Essay on the Approach to Family Planning Programme Implementation

Since its inception in 1952, the family planning programme has undergone several revisions which, despite the criticism they have called forth, nevertheless show that those who administer the programme are willing to learn from experience.

It is obvious that rigidity in the implementation of the programme would not have been the correct stance to adopt.

(a) The Clinic Approach:

The family planning programme in India started with a very cautious approach. The First Five- Year Plan emphasised field research with a view to identifying values norms, customs and beliefs concerning child-bearing.

The natural method of family planning (the Rhythm Method) was considered to be the most appropriate for the Indian masses, and this method was propagated.

It may be pointed out here that India was the first country in the world to adopt family planning as a nation-wide programme and that there was no model that she could follow.

The only model that was available for this purpose was the one used by the Planned Parenthood Organisations in the West, which set up family planning clinics and those who needed family planning were expected to take the fullest advantage to these facilities.

The limitations of such an approach may well be imagined. It is based on the assumption that those who need family planning would visit such clinics without any hesitation.

Such an assumption, however, ruled out the need to reach out to people to educate them about the need for family planning. Moreover, the Planned Parenthood model leaned heavily in favour of services for women rather than for couples.

It also leaned heavily on medical personnel, which was, and is, rather scarce in India. This “clinic approach,” as it was called, “could be expected to reach only a relatively small fraction of the people, and could not be expected to make much impact on birth rates.”

The approach was, therefore, not considered suitable for a developing country like India. Hence, the need for the adoption of “extension approach” to family planning was soon realised.

(b) The Extension Approach;

In 1963, in his report of historic importance, Lt. Col. B.L. Raina highlighted the need to strengthen the extension approach, which involves the adoption of an educational approach to bring about changes in the knowledge, attitudes and behaviour of the people in regard to family planning.

It also involves the acceptance of the principle that “the power, inherent in a group itself to bring about changes in deeply-rooted practices among the members of the group, is greater than the influence of individual instruction by outsiders.”

In the extension approach, therefore, influential formal and informal leaders in different sub-groups of the population are first identified and then encouraged to gain knowledge and to take interest in popularising the acceptance of the small family size norm among their own group.

This approach thus calls for actively working with the people for whom the programme is meant rather than working for them as outsiders. It also involves the transference of responsibility to such groups as Panchayat Samitis, village development committees or other groups.

The extension approach as outlined in the Report of the Director of Family Planning for 1962-63, envisages certain operational goals for the family planning programme with a view to reducing the birth rate as expeditiously as possible, to 25 per thousand populations.

These operational goals should “create, for 90 per cent of the married adult population of India, the three basic conditions needed for accelerating the adoption of family planning by couples: Group acceptance, knowledge about family planning and easy availability of supplies and services.”

It is necessary to elaborate on these three conditions. The emphasis on the need for group acceptance of family planning recognised the fact that individuals do not live in a vacuum but are greatly influenced by the group in which they live.

It is difficult for individuals to accept new forms of behaviour unless they are acceptable to their group as a whole. If family planning is to be adopted by individual couples, they would do so more easily if the idea of family planning is acceptable to their group.

It is, therefore, necessary to build up group and community support for the programme rather than work with individuals and expect them to adopt family planning by becoming “rebels” or “deviants”.

While the first condition for the acceptance of family planning is socio- psychological and may be considered to be somewhat difficult to define, the other two are more practical.

It is obvious that if a couple has to practice family planning, knowledge about family planning is essential knowledge that it is possible to prevent conception, knowledge about the various methods of contraception so that the most suitable method may be chosen, and knowledge about where such methods are available.

The third condition, “easy availability of supplies and services,” has also to be fulfilled if couples are to practice family planning successfully. It is true that if motivation for family planning is strong enough, a couple would seek out the sources of supplies and services even if they are not easily available.

But such strong motivation is not always forthcoming. It is better, therefore to facilitate the practice of family planning by removing both physical and psychological barriers associated with the usual sources of services for that purpose.

If a family planning centre is at a considerable distance and the clinical atmosphere is quite imposing, both these factors may act as barriers to the acceptance of the family planning programme.

(c) The Integrated Approach:

The “integrated approach” to family planning, which has assumed importance today, is not of recent origin. Even in the Second Five-Year Plan period, it was clarified that the “Family Planning Service is likely to succeed if the clinics are associated with maternity and child health work or with centres which provide medical aid and welfare services.”

The principle of integration of family planning services with maternal and child health services have thus been accepted almost since the beginning of the family planning programme. An explicit reference to this aspect is found in the Draft Fifth Five-Year Plan.

“According to the approach formulated for the Fifth Five-Year Plan, the Family Planning Programme will form an integral part of Maternal and Child Health (M.C.H.) and Nutrition Services. With this change in strategy, it is expected that the programme will find a wider acceptance among the people.”

The rationale for such integration is that when infant and child mortality rates are high, as in India, parents cannot be expected to limit the size of their families unless they have some confidence that the children they already have will survive to adulthood.

Such confidence can be created only by providing preventive and curative medical services for children. It is also obvious that while providing such services, health workers may approach mothers for family planning with greater credibility.

At present the special schemes under the family planning programme include the following Maternal and Child Health Programmes: (i) Immunisation of infants and pre-school age children against D.P.T.; (ii) Immunisation of expectant mothers against tetanus; (iii) Prophylaxis against Nutritional Anemia among mothers and children; and (iv) Prophylaxis against blindness caused in children by vitamin “A” deficiency.

The emphasis laid on the provision of maternal and child health-services in the family planning programme may be highlighted by pointing out that one- fourth of the entire outlay for family planning in the Sixth Plan is meant for maternal and child health services.

With the appointment of multi-purpose workers, a new concept in the delivery of health nutrition and family planning services has been introduced.

It was pointed out by the Committee on Multi­purpose Workers under the Health and Family Planning Programme, which was appointed by the Government of India in 1973.

That while many health administrators were of the view that the staff of the primary health centres and sub-centres were not able to adequately meet the health and family planning needs of the population to be covered, community leaders complained that rural folk were not happy about the fact that too many workers were visiting their homes for individual health programmes, and that the present health and family planning workers were not in a position to provide remedies for even simple ailments like headache, cuts and burns.

The health and family planning workers endorsed these views, and added that their acceptability would increase if the expectations of the villagers were fulfilled.

The entire country was expected to be covered by the Multi­purpose Workers Scheme during the Fifth Five-Year Plan Period. Under this scheme comprehensive health and family planning care is provided through a team of two workers, one male and female at the sub-centre level, with one sub-centre for a population of 5,000.

These multi-purpose workers are responsible for providing first aid and treatment for minor ailments in addition to health and family planning care and nutrition education.

“It is envisaged that, under the scheme integration and health and family planning services and nutrition, education will take place from the sub- centre through the P.H.C. (Primary Health Centre) and District levels to the States.”

In October, 1977, the Community Health Workers’ Scheme was introduced in selected primary health centres. This scheme has the objective of providing preventive and promotional services of health and family planning through a trained community health worker selected by the community itself for every village or a population of one thousand.

This worker is also responsible for treating minor ailments and for providing referral services. The designation of this trained person was later changed to “Community Health Volunteer,” to emphasise the fact that he was not a Government employee, and to highlight the principle of community participation and involvement.

Recently it has been decided that this person will be known as Village Health Guide. The salient features of the revised scheme are that females are to be selected as Health Guides and should preferably be 30 years of age or above and should be residing in the village permanently.

Male Health Guides are to be selected only if females are not available and preference should be given to ex-servicemen, freedom fighters or persons known for their social service.

As on 31.3.1988, there were about 4.01 lakh such trained persons in the country. During the Seventh Plan period (1985-90), it was proposed to give priority to the training and placement of village health guides.

Another aspect of the integrated approach is the post-partum programme, which is restricted only to hospitals, where women are enrolled either for delivery or for abortion.

The All-India Hospital Post-Partum Programme was initiated in January 1970. By the end of 1974-75, there were 255 such centres in the country. By the end of 1979- 80, this programme covered 524 hospitals in the country but these hospitals were either at the district level or above that level.

In 1980-81, it was, for the first time, extended to 50 sub-district hospitals. During the Sixth Plan, the programme was to be extended to 300 sub district hospitals.

As of March 1989, 554 post-partum centres have been sanctioned in medical colleges, district hospitals and maternity hospitals. Another 400 centres have been sanctioned for sub divisional hospitals. More sub-divisional level post-partum centres were to be established during the Seventh Plan period.

The rationale for this programme is that when women go to hospitals for maternity care, they are in a positive frame of mind to receive family planning education, for the need for family planning is uppermost in their minds at that time.

In fact, Zatuchni, Director of the International Post-Partum Family Planning Programme of the Population Council, New York, has listed fourteen advantages of such an approach, some of the more important of which stem from the very nature of a hospital which makes it a respected institution with good resources capable of providing continuing service to its patients.

The wide sphere of influence of hospital patients who return to their families is also mentioned as an advantage of this approach.

An extension of the Integrated Approach was the introduction of the Child Survival and Safe Motherhood (CSSM) Programme in 1992-93. Details of this Programme are given in the Section on Mortality – Influencing Policies of this chapter.

(d) The Camp Approach:

The idea of holding mass vasectomy camps was not entirely new when it was reintroduced in a big way in 1971-72. As early as 1961, the first vasectomy camp in the world was organised by the Government of Maharashtra, where 1,400 men were sterilised in 3 days.

In November-December 1970, a massive vasectomy camp was held in the Ernakulam District of Kerala, where a total of 15,005 vasectomies were performed over a period of one month.

This performance was repeated in July 1971 on a much larger scale, when 63,418 vasectomies were performed in a one-month period.

Some of the salient features of these camps, which contributed to their spectacular success, have been identified by the moving spirit behind these camps, the Collector of Ernakulam District.

These are: (i) The inter-departmental co-operation that the District Collector was able to generate; (ii) The festival atmosphere which these camps were able to create, dispelling of clouds of secrecy and embarrassment; (iii) The support from the representatives of the people as well as from industries which the organisers were able to muster; (iv) The special precautions taken while making technical arrangements in order to minimise infection and other complications following surgery; (v) Increased incentives to acceptors in addition to special prizes; and (vi) The employment of good management techniques for the organisation of these massive camps.

Encouraged by its success in Ernakulam, the Department of Family Planning allowed the States to organise such massive camps and provided additional support. The result was that the majority of vasectomies came to be performed in such camps.

Of the 2.19 million vasectomies in 1971-72, about 61 per cent were performed in mass vasectomy camps. In 1972-73, of the 3.12 million vasectomies, 83 per cent were performed in such camps.

This approach, however, has some limitations. In the first place, the setting up of a vasectomy camp involves tremendous organisation and inter-departmental co-operation and co-ordination, which is often possible only at the cost of other developmental programmes.

It disrupts the normal activities of several departments and leads to lethargy in the implementation of the family planning programme following concentrated activity in vasectomy camps. Moreover, the danger of poor motivation on the part of acceptors and a degree of coercion on the part of organisers can never be completely ruled out.

Even the slightest negligence on the part of doctors could have disastrous results, which would ultimately be counter-productive, as happened in Gorakhpur, where eleven men died of tetanus following vasectomy in a vasectomy camp.

When, in 1973-74, the family planning budget was reduced by Rs. 6 crores, the exact amount earmarked for vasectomy camps, it was evident that the camp approach was on the way out. The report of the Ministry of Health and Family Planning to Parliament made this point very clear.

“While the number of vasectomy operations did touch a record level, it has been felt that, in a larger perspective, and such camps might become counter-productive.

It was, therefore, decided not to continue this strategy, on a regular basis but to make an optimum utilisation of available resources to strengthen the normal programme, even at the risk of a decrease in the number of acceptors in the short-term.”

As expected, the figures for vasectomy for the year 1973-74 dropped to 9.42 lakhs as against 3.12 million in 1972-73 and 2.12 million in 1971-72. Some states continued to organize camps for various family planning methods on a small scale and these camps were known as mini- camps.

(e) The Reproductive and Child Health Approach:

The Population Policy of India underwent a major shift with the Programme of Action Adopted at the International Conference on Population and Development (ICPD) held at Cairo in September 1994.

The Programme of Action placed the population problem in the context of development. It was recommended that instead of population control programmes focusing on geographic targets, the emphasis should be on the needs of individuals.

The details of the ICPD Programme of Action are available in Chapter 13, Population Policies in the section on Role of the United Nations System in the field of population.

It may be reiterated that at the ICPD, the nations of the world agreed that governments should give special attention to the education of girls, the health of women, the survival of infants and young children, and in general, the empowerment of women.

It was also recommended that comprehensive reproductive health services should be provided to enable couples to achieve their reproductive goals, and to determine freely and responsibly the number and spacing of their children.

Thus the ICPD Programme of Action endorsed the concepts of reproductive and sexual health and rights and emphasized the need for providing services to achieve these goals.

It is against this background that the Population Policy of India has to be studied, with particular reference to reproductive and sexual health and rights and the provision of services required for meeting those goals.

Reproductive Health:

Reproductive health has been defined by the World Health Organisation as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes.”

This definition of reproductive health implies two conditions. The first condition is that people are able to have a satisfying and safe sex life and the second condition is that they have the capacity to reproduce and the freedom to decide if, when and how often to do so.

The second condition implies that men and women have the right to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice for regulation of fertility, which are not against the law of the land.

It is also implied that people have the right to access to appropriate health care services that would enable women to go through pregnancy and childbirth safely and provide couples with the best chance of having a healthy infant.

As one of the nations adopting the ICPD Programme of Action, India took steps to incorporate this programme in the national context.

The joint mission of the Government of India and the World Bank set-up in November 1994 recommended the Reproductive and Child Health Approach in its report submitted in 1995.

The Government of India then decided to adopt the Reproductive and Child Health Approach to the Family Welfare Programme.

The package of essential reproductive and child health services includes the following: (1) services for the prevention and management of unwanted pregnancy; (2) the promotion of safe motherhood, and child survival; (3) nutritional services for vulnerable groups; (4) services for the prevention and management of reproductive tract infections and sexually transmitted infections; and (5) reproductive health services for adolescents.

While services for the prevention and management of unwanted pregnancy include family planning and abortion related services, services for the treatment of infertility are also included in the package of essential reproductive and child health services, as the fear of sterility and delayed childbearing are major barriers to contraceptive acceptance in the Indian cultural context.

Services for safe motherhood and child survival have been an integral part of the Indian Family Welfare Programme for several years and continue to be so in the RCH Approach.

As for services for reproductive tract infections, it is known that such infections are widely prevalent in India and demand the attention they deserve in the RCH Approach. With the advent of the HIV/AIDS pandemic, the inclusion of services for sexually transmitted diseases is fully justified.

The adolescent group, (10-19 years) has so far been neglected in all health services. Reproductive health services for adolescents would fill this gap to help them not only to prevent and manage reproductive health problems but also to deal with their own sexuality in a responsible manner.

The RCH Approach not only suggests a package of integrated services, but also an emphasis on individual needs rather than on demographic goals, which were often attempted to be reached through family planning method-specific targets, even using coercive means. The RCH Approach also implies providing client-centred quality services.

It is obvious that all the services included in the RCH package cannot be introduced simultaneously throughout the country. It is necessary to priorities and develops a phased approach so that health interventions can be added in an incremental way as resources become available and the implementers develop the necessary skills.

In the meanwhile, the criteria suggested by Pachauri for prioritizing services to be included in the package could be as follows: (1) levels of fertility and mortality; (2) disease burden; (3) cost-effectiveness of available health interventions; and (4) the capacity of the health system to deliver wealth systems.

In keeping with the spirit of the ICPD Programme of Action, the God did not fix contraceptive targets, on a trial basis, for Kerala and Tamil Nadu during 1995-96, as well as one or two districts in the other states.

On 1st February 1996, the method-specific target approach was withdrawn from the entire country. By then, the limitations of fixing numerical method-specific targets had become evident. The pressure on the staff for fulfilling these targets was immense.

The target was allotted to individual states, which then allotted these targets to various districts as well as to individual health workers. This approach led to over reporting of performance by the staff and sometimes use of coercive methods. The quality of the services provided also suffered because of the undue emphasis on targets.

A fear is sometimes expressed by policy makers, programme planners and implementers and those who are concerned about the population problem that the family planning programme would get diluted if broader reproductive health services are provided.

The fear is based tin the assumption that the services would be spread thinly and justice may not be done to any of the essential services included in the package.

It needs to be emphasized that family planning is at the centre of the package and that good quality family planning services cannot be provided unless other related reproductive needs are addressed.

Problems related to reproductive tract infections, which are widely prevalent in India, sterility, pelvic inflammatory diseases, stillbirths and abortions also need to be treated if contraceptive methods are to be accepted, with full conviction of their safety.

Reproductive health problems are important enough to justify their inclusion in the package of essential services. The fact that these reproductive health problems have a bearing on the acceptance of family planning cannot be overlooked.

The fear that inclusion of other reproductive health services may dilute the family planning programme is, therefore, unfounded.