Benefits of integrating family planning with health services : the Narangwal experiment

This s e r i e s of unreferred dis~:ussion pap 1 s is intended to provide a? i n i t i a l circulation of work prepared under the auspices of the Poptilation and Human Resources Division. Commen a r e therefore very welccme. Ifie papers should not be cited without clearance by the authors. The views expressed are not necessarily those of the Vorld Bank Group. Population and Human Resources Division t Discuseion Paper So. 81-62 BENEFITS OF RJTEGMTIYG FA.FULY PLANNING WITH HEALTH SERVICES: TLE NARXNGWAL E!!BRDENT December 1981 Prepared by: , I Carl Taylor, i7.S .3. Sarna, Robert park^ i and a 'Jillian Beir..ie (Johns Hopkins Gnivbrsity) R s h i d Faruqee (Tie 'A'orld Bank) Prepared f o r: Xesearch Project 671-38, Narazgdal P ~ ~ u l s t i aend Xutriticn  Contents PagecNo. The Narangwal Teams v i i Preface x i PART I: THE W G W A L EXPERIMENT . Chapter 1 Sackground, Design, and Pnlicy I s s u e s C a r l E. Taylor Chapter 2 ,Hain Research Findings on Policy I s s u e s C ~ r E. l Taylor, W i l l i a mA.Seinke Rashid Faruqee, Robert L. Parker and R.S.S. Sarna PART 11: THE DETAILED FINDINGS Chapter 3 The Use of Family Planning R.S. S. Sarma and Rashid Faruqee Chapter 4 The Use of Health Services Robert L. Parker and William A. Reinke Chapter 5 RcLations between t h e Use of Health S e r v i c e s and Family Planning William A'. Reinke and Robert L. Parker Chapter 6 Determinants of the Use of Family Planning t Robert L. Parker, William A. Reinke R.S.S. Sarna and Narindar U. Kelly Chapter 7 Z Determinants of F e r t i l i t y and Its Decline 's -- i Rashid Faruqee and R.S.S. Sarna Chapter 8 ) E f f i c i e n c y and Equity o f Services - Robert L. Parker and R.S.S. Sarma A p p e n d i ~A Data C o l l e c t i o n Methodology Appendix B 3 e s c r i p t i o n of Services Prcvided i n the Narangwal Population Study  Table 1.1 Selected Demographic, Socioeconomic and Other C h a r a c t e r i s t i c s of t h e Experimental Groups of Villages, 1971 27 Table 1.2 The L i t e r a t e Populatiozi i n Narangwal Villages: Indian Government Census 1961 and 1971 28 Table 1.3 Cross- Sectional Surveys, Longitudinal Data Collection, and Service Input Information Table 1.4 Summary o f Service I n p u t s Table 3.1 Percentage D i s t r i b u t i o n of Current Users of Family Planning by Nethod Currently Being Used on March 31 of Each Calendar Year by Experimental G r ~ u p Table 3.2 Pregnancy Rate and Relative Effectiveness of Contraceptives Table 3.3 Knowledge and P r a c t i c e o f Family Planclng before the P r o j e c t Table 3.4 T r a n s i t i o n from P r i o r Use t o Project- U s e by Type of Contra- c e p t i v e Methods i n the FP-Service V i l l a g e s Table 3.5 Sociodemographic 3 i f ferences i n T r a n s i t i o n from Preproject t o P r o j e c t P r a c t i c e of Contraception Table 3.6 D i s t r i b u t i o n c f Women by Their Preproject Response Regarding A t t i t u d e s and B e l i e f s Towards Family Planning and About Child Mortality and Their Contraceptive Behavior d u r i ~ : ~ , the P r o j e c t Table 4.1 Relationship between Volume of Children's Services and Change i n A t t i t u d e s and B e l i e f s I t ~ a b l e ~ 4 . 2 E f f e c t s of Children's Services on Mortality Rates, by Age, Caste, and Experimental Group, 1970-73 Table. 4.3 E f f e c t s of Children's S e e i c e s on Morbidity Levels, 1970-73 '2 Table 5.1 Relationship between ~ r o j k Use of Health Services and t Acceptance of Family Plazning * Table 5.2 a e l a t i o n s h i p between Famiry P l a n n i ~ gP r a c t i c e and Average Number of i i ~ a l t hService Contacts during E a r l i e r and L a t e r Portions of t h e Project Table 5.3 Relationship o f Family Planning P r a c t i c e before t h e P r o j e c t to Use of Health Services during t h e P r o j e c t 152 Table 5.4 Combined E f f e c t of P r i o r and Project Family Planning P r a c t i c e on Use of Health Services i n 1971 155  Page No. Table 5.5 Relationship of Project Family Planning Practice t o P r i o r Family Planning P r a c t i c e and Use of Health Services, 1971 157 Table 5.6 Estimated Net Effect of Health Services on Project Use of Family Planning 162 Table 6.1 Results of the Multiple Regression Analysis Examining Service U t i l i z a t i o 3 i n 1969-1971 and its E f f e c t on Use o r Nonuse o f Family Planning at Anytime during the Project, 1969-73 Table 6.2 Adjustment Factors f o r S i g n i f i c a n t Variables i n t h e Regression Analysia i n Table 6.1 Table 6.3 Summary of E f f e c t s on Contraceptive Use Table 6.4 Results of the K u l t i p l e Regression Analysis Examining the Volume of Service Contacts i n 1969-73 and its E f f e c t on Use or Nonuse of Family Planning a t Any Time during the P r o j e c t , 1969-73 Table 6.5 Mean Number of Services and Associated Regression C o e f f i c i e n t s from the Regression Analysis i n Table 6.4 Table 6.6 Results of the Mu1t i p l e Regression Analysis Examining the Volume of Service Contacts i n 1969-73 and its Effect on the Duration of Family Planning Use Among A l l Project Users Table 6.7 Regression Analyses f o r Experimental Groups of Villages Table 7.1 Age- Specific 5-Year Period Marital F e r t i l i t y Rates by Major Sikh Caste Groups, Narangwal Study Villages, 1949-1968 Table 7.2 Women's Age at Marriage and Age a t Cohabitation by Harriage Cohort, Narangwal Study Villages Table 7.3 Hean Kumber of Live Births Per Married Woman, F e t a l Death Rate, and Child-boss Rate, by Age Table 7.4 islean Number of Live- Births Per Married Woman by Age -- and Religion- Caste Table 7.5 Mean tiumber of Live- Births Per Married Women by Age'i - and Education of Husband -- Table 7.6 Sonparison of Average Number of Surviving Children +th Average Number of Children Desired by Continuously ,Married Women a t Original and Reinterview by Sex of Child and Age Cohort of Wife, Narangwal, India Table 7.7 Regression Coefficients and Their Levels of Significance Table 7.6 Percentage of Women who had a Birth i n a Calendar Year, bjr P r a c t i c e of Contraception the Preceding Year  Page No. Table 7.9 Percentage of Waen who had a Birth, by Practice of Family Planning i n Preceding Year and Religioa-Caate 225 Table 7.10 Percentage of Women who had a Birth, by Practice of Family Planning i n Preceding Year and Education of Husband Table 7.11 Percentage of Womln vho had a Live Birth, by Practice of Family Planning i n Preceding Year and Occupation of Husband Table 7.12 Relation of PtobabiLity of Birth i n a Calendar Year to Selected Variables Table 7.13 Annual HarLtal F e r t i l i t y Rates, by Experimental Group and Village, 1970-73 Table 7.14 Crude Birth h i e s , by Experimental Group, 1970-73 Table 7.15 Percentage of Womerl who had a Birth, by Practice of Family Planning i n Precetiing Year and Experimental Group Table 7.16 Regression Results with the Dependent Variable: Percentage Cecline i n Average h n u a l Probability of Birth Table 7.17 Hean Number of Service Contacts by Type and Percentage Decline in Fertt1.it y Table 8.1 Distribution of Costs by Specific Categories of Expenditures i n Each Experimental Group Based on Average Annual Costs Table 8.2 Averags h n u a i Cost per Capita f o r Different Services i n Each Experhental Gror~p Table 8.3 Average Cost per Service Contact f o r Different Services i n Each Experimental Group Table 8.4 Estimated Annual Per Capita Expenditure on Xealth by Source of Care f o r Each Experimental Group =;A ControA Villages ' (rupees) Table 8.5 P e r c e ~ t a g eof Families with Various Socioeconomic Character- i s t i c s Using Curirtive Services f o r Women o r Children during the Project, 1969-73 Table 8.6 Percontagc of Families with Various Socioeconomic Character- i s t l c s Using Other Services f@rWomen o r Children during the Project, 1969-73 . Comparison of Preproject Use (Modern Temporary and Permanent Hethods) and Project Use Rates, by Sociodemographic Group Table 8.8 Sociodemographic Differences i n Recruitment to Project of Previous Nonusers of Fawily Planning  Page No. Table B.l Effective Starcing Dates of the Major Service Components i n Study Villages and Experimental Groups 292 Table 8.2 Coordination of Routine Children's and Women's Services a f t e r the Neonatal Period 296 FIGURES Figure 1.1 Map Showing Experimental Groups of Villages 19 Figure 1.2 Experimental Design f o r the Narangwal Population and Nutrition Projects 22 Figure 1.3 Outputs (Behavioral Factors) 35 Figure 2.1 Sequence of Organizing Integrated Prlmary Care fo Health, : Population and Nutrition 64 Figure 2.2 Fourteen Health-Service Entry Points f o r Family Planning & t i - ~ a t i o n a lActivities 67 Figure 3.1 Percentage of Currently Married Women Aged 15-49 who were Acceptors of Family Planning a t Specified Points i n Time by Experimental Group 76 Figure 3.2 Cumulative Rates of New Acceptors i n Experimental Groups 77 Figure 3.3 Percentage of Currently Married Women Aged 15-49 who were Practicing Family Planning by Experimental Group Figure 3.4 Trends i n Contraceptive Practice Rates i n Experimental Groups Figure 3.5' ' Percent Currently Harried'Women Aged 15-49 who were "Effective Users" of Family Planning a t Specified Points i n Time by Experimental Group 85 - +- Figure 3.6 Trends i n Effective- User Rates i n Experimental Groups 87 ' - i Figure 3.7 Preprogram Use of Permanent, Modern-Temporary and Traditional Methods among Experimental Groups s I Figure 4.1 Average Number of Recorded Service Contacts Made by A l l Staff Working i n Each Experimental Group Figure 4.2 Percent of Ill Individuals Receiving Treatment from Different Sources of Care i n Each Experimental Group, 1973-74  Page No. Figure 4.3 Effect of Children's Services on Average Weight, Adjusted f o r Sex and Caste, Expreesed a s a Percentage of the Hamarc? Median Weight Standard, 1970-73 134 Figure 4,4 Effect of Children's Services on Average Height, Adjusted f o r Sex and Caste, Expresaed a s a Percentage of the Hamard Median Eeight Standard, 197073 136 Figure 5-1 Health Sarvices aud Family Planning Use by Experimental Group Over Time 142 Figure 5.2 Graph of Relatlonships between Program Family Planning, Prior Family Planning and Health Service Use 160 Figure 6..1 Bivariate Relationship between Contraceptive Use and Selected Explanatory Variables 179 Figure 6.2 Bivariate Relationship betveen Contraceptive Use and the Volume of Service Contacts i k Figure 6.3 Bivariate Relationship between Duration of Contraceptive I Use and the Volume of Service Contacts 189 Figure 7.1 Percentage of Wives, Aged 15-39 Years, Wanting More Children by Number of Living Daughters and Sons, Narangwal, India Figure 7.2 Percent Women who Had Birth i n a Calendar Year by Previous Parity and Practice of Family Planning i n Previous Year 221 Figure 7.3 F e i t i l i t y Decliae and Its Relationship with Services 246 Figure 8.1 Average Time Spent Providing Direct Services to A l l Staff Working Ln Each Experimental Group, 1971 251 . I Figure 8.2 Average Time Spent Providing Direct Services by Family Health Workers i n FPWSCC, FFWS, FPCC Villages, and F a t l y Planning Ed-~catorsi n the FPED Villages, 1974 - - 254 '? i  - v i i - - The Narangwal Teams e a r l E. Taylor and R.D. Singh -- Principal Investigators and . Senyukta Vohra, Inder S. Uberoi, Susheila B. Takulia, Eiarbans S. Takulia, R. S. Tak, G. Subbulakehmi, K. Sivaram, R.S.S. S a m , Kailash S h a m , William A. Reinke, Robert L. Parker, A.K.S. Hurthy, Colin W. HcCord, Norah Masih, Dolores I.aliberte, Ranjit Krmrar, N. Sengupta Kielmann, Arnfried A. i Kielmann, Nandini N. Khosla, D. N. Kakar, Ruth K. J u l i u s , Kamlesh S. J a i n , Jeanne A. G r i f f i t h , Alice H. Forman, E l s i e Ferguson, Donald C. Ferguson, t Shridhar Duivedi, Cecile DeSwemer, R. Bruce Conyngham, Sush*m Bhatia, 5, Thomas E.C. Barns, and Dee Raj Arora. I i Analysis and Report Preparation E Carl E. Taylor, R.S.S. Sa~ma,William A. Keinke, Robert C. Parker, and Ra~shidFaruqec- Editors and D. Storms, K. Sivaram, Jeanne S. Newman, Frederic .4. Nass, A.K.S. Murthy, Ranjit Kumar, Arnfried A. Kielmam, Narindar U. Kelly, P.L. Grover, Cecile DeSveemer, Sushum Bhatia. assisted by Hartha S. L i s t , A. .Ula Crawfox:d, Carol A. Buckley, and Peggy E. Bremer. 9' :'" i.p- i.,. Si rk$ P $@ S q k  Famflv Health Workers Shashi K. Wasti Hadalsa H. Khera Veena Vema Satnun Kaur Usha Trivedi Halkit Kaur Sudershan Trikha J a g j i t Kaur Kanchan S o d Gurmit Kaur Bij a y Solomon Gurcharan Kaur Krishna G. Singla Chitranjan Kaur Kamla Sikka Amar Kauru Rajinder Sharma Sudesh h n t a S a r l a Sehgal Amarjit h k a r i a d Kamlesh Sahnl Mavis Jatiram Daljit K. Sachdeva Surinder K. Grewal Mary P. Peter armail K. Dhillon S h e i l a P a t i l S a r l a Devi Harjinder Narang Pushpa Dawar Nirmal S. Moudgil '&mini W. Dass Inder Nohini Roselyne R. Daniel Bayant K. Mayo Veena Chopra Zarina D. Masih Unnila Chopra Veena Masih Raj K. Chib Shanti B. Masih Virbala Chhabra Grace W. Masih Sheela Chand h r j i t Mangat Svaran Chadha Vidya W. Malik Shakti B. Chadha V i j a y Malho tra Raj D. Babbar P e t e r Ganda Ma1 Surinder K. Arora Surinder hakkar Sampuras b o r a .. Surinder Kwatra Harinder K. Arora Vijay Khera Family Planning Educators Laboratory Technicians Sukhdev Kaur Prem P r a s s e r Naohhatar Kaur Fazal Masih Harbinder Kaur Dhrshana Kumari -Family ~ e a f t hSupervisors Rupinder Brar Savita S e t h i I Family Planning Workers Kamlesh Sahni N i r m a l P u r l S u r j i t Singh Promilla M. Nanda Sukhdev Singh J e e t Kaur Kushdev Singh A m a r j i t E. Gandhi Sukhdev S. Greual Swarn Dogra G a j jan S. Grewal Surinder Bala Kuldip S. Ghumarl Ramesh C. Kaushal Family Planning Supervisor Neena K. Narula  F i e l d Interviewers and I a v e e t i g a t o r s Data Processing S t a f f .Wadyal Arpana Wattae Sukhwsnt K. Walia Kailash Vem Surinder S Darshan S. Surah J a t i n d e r K. Wadyal Harn?k S. Sundra Jagdish Verma Sunita Sood Sushma Uberoi Manjula Sood Verna Singh S u r j i t Singh Rulda Singh Meua Singh Mukhtiar Singh Jaswant Singh k h a n Singh Harnek Singh Malkiat Singh Gobind Singh Curcharan Singh Darshan Singh S.B. La1 Sherry Balwant Singh A.K. Seth B?.ldev Singh Nilu Sapra S.D. S i L r i R.K.V. Rao U s h a Sharma Kulwant Rai R.D. Sharma Neela Yurthy Kusum L. S h a m Shashi Hennan J.P. Sharna Shivcharan K. Mangat Bindu Saxeaa V.K. Malhotra Surinder S a i n i Xanohar Khosla Shashi Sabharwal Kulwant Kaur Bela R a n i Ramesh C. Kashyap Nirmal Puthia Indra Kalrar Ramesh Monqia D.C. J o s h i Ta jinder kianocha S u r j i t S. Greual Prem Malik R.C. Gupta Manohar L. Sharma A.K. Gupta Madan Khoslz Usha Goyal Sukhdev L. Kaushal D.C. Garg Sur jit Kaur Vinod Dhir Sukhwant Kaur P h i l i p Dayal Manjit Kaur Madan Chakravarty Gumat P. Kaur Indu Bhatia Balwinder Kahlon Krishna Bhambri Cameron James Iftikhar Baig Jagmohan S. Hans S u s h a n Gupta Nirmal Gupta -F i ~ l dSupervisors Manjit Grewal Jaswant S. Grewal Amrik M. Seerha G u m a i l K. Grewal Satinder P r a q a k a r Xarveen Goindir Manjit A. Zumar R i t a K. Gawari B a ljit J. Haqs Reena Gandhi B. B. Garg Rajeshwari Dwivedi Suman Dhir Shobha Chhabra S a l i l c ~ hDarshan Parminder Cheema Hardeep Chandha Kanta Bhatia Xdarsh Bhatia  Biochemists- Nutritionists -c S o i t l S c i e n t i s t s G. Scbbulakshmi Harbaas S. Takulia N. Sengupta Kielmann R. S. Tak B i d a D. Arora Alan L. Sorkin R.D. Singh Public Health Nurses Jeanaz S. Newman Ran jit Kumar Indet jit Walia D.N. Kskar Senjukta Vbhra Swaran L. Gupta Norah Maaih Prakaeh L. Grover Harbhajan K. Malhotra Donald C. Ferguson Dolores L a l i b e r t e Raahid Faruqee Ruth K. J u l i u s Shridhar Dwivedi Alice Forman Jagdish Bhatia S h i r l e ) 23.Bohnert Des Raj Arora Physicians Statisticians- Programmers Inder S. Uberoi K. Sivaram Carl E. Taylor R.S.S. Sarma Sushiela B. Takulia Satya P. Sangal N i r m a l Sharma D. A l l i e t e t Robertson Kailash S h a m W i i l i a m A. Reinke Aari Shankar Be:t y Parker Robert L. Parker Thomas Palmer Charlotte Neumann Fredetic A. N-ss Alfred K. Neumann A.K.S. Murthy Colin W. McCord Kamlesh S. J a i n Arnfried A. --delmann George Immerwahr Nandini N. Khcdla E l s i e Ferguson J a s b i r Kaur Larry Curcj.0 Har jinder Kaur William J. Blot Alfred M. Haynes Kamlesh Gupta Administrators Jeanne A. G r i f f i t h t Cecile D e Sweemer Shamsher Singh R. Bruce Conyngham Jamison Mzredith Sushum Bhatia-' Ramesh LYannan Thomas E. C. .Barns J u l i a Detato Joseph D. Altar Colvin Dayal Sam A. David - K. G. Bhambri Although many o t h e r administrative and support s t a f f a r e not l i s t e d , we would l i k e t o recognize t h e i r important coutribution t o t h e project. They i n c l c d e secretaries, clerical and account? staff, construction and maintenance staff, watchmen, v i l l a g e attendants, d r i v e r s , and mechanics.  - x i - Preface Narangwal is more than the name of a village idpunjab. It alco is the name for a new vay of ~ ~ l v i noldg probleme of village health. The Narangwal . research projects have explored the frontiers of what primary health care can do for poor and deprived people throughout the vorld. The research produced sone of the most inportant evidence so f a r on how t o organize effective pri- mary health care and cn the need f o r integrating service6 at the periphery. It showed how auxiliary-based health care can be provided for an annual expenditure of l e s s than $2 a person. The research was adapted and devi~opedi n a design that shows what can be done i n controlled f i e l d t r i a l & . By measuricg the inputs of services and the outputs and outcomee of improved health and family planning, it was possible to calculate the effect and cost- effectiveness of different intervcrr tions. The findings should help national health p l a ~ e r ai n t h e i r judgments of probable costs and benefits. Our experience indicqtea, however, that t r i a l s a r e needed i n each nev area--to adapt what was learn=. a t Narangwal to local . conditions. The Narangwal population project grew out of long invoivement i n the l i f e and problems of village India. Members of the s t a f f spent many years working i n the villages and living i n village homes with simple hygienic 'C improvements that would demonstrate h e a l t h f h living. - The depth of understand- ing that ccmes from sharing the l i f e of vi-gers - cannot be matched by sophie- ticated data gathering.  - x i i - The more formal origins of the population project derive from the research a c t i v i t i e s of the Naran~walRural Health Research Center. I n two adjacent villages--Bara (big Narangwal) with 1,800 people; and Chota ( l i t t l e Narangwal) with 800 people--the research center was s e t up i n 1961 i n collaboration with t.5e Indian Council of Medical Research (ICMR). I t is near a teaching health center, started by the Ludhiana Christian Medical College r i n 1955 t o provide a base f o r r u r a l internship training. The f i r s t project of the Rural Health Research Center was a study of the r u r a l orientation of physicians (Taylor and others 1976). That led t o a s e r i e s of studies on indigenous practitioners and on the b e l i e f s of v i l l a g e people about d i e t and disease. A research project w a s then undertaken to develop a method f o r measuring hzalth needs and resources f o r primary c a r e (Johns Hopkins 1970). With t h i s background information as the basis, two research projects were started on the two health problems that seemed most important i n village India. One was the Narzngual population study reported here. The other was a similar controlled experiment on the interactions between malnutrition and infection i n children of weaning age. The nutrition project included a l l children under three i n four groups of villages: one group received nutrition- a l surveillance and supplements; another was provided health care emphasizing infection control through immunizations and earl.y diagnosis and treatment; the . t third received both n u t r i t i o n and health care measures; and the fourth conti- nued to receive routine government services and served a s a control. -- The use of p$ary-care a u x i l i a r i e s led to dramatic improvements i n growth, development, - mortazity, and mcrbidity. The n u t r i t i o n and population projects were developd . e i n pa?allel, and the combined nutritit--. and healrh care group of v i l l a g e s f o r the n u t r i t i o n project was also tne c k ~ care and family planning group of d  v i l l a g e s f o r the population project.. The methods that evolved f o r providing services a r e summarized i n two f i e l d manuals f b r v i l l a g e s i l i a r i e s on child care and child n u t r i t i o n (Uberoi and others 1974; De Sweuner and others The i n i t i a t i v e for t h i s reaearch came f r m the Indian Ministry of Health and Family Planning. National leaders knew that balanced and continuing long- ten. development of services needed f i e l d research on how t o make family planning a c t i v i t i e s an effec-tive part of routine health services. The Ministry of Health and Family Planning delegated responsibility f o r the oversight and surveillance of the Narangwal projects t o the ICXR so that the research ..odd become part of the national research e f f o r t . Annual reports were made t o the ICUR t o keep research i n l i n e v i t h national objectives. Direct comm~micationsvere also maintained with o f f i c i a l s i n the M n i s t r y of Health and Family Planning, and there were numerous s i t e v i s i t s and con- ferences a t Narangwal throughout the research. The f i r s t f e a s i b i l i t y funding w a s from a PL-480 grant by the U. S. Department of Health, Education, and Welfare. The project vas greatly expanded with long-term financing from the U.S. Agency f o r International Development. Funds were also contributed by the World Health Organization (891181122 and H9/181/23). Most important, , I the ICMR provided d i r e c t research grants a f t e r the PL-480 grant ended, indi- cating ..he commitment of the Indian government to t h i s research. - - .dhen the ~ a r a n ~ w @studies began, o f f i c i a l s in the Ministry of Health and the research woTkers agreed that the second stage would be t o have 4 demonstration projects that-apply Narangval methods and findings, adapted to local conditions, i n other parts of India. Several such projects have  - x i v - succeeded i n the y e a r s s i n c e the Narangwal f i e l d work stopped. They show t h e value of community p a r t i c i p a t i o n and the ways a h e a l t h team can help people solve t h e i r own h e a l t h problems. As the n a t i o n a l program of t r a i n i n g community h e a l t h w r k e r s develops i n India, there w i l l have t o be a continuing stimulus from demonstration and research projects, And the focus w i l l have t o be sharpened i f i n t e g r a t e d packages of primary h e a l t h care, family planning, and n u t r i t i o n a r e t o begin t o improve the q u a l i t y of l i f e of the r u r a l poor. The findings of the Narangval research w i l l be important i n supporting t h i s continuing e f f o r t . I n expressing appreciation t o those who made the Narangwal population project possible, we must f i r s t recognize a long and distinguished sequence of Indian government o f f i c i a l s . The decisions t.. do the research were by the M n i s t r y of Health and the ICMR. The c r e d i t f o r sponsoring the research and bringing i t to f r u i t i o n must go t o the directors- general of the ICMR-- s t a r t e d under Professor Wahi, continued under D r . Gopalan, and e s p e c i a l l y helped by Prof.=ssor Ramalingaswami. With t h e i r colleagues a t the IC.W, t h y - provide1 i n t e l l e c t u a l and administr=cive support t h a t went f a r beyond thz o f f i c i a l requirements of l i a i s o n with the research team. ' Many o f f i c i % l s of the Ministry of Health helped i n times of' uncertainty. A t t h e Narangwal conferences, l e a d e r s i n academic i n s t i t u t i o n s and i n c e n t r a l and state governments provided i n s i g h t s &out what should and s i coul-d be done and about how t o i n t e r p r e t t h e findings. S p e c i a l mention must - be F d e of o f f i c i a l s i n the Tunjab Health services--incgding t h e h e a l t h s e c r e t a r i e s , d i r e c t o r s of h e a l t h s e r v i c e s , s t a t e o f f i c i a l s i n Chandigarh,  X V - and d i s t r i c t o f f i c i a l s i n Ludhiana-*ho helped i n ways ranging f- -m selecting study areas and seconding s t a f f t o discussing a t length how the research could be made relevant. Many colleagues i n academic and research i n s t i t u t i o n s participated i n the f i e l d research, especially those from the Ludhiana Christian Medical College, A l l India I n s t i t u t e of Medical Sciences, and the Chandigarh Pocc Graduate I n s t i t u t e . We also thank the many agencies that supported the research. We got ~*.ctrneededfinancial support a t a c r i t i c a l stage from the ICMR. A t the U.S. Agency f o r International Developent, the Asia Bureau made the decision t o pay f o r the f i e i d w r k , and the Office of Program Planning and Coordination l a t e r supported the analysicr. We received gravts from the special program of the WHO f o r research on human reproduction and from the Merrill Fund. The U.S. National I n s t i t u t e of Health assisted i n the analysis. And the Develop- ment Policy Staff of the World Bark, especially Timothy King and Ravi Gulhati, supported the l a s t stage of analysis that led to t h i s book. Those of us who have had the privilege of producing t h i s analysis and report f e e l a special debt of gratitude to our many colleagues who shared the f i e l d work. Listing t h e i r names and roles cannot give enough recognition of the pride and e f f o r t that made the f i e l d experience so productive. But the 16ng list a t the front of t h i s book indicates theeimportance of the contribu- tions by a large number of researchers and f i e l d s t a f f over the l i f e of the project. Starting with f i f t e e n or so, the s t a f f grew t o about 150 by the end of the project; a t any time during the project an average of two professionals from six countri-es s t h e r than $dia were 'on the f i e l d s t a f f i n Narangwal. The excitsuent of l i v i n g and working together i n the villages strengthened the  t i e s of collaboration. And a s individuals moved t o new positions during o r a f t e r the project, they carried an imprint of t h i s experience. A l l i n the Narangwal family know t h a t l i f e brings few opportunities t o m r k with so congenial and dedicated a group. Our deepest thanks go to our mnderful hosts i n the villages. Their hospitality made us f e e l that the v i l l a g e s were our homes. We often ,iden- t i f i e d so completely v i t h t h e i r joys and concerns t h a t we worried about ~ e i e n - t i f i c objectivity; t u t because ccnmunity participation c a l l s f o r seeing things through the eyes of l o c a l people, t h i s identification became an asset. With patience and goodwill they welco~aedour research a c t i v i t i e s . Their under- standing of the reasons f o r the research led to t h e i r pleasure i n knowing that lessons from t h i s work might help programs i n v i l l a g e s elsewhere i n India and the world. To our v i l l a g e friends, we express our deepest gratitude-for the shared hope that t h i s book can help improve the quality of l i f e of the world's neediest people. Carl E. Taylor R.S.S. Sarma William A. Reinke Robert L. Parker Rashid Faruqee  PART I THE W C ; W A L EXPERIMENT  Chapter 1 - Carl E. Taylor Background, Design, and Policy Issues The f i r s t thing people do when t h e i r living conditions h p r o v e is to seek better health care f o r t h e t r children. National decisionmakers thus r e j e c t the occasional suggestions by international experts t h a t e f f o r t s should be focused on family planning while child health services remain undeveloped. Because the services f o r both health and family planning need to be developed, it makes sense to promote the Favorable interactdons between them, not to view them 3s competitive. i /P : The arguments against integrat,'.on usually turn on the ineffective- 1 ness, inefficiency, and low s t a t u s of health ministries. It sometimes is 3:* 1, said that family planning cannot wait f o r health services, which seldom a r e readily available to v i l l a g e Families. O r i t is claimed that services f o r e 1 family planning can be provided %are effectively and e f f i c i e n t l y a s a separate t: activity. The proponents of single-purpose programs of ten justify separate 6 3 services by saying t h a t an intensive, , ~ncentratede f f o r t w i l l have a more $ $ ~4 hmediate effect- ad that these services can be integrated l a t e r . The reason XI 1?i r a f o r such focused e f f o r t is clear i f there is a prospect of a categorical cam- k! . r 1; paign against4 an infectious disease t h a t can be eradicated. The saving from eradicating smallpox has been tremendous because vaccination progrsms a r e no - - longer needed. But there has been a massive re-gence s f malaria because i there was no health infrastructure i n which to @corporate the maintenance I * 1; f phzse of the control program. With present control measures, the sane w i l l be S true of almost a l l programs to control major diseases. :1  i f t h e case f o r single- purpose programs is tenuous f o r the prin- c i p a l diseases, it is even more tenuous f o r separate family planning ser- vices. I n most c o u n t r i e s t h e demand f o r contraception-- by parents whose f a u i l i e s already exceed t h e i r desired family s i z e o r t h e i r a b i l i t y t o c a r e f o r more children- - has not y e t been met. A t t h e s t a r t , it seemed t o make sense t o g e t some family planning s e r v i c e s out t o them as f a s t a s possible. The experience, however, has been t h a t when such a s e r v i c e is s e t up sepa- r a t e l y from health s e r v i c e s , long-term negative e f f e c t s have followed. P a r t i c u l a r l y damaging have been t h e personnel a t t i t u d e s of jealousy and competition created by providing s p e c i a l incentives f o r one group, because t h i s has reduced subsequent chances f o r cooperation with o t h e r h e a l t h and development workers. WHY INTEGRATE HEALTH AND FAMILY PLANNING? Six arguments suppqrt t h e benefits of i n t e g r a t i n g programs f o r health and family planning. The f i r s t is efficiency and effectiveness. An i n i t i a l but one- step increase i n family planning can be produced j u s t by providing ser- v i c e s to meet e x i s t i n g demand. For continuing e f f e c t s on f e r t i l i t y , however, demand must be increased by influencing motigation f o r E m i l y planning by t h e nost d i r e c t means t h a t f i t each l o c a l s i t u a t i o n . Of these, one of t h e most - universally a v a i l a b l e is the organizational b e n e f i t of combining health and .. -- family planning services. -Rather than have four t o six vorkers carry out one -- * t a s k each, a s i n g l e m ~ l t i p u ~ p o sworker can carry o u t s e v e r a l tasks, i f t h e e - - package is simple enough f o r consisten: performance. This kind of integration can improve the s t r u c t u r e of the organization, t h e t r a i n i n g of personnel, and the use of supplies, equipment, and f a c i l i t i e s .  - 5 - Second, integrated programs offer more d i v e r s i t y of responsibility and therefore more challenge t o field-workers. The routine of doing only one task can sap the motivation that leads t o service of good quality. It also helps t o have variation i n tasks, so that imrkers can g e t a favorable response from people f o r a t lee.st some of what they do. A major danger of integration, however, is the overloading of tasks, which then permits workers t o concen- t r a t e on what they arc most comfortable with or on what brings the greatest reward and social response--because they obviously cannot do everything they have been asked t o do. I f the population covered and the package of services a r e kept small enough, it is possible ta avoid such overloading i n integrated services. Because health workers usually a r e most interested i n curing patients, it is important that curative a c t i v i t i e s should not crowd out both preventive health services and family planning. There must be established routines, good management, and supportive supervision t o ensure continuing attention to family planning i n integrated services. Third, integrated services make sense t o families. When a health o r family planning vorker v i s i t s homes, patients l i k e t o have a l l t h e i r problems cared f o r , rather than have some of t h e i r problens referred t o other personnel f o r reasons the people cannot understand. They want to g e t care f o r r t & themselves and t h e i r children from one person i n one c l i n i c , and they do not l i k e to go t o various c l i n i c s a t different times. Fourth, public relations can be improved by attaching a c t i v i t i e s B that have equivocal acceptance to programs that ha;e spontaneous and contin- uous demand. Even though some parents a r e eager f d r family planning because B 3 they have more children than they can care f o r , there generally is a much h - l a r g e r number of demographically important low- parity parents who have mixed t B  f e e l i n g s about family planning- For them the case f o r ear1y spacing o r llmita- t i o n is more con i n c i n g vhen it comes from a health vorker they have learned t o t r u s t because of continued help f o r t h e i r h e a l t h problems. F i f t h , family planning f o r women has been shown ( i n h o s p i t a l post- partum studies) t o be especially e f f e c t i v e vhen provided a s a routine p a r t of maternal care. The reason i s the high motivation associated v i t h pregnancy. When education s t a r t s i n the prenatal period, the mother accepts as n a t u r a l t h e proposition t h a t family planning should begin immediately a f t e r d e l i v e r y t o protect her h e a l t h and the vell-being of the c h i l d . I n the normal routine of maternal care, e n t r y points f o r family planning can be i d e n t i f i e d and r e a d i l y introduced. The high motivation a t t h i s time has s e v e r a l sources. I n a d d i t i o n t o health, t h e r e a r e considerations of t i m e and money: parents would have d i f f i c u l t y caring f o r the c h i l d r e n i f another pregnancy s u p e r vened. There a l s o seems t o be a n important psychological consideration: having j u s t passed through one pregnancy, mothers tend t o want a r e s p i t e before another . C u l t u r d patterns and prolonged l a c t a t 2on support such spacing, but a r e l e s s e f f e c t i v e i n s o c i e t i e s that a r e rapidly changing. Sixih, it seems reasonable t h a t the experience o r expectation of reduced i n f a n t and c h i l d mortality w i l l increase tGe p r a c t i c e of family , L planning. As long as the proportion of children who d i e i n zhildhood remains substantJa1, a major psychological o b s t a c l e must be overcome i n promoting - t h e l i m a a t i o n of family size. Bealth s e r v i c e s t h a t lead t o s i g n i f i c a n t - * reductions i n c h i l d mortality may thus be an important, though not e s s e n t i a l , - means of encouraging lower f e r t i l i t y i n a r e a s where f e r t f l i t y and m o r t a l i t y a r e high. E f f o r t s t o reduce c h i l d l o s s and especially t o increase the p e r ception of higher c h i l d survival, although n o t guaranteeing a . d e c l i n e i n  f e r t i l i t y , wodd be expected t o shorten the demographically Lmportcnt lag betveen t' iecline of mortal.ity r a t e s and f e r t i l i t y rates. Dr.. jite t h e m argun~entsf o r integration, it has been d i f f i c u l t t o integrate hervices once separate services have been s e t up. Competitiveness a t the periphery is strong, and workers have t o change basic a t t i t u d e s i f they a r e to work effectively i n an integrated services. Our experience has been that vorkers from special programs proved more r e s i s t a n t to taking on expanded a c t i v i t i e s than workers i n comprehensive services, who seemed from the begin- ning to be more ready t o adapt to changed emphasis and responsibilities. A t the top and middle administraitive levels, the p r o b l w s of separate services have been just a s great a s those a t the periphery. Some categorical programs have v i r t u a l l y been paralyzed because the people running them spend so much of t h e i r e f f o r t justifying t h e i r separate existence. In one country on the Indian subcontinent, integrated services had to be designated as a categorical i program outside regular health services to get the attention and p r i o r i t y t o cornpet. v i t h the continuing categorical programs. I n India, rudimentary services f o r maternd and child health were 1 I essentially destroyed when tht? v e r t i c a l family planning program vas s t a r t e d i n 1 the 1960s. It is important nov i n the cc-verse situation that, as integration 8 , * i is carried out, there should be special provisio& to ensure that family C 8 I planning services a r e not downgraded. A rational approach t o integration - - . requirts getting avay from l o o k i 4 a t the problem purely i n either- or terms. B i I Any integrated program +uld have program p r i o r i t i e s c l e a r l y f: i: Jc focused i n a general framevork t o achieve benefits similar to those i n ver- t i c a l programs. As much attention should be devoted to effective management i  i n integrated programs a s i n categorical programs, In the past, the best man- agement capability was usually absorbed by v e r t i c a l programs, which have had special glamour and resources. This pattern made i t almost impossible t o develop the general health infrastructure with vhich the special rrograms were eventually t o be integrated. Proponents of separate v e r t i c a l services genei-ally agree that such services vill eventually have t o be integrated. If two o r more separate services a r e combined a f t e r each has become strong, the r i v a l r i e s and adjust- ments vill be traunaatic. The alternative usually recommended is t o add services progressively t o one service a f t e r it ha; achieved good coverage. The problem is t h a t each categorical service then sees i t s e l f a s being the one to which other a c t i v i t i e s should be added, and the problems of eventual integration remain. UBAT IS TEE EVIDENCE? It is generally recognized that high fertility and short birth intervals cause extensive danage t o the health of mothers and children i n most developing countries (Omran 1971 and 1976). The converse influence of health on f e r t i l i t y and birth intervals (and thus on population grovth) is much more complicated . , and remains the focus of a djcrr policy confrontation i n many countries and international agencies. The obvious d i r e c t effect of better health is t o - reduce mortality. But i f f e r t i l i t y remains high, the populat~oI)increases. L Of more interest f o r its long-term e f f e c t is a group of i n t e r a c a n g factors * i? by which h e e t h services promote family planning and thus r e d u c e f e r t i l i t y . Attempts t o unravel the many determinants of population growth have mainly relied on increasingly complicated s t a t i s t i c a l analyses of  cross- sectional scrveys t o determine associations betveen and among variables (Norman and Hofstatter 1978; Kendall 1979; UNFPA 1980). Such interpretations of the spontaneous influences on population growth and national developent do not always lead to an understanding of what happens when different kinds of program interventions o r social changes a r e deliberate. This kind of i n f o r nation is best obtained i-om prospective f i e l d research, such a s t h a t reported here. Recent analysis i n several developing countries has confirmtd the d i r e c t e f f e c t of Zamily planning services i n reducing population growth (Xauldin and Berelson 1978), but more all have to be done to maintain the decline i n f e r t i l i t y . Largely because of the apparent succesa of programs i n such countzies a s China, the projection of world populh~ioni n 2000 has come . down from more than 7 b i l l i o n ten years ago and between 6 and 7 b i l l i o n f i v e years ago ( b r l d Bank 1974) t o about 6 billion today (World Bank 1980). There is growing information on imw program interventions from other development sectors can influence the Fractice of family planning with special attention to education and the r o l e of women (Ridker 1976, but see World Bank 1980). The Narangwal study was focused on health because it has many natural program links to family planning. 4 Ekperience i n a growing number a