Report No. 14644-IN India's Family Welfare Program: Toward a Reproductive and Child Health Approach June 23, 1995 Population and Human Resources Operations Division South Asia Country Department II (Bhutan, Indid, Nepal) Z~~~~~~ N~~~~~~ : . t . . . , .> - x TS .s . . , . 1~~~~~~~~~~~~~ ' 7A7 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ - . .. .. .: : ' , - .' %, " % , ,~~~~~~~~~~~~ ABBREVIATIONS AND ACRONYMS AIDS Acquired Immuno-deficiency Syndrome ANM Auxiliary Nurse-Midwife ARI Acute Respiratory Infection TIC Comnmunity Health Center CSSM Child Survival and Safe Motherhlood Program FRU First Referral Unit FWP Family Welfare Program GOI Governinent of India ICDS Integrated Clilid Development Services ICPD International Conference on Population and Development IDA International Developmenit Association IEC Iniformation, Education and CommuLicatioln IPPF International Planned Parenthood Federation IUD Intra-Uterine Device MCII Maternal and Child Health MOIIFW Ministry of llealth and Family Welfare MTI' Medical Termination of Pregnancy MPW Multi-purpose Worker NDC National Development Council NFI IS National Family Health Survey OCs Oral Contraceptives PEM Protein-Energy Mahlnutrition PMI' Private Medical Practitioner PHC Primary I lealth Center PVO Private Voluntary Organization RCH Reproductive and Child Health Approach RTI Reproductive Tract Infection SC Sub-Center SRS Sample Registration System STI Sexually Transmitted I nfection TBA Traditional Birth Attendant T'FR Total Fertility Rate TT Tetanus Toxoid UNFPA United Nations Fund for Population Activities WHO World Health Organization FOREWORD This report is is the product of extensive collaboration between the government of India, the states, and the World Bank team that drafted it. Earlier drafts of the report were discussed in detail in meetings chaired by the Secretary of Family Welfare, in which state Secretaries of Family Welfare and other high-level officials and experts participated. Written comments and suggestions from the government of India and the states have been incorporated into the report. This work was carried out by a team led by Anthony Meashamn (Adviser, Population, Health and Nutrition and Mission Leader), and composed of Meera Chatterjee (Women-in- Development Officer), Harry Cross (The Urban Institute, Washington), Catherine Fogle (Population Specialist), Gillian Foo (Consultant), Richard Heaver (Consultant), Anrudh Jain (Population Council, New York), M.E. Khan (Population Council, New Delhi), Tom Merrick (Senior Adviser, Population), Sudhir Mehra (Consultant), Indra Pathmanathan (Public Health Specialist), Saroj Pachauri (Population Council, New Delhi), V.J. Ravishankar (Economist), John Townsend (Population Council, New Delhi), Prem Talwar (Consultant), Anne Tinker (Senior Health Specialist), and Caby Verzosa (Population Specialist). The report was drafted by Anthony Measham and Richard Heaver, under the overall direction of Richard Skolnik, Chief, Population and Human Resources Operations Division, and Heinz Vergin, Director, South Asia Country Department 2 (Bhutan, India and Nepal). Annexes and background papers were contributed by Tom Merrick, Anrudh Jain, Meera Chatterjee, Richard Heaver, Saroj Pachauri, Caby Verzosa, John Townsend, M.E. Khan, Indra Pathmanathan, and V.J. Ravishankar. Comments on the draft were received from peer reviewers Shanti Conly (Population Action International), Peggy Curlin (Centre for Development and Population Activities), Maria MacDonald, and Christopher Walker, as well as from all members of the team. Thanks go to Sarah Brijnath and Shirin Sen for excellent support and word processing assistance. The team wishes to express its thanks for the encouragement and extensive collaboration of the Ministry of Health and Family Welfare, and in particular to Mr. V.K. Shunglu, former Secretary, Mr. J.C. Pant, Secretary, Mrs. Adarsh Misra, Joint Secretary, Mr. K.S. Sugathan, Joint Secretary, and Mrs. Rita Menon, Director, Department of Family Welfare. The team made field trips to Karnataka and Uttar Pradesh in October 1994 and to Madhya Pradesh and West Bengal in February 1995, and wishes to thank Mr. Gautam Basu, Mrs. Sumita Khandpal, Mr. G.S. Shukla, and Mrs. Leena Chakraborty and their colleagues for their excellent hospitality and collaboration. The report is a "living document" in the sense that the issues covered in it are the subject of ongoing discussions at the central and state levels and in the broader policy and research community. It is likely that further modifications of the document may result from this discussion and debate. Such changes will then be incorporated into a revised version of the report. This report focuses on one important aspect of the broad range of population policy issues that India faces-how the Family Welfare Program can carry out the commitment given at the Cairo population conference to implement a client-centered approach that responds more effectively to the reproductive health and family planning needs of women and men in India. This report makes preliminary estimates of the cost of implementing this approach. Additional related discussion of how to finance these costs is contained in the May 15, 1995 report on health finance (India: Policy and Finance Strategies for Strengthening Primary Health Care Services) and the India Country Economic Memorandum of May 30, 1995. The adoption of this focused approach does not mean that the authors of the report think that facilities and the "supply" of family welfare services are the only factors that are important for promoting fertility reduction. On the contrary, the report recognizes that a variety of developmental factors-in particular girls' education-are important determinants of fertility declines and reproductive, child, and overall health outcomes. However, these "demand-side" issues are not explored in the report. They are being addressed more thoroughly in other studies, which are investigating the relative roles of demand and supply factors in promoting fertility reduction. Finally, it will be important in moving toward a reproductive and child health approach for the government to take careful account of links between family welfare and other health services. It will also be important to take account of the emerging role of the private and voluntary sectors, particularly as they develop in the increasingly dynamic Indian economy. INDIA'S FAMILY WELFARE PROGRAM: TOWARD A REPRODUCTIVE AND CHILD HEALTH APPROACH TABLE OF CONTENTS Page No. EXECUTIVE SUMMARY ........................................................i I. INTRODUCTION A. Background ........................................I B. Objective, Scope and Limitations of the Report ........................................2 II. FAMILY WELFARE PROGRESS TO DATE A. The Evolving Policy Context .................... ................................3 B. Program Development ....................................................4 C. The Unfinished Agenda .............. .....................................6 D. Major Issues ....................................................7 III. ESSENTIAL REPRODUCTIVE AND CHILD HEALTH SERVICES A. An Essential Reproductive and Child Health Services Package ............... 12 B. Additional Reproductive and Child Health Services ................................. 16 C. The Need for Advocacy .............. ..................................... 17 IV. THE PUBLIC SECTOR PROGRAM: MANAGING FOR QUALITY AND CLIENT SATISFACTION A. Changing the Signals .18 B. Improving Access to Services .19 C. Responding to Clients' Needs .22 D. Supporting the Front-Line Workers .24 E. Strengthening Referral Systems .27 F. Summary .27 V. THE PRIVATE SECTOR: MAKING USE OF UNTAPPED POTENTL&L A. Social Marketing .......................... 29 B. Private Medical Practitioners .......................... 31 C. Private Voluntary Organizations .32 VI. FINANCING THE REPRODUCTIVE AND CHILD HEALTH PROGRAM A. Current Resource Allocation to the FWP .................................................. 34 B. Future Funding Requirements .......................... ......................... 35 C. Using Funding as a Performance Incentive ............................................... 38 VII. TABLES Major Recommendations of the Report 1. Recommended Reproductive and Child Health Services ........................................ 12 2. Changing the Signals ................................................... 18 3. Summary of Management Interventions ............................ ....................... 28 4. Estimated Per Capita Spending on FWP, 1994/95 ................................................. 34 5. Financing Requirements 1995- 2000 ................................................... 37 VIII. ANNEXES I Government of India Action Plan for Revamping the Family Welfare .......... ....... 40 2 Family Welfare Policy Issues ................................................... 49 3 Estimates of Unwanted and Wanted Fertility in India ............................................ 59 4 Addressing Gender and Poverty Concerns in a Reproductive Health Program .64 5 Essential Reproductive and Child Health Services at Different Levels of the Health Service System .74 6 Management of Reproductive Tract Infections and Sexually Transmitted Infections ......................... 76 7 IEC and Social Marketing ......................... 81 8 Indicators and a Management Information and Evaluations System for a Reproductive and Child Health Program .................................................. 91 9 Enhancing the Role of Private Voluntary Organizations (PVOs) .............. ............ 99 10 Financing Requirements and Sustainability of India's Reproductive and Child Health Program .................................................. 109 BIBLIOGRAPHY .120 INDIA'S FAMILY WELFARE PROGRAM: TOWARD A REPRODUCTIVE AND CHILD HEALTH APPROACH EXECUTIVE SUMMARY i This report reviews India's Family Welfare Program (FWP). In collaboration with the Ministry of Health and Family Welfare (MOHFW), a World Bank team identified the major constraints affecting the program, and suggests in the report ways in which these constraints might be overcome. The main recommendation of the report is that the program be re-oriented expeditiously to a reproductive and child health approach, the main objectives of which would be to meet individual client health and family planning needs and to provide high quality services. Reproductive health can be defined as a state in which "people have the ability to reproduce and regulate their fertility; women are able to go through pregnancy and childbirth safely; the outcome of pregnancy is successful in terms of maternal and infant survival and well being; and couples are able to have sexual relations free of the fear of pregnancy and of contracting disease" (Fathalla 1987). This report also encompasses child health, which is an integral part of India's FWP. ii. The 1994 Cairo International Conference on Population and Development formalized a growing international consensus that improving reproductive health, including family planning, is essential to human welfare and development. This consensus provides a new vision of population policy, which recognizes a crucial distinction between the overall goals of population policy and those of a reproductive health program. The principal goal of a reproductive health program is to reduce unwanted fertility safely and to provide high-quality health services, thereby responding to the needs of individuals, as well as to concerns regarding population stabilization. A growing body of evidence, and the Cairo consensus, suggest that numerical, method-specific targets and monetary incentives for providers should be replaced by a broader system of performance goals and measures, focused on a range of reproductive health services. The evidence also suggests that setting a broader range of reproductive health goals enhances fertility reduction, as well as client satisfaction and health status. The government of India strongly supports the Cairo Program of Action, and the reproductive health approach, as reflected in the India Country Report prepared for the Cairo Conference, and the Action Plan for Revamping the Family Welfare Program, 1992 (Annex 1). The Indian Family Welfare Program and its Context iii. The government of India has taken several policy initiatives in recent years. A high- level population committee was set up in December 1991 as a sub-committee of the National Development Council (NDC), which comprises all Chief Ministers of the states. The committee made recommendations to the NDC for formulation of a national policy and establishment of mechanisms for its implementation. An expert group constituted by the Department of Family Welfare issued in May 1994 a draft report for a National Population Policy. The report is currently under consideration by the government of India. iv. India today faces a radically different demographic and health situation compared with conditions when the national family planning program was launched in 1951. In the intervening period, mortality fell by nearly two-thirds, fertility declined by about two-fifths, and life expectancy at birth almost doubled. India's population has more than doubled since 1961. Mortality and fertility decline ran roughly in parallel for many years, so that the population ii growth rate remained above 2 percent per year until 1991. By 1992, India had achieved 60 percent of its goal of replacement fertility (2.1 births per woman), with fertility having declined from about 6 to 3.4 births per woman. Demand for fertility reduction is high-meeting the unmet demand for family planning would take India more than half the remaining distance to replacement fertility. And other factors, such as female education and employment, which increase the demand for smaller families, are moving in a direction that assures continuing declines in fertility and the population growth rate. v. The FWP, now in its fifth decade, has made an important contribution toward improving the health of mothers and children, and providing family planning services. The contraceptive prevalence rate now stands at slightly over 40 percent of eligible couples. For the past decade, the program has gradually shifted away from a predominant focus on family planning to a broader effort to improve maternal and child health. In 1992, the MOHFW developed a far- sighted action plan to strengthen the program, including several recommendations that are congruent with the reproductive health approach. This plan responded to a series of reports and analyses, highlighting constraints limiting the effectiveness of the program. Also in 1992, India took a further significant step towards the reproductive health approach when it initiated the Child Survival and Safe Motherhood (CSSM) Program. vi. The current achievements of the FWP are given below: National Health Policy (1983) Parameters 1951-61 1981 1992 goals by 2000 Crude Birth Rate 41.7 37.2 28.7 21 (SRS 1993) Total Fertility Rate 6.0 4.5 3.6 0 (SRS 1992) Infant mortality rate 146.0 110.0 74 60 (per 1000 live births) (SES 1993) Couple protection rate %) 10.4 22.8 45.4 60 (1970-71) (Mar. 1994) No. of births averted 0.04 44.2 168.8 0 (estimated in millions) (Mar. 1994) Life expectancy at birth 41.3 50.5 58.6 0 (years) (1971-81) (1986-91) vii. Although India has been a leader in developing health and population policy, major implementation problems have plagued the FWP for more than two decades. The problems can be summarized as follows: many who need the services are not reached by the FWP; most of those reached do not get access to the range of services they need; and services are often of unsatisfactory quality. Issues of access and quality are therefore the key elements of the unfinished agenda. Of course, further improvements in the quality of and access to other social iii services-especially education for girls-will be critical determinants of the effectiveness of the Family Welfare Program in actually reducing fertility and improving family health. Key Issues viii. This report focuses on five key issues, all of which are receiving substantial attention, but so far remain unresolved: * moving away from numerical, method-specific contraceptive targets and incentives to a client-centered system of performance goals and measures; * expanding the use of male methods and reversible methods, and broadening the choice of contraceptives; * improving the breadth, availability and quality of services, and involving communities in managing the public sector program; strengthening the role of the private sector in the FWP, and * assuming adequate funding for the current program, and the expansion implicit in adopting the reproductive health approach. Contraceptive Targets and Incentives ix. The report concludes that the current contraceptive target and incentive system gives a demographic planning emphasis to the FWP, which is antithetical to the reproductive and child health, client-centered approach advocated in the India country report for the Cairo Conference. In particular, emphasis on numerical targets is a major reason for the lack of attention to individual client needs, and is detrimental to the quality of services provided. The GOI had taken the initiative before the Cairo Conference to undertake discussions with women's groups, NGOs, and other experts regarding alternative performance goals. This report recommends that the targets be replaced by a broad set of performance goals and measures on the general lines of those successfully employed for the past six years in the Bombay and Madras urban slums family welfare project. It is further recommended that provider, motivator, and acceptor incentives be dropped. The issue has been discussed with the states but no consensus on dropping the incentives has yet been reached. x. The government has invited the states to eliminate targets in one district beginning in April 1995. These districts provide an excellent opportunity to replace targets by a set of indicators specific to reproductive and child health to test the feasibility of providing an essential reproductive and child health package (see para. 47) to assess its cost, and to evaluate whether it enhances couples' ability to avoid unwanted pregnancies safely in comparison to the current approach. Contraceptive Method Mix xi. The report concludes that a second major reason for the problems evident in the FWP is insufficient emphasis on reversible methods of contraception. According to the 1992-93 National Family Health Survey, "The focus of the family welfare program on permanent methods of contraception is evidently not satisfying the needs of a large group of women in India who wish to space their births. The encouragement of spacing methods for women who want il, more children wvould be likely to lower overall fertility and population growth, as well as to provide healthi benefits to both mother and children." Demand for sterilization is high and should be met. Despite wanted -cirility being close to replacement level in ten states, the unmet demand for reversible contraceptive methiods in four major states, as well as other states, constitutes an imiportanit challenige. xii. The report recommenids greater emphasis on male contraceptive methods, especially vasectomy and condomiis, and greater choice ot metilods. The Public Sector Program: Managing for Quality, and Client Satisfaction xiii. Clhanging the Signals. Shifting to the reproductive healthi approach implies clianging the implementationi signals to 250,000 family welfare staff'. Client satisfaction becomes the primary programil goal, with demographic impact a secondary, thoughi important, conicern. Broadening the service package is necessary. Improving service quality becomes the top priority. And it iilplies substanltial changes in how the program is managed at the field level. What is required is a quiet revolutioni in the wvay the program is planned and managed. The required changes in signals are sumimiarized in Table 1. Table 1: Changing the Signals aE . L E EM10-M. Primary goal Reach two-child family size norm While still encouraging smaller families, help clients meet their own health and fainily planning goals Priority services Family planning, especially Full range of family planning services female sterilization Immunization Full range of MCH services Performance measures Number of cases Quality of care, client satisfaction, coverage measures Management approach Top-down, target-driven Decentralized, client needs-driven Male-dominated Gender-sensitive Attitude to client Motivate, persuade Listen, assess needs, inform Accountability To the bureaucracy To the client and community, plus health and family welfare staff xiv. To help change the signals. the report recommends specific actions in five areas: * define a package of essential services, * improve access to good quality services, * make services more responsive to client needs, v * make sure front-line workers have the skills, support and supplies they need, and * strengthen the referral system. Defining an Essential Package of Reproductive and Child Health Services xv. Table 2 below summarizes recommendations for a package of essential reproductive and child health services in India. Recognizing the wide variation in health infrastructure, staffing and overall capacity in different parts of India, an essential package of services is presented for possible use everywhere, and additional services for use in selected districts and urban areas. Three points deserve emphasis. First, most of the services included in the essential package are already included in the FWP, but often are not provided for want of resources, adequate training, and other reasons. Second, child survival interventions are included in this package, which is therefore labeled the essential reproductive and child health package. While some reproductive health interventions benefit both woman and child, others, such as treatment of diarrheal disease in children, do not. Nevertheless, since the woman and child form a dyad, and programs naturally wish to provide services to both elements of the dyad, they are included in the package. Table 2. Recommended Reproductive and Child Health Services E.euitial I acliage Additional Services Nation-Wide in Selected Disiricts Family planning Growth monitoring, nutrition education, and food supplementation for children under six and pregnant and lactating women (through ICDS) Safe abortion Reproductive health services for adolescents Safe motherhood Diagnosis and treatment of cervical cancer Prevention and management of reproductive Advanced diagnosis and treatment of reproductive tract and sexually transmitted infections tract and sexually transmitted infections Child survival Health, sexuality and gender inforrnation, education and counseling Referral services for all of the above interventions xvi. A third important point is that the interventions included in Table 2 are among the most cost-effective health interventions. While some elements of the package necessarily are more cost-effective than others, health improvements depend on the whole set being made available. Consequently, the report does not recommend priorities within the essential package. If sufficient resources are not available to provide the whole package, it is better to phase in introduction of the whole package than to strengthen individual services on a piecemeal basis. xvii. Strengthening Service Delivery. Table 3 summarizes the main management interventions required for strengthening the reproductive health focus and improving quality and vi client satisfaction in the public sector FWP. While all of these recommendations are deemed important, efforts to increase community involvement in assuring that the program meets client needs deserve special emphasis. In many areas, the growing responsibility and capacity of the Panchayati Raj institutions provide an excellent opportunity for making the program more responsive and accountable. A major effort is also required to increase the involvement of women's and other community groups in prioritizing needs, identifying clients, monitoring progress, and disseminating information. Table 3. Summary of Management Interventions Doable? Low Cost? Improve Access to Services Make work routines more efficient Yes Yes Give ANM inore help from other workers Yes Yes Make sure workers are resident Yes Yes Make sure workers are mobile Yes No Hire more female workers Yes No Respond to Client Needs Listen to clients' needs (two-way IEC) Yes Yes Develop district plans meeting local needs Yes Yes Capitalize on opportunities of Panchayati Raj Yes Yes Support the Front Line Workers Broaden the range of performance measures in the MIS Yes Yes Improve the quality of in-service and pre-service training Yes Fairly Redesign the focus of supervision to on-the-job training Yes Yes Improve the Referral System Train field staff in recognizing referral needs Yes Yes Strengthen the First Referral Unit (FRU) Network Yes No Strengthen the Primary Health Care Center (PHC) network Yes No The Private Sector: Making Use of Untapped Potential xviii. The private sector accounts for more than three-quarters of all health care expenditure in India. It focuses mainly on curative care, quality is variable, and the poorest population groups cannot always afford its services. While the private sector provides a number of reproductive health services, such as delivery care and provision of reversible contraceptives, the poor rely mainly on the public sector for preventive care, and for hospital services. Nevertheless, the private sector offers substantial potential for increasing the coverage of some reproductive health services. In some instances, for example, contracting private doctors, the financing may come from the public sector, while the services can be efficiently provided by the private sector. This will result in providing clients with a wider choice, and will also enhance service quality. There is a considerable amount of experimentation underway in involving the private sector in the delivery of different state programs. These experiments should be monitored, with a view to vii seeing whether emerging innovations could have broader application in other localities, through the dissemination of best-practice example. xix. The scope for further evolution of the private sector's role notwithstanding, the report concludes that for the near term the private sector can contribute most in this area through the social marketing of reproductive health services and products. To achieve this the following actions are required: * broadening the product range to include other health and micronutrient products, * giving high priority to the social marketing of oral contraceptives, * expanding the market, especially in rural areas, * improving the condom marketing program, and * strengthening the management of the Social Marketing Program. xx. A second area of untapped potential is greater involvement of private medical practitioners, both indigenous and allopathic, in providing reproductive health services. In addition, the report suggests ways of increasing the contribution of private, voluntary organizations, which have proved effective at community mobilization and the provision of high-quality services. Financing the Reproductive and Child Health Program xxi. The government will need to gradually phase in the reproductive and child health approach. First, it will need to fill critical gaps in inputs at the existing FWP facilities. Second, and somewhat in parallel with the first step, it will need to expand services to areas that are not now served and where there are not now and not likely to be for some time, other suppliers of these services. In carrying out both of these steps, the government will need to take careful account of the links between the FWP and other health activities, and the emerging role of the private and voluntary sectors. Finally, it is critical that services are adequately financed, so that they are of acceptable quality and likely to achieve their aims. xxii. Underfinancing. The government of India spends considerably less on family planning and material and child health services than many developing countries. At about Rs. 19 or US$0.60 per capita per year, the Government in fact spends less on family planning and maternal and child health than the US$0.90 recommended for family planning services alone by the 1993 World Development Report, Investing in Health. Moreover, India has not been able to meet its own current funding norms for the FWP and the Union government continues to be in arrears to the states in allocating resources for the program. xxiii. Financing Needs. The report estimates the cost of providing the Reproductive and Child Health (RCH) package of services nationally if all of the expenses are to be funded by the public sector. The text of the report develops alternative scenarios for estimating such additional costs to the government in moving to the RCH approach, the executive summary presents these results in summary form. The additional costs to the Government in moving to the RCH approach are: (a) those costs that would be incurred in meeting the government's own staffing, facility, drugs, medicine, and other supply norms and for fully funding the existing FWP and (b) those costs from services that are currently not covered under the FWP but would be incurred in providing viii the additional services for the RCH essential package nationwide and some additional services in selected districts as shown in Table I (p. 11). In the instance that the government would bear the total cost of shifting to the RCH approach, the costs of the two components, over a five-year period, is estimated at US$1.7 billion (Scenario B in the text). xxiv. Under the scenario noted above, the additional costs associated with meeting the government's norms and fully funding the existing FWP comprise about 83 percent of the incremental costs, while only 17 percent of the incremental costs are associated with the provision of additional services in moving to the RCH approach. The capital costs are Rs. 21.5 billion, or around US$700 million, over a five-year period. The recurrent costs are Rs. 32.1 billion, or about US$1.03 billion. These numbers suggest that under a scenario in which the public sector funds the program totally, an 8.9 percent increase in recurrent costs per year in real terms for the FWP would be needed up until FY2000. xxv. It is possible, however, that some RCH services may be provided by the private and PVO sectors where opportunities exist. In addition, priority for public expenditure will need be placed on the satisfactory operations and maintenance of existing services as India moves to the RCH package of services. Moreover, it will also be very important that any expansion of facilities be based on well-defined criteria, that take account, among other things, of need, demand, equity, and the possibilities for private and PVO services in the area. To the extent that the private and PVO sectors might be able to provide services, and to the extent that requirements for public financing of facilities is reduced, the capital and recurrent cost requirements from the public sector would also be less. xxvi. Given the large section of the population under the poverty line and the special difficulties faced by women, the public sector will have to play an important role in financing the RCH package of services. Under such conditions, a joint commitment of all levels of government at the center and in the states will be necessary and the central government will need to consider how to enhance the overall budget for the sector within the context of the macroeconomic and fiscal constraints, taking into consideration the contributions made by the private and PVO sectors. Furthermore, some reallocation of resources will be required within the FWP both at the center and state levels. xxvii. Using Finance as a Performance Incentive. The central government might consider linking incremental funding to the states with their progress in re-orienting the program to the reproductive and child health approach. Progress could be measured by goals achieved, service delivery gaps filled, and steps taken by the states to improve their finances. The following might be considered as performance indicators: * achievement in spending the previous year's budget allocation from the center, * progress against agreed indicators of re-orientation toward the reproductive and child health approach, * amount spent to upgrade primary health care services, and steps taken by the states to improve their finances. ix xxvii. The major recommendations of the report are summarized in Table 4. Table 4: Major Recommendations of the Report Overall Recommendation Re-orient the Family Welfare Program, as quickly as possible, to a reproductive and child health approach that meets individual client health needs and provides high quality services. Policy Recommendations Eliminate method-specific contraceptive targets and incentives. Replace them with broad reproductive and child health goals and measures. Increase the emphasis on male contraceptive methods and broaden the contraceptive method mix. Public Sector Recommendations Improve access to reproductive and child health services. Respond more effectively to client needs, for example, by listening to clients' preferences, and by improving service quality. Increase support for the front line workers, for example, by enhancing the quality of training, and providing adequate supplies. Improve the referral system, especially for essential obstetric care, by strengthening the Primary Health Centers and First Referral Units. Private Sector- Recomniendationis Increase the role of the private sector, especially by: a) revitalizing the social marketing program and adding health and nutrition products; and b) expanding the use of private medical practitioners in the provision of reproductive and child health services. c) continuing to encourage experimentation with an expanded role for the private sector in implementing publicly funded programs; monitoring the experiments and identifying best- practice for dissemination system-wide. Finance Reconiunendations Increase the budget for reproductive and child health, to meet the staffing and other critical gaps, to enhance service quality, and to offer an essential reproductive health package; and use funding as a performance incentive to re-orient the program towards a reproductive and child health approach by taking steps to improve state-level finances. INDIA'S FAMILY WELFARE PROGRAM: TOWARD A REPRODUCTIVE AND CHILD HEALTH PROGRAM 1. INTRODUCTION A. BACKGROUND 1. The 1994 Cairo International Conference on Population and Development (ICPD) formalized in its Program of Action, a growing international consensus that improving reproductive health, including family planning, is essential to human welfare and development. Reproductive health can be defined as a state in which "people have the ability to reproduce and regulate their fertility; women are able to go through pregnancy and childbirth safely; the outcome of pregnancy is successful in terms of maternal and infant survival and well being; and couples are able to have sexual relations free of the fear of pregnancy and of contracting disease" (Fathalla, 1987). The government of India (GOI) strongly supports the Program of Action, in general, and the reproductive health approach, in particular, as reflected in its own action plan for revamping the FWP and the Program of Action in the India Country Report prepared for the Cairo Conference. A New International Vision of Population Policy 2. An important context for this review is the new international vision of population policy that emerged from the Cairo Conference, which recognizes a crucial distinction between the goals of overall population policy and those of a reproductive health program. In the past, family planning program success or failure has been defined, almost entirely, in terms of its contribution to declines in fertility and population growth rates. The new consensus recognizes that an important goal of reproductive health programs should be to reduce unwanted fertility safely, thereby responding to the needs of individuals for high quality services, as well as to demographic objectives. 3. The Cairo Conference articulated a call for broader, more holistic approaches to population that link demographic concerns, including fertility reduction, to a range of social development and poverty reduction objectives, particularly those which affect the health and socioeconomic status of women, as well as increased male involvement in, and responsibility for sexual and reproductive behavior. At the program level, ICPD called for high quality, client-centered approaches that address a range of reproductive health needs, including safe motherhood and family planning, as well as other problems such as reproductive tract infections (RTIs) and sexually transmitted infections (STIs). ICPD recommendations represent a more effective way of achieving the overarching objectives of population policy, poverty reduction, and improvement in human welfare, and are also more acceptable on humanitarian grounds. 4. Reproductive Health Approach. The concept of a reproductive health approach is therefore central to this new vision of population policy. While fertility reduction concerns can be addressed at the level of broad social policy, the design and management of 2 reproductive health programs need to be directed primarily at the needs of actual and potential clients. Correspondingly, performance can be measured by effectiveness in meeting client needs and improvements in reproductive health status, through indicators that demonstrate continued effective use of temporary methods for couples who want to space pregnancies, permanent or temporary male and female methods for those who want to limit pregnancies, and reduced maternal mortality and morbidity. Demographic performance targets are to be avoided by family planning programs because of the distorting effect they have on achieving these broader reproductive health objectives, notwithstanding the importance of population stabilization as a population policy goal. Improving the health of individuals commands equal priority with helping couples to plan their families in the reproductive health approach. B. OBJECTIVE, SCOPE, AND LIMITATIONS OF THE REPORT 5. The government of India (GOI) has enunciated specific health goals. These goals include achieving a contraceptive prevalence rate of 60 percent before 2006-2011, an infant mortality rate below 60/1000 live births, and substantial reductions in maternal and child morbidity and mortality. The Family Welfare Program (FWP), whose effectiveness can be increased by adopting the reproductive health approach, represents a principal means of achieving these goals. The objective of this report, therefore, is to identify, in collaboration with the MOHFW, the specific constraints that stand in the way of re-orienting the FWP towards a reproductive health approach, and to spell out feasible actions that could be taken to overcome them. This report encompasses child health, in addition to reproductive health, because child health is an integral part of India's FWP. 6. The scope of the report is limited. While the report considers links between initiatives in family welfare and other aspects of social policy and poverty reduction, it does not address the full array of population policy issues that the GOI is considering. For example, while female education is a key factor in improving women's opportunities, health and welfare, and is receiving substantial GOI support, it will not be emphasized in this report. While consideration of the broader issues is warranted and is being undertaken by the Indian authorities, the focus of this report is on practical guidance to strengthen the FWP. 7. This report focuses mainly on public provision of reproductive and child health services, while also examining the potential for expansion of the private sector role, which is supported by GOI. While the public sector FWP probably provides services to no more than 50 percent of the population, it dominates the provision of preventive health care in India. It is by far the largest provider of clinical family planning methods, such as sterilization and the IUD, and it is often the only source of these services for the poor. Private providers are the major source of ambulatory, curative care, for both the poor and the better-off. 8. The context for the provision of reproductive and child health services is extremely diverse in the different regions and states of India, as well as between urban and rural areas. This diversity should constantly be borne in mind by the reader, especially vis-a-vis the generalizations that necessarily appear in a short report. 3 11. FAMILY WELFARE PROGRESS TO DATE A. THE EVOLVING POLICY CONTEXT 9. The policy context today is radically different from the one faced by the government of India when the national family planning program was launched in 1951. In these forty- four years, mortality has fallen by nearly two-thirds, fertility has declined by about two fifths, and the demand for family planning by Indian couples in all strata of society has increased dramatically. For decades, the mortality and fertility declines ran roughly in parallel, with the result that the population growth rate remained above 2 percent per year, and India's population more than doubled from 1961 until now. The 1991 census, however, demonstrated that the population growth rate had fallen to below 2 percent for the first time, reflecting accelerating fertility decline. Because of the young age structure of India's population, the momentum for continued growth remains strong, with the projected population size in 2025 expected to be between 1.5 and 1.9 billion. 10. Annex I sets out the government's 1992 action plan for revamping the FWP. Annex 2 briefly describes the evolution of population policy in India from 1951 to the present, while Annex 3 sets forth the changes in fertility preferences over time, highlighting the large unmet need and demand for family planning services that currently exists, especially for reversible methods, as demonstrated by National Family Health Survey (NFHS) data. 11. Demand for Children. Demand for smaller families derives mainly from improvements in the female literacy rate, female age at marriage, women's status and employment, social security, and overall economic and social development. In India, all of these factors are moving in the right direction, albeit at varying speeds, and can be expected to continue to depress the demand for children. India seems likely to achieve replacement fertility-2.1 births per woman-early in the next century. The earlier it does so, the smaller will be the ultimate population size. The FWP will make an important contribution to achieving replacement fertility. 12. Wanted fertility. With a total fertility rate (TFR) of 3.4 births per woman, and replacement level at 2.1 births, Indian couples are having, on average, 1.3 births more than the number required to achieve the goal of replacement fertility. How close is wanted fertility to the replacement level? The desired fertility rate varies from about 1.8 births in Kerala to 3.8 births in Uttar Pradesh (U.P.). Wanted fertility is quite close to replacement fertility in the following ten states: Andhra Pradesh (A.P.), Gujarat, Jammu, Karnataka, Kerala, Maharashtra, Orissa, Punjab, Tamil Nadu, and West Bengal. In Assam, Haryana, Rajasthan, Bihar, Madhya Pradesh (M.P.), and U.P. achievement of replacement fertility would require reductions in both wanted and unwanted fertility. 13. Unwanted Fertility. By 1992/93, India had achieved 60 percent of its goal of replacement fertility. As shown in Annex 2, 46 percent of currently married women want to delay or limit their future childbearing, in addition to the 31 percent who are already sterilized. Unwanted fertility varies from about 0.2 births in Kerala, to about I birth in Bihar, Rajasthan, and U.P., and 1.2 births in Haryana. In all states, except Kerala, at least 20 4 percent of fertility is unwanted; close to 30 percent is unwanted in Assam, Haryana, Jammu, Punjab and Tamil Nadu. Fertility is lower, and unwanted fertility is higher in urban than in rural areas. Eliminating unwanted births-the priority for family planning services in a reproductive health approach-would take India more than halfway to replacement-level fertility. 14. Recent Policy Developments. A high-level population committee was established in December 1991 as a sub-committee of the National Development Council (NDC), which comprises all state Chief Ministers. In 1992, the committee made an exhaustive set of recommendations to improve the FWP, which were reflected in the MOHFW action plan discussed in para 19, below, and in Annex 1. In addition, the committee recommended formulation of a national population policy and establishment of mechanisms for its implementation. It constituted a committee of experts, headed by Mr. M.S. Swaminathan, to draft the policy. 15. In May 1994, the Swaminathan committee submitted to MOHFW a draft report with recommendations for a new national population policy. The report proposes the establishment of population and social development committees at the national, state, district, and local levels of government, to promote an enabling political environment and community involvement in addressing family welfare issues. Recommended mechanisms for implementation of the policy, including the establishment of a population and social development fund, are still under discussion. Considering the major implications for reorganization and system change, the Department is considering a policy paper in the near future. B. PROGRAM DEVELOPMENT India's Family Welfare Program (FWP) Achievements 16. The FWP, now in its fifth decade, has helped to bring India about two-thirds of the way towards its goal of replacement-level fertility, and to achieve significant improvements in the health of mothers and children. (The term FWP will be used in this report to cover all actions, in the public and private sectors, included in the effort led by the Ministry of Health and Family Welfare (MOHFW) and its counterparts at state and local level.) According to the NFHS, the TFR in 1992/93 was 3.4 per woman, a decline of 2.6 births from an initial TFR level of about 6 in the 1 950s. The infant mortality rate was estimated at 79 per thousand live births, while the maternal mortality ratio stood at 420 maternal deaths per 100,000 live births, as against about 146 and 800, respectively, in the 1 950s. 17. The MOHFW has established an impressive network of over 2,300 community health centers (CHCs), 21,000 primary health centers (PHCs), and 131,000 village-level sub-centers (SCs), to provide primary health care, including maternal and child health (MCH) care and family planning, at the grassroots level. According to NFHS data, slightly more than 40 percent of eligible couples in India are using contraception. NFHS figures also show that over 60 percent of mothers had received tetanus-toxoid (TT) immunizations during their most recent pregnancy; over 50 percent had received iron-folate tablets to combat anemia; and over 60 5 percent of infants had received at least one immunization provided by the Universal Immunization Program (UIP). Current coverage is reported at over 80 percent in respect of tetanus toxoid and over 90 percent for the other vaccine-preventable diseases. 1 8. For the last decade, the FWP has gradually shifted its focus away from a predominant focus on family planning to a general effort to improve maternal and child health. The UIP exemplifies this gradual change, while efforts increased in rural areas and urban slums alike, to provide maternal health services and care to children under five. By 1992, ANMs were spending more time on immunization than on family planning. Efforts to improve the quality of services were boosted by substantial strengthening of the training infrastructure in the late 1980s and early 1990s and the introduction of the Child Survival and Safe Motherhood Program in 1992 gave further impetus to the shift in program direction (para. 20). 19. Action Plan for Revamping the FWP. In 1992, MOHFW developed a far-sighted strategy to address those problems identified in the NDC Commission on Population Report in its Action Plan for Revamping the Family Welfare Program in India (see Annex 1). Several of the key recommendations of this plan, which considerably pre-dates the Cairo Conference, are congruent with the reproductive health approach which received consensus support two years later. These include: * improving the quality and outreach of FW services, including MCH and immunization, and establishing the Child Survival and Safe Motherhood Program, * speeding up FWP implementation in Bihar, Madhya Pradesh, Rajasthan, and U.P., and in the remaining districts outside these four states with weak social indicators, * modifying the system of targets and incentives for family planning, * promoting a broader range of contraceptive method choices, and * revitalizing the community-based support for FW workers. 20. Child Survival and Safe Motherhood Program (CSSM). India took an important step in shifting the FWP further toward the reproductive health approach when it initiated the CSSM program in August 1992. The goals of the program are to improve the health status of women and children and to reduce maternal, infant, and child mortality. The child survival component of the program is to be operational in all 466 districts of the country by 1997, while the safe motherhood component will cover 219 districts. In addition, a number of states are implementing the safe motherhood component even in districts not earmarked to receive GOI support for this component. The package of services offered under CSSM is as follows: 6 Children Mothers * Essential newborn care * Immunization * Immunization * Prevention and treatment of anemia * Appropriate management of diarrhea * Antenatal care and early identification of maternal complications * Appropriate management of acute * Delivery by trained personnel * respiratory infection (ARI) * Promotion of institutional deliveries * Vitamin A prophylaxis * Management of obstetric emergencies * Birth spacing 21. Good progress is evident with the child survival component of the program, although essential newborn care and AR] management are lagging behind the rest of the package, being the most recently introduced interventions. Progress with the safe motherhood component is slow, partly because the program represents a significant expansion of previous actions in the area of maternal care, and also because the implementation of this component requires some physical upgrading of the first referral level units (FRUs), training of physician specialists, and procurement of equipment not usually found below the level of the district hospital. C. THE UNFINISHED AGENDA 22. India has been a leader in developing health and population policy. However, major implementation problems have plagued the FWP for more than two decades. These problems can be summarized as follows: many people in India who need its services are not reached by the program; most people reached by the program do not get access to the range of services they need; and those services which are provided are often of unsatisfactory quality. Issues of access and quality are therefore the key elements in the unfinished agenda. The issues are illustrated below with data taken from the NFHS. 23. Poor Average Performance. Three key indicators demonstrate the continuing limited reach of the FWP: antenatal care coverage; immunization coverage; and knowledge of different family planning methods. With regard to antenatal care, just under half of all pregnant women in India received no antenatal check-up at all in 1992/3, in contrast to the three antenatal contacts recommended in the family welfare protocol. With regard to immunization, only 35 percent of children under two received all six antigens, while 30 percent received none of them according to NFHS data. However, coverage level surveys show a significantly higher percentage with respect to fully immunized infants and mothers. With regard to knowledge of contraceptive methods, while over 95 percent of married, reproductive-age women had heard of a modern method of contraception, nearly 40 percent had not heard about the IUD and about a third had not heard about the pill. 24. Regional variation. The regional variation in program performance is striking. While in Kerala over 96 percent of pregnant women received an antenatal check-up, in U.P. and M.P., respectively, no more than about 30 percent and 36 percent did so. Total immunization coverage varied from 64 percent in Maharashtra and Tamil Nadu to about 11 7 percent in Bihar and 20 percent in U.P. And while on average, 30 percent of Indian children had had no immunizations, in Rajasthan the figure was about 48 percent, and in Bihar 53 percent. Knowledge of the IUD varied from over three-quarters of women in Karnataka, Kerala, and Tamil Nadu to less than half in A.P., Bihar, M.P., and Rajasthan. The reasons for these striking regional variations are complex. On the demand side, they include the higher rates of poverty and illiteracy in the large northern states, resulting in low priority for preventive care, poor knowledge of services, and difficulty in obtaining them. On the supply side, they include lower per capita financial outlays for health and family welfare in the northern states as compared to the southern; lower commitment to the social services; and weaker administrations, leading to under-performance in all government programs, not only family welfare. 25. Inequity. The NFHS does not present coverage data by income-group. Nevertheless, it breaks them down by background characteristics of clients, some of which are reasonable proxies for poverty. From these, it is clear that the poor have worse access to family welfare services than the better-off. For example, while about half of all pregnant women received at least one antenatal check-up, this service reached only about 26 percent of women with six or more children, and 35 percent of illiterate women. Only 24 percent of the children of illiterate women had full immunization coverage, against 49 percent of those who had completed primary education, and 70 percent of those who had completed high school. Again, the reasons for inequity are complex. On the demand side, the poorly educated may not appreciate the importance of preventive care, the poor have less voice to demand services, and the poor can ill-afford time off from work to seek care. On the supply side, the poor are concentrated in the large, northern states which have the weakest administrations and outreach services, and the poor may be discouraged from seeking care by the behavior of higher status service providers. D. MAJOR ISSUES 26. The gap between policy and implementation is the major focus of this report. Key issues will be presented in this section, the elements of an essential reproductive and child health package are presented in Section 111; their management implications are taken up in Sections IV and V, and financial issues are dealt with in Section VI. Overall, five key issues, which are receiving substantial attention from GOI, remain: * how to move away from numerical, method-specific contraceptive targets and incentives to a client-centered system of performance goals and measures; * how to expand the use of male methods and reversible methods, and broaden the choice of contraceptives; * how to strengthen the quality of services, and overall management of the program; * how to strengthen community involvement in the FWP; and 8 * how to assure adequate funding for the current program, and the expansion implicit in adopting the reproductive health approach. Targets and Incentives for Specific Contraceptive Methods 27. Many GOI reports, including the action plan and the Swaminathan committee report, recognize that contraceptive targets and monetary incentives imbue the FWP with a demographic planning emphasis that is antithetical to the reproductive health, client-centered approach advocated in the GOI-ICPD Country Statement. However the NDC Committee's report has not only recommended continuation but introduction of additional incentives and disincentives. The issue has been discussed with the states and no consensus has emerged so far. Such targets and incentives are of concern for several reasons: they tend to distort program performance by directing attention to the total number of acceptors of a given method, rather than to the needs of the individual client, and can lead to biases favoring one method over another; they raise issues related to possible infringement of individual reproductive preferences; they are difficult to administer; and they are expensive. These issues are discussed in more detail in Annex 2. 28. Targets and Provider and Motivator Incentives- Possible changes in the current method-specific target and incentive system are under consideration by GOI. The government has already abolished condom targets, effective from April 1, 1995. In another signal step, the government has invited the states to eliminate all targets in one district from April 1995. Four larger states are considering elimination of all targets in two districts effective from April 1, 1995. These districts present an excellent opportunity to test the feasibility of providing an essential reproductive and child health package (see para. 43), to assess its cost, and to evaluate whether it enhances the couples' ability to avoid unwanted pregnancies safely, in comparison to the current approach. A set of program goals and indicators has been worked out that would replace the earlier targets and emphasize quality issues in these districts. 29. Since the early 1980s, all states have increasingly emphasized the maternal and child health approach to family welfare and have introduced some of the features of the reproductive health approach, principally the de-emphasis of method-specific contraceptive targets. The urban slums family welfare project in Madras and Bombay has been particularly successful. It is monitored by means of a set of performance measures which give as much weight to MCH as to family planning, as described in para. 88. While contraceptive targets and incentives have not been eliminated, they received less emphasis. Contraceptive prevalence has continued to rise in all project areas and the project has contributed to substantial declines in under-five mortality and fertility over a six-year period. 30. Tamil Nadu has experimented, over the last three years, with various changes in the target and incentive system, such as abolishing method-specific targets for field workers, reducing the level of monetary incentive for sterilization, and eliminating the motivator certificate. None of these changes resulted in a decline in program performance, and the experiments are being applied on an expanded basis. 9 31. A growing body of evidence, and the Cairo consensus, suggest that numerical, method-specific targets and monetary incentives for providers should be replaced by a broader system of performance goals and measures, focused on a range of reproductive and child health services. The evidence also suggests that setting a broader range of reproductive health goals enhances fertility reduction, as well as client satisfaction and health status. Therefore, this report recommends that method-specific contraceptive targets be replaced by performance goals and measures along the general lines of those employed in Bombay and Madras (see para. 88). Provider and motivator incentives have already been discontinued for intra-uterine devices. This report recommends that GOI now consider eliminating the current system of provider and motivator incentives for sterilization. 32. Incentive Payments to Acceptors. Support for acceptor incentives, or compensation, is greater in India, based on the argument that the cash and other assistance compensates the acceptor for work time lost, travel time, and the various outlays associated with the sterilization procedure or IUD insertion. While acceptor incentives for IUD insertion have already been eliminated in some states, for example, Tamil Nadu, the incentives for sterilization continue in all states, albeit with less augmentation of the GOI allowances by the states than before. They also represent a much smaller incentive by virtue of having remained at the same level for over a decade. 33. Tamil Nadu is already experimenting with using the savings accrued from reducing the incentive level to expand the quality and outreach of all maternal and child health services. There are strong arguments in favor of phasing out acceptor incentives. The main argument for eliminating acceptor sterilization incentives is that similar incentives are not offered for any comparable procedure. Another important argument is that the savings- about 6 percent of the GOI family welfare budget-could yield higher returns if used in other ways. Broadening the Choice of Reversible Contraceptive Methods 34. Female sterilization still accounts for about three-fourths of contraceptive prevalence in India. According to the NFHS report, "The focus of the family welfare Program on permanent methods of contraception is evidently not satisfying the needs of a large group of women in India who wish to space their births. The encouragement of spacing methods for women who want more children would be likely to lower overall fertility and population growth, as well as to provide health benefits to both mother and children." Demand for sterilization is certainly high and should be met. Despite the high demand for sterilization, unmet demand for reversible methods is very considerable. The main point here is that unmet demand for reversible methods is higher than for sterilization, which is universally available, so that increasing contraceptive choice for individuals deserves high priority. 35. Male methods. Male methods account for only 6 percent of current contraceptive use, according to NFHS and GOI data: only 3.4 percent of couples rely on vasectomy, and 2.4 percent on condoms. Cultural reasons are frequently advanced as the reason for low acceptance of vasectomy, but the FWP clearly has not emphasized male sterilization nearly 10 to the extent of tubectomy. This report recommends that a vigorous effort be undertaken to promote vasectomy along with tubectomy, in view of the greater simplicity of the procedure, the need for men to take more responsibility for family planning, and the lower mortality and lower incidence of complications associated with the male sterilization procedure. The GOI has already recommended greater emphasis on vasectomy to the states. There is an even more pressing need to promote the use of condoms, both through a revitalized social marketing effort and through the FWP. The growing HIV epidemic makes greater use of condoms an urgent priority. 36. Reversible Methods. NFHS data show that only 5.5 percent of couples use reversible modern contraceptive methods. The MOHFW action plan, the NFHIS report, and many other analyses have recommended increased emphasis on reversible methods, especially "for younger couples with high fertility potential", in the words of the action plan. 37. Despite the fact that oral contraceptives (OCs) have been available in the FWP since the mid-1970s, only 59 percent of rural women know of this method, and this percentage falls below half in rural U.P. and M.P. Oral contraceptives are used by only 1.2 percent of couples, according to the NFHS. The low prevalence of use of oral contraceptives, especially through the public sector, reflects logistic problems and inadequate information, education and communication (IEC) for this method. Experience in neighboring countries suggests substantial potential for greater use of this method by younger couples, if the necessary counseling, support, and supplies are in place. 38. A non-hormonal, once-a-week oral pill "Centchroman", developed through indigenous research and development, has been introduced in the market. This oral pill is free from many side effects commonly associated with hormonal pills. 39. The MOHFW recommended in the action plan that injectables "be introduced under the Program, initially under controlled conditions and gradually on a wider scale". GOI is of the view that the method should be introduced on a wider scale, only after more research on quality service provision, side effects, and consumer acceptance. Injectables became available in the private sector in 1994, at Rs. 120 per three-monthly dose, well above the price affordable to the vast majority of Indian couples. Given the need for safe, effective, and convenient reversible methods mentioned above, there seems to be every reason to phase this method into the program, with the necessary training, surveillance, and monitoring by the Indian Council of Medical Research and the medical colleges engaged in research and demonstration efforts regarding contraceptive methods. 40. Barrier methods other than the condom, for example, diaphragms, would also be a welcome addition to the FWP. While the demand may be relatively limited, their availability would broaden the effective method choice available to couples. 41. FWP Supply Needs. India is at present self-sufficient in the provision of IUDs and condoms, and receives hormone supplies for the oral pill as an annual commodity grant from UNFPA. Substantial expansion of the use of reversible methods in the public sector in the near future will, however, put stress on these existing contraceptive supply sources, and may 11 require additional ones. In order to assure adequate supplies of reversible as well as permanent methods, over the next few years, the likely evolution in method mix should be reviewed in light of the numbers of women and men of reproductive age and their requirements. Adoption of the broader reproductive health approach will also require expansion in the supplies of drugs and equipment. Managing for Quality and Client Satisfaction 42. Successive reports on the FWP, including the action plan, the NDC population committee report, and the Swaminathan committee report, have highlighted the need to strengthen the management of the FWP. How this might be accomplished is a major feature of this report, and occupies Sections III, IV, and V. Section III sets the stage by presenting an essential reproductive and child health services package in some detail. Section IV discusses the management implications of the essential package, with particular emphasis on improving the quality and client satisfaction with the public sector program. Section V then suggests ways in which the potential of the private sector might be tapped further. Role of the Community in the Reproductive and Child Health Program 43. The critical importance of having the community, especially women's groups and those representing the poor, scheduled castes and scheduled tribes, play a substantial role in the planning, implementation, and monitoring of the FWP has been emphasized by innumerable reports for over twenty years. While this involvement has grown over time, especially in those states where the panchayat system is well developed, and where mahila mandals, village health committees, and similar groups are functioning well, the potential for a larger role is enormous, and the benefits of such involvement are likely to be considerably large. The implementation of the Panchayati Raj Act of 1992 provides one vehicle which could make the community's major role a reality. Section III discusses the implications of this community role for improving the quality of services, and how the FWP can best nurture and sustain a growing partnership with communities, while Annex 4 provides a discussion of how the community role can be expanded, with particular emphasis on women and the poor. Funding the Reproductive and Child Health Program 44. Like the report of the NDC population committee, this analysis reveals that the FWP is substantially underfunded in relation to its current goals. Section VI presents the rough size and composition of the current funding gap, and looks at the resource situation in India compared to that in other low-income countries. Implementing the reproductive health approach advocated in India's ICPD Country Report, even in a carefully phased and cost- effective manner will require a quantum increase in resources for the FWP. Section VI attempts to estimate the order of magnitude of the current funding gap, and the further requirements of the reproductive health approach. It also makes recommendations for how central funding could be used as an incentive to encourage the states to reorient the FWP toward reproductive health. 12 III. ESSENTIAL REPRODUCTIVE AND CHILD HEALTH SERVICES 45. This section discusses which reproductive and child health services should be made available through the health and family welfare programs. Because of the wide variations in different parts of India in health infrastructure and staffing, as well as in technical and management capacity, it is inappropriate to propose a single reproductive and child health services package for the country. Instead, different levels of services are proposed for different conditions (see Table 1). It is recommended that an essential services package be made available nationwide over a five- to ten-year period (paras. 47-58), and additional services on a more restricted basis where the delivery capacity exists (paras. 59-63). Table 1. Recommended Reproductive and Child Health Services 1*1~~~1 fi U SYU-4 it I i I S1| 1 IA laily planning Growth monitoring, nutrition education, and food supplementation for children under six and pregnant and lactating women (through ICDS) Safe abortion Reproductive health services for adolescents Safe motherhood Diagnosis and treatment of cervical cancer Prevention and management of Advanced diagnosis and treatment of reproductive tract and sexually reproductive tract infection and sexually transmitted infection transmitted infections Child survival Health, sexuality and gender information, education and counseling Referral services for all the above interventions A. AN ESSENTIAL REPRODUCTIVE AND CHILD HEALTH SERVICES PACKAGE 46. Child survival interventions are included in this package, which is therefore labeled the essential reproductive and child health services package. While some reproductive health interventions benefit both woman and child, others, for example, treatment of diarrheal disease in children, do not. Nevertheless, since the woman and child form a dyad, and programs naturally wish to provide services to both elements of the dyad, they are included in the package. 13 47. Most of the services in the essential package in Table I are theoretically included in the FWP but often are not provided for want of resources, adequate training, and other reasons. Key issues are gaps in the range of services in many areas, services delivered are often of a low quality, and service coverage is poor. The section which follows summarizes for each service the major changes required in content, quality, or coverage. While adding the new services and improving quality are major challenges, they do not require a quantum increase in resources, as explained in Section VI. Increasing coverage by filling current staff and infrastructure gaps, however, requires very substantial additional resources. 48. There are also major issues about which service should be available at which level of the health system. For example, medical termination of pregnancy (MTP) and RTI/STI diagnosis and treatment are currently available only at higher levels of the health system. Making services available at lower levels increases coverage, but staffing, training, and quality control become more difficult, and costs rise. Annex 4 contains detailed proposals for which specific services should be provided at each level of the rural health system-from community to First Referral Unit. These suggestions need careful review, because of their important access, training, managerial, and cost implications. They will also need adaptation, according to local health service capacity. Tamil Nadu or Kerala, for example, may be able to offer certain services at PHCs, while some northern states may only be able to offer them at the hospital level for the forseeable future. Similar recommendations also need to be developed for urban areas, where the service delivery infrastructure follows a different pattern. 49. About half of the Indian population probably are potential clients of the FWP. Within this group, the suggested priority targets for the essential services package are all couples of reproductive age, with a special effort to reach those at highest risk- women who are pregnant or have an infant, the very poor, and high risk adolescents. The last group is of particular importance, because of the high risk of childbearing during adolescence to both mother and child. Family Planning 50. Additional reversible methods should be added to the choice of contraceptives, and more emphasis should be given to male methods (see para. 35). A greater emphasis on informed choice and quality of service is essential if clients are to meet their family planning goals. Currently, many clients hear more from service providers about sterilization than they do about other methods, and clients seldom receive good quality counseling about reversible methods. Clients must receive full information on the advantages, disadvantages, and contraindications for the full range of contraceptive methods, and on support, referral and follow-up care. 51. Safety is clearly an issue for contraceptive methods which involve surgery, but it is also of special importance for the IUD, especially in a population among which RTIs and STis are common. Where ANMs have unrealistically high acceptor targets for IUDs, they have little incentive to screen clients for contraindications; and most ANMs have neither the 14 training nor the equipment to conduct a proper pelvic examination before insertion. More careful screening is required, as is better training in aseptic insertion, and routine follow-up. Expanding RTI and STI Services 52. While RTI and STI services are included as part of the FWP, they are currently available only at district and subdistrict hospitals and some CHCs. Expanding availability of these services at lower levels of the health system merits high priority, as does more health education about preventing and recognizing RTIs and STIs. HIV infection is lethal. Other STIs can result in infertility, chronic pelvic inflammatory disease, ectopic pregnancy, and other problems. Insertion of an IUD when an RTI or STI is present substantially increases the risk of infertility or serious disease, thus making it an obligation to provide RTI and STI screening wherever this contraceptive method is made available. RTIs and STIs can cause fetal death or adversely affect child survival by causing pre-term delivery of low birth weight infants, or by passing on infection during delivery. And RTIs and STIs may decrease contraceptive acceptance or continuation when the client believes the symptoms of infection are a side-effect of method use. 53. There is a dearth of reliable estimates of RTI and STI prevalence in India. But the limited data suggest that prevalence is widespread enough to justify routine testing of all pregnant women for at least syphilis, which has been found in between I percent and 5 percent of women attending antenatal clinics in different cities (see Annex 6). Laboratory diagnosis and treatment facilities for RTIs and STIs at referral institutions should be upgraded, and carefully designed approaches to syndromic treatment by ANMs should also be considered. Recent analyses (Piot and Rowley 1992, and World Bank 1993) suggest that treatment of RTIs and STIs is highly cost-effective. The RTI and STI component of the proposed reproductive health package is currently under development by the Department of Family Welfare. Further details of the rationale, cost-effectiveness, and operational implications of such a component are given in Annex 6. One issue to be resolved is the appropriate distribution of services for screening and treatment for RTIs and STIs, between PHC and subcenter levels. Safe Abortion 54. The 1971 Medical Termination of Pregnancy (MTP) Act was a landmark piece of social legislation, but has failed to translate into reality for most Indian women, especially in rural areas. Today, there are more illegal abortions than before the Act was passed, leading to about 15,000-20.000 abortion-related deaths a year. MTP services, like RTI and STI services, are today mainly available at district hospitals and some CHCs, but rarely at the PHC level. Equipment and training are required on a large scale to improve the availability of this service, complemented by IEC efforts to inform women of the availability of the service. 15 Safe Motherhood 55. Maternity care should be designed to prevent maternal mortality and morbidity, and hence to ensure timely detection, management, and referral of complications during pregnancy. Antenatal services can detect and manage complications such as anemia, infection, pre-eclampsia, and mal-presentation, as well as provide an opportunity for tetanus immunization, iron supplementation, counseling on health, nutrition, and family planning. and treatment of pre-existing conditions, such as tuberculosis or malaria. All deliveries need to be attended by someone trained in hygienic delivery and recognition of complications. Postpartum services include early detection and management of infection and hemorrhage, and counseling in breastfeeding, health, nutrition, and family planning. Provision of these services is highly cost-effective (World Bank 1993). 56. Coverage of antenatal and postnatal care services is extremely low in the larger, northern states (para. 24), and needs to be greatly expanded. Many traditional birth attendants (TBAs) remain untrained, and trained TBAs need refresher training to ensure that they can recognize the signs of complicated deliveries. ANMs need further training to identify and refer the highest risk pregnancies (for example, under 18 years, severe anemia). and the referral system needs to be strengthened (para. 59). Institutional deliveries are essential for the highest risk pregnancies (for example, mothers under 1 8), and deliveries at PHCs should be encouraged for mothers in general, wherever the referral network is strong enough to handle them. Child Survival 57. The expanding child survival component of the CSSM program is helping to reduce the prevalence of the vaccine-preventable diseases, deaths from dehydration and diarrrhea, and acute respiratory infections. But much remains to be done, especially to eradicate polio, eliminate neonatal tetanus, and improve the performance of the diarrheal disease and acute respiratory infection control programs. In addition, interventions are needed to reduce perinatal and neonatal mortality, which make up 50- 60 percent of infant mortality. These include treatment of birth asphyxia and prevention of gonococcal eye infection, which can cause blindness in newborns; this latter intervention is particularly cost-effective, at US$1.40 per case averted. The links between low birth weight (an important risk factor for infant mortality) and poor maternal health and nutrition further underline the importance of improving antenatal care. IEC and Other Action on Sexuality and Gender 58. While improved IEC will be essential for effective implementation of all the above interventions, more effective IEC on sexuality and gender relations is a special need, because of its past neglect. This has two dimensions. With respect to clients, counseling on sexuality, STIs and gender relations is needed, plus information and motivation to empower women to ensure that their health needs are addressed, and to encourage men to be more responsible for family planning, the health and nutrition of pregnant women, and child- 16 rearing. There is an equal need to sensitize providers on gender issues at all levels of the system, which is heavily male-dominated. A vigorous effort is recommended to increase the number of female doctors in the health and family welfare programs, as well as the number of female managers. GOI has already advised the states to ensure the services of female doctors are available at primary health centers and CHCs, if necessary on a contract basis. Issues and recommendations for improving the program's gender sensitivity are detailed in Annex 4. Improvement of Referral Services 59. Referral for hospital delivery is critical for very high risk pregnancies, for example, after a previous stillbirth or caesarean section, and is especially important for life-threatening conditions such as obstetrical emergencies, and pneumonia or other infections among young children. To ensure that referrals are completed in a timely manner, pregnant women and dais need to learn the early signs of complications, and communities need to plan to mobilize transport to the referral unit. To ensure that referred cases are properly treated, the PHC needs to be developed throughout the country as an effective intermediate referral institution. In districts not covered by the safe motherhood component of the CSSM program, selected CHCs need to be strengthened to provide emergency obstetric care, through additional investment in improvement of operation theaters, staff training, equipment, and supplies.. B. ADDITIONAL REPRODUCTIVE AND CHILD HEALTH SERVICES Intermediate Level of Services 60. Two additional sets of interventions are also of high priority, but likely only to be implementable in parts of the country covered by the Integrated Child Development Services Scheme (ICDS), or by PVO programs with similar outreach capacity and service content. These are interventions against protein-energy malnutrition (PEM) for vulnerable groups, and reproductive health services for high risk adolescents. 61. Protein-Energy Malnutrition. In view of the very strong links between maternal nutrition and maternal and child health, and between child nutrition and child health, programs to improve women's and children's health cannot be fully effective unless they also provide counseling, growth monitoring, and supplementary or complementary feeding. Ideally, this service should be available to all vulnerable groups. However, while nutrition education can be provided to all pregnant and lactating women as part of routine pre- and postnatal care, growth monitoring and supplementary feeding are time-consuming interventions that cannot be managed by the ANM. These interventions are, however, available to poor clients in the 50 percent of development blocks in the country that are covered by ICDS. 62. Reproductive Health Services for Adolescents. Adolescents, defined here as the 15- 19 year age group, have been neglected by the health services. Yet this age group has important health and information needs, particularly with regard to nutrition, sexuality, and reproduction. One in four married adolescents is a mother, and all married adolescents, 17 because of their high health risk, require special attention through the essential services package (para. 46). A majority of adolescent girls, married or not, are anemic, often to a moderate or severe degree (Gopalan 1992). In addition, what little is known about the fertility of unmarried adolescents suggests that their situation is bleak. Adolescents are far less likely to practice contraception than women aged 20-24; unmarried adolescents constitute a sizeable proportion of abortion seekers; and studies in Bombay, Solarpur (Solpurkar and Sangam 1985), and Baroda (Bhatt 1978), show that they often delay their abortions until dangerously late because of ignorance or fear of social stigmatization. 63. Ideally, therefore, special counseling and service provision should be made available to all adolescents. In practice, however, because of the numbers involved, special counseling for all adolescents may only be feasible in areas, such as ICDS blocks, where there are paid field workers at the village level (who may be able to take on the load). Operational research is needed on the feasibility of adding sexuality and reproduction-related messages to the counseling received by adolescents reached by ICDS, and by private voluntary organizations (PVOs) providing similar outreach services. Throughout the country, the mass media and the school system should be used as channels to get messages on these themes to all unmarried adolescents. Comprehensive Services 64. A more comprehensive package of reproductive health services should include more sophisticated diagnosis and treatment of RTIs and STIs, and cervical cancer screening and treatment, which have been shown to be cost-effective interventions (World Bank 1993). However, there is little experience in India with managing these outside specialist referral institutions. Operational research is therefore recommended on these interventions, in the selected districts of Kerala and Tamil Nadu, where maternal health services are already relatively well developed. C. THE NEED FOR ADVOCACY 65. Finally, there is a great need for information about, and advocacy for, reproductive health services in India. The information gap on the concept and ideology of reproductive health and gender issues is currently a deterrent to the implementation of a reproductive health program. In a country as large and diverse as India, many constituencies must be informed before large-scale change is possible. Information and advocacy programs are needed at the state and central levels initially, and must subsequently be directed at client constituencies in the panchayats and women's groups, and provider constituencies at the district level and below. 18 IV. THE PUBLIC SECTOR PROGRAM: MANAGING FOR QUALITY AND CLIENT SATISFACTION A. CHANGING THE SIGNALS India's Commitment to Reproductive Health 66. India's signing of the Cairo declaration marks a policy commitment to the reproductive health approach. The challenge now is to that which determine the behavior of more than 250,000 FWP staff and an uncounted number of private service providers. The required shift has a number of dimensions, summarized in Table 2. It recognizes that client satisfaction is the primary program goal, with demographic impact a secondary, though important, concern. It requires a broadening of the service package, and a drive to improve service quality. And it means a series of changes in the way the program is managed at the field level, affecting how performance is measured, how workers deal with clients, and to whom workers feel accountable. These changes require a quiet revolution in the way the FWP is planned and managed. Table 2. Changing the Signals T Si, ' b jiNWil.i Primary goal Reach two child family size While still encouraging smaller norm families, help clients meet their own health and family planning goals Priority services Family planninig, especially Full range of MCH services female sterilization Immiunization Full range of MCH services Performance measures Number of cases Quality of care, client satisfaction, coverage measures Management approach Top-down, target-driven Decentralized, client needs-driven Male-dominated Gender-sensitive Attitude to client Motivate, persuade Listen, assess needs, inform Accountability To the bureaucracy To the client and community, plus health and family welfare staff 19 Policy Changes 67. As recommended in Section 11, the following changes in target and incentive policy will be a precondition for changing the implementation signals: * eliminate provider incentives as soon as possible; * end the practice of giving family planning targets to revenue departments; * replace method-specific contraceptive acceptance targets by goals and measures for overall prevalence; and * develop performance goals and associated performance measures for key MCH and other reproductive health interventions. Implementation Imperatives 68. Complementary actions at the implementation level will be essential if quality and client satisfaction are to become a reality. The remainder of this section recommends specific actions in four areas: * improving access to good quality services; D making services more responsive to client needs; * making sure front-line workers have the skills, support, and supplies they need; and - strengthening the referral system. B. IMPROVING ACCESS TO SERVICES 69. The poor coverage of several key services, especially in the most populous northern states, was summarized above (paras. 23-25). Better access to good quality services is a pre- condition for improvement in quality and client orientation. This is because quality care depends not only on the client-provider contact taking place, but also on it being frequent enough and long enough for a relationship of trust and confidence to be established, and for changes in health behavior, once initiated, to be sustained. Of the five sets of measures for improving access that are recommended below, the first three are inexpensive to implement, the last two relatively costly. Make Work Routines More Efficient 70. Free Up Time for Service Delivery. Field workers in most states spend substantial time in meetings at block and sector headquarters and in filling out records and reports; the latter can take 20 percent or more of an ANM's time. A review of monthly tour programs in 20 each state is recommended to reduce the time spent on low priority activities. With regard to the record-keeping system, substantial efforts at rationalization of paper work are under way. Other states could follow West Bengal and Tamil Nadu's lead, and reduce the fieldworker's paperwork to two or three key registers. 71. Spend more time with priority clients. It is recognized that ANMs need to concentrate their time on the highest priority clients, especially the poorest, but need guidance on how best to do this. ANMs now receive more guidance on which villages to visit, and when, than on which clients they should spend time with in each village. The CSSM program employs a "birth-based" approach to client prioritization, in which ANMs focus their time on newly pregnant women, and follow them with antenatal, delivery, postnatal and child care until the child has survived its critical first year. This experience should be reviewed, with particular respect to whether it has increased the time workers spend with the poorest families, who are usually at highest health risk. And since the policy goal of reducing population growth cannot be discarded, the prioritization of ANMs' services should also concentrate on couples where the wife is aged 20-29 and those women who are either pregnant or who have just delivered. High priority should be given to evaluating different approaches to client targeting, since improvements in field work routines are inexpensive, but offer a high performance payoff. Give the ANM More Help from Other Workers 72. Expand Community Linkages. With more than 150 pregnant women in a typical service area at a given time, ANMs need help in identifying priority clients and encouraging them to seek services. Community networking through Mahila Mandals and other women's groups, and link couples selected from the community, plus close collaboration with ICDS workers are recommended. 73. Increase the Contribution of the Male Worker. Increasing the male Multi-Purpose's Worker (MMPW) role in family welfare will also be necessary, if better gender balance in field service provision is to be achieved. Male workers can do much more to provide IEC to priority male clients identified by themselves and other field workers. This poses a major policy issue, since many states, short of money and disillusioned with the performance of the MMPW have allowed the male worker ratio to increase toward 1:8,000-10,000 clients. In addition, spending on the disease control programs is increasing, and the workload of these programs threatens to cut into the time both ANMs and MMPWs can spend on reproductive and child health work. A review of MMPWs' and ANMs' work loads should be carried out as a basis for policy decisions on the future strength of the MMPW cadre, and rationalization of the ANM's role in other programs. Make Sure Workers Are Resident 74. In many parts of the country, a majority of ANMs and a high proportion of LHVs and doctors live outside their service areas. This long-standing problem must be resolved, because field staff who have to spend several hours traveling to and from work cannot provide adequate service coverage. States should consider initiating disciplinary action 21 against workers who refuse to live in their service areas. The panchayats may be well- placed in the future to make sure workers live in the local community. 75. A minority of ANMs do not live in their place of assignment for reasons of safety, because their subcenters are located outside village centers. These centers should be identified, and converted into clinics without residential accommodation. New subcenters continue to be built outside village centers, contrary to site location guidelines. The central government should consider refusing to finance subcenters so constructed. Make Sure Workers Are Mobile 76. Another long-standing problem is lack of transport for field supervision and referral, and the inadequacy of petrol, oil, and lubricants (POL) allowances. POL allocations have been enhanced from January, 1994 for the seven northeastern states and will be enhanced for all states from 1995-1996. Resolving this problem will be expensive (Section VI), but is essential if field staff are to have the mobility to do their jobs, if the PHC is to play its intended role as a support and referral institution, and id referred patients are to reach the appropriate facility in a timely way. A jeep should be provided for every PHC without one, and POL allowances, which in many states have remained unchanged for years, should be doubled or tripled, following the recent example of Maharashtra and Tamil Nadu. Mopeds or bicycles should also be provided to ANMs with large service areas and poor public transport, who cannot regularly visit remoter villages. Finally, the system of transport allowances-which are between one and three years in arrears in several northern states- needs to be revamped. The amounts need to be substantially increased, and program managers must ensure that they are paid. Hire More Female Workers 77. Referral completion rates are unlikely to improve, especially for women with RTIs and STIs, unless female clients are treated by female doctors, who are not available at most PHCs away from urban centers. This long-standing problem has no clear-cut solution; public sector salaries are an insufficient incentive to attract female doctors to remote areas. Contracting out key referral services at PHCs to PVOs, trusts, and the private sector is an alternative that the central government is recommending to the states. 78. The ANM-to-population ratios shown in PHCs and other health facilities are overstated because the population figures are based on 1981 census data, since which populations have increased by more than a third. At present, average coverage data are all that are available at the state and central levels. A facility-wise coverage survey is urgently required to determine what proportion of ANMs currently serve significantly more people than the planned norm, and hence have undoable jobs. Quality reproductive and child health services cannot be delivered unless there is at least one ANM per 5,000 population. It will therefore be essential to substantially increase the number of ANM posts over the next five years, both to fill current vacancies, and to ensure that population growth does not further erode existing service coverage levels. 22 C. RESPONDING TO CLIENTS' NEEDS 79. Many reviewers have noted that the FWP does better at fulfilling the targets set by central policymakers, than at meeting the needs of its clients. This section discusses how the program might do more to satisfy its clients through: * listening to their needs, and providing them with the information they need to make their own choices; * tailoring local plans and IEC strategies to local needs; and * involving local communities in planning, monitoring, and decisionmaking. Listening to Clients 80. Currently, too much of the communication between provider and client is one-way. The need is for fieldworkers to spend less time motivating clients to accept contraception or immunization, and more time listening to clients, discussing their health and family planning needs, and informing them of the range of health services and family planning options available. Training in listening and counseling skills is necessary. Providers must also respond to the client's need for the type of information that facilitates behavior change: this includes better knowledge of the method or product, how to use it correctly, how to manage side-effects, and where to obtain resupply and follow-up services. In addition to worker training, the proposed move away from method-specific targets (para. 31) will help to signal to workers that the aim is client satisfaction rather than acceptor numbers. 81. IEC strategies need to be redesigned in several ways to respond to local needs. First, IEC planning needs to be decentralized from state to district level, as is already happening with training. Second, local communication strategies need to be precisely defined, identifying priority target audiences, specific behavioral changes, message concepts, and channels of communication. Third, IEC messages should concentrate on fewer themes, which are of most importance to local problems and priorities. And fourth, there is a need to set up a research mechanism for tracking changes in knowledge, attitudes, beliefs, and practices as a result of IEC activities, to provide feedback to program implementors. Adequate financial provisions for effective IEC are essential. Needs and recommendations in these areas are detailed in Annex 7. Local Plans for Local Priorities 82. Progress in decentralizing family welfare planning to the district level has been slow. Most local plans remain top-down, based on targets and norms set by the state, far from the ideal in which local priorities are jointly defined by local communities and family welfare staff. But Madhya Pradesh, for example, is experimenting with district and block-level workshops, through which local plans will be developed, and initiatives with district planning are also being taken in Rajasthan, Tamil Nadu, Uttar Pradesh, and West Bengal. Lessons from these initiatives should be collated and disseminated in the form of planning 23 guidelines. District managers need training in planning techniques, especially in how to link the district planning process and the development of local IEC strategies and training curricula. Most importantly, the role of local people in program planning and management needs to be more clearly defined and strengthened. The next section focuses on this key need. Community Involvement 83. The Panchayati Raj Act of 1992 initiated one of the most significant changes in the organization of government since independence. It will have profound effects on the management of the FWP, which is to be placed underpanchayat control. However, it is not yet clear how Panchayati Raj will develop, since it is being implemented with different speed in different states, and states have discretion in how much authority and money they devolve. Panchayati Raj presents an opportunity for local communities to define their own needs and make local government more accountable to local people for the quality and quantity of services it provides. But it also presents risks-that panchayats may not speak for the poorest and neediest; that they may be more interested in infrastructure creation than social sector development; or that they may interfere with the technical integrity of the program, for example, by demanding curative care at the expense of preventive care, as happened after decentralization in China. 84. The shape that Panchayati Raj takes will be determined by the states, not the central government. Nevertheless, at least four steps can be taken by FWP managers to capitalize on the opportunities and minimize the risks of decentralization. The FWP could: * develop a major IEC campaign to inform the panchayats about the importance of reproductive and child health, and the rationale for the essential services package; - offer panchayats financial incentives to take reproductive and child health initiatives and to build ownership of and responsibility for the program; * form partnerships with panchayats at the district level, to ensure that district plans reflect a balance between panchayats' felt needs, epidemiological priorities, and equity concerns; and * define specific ways in which panchayats can help improve program quality, for example, by organizing transport for emergency referrals, supervising and monitoring the personnel at health facilities, and recording births, deaths, and age at marriage. 85. The panchayats represent only one potential form of community involvement. In addition, more could be done to brief existing women's and other community groups on local health problems and progress, and involve them in identifying clients, monitoring progress, and helping with the spread of information. Such groups are more prevalent in some states, such as Andhra Pradesh, than others. Elsewhere, an unresolved issue is the 24 degree to which field workers should be involved in community group formation. The skill needs and time costs of organizing community participation of this kind have often been underestimated. Where it has worked-as with the women's groups formed under the Tamil Nadu Nutrition Project-it has enormously facilitated program implementation. But because of the difficulties and existing pressures on the ANM, careful field testing of community group formation plans should precede any adoption of new large-scale schemes. 86. Other people who belong neither to panchayats nor women's groups also have a key role to play in ensuring that services are available and meet their needs. The FWP could help develop their role in three practical ways. First, a special IEC campaign could be developed to inform people in villages and slums of the essential reproductive and child health services to which they are entitled. Special efforts could be made to publicize these services wherever the poorest people live in each PHC area. Second, the essential services, workers' tour programs, and clinic hours could be publicized on subcenter and village walls, so that clients know when to expect services, and can hold workers accountable for delivering them. Third, user-friendly performance monitoring information could be developed and posted outside the subcenter, as well as being made available to the local panchayat. D. SUPPORTING THE FRONT-LINE WORKERS 87. The measures discussed above will help to ensure that clients have access to services, and that these services are tailored to meet local needs. However, these are necessary, not sufficient conditions for quality care. In addition, performance measurement, training, supervision, and logistics systems need to be strengthened to give workers the incentives, skills, support, and supplies they need. Performance Measurement 88. The management information system (MIS) has been primarily used to feed information on target achievement up to state- and central-level managers. In doing so, it has operated as a powerful incentive mechanism, encouraging workers to focus on delivering their target numbers of cases, especially for family planning and immunization. The need to broaden the range of indicators so that workers focus equally on the full range of services that make up the reproductive and child health package was discussed in Section 11 (para. 31). There is an important trade-off between increasing the number of indicators to give a more balanced measure of the range and quality of services, and the need to reduce the paperwork that takes up too much of the ANM's time. A set of indicators which meet both objectives needs to be finalized. GOI is planning to test the following set of indicators: * the proportion of institutional deliveries and deliveries by trained personnel in relation to the total estimated number of deliveries; * the number of health facilities providing MTP services and the number of women treated for complications following unsafe abortion; 25 * the number of health facilities providing emergency obstetric care; * the number of polio and neonatal tetanus cases reported; * number of planned IEC sessions on diarrheal diseases and ARI and number actually held. * the number of pneumonia cases in children under five years of age identified and treated; * the proportion of the total acceptors of sterilization with two, three, and more than three children; * the proportion of the total acceptors of reversible methods, with wife's age less than 30; and * the total number of immunization sessions planned and number of sessions actually held. Monitoring indicators for a reproductive health approach are discussed in more detail in Annex 8. Training 89. A quiet transformation of the family welfare training system has begun during the past five years. A new infrastructure of state institutes of health and family welfare, regional and divisional training centers, and district training teams has been created. States are beginning to recognize the key importance of training for quality improvement. And where, five years ago, field workers seldom if ever received in-service training, most staff at the periphery have now received at least two exposures. The secondary cities and the northeastern states, which have serious infrastructure deficiencies, are an exception to this encouraging trend. A consolidation of this effort to strengthen training is needed in four areas. * The skills of trainers and methodology of training need to be improved. This is partly a matter of improving the content and methodology of trainer training. But it will also be essential to attract better quality trainers into the system, and to make sure that they stay in their posts once trained. This in turn means providing an appropriate career structure for trainers, so that training assignments are not seen as sideline jobs. * Field staff need more training in how to plan their work routines and in how to carry out quality two-way interpersonal IEC. Since the training content in these areas should vary depending on local plans and IEC strategies (soe paras 81-82), and on workers' skill levels, this type of training is best delivered at the block level, by PHC staff who can tailor it to local needs. Trainers at the block 26 level need to be selected and trained in the appropriate skills by the core training team, which has now been formed in most districts. This kind of "cascade" training has proved effective under the CSSM program, and should become routine. * A major drive is needed to improve the quality of technical care delivered by ANMs and LH Vs, especially in clinical skills such as pelvic examinations, IUD insertions, and deliveries. Unlike training in work planning and IEC, this training must be carried out at clilical facilities where the right type and number of cases are available. Because many workers have in the past graduated from clinical courses without the requisite hands-on practice, a careful evaluation is needed of case numbers and training loads at existing clinical training facilities to assess the expansion required for quality implementation of the essential reproductive and child health package. * It will be essential to redesign the content of pre-service training for ANMs, LHVs and doctors, so that it gives them the key technical, IEC, and planning skills. This recommendation has been often made, but never implemented. Pre- service training remains largely didactic rather than interactive, and theoretical rather than hands-on. As a result, unnecessary in-service training time is spent giving field staff skills which they should already possess. Supervision 90. Little progress has been made in re-orienting supervision from an inspectional to a supportive approach, largely because the target and incentive system has encouraged supervisors to focus on target achievement at the expense of quality. A better criterion for measuring supervisor performance would be their success in using the MIS and field visits to identify unmet client needs and worker skill deficiencies, and to rectify these through on-the- job training. If the primary focus of supervision is to shift to on-the-job training, the skills of most supervisors will need to be strengthened-especially the IEC skills of doctors who are clinically-oriented, and the clinical skills of LHVs, which are often no better than those of the ANMs they supervise. This will further increase the load at clinical training facilities. Procurement and Logistics 91. Absence of supplies at health facilities has been the consequence of procurement and logistics breakdowns and inefficiencies, as well as under-funding. It will be particularly important to avoid a repeat of the eight-month stock-out of oral contraceptives which took place in 1992/3, if clients are to gain confidence in this method. There are issues to be addressed at central, state, and peripheral levels. At the center, there has been over-reliance on producers with multi-stage manufacturing technologies who cannot quickly fill supply gaps, and frequent changes of pill production contractors has led to quality control problems. Moves are currently being made to limit procurement to suppliers with proven efficiency. At the state level, deficiencies in storage and transportation and associated budgets need to be made good. At the periphery, subcenters need to hold stocks equivalent to three months per 27 user, rather than the one month now common, to avoid supply breakdowns, especially during the monsoon. Finally, the reproductive health approach will require enhanced priority to and outlays for essential drugs as well as contraceptives. E. STRENGTHENING THE REFERRAL SYSTEM 92. Frontline workers need the support of effective referral services at both FRU and PHC level if they are to be credible and effective. In the case of the FRU and obstetric care, the referral process needs to begin with recognition of potential complications. TBA and ANM pre-service and in-service training should give greater emphasis to their role in training mothers to recognize the signs of impending complications. Assisted by the local panchayat, health workers need to set up an emergency transport system from each village, to ensure timely referral. The key reproductive health function of the FRU is to reduce maternal mortality by treating obstetrical emergency cases and abortion complications. Under the CSSM program, the network of FRUs is being extended to cover 50 percent of the country, significant additional investment is required to achieve national coverage. 93. PHCs are also in great need of strengthening. More than 6,800 PHCs remain to be constructed to meet current norms and many PHCs are without their full complement of staff, for example, 1,295 PHCs had no doctor and 6,780 had no laboratory technician in 1994 (MOHFW 1994). Yet the PHC has a key role to play in reducing the most common causes of child and maternal death-by treating infants referred with dehydration or severe respiratory infections, and by dealing with the large proportion of high risk pregnancies (such as anemia and toxemia cases) which, with proper management, need never develop into obstetric emergencies. The PHC also has a key role to play in family planning (for example, for sterilization), in providing MTP services, and in diagnosing and treating common, reproductive health related diseases (such as RTIs and STIs). Because the subcenter level of care has been centrally funded, and the PHC primarily state-funded, few resources have flowed into the PHC network. The large PHC financing gap must be filled if the essential reproductive and child health services set out in Section III are to reach everyone. F. SUMMARY 94. The following table summarizes the main recommendations made for strengthening the reproductive and child health focus and improving quality and client satisfaction in the public sector FWP. 28 Table 3. Summary of Management Interventions Doable? Low cost? Improve access to services Make work routines more efficient Review and revise tour programs Yes Yes Develop systems for prioritizing clients Yes Yes Cut time on recording and reporting Yes Yes Give ANM more help from other workers Expand the link worker scheme Yes Yes Increase the contribution of the MMPW) Yes Fairly Make sure workers are resident Discipline or terminate non-resident staff Yes Yes Convert badly located sub-centers into clinics Yes Yes Make sure workers are mobile A jeep for every CHC and PHC Yes No Raise POL allowances Yes No Bicycles or mopeds for ANMs with large service areas Yes No Make sure TA is paid Yes No Hire more female workers Hire more ANMs with large service areas Yes No Contract key PHC services to female private sector doctors Yes No Respond to client needs Listen to clients' needs (two-way IEC) Yes Yes Develop district plans meeting local needs Yes Yes Capitalize on opportunities of Panchayati Raj Yes Yes IEC campaign on concept and importance of reproductive health Yes Yes Matching grants for reproductive health initiatives Yes Fairly Form partnerships to produce joint district plans Yes Yes Define ways panchayals can help improve program quality Yes Yes Support the front line workers Broaden the range of performance measures in the MIS Yes Yes Improve the quality of in-service and pre-service training Improve the skills of trainers Yes Yes Improve training in work planning and interpersonal IEC Yes Yes Improve training in clinical skills Yes No Redesign the content of in-service training Yes Yes Redesign the focus of supervision to on-the-job training Yes Yes Improve the referral system Train field staff in recognizing referral needs Yes Yes Strengthen the FRU network Yes No Strengthen the PHC network Yes No 29 V. THE PRIVATE SECTOR: MAKING USE OF UNTAPPED POTENTIAL 95. Three-quarters of all health expenditures in India are accounted for by the private sector. The private sector's great advantages are its reach, convenience, and client- friendliness. Unlike family welfare subcenters, private medical practitioners and commercial outlets for drugs are ubiquitous. They have flexible hours and a commitment to client service, on which providers' livelihoods depend. For all these reasons, most people in India turn first to the private sector for curative care, for which even poor people are prepared to pay substantial sums. The private sector's limitations are that it focuses mainly on curative care because that is what clients are prepared to pay for, that the poorest cannot always afford services, and that quality, as in the public sector, is very variable. 96. The private sector already plays an important role in delivering several reproductive and child health products and services-notably primary level maternal and child health and family planning services. The 1992 NFHS for U.P. found, for example, that about 50 percent of rural women using spacing methods obtained them from private sources. The private sector presents the government with tremendous untapped potential for increasing the coverage of some reproductive and child health services. The challenge for government is similar to its own challenge in the public sector-how to maximize reach, through giving the private sector appropriate incentives, how to broaden the range of reproductive and child health related services, and how to improve quality. These issues are considered in turn for the three major components of the private sector-the contraceptive social marketing program, private medical practitioners, and private voluntary organizations (PVOs). A. SOCIAL MARKETING 97. In India, the term social marketing is used to mean the sale of contraceptives in commercial outlets at subsidized prices. The social marketing program for condoms is fairly substantial, with condoms marketed through 520,000 outlets, and condoms sold or distributed free through the social marketing program representing about half of all condom use in the country. Nevertheless, several important issues related to the social marketing program remain to be resolved (a more detailed presentation of issues and recommendations can be found in Annex 7). These include: * the incentives to commercial participants are insufficient, and several of the major suppliers are threatening to withdraw from the program; * the social marketing program is dominated by condoms, at the expense of other products, and focuses on sales and supply, rather than the marketing of information; * the free distribution of condoms is wasteful, and their frequency of use unsatisfactory; and * the program has limited reach, and is urban-biased. 30 Incentives to Commercial Participants 97. The social marketing program is implemented by a small number of large, private companies, and medium-sized PVOs. Several of the large commercial participants in the market have for some time threatened to drop out, because they argue that incentives to participate are inadequate, and because of changes in their corporate philosophy. ITC Limited, one of the largest participants, has recently redeployed its condom marketing sales force to other activities. This action makes it clear that a review of the incentives for private sector participation is overdue, and that what is needed is a comprehensive strategic solution, since the dissatisfaction of commercial participants has been long-standing. As well as looking at the economics of participation, the proposed review should assess the current system of dividing the market geographically between companies; the potential for attracting medium-size companies into the market in addition to the traditional, large players; and the degree to which bureaucratic constraints in program management are a disincentive to participants (see also para. 102). Broadening the Product Range 98. As in the public sector, in the context of moving to a reproductive health approach, there is a need to broaden the range of products available to clients, and hence increase client choice and satisfaction. The social marketing of oral pills is still relatively limited, and needs to be rapidly expanded. This has been government policy for some time, but little priority has been given to social marketing of this method, despite its suitability for the commercial sector. Condoms need to be made more available in rural areas. And consideration should be given to extending the product range beyond contraceptives, for example, to include oral rehydration salts, iron supplements, and iodized salt. Expansion of the product range calls for a closer link between IEC and social marketing. While social marketing provides tangible products or commodities, IEC creates health-seeking behavior. This requires greater knowledge about consumer behaviors and preferences, and the development of an IEC strategy, segmented by audience, to accompany the sales effort. Expanding the Market 99. There remains tremendous scope to expand the number of retail outlets in the program, especially in rural areas. In Haryana, Rajasthan, and U.P., for example, 71 percent of retailers, including grocers, general stores, chemists, confectionery, and other outlets, have never stocked condoms. New distribution channels will need to be developed, for example, chemists for oral pills, food companies for nutrition supplements. In order to give the private sector an incentive for expansion, subsidies should be considered for market development costs, in addition to the normal subsidies on sales. Improving the Condom Marketing Program 100. The real size of the condom market is unknown, since free condoms distributed in 1993/4 were, at 890 million pieces, more than twice the volume of sales from social marketing and commercial outlets. Many of these free condoms never reach the client, and 31 surveys show that clients use only half that do. The recent removal of method-specific targets for condoms should reduce this wastage. Surveys also show that only 70 percent of condom users use them every time they have intercourse. The recent replacement of dry with lubricated condoms is a major service quality improvement, which should help to increase this proportion. But a major IEC campaign is also required to inform consumers of the dangers of intermittent use, in terms of pregnancy risk and STI transmission. Strengthening Program Management 101. Program management will need to be strengthened at both center and state levels to facilitate the above changes, with a special focus on product procurement; distribution and logistics management; communication support; and capacity to monitor the performance of products, markets (by geographical area and client segment) and participants (commercial and PVO). It has proved very difficult to attract staff with the appropriate skills into the public sector. One possible avenue that should therefore be explored is the augmentation of MOHFW capacity by subcontracting the management of the national social marketing scheme to a specially created autonomous "social corporation", with MOHFW, PVOs, and the commercial private sector represented on the board, and the MOHFW role limited to overall strategy formulation and oversight, rather than day-to-day management. B. PRIVATE MEDICAL PRACTITIONERS 102. Private medical practitioners (PMPs) provide more than two-thirds of all health care in India. These human resources therefore provide a good opportunity to link public sector financing with private sector provisional services. This will provide clients with a wider choice, and will also enhance quality service. 103. There have been relatively few in-depth studies of PMPs. The data below are taken from recent studies in U.P. (CFDRT. 1993, Levine et al, 1993). but appear likely to be representative of the situation in other parts of the country. PMPs are extremely numerous, a conservative estimate of the number in U.P. is 100,000. They are also much more accessible than ANMs or MMPWs because many of them live in villages of between 500 and 2,000 inhabitants. The U.P. surveys showed that over a third of villages of this size had a PMP, while only 4 percent of them had a government subcenter. 104. Although PMPs derive most of their income from providing minor curative care, they also provide a significant amount of MCH and family planning services, and some conduct deliveries. For example, 9 out of 10 PMPs surveyed in U.P. give their clients family planning advice, and 3 out of 10 actually provide or prescribe family planning methods. Because of the government program's emphasis on sterilization, and most PMPs' inability to provide this method, PMPs are important providers of reversible contraceptive methods. Many PMPs have had no formal training in MCH and family planning, but 90 percent of those surveyed were eager to have access to training because they thought it would improve their practices. More than two-thirds were willing to be depot-holders for contraceptives. 32 105. For all of the above reasons of access and relevant service activities, there is a very strong case for the government to play a more active role in supporting and promoting PMPs' involvement in reproductive and child health care. In the case of qualified, allopathic practitioners, experiments should be carried out with the contracting out of specific referral services at PHC and CHCs which are difficult to staff because of their remoteness. In the case of traditional practitioners, a program should be launched in each major state to encourage their involvement in reproductive and child health, building on the experience being developed in an ongoing project to support PMPs in U.P. The primary need is for training to broaden the range of services they provide, and to improve the quality of both counseling and technical skills. 106. A major issue in developing such a program is how to organize such training cost- effectively. The large numbers and scattered location of PMPs, which make them so convenient for client access, present a major challenge for training programs. Surveys show that many PMPs are part-time workers, and that a minority of PMPs with full-time practices and larger client loads provide a majority of care. One study in U.P. (Levine et al, 1993) found that about a third of practitioners received about 60 percent of the client visits. Training and support could therefore be made more cost-effective by targeting high client- load practitioners. Surveys show that many PMPs are members of professional associations, and that most would like more information and networking through such associations. Strengthened PMP associations may therefore be a potential channel for "cascade" type training, along the lines of the family planning training which has been provided to many modern, allopathic practitioners through the Indian Medical Association. C. PRIVATE VOLUNTARY ORGANIZATIONS 107. PVOs are likely to have a relatively limited role to play in the delivery of reproductive and child health services in India because of their restricted client coverage and the fact that few operate in the rural areas of the north where the poorest clients are concentrated. Nevertheless, where they are active-as, for example, in many inner city slum areas-PVOs are often very effective at community mobilization, and provide high quality services responding to local needs. Recognizing this, in 1991 the Government set up a new mechanism for PVO financing, with three channels for support. These are through the central MOHFW, through state standing committees on voluntary action, and through six large PVOs who would act as "mother unit" intermediaries for the transfer of funds to smaller PVOs. These three channels began to operate at different times during 1992 and 1993. 108. During the period 1991-94, an amount of only Rs. 856.52 lakhs was released to the states out of an available Rs. 24.59 crores for PVO support. The data available show that the number of project proposals submitted by PVOs is low (indicating a poor response), that the proportion of proposals funded is low (suggesting problems in the application and approval process), and there is some evidence of inefficiency in projects funded. Four critical issues need to be addressed to improve PVO involvement in the FWP. Further details are provided in Annex 9. 33 * Both the central and state units dealing with PVOs are understaffed and follow complicated bureaucratic procedures, leading to delays in processing application, and inadequate support for "mother units". Since MOHFW is committed to increasing the role of PVOs, the staffing issue must be addressed, and procedures reviewed to eliminate bottlenecks. More "mother units" should then be established and supported. * The attitude of government officials needs to be reoriented so that PVOs are seen as collaborators. Continuous dialogue between PVOs and the government could help to improve the quantity and quality of collaboration. * Planned technical assistance to weaker PVOs has not been provided. This will be essential if the quantity and quality of applications is to increase, especially for the poorer areas which are often served by the weaker PVOs. * New strategies need to be developed to strengthen the reproductive and child health focus of PVOs, and mobilize PVOs for this work in remoter, underserved areas, and in the organized private sector. 34 VI. FINANCING THE REPRODUCTIVE AND CHILD HEALTH PROGRAM 109. This section begins by presenting the prevailing level of resources allocated to the Family Welfare Program, comparing resource allocation by state. The section then estimates what it would cost, over the next five years, to fill the funding gap of the current FWP, that is, to bring the level of infrastructure, staffing, and recurrent costs to that required to meet the GOI guidelines for the program, and to put in place the reproductive and child health package shown in Table 1, page I1. The section closes with a discussion of how central governimient tunding could be used as an incentive to encourage states to reorient the FWP toward a reproductive health approach. Annex 10 presents the calculations on which the data are based. A. Cl RRENT RESOURCE ALLOCATION TO THE FWP Table 4. Estimated Per Capita Recurrent Spending on FWP, 1994/95 (Rupees) -----------------Centrally Funded----------------------- "Ret.:X.el4.i ... 3.77 6.29 1.26 1.03 2.13 4.03 18.51 Bf glBhar . -.-'. ' ' '2.26 5.29 1.07 0.99 2.76 3.28 15.65 4.94 6.08 1.56 1.41 2.03 3.44 19.46 Rl'.....-.'- 4.68 8.66 1.89 1.12 2.25 7.16 25.75 U .". -- - ' 3.88 6.25 1.04 0.86 1.74 3.78 17.53 3.96 7.05 1.17 0.53 2.32 3.21 18.24 4.81 8.03 3.34 3.18 1.67 1.63 22.65 -$ ... ............- 4.79 7.35 1.41 0.58 3.03 3.17 20.34 .*'.x . -N . > - - '.: 4.78 6.49 1.42 0.71 2.99 2.32 18.72 .... ... . . . . . i .S.-.. .....:.- A'0.l'^-I}t....di .. ......t . 4.19 6.59 1.41 0.91 2.46 3.43 18.99 iVote: A working definition of Family Welfare Program (FWP) spending is the sum of central expenditure on all components of the program, state financed expenditure on ANM salaries and 20 percent of the salaries of PHC doctors and all paramedics in each state. 1 10. Table 4 shows the estimated level of per capita recurrent spending on the FWP for 1994-95 and its composition, for various states and for India as a whole. At about Rs. 19.00 or US$0.60 per capita per year, India spends far less on family welfare than many developing countries. In fact it spends less on maternal and child health and family planning than the $0.90 (Rs. 28) recommended for family planning alone by the World Bank's 1993 World Development Report, Investing in Health. That report considered spending on MCH and family planning to be among the most cost-effective health interventions, and recommended spending US$5.40 (Rs. 167) per capita for these services in low-income developing countries. 35 111. The annual allocation for the FWP varies from a low of about Rs. 16 (US$0.50) per capita in Bihar, to a high of about Rs. 26 (US$0.71) per capita in the Rajasthan, and about Rs. 19 (US$0.51) per capita for the four Hindi-belt states. The explanation for these differences by state is that each year's funding is based partly on the state's performance in spending the resources allocated for the previous year, as well as on the size of the state's population. In addition, resources from externally-funded area projects are not evenly spread across the states. Overall, the pattern of resource allocation bears little relation to the need for funds, as reflected in such social indicators as crude birth rate or infant mortality levels. 112. Financing of the subcenters is a case in point. First, the GOI norm of Rs. 26,000 for funding each subeenter is far below requirements, which are at least Rs. 45,000 (US$1452) per subcenter: the current annual salary for the ANM alone amounts to about Rs. 38,000 (US$1225). Second, the amount actually budgeted is even less than the norm; the 1994-95 budget allocated Rs. 185 crores US$60 million) of GOI funding for 98,000 sub-centers, or only about Rs. 20,000 (US$645) per subcenter. As a result, the GOI has accumulated deficits in its funding of subcenters. Partial payment for such arrears to state governments amounted to Rs. 200 crores (US$65 million) in 1993-94 and Rs. 150 crores (US$48 million) in 1994-95. 113. Per recurring capita expenditures on health and family welfare services have declined in real terms in the majority of states over the three years since 1990-91. The average for all states declined by 12 percent (Figure B); the steepest falls were in the case of West Bengal-22 percent and Uttar Pradesh-l 9 percent. Non-salary recurring expenditure on the family welfare program declined from Rs. 51 crores in 1991-92 to Rs. 30 crores (US$9 million) in 1993-94 in the case of Uttar Pradesh. 114. In summary, the FWP is substantially underfunded when viewed in international perspective. India spends less per capita for maternal and child health and family planning (US$0.60 or Rs. 19) than the US$0.90 (Rs .28) recommended by the Bank for family planning alone, and less than 15 percent of the amount recommended for MCH and family planning. Second, India has not been able to meet its own funding norms for the FWP. And third, GOI has been in arrears to the states for the last several years in allocating resources for the program. B. FUTURE FUNDING REQUIREMENTS 115. The government will need to gradually phase in its development of the reproductive and child health approach. First, it will need to fill in critical gaps in inputs at the existing FWP facilities. Second, and somewhat in parallel with the first step, it will need to expand services to areas that are not now served and where there are not now and, are not likely to be for some time, other suppliers of these services. In carrying out both of these steps, the government will want to take careful account of the links between the FWP and other health activities, and the emerging role of the private and voluntary sectors. Finally, where services are provided it is critical that they be adequately financed so that they are of acceptable quality and likely to achieve their aims. 36 116. This report examines two scenarios for additional financing requirements, called Scenario A and Scenario B, corresponding respectively to a less and more complete filling of the physical and human infrastructure gaps. Each scenario takes into account the appropriate sequencing of anticipated expenditures, including those for prioritized capital requirements, construction activities, and staffing needs. Each scenario is also compared with a baseline scenario to derive the additional resource requirements during the period 1995-2000. The scenarios are defined as follows: * Baseline. Existing level of input supply and percentage coverage of population are maintained; absolute numbers of beneficiaries and the number of ANMs employed increase in proportion to the population. * Scenario A. The subcenter gap and critical staffing gaps (ANM and five categories of PHC staff) at existing PHCs are filled; no new PHC is created; new subcenters are constructed to fulfill Eighth Plan targets by 2000; all subcenters provided with one bicycle or moped by 2000. Many districts in the country have upgraded facilities for referrals under essential obstetric care. Left out districts will be given OT/Labor room/Observation bed/ambulance facilities, etc. * Scenario B. Equals Scenario A plus creation of new PHCs to fulfill Eighth Plan targets by 2000, and provide every old and new PHC with a jeep. 117. If Government were to bear the total cost of shifting to the RCH approach, the cost of the two components, over a five-year period, is estimated at $1.7 billion (Scenario B). Annex 1 0 (tables A-9 and A- 10) provides projected costs by year for each scenario. Table 5 shows that the main cost of moving to the reproductive health approach is comprised of additional physical facilities, staff, supplies, equipment and transport to fill the existing infrastructure gap in the FWP. In other words, the main cost of moving to a reproductive and child health approach is that of bringing the FWP up to existing coverage norms. The additional cost for covering the whole country with the essential reproductive and child health package by 1999/2000 is a relatively modest Rs. 890 crores ($287 million), only about 17% of the requirement for Scenario B. Capital costs make up 30% of the total requirement under Scenario A, and 40% under Scenario B. Salaries and other fixed recurring costs make up 51 % and 43% respectively, under the two scenarios. 119. The costs of strengthening the private sector contribution to the FWP have not been included in Table 5, because it is anticipated that these could be funded from reallocation of resources within the FWP. For example, the movement away from free distribution of condoms, which currently consumes about Rs. 100 crores (US$32 million) to priced contraceptives can generate resources needed for storage facilities in the states. 37 Table 5. Financing Requirement 1995-2000 (Rs. crores at 1994-95 prices) I :-iascine Sccario A Secnario 13 Diffcecnce (additional) (additional) (1-A) ,, ,, ,, ,., .......... ., .. . ..:. .: ' .'; ......:'''' . ..... ............ . '. '. '. ' . ' . '. . ........ ......... 1,280 2,146 866 -- - . ' . R ..... ....., .:.. , ::'':': : ''''''"":' :'"::'" '' '.. . . . . . . . . ............:. "m- . : . . :. . .--.:::: - :.::::.: 8,463 2,953 3.206 253 .''..'''..'',.~~~~~~~~~~~~~. ........' ' 8tda~~~~~~frs ~~~6,250 914 1.065 151 ..-.~ ~ ~ ~~~~~ . .. ...-. . .-.....i... ~~~~~~~~~~. . . . . . . . ' > R '.. . . . . . . .39143630 Otb....do.ts664 1.230 1,251 21 uUypkuu~~~~~~~g ~1,158 406 427 2 1 OtU riv&0st 391 403 463 60 To~~~~1zeur~~~~~~~ 8,208 4,233 5,352 1,119 , .. -...... ......... . . ... . ., . ......... . ......................... Composition of the Financing Gap I15. The Facility Gap. The facility gap may be defined as the difference between the existing number of PHCs and SCs and the number required by the Eighth Plan targets, a conservative assumption, since the targets were based on 1991 population figures. The construction cost of additional sub-centers is estimated at Rs. 681 crores or US$220 million (Scenario A), while the cost of additional PHCs is estimated at Rs. 481 crores or US$155 million (Scenario B includes both facility gaps, aggregating to Rs. 1162 crores (US$375million). 116. The Staffing Gap. The staffing gap is defined as the difference between the existing and required numbers, under each scenario, of the six most essential categories of staff at PHCs and SCs. These are: auxiliary nurse midwife (ANM), lady health visitor (LHV), medical officer, health educator, health assistant (male), and laboratory assistant. No additional positions of male multipurpose workers have been costed, given the states' unwillingness to hire more of these workers. Scenario A estimates what it would take to fill the subcenter and ANM gap fully, and fill all vacancies of the other five categories of staff at existing PHCs only. This works out to Rs. 914 crores (US$295 million). Scenario B adds a further Rs. 150 crores (US$48 million) for the additional staff at new PHCs created during 1995-2000 (it has been assumed that facilities built during one year would be staffed during the following year). 117. The Transport Gap. The lack of mobility of outreach workers and their supervisors and other staff at the primary level is a critical constraint in the FWP. The shift to a reproductive and child health approach, requiring greater client-provider contact, makes mobility even more critical. Scenario A estimates the cost of providing every ANM at every sub-center with a bicycle or a moped (assuming an average unit cost of Rs. 8000 or US$258) as being Rs. 64 crores (US$21 million) over the period 1995-2000. Scenario B estimates an 38 additional Rs. 360 crores (US$116 million) for providing every PHC with a jeep by the end of the decade. Conclusions 118. Under the scenario noted above, the additional costs associated with meeting the government's norms and fully funding the existing FWP comprise about 83 percent of the incremental costs, while only 17 percent of the incremental costs are associated with the provision of additional services in moving to the RCH approach. The capital costs are Rs. 21.5 billion, or around US$700 million, over a five-year period. The recurrent costs are Rs. 32.1 billion, or about US$1.03 billion. These numbers suggest that under a scenario in which the public sector funds the program totally, an 8.9 percent increase in recurrent costs per year in real terms for the FWP would be needed up until FY2000. 119. It is possible, however, that some RCH services may be provided by the private and PVO sectors where opportunities exist. In addition, priority for public expenditure will need be placed on the satisfactory operations and maintenance of existing services as India moves to the RCH package of services. Moreover, it will also be very important that any expansion of facilities be based on well-defined criteria, that take account, among other things, of need, demand, equity, and the possibilities for private and PVO services in the area. To the extent that the private and PVO sectors might be able to provide services, and to the extent that requirements for public financing of facilities is reduced, the capital and recurrent cost requirements from the public sector would also be less. 120. Given the large section of the population under the poverty line and the special difficulties faced by women, the public sector will have to play an important role in financing the RCH package of services. Under such conditions, a joint commitment of all levels of government at the center and in the states will be necessary and the central government will need to consider how to enhance the overall budget for the sector within the context of the macroeconomic and fiscal constraints, taking into consideration the contributions made by the private and PVO sectors. Furthermore, some reallocation of resources will be required within the FWP both at the center and state levels. C. USING FUNDING AS A PERFORMANCE INCENTIVE 121. How to allocate additional resources for reproductive health services is as important an issue as making those resources available. At present, resources for the FWP have been distributed to the states and districts on the basis of population numbers, developmental need, and contraceptive target achievement. Linking financing to target achievement has had several adverse consequences, including reinforcement of the focus on family planning acceptor numbers rather than on quality, and inflation of the performance reports for reversible contraceptives in some states. It is also inconsistent with the approach to the population policy developed at the Cairo conference (para. 3), for, if contraceptive prevalence rates are as much the product of socioeconomic factors as of program performance, judging the program on the basis of an achievement indicator which it can only partially influence is inappropriate. This report therefore recommends that the linkage 39 between target achievement and funding be discontinued, and that the government develop an alternative performance incentive mechanism for the states. 122. As an alternative, the government might consider linking incremental funding to states' demonstrated willingness to reorient the FWP towards a reproductive and child health approach. Specifically, in addition to population size and financing need, the following might be considered as indicators of performance: * achievement in spending the previous year's budget allocation from the center; * progress against agreed upon indicators of reorientation toward the reproductive and child health approach; and * amount spent by the states to upgrade the primary center network. 40 Annex 1 MINISTRY OF HEALTH AND FAMILY WELFARE GOVERNMENT OF INDIA ACTION PLAN FOR REVAMPING THE FAMILY WELFARE PROGRAM IN INDIA 1. DEMOGRAPHIC SCENARIO 1.1. According to the 1991 census, the country's population is 843.93 million-a substantial rise from 342 million in 1947 and 684 million in 1981. The annual addition to the population is 16 million. The All-India average annual growth rate during the 1981-91 decade has been of the order of 2.11 percent marginally lower than 2.22 percent during the preceding decade. 1.2. The latest available Sample Registration System (1989) estimates indicate All-India birth rate of 30.6, death rate of 10.3 and infant mortality rate of 91. Two important parameters influencing fertility behavior are female literacy and age at marriage for women. Couple protection rate (CPR) also indicates the level of efforts made for birth control. 1.3. The long term demographic goals as laid down by the National Health Policy (1983) are to achieve the birth rate of 21 per thousand, death rate of 9 per thousand, natural growth rate of 1.2 percent, infant mortality rate below 60 per thousand live births and couple protection rate of 60 percent by the year 2000 AD It has already been recognized that given the current level of achievements, the goals may not be achievable at the National level before 2006-2011 AD. 2. FUTURE STRATEGIES Faced with grim prospects of population explosion, it is necessary to devise innovative strategies for imparting new dynamism to the Family Welfare Program. While the population control program has to essentially evolve as a multi-sectoral program comprising many aspects which go beyond family planning, a result-oriented action plan has been developed. The broad framework is summarized below: 2.1. National Consensus and Efforts The population control program should emerge as a national consensus with willing participation of all segments of the society cutting across political, religious and cultural barriers. It has to be backed by strong political commitment and will not only at the national level but also at the level of States/UTs, which are primarily responsible for implementation of the program. Political leaders, religious leaders and other opinion leaders at different levels will have to be approached for their active involvement in molding public opinion. 2.2. Improvement of quality and outreach of services A vast network of institutions has come up in the country for delivery of health and family welfare services over the successive plan periods. It has, however, been recognized that the quality of service delivery extended to the people is not satisfactory. Besides, the outreach of services is also not adequate for the people in remote rural areas and urban slums. The following steps would be taken: (a) Keeping in view the general constraint of resources (financial, administrative and managerial) for pushing the family welfare program, the thrust during the Eighth Five-Year Plan 41 Annexmi would be first to consolidate the existing infrastructure. There is no point in going for opening of new subcenters, etc. in the future, if the existing sub-centers are not functioning properly. However, keeping in view the norms fixed during the Seventh Five-Year Plan, new institutions will be sanctioned if adequate funds are made available. Special attention will be paid to creation and strengthening of infrastructure in the urban slums where these are particularly deficient. (b) Integrated training modules for training and re-training of medical and para-medical personnel involved in the delivery of family welfare services will be developed and adequate funds made available for organizing different training programs in the institutions already set up for the purpose. (c) As motivation is a key factor in improving the quality of delivery of services, it will form a key element in the training modules for medical and para-medical personnel at all levels. (d) Special attention shall be paid by the state governments/UT administrations to have a proper organization for maintenance of equipment, vehicles and buildings and, wherever possible, train even the existing family welfare workers for doing small repairs. This would ensure proper utilization of vital equipment and valuable assets created under the program. (e) The supervision at all levels will have to be vastly improved. This will primarily focus on identification of problems, finding solutions thereto and improving understanding and capabilities of key functionaries involved in the delivery of services. (f) Special attention shall be paid to the construction of buildings for Primary Health Centers and sub-centers through Area Development Projects and under the Minimum Needs Program of the States Plans. (g) The state governments and UT administrations would look into the practical problems of the workers like ANMs in the field conditions such as their place of stay, mobility and traveling expenses etc. as inadequate attention to these problems seriously hampers the working of the main propagators and service providers of the family welfare program at the grass root level. 2.3 Special Strategy for 90 Districts The demographic and health profile of the country is not uniform. Examination of the statewide data regarding behavior of the important demographic and health indicators shows very clearly that any operational strategy, to be successful, will have to be based on disaggregated approach. The four states of Bihar, Madhya Pradesh, Rajasthan and U.P. which constitute about 40 percent of the country's population, have IMR and MMR levels distinctly higher than the national average. These are also the states where female age at marriage, female literacy and share of women in non-agricultural employment are distinctly lower than the national average. Unless special efforts are made to bring up the profile and performance of these states in regard to health and family welfare, it would be well-nigh impossible to accelerate the achievement of demographic and family welfare goals at the national level. Special area development projects have already been launched in these states with the help of World Bank, UNFPA and other funding agencies. The pace of the implementation of these projects primarily designed to strengthen the infrastructure and to improve the training of their staff requires to be speeded up with due attention to quality of implementation. 42 Annex 1 2.3.1 The relevance of the disaggregated approach does not stop at the identification of the four states. An analysis of demographic indicators at the district level indicates that there are 90 particularly bad districts where the CBR is above 39 per thousand (1981 census). A list of these districts is placed at Annex 3. The following steps would need to be taken to improve the program performance in these districts: (a) Micro-level planning by the states to identity the needs on a realistic basis for reduction in birth rate in these districts. Resources will be allocated for strengthening of infrastructure and provision of other essential inputs after taking into account the inputs already provided in these districts through area development projects and other special projects, if any. (b) All posts at grass root level of family welfare workers and supervisory officers would be filled up and only motivated officers with excellent record in these districts would be posted. (c) Priority for construction of subcenters and buildings for other health institutions would be given in these districts under the area development projects. (d) Intensive training of medical and para-medical personnel would be organized. (e) Since many of the low performance districts have large minority populations, minority community leaders at local levels would be involved in launching imaginative IEC programs designed to increase family planning acceptance by all sections of the society through methods best suited to individual needs. (f) In order to improve the inter-personal communication efforts at the grass root level, a scheme of link volunteers would be tried out in some of the districts on a pilot basis. Dept. of Woman and Child Development would be requested to cover all the 90 districts with ICDS program and suitable linkages developed at the delivery level with ICDS functionaries to delivery health, nutrition and family welfare services as a package. (g) The district collectors would be fully involved in coordination/supervision of family welfare program related activities in these districts. 2.4 Package of Incentives/Disincentives 2.4.1 The present scheme of compensation for loss of wages to acceptors of sterilization/IUD, places great emphasis on target achievement with the result that the quantity has taken precedence over quality and some specific methods seem to have over-shadowed others. It has increasingly been recognized that we should get rid of "tyranny of targets" altogether. Targets based on micro-level planning suiting the local specific needs may, however, continue to be fixed for monitoring of the program. 2.4.2 The above scheme will be modified to provide for greater flexibility to the states and to cover younger age couples with greater fertility potential under spacing methods. The resources meant for the purpose would be provided to the states/UTs in relation to their overall birth rate reduction efforts. In order to work out a suitable formula for devolution of resources under the scheme, a Committee under the chairmanship of Shri S.B. Mishra, Joint Secretary in the Ministry of Health and Family Welfare will be constituted which will have four State Health Secretaries as its members-two from good performing States and two from poor performing States. The committee will finalize its recommendations within three months of its constitution. 43 Annex 1 2.4.3 No more incentive to govemment employees will be considered. A suitable package of disincentives will be developed for this section of the society for adoption by the state governments as well. It will also be recommended to the employers in the organized sector. 2.4.4 The motivators fee presently being paid to service providers will not be paid any more as it also leads to emphasis on achievement of specific methods of contraception. 2.4.5 States Award Scheme already decided to be scrapped retrospectively with effectiveness from the financial year 1988-89, would not be revived as it had been leading to falsification figures and unhealthy competition. However, suitable incentives to encourage good performance shall be built in the proposed modified scheme of compensation. 2.4.6 An innovative package of incentives/disincentives would be formulated with emphasis on community based incentives and social security measures for individuals adopting small family norm. The community based incentives would be linked to various benefits being made available to the public under different socio-economic development plans of the government. 2.5 Promotion of Different Contraceptive Methods/Devices 2.5.1 Sterilization procedures were the mainstay of the program in the past. However, acceptors have generally been the higher age and the high parity couples who have already completed the desired family size. The contribution of sterilization to the fertility decline, therefore, has been less than anticipated. While sterilization would continue to play an important role in the population control efforts, it would be ensured that the profile of the acceptors would be of the right quality in terms of age and number of children already born. 2.5.2 Spacing methods will be vigorously pushed for adoption by the younger age couples with high fertility potential. This would require good follow up services for acceptors of IUD insertions to bring down the drop out rates, improvement in the distribution arrangements of conventional contraceptives and oral pills in rural areas and urban slums through strengthening of schemes for social marketing of contraceptives and launching of community based distribution of contraceptives. The free distribution schemes which are somewhat wastage-prone would be gradually curtailed and limited only to such areas where these are actually needed for economic reasons or for lack of outreach of social marketing/community based distribution programs. 2.5.3 The quality of contraceptives would be improved. In this regard supply of dry condoms under the free distribution scheme would be gradually phased out and only lubricated condoms made available. 2.5.4 The production arrangements for weekly oral pills (Centchroman) and oral contraceptive pills (Mala N and Mala D) shall be gradually improved so as to make these easily available across the length and breadth of the country in greater numbers. 2.5.5 In order to give a wider choice of contraceptives to the acceptors, new contraceptives such as Norplant-6 and injectibles shall be introduced under the program, initially under controlled conditions and gradually on a wider scale. 44 Annex 1 2.6 Universal Immunization Program and MCH Program 2.6.1 Consistently high coverages are being reported from most of the states in the UIP. However, there still remain areas where the coverage levels are low. Special attention would be focused on such areas during the coming years, while sustaining the high level of coverage achieved elsewhere. 2.6.2 All such cases where reported coverages are more than 100 percent of the target fixed, the reasons for high coverages would be routinely investigated to ensure that no over-reporting is allowed as this would otherwise lead to a sense of complacency leading to outbreak of the vaccine preventable diseases. 2.6.3 The ultimate objective being reduction of vaccine preventable diseases the priority in the coming years would be to concentrate on the quality aspects of the services delivery and on documenting reduction in disease incidence. The following activities in this context would be strengthened: (a) Initiate active surveillance in areas where low incidence has been recorded in the last two years. L-ist of cases, particularly of polio and ieo-niatal tetanus would be the lead diseases under monitoring. (b) Set up network of Polio Virus Isolation Laboratories while increasing the number of field samples of Oral Polio vaccine to ensure that at least one full sample is lifted from every Primary Health Center area in a year. (c) Time-bound investigation of all adverse reactions following vaccination. 2.6.4 For overall improvement in the management of the program, all supervisory posts created so far, particularly that of the District Immunization Officers and Refrigeration Mechanics, would be filled up by the states/UTs. 2.6.5 All states/UTs would also take priority action to take over the maintenance of the cold-chain created over the last four-five years and further planned to be strengthlened in the coming years. 2.6.6 About 1.5 million children below five years of age die because of Diarrhea in the country every year. Even though the Oral Rehydrationi Therapy Program is being implemented for quite some time now, it has met with only partial success. There are still many medical practitioners who are not propagating it or prescribing ORS. The program would be more vigorously promoted through the training of medical and para-medical personiel and through hiealthi education to people, particularly mothers. 2.6.7 Keeping in view the Health for All goal by 2000 a new Child Survival and Safe Motherhood Program is proposed to be implemented with IDA/UNICEF assistance il a phased manner. It would provide for universalisation of IFA to cover all pregnant mothers, universalisation of vitamin A to all children up to the age of three years, expanding the pilot project on control of acute respiratory infections and strengthening primary health care infrastructure coupled with an intensified training of traditional birth attendants in the higher IMR/MMR states of Assam, Bihar, Orissa, Madhya Pradesh, Rajasthan and U.P. It is expected that this project would not only help in lowering the IMR/MMR and child mortality rate but would also contribute significantly to improve the family welfare services. 45 Annex 1 2.7 Urban Area Schemes 2.7.1 The Schemes like post-partum centers, urban family welfare centers, and health posts are designed to provide Family Planning and Maternal and Child Health Care services to population living in the urban areas including slum areas. While the post-partum centers have generally become hospital based programs and are not effectively catering to the areas/population attached to them, the quality and outreach of services being provided by the urban family welfare centers/health posts are also not satisfactory. This has resulted in a situation in which the F.P. and MCH services are not effectively reaching the urban slums population which is an area of major concern. The following steps would be initiated: (a) With a view to strengthen infrastructure and services, Urban Revamping Schemes covering towns with two lakh population and above with special focus on slum areas are already being developed. The operationalization of these schemes would be expedited with adequate funding support from central budget and external agencies. (b) The involvement of voluntary organizations in catering to the needs of slum population will be enhanced. Preference would be given to voluntary groups already active in such areas. (c) The urban institutions whether under the government or in the voluntary sector will be closed down or shifted elsewhere in case an optimum level of performance is not recorded. It would be ensured through proper monitoring and supervision mechanisms that these institutions do seriously endeavor to meet the respective program objectives, particularly those related to serving the target population assigned to each. Adequate flexibility would be given to states/UTs to meet these objectives. (d) Suitable coordinating mechanisms would be developed to ensure that the urban institutions function in an integrated manner and not in total isolation of each other and the overall program objectives. 2.8 Village Health Guide Scheme There is a general impression that this important scheme designed to provide for the basic linkage between the community and the Health and Family Welfare service delivery system, is not working well. VHGs are presently getting only Rs. 50/per month as honorarium and in most parts of the country, they are not rendering much service to the community. Some states (J. and K., Tamil Nadu, Kerala) did not implement the scheme from the very beginning and some others like Assam and Haryana have scrapped it. The decision to replace male health guides with female health guides has also led to a plethora of writ-petitions in different high courts. The general experience has been that wherever female health guides are in position, the ground situation of service delivery is much better. 2.8.1 The following steps would be taken: (a) All the pending court cases would be effectively followed up and got decided on a priority basis. (b) The existing number of village health guides shall be fully utilized by states/UTs with reduced functions, if necessary. Their services may primarily be utilized as motivators and depot-holders for contraceptives, oral rehydration salts, IFA tablets and so on. 46 Annex 1 (c) The possibility of revitalization of the scheme to make it more effective or alternatively of disbanding it would be examined further taking into account the varied implications including from the legal angle. 2.9 Continuation of ANM/LHV Training Schools There are a large number of ANM/LHV/MPW (M) training schools in different parts of the country. As regards ANM/LHV training, many States/UTs have already fulfilled targets of recruitment and basic training of workers. In so far as the scheme of training of Health Worker (Male) is concerned, most States have stopped training as fresh recruitment is not taking place. There is a large number of vacancies of MPW (M) in different States/UTs which has caused serious concern. 2.9.1 The following steps would be taken: (a) The existing infrastructure of ANM/LHV training schools would be thoroughly reviewed for each State/UT to ensure its proper and effective utilization. Schools without buildings and those being run through voluntary organizations shall be closed down gradually. The remaining schools will be utilized for running integrated training modules for para-medical workers, including of voluntary sector, and for continuing education programs. (b) States/UTs would initiate action to create posts of MPW (M) to meet the existing gaps in a phased manner and effectively utilize the available training infrastructure. (c) Net working arrangements of training institutions at different levels would be developed with a view to ensure uniformity in training modules, avoid duplication and bring about effective coordination. 2.10 Information, Education, Communication Information, Education and Communication (IEC) inputs need to be revitalized not only to propagate the Family Welfare Program but also to bring about attitudinal changes so as to cover a part of the ground which should be normally prepared through education and social work. The new IEC strategy would have the following key elements. (a) The IEC message would be to associate family welfare with planned parenthood and not just with the adoption of contraception. (b) The messages would be positive with thrust on quality of life issues and removal of ignorance, apathy and misgivings about the family welfare programs. (c) In order to involve the community in generating demand for family welfare services, the scheme of Mahila Swasthya Sangh which has been recently introduced in some selected districts would be further strengthened in case the results are found to be encouraging. (d) The messages through the mass media would be of a balanced nature so that these do not harm sensibility in our sociocultural ethos. (e) In order to cover 40 percent of the population which is not covered by any mass media presently, special attention shall be paid on traditional art forms, folklore, field publicity and 47 Annex 1 interpersonal communication. Feature films with entertainment value would be developed for being shown on 16 mm projectors for conveying the required messages in a suitable manner. (f) Increased emphasis would be laid on development of media material in a decentralized manner so that these are produced taking into account the regional diversities in thie country and local specific needs. (g) Regular training of IEC staff at different levels would be undertaken to expose them to latest IEC techniques, improving their motivation and administrative/managerial abilities. (h) The funds provided for media activity would in no case be diverted as is happening in some states presently. The importance of IEC activities in achieving the desired goals would need to be fully realized by the states/UTs. (i) IEC efforts would increasingly focus on the need for participation of males in adopting contraception with a view to remove misgivings about the vasectomy, which is a mucli simpler procedure than the female sterilization. (j) The Rajasthan experiment of integrating the IEC activities of the entire H and FW sector and developing linkages with other sister departments for a coordinated IEC effort has been noted to be leading to better achievements. Other states/UTs may like to study this experiment for possible replication. 2.1 1 Involvement of Non-Governmental Sector For supplementing the efforts of the government, it is necessary to involve the nongovernmental organizations and voluitary agencies in a very big way. Even though the need for this has been realized for quite some tilme with a view to make the Family Welfare Program a people's movement, harsh reality is that so far the contribution from the nongovernmental sector is rather limited and the program is perceived by the people as the government's program. Voluntary sector and NGOs cannot only supplement the family welfare services provided by the government but also it is expected that they would have a better understanding of how to bridge the communication gap with the people and take the message of small family and Maternal and Child Health to them in the language they understand. 2.1 1.1 Instead of waiting for a voluntary agency to approach the government for assistance, it would be necessary to identify local level individuals (youths in the villages, panchayat level leaders, private medical practitioners including ISM practitioners, ex-servicemen, retired government servants with a social conscience etc.) to motivate them to participate in the family welfare program, impart training to them and involve them either individually or collectively for generation of demand for the family welfare services and propagation of small family norm. 2.11.2 The network of cooperative sector institutions, organized sector, trade unions, Zilla Parishads, municipal corporations, and panchayats, would be fully involved in the implementation of family welfare programs in a systematic manner. 2.11.3 Increased powers to sanction schemes for nongovernmental sector would be delegated to the states/UTs which may further be delegated to the district level with a view to expedite the sanction of schemes and also because the actual work of identifying and encouraging the voluntary workers at 48 Annex 1 grassroot level, necessarily will have to be done by the district officers and other officers of the state governments in this field. 2.11.4 In view of the fact that the NGOs in some states/areas have achieved exceedingly good results, visits of NGO workers from the poor performance states/areas would be arranged to a good performance State/Area. Further, the available infrastructure would also be utilized for training of voluntary sector workers to improve their administrative, financial and managerial abilities. 2.11.5 In order to have the desired impact of the eliciting participation of voluntary and NGOs, a suitable organization would be evolved at central level which will have the desired degree of flexibility in sanctioning schemes and ensuring smooth flow of funds. 2.11.6 Increased allocations would be made in the central budget for implementation of Family Welfare Program through NGOs/voluntary sector and receipt of external assistance for this sector would be considerably stepped up. 2.12 Inter Sectoral Coordination One of the key points which always needs to be kept in view is the distinction between the family welfare activities and the population control program. Control of population is dependent on a variety of factors, many of which go beyond the sphere of the family welfare sector, but which have an equal and perhaps even more important bearing on the birth rate. In fact, the Family Welfare Department in the Center and the Health and Family Welfare Departments in the state governments are organizations which should be essentially viewed as supply departments for making available the family welfare services, but the demand for these services and the motivation for population control comes from factors such as female literacy rate, age at marriage of girls, the status of women, position of employment of women, social security and general level of economic development. These are well beyond the pale of activities of Department of Family Welfare. 2.12.1 There is need to have an institutional mechanism at the center for inter-sectoral coordination particularly between the Ministry of Health and F.W., Ministries of Human Resources Development, Finance, Information and Broadcasting, Environment and Forests, Labour, Department of Woman and Child Development and the Department of Rural Development. A suitable institutional mechanism would be evolved at the central level to achieve the desired level of intersectoral coordination and similar mechanisms would be developed at the state level. 2.12.2 At the state level, the Chief Secretaries would be involved personally in making the Family Welfare Program a success. At the district level, Deputy Commissioners, Chief Executive Officers of the Zilla Parishads, would be involved in a greater way not to push the target achievements in a routine manner but to achieve intersectoral coordination of different departments whose activities have a direct bearing on family welfare program performance. 49 Annex 2 FAMILY WELFARE POLICY ISSUES I. THE EVOLVING POLICY CONTEXT 1. Population policy development has a long history in India, which launched its national Family Planning (later Family Welfare) Program in 1951. India has been a leader in calling for broad integrated approaches to population, as it did during the first United Nations World Population Conference in Bucharest in 1974. India continues to affirm its commitment to slowing population growth-a priority area in the Eighth Five-Year Plan (1992-1997)--and in India's statement to the International Conference on Population and Development (ICPD) in September 1994. 2. India's population policy and program approaches have evolved in several ways over the past four decades. During the 1960s, there were massive efforts to recruit IUD acceptors and promote the use of condoms, followed during the early 1970s for a year or so by even more forceful efforts to enlist both male and female candidates for surgical sterilization. The excesses of these campaigns generated widespread backlash that set the program back for several years. The late 1970s brought reconfirmed commitment to voluntarism in family planning, and the 1980s witnessed a rebuilding of public support for the program. 3. Despite many successes, including a doubling in contraceptive prevalence from around 20 percent in the early 1970s to over 40 percent by the early 1990s, the Family Welfare Program continues to suffer from long-standing problems of implementation, many which have their roots at the policy level. These problems have been addressed in the "Action Plan for Revamping the Family Welfare Program in India" drawn up by the MOHFW in 1992 (see Annex 1), and are discussed in the main body of this World Bank report. 4. The action plan recommended a twelve-point strategy for policy and program action to improve the effectiveness of the Family Welfare Program (FWP). These included: (a) generation of national consensus and policies for FWP; (b) improvement in the quality and outreach of FW services; (c) special initiatives for 90 backward districts in UP, MP, Bihar and Rajasthan; (d) modification of the system of targets and incentives, and devolution of more responsibility to the states; (e) promotion of broader range of choices in methods, including those for spacing; (f) upgrading and improving performance of immunization and MCH services; (g) improvement of FW services in urban slums; (h) revitalization of community-based support systems for FW workers; (i) revitalizing training; (j) improving information, education and communication efforts; (k) greater involvement of non-governmental organizations; and (I) strengthening intersectoral coordination between the FWP and other relevant government agencies through creation of a high-level population commission and corresponding state- and district-level bodies. 5. The government has already moved to implement many of these recommendations, with major support from IDA-financed operations including the Child Survival and Safe Motherhood 50 Annex 2 project, the Social Safety Net Credit, and several area projects. Projects were designed to strengthen the overall package of services in the FWP and to address the specific areas of program improvement called for in the strategy such as fieldworker training, strengthening of community links, upgrading of facilities, expansion of lEC, and involvement of private voluntary organizations (PVOs). 6. At the policy level, a high-level Population Committee was set up as a subcommittee of the National Development Council (NDC), which comprises all Chief Ministers of State. The Committee made a set of recommendations to the NDC for formulation of a national policy and establishment of mechanisms for its implementation. The committee constituted a group of experts to draft the policy. The reports of these two bodies have been widely circulated and are under consideration by the GOI. 7. In May 1994, the expert group submitted to MOHFW a draft report with recommendations for a new national population policy. The report proposes the establishment of Population and Social Development Committees at the national, state, district and local levels of government to promote a participatory political environment for and community involvement in addressing family welfare issues. This and other recommendations, including mechanisms for implementation of the policy, which would involve the establishment of a Population and Social Development Fund that would take the place of the Department of Family Welfare, are still under discussion. 8. The Bank takes a very positive view of the basic principles and directions for population policy development that are being articulated in India, while recognizing that the institutional and organizational roles and structures for their implementation need to be worked out among the many stakeholders represented in the democratic processes of the country. II. NEW DIRECTION IN POPULATION POLICY: ICPD IMPLICATION FOR INDIA 9. There is broad support in these policy discussions for a holistic approach to population. The holistic approach closely links population issues to broader agendas of poverty reduction and human development. It also recognizes the crucial need to address gender inequity and the many forms of discrimination against women that persist in India, including dowry, unfavorable property rights, female foeticide and infanticide, and unequal access to education and economic opportunity. 10. There are many parallels between the approach being articulated in India and the Program of Action adopted at the 1994 International Conference on Population and Development. In addition, the ICPD document can further elucidate and guide policy discussions in India. The ICPD Program of Action represents a major departure from conventional thinking on population and development. The international community has, for the first time, gone beyond mere numbers of human beings and demographic changes and explicitly placed human beings at the center of all population and development activities. Investing in 51 Annex 2 people, in their health and education, is seen as the key to population stabilization and to sustained economic growth and sustainable development. The population dimension is thus no longer seen in isolation, but in conjunction with overall development strategies, in particular with efforts to eradicate poverty, achieve sustained economic growth, and empower women to participate fully in the development of society (see "Interim Report of the Executive Director," UJNFPA, January 1995). 11. The Program of Action has specific implications for policy and program orientation. First and foremost is the need to base population programs on individuals' needs and desires rather than on demographic targets, and to place paramount importance on ensuring quality of care. Both must be translated into actions that fully respect the principles of free and informed choice. This requires, among other things, improving the quality of training in reproductive counseling, health information, and related areas; expanding the range and quality of services and contraceptive methods; and promoting greater involvement of national and sub-national PVOs and women's groups in the design, implementation and monitoring of programs. In addition, it calls for increased use of client-focused research and evaluation to develop and improve training and information, education and communication programs. 12. The concept of a reproductive health approach is central to the new vision of population policy articulated at ICPD. In the past, program success or failure has been defined in terms of its contribution to decline in fertility and population growth rates. While fertility reduction concerns can and should be addressed at the level of broad social policy, the main focus of reproductive health program design and management should be the needs of actual and potential clients (as identified through research and feedback mechanisms) rather than a specified demographic impact. 13. Correspondingly, performance should be measured by effectiveness in helping clients to realize their reproductive intentions and improving their reproductive health status, through indicators which demonstrate (a) continued effective use of temporary methods by couples who want to space, (b) male or female sterilization for those who choose this method to limit births, and (c) reduced maternal and child mortality and morbidity. The World Bank encourages its borrowers to adopt the ICPD recommendations because they represent a more effective way of achieving the overarching objective of population policy-poverty reduction and the improvement of human welfare, in addition to population stabilization-and are also more acceptable on humanitarian grounds. 14. De-linking of programs from demographic objectives does not imply that slowing of population growth should cease to be a goal of population policy, but rather that demographic objectives should be pursued simultaneously through a broad range of social policies, including education, improvements in the status of women, and health-including reproductive health and family planning. The implementation of social policy should also focus on the specific human development needs that each program area serves, though with attention to synergies that increase individual as well as community well-being-for example, keeping girls in school, which contributes to delayed initiation of childbearing, empowers women, and increases their productivity. Population objectives can inform the broader development strategy through such 52 Annex2 mechanisms as the timing and allocation of investments among particular social sectors that affect and are affected by demographic changes. 15. Policy and program issues are closely interrelated, and it will not be enough to deal with only one set of issues. Some have expressed concern that a focus on programmatic issues in reproductive health and family planning will fail because it deals narrowly with a subset of issues about the health delivery system and does not confront the fundamental social issues that are the root causes of high fertility as well as persistent poverty. The Bank strongly supports an integrated approach to population and social policy questions. At the same time, it sees the need to focus this discussion of future directions in service delivery under FWP on meeting the reproductive health needs of the population rather than on demographic objectives. It also recognizes that the broader social issues cannot be addressed solely in terms of FWP but must involve a much broader spectrum of stakeholders at every level of government and society, something which cannot be fully discussed within the scope of a report focused on programmatic issues of the FWP. 16. Thus in addressing policy issues, the Bank endorses India's 1994 policy initiatives as reflected in the shared vision of the ICPD Program of Action. This annex now focuses on key steps that need to be taken in order to translate this new vision of population policy into effective actions to operationalize the reproductive health approach in the Family Welfare Program. Three areas of policy implementation are outlined below. A. MOVING FROM TARGET/INCENTIVES TO CLIENT-CENTERED PROGRAM MANAGEMENT 17. An important first step toward implementing the new policy agenda is to move away from targets and incentives toward a client-centered approach in program design and management. Monetary incentives and demographic targets have been an important feature of India's earlier demographically-oriented FWP, but are increasingly recognized as impediments to the reproductive health approach. The government of India is now reconsidering the issue of targets and incentives and discussing alternative indicators of program performance. This is an important sign of its commitment to implementing a reproductive health approach in its population program. 18. Provider and motivator incentives have been standard FWP practice for several years. The record on these incentives is problematic, particularly because they have been tied to contraceptive-method targets. In addition to their high costs, problems of administration and potential mismanagement, and distorting effects on program performance, there are concerns about ethical issues and possible infringement on individual reproductive rights. Providers and motivators who seek a monetary reward tied to the target for a particular method may be less likely to attend to client needs. Both method-specific targets and provider/motivator incentives for methods need to be phased out. 19. Incentive payments to clients have also been employed to motivate the use of specific methods. Currently these incentives are paid for sterilization and IlUDs. Proponents of client 53 Ann 2 incentives argue that they are needed to motivate clients, and to compensate them for the loss of work time and other personal costs incurred in clinic visits. Critics, on the other hand, ask why such compensation should be paid for one reproductive health service (sterilization) and not for others. They are concerned that even when the amounts of cash payments to clients are small, the risk of coercion for impoverished individuals is real. The critics also doubt that the perceived societal benefits warrant coercion or actions that would harm the reproductive health of individuals. In addition, they also question the psychological impact of these incentives in the long term, noting that paying clients for only one service may send a message that sterilization and possibly by association other family planning methods are undesirable in themselves. 20. For those who are not persuaded by concerns about human rights or creating a negative program image, another consideration is that resources could be used more effectively in other ways. For example, funds might be reallocated to improving the quality and access to services or to invest in communication efforts with clients about how services could meet their own reproductive health needs. The benefits from improved services in terms of program effectiveness is corroborated by a growing body of research that verifies that people are more likely to use and even pay for services when they are of good quality and responsive to their needs. It is possible that reallocating incentive funds for program improvement might actually have a stronger motivating effect on users than incentives themselves. Research shows that many potential consumers say they are not using methods for reasons such as fear of side effects, cultural or perceived religious objections to certain methods, or concerns about the reactions of their spouses and other relatives-reflecting limitations in the program's communications and counseling efforts and in the choice of contraceptive options. Because much of clients' unmet need for fertility regulation reflects poor services, concentrating on service access and quality may be a far more effective way to achieve both demographic and reproductive health goals than by paying them to use a method. 21. While India's 1992 action plan calls for the elimination of targets and incentives for individuals and providers, the practices continue and remain a key aspect of the program, especially for sterilizations. Many program managers fear that the removal of targets and incentives will undercut program performance. They also interpret calls for the elimination of sterilization targets/incentives as a call to shift program emphasis away from sterilization. That is not the message. Rather, the point is that sterilization should be available to meet the reproductive health needs of individual couples who wish to stop childbearing. In all likelihood, the need for sterilization services will in fact expand rather than shrink, so that added effort will be needed to improve access and quality of those services. 22. It is also important to recognize that the elimination of targets must be accompanied by the development of alternative measures for program management and performance that will adequately reflect the new orientation toward accessibility and quality of services as well as responsiveness to client needs. The MOHFW is encouraging states to experiment with alternative approaches to setting of program objectives and measuring accomplishments. Population-based indicators of coverage could served as benchmarks for measuring progress at the level of blocks and districts; however, performance of field staff should be measured in 54 Annex 2 terms of how well workers do in providing clients in their catchment area with services and information which address the expressed reproductive health needs of that community. B. EXPANDING THE RANGE OF CONSUMER CHOICES IN REPRODUCTIVE HEALTH SERVICES 23. Implementation of the reproductive health approach also requires expansion of the range of consumer choices offered by FWP. This includes a broader range of safe and effective contraceptive methods as well as incorporating reproductive health services which are not yet available, such as management of reproductive tract infections, services that address the special reproductive health needs of adolescents (including married adolescents), and those that recognize the special needs of males. 24. While progress has been made in broadening the method mix to include a range of spacing methods, including condoms, pills, and lUDs, female surgical sterilization is still the dominant method and the one to which India women are most likely to be referred. Sterilization at low parity is a very effective method from a demographic perspective and provides clients who want to limit births with the safest and most cost-effective way of achieving that goal-as long as services are provided under proper conditions. It still accounts for nearly four-fifths of modern-method prevalence in India and has clearly been the main contributing factor in the decline of India's total fertility rate to its current level of around 3.5 births per woman. 25. Given the very early age at which Indian women marry and begin childbearing, efforts to delay marriage and/or the initiation of childbearing and expanded use of spacing methods could bring important demographic and reproductive health benefits. Re-emphasis of vasectomy for those males who want no more children and an expanded menu of temporary methods (female barrier methods, lower cost injectables, and so on) would address a broader range of consumer needs in family planning. 26. This point is illustrated in data from the 1992-93 National Family Health Survey for the state of Uttar Pradesh. The median age of sterilization is just below 30, whereas the median age of marriage is just over 15, leaving 15 years of exposure to the risk of pregnancy. Only a small fraction of married adolescents were using any temporary method to delay or space births. Overall, about half the women surveyed responded that they wished to delay or limit further childbearing, but fewer than 40 percent of these women were actually practicing family planning, with sterilization accounting for two-thirds of total contraception. That leaves an unmet need for family planning in U.P. of 30 percent of all currently married women of reproductive age. Nearly 17 percent (more than half of total unmet need) are women who reported that they would prefer to delay the birth of their next child for at least two years. While efforts are needed to attract a higher proportion of women in U.P. to use family planning to space or limit their births, much could be achieved by addressing the current unmet need by expanding access and improving the quality of services for both spacing and limiting methods. The necessity of improvement is more acute in the case of spacing methods, which account for only a third of overall contraceptive prevalence. 55 Annex 2 27. The method mix issue is a good example of the compatibility of demographic and individual reproductive health goals, and also illustrates the importance of making sure that demographic objectives at the policy level do not govern the implementation of efforts to improve method mix. Indeed, given the general agreement about the need to increase individuals' contraceptive choices and reduce the current dominance of sterilization, it is surprising to many observers that there is so much controversy in India about the introduction or re-introduction of hormonal contraceptives. 28. Some reproductive health advocates in India have opposed efforts to expand the utilization of pills and to introduce injectables and implants. Their concerns revolve around two sets of issues: (a) potential abuses with methods which put most of the control over method use in the hands of providers, and (b) the safety and efficacy of user-controlled methods under conditions in which screening, counseling and follow-up for potential side-effects and contraindications are inadequate. Their concerns are heightened by the perception that the FWP is guided by demographic rather than reproductive health objectives. 29. Indian experience with overly aggressive promotion during the 1970s provides ample evidence of potential abuses with provider-controlled methods in a demographically-driven program, particularly when methods are delivered in "camps" which bring medical personnel and users (or "acceptors") together for a one-time encounter in which there is little likelihood that the latter will get individual counseling or be offered a choice of methods based on their specific needs, and even less likelihood that there will be follow-up in case of side effects or other problems with a method. 30. These concerns are not limited to hormonal methods. Another method whose use is expanding again in India as a result of the effort to broaden the method mix is the Intra Uterine Device (IUD). IUDs (particularly the CuT-380a) are an effective long-term method when properly inserted and monitored. However, IUDs can also cause severe problems when inserted under unsanitary conditions and (with the possible exception of the CuT-380a) when the client suffers from a reproductive tract infection (RTI). 3 1. Improved quality in manufacturing, distribution and delivery is critically important if hormonal methods are to play an expanded role in fertility regulation in India. While India has the advantage of local production capacity for hormonal methods, the quality of manufacturing is a problem. The UNFPA's report on "Contraceptive Requirements and Logistics Management Needs in India" identified a number of gaps, including sub-standard manufacturing practice and poor shipping and storage that has contributed to deterioration of supplies. Similar problems affect local production and distribution of other temporary methods, including condoms and IUDs. The problems represent considerable loss of financial and human resources as well. 32. The solution to these problems is not to prohibit specific methods but rather to correct inadequacies in current systems for procuring, distributing, prescribing and monitoring their use. De-linking of method mix implementation from demographic objectives is a necessary but not sufficient condition for this to happen. Other actions are also required, beginning with revitalized systems for the development, testing, manufacture, and introduction of new methods, 56 Annex 2 as well as competency-based training and encouragement of providers to do better counseling and follow-up, along with improved systems for supporting, managing and evaluating the performance of providers. 33. Hormonal contraception as well as IUDs have proved themselves to be safe and effective methods of fertility regulation in many settings worldwide provided that their introduction and delivery conform to recognized standards. Groups such as the World Health Organization and International Planned Parenthood Federation have developed and are continually updating guidelines for contraceptive distribution, and recent revisions have addressed many of the issues raised by reproductive health advocates in India. The Bank encourages a program of structured dialogue between the government of India and reproductive health advocates to address specific issues regarding contraceptive safety relevant to the Indian context. WHO has also developed guides to the introduction (or re-introduction) of specific methods which emphasize the user perspective. They recommend community involvement in articulating user concerns and note that this is of equal or greater importance as dealing with technological issues in bringing a method into widespread use in a government program or the private marketplace. Involvement of reproductive health advocates in every phase of development and field-testing of new methods will go a long way to allay fears and build trust. C. BUILDING PARTNERSHIPS THAT STRENGTHEN THE CLIENT FOCUS OF THE FWP 34. A third important change needed for implementation of the reproductive health approach is increased community involvement and ownership of population issues at all levels of program design and implementation. India's proposed policy approach emphasizes the opportunity provided by the Panchayati Raj to decentralize program design and management by placing responsibility with the panchayats, the nagarpalikas and the zilla parishads, thereby developing locally relevant approaches for program implementation. Local planning and implementation of policy through the Panchayati Raj also provides an opportunity for an integrated approach to population, health, education and gender issues. "Socio-democratic charters" are proposed as a mechanism for improving the quality of life of the community under the direction of grassroots, democratic organizations which would form the building blocks for state- and national-level development plans. 35. This change would address one of the major shortcomings of the present system, which is the FWP's overly centralized system of decision and control. One consequence of this centralization is that FWP outcomes have been extremely uneven across the states and territories of India. Significant amounts from the Central and state budgets are being spent on a recurring basis to run facilities that are underutilized because they do not provide the quality of services and information that local communities want and trust. Responding to local needs and perceptions must become a high priority. 36. There is substantial state-to-state variation in experiences with the Panchayati Raj system. In Karnataka, where it was first introduced in 1988, 80 percent of health expenditures are under the control of the Zilla Parishads. An evaluation of this experience reports overall 57 Annex 2 improvement in the management of public health facilities, but found substantial differences in administrative capacity. Since the 1993 Act, other states have been moving ahead with implementation. Encouraging examples of community involvement schemes include the Mahila Swasthya Sangh, under which local health workers form committees of 15 village women to discuss family welfare issues. 37. The Panchayati Raj legislation reserves a third of the positions on the various councils for women. The involvement of women in the Panchayati Raj is a unique opportunity to bring the women's perspective to family welfare programs that women's health advocates have been calling for. While there is anecdotal evidence that women are beginning to take an active role in deliberations, there are also concerns that because of traditional attitudes toward women in India, poorer women will not be able to effectively voice their needs and concerns in the Panchayati governance process. An increasing number of community-level women's groups (Mahila Mandals) are working to train women to be effective advocates in the Panchayats, an initiative which should be supported. 38. It is still too early to judge the effectiveness of the Panchayati Raj and related movements. It is safe to say that they will require substantial nurturing (such as the initiative now being tested in Madhya Pradesh) in order that they play a genuine and constructive role. Community involvement in management clearly involves risks related to trust and responsible decision-making. The new law, which includes family welfare in the Panchayati governing process, represents both an opportunity and a challenge so that it will work effectively for the benefit of the community. III. CONCLUSION 39. India has long been a world leader in the articulation of population policy. Its recent national policy efforts along with the new vision of population and development provided by the Cairo Conference have opened a window of opportunity to make India's Family Welfare Program even more effective in serving both national social and demographic objectives and the individual reproductive health needs of its population. Elimination of targets and incentives in program management, broadening the range of contraceptive choices and other services provided by that program, and greater involvement of the community in population policy and programs are key changes needed to move India's program toward an effective reproductive health approach. 40. The new vision of population in India also requires a change in the orientation of the current system - to an approach that puts the interests of the individual client at the center of policy and program effort. This is the heart of the ICPD vision. It is taking hold in a variety of ways among the various decision-makers and stakeholders in India's population program, but the full commitment and cooperation of all those involved will be required to make it universal. 41. None of the issues presented here represents a major departure from the policy directions that are already under discussion in India. Rather, this analysis emphasizes the necessary actions required to move the Family Welfare Program more fully toward effective implementation of the 58 Annex 2 reproductive health approach. These actions must be undertaken with recognition of the diversity of conditions in different states, districts and localities. This calls for a phased implementation which will give the states wide latitude for experimentation with alternative approaches to program management and community involvement, along with the financial and organizational support and flexibility to try new approaches. The Government of India has made an admirable beginning to implement its new policy vision. 59 Annex 3 ESTIMATES OF UNWANTED AND WANTED FERTILITY IN INDIA I. INTRODUCTION 1. The major objective of the family planning component of reproductive health program is to assist couples in avoiding unwanted pregnancies, and in having the number of children they want, when they want them. While debate persists about the precise levels, there is a growing consensus that a significant portion of childbearing is unwanted in developing societies such as India. 2. The purpose of this paper is to arrive at estimates of unwanted and wanted fertility in India. The primary source of data for this analysis is the National Family Health Survey (NFHS) conducted in 1992-93. The main objective of the NFHS is to provide both national and state- level data on demographic variables, as well as assessments of the utilization of family planning and health services. Demographic variables measured include those on fertility, nuptiality, family size preferences, knowledge and practice of family planning, the potential demand for contraception, and the level of unwanted fertility. Socio-economic information was also collected. 3. The NFHS covers a sample representative of 99 percent of the population of India in 24 states and Delhi. In total, 89,777 ever-married women between the ages of 13 to 49 years were interviewed and 88,562 households were covered. H. UNWANTED CHILDBEARING 4. The indirect estimates of demand for fertility regulation at the all-India level for the 1970-1992 period are shown in Table 1. This table illustrates a primary reason for high levels of unwanted childbearing. A substantial number of women who express a desire for no more children are not contracepting. Even though contraceptive use has increased during the period of the studies (Column B), so has the proportion of women who want no more children (Column A). The percent of women who say they want no more children (and who thus represent the demand for limiting births), increased from 50 percent in 1970 to 67 percent in 1992. The proportion of women who are using contraception (excluding traditional methods) also shows a substantial increase between 1970 and 1988, but a decline between 1988 and 1992. The percent of women who said that they want no more children but are not using contraception (for example, unmet demand for limiting) has decreased from 40 percent in 1970 to 31 percent in 1992, following a U-shaped trend (Column C). Although the validity of the estimates and trends of contraceptive use and unmet need (see Column C) are subject to question, primarily due to an unexpected decline in prevalence in the NHFS of 1992, it is clear that a significant proportion of women in each survey can be characterized as having unmet need for fertility limitation. 60 Annex 3 Table 1: Changes in desire for more children, contraceptive prevalence, and unmet need, India, 1970-1992 Year Source percent wanting Contraceptive percent women no more children prevalence rate for wanting no more all women using children and not modem methods using (A) (B) contraception (C) 1970 ORG 50 10 40 1980 ORG 50 28 28 1988 ORG 58 39 19 1992 NFHS 67 36 31 5. The NFHS collected information on women's fainily size preferences; from these it is possible to estimate the extent of demand for fertility regulation and unmet need for spacing and limiting. These estimates are shown in Table 2. The demand for limiting (Column B) refers to the percent of women who said that they want no more children. Estimates for the demand for limiting exclude those who are sterilized. The demand for spacing (Column C) refers to the percent of women who want to delay the birth of their next child for two or more years. Percent current users of reversible methods is shown in Column D. The total unmet demand for fertility regulation (Column E) is estimated by the sum of the demand for limiting and spacing, minus the use of reversible and traditional contraceptive methods (for example, Column E = B+C-D). Table 2: Demand and Unmet Need for Fertility Regulation by States In India, 1990-1992 STATE UNMET DEMAND UNMET NEED Demand Demand percent Unmet Unmet Unmet Unmet for for current demand need for need for need limiting spacing users of limiting spacing reversible methods A B C D E F G H AP 13.6 12.8 2.2 24.2 4.1 6.3 10.4 Assam 47.8 22.7 28.4 42.1 10.7 11.0 21.7 Bihar 24.0 24.0 4.5 43.5 10.6 14.4 25.1 Gujarat 17.2 5.5 7.6 13.1 Haryana 29.3 17.3 14.9 31.7 7.6 8.8 16.4 Jammu 35.6 17.5 19.7 33.4 8.6 8.9 17.5 Karnataka 20.6 16.7 6.6 30.7 6.4 11.8 18.2 Kerala 19.3 16.1 15.0 20.4 4.5 7.2 11.7 M.P. 19.6 25.3 5.0 39.9 7.4 13.1 20.5 Maha* 20.4 13.5 7.6 26.3 6.8 7.3 14.1 Orissa 18.1 25.9 4.7 39.3 12.7 9.7 22.4 Punjab 37.8 13.3 24.7 26.4 6.5 6.5 13.0 Rajasthan 24.2 20.3 4.1 40.4 9.0 10.8 19.8 T.N. 27.1 14.6 10.3 31.4 6.7 7.8 14.6 U.P. 31.5 25.6 6.7 50.4 13.4 16.7 30.1 W. Bengal 34.5 20.5 26.8 28.2 8.0 9.4 17.4 INDIA 25.9 19.6 9.8 35.7 NA NA NA *Maharashtra 61 Annex 3 6. The numerator of unmet need for spacing (Column G) includes: (i) pregnant women whose pregnancy was mistimed; (ii) amenorrheic women whose last birth was mistimed; (iii) women who are neither pregnant nor amenorrheic and say they want to delay the next birth for at least two years, but are not using contraception; and (iv) women who are unsure whether they want another child or who want another child but are unsure when to have the birth. The numerator of unmet need for limiting (Column F) includes: (1) pregnant women whose pregnancy was unwanted; (2) amenorrheic women whose birth was unwanted, (3) women who are neither pregnant nor amenorrheic and say they want no more children but are not using contraception. The total unmet need (Column H) is estimated by adding unmet need for limiting and spacing (for example, Column H = F+G). 7. It should be noted that the figures presented for "Demand for limiting" (Colum B) under- represents the actual demand since women who are sterilized are excluded. By excluding sterilized women, "met need" is correspondingly understated as Column D includes only users of reversible methods. 8. Nevertheless, these data clearly demonstrate that a substantial proportion of women in all states want to delay or limit their future childbearing. At the national level, 20 percent of women want to delay the next birth, and 26 percent of women want to limit their childbearing. In other words, 46 percent of currently married women want to delay or limit their future childbearing. This is in addition to the 31 percent who are sterilized and the 4 percent who are infecund. Thus, only 19 percent of women want to have another child within the next two years or are undecided about whether or when to have another child (this includes those who answered "Up to God"). Of the 46 percent who definitely want to delay or limit additional births, only 10 percent are using reversible or traditional methods-leaving a level of unmet demand for fertility regulation of 36 percent. 9. There are substantial variations among states in terms of the percent of women who definitely want to postpone or delay their future childbearing. The percent of women who want to space varies between 13 percent in Punjab to 26 percent in Uttar Pradesh. The percent of women who want to limit their childbearing varies between 19 percent in Kerala and 48 percent in Assam. The estimated unmet demand for fertility regulation varies from 28 percent in Kerala to 50 percent in U.P. At least 40 percent of women in the "Hindi-belt" express a clear desire to regulate their fertility but are not using any contraceptive method. 10. The estimated percentages of unmet need for contraception for spacing or limiting purposes, however, are lower than the corresponding percentages of whose who said that they want to postpone or limit their childbearing but are not using contraception (compare Columns E and H in Table 2). The differences are mainly due to the fact that the estimates of unmet need exclude amenorrheic women whose last birth was wanted and pregnant women whose pregnancy is wanted. Those who are currently pregnant cannot use contraception and, therefore, need to be excluded from the estimate of unmet need. It is debatable whether or not who are amenorrheic should be excluded, especially for designing services. While these women are not currently exposed to the risk of pregnancy, they would get pregnant unless they start using contraception prior to or immediately following the resumption of menstruation. 62 Annex 3 II. The estimates of unwanted fertility by states are shown in Table 3. These estimates are based on the fertility experience of women during the three years prior to the survey, and through a comparison of ideal versus actual family size. A birth is classified as unwanted if the number of living children at the time of conception was greater than or equal to the current ideal number of living children. Table 3: Unwanted and wanted fertility rates by states in India, 1992-93 STATE Total fertility Wanted fertility Unwanted Unwanted rate rate fertility rate fertility as percent of total fertility rate A B C D E AP 2.59 2.09 0.50 19 Assam 3.53 2.52 1.01 29 Bihar 4.00 3.18 0.82 20 Gujarat 2.99 2.33 0.66 22 Haryana 3.99 2.81 1.18 30 Jammu 3.13 2.21 0.92 29 Karnataka 2.85 2.18 0.67 23 Kerala 2.00 1.82 0.18 9 M.P. 3.90 3.21 0.69 18 Maharashtra 2.86 2.13 0.73 26 Orissa 2.92 2.32 0.60 20 Punjab 2.91 2.15 0.76 26 Rajasthan 3.63 2.78 0.85 23 T.N. 2.48 1.76 0.72 29 U.P. 4.82 3.80 1.02 21 W. Bengal 2.92 2.20 0.72 25 INDIA 3.39 NA NA NA - Source: NFHS, 1992-93 12. Since it is widely recognized that stated fertility preferences are subject to considerable rationalization, for example, respondents are reluctant to characterize previous births as unwanted, or to express ideal family size preferences which are smaller than their existing family size--actual levels of unwanted fertility may be substantially higher than those estimated here. 13. The level of unwanted fertility varies from about 0.2 births per woman in Kerala to 1.2 births in Haryana. The level of unwanted fertility even in three of the four Hindi-belt states- Bihar, Rajasthan, and U.P-is close to one birth per woman. Unwanted fertility as a percent of the total fertility rate (TFR), shown in Column E of Table 3 indicates that in all states, except Kerala, at least 20 percent of fertility is unwanted. Close to 30 percent of the TFR is accounted by unwanted childbearing in Assam, Haryana, Jammu, Punjab and Tamil Nadu. III. WANTED FERTILITY 14. Replacement fertility is reached when women on average have 2.1 births. The TFR in India is estimated to be about 3.4 births per women; this means that women are having 63 Annex 3 approximately 1.3 births more than what is required to achieve replacement fertility. It is estimated that in India, 20 to 30 percent of the TFR is accounted for by unwanted fertility. How close is wanted fertility to the replacement level? 15. The level of wanted fertility varies among states from about 1.8 births in Kerala to 3.8 births in U.P. (see Table 3). The level of wanted fertility is close to 2. 1, the level of replacement fertility, in ten states: Andhra Pradesh, Gujarat, Jammu & Kashmir, Karnataka, Kerala, Maharashtra, Orissa, Punjab, Tamil Nadu and West Bengal. In these states, replacement fertility can be reached if unwanted childbearing is eliminated. The level of wanted fertility is between 2.5 to 3.0 in Assam, Haryana, Rajasthan; it exceeds 3 births per woman in Bihar, Madhya Pradesh and Uttar Pradesh. In these six states, the achievement of replacement fertility would require simultaneous efforts to reduce both the unwanted and wanted fertility. IV. CONCLUSIONS 16. The data in this annex suggest that a substantial proportion of women do no want another child for at least two years but are not doing anything about it. At least 20-30 percent of the TFR is accounted for by unwanted births; for the reasons given above, the actual levels of unwanted fertility may be substantially higher. A detailed analysis is required to understand the reasons for unwanted childbearing and stated unmet need for contraception. It is clear that the FWP needs to do much more than it has done to help its clients avoid unwanted childbearing. It is also clear that a substantial portion of fertility is due to wanted births - especially in the northern states. Improvements in reproductive health must be coupled with broader efforts to reduce the demand for larger family size. 64 AnneX4 ADDRESSING GENDER AND POVERTY CONCERNS IN A REPRODUCTIVE PROGRAM 1. GENDER AND POVERTY (GAP) CONCERNS A. DEMAND ISSUES 1. In most communities in India, prevailing social attitudes and practices result in women having an overall lower social and economic status than men. In effect this means that women have less access than men to "goods and services" that affect health. These include food, health care, education, employment and income. Clearly, poor people also have lower access to these items than the better-off. Both the absolute deprivation faced by poor families, and the differential access within families between women and men undermine decisionmaking power, including the ability to make decisions about preventive health and family welfare measures, and about seeking curative care. 2. Some of the important behaviors that result from the physical, social and economic constraints in obtaining health and family welfare services are: * women bear their health problems in a "culture of silence," and do not seek timely health care; * they often cannot travel beyond the area of their normal activities to obtain services; * they usually cannot approach male health providers; and, * in general, families, including the women themselves, spend less time, effort and money seeking health care for women and girls than for their male members. 3. In addition to gender, poverty also limits access to the health service delivery system. The areas of the country with the largest number of poor also have the worst health conditions, least- developed health services, and poorest support systems, such as roads and communications. The poor also demonstrate lower utilization of services: constraints on their time heighten the opportunity costs of seeking services, and they often cannot meet the direct costs. The correlation of poverty with illiteracy may mean they are unaware of the benefits of preventive care or family welfare services. There is evidence from surveys and studies that the poor perceive they are badly treated by service providers on account of their poverty and illiteracy. They are often neglected by outreach services because they may live in miserable conditions, in hamlets which are far away from village centers. And, because the poor are not organized, they cannot demand services or service conditions that would better meet their needs. In short, social and physical distances between the poor and providers of services, constrain the reach and effectiveness of health services for this group. 65 Annex 4 4. The dual handicap of being female and of being poor work synergistically to render many poor women powerless in other health- and fertility-related areas as well, such as their age at marriage, patterns of childbearing, or the care of infants and children. Furthermore, gender relations in Indian society also determine the sexual behavior of men and women. Patterns of socialization and the resultant sexual behaviors are starkly different between boys and girls, young men and women, and adult men and women. Decisions about reproduction and contraception are made in this context. Indian women in the early reproductive years play a limited role in decisions about their own childbearing and family-building. Male family members and mothers-in-law are most often responsible for these decisions. Sexual behaviors also importantly affect the transmission of sexually transmitted infections. The combination of a lack of control over sexual activity and low access to health care exposes women unfairly to reproductive tract morbidities and their serious consequences for reproductive success, well-being and survival. B. SUPPLY ISSUES 5. Over the years, the Family Welfare Program's concern with meeting demographic goals and targets has resulted in the service delivery system viewing women primarily as reproducers rather than as important producers in the Indian economy. This has led to two major lacunae in health and family welfare (HFW) efforts. First, as the non-reproductive roles of women have been obscured, adequate emphasis has not been placed on ensuring their access to general health services. This would also compensate for the familial and societal constraints women face in accessing health services, and for the limited attention to their morbidity and mortality from non- reproductive causes. Furthermore, viewing women as productive members of society, rather than as reproducers only, would result in women who are not in the reproducing category are being included in HFW efforts. These women include adolescents, unmarried, infertile and post- menopausal women. This is important as there is ample statistical documentation of higher rates of morbidity, malnutrition and mortality among females in India throughout the life cycle. While this greater burden of disease may stem from gender biases in household provision of nutrition and health "goods," it could be addressed by the health system providing services that are designed and implemented in ways which give all women ready access to them. 6. Second, although maternity-related services are provided, there is an imbalance between the provision of maternal and child health (MCH) services and family planning. Concemed with meeting immunization and contraceptive targets, personnel who are responsible for providing maternal care as well pay the least attention to it. While efforts over the past ten years have improved child health services such as immunization and oral rehydration, the "m" in MCH is still weak. The Child Survival and Safe Motherhood (CSSM) program has sought to rectify this, but the safe motherhood components still lag behind the child survival strategies. Thus, there is a need to strengthen even maternal care services. 7. Indeed, even women who do have physical and social access to health services may not use them because of perceived poor quality. "Poor quality" has been expressed by respondents in terms of: inadequate supplies of, or "ineffective," medicines; unavailability of doctors, particularly female doctors; "rude behavior" of staff; lack of attention to their health needs while pressure is exerted on them to accept family planning, etc. In addition to distant locations and inconvenient timings of health centers, "poor quality" is a major reason why rural people say they do not use 66 Annex 4 government health services. Hence, supply-side improvements-better quality services-are necessary in order to improve utilization and effectiveness. Implementing the "provider perspective" of the reproductive health approach, which emphasizes individual needs and well- being, could bring about some of the necessary change. 8. Furthermore, the disiunction between family planning efforts and maternal care or other health services has diminished the potential of family planning to be delivered in a gender-sensitive and socially-sensitive way, in which the needs of women and the aspirations of families- especially of poor families-are dealt with considerately. The constrained role of women in family planning decisions also has certain implications. In some cases, while family members may not wishi to limit the number of children or to space births, women may yet see the benefits of these strategies. Hlence, they may wish to seek contraceptive services discretely, to use methods without the kInowledge of other houselhold members or involvement of the male partner, or to obtain an abortion. This further amplifies the need for health services to be readily accessible to women, to be private, and to be safe. 9. Both women's health advocates and family planning policymakers point to the unmet demand that exists among Indian women for family planning. However, the two groups interpret this demand somewhat differently. Population planners view the unmet demand largely as a programmatic gap which needs to be filled to meet population control objectives. This approach underemphasizes the issue of choice. The prevalent belief has been that women are not capable of makinig contraceptive choices, and that the doctor or health worker knows what's best for them. This may be one reason underlying the paucity of choice and information provided by the Family Welfare Program (FWP) to women and the poor. In particular, while sterilization is a popular contraceptive method, there is a need for more information and a more widely available choice of non-surgical contraceptive methods. The concept of reproductive choice, now being advocated by population planners as well, is central to a more client-oriented program. Given the unmet demand among Indian women for family planning, services which are responsive to clients' needs would go a long way to achieving individual reproductive and health goals as well as national ones. 10. On the other hand, advocates of women's health aver that women have a right to contraception in keeping with their right to control their bodies and their lives. Thus, they see women's need or demand for contraception in the context of prevailing sexual relations in society in which men have the dominant rights of sexual access to women. The FWP has not paid adequate heed to this context. Over time, the program has developed a focus on women to achieve its goals, but has paid inadequate attention to the appropriateness of this targeting given their weak social status and often desperate economic and physical conditions. Following the "excesses" of the Emergency, which largely affected men, and the advent of minilaparotomy and laparoscopic sterilization, the program has emphasized female sterilization over other methods. While the next most favored method among family planning acceptors is the male condom, the program promotes female methods exclusively beyond this, namely the IUD and oral pills. Because the vast majority of family planning services are targeted at women, they have been the main acceptors of family planning, and often this has made them vulnerable to the inducement of incentives and to coercion. Over the past 15 years, the program has neglected men, both in terms of motivating them to adopt male methods of contraception and, more generally, in the provision of reproductive health information and education to them. The reproductive health approach aims to rectify this 67 Annex 4 imbalance between men and women by addressing, among other issues, gender roles and relationships, and the development of sexuality and sexual relations. C. HEALTH SYSTEM ISSUES 11. As the health system is part of society, many social biases extend into it which affect the provision of services and women's use of them. Gender issues arise in the relationship between different groups of service providers, and between providers and clients. The paucity of female doctors, which has the effect of limiting women's access to health care, is in part due to gender biases operating within the health system. The medical profession and health administrations have been dominated by men, another factor which has perhaps contributed to the neglect of women's health and to targeting of women for family planning. Coupled with the tendency of medical systems to want to control technology, this has led to the system's preference for provider- controlled methods of family planning (sterilization, IUDs, and more recent interest in implants and injectables) rather than user-controlled ones. These aspects reinforce the need for the health system to strengthen its client-orientation. 12. Another aspect of gender bias within the health system concerns the situation of female workers (mostly ANMs/MPWFs and LHVs/HAs/HSs), who are mainly responsible for providing services to women. These workers have multifarious job descriptions, and shoulder the major burden of outreach care or its supervision. Yet they are poorly supported in terms of mobility, security and logistics. Their training is inadequate for the more difficult tasks of motivation and systematic provision of the range of services which are their ambit. They are sometimes too young to act as role models or even to deliver MCH and FP services with conviction. At the bottom of a hierarchy dominated by male doctors and administrators, they often lack an appropriate professional role model, and may be socially or sexually vulnerable themselves. With greater professional and social support, ANMs could indeed reach their enormous potential to deliver sensitive and skilled services to the majority of needy women in the country. One way to increase support to these women workers would be to have more women managers in health administrations. 11. POLICY EMPHASES NEEDED 13. These issues underscore the point that family welfare policy which targets women without adequate consideration of the broader social relations within which they live will be unable to achieve family welfare goals. More socially-aware policy would focus on creating conditions which improve women's access to health services. In addition to expanding reproductive choice, a larger gamut of measures is necessary to enhance women's well-being and their rights over their bodies and their lives. This range of strategies encompasses efforts to address the social conditions in which reproductive choices are made and to increase gender awareness in health and family planning programs. It involves addressing gender relations within society. 14. Furthermore, policies that only recognize women as reproducers will not promote a positive social perception of women. Even family welfare policy must view women as the important producers they are in the Indian economy. The same women whose reproductive choice is the focus of family welfare policy are also key actors in development and, hence, clients of other 68 Annex 4 development programs. Women's multiple roles make demands on their time, energy and health, which often result in their inability to utilize services. Thus, their health needs must be dealt with in an efficient and integrated manner. It is worth noting that the family welfare strategy laid out in the action plan focuses efforts on the 90 lowest-performing districts in the country. These are also districts withi low female literacy, low sex ratios, high infant mortality rates, and most possibly high maternal mortality and general morbidity. Thus, an approach which integrates development provisions for women is desirable. Greater intersectoral coordination would help meet health and development goals more effectively in these districts as well as elsewhere. Several documents of the GOI, including the recent Swaminathan committee report and India's country paper for the Cairo Conference, cover the issue of intersectoral action, which is outside the scope of this report. 111. ADDRESSING GAP CONCERNS IN THE REPRODUCTIVE HEALTH PROGRAM 15. Three overarching issues emerge from the discussion above of gender and poverty concerns which will need to be dealt with by a reproductive health program. First, women's poor access to HIFW services (demonstrated both by "unmet demand" and low health facility utilization) must be addressed by actions both on the demand and supply sides. Second, the role of men in reproduction and in decisions concerning health and family welfare must be built upon and enhanced. This includes the need to socialize adolescents and youth to achieve more equitable gender relations and roles in the longer term. Third, gender dynamics within the health system need to be developed to foster both a greater responsiveness to the gender needs of clients and more equitable participation of women service providers and managers at all levels. Indeed, the health system could be a role model for society in matters of gender equality. A. IMPROVING WOMEN'S ACCESS Expanding Outreach 16. The majority of services in the essential reproductive and child health package are to be delivered at the community level. Two sets of workers are critical to achieving this: village-level workers such as dais Community Health Guides (where these exist); and Anganwadi workers in areas covered by the ICDS scheme; and female and MPWs at subcenters. It is essential for the HFW system to take stock at the local level of the availability of the different cadres of workers, and rationalize their work in ways that ensure coverage of all needy women with the essential services. Where village level workers exist, female MPWs (or ANMs) could provide logistic support and supervision for the services which could be rendered by basic health workers, while in other areas, ANMs would need to carry out more village-level tasks (with the possible assistance of women's groups, as discussed below). In either case, there is need for the ANM's own job description and routine to be streamlined, as discussed in Section IV. B, paras 70-71 and Section IV. D, para 88, in the report. Along with this, her training and supervision need to be improved so that she can readily identify the most needy women, and ensure that they receive the essential services in the appropriate sequence. Table Al provides details on the "Priority Actions" required. 69 Annex 4 TABLE Al Priority Actions needed to address Gender Issues in a Reproductive Health Program ISSUE TO ADDRESS AREA OF ACTION DESIRED OtUTCOMES PRIORITI' ACTIONS F C A Women's low access * SFJC Services * Higher coverage of poor * Develop criteria and method for client prioriti/ation It 0 to HFW services, as management ol'ANNI women (measure improvements * Streamline work routinc (iask prioritization) It 0 demonstrated by unmet outreach.training and continuously) * 'rain ANMs to manage their swork (in pre-sers ice M L need and low health super' ision training and supervision) facility utilization * Develop supersision system bascd on ahovc M 0 Train ANMs for client orientation, and in M L communications (pre-service and in-service training) PHC, CHC services *Greater facilits use bs svomen * Revise clinic timings to suit local female aclivit) H 0 (beyond basic staffing, (continuous measurement) patterns equipment and supplies) Ensure availability of female medical staff L H H olistic approach to seomen's health and reproductive H L health needs Community organization *Women's groups formed and Develop and disseminate basic materials for H L Women's Group interacting with ItFW ANMs and IltHVs on group formation, with RH Formation personnel and rsider village Topics, calendar etc community * Train and motisate ANMs and LHVs to form groups H M * Increased knoswledge among * Fornm groups pros iding appropriate material and M M suomen membcrs and financial support community, and action for health (eg use of sers ices) * Increased coserage. work achievement and etficiency of ANMs B Low participation of * Male worker roles, * Greater male acceptance of' * Train niale MPWs, HSs, BEEs, doctors M M men in FP and poor management, training. vasectomy and effective use ol - to perccie and communicate men's responsibihties' knowledge of RI-, and supervision CCs toles WH, etc * Greater male knosvledge of - to provide inlorniation to men re FP, RH, WH etc RH, WH - to motivate men for responsible sexual behavior & * Shared decision- making FP acceptance (own or svies') between husbands and wvies - to provide services with choice, access, hygiene * Lower unmet deniand among * Increase provision of vasectoms and CCs M M wsomen * Prevention of transmission of HIV, STDs IEC * Messages emphasize male roles and H L responsibilities and acceptance of FP Use range of media H M Socialization of I IEC * Early intecrention for * Messages aimed at educating youth about M M adolescents (male and above outcomes especialls development of se\uality, sexual relations, female) greater knowledge among responsible sexual behas ior. gender relations, adolescents about RH, etc prevention of'sexual abuse, reproductive health, unsafe abortions, FP use, responsible parenthood * Range of media I H * School and college programs M H C Need for gender Training * Improved knowledge and * Develop gender training modules for different cadres H L sensitization of HFW positive perceptions among of HFW personnel and managers at all levels aimed at system HFW workers and managers attitudinal change by and better ability to carry out - informing them about situation of poor/women actions listed above clients - creating a positive image of women - perceiving roles of males and females (gender roles) and differential status - appreciating women workers' snituations and ways of rectifying imbalances * Run courses for all cadres M M * ANMs management and * Improved status and efficiency Rationalize svork- load H 0 support of ANMs * Improve mobility (transport) and security (residence) M H * Enhance status M 0 * Improve training (pre-service) and supervision M M * Remove targets and provide incentives M 0 * Doctor recruitment and * Greater access of women * Actively recruit more female doctors L L career structure clients to female doctors * Provide perquisites for rural postings (housing, L M transport) preferentially to women * More women in management * Ensure promotion through affirmative action to L L positions to accelerate gender achieve a critical mass of female managers at sensitization in the long term intermediate and senior levels I Icasibihity C-Cost, I11High, M-Medium, I,=I,oss 0=7ero 70 Annex 4 17. Similarly, efforts need to be made to increase women's use of facilities at higher levels of the HlFW system, including PHCs, CHCs, subdistrict and district hospitals. In addition to the improvement of service quality by ensuring adequate staffing, supplies and equipment, and gender- sensitizing providers (as discussed below), a few other actions would facilitate women's use of these health centers (see Table Al). These include: ensuring compatibility of health center timings with local female activity patterns; ensuring the availability offemale medical staff; and dealing with women's health problems in a holistic way when they venture to seek care at these facilities. 18. The stress of the HFW system should be on ensuring the availability and accessibility of reproductive health services to the poor in rural and urban areas, the socially vulnerable, and those in remote habitations. This is essential to improve equity, including gender equity. Outreach services are required to provide care to women as close to their homes as possible, and to provide families with information about health care and available services. Information and education efforts addressing health and reproductive matters must be directed at both men and women, in order to facilitate family decisions about seeking preventive or curative care. Workers must refer their clients to secondary or tertiary services whenever necessary, and provide them help to reach these higher-level facilities. The provision of good quality services at all levels will motivate other women in turn to use them. Harnessing Demand: The Potential of Women's Groups 19. An important approach to achieving wider coverage and increasing women's access to information and services is the formation of women's groups. The group approach has been used successfully by a variety of development programs in India to improve the reach of programs to women and enhance program sensitivity, in turn, to women's needs and problems. The FWP has also initiated the formation of mahila swasthya sanghs for these purposes. The group approach has been shown to empower women to express their needs, to enable providers to interact with large numbers of women simultaneously, and to facilitate information sharing among members and its spread to the wider community. In addition to acquiring and sharing information about health needs and services, women in a group can help to dispel their members' fears, assist individuals in deciding what is best for them, and provide women with the social support and assistance often required to go to health centers, particularly in times of emergency. Women's groups can also increase awareness among women of their reproductive health rights, and help women to obtain them. They can play a role in the elimination of violence against women, including domestic violence, rape and prostitution. The groups and networks can also be the nuclei of community- based care, utilizing village dais, village-level health workers, link workers, mobile clinics, and so on. These would provide additional support to the educational and referral activities of the health system. 20. It is important to recognize that by forming women's groups, health workers such as ANMs can achieve greater efficiency in their work. However, ANMs need to be trained in group formation, and be supported through the provision of educational materials and aids and As the pattems of formation and numbers of groups vary in different program, the spread of women's groups in the country is currently unknown. This would need to be assessed on an area basis. Furthermore, the composition of these groups would need to be reviewed from the point of view of their inclusion of women who most need reproductive health services. 71 Annex 4 supervision, to keep their groups active. In the formation of groups, an ANM must receive the assistance of her supervisor (the LHV or HS) and possibly also of other extension workers in the HFW system (for example, BEEs, MPWMs), as well as staff of other programs which foster the group approach (for example, the Rural Development or Education Departments). Altematively, in areas where viable groups have been formed, ANMs' efforts may follow those of the other rural development workers. Establishing and continuing groups will require infusions of financial and material resources. In short, the formation of women's groups should not be seen as a luxurious "frill" to service delivery. Instead, it has the potential to be an important strategy to tackle critical problems which currently afflict HFW services-their low utilization by and coverage of women. It is also a useful mechanism to improve program efficiency. While it is low-cost in terms of inputs, the approach nevertheless requires careful planning, training and managerial support in order to be effective. 21. There is by now adequate experience in the country of state-managed programs (such as the four-state mahila samakhya program and the Women's Development Program in Rajasthan) for appropriate field approaches and training programs to be devised. Women's health groups can be expanded through cooperative structures and other networks Their development can be fostered, or their functioning facilitated by PVOs "hybrid" approaches involving Voluntary Link Workers could also be tried. Participatory approaches can be developed to monitor and evaluate services to help increase program responsiveness to users' needs, incorporating gender-related indicators to measure the equity and effectiveness of the reproductive health program. Indeed, women's groups are promising monitors of the proposed reproductive and child health program because they are to be the main beneficiaries of its services. Furthermore, the collective mobilization of women around their needs and interests is a way to promote gender equity. By fostering group formation and supporting innovative efforts to address women's health, development and rights more broadly, health policymakers can play an important enabling role in women's empowerment. B. ENHANCING THE ROLE OF MEN 22. As discussed above, the Family Welfare Program has down-played the role of men in the recent past although they are also key actors in family welfare activities and decisions. This gender imbalance needs to addressed by the HFW system in a number of ways. First, men must be given information about family health needs, their wives' health needs, the reproductive health of both men and women, child health care, etc . Second, they must be motivated to take responsibility for obtaining preventive and curative care, including family planning. Third, in the arena of family planning, there is a need to propagate male methods more actively and systematically, making services widely available and accessible to men. Additional male methods need to be developed and made available. Fourth, and perhaps most important, young males should be the focus of efforts to inculcate responsible sexual behavior, and improve gender relations. 23. A basic tenet of the reproductive health approach is that reproduction should be based on joint decision-making between husband and wife. Even though the costs of pregnancy are borne by women, responsibility for planning or averting births and for parenthood should be shared by men and women. Hence, couples should be in a position to select the most appropriate method for them at different stages of their reproductive and family lives. This entails giving information about male methods as well as female ones, and dispelling fears which have accumulated about male 72 Annex 4 methods such as vasectomy. This effort could be undertaken by the large number of male workers in the HFW system-MPWMs, BEEs, male health assistants/supervisors and doctors. Furthermore, men must be reached with appropriate services. Male sterilization is actually cheaper, simpler and safer than female sterilization. While the use-effectiveness of condoms is lower than that of most other methods, they provide the additional advantage of preventing sexual transmission of HIV and other infections The approaches to reaching men with services are analogous to those for reaching women: men also require choice, accessible services (in terms of location, timing and cost), and information about them. Vasectomies must also be done in hygienic conditions, and made more widely available at health centers, rather than at camps. Additional research on male methods is required to expand the range of services available for men. 24. Information, education and communication (IEC) efforts can play an important role in increasing the participation and responsibility of men in the family planning arena, thus helping to achieve greater gender equity. A major problem underlying unmet demand has been men's resistance to family planning, both for themselves and their wives (rather than women's lack of motivation). IEC efforts need to stress that men share responsibility for family planning, for reproductive health, and for women's health. They must promote the principle of responsible fatherhood. As male sexual patterns are often established at the premarital stage, including their use of contraception, educational programs should be launched for young people, particularly males, to encourage responsible sexual behavior, and the use of measures to prevent the spread of HIV and STIs. Adolescents should receive information and counseling on human sexuality, gender relations, prevention of sexual abuse, reproductive health, unsafe abortion, and responsible parenthood, including family planning information and services for those who are sexually active. C. INCREASING GENDER SENSITIVITY 25. In order to carry out the wide mandate of the reproductive health approach, workers in the health system who are most in touch with families, women and men, must be trained in communication and counseling. They must also be gender-sensitized in order to deal effectively with the needs of women clients and with sensitive matters such as sexual behavior, reproductive infections and family planning. This entails educating them about gender and poverty issues: the needs of poor women, the problems they face, the differentials that exist in health and survival between men and women, and between other social and economic groups. The workers themselves must have a positive image of women, and be trained in how to deal with their women clients sensitively. Health staff, including doctors and managers at all levels (both male and female), need to have a fuller appreciation of gender issues in society. This includes a socio-cultural appreciation of women's health (not just a medical one), and an understanding of the social context of motherhood. 26. It is also necessary for health managers to have a fuller appreciation of the needs of women workers in the health system itself . In particular, ANMs in the field, and LHVs at health centers need to be treated with dignity and given a status which will in turn encourage them to deal with their clients sensitively. Improving the service conditions of these women workers who are at the bottom of the health system hierarchy-including rationalizing their workloads, increasing mobility and security, enhancing their skills, and removing the burden of targets from them- would enhance the overall effectiveness of the HEW system Furthermore, staff assigned to work 73 AnnexA together at health centers or in the field (for example, male and female MPWs) must be trained and motivated to work in ways which support and mutually reinforce each other and thereby maximize coverage of their clients. 27. For the FWP to understand women's views about choice, accessibility or program responsiveness, or to integrate reproductive health into women's lives, as well as to sustain improvements in the lot of women workers, there should be many more women in vital decisionmaking roles at every level. Currently, besides being users, women are represented in the HFW system primarily at the field level (LHVs and ANMs). There are also female doctors, and some women at higher management levels. The intermediate levels, especially the district level where much program planning is done, have the fewest women. To increase institutional responsiveness to women's needs, many more women must be recruited as doctors, promoted to managers, and involved in decisionmaking at the program level and in policymaking. States could give female doctors perquisites on a preferential basis in order to work in rural areas, or recruit them from the private sector on part-time contracts as has been suggested. An affirmative action approach needs to be followed to ensure adequate and not just token numbers of women, as critical mass is important in bringing about change for gender equity. 74 Annex 5 Table A2: ESSENTIAL REPRODUCTIVE AND CHILD HEALTH SERVICES AT DIFFERENT LEVELS OF THE HEALTH SERVICE SYSTEM Health Community Subcenter Primary health First referral unit/ Intervention level level center level district hospital level a Prevention I Sexuality and gender No. 1 and Nos. 1-7 and Nos. 1-10 and and information, education and manage- counseling 2 Providingi oral contraceptives 8 Performing tubal I I Providing services menage- counseling (OCs) and condoms ligation for medical unwanted 2 Community mobilization ( a terminationof pregnancy and education for high risk 3 Providing IUO after screening 9 Performing pregnancy in the pregnancy adolescents, youth, men and for contra-indications vasectomy second tnmester women where indicated 4 Motivating referral for 10 Providing first 3 Community-based sterilization trimester medical contraceptive distribution termination of 5 Counseling and referral for pregnancy 4 Social marketing of medical termination of contraceptives through retail pregnancy outlets 6 Counseling/management/ referral for side-effects, method- related problems, change of method where indicatedl 7 Add other methods to expand choice, such as injectables, progestin-only OCs (for lactating women), barrier methodsl Maternity I Awareness raising for risk Nos. 1-4 and Nos. 1-8 and Nos. 1-10 and Care factors 5 Antenatal services at clinics and 9 Treatment of TB 11 Diagnosis and Prenatal 2 Counseling/education for through outreach: at least 3 treatment of Services breastfeeding, nutrition, visits 10 Routine testing RTIs/STIs family planning, rest, for syphilis exercise, etc. 6 Detection of complications e.g., hypertension, pre-eclempsia, 3 Detection and referral of ecalmpsia, severe anemia (< 8 high risk gm), malaria, T1B, diabetes pregnancies placenta previa, cephalopefvic 4 Delivery planning disproportion 7 Referral for hospital dcliverv in above cases 8 Treatment of malaria Delivery I Recognizing danger signals Nos. 1-5 and Nos. 1-8 and Nos. 1-10 and Services (rupture of membranes of 6 P . i more than 12 hours 6 Partograph 9 Dehvery services 11 Dehvery of referred duration, prolapse of the 7 S h where PHCs are cases cord, hemorrhage) 7 Supervusig home dehvery functional 12 Treatment of high 2 Conducting clean deliveries 8 Treatment for infection 10 Repair of risk cases with delivery kits episiotomy and perineal tears 13 Services for 3 Detection of complications obstetrical referral for hospital delivery emergencies, blood 4 ,,. ~~~~~~~~~~~~~~~~~~~~~~~tanesthesia, Routine prophylaxis for anhehsias gonococcal eye infection caesanan section 5 Providing transport for referral 75 Annex Health Community Subcenter Primary health First referral unit/ Intervention level level center level district hospital level Postpartum I Breastfeeding support Nos. 1-5 and Nos. 1-9 and Nos. 1-10 and Services 2 Family planning 6 Outreach care within 24 hrs 10 Management of 11 Management of counseling of delivery by ANM* referred cases referred cases 3 Nutrition counseling 7 Treatment of puerperal sepsis 4 Resuscitation for 8 Manual removal of retained asphyxia of the newbom placenta 5 Management of neonatal 9 Referral for complications hypothermnia hypo a Four postpartum visits by ANM: < 24 hrs, 7- 10 days,l 3-4 weeks and 5-6 weeks * Child I Health education for 1-6 and 1-8 and 1-9 and survival breastfeeding, nutrition, immunization, etc. 7 Treatment of infection 9 Management of 10 Laboratory referred cases diagnosis and 2 Detection and referral of 8 First aid for injuries, etc. treatment by high risk cases such as specialists low birth weight, premature babies, babies with asphyxia, infections, severe defydration, acute respiratory infections (ARI). etc. 3 Immunization 4 Vitamin A supplementation 5 Treatment of diarrhea cases and ARI cases 6 Treatment of asphyxia and management of low birth weight
World Bank Group · Pre-2003 Economic or Sector Report
India - India's family welfare program: toward a reproductive and child health approach
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World Bank Group
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Pre-2003 Economic or Sector Report
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India
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World Bank