Making Population Stabilization a Peoples’ Programme

Role of NGOs

In the course of social and economic development of nations, demographic transition also takes place. The South East Asian region which accounts for one quarter of the world’s population with only 5 % of world’s land area is known worldwide for the scale of its health challenges and the way they are being addressed. More than 1.4 billion people live in crowded proximity in the region which has an average density of as much as 206 persons per sq. km as compared to the world average of only 42. All this has a tremendous strain on the land-mass and infrastructure with fairly poor social indicators. The advantages of development continue to be outweighed by the growing disadvantages of over population and insufficient resources. During the last 50 years the population in this country has nearly trebled and as per the present projections, India’s population may reach 117.50 crores by 2010 and exceed 140 crores by 2025. The high population growth phase through which the country is passing provides it with a huge manpower resource which can be termed as a demographic bonus. Before, however, this window of opportunity can be put to advantage, we have a challenge to face especially in view of the limited resources and the widening infrastructure gaps. As the growing numbers continue to chase the limited resources, interventions on all fronts may have to be planned in a manner that the rapid population growth does not become a drag on our developmental efforts.

The National Commission on Population which was set up on 11^th May, 2000, the day the country’s population reached one billion has a mandate to review, monitor and oversee all the related social sector programmes that directly or indirectly impinge on the demographic profile. It is required to play its needed role for meeting the short-term, medium-term and long-term goals envisaged in NPP-2000. Through concerted efforts it is expected that the country’s population would stabilize by 2045.

The National Population Policy-2000 is noteworthy that it transcends purely demographic concerns and emphasizes the relevance of multi-sectoral approach to solve the population problem. It lays down a number of socio-demographic goals like making school education up to the age of 14 years free and compulsory, reducing dropouts at primary and secondary levels, promoting delayed marriage for girls and most importantly, bringing about a convergence of various social sector programmes, so as to make population stabilization a truly people-centred programme.

The paradigm shift in the whole approach to family planning wherein not only family planning, but reproductive and child health care, as also an improvement of all those issues that would assist in the demographic transition from a stage of high fertility, high mortality to a stage of low fertility, low mortality leaves us with no option, but to enter into a partnership between Government, Non-Government Voluntary Organizations, the Private Sector and the community at large.

Education, Health, Family Welfare, Women & Child Development, Rural Development, Water Supply & Sanitation and the related areas of concern would all have to be addressed as per the new population policy. The task is stupendous especially in view of the large infrastructure gaps in most of the relevant areas.

The existing infrastructure is not adequate even if we take into account the Census 1991 population. The number of SCs, PHCs and CHCs required and the shortfall as per 1991 rural population and as per the projected rural population for 2002 (End of 9^th Plan), at all India level is indicated below

In view of the enlarged zone and the impact that most of the social sector concerns are likely to have on the goals envisaged in NPP 2000, there is a wider canvass for cooperation between Government and the Voluntary Sector. A partnership between the government, non-government voluntary organizations, the private sector and the community at large is needed in areas such as education, health, family welfare, women and child development, rural development, water supply and sanitation for addressing the concerns outlined in the population policy. As the ultimate objective of voluntary action in the social sector is the welfare of the individual, the family and society at large, promotion of the small family norm by NGOs etc., can greatly facilitate the same.

To achieve the goals envisaged in NPP 2000, the objective is to promote a true partnership between the NGOs and the Government as well as to encourage strong NGO participation where the presence of Government functionaries has been weak traditionally. Involving NGOs in population stabilization programmes can indeed be a positive step since through NGOs, big or small, the Government may be able to reach out far more effectively to the people. The vigorous people’s movement involving the civil society with the active participation of Panchayati Raj Institutions, NGOs, VOs, Self Help Groups and the Youth Clubs is necessary for the implementation of programmes crucial for early population stabilization. Non-governmental organizations have valuable experience to offer and are very useful in providing services to the poor and un-served. The collaboration between NGOs and the Government is useful in the formulation and implementation of policies, in increasing the knowledge base and in improving the technical and managerial abilities. The contribution that NGOs have made in some of the areas like education, water and sanitation, ICDS, welfare of tribal communities and slum dwellers is especially noteworthy.

Increasing the level of education is useful to accelerate the transition to lower fertility rates. In India female education is closely linked to fertility decline. Generally women with more education have fewer children, are more likely to use contraception, and marry later. Several studies reveal that educated women will avail health and family planning services, no matter how difficult these may be to obtain. The average number of children born to educated women varies between 2 and 2.6 even in regions with high levels of fertility and infant mortality. In contrast, the average number of children born to women with no education is much more between 2.3 and 5.4.

It has been found that infant mortality among children born to educated women is one-quarter of the same among those of non-educated women in Kerala, while in Uttar Pradesh, an infant born to a non-educated mother is more than twice as likely to die as one born to a woman with a high school education. And infant mortality rates are far higher among women with little education in areas with few health services.

Interestingly, infant mortality among educated women in Uttar Pradesh, with fewer health services, is about the same as it is among non-educated women in Kerala, with better health services. This implies that education and health services complement each other in reducing infant mortality.

Gender bias contributes to infant mortality, as is apparent in the survival ratios of boys to girls in several states. Gender bias is also evident in school enrolments, with rural girls attending least. Slow population growth and lower prevailing fertility have conferred no advantage on them. In another sign of continuing gender inequity, maternal morbidity and mortality are "unacceptably high in many states, even in Kerala, which has almost universal hospital delivery and antenatal care.

Female education lowers fertility, and it lowers infant mortality. Education complements health services, with both increasing health-seeking behavior. To accelerate the transition from high birth rates to replacement birth rates in India, we can start by expanding female education, but simultaneously lowering infant mortality with better health services and expanded family planning services would be most effective.

The strength and experience of NGOs can be utilized adequately and appropriately in various activities, such as expanding educational opportunities to the deprived children, organization of educational activities focused exclusively on population concerns, counseling the young and old particularly in respect of reproductive health issues including HIV / AIDS and drug abuse and generation of awareness about critical population issues among the community. NGOs can be encouraged to actively participate in planning and management of adult literacy programmes to institutionalize population concerns.

The problems relating to women and children are the core issues for stabilizing the population of the country. The National Population Policy (NPP) envisages involving people and enabling women in particular to bring the issues of reproductive rights of women and of the larger conceptual issues of gender equality and of empowerment of women.

India accounts for nearly 25 % of the World’s maternal deaths. Every year about 1,25,000 Indian women die from- pregnancy related causes many of which are preventable. Poor maternal health results in low birth weight and premature babies. More than 7 % of the new-born babies perish every year. Nearly 2.3 % of the babies who survive the first year perish before they complete five years. The number is more in case of female babies. The IMR has remained around 72 per 1,000 live births with no significant improvement in the nineties. This is much below the average of 6 in developed countries, 64 in developing countries and the world average of 59. Also, there are significant disparities across States, within the States and among castes, communities and other ethnic groups.

The mean age of marriage at the national level is 19.5 years, but about 17.4 % of girls are married below the legal age of marriage 18 years. 8.3 % of fertility in India is contributed by mothers below 19 years age which is linked with premature death, neonatal deaths, low birth weight babies and maternal morbidity. Micro studies have indicated that women do not get adequate nutrition during pregnancy and lactation. According to an assessment of underweight and stunned growth of children ( 1997), in the age group of 1-5 years, almost half of girls were underweight and 20.3 % were severely underweight. Stunting was observed in 56 % of girls. The Body Mass Index (BMI) indicates that more women ( 36.1%) than male ( 28.6%) are affected by various stages of chronic energy deficiency. Of the social sectors, a large presence of NGO’s is noticed in this area. However, the area wise distribution / location of NGO’s is not uniform. Quality and care also needs re-emphasis.

Many of the socio-demographic goals outlined in the National Population Policy are concerned with women and children who constitute about 75% of our population. Underage marriage of girls, malnutrition, social and religious disabilities, gender discrimination in various forms, inadequate representation in the political and administrative set ups etc. make the condition of women generally poor. Repetitive child bearing, often against their will, is sometimes treated as an attack on the human rights of poor women. In the cultural ethos prevailing in the country, most poor and illiterate women do not exercise any free reproductive rights. Mostly the number of children they have to bear is decided by their husbands and families. Discrimination against the girl child and ‘son preference’ compels the women to go for uncalled for pregnancies and abortions. The serious consequences of these to the physical and mental health of the women concerned may not receive due consideration. All development effort including population stabilization cannot make much headway unless there is radical improvement in the status of women. It may be interesting to note that there is already a huge woman force readily available in the country for mobilization. The women Panchayat members, members of Women Self-Help Groups (SHGs), ANMs, Anganwadi Workers, lady primary teachers, etc. can be mobilized. A mass training programme using well designed training modules for these categories can help in creating awareness and a sense of participation in the implementation of various social sector programmes. This can also be useful to break down caste and communal barriers in the rural areas. Mobilisation of Mahila Shakti through SHGs can be especially important in places where NGOs are not present. As the SHGs are useful to improve the economic conditions of women, these Groups can be very effective forums to promote other social causes like gender equality, small family etc. The experience gained by women through working in PRIs, SHGs etc. may also be very important in bringing them up in leadership roles including setting up NGOs to address the felt needs of the community. The involvement of NGOs and the formation of Self Help Groups (SHGs) is necessary for the social and economic empowerment of disadvantaged women. This has been found successful mechanism for the organization, mobilization and self-development of women through the IMY and Swa Shakti projects of the Department of Women and Child Development. NGOs and SHGs can be instruments of social empowerment through awareness generation and convergence of delivery systems. The collaboration of NGOs, Panchayats and SHGs at the grassroots level could become very effective for implementation of programmes for issues relating to women, children and adolescents.

Adolescents comprise about one fifth of India’s population. A bulk of population in this age group, particularly in rural areas, are dropouts from schools and are vulnerable to exploitation of various sorts. A strong focus on the adolescents need to be built in various programmes and schemes to address their concerns related to health, sex education, nutrition, vulnerable to HIV/AIDS etc.

Because of the close linkages between safe potable drinking water, morbidity and mortality, appropriate emphasis requires to be given to the drinking water sector. In India, still a very large population is deprived of safe water facility. About 70 – 80 % diseases are water and sanitation related. As per an estimate, 15 lakhs children below age 5 die and 20 crore human days are lost every year due to water related diseases. Most deaths occur due to diarrohea and jaundice and unless these two diseases are reduced, the IMR and morbidity rate cannot be reduced. Therefore, we need to have a large conglomeration approach to address adequately the unmet needs of safe drinking water and sanitation. The strength of NGO’s already working in this sector would have to be expanded / deepened.

Welfare & Development of tribals occupy a distinct place in developmental planning. Whereas on the one hand, we are encouraged to see the achievements and improvements in the living conditions of the tribals through concerted efforts, on the other, other unresolved problems persist like land alienation, displacement, indebtedness, abject levels of poverty, illiteracy, poor environmental conditions and traditional beliefs and customs resulting in non-utilization of health services. All these lead to poor health and nutritional status of the tribal communities. Malnutrition is rather common particularly in situations where they are involuntarily displaced or resettled. They remain underserved in the coverage of RCH and require special attention especially in view of high IMR, MMR.

Amongst tribals, there are some communities which are very backward in every respect as compared to the rest. They live under the most fragile conditions. Though the special strategy of tribal sub-plan (TSP) has been under implementation since 1975 both at the Central and State levels with the objective that the benefits from various developmental programmes flow to the ST’s in population proportion, its full impact on improving the conditions of ST’s is not being felt. Poverty levels have no doubt come down, much more requires to be done before hunger, malnutrition and the consequential deficiencies and diseases are eradicated.

Though a large number of schemes on education, health & income generation, vocation training programmes are being implemented by NGO’s at present there is no co-relation between what the NGOs are doing with the various department schemes and the activities of the corresponding departments. For example while PHCs may be set up by Government, there could be an NGO implementing a scheme of hospital in the same area being funded by the Ministry of Tribal Affairs. Such situations could then be avoided and the limited resources of the various departments could be well optimally utilized for the benefit of the tribal community.

Other than tribals, another disadvantaged group as recognized in NPP 2000 are slum dwellers. Nearly 100 million people live in urban slums, with little or no access to potable water, sanitation facilities, and health care services. This contributes to high infant and child mortality, which in turn perpetruate high TFR and maternal mortality. Basic and primary health care, including reproductive and child health care, needs to be provided. Coordination with municipal bodies for water, sanitation and waste disposal must be pursued, and targeted information, education and communication campaigns must spread awareness about the secondary and tertiary facilities available.

The infrastructure availability of urban slums is very poor as can be seen from the following diagram:

Within the urban area, there is a large number of NGO’s, VO’s working with national / international partners. Here too the spread needs to be more uniform.

It has been observed that in high population growth States like Uttar Pradesh, Bihar, Madhya Pradesh, Rajasthan, Uttranchal, Jharkhand and Chattisgarh, the contribution of the voluntary sector is also weak compared to more developed States. Data given in Table I show that out of the total 12,265 NGOs in the country 4,397 NGOs i.e. 35.9% are in these States. As against this the population of the seven States is about 41 % of the country’s population. Further most of the 133 most backward districts in the country having fertility rates more than 3.5 belong to these States. It can also be noticed that most of the NGOs work in the Rural Development and HRD Sectors. This may be a reflection of the larger resources being channelised through the NGOs in these sectors.

The number of NGOs in the Health & Family Welfare sector is comparatively fewer. UP and Bihar are having a fair share of NGOs whereas Rajasthan and MP have fewer number of NGOs. Of course mere numbers cannot give any proper idea about their impact on sectoral programmes. That will depend upon the quality and capacity of the NGOs.

The scope and need for NGO involvement is the highest in the high population growth States which are considerably below the national average in important indicators like female literacy rate, under-age marriages, coverage of full immunization, full anti-natal care, Infant Mortality Rate, Maternal Mortality Rate and the adoption of family planning methods. Due to these factors, the fertility rate of these States are also substantially higher than the national average. The data presented in the table 2 below clearly brings out the considerable scope for improvement in each and every sector.

Though separate data is not available for the new States of Uttaranchal, Chhattisgarh and Jharkhand, their position regarding these indicators cannot be much different from the parent States. There is immediate need for effective intervention to address the various social, economic and demographic problems. Much needs to be done in the area of literacy, education, anti-natal care, immunization and for ensuring safe delivery for the mother. The poor nutritional status of the mother and child is also reflected in the high MMR and IMR. Even variables such as Couple Protection Rate (CPR) and the rate of sterilization which are directly relevant for fertility control are lagging behind. No doubt along with governmental efforts, involvement of NGOs in a big way can help solve these problems. Thus, there seems to be a strong case of concentrating NGO activity in the backward States. For this purpose, identification of NGOs who are already doing good work in these States and supporting them and encouraging both National level and local level NGOs to take up programmes / projects to benefit backward regions may be necessary. Further, the NGOs should be given a multi-sectoral orientation and vision so that the linkages between the success of sectoral programmes and achievement of larger objectives like demographic stabilization is not missed.

In most of the districts there is a District Family Welfare (RCH) Society in existence under the chairmanship of the DM. No doubt there are other such societies relating to other sectors at the District Level. However, it may be better to make the RCH Society autonomous and the focal organization for formulation and implementation various developmental programmes including population stabilization in the district. For this

purpose, this Society should have adequate representation from the PRIs, NGOs, women groups etc. This Society under the administrative leadership of the District Magistrate should be given adequate flexibility to effectively plan, implement and monitor the area specific schemes and programmes. The Society should set up a District Development Fund which apart from the funds allocated by the Government should also mobilize resources from corporate/cooperative sector and through voluntary donations from within and outside the country. Apart from plan funds and funds earmarked for specific schemes, the Society should have flexibility in using the resources at its disposal. The detailed annual budget of the District Development Fund should be based on the District Action Plan and approved by the Governing Body of the Society. The implementation of developmental and population stabilization programmes through the District RCH Society has been done very successfully in Andhra Pradesh. Such a semi-autonomous framework will help channelise resources directly to the needy districts. Funding from sources like the NCP through normal Governmental channels involves delays and uncertainty about the resources reaching the target areas. The process of decentralization of formulation and implementation of developmental projects has to reach to lower levels upto the village. Village level committees consisting of members of the PRIs, Self-Help Groups, Youth Clubs and local level government functionaries could be constituted for formulating and implementing developmental programmes on the basis of the felt needs of the village. During the field visits by the NCP teams in different States, it was found that most of the problems at the grass-root level can be solved provided the beneficiaries and the elected representatives of the PRIs and the voluntary organizations take interest and initiates in solving the problems. Gradually, the supervision and control of village level functionaries such as doctors, ANMs teachers, Anganwadi Workers, etc. may have to be brought under PRIs.

As per data available with the Planning Commission, there are 12265 NGOs in the country of which 91% are involved in social sector activities- 52.75% in Rural Development (RD), 17% in Human Resource Development (HRD), 10.15% Social Justice & Empowerment (SJ & E), 6.2% in Health & Family Welfare (H & FW), and 4.8% in Youth Affairs & Sports (YA & S).

About 25% NGOs are working in the southern States of which 10.4% in Andhra Pradesh, 4.15% in Karnataka, 2.84% in Kerala and 7.85% in Tamil Nadu.

About 36% NGOs are working in the demographically weak States including newly formed States – 15.84% in U.P., 4.5% in M.P., 9.33% in Bihar, 2.9% in Rajasthan, 1.7% in Jharkhand, 1.3% in Uttaranchal and 0.35% in Chhattisgarh.

About 30% NGOs are working in other major States – West Bengal (9.73%), Orissa (6.78%), Maharashtra (4.95%), Delhi (4.08%), Gujarat (2.59%), Haryana (1.5%) and Punjab (0.36%).

7.35% NGOs are working in North Eastern States – Assam (2.1%), Manipur (2.9%), Maghalaya (0.18%), Mizoram (0.28%), Nagaland (0.47%), Arunachal Pradesh (0.2%) and Tripura (0.37%).

The role of NGOs and their capacity in reaching across to large sections of the population and the quality of reach is undoubted. However, in view of the limited organizational, managerial and financial capacities of NGOs, they cannot, in any way supplant the normal government machinery in addressing the various developmental problems of the social sector. Very often the performance of NGOs depend on the presence of one or two committed individuals and the tempo of the programme is lost once these individuals stop taking interest in these programmes. On several occasions the NGO’s have to take into account the concerns of the donor agencies ( national or inter-national ) and these may sometimes result in giving a particular slant to a programme. In such situations it would be better to take into account the views of the beneficiaries / target groups in order to ensure effectiveness and transparency in their working. In order that the NGO’s can effectively complement the efforts of the governmental machinery specially among the underserved regions and groups, we may have to take a realistic view on their role and capacity and invest in their capacity building. This resource could then be used for capacity building and motivation of the target groups. Experience shows that very often and because of the constraints – organizational and financial, several NGO’s , V.O’s etc., tend to concentrate their activities in particular sectors or particular regions of the country. Since capacity building as also flow of resources takes place along with the NGO area of activity, an area-wise analysis may be required to be done so that investments can be tailored to meet these social commitments keeping in view the vast regional disparities. Through proper monitoring and allocation of funds as also recognition of the work being done by NGO’s, a partnership can be established between government / NGO’s and the community at large. Formulation and implementation of policies and programmes is likely to show a marked improvement once this is done. There are outstanding examples of inter-sectoral collaboration and close linkages between NGOs, community groups and government in many countries. For instance, in Maldives, collaboration between youth groups, island development committees (IDCs) and health workers led to the declaration of two islands as " No Smoking Islands ".

To reach the goal of population stabilization within a stipulated time frame, NGO’s could be a great force to rely upon.