Banking on unpaid ASHA and prayer
It may be a truism to state that overpopulation is the mother of all problems, including corruption which so often hogs the limelight. Yet corruption is only a side effect of the rising number of claimants to the national bread basket and some of the cookies in it. The fierce competition for the available goodies at any stage sets of f the storm of corruption . The fruits of India’s massive development in various sectors are not enough to meet the needs of her growing population. Dis-equilibrium between the pace of development and population growth continues to be the running source of all our maladies.
Since the middle of the 20th century India along with most parts of the world has witnessed a population explosion. Our first family planning programmes started over 60 years ago in 1952. Globally, 2011 witnessed the arrival of the seventh billion baby with India quite in the forefront . With our current estimate of 1.2 billion population we are still expanding faster than our development rate can cope with.
Despite a significant slowdown over the last 20 years in almost half of the country, India is still nowhere near a reasonably early population stabilization target. At our leisurely pace we are still looking at 2060 as the stabilization target year -- more than 100 years after we set up our family planning ministry. We have missed targets several times and we could miss again if we don’t act fast.
The 1983 National Health Policy target of achieving the total fertility rate (TFR) of 2.1 children per woman , which is also considered the replacement level, by the year 2000 was missed by a long chalk. Again the National Population Policy target set in 2000 of achieving 2.1 TFR by 2010 has been missed. Sadly, the 2010 TFR stands at 2.5, as revealed by the latest Sample Registration System figures from the Registrar General of India.
The long term objective of the 2000 National Population policy was to achieve a stable (zero net growth) stable population by 2045. At the current rate we are pushing the stabilisation target to 2060. That need not be so. We have the medical and monetary wherewithal and we can shorten our target rather than wait till 2045 or for another half century till 2060. Our family planning strategy needs to be more focused than ever before.
For the best part of last 40 years we have been obsessed with sterilization -- operating upon persons who have already produced three, four or more children , when the damage is done and objective of a small family already defeated.
The birth control pill, which is the easiest and least complicated contraceptive to use and which has been available worldwide for more than 50 years, has been the most popular and effective contraceptive all across Europe and other parts of the developed world. So successful indeed that desire for a smaller family and fewer children has made couples to forego cash and holiday incentives offered by certain governments. In countries like Germany and Russia which are witnessing negative or zero population growth there are few takers of such incentives offered by the state. Even in poorer countries like Romania and Hungary, young couples tend to go for smaller but prosperous families, ignoring traditional Catholic religious reservations.
But curiously the pill seems to have been virtually ignored by our planners for almost the first 25 years of its existence. Only around 1987 , the pill was in some strength brought into our basket of the attractively named “cafeteria” contraceptives, leaving it to the consumers to pick and choose without telling them to opt for one or the other . Its current usage -- nearly three crore pills or three lakh 30-day cycles per year -- translates to only a little over three to four per cent acceptors out of all other contraceptives users.
The cafeteria approach looks good in terms of free choice but in reality it doesn’t play out so fair and free. The cash incentives to motivators and acceptors of other forms of contraceptives, especially sterilisation in various forms, act as a powerful factor in the cafeteria. Sterilisations can be easily counted and monies collected by motivators and acceptors. But pills popped in at home can’t be verified and cash handouts difficult to pick. Consequently the pill seems to have fallen off the cafeteria shelves as only about three percent women in the 15-45 age group are taking to the pill, unaware of the advantages of the pill.
Over 90 per cent child bearing women in India are barely aware of the pill’s benefits like regularising of periods, bleeding control, lesser ovarian problems and, above all, spacing out pregnancies for better mother and child health.
Australian researchers at Monash and Melbourne universities say the pill can even cut the risk of developing breast, ovarian and womb cancer. They even go on to recommend the pill for nuns too for reasons of health rather than as a conrtraceptive because it reduces overall mortality and mortality due to ovarian and uterine cancer.
In India, medical or paramedical advice on the easy-to-use pill for controlling family size and better family welfare could be most well timed and effective after the first or second child birth.
But where are the medical/paramedical helpers to be found on the ground level, especially in the villages? ASHAs, Anganwadis and ANMs besides qualified staff at block and district hospitals make quite a nice ladder or a pyramid. But is the entire edifice adequately staffed. At the very base stands the grandly designated ASHA or the Accredited Social Health Activist each of whom is expected to look after 100 women in her village community. One ASHA for each village is a great idea. But what is she accredited with? Sadly in our scheme of things under NRHM (National Rural Health Mission) she is an unpaid worker. She is a part- time volunteer who is expected to work only two or three hours a day. She is our key health worker in the village. The list of her duties is a long one. Motivating women to use contraceptives, including the pill, to help India control its runaway population growth, is only one of her myriad jobs. All for no pay!
The second key worker in the village is the Aanganwadi, also a part-timer with duties such as preparing mid-day school meals for school children and taking pregnant women to nearest hospitals for safe deliveries and other medical help. She at least is lucky to have some pay , a grand sum of Rs 3,000 a month announced by Union Finance Minister Pranab Mukherjee in his 2011 budget speech over a year ago. But there was nothing for ASHA then or now in the 2012 budget.
Our long obsession with sterilisation operations -- vasectomy, no scalpel vasectomy, tubectomy, IUD -- in spite of the numerical surges running into lakhs over the last few years has failed to stem the explosive growth in the Hindi heartland of the country. And it must be underlined that the success of the southern states and some northern states cannot be attributed to sterilisation programmes. Rather it is due to factors like higher female education rate, mid-day school meals, and availability of home entertainment in the evening, thanks to the distribution of free television sets by some the ruling parties.
Sterilisations are the biggest gimmick. Collection of cash handouts by NGOs, individual motivators and volunteers who undergo such operations is the main attraction of most participants in this elaborate game. Even the medical staff who
perform these operations are in this somewhat lucrative loop. All this money would be worth investing if it could move us to nearer to the population control target. An overwhelming majority of such operations are performed on women who have already given birth to three , four or more children and have reached the menopause stage. Men, notoriously, account for a mere five percent of total number of sterilisation operations, according to the available surveys published in the quarterly journal of the National Institute of Health and family Welfare .
Reports of botched up sterilization operations at ad hoc camps run by some NGOs in Bihar (The Hindu , 23 January) , Madhya Pradesh (The Times of India 18 and 26 February) are not infrequent. Incentive -driven motivators and target chasing administrators in Madhya Pradesh went on a sterilization spree in February this year to lure poor tribals even though they are designated as “protected” because their numbers are dwindling fast. From aanganwadi workers to patwaris and tehsildars and other officials everyone was out to lure tribals to sterilization tables for a cash incentive of Rs 1100, according to the president of the Vanwasi Kalyan Parishad who alleged that the Gonds and Korku tribals in Betul district were the victims of this drive. Stung by the protests, state chief minister Shivraj Singh Chauhan had to step in , warning unscrupulous operatives to not defeat the real objective of celebrating 2012 as the year of family planning in the state.
Such incidents may be aberrations and the vast majority of operations – at the annual rate of 40 to 50 lakhs over the last three years and still rising – are safe and successful, according to health ministry officials. Yet the central fact remains that the vast majority of such operations are redundant as they are conducted on people who have already reached their non-reproductive age.
Time to re-focus family planning strategy. And time to relocate existing and new Plan finances to pay ASHA a meaningful wage commensurate with the services we expect of her.
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