Primary Health care and Family Planning Programme in Rural Gujarat: Some Issues
Item
- Title
- Primary Health care and Family Planning Programme in Rural Gujarat: Some Issues
- Date
- 1987
- extracted text
-
■a
COMMUNITY
CELL
47/1,(Tirst. IToariGi. Marks Road
UANGALORE - 560 001
Primary Health care and Family Planning
Programme in Rural Gujarat : Some Issues.
In the post 1961 are fertility control seems to have become
the main objective of the health plans in India shadowing
the efforts to contain morbidity and mortality among the
population in general and infants in particular. Plan
allocations for the Family Planning (FP) programme jumped
from Rs 22 million in the second Five year (FY) Plan to
Rs 2*+9 million in the Third FY Plan - more than 10 fold
increase *. During the Sixth FY Plan - the allocation was
Rs 10,000 million. The share of FP programme in the
total health plan outlay increased from 1.5*+ percent
during the second FY Plan to 35-67 percent during the
Sixth FY Plan. (Appendix Table 1). Such a massive
allocation for FP Programme at the Centre obviously had
an impact on the state plan expenditure on FP programmes
in the states. Gujarat, too, experienced a steep rise
in the central allocations for the FP' Progtamme since the
beginning of the Fourth FY Plan. During the first, second,
third FY Plans and the three annual plans (ending I96S-69).
The Gujarat state plans allocated modest sums for the FP
programme (not exceeding 3*5 percent of the total states
health plan outlays). From 1969 onwards almost entire
allocation, constituting 37 to 55 percent of the state's
total health plan outlays, started flowing from the centre.
The seventies and eightees witnessed piethore of FP
compaigns, drives, camps, prestige camps etc. in Gujarat
to achieve the targets set for sterilizations and other
methods of fertility control. Not only that hundreds of
FP centres and sub-centres were created and manned by
doctors and other para-medical staff in all parts of the
state, the primary health machinery, village, taluka and
district level machinery including teachers, officials
non-officials etc. were geared to work for achieving
the FP targets set by the Centre. Persuation overt and
convert pressures and all types of tactics were and are
being used to achieve the targets.
Background paper for XIII Annual Meet of the MFC at
Udaipur 26-27, January 1987. Prepared by Sudarshan
Iyengar and Ashok Bhargava.
...2....
2 That there is an urgent need for a comprehensive health
the family welfare, programme in the state is known.
Relatively high infant mortality, generally poor health
conditions of pregnant women, lactating mothers and all
other women in generail and inability to create effective
demand for primary health care services necessitate the
state’s intervention in creating health and family welfare
facilities at the door step of the poorer sections
of the population. How far the government has been able
to achieve in last 20 years needs a proper review and
assessment. The scope of present discussion is mainly
limited to a review of family planning programme in the
state. Nevertheless, the review on FP programme itself
will have definite bearing on other facets of primary
health care and the paper intends to bring forth relevant
issues in that regard too. Specifically the objectives
of the paper are the following.
a.
b.
/
bo present a briefi review of the health and FP
programme in Gujarat and examine the likely future
trend; and
to show the neglect of primary health care consequent
upta the emphasis on FP programme in Gujarat.
The paper is divided into three sections. The first
section discusses the theme and objectives of the paper.
In the second section a review of physical and financial
aspects of health and FP programme are presented. In
the third and final section relevant issues are raised.
Health and Family Planning Programme in GujaratAn Overview:______________ :__________________
As stated earlier, direct efforts to check the population - .
growth in Gujarat started with the beginning of the fourth
FY plan. The draft fourth FY plan of the Government of
Gujarat states "rapid growth of population has the effect
of diminishing the impact of economic growth. During
1951-61, the population of Gujarat registered a growth of
26.88 percent or 2.7 per annum against the all India, growth of
21.5 percent or 2.2 per annum. The rapid growth points
to the need for intensifying the measures for controlling
the growth of population through family planning methods.
...3....
3 High priority, therefore, needs to be accorded to the
Family Planning Programme. This will be fully centrally
sponsored scheme in the Fourth Plan". The financial
allocations for the FP programme thus experienced a
spurt from the fourth FY Plan. The financial outlays
for health and FP programme during plan periods for
Gujarat are presented in Table.
Following observations may be made on the basis of
Table 1.
1.
Control of communicable diseases was the single most
important plan component till fourth FY plan and
since then it was relegated to second place.
2.
Almost one half of the total Plan outlays (all plan
outlays taken together) has been allocated for FP
programme.
3.
Building new Primary Health Centres (PHCs) and stren
gthening old ones received third priority largely due
to minium needs programme (MNP). About one seventh
of the total Plan Outlays (all plan outlays taken
together) has been allocated for MNP. It should be
mentioned that from sixth FY plan onwards MNP included
a major outlay for multi-purpose health workers
scheme- with an objective to integrate the services
of vertical programmes like maleria, TB,? Control etc.
into primary health care at village level.
Both the control of communicable diseases and the FP
programme are centrally sponsored. The formed programme
was fully centrally sponsored till the sixth FY plan.
Since then the state has to provide JO percent of the
total outlay for the programme. The FP programme is
almost fully centrally sponsored. The state provides
a very small portion for FP for incentives to the accep
tors and motivators. Table 2 shows the centre's
share in the total health plan outlay.
3
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Columns 5 and. 8 show the share of centre and the state
respectively to the total health plan outlay. It may
be observed that centre's share has been more than
60 percent since the Annual Plan Period. The centre's
share is very high mainly due- to the allocation for the
FP Programme. It may be of some interest therefore to
examine changing priority of the health programme in
the state's total plan allocation for all the programmes.
Table 3 below shows the changing share of health plan
allocation to the total sat state plan.
It may be observed that the share of health plan alloca
tions show
a falling trend since Annual Plans, If
one excludes FP programme, the falling share is more
pronouncely evident. During the seventh^FY plan the
share of allocation for health programme shows an all
time low of 2.5 percent to the total plan allocation
in the state.
ft
Let us now turn our attention to the physical achieve
ment in the field of health as well as FP programme. For
the purpose of this discussion we shall mainly report on
the status in rural Gujarat. Table L- below contains
information on some of the physical health infrastructure
in Gujarat.
9
- 9 Table 3 : Share of Health and FP Allocations to the
Total State Plan Allocations During Plan
periods.
(Rs. in Lakhs )
Plan Periods
State
Plan
Outlay
Allocation for Health Plan
Including
FPP
Excluding
FPP
Second FY Plan
26,62*+
(100)
1003
(3.8)
1,002
^3.8)
Third FY Plan.
2*^385
(100)
1,652
’ .6.8)
1,602
Annual Plans.
20,810
(100)
8?2
(>+.2 )
8*+*+
(*+.l)
Fourth FY Plan.
50, *+39
(100)
*+,500
(8.9)
2, *+15
(*+.8)
Fifth FY Plan.
122,19*+
(100)
6,111
3,711
(3.0)
Sixth FY Plan.
376,000
(100
18,0?l
(4-.8)
11,309
(3.0)
Seventh FY Plan
600,000
(100)
33,58*+
(5.6)
15,060
(3.5)
(£.0)
U.6)
Source: Figures in parantheses indicate percentages.
The data in Table *+ permit the following two observations •“
1. The pace of establishing PHCs and various types of
sub-centres picked up with the beginning of the
third FY Plan.
2. FP sub-centres constitute a major share in the total
number of the sub-s centres.
....10....
/
10 -
Table 9- • Establishment of Primary Health Centre
and Sub-Centres in Gujarat.
PHO
Period
MCH
Beginning of 1st FYP
2nd
j j
6
MNP
Sub Centres
1
FP’
Total
18
18
96 288
288
FP as
% to
Total
9-26
260
686
61.0
Beginning of Three
Annual Planning
29-9- 732
390
1082
32.3
Beginning of 9-th FYP
291
786
13*+
1000
1920
92.1
291
786
139-
1000
1920
92.1
291
886
139-
1000
2020
9-9.9
291
986
139-
1600
2720
98.8
19-2
3rd
9th
6th
* As on March 1983
*
? 5
25 more PHCs have been sanctioned under MNP that are
not included in the figures on PHCs.
S ource:
Health Statistics of Gujarat 198*+.
The Government of Gujarat has. accepted certain norms for
providing the physical infrastructux-e. W° present below
in Table 9 the norms and the actual statue usinsr 1981
t
jAwsioei a ch i o->—■"ee.int’t J 981 rural
population which was 239»O'iThf>i. persons.
....1....
- 11 -
Table 5 : Norms and Actual Status of Health
Infrastructure in Hural Gujarat.
Actual Status
Norm
Particular
Upgraded PHO
1:
100,000
1:
19,50,000
PHC
1:
30,000
1?
93,000
Sub-Centres
1:
5,000
1:
8,600
Community Health
Volunteers (CHVs)
1:
1,000
1;
1,286
Sources Health Statistics of Gujarat 1981+ (for norms
and Number of Establishments).
It may be observed that the gap in the availability of
health infrastructure widens as one moves towards the
upgraded facilities. The establishment of sub-centres
appears to be near the norm largely due to the FP sub
centres which constitute 58.8 percent of all types of
sub-centres. Assuming that the FP sub-centres catre
only to FP services the ratio of other sub-centres to
the population works out to the is 21,000'.
Target and Achievements of. FP Programme in Gujarat s
The
major flank of the FP' programme in Gujarat is fertility
control through by and large terminal method. The pro
portion of couples currently protected during a given
year seems'to have'-increased substantially since
1966.67. Table 6 contain the relevant information.
....12....
12 -
1.
Couple protection through terminal method i.e.
sterilization, has generally risen steadly, over
years. However, within a span of 17 years (1966.67
to 1982-83) two years may be noted for sharp incre
ase 5 the year are 1971-72 and 1976-77.
2.
The proportion of couples currently protected during
any year through spacing method has been very low com
pared with the terminal method. The couples prote
cted through IUD have been fluctuating with in a range
of 0.9 to 2.1 percent of the total estimated eligible
Jk
couples. The proportion of couples protected through
conventional contraceptive (CC) methods have been
fluctuating over a relatively larger range of 0.8
to 3.9 percent. What is apparent- from Tanle 6 is
that the efforts to control fertility have been
largely concentrated on terminal method rather than
on spacing method. This particular aspect in further
confirmed when one looks at the FP Acceptors' profile.
The data are given in Table 7•
1.
Reading‘Table 6 and 7 together for terminal method
one can note some inconsistency which is not explained.
The number of acceptors of terminal method rose sharply
in 1967.68, 1971-72, 197^-75 and 1976-77 (Table 7).
However the number of couples currently protected
through terminal method (Table 6) rose sharply only
in two years viz. 1971-72 and 1976-77. One fails to
understand as to how the large relative‘increases in
1967-68 and 197U--75 were absorbed.
...13....
- 13.
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- 1>+ Table 7 : Methodwise Number of Acceptors in
Gujarat by year.
1
Year
Icrminal
Spacing
50
85
101
95
95
295
97
60
237
252
66
61
66
72
86
136
90
96
128
208
228
185
251
208
225
227
283
180?
17^5 . ■,
1966.67
1967.68
1968.69
1969-70
1970.71
1971- .72
1972- 73 >
1973- 7^
1975-75
1975- 76
1976- 77
1977- 78
1978- 79
1979- 80
1Q80-81
1981- 82
1982- 83
Total (1971-72
to’ 1980-81)
All India Average
for (1971-72 to
1980-81)
155
153
317
112
197
220
201
Ratio
is
is
is
is
IS
IS
is
' is
is
is
is
1$
. is
is
is
is
is
1.65
0.72
O-,65
0.77
0.91
0.56
0.93
1.60
0.83
1.35
0.72
1.65
1.22
0.95
1.12
0.96
1.17
1: ■
0.96
1:
l.h-5
Sources 1. Health statistics of Gujarat 1985.
2. Diagnostic study of Population Growth
Family Planning and Development, Gujarat
1971-82, P. 55, for All India Estimates.
o
-15 2. It is established beyond doubt that the emphasis
by the Gujarat Government has been on terminal
method rather than the spacing method.
Assuming for a moment that the emphasis on terminal
method of family planning was correct in the context of
high fertility rate in Gujarat, it would be of some
interest to examine the profile of acceptors of terminal
method in Gujarat. We present below two characteristics
of acceptors that will reflect upon the possible impact
on fertility. The two characteristics are age of wife
at the time of acceptance and. the number of living
children.
Table B ; Percentage of Acceptors of Terminal
Methods Above 30 Years of Age-Gujarat.
Year
1974- 75
1975- 76
1976- 77
1977- 78
1978- 79
1979- 80
1980- 81
Vasectomy
■59.8
43.3
60.6
55.8
60.4
58.3
55.1
Tubectomy
58.2
59.2
54.1
51.9
56.3
56.8
53.8
Weighted*
Average of
Vasectomy and
Tubectomy
58.5
56.0
55.4
52.7
57.1
57.1
54.1
* IWe have used 0.8 and 0.2 as weights for Tubsectomy and
Vasectomy respectively,. They are the actual weights
for the year 1981-82.
Source: "Diagnostic Study of Population Growth, Family
Planning and Development in Gujarat". The
Family Planning Foundation Study 1984. p.62.
....16....
- 16 -
It may be observed that the intensive efforts to moti
vate couples for sterilisation has resulted in acceptance,
of the method largely by couples where wife's age has
crossed 30 and the couple already has >+ or more living
children. This group constitutes 50 percent of the
total sterilisations performed over number of years
since 19'7’1-4— 75. Rambadhran categorically states, "the
tubectomy programme (in Gujarat) is still focussed on
women with high parity, U + which could be cases of
'complete family'
Table 9s Percentage of .Acceptors of Terminal Methods
with U or More Living Children - Gujarat
Year
Vasectomy
Tubectomy
Weighted*
Average of
Vasectomy and
Tubectomy
1977-78
IkL.8
57.7
Jif-. 6
1978-79
UO.6
57-5
5^.1
1979-80
36.7
57.8
53.6
1980-81
36.7
57.8
53.6
1981-82
37.7
51.5
14-8.7
* We have used 0.8 and 0.2 as weights for Tubectomy and
Vasectomy respectively. This are the actual weights
for 1981-82.
Source: Same as Table 8.
1Z Rambadhran V.K. "Diagnostic Study of Population
Growth. Family Planning and Development Gujarat"
November 19814— p. 63.
....17....
- 17 -
The characteristics of the acceptors thus show that
the emphasis on fertility control efen if carrect, is
likely to have had a very limited impact on fertility
control.
Such a lop.sided performance may now be viewed in the
context of financial allocations on health in general
and FP programme in particular. Earlier we have shown
relatively higher increases in the planned expenditure
on FP. We now examine the trend in per. capital expen
diture on FP during different plan periods. Table 10
contains the details.
Following observations may be made on the basis of
Table 10.
1.
Per capita expenditure has increased both for health
as well as family planning, but overall increase has
been more rapid for family planning. The changes
between sixth and seventh five year plans deserve
special attention. Per capita allocation during the
seventh plan period is more than the- per capita
allocation for all programmes of health. Viewed in
the context of lopsided approach of the FP programme
in Gujarat, such a significant increase in allocation
for FP programme should be a cause for concern.
2.
Allocation to FP programme implies allocation for
eligible couples (With the hope that the FP drive
would leave alone the singles, unmarried, old and
the children'.).
We thus calculated the allocations
....18...
18
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S
-19 Per eligible couple which shows that the allocation
since fourth five year plan has been much higher
than the per capita allocation for all the health
programmes taken together.
3.
Assuming that the actual expenditure in almost
equal to the allocations made, we have estimated
the amount likely to have been spent after each
protected couple. Date on protected couple by
year from 1966-6? to 1982-83 and estimating figures
for the year upto 1990, we have worked out the
allocation for each protected couple. The rise in
the allocation per currently protected couple is
astronomical. One is tempted to go a little
o
further and perform some more arithmetic on these
figures. Of the currently protected couples in
any year, 90 percent are protected through terminal
method i.e. sterlisation. Further, the records
suggest that atleast 50 percent of the sterilisations
have been performed on those couples who fall in the
category of 'complete family'. The money spent on
those couples are less likely to make any positive
dent on fertility control that has been the avowed
policy of the government of Gujarat. In effect the
actual expenditure on each protected couple is to
be read as double the amount reflected in row 'C'
of Table 10.
The argument may have been stretched a little too for
but the point ope wishes to make is that FP programme
in Gujarat should be considered a failure even judging
through government's own objective of fertility control.
One more aspect that needs attention at this stage
relates to the method of implementation of FP pro
gramme . It is generally' contended that the programme
is for family welfare and not for family planning and
hence it Is only motivation through which the FP
methods are pushed. Under such relaxed circumstances
one would expect that the acceptors would by and large
belong to relatively more literate class with better
socio-economic conditions. The tables belovt will indi
cate that it is not so. Table 11 below gives the per
centage of couple that are covered by sterilisation by
district for the years 1980 and 1983.
....20...
1
30 The list of districts in Table 11 m has been serialised
by the conventional regions, Kachchh, Saurashtra (2 to
?), central Gujarat (8 to 11), North Gujarat (12 to D+)
and South Gujarat (15 to 18). Gandhingar belongs
to Central Gujarat but we have listed it at the end
since it has only one taluka consisting of a few
villages and it is the capital town of the state.
One can clearly see that the coverage in South Gujarat
districts is highest. A special feature of the dist
ricts in South Gujarat is that all of them are partially
or fully tribal and socio-economically backward. Obvi
ously one would not be required to go through the Census
volume to check for the literacy rate in general and
female literacy in particular. It may be alleged that
the government functionaries are pushing the sterili
sation into tribal areas taking advantage of the poverty
(through incentive) and ignorance (overt and covert
presures). The question is? how far such steps are
justified?.
Two districts Dangs and Gandhinagar deserve special
attention. They are comparable in one major respect.
Both are one taluka districts. The Dangs in located
in the remotest south-west corner of the state and it
is inhabitated by tribals alone. The facts reagarding
the abject poverty over there is well known. Gandhi
nagar is located centrally adjoining Ahmedabad and
22% population lives in the state capital. How is it
that official machinery can not motivate couples in
villages spread within a radius of 10 kms where as the
couple protection in remote Dangs is as high as 57
percent - double the rate of the one obtained for
Gandhinagar? Another dis trict which has gained popu
larity on the success count of FP programme in
Gujarat is Bharuch. The district and state officials
are never tried of quoting statistics on this district.
It has turned into a showpiece which has been put on
display byofficials for the outstate visitors and
visitors from centre. The district has a large popu
lation of tribals and acceptance of FP is more among
them due to abject poverty.
....21....
21 -
One should not be surprised to find number of cases
where both the husband and wife have been sterilised'.
The analysis is sufficient to establish that the FP
programme in Gujarat is basied in approach, implemen
tation and performance. It seems to be providing expen
sive and to a great extent ineffective (in relation to
what it sought to achieve). With a two and a half time
increase in allocation in seventh plan over the sixth
plan, some basic issues will have to be resolved.
That the Gujarat has historically high fertility rate
and that the population pressure is likely to adversely
effect the efforts to improve socio-economic conditions
is well taken. However, one should think for a rational
approach to the problem rather than a hurried and baised
approach of fertility control.
The desire to have more* children is a result of (a) total
uncertainty regarding the survival of children atleast
upto the age of 5 and (b) lack of adequate opportunities
for livelyhood. Coupled with these are the socio-cultural
traditions all of which cultimate into the desire,
for having more children. At the conceptual level
atleast the Health and Family Welfare Programme is
designed to take adequate care of the first factor
namely improving the child survival and other health
* By more children one does not mean any number of
children. The couple and/or family does seem to
consisder various factors in determining the size of
the family. An all India survey conducted by
Operational Research Group (ORG) Baroda, in 1982
on attitude of people towards FP and composition of
families etc. came out with a finding that 82 per
cent of the respondants considered small family to
be happy family-small being 3»2 children and large
being m-c8~ children.
.. . .22...
* V
-22 aspects. However, in implementations overemphasis on
fertility control through FP methods seems to have com
pletely shadowed all other integral parts of the progra
mme. The implementing machinery has failed even to implment successfully the MCH programme which is an
important component of the FW programme. A study i-/
conducted by the the Extended Programme of Immunization
(EPI) division of the Health Directorate of GovernnEnt
of Gujarat shows that upto 1981 the percentage of
children who completed three does of Polio, DPT and BCG
was 22.h-, M).h- and 26.0 respectively.
The community health norms for gaining herd immunity
is 80 percent i.e. if 80 percent of the children in the
community are immunised, the changes of occurances of a
particular disease are reduced significantly.
Among the other health programmes the control of commu
nicable diseases has been important all along the Plan
periods atleast in terms of allocations.
The communicable diseases covered under this programme
are : Malaria, Tuberculosis, Leprosy, Filaria and
blindness prevention. Since the sixth five year plan
the state governments are supposed to provide matching
contribution (JO percent) to the allocation. But the
fact remains that state governments not only fail to
contribute the 50 percent share but they also do not
make use of provisions made by the centre. For inst
ance, the states have not even lifted their full qunta
of Insectisides alloted to then by the centre ( for
Malaria). 1 /*
1 / Health
Statistics of Gujarat 198U.
1/* Parenthesis added. V.N. Rao and others "Indepth
Evaluation of Report of the Modified Plan of
Operation under NMEP", Ministry of Health and
Family Welfare, Government of India 1985.
....23....
s
- 23 Regarding another communicable disease namely T.B.
too the performance has been far from satisfactory.
During 1981-82out of 69,150 new cases registered ‘
under twenty point programme 95996 or lb- percent com
pleted treatment which meansthat the 'case holding'
in Gujarat is far behind the national average of
30 to 35 percent.
The gross neglect of most of the health programme is
cause of serious concern. The FP programme receives
a very high priority and adversely effects the implementioned of all other health programmes. This has
been sharply brought out by a study of Ministry of Health,
Government of India itself. The study, which is an indepth evaluation of the Modified Plan of Operation under
National Malaria Eradication Programme, states that
after the introduction ofmultipurpose health workers
the implementation of Malaria programme suffered.
It says, "There has been epidemiological hxi black outs
in large areas due to totally absent or inadequate
case detection even in the transmission season". The
report takes note of the inadequate staff, vacant
posts, staff in position avoiding field works etc.
and finally states, working in NMEP has reached a low
level of morale not only because of the problems faced
by them (workers), but also because of the low priority
being given to malaria with the Family Planning Programme
virtually sweeping it out.
What is true for Malaria programme is true for all
other programmes. If the Government has accepted
the objective of 'Health for All by 2000 A.D.' there
are no signs of achieving it with the present state
of affairs in reaching the health and family welfare
schemes to the rural areas.
There is need, for a drastic change of priorities hoth
in allocation of funds and approach and strategy of impl
ementing the health and family welfare programme in an
integrated fashion.
/Chavan/
Npn.
I
Position: 714 (8 views)