Improving Quality of Care in India's Family Welfare Programme: The Challenge Ahead

Abstract

In 1952, India became the first developing country to establish a national family planning program to address the issues of high fertility and rapid population growth. In the more than four decades of its existence, the Indian family planning program has been both highly visible and the subject of intensive international interest and analysis. A primary explanation for this interest lies in India's global demographic significance. With a population approaching one billion people, India accounts for almost one-sixth of the world's people. It is estimated that by the middle of the next century, it will surpass China as the world's most populous country. Over the past four decades, significant growth and expansion of the Indian family planning program have been evident. Starting from virtually no infrastructure, the Indian program has grown to encompass over 150,000 primary health centers (PHCs) and subcenters, employing more than 300,000 family planning personnel. This network of services now extends to almost the entirety of India's people, three-fourths of whom continue to reside in 600,000 often small and isolated communities. As evidenced by the most recent National Family Health Survey in India, knowledge of family planning among reproductive-aged women is by now almost universal, and by the early 1990s 41 percent of couples were currently using a method of contraception (IIPS 1995). Largely as a result, total fertility rates in India have declined significantly over the last several decades, from 6.0 births in the 1950s to 3.4 births by the early 1990s. In addition, the program has gradually expanded the range of services it offers to include immunization, antenatal and delivery care, preventive and curative health care, and, most recently, reproductive health care. These achievements notwithstanding, it is difficult to escape the conclusion that the Indian family planning program remains characterized by considerable unfilled potential and promise. Its modest progress stands in marked contrast to the progress of a number of neighboring family planning programs in Asia-most notably Bangladesh, Indonesia, and Thailand-which despite having launched their programs much later, have achieved considerable success in raising levels of contraceptive use. Nowhere is this disparity more apparent than in the large and populous northern states, which are home to more than 400 million people, more than 40 percent of India's total population. 1 The reasons for the limited success of the Indian program extend far beyond the service delivery program itself. They encompass a host of other social, cultural, and economic factors-including low levels of female and overall educational attainment, continuing high mortality, low status of women, and extreme poverty-which influence the demand for fertility limitation (Cassen 1978; Satia and Jejeebhoy 1991). In recent years, however, there has been a growing consensus among policymakers, researchers, and informed observers that the program itself-as reflected in its priorities, emphasis, and the implementation of