IE: We, the 116 crore people: July 09, 2010

New Delhi Every year, India adds the population of Australia to its already staggering ranks of 116.1 crore people. Every 10 years, we add the population of Brazil — the fifth most populous country in the world.

As yet another World Population Day comes around on July 11, and India stands poised to eclipse China as the most populous country of the world, the government is gingerly attempting to bring incentive-based family planning back into focus. While the first attempt three decades back had run into controversy, there is a growing realisation that if unchecked, India’s population trend would negate any attempt at sustainable development.

Following the controversy generated by the 1970s sterilisation programme implemented by the Indira Gandhi government, the Family Planning Programme had been renamed National Population Control Programme. A National Population Stabilisation Fund (PSF) or Jansankhya Stirtha Kosh was formed in 2006, though sterilisation remained a touchy subject.

The undoing of India’s population stabilisation measures lies, according to experts, with two states — Uttar Pradesh and Bihar. According to the Health Ministry, only half of the Indian states, i.e. 14, have achieved the Millennium Development Goal of two children per mother by 2015. An average Indian woman has a Total Fertility Rate (TFR) of 2.68 — meaning she is likely to have three children during her child-bearing years. In Uttar Pradesh and Bihar, that number is four.

Southern states, especially Andhra Pradesh, are an exception, considered “global models” for their efforts at population control.

“Even Madhya Pradesh and Rajasthan have managed to bring down fertility rates. (On the other hand) a woman born in UP or Bihar is likely to have four children, be uneducated and likely to die during childbirth. Family planning cannot be an isolated cause anymore. Larger families are a result of illiteracy, lack of access to healthcare and it affects maternal and child health. We are now devising policies keeping in mind all these factors,” says Dr Amarjit Singh, Executive Director, PSF.

For the first time, the government has also roped in private practitioners as part of its population control measures — which in itself is a huge departure from the usual mistrust between government and private doctors.

According to a State of Mothers Report, 2010, by Save the children, India is among the worst places in the world to be a mother. It ranks first among the 12 countries which account for two-thirds of the under-five and maternal deaths in the world. Government statistics show that a majority of the women in BIMARU states are married between the ages of 15 and 17, are anaemic and unprepared for childbirth. Anaemic mothers then give birth to malnourished, underweight children.

An innovative joint venture, ‘Chiranjeevi Yojana (Plan for a long life)’ aims to check that by providing BPL women who do not opt for institutional deliveries access to skilled emergency, gynaecological and obstetric care free of cost.

Under the scheme, the government signs MoUs with private practitioners specialising in gynaecology, obstetrics and pediatrics, paying an advance of Rs 25,000 for upgradation of their clinics.

“There is usually a lot of mistrust when it comes to government reimbursing the expenses. We pay them in advance and treat them as government doctors when they are treating Below Poverty Line women. In case of legal claims, the government represents the private doctors,” explains Dr Singh of the PSF.

The pilot project was launched in 2005 in five Gujarat districts. After a costing exercise carried out by the Indian Institute of Management (IIM), Ahmedabad, and detailed consultations with Federation of Obstetric and Gynaecological Societies of India (FOGSI), the Gujarat government fixed the prices per procedure.

The scheme proved remarkably successful in halting and reversing maternal and infant mortality rates in the pilot districts, and has since been expanded to all 25 districts of Gujarat. The results have been startling: maternal mortality has gone down from 389/1 lakh child births in 1989 to 100 in 2010 in the state. Infant mortality rate is down from 54 per 1,000 births in 2006 to 50 in 2009.

The states of West Bengal and Bihar have also initiated the scheme while the Union government is looking to expand it to all BIMARU states.

Currently, 869 doctors are a part of Chiranjeevi. In the past four years, they have delivered over 5,00,000 children who otherwise would have been born at home. Besides institutional deliveries, the scheme provides incentives for sterilisation and vaccination of newborns. An off-shoot in Gujarat is the fall in numbers of Caesarean deliveries, since doctors get paid at C-sec rates even for a normal delivery.

AN off-shoot of the Chiranjeevi programme, Santushti was launched in 2008 to address the extremely sensitive issue of sterilisation. The basis of the programme, which focuses on sterilisation operations through joint ventures, is heavy monetary incentives to private doctors (the “motivator” and the person undergoing sterilisation already get a monetary incentive from the Health Ministry).

Under it, the government gives private sector gynaecologists and vasectomy surgeons an opportunity to conduct sterilisation operations in a Public Private Partnership. A surgeon receives Rs 1,500 per vasectomy/tubectomy.

Similar to the Chiranjeevi scheme, the government gives an advance of Rs 15,000 as soon as an MoU is signed. If a clinic holds a camp for sterilisation, an extra Rs 500 is given per patient. “Since the schemes, we have had over 6,000 surgeries in four states. This was otherwise an unthinkable target,” notes Dr Singh. The scheme is functioning in Rajasthan, MP, Orissa and Bihar.