CNA Approach for amily Welfare in India

Transcription

1 Approach for amiy Wefare in India

2 Review of Impementation of Community Needs Assessment approach for amiy Wefare in India Poicy Project II The Futures Group Internationa

3 Contents oreword Abbreviations Gossary of Indian Terms v vii ix Impementation of the Community Needs Assessment Approach in India 1 Gadde Narayana, Naveen Sangwan Approach for amiy Wefare in Andhra Pradesh 19 Gadde Narayana, A.Kameswara Rao Approach for amiy Wefare in Bihar 31 Daya Krishan Manga, Gadde Narayana Approach for amiy Wefare in Gujarat 41 C.V.S. Prasad, Daya Krishan Manga Approach for amiy Wefare in Karnataka 57 Ramakrishna Reddy, P.Hanumantharayappa, K.M.Sathyanarayana Approach for amiy Wefare in Madhya Pradesh 71 Ashok Das, K.M.Sathyanarayana Approach for amiy Wefare in Maharashtra 87 Sharad Narvekar, A.D.Pendse, K.M.Sathyanarayana Approach for amiy Wefare in Orissa 105 K.M.Sathyanarayana, Ranjana Kar Approach for amiy Wefare in Rajasthan 123 Hemant Dwivedi, Daya Kishan Manga, Gadde Narayana Approach for amiy Wefare in Uttar Pradesh 133 J.S.Deepak

4 Review of Impementation of Approach for amiy Wefare in India iv

5 oreword The neary five years since India aboished its target system have been fied with both confusion and innovation. Confusion, because of the uncertain trumpet that prevaied at every eve, and innovation, because states and districts have made sincere efforts to find new ways to deiver services under a broadened set of objectives. This voume traces the experiences of nine states in their overa programs and in their specia trias. An exceent synthesis chapter comes first that detais the tribuations since 1996 and reviews the nine state experiences. This book is the successor to Targets for amiy Panning in India: An Anaysis of Poicy Change, Consequences, and Aternative Choices, which appeared in Its first chapter traces the history of target setting and the consequences for the program, as we as the factors that ed to the 1996 poicy reversa. Other chapters present the experience of certain states in the first year or so of the transition. The transition continues; it is by no means compete. The puzzes of how to bend enarged objectives with softened work rues, during a fow of top down directives that often confict with each other, have yet to be entirey resoved. In one sense the ambiguities wi never be resoved in such a compex and far fung set of programs, but the major adaptations are ikey to sette down after a few more years. A mosaic of program variations now exists, each one in fux and moving toward something new. This evoution must continue, not to a perfect end point but toward a system whose principe features ack the od rigid targets and one that has widened its aims. Whie some sympathy with the od system persists and the targets in some form have not died easiy, a few profound changes have occurred that seem irreversibe: The od worker-specific, method-specific, and month-specific quotas are argey out of favour and gone. The rhetoric of the fied-the vocabuary of discourse-has been argey transformed, to speak of the fet needs of the peope, community interests, and mutipe services. Truy major changes have been made to move toward new work rues, toward other methods to accompany steriization, and toward other services than just contraception. v oreword

6 These changes are necessariy embraced within an administrative structure that continues much as before. The ine from Dehi, with its arge share of tota funding and its centra directives, down through the state managers and the districts, wi not go away. Moreover workers cannot simpy be sent out to do good by their own ights and their own motivations. The context now is an admixture of the new ideoogy with the inevitabiity of top down budgets, staff aocations, and overa goas. Much of the enduring confusion in these five years arises from that tension-how to forge a fied program that aows for worker judgment, community power, and oca options, whie simutaneousy showing rea achievements for urgent nationa goas. The nine state reviews in this voume show what is needed from the research side: a ceaseess examination of experience from the genera program and from trais of program variations. Each review broady examines the reproductive heath program in the whoe state, describes creative projects there, and traces the transition toward a target-free approach that is adapted to oca conditions, whie sti setting achievement expectations at the grassroots eve. If reviews ike those in this voume had not been done they woud have been most urgenty needed, and it is vita that they be continued on a reguar basis. The present review is offered with appreciation to Victor Barbiero, Director of the Popuation, Heath, and Nutrition Office, and to Sheena Chhabra, Team Leader of the PREM Division, both of USAID in India, for their encouragement and support. Partia financia support was provided by the Rockefeer oundation, which is gratefuy acknowedged. Reproductive behaviour has changed over most of India since the nationa program began 50 years ago, and the program, with a of its probems, deserves a generous share of credit. By 1992 fertiity had faen much beow its traditiona eve: nine of the 15 argest states had crude birth rates in the 20s and had tota fertiity rates beow three. The nationa averages were 29 and 3.4, and by the survey 48% of coupes were using contraception. Yet repacement fertiity is a good way off, and state programs wi emerge ony graduay that strike the right baance between operationa effectiveness and sensitivity to the persons they serve. That process wi be informed and advanced by studies ike the ones provided in this voume. John A. Ross Senior eow The utures Group Internationa Review of Impementation of Approach for amiy Wefare in India vi

7 Abbreviations AD AGTP AIDS AN ANC ANM ANMTC AVSC ARI AWW CBD CBR CC CDMO CDR CEO CHC CMIE CMHO CMO CMS CPR CSSM Cu-T DAP DDMHO DH WO DMHO DI PSA DIO DPC DPT DUDA Additiona Director Awareness-Generation Training Programme Acquired Immuno Deficiency Syndrome Antenata Antenata care Auxiiary nurse midwife ANM training centre Association for Vountary Surgica Contraception Acute respiratory infection Anganwadi Worker Community-based distribution Crude Birth Rate Condom Chief district medica officer Crude Death Rate Chief executive officer Community heath centre Centre for Monitoring Indian Economy Chief medica and Heath Officer Chief Medica Officer Chief Medica Superintendent Community needs assessment Coupe Protection Rate Chid surviva and safe motherhood Copper-T District action pan Deputy District Medica and Heath Officer District Heath and amiy Wefare Officer District Medica and Heath Officer District Innovations in amiy Panning Services Agency District Immunization Officer District Panning Committee Diptheria Pertussis Tetanus District Urban Deveopment Agency vii Abbreviations

8 EC ECR ELA RU W WHC GOO GOI GTZ HDI HMIS ICDS IEC I A I PS IMA IMR IPD IPP ISM ITPD IUCD/IUD K W LHV MCH MIM MMR MIS MO MH W MPHA MPW MSS MTP Eigibe Coupe Eigibe Coupe Register Expected Leve of Achievement irst Referra Unit amiy Wefare amiy Wefare Heath Centre Government of Orissa Government of India Deutsche Geseschaft für Technische Zusammenarbeit... Human Deveopment Index Heath Management Information Systems Integrated Chid Deveopment Services Information, education, and communication Iron and foic acid Innovations in amiy Panning Services Indian Medica Association Infant mortaity rate Integrated Popuation and Deveopment Indian Popuation Project Indigenous Indian System of Medicine Integrated Triba Deveopment Programme Intrauterine Contraceptive Device/ Intrauterine Device Kreditanstat für Wiederaufbau (K W) Lady Heath Visitor Materna and chid heath Materna and Infant Mortaity Materna Mortaity Rate Management Information Systems Medica Officer Ministry of Heath and amiy Wefare Mae-pubic Heath Assistant Muti-purpose Worker Mahia Swasthya Sangh Medica termination of pregnancy NACO N HS NGO NIC NID NIH W NSS OR ORS ORT PBA PHC PLA POL PRC PRI PSM PVO RCH RH RMP Rs. RTI SC ST STD SI PSA SIH W STI TBA T A T R TT UIP UN PA UNICE USAID WHO Nationa AIDS Contro Organization Nationa amiy Heath Survey Non-governmenta organization Nationa Informatics Centre Nationa Immunization Days Nationa Institute of Heath and amiy Wefare Nationa Swayam Sevika Operations research Ora rehydration sats Ora rehydration therapy Pregnancy-based approach Primary heath centre Participatory Learning for Action Petro, oi, and ubricants Popuation Resource Centre Panchayati raj institution Preventive & Socia Medicine Private vountary organization Reproductive and chid heath Reproductive Heath Rura Medica Practitioner Rupees Reproductive tract infection Schedued Caste Schedued Tribe Sexuay transmitted diseases State Innovations for amiy Panning Services Project Agency State Institute of Heath and amiy Wefare Sexuay transmitted infection Traditiona Birth Attendant Target-free approach Tota fertiity rate Tetanus toxoid Universa Immunization Programme United Nations Popuation und United Nations Chidren s und United States Agency for Internationa Deveopment Word Heath Organization Review of Impementation of Approach for amiy Wefare in India viii

9 Gossary of Indian Terms Anganwadi Ba Kayan Samitis A viage-eve centre under the ICDS Programme Chidren Wefare Committees Crore 1 crore = 1,00,00,000 Dai Dudugi Gram Pradhan Gram Sabhas Jowar Traditiona midwife Loca announcement Viage headman Viage Committees Miet Lakh 1 akh = 1,00,000 Mahia Sammean Mahia Swasthya Sangh Ma Raksha Mahotsara Panchayati Raj Vanaspati ghee Tur Tauka Pradhan/Gram Pradhan Pucca Zia Sarkar Zia Swasthya Samiti Women s conference Women s Heath Group/Organization Safe Motherhood estiva Body of oca government at viage eve Vegetabe Oi A type of puse Territoria division beow district Headman/Viage Headman a-weather District Panning Committee District Heath Committee ix Gossary of Indian Terms

10 Impementation of the Community Needs Assessment Approach in India Gadde Narayana Naveen Sangwan Background Since its inception in 1951, the Indian amiy Panning Programme has undergone many changes to meet the varied chaenges over the years. At different times, the programme has been expanded either to integrate services, as was done in the 1970s with the muti-purpose workers scheme. In recent years, in order to focus on the range of services critica for the heath of women and chidren, the programme has been expanded to incude eements of new schemes such as Chid Surviva and Safe Motherhood (CSSM), Universa Immunization, and Reproductive and Chid Heath (RCH). 1 Prior to 1996, the programme used a target approach as the means to stabiize popuation growth. A services, panning, and financing were geared to achieving the demographic goas of reducing the birth rate and the rate of popuation growth. To achieve the ong- and short-term demographic goas, this approach set targets in terms of a coupe protection rate (CPR), which was further broken down into method-specific targets, with specia focus on steriization. The centra government prescribed these targets annuay for each state, which in turn passed the annua targets through the system down to the faciity eve. 2 Thus, achievement 1 2 Leea Visaria, Shireen Jejeebhoy and Tom Merrick, rom amiy Panning to Reproductive Heath: Chaenges acing India in Internationa amiy Panning Perspectives, January 25, 1999, p Gadde Narayana, Shaini Kakkar and Venkatesh Srinivasan, Target ree Approach for amiy Panning In India in The POLICY Project (ed) Targets for amiy Panning in India: An Anaysis of Poicy Change, Consequences and Aternative Choices, The utures Group Internationa, New Dehi, Approach in India

11 of contraceptive targets became the principa indicator of success for India s popuation stabiization effort. The target system paced itte importance on cients persona choices and did not encourage the use of a wider range of famiy panning methods. As the target system increasingy took its to on services and quaity, criticism grew as we. By the end of the 1980s, popuation experts, researchers, academicians, donors, and non-governmenta women s groups in India had a registered strong objections to India s famiy panning programme. These factors, aong with In Apri 1996, the GOI internationa deveopments introduced a major during the 1994 Internationa revision of its approach to Conference on Popuation and famiy panning and Deveopment and the 1996 primary heath care. The Internationa Women s MOH W aboished Conference in Beijing, created a method-specific famiy need for a change in approach. panning targets, and repaced it with what was initiay caed the T A. In Apri 1996, the Government of India (GOI) introduced a major revision of its approach to famiy panning and primary heath care. The Ministry of Heath and amiy Wefare (MOH W) aboished method-specific famiy panning targets, and repaced it with what was initiay caed the Target- ree Approach (T A). 3 The main aim of the T A was to shift the focus to cients needs and to improve the quaity of services. This paradigm shift caed for panning to start at the basic faciity eve and to be based soey on identified cient needs and intentions. Heath workers woud conduct surveys to ascertain these needs. In other words, the former top-down approach was to be repaced by a genuine bottom-up approach in which heath workers case oads woud be determined by identified oca needs. At the same time that targets were aboished, however, MOH W provided minima guidance to the states on how to impement the new poicy. As a resut, in 1996 and 1997, most states acked operationa methodoogies to assess community needs, deveop reaistic performance goas and pans, and institutionaize quaity in service provision, especiay at the district eve and beow. T A at the operationa eve was even misinterpreted in some states as no targets means no work. To avoid these unfortunate misconceptions and direct the programme more towards cients needs, the new programme was recast into the Community Needs Assessment () approach in September The underying phiosophy of the new approach, however, remained the same as the T A. Objectives of the Paper This paper synthesizes the resuts of nine case studies carried out by the POLICY Project in the states of Andhra Pradesh, Bihar, Gujarat, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Rajasthan, and Uttar Pradesh. The objectives of the case studies were to: examine the transition from the origina target system to the T A and subsequenty to approach Anayze the countrywide impementation of and the impact of the new system on programme performance Identify programmatic shortcomings that affected the transition, draw essons from the experiences of impementation, and identify steps that coud be taken to improve the management and performance of the new cient-oriented system. 3 4 Ministry of Heath and amiy Wefare, Manua on Community Needs Assessment Approach, Government of India, 1998 Ministry of Heath and amiy Wefare, Manua on Community Needs Assessment Approach, Government of India, 1998 Review of Impementation of Approach for amiy Wefare in India 2

12 The case studies for nine states foow this synthesis chapter. Introduction of the Target- ree Approach Starting in the 1960s, the Ministry of Heath and amiy Wefare annuay fixed method-specific targets, which argey determined the character of programme impementation, monitoring, and evauation at a eves. Over the years, this ed to a situation where the achievement of contraceptive targets rather than cient services became the major objective of pubic providers. 5 The obsession with targets and emphasis on steriization resuted in poor coverage of younger and ow-parity coupes, virtua negect of modern spacing methods, and infated performance reports particuary for spacing methods. These conditions combined to severey imit the demographic impact of the programme. Not surprisingy, informed contraceptive choice, cients needs, and quaity of services were inadequatey addressed. The centraized panning and top-down target setting hindered management innovation and fexibiity. 6 As a resut, the overa reproductive heath situation in India remained poor, and GOI found itsef responding to performance shortfas by periodicay adjusting the timeframes for achieving programme objectives. Popuation experts argued that focus on numerica targets thwarted attainment of the desired demographic impact and that excessive pressure to achieve targets resuted in over-reporting and mismanagement. Non-governmenta Organizations (NGOs) and women s groups argued that the centra government s notion that India s birth rate must be reduced by vigorous promotion of contraception was a vioation of human rights. The poor quaity of care provided to women by serviceproviders was taken as a sign of how itte regard those providers had for women s heath. In the 1980s and eary 1990s, severa key stakehoders, incuding donor agencies, stimuated discussion of varied viewpoints and advocated for a shift from the target-oriented approach to innovative ways of meeting reproductive heath needs using an integrated approach. There was a growing interest in repacing the target system with an entirey different approach one that woud shift programme emphasis from providers to cients. In September 1995, GOI aboished targets in the states of In the 1980s and eary Tami Nadu and Keraa and 1990s, severa key requested every state to seect stakehoders, incuding one or two districts to test the donor agencies, stimuated T A. The new approach discussion of varied viewpoints and advocated envisaged decentraized panning for a shift from the T A to at the sub-centre eve, in innovative ways of meeting consutation with the reproductive heath needs community, to determine annua using an integrated workoads based on oca needs. approach. By shifting more expicity to identified cient needs and invoving the community, the GOI aso hoped to stimuate better quaity services. Expected eves of achievement (ELA), instead of targets, were now to be set by workers at the grassroot eve femae auxiiary nurse midwives (ANMs) and mae muti-purpose workers (MPWs) in response to community needs. Basic Characteristics of T A Provide services according to cient needs and eiminate centray determined targets 5 6 Gadde Narayana, Shaini Kakkar and Venkatesh Srinivasan, Ibid, T GI, New Dehi, 1998 Naveen Sangwan and Rishikesh M. Maru, Target- ree Approach: An Overview in Journa of Heath Management, 1.1, 1999, p Approach in India

13 Provide a wider choice of safe contraceptive methods and greaty strengthen and expand reproductive heath services Emphasize the quaity of services and decentraize programme panning and management to the district eve and beow Buid partnerships with the community and make the programme a peope s programme. Change from T A to In Apri 1996, without rigorousy addressing the experiences gained by a the states in impementing the T A, the centra government decided to aboish targets throughout India, making the entire nation target free. Targets were removed without adequate preparation and without discussion of what woud repace the od system. No new monitoring system was proposed to repace the target system. At the poicy eve, the shift to the T A was recognized as a necessary step for enhancement of the quaity of services. At the impementation eve (state and district), however, the ony guidance programme impementers received was in the form of a manua (written in Engish) to orient them on decentraized panning, starting at the sub-centre eve. To convey cearer guideines to heath workers and to simpify the impementation of the T A concept and phiosophy, the government renamed the T A as the Community Need Assessment () approach. In September 1997, the government reaized that the T A manua was not proving to be usefu in impementing the new approach and that the term T A was a misnomer. Many heath workers equated T A with no work or no more monitoring based on targets and became compacent. The formats introduced to estimate community needs and expected eves of achievement were too compex to be foowed by the workers. The training provided to heath workers in the use of these formats was inadequate and acked uniformity. To convey cearer guideines to heath workers and to simpify the impementation of the T A concept and phiosophy, the government renamed the T A as the Community Need Assessment () approach. In 1998, they deveoped and distributed a manua to repace the T A manua. Currenty, the programme foows the approach. Anaysis of the Transition from Targets to Moving away from targets to the T A is a major organizationa change. Impementation of an organizationa change of this kind in a vast bureaucratic system is a daunting task. The change process invoves three stages: panning, impementation and stabiization. The main purpose of panning is to deveop a strategy for impementation. It invoves identifying critica impementation issues and designing operationa strategies to impement the change. Figure 1 The Shift from Targets to Target Approach Community Needs Assessment Approach Driving Force Targets è Community needs Orientation Provider è Cient Concern Target Achievement è Quaity of care Goa Demographic impact è Reproductive heath status Approach Top-down è Bottom-up Review of Impementation of Approach for amiy Wefare in India 4

14 Experiences of Impementing T A/ On a piot basis in , GOI designated a singe district in 18 different states and two entire states as target free. The objective was to earn from experience and determine the feasibiity of adopting the T A nationwide. In the absence of guideines, each state responded according to their eve of comprehension of the new poicy. or instance, Andhra Pradesh designed a very comprehensive information and monitoring system and was ready to test run the system in the target-free districts of East Godavari and Medak. The government of Rajasthan introduced a new innovative information and service deivery system in Dausa and Tonk districts. Uttar Pradesh carried out operations research in Agra and Sitapur districts. Tami Nadu designed and introduced a new information system at a eves. Other states argey waited for further instructions from the centra government. The initiatives taken by the states are an indication of the recognition of the need to change or revamp the information and monitoring systems of the famiy wefare programme. GOI, without taking into account the changes contempated or impemented and without a comprehensive review of experiences gained in the first phase of impementation of the T A, imposed the T A in a states in ebruary Severa states initiay resisted the change and wanted the od target system to continue with some cosmetic changes. GOI responded to the situation by directy instructing District Coectors or District Magistrates to aboish targets and to introduce the target-free system with the hep of centray designed new formats. Guideines and a budget to train workers and medica officers were given directy to district authorities. State-eve Directorates of Heath and amiy Wefare were mere spectators to this process. The training was conducted without supervision, it was not of uniform quaity, and many did not understand the phiosophy behind the new approach. The formats provided were compex and many workers coud not understand how to cacuate the ELAs based on sampe surveys. Training programmes invoving severa hundred thousand workers throughout the country coud not be competed unti the end of amiy panning performance in most states decined from 1996 to 1997, creating a negative reaction, particuary among top-eve managers who answer directy to their immediate poitica bosses. The decine in performance in traditionay high performance states was margina, but in states ike Uttar Pradesh and Bihar, it was sharp and perceptibe. After severa consutation meetings and workshops, GOI reaized the imitations of the T A In many states with formats and manua and the weak monitoring negative effect of the term systems, the workers target free. The manua stopped visiting viages was subsequenty revised, to provide services and and in a meeting hed for expected viagers to visit representatives of state cinics that were ocated governments in September far away with no 1997, in New Dehi, the transport faciity. revised manua was approved at the same time as the name of the approach changed. In many states with weak monitoring systems, the workers stopped visiting viages to provide services and expected viagers to visit cinics that were ocated far away with no transport faciity. The term was chosen to convey the message that the workers responsibiity is to assess the needs of the community and provide services as per the community needs. A senior GOI officer, refecting on the prevaiing situation, stipuated, We may have adopted a target-free approach, but this is with reference to numerica method-specific targets. We are not in a goa-free situation. We sti 5 Approach in India

15 have our goas and objectives intact, and this needs to be emphasized. 7 The approach has modified formats for data coection. The number of formats was reduced from 14 panning and reporting formats for the T A to nine formats for the approach. GOI dispatched the Engish version of the manua and formats to state governments in 1998, necessitating reorientation of workers. In addition, GOI instructions were not cear on whether the new formats shoud repace the od ones or continue as a parae activity. Training of workers remained a major issue. A uniform training programme was designed to cover a workers in the country without taking into account differences in capabiities and skis, which turned out to In Andhra Pradesh, with be a major obstace to strong poitica backing institutionaizing the new system. avaiabe to the state s In many states, the printed programme, the formats for were not made Department of Heath and avaiabe. Impementation of the amiy Wefare initiated the approach was not uniform, formuation of a varying from district to district comprehensive state within a state as we as from state popuation poicy that to state. Given this scenario, incuded both demographic states responded to the new and RH goas. system in different ways. Some states have bended the od approach with the new approach and designed new monitoring systems. Some have tried to impement the new system, competey repacing the od system. A few others have neither the od nor the new system in pace. The T A, however, succeeded in making the exicon, and the use of such terms as quaity of services, community or cient needs, integrated approaches, and expected eves of performance are used to refect the new phiosophy of service deivery. The foowing sections of this paper summarize the experience of nine states in adopting the new system. Andhra Pradesh In the first phase of the T A, Andhra Pradesh aboished targets in East Godavari and Medak districts. Even before seecting these districts for the T A, the Directorate of amiy Wefare designed a new information and monitoring system to competey repace the od system. T A districts were seected to pretest the new system. This process was discontinued, however, after an enthusiastic beginning due to ack of support from the centra government. 8 The performance in both T A districts decined consideraby. Many at the state eve thought that the new approach woud present a major hurde to achieving the state s demographic objectives. With strong poitica backing avaiabe to the state s programme, the Department of Heath and amiy Wefare initiated the formuation of a comprehensive state popuation poicy that incuded both demographic and RH goas. 9 The egisature approved the state popuation poicy, the first of its kind in the country, in In the mean-time, the state competed training at a eves. The workers generate expected eves of performance after conducting surveys, and these numbers are compied at various eves to arrive at expected eves of performance Department of Heath and amiy Wefare, Government of Madhya Pradesh and IIHMR, Proceedings of the Workshop on Popuation Poicy for Madhya Pradesh: Identification of Issues and Chaenges, The POLICY Project, The utures Group Internationa, 1999 C.B.S. Venkata Ramana, Target- ree Approach for amiy Wefare: A Review of Experiences in Andhra Pradesh, in The POLICY Project (ed) Targets for amiy Panning in India: An Anaysis of Poicy Change, Consequences and Aternative Choices, The utures Group Internationa, New Dehi, 1998, p Government of Andhra Pradesh, Andhra Pradesh State Popuation Poicy: A Statement and A Strategy, 1997 Review of Impementation of Approach for amiy Wefare in India 6

16 at the district and state eves. At the end of this exercise, in their meetings with district officers, state officers compare the poicy objectives and the ELAs arrived at based on data coected from beow. 10 After considerabe discussion and negotiation, the district and state officers reach a consensus on the ELA for the year. The districts, in turn, distribute these numbers to a heath institutions in the district. Performance monitoring systems at both the poitica and administrative eves in the state were strengthened, and additiona resources were provided to districts to achieve resuts. Consequenty, performance, particuary steriization performance, has significanty improved whie spacing method use has remained more or ess the same over the same period of time. Senior administrators of Andhra Pradesh strongy beieve that the state government, given its structures and systems, has no capacity to serve spacing method users. So the programme strategy paces major emphasis on the pubic sector for steriization services and on the private sector for marketing of spacing methods. Recenty, the state government has promoted mae steriization. An experimenta project conducted to promote mae steriization in two districts was a major success, with the number of mae steriizations conducted in a year exceeding that of femae steriizations. According to the resuts of Nationa amiy Heath Survey II (N HS II), Andhra Pradesh s achievements are especiay significant in famiy panning acceptance, immunization coverage, and materna heath care services particuary antenata care (ANC) and institutiona deiveries. 11 Having achieved repacement eve fertiity, Andhra Pradesh now intends to concentrate its efforts on reducing infant mortaity and increasing age at marriage. Many state administrators fee that they have a successfu mode for others to foow. Bihar Bihar is one of India s arge states with ow contraceptive prevaence and high fertiity. Its performance in regard to deiveries assisted by trained providers and immunization coverage of chidren is aso a cause for concern. The Department of amiy Wefare introduced the T A in one of the reativey better performing districts in The department reviewed the experiences in impementing T A in this district with the hep of an externa agency. Even before discussing the issues invoved, GOI mandated introduction of the T A in the entire state. The state government stopped providing targets and discontinued monthy Many of the medica performance review meetings officers in the state at a eves. The department considered the T A as coud not train workers in the the tension-free use of the new formats, since approach because many in the department did there was no need for not comprehend the content accountabiity after the of the manuas themseves. In introduction of the 1998, two years after new system. introduction of the T A, a donor agency heped the state initiate the training of workers. Even after training, few workers are in a position to use the new formats. No annua surveys are conducted to determine the ELA based on community needs assessment. ELA are generated in the beginning of each year based on the past year s performance or based on workers perceptions. Many of the medica officers in the state considered the T A as the tension-free approach because there was no need for accountabiity after the introduction Gadde Narayana and A. Kameshwara Rao, Community Needs Assessment Approach in Andhra Pradesh, The POLICY Project, The utures Group Internationa, New Dehi, 1999 (Mimeo) Internationa Institute for Popuation Sciences, Andhra Pradesh: Nationa amiy Heath Survey-India, , Bombay, Approach in India

17 of the new system. 12 Performance of a methods, particuary steriization, sharpy decined in and remained ow after that. Many in the department fet that there was a perceptibe improvement in the quaity of services offered after introduction of the T A, in terms of method acceptance among ow-parity and young coupes. However, there is no evidence to support this assertion, and, therefore, it ooks more ike a justification for poor performance. More intensive efforts are required to buid capacity and to improve programme management to make the approach a success in the state. Gujarat The government of Gujarat introduced the T A in Vasad district in The workers were briefed about the T A and asked to The T A was introduced improve the quaity of services. In in a districts in Apri the initia months, due to ack of 1996 but ony in any guideines about the new November 1997 did the approach, the performance of the state receive cear district decined drasticay, guideines from the sending panic signas to the centra government on administration. Severa review how to impement the meetings with Primary Heath new approach. Centre (PHC) medica officers and workers occurred that emphasized the need for reguary updating registers of workers to serve the community. Due to these intensive efforts, method-specific performance at the end of the year was ony per cent ess than what it was in the previous year. The T A was introduced in a districts in Apri 1996 but ony in November 1997 did the state receive cear guideines from the centra government on how to impement the new approach. The Heath and amiy Wefare Department trained 2,422 medica officers and 16,890 workers by March Workers then carried out a community-eve survey with the hep of formats given to them and estimated the expected eves of performance. oowing this process, the estimated workoads were unreaisticay high in a arge number of districts and ow in others. The Directorate advised the districts to take past performance as a benchmark and compare past performance with the estimated expected eves of performance. In Gujarat, workers prepare sub-centre pans based on surveys but these numbers are scaed down or up based on past performance. 13 In genera, reported performance decined sighty in for a famiy panning methods and subsequenty remained stagnant at that eve. Monitoring of famiy panning performance is now based on ELA. In addition, the state has indicators to monitor quaity of services. State officias were not perturbed by the margina decine in performance and were confident that the new system woud be fuy institutionaized within a coupe of years and start yieding resuts. Karnataka Based on instructions received from GOI in 1995, the government of Karnataka seected Mandya district to experiment with T A. Mandya district officers passed on the information to the PHCs and workers. There was no decine in year-end performance. One of the medica officers of Mandya observed, Performance in the district remained more or ess the same even without targets because workers in this district do not have to make much effort. Peope accept famiy panning on their own. In such a situation, targets or ack of D. K. Manga and Gadde Narayana, The Target- ree Approach in Bihar: A Review of Experiences, The POLICY Project, The utures Group Internationa, New Dehi, 2000 (Mimeo) C.V.S. Prasad and D. K. Manga, The Community Needs Assessment Approach in Gujarat, The POLICY Project, The utures Group Internationa, New Dehi, 2000 (Mimeo) Review of Impementation of Approach for amiy Wefare in India 8

18 them make no difference. 14 With the introduction of T A in 1996, the state made substantia changes to the government-prescribed formats. Workers conducted annua surveys with the hep of the eigibe coupe registers (ECRs), but this data remained unutiized because the targets were prescribed from the top. After the T A was mandated, the state reaized the need to use these data and the centray prescribed coverage norms to arrive at ELA at a eves. However, the centray prescribed formats were not usefu for cacuating the expected eves of achievement for famiy panning methods. The state directorate, therefore, instructed districts to take past performance into account to arrive at ELA for famiy panning methods. Some districts considered the past year s performance and others took a three-year average of past performance eves to arrive at the expected eve of achievement for famiy panning. Karnataka aso conducted training programmes to reorient heath workers as we as members of Panchayati Raj Institutions (PRIs) and anganwadi workers (AWWs). In fact, impementation of the new system preceded the training programmes. In genera, workers, supervisors, and medica officers wecomed the new approach and adhered to a instructions provided in terms of training programmes, use of survey formats, and preparation of sub-centre-eve workpans. However, many fet that the new approach has not addressed and is not hepfu for addressing the tremendous variations within the state. Absence of such differentiated approaches makes micro-eve panning a theoretica rather than a practica exercise. The state needs to deveop different formuae for different regions or districts to estimate expected eves of performance. Steriization performance in the state improved sighty after introduction of T A. Reported performance on a spacing methods showed a decine of 5-10 per cent after Madhya Pradesh Madhya Pradesh was one of the first states to conduct eections to oca bodies after the 73 rd and 74 th amendment to the Constitution of India and devoved significant authority and responsibiity to the eected bodies. The eected bodies became responsibe for impementation of PHC and famiy wefare programmes, and a heath workers were transferred to PRIs. As a resut of structura changes in programme impementation, the previousy major roe of Department of Heath and amiy Wefare became margina. At the same time, eected representatives of PRIs had itte knowedge of programmes and acked the skis and experience to govern. It is in this miieu that the T A was first introduced in Narsinghpur district. Workers were asked to authority and conduct an eigibe coupe (EC) survey and set their own eected bodies. targets in order to improve performance. The famiy panning performance of the district dropped substantiay in After introduction of T A in the entire state, workers were instructed to foow the GOI guideines, conduct eigibe coupe (EC) surveys, and set their own ELA based on past performance. The state competed the training of district officers in Since workers did not receive any training during the two-year period in which T A was impemented, the methodoogy foowed to cacuate expected eves of achievement varied Madhya Pradesh was one of the first states to conduct eections to oca bodies after the 73 rd and 74 th amendment to the Constitution of India and devoved significant responsibiity to the 14 P. Ramakrishna Reddy, P. Hanumantharayappa and K. M. Sathyanarayana, The Community Needs Assessment Approach in Karnataka, The POLICY Project, The utures Group Internationa, New Dehi, 2000 (Mimeo) 9 Approach in India

19 from one institution to another. 15 Information coected with the hep of ECRs designed a few years prior to the introduction of the T A was not sufficient to prepare micro-pans. Reaizing this and to be in tune with the requirements of the T A formats, the Madhya Pradesh government competey modified the ECRs and made newy printed registers avaiabe to a sub-centres. ANMs coected the information but were not in a position to process the information to identify unmet need for famiy panning and RH services. Instead of training ANMs, this responsibiity was entrusted to statistica officers at the PHC eve. There was no invovement of PRIs in the assessment of community needs. The state government has, however, prepared a bueprint for training eected representatives about their roes and responsibiities. The Madhya Poitica commitment to Pradesh government formuated the famiy wefare a state popuation poicy in programme in Madhya January 2000, that ceary spes Pradesh is very high, and out its famiy panning and RH the department is trying objectives for the next decade. 16 to impement mechanisms Integrated approaches invoving to continuousy evauate eected representatives of oca performance and review bodies are essentia for achieving strategies for achieving these objectives. amiy panning poicy objectives. performance in the state decined consideraby for a methods except for ora contraceptives. Poitica commitment to the famiy wefare programme in Madhya Pradesh is very high, and the department is trying to impement mechanisms to continuousy evauate performance and review strategies for achieving poicy objectives. Maharashtra Maharashtra seected Satara and Wardha districts in to aboish targets. Satara district officias prepared a district action pan that emphasized the need for a materna chid heath (MCH) approach for famiy panning. Satara district impemented its pan after conducting a baseine survey in the district with the hep of heath workers. Wardha has not made any attempt to prepare a pan. In , T A was extended to a districts. After review of the T A manua provided by GOI, the Directorate of amiy Wefare modified the formats to suit oca conditions and termed the new approach sefdetermination of targets. 17 The quaity of training varied by district, and community invovement was negigibe. More systematic efforts were made to train workers on the approach in In addition to the materia provided by the centra government, the Directorate introduced four data coection formats to be used by sub-centre functionaries to assess community knowedge and to estimate ELA for amiy Panning/RH services. By March 1998, a heath functionaries in the state were trained in the approach. Training programmes were evauated and strengths and weaknesses identified. However, the impementation of the approach was beset with severa probems. The formats designed required severa modifications to capture the reevant information. Whie the need to modify the formats was recognized, additiona resources necessary to make the modifications were not avaiabe. Since the attempts to prepare micropans were not successfu, the government of Maharashtra decided to use the findings of each district s RCH survey to prepare district-eve pans Ashok Das and K. M. Sathyanarayana, The Community Needs Assessment Approach for amiy Wefare in Madhya Pradesh, The POLICY Project, The utures Group Internationa, New Dehi, 2000 (Mimeo) Government of Madhya Pradesh, Madhya Pradesh Popuation Poicy, January 2000 Subhash Saunke and Sharad Narvekar, Target ree Approach for amiy Wefare: A Review of Experiences in Maharashtra, in The POLICY Project (ed) Targets for amiy Panning in India: An Anaysis of Poicy Change, Consequences and Aternative Choices, The utures Group Internationa, New Dehi, 1998, p Review of Impementation of Approach for amiy Wefare in India 10

20 The draft pans prepared by the district officers required severa modifications and refinements, which were never made. During this period, famiy panning performance decined consideraby, but MCH services improved to a arge extent. Maharashtra has ong been considered as a state with cear vision for impementing innovative strategies to achieve resuts. Severa other states, particuary in the south, have recenty shown better performance than Maharashtra, however. One of the main reasons for this discrepancy is that haf of Maharashtra s popuation ives in urban areas, and there is no PHC and famiy panning service deivery system to cover urban popuations, particuary those iving in sums. 18 Senior officers of the Directorate aso beieve that the department s compacency as a resut of past performance has ed to stagnation. Severa attempts made to revamp service deivery systems have not yet yieded resuts either due to ack of systematic effort or resources. Maharashtra recenty introduced a series of disincentives that are both harsh and unreaistic to improve performance in order to reach repacement eve fertiity within a short span of time. Orissa Orissa seected the newy formed Kurda district to impement the T A in The government of Orissa introduced a new ECR in and made printed registers avaiabe to a sub-centres. Sub-centre workers conducted surveys in a viages in and updated data in to identify ECs. Method-specific targets given to the workers were withdrawn after introduction of the T A in the district. The directorate toyed with the idea of introducing a birth-based approach to improve materna and chid heath services, but these ideas never took concrete shape. After the introducing T A in a districts, the Directorate issued instructions to prepare district pans based on norms set by the state. 19 These norms stipuated that the ELA for each sub-centre shoud not be ess than 30 steriizations, and 30 IUDs, 15 ora pi, and 65 condom acceptors. Districts generay foowed these norms in preparing the pans they submitted to the Directorate. Performance was monitored weeky at the sector eve. Training of heath functionaries in the T A was competed in a districts by the end of After introduction of the approach, no further training was conducted. The formats provided by the centra government were sent to a districts with instructions that the new formats shoud repace the od T A formats. The Directorate In the 1990s, Orissa panned to conduct divided its 13 districts training in Steriization into 30 districts. The and condom performance in infrastructure avaiabe in the state decined sharpy after 27 of the new districts is introduction of the grossy inadequate, and approach whie users of ora resources are not avaiabe contraceptives and IUDs to improve the situation. increased consideraby during the same period. Orissa faces severa unique probems that are major obstaces for effective programme management. In the 1990s, Orissa divided its 13 districts into 30 districts. The infrastructure avaiabe in 27 of the new districts is grossy inadequate, and resources are not avaiabe to improve the situation. Orissa aso experiences severe cyconic storms amost every year, disrupting the norma functions of a departments. The heath department spends most of its energy and resources Tara Kanitkar (ed) Proceedings of the Workshop on Popuation Poicy for Maharashtra: Issues and Chaenges, Centre for Heath Poicy and Research, Pune, 1999 (Mimeo) K. M. Sathyanarayana and Ranjana Kar, The Target- ree Approach for amiy Wefare in Orissa: A Review of Experiences, The POLICY Project, The utures Group Internationa, New Dehi, Approach in India

21 to contain epidemics that foow natura caamities. Sti, the state has a reativey good database at the sub-centre eve, which coud be used to provide services based on cient needs. This wi ony be possibe, however, when the state identifies and formuates new strategies to provide quaity RH services. Rajasthan Even before introduction of the T A in , the government of Rajasthan decided that the unmet need for famiy panning services shoud be the foca point for a programme impementation efforts. To introduce the unmet need concept at the viage eve, sub-centre registers and report formats were competey redesigned and workers trained in their use. Workers were instructed to conduct surveys to identify unmet need for both Even before introduction imiting and spacing methods in of the T A in , the month of May, and districts the government of were to consoidate a Rajasthan decided that information and prepare district the unmet need for pans in the month of June. The famiy panning services extent to which the workers shoud be the foca point satisfy unmet need has become for a programme the basis for performance impementation efforts. monitoring and evauation. 20 In addition, the Department of amiy Wefare introduced concurrent evauation by externa survey research agencies to check for infated performance reporting at a eves. The new system was introduced in two districts to begin with and rapidy expanded to a districts. By the time the centra government decided to impement the T A, Rajasthan had its new system in operation in the entire state. There was considerabe reuctance on Rajasthan s part to repace its system with the one suggested by GOI. Rajasthan s system, which identifies needs every year in each househod, was considered far better than the approach suggested by the centra government, which invoved a series of cacuations to arrive at estimates of cient needs. In 1997, the department further expanded its system to identify unmet need for RH services. A monthy feedback system based on reviews of reported performance was estabished in To review amiy panning and RH performance, senior directorate officers visit each district once every two months. Identification of unmet need with the hep of househod surveys and a revamped monitoring system has heped Rajasthan to improve its famiy panning performance consideraby. It is the ony state that has not experienced a decine in famiy panning performance after introduction of the T A. The Rajasthan government aso formuated a state popuation poicy in 1999 that ceary articuates the goas and strategies for the famiy wefare programme. 21 Rajasthan, for understandabe reasons, has not paid much attention to the approach and the new formats proposed by GOI. Uttar Pradesh Uttar Pradesh seected two districts Agra, a highperformance district and Sitapur, a ow-performance district to experiment with the T A. With the hep of resources from the USAID-funded Innovations in amiy Panning Services (I PS) Project, the pregnancy-based approach and the unmet need for famiy panning services approach were introduced in both districts. Registers were designed and workers trained in the use of the new registers. Though famiy panning performance in both districts Ram Lubhaya, Target- ree Approach for amiy Wefare: A Review of Experiences in Rajasthan, in The POLICY Project (ed) Targets for amiy Panning in India: An Anaysis of Poicy Change, Consequences and Aternative Choices, The utures Group Internationa, New Dehi, 1998, p Department of amiy Wefare, Popuation Poicy of Rajasthan, Government of Rajasthan, 1999 Review of Impementation of Approach for amiy Wefare in India 12

22 decined drasticay after introduction of the T A, a sight improvement in MCH services was observed. In , Uttar Pradesh extended the T A to the entire state, but the training given to workers to impement the new approach was ineffective. Moreover, the state government had deeted the famiy panning programme from the 20-point programme, and district magistrates were instructed not to monitor famiy panning programme performance. 22 Overa programme performance drasticay decined. After this, the Department of amiy Wefare started systematic preparatory work to strengthen the target-free system from onwards. Training was conducted in a PHCs in the state with the hep of faciitators and a guide deveoped speciay for that purpose. A workers were trained by November Uttar Pradesh received the manua to repace the od T A manua from the centra government in March The Directorate of amiy Wefare decided to continue with the T A formats rather than introduce the formats and retrain a workers. During this period, the department took severa decisive steps to improve access to and the quaity of a wide range of RH services rather than soey concentrating on famiy panning. These steps incuded provision of quaity reproductive and chid heath services through RCH camps, tetanus toxoid (TT) campaigns covering a pregnant women, dai training to increase the proportion of deiveries conducted by trained personne, and decentraized panning at the district eve using a participatory approach. In addition, contraceptive marketing of condoms and ora contraceptives in rura areas is expected to increase spacing method use. The Government of Uttar Pradesh has recenty formuated a popuation poicy with cear strategies to integrate services, decentraize deivery systems, and improve service quaity. 23 To reaize the poicy objectives, the approach has to be further strengthened in the state by conducting annua househod surveys to identify unmet need for famiy panning and RH services. Uttar Pradesh discontinued this practice in the mid-1970s. A common feature in other states, the Department of amiy Wefare has decided to reintroduce annua househod surveys with the hep of simpe formats to identify unmet need for RH and famiy panning services in four districts on a piot basis. At the same time, the department wi deveop a The Government of Uttar Pradesh has recenty formuated a popuation poicy with more comprehensive cear strategies to management information system (MIS) to cover the entire state in a phased manner. integrate services, decentraize deivery systems, and improve service quaity. Concusions Moving from targets to the target-free approach represented a major organizationa change, and an enormous chaenge to India s pubic heath system. Panning for change invoves consensus and cear understanding among stakehoders on the reasons for change, the direction of change, and processes to be foowed in introducing change. Due to poor experience with targets, the reasons for the nationaeve change were cear and in tune with the thinking of the internationa community on the subject. The groundwork done by GOI to educate and buid consensus among stakehoders in support of the T A, however, was grossy inadequate. Resistance to a change of this magnitude was inevitabe and, therefore, strategies to overcome resistance shoud have been panned we in advance J. S. Deepak, The Community Needs Assessment Approach for amiy Wefare: A Review of Experiences in Uttar Pradesh, The POLICY Project, The utures Group Internationa, New Dehi, 2000 Government of Uttar Pradesh, Popuation Poicy of Uttar Pradesh, Approach in India

23 The GOI, instead, chose a shorter route by announcing the decision and deaing directy with districts without invoving state directorates. The deivery of critica instructions, manuas, and formats to districts to reorient workers occurred severa months after the introduction of the T A. ormats prepared to estimate and pan workoads were very compex and invoved severa cacuations based on many assumptions. Those who designed the formats never thought about the capabiities of the primary users of these formats (i.e., heath workers at the sub-centre eve). Workers in a states found it uniformy difficut to use the One of the basic new formats. In addition, the probems with the new training programmes approach is that it was conducted to famiiarize designed by the centra workers with the new government for use at the procedures did not convey the sub-centre eve. This phiosophy behind the new centray imposed, system. Workers and decentraized system goes supervisors had their own against the core tenet of a interpretation of the new decentraized approach approach that was different for assessing community needs. from the origina intent of the programme. Not surprisingy, performance dropped substantiay in many states. Interestingy, the high-performance states with strong monitoring systems experienced ony a margina decine in performance whie the owperformance states with weak monitoring systems coud not avert significant decines in performance. T A, in effect, widened the gap between high- and ow-performance states. One of the basic probems with the new approach is that it was designed by the centra government for use at the sub-centre eve. This centray imposed, decentraized system goes against the core tenet of a decentraized approach for assessing community needs. The formats introduced under the new system again rey heaviy on a series of quantitative measures for the sake of quaity improvement. The way in which the approach has been impemented undercuts the phiosophy behind the new approach. The approach has achieved some notabe positive resuts, however. Resistance to the change has decined. Those working for the famiy wefare programme at various eves are now argey convinced about the futiity of the numbers game as practiced earier. There is growing recognition of the need for a thorough review of the programme and for introduction of integrated and decentraized service deivery systems with more emphasis on RH services. The recent formuation of integrated popuation poicies by some state governments is, in a sense, an expression of this need. Severa states have aso reaized that community needs shoud take precedence over programme needs. Change of this magnitude cannot be accompished in a short timeframe. Reaizing this, many state governments have initiated steps to introduce the change in a systematic and phased manner. The process of change has just begun and wi probaby take a few more years to achieve the desired resuts. Instead of beieving that the T A or approach is aready in pace in the country, GOI shoud encourage state governments to deveop their own approaches for assessing community needs and hep them to do this by providing resources and technica assistance unti the new systems are fuy institutionaized. Review of Impementation of Approach for amiy Wefare in India 14

24 Tabe 1 Steriization Performance Based on Service Statistics Before and After Introduction of the Target-Free Approach State Before TFA After TFA Andhra Pradesh 575, , , , ,976 Bihar 206, ,927 82, , ,000 Gujarat 301, , , , ,379 Karnataka 371, , , , ,275 Madhya Pradesh 401, , , , ,243 Maharashtra 582, , , , ,714 Orissa 162, , , NA Rajasthan 203, , , , ,295 Uttar Pradesh 516, , , , ,401 Tabe 2 IUD Performance Based on Service Statistics Before and After Introduction of the Target-Free Approach State Before TFA After TFA Andhra Pradesh 338, , , , ,190 Bihar 206, , , , ,609 Gujarat 473, , , , ,189 Karnataka 299, , , , ,854 Madhya Pradesh 857, , , , ,188 Maharashtra 476, , , , ,450 Orissa 193, , , ,693 NA Rajasthan 156, , , , ,685 Uttar Pradesh 2,194,522 2,193,488 1,664,021 2,029,847 2,084,468 Tabe 3 Ora Pis Performance Based on Service Statistics Before and After Introduction of the Target-Free Approach State Before TFA After TFA Andhra Pradesh 261, , , , ,705 Bihar 65,430 67,214 43,582 56,377 44,940 Gujarat 179, , , , ,980 Karnataka 138, , , , ,931 Madhya Pradesh 476, , , , ,126 Maharashtra 418, , , , ,821 Orissa 93,904 99, , ,722 NA Rajasthan 92, , , , ,465 Uttar Pradesh 487, , , , ,290 Tabe 4 Condom Performance Based on Service Statistics Before and After Introduction of the Target-Free Approach State Before TFA After TFA Andhra Pradesh 1,252, , , , ,620 Bihar 194, ,305 99,945 78,578 98,875 Gujarat 1,292,225 1,105,558 1,105, , ,990 Karnataka 395, , , , ,626 Madhya Pradesh 1,987,146 2,004,814 1,761,754 1,650,486 1,545,022 Maharashtra 1,168,747 1,163, , , ,489 Orissa 467, , , ,967 NA Rajasthan 475, , , , ,345 Uttar Pradesh 2,897,773 2,434,224 1,769,096 2,045,682 1,923,835

25 Tabe 5 Summary of Experience in Impementing the TFA/ Approach in India Andhra Pradesh Bihar Gujarat Karnataka Madhya Pradesh Maharashtra Orissa Rajasthan Uttar Pradesh Review of Impementation of Approach for amiy Wefare in India 16 TFA in Performance in seected districts in TFA in Approach Current Situation Seected two districts, designed a comprehensive MIS but did not impement the MIS due to ack of positive response from GOI Performance decined consideraby in both districts Introduced TFA in a districts and aso continued with the od system Seected one district but no instructions were given to the district officers by the Directorate Performance decined consideraby Introduced target-free training in a districts and the department stopped targets at a eves Seected one district and series of performance review meetings were conducted to arrest possibe decine in performance Performance decined ony by 17 per cent Introduced TFA in a districts and conducted househod surveys with the hep of heath workers Seected on highperforming district but no guidance provided on what needs to be done Performance of the district more or ess remained the same Aboished targets but districts took into consideration past performance to arrive at ELAs Seected one district and conducted EC survey Performance of the district dropped substantiay Aboished targets and shifted programme impementation to eected bodies of panchayats Seected two districts and prepared micro-pans in one district and no pans in the other Performance in the seected districts decined marginay TFA was introduced in a districts and GOI formats were modified consideraby Seected one new district with weak infrastructure and conducted EC survey Performance decined significanty Targets were aboished in a districts but state circuated performance norms per sub-centre Seected two districts even before TFA to provide services based on identified unmet need Performance improved marginay in both districts State pursued its own system of househod surveys to identify unmet need. Serving coupes with unmet need was the objective Pregnancybased approach and unmet need approach was introduced in two districts in which targets were aboished Performance decined consideraby in both districts Aboished targets in a districts and famiy panning programme was deinked from 20-point programme

26 Tabe 5 Summary of Experience in Impementing the TFA/ Approach in India Andhra Pradesh Bihar Gujarat Karnataka Madhya Pradesh Maharashtra Orissa Rajasthan Uttar Pradesh Training for TFA system Training programmes acked quaity and uniform understanding of manuas. Supervision of training neary absent Training was done two years after introduction of the new approach Training for TFA system was not effective and done without systematic panning Training was conducted after introduction of new system No training in the first two years Training was imparted and TFA was renamed as sef - determination of targets approach Training was conducted in a districts and manuas and formats were distributed Training was conducted but more to satisfy GOI than to introduce the new approach Training was given for TFA system systematicay with faciitators and guideines in pace Approach Introduced in and workers were given training, manuas and formats training was not imparted Competed training a Medica Officers and workers by March 1998 Training conducted and formats distributed Training conducted and formats distributed and at the same time competey modified ECRs suppied Four new formats were introduced in addition to GOI formats and training conducted more systematicay No training was given on approach No training was given and the department foowed its own approach and expanded unmet need concept to RH services No training was imparted on approach 17 Approach in India Current Situation Objectives set in Andhra Pradesh Popuation Poicy are given more importance than numbers generated from beow. ELA is based on negotiations with district officers Neither is the od target system nor new approach based on cient needs Workoad identified with formats was much higher than average annua performance of districts. Districts compare past performance and expected workoad and arrive at reaistic ELAs Average performance for the past three years and estimates based on GOI norms are compared and ELA is arrive at by each district. Heath workers coect information with the hep of ECRs but do not know how to utiize the information. The coected data remains unutiized. Process foowed to arrive at ELAs varied from one institution to the other New formats introduced were not usefu to cacuate ELA. District tried to use survey data to prepare district pans but coud not succeed. Largey foows a combination of od and new approaches Most of the districts foow the methodspecific norms given by the state government. EC surveys are conducted on annua basis to identify eigibe coupes that need services Workers conduct annua survey in May to identify unmet need for Famiy Panning and RH services. Workers are asked to contact coupes with unmet need and provide services based on method choice of cient Workers estimate the ELA and consoidated numbers are submitted to Directorate. Then Directorate negotiates with districts to arrive at a number that is reaistic and achievabe

27 Tabe 5 Summary of Experience in Impementing the TFA/ Approach in India Andhra Pradesh Bihar Gujarat Karnataka Madhya Pradesh Maharashtra Orissa Rajasthan Uttar Pradesh Review of Impementation of Approach for amiy Wefare in India 18 Monitoring Systems Famiy Panning Performance Performance monitoring systems are strong with high eve of poitica commitment Steriization performance improved consideraby whie performance of spacing methods fuctuated. Monitoring systems were weak before TFA and further deteriorated after TFA Famiy panning performance of a methods decined significanty. Performance monitoring systems are in pace but need to be strengthened Famiy panning performance decined by 5-10 per cent for different methods over a period of three years. Monitoring systems are in pace and no changes introduced after TFA Steriization and IUCD performance marginay increased, ora pi users remained same and condoms users decined. Monitoring systems are generay weak due to ack of awareness among eected representatives about heath systems Steriization, IUCD and condom performance decined consideraby and ora pi performance improved significanty. Monitoring systems are strong for rura heath institutions but urban service deivery systems are weak Steriization and IUCD performance marginay decined and ora pi and condom performance decined significanty. Monitoring systems are weak mainy due to formation a arge number of new districts. The newy formed districts do not have necessary infrastructure Steriization and condom performance decined but ora pi and IUCD performance improved significanty. Monitoring systems were strengthened further at a eves Steriization and IUCD performance consistenty improved but the ora pi and condom performance fuctuated. Monitoring of performance is weak argey due to poitica interference Steriization performance decined by 40 per cent in and marginay improved after that. IUCD performance remained the same and ora pi performance improved consideraby. Condom performance decined.

28 Community Needs Assessment Approach for amiy Wefare in Andhra Pradesh Gadde Narayana A.Kameswara Rao T he target-free approach (T A) in Andhra Pradesh was first impemented in in one district and, based on the decision taken by the Government of India (GOI), the new approach was extended to a districts in the state in Apri The Department imparted training to a workers, supervisors and medica officers (MOs) on T A and the methodoogy to conduct surveys and set their own targets. The experiences of impementing T A up to March 1997, were earier reviewed and the report was prepared. This study is, therefore, an update of the earier effort and records the changes occurred during the year and anayzes the famiy panning performance. The main objectives of the study are to : (i) Describe the processes foowed to impement the new system; (ii) Record the opinions of personne at various eves on the new system and its impementation; and (iii) Anayze the impact of the new system on performance. A personne directy concerned with impementation of the new system at the Directorate of amiy Wefare were interviewed. Information was aso coected from different personne representing various eves in the organization in East Godavari and Medak district. Target- ree Approach Preparation to strengthen the target-free system for began in November 1996, with funds provided by the UNICE. The Directorate of amiy Wefare conducted the state eve workshop for the district medica and heath officers (DMHO), deputy district medica and heath officers (DDMHO) and Chief Executive Officers (CEOs) of Zia Parishads Approach in Andhra Pradesh 19

29 (district eected bodies) in November One more workshop was conducted by the Directorate to the statistica officers of the department in March A series of workshops were conducted in the months of Apri, May and June 1997, for bock eve officers such as MOs of primary heath centres (PHCs), bock deveopment officers, and eected representatives of Mandas. oowing this, training programmes were conducted in the months of Juy and September 1997, to the heath workers and the first ine supervisors. The femae workers were supposed to conduct househod surveys and set their own expected eves of achievements. The district eve officers fet that it woud not be possibe for workers to conduct surveys and set their own performance eves amost at the end of the fisca year. Moreover, the intensive efforts to achieve famiy panning performance, particuary steriizations, in a fisca year are aways carried out from September to March. The workers spend most of their time on motivation of steriization cases and the MOs are not wiing to spare their time for surveys and other activities during this period. The Department of amiy Wefare had simiar experience with impementation of T A in The Department of amiy Wefare had taken an advance action in ebruary 1997 and asked the Directorate to cacuate the expected eves of performance for each district for the year The Directorate-cacuated expected eves of performance was communicated to a district coectors by the Secretary of amiy Wefare and to a district heath and famiy wefare officers by the Commissioner of amiy Wefare. The amiy Wefare Department has prepared its Annua Pan for month-wise and district-wise. A copy of the pan is encosed for your information. The first part of the Action Pan reated to the reguar programme of the Department, i.e., amiy Panning and MCH programmes. The ELAs in respect of these two programmes have been shown month-wise and districtwise. Advance panning has been done and is being communicated to you to faciitate achievement of expected eves of performance every month and to avoid rush of activity in the ast month of the year. I request you to pease review the performance every month and to avoid rush of activity in the ast month of the year. I request you to pease review the performance every month on famiy panning and mother and chid heath programme as per the ELAs communicated in the Pan and ensure that they are achieved within the time frame fixed. The second haf of the Action Pan deas with specia programmes proposed to be impemented in the State in for the wefare of the famiy. Seven specia campaigns are programmed during the year for famiy wefare, ORT, ARI, schoo heath check-up and puse poio immunization. Whie detais of the campaigns wi be communicated at the appropriate time, the Action Pan wi hep you to pan your programme in the district and aso hep in initiating action for impementation of these campaigns without deay. 1 In a foow-up etter to the district coectors written on Apri 30, 1997, the Secretary of amiy Wefare conveyed the seriousness attached to the achievement of expected eves of performance: A etter from the Secretary, amiy Wefare addressed to the district coectors stated: Pease refer to my etter dated March 22, 1997, encosing the Action Pan for in respect of amiy 1 DO Letter No. 9964/D1/97-1 from the Secretary amiy Wefare, Government of Andhra Pradesh to a district coectors, March 23, Review of Impementation of Approach for amiy Wefare in India 20

30 Wefare Programmes. In the Action Pan, the ELAs monthwise in both famiy panning and materna and chid heath programmes have been indicated. These ELAs are to be broken up into month-wise ELAs for every viage and habitation in the district, based on the number of eigibe coupes and mother and chidren who need to be covered under the programmes. I request that this exercise, if not done so far, may pease be undertaken immediatey and finaized by the end of May at the atest. The reviews of the ANMs, PHC doctors, and DMHOs work shoud be based upon the month-wise viage-wise/habitation wise ELAs. The eected representatives and community eaders in the viages and habitations/gram panchayats/mandas shoud aso be communicated a copy of the month-wise ELAs under the programme and they shoud be requested to support the efforts of the Heath and amiy Wefare Department and the district administration in achieving ELAs for each month. The Hon be Chief Minister is reviewing the impementation of the amiy Wefare Programme every month against the monthy ELAs fixed and communicated to a districts. I request that every attempt may be made to ensure that the ELAs are achieved as communicated. 2 The etter from the Secretary, amiy Wefare, triggered a series of simiar actions at various eves. The Director of amiy Wefare in a etter dated June 11, 1997, addressed to a DMHOs, mentioned: The Secretary to Government ( W) has desired to communicate the month-wise ELAs to the district to achieve the cent per cent achievements and aso review the programme every month with cooperation of senior officias of the Directorate who wi be visiting the districts every month. 3 In respect of famiy panning ELAs, pease ensure that a minimum of 60 per cent of the eigibe coupes covered under permanent methods are those with two chidren and beow. The fertiity rate wi not decine to the desired eve if we keep on covering coupes with three chidren and above under steriization method. This aspect is to be kept in mind when viage-wise/ habitation-wise ELAs are fixed for sterization. I request that monthy reviews with PHC doctors and aso ANMs may pease be conducted at manda eve as far as possibe by you, so that the seriousness that the government has attached to the programme is conveyed right down to the grassroot eve workers. Eected representatives and community eaders may aso be invited to these monthy meetings so that probems, if any, at the fied eve may be soved in consutation with them and their support generated in achieving monthwise ELAs. In a separate etter on May 13, 1997, addressing the issues reated to famiy panning performance in urban areas, the Director stated: A the district medica and heath officers are hereby informed that after carefu consideration by the Government, the ELAs in respect of steriization, IUCDs, ora pis and CC users for the year have been arrived and the same are herewith communicated district-wise for its adoption. The DM & HOs are aso informed that the performance in Municipaities is very poor during the year and the Honorabe Chief Minister is reviewing the performance of famiy wefare programme every month. They are, therefore, requested to communicate the ELAs to the Municipa Commissioners and may be requested to take appropriate steps right from the beginning of the year so as to achieve the ELAs given for the year This may be treated most speciay urgent and the 2 3 DO Letter No., 9964/D1/97-2 from the Secretary of amiy Wefare, Government of Andhra Pradesh Apri 30, Letter Ref. No. 4741/D W/D&E-2/97 from the Director of amiy Wefare, Government of Andhra Pradesh, June 11, Approach in Andhra Pradesh 21

31 action taken report may be sent to this office by return post. 4 The DMHO in turn communicated to PHC MOs about the seriousness attached to the programme. or instance, the Medak DMHO in a etter addressed to a PHC and Community Heath Centre (CHC) MOs on 16 May, 1997 said : The Secretary, amiy Wefare, in her etter cited, has issued certain guideines for preparation of action pan for the year Accordingy, the distribution of ELAs for the year in respect of a institutions of Medak district is prepared. The Action Pan prepared is based on the expected eves of achievement (ELA) month-wise in both famiy panning and CSSM programme. These ELAs are to be broken up into month-wise ELAs for every viage and habitation-wise in the district, based on the number of eigibe coupes under programmes. In respect of famiy wefare ELAs, it shoud be ensured that 60 per cent of eigibe coupes to be covered are those with two chidren and beow. 5 The Government of Andhra Pradesh, based on the objectives of the State Popuation Poicy, set the ELA for a famiy panning methods. The expected performance eves were communicated to a the district coectors, the Municipa Commissioners and the DMHOs who, in turn communicated the message to a working beow them. Another significant aspect of a this communication is the emphasis given to the review of programme performance and the person going to review it. The etter hinted to review of performance by the Chief Minister at state eve and review of performance by district coectors at the district eve. Pressure was on the district coectors and the DMHOs to achieve the performance because the Chief Minister intended to review performance and the pressure was on PHC MOs and workers because their performance woud be reviewed by the district coectors. Layers of pressure were, thus, buit into the system. Another significant aspect of the programme is the eary action. Right from the beginning of the fisca year, the expected eves of performance were communicated to various eves and the monitoring of performance had begun from the first month onwards. A simiar etter by the DMHO of East Godavari communicated the message, athough ess specific in nature, to the PHC MOs in the district: A MOs in the district are informed that the district coector is reviewing the individua MPHAs (mae and femae) performance every month against the monthy ELAs fixed and insisting that the MOs shoud ensure the achievement of ELAs as communicated. 6 Andhra Pradesh Popuation Poicy Andhra Pradesh is the first state in the country to formay approve the State Popuation Poicy. 7 The State Legisative Assemby approved the document in March The Chief Minister formay reeased the document for the pubic on Juy 11, 1998 ceebrated as The Word Popuation Day. The document was widey circuated and a series of seminars were conducted at the state eve to Letter Re No 4741/D& E-2/D&E/97 from the Director of amiy Wefare, Government of Andhra Pradesh, May 31, 1997 Letter Ref. No. 2182/ W/STAT/97 from the District Medica and Heath Officer of Medak District to a Primary Heath Centre Medica Officers dated May 16, Letter Ref. No. 2665/SO( W)/96 from the District Heath and Medica Officer of East Godavari District to a Primary Heath Centre Medica Officers, June 11, Government of Andhra Pradesh, Andhra Pradesh Popuation Poicy: A Statement and A Strategy, Review of Impementation of Approach for amiy Wefare in India 22

32 disseminate the contents and to seek cooperation and support of various sections of society. The direction to the programme argey comes from various strategies and impementation mechanisms stated in the poicy document. The Popuation Poicy has set an objective of reaching repacement eve of fertiity by the year 2001, by promoting usage of spacing methods among newy married and coupes with one chid, and by encouraging use of permanent methods after two chidren. Based on this objective, working backwards, number of new acceptors of steriization and spacing methods every year has been cacuated. The state government has a taken a series of steps to transate popuation poicy into practice. Even before the popuation poicy was formay reeased to the pubic, the Department has constituted a State Counci for Popuation Stabiization with the Chief Minister as Chairman, Minister of Heath and amiy Wefare as Vicechairman, and with severa ministers and senior secretaries as members. Later, reigious eaders and experts were added to the Counci. 8 Simiar committees were constituted at district and municipa corporation eves. 9 These committees are not yet fuy functiona but the constitution of committees in it sef is a first step in the initiation of processes to invove peope from different waks of ife and take their inputs in effective impementation of programme. The Department of Heath and amiy Wefare, AP, has taken a few significant steps to improve access to services. Estabishment of women heath centres is one such measure. In each district four to five PHCs were converted into women heath centres to provide round-the-cock reproductive heath services. To improve services in remote areas, and aso to create empoyment to a arge number to auxiiary nurse midwives (ANMs), a sef-empoyment scheme was aunched to train ANMs in reproductive heath services. These ANMs wi be paced in a viage of their choice and they wi be aowed to either charge for services or accept payments from the gram panchayat. A the other measures initiated Andhra Pradesh is the during this period are to improve first state in the country steriization performance. Ski to formay approve the training for MOs in doubepuncture aparoscopy was State Popuation Poicy. The document was widey circuated and a series of aunched to cover a government seminars were conducted doctors with post-graduate at the state eve to quaification in gynaecoogy and disseminate the contents obstetrics. Simiary, efforts were and to seek cooperation made to popuarize the mae and support of various steriization method. Specia sections of society. campaigns were aunched in two districts and the number of acceptors of vasectomy, as a resut, increased consideraby. But in Waranga and Karimnagar districts, traditionay 20 per cent of a acceptors of steriization operations are vasectomy acceptors. The experiences of these districts cannot be automaticay 8 9 GO Ms. No., 137 amiy Wefare Programme Impementation of State Popuation Poicy Constitution of a State Counci for Popuation Stabiisation Orders issued on May 6, GO Ms., 270 amiy Wefare Programme Impementation of State Popuation Poicy Constitution of State Counci for Popuation Stabiization Incusion of certain names as specia invitees Orders issued on Juy 9, GO Ms. No., 311 amiy Wefare Programme-Impementation of State Popuation Poicy-Constitution of District Leve Societies for Popuation Stabiization and Manda eve and Gram Panchayat Leve Committee Orders-Issued on August 14, GO Rt No 148 amiy Wefare Programme Impementation of State Popuation Poicy Constitution of Governing Body and Executive Body of Hyderabad City Popuation Stabiization Society, Orders issued. Approach in Andhra Pradesh 23

33 transmitted to other districts. The state government, therefore, decided to conduct a study to find out reasons for high acceptance of vasectomy in these two districts before deveoping strategies and scaing up activities to other districts with ow vasectomy acceptance. New incentive and award packages were introduced to improve performance. The Chief Minister distributed cash awards and merit certificates for best performing districts, best MOs, supervisors and workers, and aso a few coupes who adopted steriization after two daughters, which acts more ike a symboic The Chief Minister of gesture. Simiar packages were Andhra Pradesh monitors performance at two eves. aso introduced at the district He conducts reguar eve. A specia scheme was aso monthy meetings with drawn to provide heath heath officers at state eve insurance coverage for coupes to review performance and who adopt a permanent method he aso reviews district after one or two chidren, coectors performance and this was sent to the GOI every month, of which for financia assistance. Simiary, famiy panning is an the meeting of Heath Ministers important component. of southern states, hed in Hyderabad, strongy recommended to the GOI to increase compensation towards oss of wages to steriization acceptors from Rs. 200 per person to Rs In addition to the above measures to improve access to and quaity of services at a eves of programme impementation, performance monitoring has become a strong component. The Chief Minister of Andhra Pradesh monitors performance at two eves. He conducts reguar monthy meetings with heath officers at state eve (at times, the district heath officers are aso invited to the meetings) to review performance and he aso reviews district coectors performance every month, of which famiy panning is an important component. No previous Chief Minister of the state had given so much importance to famiy panning. In fact, popuation stabiization has taken a centra roe in a deveopment activities. In a pubic speeches, the Chief Minister mentions the need for reaching popuation stabiization as eary as possibe and takes fu credit for improved famiy panning performance in the state. Experiences of Impementing T A at District Leve Information was coected from heath functionaries at district, bock and sub-centre eves on experiences of impementing T A in East Godavari, a high performing district and Medak, a ow performing district. The processes foowed and opinions given are described beow. East Godavari: The Commissioner of amiy Wefare advised East Godavari district to generate expected eves of performance from grassroot eve. A district eve workshop was conducted for a MOs for two days from Apri 22-23, In turn, the MOs conducted meetings at PHC eve for supervisors and workers. The orm 2 manua which was issued as part of T A, was used to coect information from cients. Based on the information coected, East Godavari set its own targets that were different from the performance eves communicated by the Directorate (see igure 1). The differences between the expected eves of performance given by the states and those generated from beow was margina for steriizations, IUCDs and ora pi users. The major difference was in regard to condom users. The expected 10 Note of Coordination Among Socia Sector Programmes, Presented by Government of Andhra Pradesh in Southern State Heath Ministers Conference, hed in Hyderabad on June 21, Review of Impementation of Approach for amiy Wefare in India 24

34 Fig. 1 Difference Between Expected Leve of Performance Generated From Beow and Given From Above in East Godavari District: performance eve given from above cacuated much higher condom-users compared to the number generated from beow. In any case, performance monitoring is done based on the state-given number and not based on numbers generated from beow. East Godavari district, however, demonstrated that it is possibe to generate expected eve of performance based on cient needs. Medak : In contrast to East Godavari, there was no progress in Medak district. Training programmes were conducted at district eve for MOs but most of the medica officers coud not comprehend the training contents and were, therefore, not in a position to transate the training curricuum into practice. The district had accepted the expected eve of performance given by the state and distributed these on pro-rata basis to individua workers. In both Medak and East Godavari districts, the nomencature was changed from T A to participatory panning approach to community needs assessment (), approach causing considerabe confusion at a eves in the organization. Each time the nomencature was changed, there was a demand for re-orientation training. At the same time, no serious effort was made to conduct the training programmes in a systematic manner. Many trainers did not understood the contents of manuas suppied to them. As a resut, the variation between districts in regard to impementation of T A was significant. The better performing districts coud generate data on expected eve of performance from beow, whie the districts with ow eves of performance coud not. In any case, the performance eves given to districts by the Directorate were taken into consideration for monitoring performance and the expected performance eves generated from beow were ignored in The same procedure was foowed in the foowing year. amiy Panning Performance in Andhra Pradesh Steriizations Andhra Pradesh has achieved ony 84 per cent of expected eve of steriization performance for the year , which is much ower than the percentage achievement in the previous three years. This is not due to ow performance in actua terms but due to unexpectedy high eves of performance objective set for Whie the expected eves of performance for the years to varied from 600,000 to 525,000, the expected eve of performance was increased to 750,000 in , which was 43 per cent more than what it was in the previous year. The increase was argey due to the persona intervention of the Chief Minister in one of the review meetings. He opined that the objectives shoud be high and everyone shoud make every effort to see that the objectives were achieved. He provided additiona funds from state resources to famiy wefare programme for the first time and promised more, if necessary. Given this, the heath Approach in Andhra Pradesh 25

35 Tabe 1 Expected and Actua Leve of Steriization Performance in Andhra Pradesh from to Year Expected Performance Actua Performance Per cent Achieved , , , , , , , , , , officers had no aternative but to have very ambitious objectives. In absoute terms, the government of Andhra Pradesh has done the highest number of steriization operations compared to any other previous year in the history of the programme. However, this is a resut of enormous pressure exerted on the system at a eves, as is evident from the comparative anaysis of quarter-wise performance from to The first quarter steriization performance was 17.2 per cent of the tota performance in and decined to 12.8 per cent in Simiary, the ast quarter performance increased from 32 per cent in to 40 per cent in Increase in performance in the ast quarter is due to intensive monitoring, that begins in December depending on the extent of achievement of objectives upto that month. Monitoring of Fig. 2 Steriization Performance in Andhra Pradesh performance in the ast four months of the fisca year is done on amost daiy basis for a institutions. Encouraged by the resuts of performance, the state retained the expected performance eve at 750,000 operations for the year The district coectors were made administrative eaders of the programme. They were given a free hand to mobiize funds ocay from industriaists/ businessmen, in addition to the fexibe resources provided to the district eve societies from the state government funds. The Chief Minister, in the innovative Dia CM programme on Doordarshan and Radio, specificay chose popuation as a subject to appea to the peope to use contraceptive methods. Monitoring at a eves was tightened and more emphasis was paced on districts with traditionay ow performance. As a resut, the steriization performance in the state in was the highest ever achieved. Neary haf of the districts exceeded the expected eves of performance and two-thirds of these districts were from the ess deveoped Teangana region. Enormous increase in steriization performance in the state coud be gauged by the fact that ony 76 operations per 10,000 popuation were conducted in Andhra Pradesh in and this increased to 95 operations in and reached a peak eve of 100 operations in A steriization performance reported by the government is not pubic sector performance but incudes private sector contribution. Neary 30 per Review of Impementation of Approach for amiy Wefare in India 26

36 Tabe 2 Per cent Quarter-wise Performance of Steriization Operations in Andhra Pradesh: to st Quarter nd Quarter rd Quarter th Quarter cent of tota steriization operations in a given year are done by the private sector. 11 In , private hospitas might have provided services to 219,292 steriization acceptors. The private hospitas charge for services provided, depending on the market segment they cater to, varying from Rs. 1,500 to Rs. 6,000 per cient. 12 Even if minimum charges are taken into consideration, steriization acceptors using private sources for services spend about Rs. 328 miion on hospita expenses aone. Increasing use of private sector and aso growing number of private sector hospitas has consideraby contributed to improved steriization performance. Spacing Methods Andhra Pradesh has the owest proportion of spacing method-users as per the Nationa amiy Heath Survey (N HS) conducted in 1992, and this continued to the same based on preiminary resuts of N HS II conducted in There are no serious steps initiated to rectify the situation. The state government has tried to market ora pis and condoms through a network of fair price shops, aready in pace to se essentia commodities such as rice and cooking oi at subsidized rates. But these shops function ony on days the essentia commodities are suppied to them. Socia marketing of contraceptives through this mechanism is neither feasibe nor effective. Athough the popuation poicy document recognizes the need for promotion of spacing methods among newy married and coupes with one chid, no strategy was deveoped in year , to create demand and aso to step-up activities reated socia and commercia marketing. IUCD The expected eve of Athough the popuation poicy document performance for IUCD was recognizes the need for 350,000 insertions but the promotion of spacing reported achievement was ony methods among newy 293,872 insertions. Of the tota married and coupes with districts, eight districts exceeded one chid, no strategy was the expected performance, 11 deveoped in year districts coud not reach the 98, to create demand and expected eves and the remaining aso to step-up activities were nearer to expected eves. reated socia and The performance eves varied commercia marketing. from 28 per cent in Medak district to 117 per cent in Prakasham district. The reported performance decined consideraby between and and remained more or ess at the same eve after that. The Department of amiy Wefare does not coect information on the extent of expusions and removas. Ora Pis The expected eve of performance was in regard to the number of ora pi-users but the statistics Jaikishan Desai, Roe of Private Sector in amiy Panning Services in India, Washington, The utures Group Internationa 1997 (mimeo). The cient fee information has been coected from different private hospitas in Hyderabad City in 1998, catering to different market segments. Approach in Andhra Pradesh 27

37 submitted to the Department were in terms of number of cyces distributed. The Directorate divides the number of pi cyces distributed by 13 to get the number of actua users. The information provided is considered highy unreiabe. The actua performance for the year was 85 per cent of expected performance but five per cent higher than what it was ast year. Condoms The expected eve of performance for condoms was not given for but was reintroduced in The performance for the year was 89 per cent of the expected eve but decined to 67 per cent in As is the case with ora pi cyces, the number users of condoms are reported to the Directorate but ony number pieces are distributed. The Directorate divides number of pieces of condoms distributed by 72 to get the number of users of condoms. The performance fuctuates based on expected eve of performance for the year and the suppy situation of contraceptives. No one, even at the Directorate eve, give any credence to the spacing method performance reported by districts. Every one considers the data unreiabe and shoud, therefore, be not taken seriousy. Monthy performance reviews at a eves in the organization ony concentrate on steriization performance and not on spacing methods. Andhra Pradesh, even after the aboition of T A, soey depends on the promotion of steriization methods to reach repacement eve fertiity in the next three years. Private sector contribution to spacing method use is aso negigibe. The wastage invoved in free distribution of contraceptives in the state is enormous. ertiity Transition in Andhra Pradesh Andhra Pradesh has been experiencing rapid fertiity transition and has amost reached the repacement eve of fertiity. The tota fertiity rate (T R) in Andhra Pradesh in 1991 was and decined to 2.25 in The fertiity decined among a age groups of currenty-married women in the reproductive age of years. The main reason for decine in fertiity is increased use of modern methods of contraception. Ony ess than haf of the tota coupes (47 per cent) used any contraceptive method in and neary 60 per cent of coupes used any method in There was no change in percentage of users of spacing methods. Tabe 3 Expected Performance and Actua Performance of Spacing Methods and Per cent of Expected Performance Achieved Year IUD Ora Pis Condoms EP AP PA EP AP PA EP AP PA , , , , ,520,000 1,252, , , , , * 820, , , , , , , , , , , , , , , , , , , EP=Expected Performance; AP=Actua Performance; PA= Per cent Achieved * Not given Popuation Research Centre and Internationa Institute of Popuation Sciences, Nationa amiy Heath Survey, 1992 : Andhra Pradesh, Mumbai, May Indian Institute of Heath and amiy Wefare and Internationa Institute of Popuation Sciences, Nationa amiy Heath Survey, (N HS II), Preiminary Report, June Review of Impementation of Approach for amiy Wefare in India 28

38 Ony 1.9 per cent coupes were current users of modern spacing methods in and aso in The main increase in method use was due to steriization users who increased from 44 per cent in to 57 per cent in ertiity preferences in Andhra Pradesh have undergone major changes in recent times. In , ony 10 per cent coupes with one chid and 49 per cent coupes with two chidren opted for steriization and this increased to 11 per cent for coupes with one chid and 72 per cent coupe with two chidren in Acceptance of steriization after two chidren has become a universay accepted norm in Andhra Pradesh. Fig. 3 Percentage of Currenty Married Women in Reproductive Age with One or Two Chidren Who Opted for Steriization Materna Chid Heath Services There was substantia improvement in MCH services in Andhra Pradesh in recent times. Pregnant women who received two or more doses of TT, increased from 75 per cent in to 82 per cent in and those who received iron and foic acid (I A) tabets during the same period increased from 76 per cent to 81 per cent. Institutiona deiveries increased from 33 per cent to 50 per cent, and deiveries by trained personne from 49 per cent to 65 per cent. Percentage of chidren given a required doses of a types of immunization increased from 45 per cent to 52 per cent and those not getting even any immunization decined from 18 percent to five per cent. Concusion The Government of Andhra Pradesh rigorousy pursued the famiy panning programme in Its state popuation poicy was approved and steps were initiated to impement the poicy. Athough opportunity was given to the districts to generate expected eves of performance, foowing the methodoogy prescribed by the GOI, the performance, eves expected from each districts were actuay determined at the state eve, based on Source: N HS I and II objectives set to achieve repacement eve of fertiity in the popuation poicy. The nomencature of T A had been changed to participatory panning approach and then to community needs assessment () approach, causing considerabe confusion among workers as we as MOs. Training programmes were conducted at various eves to famiiarise workers with new methodoogy but the quaity of training was such that many workers had not understood the basic concepts. Districts with more efficient management systems were abe to generate the expected eves of performance from beow whie districts with weak systems did not attempt the new approach. Training programmes, funded by different agencies, acked uniformity and the state had issued instructions to conduct the training programmes without putting any effort to improve the quaity of training. In programme impementation, improved steriization performance became the centra theme of the programme. Monitoring by the Chief Minister increased pressure on a functionaries in the organization. More camps were conducted and Approach in Andhra Pradesh 29

39 performance monitoring in urban areas was for the first time given considerabe importance. Steriization performance in was the highest in the history of this programme in the state. Andhra Pradesh has aso succeeded in increasing the number of steriization acceptors with two or ess chidren. But this has aso increased the number needing recanaization services, given the high infant mortaity rate (IMR) in the state. However, no significant efforts were made to improve the demand for and access aspects of spacing methods. Andhra Pradesh continues with its traditiona approach of promoting steriization method to achieve repacement eve of fertiity by 2001 and is cose to achieving this objective. Strong poitica support to the programme, administrative commitment, mobiization of additiona resources, invovement of district coectors in programme impementation and effective monitoring systems are the main factors that have contributed to the success of programme in Andhra Pradesh. Review of Impementation of Approach for amiy Wefare in India 30

40 Community Needs Assessment Approach for amiy Wefare in Bihar Daya Krishan Manga Gadde Narayana Background Bihar has a popuation of 86 miion according to the 1991 Census, which ranks it as the second most popuous state in India. Bihar s economy is predominanty agrarian with about 87 per cent of the popuation iving in rura areas and argey dependent on agricuture for their iveihood. About 53 per cent of the rura and 58 per cent of the urban popuation ive beow the poverty ine. The state recorded a growth rate of 2.4 per cent per annum during , which was very cose to the nationa average. The sex ratio in the state has consistenty decined over the years: it was 954 femaes per 1,000 maes in 1971, 946 in 1981 and 911 in The ife expectancy for maes was 56 years and for femaes, 54 years. The age structure of the popuation is young: the proportion of the popuation under age 15 years is 41 per cent whie that of 65 years and over is four per cent. In 1991, persons beonging to schedued castes (SC) and schedued tribes (ST) constituted 15 per cent and eight per cent of the state s popuation, respectivey. The crude birth rate (CBR) was 31 and the crude death rate (CDR) was 9.4 in 1998, according to the Sampe Registration System Buetin. 1 Athough there has been a steady decine in fertiity in the state, the tota fertiity rate was sti 4.4 in The infant mortaity rate (IMR) was 68 per 1,000 ive births in rura areas and 51 in urban areas. ertiity preferences among currenty-married women age years 1 Registrar Genera of India, Sampe Registration System Buetin, October 1999, Government of India, New Dehi. 31 Approach in Bihar

41 showed that 30 per cent wanted no more chidren and 16 per cent did not want chidren for at east two years. The unmet need for contraception among currenty married women in the reproductive age groups was as high as 25 per cent, of which 11 per cent had an unmet need for imiting methods and 14 per cent had an unmet need for spacing methods. In 1998, ony 21 per cent of eigibe women in Bihar were current users of any modern method of famiy panning. Of the tota number of modern method users, 89 per cent had accepted steriization. 2 The Target- ree Approach: The Beginning The state government impements the famiy wefare programme through a vast network of primary heath centres (PHCs), additiona primary heath centres and sub-centres in rura areas. Prior to the introduction of the T A, the GOI aotted annua performance targets to the Bihar Department of amiy Wefare. The Department, in turn, distributed the targets proportionay to the districts in the state, and the districts set the targets for the PHCs and sub-centres. The Bihar Department of amiy Wefare impemented the target-free approach (T A) in one district in on an experimenta basis and then extended it to a districts in , in accordance with the instructions and guideines provided by the According to senior Government of India (GOI). administrators, the RCH service deivery system in The T A was subsequenty Bihar has many serious probems. The infrastructure at service deivery points is grossy inadequate, many staff positions at various eves are renamed the community needs assessment () approach. This study was undertaken in Apri 1999 to document the process of impementing the approach in Bihar. Information vacant, and the morae and was coected from key commitment of the personne in the state workers are ow. Secretariat and Directorate to review the processes foowed and to anayze data on famiy panning performance over the past four years. District officers in Patna and the medica officers (MOs), supervisors and workers of Danapur bock were aso interviewed with the hep of a checkist specificay prepared for the purpose. According to senior administrators, the reproductive and chid heath (RCH) service deivery system in Bihar has many serious probems. The infrastructure at service deivery points is grossy inadequate, many staff positions at various eves are vacant, and the morae and commitment of the workers are ow. The heath staff, more often than not, does not receive saaries and other remuneration on time. The programme budget is reeased at the end of the fisca year eaving itte time to organize services. Supervision is one of the weakest components of the programme. Severa donor-assisted programmes have been impemented in the state to strengthen heath infrastructure and to improve service deivery systems. The India Popuation Project (IPP) assisted by the Word Bank ( ) aims to strengthen infrastructure, training, and service deivery. UNICE funded the Chid Surviva and Safe Motherhood (CSSM) programme, which covered a districts of the state in phases. UN PA began providing assistance in November 1997 to the RCH Project in Patna district to improve the quaity of services. The Word Bank has assisted with the impementation of this project, 2 Internationa Institute for Popuation Sciences and Popuation Research Centre, Nationa amiy Heath Survey: Bihar, , Mumbai. Review of Impementation of Approach for amiy Wefare in India 32

42 which wi eventuay cover a districts in the state in a phased manner. In addition, CARE-India is providing assistance to the Integrated Chid Deveopment Services (ICDS) scheme whie Action Aid is working with non-governmenta organizations (NGOs) to create awareness about Acquired Immuno Deficiency Syndrome (AIDS). It is within this context that the state decided to experiment with the T A in Patna, based on the advice given by the GOI in a meeting of State Secretaries organized in Apri The Directorate of Heath and amiy Wefare informed district heath and famiy wefare officers about the decision in May In the absence of specific guideines from any quarter, district heath administrators were not cear about what was to be done under the new approach. The Chief Medica and Heath Officer (CMHO) of Patna caed a meeting of a PHC MOs in the district, informed them about the seection of Patna for the T A for , and advised them to concentrate more on improving quaity. Ony in September 1995 was the CMHO informed about the methodoogy to be used to hep workers set their own expected eves of achievement (ELA). A set of formats used in Tami Nadu was provided as an exampe. The formats suppied were compex, and there were no resources to train heath personne in how to use them. It took severa months for the PHC MOs to fi them out. In October 1995, GOI caed for a meeting to discuss experiences impementing the T A. The Director of Medica, Heath and amiy Wefare and the CMHO of Patna represented Bihar. During the meeting, GOI instructed the states to prepare district activity pans based on the guideines provided. In ebruary 1996, the Department of amiy Wefare decided to evauate T A in Patna. The Popuation Research Centre conducted the study. It competed the evauation in two phases covering four PHCs in each phase. 3 The report on the first phase was submitted to the government on November 18, 1996, and that on the second phase was submitted on ebruary 28, The reports covered infrastructure in each heath institution, quaity of famiy panning services, beneficiaries of MCH services, and characteristics of eigibe coupes (EC). 4 Yet even The T A manua and before the findings were seriousy report formats were reviewed, the GOI decided to very compex and extend the T A to a districts in required information on the country as of Apri severa indicators. 5 Most of the femae heath The T A manua and report workers, supervisors, formats were very compex and and MOs were not abe required information on severa to use the manua or to indicators. 5 Most of the femae fi out the formats. heath workers, supervisors, and MOs were not abe to use the manua or to fi out the formats. Reaizing this, GOI caed for two meetings in Dehi in August 1997, and consuted some grassroot workers. As a resut, the number of formats in the manua was reduced to nine, compared to the 14 prescribed earier. The revised approach was renamed the approach. 6 The new manua was not transated into Hindi unti June Printed copies were sent directy to Letter from the State Secretary of amiy Wefare addressed to the Director (Evauation), dated Juy 2, Popuation Research Centre, Concurrent Evauation of amiy Wefare Programme in Patna District November Ministry of Heath and amiy Wefare, Manua on Target- ree Approach in amiy Wefare Programme, Government of India, Ministry of Heath and amiy Wefare, Manua on Community Needs Assessment Approach, Government of India, Approach in Bihar

43 districts. Interestingy, no copies were sent to state headquarters. State heath officers came to know about the new manua and formats during their supervisory visits to the districts. The Directorate then instructed district officers to foow the new formats when writing their activity pans. The number of formats suppied by GOI to the districts was not, however, enough for a the femae heath workers. The state government started printing them, but a fina decision on their reproduction has not yet been made. Since printed formats were not avaiabe, the PHC MOs were advised to consider the ELA for to be the same as those for Orientation Workshops The Department of Heath and amiy Wefare coud not conduct any orientation workshops in the first quarter of 1997 due to a ack of understanding of the new approach. After proonged discussions, the Department, in consutation with UNICE, decided to use the training support teams aready constituted to impart RCH training. UNICE had earier identified 13 professiona trainers from the NGO sector who were proficient in participatory training for use in their own projects. These trainers were reoriented in the T A and were pressed into service to conduct training sessions for trainers by zones. A tota of 240 trainers were trained from September to December Those trainers aong with the training support teams trained a workers, supervisors, and MOs by October The topics covered in these orientation workshops incuded the foowing: The historica deveopment of the famiy panning programme in the country The status of the heath and famiy wefare programme in Bihar An anaysis of the strengths and weaknesses of the famiy wefare programme Components of the RCH programme An assessment of community heath and cient needs Community participation. Thus, personne at the sub-centre and PHC eves were oriented in assessment of community heath needs for the first time in 1998, two years after the introduction of the approach in the entire state. After Apri 1996, the Directorate had accepted the ELAs provided by the districts. No targets were set from above during this period. Monitoring of performance was done based on the ELAs. Opinions of Heath unctionaries on the Approach Most of the officers at the state and district eves have shared common concerns regarding the T A and its impementation in the state. They fet that the approach benefited the programme in two ways the quaity of services provided to cients improved; and performance reporting became more reiabe particuary for spacing methods. One of the MOs said, We consider the target-free approach as the tension-free approach as there is no pressure to achieve numerica targets. Workers now concentrate on young and ow-parity coupes both for steriization and spacing method services. About the manua and formats, the MOs fet the cacuations invoved in estimating the ELA were very cumbersome. Most of the femae workers were not abe to foow the procedures suggested. In addition to this, the frequent changes in manuas, formats, and instructions given for the impementation of the new system resuted in considerabe confusion Review of Impementation of Approach for amiy Wefare in India 34

44 confusion that often ed to inaction. The MOs stressed the need for fexibiity in the preparation of sub-centre pans. Reproductive Chid Heath (RCH) Services After the introduction of the T A, Bihar started shifting the focus of the programme from imiting methods to a more comprehensive package of heath services for women and chidren. Severa projects funded by donor agencies are being impementing in the state to institutionaize this shift in focus. The Word Bank-Assisted RCH Project The RCH Project was impemented in November A districts were to be covered in a phased manner over a period of five years. The project creates infrastructure, improves service-deivery skis of workers, and invoves NGOs in the provision of RCH services. A tota amount of Rs. 4,491 miion has been sanctioned. To avoid deays, the funds are routed through a newy formed Heath and amiy Wefare Vountary Action Society at the state eve instead of through the government treasury. Simiar societies have been registered at the district eve. The RCH Project provides for severa consutants to assist the Directorate in project impementation. The Directorate has initiated recruitment, but the positions have not yet been fied. Currenty, the Directorate is coecting and compiing information on the equipment avaiabe in different heath institutions. Institutions not having standard equipment wi be suppied with a required items. our mother NGOs have been identified, though funding to smaer NGOs has yet to begin. Two types of training programmes are envisaged as part of the project one for awareness generation and the other for ski deveopment. The State Institute of Heath and amiy Wefare (SIH W) has been recognized as a regiona training centre by the Nationa Institute of Heath and amiy Wefare (NIH W) for a training programmes. The facuty of SIH W attended a master trainer s training programme at NIH W for three weeks in August- September SIH W has so far conducted three training programmes covering three district teams. Each district team was comprised of the MO in charge of district training teams, principas of auxiiary nurse midwife (ANM) training centres, a mass media officer, one gynaecoogist, and one paediatrician. These training teams are supposed to conduct training of Two types of training various groups at district eves. programmes are Due to a deayed decision on the envisaged as part of the mechanism to be used for RCH project one for funding, training at the district awareness generation eve has not yet begun. and the other for ski deveopment. SIH W UN PA- unded has been recognized as a Reproductive Heath regiona training centre Project by the NIH W for a training programmes. UN PA initiated this project in Patna in After a series of consutations and a workshop, UN PA identified priority areas for RCH services in January These incuded prevention of unwanted pregnancies, safe motherhood, reproductive tract infection (RTI)/sexuay transmitted infection (STI) management, chid surviva, infertiity probems, adoescent education, and gender equity. Launched in October 1997, for a period of three years, the project uses women s groups at the district and bock eves to highight heath needs of women and to monitor programme impementation. Border Custer Districts Project In 1999, UNICE seected Bhojpur, Siwan, and Gopaganj districts in Bihar as areas in which to 35 Approach in Bihar

45 reduce by haf the infant and materna mortaity rates over the next four years. The specific objectives of the project are to strengthen ogistics and enhance the capabiities of service providers to render quaity cinica and preventive care to the community. Project interventions incude registering a pregnant women, immunizing a chidren, improving neonata care, deveoping new strategies to reduce materna deaths, and increasing the number of institutiona deiveries. Contraceptive Marketing Janani, a registered society, has been impementing a socia marketing programme in Bihar since June Janani adopted a unique strategy that combines a strong marketbased approach with a community-based distribution system for the deivery of the entire range of contraceptive services and products to every section of the society with specia focus on rura areas. In the first phase, marketing infrastructure was estabished with the introduction of ora contraceptives with the brand name Apsara and Mithun condoms were added to the programme ater on. An extensive fied distribution and promotiona network of 123 stocking and feeder points was created, feeding 8,000 outets consisting of pharmacies, cigarette shops, grocery stores, and genera merchants. A fied force of 40 saes persons and 10 managers ensure that these outets are served reguary and that the products are readiy avaiabe to consumers. Janani adopted a unique strategy that combines a strong market- based approach with a community-based distribution system for the deivery of the contraceptive services and products to every section of the society with specia focus on rura areas. The price of the products was decided on the basis of an easticity test conducted through a we-known market research agency. The ow cost of contraceptives to consumers was possibe due to the subsidy offered by the Ministry of Heath and amiy Wefare (MOH W) and UN PA. Janani procures ora pis at one rupees from the government and spends an additiona Rs. 1 on repackaging. Simiary condoms are procured at Rs per unit and Rs is spent on repackaging. In 1998, Janani sod 1.5 miion cyces of ora contraceptives and 10 miion condoms in the state. To further boost the programme, eary in 1999, Janani introduced the sae of essentia drugs in arge trade packs to rura service providers at competitive prices with free Mithun condoms and Apsara ora pis. The cost of contraceptives is buit into the sae price of essentia drugs. This has heped to invove those service providers who had never shown any previous interest in distributing contraceptives. Suppying rura shops with ow saes voumes is an expensive proposition for any rura marketing agency. To overcome this probem, Janani evoved an innovative approach to invove rura medica practitioners (RMPs) who provide curative services to 75 per cent of a possibe cients. Janani trained them and their wives and offered them a package of services. Janani now has a network of 4,300 trained RMPs who are franchisees under the Janani project, which are identified by the butterfy ogo. Butterfy Centres are aggressivey marketed as centres for good quaity famiy panning services. Each RMP pays an annua membership fee of Rs Janani has aso created a network of non-speciaist doctors under the Surya Cinic franchise to provide cinica famiy panning services. A training cinic was estabished for this purpose in Patna in December The Surya Cinic in Patna provides services at a reasonabe cost and conducted 1,784 medica terminations of pregnancy, 866 Copper-T (Cu-T) IUCD insertions, and 82 miniap procedures in one year. After consoidating the programme in Bihar, Janani has pans to expand the programme to other Review of Impementation of Approach for amiy Wefare in India 36

46 states. Janani s experiences have ceary shown that coupes are wiing to adopt famiy panning methods and pay for services of quaity and easy access. Fig. 1 Steriization Performance in India amiy Panning Performance: to Steriization In , before the introduction of the T A, the state was given a target of 600,000 steriizations by the GOI. The Heath and amiy Wefare Department distributed the target to the districts, which in turn distributed targets to PHCs based on the popuation size of the districts. The actua number of steriization operations done was 206,188, one-third of the target set. No district except Singhbhum coud achieve its target. The extent of target achievement varied from nine per cent to 86 per cent. In amost a districts, 56 per cent of the tota target was achieved in the month of March. or , the state was aocated a target of 679,300 steriizations. Targets were distributed to a districts except Patna, which had been decared as the target-free, experimenta district. The achievement for the year was 39 per cent, which was five percentage points higher than the previous year. In , 60,000 more operations were done than in , but acceptance in Patna decined by 10 per cent with the T A. Again, except for Singhbhum, no other district achieved the target set. In , targets were aboished in the entire state, and PHCs and districts generated their own ELA. The tota ELA for the state was set at 25 per cent ess than the target set for Acceptance decined drasticay to the owest eve in the history of the programme. Ony 82,421 steriization operations were performed during the first year of the T A, that was 16 per cent of the ELA or 30 per cent of the previous year s performance. The ELA for the year was set at 10 per cent ess than that of Performance improved consideraby but it was sti 27 per cent ess than it was in In , the ELA was set at exacty the same eve as it was the previous year, but performance sti decined by 37 per cent. In short, after the introduction of T A, steriization acceptance in Bihar dropped consideraby in the first year and marginay improved in the next two years but never reached the eves. Spacing Methods The anaysis of spacing methods was based on service statistics over a period of five years. The first two years represent the target approach period and the next three years, the T A period. In genera, spacing method data are ess reiabe than steriization data as they are driven more by the number of condoms, ora contraceptives, and IUDs suppied during a particuar year than by the number of actua method users. This methodoogy remained unchanged even after the introduction of the T A. IUDs The target for IUDs for , a target-approach year, was 508,000 and the achievement was 206,551 (40.7 per cent). Performance varied among districts from 10 per cent to 100 per cent. Amost 35 per 37 Approach in Bihar

47 cent of tota IUD acceptance was in the month of March, the ast month of the reporting year. Of a tota of 39 districts, ony 12 reported more than 50 per cent achievement, and two districts reported 100 per cent. The state target was increased to 575,200 insertions for ; a districts were given targets except Patna. Acceptance increased by 30 per cent. After the introduction of the T A in the entire state in , the ELA was ess than the targets given in the previous years. It was ower by 15 per cent for , compared to , but acceptance decined by 43 per cent during the same period. There was a margina increase in expected eves in and , and there was aso a margina improvement in performance. Neary 35 per cent of tota IUD insertions were done during March, which raises severa questions about the reiabiity of the data. The performance among districts varied from no-acceptors at a to 120 per cent of the ELA. Ora Pis The Department set a target of 159,000 users for Reported achievement was 41 per cent of the target. The differentias in performance among districts were very significant. Whie Ranchi reported 400 per cent performance, Saharsa reported just six per cent. During this year, haf of the tota annua acceptance was reported in March. The target in the next year was raised to 180,000 pi-users, but acceptance remained more or ess the same. In the foowing year, , after the introduction of the T A, the ELA for ora pi users increased by 60 per cent, but acceptance decined by 36 per cent, compared to the previous year. ELA increased further in , but performance remained more or ess the same. Condoms GOI set a target of 603,000 condom users in in Bihar. Reporting is based on the number of condoms distributed: the number of users is arrived at by dividing the number of condoms distributed by 72. In other words, it is assumed that for every 72 condoms distributed, there is one condom-user. The target achieved in was 32 per cent. No annua target was specified for condom-users in The reported performance was ony marginay ower that year than it was in the previous year. In , after the introduction of the T A, the ELA was estimated to be 562,800 users for the year. Acceptance was ony 18 per cent of this number, and further decined to 12 per cent in and to 16 per cent in Concusion Bihar first impemented T A in Patna district on an experimenta basis in The district officers were not famiiar with the approach and, therefore, decided to impement it in one bock first and then Tabe 1 IUD, Ora Pis, and Condom Performance in Bihar from to Year IUD Ora Pis Condoms ELA Actua Per cent ELA Actua Per cent ELA Actua Per cent , , ,000 65, , , , , ,000 67, Ni 191,305 Ni , , ,800 43, ,800 99, , , ,000 56, ,566 78, , , ,000 44, ,566 98, Review of Impementation of Approach for amiy Wefare in India 38

48 sowy extend it to other bocks. It took amost seven months to introduce the new formats for data coection and reporting. Even before reviewing impementation experiences in Patna, the GOI decided to do away with the T A and changed the term to, and thereafter decided to extend the approach to the entire country. The Department of Heath and amiy Wefare informed a districts about the decision. It took amost one year to conduct the workshops to reorient the workers about the approach. The new formats which were introduced coud not be printed due to procedura deays; to date, the workers and supervisors sti. The Department accepted the ELAs for famiy panning worked out by each district and did not set any targets in , , and amiy panning performance in Bihar significanty decined for a methods after the introduction of this approach. Many attribute the decine in performance to improved quaity in reporting, athough there was no evidence in favour of that assumption. or a methods, neary 30 to 40 per cent of annua performance was achieved in the ast two months of the reporting period. Programme performance aso suffered because of deays in aocating of funds to the programme, non-payment of saaries, arge numbers of vacant positions at various eves and poor infrastructure. In fact, there is no evidence to suggest that the approach has resuted in either improved programme management or quaity of performance reporting or quaity of services. A majority of workers, even after reorientation training, are sti not abe to foow the manuas suppied to them. In many districts they have not prepared activity pans based on surveys of community needs. The ELA worked out at PHC and district eves were based on the perceptions of workers and MOs rather than those of cients. The monitoring of performance at monthy review meetings with workers was discontinued. More intensive efforts are required to buid capacity and to improve programme management at a eves for the impementation of the approach to be a success. The GOI initiated an annua district survey to ascertain the The heath and famiy status of RCH services in Bihar. wefare programme in The survey 7 covered 21 districts Bihar needs a major review and revamping in 1998; the findings are beak and in order to improve the unfattering. Of the tota current heath status of women users of modern famiy panning and chidren. methods, 90 per cent are users of imiting methods. Spacing method use, in genera, was insignificant. Neary twothirds of a births were third or higher order births. The antenata services provided to pregnant women in a given year varied from five per cent in the owest performing district to 26 per cent in the highest performing district. The heath and famiy wefare programme in Bihar needs a major review and revamping in order to improve the heath status of women and chidren. 39 Approach in Bihar

49 Community Needs Assessment Approach for amiy Wefare in Gujarat C.V.S. Prasad Daya Krishan Manga Objectives of this Study The Government of Gujarat introduced the T A at the behest of GOI, first on an experimenta basis in one district in and then in a districts in The GOI redesigned the T A and renamed it the approach in September Using this approach, heath workers are expected to provide quaity Reproductive and Chid Heath (RCH) services and to assist coupes in meeting their reproductive heath intentions. amiy panning targets are not imposed from the top, rather the workers themseves decide on expected eves of achievement (ELAs) based on their assessment of community needs. This paper describes the experiences in Gujarat with the impementation of the T A an innovation of great significance in the state. The main objectives of the study are the foowing: Document the processes of impementation of the T A and the approach in the state Record the experiences of heath workers regarding the approach and its impementation Anayze the impact of the approach on famiy panning and the RCH programme. 1 Letter from the Secretary of amiy Wefare, GOI, addressed to a secretaries dated ebruary 9, Approach in Gujarat

50 Data for the study were coected from interviews with concerned senior programme managers at state and district eves. ied workers in two primary heath centres (PHCs) and four sub-centres in the districts of Gandhinagar and Panch Maha were aso interviewed using a checkist, speciay prepared for the purpose. Performance data on famiy panning and RCH services from were coected and anayzed. Documents and correspondence reated to the impementation of the T A/ approach were coected and reviewed. The Target- ree Approach: Experimenta Phase ( ) In 1995, the Ministry of Heath and amiy Wefare (MOH W) of GOI decided to impement a T A to famiy panning on an experimenta basis in one or two districts of each state in the country. Initiay, Gujarat identified Vasad and Panch Maha, based on their consistenty high famiy panning acceptance rates. Later it was decided to impement the T A in Vasad ony. The Commissioner for Heath and amiy Wefare informed Vasad district officers about the T A in March 1995 and that no specific targets for famiy panning services were to be aotted for the year The MOH W, GOI, suggested indicators for monitoring programme performance in the experimenta districts. These indicators were coupe protection rate (CPR), the age and parity of acceptors, antenata care (ANC) registration and immunization of chidren ess than one year of age. After the performance review conducted in August 1995, in the meetings, district and state officias expained the T A and emphasized that it demanded more intensive work and a higher eve of commitment to serving the community. The Additiona Director for amiy Wefare briefed the district heath officias of Vasad on the T A at Gandhinagar in Apri Later, a PHC medica officers (MOs) in the district were instructed in T A in sma groups. Trainers expained that the approach represented a paradigm shift and that now the MOs shoud pace more emphasis on invoving the community in assessing its need for RCH services, incuding famiy panning. They shoud further pan services based on perceived needs and shoud ensure the services provided woud be of high quaity. The same message was, perhaps, not propery or adequatey communicated to the fied workers; hence, they were confused about the concept. As a resut, performance suffered. In fact, the performance review conducted in August 1995 aarmed district officias to the point that state and district programme managers convened a meeting of a PHC-MOs to discuss the situation and to suggest corrective measures. This was foowed by a series of meetings at the PHC eve for the staff of the heath and the Integrated Chid Deveopment Services (ICDS) departments. In the meetings, district and state officias expained the T A and emphasized that it demanded more intensive work and a higher eve of commitment to serving the community. Heath workers were instructed in how to estimate ELAs for sub-centre areas. District programme managers reiterated that a coupes with perceived needs for famiy panning and materna and chid heath (MCH) care woud have to be provided high-quaity services. Iustrations were used to emphasize that before the introduction of the T A, each sub-centre worker was serving 215 famiy panning cients, whie under the new approach each worker woud have to provide famiy panning and MCH services to 390 cients. In these training meetings, the programme officers emphasized that under T A there was no room for compacency and reiterated that more intensive efforts woud be needed to provide improved and better services to a cients with perceived needs. Programme managers emphasized Review of Impementation of Approach for amiy Wefare in India 42

51 reguar updating of eigibe coupe registers (ECRs) for assessing cients needs and for providing famiy panning and MCH services. Acceptance of famiy panning decined in Vasad during , though a better profie of acceptors in terms of age and parity was reported. Vasad reported 14,590 steriization acceptors in , a decine of 17.2 per cent over the number in (16,989). Likewise, acceptance of Intrauterine Devices (IUDs) decined by 21 per cent, pis by 12 per cent, and condoms by 16.5 per cent, compared to However, state and district officers were content with the new approach. According to them, a margina decine in the first year of impementation of an innovation of this nature was acceptabe as ong as it was accompanied by improvement in the quaity of services. The MOH W/GOI organized a meeting in March 1996, to review the experimenta phase of T A impementation. The district and state officers representing Gujarat gave positive feedback. 2 They said that the sight decine noted in performance was not a concern at this stage, rather that it was to be expected. However, they expressed a need for more intensive efforts to train fied workers to hep them understand the phiosophy of the new approach, enhance their skis in assessing perceived community needs, and deveop decentraized pans for effectivey serving the community. They aso suggested that the expansion of the T A to the remaining districts of the state shoud be done in a phased manner. Expanding the T A The MOH W announced that it panned to expand the T A to a districts in the country in a meeting of State Secretaries on ebruary 1-2, In short, beginning in Apri 1996, a method-specific targets woud be removed from the famiy panning programme. The etter from the Secretary of amiy Wefare, GOI, dated ebruary 9,1996, addressed to a State Secretaries of amiy Wefare incuded the foowing information: Pease refer to the discussions in the meeting of State Secretaries on ebruary 1-2, 1996, on the issue of extending T A a over the country in This coud be converted to an exceent opportunity to make famiy wefare in India a truy peope s programme. As discussed in the conference, grassroots workers may get together to give an estimate of ikey acceptance of different famiy wefare activities in for every quarter in their jurisdiction to form part of their PHCeve famiy wefare and heath care pan The etter contained broad guideines/suggestions for impementing the T A. The state prompty caed for the remova of targets and the impementation of the T A in a districts and municipa corporations in a meeting in May State officias requested district heath officers of parent districts to impement the approach in newy estabished districts aso. The district officers in turn tod the staff of community heath centres (CHCs)/PHCs about the remova of famiy panning targets and shared a copy of the etter from the State Directorate with them. The Secretary of amiy Wefare, GOI, aso informed a district coectors about the impementation of the T A in a separate communication dated March 4, 1996, and asked them to organize orientation workshops at the district and PHC eves during the month of March and Apri in However, these workshops coud not be organized due to difficuties in funding and a ack of guideines, instructions and resource persons. 2 Letter from Secretary amiy Wefare, GOI, addressed to a district coectors dated March 4, Approach in Gujarat

52 Nothing much happened during the next five to six months because there were no cear guideines or instructions on impementing the T A and deveoping PHC and district pans. Other states in the country had simiar experiences. Reaizing this, the MOH W organized a two-day workshop for state officers in New Dehi in September 1996 in which the T A and its impementation were discussed. A foow-up pan for organizing state and district orientation workshops was deveoped and finaized. In November 1996, an orientation workshop was hed in the state for concerned officers of the Heath and amiy Wefare Directorate, for regiona deputy directors, for district heath officers, for additiona district heath officers, for chief deveopment officers, for immunization officers, and for commissioners of municipa corporations, aongwith medica coege professors of preventive and socia medicine (PSM), paediatrics, and gynaecoogy. In the workshop, the T A was expained; and the process of preparing sub-centre, PHC, and district pans was discussed, as were the panning formats in the manua. A pan was finaized for conducting district-eve orientation workshops. The participants in the state-eve workshops were assigned the responsibiity of organizing and faciitating the district workshops. 3 The district workshops for medica officers were conducted during Apri and May 1997, whie bockeve workshops for the staff of heath and ICDS departments were hed during June and Juy In a, 2,422 medica officers and 16,890 fied staff were trained in the T A in these workshops. Workshops for urban areas were hed in the atter part of They asted two days and focused on the preparation of district famiy wefare and heath care pans using ormat 3 from the T A manua. Bock-eve workshops focused on estimating community needs and deveoping sub-centre pans using ormat 2 from the manua. The MOH W suppied the manua in Engish to the state in May It was transated into the oca anguage and was used in district and bock orientation workshops as background materia. 4 The expected eves of achievement for famiy panning and RCH services were estimated, using the methodoogy described in the manua. The manua incuded norms for estimating the workoad for famiy panning and other MCH services by method. The norms specified the proportion of coupes to be covered with spacing and imiting methods based on parity and age of wife. According to the norms, 50 per cent of married women with no chidren shoud be provided spacing methods; the same proportion of women with one chid shoud be motivated for IUD and pi acceptance. Haf the women with two chidren shoud be motivated for IUD acceptance whie the remaining haf shoud accept steriization. One hundred per cent of women with three or more chidren shoud be motivated for a imiting method. The workoads estimated using these norms were unreaisticay high. The programme managers, therefore, decided to adopt the targets of the previous year ( ) as expected eves of performance for the year Thus, even with intensive efforts to orient staff at a eves, confusion prevaied over the vaidity of the approach and the suggested norms for estimating ELAs, particuary for famiy panning. Improvement in the quaity of famiy panning services was equated by and arge with increased acceptance by younger coupes with ower 3 4 N. D. Ghasura, Bea C. Pate and M. E. Khan, Impementing the Target- ree Approach in Gujarat, Presented in the Nationa Workshop on Target- ree Approach, Lucknow, November 24-25, 1997 Manua on Target- ree Approach, Ministry of Heath and amiy Wefare, Government of India, 1996 Review of Impementation of Approach for amiy Wefare in India 44

53 parity. Therefore, emphasis was paced on recruiting such coupes as famiy panning acceptors. Despite the repeated message in orientation workshops and monthy meetings that under this approach the responsibiity of the workers woud increase, grassroot workers interpreted the T A differenty. Some construed it as no work or no serious commitment whie others took it as a tension-free approach and reaxed. It is noteworthy that most T A workshops were conducted in the atter part of 1997, whie during the financia year , ony state-eve orientation workshops were hed. Thus, during , the impementation of the T A and preparation of sub-centre pans were done amidst a state of confusion due to a ack of cear instructions, guideines and proper training of fied workers. Meanwhie, MOH W received severa reports that the manua had too many compicated formats that were difficut for fied workers to comprehend. The Ministry, therefore, organized a series of workshops on August 19 and August 28, 1997, to simpify the manua and reduce the number of formats. Based on the recommendations of the workshops, the manua was revised, and in a meeting in New Dehi in September 1997, State Secretaries approved the revisions. The approach was then renamed the Community Needs Assessment or approach, in order to remove the misunderstanding and confusion resuting from the misinterpretation by the fied workers of the T A as the no-work approach. The number of formats was reduced from 14 panning and reporting formats for the T A to nine formats for the approach. The MOH W dispatched the manua in Engish to a states in Meanwhie, states continued to foow the earier manua. The Community Needs Assessment Approach The approach further emphasized decentraization in the panning process and reinforced the need for community consutations at the viage eve to deveop sub-centre pans for providing quaity services, incuding famiy panning, under the RCH programme. More emphasis was paced on issues reated to improving quaity of services at a eves in the PHC system. In this context, it was reiterated that decentraized pans for a eves from sub-centres to districts were to be deveoped after assessing the heath needs of coupes by taking directy to them, and by invoving forma and The approach informa viage eaders and further emphasized women s groups in the process. decentraization in the panning process and The manua describes the reinforced the need for revised methodoogy for community consutations at the viage eve to preparation of sub-centre, PHC, deveop sub-centre pans and district pans in detai. It for providing quaity suggests that a househod survey services, incuding famiy shoud be conducted by the panning, under the auxiiary nurse midwives (ANMs) RCH programme. during ebruary and March, using the formats in the manua. Community needs for RCH and famiy panning services estimated using the househod survey findings shoud be vaidated in discussions with Anganwadi workers (AWWs), members of Mahia Swasthya Sangh (MSS) and Panchayat heath committees. The estimates of ELAs or community heath needs for the current year shoud be compared with the achievements of previous years. The estimates shoud be 5-25 per cent higher than the actua performance of the previous year; if cacuations do not yied those resuts then the estimates shoud be carefuy reviewed. The manua further suggests that Attention shoud be paid to famiy panning services, particuary mae steriization since it is ony three per cent of the tota 45 Approach in Gujarat

54 number of steriization operations, and that estimates shoud aso be compared with the estimates from demographic cacuations. The manua concudes, It is important to understand that neither the requirement assessed on the basis of househod survey nor the figures arrived at by the demographic cacuations shoud be treated as fina or beyond question; actuay, it woud be highy desirabe to study past trends. Tak to oca functionaries of different departments such as Anganwadi workers, practitioners of Indian Systems of Medicine, and Mahia Swasthya Sangh. According to the manua, the PHC pan woud be a compiation of a sub-centre action pans under that particuar PHC. The MO in According to the charge of the PHC shoud manua, the ANMs woud cacuate the requirements for pay a key roe for which drugs, vaccines, equipment and they woud undergo other suppies to provide the frequent in-service services incuded in the pan. The training to upgrade their MOs coud easiy estimate knowedge and skis and requirements based on existing understanding of stocks of suppies and the net their duties. requirements for serving the perceived needs of the popuation. Ony information not generated at sub-centres woud be added at the PHC eve, e.g., the number of medicay terminated pregnancies (MTPs) and the number of cases of reproductive tract infections (RTIs) and sexuay transmitted infections (STIs) treated and referred. A additiona information required is printed in capitas in orm 2 of the manua. It aso describes detaied procedures for preparing first referra unit ( RU) and district famiy wefare and heath care activity pans. The manua ceary enunciates what grassroot workers shoud do to provide RCH services using the approach. According to the manua, the ANMs woud pay a key roe for which they woud undergo frequent in-service training to upgrade their knowedge and skis and understanding of their duties. Training in the T A/ Approach T A training was conducted in 1997 with the hep of UNICE, the State Institute for Heath and amiy Wefare (SIH W) and faciitators from medica coeges, but no training or orientation sessions have been conducted in since it was introduced in 1998 nor are any proposed. However, programme managers have informed medica officers in heath centres and district hospitas about the new approach during routine monthy meetings. 5 During our fied visits, we observed that the Director of Education and Information, the State Demographer, and other concerned state officias were training computer/statistica assistants and other cerica staff at the District Heath Office in RCH and the approach. The objective was to invove them in programme monitoring at the grassroot eve and to assist them in preparing sub-centre pans. The manua in Engish has been suppied to a states incuding Gujarat. During our fied visits, we saw the manua (in Engish) in the hands of the district heath officers in both Gandhinagar and Panch Maha; however, they had ony one copy each. They had not copied it or distributed it to the PHCs. Grassroot workers are meanwhie forced to use panning and reporting formats in Engish, a anguage with which they are not very comfortabe. RCH Training Six-day, UNICE -supported RCH training programmes for ANMs were conducted from 5 Manua on Community Needs Assessment Approach, Heath and amiy Wefare Department, Government of India, Dehi, 1998 Review of Impementation of Approach for amiy Wefare in India 46

55 January to Apri 1998, by UNICE district training teams and three to four teams of trainers at the district eve. The curricuum was designed by MOH W/UNICE for ANMs and their supervisors. One session was excusivey devoted to the new approach. One of the SIH W trainers said, After the RCH training, a the ANMs were abe to deveop sub-centre pans using the methodoogy suggested in the T A manua. However, some ANMs required assistance from medica officers of PHCs. Later, MOH W modified the approach and the manua was sent to the state in The manua and formats have been transated into the oca anguage by the state. The staff at the SIH W fees, however, that the transation needs to be simpified further so that the workers wi be abe to understand it. The printing of the manua and the formats wi be done once the transation is finaized. No separate training or orientation was done in the revised approach or in the use of the simpified panning and reporting formats. The SIH W trainer reported that training or orientation in woud be carried out as a part of the training programme for ANMs proposed under the RCH project. Experiences of unctionaries with the T A/ Approach As mentioned previousy, the T A/ approach envisaged that functionaries at a eves of the service deivery system woud work rigorousy to deveop famiy wefare and heath care activity pans annuay and woud invove the community in the process. The pans were to be prepared every March before the start of the new financia year. After assessing community needs, the workoad for each RCH and famiy panning service woud be estimated in reaistic terms at the sub-centres. In addition, the avaiabiity of suppies incuding contraceptives, equipment, and manpower woud be stipuated. This activity pan was to enabe heath workers to pan their day-to-day work routines and make overa pans for the year. In a four sub-centres visited in the districts of Gandhinagar and Panch Maha, the staff prepared the pans for with the hep of their respective supervisors. To be more specific, the supervisors assumed primary responsibiity for computing the workoads. There were instances in which the supervisors had correct information about the popuation of the viages in the sub-centre, incuding the number of eigibe coupes (EC), the number steriized, the number currenty using a modern spacing method, the number potentiay needing counseing services, and the distribution of coupes by number of iving chidren. However, the ANMs contacted were not confident about the process of assessing community needs for famiy panning and RCH services, nor coud they produce proper records. Aso, a discrepancy was observed between the ists of EC by parity and ists of coupes with unmet need for famiy panning maintained by the ANMs and supervisory staff at the PHC. Though it is not proper to generaize on the basis of these four observations, one may agree that the approach is not yet we understood at the sub-centre eve by the ANMs whie supervisors, on the other hand, have a very good understanding. This difference might be mainy attributabe to the differences in their education and exposure eves. A group discussion with six MOs from different PHCs and CHCs in the Panch Maha district indicated that they were we versed in the T A. They confirmed that training programmes had been conducted at a eves during They admitted, however, that they did not know about the recent changes to the approach. In spite of this, their action pans were prepared and submitted on time to the district office, and the district pan was prepared foowing the guideines in the T A/ 47 Approach in Gujarat

56 manua. At the state eve, the Heath and amiy Wefare Directorate compied the state pan from to and submitted it to the MOH W. of iving chidren. The district performance is discussed with the Chief District Heath Officer during the meeting hed every three months at the state eve. During discussions, one state officer commented on the process of preparing district activity pans. He said, Decentraized district pans are prepared at each district foowing the approach. The ANMs prepare sub-centre pans based on the househod survey carried out during March and the consutations with the community. The sub-centre pans are coated at the PHC to form the PHC pan. A the PHC pans are coated and pans of urban areas are added to them to prepare district pans on orm 4 State officers fet that the of the manua. The district approach has sends a copy of it to the resuted in improvement MOH W directy and one copy in the quaity of data to the Department of amiy reported by the fied Wefare in the state. The state workers. There was a prepares its pan by coating the sight decine in district action pans and finaizes performance initiay, but it has stabiized now. the estimated workoad for each district. During discussions it emerged that a the workers are not abe to prepare sub-centre pans as envisaged by the T A/ approach, so they do need more training on a reguar basis. Some information is provided at the PHC monthy meetings, but it is not enough. One state officer said, The statistica and computer assistants are trained for two days every year. They in turn provide training to other staff at the PHC eve. The formats are sti in Engish and many workers are finding it difficut to comprehend them. State officers fet that the approach has resuted in improvement in the quaity of data reported by the fied workers. There was a sight decine in performance initiay, but it has stabiized now. The performance in MCH indicators is better than that in famiy panning. The workoad for MCH indicators was prepared ony ast year, and during this period performance had not decined. He further said, The pan prepared by the district is reviewed to see the workoad estimated by the district. If it is found to be too ow then a revised workoad is estimated based on the past performance during the ast two-three years, the number of unprotected EC in the district, and the capabiity of the district. The revised workoad is then communicated to the district and to GOI. Such revisions were done in case of two-three districts ony during the year The programme performance was monitored based on the workoad submitted by the districts. No targets are given by the state in any form. The performance is aso monitored on quaitative aspects such as age of wife and distribution of acceptors according to number The manua provides formats for reporting and monitoring performance every month at different eves against the estimated eve of achievement: subcentre, PHC, CHC, RU, district, and state. Compared to the formats in the T A, those in the manua are fewer and simper. The formats cover information on the previous month s performance, the current month s performance, and cumuative performance up to the month for the previous year, and cumuative performance for the current year vis-à-vis the expected achievement in the current year. During our fied visit, we observed at both district heath offices that the staff was not very comfortabe Review of Impementation of Approach for amiy Wefare in India 48

57 fiing out the reporting and monitoring formats, perhaps because they did not thoroughy understand a the coumns. The district heath officers did, however, understand them and were heping their cerica/computer staff in the preparation of the progress reports. Unfortunatey, the heath officers coud not spare enough time for this purpose and, therefore, use of the formats was not progressing we. We were tod that most of the districts are reporting performance on the formats suggested in the manua as we as on the T A formats, whie ony 50 per cent of districts are sending performance reports on ormat 9 of the manua. The MOH W suggested computerizing the reporting formats and invoving the Nationa Informatics Centre (NIC) network in the process. The NIC was entrusted with the responsibiity and started computerizing the formats, but due to preoccupation with other activities at the district eve, adequate time was not given to compiation and onward transmission of reports through the NIC network. The state government has frequenty written to the NIC asking them to compete the process. Besides impementing the approach, the state government is impementing other projects and interventions to increase access to and quaity of RCH and famiy panning services. A few important projects and activities are briefy described beow. Innovative Projects and Activities Word Bank-Assisted RCH Project The state government submitted the RCH project to the MOH W on March 16, 1998, for funding worth Rs. 152 crore (a crore is 100,000,000). It is a five-year project to improve the quaity of RCH services that wi be impemented in a districts in a phased manner. The first phase is for two years; expansion wi be based on the experience gained therein. In March 1998, the MOH W reeased the sum of Rs crore as an ad hoc grant for minor civi works, contractua staff, procurement of drugs and procurement of other suppies. Over and above the RCH project, GOI has reeased the sum of Rs crore for the RCH sub-project in Vadodra District against the tota project cost of Rs crore. The funds reeased by GOI on March 31, 1998, coud not be used as they needed revaidation, which was not received unti August 31, The Vadodra project is aso for five years. Interventions incude information, education and communication (IEC) orientation activities, deveopment and Besides impementing the procurement of IEC materias, approach, the state monitoring and evauation, government is strengthening of infrastructure, impementing other and strengthening of RCH projects and services at RUs/CHCs with interventions to increase provision of RTI/STI services. Of access to and quaity of the tota Rs crore sanctioned RCH and famiy panning services. unti September 1999, Rs crore has been spent. Major expenditures were for construction of 50 subcentre buidings with maternity wards and abour rooms. Other activities were minor civi works at PHCs, orientation training activities for newy married coupes, fok IEC programmes, counseing camps for adoescents, orientation camps for eected femae representatives and other women in 200 viages, 12 bock-eve workshops for traditiona birth attendants (TBAs), and a baseine survey. The RCH project provides for additiona positions at the state eve for effective managers, but the positions have not yet been created. However, existing positions have been re-designated to satisfy MOH W requirements for providing funds under the project. The project aso provides positions for five consutants. These positions have been 49 Approach in Gujarat

58 advertised and a seection committee has been formed by the state. To date, seections have not been made. it has not yet started in the state. The state does conduct the foowing ski-based training programmes: Gujarat receives funds for the RCH project from GOI through the norma treasury channe. However, to faciitate the fow of funds and provide requisite fexibiity in impementation of the project, the state has created RCH societies at the district eve under the chairmanship of the District Chief Executive Officer. Project funds are paced at the disposa of the society. The SIH W has been identified as a noda agency for a RCH training activities in the state. Training committees have accordingy been constituted at the state and district eves and awareness-generation training programmes (AGTP) have been organized in coordination with UNICE for state, district, subdistrict and tauka personne and for grassroot workers in heath and reated departments. Personne are trained in groups of in divisiona training centres by district training teams and by the facuty of ANM training centres/lady Heath Visitor (LHV) training schoos. These two-day training sessions cover the topics recommended by NIH W incuding the concept of RCH, strategies for programme impementation, the popuation exposion, materna care, adoescent heath, RTIs/ STIs, and methods of famiy panning. Sociodemographic data by district was aso presented. The sessions were interactive, and audio-visuas were used to make them interesting and effective. The AGTPs started in December 1998 and, to date, 218 groups have been trained, covering 4,300 functionaries in the state. The tota number of trainees is approximatey 90, Besides the AGTPs, ski-based training for a categories of heath functionaries is another important intervention of the RCH project, though Medicay Terminated Pregnancy (MTP) Training There are eight MTP training centres in the state; six centres are ocated at medica coeges and two at other paces. One MO is sent for training to each training centre for 15 days as per GOI circuar dated August 4, or certification, a trainee has to assist 10 MTP cases, perform 10 MTPs under supervision, and perform five MTPs independenty. The trainees are trained in the suction technique of conducting MTPs of ess than 12-weeks duration. After the successfu competion of training, a certificate of Pane Surgeon is awarded. ifty-four MOs have been trained since The trainees are seected from PHCs where operating theatres are avaiabe and instruments for MTP have been suppied. Laparoscopic Steriization Training Ony a quaified gynaecoogist with at east one year of experience can receive training/orientation at one of the five medica coeges in the state. Training asts one month, of which 15 days are in the institution and 15 days are in camps. Trainees are required to assist with 25 steriization cases and perform 25 steriizations in the camps. The trainees are examined by the institution for proficiency and, if found successfu, are awarded a certificate of Pane Surgeon. ifty doctors were trained in aparoscopic steriization between 1996 and UN PA IPD Project Kutch, Sabarkantha, Banaskantha, Surendra Nagar and Dahod districts are covered under the UN PA Integrated Popuation and Deveopment (IPD) project, which was sanctioned on June 4,1999. The project focuses on decentraization, quaity Review of Impementation of Approach for amiy Wefare in India 50

59 of care, introduction of a more comprehensive package of RCH services, and on providing women access to information and a roe in programme management. The districts in the project were chosen based on socioeconomic criteria and heath needs. Three-fourths of project activities are directy reated to RCH; the remaining one-fourth is concerned with socia deveopment. The project is under the direction of a state committee headed by the Chief Secretary and a state project management committee with representatives from the project districts. To faciitate impementation of the project and ensure the smooth fow of funds, the district RCH societies created under the Word Bank RCH project have been restructured. Each project district has an RCH committee that incudes a UN PA representative. Project funds have been reeased by GOI to the state, though the state has yet to reease the funds to the district societies. UNICE Border Custer Districts Project GOI has asked UNICE to work cosey with state governments to acceerate the impementation of an RCH programme in seected border districts. UNICE is, therefore, funding a four-year project in custer districts with the objective of reducing infant and materna mortaity rates (MMR) by 50 per cent. In Gujarat, Danga and Vasad districts were seected in consutation with the state government. The specific objectives of the project are to strengthen ogistics and enhance capabiities of the service providers to offer quaity cinica and preventive care to the community. Specificay, the project aims to do the foowing: Register 100 per cent of pregnant women Immunize100 per cent of chidren Reduce chidhood mortaity from common diseases Reduce neonata deaths by improving neonata care Identify causes of materna mortaity and devise strategies to reduce it Promote birth spacing and the use of imiting methods of contraception Improve the quaity of deiveries in pubic and private institutions Improve the functioning of RUs Provide RTI/STI and AIDS-reated services. Key components of the project are community, need-based, sub-centre service deivery; community-based monitoring and management of sub-centres; an effective ogistics system; an improved referra system; and training of heath workers. Mahia Sammean (Women s Conference) The theme of WHO Day in 1998 was Safe Motherhood; it was ceebrated with much fanfare and a massive mobiization of the community and of women s organizations in particuar. The focus of the weekong ceebration was the heath exhibition and the Mahia Sammeans, which were addressed by the Chief Minister, the Minister of Heath, and other ministers and senior officers of the state. Over one akh peope visited the heath exhibition. In addition, a Jeevan Raksha Yatra was organized to cover 10 per cent of Gujarat s viages. In this activity, a team of medica, paramedica personne and nursing students camped in the 51 Approach in Gujarat

60 viages and provided information and services to the residents. Fig. 1 Steriization Performance in Gujarat Ma Raksha Mahotsava (Safe Motherhood estiva) The Ma Raksha Mahotsava was hed from October 1-6, Two-day camps were organized to provide women with diagnostic faciities and services for RTIs/STIs, for cancer and reated probems, and to give tetanus toxoid (TT) immunizations to a pregnant women and adoescents within years of age. Iron and foic acid (I A) tabets, nutrition and heath education for chid rearing and breastfeeding, and immunization services were aso provided. A maternity benefit of Rs. 300 was offered to a eigibe pregnant women who attended the festiva. amiy Panning and RCH Performance Limiting Methods Gujarat has performed very we in achieving steriization targets over the past 10 years. In and , the acceptance of imiting methods was 100 per cent or more of the steriization targets aotted to the state. After impementing the T A on an experimenta basis in Vasad in , overa acceptance dropped by seven percentage points compared to the previous year. Vasad reported a drop of 17 percentage points in that year. The T A was extended to a districts of the state in That year the state reported a decine of 12 percentage points in acceptance compared to that in The decine was about 20 per cent compared to eves. This was a significant drop in performance that can be directy attributed to the new approach. Acceptance consistenty decined thereafter in and though the drop was margina. The absoute number of steriization acceptors was more or ess constant from whie the ELA increased marginay by 20,000 in compared to the base year (see igure 1). Inter-district variation in acceptance was not significanty different pre-t A and post-t A/. Anaysis of state data reveas a gradua and consistent reduction in the average number of chidren among coupes who choose steriization. The average for tubectomy acceptors decined from 3.11 chidren in to 3.05 chidren in It woud seem, therefore, that the impementation of T A/ increased acceptance by coupes with ower parity. This is a wecome trend and indicates a change in programme phiosophy in which providers are not under pressure to chase numerica targets. However, ooking at the trends, one cannot attribute the reduction in parity of steriization acceptors entirey to the new approach as the decine started before the new approach was introduced statewide. Spacing Method Performance Spacing method use constitutes about one-third of the reported contraceptive prevaence rate in the state; the remaining two-thirds consists of imiting method users. Traditionay, the state has performed very we in achieving spacing method targets. In Review of Impementation of Approach for amiy Wefare in India 52

61 Tabe 1 Spacing Method Performance in Gujarat from Year IUD Ora Pis Condoms ELA* Per cent ELA* Per cent ELA* Per cent Achievement Achievement Achievement , *Expected Leves of Achievement figures in thousands. pre-t A years, achievement was amost 100 per cent. In , acceptance of IUDs was 98.3 per cent, acceptance of pis was per cent, and acceptance of condoms was per cent of annua state targets. When the T A was impemented in Vasad in , however, spacing method acceptors decined by 12 to 21 percentage points for IUDs, pis, and condoms. The T A was extended to a districts in , and acceptance of spacing methods decined significanty thereafter. When compared with pre- T A performance eves, IUD acceptance dropped by 10 percentage points in , by 13 percentage points in , and by 10 percentage points in Pi use decined by 10 percentage points in , by 22 percentage points in , and by 18 percentage points in Condom use recorded a decine of nine percentage points in , 24 points in , and 28 percentage points in State officias attributed this decine in spacing methods use to better reporting, which impies that earier data were infated and unreiabe. Trends in Mean Number of Chidren per amiy Panning Acceptor The state set the ELAs for spacing methods for cose to the targets aotted by GOI in The decine in acceptance during the first year of impementation of the T A was significant and was directy attributed to the new approach. In , the ELAs were set at sighty higher eves. In terms of absoute number of users, acceptance of a spacing methods increased marginay, but due to the higher ELAs, the achievement in percentage terms decined compared to the pre-t A period. State officias were a bit cynica about the approach as far as target setting was concerned. They admitted that due to pressures from GOI, they had to insist on the achievement of the targets. The ony difference was that the targets for the year were considered benchmarks for a subsequent years for setting ELAs and measuring performance. If the districts set targets using the T A/ approach that did not match the benchmark targets of , they were reviewed and revised accordingy by the state. The state sent the revised targets to the district and to GOI. Unike the pre- T A period, however, there seemed to be an eement of eniency on the part of the officias monitoring famiy panning target achievement. They reportedy did not react very criticay if achievement was not 100 per cent. MCH Programme Performance One of the objectives of the T A to famiy panning was to aow grassroot workers to concentrate on MCH activities. A perusa of Tabe 2 beow indicates 53 Approach in Gujarat

62 that the achievement of targets set for seected MCH indicators ike TT (among pregnant women), DPT/ Poio, I A (mother), and institutiona deiveries has been consistenty good in the state. However, regarding Vitamin A and I A, the performance decined after the impementation of the T A. Thus, it appears that the new approach has not yet improved the performance on Vitamin A and I A indicators. Like the ELAs for famiy panning, the ELAs for MCH were aso based on the benchmark targets of Concusion The present review is based on discussions with state officias, district officias of Gandhinagar and Panch Maha, and grassroot workers as we as on the anaysis of officia performance statistics. Indications are that Gujarat has been sowy gearing up to the new approach. Athough one round of training was competed in , sub-centre workers were not confident about estimating workoads and setting their own ELAs. Their supervisors often assisted them in preparing sub-centre pans. The study aso indicates that the state insisted that the famiy panning targets of be used as benchmarks for setting ELAs under the T A/ approach. Both state and district programme managers insisted that workers meet the ELAs during T A/ impementation, but initia confusion and ack of understanding of the approach aongwith weak monitoring resuted in a decine in performance for a indicators. This trend must be reversed or a the famiy panning/popuation contro gains achieved in the past might be erased. Regarding other RCH services, performance figures revea that the shift in poicy has yet to percoate down to the grassroots eve even after amost three years. One of the reasons is a ack of necessary skis and comprehension of sub-centre staff. State officias were quite enthusiastic about the introduction of the T A/ approach. According to them, there was a quaitative improvement in acceptance of imiting methods of famiy panning in terms of a reduction in the age and parity of acceptors. urthermore, they thought the use of the new approach yieded better data on the acceptance of spacing methods. They aso fet that after the T A/ approach was introduced, heath workers were abe to devote more time to MCH and other RCH services. Anaysis of performance for does not, however, substantiate any of these caims. The trend of accepting imiting methods at younger ages and ower parities began prior to the introduction of the T A/ approach, and it continued thereafter. If use of the approach resuted in better quaity data on spacing method acceptance, then we must accept the fact that workers infated earier figures in fear of punitive action for not achieving targets. or other RCH services, the study Tabe 2 Percentage Achievement of ELAs in the MCH Programme in Gujarat Year TT (pregnant women) DPT/POLIO IFA Vitamin A Inst. De State Bureau of Heath Inteigence, Heath Review of Gujarat , Commission of Heath, Medica Services and Medica Education, Government of Gujarat, Gandhinagar, 1997 Review of Impementation of Approach for amiy Wefare in India 54

63 did not show any appreciabe increase in performance or in improvement of quaity after the introduction of the T A approach. State officias identified high numbers of vacancies both in the administrative and technica staff at different eves aong with difficuties in the fow of programme funds as factors that adversey affected the impementation of the RCH programme. Nonetheess, they were confident that in the current financia year, the programme wi gain momentum and performance wi reach pre-t A eves. The findings of this study suggest that the MOH W pushed the impementation of the T A ignoring both experiences in the experimenta phase and state opinion. urthermore, the approach was revised and changes were introduced frequenty without adequate preparation and training support. The introduction of an innovation of this significance and scae perhaps warranted more intensive investment and support from GOI. The states shoud have been permitted fexibiity in the timing and scope of impementation. Efforts shoud aso have been made to quicky transmit a the poicy changes that occurred from time to time. or exampe, the T A was renamed the approach, and panning and monitoring formats were revised. In the fied, however, many of the doctors contacted during our fied visits did not have any idea as to what aterations had occurred with the name change whie the ANMs and supervisory staff had yet to hear about the approach itsef. The use of information technoogy for the faster fow of information from fied to state and vice-versa is a giant stride in the management of pubic heath programmes. However, efforts made so far in this regard have been perfunctory. Aternative ways of monitoring and evauating programmes are essentia for making timey management decisions, especiay when routine reports do not provide required or reiabe data. The introduction of an innovation of the nature of the approach needs consistent support for a substantia period before it is internaized by the system. More intensive, reguar training programmes shoud be organized, and supportive supervision shoud be strengthened unti programme managers are confident that the majority of their heath workers are conversant with the new approach. 55 Approach in Gujarat

64 Community Needs Assessment Approach for amiy Wefare in Karnataka Ramakrishna Reddy P. Hanumantharayappa K.M.Sathyanarayana Background Karnataka is one of the severa progressive states in southern India. Even before independence it had moved to the forefront of the nationa famiy panning programme by estabishing famiy panning cinics in Mysore and Bangaore in the 1930s which was the first officia cinics in the country. The contraceptive prevaence rate 12 per cent in 1971 in the state. increased to 55 per cent in The tota fertiity rate (T R) dropped from 4.4 to 2.5 over the same period. urthermore, there have been remarkabe improvements in materna and chid heath (MCH) indicators, especiay in infant, chid, and materna mortaity rates. 1 Latey, however, famiy panning acceptance has remained more or ess constant, and fertiity eves have reached a pateau. There is aso an enormous regiona variation in the success of the programme. or exampe, whie the divisions of Mysore and Bangaore are performing better than the state average, Gubarga and Begaum are not doing neary so we. Major concerns incude the avaiabiity of heath faciities in rura areas and the often non-existent heath structure in urban areas, vacant staff positions, and, more importanty, cient accessibiity to basic services. Reaizing the need for improvement in these areas, the state has initiated severa need-based projects. In the ast five years, these 1 Sampe Registration System, Registrar Genera of India, 1998 and Popuation Research Centre and Internationa Institute for Popuation Sciences, Nationa amiy Heath Survey: Karnataka, Mumbai, Approach in Karnataka 57

65 have incuded the Karnataka Heath Systems Deveopment Project, the KfW Project, India Popuation Projects VIII and IX, the Border Custer Districts Project, and the Reproductive and Chid Heath (RCH) Services Project. 2 The community needs assessment () approach, formery known as the target-free approach (T A), was introduced in 1995 on an experimenta basis, in one district in accordance with the mandate of the Government of India (GOI). In the foowing year, again based on the decision of GOI, it was extended to a districts in the state. The way the state has gone about impementing the new approach from 1995 ti the present and the modifications it has made in the process have been reviewed and documented. The Community Needs Assessment Approach Experimenta Phase: The state became aware of the approach in January 1995 after receiving a etter from the Secretary of amiy Wefare, GOI. In the absence of any guideines, state officers were not cear on just how to experiment with the new approach but, after a series of discussions, decided to try the new approach in one district. The criterion for seecting the district was consistent famiy panning performance. In addition, vountary acceptance of famiy panning methods was given due consideration. Mandya was the obvious choice. Thus, in March 1995, the Additiona Director for amiy Wefare wrote the foowing to the District Heath and amiy Wefare Officer (DH WO) in Mandya: The main objectives of this study are the foowing: (i) To describe the processes foowed to impement the new system; (ii) To record the opinions of personne at various eves on the new system and its impementation; and (iii) To anayze the potentia effects of the new system on performance. Sampe data were gathered in Mandya and Hassan districts from two primary heath centres/community heath centres/ PHCs/CHCs and four sub-centres. In addition, two PHCs that had an important roe in executing the new approach were visited. Heath personne in the seected institutions were interviewed using broad guideines prepared specificay for this purpose. A correspondence and other documents avaiabe at a eves from the Department of amiy Wefare were coected and reviewed. Performance data were coected from the Directorate of amiy Wefare and from districts as we. In the financia year , the GOI is thinking of impementing the target-free approach in one district of the state on an experimenta basis, and therefore we have decided to make your district target free. Emphasis wi be on providing quaity services and hence you wi have to ensure it. You are, therefore, requested to work out your performance goas and work accordingy. 3 There was no further communication from the state for severa months. Neither the state nor the district made any effort to discuss guideines for impementing the new approach though they coud have done so at monthy state-eve meetings. Meanwhie, as part of its norma routine, Mandya carried out the eigibe coupe (EC) survey and updated the eigibe coupe registers (ECRs). After conducting this exercise, district and bock officers and fied workers were informed of the new approach in a monthy meeting and in a etter, which stated the foowing: 2 3 Human Deveopment in Karnataka, Panning Department, Government of Karnataka, Bangaore, Letter from the Additiona Director, amiy Wefare, to Mandya district, March Review of Impementation of Approach for amiy Wefare in India 58

66 During the year , targets for the famiy panning programme have been removed. However, it is required that the workers shoud perform to the eves of ast year. Since the EC survey had aready been competed, the district statistica officer coated the information and worked out the expected eve of achievement (ELA) for each of the famiy panning methods. The yardstick for monitoring the performance of fied workers was the previous year s performance and the performance in that particuar month. The Government of Tami Nadu has recenty issued detaied instructions on the MCH approach to famiy panning and specific services that wi be quantified and monitored. I am sending herewith a copy of the order issued by the Tami Nadu government in this regard. This is an interesting experiment worth emuating. We propose to conduct a concurrent evauation of programme performance in the target-free districts/ areas through Popuation Research Centres. The concurrent evauation wi aso study the quaitative improvement in services. In August 1995, the first guidance on the impementation of the new approach arrived in the form of a etter from the Secretary of amiy Wefare, GOI, to the State Secretary. It read as foows: As you are aware, an important decision was taken in the meeting of the state secretaries in charge of famiy wefare on Apri 3 and , to exempt at east one district from the contraceptive targets. The objective of exempting one district from targets was to improve the quaity of services. To carry this message down to the grassroot workers, it woud be necessary to sensitize the district eve officers, the PHC Medica Officers (MOs) and the heath workers on specific aspects of quaity improvement and the steps to be taken in this regard. Such sensitization coud be done during (i) monthy meetings of district eve officers at state headquarters; (ii) meetings of PHC MOs at the district eve; and (iii) meetings of mae/femae heath workers at the PHC eve. You may identify resource persons for conducting such sensitization of a personne in the target-free district/areas. May I request you to take suitabe steps to improve the quaity of services in these district/areas and apprise me of the action taken. 4 State officias in Karnataka reviewed the order mentioned and decided that the Tami Nadu approach did not add anything worth considering. The state, therefore, did not inform the district of its contents nor did it make any effort to understand the impementation mechanism described therein. Overa, famiy panning performance in Mandya in was more or ess consistent with Steriization and IUD acceptance definitey increased, but there was a decine in the use of ora pis and condoms. It woud appear, therefore, that the ony effect that the approach had on the famiy panning programme was that the district worked out its own targets for the first time ever. However, it can be inferred that the new approach was not fied-tested in the rea sense because the district did exacty what it had been doing previousy to work out ELAs. In contrast, there was substantia improvement in MCH indicators as more 4 Letter from the Secretary, amiy Wefare, GOI, addressed to the State Secretary of Karnataka, August Approach in Karnataka 59

67 women received antenata (AN), nata, and postnata care. Immunization coverage for infants improved as we. Expansion of The decision to expand the approach was made in a meeting of State Secretaries in New Dehi on ebruary 1 and 2, Without deiberating on the experiences of various states in the experimenta year and despite strong opposition from many of them, GOI announced its pans to extend the approach to a districts in the country. Since the new approach had not reay been tried out in Karnataka, and the officias present at the meeting were not aware of the methodoogy Mandya had used during the experimenta year, they did not oppose the government s decision. In genera, however, they thought that it woud be difficut for fied workers with imited academic quaifications to comprehend the approach and that the process of change from targets to target-free woud require a considerabe amount of time and a substantia obigation of resources. GOI insisted that the new approach woud improve the quaity of services and stated that proper guideines and an impementation manua woud be prepared and given to a states. Subsequenty, the Secretary of amiy Wefare, GOI, wrote to a State Secretaries on ebruary 14, 1996, about the use of the approach in the famiy wefare programme. It stated the importance of the new approach, proposed the methodoogy for preparing pans at various eves of the service deivery system, and mentioned that the new approach woud provide an exceent opportunity to make famiy wefare in India a truy peope s programme. The etter outined the procedure for preparing pans in the foowing manner: A draft format for the PHC pan as is being used in Tami Nadu, circuated in the ebruary meeting as part of the agenda notes, may be used. You may ike to initiate this exercise of invoving a heath personne, viage pradhans, primary schoo teachers, and NGOs working in each PHC in your state on the basis of this format or with such modification to it as you deem necessary. A detaied format for preparing the PHC/ WHC pan is under preparation at our eve and coud be made avaiabe before the end of March However, the preparation of your W and heath care pan need not wait for this data format. The performance of each PHC woud need to be evauated against its own pan by the district heath and W system at the end of each quarter to advise them suitaby. They woud aso need to tune the IEC activities in the PHC area and districts to prompt this bottom-up approach of panning and impementation of a sensitive programme ike famiy wefare. A the PHC W pans woud need to be aggregated into the district W pans and the district W pans woud simiary need to be aggregated in the state W pan. A timetabe for preparation of the pans at various eves may be set. I woud suggest that the PHC pans may be finaized by Apri 30, 1996, the district pans by May 15, 1996, and the state pans by May 31, We woud ike to have your state W pan by the first week of June A system of evauating the performance of each district every quarter may be worked out at the state eve. A simiar exercise to evauate the performance of each state woud be carried out at the nationa eve. This exercise woud need sensitization of the entire heath and famiy wefare organization in the state with the deputy commissioners/ district magistrates paying a eading roe aong with the district heath and W system in active coaboration with Review of Impementation of Approach for amiy Wefare in India 60

68 panchayati raj dignitaries, primary schoo teachers and active NGOs. 5 The state directorate forwarded the Secretary s etter to a DH WOs and asked them to foow the instructions carefuy. However, before the ebruary etter from GOI reached the districts, the district magistrates received a different etter sent directy from the GOI Secretary of amiy Wefare dated March 4, In it, the Secretary discussed sensitization workshops, the budget for conducting them, and a set of guideines. The budget for sensitization was reeased to the districts on an average basis without considering the number of PHCs and had to be coected from the regiona director s office. The state was unaware of the Marchetter and, surprisingy, none of the districts reported it. On Apri 4, 1996, the Joint Secretary of amiy Wefare, GOI, wrote a etter to the State Secretary about the sensitization workshops with a copy of the March 4, etter attached. 7 The state ater corresponded with the regiona director and determined the exact budget for each district. Oneday sensitization workshops at the state, district, and bock eves were utimatey conducted between Juy and September 1996, for a heath personne, representatives of NGOs, members of panchayati raj institutions (PRI), anganwadi workers (AWW), and Nationa Swayam Sewika (NSS) vounteers. The GOI sent a detaied pan of the bottom-up approach to a states on March 27, After reviewing it, Karnataka fet that the districts shoud foow the government s instructions exacty and shoud estimate perceived needs and service requirements. The GOI data coection format incuded 17 questions on antenata care (ANC), deiveries, post-nata care, immunization of chidren, acute respiratory infections (ARI), diarrhoea in chidren, and famiy panning. The GOI coverage norms were tagged to these indicators with the exception of those for famiy panning. The states were advised to prescribe their own famiy panning norms to arrive at tota service requirements. The format provided an idea of the magnitude of the task of restructuring demand for reproductive and chid heath (RCH) services and famiy panning in terms of perceived needs instead of as a function of the previous year s performance. The Impementation of the Approach Traditionay, data coected annuay in the ECRs were to be used for working out MCH and famiy panning targets; however, because targets were set by the state, this ocay gathered information was rarey used. With the introduction of the approach, however, the state expected that ECR data woud become quite vauabe. Hence, the districts were asked to coect the data and use the GOI-prescribed coverage norms to arrive at the ELA for various MCH indicators. These cacuations were simpified by uniformy appying a birth rate of 19 per 1,000 popuation, despite the enormous regiona variations within the state. As there were no specified norms from GOI for cacuating famiy panning ELA, the state used its own methodoogy. Districts were instructed to cacuate the ELA on the basis of the perceived need or the Letter from the Secretary, amiy Wefare, GOI, addressed to the State Secretary in ebruary 1996 and subsequenty marked to the districts March Letter from the Secretary, amiy Wefare, GOI, addressed to district coectors/magistrates March Letter from the Joint Secretary, amiy Wefare, GOI, marking the etter addressed to district coectors/ magistrates to the State Secretary Apri Approach in Karnataka 61

69 unmet need. This ed to confusion because the ECR Survey ormat-hmis Version 2.0, did not capture information on unmet need for famiy panning but nevertheess the state sent a etter to the districts. In the absence of a ceary stated methodoogy, the districts were informay asked to consider past performance whie formuating their activity pans. A few districts considered ony the previous year s performance whie other districts considered the average of the past three years. Thus, there was no uniformity among districts in the preparation of activity pans. Nevertheess, the state had introduced the new approach, and the activity pans that were prepared The impementation of by heath functionaries were the approach in consoidated at the PHC, the first year of the district, and state eves. A stateeve pan was prepared and expansion phase was imited to state and district officers ony. submitted to GOI by Juy This resuted in State officias monitored enormous confusion as progress in the preparation of they interpreted the T A the activity pans. in various ways and cacuated the ELA for Athough the activity pans were famiy panning methods ready by the end of Juy 1996, to suit themseves. staff orientation and the transation of the GOI manua into the oca anguage had yet to be done. No effort was made to do either as a resut of a deay in deegating responsibiity to officers at the state eve. In September 1996, the GOI organized a two-day orientation workshop in New Dehi for state officers to discuss the various terms and definitions used in the manua. Three officers from Karnataka participated; on returning to the state, they were given the task of conducting orientation training for a heath personne. In November 1996, a 10-day training session was conducted for state and DH WO, senior programme officers, and chief executive officers (CEOs) of the Zia Panchayats. (since Karnataka had aready impemented the Panchayati Raj Act, the CEOs had assumed the roe hitherto payed by the district magistrates and were the chairpersons of the district heath committees where pubic heath and famiy wefare came under their purview. They were, therefore, incuded in order to famiiarize them with the recent changes in the famiy wefare programme). The session focused on the roes and responsibiities of the district heath committee, the essence of the manua, and the monitoring and compiation of progress reports. Aso, a detaied pan for training staff was outined. Trainers at district eves and beow were identified from among the heath officers attending, and a workshop itinerary was prepared. To faciitate training, state officers were assigned to districts. A 10-page booket in the oca anguage that outined the concept of and expained the methodoogy for estimating ELA was circuated to a the participants. Thus, the impementation of the approach in the first year of the expansion phase was imited to state and district officers ony. This resuted in enormous confusion as they interpreted the T A in various ways and cacuated the ELA for famiy panning methods to suit themseves. This practice continued into the next haf of the fisca year unti a remaining heath professionas and functionaries were trained. In the atter part of , the state finay began district and tauka eve training and continued it unti the end of June A heath personne, members of PRIs, chid deveopment officers, and AWWs were trained in these workshops, but in fact, the famiy wefare programme for had aready been impemented. The activity pans and progress reports that had been introduced aongwith the new approach were aready operationa, and the sub-centres had aready coected information according to the Review of Impementation of Approach for amiy Wefare in India 62

70 prescribed formats that had been compied at various eves to represent PHC, district, and state pans. Training shoud have preceded impementation, as it didn t, the heath department had aready impemented the approach without understanding the concepts underying the approach. In , the districts in which training had been competed foowed the procedures earned in the training sessions whie other districts prepared pans based on the previous year s methodoogy. Aso around this time, the birth rate previousy used to cacuate MCH indicators was revised from 19 to 18 per 1,000. This figure once again was uniformy appied irrespective of the actua birth rate of the district. It is difficut to understand how the state arrived at this figure when the sampe registration system for those years reported much higher rates. Due to the variety of methodoogies being appied, confusion prevaied especiay in the famiy panning programme. During this time, GOI modified the new approach by revising the formats used to make activity pans and progress reports. The number of formats was reduced drasticay from more than 30 to nine, 8 but Karnataka continued using a the od formats to avoid further confusion at the fied eve since the workers were reconcied to them. State officias introduced the new formats ony at the PHC eve and above, after conducting four regiona workshops in Bangaore, Begaum, Gubarga and Mysore with financia assistance from UNICE. In addition, two workshops, one in 1998 and the other in 1999, were conducted for statistica assistants. MOs and statistica assistants then started compiing information using the newy introduced formats, so their reports to GOI changed accordingy. Due to the deay in training of ower-eve heath staff, the new approach coud not be impemented in the true sense. GOI was unaware of this. As the state submitted activity pans and progress reports to GOI on time, the government presumed that the new approach was working we and that heath personne had understood the concept and were impementing it correcty. This practice of evauating performance soey on the basis of the timey submission of forms did not bode we for the transition from targeted to target-free programmes. Experiences in Impementing the Approach Heath personne from the seected districts, PHCs, and sub-centres were interviewed about the approach. The processes foowed and opinions given are The genera feeing at the summarized beow. district eve is that the new approach is a The genera feeing at the district wecome change from topdown targets as it makes eve is that the new approach is a wecome change from topdown targets as it makes fied fied workers more responsive and responsibe. The workers more responsive and methodoogy proposed by responsibe. The methodoogy GOI is being foowed proposed by GOI is being aong the suggested foowed aong the suggested guideines, and it seems to guideines, and it seems to be be working we. working we. Instead of the state setting targets, the districts set them through a consutative process. The feeing is that the approach is more usefu than top-down target setting due to the participation of a staff in the process. The confusion that prevaied when targets were removed has given way to a more confident approach to programme impementation. Monitoring at the PHC and sub-centre eves has become easy. 8 Letter from the Secretary, amiy Wefare, GOI, addressed to the State Secretary January Approach in Karnataka 63

71 The DH WO of Mandya district expained that despite initia fuctuations, the district has been abe to maintain its performance eves. Even though acceptance of steriization has dropped, the decine is insignificant compared to that esewhere in the state. In this context, he stated the foowing: The interesting aspect in the district is that it is immateria to peope what approach the district is foowing because peope over here come vountariy for famiy panning services and demand quaity services. Providing quaity services is the major concern, and we at the district have taken measures to assure this. Having said this, he informed us The auxiiary nurse that the district has adhered to a midwives (ANMs) instructions received from the enthusiasticay caimed GOI and has executed the that the approach programme accordingy. Athough is better than the one with targets imposed there were deays in training staff, from above. They efforts have been made to make expained that their task them thoroughy understand the is now defined by new approach. The concept of the benchmarks derived approach has been from the prevaiing birth constanty reiterated in monthy rate in their sub-centre meetings, and that has paid off. A areas instead of by targets staff members are aware of based on popuation size. and have participated in the preparation of the activity pans after discussing them with panchayati raj members and AWWs. The statistica assistants have payed an important roe in the compiation of the forms and in monitoring and have been the major ink between the programme officers and the fied workers. The DH WO of Hassan district expressed simiar views. Regarding famiy panning performance and the strategy of identifying perceived needs, both DH WOs agreed: If you see the performance of the past few years and at present, there is nothing wrong in admitting that performance has remained more or ess the same, but if the age and parity of acceptors are anayzed, they have come down consideraby, and this is a positive sign for the programme. Even now there is no carity on how the ELAs for famiy panning methods have to be arrived at. Based on past performance, the ELAs are being worked out. This methodoogy wi not address cient needs and hence a methodoogy that can ook into this aspect shoud be deveoped and impemented. They aso mentioned that eadership at the oca eve, commitment of staff, and cose monitoring of the programme were key factors to success and that their districts had been abe to exhibit a of those characteristics. This was found to be true because the MOs of PHCs, who were knowedgeabe about the approach were abe to provide direction to the programme. They had definite time sots for reinforcing the concept in monthy meetings, and therefore, the supervisory staff and sub-centre functionaries in their PHC areas had a cear understanding of what was expected of them. On the contrary, in PHCs in those districts where the commitment of the MO was weak, the understanding among staff members of the approach and its impementation was aso weak. It was agreed that one-time training without constant reinforcement woud not have much effect. This was demonstrated in the PHCs where the MOs acked proper understanding. The auxiiary nurse midwives (ANMs) enthusiasticay caimed that the approach is better than the one with targets imposed from above. They expained that their task is now defined by benchmarks derived from the prevaiing birth rate in their sub-centre areas instead of by targets based on popuation size. However, regarding the use of birth rates for cacuations, one of the ANMs remarked: Review of Impementation of Approach for amiy Wefare in India 64

72 In my area, the birth rate seems to be ess than that proposed by the district or state. By appying this rate, the workoad in my area gets over estimated, and it becomes difficut to achieve the ELAs. In spite of compaining about it, the medica officer has not been abe to resove the probem, and I am tod that in the next year, we wi try to work out something on the basis of which the cacuations wi be done. I think some aternative has to be deveoped or ese the present approach wi end up as a target-driven approach given in a different way. The pressure to perform sti continues and temporary denia of saary/pecuniary benefits is recommended if the sef-determined ELAs are not met. Other ANMs endorsed this view as we. The review team discussed these perceptions from the fied with the Additiona Director, who is aso the RCH programme director and has been associated with the approach since its inception. The Additiona Director said the foowing: The new approach has a sound methodoogy and has a good phiosophy associated with it. Athough I was not convinced in the beginning, I deveoped a iking after I understood the concept of it thoroughy. or a person at my eve it took some time, and you can imagine how much time and effort are required to change the mind-set of the heath functionaries at the grassroot eve. Proper training of functionaries supported by a we-equipped service deivery system form the essentia ingredients of the programme. The ony apprehension I had then, and I sti have, is that the GOI hurriedy pushed the impementation of the new approach without paying much heed to training and strengthening service deivery systems. because funds were not reeased on time. In this context, it was difficut to impement something they were not confident about. Moreover, Karnataka s famiy panning programme performance had sipped. The fertiity rate that was once comparabe with those of the neighbouring states of Andhra Pradesh and Tami Nadu had stabiized whie the rates of the other states had moved coser to or had reached repacement eves. The Additiona Director, therefore, remarked: With very itte improvement in In order to maintain the performance over the past few tempo of famiy panning years, I fee that Karnataka has acceptance, the state become the BIMARU (sick) state must cosey monitor the of South India. The state, unike age, parity, and Andhra Pradesh, acks poitica education eves of wi and commitment at a eves, acceptors of steriization and that has resuted in inordinate and IUDs. The pressure deays in decision-making that on workers to perform remains despite the new have hampered the programme methodoogy. and its performance. Hence, nothing new was attempted except for sharing the monitoring and activity formats to satisfy the immediate needs of GOI. A heath personne have since earned how to estimate ELA, yet the state sti acks a cear-cut methodoogy for addressing cient needs. To hep sove the probem, birth rates of 19 and subsequenty 18 per 1,000 were used to cacuate indicators throughout the state in spite of we-documented regiona variations. The technique of surveying 100 mothers proposed as part of the approach was aso tried out, but it did not give a cear indication of cient needs. The state was tasked with the impementation of the new approach, but it had not readied its resources. There were deays on a fronts. In the beginning, state officias did not have a cue about as the training of master trainers had not taken pace In order to maintain the tempo of famiy panning acceptance, the state must cosey monitor the age, parity, and education eves of acceptors of steriization and IUDs. The pressure on workers to perform remains despite the new methodoogy. The Approach in Karnataka 65

73 Additiona Director was happy that in most regions of the state acceptance was vountary, though that is not aways the case in the northern part, where ower eves of acceptance have negativey affected the state average. In regard to agging performance, the Additiona Director was optimistic and said this: With more efforts by the Department, the state can surge ahead in the RCH and famiy panning programmes. Even though there are regiona imbaances in the northern parts of the state, various innovative projects and schemes have been initiated, but it wi take time before these districts yied the fruits of the interventions. The state demographer added these comments: The statistica assistants have done an exceent job in carrying the message of the new approach down to the grassroot eve. In the first year, in the absence of proper training, the responsibiity for compiing the GOI forms was entrusted to them. In the subsequent year, they payed an active roe and were abe to impart the necessary working knowedge to the ANMs. Scrutinizing, compiing and timey monitoring of activity pans were a done by them. When asked about orienting heath workers to the newy introduced forms, the state demographer said that Karnataka intends to do so as part of the overdue RCH training. urthermore, the concept of unmet need wi be taught, and the ECRs wi be revised to incude questions reated to the estimation of unmet need. The ELAs for each method wi be worked out on the basis of data coected in these ECRs. In the ight of these discussions, it can be inferred that Karnataka did make efforts to hep workers understand the new concept, but discussions with heath functionaries reveaed that the pressure to perform, especiay in steriization, had actuay increased. amiy Panning Performance Limiting Methods The annua acceptance of steriization steadiy increased in Karnataka from 371,535 in to 395,624 in However, in , when the state actuay impemented the approach by training a fied workers, acceptance dropped by six per cent from the previous year. Steriization acceptance in was comparabe with the eve of In other words, the decine in acceptance was margina because the pressure to achieve ELA in steriization has been maintained since the introduction of the new approach. The state caims to have taken measures to cosey monitor the age, parity, and education of acceptors and notes that there has been a sight drop in the average age and parity for women. State officias are confident that if pressure on performance in genera and on steriization in particuar is maintained, the state wi be abe to achieve better resuts in the years to come. Tabe 1 Expected and Actua Leve of Steriization Performance in Karnataka from to Year Annua Performance Percentage Increase/ Decrease Over the Past Years Performance ,535 *** , , , , Review of Impementation of Approach for amiy Wefare in India 66

74 Spacing Methods The Nationa amiy Heath Survey (N HS) in 1992 found that in Karnataka, ony one-tenth of modern contraceptive-users were using a spacing method. With over a third of the popuation in urban areas, the percentage of spacing-method use to tota use is quite sma. The state reaizes the strong potentia demand for spacing methods and is making a considerabe effort to promote them by way of rigorous marketing, IEC campaigns, and area-specific interventions. Yet the eves as reported in the service statistics have not increased as expected. The performance in the ast five years in terms of the percentage increase/decrease for each spacing method is summarized in Tabe 2. IUDs Acceptance of IUDs in the ast five years has increased by 13 per cent; however, the pattern of increase has not been consistent. In , there were 299,504 acceptors; that number rose to 345,937 in , an increase of over 15 per cent. In the foowing year, acceptance increased by another nine per cent. It then decined by one per cent in , and by nine per cent in This is a matter for concern. Uness the state takes proper measures, it wi be difficut to sustain the present eve of use and to motivate new acceptors. The state is now monitoring retention rates. Those rates wi give a better idea of the number of births averted, which can have a considerabe impact on reducing fertiity. Ora Pis The common practice for setting the ELA for ora pis is in terms of the number of users. Performance records at the district and ower eves, however, provide information in terms of the number of cyces distributed. That number is aggregated at the state eve and divided by 13 cyces to get the number of users. In other words, the cacuations are restricted to distribution numbers without considering vita information on continuation rates. Ora pi acceptance has been simiar to that of IUDs except for the fact that the extent of decine in acceptance has been smaer. oowing the introduction of the new approach by the state in , performance decined marginay; in it dropped by five per cent. Overa, however, acceptance increased by eight per cent during the reference period. Condoms The cacuation of condom-users is based on a methodoogy simiar to that used for determining ora pi-users, and identica probems exist. The annua number of users is arrived at by dividing the number of condoms distributed by 72. Unike other spacing methods, condom-use in Karnataka has been decining steadiy since In that year, there were 395,108 users. In the foowing year, the tota Tabe 2 Annua Performance and Percentage Increase/Decrease of Spacing Methods in Karnataka from to Year IUD Ora Pis Condoms AP PI/PD AP PI/PD AP PI/PD ,504 *** 138,232 *** 395,108 *** , , , , , , , , , , , , AP= Annua Performance; PI/PD= Percentage Increase/Percentage Decrease over the past year Approach in Karnataka 67

75 decined by five per cent. After that, the decine was much greater unti in , condom-use had faen to 70 per cent of what it was in Steriization Equivaents In order to provide a more hoistic picture of programme performance, Karnataka routiney reports to GOI on steriization equivaents as we as on the annua acceptance of each famiy panning method. Steriization equivaents are cacuated by combining steriizations with spacing methods according to the foowing formua, suppied by GOI. Steriization Equivaents = Steriizations + 1/3 the number of IUD insertions + 1/8 the number of condom-users + 1/9 the number of ora piusers. The resuts of this cacuation for Karnataka are shown in igure 1. A spacing method users are converted in this way and are added to actua steriization statistics. The state has paced more emphasis on both imiting and spacing methods, but the pressure to increase the number of steriization acceptors is greater. An anaysis of steriization equivaents reveas that performance has been reasonaby good. Acceptors increased from 509,000 in to 555,000 in In , after the introduction of the approach, the number dropped to 532,000, which was the performance eve in In , however, despite a decine in spacing method acceptance, the number of steriization equivaents rose substantiay, due mainy to increased steriization acceptance. If the state intends to monitor performance through steriization equivaents, then the quaity of data on spacing methods needs to improve. The number of reguar users, the duration of use, and continuation rates for each spacing method wi have to be coected and anayzed. To do this, monitoring formats wi have to be redesigned. If not, inferences drawn from the existing data wi be miseading. amiy panning service statistics ceary indicate a decine in performance for spacing methods since the effective introduction of the approach, even though the acceptance of IUDs and ora pis increased over the five-year period. State officias attributed some of the decine to poor infrastructure in the northern region of the state but put the majority of the bame on and the confusion that resuted from its introduction. Yet, there is sti optimism at the state eve because of various innovative interventions that have been undertaken. Fig. 1 Steriization Equivaents in Karnataka Performance in Reproductive and Chid Heath The famiy panning programme suffered from the approach because there was no cear system for working out method-specific ELA. This was not the case for RCH indicators. ELA coud easiy be cacuated by appying the state-determined birth rate to the GOI coverage norms. The resut was performance better than the expected eves. In 1999 for instance, the coverage for ANC and chid immunizations incuding DPT, poio, and meases was higher than the proposed eves. As a matter of fact, Review of Impementation of Approach for amiy Wefare in India 68

76 the performance in RCH indicators improved over the previous year, and the infant mortaity rate (IMR) in 1998 was 58 as compared to the nationa average of 72. Thus, overa performance in RCH seems to have improved consideraby, but before drawing such an inference it is worthwhie to examine the GOI coverage norms and the birth rate used. The norms were generaized at the nationa eve and the birth rate which the state used was ow. Those two factors together coud have resuted in underestimation of the ELA, thus, aowing achievement eves of more than 100 per cent to be reached. Concusion Karnataka has made efforts to impement the approach in ight of the guideines provided by GOI. Due to a deayed start, however, the approach coud not be fied-tested in the true sense for over a year and a haf. When the heath system was ready to absorb the new concept and impement it, GOI modified the existing data coection formats. MOs and assistant statistica officers were reoriented in their use, but fied workers were not. The centra government s monitoring of the impementation of the new approach in both the origina and revised forms consisted soey of ogging in the monthy reports that the state reguary submitted. Due to this, GOI faied to understand what was reay happening. Athough the state did not impose any targets on the districts, there was no ceary defined system for setting ELA for famiy panning methods, so confusion about their cacuation was widespread. There was a system for working out ELA for RCH indicators, though cacuating coverage norms based on a standardized birth rate ower than the actua one that further ignored regiona and district variations defied the very principes of bottom-up panning. urthermore, athough RCH ELA were set at the sub-centre and PHC eves, no effort was made to use the ECR data, and no thought was given to modifying the registers to capture missing information. In the past five years, the overa number of famiy panning acceptors generay increased, but after the state impemented the approach at the fied eve, acceptance rates began to fa. The extent of the drop in Karnataka has made the rates for spacing methods was efforts to impement the considerabe. Athough the state approach in ight is monitoring acceptance of the guideines independenty and in terms of provided by GOI. Due steriization equivaents, to a deayed start, continuation rates for ora pis however, the approach and condoms and retention rates coud not be fied-tested for IUDs have to be anayzed. in the true sense for over a year and a haf. The RCH programme begun in 1997 is not yet operationa at the fied eve. The concept of the approach must be integrated into the RCH training package and the ECRs must be modified to capture unmet need. The state needs to meticuousy pan the integration process based on a ong-term goa. In the absence of it, the state wi find it difficut to impement bottom-up panning and to increase performance eves. Approach in Karnataka 69

77 Community Needs Assessment Approach for amiy Wefare in Madhya Pradesh Ashok Das K.M. Sathyanarayana Background Madhya Pradesh covers 14 per cent of the tota and area of India, which makes it the argest state in the country. It ranks sixth in terms of popuation and 22 nd in terms of popuation density among India s 32 states and union territories. 1 It is divided into 61 districts, each of which is subdivided into 12 administrative divisions. According to the 1991 census, the popuation of the state was 66 miion, three-fourths of which was concentrated in rura areas. The popuation density was 149 persons per square kiometre compared to 274 for the country as a whoe. The sex ratio was 931 femaes per 1,000 maes. Over 40 per cent of the popuation is iterate: neary 60 per cent of maes but ony 29 per cent of femaes are iterate. Schedued Castes and Schedued Tribes constitute 40 per cent of the popuation. In genera, the age at marriage of femaes is ess than the ega age of marriage. 2 Agricuture is the singe argest sector of the economy empoying over three-fourths of the abour force. It accounts for haf of the income of the state. 3 Major agricutura products incude wheat, rice, jowar, bajra, sugar cane, maize, cotton, groundnuts, gram, and tur. The state is sefsufficient in the production of food grains. The annua rate of increase in food grain production in the ast two decades was 2.2 per cent Madhya Pradesh Popuation Poicy, Government of Madhya Pradesh, 2000 Nationa amiy Heath Survey: Madhya Pradesh, Popuation Research Centre and Internationa Institute for Popuation Sciences, Mumbai, 1992 Directorate of Economics and Statistics, Government of Madhya Pradesh, 1992 Centre for Monitoring Indian Economy, Mumbai, 1991 Approach in Madhya Pradesh 71

78 Madhya Pradesh is ess deveoped in terms of industry when compared with other states in India. Jute goods, cement, sugar, newsprint, and vanaspati ghee are the main industria products. Except for Bharat Heavy Eectricas Limited in Bhopa and the Bhiai Stee Pant in Durg, there are no major industries. Nevertheess, the state is making rapid strides in the production of cotton, eather goods and auminium. The human deveopment index (HDI) of a state provides an overa picture of its socia and economic status. In Madhya Pradesh, it is very ow; in fact, when compared with other states of the country, it is ony sighty higher than that Athough popuation size of Uttar Pradesh which has the has increased aarmingy, owest HDI ranking. 5 The the tota fertiity rate in proportion beow the poverty MP decined from 5.6 in ine decined from 62 per cent 1971 to 4.0. During this in to 42 per cent in period, the contraceptive , yet the actua number prevaence rate increased of poor remained constant at 30 from 10 to 42 per cent, miion persons. Infrastructure in which contributed to the the state is inadequate and hence decine in fertiity. many viages are inaccessibe. In fact, pucca (a-weather) roads connect ony 23 per cent of viages. The percentage of househods with basic faciities such as eectricity, safe water, and toiets varies from 3 per cent in Rajgarh district to 41 per cent in Indore. urthermore, there are considerabe variations among districts in amost a demographic, socia and economic indicators. Amost haf of a viages in the state (71,526) have fewer than 500 inhabitants, athough this proportion varies from 29 per cent of the viages in the district of East Nimar to 66 per cent in Rajgarh. The popuation of Madhya Pradesh neary doubed from four crores in 1971 to seven crores in 1997 (1 crore = 10,000,000). It continues to grow by over 15 akh per year, at an average rate of 2.2 per cent per annum (1 akh = 100,000). The state s popuation reached its first crore in 1821; after that it took 104 years to reach its second. At the current rate of growth, it takes ony seven years to add another crore to the popuation. The popuation has increased so rapidy because decines in mortaity outpaced decines in fertiity. The birth rate that was over 45 in 1951 dropped to 30.6 in Simiary, however, the death rate dropped rapidy from around 30 to 11.2, and infant mortaity fe from over 150 to 97 during the same period. Athough popuation size has increased aarmingy, the tota fertiity rate in Madhya Pradesh that was hovering around 5.6 in 1971 decined to 4.0 in During this period, the contraceptive prevaence rate increased from 10 to 42 per cent, which contributed to the decine in fertiity. Given the poor socia and economic environment and the tota dependence of the popuation on pubic sector institutions, a reduction of over 1.5 chidren per woman in a period of three decades is a major achievement for the famiy wefare programme in the state. Regarding the heath status of mothers and chidren, however, there is great need for improvement. The percentage of chidren aged months who have received any vaccinations increased from 62 per cent in to 80 per cent in in rura areas, and from 80 per cent to 94 per cent in urban areas. Whie immunization services have successfuy reached more chidren than six years ago, the proportion of chidren receiving a required doses of 5 6 The Madhya Pradesh Human Deveopment Report, Panning Department, Government of Madhya Pradesh, Bhopa, 1998 Sampe Registration System, Registrar Genera of India, 1998 Review of Impementation of Approach for amiy Wefare in India 72

79 a vaccines has not shown appreciabe improvement. The proportion of pregnant women who obtained antenata care (ANC) services increased from 52 per cent in to 62 per cent in It is interesting to note that during this period, ony 22 per cent of deiveries in the state were institutiona deiveries and of these, two-thirds occurred in private heath institutions. Trained personne assisted ess than one-third of a deiveries. Skied personne such as doctors, midwives and trained dais (traditiona birth attendants) attended an additiona 20 per cent of births at home. Over two-thirds of births in rura areas and one-seventh of births in urban areas occurred at home, attended by traditiona birth attendants (TBAs) who are often untrained and work in unhygienic conditions. 7 It is not surprising that the materna mortaity in the state is among the highest in the country, at 498 mothers dying per 100,000 ive births. Thus, from the point of view of per capita income, iteracy, urbanization, infrastructure, faciities in genera, and heath faciities in particuar, Madhya Pradesh beongs to the category of ess-deveoped states of India. District Panning Committee Poicy decisions STATE GOVERNMENT Chief Minister Recommendations to government Mantraayas Chief Secretary Poicy decisions Recommendations to government District Government Minister-in-Charge Poicy decisions Recommendations to government Disctirct Panning Committees Deveopment Pans for District MINISTER-Functiona Head Coector executive head Eected members from civic bodies, Nominated members/experts Poicy decisions and fina deveopment pan for districts/janpadh/viage District Panchayats Janpadh Panchayats Viage Panchayats Panning of projects in districts and impementation Panning and monitoring of deveopment projects Panning of deveopment in viages, gram sabhas monitoring of projects 7 Nationa amiy Heath Survey (Preiminary Report): Madhya Pradesh, Internationa Institute for Popuation Sciences, Mumbai, 1999 Approach in Madhya Pradesh 73

80 Democratic Decentraization In an effort to acceerate the pace of deveopment in the state, Madhya Pradesh initiated the process of democratic decentraization. The 73 rd and 74 th constitutiona amendments passed by the Indian Pariament in1992 enabed decentraized government through Panchayati Raj Institutions (PRIs) in rura areas and oca urban bodies in urban areas. Madhya Pradesh was the first state to conduct eections to PRIs and devoved significant authority and responsibiity in etter and spirit to the eected bodies. In , the state transferred 18 deveopment departments, critica to the improvement of iving conditions of rura peope, to different ayers of the PRIs, incuding education, heath and To acceerate the process famiy wefare, and women and of decentraization and chid deveopment among others. make it more effective, in 1999 the state To acceerate the process of government passed the DPC Amendment Bi in decentraization and make it more the assemby. Under the effective, in 1999 the state new system, many powers government passed the District of the state government Panning Committee Amendment were decentraized and Bi in the assemby. Under the new deegated to recenty system, many powers of the state created DPCs. government, hitherto exercised from the state capita, were decentraized and deegated to recenty created district panning committees (DPCs) or Zia Sarkar. The committees have a minister as chairperson, a district coector as secretary, and a number of officia and non-officia members. The DPC has powers and responsibiities to pan and impement many deveopment programmes. At the ower eve, the viage panchayats are expected to undertake and finaize proposas concerning various deveopmenta activities. They then rank them by priority and send them to the janpadh panchayat for approva. Subsequenty, the DPC wi deiberate, set financia priorities, and cear the projects in their annua pan. The viage panchayats, however, have a greater roe in the supervision and impementation of the projects. 8 urthermore, the Mahia and Ba Kayan Samiti (Women and Chid Wefare Committee) has been formed to oversee women and chid deveopment and heath programmes. This Committee is presided over by an eected woman representative, and the chief medica officer acts as its secretary. It meets once in a month and reviews activities concerning the wefare of women and chidren, pubic heath as we as famiy wefare. Objectives of this Study Whie the process of democratic decentraization was going on in the state, GOI decided to experiment with decentraized management of the famiy wefare programme. The pan was to impement the T A on an experimenta basis in one district of each state in the country in In , GOI expanded the programme to a districts in a states of the country. In September 1997, GOI reviewed, redesigned, and renamed the T A as the approach. The way Madhya Pradesh went about impementing the T A from and subsequenty the and the modifications it made in the process of impementation, have been reviewed and documented herein. It is especiay interesting to study how effectivey the state government impemented the T A/ approach, given the degree of decentraization and the way they amagamated the approach with the PRIs. The main objectives of this study are the foowing: To describe the processes foowed to impement the new system 8 Bhopa Today, MP Chronice, March 25, 1999 Review of Impementation of Approach for amiy Wefare in India 74

81 To record the opinions of personne at various eves with regard to the new system and its impementation To anayze the impications of the new system on performance. A personne concerned with impementing the new system were interviewed. Hoshangabad district was seected to coect data at the district and subdistrict eves. As part of the methodoogy, one PHC or CHC and two sub-centres were seected. A reevant heath personne in the seected institutions were interviewed with the hep of a broad set of guideines prepared specificay for this purpose. A correspondence and other documents avaiabe at the department at a eves were coected and reviewed. Performance data were coected from the Directorate of amiy Wefare and from the districts as we. T A in the Experimenta Phase ( ) The state became aware of the T A in the month of January 1995 on receipt of a etter from the Secretary of amiy Wefare, GOI. In the absence of any guideines, the state officers were not competey cear as to how the experiment with the new approach woud proceed, but after discussions at the state eve, they decided to seect Narsinghpur as the experimenta district. The criteria aid down for seecting the district were size, proximity to state headquarters, higher socioeconomic status, and consistenty good performance in steriization. In March 1995, the Director of Pubic Heath and amiy Wefare wrote to the Chief Medica and Heath Officer (CMHO) of Narsinghpur about impementing the target-free approach and the decision of the state to experiment in that district. The etter further stated that under the new approach, the district woud be exempted from targets for the year, but targets shoud nonetheess be worked out using information coected in the ECRs. It aso emphasized that need-based quaity services shoud be provided. This was the ony officia reference to T A that Narsinghpur received. The topic never figured in any discussions with the district either during monthy meetings or in the form of other correspondence. As part of its routine activities, Narsinghpur carried out the eigibe coupe (EC) survey and updated the ECRs. After conducting this exercise, district and bock officers and fied workers were not cear about how to identify community needs. Hence, in his correspondence to medica officers, the district CMHO stated the foowing, The targets for the famiy panning programme have been removed for the year. In the absence of sufficient guideines, it is required that the workers estimate their own performance eves and perform better than what they have achieved in the previous year. In order to compy, the statistica officer/assistants compied information from the ECRs by institution and worked out the expected eves of achievement (ELAs) for each of the famiy panning methods without taking cient needs into consideration. In fact, the ECR that was used was not designed to capture information on cient needs. The assessment of the performance of fied workers was based on what they had done the year before in that particuar month. Thus, the T A was simiar to the target approach except for the fact that instead of the state fixing targets for the district, the district itsef worked them out for the first time in the history of the programme. In reaity, however, it can be inferred that the new approach was not operationa because the district did exacty what it had done earier. In August 1995, the Secretary of amiy Wefare (GOI) sent a etter to the State Secretary outining the new approach. After reviewing the etter, state Approach in Madhya Pradesh 75

82 officias sent a copy to Narsinghpur teing them to adopt reevant items that suited them. Instead of jointy discussing and formuating a strategy for impementation, the state directorate merey acted as a post office. As a resut, the new approach was not propery impemented and there was confusion at both the state and district eves. In , overa famiy panning acceptance in the district dropped substantiay, but MCH indicators such as ANC, nata and post-nata services improved over the previous year. In addition, the immunization coverage of infants showed remarkabe progress. Expansion of T A (1996 onwards) The decision to expand T A to a districts of the country was made at a meeting of a State Secretaries in New Dehi on ebruary 1 and 2, Actuay, GOI had decided on expansion beforehand, and it caed the meeting to ratify the decision it had aready made. Though there was strong opposition from a few states, Madhya Pradesh agreed to abide by the GOI decision mainy because it had not truy impemented the new approach. In genera, the state officias fet that T A woud be difficut for fied workers to comprehend, but GOI promised that proper guideines and a manua on impementation woud be prepared and given to a states. Subsequent to the meeting of State Secretaries, the Secretary of amiy Wefare (GOI) wrote to them on ebruary 14, 1996, about using the T A in the famiy wefare programme. The etter stated the importance of the new approach, proposed training of heath functionaries and other stakehoders, and suggested fine-tuning of IEC activities to suit the new approach. In the absence of data formats, the etter further outined broad guideines on the preparation of activity pans, on consoidating pans at various eves and the dates for submitting those pans to GOI. The state directorate sent the Secretary s etter to a CMHOs and asked them to foow the instructions carefuy. However, before the ebruary 14, etter from GOI coud reach the districts, another etter dated March 4, 1996, from the same Secretary addressed directy to the district magistrates arrived in their offices. That etter mentioned the training workshops and the budget for conducting them, incuding a set of guideines. The etter created confusion because the districts were unti then unaware of the deveopments that had taken pace between GOI and the state, and at the same time the state was unaware of this etter on training as none of the districts, surprisingy, reported the matter. On Apri 4, 1996, the Joint Secretary for amiy Wefare (GOI) wrote a etter to the State Secretary about the training workshop with a copy of the Secretary s March 4-etter addressed directy to the districts attached. The budget for training was reeased according to a standard formua and had to be coected from the Regiona Director s Office. The state ater corresponded with the Regiona Director and determined the exact amount aocated, but the amount was not enough to conduct workshops in a districts. Hence, the state decided to have three one-day workshops. Two were hed in Bhopa: one for state officers, CMHOs and District Immunization Officers (DIOs) from a few districts, and the other for statistica officers and assistants. The third was hed in Gwaior in November and December 1996, for the remaining CMHOs and DIOs and for media officers. Thus, training was confined to state- and district-eve officers ony. GOI sent a detaied pan of the bottom-up approach to a states in the country on March 27, After reviewing it, state officias fet that the districts shoud foow the instructions in toto to estimate perceived needs and the corresponding service requirements. Review of Impementation of Approach for amiy Wefare in India 76

83 The GOI schedue had 17 questions covering ANC, deiveries, post nata care, immunization of chidren, acute respiratory infections (ARI), diarrhoea cases among chidren and famiy panning. GOI coverage norms were aso tagged to these indicators with the exception of famiy panning. In that regard, the states were advised to prescribe their own norms to arrive at tota service requirements. The format provided an idea of the magnitude of the task of estimating demand for RCH and famiy panning services expressed as perceived needs instead of basing demand on the previous year s performance. Impementation of T A/ As a routine exercise, a districts are supposed to coect data on eigibe women using the ECRs avaiabe at each sub-centre. urther, they are supposed to use the ECRs for working out MCH and famiy panning targets. However, with the topdown approach, the data coected annuay from the ECRs was rarey used. With the introduction of the T A, the state expected that ECR data coud be effectivey used; hence, the registers became the most important too for formuating annua pans. The districts were asked to coect data from the ECRs and use the GOI prescribed coverage norms to arrive at ELAs for various MCH indicators. Cacuating ELAs for MCH indicators was simpified by uniformy appying the state s birth rate despite the fact that a invoved were fuy aware of its enormous regiona variations within the state. As there were no norms specified by GOI for cacuating famiy panning ELAs, the state decided on its own methodoogy. The state tod districts to cacuate ELAs based on perceived needs, not captured in the EC surveys. This ed to confusion because these instructions coud not be executed in a practica fashion. In the absence of a cear-cut methodoogy, the districts were ater informay asked to consider past performance when formuating activity pans. A few districts considered ony the past one year s performance, whie other districts used a three-year progressive average. (Hoshangabad used the three-year average.) Hence, there was no uniformity among the districts in the preparation of activity pans. Nonetheess, the new approach was impemented and the activity pans prepared by heath workers were consoidated at the PHC, district and state eves. The state pan was prepared and sent to GOI by August Preparing activity pans preceded training in the T A manua because the manua had not yet been transated into the oca anguage and because there was pressure from GOI to compete the state pan. Moreover, the state had yet to pan training activities. In September 1996, whie the state was discussing its future course of action, GOI organized a two-day T A orientation workshop in New Dehi for stateeve officers to discuss the definitions and terms used in the manua. Both the Joint Director and the Deputy Director in Charge of amiy Wefare from Madhya Pradesh, participated and on returning were assigned the task of conducting orientation training for a heath personne in the state. Training was conducted for two days in ebruary and March 1997, for state and district heath and famiy wefare officers, senior programme officers and chief executive officers (CEOs) of the Zia Panchayats. As Madhya Pradesh had impemented the Panchayati Raj Act, the CEOs who had assumed the roe hitherto payed by the district magistrates and served as the chairpersons of the district heath committees, were invited in order to famiiarize them with the recent changes in the famiy wefare programme. During training, the roes and responsibiities of the district heath committees, the essence of the manua, and the monitoring and compiation of progress reports were discussed. Detaied pans for training Approach in Madhya Pradesh 77

84 other staff were outined, and district resource persons were identified. Thus, the impementation of T A in the first year of the expansion phase was confined to state and district officers. This resuted in enormous confusion as each interpreted the new approach in his/her own way and cacuated the expected eves of achievement for famiy panning according to convenience. The actua training of district and other functionaries finay started in Apri 1997 with funds from UNICE. It asted over two months. A heath personne, members of PRIs, chid deveopment officers, representatives from non-governmenta organizations, and AWWs were trained in these workshops. Meanwhie, the activity pans and progress reports that had been introduced aongwith the new approach were aready in use, and during the year the sub-centres had coected information according to the prescribed formats. Later, information from the formats was compied at various eves to form PHC, district and state pans, respectivey. Athough training in the T A shoud have preceded its impementation, efforts to incorporate T A concepts were made by the heath department. Nevertheess, confusion regarding the cacuation of expected eves of famiy panning performance persisted as each district foowed its own methodoogy. In the month of June 1997, the state reviewed the district pans and found many discrepancies. Immediatey thereafter, the Director in his etter number 3, W/T A/97/ , dated June 12, 1997, wrote the foowing to the CMHOs : The district action pans from some districts were examined in the meeting of immunization officers on 29 and 30 May The district action pans prepared had a number of discrepancies, and these were discussed with the Immunization Officers and cear directions were given to them to review the T A manua and district action pan format and necessariy send it to the Directorate to the Joint Director, amiy Wefare, after revising the district action pan accordingy, so that state action pan can be prepared on this basis and dispatched to Government of India. You are, therefore, informed to pease give persona attention to this matter and send the district action pan to the Directorate, on time, after thorough examination. I woud ike to mention here that an aspect is crosschecked at two-three paces in the format of district action pan. So, prepared action pan fais if there are differences in data. Hence, fu care, attention and cross-checking is required whie preparing it. Normative need, fet need, service need and eve of work done in district, were discussed in detai in the meeting of Immunization Officers and in this regard, the copy of directions sent by Government of India has aready been sent to you. Do not make any changes in the format given by Government of India and give separate figures for each coumn. These facts are very much essentia in preparing the district action pan. 9 oowing this etter, the districts reworked their action pans and submitted them to the state. Subsequenty, the state action pan was prepared on this basis and sent to GOI in August Reaizing the probems in cacuating the ELAs for famiy panning methods, in , Madhya Pradesh modified the ECR (see Annexure for detais). The new ECR was we designed and covered various aspects of RCH and famiy panning. A brief description of it foows: Coumns 1-17 provide information on background characteristics of the coupes, number of chidren ever born and surviving, 9 Letter from the Director, amiy Wefare, to the district CMHO s, June 1997 Review of Impementation of Approach for amiy Wefare in India 78

85 number of births in the ast year and current surviva status Coumns are reated to the woman s reproductive status and incude questions on the menstrua cyce and a question on reproductive infections Coumns are questions on the unmet need for famiy panning Coumn 26 provides the pregnancy status of the women, whie coumns are reated to ast pregnancy and pace of deivery and assistance at deivery Coumns are on current use of famiy panning method, whie questions are on future intention to use famiy panning method Coumns are reated to the immunization status of chidren. Meanwhie, GOI had modified the T A formats for making activity pans and progress reports and renamed the approach to the approach. The number of formats was reduced and made simpe to reduce the paper work. The new state ECR and the new formats were introduced together at the fied eve after orienting heath workers, and data coection commenced in the month of Apri As funds for printing the new activity pan formats were not avaiabe, the state had to resort to using handmade ones. Nevertheess, the state ensured that ECR data were coected and that activity pans were prepared. After coecting data, however, the ANMs did not know how to work out the unmet need for famiy panning services. Hence, the ECRs were sent to the statistica assistants in the PHCs. The statistica assistants did not consider the ECR data when working out ELAs and service requirements; instead, they resorted to the earier methods of averaging performance over the ast three years or considering the previous year s performance. Thus, the pan to use the revised ECR to work out ELAs for famiy panning based on cient needs was deraied. The CMHO of Hoshangabad district reiterated this fact and mentioned the foowing: Staff members were trained how to coect information from the newy designed ECR and during the course of training were introduced to the concepts of unmet need. However, the training did not specify any procedure of cacuating unmet need from the data coected. The district-eve trainers aso were not sure about it and hence we checked with the state officias who were aso not sure. Therefore, we had to resort to the od methodoogy. Interestingy, the ECRs that are supposed to be kept by the ANMs at the sub-centres are not avaiabe there; instead, they are at the PHCs in the custody of the bock medica officer-in-charge. The data from them have rarey been used so their utiity has been negigibe. Uness proper procedures are aid down for using ECR data, the introduction of new registers or formats just tends to add paper work to the system. In the true sense, the ECR has not been propery used so the methodoogy for estimating ELAs did not incude the cient s perspective as proposed by the approach. Since the state submitted the activity pans and the progress reports to GOI on time, GOI presumed that the new approach was working we and that heath personne had understood the concept and were impementing it in the right way. With regard to the invovement of district panning committees, or Zia Sarkars, in the impementation of the approach, very itte has happened. Apart from orienting them and forming committees at various Approach in Madhya Pradesh 79

86 eves, there has been itte interaction between heath providers and DPC members. The approach was supposed to be worked out with the community and other stakehoders, but this has not happened. In fact, the new approach has not generated either community interest or participation, especiay from the PRIs. The heath coordination committee that was constituted as part of the DPC has yet to meet, so the heath department continues to work in isoation. Fig. 1 Steriization Performance in Madhya Pradesh Reaizing the importance of an integrated approach and of the roes and responsibiities of the DPC, the state has decided to draw a bue print of activities and train DPC members. As a matter of fact, the mae worker at the sub-centre has been transferred to the viage panchayat and is supposed to report to the Pradhan (viage headman) on a day-to-day basis. The state at present is drafting a pan of action for continuous invovement viage panchayats in deveopmenta activities, which woud incude heath and famiy wefare. amiy Panning Performance in Madhya Pradesh Limiting Methods Tabe 1 depicts steriization performance between , the base year, and Tabe 1 Steriization Achievements in Madhya Pradesh from to Year Steriization Percent Acceptance Increase/ Decrease* , , , , , ** 407, * Base Year ; ** Provisiona igures Acceptance in was 401,855, but in the foowing year it decined by over four per cent. The downward trend continued with the introduction of the T A to the extent of an 11 per cent drop in compared with the base year. However, in , there is an improvement in the performance eve, and the state coud record as many as 407,000 acceptors, which is higher than what it was before the introduction of T A. igure 1 ceary demonstrates that steriization acceptance in Madhya Pradesh steadiy decined unti , when it was far beow the eve. If this trend were to continue, then with the growing number of eigibe women, it woud be difficut for the programme to sustain the efforts made to date. However, acceptance in has increased by 14 per cent over the previous year. If this trend continues, then fertiity in the state can be brought down to the eves envisaged in the state s popuation poicy document. Spacing Methods According to the Nationa amiy Heath Survey, ony one in every nine users was using a spacing method in Madhya Pradesh. Given that around one-fourth of its popuation ives in urban areas, the percentage of spacing method use in Review of Impementation of Approach for amiy Wefare in India 80

87 reation to tota use is quite sma. The state is making considerabe effort (through rigorous IEC campaigns and innovative programmes) to expand spacing services in urban areas, yet acceptance eves during the ast five years as expressed in service statistics have decined substantiay for a methods except ora contraceptives. The data are presented in Tabe 2, using as the base year. IUDs In the five years since , the number of IUD users has dropped by a third in Madhya Pradesh. The decine in was seven per cent; whie the decine in IUD-use reached 30 per cent in the foowing year. In , there was sight improvement over the previous year s performance, but in comparison to acceptance in the base year, it was down by 28 per cent. That decine increased further in subsequent years. Athough state officias caim that there have been improvements in the quaity of services, there is no evidence to substantiate this statement. Data on number of cients rejected/not found suitabe for insertion, on continuation/dropout rates, on age and parity of acceptors and so on, have not been recorded propery. urthermore, very few efforts have been made to improve the technica competency of heath personne. Ora Pis Setting ELAs for ora pi use is done in terms of number of users, but acceptance records at district and ower eves provide information on the number of cyces distributed. This number is aggregated at the state eve and divided by 13 cyces to get the number of users. Unike steriization and IUDs, pi acceptance registered an increase of over 20 per cent from to In , the experimenta phase of the T A, pi use increased over the base year by seven per cent. In , it increased an additiona four per cent, though in absoute terms the performance that year was ower than that in Nonetheess, in the years foowing acceptance rose consideraby. Condoms The method of cacuating the number of condom acceptors is simiar to that used for determining ora pi users, and identica probems exist. The number of condoms distributed is divided by 72 to obtain the number of users. In , there were 1,987,146 users; it increased by a negigibe one per cent in the foowing year. After that the use of condoms decined drasticay unti in it was about 22 per cent ower than the base year. The decine continued into the foowing year as we. Tabe 2 Annua Performance and Percentage Increase/Decrease of Use of Spacing Methods in Madhya Pradesh from to Year IUD Ora Pis Condoms AP PI/PD AP PI/PD AP PI/PD * 857, , ,987, , , ,004, , , ,761, , , ,650, , , ,545, ** 579, , ,458, AP = Annua Performance; PI/PD = Percentage Increase/Percentage Decrease since ; * Base Year; ** Provisiona igures Approach in Madhya Pradesh 81

88 Steriization Equivaents Besides providing famiy panning performance data, Madhya Pradesh aso provides information on steriization equivaents and uses it as a too for monitoring famiy panning performance. Athough the state has paced equa emphasis on both imiting and spacing methods, the pressure to achieve steriization goas is immense. The methodoogy of using steriization equivaents no doubt gives an overa index of famiy panning performance, but as the name suggests, it argey depends on steriization performance and variations in it. In this methodoogy, a spacing method use is expressed as an equivaent of steriization and is added to actua steriization acceptance using a standard formua. The formua given by GOI is the foowing: Steriization Equivaent = Steriization + 1/3 the number of IUD insertions + 1/8 the number of condom users + 1/9 the number of ora pi users. An anaysis of steriization equivaents is presented in igure 2. The anaysis reveas that overa performance in the state decined by 22 per cent from to Fig. 2 Steriization Equivaent Performance in Madhya Pradesh 99. Acceptance was 851,000 in but dropped to 818,000 in With the expansion of the T A to a districts in , the decine was more rapid. It continued thereafter with sight variations unti acceptance fe to 699,265 in However, in , overa performance improved and the state performed better than it had before the introduction of T A in Though it is a positive sign, the quaity of reporting continues to be the same. The number of reguar users, the duration of use, and continuation rates for each spacing method are sti not being coected and anayzed. To do this, either the monitoring formats have to be redesigned or inferences must be drawn from the existing data. Otherwise, no cear picture of the increase in contraceptive use and specificay in spacing method use wi emerge. On the whoe, there was a drastic decine in famiy panning acceptance, barring ora pi use. State officias were concerned and attributed the decine to poor accessibiity to cients and to ack of infrastructure in the state, but the major share of the bame must rest on the T A/ approach and the confusion that resuted from its introduction. Yet, the recent increase in steriization performance is an optimistic sign. In order to keepup the momentum, the state has formuated a state-specific popuation poicy and has undertaken projects funded by internationa donor agencies to increase access to and improve the quaity of RCH care services. A few of the projects initiated or in the process of initiation are described in the foowing section. Innovative Interventions Madhya Pradesh Popuation Poicy Madhya Pradesh formuated a comprehensive state popuation poicy that was approved by the State Cabinet in January One of the main objectives of the poicy is to reduce the tota fertiity rate from the current eve of 4.0 to 2.1 by or this, Review of Impementation of Approach for amiy Wefare in India 82

89 Madhya Pradesh proposes to increase the contraceptive prevaence rate from the present eve of 42.0 to 65 in 2011 through provision of universa access to a fu range of safe and reiabe famiy panning methods. This they pan to achieve by reducing the proportion of coupes that have an unmet need for contraception to space and imit births by haf by 2005, then by 75 per cent by 2009, and utimatey by 90 per cent by The second major objective is to reduce the IMR from 97 in 1997 to 65 by The main strategies to achieve these objectives are the foowing: Create a conducive environment for famiy panning and reproductive heath services participation in RCH programmes are additiona features of the project. Border Custer District Project, funded by UNICE The aim of this project is to reduce MIM rates by haf in the next three years. A UNICE study found that districts aong the state borders have higher rates of fertiity and mortaity, especiay MIM, and that these far-fung districts share socia and cutura traits with districts across borders. Custers of such districts were formed a over the country. Tikamgarh, Guna, Shivpuri, Morena, and Sheopur districts in Madhya Pradesh are part of the project. Project activities got underway eary in Increase demand for these services Coaborate with other deveopment sectors, non-governmenta organizations, and DPCs/PRIs Improve service deivery systems mainy to enhance access to and quaity of services. Madhya Pradesh proposes to review and deveop appropriate impementation structures to achieve this goa. The heath department is now preparing an eaborate decentraized impementation pan for each component of the poicy with detais of what shoud be done and the person responsibe for it. Integrated Popuation and Deveopment (IPD), funded by UN PA This project has just begun in the districts of Rewa, Satna, Sidhi, Chattarpur, and Panna. It addresses reproductive heath and deveopment issues incuding those of women. Improving technica competency of heath staff and TBAs in safe deivery practices and neonata care, vocationa training for women, and gender sensitization of PRIs and their RCH Project funded by GOI and the Word Bank This is a five-year project that started in The main objective is to improve the performance of the famiy wefare programme in reducing materna, infant and chid mortaity, and unwanted fertiity. The project has progressed in phases. The initia phase covered 11 districts; in the second year, another 14 districts were covered. In 1999, however, GOI directed that the project be expanded to a districts in the state. Activities incude upgrading faciities, training, IEC, oca capacity buiding, and management of the programme. To begin with, state functionaries were oriented and a six-day training course was hed for fied workers in the districts that were covered in the first two phases. Training is currenty going on in the remaining districts. In addition to this, the project proposes to incude urban areas as the urban popuation especiay in the sums in major cities is increasing rapidy where heath infrastructure is very poor. In fact, providing basic heath services to the growing urban sum popuation is a serious probem. To cater to this segment, the state has decided to work cosey Approach in Madhya Pradesh 83

90 with urban administrators and provide services through urban heath posts and private sector providers. Necessary equipment and instruments wi be provided to functioning centres as part of the project. Sector Investment Programme by the European Commission The project aims to enhance the capabiities of personne invoved in the impementation of the approach, using a sector-based approach to determine project priorities through a set of poicy reviews of the foowing aspects of the programme: Workforce management options on the simpe tenet, Hep those who need services. It is carried out with the hep of an appropriate service deivery system that aims to serve every coupe interested in spacing or imiting chidbearing and/or enhancing chid surviva. It aso aims to prevent materna mortaity and morbidity incuding that from RTIs and sexuay transmitted diseases (STD). The broad objective of the project is to deveop a prototype for managing the famiy wefare programme at the district eve, so that workers wi be abe to convert existing and future needs for famiy wefare services into acceptance. The prototype can then be used throughout the state to achieve the goa of popuation stabiization. The project wi ast for more than two years. It is currenty in the experimenta stage in Rajgarh district. Deineation/decentraization Rationa use of infrastructure Performance-based funding options. Subsequent to these reviews, project activities wi be decided at the fied eve. In Madhya Pradesh, the project began in October 1999 in the districts of Sidhi and Guna. It wi be impemented over four years at an estimated cost of Rs. 100 crore. A state sector reform bureau has been constituted under the chairmanship of the Commissioner of Heath to oversee project activities. Vikap Project of the Government of Madhya Pradesh, with the technica support of IIHMR, Jaipur Vikap is a system-based service deivery mode that provides a comprehensive framework for impementing the famiy wefare programme from the perspective of the needs of cients. In other words, it is a cient-centred, strategic approach based Janani Project, with the financia support of DKT Internationa This is a socia marketing venture that aims to provide good quaity famiy panning products in a costeffective way to the most vunerabe section of the society at an affordabe price and at an easiy accessibe service deivery point. To accompish this, the project has estabished Surya Cinics, where doctors, both graduates and postgraduates, are trained to provide cinica famiy panning and abortion services. Subsequent to their training, a doctors are entited to use Surya Cinic franchises and provide steriization, IUD and abortion services at pre-determined prices. In addition, the project uses the services of registered medica practitioners and chemists for referring cients to these cinics. To maintain the interest of the practitioners and chemists, incentives are paid for the cients referred. This project was initiay started in Bhopa and the resuts were encouraging. Hence, the state decided to expand activities to other cities. Apart from these innovative projects, the third phase of the DANIDA project has been sanctioned but is Review of Impementation of Approach for amiy Wefare in India 84

91 yet to get underway. Likewise, JAIKA, a Japanese donor agency, is panning a feasibiity study, so a situationa anaysis is underway in the districts of Sagar and Damoh. With a this hep, it is expected that Madhya Pradesh wi be abe to reach its goa of achieving repacement fertiity in the proposed time frame. Concusion Madhya Pradesh has made efforts to impement the T A/ approach in ight of the guideines provided by GOI. Due to a deayed start, however, the approach coud not be fied-tested in the true sense for over a year after its introduction. When the heath system was ready to absorb the new concept and impement it, GOI modified the existing data coection formats. State and district officers (medica and media) and CEOs of PRIs were oriented in their use, but fied workers were not. Apart from attending the introductory training, there was no further invovement of the CEOs and very itte has been done to invove them or their counterparts in bock and viage-eve panchayat institutions. In addition, the centra government s monitoring of the impementation of the new approach in both the origina and revised forms consisted soey of ogging in the monthy reports that the state reguary submitted. Due to this, GOI faied to understand what was reay happening. Athough the state did not impose any targets on the districts, there was no ceary defined system for setting ELAs for famiy panning methods, so confusion about their cacuation was widespread. There was a system for working out ELAs for RCH indicators, though cacuating coverage norms based on a standardized birth rate ower than the actua one that further ignored regiona and district variations defied the very principes of bottom-up panning. Moreover, athough ELAs were set at the sub-centre and PHC eves, no effort was made to use ECR data. In the period prior to and after the introduction of T A/, the overa number of famiy panning acceptors decined; the decine was more rapid after the state impemented the approach at the fied eve. Ony in the past year has steriization acceptance improved; it is higher than it was before the introduction of T A/. Barring ora pis, the extent of decine in spacing method use was considerabe and has continued. Athough the state is monitoring acceptance independenty and in terms of steriization equivaents, continuation rates for ora pis and condoms and retention rates for IUDs have to be anayzed. Madhya Pradesh faces the Madhya Pradesh faces the arduous task of reducing fertiity arduous task of reducing by 2011 as per the popuation fertiity by 2011 as per poicy approved by the state the popuation poicy government. Low eves of socia approved by the state and economic deveopment, government. Low eves of aongwith eary marriage for socia and economic femaes and the ow status of deveopment, aongwith women are not conducive to the eary marriage for femaes achievement of the objective. and the ow status of Probems are further women are not conducive compounded by the fact that the to the achievement of service deivery systems are the objective. inadequate and i-equipped. Though a ot of donor-funded activities have been initiated, the amiy Wefare Department has not conducted a systematic review of the strategies. Instead of working out strategies through need-based projects, it has introduced severa donor-funded projects whose objectives overap. urther, it has not speed out the strategy to address cients needs, though unmet need has been repeatedy mentioned in the popuation poicy document. Nonetheess, by addressing cients needs, consoidating the gains of these innovative projects, and then expanding the successfu ones, the state can achieve its popuation poicy goas. Approach in Madhya Pradesh 85

92 Community Needs Assessment Approach for amiy Wefare in Maharashtra Sharad Narvekar A. D. Pendse K. M. Sathyanarayana Background The impementation of the community needs assessment () approach in Maharashtra, from the inception of the programme in 1995 through 1997, has been reviewed and documented. The study describes the processes which were foowed to impement the new system, recorded the opinions of various functionaries on the impementation process, and anaysed the impications for famiy panning performance at the state and district eves. The findings were interesting and reevant; therefore, we have provided the foowing summary of the study as background information on the impementation of the approach since The Government of India (GOI) introduced the approach on an experimenta basis in and instructed Maharashtra to try it out. In the absence of any nationa guideines, the state had been considering an aternative system of management to sustain the famiy panning efforts that it had made in the past. The Directorate of amiy Wefare was concerned about the success of the famiy panning programme in reducing fertiity because, athough the contraceptive prevaence rate had increased consideraby, fertiity rates had remained more or ess constant. In a review of the programme, it emerged that the emphasis paced on monitoring performance against targets without adequate attention to quaity contro had resuted in infated achievement figures. Higher achievement figures ed to a sense of compacency that aowed heath panners to ignore fied reaities. As a resut, area-specific panning and community needs and participation were overooked. After the Approach in Maharashtra 87

93 importance of participatory panning was reaized, it became the centra theme of discussion. Maharashtra decided to experiment with the approach in two districts, namey Satara and Wardha. Satara, a progressive district, came out with a pan that emphasized the need for a materna and chid heath (MCH) approach to famiy panning, whereas Wardha did not have any specific pan. The directorate encouraged Satara to try out its new pan whie no changes were made in the impementation of the famiy panning programme in Wardha. The approach proposed by Satara was decentraized and better focused than the previous, target-driven approach in terms of both In , the quantitative and quaitative Government of indicators, yet it did not ensure Maharashtra (GOM) tried community participation. The out the approach eves worked out for various statewide. The GOI indicators were argey based on manua on the providers perceptions even approach was reviewed by though the eigibe couperegister was modified and a the state and modified to suit oca requirements. survey was conducted. The resut was that MCH care improved, but famiy panning acceptance decined. Nonetheess, the impact of famiy panning on fertiity was significant because a higher percentage of younger women with ower parities were using contraceptive methods. functionaries was carried out in Apri There was, however, no consistency among the district trainers due to the absence of specific guideines, and so training was done in a haphazard manner. urthermore, the procedure for cacuating the expected eve of achievement (ELA) for various indicators was discussed as part of training. The ELAs for famiy panning methods were based on certain proportions and districts were asked to determine ELAs accordingy. Thus, on the whoe, the district action pans did not take community needs into consideration and so were not in tune with the principes of the approach. This faiure was attributed to confusion about the new system. amiy panning performance decined consideraby that year. In brief, the study concuded that though remova of targets was viewed as a way of definitey improving service deivery, severa other reated factors that coud have faciitated improvements in quaity of services were not addressed during the year. 1 In addition to impementation, as part of its Ninth Pan, the state identified areas for service concentration in order to achieve the nationa goa of Heath for A by the Year 2000 A.D. 2 Officias beieved that addressing state issues aong with the nationa agenda woud improve agging performance and provide better service quaity. The state-specific areas were the foowing: In , the Government of Maharashtra (GOM) tried out the approach statewide. The GOI manua on the approach was reviewed by the state and modified to suit oca requirements. The nomencature was changed to sef-determination of targets. Sensitization training of a district Setting up the rura heath institutions sanctioned by the master pan Expanding and strengthening nationa heath programmes 1 2 Subhash Saunke and Sharad Narvekar in Target for amiy Panning in India, The Poicy Project, The utures Group Internationa, 1998 A.D. Pendse, Heath Status of Maharashtra, Pubic Heath Department, Government of Maharashtra, 1996 Review of Impementation of Approach for amiy Wefare in India 88

94 Consoidating the infrastructure created by the first eight pans Upgrading and modernizing hospita faciities to improve curative services at district eve Creating infrastructure in urban sums and ow income areas Impementing the famiy wefare programme on the basis of Impementing a menta heath poicy and providing menta heath services at the grass-root eve through the existing heath infrastructure Training and reorienting medica and paramedica personne Invoving non-government organizations (NGOs) and private medica practitioners in the deivery of heath services and in the impementation of nationa heath programmes Providing adequate support to indigenous systems of medicine Controing epidemics in triba subpan areas, especiay in sensitive Integrated Triba Deveopment Programme (ITDP) bocks Strengthening bood transfusion services through the state bood transfusion counci Effectivey impementing the AIDS contro programme. Even though the state s intentions were cear, it coud not in the rea sense integrate these areas into the nationa agenda as severa issues requiring additiona resources were yet to be discussed at the poicy eve. These incuded strengthening heath infrastructure, improving IEC support, providing continuous training support, extending the approach to urban areas, deveoping monitoring mechanisms based on cient satisfaction and process indicators, and conducting concurrent evauations. 3 The present study is a continuation of the previous one, except for the fact that the impementation process has been reviewed since The aim is threefod: (i) To eicit the processes foowed to impement the new system; (ii) To record the opinions of Even though the state s personne on the new system intentions were cear, it and its impementation; and (iii) coud not in the rea sense To anayse the impact of the new integrate these areas into system on performance. A the nationa agenda as personne directy concerned severa issues requiring with impementation at the additiona resources were yet to be discussed at the Directorate of amiy Wefare poicy eve. were interviewed. At the beginning of fisca year , state officias worked out a pan of action and budgetary requirements to accompish each activity specified in the Ninth Pan. or a few ITDP activities, the state coud generate its own resources and work out an integrated approach for impementation with other government departments. However, for activities such as improving/upgrading services in the secondary heath system and effectivey impementing the AIDS contro programme, the state prepared proposas and negotiated financia assistance with internationa donor 3 4 Subhash Saunke and Sharad Narvekar in Target for amiy Panning in India, The Poicy Project, The utures Group Internationa, 1998 Review of State Project Documents (Unpubished) Approach in Maharashtra 89

95 agencies such as the Word Bank, WHO, NACO, USAID, UNICE, K W, GTZ and UN PA. Some projects initiated since 1997 that have directy or indirecty increased access to and improved the quaity of heath care are summarised beow. 4 They demonstrate that Maharashtra has made an a-out effort to address its heath priorities. Nava Sanjivini Yojana in ITDP funded by the GOM The objective of this intensified project is to reduce the infant mortaity rate (IMR) aong with the incidence of meases, mumps, rubea and neonata deaths in triba areas. As the majority of the areas are inaccessibe during the rainy season, specia efforts are required to provide basic heath and reproductive services. In this project, rescue camps, additiona medicines, and staff and funds for mobiity are provided. Vacant positions have been fied, and medica and paramedica personne have been trained in neonata management and provided with additiona incentives. Efforts are aso being made to ensure the services of speciaists at each faciity. Moreover, a ink worker has been seected from the community itsef and trained to provide services. A sum of Rs. 800 is given in kind to each antenata care mother as a subsistence aowance. Various government departments such as triba, socia wefare, pubic works, revenue, and rura deveopment are invoved. Intensive monitoring of this project is being done at the state eve and specia monitoring of Grade IV staff is being carried out as we. Basic Heath Care Programme as part of the Indo- German Deveopment Cooperation Project, funded by GTZ and K W This project is operating in the districts of Ratnagiri, Raigarh, Sindhudurg and Pune. It was initiated at the end of 1996, came into being in 1997, and wi in a probabiity, be competed by There are two components: infrastructure and technica assistance. K W is providing funds for construction, renovation and repair of buidings, vehices, and equipment for the centres; GTZ is providing technica assistance to heath personne. The project is expected to improve the infrastructure and the competency of heath personne, thus satisfying the twin objectives of increasing access to the services offered as we as improving its quaity. Integrated Popuation and Deveopment (IPD), funded by UN PA The project began in 1999 in the districts of Thane, Dhue, Gadchiroi and Chandrapur and in five to six corporations incuding Kayan, Uhasnagar, Bhiwandi, Thane, and Pune. It addresses reproductive heath and deveopment issues incuding those concerning women. Training traditiona birth attendants (TBAs) in safe deivery practices and neonata care, vocationa training for women, and gender sensitization of Panchayati Raj institutions (PRIs) and their participation in reproductive and chid heath (RCH) programmes are additiona features of the project. 4. Reproductive Heath Project, funded by UN PA Started in Juy 1997, in the district of Nasik and Wardha, the basic objective is to improve access to reproductive heath services. The project wi address cients unmet needs and aso provide funds for constructing abour rooms in subcentres and repairing the sub-centres wherever required. Training medica officers and paramedica staff in the treatment of reproductive tract infections (RTIs) and sexuay transmitted infections (STIs) is another objective of the project. Review of Impementation of Approach for amiy Wefare in India 90

96 5. Border Custer District Project, funded by UNICE The aim of this project is to reduce materna and infant mortaity (MIM) rates by haf in the next three years. A UNICE study found that districts aong state borders have higher rates of fertiity and mortaity, especiay materna and infant mortaity, and that these far-fung districts share socia and cutura traits with districts across borders. Custers of such districts were formed a over the country. Latur, Osmanabad and Nanded districts in Maharashtra are part of the project. Urban RCH Programme, funded by GOI Neary haf of Maharashtra s popuation resides in urban areas where heath infrastructure is very poor, so providing basic heath services to the growing sum popuation is a serious probem. To cater to this segment of the popuation, as part of the RCH programme, the state has decided to create an urban infrastructure aong the ines of the rura heath posts. Necessary equipment and instruments wi be provided as part of the project; in fact, Kits A and B have aready been aotted to centres that are functioning. Maharashtra Heath Systems Deveopment Project, funded by the Word Bank The Word Bank has aoted Rs. 725 crore to upgrade services in the secondary heath system in districts, sub-districts, and community heath centres (CHCs); improve management deveopment; and strengthen institutions. The primary heath system and the famiy wefare programme wi aso benefit from resuting improvements in service deivery at first-referra units, from the estabishment of hospita training teams, from triba area strategies, from strengthening surveiance systems, and from improvements in referra systems. Impementation of the AIDS Contro Programme, funded by the Word Bank and USAID Impementing the AIDS contro programme has been a matter of concern as very few peope in the state are aware of AIDS and its mode of transmission. At present, Maharashtra has the highest number of AIDS cases in the country; in fact, neary two-thirds of the country s reported HIV cases are from Maharashtra aone. 5 The second phase of the programme has just begun. State and district AIDS societies have been formed as part of this phase to counter the rapid spread of the disease and to educate peope. The state society has been made responsibe for the overa management of the project, which wi in turn be supported by district societies. The state and district societies wi formuate district-specific pans that are effective and peope friendy. The state society wi aso coordinate with the Mumbai Municipa Corporation Society and the USAIDassisted Programme Management Unit to avoid dupication of activities. A stakehoders wi be invoved in panning, impementing and reviewing project activities. urthermore, a draft poicy on impementing the AIDS contro programme has been prepared and is awaiting cearance from the government. 6 Community Needs Assessment Approach Training workers in the approach in was taken up as part of the state s RCH programme. 5 6 Subhash Saunke in Programme for Chidren in Maharashtra, 1997 AIDS Contro Project-Phase II, Project Impementation Pan (Extract), Government of Maharashtra, 1999 Approach in Maharashtra 91

97 Three workshops of two days duration, were organized for district and division-eve officers to discuss the preparation of subcentre pans, based on the perceived needs of the community. Unfortunatey the training was superficia, so the participants did not fee confident enough to undertake the exercise in their districts. Reaizing the importance of, the state experimented with participatory panning on a piot basis in Nasik district. A capacity-buiding workshop was organized jointy with UNICE in March 1997, and a state and district-eve officers attended. In addition, a manua prepared by GOI and UNICE tited Training of ANMs for Buiding Effective Community Partnerships for Impementing the Reproductive and Chid Heath (RCH) Programme, was given to the state. The importance given to is highighted in this etter from the Joint Secretary, GOI, dated May 14, 1997, to the Secretary ( amiy Wefare). As you are aware, the heath programmes for mothers and chidren have been going from strength to strength. In the ast ten years, you have a made tremendous efforts in making the immunization programme a big success. Based on the achievements of the UIP, we were abe to expand the programme into arger Chid Surviva and Safe Motherhood (CSSM) issues. The CSSM programme has equipped a sub-centres with equipment and drug kits and has strengthened PHCs and first referra centres in many areas. Programmes aso have ife cyces and as they grow, they expand and change. Two such major changes have come about in One is the whoe process of peope s participation and community needs assessment. This wi be the overriding approach and underying principe of a heath activities henceforth. The other is the expansion of the CSSM programme into the RCH programme to incude a issues of women s heath, and adoescent heath. The nationwide effort of peope s participation in panning and supporting the impementation of the heath programmes requires a ot of change in attitude and methods of working of a the stakehoders government heath workers, community, eected eaders, NGOs, the private sector and other government departments. One of the ways of bringing about changes in attitudes and methods of working is through training. Training in RCH wi be integrated and wi take pace in many rounds, so that there is an opportunity for the heath staff to practice what they earn and to share their successes and faiures with their coeagues in the subsequent training sessions. The beginning of this training is the six days ANM training to be impemented a over the country. What is unique about this is a fresh approach to training both in the methodoogy as we as in the training of trainers themseves. or the first time, we have been abe to deveop a faciitator s guide for the trainers. A vast number of trainers wi be trained a over the country with the aid of faciitators guide and training wi be monitored and evauated. We wecome your fu participation in using this guide, adapting it to oca exampes and situations and in giving feedback to us. 7 The faciitator s guide was reviewed and certain modifications were made by the state to adapt it to their requirements. It was then transated into the oca anguage in record time, and copies were made avaiabe at the time of training. As stated in the GOI etter, the workshop was for six days duration. The overa objectives of the training programme were as foows: Increase the participants abiity to train groups, especiay the TBA, using participatory methods 7 Letter from Joint Secretary, amiy Wefare] GOI, addressed to State Secretary on May 14, 1997 Review of Impementation of Approach for amiy Wefare in India 92

98 Increase the participants abiity to enhance community participation in panning and impementing heath programmes Enhance the participants understanding of the way the RCH programme wi improve materna/ chid heath. The transated guide contained specific topics to be covered in each session and pedagogic toos to be used to ensure that uniform training was imparted throughout the state. A brief description of the topics covered in the training programme is given beow: Adut earning principes Methodoogy of assessing community needs and preparing sub-centre action pans Methods of participatory earning for action (PLA) n n n n n Chapati diagram Seasona diagram Reative ranking Participatory mapping Viage transect fish bow technique Training needs assessment In addition to the centra government s RCH training package, the state government introduced four data coection formats to be used by sub-centre functionaries to assess community knowedge and to estimate the ELAs for RCH and famiy panning indicators. They were designed to hep the subcentre functionaries and their supervisors determine the service requirements, the perceived needs and the awareness eves of their communities. ormat 1 assesses programme requirements, ormat 2 surveys community needs and knowedge about services, ormat 3 is used to cacuate community needs in a sub-centre area and ormat 4 is used to work out service needs. Taken together, the formats were expected to furnish both community and provider perspectives, thus satisfying the basic premise of the approach whie simutaneousy heping to impement the programme by addressing specific micro-eve strategies. ormat 1 deveoped by GOM resembes orm 2 of the GOI T A Manua of This format provides the state coverage norms for various RCH indicators in percentages presented in absoute numbers aongside the percentage norms of each indicator. Assuming a birth rate of 25 per 1,000 popuation and popuation coverage of 5,000 by each sub-centre, the annua programme requirement of each sub-centre is worked out. No norms have been specified for famiy panning methods, but it is mentioned that the ELAs have to be cacuated for each of the famiy panning methods by using eigibe coupe (EC) surveys. Participatory panning for key RCH activities Roe pay as a means of communication Organising training sessions for AWWs and TBAs ied visit for practicing the above-mentioned skis. Whie ormat 1 provides the programme requirements, community needs and knowedge about RCH services among women who have a chid between 0-5 years is captured in ormat 2. In a, there are 15 questions, each reated to an indicator. A the questions are asked to women who have not undergone steriization whie questions are appicabe ony to those who are aready steriized. Approach in Maharashtra 93

99 Format 1: Norms Prescribed to Cacuate Programme Requirements in S. Types of Services Percentage Coverage Programme Requirement No. Norm of GOM for a Subcentre with 5000 Popuation and Birth Rate of 25 1 Antenata registration 100% 125 pus 10% wastage Eary antenata registration 60% 84 3 Awareness about signs/symptoms of high-risk pregnancy 100% Detection of anaemic antenata (AN) mothers and treatment with Iron and Foic Acid (IFA) tabets 50% 69 5 Tetanus toxoid (TT) for AN mothers 100% Three visits competed to AN mothers 100% Institutiona deiveries 33% 46 8 Skied attention at deivery 95% (of tota deiveries) Recording of birth weight 95% (of expected births) Awareness about signs/symptoms of high-risk newborn 100% Infant immunization 100% Chidren given Vitamin A doses 100% Ora Rehydration Sats (ORS) treatment for diarrhoea among 0-5 years chidren (assuming a prevaence of two episodes/ 100% of under-5 years year) chidren with diarrhoea 1,250 ORS packets 14 Treatment of pneumonia (assuming a 10% of chidren with cough prevaence of two episodes/year) and fever Steriization Spacing methods As per cient needs Through EC Survey the ELA has to be cacuated Format 2 Community Needs/Knowedge about Services, S. Indicator Mothers (a mothers having a chid No. in 0-5 years age group) Repying Tota % 1 What wi you do when you have missed three periods? (Antenata registration) 2 If answer to question 1 is yes, then at what month shoud this registration be done? (Before 16 weeks) 3 What are the danger signs of high-risk pregnancy? (Beeding, fits, edema over egs) Yes Mothers Repying Yes Review of Impementation of Approach for amiy Wefare in India 94

100 S. Indicator Mothers (a mothers having a chid No. in 0-5 years age group) Repying Tota % Yes Mothers Repying Yes 4 Is there a need to take tabets for improving haemogobin during pregnancy? (IFA tabets) 5 Is there a need for injections during pregnancy? (Tetanus toxoid) 6 How many antenata checkups shoud a pregnant woman have? (Minimum three) 7 Where do you want to have your deivery? (Home/hospita) 8 Who shoud conduct your deivery? (Trained/untrained person) 9 Is it necessary to record the weight of the newborn? (Yes) 10 For which inesses shoud a newborn be taken to the doctor? (Low birth weight, difficut respiration, congenita defects) 11 Which vaccines shoud be given to your chid before the first birthday? (DPT/Poio/BCG and meases one of these three or a) 12 What medicine needs to be given to a chid for prevention of night bindness? (Vitamin A) 13 Woud you give ess/more fuids to your chid if it has diarrhoea? (More fuids) 14 If your chid is coughing and sneezing (rapid breathing and difficuty in breathing) woud you take the chid to the doctor? (Yes) 15 Do you wish to have more chidren? (Yes/No/Question does not arise) a. If yes; do you wish to deay the next chid? (Yes/No) b. If yes; which spacing method woud you ike to use? Questions 1 to 15 or a mothers who have a chid in 0-5 years age group and who have not accepted steriization Questions 10 to 15 or a mothers who have a chid in 0-5 years age group but have accepted steriization Expected answers are given in the brackets. Match the responses of the mothers with the expected answers and then enter Yes/No in the sma squares against each mother Approach in Maharashtra 95

101 Format 3 Cacuating Community Needs in a Sub-centre Area, S. Types of Services Percentage of Mothers Actua Service Need No. Needing Services (from Format 2) 1 Antenata registration % arrived from Format 2 Estimated programme need in Format 1 * % in coumn 2 Eary antenata registration do 3 Awareness about signs/symptoms of highrisk pregnancy do 4 Detection of AN mothers with anaemia and treatment with IFA tabets do 5 TT for AN mothers do 6 Three visits competed to AN mothers do 7 Institutiona deiveries do 8 Skied attention at deivery do 9 Recording of birth weight do 10 Awareness about signs/symptoms of highrisk newborn do 11 Infant immunization do 12 Chidren given Vitamin A doses do 13 ORS treatment for diarrhoea among 0-5 years chidren (assuming a prevaence of two episodes/year) do 14 Treatment of pneumonia (assuming a prevaence of two episodes/year) do 15 Steriization Mother wiing to Actua numbers Spacing methods accept steriization and mother wiing to accept spacing methods In ormat 3, the community needs are cacuated based on the correct responses given by women in ormat 2. Thus, the percentage of women who responded appropriatey to each question in ormat 2 is mutipied by the absoute number of the corresponding indicator in ormat 1 to get the community needs of each indicator. In ormat 4, the service need is cacuated after considering the programme requirement from ormat 1 and the community needs and knowedge from ormat 3 aongwith the past year s performance. The expected numbers obtained in these two formats are compared with the past year s performance and then the ELAs for RCH and famiy panning activities are worked out. Consequenty, the numbers arrived at become the annua work pan of the sub-centre. These sub-centre pans are aggregated to arrive at PHC pans, then district and state pans are compied in a simiar manner. 8 The GOI reviewed Maharashtra s guide and fet that the formats were not in tune with what had been proposed in the manua. The state officias expained that they were gathering additiona information that woud be usefu in formuating 8 Training of Auxiiary Nurse Midwives for Buiding Effective Community Partnerships for Impementing the Reproductive and Chid Heath Programme, GOI, GOM and UNICE, 1997 Review of Impementation of Approach for amiy Wefare in India 96

102 Format 4 Cacuating Service Needs in a Sub-centre Area, S. Indicators Programme Community Previous Expected No. Need (from Need (from Performance Number for Format 1) Format 3) from Registers Providing Services 1 Antenata registration 2 Eary antenata registration 3 Awareness about signs/ symptoms of high-risk pregnancy 4 Detection of anaemic AN mothers and treatment with IFA tabets 5 TT for AN mothers 6 Three visits competed to AN mothers 7 Institutiona deiveries 8 Skied attention at deivery 9 Recording of birth weight 10 Awareness about signs/ symptoms of high-risk newborn 11 Infant immunization 12 Chidren given Vitamin A doses 13 ORS treatment for diarrhoea among 0-5 years chidren (assuming a prevaence of two episodes/year) 14 Treatment of pneumonia (assuming a prevaence of two episodes/year) 15 Steriization Spacing methods district-specific pans, incuding IEC pans, based on the knowedge and perceptions of the community. After deiberations with state officias, GOI agreed to the use of the formats but insisted that monthy reports be submitted aong the nationa guideines. Regiona officias were trained from June 16-21, 1997, at the Heath and amiy Wefare Training Centre in Kohapur. District-eve officias were trained by August 30, Athough the state was then prepared to train periphera functionaries, it came to their notice that GOI had committed to the training of auxiiary nurse midwives (ANMs) ony. At this juncture, state officias fet it was imperative to train periphera functionaries, as it woud provide administrative convenience for the management of the programme. Hence, they decided to approach UNICE for funds to train mae heath assistants, heath workers, and at east one medica officer from each Primary Heath Centre (PHC). Once the proposa was agreed upon, financia and other training-reated ogistics such as training oad, venues and dates of training were worked out. The training of periphera staff started at the district eve in October 1997 and was competed by March In a, 4,468 medica officers, 4,206 mae and 3,369 femae heath assistants, and 9,410 mae and 11,866 femae heath workers were trained. Approach in Maharashtra 97

103 In November 1997, the state directorate decided to review the way RCH training was being conducted in 15 districts. The study ooked into different aspects of the training programme incuding the invovement of district administrators, coordination with training institutions, training arrangements, standardization in use of training materias and pedagogic toos, participant feedback and monitoring. The study identified certain strengths and weaknesses and recommended mid-course corrections that were to be incorporated ater. It was found that the training was we accepted by staff members. As it was done jointy for medica and paramedica personne, it resuted in better coordination at the fied eve and invoved medica officers more in impementation. However, at the same time, it was found that the faciitators were not very comfortabe with PLA techniques, so the sessions were ess interactive. Hence, reorientation of the faciitators for two days in PLA was suggested. It was aso noted that a ack of proper coordination between district administrators and training institutions had somewhat hampered the training programme and that the monitoring of participants after training had not been done as expected. The review, therefore, caed for more invovement of the district administrators especiay in extending organizationa support. Other recommendations incuded assistance in carrying out at the subcentre eve and participation of mae workers in deveoping and impementing sub-centre work pans. 9 Experience in Impementing the Approach Since the RCH training started in the midde of fisca year , it coud not be put into practice at the community eve at that time. The state had aready worked out district ELAs for the year as stipuated by GOI and had submitted them to the centra government as its annua pan. Whie the state pan was ready, the districts had yet to submit theirs, so they foowed exacty what was in the state pan and made no effort to assess community needs that year. At this point, the state did not insist that the districts at east experiment with what they had earned during training. Tabe 1 beow summarizes the ELAs for RCH and famiy panning indicators for The impementation of the approach in was initiated at the beginning of the fisca year. As suggested by the RCH training review, the master trainers were reoriented for two days in PLA techniques. Since training was competed, the districts were asked to assess community needs in accordance with the formats deveoped. A few districts carried out the survey, but the majority coud not do so. After compiing programme and community needs aongwith the previous year s performance, the districts coud not easiy work out the ELAs. They, therefore, added a percentage to the previous year s performance and submitted it as their work pans. Since there was no consistency in the way the districts had cacuated their ELAs, the state directorate again worked out district-eve ELAs, thus ignoring the principes of bottom-up panning. Even though a ot of effort went into deveoping the training package and into the actua training, the effort was not particuary reevant because of probems with the formats. The expected numbers in ormat 3 are appropriate responses of ony women who have a chid between 0-5 years of age. Cacuating the community needs on this basis and then arriving at the ELAs wi resut in a gross underestimate because this format considers ony the appropriate responses. urther, it is appicabe to 9 Sharad Narvekar, Mid-term Review of RCH Training Programme in Maharashtra, 1998 Review of Impementation of Approach for amiy Wefare in India 98

104 Tabe 1 District/Corporation ELAs for the Year District/Corporation 0-1 Chidren ANC Mothers Steriization IUD Ora Pi Users Raigarh 48,108 52,531 11,740 8,663 10,880 Ratnagiri 38,824 42,394 10,203 9,244 8,092 Thane 88,409 96,537 17,772 13,778 15,495 Ahmadnagar 89,675 97,920 25,669 24,029 18,663 Dhue 67,098 73,267 16,656 11,346 12,430 Jhagaon 83,767 91,469 23,204 19,316 15,901 Nasik 82,712 90,316 22,248 17,007 17,184 Pune 92, ,915 26,373 16,533 16,169 Soapur 70,474 76,954 20,843 16,626 14,812 Satara 64,144 70,042 18,394 13,515 14,569 Kohapur 68,153 74,419 21,274 17,838 15,788 Sangi 57,184 63,310 18,931 15,064 14,141 Sindhudurg 21,000 23,040 4,409 5,525 5,078 Aurangabad 44,099 48,153 11,672 8,896 11,966 Beed 49,163 53,683 14,318 12,075 10,445 Jaana 37,347 40,781 10,429 8,920 8,311 Nanded 69,208 75,751 19,515 8,740 14,702 Latur 45,365 49,536 13,996 10,675 10,024 Osmanabad 33,760 36,864 10,257 8,299 6,728 Parbhani 57,181 62,438 15,408 13,807 14,104 Akoa 58,025 63,360 16,041 14,485 14,768 Amarawati 44,099 48,153 11,492 10,786 9,773 Budhana 50,218 54,835 11,256 12,047 11,636 Yeotma 54,016 58,982 15,305 14,697 13,898 Bhandara 53,805 58,752 16,271 13,657 12,863 Chandrapur 47,264 51,160 12,699 11,305 12,149 Gadchiroi 21,100 23,040 6,012 4,681 5,686 Nagpur 43,677 47,392 12,768 11,970 11,496 Wardha 27,430 29,952 8,563 7,506 6,361 District Tota 1,607,723 1,755, , , ,112 Corporations Gr. Bombay 258, ,013 45,053 49,491 11,625 New Bombay 7,807 8,525 1,918 1,566 1,709 Thane 26,164 28,570 4,716 6,010 4,879 Kayan 30,384 33,178 4,719 4,990 4,971 Nasik 21,100 23,040 6,503 4,106 3,281 Pune 42,200 46,080 14,315 9,461 6,081 PCMC 16,669 18,200 4,412 2,428 2,040 Soapur 15,614 17,050 7,471 3,878 3,588 Kohapur 10,550 11,520 3,767 3,175 3,372 Aurangabad 17,724 19,354 5,432 5,169 4,364 Amarawati 12,871 14,054 3,080 3,163 2,936 Nagpur 42,200 46,080 10,736 10,351 6,795 Tota Corp. 501, , , ,788 55,641 State Tota 2,109,270 2,303, , , ,753 Approach in Maharashtra 99

105 ony a segment of women; women of zero parity or newyweds who are ikey to space or give birth soon are not captured. To compensate, past performance was taken into consideration. If one were to foow this methodoogy, however, the entire exercise of ooking into various aspects in different formats seems to be futie as the services provided are definitey not addressing community needs. Apart from getting an idea of future intentions to use famiy panning methods and of the specific IEC messages that woud need to be designed to increase community awareness, nothing concrete emerged from the formats. State officias want to modify them, but to date very itte effort has been made to do so. In , there has not been any significant change in the state s approach to the impementation of. However, the recent Mutipe Indicator Custer Surveys (MICS) for both rura and urban areas and the RCH survey findings for 15 districts have made the extent of inter-district variations in RCH and famiy panning indicators very apparent. As a matter of fact, the survey resuts have been thoroughy discussed at the state eve in a series of meetings between state and district officers. Nonetheess, with an aim of addressing state-specific priorities and pans, the Secretary of Heath of Maharashtra intends to formuate an RCH poicy. In this context, etters have been sent to a districts requesting that they prepare district-specific pans in accordance with the present scenario and with the goa of Heath for A by the Year 2000 A.D. In a two-day workshop tited ormuation of RCH Poicy for Maharashtra jointy organized by GOM and the POLICY Project at Pune from August 20-21, 1999, district-eve officers made a presentation on district pans. At the end of the workshop, the state decided to take into consideration the issues that had emerged and has constituted a committee to draft a state-eve RCH poicy. amiy Panning Performance in Maharashtra Limiting Methods As shown in Tabe 2, the state target for steriization for the year was 600,000 of which 582,454 were actuay performed. In , the year when the approach was introduced in two districts, performance decined in absoute terms but showed a percentage increase because the ELA (expected performance) was ower than the previous year. With the introduction of the new system statewide in , performance dropped substantiay. This pattern was observed esewhere in the country. During that year, however, in the absence of any targets, the state had worked out the ELAs using the proportion 7 per 1,000 popuation, which consideraby increased the expected eve; in fact, it was the highest in five years. In , performance eves were cose to those of , but in performance once again dropped. Tabe 2 Expected and Actua Leves of Steriization Performance in Maharashtra from to Year Expected Performance Actua Performance Per cent Achieved , , , , , , , , , , Review of Impementation of Approach for amiy Wefare in India 100

106 igure 1 shows that since the advent of the approach, steriization acceptance in Maharashtra has been fuctuating and has yet to reach the eve prior to introduction. Nevertheess, the state is cosey and reguary monitoring the age and parity of steriization and IUD acceptors, and it was mentioned during our discussion that there have been sight changes. The age at acceptance of steriization was 29.0 years in but decreased to 28.4 years in , and the average parity dropped from 2.90 to 2.85 chidren. State officias are confident that if the performance eve in the coming two years is increased to around seven akhs (700,000) and if age and parity are cosey monitored, the state wi be abe to achieve its goa of reaching repacement fertiity. Tabe 3 dispays the distribution of steriizations in each quarter over the period Performance uniformy increased from the first to the ast quarter in those years. In the year , 15 per cent of tota performance was achieved in the first quarter; this increased to 21 per cent in the second quarter, 29 per cent in the third quarter, and 35 per cent in the fourth quarter. A simiar pattern of performance is observabe for subsequent years even after the introduction of the approach in It can be inferred that athough enormous changes were made in the panning process to impement the new approach, actua performance seems to be Fig. 1 Steriization Performance in Maharashtra more or ess simiar to what it was before its introduction as neary three-fifths of operations were done in the atter haf of the year. Spacing Methods According to the 1992 Nationa amiy Heath Survey, ony one in every eight users was using a spacing method in Maharashtra. 10 Given that haf of its popuation is in urban areas, the percentage of spacing method use in reation to tota use is quite sma. The state is making considerabe efforts through rigorous IEC campaigns to expand spacing services in urban areas, yet acceptance eves as expressed in service statistics have decined substantiay during the ast five years. The data are presented in Tabe 4 using as the base year. Tabe 3 Per cent Distribution of Steriization by Quarter in Maharashtra from to Quarters st Quarter nd Quarter rd Quarter th Quarter Nationa amiy Heath Survey, Popuation Research Centre and Internationa Institute for Popuation Sciences, Maharashtra, Mumbai, 1995 Approach in Maharashtra 101

107 Tabe 4 Annua Performance and Percentage Increase/Decrease of Use of Spacing Methods in Maharashtra from to Year IUD Ora Pis Condoms AP PI/PD AP PI/PD AP PI/PD ,283 *** 418,194 *** 1,168,747 *** , , ,163, , , , , , , , , , AP = Annua Performance; PI/PD = Percentage Increase/Percentage Decrease since IUD Since , the number of IUD users has steadiy decreased. In it dropped by one per cent; in , it dropped by five per cent; and in and , it was down 12 and 16 per cent, respectivey. This considerabe decine coincides with the introduction and adoption of the approach. However, in spite of the drop in acceptance rates, there have been changes in the age and parity of acceptors. The age at acceptance dropped from 25.4 years to 24.6 years by and average parity decreased from 1.6 to 1.5. Districts are coecting data on retention rates, but the data has not been anaysed at the state eve. Ora Pis The common practice for setting ELAs for ora pi use is in terms of the number of users, but performance records at district and ower eves provide information on the number of cyces distributed. That number is aggregated at the state eve and divided by 13 cyces to get the number of users. In other words, the cacuations are restricted to numerica achievements without considering vita information regarding continuing users and dropout rates. As was observed with IUDs, foowing the introduction of the approach in , acceptance steadiy decined. The extent of decine in was 14 per cent since Condoms The cacuation of condom-users is based on the same methodoogy used for determining ora piusers, and identica probems exist. The number of condoms distributed is divided by 72 to obtain the number of users. In , there were 1,168,747 users, and in the foowing year it remained more or ess at the same eve. After that, however, use dropped by as much as 50 per cent. In other words, condom use in was haf of what it was in This anaysis of spacing methods ceary reveas a drastic decine in performance over the reference period. State officias expained that they aren t too concerned about ora pi and condom use because they fee that the data on these methods are unreiabe. Hence, the focus is more on cinica methods of famiy panning, but even those acceptance rates have decined. The officias put the bame on the approach and the confusion that resuted from its introduction. Nonetheess, they are optimistic now that the systems are in pace, that functionaries have been trained, and everybody knows what is expected. They concuded by saying that if everything works we, performance wi definitey improve in the next coupe of years. Review of Impementation of Approach for amiy Wefare in India 102

108 Reproductive and Chid Heath Indicators Whie famiy panning indicators have been disappointing, RCH indicators have not. With the incusion of the approach in the RCH programme, considerabe efforts have been made to improve access and quaity. The department is monitoring a the RCH indicators specified in ormat 4 on a monthy basis. Significanty, both the MICS and RCH surveys have indicated remarkabe improvements. or instance, the RCH survey indicates that neary nine out of 10 pregnant women were registered for antenata care (ANC) and more than haf of them received ANC services (three visits). Moreover, the percentage of institutiona births and births attended by trained personne increased, and over three-fourths of infants were fuy immunized. 11 As a resut, materna and infant mortaity has decined. The sampe registration survey data in 1997 pointed out that the infant mortaity rate was 46 in contrast to the nationa average of This ceary impies that by concentrating on RCH indicators, Maharashtra has been abe to neary achieve the goa of Heath for A by the Year 2000 A.D. Concusion Maharashtra has taken enthusiastic steps to address state heath priorities and goas. By integrating various projects funded by internationa donors, it has increased access to and improved the quaity of services. urther, it successfuy amagamated stateeve issues with the nationa agenda and introduced the approach in as part of the RCH programme. In addition to the centra government s RCH training package, the state government designed data coection formats to address programme requirements, to survey community needs and knowedge about services, to cacuate community needs in a sub-centre area, and to cacuate service needs. However, apart from getting an idea about future intentions of using famiy panning methods and of the specific IEC messages needed to increase community awareness, nothing concrete emerged from the new formats. Though state officias fee the need to modify them, very itte effort has been made to do so. Due to faws in the design of the formats and to the increase in paper work, it was difficut for the staff, specificay sub-centre staff, to comprehend and impement the approach. RCH training started in the midde of fisca year , so it coud not be put into practice at the community eve that year. In , the districts coud not work out their ELAs with precision. As there was no consistency in the way the districts cacuated their eves, the state directorate once again worked out district-eve ELAs ignoring the principes of bottom-up panning. During this period, famiy panning indicators dropped substantiay incuding a considerabe decine in the use of spacing methods. The state is monitoring the age and parity of IUD and steriization acceptors though, and both have dropped somewhat. Uness minor changes are made in the design of impementation, it wi be difficut for the state to adopt the bottom-up approach and step up its performance eves. RCH indicators on the other hand, have shown decided improvement. With the incusion of the approach in the RCH programme, Maharashtra has been abe to neary achieve the goa of Heath for A by the Year 2000 A.D Nationa amiy Heath Survey, Popuation Research Centre and Internationa Institute for Popuation Sciences, Maharashtra, Mumbai, 1995 Sampe Registration System, Registrar Genera of India, 1998 Approach in Maharashtra 103

109 Community Needs Assessment Approach for amiy Wefare in Orissa K. M. Sathyanarayana Ranjana Kar Background Orissa is the ninth argest state in India covering over 5 per cent of the tota and area of the country. According to the 1991 census, the popuation was miion; 972 femaes were enumerated for every 1,000 maes. Neary nine out of 10 persons resided in rura areas, the owest eve of urbanization in the country though the urban popuation increased from 11.8 per cent in 1981 to 13.4 per cent in In genera, ow popuation density couped with enormous regiona variations characterizes the settement pattern in the state. The popuation density in 1991 was 203 persons per square kiometre varying from ess than 100 persons per square kiometre in triba districts to more than 500 persons per square kiometre in coasta districts. The average size of a viage is around 500 persons, but viages of ess than 500 account for neary two-thirds of the tota number. Accessibiity to these viages is a major probem as 30 per cent of the area in coasta and hiy tracts has yet to be connected by a-weather roads. 1 The iteracy rate is 48 per cent, which is sighty ower than the nationa rate of 52 per cent. However, there are wide variations among different areas, caste groups, and sexes. The iteracy rate in rura areas is 46 per cent whie in urban areas it is as high as 72 per cent. Likewise, among maes the iteracy rate is 63 per cent whereas it is ony 35 per cent for femaes. 1 Ranjana Kar in Spatia Information of Demography and Heath, 1996 and Heath Statistics of Orissa, 1997, Government of Orissa 105 Approach in Orissa

110 Regarding popuation growth and fertiity, Orissa recorded an average annua growth rate of 1.95 per cent during compared with the nationa growth rate of 2.1 per cent; it was the fourth owest growth rate in the country. The birth rate decined from 34.6 in 1971 to 26.8 in 1996, and the death rate decined during the corresponding period from 15.5 to The tota fertiity rate was 4.7 in 1971, but it decined to 2.9 in per cent ower than the nationa rate. The age-specific fertiity rates in the past two decades have shown significant changes with peak fertiity occurring in the age group years. Whie fertiity eves in the state are Whie fertiity eves in ower than those nationwide, the the state are ower than death rate is significanty higher. In those nationwide, the fact, in 1998, Orissa registered the death rate is significanty highest infant mortaity rate (IMR) higher. In fact, in 1998, in India: 98 compared with 72 per Orissa registered the highest infant mortaity thousand ive births for the country rate (IMR) in India: 98 as a whoe. The IMR itsef accounts compared with 72 per for neary one-third of the tota thousand ive births for annua deaths. About three-fifths the country as a whoe. of infants die in the neonata period, and sighty ess than one-third die within a day of birth. It is worth noting that the state recorded the owest number of institutiona deiveries and deiveries by trained personne in India. According to estimates, the percentage of coupes effectivey protected from pregnancy increased steadiy from 15 per cent in 1971 to 40 per cent in In 1980, the rate in Orissa was 27 per cent, which was higher than the nationa rate of 22 per cent. By 1992, however, it was ower than the nationa rate, indicating a sow down in famiy panning acceptance. urthermore, there were differentias between urban and rura areas in terms of modern contraceptive use. The contraceptive prevaence rate in urban areas was 45 per cent as opposed to 32 per cent in rura areas. This was mainy due to greater use of a modern methods of contraception by urban women. However, many users in both areas were users of a imiting method whie use of spacing methods, though higher in urban areas, was not significanty different from that in rura areas. Amost a current users, irrespective of their pace of residence, received famiy panning services from a pubic heath faciity. On the whoe, it can be inferred from these statistics that there was neary tota dependence on pubic heath faciities for services and that the use of spacing methods was imited. 2 A arge proportion of the avaiabe time of a heath personne at a eves in Orissa is devoted to preventive and curative heath care. Because of the high incidence of epidemics, the state has estabished Zia Swasth Samiti (district heath committee) in a districts with District Magistrates as the chairpersons. The District Magistrates review a the heath and famiy wefare programmes each month and submit a report to the State Secretary. As the defacto chiefs of a programmes in the districts, the coectors aso monitor famiy wefare programmes and thus pay an important roe in the management of heath and famiy wefare in the state. Other government departments such as socia wefare, revenue, and education aso participate in the heath and famiy wefare programmes. Objectives of the Study This study was undertaken to document the experience and understanding of the impementation of the Target ree Approach (T A). The GOI in September 1997, reviewed, redesigned and renamed 2 Nationa amiy Heath Survey: Orissa, Popuation Research Centre, and Internationa Institute for Popuation Sciences, Mumbai, 1992 and Sampe Registration System, Registrar Genera of India, 1998 Review of Impementation of Approach for amiy Wefare in India 106

111 the T A as the Community Needs Assessment () Nonetheess the specific objectives of this study are as foows: To record exacty the processes foowed to impement the new system To soicit the experiences of personne with the new system and its impementation To anayze the impications of the new system on performance. A personne responsibe for impementing the new approach in the state were interviewed. The burden of managing heath programmes after the formation of 17 new districts in 1993 increased consideraby. urthermore, the heath budget as a percentage of the tota state budget has been decreasing drasticay. Since the popuation is virtuay totay dependent on pubic heath institutions, it is imperative that services of proper quaity are provided. To this day, however, the systems to provide such services are yet to be in pace, and sufficient aocations to the newy formed districts are yet to begin. Even though efforts are continuing, it wi take sometime to estabish systems in genera and support systems in particuar and run the programmes in accordance with GOI norms. The former 13 districts in the state were reorganized into 30 districts in Khurda and Ganjam districts were seected to coect data at the district and sub-district eves. (Khurda was chosen by the state as the tria district for initia impementation of the T A approach). As part of the methodoogy, two Primary Heath Centres (PHCs)/Community Heath Centres (CHCs) and four sub-centres were seected and visited. A reevant heath personne in the seected institutions were interviewed using broad guideines prepared specificay for this purpose. Correspondence and documents avaiabe from the department were coected and reviewed. Performance data were coected from the Directorate for amiy Wefare and from the districts as we. Introduction of the T A Approach and Experiences The impementation of the new system in the experimenta and subsequent phases must be understood in the context of the foowing specific issues facing the state at that time, issues that might not have been taken into account when the decision to adopt the T A approach was made at the nationa eve. Due to its geographica Most disasters are foowed ocation, Orissa is one of the by epidemics and reated few states in the country heath hazards, so where amost a the natura indicators in heath and disasters (droughts, foods, nutrition have amost cycones) occur. oods and aways been adverse in the cycones most frequenty state, especiay for women. ravage the densey popuated Heath workers have to coasta areas, and droughts are spend a major part of common in southern and their time combating western Orissa. Neary onethird of the tota area of the disease outbreaks. state suffers one of these recurrent natura caamities from time to time. Most disasters are foowed by epidemics and reated heath hazards, so indicators in heath and nutrition have amost aways been adverse in the state, especiay for women. Heath workers have to spend a major part of their time combating disease outbreaks. Orissa has higher morbidity rates than any other state in the country. urthermore, if heath indicators such as number of institutions and their maintenance, doctor/popuation ratio, nurse/ popuation ratio, popuation/bed ratio, number 107 Approach in Orissa

112 of vehices in running condition, and avaiabiity and suppy of medicines are anayzed, taking into account ocation and accessibiity to viages, then the overa status is dismay poor. The Department of Internationa Deveopment (D ID) has been operating in the state since 1981 so has had a great dea of experience with the deveopment of the heath sector. The evauation they conducted after the competion of phase two of their project indicated major shortfas in the heath system. Despite the provision of training and infrastructure, the quaity of services was poor, and many users were dissatisfied. Some of the buidings constructed as part of the project had aready faen down due to ack of maintenance. Outreach services had suffered due to ack of transport, and drugs had aways or often been in short suppy. System faiure was widey seen to be the underying cause. The Government of Orissa (GOO), recognizing the need for reform, has aready begun to work to introduce changes in personne poicies and in systems for procuring drugs. Phase three of the D ID project is expected to contribute to this agenda. 3 The state seected priority areas and is in the process of setting up a coordinating ce for a donor projects. On the question of readiness to impement T A, the state Director of amiy Wefare mentioned the foowing: Improving the government systems, increasing access to services and improving quaity of services are the major concerns of the government. With frequent natura caamities, most of our time is spent on preventive and curative activities. Virtuay with itte presence of private sector medica institutions in rura areas, the responsibiity of providing services is totay on the pubic sector. The pubic sector especiay in the newy formed districts does not have proper infrastructure, supportive and periphera staff in position. Vehices according to norms have not been aotted and the existing ones that are in condemnabe position have not been repaced. Mobiity to interior and inaccessibe areas is a probem especiay during caamities. The majority of sub-centres is in a diapidated condition and moreover is ocated outside the viages making it unsafe for the workers to reside. Communicabe diseases are rampant and medicines are in short suppy. Every natura caamity is foowed by an epidemic so most of us are busy managing the aftermath of the recurring caamities. In addition to the target-fee approach, the GOI began a Reproductive and Chid Heath (RCH) programme. It is underway but is sti in the infancy stage. Efforts have been made to gear up organizationa resources, but it wi take sometime before the RCH programme is impemented. In this context, the state was working out specific strategies using avaiabe resources and was at the same time negotiating projects with donor agencies such as the Word Bank, UN PA and DANIDA. After becoming aware of the T A in ebruary 1995, the state started gearing up to impement it. At this juncture, officias were engrossed in addressing state priorities whie at the same time preparing to experiment with the new approach. In March 1995, the state chose the newy formed Khurda to be the experimenta district for impementation. The stated rationae for seecting the district was its proximity to state headquarters; nevertheess, the most important consideration was that the district was represented by the then Chief Minister of the state. 3 Orissa Heath and amiy Wefare Project Phase 3, Department of Heath and amiy Wefare, Government of Orissa, December 1997 Review of Impementation of Approach for amiy Wefare in India 108

113 In Apri 1995, the Directorate issued a etter to the Chief District Medica Officer (CDMO) that stated the foowing: In the financia year , GOI is thinking of impementing the target-free approach in one district of the state on an experimenta basis and therefore we have decided to make your district target-free. Emphasis wi be on providing quaity services and hence you wi have to ensure it. urther you are requested to carry out the eigibe coupe survey, and sensitization about the new approach for district-eve functionaries wi be taken up first at the Directorate on receiving further instructions from the GOI. 4 When Khurda was seected, there were no proper heath systems in pace. As it was part of state headquarters, the office of the CDMO was in Bhubaneshwar itsef. It was moved to the district in 1998 but, for a practica purposes, the CDMO maintains two offices: one in Bhubaneshwar and the other in Khurda. The staff is in both paces: the ogistics unit is sti ocated in Bhubaneshwar whie the other units in the department have shifted to Khurda. Unti May 1995, there was no communication whatsoever from the Directorate of amiy Wefare regarding guideines for impementation. However, on June 8, 1995, the Director, in etter number to the CDMO, informed him of the introduction of the T A in the district. The monthy formats proposed by GOI for monitoring the new approach were encosed. The etter mentioned the foowing: It has been proposed by the GOI to adopt one district in the state where quantitative targets are to be repaced by quaitative indicators as a piot approach in The state government has decided to seect Khurda district for the purpose. Accordingy, no specific targets in famiy panning methods are being given to the district. The GOI has prescribed performa for monitoring famiy wefare indicators in respect of the district seected for the purpose. A copy of the same is encosed for submission of the detai of P acceptors according to age, parity, etc. This monthy report shoud be furnished to this Directorate by the 5 th of the succeeding month to which the report reates. A the prescribed monthy reports for famiy panning and CSSM programmes shoud be continued in addition to the GOI monitoring report. urther, the monitoring of the institution wise report for the district shoud aso be furnished without targets and achievements to the state. In addition, the GOI guideines say that 10 per cent of steriization cases covered shoud be vasectomy cases. The monthy reports starting from May 1995 may be furnished accordingy and a institutions intimated about the detai procedure for effective adoption of the piot project. 5 oowing this etter, district-eve officers attended a two-day workshop conducted by the Joint Director of amiy Wefare, wherein a pan for intensive and specific monitoring at various eves was drafted. Subcentre formats for weeky and monthy reviews at sector and bock eves were finaized aong the ines of the GOI format and a means of assessing the programme in the fied with due emphasis on age and parity of acceptors was drafted. Khurda, as part of its routine activities, had by then carried out the Eigibe Coupe (EC) survey and had 4 5 Letter from Directorate to the CDMO of District Khurda informing him of the seection of the district for experimentation in T A, Apri 1995 Letter from Directorate to the CDMO of District Khurda specifying the GOI guideines and the monthy formats for reporting famiy panning and CSSM programme performance, May Approach in Orissa

114 updated the eigibe coupe registers (ECRs). An interesting point is that in , Orissa had introduced five-year, sub-centre-eve, printed ECRs. These records were we maintained. Since the survey had aready been competed by May 1995, the district statistica officer had been abe to coate the information on age and parity of eigibe women by institution in very itte time. consideration the perspective of the potentia users because the ECR that was in use was not designed to coect information on unmet need. Hence, the estimation of ELAs in the experimenta phase remained more or ess simiar to the previous approach except for the fact that instead of the state fixing the targets for the district, the district worked out its own. During monthy meetings at the district and bock eves, bock-eve and other functionaries were informed of the new approach, and the newy deveoped monitoring formats were introduced in the subsequent month. In the absence of targets, the district worked at a eisurey pace with ess pressure from senior officias. Yet, the monitoring of performance in famiy wefare was done routiney in weeky sectoreve meetings and in monthy meetings at oowing this, the district did not have any specific methodoogy to work out the expected eves of achievement (ELAs) for each of the famiy panning methods. Hence, the district decided to do exacty what it had done before the introduction of the new approach. The statistica officer stated the foowing: the bock, district, and state eves. The GOO, much before the introduction of the new approach, had deveoped indirect estimates based on the popuation of each sub-centre. The assumption was based on 5,000 popuation; and the target for each year and for each method used to be: 30 new acceptors of steriizations; 30 new acceptors of IUDs; 15 new acceptors of ora pis; and 65 new acceptors of condoms. Using this very ogic, the expected eves of achievement of each method for the year were arrived at. Thus, the ELAs in the experimenta year in the experimenta district were determined on the basis of popuation. Information on both age and parity of the eigibe women that was avaiabe was not utiized. Besides this, the methodoogy did not take into In the ast week of August 1995, the Directorate sent a etter addressed to the State amiy Wefare Secretary of (GOI) to the district aong-with one of their communications. The etter detaied the MCH approach to famiy panning in Tami Nadu. Since MCH indicators had not been up to expectations in Orissa, the state Directorate was keen to understand what Tami Nadu had done. After review and discussion at the state eve, however, nothing new emerged except for an emphasis on a birth-based approach and on quaity of services. In the absence of targets, the district worked at a eisurey pace with ess pressure from senior officias. Yet, the monitoring of performance in famiy wefare was done routiney in weeky sector-eve meetings and in monthy meetings at the bock, district, and state eves. Monitoring of each sub-centre worker, continued to be based on what the worker had achieved in the same period in the previous year. Apart from the introduction of new monitoring formats from GOI, no other significant change occurred. On the whoe, in fact, experimenting with the new approach was imited to using the newy designed monitoring formats. In the absence of proper guideines, the district did what it coud do best, and district officias in the first year of experimentation showed a sort of commitment to achieve what they themseves had proposed. With the exception of ora pis, the acceptance of famiy panning in in Khurda district decined Review of Impementation of Approach for amiy Wefare in India 110

115 compared to the previous year ( ). MCH indicators during this period improved sighty as there was a higher percentage of ANC registration and foow-up, more births were assisted by trained personne, and there was better coverage of chidren under immunization programmes. Expansion of T A In a meeting of State Secretaries in New Dehi on ebruary 1 and 2, 1996, GOI announced pans to extend T A to a districts in the country. This decision was not taken in a systematic way because a review of the impementation in various states was not conducted nor was the process for identifying cients considered. Many states that had made unsuccessfu attempts to impement T A were opposed to the pan but were eft with no option as GOI had aready made a decision. GOI continuay insisted that the new approach woud improve the quaity of services, and in this context it was agreed that GOI woud prepare and circuate a set of guideines and a manua to a the states. The manua was expected to provide carity in impementing the new approach. The majority of the participants fet dissatisfied at the way the decision had been made by GOI; Orissa was no exception. After the meeting, the Directorate in Orissa eaborated on the procedures to impement the GOI directive and issued etters to a the CDMOs on March 22, 1996, aong-with the nationa Secretary s etter. The etter, marked URGENT/IMPORTANT, asked them to foow the instructions carefuy. In this context, the Director of amiy Wefare mentioned the foowing: "Regarding the T A approach, neither fertiity nor famiy panning is a major probem because the state surprisingy is doing we in the famiy panning programme and the fertiity eves are coming down significanty in the triba districts when compared with those of the coasta ones. What is required from the nationa government is a feasibiity anaysis of whether the new approach, given the situation in Orissa, can be impemented or not. This was not taken into consideration despite our repeated requests. In other words, the state was not fuy prepared to test or impement the new approach but the nationa government order had to be executed and, therefore, according to instructions we have communicated with the districts and impemented the programme. Before the ebruary 14, 1996 etter from GOI coud reach the districts, the District Magistrates received a etter directy from the Secretary of amiy Wefare (GOI), dated March 4, It mentioned a set of guideines, the workshops and the budget for conducting them. The aocation of budgets to the districts did not take into consideration the actua number of PHCs but rather assumed an average number of them. The funds had to be procured from the regiona director s office. A few districts received more funds than they required, but most districts did not. The state was unaware of this etter, and none of the districts, surprisingy, brought it to the notice of the state. Nevertheess on Apri 4, 1996, the Joint Secretary, amiy Wefare, GOI wrote a etter to the State Secretary about the workshop with a copy of the GOI Secretary s etter addressed directy to the districts. The state issued this etter to the districts as a matter of routine on Apri 20, Later, after corresponding with the regiona directors, the exact funding for each district was worked out, and the workshops at the state, district, and bock eves were conducted between Juy and August This apart, GOI addressed a etter to the State Secretary on March 27, 1996, that provided a detaied pan of the bottom-up approach. The etter was dispatched to the districts on Apri 4, The state fet that the districts shoud foow the 111 Approach in Orissa

116 GOI instructions exacty to estimate perceived need and service requirements. The procedures for working out both were outined in detai. urther, the GOI schedue had 17 questions covering ANC, deiveries, post-nata care, immunization of chidren, Acute Respiratory Infections (ARI), diarrhoea cases among chidren, and famiy panning. GOI coverage norms were aso tagged on to these indicators as exampes, except for famiy panning. With regard to famiy panning, the states were advised to prescribe their own norms to arrive at tota service requirements. State-eve officias sent the etter to the districts and started monitoring their progress. When they discovered that famiy panning service requirements were grossy underestimated, they decided to deveop state estimates. Hence, as a foow-up to the GOI etters dated ebruary 14 and March 27, the state Directorate issued a reminder in etter number 11873/ W-DE-1/96 on May 10, 1996, to a the CDMOs. It outined a specific methodoogy for estimating famiy panning service requirements and state norms for the indicators that differed from GOI norms. The etter stated the foowing: Pease refer to the guideines issued vide this Directorate circuar No. 4854/ W dated ebruary 27, 1996 and DO No / W dated Apri 25, 1996, for preparation of PHC-eve and district-eve pans under the target-free approach. The due date for receipt of district-consoidated reports is May 15, In this regard, it is expected that the bock-eve pans have aready been given a fina shape taking into account the popuation size, demographic indicators, and famiy panning status of the eigibe coupes. During fied checks, it was observed that the guideines and the exampes given for assessing the service needs of a sub-centre have not been propery understood, and action pans drawn up incude underestimating the service needs on severa counts. In most cases, the famiy panning service needs have not been propery assessed. The anayses of the eigibe coupes in regard to their famiy panning service status and service needs have not been propery done. In order to further simpify in understanding the issues, the foowing exampes may be brought to the notice of a periphera staff. A. MCH service assessments are to be made on the basis of the birth rate of 28 per 1,000 popuation, and an average popuation of 5,000 per sub-centre shoud be assumed. Accordingy, the estimates of services sha be as foows: B. Primariy, the eigibe coupes register shoud be updated through compete enumeration of the entire popuation. The number of coupes by parity, that is, the number of chidren and number of coupes practising each of the famiy panning methods by parity, shoud be found out for assessing the service needs. The estimated number of eigibe coupes per 1,000 popuation is 165. Hence, the estimated number of coupes for a sub-centre with 5,000 popuation sha be 825. The percentage of eigibe coupes protected in the state is around 40 per cent. These indicators may be used to check the eigibe coupe survey findings with 10 per cent pus or minus range. As per the state average performance, the minimum number of acceptors per subcentre of 5,000 popuation in each of the four methods is as foows: FP Method Estimated Number of Accep- ( ) tors for One Sub-centre Area Steriization 30 IUD 30 Ora pi (13 cyces per user) 15 Condom reguar users (72 pieces per user) 65 Review of Impementation of Approach for amiy Wefare in India 112

117 Service Estimated Number I. Antenata registration 100% Pregnancy wastage 10% 14 - Tota ANCs 154 II. Eary antenata registration 60% 92 III. Detection and referra of high-risk pregnancy 15% 23 IV. Iron/Foic acid to ANC 100% 154 V. Treatment of anaemic expectant mothers 50% 77 VI. TT (Mother) 100% 154 VII. Institutiona deiveries 25% 35 VIII. Deivery by trained attendant 95% 133 IX. Growth monitoring of ive birth 95% 133 X. Referra of high-risk births 10% 14 XI. Infant immunization 100% of ive births 140 The actua service need may be more, but the above state-eve estimation may be used as a practica guide to check the bock-eve pans, and any abnorma deviation beyond 10 per cent needs to be expained with reference to the actua number of coupes in need of different methods. It is, therefore, requested that the pans aready drawn up may be rechecked on the basis of the above norm. The district consoidated report shoud be submitted by May 15, 1996, aong with detaied notes on the indicators and estimation adopted for the purpose. 6 Using the state-specific guideines, the districts recacuated their estimates and compied the reports in accordance with GOI activity pans. These pans were then submitted to the state by June Whie the state prepared the activity pans, training in the GOI manua was postponed. State-eve trainers had to be identified, and the manua had to be transated into the oca anguage. Whie the transation of the manua was going on, GOI conducted training for state-eve officers in New Dehi in September, Two senior officers the Director of the State Institute of Heath and amiy Wefare (SIH W) and the Joint Director ( amiy Wefare) attended. On their return, the transated manua was finaized, and copies were made. On November 6 and 7, 1996, training for state and district officias was conducted. No forma training was organized for other district officias and functionaries except for orientation during monthy/ weeky meetings. Khurda, which aready gained had the experience of impementing the new approach in the previous year, continued with what they had done earier. Thirtythree introductory workshops were hed by August Later, the district started providing services according to the activity pan formuated aong the ines of the state circuar. District performance in famiy panning in the year , was affected by the T A. Compared with , the year before the target-free approach was introduced in Khurda, the overa decine in famiy panning performance was four per cent, and the extent of decine in condom use was to the extent of 10 per cent. 6 Letter from Directorate to the CDMOs of a districts specifying the state guideines for impementing T A, May Approach in Orissa

118 Ganjam district, unike Khurda, did not have prior experience in impementing the new approach. It foowed a the instructions set by the state Directorate and then devised a pan. As one of the more progressive districts in the state, it did not take much time to adapt to the new approach. As many as 44 one-day workshops, were conducted at various eves in the district in the absence of any guideines. In Apri 1996, the district carried out the ECR survey and then estimated famiy panning service requirements and formuated its activity pans by the end of May. With regard to overa famiy panning performance, there was a negigibe decine. or instance, in in Ganjam there were 13,823 steriizations; after the introduction of the new approach in , 13,457 steriizations were performed. However, a decine in the acceptance of spacing methods was observed, and the extent of drop in condom acceptance was considerabe. In , preparations for instituting T A started in the beginning of the fisca year. UNICE gave funds for orientation training, and the state and the districts worked out a training itinerary. In Ganjam, seven to eight two-day workshops were hed for medica officers and IEC staff from June 6-28, 1997, at district headquarters. Three faciitators from the state and an equa number from the district conducted the training. Simiary, a five-day training programme was organized at the bock eve, and 44 such programmes were hed before August Over 2,900 persons from the heath department and from outside (other departments, NGOs, panchayat and ward members, schoo teachers, and so on) were trained at a cost of neary Rs. 9 akh (a akh = 100,000). In Khurda, on the other hand, heath functionaries were busy with the Chid Surviva and Safe Motherhood (CSSM) training unti November 1997, so district staff gave very itte attention to T A. In spite of repeated reminders from the state, the district did not respond, so at the end of the fisca year T A training funds were withdrawn. Hence, none of the bock-eve staff or the periphera staff was officiay trained in the approach. Khurda did exacty what it had done in the past two years. The ECR survey was conducted and then activity pans were prepared foowing the state guideines given the previous year. However, in May 1997, the district received a etter from the Additiona Secretary ( amiy Wefare) in Orissa, that suggested remedia steps to enhance the decreasing acceptance of IUDs. The etter ceary stated that the expected eve for IUDs woud have to be triped and submitted as the ELA in the district activity pan. Khurda did as instructed. Ganjam district aso received the etter about increasing IUD acceptance. In addition to this etter, around the same time, another etter from the Directorate proposing a new methodoogy for working out the ELAs was issued to a the districts. (Surprisingy, district officias in Khurda did not get that etter and were unaware of it.) Instead of using the earier estimates, this etter instructed the district to foow a new approach to arrive at ELAs for each famiy panning method and to estimate famiy panning service needs (see Box 1). The district statistica officer based his cacuations for on the guideines described in Box 1. or famiy panning methods, the basis for the coverage norms shifted from the genera popuation to coupes, and parity was incuded. This methodoogy seems to be more reaistic than the previous one. How the state arrived at these coverage norms is sti a mystery. Nonetheess, this methodoogy was communicated to a the PHCs in Ganjam though the medica officers and the heath workers in the seected PHCs have yet to use it to estimate famiy panning service needs. Review of Impementation of Approach for amiy Wefare in India 114

119 Overa, famiy panning acceptance in in Khurda district dropped substantiay from eves. Major decines were observed for steriization and condoms whie it improved for IUDs and ora pis. A simiar situation existed in Ganjam district as we. In both districts, IUD acceptance improved consideraby because of the etter from the state requiring higher ELAs. Our impressions of state-specific probems gained from earier discussions with the Director ( amiy Wefare) were reaffirmed during our discussions with the CDMOs. The CDMO in Ganjam, one of the better districts in the state, decared the foowing: headquarter are not reimbursed for HRA on time. This acts as a de-motivating factor. urthermore, equipment and instruments are not suppied reguary. There is no proper storage faciity either at the district or at the periphera eve. ive PHCs are inaccessibe, and mobiity is a probem. There is a short suppy of medicines and even basic things required for infection prevention are not suppied reguary. In this condition, it is difficut to provide good quaity services. However, we try to provide the best services we can with a these imitations. The views expressed by the CDMO were reiterated by the medica officer of the PHC and subsequenty by the ANMs as we. Our district is doing reasonaby we in famiy panning athough the performance in the ast two years has come down. The district is more economicay advanced than the rest of the state. However, the heath department and faciities need considerabe improvement. In many paces, the infrastructure at bock, sector and sub-centre eves is in a diapidated state as the maintenance budget is very meagre and does not aow for major repairs. Even after repeatedy sending reminders to the state, nothing has been done. Auxiiary nurse midwives (ANMs) quarters are not avaiabe in haf of the sub-centres and wherever avaiabe, they are in a bad shape. Hence, the ANM cannot reside there. If she stays in the viage headquarter, she is not given house rent aowance (HRA). Those without this faciity and staying in viage Since quaity of service was one of thrusts of the new approach, we discussed service deivery with functionaries at the PHC and sub-centre eves. In the course of our discussions, we found that both monitoring and supportive supervision in the form of increased numbers of fied visits by the heath workers and their supervisors had improved, and that weeky meetings at PHCs had been introduced. Other than these measures, no improvements in the quaity of services were visibe, as no efforts had been made to enhance the technica competency of the staff. Athough the statistica assistants had cassified potentia cients (potentia as identified by the provider after anayzing the age and parity of eigibe Box 1 Steriization IUD Condom Users Pi Users Coupes having 3 chidren pus Coupes having 2 chidren 8% coupes to be covered Coupes having 2 chidren pus Coupes having 1 chid 8% coupes * Coupes having 2 chidren pus Coupes having 1 chid pus Coupes having no chidren Coupes having 2 chidren pus Coupes having 1 chid pus Coupes having no chidren 13/1,000 coupes 3/1,000 coupes 115 Approach in Orissa

120 women) at the sub-centre eve, the heath workers in the fied did not know who their potentia cients were despite having we-maintained ECRs. Moreover, they did not have proper knowedge about the correct use of methods, about detais of side effects, and about contraindications. Aso, stock registers indicated that the sub-centres had not received any iron or foic acid (I A) tabets for over a year and a haf. In such conditions, how far can the new approach go toward improving the quaity of services? Note that in spite of these deficiencies, the faciity survey of the RCH project was competed, though upgrading existing faciities and adding new ones has not begun. In reaity, T A has not been propery impemented. Though the state did adhere to the GOI formats, it set procedures for estimating the ELAs for each famiy panning method because of the void created by GOI when targets were removed. In other words, the procedure for making estimates was decentraized, so Orissa foowed its own pattern and impemented the programme in its own convenient way. The responsibiity for fixing targets shifted from GOI to GOO, and the districts did exacty what the state government asked them to do. Indirect cacuations standardized at the state eve were used as the ELAs. If impementing the T A approach consists merey of submitting GOI activity pans and monthy progress reports, then Orissa has impemented it; this is the understanding of a the officias and heath functionaries in the state. In this context, we asked a few ANMs about their understanding of the T A approach and the processes of impementation. One ANM in Ganjam district, who had performed better than other workers in the PHC area, offered this expanation: prepare monthy reports and submit them in the meetings. If the monthy targets were not achieved, the medica officer used to demand an expanation. Even now the same thing is done. However, targets are not given directy. Based on the ECR survey, the eigibe coupes are cassified by age and parity before submitting to the PHC. The PHC statistica assistant then examines it and informs me that I wi have to perform this number of steriizations, this number of, etc., for the year. These numbers are ater broken down into monthy targets. Whie aotting these numbers, the medica officer says this percentage of women in this parity wi have to be covered for this method and so on. Against this, the ogistics requirement was estimated and the suppies have been given accordingy. Later, during fied visits, I try to contact such women and motivate them. The new thing in this approach is that younger women in ower parities are approached because their profie is avaiabe. urther, the monitoring and reporting has strengthened. Weeky meetings are hed at sector eve and the supervisor visits me more often and heps me in carrying out the determined activities. Another ANM in Khurda district tod us this: I got posted to this district from a neighbouring district. I did not see anything different in the way the new approach is being impemented. I have been doing exacty the same thing I was doing there. I was updating the ECR and submitting it to the PHC. The PHC statistica assistant used to do some cacuation and then come up with the workoad of my centre. According to my workoad, I pan my activities aong with my supervisor s hep and visit the viages. Earier I used to be reprimanded if I had not performed we but now I am given a chance to expain and then supportive supervision in the form of more supervisory visits is provided if it is a genuine case. Before the T A approach was introduced, I was given targets by the medica officer, and every month I used to In view of these discussions, it emerges that the most important ink in the execution of the new approach Review of Impementation of Approach for amiy Wefare in India 116

121 seems to be the statistica assistants because they are the ones who determine activities at the subcentre eve. The ANMs are sti unaware of how their workoads are compied or cacuated. Discussions with heath functionaries indicated that the pressure to perform we had actuay increased because of weeky monitoring from the PHCs. Nevertheess, it can be deduced that Orissa made efforts to impement the approach in its own way and to hep heath functionaries understand the importance of it. After reviewing the impementation of T A, GOI found that due to compex cacuations, the heath workers were handicapped in fuy utiizing the manua and setting performance norms for themseves. Therefore, two workshops were hed on August 19 and 28, 1997, in the Nationa Institute of Heath and amiy Wefare (NIH W) in New Dehi. Grassroot workers ike ANMs and medica officers from PHCs of different states aong-with district and GOI officias participated and provided feedback on their experiences and on the effectiveness of the manua as we. oowing these workshops, the manua was simpified and was officiay introduced in Apri The revised manua, caed the, was given to a the states to be used from the beginning of fisca year Orissa too received the manuas and sent them to the districts asking them to compie information using the new formats. In the absence of any training or orientation, heath functionaries (statistica assistants ony) started compiing information and submitting annua pans and monthy reports aong the ines of the newy designed formats. At the time of our visit, the State Institute of Heath and amiy Wefare (SIH W), which was aso responsibe for training, was transating the manua into the oca anguage. In this regard, we discussed the training itinerary and its utiity with the Director of the SIH W. The Director mentioned that training was ikey to start in January 1999 because the manua had yet to be finaized and copies had to be avaiabe at the sessions. The state had aready received Rs. 7 akh from GOI in Juy 1998, but there had been a deay on the part of the state. The training caendar was to be finaized after consutations with the Directorate and Secretariat. When asked about the utiity of training, the director mentioned this: The training in its new form is nothing new except for a few changes here and there. Since the workers were trained earier, the state thought that it coud be impemented without much effort. The state, therefore, sent the monitoring formats to a the districts and asked them to compie information in the new formats. Accordingy, the districts have prepared and submitted the pans to the state. The state pan was competed and sent to GOI in September However, the main issue is not the manua training as it is ony oaded with mathematics. A person good at it can do very we. However, behind the mathematics or the numericas one needs to understand what our goa is and how do we strategize to reach that goa? Earier we had the Heath for A or Reaching Repacement ertiity by such and such a time frame as our goas. With the introduction of T A/, nobody is emphasizing it and probaby it is forgotten. In the absence of such goas, it is difficut to work out stateeve strategies and subsequenty the activities to achieve them. This is what has happened in the eary years of impementation of the new approach, and we are sti continuing doing this. The state has had discussions on this particuar issue and is ikey to spe out state-specific goas and in accordance try work out an impementation pan. Most probaby we wi be integrating our RCH package with training as a singe package so that the district officias who are the rea impementers of the various programmes are not frequenty caed for various training sessions now and then. 117 Approach in Orissa

122 Despite deay in impementing the approach, the state has been seriousy contempating integrating various training programmes. Athough this is a good idea, there has been no movement in the deveopment of training packages, curricuum, and pedagogic toos to be used. It seems to us that at this pace it wi take a ong time for such a package to become a reaity. amiy Panning Performance Overa acceptance of famiy panning to a arge extent decined at the state and at the district eves, though resuts for specific methods were mixed. The expected and actua eves of steriization acceptance after the Despite deay in impementing the introduction of T A decined approach, the state has whie the acceptance of IUDs and been seriousy ora pis improved consideraby. contempating integrating Condom use, ike steriization, various training dropped. We offer the foowing programmes. Athough anaysis for each method of this is a good idea, there has famiy panning from to been no movement in the deveopment of training packages, curricuum, and Limiting Methods pedagogic toos to be used. The steriization target for the year was 200,000; 162,085 were performed for an achievement rate of 81 per cent. In , the target for steriizations remained the same since Khurda district was not given any targets. The performance during this year dropped by eight per cent from the previous year (148,659 steriizations performed). With the introduction of the T A in the state in , the expected eve of achievement for steriization was around 191,513; 134,825 were conducted for an achievement rate of 70 per cent. However, when compared with the overa performance of , there was a nine per cent decine. Neary 23 out of the 30 districts in the state witnessed a considerabe decine in acceptance. In , acceptance dropped further as ony 127,046 steriization operations were conducted. The overa decine between and in steriization was around 21 per cent. The ELA for steriization as depicted in igure 1 indicate that it has come down from 200,000 in to 177,000 in Instead of ELAs increasing in proportion to popuation growth and because of annua attrition among users, they have dropped by 13 per cent. This is not good because, in genera, owering ELAs creates a tendency to under-perform as seen in the case of Orissa. The impact of the programme on fertiity is bound to suffer due to this, especiay in the absence of monitoring the age and parity of new acceptors. rom , quartery acceptance of steriization uniformy increased from the first to the ast quarter each year. In the year , more than threefourths of the steriizations were done in the second haf of the year. Ony five per cent of tota performance was achieved in the first quarter; this increased to 17 per cent in the second quarter, 34 Tabe 1 Expected and Actua Leves of Steriization Acceptance in Orissa from to Year Expected Acceptance Actua Acceptance Percentage Achievement , , , , , , , , Review of Impementation of Approach for amiy Wefare in India 118

123 Fig. 1 Steriization Performance in Orissa services, provision of spacing methods on a continuous basis is a probem despite the fact that there is more unmet need for spacing than for imiting. The government, therefore, has made considerabe efforts to provide these services. As expressed in the service statistics in Tabe 3 beow, the acceptance of IUDs and ora pis has improved dramaticay over the years as a resut. per cent in the third quarter, and 44 per cent in the fourth quarter. A simiar pattern of performance is observabe for subsequent years even after the introduction of the T A in It can, therefore, be inferred from Tabe 2 and igure 2, that though enormous changes were made in the panning process to impement the new approach, actua performance seems to be more or ess simiar to what it was before its introduction. Neary threefifths of operations continued to be done in the atter haf of the year. Spacing Methods In 1992, the Nationa amiy Heath Survey (N HS) found that ess than one-tenth of acceptors of modern contraceptives were using a spacing method in Orissa. As a majority of the popuation is in rura areas with imited accessibiity to pubic heath IUDs In , 193,582 new acceptors of IUDs were recruited; in , the number was 209,074. With the expansion of the T A to the entire state in , acceptance dropped by eight per cent compared with In , the ELA was increased drasticay foowing the etter of Additiona Secretary ( amiy Wefare) of Orissa. As a resut, performance aso improved substantiay. Thus, between and , acceptance improved by 27 per cent. This was possibe because of cose monitoring by the department staff and the secretariat as we. Ora Pis The number of ora pi users in the state was 93,904 in Unike the acceptance of steriization and IUDs, in pi acceptance improved over the previous year by six per cent. In , there were 106,472 users. In , acceptance rose by just over one per cent over the past years performance but in comparison to the base year , there was a 15 per cent increase. Acceptance increased in a districts in the state Tabe 2 per cent Distribution of Steriization by Quarter in Orissa from to st Quarter nd Quarter rd Quarter th Quarter Approach in Orissa

124 Tabe 3 Annua Performance and Percentage Increase/Decrease of Spacing Methods in Orissa from to Year IUD Ora Pis Condoms AP PI/PD AP PI/PD AP PI/PD , , , , , , , , , , , , AP= Annua Performance; PI/PD= Percentage Increase/Percentage Decrease over the base year Fig. 2 Quartery Steriization Performance from to from a minimum of three per cent in Boangir district to a maximum of 65 per cent in Phubani district. It shoud be noted that GOI sets targets in terms of the number of ora pi-users but monitors acceptance in terms of the number of cyces distributed. In doing so, very important, crucia information on dropout rates and duration of use that coud be anayzed in the various registers is generay overooked. Consequenty, cacuations are restricted to numerica achievements without considering quaity issues. Wastage is not accounted for, and in the fina cacuations, the actua numbers get infated. urthermore, ora pi acceptance argey depends on suppy. It has been observed that the suppy of pis is not actuay driven by demand. In fact, an increase in the number of users directy depends on the quantity of suppies received and distributed. To find out the precise situation, we anaysed stock data in Khurda and Ganjam. It reveaed that the distribution to the districts from the state fuctuated consideraby. or instance, the suppy to Ganjam in fuctuated from a minimum of 5,000 cyces to a maximum of 40,000 cyces per month, and the quantity increased in the ast quarter of the fisca year. In , an average of 8,000 cyces was distributed each month though it varied from 1,000 to 14,000 cyces. A simiar pattern of distribution was observed in Khurda district. Given these fuctuations, the methodoogy for cacuating users based on numbers of cyces distributed is questionabe. Reported figures are ikey to be infated rather than based on actua use. The ack of information on continuous users is a major constraint to reaching any concusions on the actua number of users of ora contraceptives. Condoms The cacuation of condom users is done on simiar ines as that of pi-users, and identica probems exist in the cacuation of reguar users, continuation and dropout rates, and so on. In , there were 467,838 condom-users. That number decreased by about five per cent in The Review of Impementation of Approach for amiy Wefare in India 120

125 trend continued in the foowing years unti in , acceptance was about 70 per cent of that in Overa, when compared with the period prior to and after the introduction of the new approach, the decine in performance was over 45 per cent, and districts that had been performing we faired bady. Regarding the suppy of condoms, the quantity distributed by the state to the districts and by the districts to other centres varied from month to month. or instance, Khurda received 360,000 condoms in the beginning of Apri 1996, and it distributed 162,000 condoms by the end of the month. In May, Khurda did not suppy condoms to any PHCs. In June, Khurda received 420,000 condoms and distributed ony 54,000. None were suppied or distributed unti the end of November. In December, however, 24,000 condoms were distributed against a receipt of 60,000 from the state. In January, the district received 12,000 and distributed a of them. The fuctuation in receiving and distributing condoms reinforces the fact that condom use is suppy driven; generay, higher performance was reported when suppies were abundanty avaiabe whie ower performance was reported for months when there was ess stock. Concusion Orissa has been making efforts to provide a basic package of heath services to its peope by streamining its existing heath service deivery system, but the formation of 17 new districts has put additiona pressure on the meagre heath budget of the state. Hence, the state determined its priorities and financia deficits and ater negotiated with various donor agencies to pug the shortfas. To faciitate this process, a coordination ce for impementing projects funded by donors was set up, but it has yet to function. In this context, the state was forced by GOI to impement the T A with the expectation that it woud improve the quaity of services. The state has impemented the T A in accordance with GOI instructions. Since it was introduced ate, ony state-eve training coud be conducted in the first year. Due to this deayed beginning, the approach coud not be fied-tested, yet the activity and monitoring forms that shoud have been introduced after fied-testing were put into use. A simiar situation existed in case of the revised approach extended to a districts. The training of functionaries was not carried out in a systematic way. Even to this day, two or three districts have not done any training, and the Directorate has remained sient about it. urthermore, the technica The state has competency of the workers has impemented the T A in not been assessed, and very few accordance with GOI efforts have been made to instructions. Since it was improve the quaity of services. introduced ate, ony The procedure for setting targets state-eve training coud shifted from the centra be conducted in the government to the state, and the first year. state formuated its own procedures for working out ELAs in the void created by the GOI. The cient s perspective, which is the underying force of the new approach, has not been considered in T A impementation. The programme has remained a provider s programme, thus defying the basic principes of bottom-up panning. During this period, famiy panning acceptance, particuary that of steriization and condoms, dropped substantiay, but there was remarkabe improvement in that of ora pis and IUDs. Acceptance of IUDs decined in the first year of the new approach, but went up in subsequent years because of measures taken by the state. Information on age and parity of acceptors that is avaiabe at the 121 Approach in Orissa

126 department has not been anayzed though the ELAs have been cacuated based on parity. In addition to a this, the GOI mandated RCH programme is in its infancy, and its functionaries are yet to be trained in the revised approach. Even though the think tank at the state eve favours the integration of RCH with the approach, very itte has been done in that regard. If this thinking is transated into action, then ony a change for the better can be expected, but that does not seem to be forthcoming in the near future. Review of Impementation of Approach for amiy Wefare in India 122

127 Community Needs Assessment Approach for amiy Wefare in Rajasthan Hemant Dwivedi Daya Kishan Manga Gadde Narayana Introduction Rajasthan is one of the argest Indian states, constituting 5 per cent of the tota popuation and 11 per cent of the and area of the country. The state is divided into 32 districts which are grouped into 6 administrative divisions. The tota popuation of Rajasthan in 1951 was 16 miion and increased to 44 miion in Rajasthan is one of the major states in India with high infant mortaity, materna mortaity and fertiity rates. The tota fertiity rate of Rajasthan at 4.1 in 1997 is doube than that of repacement eve of fertiity. According to the popuation projections prepared by the Expert Group constituted by the Registrar Genera of India, based on pace of decine of tota fertiity rate in the past 10 years, Rajasthan is ikey to achieve repacement eve of fertiity ony in The socio-economic conditions acted as main barriers to the use of modern contraceptive methods in Rajasthan. Even after considerabe effort made by the Government of Rajasthan and severa vountary agencies, the femae iteracy at 20 per cent is the owest in the country. Neary 82 per cent of women in chid bearing age are iiterate. Chid marriages and ow status of women are other contributing factors. Reaizing the need to achieve popuation stabiization as eary as possibe, the Government of Rajasthan initiated severa measures to reform reproductive chid heath program management in the past 5 years, even before the introduction of target free approach in the county. The main aim of these initiatives is to expore aternate approaches to services deivery, to increase access to and quaity of reproductive and chid heath services. Rajasthan Government has reviewed these new systems from Approach in Rajasthan 123

128 time to time, scaed up the successfu interventions and discontinued the ess successfu ones. Objectives of the study The main objective of this study is to document the experiences of impementing reproductive chid heath program in Rajasthan in and in the context of impementation of target free approach. The study has anayzed the new innovative strategies and interventions introduced to improve efficiency and effectiveness of program impementation. In addition, program managers at various eves in the organization were interviewed on issues reated to impementation of new strategies. Performance of Rajasthan famiy panning program for the past three years has been anayzed. The programmme administrators, particuary the Secretary of amiy Wefare in Rajasthan, in , much before the introduction of the target free approach, decided that the unmet need for famiy panning services shoud be the foca point of a Programme Unmet need and decentraized panning The program administrators, particuary the Secretary of amiy Wefare in Rajasthan, in , much before the introduction of the target free approach, decided that the unmet need for famiy panning services shoud be the foca point of a program impementation efforts. rom then onwards, the program emphasis was argey on annua surveys of a eigibe women by heath workers at sub-centre eve to identify the unmet need for both spacing and termina method use. or this purpose, the Eigibe Coupe Survey Register was comprehensivey reviewed and redesigned. A workers were trained on how to coect and anayze the information. The Service Deivery Registers were designed to record the names of currenty married women with unmet need for each method of famiy panning. These bookets have become very effective mainy to provide services to women with unmet need and aso have become effective toos for monitoring program performance. The orientation training programmes were conducted in Apri 1997 in a 31 districts of the state. A team of trainers consisting of the Joint Directors and Demographer visited a districts and conducted training to workers in groups. These training programmes concentrated on how to coect accurate information at househod eve, how to compie coected information and how to convert information into micro pans. Progress of training, data coection and preparation of micro pans were cosed monitored by the Secretary ( amiy Wefare) and the Director ( amiy Wefare). In the year specia emphasis was paced on survey of coupes in urban sums. As per the guideines drawn by the department, the workers are expected to compete the survey work in the month of May. The primary heath centres are supposed to consoidate the unmet need identified in a subcentres in the first two weeks of June and the district eve pans, by the end of June. In effect, the unmet need identified in the month of May of every year becomes the annua expected performance of the workers or a micro pan for subcentre, and annua pans for primary heath centres and districts. Program performance monitoring is done based the extent to which the unmet need for famiy panning has actuay been met. To over come the probem of fudged performance reports, the department had introduced concurrent evauation by externa survey research agencies in The investigators from these agencies coect information from randomy seected househods in viages and report on the actua performance and aso reasons for non-use of famiy panning methods by coupes who have unmet need. This consideraby heped to improve the quaity of service statistics in the state. After two Review of Impementation of Approach for amiy Wefare in India 124

129 years, in 1998, the concurrent evauation was discontinued and more emphasis was aid on the reguar monitoring. In the year , program emphasis shifted more towards creation of demand for spacing method use among young married coupes, and to ante-nata care services and immunization coverage. The Secretary ( amiy Wefare) in a etter written to a Division Commissioners, District Coectors, Joint Directors, Chief Medica and Heath Officers on December 1997 stated: I woud request that specia attention be paid to the famiy wefare programme in view of imited time at our disposa. I woud ike to reiterate our view, expressed from time to time, that instead of the target free approach, Rajasthan is foowing the system of sef assessed target (SAT) where in ANMs have gone from house to house in the months of Apri and May and ascertained the reproductive heath and coverage needs of a the eigibe coupes residing in the viages of their subcentres. This confusion with regard to target or ack of target must be finay resoved and cosed as from our point of view, it not a usefu debate. Suffice to say that since targets have not been imposed either from Dehi or Jaipur as was the case earier, but is refective of resuts of the house to house to survey conducted by the ANMs, they are a refection of the service requirements that must be deivered by our medica and heath infrastructure. You wi yoursef see, there is a strong emphasis on spacing methods, especiay IUD insertion as we as measures to check reproductive heath disorders through Mahia Swasthya Meas. The minimum eve of achievement expected from you, however is ony a fraction of the actua need as expressed by eigibe coupes in their reproductive cyce. I trust you wi have no probem in evoving a suitabe strategy for achieving the minimum eve, which is reaistic and attainabe. In the year , Rajasthan Government invoved the district coectors in program impementation particuary to estabish coordination inkages between workers of different departments and to monitor program performance on a reguar and continuous basis. The Commissioners at divisiona eve and the Secretary, amiy Wefare caed for the meetings of district coectors to brief them about the program objectives and the strategies and aso to review the issues invoved in impementation. or instance, the Chief Secretary of Rajasthan in a etter to a district coectors stated the areas which need specia attention to improve performance: 1. As per the district micro pan, the individua institution shoud be the basic unit for programme monitoring. 2. The doctors and fied functionaries who have not acted sincerey for improving programme performance shoud be hed responsibe for poor performance. 3. The eigibe coupes with unmet need of imiting for famiy panning shoud be contacted propery and services sha be made avaiabe to them. 4. It has to be ensured that surgeon team reaches at camp site in time. 5. The acceptors of spacing methods shoud get reguar suppy of methods 6. In our state IMR is increasing since the ast three years. So far as service statistics of immunization is concerned the coverage eve is more than 90 percent, but increase in IMR put a question mark on those figures. The foowing points are to be taken care in the immunization programme: Approach in Rajasthan 125

130 A pregnant women shoud be registered for ANC services, in this the heath worker shoud see the popuation and birth rate of the area for making projection of expected deiveries It shoud be ensured the chidren are immunized at right time Specia emphasis shoud be given to institutiona deiveries, the untrained dais are to be trained in order to increase deiveries by trained hands. The Secretary, amiy Wefare Rajasthan continued hed severa meetings with the with severa of its chief medica and heath officers, innovative approaches the deputy chief medica and aunched in the eary heath officers, and the district 1990s and added a few materna and chid heath officers more and scaed up some to stress on the importance of during supportive supervision and programme monitoring. Monthy feed back system was estabished based on review of program performance in The Secretary ( amiy Wefare) and the Director ( amiy Wefare) reviewed the previous month performance of every district during the first week of every month. The review is based on objectives set by the districts for themseves for the year. eed back based on review was sent to the District Coectors by the Secretary ( amiy Wefare) and to the Chief Medica and Heath Officers and the Deputy Chief Medica Officers by the Director ( amiy Wefare). Based on the comments, the district coectors conducted the meetings of PHC medica officers who in turn reviewed the performance of the subcentre staff. These meetings were aso utiized to deveop district specific information, education and communication strategies to generate more demand for services. In addition to the above, bi-monthy review of program impementation was introduced in Supervisory teams of state eve officers were constituted and each team was given a custer of districts to monitor program performance in each district on bi-monthy basis. These supervisory teams made reguar visits to a districts in their designated areas and submitted the reports to the Secretary ( amiy Wefare). These reports formed the basis for bimonthy program performance review conducted by the Secretary ( amiy Wefare) for a Chief Medica and Heath Officers. Innovative approaches Rajasthan continued with severa of its innovative approaches aunched in the eary 1990s and added a few more and scaed up some during Jan Manga Jan Manga program has been expanded rapidy to cover 12,000 viages. This is a program impemented through vounteers seected from viages. Jan Manga vounteers are a coupe who are current users of famiy panning. They serve as information providers for popuation of approximatey 1,000 and aso act as depot hoders for spacing methods. The department after seection provides them training for a period of three days. These coupes contact eigibe women on reguar basis and counse them about famiy panning methods. They aso suppy ORS packets to those who are in need. The PHC MOs conduct a meeting of vounteers once in two months to provide them IEC materia and aso repenish the stock of contraceptives. There is no monetary compensation given to Jan Manga coupes but they are encouraged to charge fixed service fee for contraceptives distributed. The scheme, to begin with, was tested in Udaipur district and scaed up to cover 12,000 viages. Review of Impementation of Approach for amiy Wefare in India 126

131 Ayur Swasthya Karmi Scheme This scheme has been promoted to invove the practitioners of Indian Systems of Medicine. Many of the triba districts in Rajasthan do not have quaified medica practitioners in private sector. The heath personne of pubic sector, even if posted, are reuctant to stay in triba areas. A arge proportion of positions of pubic heath sector, as a resut, have remained vacant for ong periods of time. Given this, the department thought it appropriate and necessary to invove ISM practitioners who ive in triba areas and provide services to triba peope in impementation of reproductive and chid heath program. Jhado bock in Udaipur district was seected for the purpose on an experimenta basis in The Indian Medicine Board has been seected as an impementing agency. The ISM practitioners were trained to provide materna and chid heath services to triba popuation. No evauation of the project has been done so far. Invovement of Eected Panchayat Leaders in amiy Wefare Program During , specia efforts were made to invove eected representatives of Panchayat Raj and Municipa Councis. In November 1997, in every district one workshop was organized for eected representatives of rura and urban bodies. The training programmes deat with various services provided by heath department and the need to achieve popuation stabiization. Each program was attended by a team officers from the state eve incuding the Secretary ( W) and the Director ( W). In addition to this, active inkages were estabished between panchayat members and heath service deivery functionaries at various eves. Rajasthan has constituted Mahia Swasthya Sangh in each viage to share information and to promote utiization of heath services. Eected women members of Gram Panchayat were made ex-officio members of the Mahia Swasthya Sangh. Simiary participation of the medica officers of the primary heath centres and community heath centres in the monthy meetings of eected representatives at Panchayat Samiti was made compusory. As a resut of these efforts the interactions between eected representatives and heath personne at various eves improved consideraby. More systematic and institutionaized effort is required to convert interactions into effective participation. Tetanus Toxoid Campaign One of the significant steps taken by the Rajasthan Government in was to conduct TT campaign for women. The infant mortaity rate in Rajasthan showed no appreciabe decine in the past five years. The main objective of this campaign approach Neary 8 out every 100 chidren is to provide two doses of die before reaching 12 months TT vaccine at an interva age. Neonata tetanus mortaity of 4 to 5 weeks to a continued to be one of the key married women in the contributors of infant mortaity. age 15-30, irrespective of Ony 28 percent of pregnant their previous women received TT injections in immunization status and 43 percent in More than haf of the mothers did not receive any TT coverage. Given this, the department considered it essentia to increase the TT coverage of women foowing campaign approach. The campaign approach heps to mobiize a possibe resources to a imited period and gives a very high visibiity to the service. The main objective of this campaign approach is to provide two doses of TT vaccine at an interva of 4 to 5 weeks to a married women in the age 15-30, irrespective of their previous immunization status. To begin with a panning meeting at state eve was organized in ebruary 1998 to prepare the operationa guideine for the campaign. oowing this, district and bock eve meetings were hed in the same month to discuss the detais of campaign Approach in Rajasthan 127

132 approach. A detaied ogistic pan was prepared to keep the suppy chain active. Viage contact surveys were conducted in a viages of the state in the month of March with the hep of subcentre heath workers and a married women in age were enumerated. A simiar survey was conducted in a sum areas of 6 major towns in Rajasthan. Based on tota women in age 15-30, the tota vaccine requirement was cacuated. In addition, estimates were done for steriized syringes and needes, pressure cookers, drum steriizer, kerosene oi, vaccine carriers, and stationery. Immunization sites in Rajasthan decided to each viage were identified in conduct awareness advance. Immunization teams generation programmes not ony to heath were constituted, each team personne but aso to consisting of one supervisor and anganwadi workers, two workers. Each team was eected women punch given responsibiity of covering and surpunch, schoo a custer of viages and a route teachers and other oca map was prepared and date on infuentia persons. which immunization camp was to be hed was worked out. A pregnant mothers immunized in each viage were given disposabe deivery kits. Information, Education and Communication Bureau of Rajasthan heath department designed and printed pubicity materia such as banners, posters, hand outs, pamphets, bookets and wa paintings. TV shows, pane discussions, radio taks, press briefings were organized to create awareness about the campaign. Other departments such as Panchayati Raj, Women and Chid Deveopment, Rura Deveopment and Education departments were invoved in mobiization of women in each viage. Jan Manga coupes and Mahia Panchs were invoved to contact and share information with married women in the age group. The first round of campaign was done from Apri and the second round of campaign was done from May 24-30, Neary 3.5 miion women in chid bearing age of (80 per cent) were given two doses of TT injection. Community Awareness Generation Programmes The Ministry of Heath and amiy Wefare, Government of India advised Rajasthan to conduct community awareness generation programmes for heath personne at subcentre eve. Rajasthan decided to conduct these programmes not ony to heath personne but aso to anganwadi workers, eected women punch and surpunch, schoo teachers and other oca infuentia persons. Three resource persons, two from externa agencies and one from heath department were identified for each district. Three day training of trainers programs were conducted for the resource persons. In a 1,646 training programs were conducted at sector PHC eve between December 1998 to ebruary The training sessions covered popuation issues, reproductive heath issues of adoescents and women, chid heath, famiy panning, and STD/RTI/ AIDS. The Government of India provided the RCH booket and the Manua for Community Needs Assessment as training materia. Whie sufficient financia resources were made avaiabe for training programs, no money was given for printing and distribution of training materia. Due to this, the training materia coud not be distributed. There was aso no foow up after the training programs. Rajasthan has decided to retain its own system of identification of unmet need than foow the new system proposed by the Government of India under the community needs assessment. Review of Impementation of Approach for amiy Wefare in India 128

133 Rajasthan Popuation Poicy Another significant step taken by Rajasthan was formuation of a comprehensive state popuation poicy which was approved by the Cabinet on Juy 31, One of the main objectives of the poicy is to reduce tota fertiity rate from 4.1 in 1997 to 2.1 in or this, Rajasthan proposes to increase the contraceptive prevaence rate from 32.1 in 1997 to 65.9 in The second major objective is to reduce infant mortaity rate from 85 in 1997 to 53.8 in The main strategies to achieve these objectives revove round increase in age at marriage, gender equaity and empowerment of women, contributions by various deveopment department, invovement of panchayati raj institutions, non-government organizations, and private and corporate sector and effective management of famiy wefare program. Rajasthan proposes to review and reorganize the heath department to improve demand for and quaity of services, invove eected eaders in decision making, revamp information and suppy systems, and encourage operations research. The heath department is now preparing an eaborate impementation pan for each component of poicy with detais of what shoud be done and responsibe person to do it. Opinions of heath personne on target free approach Personne of heath department at various eves were interviewed to eicit their opinions on the target free approach, renamed as the community needs assessment approach. The Secretary ( W) fees that the new approach wi be successfu ony when program monitoring mechanisms are strengthened and ony when the interventions are cient oriented. She fet that the reguar review and monitoring of famiy wefare program and coordination inks with other deveopment departments has consideraby improved the performance in According to her, convergence of services at oca eve is essentia for the success of the program. She aso opined that more importance shoud be given to dai training and suppy of disposabe deivery kits to pregnant women in rura areas. Interventions such as TT campaign conducted in the state to reduce IMR and MMR, she thought, woud have a major impact on acceptance of services and increased use of modern methods of famiy panning. The Director ( W) fet that Rajasthan has improved its performance mainy due to the survey and micropanning approach foowed. Because of the compusory annua surveys, the heath workers contacts with workers improved and aso services The Director ( W) fet provided to cients. The cient that Rajasthan has survey provided a cear improved its performance understanding of the mainy due to the survey reproductive heath needs in a and micro-panning subcentre area. He said that approach foowed. Because frequent transfer of medica of the compusory annua officers is a major obstace in surveys, the heath workers successfu impementation of contacts with workers the program. improved and aso services provided to cients. The district eve officers of both Tonk and Ajmer fet that identification of unmet need resuted in better monitoring and program performance. They thought that the decision to aboish incentives scheme ed to better quaity of services with emphasis on cient needs. According to them, the spacing method users have not increased significanty. They attributed this to nonavaiabiity of mae workers or ow participation of mae workers in famiy panning program impementation. There was considerabe improvement in quaity of data coected and feed back given on performance. Improved program management skis is essentia, according to district and PHC medica officers, to achieve objectives of Approach in Rajasthan 129

134 the program. The femae heath workers viewed the new system when it was introduced with some amount of distrust. Door to door survey to identify unmet need was considered a cumbersome process without any commensurate benefit. After a coupe of years, they fet that the new system was very hepfu not ony to focus their efforts specificay on cients with unmet need which heped them achieve better resuts. amiy panning performance amiy panning performance based on service statistics has been compared for the past four years for each modern method. Whie service statistics in genera are reiabe for steriization method, their reiabiity for spacing methods is ow. Steriization Performance The emphasis on steriization has remained the same even after the introduction of unmet need approach mainy because the number of coupes with unmet need to imit is very high in Rajasthan. The state imposed tragets in and for steriization method remained the same at 250,000 steriizations per year. Ony in and again in , the estimated unmet need identified based on househod survey done by femae heath workers was considered as expected eve of performance. The number of coupes with unmet need for steriization as a resut increased to 582,309 in and 457,122 in As a resut, the actua performance as proportion of expected performance has actuay decined compared to previous two years. However, the performance in actua terms has increased consideraby in and The steriization performance in the past four years showed an upward trend. The tota steriizations done in were ony 168,245 and the performance in was 229,295 steriization operations, an increase of about 37 percent and an average annua increase of 12 percent. Given the high unmet demand for sterizations, there is sti scope to improve the performance. Rajasthan has decided to provide steriization services in more heath institutions which wi increase the access to services. With increased access, the number of acceptors is ikey to go up. Another significant aspect is that performance is not uniform in a districts. Whie some districts have increased the performance eves, others have not shown any improvement. These differentias have to be taken into consideration to evove effective district eve service deivery strategies. Fig. 1 Steriization Performance in Rajasthan IUCD Performance Number of IUCDs inserted aso showed a marked increase in the past four years. In , the expected performance was 282,000 IUCD insertions and achievement was 168,239 insertions. In , the expected performance increased to 327,185 insertions and the actua performance was 232,685. As has been the case with steriizations, the expected performance of IUCD has increased consideraby over a four year period. The actua performance has aso kept pace with rising expectations. Review of Impementation of Approach for amiy Wefare in India 130

135 Fig 2 IUCD Performance There were ony 325,465 users of pis in The extent of achievement of expected eve of performance aso varied from 74 per cent in to 215 per cent in The performance reported indicates that more the expected eve of achievement in a given year, more the performance reported, which is to a arge extent an indication of fudged numbers. The monthy performance reports of districts ceary indicate that the emphasis on unmet need has not resuted in reiabe reports for spacing methods. or instance, Pai district which has reported the highest IUCD performance in the year has shown considerabe fuctuations in month wise performance. Ora Pi Performance In Rajasthan, the expected eve of achievement was 125,000 ora pi users in and that substantiay increased to 385,540 users in In the foowing year, the expected eve decined to 328,640 users. Ora pi performance has dramaticay increased from 92,268 users in to 484,067 users in After this the reported performance showed considerabe decine. ELA : Expected Leve of Achievement Condom Performance The expected eve of achievement for condoms was 677,000 users for and of this, 70 per cent was achieved. The Heath and amiy Wefare Department decided not to have any expected eves of achievement for and The performance nevertheess steadiy and significanty increased by amost 50 per cent in compared to performance in In the foowing years, the Department again decided to reintroduce expected eves of performance for condoms. In , 341,055 users were expected but the actua performance reported was 470,874 users. The expected eve of performance remained more or ess same for but the actua performance decined to 374,345 users. Like the reported performance on pi users, the condom users performance was more reated to quantity of condoms suppied in a particuar year than the actua users. Tabe 1 Expected and Actua Leves of Performance of Ora Contraceptives and Condoms in Rajasthan : to Ora Contraceptives Condoms Year ELA Achievement Percent ELA Achievement Percent ,000 92, , , , , , , , , , , , , , , , , Approach in Rajasthan 131

136 Concusion Rajasthan faces a formidabe task of reducing fertiity by 2016 as per the popuation poicy approved by the Government. Low eves of economic deveopment, ow status of women, and eary age at marriage in Rajasthan are not conducive to the achievement of objectives. Probems are further compounded by the fact that the service deivery systems are i equipped to provide quaity services. Rajasthan Government with committed administrators at top eve has taken a series of innovative steps particuary in schoo education and heath to improve the quaity of ife of its peope. The pioneering effort done with the hep of Rajasthan RCH programme camp approach to particuary revoves round the provide antenata services concept of unmet need for to pregnant women is a famiy panning. ied workers major step taken and wi contact eigibe coupes and definitey hep to reduce materna and infant ascertain whether the need for mortaity and morbidity. famiy panning services has been fufied or not. The unmet need identified is converted into expected eves of performance and the actua performance is measured against this indicator. The unmet need concept at east prompts workers to visit househods in their area once a year. However what is not known is the extent to which the programme has succeeded in converting the unmet need into demand. The amiy Wefare Department has not done a systematic review of this strategy. The atest evidence on the subject has indicated that a arge number of coupes without unmet need at a given point of time become coupes with unmet need and vice versa. The unmet need is a dynamic concept and the programme strategies have not taken this aspect into consideration. Given this, unmet need is a more reiabe too for advocacy than programme impementation. Rajasthan Government has introduced severa innovative schemes in a imited area and scaed up a few successfu eements. Lack of innovative approaches is a major probem in centray run socia deveopment programmes and equay probematic is the proiferation of innovative schemes without systematic efforts to identify successfu eements and cear strategies to scae up successfu eements. Rajasthan to a arge extent beongs to the atter category. There are too many innovative programmes but itte effort has gone to consoidate the gains and expand the key innovations. Rajasthan in the past two years has shifted its focus to a more comprehensive package of reproductive and chid heath services. The pioneering effort done with the hep of campapproach to provide antenata services to pregnant women is a major step taken in this direction and wi definitey hep to reduce materna and infant mortaity and morbidity. Service statistics on ora pi and condom performance is as ess reiabe as it was before in spite of the fact that the expected eves of achievement are based on unmet need. Remedia measures have to be more systematic than cosmetic. Rajasthan Government shoud re-introduce the system of concurrent evauation with externa agencies to rectify the situation. Review of Impementation of Approach for amiy Wefare in India 132

137 Community Needs Assessment Approach for amiy Wefare in Uttar Pradesh J.S.Deepak Background Uttar Pradesh is one of the argest states in India, constituting one-tenth of the tota and area of the country. It is presenty divided into 83 districts that are grouped into 18 administrative divisions. Neary 80 per cent of the popuation ives in rura areas, and agricuture is the singe argest occupation empoying 72 per cent of the abour force. Agricuture aso accounts for 46 per cent of the state s income. Uttar Pradesh ranks third in India in terms of both the per capita production of food grains and the growth rate of the production of food grains. 1 According to the 1991 census, the popuation of Uttar Pradesh was 139 miion. The birth and death rates were, in genera, higher than the average rates for the country as a whoe. The tota fertiity rate was 6.6 in 1971, but it decined to 4.0 in The age patterns of fertiity in the ast 20 years have shown some positive changes as the contribution to the popuation size of women aged 30 years and above has been steadiy decining. The crude death rate decined from 20 in 1971 to 8.1 in The modern contraceptive prevaence rate in Uttar Pradesh was six per cent in 1971 but increased to 22 per cent in Of the tota number of modern contraceptive users, 71 per cent are users of imiting methods, and the remaining 29 per cent are users of spacing methods Nationa amiy Heath Survey: Uttar Pradesh, Popuation Research Centre and Internationa Institute for Popuation Sciences, Mumbai, 1992 Nationa amiy Heath Survey (Preiminary Report): Madhya Pradesh, Internationa Institute for Popuation Sciences, Mumbai, 1999 and Sampe Registration System, Registrar Genera of India, 1998 Approach in Uttar Pradesh 133

138 The Government of India (GOI) foowed a targetbased approach to famiy panning from the inception of the programme. Targets for each method were assigned to the states and subsequenty were distributed to district and ower eves. Monitoring was based on the achievement of the targets given to each state. Over a period of time, however, service statistics indicated that the contraceptive prevaence rate had increased without a corresponding decine in the fertiity rate. The GOI, therefore, caed for a meeting of a secretaries in charge of famiy wefare programmes on Apri 3 and 4, 1995, and decided to exempt at east one district in each state from targets to expore various aternatives to monitoring programme performance. Objectives of this Study The main objective of this study is to document experiences with the impementation of the Target- ree Approach (T A). The specific objectives are the foowing: To describe the processes foowed to impement the new system To record the opinions of personne on the new system and on the impementation processes To anayze the impications of new system on performance. interview guide. Correspondence and other documents avaiabe with the Department of Heath and amiy Wefare were anayzed. The Experimenta Phase: Agra and Sitapur were chosen as the experimenta, target-free districts by the state administration. Agra was seected because it was among the better performing districts in famiy panning. Sitapur, on the other hand, traditionay had not performed so we, but it was a focus district of the State Innovations in amiy Panning Services Agency (SI PSA). SI PSA adopted three bocks in Agra and five bocks in Sitapur for initiating operations research (OR) to strengthen programme management under the target-free approach. The Popuation Counci provided technica assistance to the OR Project in these two districts. The OR Project foowed two broad interventions: adoption of the pregnancy-based approach (PBA), and addressing unmet need to impement the (T A). In the PBA, the Auxiiary Nurse/Midwives (ANMs) were expected to identify a pregnant women in their areas of work and to make three visits to provide antenata and post-nata services. Whie the PBA focused on pregnant women, the unmet need approach addressed a women who did not want a chid at a or who wanted a chid after two years. To impement these interventions the foowing occurred: Personne at various eves directy concerned with the impementation of the new system were interviewed. Varanasi was seected to coect data at the district and sub district eves. As part of the methodoogy, one Community Heath Centre (CHC)/Primary Heath Centre (PHC) and two subcentres in Varanasi were randomy seected. A concerned heath personne in the seected institutions were interviewed with the hep of an A modified Eigibe Coupe Register (ECR) to identify the women with unmet needs was introduced ANMs were given a one-day, intensive, in-service training course emphasizing identification of coupes with reproductive intentions and how the ECR coud be used for panning their work more efficienty Review of Impementation of Approach for amiy Wefare in India 134

139 A aminated sheet describing ways to use ECR information was provided to improve the knowedge of the ANMs about the areas they serve The need to upgrade service deivery points was anaysed and the centres were equipped according to government norms The need for training was assessed and training was carried out Changes in the stye of review meetings were introduced Procedures for the reguar monitoring of ANM performance were worked out in detai at the grassroot eve; however, with constant and repeated orientation, they started appreciating the importance of the approach. Though famiy panning performance decined drasticay in both districts after the introduction of the T A, a sight improvement in MCH services was observed. 3 Impementation of the Target- ree Approach On ebruary 1, 1996, GOI caed a meeting of State Secretaries to announce the expansion of the T A to every district in the country. There were severa drawbacks to this pan. The decision was made without reviewing the experiences of the experimenta districts in Training in supportive supervision was carried out Loca women vounteers for every 50 househods were recruited to estabish inks between eigibe women and ANMs, and a day, pace and time for increasing interaction between the ANMs and the community were worked out. Reproductive Tract Infection (RTI) case management services were integrated into PHC responsibiities The ANMs were trained to use two ogbooks to better manage services according to cients needs. Initiay, there was resistance and a ack of understanding of the new approach among district functionaries. They strongy beieved that famiy panning targets were essentia to get the work done There were no definite guideines at the Directorate eve for impementing the T A, so districts foowed at east two different methods. A few districts, ike Varanasi, took a compete census of a Eigibe Coupes (EC) to estimate reproductive heath needs. Other districts undertook surveys in 10 sampe viages to arrive at estimates for each viage The training given to the workers and supervisors was neither uniform nor systematic, so most workers reached the concusion that no target meant no work The T A manua had not been transated into Hindi. Thus, in the year , the T A in the rea sense was not impemented in Uttar Pradesh. The famiy panning programme was deeted from the 20-point 3 4 End-of-Evauation of the Operations Research Project in Agra and Sitapur, The Popuation Counci, New Dehi, 1999 Narayana, Gadde, An Anaysis of Poicy Change, Consequences and Aternative Choices, Targets for amiy Panning in India, The POLICY Project, The utures Group Internationa, New Dehi, 1998 Approach in Uttar Pradesh 135

140 programme, and district magistrates were no onger directy responsibe for monitoring performance as they had been before the introduction of the T A. 4 After the sharp decine in acceptance, the Department of amiy Wefare started systematic preparatory work in December 1996 to strengthen the target-free system from onwards. The Secretary of amiy Wefare, in his etter dated December 30, 1996, asked the Executive Director of SI PSA for financia and technica assistance to carry out T A training in the state. SI PSA identified the Association for Vountary Surgica Contraception (AVSC) to provide training. AVSC deveoped a faciitator s guide and piot tested it in the Pindra PHC The approach in Varanasi. 5 oowing this, an offers a unique itinerary for each district was opportunity to try out worked out, and faciitators were innovative activities. The trained. The faciitators in turn ack of fexibe funding conducted training for three days and technica support to at bock eves and beow. The design innovations are usuay the main training of a workers was constraints in their competed by November impementation. Meanwhie, in a meeting of state secretaries in September 1997, the GOI announced a shift from the target-free to the Community Needs Assessment () approach. Two workshops were hed before this announcement in the Nationa Institute of Heath and amiy Wefare (NIH W) to assess the experiences of PHC medica officers from different states in regard to the impementation of T A. Based on the deiberations in these workshops, the T A manua was revised and simpified. The new manua tried to address the foowing: (i) Consutative mechanisms to impement the approach, and (ii) The reporting system and items to be reported. The manua was sent to a the states; Uttar Pradesh received a copy of it in March However, no efforts were made to transate the manua or to train heath workers. Therefore, the state foowed and continued to foow the procedure it had deveoped in Juy 1996 to estimate the Expected Leves of Achievement (ELAs), which had repaced targets under the new system. The Director Genera of amiy Wefare beieves that the guideines from GOI were confusing, so the workers were not cear about their responsibiities. According to him, Ony a sma proportion of workers woud be conducting surveys actuay; the rest of the data are generated at the PHC eve. In genera, whatever the districts reported has been accepted at the directorate eve. Ony in the case of five to six districts where the estimation was far off the mark have changes been made at the state eve. In actua terms, the system is not working. Innovative Activities The approach offers a unique opportunity to try out innovative activities. The ack of fexibe funding and technica support to design innovations are usuay the main constraints in their impementation. Thanks, however, to the presence of the USAID-funded Innovations in amiy Panning Services (I PS) Project, impemented by SI PSA, whereby it has been possibe in Uttar Pradesh to deveop specific strategies to fufi the needs of different areas, try them out on a piot scae, evauate them, and then repicate them in arger areas after necessary adaptations. Some of the notabe innovations tried out are described beow. RCH service deivery through networks of Non- Governmenta Organizations (NGOs), mik 5 aciitators Guide for Impementing Target ree Approach AVSC Internationa, New Dehi, 1996 Review of Impementation of Approach for amiy Wefare in India 136

141 cooperatives, indigenous medica practitioners, and traditiona birth attendants. have been funded, and 50 have been evauated by externa agencies. Private-sector participation in famiy panning services was abysmay ow in Uttar Pradesh before the aunching of the I PS Project, and there was considerabe skepticism about the impact that NGOs coud make on the programme. To begin with, SI PSA, after coecting information from a variety of government and NGOs, prepared a ist of NGOs working in the deveopment fied. These NGOs were then informed of the funding avaiabe for a imited period for innovative famiy panning projects and were encouraged to submit project proposas. A system was aso estabished to verify the credentias of NGOs and to ook at their annua accounts and activities for the preceding three years. The programme officers of SI PSA visited NGOs seeking funds to check detais of the organization, office infrastructure, and the type of activities carried out. NGO projects generay seect women vounteers for community-based distribution (CBD) to promote famiy panning and MCH services. The main goa of NGO projects is to increase the use of modern spacing methods among young, owparity coupes. CBD vounteers visit a househods in their viages at reguar intervas and encourage coupes to adopt the famiy panning methods of their choice. A computerized information system has been designed to monitor the performance of NGOs. At the end of the project, their performance is evauated by an expert externa agency in ight of the objectives stated in the project agreement. Based on the findings, a decision is made to extend, expand, or discontinue a project. So far, more than 90 projects An evauation in 15 districts was conducted by an externa agency in January 1999, to assess the extent of the increase in the number of spacing method users as a resut of SI PSA-funded private vountary organization (PVO) projects. As part of this evauation, 1,300 married women in the age group were interviewed. The findings showed that 7.2 per cent were using one of the spacing methods. This is amost doube the prevaence rate of 3.7 per cent for these methods recorded in June This means that the number of spacing method users in these districts increased from 238,000 to 463,000 in the ast 3.5 years. Of the tota of 225,000 new users, 170,000 Private-sector had accepted since January participation in famiy The evauation concuded by panning services was saying, This shows that famiy abysmay ow in Uttar panning services have grown Pradesh before the rapidy and SI PSA-funded aunching of the I PS projects are contributing Project, and there was significanty to famiy panning use considerabe skepticism in Uttar Pradesh. 6 Such projects about the impact that are operationa in 20 districts of NGOs coud make on Uttar Pradesh and have heped to the programme. rapidy increase access to quaity services in rura areas. Viage mik cooperatives offer an opportunity to invove arge networks of vounteers in the promotion of famiy panning because they are economic groups with exceent ogistics that have amost a miion members with a good understanding of rura marketing. Projects funded through the ederation of Mik Cooperatives use viage cooperatives to seect a woman famiy wefare promoter from the community. Members of the 6 Innovations at Work, SI PSA, and Unpubished Evauation Documents of SI PSA, Lucknow, 1999 Approach in Uttar Pradesh 137

142 mik cooperatives hep the vounteers provide famiy panning services. Uttar Pradesh has neary 40,000 registered, indigenous system of medicine (ISM) practitioners, that is, unani, ayurvedic, and homeopathic medica practitioners, and probaby an equa number of nonregistered practitioners. A arge proportion of the rura popuation seeks heath services from ISM practitioners because of their accessibiity and ow fees. Recognizing the potentia of ISM practitioners to improve counseing and access to famiy panning services, SI PSA aunched two projects on a piot basis in Sitapur and Jhansi districts to train ISM practitioners. A needs assessment was done, and training curricua and materias Recognizing the were then deveoped and tested. potentia of ISM practitioners to improve An evauation of the ISM training counseing and access to programmes was conducted by famiy panning services, an externa agency in The SI PSA aunched two findings reveaed that not ony had projects on a piot basis in Sitapur and Jhansi the genera cient oad of ISM districts to train practitioners increased after ISM practitioners. training but there had aso been a substantia increase in the proportion of ISM practitioners providing famiy panning services to cients. Encouraged by the resuts, SI SPA has scaed up activities in the ast two years to cover 10 more districts. So far, about 7,000 ISM practitioners have been trained in these districts. The projects not ony provide basic training of four days duration to ISM practitioners but aso offer reorientation training after a period of six months. In addition, project staff members visit trained ISM practitioners reguary to observe the counseing sessions, to identify needs for retraining, and to sove probems reated to contraceptive suppies. 7 Traditiona Birth Attendants (TBAs) or dais have aways assisted deiveries, especiay in rura areas. One-third of a deiveries taking pace in Uttar Pradesh are assisted by TBAs, but a arge proportion of dais has never been trained. The practices foowed by untrained dais have significanty contributed to neonata deaths. Recognizing the cose reationship between infant mortaity and famiy panning use, SI PSA has initiated training programmes for untrained dais. Piot projects have been impemented in Rampur, Sitapur and Agra districts. The objective of these programmes is to encourage dais to conduct deiveries in aseptic conditions, to identify and refer high-risk pregnant women to hospitas and to promote famiy panning. A compete census was done of dais in a viages of these three districts. Master and ead trainers were trained and, in turn, imparted training to more than 2,000 dais. Each one has been given an identity card and a deivery kit. An evauation of SI PSA-supported training for dais conducted by an externa agency in 1999 found the foowing: 98 per cent of dais were providing famiy panning services to cients 53 per cent of dais were abe to identify high-risk pregnancies 28 per cent of dais were abe to answer questions on pi use correcty Deiveries assisted by trained dais had increased to nine per cent from three per cent before training 7 Evauation of ISMP Project in Jhansi and Sitapur Paper presented in a workshop hed at Lucknow for the I PS Mid-term Review Team; The Poicy Project, The utures Group Internationa, New Dehi, 1997 Review of Impementation of Approach for amiy Wefare in India 138

143 Encouraged by the impressive findings of the evauation, SI PSA has begun to expand dais training to 12 more districts in a phased manner. 8 Rura networks of trained ISM practitioners and TBAs are increasing famiy panning outreach and improving deivery services. Decentraized panning and impementation of RCH activities using a mix of pubic and private sector interventions managed by an autonomous society at the district eve The panning process for the Reproductive and Chid Heath (RCH) programme has remained highy centraized, but effective and efficient impementation of programmes aimed at behavioura change require decentraized pans that take into consideration oca resources and cient needs. Recognizing the need to decentraize RCH at the district eve, SI PSA faciitated the formuation of district action pans (DAPs) in six districts. This pioneering effort was the first of its kind in Uttar Pradesh and perhaps in a of India. Baseine surveys were conducted, information on key indicators was disseminated to a stakehoders in both the pubic and private sectors, workshops were conducted to identify districtspecific issues, and a census of faciities was done to identify gaps. Districts set their own objectives and evoved strategies to achieve them through a decentraized management system. The district action pans were approved in March In each district, the oca District Innovations in amiy Panning Services Agency (DI PSA) was registered as a society with representatives from the private and pubic sectors. SI PSA estabished Project Management Units at the district eve to sove probems at the time of impementation, to disseminate information, and to act as a ink between the pubic and private sectors. The district action pans incude the foowing five ceary identified strategies: Creating a conducive environment Generating demand through IEC Improving access to integrated services Improving quaity of services Invoving the non-governmenta sector The panning teams identified specific activities for each strategy and prepared a time frame for impementation of each. In the six DAP districts, neary Recognizing the need to 800 reigious eaders attended the decentraize RCH at the meetings on famiy panning. district eve, SI PSA urthermore, 4,500 Pradhans faciitated the attended training programmes, formuation of district and a workers in the private and action pans (DAPs) in pubic sectors received training in six districts. This interpersona counseing. In pioneering effort was the addition, 792 femae heath first of its kind in Uttar workers received IUD insertion Pradesh and perhaps training; 1,128 integrated RCH in a of India. camps were conducted; 28 innovative PVO and organized sector projects were impemented; and three mik cooperative projects covering a popuation of 17.9 miion were initiated. At the end of one year of impementation of the district action pans, acceptance of a methods of famiy panning in both the private and pubic sectors improved consideraby. Steriization acceptance 8 Innovations at Work SI PSA, and Unpubished Evauation Document of SI PSA, Lucknow, 1999 Approach in Uttar Pradesh 139

144 increased by about 20 per cent and spacing services aso expanded. Providing integrated services, improving the quaity of those services, and increasing access to services have a contributed to the gains in performance in the DAP districts. This mode has been found suitabe for repication, and SI SPA, encouraged by the resuts, has decided to extend the decentraized district action pan approach to six more districts. 9 RCH camps at CHCs and bock PHCs These camps provide an opportunity to integrate the efforts of providers and to increase access to reproductive heath services. Each camp incudes a gynaecoogica check-up, a chid examination and immunization, famiy panning counseing and services, and transportation for steriization cients. Though steriization camps have been part of the famiy panning programme for many years, these RCH camps, which are becoming popuar as Parivar Swasthya Seva Divas, are different in the foowing ways: They provide assured services as per a predetermined caendar They combine the benefits of rura outreach and high quaity services They provide an array of MCH and famiy panning services under one roof. The organization of camps invoves detaied panning of pubicity, manpower depoyment, camp arrangements, post-camp services ike transportation, and the avaiabiity of consumabes and medica equipment. Each camp is schedued in advance and pubicized through advertisements in oca newspapers. Speciay designed banners and handbis promote them as Parivar Swasthya Seva Divas. In rura areas, the word is spread by paying attractive jinges on audio-cassettes carried around in hired rickshaws or vehices. Since most of these camps are in remote rura areas, the avaiabiity of a team of surgeons, an anaesthetist and a femae gynaecoogist must be ensured at the district eve. An enhanced budget for maintenance and POL (petro, oi, and ubricant) for vehices is provided so that an adequate number can be depoyed to transport doctors to RCH campsites and steriization cients to their homes. SI PSA has aso provided funds for the purchase of beach, antiseptics, goves, medicines, and aparoscopes for use in these camps. Deputy chief medica officers monitor the camps as per a standard proforma. This integrated approach to providing NCH, and famiy panning services has been found to be more cost-effective and aso more convenient for cients. SI PSA wi fund 13,000 of these camps over the two-year period beginning May 1998; 9,000 had been hed by December On an average, 50 cients attend each camp and more than haf of them use the integrated MCH services. In many districts, more than 33 per cent of steriization procedures have been performed in such camps, which indicates their success and popuarity. Assured avaiabiity of services aong with the orientation of Pradhans is aso heping to raise community awareness about reproductive heath and to mobiize institutiona support for services. 10 Tetanus Toxoid Campaign The infant mortaity rate (IMR) in Uttar Pradesh is 85 per thousand ive births, of which about four per 9 10 Making things Happen, The POLICY Project, The utures Group Internationa, New Dehi, 1999 Johri, Aradhana, Specia Campaigns in Uttar Pradesh, Paper presented in the Uttar Pradesh Popuation Poicy Workshop hed at Lucknow, Organized by the GOUP and The POLICY Project, The utures Group Internationa, New Dehi 2000 Review of Impementation of Approach for amiy Wefare in India 140

145 cent is estimated to be due to neonata tetanus. As per the Centra Bureau of Heath Investigation, Uttar Pradesh accounts for 21 per cent of the tota number of neonata deaths in India. The materna mortaity rate (MMR) is aso high at 707 per 100,000 ive births. The idea of conducting a tetanus toxoid (TT) campaign to immunize women was suggested by SI PSA and adopted by the government of Uttar Pradesh. The TT campaign formed the cornerstone of an acceerated strategy for reducing Materna and Infant Mortaity (MIM) in the state. 11 The foowing were the steps in the panning process: The Principa Secretary of Medicine, Heath and amiy Wefare of Uttar Pradesh met with SI PSA on ebruary 5, The Director Genera of amiy Wefare, his key staff, SI PSA officers, and additiona directors of divisions who endorsed the idea of conducting a TT campaign aso attended the meeting. The foowing decisions were made: n The campaign shoud be organized in 15 SI PSA districts in two phases, and a pregnant women shoud be covered n n n n A baseine survey shoud be done in each subcentre area by the ANMs to get ists of pregnant women The campaign shoud be run in the pains for a week and for two weeks in the his The strategies for rura areas and urban areas shoud be different In urban areas, the support of Indian Medica Association (IMA) and private practitioners woud be accepted n n n n n In rura areas, TT vaccinations woud be offered for a day at sub-centres and then from door-to-door in viages on the other days The campaign woud use gass syringes and needes avaiabe at PHCs/CHCs/ sub-centres; disposabe syringes woud not be used IEC materia shoud be prepared at the state eve with assistance from SI PSA; messages shoud focus on the benefit of the campaign for the newborn Immunization cards woud be avaiabe to a pregnant women who receive TT vaccinations Meetings shoud be hed at the state and district eves for coordination with other departments. District magistrates shoud chair district-eve meetings. It was aso decided that SI PSA shoud provide technica assistance in drawing up schedues, drafting instructions, and working out other detais as the campaign was being hed for the first time in Uttar Pradesh. The Director Genera for amiy Wefare was asked to assess the avaiabiity and adequacy of the vaccine, syringes, and the cod chain. SI PSA, in consutation with the Director Genera for amiy Wefare, deveoped a TT campaign timetabe providing dates by which different meetings shoud be hed at the state, district, and sub-district eves. This timetabe incuded detais of participants as we as actions to be taken in the meetings. A workshop was organized on March 8, 1999, in which 11 ANMs, seven Lady Heath Visitors 11 Innovations at Work, SI PSA, and Strategy Document of TT Campaign, SI PSA, Lucknow, 1999 Approach in Uttar Pradesh 141

146 (LHVs), two medica officers in charge of PHCs, two deputy chief medica officers, and one senior medica officer (Stores)) were invited. The foowing items were discussed: The timing of the campaign The target segment The ists of pregnant women for vaccination n n The programme woud be initiated from the first week of May 1999 in two phases. The first dose woud be provided on May 1, 3, and 5, The second dose woud be provided on June 2, 5, and 7, An estimated 49 akh women were ikey to be covered in each phase (1 akh = 100,000) The enumeration of pregnant women woud be conducted from Apri 12-17, 1999 The time of the day during which vaccination n The strategies for rura and urban areas woud services woud be provided at booths and be different keeping avaiabe resources in door-to-door mind The system for carrying vaccines to the fied and receiving suppies from PHCs Matters reated to reporting Logistics on the avaiabiity of syringes and needes, ice packs, pressure cooker steriizers, cotton woo, kerosene, and spirits. The meeting aso identified what materias were readiy avaiabe and what additiona resources were required for the campaign. The Principa Secretary for Medica, Heath and amiy Wefare hed another meeting on March 10, 1999, in which senior officers of the amiy Wefare Department and SI PSA participated. The foowing points were decided at this meeting: n n n The avaiabiity of vaccine, cod chain equipment, syringes, and needes woud be ensured. The one syringe, one vaccine, one beneficiary norm woud be foowed. Steriization of syringes and needes woud be speciay taken care of or proper pubicity, IEC materias such as handbis, posters, and banners were deveoped. Wa paintings were aso done aong with oca announcements (dugdugi). The distribution of IEC materias woud start at the time of enumeration The invovement of NGOs, other state government functionaries and eected bodies woud be sought to make the campaign more effective n A pregnant women throughout the state woud be covered under the campaign for TT immunization and the distribution of iron and foic acid (I A) tabets. Ora Rehydration Sat (ORS) packets woud aso be made avaiabe as needed n Efforts woud be made to anticipate and meet a ogistica requirements. Detais of the campaign were worked out by SI PSA aong with the Department of amiy Wefare and were communicated to Chief Medica Officers Review of Impementation of Approach for amiy Wefare in India 142

147 (CMOs) and Additiona Directors of Divisions vide the Principa Secretary for Medica, Heath and amiy Wefare of Uttar Pradesh in a etter dated March 26, These instructions incuded guideines for conducting a survey of pregnant women between Apri 12 and 17, 1999, and for making micro-pans for impementing the campaign in sub-centres, PHCs and districts. Instructions were aso incuded for the medica officer in charge on preparing ists of pregnant women, on IEC activities, on steriizing syringes and equipment, and on storing and distributing vaccines. The use of immunization cards, forms, reporting proforma, and the system for monitoring and supervision were aso highighted. CMOs were aso requested to hod the foowing two meetings in their districts on specific days: On Apri 13, 1999, a meeting of a CMOs was hed by the Principa Secretary for Medica, Heath and amiy Wefare to take stock of the situation and to finaize the aocation of personne, vaccine, syringes and IEC materia to a districts. Detaied monitoring pans were aso shared with the officers. Senior officers from headquarters of the rank of director and additiona director (AD) were depoyed for monitoring in each division. They were briefed by the Director Genera of amiy Wefare and were provided with two checkists deveoped by SI PSA. They were to use one checkist whie the other was to be used for monitoring by medica officers and deputy CMOs in the districts. A meeting chaired by the District Magistrate to coordinate with representatives of other departments ike Integrated Chid Deveopment Services (ICDS), the District Urban Deveopment Agency (DUDA), oca urban bodies, deveopment departments ike education, rura deveopment, Panchayati Raj and NGOs. This meeting woud brief them about the strategy and obtain the support of other departments for the TT campaign. A meeting of a deputy CMOs and medica officers of CHCs/PHCs to share the scheme with them and assign their responsibiities. As time was short, these medica officers were to deveop pans to hod meetings of workers at their CHCs/ PHCs and brief them and aso assign duties for the campaign incuding the baseine surveys to be done by ANMs. The CMOs woud aso obtain feedback from these officers on ikey difficuties, district resource requirements and doubts, if any, for carification from Lucknow (the capita of Uttar Pradesh). IEC materia was deveoped by SI PSA. Artwork was distributed to districts for printing handbis and coth banners. A 10-point informative fier entited Ten Important acts informing providers and cients about TT was aso made avaiabe. The handbis were to be used during the baseine survey to educate and inform cients in rura areas and sums about campaign dates. Coth banners were for informing peope about the campaign. Pre-recorded cassettes were aso provided to PHCs for pubicity a few days before the campaign. TV, radio, and press were used to popuarize the campaign incuding broadcasting messages from the Chief Minister and the Heath Minister promoting TT vaccinations. Pane discussions were aso hed with experts on radio and TV to provide information and to buid confidence. After the first phase of the campaign, the Director Genera of amiy Wefare debriefed observers. On the basis of this and the reports of ADs and CMOs, Principa Secretary for Medica Heath and amiy Approach in Uttar Pradesh 143

148 Wefare of Uttar Pradesh hed a meeting to incorporate corrections for the second phase. To evauate this campaign, the Popuation Resource Centre (PRC) in Lucknow carried out a coverage survey in five randomy seected districts from five regions of the state. The districts covered were Agra, Aahabad, Amora, Sitapur, and Laitpur. By using the 30 custer samping technique, 1,023 pregnant women from 100 custers (both urban and rura) of the five seected districts were interviewed. The findings indicate that before the campaign, 31 per cent of pregnant women had received a first dose of TT vaccine and 13 per cent had been fuy immunized. After the campaign, an additiona 29 per cent of women received a first dose of vaccine whie an additiona 20 per cent became fuy immunized. Thus, at the end of the campaign, 59 per cent of pregnant women had received the first dose of TT and 33 per cent had received at east two doses 12. Effects of the Community Needs Assessment Approach The impact of the adoption of this poicy reform in Uttar Pradesh on certain critica areas has been as foows. Community Invovement Evidence from the fied suggests that the approach has not invoved the community in any significant way in the work of the pubic sector. Decentraization has taken pace within government structures ony as the state has taken over some of the roes of the nationa government reating to the issue of guideines, fixing work oads, etc. Community eaders are aso not interested in decentraized panning under as it does not invove the transfer of funds. The training of Pradhans in six districts and their orientation to RCH services by SI PSA, whie increasing their knowedge about their roes, has not resuted in their greater invovement in the programme or in their support for the ANMs. Programme personne themseves are aso not proactive about the approach as they are afraid to raise community expectations that the programme is not ready to meet. The roe of the heath workers, however, has increased. They have more autonomy in being abe to pan their visits to househods for MCH activities. Heath functionaries are not, however, interested in invoving community eaders in the programme because the eaders have a poitica agenda. The government of Uttar Pradesh, as part of its decentraization initiative, issued an order on Juy 9, 1999, pacing the services of mae Muti- Purpose Workers (MPWs) aong with grassroot workers from seven other departments under the supervision and contro of Gram Pradhans. This was strongy resented both by the workers and by pubic sector programme managers who have voiced their concerns at severa forums. In the community deveopment bocks of the 15 districts where SI PSA is impementing its NGOmanaged, CBD projects, there is a coser invovement of the community in the RCH programme. These NGOs usuay have previous experience working in the deveopment sector and so seect women vounteers from within the community for promoting famiy panning and MCH services. These vounteers visit viage househods at reguar intervas. As members, they can better appreciate the needs of the community and respond to them, which bring the RCH programme coser to the community. The use of NGOs by SI PSA for panning, monitoring, and faciitating fok performances with heath and famiy panning 12 Innovations at Work, SI PSA, Lucknow, 1999 Review of Impementation of Approach for amiy Wefare in India 144

149 messages woven into them has further strengthened this inkage. The response of the community to these fok performances has been overwheming and has aso generated demand for making heath services avaiabe to the viagers. Service Quaity Removing targets was expected to improve the quaity of services. The new monitoring system incuded a number of quaity indicators. Whie there was no significant improvement in eary acceptance of contraception or in continuation rates, the knowedge about modern methods seems to have increased. The Rapid Househod Survey of December 1998, has data for a major states. It shows that 74 per cent of women in Uttar Pradesh knew of a modern methods of contraception. Uttar Pradesh thus ranked third after Keraa and Punjab in this indicator showing the avaiabiity of informed choice of methods. urther, as per this survey, onefourth of users were informed about the side effects of the famiy panning method they had seected. No improvement is discernabe, however, in indicators ike eary prenata registration or timey immunization of chidren. 13 Programme Priorities Since the adoption of the approach, Uttar Pradesh has focused on MCH services and not on famiy panning aone. Ante-Nata Care (ANC) and safe deiveries, that is, deiveries assisted by persons trained in midwifery, have emerged as programme priorities. Efforts are aso being made to reduce infant and materna mortaity through strategies ike the campaign to provide TT vaccinations to pregnant women. These initiatives heped increase the proportion of women who have received two or more doses during their pregnancies. Simiary, wider expansion of training for TABs under the I PS Project has resuted in 34 per cent more deiveries attended by trained providers. 14 The I A coverage for pregnant women has aso gone up by 10 per cent according to the 1999 Nationa amiy Heath Survey (N HS-2) resuts. 15 The timey immunization of chidren has aso received specia attention. The government of Uttar Pradesh has increased the number of immunization days from one to two per week. Now, every Wednesday and Saturday (instead of ony Wednesday) the ANM has to be present in her service area to provide routine immunization services for a preventabe diseases. In addition, Uttar Pradesh is foowing the puse poio immunization schedue with three nationa immunization days (NIDs) and three sub-nids for extended reach and coverage of resistant groups. However, this does not seem to have had a major impact. The tota immunization rate remained constant at 20 per cent from 1993 to However, there has been some improvement in the immunization status for BCG and meases, and at east one immunization service has reached 71 per cent of chidren, a 24 per cent increase over the eve. 16 Worker s Status in the Community Various studies have shown that workers reported positive images of themseves and of the programme because they were taking more about the mother s and chidren s heath and ess about famiy panning Rapid Househod Survey: India, Internationa Institute for Popuation Sciences, Mumbai, and MOH W, GOI, New Dehi, Innovations at Work, SI PSA, and Unpubished Study Report on TBA s, SI PSA, Lucknow, 1999 Nationa amiy Heath Survey (Preiminary Report): Madhya Pradesh, Internationa Institute for Popuation Sciences, Mumbai, 1999 Nationa amiy Heath Survey (Preiminary Report): Madhya Pradesh, Internationa Institute for Popuation Sciences, Mumbai, Approach in Uttar Pradesh 145

150 They were aso providing comprehensive heath care that incuded immunizations, antenata check-ups, househod visits, and famiy panning counseing. The views expressed by workers in this context are eoquent. One worker remarked, The pressure of targets is no onger there and we are abe to pan our work better. We cater to the probems of women and chidren and can visit viages more often. Our acceptabiity in the community has aso increased. The sef-esteem of workers aso increased on two counts. In the earier system, the vigorous monitoring of steriization targets at the PHC and district eves aong with threats of punishment and the guit associated with non-achievement of targets made them fee inadequate and demoraized them. Under, they fee that the monitoring system is a better measure of their overa performance. Secondy, before, ANMs were unabe to screen or counse cients. However, after undergoing cinica and counseing training, their skis have improved. Training has aso been hepfu in changing the attitudes of workers and in equipping them to a certain extent with the abiity to discuss cients needs and offer services according to cients choices and preferences. services. The dependence on the pubic sector for IUDs increased by 11 percentage points in compared to showing that the training of ANMs, their improved skis and the time they are abe to devote to counseing has made them better accepted as providers of IUDs. amiy Panning Performance under the New Approach Acceptance of famiy panning methods decined in the first year after the adoption of the T A. Thereafter, steriization acceptance improved but has sti not reached pre-t A eves. The use of spacing methods, however, has increased by 11 percentage points (i.e., from per cent) in the ast six years. urther, the roe of the private sector as a provider of spacing methods (condoms and pis) has grown significanty as three-fourths of a condom-users got their suppies from the private sector in compared to 57 per cent in Likewise, over 70 per cent of a pi-users depend on the private sector today as compared to 48 per cent six years ago. This is an indication that SI PSA-supported, NGO, community-based distribution workers, aongwith interventions in the commercia sector, are having an impact by improving accessibiity to condoms and pis. 15 Cients Perceptions about Services Reduced emphasis on steriization has resuted in greater avaiabiity of spacing methods and of MCH Steriization The number of acceptors of steriization in was 516,970, and in the foowing year it Tabe 1 Tota Users of Spacing Methods Reported by Service Statistics in Uttar Pradesh, Method Year IUD Ora Pis Condoms ,194, ,250 2,897, ,193, ,509 2,434, ,664, ,525 1,769, ,029, ,044 2,045, ,084, ,290 1,923,835 Review of Impementation of Approach for amiy Wefare in India 146

151 increased to 519,399. Aahabad, aizabad, Garhwa, Jhansi, and Kumaun divisions performed better whie the remaining nine divisions did not. With the introduction of the T A in the state in , ony 266,350 steriization operations were conducted, a decine of 95 per cent from eves. Surprisingy, a divisions in the state, incuding the five divisions that had performed we in indicated poor performance. It shoud be noted that two districts each in Varanasi and Gorakhpur became part of the newy created Azamgarh division and hence their performance in decined. In , however, performance started to improve, and in acceptance was up by 14 per cent over the previous year. Sti, when compared with , overa performance was down by 49 per cent. On the whoe, it can be deduced that due to the introduction of the T A in the state, steriization performance dropped substantiay. A divisions that had performed we during the period prior to the T A performed beow expectations. Nevertheess, a cose examination of trends from indicate that steriization acceptance is ikey to improve in the coming years as a divisions have started performing more operations than in the previous year. Even though information on age and parity of new acceptors was avaiabe in the management information system formats, no effort was made to anayze the data either at the district or state eves. Anaysis of this type wi provide insights in understanding the impact of the programme on fertiity. Spacing Methods IUDs In , as many as 2,194,522 new acceptors of IUDs were recruited whie in the subsequent year 2,193,488 insertions were done. In the two years foowing the introduction of T A, the programme Fig.1 Tota Steriizations Performed in UP registered 1,664,021 and 2,029,847 new acceptors, respectivey. When is compared with , acceptance dropped by a third and a divisions performed bady. However, in and , the number of acceptors increased substantiay and reached 95 per cent of the tota. As observed in the case of steriization, no efforts are being made to anayze the characteristics of new acceptors. Ora Pis The common practice for setting the target for ora pis is in terms of the number-users, but performance records at the district eve and beow provides information on the number of cyces distributed. That number is aggregated at the state eve and divided by 13 to get the tota number of users. oowing this procedure, vita information on continuing users, dropout rates, and so on that coud be anayzed through the monitoring formats is usuay overooked. Consequenty, the cacuations are restricted to numerica achievements without considering quaity issues. The number of pi-users in the state was 487,250 in ; in , it was 558,509. Unike the performance in steriization and IUD, the number of Approach in Uttar Pradesh 147