First, it was the school health cards. This was followed by the initiative to introduce a chapter on kala azar in text books in government-run schools across the state, to create awareness about this potentially fatal parasitic disease spread by a tiny sand fly that affects hundreds every year and can be fatal. However, even while protecting its children, the Bihar health department is actively engaged in stabilizing the population in the state. With the birth rate higher and death rate lower than the national average, Bihar is the third most populous state in India. According to Mr. Sanjay Kumar, Executive Director, State Health Society, Bihar, the fertility rate is worrying as it is the highest in India. “We need to take advantage of technology to address the high unmet need for family planning. A greater focus on increasing the participation of men is also needed,” he said in an interview.
Despite the dip in decadal growth of population, Bihar remains the third most populous state in the country. What are some of the biggest challenges?
I am happy that Bihar has seen a dip in population during 2001-2011. What is worrying is that at 3.9 our total fertility rate (TFR) is the highest in the country. This is a big challenge. Our high TFR is because 46 percent of the girls get married by the age of 16 and 58 percent become mothers by the age of 19. This precludes them from the possibility of higher education. There are many reasons for them being unable to pursue higher education including poverty, inaccessible terrain and having to commute long distances between school and home. Not being able to go to high school means that these girls are not in a position to exercise their reproductive rights. So, it is essential that girls marry after the age of 18.
What are the steps you have taken to achieve this goal?
We have initiated several campaigns to raise awareness. One of them is to tap the grassroots representatives of the people. We have 160,000 panchayat leaders and 50 percent of them are women since we have reserved half the seats for them. We are trying to leverage this advantage and train them to exert influence
on their communities. We want them to become change agents. If TFR is to be lowered, then infant mortality rate (IMR) and maternal mortality rate (MMR) have to be lowered as well. Only when we are able to prevent children from dying will parents consider having fewer children. We are striving to better the national MMR and IMR indicators. We have managed to better the national figure as far as routine immunization is concerned, achieving 67 percent compared to the national figure of 61 percent. Furthermore, we have fixed days for various services like ante natal check up (ANC), village health and sanitation days and family planning services. In fact, the number of sterilizations during the period 2009-2010 was three lakh. In 2010 2011, this increased to five lakh fifteen thousand. Unfortunately, only two percent of these are male sterilizations and 98 percent female, indicating the gender imbalance.
Why is it that family planning focuses primarily on women? How are you planning to increase participation of men?
Yes, we need to have a campaign focusing on men and increase their role. We want women to become empowered and to be able to exercise their reproductive rights. Increased participation of men is also important to address the unmet need for family planning (FP) services which is at 37 percent. This suggests that the demand for FP services is high but the supply of these services is low. So there is an urgent need to augment these services.
At present, sterilization seems to be the popular FP choice. How are you motivating them to consider other means?
Unfortunately, half of the women who undergo sterilization already have three to four children. So it really doesn’t help in population stabilization. That is why we have placed family planning counselors at all 76 first referral units (FRUs), six government medical colleges and three pre-identified hospitals. These 85 counselors are located in those facilities that do not have family planning corners run by any NGO.
How is this partnership between the state government and Janani helping to counsel women and men to avail of family planning services?
Counseling will help in creating awareness and demand for postpartum family planning (PPFP) services among communities since Bihar has 28 lakh births annually and almost half of them are institutional. This means that we don’t have to worry about tracking them nor do we have to hunt them down. They are present in our hospitals and can be counseled easily. We counsel those who already have three to four children to opt for a terminal method. For those who have one child, spacing is advised while those with two children are counseled to go in for terminal methods.
How do you plan reaching out to districts like Kishanganj which have a poor FP record?
We strongly believe that technology should be taken advantage of in family planning. Injectables need to be given a greater push. Statistics show that in countries like Indonesia, 56 percent of women use injectables.
Is this why Bihar is revising its population policy?
Yes, we are in the process of revising our population policy. A draft policy is ready and discussions on it are expected soon. I cannot reveal the changes in the policy until it has been finalized. But it is something which we need. Bihar has a high density of population. The availability of land has shrunk and will continue to do so until population is stabilized.
How are you bridging the gaps between policy and its implementation?
We do face challenges in implementation of programs like the Janani Suraksha Yojana which pay incentives to health workers and beneficiaries. Disbursement of payment is often irregular, which discourages the workers. To resolve the issue a study in collaboration with the International Finance Corporation and the Bill
and Melinda Gates Foundation was undertaken to analyze government to person (G2P) health payments in the state. The study recommended an innovative solution. Called the health operations payment engine (HOPE), this system will enable centralized payment processing and make payments through electronic fund transfers. This is the first such scheme in the country. It has been piloted in five districts and will roll out in the rest of the state soon.
Have public private partnerships (PPPs) contributed to better implementation?
PPPs have played an important role in improving health care. As far as family planning services
are concerned, we are partnering with NGOs ensure delivery of low cost health services. These NGOs are involved in the area of postpartum family planning (PPFP) and pre-service education (PSE) for nursing and midwifery cadre in the state. Training has also been conducted for the 22 master trainers who will eventually train 80,000 Accredited Social Health Activists (ASHAs) through district level trainers.
Does this mean you are expanding the role of ASHAs?
Yes, ASHAs are able to reach out to a large number of people. I pointed this out in the letter I wrote last year to each of the ASHAs and recognized their efforts in raising the health profile. They have been asked to focus on family planning along with their other duties. ASHAs are being given an incentive to bring couples for sterilization. A sum of Rs 150 is given for each ligation and Rs 200 for vasectomy.
Many good programs miss the mark because of weak or no convergence. How are you ensuring FP programs stay on course?
You have raised a very important issue. Convergence is critical to the success of all programs. Some of our schemes like the school health card program are a good example of convergence between the health and education departments. Muskan Ek Abhiyan is another scheme which has been successful because of the coordination between the ASHA and the auxiliary nurse midwife (ANM) – both under the National Rural Health Mission – and the anganwadi worker under the ICDS program run by the Women and Child Department. Several initiatives have been taken towards population stabilization. But for all programs to succeed we require greater convergence and for that we need a restructuring of government departments.