World Bank Document

-4^A>- - |C= O N F I D E N T I A L Report No. PP-.5

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Public Disclosure Authorized be returned to GENERAL FILES immediately after use.

This report is available only to those members of the staff to whose work it relates. Any further release must be authorized by the department head concerned.

INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT

INTERNATIONAL DEVELOPMENT ASSOCIATION Public Disclosure Authorized

POPULATION PROJECT

REPORT OF PREAPPRAISAL MISSION

INDIA

( n two volumes) Public Disclosure Authorized

VOLUME I

THE MAIN REPORT

November 27, 1970 Public Disclosure Authorized

Population Projects Department CURRENCY EQUIVALENTS

US$ 1.00 7.5 Rupee

Rupee 1.00 US$ 0.13

GLOSSARY

ABBREVIATIONS

ANM Assistant Nurse-Midwife BEE Block Extension Educator DFPB District Family Planning Bureau DFPO District Family Planning Officer DMOH District Medical Officer of Health DMOH-FP District Medical Officer of Health and Family Planning FPHA Family Planning Health Assistant FWW Family Welfare Worker IPPF International Planned Parenthood Federation IUD Intrauterine Device LHV Lady Health Visitor MCH Maternal and Child Health MIES Management-Information and Evaluation System Oxfam Oxford University Famine Relief Fund PHC Primary Health Center RFPTC Regional Family Planning Training Center RFPWC Rural Family Planning Welfare Center SFPB State Family Planning Bureau SFPO State Family Planning Officer WHO World Health Organization UFPWC Urban Family Planning Welfare Center UN United Nations UNDP United Nations Development Program UNICEF United Nations Childrens Fund U.P. Uttar Pradesh USAID United States Agency for International Development INDIA POPULATION PROJECT

TABLE OF CONTENTS

SUMMARY AND CONCLUSIONS ...... i-il

I. INTRODUCTION 1...... 1

II. THE POPULATION PROBLEM 3...... 3

III. THE FAMILY PLANNING PROGRAM ...... 5

A. Organi2Ztion 5...... 5 B. The Statistical System ...... 8 C. Family Planning Progress ...... 9 D. Appraisal of Recent Trends ...... 13

IV. THE PROJECT

A. Introduction ...... 17 B. Urban Program ...... 18 C. Optimal Government of India Pattern Districts .. 19 D. Intensive Rural Program Districts ...... 20 E. Basic ANM and Dai Training ...... 24 F. The Population Centers ...... 25 G. Physical Facilities and Equipment ...... 28 H. Costs ...... 30

ANNEXES

1. Organizational Chart of Family Planning Activities at the Center 2. Organizational Chart of Family Planning Activities in a State 3. Organizational Chart of Family Planning Activities in a District 4. Organizational Chart of Action/Implementation Committees 5. Management-Information and Evaluation System 6. Inputs and Results in Project Areas 7. Staff and Equipment Requirements of Service Motivation Teams 8. Location of Primary Health Centers and Number of Subcenters 9. Cost Estimates for Project 10. Addition to Annual Expenditures

MAPS

1. India Population Project 2. Uttar Pradesh State: Population 3. -Mysore State: Population INDIA POP'ULATION PROJECT

SUMMARY AND CONCLUSIONS

i. In the past few years the international community has become increasingly concerned with India's family planning program. The annual growth rate of 2.5% and the addition of 14 million persons each year have been matters; of serious concern to the Government of India in their efforts at social and economic improvement. Following the Aid India Consortium meeting, especially organized by the Bank in November 1969 to consider India's program, further discussions were held with the Government of India to dcter- mine in a preliminary manner the objectives and location of a possible Bank project. The pro,ject would aim to develop a comprehensive program in the selected districts which would include the components of the Government of India program but would also have variations and improvements that are relevant to the whole Indian program. This would require a management- information system and an evaluation unit for assessing the work in the project area on a continuing, basis. It was agreed provisionally that the project area would comprise six districts in Uttar Pradesh (U.P.) and six districts in Mysore State - covering a total population of about 20 million persons. A preappraisal mission visited India from July 13 to August 21, 1970. ii. The mission found that while the achievements of the Indian program were considerable, the program is not functioning as well as it should or could. A large nrumber of persons have accepted family planning services and an extensive and complex administrative machine to implement policy decisions has been built. But performance falls short of a solution of India's population problem, of the targets set by the Government and the expectations of the Government. Over the last two years sterilizations and IUD insertions have markedly declined. Though the distribution of condoms has greatly increased, overall performance has declined. What is more disturbing is that this decline has occurred despite a great increase in resources available for family planning. iii. The mission could not determine the reasons for these trends. Though specific recommendations are made by the mission, the basic aim of the project is to provide a framework for experimentation and orderly change. Operational questions should be continuously and systematically asked and the policy implications of their answers should be speedily and effectively implemented. iv. The project consists of the following:

First, the provision of family planning services in three ways:

I. An Urban Program including a particular concentration on postpartum motivation and service in Lucknow (U.P.) and Bangalore City (Mysore);

II. An Optimal Government of India Program to implement the Government pattern in twelve Districts - six in U.P. and six in Mysore; and III. An Intensive Rural Program including a particular concentration on recently-delivered mothers in rural areas. This program will have inlputs additional to those sanctioned in the. Government plan and will be implemented in four Districts - two in U.P. and two in Mysore.

v. Second, two new Population Centers in Lucknow and Bangalore to be primarily responsible for the management-information system and training. The management-information system would monitor progress in project areas, evaluate performance and recommend changes that would be relevant to other parts of India. These Centers should haye close links to the State family planning administration. Their Board waould have to be influential so that the recommendations of these Centers can be quickly implemented. vi. Third, the following Physical facilities and Equipment:

(a) Two Population Centers in Lucknow and Bangalore City and nine District Family Planning Bureaus - one in each District (except Bangalore rural);

(b) Two Regional Family Planning Centers - one in Lucknow and one in Bangalore;

(d) Ten maternity-sterilization wards - one for each District Hospital;

(e) Sixteen Maternity Homes with 15-20 beds and 14 Urban Family Welfare Centers in Lucknow and Bangalore City;

(f) Complete Primary Health Centers consisting of a dispensary, family planning clinic and staff living quarters for health and family planning personnel (according to the Government of India pattern) in all Districts where these buildings do not presently exist; and maternity wings (15-20 beds) in selected PHCs of the four Intensive Districts (Scheme III) in addition to the Government pattern;

(g) Subcenters for ANMs (and FWWsin U.P.) according to the Government of India pattern, in all Districts where these buildings have not been constructed; and subcenters for dais, in addition to the Government pattern in the Intensive Districts (Scheme III) of U.P.; and

(h) Fourteen ANN Schools - five in Lucknow and Bangalore City and one school attached to every District Hospital vii. Total project costs - consisting of physical facilities and equipment and technical assistance - are estimated to total Rs.113 million (US$15.1 million). - iii-

The direct foreign exchange component is about Rs.7.5 million (US$1.00 million). Recurrent expenditures of the project that are additional to the present sanctioned level are e!stimated to total Rs.18.6 million (US$3.6 million) over the first five years. About 59% of project costs and additional recurrent expenditures are for U.P. State and 41% for Mysore State. viii. The Populatiorl project outlined in this report will establish, over a sizable population (20 million) the base for continuing assessment of the program with opportunities for variation and experimentation; thus providing in thie longer term a valuable tool for improvement of the performance of the whole program. INDIA POPULATION PROJECT

I. INTRODUCTION

1.01 In the past few years the international community has become increasingly concerned with India's family planning program. The annual growth rate of 2.5% and the addition of 14 million persons each year were matters of serious concern in relation to the efforts at social and economic improvement of the Government of India.

1.02 In November 1969, at the request of members of the Aid India Consortium, the Bank organized a special meeting in Stockholm for representatives of the Consortium countries and representatives of the Government of India to consider the India program. The meeting discussed in parti' ular the United Nations' report evaluating India's family planning effort.' It was agreed that external assistance could make a significant contribution to the program provided financing covered local currency expenditures. The Bank indicated that it was interested in becoming involved in a family planning project. This was welcomed by donor countries and the Government of India.

1.03 This was further discussed in early 1970 to determine in a preliminary manner the objectives and location of a possible Bank project. The project would aim to develop a comprehensive program in the selected districts which would include the components of the Government of India program but would also have variations and improvements that are relevant to the whole India program. This would require a management-information system and an evaluation unit for assessing the work in the project area on a continuing basis. It was agreed provisionally that the project area would comprise six districts in Uttar Pradesh (U.P.) and six districts in Mysore State - covering a total population of about 20 million persons. This selection of districts was made because the Bank felt it desirable to be involved iL both North and South India, but in terms of a manageable project, not more than two States. Mysore was selected partly because of the wealth of demographic data collected in the UN Mysore Population Study of 1961. The preliminary selection of districts in both States was made by the Government of India with the concurrence of the two State Governments. The mission examined relevant data during its mission and accepted the districts proposed in Mysore (those in Bangalore Division); however, in consultation with State and Central Government officials, it proposed modifications to the districts in U.P. where the project will be developed.

1.04 The detailed information on family planning, inputs, results and other demographic and socio-economic data were collected in May and June 1970 in the selected districts. A preappraisal mission visited India from July 13 to August 21. It consisted of Messrs. K. Kanagaratnam (Chief), G. Zaidan (Deputy), and Messrs. P. Demeny (East-West Center - Hawaii University), I. Sirageldin (Johns Hopkins University), F. Wilder (Ford Foundation) and G. Zatuchni (Population Council) as consultants. Mr. R. Cassen aind Mr. T. Lankester from

1/ United Nations, October, 1969 "An evaluation of the family planning program of the Government of India". i

-2- the Bank assisted the mission in the field and during report writing in Washington. Mr. T. Lankester (with research assistants) collected the basic data (reproduced in Volume II) before the arrival of the preappraisal mission. The mission was joined during its final week in Inadia by Professor R. Freedman, the Bank's consultant on population matters.

1.05 The mission spentttwo weeks in New Delhi, ten days in Mysore and another ten days in U.P.,, Mission members also visited Maharashtra State and Gandhigram. This report zontains the findings and recommendations of the mission. N. -3-

II. THE POPULATION PROBLEM

2.01 India's population has been growing at a rapid and accelerating rate. From a total population estimated at 238 million in 1901, India's population nearly doubled to 439 million in 1961. It is estimated to be 554 million in 1970-1, but the 1971 census may show it to be even higher. More important than the growth in size, is the increasing rate of growth of the Indian population. From an average annual growth rate of 0.7% in the 1921-31 period, the growth rate increased to 2.0% in 1951-61 -- nearly a threefold increase. The current growth rate is estimated to exceed 2.5%; every year 14 million persons are added to the population.

2.02 These trends are the result of a more or less constant birth rate coupled with a rapid decline in mortality, particularly since the second World War. In 1951-60, the birth rate was officially estimated to be 41.7/1,000 while the death rate was 22.8/1,000. The death rate declined sharply to an estimated level of 14.0/1,000 in 1966-70. (The expectation of life at birth increased from 32 years in 1941-51 to an estimated 53 years 1966-70). This decline was due to the success of public health programs -- malaria, smallpox and other major epidemic disease have been substantially controlled. Also, administrative response to national disasters such as flood and drought has greatly improved; consequently deaths from famine and malnutrition have been reduced.

2.03 The population of India is diverse in language, culture, religion and socio-economic development. It is predominantly Hindu (83.5%) with significant Muslim (10.7%) and Christian (2.5%) minorities. The population is predominantly rural, though there has been a slow migration to the towns. In 1921, 88.8% of the population lived in rural areas; in 1961, the proportion was 82.0%. The population of India is a young population with 41% of persons aged less than 15 years.

2.04 The previous trends have serious demographic, economic and social implications:

(a) The number of eligible couples,- estimated to number 55.1 million in 1970-1, are increasing by more than 1.25 million couples every year. The growth of the labor force, presently estimated at 200 million, is projected to increase by 30 million in 1971-5, 35 million in 1976-80, and 41.0 million in 1981-5. All these trends are implied by the births of the past fifteen years and the expected improvements in health of children.

(b) Real net national;--product has been growing annually by 3.5% from 1951-66, but because of the population growth rate of 2.1% in 1951-60 and of 2.5% in the sixties, more than 60% of the growth in income has been absorbed by the increasing population, while living standards have improved little. More important, the growth of per capita income has been decreasing - from 1.65% per year in 1951-60 to 0.6% per year in 1961-6. In more recent years, when economic conditions were unfavorable, economic growth was insufficient to counter population

1/ To allow for sterile, pregnant and other women not wishing to practice contraception, this is estimated to be five-ninths of married women aged 15-44. -4-

growth. In 1968-9 -- after the years of serious drought of 1965-6 and 1966-7 and a prolonged industrial recession -- per capita income was still below its 1964-5 level.

(c) A particularly serious economic and social problem is that of unemployment. The present level of unemployment and underemployment is very considerable. Given the projected increase of the labor force and rough estimates of the present level of unemployment, about 40 million additional jobs have to be created in 1971-5, and about 75 million jobs over the next decade.

2.05 While family planning efforts can make a significant difference to India's growth rate, India's population will continue to grow substantially for most of this century. Even if fertility declines at a moderate pace, the Registrar General estimates that India's population will grow to 638 million in 1976 and 702 million in 1981. The UN estimates that India's population will reach 983 million in 1990, if fertility remains constant. Even if fertility declines very rapidly -- reaching a birth rate of 25/1,000 in 1975 -- the population will reach 668 million in 1990.

2.06 Uttar Pradesh. Uttar Pradesh (U.P.) has a population of 91.5 million. It is the largest State of India and one of the poorest. In 1961, 13 percent of the population was living in urban areas and only 3 percent of the male labor force was in non-household manufacturing industry. The medical system is exceptionally thin, particularly in rural areas. Levels of socio-economic development in U.P. vary considerably. Western districts, where the "green revolution" has had an impact, are the most developed while socio-economic conditions in the east are far less favorable. Accord- ing to India's demographic estimates the population of U.P. increased from 56.5 million in 1941 to a present level of 91.5 million. In 1941-50, the birth rate was 38.6/1,000 and the death rate 27.2/1,000 giving a growth rate of 1.1% per year. Because of the rapid decline in the death rate to a current level of 16/1,000 the growth rate has more than doubled to 2.3% per year. The demographic, economic and social implications of these trends are as grave as for the whole of India. For example, per capita income in constant prices has remained constant irL U.P. from 1961-6.

2.07 Mysore. Mysore has a population of over 30 million. In 1961, 22 percent of persons lived in urban areas. Literacy rates are relatively high by Indian standards and the medical system is better and more wide- spread than in most other States. The level of economic development is similar to the Indian average, though the southern part of the State (Bangalore Division) where a sizeable industrial sector has developed, is well above the average. The State has a reputation for efficient and enlightened administration. Mysore's population grew from 7.4 million in 1941 to 23.6 million in 1961. It is currently estimated to number 30 million with an annual growth rate of 2.4%. The birth rate is estimated to be 39.1/1,000 while the death rate is 15.1/1,000. -5-

III. THE FAMILY PLANNING PROGRAM

3.01 Brief History. Although the Government adopted a policy favoring family planning in the First Five-year Plan (1951-55), the program consisted mainly of a few pilot projects and some studies during this period. In the Second Plan (1956-61), the program expanded; a national organization was set up, clinics for providing family planning services were opened, various training centers were established, and sterilization as a method of contraception was given official support. In 1963, an "Extended Program", designed to provide family planning services to the rural population through the health services, was adopted. Program targets were set to reduce the birth rate to 25/1,000 in 1975. The "cafeteria" approach offering a choice of several contraceptive methods, was introduced. In succeeding years the "Extended Program" was steadily implemented while other significant developments took place. In particular, a separate Department of Family Planning was created in the Ministry of Health; compensation payments to acceptors of sterilizations and IUDs were introduced; the "Intensive District Program" and the "Selected Area Program" were designed to give priority to densely populated districts, or groups of contiguous districts; demographic and bio-medical research was expanded; selected hospitals in various cities of India received special assistance for postpartum family planning work; and country-wide schemes for the commercial distriblution of condoms at subsidized rates were introduced. The following sections concentrate on developments in recent years.

A. ORGANIZATION

Central Level.

3.02 The indian Family Planning program is a centrally sponsored program financed almost entirely by the Central Government (Government of India). The Center lays down standards of staffing and facilities (the Government of India pattern). However, responsibility for implementing the program rests with the State Governments. At the Center a small Cabinet Committee, chaired by the Finance Minister expedites policy decisions and reviews program progress. Policies for the Center and States are laid down by the Central Family Planning Council, which is chaired by the Health Minister, and includes the Minister of State responsible for family planning, the State Health Ministers, and representatives of organizations working in family planning.

3.03 In 1966, a Department of Family Planning headed by a Secretary was established in the Ministry of Health. It plays a dominant role in the India family planning program because it is responsible for budgetary planning and financial control. It is divided into:

(a) an administrative section concerned with planning and budgeting, administration and aided programs;

(b) a technical section responsible for services, training, research, supplies and evaluation; and

The Department also has direct operational responsibility for programs in Union Territories (with a population of 14 million), and the Central Government employees programs (10 million employees). The organization chart at the Center and the composition of relevant committees is shown in Annex 1.

3.04 In addition to the Central Family Planning Council, the Government of India is linked to the State Governments by six Regional Directors. The Northern Region consists of the State of Uttar Pradesh alone, with a Regional Director in Lucknow. Mysore is part of the Southern Region with a Regional Director in Bangalore. The Regional Director is an employee of the Central Government. He has no executive responsibilities buit he can be influential because of his close working relationship with State officials.

State Level.

3.05 The basic organizational structure is more or less similar in every State though some differences exist in U.P. Responsibility for family planning activities are part of the functions of the Health Secretary and the Director of Medical Services for Health and Family Planning. A high level Implementation Committee has been constituted in several States to review program progress . In Mysore, the committee is headed by the Chief Secretary with senior representatives of Health, Finance and other Departments including the Development Commissioner and Chief Engineer. In U.P., the equivalent committee exists mainly on paper and has not yet come io play an important role. Program administration is the responsibility of the Deputy Director of Health and Family Planning who is the State Family Planning Officer (SFPO). He heads the State Family Planning Bureau (SFPB) which is responsible for the appointment of District staff, general administration and coordination of State programs, supervision of District efforts, training of field workers, communication, and supply and maintenance of vehicles. Annex 2 shows the organization at the State level.

District and Field Levels.

3.06 In effect, the District is the main administrative unit of program-implementation (Annex 3). Typically, it has a population of 1.5 - 2.0 million and an area of about 5,000 square miles. Each District has an Action Committee, chaired by the head of the District Administration (known as Collector, Deputy Comnmissionaer or District Magistrate) to coordinate and expedite family planning work. The District Medical Officer of Health (DMOH) is the head of the public health service in the District. In most States, a District Family Planning Officer (DFPO) has been added to be responsible for family planning. In U.P., the organization of the District was recently revised to achieve a closer integry,aion of health and family planning. Family planning has been added to the resp,onsibilities of the DMOH, (renamed as District Medical Officer of Health and Family Planning (DMOH-FP), while the DFPO has become an additional DMOH-FP and is now subordinate to the DMOH-FP. The DFPO, or additional DMOH-FP, heads the District Family Planning Bureau (DFPB). The main responsibilities of this Bureau are to supervise and manage all program activities in the field, organize efforts of governmental units, supervise the voluntary organizations receiving Government subsidies and stimulate the active participation of industrial employers, private physicians, etc.

3.07 The Indian family planning organization is closely interwoven with the general provision of health services, particularly at the field level. There are distinct budgets for health and for family planning, but each functionr4 -7-

relies on the other to varying extents for the provision of services. Thus the basic unit for the provision of health services in rural areas is the Primary Health Center (PHC) covering one Development Block, which is a District subdivision with 80,000 to 100,000 people. A typical District will have 15-20 PHCs, varying in distance between each other from 10 to 100 miles. When staffed and equipped for family planning, the PHC is called the Rural Family Welfare Planning Center (RFWPC). Its basic staff consists of additional medical and paramedical personnel most of whom also contribute to the public health work of the PHC1. Conversely, staff provided to the PHC under the health budget, also perform family planning work. The Government of India staffing pattern for each RFPWC is as follows:

- two doctors, one in the health budget, the other in the family planning budget;

- one block extension educator (BEE);

- one computor-statistician;

- one storekeeper cum accountant;

- one lady health visitor (LHV) per 40,000 population;

- one male family planning health assistant (FPHA) per 20,000 population

- two auxiliary nurse-midwives (ANMs), one under the health budget, the other under the family planning budget.

3.08 Each PHC has under it 8-10 subcenters staffed with one ANM per subcenter. The Government of India pattern provides for one subcenter or ANM per 10,000 persons in addition to the ANMs at the PHC. Three of the ANMs at the subcenter level are under the health budget while the remainder (five to seven) are in the family planning budget. The facilities and services that they provide are identical, regardless of the source of funding. In U.P., where there is a grave shortage of ANMs, ANMs under family planning are sub- stituted by Family Welfare Workers (FWW), and ANMs under the health budget by trained indigenous midwives (dais).

Urban Areas.

3.09 According to the Government of India Plan, urban areas should have a City Bureau equivalent to the District Bureau. The City Bureau is responsible to the'-municipalDauthorities and not to the District Administration. City Bureaus should coordinate family planning activities in large cities. These activities include the provision of family planning services by:

(a) Urban Family Welfare Planning Centers (UFWPC), which are sanctioned at the rate of one per 50,000 population in the Government of India pattern;

(b) voluntary organizations such as the Christian Medical Association, Red Cross, India Family Planning Association (IFPA) etc.: -8-

(d) postpartum programs in maternity hospitals.

The City Bureau is also responsible for involving persons such as private doctors, Government employees. and employees in industry, in the family planning program. While all these are the functions of the City Bureaus in principle the Bureau has not functioned effectively in Bangalore, while Lucknow does not yet have such a Bureau.

B. THE STATISTICAL SYSTEM

3.10 At the State level, Demographic and Evaluation Cells have been author-- ized recently in the State Family Planning Bureau to streamline service statistics. A Statistical Assistant is provided in the District Bureau and a computor (compilation clerk) at the Block level. At the District level, each Bureau has a District Field Operation and Evaluation Division consisting of one statistical investigator and two field and evaluation workers. The statistical investigator does mainly clerical work; collecting the routine performance data from the various health centers, checking the returns, correcting and adding, and filing summary forms to the State Bureau. Systematic field checking of the accuracy of the data, analysis of the data, and the preparation of reports on internal performance (e.g. worker productiviLy) is not being done. This is due to the inadequate analitical capability of the District Bureau and because these management functions are not considered to be part of the responsibility of the District Bureaui. For a further description of the statistical system see Annex 5.

Information

3.11 Standard formats for records, registers and returns have been developed by the Center. Each unit offering family planning services including clinical work, distribution of conventional contraceptives, education and motivational work is required to maintain registers. The units report these data every month to the main Family Welfare Planning Center (usually the PHC) where it is aggregated and forwarded to the District Family Planning Bureau. In the District, the data are again aggregated and forwarded to the District Family Planning Bureau. In the District, the data are again aggregated before being submitted to the State. Finally the State again aggregates these data and sends it to the Center.

3.12 These successive aggregations mean that much of the detailed data that arecollected in the field is not transmitted to higher levels. Such a loss of information occurs particularly between the PHC level and the District Bureau. In short, a large amount of data is lost, and what remains is not adequately analysed.

3.13 Furthermore, there is a clear dichotomy ard separation in the reporting system between cost data and performance data. The Statistical Assistant at the District Bureau is only responsible for performance statistics while the accountant is only responsible for cost data. This situation is also true at the State level. Financial accounts and physical achievements of various program activities are not correlated. -9-

Evaluation of 3.14 Internal evaluation is a major responsibility of the Department State Family Planning. The Department issues a monthly set of statements by on population, sanctioned staff in position .at State and District levels, numbers of Urban and Rural Family Welfare Centers required and functioning, in sterilization and IUD program progress, and the number of persons trained of the various courses. These reports are supplemented by progress reports Regional Directors and by tour reports of officials of the Family Planning Department. An Annual Report is also issued by the Ministry of Health which and contains various details on the program. The State Bureau issues monthly annual reports, but not as comprehensive as those of the Center. Monthly acceptance rates are generally limited to the total number of acceptors of different methods of family planning. There is no systematic and periodic analysis of data on different characteristics of acceptors, though such information is often collected at the peripheral level.

C. FAMILY PLANNING PROGRESS

3.15 The following table summarizes progress and expenditures in family planning in India, U.P. and Mysore:

India

Condoms Family Planning Sterilizations IUDs Distributed Expenditures (000's) (000's) (000's) (Million Rs)

1965-6 670 810 24,000 120 1966-7 890 910 16,000 134 1967-8 1,840 670 24,000 265 1968-9 1,660 480 59,000 305 (revised) 1969-70 1,370 440 95,000 400 (revised)

Uttar Pradesh

1965-6 40 45 NA NA 1966-7 80 107 1,400 14.6 1967-8 159 103 2,200 26.6 1968-9 156 91 6,200 37.6 1969-70 78 81 8,400 NA

Mysore

1965-6 26 76 NA NA 1966-7 52 88 NA 8.8 1967-8 110 41 NA 13.0 1968-9 92 20 NA 12.7 1969-70 49 13 NA 13.0 -10-

These figures show the same pattern in India, U.P. and Mysore. Sterilizations In (male and female) increased up to 1967-8 but have since markedly declined. 1969-70, they were less than one-half their peak level in both U.P. and Mysore, although tubal sterilization increased in the last two years. IUDs reached peak their peak in 1966-7, and have since declined to less than one-half their level. However, there has been close to a fourfold increase in the distribution of condoms between 1967-8 and 1969-70. The total number of new acceptors decreased from 3.43 million in 1968-9 to 3.23 million in 1969-70. These achieve- than ments, though large in number, are insufficient when compared with the more 1.25 million eligible couples that are being added every year. These figures were derived by adding to reported sterilizations, IUD instertions, an estimate of the number of condom users, on the assumption that 72 condoms equals one acceptor. On this basis, about 15% of India's eligible couples were estimated to be protected by the program in March 1970. In Uttar Pradesh, the total number of acceptors has declined between 1967-8 and 1969-70. This is almost certainly true for Mysore as well though figures for condom distribution were not available. What is particularly disturbing is that this decline has been associated with large increases in resources going into family planning. India Expenditures between 1966-7 and 1969-70 have increased by three times for this as a whole. The cost per practising acceptor has more than doubled over users is period -- from Rs 60 to Rs 124 per acceptor. If the number of condom based on the ratio of 144 condoms per acceptor instead of 72 (an equally Rs 207 per plausible ration) then the cost per acceptor will have increased to acceptor -- more than a threefold increase.

Inputs - All India

3.16 The increase in financial resources is a reflection of the rapid expan- and sion of personnel and equipment for family planning. However, personnel By equipment still fall short of the sanctioned Government of India pattern. two-thirds March 1970, 318 out of India's 327 Districts had District Bureaus and of the sanctioned technical staff in these Bureaus were in position compared Centers, with one-half in 1968. There were 4,812 Rural Family Welfare Planning sub- up by one-third since 1966, but still 600 short of the target; also 29,000 centers were functioning versus only 7,000 in 1966. Finally, Urban Family been Planning Centers increased by one-third since 1966. This expansion has accompanied by a huge recruitment of personnel -- 150,000 persons are now employed in the program. However, a large proportion have been inadequately trained, impairing the effectivness of the program. Progress in construction and has been very modest and much of the program is carried out in crowded and barely working facilities, which are often rented. The backlog of training being made buildings is readily recognized in India, and efforts are currently to remedy it.

Inputs - Uttar Pradesh of 3.17 U.P. has had particular difficulty in implementing the Government and India program. This has been partly because of the shortages of personnel the facilities in U.P. but also because the State Government has not accorded program the priority which it deserves. In all the U.P. Districts, District additional Bureaus have been established. Five of the Districts were without an DMOH-FP and various posts, including that of administrative officer, computor positions and field and evaluation workers, had not yet been sanctioned. Most that are sanctioned for Bureaus have been filled, with the notable exception of female doctors. Here, 84 are sanctioned but only 29 are posted. -11-

3.18 At the field level, there are presently 740 PHCs functioning with only 630 doctors in position. Thus 110 PHCs are without a doctor at all, and the other 630 do not have a second doctor as envisaged in the Government of India pattern. FPHAs number 3,500 at present, almost the required number. Amongst ANMs, the staff shortage is perhaps worst of all. According to the Government of India pattern,there should be 1,750 ANMs at PHCs, and 7,500 at subcenters, making 9,250 in all. In fact, the total number in position at present is 2,046. Some attempt has been made to alleviate the ANM gap hty posting indi en- ous midwives (dais) who have been trained and Family Welfaru Workers (FWW)'1 there are 1,454 trained dais and 2,140 FWWs substituting for ANMs at subcenters. However, FWWs and dais are believed to be less effective than ANMs because of inadequate training. The mission's observations in the field and examination of some local records confirm a general impression that the FPHAsare ineffective.

3.19 On construction, 400 PHCs have a dispensary of their own; 38 family planning clinics have been constructed and 40 are under construction leaving a balance of almost 800. Of the 7,500 subcenters required, only 216 have so far been built; another 163 are under construction. In the ten Districts where information was collected, only about 15 percent of the PHCs had vehicles.

3.20 The family planning program in urban areas has more personnel and better facilities. There are 212 Urban Family Welfare Planning Centers (147 State, 34 local bodies, 28 voluntary organizations, 13 bodies in the public sector), which for an urban population of about 16 million is probably adequate. Five hospitals have been designed for the postpartum program.

Inputs - Mysore

3.21 At the District level, the 19 District Bureaus are adequately staffed as to number and category except for (a) administrative officers, who have been sanctioned but none of whom are in position; and (b) female doctors, of whom 9 are in position instead of the 19 required.

3.22 In rural areas, there are 265 PHCs in Mysore. These centers had 348 doctors in position in June 1970 leavI-ng a gap of 182. There are vacancies in other positions. Compared with the 265 required for each, there are 183 extension educators, 246 statisticians and 178 storekeepers cum accountants. There are nearly 900 FPHAs posted compared with the 1,100 or so required, and 300 LHVs compared with a requirement of 530. Thus, there are quite substantial staffing gaps. The situation, however, looks considerably different when account is taken of the large network of the "Myscre Type Health Units" and dispensaries. These were mostly established before the Government of India pattern was proposed, and now continue to function beside it, doing both health and family planning work. In all there are about 700 such units functioning in rural areas. Most of these have a doctor in position.

3.23 As regards ANMs there should according to the Government of India pattern be about 2,700 of them, and there are now 2,650 (in all types of health units) which, on a population basis, exceeds by several times the number available in most of north India.

1/ Dai training consists of 20 lessons in hygiene and basic obstetrics and 20 practical sessions with an ANM. FWWs are female workers dealing with with Family Planning; they are given just 30 days training at a Regional Family Planning Training Center. -12-

3.24 Most of the Mysore Type Health Units and dispensaries have buildings of their own, many of them old but mostly fairly adequate. So far 136 PHC dispensaries have been constructed, the remaining 129 being housed in rented buildings. Very few family planning clinics have yet been completed, though about 25 are under construction. Almost everywhere, staff quarters for both medical and family planning staff are lacking. This includes subcenters, of which out of the 2,200 required, only 147 have been constructed normally the ANM has to rent her own dwelling. Of these 265 PHCs, only 69 have a vehicle.

3.25 In urban areas, there are 53 Urban Family Planning Centers, and 3 hospitals designated for the postpartum program. Several other hcspitals, a number of MCH centers and maternity homes (mainly in Bangalore) also do family planning work.

Special Programs

3.26 Because India is so large, and its resources are limited, the Government has encouraged the concept of concentrating on particular areas. This is the basis of the intensive and selected areas program. The intensive program aims at adding inputs - above the Government of India pattern - in a few Districts with large population in each State. These areas have not exhibited a more marked progress than the average, mainly because, in practice, they have received only minor additional inputs.

3.27 Selected Area Project. In June 1968, USAID concluded an agreement for assistance to the Selected Area Program, to be carried out in the Varanasi Division of Uttar Pradesh. Inputs were to be intensified. In fact, limited funds were distributed, and the additional inputs that are in position are minor.

3.28 Gandhigram. The Gandhigram experiment covering initially one Block in Tamil Nadu has proved successful. In 1959 the Institute of Rural Health and Family Planning in Gandhigram started an intensive "action-research" family planning program in a Development Block. Methods of implementation have been continuously assessed and periodically modified. There has been a significant decline in fertility -- 34.8% during the period 1959-68. While some inputs were added, the program has been successful mainly because of emphasis on quality -- through field training and regular supervision. It has been run by regular State Health Officials under the overall technical guidance of the Institute and illustrates the possibility of successful close cooperation with the Government program. Work in the first Block (with a population of about 100,000) is now being expanded to five neighboring Blocks. The Institute has used the program to test new techniques such as the roles of different categories of family planning workers, evolved more adequate supervision and developed skill and knowledge needed by staff in other extension work. On the basis of the action- research program the Institute has built up a successful training program. Though Gandhigram demonstrates that success can be achieved -- that is, that there may be a large demand for family planning services -- this applies to an area of limited size. The problems of training and supervision become more complex when applied to a whole District. Furthermore, the Gandhigram experiment included improvements in health and community development, which are not part of family planning efforts in the All-India context.

Foreign Aid

3.29 Early assistance (1959-60) to the Indian Program was from the Ford -13-

Foundation and the Population Council for fellowships and consultants. Later assistance also came from bi-lateral sources including the United States, Sweden, Japan and Denmark. This consisted primarily of providing commodities and consultancy services. The United Nations has also helped the program through the UNDP, WHO and UNICEF. Multi-lateral aid consisted primarily of equipment, experts, fellowships and two teams to evaluate the Government program. Until 1969, donors financed foreign exchange costs. In that year, however, bi- lateral and multi-lateral donors became prepared to finance local currency expenditures, because the foreign exchange component was small and restricted opportunities for assistance. Following the November 1969 Consortium in Stockholm, and the May 1970 meeting in Paris several offers of aid for local currency finance have been made. They includeUS$ 2.4 million from the United Kingdom, and US$ 20.0 million granted by the United States in June 1970 for training and evaluation, construction of buildings, and support for the Inten- sive District program. Sweden, Norway and Canada are among other countries likely to conclude new agreements of a similar nature to assist the India program. IPPF and Oxfam are two of the most important sources of support for voluntary family planning in India.

D. APPRAISAL OF RECENT TRENDS

3.30 While the achievements of the India program are considerable the program is not functioning as well as it should or could. A large number of persons have accepted family planning services and an extensive and complex administrative machine to implement policy decisions has been built. But performance falls short of a solution of India's population problem, of the targets set by the Go,rernment and the expectations of the Government. This is the more disturbing because resources for family planning have greatly increased. The "productivity" of the program -- that is, the results obtained from each rupee spent -- has fallen to between one-half and one-third its level from two years back. The mission attempted to find explanations for recent developments, particularly the reversal of trends, but found no simple explanations. Nor was there a consensus on the reasons among persons who met the mission. Many reasons were mentioned but the relative importance of each, and the implications that this has for future progress, must await further analysis and study.

3.31 Generally, the possible reasons for the program's inadequate performance can be grouped under several headings:

3.32 Administrative: The family planning program is administered neither better nor worse than other Government of India programs. However, this is a program which requires management far above the average to achieve success. Particular weaknesses are the following:

(a) persistence of inefficiencies due to inadequate supervision and the difficulty of dismissing personnel for poor performance;

(b) flow of adequate information to administrators about what is happening in the field or about the reasons for trends that are reported;

(d) no overall program design or coordination among the various groups offering family planning services in cities; -14-

(e) reliance of the Health Ministry and State Health Departments on other agencies which do not perform this function satisfactorily. For example, construction work is undertaken by State Public Works Depart- ment which do not give priority to family planning work. Similar difficulties arise in transportation where vehicle maintenance is handled by the State Transport Organization.

3.33 Quantity and Quality of Personnel: To implement the Government pattern, India has embarked on an ambitious training program that is the largest in the world. In doing so, more attention has been given to numbers than quality. This "crash approach" has resulted in large numbers of poorly selected, ill- motivated and inadequately trained persons. Such persons can have negative effects on the program. A training program of six days' or even 30 days' duration is inadequate. Insufficient emphasis i.s given to field training and particularly to supervision in the field. Aggravating the situation still further are excessive training loads because of the insufficient number of trainers. In spite of the crash approach to training, numbers are still short of the Government of India pattern, which would cover only one-third to one-half of the India population even if it were implemented according to plan. This situation is a reflection of the small number of skilled personnel. The small number of doctors, particularly lady doctors, has already been emphasized, as had the inadequate number of ANMs. The inadequacy of their basic training is discussed in para. 4.22.

3.34 Contraceptive Methods: In principle, the India program offers a "cafeteria" approach. In practice, choice of different methods in rural areas is limited. According to the Plan, women should be able to have an IUD insertion at the PHC provided a lady doctor is there. This is rare in U.P. and only a little less rare in Mysore. Also the reported side effects have undermined the popularity of the IUD and the difficulty of follow-up reduces its effectiveness. In practice, rural women seeking contraception, resort to sterilization after having had at least three children. Even this is done only in hospitals or camps. Men fare better in that vasectomies are available at most PHCs and hospitals. Other than this "feared" operation, rural men have no other choice except for condoms - the least effective of the methods offered in the program.

3.35 The reasons for the declining performance in recent years is a more relevant question but also more difficult to answer. The following are some possibilities.

i. The "Crash" Approach to the Provisions of Services. Because of the political priority given to this program, and following the setting of targets in 1966, there was too much concern with immediate results and too little with methods of achieving these results and their long-term implications. Revenue workers and agricultural extension workers were active in 1966-7 and 1967-8, using their influence to enlist a large proportion of acceptors. The use of these workers was a useful support to the program. This is much less so and may-explain the recent decline in performance.

ii. Monetary Incentives. This was first offered in 1966 and was one reason for the increase in vasectomies in the following two years -15-

when harvests were bad. (Most of the acceptors came from the lower castes). The recent decline irL sterilizations may be due to the smaller effect that these incentives have in years when economic conditions are more favorable

iii. Training. It is possible that the "crash" approach to training has had adverse effects which are now beginning to be felt - in particular with respect to FPHAs, many of whom have been put on the job with little (6 days) or no training.

3.36 Information and Evaluation: Though program performance has declined, there have been no special reports from the District to the State or from the State to the Center showing concern for this or an analysis of these trends. Conversely, though much research is going on in India and abroad, r-nuch of this research is not related to program operations, and when it does have policy implications, there is a reluctance to translate research findings into changed action progrELms. This lack of interaction is a reflection of the weakness of the statistic:l system (Annex 5 contains a further appraisal of the information and evaluation system). It may be due to the following:

(a) The Demographic Cells in Bangalore and Lucknow are too low in the hierarchical structure to do independent evaluation and question some of the basic premises of the program. At present, the Demographic Cells are geared to the analysis of service statistics. These cannot adequately explain program limitations because of the relatively small number of acceptors in the program.

(b) More generally, there is inadequate analytic capability at the State and District levels, to evaluate the quality of data, supervise its collection and flow and analyse it.

i. The large number of records at the lowest levels is inefficient from an operation and management point of view;

ii. Most of the effort of collecting detailed data is wasted; data is aggregated and most of the detail is never transmitted to higher levels for analysis; instead, it remains largely in disaggregated form at the PHC level;

iii. Records and reports are not kept adequately at the lower units, nor are they designed for speedy data processing;

iv. Performance and cost data are collected, aggregated, and analysed separately at all levels;

v. Achievement data collected in the system refer only to participating couples. This has limited value in explaining the level of demand for family planning services or in suggesting improvements. No efforts are made to relate additional studies to the problems of the program. -16-

3.37 While the foregoing summarizes some of the difficulties of the program, the mission also observed encouraging signs that deserve mention. Among these are the following.

3.38 Knowledge and Awareness. Several studies show, and the observations of the mission confirm, that awarenes.s of conatraceptive methods is present in both urban and rural areas, This is a tribute to the success of the mass communications campaign. However, the gap between general awareness and effective knowledge and practice is wide and may even have increased because of this very success.

3.39 Potential for Improved Performance. Not only has success on a limited scale been demonstrated (e.g. Gandhigram), but more to the point, large areas have markedly different rates of performance, suggesting that overall performance can be improved. Among States there is mujch variability. In 1968-9, the number of sterilizations per 1,000 populaition varied from 1.0 in Assam to 5.5 in Maharashtra. IUD insertions varied from 0.2 in Maharashtra to 3.0 in Haryana. Equally, large variations exist between Districts of the same State. While this is partly due to the large variety of conditions prevaiiing in India, it is also the result of varying ineffectiveness in the provision of these services. More or less similar Districts that have very different performance rates (varying by a factor of two or three) can be found. This suggests that there is potential for substantial progress.

3.40 In summary, the Indian family planning program is not functioning as well as it should or could. Is this due to the way in which family planning services are provided or to the demand by the popu:Lation for such services? This, and many other questions relevant to the program operation, have not been asked by persons within or outside the program. The study of such questions is a necessary first step to reverse present trends. The basic aim of the mission's recommendations is to provide a framework for orderly change. Operational questions should be continuously and systematically asked and the policy implications of their answers should be speedily and effectively implemented. -17-

IV. THE PROJECT

A. INTRODUCTION

4.01 The project will cover twelve Districts, six in Mysore State and six in U.P. with a total estimated population of 19.85 million in 1970. Its objectives are to:

(a) implement the Government pattern for providing family planning services, and add inputs in some areas to test alternatives to this pattern;

(b) provide a management-information and evaluation system (MIES) to evaluate performance and recommend changes;

(c) ensure that the recommendations that subsequently emerge are speedily implemented in the project area or on a wider basis if appropriate; and

(d) provide the necessary facilities and technical assistance to implement the above.

4.02 The project consists of the following:

A. The provision of family planning services in the following ways:

I. An UrbaPgram including a particular concentration on postpartum motivation and service in Lucknow (U.P.) and Bangalore City (Mysore);

II. An Optimal Government of India Program to implement the Government pattern in-Lwelve Districts -- six in U.P. and six in Mysore; and

III. An Intensive Rural Program including a particular concentration on recently delivered mothers in rural areas. This program will have inputs additional to those sanctioned in the Government plan and will be implemented in four Districts -- two in U.P. and two in Mysore. 4.03 To control for differences in the levels of socio-economic development, the second and third schemes would be implemented in at least one District with relatively advanced socio-economic conditions and at least one with relatively backward conditions. Differences in socio-economic conditions would be present within each District so that the demand for family planning services can be analysed within as well as between Districts. The following is the suggested location of each scheme:

I. Urban Program Lucknow City Bangalore Urban

II Optimal Government Sultanpur, Tumkur, Shimoga, of India Districts Muzaffarnagar, Bangalore Rural Pratapgarah

III. Intensive Rural Faizabad, Kolar, Program Districts Saharanpur Chitradurga -18-

4.03 B. A new Population Center in Lucknow and another in Bangalore to be primarily responsible for the management-information system and training. The management-information system would monitor progress in project areas, evaluate performance and recommend changes that would be relevant to other parts of India. These Centeis should have close links to the State family planning administration. Their Board would have to be influential so that the recommendations of these Centers can be quickly implemented.

4.04 C. Physical facilities, equipment (and in some cases vehicles) for the following:

(a) Two Population Centers in Lucknow and Bangalore City and nine District Family Planning Bureaus -- one in each District (except Bangalore rural);

(b) Two Regional Family Planning Centers -- one in Lucknow and one in Bangalore;

(d) Ten maternity-sterilization wards -- one for each District Hospital;

(e) Sixteen Maternity Homes with 15-20 beds and 14 Urban Family Welfare Centers in Lucknow and Bangalore City;

(g) Subcenters for ANMs and 5TWW in U.P.) according to the Government of India pattern, in all Districts where these buildings have not been constructed; and subcenters for dais, in addition to the Government pattern in the Intensive Districts (Scheme III ) of U.P.; and

(h) Fourteen ANM Schools - five in Lucknow and Bangalore City and one school attached to every District Hospital

4.05 The following sections describe each of the three schemes, the basic training of ANMs, the Population Centers, the physical facilities and equipment, and the costs of the project.

B. URBAN PROGRAM

4.06 In situations where all fertile women are given-institutional maternity care, there exists an excellent opportunity to provide them and their husbands, with family planning information and services. Experience in the postpartum program of India indicates that 30% or more of women who deliver in hospital accept some method of contraception. In some Indian hospitals, 60% of women with three or more children have accepted sterilization. What is needed is a formal program to contact every couple in the antenatal period and particularly during the confinement and postpartum period. Voluntary agencies and private physicians can support this urban postpartum program in the areas of information -19-

- motivation and services, including follow-up. Their efforts as those of all facilities other than maternity institutions should be directed to all aspects of family planning work. The following are the components of the urban program:

4.07 Organization. There is urgent need for better coordination of family planning activities, both public and private. The Urban Family Planning Bureau in Bangalore is at present less effective than it should be, and no bureau has so far been established in Lucknow. Some effective coordinating body should be established in each city (a) to draw up a detailed plan of operation to provide riaternal and child health (MCH) care and family planning services (integrated or separate) covering the whole city; and, once the plan is adopted, (b) to coordinate services, supplies, information efforts and the collection of relevant data. The data would be analysed by the Population Center. The Center would work closely with this body in planning, and evaluating family planning activities. It might be composed of selected members of the State Government representing Health, Education, Industry and others; representatives of the Municipal Corporation; and private and public voluntary agencies. It should include the Director of the Evaluation Division in the Population Center. The question should be considered whether it is appropriate for such a body to report to the Municipal Bureau.

4.08 Training. Persons not presently trained by the Regional Family Planning Training Centers (RFPTC) such as private doctors and some of the hospital staff would be trained by the Population Center.

4.09 Communication. In addition to present activities, the following should be emphasized:

i. seminars, lectures, materials are necessary to mot.Lvate employees of the Government, the industrial sector and others who are not presently being sufficiently motivated; and

ii. increased efforts to involve opinion leaders through mass media should start in the urban areas. It would rapidly extend to the Intensive Districts, to other project areas and to the whole State. The present staff at the State level -- one officer, an editor and an artist -- are inadequate for a population of 95 million in U.P. and 30 million in Mysore. The system of direct mailing of family planning materials to opinion leaders, presently in existence in New Delhi, should be used in Mysore and U.P. Material for this purpose (bulletins, news- letters etc.) should be developed. It would include information on recent progress, policy changes, technical information, etc.

4.10 The foregoing are only some of the components of the urban program. The detailed plan which the Urban Council will draw up could include other components -- for example, oral pills could be offered in the program, a plan for contacting and following up women who do not deliver in institutions could be implemented (particularly in Lucknow where this proportion is large), larger incentives could be offered to private doctors.

C. OPTIMAL GOVERNMENT OF INDIA PATTERN DISTRICTS

4.11 The objective of this part of the project is to determine how effective the Government of India pattern is. An answer to this question has not been possible to date because this pattern has not been fully implemented. The progress of the program will depend on the efficiency with which family planning services are provided and the demand for the services by the -20- population. To help to determine the relative importance of each of these factors, the Government program will be implemented in Districts with relatively advanced socio-economic conditions and Districts with backward conditions. This program includes two major components:

4.12 a. Personnel. All the personnel sanctioned in the Government of India pattern should be in position. The gaps which presently exist in the project areas are shown in detail in Volume II. They are summarized in Annex 6. Whether these gaps can be filled within a reasonable period of time by transfer from other districts into the project area or by stepping up the rate of training will require further discussion. In some cases this may be difficult or impossible as for example with lady doctors. At the same time more personnel will have to be trained so that the Government pattern can be implemented over the whole State.

4.13 b. Training. The quality of personnel is as important as their number. Training and supervision should be improved on the basis of the Government plan. Responsibility for this would be primarily that of the RFPTCs, which presently do most of the family planning training. There are seven RFPTCs in U.P. and six in Mysore. The training they provide is too short to be effective -- doctors are trained for 7 days, LHVs and FPHAs for 30 or 7 days (thle latter is the "crash" program), BEE and ANMs for 30 days. The capabilities of the RFPTCs in Lucknow and Bangalore should be strengthened to allow the retraining of family planning workers (medical officers, LHVs, FPHAs and others presently trained in the RFPTCs), and the more intensive training of new personnel. The RFPTCs will concentrate initially on six Districts and retrain family planning personnel in less than two years. This can then be extended to other Districts in the project area and ultimately to the whole State. Teach- ing staff will have to be expanded from the present 22 sanctiolned positions to 32; and the present inadequate facilities and hostel accommodations will have to be replaced. The Population Center's Training Division will work closely with the RFPTC in the development of curricula and materials and in evaluating the effectiveness of the training program.

D. INTENSIVE RURAL PROGRAM DISTRICTS

4.14 This part of the project would consist of the Government of India pattern (i.e. thte components of the preceding section) plus additional inputs to be outlined in this section. To control for the effect of demand conditions, this program would be implemented in a relatively advanced District and a relatively backward one in each. State.

4.15 This program is focused on providing a minimum standard of maternity, child care and family planning services to all eligible persons. It is based on the well proven concept that the postpartum period is the best time to inform women about contraceptive methods. Not only are women most receptive to advice at this time, but they have confidence in the personnel providing MCH care. Also, family planning services can be easily followed up. Finally, the more successful is better MCH care in reducing infant-mortality, the greater the motivation towards adopting family planning. The components of area:

(a) a redefinition of the role of personnel in the program; (b) the use of mobile teams for service and motivation; -21-

4.16 a. Personnel. The role of the various categories of personnel would be as follows

i. ANMs and Dais. MCH services and family planning will be provided under medical supervision by ANMs in Mysore and by ANMs and dais in U.". The targeted ratio will be one ANM and dai per 5,000 population equal to about 200 deliveries per year. This ratio will be flexible depending, in particular, upon the topography of the area. It is a minimum standard, since ideally there should be one medical attendant per 2,500 population. Many dais will have a clinic with living quarters, and in addition to their present referral fee, they should be paid a regular salary in rante of about Rs 90-150 per month. As additional ANMs are trained, they will supersede these trained dais. Specific job des- criptions for ANMs and dais should include:

1. Identification of all newly pregnant women, by name, address, age, number of pregnancies, number of live births, number and sex of living children, and last pregnancy interval. Copies of this information will be given to the Family Planning Health Assistant (FPHA) and to the responsible PHC doctor on a monthly basis.

2. Provision of minimum maternal care -- namely, two antenatal visits, presence during labor and delivery, one postnatal visit, and referral to qualified medical personnel in cases with complications.

3. Provision of immunization procedures in coordination with the PHC and basic health worker.

4. Provision of infant care in homes and identification and referral to PHC of sick children.

5. Provision of family planning information and referral for contraceptive services.

6. Provision of follow-up for contraceptive and other medical services.

7. Serve as depot holders for conventional contraceptives.

ii. LHVs and ANM Supervisors. Supervision of ANMs and dais is now the responsibility of LHVs. This can continue to be so, but in some cases ANMs should be promoted to become supervisors. This new system is desirable because (1) it would encourage more young girls to become ANMs; and (2) an ANM may be a more effective supervisor than the LHV because she is more familiar with local conditions and problems. There should be one supervisor for every 5 workers. The supervisor should visit the subcenter on a weekly basis and also report weekly to the PHC doctor. -22-

iii. FPHAs. The FPHAs job description should include t1ie following:

1. Obtain lists of pregnant women from ANMs and dais;

2. Contact husbands of these women to provide them with family planning information;

3. Escort men to PHCs for contraceptive services;

4. Follow-up acceptors, particularly those having had a vasectomy, and refer men to doctors when there is a medical problem;

5. Participate in camps; and

6. Serve as depot holders for condoms.

These functions are different from the FPHAs present responsibilities. They will have to be trained and assigned to the PHC doctor.

4.17 b. Mobile Teams. Two types of teams would be used:

i. Large service-motivation teams. These mobile teams would provide family planning and MCH services in the villages. The medical staff would remain for about one week at: each stop and it would be preceded by motivational staff using group and interpersonal communications. Some personnel would remain for the follow--up of sterilization and IUD cases. This approach would be tried in one of the two Intensive Districts of each State. This approach seems to be desirable because of:

1. the inadequacy of medical staff, in particular, lady doctors at the PHC level;

2. the creation of a group psychology that leads individuals to adopt family planning more easily if they know their neighbors are also accepting these services; this has been borne out by the success of the camp technique in India; and

3. the members of this unit would work as a team for extended periods of time. This would improve their effectiveness.

Each mobile team would consist of about 30 persons - three doctors, six nurses, and nurse-aids, six motivators and fifteen persons for administrative and supporting work. Each stop would cover roughly 12 villages. The whole District would be covered in about three years. Annex 7 gives details on the staffing requirements and equipment for this team.

ii. Lady-Doctor teams. These mobile teams would operate in the two Intensive Districts with no service-motivation teams. Each District would have one or two lady doctors and assistants to visit PHCs and provide family planning services, including IUD inser.ion and sterilization. Abnormal pregnancy cases will also be treated. The need for such teams is based on the scarcity of lady doctors in PHCs. -23-

These mobile teams could be used until every PHC has a lady doctor, The mobile lady doctor will be assigned to the District Hospital which will provide her with supplies and equipment. She may stay overnight in PHCs with living quarters. A ppl-iatrician will also be assigned to the District Hospital and he will visit each PHC once every other week.

4.18 c. Mobile Training. This will be done in the field by one mobile District Family Planning Training Team for each District. Field training and supervision has two advantages:

i. it is more relevant to local conditions; and ii. all workers are trained together and learn to work as a team.

These new teams will be the field training unit of the RFPTC and will be responsible to its Director. Each team could consist of one doctor, one nurse, one health-educator social scientist, and one statistician. It will be responsible for on-the-job training, retraining and supervision of extension educators, FPHAs, LHVs, ANMs, FWWs, etc. at the PHC and subcenter level. The team will spend 1-2 weeks at the PHC level, covering the District in 9-12 months; it will then revisit the PHCs regularly for supervision. Each team will need transportation; living quarters in about two PHCs per District should also be provided.

4.19 d. Communication. The following additional measures are recommended:

i. Group Motivation for the Greater Involvement of Leaders. Since the success of family planning depends critically on the involvement of opinion leaders -- village leaders, Panchayat Chairman, Mayors, Block Development Officers -- greater efforts should be made to enlist their support. Suggested possibilities are

1. Orientation Courses and Fairs. This would consist of orientation courses once every year for leaders at the Block, District and Divisional levels. In the case of local leaders, motivation could take the form of assembling them in groups in the same kind of carnival atmosphere that attracts them to local fairs and markets. Transportation as well as food and lodging should be provided and they should be addressed by political and religious leaders. Each such fair lasting about two days could cover about 500 villages, so that 3 or 4 fairs every year would cover the whole district. They should be timed to precede camps in particular areas.

2. Incentives. Some form of financial benefit to village leaders or Panchayat Chairmen could be tried to determine whether this would improve performance. The benefit would be related to the number of camps held in a particular area or the results of these camps.

ii. Face-to-Face Motivation. Incentives to acceptors who refer other patients could be tried. A satisfied customer is a program's best motivator. This is especially so in the closely-knit life of the Indian village and family. -24-

4.20 e. Organization. The coordination of the rural postpartum will be the responsibility program of the DMOH, the District Civil Surgeon and the District Women's Hospital Superintendent. The unit will be responsible for: i. coordinating the activities of all units;

ii. ensuring a high level of training and supervision; and iii. collecting the statistical information and collating it in the form of a monthly report.

E. BASIC ANM AND DAI TRAINING 4.21 The previous sections have outlined several approaches on the basis of the existing limited resources of personnel. Concurrently mentation with the imple- of these approaches, measures should be taken to remove bottlenecks. existing In particular, the shortage of ANMs is a matter of serious concern. She is the key field worker in MCH and family planning. In theory she is responsible for antenatal care, labor and delivery, postnatal care, and family planning motivation for a population of 10,000. Her training consists of two years of basic hospital nursing and midwifery practice, after 8-10 years of schooling. In reality, she is a multi-purpose health worker catering not only to MCH needs, but also to treating minor ailments, and maintaining a register of couples eligible for family planning and other records. These statistical duties require about 25% of her time. Additionally, travel on foot requires another 25%. Accordingly, she has only half the time to provide the needed MCH and family planning services. In practice, due to weather, road conditions, and insecurity at night the ANM limits her activity to an area immediately surrounding the subcenter which has an average population of 3,000-5,000. An ANM cannot possibly deal with a larger population. Even the Government of if India pattern of 1 ANM per 10,000 population were fully implemented, not more than half of rural women would have access to an ANN. In Mysore, the ratio is currently 1 AN4 per 7,000 and is expected to improve. In U.P., the ratio is about 1 ANM per 45,000 population and the situation is not improving. The latter State recognizes this difficulty and trains FWWs and indigenous dais to replace ANMs.

4.22 A survey of ANM training programs of the Ministry of Health's Training Division (April, 1970) revealed that the quality of training is also deficient. There was less than full enrollment, inadequate stipends (40-50 rupees month is insufficient per for basic nutritional needs), hostel accommodation, teaching staff and teaching aids. While the curriculum developed by the Nursing Council is adequate, in practice training in rural field work and family planning training is weak or non-existent. Finally, there is insufficient supervision during training. Teachers themselves are not lacking in number only but are inadequately motivated towards family planning public health. and

4.23 A mere increase in the number of such graduates would only marginally benefit the MCH and family planning efforts. Indeed, both could by a large be hindered number of poorly motivated, poorly selected and inadequately Eiained women. Thus it is essential to start now improving the quality of -25-

such personnel, though this is both difficult and will bear fruit only over the long run. The mission therefore recommends the following:

a. Better selection of candidates through aptitude and other testing procedures.

b. Improvement of trainers by increasing their number and quality.

c. Increasing the stipends 6f students to a minimum of 90-100 rupees per month.

d. Continuing on-the-job training and supervision by better qualified LHVs and nurses.

e. Incentive payments to ANMs for each pregnant woman given care and incentive payments for family planning motivational work and follow-up work. f. Institute a system of promotion for the best ANMs to supervise other ANMs and dais.

g. In the case of U.P., a reorganized training program for dais should be implemented in Intensive Districts so that a ratio of one per 5,000 population is reached. This should include adequate selection of candidates and sufficient stipends during training (about 75 rupees per month). The training program would be on a full time basis for 10-12 weeks at the local ANM training school. Continued on-the-job training by ANM supervisors and LHVs should be part of the program. Trained dais should be given an adequate salary supplemented by incentives for MCH care and family planning motivation. The following salary-incentive scales are recommended.

Training Family Planning Stipend (IUD and Depot Holders (Rs/month) Salary MCH terilization) (Condoms)

ANM 90-100 8 Rs per 5Rs per 5 paise per delivery acceptor 3 pieces

Dais 75 90-150 6Rs per 5Rs per 5 paise per delivery acceptor 3 pieces

1/ Including at least 2 antenatal visits, labor and delivery, and 3 postnatal visits.

F. THE POPULATION CENTERS

4,.24 Objectives. Previous sections outlined the proposals of the mission for improving the delivery of family planning services. Those recommendations were based on what appeared to be reasonable to the mission but with no -26- assurance that these measures would resolve the present difficulties. It is therefore important to evaluate how effective these recommendations will be in practice and to determine the reason for their success or failure. This continuous evaluation, leading to further recommendation for change in the most basic part of the project. The Population Centers were conceived is response to the need for orderly change. Their principal objective is to analyse performance in the project areas, and to frame specific suggestions for improving this performance on a continuous and systematic basis. The Center is not conceived of as a passive reviewing agency. It is therefore essential that the organization of each Center be such that its recommendations for change can be quickly and effectively implemented.

Functions

4.25 These relate to (a) management-information and evaluation and (b) training. A separate Division within the Center would be responsible for each group. The respective functions of each Division are summarized below.

4.26 a, Management-Information and Evaluation, This system is discussed in detail in Annex 5. The following are its main functions:

i. Appraise critically the present evaluation system, in close cooperation with the State Demographic and Evaluation Cells. The accurancy, analysis and flow of existing records should be improved.

ii. Redesign the reporting system at various levels to improve supervision, inspection, and evaluation and research. This will reduce the complexity and inefficiency of the existing system.

iii. Integrate the collection and analysis of performance and cost data at all levels. This will be part of the redesigning of the system and will require the revision of existing forms and training for maintaining the data.

iv. Plan and implement studies

(a) on the basis of existing data (for example which are the workers that are most effective, what are the characteristics of acceptors, etc.); and

(b) that need additional data (for example, what happens to IUD acceptors. If such a study shows high continuation then program efforts can be concentrated on new acceptors rather than follow-up).

v. Undertake studies on the structure of demand for family planning services;

vi. Analyse the reproductive histories of the general population of child-bearing age and not just the minority reached by the program; and estimate the demographic parameters of the project areas.

vii. Disseminate ideas through the publication of regular reports. These should flow upwards to the State and Governments of India as well as downward to all levels of personnel engaged in the project areas; and -27-

viii. Train and retrain evaluation personnel such as district level statisticians and block level computors. Training curricula will be devoted primarily to the introduction of new techniques and methodology and should involve all concerned with the implementation of new programs in project areas. This will involve the creation of mobile training teams in addition to static facilities provided at the Ceniter. These supervisory teams should frequently tour to observe how different types of personnel and units are operating. There should also be regular seminars of staff, at various program levels, to hear their problems and inform them of the Center's activities.

4.27 b. Training. The functions of this Division are as follows:

i. Train the service-motivation and lady doctor mobile teams.

ii. Work with and advise the RFPTC and mobile District Family Planning Training teams in the development of curricula, materials and programs.

iii. Train persons in urban areas that have not been trained, for example private doctors, and some of the hospital staff.

iv. Develop and implement evaluative techniques, in cooperation with the Evaluation Division of the Center and relevant Government agencies, for training programs and subsequent worker performance; and suggest changes in the training programs in the light of these investigations.

Organization.

4.28 a. The Governing Board should be an influential body that can secure the speedy implementation of the Center's recommendations in the project areas and transfer this experience to the whole State, where this is desirable. The State Chief Secretary or someone of similar standing should be the Chairman of the Board. Other members should include key administrators and politicians, such as those presently at the State Implementation Committee, and two representatives from the Government of India -- one from the Ministry of Health and the other from the Planning Commission. (The Government of India representatives need not attend all its meetings). The Center must have the administrative and financial control necessary to function effectively. The Center's budget must be drawn upon flexibly. Delays in staffing and procurement would thus be avoided.

4.29 b. The Director of the Center should be of a level at least equal to that of State Director of Medical Services so that he can function effectively. His deputy could be ranked as an Assistant to the State Family Planning Officer with responsibility for program implementation in the project areas. The SFPO could be involved in the Center through an ex-officio appointment.

4.30 c. The Center should have financial and technical control, under well defined limits, in the project areas. Administrative control would be with the SFPO. -28-

4.31 The Center should be responsive to the specific information requests of the program administrators as a matter of first priority. Unless there is a close interaction between the research-evaluation side and the program operators, the ideas developed by the Center will be unutilized, and in time will cease to be developed. Such interaction, is facilitated by the joint appointments in the Center and State Administration. It would also be helped by:

i. accommodating the State Demographic and Evaluation Cell and the Urban Council in the same complex of buildings as that of the Center. The Center should provide logistical support to these units (e.g. data processing) and the same persons should do work for the Center and the other groups; and

ii. requiring the Center by charter to issue a regular report to the Central Government and the Planning Commission on Recent Progress and Plans for the Future in Population and Family Planning.

4.32 Personnel. The Center should have a staff of significant size (about fifty) to reach its full potential. This includes a Director, Deputy Director, and four to six junior staff as program directors. A cadre of research supar-- visors (about 10) will also be required to undertake base-line surveys and to train temporary staff for this purpose. The Training Division of the Center should have a staff of about ten persons.

4.33 Advisory Service. Two outstanding persons - one senior with status and experience and one junior but with experience - are needed. At least one should have experience in survey work in developing countries, in relation to a population program. Short-term consultants who are specialists in sampling, communications, computer work, etc., will be needed. The senior advisor, while sympathetic to research, should be familiar with program operations. The junior advisor will be responsible for the research side.

4.34 Operating expenditures for the Center cannot be accurately estimated until the staffing pattern is established more exactly. Rough operating costs are estimated at Rs 500,000 equivalent per year.

G. PHYSICAL FACILITIES AND EQUIPMENT

4.35 The project includes the following facilities:

1. In Lucknow Urban and Bangalore City.

a. Additional Delivery Beds. Four hundred additional maternity beds will be constructed in Lucknow and 160 beds in Bangalore so that more deliveries can be institutionalized for an effective postpartum program This is composed of:

i. a new 100-bed maternity hospital and 10 additional maternity homes with 30 beds each in Lucknow; and

ii. a new 100-bed maternity hospital and the addition of 10 beds in each of six urban maternity homes in Bangalore City. -29-

On the basis of 30 deliveries per bed per year (women stay in hospitals 10-12 days after delivery) these extra beds would serve an additional population of 300,000 in Lucknow and 120,000 in Bangalore. This is less than the population presently not receiving this service. Further- more, the urban population is expected to grow as a result of natural increase and migration to the cities. This expansion of facilities is particularly modestfor Lucknow, where 70% of deliveries do not occur in institutions, and where maternity hospitals are overcrowded.

b. Family Planning Clinics. Fourteen Urban Family Welfare Centers will be constructed and renovated -- 6 in Lucknow and 8 in Bangalore. Family planning services are provided in the existing centers but they are inadequate.

In addition to the above the project will include physical facilities located in Lucknow and Bangalore and serving the whole project area. These facilities are the two Population Centers, two RFPTCs and five of the ANM Schools. Two of these ANMs Schools would be attached to the two new maternity hospitals, while the three others - two in Lucknow and one in Bangalore - would be attached to existing hospitals.

2. In All Other Areas. Outside Lucknow and Bangalore City, facilities and equipment would be constructed according to the Government of India pattern. The project also includes facailities that are not in tiie family planning budget -- for example, buildings for administration. The following is the list of all facilities:

a. District Family Planning Bureaus. Existing buildings are inadequate. One such building would be required in each of nine Districts (excluding Bangalore Rural).

b. Maternity-Sterilization Wards (20-30 beds per ward). These would be added to District Hospitals for the increase in institutional deliveries, postpartum education and sterilization operations. An operating room would be added where necessary.

c. Primary Health Centers. These comprise a dispensary, a family planning clinic and living quarters for staff both under health and family planning. The Government of India pattern sanctions 1 unit per Block of 80,000 - 10,000 population. Most of these, in particular living quarters for staff have not been built. The number of the various units comprising a PHC included in the project is as follows. t7he location of each of these units is given in Annex 8).

U.P. Mysore Total

Dispensary 39 3 42

Staff Quarters (Health) 54 25 79

Family Planning Main Center 82 73 155 Staff Quarters (Family Planning) 86 73 159 -30-

d. Subcenters. These are sanctioned at the rate of 1/10,000 population but few are actually constructed. The project includes a total of 1,325 subcenters -- 508 in Mysore and 817 in U.P. The number of subcenters to be constructed in each District is given in Annex 6. The location has yet to be determined.

e. Facilities for ANM Training. The project includes:

i. The building of 14 ANM schools -- 5 in Lucknow and Bangalore City and 9 in the other Districts. The latter are attached to maternity hospitals for training. These schools would include hostel accommodation, and equipment.

ii. Living quarters in PHCs near the schools for rural health training. The precise location of these quarters has still be be selected. These living quarters could also be used by mobile teams (service-motivation or lady doctors) when not occupied by students.

iii. Expand the District Hospitals maternity sections to allow a larger increased intake of studies in ANM schools.

3. Additional Facilities in Intensive Districts. These are additional to the Government of India pattern and to the facilities included in other rural Districts. They consist of:

a. Maternity Wings (15-20 beds each) in 4-6 PHCs per District close to the District Hospital. These would increase the number of institutional deliveries and facilitate the task of family planning education and follow-up. Even with these additional beds, however, more than half the deliveries would not be institutional deliveries. The PHCs where these wings would be added have to be identified.

b. Living Quarters in PHCs. In 4 PHCs per District, living quarters would be added for the mobile service-motivation and lady doctor teams. These PHCs should be well distributed over the whole District and have yet to be identified.

c. Dais Subcenters. Nine hundred centers would be added in the two Intensive Districts of U.P. They would be slightly smaller than the present ANM subcenters. The design and location of these subcenters has to be determined.

H. COSTS

4.36 Total costs of the project are estimated to be Rs 113 million (US$ 15.1 million). The breakdown of this total is shown in the following table. The direct foreign exchange component is estimated to be Rs 7.5 million (US$ 1.0 million) for technical assistance. To this should be added specialized medical equipment whose cost is minor, but which has not yet been estimated. Annex 9 gives further details on the breakdown of these estimates and their distribution between U.P. and Mysore. The detailed phasing of these expenditures has -31-

yet to be determined. An approximate phasing is as follows - Rs 17 million (US$ 2.26 million) in the first year, Rs 34 million (US$ 4.5 million) in each of the two subsequent years, Rs 17 million (US$ 2.26 million) in the fourth year, and Rs 11 million (US$ 1.5 million) in the last year.

ESTIMATED COSTS OF THE PROJECT (in 1970 constant prices) Rs(OOO's) US$(000's) I. Construction and Equipment

A. Urban Areas (Lucknow Urban and Bangalore City

1. Population Centers 3,000 400 2. Maternity Hospitals with ANM Schools 6,000 800 3. Maternity Homes 5,100 680 4. Urban Family Welfare Centers 1,050 140 5. Regional FP Training Centers 1,000 133 6. ANM Schools 1,200 160

Subtotal 17,350 2,313

B. Rural Areas

7. Administrative Buildings 6,750 900 8. Maternity-sterilization Wards in District Hospitals 6,000 800 9. ANM Schools 3,600 480 10. PHC and FP Centers (Government of India 22,345 2,979 11. Additional maternity wing for PHC 4,000 533 12. Subcenters (Government of India pattern) 19,875 2,650 13. Additional Dai Subcenters 9,000 1,200 14. Vehicles 2,790 372

Subtotal 74,360 9,915

Total 91,710 12,228

II. Contingencies (15% of I.) 13,757 1,834

III. Technical Assistance 7,500 1,000

Total 112,967 15,062 -32-

4.37 Additional recurring expenditures are estimated to reach a level of Rs 5.3 million (US$ 0.71 million) per year. These are mainly salaries of posts not presently in the Government of India pattern. They exclude the remuneration of foreign advisors. Annual expenditures will fall short of this in the first two years of the project. Thus over the five year period total additional recurring expenditures are tentatively estimated to be Rs 18.6 million (US$ 3.6 million). Other expenditures are in the Government of India pattern, but because all sanctioned staff should be in position in the project area, this will mean that expenditures in the project Districts will increase. Annex 10 gives further details on the additional recurring expenditures and their distribution between U.P. and Mysore.

4.38 About 59% of the total costs (Rs 62 million or US$ 8.3 million) of the project are for U.P. and 41% Rs 43 million or US$ 5.7 million) are for Mysore. The same proportions apply to the additional recurring expenditures generated by the project. The following is a summary of the respective figures:

U.P. Mysore Total Rs US$ Rs US$ Rs US$

1. Construction and equipment 62 8.3 43 5.7 105 14.0 including contingencies

2. Additional Operating Expenditures 11 1.5 7 0.9 18 2.4 over first five years

Total 73 9.8 50 6.6 123 16.4

4.39 Replicability

A concern of the Bank and of the Government has been that whatever is proposed in the project should be replicable , that is, that facilities, personnel and services should be provided on a scale that can ultimately be repeated in other parts of India where conditions are similar in relevant respects. There is much in the proposed project which is of an exploratory nature, and therefore only those aspects of the project which prove particularly effective would in fact be subject to replication elsewhere. The project's costs for facilities and manpower do not therefore form a basis for calculating what such a program would cost on an India-wide basis. Further there is a major information and research component in the project, which should provide results of value to the family planning program in general; this research and information effort is clearly on a greater scale than would be considered necessary for every State capital in India. Subject to such considerations, it is believed that the project does provide for replicability in the sense stated above."

November 27, 1970 INDIA ORGANIZATIONAL CHART OF FAMILY PLANNING ACTIVITIES AT THE CENTER

FINANCE MINISTER MINISTER OF HEALTH AND FAMILY PLANNING AND WORKS, HOUSING AND URBAN DEVELOPMENT

MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY PLANNING AND WORKS,HOUSING & URBAN DEVELOPMENT

MINISTER OF STATE IN THE MINISTRY OF HOME AFFAIRSAND MINISTER OF STATEDEPARTMENTS OF ELECTRONICSAND SCIENTIFIC AND INDUSTRIAL RESEARCH.

MINISTER OF STATE IN THE MINISTRY OF LAW AND IN THE DEPARTMENTOF SOCIAL WELFARE

MINISTER OF STATE IN THE MINISTRY OF FINANCE

CENTRALFAMILY PLANNING COUNCIL MINISTRY OF HEALTHAND FAMILY PLANNING CENTRALFAMILY PLANNING INSTITUTE AND WORKS,HOUSING AND URBANDEVELOPMENT MINISTER FOR HEALTH, DEMOGRAPHIC AND COMMUNICATION FAMILY PLANNING,WORKS - CHAIRMAN MINISTER ACTION RESEARCHCOMMITTEE HOUSING AND URBAN ------MINISTER OF STATEFOR HEALTH ------DEVELOPMENT I AND FAMILY PLANNING BIO-MEDICAL RESEARCHCOMMITTEE SECRETARYFOR HEALTHAND (I.C.M.R.) MINISTER OF STATEFOR FAMILY PLANNING HEALTHAND FAMILY -VICE INTERNATIONAL INSTITUTEFOR PLANNING CHAIRMAN POPULATION STUDIES

STATEHEALTH MINISTERS - MEMBERS

REPRESENTATIVESOF ALL INDIA ORGANIZATIONS AND OTHERDEPARTMENTS -MEMBERS EXECUTIVEBOARD CONCERNED WITH FAMILY PLANNING WORK D E P A R T M E N T O F F A M I L Y P L A N N I N G SERTR ORHAT N SECRETARYFOR HEALTHAND FAMILY PLANNING - CHAIRMAN

JOINT SECRETARY (MINISTEROF FINANCE)

COMMISSIONER (FAMILY PLANNING SECRETARIALWING NIRODH MARKETING ORGANIZATION (COMMISSIONERTCHNICLING FAMILY PLANNING AND MATERNALAND CHILD HEALTH (JOINT SECRETARY) (MARKETING EXECUTIVE) AND MATERNAL AND CHILD HEi~ALTH) JOINT SECRETARY(FAMILYPLANNING) -CO NVEN ER

MATERNAL AND CHILD HEALTH PROGRESS& SERVICES TRAINING, RESEARCHAND TECHNICAL OPERATIONS SUPPLIES MASS EDUCATION AND MEDIA REGIONAL OFFICES(S) (DEPUTYCOMMISSIONER) EXTENSION EDUCATION (DEPUTYCOMMISSIONER) (ASSISTANTCONEMISSIONER) (ASSISTANTCOMMISSIONER) (REGIONAL DIRECTOR) (DEPUTYCOMMISSIONER) All POUCY, PLANNING, GRANTS > ADMINISTRATION BUDGETAND FINANCE INTELLIGENCE, EVALUATION AIDED PROGRAMS z (DEPUTYSECRETARY) (DEPUTYSECRETARY) AND RESEARCHMANAGEMENT (DIRECTOR) | (DEPUTYSECRETARY)X

IBRD- 5363

Supplies ather than conventionals, which are the responsibility of the marketing executive. INDIA ORGANIZATIONAL CHART OF FAMILY PLANNING ACTIVITIES IN A STATE

STATE CABINET COMMITTEE

UNION HEALTFH MINISTRY STATE FAMILY I DEPARTMENT OF HEALTH DEPARTMENT OF PLANNING MINISTER OF HEALTH ACTION/IMPLEMENTATION FAMILY PLANNING COUNCIL SECRETARY FOR HEALTH COMMITTEE

DIRECTORATE OF HEALTH SERVICES DIRECTOR OF HEALTH AND FAMILY PLANNING SERVICES

|REGIONAL OFFICE J|STATE FAMILY PLANNING BUREAU 1 (REGIONAL (ADDITIONAL/JOINT/DEPUTY GRANTS COMMITTEE DIRECTOR) DIRECTOR OF HEALTH SERVICES- AWARDS COMMITTEE STATE FAMILY PLANNING OFFICER)

OPERATION, PLANNING AND EDUCATION AND ADMINISTRATIVE AND TRAINING DIVISION INFORMATION DIVISION STORES DIVISION STATISTICS, DEMOGRAPHY AND ASSISTANT DIRECTOR OF MASS EDUCATION AND ADMINISTRATIVE OFFICER EVALUATION DIVISION HEALTH SERVICES COMMUNICATIONS OFFICER (FAMILY PLANNING) z AUD IT PARTY Z

IBRD - 5362 INDIA ORGANIZATIONAL CHART OF FAMILY PLANNING ACTIVITIES IN A DISTRICT

C STATEDIRECTORATE OF HEALTH SERVICESS C DIRECTOROF HEALTH SERVICESM

STATE CENER DISTRICT AION DISTRT FAMILY PLANNING BUREAUDl OF HEALTH SERVICES ADDITIONAL/JOINT/DEPUTY DIRECTOR l OF HEALTH SERVICES

CIVIL SURGEON DISTRICTHEALTH ORGANIZATION CHIEF MEDICAL OFFICER OF HEALTH

FAMILY PLANNINGP RURBAN WEALFARECENTERS DI IMPLEMENTATION -- DISTRICTFAMILY PLANNING OFFICER DISTRICT LEVEL STATESTERILIZATION U NITS

- ITHSIAS l| ADMINISTPATIVE DIVISION |||EDUCATION AND INFORMATION |F| EUD OPERATIONS AND l *l DIVISIO N ll EVAWATION DIVISION l

--- i MOBILE FAMILY PL-ANNING MBLE FAMILY PLANNING STORES ADMIN ISTRATIO N ACCO UNTS l U NITS (SERVICES) bdT(STERI LIZATIO N) l EVAWATIO N Tx

| RURALFAMILY PLANNING | WELFARECENTERSl

BLOCK LEVEL|Z

SUBCENTERS

IBRD- 5361 ACTION/ IMPLEMENTATION COMMITTEES

I. AT STATE LEVEL 1II. AT DISTRICT LEVEL III. AT BLOCK LEVEL

Chief Secretary Chairman Collector Chairman Chairman or President of Chairman Panchayat Samiti, Union Development Chairman, Zila Parishad or Anchalik Panchayat Commissioner Member Civil Surgeon ) Elected representative Health Secretary Member ) of the Samiti Member District Planning Officer) Director of M & HS Member ) Seven Block Medical Officer Member District Health Officer ) members Other important ) FP Extension workers Members State officers Members Other important ) district officers and ) Block Development Officer Secretary Regional Director Member non-officials )

Joint Director District FP Officer Secretary (Family Planning) Secretary ANNEX 5

MANAGEMENT-INFORMATION AND EVALUATION SYSTEM (MIES)

A. INTRODUCTION

B. THE PRESENT MIES SYSTEM

Managerial Pattern and Responsibilities The Central Department The State and Union Territory Bureau The District Bureau

The Information System

The Evaluation System

The Measurement of Fertility

C. LIMITATIONS OF THE SYSTEM AND RECOMMENDATIONS

Limitations of the System Supply or Demand Recommendations

D. THE POPULATION CENTER

E. TRAINING REQUIREMENTS ANNEX 5 Page 1 of 27 pages

THE MANAGEMENT-INFORMATION AND EVALUATION SYSTEM

A. INTRODUCTION

1. This Annex discusses the following:

(i) The type of Management-Information and Evaluation System (MIES) which exists in India at the Central, State, District and Block levels in general and particularly with reference to the two States of Mysore and U.P.

(ii) The strengths and limitations of the existing system.

(iii) The changes and/or experimentations needed with reference to future efforts in the type of data to be collected, methodol- ogical problems, managerial deficiencies, and rationalization and standardization of records.

(iv) The proposed mechanism needed to strengthen the system in the project areas.

(v) The training requirements of the system and the time dimension of such institution building.

(vi) The Population Center: its set-up, role, staffing pattern, and some suggested research areas.

(vii) The strength of advisory support for the Center.

2. There are, however, various aspects and dimensions that must be considered when designing a general system of MIES for a family planning program. Our discussion of the Indian system and proposals for the project will focus on the following areas:

(a) The Organizational Structure of the Family Planning Program

This includes the financial and administrative set-up as related to managerial and evaluative efforts, the relation of the program to other agencies, the existence of managerial and analytical capabilities, the expected time lag on the information flows and the existence of political and other constraints that delay or prevent the implementation of decisions based on the system's findings and analysis.

(b) Input-Output Analysis or 'Supply' Analysis

This includes monitoring the various inputs to the program (e.g. personnel, supplies, transport, etc.) as related to ANNEX 5. Page 2 of 27 pages

intermediate outputs (e.g. contraceptive services) and to final output (i.e. birth prevented). The latter being done partly through the system's internal flow of data but supplemented by special survey findings and other sources of data. Supply analysis should also include the monitoring of other sources of supplies from private and commercial channels.

The study of demand should go beyond assessing the level of potential or latent demand (e.g. what kind of people practice and do not practice contraception). More specifically, it should examine more critically the structural relations underlying the demand to find ways and means to increase such demand. This clearly will need careful studies of the effects of education, motivation and incentives; as well as changes in institutions, rules, regulations, and taxations that may affect fertility behavior. This type of analysis is, by its very nature, inter-disciplinary and needs the cooperation and coordination of various and different public and private agencies.

(d) Cost Considerations of Such a MIES

Whether more emphasis will be given to cost-supply analysis relative to demand analysis will depend on the efficiency of the system on the one hand, and on the strength of the demand on the other hand. In India, both sides seem to be equally important and both of them need further strengthening.

B. THE PRESENT MIES SYSTEM

3. Good program management at various levels (i.e. Center, State, and District) requires: (a) adequate capable managers; (b) a good program information system; (c) analytical capability that is able to utilize the information system to answer various questions raised by program managers and to raise new questions themselves; (d) ability to implement decisions; and (e) having a chance of success since otherwise its conclusions will have little weight.

Managerial Pattern and Responsibilities

4. The responsibilities of program managers are determined in part by their place in the organizational structure and in part by the constitutional, legal and policy framework within which the program operates. Family Planning in India is a State subject, but the India Family Planning Program is a centrally sponsored scheme. Basically there are three main adniinistrative units in the Program: (1) the Central Department of Family Planning; (2) the State ANNEX 5 Page 3 of 27 pages

and Union Territory Family Planning Bureaus; and (3) the District Family Planning Bureaus. To evaluate management-information needs at the various levels, it is important to examine the major responsibilities assigned to the offices and sections of these three units, the interrelations and inter- actions among these units and the impact of the level of efficiency of one unit on the functions of the other units and the program as a whole.

5. The Central Department is the planner and financial controller of the family planning program. It has more flexibility (and responsibility) in managing budgeted funds than most other Departments. More specifically, the major responsibilities assigned to the Central Department of family planning are to:

(a) formulate and coordinate policy for family planning and maternal and child health (MCH);

(b) coordinate the development of five year plans for family planning and MCH;

(d) make decisions concerning the introduction of new contraceptive methods into the program;

(e) control supply and transport to a large extent;

(f) control the strategy, design, content, production, research and evaluation of mass communication and educational projects;

(g) establish program objectives (targets);

(h) coordinate the flow of external aid;

(i) promote the sale of condoms (nirodh) through private distribution channels;

(j) coordinate and participate directly in the operation of (1) programs addressed to the 10,000,000 employees of Central Government organizations; and (2) the full range of field programs in Union territories, with a total population of some 14 million;

(k) keep the Cabinet, Parliament, and the public informed on the status or the program; and

(1) coordinate demographic, communication and biomedical research. ANNEX 5 Page 4 of 27 pages

6. These various responsibilities, combined with the growth of the total family planning enterprise have created new and complex problems of management. In late 1969, provision was made to allow for the addition of a Program Analysis and Research Information Unit at the Center (PARI). The purpose of creating the PARI unit in the Department of Family Planning is to:

(a) build a stronger link between the Department and the family planning research institutes;

(b) bring a deeper analytic capability into the Department; and

7. The way in which PARI develops is relevant to the activities that the Population Centers of the project may undertake. It is envisaged that the first set of activities in which PARI may be involved will include the following:

(a) examine ways to integrate program data;

(b) redesign the reporting system;

(d) develop input-output co-efficients for the program;

(e) develop capacity-use, efficiency and cost-effectiveness measures that can be integrated into the system;

(f) project the number of births required to be prevented through family planning; and

(g) develop an analytic framework for projecting the program's capacity to prevent births for use during 1971-72 annual plan and budget development process.

8. Many of these activities (e.g. the first three) are similar to the project objectives. However, the frame of reference of these studies will be the whole of India, rather than a limited geographical area such as the Bank project. This may lead to developments along different lines, but it is useful to coordinate efforts at an early stage to gain better understanding and cooperation in the long run.

9. Center personnel, in addition to that of the Central Department of Family Planning, are posted also at four of the five Central Training Institutes, namely, the Central Family Planning Institute, New Delhi; All-India Institute of Hygiene and Public Health, Calcutta; and the Bombay Training Institute. The Gandhigram training institute, although autonomous, is partly funded by a Central subsidy. ANNEX 5 Page 5 of 27 pages

10. Furthermore, there are six regional directors and their staffs wqho are supported by 16 centrally-staffed Family Planning Field units. The staff of the regional director could be strengthened; the utility of their role depends on the personality of the Director and his success in establishing liaison with the State Government.

The State and Union Territory Family Planning Bureaus

11. Family planning is a State subject. Thus, although family planning is centrally sponsored and financed, the States prepare and forward budget proposals and have the primary responsibilities for program implementation and use of funds. Also, the State Governments can, and often do: (a) decline Central grants-in-aid; (b) refuse to expand service capacity as desired by the Center; and (c) introduce (with agreement from the Center) minor deviations fro-m the Central pattern. Furthermore, most facilities constructed become the property of the State and most field personnel are State Government employees.

12. In general, the main responsibilities of the State Family Planning Bureau (SFPB) are:

(a) overall supervision of District efforts and provision of general leadership and directions to all program operations;

(b) financial and operational control over field activities;

(d) administering and executing training of the lower echelon workers;

(e) administering mass communication activities;

(f) administering transport; and

(g) administering the postpartum program.

13. At the State level the program is managed by the State Bureaus headed by a State Family Planning Officer and responsible -to the Director of Health and Family Planning. There are two divisions in the State Family Planning Bureau: (a) Operation Division, headed by an assistant director. This division includes an Education and Information unit; and a Planning field operation, Evaluation and Training unit; and (b) Administrative and Stores Division headed by an administrative officer. ANNEX 5 Page 6 of 27 pages

14. To strengthen the State evaluation and analytical capabilities, an expanded demographic and evaluation cell within the SFPB has been sanctioned in 1969. Recruitment of a demographer, a social scientist, a statistician, a statistical investigator, a statistical assistant and other supporting staff started in 1970. Most of the staff in the Lucknow unit are in position and recruitment of the demographer was done in August 1970; but the unit needs space, facilities and training.

15. To speed the decision-making process and for effective interdepartmental coordination and communication, a State Implementation Committee has been formed. The Committee, headed by the Chief Secretary of the State, includes, as members, the Development Commissioner, the Health Secretary, and other important State officers. The main utility of the Committee is that any decisions that need cooperation from departments other than Health could be approved and implemented. The full potential of the Committee, however, is yet to be reached. Its meetings are infrequent and the follow- up of decisions taken seems to be difficult.

The District Family Planning Bureau

16. The District Family Planning Bureau (DFPB) is the key operational unit in the program infrastructure. Administration of actual field operations is, as a rule, delegated by the State to District Family Planning Bureaus. It is obvious that the District Bureau has to supervise an extremely large number and wide range of types of facilities and programs.

17. In general, the main responsibilities of the DFPB are:

(a) supervise and manage all program activities in the field, i.e. (1) manage the rural family planning organization at the 15-25 Primary Health Centers in the District, and (2) supervise and administer the urban family planning activities through its urban unit. This function includes the management of personnel, information, records, material and other resources;

(b) organize the efforts of governmental organizations in the District;

(d) stimulate the active participation of industrial employers, private physicians and the numerous practioners of indigenous medicine. This implies the ability to draw upon relevant governmental and community resources which can, if successful, greatly influence program results.

18. To a large extent, the quality of the program at the block and village level, including maintenance and use of records, is affected by the nature of ANNEX 5 Page 7 of 27 pages

supervision froam the district. However, as will be discussed below, a critical point for management improvement is at the Dlistrict level. The District Family Planning Bureau is managed by the District Family Planning Officer who is a medical doctor. There are three divisions in the Bureau: (a) the Administrative division, (b) Education and Information division, and (c) Field Operation and Evaluation division. The full burden of administrative responsibilities lies on the shoulders of the DFPO. An administrative officer is sanctioned but was not in position in the Districts visited in U.P. and Mysore. The rank and training of such an administrative officer are essential qualities to assure him an effective administrative role in the District Bureau.

19. The District Field Operation and Evaluation Division consists of one statistical investigator and two field and evaluation workers (one male and one female). The job of the statistical investigator is basically a clerical one: collecting the routine performance data from the various health centers, checking the returns, correcting and adding, and filing summary forms to the State Bureau. No analysis of the data is done, no preparation of internal performance reports is being done, and almost no systematic field checking of the accuracy of the data collected is being done. This is apparently the case partly because of the lack of an adequate analytical capability in the District Bureau and partly because some of these management functions that require this type of data and its analysis are not perceived by the DFPO either as part of his job description or within his authority.

20. It is important to note, however, that the responsibilities of the District program manager have become much greater and complex due to: the shift from a passive to an active program strategy through the single- purpose-worker-type extension approach. This E done essentially by using a large cadre of Family Planning Health Assistants (FPHA) in the rural and urban areas, one for each 20,000 people. These workers conduct a house-to- house motivational and educational effort directed towards all eligible couples in their jurisdiction. This community extension approach added a new load on the administrative responsibility of the District Family Planning Officer because of the involvement of the community. This added load did not, however, have a parallel added analytical capability in the DFPB.

The Information Mechanism

21. As mentioned, good program management, in its various levels requires, among other things, adequate program information; but such information comes through both an adequate program data-reporting network and systematic analysis of the data. For example, in order to handle their various responsibilities, program managers, given their administrative constraints, need to know:

(a) What is happening under their jurisdiction; (b) Why things are happening as they are; (c) How to improve things; and (d) How to implement changes quickly. ANNEX 5 Page 8 of 27 pages

We shall examine the type, quality and regularity of service statistics collected in the system.

22. A detailed set of records, registers and returns that bring out the performance of each operational unit has been worked out by the Center as a standard format. Utilizing the various records and registers kept at the peripheral levels, standardized reporting pro forma has been prepared for collection and transmission of monthly data on the various efforts made and performance achieved at the different levels from the black to the Center. The states collect the information from District Bureaus which in turn obtain the data from the block and so on down the line to the peripheral workers. The Demographic Cells are required to undertake major responsibilities in rationalizing and streamlining the service statistics system. A Statistical Assistant is provided in the District Bureau and a computor (compilation clerk) at the block level.

23. Each peripheral unit (i.e., any unit offering family planning services to the people including clinical work, distribution of conventional contraceptives, educational and motivational work for family planning, for example, Rural and Urban Family Welfare Planning Centers, sub-centers, clinics, hospitals, private medical practitioners, mobile and static units, central family planning corps, central family planning field units etc.) is required to maintain a record of such activities in one or more of the following 'primary registers' according to the scope of their individual activities:

(a) daily case register; (b) conventional contraceptive couple register; (c) conventional contraception stock register; (d) IUD register; (e) sterilization register; and (f) register for community education and training activities.

24. These registers are the basis for the monthly reports originating from the peripheral units. Many of these registers are not well maintained. This is mainly because of lack of supervision, lack of supplies of forms and/or stationery, and lack of training and motivation.

25. Besides these basic registers, there are two other types of register required to be maintained for follow-up purposes and motivational work:

(a) individual case cards for male sterilization, female sterilization and IUD insertions; and

(b) eligible couple register to be kept by the Family Planning Health Assistant for his motivational and referral work.

The multiplicity of record-keeping at the peripheral level creates some mis- allocation of time-use and, coupled with inadequate supervision and necessary supplies, some inefficiency. ANNEX 5 Page 9 of 27 pages

26. All peripheral units have to report their data on a monthly basis to the main Family Welfare Planning Center at the Primary Health Center where it is aggregated for all peripheral units in that area and submitted to the District Family Planning Bureau. In the District, the data are aggregated and submitted to the State and once more aggregated and submitted to the Center. Aggregated data by area of jurisdiction (i.e. Primary Health Center, District, State) are presented separately for the performance of Family Welfare Planning Centers, hospitals and clinics, camps, mobile units and private medical practitioners, and by whether they are state- controlled, local bodies, or voluntary organizations.

27. The pro formae of the returns from all levels are designed uniformly and have four basic types:

(a) Form P: Monthly report on the number of service units and their performance. They include the following: P1 - for sterilization and IUD;

P2 - for distribution of conventional contraceptives; and

P3 - combined form for sterilization, IUD, and conventional contraceptives by single peripheral units-

(b) Form E: Monthly report on activities for Community Education.

T2 - for orientation training.

(d) Form S: Quarterly report on staff, equipment and transportation.

28. The scheduling of the flow of all returns is given in a tabular form in the following table. There are usually, as expected in such a large operation, some delays in handling and submission of returns. Control registers, kept at every receiving unit, are designed to detect such delays. Also, there are supposed to be nonthly regular meetings at the District level with personnel from the PHC's to review and discuss various administrative problems as related to the reports submitted.

29. The SFPB issues a monthly memorandum to all DFPB giving them ranking by performance relative to target and encourages those Districts with high achievement. The statements also in23ude queries to Districts low in the ranking. Ranking, however, is done merely with regard to performance without taking cost and utilization into account.

30. There is a clear dichotomy in the reporting system between cost data and performance data. This dichotomy persists from the District level where cost and capacity utilization data are collected separately from performance data. The statistical assistant at the DFPB is only responsible for performance ANNEX 5 Page 10 of 27 pages

Summary Statement of Reports Sent by Units of Various Levels

Last Day of Month Return From Form Treguency Destination for Sending l.(a) Rural areas - Contra- ceptive depot holders/ distribution center P3 Monthly Sub-center 3rd

(b) UJrban areas Contra- ceptive depot holders/ distribution center/ hospitals/clinics/ private-medical practitioners P3 Monthly FWPC 6th

2. Rural areas - sub-center P3, E Monthly Main PHC 6th

3.(a) Rural areas - Main PHC P1 , P2, E Monthly DFPA 10th S Quarterly

(b) Urban areas FWPC (under a City Bureau) Pl, P2, E Monthly City Bureau 8th S Quarterly "

FWPC (not under a City Bureau) P1 , P2 , E Monthly City Bureau 10th S Quarterly " "

4. City Bureau P1, P2, E Monthly DFPB 10th S Quarterly "

5. DFPB P1, P2, E Monthly (i) SFPB 15th S Quarterly copy to: (ii) FP Commis- sioner (E&I Section)

6. State Training Centers T1 , T Monthly (i) SFPB 15th s copies to: (ii) Regional Directors (iii)FP Commis- sioner (Training Section) ANNEX 5 Page 11 of 27 pages

Last Day of Month Return From 'Form Frequency Destination for Sending

7. SFPB Pl,P2 ,E,Tl,T2 Monthly FP Commissioner 25th S Quarterly (E&I) copy to: Regional Directors, FP Commissioner (PB Section)

8. Central FP Field Ulnits T2 , E Monthly FP Commissioner 15th S Quarterly (E&I) copy to: Regional Director, FP Commissioner (Training)

9. Central FP Units T1 , T2 Monthly FP Commissioner 15th S Quarterly

10. Central FP Corps C1 , C MQithly FP Commissioner 15th Central FP Corps ANNEX 5 Page 12 of 27 pages

statistics and is not aware of other data which are the responsibility of the accountant. District Family Planning Officers do not have the opportunity of utilizing the full potential of the data they receive every month. Proper design and training could provide adequate perspective and timely information for better management and control of their activities. This situation is also true at the state level. Cost andcapacity data are prepared only in financial terms with a limited purpose. They do not correlate financial accounts with physical achievements of the various program activities.

31. It seems important to have cost data and performance statistics more closely integrated, from the peripheral units upward. The purpose is twofold: (a) to assist administrators to think in terms of cost-effectiveness; and (b) to assist program management, analysis and planning to be more effective at the various levels. This would require a redesigning of the reporting system and some revision in the pro formae. Any revisions of the reporting system must be designed to have minimal revisions in the future. Revisions will always be necessary because of the dynamic nature of the program.

The Evaluation System

32. The objectives of the evaluation efforts undertaken by the program- administration are described by the Family Planning Department as follows:

"The focus of evaluation of the family planning program at present is on the purposive assessments of impact of the program, identification of areas of success and failures and reasons thereof, and feeding back this information for modification and improvement of program implementation." 1/

33. The present evaluation effort is short of what is necessary for program development and planning. This deficiency is greater on the State level because of the following: (a) the lack of analytical capabilities that could utilize the existing potential of service statistics and supplement them with additional data; (b) the need for more integrated program statistics; and (c) some inherent limitation on the scope of evaluation within the system.

34. Internal evaluation is the major responsibility of the Department of Family Planning. The Department is responsible for developing and analyzing specific family planning program data on an All-India basis. The Department issues a monthly set of statements giving data, by State and Union Territories, on population, family planning sanctioned staff in position at State and District levels, t:he numbers of urban and rural Family Welfare Centers required and functioning, sterilization and IUD program progress, and the number of persons trained in various courses. These are the main periodic reports prepared by the Department. They are supplemented by progress reports of the

1/ System of Evaluation of Family Planning Programme, Government of India, Ministry of Health and Family Planning, Department of Family Planning, New Delhi, 1958. ANNEX 5 Page 13 of 27 pages

Regional Directors and by tour reports of the officials of the Family Planning Department. An Annual Report is also issued by the Ministry of Health which contains various details on theprogram. The SFPB issues monthly and annual reports, but not as comprehensive as those of the Center.

35. Month-to-month acceptance rates are based on the numbers transmitted and processed from the periphery to the Center and are generally restricted to the total number of acceptors of different methods of family planning. There is, however, no systematic and periodic analysis of data on different characteristics of acceptors (e.g. the interval since the last birth (open interval), parity, etc.) though such information is often collected at the peripheral level.

36. The quality and reliability of service statistics becomes the more important as a result of the recent Government of India initiative in strengthening its analytical capabilities. These recent developments include: an enlarged and functionally expanded wing in the Central Department of Family Planning and the expansion of State Demographic and Evaluation Cells. Further- more, the Planning Commission has completed its second thorough and critical internal review of the Indian program and the Ministry of Health has undertaken and completed its own review of its current program. Similar developments at the State level are, however, lagging.

37. The expanded Demographic and Evaluation Cells are assigned major responsibilities in examining and streamlining the system of service statistic and understanding supportive evaluation studies, e.g., follow-up of IUD and sterilization clients. These cells, however, need professional guidance in order to carry on some of their prescribed functions.

38. The existing organization of these expanded Demographic Cell.s in Bangalore and Lucknow are far from ideal for the following reasons:

(a) They are too low in the hierarchical structure to do independent and objective research and evaluation that may question some of the basic premises of the system.

(b) They are geared to the routine analysis of service statistics. Service statistics, however, at the present low participation rates have limited value in explaining program limitation and in giving guidelines for its management and development.

(c) They do not have adequate capabilities to conduct special studies to supplement the deficiencies of service statistics mentioned in (b) above. Thus, these efforts will be limited in scope and analytical value and, because of their low set-up in the hierarchal structure, their findings may not have much weight even within their own department. ANNEX 5 Page 14 of 27 pages

(d) A thorough evaluation of present participation rates, prediction about future participations and careful examination of ways and means to achieve program targets in the coming years will certainly require raising basic questions about possible limitations of the present system. It needs the undertaking of carefully designed basic studies with a wide range of implications in the structure of demand for family planning and its supply. Answers to these questions may have far-reaching conclusions and are beyond the capacity of the existing evaluation cells to undertake effectively.

39. These cells, however, if given adequate training and,support, could be invaluable in improving the quality of data collection in the State. This could be done through adequate supervision and training of the staff at the peripheral units and through carefully designed probability sample checking of returns in the field.

The Measurement of Fertility

40. Ultimately, the family planning program will be evaluated in terms of its impact on fertiliLy. An All-India or an All-State evaluation in these terms seems to be rather unrealistic in the India set-up at the present time. Serious efforts in this direction are needed.

The Population Census

41. The population census is one important source of data for measuring changes in population growth. The next population census in India is scheduled for 1971. The 1971 Census will include a question about current fertility. The census, however, has many deficiencies as a means of direct family planning evaluation:

(a) Estimated intercensal growth rates represent the outcome of a ten- year period of changes in fertility, mortality and net migration. The estimated growth rate becomes an average over the ten-year period and does not necessarily represent the period of evaluation.

(b) Uneven change in fertility, mortality, or migration will distort estimated growth rates for single years.

(c) Variation in census quality will introduce errors in the estimated intercensal growth rates. These errors may be greater than the expeoted short-term changes in demographic rates.

(d) The time lag is too large to give the most useful program evaluation.

(e) The census, by its very massive nature, does not include questions on family planning practice and other questions needed for evaluation. ANNEX 5 Page 15 of 27 pages

42. The 1971 Census, however, will give base-line data on current fertility and various socio-economic variables. An examination of the age distribution will also give an indirect measure of change in fertility. Also, updated and detailed maps and listings, prepared through the Census operation, are a valuable sampling frame. This information and material must be used in the project areas when designing base-line surveys.

Vital Registration

43. An adequate civil registration system would be the ideal method of keeping track of annual changes in fertility and mortality. However, in India, as in most of the world, the vital registration system is diot functioning adequately. More than half the births are not usually registered according to official statistics.

44. Acknowledging these deficiencies, the Registrar General's Office has undertaken the State Sample Registration Scheme on a State-wide probability sample basis. The Sample Registration Scheme uses a local resident (often the village school teacher) as a part-time registrar in a sample area of about 2,000 persons. In addition, a semi-independent survey is conducted every six months to supplement the registrar's reports of vital events, to update estimates of the base population, and to produce estimates of births and deaths.

45. Some estimates from the Sample Registration Scheme indicate higher vital rates (almost double) than those based on civil registration. Reporting of vital events in the Sample Scheme, however, is not complete and variation in coverage may very well overshadow any change in fertility resulting from the program. Bearing these points in mind, it is useful to have the project areas represented as units for which separate measurements are possible in the Sample Registration Scheme. This will help, if supplemented with carefully conducted independent surveys, as a continuous external evaluation tool.

46. Some innovations may be needed to improve coverage and efficiency of the Civil Registration System. Such innovations may be more effectively introduced if more stress is given to the legal aspects of civil registration. For example:

(a) More use of teachers in rural areas as part-time registrars may improve quality and quantity of returns as the Sample Registration Scheme indicated.

(b) Looked at from the legal point of view, it might be desirable to consider giving the administrative responsibility of civil registration to either the Revenue or Police Department.

47. Another aspect of vital registration which is related to family planning and needs careful consideration is the use of vital statistics at the peripheral level as an identification for eligible couples. This could be a good starting place for a rural postpartum program. It is true, in order to have estimates of births and deaths through a vital registration scheme, coverage and quality are essential. However, in order to have a highly effective postpartum program, ANNEX 5 Page 16 of 27 pages

or an eligible-couple-referral scheme, less than full coverage will be sufficient. It is possible that even a 20 to 30 percent coverage will be very effective as a reference for couples eligible for family planning services. Such an approach may replace and supplement much of the field enumeration and registration done by the FPHA.

C. LIMITATIONS OF THE SYSTEM AND RECOMMENDATIONS

Limitations of the System

48. Based on various reports and field observations, program achievement for the year 1969/70, in terms of total IUD insertions and sterilizations performed has been substantially below the 1968/69 level, and most probably the 1970/71 level will still be lower. This level of performance has many implications for the program's planned goals in the coming decade. However, the existing information and evaluation system does not give adequate answers to:

(a) tht extent and structure of such decline and low performance; (b) reasons causing such decline; (c) clues to possible corrective actions.

The system is unable to give answers to such crucial questions and prior indications of their possible occurrence - a function vital for good management - both at the State and the District levels. For example, there has been no special report from the District to the State or from the State to the Center showing concern about possible decline or analysis of the current low level of performance.

49. Our analysis of the information and evaluation system indicates that there are a variety of reasons for this decline:

(a) There is a need for managerial training for responsible administrative officers in the State and the District levels, especially the latter. Some responsibilities that are important for efficient management, e.g. the responsibility of District Officer to reallocate personnel, material and transport within the District are not clear to the District Officer. Also important is the lack of financial flexibility at the District level.

(b) There are no adequate analytic capabilities at the State and District level that give systematic evaluation of the quality of data, supervise the flow of information and its collection and do substantive analysis of the data collected.

(c) Records and reports are not designed for speedy data processing, they do not integrate cost and achievement data, and are not kept adequately at the peripheral units. This makes it difficult to conduct additional analysis or sample studies needed to supplement the existing reporting system. ANNEX 5 Page 17 of 27 pages

(d) Achievement data collected in the system refer only to participating couples. There is no built-in mechanism for follow-up reporting or studies. However, given the present low participation rates, the data will have limited use in explaining reasons for inadequate demand or in suggesting measures to improve the situation.

(e) Some of the operational functions in the peripheral level require a large input of registers and recordings which conflict with efficient operation and management. The FPHA's are required to keep couple registers and update them for their area of work. Recording of data is expensive mainly in terms of the opportunity cost of time; and most of the utility of data collected is derived from its further use. Its use could be either operational, i.e. for efficient continuous operation at the relevant unit, or could be for information and evaluation at higher levels. Data collected by the peripheral workers (e.g. ANM and FPHA may be evaluated in terms of these two functions.

Supply or Demand

50. The system of information and evaluation must be able to answer the questions concerning the reasons for short- and long-run fluctuations in performance. There are indeed a large number of factors that contribute to the functioning of a family planning program. The question of whether the important factors relate to deficiencies in the supply side of family planning services being provided or to lack of demand for such services has a practical significance. However, little has been done in this important area.

51. Several reasons are usually given on the supply side to explain the present low participation rates in rural areas; these are as follows:

(a) Medical and paramedical personnel, especially the female, do not accept employment in rural areas, and if they do they are usually less motivated than expected.

(b) Medical facilities, including reasonable accommodation, are inadequate in most rural areas.

(d) There is insufficient in-service training mainly because of the cost involved.

(e) The decline may be due to limited demand but the evaluation system gives no clues of this.

52. Several of these reasons do not exist in urban areas. However, the participation rates, although generally higher in urban areas are not as high as they should be. More important, the general decline in performance during the last and current financial years is also true in urban areas. This can be due either to a decline in the efficiency with which services are provided or ANNEX 5 Page 18 of 27 pages

to a decline of demand. With existing information, it is impossible to say which of these factors is the more important.

Recommendations

53. It must be mentioned that there is no single factor or a group of factors that could be singled out as responsible for the success of an organization. It is usually a combination of factors (their level and mix) that are responsible.

54. Data Collection and Reporting

(a) Redesigning the reporting system to facilitate its analytic purposes and to reduce its complexity. For example, the use of 'book registers' to record individual cases on the peripheral level is difficult to maintain, to supervise, and to update systematically for extended periods. Consideration should be given to a 'coupon system' or to a 'clinical record system' that includes pre-coded questions. They are simpler for coding, quick sorting and analysis. Details of such systems are given in 'A Handbook for Service Statistics in Family Planning Programs,' a publication of The Population Council.

(b) Integrating performance and cost data not only in the reporting book, but also as part of the normal managerial function of the administrative staff in the District and theState. A thorough discussion of cost effectiveness on the operational level seems essential. Extensive training and demonstration will be needed to implement such procedure.

(c) Reporting of performance statistics at the State level may include some basic client characteristics, e.g. parity and the time since last pregnancy (open interval). Such information is essential for program evaluation. The two items suggested for inclusion in a standard format of reporting are relatively easy to report and are more reliable than data on age for example.

(d) Bookkeeping at the various levels may be redesigned to give easy and efficient access for adequate supervision, inspection, and as a source for evaluation and research needs. For example, more consideration may be given to the filing system and storage facilities of these basic data at the various levels within the State.

(e) Standard reporting forms may be printed by the State Bureau and made available in adequate supply to the District and peripheral levels. ANNEX 5 Page 19 of 27 pages

55. Personnel and Training

Cf) The [District statistical investigator needs crmore training in handling the data and checking its quality. This training could be done by having a training course of 2-3 weeks in the State Bureau, followed by in-service training. Training may by the responsibility of the Demographic Cell of the State.

(g) An additional administrative-statistical officer is needed at the District level. The purpose is to relieve the DFPO of some of his routine administrative role so that he can spend more time on technical supervision, public relations, and overall planning and policy.

(h) The State Demographic and Evaluation Cell needs both guidance and training. This could be done by the staff of the suggested Population Center.

(i) More supervision is needed. Not inspection but guidance. Thus, supervisors in the area of reporting and evaluation must know the technical aspects and underlying logic of the reporting system and be able to demonstrate how to do it.

56. Vital Registration

(j) Given the reasonable spread of primary education (there are at least 1000 teachers per district), it is recommended that primary school teachers be used on a part-time basis to collect vital rates in the villages. This has been proved practical in the Sample Regis- tration Scheme. It will probably improve the quality and coverage of vital registration at a relatively low cost. The teachers, then may be used as the focal point of contact for motivational work.

(k) More emphasis should be given to the use of the existing vital registration system (with suggested improvements mentioned above) as a reference for eligible couples, and not only as a source of data to est:imate vital rates. Thus, Family Planning Health Assist- ants and other workers doing field motivational work may use the teachers' and the collected data instead of collecting their own data.

(1) Some means to increase the demand for vital registration may be tried. For example, the use of attractive birth certificates bound in hard plastic covers for easy maintenance and storage.

(m) The Sample Registration Scheme should continue. More use of its findings, especially on the operation side may be made ANNEX .5 Page 20 of 27 pages

and the project areas may be represented in the Scheme. This could be done by appropriate arrangements with the Registrar General.

(n) In U.P. the Health Department is responsible for civil vital registration. The system as described in 'Guide on Birth and Death Registration' by the Family Planning Communication Action Research Project of Lucknow, needs careful examination in view of the above comments.

57. General Recommendations

(o) Family planning is given a high priority in the Government of India planning process. Family planning, however, is a highly complex and interdisciplinary subject. It touches on and affects almost all aspects of life. No scientific discipline alone, and for that matter no single Governmental Department could examine and control population growth and its consequences. It needs the joint efforts of the various disciplines of the whole Government machinery to achieve the ambitious goal of reduced fertility.

(p) In India, Health facilities have been, and will continue to be, the major outlet of contraceptive supplies until new effective and acceptable non-medical methods of contraception are introduced. Furthermore, because of the health orientation of the subject, health facilities and personnel play a major role in motivation. This must continue and be strengthened; but all other Departments must get into the field as well, both as potential sources of distribution and as major factors influencing demand. Such combined effort needs a high level of interdepartmental cooperation and coordination.

(q) It is evident that there is a sizable gap between actual performance and desired targets of client participation. If it becomes apparent to the Government that the present active motivational approach is not sufficient to lead to sufficient participation to reduce fertility, the population problem will become increasingly acute. Society must decide on either living with the consequences of such population pressures, or trying various other ways and means to effect demand more directly: e.g. give more incentives to acceptors and/or make changes in laws and

regulations that may affect fertility su,J fiS marriage laws, inheritance laws and various types of tax.aLon. A successful family planning program must always examine the various factors that affect the supply side as well as those affecting the demand side. Changing the factors that make demand more favorable are as important as changing the factors that make supply more ANNEX 5 Page 21 of 27 pages

efficient. A program that does not examine all possible factors is incomplete. Various policies and strategies, however, will vary in terms of their immediate potential effect, their financial and administrative feasibility, and/or their social and political accept- ability. To study, experiment, and implement such varied policies, the cooperation of all Governmental and private agencies will be needed (e.g. Health, Labor, Agriculture, Justice, Finance, Planning, Welfare and Voluntary Agencies).

58. Areas of Research and Experimentation

1. An Urban Approach - It is important to answer the following questions:

(i) Under the most favorable circumstances and conditions that could be offered :Ln India, and with the implementation of the full potential of the family planning program for a period of 3-5 years, what will be the reduction in fertility and its cost?

(ii) What is the pattern of the diffusion process from the urban to the rural community?

(iii) Is it feasible to attain the targeted reduction in fertility within the existing system and what are reasons for success or failure?

To design such experiments, an overall effort in large urban areas, i.e. Lucknow and, Bangalore, is necessary. All efforts should be made to make the! supply of family planning services as efficient as possible. This is feasible in urban areas. )Many problems related to personnel, transportation, accommodation, supervision and training either do not exist or can be dealt with effectively in urban areas. Careful monitoring of the experiment is necessary to measure the base line, the progress, and the various inputs including those of management, quality of personnel and advisory support.

2. Other Studies - There are many other possible areas of research that need further examination. In particular, the relationship between infant and child mortality and the demand for family planning services is worthy of attention. Also, more experimentation with incentives needs to be done. A careful evaluation is needed before judging the full potential of such procedures. Trials in limited areas are needed for testing:

(i) The relative effects of concentrating on reducing infant mortality as rapidly as possible in a limited area and offering family planning services within this scheme, as opposed to providing family planning services with little or no MCH care.

(ii) Incentive for current family planning users (e.g. IUD or vasectomy) who refer new clients for IUD or vasectomy. Users will be paid if they are continuous users and if they refer a client who becomes a user.

(iii) Incentives for communities and community leaders. ANNEX 5 Page 22 of 27 pages

Mechanisms to Strengthen Evaluation and Research

59. The type of research and experimentation that is being recommended requires technical skills and training. Such capabilities are not available in the existing State Demographic and Evaluation Cells and the economics of raising the capabilities of these units may have questionable value and may not be feasible given their status in the governmental hierarchy.

60. The importance of the expected findings of the type of experiments being recommended, the policy implications of its conclusions, and the complexity and interdisciplinary approach of its design and analysis warrant giving such projects high priorities. Also, it is important to involve Departments other than the State Bureau in the formulation and supervision of such extended work.

61. A strong organization should be formed in the State and be attached to a high-level secretariat, possibly headed by the State Chief Secretary. The following section will discuss the details of this State Population Center.

D. THE POPULATION CENTER

General Purpose

62. The central function should be continuous review in the broadest sense of the population trends and programs of the selected districts and cities. This means (1) information for understanding what is happening; (2) the generation of new ideas and their effective communication to the appropriate administrators; and (3) cooperation with the administrators to work out specific plans for implementation and evaluation of new ideas that are accepted as feasible by the administrators.

63. The Center should be a nucleus for other activities as well (e.g. training). However, its primary objective is to demonstrate that it is possible to understand by systematic observation and research: (a) essential elements of the complex bio-social system that sets fertility levels in the area; (b) the specific nature and effects of the program; and (c) the range and tested feasibility of plausible and promising alternatives to what is being done.

Evaluation Objectives

64. The essential beginning should be a fair but critical monitoring of the present evaluation system:

(a) This should begin in close cooperation with the new State Demog- raphic and Evaluation Cell to improve the accuracy, speed the flow, and begin the genuine analysis of the existing records. What can be done within the existing record system? ANNEX 5 Page 23 of 27 pages

(b) Since this will never work without training and liaison with district level statisticians and block level computors, a program for training, retraining, and continuing liaison with evaluation personnel should be an early part of the program.

(c) There must be close and continuous interaction with the State Demographic and Evaluation Cell. This would be eased if they were housed in offices adjoining those of the Center, with such services as mechanical tabulation, standard printing of forms, etc. provided. The situation should encourage frequent joint meetings, formal and informal.

(d) A "supervisory team" should be frequently on tour to observe how different types of personnel and units are operating. It is clear that some problems are so acute that they do not require refined statistics for diagnosis. Administrative and organizational reviews can be done by teams from the Center and the regular government organization.

65. The Center must go far beyond these minimal services for making the existing records and operations work as well as pos3ible. It should also cover:

(a) The description and analysis of the reproductive histories of the general population of child-bearing age and not just the minority reached by the program.

(b) The fertility and family planning histories of samples of all couples ever served by the program - especially after they leave the program.

(d) The study of the characteristics and performance of various types of workers and of administrative arrangements.

(e) Demographic rate estimates for program areas.

66. The Center should be responsive to the specific information requests of the program administrators as a matter of very high priority. However, it is essential that such service be rendered with candor. Requests for information that does not exist should not be met by creating fictitious figures. It should be clear in the organization and charter of the Center that long-range as well as short-range research is part of its essential task. For example, learning just why Tndian birth rates after age 30 are so low in comparison with other high fertility countries, may be at least as important as estimating the condom sales in district X for 1971. Research on the general and the specific should proceed simultaneously. The Center will earn respect and tolerance if it can answer a reasonable number of current administrative questions, but it will really score if it can be ready to answer the questions, now unformulated, that will arise three years later. ANNEX 5 Page 24 of 27 pages

Management and Advisory Services

67. Analysis of data from routine records, surveys, the statistics of other agencies, observation, etc. should have as one objective, recommendations and ideas for strengthening or changing the operation of the program. Such ideas will emerge sometimes because the research has been designed to answer specific questions (e.g., what kinds of couples want family planning now? What kinds of workers accomplish the most under what circumstances?, etc.). There should be a link and constant prodding from the program side for practical results. For Somple, if it could be shown that the great majority of IUD dropouts use other methods to keep their fertility low without program aid, then an important administrative decision could be made to concentrate fieldworker resources on new cases rather than on follow up of dropouts.

68. Unless there is a close interaction between the research-evaluation side and the program operators, these ideas will not be utilized, and in time will cease to be developed. To facilitate such interaction:

(a) There must be some real linkages by persons having appointments in both the program and Center.

(b) The Center must do its best to find out what are the perceived needs of the administrators and serve those so far as that is possible, without prejudice to its b- .-i objective.

(c) Administrators will become enthusia.--, allies when they find that their programs are becoming famous and discussed by reason of the analysis and write-ups of the research process. Open publication and analysis of the defects as well as the strengths of the program can be a credit for administrators if accompanied by objective and critical analysis of what the problem is and what solutions are proposed.

Other Functions of the Center

69. Training - The main function of the training activities of the Center will be related to development and the introduction of new techniques and the evaluation of the training program; but, to be effective, the Center must also do some training. The Training Division should:

(a) Train all statisticians, demographers, social scientists employed by the State program;

(b) Train personnel for new programs initiated in program areas;

(d) Circulate materials that are prepared in the Center to other training units in the State. ANNEX 5 Page 25 of 27 pages

70. Administrative Seminars - Whether regarded as training or not, there should be regular seminars of the district level officers in the program areas to hear their problems, tell them about the research underway, and exchange ideas for program implications and changes.

71. The Center should offer to provide space and some equipment to physically house the State Demographic Evaluation Cell and the Urban Council. The rationale for all this is:

(a) Proximity will facilitate interaction.

(b) Since skilled personnel will be scarce on, both sides,the same persons can be used for different tasks. Training, research and operations should not be isolated. The appointments can be in one unit or another but it should be possible to have a researcher or an administrator really involved part- time in training and vice-vrersa.

(c) The Center will furnish logistical services for the program, both regularly for a few things (e.g. data processing) and as necessary, for special needs.

72. The generation of ideas is a primary product of the Center. It must be made as clear as possible that this is not a clerical-statistical operation only. For this purpose, the Center should issue a regular report to the state ard to the Central Government and the Planning Commission on "Population and Family Planning in Mysore (U.P.): 1971 - the Record to Date and Plans for the Future."

Needed Resources

73. Personnel Requirements - A staff of significant size will have to be built up for the Center to reach its full potential, but the key essentials for the evaluation side are:

(a) One senior Indian with status, imagination, and sympathy for research and experimentation.

(b) One Deputy Director who is senior and with experience and basic background in social research and demography.

(c) Four to six Indians who have training and drive. It would be possible to put together a team of 4-6 such young Indians who could make all the difference given a competent and resourceful directcr. Their basic background should be in survey methodology and statistics; in socio-medicine, and demography-economics.

(d) Ten Research Supervisors who will constitute the core of the unit. Basic background may be at least a Master's in any of the social sciences. Research supervisors will undertake on-the-job extensive training in the following areas: sample design and execution, data MNEX 5 Page 26 of 27 pages

processing, including computer facilities, interviewing techniques, editing and coding techniques. They will be trained for at least 6 months initially while developing the initial material for the b,ase-line surveys to be conducted in the project areas. These benchmark surveys in Lucknow and Bangalore should be the first act:ivities of the Center. Staff will be recruited for that purpose and trained. The best ten will be retained as research supervisors. This core of research supeirvisors will be the basis for training and re-training temporary interviewers, editors, or coders needed for special surveys. The- will also be responsible and involved in training program personnel in the Demographic and Evaluation Cells; and

Four computer key-punching operators to operate mechanical tabulation equipment.

74. Equipment and facilities - The following seem to be minimum essentials:

(a) a budget which can be drawn on flexibly with changing needs. This is essential;

(b) adequate space equipped with reasonable office equipment to include functioning typewriters and calculators;

(d) vehicles for staff, interviewers, etc. and telephone connections between the points at which research is done.

75. Advisory Service - Two outstanding persons - one senior with status and experience and orLe junior but with experience - are needed. At least one should have experience in survey work in developing countries, preferably in relation to a populat:ion program. Short-term consultants who are specialists in sampling, communic ations, computer work, etc., will be needed. The senior advisor, while sympathetic to research, should be familiar with program operations. The junior advisor will be responsible for the research side.

E. TRAINING

76. Most of the technical training in the project area will be done by the Center. The following is a schematic presentation of the various training functions and their expected time path:

(a) Recruitment of Advisors a:id Directors - 6-12 months Recruitment of senior and middle level staff at the Population Center

(b, Training I: Development of Base-line Survey 8-12 months

In this training all the senior and middle level staffS of the Center will undergo extensive on-the-job training through the development of the necessary material for the base-line survey. They all must go to ANNEX Page 27 of 27 paSes

the field, check the available data at the peripheral levels, do actual interviewing, etc. The following are some of the basic functions to be done:

- study all available data - study forms and registers - prepare the survey objectives - prepare the sample frame - prepare the sample design and material - prepare the questionnaire - study interviewer instruction books - edit and code - pre-test the questionnaire.

During this period it will be most usefiul to involve the State Demographic and Evaluation Cell's personnel and the statistical officers in the District Bureau.

This will be a continuous function. The time needed for these units to reach their full capacity utilization cannot be precisely estimated. The Population Center must reach a high level of maturity to be able effectively to assist and influence the units in the State and Districts.

77. In general, the success of the Center will depend largely on its personnel - their technical capabilities as well as their personalities. ANNEX 6 Page 1 of 4 pages

INPUTS AND RESULTS IN PROJECT AREAS

A. INPUTS

The first table shows the number of maternity beds in UP and Mysore, while tables 2 and 3 show the availability of key staff in each of Districts included in the project of UP and Nysore.

TABLE 1: MATERNTTY BEDS IN UP AND MYSORE

TOTAL I, U.P. DISTRICT HOSPITAL PHC OTHER MATERNIY BEDS

Lucknow R. -- 24 -- 24 Faizabad 44 26 28 98 Sultanpur 34 55 4 93 Pratapgarh 20 -- -- 20 Muzaffarnagar 44 51 91 Saharanpur 30 50 80

RURAL TOTAL 406

Lucknow City - in 4 hospitals -

II. MYSORE DISTRICT

Bangalore R. 32 81 34 147 Kolar 120 73 69 262 Tumkur 192 32 28 252 Chitradurga 115 34 11 160 Shimoga 80 80 160

RURAL TOTAL ga1

Bangalore City - in 8 hospitals and 18 maternity 1,591

The above tables indicate 1.3 maternity beds per 10,000 population in M4ysore Rural and 13.2 beds per 10,000 population in the city of Bangalore.

In the rural areas of U.P0 the level is 0.46 beds per 10,000 population, while in Lucknow city, the ratio is 5.2 beds per 10,000. ANNEX 6 Page 2 of 4 pages

TABLE 2: U.P. - MCH/FP STAFF - RURAL

DISTRICT iEADQUAMCERS STAFF Opera- PHC ANM TOTAL IN GOVT. SERVICE Adm Infor. tional Mobile Doctor PHC & Sub- DISTRICT Unit Unit Unit Unit M F LHV BEE FPHA Centers Doctors Nurses ANM FWW DAIS

BUNGALORE RURAL

Required 8 6 3 14 8 8 16 8 40 82 - - - - - In Position 5 5 1 11 8 - 10 8 32 69* NA NA 27 42 37

FAIZABAD

Required 8 6 3 1-4 18 18 36 18 91 181 - - - - - In Position 4 5 1 8 17 - 12 16 68 69* 31 36 16 53 54

SULTANPUR

Required 8 6 3 14 19 19 38 19 85 207 - - - - - In Position 5 4 1 9 13 - 11 19 76 39* 7 2 27 12 78

PPATAPGARH

Required 8 6 3 14. 15 15 30 15 75 179 - - - - Tn Position 5 4 0 7 13 - 8 15 60 41* 23 3 23 18 54

MUZAFFARNJAGAR

Required 8 6 3 14 14 14 28 14 56 140 - - - - - In Position 5 1 1 7 12 - 11 9 55 88* NA NA 31 57 62

SAHARANPUR

Required 8 6 3 14 16 16 32 16 75 150 - - - - - In Position 5 5 1 7 15 - 16 15 52 74* 47 NA 31 43 53

Includes Family Welfare Workers (FWW). ANNEX 6 Page i of 4 pages

TABLE 3: MYSORE - MCH/FP STAFF - RURAL

DISTRICT HEADQUARTERS STAFF Opera- PHC ANM TOTAL IN GOVT. SERVICE Adm Infor. tional Mobile Doctor PHC & Sub- DISTRICT Unit Unit Unit Unit M F LHV BEE FPHA Centers Doctors Nurses ANM FWW DAIS

BUNGALORE RURAL

Required 8 6 3 14 19 19 38 19 70 178 - - - - - In Position 4 4 2 6 29 13 39 19 32 242 115 0 242- -

KOLAR

Required 8 6 3 14 15 15 30 15 56 142 - - - - In Position 3 4 3 5 15 5 17 15 21 201 99 44 201 -

TUT4IUR

Required 8 6 3 14 16 16 32 16 75 182 - - - - In Position 6 2 3 5 21 5 20 16 58 216 117 35 219 -

CHITRANDURGA

Required 8 6 3 14 13 13 26 13 56 137 - - - - In Position 4 2 1 6 17 5 9 13 35 144 92 49 147 -

SHIMOGA

Required 8 6 3 114 10 10 20 10 35 212 ------In Position 5 3 3 6 10 6 14 10 35 212 102 55 221 ANNEX 6 Page 4 of 4 pages

B. RESULTS

In Bangalore Division, IUD acceptance has decreased by 70.2% from 1967-68 to 1969-70. Similarly, vasectomy acceptance has decreased by 81.7%, Tubal sterilization has increased by 357.5%, and condom users have increased by 7.7%. Total acceptances have decreased by 47.7% (on the basis of 72 condoms distributed equal one acceptor per year). In the project area of U.P., IUD acceptors decreased by 17.5%, from 1967-68 to 1969-70. Tubal sterilizations increased by 49.6%, and condom users increased by 813% (on the basis of 72 condoms distributed equals one acceptor per year). These results are subject to the methods of calculating condom users. The following table summarizes these results:

TABLE 4: PROGRAM PROGRESS

BANGALORE DIVISION (MYSORE)

YEARL IUD VASECTO0MY TUBECTOMY CONDOM USERS TOTAL ACCEPTORS

1967-68 20,007 39,894 2,466 14,376 76,743

1968-69 10,274 24,629 4,291 16,474 55,668

1969-70 5,964 7,305 11,282 15,484 40,035

U.P. DISTRICTS

1967-68 16,089 12,910 924 2,304 32,227

1968-69 13,489 14,780 1,158 6,023 35,450

1969-70 13,270 6,739 1,382 21,040 42,431

Pieces distributed divided by 72 ANNEX 7 Page I-of 2 pages

STAFF AND EQUIPMENT REQUIREMENTS OF SERVICE

MOTIVATION TEAMS

1. The desirab.ility of trying such an approach is based on the following:

(a) The inadequacy of medical staff, in particular lady doctors at the PHC level;

(b) The creation of a group psychology that leads individuals to adopt FP more easily if they know their neighbors are also accepting these services; this has been borne out by the success of the camp technique in India.

2. At each stop, covering roughly 12 villages the team would face some 1250 couples, of which about 40% or 5X) may have three or more children. Of these one-third or 165 cases could accept sterilization, say 70%, for vasectomy and 30% for tubectomy. In addition, about 150 IUD cases can be expected. Given the above, 6 doctor-days for vasectomy operations, 5 doctor-days for tubectomy and 5 doctor-days for IUD insertion, the team would cover the District in three years.

a. Staff

Medical -- 1 male doctor, 2 female doctors, 2 operating room nurses, 2 operating room attendants, 2 nurses' aids

Motivational -- 2 Extension Educators (male), 1 Social Worker (Male) 1 Social Worker (Female), 2 auidio-visual technicians

Administrative -- 1 Team Administrator, 1 Administrative Assistant, 1 Computor, 2 U.D. Clerks, 2 bearers (medical), 1 bearer (motivational), 5 drivers, 1 cleaner

b. Equipment

Medical -- 1 generator, 2 OR lights, 2 OR tables, instruments, surgical supplies, drugs, medicines, vaccines

Motivational -- 2 motion picture projectors, 2 generators, 2 public address systems, 2 screens, 2 sets audio- visual materials (films, group teaching aids.)

Vehicles -- 1 Bus (for equipment transport, staff transport, patient transport); 1 audio-visual bus-van (evenings for village motivation, daytime for patient and staff transport); 2 Jeep station wagons (staff/transport, supplies and as second audio-vi6usal unit; ANNEX 7 Page 2 of 2 pages

1 utility Jeep (staff and patienttransport, administrative use).

The cost estimates for this equipment are as follows:

Vehicles Unit Cost Total Cost (Rupees) (Rupees)

1 Bus 32,000 32,000 1 A-V Bus-Van 32,000 32,000 2 Jeep Station Wagons 20,000 40,000 1 Jeep, Utility 18,000 18,000

Vehicles: Subtotal 122,000

Audio-Visual Equipment

2 Film Projectors 4,000 8,000 2 Generaators 3,000 6,000 3 PA Systems 3,000 6,000 2 Projection Screens 1,000 2,000 2 Sets, Films, Other 5,000 10,000

A-V Equipments Subtotal 32,000

Medical/Surgical Equipment

1 Generator 3,000 3,000 2 OR Lights 1,500 3,000 2 OR Tables 600 1,200 Instruments .15,000 15,000

Medical/Surgical Subtotal 22,000 Equipment:

TOTAL 176,000 ANNEX 8 Page 1 of 13 pages

INDIA POPULATION PROJECT

LOCATION OF PRIMARY HEALTH CENTERS AND NUMBER OF SUBCENTERS

1. SUMMARY TABLE

UTTAR PRADESH STATE

2. Lucknow District (rural) 3. Faizabad District 4. Pratapgarh District 5. Sultanpur District 6. Muzaffarnagar District 7. Saharanpur District

MYSORE STATE

8. Bangalore District (rural) 9. Chitradurga District 10. Kolar District 11. Shimoga District 12. Tumkur District

Note: In the following tables NA denotes PHC dispensaries, family planning wings, or staff quarters which have not been constructed. These are included in the project. The project also includes incomplete buildings (denoted by I). Only those buildings that have been constructed (denoted by A) are not in the project. ANNEX 8 Page 2 of 13 pages

1. SUMMARY TABLE

A. UTTAR PRADESH

Lucknow Faizabad Pratapgarh Sultanpur Muzaffarnagar Saharanpur Total 1. PHCs

a. Dispensary 4 5 11 5 7 7 39 l/ b. Staff Quarters 5 6(12.1) 15 5(8.1) 6 7 54 c. FP Main Center 5 18 14b 18 13 14 82 d. FP Staff Quarters 8 18 15 18 13 14 86 2. Subcenters J/60 177 139 187 138 116 710 i/ According to the GOI plan of 1 Subcenter per 10,900 population.

2/ For cost purposes, staff quarters under construction are assumed to be one-half completed.

B. MYSORE

Bangalore Chitradurga ShimoEa Kolar Tumk-jr Total 1. PHCs

a. Dispensary NA NA 1 NA 2 3 b. Staff Quarters 4 4 4 6 7 25 c. FP Main Center 19 13 10 15 16 73 d. Staff Quarters 19 13 10 15 16 73 2. Subcenters 60 92 62 69 125 508

C. TOTAL PROJECT PHCs Dispensaries - 42 Staff Quarters - 79 FP Main Center - 155 Staff Quarters - 159 Subcenters - 1,325 ANNEX a Page 3 ,f 13 pages

2. UTTAR PRADESH - LUCKNOW (Rural)

A. PRIMARY HEALTH CENTERS

Health Wing Family Planning Wing Name of PHC Dispensary Staff Quarters FP Main Center Staff Quarters

1. Mohonlalgany NA NA A NA. 2. Malihabad NA NA NA NA 3. Kapari NA NA NA NA Lk. Chinhat NA NA NA NA ' Sarajninagar A A NA NA 6. Bakghi-Ka-Talal A NA A NA 7. Goshainganj A A A NA 8. Mall A A NA NA

Total needing construction 4 5 5 8

B. SUBCENTERS

Personnel (ANMs and FWWs) 1/ Buildin s /

Sanctioned Functioning Required Constructed ? Constructed_/Not 80 77 3 20 6o

1/ Both are under health and FP budgets.

2/ Includes buildings under construction. ANNEX 8 Page 4 of 13 pages

3. UTTAR PRADESH - FAIZABAD

A. PRIMARY HEALTH CENTERS

Health Wing Family Planning Wing Dispensary Staff Quarters FP Main Center Staff Quarters Name of PHC

1. Sohawal NA NA NA NA 2. 'MayaBazar NA NA NA NA 3. Harintinganj NA NA NA NA 4. Ehion NA NA NA NA 5. Ramnagar NA NA NA NA 6. Mashoda A I NA NA 7. Tarun A I NA NA 8. Milki Pur A I NA NA 9. Khandasa A I NA NA 10. Pura Bazar A I NA NA 11. Katehri A I NA NA 12. Bhiti A I NA NA 13. Bashari A I NA NA 14. Jahangirganj A NA NA NA 15. Akberpur A I NA NA 16. Jalalpur A I NA NA 17. Tanda A I NA NA 18. Bikapur A I NA NA Total Needing Construction 5 6(12.I) 18 18

A = Available or under construction. NA = Not available. I = Incomplete (i.e., staff quarters exist for only part of staff).

B. SUBCENTERS

Personnel (ANMs and FWWs)Vl Buildings Sanctioned Functioning Required Constructed j Not Constructed

183 88 95 6 177

1/ Based on 1 per 10,000. Note that project may require 1 per 5,ooo). 2/ Both are under health and FP budgets. ANNEX 8 Page 5 of 13 pages

4. UTTAR PRADESH - PRATAPGARH

A. PRIMARY HEALTH CENTERS

Health Wing Family Planning Wing Name of F'HC Dispensary Staff Quarters FP M?in Center Staff Quarters

1. Amargarh NA NA A NA 2. Patti NA NA NA NA 3. Mangraura NA NA NA NA 4. Sandwa-Chandika A NA NA NA 5. Sangipur NA .NA NA NA 6. Gaura NA NA NA NA 7. Shedgarh NA NA NA NA 8. Sadar NA NA NA NA 9. Lalganj NA NA NA NA 10. Derwa NA NA NA NA 11. Babaganj A NA NA NA 12. Laxmanpur A NA NA NA 13. Mandhata NA NA NA NA 14. Kunda A NA NA NA 15. Katra Gulab Singh NA NA NA NA

Total Needing Construction 11 15 11

B. SUBCEN'iERS

Personnel (AN4s and FWs) Buildings Sanctioned rnlNctiani Required Constructed Not Constructed

150 61 89 11 139 ANNEX 8 Page 6 of 13 pages

5. UTTAR PRADESH - SULTANPUR

A. PRIMARY HEALTH CENTERS

Health Wing Family Planning Wing Name of PHC Dispensary Staff Quarters FP Main Center Staff Quarters

1. Dubeypur A I NA NA 2. Kurwar NA NA NA NA 3. Kurebhar A I NA 1/ NA 4. Joaisinghpur A I NA NA 5. Bhadaiyan NA NA NA NA 6. Dhanpatganj A A NA 1 NA

7. Amethi A A NA _ NA 8. Gauriganj A I NA NA 9. Bhetua NA NA NA NA 10. Bhadar A I NA" NA 11. Musafirkhana A A NAl! NA 12. Jagdishpur A A NA NA 13. Jamon A I NA NA 14. Baldirai A I A A 15. Kadipur A A NA - NA 16. Dostpur NA NA NA NA 17. Akhand Nagar A A NA 1/ NA 18. Kamaicha NA NA NA NA 19. Lambhua A I NA NA

Total Needing Construction 5 5(8.1) 18 18

1/ PHC with FP extension. The FP wing is not designed according to the GOI pattern.

B. SUBCENTERS

Personnel (ANMs and FWs) Buildings Sanctioned Functioning Required Constructed Not Constructed

194 49 143 7 187 ANNEX 8 page 7 of 13 pages

6- UTTAR PRADESH - MUZAFFARNAGAR

A. PRIMARY HEALTH CENTERS

Health Wing Family Planning Wing Name of PHC Dispensary Staf a-rters FP Main Center Staff Quarters

1. Monna A A NA NA 2. Jansath .t A NA NA 3. Baghra A A NA NA 4. Buidhana A A NA NA 5. A A NA NA 6. Kandhla A A NA NA 7. Kairana A A A NA 8. Purqazi NA A NA NA 9. Megha Kheir NA NA NA NA 104 Ghahibpur NA NA NA NA 11. Charthawal NA NA NA NA 12. Shabnimr NA NA NA A 13. Thana Bhawan NA NA NA NA 11. Kurmali NA NA NA NA

Total Needing Construction 7 6 13 13

B. SUBCENTERS

Personnel (ANMs and PIWWs) Buildings Sanctioned Functioninfg Required Constructed Not Constructed

l4o 88 52 2 138 ANNEX 8 Page 8 of 13 pages

7. UTTAR PRADESH - SAHARANPUR

A. PRIMARY HEALTH CENTERS

Health Wing Family Plarring Wing Name of PHC Dispensary Staff Quarters FP Mbin Center Staff Quarters

1. Nakur A A A A 2. Gangoh A A NA NA 3. Sarsawa A A NA NA 4. Nagal A A A A 5. Deobqd A A NA NA 6. Nanuta NA NA NA NA 7. Rampur NA A NA NA 8. Roorkee NA NA NA NA 9. Bhagwanpur NA NA NA NA 10. Bahadrabad A A NA NA 11. Narson NA NA NA NA 12. Laksar A A NA NA 13. Muza f Jrabad A A NA NA 14. Sidholi Sadim NA NA NA NA 15. PuwTa rka NA NA NA NA 16. Sunehtikharkheri A NA NA NA

Total Needing Construction 7 7 14 14

B. SUBCENTERS

Personnel (ANMs and FWWs) Buildings 3anctioned Functioning Required Required Constructed Not Constructed

128 Q7 hi 128 12 116 ANNEX 8 Page 9 of 13 pages

8. MYSORE - BANGALORE (Rural)

A. PRIMARY HIEALTH CENTERS

Health Wing Family Planning Wing Name of PHC Dispensary Staff Quarters FP Main Center Staff Quarters

1. Anekal A A NA NA 2. Dommasandra A A NA NA 3. Hesaraghatta A A NA NA 4. Kadugondanahalli A A NA NA 5. Singasandra A NA NA NA 6. Hosahalli A A NA NA 7. Mudigere A A NA NA 8. Bettahalsur A A NA NA 9. Doddaballapur A A NA NA 10. Kanaswadi A NA NA NA 11. Jadagenahalli A A NA NA 12. Sulebele A NA NA NA 13. Hosadurga A A NA NA 14. Kanakapura A A NA NA 15. Magadi A A NA NA 16. Solur A A NA NA 17. Nelamanagala A A NA NA 18. Bidadi A A NA NA 19. Konankunte A NA NA NA

Total 'Tcding Construction 0 4 19 19

B. SUBCENTERS

Personnel' Buildings Sanctioned Functioning Required Constructed Not Constructed 182 177 5 22 16o

1/ Includes Mysore-type subcenter units. ANNEX 8 Page 10 of 13 pages

9. MYSORE - CHITRADURGA

A. PRIMARY HEALTH CENTERS

Health Wing Family Planning Wing Name of PHC Dispensary Staff Quarters FP Main Center Staff Quarters

1. Parasurampura A A NA NA 2. Thalak A A NA NA 3. Pandarahalli A A NA NA 4. Sirigere A A NA NA 5. Anaji A NA NA NA 6. Kodaganur A A NA NA 7. Harihar A A NA NA 8. Yeraballi A NA NA NA 9. Dindawara A NA NA NA 10. Holalkere A A NA NA 11. Hosadurga A NA NA NA 12. Molakalmur A A NA NA 13. Jaglur A A NA NA

Total Neding Construction 0 4 13 13

B. SUBCENTERS

Personnel Biuildings Sanctioned Punctioning Required Constructed Not Constructed

NA NA NA 19 92 ANNEX 8 Page 11 of 13 pages

10. MYSORE - KOLAR

A. PRIMARY HEALTH CENTERS

Health Wing Family Planning Wing Name of PHC Dispensary Staff Quarters FP Main Center Staff Quarters

w. Bagepalli A NA NA NA 2. Kamasamudra A A NA NA 3. Kyasamballi A NA NA NA 4. Dibbur A A NA NA 5. Batalapalli A Ak NA NA 6. Kaiwara A NA NA NA 7. Nangondlu A N4A NA NA 8. Thondebavi A INA NA NA 9. Gudibanda A Ai NA NA 10. Sugutur A NA NA NA 11. Vakkaleri A A NA NA 12. Malur A A NA NA 13. Mulbagal A A NA NA 14. Sidlaghatta A A NA NA 15. Kurgepalli A A NA NA Total Needing Construction 0 6 15 15

B. SUBCENTERS

Personnel Buildings Sanctioned Functioning Required Constructed Not Constructed

112 120 2 43 69 ANNEX 9 Page 12 of 13 pages

11. MYSORE - SHIMOGA

A. PRIMARY HEALTH CENTERS

Health Wing Family Planning Wing Nameof PHCDispensary Staff Quarters FP Main Center Staff Quarters

1. Arebilichi NA NA NA NA 2. Karebilichi A A NA NA 3. Tavarakere A NA NA NA 4. Honnali A NA NA NA 5. Hosanagar A A NA NA 6. Tahalaguppa A A NA NA 7. Ayanoor A A NA NA 8. Shirolkoppa A A NA NA 9. Sorab A A NA NA 10. Konandur A NA NA NA

Total Needing Construction 1 410 1

B. SUBCENTEIIS

Personnel Buildings Sanct.ioned Functioning Required Constructed Not Constructed

NA NA NA 31 62 ANNEX q Page 13 of 13 pages

12. MYSORE - TUMKUR

A. PRIMARY HEALTH CENTERS

Health Wing Family Planning Wing Name of P4C Dispensary Staf? Quarter-s FPMin Center Staff Quarters

1. Chikkanayakanahalli A A NA NA 2. Gubbi A A NA NA 3. Holavanahalli A A NA NA 4. Amruthur A A NA NA 5. Kunigal NA NA NA NA 6. Hosakere A NA NA NA 7. Ku.dlapur A NA NA NA 8. Kotegudda A A NA NA 9. Pavagada NA NA NA NA 10. Bargur A A NA. NA 11. Sira A A NA NA 12. Biligere A NA NA NA 13. Nonavinakere A NA NA NA 1h. Kyatasandra A A NA NA 15. Nagavalli A NA NA NA 16. Thuruvekere A A NA NA

2 7 16 16

B. SIJBCENTERS

Personnel Buildings Sanctioned Functioning Required Constructied Not Constructed

173 169 48 125 ANNEX9 COST ESTIMATES FOR PROJECT Page 1 of 2 pages

Total .Gdt (in 00'1E Item Unit Cost (000's) Number U.P. 1ysore Total Re I.P.Uj PbYsore Total Re US$ Rs U. Tts V .1 LUCFW.O..Alir- LAUICALrONL,1 .

1. :opulatlon Center 1,500 200 1 1 2 1,500 200 1,500 200 3,Q' L.0O79 .aternlty Roa.1t;lL *lth AWElZchool: l1'-tcd tio.pitale attached to present r-eIical college inistitution, inoluding outpatient facilities, operating roomo and other supportive services 3,000 400 1 1 2 3,000 400 3,000 400 b,00n 800 aternity s,omese:Construction or renovrtion or these homes as satelite care centers of tnaternity hospitals - 450 60 10 6 10 to 30 beds El '60) '8) new extenfions 16 4,500 600 600 80 5,100 (r0

h. Urbanr'.mily 'Jelrare 'enters: Some ornstruction but mainly renovation 75 10 6 8 14 450 60 600 80 1,050 140

4 '.-'ional 'inlY E''lanl-nj- Trainln, 'e-ter: onstrucLioiI oer-'nter Inaluding hoetel acconolation 500 67 1 1 2 500 67 500 67 1,000 l1< .hools: Construction of school including classroom, demonstration room e-uiaumert and hostel accoaodation 'ttached to Urban Hospitals 400 53 2 1 3 800 107 400 53 1,200 160

Sub-Total: Urban 10,750 1,433 6,600 880 17,350 ?,31'

7. ,iihr--:,.t - :'uL l1n,g: for District A'iniistration - one per District excert Banr-alore ural 750 100 5 4 9 3,750 500 3,000 400 6,75n ,00

- terlllztlon 'lards: -!to:rul !- 0 beds in *A.trict oesoittls, uith onerating room if uecesar.y 300 40 5 5 10 3,000 400 3,000 400 u,h)oo "'U . - -,hool : 'tta Thed to ''istriet C--,Itest. 'or all rural l2iatricta exceut -angalore '.ural 400 53 5 4 9 2,000 267 1,600 213 *,C'4

1- * rkwnr alth *entern

'. .: '-.ter-nty toi of 15-20 beds in n:!.::',' arUI *oatparum District lr). In-lu'les operating room annd aupportive services l-O P112's c.lose to 'dat,riet Hospital per t1istrict 200 27 10 10 20 2,000 267 2,000 U67 ! ,l :.':

. . en2arien 100 13 39 3 42 3,900 520 300 40 4,200

. trt uartera 80 11 54 25 79 4,320 576 2,000 267 t, 20 :1, li. 'aln 'enter 25 3-3 83 73 155 2,o50 273 1,825 6L3 . ': *1

It.. FT' 'tafl uartera 50 6.7 BE, 73 159 11,300 573 3,650 407 ,'ho 2'q

11 - *ut- *:terr'e-:S

J-. - ' :-'entero 15 2 508 817 1,325 7,620 1,016 12,255 1,634 1 Cj-

i: ' iditional .ut-'ente-a 10 1.3 900 - 900 9,000 1,200 - - *, ,

'ehi^lea 22.5 3 75 49 124 1,688 225 1,103 147 ,7 '-

'ub-Total: Rural Areas 43,628 5,817 33,733 4,098 71 i. -LO

Total: 54,378 7,250 37,3P3 4,978 G,I P. 11

-. 'ox.t-n. e 1< of' total) 8,156 1,088 c600 747 l',797 1,4'.

Total: 62,5 4 8, 38 , . 5,725 11' it I 11,

Y"itn e atnittacnce Decenotes attathed ANNEX 9 Page 2 of 2 pages

Notes on Table

1. Costs are in 000's of constant 1970 rupees. Construction costs estimated on the basis of 25.00 rupees per sq. foot.

2. Ten new maternity homes in Lucknow with 30 beds each and the addition of 10 beds to six existing homes in Bangalore City. Total addition of beds: 300 in Lucknow and 160 in Bangalore. Costs of 450,000 rupees are for new homes. Extension costs of adding 10 beds are 10,000 rupees.

3. Attached to Vanivillas Hospital in Bangalore and to Queen Mary and Dufferin Hospital in Lucknow.

4. Number of PHC Dispensaries, staff quarters for health Family Planning Main Center and staff quarters for family planning determined on the basis of the gap between requirements as determined by Government of India and PHCs actually constructed or under construction. The location of these PHCs is shown in Annex 6. The summary of this Annex shows the required number of each of the PHC components.

5. For ANM-Subcenters. The number is determined by the gap between requirements according to the Government of India plan and subcenters already constructed or under construction. In Mysore, this includes Mysore State type health units and total number to be constructed will result in a ratio of 1 subcenter per 7,800 population ( on the basis of 1970 population). For U.P., the sanctioned subcenters (576 sanctioned, of which 68 have been constructed) fall short of the Government of India pattern of 1/10,000, instead the number is 1/17,000 on the basis of 1970 population. The addition of 900 subcenters will lead to an average ratio of 1/6,700. Subcenters for ANMs are those designed in the Government plan (600 sq.ft.) whereas dai subcenters include one clinic room and suitable quarters, with a total area of 400 sq. ft.

6. Provision of vehicles as follow:

- PHC - one jeep - PHC-Maternity Wing - one bus-ambulance - ANM School - two buses - Maternity liospitals - one sedan, two bus-ambulances - District Headquarters - two jeeps, one sedan - RFPTC - one jeep, one bus - District Training .Team - one jeep ANNEX 10 Page 1 of 3 pages

1/ ADDITIONAL ANNUAL OPERATING EXPENDITURES (in 000's)

A. SUMMARY TABLE

U.P. Mysore Total Rs2/ US$ Rs2/ US$ Rs2/ US$

1. Population Center 500 67 500 67 1,000 133

2. Rural Postpartum Program for Intensive District (Variant III) 1,700 227 550 73 2,250 300 3. Urban Postpartum Program 650 87 575 76 1,225 163 4. Training 175 23 175 23 350 47 5. Mobile Service-Motivation Teams 200 27 200 27 400 53 6. District Administration 50 67 50 67 100 13 3/ 3/ 4/ 3/ 3,275 43T 2,050 273- 5,35w 713-

B. DETAILED BREAKDOWN OF ESTIMATES 5/ Unit Total Cost 1. Population Center - Cost U.P. Nysore

a. Administration 100,000 100,000 b. Evaluation Division 200,000 200,000 c. Training Division 100,000 100,000 d. Other 100,000 100,000

Total 500,000 500,000

Grand Total 1,000,000

1/ These are in constant prices, using where possible, present Government Scales. They are the expenditures that would be required once the whole project becomes fully operational. First and second year expenditure will be lower than figures shown here. Excludes costs of foreign advisor. 2/ Rounded to nearest Rs 25,000. 3/ May not add up due to rounding. 7/ Rs 25,000 added for Deputy Secretary at the Center. 5/ Crude estimates on basis of a professional staff of about 25-30 persons plus clerical and other supporting staff. ANNEX 10 Page 2 of 3 pages Total Annual Total for 1/ Expenditures/ whole 2/ 2. Rural Postpartum Program Unit Scale District Program-

1. District Level a. Pediatriqian 1 10,800 10,800 43,200 b. Ob-gp 3 1 10,800 10,800 21,600 c. ANMNA 5 2,400 12,000 24,000 d. Operating Theatre Nurse 1 3,600 3,600 14,400 e. Operating Theatre Attendant 1 1,200 1,200 4,800 f. Driver 1 1,680 1,680 6,720

2. PHC Level a. LHV 33 3,000 99,000 396,000 b. ANM 13 2,400 31,200 124,800 c. Female Medical Doctor 12 10,800 129,600 518,400

3. Sub-Centers-4/ a. Dais 217 1,500 325,500 651,000 b. ANM 94 2,400 225,600 451,200

5/ 3. Urban Postpartum Program Lucknow Bangalore

1. Maternity Hospital Staff a. Ob-gyn (4) 48,000 48,000 b. Pediatrician 12,000 12,000 c. Operating Theatre Nurse (4) 96,000 96,000 d. Operating Theatre Attendant (8) 6,720 6,720 e. Sister Nurse (8) 24,000 24,000 f. Staff Nurse (8) 20,000 20,000 g. Supervisor Nurse (2) 7,200 7,200 h. ANM (12) 21,600 21,600 i. Other (12) 14,400 14,000

2. Maternity Homes-/ 325,000 250,000 3. Urban Family Welfare Centers7/ 72,000 72,000 Total 646 _,O0 571,920

Grand Total 1,218,840

1/ This is for four Districts - two in U.P., two in Mysore. Figures are average figures for the "typical" Districts. 2/ Times 4 for all except sub-centers. Time 2 for sub-centers, where there are additional expenditures only in U.P. 3/ Additional for U.P., already sanctioned in Mysore. T/ Only in U.P. 5/ Administrative Staff that will assist urban program included under Population Center. 6/ Ten in Lucknow, six in Bangalore. Staff is always additional, even when maternity homes are an extension of existing home as in Bangalore. 7/ Two additional centers in each of Lucknow and Bangalore are in project, one of which will be attached to maternity hospital. ANNEX 10 Page 3 ot 3 pages

U.P. Mysore 4. Mobile Service-Motivation Teams' 45,000 a. Medical - 3 doctors 45,000 2 OT Nurses 6,000 6,000 2 OT Attendants 2,400 2,400 7,200 b. Motivation - 2 Male Extension Educators 7,200 1 Female Social Worker 3,600 3,600 1 Male Social Worker 3,600 3,600 2 Audio-Visual Technicians 4,800 4,800 12,000 12,000 c. Administrative - 1 Team Administrator 1 Administrative Assistant 9,600 9,600 1 Computor 1,800 1,800 5 Drivers 9,000 9,000 2 Bearers 2,400 2,400 2 Clerks 2,400 2,400

(medical drugs, audio-visual materials, d. Supplies -80,000 food, maintenance of vehicles) 80,000 Total Recurring Costs 189,800 189,800

Grand Total 379,600

U.P. Mysore 5. Training 80,000 1. RFPTC 3/ 80,000 100,000 2. District Training Tea 4/ 100,000 Total 180,000 180,000 Grand Total 360,000

Unit Total Cost U.P. Mysore 6. Administrative Cost ---21,600---- - Center: 1 Deputy Secretary 21,600 - District: 1 Administrative-Statistical Officer 9,600 48,000 48,000

Total 48,000 48,000 Grand Total 117,600

non-recurring costs 1/ One such team per State. Each team will also require vehicles (1 bus, 1 A-V van, 2 jeep station-wagons), audio- in the form of projection services, visual equipment (2 film projectors, 2 generators, 2 equipment (OT lights and tables, 1 generator), films) and medical-surgical at Rs 175,000 and instruments. Total cost of this equipment is estimated per team. Population Training Division of Institute - latter is shown under 2/ Excludes (salaries of 10 Institute and is estimated to cost Rs 2000,000 annually persons, equipment and supplies). 3/ For additional staff of ten at each RFPTC. health-educator/social 4/ Includes salaries for team (one doctor, one nurse, one scientist, one statistician), supplies and petrol. MAP I

tHNAMA. C)

TENRI TD I B E T

L..

IBHUTAN I ASS , ADOI RA ' ,*SAJEEL1,, "RR

JODHPURAsA R JALPAIGURII4.

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* NATICNAL CAPITenAL KANAR LA ANlNTAP o

NTAN O NOAPU ,RR150,POPULATIONNA ( PROJECT GUTU STATE B OUNDANNO DTS 0 0 N S O

13~ POPULATIO L ROEC

MADRAS STAT CAPITALS

CRTUURIYAO NOVEMER 190 I lORL320 MAP 2

UTTAR PRADESH STATE

I N D I A POPULATION (91.5 MILLION)

. // . .*STATE BOUNDARY GARHWAL ...... DIVISIONAL BOUNDARY

UTTARKASHI N DISTRICT BOUNDARY

--_*. __LUCKNOWDIVISION NAMES

c *....TEHRI GARHWAL CHML sMEERUT TENIKUMflAONk MEU DISTRICT NAMES - '\ 0* POPULATIONIN MILLIONS \ PITHORAGARH

SAHARANPUR/ SAHARANPUR PAURI GARNWAL/ ' ' DENSITY OF POPULATION PER SOUARE MILE:

-ALMORA f - * *ABOVE 1000 MVZAFFARNAGAR. . . 'j @ ,BIJNOR **-.- a-\ \ 750 -1000 v - ( . NAINI TAL

MEERUT * 5DD0-0 - 750 MMEERU MMORADABADXRAMPUR ROHELKHAND

F 0 .* 250 - 500

BULANDSHAHR- jBAREILLY / P1L I ULUCKNOW 8 , \ B BELOW 250 j BUDAUN ' / .

*. - / KNERI FAIZABAD

MA URA BAHRAICH - AGAV-.. . NRO SITAPUR (i ______AGRA *HARDOI ll* GORAKHPUR

\ MA A A GON A GORAKNPURI ETAWAN.- ~ ~..BASTI %0 j 'ARA BANKI r DEOA K.

..... KANPUR UNNAO . - 0 25 50 100 / FAIZABAD * ..J AILAE . RAEBARELI SULTANPUR (Approcimale Scrale) *-~ / / RAE I . 0 ' .. ,AZAMARH

JNANSK' P***fATEHPUR PRATAPGARH 0 . BALLIA .

NAMIRPURw * D ( 0 . JAUNPUR 0

' *- - ( GHAZIPUR (( . 0 .k. BANDA ALLAHABAD , Q7

BUNDELKHAND J . MIRZAPUR I VARANASI \ &. ALLAHABAD 0 l

NOVEMBER 1970IBD31 MAP 3 a< r NDI A -I N D l A .MYSORE STATE POPULATION (29.5 MILLION)

BIDAR

GULBARGA ( . GULBARGA BELGAUM ¶ *

/ * -STATE BOUNDARY

...... DIVISIONAL BOUNDARY BIJAPUR - DISTRICTBOUNDARY

,.. -, . MYSORE DIVISION NAMES

t RAICHUR BANGALORE DISTRICT NAMES & BELGAUM *-'-.JPO"ULATIONR IN MILLIO!S

DENSITY OF POPULATION PER SQUARE MILE: - -- * 2 9

ABOVE 500

DHARWAR . R / 5 ,401 - 500

C? .- BELLARY 301-400 NORTH KANARA /

201 - 300

... BELOW 200 ~t .: - CHITRADURGA B 2 SHIMOGA

i...... - /D

CHIKMAGALUR , . TUMKUR KOLAR . g * © ,i ...... ' .N.' . r BANGALORE . SOUTH 3 .;. .. *.. KANARA A/ HASSAN *.* . \ BANGALORE CITY :

I.f ( MANDYA Jr

COORG BANGALOREB

MYSORE MYSORE

0 25 50 100

MILES NOEME 9Appro70mBe Scale)

3210 NOVEMBER 1970 I BRD