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
IN AUGUST 1966 the population of India crossed the 500 million mark. Since then it has been increasing at a rate of more than a million a month. We in India have to contend with an annual increase in population which is more than the total population of Australia, or that of Norway and Sweden combined. If things go on at the same rate, India will have a billion people just 27 years from now—as many people as there were in the whole world in 1830.
This tidal wave of population in India and in many other developing countries is not the result of any striking increase in birth rates but of a truly spectacular and successful fight against death and disease. Over the years the death rate in India has actually been falling, as the accompanying chart shows. In the decade 1911-21, the death rate was 48.6 per thousand, and in the intervening half century it has been brought down by almost 75 per cent to 14 per thousand last year (see Chart 1). But the birth rate has dropped only by some 20 per cent in this same period. Life expectancy at birth, which was only 32 years in 1950, had jumped to 50 years by 1966. It was because of this sharp fall in deaths that the population began to soar. As long as this irresistible increase in population continues, the gains arising from India’s economic development are eaten up and efforts to raise the standards of living of the people through Five Year Plans are nullified.
Lowering the Birth Rate
The target set by the Government of India early in 1965 was to bring down the birth rate from the then 41 per thousand to 25 per thousand within as short a time as possible. This is to be achieved by adopting all known methods of contraception and by motivating the people to adopt these. What does this target mean? There are at present 90 million couples in the reproductive age group in India. To achieve the birth rate target of 25 per thousand, at least half the couples in the child-bearing age must practice contraception regularly. In other words, we have to raise the percentage of couples doing so from the present 5 per cent to 50 per cent of the childbearing age group. Since the number of childbearing couples increases pari passu with population, by the early or mid-1970’s at least 70 million couples must be practicing contraception regularly. The magnitude of the task will be appreciated if it is realized that 80 per cent of these couples reside in 560,000 villages and that many of them are illiterate. Most of them will be conservative and shy, as are villagers everywhere. They present vast problems both in persuasion and in logistics.
The Indian government was the first anywhere to adopt an officially sponsored family planning program. Funds were provided in the First Five Year Plan which began on April 1, 1951. But progress during the first ten years was painfully slow. Although the country’s top leadership was convinced of the urgency of the problem and the need to take action, the same urgency was not felt at middle levels and at state levels. One reason was a basically conservative attitude with regard to this highly personal matter. An even more important factor was the lack of a safe, cheap, and reliable method of contraception, which was at the 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 responsibility, 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 provision of funds to Rs 270 million ($57 million). Even these new efforts, however, took some time to gather momentum. Starting in 1963, far-reaching changes in organization were introduced. Family planning in the rural areas was made part of the extension activities. The technical direction of the Plan at the center was greatly strengthened, and in 1965 a Committee of the Cabinet was constituted specifically for family planning. This Committee is now presided over by the Prime Minister herself. In 1966, a new Department of Family Planning was created in the central government. In preparing the Fourth Plan (1966/71), family planning was given the highest priority next only to agricultural production. The Plan provided Rs 2.29 billion ($306 million) which was eight times the amount provided in the Third Plan and represented the equivalent of Rs 26 ($3.50) for every couple in the reproductive age. Though this amount is large, it has been made clear that further funds as required would be made available. Further, the central government agreed to finance the whole of the capital expenditure incurred by the states in family planning and practically the whole (97 per cent) of the recurring expenditure. Administrative and financial controls which had hampered the program in the early years were removed and the jungle of red tape cut through. Most important, there was the public commitment of the top leadership in the country—the President, the Prime Minister, the Cabinet Ministers, and State Chief Ministers.
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 with planning and policy matters, issue of sanctions and grants, development, budget, and coordination with state governments. The technical wing provides the technical advice and direction and also keeps track of the progress and implementation of the various aspects of the program in the country. There are six regional health offices of the Government of India, each headed by a Regional Health Director to watch and help in the progress of family planning work in the states falling within their respective jurisdictions.
The states have their own family planning Cabinet Committees and their family planning bureaus. To ensure close cooperation between the state and central governments and to evolve new policies as well as to review progress and exchange experience, there is a central Family Planning Council with the Union Minister for Health and Family Planning as chairman and state ministers for health and family planning and others prominently connected with family planning work as members. Each of the 335 districts (population 1-3 million) in the states has its own family planning bureaus. Under the district bureau, there are urban and rural family planning centers and subcenters. The objective is ultimately to have one urban family welfare center for every 50,000 of urban population, one rural primary health center for a rural population of 80,000, and a subcenter for a population of 10,000.
Full cooperation with the public, particularly the doctors, surgeons, and gynecologists, is sought at the various stages. There are expert committees set up to advise the Government of India on research and evaluation, and separate technical committees to advise on the intrauterine contraceptive device (IUD) and sterilization; the universities and research institutions are fully associated with these committees.
Proper training of the medical, paramedical, and mass communication personnel is an essential prerequisite for the success of the family planning program. Each one of the 125,000 program personnel must be personally convinced of the urgent necessity of curbing the present disastrous rate of population growth; every one of them must be given the skills required for doing the job effectively. This training task is perhaps the single most critical problem confronting the program.
A comprehensive program developed in consultation with the state governments provides for training of 1,500 key personnel at the state and distinct levels in five central training institutes. The remaining 123,500 field workers are being trained at the state and district levels. So far 2,727 doctors and 9,471 other personnel have undergone long courses at the five training centers. In addition, 8,056 doctors and 64,578 other personnel had undergone short courses by midsummer of last year. There are now 31 state training centers and these will be increased to 46. District level units are also being established.
Mass Communication and Education
In the final analysis, the success of the program will depend on the extent to which the average man and woman in the country can be made aware of family planning and be motivated to practice birth control. Information and knowledge must be made to flow throughout the country in the 13 regional languages as well as in Hindi and English. It has to reach every one of the cities and towns and villages. Ultimately this knowledge, together with supplies and services, must be made available to every one of the 90 million (140 million in 1975) couples in the reproductive age group. In addition a large volume of technical information has to be distributed to all types of workers within the total family planning organization. Simultaneously, contact must be maintained with political, religious, social, industrial, and educational leaders, as well as the news media, to ensure that the tempo of the program is kept up.
All available mass communications media are being utilized including booklets, posters, and flash cards. Every station in the All India Radio network has special family planning cells and there is a specific time slot every day for a family planning program. Films of various lengths and themes have been produced for exhibition in commercial theaters as well as in mobile publicity vans. The objective is to have at least one such van for each district. The press is carrying stories, commentaries, and advertisements. Family planning exhibits, by themselves or through stalls in other fairs, are being held throughout the country. Hoardings and bus boards have been erected all over the country, although not all of the rural areas have been effectively covered as yet. A simple, easily recognizable and easily reproducible symbol—an inverted equilateral triangle in red—has been adopted as a symbol of family planning. This red triangle is used on all family planning centers, contraceptive supply packages, and on literature, vehicles, and the clothing of field workers. It identifies the center, the depots, and the workers to illiterate persons.
BIRTH RATE AND DEATH RATE IN INDIA
The extension educators in the field have to complete the communications task by directly motivating married couples to adopt family 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 discussions. Married couples in the reproductive age group must be informed of the methods and services that are available and assisted in selecting the method best suited to them as individuals. 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. Conventional contraceptives (jellies, creams, foam tablets, diaphragms, and prophylactics) are supplied 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 for such minor expenses as bus fare and other incidentals.
Of the conventional contraceptives, prophylactics have been found to be potentially the most popular. Pilot projects carried out in rural areas last year established the great acceptance of this device, and its use is featured in the present Indian program. In the current year 200 million are expected to be used, a six-fold increase over the previous year which itself was a sharp increase over the earlier years. Distribution of such a large number of prophylactics is no easy task. The present arrangements envisage (1) free supplies through family welfare centers and hospitals; (2) supplies at nominal rates (US$0,007 for three) through depot holders (postmen, school teachers, private medical practitioners, and the like will be appointed part-time depot holders); and (3) commercial distribution (at the rate of US$0.02 for three) through commercial houses and distribution chains dealing with such common articles of everyday consumption as tea, cigarettes, matches, soap, etc. The central government supplies the prophylactics free to the commercial distributors and even bears a portion of the distribution costs and overheads. The nominal price charged is only to ensure that the device is not thrown away or wasted. Even the higher price charged covers only part of the distribution costs.
Factories in India can manufacture only 60-70 million prophylactics a year, so the major portion of the country’s requirements are imported. To cope with the increasing demand, the government is establishing a factory in the State of Kerala. This factory, with a capacity of 144 million prophylactics a year, will go into production by the end of 1968. There are already expansion plans for it to double its production. Private sector units are also expanding their capacity to produce 112 million a year.
Sterilization of both the male (vasectomy) and female (tubectomy) has been a method of family planning in India for some time. The chief advantage of sterilization is that it is 100 per cent effective and, at least for males, has practically no side effects. Sterilizations performed in government hospitals and family planning centers are free; private doctors are also encouraged to carry out the operations and can claim their fees from the government at prescribed rates. Male sterilization is also carried out in mobile vans, and eventually each of the 335 districts will have a sterilization van. That this method has after all reached the rural areas is evidenced by the great increase during last year. Over 862,000 operations were carried out during the 12 months ended March 1967; this represents 68.1 per cent of the target set to be attained under optimum conditions. The total number of sterilizations carried out up to the end of June 1967 was 1.76 million, of which almost one third has been carried out in the State of Madras alone. Other states, including some that have been lagging behind in family planning work, are catching up, and this development holds a good deal of promise. The target set for the year 1967/68 is 1.5 million sterilizations, and it may even be surpassed.
One state government has proposed compulsory sterilization for couples who have three living children. Some Chief Ministers, however, feel that better results could be achieved through persuasion than through compulsion. The central government is, however, carefully examining the legal, social, and political aspects of this proposal and has indicated that any legislation in this direction will be introduced only after the fullest consultation of public opinion.
A much more popular and a much less controversial proposal is that made by the Minister of Health and Family Planning recently to present a transistor radio to every man or woman undergoing sterilization. Transistor sets are greatly in demand in India and have high prestige value. Sterilized persons who had hitherto remained silent for understandable reasons will in effect now talk through their radio sets, which will be the ideal vehicle for carrying the message of family planning in rural areas.
After numerous studies and trials, the Government of India in July 1965 embarked on a vast IUD program, using the Lippes loop. Hailed as the ideal contraceptive, the Lippes loop became very popular within the first few months, particularly with persons who had been using the conventional contraceptives. Dr. Jack Lippes, the American inventor of the loop, who visited India in June 1966, was impressed with the number of insertions achieved in some states. The program has, however, fallen short of its eariler expectations. While the Lippes loop is simple and cheap, it nevertheless encountered some resistance. In the first 9 months of the program, 800,000 loops were inserted, but the insertions during the next 12 months were only 915,000 against a target of 4 million. This shortfall was due not only to the genuine failures and difficulties; there were also wild rumors set afloat by interested parties that loops would cause cancer and were giving electric shocks to the husband, and so on; such rumors did a lot of damage to the IUD program. These doubts have now been set at rest by extensive studies and follow-up work carried out by leading gynecologists and research workers in several medical colleges and universities as well as in the field. These studies have shown that while the rate of expulsion, bleeding, 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 adequate. Greater care is now being given to follow-up work, and it is hoped that, with all these improvements, the target of 2 million insertions for the current year (1967/68) will be achieved.
The Indian Council of Medical Research is carrying out studies of the various types of oral contraceptives. Though pills have not yet been introduced as part of the official program, selected brands have been allowed to be marketed in India as oral gestogens. They can, however, be purchased only with a doctor’s prescription, and the user is advised to have a periodic checkup undertaken by her own physician. Oral contraceptives are somewhat costly and may not be suitable for the Indian villagers. However, for the 20-30 per cent of the women who are not able to tolerate or retain the IUD, the pill may be a good alternative, if regularity of use and necessary medical checkups can be ensured. Such women are already motivated and can be expected to be careful in their use of the pills. The government is, therefore, considering the use of oral contraceptives as an adjunct to the IUD program. Research is also being carried out on some local herbs used for preventing conception in the indigenous systems of medicine.
HOW INDIA’S FAMILY PLANNING PROGRAM IS ORGANIZED
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 forthcoming 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 period for which they received the scholarship. This novel scheme has had a very favorable response.
Research in different aspects of the program—bio-medical, demographic, communication, social, and operational—has been carried out since its inception; there are at present 9 demographic, 9 communication, and 8 bio-medical research centers in the country. Besides these, the Indian Council of Medical Research, the Central Family Planning Institute, Central Drugs Research Institute, and several universities are carrying out research in various fields. Extensive studies are being carried out on the IUD and on a wide variety of oral contraceptives. Research on animals, for example, has shown that cadmium salts can be used to produce sterility in the male as well as the female. Already field trials have been carried out to sterilize useless cattle through such intraovarian injection of cadmium chloride. Extensive research has also been carried out to develop a simple, harmless, and low cost postcoital oral contraceptive.
A program of this magnitude encompassing some 140 million people in the most personal aspect of their lives cannot run smoothly all the time. There have been, and there will continue to be, snags, difficulties, setbacks, and disappointments. What is most encouraging now is the widespread realization of the urgency of the problem and the commitment of the political leadership of the country to do all that is possible to achieve the target. The very fact that such a revolutionary proposal as compulsory sterilization of parents with more than three children was put forward and found acceptable to a number of state governments and many sections of public opinion shows the seriousness with which this matter of population is now regarded in the country.
Other proposals which are under active consideration are the liberalization of the abortion law to permit families to limit the number of children without legal difficulty or physical risk, and the raising of the legal age for marriage for boys and girls.
After 16 years, India’s program for population control can truly be said to have come of age. It is now well staffed, mass based, politically supported, and adequately financed. While we cannot be certain that we will reach our goal of a birth rate of 25 per thousand by 1975, we are confident of coming close to it. Already one state (Madras—population 38 million) has brought down its birth rate to 32.6 per thousand; this is also a state where sterilization has been encouraged for a long time. Some other states are not far behind. The position may change dramatically if there is a breakthrough in research and a lasting pill or injection is found. But even as things are now, 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.
The Rio Meetings
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 IDA. An article on the Bank Meeting by Martin Shivnan appears on page 261.
The principal topic at the Fund Meeting 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.