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Point of Use POU - An Approach Towards Safe Drinking Water HUP |
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Point of Use (PoU)
An Approach Towards Safe Drinking Water
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Point of Use (PoU): An Approach Towards Safe Drinking Water
Prepared and Published by:
Health of the Urban Poor [HUP] Program
Population Foundation of India
B-28, Qutab Institutional Area, New Delhi – 110 016
Authors
Biraja Kabi Satapathy
Dr. Himani Tiwari
Merajuddin Ahmad
Anil Kumar Gupta
Meeta Jaruhar
D. Johnson Rhenius Jeyaseelan
Rakesh Kumar
Dipankar Barkakati
Shipra Saxena
Special Inputs
Dr. Sainath Banerjee
Dr. Subrato Mondal
Dr. Lalitendu Jagatdeb
Editing Support
Sanjay Vijayvargiya
Designing & Layout
Ajith Kumar
Photographs
HUP
© June, 2012
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Contents
Acknowledgement
ii
Preface
1
Context and Background
3
Conceptual Framework and Utility of PoU Model
6
Capacity Building Process on PoU Water Disinfection Methods
8
PoU Training by HUP: Experiences of Cities
10
Adopted Training Process
12
Objective Setting and Planning
13
Box 1: Lack of Access to Safe Water - Some Facts
3
Box 2: Factors Responsible for Water Contamination
6
Box 3: Flowchart on the PoU Water Disinfection Training Process
10
Box 4: PoU Points to Remember
14
Table 1: PoU Training Program
9
Table 2: Summarized Water Testing Results of Four Cities
11
References
14
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Acknowledgement
In 2011-12, the USAID|India supported Health of the Urban Poor (HUP) Program
carried forward the work of PRATINIDHI (Supported by USAID|India in 2007 - 2010) ,
piloted in Uttar Pradesh. We thank the HUP Water Supply and Sanitation Specialists
Biraja Kabi Satapathy, Johnson Rhenius and Dipankar Barkakati of HUP-PFI, Himani
Tiwari and Rakesh Kumar of HUP-IIHMR, Merajuddin Ahmad, Anil Gupta and Meeta
Jaruhar of HUP-Plan for compiling this report.
Thanks also to the HUP-PFI editorial team, Shipra Saxena (Water Supply and
Sanitation Specialist and Team Leader) and Sanjay Vijayvargiya (Consultant).
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Preface
Water is the most essential human need. The provision of safe drinking water alone
can reduce the burden of disease and contribute towards enhancing productivity
and reducing poverty.
Diarrhea tops the three causes of child mortality worldwide; about 88 percent of
diarrheal deaths occur due to unsafe water, inadequate sanitation, and poor
hygiene.
In India, diarrhea is a major killer and about 1,000 children die every single day due
to diarrhea1. Despite huge public sector investments in the water and sanitation
sector, the improvement in the situation remains marginal. Even with a significantly
high economic growth rate, the reported 10 million cases of diarrhea and about half
a million cases of diarrheal deaths of children every year are issues of serious
concern.
Several factors are responsible for this disheartening picture. These include
untreated waste disposal, crude dumping of industrial and domestic waste, surface
water runoff from agricultural fields, natural contamination, and, fecal
contamination, the most serious threat to water quality. Despite several protection
methods, water can be contaminated at source (even if defined as a safe source of
water) as well as at the Point of Use (PoU).
In addition to the above factors, unhygienic living conditions and unhygienic
behavior, including water handling practices, affect the quality of water. The urban
poor and those living in slums are the most vulnerable to water quality and
waterborne diseases. It seems rather alarming that water at PoU is more
contaminated when compared to water at source.
Factors such as awareness (about cause and effect), acceptance (about situation and
practices), affordability (of the available informed choices and options) and
adoptability (of the available solutions) also affect water quality at the household
level of the urban poor.
Water disinfection at PoU is an approach towards safe drinking water for the urban
poor. It includes peoples’ education through information sharing, demonstration
and interaction about available options to improve water quality at the household
level.
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Health of the Urban Poor (HUP) Program and Population Foundation of India (PFI)
organized a four day training program on PoU in four cities Delhi, Jaipur,
Bhubaneswar and Pune in collaboration with PRATINIDHI.
This report is based on the training provided by the facilitating organization for
mass dissemination of information and practices.
Dr. Sainath Banerjee
Chief of Party, HUP
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Context and Background
Water and sanitation are essential human needs. In India, 70-80 percent of
morbidity is related to water contamination, unsafe sanitation practices, unhygienic
environmental conditions and ignorance in matters of personal hygiene2.
Box 1: Lack of Access to Safe Water - Some Facts
1.1 billion people in the world do not have access to safe drinking water, roughly
one-sixth of the world's population.
2.2 million people in developing countries, most of them children, die every
year from diseases associated with lack of access to safe drinking water,
inadequate sanitation, and poor hygiene.
Half of the world's hospital beds are filled with people suffering from water-
related illnesses.
In the past 10 years, diarrhea has killed more children than all the people lost to
armed conflict since World War II.
There were only 181 million fewer people living without safe drinking water in
rural settings in 2004 (899 million) vs. 1990 (1.08 billion).
50 percent of people on earth lack adequate sanitation.
Some 6,000 children die every day from diseases associated with lack of access
to safe drinking water, inadequate sanitation and poor hygiene, equivalent to
20 jumbo jets crashing every day.
The average distance that women in Africa and Asia walk to collect water is 6
km.
Tens of millions of children cannot go to school as they must fetch water every
day. Dropout rates for adolescent girls, who even make it that far, skyrocket
once they hit puberty, as there are no private sanitation facilities at their
schools.
80 percent of diseases in the developing world are caused by contaminated
water.
Waterborne diseases cost the Indian economy 73 million working days per year.
If we did nothing other than provide access to clean water, without any other
medical intervention, we could save 2 million lives a year.
The water and sanitation crisis claims more lives through disease than any war
claims through guns.
Source: www.water.org
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Diarrhea heads the list of top three causes of
child mortality worldwide. It leads to millions
of deaths among children under the age of
five. Despite the existence of inexpensive and
efficient means of treatment, diarrhea kills
more children than HIV/AIDS, malaria, and
measles combined. According to a report issued
in October 2009 by UNICEF and the World Health
Organization (WHO)3:
In the developing world, 24,000 children under the age of five die every
day from preventable causes like diarrhea. It is truly a tragedy that these
deaths take place since inexpensive and effective treatments for
diarrhea already exist. (UNICEF/WHO 2009)
About 88 percent of diarrheal deaths worldwide are attributable to unsafe water,
inadequate sanitation, and poor hygiene. In India, diarrhea kills about 1,000
children below the age of five years every day. There is an urgent need to shift
attention and resources back to treating and preventing diarrhea.
India is one of the fastest growing economies in the world and is urbanizing at a
rapid pace. Its urban population growth is about two times of its overall
population growth. In a country of more than 1,210 million people, 31.16
percent (377 million) comprise the urban population4. Rapid urbanization,
clubbed with other factors like natural calamities and rural-to-urban migration
of people in search of gainful employment opportunities or means of survival,
contributes toward a significant increase in slums, especially informal human
settlements and slum population in urban areas. The population growth trend
analysis indicates that in most cities slum population growth is higher than urban
population growth, which is higher than the rural population growth.
A faster pace of urban population growth has resulted in higher poverty
concentration in urban centers. Estimates for 2004-5, with some
revisions in the methodology for setting the poverty line,
suggested 25.7 percent of urban people falls below
the poverty line. Despite achieving a higher
economic growth rate, more than 20 million
urban poor were added from 1973-74 to 2004-
5. Poverty assessment procedure and methods
for declaration of poverty line is facing resistance
from almost all sections of the society and
according to the recent estimates of Planning
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Commission 20.9 percent of the urban people are below poverty line.5 Though the
percentage of the urban poor has gone down, there is an increase in the absolute
number.
The relationship between poverty and poor health is well established. In addition to
loss of productivity due to high morbidity, direct financial consequences, including
sudden increase in expenditure and debt trap to meet health and other survival-
related expenditure, multiply the vulnerability of the urban poor.
The provision of safe drinking water is a fundamental right under Article 21 of the
Indian Constitution and is therefore, a national objective. Despite significant public
sector investments in the water and sanitation sector, the situation has not
improved, especially in terms of reducing water-related morbidity and mortality.
Various studies reveals that people living in slums and slum-like conditions face
unprecedented challenges in meeting their safe drinking water needs and that
provision of basic services including water is generally linked to tenure status.
The national objectives of reducing morbidity and mortality largely depend on the
reduction of diarrhea, jaundice, etc. Communicable diseases, like tuberculosis,
malaria, kala-azar, dengue fever, chikungunya and other vector borne diseases,
and water-borne diseases like cholera, diarrhoeal diseases, leptospirosis etc,
continue to be a major public health problem in India. In fact, diarrhoeal diseases,
respiratory infections, tuberculosis and malaria cause about one quarter of all
deaths in the country. (Report of the working group on disease burden for the 12th
Five Year Plan, 20116)
The burden of waterborne
diseases cannot be reduced
without ensuring access to,
and availability of safe
drinking water at the
household level. Point of
Use (PoU) methods of water
disinfection is one such
approach that reduces the
burden of waterborne
diseases and thus
contributes toward
reducing poverty.
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Conceptual Framework and Utility of PoU Model
It is reported that 95 percent of urban households have access to improved source
of water7 and access to improved source of water is not a reflection of the availability
of safe drinking water. According to Census 2011 reports, in India, 62.0 percent
urban households get tap water from a treated source and 8.6 percent urban
households get tap water from an untreated source. It is also reported that
approximately 10 million diarrhea cases are reported each year (Planning
Commission 2008), about half a million children die every year due to water-related
diseases, and about 80 percent of morbidity is related to water contamination. As
per NFHS-III 8.9 percent of the urban children under age five years with reported
diarrhea (two weeks preceding the survey) . The burden of disease8 study by HUP in
2011 shows that malaria, diarrhea, dengue were among the most commonly
suffered infection. Diarrhea ranked third in Pune, first in Bhubaneswar and fifth in
Jaipur among the major cause of hospitalisation.
There are several causes of surface water and groundwater contamination
including crude dumping of municipal solid waste, untreated disposal of
sewage water, crude disposal of industrial effluents, natural contamination,
Box 2: Factors Responsible for Water Contamination
Latrines near the source of water.
Latrines upstream from the source of water.
Other potential sources of fecal contamination near or upstream from the
source (for example, open defecation, septic tanks, cesspools, garbage
leachates, etc.)
Stagnant water at or near the water source.
Poorly constructed or maintained sewer lines.
Waterlogging.
Groundwater source inadequately protected from contamination. For instance,
hand pumps with broken platforms.
Surface water intake inadequately protected from local sources of
contamination (for example, no fencing, broken fencing, poorly constructed or
damaged intake structures, inadequate screening).
Infrequent cleaning or non-cleaning of water tanks.
Improper or unhygienic handling of water.
Animals with access to the water source.
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etc. The most serious threat to water quality in surface water and groundwater
systems is fecal contamination. Despite providing safe drinking water at
source there is a possibility of it being contaminated by the time it reaches the
intended users.
PoU water purification helps to improve water quality at the household level. PoU
water treatment refers to a variety of different water treatment methods (including
physical and biological) used to improve water quality for intended use (drinking
and cooking and other human needs) at the point of consumption instead of at a
centralized scale (involving a distribution network).
Common PoU treatment methods include either one or a combination of the
following methods meant for water purification at household levels.
Boiling
Solar Disinfection (SODIS)
Water filters
Chlorination
It is estimated that about 68 percent of the total population and more than half of
the urban population9 do not use any method of water purification at the household
level due to various reasons including the following.
People don’t believe their drinking water source is unsafe.
Some of the purification methods alter the taste and smell of water.
Even if water is purified, storage of water may be improper and this leads to
re-contamination.
Regular supply of water is not
available.
There is limited availability,
accessibility, and affordability
of commercial products used
for water purification.
Instructions on use of water
purification products are often
complicated and hence not
clearly understood.
Chlorine products are
sometimes or often sold
diluted or with inconsistent
concentration of chlorine.
There are varieties of
technologies available and it is
difficult to evaluate options.
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Boiling water is inconvenient, alters the taste, and consumes too much
cooking gas/fuel.
Capacity Building Process on PoU Water Disinfection Method
PoU water disinfection is a process oriented method which includes capacity
building of various stakeholders, educating community level health service
providers, awareness generation, problem realization and suggesting solutions.
Identification and listing of the stakeholders including Anganwadi Workers (AWWs),
Urban Accredited Social Health Activist (ASHA) community leaders, leaders of
women’s Self Help Groups (SHGs) and other community institutions, etc., is
advisable in order to support slum visits and house-to-house contact before the
structured training program.
A structured participatory training program comprises classroom sessions, slum
visits, demonstrations, door-to-door campaigns and open discussions for sharing
experiences. All of these are organized for the development of master trainers on PoU.
Generally, the four-day training program is divided into various sessions to
facilitate step-by-step learning of participants, followed by a review meeting for
consensus building on future action points.
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The division of the four-day training program into different sessions is presented in
Table 1 below.
Table 1: PoU Training Program
Day
Session
Main Content / Activities
Day 0
Planning & preparation
of activities for the next
days.
Walkthrough
observations in selected
slums.
Discussion on context.
Objectives of the training.
Concept & approach of PoU.
Experiences and learning sharing.
Identification of drinking water
sources in the locality for water
testing.
Identification/selection of households
for water testing.
Orientation on effective
communication for awareness
generation.
Day 1 Water testing
Two water samples, one from the
source and the other from the point
of storage (PoU) are collected from
every 10th house of the selected
location.
Public address about the purpose of
the process and distribution of
information brochures, etc.
Sharing experiences of the household
visits.
Day 2
Day 3
Community interaction
Sharing and interaction
with the community.
Review
Rally covering selected locations.
House-to-house visits to share the
purpose of program. Invite the people
to participate in the “water testing
result sharing” event planned for the
next day.
Sharing the water testing results.
Sharing the promotion of PoU
techniques.
Follow-up household visits.
Review of the program and planning
for way forward.
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The activities of the four days are logically linked and helpful for participants to
understand and promote the PoU disinfection method. The process flow chart of the
training program is given below (Box 3).
Box 3: Flowchart on the PoU Water Disinfection Training Process
Planning and preparation
including walkthrough
observations in select
slums.
Listing of water sources.
Listing/identification of
houses for water sample
collection.
Water sample collection
from every 10th house (one
from source and from PoU).
Result Sharing
Promotion of PoU
methods and techniques.
Follow-up household
visits.
Mass and house-to-
house interaction in the
location(s) from where
samples are collected.
Inviting people for
sharing of water testing
results.
Review and follow-up
planning.
PoU Training by HUP: Experiences in Different Cities
HUP-PFI, in collaboration with PRATINIDHI, had organized training programs on
PoU water disinfection in four cities: Delhi, Jaipur, Bhubaneswar and Pune for its
partner non-governmental organizations (NGOs) in 2011. Besides community
workers and partner NGOs of HUP under City Demonstration Programs, AWWs,
ASHAs, Auxiliary Nurse Midwives (ANMs), representatives of municipal
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corporations, the Public Health Engineering Organization, health and urban
development department, water and sanitation specialists of HUP, etc. participated
in the four-day training program.
The training was conducted using the design presented in Box 3. Water sample
collection, water testing, and sharing of the water test result is one of the key strategies
under the promotion of PoU water disinfection methods. As per the design of the
program, two water samples (one from the water source and one from the point of
storage or PoU) were collected from the sample households of the selected slum
location and tested, the results of which is presented in Table 2 below.
Table 2: Summarized Water Testing Results of Four Cities
Reported Contamination
(% of sample collected)
At Source
At POU
Delhi
45
65
Jaipur Bhubaneswar Pune
40
43
11
55
65
42
As the Table 2 shows there is a marked differentiation in the percentage of water
contamination at Point of Source and Point of Use in all four cities. The average difference
in the water contamination at Point-of-Source and Point -of-Use is more than 22%.
Sharing the results of the water test samples with the causes of water contamination
at PoU along with the implications of consuming contaminated water in a large
gathering (including community) proved to be an effective tool for sensitizing the
community towards PoU disinfection. It has also proved to be an effective
mechanism of behavior change communication.
During the discussion and interaction, the community was informed about the
various available, affordable and cost-effective methods of PoU disinfection.
Besides the concerned community workers and community members, government
officials were also invited to the programs. Several suggestions came up for the
promotion of PoU for providing safe water at the household level.
The overall key suggestions and recommendations for further action provided by the
concerned government officials to facilitate PoU disinfection include the following:
The Public Health Engineering Department (PHED) and HUP can work together to mobilize
the community and promote water and sanitation (WATSAN) in Rajasthan. Training can
be organized for another two to five slums on PoU in convergence with PHED.
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Water testing is a priority for the PHED. The HUP can help in developing a common
Management Information System (MIS) on issues for the PHED, the Health and
Family Welfare department (Ministry of Health and Family Welfare), and Intergrated
Child Development Services (ICDS) department. The health and family welfare
department can also help in providing chlorine tablets to the community.
Similar trainings may be conducted in other slums of the city, with an
economically viable model in order to create awareness on safe drinking water
among the slum dwellers.
In Odisha it was felt that water treatment at both source and PoU needs to be
promoted concurrently.
Front line workers like AWW, ASHA, ANM and community organizers can be
trained and assigned to sensitize community members on safe water, sanitation,
and hygiene during their regular visit to slums.
Sanitary surveys to assess the environmental vulnerability of water sources can
be initiated in the city.
A leverage plan can be developed to strengthen the initiatives to provide safe
drinking water and its proper utilization at the community level10.
Training of Trainers (TOT) as formal training input for staff members of all
implementing agencies11.
Besides other suggestions, a doable action plan was prepared in Bhubaneswar city
during the review meeting. It included the following:
Mapping of the water sources in Bhubaneswar city.
Mapping of organizations and individuals associated with water management in
cities in Odisha.
Capacity building of front line workers of women and child development, health
and family welfare, housing and urban development on safe water, sanitation,
and hygiene.
Involvement of community-based organizations (CBOs), like the Mahila Mandals,
youth clubs, etc., in tracking the entire process of water disinfection at PoU.
Sensitization programs using various information, education and
communication (IEC) materials and activities in collaboration with government
departments12.
Adopted Training Process
HUP-PFI, in collaboration with PRATINIDHI, had organized four-day structured
training programs on PoU water disinfection in four cities: Delhi, Jaipur,
Bhubaneswar, and Pune in 2011. The adopted training process is given below.
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1. Objective Setting and Planning
1.1 Context & Objective Setting
Presentation and discussion on overall scenario of urban water, sanitation and
hygiene (WASH) and vulnerability of the urban poor.
Discussing the burden of waterborne diseases and
importance of safe water in reducing the burden of
diseases.
Presenting the objectives of the workshop.
Contextualization of the workshop objectives with HUP
objectives.
Listing of the participants’ expectations.
Discussing the concept and importance of PoU methods.
1.2 Participatory Planning & Preparation for Next Three Days
Consultation on water and health-related issues.
Walkthrough observation in selected slum locations
for identification and listing of water source, water
supply timing, identification of houses for sample
collection.
Deliberation on sample collection techniques.
Developing interpersonal communication skills.
2. House-to-House Visits for Sample Collection
Meeting with community leaders and local service providers
to plan the sample collection from the entire cluster.
Forming teams to cover 10 percent households in the
sample collection.
Collecting two water samples from each sample
household—one from source and one from PoU.
Use of IEC materials for environment building and
awareness generation.
3. House-to-House and Mass Contact
Participants gathered at pre decided point for house-to-house contact in the
selected locations.
Start rally for publicity and awareness generation using placards, banners, and
other attractive materials including puppets, etc.
Contact every household and invite them for water testing result sharing.
4. Sharing of Water Testing Results
Follow-up with the community members for ensuring their participation during
water testing result sharing.
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Sharing of the results.
Discussion on causes and effects of water
contamination.
Sharing of various available options of PoU water
disinfection.
Follow-up household visits after the demonstration
exercise.
5. Review Meeting and Follow-up Planning
Review and reflect on the proceedings and findings of the entire
training program in the presence of concerned
government functionaries.
Preparation of a doable collaborative action plan for
providing safe drinking water to the urban poor
households.
Box 4: PoU Points to Remember
1. Wash hands with soap before filling water and use clean bucket or pitcher
to store water.
2. Cover the bucket or pitcher after filling the water and do not dip finger in
the drinking water.
3. Use handled pot to get drinking water from the pitcher or bucket.
4. Use platform or table to store drinking water above the ground level.
References
1 386,000 annual diarrhea deaths were reported by UNICEF/WHO in a report in 2009. For details, see
http://www.reuters.com/article/2009/10/14/us-diarrhoea-children-idUSTRE59D3L620091014
2 Chapter 6, Eleventh Five Year Plan (Planning Commission 2008).
3 UNICEF/WHO in a report in 2009, ibid
4 Census of India 2011, “Size, Growth Rate and Distribution of Population”, available at
http://www.censusindia.gov.in/2011-
provresults/data_files/india/Final%20PPT%202011_chapter3.pdf (accessed on 7 April 2011).
5 Planning Commission, Government of India, March 2012, press note on poverty estimates available
at http://planningcommission.nic.in/news/press_pov1903.pdf
6 Report of the working group on disease burden for the 12th five year plan, WG-3 (1): communicable
disease, 2011, available at
http://planningcommission.nic.in/aboutus/committee/wrkgrp12/health/WG_3_1communicable.pdf
7 HUP-PFI, 2012. The burden of Disease among India’s Urban Poor - A Study at three sites (Draft).
8 National Family Health Survey (NFHS)-III 2005-06, available at http://www.nfhsindia.org/NFHS-
3%20Data/VOL1/India_volume_I_corrected_17oct08.pdf (accessed 10 September 2011)
9 NFHS-III 2005-6, see note 4.
10 HUP Training report on point of use in Jaipur, November 2011.
11 HUP Training report on point of use in Bhubaneswar, November 2011.
12 HUP Training report on point of use in Delhi, August 2011.
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Health of the Urban Poor (HUP) Program
Vision
A responsive, functional, and sustainable health system that provides need based, affordable and
accessible quality health care, improved water, sanitation and hygiene for urban poor in eight states.
Goal
To improve the health status of the urban poor by adopting effective, efficient and sustainable
strategic intervention approaches, adopting the principle of convergence of the various development
programs.
Jaipur
Delhi
Agra
HUP States and Cities
Pune
Bhubaneswar
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IIHMR
JAIPUR
For more information please contact:
Health of the Urban Poor (HUP) Program
Population Foundation of India
B-28, Qutab Institutional Area, New Delhi-110016, Tel: 91-11-43894166, Fax: 91-11-43894199
E-mail: info_hup@populationfoundation.in, www.populationfoundation.in
This document is made possible by the support of the American people through the United States Agency for International Development (USAID). The
contents are the responsibility of the Population Foundation of India and do not necessarily reflect the views of USAID or the United States Government