Other States in India can study how the family planning programme has worked in Kerala and incorporate those features in their own programmes
The recent tragedy of several women losing their lives in the state-sponsored tubectomy camp in Takhatpur, Chhattisgarh, has caused severe damage to the national family planning programme. This,
however, is not an invalidation of the importance of sterilisation as an integral part of the programme, but only a lurid example of bureaucratic and professional bungling and misconduct reminiscent of the ‘forced sterilisations’ of the late 70s. Reports obtained by the Union Health Ministry suggest that the deaths were caused by the use of non-sterilised surgical equipment and spurious drugs. Chaiti Bai, a member of the protected Baiga tribe, was one of the victims despite the State government having banned the sterilisation of members of this tribe. The fact is that tubectomies are not meant to be performed in camps, but only in taluk or district hospitals or in private hospitals with adequate precaution and infrastructure. Investigations need to be done to find out who was responsible for performing tubectomies in makeshift and dilapidated premises.
Let us discuss Kerala’s example, where the proportion of couples effectively protected by family planning methods is the highest in India. Even in 1991, as per Census data, 80 per cent of couples in Kerala were using family planning methods as against 43 per cent in India as a whole. The figures for Kerala for general fertility rate, gross reproductive rate and total fertility rate are the lowest in India. In Kerala, the majority of births occur with an interval of 36 months and above, which is the second best in India following Assam. The birth rate in the State is 40 per cent below that of the national average, and almost 60 per cent below the rate for poor countries in general.
The dramatic fall in birth rates and success in other demographic indicators in Kerala can be attributed to the State’s successful performance in areas ‘beyond family planning’: literacy, women’s empowerment, access to health services, social welfare measures, the public distribution system, nutritional security and poverty alleviation, among others. But superimposed on this was the State-level intensive campaign in Ernakulam from 1970 to 1973 which emphasised on male sterilisation. This achieved dramatic results. In a month-long camp held in Ernakulam Town Hall, 64,000 vasectomies were performed safely in a festive atmosphere. It is now clear that this campaign, which created a shift in mindset all over Kerala in favour of family planning, was majorly responsible for the reversal of the decadal population growth rate of the State from ascending to descending in 1971.
Improving the programme
Sterilisation is by far the most effective family planning method in the country; yet the government admits that there is no improvement in the number of sterilisations. As the family planning programme has fallen short of its targets, the date by which the birth rate of 25 per 1000 is to be achieved has been allowed to recede. It is evident that the present rate of achievement in family planning has to be accelerated if the nation is to witness the needed decline in birth rate.
“The dramatic fall in birth rates in Kerala can be attributed to the State’s performance in other areas such as literacy, women’s empowerment, access to health services and poverty alleviation”
One of the key aspects towards improving the national family planning programme is the involvement of the district Collector and Panchayati Raj institutions in its implementation. The Panchayati Raj system is a huge grassroots-level mechanism which will help in mobilising people for the programme throughout the country. It may be noted that the Collectors’ and Panchayati Raj system’s combined efforts were responsible for the outstanding success of the Ernakulam campaigns.
National commitment has to be measured in terms of results achieved and rewards for excellent performance. The existing facilities by way of manpower and infrastructure in the national family planning programme were and are still grossly underutilised in terms of results achieved. This becomes clear if one looks at the effectiveness of functioning by grassroots-level workers employed by the government for the programme. A Public Health Centre covers only an average rural population of 34,876 and a sub centre covers 5,624. If each of the institutions related to family planning alone (1,80,243) were to achieve one male sterilisation in two weeks, we would reach an annual achievement of five million male sterilisations in the country.
At present, 97 per cent of sterilisations per year are sterilisations of women; only three per cent are male. This gender imbalance has to be corrected. The active cooperation and participation of men is vital for ensuring programme acceptance. The strategy should be to make vasectomies popular again, especially no-scalpel vasectomies, and focus on men in information campaigns. Based especially on the Ernakulam experience, I suggest that for a period of three years, a sustained campaign focussing on male sterilisation be organised. The annual national achievement could then become 12.5 million, with five million sterilisations of women and five million of men through the intensive campaign, and 2.5 million sterilisations with IUD insertions, distribution of Nirodh and other spacing methods.
This is eminently feasible given a focussed approach with the full participation of the government, NGOs and Panchayati Raj institutions. This campaign will enable the family planning programme to reach its full potential and help the country achieve zero population growth rate. In order to avoid any possibility of mismanagement and possible excesses in a campaign approach of this nature, we can set up an inbuilt precautionary mechanism in the following manner.
One, all campaigns should be supervised by a team of officials and non-officials including voluntary workers and representatives of the Central and State governments. The job of the supervisory team should be to ensure that services are given only after proper motivation and they are technically perfect. Also, proper aftercare should be organised and there should be no coercion for the adoption of any particular method of the programme.
Two, a detailed compendium of instructions on how to organise an intensive campaign in a district and Community Development Block can be prepared. District Collectors, Block Development Officers and Panchayati Raj leaders, before organising camps or campaigns in their areas, must be trained and must undergo an orientation course.
A similar set of instructions can be prepared for voluntary organisations which come forward to do campaigns in their areas with infrastructural, technical and financial support from the Family Planning Department.
In sum, there is an urgent need to revisit and upgrade the family planning programme for greater results. By using the existing infrastructure and manpower, the stipulated goals of the programme can surely be achieved in a decade. Other States in India can study how the programme has worked in Kerala and incorporate those features in their own States.
(S. Krishna Kumar is an IAS officer of the 1963 batch, former district Collector of Ernakulam, and former Union Minister of State for Family Welfare.)
