- - - = 4^A> |C O N F I D E N T I A L

Report No. PP-.5

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be returned to GENERAL FILES immediately after use.

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

INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT

INTERNATIONAL DEVELOPMENT ASSOCIATION

POPULATION PROJECT

REPORT OF PREAPPRAISAL MISSION

INDIA

( n two volumes)

VOLUME I

THE MAIN REPORT

November 27, 1970

Population Projects Department

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CURRENCY EQUIVALENTS

US$ 1.00 7.5 Rupee

Rupee 1.00 US$ 0.13

GLOSSARY

ABBREVIATIONS

ANM Assistant Nurse-MidwifeBEE Block Extension EducatorDFPB District Family Planning BureauDFPO District Family Planning OfficerDMOH District Medical Officer of HealthDMOH-FP District Medical Officer of Health and Family PlanningFPHA Family Planning Health AssistantFWW Family Welfare WorkerIPPF International Planned Parenthood FederationIUD Intrauterine DeviceLHV Lady Health VisitorMCH Maternal and Child HealthMIES Management-Information and Evaluation SystemOxfam Oxford University Famine Relief FundPHC Primary Health CenterRFPTC Regional Family Planning Training CenterRFPWC Rural Family Planning Welfare CenterSFPB State Family Planning BureauSFPO State Family Planning OfficerWHO World Health OrganizationUFPWC Urban Family Planning Welfare CenterUN United NationsUNDP United Nations Development ProgramUNICEF United Nations Childrens FundU.P. Uttar PradeshUSAID United States Agency for International Development

INDIA POPULATION PROJECT

TABLE OF CONTENTS

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

I. INTRODUCTION 1.......................................1

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

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

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

IV. THE PROJECT

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

ANNEXES

1. Organizational Chart of Family Planning Activities

at the Center2. Organizational Chart of Family Planning Activities

in a State3. Organizational Chart of Family Planning Activities

in a District4. Organizational Chart of Action/Implementation

Committees5. Management-Information and Evaluation System6. Inputs and Results in Project Areas7. Staff and Equipment Requirements of Service

Motivation Teams8. Location of Primary Health Centers and Number

of Subcenters9. Cost Estimates for Project

10. Addition to Annual Expenditures

MAPS

1. India Population Project2. Uttar Pradesh State: Population3. -Mysore State: Population

INDIA POP'ULATION PROJECT

SUMMARY AND CONCLUSIONS

i. In the past few years the international community has become increas-ingly concerned with India's family planning program. The annual growthrate of 2.5% and the addition of 14 million persons each year have beenmatters; of serious concern to the Government of India in their efforts atsocial and economic improvement. Following the Aid India Consortium meeting,especially organized by the Bank in November 1969 to consider India'sprogram, further discussions were held with the Government of India to dcter-mine in a preliminary manner the objectives and location of a possible Bankproject. The pro,ject would aim to develop a comprehensive program in theselected districts which would include the components of the Government ofIndia program but would also have variations and improvements that arerelevant to the whole Indian program. This would require a management-information system and an evaluation unit for assessing the work in theproject area on a continuing, basis. It was agreed provisionally that theproject area would comprise six districts in Uttar Pradesh (U.P.) and sixdistricts in Mysore State - covering a total population of about 20 millionpersons. A preappraisal mission visited India from July 13 to August 21, 1970.

ii. The mission found that while the achievements of the Indian programwere considerable, the program is not functioning as well as it should orcould. A large nrumber of persons have accepted family planning services andan extensive and complex administrative machine to implement policy decisionshas been built. But performance falls short of a solution of India'spopulation problem, of the targets set by the Government and the expectationsof the Government. Over the last two years sterilizations and IUD insertionshave markedly declined. Though the distribution of condoms has greatlyincreased, overall performance has declined. What is more disturbing is that

this decline has occurred despite a great increase in resources available forfamily planning.

iii. The mission could not determine the reasons for these trends.Though specific recommendations are made by the mission, the basic aim ofthe project is to provide a framework for experimentation and orderly change.Operational questions should be continuously and systematically asked andthe policy implications of their answers should be speedily and effectivelyimplemented.

iv. The project consists of the following:

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

I. An Urban Program including a particular concentration on post-partum motivation and service in Lucknow (U.P.) and BangaloreCity (Mysore);

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

III. An Intensive Rural Program including a particular concentra-tion on recently-delivered mothers in rural areas. Thisprogram will have inlputs additional to those sanctioned inthe. Government plan and will be implemented in four Districts- two in U.P. and two in Mysore.

v. Second, two new Population Centers in Lucknow and Bangalore to beprimarily responsible for the management-information system and training.The management-information system would monitor progress in project areas,evaluate performance and recommend changes that would be relevant to otherparts of India. These Centers should haye close links to the State familyplanning administration. Their Board waould have to be influential so thatthe recommendations of these Centers can be quickly implemented.

vi. Third, the following Physical facilities and Equipment:

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

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

(c) Two 100-bed maternity hospitals - one in Lucknow, the other inBangalore City;

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

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

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

(g) Subcenters for ANMs (and FWWsin U.P.) according to the Governmentof India pattern, in all Districts where these buildings havenot been constructed; and subcenters for dais, in addition to theGovernment pattern in the Intensive Districts (Scheme III) of U.P.;and

(h) Fourteen ANN Schools - five in Lucknow and Bangalore City and oneschool attached to every District Hospital

vii. Total project costs - consisting of physical facilities and equipmentand technical assistance - are estimated to total Rs.113 million (US$15.1 million).

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The direct foreign exchange component is about Rs.7.5 million (US$1.00 million).Recurrent expenditures of the project that are additional to the presentsanctioned level are e!stimated to total Rs.18.6 million (US$3.6 million)over the first five years. About 59% of project costs and additionalrecurrent expenditures are for U.P. State and 41% for Mysore State.

viii. The Populatiorl project outlined in this report will establish, overa sizable population (20 million) the base for continuing assessment of theprogram with opportunities for variation and experimentation; thus providingin thie longer term a valuable tool for improvement of the performance ofthe whole program.

INDIA POPULATION PROJECT

I. INTRODUCTION

1.01 In the past few years the international community has become increasinglyconcerned with India's family planning program. The annual growth rate of2.5% and the addition of 14 million persons each year were matters of seriousconcern in relation to the efforts at social and economic improvement of theGovernment of India.

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

1.03 This was further discussed in early 1970 to determine in a preliminarymanner the objectives and location of a possible Bank project. The projectwould aim to develop a comprehensive program in the selected districts whichwould include the components of the Government of India program but would alsohave variations and improvements that are relevant to the whole India program.This would require a management-information system and an evaluation unit forassessing the work in the project area on a continuing basis. It was agreedprovisionally that the project area would comprise six districts in UttarPradesh (U.P.) and six districts in Mysore State - covering a total populationof about 20 million persons. This selection of districts was made because theBank felt it desirable to be involved iL both North and South India, but interms of a manageable project, not more than two States. Mysore was selectedpartly because of the wealth of demographic data collected in the UN MysorePopulation Study of 1961. The preliminary selection of districts in bothStates was made by the Government of India with the concurrence of the twoState Governments. The mission examined relevant data during its mission andaccepted the districts proposed in Mysore (those in Bangalore Division);however, in consultation with State and Central Government officials, itproposed modifications to the districts in U.P. where the project will bedeveloped.

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

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

i

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

1.05 The mission spentttwo weeks in New Delhi, ten days in Mysore andanother ten days in U.P.,, Mission members also visited Maharashtra State andGandhigram. This report zontains the findings and recommendations of themission.

N.

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II. THE POPULATION PROBLEM

2.01 India's population has been growing at a rapid and accelerating rate.From a total population estimated at 238 million in 1901, India's populationnearly doubled to 439 million in 1961. It is estimated to be 554 million in1970-1, but the 1971 census may show it to be even higher. More importantthan the growth in size, is the increasing rate of growth of the Indianpopulation. From an average annual growth rate of 0.7% in the 1921-31 period,the growth rate increased to 2.0% in 1951-61 -- nearly a threefold increase.The current growth rate is estimated to exceed 2.5%; every year 14 millionpersons are added to the population.

2.02 These trends are the result of a more or less constant birth ratecoupled with a rapid decline in mortality, particularly since the secondWorld War. In 1951-60, the birth rate was officially estimated to be41.7/1,000 while the death rate was 22.8/1,000. The death rate declinedsharply to an estimated level of 14.0/1,000 in 1966-70. (The expectation oflife at birth increased from 32 years in 1941-51 to an estimated 53 years1966-70). This decline was due to the success of public health programs --malaria, smallpox and other major epidemic disease have been substantiallycontrolled. Also, administrative response to national disasters such asflood and drought has greatly improved; consequently deaths from famineand malnutrition have been reduced.

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

2.04 The previous trends have serious demographic, economic and socialimplications:

(a) The number of eligible couples,- estimated to number 55.1 million in1970-1, are increasing by more than 1.25 million couples every year.The growth of the labor force, presently estimated at 200 million,is projected to increase by 30 million in 1971-5, 35 million in1976-80, and 41.0 million in 1981-5. All these trends are impliedby the births of the past fifteen years and the expected improvementsin health of children.

(b) Real net national;--product has been growing annually by 3.5% from1951-66, but because of the population growth rate of 2.1% in 1951-60and of 2.5% in the sixties, more than 60% of the growth in income hasbeen absorbed by the increasing population, while living standardshave improved little. More important, the growth of per capita incomehas been decreasing - from 1.65% per year in 1951-60 to 0.6% per yearin 1961-6. In more recent years, when economic conditions wereunfavorable, economic growth was insufficient to counter population

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

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

(c) A particularly serious economic and social problem is that of unemploy-ment. The present level of unemployment and underemployment is veryconsiderable. Given the projected increase of the labor force andrough estimates of the present level of unemployment, about 40 millionadditional jobs have to be created in 1971-5, and about 75 millionjobs over the next decade.

2.05 While family planning efforts can make a significant difference toIndia's growth rate, India's population will continue to grow substantiallyfor most of this century. Even if fertility declines at a moderate pace,the Registrar General estimates that India's population will grow to638 million in 1976 and 702 million in 1981. The UN estimates that India'spopulation will reach 983 million in 1990, if fertility remains constant.Even if fertility declines very rapidly -- reaching a birth rate of 25/1,000in 1975 -- the population will reach 668 million in 1990.

2.06 Uttar Pradesh. Uttar Pradesh (U.P.) has a population of 91.5million. It is the largest State of India and one of the poorest. In 1961,13 percent of the population was living in urban areas and only 3 percentof the male labor force was in non-household manufacturing industry. Themedical system is exceptionally thin, particularly in rural areas. Levelsof socio-economic development in U.P. vary considerably. Western districts,where the "green revolution" has had an impact, are the most developedwhile socio-economic conditions in the east are far less favorable. Accord-ing to India's demographic estimates the population of U.P. increased from56.5 million in 1941 to a present level of 91.5 million. In 1941-50, thebirth rate was 38.6/1,000 and the death rate 27.2/1,000 giving a growthrate of 1.1% per year. Because of the rapid decline in the death rate toa current level of 16/1,000 the growth rate has more than doubled to 2.3% peryear. The demographic, economic and social implications of these trendsare as grave as for the whole of India. For example, per capita incomein constant prices has remained constant irL U.P. from 1961-6.

2.07 Mysore. Mysore has a population of over 30 million. In 1961, 22percent of persons lived in urban areas. Literacy rates are relativelyhigh by Indian standards and the medical system is better and more wide-spread than in most other States. The level of economic development issimilar to the Indian average, though the southern part of the State(Bangalore Division) where a sizeable industrial sector has developed,is well above the average. The State has a reputation for efficient andenlightened administration. Mysore's population grew from 7.4 million in1941 to 23.6 million in 1961. It is currently estimated to number 30million with an annual growth rate of 2.4%. The birth rate is estimatedto be 39.1/1,000 while the death rate is 15.1/1,000.

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III. THE FAMILY PLANNING PROGRAM

3.01 Brief History. Although the Government adopted a policy favoringfamily planning in the First Five-year Plan (1951-55), the program consistedmainly of a few pilot projects and some studies during this period. In theSecond Plan (1956-61), the program expanded; a national organization was setup, clinics for providing family planning services were opened, various train-ing centers were established, and sterilization as a method of contraceptionwas given official support. In 1963, an "Extended Program", designed to pro-vide family planning services to the rural population through the healthservices, was adopted. Program targets were set to reduce the birth rate to25/1,000 in 1975. The "cafeteria" approach offering a choice of several con-traceptive methods, was introduced. In succeeding years the "ExtendedProgram" was steadily implemented while other significant developments tookplace. In particular, a separate Department of Family Planning was createdin the Ministry of Health; compensation payments to acceptors of steriliza-tions and IUDs were introduced; the "Intensive District Program" and the"Selected Area Program" were designed to give priority to densely populateddistricts, or groups of contiguous districts; demographic and bio-medicalresearch was expanded; selected hospitals in various cities of India receivedspecial assistance for postpartum family planning work; and country-wideschemes for the commercial distriblution of condoms at subsidized rates wereintroduced. The following sections concentrate on developments in recent years.

A. ORGANIZATION

Central Level.

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

3.03 In 1966, a Department of Family Planning headed by a Secretary wasestablished in the Ministry of Health. It plays a dominant role in the Indiafamily planning program because it is responsible for budgetary planning andfinancial control. It is divided into:

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

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

(c) The Nirodh Marketing Organization, responsible for the distributionof condoms throughout the country.

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

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

State Level.

3.05 The basic organizational structure is more or less similar in everyState though some differences exist in U.P. Responsibility for family planningactivities are part of the functions of the Health Secretary and the Directorof Medical Services for Health and Family Planning. A high levelImplementation Committee has been constituted in several States to reviewprogram progress . In Mysore, the committee is headed by the Chief Secretarywith senior representatives of Health, Finance and other Departments includ-ing the Development Commissioner and Chief Engineer. In U.P., the equivalentcommittee exists mainly on paper and has not yet come io play an importantrole. Program administration is the responsibility of the Deputy Director ofHealth and Family Planning who is the State Family Planning Officer (SFPO).He heads the State Family Planning Bureau (SFPB) which is responsible for theappointment of District staff, general administration and coordination ofState programs, supervision of District efforts, training of field workers,communication, and supply and maintenance of vehicles. Annex 2 shows theorganization at the State level.

District and Field Levels.

3.06 In effect, the District is the main administrative unit of program-imple-mentation (Annex 3). Typically, it has a population of 1.5 - 2.0 million and anarea of about 5,000 square miles. Each District has an Action Committee,chaired by the head of the District Administration (known as Collector, DeputyComnmissionaer or District Magistrate) to coordinate and expedite family planningwork. The District Medical Officer of Health (DMOH) is the head of the publichealth service in the District. In most States, a District Family PlanningOfficer (DFPO) has been added to be responsible for family planning. In U.P.,the organization of the District was recently revised to achieve a closerintegry,aion of health and family planning. Family planning has been added tothe resp,onsibilities of the DMOH, (renamed as District Medical Officer ofHealth and Family Planning (DMOH-FP), while the DFPO has become an additionalDMOH-FP and is now subordinate to the DMOH-FP. The DFPO, or additionalDMOH-FP, heads the District Family Planning Bureau (DFPB). The mainresponsibilities of this Bureau are to supervise and manage all programactivities in the field, organize efforts of governmental units, supervise thevoluntary organizations receiving Government subsidies and stimulate theactive participation of industrial employers, private physicians, etc.

3.07 The Indian family planning organization is closely interwoven with thegeneral provision of health services, particularly at the field level. There

are distinct budgets for health and for family planning, but each functionr4

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

- two doctors, one in the health budget, the other in the familyplanning budget;

- one block extension educator (BEE);

- one computor-statistician;

- one storekeeper cum accountant;

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

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

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

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

Urban Areas.

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

(a) Urban Family Welfare Planning Centers (UFWPC), which are sanctionedat the rate of one per 50,000 population in the Government of Indiapattern;

(b) voluntary organizations such as the Christian Medical Association, RedCross, India Family Planning Association (IFPA) etc.:

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(c) the Municipal Corporation which Operates maternity homes in some

cities e.g. Bangalore (but not in Lucknow); and

(d) postpartum programs in maternity hospitals.

The City Bureau is also responsible for involving persons such as private

doctors, Government employees. and employees in industry, in the family

planning program. While all these are the functions of the City Bureaus in

principle the Bureau has not functioned effectively in Bangalore, while

Lucknow does not yet have such a Bureau.

B. THE STATISTICAL SYSTEM

3.10 At the State level, Demographic and Evaluation Cells have been author--

ized recently in the State Family Planning Bureau to streamline service

statistics. A Statistical Assistant is provided in the District Bureau and acomputor (compilation clerk) at the Block level. At the District level, each

Bureau has a District Field Operation and Evaluation Division consisting of

one statistical investigator and two field and evaluation workers. The

statistical investigator does mainly clerical work; collecting the routine

performance data from the various health centers, checking the returns,

correcting and adding, and filing summary forms to the State Bureau. Systematic

field checking of the accuracy of the data, analysis of the data, and the

preparation of reports on internal performance (e.g. worker productiviLy) is

not being done. This is due to the inadequate analitical capability of the

District Bureau and because these management functions are not considered to

be part of the responsibility of the District Bureaui. For a further des-

cription of the statistical system see Annex 5.

Information

3.11 Standard formats for records, registers and returns have been developed

by the Center. Each unit offering family planning services including clinical

work, distribution of conventional contraceptives, education and motivational

work is required to maintain registers. The units report these data every

month to the main Family Welfare Planning Center (usually the PHC) where it

is aggregated and forwarded to the District Family Planning Bureau. In the

District, the data are again aggregated and forwarded to the District Family

Planning Bureau. In the District, the data are again aggregated before being

submitted to the State. Finally the State again aggregates these data and

sends it to the Center.

3.12 These successive aggregations mean that much of the detailed data that

arecollected in the field is not transmitted to higher levels. Such a loss of

information occurs particularly between the PHC level and the District Bureau.

In short, a large amount of data is lost, and what remains is not adequately

analysed.

3.13 Furthermore, there is a clear dichotomy ard separation in the reporting

system between cost data and performance data. The Statistical Assistant at

the District Bureau is only responsible for performance statistics while the

accountant is only responsible for cost data. This situation is also true at

the State level. Financial accounts and physical achievements of various

program activities are not correlated.

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Evaluation

3.14 Internal evaluation is a major responsibility of the Department of

Family Planning. The Department issues a monthly set of statements by State

on population, sanctioned staff in position .at State and District levels,

numbers of Urban and Rural Family Welfare Centers required and functioning,

sterilization and IUD program progress, and the number of persons trained in

various courses. These reports are supplemented by progress reports of the

Regional Directors and by tour reports of officials of the Family Planning

Department. An Annual Report is also issued by the Ministry of Health which

contains various details on the program. The State Bureau issues monthly and

annual reports, but not as comprehensive as those of the Center. Monthly

acceptance rates are generally limited to the total number of acceptors of

different methods of family planning. There is no systematic and periodic

analysis of data on different characteristics of acceptors, though such

information is often collected at the peripheral level.

C. FAMILY PLANNING PROGRESS

3.15 The following table summarizes progress and expenditures in family

planning in India, U.P. and Mysore:

India

Condoms Family Planning

Sterilizations IUDs Distributed Expenditures

(000's) (000's) (000's) (Million Rs)

1965-6 670 810 24,000 120

1966-7 890 910 16,000 134

1967-8 1,840 670 24,000 265

1968-9 1,660 480 59,000 305 (revised)

1969-70 1,370 440 95,000 400 (revised)

Uttar Pradesh

1965-6 40 45 NA NA

1966-7 80 107 1,400 14.6

1967-8 159 103 2,200 26.6

1968-9 156 91 6,200 37.6

1969-70 78 81 8,400 NA

Mysore

1965-6 26 76 NA NA

1966-7 52 88 NA 8.8

1967-8 110 41 NA 13.0

1968-9 92 20 NA 12.7

1969-70 49 13 NA 13.0

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These figures show the same pattern in India, U.P. and Mysore. Sterilizations

(male and female) increased up to 1967-8 but have since markedly declined. In

1969-70, they were less than one-half their peak level in both U.P. and Mysore,

although tubal sterilization increased in the last two years. IUDs reached

their peak in 1966-7, and have since declined to less than one-half their peak

level. However, there has been close to a fourfold increase in the distribution

of condoms between 1967-8 and 1969-70. The total number of new acceptors

decreased from 3.43 million in 1968-9 to 3.23 million in 1969-70. These achieve-

ments, though large in number, are insufficient when compared with the more than

1.25 million eligible couples that are being added every year. These figures

were derived by adding to reported sterilizations, IUD instertions, an estimate

of the number of condom users, on the assumption that 72 condoms equals one

acceptor. On this basis, about 15% of India's eligible couples were estimated

to be protected by the program in March 1970. In Uttar Pradesh, the total

number of acceptors has declined between 1967-8 and 1969-70. This is almost

certainly true for Mysore as well though figures for condom distribution were

not available. What is particularly disturbing is that this decline has been

associated with large increases in resources going into family planning.

Expenditures between 1966-7 and 1969-70 have increased by three times for India

as a whole. The cost per practising acceptor has more than doubled over this

period -- from Rs 60 to Rs 124 per acceptor. If the number of condom users is

based on the ratio of 144 condoms per acceptor instead of 72 (an equally

plausible ration) then the cost per acceptor will have increased to Rs 207 per

acceptor -- more than a threefold increase.

Inputs - All India

3.16 The increase in financial resources is a reflection of the rapid expan-

sion of personnel and equipment for family planning. However, personnel and

equipment still fall short of the sanctioned Government of India pattern. By

March 1970, 318 out of India's 327 Districts had District Bureaus and two-thirds

of the sanctioned technical staff in these Bureaus were in position compared

with one-half in 1968. There were 4,812 Rural Family Welfare Planning Centers,

up by one-third since 1966, but still 600 short of the target; also 29,000 sub-

centers were functioning versus only 7,000 in 1966. Finally, Urban Family

Planning Centers increased by one-third since 1966. This expansion has been

accompanied by a huge recruitment of personnel -- 150,000 persons are now

employed in the program. However, a large proportion have been inadequately

trained, impairing the effectivness of the program. Progress in construction

has been very modest and much of the program is carried out in crowded and

barely working facilities, which are often rented. The backlog of training and

buildings is readily recognized in India, and efforts are currently being made

to remedy it.

Inputs - Uttar Pradesh

3.17 U.P. has had particular difficulty in implementing the Government of

India program. This has been partly because of the shortages of personnel and

facilities in U.P. but also because the State Government has not accorded the

program the priority which it deserves. In all the U.P. Districts, District

Bureaus have been established. Five of the Districts were without an additional

DMOH-FP and various posts, including that of administrative officer, computor

and field and evaluation workers, had not yet been sanctioned. Most positions

that are sanctioned for Bureaus have been filled, with the notable exception

of female doctors. Here, 84 are sanctioned but only 29 are posted.

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3.18 At the field level, there are presently 740 PHCs functioning with only630 doctors in position. Thus 110 PHCs are without a doctor at all, and theother 630 do not have a second doctor as envisaged in the Government of Indiapattern. FPHAs number 3,500 at present, almost the required number. AmongstANMs, the staff shortage is perhaps worst of all. According to the Governmentof India pattern,there should be 1,750 ANMs at PHCs, and 7,500 at subcenters,making 9,250 in all. In fact, the total number in position at present is2,046. Some attempt has been made to alleviate the ANM gap hty posting indi en-ous midwives (dais) who have been trained and Family Welfaru Workers (FWW)'1there are 1,454 trained dais and 2,140 FWWs substituting for ANMs at subcenters.However, FWWs and dais are believed to be less effective than ANMs because ofinadequate training. The mission's observations in the field and examinationof some local records confirm a general impression that the FPHAsare ineffective.

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

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

Inputs - Mysore

3.21 At the District level, the 19 District Bureaus are adequately staffedas to number and category except for (a) administrative officers, who have beensanctioned but none of whom are in position; and (b) female doctors, of whom9 are in position instead of the 19 required.

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

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

1/ Dai training consists of 20 lessons in hygiene and basic obstetrics and20 practical sessions with an ANM. FWWs are female workers dealing withwith Family Planning; they are given just 30 days training at a RegionalFamily Planning Training Center.

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3.24 Most of the Mysore Type Health Units and dispensaries have buildings

of their own, many of them old but mostly fairly adequate. So far 136 PHCdispensaries have been constructed, the remaining 129 being housed in rented

buildings. Very few family planning clinics have yet been completed, though

about 25 are under construction. Almost everywhere, staff quarters for both

medical and family planning staff are lacking. This includes subcenters, ofwhich out of the 2,200 required, only 147 have been constructed normally the

ANM has to rent her own dwelling. Of these 265 PHCs, only 69 have a vehicle.

3.25 In urban areas, there are 53 Urban Family Planning Centers, and 3

hospitals designated for the postpartum program. Several other hcspitals, a

number of MCH centers and maternity homes (mainly in Bangalore) also do family

planning work.

Special Programs

3.26 Because India is so large, and its resources are limited, the Government

has encouraged the concept of concentrating on particular areas. This is the

basis of the intensive and selected areas program. The intensive program aimsat adding inputs - above the Government of India pattern - in a few Districts

with large population in each State. These areas have not exhibited a more

marked progress than the average, mainly because, in practice, they havereceived only minor additional inputs.

3.27 Selected Area Project. In June 1968, USAID concluded an agreement for

assistance to the Selected Area Program, to be carried out in the Varanasi

Division of Uttar Pradesh. Inputs were to be intensified. In fact, limited

funds were distributed, and the additional inputs that are in position are minor.

3.28 Gandhigram. The Gandhigram experiment covering initially one Block in

Tamil Nadu has proved successful. In 1959 the Institute of Rural Health and

Family Planning in Gandhigram started an intensive "action-research" family

planning program in a Development Block. Methods of implementation have been

continuously assessed and periodically modified. There has been a significant

decline in fertility -- 34.8% during the period 1959-68. While some inputs were

added, the program has been successful mainly because of emphasis on quality --through field training and regular supervision. It has been run by regular

State Health Officials under the overall technical guidance of the Institute and

illustrates the possibility of successful close cooperation with the Government

program. Work in the first Block (with a population of about 100,000) is now

being expanded to five neighboring Blocks. The Institute has used the program

to test new techniques such as the roles of different categories of family

planning workers, evolved more adequate supervision and developed skill and

knowledge needed by staff in other extension work. On the basis of the action-

research program the Institute has built up a successful training program.

Though Gandhigram demonstrates that success can be achieved -- that is, that

there may be a large demand for family planning services -- this applies to an

area of limited size. The problems of training and supervision become more com-

plex when applied to a whole District. Furthermore, the Gandhigram experiment

included improvements in health and community development, which are not part of

family planning efforts in the All-India context.

Foreign Aid

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

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Foundation and the Population Council for fellowships and consultants. Later

assistance also came from bi-lateral sources including the United States,Sweden, Japan and Denmark. This consisted primarily of providing commoditiesand consultancy services. The United Nations has also helped the programthrough the UNDP, WHO and UNICEF. Multi-lateral aid consisted primarily of

equipment, experts, fellowships and two teams to evaluate the Government program.Until 1969, donors financed foreign exchange costs. In that year, however, bi-

lateral and multi-lateral donors became prepared to finance local currencyexpenditures, because the foreign exchange component was small and restricted

opportunities for assistance. Following the November 1969 Consortium inStockholm, and the May 1970 meeting in Paris several offers of aid for local

currency finance have been made. They includeUS$ 2.4 million from the United

Kingdom, and US$ 20.0 million granted by the United States in June 1970 for

training and evaluation, construction of buildings, and support for the Inten-sive District program. Sweden, Norway and Canada are among other countrieslikely to conclude new agreements of a similar nature to assist the India program.IPPF and Oxfam are two of the most important sources of support for voluntaryfamily planning in India.

D. APPRAISAL OF RECENT TRENDS

3.30 While the achievements of the India program are considerable the programis not functioning as well as it should or could. A large number of personshave accepted family planning services and an extensive and complex administra-tive machine to implement policy decisions has been built. But performancefalls short of a solution of India's population problem, of the targets set bythe Go,rernment and the expectations of the Government. This is the more dis-turbing because resources for family planning have greatly increased. The"productivity" of the program -- that is, the results obtained from each rupeespent -- has fallen to between one-half and one-third its level from two yearsback. The mission attempted to find explanations for recent developments,

particularly the reversal of trends, but found no simple explanations. Nor wasthere a consensus on the reasons among persons who met the mission. Many reasons

were mentioned but the relative importance of each, and the implications thatthis has for future progress, must await further analysis and study.

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

3.32 Administrative: The family planning program is administered neitherbetter nor worse than other Government of India programs. However, this is aprogram which requires management far above the average to achieve success.Particular weaknesses are the following:

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

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

(c) insufficient financial flexibility, particularly at the District level;

(d) no overall program design or coordination among the various groupsoffering family planning services in cities;

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

3.33 Quantity and Quality of Personnel: To implement the Government pattern,India has embarked on an ambitious training program that is the largest in theworld. In doing so, more attention has been given to numbers than quality.

This "crash approach" has resulted in large numbers of poorly selected, ill-motivated and inadequately trained persons. Such persons can have negativeeffects on the program. A training program of six days' or even 30 days'duration is inadequate. Insufficient emphasis i.s given to field training and

particularly to supervision in the field. Aggravating the situation stillfurther are excessive training loads because of the insufficient number oftrainers. In spite of the crash approach to training, numbers are still short

of the Government of India pattern, which would cover only one-third to one-halfof the India population even if it were implemented according to plan. Thissituation is a reflection of the small number of skilled personnel. The smallnumber of doctors, particularly lady doctors, has already been emphasized, ashad the inadequate number of ANMs. The inadequacy of their basic training isdiscussed in para. 4.22.

3.34 Contraceptive Methods: In principle, the India program offers a"cafeteria" approach. In practice, choice of different methods in rural areas

is limited. According to the Plan, women should be able to have an IUD insert-ion at the PHC provided a lady doctor is there. This is rare in U.P. and onlya little less rare in Mysore. Also the reported side effects have undermined

the popularity of the IUD and the difficulty of follow-up reduces its effect-iveness. In practice, rural women seeking contraception, resort to steriliza-tion after having had at least three children. Even this is done only inhospitals or camps. Men fare better in that vasectomies are available at mostPHCs and hospitals. Other than this "feared" operation, rural men have no other

choice except for condoms - the least effective of the methods offered in the

program.

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

possibilities.

i. The "Crash" Approach to the Provisions of Services. Because of thepolitical priority given to this program, and following the settingof targets in 1966, there was too much concern with immediateresults and too little with methods of achieving these results andtheir long-term implications. Revenue workers and agriculturalextension workers were active in 1966-7 and 1967-8, using theirinfluence to enlist a large proportion of acceptors. The use ofthese workers was a useful support to the program. This is muchless so and may-explain the recent decline in performance.

ii. Monetary Incentives. This was first offered in 1966 and was onereason for the increase in vasectomies in the following two years

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

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

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

(a) The Demographic Cells in Bangalore and Lucknow are too low in thehierarchical structure to do independent evaluation and question someof the basic premises of the program. At present, the DemographicCells are geared to the analysis of service statistics. These cannotadequately explain program limitations because of the relatively smallnumber of acceptors in the program.

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

(c) The present information system has several limitations:

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

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

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

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

v. Achievement data collected in the system refer only to participat-ing couples. This has limited value in explaining the level ofdemand for family planning services or in suggesting improvements.No efforts are made to relate additional studies to the problemsof the program.

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

3.38 Knowledge and Awareness. Several studies show, and the observations ofthe mission confirm, that awarenes.s of conatraceptive methods is present in bothurban and rural areas, This is a tribute to the success of the mass communica-tions campaign. However, the gap between general awareness and effectiveknowledge and practice is wide and may even have increased because of this verysuccess.

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

3.40 In summary, the Indian family planning program is not functioning as wellas it should or could. Is this due to the way in which family planning servicesare provided or to the demand by the popu:Lation for such services? This, andmany other questions relevant to the program operation, have not been asked bypersons within or outside the program. The study of such questions is anecessary first step to reverse present trends. The basic aim of the mission'srecommendations is to provide a framework for orderly change. Operationalquestions should be continuously and systematically asked and the policy implica-tions of their answers should be speedily and effectively implemented.

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IV. THE PROJECT

A. INTRODUCTION

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

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

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

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

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

4.02 The project consists of the following:

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

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

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

III. An Intensive Rural Program including a particular concentration onrecently delivered mothers in rural areas. This program will haveinputs additional to those sanctioned in the Government plan andwill be implemented in four Districts -- two in U.P. and two inMysore.

4.03 To control for differences in the levels of socio-economic development,the second and third schemes would be implemented in at least one District withrelatively advanced socio-economic conditions and at least one with relativelybackward conditions. Differences in socio-economic conditions would be presentwithin each District so that the demand for family planning services can beanalysed within as well as between Districts. The following is the suggestedlocation of each scheme:

I. Urban Program Lucknow City Bangalore Urban

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

Pratapgarah

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

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4.03 B. A new Population Center in Lucknow and another in Bangalore to beprimarily responsible for the management-information system and training. Themanagement-information system would monitor progress in project areas, evaluateperformance and recommend changes that would be relevant to other parts ofIndia. These Centeis should have close links to the State family planningadministration. Their Board would have to be influential so that the recommenda-tions of these Centers can be quickly implemented.

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

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

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

(c) Two 100-bed maternity hospitals -- one in Lucknow, the other inBangalore City;

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

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

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

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

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

4.05 The following sections describe each of the three schemes, the basictraining of ANMs, the Population Centers, the physical facilities and equip-ment, and the costs of the project.

B. URBAN PROGRAM

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

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

4.07 Organization. There is urgent need for better coordination of familyplanning activities, both public and private. The Urban Family Planning Bureauin Bangalore is at present less effective than it should be, and no bureau hasso far been established in Lucknow. Some effective coordinating body should beestablished in each city (a) to draw up a detailed plan of operation to provideriaternal and child health (MCH) care and family planning services (integratedor separate) covering the whole city; and, once the plan is adopted, (b) to co-ordinate services, supplies, information efforts and the collection of relevantdata. The data would be analysed by the Population Center. The Center wouldwork closely with this body in planning, and evaluating family planning activities.It might be composed of selected members of the State Government representingHealth, Education, Industry and others; representatives of the MunicipalCorporation; and private and public voluntary agencies. It should include theDirector of the Evaluation Division in the Population Center. The questionshould be considered whether it is appropriate for such a body to report tothe Municipal Bureau.

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

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

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

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

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

C. OPTIMAL GOVERNMENT OF INDIA PATTERN DISTRICTS

4.11 The objective of this part of the project is to determine how effect-ive the Government of India pattern is. An answer to this question has notbeen possible to date because this pattern has not been fully implemented.The progress of the program will depend on the efficiency with which familyplanning services are provided and the demand for the services by the

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population. To help to determine the relative importance of each of thesefactors, the Government program will be implemented in Districts with relativelyadvanced socio-economic conditions and Districts with backward conditions. Thisprogram includes two major components:

4.12 a. Personnel. All the personnel sanctioned in the Government of Indiapattern should be in position. The gaps which presently exist in the projectareas are shown in detail in Volume II. They are summarized in Annex 6. Whetherthese gaps can be filled within a reasonable period of time by transfer fromother districts into the project area or by stepping up the rate of trainingwill require further discussion. In some cases this may be difficult orimpossible as for example with lady doctors. At the same time more personnelwill have to be trained so that the Government pattern can be implemented overthe whole State.

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

D. INTENSIVE RURAL PROGRAM DISTRICTS

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

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

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

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(c) intensive on-the-job training and supervision;

(d) special efforts in communication; and(e) organization.

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

be as follows

i. ANMs and Dais. MCH services and family planning will be provided under

medical supervision by ANMs in Mysore and by ANMs and dais in U.". The

targeted ratio will be one ANM and dai per 5,000 population equal to

about 200 deliveries per year. This ratio will be flexible depending,

in particular, upon the topography of the area. It is a minimum stand-

ard, since ideally there should be one medical attendant per 2,500

population. Many dais will have a clinic with living quarters, and in

addition to their present referral fee, they should be paid a regular

salary in rante of about Rs 90-150 per month. As additional ANMs are

trained, they will supersede these trained dais. Specific job des-

criptions for ANMs and dais should include:

1. Identification of all newly pregnant women, by name, address, age,

number of pregnancies, number of live births, number and sex ofliving children, and last pregnancy interval. Copies of thisinformation will be given to the Family Planning Health Assistant(FPHA) and to the responsible PHC doctor on a monthly basis.

2. Provision of minimum maternal care -- namely, two antenatal visits,

presence during labor and delivery, one postnatal visit, andreferral to qualified medical personnel in cases with complications.

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

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

5. Provision of family planning information and referral for con-

traceptive services.

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

7. Serve as depot holders for conventional contraceptives.

ii. LHVs and ANM Supervisors. Supervision of ANMs and dais is now the

responsibility of LHVs. This can continue to be so, but in some cases

ANMs should be promoted to become supervisors. This new system is

desirable because (1) it would encourage more young girls to become

ANMs; and (2) an ANM may be a more effective supervisor than the LHVbecause she is more familiar with local conditions and problems.

There should be one supervisor for every 5 workers. The supervisor

should visit the subcenter on a weekly basis and also report weekly to

the PHC doctor.

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

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

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

3. Escort men to PHCs for contraceptive services;

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

5. Participate in camps; and

6. Serve as depot holders for condoms.

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

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

i. Large service-motivation teams. These mobile teams would providefamily planning and MCH services in the villages. The medical staffwould remain for about one week at: each stop and it would be precededby motivational staff using group and interpersonal communications.Some personnel would remain for the follow--up of sterilization andIUD cases. This approach would be tried in one of the two IntensiveDistricts of each State. This approach seems to be desirable becauseof:

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

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

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

Each mobile team would consist of about 30 persons - three doctors,six nurses, and nurse-aids, six motivators and fifteen persons foradministrative and supporting work. Each stop would cover roughly12 villages. The whole District would be covered in about threeyears. Annex 7 gives details on the staffing requirements and equip-ment for this team.

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

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These mobile teams could be used until every PHC has a lady doctor,

The mobile lady doctor will be assigned to the District Hospital

which will provide her with supplies and equipment. She may stay

overnight in PHCs with living quarters. A ppl-iatrician will also

be assigned to the District Hospital and he will visit each PHC

once every other week.

4.18 c. Mobile Training. This will be done in the field by one mobile

District Family Planning Training Team for each District. Field training and

supervision has two advantages:

i. it is more relevant to local conditions; and

ii. all workers are trained together and learn to work as a team.

These new teams will be the field training unit of the RFPTC and will be

responsible to its Director. Each team could consist of one doctor, one nurse,

one health-educator social scientist, and one statistician. It will be

responsible for on-the-job training, retraining and supervision of extension

educators, FPHAs, LHVs, ANMs, FWWs, etc. at the PHC and subcenter level. The

team will spend 1-2 weeks at the PHC level, covering the District in 9-12

months; it will then revisit the PHCs regularly for supervision. Each team

will need transportation; living quarters in about two PHCs per District

should also be provided.

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

i. Group Motivation for the Greater Involvement of Leaders. Since the

success of family planning depends critically on the involvement of

opinion leaders -- village leaders, Panchayat Chairman, Mayors, Block

Development Officers -- greater efforts should be made to enlist their

support. Suggested possibilities are

1. Orientation Courses and Fairs. This would consist of orientation

courses once every year for leaders at the Block, District and

Divisional levels. In the case of local leaders, motivation

could take the form of assembling them in groups in the same kind

of carnival atmosphere that attracts them to local fairs and

markets. Transportation as well as food and lodging should be

provided and they should be addressed by political and religious

leaders. Each such fair lasting about two days could cover about

500 villages, so that 3 or 4 fairs every year would cover the

whole district. They should be timed to precede camps in

particular areas.

2. Incentives. Some form of financial benefit to village leaders or

Panchayat Chairmen could be tried to determine whether this would

improve performance. The benefit would be related to the number

of camps held in a particular area or the results of these camps.

ii. Face-to-Face Motivation. Incentives to acceptors who refer other

patients could be tried. A satisfied customer is a program's best

motivator. This is especially so in the closely-knit life of the

Indian village and family.

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4.20 e. Organization. The coordination of the rural postpartum programwill be the responsibility of the DMOH, the District Civil Surgeon and theDistrict Women's Hospital Superintendent. The unit will be responsible for:

i. coordinating the activities of all units;

ii. ensuring a high level of training and supervision; and

iii. collecting the statistical information and collating it in theform of a monthly report.

E. BASIC ANM AND DAI TRAINING

4.21 The previous sections have outlined several approaches on the basisof the existing limited resources of personnel. Concurrently with the imple-mentation of these approaches, measures should be taken to remove existingbottlenecks. In particular, the shortage of ANMs is a matter of seriousconcern. She is the key field worker in MCH and family planning. In theoryshe is responsible for antenatal care, labor and delivery, postnatal care,and family planning motivation for a population of 10,000. Her training con-sists of two years of basic hospital nursing and midwifery practice, after8-10 years of schooling. In reality, she is a multi-purpose health workercatering not only to MCH needs, but also to treating minor ailments, andmaintaining a register of couples eligible for family planning and other records.These statistical duties require about 25% of her time. Additionally, travelon foot requires another 25%. Accordingly, she has only half the time to pro-vide the needed MCH and family planning services. In practice, due to weather,road conditions, and insecurity at night the ANM limits her activity to anarea immediately surrounding the subcenter which has an average population of3,000-5,000. An ANM cannot possibly deal with a larger population. Even ifthe Government of India pattern of 1 ANM per 10,000 population were fullyimplemented, not more than half of rural women would have access to an ANN.In Mysore, the ratio is currently 1 AN4 per 7,000 and is expected to improve.In U.P., the ratio is about 1 ANM per 45,000 population and the situation isnot improving. The latter State recognizes this difficulty and trains FWWsand indigenous dais to replace ANMs.

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

4.23 A mere increase in the number of such graduates would only marginallybenefit the MCH and family planning efforts. Indeed, both could be hinderedby a large number of poorly motivated, poorly selected and inadequatelyEiained women. Thus it is essential to start now improving the quality of

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

a. Better selection of candidates through aptitude and other testingprocedures.

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

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

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

e. Incentive payments to ANMs for each pregnant woman given care andincentive payments for family planning motivational work andfollow-up work.

f. Institute a system of promotion for the best ANMs to superviseother ANMs and dais.

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

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

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

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

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

F. THE POPULATION CENTERS

4,.24 Objectives. Previous sections outlined the proposals of the missionfor improving the delivery of family planning services. Those recommendationswere based on what appeared to be reasonable to the mission but with no

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assurance that these measures would resolve the present difficulties. It istherefore important to evaluate how effective these recommendations will be inpractice and to determine the reason for their success or failure. This con-tinuous evaluation, leading to further recommendation for change in the mostbasic part of the project. The Population Centers were conceived is responseto the need for orderly change. Their principal objective is to analyse per-formance in the project areas, and to frame specific suggestions for improvingthis performance on a continuous and systematic basis. The Center is not con-ceived of as a passive reviewing agency. It is therefore essential that theorganization of each Center be such that its recommendations for change can bequickly and effectively implemented.

Functions

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

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

i. Appraise critically the present evaluation system, in close co-operation with the State Demographic and Evaluation Cells. Theaccurancy, analysis and flow of existing records should be improved.

ii. Redesign the reporting system at various levels to improve super-vision, inspection, and evaluation and research. This will reducethe complexity and inefficiency of the existing system.

iii. Integrate the collection and analysis of performance and cost dataat all levels. This will be part of the redesigning of the systemand will require the revision of existing forms and training formaintaining the data.

iv. Plan and implement studies

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

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

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

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

vii. Disseminate ideas through the publication of regular reports. Theseshould flow upwards to the State and Governments of India as wellas downward to all levels of personnel engaged in the projectareas; and

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viii. Train and retrain evaluation personnel such as district levelstatisticians and block level computors. Training curricula willbe devoted primarily to the introduction of new techniques andmethodology and should involve all concerned with the implementa-tion of new programs in project areas. This will involve thecreation of mobile training teams in addition to static facilitiesprovided at the Ceniter. These supervisory teams should frequentlytour to observe how different types of personnel and units areoperating. There should also be regular seminars of staff, atvarious program levels, to hear their problems and inform themof the Center's activities.

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

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

ii. Work with and advise the RFPTC and mobile District Family PlanningTraining teams in the development of curricula, materials andprograms.

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

iv. Develop and implement evaluative techniques, in cooperation withthe Evaluation Division of the Center and relevant Governmentagencies, for training programs and subsequent worker performance;and suggest changes in the training programs in the light of theseinvestigations.

Organization.

4.28 a. The Governing Board should be an influential body that can securethe speedy implementation of the Center's recommendations in the project areasand transfer this experience to the whole State, where this is desirable. TheState Chief Secretary or someone of similar standing should be the Chairman ofthe Board. Other members should include key administrators and politicians,such as those presently at the State Implementation Committee, and two represent-atives from the Government of India -- one from the Ministry of Health and theother from the Planning Commission. (The Government of India representativesneed not attend all its meetings). The Center must have the administrative

and financial control necessary to function effectively. The Center's budgetmust be drawn upon flexibly. Delays in staffing and procurement would thusbe avoided.

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

could be involved in the Center through an ex-officio appointment.

4.30 c. The Center should have financial and technical control, under welldefined limits, in the project areas. Administrative control would be withthe SFPO.

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

i. accommodating the State Demographic and Evaluation Cell and theUrban Council in the same complex of buildings as that of theCenter. The Center should provide logistical support to theseunits (e.g. data processing) and the same persons should do workfor the Center and the other groups; and

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

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

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

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

G. PHYSICAL FACILITIES AND EQUIPMENT

4.35 The project includes the following facilities:

1. In Lucknow Urban and Bangalore City.

a. Additional Delivery Beds. Four hundred additional maternity bedswill be constructed in Lucknow and 160 beds in Bangalore so that moredeliveries can be institutionalized for an effective postpartum programThis is composed of:

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

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

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On the basis of 30 deliveries per bed per year (women stay in hospitals10-12 days after delivery) these extra beds would serve an additionalpopulation of 300,000 in Lucknow and 120,000 in Bangalore. This isless than the population presently not receiving this service. Further-more, the urban population is expected to grow as a result of naturalincrease and migration to the cities. This expansion of facilitiesis particularly modestfor Lucknow, where 70% of deliveries do not occurin institutions, and where maternity hospitals are overcrowded.

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

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

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

a. District Family Planning Bureaus. Existing buildings areinadequate. One such building would be required in each of nineDistricts (excluding Bangalore Rural).

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

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

U.P. Mysore Total

Dispensary 39 3 42

Staff Quarters (Health) 54 25 79

Family Planning MainCenter 82 73 155

Staff Quarters (FamilyPlanning) 86 73 159

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

e. Facilities for ANM Training. The project includes:

i. The building of 14 ANM schools -- 5 in Lucknow and Bangalore Cityand 9 in the other Districts. The latter are attached tomaternity hospitals for training. These schools would includehostel accommodation, and equipment.

ii. Living quarters in PHCs near the schools for rural health train-ing. The precise location of these quarters has still be beselected. These living quarters could also be used by mobileteams (service-motivation or lady doctors) when not occupied bystudents.

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

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

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

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

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

H. COSTS

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

-31-

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

ESTIMATED COSTS OF THE PROJECT(in 1970 constant prices)

Rs(OOO's) US$(000's)I. Construction and Equipment

A. Urban Areas (Lucknow Urban andBangalore City

1. Population Centers 3,000 4002. Maternity Hospitals with ANM Schools 6,000 8003. Maternity Homes 5,100 6804. Urban Family Welfare Centers 1,050 1405. Regional FP Training Centers 1,000 1336. ANM Schools 1,200 160

Subtotal 17,350 2,313

B. Rural Areas

7. Administrative Buildings 6,750 9008. Maternity-sterilization Wards in

District Hospitals 6,000 8009. ANM Schools 3,600 480

10. PHC and FP Centers (Government of India 22,345 2,97911. Additional maternity wing for PHC 4,000 53312. Subcenters (Government of India pattern) 19,875 2,65013. Additional Dai Subcenters 9,000 1,20014. Vehicles 2,790 372

Subtotal 74,360 9,915

Total 91,710 12,228

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

III. Technical Assistance 7,500 1,000

Total 112,967 15,062

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

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

U.P. Mysore TotalRs US$ Rs US$ Rs US$

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

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

Total 73 9.8 50 6.6 123 16.4

4.39 Replicability

A concern of the Bank and of the Government has been that whateveris proposed in the project should be replicable , that is, that facilities,personnel and services should be provided on a scale that can ultimately berepeated in other parts of India where conditions are similar in relevantrespects. There is much in the proposed project which is of an exploratorynature, and therefore only those aspects of the project which prove particularlyeffective would in fact be subject to replication elsewhere. The project'scosts for facilities and manpower do not therefore form a basis for calculatingwhat such a program would cost on an India-wide basis. Further there is amajor information and research component in the project, which should provideresults of value to the family planning program in general; this researchand information effort is clearly on a greater scale than would be considerednecessary for every State capital in India. Subject to such considerations,it is believed that the project does provide for replicability in the sensestated above."

November 27, 1970

INDIAORGANIZATIONAL CHART OF FAMILY PLANNING ACTIVITIES AT THE CENTER

FINANCE MINISTERMINISTER OF HEALTH AND FAMILY PLANNING ANDWORKS, HOUSING AND URBAN DEVELOPMENT

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

MINISTER OF STATE IN THE MINISTRY OF HOMEAFFAIRS AND MINISTER OF STATE DEPARTMENTS OFELECTRONICS AND SCIENTIFIC AND INDUSTRIALRESEARCH.

MINISTER OF STATE IN THE MINISTRY OF LAW ANDIN THE DEPARTMENT OF SOCIAL WELFARE

MINISTER OF STATE IN THE MINISTRY OF FINANCE

CENTRAL FAMILY PLANNING COUNCIL MINISTRY OF HEALTH AND FAMILY PLANNING CENTRAL FAMILY PLANNING INSTITUTEAND WORKS,HOUSING AND URBAN DEVELOPMENT

MINISTER FOR HEALTH, DEMOGRAPHIC AND COMMUNICATIONFAMILY PLANNING,WORKS - CHAIRMAN MINISTER ACTION RESEARCH COMMITTEEHOUSING AND URBAN ------ MINISTER OF STATE FOR HEALTH -------DEVELOPMENT I AND FAMILY PLANNING BIO-MEDICAL RESEARCH COMMITTEE

SECRETARY FOR HEALTH AND (I.C.M.R.)MINISTER OF STATE FOR FAMILY PLANNINGHEALTH AND FAMILY -VICE INTERNATIONAL INSTITUTE FORPLANNING CHAIRMAN POPULATION STUDIES

STATE HEALTH MINISTERS - MEMBERS

REPRESENTATIVES OFALL INDIA ORGANIZATIONSAND OTHER DEPARTMENTS -MEMBERS EXECUTIVE BOARDCONCERNED WITH FAMILYPLANNING WORK D E P A R T M E N T O F F A M I L Y P L A N N I N G SERTR ORHAT N

SECRETARY FOR HEALTH ANDFAMILY PLANNING - CHAIRMAN

JOINT SECRETARY(MINISTER OF FINANCE)

COMMISSIONER (FAMILY PLANNINGSECRETARIAL WING NIRODH MARKETING ORGANIZATION TCHNICLING AND MATERNAL AND CHILD HEALTH(COMMISSIONER FAMILY PLANNING(JOINT SECRETARY) (MARKETING EXECUTIVE) AND MATERNAL AND CHILD HEi~ALTH) JOINT SECRETARY(FAMILY PLANNING)

-CO NVEN ER

MATERNAL AND CHILD HEALTHPROGRESS & SERVICES TRAINING, RESEARCH AND TECHNICAL OPERATIONS SUPPLIES MASS EDUCATION AND MEDIA REGIONAL OFFICES(S)

(DEPUTY COMMISSIONER) EXTENSION EDUCATION (DEPUTY COMMISSIONER) (ASSISTANT CONEMISSIONER) (ASSISTANT COMMISSIONER) (REGIONAL DIRECTOR)(DEPUTY COMMISSIONER)

AllPOUCY, PLANNING, GRANTS >ADMINISTRATION BUDGET AND FINANCE INTELLIGENCE, EVALUATION AIDED PROGRAMS z

(DEPUTY SECRETARY) (DEPUTY SECRETARY) AND RESEARCH MANAGEMENT (DIRECTOR) |(DEPUTY SECRETARY)X

IBRD - 5363

Supplies ather than conventionals, which are the responsibility of themarketing executive.

INDIAORGANIZATIONAL CHART OF FAMILY PLANNING ACTIVITIES IN A STATE

STATE CABINET COMMITTEE

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

DIRECTORATE OF HEALTH SERVICESDIRECTOR OF HEALTH AND FAMILYPLANNING SERVICES

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

STATE FAMILY PLANNING OFFICER)

OPERATION, PLANNING AND EDUCATION AND ADMINISTRATIVE ANDTRAINING DIVISION INFORMATION DIVISION STORES DIVISION STATISTICS, DEMOGRAPHY ANDASSISTANT DIRECTOR OF MASS EDUCATION AND ADMINISTRATIVE OFFICER EVALUATION DIVISIONHEALTH SERVICES COMMUNICATIONS OFFICER (FAMILY PLANNING)

zAUD IT PARTY Z

IBRD - 5362

INDIAORGANIZATIONAL CHART OF FAMILY PLANNING ACTIVITIES IN A DISTRICT

C STATE DIRECTORATE OF HEALTH SERVICES SC DIRECTOR OF HEALTH SERVICES M

STATE CENER DISTRICT AION DISTRT FAMILY PLANNING BUREAUDlOF HEALTH SERVICES ADDITIONAL/JOINT/DEPUTY DIRECTOR

l OF HEALTH SERVICES

CIVIL SURGEON DISTRICT HEALTH ORGANIZATIONCHIEF MEDICAL OFFICER OF HEALTH

RURBAN FAMILY PLANNINGPWEALFARE CENTERS DI

IMPLEMENTATION -- DISTRICT FAMILY PLANNING OFFICERDISTRICT LEVEL STATE STERILIZATION

U NITS

Tx

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

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

| RURAL FAMILY PLANNING| WELFARE CENTERSl

BLOCK LEVEL|Z

SUBCENTERS

IBRD - 5361

ACTION/ IMPLEMENTATION COMMITTEES

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

Chief Secretary Chairman Collector Chairman Chairman or President of ChairmanPanchayat Samiti, Union

Development Chairman, Zila Parishad or Anchalik PanchayatCommissioner Member

Civil Surgeon ) Elected representativeHealth Secretary Member ) of the Samiti Member

District Planning Officer)Director of M & HS Member ) Seven Block Medical Officer Member

District Health Officer ) membersOther important ) FP Extension workers MembersState officers Members Other important )

district officers and ) Block Development Officer SecretaryRegional Director Member non-officials )

Joint Director District FP Officer Secretary(Family Planning) Secretary

ANNEX 5

MANAGEMENT-INFORMATION AND EVALUATION SYSTEM (MIES)

A. INTRODUCTION

B. THE PRESENT MIES SYSTEM

Managerial Pattern and Responsibilities

The Central DepartmentThe State and Union Territory Bureau

The District Bureau

The Information System

The Evaluation System

The Measurement of Fertility

C. LIMITATIONS OF THE SYSTEM AND RECOMMENDATIONS

Limitations of the System

Supply or DemandRecommendations

D. THE POPULATION CENTER

E. TRAINING REQUIREMENTS

ANNEX 5Page 1 of 27 pages

THE MANAGEMENT-INFORMATION AND EVALUATION SYSTEM

A. INTRODUCTION

1. This Annex discusses the following:

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

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

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

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

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

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

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

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

(a) The Organizational Structure of the Family Planning Program

This includes the financial and administrative set-up as relatedto managerial and evaluative efforts, the relation of the programto other agencies, the existence of managerial and analyticalcapabilities, the expected time lag on the information flows andthe existence of political and other constraints that delay orprevent the implementation of decisions based on the system'sfindings and analysis.

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

This includes monitoring the various inputs to the program(e.g. personnel, supplies, transport, etc.) as related to

ANNEX 5.Page 2 of 27 pages

intermediate outputs (e.g. contraceptive services) and tofinal output (i.e. birth prevented). The latter being donepartly through the system's internal flow of data but sup-plemented by special survey findings and other sources ofdata. Supply analysis should also include the monitoring ofother sources of supplies from private and commercial channels.

(c) Demand Analysis

The study of demand should go beyond assessing the level ofpotential or latent demand (e.g. what kind of people practiceand do not practice contraception). More specifically, itshould examine more critically the structural relations under-lying the demand to find ways and means to increase suchdemand. This clearly will need careful studies of the effectsof education, motivation and incentives; as well as changes ininstitutions, rules, regulations, and taxations that may affectfertility behavior. This type of analysis is, by its verynature, inter-disciplinary and needs the cooperation andcoordination of various and different public and privateagencies.

(d) Cost Considerations of Such a MIES

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

B. THE PRESENT MIES SYSTEM

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

Managerial Pattern and Responsibilities

4. The responsibilities of program managers are determined in part bytheir place in the organizational structure and in part by the constitutional,legal and policy framework within which the program operates. Family Planningin India is a State subject, but the India Family Planning Program is acentrally sponsored scheme. Basically there are three main adniinistrative unitsin the Program: (1) the Central Department of Family Planning; (2) the State

ANNEX 5Page 3 of 27 pages

and Union Territory Family Planning Bureaus; and (3) the District FamilyPlanning Bureaus. To evaluate management-information needs at the various

levels, it is important to examine the major responsibilities assigned tothe offices and sections of these three units, the interrelations and inter-actions among these units and the impact of the level of efficiency of one

unit on the functions of the other units and the program as a whole.

5. The Central Department is the planner and financial controller of

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

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

(b) coordinate the development of five year plans for family

planning and MCH;

(c) oversee and finance all medical research;

(d) make decisions concerning the introduction of new con-

traceptive methods into the program;

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

(f) control the strategy, design, content, production, researchand evaluation of mass communication and educationalprojects;

(g) establish program objectives (targets);

(h) coordinate the flow of external aid;

(i) promote the sale of condoms (nirodh) through private dis-

tribution channels;

(j) coordinate and participate directly in the operation of

(1) programs addressed to the 10,000,000 employees of

Central Government organizations; and (2) the full rangeof field programs in Union territories, with a total popula-tion of some 14 million;

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

(1) coordinate demographic, communication and biomedical research.

ANNEX 5Page 4 of 27 pages

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

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

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

(c) initiate an examination of the program data-gathering andreporting machinery.

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

(a) examine ways to integrate program data;

(b) redesign the reporting system;

(c) improve accuracy and expedite the flow of data;

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

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

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

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

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

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

ANNEX 5Page 5 of 27 pages

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

The State and Union Territory Family Planning Bureaus

11. Family planning is a State subject. Thus, although family planningis centrally sponsored and financed, the States prepare and forward budgetproposals and have the primary responsibilities for program implementationand use of funds. Also, the State Governments can, and often do: (a) declineCentral grants-in-aid; (b) refuse to expand service capacity as desired bythe Center; and (c) introduce (with agreement from the Center) minor deviationsfro-m the Central pattern. Furthermore, most facilities constructed becomethe property of the State and most field personnel are State Governmentemployees.

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

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

(b) financial and operational control over field activities;

(c) coordinating theflow of information, money and materialbetween the Center and the Districts;

(d) administering and executing training of the lower echelonworkers;

(e) administering mass communication activities;

(f) administering transport; and

(g) administering the postpartum program.

13. At the State level the program is managed by the State Bureaus headedby a State Family Planning Officer and responsible -to the Director of Healthand Family Planning. There are two divisions in the State Family PlanningBureau: (a) Operation Division, headed by an assistant director. This divisionincludes an Education and Information unit; and a Planning field operation,Evaluation and Training unit; and (b) Administrative and Stores Divisionheaded by an administrative officer.

ANNEX 5Page 6 of 27 pages

14. To strengthen the State evaluation and analytical capabilities,an expanded demographic and evaluation cell within the SFPB has beensanctioned in 1969. Recruitment of a demographer, a social scientist,a statistician, a statistical investigator, a statistical assistant andother supporting staff started in 1970. Most of the staff in the Lucknowunit are in position and recruitment of the demographer was done in August1970; but the unit needs space, facilities and training.

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

The District Family Planning Bureau

16. The District Family Planning Bureau (DFPB) is the key operationalunit in the program infrastructure. Administration of actual field opera-tions is, as a rule, delegated by the State to District Family PlanningBureaus. It is obvious that the District Bureau has to supervise anextremely large number and wide range of types of facilities and programs.

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

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

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

(c) supervise the performance of voluntary organizationsreceiving government subsidies; and

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

18. To a large extent, the quality of the program at the block and villagelevel, including maintenance and use of records, is affected by the nature of

ANNEX 5Page 7 of 27 pages

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

19. The District Field Operation and Evaluation Division consists ofone statistical investigator and two field and evaluation workers (one maleand one female). The job of the statistical investigator is basically aclerical one: collecting the routine performance data from the varioushealth centers, checking the returns, correcting and adding, and filingsummary forms to the State Bureau. No analysis of the data is done, nopreparation of internal performance reports is being done, and almost nosystematic field checking of the accuracy of the data collected is beingdone. This is apparently the case partly because of the lack of an adequateanalytical capability in the District Bureau and partly because some of thesemanagement functions that require this type of data and its analysis are notperceived by the DFPO either as part of his job description or within hisauthority.

20. It is important to note, however, that the responsibilities of theDistrict program manager have become much greater and complex due to:the shift from a passive to an active program strategy through the single-purpose-worker-type extension approach. This E done essentially by using alarge cadre of Family Planning Health Assistants (FPHA) in the rural andurban areas, one for each 20,000 people. These workers conduct a house-to-house motivational and educational effort directed towards all eligiblecouples in their jurisdiction. This community extension approach added anew load on the administrative responsibility of the District Family PlanningOfficer because of the involvement of the community. This added load didnot, however, have a parallel added analytical capability in the DFPB.

The Information Mechanism

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

(a) What is happening under their jurisdiction;(b) Why things are happening as they are;(c) How to improve things; and(d) How to implement changes quickly.

ANNEX 5Page 8 of 27 pages

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

22. A detailed set of records, registers and returns that bring outthe performance of each operational unit has been worked out by the Centeras a standard format. Utilizing the various records and registers kept atthe peripheral levels, standardized reporting pro forma has been preparedfor collection and transmission of monthly data on the various efforts madeand performance achieved at the different levels from the black to theCenter. The states collect the information from District Bureaus which inturn obtain the data from the block and so on down the line to the peripheralworkers. The Demographic Cells are required to undertake major responsibil-ities in rationalizing and streamlining the service statistics system. AStatistical Assistant is provided in the District Bureau and a computor(compilation clerk) at the block level.

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

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

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

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

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

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

The multiplicity of record-keeping at the peripheral level creates some mis-allocation of time-use and, coupled with inadequate supervision and necessarysupplies, some inefficiency.

ANNEX 5Page 9 of 27 pages

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

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

(a) Form P: Monthly report on the number of service unitsand their performance. They include the following:

P1 - for sterilization and IUD;

P2 - for distribution of conventional contraceptives; and

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

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

(c) Form T: Monthly report on training as follows:Ti - for regular/special courses of training; and

T2 - for orientation training.

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

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

29. The SFPB issues a monthly memorandum to all DFPB giving them rankingby performance relative to target and encourages those Districts with highachievement. The statements also in23ude queries to Districts low in theranking. Ranking, however, is done merely with regard to performance withouttaking cost and utilization into account.

30. There is a clear dichotomy in the reporting system between cost dataand performance data. This dichotomy persists from the District level wherecost and capacity utilization data are collected separately from performance data.The statistical assistant at the DFPB is only responsible for performance

ANNEX 5Page 10 of 27 pages

Summary Statement of Reports Sent by Units of Various Levels

Last Day of MonthReturn From Form Treguency Destination for Sending

l.(a) Rural areas - Contra-ceptive depot holders/distribution center P3 Monthly Sub-center 3rd

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

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

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

(b) Urban areasFWPC (under a City

Bureau) Pl, P2, E Monthly City Bureau 8thS Quarterly "

FWPC (not under aCity Bureau) P1, P2, E Monthly City Bureau 10th

S Quarterly " "

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

5. DFPB P1, P2, E Monthly (i) SFPB 15thS Quarterly copy to:

(ii) FP Commis-sioner (E&ISection)

6. State Training Centers T1 , T Monthly (i) SFPB 15ths copies to:

(ii) RegionalDirectors

(iii)FP Commis-sioner(TrainingSection)

ANNEX 5Page 11 of 27 pages

Last Day of MonthReturn From 'Form Frequency Destination for Sending

7. SFPB Pl,P2,E,Tl,T2 Monthly FP Commissioner 25thS Quarterly (E&I) copy to:

Regional Directors,FP Commissioner

(PB Section)

8. Central FP Field Ulnits T2 , E Monthly FP Commissioner 15thS Quarterly (E&I) copy to:

Regional Director,FP Commissioner

(Training)

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

10. Central FP Corps C1 , C MQithly FP Commissioner 15thCentral FP Corps

ANNEX 5Page 12 of 27 pages

statistics and is not aware of other data which are the responsibility of

the accountant. District Family Planning Officers do not have the oppor-

tunity of utilizing the full potential of the data they receive every month.

Proper design and training could provide adequate perspective and timely

information for better management and control of their activities. This

situation is also true at the state level. Cost andcapacity data are prepared

only in financial terms with a limited purpose. They do not correlate

financial accounts with physical achievements of the various program activities.

31. It seems important to have cost data and performance statistics

more closely integrated, from the peripheral units upward. The purpose is

twofold: (a) to assist administrators to think in terms of cost-effectiveness;

and (b) to assist program management, analysis and planning to be more

effective at the various levels. This would require a redesigning of the

reporting system and some revision in the pro formae. Any revisions of the

reporting system must be designed to have minimal revisions in the future.

Revisions will always be necessary because of the dynamic nature of the

program.

The Evaluation System

32. The objectives of the evaluation efforts undertaken by the program-

administration are described by the Family Planning Department as follows:

"The focus of evaluation of the family planning program at present is

on the purposive assessments of impact of the program, identification

of areas of success and failures and reasons thereof, and feeding

back this information for modification and improvement of program

implementation." 1/

33. The present evaluation effort is short of what is necessary for

program development and planning. This deficiency is greater on the State

level because of the following: (a) the lack of analytical capabilities that

could utilize the existing potential of service statistics and supplement

them with additional data; (b) the need for more integrated program statistics;

and (c) some inherent limitation on the scope of evaluation within the system.

34. Internal evaluation is the major responsibility of the Department of

Family Planning. The Department is responsible for developing and analyzing

specific family planning program data on an All-India basis. The Department

issues a monthly set of statements giving data, by State and Union Territories,

on population, family planning sanctioned staff in position at State and

District levels, t:he numbers of urban and rural Family Welfare Centers required

and functioning, sterilization and IUD program progress, and the number of

persons trained in various courses. These are the main periodic reports

prepared by the Department. They are supplemented by progress reports of the

1/ System of Evaluation of Family Planning Programme, Government of India,

Ministry of Health and Family Planning, Department of Family Planning,

New Delhi, 1958.

ANNEX 5Page 13 of 27 pages

Regional Directors and by tour reports of the officials of the Family Planning

Department. An Annual Report is also issued by the Ministry of Health which

contains various details on theprogram. The SFPB issues monthly and annual

reports, but not as comprehensive as those of the Center.

35. Month-to-month acceptance rates are based on the numbers transmitted

and processed from the periphery to the Center and are generally restricted to

the total number of acceptors of different methods of family planning. There

is, however, no systematic and periodic analysis of data on different charac-

teristics of acceptors (e.g. the interval since the last birth (open interval),

parity, etc.) though such information is often collected at the peripheral level.

36. The quality and reliability of service statistics becomes the more

important as a result of the recent Government of India initiative in strength-

ening its analytical capabilities. These recent developments include: an

enlarged and functionally expanded wing in the Central Department of Family

Planning and the expansion of State Demographic and Evaluation Cells. Further-

more, the Planning Commission has completed its second thorough and critical

internal review of the Indian program and the Ministry of Health has undertaken

and completed its own review of its current program. Similar developments at

the State level are, however, lagging.

37. The expanded Demographic and Evaluation Cells are assigned major

responsibilities in examining and streamlining the system of service statistic and

understanding supportive evaluation studies, e.g., follow-up of IUD and steril-

ization clients. These cells, however, need professional guidance in order to

carry on some of their prescribed functions.

38. The existing organization of these expanded Demographic Cell.s in

Bangalore and Lucknow are far from ideal for the following reasons:

(a) They are too low in the hierarchical structure to do independent

and objective research and evaluation that may question some of

the basic premises of the system.

(b) They are geared to the routine analysis of service statistics.

Service statistics, however, at the present low participation

rates have limited value in explaining program limitation and in

giving guidelines for its management and development.

(c) They do not have adequate capabilities to conduct special studies

to supplement the deficiencies of service statistics mentioned in

(b) above. Thus, these efforts will be limited in scope and

analytical value and, because of their low set-up in the hierarchal

structure, their findings may not have much weight even within their

own department.

ANNEX 5Page 14 of 27 pages

(d) A thorough evaluation of present participation rates, prediction

about future participations and careful examination of ways and

means to achieve program targets in the coming years will certainly

require raising basic questions about possible limitations of

the present system. It needs the undertaking of carefully designed

basic studies with a wide range of implications in the structure

of demand for family planning and its supply. Answers to these

questions may have far-reaching conclusions and are beyond the

capacity of the existing evaluation cells to undertake effectively.

39. These cells, however, if given adequate training and,support, could

be invaluable in improving the quality of data collection in the State. This

could be done through adequate supervision and training of the staff at the

peripheral units and through carefully designed probability sample checking of

returns in the field.

The Measurement of Fertility

40. Ultimately, the family planning program will be evaluated in terms of

its impact on fertiliLy. An All-India or an All-State evaluation in these terms

seems to be rather unrealistic in the India set-up at the present time. Serious

efforts in this direction are needed.

The Population Census

41. The population census is one important source of data for measuring

changes in population growth. The next population census in India is scheduled

for 1971. The 1971 Census will include a question about current fertility. The

census, however, has many deficiencies as a means of direct family planning

evaluation:

(a) Estimated intercensal growth rates represent the outcome of a ten-

year period of changes in fertility, mortality and net migration.

The estimated growth rate becomes an average over the ten-year

period and does not necessarily represent the period of evaluation.

(b) Uneven change in fertility, mortality, or migration will distort

estimated growth rates for single years.

(c) Variation in census quality will introduce errors in the estimated

intercensal growth rates. These errors may be greater than the

expeoted short-term changes in demographic rates.

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

(e) The census, by its very massive nature, does not include questions

on family planning practice and other questions needed for evaluation.

ANNEX 5Page 15 of 27 pages

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

Vital Registration

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

44. Acknowledging these deficiencies, the Registrar General's Office hasundertaken the State Sample Registration Scheme on a State-wide probabilitysample basis. The Sample Registration Scheme uses a local resident (often thevillage school teacher) as a part-time registrar in a sample area of about2,000 persons. In addition, a semi-independent survey is conducted every sixmonths to supplement the registrar's reports of vital events, to update estimatesof the base population, and to produce estimates of births and deaths.

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

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

(a) More use of teachers in rural areas as part-time registrarsmay improve quality and quantity of returns as the SampleRegistration Scheme indicated.

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

47. Another aspect of vital registration which is related to family planningand needs careful consideration is the use of vital statistics at the peripherallevel as an identification for eligible couples. This could be a good startingplace for a rural postpartum program. It is true, in order to have estimates ofbirths and deaths through a vital registration scheme, coverage and quality areessential. However, in order to have a highly effective postpartum program,

ANNEX 5Page 16 of 27 pages

or an eligible-couple-referral scheme, less than full coverage will besufficient. It is possible that even a 20 to 30 percent coverage will bevery effective as a reference for couples eligible for family planningservices. Such an approach may replace and supplement much of the fieldenumeration and registration done by the FPHA.

C. LIMITATIONS OF THE SYSTEM AND RECOMMENDATIONS

Limitations of the System

48. Based on various reports and field observations, program achievementfor the year 1969/70, in terms of total IUD insertions and sterilizationsperformed has been substantially below the 1968/69 level, and most probably the1970/71 level will still be lower. This level of performance has many implica-tions for the program's planned goals in the coming decade. However, theexisting information and evaluation system does not give adequate answers to:

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

The system is unable to give answers to such crucial questions and priorindications of their possible occurrence - a function vital for good management -

both at the State and the District levels. For example, there has been nospecial report from the District to the State or from the State to the Centershowing concern about possible decline or analysis of the current low level ofperformance.

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

(a) There is a need for managerial training for responsible adminis-trative officers in the State and the District levels, especiallythe latter. Some responsibilities that are important for efficientmanagement, e.g. the responsibility of District Officer to reallocatepersonnel, material and transport within the District are not clearto the District Officer. Also important is the lack of financialflexibility at the District level.

(b) There are no adequate analytic capabilities at the State and Districtlevel that give systematic evaluation of the quality of data, super-vise the flow of information and its collection and do substantiveanalysis of the data collected.

(c) Records and reports are not designed for speedy data processing,they do not integrate cost and achievement data, and are not keptadequately at the peripheral units. This makes it difficult toconduct additional analysis or sample studies needed to supplementthe existing reporting system.

ANNEX 5Page 17 of 27 pages

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

(e) Some of the operational functions in the peripheral level requirea large input of registers and recordings which conflict withefficient operation and management. The FPHA's are required tokeep couple registers and update them for their area of work.Recording of data is expensive mainly in terms of the opportunitycost of time; and most of the utility of data collected isderived from its further use. Its use could be either operational,i.e. for efficient continuous operation at the relevant unit, orcould be for information and evaluation at higher levels. Datacollected by the peripheral workers (e.g. ANM and FPHA may beevaluated in terms of these two functions.

Supply or Demand

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

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

(a) Medical and paramedical personnel, especially the female, donot accept employment in rural areas, and if they do they areusually less motivated than expected.

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

(c) Transportation and communication necessary for initial visitsand follow-up services are not usually available.

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

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

52. Several of these reasons do not exist in urban areas. However, theparticipation rates, although generally higher in urban areas are not as highas they should be. More important, the general decline in performance duringthe last and current financial years is also true in urban areas. This can bedue either to a decline in the efficiency with which services are provided or

ANNEX 5Page 18 of 27 pages

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

Recommendations

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

54. Data Collection and Reporting

(a) Redesigning the reporting system to facilitate its analyticpurposes and to reduce its complexity. For example, the use of'book registers' to record individual cases on the peripheral levelis difficult to maintain, to supervise, and to update systematicallyfor extended periods. Consideration should be given to a 'couponsystem' or to a 'clinical record system' that includes pre-codedquestions. They are simpler for coding, quick sorting and analysis.Details of such systems are given in 'A Handbook for ServiceStatistics in Family Planning Programs,' a publication of ThePopulation Council.

(b) Integrating performance and cost data not only in the reportingbook, but also as part of the normal managerial function of theadministrative staff in the District and theState. A thoroughdiscussion of cost effectiveness on the operational level seemsessential. Extensive training and demonstration will be neededto implement such procedure.

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

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

(e) Standard reporting forms may be printed by the State Bureau andmade available in adequate supply to the District and peripherallevels.

ANNEX 5Page 19 of 27 pages

55. Personnel and Training

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

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

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

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

56. Vital Registration

(j) Given the reasonable spread of primary education (there are at least1000 teachers per district), it is recommended that primary schoolteachers be used on a part-time basis to collect vital rates inthe villages. This has been proved practical in the Sample Regis-tration Scheme. It will probably improve the quality and coverageof vital registration at a relatively low cost. The teachers, thenmay be used as the focal point of contact for motivational work.

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

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

(m) The Sample Registration Scheme should continue. More use ofits findings, especially on the operation side may be made

ANNEX .5Page 20 of 27 pages

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

(n) In U.P. the Health Department is responsible for civil vitalregistration. The system as described in 'Guide on Birth andDeath Registration' by the Family Planning CommunicationAction Research Project of Lucknow, needs careful examinationin view of the above comments.

57. General Recommendations

(o) Family planning is given a high priority in the Governmentof India planning process. Family planning, however, is ahighly complex and interdisciplinary subject. It toucheson and affects almost all aspects of life. No scientific disciplinealone, and for that matter no single Governmental Departmentcould examine and control population growth and its consequences.It needs the joint efforts of the various disciplines of thewhole Government machinery to achieve the ambitious goal ofreduced fertility.

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

(q) It is evident that there is a sizable gap between actual perfor-mance and desired targets of client participation. If it becomesapparent to the Government that the present active motivationalapproach is not sufficient to lead to sufficient participationto reduce fertility, the population problem will become increas-ingly acute. Society must decide on either living with theconsequences of such population pressures, or trying variousother ways and means to effect demand more directly: e.g. givemore incentives to acceptors and/or make changes in laws andregulations that may affect fertility su,J fiS marriage laws,inheritance laws and various types of tax.aLon. A successfulfamily planning program must always examine the various factorsthat affect the supply side as well as those affecting the demandside. Changing the factors that make demand more favorable areas important as changing the factors that make supply more

ANNEX 5Page 21 of 27 pages

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

58. Areas of Research and Experimentation

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

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

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

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

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

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

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

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

(iii) Incentives for communities and community leaders.

ANNEX 5Page 22 of 27 pages

Mechanisms to Strengthen Evaluation and Research

59. The type of research and experimentation that is being recommended

requires technical skills and training. Such capabilities are not available

in the existing State Demographic and Evaluation Cells and the economics of

raising the capabilities of these units may have questionable value and may

not be feasible given their status in the governmental hierarchy.

60. The importance of the expected findings of the type of experiments

being recommended, the policy implications of its conclusions, and the com-

plexity and interdisciplinary approach of its design and analysis warrant

giving such projects high priorities. Also, it is important to involve

Departments other than the State Bureau in the formulation and supervision

of such extended work.

61. A strong organization should be formed in the State and be attached

to a high-level secretariat, possibly headed by the State Chief Secretary.

The following section will discuss the details of this State Population

Center.

D. THE POPULATION CENTER

General Purpose

62. The central function should be continuous review in the broadest

sense of the population trends and programs of the selected districts and

cities. This means (1) information for understanding what is happening;

(2) the generation of new ideas and their effective communication to the

appropriate administrators; and (3) cooperation with the administrators to

work out specific plans for implementation and evaluation of new ideas that

are accepted as feasible by the administrators.

63. The Center should be a nucleus for other activities as well

(e.g. training). However, its primary objective is to demonstrate that it

is possible to understand by systematic observation and research: (a) essential

elements of the complex bio-social system that sets fertility levels in the

area; (b) the specific nature and effects of the program; and (c) the range

and tested feasibility of plausible and promising alternatives to what is being

done.

Evaluation Objectives

64. The essential beginning should be a fair but critical monitoring of

the present evaluation system:

(a) This should begin in close cooperation with the new State Demog-

raphic and Evaluation Cell to improve the accuracy, speed the

flow, and begin the genuine analysis of the existing records.

What can be done within the existing record system?

ANNEX 5Page 23 of 27 pages

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

(c) There must be close and continuous interaction with the StateDemographic and Evaluation Cell. This would be eased if theywere housed in offices adjoining those of the Center, with suchservices as mechanical tabulation, standard printing of forms,etc. provided. The situation should encourage frequent jointmeetings, formal and informal.

(d) A "supervisory team" should be frequently on tour to observehow different types of personnel and units are operating. Itis clear that some problems are so acute that they do not requirerefined statistics for diagnosis. Administrative and organiza-tional reviews can be done by teams from the Center and theregular government organization.

65. The Center must go far beyond these minimal services for makingthe existing records and operations work as well as pos3ible. It shouldalso cover:

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

(b) The fertility and family planning histories of samples of allcouples ever served by the program - especially after theyleave the program.

(c) The design and monitoring of experimental program variationsin cities, districts, and blocks.

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

(e) Demographic rate estimates for program areas.

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

ANNEX 5Page 24 of 27 pages

Management and Advisory Services

67. Analysis of data from routine records, surveys, the statistics ofother agencies, observation, etc. should have as one objective, recommenda-tions and ideas for strengthening or changing the operation of the program.Such ideas will emerge sometimes because the research has been designed toanswer specific questions (e.g., what kinds of couples want family planningnow? What kinds of workers accomplish the most under what circumstances?,etc.). There should be a link and constant prodding from the program sidefor practical results. For Somple, if it could be shown that the greatmajority of IUD dropouts use other methods to keep their fertility low withoutprogram aid, then an important administrative decision could be made toconcentrate fieldworker resources on new cases rather than on follow up ofdropouts.

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

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

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

(c) Administrators will become enthusia.--, allies when they findthat their programs are becoming famous and discussed by reasonof the analysis and write-ups of the research process. Openpublication and analysis of the defects as well as the strengthsof the program can be a credit for administrators if accompaniedby objective and critical analysis of what the problem is andwhat solutions are proposed.

Other Functions of the Center

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

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

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

(c) Develop mobile or district level retraining and seminar programsfor local personnel of all kinds; and

(d) Circulate materials that are prepared in the Center to othertraining units in the State.

ANNEX 5Page 25 of 27 pages

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

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

(a) Proximity will facilitate interaction.

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

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

72. The generation of ideas is a primary product of the Center. It mustbe made as clear as possible that this is not a clerical-statistical operationonly. For this purpose, the Center should issue a regular report to the stateard to the Central Government and the Planning Commission on "Population andFamily Planning in Mysore (U.P.): 1971 - the Record to Date and Plans for theFuture."

Needed Resources

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

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

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

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

(d) Ten Research Supervisors who will constitute the core of the unit.Basic background may be at least a Master's in any of the socialsciences. Research supervisors will undertake on-the-job extensivetraining in the following areas: sample design and execution, data

MNEX 5Page 26 of 27 pages

processing, including computer facilities, interviewing techniques,editing and coding techniques. They will be trained for atleast 6 months initially while developing the initial materialfor the b,ase-line surveys to be conducted in the project areas.These benchmark surveys in Lucknow and Bangalore should be thefirst act:ivities of the Center. Staff will be recruited for thatpurpose and trained. The best ten will be retained as researchsupervisors. This core of research supeirvisors will be the basisfor training and re-training temporary interviewers, editors, orcoders needed for special surveys. The- will also be responsibleand involved in training program personnel in the Demographic andEvaluation Cells; and

Four computer key-punching operators to operate mechanical tabulationequipment.

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

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

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

(c) a small unit for key-punching and for mechanical tabulation.Access to a computer is desirable, but not essential;

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

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

E. TRAINING

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

(a) Recruitment of Advisors a:id Directors - 6-12 monthsRecruitment of senior and middle levelstaff at the Population Center

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

In this training all the senior and middle level staffS of the Centerwill undergo extensive on-the-job training through the development ofthe necessary material for the base-line survey. They all must go to

ANNEXPage 27 of 27 paSes

the field, check the available data at the peripheral levels,

do actual interviewing, etc. The following are some of the

basic functions to be done:

- study all available data- study forms and registers- prepare the survey objectives- prepare the sample frame- prepare the sample design and material

- prepare the questionnaire- study interviewer instruction books

- edit and code- pre-test the questionnaire.

During this period it will be most usefiul to involve the State

Demographic and Evaluation Cell's personnel and the statistical

officers in the District Bureau.

(c) Training II: Training of Personnel in the State Demographic

and Evaluation Cell and in the District

This will be a continuous function. The time needed for these

units to reach their full capacity utilization cannot be precisely

estimated. The Population Center must reach a high level of

maturity to be able effectively to assist and influence the

units in the State and Districts.

77. In general, the success of the Center will depend largely on its

personnel - their technical capabilities as well as their personalities.

ANNEX 6Page 1 of 4 pages

INPUTS AND RESULTS IN PROJECT AREAS

A. INPUTS

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

TABLE 1: MATERNTTY BEDS IN UP AND MYSORE

TOTALI, U.P. DISTRICT HOSPITAL PHC OTHER MATERNIY BEDS

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

RURAL TOTAL 406

Lucknow City - in 4 hospitals -

II. MYSORE DISTRICT

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

RURAL TOTAL ga1

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

The above tables indicate 1.3 maternity beds per 10,000 population inM4ysore Rural and 13.2 beds per 10,000 population in the city ofBangalore.

In the rural areas of U.P0 the level is 0.46 beds per 10,000 population,while in Lucknow city, the ratio is 5.2 beds per 10,000.

ANNEX 6Page 2 of 4 pages

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

DISTRICT iEADQUAMCERS STAFFOpera- PHC ANM TOTAL IN GOVT. SERVICE

Adm Infor. tional Mobile Doctor PHC & Sub-DISTRICT Unit Unit Unit Unit M F LHV BEE FPHA Centers Doctors Nurses ANM FWW DAIS

BUNGALORERURAL

Required 8 6 3 14 8 8 16 8 40 82 - - - - -

In Position 5 5 1 11 8 - 10 8 32 69* NA NA 27 42 37

FAIZABAD

Required 8 6 3 1-4 18 18 36 18 91 181 - - - - -

In Position 4 5 1 8 17 - 12 16 68 69* 31 36 16 53 54

SULTANPUR

Required 8 6 3 14 19 19 38 19 85 207 - - - - -

In Position 5 4 1 9 13 - 11 19 76 39* 7 2 27 12 78

PPATAPGARH

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

MUZAFFARNJAGAR

Required 8 6 3 14 14 14 28 14 56 140 - - - - -

In Position 5 1 1 7 12 - 11 9 55 88* NA NA 31 57 62

SAHARANPUR

Required 8 6 3 14 16 16 32 16 75 150 - - - - -

In Position 5 5 1 7 15 - 16 15 52 74* 47 NA 31 43 53

Includes Family Welfare Workers (FWW).

ANNEX 6Page i of 4 pages

TABLE 3: MYSORE - MCH/FP STAFF - RURAL

DISTRICT HEADQUARTERS STAFFOpera- PHC ANM TOTAL IN GOVT. SERVICE

Adm Infor. tional Mobile Doctor PHC & Sub-

DISTRICT Unit Unit Unit Unit M F LHV BEE FPHA Centers Doctors Nurses ANM FWW DAIS

BUNGALORERURAL

Required 8 6 3 14 19 19 38 19 70 178 - - - - -

In Position 4 4 2 6 29 13 39 19 32 242 115 0 242- -

KOLAR

Required 8 6 3 14 15 15 30 15 56 142 - - - -

In Position 3 4 3 5 15 5 17 15 21 201 99 44 201 -

TUT4IUR

Required 8 6 3 14 16 16 32 16 75 182 - - - -

In Position 6 2 3 5 21 5 20 16 58 216 117 35 219 -

CHITRANDURGA

Required 8 6 3 14 13 13 26 13 56 137 - - - -

In Position 4 2 1 6 17 5 9 13 35 144 92 49 147 -

SHIMOGA

Required 8 6 3 114 10 10 20 10 35 212 - - - - -

In Position 5 3 3 6 10 6 14 10 35 212 102 55 221 --

ANNEX 6Page 4 of 4 pages

B. RESULTS

In Bangalore Division, IUD acceptance has decreased by70.2% from 1967-68 to 1969-70. Similarly, vasectomy acceptance hasdecreased by 81.7%, Tubal sterilization has increased by 357.5%, andcondom users have increased by 7.7%. Total acceptances have de-creased by 47.7% (on the basis of 72 condoms distributed equal oneacceptor per year). In the project area of U.P., IUD acceptors decreasedby 17.5%, from 1967-68 to 1969-70. Tubal sterilizations increased by49.6%, and condom users increased by 813% (on the basis of 72 condomsdistributed equals one acceptor per year). These results are subjectto the methods of calculating condom users. The following tablesummarizes these results:

TABLE 4: PROGRAM PROGRESS

BANGALORE DIVISION (MYSORE)

YEARL IUD VASECTO0MY TUBECTOMY CONDOM USERS TOTAL ACCEPTORS

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

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

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

U.P. DISTRICTS

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

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

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

Pieces distributed divided by 72

ANNEX 7Page I-of 2 pages

STAFF AND EQUIPMENT REQUIREMENTS OF SERVICE

MOTIVATION TEAMS

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

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

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

(c) The working of the members of this unit together for extendedperiods of time would improve their effectiveness.

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

a. Staff

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

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

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

b. Equipment

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

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

Vehicles -- 1 Bus (for equipment transport, staff transport,patient transport); 1 audio-visual bus-van (eveningsfor village motivation, daytime for patient andstaff transport); 2 Jeep station wagons (staff/trans-port, supplies and as second audio-vi6usal unit;

ANNEX 7Page 2 of 2 pages

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

The cost estimates for this equipment are as follows:

Vehicles Unit Cost Total Cost(Rupees) (Rupees)

1 Bus 32,000 32,0001 A-V Bus-Van 32,000 32,0002 Jeep Station Wagons 20,000 40,0001 Jeep, Utility 18,000 18,000

Vehicles: Subtotal 122,000

Audio-Visual Equipment

2 Film Projectors 4,000 8,0002 Generaators 3,000 6,0003 PA Systems 3,000 6,0002 Projection Screens 1,000 2,0002 Sets, Films, Other 5,000 10,000

A-V Equipments Subtotal 32,000

Medical/Surgical Equipment

1 Generator 3,000 3,0002 OR Lights 1,500 3,0002 OR Tables 600 1,200Instruments .15,000 15,000

Medical/Surgical Subtotal 22,000Equipment:

TOTAL 176,000

ANNEX 8Page 1 of 13 pages

INDIA POPULATION PROJECT

LOCATION OF PRIMARY HEALTH CENTERS AND NUMBER OF SUBCENTERS

1. SUMMARY TABLE

UTTAR PRADESH STATE

2. Lucknow District (rural)3. Faizabad District4. Pratapgarh District5. Sultanpur District6. Muzaffarnagar District7. Saharanpur District

MYSORE STATE

8. Bangalore District (rural)9. Chitradurga District

10. Kolar District11. Shimoga District12. Tumkur District

Note: In the following tables NA denotes PHC dispensaries, familyplanning wings, or staff quarters which have not been constructed.These are included in the project. The project also includesincomplete buildings (denoted by I). Only those buildings thathave been constructed (denoted by A) are not in the project.

ANNEX 8Page 2 of 13 pages

1. SUMMARY TABLE

A. UTTAR PRADESH

Lucknow Faizabad Pratapgarh Sultanpur Muzaffarnagar Saharanpur Total1. PHCs

a. Dispensary 4 5 11 5 7 7 39 l/b. Staff

Quarters 5 6(12.1) 15 5(8.1) 6 7 54c. FP Main

Center 5 18 14b 18 13 14 82d. FP Staff

Quarters 8 18 15 18 13 14 862. Subcenters J/60 177 139 187 138 116 710

i/ According to the GOI plan of 1 Subcenter per 10,900 population.

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

B. MYSORE

Bangalore Chitradurga ShimoEa Kolar Tumk-jr Total1. PHCs

a. Dispensary NA NA 1 NA 2 3b. Staff

Quarters 4 4 4 6 7 25c. FP Main

Center 19 13 10 15 16 73d. Staff

Quarters 19 13 10 15 16 732. Subcenters 60 92 62 69 125 508

C. TOTAL PROJECT

PHCsDispensaries - 42Staff Quarters - 79FP Main Center - 155Staff Quarters - 159Subcenters - 1,325

ANNEX aPage 3 ,f 13 pages

2. UTTAR PRADESH - LUCKNOW (Rural)

A. PRIMARY HEALTH CENTERS

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

1. Mohonlalgany NA NA A NA.2. Malihabad NA NA NA NA3. Kapari NA NA NA NALk. Chinhat NA NA NA NA' Sarajninagar A A NA NA6. Bakghi-Ka-Talal A NA A NA7. Goshainganj A A A NA8. Mall A A NA NA

Total needingconstruction 4 5 5 8

B. SUBCENTERS

Personnel (ANMs and FWWs) 1/ Buildin s /Sanctioned Functioning Required Constructed ? _/Not Constructed

80 77 3 20 6o

1/ Both are under health and FP budgets.

2/ Includes buildings under construction.

ANNEX 8Page 4 of 13 pages

3. UTTAR PRADESH - FAIZABAD

A. PRIMARY HEALTH CENTERS

Health Wing Family Planning WingDispensary Staff Quarters FP Main Center Staff Quarters

Name of PHC

1. Sohawal NA NA NA NA2. 'Maya Bazar NA NA NA NA3. Harintinganj NA NA NA NA4. Ehion NA NA NA NA5. Ramnagar NA NA NA NA6. Mashoda A I NA NA7. Tarun A I NA NA8. Milki Pur A I NA NA9. Khandasa A I NA NA

10. Pura Bazar A I NA NA11. Katehri A I NA NA12. Bhiti A I NA NA13. Bashari A I NA NA14. Jahangirganj A NA NA NA15. Akberpur A I NA NA16. Jalalpur A I NA NA17. Tanda A I NA NA18. Bikapur A I NA NA

Total NeedingConstruction 5 6(12.I) 18 18

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

B. SUBCENTERS

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

183 88 95 6 177

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

ANNEX 8Page 5 of 13 pages

4. UTTAR PRADESH - PRATAPGARH

A. PRIMARY HEALTH CENTERS

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

1. Amargarh NA NA A NA2. Patti NA NA NA NA3. Mangraura NA NA NA NA4. Sandwa-Chandika A NA NA NA5. Sangipur NA .NA NA NA

6. Gaura NA NA NA NA7. Shedgarh NA NA NA NA8. Sadar NA NA NA NA9. Lalganj NA NA NA NA

10. Derwa NA NA NA NA11. Babaganj A NA NA NA12. Laxmanpur A NA NA NA13. Mandhata NA NA NA NA14. Kunda A NA NA NA15. Katra Gulab Singh NA NA NA NA

Total NeedingConstruction 11 15 11

B. SUBCEN'iERS

Personnel (AN4s and FWs) BuildingsSanctioned rnlNctiani Required Constructed Not Constructed

150 61 89 11 139

ANNEX 8Page 6 of 13 pages

5. UTTAR PRADESH - SULTANPUR

A. PRIMARY HEALTH CENTERS

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

1. Dubeypur A I NA NA2. Kurwar NA NA NA NA3. Kurebhar A I NA 1/ NA4. Joaisinghpur A I NA NA5. Bhadaiyan NA NA NA NA6. Dhanpatganj A A NA 1 NA7. Amethi A A NA _ NA8. Gauriganj A I NA NA9. Bhetua NA NA NA NA

10. Bhadar A I NA" NA11. Musafirkhana A A NAl! NA12. Jagdishpur A A NA NA13. Jamon A I NA NA14. Baldirai A I A A15. Kadipur A A NA - NA16. Dostpur NA NA NA NA17. Akhand Nagar A A NA 1/ NA18. Kamaicha NA NA NA NA19. Lambhua A I NA NA

Total NeedingConstruction 5 5(8.1) 18 18

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

B. SUBCENTERS

Personnel (ANMs and FWs) BuildingsSanctioned Functioning Required Constructed Not Constructed

194 49 143 7 187

ANNEX 8page 7 of 13 pages

6- UTTAR PRADESH - MUZAFFARNAGAR

A. PRIMARY HEALTH CENTERS

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

1. Monna A A NA NA2. Jansath .t A NA NA3. Baghra A A NA NA4. Buidhana A A NA NA5. A A NA NA6. Kandhla A A NA NA7. Kairana A A A NA8. Purqazi NA A NA NA9. Megha Kheir NA NA NA NA

104 Ghahibpur NA NA NA NA11. Charthawal NA NA NA NA12. Shabnimr NA NA NA A13. Thana Bhawan NA NA NA NA11. Kurmali NA NA NA NA

Total NeedingConstruction 7 6 13 13

B. SUBCENTERS

Personnel (ANMs and PIWWs) BuildingsSanctioned Functioninfg Required Constructed Not Constructed

l4o 88 52 2 138

ANNEX 8Page 8 of 13 pages

7. UTTAR PRADESH - SAHARANPUR

A. PRIMARY HEALTH CENTERS

Health Wing Family Plarring Wing

Name of PHC Dispensary Staff Quarters FP Mbin Center Staff Quarters

1. Nakur A A A A

2. Gangoh A A NA NA

3. Sarsawa A A NA NA

4. Nagal A A A A5. Deobqd A A NA NA

6. Nanuta NA NA NA NA

7. Rampur NA A NA NA

8. Roorkee NA NA NA NA

9. Bhagwanpur NA NA NA NA

10. Bahadrabad A A NA NA

11. Narson NA NA NA NA

12. Laksar A A NA NA13. Muza f Jrabad A A NA NA

14. Sidholi Sadim NA NA NA NA

15. PuwTa rka NA NA NA NA

16. Sunehtikharkheri A NA NA NA

Total NeedingConstruction 7 7 14 14

B. SUBCENTERS

Personnel (ANMs and FWWs) Buildings

3anctioned Functioning Required Required Constructed Not Constructed

128 Q7 hi 128 12 116

ANNEX 8Page 9 of 13 pages

8. MYSORE - BANGALORE (Rural)

A. PRIMARY HIEALTH CENTERS

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

1. Anekal A A NA NA2. Dommasandra A A NA NA3. Hesaraghatta A A NA NA4. Kadugondanahalli A A NA NA5. Singasandra A NA NA NA6. Hosahalli A A NA NA7. Mudigere A A NA NA8. Bettahalsur A A NA NA9. Doddaballapur A A NA NA

10. Kanaswadi A NA NA NA11. Jadagenahalli A A NA NA12. Sulebele A NA NA NA13. Hosadurga A A NA NA14. Kanakapura A A NA NA15. Magadi A A NA NA16. Solur A A NA NA17. Nelamanagala A A NA NA18. Bidadi A A NA NA19. Konankunte A NA NA NA

Total 'TcdingConstruction 0 4 19 19

B. SUBCENTERS

Personnel' BuildingsSanctioned Functioning Required Constructed Not Constructed

182 177 5 22 16o

1/ Includes Mysore-type subcenter units.

ANNEX 8Page 10 of 13 pages

9. MYSORE - CHITRADURGA

A. PRIMARY HEALTH CENTERS

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

1. Parasurampura A A NA NA2. Thalak A A NA NA3. Pandarahalli A A NA NA4. Sirigere A A NA NA5. Anaji A NA NA NA6. Kodaganur A A NA NA7. Harihar A A NA NA8. Yeraballi A NA NA NA9. Dindawara A NA NA NA

10. Holalkere A A NA NA11. Hosadurga A NA NA NA12. Molakalmur A A NA NA13. Jaglur A A NA NA

Total NedingConstruction 0 4 13 13

B. SUBCENTERS

Personnel BiuildingsSanctioned Punctioning Required Constructed Not Constructed

NA NA NA 19 92

ANNEX 8Page 11 of 13 pages

10. MYSORE - KOLAR

A. PRIMARY HEALTH CENTERS

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

w. Bagepalli A NA NA NA2. Kamasamudra A A NA NA3. Kyasamballi A NA NA NA4. Dibbur A A NA NA5. Batalapalli A Ak NA NA6. Kaiwara A NA NA NA7. Nangondlu A N4A NA NA8. Thondebavi A INA NA NA9. Gudibanda A Ai NA NA

10. Sugutur A NA NA NA11. Vakkaleri A A NA NA12. Malur A A NA NA13. Mulbagal A A NA NA14. Sidlaghatta A A NA NA15. Kurgepalli A A NA NATotal Needing

Construction 0 6 15 15

B. SUBCENTERS

Personnel BuildingsSanctioned Functioning Required Constructed Not Constructed

112 120 2 43 69

ANNEX 9Page 12 of 13 pages

11. MYSORE - SHIMOGA

A. PRIMARY HEALTH CENTERS

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

1. Arebilichi NA NA NA NA2. Karebilichi A A NA NA

3. Tavarakere A NA NA NA

4. Honnali A NA NA NA5. Hosanagar A A NA NA6. Tahalaguppa A A NA NA7. Ayanoor A A NA NA8. Shirolkoppa A A NA NA

9. Sorab A A NA NA

10. Konandur A NA NA NA

Total NeedingConstruction 1 410 1

B. SUBCENTEIIS

Personnel BuildingsSanct.ioned Functioning Required Constructed Not Constructed

NA NA NA 31 62

ANNEX qPage 13 of 13 pages

12. MYSORE - TUMKUR

A. PRIMARY HEALTH CENTERS

Health Wing Family Planning Wing

Name of P4C Dispensary Staf? Quarter-s FPMin Center Staff Quarters

1. Chikkanayakanahalli A A NA NA

2. Gubbi A A NA NA

3. Holavanahalli A A NA NA

4. Amruthur A A NA NA

5. Kunigal NA NA NA NA

6. Hosakere A NA NA NA

7. Ku.dlapur A NA NA NA

8. Kotegudda A A NA NA

9. Pavagada NA NA NA NA

10. Bargur A A NA. NA

11. Sira A A NA NA

12. Biligere A NA NA NA

13. Nonavinakere A NA NA NA

1h. Kyatasandra A A NA NA

15. Nagavalli A NA NA NA

16. Thuruvekere A A NA NA

2 7 16 16

B. SIJBCENTERS

Personnel Buildings

Sanctioned Functioning Required Constructied Not Constructed

173 169 48 125

ANNEX 9

COST ESTIMATES FOR PROJECT Page 1 of 2 pages

Total .Gdt (in 00'1EItem Unit Cost (000's) Number U.P. 1ysore Total

Re Uj I.P. PbYsore Total Re US$ Rs U. T ts V

.1 LUCFW.O.. Alir- LAUICALrONL ,1 .

1. :opulatlon Center 1,500 200 1 1 2 1,500 200 1,500 200 3,Q' 79 L.0O

.aternlty Roa.1t;lL *lth AWEl Zchool:l1'-tcd tio.pitale attached to presentr-eIical college inistitution, inoludingoutpatient facilities, operating roomoand other supportive services 3,000 400 1 1 2 3,000 400 3,000 400 b,00n 800

aternity s,omese: Construction orrenovrtion or these homes as satelitecare centers of tnaternity hospitals - 450 60 10 610 to 30 beds El '60) '8) new extenfions 16 4,500 600 600 80 5,100 (r0

h. Urban r'.mily 'Jelrare 'enters: Someornstruction but mainly renovation 75 10 6 8 14 450 60 600 80 1,050 140

4 '.-'ional 'inlY E''lanl-nj- Trainln, 'e-ter:onstrucLioiI oer -'nter Inaluding hoetel

acconolation 500 67 1 1 2 500 67 500 67 1,000 l1 <

.hools: Construction of schoolincluding classroom, demonstrationroom e-uiaumert and hostel accoaodation'ttached to Urban Hospitals 400 53 2 1 3 800 107 400 53 1,200 160

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

7. ,ii hr--:,.t - :'uL l1n,g: for DistrictA'iniistration - one per Districtexcert Banr-alore ural 750 100 5 4 9 3,750 500 3,000 400 6,75n ,00

- terlllztlon 'lards:-!to:rul !- 0 beds in *A.trict

oesoittls, uith onerating room ifuecesar.y 300 40 5 5 10 3,000 400 3,000 400 u,h)oo "'U

. - -,hool : 'tta Thed to ''istrietC--,I test. 'or all rural l2iatricta

exceut -angalore '.ural 400 53 5 4 9 2,000 267 1,600 213 *,C'4

1 - * rkwnr alth *entern

'. .: '-.ter-nty toi of 15-20 beds inn:!.::',' arUI *oatparum District

l r). In-lu'les operatingroom annd aupportive services l-O P112'sc.lose to 'dat,riet Hospital per t1istrict 200 27 10 10 20 2,000 267 2,000 U67 ! ,l :.':

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

. trt uartera 80 11 54 25 79 4,320 576 2,000 267 t, 20 :1,

li. 'aln 'enter 25 3-3 83 73 155 2,o50 273 1,825 6L3 . ': *1

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

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

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

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

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

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

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

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

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

Y " itn e atnittacnceDece notes attathed

ANNEX 9Page 2 of 2 pages

Notes on Table

1. Costs are in 000's of constant 1970 rupees. Construction costs

estimated on the basis of 25.00 rupees per sq. foot.

2. Ten new maternity homes in Lucknow with 30 beds each and the addition

of 10 beds to six existing homes in Bangalore City. Total addition of beds:

300 in Lucknow and 160 in Bangalore. Costs of 450,000 rupees are for new

homes. Extension costs of adding 10 beds are 10,000 rupees.

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

Dufferin Hospital in Lucknow.

4. Number of PHC Dispensaries, staff quarters for health Family Planning

Main Center and staff quarters for family planning determined on the basis of

the gap between requirements as determined by Government of India and PHCs

actually constructed or under construction. The location of these PHCs is

shown in Annex 6. The summary of this Annex shows the required number of each

of the PHC components.

5. For ANM-Subcenters. The number is determined by the gap between

requirements according to the Government of India plan and subcenters already

constructed or under construction. In Mysore, this includes Mysore State

type health units and total number to be constructed will result in a ratio

of 1 subcenter per 7,800 population ( on the basis of 1970 population). For

U.P., the sanctioned subcenters (576 sanctioned, of which 68 have been con-

structed) fall short of the Government of India pattern of 1/10,000, instead

the number is 1/17,000 on the basis of 1970 population. The addition of 900

subcenters will lead to an average ratio of 1/6,700. Subcenters for ANMs

are those designed in the Government plan (600 sq.ft.) whereas dai subcenters

include one clinic room and suitable quarters, with a total area of 400 sq. ft.

6. Provision of vehicles as follow:

- PHC - one jeep

- PHC-Maternity Wing - one bus-ambulance

- ANM School - two buses- Maternity liospitals - one sedan, two bus-ambulances

- District Headquarters - two jeeps, one sedan

- RFPTC - one jeep, one bus- District Training .Team - one jeep

ANNEX 10Page 1 of 3 pages

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

A. SUMMARY TABLE

U.P. Mysore TotalRs2/ US$ Rs2/ US$ Rs2/ US$

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

2. Rural Postpartum Program forIntensive District (Variant III) 1,700 227 550 73 2,250 300

3. Urban Postpartum Program 650 87 575 76 1,225 1634. Training 175 23 175 23 350 475. Mobile Service-Motivation Teams 200 27 200 27 400 53

6. District Administration 50 67 50 67 100 13

3/ 3/ 4/ 3/3,275 43T 2,050 273- 5,35w 713-

B. DETAILED BREAKDOWN OF ESTIMATES5/ Unit Total Cost

1. Population Center - Cost U.P. Nysore

a. Administration 100,000 100,000

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

Total 500,000 500,000

Grand Total 1,000,000

1/ These are in constant prices, using where possible, present Government Scales.They are the expenditures that would be required once the whole projectbecomes fully operational. First and second year expenditure will be lowerthan figures shown here. Excludes costs of foreign advisor.

2/ Rounded to nearest Rs 25,000.3/ May not add up due to rounding.7/ Rs 25,000 added for Deputy Secretary at the Center.

5/ Crude estimates on basis of a professional staff of about 25-30 persons plusclerical and other supporting staff.

ANNEX 10Page 2 of 3 pages

Total Annual Total for

1/ Expenditures/ whole 2/

2. Rural Postpartum Program Unit Scale District Program-

1. District Levela. Pediatriqian 1 10,800 10,800 43,200

b. Ob-gp 3 1 10,800 10,800 21,600

c. ANM NA 5 2,400 12,000 24,000

d. Operating Theatre Nurse 1 3,600 3,600 14,400

e. Operating Theatre Attendant 1 1,200 1,200 4,800

f. Driver 1 1,680 1,680 6,720

2. PHC Levela. LHV 33 3,000 99,000 396,000

b. ANM 13 2,400 31,200 124,800

c. Female Medical Doctor 12 10,800 129,600 518,400

3. Sub-Centers-4/a. Dais 217 1,500 325,500 651,000

b. ANM 94 2,400 225,600 451,200

5/3. Urban Postpartum Program Lucknow Bangalore

1. Maternity Hospital Staffa. Ob-gyn (4) 48,000 48,000

b. Pediatrician 12,000 12,000

c. Operating Theatre Nurse (4) 96,000 96,000

d. Operating Theatre Attendant (8) 6,720 6,720

e. Sister Nurse (8) 24,000 24,000

f. Staff Nurse (8) 20,000 20,000

g. Supervisor Nurse (2) 7,200 7,200

h. ANM (12) 21,600 21,600

i. Other (12) 14,400 14,000

2. Maternity Homes-/ 325,000 250,000

3. Urban Family Welfare Centers7/ 72,000 72,000

Total 646 _,O0 571,920

Grand Total 1,218,840

1/ This is for four Districts - two in U.P., two in Mysore. Figures are average

figures for the "typical" Districts.2/ Times 4 for all except sub-centers. Time 2 for sub-centers, where there are

additional expenditures only in U.P.3/ Additional for U.P., already sanctioned in Mysore.

T/ Only in U.P.5/ Administrative Staff that will assist urban program included under Population

Center.6/ Ten in Lucknow, six in Bangalore. Staff is always additional, even when

maternity homes are an extension of existing home as in Bangalore.7/ Two additional centers in each of Lucknow and Bangalore are in project, one

of which will be attached to maternity hospital.

ANNEX 10Page 3 ot 3 pages

4. Mobile Service-Motivation Teams' U.P. Mysore

a. Medical - 3 doctors 45,000 45,000

2 OT Nurses 6,000 6,000

2 OT Attendants 2,400 2,400

b. Motivation - 2 Male Extension Educators 7,200 7,200

1 Female Social Worker 3,600 3,600

1 Male Social Worker 3,600 3,600

2 Audio-Visual Technicians 4,800 4,800

c. Administrative - 1 Team Administrator 12,000 12,000

1 Administrative Assistant 9,600 9,600

1 Computor 1,800 1,800

5 Drivers 9,000 9,000

2 Bearers 2,400 2,400

2 Clerks 2,400 2,400

d. Supplies (medical drugs, audio-visual materials,

food, maintenance of vehicles) 80,000 -80,000

Total Recurring Costs 189,800 189,800

Grand Total 379,600

5. Training U.P. Mysore

1. RFPTC 3/ 80,000 80,000

2. District Training Tea 4/ 100,000 100,000

Total 180,000 180,000

Grand Total 360,000

Unit Total Cost

6. Administrative Cost U.P. Mysore

- Center: 1 Deputy Secretary 21,600 ---21,600----

- District: 1 Administrative-StatisticalOfficer 9,600 48,000 48,000

Total 48,000 48,000

Grand Total 117,600

1/ One such team per State. Each team will also require non-recurring costs

in the form of vehicles (1 bus, 1 A-V van, 2 jeep station-wagons), audio-

visual equipment (2 film projectors, 2 generators, 2 projection services,

films) and medical-surgical equipment (OT lights and tables, 1 generator),

and instruments. Total cost of this equipment is estimated at Rs 175,000

per team.2/ Excludes Training Division of Institute - latter is shown under Population

Institute and is estimated to cost Rs 2000,000 annually (salaries of 10

persons, equipment and supplies).3/ For additional staff of ten at each RFPTC.

4/ Includes salaries for team (one doctor, one nurse, one health-educator/social

scientist, one statistician), supplies and petrol.

MAP I

iv<JAMMU & KASHMIR

tHNAMA. C )

TENRI TD I B E T

L..

IBHUTAN I ASS, ADOI RA ' ,*SAJEEL 1,, "RR

JODHPURAsA R JALPAIGURI I4.

,N A U> g7 U.AN A A \ COUCHNI 2U ADL A 3'9 NAGAS ARALANof-R oA J M es

ONA NR NEA UG SAA ,' 'UI .j N U , H N UNITES

BAR.<g\ I M/ EGPLA A.ITIO HILL

5AL NUALUAR}

URULLA E ST AITT L ..uj.ULL..

GA Vl N l AA. N. C H TE BOUNRARIE

-NSA ARAR U .UARCOT IU K

,RR150 ( ,POPULATIONNA PROJECT

Ess

LA KANAR o ANlNTAP

CRTUURIYAO I

STATE B OUNDAN

MADRAS STAT CAPITALS

* NATICNAL CAPITenAL

NTAN O NOAPU

GUTU NO DT S0 0 N S O

13~ POPULATIO L ROEC

NOVEMER 190 lORL320

MAP 2

UTTAR PRADESH STATE

I N D I A POPULATION (91.5 MILLION)

. .// .*STATE BOUNDARY

GARHWAL ................ DIVISIONAL BOUNDARY

UTTARKASHI N DISTRICT BOUNDARY

_*. -- __LUCKNOW DIVISION NAMES

c *....TEHRI GARHWAL CHML sMEERUTTENIKUMflAONk MEU DISTRICT NAMES

- '\ 0* POPULATION IN MILLIONS

\ PITHORAGARH

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

-ALMORA f- * *ABOVE 1000

MVZAFFARNAGAR. . .

'j @ ,BIJNOR **-.- a-\ \

v - ( . NAINI TAL 750 -1000

* MEERUT 0-0 5DD -750MMEERU

MMORADABAD XRAMPUR ROHELKHANDF 0 .* 250 - 500

BULANDSHAHR - jBAREILLY / P1 L I ULUCKNOWB 8 , \ BELOW 250

j BUDAUN / .'

*. - / KNERI FAIZABAD

MA URA BAHRAICH -

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

GON A A A \ M A GORAKNPUR I

ETAWAN.- ~ ~..BASTI % 0 j'ARA BANKI r DEOA K.

..... KANPUR UNNAO . -

0 25 50 100 / FAIZABAD * ..J

AILAE . RAEBARELI SULTANPUR

(Approcimale Scrale) *-~ / / RAE I . 0 ' .. ,AZAMARH

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

NAMIRPUR w D ( 0 . JAUNPUR 0 *

' *- - ( GHAZIPUR

(( . 0 .k. BANDA ALLAHABAD , Q7

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

\NNOVEMBER 1970IBD31

MAP 3

a < r N D I A-I N D l A .MYSORE STATE

POPULATION (29.5 MILLION)

BIDAR

GULBARGA( . GULBARGABELGAUM ¶ *

/ * -STATE BOUNDARY

................ DIVISIONAL BOUNDARYBIJAPUR

- DISTRICT BOUNDARY

,.. -, . MYSORE DIVISION NAMES

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

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

ABOVE 500

DHARWAR .

R / 5 ,401 - 500

C? .- BELLARY 301-400

NORTH KANARA /

201 - 300

... BELOW 200

~ t .: - CHITRADURGA B 2SHIMOGA

i.. .... - /D

CHIKMAGALUR , . TUMKUR KOLAR

. © ,i g * N ...... ' . .'. r BANGALORE .

SOUTH .. *. .3 .;.KANARA A/ HASSAN *.* . \ BANGALORE CITY :

I.f

( MANDYA Jr

COORG B BANGALORE

MYSORE MYSORE

0 25 50 100

MILES

NOEME 9Appro70mBe Scale)

NOVEMBER 1970 I BRD 3210