CHAPTER TWO: TREDS I FAMILY PLAIG USE AD PUBLIC SECTOR OUTLAY I IDIA 2.1 Introduction: This chapter examines the trends in use of family planning methods, changes in use of family planning methods over the years and unmet need for family planning in India and its states. We have attempted to understand the characteristics of condom, pills, IUD and female sterilisation users in India. The available statistics on the expenditure of the government of India on family planning is also given. 2.2 Trends in Current Use of Family Planning Methods: The current use of modern methods of family planning methods have shown an increase of about 15 percent for the country during 1992-98. The increase is also noticed both in terminal and spacing methods. While use of spacing methods had increased by 19 percent, the use of terminal methods had increased by 14 percent during this period. However, the use of modern spacing methods is still at a very low level and the large percentage increase in the users of spacing methods does not affect the overall trends. The use of spacing methods in India had increased from 5.5 percent in 1992-93 to 6.8 percent in 1998-99 while the use of terminal methods had increased from 36.3 percent to 42.8 percent during this period. This is an indication of the reliance on terminal methods, particularly female sterilisation in India, which means that there is a potential demand for the use of spacing methods in many states of India. Since our thrust is on spacing methods, the states are arranged in an ascending order of the use of spacing methods in 1998-99 (Table 2.1). It may be noted that the use of spacing methods is lowest in the state of Andhra Pradesh (only 1.8 percent) which has already achieved the replacement level of fertility. This is followed by Bihar, Tamil adu, Karnataka, 14
Madhya Pradesh, Orissa and Kerala. It is not surprising to note that the demographically developed states such as Tamil adu, Kerala and Andhra Pradesh have a very low use of spacing methods. This is an indication of the acceptance of terminal method as the main method of family planning and we need to explore why couples prefer terminal method over spacing methods even in demographically better off states of India. There are only three major states of India (Haryana, West Bengal and Punjab) where the use of modern spacing methods is more than 10 percent. It is highest in Punjab (23 per cent) followed by West Bengal (13.5 percent). The changes in the use of spacing methods, permanent method and modern method for major states of India during the six years (1992-93 and 1998-99) are given in the same table. The decline in the use of spacing methods is sharpest in Tamil adu (33 percent) followed by Bihar (32 percent) and Kerala (20 percent). The increase is highest in West Bengal (50 percent) followed by Assam. In the case of permanent methods, all states except Punjab have noticed an increase in the use of these methods. While the use of terminal methods has declined in Punjab, the use of spacing method has increased in the state. 15
Major states/ India Table 2.1: Trends in use of spacing methods and permanent method of contraception in India and states Modern Method FHS I (1992-93) FHS II (1998-99) Spacing Method Perman ent Method Modern Method Spacing Method Permanent Method Change Percentage Change in use of Modern Spacing Perman Method Method ent Method Andhra Pradesh 46.5 1.8 44.7 58.9 1.8 57.1 21.05 0.00 21.72 Bihar 21.6 2.9 18.7 22.4 2.2 20.2 3.57-31.82 7.43 Tamil adu 45.2 5.7 39.5 50.3 4.3 46 10.14-32.56 14.13 Karnataka 47.3 4.8 42.5 56.5 4.4 52.1 16.28-9.09 18.43 Madhya Pradesh 35.5 4 31.5 42.6 4.7 37.9 16.67 14.89 16.89 Orissa 34.6 3 31.6 40.3 4.7 35.6 14.14 36.17 11.24 Kerala 54.4 6.1 48.3 56.1 5.1 51 3.03-19.61 5.29 Rajasthan 30.9 3.2 27.7 38.1 5.8 32.3 18.90 44.83 14.24 Uttar Pradesh 18.5 5.3 13.2 22 6.4 15.6 15.91 17.19 15.38 India 36.3 5.5 30.8 42.8 6.8 36 15.19 19.12 14.44 Maharashtra 52.5 6.4 46.1 59.9 7.6 52.3 12.35 15.79 11.85 Gujarat 46.9 5.8 41.1 53.3 8.1 45.2 12.01 28.40 9.07 Assam 19.8 5.4 14.4 26.6 10 16.6 25.56 46.00 13.25 Haryana 44.3 9.6 34.7 53.2 12.5 40.7 16.73 23.20 14.74 West Bengal 37.3 6.7 30.6 47.3 13.5 33.8 21.14 50.37 9.47 Punjab 51.3 17.4 33.9 53.8 23 30.8 4.65 24.35-10.06 In order to know in detail, the use of spacing methods, we have further examined the three spacing methods such as condoms, pills and IUDs. The use of these three methods in 1992-93, 1998-99 and the percentage change for states and India is given in Table 2.2. In this table the states are arranged in ascending order of change in use of IUD. In 1998-99, the use of IUD was only 1.6 percent while pill use was 2.1. percent and condom use was 3.1 percent in the country. It was found that among these three methods, the IUD had registered a decline 16
while use of pills and condoms had registered an increase during the five-year period. In the country as a whole, use of condoms had registered an increase of 23 percent, use of pills had registered an increase of 44 percent, while IUD use had registered a decline of 19 percent during this period. All the states except Gujarat, Haryana, Rajasthan and Assam had registered either a decline or no increase in the use of IUD. The maximum decline is observed in the state of Orissa (87 percent) followed by Kerala, Tamil adu, Madhya Pradesh and Maharashtra. It may be noted that the highest use of IUD in 1998-99 was in Gujarat (3.1 percent), followed by Haryana (3.6 percent). There are many states where the use of IUD was less than one percent. This is an indication that the IUD has lost its popularity and this may either be due to the low quality of services or method related problems leading to contraceptive morbidity. A more detailed investigation into the declining use of the IUD would be in order. In the case of condoms, states such as Bihar, Karnataka and Madhya Pradesh had shown a decline in use, while all other states have registered an increase in the method. The highest use of condom is in the state of Punjab (14 percent) followed by Haryana and Uttar Pradesh, while the lowest use is in Bihar, Andhra Pradesh and Orissa (less than one percent in each of these states). In the case of oral pills, states such as Tamil adu, Bihar and Kerala had registered a decline in use. All other states had registered an increase in the use of oral pills. The state of West Bengal has the highest use of oral pills (9 percent) followed by Assam. 17
Table 2.2: Trends in use of Spacing Methods in India and States Major states FHS I FHS II Percentage Change in use of Condom Pill IUD Condom Pill IUD Condom Pill IUD Orissa 0.6 0.9 1.5 0.9 3 0.8 33.33 70.00-87.50 Kerala 2.9 0.5 2.7 3.1 0.4 1.6 6.45-25.00-68.75 Tamil adu 1.6 0.6 3.5 1.5 0.3 2.5-6.67-100.00-40.00 Madhya 2.2 0.7 1.1 2.9 1 0.8 24.14 30.00-37.50 Pradesh Maharashtra 2.5 1.4 2.5 4 1.7 1.9 37.50 17.65-31.58 India 2.4 1.2 1.9 3.1 2.1 1.6 22.58 42.86-18.75 Karnataka 1.2 0.4 3.2 1 0.6 2.8-20.00 33.33-14.29 Uttar Pradesh 3.2 1 1.1 4.2 1.2 1 23.81 16.67-10.00 Punjab 8.9 2.2 6.3 13.8 3.1 6.1 35.51 29.03-3.28 Andhra 0.7 0.5 0.6 0.7 0.5 0.6 0.00 0.00 0.00 Pradesh Bihar 1.3 1.1 0.5 0.7 1 0.5-85.71-10.00 0.00 Rajasthan 1.5 0.5 1.2 3.1 1.5 1.2 51.61 66.67 0.00 Gujarat 1.8 1 3 3.5 1.5 3.1 48.57 33.33 3.23 West Bengal 1.9 3.5 1.3 2.9 9.2 1.4 34.48 61.96 7.14 Haryana 5.2 1.2 3.2 6.8 2.1 3.6 23.53 42.86 11.11 Assam 1.7 2.8 0.9 1.8 6.3 1.9 5.56 55.56 52.63 18
2.3. Trends in Unmet eed for Family Planning Women who do not want any more children and those who want to postpone a child birth for two years or more but are currently not using any method of family planning are said to have an unmet need for family planning. In both the FHS 1 and FHS 2, the question relating to unmet need was asked. Accordingly, the unmet need of spacing and unmet need for limiting is computed. The trends in unmet need and the percentage change in unmet need is an indication of the success implementation of programmes in a state/country. The unmet need for limiting, spacing and the percentage change in India and states during 1992-93 and 1998-99 is given in Table 2.3. and it appears that the unmet need for family planning in the country had declined from 19.5 percent in 1992-93 to 15.8 percent in 1998-99. Still the level of unmet need is higher compared to other countries. The decline is noticed both in unmet need for spacing and limiting. The unmet need for spacing had declined from 11 percent in 1992-93 to eight percent in 1998-99. The unmet need for spacing was highest in Bihar (13 percent) followed by Uttar Pradesh (12 percent). Thus there is a potential demand to increase the use of spacing methods in these states. The unmet need for spacing is minimum in Punjab followed by Haryana where the proportion of use is relatively higher. The percentage change in unmet need for spacing is an indication of the effectiveness of family planning programmes in these states. It may be noted that the unmet need for spacing has increased in the state of Maharashtra while it has declined in all other states. The highest change in unmet need is in Haryana followed by Punjab. From table 2.3 it is clear that the use of spacing method can be increased if we are able to meet the unmet need for spacing in many states of India. 19
Table 2.3: Trends in Unmet eed of family planning in India and States Major States and India FHS II FHS - I Change in unmet need Unmet need for Family Planning Unmet need for Family Planning Spacing Limiting Total Spacing Limiting Total Spacing Limiting Total Maharashtra 8.1 4.9 13 7.3 6.8 14.1-10.96 27.94 7.80 Kerala 6.9 4.9 11.7 7.2 4.5 11.7 4.17-8.89 0.00 Bihar 12.6 11.9 24.5 14.4 10.6 25.1 12.50-12.26 2.39 Tamil adu 6.6 6.4 13 7.8 6.7 14.6 15.38 4.48 10.96 Andhra Pradesh 5.2 2.5 7.7 6.3 4.1 10.4 17.46 39.02 25.96 Rajasthan 8.7 8.9 17.6 10.8 9 19.8 19.44 1.11 11.11 India 8.3 7.5 15.8 11 8.5 19.5 24.55 11.76 18.97 Uttar Pradesh 11.8 13.4 25.1 16.7 13.4 30.1 29.34 0.00 16.61 Karnataka 8.3 3.2 11.5 11.8 6.4 18.2 29.66 50.00 36.81 Orissa 8.7 6.8 15.5 12.7 9.7 22.4 31.50 29.90 30.80 Madhya Pradesh 8.9 7.3 16.2 13.1 7.4 20.5 32.06 1.35 20.98 West Bengal 6.3 5.5 11.8 9.4 8 17.4 32.98 31.25 32.18 Assam 7 10 17 11 10.7 21.7 36.36 6.54 21.66 Gujarat 4.8 3.7 8.5 7.6 5.5 13.1 36.84 32.73 35.11 Punjab 2.8 4.5 7.3 6.5 6.5 13 56.92 30.77 43.85 Haryana 2.9 4.7 7.6 8.8 7.6 16.4 67.05 38.16 53.66 20
2.4 Characteristics of Condom and Pill Users: After examining the trends in current use, changes in the use of family planning and unmet need for family planning, we need to focus on the characteristics of condom, pill and IUD users in India. For this purpose, the background characteristics of the condom and pill users are tabulated and given in Table 2.4. The background characteristics are age of the women, age of her husband, educational attainment of women, standard of living, number of living children and husband s occupation. The age of the women has been categorized into four broad age groups such as less than 20, 20-29, 30-39 and above 40 years. Since the condom is a male method of contraception, we have also reclassified the age of the husbands into four categories. The tabulation is done separately for rural and urban areas. The use of condom is high among males aged 30-39 (51 percent) compared to other age groups and this trend is similar both in rural and urban areas. Also, the use of pills is highest among the women aged 20-29 (54 percent) compared to other age groups. However, it is lower in the age group 30-39 (33 percent). With respect to educational attainment, the use of condom is high among those women whose education is more than high school and above (54 percent) compared to 11 percent among illiterate women. This could probably be due to the fact that the educated women ask their husbands to use condoms while illiterate women may not be able to do so. But this is not true in the case of pills. The use of pill is highest among illiterate women and then declines as the educational level goes up. However, it again increases for those who are in high school and above. In rural areas the use of pills varies inversely with the education of women. One of the important factors that affect the use or non-use of spacing methods is the household standard of living as measured by the standard of living index (SLI). It is found 21
that the use of condom increases with a rise in the standard of living. Among all condom users, only 6.6 percent users are from households with a low standard of living, 34 percent are from households with a medium standard of living and 58 percent are from households with a high standard of living. This is a clear indication that the ability to pay has a role in the use of condom and the trend is similar in both rural and urban areas. In the case of oral pills, this was not the case where only 23 percent users were from low standard of living (SLI) households, 50 percent from medium and 26 percent users are from high SLI households. The pill is freely supplied by the government in many of the states and as such, it is not affected much by the standard of living of the household. One important factor determining the use of oral pills and the condom is the number of living children and in the Indian context couples are encouraged to use these methods to space births. Accordingly, the use of both condoms and pills by the number of living children is given in the same table. It may be noted that among the condom users, only four percent do not have any children, 25 percent has one living child, 37 percent has two children, 17 percent has three children and 16 percent has four or more children. It is necessary to emphasize women with one child to make more use of condoms. Among pill users, 2 percent women have no living children, 24 percent have one living child, 31 percent have two living children, 18 percent have three living children and 25 percent have 4 and above living children. Thus, the use of condom and pill is higher among mothers with 1 or 2 living children. As the use of condom varies largely with the standard of living of the households, we also attempted to understand the use by husband s occupation. The use of condom is high among skilled manual labour followed by clerical and professional workers. It as lowest among agricultural employee followed by service and unskilled manual 22
labours. This again supports the hypothesis that the use of condom depends more on the ability of the person to pay for the same. It may further be noted that the use of condom is very skewed among the states and within the country. It mainly concentrates in prosperous states like Punjab, Haryana and West Bengal In case of pills, the use is highest among sales workers followed by skilled manual workers. It is lowest in case of agricultural employee and services. It may be observed that there is a large difference in the use of both condom and pills among the agricultural employee and agriculturally self employed persons. While the use is higher among those agriculturally self employed, it is minimum among agricultural employee. The promotion of condom and pill should aim to reach the low socio economic households. 23
Table 2.4 Characteristics of Condom and Pill Users in India (Percentage of women using condoms and pills by background characteristics) Characteristics Condom Pill Rural Urban Total Rural Urban Total Age of Husband Less than 30 30-39 40-49 Above 50 30.5 48.7 17.6 3.2 997 18.8 52.5 25.8 2.9 1596 23.3 51.1 22.6 3.4 2593 25.3 47.4 22.7 4.6 1190 22.8 51.4 21.7 3.9 773 24.5 48.8 22.3 4.4 1787 Age of wife Less than 20 20-29 30-39 Above 40 Education Illiterate Literate <Primary Middle Comp High comp & above Standard of Living Low Medium High Religion Hindu Muslim Christians Others Living children 0 1 2 3 4 and above Husband s Occupation Prof/Tech Clerical Sales Agrl self emplo Agricultural employee Service Skilled manual Unskilled manual 8.1 54.5 31.5 5.9 999 28.1 19.4 17.5 35.0 1000 14.2 43.7 40.1 1000 70.8 15.6 2.6 11.0 999 5.0 22.9 33.6 18.8 19.7 1000 14.4 5.8 13.4 30.9 0.3 5.6 22.8 68 962 1.9 44.6 44.1 9.4 1596 11.2 12.0 11.3 65.5 1595 1.9 27.4 69.0 1596 73.1 18.2 1.9 6.7 1595 3.3 26.5 39.6 16.7 13.9 1595 25.4 10.5 27.0 2.3 0.1 4.8 25.6 4.3 1556 4.3 48.4 39.3 8.1 2595 17.7 14.9 13.7 53.7 2595 6.6 33.7 57.9 2596 72.2 17.2 2.2 8.4 2595 3.9 25.1 37.3 17.5 16.1 2595 21.3 8.7 21.8 13.2 0.2 5.1 24.5 5.2 2521 6.9 54.5 33.1 5.5 1190 38.9 33.1 14.3 13.7 1190 29.5 51.1 18.6 1189 67.4 26.6 1.4 4.5 1190 1.5 22.3 30.1 18.6 27.6 1190 7.8 3.1 16.8 41.3 0.2 3.3 20.7 6.9 1157 4.2 53.4 34.1 8.3 599 20.0 27.2 17.9 34.9 599 9.0 47.9 42.1 599 75.3 19.6 1.3 3.8 598 3.2 27.7 34.1 15.5 19.5 599 13.5 8.9 25.9 2.3 0.4 6.4 35.1 7.6 564 6.0 54.2 33.4 6.4 1788 32.6 31.1 15.5 20.8 1789 22.7 50.0 26.5 1788 70.0 24.3 1.4 4.3 1789 2.1 24.1 31.4 17.6 24.9 1789 9.7 5.0 19.8 28.5 0.2 4.3 25.4 7.2 1721 24
2.5. Characteristics of IUD and Female Sterilisation Acceptors in India: After examining the characteristics of condom and pill acceptors, we are interested to know about the characteristics of IUD and female sterilisation acceptors in India. The characteristics of IUD and female sterilisation by background characteristics is given in table 2.5. The background characteristics are age of women, educational level, standard of living of the household, religion, number of living children and husband s occupation. With respect to age, the use of IUD concentrates on age group 20-29 (52 percent) and then in 30-39 age group (38 percent) women. In case of female sterilisation, it is highest in the age group 30-39 (45 percent). With respect to educational level, among users of IUD, 51 percent are with high school and above education. The promotion of IUD need to be spread to other educational level of women. In case of female sterilisation, 58 percent users are illiterate; while 23 percent are literate but less than primary; and 11 percent are high school and above. It is an indication that the illiterate and poor women prefer female sterilisation and so the use of spacing methods remains low among them. To promote spacing method, there is a need to promote across educational group and economic standard. With respect to standard of living, the use of IUD is high among high SLI (56 percent) as compared to low and medium SLI. But in case of female sterilisation, it does not show any pattern. With respect to the number of living children, both the methods are low for women with no children. The use of IUD is high among women with two living children ( 44 percent) while in case of female sterilisation, it is highest for those with four children and above. Thus a large proportion of women in India accepts terminal method only after 3 or 4 children. As a result, though the contraceptive prevalence shows high, the fertility does not correspond accordingly. 25
Table 2.6 Characteristics of IUD and Female Sterilisation Acceptors in India (Percentage of women accepting IUD and Female Sterilisation by background characteristics) Characteristics Age Less than 20 20-29 30-39 Above 40 Education Illiterate Lit <Primary Middle compl High School & above Standard of Living Low Medium High Religion Hindu Muslim Christians Oters Living children 0 1 2 3 4 and above Husband s Occupation Proff/Tech Clerical Sales Agrl self employed Agricultural employee Service Skilled manual Unskilled manual IUD Female Sterilisation Rural Urban Total Rural Urban Total 4.2 53.6 35.7 6.5 616 28.2 22.7 18.0 31.0 616 12.5 43.6 42.9 615 74.5 9.8 3.7 12.0 615 0.2 24.8 40.4 17.9 16.7 616 11.9 6.2 11.5 38.3 0.7 5.2 21.2 5.0 598 1.7 50.8 40.0 7.5 773 7.5 14.0 12.3 66.2 773 2.6 29.2 67.1 773 75.0 13.5 3.2 8.3 773 0.1 31.1 46.9 14.3 7.5 774 23.2 11.0 27.6 2.8 0.1 5.0 26.1 4.1 754 2.8 52.1 38.1 7.1 1389 16.8 17.8 14.8 50.6 1389 7.0 35.6 56.4 1388 74.8 11.7 3.5 10.0 1388 0.1 28.4 44.1 15.9 11.5 1389 18.2 8.9 20.5 18.6 0.4 5.1 23.9 4.5 1353 0.5 29.1 44.1 26.3 20937 65.9 21.9 6.1 6.1 20939 35.2 49.6 14.2 20938 89.1 5.5 2.3 3.0 20940 0.1 1.9 26.6 34.2 37.2 20939 4.8 2.5 6.5 58.7 0.2 3.5 15.7 8.2 20357 0.2 22.9 46.6 30.2 7972 36.4 26.7 13.0 24.0 7971 12.0 47.8 38.8 7971 80.8 11.5 3.5 4.2 7972 0.1 2.0 31.1 34.3 32.5 7971 12.8 8.3 17.8 6.9 0.4 7.7 35.0 11.2 7637 0.4 27.4 44.8 27.4 28909 57.7 23.2 8.0 11.1 28910 28.8 49.1 21.0 28910 86.8 7.2 2.6 3.4 28910 0.1 2.0 27.8 34.2 35.9 28910 7.0 4.1 9.6 44.6 0.2 4.6 20.9 9.0 27994 26
2.6. Outlay Under Family welfare Programme: The family planning service is free service since its inception in 1952. The central government provides the full support to states in providing family planning services. As a result, the cost of family planning is directly born by Central Government. Even to a promoter, the use of family planning services, incentives were provided to acceptors before 1996. Here, we review the plan wise outlay for family welfare services. It is given in Table 2.7. From the table it may be noted that there is continuous increase in the outlay over the years. The outlay during the first plan periods was 0.65 crore, increased to 5 crores in second plan and was 6195 crore in Eighth Plan. This is an indication of increasing expenditures on family welfare programme. Table 2.7: Outlays under the Family Welfare Programme form 1 st Five Year Plan Period Outlays (Rs. In crores) First Plan (1951-56) 0.65 Second Plan (1956-61) 5.00 Third Plan (1961-66) 27.00 Annual Plan (1966-69) 82.90 Fourth Plan (1969-74) 285.80 Fifth Plan (1974-78) 285.60 Annual Plan (1978-79) 111.80 Annual Plan (1979-80) 116.20 Sixth Plan (1980-85) 1309.00 Seventh Plan (1985-90) 2868.00 Annual Plan (1990-91) 675.00 Annual Plan (1991-92) 749.00 Eight Plan (1992-97)* 6195.00 Annual Plan (1997-98)* 1750.35 Annual Plan (1998-99)* 2239.35 Annual Plan (1999-2000)* 2720.00 27
The annual expenditure of family welfare in recent years is given in Table 2.8 Table 2.8: Annual Expenditure on Family Welfare (Rs Crore) Year 1989-90 1990-91 1991-92 1992-93 1993-94 1994-95 MCH 72.45(11.23) 88.60(11.15) 99.60(11.49) 95.25(9.06) 125.24(9.75) 151.59(10.51) PPP 22.00(3.41) 28.25(3.55) 28.25(3.25) 50.30(4.78) 49.65(3.80) 49.47(3.43) Voluntary 5.4(0.84) 5.34(0.67) 5.80(0.67) 6.97(0.06) 10.00(0.78) 8.80(0.61) Sector CHG 18.00(2.79) 50.00(6.29) 24.00(2.77) 21.00(2.00) 21.00(1.63) 10.00(0.69) Grand Total 645.04 794.72 866.60 1051.41 1284.91 1442.03 From both the tables it is clear that there is a continuous increase in public sector expenditure on family planning. Though the use of family planning through private sector is increasing during the given years, it is still low. 28