The number says it all

India's latest Total Fertility Rate figures are heartening. But new challenges emerge


The question of how many is too many, at least when it comes to number of people, is one that can be answered rather easily. Demographers, population specialists, and public health experts use a simple figure to analyse a country's population policy, to see if it is on track, or, desperate measures need to be taken. This number is the Total Fertility Rate (TFR)—the average number of children that an average woman will have in her life.

For a country with a history of population control measures, taken in the backdrop of anxieties around population explosion, the current TFR is rather encouraging. According to data from the National Family Health Survey (NFHS) India's TFR is 2.2. This means we are only 0.1 units away from the ideal figure of 2.1. Going by previous surveys, the decline in TFR has been steady—from 3.4 in the first survey in 1992-93, to 2.2 in the latest one. Experts say once the TFR reaches 2.1, we can rest easy. For, that is when the population will reach a level of replacement fertility, or, simply put, one generation will replace the other. When that happens, the working population stays robust, and we reap the demographic dividend.

In India, 24 states have already reached that level. In West Bengal, for instance, the number has gone down to 1.8, and in Punjab, it is 1.6.

But moments of concern are far from over. In June last year, United Nations released a report on world population, which said that by 2024 India's population is set to overtake that of China's. The report titled World Population Prospects: The 2017 Revision, said India, with its 1.3 billion inhabitants, remains one of the two most populous countries (the other being China), and comprises 18 per cent of the total global population. The report may not have elicited an official response from the government, but the following month, some anxiety was palpable at an event to mark the World Population Day. On July 11, Health Minister J.P. Nadda unveiled Mission Parivar Vikas (MPV), the Centre's new policy on population stabilisation. It will focus on 146 districts in the country, in the seven high focus states of Uttar Pradesh, Bihar, Madhya Pradesh, Rajasthan, Jharkhand, Chattisgarh and Assam. In some areas of these districts, that have been shortlisted according to their TFR, the rate of fertility is as high as 4. Uttar Pradesh has 57 such districts, Bihar has 37, Madhya Pradesh has 25, and Assam has 2. They contribute 28 per cent to the total population of the country, 30 per cent of the total maternal deaths, and 50 per cent of the total infant deaths.

“Women are still marrying early, illegal abortions are high, women in their late 20s have had to undergo hysterectomies because of complications of sterilisation.” - Dr Mohan Rao, community health professor, JNU

For these areas, the MPV launch has much to offer—new injectable contraceptives, Postpartum Intrauterine Contraceptive Devices, sterilisation services with enhanced compensation, and condom boxes at strategic locations.

Experts such as Dr Mohan Rao, professor, community health and medicine at the Jawaharlal Nehru University, feel the new policy is old wine in new bottle. “The MPV scheme is the new avatar of a previous policy that the UPA government had launched in 2004, but was dropped after opposition from public health activists,” he says.

In The Lineaments of Population Policy in India (2017), a collection of documents edited by Rao, he writes about the UPA's common minimum programme of 2004. This programme aimed at a sharply targeted population-control programme that would be launched in the 150-odd high fertility districts. This was followed by shortlisting of 209 districts, with huge sterilisation targets through massive incentives to doctors and community health workers or Accredited Social Health Activists.

Though these regressive policy measures were dropped, Rao feels that much has not changed on the ground. Despite the death of 13 women at a mass sterilisation camp in Chhattisgarh in 2014, target-driven sterilisation continues to be a reality across several states, and women's health is ignored. “The focus is still on population control and chasing targets, which are now only termed as 'achievements'. Injectable contraceptives, as research has shown, have had a high drop-out rate and need medical monitoring. Besides, women are still marrying early, illegal abortions are high, women in their late 20s have had to undergo hysterectomies because of complications of sterilisation, and access to quality healthcare is still missing in many states,” said Rao.

Instead of a pre-occupation with numbers, the government ought to focus on development indicators such as health and education, said Rao. “If we examine the 146 districts listed in the MPV, these are the ones where development indicators are poor. Instead of family planning, the government needs to focus on a development package for these states,” he added.

Awaiting Disaster: A daily sight in Mumbai, when passengers are pushed in and out of crowded local trains | PTI Awaiting Disaster: A daily sight in Mumbai, when passengers are pushed in and out of crowded local trains | PTI

Dr Faujdar Ram, former director of Indian Institute of Population Sciences, agrees: “Fertility rate has declined; child survival and maternal mortality rates have improved. But, in bringing the fertility level further down in states where it has historically been lagging, there is a need to look at the development indices too. Unless we improve access to healthcare and service delivery systems, fertility behaviour will not change. People want services—for instance, there's still a huge unmet need for contraceptive use. Many still rely on traditional methods of contraception, which means modern methods are out of their reach.” According to NFHS, the usage of modern methods of contraception [birth control pill, condoms, sterilisation, intra-uterine] stands at 47.8, a small change as compared to the previous (2005-06) figure of 48.5.

Population expert Shailaja Chandra says that the focus needs to be on crucial issues such as the age of marriage. "Early marriage and childbearing means women don't finish their education, and consequently, are not fit for employment. Look at the decline in our female workforce. There's no political will in incentivising delay in childbearing. Typically, couples will have two children quickly, before they proceed for sterilisation,” says Chandra, former head of the Jan Sthirtha Kosh (Population Stabilisation Fund).

Chandra's concern is supported by latest NFHS data—26.8 per cent of women (20-24 years) were married before the legal age of 18. About two-fifths of women marry before reaching the legal age for marriage in West Bengal (44 per cent), Bihar (42 per cent), Jharkhand (39 per cent), and Andhra Pradesh (36 per cent). About one-third of women in Rajasthan, Assam, Madhya Pradesh, and Tripura (33 per cent each), as well as Dadra and Nagar Haveli (32 per cent) and Telangana (31 per cent) marry before reaching the legal minimum age for marriage.

Education plays a key role in helping the cause of fewer children and better health indicators. The number of children per woman declines with women's level of education—women with no schooling have an average of 3.1 children, compared with 1.7 children for women with 12 or more years of education. “Many years ago, when I spoke to a few sarpanches in Madhya Pradesh, they told me how they had to overlook marriage below legal age because they needed the votes. To counter this, the government needs to give incentives such as jobs for those who delay childbearing until after 20 years, and space out their children as well," says Chandra.

“There is no political will in incentivising delay in childbearing.” - Shailaja Chandra, population expert

Public health activists say that there is a need to reflect on how states such as Kerala, with a TFR of 1.6, reduced its fertility rates by investing in long-term measures like educating and empowering girls and women, by ensuring equal rights, and improving health care delivery. Countries such as Sri Lanka have lowered fertility rates by increasing the age of marriage, while Bangladesh succeeded by mobilising a cadre of village-level health workers to build awareness and acceptability of family planning.

In India, however, coercive policies are still invoked, every now and then. If in the winter session of Parliament, a BJP member from Saharanpur advocated for two-child norm to reduce numbers, in Assam the state government passed a population policy last year that exempts couples with more than two children from government jobs. “It is unclear as to what the government wants to achieve with this policy. Those who are seeking jobs in state government are already educated, aware and conscious of having fewer children. Then what purpose will the policy serve? They are also less than five per cent of the total population,” says Dr Akhil Dutta, professor, political science at Gauhati University. Dutta says that while the population in the industrial belt of Upper Assam is lower because of economic advancements, it is higher in economically backward districts, populated by immigrants with lower access to healthcare services.

Coercive policies often have counter-productive results, especially if one looked at China's one-child policy, that the country did away with a few years ago. In 2015, at the fifth plenum of the 18th party Congress, the Communist Party of China announced the shift from one-child policy to two-child policy. “The effects of the one-child policy can not be reversed so easily by asking people to have two children all of a sudden. The one-child norm was not a monolith really; in rural areas, people were allowed to have two children if the first was a girl. This patriarchal regressive policy went on until the effects started to show. Now, there's a single child generation that is facing the burden of taking care of the elderly by themselves, and elderly care is emerging as a huge concern. Unlike India, at least there is an acceptance of the emerging issue of elderly care,” says Madhurima Nundy, associate fellow at the Institute of Chinese Studies in New Delhi.

In India too, in a few years from now, the care of the elderly will turn into a full-fledged crisis, says Dr Sushanta Banerjee, research director, Ipas Development Foundation. “We are under-prepared for the crisis of ageing. States such as Kerala, West Bengal, Punjab and many in the south have TFR in the range of 1.42-1.5. This means that there will be fewer younger people in the next decade, and the population of the elderly will increase. Unequal development forces people to leave their homes and migrate for work to other cities, leaving the elderly behind. With an increase in life-span, a rise in diseases, and no state support in terms of pension, the elderly will be at a huge disadvantage. Controlling population can be an automatic process if education and health are taken care of. But the old-age crisis is something that cannot take care of itself,” he says.

At 8.6 per cent of the total population, India's elderly are going to become a cause for some anxiety for demographers and policy makers in the coming years. They may seem like a small percentage now, but with 103.9 million people over 60 years of age according to 2011 census data, this is a population that can not be ignored.