According to the recently released National Family Health Survey (NFHS)-5 , India’s Total Fertility Rate (TFR), which is the number of children a woman would have in the course of her life, is 2, a decrease from 2.2 in NFHS-4. Is this cause for cheer and should women be credited with stabilising the population? Poonam Muttreja and S. Irudaya Rajan discuss whether governments should stop focusing on population control, in a conversation moderated by Serena Josephine M. Edited excerpts:
India launched its National Programme for Family Planning in 1952. What are the factors that have helped the country bring down its TFR?
Poonam Muttreja: Yes, it was good that India had an early start. But while India has the oldest family planning programme, it does not have the best or even an average programme. I’d first like to give credit to the women and their aspirations. The men have demonstrated that they are not responsible for family planning and rarely support women in family planning decisions. The decline is on expected lines. If you look at NFHS-4, women, on average, wanted 1.8 children. So, it’s just that we have a huge unmet need for family planning. It was 13% in NFHS-4. In NFHS-5, it has come down to close to 10% on average in many States. There are 16.4 million abortions every year, which I think is an under-estimate and a proxy for contraception. So, there is determination in India in spite of men not participating. Having said that, I do want to say that in the last five or six years, we’ve had new methods introduced, though we need to do a lot better on numbers and we need more temporary methods. Another reason for women having or desiring fewer children is education. It is the best contraceptive pill, and better education means women will have fewer children. There are many factors for the drop in TFR, but I’d like to give maximum credit to women. Also, fertility has come down across religious lines.
S. Irudaya Rajan: Though I agree that the programme was managed by women because the sterilisation rate among women is extremely high compared to that of men, the fertility decline is not the end of the story but the beginning of a new era. Most policymakers and journalists think that when you achieve a fertility rate of 2.1, the population policy is over. Unfortunately, the population policy is not just a fertility control policy. We have to educate our administrators and policymakers that population policy includes not just fertility but also mortality and migration. These are the three components of population growth. This is the beginning of the work that the government has to do in terms of child nutrition, child mortality and providing employment for the youth — what we call the demographic dividend. I don’t think it is time to celebrate the NFHS-5 results.
Many view this drop in TFR as a sign of population stabilisation. Is that really so?
S. Irudaya Rajan: I don’t think it is a sign of population stability. Kerala, for instance, has almost the same replacement level of fertility for close to 30 years now. We have not stabilised; the population is still growing. Population momentum will set in right now and continue for perhaps a few years or a decade. Only then can we talk about population stabilisation. Basically, population momentum means that the population will continue to grow and it is not going to have a negative growth rate. Kerala still has a positive growth rate and we expect a negative growth rate may be after the 2031 to 2041 Census. It will take several decades for India to reach population stabilisation. This is the first point.
As I said earlier, this fertility decline is not going to end the story of India’s human development. Even as we discuss the low fertility rate, according to the data, 23% of women were married before 18 years. The percentage of women aged 15 to 19 years who were already mothers/pregnant at the time of survey was 6.8. However, adolescent fertility rate for women aged 15 to 19 years was 43. This is only the beginning of a new era in India’s population policy. It is very important for us to wait and do more work than what we have done so that we have healthy women, healthy children and a healthy society.
At this point in time, does India need a population control law or drastic measures such as the two-child norm proposed by Uttar Pradesh and Assam? Do you think the country should move away from coercive measures for population control, keeping in mind the lessons learned from China’s one-child policy that was scrapped a few years ago?
Poonam Muttreja: If there’s anything in the news in the NFHS, it is that it’s taking the wind out of those who are saying India needs coercive population control measures. India needs to move away from not only the coercive measures it has, but shouldn’t even think about population control measures. Let me explain why. First, Kerala, Tamil Nadu and other States that have achieved a TFR of 2 [have done so] without coercion. Second, we are going to have a balance in India as migrants from Bihar and U.P. are already moving to the southern parts. The country will balance its population even when we reach a minus growth rate. Let there be a secular decline, which is already happening. In fact, 70% of the population is going to be fuelled by population momentum as we have a very young population. We need to provide three or four things keeping them in mind. Our population policy needs to get more spacing methods, which are long lasting. A large percentage, if you look at people’s access to family planning, depends on where you live, what your wealth quintile is and what your age is. Younger girls have the least access to family planning services and so, there are high teenage pregnancies. We need to not only increase the age of marriage but keep girls in school and university for their own empowerment and growth. If we keep focusing on coercion, we will not focus on the right things. We are barely talking about ageing. Those who are talking about coercive policies in U.P. and Assam haven’t thought about investing in ageing and improving the health systems. If we use coercive methods and use the population to create greater disharmony, if we victimise or demonise one particular population, we should remember the Emergency and the impact that forced sterilisations had. The biggest lesson from that is that we shouldn’t be talking about population control or population in a coercive manner.
S. Irudaya Rajan: We should not do politics with fertility. We should talk about the quality of family planning services, which is pathetic. Family planning programmes have been about following the women. They have the first child, then the second. In between they probably have one abortion as there was no method [of contraception]. And then sterilisation. We should change this and propagate temporary methods [of contraception] among men and women. We need innovations in family planning programmes.
What do you think of incentives and disincentives in family planning?
Poonam Muttreja: There is no evidence to show that linking incentives and disincentives to family planning and social schemes work globally. In India, we invest so much money in incentives for sterilisation. That’s part of the problem why women are not able to have the number of children that they wish to have. They have more children than they wish to have and go through multiple abortions, which impacts their health. Abortion-related mortality is close to 8%.
S. Irudaya Rajan: I am against providing incentives. I think people are addicted to the two-child family. We should think of new ideas of how to promote the quality of family planning services. Historically, if you look at India’s family planning programme, we started with the ‘cafeteria approach’ where you can ask what they have and choose. Now, you will be told there is only sterilisation and not many are promoting other methods. Many couples are using abortion as a contraceptive method. This indicates that we have failed to promote temporary methods.
The use of contraceptives has improved, as per the latest NFHS, but male sterilisation continues to be low. What are the implications of the continued thrust on women with regard to family planning?
Poonam Muttreja: Once again, NFHS-5 proves that women are taking more responsibility and men are taking less. How do we change men? There are myths about adopting contraception. I don’t believe coercion is needed, but we need more communication on behavioural change. We have to change social norms, especially among the younger population, but we don’t even have sex education. Much of our population momentum is going to come from the young. We should recognise that the overuse of female sterilisation has been adversely impacting women's health.
S. Irudaya Rajan: We have to start educating women as well because some do not want their husbands to be sterilised. Family planning should be converted into family welfare. A family includes men and women. We should recognise this in our data collection. I think we have to do more research on women and men. We should convert that into a family affair. Probably then we will succeed.
So, if not population control, what should be the focus areas?
Poonam Muttreja: I think there’s going to be the targeting of one minority community, which is the reason behind the population control push. As Professor Rajan said, we shouldn’t do politics in population. Given that India has a strong preference for sons and an aversion for daughters, our sex ratios will get more skewed. I don’t believe that on the whole, the population will decline faster. It will just distract us from all the good things that we are talking about doing such as expanding choice and social indicators like age at marriage.
S. Irudaya Rajan: There are two important components. One, what we are celebrating is that in India people are living longer. Now, living longer is being celebrated because it gives you the human development index. But we are only adding years to the people, not a better quality of life for our senior citizens. Second, migration is going to play a major role in India. My estimate is that right now, 600 million people are internal migrants. But we don’t have any policy on migration. We should look at population policy beyond fertility. We should include mortality decline, quality of life in old age and create a migration policy.
What is the way ahead in terms of population control, family planning and in men taking greater responsibility in adopting sterilisation?
Poonam Muttreja: The family planning budget is only 6% of the health budget. Within that, we spend 2.5% on temporary methods of contraception. The money spent on incentives is 60% of the budget. This can instead be used on bringing about behavioural change. We have to recognise that India is going to keep growing because of a young population. And they don’t need family planning, they need access to contraception.
S. Irudaya Rajan is the chairman of the International Institute of Migration and Development; Poonam Muttreja is the executive director of the Population Foundation of India