POPULATION ISSUES AND WOMEN'S HEALTH
Item
- Title
- POPULATION ISSUES AND WOMEN'S HEALTH
- extracted text
-
RF_WH_11_3_PART_1_SUDHA
*3* manlal
i
ON
TARGET FREE
APPROACH
IN
FAMIL Y WELFARE PROGRAMME
MINISTRY Oh HEAL TH <£ FAMIL > WELL ARI.
YEH DEI H!
1.
INTRODUCTION;
In keeping with the democratic traditions of the country, the Family Welfare Programme
seeks to promote responsible and planned parenthood through voluntary and free choice of the
following methods of contraception approved under the National Family Welfare Programme.
(i)
(ii)
(iii)
(iv)
(v)
(vi)
Sterilisation (Vasectomy & Tubectomy)
IUD Insertions
Oral Pill Users
Conventional Contraceptives (Condoms)
Indigenous/Traditional method
Natural Method
India's Family Planning Programme (renamed as Family Welfare in late 1970's) has had
a single objective for nearly 30 years, to reduce fertility as quickly as possible. The program has
sought to achieve this goal through a strategy based on contraceptive targets and cash incentives
to acceptors and providers.
The objective of the Family Planning Programme is to reduce the birth rale
Contraception is only an instrument for bringing about reduction in birth rate. The success of the
programme with reference to the objective can be judged only on the basis of the reduction in thi
birth rate. The contraceptive target monitoring now being done has led to a situation where the
achievement of contraceptive targets has become an end in itself. According to the Nationa
Family Health Survey conducted recently, the extent of contraceptive acceptance is less than
indicated by statistics provided by state governments. Although, some state governments receive
very good grading for sterilisation under the 20 Point Programme, this has not led to
corresponding reduction in the birth rale. It has also been observed that a disproportionate!’
large proportion of the target (40%) is achieved in the last 3 months of the financial year although
the service ought to be provided evenly throughout the year.
Since past few years, the Government of India recognized that contraceptive targets and
cash incentives have resulted in the inflation of performance statistics and the neglect of quality
of services. As a result, cash incentives for IUD insertions were withdrawn. GO1 did not fi:,
contraceptive targets for Kerala and Tamil Nadu during 1995-96 and in other States one or two
districts were made "target free". Further, State Governments were given freedom to introduce
incentives for improving the quality of services.
While there are no two opinions about the need to remove numerical targets for the sak.of quality of service, there is a concern that such a move, when taken country-wide, may lead t)
decline in performance initially. A system of getting estimates of expected levels of acceptance
from the State Governments was in vogue for the last three years but now this exercise will be
carried out by the grass root workers in consultation with the community to estimate real needs
assessment. This will be coupled with the formulation of a PHC level plan covering all activities
of la.T_:y welfare, the materials and supplies required and an operational strategy to achieve the
objectives.
Grass root level workers like ANM, Multipurpose Health Workers both male and female.
shall be asked to give an estimate of the various family welfare activities required in the
area/population covered by them. It is expected that at the PHC level, the local NGO activist.,
primary school teachers, pradhans and panchayat members, private practitioners of indigenous
systems of medicines would be involved in the formulations of the PHC based Family Welfare
Health Care Plan. While in the first year the process of estimation can be tentative but in future
years the endeavour should be to start the planning process at village level itself. Aggregatior
of all such estimates of grass root workers of various subcentres and at the Primary Health Centre
shall be prepared at each PHC. District Family Welfare Plan shall be an aggregation of all such
plans formulated at each PHC in the district. State Level Family Welfare Plan shall be ar
aggregation of all such District Family Welfare Plans. All the State level Family Welfare Plant.
shall be compiled at National level to work out requirement of all materials and supplies.
Although the input requirements for family welfare activities shall be based on the
requirement given by the grass root level workers like ANM, the monitoring of the performance
of ANM shall not be merely on the basis of achievements in this regard alone, but would be
done with the help of indicators relating to improvement and quality of service.
A system of evaluating and introducing corrections in the performance of PHC even'
month by the district health staff and that of each district by the state level staff every quarter has
been worked out. A similar exercise to evaluate the performance of each state would be carried
out at the national level. The present manual tries to answer all such issues for the guidance o;
the field workers, the administrators and other persons responsible for implementing this
programme.
There should be minimum change in the records that ANM and other field workers artrequired to maintain in order that the changed system of working helps them to utilize their time
fully to improve the quality of services that they arc required to provide to the community The
Eligible Couple (EC) Register will continue to be one of the most important records at ANM
level.
NEW FOCUS OF FW PROGRAMME - A Target free approach
2.
Family Welfare Programme is to be implemented from the First April 1996 on the basu
of Target Free Approach. Besides, the focus of the national Family Welfare Programme is to
undergo a change from a segregated approach under Family Planning and Maternal and Child
Services to that of integrated approach under Reproductive and Child Health (RCH) Services in
future. This means that RCH is equivalent to Family Planning + CSSM + prevention of
RTI/STD and AIDS + a client approach to providing FW & Health Care Services.
As the National Family Welfare Programme moves from Target Based Activity to Client
Centered Demand Driven Quality Services Programme, there is a need to change various aspects
of its operations including increased levels of male participation.
Illustrative list of services to be provided to general public from PHC &
2.1
Sub-Centres:
The following services may be provided to general public from Sub-Centres. PHCs and
in some cases, with tie-up of referral, from nearest CHCs and district hospitals:
Mother Care Services
I.
Ante Natal Care:
(A)
(i) Registration of Ante-natal Care Cases preferably before
16th week of pregnancy.
(ii)
Providing ante natal care to pregnant mothers by
atleast three visits.
(iii) Detection and treatment of anaemic pregnant mothers.
(iv) Timely detection and referral of high risk pregnant
mothers.
(B)
(i)
Natal Care:
As far as possible delivery should take place in
Hospitals. PHCs or subcentres under the supervision of
qualified personnel.
(ii)
As far as possible, the domiciliary deliveries should be assisted by LHV. ANM
or by trained birth attendants.
mi) Detection and referral of high risk labour cases.
tn) Identification of existing Dais and organising dai
training.
(v) Provision of Dai Kits.
3
(C)
Post Natal Care
(i)
Growth Monitoring of new bom.
(ii) Detection and referral of high risk new born babies.
(iii) Neo-natal resuscitation wherever facilities are avail
able and by education of dais & community in other areas.
II.
Immunisation:
Immunisation services against following communicable diseases to children.
(i)
Tuberculosis
(ii)
Polio
(iii)
Diphtheria
(iv)
Whooping Cough
(v)
Tetanus
(vi)
Measles
III.
Prophylactic Services:
Prophylactic Services against anaemia and Vitamin A deficiency to
(i)
(ii)
(iii)
IV.
Curative Services for
(i)
(ii)
V.
Pregnant Mothers
Nursing Mothers and IUD Acceptors
Children below 5 years of age.
Diarrhoea cases with ORS
Respiratory infection cases with cotrimoxazole.
Contraceptive Services
(i)
Male Sterilisation Operation.
(ii)
Female Sterilisation Operation.
(iii)
Copper T. insertions.
(iv)
Oral Pill - distribution.
(v)
Nirodh distribution.
(vi)
Indigenous/traditional methods
(vii)
Natural methods.
VI.
MTP
(i)
(ii)
Assessing abortion needs and providing the same by early detection.
Assessing need for expanding services by increasing trained staff
and registered centres.
4
VII.
Emergency Obstetric Care
Assessing expected high risk cases.
Provide for referral in existing Post Partum Centres.
Provide for referral at identified First Referral Units.
VIII. Nutrition Counselling and Supplementary Nutrition
(i)
(ii)
(iii)
(i)
Linkages with ICDS and Anganwadi for provision of supplementary nutrition
for pregnant/lactating mothers and for infants.
(ii)
Nutritional Counselling through linkages with ICDS/AWW/ANM for anaemic
children, adolescents, mothers.
HcrWiexs
2.2
Activities at Sub-centre and PHC
Following activities should be carried out at Subcentre and PHC level for provisions cf
quality of care to general public.
2.2.1. At sub centre level
Immunization, MCH Information Education and Communication
Services are to be provided by Subcentre.
*
Activities to be carried out during an immunisation/MCH
session arc:
For children
*
immunization of children
*
administration of Vitamin A concentrated solution for prophylaxis
and therapy
•
Diagnosis of anaemia in children and distribution of IFA (small) tablets
'
ante-natal check up of pregnant women
•
TT immunization
For Pregnant Women
‘
’
administration of IFA for prophylaxis and therapy
deworming of pregnant women who show clinical signs of
anaemia (in 2nd/3rd trimester) in areas with high prevalence of Hook Worm
infestation.
Communication and counselling
1
On infant feeding(exclusive breast-feeding and weaning)
On home management of diarrhoea and ARI
On birth spacing as a health promotion measure
Recognition of danger signs for seeking immediate medical help
5
Provide
*
prepared ORS solution to a child with diarrhoea and give ORS
packets for use at home
*
tablet Cotrimoxazole to a child with Pneumonia
*
oral pills and condoms
Gather Information by talking to mothers.
uovsr-. i
*
On new births or pregnancies in the village
*
cases of measles, diarrhoea and pneumonia
*
counselling on polio and neonatal death
*
counselling for reproductive health
Update records
For holding the sessions it should be ensured that the health worker:
Reaches the FIXED PLACE on the FIXED DAY at the FIXED TIME
as per subcentre work plan
•
carries vaccines in cold chain and has enough syringes and
needles so that she can use syringe and one needle for
every beneficiary after ensuring proper sterilisation.
*
has sufficient quantities of Vitamin A. 1FA tablets (both
large and small), ORS packets and Cotrimoxazole tablets for
giving to children who may need them.
*
has the mother and child cards and register with her and
updates these during the session
•
carries educational aids for interpersonal/group communication
7k.s
> -• .
-■
The health workers should contact local influencial persons like/Anganwadi worker. TB?.
Village Pradhan, Panchayat Members, Other sector workers etc. on arrival and obtain their help
for mobilising the beneficiaries. Special efforts should be made with their help to identify and
motivate drop outs and those who do not avail services from out reach areas. The opportunity
should be utilised by Subcentre Team to inform the mothers and organised groups about the
different services and to encourage them to avail these.
2.2.2.
At PHC Level
The PHC workplan includes, activities of the Sub-centres and the PHC. The
responsibility of ensuring proper implementation of the plan however, lies with the PHC. It s
necessary that all medical Officers of the PHC are familiar with the plan and the programrre
components.
6
;C
In addition to the immunization and MCH activities being carried out at the sub-centre
level (Immunisation/MCH session. Sub-centre clinic and Village visits), the PHC is responsible
for delivery of both preventive and curative services in the area. This involves scheduling
immunization/MCH sessions and antenatal clinics in addition to the routine inpatient and
out-patient services. The activities to be carried out during the immunization/MCH session a:
the PHC are essentially the same as in a similar session at the Sub-centre level.
Correct Case Management of children with diarrhoea, ARI and sick newborns is an
important activity at the PHC level. The PHC is required to provide treatment to children
referred to it andshould be able to organise the facilities required for management of these cases
as per guidelines.
The PHC should provide services for safe delivery of all uncomplicated pregnancies.
The labour rooms should be clean and provided with the required supplies for carrying out
deliveries and essential care of the newborns. Provision of these services can generally be
planned within the existing resources of the PHC.
Management of complications of pregnancy like hypertensive disorders, severe anaemia
and sepsis should be available at PHC level. Referral of severe cases to the first referral unit,
(FRUs) for various childhood and maternal emergencies should be made as per guidelines. The
names and location of the FRUs should be known to all doctors and health workers of
PHC/Sub-centrc area.
It should be ensured that the PHC is equipped with relevant supplies like medicine,
intravenous fluids and have a regular duty roster providing for round the clock attendance in case
of need. Care be taken to indent sufficient stocks of vaccines, needles and syringes from the
district stores in time and distribute to the outreach centres according to the plan. MO should
monitor the use of individual items in the drug kits supplied to the subcentres and provide for
timely replishmcnt out from the PHC stocks, and out of items which are not used in other
subcentres. All health workers in PHC area should receive vaccines for conducting imunizatioi
sessions/MCH sessions, in vaccine carriers with fully frozen ice packs.
The PHC is the unit for carrying out all surveillance related activities. These include
case/death analysis, interpretation, action and reporting. Decisions that will have to be taken tt
PHC level include containment measures for outbreaks, mop-up rounds, investigation oi acutr
flaccid paralysis, neonatal and maternal deaths through line listing and special investigations sue i
as stool test, etc.
Monitoring the implementation of sub-centre work plans, their performance an!
coverage levels of individual sub-centre areas and identifying problem areas is to be done by the
PHC medical officers. Based on the reasons identified for a particular problem, possible
solutions should be identified in consultation with the health workers and the community. Care
be taken to monitor the establishment and functioning of the village level depots for ORS
packets, condoms and in some cases oral pills.
Regular reporting of the achievements and problems, to the district/state health
department is an important activity of the PHC. Providing feedback to the health functionaries
based on discussions at the district level meetings are important.
7
The meeting is an important activity to review performance, provide feedback and
guidance to the workers for improving their performance and coverage levels. The other
important meeting at PHC level would be participatory appraisal meeting with the Panchayati
Raj leaders at PHC level.
All the activities listed in the workplan of the PHC must be carried out regularlv
2.3
Prerequisites for Target Free Approach :
The following points are needed to be ensured in each
state:
(1)
Contraceptive targets for the health & non-hcalth staff like ones working in
Revenue, Rural Development, Education Departments must be abolished.'f V
(2)
The male health workers should be made responsible for motivation for
vasectomy and condom.
(3)
The motivator certificate and motivator fee, if still in use. should be withdrawn.
(4)
Family Planning performance in the district should not be used to rank the
Collectors or to assess them for their annual confidential report.
(5)
The PHC Plan shall be proposed on the basis of assessment of need of .
population for FW Services by ANM and others; the performance of
the medical officer in charge, PHC and ANM shall be judged on the basis
of their quantitative and qualitative achievement with respect to the
needs assessed. .
8
’
TARGET FREE
APPROACH
IN
FAMIL Y WELFARE PROGRAMME
MINISTRY OE HEALTH & FAMIL Y WELFARE
MEW DELHI
D.O. No. M.110t5/15/94'-E&l.
rarnq ht? qfvqrq
qfaqTC
fq«TH
THniui *p?h, r? f^ft-HOOl 1
J. C. PANT i.A.s.
Secretary
GOVERNMENT OF INDIA
MINISTRY OF HEALTH & FAMILY WELFARE
DEPARTMENT OF FAMILY WELFARE
NIRMAN BHAVAN, NEW DELHI-110011
Phone : 301 84 32
Fax No. t 301 88 87
Dear
Kindly refer to our discussions on the subject of Target Free Approach on 4th April,
1996 in the Conference of State Secretaries of Family Welfare. I am enclosing a copy of
the draft of the Manual on Target Free Approach in Family Welfare Programme. We would
welcome your suggestions for improvement. We shall be happy to incorporate them while
this draft is being sent for printing. You may also like to explore the desirability of this
manual being translated into the official language of your State.
.Yours sincerely.
( J.C. PANT )
Secretary (Family Welfare),
Govt, of Karnataka,
BANGALORE - 560 001.
Post Script : It is expected that the preparation of the PHC based family welfare ancT
health care plans must have been taken in hand earnestly in all the districts of your state-'
by now. A difficulty raised by field workers in some states relates to the birth rate (BR;they should take for assessing input needs for MCH activities. This is to clarify that the.
State Directorate of Family Welfare should be communicating to the districts the birth ralL_
(BR) they should take for calculating their needs for MCH inputs. If this has not been done
so far, it should now be ensured on priority.
FOREWORD
From First April 1996 the Family Welfare Programme is-to be
implemented all over India on the basis of Target Free Approach. From
now onwards the centrally determined targets will no longer be the driving
force behind the programme. The demand of the community for quality
services would be expected to become the driving force behind the
programme making it a people's programme.
2.
The changeover to a target free approach necessitates decentralised
planning in consultation with the community at the grass root level to
provide quality services under Family Welfare Programme to the
community. Besides, the monitoring and evaluation of the performance
also requires a fresh look at the issues of quality of care at different levels
of the Primary Health Care System.
3.
The Manual on Target Free Approach in Family Welfare
Programme has been prepared to provide guidance on decentralised
planning at the level of PHC, to improve quality of care and how to monitor
the improvements in the quality of care in the services provided to the
community by the Primary Health Care System of the country. This
manual is a result of intense discussions with State Family Welfare
Secretaries and Directors as well as management experts and experts of die
Family Welfare Department.
Decentralized planning means close
association of the community and its leading lights and opinion leaders
such as village pradhans, primary school teachers in the formulation of the
PHC based family welfare and health care plan. I hope this manual will
provide guidance to various functionaries at different levels of the Primary
Health Care System to plan for and provide quality care in the services
provided to the community as per the requirements of the community under
Family Welfare Programme to make it a truly people's programme.
(J.C. Pant)
Secretary to the GovL of India
Ministry of Health & F.W.
INDEX
Sl.No.
CONTENTS
Pa£es
1.
Introduction
'
2.
New Focus of FW Programme - A Target Free
approach.
.
2.1
Illustrative list of services to be provided
to general public from PHC & Sub-Centres
2.2
Activities
2.3
Prerequisites for Target Free Approach
3.
Improving quality of care
3.1
Service Delivery Aspect
3.2
Informational Aspect
3.3
Technical Aspect
3.4
Interpersonal aspect
3.5
Social aspects
9
4.
Expected Outcome of Target Free
Family Welfare programme.
11
5.
Preparation of Sub-centre Action Plan
5.1
Defining workload Norms for ANM1’
5.2
Consultations
5.3
Requirement of the Area Vs Felt Need of the
population- Subcentre Action Plan
12
6.
Preparation of PHC, FW&HC Plan
6.1
Data Base required for Planning at PHC-level
6.2
Format for PHC FW & HC Plan
14
7.
Preparation of District & State FW&HC Plan
16
8.
Monitoring and Evaluation
8.1
Performance of ANMs
8.2
Performance of Health Worker(Male)
8.3
Performance of Medical Officer PHCs
8.4
Periodicity of Supervision
8.5
Inspection and Supervision
8.6
Client based Records
8.7
Procedures for the Rapid Survey
8.8
Monitoring system of FRUs and PP centres for
quality of care
8.9
Monitoring Indicators
8.10
Reporting System
8.11
Summary Reporting
17
9.
Training
9.1
In-service training
9.2
Objectives of the Training
9.3
Making a Training District Plan
24
10.
I.E.C. Programmes
10.1
Available Media Equipments and Materials:
10.2
Communication Needs
10.3
IEC Objectives
10.4
EEC Strategy
10.5
Existing EEC Schemes
26
11.
Alternate Strategic Initiatives
11.1
11.2
11.3
Increasing Coverage
Reducing Unmet Need
Ensuring Quality of Care
ANNEXURES
Forms 1 to 14
31
1. INTRODUCTION:
In keeping with the democratic traditions of the country, the Family Welfare Programme
seeks to promote responsible and planned parenthood through voluntary and free choice of the
following methods of contraception approved under the National Family Welfare Programme.
(i)
(ii)
(iii)
(iv)
(v)
(vi)
Sterilisation (Vasectomy & Tubectomy)
IUD Insertions
Oral Pill Users
Conventional Contraceptives (Condoms)
Indigenous/Traditional method
Natural Method
India's Family Planning Programme (renamed as Family Welfare in late 1970's) has had
a single objective for nearly 30 years, to reduce fertility as quickly as possible. The program has
sought to achieve this goal through a strategy based on contraceptive targets and cash incentives
to acceptors and providers.
The objective of the Family Planning Programme is to reduce the birth rate
Contraception is only an instrument for bringing about reduction in birth rate. The success of the
programme with reference to the objective can be judged only on the basis of the reduction in the.
birth rate. The contraceptive target monitoring now being done has led to a situation where the
achievement of contraceptive targets has become an end in itself. According to the Nationa
Family Health Survey conducted recently, the extent of contraceptive acceptance is less than
indicated by statistics provided by state governments. Although, some state governments receive
very good grading for sterilisation under the 20 Point Programme, this has not led to
corresponding reduction in the birth rate. It has also been observed that a disproportionately
large proportion of the target (40%) is achieved in the last 3 months of the financial year although
the service ought to be provided evenly throughout the year.
Since past few years, the Government of India recognized that contraceptive targets and
cash incentives have resulted in the inflation of performance statistics and the neglect of quality
of services. As a result, cash incentives for IUD insertions were withdrawn. GOI did not fix
contraceptive targets for Kerala and Tamil Nadu during 1995-96 and in other States one or two
districts were made "target free". Further, State Governments were given freedom to introduce
incentives for improving the quality of services.
While there are no two opinions about the need to remove numerical targets for the sake
of quality of service, there is a concern that such a move, when taken country-wide, may lead to
decline in performance initially. A system of getting estimates of expected levels of acceptance
from the Slate Governments was in vogue for the last three years but now this exercise will be
carried out by the grass root workers in consultation with the community to estimate real needs
assessment. This will be coupled with the formulation of a PHC level plan covering all activities
of family welfare, the materials and supplies required and an operational strategy to achieve the
objectives.
Grass root level workers like AN.M. Multipurpose Health Workers both male and female.
shall be asked to give an estimate of the various family welfare activities required in the
area/porulation covered by them. It is expected that at the PHC level, the local NGO activist.;.
primary school teachers, pradhans and panchayat members, private practitioners of indigenous.
systems of medicines would be involved in the formulations of the PHC based Family Welfare
Health Care Plan. While in the first year the process of estimation can be tentative but in future
years the endeavour should be to start the planning process at village level itself. Aggregatior
of all such estimates of grass root workers of various subcentres and at the Primary Health Centre.
shall be prepared at each PHC. District Family Welfare Plan shall be an aggregation of all such
plans formulated at each PHC in the district. State Level Family Welfare Plan shall be an
aggregation of all such District Family Welfare Plans. All the State level Family Welfare Plans
shall be compiled at National level to work out requirement of all materials and supplies.
Although the input requirements for family welfare activities shall be based on the
requirement given by the grass root level workers like ANM, the monitoring of the performance
of ANM shall not be merely on the basis of achievements in this regard alone, but would be
done with the help of indicators relating to improvement and quality of service.
A system of evaluating and introducing corrections in the performance of PHC every
month by the district health staff and that of each district by the state level staff every quarter has
been worked out. A similar exercise to evaluate the performance of each state would be carried
out at the national level. The present manual tries to answer all such issues for the guidance of
the field workers, the administrators and other persons responsible for implementing this
programme.
There should be minimum change in the records that ANM and other field workers an:
required to maintain in order that the changed system of working helps them to utilize their time
fully to improve the quality of services that they are required to provide to the community. The
Eligible Couple (EC) Register will continue to be one of the most important records at ANM
level.
2
2.
NEW FOCUS OF FW PROGRAMME - A Target free approach
Family Welfare Programme is to be implemented from the First April 1996 on the basi;
of Target Free Approach. Besides, the focus of the national Family Welfare Programme is to
undergo a change from a segregated approach under Family Planning and Maternal and Child
Sendees to that of integrated approach under Reproductive and Child Health (RCH) Services in
future. This means that RCH is equivalent to Family Planning + CSSM + prevention of
RTI/STD and AIDS + a client approach to providing FW & Health Care Services.
As the National Family Welfare Programme moves from Target Based Activity to Client
Centered Demand Driven Quality Services Programme, there is a need to change various aspects
of its operations including increased levels of male participation.
2.1
Illustrative list of services to be provided to general public from PHC &
Sub-Centres:
The following services may be provided to general public from Sub-Centres, PHCs and
in some cases, with tie-up of referral, from nearest CHCs and district hospitals:
Mother Care Services
I.
(A) Ante Natal Care:
(i)
Registration of Ante-natal Care Cases preferably before
16th week of pregnancy.
(ii)
Providing ante natal care to pregnant mothers by
atleast three visits.
(iii)
(iv)
Detection and treatment of anaemic pregnant mothers.
Timely detection and referral of high risk pregnant
mothers.
(B) Natal Care:
(i)
As far as possible delivery should take place in
Hospitals, PHCs or subcentres under the supervision of
qualified personnel.
(ii)
As far as possible, the domiciliary deliveries should be assisted by LHV, ANM
or by trained birth attendants.
(iii)
Detection and referral of high risk labour cases.
(iv)
Identification of existing Dais and organising dai
training.
(v)
Provision of Dai Kits.
(.C)
Post Natal Care
(i)
Growth Monitoring of new bom.
(ii)
Detection and referral of high risk new born babies.
(iii)
Neo-natal resuscitation wherever facilities are avail
able and by education of dais & community in other areas.
II.
Immunisation:
Immunisation services against following communicable diseases to children.
(i)
(ii)
(iii)
(iv)
(v)
(vi)
III.
Tuberculosis
Polio
Diphtheria
Whooping Cough
Tetanus
Measles
Prophylactic Services:
Prophylactic Services against anaemia and Vitamin A deficiency to
(i)
(ii)
(iii)
IV.
Curative Services for
(i)
(ii)
V.
Pregnant Mothers
Nursing Mothers and IUD Acceptors
Children below 5 years of age.
Diarrhoea cases with ORS
Respiratory infection cases with cotrimoxazole.
Contraceptive Services
(i) Male Sterilisation Operation.
(ii) Female Sterilisation Operation.
(iii)
Copper T. insertions.
(iv)
Oral Pill - distribution.
(v)
Nirodh distribution.
(vi)
Indigenous/traditional methods
(vii)
Natural methods.
VI.
MTP
(i) Assessing abortion needs and providing the same by early detection.
(ii) Assessing need for expanding services by increasing trained staff
and registered centres.
4
VII.
Emergency Obstetric Care
(i) Assessing expected high risk cases.
(ii) Provide for referral in existing Post Partum Centres.
(iii)
Provide for referral at identified First Referral Units.
VIII.
Nutrition Counselling and Supplementary Nutrition
(i)
Linkages with ICDS and Anganwadi for provision of supplementary nutrition
for pregnant/lactating mothers and for infants.
(ii) Nutritional Counselling through linkages with ICDS/AWW/ANM for anaemic
children, adolescents, mothers.
2.2
Activities at Sub-centre and PHC
Following activities should be carried out at Subcentre and PHC level for provisions cf
quality of care to general public.
2.2.1.
At sub centre level
Immunization, MCH Information Education and Communication
Services are to be provided by Subcentre.
*
Activities to be carried out during an immunisation/MCH
session are:
For children
*
immunization of children
*
administration of Vitamin A concentrated solution for prophylaxis
and therapy
*
Diagnosis of anaemia in children and distribution of IFA (small) tablets
*
ante-natal check up of pregnant women
*
TT immunization
For Pregnant Women
*
*
administration of IFA for prophylaxis and therapy
deworming of pregnant women who show clinical signs of
anaemia (in 2nd/3rd trimester) in areas with high prevalence of Hook Worm
infestation.
Communication and counselling
*
On infant feeding(exclusive breast-feeding and weaning)
*
On home management of diarrhoea and ARI
*
On birth spacing as a health promotion measure
*
Recognition of danger signs for seeking immediate medical help
Provide
*
-
prepared ORS solution to a child with diarrhoea and give ORS
packets for use at home
’
tablet Cotrimoxazole to a child with Pneumonia
*
oral pills and condoms
Gather Information by talking to mothers
*
On new births or pregnancies in the village
*
cases of measles, diarrhoea and pneumonia
*
counselling on polio and neonatal death
*
counselling for reproductive health
Update records
For holding the sessions it should be ensured that the health worker:
*
Reaches the FIXED PLACE on the FIXED DAY at the FIXED TIME
as per subcentre work plan
*
carries vaccines in cold chain and has enough syringes and
needles so that she can use syringe and one needle for
every beneficiary after ensuring proper sterilisation.
*
has sufficient quantities of Vitamin A, IFA tablets (both
large and small), ORS packets and Cotrimoxazole tablets for
giving to children who may need them.
*
has the mother and child cards and register with her and
updates these during the session
*
carries educational aids for interpersonal/grbup communi
cation
The health workers should contact local influencial persons like Anganwadi worker, TBA,
Village Pradhan, Panchayat Members, Other sector workers etc. on arrival and obtain their help
for mobilising the beneficiaries. Special efforts should be made with their help to identify and _.
motivate drop outs and those who do not avail services from out reach areas. The opportunity a
should be utilised by Subcentre Team to inform the mothers and organised groups about the
different services and to encourage them to avail these.
.
~
2.2.2.
At PHC Level
The PHC workplan includes, activities of the Sub-centres and the PHC. The
responsibility of ensuring proper implementation of the plan however, lies with the PHC. It :s
necessary that all medical Officers of the PHC are familiar with the plan and the programme
components.
6
In addition to the immunization and MCH activities being carried out at the sub-centre
level (Immunisation/MCH session, Sub-centre clinic and Village visits), the PHC is responsible
for delivery of both preventive and curative services in the area. This involves scheduling
immunization/MCH sessions and antenatal clinics in addition to the routine inpatient and
out-patient services. The activities to be carried out during the immunization/MCH session a:
the PHC are essentially the same as in a similar session at the Sub-centre level.
Correct Case Management of children with diarrhoea, ARI and sick newborns is an
important activity at the PHC level. The PHC is required to provide treatment to children
referred to it andshould be able to organise the facilities required for management of these cases
as per guidelines.
The PHC should provide services for safe delivery of all uncomplicated pregnancies.
The labour rooms should be clean and provided with the required supplies for carrying out
deliveries and essential care of the newborns. Provision of these services can generally be
planned within the existing resources of the PHC.
Management of complications of pregnancy like hypertensive disorders, severe anaemia
and sepsis should be available at PHC level. Referral of severe cases to the first referral units
(FRUs) for various childhood and maternal emergencies should be made as per guidelines. The
names and location of the FRUs should be known to all doctors and health workers of
PHC/Sub-centre area.
It should be ensured that the PHC is equipped with relevant supplies like medicine,
intravenous fluids and have a regular duty roster providing for round the clock attendance in case
of need. Care be taken to indent sufficient stocks of vaccines, needles and syringes from the
district stores in time and distribute to the outreach centres according to the plan. MO should
monitor the use of individual items in the drug kits supplied to the subcentres and provide for
timely replishment out from the PHC stocks, and out of items which are not used in other
subcentres. All health workers in PHC area should receive vaccines for conducting imunizatio i
sessions/MCH sessions, in vaccine carriers with fully frozen ice packs.
The PHC is the unit for carrying out all surveillance related activities. These include
case/death analysis, interpretation, action and reporting. Decisions that will have to be taken a
PHC level include containment measures for outbreaks, mop-up rounds, investigation of acute
flaccid paralysis, neonatal and maternal deaths through line listing and special investigations suci
as stool test, etc.
Monitoring the implementation of sub-centre work plans, their performance and
coverage levels of individual sub-centre areas and identifying problem areas is to be done by the
PHC medical officers. Based on the reasons identified for a particular problem, possible
solutions should be identified in consultation with the health workers and the community. Care
be taken to monitor the establishment and functioning of the village level depots for ORS
packets, condoms and in some cases oral pills.
Regular reporting of the achievements and problems to the district/state health
department is an important activity of the PHC. Providing feedback to the health functionaries
based on discussions at the district level meetings arc important.
7
The meeting is an important activity to review performance, provide feedback and
guidance to the workers for improving their performance and coverage levels. The other
important meeting at PHC level would be participatory appraisal meeting with the Panchayali
Raj leaders at PHC level.
All the activities listed in the workplan of the PHC must be carried out regularly.
2.3
Prerequisites for Target Free Approach :
The following points are needed to be ensured in each
state:
(1)
Contraceptive targets for the health'& non-hcalth staff like ones working in
Revenue, Rural Development, Education Departments must be abolished.
(2)
The male health workers should be made responsible for motivation for
vasectomy and condom.
(3)
The motivator certificate and motivator fee, if still in use, should be withdrawn.
(4)
Family Planning performance in the district should not be used to rank the
Collectors or to assess them for their annual confidential report.
(5)
The PHC Plan shall be proposed on the basis of assessment of need of
population for FW Services by ANM and others; the performance of
the medical officer in charge, PHC and ANM shall be judged on the basis
of their quantitative and qualitative achievement with respect to the
needs assessed.
8
3
IMPROVING QUALITY OF CARE
Following arc the some of the aspects of quality of care for Family Welfare Service;
which need to be looked at by the staff at PHC and Sub-centres.
3.1.
Service Delivery Aspect:-
3.1.1
Does the package of FW service offered by PHC/Subcentres meet the needs of general public?
3.1.2
DO PHC/Sub-centres inform the general public about the
choice they can have for contraceptive methods?
3.1.3
Is there adequate follow-up for continued use of the
services offered by PHC/Sub-ccrures?
3.1.4
Are there effective referral linkages?
3.2
Informational Aspect:-
3.2.1
Do general public receive comprehensive health educa
tion?
3.2.2
Are general public informed about the side effects of
contraception and how to address them?
3.3.
Technical Aspect:-
3.3.1
Are the service providers (doctors, LHV, ANM) techni
cally competent?
3.3.2
Do they use sound and appropriate technical practices?
3.3.3
Do they take universal precautions for sepsis?
3.3.4
Quality of materials & supplies used by the service
providers.
3.4
Interpersonal aspect
3.4.1
Behaviour of the service provider. Is he/she gentle,
harsh, indifferent to the clients.
3.4.2
How are general public treated in:time spent
showing concern for the client
caring for the privacy & dignity of the Client.
3.4.3
-
Listening & counselling general public.
9
3.5.
Social aspects:-
3.5.1
Are services gender sensitive?
3.5.2
Is there male participation and responsible sexual
behaviour.
3.5.3
Do women have a role in programme.
While all of these aspects to improve quality of care require attention, it may be useful
to institute a process of quality improvement by first emphasising counselling, follow up and
inter-personal aspects of the services and then adding other aspects.
4.
EXPECTED OUTCOME OF TARGET FREE FAMILY
WELFARE PROGRAMME
4.1.
Hundred percent ante natal registration and atlcasl 3 ante natal check-ups of
pregnant women.
4.2
Hundred percent T.T. vaccination of pregnant women.
4.3.
Increase in the proportion of institutional deliveries as compared to the existing
level.
al
4.4
Increase in the proportion of deliveries by trained persons as compared to the
existing level.
4.5.
Provision of quality obstetric care for complications of pregnancy, abortions
complications of deliveries at CHC level or FRU level.
4.6.
Hundred percent registration of births and neonatal deaths in the area.
4.7.
Appropriate measures for underweight babies.
4.8.
Promotion of breast feeding.
4.9.
Hundred percent immunisation of infants.
4.10.
Universal availability of ORS in all villages at all
4.11.
Provision of facility of treatment of acute respiratory infections including
pneumonia at all subcentres.
4.12.
Improvement in acceptance of contraceptives by couples with wife less than
30 years of age.
4.13.
Improvement in acceptance of contraceptives by couples having 2 or less
children with larger spacing between children.
4.14.
Improvement in the proportion of spacing methods in the contraceptive method
mix.
4.15.
Availability of oral pills and condoms in all villages at all times.
4.16.
Counselling for RTI & STD at subcentre level.
4.17.
Referral of suspected cases of RTl/STD from sub-centre and diagnosis and
treatment facilities for RTI & STD at CHC and District level.
4.18.
To ensure adequate postnatal care & FP Counselling; all mothers should be
visited after 15 days of deliver)' or EDD.
11
ad
5.
PREPARATION OF SUBCENTRE ACTION PLAN:
Subcentre Action Plan forms the basis of PHC level decentralised planning. It provides
us the requirement of various sendees by the population living in the area of subcentre as their
felt need.
5.1
Defining Workload Norms for ANM:-
The activities that are required to be carried out by ANM's at the level of subcentre for
the implementation of quality conscious Family Welfare Programme are listed in FORM-1.
These c;m be classified into
(a)
(b)
(c)
Specific tasks (e.g. giving TT2).
Quality tasks (e.g. early registration of ANC).
Surveillance task (e.g. number of maternal deaths
reported).
Norms are being suggested for the specific tasks and quality tasks. Every State must
decide on the norms for quality tasks depending upon the availability of health infrastructure and
the needs of the population (for example work load of ANC in a State with 5000 population per
subcentre and birth rate of 20/1000 would be 110 per year, as compared to 310 per year for a state
having 8000 population per subcentre and birth rate of 35/1000). Hence the State can decide that
instead of 60% coverage norm for early ANC Registration only 30% coverage is expected to be
registered in first trimester of pregnancy. In the first year of operation these values for norms will
have to come from State level data or other studies from similar population. In the subsequent
years district level estimates will be available from the monitoring system and hence more
realistic norm can be set locally.
Once these norms have been decided, the ANMs will calculate their own workload. It
can be argued that this step is mechanical and can be done by computers. But however, if the
field worker (ANM) herself estimates her own workload, she will be more involved and
motivated in the implementation of programme.
5.2
Consultations:
While doing the exercise of preparing Subcentre Action Plan and Primary Health Centre
(PHC) level Family Welfare and Health Care Plan there is a need to associate following
categories of personnel
1)
Personnel of the Primary Health Care System including Medical
and Para-medical staff.
2)
Private Medical Practitioners available in the area of PHC.
3)
Medical Practitioners of the Indigenous Systems of Medicine available in the
of Primary Health Centre.
4)
Ex-servicemen residing in the area of the PHC.
5)
Grass root level workers of other departments including Primary School Teachers.
6)
Pradhans of Gram Panchayats falling in the area of PHC.
7)
Anganwadi workers.
12
area
While formulating the Sub-centre Action Plan and PHC level Plan, the above mentioned
people should be consulted and advice given by them, if any, may be taken into account. It is
expected that the moment these people are consulted they also become activists helping us in
the process of implementation of PHC level Plan under Target Free Approach.
5.3
Requirement of the Area Vs Felt Need of the Population Subcentre Action Plan.
The illustrative list of services which are to be offered to the general public from PHC
and Sub-centres should be available to all the persons living in the area of jurisdiction of the
PHC/Subcentres. One can easily estimate the requirement of services of the entire population
of the PHC/Subcentres. Pregnancy related services can be estimated from the population to be
covered and the birth rate of that population. Similarly curative services like treatment for
diarrhoea can be estimated from the population and the prevalence rate of the illness. Similar! /
for contraception services, all the eligible couples are needed to be protected. Requirement of
the Area for a particular service is the demand of the service for hundred percent coverage. But
all the people living in that area need not be willing to avail of the services. Felt Need of the
Population pertains to the number of sendees for, which they are willing to take up from the
delivery point. For example not more than 60% of the pregnant women in an area of a subcentre
are willing to be registered for ante natal care. Then although the Requirement of the Area fcr
ANC is 100% but yet the Felt Need for ANC shall be only 60%. We must plan for making
available the Family Welfare and Health Care Services as per the felt needs of the population.
In the ideal situation the Area Requirement of the service shall be equal to the Felt Need
for the same service by the population living in that area. In that event the Family Welfare
Programme shall become the people's program.
In the present context, during the implementation of Target Free Family Welfaie
Programme, it might be noticed in the field that the Felt Need of the Population is less than the
Area Requirement for the same service. It is likely to be the trend in the beginning. The gap is
likely to be bigger for contraception services than for the MCH services. This should not be a
cause for concern. As soon as the quality of care of services through the PHC and subcentre s
improve, more and more people shall start coming forward to avail the services being provided
by the PHC & Subcentres.
Format of Subcentre Action Plan (FORM-2) does give the list of services to be provided
from Subcentre. It also contains the methodology to calculate the Area Requirement with respect
to all the services. ANM should be expected to fill up the Felt Need of the population for service
in the area of her subcentre in the 1st column. This shall be a realistic assessment of the need of
the population. This should be filled up after she has visited all the households in her area lo
assess their need.
13
6.
PREPARATION OF PHC FW&HC PLAN
Subcentre Action Plan with respect to all the subcentres of the PHC can give us the feb:
need of the population of PHC with regard to the services being offered to general public through
PHC and subcentres. Medical Officer Incharge of PHC has to calculate the materials, vaccines,
medicines etc. required to accomplish the services. Depending upon the existing stock of
supplies, the net requirement for serving the felt needs of the population can be worked out. I:
forms the basis of PHC FW&HC Plan. It shall also identify the resources available within the
area as well as support from outside like NGOs, corporate sector, private sector. It shall also lake
into account the available hospital facilities in the area and health manpower available. The mos:
convenient First Referral Unit (FRU) should also be identified and notified for general
awareness.
6.1
Data Base Required for Planning at PHC-Ievel
6.1.1.
6.1.1.1
6.1.1.2.
6.1.1.3.
6.1.1.3.
6.1.2.
6.1.2.1.
6.1.2.2.
6.1.2.3.
6.1.2.4.
6.1.2.5.
6.1.3.
6.1.3.1.
6.1.3.2.
6.1.3.3.1.
6.1.3.3.2.
6.1.3.4.
6.I.3.5.
6.1.3.6.
6.1.3.7.
6.1.3.8.
6.1.4.
6.1.4.1.
6.1.4.2.
6.1.4.3.
6.1.4.4.
6.1.4.5.
GENERAL
.General Information about Block
- Geographic location/character
- No. of Sectors
Persons below poverty line
Religion/literacy
SC/ST population
DEMOGRAPHIC
Total Population, age, sex structure.
Sex ratio - 1981-1991
Age at marriage
Birth/Dcath rate
Fertility Rates.
PROGRAMME PERFORMANCE
Family Welfare Programme Sector-wise performance for the
year 1995-96, and every year thereafter.
MCH.ANC,PNC,Deliveries, Sector-wise performance for the
year 95-96, and every year thereafter.
Line listing of Polio and Neonatal Tetanus.
Investigation of cases of neonatal tetanus, polio & measles.
Data on performance of other health programmes.
Epidemic/out-breaks data/investigation report for last
three years.
Medical Emergencies at each health institution for last
three years.
Information on Eligible Couples.
Sector-wise Demographic Profile of FP acceptors for last
three years.
INFRASTRUCTURE - HEALTH
Private Practitioners
- Qualified
Private Hospitals/Nursing Homes with bed strength.
No. of Sub-centres
No. of PHCs
No. of Block PHC/CHC/PP Centre and Referral Hospital
6.1.4.6.
6.I.4.7.
6.1.4.8.
6.1.4.9.
6.1.4.10.
6.1.4.11.
6.1.5.
6.1.5.1.
6.1.5.2.
6.1.5.3.
6.I.5.4.
6.I.5.5.
6.I.5.6.
6.I.5.7.
6.I.5.8.
6.I.5.9.
6.1.5.10.
6.1.5.11.
6.1.5.12.
6.1.6.
6.2
Budget for each institution for the year 1995-96 and
subsequent years.
Vehicles with status.
Cold Chain equipment available/status
Supplies of drugs and other equipment
Personnel Section
- Staff in position
- vacant position
Other Health Facilities
INFRASTRUCTURE
Roads/othcr means of transport
Population of villages
Electricity Connections at PHC/Subcentre
Drinking water-all villages
Education/Adult Education facilities
Ration shop
Panchayat
Post office
NGOs
Banks
ICDS
Accessibility to Sub-centres
Sector maps showing important infrastructural facilities.
Format of Model PHC Family Welfare and Health Care Plan is given at FORM-3.
States are free to enlarge upon this basic format to suit their own needs.
7
PREPARATION OF DISTRICT & STATE FW&HC PLAN
Aggregation of plans of all the PHC's CHC's Rural Hospitals and District Hospital
functioning in a district give us the District FW&HC Plan. Similarly aggregation of all the
District FW&HC Plans of the State give us the State FW&HC Plan. The plans, prepared at the
field level, become the driving force for the programme, however, the plans at each successive
higher level are not simply the aggregate of the plans at the lower levels. Each level must also
plan for its activities. Thus, while ANMs at Subcentre level would plan for carrying out desired
activities. PHC would have to plan for providing support through inputs from the medical
officers and supervisors. They would also need to plan for necessary logistics support. The
District level may need to plan for improving access, availability and quality of services. The
plans at each level would have to use an appropriate mix of coverage, unmet need and quality of
care objectives. The District level Plan should provide for an elaborate system of field checking
to ensure quality of sendees at PHC and Sub-centre level. The State level Plan must provide for
an elaborate system of field checking in each district of the State. The State Plan must also
elaborate the logistic arrangements for supply of essential inputs for Family Welfare Programme
down to the PHC. Sub-centre & Panchayat level.
16
8
MONITORING AND EVALUATION
ANMs and Health Worker (Male) at Subcenlre level and Medical Officer at PHC level
form the backbone of the Primary Health Care Delivery System. Any attempt at improving the
quality of care of family welfare services must take a look at the functioning of these
functionaries.
Monitoring of the quality of care provided by these functionaries is proposed to be done
through following instruments.
a. Monthly Activity Report.
b. Technical Assessment Checklist.
This has following 3 parts.
i.
Observation on skills and practices..
ii.
Facility check list.
•iii.
Knowledge and opinion of community.
Monthly Activity Rreport is to be submitted by the functionary him/her self to his/her
next supervisory officer. The Supervisory officer shall fill up the Technical Assessment
Checklist. The Checklist about observations on skills and practices shall be filled up after the
Supervisor actually observes the functionary on the job. The Facility Checklist shall be filled up
after actual inspection of the stock and stores provided to the functionary for carrying out his/her
duties. The Checklist about knowledge and opinion is to be filled up in following way.
*
*
*
*
*
Select the worker/doctor for review.
Select one of the villages randomnly in his/her area.
Start with a household with most recent birth.
Interview 10 eligible couples with youngest child less than
2
years.
(Additional target groups are to be interviewed in case of
assessment of performance of MO, PHC).
The most important use of this review is to strengthen the supervisors ability to take
corrective action. It should be seen as a part of on thejob training for skill improvement and
enhancement at all the levels.
8.1
Performance of ANM:
There are 23 activities to be carried out by ANM under Family Welfare Programme
(Form-1). For evaluation of the ANM for carrying out these activities following instruments aic
to be used.
8.1.1.Monthly Activity Report by ANM (Form-4)
Monthly activity report of ANM is a two page document listing 27 items to be carried out.
The worker should report not only the services she provides but also the services provided by
others in the area. For example, if a woman gets ANC sendees from a private clinic, should the
worker include those in her activity report? Yes, she must report all services received by people
in her area. She can collect the information from clients during household visits as she :.s
expected to visit all households at least once a quarter.
17
8.1.2
Technical Assessment of ANM by the Supervisor
It shall be sent by LHV. The report shall have following parts:
8.2
i.
ii.
Assessment of ANM's records (Form 5.1)
Observations on skills & practices (Form 5.2)
iii.
iv.
Facility checklist (Form 5.3)
Knowledge and Opinion of EC/Community (Form 5.4)
Performance of Health Worker (Male)
There are only 8 activities to be carried out by male health worker. Following formats
are to be used for the evaluation of the performance of Male Health Worker.
8.2.1.
Monthly Activity Report by HW(M) in Form-6.
8.2.2.
Technical Assessment Report by supervisor shall be sent by the Health Asstt. (Male). Ii
shall have following parts.
i.
ii.
8.3.
Observation on skills and practices (Form 7.1)
Knowledge and opinion of the EC/Community (Form 7.2)
Performance of Medical Officer PHC
Medical officer of PHC plays a crucial role in the primary health care system. There arc
25 activities to be carried out by MO, PHC. Following formats are to be used for the evaluation
of the performance of medical officer of PHC.
Monthly
8.3.1.
Activity Report by MO, PHC in Form-8.
Technical
8.3.2.
Assessment Report by Supervisor.
It shall be sent by Block Medical Officer. It shall have following parts.
i.
Observation on skills and practices (Form 9.1).
ii.
Facility check list (Form 9.2).
iii.
8.4
Knowledge and opinion of community (Form 9.3).
Periodicity of Supervision:
While the monthly activity report is to be submitted by the functionaries once every
month to their supervisors, the technical assessment is proposed to be taken up once in a quarte-'.
The supervisors have to check out time table to cover all the workers/doctors working under them
at least once every quarter. LHV shall review the work of ANMs once every month.
8.5.
Inspection and Supervision
Following system of inspections shall be followed to supervise the qualitative aspects of
the reporting. For all supervisory inspection formats of Technical Assessment Check lists be
used.
8.5.1.
District Health Officer shall ensure inspection and supervision of the work of atleast two
ANMs, two HW(M) and one MO (PHC) per PHC for all the PHCs in the district once every
quarter.
8.5.2.
State Directorate of Health & Family Welfare shall ensure inspection and supervision
of work of atleast two ANMs, two HW(M) and one MO (PHC) per PHC for 10 percent of the
randomly selected PHCs in a district with respect to all the districts once in a year.
8.5.3.
Evaluation and Intelligence Division of the Department of Family Welfare, Ministry
of Health and Family Welfare has 8 Regional Evaluation Teams. Their area of jurisdiction is
as follows. Each team shall be carrying out inspection in two districts of one of the States
allocated to them every month. They shall inspect work of atleast two ANMs, two HW(M) and
one MO (PHC) in 10 percent of the randomly selected PHCs of each district. Each State
Government shall provide necessary technical assistance to the Regional Evaluation Team to
carry out the inspection.
States of jurisdiction
SI.
HQ. of the Regional
Evaluation Team
1.
DELHI
J&K, HLMACHAL PRADESH, PUNJAB, DELHI,
HARYANA, RAJASTHAN, CHANDIGARH
2.
LUCKNOW
UTTAR PRADESH
3.
PATNA
BIHAR
4.
CALCUTTA
WEST BENGAL, SIKKIM, ASSAM, TRIPURA
MEGHALAYA, ARUNACHAL PRADESH,
NAGALAND. MIZORAM, MANIPUR
5.
PUNE
MAHARASHTRA, GUJARAT, DAMAN & DIU,
GOA, DADRA & NAGAR HAVELI
MADHYA PRADESH, ORISSA
6.
BHOPAL
7.
BANGALORE
KARNATAKA, ANDHRA PRADESH
8.
MADRAS
TAMIL NADU, KERALA, LAKSHADWEEP,
PONDICHERRY, A&N ISLANDS
8.6
Client Based Records:
Another step suggested for improving the quality of services is to introduce client centred
approach in record keeping. The system of recording different services in different registers, has
been found to hinder this approach. This is so because the ANM does not have in front of her,
a full record of the client's health needs when she meets her at home or in the clinic. If the ANM
could have such a record, presumably she will be able'to provide services in a comprehensive
manner. Incidentally, if the clients can read their records, they themselves will know what
services they arc entitled to get.
This assumption was tested in Maharashtra and found to hold good. This was done by
introducing a ''Family Health Card" which replaced all registers. Use of the Family Health Card
19
led to improvement in coverage of services and in quality of supervision. It also reduced the
burden of record keeping. Some states like Tamil Nadu and UP have developed comprehensive
Mother and Child registers, which are similar in concept, to the Family Health Card. In case of
Tamil Nadu, services are recorded in three registers (EC, Mother Care, Child Care). In UP,
services are recorded in 2 registers (EC and CSSM). These registers are easy to use, and contain
all services given to a client (i.e. a pregnant woman, EC or a child), in one place. Family Health
Card of course goes much further in that direction. Simplifying the concept of Family Health
Card, a format for Client-Based RCH related sendees provided to mother and her children is
suggested.
It is recommended to change over to Client-Based records on a pilot basis at this stage
It is suggested that this format is used as an instrument to be used in the rapid surveys meant to
assess the coverage and quality of services. This.instrument will help in assessing the extent to
which the ANMs maintain client-centred information, and also the comprehensiveness and
quality of services. If the ANMs find this format useful as a basic record, then these may be
introduced at a later stage. Some states may consider trying these records in one block, to assess
their efficiency and costs (FORM-12).
8.6.1.Registers and Record at Subcentre level
Manuals for Health Worker (Female)/ANM and Health Worker (Male) and instructions
of the state governments have defined a number of registers and records to be maintained at sub
centre level. There is no intention to change the existing records being maintained by Health
worker (Female)ZANM and Health Worker (Male) at sub centre level.
Eligible
8.6.2.
Couple Register
Eligible Couple Register should be updated every year in the month of April every year
after a fresh door to door survey by the ANM.
8.7
Procedures for the Rapid Survey by PRC or other Agencies
For assessing the coverage, quality and client satisfaction with the FW services, client
surveys will be conducted, by independent agencies in each district, once a year. These surveys
will be designed to be economical and rapid so that the results will be available within a month
of starting the surveys. Survey instruments will be kept short and simple, keeping these require
ments in mind.
The suggested sampling method for the rapid survey is;
c
Select 25 PHCs randomly per district.
C
Select 2 ANMs randomnly per PHC.
C
Select one village, from the ANM's area.
c
Using cluster sampling method select 20 ECs in each
village.
For each selected households, information included in the Client-Based FW Record will
be obtained by first extracting that information from worker's register, and then confirming it
with the clients. In case the family is not recorded with the worker, the information will be
collected only from the mother. This process of extracting information from worker’s registers
is meant for improving the quality of their recorded data, over time.
In addition to the services, information will be collected on EC's knowledge, attitude and
20
trom 1000 ECs per'district, will be adequate to provide very usulul measures ol quality, arid"
coverage of various services. The survey design can be modified in terms of sample size and
frequency of survey, by taking into account the cost aspects.
Along with the Rapid Survey, a Facility Survey will also be carried out, using a format
somewhat similar to the supervisors check-list. This Facility Survey carried out by independent
agency will corroborate the assessment of the supervisors and also provide an independent
assessment of the skills, knowledge and facilities available with the ANMs and others once a
year.
8.8
Monitoring System of CHC/FRUs and PP Centres for quality
of Services:The system outlined above mainly deals with the services provided at the Subcentres and
PHCs levels. A similar system of monitoring will be needed at the FRU level. In that system,
in place of Client-Based record, there will be a Case Sheet. There will be a Monthly Activity
Report from FRUs (FORM-10). In place of client survey, an in-depth analysis of a sample cf
case-sheets(FORM-ll.l), and a facility survey at the FRUs(11.2) will be carried out once a year.
These three components of the monitoring system together, will provide adequate information
to assess quality of care provided at the FRUs, as well as their status in terms of specialists, staff,
equipments, and supplies.
8.9
Monitoring indicators
Following is the illustrative list of three types of indicators which shall be used to assess
the effectiveness and impact of the Target Free Family Welfare Programme. These are the
indicators to assess the Accessibility, Quality and Impact of the Programme. The data required
for calculation of these indicators shall be available from the monthly activity reports and from
the technical assessment check lists.
Indicators for Evaluation of Subcentres
Item
)1. Ante-natal
Care
Accessibility Indicators
Quality Indicators
Impact Indicators
Wo. of ECs/ANM
1 ANC registered before 12
.vceks
% deaths from maternal c
:auses among Ecs.
7c ANC sessions held as
7c with 5 ANC visits
Maternal Mortality Ratic
7c ANC receiving all Services
Prevalence of maternal
norbidity
7c High Risk referred
Mean Birth Weight
7o SCs with IFA, TT
7c HR followed up
7o Low Birth Weight
7o SCs with no ANM. TBA
7c Deliveries at SCs
Dbstetric mortality
7c SCs with DDKs
7c Deliveries by ANMs/TBAs
’revalence ;of obstetric
norbidity
7c SCs with infant weighing
’<■ Birth weight recorded
Weonatal Mortality Kate
planned
% SCs with no ANM
7o ANMs without requisite
tkills
7o SCs with working
iquipment for ANC
)2. Intra-natal
Care
7c ANM/TBA without
cquisire skills
nachincs
7c HR referred
r HR followed up
Item
Accessibility Indicators
Quality Indicators
mpact Indicators
)3. Post-natal
Care
Prevalence of Post-natal
naternal morbidity
7c SCs with no ANM, TBA
7c PNC with 3 PNC visits
zc ANM/TBA without
equisite skills
7c PNC receiving all counselling Prevalence of Neo-natal
norbidity
7c PNC complications referred
7o Children breast fed within 6
tours of delivery
7c Complicated cases followed
JP
M. Immunisation
'Jo. of Infants/zVNM
7c Children 12-23
7o Deaths because of VPDs.
nonths fully immunised
7c Immunisation sessions held
is planned
Drop outs from immunisation
7c SCs with no ANM
7c SCs with working
:quipment necessary for
mmunisation
7c SCs with vaccine supplies
)5. Family
Planning
'Io. ofECs/ANM
7c Ecs offered choice
Couple Protection Rate
7o SCs with no ANM
7c Acceptors screened for
tontra-indications
Prevalence of terminal method:
7c AN.Ms without requisite
skills
7c Acceptors followed up
Prevalence of spacing methods
T SCs with equipment for FP 7c Acceptors with complications
7o SCs with FP supplies
% complicated cases referred
7o Abortions related morbidity
7c Referred cases followed up
06 Surveillance
for Diseases
% AN.Ms with requisite
skills
% ECs screened for
RTIs/STDs
Prevalence of RTIs/STDs
% ECs counselled for
prevention of RTL/STDs
% SCs with ORS packets
% ADD given ORS
Prevalence of ADD
% SCs with medicines
% ARI treated
Prevalence of ARI
% Children 12-23 months
fully immunised
Prevalence of VPDs
% Cases referred
% ADD related mortality
% Referred cases followed
up
% ARI related mortality
8.10.Reporting System
The detailed format of preparing monthly reports from PHC/CHC/District
Hospital/Private Hospitals is given in FORM-14. On tnik' format information shall be
collected by the Chief Medical Officer of the district before 5th of the following month
and shall be sent by him to Director Health and Family Welfare of theState before 10th
of the following month. The DH&FW of the state in tum shall forward this information
with respect to the entire State to the :
Chief Director(E&I)
Department of Family Welfare
Ministry of Health & Family Welfare
Govt, of India
Nirman Bhavan
New Delhi-110 011.
by 20th date of the following month through speed post or Fax No.
(01I)-3O19O66, (011 )-3017740 Format of monthly report is given at (FORM-14).
8.11.Summary Reporting
The summary report of the progress is also required to be given to Chief
Director (E&I), Department of Family Welfare, Ministry of Health & Family Welfare,
Nirman Bhavan, New Delhi by telegram or Fax No. (011)-3019066, (011 )-3017740 by
7th of the following month by the Director Health & Family Welfare of the State.
Monthly Report to Govt, of India through FAX
Items to be reported
Progress of
the month
Vasectomy done
Tubectomy done
Cumulative
total
/V library
aU
A*°
V V °ocumentatIOn
\
UNIT
JTalore.
Total sterilisation done
Condom pieces distributed
Oral Pill Cycles
distributed
T.T.(PW) doses given
DPT doses given
OPV doses given
BCG doses given
Measles vaccine does given
MTP performed
Vit. A doses given
ORS packets distributed
23
9.3.3
While top most priority has been given for knowledge and skill development
of the health providers, it is also considered necessary that the functionaries of other
departments working at the grass root level who are already of great help in
furtherance of maternal and child health care programmes should be coopted fully
into the programme. It is thus recommended that a "team approach" should be built
up at the grass root level. To further the efficacy of functioning of the "village team"
of ANM/AWW/TBA, it is recommended that joint orientation/ training of these
functionaries should take place in all districts. Any experiments in joint training in
any State should be studied and followed with modifications if necessary. The
district planning should incorporate this joint orientation/training as well.
9.3.4
NGOs/voluntary organisations/private hospitals, universities, autonomous
institutions may be utilised for training purposes.
9.3.5
The initial training at the district may not be sufficient for required skill
development e.g. I.U.D. insertions, sterilisation operations, and delivery cases. This
may require placement of the trainees to different health facilities at a later date. To
ensure quality, a minimum prescribed number of procedures will have to be carried
out by each trainee before she is certified as having been trained. District training
has to be flexible enough to allow this.
9.3.6
District Training Coordinators and the Trainer must certify the trainee as
having acquired requisite skills. This is necessary to ensure accountability of the
system.
9.3.7
While this model plan has not specifically mentioned urban areas, the
training planning for urban areas should be on similar lines.
I.E.C. PROGRAMMES
10
Communication Programmes aim at generating demand and better utilization of health
and family welfare services in the community and empowers people to take care of their health
The Government of India provides guidelines for IEC programmes in each State and allocates
the budget planned at STate level and distributed to the District and below:
Now, it is being realized that the EECI programmes have to be area specific and addressed
to the problems of the area. This warrants decentralized planning approach in designing IEC
programmes.
The community receives different messages from peripheral functionaries of different
departments of Health, Nutrition and Family Welfare. It necessitates uniform approach to the
target audience by different personnel. The another important dimension of IEC programme
must be based on needs of the area.
It is observed that there is a need for improving interpersonal communication skills
among the health providers at grassroots level. The existing communication resources are not
fully utilized.
10.1
Available Media Equipments and Materials:
Media equipments and materials available in PHC.
Film Projector
ii.
Cassette player
iii.
8 mm Projector
iv.
Tape Recorder
v.
Slide projector
vi.
Communication materials given by ICDS
Communication
vii.
materials given by UNICEF and AIDS cells.
i.
10.2
Communication Needs.
The situation Analysis of PHC reveals the following thrust areas for designing EEC
programmes:
* Reproductive Health of Adolescent Girls
* Counselling of adolescents entering the reproductive age
group for family life education
* Women's education
I
Higher age at marriage
“ Early Ante-natal registration and Care
* Nutrition during pregnancy and lactation
* Institutional delivery
* Vaccine preventable diseases
“ Protected water supply
* Diarrhoea and ARI Management
| Low Birth weight
’ Birth Interval, Birth Spacing
* Medical Termination of Pregnancy
26
* Child labour
* Childhood disability
* Rational drug use
* Breast feeding
10.3
■
I EC Methodology
The proposed IEC activities in the PHC will have the following objectives:
i.
ii.
iii.
iv.
10.4
Identify the communication needs in their areas.
Identify and utilise the communication channels
effectively in the community
Utilise the available Audio Visual materials
effectively.
Improve interpersonal communication skills among
peripheral workers.
IEC strategy
Even though the awareness about Health and family welfare programme, is more but the
acceptance and the utilisation are not upto the expected level. There is a wide gap between the
awareness and the acceptance of healthy way of life. It is observed that many of our Health
personnel are lacking interpersonal communication skills. It is also observed that there is no
proper functional co-ordination on IEC activities among inter and intra-departmental personnel
working at various levels. So, the proposed EEC strategies are as follows:Identifying the communication needs to plan IEC
activities.
ii. Involve community and NGOs through unified messages.
Effective
iii.
use of mass media for back up (Ex.Cable T.V.
folk media).
Strcngthening
iv.
Interpersonnel communication.
i.
10.5
10.5.1
(i)
Existing IEC Schemes
CENTRAL SECTOR IEC SCHEMES
Sensitization of Opinion Leaders:
With the support of UNFPA this scheme is being implemented in 135 weak districts to
sensitize various Opinion Leaders such as religious, social, political, official and other
leaders of the society.
(ii)
Hiring of TVA'CP Scheme:
This scheme is being implemented from 1994-95 to organise video shows by hiring
TV/VCP in demographically weal: districts to create awareness for small family norm.
(iii)
Scheme of health awareness through Nehru Yuva Kendra Sangathan:
27
(iv)
Population Clocks:
Population Clocks have been installed at ISBT, AILMS, Pragati Maidan and Nirman
Bhavan, Delhi, Tribune Office, Chandigarh and Bus Stand of Bangalore. The
Population Clock at Lucknow has been installed. It is shown on the T.V. also.
(v)
Counselling of Health Workers:
This scheme is to be implemented with UNFPA assistance in the States for success of
the Family Welfare Programme by using counselling approach. An amount of Rs.
1261.4 lakhs will be available for the year 1995-96 to 1997-98 for this activity.
(vi)
Swasthya Mela
The main intention is to make family welfare synonymous with family health care in
order to improve the credibility of the health care delivery system and promote the small
family norm. Swasthya Mclas are being organised in the States, at the PHC level whic h
are ill served.
(vii)
Pulse Polio Immunisation (PPI):
For eradication of Polio from the country unprecedent social mobilization of PPI is
being done through multi-media approach.
(viii)
IEC for School Health check up:
For social mobilisation and for Primary School Health Check-up, campaign approac h
is being followed to create awareness of its importance among the people of India.
(ix)
PHC Sensitisation:
Since this Ministry gave up the target approach, all kinds of opinion Leaders are being
sensitised for making suitable Family Welfare Plan for themselves. This is a beginning
for bottom up approach.
(x)
Social Safety Net Schemes:
The scheme is being implemented with World Bank assistance in 90 demographically
weak districts of the country. The scheme envisage infrastructural facilities at PHCs.
(xi)
Population Education through NGOs:
NGOs who wish to work on Population Education are being provided with funds for
running Population Education activities.
(xii)
IEC Fellowship:
IEC short term training cum observation study tours are being organised with the
support of WHO-funding for updating the knowledge of IEC Officers working for
Family Welfare Programme.
28
10.5.2
(i)
IEC SCHEMES IN STATES/UTs.:
Mahila Swasthya Sangh:
74,177 Mahila Swasthya Sanghs arc working in States/UTs. al grass root levels for
creation of awareness about Health and Farpily Welfare Programmes through
inter-personal communication.
(ii)
Joint Training:
The Joint Training Scheme is being implemented to train the grass root level workers
and bringing about convergence with ANM & Anganwadi Workers.
(iii)
Training of Block Extention Educators (BEE)
Block level Extension Educators are being oriented for 14 days training in LEC
activities.
(iv)
Local Specific IEC Activities:
The folk activities are being organised in regional languages and local specific printed
materials are being printed and distributed in demographically weak districts.
(v)
Mass Education and Media (MEM) Activities:
OTC, Exhibition, Films shows, printed publicity, advertisement in newspapers, Bus
panels, population education in schools, celebration of national and international days,
workshops, seminars and social mobilization etc. are being organised under this
scheme.
(vi)
IEC Bureau:
For better functioning of IEC set-up in the States/UTs Bureaus are being set up.
10.5.3
(i)
Population Education Projects of IEC
National Council of Education Research and Training.
Project aims integrating population related messages in the curricula and text books.
training of teachers and allied functionaries and popularising the message of smaL
family norm among the younger generation through co-curricular activities, it is being
implemented all over the country through NCERT in schools and non-formal educatior
centres.
(ii)
University Grants Commission (UGC)
Through youths of universities and colleges the issues concerning family size, quality
of life and the impact of population growth are publicised for creating awareness and
generate demand for small family norm. The programme is being implemented through
Population Education Resource Centre (PERCs), established in the Department of
Adult, Continuing Education and Extension in 12 Universities.
29
(iii)
Deptt. of Adult Education (DAE)
Under litis project steps are being taken to integrate population education components
with total literacy campaign, it is expected that about 70% of illiterate girls and women
will receive population education messages through this effort.
(iv)
Directorate General of Employment and Training (DGET)
The project would seek to include education and counselling of students of ITIs in the
areas of gender rclations.and equality, responsible sexual behaviour and family planning
practice, family life, reproductive health, sexually transmitted disease, HIV infection
and AIDS prevention.
30
11
ALTERNATE STRATEGIC INITIATIVES AT DISTRICT LEVEL:-
Targets in the Family Welfare Programme, for long, have been the driving force and have
guided its operations. A major strategic issue is - what alternate driving force should be used in
the absence of targets. Several possibilities need to be considered.
11.1
Increasing coverage : The targets for service provision are substituted by those for
coverage of different programme services as the major force. Targeted coverage levels may
differ for different population segments. Many states have revised (or are considering revising)
MIS to reflect this focus.
For instance, in Maharashtra, the focus is on coverage within a
sub-centre area by different services rather than services provided by a specific ANM. The main
instrument for organising work becomes the family register or card. The record of specific
services provided could emanate from specific service delivery sites (immunization sessions,
camps, clinics etc.) or from service delivery records. The coverage-based focus is closest to the
current target system. Its advantage is that it removes method-specific targets in family planning
and minimizes conflict for'credit' for services. While this focus leads to improving accessibility
and availability of services, it does not directly emphasize improvements in quality of care.
11.2
Reducing Unmet Need : Here the targets are substituted by the unmet need for services.
For family planning, this means focus is on couples who do not desire additional child or wish
to space their next child but are not practicing contraception. For most other MCH/RH services
(such as ANC), the goal of providing services to all those who need it remains. The advantage
of using unmet need as a focus is that it separates out the responsibility of providing services to
that of institutionalizing small family norms. It also may lead to focus on those geographic areas
where the unmet needs may be the highest, and appropriately emphasise demand creation and
service delivery interventions.
11.3
Ensuring Quality of Care : Here the major driving force is making quality services,
defined according to specific standards, accessible and available. The onus of use of these serv
ices is on clients. Generally accessible quality sendees are utilized better and thus both coverage
would increase over time and unmet need would reduce. But this may not happen for services
whose need is not perceived. For instance, many women have silently suffered RTIs and have
not been able to seek or have not sought such services. So IEC coverage may have to accompany
improved quality if the utilization of such services is to increase rapidly.
31
muicdiic nu iiuiui iu uc 5ci;
Activity
1. ANCs Registered(total)
2. Early Registration(less than 16 weeks)
3. ANCs received TT 2 doses
4. ANCs received IFA Therapy
5. ANCs completed 3 visits
6. ANCs Clinics conducted
7. ANCs examined
8. ANCs referred
9a. Institutional Deliveries
9b. Deliveries by trained person
10. PNCs completed 3 visits
11. MTPs referred
12. Birth Weight recorded
13. BW below 2.5 kg.
14. High risk newboms referred
15. No. Imm sessions conducted
16. Immunizations:
a. BCG
b. DPT(3)
c. Polio(3)
d. Measles
17. Children fully immunized
18. Children given Vit A (5 doses)
19. Adverse imm. events referred
20a. Joint sessions with AWW
20b. Joint sessions with Dai
20c. Joint sessions with women's groups
21a. Total Eligible Couples listed
b. Current Users of Pmt. methods
c. Current Users of Spacing methods
1
d. Potential Accpt. of Pmt methods
e. Potential Accpt. of spacing methods
f. Non Users
22a. Cases reported
i. Polio
ii. Measles
iii. NN Tetanus
iv. ARI U5 treated
v. ARI U5 referred
vi. Diarr. U5 treated
vii. Diarr. U5 referred
22b. RTI/STD referred
22c. Gyn Prob referred
22d. Infertility cases referred
23. Vital events recorded
a. Live births
b. Neonatal deaths (U28d)
c. Infant deaths (under ly)
d. Child (1-5) deaths
e.
Maternal deaths
f. Marriages
g.
Marriages of girls below 18 years
-
Type
Norm
Task
Qual
Task
Qual
Qual
Task
Task
Qua!
Qual
Qual
Task
Task
Task
Qual
Task
Task
Pop * BR* 1.1
60% of ANC Reg
100% of ANC Reg
50% of ANC Reg
90% of ANC Reg
1/1000 pop/month
3* ANCs registered
15% of ANC Reg
25% of Exp. Delivery
95% of Exp. Delivery
100% Exp. Delivery
**********
Task
Task
Task
Task
Qual
Task
Task
Task
95% of Ecp Births
**********
10% of live births
1/1000 pop/month
100% of live births
100% of live births
100% of live births
100% of live births
No. of live births
33% *(ch under 3)
100% of AWW/pm
Task
Task
Task
Task
Task
Task
Survey
Survey
-32-
A. GENERAL
PHC
Sub-centre
Population of Sub-centre
(rounded to nearest thousand)
Name of ANM/
Female Health Worker
B. SERVICES
SI.
No.
(1)
Services
Method of assessing demand of the area of sub-centre
Felt need of the
population of the
sub-centre
Coverage
norm
1996-97
Annual
Monthly
(5)
(6)
(2)
Methodology
(Example of a state with birth rate of 20 &
5000 population per sub-centre)
’’
(3)
A.N. Registration
100%
MCH, Nutritional Counselling. &
Prophylaxis for
Nutritional Anaemia
(4)
20
Population X BR = 5000 X--------- = 100
1000
Add 10% pregnancy wastage
= 10
110
2.
Early A.N. Registration
(i.e. within 16 weeks)
60% of the
AN Mother
60
110 X -—......
100
=
66
Detection and referral of high risk 100% of the
pregnancies (15% of AN Mothers High Risk
will be high risk Mothers)
Mothers
15
110 X —-......
100
=
16.7 = 17
Detection and Treatment of
Anaemic Mothers
50% of the
AN Mothers
50
110 X----------=
100
5.
T.T. AN Mothers
100% of AN
Registered
110
6.
3 visits completed
.AN Mothers
Minimum 3
visits to be
given.
CSSM Schedule of AN visits to be followed
Institutional Delivery
(GH + PHC + HSC + PNH)
25% of the
expected
delivery
25
100 X ---------- =
100
25
Skilled attention at delivery
(Institution + Health Worker +
Trained Dai)
95% of the
expected
delivery
95
100 X ............. =
100
95
Growth Monitoring of the New
Born Live Births
95% of birth
weight
recording
95
100 X ............. =
100
95
3.
4.
7.
8.
9.
55
110 mothers to be completed with minimum of
3 visits
-33-
(1)
(2)
(4)
(3)
10. Detection and referral of high risk 107c of the
new born
live births
10
11. Infant Immunisation
(BCG, DPT, OPV, Measles)
(DPT/OPV Boosters)
(DT at 5 years)
1007c of the
infants
100
12. Vit A' Solution for the children
upto 5 years to be given in
campaign twice a year
1007c of the
children upto
3 years
20
(6)
5000
X........... X 3 = 300
1000
13. Diarrhoea cases treated with ORS 1007c of
each child in 0-5 years age group Episodes
is likely to get 2 episodes of
diarrhoea in a year
5000
20 -X........... X 5 X2 = 1000
1000
14. ARLPneumonia cases
(upto 5 years)
100%
Each child in 0-5 years is likely to get 2
episodes of ARI in a year. 107o of ARI cases
arc likely to be pneumonia cases
15. F.P. Acceptance
Acceptance of (a) number of couples with 3 or more
children
contraception
(i) number already accepted a permanent
by all eligible
method
couples in the
area
(ii) number expected to accept a permanent
method during the year
(b)
(5)
number of couples with 2 children
(i) number already accepted a permanent
method
(ii) number expected to accept a permanent
method
(iii)number expected to continue with/
accept a spacing method
IUD
OP
Condom
(c)
number of couples with less than 2
children
(i) number expected to continue with/
accept a specing method
IUD
OP
Condom
-34-
1
C. EQUIPMENTS
1.
2.
3.
4.
5.
6.
7.
8.
IUD Kit
Examination Table
Weighing Machine
BP Instrument
Delivery Kits
Steam Sterilisers
Syringes & Needles
Immunisation Cards
Available / Not Available
Available / Not Available.
Available / Not Available
Available / Not Available
Available / Not Available
Available I Not Available
Available / Not Available
Available / Not Available
D. FACILITIES & HELP AVAILABLE TO SUB-CENTRE
1.
2.
3.
4.
5.
6.
Number of Trained Dais available
Number of Anganwadis working
Number of Voluntary ORS Depot functioning
Number of Private Medical Practitioners (MCH, ISM&H)
Number of Primary School Teacher
Male
Female.
Number of Panchayat iMembers
Male^i
Female.
FORM
PHC FAMILY WELFARE & HEALTH CARE PLAN
Stale
1.!
2.
1.5
Population of PHC
1.6
Eligible couples
on 1st April
PERFORMANCE & EXPECTED DEMAND
SERVICE
(D
2.1
FAMILY WELFARE
2.1.1
Male Sterilisation
2.1.2
Female Sterilisation
2.1.3
IUD Insertion
2.1.4
Oral Pill Users
2.1.5
Nirodh Users
2.1.6
Follow-up Sessions
PERFORMANCE
LEVEL
LN LAST YEAR
1.4.95-31.3.96
(2)
-36-
EXPECTED NEED
IN NEXT YEAR AS
COMPILED FROM SUB
CENTRE ACTION PLAN
(3)
1
(1)
2.2
MOTHER CARE
2.2.1
Ante-Natal Care
2.2.1.1
ANC cases registered
2 2.1.2
ANC cases with three
contacts
2.2.1.3
Detection & treatment of
anaemic mothers
2.2.1.4
TT to AN mothers (Total)
2.2.1.4.1
TT(1)
2.2.1.4.2
TT(2) / Booster
2.2.1.5
Detection & referral of
high risk mothers
2.2.2
Natal Care
2.2.2.1
Deliveries in PHC & Sub
centres
2.2.2.2
Domiciliary deliveries
conducted
2.2.2.2.1
by LHV/ANM
2.2.2.2.2
by Trained dai
2.2.2.23
by Untrained dai
2.2.2.2.4
by others
2.2.23
High risk cases referred
1
2.2.3
Post-Natal Care
2.2.3.1
Birth weight recording of
new bom live birth
2.2.3.2
Detection and referral of
high risk new bom
1___
<2’
1
-37-
1
<»
"
1
(I)
L Z‘J
■ (3)___________
_______________
IMMUNISATION
1
8 C G.
O.P.v
OPV routine
2.3 2.2
OPV for PPI
D.P.T. (1.2.3)
Measles (after 9 inonthsl
DPT (18 months)
OPV (18 months)
2.:,-
D.T .(5 years)
__________
T.T. (10 years)
r
2.3 9
TT (16 years)
2.4
ANAEMIA & VIT.'A*
2 4.1
Anaemia treatment given to
2.4 1.1
Pregnant women
2.4.1.2
1 .. .
.
,
Nursing mothers &.
IUD acceptors
2.4.1.2
Children below 3 years of age
I
■
Vitamin A solution given to
children 9 months to 3 years age
l 25
DIARRHOEAL DISEASES
2.5.1
Acute cases recorded
2.5.2
Cases treated with OP.S
2.6
RESPIRATORY INFECTIONS
2 6.1
Pneumonia cases recorded
I 2.6.2
j 2.6.3
Cases treated with Cotrimoxzole
Pneumonia cases referred
i
-38-
3.
MATERIALS AND SUPPLIES -
Stock
i
Position on .
"
1st April
p’Qi.mr
Items
Additional quantity requ ired in
>
2nd Quarter
3rd Quarter
4th Quarter
TOTAL
Contraceptives
3.11
Nirodh
-------------------- -------------------
———
Oral Pill
(cycles)
3-1.3
IUD's
3.1.4
Tubal Rings
3.2
Dai Kits
1
i
1
3.3
Vaccines (doses)
3.3.1
DPT
3.3.2
OPV
3.3.3
TT
3.3.4
BCG
1
i
Measles
-------------------- t......................
3.3.6
DT
3.4
Prophylactics
—
—
IFA Tablets
(large)
3.4.2
IFA Tablets
(small)
3.4.3
Vit. 'A' Sol.
(100 ml)
3.5
ORS
Packets
I
------------------ - ------------—
_______ Cotrimoxzoie
L.
j Tablets
1__________ 1 (paediatric)
FjB&ai
i
—
4. EQUIPMENT & FACILITIES
TOTAL
AVAILABLE
4.1
Vehicle
4.2
Refrigerator
I 4.2.1
I LR
4.2.2
Cold Box
1 4.2.3
Deep Freezer
4.2.4
Vaccine Carrier
4.3
Xray Machine
4.4
IUD Kits
4.5
Examination
Table
4.6
Weighing Machine
4.6.1
Adult
4.6.2
Infant
4.7
BP Instrument
4.8
Needles
4.9
Syringes
4.10
Autoclare
4.11
Steam Steriliser Drums
4.12
O.T. Table
4.13
MTP Suction Apparatus
4.14
Equipment for Infant
Resuscitation
IN WORKING
ORDER
ADDITIONAL
REQUIREMENT
£. INFORMATION. EDUCATION AND COMMUNICATION
5.1
Action taken to mobilise
(a) The medical fraternity Allopathic,
Ayurvedic, Unani & Homeopaths
(b) The para medicals including Dais
(c) Primary School Teachers
(d) Panchayat Members
(e) Ex-servicemen (army & civil)
(f) N.G.O. activities
(g) Anganwari worker
5.2
Counselling facilities at PHC & Subcentre
5.3
Action taken to mobilise
(a) Village folk dances & singers
(b) Street plays
(c) Puppettiers
(d) Video films
(e) Radio
(f) Film shows
5.4
Urging Panchayat Members to prepare village
level family welfare & health care plans
6.0 VACANCY POSITION
Category
5.1
MO (Including Specialist)
5.2
Dental Surgeon
5.3
Staff Nurses
5.4
Pharmacist/Compounder
5.5
Lab. Technician/Lab. Asstt.
5.6
Radiographer
5.7
Driver
Sanctioned
5.8
Driver
5.9
Para-medical supervisosrs
(Malaria Inspector, BEE.PHN.LHV)
5.10
Multi-purpose worker
Male
Female
Vacant
Male
Female
______ id__
—Hr
-41-
FORM - 4
ANM's Activity Reports for Month
Subcentre Population
SC PHC
No. of ECs
Current Users of FP
Activity
Performance
Service Need
Annually
(1)
Monthly
(2)
Monthly
(3)
1. ANC Registration(total)
’. Early Registration(less than 16weeks)
3. ANCs received TT 2 doses
!. ANCs received complete IFATherapy
la.ANCs received treatment for Anemia
5. ANCs completed 3 visits
5. ANC clinics conducted
7. ANCs examined
J. High risk \NCs referred
^Institutional Delivery
Jb.Delivery by trained person
lO.Birth Weight Recorded
ll.BW below 2.5 Kg.
12.High risk newborns referred
l3.No. of PNCs completed 3 visits
14.MTPs referred
15.No. Imm sessions conducted
l6.No. children Immunized
BCG
DPT3
■■
Polio3
Measles
!7.Children fully immunized
18.Children given Vit A(5 doses)
* •♦indicated "no norms s to be used
-42-
Cumulative
(4)
% Ach
(4/1)
Activity
Service Need
Annually
(1)
Performance
Monthly
(2)
Monthly Cumulative % Ach
(3)
(4)
(4/1)
19. Adverse events foll.lmm.
20a. Joint Sessions with AWW
20b. Joint sessions with Dai
20c. Joint sessions with women's
groups
21a. Current users of pmt.methods
(i) Vasectomy
(ii) Tubectomy
21b. Current acceptors of spacing
nethods
(i) IUD
(ii) OP Users
(iii)Condom Users
(iv)Traditional/Indigenous method
(v) Natural methods
21c. Potential acceptors of pmt.
nethods :
(i) Vasectomy
(ii) Tubectomy
21 d. Potential users of spacing
methods :
21 e. Non users
22. No. IUDs discontinued
23. No. FP users followed-up
24. Complications due to
:ontraception
' 25. Sterilization Failures
26a. No. of cases of:
Polio
Measles
NN Tetanus
ARI U5 treated
ARI U5 referred
Diarr. U5 treated
Diarr. U5 referred
26b.No.of cases of Reproductive
problems
RTI/STD referred
Other Gyn Prob, referred
Infertility cases referred
27. Vital Events Recorded:
Live Births
Neonatal deaths (28d)
Infant deaths (under 1)
Child (1-5) deaths
Maternal deaths
Marriages
Marriages of girls below 18 years
-43-
FORM 5. 1
Technical Assessment check-list
Assessment of ANMs records
Month
PHC
Village
Sub-centre
ANM
HH
Name
Iteml
Item2
Item3
Item4
Item5
1
9
3
4
5
6
7
8
9
10
Score
Total score
Items: (1) No, of living children,
(2)
Contraceptive status of EC,
(3)
Immunization status of the youngest child,
(4)
Did she receive TT/IFA during pregnancy
(5)
Whether the child was weighed at birth
(6)
Who did the delivery
Scoring system : ANM recorded the item correctly
ANM recorded the item wrongly / not recorded
-44-
+1
0
Item6
Form 5.2
Technical Assessment Check-list for ANM
Observations on skills, Practices and Facilities
PHC
Month
Sub-centre
Name of ANM
-45-
Yes/No
For Child Immunization:
17. Uses single needle, single syringe
18. Throws away opened measles vial
19. Imm card filled
20. Advised mother about next visit
21. Cold chain maintained
Postnatal Visit:
22. Asked mother about:
Fever
Foul smelling discharge
Bleeding
23.
Checked for
Involution of uterus
Cord healing
Recorded baby weight
24.
Mother advised about:
Proper breast feeding
Keeping baby warm
Contraception
25.
O'ounsels on contraception
Contraception (for any method):
26.
27.
Uses screening criteria and rules out contra indications
Informs woman about side effects and action
Treatment of ARI / Diarrhoea
28.
Can count respiratory rate
29.
Advise about feeding and fluid
30.
Advises about danger signs
46
Comment
s
Form 5 3
FACILITY CHECKLIST FOR SUB-CENTRE
PHC
Month
S u b - Ce n t re
Available
Selected Equipments and Supplies
Y
A. Facilities
Accommodation
Water
Electricity
B.
Furniture and Equipment
Examination Table
Benches for clients
Cupboard for drugs
Foot stool
Vessels for water storage
Waste disposal containers
Brooms and Mops for cleaning
Steam sterilizer
Delivery Kit
Torch light
Stove
Weighing scale
BP apparatus
Vaccine carrier
C.
Supplies and Drugs
Thermometer
Gloves
Syringes and Needles
Slides for blood test
ORS Packets
DDKs
Uristix
Kerosene
Co-trimoxazole
Vit A solution
IFA tablets (big and small) and syrup
IUDs
OPs
1
■
Condoms
Antiseptic solution
Chloroquine tablets
Paracetomol tablets
Metronidazole tablets
D.
EC material
Posters
Models
47
N
Quantity/Quality
r o rm
. <
8
10
Technical Assessment Checklist for ANM
Knowledge and Opinion of EC/Community
Month
PHC
Sub-centre
V i 11 age
■
ANM
Households
1
Were you visited by the ANM during the last month
Is the .ANM available when needed
Does she treat you with respect when you go to her
Did you have any problem in the last pregnancy
If yes, were you given timely advise
Was your delivery conducted by a trained person
Was your baby weighed after birth
Were you visited at home after delivery
Did you get information about proper breast feeding
practices
Do you know the danger signs of ARI
Do you know what fluids are to be given to your child
during diarrhoea
Do you know against what diseases immunization is
given dto your child
Do you know at what age Measles vaccine is given
What is your desired family size
How many children do you have
Are you aware of contraceptive methods
Are you aware of side effects of contraceptive methods
Are you aware of the ideal gap between two children
Have you had an abortion
If yes, were you given advise and treatment
Did you have RTI/Gynaea problem
If yes, did you seek the services of ANM
48
2 3
4
5
6
7
9
Monthly Reporting Format for the Health Worker
Name of the Sub-centre :
Name of the Worker :
[/$/' LIBRARY
J (
S, xv.
Month :
\
Activity
Annual .Monthly
Service need Service
need
1
1. Health clinics
i No. of Health clinics attended with ANN'
2. Family planning methods
i. No. persons motivated for vasectomy
ii. No. persons using CCs
iii. No. vasectomy cases followed up
3. Communicable diseases
A. Malaria
i. No. of fever cases identified
ii. No. of blood smear slides sent to PHC
iii.No. of cases given presumptive treatmen
iv. No. of positive cases given radical treatment
v. No. of high risk villages identified
vi. No. of anti-mosquito activities co-ordinated
B. Tuberculosis
i. No. of suspected cases identified and
referred
ii. No of TB cases followed up
C. Leprosy
L No of suspected cases identified and referred
ii. No. of suspected cases followed up
D. Epidemics
i. No. of GE cases identified and reported
ii. No. of cases of preliminary treatment given
iii. No. of cases referred
iv. No. of cases other epidemic diseases
referred (Filariasis, Malaria etc)
2
AN°
documentation
<
UNIT
Achievement
Monthly Cumulative Percentage
3
4
>
y
>,
Annual Monthly
Service need Service
need
1
4. Environmental sanitation
i. Number of drinking water sources
chlorinated
5. School health
i. No. of school health programmes
participated
ii. No. of school children examined
and treated
iii. No. of school children referred
iv. No. ofschool children immunized
v. No. ofschool health cards filled
6.1nteraction with community
No. of meetings with village health
committees
ii. No. of meeting with youth committees
iii. No. of meetings with village leaders
iv. No. of meetings with PMPs
7.IEC
i. No. of Health Education programmes
on environmental sanitation conducted
ii. No. of group talks to males on
contraceptive methods
ii. No. of health talks to males on
reproductive health '
(STD/RTIs/ Infertility)
8. Reporting and recording
i. Malaria reports
ii. Other communicable diseases reports
J
iii. School health reports
-50-
2
Achievement
Monthly Cumulative Percentage
3
4
%
Technical Assessment Check-list for hw(M)
Male Health Worker
I’HC
Month -- ---------------------------------
Observation of Skills and Practices
Activities
Grading *
Yes / No
E
1.
Family planning methods
A) Motivating for vasectomy
i) explained the method
ii) listed the benefits
iii) spoke about use of CCs after Vasectomy
iv) discussed the misconceptions if any
B) Motivated for use of condoms
i)explained the benefits
ii) demonstrated use and disposal
2.
Communicable Diseases (Malaria)
i)
Took aspetic precautions before taking
smear
ii)
Selected the correct site for skin prick
iii)
Allowed time for forming a blood drop
iv)
Kept a clean slide ready
v)
Prepared both thick and thin smear
vi)
Identified the slide correctly
vii)
Provided presumptive treatment according to age
viii)
Transferred the blood smears to the PHC
ix)
Made correct entry into the records
x)
Provided radical treatment to the smear positive
cases
3.
Environmental sanitation
i)
Estimated the volume of water in the source
ii)
Estimated the free and combined chlorine demand
iii)
Calculated the correct requirement of bleaching powder
iv)
Contact period of chlorination correctly followed.
E = Excellent; G - Good; A = Average and P = Poor.
G
A
P
FORM - 7.2
Technical Assessment Checklist for HW (FW)
Knowledge and Opinion of EC/ Community
:ame of HW(M)
Month
Item
Households
-------------------------------------------------------- —------------
1
2
i3
4
5
Fes / No
6
7
8
_9___
10
1. Were you visited by the Male worker during
the last month?
2. Did he collect blood smear during the last
episode of fever in your family?
3. Did he give you presumptive treatment?
4. Did he inform you about the blood smear report ?
5. Did he give you radical treatment (in Positive
cases only)?
ZS*
6. Did he ever advise you to consult the PHC
MO for any ailment?
7. Did he advice you about the correct use of
condoms?
8. Did he supply you condoms regularly?
(Ask user only)
.
9. Did he explain how to dispose off the
condoms?
10. Does periodically seek your assistance
in the implementation of the heal th programmes?
(Ask a village leader)
11. Does he visit your village atleast once a month?
(Ask a village leader/elder)
12. Did he help you in chlorination of water
sources? (To be asked to a village leader)
13. Did he seek your assistance and help in
environmental sanitation? (Asked a member
of youth club or village leader)
14. Did he refer you to the PHC MO for further
mangement of your ailment
(Ask a TB patient)
15. Did he visit you for followup care ?
k
r
r"
16. Did he refer you to the PHC MO for further
mangement of your ailment ?
(Ask a Leprosy patient)
17. Did he visit you for followup care?
18. Does he periodically visit your school?
(Ask a school teacher)
Name of the Supervisor :
Date
Signature
-5 2-'
Name of tiie MO
Name of the PHC :
Month
District
Activity
Annual
Service
need
Achievement
Monthly
Service
Monthly Cumulative Percentage
need
1) O.P. Clinics conducted
a) No.of cases examined
b) No.referred from SCs
c) No. treated
d) No. referred to FRU/hospital
’) ANC clinics conducted
a) No.of cases examined
b) No.referred from SCs
c) No. of high Risk cases identified
d) No. referred to FRU/hospital
3) Immunisations performed
i) a) DPT (3)
b) OPV (3)
c) BCG
d) Measles
ii) a) No. fully immunised
b) No. partially immunised
c) No. not at all immunized
iii) Cases of adverse effects of
immunization managed
iv) No. of Immunisation sessions
attended at periphery
4) ARI
a) No. of cases treated
b) No. of cases referred from SCs
:) No. referred to FRU/hospital
d) No. of deaths due to ARI
5) Diarrhoea
a) No.of diarrhoeal cases treated
b) No.of cases referred from SCs
:) No. referred to FRU/hospital
d) No. of deaths due to diarrhoea
5) Deliveries conducted at PHC
a) No. of Institutional deliveries
conducted
i) Conducted by MO
ii) Conducted by other trained
personnel
iii) Complicated deliveries referred
to FRU/hospital
iv) Recording of Birth Weight
53
Service 1 Service
| need
need
7) MTP performance at PHC
a) No.of MTPs performed at PHC
b) No.referred from Scs
c) No.referred to FRU/hospital
3) Sterilizations performed
a) No. of tubectomies performed
i) With one child
ii) With two children
iii) With more than two children
iv) No. followed
v) No. of failure cases reported
b) No. of vasectomies performed
i) With one child
ii) With two children
iii) With more than two children
iv) No. followed
v) No. of failure cases reported
?) IUD inserted
a) No. of cases screened for IUD
b) No. of women inserted IUDs
c) No. of IUD acceptors followed up
d) No. of dropouts
10) O.P. Users
a) No. of O.P. users screened
b) No. of O.P. acceptors followed
c) No. of dropouts
11) Reproductive Health
a) RTIs/STDs
i) No.of cases of RTIs/STDs
examined
ii) No. of cases treated
iii) No. referred to FRU/Hospital
Infertility
i) No. of couples of Infertility
identified
ii) No. referred to FRU / Hospital
:) Malignancy
c
No. of suspected cases of cancers of
reproductive tract referred:i) Referred from PHC
ii) treated at CHC/PPC/FRU
iii) Referred to Distt.Hospital'
54
N <W<71'£M&rfZ
Monthly Cumulative Percentage
Activity
Achievement
Annual Monthly
Senice Service
Cumulative Percentage
Monthly
need
need
to Total
1) Dysfunctional Uterine Bleeding
(DUB)
No. of cases of menstrual disorders
referred to FRU / Hospital
12. Disease surveillance report
(Once in 3 months)*
a) Vaccine Preventable Diseases
i. Polio
ii. Tetanus
iii. Diphtheria
iv. Pertussis
v. Tuberculosis
■■
b) Other Diseases
i. Malaria
1. No. of B.S. taken
2. No. of Positive cases
2.1 PF
2.2 PV
2.3 Mixed
3. Presumptive treatment given
4. Radical treatment given
5. No. referred out
6. No. of deaths
ii. Tuberculosis
1) No. of sputums examined
1.1 New cases
1.2 Follow-up cases
2) No. of sputum positive cases
3) No.given SCCs (Short Course
Chemotherapy)
4) No. completed SCCs
5) No. under treatment
6) No. referred out
iii. Leprosy
1) No. of cases reported
2) No. of suspects referred
iv. Epidemics Reported
1) No. of Epidemics of G.E.
2) No. of deaths
3) Other Epidemics if any
’ Note: The disease surveillance part of this report should be submitted only once in three
months.
55
Achievement
\nn.ual Monthly
Service
Monthly Cumulative Percentage
need
io Total
a) Monthly Mos meeting at District
b) Monthly Staff Review
c) With ICDS staff
d) With Block Level officials
e) Community Level Leaders;
Representatives
f) With Women Groups
g) Any oilier Meetings
h) Review of work of NGO
working in area done
l4. EEC Activities
a) No. of health campaigns
conducted
b) No. of NGOs contacted and
involved
c) No. of Schoo! Health Camps
held
b)
No. of training programmes
conducted for non health
functionaries
[16. Transport
a) No. of cases transported in PHC
vehicle
i: Tubectomy Cases
ii) Emergency obstetric cases
iii) Other emergencies
1
FORM 9.1
Technical Assessment Checklist for PHC Medical Officers
Name of the M.O.
Name of the PHC
:___________________
Month :
______________________ Year
:
Activities
Grading *
Yes/No
E
1. New OP Case
a) History taken
b) Physical examination done
c) Provisional diagnosis made
d) Treatment initiated
e) Referred to FRU / Hospital
f) Adequate time spent on each patient
g) Necessary' advise imparted
2. Examination of AN cases
a) Correct estimation of gestation period
b) Correct identification of high risk
3. Correct assessment and treatment of child with
diarrhoea
4. Correct assessment and treatment of child with ARI
5. Correct assessment of STD/RTI
a) STD / RTI cases treated
b) STD/RTI cases referred to FRU / Hospital
6. Correct decision taken in an emergency case /
delivery case for
a) Treatment at PHC
b) Referral outside
c) Use of drugs - raational or not
7. FP Methods
A. Tubectoiny
i) Pre-operative check-up
ii) Aseptic precautions
iii) Ability to locate the tubes
iv) Ligation of the tubes
v) Skin suturing and ASD
vi) Post-epcrative advice
G
A
P
Yes/No
Activities
Grading *
E
G
A
P
B. Vasectomy
:: Pre-operative check-up
ii) Preparation of the surgical area - care of asepsis
iii) Incision and control of intra-operative
haemorrhage
iv) Identification of Vas
v) Ligation of Vas
vi) Skin suturing and ASD
vii) Post-operative advice
-
C. IUD Insertion
i) Screening the patient
n■
XseptTc precautions
iii) Insertion of IUD
iv) Inspection of the IUD threads
v) Post-IUD insertion advice .
7. Records and reports
a) Complete and update
b) Accurate
8. Clean and tidy PHC premises
9. Provision made for round-the-clock availability of
staff.
10.PHC vehicle available round-the-clock in road
worthy condition.
1 l.MO staying at head quarters
Note:
The Supervisor is a district level officer and visits the PHC once in two months. The
Supervisor will directly observe the skill of the Medical Officer while examining;
1. A new OP case
3. A child with diarrhoea
5. A person with RTI / STD
2.
A pregnant woman
4.
A child with ARI
6. Any emergency or critical situation
occuring during the visit
E = Excellent
A = Average
P
G = Good
58
= Poor
Facility Check List for PHC
Month
PHC
District
Activity
1.
PHC Building
Yes/No
Own or Rented
2,
PHC Premises Clean and Tidy
Yes/No
3.
Equipment
Yes/No
4.
a)
Ambulance
b)
Cold Chain Equipment
Yes/No
c)
B.P. Apparatus
Yes/No
Yes/No
d)
Weighing Machine
Yes/No
e)
Micro Scope & Lab. Equipment etc.
Yes/No
f)
Auto Clave
Yes/No
g)
Oxygen Cylender
Yes/No
h)
Surgical Equipment relating to PHC expertise
i)
Labour Room Table & Equipment
Yes/No
j)
Examination Table
Yes/No
k)
Resuscitation Equipment
Yes/No
Drugs*
Vital"
Essential
Yes/No
Desirable
Yes/No
Yes/No
"Note 1:
The supervising officer must make a list of essential facilities and drugs of
accute shortage even during his quarterly visit and the same should be brought
to the notice of higher ups immediately,
* Note 2:
A detailed VED (Vital, Essential and Desirable) categorization of drugs at
PHC will be provided to be supervising officer.
FORM 9,3
Technical Assessment checklist
• o' MO PH'”
Knmdedge and opinion of the community
Month
Note: The supervising officer will spend one full day in the village interacting with at least 10
people representing a cross section of the society. He should make it a point to select the cases
perferably from those hailing from weaker sections and women.The same village should not be
revisited by the subsequent supervising officer.
Two sets of questions are given to the supervicry officer. The first set is common to all barring Dais
and Anganwadi workers. The second set of questions is for the specific target groups in addition to
the tirst set of questions.
The main objective of the two set of questions is to asess the community satisfafaciion on the
overall functioning of PHC and die Medical Officer in particular.
-60-
SECOND SET OF QUESTIONS FOR DIFFERENT TARGET GROUPS
The persons to be interviewed are :
1. Pregnant woman
2.
One recently delivered woman and baby
3.
Tubectomised wonian/Vasectomised man
4.
Dai of the village
5.
Anganwadi worker if available
6.
Women group representative
7.
One youth of the village
8.
One village leader
9.
One IUD acceptor
10.
One CC/OP user
Yes/No
Comments
Pregnant woman
Did you register before 16 weeks of
pregnancy?
i
Have you been given IFA tablets ?
Have you been informed about danger
signals in pregnancy and the need to
contact PHC MO ?
Recently delivered woman
Is your delivery Institutional ?
Were you told about tire post partem care ?
Was the child given with BCG vaccination ?
Were you informed about breast feeding ?
Mother with two year old child ?
Did your child get all doses of Immunisation ?
Was your child affected with Diarrhoea
any time ?
If yes, were you advised about the feed
and the use of ORT ?
Tubectomised woman/Vasectomised man
Do you have less than two children?
Are you satisified with the follow up care
after the operation?
1
Do you have any complications?
1
1
|___________
-61- 1
r
Yes/No
i
I
Dai
Are you trained?
I
Are you aware of the five civaits :
1
Can you identify a high risk case?
1 Anganwadi Worker
Does die ANM seek your cooperation?
Are there any cases of adverse effect of
immunisation?
Women group representative
Do the PHC staff keep in touch with
Do they involve you in Health andFW aetvities?
Youth and Youth club member
Do the PHC seek your cooperation ?
Were you involved in promoting H and
FW issues?
Village Leader
Does MO/or other PHC staff seek your
cooperation for social mobilisation?
Are you involved in promoting
Environemental santiation?
i
IUD acceptor
Were you told about the advantages and
possible side effects?
Are you satisified will’ die services of
PHC staff in tills regard. !
Condom User
Were you told about the method of using
Condoms?
Are you supplied with the axxtom by die IV.C!
OP user
Are you infansd about the methx! cf using UP?
Were you told about die Ivnefns and
possible side effects of OP ?
j
Are you supplied with fjp tablets?
Have you experienced any
I
complications?
-62-
—
Comments
---------
...... . ....... / ' ----- -
Name of the MO IC
r
:
■
Name of the CHC/PPC/FRU:
Activity
1
|
ft-
Kc
!<■
1) O.P. Clinics conducted
a) No.of cases examined
b) No.referred from PHC's
c) No. of High Risk cases
identified
d) No. treated
e) No. referred to Distt.Hospital
2) Immunisations complications
a) Cases of adverse effects of
immunization managed
b) No. of Immunisation
complication attended at
periphery
g
cC
:C
'C
■3 C
ic
fc
3) ARI
a) No. of cases treated
b) No. of deaths due to ARI
c) No. of cases referred from PHC
d) No. referred to Distt.Hospital
C
’. C
t) Diarrhoea
a) No.of diarrhoeal cases treated
b) No.of deaths due to diarrhoea
c) No.of cases referred from PHC
c
(
c
c
c
c
c
c
c
€
(.
c
£
<
. C
(.
c
Month:
Year
Fon" -
:
:
District
I
■-^rr^
5) Deliveries conducted at CHC/FRU/
PP Centre
a) No. of deliveries conducted
b) Complicated deliveries referred
from PHC
c) Complicated deliveries managed
at CHC/PP Centre
d) Complicated deliveries referred to
Distt. Hospital
e) Neonatal resuscitation done
7) MTP performance at CHC/FRU
a) No. of MTPs persformed at
CHC/PP Centre
b) No. referred from PHC
c) No. referred to Distt.Hospital
d) Complications after MTP
Annual
Service
need
Monthly
Achievement
Service
Monthly Cumulative Percentage
need
to Total
Activity
Achievement '
Annual .Monthly
Service Service
Monthly Cumulative Percentage
need
need
to Total
3) Sterilizations performed
a) No. of tubectomies performed
i) With one child
ii) With two children
iii) With more than two children
iv) No. followed
v) No. of failure cases reported
b) No. of vasectomies performed
i) With one child
ii) With two children
iii) With more than two children
iv) No. followed
v) No. of failure cases reported
)) IUD inserted
a) No. of cases screened for IUD
b) No. of women inserted IUDs
c) No. of IUD acceptors followed up
d) No. of IUD Removal for:
1. Request
2. Complication
3. Expulsions
e) IUD Failure cases reported
10) O.P. Users
a) No. of O.P. users screened
b) No. of O.P. acceptors followed
c) No. of dropouts
11) Reproductive Health
a) RTIs/STDs
i) No.of cases of RTIs/STDs
examined
ii) No. of cases treated
iii) No. referred to Distt.Hospilal
a) Infertility
i) No. of couples of Infertility
identified
ii) No. of couples refered from PHC
iii) No. of couples treated/cured/
regained fertility
:) Suspected cancer
No. of suspected cases of cancers of
reproductive tract referred:i) Referred from PHC
ii) treated at CHC/PPC/FRU
iii) Referred to Distt.Hospital
-6 4-
Activity
Annual
Service
need
1) Dysfunctional Uterine Bleeding
(DUB)
No. of cases of menstrual disorders
referred to Distt. Hospital :
i ) Referred from PHC
ii) Treated
iii) Referred to Distt. Hospital
12. Meeting attended / conducted
a) Monthly Mos meeting at District
b) Monthly Staff Review
c) With Block Level Official
d) Community Le vel Leaders/
Representative
e) With Women Groups
f) Any other Meetings
13. Training
a) No. of staff training programmes
conducted
b) No. of training programmes
conducted for non health
functionaries
•
14. Transport
a) No. of cases transported in FRU
vehicle/ambulance
i) Tubectomy Cases
ii) Emergency obstetric cases
iii) Other emergencies
-65-
Monthly
Achievement
Sendee
Monthly Cumulative Percentage
need
to Total
FORM
Technical .Assessment checklist for FRU Medical Officers
Name of the M.O
Month :
Name of the Institution :___________________________________ Year :
Grading *
Yes/No
Acth ities
______________________________________________________
E
G
A
1. New OP Case
a) History taken
b) Physical examination clone
c) Provisional diagnosis made
d) Treatment initiated
e) Referred to Hospital
0 Adequate time spent on each patient •
g) Necessary advise imparted
2. Examination of AN cases
a) Correct estimation of gestation period
b) Correct identification of high risk
3.‘ Ward Patient
a) History taken
b) Physical Examination done c) Provisional Diagnosis made
d) Relevant Investigations done
e) Treatment Initiated
f) Adequate time spent on each patient
g) Behaviour with the patient
h) Opinion of specialists taken
i)
Referred to Disit. Hospital
4. MTPcase
a) History taken
b) LMP recorded
c) Physical examination done
d) Concern shown for confidentiality
••
5. Correct assessment and treatment of child with
diarrhoea
6. Correct assessment and treatment of child with ARI
7. Correct assessment of STD/RTI
a) STD /RTI cases treated
b; STD/RTI cases referred to FRU/'hospsital
•8. Correct decision take:! in an emergency case/
de!i\ery case for
a; Treatment at FRU
b; Referral outside
66
p
Yes/No
Activities
E
Grading *
| G | A | P
F.P. Methods
9.
A.
i)
ii)
iii)
iv)
v)
vi)
Tubectomy
Pre-operative check up
Asceptive precautions
Ability to locate the tubes
Ligation of the tubes
Skin suturing and ASD
Post-operative advice
Vasectomy
Pre-operative checkup
Preparation of the surgical area
Incision and control of intra-operative
haemorrhage
iv)
Identification of Vas
v)
Ligation of Vas
vi)
Skin suturing and ASD
vii)
Post-operative advice
B.
i)
ii)
iii)
C.
i)
ii)
iii)
iv)
v)
10.
11.
12.
IUD Insertion
Screening the patient
Aseptic precautions
Insertion of IUD
Inspection of the IUD threads
Post-IUD insertion advice
Records and reports
a) Complete and update
b) Accurate
Clean and tidy FRU premises
Provision made for round-the-clock availability of
staff.
FRU vehicle available round-the-clock in road
worthy condition.
14.
MO staying at head quarters
13.
Note: The Supervisor is a district level officer and visits the FRU once in three months. The
Supervisor will directly observe the skill of the Medical Officer while examining the
cases listed above.
E
= Excellent
A = Average
G
= Good
P = Poor
-67-
FORM 11.2
Facility Check List for CHC/PPC/FRU
Name of the Institution
District
:
:
Activity
1.
FRU Building
Month :
Year :
Ycs/No
Own or Rented
2.
FRU Premises Clean and Tidy
Yes/No
3.
Equipment
Ycs/No
4.
a)
Ambulance
Yes/No
b.
B P. Apparatus
Ycs/No
c)
Weighing Machine
Yes/No
d)
Micro Scope & Lab. Equipment etc.
Yes/No
e)
Auto Clave
Yes/No
f)
Oxygen Cyiender
Yes/No
g)
Surgical Equipment relating to FRU expertise/
responsibility.
Ycs/No
i)
Labour Room Table & Equipment
j)
Examination Table
k;
Resuscitation Equipment
1)
Neonatal Resuscitation Equipment
m)
Anaesthesia Equipment
n)
Incinerator
■.
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Drugs*
Vital
Yes/No
Essential
Yes/No
Desirable
Yes/No
'’Note I:
The supervising officer must make a list of essential facilities and drugs of
accutc shortage even during his quarterly visit and the same should be brought
to the notice of higher ups immediately.
*Note 2:
A detailed VED (Vital, Essential and Desirable) categorization of drugs at
PHC will be provided to be supervising officer.
FORM
FAMILY REPRODUCTIVE. HEALTH CARD
Registration Date
PHC :
Subcentui :
Village
Name of head of the KH :
EC No.
Water Source
House Type :
Rcligion/Castc :
Total
Females:
Males:
Family Size
:
:
Primary Immunisation (Under 1 Year)
Sex
Name
DOB
DPT
OPV
1 1 2
0
1
r
|
OPV
12
1
j
3 i 1
i
1
Vit A
Measles
3
1
1
Immunisation (Children 1-5 Years)
1
;
Name
Sex
DOB
1 DPT
OPV
| (B)
(B)
1
1
i
IFA
VIT A
4 1 5
2
1
— I—- —____ 11
3
1
|_
1
Pregnancy History of EC and Contraceptive Status
IfStcrlised, Date:
Education :
No. of
i’regnancies
Children Living
Outcome
LB
SB
Spontaneous
|
Children
Abortion
Female* '
Male
Dead
Induced
___________ ]
|
-69-
I
____
Death Record
:
Name
Sex
1 Age
|1
Cause
Death Dale
|
1
Family Planning Foll'ov.’-up by month
1
1996
4 | 5
3
2
3
1 4 1 5
1
i__
I
6
3
! 4 1 5
i 1
6
8
9
10
11
12
8
9
10
11
12
7
8
9
II- 10
11
12
7
8
9
10
11
12
7
6
2
?. egnancy/FP Status
j Complications
1997
1 rregnancy/FP Status
1
1
i Complications
7
1998
1
1
2
• ?.-egnancy/FP Status
1
1
1
1
i Complications
_________________ 1999
1
1
2
! ?regnancy/FP Status
j___
j Complications
1
L
i 4 i 5
|
1
I
3
i
i
I
!
6
i
ANC Information
! Anc Reg
:
I
Y/N
j Weight *
EDD
1
i
1
|
2 | 3 |
1
1
1 1
I
IFA
|
BP*
TT
2 | 3 j 1 i 2 I 3 1 1 j 2 3
i
1
Urine*
1
2
HR** Ref
3
u ' 1___
Illi!
Record lor ail 3 ANC visits
Malpresentation, Twins, Previous LSCS, Anaemia, TB, Toxaemia, Haemorrhage
(Use the first letter of word as code. If factor other than these, specify.)
Delivery & PNC Information
! Delivery Delivery [Delivery | Outcome Birth j PNC* |Breast**
PNC***
Weight 1 Visit | Feeding Complications
J -Date | Place |
by
j
____ I
I
1
1
I
1
l
Treated/
Referred
Mention number of PNC visits
Mention the number of hours or days after which, breast-feeding was initiated
Infections; Injury to Genital tract; Haemorrhage; Foyer; Sudden death; Uterine problems
lactation failure.
-70-
FORM
Assessment of Quality and Client Satisfaction
Not Recorded
No
Has the ANM visited you in last three months?
During last pregnancy did you suffer from any of the following problems?
>} Swelling of feet
(b) Bleeding
(c) Excessive tiredness
(d) Convulsions
(c) Night blindness
(f) None
Yes
you advised to go to hospital for delivery ?
Not Recorded
No
Where did the delivery take place?
(a) Government Hospital,
(b) Private Hospital
(d) At Home
(c) Not recorded
If delivered at Home, Q4a
Who conducted the delivery?
(c) Relations
(b) Trained Dai
(a) ANM
(c) PHC/HSC
lb. Was the Disposable Delivery Kit used?
(4) Not Recorded
No
Did the ANM advise you about breast feeding?
Not Recorded
No
When did you start breast feeding?
Not Recorded
Daxs
At what age should the baby given supplementary feed?
Do you know the danger signs of ARI?
Months
Yes
No
Not Recorded
No
Not Recorded
Has ANM told you what to do when your child has diarrhoea?
(a) Continue Feeding
(b) Give fluids
(c) Specify
Was your baby weighed after birth?
Did you have any problems immediately after delivery?
(a) Fever
(b) Bleeding
(c) Foul smelling discharge
(d) None
Did you get any treatment at that time?
(b) From ANM
(c) From PHC
De ou want any more children?
Yes
When do you want to hate the child ? After
-7 1-
No
Not Recorded
Months
ANM advised >ou about spu
(c) Condom
. (b) Oral Pills
(a) IUD
Qi5.
(d)Othcr, Spcci fy____________ I
Are you currently using any method?
(b)Ycs: _______ _______ Method
(a) No
if using, Q15a. Did you experience any problems with the method? Yes
If Yes, Q15b.
Were you able to get treatment for it?
If Yes, Q15c Where? (a) PHC doctor
Ql-6.
(b) Private doctor
No
No
Not Recorded
Not Recorded
(c) Vaid (d) Home treatment
i
Have you used any method in the past and discontinued?
(a; No
Q17
Yes
(b)Yes:
Oral Pills
IUD /
i-
/ Condom / Other, Specify_
Arc you suffering-from any of the following health problems?
(a) White discharge
(b) Back ache
If Yes, Q 17a.
Have you sought treatment for it?
(a) No
(b) Yes,
From:
•
o 1
(c) Abdominal pain
ANM /
PHC / Hospital
/ Private doctor
Please p.ivo vour opinions about Government Health Center,,
o <
•i ■
017.
Do you find the center well equipped?
Very well
Somewhat
Not well equipped^ '
QI8.
Are the center's timingc convenient?
Yes
No
Not Recorded
Is doctor available when you yisit?
Always
Sometimes
Never
Q20.
Do you have to wait long for service?
Always
Sometimes
Never
Q21.
Is there privacy where you are examined?
Vcrv much
Somewhat
Not much
Are you examined properly?
Venpvell
Somewhat
Not well
Q23.
Is the staff friendly?
Very much
Somewhat
Not much
Q2<
Are medicines available at the center?
Always
Sometimes
Never
Q2?
Do they explain how to take medicine?
Always
Sometimes
Never
Q26
Is the treatment effective?
Always
Sometimes
Never
j
c-’
o
4. IMMUNIZATION
5. ANAEMIA & VITA'
C.2 ZX-AIAW ORS KPCT5 FUhCTOKMS :
u' MORBIDITY & MORTALITY {CUX’.T- •
DISEASES
'. S-i •- . *,
!U
IM
U»
IM>
tt.’
___ IM
PHC A-tfrA”
C____
:
1 C-S-S-E-r.
_ _
ACUTE OLLffPHCQU. PSEASES • _ ]_ _______ =____
PPHTHERA___________ ■
ACUTE POXfcOTUTC___________ •___
j______
NEONATAL TETANU3__________ !
•
TETANUS p^cr tMA 1 l -q_______ !_
j______
WHOCFTC COU3M___________ J___
j______
MEASLES__________________ •___ ;______j______
ACUTEKI pxi Pr^rwa & YA
j
___________________ [
_
J
I
HJL To bo fX»d up by PMC CcCor
• All CASES WTrt THREE OR MORE LOOCC UT7T\-.-- A A'. K"-£ SPECTJVE Of AETKXOGY / CAUSATION
•* iwac&Mj.
VL.
jupC&NJ*-*
r>,
.A <
GROUP EDUCATIONAL ACT*
. x*x mxxrs x/tt « Muxeera *--c fsftcrxd I
■. O:
jrtA u€
tt
\e^ Vt
C.
CT-OH MANUAL
iil?
FOR
MONTHLY REPC:-T "suM PRIMARY HEALTH CENTRE
TO
DISTRICT
ITEM No.:
(Corroesponding to actual prolo’-r.
1.
GENERAL
1.1
Write the name c: tl.e
district NIC unit.
. ■: ?jli and give State Code as obtained from
1.2
Write the name of the
from district NIC unit.
■ ■’ .<; 'uli and give the district code as obtained
1.3
Write the name of the ' •
district NIC uni'.
1.4
Indicate the month whir: • I-. being reported on e.g. for January as 01,
February as 02 and D?•: ■ as 12
1.5
indicate the year of rec;. •
1.6
Indicate the date on
First two boxes
Middle two boxes
Last two boxes
• • jl: and indicate PHC code as obtained from
.-j for 1990, 91 for 1991 etc.
report Is being sent.
• ’ •.. Cite
e.g. 05
month e.g. 03
Year e.g. 90
Indicate population cur-
■? year in number.
Indicate number of
year.
■ -les as on First April at the beginning of the
2-famh.y welfare
Total Eligible cotipL? • t •".■
quarters sub-contra J;.r- ■
. ? by all the subcentres including headmonth.
-76-
2.2
Total': The reports from all the sub-centre areas Including headquarter.sub-centre area Irrespective of place of operation will get reflected in th’s
row.
'PHO: The operations done in PHC headquarters only should c.c.i
reflected In this row.
2.3
Number of cases followed up by all the sub-centres including PHC head
quarters sub-centre.
2.4
'Total': The reports from all the subcentre areas Including headquarters
subcentre area irrespective of place of insertion should be shown.
2.5
2.6
'PHC; The IUD inserted in PHC headquarters including subcentre ANf.i
get reflected.
■ Number of IUD cases followed up by all the subcentres including PHC
headquarters sub-centre.
Column 1-4 : Number of women using Oral Pills at the beginning ulha
month Irrespective of source of pin in the total PHC area (including sub
centres). Rest of the columns also relate to same area namely, all sub-cert
areas Irrespective of source of pill.
Column 5 : Number of Oral Pill cycles distributed by PHC through a.'.is i
subcentres and voluntary organisations.
2.7
Number of Nirodh Pieces distribute^,by PHC through PHC headquarter
outlets, sub-centre outlets and voluntary organisation outlets etc.
2.8
TOTAL’: Number of MTP cases done In all the sub- centre areas iriduping
headquarters sub-centre area irrespective of the place of operation will c °t
reflected in this row.
’PHC: Number of MTP cases done in PHC headquarters wiil get i-. ledcd i
this row.
3. MOTHER CARE
3.1 ANTE NATAL CARE
3.1.1
Ante-natal cases registered by all the subcentres including PHC head
quarters sub-centre.
3.1.2
Number of cases followed up by all the sub-centres including PHC h
quarters sub-centre for minimum three consultations between the i~? '• ■
and health functionaries Including ANM.
.3.2 NATAL CARE
4.
3.2.1
Domiciliary deliveries conducted by different categories of personnel in
the sub-centre areas including headquarters sub-centre
3.2.2
Deliveries conducted in the PHC Hospital.
3.2.3
Number of high risk cases referred by the PHC to the Tehsil/Disl./any
other hospital.
3.2.4
Details of pregnancy outcome in all the sub-centres areas Including
headquarters sub-centres.
IMMUNISATION
• 4.1
TOTAL': The total immunisation done in the PHC area irrespective of
source of immunisation will get reflected in this row.
4.2
As in 4.1
4.3
As in 4.1
5, ANAEMIA & VIT 'A'
The data will be derieved from sub-centre reports and PHC clinic1
report. Every mother and child gets initiated when they are put on the '
course. The new initiators will get reflected against the ’INITIATED'
column. So long as they are continuing the course and collect the drug,
they are reflected against 'CONTINUING' column. The number of
beneficiaries who received the final dose in the month, will figure in the
'COMPLETED' column.
The data will be derieved from sub-centre reports.
6.2
Self F'-'•matory
C C
‘PHC: Immunisation given by the PHC headquarters and/or sub-centres will .j
get reflected in this row.
-Zjdeaihs
These deaths will have to be detected by sub-centre workers in the
respective areas and details should be noted by them In the respective
registers for the further administrative follow-up. However.here only the
number of deaths(sex-wise) to be shown against respective items. Extra
care should be taken to ensure that only correct figures be shown and
no death is either missed or over-reported. Every death reported should
have its details (Name,age etc.) in the sub-centre registers and PHC
records.
>
£<zubrary ’
AND
,
\ documentation )
J*”
'S^GALO^^
S. FACILITIES
.8.1
TOTAL': Show the total number of vehicles in the box. This is irrespec
tive of whether the vehicle is in order or not. This will take into account
only those vehicles which are working for the PHC. If the vehicle is
sanctioned against the PHC bu< is working somewhere else the same
should not be taken into account for this report.
'ON ROAD' : Show only the number of vehicles which is in working
order. Vehicles sent for servicing, or minor repair should also be taken
as In working order.
8.1
b) Show kilometers covered by petrol driven/diesel driven vehicles during
thp month in the respective boxes.
'6.1.c) Show quantity of petrol/diesel put in the tanks of the vehicles during
the month in the respective boxes.
8.2
TOTAL': Show total number of ZRAy rt«Rlri;*the PHC as well as in all
the sub-centres irrespective of whether they are working or not.
'WORKING': Show only the number of working refrigerators.
:8.3
As in 13.2.
fl. VACANCY POSITION
’SANCTIONED': Please show Number of total posts sanctioned for the
PHC including subcentres.
’VACANT' : Indicate number of posts vacant in’the PHC including
subcentres. Even if a doctor has been posted against the PHC, but Is
working some where else, the post should be taken as vacant. Similarly
K some doctor stands posted against a post In some other place, but
Is working In your PHC, the post should be considered as filled In (or
the purpose of report Short temporary duties should not be taken Into
account(not exceeding 15 days). The above classification applies for all
the staff.
|0. INVENTORY
'STOCK SUFFICIENT FOR MONTHS’: Indicate the number of months
for which the balance stock Is likely to be sufficient without taking Into
consideration future supplies. Also take Into consideration the averge
consumption rate and the anticipated sease nal/gross fluctuation in the
usage of the item.
11. MORBIDITY AND MORTALITY (CLINICAL DATA)
11
| |.B
.A
Here indicate only the number of cases attended by the PHC and
deaths in PHC Hospital, (and not at sub-centres)
The cases and deaths In the PHC Area (including all Sub-Centre areas)
which have been verified either by the PHC Medical Officers or by qualified
Medical Practicioners and line listing provided to PHC authorities.
I 2. GROUP EDUCATIONAL ACTIVITIES
Indicate total number of meetings/film shows/puppet shows/public
semlnars/symposia etc. against Individual items organised In the PHC
area through PHC/sub-centre Initiative.
-80-
K>H - H; 3.S"
Draft for comments
Towards a Target-free Population Programme
Health Watch Consultation
25-26 March, Ahmedabad1
The backdrop:
A series of regional consultations were organized by NGOs in
preparation to the International Conference on Population and
Development,
Cairo,
September,
1994. Organizations working on
health and population issues, rural development, environment etc.
and groups working with women came together. This was the first
time that such a diverse group focused on the population question.
For over four decades there was little dialogue among groups who
focused on family planning and those who worked on other social and
economic issues.Family Planning was viewed with suspicion and many
grassroots groups made it a point to distance themselves from the
programme, while in their day to day work with poor women they made
it a point to respond to the contraceptive needs of men and women.
The regional consultations created an opportunity for the two
constituencies to come together and reflect on the reasons. It
emerged that the main irritant was the public face of a top down
family planning programme which primarily focused on meeting method
specific targets. The unfortunate situation .in 1995-97 further
alienated social action groups from the programme.
However, the pre-Cairo consultation created an opportunity for
different constituencies to come together and arrive at a common
understanding of the complex inter-linkages between population,
poverty and development. These consultations also provided space
for groups to speak out their problems and concerns. The meetings
held in 1993 and 1994 generated a exhaustive list of problems faced
on the ground and alternative approaches to reaching primary health
care and family planning services. Simultaneously, the government
was also taking stock of the family welfare programme. Government
of
India official paper to Cairo reflected a shift
from a
"population control"
strategy.
The importance of
a holistic
reproductive health approach was suggested. As a first step, the
government was planning to remove method specific targets in select
areas as a test'case. Thus a paradigm shift from a family planning
centered approach to a reproductive health approach emerged as the
basis for future policies. Government's seriousness in reorienting
the family planning programme towards a client centered approach,
with an emphasis on quality of care was evident.
After the Caii'- conference, Government of India declared one or two
This draft report has been compiled by Ms Prabeen Singh
and Ms Vimala Ramachandran for Health Watch.
districts in each state as "target-free"districts. By January 1996,
the government was planning to do away with method specific targets
altogether.
In March 1996 a special task-force was set up to
develop
alternative
indicators.
Simultaneously,
GOT
started
planning new initiatives, namely: Reproductive and Child Health
programme in select districts, revamped CSSM programme, district
based micro-planning to generate a holistic health delivery model
etcetera.
Health Watch, a network of voluntary organizations, researchers,
development activists and experts was asked by GOI to coordinate a
series of regional consultations with NGOs to generate discussion
on GOI's new approach to health and family planning. This workshop
is the first in a series.
Objectives of the consultation:
This round of NGO consultation is designed to take off where the
earlier round left off. In 1993 and 1994 NGOs working in a wide
range of issues came together for first time to articulate their
own experience in the health and family welfare sector. The issues
tabled in the first round was taken on board and it was felt that
the second round should endeavour to take the debate to another
level. After recapturing the main changes initiated by Government
in 1995 and 1996, this consultation focused on a few key issues,
namely:
sub-committee
on
a)
Feedback on Government
removal of targets;
b)
Inter-linkages between primary health care, safe motherhood,
family planning and reproductive health: drawing upon NGO
experiences;
c)
Empowering women to access services
providers responsive to women's needs;
d)
Involving men
in primary health care,
safe
motherhood,
reproductive health and family welfare: exploring new ground;
e)
Exploring avenues of NGO - government partnership.
of
India
and
report
making
service
Is there a role for NGOs in the changing scenario?
Over the-years it has become evident that the government perceives
NGOs primarily as service providers and not as partners in policy
making, strategizing and programme development. On the other hand
many NGOs perceive themselves as catalysts in the development
process, providing services being just a part of a much larger
identity. While there may be instances of close collaboration
between government agencies and voluntary groups, by and large the
relationship has been fraught with mutual suspicion. Over the last
decade there have been efforts to allay suspicions and create
opportunities for meaningful ^partnership.
The relationship between the two have been particularly stormy in
health and family planning. NGOs are not an undifferentiated mass while NGOs involved in family planning and population related
activities worked in close collaboration with the government,
women's organizations, NGOs involved in primary health care, human
rights groups, rural development agencies and the like made it a
point to publicly distance themselves from • the family planning
programme of the government. The main irritant was a target based
approach which gave primary importance to the realization of method
specific family planning targets. However, in the changed scenario,
where targets themselves have been abolished, the distance between
the two constituencies may be reduced.
Given new opportunities, it would be possible to delineate specific
areas of collaboration or partnership, namely:
**
Drawing upon micro level experiences in the non-government
sector with a view to adapt the generic lessons to national
programmes. Essentially this involves systematic efforts' to
forge linkages between micro level experiences and macro
policies and programmes of the government.
Government's
resolve to move
towards a holistic reproductive health
approach with an emphasis on quality of care has provided a
golden opportunity to forge such linkages;
**
Gi\ven "hands on" experience of voluntary organizations, the
government could draw upon them to participate in planning,
design and monitoring national programmes and adapting them to
different regions. In this context the key issue is how NGOs
can be strategically located in government programmes, keeping
in mind the comparative advantage and specific expertise of
voluntary groups.
**
Recognizing that the entire weight of all service delivery
programmes fall on the shoulders of the extension worker (ANMs
for example). Ensuring a good working relationship between the
community and service providers is a difficult task. NGOs
could be involved in building such bridges and help develop
support systems for field level functionaries.
Implications of going target-free:
Mr S Ramasundaram outlined the new initiatives taken by GOI and the
implications of declaring the health and family welfare programme
"target-free". It was acknowledged that the entire system cannot
change overnight and that transition from a target, oriented
programme to one based on holistic health and quality of life
indicators will be painful. Drawing upon the experience of Tamil
Nadu, he emphasizes the critical role of ANMs in reorientation of
the family;welfare programme. Though their capacities are vastly
overstretched, ANMs are probably the only category of personnel who
can still be counted on to deliver some services. There is a trend
(in Tamil Nadu) towards reducing the numbers of male workers for
various reasons (costs, unionization, indiscipline, less scope of
work) . Non-health departments which had ruthlessly pursued the
objective of sterilization targets were no longer called upon to do
so as a result of reforms in 1991-92, and it was noted that in
spite of this, population growth rate did not accelerate.
The
reasons ■'for this are attributed to the role of ANMs in advocating
total health programmes for women and children rather than focusing
on birth control alone.
The Government's 15 point programme of 1993 gave a further impetus
to MCH and FW services relying on ANMs to deliver these services.
At the same time, the Child Survival and Safe Motherhood (CSSM)
programme was being introduced in batches in districts. The focus
was on additional training of ANMs in order to enable them to
deliver the full range of MCH and FW services. It was realized that
ANMs have to be treated as key members of the health delivery team
rather than as subordinate extension staff. ANMs came up with
innovative ideas such as the suggestion to abolish the motivator
certificate and motivator fee. In the absence of the motivator
certificate, the ANM was given credit if the acceptor's address
fell within the ANMs jurisdiction. This procedure also ensured that
there was no competition among the ANMs themselves.
Year end statistics for 1994-95 revealed that for the first time in
nearly'thirty years, Tamil Nadu achieved the GOI target in all the
four contraceptive methods. Nearly
three crore rupees were saved
in TA and motivator fees. Above all, the ANMs showed that they were
the most important people in the implementation of the FW programme
and not the staff of other departments, not even the male staff of
the health department.
The discussion centered around how the basic approach and the mind
set can be changed. While there is a recognition of the need for
change at the policy level, the mind-set across the country is
still dominated by a population control strategy. Unless we bring
about a change in the perspective of service providers down the
line, health administrators and others involved with health and
family welfare - new indicators and goals will have little meaning.
A new list of monitoring indicators or the notion of selfdetermined "targets" will continue to be perceived as in the old
way.
There
is
also
a
danger
of
the
programme
becoming
"responsibility-free".
The
importance
of
locating
the
new
indicators in the context of the paradigm was emphasized. This
session concluded with the question whether NGOs can play a
strategic role in actualizing a paradigm shift.
Forging
inter-linkages
between
primary
health
motherhood, family welfare and reproductive health:
care.
safe
This session focused on tracing the evolution of health programme
of select organizations with a view to look at inter-sectoral
linkages. CINI, a group working in West Bengal started working with
children in 1974. Initially services were provided through out
patient
clinics,
gradually by 1980
they started
'under-five
clinics' in urban slums and in rural areas. This led them to
initiating training with a view to strengthen preventive and
promotive health and some curative services through semi-literate
health workers. Training of semi-literate workers involved them in
literacy and income generation programmes, organizing meeting of
Mahila Mandals and finally this led them to look at women's health,
contraception and now reproductive health. Intensive training of
village dias was a logical outcome. Now CINI is involved in
integrated health services for women and children, literacy and
income generation activities, awareness and confidence building of
women and service providers. The Mahila Mandals are the nodal point
where awareness,
literacy, health services, contraception, and
economic activities converge.
In the initial phase almost all
curative health service were provided by qualified doctors. Now
almost all services are provided by community based health care
workers who are supported by qualified doctors.
The experience of SEWA Rural, Jhagadia which had been managing a
Primary Health Centre since 1989 brings out the difficulties in
balancing good quality health care, ability to respond to needs of
the community through innovations and the pressure to meet targets.
They we're able to strike a balance between seemingly irreconcilable
objectives by adopting a spirit of comprehensive care, inter
linking various vertical programmes and focusing on quality of
care. People's needs were taken as the point of departure and
conscious effort made to keep curative services on the same level
as
preventive
health
care,
including
addressing
water
and
sanitation issues. Health workers are involved in setting their own
targets
(including FP)
followed by reflection on achievement,
analysis of strengths and shortfalls - all within a quality
framework. One of the innovative methods adopted by SEWA Rural is
to functionally integrate the PHC and the ICDS programme - with one
complimenting the other. For example, a common supervisor takes
care of all health and ICDS programme in a geographically distinct,
but smaller area. The aanganwadi worker, who is always present in
the village, weighs the new born, promotes breast feeding and
assists the family in proper care in the first few days. Male
multipurpose workers also play a crucial role in MCH. Maintaining
motivation levels and team spirit is the key for effective
cooperation between workers of different programmes.
Sahayog a small group working in the hills of Uttar Pradesh shared
their experience of working in a difficult terrain where the
existing
primary
health
care
system
of
the
government
is
practically dysfunctional. The presentation focused on women's
heavy workload, its impact on their health and general nutritional
status of women and the need to ensure government primary health
care system starts working. The basic issue in this region is the
reluctance of doctors and other service providers to work in a
difficult terrain, especially if they are not recruited from the
hills.
The position, skills, motivation, empowerment and back-up system of
the ANN emerged as key issues. Any effort to forge inter-linkages
would have to start by enabling the service providers to coordinate
with each other and acquire the necessary confidence to work in a
more holistic manner. A four-fold approach adopted in Andhra
Pradesh provided
a
good
analytical
framework
to
steer
the
discussion into empowerment of women., namely:
Step one
Changing mind-set - prioritizing issues in population and
development,
sensitization
of
policy
makers,
administrators,
service
providers
and
technical
professional.
Step two
Strengthening knowledge and skills of service providers
and
technical
support
professionals,
enhancing
communication and organizational skills;
St three
Creating mechanisms for mobilization of the community harnessing support of the community,
improving the
credibility of government services and service providers
and forging networks in the community;
Step four Departmental support and motivation - change in attitude
of supervisors, guidance for workers at all levels,
building
accountability
systems
and
transparent
monitoring system with agreed set of indicators.
Empowering women to access services and making services responsive
to women's needs:
The Tamil Nadu's experience reinforces the critical role of ANMs in
a target-free programme and had brought the issue of empowerment of
service' providers
(especially women)
to the fore.
While the
empowerment of women in general is important, in this case the
empowerment of ANMs emerged as a key variable in reorienting the
family welfare programme in Tamil Nadu. Over the past two years in
Tamil Nadu, ANMs have become more aware of their rights. They now
fix their own targets for each of the MCH and FW activities. Their
commitment to their work and the resultant successes are the
outcome
of
a
continuing
dialogue
between
them
and
other
functionaries. However, empowerment of ANMs alone is not enough,
concrete steps need to be taken to empower women in general.
Several
factors
need
to
be
considered
in
the
issue
of
women's
empowerment starting with woman's recognition of her fertility
status as a source of her own power, her freedom to choose her own
sexual partner, control over her own body, access to information
and resources, and participation in decision making. Empowerment of
women does not imply the 'disempowerment' of men, it really is
ability of and space for women to dialogue with men, the power to
negotiate and articulate their demand.
SEWA, Ahmedabad and SARATHI, Panchmahals and Baroda shared their
experience of working with women and empowering them to articulate
their health problems and gain access to services. Dr Prakashamma's
presentation in
the earlier session gave
a good analytical
framework, i.e, looking at women in a holistic manner and not
confining attention to a specific period in her life (girl child,
adolescent, mother, middle-age and old). From the adolescent stage
to menopause her requirement for reproductive health services,
maternal and child health services and interventions to ensure
motherhood is safe may be an intensive period. This should not get
precedence over other aspects of a women's life.
SAARTHI - a voluntary organization working in Panchmahals District
of Gujarat outlined their strategy and shared their experience.
What does empowerment really mean in the area of women's health?
In order to work in a gender sensitive manner the first step is to
develop
the
confidence
and
self-esteem of
ANMs
the
key
functionary in rural areas. Their ability to identify with women as
women
provided
an
excellent
starting
point.
SAARTHI's
has
simultaneously focused attention on women as service providers and
recipients.
The common point being their identity as women.
SAARTHI' s approach is to "start with the self". They look at
empowerment at four different levels, namely:
Intrapersonal empowerment
Interpersonal empowerment
Empowerment as a group
Empowering the community
Building self-confidence, shedding
of "sharam" or in other words a
sense of shame associated with one's
body,
owning one's own body and
ability to articulate ones needs;
Increasing
control
within
relationships. Women's control over
their bodies critically hinge on
their ability to negotiate within
relationships.
Appropriating and accessing health
services that rightfully belong them
as a group;
Organizing, demanding and receiving
health care,
dealing with issues
which
are
health
related,
e.g.
violence.
Focus group discussions provide the basis for building rapport and
also identifying needs. In many focus group discussions ANMs could
not answer several technical questions that were raised. They made
a list of issues on which they wanted technical training. At first,
SAARTHI thought of calling a clinician to provide training.
However, on reconsideration, they adopted another approach. Each
ANN was asked to pick one topic. She then went to libraries, to
doctors and accessed other sources. They got together again and
shared the knowledged with their colleagues. This process de
mystified the learning process and empowered them.
Drawing upon their field experience, empowerment for SEWA meant the
process whereby each group articulates its needs and determines
priorities. The first step towards empowerment is women coming
together in groups at different. As members of a group women are
able to exert pressure on the public health system. Women's
empowerment therefore leads to enhanced ability to initiate action
at individual and collective levels; and gaining greater control
over decision making processes, over households and community
resources. Women's groups have tremendous potential - they can
monitor programmes, manage health-care and .child-care cooperatives
and set priorities for action.
In
the
discussions
that
followed
focused on
formation
and
sustainability of women's groups, building rapport between women's
groups
and
service
providers
in
a
mutually
strengthening
relationship and bringing violence against women centre-stage in
reproductive health'programmes . National programme for reproductive
health should draw upon the experience of NGOs - in particular
their experience of empowering the ANMs and enhancing her skill and
motivation.
In this context,
the importance of revamping the
training programme for ANN was identified as an important area for
action in the immediate future. This assumes a sense of urgency in
the
light
of
the
Panchayati
Raj
Act
and
devolution
of
administrative powers to the Panchayats.
Convergence of different social sector (health, education etc) and
economic programmes happens at the village level with women's
groups functioning as the nodal point for articulating demand and
accessing services. Experience of many micro-level programmes have
demonstrated that when women do come together as a group, they do
not confine their interest to any one area or issue. Groups that
come together for credit and savings articulate health issues and
vice-versa.
The main challenge is one of bringing women together as a group and
sustaining that group identity over a period of time. Women may not
always come together for health alone, however they may readily
come together around another issue which may be perceived by them
as being of prime importance. Some groups take little time to get
off the ground while others take over a year or two.
It is
therefore important to recognize the existence of such differences
and plan for it. The government could draw upon lessons from the
NGO sector in organizing and sustaining women's groups.
8
Involvement of Men and Male Responsibility
CINI and URMUL trust shared their experience involving men in
health programmes. As their efforts have been rather recent, they
decided to conduct focus group discussions.
Some startling issues emerged in focus group discussions,
namely:
Most men felt that women consulted other women on their health
problems and there was no real need for men's involvement,
except when a case involved hospitalization;
The local dai
(midwife) was competent to handle most problems;
Pregnant women need care,
good nutrition etc.;
Birth control devices should be adopted by women because the
men have to do the hard work. Operations will weaken men.
Women do not need much energy for household work;
Early marriage was necessary because it provided security for
the girls,
it reduced expenses for the parents and was
socially acceptable;
Men had little role in participating in women's health
problems but they were willing to be educated and to be
trained so that they could educate other men.
Full consent of family for abortion. Most of them did not seem
td be aware of complications following abortions;
Reluctance to talk about STDs and AIDS and reproductive health
problems of men.
During discussions it emerged that most groups have not really
worked with men on health issues - either in involving them in MCH
or in addressing the latent fears about contraception, vigour and
strength.
This
areas
has
been neglected
and demand urgent
attention. There is a need to discuss male vulnerability and their
own fears, and for males to come to terms with their own sexuality
right from childhood. It is important to find out how men think and
feel about their own sexuality. Just as with women there should be
"know your own body" sessions with men and adolescent boys.
In poor families men also get up early and perform the domestic
chores - especially when men and women have to go for wage labour.
The experience of 1SEWA was interesting. Men showed interest in
reproductive health and were willing to undergo training. Fora for
men to come together and discuss their problems was welcomed. In
joint discussions with women, men get defensive about themselves.
At meetings held by the Medico Friends Centre men have an
opportunity
co
discuss
themselves
in
a
spontaneous
manner.
9
Generally it is felt gender sensitization can become a mechanical
exercise if men themselves are not given the space to freely
present their own point of view.
Wrap-up:
One of the major aspects in NGO functioning is the flexibility they
exhibit in working with people and their ability to respond to the
needs as and when they emerge. This is absent in government
programmes. While the need for government to work in departments is
appreciated,
there is still a lot of room effective inter
departmental coordination. This is possible at the field level
where all programmes converge. A community fund at the disposal of
the Mahila Mandal could enable the community to plan for and
implement specific inputs for example a fund to transport
critically ill people to hospitals (especially women and children),
to pay for a school-mother to escort girls to middle school outside
the village,
build water harvesting system or provide
safe
sanitation etc.
The specific problems of each area would require region specific
strategies. For example health extension work in Uttarakhand would
differ from the harsh terrain of Bundelkhand in Uttar Prade'sh.
National
programmes
should
be
designed
for
region
specific
adaptation.
Some concerns expressed by the group:
Are we overloading the health worker (ANM) without planning to
strengthening and encouraging them, enhancing their selfconfidence and their skills and above all empowering them in
a system where they are the most disempowered functionary?
How do we ensure simplification of the multitude of forms that
she has to fill out?
If the government agrees to work towards district plans for
primary health care which includes reproductive health,
maternal and child health, family planning and safe motherhood
components - then NGOs can be involved at the planning stage
and also participate in ongoing implementation, monitoring and
training. Government could initiative this through district
level committees where people from different walks of life
could be involved - namely NGOs, medical practitioners, social
workers etc.
The training curriculum of ANM and other health workers needs
to be modified to integrate an empowerment approach.
10
Communicating the paradigm shift:
While alternative indicators are an essential prerequisite to
operationalise a paradigm shift in Health, Population and
Development it was felt that the new concept should be
communicated directly
to
all
levels
of
administration.
Guidelines and reporting formats cannot capture the conceptual
nuances and the rationale
for a paradigm shift.
If is
therefore important to work towards a time-bound plan to
disseminate knowledge and information about the paradigm
shift.
A well-knot and coordinated team could work around a time
bound plan. This team comprising of a few officials (including
young IAS probationers), social workers involved in the sector
(especially those who have been involved in the population
debate
over
the
last
three
years),
social
scientists,
researchers, good communicators etc. could work together and
develop a good workshop design. This group could break up into
teams of five and fan out to all the states.
Sirrfilar teams could be set up at the state level who would
prepare a plan for district and block level workshops. The
national team could work in coordination with the state team
after an intensive orientation workshop.
Health administrators, service providers, staff of training
and technical institutions, staff of specialized research
institutions etc would be oriented in three day workshops. The
main purpose of this workshop would be cover a wide range os
issues and enable health care providers, administrators and
support institutions to internalize the paradigm shift. The
issues covered in the workshops could include the following:
Develop an understanding of the complexities involved
■population and development, linkages between population,
poverty and development and analysis of India family
planning programme since the 1950s - its strengths and
weaknesses;
Understand and appreciate the importance of the paradigm
shift, its implication in day to day functioning of
health and family welfare programmes,
Understand and appreciate the new set of indicators;
clarify any doubts and modify indicators to suit regional
requirements;
What is reproductive
MCH/FP and CSSM.
Balancing
outreach
health,
and
how
quality
is
of
it
different
care
need
from
for
a
caring health delivery system;
How do you form a women's groups or a men's support
group? Improtance of a strong community group in a health
care programme
- even though the group may not be
exclusively preoccupied with health and family planning;
How
do
you
forge
inter-1 inkages
vertically implemented programmes;
between
different
How do you forge effective linkages between health care
and other social
sector programmes
like water and
sanitation;
The list of
region. •'
issues
could
be
expanded and modified
to
suit
each
Feedback on the GOT task force report on alternative indicators2:
We welcome the initiative MOHFW has taken to alter the prevailing
system, of method specific targets for family planning. We have
reviewed the report of the committee appointed to develop an
alternative system of indicators (submitted to MOHFW on 18 March,
1996).
Given
below
are
some
observations
and
comments
for
consideration:
Recommendations on emphasis on Reproductive Health in Appendix
1 and Table 2.
1.‘
This
should be a combined activity report of
the
subcenter team of M & F workers, and not an individual
worker's report.
The proposed alternative system carries heavy emphasis on
MCH and Family Planning, reflecting few of the elements
'considered essential for operationalizing a comprehensive
Reproductive Health approach.
We would like to see
included references to essential reproductive health
services as follows:
In Appendix 1 (ANM activity report), item 26 (number of
cases)
RCH INDICATORS - RTI's referred, STDs referred, STD/RTI
numbers counselled for partner treatment and behaviour,
infertility cases referred, abortion / MTP cases referred
and followed up, septic abortions referred and followed
up,
Hysterotomies cases reported,
long-term women's
problems referred
(prolapse, post-menopausal bleeding
See
Annexure
indicators.
for
specific
recommendations
on
Delete some items or: MCH if there is a constraint
space for accommodating item on RH described above.
Suggestions
for further simplification,
and/or rationalization are in Annexure I.
II
Recommendations
(Appendix 2)
on
the
supervisor's
of
modification
monitoring
system
The supervisor may assess some aspects of technical
quality in discussion with clients (for eg treatment of
IUD complications etc.)
Technical assessment therefore
need not be limited to observation of worker-client
interaction.
The system should also reflect the RH approach.
Part 2
of the checklist should not be limited to just "Eligible
Couples" (married women between the age group 15-45), as
other women have a variety of reproductive health needs,
as do men.
It is suggested that 7 women and 3 men be
met, who represent persons with other RH problems also.
iii)
‘
Ill
In Part 3 of the Supervisory checklist, there is need to
include an item to assess whether clients have been
checked for anaemia.
It is suggested that item 13
(advised for contraception) be deleted.
The checklist
needs to more accurately reflect the RH approach.
Thus,
items such as observing communication and counselling
skills,
group meeting facilitation skills,
conscious
efforts to include men, etc. need to be assessed.
Recommendations on Family Reproductive Health Record (Appendix
3a)
In addition to RTIs and STDs include abortion, operations
(hysterectomies
&
others),
infertility
etc.
Disease
surveillance should include problems which affect reproductive
health - example: anaemia (it is important to monitor this
among adolescent girls), TB, malaria, menstrual disorders,
uterine problems and effect of violence on health.
There should be a note before the surveillance section which
clearly states that men's and adolescents histories are very
important and should be recorded consciously
IV
Recommendations
on
Assessment
Satisfaction (Appendix 4b)
of
Quality
and
Client
We find this survey to be quite cursory.
We would suggest a
more comprehensive survey to assess, namely:
i)
ii)
iii)
client satisfaction and provider (communication, counselling etc.)
technical quality of services
(to
standards are being adhered to)
coverage of services
client
interaction
assess
if
medical
We believe that having a more comprehensive survey will reduce
the burden of data to be collected through service statistics.
The outline of such a survey needs to be developed in greater
detail at this stage itself.
Such a survey should be
organized periodically at the district level.
Recommendations for Indicators for Evaluation of Sub Centres
(Appendix 4)
i)
Add coverage and impact indicators such as anaemia in
adolescent girls; safe MTPs rate, infertility prevalence
rate.
We particularly suggest inclusion of infertility
as effective intervention in several areas (RTI, MTP etc)
will show up in reduced levels of infertility.
We understand that formats are being developed for monitoring
male MPWs, and that a checklist is being developed that can be
used by lay persons, such as Panchayat members.
We welcome
these initiatives, particularly the latter.
We hope there
will be such a "non-medical" checklist for each tier of the
health system.
We look forward to receiving the survey format once it has
been developed in more detail, as well as the monitoring
formats for PHC, CHC, District Hospitals, etc.
We hope we will have the opportunity to review the revised
version of
the proposed alternative system when
it
is
available.
Annexure I
Suggestions for simplification, modification and/or rationalization
on Reproductive Health in Appendix 1 and Table 2
unwed
i)
Add to item 1
’ANC registration) :
pregnancies registered" (Qual)
ii)
Remove 5 (ANC completed 3 visits), 6 (ANC clinics conducted);
modify 7 as "ANC examined 3 or more times" (qual) - more
relevant
iii)
The criteria for referral for item no. 8 (Appendix 3a, 2nd
page, under head of "ANC Information") - need revision essentially in context of Safe Motherhood approach, where
every pregnant woman is at risk, and the most important
referral criteria are complications as and when they occur.
iv)
Modify
items
9b
untrained persons"
v)
Modify item 12: "Birth weights recorded within 1 week" (wts
recorded later than 1 week after birth should not be reported
as birth wt.)
vi)
Reduce Low Birth weight
instead of 2.5 kg)
vii)
Specify criteria for HR newborn referral
(item 14) :
(we
suggest only important criteria for this purpose: gestational
age less than 8 completed calendar months, or birth weight
less than 2 kg, or failure in breast feeding [either failure
in
establishing
breast
feeding,
or
later
reduction or
cessation of breast feeding])
thus:
(qual)
lb:
"Number
"Non-institutiorial
cut-off
to
2
kg.
of
Deliveries
(item
13,
2.0
by
kg
viii Add item: No. of PNC complications (a) referred (task) and (b)
getting institutional care (qual)
ix)
Add
item:
No.
of
live births
in which
established within 3 days of birth (qual)
x)
Modify items no. 8, 11, 14 and 19: the thrust should be on how
many women actually got institutional care (a parameter that
assesses whole system), instead of counting only "referrals".
We suggest, for a start, we count both, referrals as well as
those who got care (For example, 8a: Number of ANCs referred
[task],
8b: Number of ANCs getting care at institutions
[qual] )
xi)
Modify item 11 to Ila and 11b as above.
Plus add 11c:
of pregnancies terminated by unauthorized personnel”
breast
feeding
"Number
(qual) ■
specify "2 doses a year"
for Vitamin A.
Add item:
Number of newly married couples registered (task)
Number of such couples contacted at least 3 times (qual)
(Identifying young couples, and sensitizing them to aspects of
fertility, sexuality and related matters will be a critical
investment for the success of all RCH programmes)
Add item :
Number of couples with infertility referred (task)
Number of infertile couples receiving institutional care
(qual)
Item 23 of Table 2 and 26 of Appendix 1: As regards RTIs and
STDs referred, we suggest following modifications:
No.
of women with vaginal discharge treated
(Mostly
"non-serious"
conditions
like
trichomoniasis,
candidiasis and bacterial vaginosis, which can be clinically
managed by the ANM, within her current repertoire of drugs metronidazole and genital violet, even without necessarily
performing internal examination)
No. of men with urethral discharge (and their wives, who
are usually asymptomatic) referred.
'.this will "catch" most cases ot symptomatic "serious" STDs
like
gonorrhoea
and
chlamydia,
which
need
"higher"
antibiotics, and therefore to be seen by a doctor.
However,
with training, and provision of appropriate drugs to health
workers, even this can be managed by them using the syndromic
approach.
Obviously, this is a good example of where to
involve male health workers)
Add to item 23 of Table 2 and 27 of Appendix 1: (all these are
good examples of where close coordination with male worker
would be useful)
Number of cases of severe anemia treated
Men
Number of blood smears taken for malaria
Number of new TB detections
Number of TB cases completing treatment
Total number of patients (all conditions)
Men
Women
Under 5 children
16
treated
Modify/add co item 24
(Vital Events recorded)
thus
:
Pregnancy outcomes -.
♦
Live births (any gestation)
♦
Still births (after 28 weeks gestation)
♦
Abortions (before 28 weeks)
Spontaneous
MTPs
Induced
Neonatal Deaths
Total infant deaths (or post neonatal deaths)
Total U5 deaths (or 1-5 year child deaths)
Number of deaths of women of 15-45 years
Number of maternal deaths
Remove from Appendix 1 items 22
(IUDs discontinued) ,
23
(regular OCP users) and 24 (condom pieces distributed): These
are better monitored by an annual report from workers on
contraceptive prevalence. This may be determined by an annual
survey if need be.
Monthly reporting is of not much use. Add
along
with
above
indicators,
to be
reported
annually:
"Proportion of sex workers in the area using barrier methods"
(qual).
This will be an important determinant of STD/AIDS
control.
)
Add item to monitor number of women's group meetings held
and items discussed.
Agenda
I'tam Nu .X
DEPARTMENT OF FAMILY WELFARE
---------------------------------------------
(I
I'
L,8nARY
/
and
Agenda Item No- 1^OCumentat^
Gal C R'<^5
Target-Free Approach in Family Welfare Programme
1.0
During
1995-96,it was
decided
to
experiment
with
replacement of contraceptive targets in the States of Kerala,
Tamil Nadu, Union Territory of Chandigarh and 18 Districts in
major States. List of Districts at Appendix-I. Although no target
has been given for any of the contraceptive methods namely
sterilisation, IUD, OP users and CC users but information of
number of acceptors for each method is being collected frcm these
States/Districts. Apart from these, information regarding quality
improvement as a result of doing away with the targets is also
being collected frcm the Districts involved in target free
approach. Following is the information being, collected frcm these
districts:
Of the total acceptors of sterilisation, umber with 2
or
less than 2 children, number with 3 children and
with more than three children.
Of the total acceptors' of spacing methods,
number of couples with wife's age leSs than
30 .
Total
number
planned
and
held.
of
immunisation
number oj sessions
sessions
actually
Proportion of institutional deliveries and
deliveries by trained personnel in relation
to t h e|t o t a 1 estimated number of deliveries.
v.
Number
of
health
institutions
providing
MTP services and
the
number of women
treated
for
complications
following
unsafe
abortions.
Number
of
health
institutions
providing
emer-gency
obstetric
care.
vi
Number of
reported.
polio
and
neonatal
tetanus
cases
vii.
Number
of
planned
IEC
sessions
on
diarrhoeal diseases and ARI and actually held. Number
of pneumonia cases in children under 5 years of age
identified and
treated.
(Expe c t edjnurnber of
cases of
pheurnonia
can be
taken
to be
10
to 20
times
the
estimated number of/deaths which is roughly 25% of the
total deaths in children under 5 years of age).
An analysis of
the feed-back received
the
target
free
States
and
Districts
has
compiled which can be seen at Appenf(^x
II.
orn
been
2.0
On the 26th and. 27th October, 1 995 a two days
conference of CMOs/DHOs of
target free disttricts
was organised at New Delhi to review the qualitative
and
quantitative'
achievements
of
Family
Welfare
Programme
in
target-free
districts.
Following
recommendations were made
by
the
participants
in
the
conference
to
evolve
new
strategies
for
improving
the
quality
of
service
under
Family
Welfare Programme’.
(i)
th e
Supe rv ision
of Health workers on
rather than
basis of job functions ,
number of sterilisations , etc.
(i i )
Focus
of • the service on
and cl ien t satisfaction.
(iii)
Ensuring
availability
of
medical
and
paramedical personnel at the service faciliityqP
at thqtiate and time ‘ announced in advance.
health
s amp 1 e.
of
the
worke rs
through
checking of beneficiaries.
and
by
Medical
Officers
pre-announced time schedule.
Non-deployment
Development
of
health
need
client
villages
workers
of
prog rammes
Anganwadi Workers.
Close
of th
a nd
the
understand thei
2n t
timings
(ix)
Adoption
existing
transport fa
PHCs.
flexible
f r om
Improving
Ensuring
people
needs,
timings
the
thei
availability
medicines and
Development
mon itoring
of quality indicators
the
programme
at
I
3
Concurrent evaluation to assass client
(xiii)
and
It has been decided to extend the
Approach
throughout the
country in the
a system of decentralised planning.
0.0.
letter written
to the
States
by
Target Free
year 1996-97
through
The copies of three
Sec r a ta ry (FU ) ,
Government
outlining tne new approach is
herewith.
copy of
latter
dated 9-2-96.
(? )
copy of
letter
dated 27-3-96.
(3)
copy of
letter dated 3-4-96.
(1 )
perception
client satisfaction.
of
enclosed
India
9
P.O. No. M. I IO 15/ I5/94- E6I.
tqiRU trg qficfTT
PSITe'q
qprqK q;5*noi fq^rn
fanfa *iqH,
f^w)-l 10011
J. C. PANT i.a.s.
Secretary
GOVERNMENT OF INDIA
MINISTRY OF HEALTH & FAMILY WELFARE
DEPARTMENT OF FAMILY WELFARE
NIRMAN BHAVAN, NEW DELHI-110011
Phone : 301 84 32
Fax No. i 301 88 87
February 09, 1996.
Dear
Sub:- Target Free Approach in Family Welfare Programme.
Please refer to the discussions in the meeting of State Secretaries on 1-2 February,
1996 on the Issue of extending the Target Free Approach all over the country In 1996-97.
This could be converted to an excellent opportunity to make family welfare in India a truly
peoples' programme.
2.
As discussed in the Conference, grass-root wdrkers may get together to give an
esUmate oUikely acceptance of various family welfare activities in 1996-97 for every
quarter in their area of jurisdiction to form part of their PHC level Family Welfare and
Health Care (FWHC) Plan for 1996-97. The PHC family welfare and health care (FWHC)
plan should also contain the materials and supplies required to accomplish the activities
estimated by grass-root level workers as well as the non-governmental agencies, village
pradhans,_ primary school teachers In the area and population covered by that PHC. A draft
format for the PHC plan as is being used in Tamil Nadu was circulated in the meeting as
part of the Agenda Notes (copy enclosed). You may like to initiate this exercise of
involving the total health personnel, village pradhans, primary school teachers and NGOs
working In each Primary Health Centre In your State on the basis of this format or with
such modification in it as you deem necessary. A detailed format for preparing PHC FWHC
plan is under preparation at our level and could be made available before the end of
March, 1996. However, the preparation of your family welfare and health care (FWHC)
plan need not wait for this detailed format. The performance of each PHC would need to
be evaluated against their own plan by the district health and family welfare system at the
end of every quarter to advise them suitably. There would also be need to tune the IEC
activities in the PHC areas and the districts to promote this bottom up approach of
planning and implementation of a sensitive programme like family welfare.
3.
All the PHC family welfare plans would need to be aggregated into the District
Family Welfare Plans and the district family welfare plans would similarly need to be
aggregated into the State Family Welfare Plan. A time-table for preparation of the plans
at various levels may be set. I would suggest that the PHC plans may be finalised by 30lh
April, 1996, the district level plans by 15th May, 1996 and State level plans by 31st May,
1996. We would like to have your state level family welfare plan by the first week of
June, 1996.
-
2
-
■'
4.
A system of evaluating the performance of each district every quarter may be
worked out at the state level. A similar exercise to evaluate the performance of each
state would be carried out at the national level. This exercise would need sensitisation of
the entire health and family welfare organisation in the state with the Deputy
Commissioners/District Magistrates playing a leading role to activise the district health and
family welfare system in active collaboration with panchayati raj dignitaries, primary
school teachers and active non-governmental agencies.
Yours sincerely,
( J.C. PANT )
P.O. No. M.l 1015/15/9'1-E&l.
fcUFUT rig qfrq[<
qftcjr< EEsznui famn
fanfa *r<h,
fifSwY-l 10011
J. C. PANT i.a.s.
Secretary
GOVERNMENT OF INDIA
MINISTRY OF HEALTH & FAMILY WELFARE
DEPARTMENT OF FAMILY WELFARE
NIRM'AN BHAVAN, NEW DELHI-110011
Phone : 301 84 32
Fax No. / 301 88 87
March 27, 1996.
Dear
Sub:- Target Free Approach in Family Welfare Programme with effect from 1st April,
1996.
In continuation of my earlier letter of even number dated 9th February, 1996, I
sincerely hope that you must have taken all necessary steps and done the preparatory
work for implementation of the Family Welfare Programme in your state with effect from
1st April, 1996 on a Target Free basis.
2.
A two-day workshop was held in New Delhi on the subject of Development of
Quality Indicators to monitor Family Welfare Programme under Target Free Approach. Lot
of action points had emerged after the two day deliberations. I am enclosing a copy of the
Guidelines based on the Action Points which emerged along with a copy of the Format for
preparation of PHC level Family Welfare and Health Care Plan for further necessary action
at your end. Detailed guidelines relating to quality indicators, format for periodical reports
and monitoring system are being prepared and would be sent to you shortly.
Yours sincerely,
( J.C. PANT )
_
Objective
()
______ ...
ivi
i icpiaiiuon
I
The objective of the plan may be slated in terms of improvement in the coverage and
acceptance of various health & family welfare services provided through the Primary Health
Centre and the Sub-Centres under the PHC.
Strategies
The strategies to be adopted may be expressed in terms of
improving availability of the medical and para-medical personnel at (he 1’1 IC/Sub-Cenlrc
i.
al the limings indicated in advance.
ii.
iii.
maintaining the premises clean and hygienic.
organising meetings with Panchayal members, Primary School teachers, women's groups,
youth clubs, anganwadi workers, ex-servicemen etc. to prepare the plan and to spread
health and family planning messages.
iv.
slocking adequate quantity of medicines and supplies in advance.
v.
raising local resources to supplement (he support given by the Government to augment
the supply of medicines, etc.
yi.
organising Swaslhya Melas with (he help of community support.
vii.
utilisation of local NGOs and private practitioners including ISM&H in preventive and
promotive health education and distribution of oral pills and condoms.
etc.
Organisation of Services
The expected need for various services should be first assessed in the beginning of the
year and indicated in the format. The places where these services will be made available should
also be indicated in the plan - along with the days on which such services will be available, for
instance in the case of stcrilsation, days on which sterilisation will be done in the PHC may be
indicated. Similarly, days of immunisation sessions in various sub-ccntrcs/villagcs may be
indicated in the Plan, keeping in view the PPI posts also.
The timings of OPD, special sessions for counselling for family planning, limings for
follow-up of contraceptive acceptors etc. may also be clearly indicated in the Plan.
Local-specific IEC activities .should be a vital component of 1’11C Plan. 'I he is pc ol IIX'
activities to be organised may be finalised in consultation with the community leaders tint! till the
activities proposed for the year should be included in the Plan.
Review of implementation of Plan
The system of reviewing implementation may be specified in the Plan.
Such icview
could be done through monthly meetings of the staff. as well as with members of (he village
panehayals of the Pl IC area etc. every quarter.
A formiTl lor listing the activities Io be planned is attached.
ITIC FAMILY WELFARE & HEALTH CARE PLA’T.
1. GENERAL
1 .1
Slate
1.2
District
1.5
Population of Pl IC
1.3
P11C
1.6
Eligible couples
on 1st April
PERFORMANCE & EXPECTED DEMAND
2.
SERVICE
(1)
2.1
FAMILY WELFARE
2.1.1
Male Sterilisation
2.1.2
Female Sterilisation
2.1.3
IUD Insertion
2.1.4
Oral Pill Users
2.1.5
Nirodli Users
2.1.6
Follow-up Sessions
PERFORMANCE
LEVEL
IN LAST YEAR
1.4.95-31.3.96
(2)
EXPECTED NEED
IN NEXT YEAR AS
COMPILED FROM SUB
CENTRE AC TION PLAN
(3)
2.2
MOTHER CARE
2.2.1
Ante-Natal Care
2.2.1.1
ANC cases legistercd
2.2.1.2
ANC cases with three
contacts
2.2.1.3
Detection & treatment of
anaemic mothers
2.2.1.4
TT to AN mothers (T'otal)
2.2.1.4.1
TT( 1)
2.2.1.4.2
TT(2) / Booster
2.2.1.5
Detection & referral of
high risk mothers
2.2.2
Natal Care
2.2.2.1
Deliveries in 1’11C &Subccnlrcs
2.2.2.2
Domiciliary deliveries
conducted
2.2.2.2.I
by I.I1V/ANM
2.2.2.2.2
by Trained dai
2.2.2.2.3
by Untrained dai
2.2.2.2.4
by others
2.2.2.3
1 ligh risk cases referred
2.2.3
Post-Natal Care
2.2.3.1
Biilh weight recording ol
new born live birth
2.2.3.2
1 Ivtection ami icferral ol
high risk new born
1
l2,
I
___________ (3)
-
___«_____L
2.3
IMMUNISATION
2.3.1
B.C.G.
2.3.2
O.P.V.
2.3.2.1
Ol’V routine
2.3.2.2
Ol’V for 1’1’1
2.3.3
D.I’.T. (1,2.3)
2.3.4
Measles (after 9 months)
2.3.5
DPT (18 months)
2.3.6
Ol’V (18 months)
2.3.7
D.T .(5 years)
2.3.8
T.T. (10 years)
2.3.9
TT (16 years)
2.4
ANAEMIA & VIT.'A'
2.4.1
Anaemia treatment given
to
2.4.1.I
Pregnant women
2.4.1.2
Nursing mothers &
1HI) acceptors
2.4.1.2
Children below 3 years of
2.4.2
Vitamin A solution given
Io children 9 months to 3
(2)
1
(3)
Ik.
2.5
DIARRHOEAL DISEASES
2.5.1
Acute eases recorded
2.5.2
Cases treated with ORS
2.6
RESPIRATORY INFECTIONS
2.6.1
Pneumonia eases recorded
2.6.2
Cases treated with
Cotrimoxzole
2.6.3
Pneumonia cases referred
MATERIALS ZvNi) SUPPLIES
3.
ilcins
Slock
Position on
1st April
3.1
Contraceptives
3.i i
Nirodh
3.1.2
Oral fill
(cycles)
3.1.3
IUD's
3.1.4
Tubal Rings
3.2
Dai Kits
3 3
Vaccines (doses)
3.3.1
DPT
3.3.2
OPV
3.3.3
IT
3.3.4
BCG
3.3.5
Measles
3.3.6
DT
3.4
Prophylactics
3.4.1.
1FA Tablets
(large)
3.4.2
ll:A Tablets
(small)
3.4.3
Vit.'A' Sol.
(100 ml)
3.5
ORS
•Packets
3.6
Coirhnoxzole
.3.6.1
Tablets
(paediatric)
Additional quantity required in
1st Quarter
2nd Quarter
1
3rd Quarter
4 th Quarter
TOTAL
4.0 EQU1?MENT & FACILITIES
I OTA I,
AVAILABLE
4.1
Vehicle
4.2
Refrigerator
4.2.1
I LR
4.2.2
Cold Box
4.2.3
Deep Freezer
4.2.4
Vaccine Carrier
4.3
Xray Machine
4.4
IUD Kits
4.5
Examination
Table
4.6
Weighing Machine
4.6.1
Adult
4.6.2
Infant
4.7
BP Instrument
4.8
Needles
4.9
Syringes
4.10
AutoclaVc
4.1 1
Steam Steriliser Drums
4.12
O.T. Table
4.13
MTP Suction Apparatus
4.14
Equipment for Infant
Resuscitation
■
IN WORKING
ORDER
ADDITIONAL
REQUIREMENT
5.0
Information, Education and
Communication
5.1
Action taken Io mobilise
(a) The medical fraternity Allopathic,
Ayurvedic, Unani & Homeopaths
(b) The para medicals including Dais
(c) Primary School-Teachers
(d) Panchayat Members
(e) Ex-scrviccmcn (army & civil)
(D N.G.O. activities
(g) Anganwari worker
5.2
Counselling facilities at PIIC & Subcentre
5.3
Action taken to mobilise
(a) Village folk dances & singers
(b) Street plays
(c) Puppettiers
(d) Video films
(c) Radio
(f) Film shows
5.4
Urging Panchayat Members to prepare village
level family welfare & health care plans
6.0 VACANCY POSITION
Category
5.1
Sanctioned
Vacant
MO (Including Specialist)
5.2
Dental Surgeon
5.3
Staff Nurses
5.4
Pharmacisl/Compoundcr
5.5
Lab. Tcchnician/Lab. Asslt.
5.6
Radiographer
5.7
Com[jn ter
5.8
Driver
5.9
Para-medical supervisosrs
(Malaria Inspector, BEE,Pl IN,LI IV)
5.10
Mu11i-purposc worker
Male
Female
Male
Female
SUB-CENTRE ACTION PLAN
A. LLLNERzLL
Pl IC
Sub-centre
Population of Sub-cenlic
Name of ANM/
Female Health Worker
(rounded to nearest thousand)
B. SERYJLCJLS
■SI.
No.
Method of assessing demand of the area of .sub-centre
(1)
(2)
1.
A.N. Registration
MCII, Nutritional Counselling, &
Prophylaxis lor
Nutritional Anaemia
Pell need of the
population of the
sub-centre
Methodology
(Example of a state with birth rate of 20 &
5000 population per sub-ccntrc)
Annual
Month
norm
1996-97
(3)
(•1)
(5)
(6)
100%
20
Population X BR = 5000 X--------- = 100
1000
Add Itl'/r pregnancy wastage
10
110
2.
Early A.N. Registration
(i.e. within 16 weeks)
60% of the
AN Mother
60
no X --.........
100
=
66
Detection and referral of high risk 100% of the
pregnancies (15% of AN Mothers High Risk
will be high risk Mothers)
Mothers
15
110 X .............
100
=
16.7 =
Detection and Treatment of
Anaemic Mothers
50% of the
AN Mothers
50
lit) X .............
too
=
55
5.
T.T. AN Mothers
100% of AN
Registered
III)
6.
3 visits completed
AN Mothers
Minimum 3
visits to he
given.
CSSM Schedule of AN visits to be followed
institutional 1 Iclivciy
((ill i- PHC i IISC » I’NII)
25% of j,be
expected
delivery
25
100 z\ ............. =
100
Skilled attention al delivery
(Institution + Health Worker +
Trained Dai)
95% of the
expected
(howlli Monitoring ol the New
Botn 1 .ivc Biiills
95'3 of Im th
weight
recotding
3.
■1.
7.
X.
9.
17
1 10 mothcis to be completed with minimum ol
25
100 X ............. 100
95
100 X ............. ■:
l,5
2. \
10. Dclcehon and iclcnai of high risk 10% of the
new born
ivc births
10
: 1. Infant Immunisation
(BCO. DPT, OPV, Measles)
(DPI7OPV Hoosiers)
(I)T al 5 years)
100% of the.
infants
100
12. Vil. 'A' Solution lor the children
upto 5 years Io be given in
campaign twice a year
100% ol the
children upto
3 years
13. Diarrhoea eases healed with ORS 100% of
each child in () 5 years age group Episodes
20
5000
X.........- X 3 = 300
1000
20
5000
X........... X 5 X 2 - 1000
loot)
is likely (<> gel 2 episodes ol‘
diairhoea in a year
14. ARl/Pncumonia eases
(upto 5 years)
100%
15. P.P. Acceptance
Acceptance of (a) number of couples with 3 or more
contraception
children
by all eligible
(i) number already accepted a permanent
couples in the
method
area
(ii) number expected to accept a pet manent
method dm ing the year
Each child in 0-5 years is likely to get 2
episodes of ARI in a year. 10% of ARI eases
arc likely to be pneumonia eases
(b)
number of couples with 2'childicn
(i) number already accepted a permanent
method
(ii) number expected to accept a permanent
method
(iii)numbcr expected to continue with/
accept a spacing method
IUD
OP
Condom
(c)
number of couples with less than 2
children
(i) number expected to continue with/
accept a specing method
IUD
OP
Condom
c. jmiMTi
1.
2.
3.
4.
5.
6.
7.
8.
IUD Kit
Examination 'fable
Weighing Machine
BP Instrument
Delivery Kits
Steam Sterilisers
Syringes & Needles
Immunisation Cards
Available / Not Available
Available / Not Available
Available / Not Available
Available / Not Available
Available / Not Available
Available / Not Available
Available / Not Available
Available / Not Available
I)■ FACILITIES & HELP AVAILABLE TO SUB-CENTRE
I.
2.
3.
4.
5.
6.
Number of Trained Dais available
Number of Anganwadis working
Number of Voluntary ORS Depot functioning
Number of Private Medical Practitioners (MC11, ISM & 11)
Number of Primary School Teacher
Male
Female.
Number of Panchayal Members
Male
Female.
UJH - If S 3 .7-
Workshop on Population Issues and Women's Health : A New Approach
IIHFW, Hyderabad
List of participants
Name
Telephone No.
Fax No.
Dr. Gita Sen
Indian Institute of Management
Bannerghatta Road
Bangalore 560 076
080-6632450
6644050
Ms. Sandhya Rao
Parivar Seva Sanstha
2 and 2/1, AMM Towers
DN No.53, Hosur Road
Bangalore 560 027
080-2214270
t
080-2214270
Ms. Gangamma
Mahila Samakhya Karnataka
3308, 13th Main, 8th Cross
HAL II Stage
Bangalore 560 008
080-5277471
5262988
Ms. Subhadra Venkatappa
Family Planning Association of India
375, 1st Cross, 9th Main
Judges Colony, R T Nagar
Bangalore 560032
080-3434818
3338755
Ms. Neerajakshi
Voluntary Health Association of India
Rajani Nilaya, 60 R K Mutt Road
3rd Cross, Ulsoor, Bangalore 560 008
080-5546606
_______ Name________________________
Mr. Gurudatt Prasad
ACTION
Krishna^Sadajirf r*
Dr. Med Ranga Prasada Rao Gardens
Hukjmpet
Rajmundry 533103
_ Telephone No
Fax No
0883-614-42
Dr. V. Janardhan Rao
Health Director
WDT Hospital
Kalyandurg 515761
Anathpur
Ms. Mrud/la
State Programmer
Andhra Pradesh Mahila Samitha Society
Plot No. 8, Aparajitha Housing Colony
Vid^tdaya School Lane
Ameerpet
Hyderabad 500016, A.P.
Mrs. Sarah Kamala
Andhra Pradesh Academy of Rural Development
Govt of A.P.
Rajendra Nagar, Hyderabad 500 030
245337
245959
Mrs. Sushila Ramidamy
Academy for Nursing Studies
6-1-630/2A, Nagarjuna Nagar
Ameerpet,Hyderabad
241228
Mrs Vimala Ramachandran
XC-1 Sah Vikas,68 I.P. Extn
Delhi 110092
2432770
2432949
257005
Name
Telephone No
Mrs Prabheen Singh
A 10/3, Vasant Vihar
New Delhi 110054
6874320
Mr. Vinod
Community health Worker
53534
Janadaya, Konapurpet, Mauvi
Raichur, 584123, Karnataka
Mr. /Civaji
Sangamitra Service Society
Vijayawada 520007, A. P.
554002
554374
Mr. N. S. Chandrasekhar
Creator's Charitable Organization
78-8-4 Gandhipuram - 3
Rajamandry 533 103, A.P.
76710
Mrs J. Kausalya
Villages Jon Partnership
42058
Teacher's Colony
H-No 8-5-20B/1
Mahboobnagar, A.P.
Mrs N. Shanti
Mahila abhyudaya Seva Samstha
F-l, Shirdi Appartments, Rajabhavan road
Somajiguda, Hyderabad
3325630
Fax No
Name
Telephone No
Fax No
DR. M Antony David
Head-Dept, of Community Health
Catholic Health Association of India
P B 2126, Gunrock Enclave
Secunderabad 500003, A.P.
040-848293
848457
811982
S.P. Doss
Head-Dept, of Community Health
Catholic Health Association of India
P B 2126, Gunrock Enclave
Secunderabad 500003, A.P.
040-848293
848457
811982
Dr. Nandini Gandhi
President,
Family planning Association
Hyderabad.
Mr. B. Nageswara Rao
Sravanti Association
32-1-50 K V R Swamy Road
Rajahmundry 533101, A.P.
0883-61139
Mr. M. Subba Rao
Director
MASSES
Velayanandapuram
Gudur 524101, A.P.
Mr. C H Sundera Rao
President^
Nidubrolu 522124
Ponnur Mandal
Guntur Dist., A.P.
51206
.
Y\ ,
08624-51285
Name
Telephone No
Fax No
Mrs. Rachel Chatterjee
Andhra Pradesh
Dr. V . Rukmini Rao
Secretary, Deccan Development Society
A-6, Meera Apartments
Bashirbagh
Hyderabad 560 029
040-231260
232867
Dr. K. Rajashekhar
HERSELF Society
Shyam Nagar
Nandyal
Kurnool, A.P.
08514-44056
Mr. D Srinivasu
Regional Coordinator
AWARE
5-9-24/78 Lake Hill Road
Hyderabad 500463
040-236311
Mrs. Sumabala,
ASMITHA
House No.45, Road No.2
West Maredpally, Secunderabad. 500 026 A.P.
803745
G. Vijaya Lakshmi
ASMITHA
House No.45, Road No.2
West Maredpally, Secunderabad. 500 026 A.P.
803745
231260
_______ Name
Telephone No
1
r,
Fax No
Ms. Sucharita S Eashwar
Executive Director
VOICES
P B 4610, 59 Millers Road, Benson Town
Bangalore 560 046
080-5546564
563017
569261
Ms. Sangeeta Cavale
Programme Executive
VOICES
P B 4610, 59 Miller Road, Benson Town
Bangalore 560 046
080-5546564
563017
569261
20.
Mr. Azmathullah
Manager
VOICES
P B 4610, 59 Miller Road, Benson Town
Bangalore 560 046
080-5546564
563017
569261
21.
Ms. Suneeta Krishnan
SFA Alpine Court
2-B Cross, 7th Main
Koramangala 1st Block
Bangalore 560034
5538205
Ms. Gouri R
Mahila Samakhya Dist Implementation Unit
Sangamesh Building, Viveknagar
Near Ibrahimpur
Basavana Bagewadi Road
Bijapur 586 101
08352-22086
Dr. Dara Amar
Professor and Head Dept, ofCommunity Health
St. John’s Medical College
Bangalore 560034
5530724, Ext 413,
Ms. Mani Makalai
Institute of Social Studies Trust
‘Sreeshyla’, No.42, 4th Temple Street
15th Cross, Malleswaram
Bangalore 560003
3340315
■■
5531786
Name
Teiphone No
Fax No
Dr. J. C. Mahanty
IIHFW, Vengalraonagar
Hyedrabad.
3810416
3812816
Dr. M. Prakasamma
IIHFW, Vengalraonagar
Hyderabad.
Dr. V. Umadevi
IIHFW, Vengalrao nagar
Mr. T. Dass
Women's Devolopment Society
6-88-34/1
Boregaon, Nizamabad, A.P.
4!972
Dr. S Balavenkataiah
Kumool Dist Rural Devlopment Society
13, Raghunath Complex
Kallur, Kurnool, A.P.
26882
Mr. K. Sivakumar
MASS,Paddapalli
Karimnagar, A.P.
08452-64353
Mrs P. Jamuna
Gramya
1-16-79/3 Sainagar Colony
Alwal, Secunderabad
862007
A.
fe ^0
<^JLc'^Uv\
Name
Telephone No.
Dr. S P Tekur
Community Health Cell
367, 1st Main, 1st Block
J K Sandra
Bangalore 560 034
080-5531518
Dr. Pankaj Mehta
52, NGEF Layout, 1st Main Road
Sanjaynagar
080-3361615
3365948
080-3334896
Ms. K R Sreevidya
Institute of Social Studies Trust
Sreeshlya” No.42, 4th Temple Street
15th Cross, Malleswaram
Bangalore 560 003
080-3340315
080-3311764
Dr. Shobha Raghuram
HIVOS
India Regional Office
Flat No.402, Eden Park
20 Mittal Mallya Road
Bangalore 560 001
080-2210514
2270367
080-2270367
Ms. C S Veeramatha
Institute for Social and Economic Change
Population Research Centre
Nagarbhavi Post
Bangalore 560 072
080-3355519
Dr. Vijaylakshmi Hebbare
Indian Society of Health Administrator
104 (15/37), Cambridge Road Cross
Ulsoor, Bangalore 560 008
080-5574297
Fax No
Bangalore 560 094
*
Name
Telephone No
Dr. R Radha
Research Officer
State Family Welfare Bureau
Directorate of Health and Family
Welfare Services
Ananda Rao Circle
Bangalore 560 009
080-2870224
2870205
Dr. M Roopa
Consultant
Vivekananda Girijana Kalyana Kendra
B R Hills 571 441
Yelandur Taluk
Mysore Dist., Karnataka.
08224-8425
Ms. Dhanalakshmi
MYRADA
Post Box No.5
Challakere 577 522
Chitradurga Dist.
08195-2243
Sr. Maria Rose
‘Janodaya’
Good Shepherd Sisters
Manvi - 584 123
Raichur Dist., Karnataka.
08538-53534
Ms. Poornima
Health Coordinator
Samraksha
Jalahalli, Deodurg Taluk
Raichur 584 116, Karnataka
55223
56063
Ms. Emelda Rani
Family Planning Project Director
Hope Foundation BangaloreP B 3828
080-5588819
Fax No
080-2870224
5288819
INVOLVEMENT
OF
NGOs AND PEOPLE'S
ORGANISATION
HEALTH PROGRAMMES IN RURAL AREAS
(COMMON!1Y)
- GVVSDS
IN
PRASAD «
Health
is an important requirement of people and the country
is
aiming
at
achieving
health for all by 2000 AD.
The
task
of
providing health cover to people particularly in the rural
areas
was taken up by the government while the urban dwellers had other
options.
Health
services are provided through
Primary
Health
Centres (PHCs), sub-centres, Anganwadi centres etc.
The delivery
of these services is fraught with several problems including non
availability
of
medicines,
doctors
&
other
para
medical
personnel,
ameneties,
equipment and even
quality
of
services
rendered.
One of the main reasons for this is the whole set
tip
is
not accountable at least directly to people
with
consequent
apathy and non involvement.
This is more or less the same
story
with many programmes.
The need for making people responsible for these services and the
personnel
accountable to people was well recognised.
Effective
involvement
of
people in the programmes through
awareness
can
increase
the
efficacy of the programmes and
their
usefulness.
This link between people and the government personnel with direct
accountability is missing.
Andhra
Pradesh
has
a rich tradition of voluntary
work
and
a
number
of voluntary'organisations <Non-government
organisations
or NGOs) are working in the State.
They are primarily engaged in
organising
people - forming them into Mahila Mandals,
Sanghams,
Youth
Clubs
etc. These formations bring into
development
work
organised
communities which take up a number of activities
like
thrift & credit, income generation programmes etc.
This is
also
an
effort
to rebuild the village community which
is • destroyed
systematically in the development process to become crowds.
Any
development activity presupposes an organised community that
can
dynamically respond and absorb a programme.
In the absence of an
organised
community as a partner in development
programmes
the
success would be minimal.
The
experience of the NGOs and the peoples’
organisations
that
are
created including DWCRA groups, CBCS groups can be made
use
of for providing a more qualitative, reliable and people oriented
health programme particularly in the rural areas.
The
organised
community backed by an NGO will then take the responsibility for
the
health services in a geographical area with the
support
of
Sri Prasad is chairman, Vasavya Society for Rural
Development
(VASORD), 14, shilpa, Erramanjil, Somajiguda, Hyderabad 500
482. Ph: 226486
the
the
government.
This transfer of
community/NGO will enable the
responsibility and resources to
community to do the following:
7.
Health camps with expert doctors at regular
meet the special health needs of the area.
8.
Referral
problems.
9.
Documentation
of
health
priorities
health services.
TO.
service
with
hospitals
intervals
in Hyderabad
the
work and
experience
for the area and suitably
for
to
major
to
develop
modify
the
Suggestions
to
the government for any
policy
support,
programme support etc. based on the experience gained
by
the community, policy changes needed.
The task is comprehensive and an enabling atmosphere is
required
to
make
community health a reality.
Policy
support
from
the
government is necessary with a working mode1/arrangement for this
purpose.
An outline for this purpose is given below:
say a Mandal
cover.
to
the
1.
A
geographic
community
for
2.
This
community should have been functioning for
two
or
three
years
as a cohesive group
with
activities
like
thrift, credit, income gene/ation and community
oriented
programmes.
The
group
should have
been
involved
in
activities
on
health, education,
social
issues,
etc.
They must be having necessary systems, records and should
area,
health
is
entrusted
be functioning as an institution with democratic process.
In
essence,
the community should be able
to
own
the
programme
conceptualise,
plan
and
implement
the
programme with the support from the government and
other
sources.
Proven record of such initiatives indicates the
strength of the community.
3.
This
community should preferably be backed by an NGO
of
considerable
standing and reputation who is
willing
to
support
the community in shouldering the
responsibility
of health care.
4.
The
legal
holder
communi t y/NGO.
5.
All
the
resources,
manpower,
infrastructure
will
be
placed at the disposal of the community—for managing
the
prog ramme.
6.
In
case
of
staff, the
existing
persons
either
can
continue in the area under the administrative control
of
the
community
or
new staff can
be
appointed
by
the
community
for
this purpose from out of the
funds
made
available by the government.
7.
The
community/NGO
should
make
mobilising additional resources to
services and their quality.
8.
This
should be'a long-term commitment from
all
parties
concerned
though a pilot phase can also be
contemplated
for
better understanding of the problems that
might
be
encountered .
*?.
The
expected outcome should be defined in the
beginning
in
terms of FP adoption, immunisation status, number
of
patients
treated, number of safe deliveries in the
area
etc.
The
services should be an
improvement
over
the
earlier pattern.
for
this
programme
can
be
the
all
endeavours
for
strengthen the
health
between
out
the
A model
•10.
A memorandum of understanding < HOU) is desirable
the
community
and the government which spells
details of the arrangement and clarity of roles.
HOU is provided below:
■11.
The
present staff - medical and para medical
should
be
taken
into
confidence, discuss the programme
with
the
respective
associations
if
necessary
before
a
final
decision
is
taken.
This
approach
calls
for
a
new
orientation to those who work in this experiment as
they
will tie accountable to the community in which they
work.
This was not the case before.
12.
It
is desirable that in a given area the total staff
is
recruited
by the community/NGO for this purpose,
orient
and train them suitably and conduct the programme.
This
will
give an opportunity to the community/NGO
to
mould
.the personnel in the programme as per the requirements.
13.
Financial
autonomy
and
flow
should
be
ensured
with
sufficient
provisions
with a
flexible
approach.
The
funds
should be made available in advance to enable
the
programme
to be conducted smoothly.
Financial
problems
not
only disrupt the programme but will cause a
lasting
damage
to the community and the NGO which affects
their
reputation and other works in the area.
14.
Necessary financial systems, records shall be
maintained
by
the
community/NGO
for
the
amounts
received
with
necessary
transparency, accountability
and
efficiency.
Periodic
audit
of
the
finances,
monitoring
and
evaluation
of
the
programme should
be
undertaken
to
assess the impact of the programme.
This will enable the
community
to
reflect on the performance and
strive
to
improve in
future.
15.
Capacity building of the community and the NGO should
be
a
priority to ensure better results.
While
these
arehigh on commitment and enthusiasm, are low on procedures,
systems, financial management etc.
Imparting
managerial
skills
and methodology for systematic implementation
of
the programme will go a long way in improving the
health
status.
16.
The
very
existance of a large number of
NGOs
and
the
communities they have built is a positive factor to recon
with
an
appropriate strategy with
policy
support
for
utilising this vast potential is equally essential.
17.
It
should
not be that a programme is entrusted
by
the
government
to the community but it should be
undertaken
in partnership.
The atmosphere in which the programme is
implemented
plays a significant role in the
success
of
the
programme.
It
is not a contract
granted
to
the
community but joining the community in their
aspirations
for better health.
18.
Government can do much more than merely entrusting health
programme
and
the
resources
to
the
community.
The
support
in terms of information,
campaigns,
training,
access
to
institutions and
linkages.
Propagate
such
community based programmes which can gradually spread
in
the State.
19.
The
community
should be able
to
innovate
appropriate
approaches in realising the objective of health for
all.
It
should
be village based preventive
approach
rather
than merely a curative approach.
20.
It
is
necessary
to see the
health
programme
by
the
community in a larger context.
The community once it has
become
strong
enough
should be
entrusted
with
other
responsibilities
like
education,
sanitation,
rural
energy,
poverty alleviation and other
programmes.
The
role
played
by NGO then, will be a supportive
one
and
that
of the government, providing enablilng
atmosphere,
policy support, financial resources and other support.
21.
The
programme should aim at self reliance over a
period
of
time.
In that case, the strength of
the
programme
increases
much
beyond
the
support
extended
by
the
government.
For this and other purposes, the
community
should
generate
resources
through
income
generation
programmes, donations etc.
22.
The
services
-should
be
charged
for
to
ensure
sustainability.
While the poor get a cover with a family
card for a nominal payment, those who can afford will pay
full charges for the services.
This goes without
saying
that the services should be qualitative and competitive.
kJH -1^'3^
June 27, 1996
Draft
Review of Manual on Target Free Approach in Family Welfare
Programme, Ministry of Health and Family Welfare, May 1996
Almost since its inception in the mid-1960's,
the family
planning programme approach based on contraceptive method
specific targets, incentives and disincentives,
espoused until
recently by the government of India, has come in for criticism
from a broad
spectrum of social
actors.
The
principal
criticism has been that it is intrinsically distortionary of
the health and welfare goals of the programme. There is ample
direct evidence of these distortionary effects from the field
in many parts of the country. The casualty in this has been
women's access to health care,
the quality of the family
planning services provided through the public system, and the
morale of the department's personnel.
A change in programme direction has been long overdue. When
the Ministry of Health and Family Welfare (MOHFW) announced in
April
1995 that each state could experiment with one or two
target—free districts, and when this was extended in April
1996 to make the entire country free of targets,
this was
greeted by many health activists as a positive step. But how
to move a programme that has been dependent on targets for
almost' 30 years, and make it refocus its priorities towards
meeting people's (and especially women's) reproductive health
needs through quality services? A major
concern of the
ministry’s has been
to devise alternative indicators to
evaluate the performance of field staff once targets are gone.
Some
programme managers are nervous
that the fertility
transition that is under way in the country will stall if
field level staff are not under the pressure of targets.1
The Manual under review here is a detailed attempt to spell
out procedures for planning,
monitoring
and evaluation of
field
level work
in
the target-free era,
and to devise
alternative performance indicators for field-level personnel
from
the auxi1iary—nurse—midwife on upwards.
This review
examines the following:
the Manual's general
approach,
the
adequacy of its conception of reproductive health and quality
of care, its approach to the role and empowerment of women,
and the specific
procedures for planning,
monitoring and
evaluation of programmes.
1
"While there are no two opinions about the need to
remove numerical targets for the sake of quality of service,
there is a concern that such a move, when
taken country-wide,
may lead to decline in performance initially." (Manual, p 1).
General Approach
The Foreword to the Manual states clearly that,
"From now
onwards the centrally determined targets will no longer be the
driving force behind
the programme.
The demand of
the
community for quality services would be expected to become the
driving force behind the programme making
it a people's
programme." To what extent does the rest of the Manual live up
to the expectations generated by the Foreword? The picture is
mixed.
Strengths
On the
positive side,
the Manual
.is clear
that the
prerequisites for the
target-free approach
(p 9)
should
include the withdrawal of motivator certificates and
fees,
that targets be abolished for both non-health and health
staff,
that district collectors should not be evaluated on the
basis of FP performance. Further,
and perhaps for the first
time, it emphasizes needs assessment as a prerequisite both
for planning at the PHC and sub—centre
level,
and
for
evaluation of staff. This needs assessment is to be done in
consultation with a number of
local
level
functionaries
including panchayat pradhans and anganwadi workers (p 12).
An
additional
positive
feature throughout the
Manual
is a
stronger emphasis on maternal health than has been the case
till now.
Weaknesses
But there are also some flaws that weaken the
general
approach.
While the Foreword to the Manual
emphasizes the
importance of decentralizing and improving programme quality,
the Introduction that follows (and sets the tone for the rest
of the Manual) justifies the target-free approach mainly in
terms of efficient reduction of the birth rate.
Unlike the
Training Guidelines also recently issued by MOHFW, the Manual
Joes not clearly acknowledge the programme's past weaknesses
in meeting women's health needs, but focusses on its weakness
in being able to reduce the birth rate.
But without a clear assessment of why the programme was unable
to n >et women's health needs in
the
past,
the primary
justification for the shift to the reproductive health and
rights approach is
left unstated. Whether this ambivalence in
approach emphasizing decentralization
and quality
of
services on the one hand,and marginalizing women's involvement
on the other - reflects uncertainty at very high levels in
MOHFW is unclear.
But/the result is a Manual that gives no
role to local women in planning,
monitoring or evaluation at
the local level.
Unless this flaw is set right, the Programme
once again runs the danger of going off
at a tangent to
women's health.
Reproductive health and Quality of Services
The new integrated
reproductive and child health
(RCH)
approach is
defined
(p
3)
to
include FP
+ CSSM
+
RTIs/STDs/AIDS + a client-centred approach.
Strengths
Reproductive morbidity and servi< :e quality are included in the
definition of RCH.
There is a stronger emphasis on maternal
an emergency care) in the
health
(ante-natal,
post-natal
procedures laid down, and more importance to making abortion
safe and accessible.
Weaknesses
The RCH definition is too narrow,
and the implications of
reproductive morbidity for the kind of health or FP services
provided is unevenly spelled out.
First, although it may be
legitimate to start with a definition of RCH that is primarily
MCH focussed, this can surely only be a starting point. It is
well known that a significant proportion of maternal mortality
is caused by the effects of anaemia and poor nutrition carried
over
from young ages (itself a result of both poverty and
gender bias).
Women's reproductive
morbidity is
closely
associated with gender biases and male sexual behaviour,
and
carries over
into
post-menopausal .years
as well.
The
definition of RCH must include the health of young girls and
older women, and programmes for men. Problems of irregular and
post-menopausal
bleeding,
prolapse,
infertility,
cervical
cancer,
and a range of
long-term problems
need to be
addressed.
If this is to be done in a phased manner, the
phasing needs to be clearly specified.
The treatment of RTI's in the Manual is uneven. Ideally RTIs
/STDs should be discussed in terms of prevention and cure /
management, in relation to family planning services, in the
context of maternal and infant care,
and in relation to HIV
prevention. Each of these is a complex issue with implications
for how services are provided, and for the training of health
providers. These linkages are missing in the report.
The illustrative list of services to be provided at sub
centres and PHCs
(pp 3-5) does not mention RTIs. Neither does
the data base required for preparation of the PHC plan (pp 1415),
or the PHC plan itself (Form 3). Without these, it is not
clear how counselling for RTI/STD at the subcentre level
and
referral of cases from the subcentre to the CHC can be an
"expected outcome of
the programme"
(p 11).
RTI/STD and
infertility referral
have been included in the ANM activity
form
(Forms 1 & 4) in response to comments on an earlier
draft, but this has not been properly integrated into the body
of the Manual or into the training requirements. RTI treatment
is included in the checklist for MOs, but clearly not at lower
levels. The monthly fax report to be sent to GDI will include
FP methods information, child immunization,
tetanus toxoid
doses given, and MTP, vitamin A and ORS.
The R in RCH seems
practically to disappear here.'
Empowering women
Weaknesses
As mentioned earlier, there is no role envisaged for
local
women in planning,
monitoring or evaluating the programme,
even though the Manual spells out the need for ANMs to work
closely with anganwadi' workers arid TBAs,
and to consult
panchayat memb s, local medical practitioners etc. This is a
serious flaw in the approach for two reasons. On the one hand,
it once again marginalizes the most important stakeholders of
the programme. Who is likely to have better knowledge and
awareness of their health needs, and of how well or poorly the
programme is working than women themselves? Many of the best
experiences (governmental and non—governmental) in providing
health services have worked because those served have played a
central
role in planning the programmes.
Furthermore, given
the prevalence of.gender bias in communities and among service
personnel,
women's health all too often gets short shrift
unless women themselves have a central role.
A second reason why the approach is flawed has to do with the
monitoring and evaluation requirements of the new programme.
If women's groups could
be centrally involved,
top-down
monitoring and evaluation becomes
less necessary.
In the
absence of such
stakeholder involvement,
the alternative
monitoring system suggested by the Manual
is cumbersome and
complex.
Procedures for planning, monitoring°and evaluation
Planning
The PHC will prepare both subcentre action plans and the PHC
plan for
services in
consultation with various
health
functionaries,
primary school teachers,
panchayat pradhans
etc. On the basis of this needs assessment, activity norms for
ANMs will be set. Interestingly, the basis of the norms set in
form 2 (pp 33—34)
appears arbitrary and once again tilted
against maternal
health.
(For example the norm for early
antenatal
registration is only 607. while the child health
norms are around 95 -1007.) The availability
(though not
adequacy) of equipment and facilities is also to be checked;
here access to clean water and toilets is excluded.
The PHC
plan is then to be drawn up and aggregated upwards to arrive
at district and state plans.
Monitoring and evaluation
The ANN will
submit monthly reports with details on 27 sets of
activities;
her performance will
be assessed by the LHV
through both direct observation of her skills and practices,
and by asking the opinion of the community once each month.
Similar assessments of the PHC medical officers will be done
by the Block MO.
ANN record keeping is not being changed at
present, but there is to be a pilot attempt to shift to client
based records such as health cards.
Strengths
Once a year independent agencies will
surveys in each district of programme
client satisfaction.'
conduct client sample
coverage, quality and
Weaknesses
As already pointed out,
the forms are still
narrow concept of reproductive health, mainly
MCH.
using a very
focussing on
The reporting requirement for ANMs seems cumbersome,
and
therefore open to misrepresentation.
The crosscheck on the
ANN'S activies is to be provided by the LHV' s survey of the
community's opinion, but in the absence of an active group of
women in the community, this may not work very well.
Overall, the principal need at present is to develop a system
by which women's groups at the local level can be empowered to
play a greater and pivotal role in planning, monitoring and
evaluation.
Gita Sen
Indian Institute of Management
Banga1ore
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DATE
HEALTH WATCH
JUNE
ISSUE - 1
SUMMARY OF THE DISCUSSIONS HELD AT THE
NGO MEETING IN AHMEDABAD,
1995
PARTNERSHIP WITH THE GOVERNMENT :
THE PROCESS
In India some of the same concerns were voiced
during the meetings of the grassroots level workers
organized by the NGOs in different states between
INTRODUCTION
October 1993-January 1994, prior to the ICPD.
There has been a growing concern in India among
These meetings also brought out that the official
scholars, researchers, women’s groups, non-govern
health and family welfare programme in its present
mental organizations (NGOs), etc. that the demo
form puts no or little emphasis on participatory man
graphic rationale for lowering the birth rate has
agement, quality of care and reproductive health.
become the overarching concern of the government
These issues were taken up for further discussion in
such that the larger developmental goals as well as
three national thematic meetings held during Febru
individual health needs or reproductive goals are lost
ary - April 1994 at Bangalore, Ahmedabad and New
sight of. The developmental approach recognizes the
Delhi.
interrelations between population, resources and
The Indian NGOs attending the last preparatory
environment for sustainable development and well
committee meeting had established a channel of
being of mankind. It also emphasizes the need for a
dialogue with the official delegates. This process of
holistic, integrated and decentralized approach to
meeting and attempting to strike a meaningful part
both population and development. It implies that,
nership between GO and NGOs had continued in
subject to the resolution of inter-group conflicts, and
Cairo. In fact, before going to Cairo some of the
to the extent possible, planning, implementation and
representatives of the NGOs had met with the mem
monitoring of all developmental activities must be
bers of the official delegation in New Delhi to under
undertaken by local people in accordance with their
stand the respective positions on various issues of
own needs and priorities. Essential to the develop
population and development.
mental approach is viewing women as active and
In Cairo, two major decisions were taken to
empowered participants in the development
strengthen this process: a) Government would call a
programmes.
meeting of the NGOs to further the dialogue and b)
The Programme of Action (POA) adopted at the
NGOs themselves would meet prior to the meeting
International Conference on Population and
with the Government to identify the key issues which
Development (ICPD) held in Cairo in September
call for discussion with the government. A meeting of
1994,
to which India is a signatory, has incorporated
the NGOs was held in Ahmedabad during December
this approach, which has been articulated by
1-2, 1994. About 35 participants, representing
women’s organizations throughout the world. The
diverse points of view, were invited to the meeting of
active involvement of women’s organizations during
whom 20 were able to participate.
the regional and national consultations as well as
during the three preparatory committee meetings held
in New York prior to the Cairo conference has helped
PRIORITY ISSUES
to define women’s position on population policies and
In the context of the concerns expressed in the ICPD
programmes. It requires a shift in the population
document, the group which met in Ahmedabad
policy objectives from the concern with population
identified the following as priority issues which call for
size or numbers to provision of reproductive health
serious discussion and dialogue between the govern
services of acceptable quality with a proper
ment and the NGOs at this time.
acknowledgement of women’s reproductive rights.
DECEMBER 1-2, 1994
1.
Removal of Method-Specific Contraceptive
Targets, Incentives and Disincentives for Family
care services including enhanced supply of drugs at
the primary health centres.
Planning
In view of the decline in fertility experienced in many
parts of the country and the distortions that have.
marked the family planning programme, the time is
ripe for removing the method specific contraceptive
targets from the programme, discontinuing incentive
payments to the acceptors or to the providers and
any form of disincentives for the non-acceptors. In
this context, there is a need to a) developing alterna
tive performance indicators including some based on
MCH services and provision of primary health care; b)
implementing target-free programme with emphasis
on making full information available to people and on
meeting their health and reproductive goals, in a
phased manner in collaboration with NGOs; c) re
viewing the experiences when the target approach is
replaced by people-based approach.
4.
Regular Dialogue with NGOs
This began prior to the Cairo Conference and should
be continued and strengthened in the years ahead.
Initially, this could be done by a) involvement of
NGOs in the six-monthly meetings of health and
family welfare secretaries at the centre (similar meet
ings at the state level would be useful and need to be
organised regularly); b) active participation by NGOs
in sensitization and training programmes on the Cairo
Programme of Action for health and family welfare
functionaries; c) active participation by the NGOs in
discussions on resource allocation for health and
family welfare.
We urge the government and the NGOs to consider
these recommendations seriously, initiate the process
of wider discussion and dialogue and also implement
2.
Expansion of services with emphasis on repro these as part of the commitment to people’s health
ductive health and on quality of services
and well-being that we collectively made at Cairo.
The current health and family welfare programmes
should be expanded to include reproductive health
Leela Visaria, GIDR
services with an emphasis on quality of care. This
Mirai Chatterjee, SEWA
could be done by a) starting a programme for repro
December 14, 1994
ductive health which includes facilities for diagnosing
and treating reproductive tract infections, infertility
and sexually transmitted diseases, etc. However,
NEWS ITEM
these facilities should be integrated into the existing
programmes and not established as separate vertical
activities; b) improving MTP services both in terms of
access, safety and quality; c) improving quality of
contraceptive services along with emphasis on male
responsibility. Resources used for incentive pay
ments at various levels could be channelled into the
implementation of the new approach.
3.
Increasing Resource Allocation for
Primary Health Care
Resource allocation for improving access and quality
of primary health care is essential. Increased alloca
tions are required for a) strengthening, developing
and where required, increasing the number of local
health functionaries; b) strengthening and expanding
health infrastructures like primary health centres and
subcentres; c) improving the range of primary health
(From Times of India (Ahmedabad Edition) of
February 22, 1995)
FP PRIZES PRESENTED: Forty-one motivators and
employees have been awarded incentive cash prizes
for outstanding family planning performances in
Hansot and Ankleshwar talukas in 1993-94 at
Hansot. Ms. Jashuben R. Patel, steadier,_was_tbe
first_among_othenprize.winners. Mr. J.B. Choudhary,
TDO, Hansot, said the taluka achieved 87 per cent
result with 379 sterilisation operations against the
target of 433 operations. Mr. Mukeshpuri DDO
Broach who gave away the prizes called upon the
employees and motivators to cross the target in both
Hansot and Ankleshwar talukas.
Note on Meeting of State Secretaries for
Family Welfare
April 3, 1995, Vijyan Bhavan, New Delhi
As a follow up of the note prepared by Health Watch
in December, 1994 and the discussions held in Delhi
during December 16-17, 1994 and Jaipur in February
1995,
the Ministry of Health and Family Welfare
agreed to inviting some Health Watch members to a
meeting of State Secretaries on April 3, 1995.
The Secretary of Family Welfare finally selected the
following persons based on areas of work i.e. re
search, grassroots organisation etc.
1. Gita Sen
: To present an overview on the
outcome of ICPD
2.
Banco Coyaji: To make a presentation on
reproductive health in the context of primary health
care
Vimla Ramachandran and Mirai Chatterjee were also
present and supplemented to Gita’s presentation,
with examples from Mahila Samakhya and SEWA’s
experiences, respectively.
Gita, Dr. Coyaji, Mirai, Ena and Wasim Zaman, Coun
try Director, UNFPA met on April 2, 1995 to connect
with each other and prepare for the meeting of the
3rd of April 1995. Vimla was in touch with the group
as well.
The Meeting
a.
Pre-Lunch Session:
The meeting of State Family Welfare (FW) Secretar
ies was chaired by Mr. Shunglu, assisted by the two
joint Secretaries Ms. Adarsh Misra and Mr. K.S.
Sugathan. The inauguration, was by the minister of
state for health, Dr. C. Silvera. Mr. Dayal, Secretary,
Health also spoke briefly. The Minister and Mr. Dayal
left soon after the inauguration session. However, all
state secretaries remained present.
Gita’s Presentation went off very well. It was, as
usual clear, concise and digestible. Vimla and Mirai
added on a bit. Then Dr. Banoo Coyaji made a
presentation giving a historical perspective which was
very interesting and useful. After this the floor was
opened for discussion.
Instead of focussing on issues like removal of targets,
specifically raised by Gita, a discussion on what an
NGO is and merits and demerits of NGOs followed!
Some clarifications on ICPD’s Programme of Action
were also sought. In short, it was not a very substan
tive discussion.
b.
Post-Lunch Session
We were invited to stay on for the post lunch session.
Mr. Sugathan started out by saying that in 1995-96
the focus was to be on qualitative improvement of
services. Also, he mentioned that government func
tionaries outside of the FW department will be dis
couraged from monitoring family planning services.
Each state secretary presented her/his 1994-95
targets and the proposed ones for 1995-96. There
was also some discussion of the accuracy of data
collection-spot checks had been carried out. Further,
each Secretary specifically mentioned at least one or
two districts in her/his state which will be target free
during 1995-96 (see attached list).
When the Punjab Secretary spoke, Mr. Shunglu
specifically asked her whether she planned to use
injectables since people in Punjab could afford to pay
for these. He also mentioned that Depo Provera has
been cleared by the Drug Regulation department and
that it is available on the open market. The punjab
Secretary responded by saying that the doctors in her
state were not keen to use injectables yet, partly
because of the controversy surrounding these in
recent years. Finally Kerala and Meghalaya re
quested that their states be completely target free.
Most of us, except for Dr. Banoo Coyaji, stayed only
till the afternoon tea break. We need to get Banoo’s
help to add what went on thereafter. Rajasthan, U.P.,
West Bengal and Tamil Nadu Secretaries were to
speak and then they were to discuss the sex-determi
nation bill passed by the Parliament.
Implications/Outcome of State Secretaries Meet
ing and Health Watch’s Participation
1. We have made some progress in that two of our
suggestions (i.e. dialogue with government and
participation in state secretaries meeting and removal
of targets in a phased manner in some districts) have
been acted upon.
2.
All states gave names of districts with high family
planning performance as their choice for target free
areas. If at least some of the “difficult” districts had
been selected, then we would have had a better
chance to see how a target free approach by govern
ment can work in such areas.
Secretary put it: “The centre is where the States’
money for family planning comes from. So of course
we do what they tell usl.
8.
We can start dialogue with our state secretaries
regarding the target free districts, how performance
will be monitored etc. A letter from the centre will
3.
The atmosphere vis a vis NGO’s seems to be quitehelp but we may as well begin. Our impression is
that states need help with performance indicators.positive. The two joint secretaries and secretaries of
some southern states (Kerala, Tamil Nadu,
Karnataka) and of Maharashtra are particularly open
and supportive. We need to build on this, take their
support and keep up the pressure for dialogue and
constructive debate followed by action. The time is
definitely ripe for us to now start talking of Health
Watch. The government needs to know that we are
an organised group of people, representing various
organisations, but committed to the implementation of
the ICPD Programme of Action.
Mirai Chatterjee
April 6, 1995
Attachment 1
List of States and Their Target Free Districts
States
1.
4.
We will have to get at least a part time coordinator 2.
for Health Watch to work out of the current secretariat 3.
at GIDR. Leela is agreeable to guide someone in
4.
keeping track of us all and our strategies for action.
5.
She already has someone in mind.
6.
5.
Our next action should be to start constructive
dialogue with our state secretaries in our home
states. We mentioned this several times to the
Secretary and Joint Secretary. We hope that they will
write to the state secretaries suggesting meetings
with a wider group of NGOs at state level. (See the
attached letter that Gita Sen has written to Mr.
Shunglu.)
6.
It was clear that the states are only too happy to
do away with targets! What is to be seen is, however,
what sort of performance indicators will replace these
and who will decide on these. Some clue to these
questions are covered in Mr. Shunglu’s note to the
state secretaries (See Attached Note).
7.
It was very clear that despite the centres protesta
tions to the contrary at our December 1994 meeting
with the government, it is the centre and not the
states which sets the tone and calls the shots vis-avis any changes we would like to see. As one State
Andhra Pradesh
Assam
Bihar
Maharashtra
Gujarat
Haryana
7. Himachal Pradesh
8. Jammu & Kashmir
9. Karnataka
10. Kerala
11. Madhya Pradesh
12. Meghalaya
13. Manipur
14. Punjab
15. Orissa
16.U.P.
17. Rajasthan
18. West Bengal
19.Tamil Nadu
Target Free Districts
“
E. Godavari
Sibsagar
Patna
Satara & Wardha
Valsad
Ambala
Sirmour
Jammu
Mandya
Whole State
Narsinghpur
Whole State
Vishnupur
Fatehgar Sahib
Bhubaneshwar(?)
Sitapur, Agra
Dausa, Tonk
Hoogly
Whole State
f)
Attachment 2
u'»v’
Agenda Item No.2:
%
Sterilisations IUD
insertions
Eq. C.C.
Users
100%
and
Above
Gujarat
Kerala
Madhya Pr.
Maharashtra
Tamil Nadu
Gujarat
Gujarat
Karnataka Madhya Pr.
Tamil Nadu Punjab
Tamil Nadu
75100%
Andhra Pr.
Haryana
Andhra Pr. Andhra Pr.
Haryana
Karnataka
Haryana
Haryana
Karnataka
Kerala
Madhya Pr. Karnataka
vMadhya Pr. Maharashtra Maharash
Orissa
Punjab
Maharashtra Orissa
Orissa
Rajasthan
Orissa
Punjab
Rajasthan
West Bengal Punjab
Uttar Pr.
Uttar Pr.
Himachal Pr. Uttar Pr.
Himachal Pr.
Achvt.
Eq.O.P.
Users
Review_of_th&Eamily_Planning_Performaoce_Quring
1994r&5_and_Expected_Lev_eLoLAchLe_vemenLfor
19.95-96
(a)_Bevie_w_otthe_progress otfamily planning_perfor-
manceJnrelation_to.expected_Le.vels.ofAchievements
duririg_t994z9.5_(up_to_.J.anuary.,JL9.95).
Based on the latest performance figures received
from the various states/UTs, the Table below
summarises the position in relation to expected level
of achievements (ELAs) by methods of family plan
ning at national level during the year 1994-95 (up to
January 1995).
Methods Achievements#
% Increase
%Achievement
1994-95 1993-94 (+) or
of proportionate SO(April 94(Corres- decrease (-)
ELAs
75 %
to Jan 95)
ponding period)
1
2
3
4
5
(+)1.2
(+)14.7
(-) 3.5
(+) 20.3
82.9
84.4
63.6
70.2
—
IUD insertions
Eq. C.C. Users
Eq. O.P. Users
32.46
49.49
134.59
37.06
32.06
43.14
139.42
30.79
Total Acceptors
253.60
245.41 (+)3.3
Sterilisation
# Achievement figures are provisional.
Expected Level of Achievements - State-wise
Classification of 17 major States in relation to per
centage achievement of proportionate ELAs by family
planning methods during 1994-95 (up to January,
1995) is given in the Table below.
Uttar Pr.
2550%
J & K.*
Less
than
25%
Assam
Bihar *
Gujarat
Tamil Nadu
Andhra Pr.
Assam
Rajasthan
Himachal Pr
Assam
Kerala
Kerala
West Ben.
Rajasthan Himachal Pr
West Bengal
Jammu & K.‘
Bihar *
Bihar*
Assam
West Bengal
Bihar*
J & K.*
J & K.*
-------------------------—
‘Figures are up to November 1994
A statement showing state-wise position by Family
Planning methods is enclosed (Annexure-2.1)
(b) ExpectedLey_el_otAchLeYemenLfor_J995-96
With reference to the discussions held in the last
meeting of the state secretaries regarding replace
ment of the contraceptive targets and the abolition of
condom targets, it has now been decided to adopt a
pilot approach in 1995-96. It is proposed that one
district from each of the major states may be ex
cluded from all contraceptive targets. The selected
district will not be given any contraceptive target for
any of the four methods, namely sterilisation, IUD, OP
users and CO users but information of the number of
acceptors for each method will be continued to be
collected. In addition, information on quality improve
ment as a result of target removal will also be col
lected. The district selected for exclusion should be
reasonably well performing with indicators above the
state average vis-a-vis immunisation, couple protec
tion, female literacy and infrastructure. In the se
lected district, in addition to the number of acceptors
for each method, following indicators relating to
qualitative aspects of FP and MCH will be monitored.
2. Given the demographic goals, the expected levels
of acceptance under sterilisation, IUD insertions and
OP users required during 1995-96 for each State/UT
has been worked out and the states have been asked
to suggest the expected level of users of these
methods based on the assessment of voluntary
demands, after excluding the ELAs in respect of the
district which is to be exempted of all targets.
3.
All the State governments were requested to
intimate ELAs for sterilisation, IUD and OP for the
year 1995-96 and the districts selected for target free
approach vide d.o letter No.M.11015/15/94-E&I dated
9/13th February, 1995. Replies have been received
from Andhra Pradesh, Kerala, Tamil Nadu, Sikkim
and A&N Islands. In case of other States it is pre
sumed that ELAs as indicated in the enclosed statement are acceptable to the State governments.
It is suggested that no targets should be allotted to
other departments like Revenue Dept., etc.
4.
In case of condom users, no ELAs are to be fixed
as decided in the last meeting of State Secretaries
i Of the total acceptors of sterilisation, number with 2 and the States have been asked to let us know the
children, number with 3 children and with more than 3 expected demand for condom based on the assess
children.
ment of voluntary demand taking into account the
ii Of the total acceptors of spacing methods, number requirement for FP and AIDS control for 1995-96 so
of couples with wife’s age less than 30.
as to ensure timely and adequate supplies.
iii Total number of immunisation sessions planned and
number of sessions actually held.
5.
The declining male acceptance of FP in the recent
iv Proportion of institutional deliveries and deliveries past has been a matter of concern. While several
by trained personnel in relation to the total estimated
reasons have been assigned for declining male
number of deliveries.
participation, it also appears that the non-involvement
v
Number of health facilities providing MTP services of the male health worker is a significant reason for
and the number of women treated for complications
poor male participation. While we need to reverse
this process through a sustained IEC campaign, it is
following unsafe abortions. Number of health facili
ties providing emergency obstetric care.
also suggested that adoption of targets for vasec
vi Number of polio and neonatal tetanus cases
tomy for male multipurpose workers could signifi
reported.
cantly improve male participation. It has, therefore,
vii Number of planned IEC sessions on diarrhoeal
been proposed to the states that the target for male
diseases and ARI and actually held. Number of
sterilisation be kept at 10 % out of total sterilisation,
pneumonia cases in children under 5 years of age
and in those States where the participation level is
identified and treated. (Expected number of cases of 10% or more the target may be kept at 15% of the
total during 1995-96.
pneumonia can be taken to be 10 to 20 times the
estimated number of deaths which is roughly 25% of
the total deaths in children under 5 years of age.)
May 1, 1995
Mr. V.K. Shunglu
Secretary
Ministry of Health and Family Welfare
Nirman Bhavan New Delhi 110 011
Dear Mr. Shunglu:
This is just a brief note to express my appreciation for
your efforts to continue the dialogue with NGOs and
other members of civil society on how best to move
forward in the family welfare program post Cairo. On
our side, the opportunity to meet a number of the
state secretaries during the meeting in early April was
useful.
In order to build on the good start made, there need
to be a series of dialogues and workshops in the
states, both to sensitise more government personnel
to the Cairo agenda, and to begin a process of
systematic dialogue about the best way to move
forward from the era of targets, incentives and poor
quality of care. Your leadership in this is vital, since
the states do look to you for direction and guidance.
I hope that you will provide this so that the experi
ment of replacing method-specific targets can be
come a genuinely fruitful one.
With best wishes,
Sincerely,
Gita Sen
Professor
cc. Mr. Wazim Zaman, UNFP
for private circulation only
e
Health Watch
C/o. Gujarat Institute of
Development Research
Near Gota Char Rasta
Gota 382 481, Ahmedabad (India)
Phone : 079-7474809-10
Fax : 079-7474811
Women advocating change
Working for a sensitive women’s health programme in India
Vimala Ramachandran
Since the mid-seventies women’s organisations, social activist groups, radical political
parties and other community based organisations have consistently raised their voice
against contradictory positions taken by the government on population and family
planning. At one level, in the Bucharest conference, India came out with the slogan "development is the nest contraceptive”. At another level, back home - the government
intensified its efforts to control population growth. The darkest period was the
emergency years (1975-77) when excesses committed in the programme brought the
government down. After a lull of a few years, the renamed (not revamped) Family
Welfare programme came back with a bang - with one significant different. The targets
were to be women - male sterilisation had proved politically volatile. Tubectomy camps,
laproscopy techniques coupled with incentives and disincentives became the one point
programme of the government. The entire might of the administration was geared
towards achieving targets. This approach continued through the eighties
The first glimmer of doubt was expressed by the Planning Commission in their
approach paper to the Eighth Plan. It said "in spite of massive efforts in the form of
budgetary support and infrastructure development, the performance of the family
welfare programme has not been commensurate with inputs. Right from the beginning
the achievement of the set of goals has been unsatisfactory, resulting in the resetting of
targets,... While the Seventh Plan targets of achieving CPR of 42% was achieved, this
was not matched by commensurate decline in the birth rate, possibly because of
improper selection of cases... Containment of population is not merely a function of
couple protection or contraception but is directly correlated with female literacy, age of
marriage of the girls, status of women in the community, IMR, quality and outreach of
health and family planning services and other socio-economic parameters.. .The Family
Welfare Programme has essentially remained a uni-sector programme of the Ministry of
Health and Family Welfare ..(it) has also suffered on account of centralised planning
and target setting from the top.... Monitoring mechanism under the programme has
been reduced to a routine target reporting exercise incapable of identifying roadblocks
and applying timely correctives."
Community based groups, social activists and women's organisations started raising
their voice against the family welfare programme. Almost all of them made it a point to
distance themselves from it Activists in the women’s movement and women's
organisation critiqued the programme from the outside. By the early nineties this
became very sharp - so much so that the Ministry of Health and Family Welfare started
looking upon women's groups as adversaries. Women’s groups agitated against
human rights violations in the form of family planning, harmful technologies and
abysmal quality of health care services. Women’s development programmes within the
government like WDP, Rajasthan and Mahila Samakhya - made a conscious efforts to
not only distance themselves from Family Planning but also actively campaigned for
women’s right to make her own decisions and right to dignity.
Where did all this lead? Right through the eighties and in the first half of the nineties,
there was little dialogue between the two constituencies - family planning wallahas and
women’s groups. As a result voluntary organisations, demographers part of the
population lobby and family planning associations were identified with the
establishment. Government propaganda, lessons in school text books, media stories
about population bomb, international advocacy for reduction in population growth
(including policies of IMF and the World Bank) etc. created a situation whereby the two
extreme positions received public attention, namely: one who said that population has
to be controlled at any cost as it is the root cause of poverty and the other which argued
that high population growth rate is a symptom of poverty, ill-health and lack of social
security. Middle of the readers who argued for a more nuanced and balanced view of
the population - poverty linkages were either silent or their adocacy ineffective.
By the time we were approaching the mid point of the nineties an appreciable softening
among the population hardliners became evident. Many decades of pumping money
into contraceptives and sterilisation did not yield desired results. Evidence from many
poor counties demonstrated that human development indicators are not necessarily
correlated with economic prosperity. Quality primary health care, maternal and child
survival programmes, good sanitation and primary education can turn the tide. When
infant mortality decreases and people feel assured about the survival of their children
family size begins to decline. Globally the efforts to develop human development
indicators and ranking countries according to quality of life forced demographers and
population control wallahas to rethink. The environment question, carrying capacity of
the planet also pointed towards consumption patterns among the rich and the poor
across the world and within countries. All these effectively diffused the population
bomb.
In India a few women’s organisation, social activists, researchers and officials
recognised the historical opportunity. By 1993 it was evident that a significant section of
policy makers and administrators within government were talking about the need to
overhaul the family welfare programme. Target fatigue had set in. A draft note for
discussion among Secretaries to Government of India made the round in the early
nineties. Some senior civil servants reached out to talk to women activists. Preparatory
activities for the Cairo conference provided a glimmer of hope. Intensive lobbying at
the national level at a time where the population, poverty and development issues was
being reopened globally could bring about change. There was considerable evidence
of internal debate between women's health advocates and population control lobbies
within international organisations. Reproductive rights and reproductive health became
central to the debate.
Within India efforts to bring together women's groups, advocates for primary health
care, demographers, family planning groups, environmentalists and other concerned
activists started in 1993. The initial reaction was one of mutual suspicion. Some
women’s groups refused to co-ordinate regional consultations if it was being funded
and supported by some donor agencies, others refused to come together with "family
planning wallahs". The more establishment friendly groups were apprehensive about
sharing a platform with women activists - calling them a shrill and unreasonable lot.
A
Many civil servants expressed cynicism about the success of efforts to initiate dialogue
between traditional adversaries.
With a lot of hesitation and apprehension the first group of people met to talk about the
Cairo draft Programme of Action and whether it is relevant for India. This meeting
immediately turned into a forum to ventilate feelings about the family planning
programme. The Cairo document was barely touched! In one meeting population,
development, poverty, the inter-linkages between them etc. was not even discussed.
The entire discussion centred around immediate health problems of the people. At the
other end of the spectrum, another turned into a vitriolic attack on India's population
control policy. In all eighteen meeting were organised by one group as preparatory
activities for the ICPD conference. Simultaneously women's groups in different parts of
the country organised their own meetings to talk about the Cairo agenda and whether it
has any relevance in India. Existing health networks like Medico Friends Circle and
Voluntary Health Association of India initiated their own consultative process.
The Cairo conference was a turning point. The entire debate centred around women's
control over her own body, her right to say “No'' and "Enough" - abortion, invasive
contraceptive technologies, male responsibility, right to treated with respect and dignity,
rights of people within unconventional relationships, family reunification rights, forced
migration - all these issues turned Cairo into a women’s conference.
In the immediate post-Cairo phase persistent efforts by a core group of people
determined to see concrete changes in India’s policy and programmes worked from
within and outside government to keep the debate alive. Among women’s groups there
was a debate on the need to keep channels of communication with government open
and work towards removal of family planning targets, improving quality of health care
services and sensitive women's reproductive health programme.
Forging strategic alliances became the first point of conflict. Given the fact that a large
proportion of India's family welfare and health programmes are funded by multilateral
agencies like UNFPA and the World Bank - would it be appropriate to open channels of
communication with them and the government simultaneously? There were no easy
answers? It was evident that advocating for change involves walking a tight rope.
Providing constructive criticism, alternative strategies, concrete inputs into programme
design, monitoring indicators etc. may result in a few changes. We would also have to
live with some not-so-desirable components. We may also be identified with some new
initiatives - with little control over the key processes and outcomes. In short, it is a risky
business to advocate for change and enter into partnership with government and
funding agencies to concretise broad policy level statements into concrete
programmes. A small group of people involved in the pre-Cairo consultative process
decided that it was worth the risk. Health Watch - a network of like minded NGOs,
activists, researchers and concerned citizens was thus formed in December 1994. It
took almost a year to work out a common agenda and carve a role for itself in the
present scenario.
A second round of region-wise consultations begin in Hyderabad on 28 and 29 June,
1996.
Women’s groups, voluntary organizations working..oo health, environment,
human rights, education, contraceptive services, etc., social activists, researchers,
3
EVENTS
A turning point
The international conference on population
President Hosni Mubarak at the opening of the conference... a momentous event.
An article of the preamble to the
Inou K. Mallah
Programme of Action states: “The
present Programme of Action recom
Cairo, Egypt, the cradle of civili- mends to the international community
tion, a new chapter in history was a set of important population and
carved on the tablet of time between development objectives, including both
September 5 and 13 at the qualitative and quantitative goals that
International
Conference
on are mutually supportive and are of crit
Population and Development (ICPD) ical importance to these objectives.
- a momentous event.
Among these objectives and goals arc:
It was a historic conference in many sustained economic growth in the con
ways. Convened by the United text of sustainable development; edu
Nations, it was a successor to the 1974 cation,
especially
for
girls;
World Population Conference held in gender-equity and equality; infant,
Bucharest and the 1984 International child and maternal mortality reduction;
Conference on Population held in and the provision of universal access to
Mexico City. The ICPD spelt out reproductive health services, including
actions to address issues related to family-planning and sexual health.”
rapid population growth and affirmed
Another article states: “While the
that people have the right to decide ICPD does not create any new interna
freely and responsibly the number and tional human rights, it affirms the
spacing of their children, and to have application of universally recognised
the information, education, and the human rights standards to all aspects
means to do so.
of population programmes. It also rep
E
Frontline, October 21,1994
resents the last opportunity in the 20th
century for the international communi
ty to address collectively the critical
challenges and inter-relationships
between population and development.
The Programme of Action will require
the establishment of common ground,
with full respect for the various reli
gious values and cultural backgrounds.
The impact of this conference will be
measured by the strength of the specif
ic commitments made here and the
consequent actions to fulfil them, as
part of a new global partnership among
all the world’s countries and peoples,
based on a sense of shared but differ
entiated responsibility for each other,
and for our planetary home.”
And the first paragraph in the pre
amble to the Principles in Chapter II
states: “The implementation of the
recommendations contained in the
Programme of Action is the sovereign
right of each country with national
119
laws and development priorities, with
full respect for die various religious
and ethical values and cultural back
grounds of its people, and in conformi
ty
with
universally-recognised
international human rights.”
In his keynote address at the inaugu
ration of the ICPD, Egyption President
Hosni Mubarak, who received the
U.N. population award for this year,
called for avoidance of extremism, dis
cussion and dialogue, particularly
between the North and the South, and
an exchange of opinions in an ambi
ence of democracy in order to find a
common denominator.
U.N. Secretary-General Dr. Boutros
Boutros-Ghali called the conference “a
turning point for the all-important
population issue.” He made a plea for
tolerance and urged the participants
not to impose any one belief or culture
on the entire international community.
He, however, warned that tolerance
should not result in meaningless com
promises but reflect a political will to
solve over-population and under
development in the world.
U.S. Vice-President Al Gore called
for a “holistic” solution to the popula
tion quesuon “which is rooted in faith
and a commitment to basic human val
ues of the kind enshrined in all of our
major religious traditions and princi
ples increasingly shared by men and
women all over the world: the central
role of the family, the importance of
the community, the freedom of the
human spirit, the inherent dignity of
every individual woman, man and
child on this planet, poliucal, economic
and religious freedom, and universal
and inalienable human rights.”
Impressive though these speakers
were, it was a field-day for the women
delegates. Addressing the plenary ses
sion, Dr. Nafis Sadik, SecretaryGeneral of the ICPD, said that
differences over the Draft Programme
of Action to be adopted were the
“result of misunderstanding of the
content or the intent of the draft. All of
this can be done without in any way
infringing national sovereignty. Each
nation will address the issue according
to its own laws and practice.”
Norwegian Prime Minister Gro
Harlem Brundtland urged delegates to
be realistic about abortion and sex edu
cation. “Morality becomes hypocrisy if
it means accepting mothers suffering
or dying in connection with unwanted
pregnancies, illegal abortions, and
unwanted children,” she said.
Pakistan Prime Minister Benazir
Bhutto’s speech was high on rhetoric:
“I dream of a Pakistan, of an Asia, of a
world, where every pregnancy is
planned and every child conceived is
The labour of the rich
Of India’s population policy
ImranaQadeer
HE media termed it a “low pro
file” performance. But the Indian
delegation’s
stance
at
the
International
Conference
on
Population and Development (ICPD)
in Cairo marked yet another step in
walking the razor’s edge - between
what the Indian people really need
and what their rulers want.
Under the benevolent patronage of
the
Rockefeller
and
Ford
Foundations, India was the first
nation to adopt a family planning pro
gramme. The neo-Malthusian princi
ple underlying the programme,
though, was first enunciated by Dr.
Karan Singh, then Union Health
Minister, in April 1976: “Indisputably
we are facing a population explosion
of crisis dimensions which has largely
diluted the fruits of the remarkable
economic progress that we have made
over the past two decades.” This
principle has been the basis for the
evolution of policy ever since.
The reluctance of Karan Singh’s
Ministry to force the pace of the pro
gramme, in spite of the perceived
“crisis”, was soon abandoned under
the Emergency. But the coercion of
targets bred a massive public reaction.
Consequently,
the
Janata
Government’s Draft National Health
Policy of 1979 retreated into talking
only of health services. The succeed
ing Congress Government was still
wary of neo-iMalthusian principles, so
a 1980 Working Group on
Population outlined a strategy for
promoting “demand” for family plan
ning services by reducing infant and
maternal mortality through compre
hensive health care.
Thus, the early 1980s saw a signifi
cant expansion of the health services
infrastructure. However, before any
radical transformation could take
place, the Malthusian principle quick
ly reasserted itself. Under the Seventh
Plan, investment in the family plan
ning programme shot up from 15 per
cent to 25 per cent of the health bud-
T
Prof. Imrana Qadeer is with the
Centre for the Study of Social
Medicine and Community Health,
School ofSocial Sciences,
Jawaharlal Nehru University, Delhi.
get, and it usurped the entire health
services through the earlier thrust on
integration.
This transition, though, did not
produce any results. Experts ascribed
this to “poor management”, and a
revised strategy was constructed in
1986 to “go beyond” the family plan
ning programme. In practice this hol
low slogan expected that biogas,
smokeless chulhas and pressure cook
ers would “reduce the workload at
home and release women for work”!
Understandably enough, population
control strategies remained consis
tently ineffective. This became yet
another pressure point for multilateral
aid agencies to push for “structural
reforms”. National policy planners
suddenly became “aware” of the
years of accumulated evidence that
emphasised that people themselves
were expressing a need for family
planning services. But this “need”
was subtly distorted to focus on
women. In the name of women’s
“choice” and “reproductive rights,”
policy legitimised the 20 million spen
by the Population Council on
researching a single (and controver
sial) hormonal contraceptive Norplant. Such injectables and vac
cines became an integral part of the
agenda for the Structural Adjustment
Programme (SAP).
Prior to Cairo, the Indian
Government was thus faced with two
dilemmas. The first was that under
SAP it no longer had any money for
welfare services, but neither could it
again coerce people into controlling
family size. The second lay in the
worldwide
recognition,
from
Bucharest to Rio de Janeiro, that pop
ulation numbers were not the crucial
factor in underdevelopment. The
genius of the policy planners lies in
how they have grasped both dilemmas
and, through a process of clever
manipulation, used their opponent’s
arguments to justify their own case.
Two policy documents presented in
Cairo clearly demonstrate this genius.
India’s country statement for the
ICPD is the first of these documents.
It parrots the ICPD line. Emphasising
the link between population and
development, it transforms “targets”
into “goals” and underlines the need
for women’s education, employment,
improved status, nutrition and health.
Frontline, October 21,1994
Having made all the politically correct table development.
statements, it subtly changes course
Having paid its respects to all the
and focusses on family planning as a minor gods in the pantheon, the
-basic need”. Surer, but comparative Swaminathan Committee returns
ty more dangerous, contraceptives are resoundingly to the principal deity:
thus made acceptable to fulfil this “Population, poverty and environ
need. And, of course, this has to be mental degradation have dose link
seen in the context of SAP. “Until ages, and the quest for food,
these reforms are achieved the cost education, health and work for all will
could be high, in terms of continuing remain illusory' unless success is
cuts in employment, in lower growth achieved in limiting the growth of
of financial allocations for priority in population”! For limiting this growth,
agriculture, social sector and infra the Draft Policy quietly suggests leg
structure, and limitation of resources islative steps, including cutting off of
for environmental protection.”
employment, promotional and elec
However, forced to recognise the toral avenues for those with more
political opposition to SAP, the coun than two children. It even suggests
try statement gen
that since the
uflects in that
Army has done
direction: “There
such good work
1 are real risks to
in planting trees it
the poor from the
would do equally
International
reforms.” Then
well in “promot
Conference
on
the buck is passed
ing small family
on: “Poverty and
Population and norms”. And it
social sector pro
neatly sidesteps
Development
grammes must be
the question of
supported by sig
where, within a
nificant conces
shrinking budget,
ICPD
94
sional
funding
its
high-power
from multilateral
Commission will
agencies
and
obtain
the
bilateral donors.” In other words, resources tq launch any form of social
India is a beggar, but a good, “credit development.
worthy” one!
The Draft Policy, thus, is a magnif
The second, even more brilliant, icent piece of sound and fury that sig
document is the Population Policy nifies
the
surreptitious
and
Draft prepared by the Swaminathan ever-more-powerful return of an
Committee. It surpasses the country internationally discredited Malthus. It
statement in its appropriation of radi has a preamble that eulogises devel
cal language to cover up a series of opment but has no clues about how to
contradictory statements and half achieve it except through population
truths. Thus, it is convinced that control. It advances a set of alterna
(‘development which is not equitable tive strategies for tackling the discred
’is not sustainable,” and that an ited family planning programme and
“enabling environmnt and empower gender inequality which eventually
ing mechanisms” are needed to boil down to “choice” within a set of
improve the quality’ of life of the poor. hormonal contraceptives. And it dis
The rise in pollution is attributed to guises the malevolence of coercion
“the lifestyle of the rich" (and also the under a paean to “efficiency” and
increasing population). It proposes to “political will”.
continue the Minimum Needs
This Draft Policy, emerging from
Programme (to address inequality) the low profile of Cairo, is now on the
and the integration of maternal and table of Parliament. It tells India’s
child health and family planning with donors how keen the Indian
general health services. Its major con Government is to please them - if so
cern is with gender inequality and the permined by its political opponents.
discrimination against women. The Will Parliament, as the responsible
committee enthusiastically espouses voice of the Indian people, be able to
the cause of women through new restrain this headlong plunge into a
inheritance laws, better educational mythical “liberalisation”? Or will the
and job opportunities and improved mighty labours of the Swaminathan
health care. It further recommends Committee, aggravated by the diston
the setting up of a high-power ed fear of epidemics, lead our legisla
Population and Social Development tors into the recurring trap of
Commission to plan, implement and multilateral debt, technology, and
monitor the entire strategy for equi domination? ■
’
Frontline, October 21,1994
nurtured, loved, educated and sup
ported. I dream of a Pakistan, of an
Asia, of a world not undermined by
ethnic divisions brought upon by pop
ulation growth, starvation, crime, and
anarchy. I dream of a Pakistan, of an
Asia, of a world, where we can commit
our social resources to the develop
ment of human life, and not to its
destruction. That dream is far from the
reality we endure...” Playing to a home
gallery, she affirmed that Pakistan
would not endorse any clause repug
nant to Muslims, though she veered
around to say, “Leaders are not elected
to let a narrow-minded minority dic
tate an agenda of backwardness. We
are committed to an agenda for
change.”
All the three women-speakers
received thunderous ovations.
Earlier, on September 5, addressing
the NGO Forum at the Cairo Indoor
Sports Stadium, Egypt’s First Lady
Suzanne Mubarak said the ICPD
offered a great opportunity to reach a
new understanding on policies that will
help upgrade the quality' of life and
wellbeing of all peoples. “The success
of any population programme greatly
depends on the free choice of the peo
ple involved,” she said.
Shuttling between the plenary’ ses
sion of the U.N. and the seminars and
discussions at the NGO Forum, one
had the feeling of living in split time
with the pendulum swinging from the
rational, at the conference, to the emo
tional at the NGO Forum.
The Indian delegation to the ICPD
was led by Union Minister for Health
and Family Welfare B. Shankaranand,
and included Union Minister of State
for External Affairs Salman Kursheed
and Dr. M. S. Swaminathan. Nearly
200 Indian NGOs representing various
voluntary organisations, such as the
Self-Employed Women’s Association
(SEWA) and the All India Women’s
Conference, were present. In all there
were nearly 14,000 delegates from 183
countries.
Before the conference got under
way, there were threats by fundamen
talists warning delegates to stay away
from the conference or face the conse
quences. Security in Cairo was tight
and there was no untoward incident.
But there was high drama within the
conference venue, with the Vatican
taking an intransigent stand on abor
tion and fundamentalists trying to
hijack the conference agenda by
deflecting attention away from the
main issues and protesting para 8.25,
which, as Nafis Sadik pointed out, had
become synonymous with controversy.
The para says, “In no case should
abortion be promoted as a method of
121
family planning. All governments and with die concept of woman-power as
relevant inter-governmental and non shakthi, as I had mentioned in my
governmental organisations are urged paper on a holistic approach to family
to strengthen their commitment to welfare.
women’s health, to deal with the
The Programme of Action calls for
impact of unsafe abortions as a major an increase in funding for global popu
public concern and to reduce the lation programmes from the present 5
recourse to abortion through expanded billion to about 17 billion by the year
and improved family-planning ser 2000. The funding requirement is
vices. Prevention of unwanted preg expected to rise to 18.5 billion in 2010
nancies must always be given die and 20.5 billion in 2015. The specific
highest priority and all
attempts should be made to
eliminate the need for abor
tion. Any measures or
changes related to abortion
within the health-system can
only be determined at the
national or local level,
according to the national
legislative process...”
Given the cautious word
ing of this para, and tire sov
ereignty clause in Chapter
II, one wonders what all the
^controversy and excitement
were about.
At both the U.N. and the
NGO forums, there was
rhetoric and more rhetoric;
there was dialogue and dis
sension; there were strident voices, details of these funding proposals arc
gender voices, there were fundamental expected to be taken up at the forth
tones and tolerant tones. There were coming U.N. General Assembly ses
petitions and demonstrations; there sion in New York.
was tension and humour; tiiere was
The closing session of the ICPD
controversy and consensus. But it was took place amidst tight security.
a long and convoluted process to arrive Summing up, Nafisa Sadik said: “This
at that consensus. As Dr. Maher has been an outstanding conference...
Mahran, who presided over the closing You have drafted a programme of
session of the ICPD, said: “It was a action for the next 20 years... which
long and protracted delivery.” Much shows us the path to a better reality. It
of the controversy and heated debate contains highly specific goals and rec
centred around the Vatican’s uncom ommendations in the mutually-rein
promising stand; the Muslim funda forcing areas of infant and maternal
mentalists also joined it. “Strange mortality, education and reproductive
bed-follows” a newspaper columnist health, and family-planning; but its
dubbed them, while another newspa- effect will be more far reaching than
.per ran a column under the headline that. This programme of action has the
“Between the devil and the deep See.” potential to change the world.
And at the NGO forum, delegates Energetic and committed implementa
went around with badges saying, “I’m tion will bring women at last into the
poped out.”
mainstream of development; it will
Women’s voices dominated both the protect women’s health, promote their
U.N. and the NGO forums. education and encourage and reward
Newspaper reporters made much of their economic contribution. Il will
Jane Fonda’s and Sushmita Sen’s ensure that every pregnancy is intend
appearances at the ICPD. African ed and every child is a wanted child; it
women, whose presence was very will protect women from the results of
strong, vociferously debated crucial unsafe abortion; it will protect tire
issues like poverty, female circumci health of adolescents, and encourage
sion and so on. The Indian delegates’ responsible behaviour. It will combat
balanced and dignified presence was in .111V/AIDS; it will promote and educa
sharp contrast to the shrillness and stri tion for all and close the gender gap in
dency of some of the Western femi education; it will protect and promote
nists. “The empowerment of women” the integrity of the family.”
was a phrase which resounded and
The Programme of Action will now
reverberated in the halls of both be placed before the General
forums. But Indians have always lived Assembly. As with tire proceedings, the
122
outcome of the ICPD also met with
divided opinion. There were the cynics
who said the conference was another
wasteful exercise in futility. They
sneered at the sacrosanct sovereignty
clause in Chapter II of the Programme
of Action, which, they claim, is legally
non-binding. Some feminists were
furious that abortion had eclipsed
other major issues. But, on the whole,
the response was overwhelmingly posi
tive. It was rightly felt that the
conference was a forum which
resolved many contentious
issues, though many still
remain, and that it has cut
across die North-South divide.
Others, like Pakistan’s former
caretaker Prime Minister
Moccnuddin Qureshi, pointed
out that against the backdrop
of threats made by Muslim
fundamentalists, the fact that
the conference took place at all
was a major achievement.
My personal assessment is
that the ICPD was a momen
tous meeting of the interna
tional community. Its holistic
approach to issues and con
cern with the democratic
process frequently found articulation
in the phrase ‘freedom of choice’. It
achieved many things: It demonstrated
beyond doubt that fundamentalistic
forces could not blackmail or hold the
international community to ransom.
From that perspective alone it could be
called a run-away success. The con
sensus (not to be confused with una
nimity), though with reservations, was
significant because it was achieved
after so much debate. Even more sig
nificant was that it set off a revolution
ary process in the participants’
thinking. No one who attended tire
ICPD would have returned home the
same. So many doors have been
opened in the minds, so many ques
tions raised in the interaction. Real rev
olution has to start in people’s minds
and. hearts, and the spirit and motiva
tion have to come from within. No one
can force it on another.
Js there a meeting point between
rhetoric and reality, between funda
mentalism and freedom of religious
expression, and confrontation and
consensus? Where docs one person’s
right end and another's begin? Where
does the role of the Government end
and that of an NGO begin? And where
indeed does policymaking end and
practical action begin? zThese were
some of tire question*- that reverberated
in the conference halls and corridors.
Perhaps the answers are yet to be
found. But, one hopes, they will be
found sooner titan later. ■
Frontline, October 21,1994
lol
ESTIMATED
CHILD
POPULATION
(0-6 years)
The number of pre-scr.c: children
(0-6 years) is estimates o reach
122 million at the close othis
century. Population protons are
made under varying assurotions
regarding the future coure of
fertility and mortality.
There will be an IncrenHrt in the
absolute number of chiicsr in each
quinquennium, but thei'roportion
to the country’s total pcruation
will consistently reduce a 13 per
cent under medium variazof future
population growth.
ESTIMATED CHILD POPULATTN (0-6 YEARS)
(Medium Variant of Popuacn growth)
In addition, local cultural beliefs and alternative systems of
health care have been frequently ignored and little value has been
placed on community participation. War and civil strife has a
devastating effect on the lives of large numbers of people and a
negative impact on their health and development.
There has been increasing awareness of the adverse impact on
health of many economic and health policies and a realization that a
purely technological approach to health care could not solve major
global health problems, especially those resulting from poverty.
Policy-makers now recognized the importance of targeting the socio
economic, environmental and political determinants of health.
A new global health policy for the twenty-first century
A strengthened relationship between WHO and NGOs, based
on a recognition of each other's comparative advantages and on
common goals, would be a powerful combination of interests.
To be successful, this new relationship should be based on
clear principles and joint policies and plans. One of the priorities of
the Geneva consultation was to define this new partnership and to
identify specific mechanisms for cooperation.
Determinants of health
Macro factors
Political
Economic
Educational
Environmental
Technology
Proximate factors
Safe, sufficient food
Water & sanitation
Industry actions
Social networks
Social capital
Behaviour
Culture
Health services
Biological Factors
Genetic
NGOs are particularly adapted to address the multiplicity of these
global health challenges, as they are already working in all these
sectors.
■A KUw
HoJbtk,
Aw
'I
«
0
VJHo
' r
CHILDREN IN INDIA
There are an estimated 300 million children between 0 and 14 years of age in India
today, representing a little over one-third of India’s population.
‘SBoys s Girls
Source: Census of India (1981) and Report of the Expert Committee on Population
Projections quoted in National Institute of Public Cooperation and Child
Development (1993).
As the graph indicates, despite the reduction in the birth rates from 41.9 per 1,000
population in 1960-61 to 29.5 in 1990-91, the child population has continued to increase.
It is expected to reach a high of 307 million in 1996 after which there is likely to be a
gradual reduction in child population with the decline in birth rates.
Also, there were an estimated 7.8 million fewer girls than boys in 1991. The femaleto-male ratio works out to 0.949.
Tkz>
-fe bo
>
5
Uw/D&F
Recent studies also point out that children in urban slums and poor neighbourhoods
ir. urban areas live under particularly vulnerable conditions of health and nutritional wellbeng. The risk of a slum child receiving a calorie-deficient diet, for instance, is reported
tc be twice as high as compared to those of children from middle income and low income
fanilies.
Government of India has taken several steps to address the problem of malnutrition.
Tie Integrated Child Development Services (ICDS) launched in 1975 has expanded to
beiome the largest nutrition programme in the world with 3,066 projects covering 16.2
milion children in the age group of 0 to 6 years and 3.2 million pregnant women. The
paikage of services provided under this programme includes supplementary feeding,
inmunization, health check-up, referral services, non-formal pre-school education and
nurition and health education. India’s performance in terms of food production has also
been impressive over the last few years, with record level of 180 million tonnes of foodgrain
produced in 1992-93. The country has built up a food buffer stock of 23 million tonnes, and
hs in place a network of more than 400,000 fair price shops for public distribution of
ezential commodities to the poor at lower-than-market prices. Despite these and other
programmes like the use of ORT and universal immunization, nutritional deprivation and
lunger are the norm, with over 43.8% (1988-90) children suffering from moderate
manutrition and about 37.6% (1988-90) from mild malnutrition.
% of expected w eight
PREVALENCE OF MALNUTRITION AMONG
CHILDREN (1 TO 5 YEARS)
Source: National Institute of Nutrition (1993).
Government of India’s Nutritional Policy recognizes that nutrition is a multisectoral
issie, and has called for evolving a mix of both direct nutrition interventions as well as
de'dopment policy instruments which will create conditions of improved nutrition. The Oslo
Inriative for a World Alliance for Nutrition and Human Rights observes that "in order to
entire sound nutrition as much attention has to be given also to child care and protection and
primotion of child health as to food security." Efforts to develop more such integrated
approaches will need to be reinforced and strengthened.
13
POPULATION BELOW POVERTY LINE
260 million
RURAL
CHILDREN BELOW POVERTY LINE
99 million
RURAL
URBAN
URBAN
Ck\W MW H JwUaz - 1>MIC£F • I9g|
CHILD WORKERS
BY NATURE OF ACTIVITY
1971
Cultivators
Agricultural labourers
Livestock, Forestry, Fishing & Plantations,
Orchards and allied activities
PERCENTAGE
OF CHILD WORKERS^
WITH RESPECT TO
TOTAL CHILD WORKERS
Mining and quarrying
Household Industry
Other than Household Industry
Construction
Trade and Commerce
Transport, Storage and Communication
Other Services
__
77
ft L'"-"A°BY V
CHART NO-I
P O F t P L./V h H o F n F 3 JNi ':i > 0 A 1 :'• > ’ 1 ■ ■ ■ . ' ’ EZZ
1000 800
600
Population in millions
400
200
0
900
920
940
960
980
Females per 1000 Males
source: REGISTRAR GENERAL OF INDIA
2
2
2
*
- 2
CENSUS YEAR
5
™
CHART NO-3
DIRTH RATE, DEATH RATI; AND NATURAL GROWTH RAH
IN INDIA
I993
1
Rate per 000 Population per Annum
1901 - 1993
2000 World Population Data Sheet Highlights
Table of Contents
■
The impact of the current pace of world population growth can be a
ated when we consider that the 6 billion mark was reached last year and the
next billion will arrive in only about 13 years.
Book Edition
Despair and Hope: The HIV/AIDS Epidemic
Population data for:
World
Africa
North America
Latin America & the Caribbean
Oceania
Asia
Europe
Acknowledgments, Notes,
Sources, and Definitions
About the Population Reference Bureau
Copyright © 2000 Population Reference Bureau, June 2000
ISSN 0085-8315
Data prepared by PRB demographers Carl Haub and
Diana Cornelius
Design and production: Heather Lilley, PRB
Photo © 2000 Artville
1
.
Over the next half century, Africa is projected to become home to a larger
share ofiuorld population; Africa's population will increase from 13 percent of
the world's population in 2000 to 16 percent by 2025, and to 20 percent by 2050.
During the same time, Europe's population is projected to decline from 12 per
cent of the current world total to 7 percent by 2050. Asia’s proportion of wo
population is projected to decline slightly, from 61
percent today to 58 percent by 2050. Changes are
not projected for the proportions ofzuorld popula
tion living in the Americas and Oceania.
2-3
4
4-5
5
6-7
8-9
10-11
12
India's population officially reached 1 billion on May 11, 2000. With over
one-third of its population underage 15, India's population will continue
to grow for many decades, and India is likely to become the world's largest
country in population by mid-century.
Although the use of modern family planning methods has increased worldwide, nearly two-thirds of women in less developed countries (apartfrom
China) are not using modem contraception. In sub-Saharan Africa, nearly
90 percent are not using modem contraception.
World's Largest Countries
in 2000
Rank
Population
Country(millions)
■
*
World's Largest Countries
in 2050
Rank
Country
(millions)
Despair and Hope: The HIV/AIDS Epidemic
ore people died of AIDS in
1999 than in any previous year.
The 2.6 million deaths in 1999
brought the estimated total number of
deaths since the beginning of die epi
demic to 16.3 million.
The annual number of deaths from
AIDS is not expected to peak for many
years because of the large number of
people already infected. The Joint Unit
ed Nations Programme on I-UV/AIDS
jrid the World I-Iealdi Organization esti
mate that in 1999, 5.6 million people
became infected with the human
immunodeficiency virus (HIV), which
causes die life-threatening illness AIDS.
Nearly 34 million people currently live
with HIV/AIDS.
The AIDS epidemic affects people of
M
Africa Dealt Worst Blow
Infection rates are not equally distrib
uted around the globe. Ninety-five per
cent of people who are infected with HIV
live in developing countries. The highest
concentration of people with the HIV
infection is in Africa, which accounts for
13 percent of the world’s population but
69 percent of the cases of HIV infection.
By contrast, Asia contains 61 percent of
world population and 20 percent of HIV
cases. The Americas have 14 percent of
world population and 8 percent of HIV
cases. Europe contributes 12 percent of
world population and 2 percent of its
population lives with an HIV infection.
Half of 1 percent of world population
lives in Oceania and those countries have
an even lower percent of HIV cases
■jwaridwi rle^.-O 1-nercnni----------- —
all acres Ahniit-half.nf.all.tM.-onlft.wba—e in
tV.Just
Become a MEMBER of the POPULATION REFERENCE BUREAU
1 milition
.2 mili Tan
'S
n
he
; with
i peoth
Koun-
gs titat
■d with
12 oiIO men
l
Percent of World's
HIV/AIDS Cases
Percent of
World Population
0.5%
Oceania
who are infected. One reason for this
difference by gender is that women con
tract the disease at younger ages and
may be more likely to become infected
during any single exposure.
HIV/AIDS is having a devastating
effect on life expectancy in some coun
tries. A child born in'Southern Africa in
the early 1950s could expect to live to
age 44. By the early 1990s, life expectan
cy in this region had risen to nearly 60
years. But because of AIDS, that gain is
expected to be lost. A child born in
Southern Africa between 2005 and 2010
is expected to live just 45 years. (See the
demographic data for the current life
expectancies in other countries.)
positive. President Yoweri Museveni has
openly discussed the problem since
1986. People at all levels of society—
political, community, and religious lead
ers—have been involved in the
campaign to halt AIDS in Uganda, and it
has made a major impact on the epi
demic in this country. Still, it took sever
al years to begin to see declines in the
rate of new infections. It is not clear
whether other African countries will
repeat this experience. There have been
recent signs of government leadership in
halting the spread of HIV in Kenya and
Tanzania; the presidents of these two
countries have stated that die countries
need to deal with HIV in order to curb
the epidemics in sub-Saharan Africa.
Uganda Provides Hope for Africa
However, there is a glimmer of hope in
Africa. In Uganda the rate of new HIV
infections has declined since the earlv
1990s when three in 10 pregnant women
in the capital city of Kampala were HIV
Thai Effort Successful
In Asia, Thailand’s experience shows
even more dramatically the effects that
concerted action bv the government,
(Continued on page 9)
2000 WwU Ptfolalim Data Slud
1
Despair and Hope: The HIV/AIDS Epidemic
ore people died of AIDS in
1999 than in any previous year.
The 2.6 million deaths in 1999
brought the estimated total number of
deaths since the beginning of the epi
demic to 16.3 million.
The annual number of deaths from
AIDS is not expected to peak for many
years because of the large number of
people already infected. The Joint Unit
ed Nations Programme on HIV/AIDS
^iid the World Health Organization esti
mate that in 1999, 5.6 million people
became infected with the human
immunodeficiency virus (HIV), which
causes the life-threatening illness AIDS.
Nearly 34 million people currently live
with HIV/AIDS.
The AIDS epidemic affects people of
all ages. About half of all people who
contract AIDS are under age 25. Over 90
percent of the children under age 15
who contract HIX' are bom to mothers
with HIV. Women can pass HIV to their
children during pregnancy or delivery
and through breastfeeding. Over the
course of the epidemic, AIDS has left
over 11.2 million children under age 15
without their mothers and many of those
same children without a father. While
e therapies can lengthen the life of
eone with AIDS, there is still no cure
for AIDS.
The elderly population is affected
indirectly by HIV/AIDS, as older people
become the primary caretakers of their
own children who are dying of AIDS and
also may become caretakers of grand
children orphaned by AIDS.
M
<
© 2000 Population Rrferrm-r Burma
Africa Dealt Worst Blow
Infection rates are not equally distrib
uted around the globe. Ninety-five per
cent of people who are infected with HIV
live in developing countries. The highest
concentration of people with the HIV
infection is in Africa, which accounts for
13 percent of the world’s population but
69 percent of the cases of HIV infection.
By contrast, Asia contains 61 percent of
world population and 20 percent of HIV
cases. The Americas have 14 percent of
world population and 8 percent of HIV
cases. Europe contributes 12 percent of
world population and 2 percent of its
population lives with an HIV infection.
Half of 1 percent of world population
lives in Oceania and those countries have
an even lower percent of HIV cases
worldwide—0.1 percent.
In sub-Saharan Africa about one in
every 30 people is infected with HIV. Just
over half of these people live in the
countries of Eastern Africa. Over 8 mil
lion people live with the HIV infection
in five Eastern African countries: 1.2 mil
lion in Mozambique, 1.4 million in Tan
zania, 1.5 million in Zimbabwe, 1.6
million in Kenya, and 2.6 million in
Ethiopia.
In Western Africa, Nigeria has the
largest population of people living with
HIV—2.3 million. Nearly 3 million peo
ple in South Africa are infected with
HIV—the highest number of any coun
try in Africa.
New evidence in Africa indicates that
more women titan men are infected with
HIV on that continent—perhaps 12 or
13 women are infected for every 10 men
Percent of World's
HIV/AIDS Cases
Percent of
World Population
0.5%
Oceania
who are infected. One reason for this
difference by gender is that women con
tract the disease at younger ages and
may be more likely to become infected
during any single exposure.
HIV/AIDS is having a devastating
effect on life expectancy in some coun
tries. A child born in'Southern Africa in
the early 1950s could expect to live to
age 44. By the early 1990s, life expectan
cy in this region had risen to nearly 60
years. But because of AIDS, that gain is
expected to be lost. A child born in
Southern Africa between 2005 and 2010
is expected to live just 45 years. (See the
demographic data for the current life
expectancies in other countries.)
positive. President Yoweri Museveni has
openly discussed the problem since
1986. People at all levels of society—
political, community, and religious lead
ers—have been involved in the
campaign to halt AIDS in Uganda, and it
has made a major impact on die epi
demic in this country. Still, it took sever
al years to begin to see declines in the
rate of new infections. It is not clear
whether other African countries will
repeat this experience. There have been
recent signs of government leadership in
halting the spread of HIX' in Kenya and
Tanzania; the presidents of these two
countries have stated that the countries
need to deal with HIX' in order to curb
the epidemics in sub-Saharan Africa.
Uganda Provides Hope for Africa
However, there is a glimmer of hope in
Africa. In Uganda the rate of new HIV
infections has declined since the early
1990s when three in 10 pregnant women
in the capital city of Kampala were HIV
Thai Effort Successful
In Asia, Thailand’s experience shows
even more dramatically the effects that
concerted action by the government,
(Continued on page 9)
2000 II’otM Population Dola Shea
Demographic Data and Estimates for the Countries and Regions of the World
"Doubling
Births Deaths Natural
Projected
Population per
per Increase
Population
mid-2000 1,000 1,000 (annual, at Current
(millions)
(millions) pop.
Rate
2025
2 050
%)
popI Eastern Africa
246
42
42
Comoros
' ■ w
0.6
38
10
Djibouti
0.6
39
16
Eritrea
4.1
43
Ethiopia
64.1
45
^nya
^Madagascar
30.3
14.9
Malawi
10.4
Burundi
18
17
infant
Total
Mortality Fertility
Rote0
Rate1*
2.4
29
390
I584
102
6.0
2.5
28
16.1
75
6.5
25
10.5
1.1
30
1.0
2.8
1.8
Percent of
Percent of
Married
Adult
Population Women Using
Percent of
Contraception
15-49
Data
Life Expectancy
Population
Modern
Avail.
with
All
at Birth (years)
of Age
<15
65+ Total Male Female Code' Urban HIV/AIDS Methods Methods
45
48
3
3
46
47
45
46
47
47
77
5.1
42
3
59
57
62
C
B
115
82
5.8
41
3
48
47
50
D
6.1
43
3
55
52
57
45
3
46
47
46
3.0
23
8.4
21
2.4
29
187.9
35
44
14
2.1
33
115.0
34.4
38.7
74
6.7
4.7
3
49
45
48
14
2.9
24
28.5
6.0
45
3
52
51
22
1.9
36
12.6
46.9
14.7
96
41
127
5.9
46
39
38
70
67
40
70
116
20
10.4
8
8.3
29
0.1
83
10.3
16
3.2
19
—
21
—
AFRICA
Govt.
View
Birth
Rate*1
1
1 Area, Density, and Capital City
Population
1998 iArea of countries per
(USS) (square miles) square mile Capital Qty
GNP
Per
260
2,456,184
100
H
140
10,745
563
Bujumbura
861
671
Moroni
—
H
H
370
—
8,958
71
Djibouti
14
—
11
8
4
4
H
200 |
45,405
91
Asmara
9.3
3
H
100
426,371
150
Addis Ababa
11.6
39
32
H
350
224,081
135
Nairobi
19
10
H
260
226,656
66
Antananarivo
22
14
H
210
45,745
227
Lilongwe
60
S
3,730
788 1,510
Port Louis
5
H
309,494
62
Maputo
73
67
—
210
—
969
739
St Denis
12.8
21
13
H
230
10,170
711
49
C
B
20
53
B
22
0.1
40
C
20
14.9
74
A
43
0.1
75
39
B
28
14.2
6
79
B
73
z
Mauritius
1.2
17
7
1.1
66
1.4
19.4
2.0
26
3
6
Mozambique
19.1
41
19
32
20.6
22.9
134
5.6
46
2
Reunion
0.7
20
5
2.2
1.4
49
1.0
1.2
9
2.2
30
6
40
74
Rwanda
7.2
43
20
2.3
30
8.0
39
39
40
D
Seychelles
1.1
65
0.1
6.5
2.0
3
18
121
9
45
0.1
8.9
0.1
28
7
70
67
73
B
59
—
—
—
H
6,420
174
472
Kigali
Victoria
18
2.9
24
14.9
126
44
3
46
45
D
24
0.3
—
—-
246,201
29
Mogadishu
3
2
53
52
C
20
9.4
24
—
16
S
45
48
54
H
220
364,900
97
Dar-es-Salaam
42
42
43
B
8
H
310
93,066
251
Kampala
38
B
290,583
33
Lusaka
B
H
H
330
39
620
150,873
75
Harare
320
380
2,553,151
38
481,351 |
27
84 Yaounde
Bangui
Tanzania
35.3
42
13
2.9
24
59.8
25.5
88 3
99
7.0
5.6
Uganda
23.3
48
20
2.9
24
48.0
84.1
81
6.9
49
20.3
109
6.1
3
37
9.3
80
4.0
45
44
3
40
37
41
47
Somalia
9.6
42
23
2.0
35
14.3
11.3
30
20
69
9.5
96
46
16
1.0
3.0
23
185
303
106
6.6
46
3
49
48
51
Angola
12.9
48
19
3.0
23
25.1
36.9
125
6.8
48
3
47
45
48
Cameroon
15.4
37
12
26
27
24.7
34.7
77
5.2
43
3
55
55
56
38
18
2.0
34
4.9
6.4
97
5.1
44
4
45
43
46
Zambia
Zimbabwe
1 Middle Africa
9.5
38
32
19.1
26
14
25.8
54
50
32
4.3
10
3
D
32
44
2.1
4.9
—
19
—
7
H
610
183,568
C
39
10.8
15
3
S
300
240,533
I
15
Luanda
Central African Republic
3.5
Chad_________________
8.0
50
17
17.3
31.5
110
6.6
44
3
48
46
51
B
22
2.7
4
1
S
230
495,753
16
N'Djamena
2.8
40
16
3.3
2.4
21
Cfftgo________________
■^o?Dem7Rep. of (Zaire)
29
4.6
6.9
109
5.3
3
48
45
50
C
41
7.8
—
—
H
680
132,046
21
Brazzaville
52.0
48
16
3.2
22
105.3
181.9
109
7.2
43
48
3
49
47
50
8
3
S
110
905,351
57
Kinshasa
Equatorial Guinea
0.5
41
16
28
0.8
1.1
108
5.6
43
4
50
48
52
D
37
1.2
—
—
1,110
10,830
42
Malabo
Gabon
Sao Tome and Principe
1.2
38
16
2.2
32
2.0
2.7
87
5.4
39
6
52
51
54
C
73
4.3
—
—
S
L
4,170
103,347
12
Libreville
20
0.3
0.5
51
6.2
47
4
64
63
66
B
44
54
53
55
42
—
52
Sao Tome
5
—
53
H
35
—
13.5
41
4
44
43
45
C
49
25.1
—
19
H
0.2
43
9
3.4
50
26
13
52
43
43
51
45
1.2
1.2
57
3.1
4.1
29
270
371
432
3.100
1,032,730,
48
3.070
224 606
7
183
Gaborone
6
Windhoek
Botswana
1.6
32
17
1.3
1.6
Lesotho
2.1
33
13
2.1
33
2.4
2.8
85
4.4
41
5
53
52
55
C
16
8.4
—
23
H
570
11,718
Namibia
1.8
36
20
1.7
42
2.3
3.8
68
44
4
46
47
45
B
27
19.9
29
26
H
1.940
South Africa
43.4
25
12
1.3
55
35.1
32.5
45
5.1
2.9
34
5
55
54
57
B
45
12.9
56
55
H
3,310
318,259
471,444
1.0
41
22
1.9
37
1.6
3.1
108
5.9
47
3
38
36
39
C
22
18.5
21
19
H
1,400
6,703I
1 Southern Africa
_______
Swaziland
© 2000 Population Reference Bureau
For notes, see page 10.
i
Maseru
92 Pretoria
150
Mbabane
2000 WoM Population Data Shea
Demographic Data and Estimates for the Countries and Regions
WORTH
AMERICA
"Doubling
Births Deaths Natural Time"
Projected
Population per
per Increase in Years
Population
mid-2000 1,000 1,000 (annual, at Current
(millions)
(millions) pop. pop.
2025
2050
Rato
%)
NORTH AMERICA
Canada
306
30.8
United States
LATIN AMERICA & THE
CARIBBEAN
| Central America
14
11
9
7
0.6
0.4
124
178
374
36.0
275.6
15
518
24
6
1.8
39
703
136
26
5
2.1
33
192
32
5
2.7
26
9
0.6
120
337.8
444
40 2
Infant
Total
Mortality Fertility
Rate’
Rate*
-7
5.5
7n
1.5
21
19
13
12
77
79
74
80
76~ " 81
7.0
2.1
21
13
77
74
79
823
35
2.8
33
5
70
66
73
232
34
3.1
38
4
71
68
74
34
3.9
41
4
72
70
74
403.7
A
A
0.7
75
78 ' "o.3
77
80
GNP
Per
Govt.
View
of
Birth
Rated
1998
(USS)
70
’ 66 ~
s
28,230
19,170
7,699,508
3,849,670
s
29,240
3,717,796
3,880
7,946,649
65
3,230
957,452
145
Married
Adult
Population Women Using
Percent of
Contraception
15-49
Data
Life Expectancy
Population
Modern
All
Percent
with
Avail.
at Birth (years)
of Age
<15
65+ Total Male Female Code* Urban HIV/AIDS Methods Methods
75
0.8
76
71
74
0.6
68
59
67
0.4
62
53
50
1.9
47
42
Area, Density, and Capital Cityl
Population
Area of countriesi per
(square miles) square mile Capital City
25
8
I
Ottawa
74 Washington, DC
2,660
8,865
29
Mt]
Belmopan
_
2,770
19,730
182
San Jose
San Salvador
Costa Rica
3.6
22
4
1.8
39
5.8
7.0
13
3.2
33
5
77
75
79
B
45
0.6
75
65
s
s
El Salvador
6.3
30
7
2.4
29
9.8
13.6
35
3.6
36
5
70
67
73
B
58
0.6
60
54
H
1,850
8,124
773
Guatemala
12.7
37
7
2.9
24
22.3
32.2
45
5.0
44
3
64
61
67
B
39
0.5
38
31
H
1,640
42,042 I
301
Guatemala
Honduras
6.1
33
6
2.8
25
8.6
11.0
42
4.4
42
3
68
66
71
B
45
1.5
50
41
H
740
43,278 |
142
Tegucigalpa
Mexico
36
69
75
Belize
0.3
0.4
0.5
B
Mexico City
99.6
24
4
2.0
132.5
152.1
32
2.7
37
5
72
B
74
0.4
65
56
H
3,840
756,062
132
Nicaragua
5.1
36
6
3.0
23
8.7
11.6
40
4.4
44
3
68
66
71
B
63
0.2
60
57
H
370
50,193
101
Managua
Panama
2.9
22
5
1.7
41
3.8
4.3
21
2.6
32
5
74
72
77
C
56
0.6
—
—
S
2,990
29,158
98
Panama City
1 Caribbean
36
22
8
1.3
52
46
51
47
2.6
30
7
69
66
71
61
1.8
—
—
—
90,618
401
Antigua and Barbuda
0.1
22
6
1.6
45
0.1
0.1
17
2.2
28
8
71
69
74
B
37
—
-
—
s
8,450
170
400
Bahamas
0.3
21
5
1.5
45
0.4
0.5
18.4
2.2
32
5
74
70
77
A
84
3.8
—
—
H
—
5,359
Barbados
0.3
14
9
0.5
130
0.3
0.3
14.2
1.8
24
10
75
72
77
A
38
2.9
—
—
S
—
Cuba
11.1
14
7
0.7
103
11.7
10.6
7
1.6
22
9
75
73
78
C
75
z
—
—
S
—
Dominica
0.1
16
8
0.8
83
0.1
0.1
14.6
1.9
38
7
78
75
80
A
—
—
—
—
S
Dominican Republic
8.4
28
6
2.2
32
12.1
14.9
47
3.1
36
4
69
67
71
B
62
1.9
64
59
H
Grenada_________
0.1
29
6
2.3
30
0.2
0.2
14
3.8
43
5
71
68
73
B
34
—
54
49
H
Guadeloupe
1.1
58
166 j 1,560
1
St. John's
Nassau
Bridgetown
Havana
42,803
260
3,150
290
262
1,770
18,815
449
Santo Domingo
3,250
131 i
747
St. George's
Roseau
____
0.4
17
6
61
0.5
0.5
10.0
2.0
26
9
77
73
80
A
48
—
—
—
—
—
660
680
Haiti________________
6.4
33
16
1.7
40
9.6
11.9
103
4.7
40
4
49
47
51
C
34
5.2
18
14
H
410
10,714
599
Basse-Terre
Port-au-Princ^y)
_______
2.6
22
7
1.6
45
3.3
3.8
24
2.6
31
7
71
70
73
B
50
1.0
66
63
H
1,740
4,243
615
Kingston
Martinique___________
0.4
15
6
0.9
81
0.5
0.5
9
1.8
24
11
78
75
82
C
81
—
—
—
—
—
425
961
Fort-de-France
Netherlands Antilles______
0.2
17
6
1.1
62
0.3
0.3
14
2.2
27
7
75
72
78
B
—
—
—
—
—
—
309
715
Willemstad
4.2
11.3
—
78
68
Jamaica
Puerto Rico
St. Kitts-Nevis___________
Saint Lucia_____________
■^Vincent & the Grenadines
Trinidad and Tobago
___ ____ ______
4
2000 World Population Data Shat
3.9
17
8
0.9
75
4.2
25
10
74
70
79
A
71
—
—
3,456
1,133
0.04
20
11
0.9
82
0.1
0.1
24
2.2
31
9
67
64
70
C
43
—
—
—
H
6,190
139
309
Basseterre
0.2
19
6
1.2
56
0.2
0.2
16.8
2.5
33
6
72
71
72
A
48
—
—
—
H
3,660
239
656
Castries
0.1
19
7
1.2
59
0.1
0.2
20.4
2.0
37
7
73
71
74
A
44
—
—
—
H
2,560
151
1.3
14
7
0.7
103
1.5
1.5
16.2
1.7
28
6
71
68
73
A
72
0.9
—
—
H
4,520
1,981
2.1
For notes, see page 10.
San Juan
744 ’ Kingston
654
Port-of-Spain
© 2000 Population Reference Bureau
—
Demographic Data and Estimates for the Countries and Reaions of the World
LATIN AMERICA
R. TMC
CARIBBEAN
Births
Population per
mid-2000 1,000
(millions) P°P345
37.0
23
19
per
1,000
P°P6
8
Bolivia
8.3
30
Brazil
170.1
Chile
15.2
^jglombia
| South Ameirica
Natural
Increase
%)
"Doubling
Time"
Projected
Population
at Current
(millions)
Rate
2025
2050
Infant
Total
Mortality Fertility
Rate’
Rate*
Percent of
Percent of
Aauit
marriea
Population Women Using
Data
15-49
Contraception
Population
Life Expectancy
Avail. Percent with
All
Modern
of Age
at Birth (years)
<15
65+ Total Male Female Code' Urban HIV/AIDS Methods Methods
Birth
Rated
A
78
90
0.6
0.7
72
—
63
—
S
4,270 6,898,579
1,073,514
8,030
50
35
Buenos Aires
B
62
0.1
48
25
S
1,010
424,162
20
LaPaz
B
78
0.6
77
70
3,300,154
52
Brasilia
85
0.2
—
4,990
292,135
52
Santiago
71
0.4
72
59
s
s
s
4,630
—
2,470
439,734
91
Bogota
B
63
0.3
57
46
H
1,520
109,483
116
Quito
1.7
1.1
42
62
465
47.2
540
54.5
34
19.1
w
10
2.0
34
12.2
15.5
67
21
6
1.5
45
221.2
244.2
38
18
5
1.3
54
19.5
22.2
10.5
2.4
29
7
75
72
78
A
40.0
26
6
2.0
34
58.3
73.3
28
3.0
33
4
69
65
73
B
^Wuador
12.6
27
6
2.1
33
17.8
21.2
40
3.3
35
4
69
67
72
Argentina
2.6
32
29
5
9
69
73
66
70
73
77
4.2
40
4
60
59
62
2.4
30
5
68
64
71
OCEANIA
——__ .
GNP
Area, Density, and Capital City I
Per
Population
Capita,
1998 Area of countries per
(uss) (square miles) square mile Capital Gty
Govt.
View
French Guiana
0.2
27
3
2.4
29
0.4
0.6
18
3.4
36
4
74
71
77
C
79
—
—
—
—
—
34,749
6
Cayenne
Guyana
0.7
24
7
1.7
40
0.8
0.8
63
2.7
35
4
66
63
69
c
36
2.1
—
—
s
780
83,000
8
Georgetown
Paraguay
5.5
32
6
2.7
26
9.4
12.6
27
4.3
41
4
70
68
72
B
52
0.1
57
48
H
1,760
157,046
35
Asuncion
Peru
27.1
27
6
2.1
32
39.2
47.9
43
3.4
34
5
68
66
71
B
72
0.6
64
41
H
2,440
496,224
55
Lima
Paramaribo
Montevideo
Suriname
0.4
26
7
1.9
37
0.5
0.4
29
2.4
33
5
70
68
73
D
69
1.2
—
-
S
1,660
63,039
7
Uruguay
3.3
16
10
0.7
107
3.9
4.2
14.5
2.3
25
13
74
70
78
A
92
0.3
—
—
L
6,070
68,498
48
Venezuela
24.2
25
5
2.0
34
34.8
42.2
21.0
2.9
37
4
73
70
76
A
86
0.7
—
—
S
3,530
352,143
69
OCEANIA
31
18
7
1.1
65
39
44
29
2.4
26
10
74
72
77
70
0.1
61
56
15,400
3,306,692
9
1.7
21
12
79
76
82
85
0.1
67
63
s
20,640
2,988,888
6
A
Caracas
Canberra
7
0.6
110
22.8
24.9
5.3
Fed. States of Micronesia
0.1
33
7
2.6
27
0.2
0.3
46
4.7
44
4
66
65
67
C
27
—
—
—
H
1,800
270
440
Palikir
Fiji
0.8
22
7
1.5
46
1.1
1.3
13
3.3
35
3
67
65
69
C
46
0.1
—
—
S
2,210
7,054
115
Suva
Australia
19.2
13
French Polynesia
0.2
21
5
1.6
44
0.3
0.4
10
2.6
3
72
69
74
c
54
—
—
—
—
—
1,544
150
Papeete
Guam
0.2
28
4
2.4
29
0.2
0.3
9.1
3.5
32
5
74
72
77
A
38
—
—
—
—
—
212
720
Agana
Kiribati
0.1
33
8
2.5
28
0.2
0.2
62
4.5
40
3
62
59
65
C
37
—
—
—
H
1,170
282
326
Tarawa
Marshall Islands
0.1
26
4
2.2
31
0.2
0.3
31
6.6
49
3
65
67
c
65
—
—
—
H
1,540
69
978
Majuro
0—
0.01
19
5
1.4
48
0.02
0.02
25
3.7
43
1
61
57
65
B
100
—
—
—
S
—
9
1,360
Yaren
0.3
0.3
7
2.7
31
5
72
69
77
c
59
—
—
—
—
—
7,174
30
Noumea
4.5
5.5
2.0
23
12
77
74
80
A
85
0.1
75
72
S
14,600
104,452
37
Wellington
67
64
31
63
New Caledonia
0.2
21
5
1.7
42
New Zealand
3.8
15
7
0.8
89
4.4
Palau
0.02
18
8
1.0
68
0.03
0.03
19
2.5
28
6
71
C
71
—
—
—
s
—
178
108
Koror
Papua-New Guinea
4.8
34
10
2.4
29
7.7
9.5
77
4.8
40
4
56
56
57
C
15
0.2
26
20
H
890
178,703
27
Port Moresby
0.8
1.1
25
5.4
43
3
71
69
74
C
13
—
—
—
H
760
11,158
39
Honiara
19
4.2
43
4
71
70
72
c
32
—
—
—
S
1,750
290
372
Nukualofa
Solomon Islands
0.4
37
6
3.1
23
Tonga
0.1
27
6
2.1
33
0.2
0.2
Vanuatu
0.2
35
7
2.8
25
0.3
0.3
39
4.7
44
3
65
64
67
c
18
—
—
—
S
1,260
4,707
41
Port-Vila
Western Samoa
0.2
31
6
2.5
28
0.2
0.2
25
4.2
39
4
68
65
72
c
21
—
—
20
H
1,0701
1,097
161
Apia
© 2000 Population Reference Bureau
For notes, see page 10.
2000 World Populalitm Data Shell
2
I
Demographic Data and Estimates for the Countries and Regions of the World
ASIA
-Doubling
Births Deaths Noturol Time"
Pro|ected
Popoiolion per
per Incrense in Years
Population
mid-2000 1,000 1,000 (annual, at Current
(millions)
(millions) pop. pop.
%)
Rate
2025
2050
Percent of
Percent of
Adu"
Mo,ri'd
Percent of
Population Women Using
Infant
Total
Population
tile Expectancy
Dote
15-49
Contraception---Mortality Fertility
of Age
at Birth (years)
Avail. Percent with
All
Modern
Rale*
Rate" <15
65+ Total Male Female Code1 Urban HIV/AIDS Methods Methods
Gwl'
View
of
Birth
Rate
GNP I Area, De nsity. and Capital City
Per
Population
Capita,
1998 Area of countries per
(square miles) square mile1 Capital Gty
(USS)
ASIA
3,684
22
8
1.4
48
4,723
5,267
56
2.8
32
6
66
65
68
35
0.3
62
57
2,130
12,262,691
300
Asia (Excl China)
2,420
26
8
1.7
40
3,292
3.898
64
3.3
35
5
64
63
65
38
0.5
50
43
2,910
8,566,591
283
I Western As ia
189
28
7
2.1
33
300
396
55
4.0
37
4
68
66
70
3,620
3.8
10
6
0.4
161
4.1
3.8
15
1.3
25
9
75
71
78
Armenia
B
65
z
—
—
67
z
22
—
L
1,823,873
104
460
11,506
331
Yerevan
33,436
231
Baku
Azerbaijan
7.7
15
6
0.9
77
9.8
11.5
17
1.9
33
6
72
68
75
B
52
z
—
—
5
480
Bahrain
0.7
22
3
1.9
37
1.7
2.9
8
2.8
31
2
69
68
71
B
88
0.2
62
31
5
7,640
Cyprus
0.9
14
8
0.6
124
1.0
1.1
8
1.9
24
10
77
74
79
C
64
0.3
—
—
L
11.920
3,571
247
Nicosia
Georgia
5.5
9
8
0.2
462
4.8
4.2
15
1.2
24
11
73
69
76
B
56
z
41
20
L
970
26,911 |
203
Tbilisi
Iraq
23.1
38
10
2.8
25
41.0
54.9
127
5.7
43
3
59
58
60
C
68
z
-
—
5
—
169,236
137
Baghdad
Israel
6.2
22
6
1.5
45
8.3
9.4
6.0
2.9
29
10
78
76
80
A
90
0.1
—
—
L
16,180
8,131
766
Jerusalem
Jordan
5.1
33
5
2.9
24
8.8
12.0
34
4.4
42
3
69
68
70
B
78
z
53
38
H
1,150
34,444
148
Amman
Kuwait
2.2
24
2
2.2
32
3.8
4.4
13
3.2
29
1
72
72
73
B
100
0.1
—
—
S
—
6,880
318
Kuwait
Lebanon
4.2
23
7
1-6
43
5.6
6.5
35
2.4
30
6
70
68
73
D
88
0.1
—
—
S
3,560
4,015
1,046
Beirut
Oman
2.4
43
5
3.9
18
5.2
9.0
25
7.1
46
3
71
69
73
B
72
0.1
24
18
H
—
82,031
29
Muscat
266 I 2,594
Manama
Palestinian Territory
3.1
41
5
3.7
19
7.4
11.2
27
6.0
47
3
72
70
73
B
-
-
-
-
-
1,560
2,417
1,283
—
Qatar
0.6
20
2
1.8
38
0.8
0.8
20
4.2
27
1
72
70
75
C
91
0.1
—
—
S
—
4,247
139
Doha
TTjdi Arabia
21-6
35
5
3-°
23
40 0
54 5
46
6-4
42
3
70
68
71
C
83
z
-
-
s
6,910
829,996
26
Riyadh
Svrja
16.5
33
6
28
25
26.9
35.3
35
4.7
45
3
67
67
68
B
51
z
40
28
5
1,020
71,498
231
Damascus
“TTTy __________________ 653
22
7
15
46
88.0
1°°-7
38
23
30
5
69
67
71
B
66
z
64
38
H
3,160
299,158
218
Ankara
United A?ab Emirates_________ 2-8
24
2
2.2
32
3.8
4,2
16
4.9
33
2
74
73
76
C
84
0,2
28
24
S
17,870
32,278
88
Abu Dhabi
B
H
280
203,849
84
Sana'a
17 0
39
11
2-8
25
388
1,475
28
9
1.9
37
2,037
Afghanistan
267
43
18
2-5
28
48-0
76.2
Bangladesh
Yemen[south Central Asia
693
2,451
"
9’’
49
3
59
58
61
75
3.6
38
4
61
60
62
150
6.1
43
3
46
46
45
59
58
1281
27
8
1.8
38
177.3
210.8
82
3.3
43
3
59
09
Bhutan ___ ____
___
1'002'1
India____
_____
674
Iran
____________ 14 9
Kazakhstan
40
9
3J
22
L4
2-°
71
5-6
43
2
88
_______ __________
Kyrgyzstan
£
7 pt,/,M'‘"" DM ShM
2000 Worf
26
z
21
TO
29
0.6
46
40
D
20
z
-
_
B
20
z
49
42
Dhaka
D
15
z
8
-
Thimphu
39
1'363'°
1.628.0
72
3.3
36
4
61
60
61
B
28
08
21
6
14
48
908
1029
31
29
39
5
89
68
71
B
63
z
14
10
04
161
14 6
13 0
21
17
29
7
85
59
70
B
56
z
22
7
L5____ f“_____ 6-1
26
28
37
8
67
63
71
B
34
z
27
9
18
For noles> see page JQ
510
H
251,772
106
H
35^
55,598 2,305
H--------- W-------- ^7
48
48
43
H
440
1 269 340
789
73
56
H
1,650
630 575
107
«------- 54--------[------- i^O 1 049 15t
14
60
49
5
380
76,641
64
AA
■n
Kabul
New Delhi
Tehran
Astana
Bishkek
kilion Rtfemux Hureau
Demographic Data and Estimates for the Countries and Regions of the World
-Doubling
Births Deaths Natural Time"
Projected
Population per
per Increase
Population
mid-2000 1,000 1,000 (annual, at Current ____(millions)
(millions) pop.
pop.
Rate
2025
2050
%)
Infant
Total
Mortality Fertility
Ratek
Rate0
Percent of
Percent of
Govt.
Married
Adult
View
Population Women Using
Percent of
Contraception__
15-49
Life Expectancy
Population
Modern Birth
All
Avail. Percent with
at Birth (years)
of Age
<15
65+ Total Male Female Code1 Urban HIV/AIDS Methods Methods Rated
ASIA
GNP I Area, Density, and Capital City 1
Per I
Capita,
Population
1998 Area of countries per
(USS) (square miles) isquare milei Capital Qty
116 2,469
Maldives
0.3
35
5
3.0
23
0.5
0.7
27
5.4
45
3
71
71
72
B
25
0.1
18
—
H
1,130
Nepal
23.9
36
11
2.5
28
38.0
49.3
79
4.6
41
3
57
58
57
B
11
0.2
29
26
H
210
56,826
421
Pakistan
150.6
39
11
2.8
25
227.0
285.0
91
5.6
43
3
58
58
59
C
33
0.1
18
13
H
470
307,375
490
Islamabad
Sri Lanka
19.2
18
6
1.2
60
23.9
25.9
17
2.1
35
4
72
70
74
B
22
0.1
66
44
5
810
25,332
757
Colombo
370
55,251
115
Dushanbe
—
188,456
28
Ashkhabad
Tashkent
Tajikistan
^Lrkmenistan
6.4
21
5
1.6
43
8.4
9.5
28
2.7
44
4
68
66
71
B
27
z
21
—
H
5.2
21
6
1.5
48
6.8
7.5
33
2.5
40
4
66
62
69
B
44
z
20
—
S
B
S
Uzbekistan
24.8
23
6
1.7
40
31.5
33.8
22
2.8
40
4
69
66
72
Southeast Asia
S28
24
7
1.7
41
717
836
46
3.0
34
4
65
63
67
Brunei
0.3
25
3
2.2
32
0.5
0.7
24
3.4
34
3
71
70
73
Cambodia
12.1
38
12
2.6
27
21.2
29.0
80
5.3
43
3
56
54
58
East Timor
0.8
34
16
1.8
39
1.2
1.4
143
4.6
42
2
46
45
47
Indonesia
212.2
24
8
1.6
44
273.4
311.9
46
2.8
34
4
64
62
66
Laos
5.2
41
15
2.6
26
8.4
11.8
104
5.6
44
4
51
50
52
C
Malaysia
23.3
25
5
2.1
34
37.0
48.2
8
3.2
34
4
72
70
75
C
Myanmar
48.9
30
10
2.0
35
68.1
87.8
83
3.8
37
4
54
53
56
c
Male
Kathmandu
38
z
56
51
36
0.6
56
48
B
67
0.2
-
-
s
-
2,228
B
16
2.4
22
16
H
260
69,900
B
—
—
—
—
—
—
5,741
137
Dili
B
39
0.1
57
55
H
640
735,355
289
Jakarta
17
z
25
21
H
320
91,429
57
Vientiane
57
0.6
—
—
H
3,670
127,317
183
Kuala Lumpur
26
1.8
17
14
S
—
261,228
187
Yangon
115,830
693
Manila
950
172,741
144
1,240
1,735,448
304
Seri
149 Bandar
Begawan
173 Phnom Penh
Philippines
80.3
29
7
2.3
31
117.3
139.6
35
3.7
38
4
67
66
69
B
47
0.1
49
32
H
1,050
Singapore
4.0
13
5
0.8
84
8.0
10.4
3.2
1.5
22
7
78
76
80
A
100
0.2
65
—
L
30,170
Thailand
62.0
16
7
1.0
70
72.1
71.9
22
1.9
24
5
72
70
75
B
31
2.2
72
70
S
2,160
198,116
313
Bangkok
Vietnam
78.7
20
6
1.4
48
109.9
123.7
37
2.5
34
6
66
63
69
B
24
0.2
75
56
H
350
128,066
615
Hanoi
1,493
15
7
0.8
85
1,669
1,585
29
1.8
24
8
72
70
74
38
0.1
81
78
3,880
4,546,050
328
1,264.5
15
6
0.9
79
1,431.0
1,369.0
31
1.8
25
7
71
69
73
B
31
0.1
83
81
s
750
3,696,100
342
7.0
7
5
0.3
256
8.6
7.6
3.2
1.0
17
11
80
77
82
A
95
0.1
—
—
—
23,660
I East Asia
China, Hong Kong SARC
239 16,714
413 16,949
0.4
10
3
0.7
96
0.6
0.8
6
1.2
25
8
77
75
80
B
99
—
—
—
—
—
126.9
9
8
0.2
462
120.9
100.5
3.5
1.3
15
17
81
77
84
A
78
z
64
57
L
32,350
145.869
Korea, North
21.7
21
7
1.5
48
25.7
26.4
26
2.3
28
6
70
67
73
C
59
z
-
—
S
—
Korea, South
47.3
14
5
0.9
82
53.3
51.1
11
1.5
22
7
74
71
78
8
79
z
77
66
S
8,600
3.4
4.1
34
2.7
35
4
63
60
66
C
52
z
57
41
S
25.3
25.2
6.6
1.5
21
8
75
72
78
A
77
-
-
-
-
China, Macao SARC
Japan
Mongolia
Taiwan
© 2000 Population Reference Bureau
2.5
22.3
20
13
7
6
1.4
0.7
50
97
F°r notes, See page 10.
Singapore City
____________
Beijing
—
8 57,628
Macao
870
Tokyo
46,541
466
Pyongyang
38,324
1,234
Seoul
380
604,826
4
-
13,969 ' 1,593
Ulan Bator
Taipei
2000 World Population Data Shed
Z
Acknowledgments, Notes, Sources, and Definitions.
Acknowledgments
6 authors 9ratefully acknowledge the assistance and
peration of staff members of the International
rograms Center of the U.S. Census Bureau; the
opulation Division and the Statistics Division of the
ntted Nations (UN); the Population and Migration
'vision of the Council of Europe; the Institut national
a etudes demographiques (INED), Paris; the World Bank;
and Ralf Ulrich, CEO, Eridion GmbH, Germany, in the
preparation of this year's Data Sheet. Suzanne Baker, PRB
Policy Fellow, produced many of the population projec
tions in this year's Data Sheet.
.
Notes
(—) indicates data unavailable or inapplicable
z = Less than 0.5 percent
j* Infant deaths per 1,000 live births
b Average number of children born to a woman during
her lifetime
c A=complete data ... D=little or no data
d H=too high; S=satisfactory; L=too low
e Special Administrative Region
f The former Yugoslav Republic
The Data Sheet lists all geopolitical entities with popu
lations of 150,000 or more and all members of the UN.
These include sovereign states, dependencies, overseas
departments, and some territories whose status or bound
aries may be undetermined or in dispute. More devel
oped regions, following the UN classification, comprise
all of Europe and North America, plus Australia, Japan,
and New Zealand. All other regions and countries are clas
sified as less developed. Country regional designations
also follow UN practice. As a result, North America does
not include countries of Latin America classified as less
developed.
World and Regional Totals: Regional population
totals are independently rounded and include small coun
tries or areas not shown. Regional and world rates and
percentages are weighted averages of countries for which
data are available; regional averages are shown when
data or estimates are available for at least three-quarters
of the region's population.
IQ
2000 World PofuMion Dola Shr
Sub-Saharan Africa: All countries of Africa except the
Northern African countries of Algeria, Egypt, Libya,
Morocco, Tunisia, and Western Sahara.
World Population Data Sheets from different years
should not be used as a time series. Fluctuations in val
ues from year to year often reflect revisions based on new
data or estimates rather than actual changes in levels.
Additional information on likely trends and consistent
time series can be obtained from PRB, and are also avail
able in UN and U.S. Census Bureau publications.
Sources
The rates and figures are primarily compiled from the
following sources: official country statistical yearbooks
and bulletins; United Nations Demographic Yearbook,
1998 (forthcoming) and Population and Vital Statistics
Report, Data Available as of 1 April 2000 (forthcoming) of
the UN Statistics Division; World Population Prospects: The
1998 Revision of the UN Population Division; the UN
Statistical Library; Recent Demographic Developments in
Europe, 1999 of the Council of Europe; Population 54:4-5
(INED) La conjoncture demographique, by Alain Monnier;
and the data files and library resources of the
International Programs Center, U.S. Census Bureau. Other
sources include recent demographic surveys such as the
Demographic and Health Surveys, Reproductive Health
Surveys, special studies, and direct communication with
demographers and statistical bureaus in the United States
and abroad. Specific data sources may be obtained by
contacting the authors of the 2000 World Population Data
Sheet.
For countries with complete registration of births and
deaths, rates are those most recently reported. For more
developed countries, nearly all vital rates refer to 1998 or
1999, and for less developed countries, for some point in
the late 1990s.
Definitions
Mid-2000 Population
Estimates are based on a recent census, official nation
al data, or UN and U.S. Census Bureau projections. The
effects of refugee movements, large numbers of foreign
workers, and population shifts due to contemporary polit
ical events are taken into account to the extent possible.
Birth and Death Rate
The annual number of births and deaths per 1,000
total population. These rates are often referred to as
"crude rates" since they do not take a population's age
structure into account. Thus, crude death rates in more
developed countries, with a relatively large proportion
of high-mortality older population, are often higher
than those in less developed countries with lower life
expectancy.
Rate of Natural Increase (RNI)
The birth rate minus the death rate, implying the
annual rate of population growth without regard for
migration. Expressed as a percentage.
A
Population "Doubling Time" at Current Rate
The number of years it would take for the population
to double if the rate of natural increase remained con
stant. Based upon the unrounded RNI, this column pro
vides an indication of potential growth associated with a
given RNI. It is not intended to forecast the actual dou
bling of any population. Projections for 2025 and 2050
should be consulted for a more plausible expectation of
future growth or decline.
Projected Population in 2025 and 2050
Projected populations based upon reasonable assump
tions on the future course of fertility, mortality, and
migration. Projections are based upon official country pro
jections, series issued by the UN or the U.S. Census Bureau,
or PRB projections.
Infant Mortality Rate
The annual number of deaths of infants under age 1^
year per 1,000 live births. Rates shown with decimals indr
cate national statistics reported as completely registered,
while those without are estimates from the sources cited
above. Rates shown in italic are based upon less than 50
annual infant deaths and, as a result, are subject to con
siderable yearly variability.
© 2000 Population Reference Bur.
Total Fertility Rate (TFR)
The average number of children a woman would have
assuming that current age-specific birth rates remain con
stant throughout her childbearing years (usually consid
ered to be ages 15 to 49).
Population Under Age 15/Age 65+
The percentage of the total population in these ages,
which are often considered the "dependent ages."
Life Expectancy at Birth
The average number of years a newborn infant can
^pect to live under current mortality levels.
Data Availability Code
Provides a general indication of data availability. An
"A" indicates a country with both complete vital statistics
(birth and death data) and either a national-level census
within 10 years or a continuous population register. If a
country has complete vital statistics or a continuous popu
lation register and a national-level census within 15 years,
they are rated "B." Also rated "B" are countries that have
one of the three sources necessary for an "A" plus either
a usable national survey or a sample registration system
within 10 years. "C" indicates that at least a census (with
in 15 years), a survey (within 10 years), or sample registra
tion system is available. "D" indicates that little or no reli
able demographic information is available and that esti
mates are based on fragmentary data or demographic
models. Countries whose demographic situations have
been seriously disrupted and for which there are few
recent data are also coded "D." There can be considerable
variation in the quality of data within the same category.
Percent Urban
Percentage of the total population living in areas
termed "urban" by that country. Typically, the population
living in towns of 2,000 or more or in national and provin
cial capitals is classified "urban."
Percent of Adult Population Ages 15 to 49 With HIV/AIDS
The estimated percentage of adults with HIV/AIDS at
the end of 1997. These data are compiled by UNAIDS and
the World Health Organization.
Contraceptive Use
The percentage of currently married or "in-union"
women of reproductive age who are currently using any
form of contraception.
"Modern" methods include clinic and supply methods
such as the pill, IUD, condom, and sterilization. Data are
from the most recent available national-level surveys, such
as the Demographic and Health Survey, Reproductive
Health Survey programs, and the UN Population Division
Levels and Trends of Contraceptive Use as Assessed in
1998. Other sources include direct communication with
national statistical organizations and the databases of the
United Nations Population Division and the U.S. Census
Bureau. Data refer to some point in the 1990s. Data prior
to 1994 are shown in italics.
Government View of Current Birth Rate
This population policy indicator presents the officially
stated position of country governments on the level of
the national birth rate. Most indicators are from the UN
Population Division, Global Population Policy Data Base,
1999.
GNP Per Capita
Gross National Product includes the value of all domes
tic and foreign output. Estimates are from The World
Bank, World Development Report, 2000 (forthcoming).
Despair and Hope: The HIV/AIDS Epidemic
^ources:
SBint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO),
AIDS Epidemic Update: December 1999.
Population Reference Bureau, 2000 World Population Data Sheet.
Werasit Sittitrai, Associate Director, Department of Policy, Strategy and Research, UNAIDS, "HIV
Prevention Needs and Successes: A Tale of Three Countries," unpublished paper based on a
speech at the Office of AIDS Research Advisory Council, National Institutes of Health, Bethesda,
MD, April 28, 1999. Available online: www.unaids.org.
Karen Stanecki, U.S. Census Bureau presentation at population seminar, National Press Club,
Washington, DC, Jan. 18, 2000.
UNAIDS, Report on the Global HIV/AIDS Epidemic June 1998.
© 2000 Population fyfenmce Burrau
Note:
The regional figures were calculated by PRB using country level data from the 1998 UNAIDS
report cited above. The 1999 UNAIDS report cited above provides updated regional prevalence
data. Those data are not reported here because the regions differ from those used on the Data
Sheet. For these latest data, and future updates, go to: www.unaids.org.
Reviewer: Chris Elias, Senior Associate and Country Representative, The Population Council,
Bangkok, Thailand.
2000 World Population Data Short
1I
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Table of ContiemiH
Overview............................................................................................................. ]
Introduction: The World of 1.7 Billion Youth............................................................ 2
Box 1: Who ore "Youth"?.......................................................................... 2
Educating Girls and Boys...................................................................................... 3
The Sexual and Reproductive Lives of Young Men and Women............................... 4
Marriage.................................................................................................. 4
Adolescent Sexual Activity.......................................................................... 5
Adolescent Childbearing..........................................................................
6
Box 2: Reaching Young Men...................................................................... 6
Impact of Adolescent Childbearing on Future World Population..................... 8
Use of Contraception.............................................................................................8
Sexual Violence Against Young Women.................................................................. 9
Sexual Abuse and Coercion........................................................................ 9
Female Genital Cutting............................................................................ 10
Youth and the HIV/AIDS Crisis............................................................................ 10
A Call for HIV/AIDS Education.................................................................. 11
Socially Marginalized Youth................................................................................ 11
Box 3: Keys to Reaching Socially Marginalized Youth................................. 12
Policy and Program Approaches.......................................................................... 12
Informing Youth Through Sexuality Education............................................13
Building Links With Services.................................................................... 13
Other Promising Approaches.............................................................................. 14
Box 4: Case in Point: MEXFAM's Adolescent Program in Mexico....................14
References......................................................................................................... 15
Definitions and Acknowledgments........................................................................ 15
APPENDIX: The World's Youth 2000 Data Tobies.............................................. 17-24
I he World's Youth 2OOo“T
■
Overview
There are more young people on Earth than ever before. At the
turn of the new century, 1.7 billion people are between the ages
of 10 and 24, and the vast majority live in less developed coun
tries. Meeting the needs of youth today is critical for a wide
range of policies and programs, because the actions of young
people will shape the size, health, and prosperity of the worlds
future population.
This report and its accompanying data sheet give a profile
of todays youth, providing data on population, education, and
health, with a special focus on sexual and reproductive health.
(The data tables appear in the Appendix, on pages 17-24.)
Young peoples needs vary tremendously depending on their
stage of life—puberty, adolescence, and early adulthood—and
on the context in which they live. While this diversity makes it
difficult to make generalizations about young people, the action
plans adopted at recent international conferences make it pos
sible to identify critical needs and compare progress in health
and education against agreed-upon goals.
Overall, young peoples health and educational prospects
are improving, and marriage and childbearing are occurring at
later, more mature stages of life, compared with previous gener
ations. Nevertheless, some concerns remain. For example:
■
■
■
Despite increasing attention given worldwide to education,
secondary school enrollments are still low in many parts of
the world, and girls’ school enrollments still lag behind
boys’.
Complications of pregnancy, childbirth, and unsafe
abortion are the major causes of death for women
ages 15 to 19.
Young people ages 15 to 24 have the highest infection rates
of sexually transmitted infections (STIs), including
HIV/AIDS.
Statistics on rape suggest that between one-third and twothirds of rape victims worldwide are age 15 or younger.
At both the 1994 International Conference on Population
and Development (ICPD) and its five-year review in 1999, par
ticipants identified adolescents as a particularly vulnerable
group. At these world conferences, governments committed “to
meet the needs of adolescents and youth for information, coun
seling, and high-quality sexual and reproductive health services”
as a way to “encourage them to continue their education, maxi
mize their potential, and prevent early marriage and high-risk
childbearing.”i Recent program experiences shed light on prac
tical ways to provide young people with the information, social
support, and services they need to protect themselves from sex
ual and reproductive health problems.
2
Introduction: The World of
1.7 Billion Youth
Figure 1:
Population by age and sex: Less and more
developed regions, 2000
At the turn of the 21st century, 1.7 billion people—more than
one-fourth of the worlds six billion people—are between the
ages of 10 and 24, making this group the largest ever to enter
adulthood (see Box 1). Eighty-six percent of 10-to-24-year-olds
live in less developed countries. The proportion of youth in
these countries is significantly higher than in more developed
countries, as shown in Figure 1.
Box 1:
Who are "Youth"?
In this report, we define youth or young people as in the 10-to-24
age group, which includes preteens and teenagers (ages 10 to 19)
and young adults (ages 20 to 24). We use the terms “adolescents”
and “teenagers” interchangeably, though the period of transition
known as adolescence may differ from place to place and between
boys and girls.
millions
Times are changing for young people around the world, in
ways that affect their lives both positively and negatively. The
current generation of young people is the healthiest, most edu
cated, and most urbanized in history (see Figure 2 for urbaniza
tion trends in less developed countries). While urbanization
brings greater access to education and health services, it also
carries greater exposure to the risks of drug and alcohol abuse,
violence, and sexually transmitted infections (STIs), including
HIV/AIDS. Modernization tends to create more employment
opportunities, but it may also bring about a loss of traditional
cultures and separation from extended families.
The context in which young men and women live greatly
influences the course of their lives. Some young people are
married and considered adults in their societies; others are still
in school and considered dependent children. Many young
people are sexually active and have become parents themselves,
but may not have achieved the legal adult age as defined by
their country or state. “Adolescence” is a modern term meaning
Note: Data reflect projections for 2000.
Sourte: United Nations Population Division, 1998.
a period of life that starts at puberty and ends at the culturally
determined entrance to adulthood (social maturity and eco
nomic independence).
Around the world, the onset of puberty is occurring earlier
and the age of marriage is rising. Thus, young people are facing
a longer period of time during which they are sexually mature
and may be sexually active before marriage. While adolescence
is generally a healthy period of life, many young people are
exposed to health risks associated with sexual activity, including
exposure to STIs, unintended pregnancies, and complications
from pregnancy and childbirth. Young people often have inad
equate or misleading information on sexuality and reproductive
health and lack access to reproductive health care.
Improving young peoples health is a critical goal in and of
itself, with long-term benefits to society as a whole. In addi
tion, the extent to which the reproductive health needs of this
generation are met will greatly affect global population growth.
In particular, the decisions these young people make regarding
family size and the timing of births will make todays youth the
“critical cohort” in determining the size of world population
for years to come.
Educating Girls and Boys
Recent world conferences have called for universal access to
and completion of primary education, and for reducing the
“gender gap”—differences in boys’ and girls’ enrollment—in
secondary education. Policymakers increasingly recognize that
advancing women through greater educational opportunities is
key to economic and social development.
In more developed regions, most girls and boys attend
both primary and secondary school. In less developed regions,
progress has been made in increasing enrollment levels, but
only 57 percent of boys and 48 percent of girls were enrolled in
secondary education as of the mid- to late-1990s (see
Education columns on pages 18-24 in the Appendix). The gap
between boys’ and girls’ enrollments is most apparent at the
Figure 2:
Adolescent population in less developed
countries by urban and rural areas, 1990-2025
Populolion ages 10 Io 19 (in millions)
631
wt Urban
<ssz> Rural
1990
1995
2000
2005
2010
2015
2020
2025
Source: United Nations Population Division, World Population Prospects 1992 and
1996.
secondary level. However, in some regions where enrollment
rates are very low for both girls and boys, merely raising girls’
enrollments will not be sufficient. Efforts must be made to
increase access to education for all.
Global school enrollment figures mask significant regional
and country differences (see Figure 3, next page). In Ghana, for
example, 44 percent of boys and only 28 percent of girls are
enrolled in secondary school. In Colombia, on the other hand,
more girls than boys are enrolled in secondary school: 69 per
cent of girls and 64 percent of boys. The data also mask impor
tant differences among countries and localities in retention
rates, attendance, and school quality. For instance, in Cote
d’Ivoire, 27 percent of primary school students had to repeat
a year of school in 1995, and in Brazil, this figure was
18 percent.2
In some of the poorest countries, fewer than half of young
women receive a basic education, that is, at least seven years of
school.3 Many young women are becoming wives and mothers
or are taking on household responsibilities rather than continu
ing their education. Several factors explain girls’ lower level of
4
IhTworld's Youth 2000
Figure 3:
Girls' and boys' secondary school enrollment,
selected countries
Percent enrolled (gross enrollment ratio)
■ Boys
Colombia Dominican
Republic
Guatemala
Nepal
Iraq
Cambodia
Ghana
Madagascar
Source: 1999 UNICEF Statistical Yearbook.
Figure 4:
Mother's education and childbearing,
selected countries
secondary school enrollment: parents perception that second
ary education is more beneficial for their sons than for their
daughters; worries about girls’ safety outside the village envi
ronment; and limited job opportunities for women in sectors
that require higher education. Decades of research have shown
that educated women have greater control of their reproductive
lives, such as decisions about the number and spacing of their
children (see Figure 4). Research also shows that women with
more education have healthier children.
Recent progress has been promising. Between 1985 and
1995, access to education improved worldwide, particularly for
girls and particularly at the secondary level/ Young women in
less developed regions are now more educated than their
mothers. For example, young women ages 15 to 19 in Morocco
are four times more likely than their mothers to have completed
seven years of schooling. In Sudan, this figure is nine times.5
Nevertheless, education levels are still low in these countries, as
in many others, and governments need to increase them.
The Sexual and Reproductive Lives of
Young Men and Women
Marriage
Age of marriage is one of many aspects of young peoples lives
that is currently in transition. Overall, marriage before age 18
is less common than it was a generation ago; however, there is
much regional variation. Figure 5 illustrates a range from as
low as 3 percent in Germany to 73 percent in Bangladesh.
(Data on marriage include formal unions that are legally or
religiously sanctioned, as well as informal, cohabiting unions.)
Compared with levels 20 years ago, early marriage has declined
by one-fourth in India and Bangladesh and by about one-half
in Indonesia. However, average age at marriage is still relatively
young in these countries, as in Bangladesh, where the average
age is 14.2.
Source: Into a New World: Young Womens Sexual and Reproductive Lives (New York: Alan
Guttmacher Institute, 1998).
0
t)
The World's Youth 2000
In sub-Saharan Africa, the proportion of married adoles
cents has decreased over the last 20 years. Nonetheless, at least
one-fourth of 15-to-19-year-old women are married in many
sub-Saharan African countries, and about half of 15-to-19-yearold women in Mali, Mozambique, Niger, Chad, and Uganda
are married. In much of Latin America and the Caribbean,
early marriage is as common for young women today as it was
for their mothers: Between 20 percent and 40 percent of
women in this region form their first union before age 18.6
Marrying later in life has a number of implications for
young people. Young women who marry later are more likely
to have a basic education than those who marry early.
Subsequently, women with more education tend to be healthier
and more prosperous, and have fewer and healthier children.
However, later marriage combined with increased premarital
sex among adolescents puts young people at greater risk of
unintended pregnancies, unsafe abortion, births outside of mar
riage, and STIs, including HIV/AIDS.
Adolescent Sexual Activity
Premarital sexual activity is common in many parts of the world
and is reported to be on the rise in all regions.7 In many coun
tries, young women and men are under strong social and peergroup pressure to engage in premarital sex. Moreover, some
features of modern life may increase both the desire and oppor
tunity for sexual activity: the mass media, the breakdown of
traditional families and mores, and increased migration, urban
ization, and materialism. For a substantial minority of young
women, early sexual activity is not consensual (see page 9).
As shown in Table 1, in Kenya there is more than a threeyear gap between age at first intercourse and age at marriage; in
Brazil, it is slightly more than two years. Surveys show that, on
average, 43 percent of women in sub-Saharan Africa and 20
percent in Latin America have had premarital sex before age 20.
Sexual activity among adolescents is even higher in some devel
oped countries: 68 percent of teenage women in the United
States and 72 percent in France have had premarital sex by age
Figure y:
Percentage of women married* by age 18,
selected countries
Bangladesh
Central Airicon Repuplic
.
I
-
■ ’
■'
STil India
■'
4Kil Cote d'Ivoire
I :':T;,
i
r
I
■ eBl Ghana
.
~
M Indonesia
Colombia
,
Brazil
I :, ijg Morocco
■KI Philippines
■n France
•jjj Germany
’Includes formal marriage and cohabiting unions.
Source: Into a New World: Young Womens' Sexual and Reproductive Lives (New York: Alan
Guctmacher Institute, 1998).
Table 1:
Age at marriage and age at first sexual
intercourse among young women,* selected
countries
Country
Median age
at marriage**
Median age at
first intercourse
Cameroon
18.0
15.9
Kenya
20.2
16.8
Niger
15.3
15.3
Bolivia
20.9
19.0
Brazil
21.0
18.8
Guatemala
19.2
18.6
Haiti
20.5
18.7
Indonesia
19.9
19.8
Philippines
22.7
22.8
’Among women 25 to 29 years old.
"Includes formal marriage and cohabitation. Median age indicates that half the
women surveyed entered their first union before this age and half after this age
Source: Demographic and Health Surveys (Calverton, MD: Macro International)
The World's Youth 2000
plete data on abortion are only beginning to be available (see
Figure 6). Unsafe abortions, which are sometimes self-induced,
can result in severe illness, infertility, and death. Even in places
where safe abortion services exist, access is often restricted for
teenage girls. Complications from unsafe abortion are the lead
2O.sSex before marriage is more common among young men
than among young women, however. In many societies, sex is
viewed as a sign of maturity and status for adolescent boys,
while for young girls it is forbidden and shameful.9 (See Box 2
for more discussion of young men.)
Serious risks and consequences accompany increased pre
marital sex, particularly when combined with inadequate infor
mation and reproductive health services. Increased sexual activ
ity places youth at greater risk of unintended pregnancies and
STIs, including HIV/AIDS (see section on HIV/AIDS, page
10). Many unintended pregnancies end in abortion, but com
ing cause of death among teenagers in some countries.10
Adolescent Childbearing
Of the 15 million young women ages 15 to 19 who give birth
every year, 13 million live in less developed countries.11 Thirtythree percent of women in less developed countries give birth
Box 2:
Reaching Young Men
Young men typically report having their first
sexual experience earlier than women and also
tend to marry later. Therefore, they experience a
longer period of time in which they maybe
sexually acdve outside of marriage. Yet, while
health specialists increasingly recognize that
young people need support and information to
take control of their sexual and reproductive
lives, the focus on womens health often leaves
men out of the picture. In fact, healdt commu
nications and services are much less likely to
target young men than young women.
Cultural standards about what is acceptable
sexual behavior for young men and women
complicate the issue of adolescent reproductive
health. In some societies, young men are
encouraged or pressured to take part in sexual
behaviors that are risky, such as having multi
ple partners or having their first sexual experi
ence with a sex worker. Yet services often do
not provide youth with the means to protect
themselves and their partners from infections
and unintended pregnancies. Limited access to
condoms and other contraceptives, even where
they are affordable, remains a major barrier to
use. Other barriers to use include attitudes and
misconceptions. For instance, some young
men believe that they should use condoms
when having intercourse with sex workers but
not with girlfriends.
Program efforts to reach young men are
now underway in many countries. Repro-
Percentage of single, sexually
active adolescent men and
number of partners they had
in one year, selected countries
Country
Brazil (Rio de Janerio)
Percent
sexually
active
Average number
of partners
in 12 months
61
2.6
Kenya
54
1.6
Cote d'Ivoire
43
2.4
Tanzania
Thailand
37
2.5
29
3.8
Togo
18
2.0
Philippines (Manila)
15
1.8
Source: Into a Neto World: Young Womens Sexual and
Reproductive Lives (New York: Alan Gutunacher Institute,
1998).
ductive health programs for young men pri
marily encourage responsible sexual behavior.
They can also support other positive behaviors
and attitudes, such as staying in school, re
examining their perceptions of gender roles
and responsibilities, supporting female part
ners in their reproductive health needs and
decisions, and avoiding violence and drug and
alcohol abuse.
Program planners need to distinguish
young mens needs from those of young
women and differentiate young men by age
groups, as developmental and emotional
changes occur rapidly during adolescence.
Some of the venues for reaching young men
include community sites such as discos, pool
halls, sports events and marketplaces; the
workplace; youth-friendly/male-friendly
clinics; and multipurpose youth centers.
Information channels for reaching young men
include the mass media (radio, television, and
popular music), and face-to-face communica
tion through peer education and counseling.
Source: C. Green. -Reaching Young Men with Reproductive
Health Programs," In FOCUS (Washington, DC: Pathfinder
International, 1998).
The World's Youth 2000
before the age of 20, ranging from a low of 8 percent in East
Asia to 55 percent in West Africa. In more developed countries,
about 10 percent of women give birth by age 20; however, in
the United States, the level of teen childbearing is significantly
higher, at 19 percent. Significant differences also exist between
countries in the same region (see Figure 7, and Teen Population
columns on pages 18—24 in the Appendix). For example, in
Senegal, 43 percent of women ages 20 to 24 gave birth by age
20, compared with 70 percent in Mali.
Early pregnancy and childbearing are typically associated
with less education and lower future income for young
mothers. For unwed teens in some countries, motherhood can
result in social ostracism. In other settings, teens may choose to
become pregnant to gain status with their peers, improve their
relationship with family members, or because they have few
other life opportunities outside of motherhood.12 These cir
cumstances carry different policy and service implications.
Young women and their children face serious health risks
from early pregnancy and childbearing. More adolescent girls
die from pregnancy-related causes than from any other cause.13
In fact, maternal mortality among 15-to-19-year-old women is
twice as high as for women in their 20s. Because adolescent
women have not completed their growth, in particular height
and pelvic size, they are at greater risk of obstructed labor
(when the birth canal is blocked), which can lead to permanent
injury or death for both the mother and the infant. Infants of
young mothers are also more likely to be premature and have
low birth weights. In many countries, the risk of death during
the first year of life is 1.5 times higher for infants born to
mothers under age 20 than for those born to mothers ages 20
to 29.14 For all women, first births are higher risk than sub
sequent births, and for teens, the risks are greater still. Because
adolescents have less experience, resources, and knowledge
about pregnancy and childbirth than older women, they and
their children suffer when obstetric emergencies occur.
Figure 6:
1,000 adolescent
Figure 7:
Percentage of women giving birth by age 20,
selected countries
Percent of women oges 20 to 24
(ft] Uganda
I
-
i
ffil Nepal
2^] Nicaragua
!
i. ....
■- .
’^1 Senegal
~ .
Peru
L____.J.__ I____2JS1 Egypt
iZZZZS Philippines
United States'
I
Morocco
SASS11"'9' “f Family “ (HyattSVillC’ MD: Nati°n:J
for
t"ZrPhiC and HCald’ SUrVeyS’ '995-1998 (011~ MD: Macro
8 T,^Xi;26oo
Figure 8:
Impact of Adolescent Childbearing on Future
Contraceptive use among married
15-to-19-year-old women, selected countries
World Population
The reproductive decisions of todays youth will have a dra
matic effect on future world population growth. United
Nations demographic projections illustrate how small differ
ences in levels of childbearing can result in large differences in
population size. For instance, the UN projected in 1998 that if
women have on average two children, world population would
rise to 9.4 billion by 2050. However, if women average 2.5
children, world population would reach 11 billion by 2050.15
Timing of births is also critical. Projections show that if
todays young women begin childbearing two and a half years
later than the current average age at first birth, population size
by 2100 would be 10 percent lower than if no change in tim
ing of birth occurred. Similarly, if they waited five years to have
dieir first births, population size would be 20 percent lower
than it would be if current patterns continue.16
Figure 9:
Contraceptive use among single, sexually active
15-to-19-year-old women, selected countries
□ Modern Method
Source: Demographic and Health Surveys (Calverton, MD: Macro International).
Use of Contraception
Generally speaking, adolescent women are less likely than
women over age 20 to use contraceptive methods. Reasons for
this include lack of information, misinformation, and fear of
side effects, along with geographic, social, cultural and eco
nomic barriers to access and use of family planning. Typically,
family planning services are designed to serve married, adult
women. Unmarried teens may find service providers hostile or
unhelpfiil, especially where strong cultural or religious beliefs
condemn sexual activity among unmarried adolescents. Teens
may be unwilling to disclose their sexual activity to parents or
service providers. Also, the sporadic and unplanned nature of
adolescent sexual activity can be an obstacle to consistent contraceprive use.
Surveys indicate that between 12 percent and 42 percent of
married adolescent women in less developed countries who say
they would prefer to space or limit births are not using family
planning. If sexually active unmarried teens were included, the
The World's Youth 2000
unmet need numbers would certainly be higher.17 Married ado
lescent women can benefit from contraceptive use by delaying
first births until their bodies are physically mature enough to
Sexual Violence Against Young
Women
carry a healthy pregnancy to term, and by delaying subsequent
births.
Sexual Abuse and Coercion
Adolescent sexual activity exists throughout much of the world,
Contraceptive use varies substantially by region and coun
try (see Figure 8, and Teen Population columns on pages
18-24 in the Appendix). Only 13 percent of married adoles
cents ages 15 to 19 use contraception in sub-Saharan Africa,
compared with 55 percent in Latin America and the
Caribbean. In Latin America and the Caribbean, 11 percent of
married adolescents in Haiti use contraception, compared with
51 percent in Colombia. Turning to Asia, in India 7 percent
use contraception, compared with 42 percent in Indonesia.
The breakdown between use of modern and traditional
methods also varies from one country to another. Modern
methods typically used by youth include condoms, oral contra
ceptive pills, and hormonal injections. Traditional methods
include the calendar or rhythm method, herbal methods, and
withdrawal. In India, of the 7 percent who use any method of
contraception, none are using a modern method. In Indonesia,
by contrast, nearly all of the 42 percent of married adolescent
women using contraception are using modern methods (see
Figure 8).
Figures 8 and 9 also highlight differences between the con
traceptive practices of married and unmarried adolescents. In
several countries in Latin America and the Caribbean, unmar
ried teens are just as likely to use contraception as their married
counterparts. In sub-Saharan Africa, unmarried adolescents are
more likely to use contraception than married teens. In Benin,
for example, 47 percent of single, sexually active 15-to-19-yearold women use a method of contraception (traditional and
modern combined), compared with 9 percent of their married
peers. While contraceptive use among married adolescents has
increased significantly in parts of Asia, less is known about the
contraceptive practices of unmarried youth in the region, as
they are often excluded from national surveys.
yet the extent to which it is nonconsensual is only recently being
assessed. Sexual abuse includes rape, sexual assault, sexual
molestation, sexual harassment, economic exchange for sex, and
incest. Because sexual violence and exploitation are abuse of
power, young people are especially at risk, and the violations can
have devastating and long-lasting consequences. Also, because
most youth reproductive health programs are geared toward
young people engaging in consensual sex, the different and urgent
needs of those who have been sexually abused are not met.18
Women are more vulnerable than men to violence and
abuse at all stages of life through infanticide, incest, child pros
titution, sex trafficking, rape, partner violence, psychological
abuse, sexual harassment, rape as a weapon of war, and harmful
traditional practices such as forced early marriage, female geni
tal cutting, and bride burning. Statistics on rape suggest that
between one-third and two-thirds of rape victims worldwide
are 15 years old or younger.19 While boys are also victimized,
girls are more likely to be subjected to sexual abuse and are at
risk of becoming infected with HIV and other STIs at a much
younger age dian boys. Other risks include unintended preg
nancies, physical injury, and psychological trauma. Studies also
show that young people who have been victims of sexual abuse
are more likely to engage in high-risk sexual behavior than
those who have not been abused.20
Sexual exploitation of children and adolescents is a multibillion-dollar illegal industry, according to UNICEF. Some
young people become prostitutes in order to make money. In
many places, such as Bangladesh, Brazil, Nepal, the
Philippines, and Thailand, young people are lured or forced
into prostitution.21 Similarly, economic deprivation leads many
young women in sub-Saharan Africa and elsewhere into sexual
relationships with older men—sometimes known as “sugar
10
The World's Youth 2000
Figure 10:
Unmarried adolescent women who have recently*
received money or gifts in exchange for sex,
selected sub-Saharan African countries
build a body of knowledge about how best to address FGC.
These efforts include developing alternative rites of passage for
adolescent girls; public declarations against FGC by families
and community members; and empowerment and advocacy
programs for women and girls. Systematic evaluation of these
efforts will be needed to determine the most promising
approaches for ending the practice.
Youth and the HIV/AIDS Crisis
“Zimbabwe: within the past 4 weeks; Uganda: last sexual encounter, other countries:
within die past 12 months.
Source: Demographic and Health Surveys (Calverton, MD: Macro International).
daddies”—who provide money and other necessities, such as
clothing and school supplies and fees, in exchange for sex (see
Figure 10).
Female Genital Cutting
Between 100 million and 180 million women around the
world have undergone female genital cutting (FGC), also
known as female circumcision and female genital mutilation, in
which parts of the female genitalia are cut away. Some 600 girls
are at risk every day. FGC is a serious health issue, with effects
including hemorrhage, shock, pain, and various infections and
other complications that can significantly damage a girl’s health
over her lifetime. Because FGC violates a womans right to
good health and bodily integrity, it is also a human rights issue.
FGC occurs primarily in Africa, but is also practiced by minor
ity groups and African immigrants in other regions.
In recent years, communities and countries have begun to
make progress toward the internationally agreed-upon goal of
eradicating FGC. Local efforts in diverse setting are starting to
About half of all people infected with HIV are under age 25,
according to World Health Organization estimates, and in less
developed countries, up to 60 percent of all new infections are
among 15-to-24-year-olds.22 In this age group of newly infected
people, there are twice as many young women as young men.
Adolescents are at high risk of contracting HIV and other
STIs because, among other reasons, they often have multiple
short-term sexual relationships and do not consistently use con
doms. They also tend to lack sufficient information and under
standing of HIV/AIDS: their vulnerability to it, how to pre
vent it, and the self-confidence necessary to protect themselves.
STIs other than HIV (such as chlamydia and gonorrhea) are
also a serious threat to adolescents. Worldwide, the highest
reported rates of STIs are found among young people ages 15
to 24. In more developed countries, two-thirds of all reported
STI infections occur among men and women under age 25,
and in less developed countries, the proportion of infected
young people is even higher.23
Young people face special obstacles in obtaining diagnosis
and treatment of HIV/AIDS and other STIs, even where serv
ices are available. They usually lack information about STIs,
their symptoms, the need for treatment, and where to obtain
services. They are also reluctant to seek care, and providers may
be hesitant to treat them. Because females with chlamydia and
gonorrhea, the most common STIs, often do not show symp
toms, and because having another STI increases an individuals
susceptibility to HIV, young people are at high risk of contract
ing and spreading these infections.2"1 They may also face legal
and/or institutional obstacles to using services, such as negative
provider attitudes or requirements for parental, spousal, or
partner consent before testing or treatment. Additionally,
young people often believe (incorrecdy) that STIs will simply
go away if untreated or that they will not recur if treated.
Young women are particularly vulnerable to STIs for both
biological and cultural reasons. Adolescent women have fewer
protective antibodies than do older women, and the immatu
rity of their cervixes increases the likelihood that exposure to
infection will result in the transmission of the disease.25 Sexual
violence and exploitation, lack of formal education (including
sex education), inability to negotiate with partners about sexual
decisions, and lack of access to contraception and reproductive
health services work together to put young women at especially
high risk. Additionally, women in many societies are not accus
tomed to discussing issues of reproductive health and sexuality
with others, which further increases their vulnerability.
A Call for HIV/AIDS Education
Policymakers are giving greater attention today to the need for
AIDS education, prevention, and treatment. It is estimated
that over 30 million adults and children worldwide are living
with HIV or AIDS, but most do not know they are infected.
An overwhelming majority, 95 percent of HIV-infected people,
live in less developed countries.26 In 1999, at the five-year
review of the ICPD, governments established the goal of giving
at least 90 percent of young men and women ages 15 to 24
access to preventive methods by 2005 in order to reduce vul
nerability to HIV infection.27 These methods include female
and male condoms, voluntary testing and counseling, and
follow-up. The Health column on pages 18-24 in the
Appendix shows, as of 1993, whether or not countries had
HIV/AIDS education included in their school curriculum.
More current data are needed to determine the extent of policy
responses to the HIV/AIDS crisis.
Despite the urgent need for raising public awareness, cul
tural and institutional barriers stand in the way of educating
people about the risks of HIV and ways to prevent it from
spreading. Many parents and educators have long been con
cerned that sex education may increase sexual activity among
young people. However, a recent assessment by the Joint
United Nations Programme on HIV/AIDS (UNAIDS) reveals
that HIV and sexual health education promotes safer sexual
practices and does not increase sexual activity.28 According to
the report, effective programs help delay first intercourse and
protect sexually active youth from STIs, including HIV, and
from unintended pregnancy. UNAIDS also reports that sexual
health education is most effective when started before the onset
of sexual activity.
Socially Marginalized Youth
There is increasing concern for young people who are discon
nected from their families and social institutions, such as
schools, religious institutions, youth clubs, or the workplace.
These “socially marginalized” youth are vulnerable to sexual
exploitation and are at a disproportionately high risk of unin
tended pregnancies and STIs, including HIV/AIDS. They
often lack access to health information, counseling, legal pro
tection, and health and other services. Living or spending most
of their time on the streets, the only social support they receive
is typically from peers living under similar circumstances.
Counting these young people is as difficult as reaching them
with assistance. Nevertheless, statistics show that significant
numbers of youth need information and services beyond what
is provided by traditional and school-based programs.
S The UN estimates that 404 million youth under the ages
of 18—or 38 percent of youth in less developed coun
tries—do not attend school.
■ UNICEF estimates that approximately 100 million young
people work on the streets in activities such as picking up
garbage, hawking small goods, parking and washing cars
1*"^orld's Youth 2W
□
□
shining shoes, and begging. Approximately 10 percent of
these youths actually live on die streets, with no connec
tion to their families or a permanent home.
A homeless teenage girl in the United States is 14 times
more likely to become pregnant than a girl with a home.29
A study of 143 Guatemalan street youth showed that all
had been sexually abused: the majority by family members,
often stepparents, or other people they knew. These youths
frequendy cited physical, emotional, and sexual abuse as
their reasons for leaving home.30
A new group of socially marginalized youth, AIDS
orphans, is often shunned by their communities and neglected.
Like other orphans in general they have higher rates of malnutridon, stunting, and illiteracy. Socially isolated because of the
stigma of the disease, AIDS orphans are more vulnerable to
Box 3:
Keys to Reaching Socially Marginalized Youth
■ Since many socially marginalized youth live in situations char
acterized by violence and distrust, programs need to establish
an environment of respect, acceptance, and stability.
■ To make initial contact, outreach programs find youth in places
where they spend most of their time, such as on the streets. For
example, programs in Guatemala, Honduras, and Mexico have
outreach teams providing street youth with emergency medical
care, HIV education, informal education, and counseling.
□ Drop-in centers and shelters offer young people a place to rest
and be safe. Transitional homes and group homes prepare youth
for independent living or help reunite them with their families.
■ Programs can work with the members of the community who
have already earned young peoples trust, such as market or
street vendors, shopkeepers, or health care providers.
Source: C. Stevens, “Reaching Socially Marginalized Youth,” In FOCUS
(Washington, DC: Pathfinder International, 1999).
abuse and exploitation and may be left to fend for themselves
on the streets. These youth are often left with care-taking
responsibilities for younger siblings and may have a harder time
staying in school. The UN predicts that HIV/AIDS will
orphan 13 million children—that is, leave them without a
mother or both parents—by the end of 2000. At the latest
count, 90 percent of the 8.2 million children who have already
been orphaned due to AIDS live in sub-Saharan Africa.31
In many places, children over age five are no longer a main
target of health services, as their survival is relatively assured.
The health needs of many youth are neglected until, as is too
often the case, adolescent girls seek health services when they
are pregnant. Likewise, boys, who are at high risk of accidents,
violence, and substance abuse, often only seek services when
they become victims of these social ills (see Box 3).
Policy and Program Approaches
Meeting adolescents’ needs for sexual and reproductive health
information and services is vital to young peoples future. At
several international conferences and conventions in the 1980s
and 1990s, governments repeated their commitment to a uni
versal agenda for action to improve the health of adolescents, as
follows32:
0
Provide health education to adolescents, both men and
women, including information on sexuality, responsible
sexual behavior, reproduction, voluntary abstinence, family
planning, unsafe abortion, STIs including HIV/AIDS, and
gender roles.
E
Encourage parental involvement and promote adult com
munication and interaction with adolescents.
Use peer educators to reach out to young people.
Provide integrated health services to adolescents that
include family planning information and services for sexu
ally active adolescents.
Make health services adolescent-friendly by ensuring confi
dentiality, privacy, respect, and the high-quality informa-
0
■
■
□
□
E
tion necessary for informed consent and by including
youth in program design.
Increase opportunities for womens education and
employment.
Take measures to eliminate all forms of violence against
women and end trafficking in women.
Eradicate female genital cutting.
■
Provide basic, accurate information about the risks of
unprotected intercourse and ways to avoid unprotected
□
intercourse.
Include activities that address social pressures on sexual
□
tion, negotiation, and refusal skills.
Employ a variety of teaching methods designed to involve
behavior. Provide modeling and practice of communica
the participants and have them personalize the informa
Research and program experience suggest that policy
makers and health providers need to remove the legal and insti
tutional barriers that keep young people from using existing
family planning and reproductive health services. In addition,
information and services need to be designed to accommodate
the unique needs of adolescents and young adults.
Informing Youth through Sexuality Education
Sexuality education for youth has long been hampered by adult
concerns that knowledge will promote promiscuity among
unmarried teens. However, worldwide reviews of studies by
WHO and UNAIDS33 conclude that sexuality education does
not encourage early initiation of intercourse, but instead can
delay first intercourse and lead to more consistent contraceptive
use and safer sex practices (see also section on HIV/AIDS edu
cation, page 11).
It is vital to reach adolescents early with information,
before the onset of sexual activity. Schools are a key location for
reaching large numbers of young people; however, as many
youth are not in school, community-based approaches are also
needed in many areas. Specialists in adolescent reproductive
health suggest the following elements for a successful sex and
HIV education program34:
■ Give a clear message on risky sexual behaviors. Focus on
reducing a few key behaviors that lead to unintended preg
■
nancy or HIV/STI infection.
Use a behavior change framework to define and evaluate
activities.
□
tion. Use teachers and peers who believe in the program
they are implementing, and provide training for them.
Incorporate behavioral goals, teaching methods, and
materials that are appropriate to the age, sexual experience,
and culture of the students.
Building Links with Services
Increasing knowledge is only the first step in the prevention of
unintended pregnancies and STIs, including HIV. To be effec
tive, educational programs (in or out of school) need to inform
youth about what kinds of services they may need and where to
get them. While school-based clinics may be an effective way to
provide services to students, community-based clinics are need
ed to reach the large numbers of out-of-school youth. Com
munity outreach may also be needed to reach young men,
street children, prostituted teens, and other marginalized
groups, who may not feel comfortable using services designed
for mothers and their children.
A number of program models incorporate youth-friendly
components in existing health services.33 Multiservice centers
for youth are only one approach to meeting these needs; link
ing social services through referral systems may be a more real
istic option in many settings. Some programs try to bring ser
vices to locations where young people study, work, or socialize
Regardless of the venue, the basic components of a youth
friendly service include specially trained providers, privacy con
fidentiality, and accessibility.36
14
Box 4:
Case in Point—MEXFAM's Adolescent Program in Mexico
In 1986, MEXFAM, Mexico’s largest private
family planning provider, began an adolescent
program in urban areas called Gente Joven or
“Young People.” The programs decentralized,
community-based approach, which uses youth
promoters for outreach activities, is flexible and
adaptable to local circumstances. Designed to
reach out to adolescents on their own turf,
such as schools, clubs, recreation centers, gang
hangouts, and sports facilities, the program has
reached over 4 million young people since its
inception. Gente Joven is built around youthto-youth activities, allowing adolescents to take
a more dynamic role in providing information
and services to their peers. The program’s inte
grated approach includes three main elements:
■ reproductive health and sex education;
■ collaboration between adult coordinators
and youth volunteers; and
■ integrated participation and action—young
people, parents, and teachers are all
involved.
Gente Joven recognizes that young people
will explore their sexuality regardless of societal
constraints; therefore, it promotes safe, healthy,
and responsible sex. The program confronts
the strong negative attitudes many adults have
toward adolescent sexuality by working to sen
sitize parents, teachers, and local politicians
through films, discussions, pamphlets, and
radio programs. Overall, key approaches to the
success of this program include:
■ Youth-centered approach. Youth-to-youth
promotion ensures that the program docs
not diverge from the needs and expressed
desires of the youth themselves.
■ Intensive training. Staff and volunteers are
trained in counseling, communication, and
sex education.
■ Dedicated staff and volunteers. Gente
Joven has been instrumental in motivating
and developing leadership potential in
young volunteers.
■ High-impact educational materials. Gente
Jovens award-winning videos, guides to
Other Promising Approaches
Programs targeting youth can use a variety of communication
approaches to provide sexual and reproductive health informa
tion, encourage dialogue oh sensitive topics, and help youth
develop the knowledge and confidence needed to safeguard
their health. Box 4 describes an innovative example. Peer coun
seling—where young people are trained to talk to their peers—
can take place in schools, the workplace, or other public places
frequented by youth. Messages can also be delivered via the
mass media and entertainment, such as popular songs, soap
operas, videos, television spots, billboards, sporting events, and
theater performances. Combining entertainment with educa
using them, and other materials go to the
heart of youth’s concerns.
■ Flexibility with accountability. The pro
gram gives its coordinators the flexibility to
build on their own talents but maintains
consistency with overall program goals
through monitoring and evaluation.
Overall, Gente Joven has been credited with
greatly improving intergencrarional communi
cation on sexuality. Five years after the pro
gram’s inception, MEXFAM reported that in
schools where the number of pregnancies was
very high, teen pregnancies dropped dramati
cally after the introduction of Gente Jovens 10hour course. The program addresses issues that
are important to youth in a frank and open
manner, encouraging reflection and discussion
on the major decisions that they confront.
Source: “Mexico: Gente Joven, MEXFAM’s Adolescent
Program” in Family Planning Programs: Diverse Solutions to
a Global Challenge (Washington, DC: Population
Reference Bureau, 1994); latest data from MEXFAM’s
website at www.mexfam.org.mx/.
tion has proven appealing and successful in reaching youth in
many settings. In addition, telephone hotlines and radio call-in
shows give youth an opportunity to discuss their concerns
anonymously with trained counselors. Pharmacies and social
marketing programs are also beginning to target young adults
as consumers of health products, especially condoms.
Young people have a variety of special needs that differ
from one setting to another. A key aspect of the design of
youth programs is the involvement of young people in helping
to determine the program approaches and components that
best respond to their concerns. In doing so, young people gain
new skills and self-confidence as they make decisions that
The World's Youth 2000 15
impact their future and that of future generations.
Ideally, countries will develop a comprehensive, multifac
eted strategy for reaching youth. Providing young people with
reproductive health information, counseling, and services can
be both challenging and controversial, because of cultural sensi
tivities about adolescent sexuality. Nevertheless, recent trends
in adolescent health and sexual activity, and particularly the
HIV/AIDS pandemic, call for urgent attention, public
discussion, and policy action. ■
References
1
United Nations, ICPD Programme ofAction (New York: UN, 1994): para
2
United Nations Educational, Scientific, and Cultural Organization
(UNESCO), World Education Report 1998: Teachers and Teaching in a
Changing World (Paris: UNESCO Publishing, 1998): 136-138.
3
19
L. Heise er al., “Ending Violence Against Women,” Population Reports,
Series L, No. 11 (Baltimore, MD: Johns Hopkins University): 9.
6.7.
Alan Guttmacher Institute (AGI), Into a Neto World: Young Womens Sexual
and Reproductive Lives (New York: AGI, 1998): 12.
4
Population Action International (PAI), Educating Girls: Gender Gaps and
20
21
Ibid.
AGI, Into a New World: Young Women's Sexual and Reproductive Lives.
22
23
B. Shane, Family Planning Saves Lives: 17-18.
J. Senderowitz, “Young People and STDs/HlV/AIDS; Part I: Dimensions
of rhe Problem,” In FOCUS (Washington, DC: Pathfinder International,
1997).
24
AGI, Into a New World: Young Womens Sexual and Reproductive Lives.
Gains (Washington, DC: PAI, 1998).
5
AGI, Into a New World: Young Womens Sexual and Reproductive Lives.
25
6
7
Epidemic Update: December 1999 (Geneva: UNAIDS, 1999).
Ibid.
Population Reference Bureau (PRB), Improving Reproductive Health in
Developing Countries (Washington, DC: PRB, 1997): 5.
26
27
Ibid.
Joint United Nations Programme on HIV/AIDS (UNAIDS), AIDS
United Nations, Key Actionsfor the Further Implementation ofthe
8
AGI, Hopes and Realities (New York.: AGI, 1994): Table 4.
Programme ofAction ofthe International Conference on Population and
9
B. Barnett and J. Stein, Womens Voices, Womens Lives: The Impact ofFamily
Development (New York: United Nations Population Fund, 1999).
28
UNAIDS, Impact ofHIV and Sexual Health Education on the Sexual
Planning (Research Triangle Park, NC: Family Health International, 1998).
10
J. Senderowitz, ‘Adolescent Health,” World Bank Discussion Papers 272
(Washington, DC: World Bank, 1995): 17.
11
AGI, Into a New World: Young Womens Sexual and Reproductive Lives.
12
B. Barnett and J. Stein, Womens Voices, Womens Lives: The Impact ofFamily
Planning.
13
United Nations Childrens Fund (UNICEF), Progress ofNations 1998
(New York: UNICEF, 1998): 21.
,z‘ B. Shane, Family Planning Saves Lives: 4.
15
C. Haub and D. Cornelius, 1998 World Population Data Sheet
(Washington, DC: PRB, 1998).
16
J. Bongaarts, “Population Policy Options in the Developing World,”
Science 1994, 263 (5148): 771-776.
17
18
B . Shane, Family Planning Saves Lives.
L. Shanler, L. Heise, L. Stewart, L. Weiss, “Sexual Abuse and Young Adult
Reproductive Health," In FOCUS (Washington, DC: Pathfinder
Behavior of Young People: A Review Update (Geneva: UNAIDS, 1997).
29
United Nations Childrens Fund (UNICEF), Progress ofNations 1998
(New York: UNICEF, 1998): 29.
30
www.casa-alianza.org, accessed online in April 2000.
31
UNICEF, Progress ofNations 1999 (New York: UNICEF, 1999).
32
Family Care International (FCI), Commitments to Sexual and Reproductive
Health and Rights for Alb Framework for Action (New York: FCI, 1995)
33
UNAIDS, Impact ofHIV and Sexual Health Education on the Sexual
Behavior of Young People: A Review Update.
* D. Kirby, “Reducing Adolescent Pregnancy: Approaches That Work,”
Contemporary Pediatrics Vo\ 16, No. 1, January 1999 (Montvale, NJ: Medical
Economics Company).
35 J. Senderowitz, “Making Reproductive Health Services Youth-Friendlv "
FOCUS (Washington, DC: Pathfinder International 1999)
36 Ibid.
International, 1998).
J
Definitions of selected terms in report and data tables
■
The percent enrolled in secondary school is the ratio of
the total number enrolled in secondary school to the
applicable age group, or the gross enrollment ratio.
□
The total fertility rate (TFR) is the average number of
children that would be born to a woman during her life
time assuming the age-specific birth rates of a given year.
available. When not available, WHO figures are based on
HIV sero-prevalence studies, reported AIDS cases, popula
tion size and structure, and the predominant modes of
transmission.
□
0
Births attended by trained personnel are births attended
by a physician, nurse, or trained midwife; definitions of
medical personnel vary from country to country and some
data may include traditional birth attendants.
Percent of adult population infected with HIV are provi
sional estimates supplied by the World Health Organization
(WHO) and based on official country estimates when
E3
Percent using contraception is the percent of married
women ages 15 - 19/sexually active, single women 15-19
who are currently practicing a form of family planning.
Single, sexually active teens are those who reported inter
course within four weeks prior to the survey.
□
Modern methods of contraception include clinic and sup
ply methods such as the pill, IUD, condom, and steriliza
tion. Any method of contraception includes modern
methods as well as traditional methods.
Acknowledgments
This report was written by Anne Boyd in collaboration with Lori
Ashford, Carl Haub, and Diana Cornelius. Nancy Yinger and Mark
Sherman provided comments on several drafts.
PRB gratefully acknowledges FOCUS on Young Adults, a project
of Pathfinder International, for providing information for portions of
this report. The author also wishes to thank the following reviewers:
Jennifer Adams and Shanti Conly, USAID; Anne Wilson, Program
for Appropriate Technology in Health (PATH); Cynthia Green,
Population Council; Nancy Murray and Lindsay Stewart, FOCUS on
Young Adults; Linda Asturias de Barrios, ESTUDIO 1360 S.A.,
Guatemala; and Nelson Agyemang, Youth Development Fund,
Ghana.
This work was funded by the U.S. Agency for International
Development (USAID) under the MEASURE Communication
project (HRN-A-00-98-000001-00).
Design and production: Heather Lilley, PRB
Managing editor: Lisa M. Hisel, PRB
Printing: McArdle Printing Company, Inc.
August 2000
APPENDIX
The World's Youth 2000 Data Tables
teen POPULATION, AGES 15-19
% Enrolled in
Population
% TFR
Total
Average
% Enrolled in
Secondary
Population
Ages
School Latest Age at First Fertilily Attributed
10-24
Secondary
_Zi»
Marriage’ Rote to Births by
Year
tai__ (% of Total) school mo_.
2000
2025
2000
Moles Females Males Females All Women (TFR) Ages 15-19
[WORLD
More Developed
Less Developed
—
81
21
—
—
474
-
373
23
36
26
—
42
47
22/-
86
—
—
26
—
47
50
14/13 |
56
22
241
198
20
88
89
99
102
Less Developed (Exd. Chino) 1,105
48
20/-
—
63
63
57
2.9
3.2
12
12
554
17
18
27
—
6
29
21
—
—
—
33
—
1,321
31
38
27
52
42
20
3.7
13
53
—
[AFRICA
256
401
33
26
15
38
33
20
5.3
12
48
--
Sub-Saharan Africa
210
352
19
10
29
23
5.8
—
-
70
—
—
29
—
52
50
56
63
33
47
29
63
57
21
3.6
7
■■
49
-
| NORTHERN AFRICA
—
—
19
21
40
12
—
24
51
12.1)
22.8
33
32
40
66
26
41
65
83
62
73
24
3.8
3
77
0.1
Y
3.5
11
31
9
—
—
—
Algeria
10.3
Egypt_________________ 22.1
Any/Modem Any/Modeta
Method
Method
31
19
99
44
30
% Using
Contraception
(females)
25
54
43
(females)
% Births
Attended
% Giving Ta^ed
Birth by
Age 20c Personnel
—
27
29
% Single,
—
1,796
1,597
%
Population
Currently
Ages 15-19
Married*
(in millions) % Illiterate
Males Females (females)
2000
71
1,663
1,423
AIDS
% of Adult
Population Education
Infected Included in
% Births
School
Attended With HIV,
by Trained Ages 15-49, Curriculum,
1993
1997
Personnel
mi
-/-
-/-
19/-
13/11
-/-
19/- ]
-/-
3.3
10
39
z
N
7.6
44
14
-
29
41
Libya__________________ 2.0
2.3
35
88
63
95
95
-
4,1
7
81
0.1
Y
0,7
2
14
-
-
-
-
-/-
-/-
Morocco________________ 9.1
9,1
32
32
20
44
34
20
3.1
8
45
z
Y
3.0
28
52
10
-
17
47
-/-
32/30
9.8
13.6
33
20
12
23
20
24
4.6
6
31
1.0
Y
3.5
22
38
15
-
26
68
-/-
4/-
3.0
2.9
32
34
20
66
63
25
2.8
3
79
z
Y
1.0
5
22
4
—
13
81
-/-
11/-
73
122
33
24
12
31
22
18
5.9
12
38
—
—
25
—
—
37
—
55
39
41/14
5/2
2.1
3.6
34
24
8
26
11
19
6.3
10
80
2.1
N
0.7
46
71
29
9
50
82
47/13
1/z
Sudan
Tunisia
■ WESTERN AFRICA
Benin_____________
19
26
-/-
9/3
Burkina Faso________
3.9
7.7
33
4
2
11
6
18
6.8
12
42
7.2
Y
1.3
44
4
62
31
31/14
Cote d'Ivoire_________
5.2
7.5
35
26
11
34
16
18
5.2
13
45
10.1
N
1.8
34
56
—
19
—
51
47/16
11/4
Gambia____________
0.4
0.6
29
16
7
30
19
—
5.6
15
44
2.2
Y
0.1
—
—
53
—
—
—
-/-
-/-
Ghana_____ _______
6.6
11.3
33
50
31
44
28
19
4.5
11
41
2.4
Y
2.2
—
—
20
8
49
63
45/23
20/13
Guinea_____________
2.5
3.9
34
24
10
20
7
—
5.5
18
31
2.1
—
0.8
—
—
—
—
—
39
-/-
3/2
—
18
5.8
17
27“
2.3
N
0.1
34
77
—
—
—
—
-/-
-/-
—
20
6.2
17
58“
3.7
—
0.4
39
62
32
41
64
62
—/12
2/—
Guinea-Bissau________
Liberia_________ -
______ __
j^glj
Mauritania______ —
Sierra Leone
Togo
__ --------------
0.4
0.6
30
10
2
—
1.2
2.3
38
31
12
—
3.8
6.8
34
12
5
17
8
16
6.7
14
47
1.7
—
1.3
—
—
49
6.9
70
50
29/16
5/2
0.9
1.5
32
17
4
21
11
23
5.5
12
47
0.5
—
0.3
41
58
14
—
84
45
-/-
-/-
j/n
3.4
7.1
32
7
3
9
5
15
7.5
15
39
1.5
N
1.1
72
88
60
10"
70
37
—/8
36.7
57.6
33
25
13
36
30
17
6.0
12
31
4.1
N
12.4
—
—
37
10.2
54
29
40/13
3.1
5.3
33
15
7
20
12
18
5.7
11
47
1.8
Y
1.0
48
70
28
9"
43
44
1.5
2.6
31
20
8
22
13
18
6.3
17
25“
3.2
Y
0.5
—
—
58
—
1.5
2.8
33
50
16
40
14
19
6.1
10
82
8.5
Y
0.5
23
56
19
16.5
Notes
a: Data prior to 1990
b: Among 18-24-year-olds
c: % ever married women ages 15-19 who are mothers
d: Among women ages 15-24
e: Among women currently ages 20-24
f: Delivery in public facilities
38
85
i/i
.
-/16
6/2 _
-/-
-/-.
56/25
15/4 _
*: May include formal and/or informal unions
. Data are based on single teens who have ever had intercourse rather than
those reporting intercourse in the last 4 weeks.
z: number rounds to zero
7.1: Numbers in italics indicate data prior to 1985.
POPULATION
| EASTERN AFRICA
Burundi
Comoros
EDUCATION
Population
% Enrolled in
Population
Ages
% Enrolled in
Secondary
Average
Total
% TFR
Ages 10-24
10-24
Secondary
School Latest Age at First Fertility Attributed
(millions)
(% of Total) School 1980____ Year
Marriage* Rate to Births by
2000
2025
2000
Males Females Males Females All Women (TFR) Ages 15-19
82
140
33
12
7
18 13
19
6.0
11
2.2
0.2
3.7
0.4
33
35
22
30
15
24
19
19
65
51
4
9
Djibouti
0.2
0.3
32
Eritreo
1.2
2.1
32
-
-
24
17
17
61
10
Ethiopia
20.1
38.2
32
12
6
14
10
18
67
12
Kenyo
11.1
13.1
37
23
16
26
22
20
47
Modoguscor
4.7
8.9
30
-
-
16
16
19
6.0
'l _
16
9
17
TEEN POPULATION, AGES 15-19
MARRIAGE AND FERTILITY
12
19
—
58
HEALTH
AIDS
% of Adull
Population Education
% Births
Infected Included in
School
Attended With HIV,
by Trained Ages 15-49, Curriculum,
1993
Personnel
199Z
43
19-*
85
8.3
0.1
3/
-/IO
-/-
11/5
-/-
N
-/IS
0.1
26
40
10
29
88
— -
7
—
—
—
-/-
13/-J
V-
21
3.2
47
23
-/-
3/1
14“
9.3
N
6.5
47
62
42
—
—
—
-/-
-/-
11
92
11.6
Y
3.7
8
11
30/20
37/24
13
77
0.1
Y
1.5
23
2.0
10
97
0.5
10.4
32
8
3
9
5
17
5.6
10
44
14.2
0.2
0.2
27
—
—
—
—
28
2.2
5
2.7
6U
27
—
6.2
Rwanda
53
3-
33
Reunion
66
—
—
—
Mozambique
63
30
46
—
27
49
41
38
0.4
33
51
29
0.7
0.1
0.3
5.9
27
Y
N
6.6
12
—
—
79“
0.3
21
% Using
% Births
Contraception
Attended ______ [females)
% Giving
by,
Trained
Any/Modern Any/Modern
Birth by
Method
Age 20c Personnel
Method
10.3
3
3.6
3
% Single,
Sexually
Active
(females)
—
Mauritius
7
%
Population
Currently
Ages 15-19
Married'
(in millions) % Illiterate
(females)
Males
Females
2000
12
55
14.9
8
46
91
28
11.1
57
75
18/6
63
53
11/7
11/6
—
— V
-/-
46/-
15
Y
1.2
31
48
36
—
N
0.1
9
8
11
—
6/3
N
2.1
33
67
45
11
65
47
7/5
1/1
—
0.1
5
2
3
—
—
—
-/-
-/-
8
7"
25
37
-8/
11/-
—
—
—
—
-/-
-/-
7/4
10/4
4.1
35
4
3
12
9
23
6.5
5
26
12.8
N
0.9
Somolio_____________
3.2
7.2
32
11
4
-
-
20
7.0
15
2“
0.3
—
1.1
—
—
Tanzania_____________
11.2
19.0
33
4
2
6
5
18
5.6
11
47
9.4
N
3.7
—
—
23
11.9
52
54
14/12
Uganda_____________
7.3
15.5
34
7
3
15
9
18
6.9
13
38
9.5
Y
2.4
24
34
47
3.6
66
44
29/22
Zambia_____________
3.3
5.3
36
22
11
34
21
18
6.1
12
47
19.1
Y
1.1
22
27
25
9.5
63
49
16/13
17/9
Zimbabwe
4.2
4.5
36
17
12
52
45
19
4.0
12
69
25.8
Y
1.4
3b
3b
19
14"
47
71
37/34
-/-
-
64
28
—
■ MIDDLE AFRICA
30
61
32
-
31
19
19
6.6
16
—
10
—.
—
—
—
-/-
6/—
Angola_____________
4.1
8.2
32
20
9
-
-
—
6.8
16
15“
2.1
N
1.3
—
—
—
-/-
-/-
Cameroon___________
4.9
8.6
32
24
13
32
22
18
5.2
13
64
4.9
Y
1.6
—
—
34
13.5
54
58
73/20
15/3
Central African Republic
1.2
1.8
33
21
7
15
6
17
5.1
15
67
10.8
Y
0.4
—
—
39
11.2
61
70
25/10
13/2
Chad______________
2.4
4.5
32
-
-
15
4
16
6.6
15
32
2.7
N
0.8
—
—
47
3.7
71
37
14/10
3/1
Congo, Dem. Rep, of [Zaire]
16.4
1.9
32
-
-
32
19
20
7.2
16
80“
4.3
Y
5.4
—
—
24
—
—
—
-/-
3/—
(LJeJsl?!____
0.9
34.6
32
89
60
62
45
22
5.3
12
7.8
Y
0.3
6
13
16
0.3
0.6
28
35
13
32
19
—
5.4
17
15
16
31
-
-
82
96
26
3.1
10
80
Botswana___________
0.6
0.7
35
20
61
68
25
4.1
9
78“
Lesotho_____________
0.7
1.1
32
14
21
25
36
—
4.4
9
50
8.4
Namibia____________
0.6
0.8
32
-
-
58
67
—
5.1
11
67
19.9
South Africa__________
12.4
13.1
31
-
-
88
103
26
2.9
10
82
12.9
Swaziland___________
0.3
0.5
33
39
37
55
54
29
5.9
10
56
18.5
Gopon_____________
■ SOUTHERN AFRICA
17
4.4
25.1
—
Y
0.1
-
-
—
—
5
IS
14
Y
0.2
11
5
6
6
Y
0.2
—
_
17
N
0.2
14
8
7
16.4
—
4.1
15b
15b
5
—
Y
0.1
15
13
-
-
—
_
26
-/-
-/-
-/-
-/63/63 1
-/-
55
42
76
-
-
—/35
17/-
-/-
-/-
29/27
21/17
-/-
66/64
-/-
-/-
MARRIAGE AND FERTILITY
Population
1^24
% Enrolled in
Population
Average
Total
% TFR
% Enrolled in
Secondary
Ages 10-24
Secondary
School Latest Age at First Fertility Attributed
—[millions)
ft of Total) School 1980
Year
Marriage* Rate to Births by
2000
2025
2000
Males Females Males Females All Women (TFR) Ages 15-19
| ASIA
1,031
1,048
ASIA (Extl. China)
714
772
29
45
31
57
44
21
3.3
1 WESTERN ASIA
57
78
31
49
31
63
48
22
1.0
0.8
28
—
—
100
79
—
Armenia
28
48
34
62
51
21
11
65
zsz
4.0
8
74
1.3
12
96
2.8
TEEN POPULATION, AGES 15 - 19
HEALTH
% of Adult
AIDS
Population Education
Infected Included in
% Births
School
Attended With HIV,
by Trained Ages 15-49, Curriculum,
1997
1993
Personnel
Azerbaijan
2.2
1.9
29
■ —
—
73
81
24
1.9
4
99
Bahrain
0.2
0.2
25
70
58
91
98
25
2.8
4
98
Cyprus
0.2
0.2
24
90
90
—
—
—
_
Population
Currently
Ages 15-19
Married*
(in millions) % Illiterate
Males Females (females)
2000
1
342
19
242
29
27
—
40
38
15
—
—
—
—
—
20
26
41
6
20
(females)
0.1
—
0.3
—
Y
0.7
—
—
9
0.2
—
0.1
1
1
6
15
—
—
—
96
99
1.9
4
100*
0.3
Y
0.1
z
1.1
1.0
23
—
—
78
76
24
1.2
12
—
z
—
0.4
—
—
17
—
12.5
33
76
38
51
32
22
5.7
4
54a
Y
2.5
—
—
18
—
Israel
1.6
1.8
26
77
89
87
23
2.9
4
99a
—
—
2.2
3.6
33
79
63
—
—
22
4.4
4
97
N
0.7
2
3
8
—
17
98
Kuwait
0.7
0.7
33
84
76
64
66
23
3.2
6
99'
0.1
Y
0.2
4
11
11
—
54c
98f
Lebanon
0.9
1.0
29
59
61
78
84
—
2.4
5
85
0.1
N
0.3
—
—
—
—
—
Oman
0.8
1.7
33
17
6
68
66
19
7.1
7
93
0.1
—
0.3
6b
88f
Qatar____________
0.1
0.2
23
64
68
80
79
23
4.2
9
98
0.1
—
0.04
48c
92’
12.0
31
36
23
65
57
22
6.4
10
90
z
N
2.2
z
Saudi Arabia________
6.7
5.9
7.5
36
57
35
45
40
22
4.7
6
54
Turkey
19.6
19.2
29
44
24
68
48
24
2.5
9
76
United Arab Emirates _
0.6
0.7
26
55
49
77
82
23
4.9
11
99
5.8
12.9
32
7
4
53
14
17
6.5
7
43
Yemen________
Notes
a: Dara prior to 1990
b: Among 18-24-year-olds
c: % ever married women ages 15-19 who are mothers
d: Among women ages 15-24
e: Among women currently ages 20—24
f: Delivery in public facilities
Y
0.5
lb
2b
6
—
36
5
6
10
4
16
15
-/-
16/-
-/-
-/-
18/-
—
—
—
Y
2.0
10
35
—
—
—
—
N
6.8
3
10
13
—
25
81
0.2
—
0.2
8
11
17
—
-
z
N
1.8
15
60
26
45
50
-
30/-
-/-
—J—
Jordan
0.1
Any/Modem Any/Moden
Method
Method
-/100
—
7.6
67
% Using
Contraception
(females)
—
49c
—
Iraq
z
—
—
Georgia
25
% Births
Attended
% Giving
by
Birth by Trained
Age 20e Personnel
—
31
19
% Single,
-/-/-/-/-/-/-/-/-/-/-/-/-
-/4/-/>
-/-
33/19
8/-
-/3/16/-
-/-/34/16
-/9/3
*: May include formal and/or informal unions
**: Data are based on single teens who have ever had intercourse rather than
those reporting intercourse in the last 4 weeks.
z: number rounds to zero
7.1: Numbers in italics indicate data prior to 1985.
POPULATION
EDUCATION
Population
% Enrolled in
Population
Ages
% Enrolled in
Setondary
Average
Total
% TFR
Ages 10-24
10-24
Secondary
School Lolest Age at First Fertility Attributed
(millions)
(% of Total) School 1980
Year
Marriage* Rate to Births by
2000
2025
2000
Males Females Males Females Ail Women (TFR) Ages 15-19
SOUTH-CENTRAL ASIA
Afghanistan
458
503
6.3
14.4
31
38
20
55
37
28
16 ~7F
3?
1?
Bangladesh
46.5
46.2
36
Bhutan
0.7
1.2
31
26
3
Indio
300.2
307.3
30
39
70
59
39
Iran
24.8
22.1
37
52
32
81
73
Kazakhstan
4.6
3.9
28
—
—
82
91
Kyrgyzstan
1.4
1.5
31
112 108
75
83
9
75
13
20
14
AIDS
% of Adult
Population Education
% Births
Infected Included in
School
Attended With HIV,
by Trained Ages 15-49, Curriculum,
1993
Personnel
1997
3.6
15
36
61
11
9’
33
18
8
56
6
15
20
33
18
34
22
2.9
5
86
21
1.7
12
100
20
2.8
6
98
—
1
TEEN POPULATION, AGES 15-19
MARRIAGE AND FERTILITY
—
7
7
7
0.8
7
7
—
%
Population
Currently
Ages 15-19
Married*
(in millions) % Illiterate
Males Females (females)
2000
156
_
2.0
N
16.6
N
0.2
N
102.0
N
8.4
—
% Births
Attended
% Giving
by,
Trained
Birth by
Age 2OC Personnel
% Single,
Sexually
Active
(females)
36
57
36
—
52
87
53
—
-/-
12/- ■
14
-/-
33/28
—
-/-
;
A
71
48
—
—
—
20
44
38
—
49
34
-/-
7/—
6
15
22
—
—
—
-/-
34/-
1.5
z
z
12
—
29
99
-/-
39/24
0.5
—
—
12
—
37
97
-/-
29/21
52
14
-/-
7/4
17
-/-
3/—
7.8
11.2
33
33
9
51
33
16
4.6
13
10
0.2
N
2.6
26
51
43
Pakistan
49.1
77.5
31
20
8
33
17
22
5.6
9
18
0.1
N
15.9
56
74
24
—
31
Sri Lanka
5.5
5.0
29
52
57
72
78
24
2.1
5
94
0.1
Y
2.0
9
10
7
—
16
Tajikistan
2.0
2.4
33
—
83
74
22
2.7
4
79
z
—
0.7
z
z
14
—
6
—
—
■ SOUTHEAST ASIA
1.4
7,8
157
1.6
8.5
155
32
—
—
—
—
24
2.5
3
96
z
—
—
58
Q_
Uzbekistan
Any/Modern Any/Modern
Method
Method
63
33
47
—
Turkmenistan
•/.Using
Contraception
$ |(We-.|
—
0.5
—
—
—
13
5
14
32
117
94
100
88
20
2.8
5
98
z
—
2.6 £w
30
40
35
53
49
21
3.0
9
64
—
—
53
4
82
-/-
20/-
—
-/-
-/-
—
—
-/-
-/-
25
100
-/-
26
48
16/15
34/30 I
-/-
-/-
Cambodia___________
3.3
4.7
29
—
—
31
17
23
5.3
2
31
2.4
N
1.2
3
8
5
—
—
Indonesia___________
63.6
61.1
30
35
23
55
48
19
2.8
11
54
0.1
N
21.3
2
3
17
—
31
32
-/-
42/42
—
N
0.5
—
—
—
—
—
-/-
-/-
Loos______________
1.7
3.0
31
25
16
34
23
—
5.6
9
Malaysia___________
6.5
7.0
29
50
46
59
69
24
3.2
4
99
0.6
Y
2.3
3
4
8
—
—
-/-
-/-
Myanmar___________
14.0
12.7
31
—
—
29
30
22
3.8
5
56
1.8
N
5.0
12
18
16
—
—
-/-
-/-
Philippines__________
24.0
27.6
32
60
69
77
78
22
3.7
6
64
0.1
N
7.9
4
1
8
Z
21
-/-
18/11
Singapore__________
0.7
0.7
19
60
60
74
70
27
1.5
2
100’
0.2
Y
0.2
1
1
1
-/-
-/-
20
2
17
Thailand___________
17.3
14.2
29
28
51
—
23
1.9
24
61
-/-
Viet Nam
25.3
23.7
32
44
40
48
46
21
2.5
5
85
0.2
Y
8.6
7
7
8
359
312
24
59
76
45
77
70
23
1.8
1
91
—
—
115
3
8
4-
19
8
-/-
|^ASIA
317.1
276.2
25
54
37
74
67
22
1.8
1
100.9
3
8
4
8
—
— ____ 2
China_____________
30
38
37
71’
2.2
Y
5.6
1
Hong Kong__________
1.5
1.1
22
63
65
71
76
27
1.0
3
—
0.1
Y
0.5
Japan_____________
22.6
18.3
18
92
94
103
104
27
1.3
1
100’
z
Y
7.5
Korea, North________
5.5
5.5
23
100’
z
-
1.7
—
—
—
Korea, South________
11.0
9.5
23
82
74
102
102
25
1.5
1
98
z
—
3.8
—
—
]
Mongolia___________
0.9
0.8
34
85
95
48
65
24
2.7
9
100
z
—
0.3
—
__
3
Taiwan
5.5
-
25
81
80
-
-
-
1.5
-
-
-
-
1.9
-
-
1
2.3
-
—
— ____ 1
18/15
■KB
11/-
-/-
-/-
39/-
2
22
-
43/14/- 1
-/-
-/-
/
-/-
—/ —
-
-/-
-/-
_ _ _ _ _ _ _ _ _ _ _ _ _ TEEN POPULATION, AGES 15-19
Population
% Enrolled in
Population
Ages
% Enrolled in
Secondary
Average
Total
% TFR
Aqes 10-24
10-24
Secondary
School Latest Age at First Fertility Attributed
__ (millioi <sl__ W • of Total) School 1980
Marriage" Rate to Births by
2000
2025
2000
Males Females Males Females All Women (TFR) Ages 15-19
1 NORTH AMERICA
Conado
1 LATIN AMERICA
1 CENTRAL AMERICA
—
%
Population
Currently
Ages 15-19
Married*
(in millions) % Illiterate
Males Females (females)
2000
—.
4
—
_
_
2
—
—
5
7
15
19
14
99
-i
8
99“
0.3
Y
2.1
25
2.1
15
99“
0.8
Y
19.4
21
2.8
14
85
0.5
—.
52
9
14
65
21
Z3I 20
91
92
99
98
87
89
105
105
26
57.7
59.1
21
91
92
98
97
155
163
30
41
43
—
42
46
25
22
% Single,
Sexually
Active
(females)
—
2.0
64
izw:
United Stoles
% of Adult
AIDS
Population Education
% Births
Infected Included in
Attended With HIV,
School
by Trained Ages 15-49, Curriculum,
Personnel
1997
1993
31
46
42
56
57
20
3.1
13
84
—
—
1.2
1.4
30
44
51
47
52
22
3.2
15
98
0.6
N
0.4
6
3
7
Costa Rica
2
15
El Salvador
2.0
2.3
32
26
23
35
39
19
3.6
15
87
0.6
Y
0.7
14
13
22
Guatemala
3.8
6.1
34
20
17
27
25
19
5.0
12
35
0.5
Y
1.3
18
27
24
23
% Births
Attended
% Giving
by
Birth by Trained
Age 2OC Personnel
—
% Using
Contraception
(females)
Any/Modem Any/Modern
Method
Method
-/-
-/-/-
—
19
_
_
-/-
—
19
—
-/-
-/-
35
—
——
55/-
38
—
-/-
29/-
—
95
—/38
53/30
46
88
—/—
23/19
45
91
—/—
15/12
28/^)
—
11"
1
Honduras
2.2
3.0
33
29
31
29
37
19
4.4
13
61
1.5
Y
0.7
—
—
—
49
—
-/-
Mexico
30.6
30.1
31
51
46
64
64
21
2.7
13
91
0.4
—
10.1
4
4
18
5"
35
Nicaragua
1.7
2.5
33
40
45
52
62
18
4.4
17
61
0.2
—
0.6
3
2
26
—
52
91
-/-
Panama
■ CARIBBEAN
0.8
0.8
29
58
—
65
60
65
22
2.6
16
86
0.6
Y
0.3
5
5
19
—
—
—
—
1.8
21
20
—■
30/-
40/38
24/-
11
28
49
55
20
2.6
15
79
4
26
2.4
1.9
21
79
83
76
85
20
1.6
21
99
—
0.8
—
27
—
—
_
Cuba
Dominican Republic
2.5
2.6
30
—
—
47
61
19
3.1
16
96
1.9
N
0.8
18
14
23
2.9
39
99
58/42
Haiti
2.9
3.5
35
14
13
21
20
21
4.7
8
21
5.2
—
1.0
47
43
15
5.4
32
71
23/10
11/8
Jamaica
0.7
0.7
29
63
71
63
67
20
2.6
18
91
1.0
Y
0.3
18
6
7
—
—
—
-/-
68/65
25
—
—
—
—
2.1
17
—
—
—
0.3
10
8
15
—
—
—
-/-
-/-
-/18
93
63/54
42/50/41
—
-/-
-/-
67
-/-
Puerto Rico_________
Trinidad and Tobago
1 SOUTH AMERICA___
11
1.0
0.4
102
10.0
Argentina
0.9
22
-/-
31
73
75
72
75
22
1.7
12
98“
0.9
Y
0,1
1
1
20
7"
30
106
30
38
42
—
—
21
2.7
14
86
—
—
35
9
6
13
—
34
10.6
27
53
62
73
81
23
2.6
12
97
0.7
Y
3.3
2
1
10
—
47
0.1
II
0.9
3
7
11
0,3
Bolivia
2.6
3.7
31
42
32
40
34
21
4.2
9
10"
36
Brazil_____ _______
50.9
48.5
30
31
36
—
—
21
2.4
16
92
0.6
tl
17.4
15
9
14
8.8
32
Chile
3.9
4.2
26
49
56
72
78
23
2.4
10
100
0.2
tl
1.3
2
1
10
—
Colombia__________
12.4
14.3
29
40
41
64
69
21
3.0
16
85
0.4
Y
4.1
5*>
4b
14
4.9
Ecuador___________
4.0
4.3
31
53
53
50
50
20
3.3
12
64
0.3
N
1.3
3
3
17
6"
Guyana_________
0.2
0.2
29
76
80
71
76
24
2.7
12
71
2.1
—
0.1
—
—
12
Paraguay_____ ____
1.8
2.6
32
29
29
46
48
21
4.3
9
61
0.1
N
0.6
4
4
16
31/10
97
66/61
54/47
—
-/-
-/-
67/43
51/^
53
61
—
—
-/-
-/-
5.6
37
95
23/13
37/30
32
_________ _
8.1
8.4
31
63
54
72
67
21
3.4
10
56
0.6
—
2.7
3
5
12
2.2
Uruguay__________
0.8
0.8
24
61
62
75
90
23
2.3
15
96“
0.3
N
0.3
2
1
11
—
Venezuela
7.4
8.5
31
18
25
33
46
21
2.9
16
69“
0.7
Y
2.3
5
3
18
-
Peru
35/29
36
-
95
27/19
81
70/33
—
-/-
-
46/31
-/-
|
POPULATION
EDUCATION
I EUROPE
I NORTHERN EUROPE
149
109
21
86
88
97 102
24
1.4
18
16
19
86
90
117 132
26
1.7
% of Adult
AIDS
Population Education
% Births
Infected Included in
Attended With HIV,
School
by Trained Aqes 15-49, Curriculum,
Personnel
1997
1993
99
7
Denmark
0.9
0.9
17
105
104
120
122
28
1.7
3
Estonia
0.3
0.2
23
126
127
100
108
23
1.2
15
94
100
100’
Finland
1.0
0.8
19
105
110
125
27
1.7
3
100
Ireland
0.9
0.9
25
85
95
113
122
26
1.9
5
—
—
Latvia
0.5
0.3
22
—
Lithuania
0.8
0.5
23
—
0.8
0.8
18
92
96
TEEN POPULATION, AGES 15-19
HEALTH
MARRIAGE AND FERTILITY
Population
% Enrolled in
Agpc
Populat ion
% Enrolled in
Average
Secondary
Total
% TFR
Ages 10-24
10-24
Secondary
School Latest Age at First Fertility Attributed
_ (millions)
(% of Total) School 1980
Marriage’ Rote to Births by
2000
2025
2000
Males Females Males Females All Women (TFR) Ages 15-19
—
_
0.1
7
0.1
z
82
85
23
1.2
11
85
88
22
1.3
13
—
121
116
26
1.8
4
100’
0.1
—
—
Y
%
Population
Currently
Ages 15-19
Married’
(in millions) % Illiterate
Males Females (females)
2000
50
—
6
—
0.3
—
—.
—
% Single,
Sexually
Active
(females)
% Using
% Births
Contraception
Attended ______ (females)
___ Single
% Giving
Married’
Birth by Trained
Any/Modem Any/Modem
Age 20c Personnel
Method
Method
7
—-
—
—
2
—
—
—
1
—
—
—
—
7
—
0.3
—
—
1
—
—
—
-/-
-/-
—
0.3
—
1
—
—
—
-/-
-/-
—
—
-/-
-/-
Y
0.2
z
z
8
—
N
0.3
z
z
—
—
—
—
-/-
-/-
Y
0.3
—
—
]
—
—
—
-/-
-/-
—
—
-/-
128
153
2
100’
0.1
Y
0.5
—
—
—
11.1
9.8
19
82
85
120
139
26
1.7
8
100’
0.1
—
—
3
—
—
18
88
90
112 111
26
1.5
99
—
Y
—
3.7
28
11
—
—
2
—
—
18
83
93
28
1.5
-/-
z
33
1.4
-/-
-/-
-/-
Z
United Kingdom
1.6
■B
0.1
I WESTERN EUROPE
Sweden
—
-/-
-/-
1
—
-/-
-Z50
-/-
-/-
-/-
-/-
-/-
Austria
1.5
1.2
18
98
87
105
102
26
1.3
3
6
100
0.2
Y
0.5
—
—
4
—
—
—
Belgium
1.8
1.5
18
90
92
142
151
25
1.6
4
100'
0.1
Y
0.6
—
—
5
—
—
—
99
0.4
Y
3.9
—
—.
1
—
7
-/-
50/-
0.1
Y
4.6
—
—
2
—
—
-/-
-/-
-/-
-/-
-/-
France
11.6
10.5
20
77
92
112
111
26
1.8
3
Germany
13.9
11.1
17
93
89
105
103
26
1.3
4
99
Netherlands
2.8
90
134
129
1
100’
3
3
1
—
—
—
-/-
Switzerland
1.3
1.1
17
-
—
—
28
1.5
1
99’
0.3
—
0.4
—
—
1
—
—
-
-/-
71
47
23
92
92
87
92
22
1.2
14
99
—
—
24
__ z
z
12
—
—
-/-
-/-
2.4
1.6
23
—
—
91
95
23
1.3
13
100’
0.2
—
0.8
—
—
-/-
-/-
Bulgaria
1.7
1.0
21
85
84
77
76
22
1.1
20
100’
z
—
Czech Republic
2.2
1.3
22
113
116
97
100
22
1.1
10
—
z
21
72
67
96
99
22
1.3
10
100’
78
79
79
82
22
1.5
9
—
1 EASTERN EUROPE
Belarus
2.3
18
95
27
1.6
Hungary
2.1
1.3
Moldova
e_
1.2
0.9
27
9.5
6.5
25
75
80
98
97
22
1.4
7
99’
Romonio____________
5.3
2.8
24
102
86
79
78
22
1.3
16
100’
34.6
23.3
24
95
97
83
91
23
1.2
17
99
Slovakia
1.3
0.9
25
—
92
96
21
1.4
12
—
Ukraine
11.1
7.2
22
—
88
94
-
1.3
13
100
-
Notes
a: Data prior co 1990
b: Among 18-24-year-olds
c: % ever married women ages 15-19 who are mothers
d: Among women ages 15-24
e: Among women currently ages 20-24
f: Delivery in public facilities
0.2
Y
0.9
10
—
0.6
1
1
16
—
—
Y
0.7
—
—
7
—
24<t
N
0.6
1
1
8
—
0.1
—
0.4
z
z
14
—
0.1
—
—
-/-
—
-/-
—
-/-
51/27
—
-/-
-/-
66/40
78/48
—
-/-
3.4
—
—
5
—
—
—
-/-
N
1.6
1
1
11
—
20
—
-/-
0.1
Y
11.9
z
z
13
—
—
-
N
0.4
z
z
—
—
—
—
-/-
-/-
0.4
-
3.8
-
—
15
-
-
-
-/-
-/-
-/-
43/9
-/-
*: May include formal and/or informal unions
**: Data are based on single teens who have ever had intercourse rather than
those reporting intercourse in the last 4 weeks.
z: number rounds to zero
7.1: Numbers in italics indicate data prior to 1985.
i
. MW
|SOUTHERN EUROPE
Albania
TEEN POPULATION, AGES 15-19
HEALTH
MARRIAGE AND FERTILITY
EDUCATION
Population
% Enrolled In
Average
Total
% TFR .
% Enrolled in
Secondary
Population
Ages
Ages 10-24
10-24
Secondary
School Latest Age at First Fertility
Marriage* Rate to Births by
_ (millions)
(% of Total) School 1980
Year
2000
2025
2000
Males Females> Males Females All Women (TFR) Ages 15-19
% of Adult
AIDS
Population Education
Infected Included in
% Births
With HIV,
by Trained iAges 15-49, Curriculum,
1997
1993
Personnel
27
19
19
74
73
95
99
25
1.3
5
—
—
0.9
0.8
28
70
63
37
38
22
2?
7
99a
z
—
23
1.6
10
97
7
Bosnia-Herzegovina
0.9
0.7
23
—
Croatia
0.9
0.7
21
—
—
81
83
24
1.5
6
—
Greece
2.0
1.3
19
85
77
95
96
25
1.3
5
97a
0.1
Italy
9.2
6.6
16
73
70
94
95
26
1.2
3
—
0.3
—
—
Macedonia
0.5
0.5
24
64
62
23
1.9
10
Portugal
2.0
1.4
20
34
40
106
116
25
1.5
7
90’
Slovenia
0.4
0.3
21
38
39
90
93
24
1.2
7
—
95
0.7
%
Population
Currently
Ages 15-19
Married*
(in millions) % Illiterate
Males Females (females)
2000
9
N
0.3
—
0.3
Y
0.3
0.7
Z
—
1
% Single,
Sexually
Active
(females)
% Births
Attended
% Giving
T
d
Birth by
Age 20c Personnel
6
—
—
—
-/-
—
—
—
—
-/-
-/-
—
—
—
—
-/-
-/-
z
9
—
—
—
-/-
-/-
z
14
—
—
-/-
-/-
z
-/-
-/-
—
-/-
-/-
—
—
-/-
-=4ik-
—
—
-/-
2.9
z
z
5
—
—
—
0.2
—
—
—
—
—
—
0.6
1
1
9
—
Y
0.1
z
z
2
Y
________
% Using
Contraception
(females)
Single
Married*
Any/Modern Any/Modem
Method
Method
116
123
1.2
3
4
—
—
2,4
2.0
23
—
—
60
64
24
1.6
10
93
0.1
—
0.8
1
1
—
—
—
—
-/-
7
8
24
63
64
111 113
25
2.4
6
93
—
—
2
—
—
6
—
—
—
-/-
Australia
3.9
4.1
21
70
72
150
155
26
1.7
6
100
0.1
Y
1.3
—
—
1
—
—
—
-/-
-/-
Fiji
0.3
0.3
32
53
57
64
65
23
3.3
9
96’
0.1
—
0.1
2
2
13
—
—
-/-
-/-
New Zealand________
0.8
0.9
22
82
84
110
116
27
2.0
8
99’
0.1
Y
0.3
—
—
2
—
—
—
-/-
-/-
Papua-New Guinea
1.5
2.2
32
15
8
17
11
21
4.8
3
53
0.2
Y
0.5
-
-
19
■. -
-
-
-/-
-/-
7.6
Spain
Yugoslavia
1 OCEANIA
_____
4.9
19
85
89
26
Notes
a: Dara prior to 1990
b: Among 18-24-ycar-oIds
c: % ever married women ages 15-19 who are mothers
d: Among women ages 15-24
e: Among women currently ages 20-24
f: Delivery in public facilities
96’
0.6
Y
2.5
-
—
-/-/-
*: May include formal and/or informal unions
Dara are based on single teens who have ever had intercourse rather than
those reporting intercourse in the last 4 weeks.
z: number rounds to zero
7.1: Numbers in italics indicate data prior to 1985.
measure
Communication
Population Reference Bureau
MEASURE Communication
1875 Connecticut Ave., NW, Suite 520
Washington, DC 20009 USA
Telephone: (202) 483-1100
Fax: (202) 328-3937
E-mail: measurc@prb.org or popref@prb.org
Website: www.measurecommunication.org
or ww5V.prb.org
1965'69
‘Wo single individual
VITAL STATISTICS
1965
World Population
3.308
(in billions)
Average Family Size Worldwide
(in number of children)
5.0
Annual Population Increment
(in millions)
68
World Contraceptive Use as
Percent of Fertile Age Couples
27
Number of Governments
Subsidizing Family Planning
21
U.S. Foreign Aid for Family
Planning (in millions)
$2.0
1970
was more important to
3.632
this effort than General
4.8
William Draper. ”
75
UNFPA Executive Director
35
First PCC Executive Director, Phyllis
Piotrow, and first PCC National Chair,
Kenneth Keating, former Republican senator
from New York.
Naps Sadik on Draper's role
in UNFPA founding.
55
$74.6
“Let us in all our lands — including this land— face
forthrightly the multiplying problems of our multiplying
populations and seek the answers to this most profound
challenge to thefuture of all the world. Let us act on thefact
that less than five dollars invested in population control is
worth a hundred dollars invested in economic growth. ”
President Lyndon B.Johnson, 1965.
U.S. Senate hearings on the "population crisis" chaired by Senator
Ernest Gruening (D-AK). Seated left to right, Senator Clifford Hanson
(R-WY), Chairman Gruening, Senator Joseph D. Tydings (D-MD),
later PCC Honorary Chair, 1967.
©
•©•................
1965 Congressional hearings, chaired
by U.S. Senator Ernest Gruening
(D-AK), on U.S. government
response to rapid world population
growth push for high level
attention in foreign aid program.
Hearings continue for three
years with extensive i ■, l
media coverage.
1965 Griswold v. Connecticut ruling
by the Supreme Court legalizes
contraceptive use by married
couples.
1967
U.S. House and Senate authorize
foreign aid funds for family
planning in new Title X of the
Foreign Assistance Act and
earmark $35 million
for fiscal year 1968.
1968
Congress mandates Center for
Population Research within the
National Institutes of Health to
support contraceptive development
and demographic research,
1968
Congress earmarks $50 million
in fiscal year 1969 for population
assistance. &&&
Extent ofPopulation Crisis Committee Involvement
AAA Major A A Moderate
Minor
■■■__________________
PCC Up Close
"Population increases have become a serious
concern... The population growth rate is too often the
highest, where hunger is already the most prevalent. ”
President John F. Kennedy, 1963.
1965 Hugh Moore, William Draper, Jr., Kenneth
Keating and Cass Canfield found
Population Crisis Committee (PCC) with
Phyllis Piotrow as Executive Director.
1965 General Draper uses new Victor Fund to
raise $4.5 million in private funds for IPPF
over three years, representing over a third
of IPPF’s budget.
1965 General Draper succeeds Senator Keating
as PCC Chair.
1968
PCC Victor-Bostrom Fund raises an
additional $7 million for IPPF by 1974.
1969
Ambassador James Riddleberger becomes
PCC Chair and Draper becomes Honorary
Chair.
1969
General Draper appointed by President
Nixon to UN Population Commission and
later as Special Consultant to UNFPA.
Indian Ambassador, Dr. P.K. Banerjee accepts PCC Victor Fund
Report at 1968 ceremony in U.S. Congress. General William
Draper, U.S. Representatives Edward Roybal (D-CA) and
George Bush (R-TX) and others look on.
“Once, as President, I thought and said that birth
control was not the business of our Federal Govern
ment. Thefacts changed my mind ...I have come to
believe that the population explosion is the world's
critical problem. ”
Former President Dwight D. Eisenhower, 1968.
19618 Agency for International
Development (AID) provides
first grant of $3.5 million to
the International Planned
Parenthood
Federation (IPPF).
19681 AID makes first purchase of
contraceptives for Third World
distribution.
1968
Paul Ehrlich publishes
The Population Bomb.
General William Draper with Mrs. Avabai Wadia and officials of the Indian
Family Planning Association in 1967.
1969
Richard M. Nixon becomes
President of the United States.
1969
United Nations Fund for
Population Activities (UNFPA)
founded with support from United
States, Japan, West Germany,
Sweden and
United Kingdom.
1969
AID establishes Office of Population
headed by R.T. Ravenholt, which
by 1972 assumes consolidated global
responsibility for U.S.
population assistance.
19707 4
'The green revolution has won a
VITAL STATISTICS
1970
World Population
(in billions)
3.632
Average Family Size Worldwide
4.8
(in number of children)
Annual Population Increment
75
(in millions)
World Contraceptive Use as
Percent of Fertile Age Couples
35
Number of Governments
55
Subsidizing Family Planning
U.S. Foreign Aid for Family
$74.6
Planning (in millions)
1975
temporary success in man’s war
3.967
against hunger and deprivation;
PCC founder Hugh Moore with
General William Draper.
4.3
it has given man a breathing
76
space.. .But thefrightening power
ofhuman reproduction must also be curbed; otherwise, the
45
79
Q success of the green revolution will be ephemeral only.
Norman Borlaug, later PCC Board member, accepting Nobel
$110.0
Peace Prizefor work on the Green Revolution, 1971.
U.S. official delegates
to the 1974 World
Population Conference
in Bucharest. From left
to right, General
Draper, CEQ
Chairman and later
PCC Board member
Russell Peterson, and
HEW Secretary
Caspar Weinberger.
“He spokefor all of us who have workedfor years
in thefield ofpopulation. And, what we in this
field have achieved— or will achieve — will be,
I believe, a testament to the man and a monument
to his memory. ”
Eulogy of General Draper by UNFPA
Exeattrue Director Rafael Salas, 1975.
.0.......
1970
President Nixon initiates
Commission on Population Growth
and the American Future.
1970
Congress amends Public Health
Services Act to establish domestic
Title X family planning program,
also named for sponsor U.S.
Senator Joseph Tydings (D-MD).
1970
India becomes second major
developing country to legalize
abortion and first to market
subsidized contraceptives through
commercial outlets.
1972
1971
China launches its first successful
family planning program
emphasizing “later, longer and
fewer.”
1972
Comstock Act defining
contraceptive information as
obscene repealed by Supreme
Court.
1972 Following medical testing, AID
approves new menstrual regulation
kit for overseas distribution.
First post-colonial censuses in
^“AA
Ne-w York Tinies supplement on
population highlights Rockefeller
Commission recommendations;
circulated to two million
,< a
high school students.
&&&•'
1971
1971
Population assistance becomes line
item in foreign aid budget with a
S125 million appropriation.
1972
World Fertility Surveys begin.
AA-
MM_____________________
PCC Up Close
the record of our time, one of the most
importantfactors in theirjudgment
will be the way in which we responded
Lawrence Kegan named PCC Executive Director.
General Andrew O’Meara assumes PCC Chair.
Senator Tydings retires from U.S. Senate; joins
PCC Board; later named National Co-Chair.
1971
On leave from PCC, Dr. Piotrow completes book,
World Population Crisis: The U.S. Response with
forward by George Bush.
1972
Hugh Moore dies. Hugh Moore Award
established. Recipients through 1989 include
Malcolm Potts, R.T. Ravenholt, Nafis Sadik,
Fernando Tamayo, Fred Sai, Ryoichi Sasakawa,
Mechai Viravaidya, Haryono Suyono.
1973
Robert Wallace named National Co-Chair with
Senator Tydings.
1974
PCC granted consultative status with United
Nations.
1974 Russell Peterson, former Governor of Delaware and
Chair of the Council on Environmental Quality,
joins PCC Board; launches efforts to link
population, environment and natural resources.
1974 General Draper and Drs. Peterson and Piotrow,
active members official
U.S. delegation to
World Population
Conference, Bucharest.
1974 Robin Chandler Duke
named National CoChair with Senator
Tydings and Mr.
Wallace; assumes
responsibility for PCC
New York office.
1974 General Draper dies.
1970
1970
1971
“When future generations evaluate
Lawrence Kegan, former
PCC Executive Director
and President.
to population growth... ”
President Richard M. Nixon, 1969.
PCC National Co-Chair Robin
Chandler Duke on the speaker's
circuit.
1973
Supreme Court legalizes abortion
in Roe v. Wade. ,,'j\
1974
Gerald R. Ford becomes President
of the United States.
1973
Amendment by U.S. Senator Jesse
Helms (R-NC) bans use of foreign
aid funds for abortion.
1974
1973
Mexico abandons pro-natalist
policy, launches strong national
family planning program for 1974.
World Population Year and
Bucharest Conference. World
Population Plan of Action adopted
by 135 countries.
1974
130 nations support resolution on
food and population at World Food
Conference. ?.
:j.
1974 Japan and Germany double
contributions to UNFPA and IPPF
following 1973 parliamentary tours
to developing
countries.
1975'79
PCC National Co-Chair Joseph
Typings, moving force behind early
international exchanges of
parliamentarians on population issues.
VITAL STATISTICS
1975
World Population
(in billions)
3.967
Average Family Size Worldwide
(in number of children)
4.3
Annual Population Increment
(in millions)
76
World Contraceptive Use as
Percent of Fertile Age Couples
45
Number of Governments
Subsidizing Family Planning
79
U.S. Foreign Aid for Family
Planning (in millions)
SI 10.0
1980
4.414
3.8
“Without controlling the growth ofpopulation, the prospects for
77
enough food, shelter and other basic needs for all the world's
51
people are dim. Where existence is already poor andprecarious,
101
$185.0
efforts to obtain the necessities of life often degrade the environ
mentfor generations to come. ” President Jimmy Carter. 1971
A
“To put it simply:
excessive population
growth is the greatest
single obstacle to the
economic and social
advancement of most
of the societies in the
developing world. ”
Select Committee on Population hearings, Committee Chairman James
Scheuer (D-NY) and U.S. Representative Paul Simon (D-IL), 1977.
World Rank President
Robert McNamara, later
PCC Board member, 1919.
• ©•............ .. • ©
1975
1975
World population passes 4 billion.
International Women’s Year .
Conference in Mexico City.
1976 Total donor country support for
population program tops quarter
billion dollars annually.^
Ryoichi Sasakawa opens Tokyo
International Symposium, 1976.
Julia Henderson, longtime Secretary-General
of the International Planned Parenthood
Federation, later PCC Board member and
SPF Committee Chair.
■■■____________________
PCC Up Close
Ambassador Edwin Martin,
PCC Executive Committee Chair,
addresses Tokyo International
Symposium, 1976.
"The rapidgrowth of the human race presents one of the
greatest challenges to man's ingenuity that we have ever
encountered."
President Gerald R. Ford, 1914.
Draper World Population Fund established with
initial contribution of 200 million yen from
Ryoichi Sasakawa.
1975
Ambassador Edwin Martin joins PCC; takes on
responsibility for diplomatic liaison activities.
1975 Victor-Bostrum Reports renamed Draper Fund
Reports.
1975 PCC establishes Special Projects Fund (SPF)
under Mr. Wallace.
1975 Dr. Piotrow rejoins PCC as Executive Director.
1975 Sharon Camp joins PCC; later named Director,
Education and Public Policy and Vice President.
1976
William Gaud, former AID Administrator,
becomes PCC National Chair.
1976
Senator Robert Taft, Jr. (R-OH), co-author of
international population aid legislation, retires
from U.S. Senate and joins PCC Board.
1976
Tokyo International Symposium co-sponsored
by PCC and Japan Science Society.
1976
Following death of Mr. Gaud, Fred Pinkham
becomes National Chair and later President.
1978
Dr. Piotrow leaves to head major population
program at Johns Hopkins; becomes Secretary
of PCC Board.
1978
Julia Henderson, retires as IPPF SecretaryGeneral; joins PCC Board.
1979
Ambassador Marshall Green retires as State
Department Population Coordinator; joins PCC
Board and volunteer diplomatic liaison team.
1979
New SPF program, established by Gordon
Wallace, to support efforts by Africans to
eradicate female circumcision.
1975
Jimmy Carter becomes President of 1979 R.T. Ravenholt forced out as head
the United States.
of now decentralized population
program.
1977
Expanded parliamentary' exchanges
on population issues lead to new
1979 International Conference of
international working group.
Parliamentarians on Population
and Development in Colombo,
1977
Cumulative AID population
Sri Lanka.
assistance tops Si billion.
1977
1977
Global 2Q0Q report calls for stronger
commitment to population
and conservation work.
1977 Congress establishes Select
Committee on Population. :
1979 Pledges to UNFPA top
Si00 million.
19S0-S4
“World population has grown faster, and to higher numbers,
VITAL STATISTICS
1980
1985
than Malthus would ever have imagined. ..It is not inevi
4.414
Average Family Size Worldwide
(in number of children)
3.8
Annual Population Increment
(in millions)
77
World Contraceptive Use as
Percent of Fertile Age Couples
51
Number of Governments
Subsidizing Family Planning
101
U.S. Foreign Aid for Family
Planning (in millions)
S185.O
5
4.845
table that history will vindicate his dire prediction of human
World Population
3.7
numbers outrunning global resources. We have a choice. But
84
that choice must be made now. Opportunity is on our side.
51
117
But time is not. ”
A. IF. Clausen, World Rank President,
and later PCC Board member, 1984.
$288.8
. the population explosion . . .
has been vastly exaggerated. ”
Ambassador James Riddleberger,
first head of U.S. foreign aid
program and later PCC Chair
and volunteer.
Future president Ronald Reagan
at presidential campaign debate
on foreign policy, 1980.
t
PCC President Fred Pinkham being shown new State
Family Planning Commission training center in
Nanjing, China, by Professor Pang Gun Fang, 1985.
(g)°.......... *0* • • • • • •
1980 First in series of regional
parliamentary conferences in Africa,
Asia, Europe and Latin America,
1981
Carter Administration submits last
foreign aid budget request; proposes
population aid level ofS345 million
for fiscal year 1982.
Ronald Reagan becomes President
of the United States; Reagan slashes
population aid request to $211
million.
1981 Campaign by Under Secretary of
State James Buckley to eliminate
population program blocked.
.............
1982
AID approves consensus document
for Administration titled AID Policy
Paper: Population Assistance.
1982
AID withdraws support from major
family planning publications.^
1983
Political threat to Pathfinder Fund’s
S8 million AID grant resolved
through Congressional action, but
only after concessions on abortion.
1981
1981 Office of Management and Budget
attempt to eliminate foreign aid for
population squashed.
MMMH________________
PCC Up Close
artificial contraception will go
straight to hell. ”
WOOMB founder John Billings
PCC budget tops $2 million.
PCC diplomatic liaison team of
Ambassadors Martin and Green and Dr.
Pinkham initiate series of calls on political
leaders in key developing countries.
1980 Special Projects Fund sets up International
Women’s Health Coalition.
1981
Tom Lilley, PCC Treasurer for six years,
dies, succeeded by Gerald Fischer.
1981
PCC founding member of Global
Tomorrow Coalition.
1982
Ambassador Riddleberger dies.
1983
PCC Board approves major new media
liaison program.
1983
William Westmoreland, Senator Taft,
Ambassador Green and other PCC
representatives brief Reagan White House
and national security officials on foreign
policy implications of rapid population
growth.
1983
J. Joseph Speidel, former Acting Director,
AID Office of Population, becomes PCC
Vice President.
1984
PCC media program attracts national
attention with appearances on major
television network news and talk shows.
1980
1980
“Anyone using any method of
Tom Lilley, former Vice President
Ford Motor Company and
longtime PCC Treasurer.
speaking on Tanzanian national
radio during U.S. government-funded
tour ofAfrica.
“First and most important. . . population
Ambassador Marshall Green, PCC Board member and executive volunteer,
is welcomed to Presidential Palace to make population presentation to
Egyptian President Mubarak and senior officials.
growth is, of itself, a neutral phenomenon. ”
James Buckley, readingfrom official U.S. statement
at Mexico City, 1984.
®>(@) •••••••
1983 Last-ditch effort fails to get Food
and Drug Administration (FDA)
approval of the injectable
contraceptive Depo-Provera.^^
1983 Congress earmarks funds for
UNFPA after Administration
proposes major drop in U.S.
contribution.
•©...................
1984
At the International Conference on 1984
U.S. government releases
Population in Mexico City, U.S.
impounded remainder of U.S.
legislators, world press and foreign
contribution to UNFPA after
assurances on abortion,
leaders castigate Reagan White
House and U.S. delegation led by
1984
Congress signals displeasure over
James Buckley for retreat on world
Reagan policies by increasing
population efforts and restrictive
population aid budget to record
new abortion policies.
S290 million for
fiscal vear 1985. :
19858 9
“But it is notjust the American
VITAL STATISTICS
1985
World Population
(in billions)
4.845
Average Family Size Worldwide
(in number of children)
3.7
Annual Population Increment
(in millions)
84
World Contraceptive Use as
Percent of Fertile Age Couples
51
Number of Governments
Subsidizing Family Planning
117
U.S. Foreign Aid for Family
Planning (in millions)
5
$288.2
1990
5.317
financial contribution that is
needed; we believe that the United
3.5
States must resume its leadership
93
role in international population
57
assistance... The nations of the
130
$238.8
U.S. Representative John Porter (R-IL),
first chair of the Congressional Coalition
on Population and Development, and PCC
Vice President Sharon Camp brief
Congressional gathering on foreign aid
budget problems.
world havejoined togetherfor the
past 20 years in supporting inter
nationalfamily planning... The continued absence of United
States support is a blow to that consensus and to the millions
in the developing world that benefitfrom UNFPA programmes. ”
UNFPA Executive Director Nafis Sadit commenting on White
House decision not to renew supportfor UNFPA, 1989.
Longtime PCC Board members, former
U.S. Senator Robert Taft, Jr. (R-OH)
and Frances Loeb.
PCC Board member and chair for
resources development Wendy Morgan
with PCC Board member and General
Counsel, J. Edward Day.
Gordon Wallace, PCC Board member and executive
volunteer, meets with Rachel Marshall of Liberia on
campaign to eradicate female circumcision.
1985
1985
U.S. government suspends support
for IPPF and cuts UNFPA
contribution by $10 million; public
scrutiny forces Administration to
retain funds for other family
planning organizations.
DKT Memorial Fund sues
government to overturn Mexico
City abortion policy; case dismissed
by appellate court in 1989.
1985
Nairobi International Conference
on Women highlights women’s
right to family planning.
1986
U.S. expenditures on population aid
drop by $50 million
to $238 million.
1985
Congress blocks AID policy
concessions to religious
conservatives on natural family
planning, restores principle of
informed consent.
1986
U.S. government withdraws entirely
from UNFPA; most UNFPA funds
directed to other family planning
programs,
1985 AID support for natural family
planning tops $7.8 million, up from
$400,000 in 1980.
PCC President Joseph Speidel with Indian
medical colleague from Parivar Seva Sanstha.
I
PCC Up Close
I
1985 Catherine Cameron becomes Director, Special
Projects Fund, and later Vice President.
1986
PCC leads new 50-organization coalition to save
development assistance appropriation from first
Gramm-Rudman budget squeeze.
1987
Dr. Speidel succeeds Dr. Pinkham as PCC
President.
198^PCC reaches U.S. audience of 100 million with
/•' Human Suffering Index wall chart.
1987
New style PCC Briefing Paper in three languages,
Access to Birth Control, reaches worldwide audience
through first PCC international media campaign.
1988
PCC budget tops $3 million.
1988
PCC and Pathfinder Fund make extensive field
study of impact of Reagan era policies on Third
World family planning programs; circulated to U.S.
policymakers and press.
1988 PCC launches new Population Policy Information
Kits in three languages for foreign officials and
activists.
1988 PCC study, Poor, Powerless and
Pregnant, reaches worldwide
audience of over 500 million.
1988 PCC media materials on new
French pill RU-486 the basis of
hundreds of news stories.
1989
PCC critique of World Bank
population program covered by
the media and acted on by
Congressional committees.
1989
PCC handling of U.S. release PCC National Co-Chair
of UNFPA State of World
Robert Wallace with Board |
members John Musser and I
Population report produces
expanded media coverage.
Nancy Lilley Stein.
“/ strongly support family planning programs which do
not condone or encourage abortion or coercive measures.
I believe that the current Kemp-Kasten law, along with
the Mexico City policy, must be maintained without dilu
tion, in order to preserve both the pro-life and pro-human
rights character of the population assistance program. ”
P^^/ent George Bush threatening to veto foreign aid bill over
restoration offundsfor UNFPA, 1989.
'
International Forum on Population in the 21st Century held in Amsterdam,1989, calls
for major increases in global spending for family planning by the year 2000.
•••••••• (^) •••••••
oo
1987
Planned Parenthood Federation of
America sues AID in anticipation of
move to defund PPFA’s
international program (FPIA).
1987 UNFPA Executive Director for 18
years, Rafael Salas, dies suddenly in
Washington, D.C., during effort to
restore U.S. funds. UN SecretaryGeneral names Dr. Nafis Sadik as
successor.
1987 World population passes 5 billion
mark; events worldwide mark “Day
of Five Billion.”
Blueprint for the Environment
signed by major U.S. environmental
groups calls for 1990 budget for
U.S. population assistance
of $500 million.
1988 French Minister of Health orders
new French abortion pill, RU-486,
back on the market, calling it the
“moral property of women.”
1988
1989
George Bush becomes President of
the United States.
1989 Joint Congressional/Administration
move to eliminate line-item budgets
for population aid blocked
by major mobilization.
1989 President Bush vetoes S14 billion
foreign aid bill over new $15 million
Congressional earmark to reestablish
U.S. contribution to UNFPA.
1989 American women’s organizations
mobilize, following Webster decision
by Supreme Court allowing state
regulation of abortion.
/he Population Crisis
2- Committee (PCC) is a
private non-profit organization.
PCC seeks to stimulate public
awareness, understanding and
action towards the reduction of
population growth rates in devel
oping countries through volun
tary family planning and other
actions needed to solve world
population problems.
(
i
National and Honorary Chair 1965-1974
William H. Draper, Jr.
Officers
National Co-Cbam
Robin Chandler Duke
Joseph D. Tydings
Robert B. Wallace
Executive Committee Chair
Edwin M. Martin
President
J. Joseph Speidel
Vice Presidents
Sharon L. Camp
Catherine Cameron
E. Borlaug
A.W. Clausen
Philander P. Claxton, Jr.
John Conyers, Jr.
J. Edward Day
am D. Eberle
illiam C. Edwards
Henry H. Fowler
Richard N. Gardner
Marshall Green
Joseph A. Greenwald
Donald A. Henderson
Julia J. Henderson
Lawrence R. Kegan
KtayW.Usta
Treasurer
Directors Emeriti
Louis J. Mulkern
Secretary
Phyllis T. Piotrow
Population Crisis Committee
1120 19th Street, NW, Suite 550
Washington, D.C. 20036-3605
(202) 659-1833
Fax: (202) 293-1795
Telex: 440450
Cable: CRISIS WASHINGTON
Bradford Moise
John M. Musser
John S. Nagel
Russell W. Peterson
John E. Reinhardt
Thomas Roberts
Victoria P. Sant
Donald R. Seawell
Elmer Boyd Staats
Nancy Lilley Stein
Marilyn Brant Stuart
Robert Taft, Jr.
Gordon G. Wallace
Paul N. McCloskey, Jr.
Robert
Wendy B. Morgan
Harold W Bostrom
Louis M. Hellman
Fred O. Pinkham
Charles E. Wampler
1990 cont.
Listing of Population Organizations: Their Purposes, Budgets and Key Personnel
Choices for the Next Century
1991
Our Diminishing World: The Land/Population Crisis
Population Politics
1991 World Population Report
Refunding of UNFPA Passes 234 to 188
Zimbabwe: Potential Model in the Midst
Half the Sky: Women and Development
The Demographic Imperative and the Politics of International Population" J
1992
Strategies for Survival: The Population/Environment Connection
ic
Turkey: An Enclave of Hope
X
The Hom of Africa
International Family Planning: Charting a New Course
Desperate Departures: The Flight of Environmental Refugees
Each issue generally is available for $3.50.
1
February, 1993
TOWARD THE 21st CENTURY
A Monograph Series by The Population Institute
Year
1988
Title
Population and Global Survival: A Vision for the Nineties
The City Upon a Hill: Utopian Dreams Meet Urban Reality in the 21st Century
Regional Powder Kega: Charting U.S. Security in an Exploding World
Population & Environment: The Growing Imbalance, the Growing Imperative
Family Planning: A Basic Human Right
Population and Development: Relearning Some Hard Lessons
A Continent in Crisis: Building a Future for Africa in the 21st Century
1989
Focus Indonesia: A Family Planning Success Story
That Special Relationship: Building a Peace That will Last in Central America
The Remarkable Journey: Two Decades of UNFPA Leadership
Strategic and Critical Materials: The United States’ Precarious Future
The Struggle to Refund UNFPA
The 1989 Soeharto Global Statesman in Population Award Presented to President
Robert Mugabe of Zimbabwe
1990
The Apocalyptic Cycle: Overpopulation, Illiteracy, Poverty
A Realistic Solution to Global Wanning
Rapid Population Growth and Tensions in the Middle East
The Long, Dry Season: Population and Water
Foreign Debt and Population
The World’s Dwindling Forests
A CHILD BORN TODAY . .
We live in a world of 5.5 billion people, which grew last year by an
unprecedented 97 million, the largest annual increase ever recorded. Three
billion young people will enter their reproductive years within this
generation. Consequently, a child bom today can expect by the year 2000 a
world in which:
• Almost one-half of the world's forests will be gone;
• One-fifth of the world's plant and animal species will be extinct;
• Deserts will claim an area one-and-a-half times the size of the United
States;
• The air we breathe will contain one-third more carbon dioxide than
it now does;
• Acid rain will have destroyed many more lakes and fish;
• Regional fresh water shortages will be up by 35 percent;
• Available agricultural land will be further depleted, forcing even
more people to move to already overcrowded cities.
The shortsightedness of the present generation dangerously narrows the
options of the next generation. Time is a luxury we do not have. Urgent
action is required now to ensure a reasonable quality of life and a stable
and secure world for a child bom today.
The Population Institute
107 Second Street, NE
Washington, D.C. 20002
Tele: 202/544-3300
FACTS ABOUT THE POPULATION CRISIS
General
With the world's population now exceeding
five billion, we will witness three billion
young people entering their reproductive
years just within the next generation.
40 percent of the developing world's
population is under age 15 and about to enter
their most productive childbearing years.
and external unrest. Today, the continent's
population is 680 million; 20 years from
now it will be 1,155, and 1.65 billion by
2020.
Egypt, a nation of 55 million people and a
key force for stability in the Middle East,
faces serious economic problems today.
There will be 69 million Egyptians by the
year 2000; 105 million by 2025.
By no later than the year 2020, the combined
populations of Asia and Africa will be 6 to 8
billion people, significantly more than now
live on the entire planet.
Economy
Unemployment in many countries of the
developing world is as high as 30 percent.
500 million women want and need family
planning but lack either information or
means to obtain it.
To accommodate their growing populations,
the nations of the world will have to produce
800 million new jobs by 2000.
Health
15 million infants under age one will die this
year — 42,000 each day -- many because
their mothers did not know how to allow
appropriate intervals between pregnancies.
In 1950, only one city in the developing
world had a population greater than 5
million; by the year 2000, there will be 46
such cities.
Nearly 1,500 women die every day because
of complications from pregnancy and
abortion, many of which might not be
necessary if unwanted pregnancies were
avoided through family planning.
Security
Poverty in Central America is a cause of
political unrest in the region. There are now
118 million people living on the land
between the Rio Grande River and the
Isthmus of Panama. By the year 2025, there
will be 204 million.
From the Arab nations in the north to South
Africa, the African continent faces internal
Environment
65 countries which depend on subsistence
farming may be unable to feed their
populations by the year 2000.
25 billion tons of arable topsoil vanish from
the world's cropland every year.
Enough timberland to cover 40 Californias
will disappear by the end of this century.
Acute shortages of fuel will affect 350
million people by the year 2000.
At least 1.7 billion people, nearly one-third
ot the planet's population, lack an adequate
supply of drinking water.
The Population Institute, September 1992
Number 7, 1991
THE DEMOGRAPHIC IMPERATIVE AND THE
POLITICS OF INTERNATIONAL POPULATION
Origins of International Population Programs
In 1958 President Eisenhower appointed a committee of 10
distinguished gentlemen to study the U.S. military assistance program. One
of the concerns they were asked to address was whether the mix of military
and economic aid was appropriate. The President named General William
Draper as chairman and the committee came to be known as the Draper
Committee.1
The committee's terms of reference did not mention population as an
issue for consideration. None of the members had ever before been
involved in population or birth control causes and none had any particular
knowledge of the subject when they were appointed.
The population issue came up the day following the establishment of the
committee when long time population activist Hugh Moore sent Draper a
long telegram admonishing him that his committee would be remiss if it
failed to deal with the population program. President Eisenhower also raised
the issue with Draper although the following year Eisenhower repudiated
the committee's recommendations relating to population. Looking toward
the 1960 election and the possibility that the Democrats might nominate a
Catholic2 as their candidate for president, Eisenhower concluded that the
Republicans should not become associated with the politically sensitive birth
control issue. To do so, he reasoned, might drive Catholic voters who (he
assumed) were already disposed to vote for their co-religionist even further
into the Democratic camp.3
This paper was prepared by James W. Brackett, longtime chief
demographerfor the Agency for International Development, who served for
four years as the chief demographerfor the Population Institute.
At a White House press conference in July 1959, Draper presented his
committee's recommendations, including one calling on the United States to
use its considerable resources to help countries curb run away population
growth.4
Broadening Interest in Population Problem
During the 1960s General Draper and a long list of other prominent
public minded citizens worked to build a consensus that something must be
done to curb run away population growth that served as a brake on the
economies of poor nations. In 1967, following several years of
Congressional prodding, the Agency for International Development (AID)
set up a population unit and hired a small staff with expertise in
demography, public health, communications, biomedical research, and
other fields needed to develop an international population program.
Growing Population Budgets
In 1968 the Congress earmarked $35 million of foreign aid money for
population activities.5 The following year, the earmarking was $50 million,
then $75 million. The increases continued for several years, reflecting a
broad although not universal consensus by members of both political parties
that something had to be done to curb run away population growth. AID
records show that $4,490,864 were programmed for population activities
for the fiscal years between 1963 and 1991.6
The United Nations Population Fund (UNFPA) recently published an
accounting of all international donor assistance for population activities
through calendar year 1989. The total was $8.8 billion. The U.S.
government's international population budget for these same years was $4
billion or about 45 percent of the total.
If donations from private American
Toward the 21st Century is a public affairs series, published
foundations are included, the United
eight times a year and is made available as a public service
by the Population Institute to policy makers and journalists
States contributed about half the
in the developing and developed world. Members of the
population assistance during the period.
Institute’s 21st Century Club (those contributors of $100.00
UNFPA's own budget from its
or more .annually) also receive copies regularly free of
beginning in 1967 through 1990 was
charge. Single issues are make available from the Institute at
S3.50 a 4°py plus postage. Orders of over 30 copies cost
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$2.5O/plus postage. Please make all checks payable:
Treasurer, Population Institute
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*
L-k
A Candy Bar or Coke From Each
American
By Washington standards none of
these figures are big bucks. The U.S.
foreign aid budget from the end of the
Second World War through 1991 was about $300 billion. The U.S.
population account is only 1.5 percent of that total. The U.S. defense
budget is approximately $300 billion annually. The total U.S. contribution
for population activities averages about $18 for each of the 250 million
Americans counted in the 1990 census. Spread over a quarter century, it is
72 cents a year. In some places you can still buy a coke or a candy bar for
72 cents.
But for ordinary Americans who must pay the bills, $4.5 billion
earmarked for one of the world's most serious problems cries for an
©Copyright The Population institute, 1989
Library of Congress ISSN Number 0897-0556
accounting. How AID used a quarter century of precious time may be even
more critical than how it spent the money, although the two are not
separable.
A Ticking Bomb
The population problem has been
compared to a ticking bomb or a
metastasizing cancer. There is some
urgency in taking effective action to
defuse the bomb or retard the process
World population did
of the cancer.
not have to be 5.4
In 1960, about a year after Draper
released his report, world population
billion in 1991 or six
reached three billion and the annual
billion in 1997.
increase in world population was about
55 million. When AID got around to
establishing a population unit eight
years later, there were 3.5 billion
human beings on earth and the annual increment in world population was 71
million. World population is now 5.4 billion with an annual increment of 95
million. About 1997, world population will likely reach six billion, double
its size in 1960. The annual increment that year will be 100 million.
In A Single Human Lifetime
Six billion also means that for the first time in human history world
population will have tripled during a single human lifetime. World
population reached two billion sometime around 1930. It grew slowly
during the 1930s, so anyone bom before about 1935 who is still alive in
1997 can say world population tripled during his or her lifetime.7
Moreover, many of that generation may experience a quadrupling of world
population. The world could have eight billion people by 2015 when people
bom in 1935 will be eighty years old. No person who lived during any
previous period in human history experienced even a doubling of world
population.8
Population Growth Peaked -- Temporally
World population did not have to be 5.4 billion in 1991 or six billion in
1997. The world population growth rate peaked at 2.1 percent around 1970
and then declined to 1.6 percent toward the end of the 1970s. The annual
increment in world population also peaked, temporarily, as it turned out, at
about 78 million in the early 1970s, and then declined to about 70 million by
the end of that decade.9
Had the trends in growth rates recorded during the period 1965 to 1979
continued and spread worldwide, the world population growth rate by now
might be around one percent and the annual increase in world population
about 55 million, its level in 1960. But between the latter half of the 1970s
and the first half of the 1980s, the down trends in growth rates reversed.
The United Nations estimates the world growth rate during the 1980s at 1.7
percent. The Population Reference Bureau's Data Sheet for 1990 placed the
world growth rate at 1.8 percent. Their 1991 data sheet lowered the estimate
to 1.7 percent.
Births Decline -- Then Rise Once Again
The number of births worldwide also peaked - temporally — at 612
million for the five year period 1970-74 and then declined to 603 million for
the period 1975-79. But then the number of births shot up to 642 million
during 1980-84 and to 687 million during 1985-89, according to United
Nations data.
Table 1 shows numbers of births for five year periods for the world and
its major regions as well as increases/decreases between five year periods.
Figure 1 shows the increases/decreases as bars. While only China and the
Developed Countries recorded actual decreases in births, in most other
regions increases in the numbers were markedly lower during the 1970s,
indicating a lower growth rate. But then between 1975-79 and 1980-84
there was an explosion of births.
Fertility Rates Follow Similar Pattern
Fertility rates followed a pattern similar to growth rates. The fertility
measure used here is the total fertility rate which indicates the number of
births an average woman will have during her reproductive lifetime if the
pattern of births by age for a particular period remains in effect. A decline of
1.0 indicates that women on average are having one fewer baby.
In the early 1960s the average number of lifetime births for all women in
the world was 5.0. For the period 1970-74 the rate had declined to 4.5 and
for 1975-79 to 3.8. These are averages for five year periods. By the end of
the 1970s the rate was probably around 3.5.
World fertility for 1980-84 was 3.6. By the end of the decade the rate
had declined slightly - to 3.4.
Although the levels of fertility
varied among major world regions, the
patterns of change were similar for all
developing regions except Africa. In
Patterns of fertility
Subsahara Africa fertility remained high
change were similar for
and constant at about 6.7 lifetime births
per woman until near the end of the
all regions except
1980s when the rate declined by about
Africa.
five percent. For North Africa there
was a slow continued decline through
the mid 1980s and then a sharper
decline during the latter half of the
decade.
i07n?rT?erlevJ°Ping regions fertility rates declined sharply through the
1970s. Then the declines slowed in the 1980s. The pattern is best seen as
Tabled? m fertl lty rateS between flve year periods. (See Figure 2 and
Why the Reversal?
What caused the reversal?
During the 1960s General Draper and others were able to broaden the
base of support for population programs. Members of both politiS pities
Table 1Births in Major World Regions For Five Year Periods: 1960 to 1990
(Millions)
Region
Increases/Decreases Between
Births
1960-64 1965-69 1970-74 1975-79 1980-84
1960-64 1965-69 1970-74 1975-79 1980-84 1985-89 and
and
and
and
and
1965-69 1970-74 1975-79 1980-84 1985-89
World
559
596
612
603
642
687
37
16
-9
38
46
More Developed
Less Developed
LDC excl China
China
Asia excl China & Japan
Latin America
North Africa
Subsahara Africa
98
462
331
131
209
48
16
56
92
504
361
144
227
51
18
63
90
522
388
134
243
54
19
71
87
516
413
103
255
56
21
82
88
554
456
98
280
59
23
94
86
602
485
117
290
61
24
109
-6
43
30
13
18
3
1
7
-2
18
27
-9
15
3
1
9
-2
-6
25
-31
12
2
2
11
1
38
43
-6
25
3
2
12
-2
48
29
19
10
2
1
16
Source: Based on United Nations data.
Figure 1Increase / Decrease in Numbers of Births in
Major World Regions Between Five Year Periods:1960 to 1990
Dedine n Fertility Rate
Change in TFR
Figure 2 .- Declines in Total Fertility Rates for Major World Regions
Between Five Year Periods:! 960 to 1990
Asia Excluding China and Japan
Table 2.- Fertility Rates for Major World Regions for Five Year Periods: 1960 to 1990
Region
World
More Developed
Total Fertility Rate
1960-64 1965-69 1970-74 1975-79 1980-84 Ca. 199C
Decrease in Total Fertility Rates Between
1960-64
and
1965-69
and
1970-74
and
1975-79
and
1960-64
and
1960-64
and
1975-79
and
1965-69
1970-74
1975-79
1980-84 PRB1991 PRB1991
1975-79
Ca1990
1980-84
and
5.0
4.9
4.5
3.8
3.6
3.4
-0.1
-0.4
-0.6
-0.2
■0.2
-1.6
-1.1
-0.4
2.7
2.4
2.2
2.0
1.9
1.9
-0.3
-0.2
-0.2
-0.1
-0.0
-0.8
■0.7
■0.1
Less Developed
6.1
6.0
5.4
4.5
4.2
3.9
-0.1
-0.6
-0.9
-0.3
-0.3
-2.2
-1.6
-0.7
LDC exd China
China
6.2
5.9
6.0
6.0
5.7
4.8
5.3
2.9
5.0
2.4
4.4
2.3
-0.1
0.1
-0.3
-1.2
-0.4
-1.9
-0.3
-0.5
-0.5
-0.1
-1.7
-3.6
-0.9
-3.0
-0.8
-0.6
Asia excl China & Ja
6.1
6.1
5.9
5.5
5.2
4.3
-0.1
■0.2
-0.4
-0.2
-1.0
-1.8
-0.7
-1.2
Latin America
North Africa
6.0
7.1
5.5
6.9
5.0
6.4
4.4
6.0
3.9
5.7
3.5
5.0
-0.4
-0.2
■O.5
-0.5
-0.6
-0.3
-0.4
■0.4
■0.5
-O.7
-2.5
-2.1
-1.6
-1.1
-0.9
-1.0
6.4
-0.0
0.0
-0.0
-0.1
-0.2
-0.3
-0.0
-0.3
Subsahara Africa
6.7
6.7
6.7
6.7
6.6
Source: Based on United Nations and Population Reference Bureau data
acknowledged the urgent need to do something to slow population growth.
George Bush was one of many strong supporters. In 1972 while he was
ambassador to the United Nations, Mr. Bush wrote the Forward to Phyllis
Piotrow's World Population Crisis: The United States Response. He
referred to the bipartisan nature of support for population programs and the
need for action to solve the problem.
His two and a half page Forward
includes the following:
The Population Office
Today, the population problem
is no longer a private matter. In
a world of nearly four billion
people, increasing by two
percent, or 80 million more,
every year, population growth
and how to restrain it are public
concerns that command the
attention of national and
international leaders.
view was that people
had large numbers of
children because they
lacked access to safe
and effective
contraceptives.
But the political base was fragile. The Catholic Hierarchy as well as
some conservative Protestant groups opposed family planning generally and government involvement therein particularly. Political ideologues on
both the left and right also opposed population programs.
The leftists were influenced by outmoded Marxist ideologies the Soviets
discarded in the mid-1960s.10 These ideologies viewed family planning
programs in non-communist countries as threats because they had the
potential of relieving the misery of the working class, thus delaying
communist revolutions.11 Apparently, Marxists in the West had not gotten
the word that their ideology was passe.
The political right was heavily influenced by religious opposition to
family planning, particularly from the Catholic Church. They iso strongly
opposed government action in any area to solve human problems, and many
viewed contraception as immoral.12
Some members of the academic community also opposed population
programs, not necessarily because they were opposed to family planning
per se but because they felt foreign aid should be used for education,
housing, job creation, etc. first. They had not understood General Draper's
message, that these poor countries had little prospect of solving their socio
economic problems even with substantial foreign aid unless and until they
first controlled run away population growth.
Some of the academic opposition, particularly from demography and
economics, sprang from the fact that AED's population office rejected their
theories which maintained that couples in the developing world had large
families because they wanted them. These couples would not change their
fertility behavior except in response to improved living standards, their
theories held.
AED's Population Office rejected these theories (although many others in
the agency supported them). The Population Office view was that people
had large numbers of children because they lacked access to safe and
effective contraceptives. The road to fertility reduction lay in satisfying the
unmet demand for family planning.13 If after satisfying this unmet demand,
developing nations still had a problem of excess fertility, actions to create
mOT|hdeeemedrgencedobfethe^boJtion issue, particularly following the 1973
Supreme Court ruling in Roe v. Wade and Doe v.Bolton, invigorated
family planning opponents to fight contraception, sterilization, and abortion
on all fronts.
Politicians Play to Family Planning Foes
While a large majority of Americans continued to support family
planning both domestically and internationally, they were not fanatics on the
subject. At election time they looked at a candidate's voting pattern on a broad
series of issues they felt were important, family planning being only one.
On the other hand, family planning foes were fanatics. They didn't
much care what positions the candidates took on a wide range of topics as
long as his or her record was "pure" on family planning and abortion.
Both political parties played up to the single issue extremists. Although
family planning foes had been given occasional plums by earlier
administrations, Carter was the first to make major concessions. By the end
of the Carter Administration the population program which had been by far
the most effective of AID activities, was in shambles. The people who were
responsible for the earlier successes had been removed or isolated. They
were replaced by accommodating bureaucrats and political appointees with
no records of accomplishment in any field.
The Reagan Administration is often blamed for destroying the U.S.
international population program, but that had largely been accomplished
before Reagan s arrival on the scene. Reagan continued the destructive
actions initiated by Carter.
Neither the Congress nor the Administrations cared much about what
happened to population funds. Family
planning foes siphoned off as much as
they could. When contracts were
awarded to unqualified contractors,
those in a position to stop the waste of
taxpayers'
funds looked the other way
The crown to (Carter’s)
or were willing participants.
pessimistic outlook was
the Global 2000 report.
Limits to Growth - No Limits to
Growth
Carter made a great to-do about the
limits to growth. The crown to his
pessimistic outlook was the Global
2000 report.
Reagan adopted the counter theme There are no limits to growth. He
called for Americans to feel good about themselves. Neither of these
presidents understood that the truth lay somewhere between their conflicting
views. The world is not going to hell in a hand basket in the next five
minutes but neither is the sky perpetually rosy.
t)
International Conference on Population, 1984
If there were no limits to growth, then population growth must not be a
problem. At the International Conference on Population in Mexico City in
1984 the head of the American delegation, James Buckley, dismissed the
population problem. Population is
neither good nor bad, he said. It is
neutral. Then he gave his — and
presumably Reagan's — solution to the
problem — free markets.14
Population growth in
Buckley pointed to the "Little
developing countries is
Tigers" of the Pacific rim, Singapore,
Taiwan, Hong Kong, and South Korea,
the result of a surplus
as examples of countries that had used
of births over deaths.
the free market to solve their population
problems. Evidently, he had no
knowledge of the real history of these
nations. All adopted strong government
run programs to curb fertility. Only
after these programs succeeded in sharply reducing fertility did their
economies take off.15
Buckley also tried to get authority from the White House to announce at
Mexico City that the United States was terminating all international
population activities, but the White House did not approve.
Population Not "Neutral1
Population is, of course, not neutral. The migration of large numbers of
people to North America, first from Europe and Africa, and later from all
over the world, had a positive impact on the development of the United
States. In fact, our Declaration of Independence acknowledges the positive
nature of immigration in its bills of indictment against George III. The
Declaration states:
He has endeavored to prevent the population of these States; for that
purpose obstructing the Laws for Naturalization of Foreigners;
refusing to pass others to encourage their migrations hither, and
raising the conditions of new Appropriations of Lands.
When the first European colonists arrived on these shores four centuries
ago, North America was sparsely populated with almost limitless natural
resources. The adults who came here could find employment almost
immediately after disembarking or they could go into the wilderness and
stake out land claims or engage in the fur trade.
Population growth in developing countries is wholly different. Rather
than adults trained at the expense of sending countries, their population
growth is the result of a surplus of births over deaths. Their new citizens
must be fed, clothed, housed, and educated 15 to 20 years before they have
the potential to become productive.
But virtually all developing countries already have serious problems of
unemployment and underemployment. When these new citizens reach
working age, many will not be able to find meaningful employment.
Politics Disrupt Population Programs
The negative actions taken by the Carter Administration and continued
under Reagan played a major role in reversing the downturn in population
growth worldwide. These actions sent a signal to forces around the world
that curbing runaway population growth was no longer a priority. The
Congress kept appropriating funds for population programs, and everyone
looked the other way as AID spent these funds on a wide range of activities,
many with little impact on contraceptive use.
AID financial records are a muddle, even for someone familiar with the
system. Understanding the budget is not helped by AID's unwillingness to
release information, even under the Freedom of Information Act.
By piecing together fragmentary and often inconsistent financial data,
country by country guesstimates were made of how AID programmed
$2,121,394,000. That is only 47 percent of the $4.7 billion population
program. While large sums were spent in the United States and other
developed countries, surely considerably more than half of the total must
have been programmed to developing countries.
AID Population Budgets and Fertility Change
By the fall of 1967 AID had assembled a staff of six or seven
professionals and two or three secretaries in its population unit.
In early 1968 the Congress earmarked funds for the population program
for the first time. The staff could then begin to do something no one else
had ever done - design and execute a program to reduce fertility.
The staff and its Director, Dr. R. T.Ravenholt, were allowed to operate
for about 10 years, albeit often in a state of siege with the old line
bureaucrats who put their feet in the spokes at every opportunity. But, by
the summer of 1977, Carter Administration operatives had taken away most
of the authority of the central Population
Office and had started the systemic
removal or isolation of key staff
members. Many programs continued
The starting period for
for a period despite the negative
atmosphere, but at a greatly diminished
fertility declines was
level of effectiveness.
1960-64, the years just
One means of judging the impact of
the political actions and the relative
before AID launched its
effectiveness before and after 1977 is to
population program.
look at the relationship between budgets
for the two periods and fertility
declines.
The budget periods chosen were
1965 through 1977 for the first period and 1978 through 1988 for the
second. The first period is actually a little shorter than the budget data
indicate. Very little population money was available prior to 1968, so the
effective period is 1968 to 1977, or nine years. The second period, 1978 to
1988, is eleven years.
The starting period for fertility declines was 1960-64, the years just
before AID launched its population program. The ending dates for the first
period was 1975-79. The second period begins with 1975-79 and ends with
circa 1990.
During the first period AID'S population budget in current dollars was
about one billion. The budget for the period 1965 to 1988 was $3.6 billion.
Thus, on a current dollar basis, those in charge of the population program
for the first period had about 28 percent of the budget while those in charge
for the second had 72 percent.
If the numbers are adjusted for
Nearly 70 percent of
inflation using the U.S. cost of living
index, 43.5 percent of the funds were
the decline in fertility in
available during the first nine years and
developing countries
56.5 percent during the second eleven
years.
and 51 percent of the
Nearly three-fourths of the
decline in developing
worldwide fertility decline between
1960-64 and 1990 occurred between
countries other than
1960-64 and 1975-79. While AID did
China occurred prior to
not have population programs in all
countries of the world, the negative
1980.
attitude of AID and the Carter and
Reagan Administrations went far
beyond countries with bilateral programs. Moreover, family planning foes
demanded and got concessions in U.S. domestic programs. Poor women in
the United States were denied access to abortion and contraception, forcing
them to have babies they did not want and could not support — and forcing
the American fertility rate higher.
Nearly seventy percent of the decline in fertility in developing countries
and 51 percent of the decline in developing countries other than China
occurred prior to 1980. (See Figure 3)
Actually, the comparison is even more unfavorable to those in charge
during the second period than the numbers indicate. As stated earlier, in
1968, there were few models the Office of Population could use as a basis
for designing family planning delivery systems. These systems had to be
developed from scratch or adapted from public health programs.
People, both in the United States and in the developing countries, had to
be trained. Programs to educate foreign leaders about the importance of
slowing population growth had to be launched.
Those who took over the Population Office in the late 1970s had at hand
most of the tools required to press ahead with program actions, but they
failed to use them effectively. The dedication to getting the job done that
prevailed during the first period was no longer present.
Individual Country Comparisons
Fifty countries were selected as the focus for special analysis. To be
selected, a country had to have received either a minimum of ten million
dollars from AID or a minimum of $0.50 per capita between 1965 and
1991. The combined population of these countries in 1991 is 2.2 billion.
The populations of individual countries range from seven thousand
(Anquilla) to 859 million (India). (See Table 3)
In the early 1960s women in these 50 countries averaged 6.2 births
during their reproductive lifetimes. Today, they average 4.4, a decline of
only 1.8 children over a quarter century. The fertility rate for all developing
countries combined declined by 2.2 children during the same time period.
k
Figure 3.- AID Population Budget for 1965-77 as a Percent
of Population Budget for 1965 to 1988 (Black Bars) and
Fertility Change 1960-65 to 1975-79 as a Percent of Fertility
Change for 1960-65 to Circa 1990 (Grey Bars)
(See text for explanation)
| [—I Fertility Change
Source: See text.
M Population Budget |
James Bracken P. O. Box 3089 Shepherdstown. WV25443 USA
Table 3.-- Countries Receiving a Minimum of $10 Million or
$0.50 Per Head of U. S. Population Funds During the Years
1965 to 1991
Country
Population
1991
(1000)
Population
funds
FY1965-91
$1000
Funds
Per
Head
Total Fertality
Rates
Circa Differ
1990 ence
1960
-64
2,176,890
$2,042,156
$0.94
6.2
4.4
-1.8
Barbados
Thailand
257
58,814
$358
$57,475
$1.39
$0.98
4.3
6.4
1.8
2.2
-2.5
-4.2
2.3 or Less
59,071
$57,833
$0.98
6.4
2.2
-4.2
Jamaica
St Kitts
Colombia
2,489
40
33,613
$22,161
$21
$37,859
$8.90
$0.53
$1.13
5.6
-3.0
6.8
2.6
2.7
2.9
2.4 to 2.9
36,142
$60,041
$1.66
6.7
2.9
-3.8
Indonesia
Panama
Anquilla
Costa Rica
Brazil
Dominican Re
Ecuador
St. Lucia
Mexico
India
181,366
2,466
7
3,111
153,322
7,321
10,752
153
85,721
859,192
$191,961
$9,126
$9
$10,677
$79,602
$10,737
$21,963
$93
$92,094
$108,953
$1.06
$3.70
$1.29
$3.43
$0.52
$1.47
$2.04
$0.61
$1.07
$0.13
5.4
5.9
-2.4
-2.9
6.8
5.8
3.0
3.0
3.2
3.3
3.3
3.6
3.8
3.8
3.8
3.9
3.0 to 3.9
1,303,411
$525,215
$0.40
5.9
3.7
-2.2
Peru
Philippines
Tunisia
Morocco
Paraguay
Egypt
El Salvador
Belize
Grenada
Bolivia
Bangladesh
Botswana
21,996
62,338
8,362
26,182
4,397
54,452
5,419
228
83
7,464
116,601
1,258
$41,375
$139,658
$37,940
$53,537
$4,797
$153,556
$51,785
$243
$218
$9,628
$306,798
$2,115
$1.88
$2.24
$4.54
$2.04
$1.09
$2.82
$9.56
$1.07
$2.63
$1.29
$2.63
$1.68
6.9
6.6
7.2
7.2
6.8
7.1
6.9
-2.9
-2.5
-3.1
-2.7
-2.3
-2.5
-2.3
6.6
6.7
6.9
4.0
4.1
4.1
4.5
4.5
4.5
4.6
4.8
4.9
4.9
4.9
4.9
4.0 to 4.9
308,780
$801,650
$2.60
6.8
4.5
-2.3
Total
7.0
6.2
7.3
6.9
-3.9
-3.7
-2.9
-3.8
-3.1
-2.9
-1.9
-1.7
-1.8
-2.0
Table 3.-- Countries Receiving a Minimum of $10 Million or
$0.50 Per Head of U. S. Population Funds During the Years
____________________ 1965 to 1991
Population
1991
(1000)
Population
funds
FY1965-91
$1000
Funds
Per
Head
Total Fertality
Rates
1960 Circa Differ-64 1990 ence
Laos
Honduras
Guatemala
Nicaragua
Zimbabwe
4,113
5,298
9,467
3,871
10,019
$5,073
$39,482
$38,529
$5,856
$10,692
$1.23
$7.45
$4.07
$1.51
$1.07
6.2
7.4
6.9
7.3
7.5
5.0
5.3
5.3
5.5
5.6
-1.2
-2.1
-1.6
-1.8
-1.9
5.0 to 5.9
32,768
$99,632
$3.04
7.0
5.4
-1.7
6.8
4.6
-2.2
Country
4.0 to 5.9
341,548
$901,282
$2.64
Zaire
Nepal
Swaziland
Nigeria
Ghana
Haiti
Senegal
Gambia
Somalia
Pakistan
Kenya
Liberia
37,832
19,612
817
122,471
15,509
6,287
7,533
884
7,691
117,490
25,242
2,730
$14,876
$44,409
$1,906
$29,773
$21,061
$32,054
$25,057
$817
$16,418
$178,596
$63,498
$9,149
$0.39
$2.26
$2.33
$0.24
$1.36
$5.10
$3.33
$0.92
$2.13
$1.52
$2.52
$3.35
5.9
5.9
6.5
6.9
6.9
6.3
7.0
6.5
6.6
7.0
8.1
6.7
6.1
6.1
6.2
6.2
6.3
6.4
6.5
6.5
6.6
6.6
6.7
6.8
0.1
0.2
-0.3
-0.7
-0.6
0.1
-0.5
0.0
0.0
-0.4
-1.4
0.0
6.0 to 6.9
364,098
$437,614
$1.20
6.8
6.4
-0.4
Mali
Afghanistan
Tanzania
Togo
Malawi
Rwanda
8,339
16,645
26,869
3,811
9,438
7,518
$7,388
$20,475
$12,324
$2,016
$7,605
$10,363
$0.89
$1.23
$0.46
$0.53
$0.81
$1.38
7.1
7.0
6.9
6.6
7.0
7.7
7.1
7.1
7.1
7.2
7.7
8.1
-0.0
0.1
0.2
0.6
0.7
0.5
7.0 or More
72,620
$60,171
$0.83
7.6
7.3
-0.4
Source: See text for sources.
Allocations to Specific Countries
No country received an exorbitant amount of AID population funds on a
per capita basis. El Salvador received the most - $12.68 based on 1975
population — enough to buy a five year supply of oral contraceptives for one
woman at prices AID sometimes pays.
India received the least on a per
capita basis — $0.13 per person, a
Bangladesh is one of
piddling amount for the world's second
the four or five poorest
most populous country.
In terms of total dollars Bangladesh
countries on earth and
received the most - $307 million. That
can least afford a
works out to about four dollars per
head. Other international donors — the
fertility rate of nearly five
United Nation, The United Kingdom,
Sweden, Canada, Japan, etc. also
births per woman.
invested large sums in Bangladesh's
population program, perhaps even more
than the United States. Yet, fertility in
Bangladesh remains high. A quarter century ago Bangladesh women
averaged 6.7 births during their reproductive lifetimes. The average is now
4.9.
Bangladesh is one of the four or five poorest countries on earth and can
least afford a fertility rate of nearly five births per woman. It was
overpopulated in the early 1960s when it had half as many people as it has
today.
U.S. population funds tended to go to countries that made only modest
progress in reducing fertility. The left pie chart in Figure 4 shows the
allocation of U.S. population funds by recent fertility levels. The right chart
shows the population of all developing countries in these ranges. Nearly
seventy percent of AID population funds went to countries with recent
fertility rates of 4.0 or higher where only 30 percent of developing country
population now live. On the other hand countries with fertility levels at or
below "replacement" received only six percent of AID's country allocations
even though they contain 34 percent of developing country population.
Nearly Half of the World's Population Live in Countries with
"Replacement" Fertility
There is some good news. Today, 2.5 billion people worldwide — 47
percent of the world's population — live in countries with fertility levels at
or below "replacement," the point at which couples have just enough
children to replace themselves.16
The slices in the pie chart in Figure 5 show the proportion of world
population in countries with various levels of fertility. Virtually all
developed countries have fertility levels at or below "replacement."
The smaller pie in Figure 5 shows the split between developed and
developing regions among low fertility nations. Thirty-eight developed
countries with a combined population of 1.2 billion and 22 developing
nations with a combined population of 1.3 billion have fertility rates at or
below "replacement." China is predominate among low fertility developing
countries. However, Thailand, South Korea, Taiwan, Cuba, Singapore,
and Hong Kong also have low fertility rates. In fact, Hong Kong's fertility
Figure 4.— Population and AID Population Budget Allocations by Fertility Range
E
Fertility Rates
2.3 or Less
2.4 to 2.9 ■ 3.0 to 3.9 H 4.0 to 5.9 ■ 6.0 to Higher
See text for sources.
James W. Brackett P. O. Box 3089 Shepherdstown, IVV' 25443 USA
Figure 5.-- Proportion of World Population in Countries With Specific Fertility
Ranges
Fertility Ranges
1
Fertility Rates
2.3 or Lower
2.4 to 2.9 ■ 3.0 to 3.9 H 4.0 to 5.9 ■ 6.0 and Higher
Source: Based on data from the Population Reference Bureau.
James W. Brackett P. O. Box 3089 Shepherdstown, WV 25443 USA
Four developed nations with a combined population of 3 million had fertility rates of 2.3
to 2.9. No developed country had a higher rate
rate of 1.2 is the lowest of any country except the Vatican whose fertility
rate is near zero.
Countries With Moderate Fertility
Twenty-four countries - 20 developing and four developed — with a
combined population of 132 million have fertility rates between 2.4 and 2.9.
Among the countries defined as "developing" are Argentina, Chile,
Colombia, North Korea, and Jamaica.
Beyond these, 25 countries with a combined population of 1.5 billion
have fertility rates between 3.0 and 3.9. Indonesia, Brazil, and Venezuela
are in the lower end of the range. India, Mexico, Turkey, and Malaysia are
at the upper end.
Thus, 67 developing countries with a combined population of 2.9
billion have fertility rates below 4.0.
Countries With Higher Fertility
The discouraging news is that after three decades of population program
activity 1.3 billion people — nearly a quarter of the world's population —
live in countries with fertility rates of 4.0 or higher. Three quarters of a
billion live in countries with fertility rates of 6.0 or higher and 165 million
live in countries where women average seven or more children during their
reproductive lifetimes.
Geographical Pattern of Recent Fertility
The shadings on the map in Figure 6 indicate recent patterns of fertility
by geographical areas. The white areas indicate fertility levels at or below
"replacement." These areas include virtually the entire northern tier of
countries from Canada and the United
States across the Atlantic to Europe, the
Soviet Union, China, and Japan. They
The countries that
extend down from East Asia to
Thailand,
Australia, and New Zealand.
recorded either no
On the other end of the spectrum are
change or increases
many countries in Africa and West Asia
where women still average six or more
are with but two
lifetime births.
exceptions in SubSaharan Africa.
Long Term Changes in Fertility
Figure 7 shows changes in fertility
rates between 1960 and circa 1990 for
149 countries. The pattern of change is a continuum from Thailand's decline
of 4.2 children to Gabon's increase of 0.9.
One hundred fourteen countries recorded at least some decline. Fifteen
registered no change, and twenty recorded increases.
The countries that recorded either no change or increases are with but
two exceptions in Sub-Saharan Africa. The two non-African countries on
the list are Afghanistan and Romania.
Figure 6.—Fertility Levels Ca. 1991
Figure 7- Decreases in Fertility Between 1960-64 and Ca.
1990 by Country
Panel One
Thailand
Hong Kong
Colombia
Korea South
Dominican Rep.
Suriname
Mauritius
Costa Rica
China
Guyana
Reunion
Martinique
Korea Nortli
Guadeloupe
Bahrain
Venezuela
Singapore
Malaysia
Ecuador
Tunisia
Jamaica
Mexico
Panama
Brazil
Peru
Cuba
Albania
Lebanon
Sri Lanka
Morocco
Kuwait
Chile
Trindad & Tobago
Egypt
Philippines
Qatar
Barbados
Indonesia
Turkey
Paraguay
El Salvador
Puerto Rico
Honduras
Viet Nam
South Africa
Botswana
Algeria
U.Arab Emirates
Libyan
*
Figure 7.-- Decreases in Fertility Between 1960-64 and Ca.
1990 by Country
Panel Two
Canada
India
Zimbabwe
Ireland
Myanmar
Nicaragua
Cambodia
Bangladesh
Iceland
Bolivia
New Zealand
Spain
Netherlands
Guatemala
Portugal
Australia
Cape Verde
Kenya
Austria
Italy
United States
Mongolia
Lao
Cyprus
Belgium
Iran
France
Papua New Guinea
Norway
Germany
United Kingdom
Malta
Denmark
Switzerland
Guinea
Jordan
Finland
Luxembourg
Yugoslavia
Israel
Iraq
Syria
Greece
Nigeria
Gnana
Poland
Senegal
Uruguay
Japan
Czechoslovakia
-5
-4
-3
s
-2
-1
0
Figure 7- Decreases/lncreases in Fertility Between 1960-64
and Ca. 1990 by Country
Panel Three
Pakistan
Argentina
Sudan
Swaziland
Bulgaria
_
u.o.o.n
Sweden
Chad
Cameroon
Congo
Namibia
Mozambique
Saudi Arabia
Djibouti
Madagascar
Eq.Guinea
Angola
Central Africa
Hungary
Bhutan
Lesotho
Mali
Somalia
Niger
Mauritania
Gambia
Oman
Liberia
Ethiopia
Afghanistan
Haiti
Cote d'Ivoire
Benin
Comoros
Zaire
Burundi
Sierra Leone
Nepal
Tanzania
Romania
Uganda
Rwanda
Burkina Faso
Zambia
Togo
Malawi
Guinea-Bissau
Gabon
Source: Based on data from the United Nations and the Population Reference
Bureau
James W. Brackett P. O. Box 3089 Shepherdstown, WV 25443 USA
El
Romania: A Window on a Right of Life State
Romania's sad history has been well publicized. It is a game preview of
what is in store for any country where the so-called "right to life" gain
power. Both abortion and contraception were outlawed and couples were
pressured to produce babies. Women
who failed to do so were punished.
Women had more children than they
could feed, so the children ended up in
The process of
state institutions, unloved and illmodernization in Africa
nourished. In the institutions they were
subjected to bizarre medical
may also contribute to
experiments, including small injections
fertility increases.
of blood, much of it collected from
sailors and dock workers in the Black
Sea port of Constanta where ADDs was
rampant.17
Possible Reductions in Sterility
Some African countries have had serious sterility problems resulting
from sexually transmitted diseases. Despite the AIDs pandemic that is
devastating much of Africa currently, some countries may have been able to
reduce sterility by reducing the incidence of Gonorrhea, genital
tuberculosis, and other diseases that cause secondary sterility.
The process of modernization in Africa may also contribute to fertility
increases. It is the tradition in some African societies for a woman to abstain
from sexual intercourse until she weans her baby. Women typically breast
fed for a very long time — up to 24 months in some cases.
But taboos are breaking down. Women breast-feed for a shorter time
and fewer Africans wait until after children are weaned to resume sexual
relations.
Most of the increases as well as some of the decreases, particularly in
Africa, are probably due to statistical error. Although most countries have
laws requiring birth registration, the systems rarely function in poorer
developing countries. Fertility data, where they are available at all, are more
typically collected by survey. Surveys are not taken very often in these
countries. Many have had only one, usually in the last few years.
The Meaning of "Replacement" Fertility
Logically, when a country achieves "replacement" fertility, population
growth should stop. But "replacement" fertility is not the same thing as zero
population growth.
Although 60 countries have fertility rates at or below "replacement,"
only five - the Falklands, Germany, Hungary, the Isle of Man, and Vatican
City — have zero or negative population growth. Another 20 have growth
rates below 0.5 percent. In 1990, the 60 low fertility countries contributed
24.3 million people to world population growth - 26 percent of the total.
Of course, if fertility remains at or below "replacement" long enough,
population growth will eventually stop or become negative, but that may not
happen for a long time. The reasons have to do with age structure.
Many developed nations experienced baby booms following the Second
World War that continued into the early 1960s. The first of the baby
boomers began reaching childbearing age in the mid 1960s. The last of them
reached childbearing age in the early 1980s. Not until about 2010 will the
baby boomers complete their childbearing.
Because the number of prospective parents rose sharply during the
period when baby boomers reached reproductive age while the fertility of
individual couples declined, the number of births remained high. In the
United States, for example, although fertility has been below "replacement"
since 1972, births have in each year since that date exceeded deaths by
about two million.
A Perpetual "Baby Boom" in Developing Countries
The developing countries have had a perpetual baby boom that only
recently began to abate. Moreover, the levels of fertility in developing
countries were much higher than fertility in developed nations even at the
peak of their baby booms. For example, the peak fertility rate in the United
States was 3.8 and that lasted only one year, although fertility remained at
3.5
or above for several years. Sustained fertility rates twice as high were
not uncommon in developing countries a decade to two ago and are still
found today in Africa and West Asia.
The age structure also affects the number of deaths and the crude death
rates. Most deaths occur at the extremes of life, infancy and old age.
Developing nations have relatively few older people, a situation that will
change only gradually over the next century or more. Because there are so
few older people, a large share of the deaths in developing countries occur
to infants and young children. But as fertility declines, young children will
represent a smaller and smaller proportion of the population. Lower fertility
and better child spacing will combine
with expanded health measures and
hopefully better nutrition to reduce
infant and child death rates.
The vast majority of the
The vast majority of the population
population of
of developed nations will be in the
middle
years of the age structure where
developed nations will
few people die.
be in the middle years
Crude death rates in many
developing countries could fall below
of the age structure
five per thousand population. In fact,
where few people die.
several countries already have death
rates below five. The combined death
rate for low fertility developing
countries is already 6.6 compared to a
death rate of 9.4 for low fertility developed countries.18
Because of these demographic factors, population growth will likely
continue for 60 to 70 years before births and deaths come into balance,
assuming, of course, that fertility remains below "replacement." During the
transition, populations can double or even triple.
What Countries Can Do
Countries can do some things to reduce but not eliminate the
consequences of their population growth.
By encouraging young people to postpone childbearing until they are in
their late twenties or early thirties,
several demographic phenomena come
into play.
First, the inter-generational span
If couples postpone
will increase, slowing the rate of
fertility, they are likely
population growth. An example may
serve to illustrate.
to use family planning
A population with a median age at
throughout their
childbearing of 25 years will have four
generations each century. A population
reproductive lifetimes.
with a median age of 33 will have only
three. If all other factors are equal, the
second population will grow more
slowly than the first.
The age structure for most developing countries is pyramidal. That is,
the number of people at any given age is smaller than the number at any
younger age. Consequently, raising the age of childbearing has the effect of
reducing the number of prospective parents.
In Kenya, for example, where the growth rate has been between 3.0 and
4.0 percent over the past several decades, each five year age group contains
about 20 percent fewer people than the preceding age group. Thus, raising
the median age at childbearing by five years reduces the number of potential
parents and potentially the number of births (assuming no change in fertility
rates) by about one fifth. A ten-year increase will reduce the numbers by
more than a third.
Raising the age at childbearing also effectively reduces the number of
years women are at risk of pregnancy. Moreover, if couples take the
necessary action to postpone fertility, they are likely to use family planning
throughout their reproductive lifetimes.
Switching from a younger to an older fertility pattern will also produce a
one time "savings" of births that do not happen during the transition period.
Even if couples ultimately have the same number of children, these "lost"
births will never be made up. Again, an example, albeit highly contrived,
may serve to illustrate the point.
Assume a population in which all births occur to women age 25 and that
no births occur to women at any other age. Now, assume that there is a
universal decision to change the childbearing pattern such that all births
occur to women age 33. During the eight-year transition, our contrived
population will not have any births at all because women who had their
babies under the old pattern will not have any more while women who
reached age 25 after the decision to switch must wait until they are 33.
Strategies for Raising the Age at Childbirth
Countries have tried to increase the age at childbirth by raising the
marriage age. That strategy can work up to a point, but there is a limit to
how long healthy adults will forgo sexual relations. If the legal age at
marriage is increased too much, couples may postpone formal marriage but
not sexual relations. Many of these premarital relationships will result in
pregnancies, thereby increasing the number of out of wedlock births with all
the social and economic consequences associated with them.
Encouraging Young People to Use Family Planning
Another approach is to encourage teenagers and young adults to use
family planning. Programs designed to do that have often failed because
young people are unreliable contraceptors. They forget to take the Pill or, in
the moment of passion, fail to don a condom.
But Norplant has changed the way contraceptive decisions are made. A
woman need only take a one time action to have the implants inserted to gain
five years protection against pregnancy. After that, she must make a
conscious decision to have a baby and take the positive action to cause it to
happen - namely, have the implants removed. Thus, the tables are reversed
with respect to fertility decision.
The AIDs pandemic should also serve to reduce fertility. Young people
particularly have a vital need to practice safe sex. If they use condoms with
the care required to prevent the transmission of AIDs, they will necessarily
prevent pregnancies as well.
Cultural changes may also be necessary. For example, some cultures
expect women to produce a baby within a year or so after marriage to prove
fecundity. Family planning programs often ignore newly married couples
and concentrate on increasing the interval between the first and second
births or on helping couples stop childbearing altogether after some
prescribed number of children. While these programs are effective in
reducing the number of births, they have the effect of reducing the intergenerational span.
Reduce Fertility Well Below Replacement for an Interim Period
Countries may also need to achieve
fertility rates of 1.0 to 1.5 for an interim
period until population growth slows.
Low fertility rates are
Hong Kong's fertility rate is now 1.2.
Italy and Spain have fertility rates of
not the consequence of
1.3 and Austria 1.4. These low fertility
government coercion;
rates are not the consequence of
government coercion. They are the
they are the cumulative
cumulative effect of fertility decisions
effect of decisions by
by individual couples, each acting in
what they believe to be their own self
individual couples.
interest.
Fertility rates aggregate the fertility
behavior of individual couples. They
are averages. In all societies some women never marry and some that do
never have children, either by choice or because they or their husbands are
sterile. These zero birth women are included in the denominators used to
derive the fertility rate but do not contribute to the numerators. Thus,
women who do have children average more births than the fertility rate
indicates.
More Effective Aid Agencies
National Public Radio observed that the United States military was able
to get the relief programs for the Bangladesh cyclone better organized the
first day than the Bangladesh government and the various aid organizations
had done during the previous weeks.
The American military is programmed
for action. It is highly organized with a
command structure dedicated to getting
There is an urgent
the job done and getting out.
need for an efficient
Regrettably, the aid agencies,
including AID, don't have the same
and effective U.S.
drive for achievement. They are quite
international population
content to let problems fester and get
worse, confident that the American
program.
taxpayers will continue to cough up the
money for luxury housing and other
perks members of the entrenched
bureaucracy have come to expect.
There is an urgent need for an efficient and effective U.S. international
population program, but the present program requires a major overhaul.
New personnel, particularly at the top, is an essential first step. A new
personnel system is needed, one that emphasizes accomplishment - one that
rewards people who get things done.
During the early 1970s, there was a proposal to establish an independent
population organization outside the Department of State and AID. That
proposal might be worth dusting off.
However the program is organized, it must be removed from politics.
The politicians must stop listening to the extremists who oppose family
planning. They must work to promote effectiveness and efficiency in
population programs.
Politicians make a big to do about the human rights aspects of family
planning. Those who make the most noise are usually family planning foes
who allege that couples are coerced into conforming to government
established birth quotas. They overlook the much more serious problem
whereby couples are forced to have babies they do not want and cannot
afford because they are denied access to safe and effective contraceptives.
Notes for Figures 1 and 2
Figure 1:
Period 1: Differences in numbers of births between 1960-64 and 1965-69.
Period 2: Differences in numbers of births between 1965-69 and 1970-74.
Period 3: Differences in numbers of births between 1970-74 and 1975-79.
Period 4: Differences in numbers of births between 1975-79 and 1980-84.
Period 5: Differences in numbers of births between 1980-85 and 1985-89.
Figure 2:
Period 1: Differences in total fertility rates for 1960-64 and 1965-69.
Period 2: Differences in total fertility rates for 1965-69 and 1970-74.
Period 3: Differences in total fertility rates for 1970-74 and 1975-79.
Period 4: Differences in total fertility rates for 1975-79 and 1980-84.
Period 5: Differences in total fertility rales for 1980-84 and circa 1990.
1. In addition to committee chairman General William H. Draper, Jr., the Committee
members were Dillon Anderson, Joseph M. Dodge, General Alfred M. Gruenther, Marx
Leva, John J. McCloy, George McGhee, General Joseph T. McNamey, Admiral Arthur
W. Radford, and James E. Webb.
2. The Democrats did nominate Catholic John Kennedy, who was elected President in
1960.
3. After leaving office Eisenhower became honorary chairman of Planned Parenthood
and made a number of public appearances supporting its activities.
4. For a detailed account of the work of the Draper Committee and the development of
United States international population policies and programs up to about 1972, see
Phyllis Tilson Piotrow, World Population Crisis, The United States Response, Praeger
Publishers, 1973.
5. Prior to 1968 AID spent a total of about S10 million on a variety of population
related activities, including a series of studies on the socio economic impact of family
planning programs. These studies were instrumental in the decision of the United States
Government to launch an international population program.
6. Budget data were derived from various published and unpublished AID reports,
including the annual submissions to the Congress.
7. In 1997 the annual increment in world population may exceed 100 million compared
with an annual increase of less than 20 million during the 1930s. Thus, world population
will likely increase as much as in the single year 1997 as it did during the five years,
1930 to 1934.
8. World population is generally believed to have reached one billion at the beginning
of the Nineteenth Century, possibly as early as 1800 but no later than 1830. It reached
two billion around 1930. Thus, the doubling time from one to two billion was between
100 and 130 years. A person who died in 1930 would have had to be at least 100 years old
to have lived during a period when world population doubled and probably 130 years old.
9. Demographic data used in this article came from a variety of sources, including the
United Nations Demographic Yearbook, the United Nations Population Projections as
Assessed in 1990, the Population Reference Bureau's Population Data Sheet 1991 and
reports from individual countries. Both the United Nations and the Population Reference
Bureau publish data in magnetic format as well as in print.
10. For an account of the changing views of Soviet Marxist on population, see James
W. Brackett, "The Evolution of Marxist Theories of Population: Marxism Recognizes the
Population Problem.” Demography, Vol. 5, No. 1, 1968.
11. According to classical Marxism, overpopulation is simply unemployment. All
capitalist societies, by Marxist definition, have unemployment and are therefore
overpopulated. Marxists maintained that unemployment was a necessary condition for the
existence of capitalist systems since there was a need for a pool of unemployed workers
from which capitalists could draw labor. Marxism would provide full employment. Thus,
the solution to the population problem was Marxism.
This ideology predated the establishment of communist systems in China and
Poland. Providing jobs to everyone in these countries proved difficult, even with very
inefficient methods of utilizing labor. The population problems in developing countries
posed other problems. Marxist theorists began talking about physical limits to the
number of human beings a given quantity of land could sustain and about quality of life.
12. Some people on the ideological right took a different tact. They expressed concern
about the "yellow peril," a term coined by Kaiser Wilhelm II, as well as the black and
brown perils. Their view was that Europeans were under threat of being overrun by rapid
increases in other races. Some advocated tying foreign aid to compulsory baby quotas. In
order to receive Western aid, nations would be assigned rigid birth quotas not unlike those
China assigns to its subregions. Fortunately, the U.S. Government, as well as other
donor countries, rejected these ideas in favor of family planning programs based on self
interest and voluntarism.
13. A good source of information on the diverse courses of action people advocated to
reduce fertility can be found in the testimony before the Select Committee on Population
on February 7, 8, and 9, 1978 published in World Population: A Global Perspective.
Hearings before the Select Committee on Population, Ninety-Fifth Congress, Second
Session, Washington 1978.
14. It is interesting to note the similarity between the Marxist view that the solution to
the population problem was communism and Buckley's view that the solution was the
free market. Both views were presented as magic wands of sorts that would cause people
to have fewer children. Neither dealt with the practical issue of how the transition would
come about. The type of political or economic system one lives under is unlikely to
affect libido. Healthy adults are going to engage in sexual activity. Unless they have
access to and use contraceptives, fertility rates will be high.Neither Buckley nor the
Marxists concerned themselves with such mundane problems. A detailed account of the
U.S. withdrawal from international population efforts can be found in Gaining People,
Losing Ground, by Werner Fomos, President of the Population Institute, Science Press,
1990.
15. Japan offers another example of a country that first sharply reduced its fertility and
then experienced rapid economic growth. Japan's fertility reduction was achieved while
Japan was under military rule of the very conservative General Douglas MacArthur, who
accomplished the fertility reduction by legalizing abortion.
16. An average of 2.3 lifetime births per woman was used as the level of "replacement"
fertility. The levels for individual countries may be higher or lower, depending on the
demographic situation. To attain "replacement" fertility, women must ON AVERAGE
give birth to just enough girl babies to ensure that one will survive to adulthood. The
fertility rate required for "replacement" depends on two factors: 1) the level of mortality,
particularly among infants and children, and 2) the sex ration at birth. Women in
countries with high mortality must necessarily have more births to achieve
"replacement:" fertility than women in low mortality countries.
Among people of European and Asian ancestry, about 106 boys are born for every
100 girls. Among people of African ancestry, the ratio is about 103 boys to 100 girls.
Thus, the fertility rate required for "replacement" will be lower for people of Africa
ancestry than for European and Asian populations, assuming the same level of mortality.
17. A more detailed account of the situation in Romania can be found in "Romania
Experiment Holds Lesson for World," Atlanta Constitution, by Werner Fomos, April 15,
1990.
18. The death rate for developed countries with fertility rates between 2.4 and 3.0 is 5.8
deaths per 1000 population. Albania accounts for 97 percent of this category. Albania's
death rate is 5.7. Although it is included among the developed countries, Albania is a very
primitive country which experienced a dramatic drop in fertility in recent years. Ils age
structure is like those of developing countries.
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k> H 1-P.3
People And Ecosystems
Complex Relationship
Dr. Vandana Shiva
Indus.'.-;
.
. socio-economic
paradigm simultaneously transforms
people and resources and the relation
ship between them. People, especially
poor people, become "population."
Resources are transformed from
self-renewing systems into industrial
raw mater. .'. The relationship between
people
rces defined through
the "commons" is also disrupted.
"Commons" are living ecosystems
nurtured by social communities which
arc bounded by ecological, ethical,
cultural, political and economic limits.
When resources are transformed into
material, commons must be
enclosed, and people must be displaced.
Three processes
simultaneously:
<' re
unleashed
identified as a primary cause of
People are rendered dispensable and
environmental
destruction.
This
turned into surplus 'population'
tendency was also articulated in the
Resources are privatised
UNCED Documents A Conf. 151/PC 45
c. Resources are exploited at rates and in and 46, which focussed heavily on
'demographic pressures.'
quantities determ:by distant
a.
market.-, not by
. demand or by
ecologies j.-.ands.
The resuit of these simultaneously
unleashed processes are:
a. the population crisis
b.
the poverty and deprivation crisis
c.
the ecological crisis.
However, instead of seeing these
three processes as being simultaneous
consequences of the same root cause, (a)
is falsely turned into a cause for (b) and
(c).
PopulaL
. and the
en vi.'.. .zaent at UNCED
Population growth in the Third
World is being increasingly and falsely
Even documents not related to
population issues erroneously identify
population growth as a cause for
environmental destruction. Thus even
the production of toxic chemicals which
has grown exponentially in the
industrialised world and has been
transferred to the Third World, is related
to population growth — for example,
Document PC 42 Add. 5 on
biotechnology states.
The expanding world population is
generating, and will continue to
generate, more wastes resulting from the
use of more chemicals, more energy and
more agricultural and industrial
products.
The report fails to recognise that the
sparsely populated rural areas of the US
use far more chemicals than the heavily
populated regions of the Third World
and that the increase in the use of toxic
chemicals is more directly a result of the
pushing of chemicals by the industry.
Neglecting
the
pressure
from
production interests in the North, and
the heavier dependence of the North on
toxic chemicals, the document falsely
identifies population growth as a cause
for the production and use of millions of
tons of toxic chemicals.
There are four main reasons why
population growth cannot be identified
as the primary cause of environmental
destruction.
Firstly, the large number of poor
people in the Third World, whose
population is growing, do not
participate in the use of most products
that are causing environmental destruc
tion because these are not within their
purchasing power. They do not use
Chlorofluoro Carbons (CFCs) for
refrigeration and hence cannot be
identified as agents of ozone destruction.
13
Secondly, the large numbers of poor
people use insignificant fractions of the
resources used by the North and the
elites of the South. Thus, an average US
citizen uses 250 times as much energy as
an average Nigerian. Northern life
styles, therefore, contribute dispropor
tionately to the pressures on resources,
including the resources of the South.
Thirdly, production processes that
have emerged from the Northern
industrialised countries are inherently
destructive of the environment and this
destruction capacity is independent of
population growth. As has been stated,
environmental destruction is a function
of the resource destroying capacity of
technologies of production (the
technology factor) and
the goods
produced or consumed per capita. In
other words:
Total pollution=pollution per unit
of economic goods produced X goods
consumed per capita X population.
environmental degradation, poverty
creation.
>nul
poptfletfeti
growth
continue unabated, in spiteof the billions
of dollars spent on population control
programmes.
Giving people rights and access to
resources to generate sustainable
livelihoods is the only solution to arrest
environmental destruction and the
simultaneous process of population
growth.
The elusive search
However, it is fashionable these days
to treat the population problem as the
number one environmental problem. An
example of this is Maurice King's thesis
that sustainability of the planet demands
that children in poor countries be
allowed to die.
The expanding world
population is generating, and
will continue to generate,
The first two factors are contributed
disproportionately by the North, both in
terms of transfer of resource-intensive'
technologies and in terms of high
consumption of resource-intensive
products.
Finally, population growth is not a
cause of the environmental crisis but an
aspect of it; both are related to the
alienation of resources and destruction
of livelihoods, first by colonialism and
then by Northern imposed models of
mal- development.
;
Population growth arises from the
same causes that lead to poverty, on the
one hand, and environmental degrada
tion and resource alienation, on the
other. This should be apparent from
Indian data, which shows that popula
tion control programmes have systema
tically failed because people in destitu
tion make a rational choice to have more
children.
I
14
The focus on population as the case of
environmental destruction is erroneous
at two levels. Firstly, it blames the
victims. Secondly, by failing to address
economic insecurity and by denying the
rights to survival that underline
population growth, current policy
prescriptions avoid the real problem.
False perceptions of the problem lead to
false
solutions.
As
a
result,
more wastes resulting from
the use of more chemicals,
more energy and more
agricultural and industrial
products.
Much of the theorising is based on a
one to one correspondence and causal
connection between rising populations
and deteriorating ecosystems.
Maurice King's analysis of the
"Demographic Trap" is an example of
such theorising. He assumes that local
population pressure is the only
environmental pressure on ecosystems,
that there is a straight- forward carrying
capacity calculus for human societies as
there is for non-human communities.
However, most ecosystems in the
Third World do not merely "carry" local
populations. They also "carry" the
demand for industrial raw material and
consumption in the North. The Northern
demand on Third World resources
implies that the threshold for support of
local populations is lowered. In other
words, what would be a "sustainable"
population size on the basis of the local
production, consumption and lifestyle
patterns is rendered non-suslainable due
to non-local use.
The theoretical and conceptual
a *** Bf'u *'"i FO0,S or
non-sustainable use, not just in visible
local demand but also in the invisible,
non-local demand for resources.
Otherwise the search for "sustainable
populations" will become an ideological
war declared against the victims of
environmental degradation in the Third
World, especially poor women, without
removing the real pressures on the
environment that come from global
economic systems.
Double burden
The "carrying capacity" in the case of
human societies is not merely a
biological function of local population
size and local biological support systems.
It is a more complex relationship that
relates populations in the North to
populations and ecosystems in the
South. The ecosystems of the South (E)
therefore carry a double burden — that
of supplying commodities and raw
materials to global market (G), and that
of supporting the survival of local
communities (L).
Reducing L, and ignoring G, cannot
protect E. Moreover, most analysis of the
relationship of population and the
environment ignores the non-local
demand for resources. This is also true of
Garell I lardin's seminal essay, "Tragedy
of the Commons." What I lardin failed to
notice about the degradation of the
commons is that such degradation is
accelerated when the commons are
"enclosed" — i.e., they stop being
commons and arc privatised.
The "enclosure of the commons"
introduces a separation between people
and resources. As commons are
enclosed, people are displaced and
resources are exploited for private profit.
In England, the enclosure of the
commons forced peasants off land and
turned it into pasture land for sheep.
"Enclosures make fat beasts and lean
people,” "sheep eat men" were some of
the characterisations of the conse
quences of the enclosure of the
commons. "Carrying Capacity" had been
problematised by the enclosure of the
commons, because the land no longer
supported people but sheep for raw
material. Disenfranchised people were
turned into a resource, worth only the
> Continued on page 35
Continuedfrom page 14 >
security.
labour power they could sell on the
market. Displacement from land make a
necessity of growth in numbers.
After many decades of failed
"population control" it might well be
more fruitful to directly address the roots
of the problem — economic insecurity.
Giving ' people rights and access to
resources so that they can generate
sustainable livelihoods is the only
solution to environmental destruction
and the population growth which
accompaniesit.
In spite of questions about its
effectiveness
in
preventing
pregnancy and protecting against
sexually transmitted diseases, the
first female condom has been
approved for marketing by the food
and Drug Administration, USA.
Maurice King's analysis of the
demographic trap fails to take these
complex ecological relationships into
account and hence settles for a naive and
somewhat cruel prescription for
sustainability.
£1
In its approval, the agency required
the company to include labelling
that emphasised that male laiex
condoms appeared to be a better i
safe-guard against pregnancy and
disease.
Colonisation
and development
projects have had the same consequence
in the Third World as the enclosure of
commons in England. Population grow th
is not a cause of the environmental crisis
but one aspect of it, and both are related to
resource alienation and to destruction of
livelihoods, first by colonialism and then
by Northern imposed models of
maldevelopment. In 1600, the population
of India was between 100 million and 125
million. In 1800, the population remained
stable. Then the rise began —130 million
in 1845,175 million in 1855,194 million in
1867,255 million in 1871 .Tire beginning of
the "population explosion" dovetailed
neatly with the expansion of Bristish rule
in India, when resources and rights and
livelihoods were taken away from
people. As Mahmood Mamd am has put it
"high birth rates are not the cause of
present impoverishment; they are the
response of an impoverished peasantry."
When people lose all other kinds of
security, children are the only economic
'vfackJ
(This paper is based on the author's
interventions in UNCED and on her response
to Maurice King in a debate on the
Demographic Trap in Oslo University in
December 1991)
Dr. Vandana Shiva is Director ofthe Research
Foundation of Science, Technology and
Natural Resource Policy, Dehradun. She has
been actively involved in citizens' action
against ecological destruction, and has
written extensively on women, ecology and
the philosophy of science.
\/oicesi
Female Condom
Ready for Sale
The female condom, sometimes
called a vaginal pouch, is essentially
a polyurethane sheath that lines the
vagina. The device, which is about
six and half inches long, is held in
place by two flexible plastic rings,
one at the cervix and one outside the
' body.
(Warren E. Lea. it, TheNav YorkTitnes,
appeared Deccan Herald, June 6, ’93).
Women's Experiences wife
Family Planning
Manisha Cuple
Women bear the major brunt of the
population policy all over the world, be
it to increase or to reduce fertility. In
India, rural women are made targets in a
family planning campaign, because they
lack visibility, articulation and political
power. Women's lack of choice and low
access to resources need to be documented in their own words and, keeping
this in mind, we have attempted Io
articulate some feelings that rural
women in Maharashtra have tried to
express. While the reality of women's
lives is neatly ignored, unsafe contracep
tives that take away choice are peddled
to them 'for their own good,' as it were
Ironically, women's real need for safe
contraception stays unfulfilled, either
because they [ecoil from government
pressure or because real choices are not
yet available to them. 1 hope that the
following article will be able to bring out
these nuances, as far as possible through
women's own experiences, which 1 have
documented and presented here.
.
I
i
■
I
I
.
•
I
I
!
The price of death
I
•
!
I
I
suspects of having performed voodoo or
witchcraft. Deserted women, widow's,
menstruating women — all come next in
the line of suspicion. In one village, a one
day old child suddenly started to turn
blue. In my presence a woman exorcist
was summoned and she said that the
grandmother who had gone to wash the
baby's clothes at the pool had perhaps
not noticed that some menstruating
wanton had defiled the water at thesame
time. She then advised that some
exorcised and "charged" materials be
placed in the backyard of another
childless woman who wished the baby
ill. The social and political factors
affecting illness and death thus go
unquestioned and a web of super-stition
takes its place, making one victim fight
the other.
1
|
■
|
Fear of the unknown
Cuu we lift the veil of superstition ami
secrecy which shrouds women's awareness
about their bodies • • • -
In our socio-economic study t>f
women's work, fertility and access to
health care in two villages, we
accidentally stumbled upon the direct
relationship that one's children's death
has with one's fertility. Besides the
agony, guilt and sense of helplessness
hat a woman undergoes after a child's
eath, she also immediately pays a high
personal price by bearing more children
to replace the dead one. In both the
llages, we found that for every dead
ild a woman had to produce two more
.dldren, on an average. Abortions,
iscarriages and still births are not
hided in this figure. We can only dare
.imagine the extent to which a woman
.retches and exerts herself to create a
sons and a daughter), and the social
consequences of children dying
(including exorcism, desertion and
mental illness) set up a trap from which
few rural tvomen can dare to escape.
"God gives, God takes," as women say, is
theonly temporary escape from insanity.
unleracting buffer by undergoing an
enormous number of conn'ptions. Tliv
desired family size of three children (two
When children die, other childless
women suffer, loo. They are the first
When children die, other
childless women suffer too.
They are the first suspects of
having performed voodoo or
witchcraft.
Health services, as well as the 'family
planning' services, are based on an
incomplete knowledge of people's
perceptions of body, anatomy, illness
and cure. On the other hand, people are
also kept in the dark about the
interventions that are going to b
performed on their bodies, especially
through contraception. Numerous
justifications may be offered for these
lapses, but that does not help to improve
the situation. Women, who bear the
major brunt of the population control
measures, feel unnerved and ill at ease
■ with contraceptives. They attribute all
kinds of side effects to birth control
methods, and their suspicions are
further strengthened when the doctor
refuses to entertain even the most
genuine symptoms and sequalae.
Through all our group meetings,
women say that 'camps' create more
side-effects than individually performed
tubectomies. Some women narrate their
horrific experiences of the Emergency
I
period of 1975-77. One woman described
how she had been picked up from the
jowar fields and tubectomised. Another
recalled how she had literally been
forced into a waiting vehicle and taken
away to the tehsil hospital. She was
sterilised at midnight in very unhygienic
conditions. 'There were more than fifty
women like me at the hospital, all scared.
We were treated like animals and were
literally thrown out after the
sterilisation." When asked whether this
experience had had long term
repercussions, she countered: "Just think
of yourself in my place. What would
have happened to you?"
Not surprisingly, then, women who
undergo sterilisations against their
wishes, or who have not been mentally
prepared to accept the interventions
about to be performed, suffer more.
Menstrual chaos and lower backache
feature as the most common complaints
after tubectomy, and often these
sequalae last long enough tojustify other
complicated interventions on their
bodies. The government health services
turn a deaf oar to any problems related to
contraception, either because they dis
believe the women, or because they do
not want to give the programme a bad
name, and so the women are left to fend
for themselves.
The private doctors, who are not
interested in contraceptives because they
are not lucrative, suddenly come to the
forefront, and suggest hysterectomy
(surgical removal of the uterus) as the
solution to the women's problem. We
havemetmany women who have under
gone hysterectomies after years of suffer
ing, post tubectomy. "If you have one
operation, the other is bound to follow.
They are like sisters." Whereas all the
tubectomies had been performed in the
public health services, all hysterecto
mies are invariably performed in private
clinics. Each hysterectomy costs
Rs. 4-5000, while the daily wage earned
by the women is never more than Rs. 15
per day.
Little choice
Within the limited choice that the
people exert within the target- oriented
FP programme, tubectomy is the most
'preferred' method. Condoms pose a
disposal problem in the villages, where
there is no garbage removal system. The
low bio-degradability of condoms also
puts a damper on its usage. Copper-T or
iambi is also not a very popular method.
16
Often health workers register false cases
of barrier methods and of Copper-T. We
have heaps of condoms and Copper-Ts,
which were found in various parts of the
village, and have witnessed large-scale
incinerations of pillsand condoms in the
Public Health Centre (PHC) premises. A
clever guess is that these devices feature
as completed targets. Once, I asked a
local nurse how she fulfilled the
Copper-T targets.
She told me: "I call the women for a
cup of tea, give them the incen live money
and enter their names on the 'protected
couple' list." When 1 asked her what
would happen if a surprise check was
conducted, she . replied: "We tell the
women to say that the iambi fell off. Even
the doctor knows that we are filling up
false records. He doesn't care, as long as
our targets are completed. 1 f we honestly
report a high rejection rate of tanibis
inserted, we get a shouting. So we learn
to report low failure figures." This nurse
considered me a good friend as 1 had let
her use my name as a tambi acceptor
whenever she ran short of her target goal.
Pressure to meet FP
targets
Reeling under the pressure of targets
for population control, the village based
health workers are in an unenviable
position. In March 1987, Manda Padwal,
an Auxiliary Nurse-Midwife (ANM) in
rural Maharashtra, committed suicide
after a reprimand from the medical
officer to complete her target of
sterilising 20 tribals within the next seven
days, at the close of the financial year.
When we investigated, we found that she
had been the sole earner in the family,
with a disabled younger brother. The
doctor said that the suicide was a result
of sexual frustration, because Manda
was unmarried and she was anyway
prone to exhibit bizarre behavior due to
this condition.
In numerous instances, both during
our visits to I’HCs all over Maharashtra
and in our area of work, we have seen the
humiliation that health workers undergo
during the monthly staff meetings. The
doctor, just having received a scolding
from the district authorities, comes down
relentlessly on his own staff. Since all
health workers do not want to go Manda
Padwal's way, they are left with no
choice except to harass people (read
women) in turn.
ANMs and village women thus play
an unending game of love and hate, each
party trying to outsmart the other
whenever possible. The fact that the
ANM is herself a frightened young
woman, living alone in a strange village,
is forgotten, because only her hard,
determined quality is seen by the local
women. "How can we be friends with
her? She taunts us when we get pregnant;
she tells lies about the side effects of
iambi. 1 can't trust her.” On the other
hand, an ANM said: "You expect me to
help the women? I am beaten by my own
husband. He comes every month to lake
my salary away and batters me, saying
that I am having affairs with the doctor,
the Multi-Purpose Workers (MPWs) and
the men in the village. He has another
wife, but he won't let me leave because
of my steady income. If my pay is
withheld for family planning reasons
(incomplete targets) he says that 1 am
giving the money to a lover."
Often we were caught in the cross fire
between these warring women. The
nurses reprimanded us for telling
women abou t the expected side effects of
contraceptives, and the women thought
we were the nurses' agents. For over a
year, during our stay in the villages, we
were seen as family planning officers
because, in the villages, health services
are synonymous with population
control. It was only after we stayed there
for some years without any 'case' to our
credit, that women started to confide in
us about their actual need for birth
control and asking us how to exercise
choice within the limited available
options.
Benefits, rights:
unheard of
Today, the pregnancy centre that we
manage regularly registers women's
demands for birth control, and women
insist that our workers (all of who are
local women) accompany anyone who
goes to the PHC for a tubectomy. "Of
course 1 don't want too many children.
But I feel so suspicious of the nurses. 1
don't feel safe and relaxed." This
individual sentiment expresses the mass
paranoia that the mindless, targetoriented population control programme
has generated among the women while,
at the same time, leaving their legitimate
need for safe and reliable contraception
unmet.
Though a 1983 state government
circular clearly grants maternity benefits
of a partial kind to all women workers on
the
state-sponsored
Employment
Guarantee Scheme (EGS) sites, we have
not come across a single case in our
cluster of villages so far where any
woman has availed of the same. In fact,
women said: "If we deliver in the
afternoon, we get paid only for the
morning's work that we put in ." Most
women work until the last week of their
pregnancy and return within a month or
two of the delivery if the drought
continues. "Is there a choice? The fields
are not irrigated and so our lives are
spent carrying and dumping stones."
Women were even surprised to hear that
some maternity and post-tubectomy
benefits had been granted to them by the
state.
me about why I had been so 'indiscreet'
in front of the woman and made him lose
face. In turn 1 asked him how he expected
the woman tobelievehim. Would shenot
find out the truth once she came to the
PHC? "That's my business," he said,
"Once she is inside the operation theatre,
she can hardly run away. Now you have
lost me a perfectly good case."
In one instance, we witnessed a
woman who had recently delivered
being motivated for sterilisation.
"Everyone except her participated in the
conversation. The woman in question sat
behind the curtain, with the infant in her
lap, and listened to what the family
members had to say. The MPW wanted
to complete his targets immediately,
whereas the girl's parents were waiting
to hear from her husband. The girl's
father-in law wanted to give the case to
the health worker in their village, and so
he was not ready for the operation in the
girl's natal village. The local MPW
threatened to sever all his relations with
the girl's parents and said, "If ever there
is any health problem in your family
hereafter, do not bother to call me. I have
no time for ungrateful people."
It is a common sight to see health
workers discuss a woman's eventual
sterilisation, over her head, during the
ante-natal care (ANC) check-up. A
It has been our constant observation
that, though sterilisations are mostly
^performed on wpmen, they have the
V least say in the matter. This alienation
; from their bodies could partially explain
I the trauma that accompanies the surgery
and makes them vulnerable to future
invasive interventions as well.
The suspicion that women harbour
about health workers is also not entirely
unfounded. In one instance, a male
health worker was motivating a woman
in my presence. He looked at me with a
flourish and said to the woman: "Now
you don't have to worry. Here is a lady
doctor from Bombay who has decided to
live in our village. She will perform all
the'operations'henceforth." I countered
him saying that this information was not
true. La ter on. still sulking, ho questioned
False promises
Women have also complained about
the false promises given at the time of
sterilisation. "Our children were
promised free medicines until the age of
twelve years. Later on we realised that
they didn't even have enough 'triple'
(immunisation) doses. We have never
leceived the medicines or the free health
check-ups they promised."
This individual sentiment
expresses the mass paranoia
that the mindless, target-
oriented population control
programme has generated
among the women while, at
the same time, leaving their
legitimate need for safe and
reliable contraception
unmet.
certain nurse will croon over a pregnant
woman or taunt her, saying. "After all
this care, don't have your operation at
your mother's village, after your
delivery. Don't betray me." Noticing my
presence, the nurses would also
hurriedly add something like "There is
no difference between girls and boys,
you know. They are equal, so don't
postpone your operation just because it's
a daughter I" It probably doesn't matter
that the mother is not asked her opinion
at any point or that nurse has never
questioned her own no-win position.
Girls and boys are certainly equal.
Once I saw a nurse in tears and I was
surprised, because the usual day for
nurses to cry is the day of the monthly
staff meeting. She bitterly complained
about how her male colleague had slyly
taken away her case. "I had 'cultivated'
this caseall through the pregnancy. How
dare she agree to go with the MPW ? Just
let her come to me for the child's
immunisation. I'll give her a good dose
of her own medicine."
Stealing a case
A community health guide from a
neighbouring village reported how it
was very difficult to motivate a woman
to insert a Copper-T and how he had,
instead, taken a few women to the taluka
place (hospital) for tubectomies. All of
them were 'stolen' by the local MPW; on
one occasion, he managed to motivate a
man for vasectomy. The same evening,
the Block Development Office-'s (BDO)
car came along and took his 'c.~. e' away.
Asked why he allowed such snatching,
he said: 'They are all big officers. I cannot
do anything, except complain to the
medical officer when he questions me
about my incomplete target figures."
Another motivated Community
Health Guide (CHG) from a nearby
village said that it was no longer very
difficult to motivate young couples to
stop after two or three births. Women
were mostly sent in for sterilisation, and
the few men who agreed to undeigo
vasectomies preferred to wait until the
end of the financial year, when the
incentives are the highest. Tire major
problems as narrated by him was "The
MPWs and the ANMs snatch away our
cases. They justify it by saying that, as
CHGs, we don'thave to complete targets
officially. Once the 'case' is taken to the
health centre, they tear off the forms
' filled in by us and fill in new ones with
their own names as motivators."
Who is bigamous?
To understand the true extent of the
"minorities" threat — which suggests
that members of minority communities
are primarily responsible for the
population explosion through their
customary large family size and the
practice of bigamy — we decided to
conduct a census of our own village. Our
findings were unexpected, to say the
least. Among the 182 households (with a
total head count of 859 individuals) we
found that every tenth Hindu household
was 'officially' bigamous, with more
than one woman openly using the same
> Continued on page 26
17
Continued from page 17 >
man's name and that the entire
community accepted these marriages as
rightful and unstigmatised in any way.
Ironically, whereas 10 per cent of Hindu
men, spread over all age groups,
educational levels and castes, were
openly bigamous, none of the 21 Muslim
households in the village are officially
bigamous.
The average household size of Hindu
families is 5.0, whereas that of their
Muslim counterparts is 5.4, indicating
that there is no considerable difference,
especially since we found that small
households (kitchen units) in the village
are not merely a representation of
reduced
fertility, but also of
opportunities (or lack of opportunities)
for migration to the cities for better
prospects. The study was conducted in
1992 by the author.
cursory glance at reality may help to
dispel some of the eugenic biases we
unnecessarily gather.
Unsafe contraceptives,
no-choice situations
About three years ago, a young
adolescent girl came to the PHC for her
first delivery. Her old grandmother
stayed the night with her. This old
woman confided in the nurse about her
own vaginal discharge. The internal
check-up revealed a foul, frothing, black
discharge. Then the grandmother told
the nurse that she had never got her IUD
(probably a Daikon shield) removed. She
had got it inserted when her youngest
son, the father of the girl in labour, was
born, 40 years earlier.
Myths and biases are excellent
breeding grounds for planned coercion
This woman certainly does not
represent the typical picture regarding
invasive contraceptives, but surely there
are a few more like her, somewhere on
the Indian sub-continent. The agony is
compounded by the fact that women's
and so we find, even in well-meaning
circles, the agreement that the growth of
access to general health sendees is also
very low, it being further reduced by the
'certain populations' needs to be
curtailed. Coercion on women, the
minorities, the working class, villagers
and the illiterate are thus justified. A
constant nagging for family planning. In
this context, it is both undesirable and
unconceivable to consider introducing
long-acting hormonal contraceptives,
'ZTt/roic
Voters Vol. I fr/o.2.
such as injectables and implants in the
Indian Family Planning Programme.
The absence of choices, low access to all
resources, including heal th services, low
self-perception of women and the
anti-people stance of population
policies, would only compound the
miseries of the common woman.
H
Manisha Gupte is involved in a rural health
education project of the Foundation for
Research in Community Health, Bombay, in
the drought-prone and semi-accessible
Purander tehsil of Pune district.
zviB
The observations made in this article
recorded over a period offive, years — during
her involvement in a study undertakenfor the
National Commission on Self Employed
Women and Women in the Unorganised
Sector, during the author's extensive travel in
rural Maharashtra to visit various PHCs and
NGOs engaged in rural community health
care and, ofcourse, during their project work.
Some copies of VOICES on
New Communication Tech
nologies/ which discusses
various facets of these new
technologies, and possibilities
for the future, are still available
at Rs. 12/- per copy.
B'WE,
MwZX. W>ft®v
yK^SO’MSP COWTO’S
b women's health advocates worldwide move to
,’
ensure that women’s voices n>" ’.sard at the 1994
^k"'; A UnitedNations International Conference on Popu'* lotion and Devr'npmcnt [1CPD] in Cairo thenoed
to understand the complexity of the issues and then ■• ay
inresolved conflicts within the women’s movement be
comes paramount.:
Intense political debates at the First International
Population Conference (Bucharest, 1974) ensured social
<<i economic concerns took precedence over quantitative
orsographic targets. Various paragraphs relating to
women’s status were included in the key document of the
(inference (World Plan f Population Action) and the
United Nations system itself >-.'as motivated to increase
its Women and Development efforts, resulting in the
Decade of Women (1975-1985).
Within the Decade, women worldwide had more
space and more resources to explore the issues affecting
them. Bence by the time of the Second International
Population Conference (Mexico City, 1984), although
feminist activists and experts we"': in attens
, .
critical mass of women’s health activists of the. world were
A' he same time participating in the First Global'Wo men’s
Health and Reproductive Rights Meeting in Amsterdam.
rj n Mexico City, a major contradiction arose. On the one •
: ’ hand the United States, which promoted population
■ ■■ growth as a ‘neutral phenomenon’ within the context
1 ■ of ‘development as economic growth fueled Dy free
markets and privatization’ [Freedman and Isaacs, 1992],
withdrew funding support for organisations working in
'he field of reproduction, such as UNFPA - a shift, seen by
many as related to increased influence on the US gov
ernment by fundamentalist anti-abortion forces.
In contrast, the conference convenors re-empha-ized the need to raise the status of women and approved
the principle that ‘governments should make family
••'..mning services widely available’ [Population, CIDA,
;9J, going far beyond the Bucharest position that ‘cou•>.« and individuals have basic rights to decide freely and
-esponr ’ .• the number and spacing of their children and
to have .e information, education and means to do so’.
Thu Amsterdam mooting, meanwhile, promoted
the belie.f that ‘women should be seen as subjects and not
objects o'" population policies’. [The concepts, iss ues and
otrategics raised in Amsterdam have since been spread
widely, resulting in an upsurge of differing positions
within the international women’s health movement. As
feminist perspectives of reproductive rights have under
gone re' nement and diversi^eation, so too have som? of
the major actors in the population establishment been
reconsidering their traditional frameworks. In doing so,
they have taken into consideration those aspects of the
feminist analysis they find digestible.
nd so, as ICPD-3 approaches, there’s a real danger
that legitimate concerns will boused by those with
negative attitudes towards contraception to make
« ® their case. It’s been tried before. In Nairobi in 1985
at the World Conference which marked the end of the UN
Decade for Women, such elements tried to co-opt Third
World women to support their anti-contraception position.
/‘st that time prcmptaction by experienced women’s health
advocates prevented what might have been a major set
back for women’s reproductive rights. However, the con
flict is far from resolved.
Most recently, the 1992 UN Conference on Environ
ment and Development in Rio de Janeiro, Brazil, exposed
the comr’-'xities and unresolved conflicts inherent in the
population issue. The old debate on the relationship be
tween pnnulation growth and the environment resur
faced, effectively distracting attention from some of the
most important causes of environmental degradation, as
well as confusing the population issue.
The Vatican won approval from many who would
normally be opposed to its position on women's status and
reproductive rights, when it rejected the argument that
'population is the problem’, affirmed the importance of
ethics, and recognised the need for a less materialistic
approach to development. On the other hand, UNFPA’s
emphasis on the narrow view of population as “the means
of avoiding world demographic disaster” [Dr Nafis Sadik,
Executive Director, UNFPA] was deeply troubling to
women’s health advocates.
.
m
»
COMPLEX ISSUES
v
he argument that social (including population) and
economic policies were influenced by racism also
resurfaced in the wake of public protests against the
" prevalence of sterilization in Brazil. The issue is
carried strongly by the Brazilian black movement, but has
far broader implications since, in the absence of an ad
equate reproductive health progn< ,me in the country,
many women seek out and pay for at< ■ diznlion services. In
the population debates, in which a large number of Brazil ■
ian women took part, allegations of genocide ugainstblack
people created n climate of suspicion between women of
different races and countries making it difficult to identify
common ground and mutual concerns.
Another crucial debate cente>ed on reproductive
technologies. Within the international women's move
ment there’s now a significant trend, particularly among
European feminists, that expresses outright rejection of
all new reproductive technologies. Third Wor ld eco • ninists have extended the critique to inch, concerns about
the role of Northern science and technology in the
marginalisation of indigenous knowledge «vstcms.
Legitimate criticisms of the
; side effects of
contraceptives, drug experimentation und ‘drug dumping*
en South women; coercive practices and genocide, are also
used by right-to-life advocates to carry forward their
objective to end family planning and abortion services all
‘ "’gather. What often gets lost are such vital realities as
errices, female and male sexual needs and vulnerabilities,
and gender power relations. Instead the most conservative
positions do not concede the legitimacy of nny population
policy or any kind of intervention.
't.i
ut without any kind of reproductive health policy,
and lacking access to the means of fertility regulntion, women are left vulnerable and open to un
wanted pregnancies, children they cannot support
and a host of preventable health problems.
Broad definitions of reproductive health should in
clude violence against women along with the more tradi
tional issues such as maternal health, contraception and
abortion, sexually transmitted diseases (STDs) and repro
ductive tract infections (RTIs). An iir
'cd approach
such ns fertility regulation programmes which include
education and counselling, screening and treatment; or
Si D and AIDs clinics which recognize the link between
STDs, RTIs and I11V, would rationalize services and
result in more efficient and effective use of limited re
sources. Such an approach would also address 11,e jasf>ue of
women’s time, whereby multiple roles as mothers, h< r>ltbcare provider^ and bread-winners result in stress thatcan
damage health. In addition, women arc not socialized to
cake care of themselves which means I hey often neglect
lheir own health, visiting clinics for the health needs of
JAWN INFOUMS
k-
children and elders ’rather than themselves. Clinics
focussing on women’s overall health and well-being be
yond the narrow confines of contraception would greatly
reduce the incidence of'drop outs' and contraceptive fail
ure.
The comp’exity of the issues involved and the dan
gerous consequences which would result from reinforced
population-control oriented policies, together present a
special challenge to the women’s movement in the pre
paratory stages of JCl’D. The event itself is wimping up to
be r mojo’- ■ 'c°. of struggle for women worldwide come
June 1994. In this context, itbecomcs critical that women
of the South participate fully in the process of developing
an agenda of consensus. What can women’s reproductions
rights advocates do in this regard? Some suggestions:
1/ Encourage women (individuals, groups, organisa
tions) to lobby their governments with the aim of
influencing final platform positions and having
their spokespersons included in conference del
egations.
•Z Make an input to the Declaration on Women’s
Reproductive Health and Justice produced by tho
International Alliance for Women’s Reproductive
Health and Justice, an initiative of the Interna
tional Women's Health Coalition (see centre
spread).
«/ Contribute to DAWN’s analysis (see page 3)
ervice providers and advocates concerned about
women’s rights and health should be natural, all®
Jjn for fertility regulation programmes: they understand
the importance of reproductive health and are
committed to promoting women’s health through the pro
vision of better services as well as by encouraging women
to take better care of themselves.
This partnership, however, depends on the level of
commitment and openness both service providers and
advocates have towards exploring avenues for collabornI ion. The need for this kind of collaboration has never been
clearer.
I Sources: DAW.Vs Preliminary Platform Document on Popu
lation and Reproductive Rights by Sonia Correa; Presenta
tion by Peggy Antrobus, DAWN General Coordinator, to
1PPF Regional Council Meeting; Terra Viva. Nutnlier-12,
June 12, J 9921
•
APPENDIX: TABLE I TO XII
TABLE III. PERCENTAGE INCREASE IN POPULATION,
1900-2000
TABLE I. ASIA IN THE WORLD PERSPECTIVE, 1900-2000
Year
Population (millions)
Per cent of world
population
56.1
54.9
55.3
56.6
57.8
58.2
58.0
925
1355
1645
2056
2581
3177
3778
1900
1950
1960
1970
1980
1990
2000
Country
1. China
2. jndia
3. Indonesia
4. Bangladesh
5. Pakistan
6. Japan
7. Philippines
8. Thailand
9. Iran
10. Republic of Korea
11. Burma
World (millions) Asia (millions) Share of Asia
(per cent)
430
290
410
525
596
601
51.4
59.5
62.7
63.1
60.3
56.9
1950-2000
4029
2423
60.1
46.5
21.4
24.9
25.6
23.1
18.9
<
178.7
TABLE IV, PROJECTED POPULATION OF SELECTED
ASIAN COUNTRIES, 2000
TABLE II. INCREASE IN POPULATION 1900-2000
836
496
654
832
989
1056
Asia
50.6
20.0
21.9
22.9
22.1
19.4
1^2.1
Source : As for Table I.
The Demo
graphic Situation in the ECAFE Region (POP/APC/2/BP/I).
1900-1950
1950-1960
1960-1970
1970-1980
1980-1990
1990-2000
World
1950-2000
Source : Economic Commission for Asia and the Far East:
Year
Year
1900-1950
1950-1960
1960-1970
1970-1980
1980-1990
1990-2000
Source : As for Table I.
Assumption A
(millions)
Assumption B
1178
1081
262
161
141
133
93
80
62
59
53
954
834
186
103
91
128
67
60
50
45
50
i
Source : As for Table I.
58
59.
I
Tr
TABLE V. RURAL POPULATION AS A PERCENTAGE
OF TOTAL POPULATION, PROJECTIONS
FOR 1980-2000
TABLE VI. LEVEL OF URBANISATION IN ASIAN
COUNTRIES, 1970
Country
Country
1980
1990
2000
Afghanistan
Bangladesh
Bhutan
Brunei
Burma
China
Hong Kong
India
Indonesia
Iran
Japan
Khmer Republic
Korea, Demo. People’s
Republic of
Korea, Republic of
Laos
Malaysia
Mongolia
Nepal
Pakistan
Philippines
Singapore
Sri Lanka
Thailand
Viet Nam, Democratic
Republic of
Viet Nam, Republic of
89.2
90.0
78.0
36.0
80.2
71.8
6.2
75.8
77.3
52.8
19.4
84.7
87.0
86.0
72.0
28.5
74.0
65.2
3.9
68.0
68.4
45.0
14.0
80.5
81.0
81.0’
66.0,
20.0;
65.0
58.5
2.0
57.0
60.0
37.0
10.0
75.0
52.6
52.9
82.2
45.0
44.1
93.3
68.0
62.6
—
73.0
82.4
43.0
43.1
78.5
36.5
39.4
89.3
62.0
55.0
—
64.0
78.2
34.5
34.5
75.0'
32.0
35.0
84.8
55.0
46.6
• -—
50.0
73.0
77.1
70.0
72.0
64.5
68.0
58.2
ASIA
70.6
64.3
56.5
Source : As for Table I.
60
V,
Estimated
Estimated Per cent
total popula urban popu of urban
tion in 1970 lation in
to total
1970
(millions)
(millions)
17.0
Afghanistan
73.2
Bangladesh
0.84
Bhutan
0.12
Brunei
27.7
Burma
773.7
China
4.2
Hong Kong
554.6
India
121.2
Indonesia
28.4
Iran
103.5
Japan
Khmer Republic
7.1
Korea,Democratic People’s
Republic of
13.9
Korea, Republic of
32.1
Laos
3.0
Malaysia
10.8
Mongolia
1.3
Nepal
11.3
Pakistan
63.7
Philippines
38.1
Singapore
2.1
12.6
Sri Lanka
Thailand
36.2
Viet Nam, Democratic
Republic of
21.2
Viet Nam, Republic of
18.0
1.6
5.1
0.13
0.07
5.0
186.9
3.8
110.4
21.6
11.5
74.7
0.9
9.7
7.0
16.0
56.0
18.0
24.2
92.0
19.9
17.8
40.6
72.2
12.8
5.6
12.8
0.5
4.9
0.66
0.52
17.2
12.1
2.1
2.8
5.4
40.0
40.0
15.1
45.0
51.6
4.6
27.0
31.8
100.0
22.3
14.8
3.9
4.3
18.2
24.1
Total Asian ECAFE Region 1975.5
494.5
25.0
Sonrce : As for Table I.
61
TABLE VII. PROJECTED GROWTH RATES OF URBAN
AND RURAL POPULATION 1970-2000
Korea,
Demos.
1970-75 1975-80 1980-85 1985-90 1990-2000
Country
Afghani
stan
Urban
Rural
Bangla
desh
Urban
Ru ral
3.4
2.5
4.0
2.5
4.3
2.3
4.6
2.2
6.2
3.2
8.0
2.8
7.0
2.7
5.5
L8
5.1
1.3
Bhutan
LTrban 4.6
Rural 1.7
6.4
1.2
4.8
1.4
4.5
1.4
4.0
1.1
3.5
—1.0
6.1
1.4
Brunei
Urban 4.7
Rural 1.5
4.8
1.1
3.7
0.7
3.8
0.0
Burma
Urban 3.3
Rural 2.2
3.3
2.1
4.0
2.1
6.1
1.0
5.0
0.6
China
Urban 3.3
Rural 1.2
3.4
1.0
3.7
0.7
3.5
0.2
3.3
0.1
2.6
2.6
—0.4 —1.1
1.3
—4.7
1.2
—5.5
Hong
Kong
India
Indone
sia
Urban
Rural
2.7
0.0
Urban 3.8
Rural 2.4
5.5
1.7
5.4
1.4
4.9
1.0
4.9
0.2
Urban 4.9
Rural 2.6
6.0
2.0
6.1
1.5
6.1
1.3
4.7
0.9
Iran
Urban 4.4
Rural 2.3
5.1
1.6
4.9
1.3
3.7
0.8
3.4 .
0.0
Japan
Urban 2.3
Rural --1.9
2.1
1.6
-2.2 —2.6
1.3
—3.0
1.1
—2.7
Urban 4.4
Rural 3.0
5.7
2.8
5.3
2.2
4.9
1.6
Khmer
Rep.
62
5.8
2.6
1970-75 1975-80 1980-85 1985-90 1990-2000
Country
Urban 4.6
4.4
4.7
3.8
3.2
1.5
1.3
0.6
0.1
-0.4
Urban 4.2
Rural 1.2
Urban 3.9
Rural 2.5
4.1
1.1
5.0
2.3
4.5
0.4
4.0
2.4
3.6
—0.3
4.8
1.6
3.1
—0.6
3.5
1.4
Urban
Rural
Mongolia Urban
Rurai
Urban
Nepal
Rural
Pakistan Urban
Rural
Philippines Urban
Rural
Singapore Urban
Rural
Sri Lanka Urban
Rural
Thailand Urban
Rural
Viet Nam Urban
Dem.Rep. Rural
Viet Nam Urban
Rep. of Rural
4.9
1.2
4.0
2.2
6.0
2.1
5.0
3.0
5.0
2.8
2.3
—
3.9
2.0
4.8
3.0
4.4
1.8
3.9
1.5
5.1
0.5
3.8
2.0
6.4
2.1
5.5
2.5
5.5
2.5
2.3
—
4.8
1.5
5.3
2.8
4.3
1.2
3.9
1.2
4.6
0.4
3.7
1.7
5.9
2.0
5.1
2.3
5.4
2.2
2.3'
—
5.0
1.0
5.1
2.5
4.3
1.1
3.9
1.0
3.4
0.3
3.6
1.6
8.3
1.6
3.9
1.2
4.7
1.4
1.1
—
4.7
0.1
4.7
1.8
3.8
1.4
4.1
1.0
2.6
0.6
3.1 .
1.1
5.6
1.4
3.6
0.7
4.1
0.7
1.0
—
4.8
1.0
4.3
1.4
3.2
1.2
3.5
0.8
Total
Asian
EAFE
Region
3.7
1.9
4.1
. L5
4.2
J.2
3.9
0.8
3.6
0.3
People’s
Rep.
Korea,
Rep. of
Laos
Rural
Malayysia
Urban
Rural
63
TABLE VUI. THE INCREASING IMPORTANCE
MILLION-CITIES URBANISATION
PROCESS, 1950-1985
OF
TABLE IX NUMBER OF MILLION-CITIES, 1950-85
Year
World
1950
1955
1960
1965
1970
1975
1980
1985
75>
90 ‘
109
136
162
191
229
273
Average annual rate of growth, 1950-1985
(per cent per year, compound rate)
Population of
towns
Total Urban
and ci
Popu Popu
ties
lation lation million old and
cities
new mil smaller
existing lion cities than a
in 1950 combined1 million
at any
given
time’
World total
More dev.
region3
Less dev.
regions3
East Asia
South Asia
Europe
Soviet Union
Africa
North America
Latin America
Oceania
2.0
3.3
2.6
4.5
2.8
1.1
2.2
1.8
2.9
1.8
2.4
1.7
2.6
0.8
1.3
2.6
1.5
2.9
2.2
4.6
4.7
4.0
1.6
2.9
4.9
2.2
4.3
2.6
4.1
3.6
4.1
1.2
1.5
4.2
1.7
4.2
2.7
6.7
5.4
7.1
1.8
5.4
9.3
3.0
6.1
3.5
3.8
4.3
3.0
1.5
2.4
4.2
1.6
3.5
1.8
’• the combination of million-cities existing at any given date.
’• the urban population excluding million-cities existing at any given
date.
’■ The more developed regions comprise Japan, Europe, the Soviet
Union, North America, temperate South America, and Australia and
New Zealand, the less developed regions comprise the rest of the
world.
More
developed
regions
Less
East
developed Asia
regions
South
Asia
51
56
64
75
83
90
108
126
24
34
45
61
79
101
121
147
8
13
16
23
27
34
40
53
13
17
23
28
36
45
50
54
Source : As for Table VIII.
TABLE X. PERCENTAGE OF WORLD’S MILLION
CITY POPULATION CONTAINED IN DIF
FERENT REGIONS, 1950-85
Year
World
1950
1955
1960
1965
1970
1975
1980
1985
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
More
Less
developed developed
regions
regions
72.6
68.0
63.6
59.0
53.7
48.6
45.6
42.3
27.4
32.0
36.4
41.0
46.3
51.4
54.4
57.7
East
Asia
South
Asia
18.1
19.7
22.0
22.5
24.2
25.4
25.0
24.2
8.6
11.1
11.8
14.0
15.2
17.1
18.5
20.6
Source : United Nations, population Division, Department of Economic
and Social Affairs: The World’s Million-Cities, 1950-1985)
(ESA/P/WP/45.)
64
Source :
As for Table VIII.
65
WWFT World Wide Fund
For Nature
CH--=6Ssrc Switzerland
Teep-ci-e ::s 549111
Tee- -3z'z ■■■■■& ch
Tee's- OSS i—42 38
Direr re
.21 54 9. .
WWF: Consumption and Population
The following is information on consumption and population
issues as viewed by WWF, including reference to the UNCED
process.
Background
The population issue is complex and can be examined in a number
of ways, among them reproductive rights, maternal and child
health care, freedom of choice and quality of life issues,
demographic trends, and family planning policies.
WWF is
concerned about the relationship between population and
degradation of the environment, particularly in light of the
dependence of people on the natural environment for basic human
needs.
WWF looks at consumption and population as relates tc
our three mission areas: preserving genetic, species and
ecosystem biodiversity; sustainable use of renewable natural
resources; and pollution and wasteful exploitation and
consumption of resources and energy.
The WWF focus is on people and their actions which place
pressure on the natural environment and resource base.
Thus
concentration is in two categories: excessive consumption and
waste, and population growth.
The Problem
Population-related characteristics as associated with the
environment manifest themselves differently around the world.
In developed countries, the pressure is due to the excessive
levels of per capita natural resource and energy consumption and
waste.
There are far fewer people there, but consumption levels
are much higher.
A disproportionate 25% of the world populamion
(found in industrialized countries) is consuming 80% of its
energy and producing 75% of its pollutants.
In their lifemime a
North American consumes 500 times more energy than a Malian
does.
In developing countries, pressure on the environment cones from
the lack of choices imposed by poverty and inequitable benefits
from the development process, and secondly, the sheer numbers of
people depending on scarce or relatively inaccessible natural
resources.
Developing countries have the highest population
growth rates in the world, and are expected to make up 80% of
the world population within decades.
The Caring for the Earth fCFE) document, published jointly by
WWF, IUCN (World Conservation Union), and UNEP (United Nations
Environment Programme) addresses consumption and populamion with
1
Registered as:
WWF ■ Fondo Mondiale per la Natura
WWF - Fonoo Muna.al para la Naturaleza
WWF - Fonds Mondial pour la Nature
WWF ■ Welt Natur Fonds
WV.F - World Wide Fund For Nat.?e
P-esfflrt
’-e
rr Edinburgh
’.
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Bazar 4
Russe E '
u;- '•eas-'S' . tmn E Nash
Uj H (3
WOMEN POVERTY AND POPULATION DRAFT; DEVAKI JAIN
(Jan.2, 1993)
PREAMBLE
The evidence .for this draft, chapter or paper has been drawn from
many sources; e.g. from those concerned with women , fSt-Om.
f-XivJ
-> <A,? ck z’
IjOWL A.<dl<xy
a
A.^
C-
'
Papers by Dr Ramalingaswamy, Af.K. Sen, Malcolm Adhisheshiah, Ashish BoseztiThe responses received by Prof Gupta, NIHFW
analysed by his team and the ideas and practices that have been
included in population discourse both nationally and internation
ally .
We have prepared a growing list of literature that has
come
to us starting with the preparation of the Chapter for the
Coun
try
paper,
moving to the international
official
and
academic
meetings
to the documents given by the expert group. This
list
is,
of
course,
too long but I have marked those
that
I
have
especially used.
I
am very concerned that sections of the chapters
for
the
official paper for Cairo that have been circulated by Dr.
Pathak
contain
recommendations and elements of Population Policy
which
are really astounding and
unacceptable to many of us, and I hope
to most of the expert group.
e.g.
a Constitutional amendment which links benefits to size
of
family.
We
cannot have any inconsistency between what
we
are
drafting as a population policy for India and the country presen
tation at Cairo that does something else.
Hence I suggest that the country paper be seen again.
Also
laws are being considered so that the centre
and
the
States could link development benefits to performance in
popula
tion
growth.
Thes idea is to
legislate
conditionality,
e.g.
maternity benefit is being linked to number of children
and
so
on.
This would also go against the grain of what is being recom
mended here, namely a non coercive , or voluntary family planning
programme,
as
the
most effective,
efficient
and
sustainable
policy to reduce the numbers while enhancing well being.
I hope the members of the Committee will ensure consistency.
Xpert Group.
DJ 3rd Jan.
1994
WOMEN POPULATION AND POVERTY
draft
Devaki Jain
I propose a chapter- which is broken down to sections as
given below. I have not achieved it .
but am sending this rough
edged , rather too long paper for the first round.
Proposed breakdown into sections
Summary of argument
Main Pillars
Review of experience
Proposed detailed strategy
What that entails in terms of change from present strategy
What goals it can achieve in terms of population growth.
Cost - how to finance such a strategy re-allocation of resources
and different methods of utilisation of resources..
SECTION 1
Introduction and argument:
The
main
pillars
of an effective
and
sustainable
population
policy has to rest on an understanding of poverty and within
it
poor
women, the characteristics of their life
situation,
their
deprivations and capabilities.
The
policy
also has to shed many myths and prejudices
such
as
that
ignorance and superstition are responsible for large
fami
lies, that therefore the poor especially women have to be
"moti
vated" through reward and punishment, and scares like the Malthu
sian
argument
or the population bomb; or its reverse that
a
small family is a happy family and that money can buy or more
aptly drv reproductive capacity.
The
policy
has
to acknowledge and believe that
the
poor
and
within them women want to have the power to determine the
number
of children they have. They are no more seeped in ignorance. They
are aware of the fact that there are methods by which
conception
can
be avoided - and even more aware of the fact
that
foetuses
can
be killed or removed through abortion of many
kinds.
Most
govt documents mention the cruel phenomena of ill-serviced
abor
tions (by quacks, unsanitary methods etc that cause deaths
among
women).
There is also enough survey research to show that, even in
the most remote areas of India and even amongst the most hidden
popoulations such as the tribal people living in forests the
consciousness of modern methods'is there, however hated, dis
dained or feared.
In fact the electoral results after 1975 show
that it was in the backward, so called ignorant areas, that this
Message caused political rejection - not as we would like to
believe because the poor were ignorant of the knife and its
value, not because of superstition that loss of fertility is loss
of life, but because in fact operations turned out to be killers
and also because there was enforcement associated with loss of
ones rights or put the other way with terror.
Further social research is revealing a less comfortable but simi
lar evidence/results, namely, that these "less visible, less
ex
posed people "are losing their own traditional customs as well as
methods
of restraining the size of their
families,
traditional
forms
of birth control not only herbal medicine
but
associated
with
custom
and
ritual and most of all
equality
in
decision
making power between men and women which is the hallmark of tri
bal and other small communities in India. (HASSF-B.R Hills.)
Once
this postulate is changed- namely the
analysis
moved
from one of dealing with ignorant, backward superstitious
people
to one. of dealing with people who are dealing with their life situatiion
as rationally as they can in their
circumstances,
the
approach would change. [A.K. Sen]
And
policy.
this has to be the first demystification of
population
The second is that single prong Interventions can
transform
fertility
patterns
- namely moving
statistical
analysis
into
homes,
(or what can be called family decisions or
couple
deci
sions) .
For example; (1) that literacy inputs into women will
bring lower fertility outputs - because we find that female
education moves with fertility. It is now being shown (Tim Dyson)
that inversely male education influences fertility even more! and
of course
that female & male literacy move together hence it
only makes the point that general educational upward movement
influences fertility.
Hence one cannot stretch too much statis
tical relationships or translate them too simplistically into
policy.
Eg. (ii) that income generating projects for women will "empower"
women i.e change gender relations., again a too simple connec
tion.
Income generating projects can often even add to the
burdens of a woman,without strengthening either her control over
resources or her decision making powers.
On the other hand
access to own income, along with organisation to strengthen
collective strength and self esteem does give women some power but not necessarily an improvement in status.
In other words, one cannot take the success of Kerala, or
any other complex outcome and draw one line inferences from its
success.
On
the other hand Kerala and some districts
and
sub dis
tricts
in
India where there have been
community
based
health
programmes
have revealed the importance of what can be called
a
broad package approach which cannot and should not be
summarised
3
as:
Development is the best contraceptive.
The
difference is that it is not development nor growth
by
itself, but it is the content and the method- also content in the
sense
of
investment in basic
social
amenities,
institutuions
which
means
both the organisation and
the
politicial
culture
which
gives
access
to these facilities. [DJ
Kerala
from
Jap
Paper]
When political will is postulated as a necessary
condition,
it
is
translated to mean either that politicians
should
also
harangue
people to limit their families, or that membership
to
legislative councils should be given as a reward to those politi
cians who have few or no childtren and so on.
Political
will or attention to population should be
trans
lated
as a will to redress the deprivation of the poor, to
pro
vide
them with social and economic security as
basic
services,
and then build their capability to avail of these entitlements.
It can then be suggested that for the poor to fulfill
their
own
desire to achieve a sense of well being, in which for
women
few child births is a strong desire, there has to be a
situation
where
they
are
offered social entitlements
to
basic
health
services, which of course includes food, may be even
livelihood,
and then their capacity built to avail of these ent itlements,
namely through education, information - but not only that but
through providiing the institutional mechanism that share power,
which offer space for groups like women to participate in deci
sion making, thus to excercise power.
Thus a base for a population policy has to be the
provision
of
a floor - which gives access to income, - it could be a
form
of employment guarantee, it could be a strentgthening of existing
labour use pockets but with the exploitation removed (SEWA)
This
floor is not to be limited to the economic zone alone,
but
roust include health and education, translated to univerasal
pri
mary education, and universal primary health care. It should also
include
basic civic amenities like water, energy, sanitaton a
blend of economic and social services.
However, the management of the provision of this floor has
to be through local self government - as then both the diversity
of India, the participation of local communities, especially the
voices of the unheard in decision making, the accountability
required for monitoring and redressal is assured.
Jean Dreze puts it very well when he says that the State
should provide the services of economic and social security to
the poor but for it to reach the poor this service has to be
accomapanied by social dynamism . - namely the commitment and
participation of civic society, namely political parties, volun
tary organisations, the elected bodies and professional institu
tions.
Because to provide a service to the poor is one thing,
but for it to reach them is quite another.
The usual queston that will emerge when such a big commit
ment is put on the national exchequer is lack of resources.
In
fact the Expert Group should know that in the ICPD (Cairo, UNFPA)
document, the G7 countries have objected to the use of the term
"poverty eradication" (they prefer "poverty alleviation") because
they say "eradication" is too costly.
Remove the poor by popula
tion control - we have no money to remove poverty, is the message
from the North
- as Malthus stalks the chapters and the propa
ganda .
But
is
this
the
case?
Can
India
not afford
such
a
policy?Basically Political will means political choices - and the
question
is
not one of raising resources but of
allocation
of
resources and also of methods through which the resources can
be
used.
The Argument 2.
The argument for reducing the growth of population at the
rate at which it is now growing in India is^presented
1) as being unsustainable in terms of natural resources
particu
larly food.
This argument has been countered from many points of
view but the most convincing and unrefutable case is in a
recent
lecture by Amartya Kumar Sen (Nov 93) who shows that the rate
of
growth of food production globally has outstripped the growth
of
population
that prices of food grains have not gone up, in
fact
are
the lowest among tradable commodities, and third
that food
production
is best and growing where population is
largest and
growing namely Asia.
He
does refer to the diferent picture presented by
sub
saharan
Africa but argues that there it is lack of democracy, seen as
a
system which encourages open information flows that has made
for
the bottlenecks.
2)as being caused by the situation of the poor - their high rates
of
mortaliity
especially
amongst infants,
makes
them
insure
against
death by having many children,
their low
income
makes
them
want
to have many hands to bring in small
incomes,
their
need
fox- fuel and fodder as free collections degraded
land
and
therefore
adds
to the imbalance between natural
resources
and
numbers.
Such arguments lend a sense not only of panic but hysteria
in the poor and heavily populated countries, that it is the
numbers that have to be brought down, numbers that are standing
in the way of reaching more widespread and higher levels of well
being.
The
natural logic then is to address a programme
of
birth
control
to
the
poor directly, targetted
and
strengthened
by
incentives and disincentives .
This in our view is exactly the reverse of what needs to
be done; the diagnosis too is exactly the reverse of the reality.
It is not the numbex* of poor that have to be reduced but
it is their poverty that has to be removed.
It is not numbers
$hat is causing poverty but the unequal distribution of resources
and resource use, the unequal distribution of all the basic aroenitiies social and economic of a civilised life.
Inequality and poverty are, of course, distinct concepts but
there
is a close causal relationship between the two. Given
the
level of development and the level of per capita
income/consuroption
expenditure,
a less unequal distribution would
result
in
lower incidence of poverty.
Poor
women
are the first to want to reduce the
number
of
child
births that they have.
But they are constrained not
only
because
of
poor quality and limited variety
of
contraceptive
services but because of their lives and livelihood situation.
The
unmet need is not for contraceptives. Their unmet need
is
for
the economic and social security, which
in
turn
would
enable
them
to exercise informed choice on
their
reproductive
path.
A.K Sen's next point is that
coercion is neither
necessary
nor
efficient.
He cites Kerala and contrasts
with
China
and
argues
that
given
information, given"
incentives"
for
small
family. ( Note in his case incentives does not mean cash or jobs,
but reduction in infant mortality, access to education and most
of all a perspective which quests for an equitable society),
people will voluntarily make a rational choice to limit numbers.
Further it is efficient in his terms becasue it does not kill off
females as is done in China which like India has a strong son
preference culture.
I quote from Sen
£>TTW-r
[^..7^
<Xy
-1>'J /
7T3,
INDIAN WOMEN'S APPROACH
It is now widely understood and largely agreed that Indian Women,
including those who are poor, not educated, unemployed, rural and so
on, would like to have the power to control their fertility.
That
they would like to have few children and at the same time ensure good
health and longevity for their children and themselves.
The problem arises only when the discussion moves from what women
want to, how this desire or need is met.
Those who work with women, especially the poor, living in very
inadequate habitats - with no water or sanitation and with uncertain
economic base, know that for women to have reproductive choice,
it is
■now not only insufficient but inefficient to offer only a cafeteria or
"wide range of contraceptives, or to take the pure "fertility control"
approach.
Their reasons for holding this view arises from :
1.
Their knowledge that the choice of how many children to have
depends on many factors external to the availability of contra
ceptives.
For example, the survival of children, the need for
hands for labour, the need for a son, the self image of the male
partner whose virility is substantiated by the women's pregnancy
and son.
2.
Their understanding of the dangers of some of the new invasive
contraceptives especially when implemented in malnourished
bodies, in bodies which have no access to nodical care in case of
trouble, and in health service structures where there is the
danger of infections.
This makes them wary of ' needlesand
'knives' - additionally in view of the entry of AIDS as an epidemic.
3.
Their understanding that womens fertility is not a function of
only her body but the power cf men and that gender relations
determine freedom of choice; and that these relations have also
to undergo change for choice to be exercised.
4.
Their experience of the current family planning services
through
the states, where incentives and targets have made poor women
victims of coercion and neglect.
)
They ask Society and the State to take, a wholesome view of this
problem and to address themselves to the broader needs as well as to
the focussed needs of society.
THE NERD FOR SOLIDARITY
There is urgent need tor convergence, for an agreed approach
which could provide a broad based platform for advocacy from those
involved with poor women and knowledgeable on reproductive health
matters.
There is urgency not only because population especially its
control has come up high on the Agenda of the State but also because
the view point that the factors which are most influential in reducing
fertility lie outside direct intervention especially into the women's
womb is gaining momentum. We need to develop a minimal 5 point policy
approach which can be Asian and the World's.
Responding to the issues raised above, I would like to make a
proposal to this conference, especially to Japan and especially to
Japan's influence on the UNFPA.
World Wide Consultations by women are revealing that broadly the
women's movement whether it is placed in the North or the South has
the
fol lowing concerns, and the following proposals.
First, as said earlier, they are concerned that the blame for environ
mental devastation is being put on "poor people".
Two, that the response, which is to control numbers is being put en
tirely on what is called the women's womb or the tubes (Shanti
Ghosh)(1).
Three, that due to these concerns that population somehow must be
controlled and reduced, technologies which have developed are being
brought and with subsidies, with
political and commercial pressure
being
put
to use especially on women in
developing
countries.
Their constructive response to these is
:
One, for the Lobbies of Asian women broadening to world wide
women to show that the problems of the environment are not necessarily
the problem generated by population. The problems of environment are
generated by waste, generation, (DJ, Berlin/SID)by over consumption of
natural resources, both in the production and consumption styles of
what is called modern industry & affluent society. Therefore, it
cannot be brought into a population agenda but has to be taken into
what is called the economic development agenda.
Two, that decision making on birth is taken by men and women. Men
have to be brought into responsibility for birth as much as women.
Men's problem, psychological and material need to be dealt with.
Women's decision making capability in this area , namely in reproduc
tive choice leading to reproductive rights has to be strengthened.
(1)
Ghosh,
Shanti
: Whither Health Care for Women and children.
'2'3323.850
ISST DFI.1II
--- ISST.RAX'tl.OPF..
0)003
Since women are seen as the perpetrators of high population,
those who are not aware of the technological devices and their re
quirements are often made victims of the implantation of technology
and often induced through monetary incentives.
These monetary incen
tives are given both to the victims as well as the motivators.
It is
now shown that the money spent on what is called the propaganda, if it
is transferred to provide better public health services, both in
quantity & quality,
no further resources are required.
Therefore, they appeal that the UNFPA should have more
emphasis on Public Health, quality of care, better facilities for
broad based health, much more information
sharing, and redressal
mechanisms for those who are victims of careless contraception
than merely the technological devices.
A
Three, that women's organisations who have the capability to
reflect and be sensitive to the needs of women need to be much more
involved in providing care and safeguards to women who go for birth
control.
Fourth, they have shown how disincentives like not getting land,
housing, electoral positions, jobs in organised sector because of
family size tend not to be disincentive only; they tend to create
inequalities within social strata.
For example, very often it is the
large masses in India who might have many children to start with at a
very early age.
By barring them entry to various decision making
powerful forums due to number of children they have borne, one would
automatically be shifting the power equation to the elite.
Therefore,
disincentives of this kind cannot be pushed on to a very unequal
society.
Targets have not worked in India nor any where because targets
tend to shift the focus of interest of the providers of health
from
providing health services to achieving goals.
Much of the havoc
caused by the Indian Family Planning experience has been due to the
target approach.(Amal Ray)
One must understand that in very poor
societies with acute unemployment, providers, grassroot functionaries
and the men and women can easily be induced to undertake various tasks
with small bits of money. Thus by providing constant cash incentives,
one may not be designing appropriate policies.
Finally, the whole issue of health care being both designed at
the community level to integrate itself with other care and with local
needs, accountability being proximate to the people who receive the
health care so that the redressal mechanisms are immediate and acces
sible
has been brought up in the Indian debate.
India will be going into a form of decentralised political man
agement through the the 73rd Amendment to her constitution.
According
to this Bill, not only will local govt, be elected but 33 1/3% have
been reserved for women. Already in three states some 60,000 women
have already been elected to these political governing councils.
India has also given many of the individual sectoral subjects for
designing and management,
bodies.
implementation and monitoring to these local
Health and family welfare
self government bodies.
is therefore,
an agenda on
local
03.3 2.1850
SST DELHI
..... ISST.BAXfiLORE.
0004
It is most important therefore, that the world takes note of this
new trend which will soon come into many other countries, and facili
tate women and men to goal their own objectives in terms of popula
tion, its size and its quality.
The issues that are being flagged by the women of the South are
greater investment in health care, the merging of general health with
maternal health, the provision of basic amenities, they would also
like to suggest that the State should be responsible for a minimal
basic service o£ health, literacy and decision making spaces.
Privat
isation of health care can only be on top of that.
Therefore, the
ideology that all health care has to be privatised while population
control strategies are pushed
through the state machineries are
rejected.
In a paper called the Economics of life and death, A.K.Sen
gives
comparative data on survival rates by sex and religion and also life
expectancy
in different countries. He shows how survival rates for
example for women are higher in Kerala, India than in Black Harlem or
Black U.S. He also shows how death rates in the U.S. vary dramatically
according to race. Establishing the point that even in advanced coun
tries subordinate social categories can live in an Island of "back
wardness". He also shows that public investment, the State, must
intervene in such a situation.
<& OPPOSE
PLATFQKM
ser.11? ELEMENTS
'
DJ/JAP , .
For V.omen
[■ y
Analysis which shifts responsibility from the wasters and polluters
to the poor.
The contraceptive approach namely the fertility approach.
The coercive approach.
& SUPPORT
The health approach.
Public health services, public investment in public health.
Women's Participation in designing health .
Local self-government, redressal mechanisms, accountability.
Basic needs/livelihoods/food security/ support structures.
WOMEN OF THE SOUTH
(HEALTH)
'
DJ/JAP'
Greater investment in health care
Merging of general health with maternal health.
Minimal basic service of health, literacy and decision making
spaces.
H H-3
CULTURAL PERCEPTIONS AND CATEGORIZATION OF
MALE SEXUAL HEALTH PROBLEMS BY PRACTITIONERS
.AND MEN LN A MUMBAI SLUM POPULATION
BY
Ravi K. Verina'. G. Rangaiyan2, S. Narkhede3,
M. AggarwaF, R. Sin gif and Pertti J. Pelto6
INTERNATIONAL INSTITUTE FOR POPULATION SCIENCES
DEONAR,. MUMBAI - 400 OSS, INDIA.
I.
Reader and head. Department of Extra Mural Studies, International Institute of Population Sciences, (UPS), ,
Mumbai-88.
2.
Lecturer. Forel Foundation Project on Capacity building in Reproductive Health, UPS, Mumbai -88.
3.
Research Officer. Ford Foundation Project on Male Sexual Health Problems in a Mumbai Slum Community, UPS,
Mumbai -88.
4.
Assistant Research Officer, Ford Foundation Project on Male Sexual Health Problems in a Mumbai Slum
Community. UPS. Mumbai -88.
5.
Assistant Rvscatvh Ofliecr. Fold Foundation Project on Male Sexual Health Problems in a Mumbai Slum
Ommiuntiy. UPS. Mumbai HH.
6.
Consultant. Johns Hopkins University and Ford Foundation Projects in India.
INTRODUCTION
This paper presents data comparing practitioners’ and community male’s cultural perceptions and
categorizing of sexual health problems in a Mumbai slum population. Structured qualitative data from
Free listing, pile sorting and ratings are frequently used to obtain a systematic picture of the vocabulary
of terminology, ways of classifying, and other information in a specific topical domain such as
"illnesses”; "types of healers/practitioners”, “foods” and so on1.
Until recently, the entire area of reproductive health was very poorly understood, particularly
with reference to South Asian populations. However, curing the 1990s a number of studies of women’s
gynaecological health issues have been reported from several areas of India and Bangladesh (Gittelshon
et al 1994: Bang and Bang 1989; Bhatia and Cleland 1995: Ross et al in press). Several of these studies
have used structured qualitative methods, in order to get culturally specific emic data and other
information about women’s perceived health problems and treatment seeking behaviours. On the other
hand male sexual reproductive health, including their vocabularies and perceptions of sexually transmitted
problems, have been much less studied.
The growing public and governmental awareness of the spread of the AIDS epidemic has shifted
attention to the importance of male sexual health problems in part because of the role of sexually
transmitted infections tSTIs) in increased risk of HIV infection. In India and elsewhere, programmes
aimed at reducing the spread of HIX’ include STD Clinics, counseling programmes, and other interventions
that try to reach men who are involved in risky sexual behaviours. The detailed information is, therefore
needed concerning all aspects of male sexual behaviours and particularly sexual health problems.
There are a number of interrelated questions that we have dealt with in this study. In addition to
the vocabulary of sexual health problems, we have explored the contrasts and similarities between the
perceptions of practitioners who treat sexual health problems and the cultural views of the men in
communities served by ±ese practitioners. In this study we are using the label, “sexual health problems”
rather than sexually transmitted diseases (STDs). This is because the concept of STDs as a category is
medical language, and may not correspond to the ways in which people in the Mumbai slum community
categorize illnesses and symptoms. Published and unpublished data from the studies of gynaecological
health problems of women and unpublished data from some recent studies of males, indicate that the
vocabularies of sexual health problems are complex, and the emerging picture suggests that both males
and females recognize the concept of sexual transmission, but the same health problems that may be
transmitted sexually are also thought to be caused by other factors, especially those associated with
Garmi. For example, in a study in a tribal area of Gujarat, the SARATHI researchers reported that
people recognize sexual transmission as one of the causes of their illnesses, but they also believe that
other factors can also be important as agents causation (Grenon, and Tazeern. 1996).
GUPT ROG: SECRET ILLNESSES
The cultural domain of the sexual health problems in Mumabi slum can be understood by the
general cover term which is used to describe them. “Gupt Rog” (Secret Illnesses)” is the most common
term to describe sexual health problems in the Hindi speaking part of India. The term Gupt Rog implies
that ±e illness belongs to the secret parts of the human body. It also suggests that the illnesses have be
associated with something shameful that are better kept secret. It is however important to remember that
many of the sexual health problems are nor necessarily thought to be transmitted through interpersonal
contacts. For example, excessive masturbation, thinning of semen and wet dreams or penile abnormalities
are clearly not transmined through personal contacts.
In that sense they are not ‘’Rog”(illness) but
problems which have very different etiology than what is expected bio-medically. During the field work
we often found both doctors and men using the term Kamjori (Weakness) to refer to all kinds of sexual
health problems. In this sense the cultural domain of sexual problems for the community in Mumbai
slums is beyond the concept of Rog. We shall discuss "kamjori” in greater detail in the following section.
Pelto (1996) has used the term contact and non-contact illnesses to describe this concept.
Contact” and "non-contact” sexual health problems: Several studies have shown that male sexual
concerns center around two quite different sectors:
s
Non-contact concerns about semen-loss including concerns about masturbation, nocturnal
emission, and other forms. These semen-loss concerns that are very pervasive among young
men in South Asia, are also related to fears of impotence (Pelto et al. 1996: SARATHI.
1996).
A. Contact or infectious problems that may indicate STDs, there are some problems: Burning
urination might not be due to infection, for example. Similarly itching and some sours.
pimples or other conditions, in the genital areas may be fungal infection ra±er than sexually
transmitted infection. In some areas of India filariasis and hydrocil occur quite frequently.
and are often reported as sexual health problems by many people (Bang and Bang: 1997.
Orissa study in progress)
In view of the above, the present paper describes the cultural perception and categorization of
sexual health problems by the practitioners and men in a Mumbai slum community.
STUDY AREA AND METHODOLOGY
The data presented here, are a pan of a study that is in progress in a slum community located
in the North-east part of Mumbai2. It is a large slum consisting of about 70,000 population and is
primarily inhabited by the people who were relocated from the central part of the Mumabi in the late
Seventies. Over a period of about two decades the slum population has grown enormously, with a large
number of illegal and unauthorized structures mainly of migrants coming from various parts of the
country. A large proportion of the population is Muslim from the Konkan area of Maharashtra, Kerala
and ±e eastern Uttar Pradesh. It is a typical overcrowded Mumbai slum with many lanes, ad-hoc
structures and lots of “joints”—such as tea and Paan shops for informal gatherings. A large number of
health practitioners are found in the lanes of this slum. Transecting the entire area, we counted 53
practitioners, some of whom had formal training in allopathy3. However, a large number of them did
nor possess any recognized degree or diploma and yet prescribed all kinds of health care tratment.
Initial contacts were made with practitioners who were willing to help in the study. Due to
unavailability of suitable male field researchers, the initial contacts were established by a senior level
female researcher and the Principal Investigator of the study. Since the practitioners contacted were
Muslim, the language used for gathering information was Hindi. The first several rounds of discussions
with the practitioners were informal discussions about the kind of patients who visit them. These
discussions also provided insight into the sexual behaviours of the community males as these practitioners
claimed to be treating a variety of male sexual problems.
The practitioners introduced us to some key informants in the community, who also happened
to be their clients. At this stage of the field work, concerted efforts were made to appoint male field
researchers and train them in collecting sensitive information. Three male researchers, carried out the
main data collection.
The techniques used to collect information on sexual problems included free-listing, pile sorting
and raring, which were used as part of in-depth interviews. An opportunistic sample of forty four
practitioners and fifty six communin' men were contacted in the initial qualitative phase of data collection
(see appendix I for the characteristics of the practitioners interviewed). Two to three sittings were
required with each respondent. In the present paper we are presenting the findings based on the freelisting of the sexual health problems and severity ratings
2 The study is part of a Ford-Foundation funded capacity building project in the area of reproductive health. .
3 A formally trained graduate in India is conferred with MBBS (Bachelor in Medicine and Bachelor in Surgery)
degree.
Free-List of Sexual Health Problems:
According to the Weller and Romney (1988), the first step in a study of cultural perceptions is
to obtain a clear understanding of the definition and boundaries of what the domain being studied. Free-
listing is a technique used to define the contents of a cultural domain. It is particularly useful to get the
culturally relevant items (vocabulary) and to delineate the boundaries of a semantic or cultural domain.
The free-listing can also be used to make inferences about the informant’s cognitive structure from the
order of recall and the frequency of recall. The free-list helps to collect the local vocabulary used for the
study items. Responses are tabulated by counting the number of respondents who mentioned each item
and then items are ordered in terms of frequency of response. Frequencies or percentages can then be
used as estimates of how salient or important each item is to the sample of informants.
In the present study, each respondent was asked “ what are all sexual health problems faced by
men in this community?" The answer to this question generated a large number of sexual health problems
by both the men and the practitioners. A variety of synonyms were used to in the case of some of the
problem. We therefore edited the list by grouping obvious synonyms under a common heading. The
examples of the problems which were grouped are as follows:
Masturbation: Hasthmaithun. muth mama, paani nikalana, hand practice.
1.
Bent penis problems: Tedhapan. ling ka mud jaana, Dahine ya baayi or muda ling.
2.
Sours on the penis: Jhakham. Phori. Phunsi. Foda.
3.
White discharge: Dhat girna, Apne ap dhatu gima, money ka gima, safeda.
4.
Loss of sexual desire: sambhog ki Eichha na hona. Sambhog na kar pana.
Data were analyzed and tabulated using ANTHROPAC
and discrepancies in spellings were
corrected before data entry.
Table 1 presents the frequency, response percentage, average rank and salience of the various
types of sexual health problems listed by men in community. Kamjori (Sexual weakness), Khujali (Itching
around genital areas), Peshab me Jalan (burning sensation during urination), Jaldi Girna (Early
ejaculation), Jhakham/Phori (Wounds on the genitals), and Dhat Girna (White discharge)) are among
the most frequently mentioned sexual problems.
Table 1: Free listing of male sexual problems by rqen in the community (N=56)
No.
1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
IT
-J
Sexual problems and local terms
Freq.
Resp.Pct.
Avg. Rank
Salience
Karnjori (Weakness)
Khujli (Itching)
Peshab Main Jalan (Burning urine)
Jaldi Girna (Early Ejaculation)
Jakham Hona/Fori /Foda (Wounds)
Dhat Girna (White discharge) ■
Echcha Na Hona (Lack of Desire)
Tedhapan (Bent penis)
Khada Na Hona (Lack of erection)
Hasthmaithun (Masturbation)
Dane Nikalna (Boils, sours;
Dhat Patla Hona (Thinning of semen)
Ling Main Dard/Sujan/Sujak (Pain)
Swapnadosh (Wet dream)
£armi (Heat)
AIDS
Pus Nikalna (Pus discharge)
Ling Se Khoon/Chamdi (Bleeding)
Hydrocil
Syphilis
Gonorrhoea
Chancroids
Herpes
35
53
31
30
28
28
27
17
17
15
15
14
13
11
11
10
9
9
8
7
55
54
50
50
48
30
30
27
27
25
23
20
20
18
16
16
14
13
9
4
2
2
3.914
3.484
3.467
4.464
3.786
3.370
4.765
4.706
4.867
3.800
4.071
5.308
4.636
4.455
2.700
3.778
3.778
5.875
5.714
2.800
1.000
3.00(>
0.285
0.271
0.294
0.212
0.251
0.312
0.155
0.135
0.111
0.149
0.113
0.084
0.085
0.108
0.120
0.094
0.094
0.058
0.041
0.039
0.036
0.011
0.007
2
1
4.000
It is interesting to note that although Kamjori and Khujali were the most frequently mentioned
items, dhat girna (Involuntary loss of semen) is upper most in the minds of men as revealed by the
measure of salience4.
Table 2 presents the frequency, response percentage, average rank and salience of the sexual
health problems listed by practitioners in the study area. Tedhapan (“bent” penis). Jaldi Girna (Early
ejaculation), Kamjori (Sexual weakness), Dhat Girna (Involuntary loss of semen), Peshab me Jalan
(burning sensation during urination), Gonorrhea, Khada na Hona (lack of erection). Pus Nikalana (pus
discharge). Syphilis, Jhakham/Phori (Sours on the genitals), were the most common sexual problems
faced by men
in the community according to the practitioners. It is important to note that although
mentioned by 68 percent of the practitioners, Tedhapan (bent penis) is assigned a very low rank and
therefore is low on the salience. Most salient sexual health problems were the Jaldi Girna (early
ejaculation), Kamjori (sexual weakness), Dhat Gima(White discharge) and Gonorrhea.
' Salience is calculated from the average rank and the frequency of a particular item.
Table 2: Free listing of male sexual problems by Practitioners (N = 44)
No.
1
2
3
4
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
T?
23
24
2n
Sexual problems and local terms
Freq.
Resp.pct.
Avg. Rank
Salience
Tedhapan (Bent Penis)
Jaldi Girna (early Ejaculation;
Kamjori (Weakness)
Dhat Girria (White discharge)
Peshab Main Jalan (Burning)
Gonorrhoea
Khada Na Hona (Lack of erection)
Pus Nikalna (Pus discharge)
Syphilis
Jakham /Fori /Foda (Sours/uicers)
Hasthmaithun (Masturbation)
Swapnadosh (Wet Dream)
Khujli (Itching)
Ling se Khoon/Chamdi (Bleding)
Ling Main Dard/Sujak iPain)
Sambhog Na Karpana (Lack of desire)
Dane Nikalna (Boil, sours)
Dhat Patla Hona (Thinning of Semen)
AIDS
Hydrocii
Garmi (Heat)
Dhat Ka Abhav (Lack of semen)
Herpes
Wans
Chancroids
30
27
25
68
61
57
52
. 52
52
48
45
45
43
39
34
34
32
27
25
20
20
16
14
9
5
5
5
5
6.467
4.333
4.160
3.522
4.783
4.174
4.714
4.500
4.400
5.842
5.294
5.267
6.467
6.714
4.333
5.273
4.667
4.778
6.429
6.333
3.500
4.000
7.000
5.500
3.500
0.208
0.367
0.351
0.341
0.285
0.309
0.257
0.279
0.243
0.167
0.182
0.175
0.094
0.107
0.135
0.133
0.111
0.099
0.041
0.048
0.050
0.033
0.000
0.027
0.027
77
73
21
20
20
19
15
15
14
; ">
9
9
6
4
-)
->
The basic contents of the two lists are same. In fact, both practitioners and the men are talking
about the same domain and put a lot of emphasis on non-contact sexual health problems. Both show
anxieties related to the sexual weaknesses, semen loss, penile size and impotence. There are a number
of differences also. For example, doctors give higher priority to Syphilis. Gonorrhea and Pus discharge.
That is. they are more concerned with the sexually transmitted infections. Men. on the other hand give
high priority to anxieties related to semen loss issues. Garmi, and itching problems and place less
emphasis on the several infectious or contact sexual problems. The big difference is observed in case of
Swapnadosh (wet dream) and Garmi (heat). In case of Swapnadosh, rhe difference is that of 14 points
with doctors giving it higher priority than the community men. In case of Garmi, the difference is of 9
points with men giving it a higher priority.
Listing of illnesses is one way of looking at the cultural perceptions. But the list does not tell us the
categorization of the sexual health problems. For this purpose we used the methods of pile sorting and
rating.
• Groupings of Sexual Health Problems:
From the list of the sexual problems we chose 23 of the more salient items for pile sorting. The
items were written on a set of cards (each item on aseparare card) and 49 males and 41 practitioners were
asked to group the sexual problems according to their similarity, without reference to any specific
criteria. The collected information was analysed by using the ANTHROPAC software. The combined
results of the pile sorting were analysed using the multidimensional scaling programme (MDS).
Figure 1, shows the results of the MDS analysis for the practitioners. It is found that swapnadosh
(wet dream;, dhargirna (white discharge), dhat patla (mining of semen), hasihmaithun (masturbation),
jaldi gima (early ejaculation) and echacha na hona (no desire for sex) are clustered together in the left
side of the spatial distribution (Group 1) while pus' nikalna, syphilis pus discharge;, gonorrhoea,
chancroids and herpes are clustered in the right side (Group 2). AIDS remained separate from the rest
of the problems. The above clusters clearly indicate some of the major domains of problems. Practitioners
have grouped rhe sexual problems that are non-infectious (Group 1) as quite separate from those that are
sexually transmitted infections (STIs).
In the case of men (Figure 2), it is found that Group 1 and Group 2 problems are somewhat
distinct, but the pattern is more scattered. In this figure also AIDS is emerged as a separate one and some
extent syphilis also did not group with any other illnesses. It is clear from the above results that
practioners. tend to group sexual problems in broad domains and perhaps have tretmenr strategy in their
mind while categorizing. They of course place due emphasis on the semen related issues. Men. on the
other hand, group the problems in a number of different categories. Among both the types of respondents
peshab main jalan (burning urination) appears somewhere in between infection oriented and non infection
oriented problems.
Funher. the groupings of sexual problems by both practitioners and men. were further analysed
using cluster analysis technique. (Figure 3 and Figure 4). The clusters tend to support the observations
obtained on the basis of multi-dimensional scaling.
Severity of Problems:
We also asked the respondents to rate the severin’ of these problems. We asked them to rate
the severity on a four point scale ranging from "not at all severe” to "ver}’ severe”, with "somewhat
severe” and "severe” in between.
Table 4. Severity Rating of Male Sexual Problems’ (Males=49)
Sr.No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Item
Mean
Std. Dev.
Bent Penis
Early ejaculation
Weakness
Burning urination
Gonorrhoea
White discharge
Lack of erection
Pus disvcharge
Syphilis
Boils/sours
Masturbation
Wet dream
Itching
Swelling
Lack of desire
Boils
Thinning semen
AIDS
Hydrocil
Skin sours
Heat
1.86
2.02
2.10
2.29
3.24
2.27
2.27
2.78
3.35.
2. J /
1.55
1.37
2.14
2.31
1.98
2-24
0.83
0.80
0.61
0.73
0.74
0.75
0.80
0.74
0.66
0.72
0.83
0.63
0.86
0.61
0.80
0.80
0.81
0.42
0.59
0.60
0.96
I
3.94
2.02
2.39
i 33
Findings are presented in Table(s) 4 and 5. .AIDS was uniformally rated as very severe.
followed by syphilis and gonorrhoea. Pus discharge was also seen as severe. Most of the non-contact
problems tended to be rated as less severe by both the practitioners and the community males. It is
interesting to note that the practitioners on the whole rated most conditions as less severe than did
their clients.
Table 5. Severity Rating of Male Sexual Problems (Practitioners=41)
Sr.No
1
?
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Item
Bent Penis
Early ejaculation
Weakness
Burning urination
Gonorrhoea
White discharge
Lack of erection
Pus discharge
Syphilis
Wound
Masturbation
Wet dream
Itching
Swelling
Lack of desire
Boils
Semen thinning
AIDS
Hydrocil
Skin sour
Heat
Herpes
Chancroid
Mean
Std. Dev.
1.73
1.73
1.68
2.10
3.00
1.71
1.85
2.85
3.15
2.34
1.71
1.54
1.78
2.39
1.90
2.27
1.85
3.98
1.71
2.34
2.24
3 97
3.32
0.80
0.80
0.60
0.76
0.86
0.86
0.75
0.84
0.72
0.90
0.80
0.74
0.78
0.66
0.85
0.86
0.84
0.15
0.71
0.84
0.96
0.80
0.68
/
Perceived Causes of the Sexual Health Problems as reported bv the Practitioners:
During the in-depth interviews, we asked the practitioners about the causes for several of these
sexual health problems and also the possible treatments.
KAMJORI: Sexual weakness Kamjori is a general concept that appears to be very salient for
both practitioners and lay persons. Kamjori refers to a wide range of symptoms, including impotence
inadequate quantity and quality of semen, and infertility among men (Table 6). According to one doctor,
kamjori begins with the practice of masturbation at a very young age. “Children start hand practice at
a very young age and gradually begin losing large quantities of semen. As a result, they feel weak and
over a period of time, become impotent or karnjor". The quantity and quality of semen appears to be
at the root of the kamjori. Most doctors clearly stated that with frequent masturbation, the quantity of
semen reduces and semen becomes thin. Thinning of semen was also attributed to food habits. For
example, according to one doctor, “hot foods, which include spices, onions, liquor and even English
medicines, produce excessive heat (sexual) in body and result in involuntary loss and thinning of semen”.
Male sexual Problems, their local terms and the perceived causes as reported by
doctors in a slum of Mumbai
Perceived causes
Local Terms
Male Sexual Problems
Intercourse without Condoms;
1. Boils, Sores, Pus or blood
Garmi, Sujak,
Use of public toilets;
Foda/Phunsi.
in the urine, ulcers around
Anal sex/homosex/oral sex;
genital areas.
Sex with “cheap” women..
Excessive sexual desire;
Excessive masturbation;
Dhat Gima, Loss of
Watching Blue films;
money, Beej gima
2. White Discharge
Sexual excitement;
Stomach problem (Gastric).
Swapnadosh;
Dhat patla hona, Dhat ka
1. Thinning of semen/
Excessive masturbation;
abhav
reduction in semen
Eating ‘hot foods’/Iiqour;
quantity
Garmi inside body.
Wrong company;
Muth mama, Hand
Exposure to sex magazines and films:
practice, Hasthmaithun
1. Masturbation
Suppression of sexual desire;
It is a illness to satisfy one’s own
sexual desire.
Excessive masturbation;
Swapna dosh
Exposure to sex magazines and films:
1. Wet dream
Unsatisfied sexual desire.
Jaldi Gima,
Ignorance about the sex;
Excessive masturbation;
Money gima
1. Early ejaculation
Mental problem;
Thinning of semen:
Ling ka khada na hona:
Thinning of semen:
7. Lack of erection
Ling ka kamjor hona.
Excessive masturbation:
,
Excessive swapnadosh:
Weak Muscles of penis;
Excessive sexual intercourse.
Table 6:
Early ejaculation and lack of erection was attributed to the excessive masturbation (once or twice a day)
and poor quality of semen. The high and sacrosanct value which is attached to semen can be gauged from
the fact that semen or Veerya was often referred to as money. One doctor summed up the importance
of semen by drawing similarities between a poor man who has no money and a sexually weak person who
has no semen. “One hundred drops of blood produce one drop of semen” was the common statement of
doctors, who believed that masturbation and excessive sexual heat (garmi) lead to their loss. Doctors
treated men for the thinning of semen with the help of a variety of Ayurvedic and Unani medications.
Some of the important sexual problems, their local terms and their perceived causes as reported
by practitioners are summarized in Table 6. It appears that masturbation is clearly singled out as one
of the problematic behaviours that leads to various forms of sexual problems associated with Kamjori.
Masturbation or ’excesaivu maatureacion", was inuughi to b« c*u*«4 by wrong company, “exposure to
sex magazines and films (even Hindi films) and suppression of sexual desires; Practitioners clearly
thought that the masturbation is a kind of illness and is a cause of several other problems.
GARMI; heat Garmi is yet another problem which indicates the prevalence of STDs among
men. Sores and various forms of pus discharges and appearance of boils and pimples are thought to be
representing Garmi. They however think of its etiology very differently than it is conceptualized biomedically. As mentioned above, excessive sexual desire results in the involuntary loss of semen and may
also be manifested in the forms of boils, sores or ulcers around the penis and genital area. Use of public
toilets, sex without condoms, oral and anal sex and sex with “cheap” women are also considered as
important reasons for garmi Garmi is generally considered a serious illness.
Treatment of Sexual Problems:
In keeping with the perception of the basic causes, the sexual problems, are treated by the
practitioners using a variety' of concoctions, aphordiasics and even standard antibiotics. Table 7 presents
treatments suggested by the practitioners for various sexual problems. The Problems considered here are
those which appeared salient from the earlier analysis. The treatments include a large number of
concotions including a number of modern medicines. Persons are treated even for masturbation and early
ejaculation. The extent of anxiety related to semen quantity and quality can be guaged from the fact that
a large number of aphordiasic preparations are provided by the practitioners.
Conclusions:
According to Indian tradition (writings in ‘Upanishids’) the term ‘Vim’ stands for both ‘Vigour’
and ’Semen’ (Nag. 1996). It is considered the source of physical and spiritual strength. The loss of Virya
through any sexual acts or imagery ( including Masturbation, swapnadosh. etc.) is considered harmful
both physically and spiritually. According to metaphysical physiology, food is converted into semen and
there are many beliefs and practices prescribed to preserve and enhance the quality and quantity of semen.
Given this background it is not surprising that semen loss in some form seems to be a major health
concern among the men in Mumbai slum area.
ACKNOWLEDGEMENT
We gratefully acknowledge ±e financial support received from the Ford Foundation for this study. We
are particularly thankful to Dr. M. Koenig, Programme Officer, Ford Foundation, New Delhi for his
support during the conduct of this study.
Table 7: Treatments offered by Practioners for a group of Sexual problems.
Problems
Boils, Sores, Pus or blood
in the urine, ulcers around
genital areas.
Local Term
Garmt, sujak.
Parma. Gagkran,
Phodi. Miyad Ana,
Pesab me jalan
' White Discharge
Dhat gima, Mani
Jana. Beej gima
Thinning of semen
Masturbation/penile
abnormalities
Swapnadosh
Early ejaculation ,
Lack of erection
Kamjori
Gonorrhoea, Syphilis
Dhat ka abhav, Beer
kam niklana, Mani
Patla hona, Beer
patla hona.
Mootrmama,
Motthi. Hathbhani, ti
Hathchlana
Chaddigeela hona,
Jhaldi gima, Chaddi
kharabhona,
Malgima
Jaldi gima.
Kamnakarpana,
Manijaldi gima.
Ling ka khada na ho
pana. Sambhog na
kar pana. Sambhog
me safal na ho
pana.
Treatment5
Norfloxin, Doxycycline, Penicillin, Candid
ointment, Incidat tab. Concoction prepared
out of: Suvarn Makardhawaj*,
Chandraprabha vati*, M. Saline,
Alkasoal*, Moos*, Satawar*,
Vidharikand*, Moosli*, Samelata”.
Kursjiryan tab*. Shilajeet cap*.
Chandraprabha vati.
Shilajeet tab. Spemanfort, Kursjiryan tab.
Majon Mogleenamani, Suparipak, Majoon
ardkurma, Lavive kabur jelly, Maullaham
Khas, habekhas.
Sioton, Suvem bhasm, Heerabhasm,
Chandibhasm,
Tila : Ointment
veergoti.parateen.junjunastr.regmare, for
massage. Herbal (Concoction prepared out
of: saiadmoosli,
sataver,vahmanshastra,safadvidharikand,Iaj
vanti.duknugokru.ka ras,trifala
Brahmnivati tab/syrup, Shilageet cap.
Shilajeet tab. Spemanfort, Kursjiryan tab.
Suparipak, Chandraprabha vati.
Aphoradiasic
Suvarnmakardhwaj.siyotone,brahmnivati.no
rflox.chandraprabhavati,majon
suparipak.majon
Mogleenamani, Jatifaladivati.tentexfort.himc
olin cream,speman coat,Tilaysurkhay,rogan
perateen,majon ardhkurma
Majon awar-a-kurma,Majon Sharab-aawar,General tonic.Vitamin B complex.
Norploxin, Doxycycline, Concoction
prepared out of: Moos, Satawar,
Vidharikand, Moosli, Samelata.
5 The treatments mentioned by the doctors include a wide range of ayurvedic medicines as well as other nonallopathic materials. We have not made inquiries into the active ingredients in those preparations.
References:
1.
Gittelsohn, J.M, M. Bentley; P.J. Pelto; and L. Landman (1994) (Eds.) Listening to Women Talk
about lheir Health: Issues and Evidence from India. The Ford Foundation, New Delhi.
2.
Bang A, and R. Bang (1989) High Prevalence of Gynaecological Diseases in Rural Indian
Women. The Lancet, January 14.
3
Bhatia, J and J.C. Cleland (1995) Self Reported Symptoms of Gynaecological Morbidity and
Their Treatment in South India, Studies in Family Planning, Vol. 26, No.4 July/August 1995.
4
Grenon, Marie-Claude and Tazeem Mawji. (1996) Men’s Perception of Illnesses of Nether Areas,
Working Paper, Sarathi, Gujarat.
5
Pelto (1996). Sexual
Communication)
6
Bang A. and R. Bang (1997). Findings on the Reproductive Tract Infections among males
presented based on a study in progress at Gadchiroli in a Workshop oh Involving Men in
reproductive Health programme, held at Baroda. May 31. 1996.
7
Nag M, (1996). Sexual Behaviour and AIDS in India, Vikas Publishing House. New Delhi.
S
Weller, S.C.. and Romney, A.K., ""Systematic Data Collection (1988)”, Qualitative Methods
Series. No. 10. Newbury Park, CA: Sage Publications.
Health problems in Bangaladesh,
Study in progress. (Personal
Figure 1, Cognitive Map of Male Sexual Problems (Males=49)
Dim 2
3
6
KA17 DHATPATLA
DHATGIRNA
PESHA3JALAN
18 AIDS
-0.60
9
SYPHILISEA
8 PUSNIKALNA
20 CHAMOI
21 GARH113 KHUJL!
10 JHAK16 DANE
-0.90
Stress in 2 dimensions is 0.132
12 SWAPNADOSH
11 HASTHHAITHUN
2 JALOIGIRNA
1 TEDHHAPAN 15 ECHC
19 G0LI7 KHA
14 SUJAN
Figure 2, Cognitive Map of Male Sexual Problems (Practitioners=41)
■3 KHUJL1
16 DANEJHAKAM
14 SUJAH
12 SWAPNADOSH
6 DHATGIRNA
17 DHATPATLA
11 HASTHMAITHUNI
2 JALDIGIRKA
15 ECHCHA NAA HCNA
19 GOLI
TEDH
Stress in 2 dimensions is 0.081
4
PESHA3JALAN
3 P9 SYPHIL
5 GONORRHO
23 CHANCROI
22 HERPES
21 GARHI
JOHNSON'S HIERARCHICAL CLUSTERIMG (Doctors)
HIERARCHICAL CLUSTERING
5 8
2
3
p
9
E
G
P
C
S D S
3 0 J
1 2 S 1
2 OU
AAETHWDT
100H3
22NS S A
L £ H A A H E
A
11
ON
XHDHMTPAD1 14
J C 8 K 6
HRI
A A I C A G N T H 9 8
SHHJH
GERK H R
M
G H I I A P H
JHIATRDAAG A U A A A U 0 A R H A I O
0 0 R
HNOTPO I J .< M L J A R P O L L I
RNNNUASLAL D A A D A L N H E E N
• A A A N
HANI S/N H I N I E I S A A s s
K 2
6 1
H
1 H
2 11
i
Level
: 1
11
1 1112
2
112 2
3 7 2 5 1 6 2 7 1 9 84004361258 9 3
0.8293
0.7317
0.7073
0.6341
0.6179
0.6098
0.6043
0.5772
0.5637
0.5285
0.4878
0.4569
0.4228
0.3584
0.3333
0.2989
0.2862
0.2055
0.0432
XXX
XXX
. . XXX . XXX . . .
............................XXX XXX
. . XXX . XXX . . .
.... XXX .. XXX XXX
. . XXX . XXX . . .
. . XXX . XXXXX . .
.... XXX .. XXX XXX
XXX XXX . XXXXX XXX
.... XXX .. XXX XXX
XXX XXX . XXXXX XXX
.... XXX . . XXXXXXX
XXXXXXX . XXXXX XXX
.... XXX . . XXXXXXX
XXXXXXX . XXXXX XXX
.... XXX . xxxxxxxxx
XXXXXXX XXXXXXX XXX
.... XXXXX xxxxxxxxx
XXXXXXX XXXXXXX XXX
. XXX . XXXXX xxxxxxxxx
XXXXXXXXXXXXXXX XXX
. XXX . XXXXX XXXXXXXXX
XXXXXXXXXXXXXXX XXX
. XXX XXXXXXX XXXXXXXXX
XXXXXXXXXXXXXXX XXX
. XXX XXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX XXX
XXXXX XXXXXXXXXXXXXXXXX
xxxxxxxxxxxxxxxxxxx
XXXXX XXXXXXXXXXXXXXXXX
xxxxxxxxxxxxxxxxxxx
XXXXXXXXXXXXXXXXXXXXXXX
xxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
JOHNSON'S HIERARCHICAL CLUSTERING (Males)
HIERARCHICAL CLUSTERING
0.6735
0.5913
0.5714
0.5573
0.5356
0.4893
0.4694
0.4C32
0.3312
0.3673
0.3342
0.307:
0.2721
0.2573
0.2171
0.1879
0.1715
0.1126
XXX . XXX
.XXX
XXX . XXX
.XXX
XXX . XXX .... XXX .
.XXX
XXXXX . XXX .... XXX .
. XXX . . . XXX XXXXX . XXX .... XXX .
. XXX . . . XXX XXXXX . XXX ... . XXXXX
. XXX . . . XXX XXXXXXX XXX ... . XXXXX
. XXX . . . XXX XXXXXXX XXX . . XXX XXXXX
XXXXX ... XXX XXXXXXX XXXXX . XXX XXXXX
XXXXX . XXX XXX XXXXXXX XXXXX . XXX XXXXX
XXXXX . XXX XXX XXXXXXX XXXXX . XXXXXXXXX
XXXXX . XXX XXX XXXXXXX XXXXX xxxxxxxxxxx
XXXXX XXXXX XXX XXXXXXX XXXXX xxxxxxxxxxx
XXXXX XXXXX XXXXXXXXXXX XXXXX xxxxxxxxxxx
XXXXX XXXXXXXXXXXXXXXXX XXXXX xxxxxxxxxxx
XXXXXXXXXXXXXXXXXXXXXXX XXXXX xxxxxxxxxxx
XXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXX
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
CONSENSUS .ANALYSIS
Males
|
RATIO
FACTOR
VALUE
PERCENT
CUM %
1
2
23.504
1.407
1.218
26.129
90.0
5.4
4.7
90.0
95.3
100.0
16.708
1.155
!
100.0
Practitioners
i
|
FACTOR
VALUE
PERCENT
CUM %
RATIO
i
1
>
-)
20.906
2.512
1.455
84.1
10.1
5.8
84.1
94.2
100.0
8.323
1.727
24.873
100.0
3
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