People's Democracy

On CMP, Health And Population Policy Initiatives

OVER the last fifteen years India has witnessed a sharp decline in the state’s commitment to public health. Thus today our country has the fifth lowest public health expenditure in the world. As the National Health Policy admitted, this is, at 0.9 per cent of the GDP, lower than the average in even Sub Saharan Africa. Along with decreasing state spending on health, increasingly policy measures have encouraged the growth of the private sector in health care so that today we have the largest and least regulated private health care industry in the world. Evidence from across the country indicates that access to health care has declined sharply over this period. The policy of levying of user fees has impacted negatively upon access to public health facilities, especially for poor and marginalised communities and to women. As health care costs have increased sharply, it is not surprising that medical expenditure is emerging as one of the leading causes of indebtedness. At the same time, this has been accompanied by policies that have reduced access of the poor to public distribution systems of food so that per capita availability of food has shown an alarming decrease.

It is thus not surprising that in addition to starvation deaths, the huge load of preventable and communicable diseases remains substantially unchanged. Infant and child mortality take an unconscionable toll of the lives of 22 lakh children every year. We are yet to achieve the National Health Policy 1983 target to reduce the Infant Mortality Rate to less than 60 per 1000 live births. More serious is the fact that the rate of decline in the Infant Mortality Rate, which was significant in the 1970s and 80s, has remarkably decelerated in the 1990s. 130,000 mothers die during childbirth every year. The NHP 1983 target for 2000 was to reduce Maternal Mortality Rate to less than 200 per 100,000 live births. However, 407 mothers die due to pregnancy related causes, for every 100,000 live births even today. As per the National Family Health Surveys in the last decade, the MMR has increased from 424 to 540 maternal deaths per 100,000 live births. Partially as a result of population policies, the disincentives and the two-child norm contained in them – at variance with the National Population Policy (2000) and the commitments made at the ICPD in Cairo – there is a massive shortfall of girls in the 0-6 years age group due to Sex Selective Abortions (SSA). Violence against women has grown, and taken many new forms, including a huge increase in so-called “honour killings”. Indeed it would be no exaggeration to state that population policies have added to this violence.

HOPE FROM UPA GOVT

It is thus with hope that we looked forward to the United Progressive Alliance government to initiate policy measures to arrest these trends. Although the Common Minimum Programme was committed to a substantial increase in health spending, this is not evident in the financial allocations made: the budget outlay for 2004-05, adjusted for inflation, shows no increase in the outlay for health and an 11.9 per cent increase for family planning, clearly indicating skewed priorities.

However, more alarmingly, the single line, “A sharply targeted population control programme will be launched in the 150-odd high-fertility districts”, from the CMP has been acted upon to unveil policy measures for 209 districts in the country. This is a truly unfortunate move, with grave consequences for thousands of women and children from the poor, marginalised communities, especially dalits and adivasis, who along with deprivation, suffer higher levels of morbidity and mortality, and a high unmet need for health and family planning services.

REGRESSIVE PROGRAMME

These 209 districts in which the “sharply targeted population control programme’’ are to be launched are precisely the same districts with poor indicators for social development, especially female literacy, infant and child survival, maternal morbidity and mortality and other indicators of human and gender development.  Instead of a package of health and development measures, what is being proposed is concentrating on a sharply targeted population control programme in these districts in five states. This profoundly regressive policy relies on targets for sterilisation, coercive incentives and disincentives, and massive subsidies to the private sector, recalling the worst days of India’s family planning history. Not only do such measures violate basic human rights, they have also been shown to be demographically unnecessary in bringing down population growth rates.

The declining Child Sex Ratio (CSR) is one deeply worrying indicator of the outcomes of such short-sighted population policies. Between 1991 and 2001, in urban areas, the CSR has declined from 935 to 903 and in rural areas from 948 to 934. More ominously, between January and June this year, in Delhi the Sex Ratio at Birth indicates 819 females being born for every 1000 males; in the prosperous and educated South Delhi zone, where demographic transition has by and large been completed, only 762 females were born for every 1000 males. A recent study by the Ministry of Health also indicated the dolorous outcome of the imposition of the two-child norm for contesting elections. A large majority of those disqualified on this ground were dalits, the adivasis and women from poor families, defeating the very purpose of democratic decentralisation. Further, the study indicated that this norm had acted as an incentive for SSA. Clearly then population stabilisation in this form cannot be the goal since it leads to profoundly unbalanced populations.

We therefore demand that the programme measures for these 209 districts be unreservedly scrapped. We cannot have a population policy that does not hinge on equity and gender justice. There should thus be no National Population Mission. Issues concerning women’s health and reproductive rights can only be part of a larger package of a health and social development policy.

We welcome the UPA’s commitment to increasing state spending on health, but this should be entirely devoted to strengthening the universal and comprehensive primary health care (PHC) system. Increasing state spending cannot become the vehicle to increasing public subsidy to the private or NGO sectors, which in fact require regulation. It is evident from the CSRs that the private sector has played a deeply regressive role in health care provision.

The Tenth Plan proposals for health and nutrition need to be reviewed keeping epidemiological priorities in mind. A basket of technologically determined vertical programmes cannot substitute for a systematic strengthening of a comprehensive, universal, integrated PHC system.

Ten years after Cairo, if the commitments made there have to have meaning, it is clear that we cannot have RCH without PHC; nor indeed can we have gender-just population policies without the enabling conditions of health and development. What we have demanded is the minimum and non-negotiable.  We are still hopeful that the UPA government promises something new.

[This statement was signed by Action India; All India Democratic Women’s Association (AIDWA); Centre for Social Medicine and Community Health (CSMCH), JNU; Centre for Women’s Development Studies (CWDS); Delhi Science Forum (DSF); Jan Swasthya Abhiyan (JSA); Joint Women’s Programme (JWP); Medico-Friend’s Circle (MFC); National Federation of Indian Women (NFIW); Saheli; Sama and Young Women’s Christian Association (YWCA)]

October 6, 2004