'People better than govt in family planning'

Civil Society News, New Delhi

A useful voluntary organization should be ahead of its time.  The  Population Foundation of India was one such when it was founded by industrialists JRD Tata and Bharat Ram all of 50 years ago.

But issues pertaining to population are complex and don’t get resolved easily. Changes have arrived, but even so women don’t have the same say as men. The poor lack access and awareness. Conservatives set restrictive boundaries for society. A communal divide results in unfounded fears.

Finding ways forward requires the ability to build new equations. Tact and forthrightness are needed in equal measure. The Population Foundation of India has held its own as a beacon for new ideas, and noticeably so in recent years with Poonam Muttreja as executive director.

Muttreja comes with the experience of founding and managing diverse social sector organizations. She knows a thing or two about advocacy and nudging the processes that finally bring transformation.

Under her, the foundation has worked aggressively but happily with government. She has also been the driving force behind Main kuch bhi kar sakti hoon, a popular television serial on women’s empowerment, now in its third season.

We spoke to Muttreja on the state of reproductive health services in India and what needs to be done to live up to the challenges of the times.

 

For a large and diverse economy with aspirations, how well has India done in family planning? What is the picture that emerges?

Well, I would give India six on 10. But I won’t give that ranking to the government but to the people of India. Despite poor quality services and limited choices, and key elements like counselling missing, the people have done better than the government.

India has had, for the past 50 to 55 years, only five methods of contraception, while the rest of the world, even neighbouring small countries, have gone on to eight or nine contraceptives. The government could have done better although family planning is the oldest programme in India.

I think it’s fantastic that population stabilization is taking place in 22 states. But even with services improving, if women don’t have agency, the education, or the freedom to decide, there is no way you can have population stabilization. And if you look at Bihar, UP, Rajasthan, Odisha and Assam, indicators for women are very poor in these states for literacy, agency and education. They lag behind the rest of the country. Also, if you don’t have good governance you are not going to have good public health systems that are responsive to people’s needs. In other states where women have had better opportunities, they have done well.

The tragedy is that we have let down the poorest women who have the maximum number of poor indicators starting with nutrition, health, education and poverty. So, family planning for the poorest and most marginalized has not worked yet. But it has worked for the better-off and it has certainly worked for educated women.

Education is the best family planning method. And women who are educated even if they are Class 12-pass, opt to have fewer children. Women who are graduates and postgraduates are likely to have just one child. India’s population is fast declining not just for one community but for all communities. And in the last census we had a huge decline amongst Muslims in terms of numbers and the percentage increase was less than in the past because, again, I think women are just exercising agency.

The one shame India has is the huge number of abortions that take place. We have 15.6 million abortions every year which are, by and large, a proxy for contraception. While abortion is a right for women, abortion as a proxy for contraception is a bad idea.

Another area where we really need to do something drastically for future demographic decline is to put in place more spacing methods and not rely so much on sterilization. Seventy percent of our population momentum is fuelled by the young. They don’t need family planning. They need access to contraception, especially those who aren’t married because sexual debut is getting younger and younger.

 

Empowerment of women and access to services are clearly linked. How much of this is the domain of the government and what has been the outcome of your own outreach to women?

The government has successfully shared information on family planning methods. Hum do hamare do is a slogan that reached people. But that didn’t give people the agency, choice, quality or access to those services. And even if women know about family planning methods, they need counselling to decide what’s best for them.

The government has done nothing to change social norms on early marriage. Anaemic young girls take the risk of having a child. The baby may die or the young girl herself. Nor have we changed the social norm that a girl has to prove her fertility at the age of 15 as soon as she gets married. Where have we seen anything done on that? We have this slogan beti bachao, beti padao. But slogans don’t get converted into practice in the absence of changing behaviour and social norms.

Changing social norms is not easy but we haven’t even attempted it. Thanks to the Emergency, family planning became such a hot potato, it got politically neglected. We took leave of family planning and women’s reproductive rights for a very long time.

There is no funding for behaviour change. The government has money for communication. It relies on non -evaluated things like posters. Global research evaluation shows that they don’t work.

Interpersonal communication does not work when it is done by people from the same community with the same regressive social norms. For example, an Asha worker gets her own daughter married at the age of 13 or 15. How can they convince people in their community not to get their daughters married at this young age? They put pressure on their daughters-in-law to prove their fertility as soon as they get married. How will they convince others?

There are so many myths and misgivings about male sterilization, which is a much easier method. We have done nothing to blow that myth. Men are totally out of the family planning circuit. Women have the privilege of giving birth to children, but they also bear the burden of family planning. Family planning is a men’s issue and a society issue.

There is no counselling. Every contraceptive has side- effects. Even abstinence has side-effects. We don’t manage all this. One contraceptive may work for one woman, but not for another.

 

You did try to change social norms through your TV serial, Main kuch bhi kar sakti hoon. What was the impact?

We were told that changing social norms and behaviour is a slow process. But in Brazil we found that due to a similar programme like ours on TV, fertility rates came down from seven to four in just five years.

We thought in India it won’t happen but we were stunned. In the evaluation of Season 1 not only did eight percent of women who never negotiated family planning pick up the courage to convince their husbands, mothers-in-law began to talk family planning to their daughters-in-law.

 

So a massive relentless campaign can change social norms. Is that what you are saying?

Totally. In India we were able to make huge changes in Seasons 1, 2 and 3 because there was a readiness for change among young girls and women. People’s aspirations have changed with access to mass media. It has penetrated even remote parts of the country. People don’t want to be poor and with little education. They want their lives transformed.

To take credit, our serial was brilliantly done. We got a Bollywood director. The quality was fantastic so people enjoyed watching it and they related to it. But we also did it so that people who were ready for a change could cash in.

We were nervous that a title like Main kuch bhi kar sakti hoon wouldn’t attract the men. But guess what? Forty -eight percent of the people who watched the show on TV were men. Fifty-two percent were women. Of this 40 percent were young people who said they could start a conversation with both parents after the episode.

So I’d like to say we haven’t given our men an opportunity to think better. I would give 50 percent credit to our programme and 50 percent to the men for their willingness to change.

 

How did the government react?

They have been very supportive. We get free airtime on Doordarshan and All India Radio. The health ministry used to send an SMS to every Asha, ANM and woman registered for pre- and post-natal care to watch the programme. We used to give a little background on every episode and SMS it to everyone we could.

We now have an artificial intelligence chat bot which is embedded in Main kuch bhi kar sakti hoon to reach out to young people on their sexual and reproductive health. The government requested us to share it with them and it’s now connected to their national helpline. Government officials also requested us to normalize use of the condom. So we did a ‘condom rap’ which has gone viral. The health ministry doesn’t have the creative ability to do a Main kuch bhi kar sakti hoon.

 

But politicians keep talking about punitive measures like the two-child norm and threatening to withdraw benefits to people who have more than two children. A law is being drafted.

The two -child norm has come from a political ideology. They don’t know the data and they don’t want to understand it either. They think Muslims are going to overtake Hindus in demographic numbers. The motivation behind it is this misinformed thinking. Hence they want to enforce punitive measures.

So we are trying to get the right information out through the media to Parliament and to all those who want to make this Bill. I think we have made huge progress. But if the government still wants to take this political decision, our work will go to waste.

 

What is the downside?

First, it’s against the rights of the unborn child. We are not going to provide free education to him or her. We are going to deprive that child of rations and everything he or she needs. It’s anti-woman. You don’t give the woman the choice, the services or the freedom to decide. How can you penalize her for having more children than she wants? Also, the government’s own data shows that India’s desired fertility rate is 1.8 percent. I mean, why not learn from Kerala, Andhra Pradesh and Tamil Nadu?

 

Are there partnerships between government and NGOs working on reproductive health and family planning?

Yes, but the government’s partnership is mainly with international organizations. Changing behaviour and social norms and working at the grassroots with women on this complex issue, which is full of myths, misconceptions and regressive norms, is not easy. You need people who are grounded in Indian realities. There are a lot of international NGOs that have come to India in the health sector and begun to engage in family planning because there is funding for it. But I think we need to look at their impact.

 

Your organisation has been working at the grassroots both in UP and Bihar. What is your learning from those experiences?

A big learning is that family planning is a preventive measure. It isn’t only about not having more children. It also prevents maternal and child mortality and intergenerational anaemia which results in young girls being anaemic.

You need family planning at the doorstep. People are not going to go for an injectable to a district hospital. You need to make it available at the primary health centre or the sub-centre. You need counselling in the village on which method to use, management of side-effects and, secondly, you need convergence. Panchayats, those in education, everyone should work together.

Convergence doesn’t happen at national or state level but at district level. Service providers need to change their behaviour. We have done convergence in many districts of Bihar and UP. Then family planning, services, demand, supply, everything works together.

 

So, priority states for you are…

Bihar, UP and now Rajasthan. Governance, especially in healthcare, is very poor in those states and we feel we should be working where people need the most help.

 

You did a report on deaths due to sterilization in a medical camp in Bilaspur in Chhattisgarh some years ago. What has been the response to that?

It was phenomenal. First, we brought out the truth because the country was being misled to believe the deaths were due to medicines. No. It was poor services that led to those deaths. We brought out the technical and other evidence. So truth prevailed.

That led to the health ministry taking our top 10 findings and recommendations and issuing a memo to every state to follow them.

We have been screaming for years that we don’t need camps that treat women in this inhuman manner and do 80 to 100 sterilizations.

By a stroke of luck a PIL that had been filed by a human rights group came up for hearing soon after our report came out. Colin Gonsalves, their lawyer, included our report in the PIL. The bench, headed by Justice Lokur, heard the PIL. And Justice Lokur took all our recommendations and asked the government to implement them over three years. We had recommended doing away with the medical camp approach, providing women with a choice of contraception, services and so on. The judgment stipulated that the government will report every quarter on the progress made. I could have retired after that.