The slogan “Dua Anak Cukup” (“two children are enough”) meets the eye everywhere as you drive through rural Indonesia. An echo of “Hum Do, Hamare Do”, the familiar slogan of India’s family planning campaign. Indonesia coined its line in 1970, nearly two decades after India started its national family planning programme, in 1952. Today it has a TFR (total fertility rate) of 2.4, according to a 2011 Unicef report, close to 2.1, the replacement level of fertility, that magic number when a country’s population starts to stabilize. TFR represents the number of children that would be born to a woman if she were to live to the end of her child-bearing years. India’s TFR is 2.5 since 2010, according to a Union health ministry report. While there is not much difference in the figures now, we should remember that Indonesia started its programme 18 years after India and is still ahead of us.
In 1952, India’s TFR stood at 5.9. Indonesia’s was 5.6 when it launched its family planning programme. In just three decades, it has come to be regarded as the poster child for family planning, with countries like Malaysia and Bangladesh and more recently health officials from Rajasthan looking to gain a first-hand experience of its programmes. So what is Indonesia doing differently?
“We designed a multi-pronged communication campaign involving community volunteers, religious leaders and midwives,” says Eddy Hasmi, director, international training and collaboration at the BKKBN (Badan Kependudukan dan Keluarga Berencana Nasional), the national body that manages Indonesia’s family planning programme. Religious leaders talking about family planning? That too in an Islamic country? That is the first surprising aspect of this plan.
Pilot programme: Familes at Rajiv Gandhi Nagar in Dharavi, Mumbai.
“We approach it through the lens of reproductive health education,” says Wan Nedra, vice-dean at Jakarta’s Farsi University and a volunteer leader with the Muslimat Nahdlatul Ulama which, along with the Muhammadiyah, is one of the two main Islamic groups in Indonesia. In their madrasas, locally known as pesantrens, children are given age-appropriate information about contraceptives and sexual rights. Volunteers and leaders of the two groups also work within the local community, advising couples on family planning.
This approach of controlling the birth rate by involving religious leaders has clearly paid off. What also helps a great deal is that family planning is managed by a national body, which ensures a uniform agenda. Something that India lacks, say experts, and has hampered the progress of its programme.
Health being a state subject in India, no uniform methodology is followed. While the Centre does not advocate an incentive-based approach, some states like Rajasthan and Madhya Pradesh have done exactly that, offering cash and other incentives to encourage couples to adopt family planning. Tamil Nadu and more recently Maharashtra have adopted a more integrated approach, including family planning in their larger focus on maternal and adolescent health, and are reporting greater success in controlling birth rates. Tamil Nadu, along with Andhra Pradesh, Kerala and Karnataka, has already achieved the replacement level of 2.1 children per woman.
“State programmes seem to be driven by ideologies rather than evidence,” observes Garima Deveshwar Bahl, program director with the non-governmental organization SNEHA (Society for Nutrition, Education and Health Action), which runs a number of projects aimed at improving the lives of vulnerable women and children in Mumbai slums.
“This February, I attended a national-level conference where the speakers were all high level and everyone seemed to have a favourite aspect of the problem,’’ says Bahl. “Some focused on the need for gender equity in access to contraceptives, yet others talked of increasing the method-mix. No one is following any sort of Indian ‘model’. There is an emphasis on the northern states without factoring in migration that is happening to urban sites across the country, particularly Mumbai.”
It is among these vulnerable migrant communities at the Rajiv Gandhi Nagar in Dharavi that SNEHA runs a pilot family planning programme in partnership with the Family Planning Association of India and the municipal corporation of Greater Mumbai. A first-of-its-kind initiative, it integrates family planning with its other health projects, given the cross-cutting impact on poverty reduction and maternal health. This sets it apart from other programmes in the country which have looked at family planning in isolation.
The programme, started in early 2010, reaches out to a community of 3,500 households, most of them first generation migrants from Jharkhand, Uttar Pradesh and Bihar. It’s a mixed community, with most families having up to five children. Rajiv Gandhi Nagar is in many ways a microcosm, representative of thousands of migrants’ colonies, found in our urban centres. If the project works here, it could be replicated elsewhere in the country.
The methods used echo the Indonesian experience. A low-cost peer educator model has been developed wherein women from the community are trained and paid a modest amount. Through street plays and door-to-door campaigns, peer educators deliver the message that women can and should plan their babies. A point that decades of government campaigns with their focus on permanent methods like sterilization have failed to deliver effectively, because it left out women and men who wanted to delay babies.
The approach, SNEHA claims, is paying off. “When we started out here, use of family planning methods was just 12%. In a short period of one year with very low-cost solutions, it has gone up to 30%,” says Bahl.
What remains unexplored however is working with religious leaders to promote family planning. Indonesia is doing this by working within the framework of Islam, which allows temporary methods, while frowning upon permanent means like sterilization and abortion.
Taking religious leaders on board is equally critical in a country like India where religious and cultural taboos often hinder the ability to make an informed choice. Take the RISHTA (Research and Intervention in Sexual Health: Theory to Action) initiative, started in 2002 by the US National Institutes of Health in collaboration with the International Institute for Population Sciences, Mumbai, to prevent HIV transmission among married men and women living in Mumbai slums. The project roped in local imams and priests as gatekeepers, using them as advocates. There was huge opposition initially, according to Rajendra Singh, who managed the six-year project. “It is a big challenge to motivate and involve religious people in sexual health programmes. We took the support of the All India Muslim Personal Law Board and other senior leaders who encouraged people to look at the health effects of unhealthy behaviours.”
The findings of the RISHTA project, as yet unpublished, are heartening, with men from the community reporting a better understanding of issues related to domestic violence and women’s rights.
“We should definitely learn from Indonesia’s experience, on how to work with religious groups in general,” says Bahl. It is an approach that could work in India where family planning remains a sensitive topic.
Shai Venkatraman is a journalist, teacher and blogger with a special interest in issues related to health and gender rights. She recently visited Indonesia on a journalism fellowship.
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