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Reviewing Reproductive and Child Health Programmes in India

Since the early 1990s, "decentralisation" and "integration" seem to be the buzz words underlying the implementation of various social development programmes in India, especially the reproductive and child health programme. Analysis reveals that the state-level effects of various RCH services are significantly higher than those at the district level. The pace of annual progress after 1998 in many RCH indicators is slower than before and a few indicators (e g, child-immunisation) have worsened, despite the expenditure on the programme being doubled. Decentralisation and integration of basic healthcare services may not be effective unless monitored centrally and backed by full time health (medical/paramedical) professionals at the delivery level.

Reviewing Reproductive and Child Health Programmes in India

Since the early 1990s, “decentralisation” and “integration” seem to be the buzz words underlying the implementation of various social development programmes in India, especially the reproductive and child health programme. Analysis reveals that the state-level effects of various RCH services are significantly higher than those at the district level. The pace of annual progress after 1998 in many RCH indicators is slower than before and a few indicators (e g, child-immunisation) have worsened, despite the expenditure on the programme being doubled. Decentralisation and integration of basic healthcare services may not be effective unless monitored centrally and backed by full time health (medical/paramedical) professionals at the delivery level.

K SRINIVASAN, CHANDER SHEKHAR, P AROKIASAMY

A
major change in the political scenario of the country was introduced in 1992 with the passing of the 72nd and 73rd constitutional amendments and the enactments of Panchayati Raj and Nagar Palika Acts, setting in motion the process of democratic decentralisation. These acts ushered in a three-tier system of political governance in the country: central government, state governments and the panchayats in the rural areas and the ‘nagar palikas’ (municipal councils) in the urban areas up to the district level. Constitutionally, all powers, responsibilities and resources are to be shared by these three tiers of elected bodies. Primary healthcare including family planning, primary education and provision of certain basic amenities to people such as drinking water and roads became the responsibility of the panchayats. Another notable feature is the reservation of one-third of the seats in panchayats for women members. Thus at the grassroot level, women are politically empowered on all decision-making issues pertaining to social development including family planning. This is definitely a great leap forward for democracy and empowerment of women.

A related development was the International Conference on Population and Development (ICPD), organised by the United Nations at Cairo in 1994 [UN 1994], which is considered a watershed in the implementation of population and health programmes. This conference was, by and large, dominated by women’s groups and was in principle against macro level fertility goals and contraceptive user targets. It was argued that such goals and targets strained women’s health and their reproductive rights. The programme of action (POA) formulated at the end of the conference and for which India is a signatory postulated that population policies should be viewed as an integral part of programmes for women’s development, women’s rights, women’s reproductive health, poverty alleviation and sustainable development. It was felt that population policies, which are based on macro demographic considerations and acceptor-target-driven programmes, are unnecessarily and unevenly burdening women with the task of regulating reproduction to suit macro level policies. Thus national programmes of family planning/welfare that were earlier formulated and implemented to achieve predetermined demographic goals of low fertility and population stabilisation were considered anti-women and had to be modified.

It was recommended that all programmes aimed at the improvement of the health of women and children must be implemented as part and parcel of an integrated package of services to meet the reproductive health needs and rights of women. This package of services should include identification and treatment of reproductive tract infections (RTIs) and sexually transmitted diseases (STDs) among women, prevention and treatment of HIV/AIDs, education of adolescents, identification and treatment of cervical cancer among women nearing menopause, improvement of sexual health and meeting the unmet needs of couples on contraception for spacing and limitation of children in addition to routine services of maternal and childcare including immunisation of children. It was argued that developmental programmes, which are not engendered, are not only unsustainable but also endangered. The POA adopted by the ICPD recommendes a set of qualitative and quantitative development goals: sustained economic growth in the context of sustainable development; education, especially for girls; gender equity, equality and empowerment of women; infant, child and maternal mortality reduction; and the provision of universal access to reproductive health services, including family planning and sexual health. Thus, integration of various reproductive and child health services with the underlying aim of safeguarding women’s rights and reproductive rights became another buzz word. Reproductive and child health programmes emerged to connote a wide array of activities requiring different skills not available at the peripheral levels.

I Current RCH Approach

The present RCH approach in the country owes its origins to two reports, one submitted by the Swaminathan Committee in 1994 and the ICPD POA briefly mentioned above. In July 1993, the government of India appointed an expert group for drafting a national population policy for the consideration of the government and adoption by Parliament. The expert group chaired by M S Swaminathan, an eminent agricultural scientist, submitted its report in May 1994. This report contains some basic directional shifts in the goals of population stabilisation programmes, organisational modifications at various levels and setting up new institutions for effective programme implementation. It recommended the setting up of population commissions at the centre and the state levels and the preparation of socio-demographic charters for each village and town implemented with underlying principles that are “pro-nature, pro-poor and pro-women”. It was recommended that the programmes in their direction and thrust should move from negative to positive goals: “population growth is depleting non-renewable natural resources, especially the underground water at an exponential pace and if not checked in time can lead to serious deficiencies of water in the country; it is assumed that development that is not equitable is not sustainable; and that gender equity is essential for development and is an integral component of development itself”. Henceforth, population policies were not to be viewed with the sole concern of reduction in fertility rates considered desirable by planners and demographers, but by considerations of reproductive health, reproductive rights and gender equity.

Simultaneously the government of India, which was a signatory to ICPD POA, promptly followed up on the recommendations by abolishing the acceptor based family planning targets since April 1996 in the country as a whole. It had already experimented with the “target-free” approach in a few selected districts in the previous year but the effectiveness of the approach was not properly assessed. Since 1997, officially, the RCH approach has been adopted as the national policy of the government of India. The official RCH programmes include the conventional maternal and child health services including immunisation of children and contraceptive services to couples, treatment of RTIs and STDs, provision of reproductive health education and services for adolescent boys and girls, screening of women near menopausal age for cervical and uterine cancer and treatment where required. Requirements for contraceptive services were to be based on community needs assessment (CNA) approach wherein all the married couples in the reproductive ages are to be visited every year, their contraceptive services in terms of spacing and limiting of family size to be assessed and the appropriate services to be planned. The targets are to be replaced by “expected goals or requirements” and the service delivery to be planned accordingly. The CNA/RCH strategy forms the present national policy in the country. Family planning services are to be an integral part of a wide array of services of maternal and childcare including treatment of women for RTIs, sexually transmitted or otherwise. The budget required for these additional services to be covered under reproductive health is substantially high. It was feared that the emphasis on contraceptive services will get diluted when budgets are not adequately increased to cover the wider goals of RCH programmes, but it was felt that population concerns should be confined to safeguarding women’s health, their reproductive rights and ensure gender equity and should not be an instrument of achieving macro level goals beyond reproductive health, though the latter is an important contributing factor for population stabilisation. Integration of basic reproductive and child health services through the primary health centres in the rural areas and particularly through the auxiliary nurse midwife (ANM) at the peripheral level by giving her additional training and involving her emerged as the dominant framework of this approach. The ANM is required to be a counsellor, educator, service provider and a person who can arrange for transportation of difficult maternity cases to the nearest hospitals, coordinate with other programmes and carry many other roles.

At present three population and health-related policies seem to be in operation in the country that overlap and impact population issues and availability of family planning services. These are the National Population Policy 2000 (NPP 2000), the National Health Policy (NHP 2002) and the recently launched National Rural Health Mission (NRHM 2005). The last one though not declared as a policy, is really a policy document in the statement of vision and objectives, setting goals, formulation of strategies and programmes and launched by no less than the prime minister of the country in April 2005. A detailed review of these policies can be had in Srinivasan (2006). All of these have the RCH approach as the basis for making improvements on the health of women and children, and the integration of different services at the level of the ANM remains the sine qua non of all health policies and programmes. In the context of such a major shift in the approach and given both the short-term and long-term population and health goals, it is essential to assess the extent to which the RCH approach to programme implementation has been successful in achieving progress in selected RCH indicators and identify the gaps in the programme. This is attempted in the next two sections.

II Evaluation of the RCH Programme: Post- and Pre-1998 Periods

Recent Trends in Selected Indicators

The recently completed National Family Health Survey-3 (NFHS-3) conducted during 2005-06 has been exemplary in the rapidity with which the survey findings have been brought out at the national and state levels in elegantly prepared series of fact sheets [IIPS 2007]. The survey is the third in the NFHS series of surveys which provide information on population, health and nutrition in India as a whole and each of the 29 states. NFHS-2 was conducted during 1998-99 and NFHS-1 in 1992-93. NFHS-3 interviewed a random sample of 1,09,041 households. It provides trend data on key indicators and includes information on several new topics, such as HIV/AIDS-related behaviour and the health of slum populations. We have used the data available from NFHS-3 fact sheets to compare the trends in the post-1998 period with the pre-1998 period by comparing the estimates of NFHS-3 and NFHS-2, to assess the magnitude of change in the post-1998 period and NFHS-2 and NFHS-1 to assess the pre1998 period. This is possible because the 1998-99 survey can be considered the dividing line of the pre- and post-RCH approach. The annual change in percentage points in the post-1998 period is compared with similar changes in the pre-1998 period. Only those indicators for which data were available in all the three points of time, 1992-93 (NFHS-1), 1998-99 (NFHS-2) and 2005-06 were used for this study. Such information was available for 29 indicators: 7 on “marriage and fertility”; 10 on “family planning” comprising “contraceptive use” (7) and “unmet need” (3); 12 on “maternity and childcare” comprising “maternity care” (3), “child immunisation” (5), “treatment of childhood diseases”

(2) and “child feeding practices” (2).

Table 1 provides data on these indicators at the state level as available from the NFHS-3 survey to indicate the current situation in the country at the state level and the range of variations across 29 states. The last two columns of the table provide the averages across the states (unweighted) and the coefficient of

Economic and Political Weekly July 14, 2007

Table 1: Levels of Fertility, Family Planning, Maternal and Child Health Indicators in India and Major States (NFHS-3) 2005-06

India AP AR AS BH CH DE GJ GO HP HR JH JK KA KE MG

Marriage and Fertility Women age 20-24 married by age 18 (per cent) 44.5 54.7 40.6 38.0 60.3 51.8 21.2 33.5 11.7 12.3 39.8 61.2 14.0 41.2 15.4 24.5
Men age 25-29 married by age 21 (per cent) 29.3 34.8 30.6 15.7 43.0 44.8 19.4 31.4 7.2 15.5 33.7 47.1 15.3 14.9 2.9 27.1
Total fertility rate (children per woman) 2.7 1.8 3.0 2.4 4.0 2.6 2.1 2.4 1.8 1.9 2.7 3.3 2.4 2.1 1.9 3.8
Women age 15-19 who were already
mothers/pregnant (per cent) 16.0 18.1 15.4 16.4 25.0 14.6 5.0 12.7 3.6 3.1 12.1 27.5 4.2 17.0 5.8 8.3
Median age at first birth for women
age 25-49 (per cent) 19.8 18.8 19.9 20.7 18.7 18.8 21.7 20.6 25.0 21.2 20.3 18.9 21.4 19.9 22.7 21.7
Married women with 2 living children
wanting no more children (per cent) 83.2 91.5 72.2 82.9 60.2 75.3 91.6 85.7 82.5 96.3 87.8 64.3 77.6 88.4 88.0 36.0
Two sons 89.9 94.1 85.0 85.2 77.4 85.7 95.2 94.8 86.3 99.5 97.4 79.9 84.9 92.7 87.5 33.1
One son, one daughter 88.1 93.6 76.0 89.7 67.5 77.3 94.6 90.1 84.8 99.4 91.8 69.3 82.5 91.4 90.9 44.2
Two daughters 62.1 85.0 45.5 67.1 20.0 46.8 70.7 48.8 71.7 63.7 25.8 32.1 38.6 76.9 86.4 27.1
Family Planning Current use (per cent)
Any method 56.3 67.7 43.2 56.5 34.1 53.2 66.9 66.6 48.2 72.6 63.4 35.7 52.6 63.6 68.6 24.3
Any modern method 48.5 67.0 37.3 27.0 28.8 49.1 56.4 56.5 37.2 71.0 58.2 31.1 44.9 62.5 57.9 18.5
Female sterilisation 37.3 62.9 22.5 13.0 23.8 40.7 23.0 42.9 25.8 49.0 38.2 23.4 26.3 57.4 48.7 9.5
Male sterilisation 1.0 3.0 0.1 0.2 0.6 3.5 0.8 0.6 0.1 6.3 0.7 0.4 2.6 0.2 1.0 0.1
IUD 1.8 0.5 3.6 1.3 0.6 0.8 5.0 4.5 2.3 1.5 4.7 0.6 2.7 3.1 2.3 1.5
Pill 3.1 0.3 8.3 10.3 1.3 1.4 4.5 2.6 1.5 2.8 2.8 3.8 4.7 1.1 0.5 4.9
Condom 5.3 0.5 2.9 2.4 2.3 2.9 23.3 6.0 7.8 11.7 11.8 2.8 8.1 2.1 5.8 2.5
Unmet need for family planning (per cent)
Total unmet need 13.2 5.0 19.3 10.8 23.1 10.5 8.0 8.2 13.2 7.3 8.3 23.7 15.0 10.2 9.0 35.1
For spacing 6.3 3.2 8.6 3.6 10.7 5.4 3.3 4.4 7.5 2.4 3.1 11.6 6.0 6.3 6.0 23.2
For limiting 6.8 1.8 10.7 7.2 12.4 5.1 4.7 3.8 5.7 4.9 5.2 12.2 9.0 3.9 3.0 11.9
Maternal and Child Health
Maternity care (for births in the last three years)
(per cent)
Mothers who had at least 3 antenatal
care visits for their last birth 50.7 86.0 36.4 36.3 16.9 54.7 74.4 64.9 95.0 62.6 58.8 36.1 74.2 79.3 93.9 53.4
Births assisted by a doctor/nurse/LHV/ANM/ other health personnel1 Institutional births1 48.3 40.7 74.2 68.6 33.4 30.8 31.2 22.7 30.9 22.0 44.3 15.7 65.1 60.7 64.7 54.6 94.3 92.6 50.2 45.3 54.2 39.4 28.7 19.2 60.5 54.3 71.3 66.9 99.7 99.5 31.7 29.7
Child immunisation and vitamin A
supplementation1(per cent) Children 12-23 months fully immunised2 43.5 46.0 28.4 31.6 32.8 48.7 63.2 45.2 78.6 74.2 65.3 34.5 66.7 55.0 75.3 32.8
Children 12-23 months who have received BCG 78.2 92.9 57.7 62.6 64.7 84.6 87.0 86.4 96.8 97.2 84.9 72.9 90.9 87.8 96.3 66.3
Children 12-23 months who have received
3 doses of polio vaccine 78.2 79.2 55.8 59.2 82.4 85.1 79.1 65.3 87.2 88.6 82.8 79.6 82.2 73.8 83.1 56.9
Children 12-23 months who have received
3 doses of DPT vaccine 55.3 61.4 39.3 45.1 46.1 62.8 71.7 61.4 87.5 85.1 74.2 40.3 84.5 74.0 84.0 47.6
Children 12-23 months who have received
measles vaccine 58.8 69.4 38.3 37.5 40.4 62.5 78.2 65.7 91.2 86.3 75.5 48.0 78.3 72.0 82.1 43.8
Treatment of childhood diseases
(children under 3 years)1(per cent)
Children with diarrhoea in the last 2 weeks
who received ORS 26.2 36.0 33.5 13.3 22.2 42.0 34.4 28.3 51.6 52.5 24.8 17.8 42.0 31.0 34.6 67.7
Children with diarrhoea in the last 2 weeks
taken to a health facility 58.0 61.4 37.9 30.6 48.7 65.3 75.1 59.8 71.5 67.3 82.7 32.5 69.1 64.8 67.4 76.6
Child feeding practices and nutritional status of children1(per cent)
Children under 3 years breastfed within one
hour of birth 23.4 22.4 55.0 50.6 4.0 24.5 19.3 27.1 59.7 43.4 22.3 10.9 31.9 35.6 55.4 58.6
Children under 3 years who are underweight 45.9 36.5 36.9 40.4 58.4 52.1 33.1 47.4 29.3 36.2 41.9 59.2 29.4 41.1 28.8 46.3
MH MP MN MZ NA OR PUN RJ SK TN TR UT UP WB Mean CV
Marriage and Fertility
Women age 20-24 married by age 18 (per cent) 38.8 53.0 12.7 20.6 21.1 36.3 19.4 57.1 30.1 21.5 41.0 22.6 53.0 53.3 36.0 44.3
Men age 25-29 married by age 21 (per cent) 15.4 54.0 11.6 20.8 18.2 22.2 27.2 56.7 24.0 8.4 11.4 21.3 51.4 26.9 27.0 53.4
Total fertility rate (children per woman) 2.1 3.1 2.8 2.9 3.7 2.4 2.0 3.2 2.0 1.8 2.2 2.6 3.8 2.3 2.7 24.3
Women age 15-19 who were already
mothers/pregnant (per cent) 13.8 13.6 7.3 10.1 7.5 14.4 5.5 16.0 12.0 7.7 18.5 6.2 14.3 25.3 13.0 49.9
Median age at first birth for women
age 25-49 (per cent) 19.9 19.4 23.7 22.3 21.8 20.0 21.4 19.6 21.9 21.0 20.3 20.5 19.4 19.0 21.4 7.0
Married women with 2 living children
wanting no more children (per cent) 88.0 81.9 64.5 43.0 57.8 82.3 91.2 72.8 95.8 94.6 92.3 86.3 64.2 89.4 81.6 18.7
Two sons 95.5 92.1 68.8 51.5 62.2 90.3 96.5 83.9 97.9 96.3 93.8 93.0 73.7 93.5 88.2 16.8
One son, one daughter 92.8 89.7 75.8 51.7 60.7 87.6 95.3 77.7 97.0 95.9 94.4 91.3 72.2 92.9 86.4 15.9
Two daughters 55.1 37.6 24.3 35.4 46.7 53.2 43.4 33.1 88.8 90.0 84.4 49.4 30.8 74.3 55.7 38.8
Family Planning Current use (per cent)
Any method 66.9 55.9 48.7 59.9 29.7 50.7 63.3 47.2 57.6 61.4 65.8 59.3 43.6 71.2 57.1 22.1
(Contd)
Economic and Political Weekly July 14, 2007 2933
Table 1: Levels of Fertility, Family Planning, Maternal and Child Health Indicators in India and Major States (NFHS-3) 2005-06

(Contd)

MH MP MN MZ NA OR PUN RJ SK TN TR UT UP WB Mean CV
Any modern method 64.9 52.8 23.5 59.6 22.5 44.6 56.0 44.4 48.7 60.0 44.9 55.5 29.3 49.9 48.6 29.5
Female sterilisation 51.1 44.3 8.1 42.9 9.9 33.1 30.8 34.2 21.2 55.0 17.6 32.1 17.3 32.2 33.6 44.4
Male sterilisation 2.1 1.3 0.5 0.0 0.0 1.0 1.2 0.8 4.5 0.4 0.5 1.8 0.2 0.7 1.2 117.1
IUD 3.1 0.7 5.4 4.9 5.2 0.6 5.5 1.6 3.1 2.1 1.0 1.5 1.4 0.6 2.5 66.3
Pill 2.5 1.7 5.3 10.6 4.7 7.0 2.9 2.0 12.8 0.2 22.0 4.2 1.7 11.7 4.9 95.9
Condom 6.4 4.9 4.2 1.7 2.8 3.2 15.5 5.8 4.2 2.3 3.5 15.7 8.7 4.5 6.3 81.0
Unmet need for family planning (per cent)
Total unmet need 9.6 11.8 12.6 17.4 26.3 15.0 7.4 14.7 16.9 8.9 10.5 11.3 21.9 8.8 14.2 47.3
For spacing 5.6 5.5 5.0 12.4 10.0 6.9 2.7 7.3 5.6 4.1 3.9 4.6 9.3 4.4 6.9 59.8
For limiting Maternal and Child Health 4.0 6.3 7.6 5.0 16.4 8.1 4.7 7.4 11.2 4.8 6.7 6.7 12.6 4.4 7.4 46.9
Maternity care (for births in the last 3 years) (percent)
Mothers who had at least 3 antenatal care
visits for their last birth 75.3 40.2 70.1 57.8 31.6 60.9 72.5 41.2 69.4 96.5 58.7 44.8 26.3 62.4 61.4 33.7
Births assisted by a doctor/nurse/LHV/ANM/ other health personnel1 Institutional births1 70.7 66.1 37.1 29.7 61.7 49.3 69.4 64.6 25.9 12.2 46.4 38.7 68.6 52.5 43.2 32.2 55.8 49.0 93.2 90.4 50.0 48.9 41.5 36.0 29.2 22.0 45.7 43.1 55.9 48.2 36.2 46.9
Child immunisation and vitamin A supplementation1 (per cent) Children 12-23 months fully immunised2 58.8 40.3 46.8 46.4 21.0 51.8 60.1 26.5 69.6 80.8 49.7 60.0 22.9 64.3 52.4 32.7
Children 12-23 months who have received
BCG 95.3 80.5 80.0 87.4 45.9 83.6 88.0 68.5 95.9 99.5 81.1 83.5 61.0 90.1 84.4 16.0
Children 12-23 months who have received
3 doses of polio vaccine 73.4 75.6 77.5 63.2 46.4 65.1 75.9 65.2 85.6 87.8 65.3 80.3 87.5 80.7 77.5 14.2
Children 12-23 months who have received
3 doses of DPT vaccine 76.1 49.8 61.2 66.6 28.8 67.9 70.5 38.7 84.3 95.7 60.2 67.1 30.0 71.5 65.1 27.4
Children 12-23 months who have received
measles vaccine 84.7 61.4 52.8 68.7 27.4 66.5 78.0 42.7 83.1 92.4 59.9 71.6 37.5 74.7 66.5 27.1
Treatment of childhood diseases
(children under 3 years)1(per cent)
Children with diarrhoea in the last 2 weeks
who received ORS 37.8 28.6 36.8 51.2 17.1 41.3 34.7 16.0 31.9 29.0 58.3 35.6 12.0 43.7 35.6 37.4
Children with diarrhoea in the last 2 weeks
taken to a health facility Child feeding practices and nutritional status of children1(per cent) 77.8 60.1 42.2 28.3 19.5 58.6 77.8 56.6 32.8 60.1 69.4 64.8 55.9 52.7 59.5 27.9
Children under 3 years breastfed within one hour of birth 51.8 14.9 57.2 65.4 51.5 54.3 10.3 13.3 43.3 55.3 33.1 32.9 7.2 23.7 36.5 50.7
Children under 3 years who are underweight 39.7 60.3 23.8 21.6 29.7 44.0 27.0 44.0 22.6 33.2 39.0 38.0 47.3 43.5 40.6 25.7

Notes: (1) Based on the last two births in the three years before the survey; (2) BCG, measles, and three doses each of polio/DPT. NB.: Names of the states are indicated by the following abbreviations; AP: Andhra Pradesh; AR: Arunachal Pradesh; AS: Assam; BH: Bihar; CH: Chandigarh; DE:Delhi; GJ: Gujarat; GO: Goa; HP: Himachal Pradesh; HR: Haryana; JH: Jharkhand; JK: Jammu & Kashmir; KA: Karnataka; KE: Kerala; MG: Meghalaya; MH: Maharashtra; MP: Madhaya Pradesh; MN: Manipur; MZ: Mizoram, NA: Nagaland; OR: Orissa; PUN: Punjab, RJ: Rajasthan; SK: Sikkim; TN: Tamil Nadu; TR: Tripura, UT: Uttaranchal; UP: Uttar Pradesh; WB: West Bengal. Source: International Institute for Population Sciences (IIPS) (2007): ‘2005-2006 National Family Health Survey (NFHS-3) Fact Sheets (Provisional Data)’, Key

Indicators for India and the States, Mumbai.

variation. From Table 1, it can be seen that in all the 29 indicators studied there are considerable variations across the states in India in 2005-06, indicated by the high coefficient of variation given at the last column of the table.

Comparison of Post- and Pre-1998 Periods

Table 2 provides for the country as a whole a comparative profile of the 29 parameters for which data were available in all the three rounds of NFHS surveys: 1, 2 and 3. The annual change in the percentage values observed during 1998-99 and 2005-06 computed from NFHS-2 and 3 data and between 199293 and 1998-99 obtained from the NFHS-1 and 2 data are also given. The last column of the table also provides a summary picture whether the post-1998 changes were worse off (slow down in progress) than the pre-1998 changes; “yes” indicating that the pace of change post-1998 is worse off and “no” implying the opposite. It is remarkable to note that in most of the variables, in 25 out of 29, the pace of improvement during 1998-99 to 200506 is slower than the pace of improvement during the period 1992-93 and 1998-99. For example take the case of the percentage of children 12 to 23 months fully immunised. This increased from

35.5 per cent in 1992-93 to 42 per cent during 1998-99 (an annual percentage point increase of 1.08 points) while in NFHS-3 the percentage was 43.5 implying an annual percentage point increase of 0.21 points in the post-1998 period. This implies that the full immunisation programme has undergone a dampening effect during 1998-99 to 2005-06 and the reasons for the same have to be explored. Similarly, the increase in the percentage of couples using modern methods of contraception was 1.05 percentage points annually during 1992-98 and this declined to

0.81 points post-1998 until 2005; the unmet need for contraception (spacing and limitation) declined by 0. 62 points annually during 1992-98 and this slowed down to 0.37 points during 19982005 and total fertility rate (TFR) decline slowed down from an annual decline of 0.09 points to 0.02 points.

Table 3 provides data at the state level for 22 states for which information was available in all three rounds of NFHS surveys for most of the 29 indicators. The indicators were grouped into three major categories: (a) marriage and fertility; (b) family planning; and (c) maternal and child health. At the all-India level the number of indicators covered in these three categories were

Economic and Political Weekly July 14, 2007

7, 10 and 12 respectively. For the different states the number of indicators for which such time series data were available and the number on which the pace of improvement in post-1998 period was less than the pre-1998 period is also given in the table. The computations were similar to that carried out at the national level. It can be seen from this table that in most of the states the pace of improvement in the post-1998 period is less than in the earlier period; with the median values of 50 per cent in the first category, 60 per cent in the second category and 65 per cent in the third category. A graphic presentation of the summarised picture of all the indicators in different sates and the country as whole is given in the figure.

Thus the RCH programme implemented after 1998 has not been particularly successful on a number of RCH indicators. If we adjust the effects for per capita expenditures spent on the RCH programmes pre- and post-RCH period, the differentials get accentuated since the expenditure on RCH after 1998 has almost doubled on a per capita basis compared to the 1992-97 period.

Expenditure on the Programme

Since 1997 the expenditure incurred on the RCH programme, both at an aggregate level and on a per capita basis, has substantially increased compared to the earlier years. This is possibly because of the loans on this programme liberally made available from the World Bank to strengthen the additional RCH components. Table 4 presents the expenditure data on various RCH components incurred in the country as a whole and in different states for the years 1995-96, typical of the pre-RCH era and 2001-02, typical of the RCH period for comparative purposes. The expenditure on RCH during 2001-02 does not include the money spent separately on the national polio eradication programme, which is estimated around Rs 900 crore for 2001-02 and increasing every year. The total expenditure on the RCH programme incurred by the central government for 2001-02 was Rs 3,445 crore compared to Rs 1,607 crore during 1995-96. On a per capita basis this works out to Rs 33.5 per person during 2001-02 compared to Rs 17.2 during 1995-96. In 1995-96, across the states, the per capita expenditure ranged from a high of Rs 28 in Himachal Pradesh and Rs 25.8 in Tripura to a low of Rs 8.2 in West Bengal, Rs 8.7 in Goa and Rs 9.0 in Bihar. Under the RCH programme, during 2001-02; the per capita expenditure on RCH ranged from a high of Rs 137.9 in Mizoram and Rs 99.1 in Sikkim to a low of Rs 16.8 in Madhya Pradesh and Rs 18.2 in Orissa. The ratios of 2001-02 to 1995-96 per capita expenditures (not adjusted for consumer price index) ranged from a

Table 2: Annual Change in Marriage and Fertility, Family Planning and Maternal and Child Health during Pre- and Post-1998, India

NFHS-3 NFHS-2 NFHS-1 Annual Change Annual Change
(2005-06) (1998-99) (1992-93) (Per Cent Points) (1992-1998)
>
1998-2005 1992-93 (1998-2005)
Marriage and Fertility 1 Women age 20-24 married by age 18 (per cent) 44.5 50.0 54.2 -0.79 -0.70 No
3 5 Total fertility rate (children per woman) Median age at first birth for women age 25-49 2.7 19.8 2.9 19.3 3.4 19.4 -0.02 0.07 -0.09 -0.02 Yes No
6 Married women with 2 living children wanting no more children (per cent) 83.2 72.4 59.7 1.54 2.12 Yes
6a Two sons 89.9 82.7 71.5 1.03 1.87 Yes
6b One son, one daughter 88.1 76.4 66.0 1.67 1.73 Yes
6c Two daughters Family Planning (currently married women, age 15-49)Current use 62.1 47.0 36.9 2.16 1.68 No
7 Any method (per cent) 56.3 48.2 40.7 1.16 1.25 Yes
8 8a Any modern method (per cent) Female sterilisation (per cent) 48.5 37.3 42.8 34.1 36.5 27.4 0.81 0.46 1.05 1.12 Yes Yes
8b Male sterilisation (per cent) 1.0 1.9 3.5 -0.13 -0.27 No
8c 8d IUD (per cent) Pill (per cent) 1.8 3.1 1.6 2.1 1.9 1.2 0.03 0.14 -0.05 0.15 No Yes
8e Condom (per cent) Unmet need for family planning 9 Total unmet need (per cent) 5.3 13.2 3.1 15.8 2.4 19.5 0.31 -0.37 0.12 -0.62 No Yes
9a For spacing (per cent) 6.3 8.3 11.0 -0.29 -0.45 Yes
9b For limiting (per cent) Maternal and Child Health 6.8 7.5 8.5 -0.10 -0.17 Yes
Maternity care (for births in the last 3 years)
10 Mothers who had at least 3 antenatal care visits for their last birth (per cent) 50.7 12 Births assisted by a doctor/nurse/LHV/ANM/other health personnel (per cent)1 48.3 13 Institutional births (per cent)1 40.7 Child immunisation and vitamin A supplementation1 15a Children 12-23 months fully immunised2 (per cent) 43.5 44.2 42.4 33.6 42.0 43.9 33.0 26.1 35.5 0.93 0.84 1.01 0.21 0.05 1.57 1.25 1.08 No Yes Yes Yes
15b Children 12-23 months who have received BCG (per cent) 78.2 71.6 62.2 0.94 1.57 Yes
15c Children 12-23 months who have received 3 doses of polio vaccine (per cent) 78.2 15d Children 12-23 months who have received 3 doses of DPT vaccine (per cent) 55.3 62.8 55.1 53.6 51.7 2.20 0.03 1.53 0.57 No Yes
15e Children 12-23 months who have received measles vaccine (per cent) Treatment of childhood diseases (children under 3 years)1 17 Children with diarrhoea in the last 2 weeks who received ORS (per cent) 58.8 26.2 50.7 26.9 42.2 17.8 1.16 -0.10 1.42 1.52 Yes Yes
18 Children with diarrhoea in the last 2 weeks taken to a health facility (per cent) Child Feeding Practices and Nutritional Status of Children1 20 Children under 3 years breastfed within one hour of birth (per cent) 58.0 23.4 65.3 16.0 61.9 9.5 -1.04 1.06 0.57 1.08 Yes Yes
25 Children under 3 years who are underweight (per cent) 45.9 47.0 51.5 -0.16 -0.75 Yes

Notes: (1) Based on the last two births in the three years before the survey; (2) BCG, measles, and 3 doses each of polio/DPT.

“yes” refers to a slow down of RCH indicator during the post-RCH period.

Source: International Institute for Population Sciences (2007): ‘2005-2006 National Family Health Survey (NFHS-3) Fact Sheets (Provisional Data)’, Key Indicators for All India, Mumbai.

Economic and Political WeeklyJuly 14, 20072936
Figure: Percentage of RCH Indicators Where Improvements were Slowed Down after 1998

90 80 70 60 50 40 30 20 10 0

Source:Same as Table 1.

high of 6.1 in Mizoram and 3.6 in Nagaland to a low of 1.2 times in Uttar Pradesh and 1.3 in Sikkim. There is no correlation between the rise in per capita expenditure on RCH and the levels of the indicators observed in the states. For example, in Mizoram, where the per capita expenditure on RCH was highest during 2001-02, in 11 out of 12 (92 per cent) indicators on maternal and childcare studied from NFHS series data, the post-1998 improvements were slower than the pre-1998 period (refer Table 4). Similarly even in Kerala, a more advanced state where the per capita expenditure on RCH during 2001-02 was Rs 34.2, there was a slowdown in 10 out of 12 maternal and childcare indicators in the post-1998 period. However, it should be pointed out that states like Kerala and Tamil Nadu have already reached very high levels of RCH programme coverage. In Bihar where there was a per capita expenditure of Rs 79.3 in 2001-02 there was a slowdown in 9 out of 12 indicators. There is a need to examine in detail how the RCH budget is really spent and why the expected pace of improvements in various RCH indicators are not achieved. This is a matter of serious concern for policymakers and programme administrators. There appears to be no synergy between different programmes that is supposed to come into force when they are implemented under one umbrella. The RCH umbrella seems to be leaking, as indicated by the overall slowdown in key indicators.

Impact of Decentralisation (Aggregation Effects)

The district level RCH surveys conducted by the IIPS since 1998 with financial assistance from the World Bank offer a wealth of data on a number of RCH indicators and important proximate determinants of these indicators. They covered all the districts of the country and the second round of these surveys were conducted during 2002-04 [IIPS 2005]. Since two-stage sampling was done within each district with the villages as primary sampling units (PSUs) and households from the selected villages at the secondary level, the data permit analysis of the effects of the state, district, village or PSU and the household on different indicators. We did a multi-level regression analysis of RCH indicators using the multi-level analysis (MLWIN) package. The effects of these factors were examined on eight indicators: These include whether the mother had a safe delivery for the births that occurred in the last three years; whether any ANC care was provided; institutional delivery; awareness about RTIs; whether there were any delivery complications; whether treatment was taken at a government health centre for pregnancy related problems and the awareness of oral rehydration therapy (ORS). Analysis of variance (ANOVA) and MLWIN was used in the analyses of data collected on 556 districts from 28 states across the country.

15 38 41 45 45 48 4 8 50 55 59 59 62 62 6 2 65 66 66 69 69 72 7 2 76 79 MG RJ UP A S TN G O MH MN K E A P O R TR DE G J NA A R HP W B MZ IND K A HR PUN

The regression coefficients and the percentage variance explained by each of the above mentioned four levels of aggregation

Table 3: State-wise Total Number of Cases and Percentages Indicating Pre-1998 Changes Greater Than the Post-1998 Period in the Three Selected Groups of Indicators

Marriage Family Maternal S= =As/ =Bs/ =Cs/ Overall and Plan-and Child A+B+C 7*100 10*100 12*100 =S/ Fertility ning Health 29*100

A(7) B(10) C(12)

India 4 7 10 21 57 70 83 72.4
AP 3 5 9 17 43 50 75 58.6
AR 3 6 10 19 75 60 83 65.5
AS 4 5 4 13 57 50 33 44.8
DE 2 5 11 18 29 50 92 62.1
GJ 1 7 10 18 14 70 83 62.1
GO 2 3 9 14 29 30 75 48.3
HP 5 5 9 19 71 50 75 65.5
HR 7 6 9 22 100 60 75 75.9
KA 6 6 9 21 86 60 75 72.4
KE 4 2 10 16 57 20 83 55.2
MG 1 2 1 4 25 20 8 15.4
MH 3 4 7 14 43 40 58 48.3
MN 2 3 8 13 50 30 67 50.0
MZ 1 6 11 18 25 60 92 69.2
NA 2 5 10 17 50 50 83 65.4
OR 3 6 8 17 43 60 67 58.6
PUN 6 8 9 23 86 80 75 79.3
RJ 2 5 4 11 29 50 33 37.9
TN 2 0 11 13 29 0 92 44.8
TR 4 3 9 16 100 30 75 61.5
UP 3 2 7 12 43 20 58 41.4
WB 7 7 6 20 100 70 50 69.0
Median 5 9 17 50.0 50.0 75.0 61.5

Notes: For north-eastern states except Assam, the data for all three time points is available only for four out of seven indicators of marriage and fertility. Therefore, in those cases, percentages of A’s is based upon four indicators and overall index is based on 26 indicators.

Source:Same as Table 1.

are given in Table 4. Two significant observations can be made from Table 4.

First, in each of the eight RCH indicators mentioned above, the effect of the state is significantly larger than that of the district or village. The state level aggregation explained more than 70 per cent of the total variance with regard to any ANC care; about 50 per cent of the total variance with regard to safe delivery and 35 per cent with regard to institutional delivery.

Second, the next important factor after the “state” is the “individual”. The district and village level aggregation effects are comparatively low in their explanatory power of the variances in the eight factors considered. The districts have practically no significance in the explanation of the variance. The state has a powerful influence on the RCH and it appears that the formation of district level RCH societies or the village level panchayats have not made much impact on the RCH indicators. This is understandable since the service delivery is in the control of the state government and the districts and panchayats have very little say in the organisation of such services. The need for education of individuals and to provide her/him with necessary RCH services and organising effective service delivery through better involvement of the state is an important finding of this analysis.

It seems more prudent and cost effective to have some of the health programmes, like the RCH, vertically implemented through the state government health system with financial assistance and monitoring from the centre and using different types of personnel in addition to the ANM rather than loading all desired activities on the poor ANM under the pretext of integration. There is a need to separate functions and skills that can be integrated in one person and those that require different types of skills and appropriate training. For example, the ANM is not suited to counsel on RTIs and STDs, in providing education on sexual health, nor in arranging transportation facilities for pregnant mothers to be taken to a hospital for delivery. This is necessary

Table 5: Effects at Different Levels of Aggregation for Selected RCH Variables (Multi Level Analysis)

Indicator/Level Estimate Per Cent Variation ß SE Explained

Safe deliveryState 1.866 0.465 49.6 District 0.351 0.024 9.3 PSU 0.79 0.013 21.0 Individual level variables 0.752 0.003 20.0

Any ANC State 3.304 0.818 70.6 District 0.333 0.023 7.1 PSU 0.37 0.008 7.9 Individual level variables 0.672 0.002 14.4

Institutional deliveryState 1.185 0.299 35.3 District 0.352 0.024 10.5 PSU 1.051 0.018 31.3 Individual level variables 0.767 0.003 22.9

Current users of any modern method State 0.459 0.117 24.7 District 0.178 0.011 9.6 PSU 0.269 0.005 14.5 Individual level variables 0.955 0.002 51.3

Awareness about RTI/STI State 0.613 0.164 26.6 District 0.49 0.03 21.3 PSU 0.489 0.006 21.2 Individual level variables 0.713 0.002 30.9

Delivery complications State 0.912 0.243 31.8 District 0.656 0.041 22.9 PSU 0.458 0.01 16.0 Individual level variables 0.844 0.003 29.4

Treatment at govt health centre for pregnancy problemState 1.085 0.274 33.0 District 0.283 0.024 8.6 PSU 1.164 0.036 35.4 Individual level variables 0.76 0.005 23.1

Awareness about ORS State 0.646 0.173 20.9 District 0.5 0.033 16.2 PSU 1.151 0.028 37.2 Individual level variables 0.796 0.003 25.7

Source:International Institute for Population Sciences (IIPS): ‘District LevelReproductive and Child Health Surveys: Round 2, 2002-04’, IIPS, Mumbai.

Table 4: Expenditure in Family Welfare for 1995-96 and on RCH Programme for 2001-02 by States: Total and Per Capita

Estimated Population Census Population Expenditure (Rs in Lakh) Per Capita Expenditure (Rs) Ratio of
States (1995-96) (2001)** 1995-96* 2001-02a 1995-96 2001-02 2001-02 to
1995-96
Per Capita
Andhra Pradesh 71359008 76210007 10653.03 28449.04 14.9 37.3 2.50
Arunachal Pradesh 981263 1097968 115.32 565.41 11.8 51.5 4.38
Assam 24534925 26655528 2888.43 6883.92 11.8 25.8 2.19
Bihar 84686487 82998509 7644.86 19466.16 9.0 23.5 2.60
Goa 1258731 1347668 132.34 269.37 10.5 20.0 1.90
Gujarat Haryana Himachal Pradesh 45990300 18804106 5624389 50671017 21144564 6077900 6588.77 2478.46 1548.64 9531.25 5760.62 3547.38 14.3 13.2 27.5 18.8 27.2 58.4 1.31 2.07 2.12
Karnataka 48913882 52850562 6153.92 22963.00 12.6 43.4 3.45
Kerala 30469946 31841374 6073.93 10905.60 19.9 34.2 1.72
Madhya Pradesh Maharashtra 63264597 87899881 60348023 96878627 6801.06 11969.08 10126.69 20821.60 10.8 13.6 16.8 21.5 1.56 1.58
Manipur Meghalaya Mizoram 2001969 2046800 789165 2166788 2318822 888573 475.76 362.56 177.57 1232.98 926.38 1225.60 23.8 17.7 22.5 56.9 40.0 137.9 2.39 2.26 6.13
Nagaland Orissa 1599791 34232198 1990036 36804660 280.58 4666.21 1249.78 6756.35 17.5 13.6 62.8 18.4 3.58 1.35
Punjab Rajasthan Sikkim 22320484 50256589 473654 24358999 56507188 540851 2057.08 8022.74 349.80 4428.65 22658.34 535.91 9.2 16.0 73.9 18.2 40.1 99.1 1.97 2.51 1.34
Tamil Nadu 59132313 62405679 7441.58 22392.74 12.6 35.9 2.85
Tripura Uttar Pradesh 2978204 152655104 3199203 166197921 768.31 23299.55 2059.85 30754.45 25.8 15.3 64.4 18.5 2.50 1.21
West Bengal India 74127081 933589132 80176197 1028610328 6099.92 160738.5 18259.75 344474.9 8.2 17.2 22.8 33.5 2.77 1.95

Notes: a: National Health Accounts Cell, 2005.

** Census of India, 2001; * Family Planning Year Book 1997-98. Ministry of Health and Family Welfare, Government of India, New Delhi. Source:National Health Accounts 2001-02, Ministry of Health and Family Welfare, Government of India, New Delhi.

Economic and Political Weekly July 14, 2007

to increase programme efficiency and effectiveness. There appears to be a need for rethinking the present approach and whether just increasing the budget using the existing approach would produce desired results. There are some functions that cannot and should not be integrated, such as sex education for adolescents and maternal and childcare. India has to evolve its own well thought out national policy appropriate to different regions rather than go by international recommendations and pressures.

As a public health principle it is useful to optimise the utilisation of the public health infrastructure at the primary level and a gradual convergence of all health programmes under a single field administration. But at the peripheral level different types of field workers with different skills are needed. Vertical programmes for control of major diseases like TB, malaria, HIV/AIDS, as also the RCH and universal immunisation programmes, would need to be continued till moderate levels of prevalence are reached.

III Discussion and Conclusions

At the district level, district RCH societies have been formed in all the districts and funds are allotted to these societies to implement RCH programmes. The RCH programme is being implemented as an integrated package of a number of reproductive and health services including the traditional antenatal, natal and post-natal care for pregnant women, care of infants including immunisations of children against common vaccine preventable diseases, identification and treatment of sexually transmitted diseases among women, education on sexuality to adolescent boys and girls, early detection and treatment of cervical cancer among women nearing menopause, etc. All of these activities including the powerful and well-funded polio vaccination programme, ultimately land up on the laps of the poor ANM at the peripheral level. Partly successful attempts have been made to involve communities actively through the recruitment and training of anganwadi workers (AGW) for the education of preschool children, nutritional supplementation programmes and assistance for the maternal and child health activities. Recently under the national rural health mission launched since March 2005, another community liaison person called ASHA, an acronym for accredited social health activist, has been involved at the rate of one for 1,000 population in the rural areas. ASHA’s main role is in promoting institutional deliveries. Both AGW and ASHA are not government employees and are part-time workers to help and liaise with the official health workers. Ultimately the professional workload on all reproductive and childcare falls on the over-worked ANM.

In this article we have analysed the effectiveness of the recently implemented RCH programme, officially implemented since 1997, both from the point of view of decentralisation and from the point of view of integration of services. Data compiled from the RCH surveys carried out during 2002-04, wherein information of various RCH parameters were collected at the district level from representative samples from 562 districts and from the three series of NFHS-1 (1992-93); 2 – (1998-99) and 3 – (2005-06) have been used. The fact that NFHS-2 was conducted during 1998-99, a year immediately after the RCH programme was launched, was taken advantage of for comparing the progress on various RCH indicators before and after the launch of the RCH programme. Our analysis reveals that in aggregation, the state level effects are very dominant, significantly more than the district level, on all the RCH indicators studied. It is almost impossible to strengthen district programmes unilaterally without strengthening the state programmes. Similarly comparing the preand post-1998 levels of various indicators at the state and national levels it is found that the pace of annual progress after 1998 in many indicators is slower than the pace of progress before 1998. This is a very disturbing fact, since the RCH programme including the maternal and childcare services, family planning and polio vaccination programme, has incurred more than double the expenditure during 1998-2004 compared to 1992-98. Decentralisation of basic healthcare services will not be effective unless backed by full time professional, medical, and paramedical, personnel at that level. They cannot be improved only through AGWs and ASHAs. Similarly integration of various services at the field level has to be done with a great deal of caution since peripheral health workers tend to develop specialised skills and interests and they cannot be expected to carry over from one programme to the other with the same effectiveness and efficiency.

m

Email: ksrini_02@yahoo.com

References

Family Planning Year Book (1997-98): Ministry of Health and Family Welfare, Government of India, New Delhi. IIPS (1993): National Family Health Survey(NFHS 1), 1998-99, International Institute for Population Sciences, Mumbai.

  • (1995): National Family Health Survey (NFHS 1), 1992-93 – India and the States’, India and the States, IIPS, Mumbai.
  • (2000): National Family Health Survey (NFHS 2), 1998-99 – India and the States’, India and the States, IIPS, Mumbai.
  • (2005): District Level Reproductive and Child Health Surveys: Round 2; 2002-04, International Institute for Population Sciences, Mumbai.
  • (2007): National Family Health Survey (NFHS 1), 2005-06, Fact Sheets for India and Different States (Provisional Data), International Institute for Population Sciences, Mumbai.
  • National Health Accounts Cell (2005): National Health Accounts 2001-02, Ministry of Health and Family Welfare, Government of India, New Delhi.

    Registrar General, India (2006): SRS Bulletin, Vol 40, No 1, Office of the Registrar General of India, New Delhi, April, and publications for the earlier years.

    Srinivasan, K (2006): Population Policies and Family Planning Programmes in India: A Review and Recommendations; C Chandrasekaran Memorial Lecture delivered at IIPS, Mumbai on February 3, 2006 and published in their Newsletter, Vol 47, January-June 2006.

    United Nations (1994): Programme of Action of the 1994 International Conference on Population and Development, United Nations, New York.

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