World Bank Reprint Series: Number Seventy-eight Ravi Gulhati India's Population Policy: Critical Issues for the Future Reprinted from Puiblic Policy, vol. 26, no. 3 (Summer 1978), pp. 415-54 Public Policy Volume 26 No. 3 (Summer 1978) INDIA'S POPULATION POLICY: Critical Issues for the Future RAVI GULHATI* The Indian birth rate has started to (leclinie as a result of socioeco- nomic progress and the family-planning effort. About 19 percent of couples of reproductive age are practicing conztr7aception. Recent offi- cial pronouncements on population policy neglect several critical is- sues. Approximately 52 million couples-half of all couples of repro- ductive age-emain desperately poor. The family-planning delivery system is not geared to their needs. To engineer a demographic transi- tion for this large segment requires policy innovations of a very highi order: (1) an overhaul of admiinistrative practices, mandates, and budget norms; (2) a combinied rural developmient and family-planning program; and (3) a recognition of regional div'ersity and the adoption of a sequential strategy. India's brief flirtationi with coercive family planning is over. The program suffered a major setback during the 1975-1977 Emergency when many political rights were abridged. It will be some time before new initiatives can be mounted. Meanwhile, it is important to analyze past experience in order to identify the major issues and options that confront the policy maker in the population field. This is the primary purpose of this article, which is concerned mainly with fertility rather than with mortality, migration, or other topics that might conceivably fall under the heading of population policy. Its object is not to add to the large volume of scholarly research on past trends in the birth rate or to rnake future projections. It takes for granted the niee(d to reduce Inidian fertility in the interest of eco- nomic and social (levelopment; this point has been arguiedl con- N'incingly in n-iiny places. Given this ol)jecti%'e, the present article * rhe views expresseti in this article are personal andc should not be .inlibuled to my enmplnvel, the World Bank. Copyright © 1978 by the President and Fellows of larvard College Published by John Wiley & Sons, Inc. '1033- 3646/178/0026-04 15$01.00 416 Public Policy focuses on the policv Ilst in nilelnts dleplove(d in the past iLlt il ploposed for the future. Ihe first section of the article looks at the miajor (lellogi;apllic facts-the rise in miiarriage age and declile ini 1arillitail fertility-that lie behind( the (eC1lille inl the bitlth rate during the last two deca(les. An atteiiipt is iiliizle to ailyiaie the coitrihiifonms to dccli iiihg fIertility of the fiamily-pliiiiigig (FP) programn anid of socioeconolmlic chailges at nitiolilul, state, anld hloishlold levels. TI'he seconid( section1 eXllllilleS recenit of ficial stateliijets of the Iildli;1i goNeTn,iiieCIt tonl popilaltio I policv an(l evatliates the feasibility andl efFectivelless of the pro- 1iOmiceld pOli(ies. Finiall', the tlhir(d sectioni takes up a mii iber of' iinportalit (testiomis that hiave beein nlegleciel in these lpolicy pro- nIonl ncemiienits. Now that the governimenit aid ima ;jor- political p)alrties have reassertedi the vol mitairy priniciple in FP, it is es"elItial to exam- inie all avemiecs of refoi-rmii c(mipatihie with this plinhciple that canl help) in rehahilitatilig Iimidiai's FP program. Fertility 1951-1971 Deiinograitphlies algr'ee thiat the ( i lle birth rate f'ell from aillabout 45 per 1,000 in 1951-1961 to abouit 40 to 42 in 1961-1971 (Adlakha and Kirk, 1974.) T1his dleclii, started a new trein(d in mo(lerni Indiati population history. Ihere is reasoni to l)elieve that imuch of' the declinie was cmcent italedl in the Sec(ihid part ot thie 1960s aild that it coiitimiiie(l beyond(l the census year 1971. UliiFMrImim;tIelv, dlata limnita- tions do niot allow a pirecise and up-to-dlate assessim-mei of, the sittua- tion. Two factors are illipoitamil inl coiimi)pihele(t1ilg the tnew trenid, the rise in age at iniarrikge and(1 the decline in inarital fertility, i.e., the numiber of births per 1,000 married womeni per year. TI'aking the overazll intei-ceiis;al (lehine in the birth rate to be 3 pooints (from 45 to 4'2 per 1 ,000), (1c1hiiges in age structure and miarriage patterns ac- CoMICmied foi' onie-tliir(I and the change in ii;waital fertilitv for two- thiirds, ri t'Sj)ect i%el- Rising MInarriage Age. Ini Fnrope. a sizable p))lt of' th(e popImlaIiOm relaiiiis single. In hIidia, by con]trast, III;hhlriage is iwiarly Ii1lhiel Sal, for there are hardly anyv social an(l iIINititIo umal al-ternativkcs. TIlhe odd inW ded l)pel5(o I 'll (C isolatioti andi C (ci5s re . 'I'his is pa i'tic tlaidri true for wonieli, wlho also depeind oin mar riage for ecolIoliic suipport. INDIA'S POPULATrION POLICY 417 Although the proportion of the "never married" population has risen sornewhat in the metropolitan cities in recent decades, the change is not quantitatively significant. Early marriage was the comionio p'ractice inl traditionil India; it is estimated that in 1900 the average marriage age for females was 13. This was part of a (leinogriaphic picture in which mortility levels were high and the reproduLiction process had to start early for the family to survive. Early marriage was also seen as providing protec- tion against immorality. The marriage ceremony did not lead im- me(Iiately to cohabitation. For imazrriaiges below the age of 15, the average interval between the forminal cere inonyv and consummation was 38 months, accordhimig to estiila;tes deri-ed fiomi the National Sample Surve (Jain, 1975). The average age at "effecCve marriage" in rural India in the 1920s wvas 15.6 years. Hiln(dlus and 'MUsliHms tended to marry much earlier than the twvo small minority corm- munities, the Sikhs andcl the Chrisikins. Not much change took place till 1950. By 1961- 1I962, the average effective marriage age for feiiiales ha(l inched tip to 16.1 vceamIs in rural areas and 17.4 years in urbain pliceN. In Kei;zlia and Mad mas the statewide (uLribani and(i rtural) aivera'ge exN(eeded 18 yeal-S, but it lagged below 15.5 years in rural Bihar, Andhli;i Pira(lesh, anid West Bengal as well as in the uLrbaTn areas of Rai jstliami. TI'he l)iLe of charnge accelerated in the 19tsiis and1 early 1970s. Data on effective marriage age for recent years are not available, but census returns are sugges- tive: the per-cenltage of girls married in the 15 to 19 age group dropped from 75 pericent in 1951 to 70 percent in 1961 and rim tlher to 56 percent in 1971. Whv is the Indiain nmrriaige age inicreasing? No definite aniswer can be given. Among the broad (letermiiniing influences, however, are e(ltmcatiomlall aidvances and the opening up of em-iiploym-ient opportunities for females in cities. It has been suggestedl 'hat even in the coimirsidc, lparents tend to delay mar- riage if a girl has the prospect of earninig good wages or conmtril)utinlg to the faLmiilv farml. F'or exammnple, the average nmariaige age for f`eniale.N inI the Khaniaiii; (listrict of' the Punjab rose from 16 years in 1945-1949 to 20 ylears a decale latei C Ihis was a period of' intensive agricultural (levelolp)llet (Mamudaii, 1973). Not all these factoris were impm1x)rteverywhere. 'Il'he process of' clh:mnge cadn be ilhitstnirt(NI in Imlicmo()snm. Severvl villages in rural V'aratiasi in E;Stris ttarP Iaideslh wse Sirveyed(l in 1967 (Chatter- 418 Putblic Policy jee, 1971). The meani age ftor recently married girls in this t)ackwardI area was only 11.9 (see 'rable 1). TIhere was little evidence of a timiie trend; in fact, the average age of males vimir;r ie(l recenttl) was sligltly lower than the corr-I)onding figuire foi' their fathers. 'FTe most accessible village, alb, ha(d a soniewlir hlighier aver age, ntit variations in coItmIltlIlica[iOIi facilitiCS did rIOt St'CMI to ('XNcliS' atIiv large or consistent imnpact. Iiitercaste (Ii felren tials were sul)stantial and they were not of recent origin. Thle mlean tiur iage age of' high-caste girls was nearly 5() percenit hiigher than for girls at thle bottom of' the caste hierarchy. Equally (In.atic was the gap in Table 1. RURAL VARANASI DllS I RIC!: MEAN AGE AI' NIARRIAGE MWale Sonl of DaIaughter7 of responlen i respondenta reden)tre flm aden Caste: Upper 18.7 17.1 14.9 Backward 14.6 1 4. 9 10.8 SchedLuled castes 13.4 12.5 1.0( and tribes Education: Above primary) 17,4 18.6 15.1 Up to primary 17.2 15.4 17.9 Illiterate and 14.4 14.1 9.8 barelv literate Landholding: Above 15 acres 1, 6.3 15.8 13.3 Betweeni 5 anid 15 acres 15.1 16.() 14.4 Up to 5 acres 14.8 13.9 10.3 Landless 13.4 14.3 11.5 Villages ranked by accessibility: 1) Umraha 15.3 16.1 12.6 Bicclcia 16.( 14.8 12.4 J gapur 13.6 13.4 10.9 Slhaiiislier-pur 15.2 15.0 11.9 TIotal 15.0 14.8 1 1.9 'lt'hese ligincs relate to recent marriages close iti time to the 1967 survey. b IThe source ofr rno(ernizatioo is the (district l lt ped u Ii 9i. Varanasi. \illage- .11 e listed in or(ler of ease of co,nmunications via roa(dl bus service, etc., witlh Varanasi. SOURCE: Cha(elie,1ee 1971. INDIA'S POPULATIOIN POLICY 419 marriage age between those who had received some formal educa- tion and those who had not. The difference between the landed households-those owning more than 5 acres-and the rest was not so large, but it was far from trivial. The traditional fear of having an unmarried adolescent daughter was receding in the face of educa- tional advance, especially among high-caste and relatively affluent groups. Declining Marital Fertility. Not only is marriage nearly universal in India, not only does it occur at a younig age, but the desired family size also tends to be large by contemiiporary W Vesternl standards. Over half of the sampled parelits smwreyed in the 1950s wished to have four or more children and of these 25 to 33 percent (lesire(I five or more. There was substantial agreement betweeni the results of these "attitude" surveys and actuial behavior recorded in the 1961 census. More than a thirid of the mnarriedi women had four or more living children and nearly one-fourth had five or more children, although many of these womnen were far from the end of their reprlo(ltctive period. Starting from tiis high level, marital fertility has declined, presumnably as the conmbi 1d(l result of socioeconomiiic progress an(l the FP programii. Althiougig the iind(erlyinig catuses cainnot be estab- lished precisely, analysis at the nationial, state, atli household levels helps to identify the relevant fa(to is. At the all-India level, the slight decline in marital fertility can be ascribed to limited improvemnents in health, education, per capita income, and, of course, the progress of the FP program that had been started in 1951. Infant and child miiortality dlecliie(d clramati- cally with the control of conllllullicable (diseases. Life expectanicy at birth rose from 27 years in the 1930s to 46 years in the 1960s. Given the higher chances of survival of the children, parents could be expected to redtuce the number of births to some extent. A relevant measure of educational advance was female literacy; this rose from 3 percent of the total female population in 1921 to 18 percent in 1971. Educationi cotul(l be expected to reduce fertility by (1) changing values an(d attitudes; (2) imnproving access to informationi, iniclld(lilng that provided by the FP pr-ogramii; (3) increasing the cost of child rearing; and( (4) raising the marriage age. 'IThe expanisionl of health and edlucationi services took )lace dutirinig a period of very slow improvnemnt in the average stanldard of living of the In(liani people. On a per capita basis, gross domnestic pro(lLict in conistanit prices rose 420 P'blic Polic? by 16 percent in the 1950s and(I 13 p)erc(cnt inl the 196ts)s I'lUlTiti- nately, even this slow pace coiil(l niot be Su1StaJined(l (lurilng the early 1970s. Nevertheless, lookhiIg at the last quai :r' centulry, somle slighlt improvemiienit in average living statI(lhr(ls ii noti(ocable, (I('Sl)itt' the pressure of poptulation. It can be arIguIe'd tCiat this iuilwrovcnirert was conducive to a decline ini fertilitv, althouigh the point is (jIWsiirialalh1, considering the small a:rgiittltle of the incoimt, expai sion over- a very low initial level. Superimposed on all these socioccoImionc c'haiigcs. was the im1;pacl of the FP effort, which has growni enorrrrotisly in collccpi. rilad itn iriagiitti(le sirnce the early 1 950s, whleni it was Irio(lt-st, Cliic-base(l, and confined to tirhari centers. A niajor (lel)arture was ina(le in 1963 with the adoption of the "extetision" appro:ich and the I,egirrrrirg of the attemnpt to expand coverage in rural areas. By 1975, there were nearly 39,000 health subcenters in rural Ind(lia supplying FP iinfor- matioii, materials, and medical expNe.rtise to 83 miiillioni couiples (GCov- ernment of India, 1975/76). In a(l(litioni, the govei umiert (ieci(le(d itn 1968 to use the (m0tH e rci;il (list!iburtii r network of ma or riva lte firms to retail con(normts, which are c(lIle(l Nirolis. Bv 1976i there were eight )rivatte and tlhree public firmiis witlh 250,)t)() etail outlets participating in the scher ne; NiromHihs are also (listribited thuro ,rlgh 7,400 post offices. Ihe main result of the FP programll, accordlig to official statistics, was that by March 1976 19 percenit of coliples of' reproductive age were protected against the risk of' p)regridrc(v. Of' these, sterilization accotintc(l for 14 per(e ilt, the intratter'ine (devi(c (IU[)) for 1.5 perc'ent, and(l comi%citionial corttra(cep)ti\ s (condoms. etc.) for the remainiing 3.4 percenit. It is Ino easy niater to translate these figures into an estiinate of the niet imnpact of' the FP program on ferttility. Many cotuples miight simnply have sl)Stistiuted corltracep)- tives offered by the p)roglralln for tr a(litionlr teclhi(cjues such as abstinence, the rhvthiii niethod, with(lrawal, and( abor'tjor. Othiers might hav'e a(lopte(l fertilitv conitrol as they gained in socioeconiorini ter iis, eveni if there had been no official FV I)program1111. Ma11Ny of" thlose COLtmttcd in the 19 )ercent figiule weire very' nelar ly at the end( of' thieir repro(ductive perio(I and( woUl(I nIot ha%c p)rO(ll(o'(mcd acl(itionaul chil- dr-en in aniy c(ase. Notwithlustar(linrg all these re'sr'v:itolls, it can be coniclti(ledi with i'caso')nablet ass,lai(e thalt the FP plmogli ai lhas helpedl sign ificartly in re(dtucinig inamr'ital fertilitv, eveni thoulgh its precise cont ribiuion (lefies nreasm r en ient. INDIA'S POPULATIoI(N POLICY 421 An analysis of interstate clifferellials in FP performance and fertil- ity tends to confirm the interaction of socioeconromiiic variables and FP inputs. Table 2 lists fourteen Indian states in descending order of the proportion of couples protected against the risk of pregnanicy. This proportion varies from 25 to 32 percent in five "leading" states to 9 to 11 perclnit in three "lagginig" states, with the reaininiriiig six states in the middle. The numbers shown are ind(lices, with the all-India average of 19 percent (row 1) equal to 100. Column 4 shows FP program expenditure per couple and s.! i be taken as a proxy for the intensity of the delivery system in each state. The five leading states seemed to have relatively strong FP prograin.;; outlays per couple were 114 to 126 percent of the national average of Rs. 7.80 (1 rupee equalled $0.13 in 1972-1973). FP centers catere(d to a population that was appreciably smaller than in the lagging states and presumnably could provide more intensive coverage. Also the work of centers in the leading states was much less hampered by staff vacancies than in otlher states. Most of the leading awil iiidldlinig states ha(d relatively lower fertil- ity than the lagging ones, althoelUgh the correspoI(lence was weak in a few cases. Columnil 5 shows the best available (lata on fertility variationis by state. Somiie of these GCjarat 5 137 121 112 127 121 132 140 Tamilnadu 8 130 126 83 98 103 142 150 Middling: Andhra 9 106 105 83 99 86 84 95 z Orissa 4 106 98 85 104 75 74 40 > West Bengal 8 94 52 NA 133 96 116 125 CZ Karnataka 5 87 119 88 75 89 111 120 Assam 2 87 32 99 113 76 100 45 0 Madya Pradesh 9 78 106 125 109 77 58 80 Lagging: > Utter Pradesh 17 58 76 130 138 78 58 70 H3 Rajasthan 5 55 86 122 13G 87 42 90 0 Bihar 11 46 44 104 NA 59 47 50 Z a 1972-1973 prices. r b Number of live births per woman over the entire reproductive period. - I Deaths under 1 year of age per 1,000 live births during late sixties and early seventies. dExpressed in 1960-61 prices; I rupee equalled $0.21. 'IRCE; Government of India, Family Welfare Programme in India Yearbook, 1975-76; Government of India, Registrar General, Sample Registration Buln, Vol. IX, No. 3, July 1975. 00l 424 Puiblic Policv the 1)iCItle lella;ill lar'gely 11111 IIallge(o. l d )bth 5 iocc olIliic lprla- meters ani( FI; inputs plav it part in (ldttl iiiiiiiig val iatioiis ini con- tracpl)tive uise and family' sic. Rc% jicw of sc1(i oC mi1c011W stt(lies b)y Jaimi (1975) and P'areek and Rao (1971) suggest thie lollowiig conclh- siorls I TIhe lower the level of per cap)ita hlolieclhold( ( osmuipll)tio ex)eI1(li- ture, thle higher thet hbil 111 rate. FoI examil)le, Irtul 1l()l l )ollc ls aIt the very bottonm of the income pyramid witlh per ca)ita expendli- tuires t1l) to Rs. I I per mlomllhl had a h)il tiitc of'f 41.3 per 1,000; lioll;eliolds Spend(ing mote tLan RKs. 14 pier capita per iiill lia(l a )ibirihate of 32.3. Urban Ie-sidleil have Iliore illf0i mma.Ii i and i11mc fc I a'rile a1tti- tudles toward Fl) than those in the couili iside... Ihlle siall-falilliil nior h1S Iisian iore a1(1ld(hercitt in Iur'bani places than ill villages. fBirdiriaies arc lower IoI urban IioII5CIIl(olds than rural onles at (ollpJlhlIl)ic levels of per (apita ce\lw1l(Iinlic , .iltiOligh this is not aiiw.iws thes case. FIoi rbtirban W0l11C Witlh more thall a fililited amlnlillt of so moolilng the [Cr tiiil\ rate de(dill'es willt cm\t' i II( I c.luc ill the 1(.%(-I of cdl tioni. Ap1mic (11t tlhe uifC(Is citl .tioni is moe ipm)1 t,iiu tlhitui tile litisbandlS. Fd(Imlim.1 is of (oIll"dcilaideb iciijn(iiaiite in mpmA);liill- inig Nai i,imiwli in kIm%l1cduc l gal (cdiig FP. It tenluls to 11,.lkc people receptive to new i 1 cas sluch as SIliall-faimiliyv nIor'ImIs and explxid(l. the choice of colltuiadeptiu e miletdioms. 'I'here is niot 1m Ii dillichi (ce ill the lcllii\ of Iillin(fIu .d111 Mu;sliliIN, but lc tifit% is lowter tor (Ull i ians and higher f)1' Sikis, L.owci- caste liill"ills have a smgnihi(Illath IligheI ciilllit. L.alldle(s laborers temm(l to liaNe a higher iesisc.lamc. to Fl than other occupait);lllOll g1 m1pN). Young people show a greaterl p)IetelnllCe for' Inil 1.1111lies tlIan1 old( p)co(p Those tli illr itl j4)illt l.iiiiilics teldl to le less il fill (d t(1wiarI FTl' than llcillhcI s of [I0 l(.,II l.liililific. I lis tentative (()II( liisioIl iis based onl a raltiel liiliicd set of studies. ''lte impo1)0ltalut of' soci0c(Collmillic p.11 .uite'l (cll he ihhlll"l.lte(l allso bhs ailuc;l ilg tel(, a .11 1'i.i , ill ( .1m ell iiCP tUse at the hloulseol( d X Nfa.um of thl('e %t1ite l-t (' , p.v tit u Natci.l Sut ipit Surt ('. 1 tl Ii t ,1 (ddl th catl Itld 1 ttisXtu s. INDIA'S POPULArION POLIC(Y 425 level. A survey conducted by the Baroda Operations Research Group (see Table 3) found that the incidence of contraceptive use in 1970 was 2.4 times higher than the overall national average for the tiny miiinorit) in India that enjoyed high incomes, college education, arnd city living. For the popuilationi living in grim poverty, the rate of contraceptive use was well below the national average. FP perfotrmn- ance, however, varied considerably even within this category of pov- Table 3. INDIA: HOUSEHOLD) CHARAC IERISI ICS AND CONTRACEPTIVE LTSE, 1970 Current users as percentage of couples at risk All Modern Terniinal methodsa methodSb methodse Family imicome (Rs. per imionith): Below 100 10 6 5 101- 200 12 8 5 201- 500 20 15 9 501- 1 ,00() 29 23 11 1,001 and above 39 31 12 Education level of wife: Illiterate 10 7 5 Primarv school 21 15 10 Secondary school 34 25 12 College 56 38 9 Location bv pol)ulationl size of settlement: Rul ral: Below 5,000 10 7 5 5,001 and above 18 13 9 Uir-ba n: Bel)w 1((,0(( 24 18 10 100,001 to 500,000 29 22 12 500,001 anllt above 32 26 10 All-Ini(ia average 14 10 6 a Consists of both modern mnethiods anti traditional ones, i.e., withdrawal, rhythm, and absti- nence. b Consists of terminal metho(ds and loop, pill, condoms, (liaphragm, ancd jelly plus foam tablets. .Male and fetnale sterilization. SOURCOE Operations Research Grioup: Famib' Plauinning Practices in In(lia. 426 Public Policy erty liousehol(ls. perlaps becatuse of (lif'fercrices in the qu1iality anldc quantity of the FP interveentioni. Suitably designed, the FP program might be able to hasten the accep.auwce o; (coitracep(tives an(d thereby the process of fertility (lecline even ini poor liotiseinlds. (CiitiqUe qf/ NA71' Poputlation Policy Popullationl policy was giveni a new twist in April 1976 an(d theti again in April 1977. TIhe stateiients that an noic eel the two policy clhaniges must be rea(d against. the long anld c(oiinto" ersial history of FP in ln(iia, which has been marked by many exper;iiiiments and maniy failures. The April 1976 policy ha(l three tiew feaiturles: a stroing political coirmntiitulleuit, a prorninent concern for the p)t()leiii of cle- mnand for FP, and the attempt to incorporate the age at mairraiage as an inistirn mniet for chanigiiig fertilitv. The 1977 p)olic endorsed these features, inaking it conivenient to discuss the two slateilneiits together in the context of earlier histoiry. Not ilhstuiuIhi g this comuliioml gi-oumi(L, there wvas a ma ijor (i i fTeretice bcetween t lie two policies. [Ihe 1976 prn)ilOmimmclcCieIIt opened the (loor to a ''comilq)ulIsor :mp)pJroach" to FI), as we explaini below. Btut this postuI'e cmOil(l nlot be t(stllilledi; it hadl to be reversed, eveni beforie niationmial electioiis in Marlch 1977 lecl to the defeat of Mrs. Garndhi's Co)nigr ess party. A iimiuth af.ter inlic election the niew ,Janata governm-ient issue(d a i'evised polvpulationi policy that rejected coilnpiilsi(ii ini io ice(naini term2iis. atlionadl (Cm?litiflt. Political suplp)m)t fOr) F1l hias beet lukcwnI iii at best during the 25-year history of' the programn. I'he Gautdhian tradition suippor-ted FP basedl oni sexuai abstinieicei but (ldbivavired iiio(lermii contracel)tiese. lJawahithrlal Nehru felt that FP wals a (diver- siotl; the maiin ctoin inutment of government must be to iraise the sltlan rd of' living of the masses. Shastii's views on this topic are nlot genlerl;fly knowtn I)uring the first dlecade of her I)iiuie tiiuiiistership, Mrs. Gamcldhi gave little at! eiit ion to FP. The- (o0igiess partv d1id niot f'ormally list F' as a political objective until its ('lm1111tdiga rhli sessiom iln 1975. 'I'le 1976 lImpinLihatiioli )oicy tin l(1 ei-scm cl the goal ofi ' I (luc ing fl'eihumv as a m111mjoI' mi;tiommal comInmi1itillelit and( a)ss)cimel the Primne Aill ist em' i)iYS0id s1.l, witlh thiis eff'ort. Il'e Y)iit tii Coi gi ess, midvir thie leadership of Sijiay (;Gatidlii, adoptedi FP as a major platnk in thle INDIA'S POPULATION POLICY 427 program for national reconstructiorn. Chief miniisters of state gov- errnments echoed this emphasis. rhey vied with eachl other to coIIm- mit themselves to very atmbitious FP targets anid pr):inisedl to nI-obilize the eIitire go'vernilnent miacliiile to realiz.e these goals. 'I'lle ilinillecliate qt:i.llntiiative res'ilt of this high-p() xccC(l ( alilpainli was astonlishing, but it ha(l to be lalaiiced aganinit the l)potests, the resistance, andI the concern felt by mnany segmenits of the p)opu! ation(M. With the relaxation of the Emergency and anhioLiniceniieiit of elec- tions ill JallUallrV 1977, the volume aci strength of oppositioni to the FP cailipaigli becamie evi(lent. Io cope with this oliLl)LUrSt Of l)l)li(U (lissent, many of the coercive FP mIeastiries, (les(rilbc(l below%, were withdrawni. The electoral defeat suifTred by 'Mrs. Gandhi and(I ther party reinfor(ced the imiipressioni that the FP prograim lha(l armosed the wrath of the people. Not suirprisingly, the Jaiiata government quickly shut the (loor on co0mpulsioll, chainged the name of the programmie to 'Tlaiji welfare," an(l, at the same timiie, expresse(l its total commitment to aclhievimig the ini(idlying ol)jeotives. In practice., however, it will not be easy to inaintain the immonientimiti onl a (1olmmm- tary basis. 'Ihe albaiicloni maemt of the 1976 ciraslh progriti has left a trenlnenl(dms void, am(d the canipaigmi is now 1 imunimig in low gear. DemaindelSmlnlai/n. For at least the first do/ei vears, the Iilndian FP progriaiii was supply-oriente(l. It a(ol)tetd as its minajor mission the expainsion of the ai%ailabilit% of (outr pl%e lllateiils. Ilie restilts of su rveys of kinowle(lge, attitu(le, antd priactice togeiliem with the wi(lesprelad existence of abortion were taken to imean that a iealyl lemnanl(l for1 FP alre(lvd exisie(l. Disappoillllitemn witlh thle results Of the programi lproiipte(l the go% emimnient to iiit iact ani extensioti effort, inclu(diling houiseholil visits amid face-to-lace iliotivatioll. TIhis was slI)j)leClnte(l in 1966 by the use of the mass imiedia to create awareniess atn(l mo0kl pu1blic opinioin. Indiila becmie onie of' the first coiiiit ties to uise inonetai c pi-'nients as a nm.'anl of' pl)roiotiiig FP. Thle piractice st:rtedl as early as 1958 in Iniiil1nad(ii and sprea(l to Mallaraslitia ail clsewliere, In 19ti6 the goverinmllenit of' India allo- cate(l 2() percetnt of' the FiP budget for suich payments. I'he fdlll(s cotl(d be divided, at the (li.cretion of' state gomernnimemmts, aniomig (amiiassers, (loctors, aII(n acceptrs of HLTD) o' sterili/ai ion. In primci- ple, the payilnents to accet)ors aiie at (oi0iipeii.ailing themi fort loss of' wages, inchtental cxpelises, ant(d in (omivemic(cni. 'IThey %erc ilot 428 Public Policy intende(d to be incentives. By 1968, thiese pav'cccents for viscctoccyll varied from Rs. 10 to Rs. 30 in difTerecit states (Visaria, 1976). Later, mass visectoiii) camps raised these IlI0LInIoItS steeplv; Rs. 86 was pai(d in the first Er-iialz actck.cx camiip andcl Rs. 114 in the second(l oine. Later still, pvllyellts otn tlle ordier of Rs. 100 beciiccie standard pr;i( tice in stalecs such as 'I'auiiilnIa(tU and(i \ciharashtra. Il,ese ale big sums for poor lhotisehol(ls andl canniot be realcisticalll' (lescrilbedI as c olip )ewil- tion. They serve as miionletary incentives andl are viewe(l as such by personls conteiiiplatiiig stcrilifaztic cn. Howv effective th.ey have been in proinotil,g behavioral chanige is not easy to establish ConCluIIsiVe%ly. Ihey seemn to have l)lpye(l a not ihisigicih( ant role in the miiass vasec- tomy camps, partiCnlaIrl V in obtainiing cceptors fromn verv low- income groups (IBRD, 1974). I'he concern with demand(i for FP domiinlated the 1976i policy statciiement, andl this emiiphasis was mnaintained in the 1977 ver!sion0 as well. TIhe approach to the problemi was miany-si(led. First, a new nitLIkirnlLelia miotivati joial strategy gear-ed esl)ecvailv to ruiral a reas wa.K, planniedl. Seconid, iioInetaril-y' incentives weire eXp)itlded, and a incea- sure of fine tUninlg was illtio(hiced; Rs. 15() was pai(l to those who had two or fewer livinig children atn(d accepted stcriliIat ion, Rs. 10()( to acceptors with three clhii(reic, anid Rs. 70 to those withl four or more. 'Third, "ggroup inicentives" pitchedi at the level of village, dis- trict, and p rofessionial organizations were advocated to SLUppleiiieiit iclceittives flor i dlivi(dl ul acceptors. Fourth, center-state relaitiols were tilted in a distinictly anti icatalist di redtiOll by freetilg rep'rese ll- tatioII in legislatures aii l allocatiloi of' fte(dr.al revecicti to states on the basis of 1971 populationi figures. Furthlercnoie, 8 l)ercelit of Cenltra,l aid to states wvas to be geired(l irectly to their performain;ce in FP. Ihe states wohl(I n0 longer gain lpolitical or financial leverage throuigh i)optllatiojl gr-owth; in fact, redlticel fertilitv woul(I be re- warcled financially. Fif th, special miieasuri-es wvere lprop)ose(l to im- prove feimale edtiGHn0c1 an(d orgaiii/e child litUritioll p)rogr;ai1is in anl aIrticippt to stiiciilaite dtlenaiid for fertility redclll[ioli :iI(l FI. Ihlese were inicagil;ative iniitiatives which partly extein(le(l al cl;al)orited the progra in aitid partly broke freslh gi-otlll(l. TIhe 1976i l)oli( nOt oIlyV iid(l to stiiutilate (eIdaicld for FP} hut it also opend(l the (door to what iuia% be (lescril)el as the coin1pnlNory) apl)proachc. \Witihc,cli citing any evidence, the policy Ntateniiicm iasscrted that ". . pUbl)liC Oillion is nIow ready to accept IuLC1 miore it rilgent INDIA'S POPULA'TION POLICY 429 measures for family planning than before."2 It ruled out niationwi(le compulsory sterilization "at least for the time being," but only be- cause the medical and administrative infrastructure was iniadequate. It permitted state goveinments to go ahead, however, if they felt they were ready to cope with the problemns of imiiplemiientationi. State governments were also permitted to introduce rules mnaking em- ployee benefits-e.g., housing, loans, medical care-conditional on the sterilization of one parent after having two children. Further- more, the use of administrative pressure in securing adherence to the two- or three-child norm derived its sanction, albeit implicitly, from the spirit of the 1976 policy. Given the near universality of the government presence in India as employer, creditor, landcllord,l, and also as the giver of licences, permits, ration cards, an-d the like, the scope for the exercise of such pressure was very large. Moreover, the distinction between "civilized pressure" or conclitionality and "coer- cion" tended to become academic, particularly when the citizen had little recourse to the courts in the case of executive arbitrariness. The big expansion in the number of sterilizations, if it really took place, could be understood only as the result of the widespread application of adininistr;ative pressure or coercioni. Official figures claimed that the sterilization target for April 1976 to March 1977 was exceeded by 91 percent. More than 8.1 million men and women were sterilized during these 12 months compared with 2.7 million in the previous year. The increase was particularly striking in Bihar (573,000 versus 167,000), Madhya Pradesh (1,001,000 versus 112,000), Rajasthan (364,000 versus 86,000), and Uttar Pradesh (838,000 versus 129,000). The new measures for stimulating de- mand for FP could not have yielded such a quick payoff. The results also could not be attr ibUted to :hanges in legislation; the Maharashtra compulsory sterilization bill was passed by the state legislature in August 1976 but iesver received the assent of the Pr-esicleint of India. (,her states that were contemplating similar legislationi, such as Puttnjab and Hlarvania, held back, awaiting the outcomne in the case of the faliartashra law. 2A survey based on 1,000) interviews with literate people in Botnbav, (alcutta, IDehli, an(i Madras concluded that ". . . public opinion even in metropolitan cities has yet to acquire the kinid of momentum which alone can maike compulsioni a viable proposition" A very high proportion (94 percent) favored FP, but only 36 percenit of those favoring I:P agreetd with a policy of stalutomuv compulsory sterilization Anotler I I percent favoretl economic tdisii'e mix%C% agminst large families (Indian Institute of Public Opinlioni; Mt.u:,hlv Public Opitniont SSurvevs, Vol. XXI, No. 5: Blue Stuppleniien i. 430 Piublic Policy The em)phasis oI1 qulick remslts tlhr'oughi rotigh and ready admrruiiiis- trative pressure and seIicomIrptilsoNI tactic s proved to be costly in ternms of both the iiijiilries to those dh-i tlv afTected and the ill-will gerieraic(d for the entire I;) effort, iiiclui(dinig the reCgriZ p)iogriamI based oni thle i(lea of v rhmtmilaV cIcetanICe ;1rr(d CXItCsion. II'h-. backlashi against th1e c unrIisoi-! applioaclr riOt Ol1y d isiet(li ted Ft' but soured the basic i elhtioti betweern goverm ilme anlll people, mak- ing it (IifICUclt tO iipl)eueICIClt olith social or economic policies. Th'IIiS episo(ie ei(led( witli the (lefCeat of Mrs. (G;aii(Ili's governrimelit, buLt the task of relhab)ilitatinig thte itegr-ity of popiiilitioii policies relliairiIS. Ihe question of stinmnlati ig (ldeniriind( for PT is ci-iii( l; we take it ul) again in the next section. Xlilim,llm, Marilage Age Law. An ilntnovation in recent l)mlatiori policy sitlerIrerits is the l)rOpOSe(l legislation to r;aise the ]ijiIjIIIIIIn mairiagel age fotr girls to 18. SiaIItinlg with the Sarida Act of 1929, there is a history of social legislhtiori in India 4rimiririg at the iremmioa11 of "nraladjiutrureitss" (child widovs, premlature child hilwis) ani(i the ir)o(ldcrii/atiorr of the sscilm of 1r:rlriage. 1'lie umilliuiiii n age ftor girls was set at 1 .11 n 92) and raised to 15 ini 1955. Ilie ob)je( tiv (es of the pi-oposed Ilaw go fuertlic: to lhelp safeguard the healtlh of thlie miiother and the child, to lead to a i!lOIt Ie'Sp)ollsil,le Ir it lit n ni to enable wvomiien to play their proper role in the countryvs socio)Cco- nomic and ctultuiral life, and finlllV to' -I1,tVC a derioIrsi1N(r bletimo- graphic irimpact" A mieaivi re of a ou tii i about thiis oolll)omlieXIi of l ilit ! is ill ordr for two reasotns. First, ifI history is a cy guide, the l)r !Osed law iS not likely l) be efTfctive. '"lie average mri:rrniage age for felimales did icrleaIse slowlv Over the last lialf'century or mor'e, buit it is doubtfull if legislation per se l)l.r '(I any significant role, except l)pel al)s in ifl fenLCilig the attitudes of the hii rba ;va rr-gar-de. I he l)reViotL.slV cite(l survey of rural Varainiasi in 1967 imirlicated 1mi a (1) two-thir(ds of receint miiariages took lad e in viol,rtiorr of' tie law, about the aiuieC propoortion as a gerreratiomi ago; (2) the rurmui.er of ric),lorlecIms whio said they kinew the legal iii iiiiti iim age varied fromi) 6 percent of the total in the least acceNsilble villages to 26( per'cent inl the Iiosi It( cesi- ble oneCs; (3) theS iruiriber Of' W(leiiIs who had M ( Ll.t'iI!r kniowl- e(ige of' the law varied frOI1om zemo to 3 pirceriii of' the total1 (4) "general ap)aIlh or1 imidiTCfC C ere C regir'dirg lrw r11d(1 legal ullauer s ;1rid their errforce cienil seermii to chla(atl erie . . . this gor rl p of' villages." INDIA'S POPULATION POLICY 431 Surveys conducted in Maharashtra also suggest that laws regarding the age of marriage had little impact (K. Dandekar, 1974). Recent policy statements recognize that "the present law has not been effec- tively or uniformly enforced." Nevertheless, new legislation is con- templated, and the authorities are considering "the question of mak- ing registration of marriages compulsory.... Second, even if the proposed law is totally effective in raising the minimum marriage age to 18, the demographic consequences are not likely to be so large as they might at first thought appear. Instead of reducing the reproductive span, the increased age of marriage is likely under Indian conditions to shorten the gap be- tween marriage and effective marriage, and between consummation and the first birth. Surveys confirm the well-known phenomenon of "adolescent sterility." Many years pass before a girl who is married young conceives. This interval tends to diminish as age at effective marriage rises (Jain, 1975). Nevertheless, some reduction in fertility will result if the minimum marriage age rises to 18. The incidence of childlessness3 tends to increase with marriage age and also that of secondary sterility (in- capacity to conceive additional children after bearing some). Surveys show some reduction in total fertility rate as marriage age increases; of course the drop is much more imiipressive above the marriage age of 20 (Jain, 1975). It is questionable whether these declines should be attributed solely to rising marriage age; the combined effects of improvements in women's education, socioeconomic status, and em- ployment opportunities are presumably also important. But even if there is no drop in the total fertility rate, the postponemiienit of marriages will bring about a relatively large temporary decline and a smaller but perceptible permanent decline in the birth rate. Issues and Options Did the April 1976 I)ol)tlatioml policy exhaust all relevant issues and explore all available options? The Maharashtra health miiiister is reported to have said, "We have tried every trick in the book and 'S. P.Jain .1975) reports the folowdiig lindings. for example: for cohorts inarrving below age 18 in rural Punjab, 2.9 percent of couples teln,iiiICdl miliNllcN% The incidlence of childlessness rose ro 4 percent for cohorts marrying at 18 to 22 years and to 7.6 percent for those marrying at 23 or above. 432 Puiblic Policy now we have comiie to the last clhapter," i.e., c(mp111pu1llsory S etV ii;ltio1ii.4 Had the govemiciriet itcl( Ie tried everv possille .ilppi ).l h Now that (coercive imteasmt -; lhave been rejecte(l by the Ji i midil govel\( lBlUilt atn(d by inijoi oppositioni j.irtics, it is impol itaut to examirille once again the vali dity of the miiiiit cis p1W ilivii ye plea. 1- I' uoii11 a el , the 1977 policy Impci1 (Ioes lnot do so. ITree (fIC'tliolls t'iv(d to be I11ise'1. Fiist, are resoturces lwcstiSt Il itvalilalc to tile FP In ogi atl heitng used to thie best a(dvanr.ige?| Th is is the tialrrow isset of tmaitgo.ttmttll. Secomd, is there a case for dlivel 1ii ig more ridnigetal i csIlltt'ices to FP. TIhis is thie i%idlet' isst of' o iillrc:tt iom. Imillv, whliat Imfi ic. andl pl-ogr;aims, F4P or others, CaWl it'-d inc the fertilitv of the very poolr househiolds who) (cmistilttt the bulk of thie hitdimit poptblitiott IThis is the wi(lest atndi molOSt (cottpli(atedl si rategic isslic. Natmt;tlld , the tiree (jiestioiis are closely irttenrelateI. If pjresewt Iesources are 1i)(llN mtisirtmiaged, otie canll scmicely miaike a case for pumpinig extll f-ll bd illto VP unlitil the existinig itlefli icricy is cradlicat endI. (it cECil ole- plovmititi, hiOever, miaia in pitlt be the restult of the fact that tlhe vol'umtIe of available ic' ltnmilces falls slhoit of the critical miinimumi iiecessary to do a re.iio)it a)h goodi jot). SitirihI v, .1 positive anIswerI to the second quiestioi iiaytlv eltcell oil hlow thle third is resolvel; additim itdAllo.itimis to F1' tunlv be ji -d ofiecl nliv if it is dclci millted that the FP dlelivery s51t'1ei has the cqcl)iit to cater to poor hotise- holds arnd that their fertilitv can be rctIiCedh b gotiie comhtimitmi of' FP anId other policy tisritelictilk. Better FP Amagemenwrt. (Governlmlelnltt e\pemnliutes on FI) hiatve lisen' steeply but they have neverl ratlihcd evenI 2 plie(cit of' total devel- opimnent outlays. These vemmlice", hotoCVer, aire tiot beiig lisenl efli- ciently, because there is (1) a lack of' consenisuis on goals, (2) a leaidlershlip) vac(uuIm at the field level of adltiillistai-iol, and (3) a gnawvilng ( liltilt ril gap hewc eeti the village (lieit lde anl the prograiii staff. 7argets. Unt11il 1966 thle goaIl of tlhe I1d(lian11 g(et( titeLiti ws;l to re(dlice the birth rate to 25 per 1I,000 as soon as 1possihl1; tIo (late was pe(ified . Wt1len thle (Ce. t i-al )el M ltni et of FP was c. tbl isbOedl inl April 1966 it set 1975 1976 as a target. 'blis wasIlater p sist tolled to 1978-1979, amid IIost itr'(ccc!t to 1981- 198-1. IUiiig thiese overall objectives itl(l ai selia s of (tite hio ' i'm i(l calculationIs. I1hie Dct) ,iitt nelit 4 titervjie' leptIted thn W111.t m 1). HIL t etlo i Stlreet marmtl, Judv 7. 7, 19;7 INDIA'S POPULATI'ION POLICY 433 assigns targets for each vear anid for each FP mnethod to individual states. In turn, targets are allocated to districts, primary health cen- ters, health subcenters, and finally to individual FP workers. The flow of instructions is from the top of the administrative p)yramiid to the bottom, with very little iiiform-lationi or analysis flowing in the reverse (ireectioni. In fact, very little relevant infor-mation is kept up to date at the primary health center or health subcenter. "rarget Couple Registers" were found to be poorly maintained in inani) cases in a study of eight prirmiary health centers in Karnataka, and even the limited information available was not used (Gopalkrishnayya, 1975). A similar conclusion emiierges from a detailed study of Noorth Bihar; the author found the available record so hopelessly inaccM-ate that he devoted 6 months to building a reliable factual picture of the prevailing situation (Blaikie, 1975). Understandlably, field staff feel little commitment to targets which are imposed on them an(d which are based on minimal information. These targets bear little relation to (o)nlimiunity (lenmiand(l for FP or the available resources. The establishmient of targets for acceptors ai(i their allocation to FP workers lead to some demoralizationi wvithirl the program and the recr -it imnent of ''(leinogmaplhicallvy margiiial" couples. A survey in Uttar Pm idlesli slowed that FP staff were punlisihe(d with nomipaytnemt of salary, threat of dismissal, or actual firing if assigned quotas were not mnet (Elder, 1974). In turn, FP workers responded, it seems, by abandoning the principles tincierly- ing extension education. TIhey passecl on the bare mumilninmmn of information to the client-how, when, the whlerec to oltai n contraceptives-but did not explaini the basic raitiniale of FP for the household or the side effects of colltr;'(cept i ve uise. ". . . the imiage of the FP workers in rural areas is that of persons who use coercionl and other kinds of pressure tactics and offer bribes to entice people to accept vasectoniN, or ttibectomny' (Ba nerji, 1973). Since revenue offi- cers andl staff controlling cre(lit aiin ag riciilt-ral iil)tits cani exercise greater leverage on villagers than FP workers, the former acquire promninience at the ex)pense of the latter. FI'rtherniore, couples acttu- ally recruitedc tenId to be (I emnogrplmpically marginal. A sllmrvey of severn Uttar P: adesh (listricts codl(lumctedl over 10( montlhs in ! 968- 1969 AoNvoeld that 62 percent of those vasectronizedl had wives aged 38 or over, five or miiore Iccildreni, or both (Elder, 1974). A 1966 SLIIm'%C%' by Ranibir Singh in onie Utta1r ra liesh district hadl shown 434 Public Policy equally disappoi ltilig resuLlts and reveaile(l Sigilic[iCUiii (li'Slortioiis in records; although official data indicated that 14 percent of' those vasectomized were over 5() vears, ain otn-the-spot verif'ic'atioI suggested that the actual figure wvas 49 percent. The history of' target settinig is dlislual. and(I the niixiety to obtain quick results throughi adiniiuiistrilaive piressnie (Itirinig 1976 has furthei uiid1(ermi11iied the imiorai;le of FP workers ad iiiimlagcrl's. It will take time to rehabilitate the voluLntary prinlciple and(i the iintegrity of' extension e(lucatiol. Once this is accomplished, the process of set- ting goals, monitoring iiiiple)iieiitati mi, and( evaluating the results will need to be recoilstrllcie(1 on the basis of' reliable in fortiationi anid the genuine involvemeint of frontlinie FVP wvork i;e and their imrtledli- ate supervisors. The hierarchical, btreitcicratic pri1-i i)e of' o1g;111i/a1- tion will have to be replaced by a much more p)arti(ip;ativ style of' opetation consistent with the inno'.ative missioni of' FI and(l its ex- perimental nature. Field Leadership. Ihe key fieldl iwn;mu gcrs of' the Indclialn progr;1;m are the directors of' the p)rinliiirv health ccouteis and the a;rtluhed rural ;,amiiilv welf'are centers. Each (lidector is respo m%ible fi'o health and FP a(ctivities covering about 1(00,00)( peop!e. The (lic c10ors supervise staff i ri volved in curative atndl p n li(vcui in ic 1 c tii i, epidemic (disease control, basic healthl e( ct iouoll, en1 virol mctl sanii- tation, an(d maternal and chil(d care services, iiichlidng FP. A part of this staff is located at health snihceniters, each of' whicl cover"s al)hlt 10,000 people. 'These execnitive heaids of' the lli'lllmnu healtlh center are physicians with a Bachelor of' Medi(cii e degree .1il1 Solle practi- cal experience. 'I'hey have an extremely difficult r'ole to play, given the incorptawbhility between the large size of' tleir task antd the very limited staff' an(d mlriaxiill rTSoLIr(ceS at their conumnan.lnid. Given also their prof'essionafl trainiing, which einiphiasizes curative iiie(ii(icie on the Wlesterin imod(lel, it is sc;rcely smrprisinMg that these (loctors have not proved to be ef'fcc'tive mana111ilgers. 'I'hev tell(I to enlmal)}1.si/e their functional role as healecrs and1 to iginore their (milnillistrallive or' super visory (dtties ((opal kI 'ikr i sma \a, 1975). l'hIlev lwx e lii PMlp t1c') C ic' with exteisIio edtiucairion an( sOliie regard VP as ;lilibolal (B1Likie, 1975). If' this picrtire is a fiair rep e sen mlt ioll of, thl(e sit i;iou, m 0111tn hard qLiest ioiis mnust b)e asked. At the vei'v lc'tst, a serx iouis oxf'ni11.111011 of the cUlrri(llmi wld traiilitig of doc'tor.s (Iesuinut to be V'P in.11nlagel.r INI)IA'S POPULATION POLICY 435 in rural settings is required. We may also ask whether the search for executive leaders of the primary health centers should be con- fined to the ranks of physicians only; perhaps people in other professions with experience in rural areas slhoul(l also be considered. After all, FP is riot si111ply a medicll ;1CaiVitV. It IlC(qlil es a n Lti(lidC il)- illmr.' appro ach ; p)erhlaps the iliost important atilihiite of a health -aid(1 FP mianageim in a riural en virloll ientC is knowledge of and work exp)erience in this enviloroninent. Of(ficials who have exercisedI execu- tive responsibilities in somie field of rural dlevelopmnernt can make sticceSf'sil FP ii:inagc'rs. TIhey would, of' course, be able to draw on the expertise of the iiiedical as well as otheer relevanit l)lofessiols. The (Cuttl(raGap ( .I hIle doctor-iiianager ai(l most of his FP andi health staff tend(l to have an urban orientation in termiiis of flmillilv ties, residence, e(lhication, and value system. When illi-i odLICillg newv ideas or techniques in the village settinig, they operate in an alien enviromnlueit. This cultural dliqt aince can iiiic(lellline the quality of the iliteriaction between the clhiaige agent and( the cliernt population., uniless the formner is extrerinely well preparedl and(I works with (de(lica- tioin timn(lem expert slupelrVision. Under Inidiani con(litions, the cultural gap has pr-oved to be an iiporltanlit iin peW in ieiit to the spread of' FP, giveni the Ii miital iois0 of staff triiiiig andi the abseilce of' execlitiVe leat(lersllil) at the prilliair\ health center Clevel. In a 197 1- 197') suirvey of' 120 villages in the Allahaba(l Divisionl of U'ttar Pradlesh, very little contact betweenl field workers and villagers wvas reported; the latter spoke negatively of such contact as did take place (Misra et al., 1976). Ihe low coniitact was amilih)litedi atimonIg other factors to (1) ahsenteeisni , ir'lc'gmilarl attendaiwce, and( ial iger- ing on the part of the workers; (2) dlisinterestedlniess of supervisory staff in fiekl work; ani(I (3) poor inotivationl and lack of' training of work- ers. 'I'wo-thir(ds of' the village wives were aware of FP imietho(ds, and nearikl half' did niot want a(lditioilal chiliren; but only 14 percent WCFC' p)acni(ilig (oilt iael)tcion. In allotler sttudy, FP wo0lkceis were s;1id to be Iiigli-liaimid u1 and timi responx sive; tlie iitixii ai'yti m'1111se- midwlN'if'e 1)1115 the L.ady Health Visitor were (des ribed as ina(ce.ssiFblec to omd'ill;lmy villa.gers (Bainicijii, 1973). Uset's of' Nii'odhli ('Onil)lai ned thiat thiey 'ould nIot get slill)lics routi FP centers, wliich were said to be sellinig tlwil ilc'gally to comiluierlcial I'('taile'rs. I'hle failuire of url)ali-oliclled(l fi'oiilinie FP wor'keu'S to be sensitive to the il u yt1lmll of peasami1t societies is after' all nOt too SLl'p)l'isiilg. 'rhe 436 P'uiblic Policy same diffictulty has beeii exCpenleclCed ill 1gr-iculltur:lal eXtlesioll, edu- cation, and( rural tevelopmem genelly, tthe change agent tends to be ethnocenitric. His air of sLiperioritv is likely to be resenited b)y villagers steepedi in traditiin and suspipioms of' o0itsi(lels trying to change things quickly witliowL (co1p)rhellemilig the totality of' village life. What. is perhapl s mioie s1ll liii g is that eveli the ;1i it ii((cls of the FP antd( health prograllms have apr)l) oahed11Cd the p i sOIIe WitIlOtlt much mniderstanmiiig of village resotn(es, attituids, an(I1 belief. In- steadl of building oni the p)revalem tr ditiomil systemil of' health care, policy makers in D)elhi an(I the state cap)itals seem deteriiiilled to lisplace the village regilute by nIcr )l tni iiipor tel techi,i(Litiies and by personinel trained in cities on the bhsis of( UlTililk ilesigllet al)r 0;(i. This approach has generated a lot of frictiom andl imneccessary tenl- sion. For ex.ample, the FP prograimi thlouMghoutl its listorv hlas suffered from a severe slhrltage of expert staff---octors, particutlal11Nv fenlllald doctors, and aiuxiviaiw Thse-Ini(li\ e . Ihe pas;Sage of timiie has nlot relieved this problem. Yacanlwv rates are iligher in phiacs far I.twa1 fromii urban ceterls and short of' basic in b ih;t icmct and e 1 anCi 1c 1 c.- tioTial kacilities. \feMam-ihle, large tlinl)ers of Inll(iall doctors and mlurses mn igi ate to thie li iii ted Kiingdmii and the t' nit tc States after finiishinig thieir medical stut(lies. Viewed from the slaildpoilln of' these indlividuls, the lplrspect of moving fromii thie metropolitaim cities of Indclia to those of Western cou xntries appears to be milu ch mnore attrac- tive tlhantirlling V.MaCaRic' in the aliell itillmr co lltvXt of, thle rtmole village. Despite this chIroimic diFficulty, p)olicv iak-kers Iavc Ulot turned to the rea(dily a%vailable alternative, the pool of ill(digenlors healtlh manpower that has alwavs I)ro\ i(le(d the bulk of me(iical care in the villages-tlhe aN r\ edic and unalli doctors, .'1aon.'Z and bhlageK. These people are in tutne with the village environ merit, tlhey are highly respected, andl flivv could play a valuable complementa1Y role in the (tf iial healftli and FIV program Mndellamuin, 1974). TIhie \\cstecl1-c(hcateawd 1n1diam doctor, hrowcecr, has tetl(ledl to regard these i(elicail Imlenl with coiwier:t1)l e colriteipta lid t lvjuically de- scribsl) their approachi as noiiscienr ific antiI o1))o01tt. Altlhouighi thle gover li ner it lhas recognized thieir' existncl )vc r' 1cgisieiiig somlie of, themii and funds have b)eeii a mclde for research in Itse schroo dls of Imedici le, it has miiade tno sel inis .isI epiiit tO imp( 11ate these in dlig- ctlit)S doctors in the ofl(i:il healthi and VP met work. tIhe idlea was IN)INA'S POPULATIION POLICY 437 put forwar(l in an official paper in 1972 and was inentioned again in 1977, but the probability of effective implementatioll remains low (Qadeer, 1977). Several attempts have been ma(le to train the village tidlwife or dlai but with disappointing results.i Yet another miianif'estation of the cultural gap separating policy iiiakers fromii villagers is the fact that the forrner have shown little ;lpl)e'CC ;ltt1IO of' t riditiomidl values that tend to lirnit fertility. Periodic sexual abstinence resulting from the observance of customary taboos, coituls initerrutptus, and the rlhythni in ethlod are used widely. 'I'lhe Operations Research (;roup survey reveals that these traditional itetlho(is account for 29 percent of all current practitioners of FP (see 'I'able 3). 'T'he rhythm method was a favorite of' the FP au- thorities during the early 1950s but long ago ceased to receive their attention. Custom reinforced by peer group pressure against preg- nancies in quick succession or after the woman has entered grand- nmohei hood are powerfuil forces that cotuld have been exploited by the FP program. InI fact they have been igniore(l. 'f'hose using coitus interruptuts have not found elncoLur;mgemnleCnJ or counsel from FP workers who regar(d this l)piatice as falling outside their puirview. Ai J()tioin, allothelr widespreadl pra -ice in rural areas, r emaitied out- si(le the FP scheme till 1972, when it was legalized. Eveni to(day most FP centers are niot e(ltij)pe(l to lperlofin abortions. 'I'he sharp (dualisrmi that selarates modern from traditional India has provedl to be ani obstacle in imnagingi health and family- plannlring activities. 'Those resporisible f'or the basic straitegy c.annlot aff'otrd to be cloctrioiaire about parlicUlar schools of' meedicine or specific techniologies. To obtain imiaxinmLumni resLults f'rom very scarce avililable resources, a search must be ma(le for all relevant solutions, takinig aiccoint of' the ecoomitics anIid the sociology of rural India. A Bigger Buidget/or FP? A great deal of' emphasis should be placed on im pr vedt mniagement of' the FP programi. Still, at some poinlt [i rilrthi pm-ogiess will not be possible WithOUt a relaxaiion of the ITrSO1mc(C (olislil'ahil fiaced by field mantagers. The nature of' this CoHsnl llrnt cani be illtisiimatedl by a variety of idices-av;tilabilit)' of velliles, (dru1gs, au11dio visual e(piil pllelnt, andl the like-but perhaps RogerS and Soloiotn tin d(late) cite thIe followviTng reasonIs for dlisl ppioiiii cl iiII u (I) thTeeda has a low sonral status In the v illalge; (2) thie in (entive tci't, I bv 1 tihe go e'i r iiiicii to thedat for FP work was too loiw to offset the loss of earnings ressltilig from fewer deliveries. A Government of [ldia report 9716- 77) statedi thlat stalte g-vinm ntihielia adl assigiti' a low priority to the dat 438 Public Policy the most instructive story relates to the auxiliary nurse-miuwlwife. She is the frontline worker in rural areas, and on her performance hinge the results of the overall prograinm e. What is she expected to do and, is her assignecl workload realistic? Accordling to the original design drawn,i up in 1966 by the fu khem:ji committee, the a lXlXiiw arv nurse-nidwife is expected to serve a populationl of 10,000 living in ten or more vill;lges sit nated at varying distances from the health subcenter. In these villages, she is usually the sole worker for (1) immunization; (2) anrtimnailarial and TB measuLres; (3) health an(l nutrition eclucation and child health services; (4) FP iniforimitioni, contraceptives, and follow-up; ani( (5) record maintenance. Clearly, this is an impossible worlkload for any individual no matter how well motivated and(l how well supervised. T he auxiliar%y nurse-midwife spends 25 percent of her working time trav-eling on foot from village to village; four to five dlays each mronth are absorbe(d by registration anl record-lkeep)iig (luties (Ulmied Na- tions, 1969). TIhere is general recogmiitioni that an aixiliary nLlir-se- midwife cannot p)et f'orT m11 (lc( CI:Ltely for a poptlalion) la ger' thaIn 3,000 to 5,000. Never-tlieless, the adhiiiiiisistritioll of the progIn1 ll;ls (COntinied( oni the basis of a patently mirif'histic iiorm'11, pu)c'su muai1bly because a rekisioii would have implie(l a mijmor expansioni in the FP bu(dget.6 The presen. normii of one autxili;arv nuirse-midwife for a populaitionl of 10,000 is a suboptimal level and(i is uInl(loubhtedhly responisible for some of the lapses of the (leliverl system. TIhis can be seeen, for exaimple, in the case of' the IUI) (caplllpigll. TIle umumnblewr of niew IUI) acceptors peaked in 1966-1 967, very soon uf'te' this imethod was illtroduced into the I uiidian progiamil, ani( then dcclinewd. Ihe (lecline was partly because of' slhortcomingigs in pi)eimisertioli scrutiny and coMISu li1g, fiu1, illsertioll plroce(linres, an(d inia(dequLate detection I'here is talk of a multipurpose health worker's scheme untler vhich workers who now letw liie in inalarta, smallpox. trachoma, iantd Fl' will he ieir .1m eil to (ieliver services ill an integratetl pat kage. I'he ultitilate pl.mn IS to have otne male aitl otne female nitldtiporpose health worker for a poptilatiotn at 5,1)00. It is recognizedl, howeset, thalt these targets will not be fulfilled for a (nnsidlerialle pciMdl, owing to shotirages oa training faitilities. In I 1975- 19761 Rs. 31) million was earmarked for this purpose; only 33 percent of this was spent. \te.imnwhile, new jolt slit i;i a- tiIns laidi (lWl tdaw reentl tor tihe aiuxihlijrs ntise miiii(h ife state that she ". . iS expectedl to toven a population ol 1(1,111)o)1)f whichi .16(11 to 41,0)1(0 ill liet lher int.'nsive area antl tile rettlainling will he tile twiliglht area. In the inllelnsise atea shle will h)e (o illt' lr all the activities and in the twviliglht area onlv oti i c(iieni (lot lbtirit' etuitled "iot) Repsnitiiiiilii es ot Hlealth WVoikers and Sit it'ri,imi.i" issuetd hv l)epartmncot tI Iin ,1ils tlainllg). I et' hro'.hure tarries nao tlte but is believedl to have heen isstiC(e in i .7'" See also (,;s,erninert of Int(iai, 1976-77. INDIA'S POPULA'I'ION POLICY 439 aid(l treatment of side effects (Estimiiates Committee, 1972). These sLpil)l)y lapses gener-ated a "whispering cainpaign" by dissatisfied ulsers that (liscOtmiUged potenitial acceptors. It is instuctive to note that while this retreat was taking place at the all-India level, the IUD losses iIn Gand(lhig ail, ani experinienital area in Iaiinna(lu, were relativelv light and quickly made up (Hauser, 1970). 'I'he experimnen- tal dleliveiv sy steni in Gandhigrarn was miuch superior in both quality anid intensity. Womeni were tolcl in advance that there might be comiplications after the IUD inisertioni and what they should do to obtaiin relief. TIable 4 compiares the l)erformlance of the delivery system based on the official model (one auxiliary nurse-midwife for a population of' 10,000) as it works in the Reddiarchatram and Dindigul blocks on Gandhigraiii with that of' the Athoor model (one auxiliary nurse- midwife for a population of 5,000). What emerges from this rough pictture is the pitiful inadequacy of service provision undfer the offl- cial rnodel. Trhe va-t bulk of pr-egnianlt imiother-s has little or no access to the pr-ogr-ami before, (lurinig, or after childbirth. By contrast, coverage ui n(ler the Athoor ino(l)el is miarkedly better, althoLugh about lhalf of the pr egnant miotlher s renlain out of reach. Neverthe- less, frequent contact with at least half of the relevant women enables the auixiliary nurse-midwife to undertake concentrated FP activitv during the period in which potential acceptors tend to be miost receptive. This contact results in higher levels of knowledge and acceptance of FP. 'Ihe nlationwide dleliveiy system in India todav is much less inten- sive then in Egypt, Taiwan, Thailanid, or Tunisia (IBRD, 1974). The conirjact witlh inainland Chiina is also instructive. There a major ef'fort has been maade to expan(d the supply of medical personnel in rur-al areas. In 1966 the physician-polation ratio in rural areas was 1:8,00() (I'eh-wei Hu, 1974). Since theni urban doctors have been I 'loc;i1ed in inial areLis, Cliinese tradiitiomil physicians have been tapped to coniplenient the Western-traine(d doctors, an(l a corps of' 1 imiillioni "barefoof (loctors" and 3 mzillioll l)lic- healthi workers has beent traiiiierl. Tlie hairefoot (loctor is a peasant trained for 3 to 6 iioiitlis who is capable of' treatiiig most diseaises coiinllmoIn in rtural areas, ad( iiiiisrering i n1t1i ni/at h )iO pltls blhi h control dle6ices, and sutpere;ising public lhealltlh workers. 'T'he averiage bar-efoot (loctor to piopulaltioni ratio is now 1:1,520; this figure allows for the fact that 440 Public Policy Table 4. EVALUATION OF DELIVERY SYSTEMS FOR HEALTH AND FAMILY PLANNING Official modelb Athoor Raddiarchatram Dindigutl model- block block Percentage of ante-natal 97 72 56 cases registered. Percentage of cases (includ- 51 20 16 ing those not registered) receiving five or more ante-natal visits. Percentage of deliveries (in- 49 18 6 cluding those not cgis- tered) performed by auxil- iary nurse-midwife. Percentage of cases (includ- 47 8 1 ing those not registered) receiving three or more post-natal visits within ten days after delivery. Percentage of FP acceptors in 13 7 sample". Percentage of sample women 92 84 84 with knowledge of one or more FP methods. Percentage of cases in which 7 44 55 register is incomplete for key item.d Percentage of children ad- 8 4 3 ministered three doses 'of DTP immunization. a One auxiliary nurse-midwife for 5,000 population. b One auxiliary nurse-midwife for 10,000 population. ISample was of women whose pregnancies were registered during 1970. d Key item was "nature of termination of pregnancy." Similar gaps existed for other items of inforination. SOURCE; Trable is adapted frons D. Narayanan Namboothiri and P. Ramankutt,. Lvaluation Report (Interin) of the MCH and Family Planning Programme in Athoor-January 1972; Buillein of the Gandlgramn Institute of Rural Health and Family Planning, Vol. 6, No. 2, January 1972. the barefoot doctor is a half-time peasant. His presence in the rural areas assures the bulk of the Chiinese people easy access to basic health care and FP facilities. INDIA'S POPULATION POLICY 44 1 rhis article is not the place to imiake a full case for allocating larger sums to health and FP in the Indlian- budget. Never-theless, the issue is iliportait, given that the present allocation is less than 2 percent of total plublic expedl(littiies. that the normiis uid(lel-iing the official mo(lel-e.g., one auxiliaryv nu rse-midwife for a pop ulation of 10,M000-are >mliop iiiial, and(l that some relaxationi in the resource coiistl'aiit will give FP mainagers more conifidence to carry out their ]liall(litte. Poor Honewholds anid FP. A large part of the FP program's potential clienitele consists of verlX poor lhousehol(ds which are difficult to reach and( which tend to have manyv chil(lren. So far the FP delivery system has ignored this segmiienlt of' the population, except for the mass vasectomv camps. To engineer a demographic transition for this group will riequire policy innovations of a high order. Perhaps inten- sive and( redesignedl FP components combined with substantial social and ecoionlnic investmenits in selected regions are required. There are no sure and triedl solutions, no international experienice to dlraw on. To pursue these issues, the governiinent mu1LIst be willing to experimient and( to learn from thie oumtcomie. Many attempts have been ima(le to mneasure the extent of' dire poverty in India based on a governmenit definiition of' a bare in:iimnu Min staii(lard of' liVilng.7 According to Bardhan (1973), about halt of the rural p)opUlat[ion was below this poverty line in 1969. UsinE,g roughlv equivalenlt nornms, Dandekar and Rath (1970) esti- mated that the comparable proportion in urban areas was also about half. Assumliirng no trend change in pi oportioiis since 1969, the iiiuplicamtion is that rouighly 52 million couple.s out of a total of' 104 millior of' ireproduLctive age in 1975-1976 were desperately poor. Appruoximnately 41 millioni of' these very poor target couples live in rtural areas. Most of these famiiilies are dependent on agriculture. P5erhaps half or miior-e ar e ctultivating lhol(Iings of less than 5 acres. In niany, cases demiiogr-aphic pressures and other factors have led to ilcns hfagiiiewntatiomi and a holdinig may consist of six to eight I he hat e mtiiiiolil standarld of living was establishedi in 1962 ba d (listi ngulishleul stluldV group .ippoinited' Iw the gnerimnent. It was set at a per capita cotisumption of Rs. 20 per month in 1i96G- 1961 prles-. OUt1ass otn health and(i education are excildeci; they are assumed to f)e prostidedl free bv the state. Bardihian uises a conservati'.e estirnate of Rs, 15 to allow for relatively lowet rtural prices awil shows that it is consistent with a miniiinsim diet of 2,10(0 calories andt 55 gi onif ptotein, which is necessai lto maintain life pruesses of an ..,ciage dlt oh in moderate dctit'itN iiiiu.i11 ii and Bial than, 1974). 442 Public Policy separate parcels situatecl in dlifferenit parts of the village (Mitilllas, 1970). These households mnay not owIn all or any of' the landl they work on, and their tenanicy ariingeiiewts canl be highly uncertain. Another third of these poor families are lanidless; they wor k as agrictultural laborers. 'rThe rest are artisans or sell their labor in miscellaneous service activities. These target groups are not only at the bottom of' the inicomlle pyramid, but many also belong to the lower castes, who for lorng have been victims of (liscriiniinatiol. Their legal rights un(ler the coIistitoL0 of inclependenit In(lia coul(d not be enforced in manly instances. To enforce these rights against the high-caste landed groups might have nmeanit eviction, deenial of' work for wages, an-d the sudden drying up of credit (Epstein, 1973). Rather tharn face these risks, the pooIr opted for a continuation of traditional sUb)seCrvielnce and minimnal securitv. I'hese power ]'elatiolis within the village are basic to an uLn(ler- standing of the attitucdes andt value clhairactetiSticS of' the rural poor. The situation varies a great (leal, but in geiieiLTl tlle p.l ter Of' chanige in recent (lecadles has acceintatled the polli/,alioll. Maill progressive ineasLir'es adorui the Iin(liani statute b)ook an(i the stuccess- ive five-year plan doct ieiit s. 'I'lie histoly' of' illmplelulIelat1 ion, howv- ever, is dismal: ". . . regardless of' intentionis, the ecom)oluiic policies adopted have, in the Indian social and political context, by an(d large, benefited the upper inicomiie groups. Anid those policies . . . which could have benefitedl the poor have beeni sua-cessfully evaclC(i or neutralised" (Srinivansani, 1974). 'I'his recor(d of stagrnationl or (le- terioration in socioeconiomic coml(litioms pltus a clii iate in whiclh gov- ernment has been uinable to tip the balanice in favor of' the poor has become part andl parcel of the psychological maiilkeLlp of the poor. They have seen prospe'itv come to the high-caste landed groups while their own Sittl;atioUM) reiuuiiledl the same or became more dles- perate. How do the poor cope with their pomeriy? 'I'hey spenid niearly all their earniings oni the clCapest f'oods; yet mianiy (1O niot get a (liet that sustains lif'e processes at even modlerate levels of' activity. In somiie cases male a(lults from these fliiiiilies have had to turnl (lodowli ea maniual jobs, becauiise suclh occtl)patiomis (ledaciiid too imcluch physical energy (Daw%twala and Visaitia, 1974). Malmunt ritionl andcl lack of' access to potable water make these Imo0i('eluC](lS SJ)eCCiall]N' N'vllnerable to INDIA'S POPULATION POLICY 443 infection. Their nioirbidlity an(d mortality rates, particularly for in- f'ants and children, are much higher than the national average. Large numbers of births are required for ensuring the survival of some of the children. Just as these households cannot afford health iunvestillents-wells, latrines, me(lical care-so also their capacity to tuse schools is limite(l. Chil(dren perforrn valuable economic r oles within these f:amilies, an(I their enrollinent in school implies a heavy opportunity cost for parents who cani ill afford to bear it. In addi- tion, parents must also pay for books, transportation charges, and other miscellaneous items even if' tuitioni is free. Superinmposed on these considerations that apply to all children are the special factors affecting girls. The likelihood of' a girl's f-inWng a lucrative job that will compensate parents for investing in her education is lower than for a boy. Moreover the payoff from investing in female education stops at marriage. A survey in West Bengal carried out in 1964-1965 illustrates the p)lenonlleiloil (Maitra et al., 1974). School attendance in rural areas as a proportion of the male population aged 6 to 14 was 31 percent for the bottom incomne (lecile comipar.ed with 83 percent for the top (lecile. I'he corresponding figures for f'emales were 12 percent anld 67 percenit, respectively. 'rhese (diffei-etials are not peculiar to West Beng;il; they are fkmli(l in mnost parts of the counitry (Bliagwati, 1973). Given this rough profile of poor rural households, it is hardly surprising that the FP delivery system has ignored them. Super- imposed on the rural-urban cultural gap iml)pe(ling program im- plementation, there is the "povertv curtain" separating FP workers from this population characterized by hunger, illiteracy, ill health, and physically segregated muid huts. Till 1977 FP workers had been assigned targets for obtaining acceptors, and no distinction was made between acceptors with dif'ferenit socioeconomic characteristics. It was natural for these workers to cmicerlrate on relatively affluent groups who were much more pre(lisposed to birth conttrol than the very poor lhousehol(ds (Blaikie, 1975). I'he process of persuading the impoverished small tarmer or landless worker to limit his f'arnily is likely to be pr-otracte(l at best, an(d the chances of success at the end of it cannot be ratedl very high. Mfeanwhile, intensive and repeated -oitact with these lhouselhols canl jeopar(lize the FP worker's rela- tioiIs with the rest of' his clientele if caste fCactoi- are at all important. For these and( other reasons, the imain contact of the FP program so 444 Public Policy far with the poor has been in the mass sterilization camiips that were held for limited periods outside the village setting. There, the camp organizers set out to obtain acceptance under the extraordinary festive atmosphere of the melaa (carnival) and through the use of incentive payments that were large compared with the budget of poor households. Ihese high-pressure tactics succeeded in raising the count of sterilizations performed, but in many cases the ac- ceptors regretted their decision afterward (Blaikie, 1975). However useful the mass vasectomy camp fnight be for obtaining quick re- sults, it does not seem like a good So.lutiOn1 in the long run. A long-term strategy must be based on an understanding of why poor households tend to have large families. Is this simply the result of a time lag in their perceptions of social change, such as the sharp decline in infant mortality? Alternatively, is there a real conflict between the private interest of the pooI household and the un- equivocal national interest in controlling population growth? Unfor- tunately, these questions cainnot be answered easily or convincingly. Yet an attermpt must be made, however spculclitive it inmy be. Robert Cassen (1976) has outlined a ra;miewo%l;rk for stiessihig the econom-iics of child(ren) viewed as iivestnuieiits: ". . . the child's asset value to parents is a negative fulnction11 of rearinig costs, opport tinity cost in parental earnings, children's earniing age, mortality anld the discount rate; and a positive function of employment and earnintgs prospects and the share of earnings over anid above constumnption that parents are likely to receive." It is instructive to pturstue this line of reasoning in the case of very poor .small farmer hotuseholds in India. Let us assume that the household consists of' parents, two sons, and one daughter (all under 5 years of age); this size, accord- ing to the celebrated family-planning slogan, should not be ex- ceeded. What are the pros ancl cons of an extra child viewed frorn the standpoint of such parents? On the artificial assumption that the small farmner anid his wife w,ish to miake a C1a1lclated decision, they will confront the Following facts and risks: 1. One or more of their children may not su-vive. 'I'his risk is much re(lhcedl in recenit leca(les buit it is still signiiclbnt. 1The aver- age probability of surviving beyond age X is 0.75; it is much less fo)r children from very poor households. Childhood lOiltality may INDIA'S PfŽFULATION POLICY 445 undermine the family's provision for social security against the risks to parents of sickness, accident, old age, and widowhood. In the absence of institutional mechanisms, villagers must lean on their own private sources, i.e., children, for support in times of difficulty. 2. The option of saving through financial instruments for use in future crises is also largely absent in much of rural India. In these circumstances, the poor parents may view their children as a form of saving (Chernichovsky, 1976). The cost of rearing an extra child consists basically of additional food, and the quantity consumed is much less than for an adult. Very little will be spent on1 new clothing or shelter or anything else. Rearing costs will add somewhat to daily outlays; no lump-sum indivisible amount is requirecl. This is a con- venient form of saving for a very poor household. 3. Very little extra parental time will be diverted to the rearing of the newborn child. In the rural setting most child feeding or caring duties can be combined easily with work on the family farm or wage employment. As the eldest child grows older, he will take over an increasing number of motherly futnictioins. 4. At a very early age, perhaps 6 or 7, the extra childl will begin to contribute to the household econioiiiy. He will look after animals, collect fuel material, and join in fetching (Irinking water, sometimes from long distances. 5. Later, the extra child will start working on the family farm and for wages. A 1974-1975 survey of six villages in AUrangabad district recorded a labor force participation rate of 22 percent for the 6 to 18 age grotup among households owning up to 2.5 acres (Naclkarni, 1976). Another 35 percent of the males and 57 percent of the females in this age group were kept at home for housework. Only the retmainlder, i.e., 44 percent of the males and 22 percent of the females, from these poor households were attending school. What value do parents attach to the extra child's labor services (items 4 and 5 above) given that the parents themselves are far from fully emnployed? If there were not the very sharp seasonal fluctua- tions in the rural labor market, it mnight not be rational for parents to value very mutch the labor power embodied in their extra chlild; he could( work only by reduLcinig their work Opp)oIItunitiCS. The extra pair of hands, however, proves %very valuiable in peak agricultural seasons, which are chara-acter-ized by oWel-Cpl)vtONloncHt an(d wage rates 446 Public Policy for hired labor that are a multiple of levels in the slack period. Workers may not be available even at peak rates dturing the busy season or they may be available only after a costly delay. The small farmer with his limited bargaining powei' is particularly vulnerable to this risk of' not finding a hired hand at the right time, By conitrast, the family worker's av'ailability is ensured, without the necessity of paying out peak wages. If the family plot is too small, some or all household members can obtain jobs at seasonal peak rates on other village lands and thereby augment family cash earnings. At least during the busy season, extra labor power is an asset allowing the household to exploit the scarcity situation more than would other- wise be possible. Basically, the parent-child relation in very poor hoLusChold(s tends to be exploitative. This is implied in statements 2 to 5 above. Living on the desperate brink of survival, the household cannot afford to spend much on child nutrition, health, or e(lUcatioii. The father has authority by virtue not onily of his ecotiomhic superiority buLt also because Indiani traditioni assigns respect f'or the lhea(l of a hlouselold and for age. If' the chiilc makes a positi'-e (cmtr ib)Litiori to liotiSehold incomiie, it may be appropriated to a large extent 1)) the fVamily creditor or for the father's outlay on liquor. In the case of a dlaugh- ter, this phase comes to ani end at her marriiage, when she leaves the parents and tjoins the husbancl's household. In the case of a son, the joint family relationship with parents is likely to continue beyond his marriage and procreation. In anticipation of' ultimatel] receivinlg the family land, the son is likely to C'OlliillUe to accept the f:ather's authority and to continue to tolerate a share of' f'anmily CO(Siumuption- smaller than his contribution to household income. This is the rough perspective for the (lecision to have a fourtlh child if it is to be madle rationally by a very poor small farmer and his wife. In the nature of the case, noI neat andl precise calculations of an economic kind are feasible. There are inany dif'ferent motives and 'ImLchl uncertairnty. Supe'i-imposed on all these f'actors are peei' group pressures, C(Olm1mnlunlity norms, and plain. old-fiashiolled selntimelnts about children. In fact, most poor households exhibit a strong pref- erence for a large 1lLlulub)Ce- of'chlild(rell. certainly many more tillam the of'ficial FP normii of' three. Given the c'omsideiauiomis ouLtlinie(d above, it would be presullml)toLus to comcluide that poor p)aenets are not be- having rationally to promote their own interests. INI)IA'S POPULATION POLICY 447 Of course, the parents' interest may conflict with the longer-term welfare of their childreni. By having the fCom-h child, the poor small f'armner is probably reducing the fLutur-e per capita earning potential of hlis progeny, coml)are(l with wlhat it would be if' he stopped at three. The fourth child ii\av- mean thiat the alrea(dy very smnall f'amily plot will have to be split amonig three sons rather than two. It also implies a much larger number of job seekers 10 or 15 years henice, assuming that all small farmers decide to have the extra child, which mnay be reflected in higher Miidereiiploymenit or lower wage rates. Even if' poor parents are aware of' these sharp initergenerational conflicts, they can hardly be expected to adopt such a long-run perspective. Their present misery compels them to live from hand to mouth and to ask not what they can do for their children but what the children can do to relieve their acute deprivation. Furthermore, it mnust be recognized that it is not inevitable that the potential benefits of lower f'ertility adopted by poor small farmers will actually accrue to their progeny. Many events can intervenie to dlistLurb this progression from cause to ef'fect. In the real wold of political ecoin- omy, it is likely that some socioeconiomiic group other tlani poor small farmiiers will appropriate the gain. A strategy f'or redutcinig the high f'ertility of very poor households must deal with the imiplications of' the analysis above. Even the best FP delivery system will not prove very effective if it is in the private interest of poor parents to have large families. Yet a policy of simply waiting for structural changes in the economiv an(I society to reduce the advantages of having many children is unrealistic. Develolment may be the best contraceptive, but there may not be enough relevant developmient in the short or medium run, given the resource and other conistrainits, including high population growth itself, facing India. 'T'he key questioni, therefore, is whether it is possible to iden- tifv' selected aspects of econiomic (levelopiinenit which have a special sigiiif-ca.ice f'or f'eriilitv reditction and( which (leserve emllph'Isis f'or this retasoIn. The April 1976 policy stateinent oll popUliltion sLuggeste(d that high priority should be assigned to chil(d ilulirilioii ancd to f'einizle educationi up to the middle level. Undoubte(dly, these are relevarnt an(d imiiportant aspects of'(levelopmiient, but it is (lif'ficult to miiaintain that they will re(dtice fertility on their own. As iLetltionie(l alreadly, larger e( ucationil opporiti uities for girls may not be used if the household needs their services within the 11ouse or on the farm. 448 Public Policy The attractiveness of female edtucation will be miiuch re(luced if there is massive underemployment. Similarly, the impact of special clhild nutrition programs can easily be offset by diversion of household food allotments from the child to other family menmbers. 'I'he search for the key element of developmeiit that will make the crucial dif- ference in fertility is not likely to be very productive (Ridker, 1976). The maniy close interconinections among dif'felrent aspects of' house- hold behavior, includiing fertility behavior, suggest that a holistic approach is necessary, i.e., an integrated andc mutually r-einiforcinig prograiii consisting of' rural development and FP. 'T'he attempt to carry out such a programii all over India at once would be hopelessly unrealistic, but a sequtienitiail pattern in which resources are deployed first in somne selected regions andl then suc- cessively in others may prove to be attractive and feasible. Of course, a basic minimum program must be carried on everyX where; it would be politically unacceptable to neglect any region altogether. But a concentrated intetnsive effort canI be stupeIi in pose(l sequentially on the minimum program to genierate the necessary, clitical IIIass in selected regions. Such a strategy implies a tempor-ary- inlcrase in spatial iniequtlaity. 'I'his is the pr6e that mnust be paidt to erid(iate absolute povert an(i lower f'ertility simntiltaiimioisly in one region after another all over In(lia. To spell out this sequienitial regional strategy fully is far beyondl the scope of this article. Many importanit rural development issues wolild have to be resolved. There is great (liversitv in rural Idl(lia nlot onily at the state and district levels but eveni (down to the block level. 'I'hese differences in natLLual resources, social and(I physical inif'ralstulCtuLr e, and culture would have to be recogniize(d and regiotns (lefined ac- cordingly. As far as FP is concerned, categorizinig regions into three groups might be tusef'ul: First, regions in which (1) FP has alr-eady macle substantial progress, (2) the process of inicomiie expallsioll is alrea(ly unider way and the number of very poor families (dimiinlishinig rapidly,, and (3) the infrastructure end(lowment is favorable Second, regions in which (1) FP has made vecry little progrcess, (2) a large pr-oporotionl of' f'amilies falls below the povertv linie, (3) the existilng inf'r'asriictuime is very limite d, anld (4) no coniceiitiiated intenisive ef'f'ort to pi'oimiote du ral developineiit is visualized for the near term INDIA'S POPUJL,A'rION POLICY 449 Third, regions that have essentially the same characteristics as those in the second category, except that they are selected for the concen ti-ated, intensive program. 'I'he first category does not present a major problem. There the FP program will need to be continued and the miianagement issues raised above will need to be resolved. If the demand for FP is really buoyant, there will be a strong case for budgetary allocations above present norms. Regions in the second category do not present a hopeful picture. No FP delivery system can be expected to produce results in such a context of widespread misery. The minimum gov- ernment program should aim at providing health and FP services through mobile dispensaries and camps. The mechanical application of the usual norms-one auxiliary nurse-midwife for a population of 10,000-to motivate couples and secure new FP acceptors in such r egions is likely to be wasteful; it would be best to conserve resources till the time comes to transfer the region to the third category. Regions in the third category present a challenge. Large invest- ments in land development, transportation, and social services will be required together with institutional and organizational changes. A verv large effort on the FP front will also be necessary at levels far higher than the present norm. A precondition for success will be a willingness on the part of the powerful landed interests to share the benefits of massive public investments equally with the under- privileged. The latter must be mobilized as a group and they miust participate actively in planning and mnijoitoriig the imnplemnentation of the initegr-atecd program. Fertility recdluction must be incorporated as an importait part of this effort. The scale of the public invest- niient program could be varied, (lependling on fertility reduction objectives accepted by the community. To qualify for a larger public investment, the CommUnity wVould have to accept more ambitious targets for lowering the birth rate. The comiplexity of administering suLch schemnes can pose major hurdles, and a piragniatic approach is essesti;izl. TIhlese i(leas deserve further exploration and expei)l mental testilig ilil(lel fiel(d coltlilions. (TunCl1us(ion)I.s JIowar(l the late 1960s the Indiaii birth rate star-ted to clecline, reflecting both socioeconomic progress-falling infant mortality, 450 Public Policy female literacy, moderinization-and the growing momentum of the FP effort. This welcome new trendl is expected to conitinue. Yct despite falling fertility, the prospect is for the population to rise from 557 mnillion in 1971 to 85() to 1,000 mnillion by the eni(d of the century. Given the existing prlessLur-e on land-reflected in very small plots, f'lragin,en-jtaltioIl of lhlolilngs, landlessness-and the massive in- cidenice of' underemploymnenit, f'ew will dotubt the niee(d to restrain future population groNvth as much and as quLickly as possible. 'IThe main quiestioni is how to dlo it. Poptulationi policy in India has a loiig anid controversial history; many tricks have been tried. The Emergency even opened the (loor to coercive methods that pro- duced great hItmian tragedty and(I astonislhing official statistics. Fortu- nately, this phase is over, but the problemii of' population policy remnains. 'rhe FP progiam has sllccee(le(1 in many places. In five states- \Jaharaslrtra, Ptunjab, Kerala, Gujarat, and( Tamilniadu-containing 27 percent of the cotuples at risk, the record is reassuring. The practice of coni iracel)tionl has spread, pa rtic'illr y a titolug middlle- an(l upper-inicome groups. A quarter ,to a tlhir(d of the population in these states is pr otected against the r isk of' pregnancy. 'I'lie inlci(lenlce of colittraceptive tuse is 2.4 timiies higlher tlhani the niation ral average f'or those enijoying higlh incomes, college edtication, anld( city living. Roughly half' of' the popuilationi, however, is dlesl)er'ately poor, and a very large part is clepeiid(ent oni agriculture. Many contintue to be victims of social discrinillna0ioim as well as pover-ty, nialinitrition, pre- lmature mortality, anid illiteracy. 'I'lhese lntlischol(ds tenll( to have matny chil(lien, partly to off'set the relatively lowv probability of their SUrviv'al but partly also because villagers lean oni children for support in tirnes of' diffrictiltV in the absence of institwltional social security niechanisins. Poor parc'nits may also be convinced that an extra child a(lcds to their income, wilatevet' the truth of the matter. Given these cond(litioIns an(I zttiti(les, it woulI not have been easy to influence tertility, even assnminng an i(leal (leliVei\v sVsteLm1. In fiact, the Indiani FP progranm is ill-eqtuipped to tackle the plobleiiis of' this large segmient. of' society. A cultural gap separates the mii'ban-orienmtcd doctor-manager and(I his badlv trainie(d staf'f fromi peasants steepc(l in tra(litioni, pali'ti'Uhla1l)' those at the hottoim of the socioeconOtinc pyramidl. Utnil receiitly, FP workem's were assignie(l arbit ary targets for ohtainirig acceptors. It was miattir.,l foir themy to concentrate on INDIA'S POPLTLA'I'ION POLICY 451 the relatively well-off households and to ignore the poor who also often belonged to the low castes. Given that the frontline worker of the system, the auxiliary nurse-midwife, has a patently unrealistic job of serving the health ancl FP rneeds of 10,000 people, it is inevitable that the uncderprivilegecl segment will get little of her time and attention. Population policy statements made in 1976 and 1977 have ex- tended and elaborate(l the FP program but they do not seem to recognize the key problem of poor households. To engineer a de- mnographic transition for this large part of' the society will require policy innovations of a high order. Household behavior concerning fertility is intimately tied up with questions of livelihood, education, health, and women's status and employment. Given these interrela- tions, a partial approach is likely to be much less rewarding than an integrated and mutually reinforcing program consisting of rural developmnenit an(d a redesigned FP component. Such an effort would be too expensive, both financially and in terms of human resour-ces, to carry out sillll.ltanweoulsly all over India. A sequential patterni is possible, however, based on the rccognition of regional diversity. Essential preconditioms for this stiategy are (1) willingness on the part of the rich to share the benefits of dle% elop)ment with the rest of the poptulation, (2) tolerance for a temporary increase in spatial inequalities, and (3) openness in reexamining existing bureaucratic mandates, niorm-zs, budlgets, and( administrative procedLures. All these are very (lemliand(linig in political termzs. Perhaps this is why recent government statements tend to dodge a number of the critical issues of population policy. BI IR)C.RA PHTY Adalaklh, A., and( I). Kirk: "Vital Rates in India 1961-71 estimated frotmn 1971 CenisLus Data," Poullotioni Stidie.% (28), 3 Malrch 1974. Bhagwvati, J.: "Eduication, Class Structure and Income Equality." 11World Devielopmentd, vol. 1, no. 5, May 1973. Banierji, I).: "Health Behaviour of Rural PopuLlationi," Economic and PoliticaI Weekly, 22 Deceiibher 1973. Bardllvhani, P. K.: "Oni the Inl(idclncme of' Poverty in Rural India in the 1960s." 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(edl.): Popuilation and DeveIlolpmenlt: The Search for Selective Interventeioni., Johnus H-Iopk-i ns, Bailtimore, 1976. 454 Public Policy Rogers, E. M., and D. S. Solomon: Traditional Midwives as Family Planning Communicators in Asia, East-West Communication Insti- tute, Hawaii (no date). Srinivasan, T. N., and P. K. Bardhan (eds.): Poverty and Income Distri- bution in India, Statistical Pubhlishii,g Society, Calcuttad 1.JI Teh-wei Hu, An Economic Analysis of the Cooperative Medical Services in the People's Republic of China, 1974 (mimeo). United Nations, Department of Economic and Social Affairs, An Evaluation of the Family Planning Programme of the Government of India, 1969 (mimeo). Visaria, P., and A. K. Jain: "India," Country Profiles, The Population Council, New York, May 1976. Visaria, P.: "Recent Trends in Indian Population Policy," Economic and Political Weekly, Special Number, August 1976.