CHAPTER2

A LITERATURE REVIEW

Interest in management of family planning programs is rather recent. It was only in the

mid 1970's that some scholars examined family planning from the management

perspective. As mentioned in the previous chapter, most of the studies have focused on

the socio-economic conditions of the population rather than the aspects of service

delivery by the health programme. In this chapter we review the relevant literature that is

available on the management of population programs. A reading of the literature on the

management of population programmes suggests that the aspects such as

decentralization, supervision, training of health personnel, quality of care, referral

mechanisms, infrastructural facilities, logistics management and management information

systems are central to the management of population programmes. With the introduction

of the RCH programme, these aspects assume more importance. We now review the

findings of studies with respect to the above mentioned aspects. We also review studies

on various aspects of the expanded service coverage as envisaged in the RCH approach.

2.1 COMMUNITY NEEDS ASSESMENT APPROACH

_The Programme of Action (PO A) of the Cairo Conference places individual desire and

childbearing preferences over demographic goals, thereby making unmet need the main

reason for the provision of family planning. The POA states: "Government goals for

family planning should be defined in terms of unmet needs for information and

services"(United Nations, 1994). Simultaneously with a need-based approach to family

planning, the Programme of Action proposes the stabilization of population growth rates

and supports demographic objectives of a country as the basis for development goals:

"Demographic goals, while legitimately the subject of government development

strategies, should not be imposed on family planning providers in the form of targets or

quotas for the recruitment of clients" (ibid.). Imposition of contraceptive targets were

common in the countries of the Indian sub-continent and other countries of Asia.

18

Target-oriented strategies were adopted in the family planning programmes of many

countries in the 1960s and 1970s. Incentives were provided to acceptors, providers and

motivators/referrers of acceptors. The well-known examples of programme use of

incentives were_ Bangladesh, Nepal, Pakistan and Sri Lanka. Programmes in these

countries provided financial remuneration to acceptors on several justifications, such as

reimbursement for transport or compensation for loss of time and wages. To the extent

that poverty was a major barrier in contraceptive acceptance, financial compensation was

found to remove the barrier and promote acceptance. In many instances, it was

presumed to have a triggering effect, sometimes expressed as "leading the client over the

fence". However, in many instances, the amounts of remuneration far exceeded what

would be needed for transport and wage loss. In such cases, incentives created a positive

inducement among potential acceptors to override other factors in the decision-making

process and led to dissatisfaction and regret among acceptors of permanent methods.

Such inducements are also known to -have led to overreporting, and neglect of

counselling and quality of care (Khan et al., 1998).

Another example of the effects of incentives can be drawn from the Philippines. During

the pre-Cairo Conference period, service providers used to receive 300 pesos for each

female sterilization and 200 pesos for each male sterilization they performed. After the

Cairo Conference, the Philippine programme adopted a policy of non-coercion to allow

couples "to decide whether to have children, when and how many, or whether to practise

family planning" (WHO, 1995), and accordingly financial incentives were withdrawn.

This policy change appears to have contributed to a shift in contraceptive mix with a

significant rise in the use of pills, injectables and condoms.

In Vietnam, despite a recent government policy of broadening the contraceptive method

mix through free and informed choice, the programme still provides financial

remuneration for performing selected methods, such as sterilization, IUD and menstrual

regulation. In the case of sterilization, the programme personnel motivating sterilization

acceptors are also benefited by the payment system. This financial incentive system

appears to create an unequal opportunity for method acceptance and, perhaps, can

potentially affect the quality of care (Knodel et al., 1995). As a result, despite a genuine

intention to broaden method mix in Vietnam, the impact so far has been minimal.

19

Imposition of contraceptive targets was common 1n the countries of the Indian sub-

continent and other countries of Asia.

The extension approach of the Indian family planning programme followed upto the

early part of the Fourth Five Year Plan was found inadequate to meet the demographic

outcome as revealed by the 1961 census. In 1965, The United Nations Advisory Mission .. to India emphasized a vigorous approach through intensified promotion of sterilizations,

IUD and diversification of the distribution of condoms to achieve a birth rate of 25 per

1000 population by the year 1973 (Raina, 1988). The inability of performance to be

quantified under the extension approach was the main reason for the introduction of the

target approach. It was felt during the time that targets were understood well, have been

in use in the industry and agriculture for a long time and hence familiar to the

administration. The ease of quantification of achievements and evaluation of the

performance was appreciated and understood (Visaria, et al., 1998).

Population experts argued that focus on numerical targets thwarted attainment of the

desired demographic impact and that excessive pressure to achieve targets resulted in

over-reporting and mismanagement. Non-governmental organizations and women's

groups argued that the central government's notion that India's birth rate must be

reduced by vigorous promotion of contraception was a violation of human rights. The

poor quality of care provided to women by service providers was taken as a sign of how

little regard providers had for women's health. In the 1980s and early 1990s, several key

stakeholders, including donor agencies, stimulated discussion of varied viewpoints and

advocated for a shift from the target-oriented approach to. innovative ways of meeting

reproductive health needs using an integrated approach.

The government began to reorient the family planning programme in the light of some

of the policy proposals of the Karunakaran Committee, the Expert Group chaired by Dr.

Swaminathan, and the concerns articulated in the POA approved in the ICPD held in

September 1994. The government started the process of abolishing targets on an

experimental basis in September 1995, in the states of Tamil Nadu and Kerala and one or

two districts in other states. The new approach envisaged decentralized planning at the

sub-centre level, in consultation with the community, to determine annual workloads

based on local needs. By shifting more explicitly to client needs and involving the

20

rl 0 () rl -

community, it was hoped to provide better quality serv1ces. Expected level of

achievement (ELA), instead of targets, were now set by workers at the grassroot level in

response to community needs (MOHFW, 1997; Visaria and Visaria, 1998; Narayana et

al., 2001; Murthy 1999b)

In April 1996, based on the limited experiences gained by the states in implementing the

TFA, the central government decided to abolish targets throughout India, making the

entire nation target free. Targets were removed without adequate preparation and

Without discussion of what would replace the old system. No new monitoring system

was proposed to replace the target system. At the policy level, the shift to the TF A was

recognized as a necessary step for enhancement of the quality of services. At the

implementation level (state and district), however, the only guidance programme

implementers received was in the form of a manual (written in English) to orient them

on decentralized planning, starting at the sub-centre level.

~-o-/·:· ..

In Sep~e~ber 1997, .the government realized that the TF A manual was no~ proving to be f!..;.::,· usefulm 1mplementmg the new approach and that the term TF A was a rmsnomer. Manf:~'

1

health workers equated TFA with "no work" or "no more monitoring based on targets\'·-.·>.'' ..

and became complacent. The formats introduced to estimate community needs and ~

expected levels of achievement were too complicated to be followed by workers. The ·

training provided to health workers in the use of these formats was inadequate and

lacked uniformity. To convey clearer guidelines to health workers and to simplify the

implementation of the TFA concept and philosophy, the government renamed the TFA

as the Community Needs Assessment (CNA) approach. Iq 1998, they developed and

distributed the CNA manual to replace the TFA manual (Narayana et al., 2001).

Tamil Nadu has been experimenting with the target free approach much before the

nation-wide initiative. During 1991-92, Tamil Nadu withdrew targets for non-health staff

in two districts (Periyar and Dindigul). By March 1992, it was clear that the Health

Department staff worked better without competition from the Departments of Revenue

and Rural Development. Family planning targets were abolished for non-health staff

throughout the state in November, 1992 (Ramasundaram, 1995). Tamil Nadu began to

reorient the target system for health workers starting from June 1994. Individual

Thesis 362.1982095482

K167 Ma

II ill// I //II/IIIII IIIII /IIIII/I Th12002

tubectomy and IUD targets for village health workers were based on the current birth

rate of the district, rather than a uniform norm; and individual vasectomy targets were set

for the male health staff (i.e., six men per worker per year) (Poornalingam, 1995).

Visaria and Visaria (1998) studied the implementation of RCH and CNA approaches in

Rajasthan and Tamil Nadu a year after its implementation. They found that each state

determined the family planning workload of the health workers differently. In Rajasthan,

family planning targets were determined at the local level with the help of an improved

version of the former Eligible Couple Register. The unmet need for family planning as

well as the segmentation of couples in terms of number of surviving children was done

during an annual survey conducted during the months of April to June each year. This

information was used to determine the workload of the health worker for different

services like antenatal care, immunization and family planning. In Tamil Nadu, the health

workers did not seem to emphasize the survey. Instead, the district-specific estimate of

the current birth rate (based on a 1995-96) survey was applied to the population assigned

to the health worker to arrive at the number of births likely to take place in her area. This

formed the basis for estimating the workload for different health services provided by

the health worker. Thus, in the new approach instead of giving uniform targets to each

_worker, the targets were determined on the basis of actual population information. This

workload was translated into targets and the workers were expected to achieve them

(Visaria and Visaria, 1998).

Murthy et al., (2002) in their study of the implementation of the CNA approach in Tamil

N a

district of Gujarat (CORT, 1998) reported that medical officers and health workers felt

that quality of the family planning programme had improved since targets were

abolished, particularly in terms of coverage and care of pregnant women. Since

grassroots workers were providing maternal and child health services and not merely

chasing women for sterilization, their credibility in the community had improved.

After the target free approach was introduced in the entire country in 1996, the absolute

number of acceptors of all family planning methods (except oral pills) in the country as a

whole declined during 1996-97 (Visaria and Visaria, 1998; Narayana, et al., 2001). The

decline in performance in traditionally high performance states was marginal, but in

states like Uttar Pradesh and Bihar, it was sharp and perceptible (Narayana, 2001). The

decline was most evident in the reported number of users of condoms and to a lesser

extent in the new acceptors of IUDs, presumably because the pressure to distort the

statistics had disappeared. However, during 1997-98, the acceptance of all methods

improved, thereby allaying fears of many skeptics that contraceptive prevalence would

decline in a target-free climate.

2.2 IMPROVED SERVICE COVERAGE

Implementation of the reproductive health approach requires an expansion of the

- package of services offered by the programme. The services include a broader range of

safe and effective contraceptive methods as well as incorporating reproductive health

services which are not yet available like the management of reproductive tract infection

and addressing the special reproductive health needs of adolescents and those that

recognize the special needs of men. (Pachauri, 1999; Visaria et al, 1999). This ts a

significant departure from the earlier focus on providing family planning services

particularly sterilization.

The package of services offered under the RCH programme with respect to maternal

health is as follows : antenatal care and early identification of maternal complications,

delivery by trained personnel, promotion of institutional deliveries, management of

obstetric emergencies, management of reproductive tract infections and sexually

transmitted diseases, improved access to safe abortion services, special services for

23

adolescents and men and promotion of birth spacing methods. We now review the

relevant literature with respect to each of these services.

2.2.1 Antenatal Care

The Safe Motherhood Initiative proclaims that all pregnant women must receive basic,

professional antenatal care (Harrison, 1990). Ideally, antenatal care should monitor a

pregnancy for signs of complications, detect and treat preexisting and concurrent

problems of pregnancy, and provide advice and counselling on preventive care, diet

during pregnancy, delivery care, postnatal care, and related issues. The Reproductive and

Child Health Programme recommends that as part of antenatal care, women receive two

doses of tetanus toxoid vaccine, adequate amounts of iron and folic acid tablets or syrup

to prevent and treat anaemia, and at least three antenatal check-ups that include blood

pressure checks and other procedures to detect pregnancy complications (MOHFW,

1997; 1998).

Studies in Ethiopia, India, Nigeria, Senegal and Zimbabwe have found that lack of

antenatal care was an important risk factor for maternal death (Kwast et al., 1988; Bhatia,

1993; Anandalakshmy et al., 1993; Hartfield, 1980; Garenee et al., 1997; Mbizvo et al.,

1993). The reason for this association is not clear. A possible hypothesis is that women

know exactly where to go in the case of an obstetric emergency, and having had a contact

with the health system in the antenatal period may lead to shorter delays in decision

making about the place of care and better outcomes Qejeebhoy, 1997). Other studies

have observed an association between antenatal care for poor obstetric history combined

with timely referral transport and a lower risk of maternal death. An association between

use of antenatal care and institutional delivery was observed in Zaire and Ethiopia

(Kwast et al., 1988; Dujardin et al., 1995; Bloom et al., 1999).

In a study of the relationship between utilization of antenatal care and contraceptive

usage, Mishra et al., (1998) found that contraceptive prevalence observed to be higher

among acceptors of ANC services as compared to non-acceptors but the former were

also more inclined to practice contraception in the future and more likely to adhere to

the small family norm as opposed to the latter. The strength of the association between

24

the two variables was observed to be higher among younger women suggesting that

widespread provision of antenatal services can effectively promote the use of spacing

methods.

Tetanus has long been a major killer of newborn children in India, especially in rural

areas. Although mortality rates have fallen considerably in recent years, an estimated

200,000 newborns still die of tetanus annually. An analysis of the NFHS-1 showed that

women's tetanus immunization providec1_ in the antenatal service package is not only

associated with lower neonatal mortality but also lower childhood mortality (Luther,

1998).

Anemia is a particularly widespread problem among women during pregnancy, when iron

requirements increase nearly five fold (Hallberg, 1988). An analysis of data from a

referral hospital in Punjab revealed that severe anemia contributed directly or indirectly

to 35 per cent of all in-hospital maternal deaths (Sarin, 1995). A case control study in

Mahrashtra showed that anemic women were significantly more likely to die of maternal

causes than women who are not anemic (Ganatra et al., 1996). The consequences of

maternal anemia for infants are equally acute in terms of perinatal mortality, low birth

weight and failure to thrive (Mathai, 1989; Ramachandran, 1989). Iron and folic acid

supplementation is shown to reduce deficiency related foetal malformations (Sloan et al.,

1992). Data from the NFHS-2 has revealed that iron and folic acid supplementation has

reduced the prevalence of anemia among pregnant women (liPS, 2000). Other studies

(Tee et al., 1999; Beard 1998; Gross et al., 1994) have also shown that iron and folic acid

supplementation is an effective means of reducing anemia among pregnant women.

2.2.2 Promotion of Safe Deliveries

Skilled care during childbirth is important because millions of women and newborns

develop serious and hard to predict complications during or immediately after delivery.

Skilled attendants-health professionals such as doctors or midwives who have

midwifery skills-can recognise these complications, and either treat them or refer

women to health centres or hospitals immediately if more advanced care is needed

(Family Care International, 1997). Despite its importance, 60 million women in the

developing world give birth each year without skilled help-cared for only by a

25

traditional birth attendant, a family member, or no one at all (WHO, 1997). In 1996,

skilled birth attendants were present at only 53% of births in the developing world.

In a study of maternal mortality in Maharashtra, Ganatra et al., (1996) found that women

who delivered in institutions or who were delivered by a trained attendant were twice as

likely to survive than those who delivered at home or were delivered by an untrained

attendant. A study in Tanzania showed that perinatal mortality in home births delivered

without a trained attendant was three times higher than that for births in hospitals or

dispensary with trained attendant (Walraven et al., 1995). In Papua New Guinea, a high

rate of obstetric complications was found amongst apparently normal pregnancies

delivered at home (Garner et al., 1994).

In rural Karnataka, as many as 90 per cent of the pregnant women planned to deliver at

home, with the hdp of a dai or a family member (39 per cent), or an ANM (51 per cent).

The preference to deliver at home reflects the high costs of institutional deliveries and

the absence of a female doctor at the facility. 6 per cent of those who planned to deliver

at a facility were compelled to deliver at home because of difficulties in arranging

transport or because the ANMs dissuaded them (Ganapathy et al.,).

Another factor affecting women's health-seeking behavior, especially as related to

pregnancy and childbirth, is that traditionally in rural India pregnancy is considered a

natural state of being for a woman rather than a condition requiring medical attention

and care. Such perceptions and beliefs constitute a "lay-health culture" that discourage

the use of professional assistance for childbirth (Sugathan et al., 2001). Bolam et al.,

(1998) reported that strong cultural preferences for either an unattended delivery or

those attended by an untrained family member contributes to the low proportion of

institutioan deliveries. Other studies observed that women were averse to using health

professionals at birth because their practice did not correlate with local experiences

(Kamal, 1992; Ram, 1994; Sargent, 1985).

Despite the availability of government and mission hospitals, 45 per cent of pregnant

women continued to deliver at home, and all were delivered by untrained attendants.

Although complications were reported, few sought treatment unless the symptoms were

26

severe (Bhandari and Mayank, 1999). Women have little recourse in obstetric

complications (such as haemorrhage or obstructed labour) that frequently occur suddenly

and without warning.

In their study of factors affecting home delivery in Nepal, Bolam et al., (1998) showed

that over half of the home deliveries were unplanned rather than chosen, precipitate

labor and lack of transport being the most important reasons for not choosing

institutional deliveries. The authors recommend that provision of an ambulance system

and local delivery units could improve the proportion of institutional deliveries.

2.2.3 Management of Obstetric Emergencies

Research has drawn attention to the importance of PSsential obstetrical care, particularly

e!I!ergency care, in reducing maternal mortality (Maine, 1991; Maine and Rosenfield,

1999). An estimated 90 per cent of the maternal deaths can be prevented by timely

medical intervention (Abou Zahar et al., 1991). Ensuring quick access to appropriate

services when obstetric emergencies arise is one of the most important aspects of safe

motherhood in developing countries (Campbell et al., 1995). Once a major obstetric

complications develop, a trained traditional birth attendant or nurse can do little at home

because surgical intervention is often necessary. It has been proposed that FRUs, where

emergency obstetric care can be provided, should be established.

There has been a consensus among the WHO and other donors that emergency obstetric

care by establishing referral systems is the most effective way to reduce maternal

mortality and this has become the main strategy for preventing maternal mortality

(Mavalankar, 1999). Such referral units were believed to be the most cost-effective way of

reducing maternal mortality (Maine, 1991).

Obstetric complications are random and unpredictable events and have few reliable

markers in the prenatal period (McDonagh 1996; Repke and Robinson, 1998). However,

contacts with the health system in the antenatal period can detect and treat various

conditions like anemia, proteinurea and pre-eclampsia. Jejeebhoy's review of maternal

mortality in India found that women with one antenatal visit have higher chances of

survival than women who had none Qejeebhoy, 1997). A possible hypothesis could be

27

that knowing where to go in the case of an obstetric emergency, and having had a

contact with the health system in the antenna! period may lead to shorter delays in

decision making about the place of care and hence better outcomes.

The CSSM programme over which the RCH programme is built on envisaged a network

of FRU's for providing emergency obstetric services (MOHFW, 1993). They were to be

well equipped with regular supplies and adequate staff. However, an assessment of the

_ CSSM programme revealed that many of the FRUs did not provide emergency obstetric

services as they did not have specialists like anesthetists and obstetricians and the

operating theaters did not have facilities for blood transfusion (MotherCare, 1996).

In their study of the role of primary health services in safe motherhood in Uttar Pradesh,

Ramarao et al., (2001) found that rudimentary capacity in terms of equipment and

supplies and staff competence to handle complications exists. They recommend three

strategies to complement and strengthen the government's initiative in providing

essential and emergency obstetric care. These include training ANMs in accurate

recognition and management of obstetric complications; developing messages to teach

communities to recognize emergency obstetric situations and arrange transportation to a

first referral unit; and building on the antenatal visit to provide information and sustain

links between services and communities.

The RCH programme recognizes the weakness in the emergency obstetric care delivery

in the primary health care system and envisages to strengthen it by hiring specialists on

contractual basis, making CHC's / PHC's operate for 24 hours so that people can seek

services beyond normal working hours, linking PHCs/ CHCs to the nearest blood bank

for regular and reliable blood supply and arranging for referral transport through

Panchayats (MOHFW, 1997).

28

2.2.4 Management of Reproductive Tract Infections And Sexually Transmitted

Diseases

It is believed that RTis are uncommon diseases restricted to a subgroup of the

population primarily involved in high risk activities. Though the prevalence of these

diseases is higher among high-risk population like commercial sex workers, truck drivers,

there is a substantial burden of disease among what has been traditionally been

considered lower risk populations, such as women presenting for family planning or

_availing antenna! services.

The NFHS-2 reported that two out of five currendy married women in India (39

percent) have at least one reproductive health problem. Thirty-six percent have problems

with vaginal discharge or urinary tract infections, 13 percent report painful intercourse,

and 2 percent report bleeding after intercourse (liPS, 2000).

Women are recognized to be vulnerable, both biologically and socially to reproductive

tract infections. Biologically, women are more susceptible to RTI's than men as the

vagina offers a larger mucosal surface exposed to their partner's sexual secretions during

intercourse and a more conductive environment for bacterial and protozoal growth. The

transmissibility of sevt>ral RTis is much greater from infected men to uninfected women

than the reverse (Cates and Wasserheit, 1991). In contrast to men, a greater percentage

of RTis are asymptomatic. Consequendy they do not seek treatment and are at an

increased risk of developing complications. Due to lack of awareness, fear of social

stigma and poor access to services - even symptomatic women often fail to seek timely

care. Women also tend to suffer more because of the synergistic effects of infection,

malnutrition and reproduction.

The consequences of untreated RTis in women range from acute distress to death (Elias,

1991). Women with pelvic inflammatory disorders (PID) are at an increased risk of tubal

infertility, ectopic pregnancy, recurrent urinary tract infection, considerable pain during

coitus, menstrual irregularities and chronic pelvic pain. The incidence of infertility in

developed countries is estimated at 15 - 25 percent of certain RTis. These percentages

29

are much higher in developing countries as treatment is much delayed, of insufficient

duration, or completely unavailable (Germain et al., 1992). Around 50 - 80 percent of

female infertility in Africa is thought to be due to RTis (Wasserheit and Holmes, 1992).

In India, RTI induced is estimated to be 6 - 7 per cent though these are thought to be

underestimates Q"ejeebhoy, 1995). Infertility can be a devastating social handicap for

women in India, and often leads to marital discord and social ostracism. Certain RTI's

like genital warts are the causal agents of cervical cancer (Luthra et al., 1992; Richter,

1990). · Studies have demonstrated that RTis are an important reason for the poor

acceptance and low continuation rates of contraceptive methods such as the IUD (Bhatia

and Cleland, 1995).

An important reason for the rapid spread of HIV in India (doubling every two years)

(Brookmeyer et al., 1995) is believed to be the high existing levels of untreated RTis,

amongst the highest in the world. There is evidence from field based projects

(particularly in Africa) that lowering the rate of new infections and reducing the

infectivity period of old infections can successfully control the transmission cycle of

RTis and positively impact the spread of HIV (Grosskurth et al., 1995).

Failure to diagnose and treat RTis in pregnant women can also adversely affect child

health and child survival. If a pregnant women infected with early syphilis remains

untreated, her foetus has about 40-50 percent chance of perinatal death or prematurity

(Adler, 1995). Infants born to mothers infected with chlamydia and gonorrhoea are at

risk of congenital infections which manifest as sepsis and pneumonia.

Till recently, treatment for RTI's in the public sector was available in clinics run as part

of the National STD Control Programme. Rural areas are not even touched by these

clinics. On the government's own admission, its clinics cover barely between 5 to 10 per

cent of all RTI patients in the country (Ramasubban, 2000).

In addition to the limited access to treat RTis, lack of awareness, cultural barriers and

economic factors prevent them from seeking timely care for RTis. Women are relatively

unlikely to seek advise when there is a tendency to view morbidities such as 'white

discharge' as normal, and when the condition is often associated with shame or guilt,

30

owing to its perceived link to promiscuity. Pelvic examinations are strongly resisted by

women, especially if performed by providers who are not sensitive to their needs

(Mamdani, 1999). The programme therefore needs to address these concerns along with

clinical interventions.

The Government of India recognized the importance of RTis and STis in undermining

the health and welfare of individuals and couples in a policy statement on the

Reproductive and Child Health Programme, which states that couples should be 'able to

have sexual relations free of fear of pregnancy and contracting diseases'. The

Reproductive and Child Health Programme includes the following relevant interventions:

establishment of RTI/STI clinics at district hospitals (where not already available),

provision of technicians for laboratory diagnosis of RTis/STis, and in selected districts,

screening and treatment ofRTis/STis (MOHFW, 1997).

2.2.5 Access to Safe Abortion Services

The POA of the ICPD, Cairo recognizes unsafe abortion as a maJOr public health

problem and the right to abort an unwanted pregnancy is acknowledged as a woman's

basic right (United Nations, 1994). The much debated paragraph 8.25 of the Program of

Action states :

In no case should abortion be promoted as a method of fami!J planning. All governments and relevant intergovernmental and NCO's are urged to strengthen the commitment to women's health, to deal with the health impact if unsafe abortion as a mqjor public health concern and to reduce the recourse to abortion through expanded and improved fami!J planning services. Women who have unwanted pregnancies should have a reaqy access to reliable information and compassionate counseling .. In circumstances where abortion is· not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management if complications arisingfrom abortion.

In the RCH programme, the Government of India has reiterated its commitment to

strengthening abortion services to ensure that all women desiring of abortion of

unwanted pregnancies should have easy access and hygienic abortion services.

Though the number of clinics and hospitals offering government approved abortion

services has increased from 3905 in 1981-82 to 9467 in 1997, this has been inadequate

compared with the estimated incidences of abortion in the country (Khan et al., 1999).

31

Moreover, these facilities are concentrated in the urban and more developed states of the

country. For instance, Bihar which has 10 per cent of the country's population has 1 per

cent of the total number of facilities.

WI:ere approved facilities exist, centres may not actually provide serv1ces. A health

facility survey in Maharasthra, Gujarat, Tamil Nadu and Uttar Pradesh (Khan et al., 1999)

showed that only a quarter of the approved PHC's in Maharashtra and Uttar Pradesh,

one-third in Gujarat and about half in Tamil Nadu were actually providing MTP facilities.

In fact, between 16-32 per cent of the authorized PHC's in these four states had never

provided MTP services.

The same study reported that abortion is not viewed by service providers positively and

disliked doing the procedure. They performed abortion services only out of a sense of

duty. Less than 20 per cent of the doctors and other staff approved of abortion

unconditionally and between 4 to 24 per cent of the doctors and 23 to 52 per cent of the

workers were totally opposed to abortion. Doctors often insist that a woman undergoing

an abortion should be sterilized. This pressure is strongest in Tamil Nadu where it was an

almost unwritten rule that an abortion must be followed by sterilization.

Due to poor availability and distribution of legal, government-approved MTP facilities,

an array of illegal services develop to cater to the demand for abortion services. The

proportion of illegal abortions has been estimated to be upto 10 times higher than the

legal component (Chhabra, 1996; Chhabra and Nuna, 1994; ICMR, 1989,Jesani and Iyer,

1993; Karkal, 1991). Illegal services have often been equat~d with those provided by

traditional birth attendants (dais), registered medical practitioners and nurses. While such

illegal providers exist, the range of illegal providers also include physicians without

specialized training in MTP and unregistered gynecologists (Ganatra et al., 2000).

In the absence of adequate facilities for abortion, inadequate information and prevailing

norms and negative attitudes of providers, women resort to illegal service providers for

abortion which puts a woman's health to severe risk. It has been estimated that about

15,000-20,000 abortion related deaths take place in the country each year (World Bank,

32

1995). The Office of the Registrar-General of India, estimates that abortion contributes

to about 12 per cent of maternal deaths every year (Government of India, 1990).

When services are available, women may not be aware of their existence or the means to

access them (Agarwal et al., 1987; ICMR, 1989; Mukhopadhyay and Garimella, 1998).

Women's perception of the legality of their action also influences the choices they make,

and formal services are less likely to be sought when women perceive abortion as being

_outside the law. Ganatra et al., (2000) estimated that despite having had an induced

abortion in thf' recent past, 25.2 per cent of the women believed abortion was illegal

while 12 per cent were unsure of its legal status.

2.2.6 Services for Adolescents

Adolescence as a transitional period between childhood and adulthood is a new concept

in India. The relationship between the physical, social and psychological changes that are

specific to the adolescents and their vulnerability to health problems have remained

largely unrecognized and unexplored (Mamdani, 1999). Though adolescents (girls and

boys between 10 and 19 years of age as per the WHO definition, 1996), numbering about

190 million comprise about a fifth of India's population, their reproductive health needs

remain ill served (liPS, 1995). Little attention had been given till recently to the sexual

health and development of this group in the national programme. As the Indian culture

prohibits premarital sexual activity, the needs of sexually active unmarried adolescents are

rarely considered.

Adolescence is a time in which individuals explore and develop their sexuality. The habits

and attitudes their acquire during this time may become life time habits that can result in

diseases many years later. As future adults and parents, it is imperative for health

planners to consider their health and development a priority, and address it in a holistic

manner- from a physical, psychological and social perspective (Mamdani, 1999). In the

Reproductive and Child Health Programme, adolescents are recognised as a special

group, needing reproductive and health care, inclusive of information and counseling

set-vices (MOHFW, 1997)

33

Several studies have reported the poor nutritional status of adolescent girls (Gopalan,

1990; Kanani et al., 1990; Ramachandran, 1989). Jude et al., (1991) in a study of

adolescent girls in a rural south Indian population found that nearly half of them

_ recorded poor growth and three out of four girls were anemic. The NFHS-2 also

recorded a higher proportion of adolescent girls (56 per cent) to be anemic (liPS, 2000).

Stunting as a result of malnutrition results in girls having small or deformed pelvises

which may prevent normal delivery. Moderate and severe anemia which often starts

during adolescence presents a serious risk; and is one of the most common contributing

causes of maternal death and morbidity (Manmadi, 1999).

Adolescence is a period of transition, growth, exploration, and opportunities. At the

same time, adolescents are vulnerable because of their ignorance on matters related to

sexuality and reproductive health, contraception and their inability to use contraception

and their inability or unwillingness to use family planning and health services. This puts

adolescents at a significant risk of experiencing negative consequences (Mothercare

Matters, 1995).

Each year, 15 million adolescents age 15 to 19 years give birth, accounting for up to one-

fifth of all births worldwide (UNFPA, 1997; Safe Motherhood Inter-Agency Group,

1999). Approximately 60 percent of these births to adolescents are unintended (ICRW,

1996). In India, nearly two-fifth of all fertility is in this age group (liPS, 2000). Unmet

need is significantly higher among adolescents (liPS, 2000) indicating a high proportion

of unintended pregnancies in India also. Contraceptive usage is very low among married

adolescents (Bhattacharryya et al., 1995; Gupta et al., 1995; Roy et al., 1995). The second

round of NFHS reported that only about 7 per cent of the adolescents are using

contraception (liPS, 2000).

Though all births carry potential health risks, the risks of childbearing are much higher

for women under age 17. Adolescents at this age more likely to experience obstructed

delivery, prolonged labor, and difficult deliveries that can result in long-term

complications, hemorrhage, or death if the woman does not have access to medical care

(AGI, 1998; McCauley and Salter, 1995).

34

Each year 1 million to 4.4 million adolescents in developing countries undergo abortion,

and most of these procedures are performed under unsafe conditions (PRB/CPO, 1994;

Noble et al, 1996). Complications of pregnancy, childbirth, and unsafe abortion are

major causes of death for women age 15 to 19. In India, the rates of induced abortion are

higher among adolescents (liPS, 1995; Chhabra et al., 1988) and disproportionately large

number of them are unmarried. Adolescents particularly those who are unmarried are

more likely to delay seeking abortion services and go in for second trimester abortions

which are not safe (Bhatt, 1978; Chhabra, 1992). The delay in seeking abortion is due to

ignorance of services and fear of social stigmatization (Chowdhury et al., 1979).

Unmarried adolescents are more likely to resort to illegal abortions for a number of

reasons : fear that the services are not confidential; inability to pay the required fees; the

prerequisite of parental/partner approval in some instances; or that health workers will

react negatively and will be insensitive to their needs (ICRW, 1997).

Though the evidence about the incidence of RTI's among adolescents in India is scanty,

the available evidence suggests that it is higher among this group. In a study of tribal girls

in Maharashtra, 10 per cent of the adolescent girls were reported to be affected by

syphilis. Young people are vulnerable to SID's because of early onset of sexual activity,

low contraceptive usage and high incidence of partner change especially among males.

Commercial sex workers are reported to be an important source of STis for a majority of

adolescent and pre-adolescent boys seen at STD clinics (Bansal, 1992; Kanbargi and

Kanbargi, 1996; Pandhi et al., 1995).

The Family Planning programme till recently has been dominated by demographic goals

and targeted at older married women. The focus has been on permanent methods aimed

at older women. The poor availability of spacing methods affected adolescents adversely

who were interested in postponing births. Moreover, unmarried adolescents were totally

left out by the program. Recent evidence suggests that sexual activity among unmarried

adolescents is increasing especially in urban areas Qejeebhoy, 1996; Bhende, 1994). Sexual

activity and fertility among unmarried adolescents poses different challenges and has to

be addressed with appropriate strategies in a very different context (Mamdani, 1999).

35

2.2. 7 Services for Men

The ICPD POA includes a statement of "Male Responsibilities and Participation". According to POA :

"Special ifforts should be made to emphasize men's shared responsibility and promote their active involvement i11 responsible parenthood, sexual and reproductive behavior, includingfami!J planning;prenata4 maternal and chzld health; prevention of STDs, including HIV; prevention of unwanted and high-risk pregnancies; shared control and contribution to Jami!J income, children's education, health and nutrition; and recognition and promotion of the equal value of children of both sexes."

The same message was reinforced at the 1995 World Conference on Women in Beijing

"Shared responsibility between men and women in matters related to reproductive and sexual behavior is essential to improving women's health."

Studies have reiterated the central role played by men in contributing to full access of

women to health care and related information and services (Kumar, 1996; Raju, 1999).

Women often do not seek treatment for reproductive health problems because family

members did not allow them to avail services (Khanna et al., 1998). In an intervention

project it was noted that treatment for reproductive tract infections for women were not

effective as partner behaviour had a bearing on reproductive health of women. Thus,

unless husbands were contacted and sensitized to the health of women, the interventions

were unlikely to succeed (Pal, 1998). In Tamil Nadu, Subramanian (1998) showed that a

significant proportion of RTis among women were a direct result of men's promiscuity.

It has been observed that targeting men in programmes have resulted in desirable health

seeking behaviour. In an attempt to increase hospital referrals for high-risk pregnancies

in Gujarat, male members were contacted and counseled. Hospital referrals increased and

there was a tangible increase in the level of awareness among family members (SEWA -

Rural Research Team, 1998).

In a review of NGO initiatives to reach out to men in India, Raju et al., (2000) report

that Indian men are ignorant not only about their bodies but also how their sexual

behaviour affects their own health let alone the health of their partners. Verma et al.,

(2001) report that men of all age groups and social classes suffer from erectile deficiency,

premature ejaculation or both and they spend large amounts of money seeking treatment.

36

Pl)blic sector facilities for STis are predominantly. MCH-FP based and consequently

targeted to women, may be unavailable to men (Mundigo, 1995; Hawkes, 1998). In a

study of STis suffered by men in Bangladesh, Hawkes (1998) found that there is

significant unmet need for STI services for men. The services include psychosexual

health services and contraceptive services. The author suggests that providing STI

services for men would be an effective strategy to curb the spread of STis and reduce the

burden of complications suffered by women - as men are more likely to initially contract

STis and later transmit it to their wives. Thus, providing services for men is not only

essential to improve the reproductive health of women but also for men themselves.

Efforts to enhance men's partnership in reproductive health have been limited and

narrowly defined and have been limited to fertility regulation and contraceptive use

(Kaza, 1998). In a policy review of men's involvement in reproductive health, Khan et al.,

1998 found that the main concern of programmes is to strengthen delivery systems to

introduce no-scalpel vasectomy and promoting the use of condom. Though issues

concerning maternal health and development find mention of men in programme, no

particular role is envisaged for them in terms of child survival, health and development

(Raju, 1999).

Despite the importance of men in improving the reproductive health of women and the

reproductive health care needs required by men themselves, health programmes of the

government of India have neither included men as a target audience for IEC activities

nor promoted their involvement in reproductive health programmes (Pachauri, 1995). A

review of family planning programmes in other countries reveals that services for men

have been lacking (Barker, 1996; Swanson et al., 1987; Green et al., 1955; Robey et al.,

1998). Though the ICPD have clearly articulated men's involvement, it does not find any

mention in RCH programme of the Government of India. The Population Policy of the

Government of India, however, recognizes the important role played by men and

envisages to focus attention on men in IEC campaigns and promote vasectomy especially

no-scapel vasectomy (Government of India, 2000).

37

2.2.8 Promotion of Spacing Methods ·

The Indian family welfare programme has been dominated by a reliance on female

- sterilization (liPS, 1995, 2000). Though widespread use of sterilization has enabled it to

achieve considerable fertility reduction, it would not be an appropriate strategy to

decrease fertility further as most Indian women adopt sterilization after bearing a large

number of children (Pathak et al., 1998). The authors suggest that in order to accelerate

the pace of fertility decline, the programme should promote the use of temporary

contraceptive methods.

Adequately spaced births are also desirable from the point of view of improving maternal

and child health. Studies have found that infants spaced at least two years apart are more

likely to survive than infants spaced less than 2 years (Srivastava, 1990; Hobcraft et al.,

1991; Miller et al., 1992). They are also less likely to be premature, of low birth weight

and malnourished (Fuentes-Afflick et al., 2000; Miller et al., 1992). The survival chances

of the elder siblings also improve when births are adequately spaced (Koeing et al., 1990;

Muhuri et al., 1997; Whitworth et al., 2002). Women who have their babies after 27 to 32

months after a previous birth are more likely to survive pregnancy and child birth than

women who gave births after shorter intervals (Coude-Agudelo et al., 2000).

In most countries, women actual birth intervals are shorter than the intervals they would

prefer (Bankole et al., 1995). Wide gaps between actual and preferred birth intervals

signify that reproductive goals are changing but contraceptive behaviour is yet to follow

i.e., there is an unmet need for spacing methods (Rafalimanana et al., 2000). Temporary

methods allow women who are unsure about their fertility desires to control their fertility

now. In high infant and child mortality situations, women would like to keep their

options open till they feel that the children they already have will survive. Spacing

methods can help these women achieve their desired family size (Pathak et al., 1998).

The PoA of the ICPD also emphasizes on the rights of individuals and couples to decide

freely and responsibly the number and spacing of their children and to have the

information, education and means to do so (United Nations, 1994). One of the objective

38

of the Population Policy of the government of India is to achieve universal access for

services for fertility and contraception with a wide basket of choices (MOHFW, 2000).

2.3 QUALITY OF CARE

Issues of quality of care have become central in debates about family planning and

provision of reproductive health services (Blaney 1993; Brown et al., 1995; Bruce 1992;

Hardon 1997; Katz et al., 1993; Lane 1994; Schuler et al., 1985; Simmons 1992; UNFPA

1994; Veney 1992). Some argue that without sufficient attention to quality, "we will

neither see a sustained increase in the contraceptive prevalence rate, nor succeed in

lowering birth rates through voluntary means"Gain 1992, xi). Others emphasize quality as

a means of providing services that address the reproductive needs of women in a way

that upholds their rights and enables them to gain control over their reproductive

capacity.

In India, as elsewhere, patients are poorly prepared to evaluate the technical capabilities

of their doctors, or to accurately predict effectiveness of medications given. However

they draw conclusions about the quality of care they receive by paying attention to

specific indicators that they believe to be associated with good (or poor) quality. These

signals of quality of care include experiences with effectiveness of treatment,

thoroughness of examination, care by a doctor (as opposed to paramedical personnel),

waiting time, facility hours, provision of medications, provider-patient communication,

and doctors' qualifications (Levine et al., 1992). Clients possibly assess service quality

more on the basis of the quality of the service delivery process than upon its technical

content. It is therefore important to understand the delivery process and how it can be

influenced to improve service quality (Murthy, 1999a).

Gupte et al., (1999) studied women's perspectives on quality of health and reproductive

health care in rural Maharashtra. Women do not have a single fixed perspective on the

quality of care and instead appear to be highly pragmatic, prioritizing quality of care

dimensions different according to specific health care needs and marital situations. The

authors find that the aspect of service delivery to which women give priority for general

health care is the doctor's full attention. Women considered availability of support staff

to clean up and convenient location and timings as important for delivery care. For

39

a~ortion care within marriage, women given priority to the absence of a requirement for

the husband's permission. For abortion outside of marriage, the assurance of

confidentiality is ranked highest. For abortion services in general, women appear willing

to trade safety and quality of care considerations for assured confidentiality, which helps

explain why the private sector is the preferred source for this service.

Roy and Verma (1999) studied the quality of care in two northern (Bihar and West

Bengal)and two southern (K.arnataka and Tamil Nadu) Indian states. The study highlights

the significant differences (frequency of outreach services, availability of physicians and

medicines) that characterize the family welfare program, with the southern states

performing consistently higher in most areas. However, certain quality of care concerns

cut across regions. These include emphasis on sterilization and limited information to

clients on method use and side effects. Studies have also suggested that higher program

quality leads to greater client satisfaction and thus to greater acceptance of services

(Donebedian, 1980; Bruce, 1990; Verma, Roy and Saxena, 1994).

Bruce (1990) outlines six elements that collectively capture the multifaceted dimension of

the quality of care. These include choice of method, information given to clients,

interpersonal relations, technical competence, mechanisms to encourage continuity and

appropriate constellation of services. We now review the literature on the quality of care

provided by the Indian family planning programme in this framework.

2.3.1 Choice of Methods

The official policy of the Indian family planning program is _that clients should be able to

choose a contraceptive method voluntarily from the full range of methods available and

they should be provided with complete information about these methods. In practice,

these mandates are rarely followed. Almost all studies found that clients do receive only

limited information and that sterilization is emphasized over other methods (CORT,

1996; IIPS, 1995; ICMR, 1986,1991; Khan and Patel, 1994; Khan and Ghosh. 1985).

A study in Uttar Pradesh reported that ANM's motivate their clients to use a particular

method based on the parity or reproductive status rather than help her choose from a

basket of contraceptives (Khan et al., 1999). Low priority accorded to spacing methods

and logistics problems like non-availability of IUD kits and supply problems with oral

40

pills discourage ANM's from promoting spacmg methods. Similar findings were

reported in Kerala and providers there felt that they are in a better equipped that the

client to select a contraceptive (Ramanathan et al., 1999).

Studies have reported limited efforts to promote vasectomy even though it is much

simpler than tubectomy with a shorter recover period and fewer side effects. Men in

Uttar Pradesh believed that tubectomy was simpler and needed less time for recovery

than vasectomy (Khan and Patel, 1994). Providers did not want to counter this well-

entrenched conviction among the villagers and believed that with the same effort they

could enlist more female acceptors for sterilization. It was also reported are fewer

doctors are trained in vasectomy and those trained were out of practice and could no

longer do the procedure (Khan et al., 1999c). In Tamil Nadu, contrary to popular belief,

some women wanted male methods and complained that these methods are not

available.

Though women have legal access to abortion services, their access is restricted as women

are asked for the husbands approval and pressure is exerted to use tubectomy after the

abortion (Ravindran, 1999; Gupte et al., 1999). The situation of women seeking abortion

outside marriage is much more difficult. Moreover, there are limited approved MTP

centres. A recent facility survey in Maharashtra, Gujarat, Tamil Nadu and Uttar Pradesh

(Barge et al., 1998) showed that only a quarter of the approved PHC's in Maharashtra

and Gujarat, one-third in Gujarat and one-half in Tamil Nadu were actually providing

family planning services. In fact, between 16-32 per cent of the authorized PHC's in

these two states have never provided MTP services. In Tamil Nadu, semces were

provided infrequently and only through MTP-cum-sterilization camps.

2.3.2 Information to Clients

Studies suggest that information that providers g1ve to clients about family planning

methods is frequently inadequate, that side effects are not clearly delineated, and that

clients are not counseled fully or effectively concerning how to deal with them (Koeing

et al., 2000).

41

Khan et al., (1999c) reported that clients in Uttar Pradesh were informed only about the

advantages about contraceptive methods and only a small fraction was informed about

the method's advantages and disadvantages. Although providers were knowledgeable

about a method's potential side effects and contraindications, they seldom shared it with

clients. Clients were told to return if they had any problems. The workers assumed that

women asking for condoms knew the correct use of the method. Studies in Tamil Nadu

and Kerala also report of incomplete information given to clients (Ravindran, 1993;

Ramanathan et al, 1999). Workers withheld information about side effects and

contraindications so as not to discourage acceptance of a method (Levine et al., 1992;

Murthy, 1999a).

Verma and Roy (1999) in their four-state study of quality of care revealed that only about

60 per cent of ANM's in Karnataka and 40 per cent of ANM's in Tamil Nadu and West

Bengal reported explaining side effects of pills to clients. The corresponding figure in

Bihar was much lower at 18 per cent. The fraction reporting having discussed the

reproductive goals of their clients was lower. Ravindran (1999) cites an example of a

women in Tamil Nadu incorrectly taking oral pills as the female worker did not explain

the correct procedure. Illiterate women often find it difficult to use medicines provided

to them if they are not guided properly. This is more so if both the mother and her child

are provided with medicines during the visit to the PHC.

Information provided to clients in sterilization camps is probably at its worst. Studies

have reported the minimal of preoperative and post-operative counseling thereby putting

clients to tremendous anxiety and trauma (Ramachandar et al., 1999; Mavalankar et al.,

1999; Ramanathan et al., 1995).

2.3.3 Client-Provider Interaction

Several Indian studies have reported that the rude behavior of health staff as been a

major reason-why women have not liked or used the government health services. Visaria

and Visaria (1992) in their study of family planning services in Gujarat report that 20 per

cent of the clients were not satisfied with government services because they had to wait

too long for the services and that the staff did not treat them properly. Levine et al.,

42

(1992) report the perception among female respondents in Uttar Pradesh that staff and

medical officers in government clinics are often rude and discourteous to clients.

A qualitative study in Tamil Nadu reports the shabby treatment meted out to clients in

health facilities. The nurses are reported to verbally abuse women and demand payment

before they render even the most basic services (Ravindran, 1999). Observations in

clinics in Delhi and Tamil Nadu report of harsh and derogatory treatment given to poor

Indian women seeking family planning services in the public sector (Gupta, 1993;

Nataraj, 1994; Ganatra et al., 1998).

Ramanathan et al., (1999) reports of a much more congenial atmosphere being

maintained in PHC's of K.erala. Their client flow analysis revealed that clients were

greeted politely and the exchanges between clients and providers took place in an

atmosphere of cordiality. However, it was observed that providers became judgemental

in the case of providing abortion services and little effort was made to maintain

confidentiality in such cases. Nevertheless, the workers were a trusted figure and had a

high level of acceptance in the community they cater to.

The review of literature suggests that interpersonal relations are at their worst in outreach

sterilization camps where many clients are catered to in makeshift facilities on a single

day. Studies have revealed the traumatic experience women undergo in sterilization

camps. The preoperative procedure such as enema, shaving and vaginal examinations are

unpleasant for women whO are most likely encountering the hospital environment for

the first time. They are not provided any information about what to expect during the

preoperative and operative phases of sterilization which would alleviate their anxiety to a

great extent. The camps are run like assembly-line production in which 10 to 15

operations are performed in one hour. There is little visual privacy and women waiting

for their turn are reported to be frightened seeing the operative procedures and seeing

the woman crying in pain (Mavalankar et al., 1999). The sedated patients are helped out

of the operation theater to the post-operative care unit by male staff because of shortages

of female workers. During this transfer, the clothes of patients are often deranged and

done in the presence of the general public. Greater effort on the part of the program

managers is required to protect patients' modesty (Ramachandar et al., 1999).

43

2.3.4 Technical Quality of Care

Important indicators of technical quality of care include providers' complete and accurate

knowledge of methods, procedures, and reproductive health care, as well as acceptable

clinical practice of family planning and reproductive health service delivery (I

(Mavalankar et al., 1999; Townsend et al., 1999). Sedatives which were to be administered

10- 15 minutes prior to surgery were given after the wound was plastered. As a result, all

the patients were crying from the acute pain of the surgery.

2.3.5 Continuity of Services

In light of the high rates of method-related complications and associated reproductive

morbidity, client follow-up represents an important component of high quality services

(Koeing et al., 2000). Most studies from India point to the absence of follow-up as an

acknowledged failing of the government program.

A study in Uttar Pradesh revealed that only 6 per cent of the men and 18 per cent of the

women who had undergone sterilization received a follow-up visit by health workers

within a month of the procedure. The corresponding figure for IUD acceptors was 3 per

cent. The findings assumed added significance as a substantial proportion of the

acceptors of vasectomy (36 per cent), tubectomy (47 per cent) and IUD (30 per cent)

reported that they developed post acceptance complications. Only a fourth of women

who reported complications received nssistance from a health worker (Khan et al., 1999).

Health workers attach importance to. follow up sterilization cases as the community

expects them to follow up on surgery cases and as sutures should be removed. A study of

sterilization acceptors in Uttar Pradesh revealed that 80 per cent received follow-up

services at home (Sawhney, 1986). However, only a few ANM's followed up on IUD

acceptors and none of them visited pill acceptors (Khan et al., 1999c). The study also

revealed that one-third of the IUD acceptors developed post insertion complications and

95 per cent of these women had the IUD removed within a month. Most ANM's

interviewed in the study gave acceptors a month's supply of pills and expected them to

come back when they needed more. No effort was made to know whether they suffered

any side effects or discontinued the method. This probably reflects the low importance

accorded to spacing methods in the family planning program.

Verma and Roy (1999) emphasize the- importance of systematic record keeping to

facilitate follow-up care. One-half of workers in West Bengal and Karnataka maintained

proper records of addresses and information required for following up patients. Only a

45

third of the workers maintained similar records in Bihar and Tamil Nadu. A significandy

higher fraction of workers in all states reported feeling pressure for achieving sterilization

targets than for following up on acceptors.

Studies in better performing states ofKerala and Tamil Nadu which have already reached

replacement level fertility also reveal the follow-up care is a neglected aspect of the

providers' work schedule (Ramanathan et al., 1999; Ravindran, 1999). Women in Tamil

Nadu reported of seeking help from private doctors at considerable expense in case of

complications in the absence of follow-up care from health workers.

2.3.6 Appropriate Constellation of Services

An appropriate constellation of services includes the availability of doctors and

medicines, equipment, and supplies; convenient clinic hours and reasonable waiting time

for seeing medical or paramedical staff; accessible location of services; and adequate

facilities. The presence of medical personnel particularly of a doctor, is central to the

availability of services. Studies find that doctors are not always present. Only half of the

PHC's in Kerala and Maharashtra had an in-house physician (Ramanathan, 1995; Murthy,

1999a). A study in Madhya Pradesh revealed that generally only one of four doctors

assigned to the PHC was on duty, and that on an average, the doctor spent two out of

the mandated five hours providing services (Singh et al., 1988). There are considerable

inter-state variations in the availability of doctors at the PHC. Roy et al., (1999) report

that only 31 and 40 per cent of the clients in Bihar and West Bengal found doctors to be

always available while the nearly two-third of the clients in the southern states of

Karnataka and Tamil Nadu reported the presence of doctors in the PHC's. Ravindran

(1999) reports that doctors in PHC's of Tamil Nadu were available only for two to three

hours a day iri the morning; and in the afternoons, they saw patients in their private

clinics.

Clients' access to services is also heavily influenced by clinics' hours - whether these

hours convenient for clients and whether their stated working hours are, in fact,

observed. Levine et al., (1992) discovered that the main reason for dissatisfaction with

government services was that it coincided with working hours. Clients in Tamil Nadu

46

were also discontented with the timings of the PHC. The remark of a woman in Tamil

N adu is illustrative (quoted in Ravindran, 1999)

Do they expect us to delivery between 10 - 5. What a waste if salary.

The reliability of working hours appears to diminish by level from PHC's to SC's. The

SC's are staffed by providers who are less likely to be resident, and staff are less likely to

be motivated than those at higher-level facilities, because services they can offer are

limited by inadequate resources (I

constrain improved quality of care in the public sector program. Resource limitations and

underdevelopment represent one important set of constraints. These barriers are

manifested in significant underfunding of basic program infrastructure especially at the

peripheral level; an absence of housing and transportation facilities for program staff; and

chronic shortages of medicines, equipment and supplies. Underdevelopment - as

reflected in an absence of suitable roads and public transportation, and communication,

electricity and water facilities, and the inability to safeguard the security of female staff-

similarly constrain the ability of the program to offer high-quality services. Weak

program management as seen by inadequate staff training, weak supervisory support for

workers, nonadherance to acceptable clinical standards, high rates of absenteeism, limited

accountability among workers and widespread corruption represent another set of

constraints that hinder the provision of quality care.

The importance accorded to numerical targets also constraints the provision of quality

services to a considerable extent. This system promotes an undue emphasis on the

recruitment of clients for female sterilization and encourages staff to link clients' access

to induced abortion with acceptance of sterilization. This also discourages the provides

to give complete information about the methods and potential side effects so as not to

lose family planning cases. Also, mass-sterilization approaches have been adopted leading

to serious lapses in technical and interpersonal quality of care. The pressure of targets

sometimes forces staff to provide contraception despite serious contraindications and

leaves little time for follow-up care despite frequent method-related complications. Also,

non-health staff were involved in recruiting sterilization acceptors resulting in unhealthy

competition and often use of coercive methods to recruit clients.

An important but overlooked barrier to improved quality is the absence of clients'

demand and expectations for certain minimum standards of care. In many studies

reviewed (ICMR, 1988; Khan et al., 1988; Visaria and Visaria, 1992; Ramanathan, 1995;

liPS, 1995) high proportions of clients express satisfaction with existing family planning

services despite the substandard level of care they experience. A crucial impetus for

change and reform is, thus, missing in the Indian context.

48

2.4 MANAGEMENT ISSUES

Myrdal (1968) in his seminal work, The Asian Drama, predicted that management will be

a critical bottleneck in the implementation of population programs. Other studies have

also shown that management of health and family welfare programmes is of critical

importance to their success (Miller et al., 1998; Rajaretnam, 1996; Srinivasan, 1995). It

has been demonstrated that policy commitment to programmes does not necessarily

translate into the implementation of effective programmes because of organizational

deficiencies (Simmons, 1987; United Nations, 1994). An important reason for the limited

success of the Indian family welfare programme has been lack of effective management

for promotion and delivery of services (Satia and ] ejeebhoy, 1991; Conly and Camp,

1992; Mavalankar, 1996). Satia and Giridhar (1991) mention a number of areas which

require strengthening in the programme. These include manpower shortages, poor

logistical support, low motivation and skill among workers and lack of client orientation.

According to Mavalankar (1996) the key problems facing the family welfare programme

are the lack of accountability and supervision, poor infrastructure and maintenance,

inadequate logistics and supplies, over-centralization of decision making and financial

powers, political interference and corruption, lack of required skills and training, lack of

overall consistent leadership, lack of involvement of staff and under-funding of the

programme a~d financial inflexibility. It is predicted that the management constraints

mentioned above problems will also be confronted in the implementation of the RCH

programme as well. We now review studies relating specific aspects of management viz.,

Infrastructure, Training, Supervision, Referral Mechanisms and Management

Information Systems.

2.4.1 Infrastructure

A review of India's family welfare programme carried out in 1995, found that inadequate

equipment and supplies at Primary Health Centres (PHC's) and Sub-centres (SC's) would

be a major constraint in the way of India adopting a Reproductive Health approach

(Murthy and Barua, 1998).

A facility survey carried out in 1992 by the Indian Council of Medical Research (ICMR)

had found that 40 per cent of the PHC's were poorly equipped. About 25 per cent of the

medical and paramedical staff positions were vacant. Health workers were not able to

49

reach many villages because of lack of transport and poor road conditions. Under such

conditions, the package of reproductive health services would be difficult to deliver.

Mavalankar (1996) observes that the physical infrastructure is in poor condition in most

PHC's in India. The construction of the centre is defective; maintenance, cleanliness and

hygiene in the PHC's is extremely neglected and running water and electricity is not

available regularly in most PHC's. Equipment in PHC's are old, dilapidated, unrepaired

and inadequate in many places and in excess at other places. He attributes this to the

absence of a proper maintenance system for the PHC equipment. Given such

deficiencies in infrastructure one cannot expect that good quality of care will be provided

at such centres.

The location of an ANM's residence has a direct bearing on her ability to provide

effective and accessible care. Housing accommodations for the workers were found to be

poorer in the northern than in the southern states of India 01 erma and Roy, 1999). In

West Bengal, only 11 per cent of the workers reported that they resided in staff quarters,

and another 30 per cent were living in the village where the PHC was located. In Tamil

N adu, 91 per cent of the workers were residing within the PHC village, and a third were

living in staff quarters.

In a study of the quality of care in Kerala, Ramanathan et al., (1999) reported that less

than half of the PHC's had private examination rooms which were essential for

maintaining the privacy of family planning clients and help protect the modesty of female

clients. Drinking water and toilet facilities, which are essential aspects of public health,

were available in less than third of the PHC's surveyed. One-fourth of the PHC's did not

have seating arrangements for the waiting patients. One- half of the PHC's did not have

a vehicle which severely restricted the quality of the outreach programmes.

In a study of the facilities available in sub-centres of Jhansi district, Sadana et al., (1998)

concluded that the conditions of sub-centres are much worse. 71 per cent of the sub-

centres functioned from single room rented accommodations. Such facilities have little

room for storing equipment and drugs and no privacy for patient examinations and

counseling. Only 11 per cent of the sub-centres have electricity and 22 per cent have

running water in the premises. One-half of the sub-centres do not have basic furniture

50

and equipment like chairs, tables, examination tables and pressure sterilizers. One-quarter

of the sub-centres do not provide IUD insertion and the lack of equipment was the

single most important reason attributed by the ANM's.

The absence of sub-centre buildings and poor availability of equipment is also reported

in a study of rural Maharashtra and Uttar Pradesh (I yer et al., 1999; Khan et al., 1999c).

One-half of the sub-centres in Maharashtra operated from makeshift rented

accommodations. Though sub-centres constructed by the government were better than

make-shift arrangements, they were often constructed in the village periphery and outside

the protection of the main village cluster. ANM's were often scared of living in such

accommodation.

Inadequate supply of medicines has been reported to seriously undermine the credibility

and hamper the work of PHC's and sub-centres (Bhatia, 1999; Khan et al., 1999c).

Medical officers in Karnataka reported that drugs are rarely supplied to their requisitions

and are not based on the morbidity pattern in their respective areas. Drugs that are not

needed are dumped on them while lifesaving and essential drugs are in short supply.

Similar complaints were also voiced by ANM's. Many ANM's resorted to buying

medicines from the market at their expense to maintain good relations with the

community and potential family planning clients (Bhatia, 1999).

The problems in supplies at health facilities has been a consequence of procurement and

logistics breakdowns and inefficiencies (World Bank, 1997). There has been an over-

reliance on producers with multi-stage manufacturing technologies who cannot quickly

fill supply problems and frequent changes in pill production contractors has led to quality

problems. It has been suggested that procurement be limited to suppliers with proven

efficiency. At the periphery, subcentres need to hold stocks equivalent to three months

per user, rather than one month to avoid supply breakdowns especially during the

monsoon.

The lack of transportation facilities and allowances hamper ANM's from covering all the

villages in the work areas (Bhatia, 1999; Khan et al., 1999c). Only a few accessible villages

were visited regularly by them. Distant and remote villages were only covered during

special drives and at the end of the year when there is excessive pressure to attain targets.

51

The problems are magnified during immunization days when they the ANM's are

required to walk long distances carrying heavy vaccine carriers, pressure sterilizers,

vaccines and drugs to distant villages (Bhatia, 1999). The allowance paid to an assistant

hired by an ANM is a measly Rs. 50 /- a month in Karnataka and there are very few

takers for this job. As a result, the ANM's are left alone to this job and remote villages

are neglected by the ANM's.

2.4.2 Training

In order to offer client-centered services, it is important that the RCH programme

should have adequate staff that has been properly trained so that the necessary skills are

available to them. Proper technical training enables paramedical personnel and others

without formal medical education to deliver clinical family planning services safely

(Lyons, ]. V. et al., 1987). Many studies, some conducted as early as the 1960s, have

shown that specially trained nurses, midwives, and paramedics can insert IUDs and

perform voluntary sterilization as safely as physicians (Gallen, M .E. et al., 1986;

Rosenfield, A. G.,l971).

Programs that offer high-quality services use training to motivate providers and build

their counseling a'ld interpersonal communication skills (Oyediran, M. A. 1993). A

conference on family planning counseling held in Istanbul in 1992, recommended that

quality of care can be improved through better training : family planning counseling

should become part of medical and nursing school curricula; interpersonal

communication skills should be incorporated into on-the-job training for all health

workers and volunteers and staff members with formal training in counseling should be

given responsibility for providing on-the-job orientation of other staff members

(Association for Voluntary Surgical Conti:aception, 1992).

On-site training in counseling should be offered because service providers come to their

jobs with widely different personal characteristics, attitudes, and expectations that affect

their ability to provide care (Huezo, C. 1993). On-site training helps providers to become

aware of their own biases and to respect the client's interests and needs (Cooperating

Agencies Task Froce, 1989). Such training also can promulgate a procedure for

counseling that is flexible enough to meet individual needs but also provides a standard

for high-quality care (Lettenmaier, C. 1987).

52

Although few studies have been conducted that carefully measure how training family

planning providers affects client satisfaction, evaluation of training programs

demonstrate that training has improved services and helped to attract more clients. A

study of the Ogun State, Nigeria found that nurses who participated in a training

program performed better than other nurses in all the areas of training - interpersonal

relations, counseling, information giving, and encouraging continued use. Their clients

were more satisfied as a result. Some 84 % of clients of the specially trained nurses

returned for follow up visits compared with only 44 % of clients of other nurses (Kim,

Y. M, et al., 1992).

Conceptually, training can accomplish four kinds / levels of changes : change in

knowledge and understanding, change in knowhow, change in behaviour and change in

habits Gain, 1999). Generally speaking, improving knowledge and understanding takes

the least amount of time, changes in knowhow requires medium amount of time and

changes in behaviour and habit formation require the most time. The additional time

required to progress from a lower level to the next higher level is governed by geometric

progresswn.

Mavalankar (1999a) observed a number of weakness in the training programs which have

limited their usefulness. The skill component is weak, training is very theoretical and not

related to day-to-day realities; there is no follow-up by supervisors and the quality of

trainers is poor.

In their study of training inputs for the CSSM programme, Mavalankar and Reddy (1996)

concede that training is seen as a process to learn new skills and gain technical skills. An

important aspect of training which is building human skills like patient relationships and

counseling, building positive attitudes towards work and developing pride in their job is

completely missing from the training inputs of health personnel.

Training should also be followed by equipment and supplies required for performing the

_job and proper monitoring to ensure that the job is being done as it was supposed to be

done. This means that training should be coordinated with logistics supervision and

monitoring. The follow up should also feed back in to the training process so that the

training improves for the next batch. Supervisors should also be seen and should act as

53

trainers who provide continuous guidance to the staff in performing their tasks. These

aspects of training need to strengthened in the present system.

Khan et al., (1999c) reported that some ANM's in Uttar Pradesh considered that training

sessions were often not useful or taught the same subject every time. A general view

among them was that the trainers were far removed from the realities of villages and that

much of the training could not be put into practice. The medical officers recommended

that reorientation training should be critically examined and designed to meet workers'

needs. These comments call for restructuring courses to make training more practical,

realistic and of immediate use to the workers.

Training is also a neglected area of the health sector. Training efforts so far have been

scanty, ad hoc, inadequate and of poor quality (Mavalankar, 1999a). Resources allocated

to training is also small. Gupta and Talwar (1990) in a study of family welfare

programmes in the seven most populous nations found that the proportion of the

budget alloc~ted to training is among the lowest in India (2 per cent) compared to

Pakistan, Bangladesh (4 per cent) and Indonesia (10 per cent). A review of training

programmes under the World Bank assisted population, health and nutrition projects in

India from 1972 to 1997, showed that in a total of 22 projects, costing 3.2 billion dollars,

only 7.6 per cent of the project budget was spent on training. Even in projects

specifically aimr::d at strengthening training, only 13 per cent of the funds were used for

training. The review concluded that "knowledge and skills related to some specific areas of service delivery were poor among health workers and that there was a need to enhance training skills of most trainers at the state and district levels." (Ramaiah, 1998). In the reproductive and child health

budget, only 6 per cent of the funds are devoted to training (MOHFW, 1997), while for

the World Bank supported compo