Indian J Pediatr 1992; 59 : 281-294
SPECIAL ARTICLE
Action Plan for Revamping The Family Welfare Programme in India K.K. Mathur
Ministry of Health and Family Welfare, Department of Family Welfare, Nirman Bhavan, New Delhi DEMOGRAPHIC SCENARIO
According to 1991 census, the country's population is 843.93 million - a substantial rise from 342 million in 1947 and 684 million in 1981. The annual addition to the population is 16 million. The all-India average annual growth rate during the 1981-91 decade has been of the order of 2.1% marginally lower than 2.2% during the preceding decade. The statement at AnncxureI brings out the comparative position in regard to the decadal variation in population, change in the decadal variation and average exponential growth rate of population in different states/UTs. The latest available sample registration systcm (1989) estimates indicate the all-India birth rate of 30.6, death rate of 10.3 and infant mortality rate of 91. Two important parameters influencing fertility behaviour are female literacy and age at marriage for women. Couple Protection Rate (CPR) also indicates the level of efforts made for birth control and is at present estimated to be 44.11%. The statement at Annexure-II brings out the comparative position of dif-
ferent states/UTs in regard to several selected indicators. The long term demographic goals, as laid down in the national health policy (1983) is to achieve the birth rate of 21 per thousand, death rate of 9 per thousand, natur',d growth rate of 1.2%, infant mortality rate below 60 per thousand live births and couple protection rate of 60% by the year 2000 A.D. It has already been rccognised that given the current level of achievements, the goals may not be achievable at the national level before 2006-2011 A.D. FUTURE STRATEGIES Faced with grim prospects of population explosion, it is necessary to devise innovative strategies for imparting new dynamism to the family welfare programme. While the population control programme has to essentially evolve as a multi-sectoral programme, comprising many aspects which go beyond the acti~5ties under family welfare sector, a result oriented action plan has been developed with the consensus of the state governments and UTs administration. The board framework is summarised below.
Reprint rcquests: Mr. K. K. Mathur, Secretary.-. National Consensus and Efforts Family Welfare, Ministry of Health and Family Welfare, Department of Family Welfare, The population control programme needs Nirman Bhavan, New Delhi-110 0l I to be fully supported through a national 281
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THE INDIAN JOURNAL OF PEDIATRICS
Vol. 59. No. 3
T,,mLg 1. Selected Indicators State
Couple Protection Rate (313.91)
R A N K
Crude Birth Rate (1989)
R Infant A Morality N Rate K (1989)
R A N K
Female Literacy Rate (1991
R A N K
census)
Age at nmrriage (Female) (1981
R A N K
census)
Major States
Andhra Pradcsh Assam Bihar Gujarat Haryana Karnataka Kerala Madhya Pradcsh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal
44.3 28.2 26.0 57.8 56.6 46.9 55.6 43.3 56.2 41.0 75.8 29.0 57.3 35.5 33.7
(8) (14) (15) (2) (4) (7) (6) (10) (5) (9) ( 1) (13) (3) (11) (12)
2.5.9 29.4 34.3 28.7 35.2 28.0 20.3 35.5 28.5 30.5 28.3 34.2 23.l 37.0 27.2
(3) (9) (12) (8) (13) (5) (1) (14) (7) (10) (6) (ll) (2) (15) (4)
81 91 91 86 82 80 21 117 59 121 64 96 68 118 77
(7) (11) (10) (9) (8) (6) (1) (13) (2) (15) (3) (12) (4) (14) (5)
33.7 43.7 23.1 48.5 40.9 43.3 86.9 28.4 50.5 34.4 49.7 20.8 52.3 26.0 47.1
(3) (9) (12) (8) (13) (5) (1) (14) (7) (10) (6) (11) (2) (15) (4)
tlimachal Pradesh J&K Manipur Meghalaya Nagaland Sikkim Tripura A&N Islands Arunachal Pradesh Chandigarh D&N Haveli Delhi Goa Daman & Diu Lakshdwcep Mizoram Pondichcr~'
52.1 21.1 ~.2 5.0 4.8 20.6 17.6 42.3 10.5 41.8 47.5 40.4 34.0 30.2 8.6 41.4 60.6
(2) (11) (10)
27.7 30.1 55.8 31.1 19.7 31.4 25.7 20.5 35.6 22.5 35.6 27.2 15.7 27.9 28.8 NA 21.1
(9) (12) (6) (13) (2) (14) (7) (3) (15) (5) (16) (8) (1) (10) (11) (0) (4)
75 66 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA
52.5
(10)
48.6 44.8 55.7 47.2 50.0 66.2 29.4 73.6 26.1 68.0 68.2 61.4 70.9 78.1 65.8
(12) (14) (9) (13)
All India
44.1
91
39.4
17.3
(10)
16.6 19.5 17.8 19.2 21.8 16.6 18.8 19.1 21.1 16.1 20.3 16.7 19.2
(12) (4) (9) (5) (1) (13) (8) (7) (2) (14) (3) (11) (6)
Smaller States & UTs
(16) (17) (12) (13) (4) (14) (5) (3) (7) (8) (9) (15) (6) (1)
30.6
(11) (6) (15) (2) (16) (5) (4) (8) (3) (1) (7)
NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 18.3
Census not done in Assam in 1981; NA-Figures are not available; **Figures are provisional; @--Separate ranking done for major and smaller states.
!.IATHUR : REVAMPING "FIIE I-"AMILYWELFARE PROGRAMME IN INDIA
283
l',~tr 2. Population, Decadal Growth Rate & Average Exponential Growth Rate, 1991 Consensus State/UTs
Population 1991 Census
Dccadal Growth Rate
Average Annual Exponential Growth P, atc
1981-91
1971-81
1981-91
1971-$1
66,304,854 858,392 22,294,562 86,338,853 1,163,622 41,174,060 16,317,715 5,111,079 7,718,700 44,817,398 29,011,237 66,135,862 78,706,719 1,826,714 1,76(I,626 686,217 1,215,573 31,512,070 20,19t.),795 43,880,640 403,612 55,638,318 2,741,827 138,760,417 67,982,732
23.82 35.86 2,3.58 23.49 15.96 20.80 26.28 19.39 28.92 20.69 13.98 26.75 25.36 28.56 31.80 38.98 56.86 19.50 20.26 28.07 27.57 14.94 33.69 2.5.16 24.55
23.10 35.15 23.36 24.06 26.74 27.67 28.75 23.71 29.69 26.75 19.24 25.27 24.54 32.46 32.04 48.55 50.05 20.17 23.89 32.97 50.77 17.50 31.92 25.49 23.17
2.14 3.06 2.12 2.11 1.48 1.89 2.33 1.77 2.58 1.88 1.31 2.37 2.26 2.51 2.76 3.29 4.50 1.78 1.85 2.47 2.43 1.39 2.90 2.24 2.20
2.10 3.04 2.12 2.17 2.37 2.46 2.55 2.15 2.58 2.39 1.77 2.27 2.21 2.g3 2.80 3.99 4.09 1.85 2.16 2.87 4.14 1.63 2.79 2.29 2.10
277,989 640,725 138,542 101,439 9,37(I,475 51,681
47.29 41.88 33.63 28.43 50.64 28.40
63.93 75.55 39.78 26.07 53.00 26.53
3.87 3.50 2.90 2.50 4.10 2.50
4.98 5.67 3.38 2.32 4.29 2.37
843,930,86l
23.50
24.66
2.11
2.22
~tates ~dhra Pradesh .~runacha'l Pradesh ~,ssam Bihar Goa ,3ujarat [-lat)'ana ~limachal Pradesh 18,:K Karnataka ~erala !~ladhya Pradesh ~laharashtra ~ianipur ~,leghalaya !,lizoram ~agaland Oris~ Punjab ?,a asthan S~kkim 7atoll Nadu Tdpura ~.:tar Pradcsh ~Vcst Bengal
]~.~'lion Tcnitoties ~,&N Islands ~.handlgarh iD&N Haveli :Daman & Diu Oelhi ~Lakshdwecp &
i
i!il India
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THE INDIANJOURNALOF PEDIATRICS
consensus with willing participation of all segments of the society, cutting across political, religious and cultural differences. It has to be backed by strong political commitmerit and will, not only at the national level, but also at the level of states/UTs, which are primarily responsible for implementation of the programme. Political leaders, religious and other opinion leaders at different levels will have to be approached for their active involvement in moulding public opinion in support of the programme. Improvement of the Quality and Outreach of Services A vast network of institutions have come up in the country for delivery, of health and family welfare services over the successive plan periods. The quality of service delivery varies markedly from state to state. It has, howevcr, been recognised that on the whole the quality of service delivery extended to the people is far from satisfactory.. Besides, the outreach of services is also not adequate for the people in remote rural areas and urban slums. The following steps would be taken to improve the quality and out-reach of services. (a) Keeping in view the general constraint of resources (financial, administrative and managerial) for pushing the Family Welfare Programme, the thrust during the 8th Five Year Plan would be first to consolidate the existing infrastructure. There is no point in going for opening of new subccntres etc. in the future, if the existing subcentres are not functioning properly. However, keeping in view the norms fixed during the 7th Five Year Plan, new institutions will be sanctioned, if adequate funds are made available. In particular, it is accepted that such institutions need to be opened in tribal
Vol. 59, No.3
and remote areas. Special attention will als0 be paid to creation and strengthening of the health infrastructure in the urban slums, where it is particularly deficient. (b) Integrated training modules for training and retraining of medical and paramedical personnel involved in the dclivc~ of family welfare services will be developcd and adequate funds made available for organising different training programmes in the institutions already set up for the purpose. Communication skills and right value orientation would be important elements of the training modules. (c) As motivation is a key factor in improving the quality of delivery of services, it will form a key clement in the training modules for medical and paramedical personnel at all levels. (d) Special attention shall be paid by thz state governments/UTs administration 1o have a proper organisation for maintenance of equipment, vehicles and buildings and, wherever possible, even the existing family welfare workers will be trained for doing small repairs. This would ensure proper utilisation of vital equipment and valuable assets created undcr the programme. (e) The supervision at all levels will have to be vastly improved. This will primarily focus on identification of problems, finding solutions thereto and improving understanding and capabilities of key functkmaries involved in the delivery of services. (f) Special attention shall be paid to the construction of buildings for primary hcahh centres and sub-centres through area development projccts and under the minimum needs programme of the stale plans. (g) Tile state governments and UTs administration would look into the practical problems of the workers like ANMs in the fie!d conditions, such as their placc of stay,
~IATHUR : REVAMPING T H E FAMILY WELFARE P R O G R A M M E IN INDIA
mobility and travelling expenses etc. Inadequate attcntion to these problems seriously hampers the working of the main propagators and providers of the servicing of the familywelfare programme at the grass root level. (h) At the state level a separate secretary/special secretary level officers needs to be made responsible for the family welfare programmes. Officers should be carefully selected for this assignment and give a stable tenure of at least two years and preferably three years.
ing of the staff, requires to be speeded tip with duc attention to the quality of implementation. The relevance of the disaggregated approach does not stop at the identification of the four states. An analysis of demographic indicators at the district level indicates theft there are 90 particularly bad districts where the crude birth rate is above 39 pcr thousand (1981 census). A list of these districts is placed at Annexure-lIl. The h)llowing steps would need to be taken to improve the programme performance in these districts.
Special Strategy For 90 Districts
(a) Micro-level planning will have to be done by the states to identify the needs on a realistic basis for reduction in birth rate in these districts. Resources will be allocated for strengthening of infrastructure and provision of other essential inputs after taking into account the inputs already provided in these districts through area development projects and other special projects, if any. (b) All posts at grass root level of family welfare workers and supervisory officers would be filled up and only motivated officers with excellent record in these districts would be posted. (c) Priority for construction of subcentres and buildings for other health institutions would be given in these districts under the area development projects. (d) Intensive training of medical and para-medical personnel would be organised. (e) Since many of the low performance districts have large minority populations, minority community leaders at local levels would be involved in launching imaginative IEC programmes designed to increase family planning acceptance by all sections of the society through methods best suited to individual needs.
The demographic and health profile of the country is not uniform. Examination of the statewise data regarding behaviour of the important demographic and health indicators shows very clearly that any operational strategy, to be successful, will have to be based on a disaggregated approach. The four states of Bihar, Madhya Pradesh, Rajasthan and U.P. which constitute about 40% of the country's population, have IMR land MMR levels distinctly higher than the national average. These are also the states where the age of females at marriage, fe;male literacy and share of women in the i non-agricultural employment are distinctly ~ilower than the national average. Unless :'~specialefforts are made to bring up the proit'de and performance these states in regard i to health and family welfare, it would be ~well-nigh impossible to accelerate the ~aehievement of demographic and family !welfare goals at the national level. Special ~area development projects have already :been launched in these states with the help ~0f the World Bank, UNFPA and other !funding agencies. The execution of these projects, primarily designed to strengthen i the infrastructure and to improve the trainI
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TABLE3. Selected Indicators for 99 I)istri,_'ls with CBR > = 39 Stale
BIHAR
GIJJARAT 1bkRYANA KERAI.A MADI IYA PRAI) ES I t
ORISSA IL~d'ASTI IAN
District
Nawada Saharsa Samastipur Kalihar Gaya Kachchh Hanaskanlha Bhiwani Malappuram Sehore Rewa Guna Damoh Gwalior Parma Raisen Hoshangabad Vidisha Tikamgarh Bhind Wesl Nimar Sagar Jhabua l]ihopal Shivpuri I~etul Chhatarpur M.orena Fast Nimar Datia Dhar Salna Baleshwar Jodhpur Udaipur Sawai Madhopur Kota Jhalawar Jalor I)ungarpur I]lharalpur Banswara Ajmer Sirohi Ganganagar Jaipur Sikar Bikaner Pall Barmer Alwar Bundi Nagaur Jhun.ihunun
Sex ratio (per 1000 males) 1.002 930 972 928 962 999 945 898 1,052 907 969 882 925 845 913 998 908 881 883 827 954 891 985 874 855 973 864 834 939 853 966 936 977 909 977 867 888 926 942 1.045 831 984 922 963 874 894 963 981 946 904 892 887 958 956
Percentage of literates (female) 12.77 9.16 12.77 11.34 15.25 26.68 11.36 16.30 55.34 9.78 11.35 9.26 16_~;2 25.98 8.66 11.51 21.88 13.07 8.44 14.67 12.19 21.11 6.35 37.88 8.12 17.42 10.24 10.09 18.91 12.26 1027 13.26 28.26 14.47 10.76 8.16 17.39 9.27 4.43 7.97 10.08 7.50 21.92 9.92 14.16 .17.18 9.08 17.57 8.83 3.71 11.38 8.92 7.12 11.40
Mean age at marriage 14.7 15.7 15.9 16.2 15.4 18.2 18.5 16.1 17.8 14.8 14.4 1.5.0 14.8 15.8 15.0 14.9 15.5 14.9 14.3 14.7 16.4 14.8 17.9 16.9 14.8 16.9 14.5 14.8 16.1 14.8 16.3 14.8 16.2 16.4 15.8 15.1 15.2 14.7 17.3 16.5 16.0 16.9 15.4 17.1 16.8 15.2 15.0 15.4 16.2 16.9 16.0 14.4 15.3 15.5
Non-agri. lalx~ur as % of main workers 4.9 2.8 12.4 6.8 6.3 22.7 17.3 10.3 32.3 8.9 8.1 16.3 43.4 45.3 14.3 15.08 18.1 23.6 9.2 25.3 6.5 57.5 4.5 58.2 9.7 7.2 15.4 15.2 10.0 20.3 4.4 17.4 24.0 15.7 22.4 14.4 36.8 8.6 t0.6 21.6 30.9 18.0 23.0 29.6 26.2 24.5 17.2 35.4 12.7 14.1 19.2 21.6 6.8 12.9
CBR
IMR
39.85 '40.61 39.09 39.61 39.82 39.38 40.80 39.40 39.32 40.77 40.55 42.03 42.94 40.71 45.54 42.62 40.89 43.35 44.48 40.17 39.73 43.23 42.65 39.61 41.58 4(I.69 42.19 44.57 39.6.5 39.97 39.39 41.20 41.69 41.55 40.65 43.34 40.14 ,~016 41.59 45.12 44.02 42.39 39.08 39.75 39.15 41.62 41.00 41.32 40.14 41.45 41.36 40.68 41.46 39.98
95 113 107 1i5 1~1 89 94 .% 4') 116 1,~ 150 150 llS 185 13.5 163 1'44 195 1~ 137 161 116 ~2 150 15~ ',;';2 132 131 156 116 181 132 86 120 141 112 124 104 W. N7 ,r :~ 121 82 108 r,.'5 62 130 102 128 125 96 92
MATHUR
: REVAMPING
State
Uttar Pradesh
West Bengal
"FILE F A M I L Y W E L F A R E
District
Tonk Churn Farrukhabad Pratapgarh Mainpuri Banda Azamgarh Shahajapur Tehri Garhwal Hardoi Moradabad Aligarh Lalilpur Pilibhit Deoria Buland.,,har Gorakhpur Budawl Sharanpur Sitapur Basil Sultanpur Elah Jaunpur Agra Bareilly Gonda Allahabad Meerut Bijnor Raebereti Ghaziabad Rampur Maldah Mut~shidabad
Sex ratio (per 1000 males) 928 954 821 1,001 82 i 860 1.020 812 1,081 821 842 840 851 841 981 863 940 801 832 841 921 970 821 1.001 821 830 890 890 841 863 940 821 843 949 959
(f) In order to improve the inter-personal communication efforts at the grass root level, a scheme of link volunteers would be tried out in some of the districts on a pilot basis. The Department of Woman and Child Development would be requested to cover all the 90 districts with ICDS programme and suitable linkages developed at the service delivery level with ICDS functionaries to delivery health, nutrition and family welfare services as a package.
PROGRAMME
Percentage of litcrates (female) 8.28 9.81 19.08 8081 18.49 8.61 12.20 10.79 9.42 9.52 10.93 16.24 9.96 9.32 9.07 13.34 10.36 7.54 18.06 8.38 7.94 9.37 19.92 10.89 19.95 12.33 5.45 12.81 27.10 14.76 10.47 21.32 8.88 14.22 17.75
IN I N D I A
287
Mean age at marriage
Non-agri. labour a.s % of main workers
14.0 15.3 16.3 14.8 16. I 15.8 15.2 16.4 16.8 16.5 17.4 16.7 14.5 16.7 16.1 16.8 15.2 16.5 17.6 16.4 15.0 14.9 16.6 15.5 16.6 16.8 15A 16.5 17.0 17.9 15.7 16.9 17.4 15.9 15.94
19.1 7.4 81.4 7.4 58.5 7.1 19.2 592 1.3 38.7 74.1 57.1 26.8 54.1 7.8 49.1 9.1 56.7 59.9 33.2 9.5 9.3 75.6 45.5 75.6 79.2 7.8 16.3 172 76.7 8.7 69.5 70.9 43.8 81.3
CBR
IMR
43.65 42.08 39.49 40.15 39.52 39.85 4020 40.44 41.18 42.06 42.47 40.56 42.31 39.89 39.97 40.59 40.41 41.06 39.24 39.43 41.29 40.87 41.07 41.83 41.07 39.80 39.69 39.69 39.43 42.93 40.92 40.50 42.62 4129 39.84
148 81 122 126 121 98 110 167 99 173 126 129 138 147 120 127 123 155 96 143 164 15 I 115 448 115 146] 157 110 93 120 172 114 150 128 104
(g) The district collectors would be fully involved in coordination/supervision of thc family welfare programme related activities in these districts. Package of Incentives/Disincentives The present scheme of compensation for the loss of wages to acceptors of sterilisation/IUD, places great emphasis on target achievement with the result that the quantity has taken precedence over quality and some specific methods seem to h a v e o v e r -
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THE INDbMNJOURNALOF PEDIATRICS
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shadowed others. It has incrcasingly been able incentives to encourage good performrecognised that we should get rid of the ance by states shall bc built in the proposed "'tyranny of targets". Targets based on mi- modified scheme of compensation. cro-level planning suiting the local specific An innovative package of incentives/disneeds may, however, continue to be fixed incentives would be formulated with emfor monitoring of the programme. phasis on community based incentives and The schcme will be modified to provide social security measurez for individuals for greatcr flexibility to the states and to adopting small family norm. The commucover younger age couples with greater fer- nity based incentives would be linked to tility potential under spacing methods. The various benefits being made available to the resources meant for the purpose would be public under different socio-economic deprovided to the states/UTs in relation to velopment plans to the government. their overall birth rate reduction efforts. In order to work out a suitable formula for Promotion of Different Contraceptive devolution of resources under the scheme, a Methods/Devices Committee comprising Shri S.B. Mishra, Joint Secretary, Ministry of Health & Fam- Sterilisation procedures were the mainstay ily Welfare, Shri P.K. Mehrotra, Secretary of the programme in the past. However, (H & F.W.), M.P., Smt. Netra Shenoy, Sec- acceptors have generally been of the higher retary (F.W.), Gujarat, Smt. S. Chandra, age, who have already completed the deSecretary, (H & F.W.), Delhi and Shri G. sired family size. The contribution of steriliGopalankrishna Pillai, Secretary, (H & sation to the fertility decline, therefore, has FW), Kerala, will be constituted. The Com- been less than anticipated. While stcrilisamittee will finalise its recommendations tion would continue to play an important within one month of its constitution. role in the population control efforts, it No additional incentives to government would be ensured that the profile of the acemployees for adopting the small family ceptors would be of the right quality in norm need to be considered. A suitable terms of age and number of children alpackage of disincentives will however, be ready born. developed for them and they may be Spacing methods will be vigourously adopted by the state governments as well. It pushed for addition by the youngcr age will also be recommended to the employers couples with high fertility potential. This in the organised sector. would require good follow up services for Motivator's fee etc. presently being paid acceptors of IUD insertions to bring down to service providers will not be paid any the drop out rates, improvement in distribumore, as it also leads to emphasis on tion arrangements of conventional contraachievement of specific methods of contra- ceptives and oral pills in rural areas and ception. urban slums through strengthening of States award scheme, already decided to schemes for social marketing of contracepbe scrapped retrospectively w.e.f, the finan- tives and launching of community based discial year 1988-89, would not be revived, as it tribution of contraceptives. The free distrihad been leading to falsification of figures bution schemes which are somewhat wastand unhealthy competition. However, suit- age-prone would bc gradually curtailed and
MA'I.'HUR : REVAMPING T I l E FAMILY WELFARE P R O G R A M M E IN INDIA
limited only to such areas where these are actually needed for economic reasons or for the lack of outreach of social marketing/ community based distribution programmes. The quality of contraceptives would be improved. In this regard, supply of dry condoms under the free distribution scheme would be gradually phased out and only lubricated condoms made available. The production arrangements for weekly oral pills (centchroman) and oral contraceptives pills (Mala N and Mala D) shall be gradually improved, so as to make these easily available across the length and brcadth of the country in greater numbers. In order to give a wider choice of contraceptives to the aceeptors, new contraceptives, such as Norplant-6 and injectibles shall be introduced under the programme, initially under controlled conditions and gradually on a wider scale. No-Scalpel Vasectomy, which is much simpler, would be popularized through training more and morc doctors and paramedical staff in this method. Fertility research programmes, especially those relating to the development of male/female vaccines, anti-fertility drugs and contraceptives/abortificients under indigenous systems of medicines shall be strengthened and coordinated. UNIVERSAL IMMUNISATION PROGRAMME AND MCH PROGRAMME /
Consistently high coverages are being now reported from most of the states in the universal immunization programme. However, there still remain areas where the coverage levels are low. Special attention would be focussed on such areas during the coming years, while sustaining the high level of coverage achieved elsewhere.
289
All such cases where reported coverages are more than 100% of the target fixed, the reasons for high coverages would be routincly investigated to ensure that no overreporting is allowed, as this would otherwise lead to a sense of complacency leading to outbreak of the vaccine preventable diseases. The ultimate objective bcing reduction of vaccine prevcntable diseases, the priority in the coming years would be to concentrate on the quality aspects of the service delivcry and on documenting reduction in disease incidence. The following activities in this context would be strengthened : (a) Initiating active surveillance in areas where low incidence has been recorded in the last two years. List of cases, particularly of polio and neonatal tetanus would be the lead diseases under monitoring. (b) Setting up of a network of Polio Virus Isolation Laboratories while increasing the number of field samples of Oral Polio Vaccine (OPV) to ensure that atleast one full sample is lifted from every primary health centre areas in a year. (c) Time bound investigation of all adverse reactions following vaccination. For overall improvement in the management of the programme, all supervisory posts created so far, particularly those of the district immunisation officers and refrigeration mechanics would be filled up by the states/UTs. All states/UTs would also take priority action to take over the maintenance of the cold-chain created over the last 4-5 years and further planned to be strengthened in the coming years. About 1.5 million children below 5 years of age die because of diarrhea in the country very year. Even though the oral
290
TI IE INDIAN J O U R N A l . O F PEDU~TRICS
rehydration therapy (ORT) programme is being implemented for quite some time now, it has met with only partial success. There are still many medical practitioners who are not propagating it or prescribing ORS. The programme would be more vigourously promoted through the training of medical and paramedical personnel and through health education to people, particularly mothers. Keeping in view thc "Health for All goal by 2000 A.D.", a new child survival and safe motherhood programme is proposed to be implemented with I D A / U N I C E F assistance in a phased manner. It would provide for-universalisation of IFA to cover all pregnant mothers, universalisation of Vitamin A to all children upto the age of 3 years, expanding the pilot project on control of acute respiratory infections and strengthening primary health care infrastructure, coupled with an intensified training of traditional birth attendants in the higher IMR/MMR states of Assam, Bihar, Orissa, Madhya Pradesh, Rajasthan and U.P. It is expected that this project would not only help in lowering the IMR/MMR and child mortality rate, bat would also contribute significantly to improve the family welfare services. URBAN AREA SCHEMES
The schemes like post-partum centres urban family welfare centres, health posts are designed to provide family planning and maternal and child health care services to population living in the urban areas, including slum areas. While the post-partum centres have generally become hospital based programmes and are not effectively catering to the areas/population attached to them, the quality and outreach of services being provided by the urban family welfare centres/health posts are also not satis-
Vol. 59, No. 3
factory. This has resulted in a situation in which the family planning and MCH services are not effectively reaching the urban slums population, which is an area of major concern. The following steps would be initiated : (a) With a view to strengthening the infrastructure and services, urban revamping schemes covering towns with two lakh population and above with special focus on slum areas are already being developed. The operationalisation of these schemes would be expedited with adequate funding support from central budget and external agencies. (b) The involvement of voluntary organisations in catering to the needs of slum population will be enhanced. Preference would be given to voluntary groups already active in such areas. (c) The urban institutions, whether under the government or the voluntary sector, will be closed down or will be shifted elsewhere in case an optimum level of performance is not reported. It would be ensured through proper monitoring and supervision mechanisms that these institutions do seriously endeavour to meet the respective programme objectives, particularly those related to serving the target population assigned to each. Adequate flexibility would be given to states/UTs to meet these objectives. (d) Suitable coordinating mechanisms would be developed to ensure that the urban institutions function in an integrated manner and not in total isolation of each other and the overall programme objectives. VILLAGE HEALTH GUIDE SCHEME There is a general impression that this ira-
iVL-%IHUR : REVAMPING T H E FAMILY WELFARI:; P R O G R A M M E IN INDIA
291
portant scheme, designed to provide for the training, many statcs/UTs have already fulbasic linkage between the community and filled targets of recruitmcnt and basic trainthe health and family welfare service deliv- ing of workers. In so far as the scheme of ery system, is not working well. Village training of health worker (male) is conHealth Guides are presently getting only corned, most states have stopped training as Rs. 50/- per month as honorarium and in fresh recruitment is not taking place. There most paris of the country, they arc not ren- are a large number of vacancies of dering much service to the community, MPW(M) in different states/UTs which Some states (J&K, Tamii Nadu, Kerala) did has caused serious concern. not implement the scheme from the very The following steps would bc taken : beginning and some others likc Assam and (a) The existing infrastructure of ANM/ Haryana have scrapped it. The decision to LHV training schools would be thoroughly replace male health guides with female reviewed for each state/UT to ensure ils health guides has also led to a plethora of proper and effective utilisation. Schools writ petitions in different high courts. The without buildings and those being run general experience has been that wherever through voluntary organisations shall bc female health guides are in position, the closed down gradually. The remaining ground situation of service delivery is much schools will be utilised for running intebetter. The consensus is that in case the grated training modules for para-mcdical scheme cannot be implemented with only workers, including of voluntary sector, and female health guides, it may be better to for continuing education programmes. scrap it altogether. (b) Statcs/UTs would initiate action to The following steps would be taken : create posts of MPW(M) to mcct the exist(a) All the pending court cases would bc ing gaps in a phased manner and effectively effectively followed up and got decided on a utilise the available training infrastructure. priority basis. (c) Net working arrangements of train(b) The existing number of village health ing institutions at different levels would be guides shall bc fully utilised by statc/UTs developed, with a view to ensuring uniformwi-:h reduced functions, if necessary. Their ily in training modules, avoiding duplication services may primarily bc utilised as motiva- and bringing about effective coordination. tors and the depot holders for contraceptives, oral rchydration salts, IFA tablets etc. INFORMATION, EDUCATION, (c) The possibility of revitalisation of the COMMUNICATION scheme to make it more effective or altcrnatively of disbanding it would be examined Information, education and communication further taking into account the varied impli- (1EC) inputs need to be revitalised, not only cations, including from the legal angle. to propagate the family welfare programme, but also to bring about attitudinal CONTINUATION OF ANM/LHV TRAINchanges, so as to cover a part of the ground ING SCHOOLS which should bc normally prepared through There are a large number of AN/LHV/ education and social work. The new IEC MPW(M) training schools in different parts strategy, would have the following key eleof the country. As regards ANM/LHV ments :
292
]'FIE INDIAN JOURNAL OF PEDIATRICS
(a) The IEC message would be to associate family welfare with planncd parenthood and not just with the adoption of contraception. (b) The messages would be positive with thrust on qu',dity of life issues and removal of ignorance, apathy and misgivings about the family welfare programmes. (c) In order to involve the community in generating demand for family welfare services, the scheme of Mahila Swasthya Sangh, which has been recently introduced in some selected districts, would be further strengthened in case the results are found to be encouraging. (d) The messages through the mass media would be of a balanced nature, so that these do not hurt the sensibility of the people at large in our socio-cultural ethos. (e) In order to cover 40% of the population, which is not covered by any mass media presently, special attention shall be paid to traditional art forms, folkfore, field publicity and inter-personal communication. Feature films with entertainment value would be developed for being shown on 16 mm projectors for conveying the required messages in a subtle manner. (f) Increased emphasis would be laid on development of media material in a decentralised manner, so that these are produced taking into account the regional diversities in the country and local Specific needs. (g) Regular training of IEC staff at different levels would be undertaken to expose them to the latest IEC techniques and to improve their motivation and admhaistrative/managerial abilities. (h) The funds provided for media activity would in no case be diverted in the future. T h e importancc of IEC activities in achieving the desired goals needs to be fully realiscd by the states/UTs.
Vol. 59, No. 3
(i) IEC efforts would increasingly focus on the need for participation of males in adopting contraception with a vicw to removing the misgivings and misunderstandings about vasectomy, which is much simpler procedure than the female sterilisation. Similarly, use of condoms would be popularised through suitable IEC programmes. (j) The Rajasthan experiment of integrating the IEC activities of the entire H & FW sector and developing linkages with other sister departments for a coordinating IEC effort is reported to result in better achievements. Other state/UTs may like to study this experiment for possible replication. INVOLVEMENT OF NON-GOVERNMENTAL SECTOR For supplementing the efforts of the government, it is necessary to involve the nongovernmental organisations and voluntary agencies in a very big way. Evcn though the need for this has been realised for quitc some time with a view to making the family welfare programme a people's movement, the harsh reality is that so far the contribution from the non-governmental sector is rather limited and the programme is perceived by the people as the government's programme. Voluntary sector and NGOs can not only supplement the family welfare services provided by the government but it is also expecte~l that they would have a better understanding of how to bridge the communication gap with the people and take the message of small family and maternal and child health to them in the language they understand. Instead of waiting for a voluntary agency to approach the government for assistance, it would be necessary to identify local level
M A T H U R : R E V A M P I N G T I l E FAMILY W E L F A R E P R O G R A M M E IN INDIA
individuals (youths in the villages, panchayat level leaders, private medical practitioners including ISM practitioners, ex-servicemen, retired government servants with social conscience etc.) to motivate them to participate in the family welfare programme, impart training to them and involve them either indi~Adually or collectively for generation of demand for the family welfare services and propagation of small family norm. The network of cooperative sector institutions, organised sector, trade unions, Zilla parishads, municipal corporations, panchayats, etc. would be fully involved in the implementation of family welfare programrues in a systematic manner. Increased powers to sanction schemes for non-governmental sector would be delegated to the dislrict level with a view to expediting the sanction of schemes and also because the actual work of identifying and encouraging the voluntary workers at grass root level, necessarily will have to be done by the district officers and other officers of the state governments in this field. In view of the fact that the non-governmental organisations in some states/areas have achieved exceedingly good results, visits of NGOs workers from the poor performance states/areas would be arranged to a good performance state/area. Further, the available infrastructure would also be utilised for training of voluntary sector workers to improve their administrative, financial and managerial abilities. In order to have a desired impact of the eliciting participation of voluntary and NGOs, a suitable organisation would be evolved at the central level which will have the desired degree of flexibility in sanctioning schemes and ensuring smooth flow of funds.
293
Increased allocation would be made in the central budget for implementation of family welfare programmes through NGOs/voluntary sector and receipt of external assistance for this sector would be considerably stepped up. INTER SECTORAL COORDINATION One of the key points which always needs to be kept in view is the distinction between the family welfare activities and the population control programme. Control of population is dependent on a variety of factors, many of which go beyond the sphere of the family welfare sector, but which have an equal and perhaps even more important bearing on the birth rate. In fact, the family welfare department in the centre and health & family welfare departments in the state governments are organisations which should be essentially viewed as supply departments for making available the family welfare services, but the demand for these services and the motivation for population control comes from factors, such as female literacy rate, age at marriage of women, the status of women, position of employment of women, social security and general level of economic development. These are well beyond the pale of activities of department of family welfare. There is need to have an institutional mechanism at the centre for inter-sectoral coordination particularly between the ministry of health & family welfare, ministries of human resources development, finance, information & broadcasting, environment & forcsls, labour, department of women & child development and the department of rural development. A suitable institutional mechanism would bc evolved at the central level to achieve the desired level of intersectoral coordination and similar mccha-
294
TI IE INDIAN JOUI:~'qAI,OF PEDIATRICS
nisms would bc developed at the States level. The question of setting up a high level body under the chairmanship of the Prime Minister for facilitating intersectoral coordiantion and periodic review of the population control programme may be considered. This body could be called the Population Commission or by some other name. Some countries like Indonesia have been able to give a marked thrust to family planning through such institutional mechanism. Thcir experience should be studied carefully and a suitable organisation and structure suggested for the high level body in India. If the Prime Minister could chair it, it will signify the importance which the nation needs to attach to population con-
Vol. 59. No. 3 trol. At the state level, Chief Minister may head committees to facilitate high lcvel intersectoral coordination anti giving political support to the family welfare programme. Chief Secretaries need to be involved personally in making the family welfare programme a success and should review it at least once in two months. At the district level, deputy commissioners, chief executive officers of the Zilla Parishads, would be involved in a greater way not to push the target achievements in a routine manner but to achieve inter-sectoral coordination of different departments whose activities have a direct bcaring on thc pcrformance of the family welfare programme.
IBUPROFEN FOR FEVER? The pharmaceutical companies have initiated an aggressive campaign encouraging pediatricians to use ibuprofen suspcnsion for the treatment of fever in children. The Food & Drug Administration in USA approved its use in 1989, although it has bccn used for this purpose in UK since 1972, and in Europe since 1983. Its advocates say that it is a "safe and effective antipyretic. Its temperature lowcring benefits last for 6-8 hours, rather than 4-5 hours as with acetaminophcn (paracetamol)." It is ccrtainly a safer alternale to aspirin, but not safer than paracetamol. It can impair platclet agglutinability and induce gastrointestinal hcmorrhage. We do not k,aow fully its full side effects. Thus, Lorin recommends that it should not be used for simple, or routine antipyresis, while a safer agent is available. And remember that fever does not always nccd treatment, as it is all important immunologic defence mcchanism. Abstracted fi'om : Rosefsky JB. Pediatrics 1992; 89 : 166-167 Lorin M1. Pediatrics ltY)2; 89 : 167.
SPECIAL ARTICLE
Action Plan for Revamping The Family Welfare Programme in India K.K. Mathur
Ministry of Health and Family Welfare, Department of Family Welfare, Nirman Bhavan, New Delhi DEMOGRAPHIC SCENARIO
According to 1991 census, the country's population is 843.93 million - a substantial rise from 342 million in 1947 and 684 million in 1981. The annual addition to the population is 16 million. The all-India average annual growth rate during the 1981-91 decade has been of the order of 2.1% marginally lower than 2.2% during the preceding decade. The statement at AnncxureI brings out the comparative position in regard to the decadal variation in population, change in the decadal variation and average exponential growth rate of population in different states/UTs. The latest available sample registration systcm (1989) estimates indicate the all-India birth rate of 30.6, death rate of 10.3 and infant mortality rate of 91. Two important parameters influencing fertility behaviour are female literacy and age at marriage for women. Couple Protection Rate (CPR) also indicates the level of efforts made for birth control and is at present estimated to be 44.11%. The statement at Annexure-II brings out the comparative position of dif-
ferent states/UTs in regard to several selected indicators. The long term demographic goals, as laid down in the national health policy (1983) is to achieve the birth rate of 21 per thousand, death rate of 9 per thousand, natur',d growth rate of 1.2%, infant mortality rate below 60 per thousand live births and couple protection rate of 60% by the year 2000 A.D. It has already been rccognised that given the current level of achievements, the goals may not be achievable at the national level before 2006-2011 A.D. FUTURE STRATEGIES Faced with grim prospects of population explosion, it is necessary to devise innovative strategies for imparting new dynamism to the family welfare programme. While the population control programme has to essentially evolve as a multi-sectoral programme, comprising many aspects which go beyond the acti~5ties under family welfare sector, a result oriented action plan has been developed with the consensus of the state governments and UTs administration. The board framework is summarised below.
Reprint rcquests: Mr. K. K. Mathur, Secretary.-. National Consensus and Efforts Family Welfare, Ministry of Health and Family Welfare, Department of Family Welfare, The population control programme needs Nirman Bhavan, New Delhi-110 0l I to be fully supported through a national 281
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Vol. 59. No. 3
T,,mLg 1. Selected Indicators State
Couple Protection Rate (313.91)
R A N K
Crude Birth Rate (1989)
R Infant A Morality N Rate K (1989)
R A N K
Female Literacy Rate (1991
R A N K
census)
Age at nmrriage (Female) (1981
R A N K
census)
Major States
Andhra Pradcsh Assam Bihar Gujarat Haryana Karnataka Kerala Madhya Pradcsh Maharashtra Orissa Punjab Rajasthan Tamil Nadu Uttar Pradesh West Bengal
44.3 28.2 26.0 57.8 56.6 46.9 55.6 43.3 56.2 41.0 75.8 29.0 57.3 35.5 33.7
(8) (14) (15) (2) (4) (7) (6) (10) (5) (9) ( 1) (13) (3) (11) (12)
2.5.9 29.4 34.3 28.7 35.2 28.0 20.3 35.5 28.5 30.5 28.3 34.2 23.l 37.0 27.2
(3) (9) (12) (8) (13) (5) (1) (14) (7) (10) (6) (ll) (2) (15) (4)
81 91 91 86 82 80 21 117 59 121 64 96 68 118 77
(7) (11) (10) (9) (8) (6) (1) (13) (2) (15) (3) (12) (4) (14) (5)
33.7 43.7 23.1 48.5 40.9 43.3 86.9 28.4 50.5 34.4 49.7 20.8 52.3 26.0 47.1
(3) (9) (12) (8) (13) (5) (1) (14) (7) (10) (6) (11) (2) (15) (4)
tlimachal Pradesh J&K Manipur Meghalaya Nagaland Sikkim Tripura A&N Islands Arunachal Pradesh Chandigarh D&N Haveli Delhi Goa Daman & Diu Lakshdwcep Mizoram Pondichcr~'
52.1 21.1 ~.2 5.0 4.8 20.6 17.6 42.3 10.5 41.8 47.5 40.4 34.0 30.2 8.6 41.4 60.6
(2) (11) (10)
27.7 30.1 55.8 31.1 19.7 31.4 25.7 20.5 35.6 22.5 35.6 27.2 15.7 27.9 28.8 NA 21.1
(9) (12) (6) (13) (2) (14) (7) (3) (15) (5) (16) (8) (1) (10) (11) (0) (4)
75 66 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA
52.5
(10)
48.6 44.8 55.7 47.2 50.0 66.2 29.4 73.6 26.1 68.0 68.2 61.4 70.9 78.1 65.8
(12) (14) (9) (13)
All India
44.1
91
39.4
17.3
(10)
16.6 19.5 17.8 19.2 21.8 16.6 18.8 19.1 21.1 16.1 20.3 16.7 19.2
(12) (4) (9) (5) (1) (13) (8) (7) (2) (14) (3) (11) (6)
Smaller States & UTs
(16) (17) (12) (13) (4) (14) (5) (3) (7) (8) (9) (15) (6) (1)
30.6
(11) (6) (15) (2) (16) (5) (4) (8) (3) (1) (7)
NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 18.3
Census not done in Assam in 1981; NA-Figures are not available; **Figures are provisional; @--Separate ranking done for major and smaller states.
!.IATHUR : REVAMPING "FIIE I-"AMILYWELFARE PROGRAMME IN INDIA
283
l',~tr 2. Population, Decadal Growth Rate & Average Exponential Growth Rate, 1991 Consensus State/UTs
Population 1991 Census
Dccadal Growth Rate
Average Annual Exponential Growth P, atc
1981-91
1971-81
1981-91
1971-$1
66,304,854 858,392 22,294,562 86,338,853 1,163,622 41,174,060 16,317,715 5,111,079 7,718,700 44,817,398 29,011,237 66,135,862 78,706,719 1,826,714 1,76(I,626 686,217 1,215,573 31,512,070 20,19t.),795 43,880,640 403,612 55,638,318 2,741,827 138,760,417 67,982,732
23.82 35.86 2,3.58 23.49 15.96 20.80 26.28 19.39 28.92 20.69 13.98 26.75 25.36 28.56 31.80 38.98 56.86 19.50 20.26 28.07 27.57 14.94 33.69 2.5.16 24.55
23.10 35.15 23.36 24.06 26.74 27.67 28.75 23.71 29.69 26.75 19.24 25.27 24.54 32.46 32.04 48.55 50.05 20.17 23.89 32.97 50.77 17.50 31.92 25.49 23.17
2.14 3.06 2.12 2.11 1.48 1.89 2.33 1.77 2.58 1.88 1.31 2.37 2.26 2.51 2.76 3.29 4.50 1.78 1.85 2.47 2.43 1.39 2.90 2.24 2.20
2.10 3.04 2.12 2.17 2.37 2.46 2.55 2.15 2.58 2.39 1.77 2.27 2.21 2.g3 2.80 3.99 4.09 1.85 2.16 2.87 4.14 1.63 2.79 2.29 2.10
277,989 640,725 138,542 101,439 9,37(I,475 51,681
47.29 41.88 33.63 28.43 50.64 28.40
63.93 75.55 39.78 26.07 53.00 26.53
3.87 3.50 2.90 2.50 4.10 2.50
4.98 5.67 3.38 2.32 4.29 2.37
843,930,86l
23.50
24.66
2.11
2.22
~tates ~dhra Pradesh .~runacha'l Pradesh ~,ssam Bihar Goa ,3ujarat [-lat)'ana ~limachal Pradesh 18,:K Karnataka ~erala !~ladhya Pradesh ~laharashtra ~ianipur ~,leghalaya !,lizoram ~agaland Oris~ Punjab ?,a asthan S~kkim 7atoll Nadu Tdpura ~.:tar Pradcsh ~Vcst Bengal
]~.~'lion Tcnitoties ~,&N Islands ~.handlgarh iD&N Haveli :Daman & Diu Oelhi ~Lakshdwecp &
i
i!il India
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THE INDIANJOURNALOF PEDIATRICS
consensus with willing participation of all segments of the society, cutting across political, religious and cultural differences. It has to be backed by strong political commitmerit and will, not only at the national level, but also at the level of states/UTs, which are primarily responsible for implementation of the programme. Political leaders, religious and other opinion leaders at different levels will have to be approached for their active involvement in moulding public opinion in support of the programme. Improvement of the Quality and Outreach of Services A vast network of institutions have come up in the country for delivery, of health and family welfare services over the successive plan periods. The quality of service delivery varies markedly from state to state. It has, howevcr, been recognised that on the whole the quality of service delivery extended to the people is far from satisfactory.. Besides, the outreach of services is also not adequate for the people in remote rural areas and urban slums. The following steps would be taken to improve the quality and out-reach of services. (a) Keeping in view the general constraint of resources (financial, administrative and managerial) for pushing the Family Welfare Programme, the thrust during the 8th Five Year Plan would be first to consolidate the existing infrastructure. There is no point in going for opening of new subccntres etc. in the future, if the existing subcentres are not functioning properly. However, keeping in view the norms fixed during the 7th Five Year Plan, new institutions will be sanctioned, if adequate funds are made available. In particular, it is accepted that such institutions need to be opened in tribal
Vol. 59, No.3
and remote areas. Special attention will als0 be paid to creation and strengthening of the health infrastructure in the urban slums, where it is particularly deficient. (b) Integrated training modules for training and retraining of medical and paramedical personnel involved in the dclivc~ of family welfare services will be developcd and adequate funds made available for organising different training programmes in the institutions already set up for the purpose. Communication skills and right value orientation would be important elements of the training modules. (c) As motivation is a key factor in improving the quality of delivery of services, it will form a key clement in the training modules for medical and paramedical personnel at all levels. (d) Special attention shall be paid by thz state governments/UTs administration 1o have a proper organisation for maintenance of equipment, vehicles and buildings and, wherever possible, even the existing family welfare workers will be trained for doing small repairs. This would ensure proper utilisation of vital equipment and valuable assets created undcr the programme. (e) The supervision at all levels will have to be vastly improved. This will primarily focus on identification of problems, finding solutions thereto and improving understanding and capabilities of key functkmaries involved in the delivery of services. (f) Special attention shall be paid to the construction of buildings for primary hcahh centres and sub-centres through area development projccts and under the minimum needs programme of the stale plans. (g) Tile state governments and UTs administration would look into the practical problems of the workers like ANMs in the fie!d conditions, such as their placc of stay,
~IATHUR : REVAMPING T H E FAMILY WELFARE P R O G R A M M E IN INDIA
mobility and travelling expenses etc. Inadequate attcntion to these problems seriously hampers the working of the main propagators and providers of the servicing of the familywelfare programme at the grass root level. (h) At the state level a separate secretary/special secretary level officers needs to be made responsible for the family welfare programmes. Officers should be carefully selected for this assignment and give a stable tenure of at least two years and preferably three years.
ing of the staff, requires to be speeded tip with duc attention to the quality of implementation. The relevance of the disaggregated approach does not stop at the identification of the four states. An analysis of demographic indicators at the district level indicates theft there are 90 particularly bad districts where the crude birth rate is above 39 pcr thousand (1981 census). A list of these districts is placed at Annexure-lIl. The h)llowing steps would need to be taken to improve the programme performance in these districts.
Special Strategy For 90 Districts
(a) Micro-level planning will have to be done by the states to identify the needs on a realistic basis for reduction in birth rate in these districts. Resources will be allocated for strengthening of infrastructure and provision of other essential inputs after taking into account the inputs already provided in these districts through area development projects and other special projects, if any. (b) All posts at grass root level of family welfare workers and supervisory officers would be filled up and only motivated officers with excellent record in these districts would be posted. (c) Priority for construction of subcentres and buildings for other health institutions would be given in these districts under the area development projects. (d) Intensive training of medical and para-medical personnel would be organised. (e) Since many of the low performance districts have large minority populations, minority community leaders at local levels would be involved in launching imaginative IEC programmes designed to increase family planning acceptance by all sections of the society through methods best suited to individual needs.
The demographic and health profile of the country is not uniform. Examination of the statewise data regarding behaviour of the important demographic and health indicators shows very clearly that any operational strategy, to be successful, will have to be based on a disaggregated approach. The four states of Bihar, Madhya Pradesh, Rajasthan and U.P. which constitute about 40% of the country's population, have IMR land MMR levels distinctly higher than the national average. These are also the states where the age of females at marriage, fe;male literacy and share of women in the i non-agricultural employment are distinctly ~ilower than the national average. Unless :'~specialefforts are made to bring up the proit'de and performance these states in regard i to health and family welfare, it would be ~well-nigh impossible to accelerate the ~aehievement of demographic and family !welfare goals at the national level. Special ~area development projects have already :been launched in these states with the help ~0f the World Bank, UNFPA and other !funding agencies. The execution of these projects, primarily designed to strengthen i the infrastructure and to improve the trainI
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Vol. 59. No. 3
TABLE3. Selected Indicators for 99 I)istri,_'ls with CBR > = 39 Stale
BIHAR
GIJJARAT 1bkRYANA KERAI.A MADI IYA PRAI) ES I t
ORISSA IL~d'ASTI IAN
District
Nawada Saharsa Samastipur Kalihar Gaya Kachchh Hanaskanlha Bhiwani Malappuram Sehore Rewa Guna Damoh Gwalior Parma Raisen Hoshangabad Vidisha Tikamgarh Bhind Wesl Nimar Sagar Jhabua l]ihopal Shivpuri I~etul Chhatarpur M.orena Fast Nimar Datia Dhar Salna Baleshwar Jodhpur Udaipur Sawai Madhopur Kota Jhalawar Jalor I)ungarpur I]lharalpur Banswara Ajmer Sirohi Ganganagar Jaipur Sikar Bikaner Pall Barmer Alwar Bundi Nagaur Jhun.ihunun
Sex ratio (per 1000 males) 1.002 930 972 928 962 999 945 898 1,052 907 969 882 925 845 913 998 908 881 883 827 954 891 985 874 855 973 864 834 939 853 966 936 977 909 977 867 888 926 942 1.045 831 984 922 963 874 894 963 981 946 904 892 887 958 956
Percentage of literates (female) 12.77 9.16 12.77 11.34 15.25 26.68 11.36 16.30 55.34 9.78 11.35 9.26 16_~;2 25.98 8.66 11.51 21.88 13.07 8.44 14.67 12.19 21.11 6.35 37.88 8.12 17.42 10.24 10.09 18.91 12.26 1027 13.26 28.26 14.47 10.76 8.16 17.39 9.27 4.43 7.97 10.08 7.50 21.92 9.92 14.16 .17.18 9.08 17.57 8.83 3.71 11.38 8.92 7.12 11.40
Mean age at marriage 14.7 15.7 15.9 16.2 15.4 18.2 18.5 16.1 17.8 14.8 14.4 1.5.0 14.8 15.8 15.0 14.9 15.5 14.9 14.3 14.7 16.4 14.8 17.9 16.9 14.8 16.9 14.5 14.8 16.1 14.8 16.3 14.8 16.2 16.4 15.8 15.1 15.2 14.7 17.3 16.5 16.0 16.9 15.4 17.1 16.8 15.2 15.0 15.4 16.2 16.9 16.0 14.4 15.3 15.5
Non-agri. lalx~ur as % of main workers 4.9 2.8 12.4 6.8 6.3 22.7 17.3 10.3 32.3 8.9 8.1 16.3 43.4 45.3 14.3 15.08 18.1 23.6 9.2 25.3 6.5 57.5 4.5 58.2 9.7 7.2 15.4 15.2 10.0 20.3 4.4 17.4 24.0 15.7 22.4 14.4 36.8 8.6 t0.6 21.6 30.9 18.0 23.0 29.6 26.2 24.5 17.2 35.4 12.7 14.1 19.2 21.6 6.8 12.9
CBR
IMR
39.85 '40.61 39.09 39.61 39.82 39.38 40.80 39.40 39.32 40.77 40.55 42.03 42.94 40.71 45.54 42.62 40.89 43.35 44.48 40.17 39.73 43.23 42.65 39.61 41.58 4(I.69 42.19 44.57 39.6.5 39.97 39.39 41.20 41.69 41.55 40.65 43.34 40.14 ,~016 41.59 45.12 44.02 42.39 39.08 39.75 39.15 41.62 41.00 41.32 40.14 41.45 41.36 40.68 41.46 39.98
95 113 107 1i5 1~1 89 94 .% 4') 116 1,~ 150 150 llS 185 13.5 163 1'44 195 1~ 137 161 116 ~2 150 15~ ',;';2 132 131 156 116 181 132 86 120 141 112 124 104 W. N7 ,r :~ 121 82 108 r,.'5 62 130 102 128 125 96 92
MATHUR
: REVAMPING
State
Uttar Pradesh
West Bengal
"FILE F A M I L Y W E L F A R E
District
Tonk Churn Farrukhabad Pratapgarh Mainpuri Banda Azamgarh Shahajapur Tehri Garhwal Hardoi Moradabad Aligarh Lalilpur Pilibhit Deoria Buland.,,har Gorakhpur Budawl Sharanpur Sitapur Basil Sultanpur Elah Jaunpur Agra Bareilly Gonda Allahabad Meerut Bijnor Raebereti Ghaziabad Rampur Maldah Mut~shidabad
Sex ratio (per 1000 males) 928 954 821 1,001 82 i 860 1.020 812 1,081 821 842 840 851 841 981 863 940 801 832 841 921 970 821 1.001 821 830 890 890 841 863 940 821 843 949 959
(f) In order to improve the inter-personal communication efforts at the grass root level, a scheme of link volunteers would be tried out in some of the districts on a pilot basis. The Department of Woman and Child Development would be requested to cover all the 90 districts with ICDS programme and suitable linkages developed at the service delivery level with ICDS functionaries to delivery health, nutrition and family welfare services as a package.
PROGRAMME
Percentage of litcrates (female) 8.28 9.81 19.08 8081 18.49 8.61 12.20 10.79 9.42 9.52 10.93 16.24 9.96 9.32 9.07 13.34 10.36 7.54 18.06 8.38 7.94 9.37 19.92 10.89 19.95 12.33 5.45 12.81 27.10 14.76 10.47 21.32 8.88 14.22 17.75
IN I N D I A
287
Mean age at marriage
Non-agri. labour a.s % of main workers
14.0 15.3 16.3 14.8 16. I 15.8 15.2 16.4 16.8 16.5 17.4 16.7 14.5 16.7 16.1 16.8 15.2 16.5 17.6 16.4 15.0 14.9 16.6 15.5 16.6 16.8 15A 16.5 17.0 17.9 15.7 16.9 17.4 15.9 15.94
19.1 7.4 81.4 7.4 58.5 7.1 19.2 592 1.3 38.7 74.1 57.1 26.8 54.1 7.8 49.1 9.1 56.7 59.9 33.2 9.5 9.3 75.6 45.5 75.6 79.2 7.8 16.3 172 76.7 8.7 69.5 70.9 43.8 81.3
CBR
IMR
43.65 42.08 39.49 40.15 39.52 39.85 4020 40.44 41.18 42.06 42.47 40.56 42.31 39.89 39.97 40.59 40.41 41.06 39.24 39.43 41.29 40.87 41.07 41.83 41.07 39.80 39.69 39.69 39.43 42.93 40.92 40.50 42.62 4129 39.84
148 81 122 126 121 98 110 167 99 173 126 129 138 147 120 127 123 155 96 143 164 15 I 115 448 115 146] 157 110 93 120 172 114 150 128 104
(g) The district collectors would be fully involved in coordination/supervision of thc family welfare programme related activities in these districts. Package of Incentives/Disincentives The present scheme of compensation for the loss of wages to acceptors of sterilisation/IUD, places great emphasis on target achievement with the result that the quantity has taken precedence over quality and some specific methods seem to h a v e o v e r -
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shadowed others. It has incrcasingly been able incentives to encourage good performrecognised that we should get rid of the ance by states shall bc built in the proposed "'tyranny of targets". Targets based on mi- modified scheme of compensation. cro-level planning suiting the local specific An innovative package of incentives/disneeds may, however, continue to be fixed incentives would be formulated with emfor monitoring of the programme. phasis on community based incentives and The schcme will be modified to provide social security measurez for individuals for greatcr flexibility to the states and to adopting small family norm. The commucover younger age couples with greater fer- nity based incentives would be linked to tility potential under spacing methods. The various benefits being made available to the resources meant for the purpose would be public under different socio-economic deprovided to the states/UTs in relation to velopment plans to the government. their overall birth rate reduction efforts. In order to work out a suitable formula for Promotion of Different Contraceptive devolution of resources under the scheme, a Methods/Devices Committee comprising Shri S.B. Mishra, Joint Secretary, Ministry of Health & Fam- Sterilisation procedures were the mainstay ily Welfare, Shri P.K. Mehrotra, Secretary of the programme in the past. However, (H & F.W.), M.P., Smt. Netra Shenoy, Sec- acceptors have generally been of the higher retary (F.W.), Gujarat, Smt. S. Chandra, age, who have already completed the deSecretary, (H & F.W.), Delhi and Shri G. sired family size. The contribution of steriliGopalankrishna Pillai, Secretary, (H & sation to the fertility decline, therefore, has FW), Kerala, will be constituted. The Com- been less than anticipated. While stcrilisamittee will finalise its recommendations tion would continue to play an important within one month of its constitution. role in the population control efforts, it No additional incentives to government would be ensured that the profile of the acemployees for adopting the small family ceptors would be of the right quality in norm need to be considered. A suitable terms of age and number of children alpackage of disincentives will however, be ready born. developed for them and they may be Spacing methods will be vigourously adopted by the state governments as well. It pushed for addition by the youngcr age will also be recommended to the employers couples with high fertility potential. This in the organised sector. would require good follow up services for Motivator's fee etc. presently being paid acceptors of IUD insertions to bring down to service providers will not be paid any the drop out rates, improvement in distribumore, as it also leads to emphasis on tion arrangements of conventional contraachievement of specific methods of contra- ceptives and oral pills in rural areas and ception. urban slums through strengthening of States award scheme, already decided to schemes for social marketing of contracepbe scrapped retrospectively w.e.f, the finan- tives and launching of community based discial year 1988-89, would not be revived, as it tribution of contraceptives. The free distrihad been leading to falsification of figures bution schemes which are somewhat wastand unhealthy competition. However, suit- age-prone would bc gradually curtailed and
MA'I.'HUR : REVAMPING T I l E FAMILY WELFARE P R O G R A M M E IN INDIA
limited only to such areas where these are actually needed for economic reasons or for the lack of outreach of social marketing/ community based distribution programmes. The quality of contraceptives would be improved. In this regard, supply of dry condoms under the free distribution scheme would be gradually phased out and only lubricated condoms made available. The production arrangements for weekly oral pills (centchroman) and oral contraceptives pills (Mala N and Mala D) shall be gradually improved, so as to make these easily available across the length and brcadth of the country in greater numbers. In order to give a wider choice of contraceptives to the aceeptors, new contraceptives, such as Norplant-6 and injectibles shall be introduced under the programme, initially under controlled conditions and gradually on a wider scale. No-Scalpel Vasectomy, which is much simpler, would be popularized through training more and morc doctors and paramedical staff in this method. Fertility research programmes, especially those relating to the development of male/female vaccines, anti-fertility drugs and contraceptives/abortificients under indigenous systems of medicines shall be strengthened and coordinated. UNIVERSAL IMMUNISATION PROGRAMME AND MCH PROGRAMME /
Consistently high coverages are being now reported from most of the states in the universal immunization programme. However, there still remain areas where the coverage levels are low. Special attention would be focussed on such areas during the coming years, while sustaining the high level of coverage achieved elsewhere.
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All such cases where reported coverages are more than 100% of the target fixed, the reasons for high coverages would be routincly investigated to ensure that no overreporting is allowed, as this would otherwise lead to a sense of complacency leading to outbreak of the vaccine preventable diseases. The ultimate objective bcing reduction of vaccine prevcntable diseases, the priority in the coming years would be to concentrate on the quality aspects of the service delivcry and on documenting reduction in disease incidence. The following activities in this context would be strengthened : (a) Initiating active surveillance in areas where low incidence has been recorded in the last two years. List of cases, particularly of polio and neonatal tetanus would be the lead diseases under monitoring. (b) Setting up of a network of Polio Virus Isolation Laboratories while increasing the number of field samples of Oral Polio Vaccine (OPV) to ensure that atleast one full sample is lifted from every primary health centre areas in a year. (c) Time bound investigation of all adverse reactions following vaccination. For overall improvement in the management of the programme, all supervisory posts created so far, particularly those of the district immunisation officers and refrigeration mechanics would be filled up by the states/UTs. All states/UTs would also take priority action to take over the maintenance of the cold-chain created over the last 4-5 years and further planned to be strengthened in the coming years. About 1.5 million children below 5 years of age die because of diarrhea in the country very year. Even though the oral
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TI IE INDIAN J O U R N A l . O F PEDU~TRICS
rehydration therapy (ORT) programme is being implemented for quite some time now, it has met with only partial success. There are still many medical practitioners who are not propagating it or prescribing ORS. The programme would be more vigourously promoted through the training of medical and paramedical personnel and through health education to people, particularly mothers. Keeping in view thc "Health for All goal by 2000 A.D.", a new child survival and safe motherhood programme is proposed to be implemented with I D A / U N I C E F assistance in a phased manner. It would provide for-universalisation of IFA to cover all pregnant mothers, universalisation of Vitamin A to all children upto the age of 3 years, expanding the pilot project on control of acute respiratory infections and strengthening primary health care infrastructure, coupled with an intensified training of traditional birth attendants in the higher IMR/MMR states of Assam, Bihar, Orissa, Madhya Pradesh, Rajasthan and U.P. It is expected that this project would not only help in lowering the IMR/MMR and child mortality rate, bat would also contribute significantly to improve the family welfare services. URBAN AREA SCHEMES
The schemes like post-partum centres urban family welfare centres, health posts are designed to provide family planning and maternal and child health care services to population living in the urban areas, including slum areas. While the post-partum centres have generally become hospital based programmes and are not effectively catering to the areas/population attached to them, the quality and outreach of services being provided by the urban family welfare centres/health posts are also not satis-
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factory. This has resulted in a situation in which the family planning and MCH services are not effectively reaching the urban slums population, which is an area of major concern. The following steps would be initiated : (a) With a view to strengthening the infrastructure and services, urban revamping schemes covering towns with two lakh population and above with special focus on slum areas are already being developed. The operationalisation of these schemes would be expedited with adequate funding support from central budget and external agencies. (b) The involvement of voluntary organisations in catering to the needs of slum population will be enhanced. Preference would be given to voluntary groups already active in such areas. (c) The urban institutions, whether under the government or the voluntary sector, will be closed down or will be shifted elsewhere in case an optimum level of performance is not reported. It would be ensured through proper monitoring and supervision mechanisms that these institutions do seriously endeavour to meet the respective programme objectives, particularly those related to serving the target population assigned to each. Adequate flexibility would be given to states/UTs to meet these objectives. (d) Suitable coordinating mechanisms would be developed to ensure that the urban institutions function in an integrated manner and not in total isolation of each other and the overall programme objectives. VILLAGE HEALTH GUIDE SCHEME There is a general impression that this ira-
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291
portant scheme, designed to provide for the training, many statcs/UTs have already fulbasic linkage between the community and filled targets of recruitmcnt and basic trainthe health and family welfare service deliv- ing of workers. In so far as the scheme of ery system, is not working well. Village training of health worker (male) is conHealth Guides are presently getting only corned, most states have stopped training as Rs. 50/- per month as honorarium and in fresh recruitment is not taking place. There most paris of the country, they arc not ren- are a large number of vacancies of dering much service to the community, MPW(M) in different states/UTs which Some states (J&K, Tamii Nadu, Kerala) did has caused serious concern. not implement the scheme from the very The following steps would bc taken : beginning and some others likc Assam and (a) The existing infrastructure of ANM/ Haryana have scrapped it. The decision to LHV training schools would be thoroughly replace male health guides with female reviewed for each state/UT to ensure ils health guides has also led to a plethora of proper and effective utilisation. Schools writ petitions in different high courts. The without buildings and those being run general experience has been that wherever through voluntary organisations shall bc female health guides are in position, the closed down gradually. The remaining ground situation of service delivery is much schools will be utilised for running intebetter. The consensus is that in case the grated training modules for para-mcdical scheme cannot be implemented with only workers, including of voluntary sector, and female health guides, it may be better to for continuing education programmes. scrap it altogether. (b) Statcs/UTs would initiate action to The following steps would be taken : create posts of MPW(M) to mcct the exist(a) All the pending court cases would bc ing gaps in a phased manner and effectively effectively followed up and got decided on a utilise the available training infrastructure. priority basis. (c) Net working arrangements of train(b) The existing number of village health ing institutions at different levels would be guides shall bc fully utilised by statc/UTs developed, with a view to ensuring uniformwi-:h reduced functions, if necessary. Their ily in training modules, avoiding duplication services may primarily bc utilised as motiva- and bringing about effective coordination. tors and the depot holders for contraceptives, oral rchydration salts, IFA tablets etc. INFORMATION, EDUCATION, (c) The possibility of revitalisation of the COMMUNICATION scheme to make it more effective or altcrnatively of disbanding it would be examined Information, education and communication further taking into account the varied impli- (1EC) inputs need to be revitalised, not only cations, including from the legal angle. to propagate the family welfare programme, but also to bring about attitudinal CONTINUATION OF ANM/LHV TRAINchanges, so as to cover a part of the ground ING SCHOOLS which should bc normally prepared through There are a large number of AN/LHV/ education and social work. The new IEC MPW(M) training schools in different parts strategy, would have the following key eleof the country. As regards ANM/LHV ments :
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]'FIE INDIAN JOURNAL OF PEDIATRICS
(a) The IEC message would be to associate family welfare with planncd parenthood and not just with the adoption of contraception. (b) The messages would be positive with thrust on qu',dity of life issues and removal of ignorance, apathy and misgivings about the family welfare programmes. (c) In order to involve the community in generating demand for family welfare services, the scheme of Mahila Swasthya Sangh, which has been recently introduced in some selected districts, would be further strengthened in case the results are found to be encouraging. (d) The messages through the mass media would be of a balanced nature, so that these do not hurt the sensibility of the people at large in our socio-cultural ethos. (e) In order to cover 40% of the population, which is not covered by any mass media presently, special attention shall be paid to traditional art forms, folkfore, field publicity and inter-personal communication. Feature films with entertainment value would be developed for being shown on 16 mm projectors for conveying the required messages in a subtle manner. (f) Increased emphasis would be laid on development of media material in a decentralised manner, so that these are produced taking into account the regional diversities in the country and local Specific needs. (g) Regular training of IEC staff at different levels would be undertaken to expose them to the latest IEC techniques and to improve their motivation and admhaistrative/managerial abilities. (h) The funds provided for media activity would in no case be diverted in the future. T h e importancc of IEC activities in achieving the desired goals needs to be fully realiscd by the states/UTs.
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(i) IEC efforts would increasingly focus on the need for participation of males in adopting contraception with a vicw to removing the misgivings and misunderstandings about vasectomy, which is much simpler procedure than the female sterilisation. Similarly, use of condoms would be popularised through suitable IEC programmes. (j) The Rajasthan experiment of integrating the IEC activities of the entire H & FW sector and developing linkages with other sister departments for a coordinating IEC effort is reported to result in better achievements. Other state/UTs may like to study this experiment for possible replication. INVOLVEMENT OF NON-GOVERNMENTAL SECTOR For supplementing the efforts of the government, it is necessary to involve the nongovernmental organisations and voluntary agencies in a very big way. Evcn though the need for this has been realised for quitc some time with a view to making the family welfare programme a people's movement, the harsh reality is that so far the contribution from the non-governmental sector is rather limited and the programme is perceived by the people as the government's programme. Voluntary sector and NGOs can not only supplement the family welfare services provided by the government but it is also expecte~l that they would have a better understanding of how to bridge the communication gap with the people and take the message of small family and maternal and child health to them in the language they understand. Instead of waiting for a voluntary agency to approach the government for assistance, it would be necessary to identify local level
M A T H U R : R E V A M P I N G T I l E FAMILY W E L F A R E P R O G R A M M E IN INDIA
individuals (youths in the villages, panchayat level leaders, private medical practitioners including ISM practitioners, ex-servicemen, retired government servants with social conscience etc.) to motivate them to participate in the family welfare programme, impart training to them and involve them either indi~Adually or collectively for generation of demand for the family welfare services and propagation of small family norm. The network of cooperative sector institutions, organised sector, trade unions, Zilla parishads, municipal corporations, panchayats, etc. would be fully involved in the implementation of family welfare programrues in a systematic manner. Increased powers to sanction schemes for non-governmental sector would be delegated to the dislrict level with a view to expediting the sanction of schemes and also because the actual work of identifying and encouraging the voluntary workers at grass root level, necessarily will have to be done by the district officers and other officers of the state governments in this field. In view of the fact that the non-governmental organisations in some states/areas have achieved exceedingly good results, visits of NGOs workers from the poor performance states/areas would be arranged to a good performance state/area. Further, the available infrastructure would also be utilised for training of voluntary sector workers to improve their administrative, financial and managerial abilities. In order to have a desired impact of the eliciting participation of voluntary and NGOs, a suitable organisation would be evolved at the central level which will have the desired degree of flexibility in sanctioning schemes and ensuring smooth flow of funds.
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Increased allocation would be made in the central budget for implementation of family welfare programmes through NGOs/voluntary sector and receipt of external assistance for this sector would be considerably stepped up. INTER SECTORAL COORDINATION One of the key points which always needs to be kept in view is the distinction between the family welfare activities and the population control programme. Control of population is dependent on a variety of factors, many of which go beyond the sphere of the family welfare sector, but which have an equal and perhaps even more important bearing on the birth rate. In fact, the family welfare department in the centre and health & family welfare departments in the state governments are organisations which should be essentially viewed as supply departments for making available the family welfare services, but the demand for these services and the motivation for population control comes from factors, such as female literacy rate, age at marriage of women, the status of women, position of employment of women, social security and general level of economic development. These are well beyond the pale of activities of department of family welfare. There is need to have an institutional mechanism at the centre for inter-sectoral coordination particularly between the ministry of health & family welfare, ministries of human resources development, finance, information & broadcasting, environment & forcsls, labour, department of women & child development and the department of rural development. A suitable institutional mechanism would bc evolved at the central level to achieve the desired level of intersectoral coordination and similar mccha-
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nisms would bc developed at the States level. The question of setting up a high level body under the chairmanship of the Prime Minister for facilitating intersectoral coordiantion and periodic review of the population control programme may be considered. This body could be called the Population Commission or by some other name. Some countries like Indonesia have been able to give a marked thrust to family planning through such institutional mechanism. Thcir experience should be studied carefully and a suitable organisation and structure suggested for the high level body in India. If the Prime Minister could chair it, it will signify the importance which the nation needs to attach to population con-
Vol. 59. No. 3 trol. At the state level, Chief Minister may head committees to facilitate high lcvel intersectoral coordination anti giving political support to the family welfare programme. Chief Secretaries need to be involved personally in making the family welfare programme a success and should review it at least once in two months. At the district level, deputy commissioners, chief executive officers of the Zilla Parishads, would be involved in a greater way not to push the target achievements in a routine manner but to achieve inter-sectoral coordination of different departments whose activities have a direct bcaring on thc pcrformance of the family welfare programme.
IBUPROFEN FOR FEVER? The pharmaceutical companies have initiated an aggressive campaign encouraging pediatricians to use ibuprofen suspcnsion for the treatment of fever in children. The Food & Drug Administration in USA approved its use in 1989, although it has bccn used for this purpose in UK since 1972, and in Europe since 1983. Its advocates say that it is a "safe and effective antipyretic. Its temperature lowcring benefits last for 6-8 hours, rather than 4-5 hours as with acetaminophcn (paracetamol)." It is ccrtainly a safer alternale to aspirin, but not safer than paracetamol. It can impair platclet agglutinability and induce gastrointestinal hcmorrhage. We do not k,aow fully its full side effects. Thus, Lorin recommends that it should not be used for simple, or routine antipyresis, while a safer agent is available. And remember that fever does not always nccd treatment, as it is all important immunologic defence mcchanism. Abstracted fi'om : Rosefsky JB. Pediatrics 1992; 89 : 166-167 Lorin M1. Pediatrics ltY)2; 89 : 167.
