India's Population Growth

CHAPTER – 1

INTRODUCTION - POPULATION GROWTH The world experienced dramatic population growth during the twentieth century, with the number of inhabitants doubling from 3 to 6 billion between 1960 and 2000. India, too, saw very rapid population growth during this period – from 448 million to 1.04 billion – and to 1.21 billion in 2010. The effects of past and projected future demographic change on economic growth in India is the main focus of this chapter. Figure 1 plots world population from 1950 to 2050, and shows the share of world population attributable to India; post-2010 data are United Nations (UN) projections.

Global population grew at roughly 2% per annum from 1960-2000, a level that is unsustainable in the long term, as it translates into population doubling every 35 years. India’s population is currently growing at a rate of 1.4% per year, far surpassing China’s rate of 0.7%. The differential between India and China will result in India surpassing China with respect to population size in less than 20 years. While a cause for concern, global population growth has not met Malthus’ pessimistic predictions of human misery and mass mortality. During the past few decades, rapid population growth has been accompanied by an unparalleled decline in mortality rates and by an increase in income per capita, both globally and in India.

GLOBAL WORLD POPULATION
In 1901 the world population was 1.6 billion. By 1960, it became 3 billion, and by 1987, 5 billion and in 1999, 6 billion. Currently, one billion people are added every 12 - 13 years. During the last decade there has been substantial decline in birth rate. The reasons for decline vary from society to society; urbanization, rising educational attainment, increasing employment among women, lower infant mortality are some major factors responsible for growing desire for smaller families; increasing awareness and improved access to contraception have made it possible for the majority of the couple to achieve the desired family size. In some countries slowing of the population growth has been due to an increase in mortality (e.g. HIV related mortality in sub-saharan Africa). As a result of all these the decline in the global population growth during the nineties is steeper than the earlier predictions. Currently, the annual increment is about 80 million. It is expected to decrease to about 64 million by 2020 -25 and to 33 million by 2045 -50; 95 % of the growth of population occurs in developing countries. Most demographers believe that the current accelerated decline in population growth will continue for the next few decades and the medium projections of Population Division of United Nations, that the global population will grow to 8.9 billion by 2050 is likely to be achieved (Figure 1)

POPULATION PROJECTION

The Technical Group on Population Projections set up by the National Commission on Population has recently come out with population projections for India and states. As per this report, India’s population is expected to reach 1.2 billion by 2011 and 1.4 billion by 2006 (see Table 5). According to this projection, population would grow by 1.4 percent during the Eleventh Five-Year Plan period (more precisely during 2006-11). Even by 2021-26, the population is expected to have a growth rate of 0.9 percent (see Table 6). An important assumption underlying this projection is that the total fertility rate would reach replacement level (approximately 2.1) only by 2021. The reason behind this gloomy expectation is the slow pace of fertility transition in several large, north Indian states. In fact, according the Technical Group, TFR would not reach the replacement level in some of these states even by 2031. Although the Technical Group did not carry forward the projection till the date of stabilization, the projected delay in reaching the replacement-level fertility would imply that India’s population would not stabilize before 2060, and until population size nears 1.7 billion.
One of the most chilling results of this exercise is the wide geographical disparity in the projected population growth. If the total population of the country is expected to grow by 36 percent between 2001 and 2026, in southern states, the growth is expected to be around 15-25 percent only, whereas in northern parts of the country, the growth is expected to be in the range of 40-50 percent (see Table 7). Of the expected addition of 370 million to India’s population during 2001-26, Uttar Pradesh alone would account for a whopping 22 percent, and the other three northern states - Bihar, Madhya Pradesh and Rajasthan – would account for another 22 percent. The population growth in these regions is also expected to cause population pressure in major migration destinations, chiefly Delhi and Maharashtra. Clearly, something urgent needs to be done to check population growth in these states.

CHAPTER - 2 DEMOGRAPHIC TRANSITION DEMOGRAPHIC SCENARIO Demographers refer to these changes from stable population with high fertility and mortality to a new stability in population due to low fertility and mortality patterns as demographic transition. Demographic transition occurs in four phases; of these the first three phases are characterized by population growth. In the first phase there is a fall in death rate and improvement in longevity; this leads to population growth. In the second phase there is a fall in birth rate but fall is less steep than fall in death rates and consequently there is population growth. In the third phase death rates plateau and replacement level of fertility is attained but the population growth continues because of the large size of population in reproductive age group. The fourth phase is characterized by fall in birth rate to below replacement level and reduction in the proportion of the population in reproductive age group; as a result of these changes population growth ceases and population stabilizes. Experience in some of the developed countries suggest that in some societies even after attainment of stable population there may be a further decline in fertility so that there is a further reduction in the population- so called negative population growth phase of the demographic transition. Different countries in the world have entered the demographic transition at different periods of time; there are also substantial differences in the rate of demographic transition and time taken to achieve population stabilization. CURRENT DEMOGRAPHIC SCENARIO India, currently the second most populous country in the world, has 17 percent of world’s population in less than three percent of earth’s land area. India began the 20th century with the population about 238 million and by 2000 it ended up with 1 billion. According to estimates, India added another 100 million by 2006 when its population reached 1.1 billion. The country added 16 million people annually in the1980s and 18 million annually in the 1990s until the present. While the global population has increased threefold during the last century, from 2 billion to 6 billion, India has increased its population nearly five times during the same period (Table-1). India’s population is expected exceed that of China before 2030 to become the most populous country in the world. India is in the middle of demographic transition. Both fertility and mortality have started declining throughout the country, though the pace and magnitude of the decline varies considerably across the states. Like many countries of the world, the onset of mortality decline preceded the onset of fertility decline by few decades. The country has witnessed significant improvements in demographic and health indicators since Independence. But an accurate assessment of India's demographic achievements is hampered by data deficiencies, particularly for the period before the 1970s. The official estimates of fertility and mortality levels at the time of independence are believed to be gross underestimates. Nonetheless, even they suggest significant achievements in this field. The crude birth rate, which was officially put at 42 per 1,000 in 1951-61, has declined to 24 in 2004, as per the estimates available from the sample registration system (SRS). The life expectancy at birth, which was about 32 years at the time of independence, has doubled. Infant mortality rate has come down from about 150 in 1951 to 58 by 2004. Considering the size and diversity of India’s population, the decline in both fertility and mortality is a significant achievement. Nearly one-third of India’s population has lowered its fertility to replacement level. Fertility in India has come down under a wide range of socio-economic and cultural conditions. Despite this achievement, many are concerned with the pace of fertility decline, particularly in the large, north Indian states. To overcome this, the northern region of India will need much more focused programmes and more investment not only in the provision of family welfare services but also for the overall socio-economic development.

CHANGE IN THE AGE & STRUCTURE
India’s demographic changes are also manifest in its age structure. The population pyramids below show the share of population in each age group, separately for males and females. In 1950, India had a very young population, with many children and few elderly; this gave India’s age distribution a pyramidal shape. Moving forward in time, the base of the population pyramid shrinks as the number of working-age individuals increases relative to children and the elderly.

Following charts depict India’s population pyramids:

In developed countries the reproductive age group population is relatively small; their fertility is low and the longevity at birth is high. Population profiles of these countries resemble a cylinder and not a pyramid.These countries have the advantages of having achieved a stable population but have to face the problems of having a relatively small productive workforce to support the large aged population with substantial non-communicable disease burden. Some of the developing countries have undergone a very rapid decline in the birth rates within a short period. This enabled them to quickly achieve population stabilization but they do face the problems of rapid changes in the age structure and workforce which may be inadequate to meet their manpower requirements.

In contrast the population in most of the developing countries (including India) consist of a very large proportion of children and persons in reproductive age. Because of the large reproductive age group (Population momentum) the population will continue to grow even when replacement level of fertility is reached (couples having only two children). It is imperative that these countries should generate enough employment opportunities for this work force and utilise the human resources and accelerate their economic growth. Planners and policy makers in developing countries like India have to take into account the ongoing demographic changes (number and age structure of the population) so that available human resources are optimally utilised as agents of change and development to achieve improvement in quality of life.

This chart illustrates several critical points. First, the ratio of working-age people to dependents has been lower in Sub-Saharan Africa than in East Asia throughout the entire period shown. This means that East Asia has had higher numbers of people in the prime years for working and saving. The difference between the two lines is primarily a reflection of a relatively high burden of youth dependency in Sub-Saharan Africa, due to its long history of high fertility. By contrast, East Asia, with a precipitous decline in fertility, experienced the most rapid demographic transition in history. Today, East Asia has more than 2.3 workers for every non-worker, dwarfing Sub-Saharan Africa’s 1.2 workers per non-worker. This difference translates into households having an entire extra worker for every non-worker, which in turn results in a commensurately large increase in income per household, ultimately aggregating upward to increased country- level growth. Fertility decline lowers youth dependency immediately, but does not appreciably affect the working-age population for 20-25 years. But when the working-age population does increase as a share of the total population, there is an opportunity for economic growth. Figure 3 suggests that the superior economic performance of East Asia since the mid-1970s is related to East Asia’s demographics.
Indeed, using rigorous theoretical and statistical tools and appropriate data,2 economists have spent the past decade garnering evidence that East Asia’s rapid economic growth was spurred by its demographic transition, during which East Asia’s age structure has evolved in a way that has been highly favorable for economic growth. The resulting body of work suggests that demographic change accounts for approximately 2 percentage points of the growth rate of income per capita in East Asia, representing one-third of the supposed miracle. Labeling the economic growth East Asia as a miracle, therefore, was partly a reflection of a failure to consider the implications of demographics.

Figure 4 plots several aspects of India’s demographic profile over time, revealing significant improvements in basic health indicators. The interplay of these mortality and fertility changes implies sizable changes in the age structure of India’s population. Since 1950, India has experienced a 70% decline in the infant mortality rate, from over 165 deaths per thousand live births in the 1950s to around 50 today. India’s child (i.e., under age 5) mortality rate has fallen from 138 deaths per thousand in the early 1980s to 75 today. Life expectancy has increased at an average pace of 4.5 years per decade since 1950. The fertility rate has declined sharply from approximately 6 children per woman in the 1950s to 2.7 children per woman today. Figure 4 shows three trends that fertility may follow in the future, based on the assumptions the United Nations makes in publishing low-, medium-, and high-fertility scenarios. The population growth rate, after peaking in the late 1970s at about 2.3% per year, has fallen to 1.4% in 2010. In spite of the decline in fertility and the population growth rate, India’s population is still projected to increase (based on the UN’s medium-fertility scenario) from about 1.2 billion today to an estimated 1.6 billion by 2050 due to population momentum (i.e., the large cohort of women of reproductive age will fuel population growth over the next generation, even if each woman has fewer children than previous generations did). Finally, the decline of crude birth and death rates shows that India is well along in its demographic transition. The sex ratio at birth in India is 1.12 males for each female – one of the highest ratios in the world. The corresponding figure for 2003 was 1.05 (United States Central Intelligence Agency, 2010). Sex-selective abortions, although illegal, are thought to be a prime reason for this high ratio. Indian families have long shown favoritism toward boys, and new technologies are allowing that preference to be expressed in differential birth rates. As in virtually all countries, life expectancy at birth in India also differs by sex. In the period 2005-2010, female life expectancy was 65.0 years, and male life expectancy was 62.1 years – very similar to the differences that are seen in developing countries as a whole and in the world. However, India differs from the world and from developing countries as a whole in the manner in which sex differences in life expectancy have evolved since 1950. In most countries, women lived longer than men in 1950, whereas in India female life expectancy, at 37.1 years, was 1.6 years less than that of men. This differential has reversed in the intervening years. (United Nations, 2009)
India’s demographic changes are also manifest in its age structure. The population pyramids of Figure 5 show the share of population in each age group, separately for males and females. In 1950, India had a very young population, with many children and few elderly; this gave India’s age distribution a pyramidal shape. Moving forward in time, the base of the population pyramid shrinks as the number of working-age individuals increases relative to children and the elderly.

The ratio of working-age to non-working-age people in India mirrored the corresponding ratio in East Asia from 1950 to 1975. Since then, it has been lower than that of East Asia – corresponding to a higher burden of youth dependency. Indeed, India’s demographic cycle now lags roughly 25 years behind that of East Asia. A purely demographic perspective suggests that the next three decades will be a period of catching up for India with respect to per capita income in East Asia. While these fertility scenarios have very different implications for the future age structure of India’s population, all three suggest further growth in the working-age share. Under the low- fertility scenario, according to which the total fertility rate will drop to 1.4 by 2030, India is expected to reach a higher working-age ratio than ever seen in East Asia. The medium scenario shows India reaching a ratio nearly as high as East Asia’s high point, and the high scenario shows a very modest increase over today’s ratio in India. In sum, the medium- and low-fertility scenarios bode well with respect to India’s potential for realizing a sizable demographic dividend, representing what could amount to an additional percentage point or more of per capita income growth, compounded year after year. This is not an insignificant amount, given that the annual rate of growth of India’s real income per capita averaged a little over 4% during the past three decades (World Bank, 2010). As an aside, it should be noted that India’s demographic indicators are similar to those of the South Asian region as a whole. Compared with the two other large South Asian countries, it is ahead of Pakistan in the demographic transition, but behind Bangladesh. An additional demographic fact deserves mention: there are an estimated 11.4 million Indians living outside of India. The countries to which Indians have emigrated in largest numbers, as of 2010, are United Arab Emirates (2.2 million), the United States (1.7 million), Saudi Arabia (1.5 million), and Bangladesh (1.1 million). In 2000, 57,000 Indian physicians were living overseas.

In 2010, Indian emigrants are estimated to be sending home remittances totaling $55 billion, the most of any country, constituting about 4.5% of GDP. (Ratha, Mohapatra, and Silwal, 2011) The number of Indian immigrants in the United States has grown rapidly in recent years (there were 1.0 million in 2000). Their median age is 37, and just over half are female. Nearly three-quarters have at least a bachelor’s degree, and nearly half work in professional occupations. Mean personal income (in 2008 dollars) is $53,000, and median household income is $92,000. (United States Bureau of the Census, International Data Base (2008 midyear estimates). As political, economic, and social conditions change over time in India and its neighbors, the number of migrants, the skills they take to other countries, and the value of the remittances they send may change significantly.

DEMOGRAPHIC REPRESENTATION * INTERSTATE DIFFERENCE The projected values for the total population in different regions is shown in the Figure 2.10.3. There are marked differences between states in size of the population, projected population growth rates and the time by which TFR of 2.1 is likely to be achieved. If the present trend continues, most of the southern and the western states are likely to achieve TFR of 2.1 by 2010.

Urgent energetic steps to assess and fully meet in availability and access to service are needed in the unmet needs for maternal and child health Rajasthan, Orissa, Uttar Pradesh, Madhya Pradesh (MCH)care and contraception through improvement and Bihar (before division) in order to achieve a faster decline in their mortality and fertility rates. The performance of these states would determine the year and size of the population at which the country achieves aster decline in their mortality and fertility rates. The performance of these states would determine the year and size of the population at which the country achieves replacement level of fertility. It is imperative that special efforts are made during the next two decades to break the vicious self- perpetuating cycle of poor performance, poor per capita income, poverty, low literacy and high birth rate in the populous states so that further widening of disparities between states in terms of per capita income and quality of life is prevented. An Empowered Action Group has been set up to provide special assistance to these states. The benefits accrued from such assistance will depend to a large extent on the states’ ability to utilize the available funds and improve services and facilities.

* GENDER BIAS The reported decline in the sex ratio during the current century has been a cause for concern (Figure 2.10.4). The factors responsible for this continued decline are as yet not clearly identified. However, it is well recognised that the adverse sex ratio is a reflection of gender disparities. There is an urgent need to ensure that all sectors collect and report sex disaggregated data. This will help in monitoring for evidence of gender disparity. Continued collection, collation, analysis and reporting of sex disaggregated data from all social offence. However, unless there is a change in social sectors will also provide a mechanism to monitor attitudes, these legislations cannot achieve the whether girls and women have equal access to desired change. Intensive community education these services. In the 0-6 age group show massive inter-state differences (Figure 2.10.5). In addition, data indicate that over the last three decades there has been a decline in the 0-6 sex ratio . (Table 2.10.2) There had been speculation as to whether female sex determination tests and selective female feticide are, at least in part responsible for this. The Government of India has enacted a legislation banning the prenatal sex determination and selective abortion while female infanticide is a cognizable efforts to combat these practices, especially in pockets from where female infanticide and foeticide have been reported, are urgently required.

The National Family Health Survey clearly brought out the sex differentials in the neonatal, post neonatal, infant and under five mortality rates . As there is no biological reason for the higher mortality among the girl children these differences are an indication of existing gender bias in caring for the girl child (Figure 2.10.5a).

In the reproductive age-groups, the mortality rates among women are higher than those among men. The continued high maternal mortality is one of the major factors responsible for this. Effective implementation of the RCH programme is expected to result in a substantial reduction in maternal mortality. Currently, the longevity at birth among women is only marginally higher than that among men. However, the difference in life expectancy between men and women will progressively increase over the next decade. Once the reproductive age group is crossed, the mortality rates among women are lower. Women will OUTNUMBER men in over 60 age group Departments of Health, Family Welfare and Women and Child Development are initiating steps to ensure that these women get the care they need.

CHAPTER – 3
CAUSES OF POPULATION GROWTH BIRTH RATE * POVERTY According to ABC News, India currently faces approximately “… 33 births a minute, 2,000 an hour, 48,000 a day, which calculates to nearly 12 million a year”. Unfortunately, the resources do not increase as the population increases. Instead the resources keep decreasing, leading to making survival for a human being more and more competitive even for the basic necessities of life like food, clothing and shelter. 
 India currently faces a vicious cycle of population explosion and poverty. One of the most important reasons for this population increase in India is poverty. According to Geography.com, “More than 300 million Indians earn less than US $1 everyday and about 130 million people are jobless.” The people, who have to struggle to make two ends meet produce more children because more children mean more earning hands.Also, due to poverty, the infant mortality rate among such families is higher due to the lack of facilities like food and medical resources. Thus, they produce more children assuming that not all of them would be able to survive. The end result is a mounting increase in the population size of India. Due to the increase in population, the problems of scarce resources, jobs, and poverty increases. Thus the cycle continues leading to an ever-increasing population that we see today. This cycle in fact might be considered as a positive feedback, in that the increase in one results in the increase of the other factor. As the poverty and the population both increase, the development of the country and the society seems even more far-fetched.
 * Religious beliefs, Traditions and Cultural Norms
 India’s culture runs very deep and far back in history. Due to the increased population, the educational facilities are very scarce. As a result, most people still strictly follow ancient beliefs. According to ABC News, the famous Indian author, Shobha De said, “God said ‘Go forth and produce’ and we just went ahead and did exactly that.” In addition, a lot of families prefer having a son rather than a daughter. As a result, a lot of families have more children than they actually want or can afford, resulting in increased poverty, lack of resources, and most importantly, an increased population. 
 Another one of India’s cultural norms is for a girl to get married at an early age. In most of the rural areas and in some urban areas as well, families prefer to get their girls married at the age of 14 or 15. Although child marriage is illegal in India, the culture and the society surrounding the girls in India does not allow them to oppose such decisions taken by their family. For many, giving a girl child in marriage is done not by choice, but rather out of compulsion. The poor economic status of tribal villagers is attributed as one of the primary factors responsible for the prevalence of child marriages in India. An example of one such incident was reported in Indiainfo.com. According to an article written by Syed Zarir Hussain on October 16th, 2000, “Forty-two-year-old Rojo Tok, a tribal peasant in Arunachal Pradesh, was all decked up in local finery to wed Mepong Taku, a girl who will turn 14 this winter.” 
 I was brought up in a very different environment and never had to worry about getting married at the age of 14 or 15. However, my parents turned their eyes away, when my maidservant’s daughter was being married off when she was only 13 years old. I was very young, but my parents simply said, “That’s just how things are with poor people” and I did not have a say in it. Due to the young age of these girls, they have more potential of bearing children, that is, since they start bearing children at a very early age, they can have more children throughout their lifetime. This results in the increase of the global fertility rate. Since these girls get married at a very early age, they do not have the opportunity to get educated. Therefore, they remain uneducated and teach the same norms to their own children, and the tradition goes on from one generation to the other. 
 DEATH RATE Although poverty has increased and the development of the country continues to be hampered, the improvements in medical facilities have been tremendous. This improvement might be considered positive, but as far as population increase is considered, it has only been positive in terms of increasing the population further. The crude death rate in India in 1981 was approximately 12.5, and that decreased to approximately 8.7 in 1999. Also, the infant mortality rate in India decreased from 129 in 1981 to approximately 72 in 1999 (Mapsindia.com, Internet). These numbers are clear indications of the improvements in the medical field.This development is good for the economy and society of India, but strictly in terms of population, this advancement has further enhanced the increase in population. 
 The average life expectancy of people in India has increased from 52.9 in 1975-80 to 62.4 in 1995-00. Although our near and dear ones would live longer, due to the increase in the population, the resources available per person would be much less, leading to a decrease in the curvature of the slope of development instead of a higher gradient. In addition, abortion is not allowed by several religions that are followed in India. In fact, in Islam, one of the leading religions of India, children are considered to be gifts of God, and so the more children a woman has, the more she is respected in her family and society. As a result, although the measures to control birth are either not available or known to the public, the facilities to increase birth through medical facilities are available.
 MIGRATION
 In countries like the United States (U.S.), immigration plays an important role in the population increase. However, in countries like India, immigration plays a very small role in the population change. Although people from neighboring countries like Bangladesh, Pakistan and Nepal, migrate to India; at the same time Indians migrate to other countries like the U.S., Australia, and the U.K. During the 1971 war between India and Pakistan over Bangladesh, the immigration rate increased tremendously. However, currently the migration in India is –0.08 migrants per 1000 population (AskJeeves.com, Internet), and is decreasing further. This is definitely good for India. This way, the population might eventually come close to being under control and more people may get better job opportunities and further education. For example, the students in my university from India, like myself, have better chances for job opportunities and better education outside India than we would have had in India.

CHAPTER – 4
IMPACT OF POPULATION GROWTH
ECONOMIC GROWTH
During the past decade, there have been two significant breakthroughs regarding the impact of demographics on national economic performance. The first has to do with the effect of the changing age structure of a population. The second relates to population health. Demographers use the “demographic transition” as a starting point for explaining this effect. The demographic transition refers to the nearly ubiquitous change countries undergo from a regime of high fertility and high mortality to one of low fertility and low mortality. As this phenomenon tends to occur in an asynchronous fashion, with death rates declining first and birth rates following later, countries often experience a transitional period of rapid population growth. This period has traditionally been the main focus of economists interested in demographics. But population growth is not the only major consequence of the demographic transition. The age structure is also transformed. This happens initially as a consequence of a baby boom that occurs at the beginning of the transition. The baby boom is not caused by an increase in births, but rather by the sharply reduced rates of infant and child mortality that are characteristic of the beginning of a demographic transition, mainly due to increased access to vaccines, antibiotics, safe water, and sanitation. This type of baby boom starts with higher survival rates and abates when fertility subsequently declines as couples recognize that fewer births are needed to reach their targets for surviving children, and as those targets are moderated.
Baby booms are very consequential economically, because the presence of more children requires that there be more resources for food, clothing, housing, medical care, and schooling. Those resources must be diverted from other uses such as building factories, establishing infrastructure, and investing in research and development. This diversion of resources to current consumption can temporarily slow the process of economic growth. Of course, babies born in such a boom will invariably reach working ages within a period of 15-25 years. When this happens, the productive capacity of the economy expands on a per capita basis and a demographic dividend may be within reach.

Environmental and ecological consequences The already densely populated developing countries contribute to over 95% of the population growth and rapid population growth could lead to environmental deterioration. Developed countries are less densely populated and contribute very little to population growth; however, they cause massive ecological damage by the wasteful, unnecessary and unbalanced consumption the consequences of which could adversely affect both the developed and the developing countries. The review on "Promotion of sustainable development: challenges for environmental policies" in the Economic Survey 1998-99 had covered in detail the major environmental problems, and policy options for improvement; the present review will only briefly touch upon some of the important ecological consequences of demographic transition. In many developing countries continued population growth has resulted in pressure on land, fragmentation of land holding, collapsing fisheries, shrinking forests, rising temperatures, loss of plant and animal species. Global warming due to increasing use of fossil fuels (mainly by the developed countries) could have serious effects on the populous coastal regions in developing countries, their food production and essential water supplies. The Intergovernmental Panel on Climate Change has projected that, if current greenhouse gas emission trends continue, the mean global surface temperature will rise from 1 to 3.5 degrees Celsius in the next century. The panel's best estimate scenario projects a sea-level rise of 15 to 95 centimeters by 2100. The ecological impact of rising oceans would include increased flooding, coastal erosion, salination of aquifers and coastal crop land and displacement of millions of people living near the coast. Patterns of precipitation are also likely to change, which combined with increased average temperatures, could substantially alter the relative agricultural productivity of different regions. Greenhouse gas emissions are closely linked to both population growth and development. Slower population growth in developing countries and ecologically sustainable lifestyles in developed countries would make reduction in green house gas emission easier to achieve and provide more time and options for adaptation to climate change. Rapid population growth, developmental activities either to meet the growing population or the growing needs of the population as well as changing lifestyles and consumption patterns pose major challenge to preservation and promotion of ecological balance in India. Some of the major ecological adverse effects reported in India include: severe pressure on the forests due to both the rate of resource use and the nature of use. The per capita forest biomass in the country is only about 6 tons as against the global average of 82 tons. adverse effect on species diversity: conversion of habitat to some other land use such as agriculture, urban development, forestry operation. Some 70-80 % of fresh water marshes and lakes in the Gangetic flood plains has been lost in the last 50 years.
Tropical deforestation and destruction of mangroves for commercial needs and fuel wood. The country’s mangrove areas have reduced from 700,000 ha to 453,000 ha in the last 50 years.
Intense grazing by domestic livestock
Poaching and illegal harvesting of wildlife.
Increase in agricultural area, high use of chemical fertilizers pesticides and weedicides; water stagnation, soil erosion, soil salinity and low productivity.
High level of biomass burning causing large-scale indoor pollution.
Encroachment on habitat for rail and road construction thereby fragmenting the habitat. increase in commercial activities such as mining and unsustainable resource extraction.
Degradation of coastal and other aquatic ecosystems from domestic sewage, pesticides, fertilizers and industrial effluents.
Over fishing in water bodies and introduction of weeds and exotic species.
Diversion of water for domestic, industrial and agricultural uses leading to increased river pollution and decrease in self-cleaning properties of rivers.
Increasing water requirement leading to tapping deeper aquifers which have high content of arsenic or fluoride resulting health problems.
Disturbance from increased recreational activity and tourism causing pollution of natural ecosystems with wastes left behind by people. The United Nations Conference on Environment and Development (1992) acknowledged population growth, rising income levels, changing technologies, increasing consumption pattern will all have adverse impact on environment. Ensuring that there is no further deterioration depends on choices made by the population about family size, life styles, environmental protection and equity. Availability of appropriate technology and commitment towards ensuring sustainable development is increasing throughout the world. Because of these, it might be possible to initiate steps to see that the natural carrying capacity of the environment is not damaged beyond recovery and ecological balance is to a large extent maintained. It is imperative that the environmental sustainability of all developmental projects is taken care of by appropriate inputs at the planning, implementation, monitoring and evaluation stages. Urbanization The proportion of people in developing countries who live in cities has almost doubled since 1960 (from less than 22 per cent to more than 40 per cent), while in more developed regions the urban share has grown from 61 per cent to 76 per cent. Urbanization is projected to continue well into the next century. By 2030, it is expected that nearly 5 billion (61 per cent) of the world's 8.1 billion people will live in cities. India shares this global trend toward urbanization. Globally, the number of cities with 10 million or more inhabitants is increasing rapidly, and most of these new "megacities" are in developing regions. In 1960, only New York and Tokyo had more than 10 million people. By 1999, the number of megacities had grown to 17(13 in developing countries). It is projected that there will be 26 megacities by 2015, (18 in Asia; of these five in India); more than 10 per cent of the world's population will live in these cities (1.7% in 1950). India’s urban population has doubled from 109 million to 218 million during the last two decades and is estimated to reach 300 million by 2000 AD. As a consequence cities are facing the problem of expanding urban slums. Like many other demographic changes, urbanization has both positive and negative effects. Cities and towns have become the engines of social change and rapid economic development. Urbanisation is associated with improved access to education, employment, health care; these result in increase in age at marriage, reduction in family size and improvement in health indices. As people have moved towards and into cities, information has flowed outward. Better communication and transportation now link urban and rural areas both economically and socially creating an urban-rural continuum of communities with improvement in some aspects of lifestyle of both. The ever increasing reach of mass media communicate new ideas, points of reference, and available options are becoming more widely recognized, appreciated and sought. This phenomenon has affected health care, including reproductive health, in many ways. For instance, radio and television programmes that discuss gender equity, family size preference and family planning options are now reaching formerly isolated rural populations. This can create demand for services for mothers and children, higher contraceptive use, and fewer unwanted pregnancies, smaller healthier families and lead to more rapid population stabilisation. But the rapid growth of urban population also poses some serious challenges. Urban population growth has outpaced the development of basic minimum services; housing, water supply, sewerage and solid waste disposal are far from adequate; increasing waste generation at home, offices and industries, coupled with poor waste disposal facilities result in rapid environmental deterioration. Increasing automobiles add to air pollution. All these have adverse effect on ecology and health. Poverty persists in urban and peri-urban areas; awareness about the glaring inequities in close urban setting may lead to social unrest. Rural population and their development Over seventy per cent of India’s population still lives in rural areas. There are substantial differences between the states in the proportion of rural and urban population (varying from almost 90 per cent in Assam and Bihar to 61 per cent in Maharashtra). Agriculture is the largest and one of the most important sector of the rural economy and contributes both to economic growth and employment. Its contribution to the Gross Domestic Product has declined over the last five decades but agriculture still remains the source of livelihood for over 70 per cent of the country’s population. A large proportion of the rural work force is small and consists of marginal farmers and landless agricultural labourers. There is substantial under employment among these people; both wages and productivity are low. These in turn result in poverty; it is estimated that 320 million people are still living below the poverty line in rural India. Though poverty has declined over the last three decades, the number of rural poor has in fact increased due to the population growth. Poor tend to have larger families which puts enormous burden on their meagre resources, and prevent them from breaking out of the shackles of poverty. In States like Tamil Nadu where replacement level of fertility has been attained, population growth rates are much lower than in many other States; but the population density is high and so there is a pressure on land. In States like Rajasthan, Uttar Pradesh, Bihar and Madhya Pradesh population is growing rapidly, resulting in increasing pressure on land and resulting land fragmentation. Low productivity of small land holders leads to poverty, low energy intake and under nutrition, and this, in turn, prevents the development thus creating a vicious circle. In most of the states non-farm employment in rural areas has not grown very much and cannot absorb the growing labour force. Those who are getting educated specially beyond the primary level, may not wish to do manual agricultural work. They would like better opportunities and more remunerative employment. In this context, it is imperative that programmes for skill development, vocational training and technical education are taken up on a large scale in order to generate productive employment in rural areas. The entire gamut of existing poverty alleviation and employment generation programmes may have to be restructured to meet the newly emerging types of demand for employment. Rural poor have inadequate access to basic minimum services, because of poor connectivity, lack of awareness, inadequate and poorly functional infrastructure. There are ongoing efforts to improve these, but with the growing aspirations of the younger, educated population these efforts may prove to be inadequate to meet the increasing needs both in terms of type and quality of services. Greater education, awareness and better standard of living among the growing younger age group population would create the required consciousness among them that smaller families are desirable; if all the felt needs for health and family welfare services are fully met, it will be possible to enable them to attain their reproductive goals, achieve substantial decline in the family size and improve quality of life. Water Supply In many parts of developed and developing world, water demand substantially exceeds sustainable water supply. It is estimated that currently 430 millions (8% of the global population) are living in countries affected by water stress; by 2020 about one fourth of the global population may be facing chronic and recurring shortage of fresh water. In India, water withdrawal is estimated to be twice the rate of aquifer recharge; as a result water tables are falling by one to three meters every year; tapping deeper aquifers have resulted in larger population groups being exposed to newer health hazards such as high fluoride or arsenic content in drinking water. At the other end of the spectrum, excessive use of water has led to water logging and increasing salinity in some parts of the country. Eventually, both lack of water and water logging could have adverse impact on India's food production. There is very little arable agricultural land which remains unexploited and in many areas, agricultural technology improvement may not be able to ensure further increase in yield per hectare. It is, therefore, imperative that research in biotechnology for improving development of foodgrains strains that would tolerate salinity and those which would require less water gets high priority. Simultaneously, a movement towards making water harvesting, storage and its need based use part of every citizens life should be taken up. Food security Technological innovations in agriculture and increase in area under cultivation have ensured that so far, food production has kept pace with the population growth. Evolution of global and national food security systems have improved access to food. It is estimated that the global population will grow to 9 billion by 2050 and the food production will double; improvement in purchasing power and changing dietary habits (shift to animal products) may further add to the requirement of food grains. Thus, in the next five decades, the food and nutrition security could become critical in many parts of the world especially in the developing countries and pockets of poverty in the developed countries. In India one of the major achievements in the last fifty years has been the green revolution and self- sufficiency in food production. Food grain production has increased from 50.82 in 1950-51 to 200.88 million tons in 1998-99 (Prov.). It is a matter of concern that while the cereal production has been growing steadily at a rate higher than the population growth rates, the coarse grain and pulse production has not shown a similar increase. Consequently there has been a reduction in the per capita availability of pulses (from 60.7 grams in 1951 to 34 grams per day in 1996) and coarse grains. Over the last five decades there has been a decline in the per capita availability of pulses. During the last few years the country has imported pulses to meet the requirement. There has been a sharp and sustained increase in cost of pulses, so there is substantial decline in per capita pulses consumption among poorer segment of population. This in turn could have an adverse impact on their protein intake. The pulse component of the "Pulses and Oil Seeds Mission" need to receive a major thrust in terms of R&D and other inputs, so that essential pulse requirement of growing population is fully met. Rising cost of pulses had a beneficial effect also. Till eighties in central India wages of landless labourers were given in the form Kesari Dal which was cheaper than cereals or coarse grains. Consumption of staple diet of Kesari Dal led to crippling disease of neuro lathyrism. Over the last three decades the rising cost of pulses has made Kesari Dal more expensive than wheat or rice and hence it is no longer given to labourers as wages for work done; as a result the disease has virtually disappeared from Central India. Over years the coarse grain production has remained stagnant and per capita availability of coarse grain has under gone substantial reduction; there has been a shift away from coarse grains to rice and wheat consumption even among poorer segment of population. One of the benefits of this change is virtual elimination of pellagra which was widely prevalent among low income group population in Deccan Plateau whose staple food was sorghum. Coarse grains are less expensive than rice and wheat; they can thus provide higher calories for the same cost as compared to rice and wheat. Coarse grains which are locally produced and procured if made available through TPDS at subsidised rate, may not only substantially bring down the subsidy cost without any reduction in calories provided but also improve "targetting" - as only the most needy are likely to access these coarse grains. Another area of concern is the lack of sufficient focus and thrust in horticulture; because of this, availability of vegetables especially green leafy vegetables and yellow/red vegetables throughout the year at affordable cost both in urban and rural areas has remained an unfulfilled dream. Health and nutrition education emphasizing the importance of consuming these inexpensive rich sources of micronutrients will not result in any change in food habits unless there is harnessing and effective management of horticultural resources in the country to meet the growing needs of the people at affordable cost. States like Tamil Nadu and Himachal Pradesh have initiated some efforts in this direction; similar efforts need be taken up in other states also. Nutrition At the time of independence the country faced two major nutritional problems; one was the threat of famine and acute starvation due to low agricultural production and lack of appropriate food distribution system. The other was chronic energy deficiency due to poverty, low-literacy, poor access to safe-drinking water, sanitation and health care; these factors led to wide spread prevalence of infections and ill health in children and adults. Kwashiorkor, marasmus, goitre, beri beri, blindness due to Vitamin-A deficiency and anaemia were major public health problems. The country adopted multi-sectoral, multi-pronged strategy to combat the major nutritional problems and to improve nutritional status of the population. During the last 50 years considerable progress has been achieved. Famines no longer stalk the country. There has been substantial reduction in moderate and severe undernutrition in children and some improvement in nutritional status of all segments of population. Kwashiorkor, marasmus, pellagra, lathyrism, beri beri and blindness due to severe Vitamin-A deficiency have become rare. However, it is a matter of concern that milder forms of Chronic Energy Deficiency (CED) and micronutrient deficiencies continue to be widely prevalent in adults and children. In view of the fact that population growth in India will continue for the next few decades, it is essential that appropriate strategies are devised to improve food and nutrition security of families, identify individuals/families with severe forms of CED and provide them assistance to over come these problem Operational strategy to improve the dietary intake of the family and improve nutritional status of the rapidly growing adult population would include: • Ensuring adequate agricultural production of cereals, pulses, vegetables and other foodstuffs needed to fully meet the requirement of growing population. • Improving in purchasing power through employment generation and employment assurance schemes; • Providing subsidised food grains through TPDS to the families below poverty line. • Exploring feasibility of providing subsidized coarse grains to families Below Poverty Line (BPL) Operational strategies to improve health and nutritional status of the growing numbers of women and children include: * Pregnant and lactating women - screening to identify women with weight below 40 Kgs and ensuring that they/ their preschool children receive food supplements through Integrated Child Development Services Scheme (ICDS); adequate antenatal intrapartum and neonatal care. * 0-6 months infants - Nutrition education for early initiation of lactation protection and promotion of universal breast feeding, exclusive breast feeding for the first six months; unless there is specific reason supplementation should not be introduced before 6 months and immunisation, growth monitoring and health care. * Well planned nutrition education to ensure that the infants and children do continue to get breasted, get appropriate cereal pulse vegetable based supplement fed to them at least 3 - 4 times a day , appropriate help in ensuring this through family/community/work place support and immunisation and health care. * Children in the 0 - 5 age group - screen by weighment to identify children with moderate and severe undernutrition , provide double quantity supplements through ICD , screening for nutrition and health problems and appropriate intervention. * Primary school children - weigh and identify those with moderate and severe chronic energy deficiency, improve dietary intake to these children through the mid-day meal. * Monitor for improvement in the identified undernourished infants, children and mothers; if no improvement after 2 months refer to physician for identification and treatment of factors that might be responsible for lack of improvement. * Nutrition education on varying dietary needs of different members of the family and how they can be met by minor modifications from the family meals. Intensive health education for improving the life style of the population coupled with active screening and management of the health problems associated with obesity.

chapter – 5
Strategies to Achieve Population Stabilization Fertility decline in India has been the effect of various socio-economic developments as well as government sponsored family welfare programme. Rising levels of education, increase in female age at marriage, influence of mass media, economic development, gender empowerment and measures for equality, continuing urbanization, diffusion of new idea, and declines in infant and child mortality have all contributed in lowering the levels of fertility. These factors, along with strong health infrastructure and focused family welfare programme, will continue to be driving the fertility transition. Even at the national level, the views regarding the ideal number of children are fast approaching the two child norm. But at the same time, preference for sons is clearly evident in many parts of India. The regional difference in fertility level is also likely to continue for many more years. Given this context, what are the strategies that can be adopted to achieve the population stabilization within a reasonable time period? National Rural Health Mission (NRHM) Recognizing the importance of health for social and economic development and for improving the quality of life, the Govt. of India launched the National Rural Health Mission (NRHM) in 2005 to carry out the necessary correction and strengthening of basic health care delivery system. The Plan of Action of NRHM envisages increasing public expenditure on health, reducing regional imbalances in health infrastructure, pooling resources, integration of organizational structures, optimization of health manpower, decentralization and district management of health programmes, community participation and ownership of assets and providing public- private partnership. The goal of the mission is to improve the availability of and access to quality health care of the people, especially for those residing in rural areas, the poor, woman and children. The expected outcomes from the Mission as reflected in statistical data are:
IMR reduced to 30/1000 live births by 2012.
Maternal Mortality reduced to 100/100,000 live births by 2012.
TFR reduced to 2.1 by 2012.
Malaria Mortality Reduction Rate – 50% up to 2010, additional 10% by 2012.
Kala Azar Mortality Reduction Rate – 100% by 2010 and sustaining elimination until 2012. * Filarial/Microfilaria Reduction Rate – 70% by 2010, 80% by 2012 and elimination by 2015. * Dengue Mortality Reduction Rate – 50% by 2010 and sustaining at that level until 2012 * Cataract operations-increasing to 46 lakhs until 2012. * Leprosy Prevalence Rate – reduce from 1.8 per 10,000 in 2005 to less than 1 per 10,000 thereafter. * Tuberculosis DOTS series – maintain 85% cure rate through entire Mission Period and also sustain planned case detection rate. • Upgrading all Community Health Centers to Indian Public Health Standards. utilization of First Referral Units from bed occupancy by referred cases of less than 20% to over 75%. * Engaging 4,00,000 female Accredited Social Health Activists (ASHAs).
The NRHM (2005-12) seeks to provide effective health care to rural population throughout the country with specific focus on 18 states that have weak public health indicators and poor health infrastructure.

National Population Policy The immediate objective of the National Population Policy is to meet all the unmet needs for contraception and health care for women and children. The medium-term objective is to bring the TFR to replacement level (TFR of 2.1) by 2010 and, the long-term objective is to achieve population stabilisation by 2045. The Policy has set the following goals for 2010: * universal registration of births and deaths, marriages and pregnancies; * universal access to information/counselling and services for fertility regulation and contraception with a wide basket of choices; * to reduce the IMR to below 30 per 1,000 live births and a sharp reduction in the incidence of low birth weight (below 2.5 kg.); * universal immunisation of children against vaccine preventable diseases; * promote delayed marriage for girls, not earlier than the age of 18 and preferably after 20 years; * achieve 80 per cent institutional deliveries and increase the percentage of deliveries conducted by trained persons to 100 per cent; * containing of STD reduction in MMR to less than 100 per 100,000 * universalisation of primary education and reduction in the drop-out rates at the primary and secondary levels to below 20 per cent for both boys and girls. Several states/districts have demonstrated that the steep reduction in mortality and fertility envisaged in the National Population Policy are technically feasible within the existing infrastructure and manpower. All efforts are being made to provide essential supplies, improve efficiency and ensure accountability - especially in the states where performance is currently sub- optimal - so that there is incremental improvement in performance. An Empowered Action Group attached to the Ministry of Health and Family Welfare has been constituted in 2001 to facilitate capacity building in poorly performing states/districts so that they attain the goals set in the Policy. If all these efforts are vigorously pursued it is possible that the ambitious goals set for 2007/2010 may be achieved. National Commission on Population The National Commission on Population adopting the small family norm; was constituted on 11 May 2000 under the chairmanship of the Prime Minister. The Deputy Chairman of the Planning Commission is the vice chairman. The Commission has the mandate to: * review, monitor and give direction for the implementation of the National Population Policy with the view of achieving the goals it has set; * promote synergy between health, educational, environmental developmental programmes so as to hasten population stabilization; * promote inter-sectoral coordination in planning and implementation of the programmes through different agencies at the Centre and in the states; and * develop a vigorous people’s programme to support this national effort. A Strategic Support Group consisting of secretaries of concerned sectoral ministries has been constituted as a standing advisory group to the Commission. Nine working groups were constituted to look into specific aspects of implementation of the programmes aimed at achieving the targets set in the National Population Policy. NCP has allocated funds for action plans drawn up by district magistrates in poorly performing districts to implement programmes aimed at accelerating the pace decline in fertility.

Meeting the unmet demand for contraception The NPP document lays great stress on meeting the unmet need for contraception as an instrument to achieve population stabilization. The presence of high level of unmet need for contraception in EAG states is not a myth, as it is supported by data from both NFHS and DLHS. But it would be a mistake to assume that inadequate access to services should be the dominant, or even a major, explanatory factor for its presence. As a carefully conducted in depth investigation in the Philippines had shown, unmet need for contraception could arise from several reasons, such as weak motivation, low female autonomy, perceived health risks, and moral objection to the use of contraception. The elimination of these factors, and thus the unmet need, could prove to be as difficult as generating fresh demand for contraception. According to the DLHS Round 2 (2002-2004) 21 percent of women in India have an unmet need for family planning. The unmet need for limiting is higher (13 percent) as compared to unmet need for spacing (9 percent). Total unmet need is highest among the younger women and women of lower parity, particularly for spacing. If all the women who say that they want to space or limit their births were to use family planning, the contraceptive prevalence rate could increase from 53 percent to 74 percent. It is important to address the unmet need for contraception, particularly for spacing by providing access to safe, effective and reversible methods. To do so it may be necessary to expand the basket of contraceptive choices. Social marketing of contraceptives and availability of the range of methods would help to meet the needs of couples who are not ready to accept sterilization. In their annual surveys of eligible couples, ANMs should be asked to identify women with unmet need for contraception and address their concerns so that unwanted pregnancies could be avoided. Even if unmet need cannot be entirely eliminated, elimination of about half the unmet need would be sufficient to have the desired effect on birth rate.

Expanding the Basket of Contraceptive Choices Female sterilization has been the mainstay of Indian family planning programme. The users of reversible methods form less than 15 percent of the users of all methods. A high level of infant and child mortality, and strong preference for sons, deter women from accepting a terminal method of contraception early. The data from the NFHS show that about half of the unmet need for contraception is for spacing. Partly the difference stems from the religious objections for the use of sterilization among Muslims. Under these circumstances, there is an urgent need to expand the basket of reversible methods of contraception offered under the programme. Research indicates that addition of a method to the basket of choices has an independent effect on the overall use. Injectibles and implants, which are not currently offered under the programme, must be introduced as early as possible. . Increasing Male involvement Male methods account for only 6 percent of current contraceptive use. Vasectomy, which used to be a popular method, went out of favour after the excesses committed in the 1970s. Vasectomy is safer and easier to perform in primary health centres than tubectomy. In recent years, the introduction of no scalpel vasectomy (NSV) has shown some signs of success in some states. Vigorous efforts should be made to promote this method, and train more doctors in performing this task. As males are the main decision makers in Indian households, IEC activities also need to focus on men for imparting knowledge on reproductive health of both men and women and about the advantages of small family. Diffusion through Satisfied Users It has become increasingly clear that fertility decline in India is the result of horizontal and vertical diffusion of a new reproductive idea and information about various methods of contraception. Strong spatial patterns in fertility decline, and systematic changes in fertility differentials by socio-economic status, support the innovation-diffusion hypothesis. The satisfied adopters of the method play a key role in this ideational change. By recruiting such couples for working in liaison with grassroots health workers, it may be possible to increase the rate of diffusion. Research has shown that contraceptive use increases in closely-knit communities through diffusion of information and the idea of small family norm. Inter- personal communication plays a key role in the ideational change. Thus satisfied users can serve as active agent in this process. The Janmangal programme in Rajasthan is based on this idea. Janani also uses "Women Health Partners" for IEC. As the family planning programme has been there for half a century, there are already some users of contraception in every community. The scheme intends to use them to rapid transmission of small family norm. ANMs would identify a ‘satisfied’ acceptor couple (SAC) of each method from caste and communities among whom the acceptance of the method is low. They would be requested to spread information about the method, and motivate others in their community. They would work in coordination with health workers at grassroots such ASHA, ANM and Anganwadi worker. For their services, a fixed honorarium could be provided. The performance of these SACs would be reviewed each year by the ANM to decide whether they could be retained for this work in the following year. The Role of Mass Media An instrument that has become increasingly important these days is the use of mass media in promotion of small family norm and providing information on reproductive and child health services. The rapidly increasing exposure to electronic media has made this an important channel of behavioural change communication. The analyses of NFHS data have shown that the exposure to mass media, and family planning messages through these sources have strong independent effects on the current use of contraception, and future intention to use among non-users. It used to be contended that interpersonal communication is a more effective agent of behavioural change than the mass media. But recent research shows that messages though media stimulate discussion between husband and wife, among friends and neighbours and with health workers. Thus mass media and inter-personal channels should be seen as complementary rather than substitutes in the process of developmental communication. Research shows that exposure to mass media has a strong independent effect on the use of family planning methods. Mass media has a wide reach, and would help to raise curiosity and create grounds for interpersonal communication to occur. However, surveys show that in EAG states, regular exposure to mass media has not yet reached desirable levels to have a wider impact. It is therefore required to raise exposure to mass media in EAG states by providing DVD/CD player and Television set to PHCs, FRUs and Mahila Mandals. As a part of this scheme, imaginatively produced DVD/CDs on reproductive and child health, including information on various methods of contraception, could be distributed. Facility surveys show that less than 20 percent of the PHCs have telephone connections. For efficient referral services and monitoring of the programmes, telephone connections are essential. It is therefore important to provide telephone connections to every PHCs, FRUs and CHCs. PHCs and FRUs receiving at least 10 outpatients/maternity cases in a day in EAG states could be identified for the supply of DVD/CD Players and TV sets. For moving the TV set between OPD and inpatient ward, a trolley could also be provided. During fixed hours in a day, DVD/CDs on RCH and family planning could be played for viewing by the outpatients/women coming for delivery. DVD/CD players and TVs could also be supplied to Mahila Mandals on the condition that they would arrange DVD/CD viewing sessions (along with TV shows) at fixed hours in a day. ANMs during their field visits should check whether these are effectively used. The production of DVD/CDs could be out-sourced. Telephone connections should be supplied to all PHC/FRU/CHCs. There should be a fixed budget line to cover monthly telephone bills and maintenance, as in other government offices. Arranging Group Meetings of Newly Wedded Couples and Pregnant and Nursing Mothers In India, about 10 marriages occur for every 1,000 population. Many women marry at young age. It is therefore extremely necessary to impart knowledge on the responsibilities of parenthood to newly weds as early as possible. Similarly, group meetings of pregnant and nursing mothers can be arranged to provide them information about maternal and child heath care and contraception. It is not sufficient to just ask the ANMs to make home visits for IEC as it is difficult to monitor such activities. Surveys show that heath workers visit less than10 percent of eligible women during a whole year. To give a formal platform for such communication strategies, ANMs with the help of SACs, and ASHAs should be asked to arrange group meetings of newly weds in a village every year. Such formal meetings will also give the required visibility to the programme. In villages with population more than one 1,000 the ANMs with the help of ASHAs and SACs will organise group meetings of newly weds, and pregnant and nursing mothers at least twice in a year. In villages with less than 1,000 populations, such meetings may be held once in a year. In these meetings, ANMs should provide information and knowledge on prenatal, natal and post natal care of women, new-born care, child immunization, virtues of small family size, interval between births, methods of contraception and abortion, STI/RTI and HIV/AIDS, with the aid of illustrative pamphlets and booklets. The active cooperation of Panchayat members should be sought to arrange these meetings. Social Marketing In spite of longstanding social marketing programme for condoms and oral pills, the use of these methods has not picked up. The growing epidemic of HIV/AIDS provides an opportunity to promote the use of condoms. The experience of our neighbouring countries suggests that substantial potential for greater use of pills by younger couples, if supported by counselling and IEC activities. The social marketing programme has suffered from (i) strong urban bias in the distribution network; (ii) low incentive to commercial participants; (iii) limited product range and (iv) simultaneous presence of wasteful, free distribution system. Surveys have disclosed large unmet need for contraceptives, particularly in EAG states. Apparently, the government delivery system is not reaching the needy. As per the NFHS data, less than 10 percent of rural women report that they are visited by the ANMs during a year. This implies that ANMs are able to visit less than 100 households in a whole year. On the other hand, there is a large pool of formally or informally qualified Rural Health Practitioners (RHPs) who meet the day-to-day health care needs of rural folks. It is proposed to use them in the delivery of non-clinical methods of contraception and referring the clinical cases to the PHCs or FRUs, for a nominal fee. The successful experimentation of this approach by Janani in Bihar gives hope that this scheme could work if implemented with care and imagination. Involvement of Private Sector There is an urgent need to increase the involvement of private sector in the delivery of family planning services, especially in areas where the pubic sector is weak. This includes inner-city slum areas and large parts of EAG states. It is estimated that private medical practitioners provide more than two-thirds of all health care in India (see Annexure: D). In rural areas, they are more respected and accessible than government grassroots heath workers. As experience of Janani in Bihar has shown, rural heath practitioners could be recruited for social marketing of non-clinical methods and for referring clinical methods to public/private health institutions. Increasing the Visibility of the Population Stabilization Programme The inverted red triangle, the eye-catching logo of the Indian family planning programme of yesteryears, has slowly fading from the public memory. There is an urgent need to bring back the visibility to the population stabilization programme. The paradigm shift in the programme calls for a new but simple logo. An award may be announced for developing a simple but effective logo. A private agency could be hired at the national level to publicise the logo and the programme. The strong presence of electronic media, particularly television, can be used for popularising small family norm and population stabilization programmes, both in rural and urban areas. Strengthening Family Welfare Infrastructure The sub-centre, manned by an auxiliary nurse midwife (ANM), is the most peripheral health institution available to the rural population. As per the norms established under the Basic Minimum Services programme in 1997, there should be one sub-centre for every 5,000 population in plain areas, and for every 3,000 population in hilly/tribal areas. In 2002, there were 1,37,271 sub-centres, or one sub- centre for 4,579 rural population. The primary health centre (PHC) is a first referral unit for six sub-centres. In 2002, there were 22,975 PHCs , one for every 27,364 rural population. PHCs provide outpatient services and have 4-6 inpatient beds. According to the norm they should have one medical officer and 14 paramedical and other supporting staff. But in many remote areas there are no functional PHCs . Community Heath Centres (CHC) are planned as first referral units (FRUs) for four PHCs for offering specialized care. According to the norm they should have at least 30 beds, one operation there, X-ray machine, labour room and laboratory facilities. The staff should consist of at least four specialists, a surgeon, a physician, a gynaecologist and a paediatrician who should be supported by 21 paramedical and other staff. Currently there are 2,935 community heath centres, or one for 2,14,000 population. But majority of CHCs do not function as FRUs as they either do not have the required number of specialists or the facilities. The facility survey undertaken as a part of RCH project has brought out the serious shortfalls in physical infrastructure, staff and supplies at pubic heath institutions. The survey considered a heath institution as adequately equipped if it had 60 percent of the critical inputs. According to this criterion, at the all India level, only 36 percent of the PHCs had adequate physical infrastructure such as building, water and electricity supply, laboratory and labour room, vehicle etc., 38 percent had adequate staff in position, 31 percent had adequate supplies of kits, drugs, vaccines and contraceptives, and 56 percent had the adequate equipments in function, such as weighing machine, vaccine carrier, BP instruments, autoclave, etc. The position of CHCs, FRUs, and district hospitals were somewhat better, but they too had severe shortage of supplies. Only 10-15 percent of them had adequate supplies. The staff in position in CHCs (25 %) and FRUs (46%) was also far from adequate. In EAG states, the position of PHCs was far worse than the all India average. Only15-20 percent of them had adequate infrastructure, staff and supplies. It was also observed that only 12 percent of medical and paramedical staff (only 4 percent in EAG states) had received adequate in-service training. The FRUs/CHC and district hospitals attended only about 10 referred cases of delivery in a month. Involvement of Local Self-Governments The 73rd and 74th Constitutional Amendments made health and family welfare a responsibility of local bodies. Being closer to the people, a decentralized institution is expected to meet their needs and preferences. The whole idea of decentralized governance is based on some key factors like people’s participation, accountability, transparency and fiscal transfers. How far decentralization of services helps in improving the quality and coverage of healthcare delivery? Experiences from across the country indicate a precondition for enhancing the effectiveness in delivery of public health services is community participation in decision-making and programme implementation. This can be facilitated through the intervention of the PRIs by making health services responsive to local needs, more accountable to the local population, focusing on local problems, prioritizing the requirements, generating public demand for the services, and efficient use of available resources. The National Population Policy (NPP-200) reiterates the crucial role of panchayats in planning and implementation of health and family welfare programmes. Decentralization is expected to bridge the existing gap between the service providers and the clients to a great extent. However, for the PRIs to be effective in health service delivery, more responsibilities need to be given in the sector-specific budget allocations, revenue-raising powers and training. In reality, the functions and powers devolved to the Panchayats vary considerably across the states. Since one-third of elected members at the local bodies are women, this is a good opportunity to promote a gender sensitive, multi-sectoral agenda for population stabilization with the help of village level health committees. Under the National Rural Health Mission (NRHM), ASHAs would be selected by and be accountable to the village panchayats (the coverage under NRHM for various health facilities/functionaries is presented in Annexure E). Expected Level of Achievement
Although the actual impact of the forgoing strategies to reach population stabilization is difficult to predict, if effectively perused, they should able to bring down the birth rate faster than what is projected by the Technical Group on Population Projections. Through these measures, it is anticipated that TFR would reach replacement if not by 2010, by 2015 - roughly by five years earlier than that projected by the Technical Group. By the end of the eleventh plan, at the all-India level, crude birth rate (CBR) is expected decline from 24 in 2004 to 19, and couple protection rate (CPR) to increase from 53 percent in 2002-04 to 64 percent. It is expected that the increase in CPR would result from reducing the unmet need for contraception by half, i.e., from 21 percent to 11 percent. The expected levels of achievement for the states are shown in Table 8.

CHAPTER – 6 Recommendations There are different ways of improving the responsiveness of health and family welfare system. Just increasing the budgetary provision will not yield the desired results unless it is accompanied by strategic reforms and programmes to involve communities in population stabilization. Health outcomes can be improved if local communities have a greater say in the provision of basic healthcare. To improve efficiency, based on the experiences so far, the following recommendations have been made: * Despite five decades of effort to promote the use of family planning methods, a large percentage of couples report unmet need for contraception. If this unmet need could be met, population stabilization goal would be achieved. Even meeting half of the unmet need could make significant dent on the birth rate. ANMs and ASHAs could be asked to identify the couples with unmet need in their area, and address their concerns. As more than half of the unmet need is for limiting family size, meeting the unmet need would call for significant expansion of sterilization services, especially in the large north Indian states, although the NHRM launched by the Government of India acknowledged this issue. * India’s Family Welfare programme placed heavy emphasize on sterilization as the major method of family planning. Many other Asian countries started their family planning programmes with spacing methods and then gradually introduced sterilization. Providing sterilization services requires well-trained medical personnel and well-equipped facilities. A permanent method may not be preferred when levels of infant and child mortality are high, or because of religious beliefs. Therefore, sterilization should be the last resort than the first one in the contraceptive choices given to the public. So there is a need to expand the range of choices of contraceptives as well as to improve the quality of services provided to couples, both in rural and urban areas. * There is an urgent need to restructure the existing PHCs and SCs. Does it make sense to have the same number of ANMs per population in every state, given that birth-rates differ considerably from state to state? Whether the Government has the capacity and funds to adequately maintain and to operate the current level of infrastructure? How best we can attract qualified doctors to government health care institutions in rural areas. Answers to such persisting questions should be immediately found within the framework of NHRM. Some successful experiments made to address these concerns should be carefully looked into for implementation at a wider scale. * There is a need for specially focusing on poorly performing districts based on the available data from the DLHS and Facility Surveys. To bridge the gap in essential health infrastructure and manpower, state should have a more flexible approach. Care should be taken to ensure the uninterrupted supply of essential drugs, vaccines and contraceptives of required quality and quantity to all the CHCs, PHCs and SCs. * The Panchayati Raj Institutions should play a bigger role in the supervision and monitoring of PHCs. In most states the PRI involvement is not very effective mainly because the health management committees are not functioning or not representing the poor. Even when the health committees are active they have no authority over medical and paramedical personnel. In many cases, there is the need to develop better co-ordination mechanism between local self- governments and health care institutions. It is necessary to orient the PRI members about their roles and responsibilities in providing better public health services as well as the need for assigning top priority to health issues among the activities of the PRIs. Although the NRHM Framework for implementation approved by the Union Cabinet specifically addresses this issue, the challenge lies in its implementation. * Concerted efforts are necessary to improve the coverage and quality of registration of births, deaths, marriages and pregnancies. A motivated ANM, Anganwadi Worker or ASHA can play an important role in this regard. The responsibility of ensuring the complete registration can be entrusted to the local bodies with clear-cut guidelines. * Strict enforcement of the Child Marriage Restraint Act, 1976, implying prevention of marriages of girls and boys below the legally permissible ages of 18 and 21, respectively, would facilitate not only reduction of high risk teenage pregnancies but also help in human resource development amongst these younger girls and boys during their formative years towards improvement in the quality of life in the long run. The Group recommends a national campaign against Child Marriages, sex selection against the girl child & for promoting institutional delivery by the Central & State Governments. * Focused attention on antenatal and institutional delivery care help towards reduction in neo-natal component of infant mortality as well as maternal mortality, which in turn has externalities towards better acceptance of the family welfare program interventions and thus accelerate the process of fertility transition and population stabilization. * To improve the operational efficiency of the programmes, the Health Management Information System (HMIS) needs to be strengthened. The timely and accurate information gives the health managers the ability to monitor inputs and outputs of the system and help them to assess the costs and returns from various procedures. In many cases, measuring performance and distributing that information will automatically provide certain incentives for the service providers to perform. * The success of the Family Welfare Programme depends to a great extent on the personnel working in various institutions. Regular in-service training to enhance their knowledge and skills and to familiarize them with the new programmes should become a part of regular activity of the health department. They should also be in a position to develop local level health plans taking into account the health conditions of the people and their requirements. It is important to periodically assess the utilization of health services and customer satisfaction. Regular surveys, both for clients as well as for health care providers, to be undertaken. The findings from these periodic surveys should provide feedback to the health department as well as to the local bodies.