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Poverty and Unmet Need for Contraception in India - a


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									 Poverty and Unmet Need for Contraception in India
   - a disaggregated analysis of some recent data

Seminar on Fertility and Poverty: micro and macro linkages
                     28-29 January 2010
 Centre for Global Health, Population, Poverty, and Policy
                University of Southampton

                      P.M. Kulkarni
     Centre for the Study of Regional Development
               School of Social Sciences
     Jawaharlal Nehru University New Delhi 110 067
   Poverty and Fertility Linkage
• The relationship is often examined in terms of the
  income-fertility linkage(Becker, Blake, Leibenstein,
  Easterlin, Lewis…)
• Possible linkages between income and fertility:
  On Demand side
  Positive, pure income effect, on account of
  affordability, if other factors are held unchanged
  Negative, quality-quantity trade-off
  On supply side
  Positive, better health at high incomes
  Negative, as cost of contraceptives could prevent
  those with low incomes from regulating fertility
• Empirical evidence showing higher fertility among
  the poor than average
        Neo-Malthusian initiatives
• Create awareness about consequences of rapid
  population growth

• Introduce the idea of fertility regulation

• Promote small family norm

• Minimise the cost of contraception to the individual
  by facilitating access at no or low cost

• Many national programmes emerged, the Indian
  family planning programme being the early one
   India’s Family Planning/Welfare
• Initiated because of Neo-Malthusian concerns of the

• Sought to reduce the rate of population growth by
  lowering fertility

• The broad approach was to create awareness about
  consequences of rapid population growth, promote small
  family norm and the idea of fertility regulation, provide
  contraceptive services
             Strategies adopted
• Clinics to provide contraceptive services free of cost

• Extension approach to promote the small family
  norm and to ‘motivate’ couples to accept family

• Cash incentives for acceptance

• Contraceptive acceptance targets

• Raising age at marriage

• Integration with the maternal and child health
  programme, services by health department
      Expectation and questions
• Given the programme strategies, the needs
  of couples for family planning, including the
  poor, should be met

• How well is the unmet need for family
  planning of the poor met ?

• Are the poor deprived more than the non-
  poor in meeting the need for family

• Are there regional variations in this?
 The concept and measurement
 of unmet need (Westoff- DHS)
• What is meant by unmet need for family planning?
• Unmet need for spacing -Fecund women in
  childbearing ages, who do not want a birth for some
  time, and are not using contraception (woman or
  husband) +
• Unmet need for limiting- Fecund women in
  childbearing ages, who do not want any more
  children, and are not using contraception (woman or
  husband) +
• Total unmet need = Unmet need for spacing +
                      Unmet need for limiting
• From India’s third National Family Health Survey
  (NFHS-3), which is the DHS in India.
• This was conducted in 2005-06
• It covered 124385 women of childbearing ages of
  whom 93089 were currently married at the time of
• Sample designed to allow unbiased estimation of
  key indicators at national and state level
• Information on fertility, fertility preferences,
  contraceptive use, and background obtained
• Data accessible to researchers
      How is poverty assessed?
• Data on income or consumption as such were not

• But based on ownership of assets and housing
  conditions, an index, called wealth index was
  constructed and its value computed for each

• This is used as proxy for income

• The index is classified into quintiles, I: the lowest as
  the poorest and the V: the highest
• Other measures possible but the wealth index is
  commonly used allowing comparisons
     Level of unmet need and
  variations in it by wealth index
• Unmet need was 12.8 percent (of couples of reproductive ages)
  in 2005-06

• Unmet need has declined over time, from 19.5 % in 1992-93, to
  15.8 % in 1998-99, and 12.8% in 2005-06

• According to the NFHS-3, for the very poor (poorest quintile of
  wealth index) it is 18.2 percent and for the richest quintile, 8.1

• Differentials by other background factors exist but those by
  education, place of residence, and caste/tribe category are
  narrower Table 1.doc
      Net effects of background
• Logistic regression analysis shows that
  All the background factors have significant influence
  on unmet need
Table 2.doc
  The odds ratios show that wealth index makes a large
  impact even after the other factors are controlled
  (0.65, 0.50, 0.35, 0.23 for II…V with I as reference
  Adjusted percentages are very close to the
  unadjusted ones

  Clearly, unmet need is higher than average among
  the poor on account of poverty
       Do states show a similar
• The picture varies substantially by state Table 3.doc
• Large gaps in JH, JK, DL, BH, HR, UP
• Moderate in RJ, AS, WB, OR, UT
• Moderate-low in CH, GJ, MP
• Very low in TN, HP, KN, AP, MH, PN, KL
• Fig2A.doc
• Fig2B.doc
• Fig2C.doc
• Depicting unmet need on map shows a broad
  regional pattern
Unmet Need Contraception in large states, India, NFHS-3 -
  Gap between the lowest and the highest wealth index
            quintiles in percentage points

                                           Less than 5 percent
                                           5.1 – 10.0 percent
                                           More than 10 percent

                                                  Not to Scale
  What do the evidence and the
       analysis convey?
• Look at it in the context of the Indian programme
• There was latent demand but demand was also
  promoted- dual objective: meet the existing demand
  but also promote demand
• Acceptor targets introduced in 1966 but
  de-emphasised in 1977 after the emergency
  intensification and dropped in 1997
• Name of the programme was changed to ‘Family
  Welfare’ and later the programme brought under
  reproductive and child health
• Now, after ICPD and the National Population Policy
  2000, the focus is on addressing unmet need for
  family planning and broadly need of reproductive
Strategies in the Indian programme having
some bearing on family planning needs of
                  the poor
 • Contraceptive services provided free of cost in
   public clinics/service centres
 • Services spread spatially, catering to rural areas as
   well, camp approach adopted for some time
 • Extension approach, services taken to people
 • Cash compensation to acceptors of family planning,
   later called incentive
 • Unmet need should be low even for the poor
 • Keeping the gap between the unmet needs of the
   rich and the poor is a measure of success of the
       Why the inter-state variations?
• Family planning/welfare is a national programme
  implemented by states
• How is it that some states have been quite
  successful in meeting the needs of the poor and
  some have not?
• The variations could, in principle, be due to cultural
• But hardly any inter-state variations are seen for the
  upper classesFig1.doc
• For the upper classes, the reliance on the
  programme is not as much as for the poor
• This points towards inter-state variations in
   Has the pattern changed over
• The first two rounds of the NFHS do not provide
  wealth index

• But NFHS-2 (1998-99) computed an index of
  Standard of Living fairly similar to the wealth index
  but with weights by judgement; this is provided in
  NFHS-3 data files as well

• This is categorised as Low, medium, and High

• A comparative view is given in Table 4. Table 4.doc
 Change from NFHS-2 to NFHS-3
• NFHS-2 also shows that unmet need is higher among
  the poor than the non-poor

• Unmet need has declined from NFHS-2 to NFHS-3 in
  all the categories
• But the decline for the poor is less than for the upper

• The gap between the Low and High categories has
  widened somewhat, by 2 percentage points, from 5.1
  to 7.5 percent
• This raises the question whether in the recent years
  the programme failed to address the needs of the
• Promotional tactics of the programme were
  criticised and changed
• But has the contraceptive service component
  become weak?
• The same department and staff have been engaged
  in both
• The conclusion is tentative given the small change
• Yet an assessment of the functioning the programme
  in various states is called for
• India shows moderate level of unmet need for family

• It is matter of concern that for the poor, unmet need
  is very high

• This has been the case in spite of various strategies
  that could meet the needs of the poor

• But there are large inter-state variations
• Some states have been quite successful in meeting
  the needs of the poor as well as of the rich whereas
  some have failed

• Apparently, there are large differences in the
  efficiency in implementation of the programme
  across the states

• The programme management must ensure that the
  need of the poor for fertility regulation is met

• The poor should be enabled to exercise their
  reproductive right

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