, Business skills). While some may benefit from new opportunities provided by globalisation there will be also people (largely rural poor, SC, ST) at risk of loosing out.

The 1999 Human Development Report argues that social fragmentation resulting from globalisation has led to a reversal in much of the progress made in terms of human development. This effect of globalisation on the population is not an issue restricted to India or countries of Asia and Africa alone. The Indian scenario reflect the fact that globalisation does not currently show ‘a human face’. While many are already caught in poverty cycles, others are at risk, since insecurity increases the vulnerable segments of the population.

Keeping this in mind, India is approaching the issue of globalisation as a process that can be managed through an integrated policy framework in which social development departments/sectors are equal partners with economic departments in order to minimise the social impact of economic restructuring. Policy measures relating to population, health, education, women’s empowerment which are sensitive to the context of economic restructuring are handled with the sensitiveness so that they can play a crucial role in attempts to give globalisation ‘a more human face’.

Assessment of status of implementation of goals of ICPD

In India, notable achievements since the ICPD, 1994 have been progress towards gender equity, equality and empowerment of women; reductions in birth rate, population growth rate, death rate and infant mortality; increasing life expectancy, particularly of women; and increase in literacy levels of women and men.

10 Section 2. Fertility levels and trends, and their implications for reproductive health, including family planning programmes

The population of India increased roughly four-fold in the last century from 238 million in 1901 to 1027 million in 2001. The average annual growth rate that accelerated steadily from 0.30 in the first decade to a high of 2.24 for 1971-81 and then fell to 2.14 in the following decade. The growth rate fell further during 1991-2001 to 1.93.

The decadal growth during 1991-2001 was 21.34% (decadal growth in 1981-91 was 23.86%). The analysis of growth rates of the states starting from the decade 1951- 1961 indicates that it took four decades for Kerala to reach a decadal growth rate of less than 10% from a high growth rate of 26.29% during 1961-71. Tamil Nadu also took 40 years to reduce its growth rate from a high of 23.2% during 1961-71 to 11.2 % during 1991-2001. Andhra Pradesh has shown an impressive fall in growth rate by over 10 percentage points within a short span of a decade. The growth rates in Rajasthan, Uttar Pradesh and Madhya Pradesh are now at a level where Kerala and Tamil Nadu were 40 years ago.

It is observed that there are wide disparities among the States in the Country as far as level of TFR is concerned. These disparities correspond to the trend of decline in growth rate of population as revealed in Census of India, 2001. The States can be broadly categorized into three groups. Group-I with states with less than or equal to 2.1. Group-II States with TFR more than 2.1 but less than 3 and Group-III States with TFR more than 3 (Table 1)

Table 1. Category of States according to their TFRs

S.No. Group-I: States with Group-II: States with Group-III: States TFR less than 2.1 TFR >2.1 but < 3.0 with TFR > 3.0 1. Goa –1.0 Manipur – 2.4 Gujarat – 3.0 2. Nagaland – 1.5 Karnataka – 2.4 Assam – 3.2 3. Andamand & N Island-1.5 Andhra Pradesh – 2.4 Haryana – 3.3 4. Delhi – 1.6 Himachal Pradesh – 2.4 Dadara & NH- 3.5 5. Kerala – 1.8 West Bengal – 2.4 Tripura – 3.9 6. Pondicherry – 1.8 Daman & Diu – 2.5 Madhya Pradesh-3.9 7. Tamil Nadu – 2.0 Sikkim – 2.5 Rajasthan – 4.1 8. Chandigarh – 2.1 Punjab – 2.6 Bihar – 4.3 9. Maharashtra – 2.7 Uttar Pradesh-4.6 10. Arunachal Pradesh – 2.8 Meghalaya-4.8 11. Lakshwadeep – 2.8 12. Orissa – 2.9

The States in Group-I such as Kerala, Tamil Nadu and Goa need to be supported to sustain and consolidate their gains to realize the other goals of reducing infant mortality rate and maternal mortality ratio.

11 The States under Group-II such as Andhra Pradesh, Kernataka, Mahashtra, West Bengal, Punjab and Orissa which are poised to achieve the replacement level of fertility by 2010 need to be further strengthened and closely monitored.

The States in Group-III which are most populous ones like Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan need enhanced attention and concerted efforts to implement the full complement of programmes of fertility regulations, maternal health and child health. Government of India while recognizing the importance of the States under this Group for impacting the population stabilization in the country has constituted an Empowered Action Group to accelerate the implementation of the programme keeping in view the specific needs of these States.

National Family Health Survey (NFHS – I) 1992-93 and NFHS-II in 1998-99 provide data on various health and family welfare indicators. NFHS-I in 1992-93 estimated the all-India TFR at 3.39, which fell further to 2.85 by NFHS-II in 1998-99. Between the two rounds of NFHS there was a decline in the Total Fertility Rate in both urban and rural areas of India. However, high TFR in rural areas especially in major states which are estimated to have TFR more than 3 is an area of concern.

Table2– Wanted and unwanted fertility comparisons: NFHS-2 versus NFHS-1

States NFHS1 1992-93 NFHS2 1998-99 TFR 92- WTFR UTFR UTFR TFR 98- WTFR UTFR UTFR 93 92 92- as % of 99 98- 98- as % of =9 93 TFR 92- 99 99 TFR 98- 3 93 99 All India 3.39 2.64 0.75 22% 2.85 2.13 0.72 25% Haryana 3.99 2.81 1.18 30 2.88 2.10 0.78 27 Punjab 2.91 2.15 0.76 26 2.21 1.55 0.66 30 Rajasthan 3.63 2.78 0.85 23 3.78 2.57 1.21 32 MP 3.90 3.21 0.69 18 3.31 2.40 0.91 27 UP 4.82 3.80 1.02 21 3.99 2.83 1.16 29 Bihar 4.00 3.18 0.82 20 3.49 2.58 0.91 26 Orissa 2.92 2.32 0.60 20 2.46 1.90 0.56 23 W Bengal 2.92 2.20 0.72 25 2.29 1.78 0.51 22 Assam 3.53 2.52 1.01 29 2.31 1.75 0.56 24 Gujarat 2.99 2.33 0.66 22 2.72 2.08 0.64 24 Maharashtra 2.86 2.13 0.73 26 2.52 1.87 0.65 26 AP 2.59 2.09 0.50 19 2.25 1.88 0.37 16 Karnata 2.85 2.18 0.67 23 2.13 1.56 0.57 27 Kerala 2.00 1.82 0.18 9 1.96 1.81 0.15 8 Tamilnadu 2.48 1.76 0.72 29 2.19 1.71 0.48 22

Table 2 provides state-wise comparisons of the total, wanted, and unwanted TFRs across the two NFHS surveys. According to the NFHS a birth was considered unwanted if the

12 number of living children at the time of conception was greater than or equal to the ideal number of children reported by the respondent. The wanted fertility rate is the level of fertility that would result if all unwanted births had been prevented.

Table 2 shows that there are differences between the major states not only in regard to TFR but also in relation to wanted and unwanted TFR. For NFHS-1, if we order the states according to how close wanted TFR was to the replacement level TFR of 2.1, we can see three broad groupings: (i) WTFR < or = replacement TFR: Kerala, Tamilnadu, AP, Karnataka, Maharashtra, Punjab (ii) Replacement TFR < WTFR < India avg WTFR: Gujarat, Assam, W Bengal, Orissa (iii) WTFR > India avg WTFR: Haryana, Rajasthan, MP, UP, Bihar

Indeed, WTFR in three states from group (ii), Gujarat, West Bengal and Orissa, was also quite close to the replacement level. Thus women’s fertility preferences in much of the country barring the states in Group-(iii) were already below, at, or very close to replacement level during NFHS-1 in 1992-93. The measure of unwanted fertility for the country as a whole was 0.75 ranging from 0.18 in Kerala to 1.18 in Haryana.

These patterns became even more striking in NFHS-2. Actual TFR is below, at or very near replacement in Kerala, Tamilnadu, Karnataka, AP, West Bengal, and Punjab. WTFR for the country as a whole has fallen to 2.13, i.e., replacement level. Using a two- fold grouping yields: (i) WTFR < or = repl TFR: Kerala, Tamilnadu, AP, Karnataka, Maharashtra, Punjab, Gujarat, Assam, W Bengal, Orissa, Haryana (ii) WTFR > repl TFR = India avg WTFR: Rajasthan, MP, UP, Bihar.

A more disaggregated look at fertility change in the country sharpens the findings of the state-wise analysis. Indeed, in some ways, it modifies it as there are regions and districts in the high growth states where fertility decline has been notable, and pockets in low growth states that show the reverse. Thus the size of the high fertility zone in the Uttar Pradesh has shrunk with significant declines in central UP. Declines have also been experienced in a number of districts of Rajasthan and Bihar. The noted improvements in female literacy during the last decade in MP in particular but also in Rajasthan and UP may presage an acceleration of these trends.

In the States of Southern India, on the other hand, while in general fertility has fallen sharply, being now at or close to replacement, pockets of higher fertility and slower declines remain. This is especially so in the districts of northern Karnataka, and the contiguous districts in AP and western Maharashtra. This points to the continuing importance of decentralisation of programmes down to the district level.

During the Ninth Plan (1997-2001) the Government of India embarked on :-  decentralised district based area specific need assessment and programmes for fulfilling the needs

13  RCH programme aimed at providing integrated good quality maternal, child health and contraceptive care.

Independent surveys have shown that several states have achieved goals set for some aspect of the RCH programme during the Ninth Plan, demonstrating that these can be achieved with in the existing infrastructure, manpower and inputs. For instance  Andhra Pradesh, Punjab, West Bengal and Maharashtra have shown substantial decline in birth rates; the latter three states are likely to achieve replacement level of fertility, ahead of the projection made.  Punjab has achieved couple protection rate and use of spacing methods far ahead of all other states  Tamil Nadu and Andhra Pradesh have achieved increase in institutional deliveries  Kerala, Maharastra, Punjab and Tamil Nadu improved immunization coverage  Tamil Nadu and Andhra Pradesh had achieved improvement in coverage and quality of Antenatal care.

During the Tenth Plan (2002-2006), the pace of implementation of the Programme will be accelerated through streamlining of infrastructure, improving quality, coverage and efficiency of services so that all the felt needs for family welfare services are fully met. Special attention will be paid to improving access to good quality services to the underserved population in urban slums, remote rural and tribal areas.

14 Section 3. Mortality and Morbidity trends and poverty

Due to improvement in provision of health services and health seeking behaviour of the people, the life expectancy has increased and the crude death rate has declined over the years. Life expectancy at birth has more than doubled in the last 50 years. It increased from around 30 years at the time of independence to over 60 years in 1992-96. In the period 1970 to 1996 the life expectancy at birth at the national level improved from 49.7 years to 60.7 years as per the Sample Registration System (SRS). During this period the life expectancy at birth for males increased from 50.5 years to 60.1 years, whereas in case of females it was from 49 years to 61.4 years. There are significant differences in life expectancy at birth across states. In Kerala, a person at birth is expected to live over 73 years (70 years for males and 76 years for females), followed by Punjab at 67.4 years (66.4 years for males and 68.4 years for females). On the other hand, life expectancy at birth in Assam, Bihar, Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh has been in the range of 55-60 years. The Crude Death Rate (CDR) has considerably declined from about 25 in 1951 to under 9 in 2000.

Infant Mortality

High Infant Mortality Rate and Maternal Mortality Ratio have been a cause of concern. Though there has been a substantial decline in IMR over the last five decades, which was 146 in 1951, has come down to 68, in 2000, however, it has remained unaltered in the last few years and has plaeutued. It is a matter of concern that the decline in peri-natal and neo-natal mortality has been very slow. The goal of achieving IMR of 30 by 2010 as envisaged in the National Population Policy needs concerted all round effort. Major causes of infant mortality include acute respiratory infections, diarrhoea and vaccine preventable diseases like measles and tetanus (in areas where immunisation coverage is not optimal). A high proportion of infant mortality (64%) is accounted for by Neo-Natal Mortality. High incidence of low birth weight babies (birth weight less than 2.5 kg) and pre mature births contribute to the high neo natal mortality.

Socio-economic factor significantly alter infant mortality in India. Children born to illiterate mothers, experience IMR close to 3 times that of children born to mothers who had high school or above education (87 v/s 33). IMR in children born among families with low standard of living index (SLI) is double that of children born among families with high SLI (89 V/s 43). There are also other factors, which are dependent on access, responsiveness and use of health systems that seem to influence infant mortality in India. The important ones in this group include birth interval and medical care received from a trained professional during pregnancy, childbirth and postnatal periods. IMR among children born to mothers who had birth intervals less that 24 months is nearly 3 times higher than their counter parts born to mothers who had birth intervals more than 48 months. Children born to women who received care from trained professionals during ante-natal, natal and post-natal period experience half levels of IMRs compared to those whose mothers did not receive any form of care (66 v/s 30).

15 The Table below (Table No. 3) provides data on percentage change in infant mortality (neo-natal and post natal) and child mortality (0-4 and under 5) rates between NFHS-I and NFHS-II, which is self – explanatory: -

Table 3. Percent change in Infant and Child mortality rates between NFHS I (1992-93) and II (1998-99) State Neonatal Post- IMR Child UFMR neonatal Mortality AP 3.31 11.60 6.53 6.25 6.25 Assam 12.38 34.13 21.65 63.54 37.06 Bihar 15.15 23.26 18.27 17.38 17.57 Gujarat 6.38 12.88 8.88 36.68 18.17 Haryana 9.11 37.25 22.51 22.63 22.19 Karnataka 18.10 28.71 21.25 17.87 20.05 Kerala 10.97 69.51 31.51 69.05 41.25 MP -3.20 2.50 -1.06 -14.40 -5.60 Maharashtra 12.09 16.43 13.47 28.23 17.35 Orissa 24.88 31.86 27.74 -19.72 20.31 Punjab -9.94 -1.33 -6.33 -6.00 -6.03 Rajasthan -33.06 12.71 -10.74 -16.41 -11.99 TN 24.68 38.14 28.80 20.90 26.82 UP 10.52 17.25 13.21 14.78 13.31 WB 38.42 28.51 35.33 23.46 31.92 INDIA 10.70 19.06 13.89 12.28 13.17

Maternal mortality

Like most developing countries India does not have reliable data on maternal mortality. Between the two round of NFHS surveys there has been no significant decline in maternal mortality ratio. In 1998 the SRS estimated MMR of 407 per one lakh live births. All these estimates suggests that more than one lakh women die due to causes related to pregnancy and child birth. Data from SRS indicate that major causes of maternal mortality continue to be unsafe abortions, ante and post-partum haemorrhage, anaemia, obstructed labour, hypertensive disorders and post-partum sepsis. There has been no major change in the causes of maternal mortality over years. Deaths due to abortion can be prevented by increasing access to safe abortion services. Deaths due to anaemia, obstructed labour, hypertensive disorders and sepsis are preventable with provision of adequate antenatal care, referral and timely treatment of complications of pregnancy, promoting institutional delivery and postnatal care. Emergency obstetric services will help saving lives of women with haemorrhage during pregnancy, complications during deliveries conducted at homes.

16 Morbidity pattern

Illness is generally categorized into short-term or acute morbidity – such as infectious diseases affecting children viz. measles, influenza, diarrhea, long-term morbidity with limited duration such as tuberculosis and permanent or chronic morbidity such as diabetes, arthritis, blindness, deafness, etc. Some of the increase in morbidity particularly of chronic variety is on account of ageing of population.

As per the 52nd round of the NSSO, nearly 5.5% of rural persons and 5.4% of urban persons reported ailment during 15 days period prior to the survey. Females reported higher ailments than males. Nearly, 12% of the persons in rural areas of Kerala reported ailment. This proportion was also high in rural areas of Assam, Himachal Pradesh, Punjab, Tripura, Chandigarh and Pondicherry. The urban areas of Assam, Kerala, Punjab, Tripura and Chandigarh are also reported higher proportion of ailments among people. The number of those reported acute ailment was nearly thrice as high as those reported chronic ailment in rural as well as urban areas. In Kerala and Andhra Pradesh the proportion of persons reporting acute ailments was nearly twice the proportion reporting chronic ailments. In Bihar, Gujarat, Haryana, Himachal Pradesh, Karnataka, Maharashtra, Tamil Nadu and West Bengal, the proportion of those reporting acute ailments was 2.5 – 3.5 times higher than those reporting acute ailments. In some other states like Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh. This ratio was between 5-9 times.

Among other source for data on morbidity, a survey done by National Council for Applied Economic Research, 1995 shows the morbidity prevalence rate (defined as number of cases of disease present in the community at one time) was 103 persons per thousand at the national level. It was marginally higher in urban areas in comparison to rural. It was also higher among females than males both in rural and urban areas, higher for those in age groups less than 5 years and more than 60 years and higher for females with age group 15-59 vis—a-vis females in other age groups. It was seen that morbidity declined with increase in education level of the health of the family, as well as with an increase in household income. The survey found prevalence of morbidity among the highest in the States of Kerala, Orissa, Himachal Pradesh, Punjab and Andhra Pradesh. It was lowest among Maharashtra, Tamil Nadu, Gujarat and Haryana. In almost all States prevalence of infectious diseases exceeded non-infectious diseases in rural areas except in Andhra Pradesh, Kerala and Karnataka. In urban areas, prevalence of infectious diseases was higher except in case of Andhra Pradesh, Himachal Pradesh, Kerala and Tamil Nadu.

Policy, programmes and interventions

Two important National Socio-demographic goals enunciated in the National Population Policy to be achieved by 2010 are :-

17  to reduce the IMR to a level less than 30 per 1000 live births  to reduce the MMR to a level less than 100 per 100,000 live births

To address each of the major factors contributing to high IMR and under five mortality, the following are important interv23.entions :  Essential newborn care  Immunisation  Nutrition  Exclusive Breastfeeding for 6months  Timely introduction of complimentary feeding  Detection and management of growth faltering  Massive dose Vitamin A supplementation  Iron supplementation if needed  Early detection and appropriate management of  Acute Respiratory Infections  Diarrhea  Other infections

Programme Initiatives

 Operationalisation of district new born care  Home based neo-natal care  Immunisation strengthening activities  RCH outreach services for remote and comparatively weaker districts and urban slums  Border district cluster strategy  Integrated management of child illness  Introduction of Hepatitis-B Vaccine to infants along with primary doses of DPT vaccine

To reduce the maternal mortality the following interventions have been considered important :-

Antenatal care

 Early registration of pregnancy (12 - 16 weeks).  Minimum three Ante-Natal Check-up  Screening all pregnant women for major health, nutritional and obstetric problems  Identification of women with health problems/ complications, providing prompt and effective treatment including referral wherever required.  Universal coverage of all pregnant women with TT immunisation.  Screening for anaemia ; providing IFA tablets to prevent anaemia or providing appropriate treatment for of anaemia.

18  Advice on food, nutrition and rest.  Promotion of institutional delivery / Safe deliveries by trained personnel; advising institutional delivery for those with health /obstetric problems .

Delivery Care  To identify women with complications early through AN check up and refer them to appropriate institution for safe delivery.  screen all women late in pregnancy and ensure that those with complications deliver in institutions  train traditional birth attendants (TBAs) in clean delivery  train TBAs to recognise problems that arise during labour and refer those with problems to hospitals  ensure that referrals are honoured  build up community support for transport of women with problems to FRU

 improve quality of services available;  address problems and needs of the women in labour seeking institutional deliveries;  aim at universal institutional delivery by make institutions people friendly  medical audit for monitoring progressive improvement in quality

Specific efforts will made to strengthen FRU/ CHC/District hospitals to provide Emergency obstetric care for all referred cases. Efforts will be to  Operationalise adequate number of FRU/CHC by posting specialists in obstetric, Gynaecology/pediatrics in institution where infrastructure is available;

Programme Initiatives

 Promoting 24 hour delivery service at Primary Health Centres (PHCs) and Community Health Centres (CHCs)  Contractual appointment of additional ANMs  Contractual appointment of Staff Nurses and Laboratory Technicians  Providing referral transport to indigent families for obstetrics emergencies  Training of traditional birth attendants (dais) in 156 districts.  Providing safe motherhood consultant in PHCs, CHCs and sub-district hospitals  Providing private anesthetists for attending to emergency obstetric cases at First Referral Units (FRUs)  Integrated financial envelop for providing flexibility to better performing states to enable them to design package of interventions to address problems of maternal health care  Reproductive and Child Health Camps for improving access of services of specialists like gynecologists and pediatricians  Development of cadre of nurse midwives in public and private sector  Training programme for doctors for providing anaesthesia

19  In-service training of para-medical staff

The National Health Policy, 1983 and the new National Health Policy, 2002 have highlighted a need for time bound programmes for setting up network of comprehensive primary health care services linked with extension and health education. It emphasizes establishment of a referral system to prevent needless load on higher levels of health care hierarchy at the same time creating a network of super specialist services by also encouraging private health care facilities for patients who can afford.

As per the Constitutional allocation of responsibilities between the Central and State Government, health has been identified as a State subject. The main responsibility of a infrastructure and manpower building rests with the State Government. However, the Central Government over the last five decades provided supplementary fund for control of major communicable as well as non communicable diseases by initiating national programmes. At the time of independence communicable diseases were a major cause of morbidity and mortality in India. Initial efforts in public health care were, therefore, directed to their prevention and control. Among the initiatives at the national level, National Anti-malaria programme, National Tuberculosis Control Programme. National Leprosy Control Programme, National AIDS Control programme are important interventions that have contributed considerably in bringing down the crude death rate from about 25 in 1951 to under 9 in 2000. However, morbidity due to communicable diseases continue to be high inspite of renewed efforts at extending the immunisation coverage of the population. National initiative on some non-communicable diseases that were perceived as major health problem has also been taken. Among these the National Goitre Control programme, the National Blindness Control programme, the National Cancer Control Programme, the National Mental Health programme are some of the major initiatives of the Central Government.

At State level apart from the overall responsibility of providing preventive and curative health care the Integrated Child Development Services, (ICDS) programme, the National Mid-day Meal Programme, various micro-nutrient schemes, as well as food for work through various anti poverty programmes are some important initiatives aimed at addressing the problem of malnutrition in women and children.

Much of the success of these initiatives, both for preventive as well as curative health care services depends on availability of health care infrastructure, trained manpower and public provisioning of resources. At the national level, the functional primary health care infrastructure, including sub-centres of primary health centers, and community health centers nearly meets the existing norms, formulated taking into account population density and terrain. At present, the national norms envisage a sub- centre for population of 3 to 5 thousand. A primary health centers for 20 to 30 thousand and the Community Health Centre for four primary health centers. There are shortages in the availability of para-medics as well as specialists at the community health centers which undermine their functioning as referral units. The disparities across states and within states between regions for infrastructure as well as for manpower are quite striking.

20 Section 4. Migration & urbanisation

Urbanisation and migration are closely linked. They reflect and have profound implications for many aspects of social and economic development. The ‘demographic’ transition is also closely associated with major changes in pattern of human mobility.

Migration

The phenomenon of migration of people and families has been with societies for as long as they have existed. Migration is a complex phenomenon, difficult to measure study or predict. India is a country of tremendous movement, migration is constantly in progress from one rural area to another, from rural to urban and vice-versa.

Unfortunately, migration data for the 2001 Census are not yet available. The Census data on migrants for 1971, 1981 and 1991 shows that the great majority of migrants in India have made intra-district movements. About 60% fall in this category, which by definition involves travel over relatively short distances. The next most common type of migrants are those who have moved between districts (inter-districts) – and again many of them will be over short distances (between adjacent districts). About 11% of migrants have moved between States. Much smaller proportion report international migration. Data indicates that intra-district and inter-district migrants together formed 26.9 percent of the population in 1981 but only 23.8 percent in 1991. It is chiefly due to changes relating to shorter distance moves that account for the decline: Census data implies that short-term migration, described as "circulatory" in character, and involves men more than women, has declined in importance. This has much to do with improved transport networks and the to and fro movements that are made with greater ease.

Women moving at marriage are prominent in all categories of migration, especially in rural to rural transfers. According to the 1991 census, for every one hundred female migrants there were only 38 male migrants. And for intra-district, inter-district and interstate migrants the corresponding figures were 28, 45 and 80.

In 1971, migrants accounted for almost one third – 30.6 % of the population. This figure rose slightly to 31.3% in 1981, but it then fell back to 27.8% in 1991. Comparing 1971 and 1981 the total number of internal migrants rose by 29.7%, but the corresponding rise was only 10.1% between 1981 and 1991. Other rural-to-rural migrants include those moving in response to various development initiatives such as dams, irrigation projects etc, and for reasons such as harvesting for a shorter term. Among people migrating from rural to urban areas for a longer duration are those seeking permanent employment, some for educational reasons. Urban to urban moves are made by and large by those seeking to improve their financial situations.

21 Migration is often associated with unemployment. Young and productive persons are moving out of the traditional family environment to pursue better careers to urban and industrial locations. Census data confirms that employment is the main reason for male movement, especial long-distance moves a trend that is intensifying over time. Between 1981 and '91 the proportion of male inter-district moves attributed to these two reasons rose from 37.9 to 41.3 percent, while the figure for interstate moves rose from 50.5 to 54.9 percent.

During 1986-'91 Delhi experienced a net addition of about 657 thousand people and gained from virtually every state in the country. Maharashtra State experienced a net gain of about 475 thousand during the same five-year period.

It is worth remarking that the roles of Uttar Pradesh and Bihar as major exporters of people dates back to atleast the early 20th Century. Similarly, the roles of Kolkata (Calcutta) in former Bengal, Mumbai (Bombay) in former Bombay and Delhi as sources of non agricultural employment – and therefore a foci for migration – are of long standing. In particular, where as Delhi and Mumbai have become the centres of intensively urbanised regional migration system – attracting greater and greater number of people- this has been much less true of Kolkata. Consequently, West Bengal has lost much of its previously powerful attractive force.

Urbanisation

As with migration, the Census is the main source of information on urbanisation and urban growth. However – and in contrast to migration, fortunately, figures on urbanisation for 2001 Census are available.

The 2001 Census identified a total of 5161 towns, an increase of 472 compared to 1991. Of these 5161 towns, 3800 were statutory (i.e. they were deemed to be towns because of their form of local self-government) and they contain the bulk of the urban population. For example, in 1991 the 2996 statutory towns contains 87.4% of the total urban population. For the country as a whole in 1991 there were 3768 urban areas and towns. This figure comprised 381 ‘Urban Agglomeration’ (UA) (embracing a total of 1301 towns ) and 3387 towns. According to the 2001 Census the number of urban areas and towns has risen quite substantially to 4378. However, the number of UAs increased only slightly to 384 in 2001.

The trend in urbanisation in India since 1951 shows a relatively low level of urbanisation and of a fairly slow pace of urbanisation. Thus, where as 17.3% of the population live in urban areas in 1951 by 2001 this figure had risen to just 27.8%. The annual growth rate of urban population peaked at 3.79% during 1971-81 but it had subsequently declined to just 2.71% during 1991-2001. Therefore, an important measure of the tempo of urbanisation- the urban – rural growth difference (URGD) has fallen quite appreciably since the 1970s). Similarly, the gain in the percentage urban has also been falling since 1971 – 81. These figures suggest not only that the level of urbanisation is low but its tempo is actually declining as the growth rate of the urban population falls. Even so

22 the country’s urban population still increased by nearly 68 million during the 1990s – giving a total urban population of about 85 million in 2001.

The very largest of urban areas, the so-called ‘million plus-city’ deserves special mention. In 1951 only 5 cities in India had more than one million people. They were Calcutta then the biggest with about 4.7 million – Bombay – 3.2 million, Madras – 1.5 million, Delhi – 1.4 m and Hyderabad – 1.1 m. By 1991 the number of such units has risen to 23. The 2001 Census lists no less than 35 urban areas in this category. They consists of 32 urban agglomeration plus three large municipal corporations (Jaipur, Ludhiana and Faridabad). Three of these urban areas qualify as ‘mega cities’ i.e. they have populations of more than 10 million. They are Greater Mumbai the largest with 16.4 million, Kolkata having the slipped into second place – with 13.2 million and Delhi coming up fast with about 12.8 million people. In addition, Chennai, Bangalore and Hyderabad were recorded a population of 6.4, 5.7 and 5.5 millions respectively. Together, these six huge UA contain some 60 million people in 2001, i.e. about 21% of the countries entire urban residents. The results of 2001 Census reveal that India’s 35 million + cities contained about 108 million people i.e. around 38% of the total urban population – a fact which also under scores the countries increasing urban population.

Future trends

Estimates suggest that India's level of urbanisation will rise to only about 36 percent by the year 2026. Perhaps the single most important statement which can be made regarding future migration in India is that because the size of the population is set to increase quite significantly during the next few decades, the absolute numbers of people involved in most types of migration will also tend to increase. The volume of net rural to urban migration has been increasing quite significantly at the national level in recent decades – will continue to rise. Likewise the major net inter-State migration will certaintly grow in size. This will be especially to for those streams which emanate from States like Bihar and Uttar Pradesh i.e. locations for which very considerable future demographic growth is projected. Urban growth and urbanisation will have clear implications on future patterns of migration. Thus, in 2026 (and in 2051) the country will be significantly more urban than is the case today. And the size of urban population will be very much greater. Thus it is virtually certain that, perhaps especially in relation to inter district and inter state migration, rural-bound movement will continue to decline in relative importance, while urban-bound movements will tend to increase. It is interesting to note that as per the projection, the urban population will grow fastest in States like Bihar, Uttar Pradesh and Madhya Pradesh – States which tend to have relatively low levels of urbanisation at present. The explanation is simply that future demographic growth will be greatest in these States. Conversely, more urbanised States – like Tamil Nadu, Maharashtra, Gujarat and Karnataka will tend to experience lower rates of urban growth because of populations are growing slower.

International migration has always been numerically small compared to the India’s population. Therefore, international migration has had – and in the future it will have – only a tiny influence upon the countrys overall rate of population growth.

23 Mobility and HIV/AIDS

Large movements of rural-urban migrations, facilitated by the rail and road networks and motivated by employment, also contribute to the spread of HIV in India. Mobile populations include truck drivers, migrant workers, traders etc. While mobility and migration are not in themselves the risk factors but they do create conditions in which people are more vulnerable.

Many studies have highlighted the higher risk behaviours among mobile populations. A study in Tamil Nadu on truck drivers found that 20% of the men had suffered from an STD at any given time and of this 20%, 90% tested HIV positive. There are currently about 180 million migrant workers in India, most of whom are men either single or living apart from their families. They also account for much of the clientele of prostitutes in the large cities. Generally aged between 20 and 45, they are attracted to the large metropolitan cities and live in the urban slums and on construction projects.

The most vulnerable of mobile populations is that of trafficked women and children. The blurred line between trafficking and legal migration means that it is difficult to estimate the numbers of women trafficked. The process begins under false/legitimate pretences such as ‘employment’ or ‘marriage’ or there are those sold or kidnapped. It is estimated that between 100,000 to 200,000 Nepali women have been involved in the sex trade in India. Former victims of trafficking are among the many HIV positive.

Table 4. Summary migration figures for India based on Census data on place of last residence, 1971-91 (thousands) Census Total All Intra- Inter- Inter-state Intern- Unclass- Popu- migrants district district migrants ational ifiable lation migrants migrants migrants

1971 Number 528585 161812 101225 35009 18293 6653 633 Percent - (100.0) (62.6) (21.6) (11.3) (4.1) (0.4) Males per 107 46 33 60 104 116 72 100 females 1981 Number 659300 206486 126469 50521 23448 6045 3 Percent - (100.0) (61.3) (24.5) (11.4) (2.9) (0.0) Males per 107 43 31 53 91 114 129 100 females 1991 Number 816154 226705 137065 57469 26202 5673 297 Percent - (100.0) (60.5) (25.4) (11.6) (2.5) (0.1) Males per 108 38 28 45 80 107 55

24 100 females

Table 5. Percentage Distribution of Migrants in Different Migration Streams

Year Rural to Rural to Urban to Urban to Total Sex Rural Urban Urban Rural Migrants Male 1961 56.7 25.7 13.0 4.6 100.00 1971 53.5 26.0 14.0 6.5 100.00 1981 45.6 30.0 17.4 7.0 100.00 1991 43.4 31.6 17.8 7.2 100.00 Female 1961 81.3 9.7 5.8 3.2 100.00 1971 77.7 10.5 6.7 5.1 100.00 1981 73.3 12.5 8.7 5.5 100.00 1991 72.2` 13.5 8.8 5.5 100.00 Person 1961 73.7 14.6 8.1 3.6 100.00 1971 70.3 15.3 8.9 5.5 100.00 1981 65.2 17.6 11.2 6.0 100.00 1991 64.5 18.4 11.2 5.9 100.00

Table. 6 Summary measures of India’s urbanisation, 1951-2001

Census Total Urban Urban Percent Gain Average Annual Growth Rate popu- Popu- Incre- Urban in (Percent) lation Lation Ment percent (millions) (millions) (millions) Urban Total Urban Rural URGD (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) (ix) 1951 361.0 62.4 - 17.29 - - - - - 1961 439.1 78.9 16.5 17.97 0.68 1.96 2.34 1.88 0.47 1971 548.2 109.1 30.2 19.91 1.94 2.22 3.24 1.98 1.26 1981 683.3 159.5 50.3 23.34 3.43 2.20 3.79 1.77 2.03 1991 846.3 217.6 58.1 25.71 2.37 2.14 3.11 1.83 1.28 2001 1027.0 285.3 67.7 27.78 2.07 1.94 2.71 1.65 1.06

25 Section 5. Population Ageing.

The issue of the elderly was not of much relevance in India's development agenda until a few decades ago. High birth and death rates kept the numbers of old people low, and traditional family structures provided the support needed by this group. But a steady decline in mortality and a consequent improvement in life expectancy have increased the proportion of the ageing population. The breakdown of the family as a traditional social unit that took care of its elderly members has brought forth the problems of this group.

The older population of India, which was 56.7 million in 1991, has grown to over 76 million in the year 2001 and is expected to grow to 137 million by 2021. It has gone from 5.1 percent of the total population in 1901, to 5.4 percent in 1951, to 6.4 percent in 1981, to 6.8 percent in 1991, and is projected to be 7.7 per cent of the total population of the country by the year 2001. Among the total older population, those who live in rural areas constitute 78 per cent.

Table 7. Over 65 years population & Dependency Ratios: All India & Major States, 2001

Major States 65+ Population (in Dependency millions) Ratios Population projections (2001) Andhra Pradesh 3.63 4.74 Assam 0.91 3.43 Bihar 4.21 4.10 Gujarat 2.14 4.38 Haryana 1.05 5.25 Karnataka 2.51 4.75 Kerala 2.17 6.63 Madhya Pradesh 3.42 4.23 Maharashtra 4.55 4.89 Orissa 1.75 4.77 Punjab 1.30 5.46 Rajasthan 2.25 4.10 Tamil Nadu 3.36 5.40 Uttar Pradesh 7.58 4.36 West Bengal 3.32 4.19 15 States 44.15

The sex ratio in the elderly population, which was 928 as compared to 927 in the total population in 1996, is projected at 1031 by the year 2016, compared to 935 in the total population . Of the total female population the percentage above 60 years out has always been more than the corresponding percentage of males.

26 A survey conducted by the NSSO on the elderly in 1995-96 estimated that 30 percent of the males and 70 percent of the females were completely economically dependent on others. This incidence of old age dependence was much higher in females in W. Bengal, Punjab, Assam, Haryana and Gujarat, and marginally more for males in Karnataka, Punjab and Andhra Pradesh compared to the national average.

The Ministry of Social Justice and Empowerment, Government of India (1999) in its document on the National Policy for Older Persons, concludes that one-third of the population in 60 plus age group is also below the poverty line. This brings the number of poor elderly persons to about 23 million.

Policies and Interventions

Inter-state and rural-urban variations in the numbers and problems of the elderly have a bearing on the policy framework for this group. Building income-financial security is, however, a common need: A survey conducted by NSSO in 1995-96 reveals that nearly 53.5 per cent of the elderly in urban areas and only 37 per cent of the elderly in rural areas possessed some financial assets. While the male-female disparity in the possession of financial assets was 3.2:1 in rural areas, it was less than half, 1.5:1 in the urban areas. This demonstrates the need for an adequate though differentiated strategy for extending financial security to the elderly in rural and urban areas.

The Government announced a National Policy for Older Persons (NPOP) in January 1999. NPOP states that all the older persons below the poverty line will be covered under the Old Age Pension Scheme. In line with the NPOP, AADHAR was established under the Ministry of Social Justice & Empowerment to provide legal, medical and social assistance to old people across the country. AADHAR also identifies committed individuals and organizations across the country right to the district level. Over 8000 NGOs and 516 district collectors and organizations have been selected to set up voluntary action groups at local levels to provide help for the elderly.

The Ministry has also recognized that poverty alleviation programmes directed at the aged alone cannot provide a solution to the income and social security problems of the elderly. A National Project entitled OASIS (Old Age Social & Income Security) has come about as a result of growing concern for the social & income security of elders. This especially benefits the 330 million young workers in the unorganized sector (including farmers, shopkeepers, professional, taxi-drivers, casual/ contract labourers etc), of the total 370 million workers in India. This project enables every young worker to build up enough savings during his/her working life, as a shield against poverty in old age.

Under the scheme of Integrated Programme for Older Persons financial assistance up to 90% of the project cost is provided to NGOs for establishing and maintaining old age homes, day care centres, mobile medicare units and to provide non- institutional services like reinforcement and strengthening of the family, awareness generation on issues pertaining to older persons, of the concept of lifelong preparation for

27 old age, facilitating productive ageing etc. The basic thrust of their programme is on people above 60 years age, particularly the infirm, destitutes and widows. As a part of strengthening the partnership between the young and old, the Nehru Yuvak Kendra Sangathan project has been launched, under which 100 new Day Care Centers for older people have been established in different parts of the country. Under the scheme of Assistance to Panchayat Raj Institutions/ Voluntary Organizations like registered Societies, Public trusts, Charitable companies or registered Self-help groups of older persons have been set up. 59 old age homes have been constructed in different parts of the country.

The Ministry of Rural Development provides an old age pension to destitute older people under the National Social Assistance Programme at the rate of Rs. 75 per month per beneficiary. The National Institute of Social Defense (NISD), a subordinate Office of the Ministry, has developed a Unique Programme to train old age care workers. Voluntary organizations are being encouraged and assisted in organizing services such as day care, multi-service citizens centers, outreach services, supply of disability related aids and appliances assistance to old persons to learn to use them, short stay services and friendly home visits by social workers. For old couples or persons living on their own help line, telephone assurance services, help in maintaining contacts with friends, relatives and neighbors. The formation of informal groups of the aged in the neighborhood are found to satisfy their needs for social interaction, recreation and other activities.

28 Section 6. Reproductive and Child Health (RCH) Programme

One of the key changes that has occurred in the Reproductive and Child Health Strategy is that it is a client centred demand driven quality service approach as opposed to previous provider – centric target based approach. The new approach implied a paradigm shift where the National Family Welfare Programme has under taken a change from a narrow segregated approach in family welfare and mother and child health services to that of an integrated approach in Reproductive and Child Health (RCH) programme. RCH is a holistic agenda and takes up a life cycle approach in addressing the issues of women’s health and child health from birth to death.

Three documents shaped the content of the RCH programme in India – the ICPD Programme of Action provided an overarching framework for reproductive health and reproductive rights, and the World Bank publications India’s Family Welfare Programme: Towards a Reproductive and Child Health Approach (World Bank, 1995) and Improving Women’s Health in India (World Bank 1996).

In 1997, Government of India initiated the Reproductive and Child Health programme aimed at providing integrated health and family welfare services to meet the felt needs for health care for women and children. Essential components undertaken for nationwide implementation include:  Prevention and management of unwanted pregnancy,  Services to promote safe motherhood,  Services to promote child survival,  Prevention and treatment of RTI/STD.

Prevention of unwanted pregnancy: The National Family Health Survey 1992-93 and 1998-99 provided nationwide data on contraceptive prevalence. Data from the Survey (Figure 1) indicate there has been substantial increase in the sterilisation and OC acceptance in the country. Only IUD and vasectomy use has shown a decline. The improvement in CPR explains the steady decline in the CBR during the nineties reported by the SRS.

Figure 1.

CONTRACEPTIVE US E BY METHOD (MARRIED WOMEN AGES 15-49)

TRADITIONALMETHODS/ 5.4 OTHERS 4.3

1.9 NFHS-II (1998-99) STERLIZATION 3.4 NFHS-I (1992-93) 1.6 IUD 1.9

2.1 PILL 1.2

3.1 CONDOM 2.4

34.2 FEMALE STERLIZATION 29 27.3

0 5 10 15 20 25 30 35 40

PERCENT Figure 2. Unmet needs for contraception

NFHS 1 and 2 n e Unmet Need for Contraception

m (Fig. 2) clearly o 25 indicate that there is W

d

e still substantial unmet i 20 r r

a need for both

M 15 terminal methods and y l t 10 spacing methods in n e r

r all states. There are

u 5 C

interstate differences

% 0 in magnitude of T otal Spacing Lim iting M ethods Methods unmet need for contraception. It is NFHS-1 NFHS-2 imperative that all the unmet needs for contraception are fully met within the Tenth Plan period and substantial reduction in unwanted pregnancy is achieved. Making balanced presentation of advantages and disadvantages of methods, improving counselling, quality of services and follow up care will enable couple to make appropriate choice to meet their needs for contraception, increase couple protection rates and continuation rates and enable the country to achieve the NPP goal of replacement level of fertility by 2010.

Figure 3

Unmet Need for Family Planning 35

n 30 e m o 25 W

d e i

r 20 r a M

15 y l t n

e 10 r r u C 5 % l h h

0 u t h a a r n a s b s a a a r d a s m a a A s e a l g e t r k n a I e j a s a h h d n a d a a h i r s i t d n j t a N e a D r s y e s s a r

r a u u r a -5 B r l a B N O r n P a K A i j P P

I G r P

a

t a

a a H a h m s r r R y a a e a K h t h T t d M W d n U a A M NFHS-1 (1992-93) NFHS-II (1998-99) Decline

30 Monitoring birth order

Monitoring reported birth order is a easy method Inter district variations of monitoring the progress towards achievement of (Birth order 3 or more replacement level of fertility. Currently in India birth as % of total births) order of 3 or more contribute to nearly half of all the births. There are massive interstate and intra mural <20% 27 differences in the contribution of different birth orders 20-40% 165 (Fig. 4). Based on this information district specific >40% 313 differential strategy can be evolved to improve Source RHS 1998-99 contraceptive prevalence rates , increase interbirth interval and reduce higher order of births. Figure 4. Contributtion of births of order of 3 and above to all births

70 1 . 8 6 . 5 60 9 8 4 . . 3 5 2 2 . 5 5 0 5 8

50 . 9 . 6 3 1 . 2 . 6 4 2 1 . 4 1 . 4 9 5 4 9 . 3 3 6 6 3 . .

40 3 5 t 3 . 3 n 3 1 3 e 3 c r e 2

P 30 . 1 3 . 2 1 2 20

10

0 r t a b K a a a s m l a n a u l r a P h s a j a a a j a n h & h h d i i r k s r n l g s a J h u s r s a t a s e t a e B u e e n y t h s O G N r h e d a d d A K s P

a a c a a a l a j n B r r r r a i r a

H a a t P P P m m

R

h s i r K a a a a e a r y H T t h t M W h d d U n a A M

Terminal Methods of Contraception

Sterilization has been the most widely used method of contraception in all states in India. (Figure 5). Currently age at marriage is very low and majority of the women complete their Inter district variations in families during early twenties. In the current Indian % Eligible couple sterilised milieu of stable marriages sterilization is the most appropriate method of contraception. There are >50 75 substantial differences between states and between 40.49 101 districts in different states in couples who have 30.39 106 adopted terminal methods of contraception. During <30 223 Source RHS 1998-99

31 nineties there has been some increase in percentage currently sterilized persons in all states except Punjab. However, percentage of women undergoing sterilisation is very low in Assam, Bihar and UP; women in these states majority of women come for sterilisation after they have three or more children. Improving access to safe, good quality tubectomy/vasectomy services through RCH Camps in CHCs/PHCs may be most viable and sustainable strategy for meeting the unmet need for sterilisation in these states. Figure 5.

Percent of Couples Currently Sterilized 7

60 5 2 2 . . 2 2 1 3 5 5 . 5 5 8 . 3 7 4 . 6 .

50 6 7 5 4 4 . 4 4 8 4 2 . 6 4 . 1 0 9 4 . 9 4 6 3 7 8 . . 3 8 40 6 5 . 4 3 7 8 6 4 3 3 . . 9 3 . 6 6 3 . . . 3 1 1 1 0 0 0 3 3 3 t 3 3 3 2 n . e 6

c 30 r 2 e 2 . P 7 0 . 7 2 . 6 7 6 . 6 . 1 1 20 5 1 4 . 1 1 3 1 10

0 r a t . b a . . . a l a s n a m a A l a a r a N s I P P a j h a P a n r i k a i r g s a n t h l r j r D a a a e t s i n r t y u B a h u y s r O t e N a s h K A a P t m I a h G a j n d B a r d r a U H n a a a t T R h s A K a e M M W

NFHS I NFHS II

Vasectomy

Vasectomy was the most widely used terminal method of contraception in the sixties and seventies but since then there has been a steep decline (figure 6). It is essential that efforts are intensified to re-popularize vasectomy.

Figure 6

32 ACCEPTORS OF VASECTOMY & TUBECTOMY

70

60

50

40 s h k a

L 30

20

10

0 9 7 9 5 7 5 1 3 5 1 3 9 1 3 7 9 6 7 7 8 8 9 7 7 7 8 8 8 9 9 9 9 ------8 8 4 0 2 4 6 0 2 4 6 8 0 2 6 8 6 7 8 8 9 7 7 7 7 8 8 8 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

VASECT OMY T UBECT OMY

Tenth Plan strategy to meet all the felt needs for contraception would include:

In all districts  Improve access to services to ensure effective implementation  Counselling and balanced presentation of advantages and disadvantages of all available methods of contraception to enable the family to make the right choice  Good quality services in the vicinity of their residence  G  ood follow up care

In states/districts where birth order three or more is over 40% of the births  Ensure ready access to tubectomy/vasectomy by sending, if necessary doctors from CHCs/District hospitals to PHC/CHC on fixed days In states/districts where birth order two or less is over 60% of the births  meet the unmet needs for spacing methods on a priority basis and also continue to provide terminal methods.

33 Management of unwanted pregnancy It is estimated that in 1998 about 9% of maternal deaths are due to unsafe abortion.t is estimated that in 1998 about 9% of maternal deaths are due to unsafe abortion. Available service data on MTPs indicate that following an initial rise, the number of MTPs have remained around 0.5 – 0.7 million in the last decade. The estimated number of illegal induced abortions in the country is in the range of 4-6 million. There has not been any substantial decline in estimated number of illegal abortions, reported morbidity due to illegal abortions or share of illegal abortions as the cause of maternal mortality. Management of unwanted pregnancy through early and safe MTP services as envisaged under the Medical Termination of Pregnancy Act is an important component of the on going RCH Programme.

Tenth plan Strategies for reducing morbidity due to induced abortion

 Reduce the number of pregnancies by fully meeting the felt but unmet needs for contraception.  Improve access to safe MTP services through:

 Registering and ensuring availability MTP services in all institutions where there is a qualified Gynaecologist and adequate infrastructure  Simplify the regulation and reporting of MTP so that all MTPs done by qualified doctors are registered.  Train physicians working in institutions with adequate infrastructure in government, private and voluntary sector in MTP so that they also can provide safe MTP services.  In places where there is a trained physician but no Vacuum Aspiration Machine, provide MVA syringes.  In districts where a gynaecologist visits CHC/PHC on a fixed day, they may perform MTPs using MVA  Explore feasibility and safety of introducing non-surgical methods of MTP in Medical College Hospitals and then in a phased manner extend service to district hospitals.  Ensure that women do accept appropriate contraception at the time of MTP so that there is no recurrence of unwanted pregnancies requiring a repeat MTP.

Services to promote Safe Motherhood

During the Tenth Plan every effort will be made

 to ensure 100% registration of pregnancies, deaths and births so that reliable district level estimates of MMR is made available on a sustainable basis.  to improve ascertainment of the cause of death through SRS and also from hospital records so that some reliable estimates on changes in causes of maternal

34 mortality over time and impact of ongoing interventions on maternal mortality can be assessed and appropriate interventions initiated. .

Antenatal care

Under the Reproductive and child health care efforts were made to improve the coverage, content and quality of antenatal care in order to achieve substantial reduction in maternal and perinatal morbidity and mortality (for details vide Section 3).

CHC/ FRU is the critical institution which provides emergency care and plays vital role in the referral system. Currently reported gaps in number of CHC/FRU will be filled by appropriately reorganizing the Subdivisional hospitals, post partum centers and block level PHCs . The required number of core specialists will be posted through appropriate redeployment of the manpower wherever adequate number of specialist are not available, bring them on contractual basis/part time basis may be considered. In view of the massive differences between districts in availability and access to services, and maternal health indices the following differential strategy will be adopted for achieving incremental improvement in antenatal care during the Tenth Plan. In all districts:  awareness generation to ensure universal screening of pregnant women; identification of women with problem;  manage/ refer women with complications to appropriate institution for care;  100% coverage for Tetanus toxoid  screening for and treatment of anaemia ;  provide information on  nearest PHC where women with problems can seek doctor’s advice,  nearest FRU with obstetricians and facilities where women with obstetric emergency can seek admission  how to access emergency transport system . In better performing districts focus on  improvement in Safe Deliveries (%) universal coverage and 100 90 content and 80 quality of ANC 70 to enable very 60 t n

early e

c 50 r e

identification of P 40 women with any 30 antenatal 20 problem through 10 examination; 0 r a t b a l a s m n a a A P P a P N l a a r a s I a h j a n a r r i a k i l s g a a r t n h a r j i D a r a s t e n y t t B u h y u h s t e O r a N h m s A K P a I d a G a a d n j B U r r n a a H T a t a A s h R M K 35 e a W M

NFHS I NFHS II  referral of those with problems to PHC/ FRU for care In poorly performing districts focus will be on  improving coverage for AN screening by ANM providing ANC at least thrice during pregnancy,  building up system of RCH camps in PHC/CHC on specific days through out the year when doctors/specialists will be available to examine women with problems and provide treatment/referral

Delivery care During the Ninth Plan it was envisaged that efforts will be made to promote institutional deliveries both in urban and rural areas; simultaneously in districts where majority of the deliveries were taking place at home, efforts were made to train the TBAs through intensive Dai’s Training Programme.

Strategy to improve delivery care during the Tenth Plan:

In view of the massive differences between the districts/ states in proportion of institutional deliveries and neonatal mortality rates a differential strategy to achieve incremental improvement in maternal and neonatal care will be taken up during Tenth Plan. In all districts  Efforts will be made to identify women with complications early through AN check up and refer them to appropriate institution for safe delivery.

In districts with low institutional delivery  screen all women late in pregnancy and ensure that those with complications deliver in institutions  train traditional birth attendants (TBAs) in clean delivery  train TBAs to recognise problems that arise during labour and refer those with problems to hospitals  ensure that referrals are honoured  build up community support for transport of women with problems to FRU

In districts with high institutional delivery  improve quality of services available;  address problems and needs of the women in labour seeking institutional deliveries;  aim at universal institutional delivery by make institutions people friendly  medical audit for monitoring progressive improvement in quality

Specific efforts will made to strengthen FRU/ CHC/District hospitals to provide Emergency obstetric care for all referred cases. Efforts will be to

36  Operationalise adequate number of FRU/CHC by posting specialists in obstetric, Gynaecology/pediatrics in institution where infrastructure is available;  If necessary provide for funding specialists on contract basis (part time) so that care is available when needed;  improve access to anesthetist and banked blood

Services to promote Child Survival

Ongoing major intervention programmes in child health include:

 immunization to prevent morbidity and mortality due to vaccine preventable diseases;  food and micronutrient supplementation programmes aimed at improving the nutritional status;  programmes for reducing mortality due to ARI and diarrhea and  essential new born care.

Under the RCH programme comprehensive integrated interventions to improve child health were initiated during Ninth Plan period (for details vide Section 3)

Operationalisation of new born care

Two third of all the neonatal deaths occur in the first seven days after birth . Percentage of infant deaths in the first week to the total infant deaths in the first 28 days is as high as 67% while the remaining 33% of deaths occur between 1-4 week. Major causes of neonatal deaths are prematurity, asphyxia, sepsis. If neonates requiring care are identified and referred to appropriate facility they can be effectively treated and it will be possible to achieve substantial decline in neonatal mortality.

In order to accelerate the decline of lMR, essential newborn care was included as an intervention under the RCH Programme. Equipment for essential newborn care was supplied to districts and skill upgradation training for Medical officers and other staff at the district hospitals and medical colleges to improve content, quality and coverage of essential newborn care was envisaged; collaboration with the National Neonatology Forum (NNF) for Operationalisation of newborn care facilities at the primary level was initiated. In addition Dept of Family Welfare and ICMR are funding research studies on the feasibility, replicability and effectiveness of community based new born care in reducing neonatal mortality in settings where access to primary health care institutions are sub-optimal.

37 Immunisation Vaccine Preventable Diseases The Universal 100000 Immunization Programme (UIP) 80000 is an integral part r 60000 e of Reproductive b m and Child Health u 40000 N (RCH) Programme. 20000 Under the 0 Immunization Diphtheria T etanus P olio Measles Programme, infant are Reported Incidence(1990) Report ed Incidence(1998) immunized Reported Incidence(1999) against tuberculosis, diphtheria, pertussis, poliomyelitis, measles and tetanus. NFHS indicate that there has not been any decline in the immunization coverage over the nineties. However none of the states have achieved coverage levels over 80%; coverage level in states like Bihar, UP and Rajasthan were very low. The drop out rates between the first second and third doses of oral polio vaccine and DPT have been very high in most of the states. Lower coverage (over 20%) is reported for measles as compared to other immunisations The Government has now taken up a scheme for strengthening of routine immunization. A pilot project on Hepatitis B immunization and injections safety has also been initiated.

During the Tenth Plan every effort will be made to achieve

 100% coverage for six vaccine preventable diseases  Eliminate Polio and neonatal tetanus through;  Strengthening routine immunisation programmes and  Discourage campaign mode operations which interfere with routine services .  Greater involvement of the private sector and  Improving awareness through all channels of communication.  Improve quality of care including ensuring injection safety using appropriate, sustainable technology.  Correct over reporting of coverage under service reporting through supervision; the concept that the reduction in the disparity between service reporting and coverage evaluation service is an indication of an improvement in quality will be introduced.  Evaluate ongoing Pilot projects on introduction of Hepatitis B vaccine including those where vaccine costs are borne by the parents.

38  Explore appropriate sustainable models of providing newer vaccines without overburdening the system and programme (including charging actual costs for the newer vaccines from persons above poverty line)  Expand on-going polio surveillance to cover all VPD in a phased manner Pulse Polio Immunization India initiated the Pulse polio programme in 1995-96. Under this programme all children under five years are to be administered two doses of OPV in the months of Dec and Jan every year until polio is eliminated. Pulse Polio Immunization in India has been a massive programme covering over 120 million of children every year. Coverage under the pulse polio immunization has been reported to be over 90% in all States. As a result of all these, the decline in number of polio cases, though substantial, was not sufficient to enable the country to achieve zero polio incidences by 2000.

Infections in children NFHS-2 collected information on the prevalence and treatment of fever, Acute Respiratory Infection (ARI), and diarrhoea which are three major causes of mortality in young children; 30 percent of children under age three had fever during the two weeks preceding the survey, 19 percent had symptoms of ARI, and 19 percent had diarrhoea. About two-thirds of the children who had symptoms of ARI or diarrhoea were taken to a health facility or health-care provider.

Diarrheal disease control programme

Diarrhea is one of the leading causes of death among children. Most of these deaths are due to dehydration caused due to frequent passage of Children with Diarrhoea stools and are preventable by timely and adequate % treated with ORS replacement of fluids. The Oral Rehydration Therapy (ORT) Programme was started in 1986-87. The main % Districts objective of the programme is to prevent death due to >50 9 dehydration caused by diarrheal diseases among children 25.49 82 under 5 years of age due to dehydration. Health <25 413 education aimed at rapid recognition and appropriate Source :RHS 1998-99 management of diarrhea has been a major component of the CSSM. Use of home available fluids and ORS has resulted in substantial decline in the mortality associated with diarrhoea from estimated 10-15 lakh children every year prior to 1985 to 6-7 lakhs deaths in 1996. In order to further improve access to ORS packets 150 packets of ORS are provided as part of the drug kit-A. Under the RCH programme two such kits are supplied to all sub-centres in the country every year. In addition social marketing and supply of ORS through the PDS are being taken up in some states. However RHS data indicate that in only 9 districts in the country ORS was used in more than 50% of cases of diarrhoea. Improving access to and utilization of Home available fluids/ORS for effective management of diarrhoea will receive priority attention as an inexpensive effective tool to reduce IMR /under five mortality in the country.

Acute Respiratory Infections Control.

39 Pneumonia is a leading cause of deaths of infants and young children in India, accounting for about 30% of the under-five deaths. Under the RCH Programme, Tablet co-trimoxazole is supplied to each sub-Centre in the country as part of Drug Kit-A.. Mothers and community members are being informed about the symptoms of ARI which would require antibiotic treatment or referral.

Strategy for Tenth Plan In view of the substantial differences in the IMR/NNMR between states and between districts differential strategy will be adopted during the Tenth Plan . Where ever data on district specific IMR and NNMR is available from CRS district specific strategy and where ever these are not available state specific strategies will be adopted. In states/districts with high IMR where Early neonatal mortality is less than 50% of the IMR focus will initially be on improving postneonatal mortality through appropriate interventions.

For all districts At Birth  Essential new born care  Weighment at birth and referral for preterm babies and neonates weighing less than 2.2 kg to institutions where paediatrician is available

Nutrition Interventions  Promote exclusive breast-feeding upto 6 months  Introduce semi-solid supplements at 6th month  Screen all children to identify those with severe grades of under-nutrition and treat them  Administer massive dose of vitamin A supplements as per schedule  Administer iron-folate supplements if needed

Health Interventions  Universal immunisation against the 6 vaccine preventable diseases  Early detection and management of ARI/diarrhoea

Prevention and treatment of RTI and STI

It has long been recognised that reproductive tract infections (RTI) and Sexually transmitted infections (STI) is one of the most common problems in women during reproductive age group. During the last two decades, there has been resurgence of interest in detection and management of RTI/STI. Part of this is because the clinicians to day have access to accurate diagnostic tests for aetiological diagnosis, are in a position to provide prompt, appropriate treatment for many RTI/STI and prevent long term health consequences of these infections. However part of their increasing interest and concern is because

40  they are seeing larger number of patients belonging to a wider spectrum of age (adolescents, women in reproductive age group and elderly women), and socio- economic strata seeking care for RTI  with the availability of antibiotics for treatment of STI/RTI and availability of contraceptives for prevention of pregnancy, there has been increasing prevalence of multi partner Problems in Management of RTI in Women sex and P iot-Fransen M odel

P artner t reated

T reat m ent effective

Com pliance

T reat correctly

Go to health unit

Seek T reat m ent

Sym ptom atic

W omen with RT I

0 20 40 60 80 100

inevitable increase in RTI/STI.  in spite of increasing availability of the specific tests for diagnosis and efforts to prescribe appropriate antibiotics, there is increasing antibiotic resistance and consequent poor response to therapy and recurrences  available data from research studies suggest that the risk of transmission of HIV infection is increased by RTI

Prevention, early detection and effective management of common lower reproductive tract infection has been included as a component of the essential RCH care through existing primary health care infrastructure. The Dept of Family Welfare has provided necessary drugs for treatment and also inputs to fill the gaps in lab technician in PHC/ CHC . However the skill up gradation training of health care personnel has lagged behind in most states. Dept. of Family Welfare has coordinated their efforts with the NACO so that NACO provides the input for diagnosis and management of RTI/STD at and above district level. The importance of prevention, early detection and effective treatment of RTI/STI is well recognized by the public health experts, practitioners and public themselves. Reliable easy to perform tests for accurate diagnosis of RTI/STI are readily available. Most of the infections still respond to commonly used antibiotics and chemotherapeutic agents. However it is important to recognize that there are problems in the current programmes for management of RTI. Piot and Fransen model of RTI/STI management graphically sums up the potential effect of treatment. The model assumes that about 40% of women have RTI/STD at any given time but even under optimal conditions only 1% complete full treatment of both partners. It is therefore hardly

41 surprising that in spite of all the current efforts to improve treatment of RTI/STI patients, gynaecologists and public health professionals feel that there has not been any substantial improvement in the situation over the last decade. However it is important to persist on health education and providing ready access to diagnostic facilities and appropriate treatment for STI/RTI so that there is steady improvement over time . Section 7. Adolescent Health

India has 230 million adolescents (in the age group of 10-19 years), accounting for 22.8 per cent of the population. So far adolescents have not received the attention they deserve. However, in view of the sheer numbers (230 million) adolescents as a group, merit special attention, since they comprise a major part of the reproductive age group they will play a significant role in determining the future size and growth pattern of India’s population.

While this group is perceived as homogenous, adolescents include a number of categories; rural and urban, school and non-school going, drop-outs, sexually exploited children, working adolescents- both paid and unpaid, unmarried adolescents and married males and females who are also parents.

An analysis within the adolescent age group indicates that the proportion of 10-14 year olds is greater than the 15-19 year olds. This has important implications for policy, as their needs are different.

The gender-wise breakdown of the adolescent population reveals an adverse sex ratio: In the age group 0-19 years, 13 million girls are estimated to be missing. This is a blatant indication of gender discrimination in this group. An increase in female deaths between 15-19 occurs because of maternal mortality among teenage mothers. Early pregnancy, malnutrition and anemia all contribute to a significantly higher female mortality in the older adolescent age group. A large number of adolescents are undernourished and the problem is more among girls (45%) than boys (20%), due to deep-rooted discrimination.

Early marriage and high maternal mortality among teenage mothers continue to be areas of concern for the country. In India, the legal age of marriage is 18 for females and 21 for men but early marriage is still the norm. 50% of women aged 20-24 are married before the age of 18, with the rural figure of 58.6 contrasting sharply with the urban percentage of 27.9(NFHS 1998-99). The percentage incidence of adolescent marriages below 18 years is as high as 68.3 in Rajasthan and 71.0 in Bihar, in contrast with the figure in Kerala (17.0) and Tamil Nadu (24.9).

Early marriage leads to an early onset of sexual activity and fertility. As many as 36% of married adolescents aged 13-16 and 64% of those aged 17-19 are already mothers or are pregnant with their first child. Factors such as poor nutrition, early marriage, high fertility and early child bearing have a bearing on this figure.

42 Data from NFHS –2 indicate that median age at marriage of girls in India is 16 years; 61% of all girls were married before they are 18 years. There are large inter-state variations in age at marriage (fig. ). Early marriages are more common in the states of Bihar, Madhya Pradesh, and Andhra Pradesh, where more than 50 percent of adolescent girls between the ages of 15-19 years are currently married. Teenage pregnancy is noted to be particularly high in Madhya Pradesh and Andhra Pradesh.

Women Aged 20-24 Years who married below age 18 NFHS-II (1998-99) 80 3 1 . 7 3 7 8 . . 4 6 . 4 70 4 2 6 6 6 60 7 . 3 9 . . 7 6 5 5 4 7 7 . 4 50 . . 4 t 1 6 0 0 . n 4 4 4 e 7 c 3

r 40 e 9 P . 1 4 30 . 2 2 2 7 6 7 1 20 . . 1 0 1 1 10

0 l . . . . . a a t a r b n a a a r l P P K a P m s a P k a a N n t g

r j a s

a l a h a r h i l r a h n r & a s i t n a i t r j r s y a y J e e s a u s h B r t u a h h O m B a t n r c K A a P d j d G a r a a t a U a n H a s h T m R e A a K i M H W M

The mean age at first birth is 19.2. Under nutrition, anaemia and poor antenatal care inevitably lead not only to increased morbidity in the mother but also to high low birth weight and perinatal mortality. Poor childrearing practices of these girls will add to the morbidity and under-nutrition in the infant thus perpetuating intergenerational cycle of under nutrition.

Programmes for Adolescents

The Department of Women and Child Development and the Department of Family Welfare are actively working towards integrating adolescents into their programmes.

The Department of Women and Child Development implements two major programmes for adolescents. The Adolescent Girls Scheme (AGS), now renamed Kishori Shakti Yojana aims at improving the nutritional and health status of adolescent girls (11-18 years), providing literacy and numeracy skills through the non-formal systems, training and equipping adolescent girls with home-based and vocational skills,

43 promoting awareness and encouraging them to marry after 18 years. This revamped scheme is expected to provide flexibility to States to adopt a need-based approach, depending on this situation of each State. The Balika Samridhi Yojana aims at delaying the age at marriage.

The Department of Women and Child Development, Government of Haryana under their Haryana Integrated Women’s Empowerment and Development Project provides information and generates awareness regarding basic health, sanitation and reproductive health. A life skills development programme for adolescent girls is also implemented by them for personal, physical and mental development of adolescents. Short duration camps for adolescent boys to impart family life education and sensitize them to gender issues are also organized.

Population education projects have been implemented with UNFPA assistance for over two decades now. Post-ICPD, the theoretical framework of Population education has been re-conceptualized as Adolescent Education to include the process of growing up, HIV/AIDS and drug abuse.

The Department of Health has a number of programmes to address the HIV/AIDS problem. Notable amongst these are the school AIDS education, university Talk AIDS and Radio and TV programmes which targets adolescents.

The Ministry of Youth Affairs and Sports (MOYA&S) through Nehru Yuvak Kendras (NYKs) undertake the following activities: establishment of health awareness units to generate awareness, educate and adopt health and family welfare programmes (including adolescences education) among the masses through the active participation of youth (Youth organizations, Youth coordinators) etc. Their activities include lectures, plays, immunisation and sterilization camps to increase awareness on issues of adolescence, gender, early marriage, child bearing etc.

In addition, the Department of Rural Development under the Training of Rural Youth for Self Employment (TRYSEM) which is a part of the Swarn Jayanti Swarozgar Yojana (SGSY) provides vocational and skill training to youth and adolescents.

There are a fairly large number of NGOs which address adolescent issues either in an integrated manner or sectorally. They work on health, education, reproductive health, employment, gender, and/or vocational issues. Some of them are doing commendable work, which has grown out of the needs assessment of the area.

Health care initiatives for Adolescents

Health care needs of adolescents are being addressed under the RCH Programme in the Department of Family Welfare

Focus is on the following :-

44  Efforts to educate the girl, her parents and the community to delay marriage;  programmes for early detection and effective management of nutritional (under- nutrition, anemia) and health (infections, menstrual disorders) problems in adolescent girls;  Appropriate antenatal care to be provided to high risk adolescent pregnant girls  Inter-sectoral coordination with ICDS is being strengthened in blocks where ICDS Centres have an adolescent care programme.

During the Tenth Plan, in addition to appropriate education, nutrition and health interventions to delay in age at marriage and to promote optimum health and nutrition in adolescent girls will be taken up through inter-sectoral coordination to break this vicious cycle. While adolescent health care will have to be the focus in the states where age at marriage is increasing, effective antenatal and intra-partum care will remain the focus in majority of the states where teen-age pregnancies are common.

45 Section 8. Demographic, economic and social impact of HIV/AIDS

The first case of AIDS in India was detected in 1986 in Chennai. Since then, HIV/AIDS has been reported in all States & Union territories. The HIV/AIDS epidemic in India is now over fifteen years old, however, the incidence of HIV continues to give cause for alarm, as the virus continues to spread into new areas as well as new low risk population groups.

As of March, 2001 India has reported a cumulative total of 20304 cases of AIDS (15563 males and 4741 females), no single State or Union Territory is free from HIV. In 83% of these AIDS cases, HIV infection was acquired through the sexual route, 4% through sharing of injection equipment and another 4% through transfusion of contaminated blood and blood products. Peri-natal transmission accounted for 2% of the total AIDS cases.

While males between 15-29 years (6022/15563) and 30-44 year (7621/15563) age brackets constitute 49% and 39% of the total male AIDS cases respectively in India, the proportion contributed by females in female AIDS cases had a reverse distribution. 50% of total female AIDS cases were in 15-29 years (2360/4741) and 37% (1692/4741) in 30-44 year age group. Of all the reported AIDS cases for 15-44 year old individuals, women constituted a significantly higher percentage of AIDS cases – compared to males – in the age range of 15-29 years. This is an important indicator of the likely impact of the epidemic on households and communities, especially children.

As per the latest available figures of March, 2002, 34362 cases of AIDS were reported to National AIDS Control Organisation (NACO). The Table 8. below gives State wise details. Age and Sex wise prevalence of AIDS based on actual AIDS cases as on March, 2002 is presented in the next table 9.

Table 8: State wise AIDS Cases in India as on 31st March 2002

Sl.No. State AIDS Cases 1. Tamil Nadu 16,677 2. Maharashtra 7,045 3. Gujarat 1,465 4. Karnataka 1,337 5. Andhra Pradesh 1,316 6. Manipur 1,095 7. West Bengal 831 8. Madhya Pradesh 759 9. Delhi 660 10. Utter Pradesh 506 11. Chandigarh 470 12. Rajasthan 394

46 13. Ahmedabad Municipal Corporation 267 14. Kerala 267 15. Nagaland 235 16. Haryana 189 17. Pondicherry 157 18. Assam 149 19. Punjab 135 20. Bihar 103 21. Himachal Pradesh 91 22. Orissa 82 23. Goa 77 24. Andaman & Nicobar Islands 20 25. Mizoram 20 26. Meghalaya 08 27. Sikkim 04 28. Jammu & Kashmir 02 29. Daman & Diu 01 30. Arunachal Pradesh 00 31. Dadra & Nagar Haveli 00 32. Lakshdweep 00 33. Tripura 00 Total 34362

Table 9 : Age and Sex wise Prevalence of AIDS in India (Based on actual AIDS cases in India, as on 31st March 2002)

Age Group Male % Female % Total %

0 – 14 yrs 2.34 1.49 3.83

15 - 29 yrs 25.48 11.56 37.04

30 – 44 yrs 41.39 9.88 51.27

>45 yrs 6.36 1.60 7.90

Total 75.47 24.53 100

HIV infection across states and the character of different Sub-epidemics

47 Indian States and Union Territories are at different stages of development of the HIV epidemics, they an be broadly classified into three groups as follows :

 States with Generalized HIV epidemic  Concentrated HIV epidemic States  Low HIV epidemic States

The table below illustrates the geographical distribution of HIV prevalence rates. High prevalent States Where HIV prevalence in antenatal women is >= 1% (States with generalized Includes states like Maharashtra, Tamil Nadu, Karnataka, Andhra HIV epidemic) Pradesh and Manipur Moderate prevalent states Where HIV prevalence in antenatal women is <1% and STD and other (Concentrated HIV high risk groups is >= 5%. epidemic states) Includes states like Gujarat, Goa, Kerala, West Bengal and Nagaland. Low prevalent states Where HIV prevalence in antenatal women is <1% and STD and other (Low HIV epidemic high risk groups is < 5%. States) Includes the remaining states. a) States with generalized epidemic In this category are included Maharashtra, Tamil Nadu, Karnataka, Andhra Pradesh, Manipur and Nagaland where HIV prevalence has reached one percent in ante natal clinic attending women representing female general population. While the first outbreak of HIV infection happened among injection drug users (IDU) in the north eastern States of Manipur and Nagaland which have common borders with Myanamar. The other States in this category has seen the epidemic taking off first among female commercial sex workers (CSW). However all the States subsequently saw a significant progress of HIV in general population. b) Concentrated HIV epidemic States HIV has infected more than 5% of the population groups observing high risk behaviour in these States but prevalence in female general population has remained below 1%. Gujarat, Goa, Pondicherry, Mizoram and West Bengal fall in this category. The epidemic is making in-roads in bridge population such as migrant laborers and clients of female sex workers in these States. c) Low HIV epidemic States Remaining States and Union Territories fall in this category where the population groups observing high risk behaviour is yet to attain a 5% prevalence level.

Although the epidemics are still strongly influenced by high-risk behaviour groups, such as commercial sex workers (CSWs) and IDUs, evidence reports that HIV/AIDS is spreading among the general population. Populations, which are extremely vulnerable to infection and the spread of the infection, are mobile populations, accounting for up to 24% of the population.

48 Factors that increase people's risk of contracting HIV are poverty, illiteracy, and gender and caste discrimination as they deprive people of the information and control they need over the lives to protect themselves. STDs are considered to be widespread both in urban and rural areas and among both men and women, and increases pre- disposition to infection with HIV.

The estimated numbers of people living with HIV in India was 3.5 million, 3.7 million, 3.86 million and 3.97 million respectively in 1998, 1999, 2000 and 2001. These estimates have used HIV sentinel surveillance data from ante-natal clinic attending women, STI clinic attendees, injecting drug users and men having sex with men. Altogether 237 select sites were used for this purpose from all over the country of which 109 were STD clinics, 110 clinics for pregnant women 11 sites for IDUs and only 2 for MSM. AIDS cases were not included at the time of calculating of estimates using sentinel surveillance data and the age range in focus was 15 to 49 years.

Sentinel Surveillance data clearly supports the evidence that HIV infection is percolating from various high-risk groups to low risk groups’ population. Data from various Sentinel sites in Maharashtra shows that over the years, the HIV infection has increased sharply among Commercial Sex Workers, rapidly progressing among STD Clinic attendees and is steadily spreading in low risk populations. The time lag for HIV infection to spread from high risk groups to low risk groups is between 3 to 5 years, as the infection will spread from CSWs to their clients which acts as bridge population and then to wives of these clients during this time period.

India’s HIV epidemic is comprised of several simultaneous epidemics with a heterosexual epidemic in Maharashtra and Tamil Nadu and an IDU epidemic in Manipur. IDU is prevalent in Manipur, Nagaland and Mizoram. In Manipur it is estimated that 70% of the drug users are infected, most being men. Through unprotected sex HIV has also been transmitted to their partners and around 2.2% of pregnant women in clinics in Manipur tested positive. In Mumbai it is estimated that prevalence of HIV among CSWs is 71% and more than quarter among CSWs in Delhi, Hyderabad, Madurai, Pune Tirupati and Vellore.

In India 50-60% of the population are carriers of the TB bacillus. In India the major opportunistic infection among people with AIDS is T.B., and many argue that there is a dual epidemic When people are infected with both T.B. and HIV, TB is much more likely to become active and infectious.

Controlling this and other opportunistic infections that affect those with HIV, such as Pneumonia and Cryptococcal Meningitis, costs money and also seriously affects individuals in their prime productive years causing serious economic loss to them and their families. Lack of adequate treatment and the development of drug resistance compound the problem. Migration has added another dimension to HIV epidemic in India. The country has seen and continues to see significant migration, both between States and between the

49 country and other neighboring countries. Nepal and Bangladesh have extremely porous international borders with India. While Bangladesh still has a low HIV epidemic, the HIV prevalence among sex workers in Nepal has reached 16% and among IDUs 50%.

Some the destination States of India also happen to be those registering high HIV prevalence. These include the more industrialized States of Maharasthra, Gujarat and Andhra Pradesh. These States attract male and female laborers from all over the country, but particularly from those States with lower income levels such as Uttar Pradesh, Bihar, Rajasthan and Madhya Pradesh. While these later States have relatively low levels of reported HIV infection, labour migration to high prevalence States may soon change the scenario. Indeed many of the migrating men leave their wives and families behind, thus increasing the likelihood that they will visit sex workers during their stays away from home.

Response

The government response has been quite encouraging. The Government of India responded to the epidemic by setting up the national AIDS Control Programme, which was implemented between 1992-1999. The immediacy of the problem prompted a reaction in India, which largely mirrored the practices followed by other countries in prevention and control of HIV/AIDS. The National AIDS Control Organisatrion (NACO) responded by putting in polace a National AIDS Control Programme (NACP) – fully funded by Central Government.

NACP I (first phase) comprised of strengthening the awareness of community support and behavioural change; improving blood safety; building surveillance and clinical management capacity to monitor and control STDs by improving clinical services. NACP II (phase two) became effective from 1999 to 2004. While Phase II will continue to be centrally sponsored by NACO it will be implemented by the State AIDS Control Societies (SACS). NACO will remain responsible for the implementation of: training, research and development; surveillance; oversight of technical resource groups; programme management; inter-sectoral collaboration and overall advocacy and social mobilisation, but will decentralise grant funds and the implementation of the projects/activities to the SACS. These would include: targeted interventions, blood safety, IEC and youth campaigns, voluntary testing and counselling, capacity development for care and support, intersectoral collaboration and social mobilisation and advocacy. The SACS are able to contract NGOs to deliver most of the targeted intervention activities

There are several strata of NGOs working in HIV/AIDS, ranging from community- based organisations and groups to ‘support’ NGOs. HIV and sexual health interventions are being managed either by NGOs with an integrated development approach or by NGOs working specifically in this sector.

Section 9. Gender equality and development

50 In India, women constitute an important target Group in the present day context of development planning and their concerns are placed on the priority list of the country’s development agenda. In India, important initiatives towards promoting women’s human rights have been taken during the last decade through the implementation of the 73rd and 74th amendments to the Constitution of India giving women a reservation of a third of the seats in elected local government bodies and through the setting up of the National Commission for Women (NCW) in 1992 with a mandate to safe guard the rights and interests of women. More recently adopted the National Policy for Empowerment of Women (NPEW), 2001 commits to “empower women through creating an enabling environment where women can freely exercise their rights both within and outside their homes, as equal partners along with men”.

The index of gender equality measuring the attainments in human development indicators for females as a proportion of that of males has improved, but only marginally, during the eighties. At the national level, GEI increased from 62 percent in the early eighties to 67.6 per cent in the early nineties. This implies that on an average that attainments of women on human development indicators were only two-thirds of those of men. At the State level, gender equality was the highest for Kerala followed by Manipur, Meghalaya, Himachal Pradesh and Nagaland in the eighties. Goa and the Union Territories, except for Delhi, had gender equality higher that the national level. In the nineties, Himachal Pradesh had the highest equality, where as Bihar was at the bottom and witnessed a decline in absolute terms over the earlier period.

In general, women were better off in the Southern India that in the Indo-gangetic plains comprising mainly the States of Bihar and Uttar Pradesh. States like Tamil Nadu and Andhra Pradesh in the south and Haryana and Jammu and Kashmir in the north have made considerable progress in improving the status of women vis-à-vis men on the human development indicators. States that have done well in improving their female literacy levels are also the ones that have substantially improved their gender equality. On the whole, gender disparities across the States have declined over the period.

However, at the societal level, gender bias seems to be deepening in the key area of preference for boys over girls. Son preference has been found to be significant as per the data of NFHS-2, which is summarised in the Table below:

Table 10. Women’s sex-preference for children: All India, 1998-99 % women who want at least 1 boy 85 % women who want at least 1 girl 80 % women with 1 boy who want no more children 76 % women with 2 boys who want no more children 83 % women with 2 girls who want no more children 47 % women with 3 children of whom at least 2 are boys who want no more >90 % women with 3 children of whom all are girls who want no more 50

51 Evidence regarding worsening sex ratios among children under the age of 6 years has been one of the most striking first results of the Census of India, 2001.

Table 11. Sex ratios: All India and Major States, 1991, 2001 State All ages 1991 All ages 2001 Age (0-6) 1991 Age (0-6) 2001 All India 927 933 945 927 AP 972 978 975 964 Assam 923 932 975 964 Bihar 907 921 953 938 Chhatisgarh 985 990 984 975 Gujarat 934 921 928 878 Goa 967 960 964 933 Haryana 865 861 879 820 HP 976 970 951 897 J & K 896 900 NA 937 Jharkhand 922 941 979 966 Karnataka 960 964 960 949 Kerala 1036 1058 958 963 MP 912 920 941 929 Maharashtra 934 922 946 917 Orissa 971 972 967 950 Punjab 882 874 875 793 Rajasthan 910 922 916 909 Tamil Nadu 974 986 948 939 Uttaranchal 936 964 948 906 UP 876 898 927 916 West Bengal 917 934 967 963

The table above shows that barring Kerala, the child sex ratio has worsened in every major state, even though there has been some improvement in the sex ratio overall in the country and in many states. But the overall sex ratio has itself worsened in Gujarat, Goa, Maharashtra, Haryana, Himachal Pradesh and Punjab. Worth noting is the fact that it is these same states (and Uttaranchal) that have also witnessed the largest declines in the (0-6) sex ratio. While there has been considerable concern about the causes of this decline and supposition that son preference and prenatal sex selection are responsible.

One encouraging aspect of the available data from the 2001 Census are the numbers on literacy. As is well known female education is a major pathway to human development through fulfilling women’s aspirations and raising their capabilities. Women’s empowerment and the meeting of reproductive and sexual rights depends on literacy and higher educational attainment. According to the 2001 Census overall literacy increased by 56.8% over the last decade; 47.1% for males, and 73.9% for females. The literacy rate overall in 2001 was 65.4%; 75.9% for males, and 54.2% for females. The significant increase in female literacy from 39.3% in the 1991 Census has meant a reduction in the male-female literacy rate gap from 24.8 to 21.7 percentage points.

52 Table 12. Literacy rates: All India and Major States, 2001 State Male rate Female Gap Decadal Decadal Increase rate increase, increase, ranked in male rate female rate desc. Order M F All India 75.96 54.28 21.68 11.83 15.00 AP 70.85 51.17 19.68 15.72 18.45 4 6 Assam 71.93 56.03 15.90 10.06 13.00 11 16 Bihar 60.32 33.57 26.75 8.95 11.58 16 17 Chhatisgarh 77.86 52.40 25.46 19.79 24.87 2 1 Gujarat 80.50 58.60 21.90 7.11 9.68 18 18 Goa 88.88 75.51 13.37 5.24 8.42 19 19 Haryana 79.25 56.31 22.94 10.16 15.84 10 8 HP 86.02 68.08 17.94 10.61 15.82 9 9 J & K 65.75 41.82 23.93 NA NA NA NA Jharkhand 67.94 39.38 28.57 12.14 13.86 7 11 Karnataka 76.29 57.45 18.84 9.03 13.12 15 15 Kerala 94.20 87.86 6.34 0.58 1.69 20 20 MP 76.80 50.28 26.52 18.26 20.93 3 3 Maharashtr 86.27 67.51 18.75 9.71 15.20 14 10 a Orissa 75.95 50.97 24.98 12.86 16.29 6 7 Punjab 75.63 63.55 12.08 9.97 13.14 12 14 Rajasthan 76.46 44.34 32.12 21.47 23.90 1 2 Tamilnadu 82.33 64.55 17.78 8.58 13.22 17 13 Uttaranchal 84.01 60.26 23.75 11.22 18.63 8 4 UP 70.23 42.98 27.25 15.40 18.61 5 5 West Bengal 77.58 60.22 17.35 9.77 13.66 13 12

The Table above gives the state-wise data for the major states.

The decadal increases in male and female literacy are strongly correlated suggesting that, even though female literacy has increased more, both sets of rates have moved together. What is striking however, provided the data are reliable, is where the highest rate improvements in female literacy have occurred.

Ranks 1 – 7: Chhatisgarh, Rajasthan, MP, Uttaranchal, UP, AP, Orissa Ranks 8-14: Haryana, HP, Maharashtra, Jharkhand, West Bengal, Tamilnadu, Punjab Ranks 15-20: Karnataka, Assam, Bihar, Gujarat, Goa, Kerala

The highest ranks are among the northern states where female literacy has been abysmal hitherto. States like MP (and Chhatisgarh) where an innovative Education Guarantee Scheme has been functioning as well as Rajasthan and UP appear to have done well. The main exception to this is Bihar whose performance continues poor. These improvements in female literacy can lead to improvements in post-primary education as

53 well in the next decade, we may begin to see significant changes in girls’ and women’s empowerment, capabilities, and rights, as well as in population growth rates via fertility and momentum declines.

Most programmes for women’s empowerment target only women. Increasingly, it has become clear that, while women and girls certainly need knowledge and capacity- building, attitudinal change requires focussing also on the beliefs and behaviour of boys and men, and on service providers and staff at all levels.

54 Section 10. Behaviour change communication and advocacy

Information, Education and Communication (IEC) has always been a significant component of Government of India’s family welfare programme. The accent, so far, has been on awareness generation about the programme and service facilities, with presumption that this would ensure increased utilisation. However, it is now evident that the time for awareness generation is over. If change in behaviour is desired, a specific programme that promotes behaviour change will be required.

In order to achieve the objectives set out in the National Population Policy, 2000, a National Communication Strategy for Reproductive and Child Health Programme has been formulated by Government of India in the Ministry of Health and Family Welfare.

The goal of communication strategy for the RCH programme is to - encourage individuals, families and communities to make informed decisions concerning reproductive and child health through a programme of health communication which facilitates behaviour change.

The key components of the strategy are:  interpersonal communication for behaviour change will the mainstay at the field level, and will encourage greater dialogue on issues of reproductive and child health between individuals within families and communities;  advocacy interventions based on normative research, including through the use of mass media, will be needed to promote societal change with regard to behaviour norms on RCH issues;  This will require decentralization of some responsibilities for IEC to states and districts from the centre and consequently the articulation of new roles for each of the three levels.;  There will be need for increased engagement with the NGO and private sector for social mobilization and IEC for RCH  As roles change, there will be critical need for capacity building at all levels to undertake the newly defined tasks and enhance the image of RCH functionaries.

The role of Central Government in advocacy of National population and women and child issues will gain importance. The central ministry will take the lead in establishing necessary capacity building and research capability support to the States. States will assume greater responsibility in addressing state specific campaign societal behaviour norms as well as for planning support for district based efforts in inter-personal communication and local publicity. Districts will become the natural focus for convergence of Government and non-governmental efforts.

Responsibilities of Districts: The changed responsibilities for IEC at the district level will enable frontline workers to respond to identify RCH need of individuals within

55 the community, facilitating the use of community specific, local knowledge and practices to promote behaviour change. The action plan of districts will make provisions for :-  Timely distribution of IEC materials  Utilization of folk media and other local channels of communication  Convergence of the efforts of related Departments and  Enhancement in the capabilities of relevant staff within the district

The district will be the central point for development of an appropriate and flexible action plan to support the communication needs of the community

Responsibilities of States: In the new organisation of responsibilities the States will take charge as an important focus of IEC activity. States will develop plans to :-

 Distribute materials timely.  Draw together State-local expertise from Government and non-government sectors in the areas of research studies, training, health care, advocacy and management support.  Undertake a concerted State specific communication campaign for population and women and chid health issues and other components of RCH  Converge the efforts of relevant Departments.  Enhance the capabilities of relevant staff within the State.

Responsibilities of the Centre: Centre will take responsibility for the overall policy development process for behaviour change within the RCH with the full involvement of and coordination with State administrations. Centre will develop plans to:-  Undertake concerted communication campaigns to draw attention to such population and maternal and child health issues which require changes in societal behaviour norms.  Undertake approaches to introduce newer concepts of issue (such as concerns within gender sensitivity, adolescent health) to national attention  Draw together national expertise from Government, voluntary and private sectors in the areas of research studies, training, health care, advocacy and management support.  Converge the efforts of relevant Departments.  Support a clearing house for issues related to population and women and child health and other components of RCH, which will be a resource for research and materials development within States and Districts.  Enhance the capabilities of relevant staff within the Central Ministry.

The Centre will thus assume responsibility for development of appropriate capabilities at State level, development of capabilities within the Central unit to contract agencies for KAPB studies, media tracking and evaluation and to support centrally

56 sponsored mass media efforts which address overarching issues within population and reproductive and child health. Section 11. Research, data and training

The ICMR is the nodal research agency for funding basic, clinical and operational research in contraception and RCH. In addition to ICMR, CSIR, DBT and DST are some of the major agencies funding research pertaining to Family Welfare Programme.

International Institute of Population Studies, Mumbai and a network of 18 Population Research Centres conduct studies on different aspects of the Family Welfare Programme and undertake demographic surveys.

Priority areas of research during the Tenth Plan include

Basic and clinical research

 Development of newer technology for contraceptive drugs and devices in modern system of medicines including immunological methods for fertility to cater to the requirements of the population in the next few decades  Exploration of the safety and efficacy of ISMandH products  Identification , characterisation genes/gene products and elucidation of their functional role of in reproduction and health of women and children.  Development and testing of new drug delivery systems for the delivery of contraceptive steroids,  Safety and efficacy studies on newer vaso-occlusive methods, spermicides based on plant products such as neem oil, saponins and other plantbased substances, safety and efficacy of contraceptives used in ISMandH and by tribal population.  Clinical studies on use of emergency contraception and non-surgical methods of MTP  Diagnosis and mangement of STI/RTI  Innovative methods for improving neonatal care at primary health care level including assessment of simple methods for diagnosis and management of sepsis, asphyxia and hypothermia in the new born,  Studies on prevention detection and management of infections in children,  early detection and management of Obstetric problems  Demographic studies  ongoing demographic transition and its consequences  continuation rates and use effectiveness of contraceptives under programme condition  operational research to provide integrated delivery of health , nutrition and family welfare services at village level through existing infrastructure and manpower

57  Operational research

 testing and validation of relationship between couple protection rate and crude birth rate and testing relationship between reduction of infant mortality rate and reduction in birth rate in the States in different levels of demographic transition.  Improve access to safe abortion services  STI/RTI - research aimed at for detection, prevention and management in different levels of health in care  socio-behavioural research to improve community participation for increased utilization of family welfare services.

Monitoring & Evaluation and Data base

The NDC Committee on Population recommended creation of district level databases on quality, coverage and impact indicators for monitoring the programme. During the Ninth Plan period this recommendation has been implemented. The following systems are being used for monitoring and evaluation of programmes in the Family Welfare Programme:

 Reports from State and implementation agency  Sample Registration System and Population Census  Rapid Household Survey - RCH  Large scale surveys- National Family Health Surveys (NFHS-I 1992-93, and NFHS- II 1998-99), Sample Surveys by NSSO Area specific surveys by Population Research Centres  Other specific surveys by National and International agencies

Department of Family Welfare has constituted regional evaluation teams which carry out regular verifications and validate the data on acceptance of various contraceptives. These evaluation teams can be used to obtain vital data on failure rates, continuation rates and complications associated with different family planning methods. Data generated by rapid household survey about the progress on programme interventions as well as its impact are being used to identify district specific problems and rectify the programme implementation.To assess the availability and the utilisation of facilities in various health institutions all over the country, facility surveys have been done during 1998-99 in 101 districts.

During the Tenth Plan efforts will be made to consolidate the gain by putting in place a sustainable systems of evaluation at district level in the from of CRS and district surveys; efforts will be made to reduce duplication of efforts through appropriate inter-sectoral coordination.

58 Training

The National Institute of Health and Family Welfare (NIHFW) is the national nodal agency to coordinate various training activities under the RCH programme all over the Country. NIHFW pursues its responsibilities of coordinating and monitoring the training activities with the help of 18 Collaborating Training Institute (CTIs) in various parts of the country.

Different types of training activities being conducted under the RCH programme are the following :-

1. Integrated skill development training for health personnel: Conduction of Integrated Skill Development Training for different categories of service providers including MO(PHC), ANM, LHV, HW(M), HA(M) and staff nurse under RCH programme is being continued at district levels in different States and UTs. 2. Training of Trainers: In order to provide adequate number of trained trainers for imparting integrated skill training at district level, TOT courses are being continued at all the CTIs. 3. Specialized clinical skill training: To enhance the clinical skills and thereby increasing the coverage and quality of services, specific skill oriented training under the RCH programme, viz. laproscopic sterilization, minilap sterilization, medical termination of pregnancy, no scalpel vasectomy for medical officers and IUD insertion for ANM and LHV has started from 1999-2000 and are being continued. 4. Specialized Management Training: Considering the complexity involved in the RCH programme to enhance the skills of the programme managers at the State as well as at the district level, specialized management training programmes were included in the training package under the RCH Programme. This was conducted by a number of reputed management training institutions. 5. Specialised Communication Training: In order to enhance the communication skills among the IEC officials at the district (DMEIOs) and at the block levels (BEEs), specialized communication training was conducted through identified communication training institutions for the entire country.

NIHFW being the nodal agency for training developed prototype training curriculum for different training courses as well as developed training materials like training modules (modules for MO, LHV, ANM, staff nurse, male health worker and health assistant), guidelines, facilitator’s guide etc.

59 Section 12. Partnerships and resources

Role of NGOs and Voluntary Organizations in FW programme

1. The National Population Policy envisages increasing role of NGOs/Voluntary Organisations (VOs) in building up awareness and advocacy for RCH interventions and also in improving community participation to ensure optimal utilization of available services. Under the RCH Programme the activities under the NGOs are increasingly getting streamlined. Earlier a number of NGOs who were getting funding from the Department of Family Welfare were relatively smaller. Several of the grass root level organizations did not have adequate technical knowledge and skills required for both advocacy and for decentralized planning in RCH Programme. In view of this the Department had evolved a concept wherein a number of well established NGOs such as Family Planning Association of India, Voluntary Health Association of India and Gandhi Gram Rural Institute are given the task of selecting, training, assisting and monitoring of smaller Field NGOs for carrying out the following functions: -  Advocacy for maternal child health interventions and small healthy family;  Improving community participation;  Counselling and motivating adolescent to delay the age at marriage, young couples to delay first pregnancy and couples with two children to limit their families by use of appropriate contraceptive method;  Act as a bridge between community and health care Past Experience of NGOs in Running providers Government PHCs and District Hospital . Maharashtra: Currently the Department  Mandwa Experiment of FRCH. of Family Welfare has 97 Mother  Gadchiroli experiment – Responsibility of NGOs covering a total of 412 running a District Hospital – Ended after districts. The number of Field initial success; field operations providing NGOs covered are over 800. In health care to the tribal population 10 states these NGOs cover all continues. districts. However, the states Rajasthan which are having high fertility NGOs running a PHC: Did not succeed – Got into and mortality still have large litigation number of districts without any . Gujarat NGO activities .The state Govt SEWA Rural- Successful in running a PHC at have also been trying involve Jagadia of NGO s in providing services by adopting a PHC/District hospital. Some of the experiments in this regard are shown in the Text box. As can be seen the results are mixed and hence needs to be carefully monitored.

60 During the Tenth Plan NGOs will have a major role in sensitizing the community in the following areas: -

 Gender sensitivity and advocacy for adequate care for girl child;  Baby-friendly hospital initiative and promotion of exclusive breast-feeding for six months in the community;Advocacy for introduction of semi-solids at the right time  Social marketing of contraceptives, ensuring easy availability of ORS/social marketing of ORS;  Sensitizing the community regarding the adverse consequences of prenatal sex determination and sex selective abortions.

The Department of Family Welfare has also proposed that the NGOs may adopt PHCs/sub-centres for effective service delivery only if they have adequate expertise and experience. The interventions undertaken by the NGOs will be independently assessed at the end of the project period. Funding of the NGOs will be dependent upon mid-term evaluation on specific bench-marks. Efforts will be made to improve networking between the NGOs, State district administration as well as Panchayati Raj institutions.

Private Sector Participation in RCH Over 80% of the practitioners of modern medicine and higher proportion of the ISMandH practitioners work in private sector. It is estimated that the private sector provides more than three quarters of all curative health care services; their contribution to MCH and family planning services however less than a third. The major limitations in the private sector include the following:  the focus has till now been mainly on curative services;  the quality of services is often variable;  poorer sections of population cannot afford to pay for these services. Under the RCH programme several initiatives were taken to improve collaboration between public and private sector in providing FW services to the poorer segments of population especially in underserved areas. Efforts were made to increase the involvement of private medical practitioners in RCH care by providing them orientation training and ensuring that they have ready access to contraceptive, drugs and vaccines free of cost so that they could provide these services in a cost-effective and sustainable basis. These efforts will continue and get augmented during the Tenth Plan. Private sector represents an untapped potential for and improving coverage quality of reproductive and child health services in the country. The challenge is to find ways and means to optimally utilise their potential.

Role of other organisations

The Governmental efforts alone will not be sufficient to achieve the desired goals of the Family Welfare Programme. The organised sector covers about 14% of the country’s population. Industry can improve acceptance of Family welfare services by educating, motivating their workers and improving access to services. Industries which

61 provide health care to their personnel and their families can extend these facilities to the people living in the vicinity especially when the industrial units are located in underserved peri urban and rural areas. They may adopt an area specific approach improve services available in a District/ Block by adopting it and investing in improving the facilities. Smaller industries could form a cooperative group for providing health and family welfare services in collaboration with the government. Managerial and other skills available in the industry can be made available to improve efficiency of service provided by the government infrastructure. The marketing skills of industry may be useful in improving the IEC&M activities and in social marketing.

Labour force in the organised and unorganised sector and their families require coverage to achieve rapid improvement in health and demographic indices. Trade unions can expand their role to cover health care of workers and their families. During the Ninth Plan period Family Welfare Projects have been undertaken in the unorganised and semi-organised sectors in different areas in the country such as the Working Women Forem in Tamil Nadu; Plantation Workers in West Bengal; Tribal Population in Gujarat; Beedi Workers in UP, MP, Orissa and West Bengal and Milk Producers in Gujarat. The lessons learnt from these projects will be utilisied to improve access to FW services. During the Tenth Plan attempts will be made to enhance the quality and coverage of Family Welfare services through involvement and participation of organised and unorganised sectors of industry, agriculture, trade/labour , agriculture workers and labour representatives. The problem solving approach of corporate sector can be used in improving operational efficiency of the health care infrastructure.

Resources Table 13. Year Outlays DBS EAP Total % Share of EAP 1992-93 8121.5 1878.5 10000.0 18.79 1993-94 10423.5 2276.5 12700.0 17.93 1994-95 10779.0 3521.0 14300.0 24.62 1995-96 11681.5 4128.5 15810.0 26.11 1996.97 11855.0 3495.0 15350.0 22.77 1997-98 13167.0 5126.5 18293.5 28.02 1998-99 17268.5 7625.0 24893.5 30.63 1999-2000 22444.0 6756.0 29200.0 23.14 2000-2001 22420.0 8000.0 30420.0 26.30 2001-02 28080.0 8583.0 36663.0 23.41 2002-03 39800.0 9500.0 49300.0 19.27

While according priority to population stabilisation efforts, the Govt. of India has increased budgetary allocations by over 300% during the last ten years. The allocation for the current year is $1000 million. This includes resources flowing in from external partners e.g. World Bank, European Commission, USAID, UNFPA, DFID, UNICEF, JICA,WHO, DANIDA and GTZ. The assistance from these partners has been to the extent of 26%.

62 Section 13. Other issues

 National Population Policy (NPP)

Government of India adopted the National Population Policy in February 2000. The overriding objective is economic and social development and to improve the quality of lives that people lead, to enhance their well-being, and to provide them with opportunities and choices to become productive assets in society. It is an articulation of India’s commitment to the ICPD agenda as applied to the country, and forms the blue print for population and development related programmes in the country. Further, the Policy 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. A cross cutting issue is the provision of quality services and supplies, information and counselling, besides arrangement of basket of choices of contraceptives, in order to enable people make informed choices and enable them to access quality of health care services.

The NPP 2000 provides a Policy framework for advancing goals and prioritising 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 of 2.1) 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 comprehensive package of reproductive and child health services by Government, industry and the voluntary/non government sector working in partnership. The schemes/programmes have been undertaken to implement the strategic themes listed in the population policy for achieving the immediate objective of meeting the unmet needs for contraception, health care infrastructure and trained health personnel and to provide integrated service delivery for basic reproductive and child health care. Some of the major socio-demographic goals to be achieved by 2010, which will lead to stable population by 2045, are: -

1. To meet the demands in full for basic reproductive and child health services, supplies and infrastructure. 2. Reducing infant mortality rate to below 30 per 1000 live births 3. Reducing maternal mortality to below 100 per one lakh live births 4. Achieving universal immunization of children against all vaccine preventable diseases 5. Achieving 80% institutional deliveries and 100% deliveries by trained persons 6. Increasing use of contraceptives with a wide basket of choices 7. Achieving 100% registration of births, deaths, marriages and pregnancies 8. Integrating Indian system of medicines in providing reproductive and child health services 9. Promoting small family norm to achieve replacement levels of fertility by 2010 10. Making school education up to age 14 free and compulsory and reduce drop out at primary and secondary school levels. 11. Promoting delayed marriage for girls

63 12. Bringing about convergences in implementation of related social sector programmes so that family welfare becomes a people’s centered programme

In order to achieve, the above national socio-demographic goals by 2010 the following 12 strategic themes have been identified. These are:

1. Decentralized planning and program implementation. 2. Convergence of service delivery at village levels. 3. Empowering women for improved health and nutrition. 4. Child Survival and Child Health. 5. Meeting the unmet needs for family welfare services. 6. Under-served population groups:

a) Urban slums; b) Tribal communities, hill area population and displaced and migrant populations; c) Adolescents; d) Increased participation of men in planned parenthood.

7. Diverse health care providers. 8. Collaboration with and commitments from non-government organizations and the private sector. 9. Mainstreaming Indian Systems of Medicine and Homeopathy. 10. Contraceptive technology and research on reproductive and child health. 11. Providing for the Older Population. 12. Information, Education and Communication.

The NPP is gender sensitive and incorporates a comprehensive and holistic approach to health and education needs of women, female adolescents and girl child. It also seeks to address the constraints to accessibility to service due to heavily populated geographical areas and diverse socio-cultural patterns in the population. A primary theme running through the NPP is provision of quality services and supplies and arrangement of a basket of choices. People must be free and enabled to access quality health care, make informed choices and adopt measures for fertility regulation best suited to them. It is in this spirit that the NPP advocates a small family norm.

 National Commission on Population (NCP)

Population stabilization efforts are a matter of priority for the government. This is reflected in the fact that Prime Minister of India heads the National Commission on Population (NCP), which was constituted on 11th May 2000. The Commission is to review, monitor and give direction for implementation of the National Population Policy with a view to achieve the goals set in the Population Policy.

64  Empowered Action Group (EAG)

Substantial differences are visible between States in the achievement of basic demographic indices. This has led to significant disparity in current population size and the potential to influence population increase. 55% of the increase in the population of India is anticipated in the eight States of Uttar Pradesh, Madhya Pradesh, Bihar, Rajasthan, Orissa, Uttaranchal, Chhattisgarh and Jharkhand. It is, precisely, these States that are perceived to be the most deficient in critical socio-demographic indices. An Empowered Action Group (EAG) has been constituted so that these States will get focused attention which will promote accelerated achievement for different programmes of health and family welfare – so that there is a tangible improvement of the performance. The EAG facilitates the preparation of area specific programmes to address the unmet need for supplies, services, health care providers and health infrastructure.

 National Population Stabilization Fund (NPSF)

At the first meeting of the National Commission on Population a decision was taken for the setting up a National Population Stabilization Fund (NPSF). The objective of the Fund is to provide a window for canalizing resources from national voluntary organizations corporate sector, industry, trade, organizations and individuals etc. to aid projects of population stabilization.

Initiatives To Address The Needs Of Underserved Population

Access to health care is poorer in the States like Uttar Pradesh, Madhya Pradesh, Bihar, Rajasthan. The Empower Action Group (EAG) constituted in the Department of Family Welfare reviews the available infrastructure, performance of the health system and health indices and suggest steps for improving access to health care so that there is rapid decline in fertility and mortality. During the Tenth Plan special efforts will be made to upgrade the capacity of health system in these states/districts to meet all the felt needs for care so that there is rapid decline in both fertility and mortality. This is an essential step if the ambitious goals for decline in fertility and mortality set in NPP 2001 are to be achieved because these states/districtrs contribute to over 50% of the country’s mortality and fertility.

Tribal population (except in the northeastern states); majority of tribal population face problems in accessing essential health care services and have poor health indices, Department of Family Welfare has already initiated several programmes with focusing meeting the health care needs of tribal population. These will be continued during the Tenth Plan. Special efforts will be made to address the health needs through area specific programmes. Increasing involvement of NGOs and tribal community in all activities is envisaged.

Urban slum population has been shown to have poor maternal and child health indices. In many slums immunization coverage is very low and children are

65 undernourished. The Department of Family Welfare and Department of Health have been investing in improving urban primary health care infrastructure and ensuring that they are linked to existing secondary and tertiary care institutions. The IPP V, VIII and Urban RCH Pilot Projects have build up capacities of urban health system in several cities. Efforts to rationalise urban health care and improve efficiency so that reproductive care needs are fully met within available infrastructure will be continued during the Tenth Plan period.

Strategies for Increasing Efficiency A vast infrastructure for delivery of health and family welfare services has been created over the last three decades based on uniform norms for the entire country. Evaluation studies have shown that they are functioning sub optimally because of  Mismatch between structure and function;  Lack of skill up gradation training to update their knowledge skills and programme orientation  absence of proper medical hierarchy with well defined functions;  lack of first line supervision and mechanism to bring about accountability;  absence of referral system and lack of functional FRUs. Under the RCH Programme DOFW has invested heavily in training of Programme Managers in managerial aspects for effective implementation of RCH programme including decentralized district-based planning, implementation, monitoring and mid- course corrections. Skill up gradation of all categories of the health care professionals and paraprofessionals is envisaged for improving the quality of screening and management of persons with complications including referral as and when required. It is expected that these efforts will promote effective functioning of the infrastructure and improve efficiency. These efforts to make the health system effective and efficient will continue during the Tenth Plan period .

66 Though all states have shown some improvement in access to health care the health and demographic indices over time, the rate of change has been very slow in some states. Efforts during the Ninth Plan to provide more funds to these states/ districts to improve infrastructure and manpower, and making schemes for implementation more flexible to enable private, voluntary sector participation has not succeeded in accelerating the rate of change in access to health care or improvement in the health indices. During the Tenth Plan, efforts will be made to improve efficiency by undertaking task analysis, assigning appropriate duties/ tasks to designated functionaries and training them to act as a multi-professional team. In such a chain, the first link will be provided by the village-based workers who will act as a liaison person between the people and health functionaries and ensure utilisation of available facilities. The Panchayati Raj Institutions will participate in the planning and assist in the implementation and monitoring of the programme. The ANM will administer vaccines, screen infants, children and pregnant women, identify and refer the "at risk" persons to appropriate institution. The medical officer at PHC will undertake PHC- based planning and monitoring of the Health and Family Welfare programmes and provide curative services, organise and supervise preventive and promotive health and family welfare-related activities and develop a viable, functional referral systems. The specialists in CHC will provide appropriate emergency care and care for referred patients, participate in the development of the CHC based RCH programmes, monitor the activities and initiate midcourse corrections. If this pattern of functioning is followed, the community, the link worker and the health functionaries will be performing the tasks that they are best suited to do and the implementation of the programme will improve because of linked effective functioning of the entire system.

 Involvement of the PRI in Family Welfare Programme

 Ninth Plan envisaged Involvement of Panchayati Raj Institutions for:  Ensuring inter-sectoral coordination and community participation in planning, monitoring and management of the RCH programme.  Assisting the states in supervising the functioning of health care related infrastructure and manpower such as Sub-Centres (SCs), Primary Health Centres (PHCs) and Aganwadis.  Ensuring coordination of activities of workers of different departments such as Health, Family Welfare, ICDS, Social Welfare and Education etc. functioning at village, block and district levels.  Improving the acceptance of the FW programme through increased community participation.

 There are massive differences between the states in involvement of PRI in Family Welfare Programme. States like Kerala have embarked on decentralized planning and monitoring programmes utilizing PRIs and devolution of powers and finances to PRIs. Rajasthan, A.P. and Haryana have implemented their own models for involvement of the PRIs in the health sector, delegation of responsibilities to PRIs and devolution of funds. In other states the involvement is

67 mainly in planning and monitoring without devolution of power and finances. In some states the PRIs have not yet started participating in the programme. There is a need to constantly review the situation and initiate appropriate interventions.

The real challenge of family welfare programme lies in effectively delivering the needed services in the remote, inaccessible, hilly, tribal and desert areas where the services provided by the government machinery are the weakest and private/NGOs Sectors are non-existent. During the Tenth Plan it is envisaged that mature Panchayati Raj Institutions with intelligent, service oriented members and committed to the public agenda will play a key role making the family welfare programme a people’s programme and improving access and utilization of FW services. The Health Committee of the Gram Panchayat, can plan and act locally, identify area specific unmet needs for reproductive health services and ensure that efforts are made to meet them. Gram Panchayat can be entrusted with a task of monitoring the attendance of service personnel and their performance. The PRIs can play a vital role in programme advocacy, monitoring the availability, accessibility and quality of services in Govt. primary health centers, NGOs and private practitioners and cost of services provided by the latter . The PRIs will have the Advance tour programmes of the ANM, MPW, a list of nearest functioning PHC with a Doctor, nearest FRU/CHC with a Pediatrician, Obstetrician, Surgeon or Physician where persons with complications and those requiring emergency care could be referred. They will monitor the funding of emergency transport provision as well as dispersal of funds under BSY and Maternity Benefit Scheme. Active role and supervision of the PRIs is also crucial for ensuring 100% registration of births, deaths, marriages and pregnancies at the village level.

Inter-sectoral Coordination Inter-sectoral coordination especially with Deptt of Health, Deptt of Women and Child Development, Human Resource Development, Rural Development, Urban Development, Labour, Railways, Industry and Agriculture is critical for increasing the coverage improving implementation of Family Welfare Programme. Some of the areas where inter-secrtoral coordination is envisaged during the Tenth Plan include :  Involvement of the extension workers of these Deptts in propagating IEC messages pertaining to reproductive and child health care to the population with whom they work.  Efforts to improve the status of girl child and woman, improving female literacy and employment, raising the age at marriage, generating more income in rural areas, improving nutritional status of women and children.  Coordination among village-level functionaries - namely Anganwadi workers, Mahila Swasthaya Sangh (MSS), Traditional Birth Attendant (TBA), Krishi Vigyan Kendra (KVK) Volunteers, School teachers to achieve optimal utilisation of available FW services. Suggested areas of convergence of services with Deptt of Education include :  Inclusion of Health, Nutrition and Population related educational material in the curriculum for formal and non-formal education.

68  Involvement of all districts Saksharata samitis in IEC activities pertaining to RCH Programme.  As a part of socially useful productive work involve school teachers and children in Class V and above in growth monitoring , immunisation and related activities in the village at least once a month. Convergence of services with the Deptt of Women and Child Development include :  Involvement of Anganwadi workers in compilation of local events such as births, deaths, identification of pregnant women  Involve Anganwadi workers in taking birth weight as soon as possible after delivery and refer neonates with weight below 2.2 kg to centres where paediatricain is available  Utilisation of Anganwadi worker in improving coverage of massive dose Vitamin- A in children (18,24,30 and 36 months ) and improving compliance in Iron-folic acid medication in pregnant women.  Identification of undernourished pregnant and lactating women and preschool children to ensure that they are given priority attention for food supplementation programmes under ICDS and appropriate health care from ANM/doctors.  In coordination with members of Panchayati Raj Institutions and agricultural extension workers to promote growing of adequate quantities of green leafy vegetables, herbs and condiments and ensure that these are supplied to anganwadies on a regular basis so that food supplements have vitamin and mineral.

The anganwadi worker can assist the ANM in organizing health check up of women and children and immunization in the anganwadi. She will act as depot holder for IFA, ORS , condoms and disposable delivery kit so that the village population have ready access to these. She can monitor regularity of IFA intake in pregnant women . She will be provided with a list indicating nearest facility to which women and children could be referred so that she can help in organising emergency referral.

Infertility It is estimated that between 5 to 10% of couples are infertile. While provision of contraceptive advice and care to all couples in reproductive age group is important, it is equally essential that couples who do not have children have access to essential clinical examination, investigation, management and counseling. The focus at the CHC level will be to identify infertile couples and undertake clinical examination to detect the obvious causes of infertility, carry out preliminary investigations such as sperm count, diagnostic curettage and tubal patency testing. Depending upon the findings, the couples may then be referred to centres with appropriate facilities for diagnosis and management. Gynaecological Disorders Women suffer from a variety of common gynaecological problems including menstrual dysfunctions at peri-menarchal and peri-menopausal age. Facilities for diagnosis of these are at the moment available at district hospitals or tertiary care centres. During the Tenth Plan period the CHCs, with a gynaecologist, will start

69 providing requisite diagnostic and curative services. Yet another major problem in women is prolapse uterus of varying degrees. The PHCs and CHCs will refer women requiring surgery to district hospitals or tertiary care centres. Cancer Cervix is one of the most common malignancies in India and accounts for over a third of all malignancies in women. Cancer Cervix can readily be diagnosed at the PHCs and CHCs. Early diagnosis of Stage I and Stage II and referral to places where radiotherapy is available will result in rapid decline in mortality due to Cancer Cervix in the country in the near future. Access to RCH services

Data from research studies and clinical experience shows that social and economic deprivation deprivation are associated with poor health outcome. Poor health in turn results in deterioration of economic status partly due to loss of wages and partly

Immunisation Coverage-Tamil Nadu Immunisation Coverage-UP 100% 100% 80% 80% 60% 60% 40% 40% 20% 20% 0% 0% P oorest next m id 20% next richest P oorest next m id 20% next richest 20% 20% 20% 20% 20% 20% 20% 20%

Full Partial none Full Partial none due to cost of health care. Specific efforts have been made to focus on health and nutrition interventions so that these vulnerable segments have better access to health and nutrition services and the vicious circle of poverty and ill health is broken. However, in spite of efforts over the last five years better access to public health services continues to elude poorer segments of the population and those whose needs are the greatest. While this is true in all States, data from Rapid Household Survey showed that interstate comparison bring out some interesting findings poorest quintile population in Tamil Nadu have better immunization coverage rates than the richest quintile in UP suggesting that socioeconomic barriers can be overcome through improved awareness and access.

During the Tenth Plan every effort will be made to improve access to essential primary health care; family welfare services and diseases control programmes totally free of cost. States/Centre are evolving and evaluating various options for reducing the financial burden posed by hospitalization among the poor.

Approach During the Tenth Plan: During the Tenth Plan efforts: to assess and meet the unmet needs for contraception; to achieve reduction in the high desired level of fertility through programmes for reduction in IMR/MMR; to enable the families to achieve their reproductive goals will continue. If the reproductive goals of families are fully met it is possible to achieve the NPP goal of replacement level of fertility by 2010. The medium and long term goals will be to continue this process accelerate the pace of

70 demographic transition and achieve population stabilisation by 2045. Early population stabilisation will enable the country to achieve its developmental goal of improvement in economic status and quality of life of the citizens. During the Tenth Plan the paradigm shift which began in the Ninth plan from:  Demographic targets to focus on enabling the couples to achieve their reproductive goals.  Method specific contraceptive targets to meeting all the unmet needs for contraception to reduce unwanted pregnancies.  Numerous vertical programmes for family planning and maternal and child health to integrated health care for women and children.  Centrally defined targets to community need assessment and decentralised area specific micro planning and implementation of health care for women and children to reduce infant mortality and reduce high desired fertility.  Quantitative coverage to emphasis on quality and content of care  Predominantly women centred programmes to meeting the health care needs of the family with emphasis on involvement of men in Planned Parenthood.  Supply driven service delivery to need and demand driven service; improved logistics for ensuring adequate and timely supplies to met the needs.  Service provision based on providers perception to addressing choices and conveniences of the couples will be fully operationalised . Reductions in fertility, mortality and population growth rate will continue to major objectives during the Tenth Plan; three of the eleven monitorable targets for the Tenth Plan and beyond are:  reduction in IMR to 45 /1000 by 2007 and 28/1000 by 2012,  reduction in maternal mortality ratio to 2/1000 live births by 2007 and 1/1000 live births by 2012 and  reduction in decadal growth rate of the population between 2001-2011 to16.2.

The focus will be on improving access to services to meet the health care needs of women and children by:  decentralized area specific approach to planning , implementation and monitoring of the performance and effecting mid course corrections  differential strategy to achieve incremental improvement in performance in all states/districts  special efforts to improve access to and utilization of the services in states/districts with high mortality and /or fertility rates  filling the critical gaps (especially CHCs) in existing infrastructure through appropriate reorganization and restructuring primary health care infrastructure  ensuring that post of specialists in CHC/FRU do not remain vacant; skill upgradation and redeployment existing manpower to fill other critical gaps  streamlining the functioning of the primary health care system in urban and rural areas; providing good quality integrated reproductive and child health services at primary, secondary and tertiary care and improving the referral services

71  providing adequate supply of essential drugs, diagnostics and vaccines; improving the logistics of supply;  well co-ordinated activities for delivery of services by public, private and voluntary sectors to improve coverage;  involvement of the PRI in planning, monitoring and midcourse correction of the programme at local level  involvement of the industries, organised and unorganised sectors, agriculture workers and labour representatives in improving access to RCH services ;  effective use of social marketing to improve access to simple OTC products such as ORT and condoms  effective Information , Education, Communication and Motivation  effective intersectoral co-ordination between concerned sectors

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