government of india policy reform in family welfare program of india : community mobilization &...

Government of IndiaGovernment of India

Policy Reform in Family Welfare Policy Reform in Family Welfare Program of IndiaProgram of India : :

Community Mobilization & Community Community Mobilization & Community Participation under Reproductive & Participation under Reproductive &

Child Health ProgramChild Health Program------------------------------------------------------------------------------------------------PrasantaPrasanta Kumar Saha, Kumar Saha, CStat (UK), CStat (UK),

Fellow of the Royal Statistical Society, UK.Fellow of the Royal Statistical Society, UK.

NEW PLAN MODELNEW PLAN MODELFORFOR

FAMILY WELFARE FAMILY WELFARE

And RCH PROGRAMME And RCH PROGRAMME

P.k. Saha

Though Family Welfare Program was initiated in early 50's in India, it was never a fully effective program till 1996-97 when Reproductive and Child Health[RCH] was introduced according to , perhaps, the most noble and ideal recommendation of the International Conferrence on Population & Development [ICPD] held in Sepetember, 1994 at Cairo, Egypt. India being one of the participating countries, accepted fully the recommendations of ICPD,94.However, as per ICPD,'94, implementation of RCH program was to be activated not through conventional system which was prevalent for decades since 1950's. The specific recommendation is to implement it through decentralized participatory planning which called for a Policy Reform in India [the Ministry of Healh & Family Welfare, Govt. of India]. It is to be noted that RCH program and Community Participation Approach for its immplementation pertains to RURAL INDIA.

GENESISGENESIS

INDIGENIOUS IDEAS:INDIGENIOUS IDEAS:

PLANG. COMMISSION.PLANG. COMMISSION.

INTERNATIONAL : ICPD ‘94INTERNATIONAL : ICPD ‘94

P.k. Saha

The concept of Decentralized Planning was originated in India long back but not in a concrete shape. The organisation called Planning Commission in India is responsible for formulating 5-year Plans for the Government of India covering all the sectors of economy. In 1992 the Committee on Population of the National Development Council [NDC] under Planning Commission recommended seriously for adopting Decentralised Planning for implementation of Population Development Program.

PLAN MODEL: PLAN MODEL: DEFINITION:DEFINITION:

Decentralized Participatory Decentralized Participatory Planning being activated Planning being activated

through Community Needs through Community Needs Assessment Approach (CNAA) Assessment Approach (CNAA)

for implementing FW / RCH for implementing FW / RCH Prog.Prog.

P.k. Saha

As mentioned earlier, RCH program is, perhaps the most ideal and noble program relating to the Reproductive Health of mothers and overall health of children of a developing society like India. Before the Decentrlized Partcipatory Planning is discussed, concept of RCH should be defined. As per ICPD, Cairo, 1994, RCH is defined as " People have the ability to reproduce and regulate their fertility, women are able to go through pregnancy and child birth safely, the outcome of pregnancies is successful in terms of maternal and infant survival and well being and couples are able to have sexual relations free of fear of pregnancy and of contracting diseases".

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Characteristics Characteristics of Community Participation of Community Participation

Model: Model:

STANDARD STANDARD FLEXIBLEFLEXIBLE

SYSTEMATICSYSTEMATIC SIMPLISTIC SIMPLISTIC

GRASSROOT Oriented GRASSROOT Oriented

CHARACTERISTICSCHARACTERISTICSContd. :Contd. :

BOTTOM-UP BOTTOM-UP

PEOPLE’SPLANPEOPLE’SPLAN

PEOPLE’S PARTICIPATIONPEOPLE’S PARTICIPATION

P.k. Saha

When we mention 'Bottom-up', it means a thorough cahange in the traditional system of execution which is normally planning is decided and execution orders are given from top level of the organization and it goes below upto the lower levels vertically in the hiererchy. In the decetralized participatory planning executed through, planning is to be done at the Sub-Center[SC] Level which is at the village level health center in India. At the SC level planning for RCH care is to be formulated in the beginning of the year after consulting actual clients, village leaders, local leaders, school teachers, Panchayats, etc so that it reflects the actual needs of RCH care at the village levels.

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PRINCIPAL OBJECTIVES :PRINCIPAL OBJECTIVES :11. . IMPLEMENTATION OF FAMILY IMPLEMENTATION OF FAMILY WELFARE AND RCH PROG. WELFARE AND RCH PROG. 2. 2. TO PROVIDE TO PEOPLETO PROVIDE TO PEOPLEBEST QUALITY SERVICES.BEST QUALITY SERVICES. AND AND 3. 3. ABOLITION OF EXECUTIVE’S ABOLITION OF EXECUTIVE’S

PRECONCEIVED FUNCTIONAL DESIGNPRECONCEIVED FUNCTIONAL DESIGN..

Preparatory Actions Prior Preparatory Actions Prior to Introduction of New Model :to Introduction of New Model :

Abolition of centrally determined method, that is abolition of specific targets for family planning

through:a) Pilot studies in States b) intimating all the State Secretaries of

Health & FW..

P.k. Saha

Since 1950's till 1996-97 there was a system of fixing Targets of mainly for achieving desired levels of acceptance of Family planning methods by the people. These targets were determined first by the Central Govt. Then the State -wise targets were sent to the concerned States for implementation. This target system suffered from many demerits.They were mainly numeric in nature. So quality of care got neglected. The Health workeres were concerend to fulfil numeric target at the cost of the quality of health care.Target system actually hampered the population stabilization program.

Preparatory actions contd.Preparatory actions contd.

c) discussion in the conference of the State Secretaries of Health & FW.

d) discussion in the Conferences of Central Council of Health & FW who fully endorsed and appreciated the new approach.

e)Visiting of Central team to States .

Steps taken for Steps taken for Operationalisation of New ApproachOperationalisation of New Approach

[contd.][contd.]1) A manual was distributed to all States in 1996-

97.2) Subsequently the same manual was simplified. 3) Simplifying the relevant Formats.4) Revised manual prepared & distributed to all

the States.5) Discussion in State Secretaries’ conference

every year.

Steps taken contd.Steps taken contd.

Secretary, Deptt. of FW, Govt. of India regularly writing to State Secretaries of Health/FW.

Workshops of District Chief Medical Officers/Officers of State Dte. of Health & FW covering about 300 districts organized in many States.

P.k. Saha

In order to activate the new approach i.e.Community Needs Assessment Approach[CNAA] by the district authorities of Health, the author[PK Saha] organised workshops under WHO Biennium Program during 2000-01 & 2001-02. Principal participants in these workshops were the Chief Medical Officers[CMO] who are the sole in-charge of entire Health program of the districts. In these workshops there lectures by the concerned experts of FW/RCH services. The author [PK Saha] presented in very details the entire CNAA. It was observed that the CMOs faced specific deficiencies in respect of abreasting this new but ideal system because of bureacratic apathy. In India the organisation dealing with entire Health Systems, it may sound absurd, are headed by bureaucrats including the Ministry at the Center. It has been recorded that the ergency expressed by the executives like us at the Center is absolutely absent in the State. Incidentally Health is the State subject as per Indian Constitution.

Steps ContinuedSteps Continued

National Population Policy 2000: Emphasizing the role of the local body at village level called Panchayat for furthering decentralized planning.

Training to Auxiliary Nurse Midwives [ANM] and Medical Officers [MO] of PHCs. .

MECHANISM OF PREPARATION OF ACTION PLAN MECHANISM OF PREPARATION OF ACTION PLAN – KEY COMPONENT OF NEW APPROACH:– KEY COMPONENT OF NEW APPROACH:

Originated at SUB-CENTER[SC] level : Interactions of Auxiliary Nurse Midwives [ANM] with people.Associating Anganwari Workers/ Women’s Groups at village

level called Mahila Swasth Sanghs [MSS] etc and Panchayat.Checking Consistency of assessment of health care needs by

ANMs of the citizens particularly at village level. Making a meaningful action plan.The Action plan is to be executed by ANM.Action Plan Coverage: No selection of clients- it is complete

coverage of all clients in a particular village.

P.k. Saha

Under the Community Participation approach, preparation of Action Plan[ mentioned earlier in this presentation as planning] on the needs of Anti-Natal Care[ANC], Delivery Status, Immunization of new-born, infants and children, reuirements of measures of family planning e.g. condoms, IUDs, Sterilization, etc is the principal component. Action plan is first prepared at SC level. Tha same Action plan has to be executed by the SC also. This shows the important and most essential spirit of Community Participation in RCH program implementation.

Key Issues of Community Participation Key Issues of Community Participation

being activated through CNAA:being activated through CNAA:MICROPLANNINGDECISION SUPPORT PLANNINGCOMMUNITY PARTICIPATIONCLIENT’S PERSPECTIVEQUALITY OF CARE.MICROLEVEL DATABASEMAINTAINING STANDARD RECORDS/FORMATS. REGULAR SYSTEM OF M & E OF PRFORMANCE

P.k. Saha

Regarding Micro-Planning, it is the planning at the grass-root levels for providing best quality of RCH care to the citizens. This concept of micro-planning was conspicuous in its absence in any sector, projects and programs in India prior to inception of RCH program Decentralized Participatory Planning in the Health Ministry in 1996-97. Perhaps, it is the same picture in other developing societies. Formulation of the Action Plans in the begining of a year at the SC level is the key factor of Micro-Planning under CNAA.

BARRIERSBARRIERS

The vertical programme structure inhibiting the setting of priorities according to plans.

Lack of inter-sectoral coordination reducing the effectiveness of plans in the health sector.

Infrastructure getting focussed more than the functions of District & State authorities to meet the unmet felt need of health care of the community.

Apathy of all the implementing authorities.

P.k. Saha

Earlier it has been hinted burearucratic set-up as one of the barriers in introducing the decentralized planning in RCH program. The concerned authorities of Health & FW in the States are reluctant to delegate their authority to the lower levels. So instructions from the Center along with providing adequate funds to the States did not generate much enthusiaism amongst the State authorities at least for first 3 years of its inception. However, the new system is getting accepted gradually.

BARRIERS contd.BARRIERS contd.

Information system not getting due importance by the medical authorities.

Some States need more time Some reservation on the part of some

States

IMPROVED SITUATIONIMPROVED SITUATION

Some encouraging signs emerging : Process of Panchayati Raj system has started in

some States.Action plans are being done through house-to-house

surveys in many districts In some districts of some States Panchayat workers

are maintaining Birth/ Death registers.However, level of motivation and awareness of

Panchayat members needs tremendous improvements.

Improved Situation contd.Improved Situation contd.

Panchayat members are being called in PHC level meeting.

ANMs are attending meetings of Gram Panchayat.

Panchayat members are being trained in developmental programmes including health services.

Training on CNAA to ANMs/ MPW(M)s/Medical Officers[MOs] is an on- going program.

P.k. Saha

PHC stands for Primary Health Center which is above the SC at the village level. Under one PHC about 30,000 people in plain areas and about 20,000 people in hilly,tribal and backward areas are covered in rural areas i.e. about 5 to 6 SCs are covered under the purview of one PHC. One SC covers about 5000 people in plain area and about 3000 people in hilly, tribal and backward areas. MPW[M] stands for Multi Purpose Workers-male who are posted at SC along with ANMs.

SUMMARYSUMMARY

Quality assessment under CNAA is one of the principal objectives. This objective has been facing lack of sincerity & commitment.

To establish system of direct interactions with the clients, other voluntary agencies’ participation has been considered.

Field Evaluation : existing system of evaluation of quality and status of health care provided by the SCs and PHCs contacting the actual clients is inadequate.

SUMMARY Contd.SUMMARY Contd.Decentralized system of planning model is

most viable and cost-effective.In a developing country like India vast number

of people, particularly in rural areas , can expect desired level of services through this model.

Panchayat system, it is expected, will be functioning in this direction within a few years.

References : References :

ReferencesReferences1. Report of the International Conference on 1. Report of the International Conference on Population and Development, Sept., 1994, Population and Development, Sept., 1994, Cairo, Egypt.Cairo, Egypt.

2. Annual Reports of the Ministry of Health & 2. Annual Reports of the Ministry of Health & Family Welfare, Government of India, New Family Welfare, Government of India, New Delhi-1996-97, 1997-98, 1998-99. Delhi-1996-97, 1997-98, 1998-99. 3. UNFPA : Technical Report, November, 3. UNFPA : Technical Report, November, 1999 : “ Planning Population and 1999 : “ Planning Population and Development Projects with a Focus on Development Projects with a Focus on Decentralization and Quality of Care”. Decentralization and Quality of Care”.

References –contd.References –contd.4. National Population Policy 2000, Department of

Family Welfare, Ministry of Health & FW, Govt. of India, New Delhi.

5. Reproductive and Child Health Program : Schemes for Implementation, October, 1997, Dept. of Family Welfare, Ministry of Health & FW, Govt. of India.

6. European Commission : ECTA: Situational Analysis, 2001/22, August, 2001: Community Needs Assessment Approach [CNAA] to District Planning.

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