Family Planning in India: Recent Developments in September 1965 K

Family Planning in India: Recent Developments In September 1965 K. S. Sundara Rajan published an article on "India's Population Problem" in Finance and Development. In this article he surveys this great problem—so important in its implications for the entire developing world—in the new perspective given by two further years of effort in India. K. S. Sundara Rajan

N AUGUST 1966 the population of India rate has dropped only by some 20 per cent in I crossed the 500 million mark. Since then it this same period. Life expectancy at birth, has been increasing at a rate of more than a which was only 32 years in 1950, had jumped million a month. We in India have to contend to 50 years by 1966. It was because of this with an annual increase in population which sharp fall in deaths that the population began is more than the total population of Australia, to soar. As long as this irresistible increase in or that of Norway and Sweden combined. If population continues, the gains arising from things go on at the same rate, India will have India's economic development are eaten up a billion people just 27 years from now—as and efforts to raise the standards of living of many people as there were in the whole world the people through Five Year Plans are nulli- in 1830. fied. This tidal wave of population in India and Lowering the Birth Rate in many other developing countries is not the result of any striking increase in birth rates i>ut The target set by the Government of India of a truly spectacular and successful fight early in 1965 was to bring down the birth rate against death and disease. Over the years the from the then 41 per thousand to 25 per thou- death rate in India has actually been falling, sand within as short a time as possible. This as the accompanying chart shows. In the decade is to be achieved by adopting all known meth- 1911-21, the death rate was 48.6 per thousand, ods of contraception and by motivating the and in the intervening half century it has been people to adopt these. What does this target brought down by almost 75 per cent to 14 per mean? There are at present 90 million couples thousand last year (see Chart 1). But the birth in the reproductive age group in India. To

250

©International Monetary Fund. Not for Redistribution Family Planning achieve the birth rate target of 25 per thou- leadership was convinced of the urgency of sand, at least half the couples in the child- the problem and the need to take action, the bearing age must practice contraception regu- same urgency was not felt at middle levels and larly. In other words, we have to raise the at state levels. One reason was a basically percentage of couples doing so from the present conservative attitude with regard to this highly 5 per cent to 50 per cent of the childbearing personal matter. An even more important fac- age group. Since the number of childbearing tor was the lack of a safe, cheap, and reliable couples increases pari passu with population, method of contraception, which was at the by the early or mid-1970's at least 70 million same time simple enough to be adopted by the villagers. There was also a lack of trained personnel. Under the Constitution of India, health, which includes family planning, is a state re- sponsibility, and the central government can only advise and assist. The family planning bureaus in the states did not function very effectively. Though the central organization was better, it did not have the necessary financial backing. The Third Five Year Plan (1961/66) was important in the history of family planning efforts. That Plan stated unequivocally that the objective of stabilizing the growth of population must be at the very center of planned development and sharply stepped up the pro- Birth control information and supplies must be vision of funds to Rs 270 million ($57 million). made available to 90 million couples. Even these new efforts, however, took some time to gather momentum. Starting in 1963, couples must be practicing contraception regu- far-reaching changes in organization were in- larly. The magnitude of the task will be appre- troduced. Family planning in the rural areas ciated if it is realized that 80 per cent of these was made part of the extension activities. The couples reside in 560,000 villages and that technical direction of the Plan at the center many of them are illiterate. Most of them will was greatly strengthened, and in 1965 a Com- be conservative and shy, as are villagers every- mittee of the Cabinet was constituted specifi- where. They present vast problems both in cally for family planning. This Committee is persuasion and in logistics. now presided over by the Prime Minister her- The Indian government was the first any- self. In 1966, a new Department of Family where to adopt an officially sponsored family Planning was created in the central govern- planning program. Funds were provided in the ment. In preparing the Fourth Plan (1966/71), First Five Year Plan which began on April 1, family planning was given the highest priority 1951. But progress during the first ten years next only to agricultural production. The Plan was painfully slow. Although the country's top provided Rs 2,29 billion ($306 million) whi<&

251

©International Monetary Fund. Not for Redistribution Finance and Development

the country—the President, the Prime Minister, the Cabinet Ministers, and State Chief Min- isters.

The Family Planning Program The chart on page 257 indicates the present organization of family planning in India. At the top there is a Cabinet Committee for family planning headed by the Prime Minister and including the Deputy Prime Minister and the central Ministers for Planning, Health and Family Planning, and Social Welfare. The Department of Family Planning is headed by a Secretary, and it has a secretarial wing and a technical wing headed by a Commissioner of Family Planning. The secretarial wing deals K. S. Sundara Rajan was born in Madras with planning and policy matters, issue of sanc- and graduated from Madras University in tions and grants, development, budget, and co- 1934. He has been serving the Government of ordination with state governments. The tech- India for 27 years in a variety of posts, including those of Commissioner of Income Tax nical wing provides the technical advice and and Joint Secretary for External Finance. He direction and also keeps track of the progress has been Executive Director for India at the and implementation of the various aspects of World Bank and Minister (Economic) in the the program in the country. There are six re- Embassy of India in Washington since 1963. gional health offices of the Government of In- dia, each headed by a Regional Health Di- rector to watch and help in the progress of was eight times the amount provided in the family planning work in the states falling with- Third Plan and represented the equivalent of in their respective jurisdictions. Rs 26 ($3.50) for every couple in the repro- The states have their own family planning ductive age. Though this amount is large, it Cabinet Committees and their family planning has been made clear that further funds as re- bureaus. To ensure close cooperation between quired would be made available. Further, the central government agreed to finance the the state and central governments and to evolve whole of the capital expenditure incurred by new policies as well as to review progress and the states in family planning and practically the exchange experience, there is a central Family whole (97 per cent) of the recurring expendi- Planning Council with the Union Minister for ture. Administrative and financial controls Health and Family Planning as chairman and which had hampered the program in the early state ministers for health and family planning years were removed and the jungle of red tape and others prominently connected with family cut through. Most important, there was the planning work as members. Each of the 335 public commitment of the top leadership in districts (population 1-3 million) in the states

252

©International Monetary Fund. Not for Redistribution Family Planning has its own family planning bureaus. Under creased to 46. District level units are also being the district bureau, there are urban and rural established. family planning centers and subcenters. The objective is ultimately to have one urban family Mass Communication and Education welfare center for every 50,000 of urban popu- In the final analysis, the success of the pro- lation, one rural primary health center for a gram will depend on the extent to which the rural population of 80,000, and a subcenter for average man and woman in the country can be a population of 10,000. made aware of family planning and be moti- Full cooperation with the public, particularly vated to practice birth control. Information and the doctors, surgeons, and gynecologists, is knowledge must be made to flow throughout sought at the various stages. There are expert the country in the 13 regional languages as committees set up to advise the Government of well as in Hindi and English. It has to reach India on research and evaluation, and separate every one of the cities and towns and villages. technical committees to advise on the intra- Ultimately this knowledge, together with sup- uterine contraceptive device (IUD) and sterili- plies and services, must be made available to zation; the universities and research institutions every one of the 90 million (140 million in are fully associated with these committees. 1975) couples in the reproductive age group. In addition a large volume of technical infor- Proper training of the medical, paramedical, mation has to be distributed to all types of and mass communication personnel is an essen- workers within the total family planning or- tial prerequisite for the success of the family ganization. Simultaneously, contact must be planning program. Each one of the 125,000 maintained with political, religious, social, in- program personnel must be personally con- dustrial, and educational leaders, as well as vinced of the urgent necessity of curbing the the news media, to ensure that the tempo of present disastrous rate of population growth; the program is kept up. every one of them must be given the skills re- quired for doing the job effectively. This train- All available mass communications media ing task is perhaps the single most critical are being utilized including booklets, posters, problem confronting the program. and flash cards. Every station in the All India Radio network has special family planning A comprehensive program developed in con- cells and there is a specific time slot every day sultation with the state governments provides for training of 1,500 key personnel at the state for a family planning program. Films of various and distinct levels in five central training insti- lengths and themes have been .produced for tutes. The remaining 123,500 field workers are exhibition in commercial theaters as well as in being trained at the state and district levels. mobile publicity vans. The objective is to have So far 2,727 doctors and 9,471 other personnel at least one such van for each district. The have undergone long courses at the five training press is carrying stories, commentaries, and ad- centers. In addition, 8,056 doctors and 64,578 vertisements. Family planning exhibits, by other personnel had undergone short courses themselves or through stalls in other fairs, are by midsummer of last year. There are now 31 being held throughout the country. Hoardings state training centers and these will be in- and bus boards have been erected all over the

253

©International Monetary Fund. Not for Redistribution Finance and Development

planning; 75,000 workers are to be employed on this kind of work. Because of the sensitive nature of the program, emphasis is placed on individual counseling and small group dis- cussions. Married couples in the reproductive age group must be informed of the methods and services that are available and assisted in se- lecting the method best suited to them as in- dividuals. Many couples require reassurance and evidence of community approval of their decision to practice birth control. Therefore every effort is made to enlist the support and active participation of voluntary organizations, particularly women's organizations and leadership groups. Full financial assistance is given to them by the central government. The objective is to have honorary education leaders for every state, district, block, and village.

Choice of Contraceptive Method The choice of the method of contraception is left to the individual's free decision. Conven- tional contraceptives (jellies, creams, foam tab- lets, diaphragms, and prophylactics) are sup- plied free at the center. Services in the form of IUD insertions, and both male and female sterilizations, are not only provided free but also with some compensation to the individual country, although not all of the rural areas have for such minor expenses as bus fare and other been effectively covered as yet. A simple, easily incidentals. recognizable and easily reproducible symbol— an inverted equilateral triangle in red—has Of the conventional contraceptives, prophy- been adopted as a symbol of family planning. lactics have been found to be potentially the This red triangle is used on all family planning most popular. Pilot projects carried out in rural centers, contraceptive supply packages, and on areas last year established the great accept- literature, vehicles, and the clothing of field ance of this device, and its use is featured in workers. It identifies the center, the depots, the present Indian program. In the current year and the workers to illiterate persons. 200 million are expected to be used, a six-fold The extension educators in the field have to increase over the previous year which itself was complete the communications task by directly a sharp increase over the earlier years. Distri- motivating married couples to adopt family bution of such a large number of prophylactics

254

©International Monetary Fund. Not for Redistribution Family Planning is no easy task. The present arrangements en- also encouraged to carry out the operations and visage (1) free supplies through family welfare can claim their fees from the government centers and hospitals; (2) supplies at nominal at prescribed rates. Male sterilization is also rates (US$0.007 for three) through depot carried out in mobile vans, and eventually holders (postmen, school teachers, private med- each of the 335 districts will have a steriliza- ical practitioners, and the like will be appointed tion van. That this method has after all reached part-time depot holders); and (3) commercial the rural areas is evidenced by the great in- distribution (at the rate of US$0.02 for three) crease during last year. Over 862,000 opera- through commercial houses and distribution tions were carried out during the 12 months chains dealing with such common articles of ended March 1967; this represents 68.1 per everyday consumption as tea, cigarettes, cent of the target set to be attained under matches, soap, etc. The central government optimum conditions. The total number of steri- supplies the prophylactics free to the commer- lizations carried out up to the end of June 1967 cial distributors and even bears a portion of was 1.76 million, of which almost one third has the distribution costs and overheads. The nomi- been carried out in the State of Madras alone. nal price charged is only to ensure that the Other states, including some that have been device is not thrown away or wasted. Even the lagging behind in family planning work, are higher price charged covers only part of the catching up, and this development holds a good distribution costs. deal of promise. The target set for the year 1967/68 is 1.5 million sterilizations, and it Factories in India can manufacture only 60- may even be surpassed. 70 million prophylactics a year, so the major portion of the country's requirements are im- One state government has proposed compul- ported. To cope with the increasing demand, sory sterilization for couples who have three the government is establishing a factory in the living children. Some Chief Ministers, however, State of Kerala. This factory, with a capacity feel that better results could be achieved of 144 million prophylactics a year, will go into through persuasion than through compulsion. production by the end of 1968. There are al- The central government is, however, carefully ready expansion plans for it to double its pro- examining the legal, social, and political aspects duction. Private sector units are also expanding of this proposal and has indicated that any leg- their capacity to produce 112 million a year. islation in this direction will be introduced only after the fullest consultation of public opinion. Sterilization A much more popular and a much less con- Sterilization of both the male (vasectomy) troversial proposal is that made by the Min- and female (tubectomy) has been a method of ister of Health and Family Planning recently to family planning in India for some time. The present a transistor radio to every man or chief advantage of sterilization is that it is 100 woman undergoing sterilization. Transistor sets per cent effective and, at least for males, has are greatly in demand in India and have high practically no side effects. Sterilizations per- prestige value. Sterilized persons who had formed in government hospitals and family hitherto remained silent for understandable planning centers are free; private doctors are reasons will in effect now talk through their

255

©International Monetary Fund. Not for Redistribution Finance and Development radio sets, which will be the ideal vehicle for shortfall was due not only to the genuine carrying the message of family planning in failures and difficulties; there were also wild rural areas. rumors set afloat by interested parties that loops would cause cancer and were giving elec- Lippes Loop tric shocks to the husband, and so on; such rumors did a lot of damage to the IUD pro- After numerous studies and trials, the Gov- gram. These doubts have now been set at rest ernment of India in July 1965 embarked on a by extensive studies and follow-up work car- vast IUD program, using the Lippes loop. ried out by leading gynecologists and research Hailed as the ideal contraceptive, the Lippes workers in several medical colleges and univer- loop became very popular within the first few sities as well as in the field. These studies have months, particularly with persons who had been shown that while the rate of expulsion, bleed- using the conventional contraceptives. Dr. Jack ing, etc., is higher in India than in Taiwan, the loop has been effective and without ill effects for 70 per cent of the women. A pilot study of 13,789 cases demonstrated that some 69.6 per cent had satisfactorily retained the loop after 12 months and 58.75 per cent after 24 months. As a result of researches in India, certain improvements have been carried out to the Lippes loop; loops are now made with a globule at one end to safeguard against the puncturing of the uterus. Experiments are also being carried out with changes in size and shape of the loop. Fortunately there is no dearth of loops; they are made in India and the production is ade- quate. Greater care is now being given to follow-up work, and it is hoped that, with all these improvements, the target of 2 million in- India's spectacular fight against death and dis- sertions for the current year (1967/68) will ease is offset by soaring population gains. be achieved. Lippes, the American inventor of the loop, who The Indian Council of Medical Research is visited India in June 1966, was impressed with carrying out studies of the various types of the number of insertions achieved in some oral contraceptives. Though pills have not yet states. The program has, however, fallen short been introduced as part of the official program, of its earlier expectations. While the Lippes loop selected brands have been allowed to be mar- is simple and cheap, it nevertheless encountered keted in India as oral gestogens. They can, some resistance. In the first 9 months of the however, be purchased only with a doctor's program, 800,000 loops were inserted, but the prescription, and the user is advised to have a insertions during the next 12 months were only periodic checkup undertaken by her own phy- 915,000 against a target of 4 million. This sician. Oral contraceptives are somewhat costly

256

©International Monetary Fund. Not for Redistribution HOW INDIA'S FAMILY PLANNING PROGRAM ISORGANIZED

INDIA

CENTAL :

STATE:

257

and may not be suitable for the Indian vil- IUD and on a wide variety of oral contracep- lagers. However, for the 20-30 per cent of tives. Research on animals, for example, has the women who are not able to tolerate or shown that cadmium salts can be used to pro- retain the IUD, the pill may be a good alterna- duce sterility in the male as well as the female. tive, if regularity of use and necessary medical Already field trials have been carried out to checkups can be ensured. Such women are al- sterilize useless cattle through such intraovarian ready motivated and can be expected to be injection of cadmium chloride. Extensive re- careful in their use of the pills. The govern- search has also been carried out to develop a ment is, therefore, considering the use of oral simple, harmless, and low cost postcoital oral contraceptives as an adjunct to the IUD pro- contraceptive. gram. Research is also being carried out on some local herbs used for preventing concep- tion in the indigenous systems of medicine. IUD insertions are, as stated earlier, made only by qualified doctors, and most Indian women prefer to have insertion undertaken by a woman doctor. Though there are 13,000 women doctors in India, not enough are forth- coming for this work, particularly in the rural areas. In order to remedy the situation, the central government has announced scholarships for women medical students on condition that they agree to serve in the family planning program after their graduation for the same Lippes loop: the vast IUD program has fallen period for which they received the scholarship. short of expectations. This novel scheme has had a very favorable Future response. A program of this magnitude encompassing Research some 140 million people in the most personal aspect of their lives cannot run smoothly all the Research in different aspects of the program time. There have been, and there will continue —bio-medical, demographic, communication, to be, snags, difficulties, setbacks, and disap- social, and operational—has been carried out pointments. What is most encouraging now is since its inception; there are at present 9 demo- the widespread realization of the urgency of graphic, 9 communication, and 8 bio-medical the problem and the commitment of the politi- research centers in the country. Besides these, cal leadership of the country to do all that is the Indian Council of Medical Research, the possible to achieve the target. The very fact Central Family Planning Institute, Central that such a revolutionary proposal as compul- Drugs Research Institute, and several univer- sory sterilization of parents with more than sities are carrying out research in various fields. three children was put forward and found ac- Extensive studies are being carried out on the ceptable to a number of state governments and

258

©International Monetary Fund. Not for Redistribution Family Planning many sections of public opinion shows the se- cally supported, and adequately financed. While riousness with which this matter of population we cannot be certain that we will reach our is now regarded in the country. goal of a birth rate of 25 per thousand by 1975, we are confident of coming close to it. Other proposals which are under active con- Already one state (Madras—population 38 sideration are the liberalization of the abortion million) has brought down its birth rate to law to permit families to limit the number of 32.6 per thousand; this is also a state where children without legal difficulty or physical risk, sterilization has been encouraged for a long and the raising of the legal age for marriage time. Some other states are not far behind. The for boys and girls. position may change dramatically if there is a After 16 years, India's program for popula- breakthrough in research and a lasting pill or tion control can truly be said to have come of injection is found. But even as things are now, age. It is now well staffed, mass based, politi- the future is hopeful.

1967 Table of Contents A Table of Contents for Volume IV of Finance and Development, covering 1967, has been prepared and is available in English, French, or Spanish free on request to:

Finance and Development International Monetary Fund Building 19th and H Streets, N.W. Washington, D.C. 20431, U.S.A.

259

IDA. An article on the Bank Meeting by Martin Shivnan appears on page 261. The principal topic at the Fund Meet- ing was the Outline plan for a new facility in the Fund, agreed by the Governors in the course of the Meeting. An account of the Meeting by Alexander G. C. Mountford appears on page 269; an article by J. J. Polak on the new facility —the Special Drawing Right—begins on page 275.

•^The Meetings were held September 25—29 at the new Museum of Modern Art Building in Rio de Janeiro, Brazil. The Annual Meetings of the World Bank and its affiliates, the International Development Association (IDA), and the International Finance Corporation (IFC) were held in September in Rio de Janeiro. Speeches at the Bank Meeting ranged over a variety of topics, among the most important being the replenishment of

Chairmen at the 1967 Meetings were both Nor- wegian: Mr. Kare Willoch, Minister of Commerce and Shipping (left) and Mr. Erik Brofoss, Gover- nor of the Bank of Norway (on the right). ^-

260