A Faulty Diagnosis: The World Bank's Prescription for India's Family Welfare Program

The recently published World Bank report, India's Family Welfare Programme: Towards a Reproductive and Child Health Approach (Washington, D.C.: The World Bank, June 1995), seeks to provide new policy directions to India's lumbering family welfare/planning programme. The Report focuses on "how the Family Welfare Programme can carry out the commitment given at the Cairo population conference to implement a client-centered approach that responds more effectively to the reproductive health and family planning needs of women and men in India."

Any discussion of this Report has to be preceded by an attempt to put it into context. India, as we know, was one of the first nations to officially launch a family planning program. A modest beginning was made in 1952 during the First Plan, using the clinic approach. In 1963,during the Third Plan, this approach was abandoned for an Extension Education Approach at the instance of international agencies. At this point of the Third Plan period, the program took wing. But even before the Extension Education Approach could take root, it was abandoned. Yet another approach - the Reorganized Program with its emphasis on the IUCD (intrauterine contraceptive device) - was initiated in 1965. This reorganization too was carried out at the behest of international agencies, including two UN Advisory Missions and the World Bank. The World Bank's interest in the population policies of developing countries was growing; it believed that "family planning programs were less costly than conventional development projects."

The IUCD strategy, however, proved a failure. With the Fourth Plan from 1969-74, emphasis shifted to vasectomy with the so-called Camp Approach; the pace of the family planning programme was considerably accelerated. By 1973, the limits of the Camp Approach - once more, adopted with the support of international agencies - became apparent. Indeed this method received glaring attention with the death of eleven vasectomised men due to tetanus at a camp in Gorakhpur.

At the same time, there was a growing awareness among international agencies - the World Bank and the Population Council among them - of the failure of the family planning solution to the poverty problem in developing countries. This led to calls for a broad-based "developmentalist" perspective. The echoes of this shift were heard in the Fifth Plan document in India; and, again, in the slogan coined by the Indian health minister at the Bucharest conference on population that "development is the best contraceptive." Notwithstanding these declarations, the Emergency in 1975 facilitated the passage of a draconian population policy which implicitly advocated compulsory sterilization. The "excesses" of the Emergency are well known and are being recalled today. What is less well known is that sterilizations, in a supposedly "welfare" program, took a ghastly toll of 1774 recorded deaths, as admitted by the government's own Shah Commission of Enquiry.

In view of the sharp fall in program performance following the withdrawal of the Emergency and the consequent change of government, the Sixth Plan set out to arrest the trend. During the next two Plan periods, the emphasis was on the sterilization of women, one of the most vulnerable sections of the Indian population.

Yet the Eighth Plan document tacitly acknowledges that the program has been a failure. It notes the fact that in spite of considerable increases in the couple protection rate, there has not been a commensurate decline in the birth rate. Indeed the late Prime Minister Rajiv Gandhi admitted this when noting that increases in allocation into the family planning program had not been accompanied by expected returns. In short, the program had once again reached an impasse.

It is in this context that the World Bank's report has arrived, attempting to inject new life into a moribund program. Appropriating the language of progressive feminists, the report advocates a "reproductive and child health approach."

There is much in the report that is difficult to find fault with. No one can deny the need for "improving the breadth, availability and quality of services." The recommendation that the program move away "from numerical, method-specific contraceptive targets and incentives to a client-centered system of performance goals and measures" is indeed very welcome. So is the recommendation to increase skills among workers in the program through appropriate training to enable them to offer a wide range of services, including contraception to men.

Nevertheless, the report leads to disquiet as the focus on reproductive health misses the epidemiological wood for the trees. Given the data on morbidity and mortality among females in India, the Bank's emphasis on reproductive health is epidemiologically not justified. Its "gender sensitivity" is thereby somewhat shallow and unconvincing. Epidemiological data indicate that the largest chunk of female mortality occurs prior to the reproductive age group. The all-India Survey of Causes of Death (Rural) for the year 1992, the latest year for which such data is available, reveals that close to 30 percent of deaths among females occurs before the age of fifteen; deaths in the reproductive age group of 15-45 years forms about half this proportion. It further reveals that deaths due to pregnancy and childbirth account for merely 1 percent of all deaths and 2.4 percent of total female deaths.

Even within the reproductive age group of Indian women, the killers are under-nutrition, infectious and communicable diseases. Among the causes of maternal deaths, anemia and puerperal sepsis together account for the largest proportion of 31 percent, followed by bleeding of pregnancy and puerperium - largely due to anemia - which account for 25.9 percent. The focus on reproductive health obscures the fact that India is yet to undergo an epidemiological transition; that the profile of diseases and deaths continues to be dominated by diseases caused by poverty.

Several earlier initiatives of the World Bank in the area of family planning have failed. Without adequate employment, income, food, water, sanitation and access to comprehensive primary health care - which the World Bank's larger policies in the economic sphere are themselves undermining - the reproductive health approach, however fashionable and "gender sensitive," appears equally doomed to failure.