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Monograph Negotiating the Population Questions Since 1970 Monograph by Radhika Ramasubban |
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Negotiating the population question since 1970
Monograph by Radhika Ramasubban
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Negotiating the Population Question
Monograph by Radhika Ramasubban
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Acknowledgements
Abbreviations
01
Introduction
10-17
02
Negotiating a Non-Governmental
Space to Articulate the
‘Population Question’
18-35
03
From Population Control to
Population Stabilisation
36-49
04
Widening the Scope of
Engagement: Reproductive
Health, Adolescent Health,
and HIV/AIDS
50-65
05
Recasting Institutional
Identity, Renegotiating the
Population Question:
Women’s Empowerment
and Rights
66-83
06
Overview and Options
for the Future
84-99
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Appendix: Four Case Studies
A
Main Kuch Bhi Kar Sakti Hoon:
Shifting Deeply Rooted Gender
Norms Using a Transmedia Initiative
100-113
B
Bilaspur and Barwani Tragedies:
Evidence-Based Advocacy for
Strengthening Public Health Services
and Widening Reproductive Choice
114-129
D
Health of the Urban Poor (HUP):
Pioneering a Convergent Approach to
Delivering Health Services to
Vulnerable Urban Populations
144-157
Bibliography
158-160
C
The PFI-led Advisory Group for
Community Action (AGCA):
Fashioning a Responsive Public
Health System
130-143
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cknowledgements
The writing of this book has been an enjoyable exercise. Part of the reason was
probably that I knew virtually nothing by way of detail about the institution, my
never having been involved in its activities in any way. So the advantage was that
I came to the project with no preconceptions and, I hope, no prejudices of any
kind. It was fun to look at every piece of information as new and try and figure out
how it fitted into the puzzle. And, of course, to live through the writing with the mys-
tery of what the total puzzle might eventually look like.
The couple of compendiums that introduced me to the broad contours of the fairly
sedate pace of the previous forty years did nothing to prepare me for the vibrant
present that I was pitchforked into at the introductory meeting where the senior
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management team of the Foundation welcomed me. As the gentle people
around the table told me the individual stories of their programmes liberally
peppered with unintelligible acronyms, I wondered where the intellectual
impulses that were propelling this energy were coming from. As I began my
work, ploughing through masses of paper, iterating between bits and pieces
of the present and the past, I was still searching for clearer connections that
joined the dots of the present to those of the past. My first proper conversa-
tion with Poonam Muttreja, Executive Director of the Population Foundation
of India (PFI), came later. Once I got her to start talking about the initiatives
that had begun under her stewardship, I could begin to see the logical im-
pulses of the present. After that, it was a relatively easy task to identify the
missing links that brought the whole together.
For someone who saw herself approaching this history as a total stranger, it
came serendipitously to me that my professional experience enabled me
to perfectly position myself with the starting and ending dots of the history.
Fifteen years ago, I had researched a fifty-year history of the Ford Founda-
tion’s oldest overseas programme, its Population, Health and Sexuality pro-
gramme in India. My pulse now quickened when I found close umbilical links
between the Ford Foundation and the Family Planning Foundation (as the
PFI was originally christened). And when I came to the nitty-gritty of the pres-
ent in which PFI honours the long-overdue policy importance of addressing
the complex, knotty, and historically shackled challenge of where and how
to begin reforming the quality of public health services, I found myself, as
a historian of public health, warming to the brave and uncertain path that
PFI is now treading. I even found an autobiographical element to link me
with PFI’s concerns! In the early 1960s, my parents had been passionate-
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ly involved in setting in motion programmes in the country’s largest public
sector undertaking (my father was a senior bureaucrat in the railways) that
sought to link family planning services and awareness raising about health,
nutrition and child development, and training in first aid and home nursing
with livelihood skills building and adult literacy programmes, all directed at
women, mainly the wives of workers. Some of the people that I encountered
on the pages of the early Annual Reports of the Foundation — not least of
them, Mr J.R.D.Tata — were familiar to me from conversations of grown-ups
that I had heard in my childhood home. So doing this history has also been
a homecoming of sorts!
Most of the source material that this history has relied on is documentary in
nature. A select bibliography is given at the end. I have refrained from clut-
tering the narrative with references and footnotes in the interests of easier
readability. I hope the reader agrees and forgives me this liberty. For the
rest, this history has relied on conversations. I am grateful to senior members
of the current staff, members of PFI’s Governing and Advisory Councils, and
associates of the Foundation on some of its key projects, who were generous
with their time and spoke to me about their work and helped provide the
flesh and blood insights beyond what reports can yield. These were: Poonam
Muttreja (Executive Director), Sanjay Pandey, Alok Vajpeyi, Sona Sharma,
Bijit Roy, Sainath Banerjee, Apala Majumdar (Senior Management Team);
A.R. Nanda (former Executive Director); M.S. Swaminathan (Member, Gov-
erning Board and Chairman, Advisory Council); Leila Seth (Member, Govern-
ing Board); Saroj Pachauri and Srilatha Batliwala (both Members, Advisory
Council); Sanjeev Grover (Hay Group); Rajani Ved (National Health Systems
Resource Centre); Dipa Nag Chowdhury (MacArthur Foundation); Lester
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Coutinho (Bill & Melinda Gates Foundation); Rekha Masilamani (Agragami)
and Shireen Jejeebhoy (Population Council). There were others whom I
would have liked to have met and talked with, but various constraints came
in the way, among which were shortage of time and the passing away of
Ranjit Roy Chaudhury soon after I started work on this project; he had been
with the Governing Body since 1993, and his insights would have been invalu-
able had I been able to speak with him.
I am grateful to PFI for thoughtfully facilitating my presence as observer at
one formal meeting each of the Advisory Council and the Advisory Group
on Community Action and one informal brainstorming session of the Main
Kuch Bhi Kar Sakti Hoon team. I hope that listening to the individual and col-
lective voices at these diverse forums has enriched the analysis presented in
this monograph. Needless to add, none of the above persons are responsi-
ble for errors, if any, of omission and/or commission.
Special thanks to Alok Vajpeyi who facilitated my work generally; Rakesh
Joyal who helped with access to the Foundation’s physical and online doc-
umentary resources; Bijit Roy who went to lengths to assemble materials for
me to consult; Usha Nair and Arogya Das who facilitated the logistics of my
travel to and within Delhi for meetings at the PFI office; and to the PFI staff
generally for the warm hospitality during the days I spent in their office.
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AGCA
Advisory Group on Community Action
ANM
Auxiliary Nurse Midwife
ARTAnti-Retroviral Therapy
ASHA
Accredited Social Health Activist
AWWAnganwadi Worker
CAH
Community Action for Health
CBMP
Community Based Monitoring and Planning
CBOCommunity-Based Organisation
CEDPA
Centre for Development and Population Activities
CHMI
Community Healthcare Management Initiative
CSR
Corporate Social Responsibility
DFID
Department for International Development
E-EEntertainment Education
EAG
Empowered Action Group
FOGSI
Federation of Obstetric and Gynaecological Societies of India
FPF
Family Planning Foundation
GoI
Government of India
HIV/AIDS
Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome
HUP
Health of the Urban Poor
HMIS
Health Management Information System
IAPPD
Indian Association of Parliamentarians on Population and Development
IBRD
International Bank for Reconstruction and Development
ICDS
Integrated Child Development Services
ICPD
International Conference on Population and Development
IDRC
International Development Research Centre
IHMP
Institute of Health Management, Pachod
IIHMR
Indian Institute of Health Management Research
IIPS
International Institute for Population Sciences
IRS
Indian Readership Survey
IIT
Indian Institute of Technology
IUDIntrauterine Device
IVRS
Interactive Voice Response System
KTKaruna Trust
MAS
Mahila Arogya Samiti
MARD
Men Against Rape and Discrimination
MCH
Maternal and Child Health
MDG
Millennium Development Goals
MIA
Micro Insurance Academy
MoHFW
Ministry of Health and Family Welfare
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MPMadhya Pradesh
MSI
Management Services International
MTP
Medical Termination of Pregnancy
NGONon-Governmental Organisation
NHM
National Health Mission
NHSRC
National Health Systems Resource Centre
NPP
National Population Policy
NRHM
National Rural Health Mission
NUHM
National Urban Health Mission
PAC
Public Accounts Committee
PDS
Public Distribution System
PFI
Population Foundation of India
PIL
Public Interest Litigation
PIP
Project Implementation Plan
PMC
Planning and Monitoring Committee
PNDT
Pre-Natal Diagnostic Techniques
PPP
Public Private Partnership
PRI
Panchayati Raj Institutions
RCH
Reproductive and Child Health
RKS
Rogi Kalyan Samiti
RKSK
Rashtriya Kishor Swasthya Karyakram
RTRDC
Regional Training and Resource Development Centre
SEARCH
Society for Education, Action and Research in Community Health
SEWA
Self Employed Women’s Association
SHGSelf-Help Group
SHSRC
State Health Systems Resource Centre
STI
Sexually Transmitted Infections
SUM
Scaling Up Management
TAM
Television Audience Measurement
TIP
Total Integrated Programme
TRDC
Training Resource Development Centre
UHND
Urban Health and Nutrition Day
UNUnited Nations
UNDP
United Nations Development Programme
UNFPA
United Nations Population Fund
UPUttar Pradesh
USAID
United States Agency for International Development
VHSNC
Village Health Sanitation and Nutrition Committee
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01
INTRODUCTION
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14JRD Tata aloAnng IwnitshtiDtur.tiBohnaraalt HRaismtolaryyinogfththeefoPunodpautiolantsiotonneFoofuPnodpualatitoionn FoofuInnddaitaio,n1o9f 7In0d–ia2015
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Introduction
T
he twin issues of population and economic growth have been debated widely in defining national goals and
achieving them. The relationship between population and development in the context of the emergence of
newly independent countries began to acquire significance in the period following the Second World War,
when the successes of government-led epidemic control measures — notably malaria control — set in motion
over the late 1940s and 1950s resulted in dramatic decline in death rates due to communicable diseases. But
the significance of health in relation to population was for long years seen to be relevant only in respect of its
link with the productivity of the workforce. The wisdom of improving maternal health and child health followed
much later; even then, they elicited concern for only their role in sustaining high population growth rates. Over
the last four decades, the above discourse has widened, and, today, it includes issues relating to gender and
women’s empowerment and rights.
Any policy framework to achieve the objectives of economic change and social welfare entails the process of
building institutions. The Population Foundation of India (PFI) has, over the last several decades, sought to
serve as such an institutional bulwark in what is now seen as an inseparably tripartite relationship of population,
health and development within the framework of women’s empowerment, gender equality and human rights.
This monograph traces the institutional history of the organisation, with the objective of gaining insights into
what makes or impedes the institutional efficacy of an organisation: the forces — external as well as internal —
that acted on it and that it had to respond to or cope with in order to play its role; the resulting nuances that
have shaped its functioning, and how it is looking to face its future challenges.
The monograph is structured into four substantive chapters. Chapter Two covers the first twenty or so years
when the foundation evolved into an institution in its own right, presented a public face as a think tank, expand-
ed its vision, and underwent a change of identity. It had started its journey as the Family Planning Foundation,
an agency driven by the objective of propagating the small-family norm; as such, it subscribed to the impor-
tance of controlling population growth rates as a necessary instrument to achieve economic growth. But, there
were also trends in the international movement of ideas that posited a more complex relationship between
population and development than was earlier believed to be so. Along the way, the Foundation sought to
build bridges with private industry, government, NGOs and the wider public through its activities of advocacy,
sponsoring policy-oriented and action research, mounting its own research investigations, producing audio-vi-
sual material on the subject of the small-family norm, and organizing orations and public events. The change
in name to Population Foundation of India signalled the start of a new phase of institutional evolution.
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Chapter Three deals with responses to the emerging
nuances in demographic trends in the country. The
picture was not an unrelievedly uniform one of high
fertility levels. Some regions were indeed showing
signs of steady decline, raising hopes of population
stabilisation in the foreseeable future. The regions with
stubborn fertility levels also showed other negative
trends such as unacceptably high rates of maternal,
infant and child mortality. Historical, social, structural,
and developmental constraints all seemed to be at
work. The discussion here elaborates on PFI’s respons-
es in its search for the roots of these constraints and
for practical ways to strengthen a more effective inte-
gration of maternal and child healthcare services with
family planning services.
In the meanwhile, national and global intellectual and activist currents were
sweeping away the population control paradigm from thinking on popula-
tion-economic growth-development, and Chapter Four devotes itself to this.
In response to universal criticism of the target-driven and coercive character of
the Family Planning Programme, the Indian government declared that the pro-
gramme would henceforth be target-free, and, in due course, it was recast as a
Reproductive and Child Health (RCH) Programme that would provide quality
maternal and child health services. But the full force of the new awareness of
women’s reproductive health and adolescent sexual and reproductive health and
rights was not absorbed. The discussion pertains to the evolution of an emphasis
on advocacy campaigns by PFI to raise awareness on these issues. The signifi-
cance of this process was also that it marked the beginning of extensive network-
ing efforts with NGOs. The discussion also includes the new climate of policy
openness that ensued and the aperture that it offered PFI to equip itself with new
skills for the unfolding future.
Chapter Five discusses the processes that are underway in the present time. It
delineates how building on the continuing policy conduciveness, PFI used the
acquired skills to exponentially extend the reach and impact of its programmes
and activities into new directions. The chapter elaborates on the significance of
the intellectual exercises that PFI put itself through to sharpen the focus of the
This monograph traces the institutional
history of the organisation, with the
objective of gaining insights into what
makes or impedes the institutional
efficacy of an organisation
organisation into one of women’s empowerment and rights, around which all
programmes would henceforth cohere and in the process, its crafting a strategic
work plan for the next few years and defining priority areas for itself. It covers the
emergence of operational nuances that have helped it turn a mirror on itself and
how these have enhanced its own functioning. The chapter also brings to the
fore both the programme features and the implications of its deepening engage-
ment with the health of the people, with women and their rights at its centre as
the population question now came to be defined by PFI.
Chapter Six pulls together the main features of the foregoing journey and poses
the options for PFI’s immediate and medium-term future.
The Appendix features four detailed case studies from among the Founda-
tion’s major ongoing works in progress. Already referred to in Chapter Five, the
case studies help in grasping both the contexts and the details of the individual
projects as well as the manner in which all the projects weave themselves into
the broad goals and strategy of the Foundation.
On the whole, the institutional history highlights that PFI has engaged itself in
multi-pronged activities such as knowledge generation through research, insti-
tutional and project support through grants, skill building of various stakehold-
ers, and advocacy and dissemination of its findings and learnings.
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Professor Amartya Sen delivering the 12th JRD Tata Memorial Oration
In the process of shaping the field of demography and population related en-
quiry and, by extension, nurturing the eventual arrival centrestage of the focus
on women’s empowerment within a rights framework, PFI has itself grown in
both depth and spread. In doing so, it has participated with others, both do-
mestically and internationally, and has influenced and itself been influenced
in an interplay of endogenous and exogenous currents and counter-currents.
In the initial period, it drew strength largely from the prestige and clout of its
founders. Over the years, it has also gone through the process of learning from
its own experiences and from findings thrown up by the analysis of data as
well as from the experiences of other actors/agencies located both vertically
and horizontally. This iterative process has unfolded at both macro and mi-
cro-levels. In doing so, the organisation unleashed a process of learning and of
enriching others engaged in its field of activity.
It has sought to align itself with the dominant concerns of its times, but, equally,
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it has reflected the ability to retract skilfully when necessary, be it on issues of
of working has reflected dynamism as evident in its willingness to learn and
population growth, the concerns of the women’s movement, or the onslaught
experiment, to make mistakes, and to shift gears and tactics in response to
of new challenges like HIV/AIDS. It has reflected a positive approach towards
endogenous and exogenous developments.
policy shifts, a flexible aptitude to blend with currents, and cultural and political
sensitivity in designing and projecting its advocacy efforts. It has participated
in helping to resolve and achieve policy goals and has integrated those con-
cerns and goals into the scope of its own work, thereby presenting itself as a
participant in the process rather than as a critic or mere bystander. The guiding
principle, thus, has been one of learning, sharing and helping. This flexible style
of working has no doubt led to shifts in its orientations. But, as a result, it has
grown to fit into its self-determined role of a think tank as well as a partner in
implementing policies and in generating support and clout for those policies
through hands-on work.
The current phase is poised at a very interesting juncture. PFI is charting a
new course of innovation, where its ongoing initiatives and activities are knitted
into both thought and practice. It has not hesitated, for instance, to return,
when appropriate, to grossly neglected, unfinished, and even discredited agen-
das, as shown by the experience of the two tragedies at Barwani and Bilaspur,
where it has demonstrated its ability to turn even tragedies into opportunities
through thoughtful and nuanced advocacy. It has also entered seemingly dif-
ficult terrains. Through two of its programmes, the teleserial Main Kuch Bhi
Kar Sakti Hoon and Community Action for Health, it attempts to establish
complementary linkages between impersonal policies and programmes that
The current ongoing phase exemplifies all of the above. PFI’s work reflects the
come from distant sources and disadvantaged people’s abilities to participate
working links it has forged with civil society and government structures at both
in these programmes as informed agents. It has thus embarked on addressing
national and ground levels. It is, thus, tuned in to stimuli from its engagements
a set of challenges that are daunting, but worthwhile, and that entail evolving
and changing situations, and extends support, whenever required, by treading
workable strategies and pragmatic programme designs and implementation
both vertically and horizontally integrated processes. It is consciously trying to
mechanisms, the clues for which rest in its own institutional history.
innovate on its feet through learning by doing and has helped evolve protocols
for those engaged alongside it, whether at the highest levels of the bureaucra-
cy and political leadership, at the middle levels of officialdom, or for commu-
nities on the ground. Consequently, it has been able to roll out infrastructural
provisions, howsoever feeble or strong they may be at the present time. What
is significant is that PFI is on an upward slope, that it is willing to make iterations
in thinking and action and between micro-conditions and macro-objectives,
and that it is attempting to define and redefine the vehicles of communication,
depending on the exigencies of the situation. It has taken risks, and its style
All of this has to do with building knowledge and skills, retaining operation-
al flexibility and sensitivity to external and internal developments, innovating
continuously, and ensuring financial viability; and, last but not least, staying
abreast of scientific developments, and micro- and macro-level trends in ideas
and practices. The study of this institutional learning curve goes to show that
while there have been occasional hiccups and periods of relative stagnation in
PFI’s growth and role fulfilment, there are certain tenets in its functioning that
emerge as reliable and abiding guidelines for the future.
....
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02
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Mr Harish Khanna delivering a speech at Population Foundation of India’s 20th Anniversary
Negotiating a Non-Governmental
Space to Articulate the‘Population Question’
I
t was at a time of transition and upheaval in the population policy scene in the country that PFI came into exis-
tence. The initiators of the idea of a Family Planning Foundation (as the PFI was originally christened) were Mr
J.R.D. Tata, a leading Indian industrialist, and the Ford Foundation, a premier American philanthropic organisa-
tion. Mr Tata was passionate about finding ways to deal with the rising population figures and their implications
for the economic and social future of the country, and he saw that working with the government to take the
family planning agenda forward as the only way ahead. The Ford Foundation, engaged in international devel-
opment with India as the flagship country for its Overseas Development Division, had a considerable presence
in Indian policy circles since the early years of Independence and was already active in the family planning arena
in India and abroad.
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Set up in 1970, the Family Planning Foundation was conceived with two objec-
tives. One was to step into the space that had hitherto been occupied by the
Ford Foundation, which had, over the 1950s and 1960s, been the Government
of India’s principal non-governmental partner in developing and implementing
India’s health and population policy. The other objective was to play the role
of building on the considerable presence of intellectual resources in the coun-
try to support research and its applications in the fields of demography, family
planning, and contraceptive technologies. It was hoped that the creation of a
quintessentially Indian philanthropic organisation would result in the nurturing
of knowledge that could suggest new directions for what was clearly a complex
It was hoped that the creation of a
quintessentially Indian philanthropic
organisation would result in the
nurturing of knowledge that could
suggest new directions for what was
clearly a complex policy arena
policy arena that was also becoming a highly politically charged and controver-
sial one. Indeed, without Mr Tata’s towering national presence and vision and the
Ford Foundation’s commitment to investing in knowledge institutions and peo-
ple, the new organisation may not have come into being in the form that it did.
The Family Planning Foundation (FPF) set off on its journey, supported by an
initial ten-year institutional grant from the Ford Foundation. At the core of this
grant was the condition of reciprocal philanthropy from within India. In other
words, the grant stipulated that during the first three years, for every three dol-
lars put in by the Ford Foundation one dollar would have to be raised by the
new institution; for the next three years it would be two dollars for every dollar
raised locally; and for the final three years, the Ford Foundation’s contribution
would be dollar for dollar. The endowment, thus generated, was expected to
put FPF on its feet as a grant-making body. The Ford Foundation also offered
the use of two buildings, one for an office and the other for the residence of the
Executive Director.
Project grants followed, so that the fledgling institution might have a constitu-
ency for its grant-making activities from the start. One of the first of these grants
was to help nurture the critical mass of specialists in the country who would feed
the knowledge-generation process. The career development programme that
the Ford Foundation had previously sponsored jointly with the Government of
India was now transferred to FPF. The programme offered fellowships and cre-
ated positions in leading universities, research institutes, and private and public
sector undertakings, to select and train young Indians, including those working
abroad, and develop career opportunities for them in the country in the field of
population dynamics and applied research in family planning.
Over the course of the decade, as Ford Foundation supported international
biomedical research teams working on improved and new contraceptive tech-
nologies made progress, the organisation sought to echo that progress within
India. One generous project grant to the infant FPF was for a new career de-
velopment scheme for the support of young Indian biomedical scientists opting
for basic and applied research careers in the field of contraceptive technologies.
Another grant came in for support to promising lines of research by established
scientists, already working in Indian research institutions, and to Indian scientists
working abroad, to find berths in India for pursuing research projects of their
choice in this field. In the field of biomedical research, the expectation was for
FPF to match the grants in terms of one dollar for every four dollars from the
Ford Foundation.
The political and policy climate in the country at the time was one of active
‘population control’. But it had not always been that way. The first decade after
Independence — the decade of the 1950s — was dominated by Gandhian ide-
alism and the vision of ‘community development’, which led to a holistic policy
approach to enhancing the quality of life of the Indian population. A primary
health care framework, with a central role for health education, immunisation,
and environmental sanitation addressed to the needs of the country’s over-
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whelmingly rural population. It formed the cornerstone of India’s first public poli-
approach to development. The time seemed ripe for more rapid and technol-
cy focused on the interlinked issues of health and development. Family planning
ogy-based development strategies, which were epitomised in the Second Five
was recognised by the government as an important area for social intervention,
-Year Plan (1956–1961). This plan heralded a shift towards a totally different
mainly for its value in improving women’s health, because it was argued that
ideological framework of development planning in India: the crafting of a mod-
the root of women’s ill health lay in narrowly spaced pregnancies and births,
ern industrial sector that would make for a quantum shift of the labour force into
aggravated by marriage at a very early age. The first decade of the family plan-
high-wage and high-productivity jobs and the concomitant movement of the
ning programme — set up in 1952 — therefore, focused on providing education,
predominantly rural population to urban areas. The resulting social transforma-
marriage counselling, and child counselling, rather than medical intervention for
tion was expected to bring with it the inculcation of modern values and norms,
birth control. The Ford Foundation was invited by the Government of India in
and among them, the norm of the small family.
1952 to offer suggestions for improving the environmental sanitation compo-
This development dream, however, proved elusive, and
the Indian economy soon started to stumble. Modern
sector jobs did not even keep pace with net additions
to the labour force, and widespread incidence of mal-
nutrition and communicable diseases in both rural
Echoing around the world — and finding
its resonance in India — was the idea that
‘population control’ was an essential part
and urban areas, poor maternal health, and high infant
mortality showed no signs of abatement. The country’s
1961 Census projected a very gloomy picture of the
population scenario and created a general climate of
of health and development and
indispensable for economic growth
urgency in the country to do something about it. The
explanation forwarded for rising population figures was
unchecked human fertility. While in industrialised coun-
tries, changes in individual behaviour and social norms
accompanying urbanisation and material prosperity
had been able to relatively quickly achieve a decline in
fertility, in newly developing countries, the problem of
high fertility rates remained stubborn. Echoing around
nent of this community development programme. It made large grants directly
to the government that helped to strengthen existing health education centres
and rural institutes of higher learning; train public health workers, community
development workers and village-level health workers; set up field research
laboratories; and analyse the technical and behavioural data generated by field
studies.
By the end of the decade, however, India’s political leaders had grown impa-
tient with the tardy progress and long-term approach of the village-oriented
the world — and finding its resonance in India — was the idea that ‘population
control’ was an essential part of health and development and indispensable for
economic growth. Given its mission of aligning itself with India’s developmental
priorities and its own flexible funding policy, the Ford Foundation began to work
with the government in helping to evolve thinking and to examine strategies
that would lead toward government policies and programmes for family plan-
ning.
At its New York headquarters, the Ford Foundation set up a fully-fledged Popu-
lation Program in 1963 to support scientific and educational efforts to meet the
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Availability of contraceptive
methods alone could not be
expected to achieve substantial
reductions in fertility
Shri Chandra Shekhar delivering the 2nd JRD Tata Memorial Oration
challenge of controlling global population growth that had its more worrying
dimensions in developing countries. Ford Foundation grants for biomedical, so-
cial, demographic, and public health research and training to US and European
institutions of higher learning — including the Population Council, a private or-
ganisation initiated with Foundation support — yielded newer (improved) gen-
erations of contraceptives, such as the oral contraceptive pills and intrauterine
devices (IUDs). But although an improvement over earlier techniques, these
contraceptives left much to be desired for use in developing countries, as they
required significant medical training and had side effects, which diminished their
acceptability. This spurred the Ford Foundation to support research efforts
for better and cheaper contraceptives. India then became the most important
country of the Ford Foundation Overseas Development Division for family
planning grants.
By the mid-1960s, the Government of India was taking a method-specific approach
(IUDs, condoms, sterilisation) to fertility control and fixing annual targets for each
contraceptive method. And, it was using the existing network of Primary Health
Centres, urban family planning clinics, and the expanding family planning centres to
vigorously promote IUDs and condoms, while also intensifying sterilisation and va-
sectomy programmes. Research and training in reproductive biology received prior-
ity as did the development of demography as an academic specialty. In this phase of
support to the Government of India, in addition to the Family Planning Programme
itself, Ford Foundation grants also went to leading Indian educational and research
centres like the All India Institute of Medical Sciences (Delhi), the Central Drug Re-
search Institute (Lucknow), and International Institute of Population Studies (Mum-
bai), to name just a few, and to a network of university departments and research lab-
oratories. The grants were meant to strengthen research and training in reproductive
biology, develop demography as a specialism, create whole new communities of
researchers in these fields, and involve top Indian scientists in the Indian family plan-
ning movement. The grant-making strategy also helped develop personnel and fa-
cilities able to evaluate and test the latest innovations in fertility control under Indian
conditions. But, availability of contraceptive methods alone could not be expected
to achieve substantial reductions in fertility; there had to be a demand for them and
they had to be easily accessible to people. Experiments in production, distribution,
and communication were called for. The Ford Foundation helped to develop com-
munication campaigns to create a demand for the newly available contraceptives.
It introduced improved versions of the IUD and supported the manufacture and
distribution of condoms.
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Family planning became a stand-alone programme
and was not integrated with other services. It became
huge in size, excessively bureaucratised, and with little
space for innovation or correction
In 1966, in a landmark development for family planning in India, the Govern-
ment of India created a separate family planning department in the Ministry of
Health and renamed it as the Ministry of Health and Family Planning with a new
Minister of State for Family Planning. By the time of the Fourth Five Year Plan
(1966–1974), family planning was firmly ingrained in government policies and
the public mind. What the Plan did was to nest this goal within a broader welfare
framework: expanding public awareness of birth control measures, widening the
choice of contraceptives, raising the legal age at marriage, and improving wom-
en’s access to education and health services. In particular, Maternal and Child
Health (MCH) services were to be integrated with family planning in order to
raise the effectiveness of the latter. The Medical Termination of Pregnancy Act
was passed and came into force in 1972. All these measures were expected to
bring down the population growth rate over the next two decades.
In effect, however, family planning became a stand-alone programme and
was not integrated with other services. It became huge in size, excessively bu-
reaucratised, and with little space for innovation or correction. Given the dif-
ficulties in promoting the extensive use of IUDs and oral pills, the emphasis
came to rest on sterilisations through special camps. By the time the state of
Emergency was declared in 1975, the actual implementation of the Population
Policy had assumed coercive proportions. Sterilisations were promoted with in-
creased monetary incentives for acceptors and pressure on government health
staff to reach pre-set targets for sterilisations. The public health system was
subverted to achieve demographic goals, which left the system under-funded
and under-provisioned and too weak to focus on its core objective of health-
care, including maternal and child healthcare. After the Emergency, the back-
lash from the coercive, sometimes compulsory, sterilisation camps — particularly
vasectomy — dealt a dramatic setback to family planning efforts. The mass of
the people, particularly the poor, the very target of family planning campaigns,
rejected family planning.
About 1970, a considerable amount of institutional soul-searching had already
begun within the Ford Foundation as to whether its hitherto role of aligning itself
directly with governments and their development agendas and goals — particu-
larly the association with the Indian population control programme — had actual-
ly contributed to its mission of international development. Where support to the
population question was concerned, the Ford Foundation resolved to engage in
more indirect grantmaking, that is, support to develop more knowledge about the
determinants of population change, which required nurturing first-rate research-
ers and supporting social science perspectives and methodologies that had the
potential to impact both national policy and international assistance programmes
as well as grassroots initiatives. The field of demography began to flourish in India
with support from the Ford Foundation, which continued to support fellowships
for population and development communications to build capacity within India.
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The Ford Foundation also looked for an institutional successor to itself within
the country, one that would help build intellectual leadership for constructive re-
search and innovation in the population arena that could feed into India’s official
family planning policy. It broached this proposal to Mr J.R.D. Tata, who had long
been convinced that the population question was perhaps the most important
one confronting the nation. For him, family planning was in essence a ‘move-
ment of social development’ that encompassed the entire population and the
dreams and possibilities of the nation as a whole for its future. This, he believed,
was too large and too vital a project to be left to the government alone; it need-
ed to be actively supported by private voluntary enterprise as a national duty.
The matching of institutional grants from the Ford Foundation with funds raised
from the local business community, however, did not prove to be an entirely
easy exercise for Mr Tata. In association with another leading industrialist, Dr
Bharat Ram, he brought a number of industrialists and prominent Indians en-
gaged in other vocations onto FPF’s Governing Board, and made ceaseless
impassioned pleas to fellow captains of industry to join in the vital national proj-
ect of enhancing the quality of life of the enfeebled population through keeping
down the relentless growth in numbers. If India was to put itself on a secure
economic growth trajectory and prosper as a society whose citizens enjoyed full
opportunities to realise their potential, he argued in his many speeches and writ-
ings, there was no getting away from a direct assault on the population problem,
and everyone needed to come on board. But, disappointingly, the response was
not a resoundingly positive one, and apart from the Tata, Birla, and Kasturbhai
Lalbhai groups, which made generous grants, Indian industry remained luke-
warm to the ‘population question’. FPF nevertheless went ahead and envisioned
a clear agenda for itself on the country’s family planning stage. This would be an
independent path of work with voluntary agencies to promote family planning
among needy couples and aid in the widespread adoption of the small family
norm. At the same time it would work in close liaison with the government in all
its programmes and, as far as possible, associate government officials formally
or informally in the technical evaluation of projects before these were finally
accepted for financial assistance.
Even as it was undergoing its own teething troubles, the newly instituted FPF
found itself having to cope with political developments in the country that
found contradictory echoes in national development policies and in the Family
Planning Programme. This, compounded by a shift in the international move-
ment of ideas around the population question, began to cause the Foundation
considerable uncertainty about its own agenda. At the Third World Population
Conference held in Bucharest in 1974, the position of the international commu-
nity was reflected in the slogan that ‘development is the best contraceptive’. The
slogan had, in fact, been authored by the Indian government led by Mrs Indira
Gandhi who, after her victorious break with the old guard of the ruling Congress
Party in 1971, had made garibi hatao (banish poverty) her banner and was spear-
heading a paradigm shift away from growth per se towards equity and the enti-
tlements of the poor, particularly poor women. For the ruling Indian political dis-
J.R.D. Tata made ceaseless impassioned pleas
to fellow captains of industry to join in the vital
national project of enhancing the quality of the
enfeebled population through keeping down
the relentless growth in numbers
pensation, its slogan at Bucharest was an instrument to assert its legitimacy on
the international stage. FPF which had spent a year advocating support for the
government’s Family Planning Programme in the country in preparation for the
World Population Year (1974), was somewhat alarmed by both the Government
of India and global voices on downplaying the need for poor countries to meet
the population problem head-on at the Bucharest Conference. It felt somewhat
reassured by Mrs Indira Gandhi’s assertion on the national stage later that year
that the Family Planning Programme would remain among the country’s highest
priorities and that it would be galvanised within the framework of the nation’s
development policy. And indeed, the Fifth Five-year Plan (1974–1978) did at-
tempt to integrate the Family Planning Programme with the Minimum Needs
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Programme (that is, a programme to provide minimum public health facilities
integrated with family planning and nutrition for vulnerable groups such as chil-
dren, pregnant women, and lactating mothers).
But in effect, the integration did not happen. And the Family Planning Pro-
gramme became increasingly vertical and impervious to change. FPF, however,
felt a brief, if guarded, flash of gratification for the relevance of its agenda, when
Mrs Indira Gandhi’s national Emergency prioritised population control, by radi-
cal means if necessary. Responding to the freedom given to them by the Centre
in this regard, even the usually somnambulant state governments proposed the
enactment of ‘radical’ laws, programmes and measures to ensure that the prior-
ities were implemented. But the family planning excesses committed during the
Emergency were far more than anything that FPF had even remotely expected.
It saw both its family planning and its fund-raising agendas undergo a grave
setback when the nation — and the states in particular, especially the northern
states that had witnessed the worst of the excesses — experienced a complete
loss of nerve in relation to family planning, and the subject itself became an
untouchable one for public policy.
It was creditable that FPF sought to commission a study on the disturbing im-
pact of the compulsory sterilisations, even while the Emergency was in progress
in 1976. The study did not happen at the time, as none of the institutions that
FPF approached showed any enthusiasm for it on the grounds that the field
conditions were not propitious. Nor did FPF show itself to be outspoken on
the subject, preferring to walk the tightrope of its being what it called, neither
‘conformist’ nor adversarial. Reiterating that FPF would persist in staying true
to its basic mission of getting the nation back on the family planning rails, the
Board argued that if FPF was to be independent of the government’s changing
policy stances, while still adopting a collaborative, constructive, and innovative
approach to national development, it was even more imperative that it refrain
from accepting government funds and that its funding sources be raised from
the private sector. Mr Tata’s appeals to the business and industrial community in
the country to contribute funds doubled in vigour. But they fell mostly on deaf
ears.
If FPF had to navigate the tricky road of keeping family planning on the coun-
try’s radar despite the ups and downs generated by the vagaries of politics, it
Shri Somnath Chatterjee delivering the 9th JRD Tata Memorial Oration
had to first negotiate an autonomous and safe space from where to continue
its journey. For this, it needed both funds and a new look at its agenda. FPF’s
dissemination of its scholarly publication, ‘Population in India’s Development:
1948–2000’ had brought it international attention at the Bucharest World Pop-
ulation Conference. Its vigorous policy advocacy activities within the country
about the time of the World Population Year had also brought it national visibili-
ty. This was most certainly a time to look outwards. FPF now turned its attention
to assessing the international policy landscape as a possible source of funding
over the long term for discrete projects with concrete outcomes. Outside of
India, in the international space, the population issue was still alive and vital even
as it was undergoing an expansion in vision.
Although in the years immediately preceding the Emergency, the Government
of India had tended to frown on funding by foreign agencies, including philan-
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In the late 1970s, the FPF would
commission basic and applied
social research projects, for which it
would draw on the growing
community of demographers and
social scientists in the country
thropic ones, things changed after the lifting of the Emergency and the election
of the new government. Some possibilities opened up for collaboration with
multilateral agencies within the UN system, such as the UNICEF, UNDP, UNF-
PA, ILO, FAO, UNESCO, IBRD, and WHO, which were all committed to sup-
porting family planning programmes in accordance with their own mandates.
One of the expanded ways of looking at the population question in the wake
of Bucharest was through the lens of nutrition of infants and children, including
pregnant women and lactating mothers, with a strong emphasis on testing ideas
on how to design and deliver comprehensive MCH programmes that included
nutrition and public health services in addition to family planning services. The
UNICEF, among the first to adopt the stance of encouraging countries to look
at family planning, not in isolation but within a broad framework of programmes
for the health and welfare of mothers and children, offered a welcome window
for FPF to widen the scope of its own work. The Ford Foundation, too, was in
the midst of taking a fresh look at the interrelated issues of child survival and
nutrition — as a successor to its ‘population’ focus — and it showed interest in
funding FPF for projects that would closely investigate the issue of infant and
child mortality and their links with both maternal health and fertility.
The debates generated internationally by the Bucharest Conference had
thrown into sharp relief the extremely complex and two-way causal relationships
between population and social, economic, political, and environmental condi-
tions. Broadening the perspective on the population issue, the Conference had
stressed that population concerns were a part of and not a substitute for de-
velopment concerns. The deliberations at the Conference had been critical of
the overriding support being extended to technology-driven family planning
programmes. Another contribution by it was according legitimacy to the con-
sensus that the prevailing development model for less developed countries was
far too heavily preoccupied with macro-economic objectives and too little con-
cerned with micro-level improvements in quality of life and livelihood opportu-
nities of the poor. Among the recommendations of the Population Tribune (an
unofficial NGO coalition at the conference supported by the Ford Foundation,
that FPF had participated in) was a call for increased attention to the status of
poor women and their quality of life in the world’s agenda for women.
In India, the Planning Commission was now framing the population issue within
a broad integrated perspective of health and equity. All of this was now making
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engagement in this field more challenging and worthwhile than ever before.
It seemed quite possible, therefore, for FPF to renegotiate a meaningful role
for itself in the new national political environment of the late 1970s, a role that
it felt could afford both ‘flexibility’ and ‘relevance’. It would commission basic
and applied social research projects, for which it would draw on the growing
community of demographers and social scientists in the country. These projects
would investigate puzzles thrown up by the population-development nexus and
generate key policy-oriented knowledge products for dissemination among
multiple audiences such as researchers, policymakers, parliamentarians, and
the general public. It would also develop projects jointly with other organisa-
tions, such as international bilateral and multilateral agencies, around common
interests. It would provide technical and financial assistance to help develop the
capabilities of voluntary organisations at the grassroots that showed the moti-
vation and confidence to engage in the field of family planning, but lacked the
resources and skills to do so (what it saw as an ‘outreach role’ for itself). And, it
would be selective in its grant-making activities, responding to only those re-
quests for assistance where worthwhile ideas were intended to be developed
through demonstration/action research projects that were ‘experimental in na-
ture, developmental in orientation, or having demonstration or replicative value’.
All of the above notwithstanding, the most promising field by far in the eyes
of FPF remained its ongoing support for biomedical research. In a few select
national research institutions, scientists were already working on developing new
contraceptive methods: easy to use, acceptable under Indian conditions, and
affordable. Given the slow, complex, and uncertain nature of efforts to spread
the social message of the small family norm and to change the mindsets of the
masses in favour of family planning as a way of life, FPF was hopeful that scien-
tific breakthroughs might yield the proverbial magic bullet that would put India
on its way to solving its problem of overpopulation.
Another significant area of work envisaged was to maintain an ongoing advoca-
cy role — what it termed ‘promotional’ — through publications, conferences, seminars,
films and electronic media, and engagement with the educated and political
elite of the country, as well as with the professional mass media. These efforts
would create a climate for informed debate and intelligent reporting, respec-
tively, on population and family planning issues. Commissioning documentary
films for dissemination through the Government of India’s Films Division and
plumbing the depths of the new electronic medium of national television to
reach out to the predominantly illiterate population about the value of the small
family norm would continue to remain one of the core activities of FPF for the
next few decades. FPF’s destiny may have been envisaged at the time of its
inception within a limited frame of grantmaking. But, it was beginning to see a
much larger role for itself, one that included interventions — creating ‘both the
expertise and the models that can bring about systematic changes’ — and ad-
vocacy. Together, these two activities — so it believed and hoped — might just
serve to make the hitherto directionless and dynamism-deficient Family Plan-
ning Programme more effective and acceptable.
Commissioning documentary films for
dissemination through the Government of India’s
Films Division and plumbing the depths of the
new electronic medium of national television to
reach out to the predominantly illiterate
population about the value of the small family
norm would continue to remain one of the core
activities of FPF for the next few decades
In the initial years, the bulk of the expenditure was on demonstration-cum-ac-
tion projects. These were followed by support to ‘futuristic-oriented studies
with policy implications’. The majority of the demonstration projects were
intended to tread the ground where fears and doubts about family planning
methods, additionally let loose during the mass sterilisation campaigns, were
rampant among the mass of the people. It was expected that these would yield
micro-level understanding of fertility behaviour that would help identify ways of
generating the most effective skills and abilities to motivate and educate people
to adopt family planning. Other more experimental projects were those that
looked to design-integrated maternal health and family planning services, with
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a role for community participation. The new policy interest
in creating a cadre of community-based health workers —
given that the male multi-purpose workers attached to the
Primary Health Centres had come into disrepute following
the Emergency for their role in vasectomy drives — led to
support for projects that sought to identify the most effec-
tive ways in which health and family planning services could
be brought together at the level of communities. FPF also
made grants to national-level voluntary organisations, with
the objective of creating within them a family planning fo-
cus and nurturing research skills that would, it was hoped,
lead to innovations as well as management skills that would
enhance their organisational effectiveness. The general
disillusionment with the government following the Emer-
gency had spawned a number of non-governmental initia-
tives at the micro-level, where small groups of profession-
PFI’s book, India’s Family Planning Programme: Policies, Practices and Challenges, authored by Leela Visaria and Rajani R Ved
ally trained youth — engineers and doctors — were seeking
to make a difference to the quality of life of poor mostly
as educators and motivators rather than as symbols of coercion…’.
rural communities. FPF sought to study their community-based interventions,
with a view to discerning clues for wider replication in public policy. Grants also
went into supporting interdisciplinary interactions within scientific and academic
communities in India and with their counterparts abroad, with a view to create
conditions for fruitful partnerships for practical result-oriented research in a hith-
erto narrowly defined field that was now being thrown wide open.
There were also practical constraints — including paucity of finances — in ad-
ministering and overseeing the field-level grants from Delhi, spread as they
were all over the country. More particularly, these included the problems related
to making available the extensive handholding that the projects required. Short-
age of interdisciplinary expertise necessary for the designing of the projects was
one of the several constraints. Another was the frequent difficulty faced by vol-
For FPF this was new terrain, the scope for work was immense and the po-
untary organisations in coming up with innovative ideas, given that for many of
tential partners for pursuing research ideas and interrogating policy directions
these agencies, population was a totally new and unfamiliar area. The tiny size
and audiences for advocacy products were all diverse. But, there were also cor-
of the core FPF staff, which perforce depended on the time and availability of a
responding factors inhibiting progress. Above all was the looming uncertainty
wide network of scholars and researchers based in their own home institutions,
about where FPF’s core agenda — family planning — was headed, and how to
to help oversee all the work of project formulation, coordination, training, writ-
meet the challenge of restoring its credibility. The Foundation perceived that,‘…
ing up the studies, and preparing the manuscripts for dissemination, was yet
as a programme it has become in the minds of many, particularly in North In-
another.
dia, another name for coercion…’ Supporting voluntary organisations to design
integrated health and family planning services repeatedly came up against the
reminder that a climate of suspicion persisted in which family planning was seen
as being packaged as health;‘…the health staff will have to re-legitimise their role
There was also the fundamental flaw that the grants tended to be relatively
small and of short duration for projects that were expected to be experimen-
tal in nature. In the circumstances, they tended to be one-off studies with little
follow-up, which meant that they did not, for the most part, add up to concrete
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outcomes that could be taken forward. If new innovations had to be nurtured
that would make a dent on the rigid Family Planning Programme, a more co-
gent and focused grant-making policy, with more funds to support the oversight
activities, was called for.
In the midst of all this, the results of the 1981 Census came as a rude shock,
showing a huge jump in population growth figures on the whole. It coincided
with the return to political power of Mrs Indira Gandhi who was able to shed the
legacy of the Emergency and reassert the primacy of family planning. The reviv-
al of political support for and a new vigour to the Family Planning Programme
was a change that FPF welcomed. The Census also threw out an intellectual
settings across different regions, that made for this perplexing picture? What
clues did it offer for action? These and other questions spurred an intensive
phase of large ‘diagnostic’ studies of population growth, family planning, and
development in the five states of Gujarat, Uttar Pradesh (UP), Odisha, Rajas-
than, and Tamil Nadu. Another landmark multi-state study coercing UP, Mad-
hya Pradesh (MP), Odisha, Karnataka, and Maharashtra examined the implica-
tions of infant mortality on fertility. A third looked at the question of incentives
and disincentives — for there were strong opinions in several quarters, including
in FPF itself, in favour of incentives — and how they might enhance people’s
responses to family planning when presented in conjunction with a well-func-
tioning family planning programme.
The 1980s was a phase of landmark studies by FPF : What was it
about the way that the development process worked in different
states, as also the different social and cultural settings across
different regions, that made for this perplexing picture? What
clues did it offer for action? These and other questions spurred
an intensive phase of large ‘diagnostic’ studies of population
growth, family planning, and development
challenge that FPF now geared itself up to meet. An important feature that it
highlighted was that the problem of rapid population growth was essentially a
regional one, with the growth rate varying from 17.50 per cent in Tamil Nadu to
32.97 per cent in Rajasthan. This raised the question of what might be the causes
for such huge demographic variations, given that the way in which the Family
Planning Programme worked was essentially the same across states and was a
centrally supported programme. What was it about the way that the develop-
ment process worked in different states, as also the different social and cultural
Studies such as these were seen as too vital to be left to others and were initi-
ated and carried out by FPF itself. What marked them was their inclusiveness
— they involved large numbers of researchers and institutions and investigated
large populations in diverse regional contexts. Task Forces were set up around
the specific themes and the results presented in comprehensive papers, with
practical recommendations for policy that were disseminated to the govern-
ment at the Centre and in the states and to parliamentarians. They were also
presented for public information and debate; a quarterly newsletter — Focus
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— was begun in the last quarter of 1987 to facilitate the wide dissemination
of successive study results. There was also a lot of thinking on how to locate
new talent in family planning communications so that television and radio might
begin to reflect the unfolding population issues and concerns in an innovative
and creative way.
After the traumatising years of the 1970s, the decade of the 1980s seemed like
a period of healing to FPF as far as the national climate for the Family Planning
Programme was concerned. With the southern states showing a clear lowering
of birth rates, the population problem was beginning to look just a little bit more
manageable. In a scenario where the Family Planning Programme was central-
ly administered and therefore identical across the country, what was necessary
was to identify the reasons outside the programme that made for the regional
variations. The government was also showing a greater openness towards the
non-governmental sector, grounded as the latter was in regional and sub-re-
gional realities. FPF saw for itself a role in bringing the macro and micro to-
gether into a national consensus around population, health, and family planning
issues, sparking off enlightened policies for social and economic change.
The five-state study on the links between infant mortality and fertility in hilly,
rural, tribal, urban, and slum areas, and the six-state study on determinants of
population growth (done in collaboration with the International Development
Research Council [IDRC] and Population Council, respectively) as well as the
state level diagnostic studies of population growth, family planning and devel-
opment clearly showed that without reforms in the sectors associated with fer-
tility — specifically, female education, maternal and child care, lowering of infant
mortality, raising of the age at marriage — major changes in fertility decisions
on the part of populations could not be expected. It was also necessary to bring
about improvements in the quality and provisioning of medical facilities and
people’s access to them and in the provision of roads which would enhance ac-
cess, and provision of water and sanitation facilities, which are vital to the health
of all age groups, particularly infants and children. All these development sec-
tors had strong population orientations and required as much attention as a
programme that sought to directly intervene in fertility control. The spotlight,
especially on the links between age at marriage and at first pregnancy and the
resulting infant mortality, highlighted the role of maternal health, an area of
concern that was also consuming the attention of a host of other international
The five state study on the links between infant
mortality and fertility and the six-state study on
determinants of population growth as well as the
state level diagnostic studies of population growth,
family planning, and development showed that
without reforms in the sectors associated with
fertility major changes in fertility decisions on the
part of populations could not be expected
agencies, most notably, the Ford Foundation. In addition, the State of World
Population Report (1988) highlighted the impact of population growth on the
environment — the ‘scissors effect’ that caused poverty and population growth
to slice away the ability of the planet to sustain itself.
The above-mentioned large studies by FPF were well received by the Centre,
and the doors were opened for their presentation to the concerned states. The
general policy and political climate in the country seemed favourable to cau-
tiously opening up the population and family planning agenda for participation
from non-threatening sources. The huge discrepancy between the contraceptive
prevalence figures put out by the Family Planning Programme and the actu-
al birth rates as revealed by the Census had led to widespread distrust of the
way the Family Planning Programme was being administered. It had also invited
scathing criticism from the Public Accounts Committee (PAC) that examined
the programme through the year 1987. In its 139th report (December 1988), the
PAC declared that, ‘even though the Family Welfare Programme has been in
operation for more than 35 years with an expenditure of over Rs 2400 crores
upto the end of the Sixth Five-Year Plan, it has not been able to check the growth
of population at all…The nature of the population has not been perceived in the
right perspective in spite of the national urgency for population control’.
The time seemed opportune for a larger leadership role for FPF in policymaking
circles. The Government of India invited FPF to come centrestage and assist
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Dr Osotimehin delivering the 13th JRD Tata Memorial Oration
in the formulation of new approaches and strategies to address the population
question. For FPF, espousing what it now called the ‘beyond family planning’
approach, infant mortality and maternal mortality were the prime factors to be
addressed if a family planning programme was to make any impact. And, infant
mortality and maternal mortality occurred predominantly in families in poverty,
among women with no access to education, and in communities with poor ac-
cess to health and family planning facilities. This, in essence, was the relationship
between population and development.
By the mid-1980s, the intellectual and policy climate was much more receptive to
advanced thinking on issues relating to maternal and child health. The Govern-
ment of India’s Health Policy Statement of 1983 and the Seventh Five-Year Plan
(1985–1990) prioritised the health status of women and children, albeit in order to
achieve a reduction in fertility rates. The Seventh Plan also explicitly recognised
the importance of better management of health and family welfare programmes.
It gave greater emphasis to maternal and child health programmes that could re-
duce infant and child mortality, an expanded programme of immunisation, health
services for schoolgoing children, and active participation in the programme by
non-governmental and community organisations. It gave number one priority to
rural poverty, and it stressed investment increases in and better management of
related areas such as irrigation, forests, wastelands, pastures and rural banking.
Given that these themes were in consonance with thinking in international policy
and development assistance circles as well, the Government of India began to
receive considerable funds from big international donors, who were flush with
funds for health following the Bucharest Conference and fired by the social jus-
tice dimension of action to improve health as a basic human right, as recognised
by the Alma-Ata Conference of 1978 for work on maternal and child health.
FPF’s mission became the dissemination of the analytical insights that it had
gained to ever-widening concentric circles of audiences. One of the most im-
portant audiences that it identified was the Indian Association of Parliamentarians
on Population and Development (IAPPD). Special studies were commissioned
and position papers and monographs prepared that presented situation reports
for the education of Members of Parliament and of state legislatures through
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seminars and special sessions of the IAPPD organised by FPF. The documenta-
tion centre of FPF began to be reorganised with a view to facilitate dissemination
of information to professionals, who included media personnel, researchers in the
field of population and development, members of business associations such as
the Chambers of Commerce and Industry and officers of the Indian Administra-
tive Service and Allied Services undergoing their foundational courses. Materials
were prepared on population education and family planning that were suited to
their diverse needs. FPF conducted seminars at the state level in collaboration
with the regional Population Research Centres — particularly in the states that
were the sites for the study linking infant mortality and fertility — with the hope of
arousing positive interest on the part of the state governments for collaborative
‘social/institutional interventions’. It also planned to prepare periodic ‘Population
Alerts’, specially focused on poorly performing states, linking the population ques-
tion with ‘ecological, environmental and human survival dimensions’, as a means
of influencing the concerned state governments, State Planning Boards, and local
voluntary sector institutions. The quarterly newsletter Focus kept the discussion
ongoing.
the country and help run demonstration projects to show how industries could
improve the quality of their workers’ lives by promoting family planning and relat-
ed health measures among them. It would begin the task of looking ahead to the
youth dividend in the population and prepare them for leadership in the task of
confronting population and sustainable development issues, and for this it would
link up with the Nehru Yuva Kendra Sangathan.
It was a turning point in the journey of FPF. In Mr J.R.D. Tata’s words, “The Foun-
dation has endeavoured, with due humility, to act as a think tank, and we feel that
by raising a renewed debate in the country on different occasions and in different
forums, we have been able to play a useful role in sustaining public interest and
concern on the subject”. In keeping with its enhanced self-image as a leading insti-
tution in the population field and enjoying the trust of government and non-gov-
ernmental actors alike, FPF changed its name in 1993 to Population Foundation
of India (PFI). The inverted red triangle set within a circle — the logo of its former
narrow family planning identity — gave way to the more gender neutral symbol of
a collectivity of people.
With nearly two decades of evolution and growth behind it, FPF thought this a
In 1990, as part of staking out the liberal space that it had carved out for itself and
propitious moment to reorganise itself with a view to become more productive
raising its own profile both nationally and internationally, the Foundation institut-
and goal oriented. The most important emerging consensus around its work was
ed an annual lecture series called, ‘Encounter With Population Crisis’. This was
that the northern states of UP, Bihar, MP, Odisha, and Rajasthan required special
renamed the J.R.D. Tata Memorial Oration in 1993 in memory of the founder, Mr
focus in the coming future. It would also henceforth reduce the number of projects
J.R.D. Tata, who passed away that year. The objective was to continue the journey
it would support and back only well conceptualised projects, where the investiga-
of expanding the understanding of the ‘population question’ and its complex di-
tors were committed to working towards useful outcomes and be amenable to
mensions and linkages in society, and to this end, the orations were published and
replicating findings. It would step up work with parliamentarians to prepare them
disseminated widely. In 1992, the Foundation moved to its own office buildings. By
to relate to development and family planning issues in their respective constituen-
occupying one building and leasing out the other, it secured for itself an assured
cies. It would lay greater stress on audio-visual communication efforts to reach illit-
income base for the next several years, and with it came the greater autonomy and
erate audiences and break down the isolation of communities in remote locations
scope to undertake work according to its own priorities. The institutionalisation of
and both inform and entertain them. It would mobilise the industrial leadership in
the organisation was complete.
....
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03
From Population Control to
Population Stabilisation
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From Population Control to
Population Stabilisation
T
wo spheres of ideas and action were developing through the 1980s and these experienced their full flowering in
the 1990s. One of these was a well-developed focus on women, particularly their health and well-being. The other
was a burgeoning NGO sector in the country that engaged in a range of developmental issues, with some of the
leading ones dedicated to health. Both of these impacted on the policy arena of family planning, population and
development, and by extension, on PFI.
The UN’s declaration of 1975 as the International Women’s Year, close on the heels of the Bucharest World Pop-
ulation Conference and followed by the announcement of 1976–1985 as the UN Decade for Women set off a
serious examination of the condition of women the world over. In the developing countries, this focus interrogated
the development process itself, and how it was impacting on women’s survival strategies, particularly those of poor
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women. In response to this stimulus, the Government of India appointed a Com-
mittee on the Status of Women in 1975. The investigations of this committee re-
sulted in a growing awareness about the condition of poor women in the country.
Women’s studies programmes came to be established in universities across the
country, and financial support became available for individuals and research in-
stitutions initiating interdisciplinary investigations into various interrelated dimen-
sions of women in poverty. These dimensions spanned work and employment
opportunities, household decision-making and intra-household allocation pat-
terns, access to health and nutrition, autonomy and decision-making power, and
the like. International foreign assistance was forthcoming in this regard. The Ford
Foundation took the lead in helping to strengthen the research base in the country
through support to the Indian Council for Social Science Research and institu-
tional grants to individual Women’s Studies departments. Support also went to
NGOs working on women-based economic development programmes for in-
vestigating linkages between women’s economic activities and their health to see
if they could integrate maternal health and family planning services into their in-
come generating programmes.
As the field grew, there were studies on: maternal nutrition during pregnancy,
breastfeeding, and lactation; anaemia among women and the implications for
birthweight; maternal work capacity in relation to health and malnutrition; and
linkages between mother’s education and child survival. When they yielded their
results, it became increasingly clear that the quality of the mother’s health had a
major effect on the survival of her children. What was also becoming more evident
was the high maternal cost of childbearing, the extent of unwanted pregnancies,
the huge unmet need for family planning and the associated factor of absence of
reproductive choice. It seemed that it was not the availability of maternal health
and family planning services per se that mattered, but the quality of these services
and access to them. Further, that access needed to be seen in terms of whether
the services met the needs and preferences of the intended users, that is, poor
women. There was the related invisible issue of the high cost to women of their
reproductive roles over the course of their life cycle in the form of gynaecological
morbidities: morbidities with short and long term implications for both maternal
outcomes and health and self-esteem of the women themselves. Women’s con-
dition as reproductive beings required also a look at their adolescence and child-
hood and their low social value as girl children. All of these were issues that went
far beyond looking at women from the perspective of child survival alone and be-
yond the blinkered lens of unilinear population control policies in which women’s
bodies figured only as instruments of fertility.
The force of these ideas called for the crossing of institutional and disciplinary
boundaries and breaking down of barriers between methodologies for the investi-
gation of the issues involved. They highlighted the relevance of the theoretical and
applied orientations of the non-demography social sciences and of scholar-activists
as researchers and opened the door for the diluting of the privilege of quantita-
tive analytical tools of demography to include qualitative, participatory and eth-
nographic methods of knowledge generation. They also, for the first time, allowed
the voices of women’s activist groups that had been born in the crucible of the UN
Decade for Women to assert their legitimacy to be heard in policy circles. Even as
the ideas placed women and their bodies centrestage for the first time as persons
in their own right and deserving of agency, that is, their rights to regulate their own
fertility in a safe and informed manner and their rights to go through pregnancy and
childbirth in safe and respectful settings, they brought into the discourse a social
force that had hitherto remained privileged and invisible: the responsibilities and
roles of men in women’s reproductive health. The 1980s and 1990s were also the
decades of the unfolding HIV/AIDS epidemic, with sexual transmission at its core.
HIV/AIDS raised an issue never ever raised before in the context of the population
question: the sexuality and sexual behaviour of men, women and adolescents.
The Indian population policy had never brought men’s responsibilities for sex and
procreation under the lens, and it generally left unquestioned the social arrange-
ment of the patriarchal family with its gender-sexuality equations. The only brief
threat to men’s sexual hegemony was in 1975–1977 in the form of state-led com-
pulsory vasectomy drives during the period of suspension of civil liberties — the
National Emergency. The political repercussions of this move had proven to be too
severe, and the drives were hastily withdrawn. Thereafter, any reference howsoever
oblique, to male sexuality in the form of contraception of any kind, including con-
doms, never strongly advocated even earlier, had receded into obscurity. The new
concept of ‘reproductive health’ included the equal rights of both women and men
to exercise their sexuality in voluntary, satisfying and healthy ways. And, the HIV/
AIDS epidemic brought to the fore for the first time the hitherto unspoken ques-
tion of adolescent sexuality and the need for policies that promoted adolescent
sexual health awareness and rights.
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The new concept gained momentum globally, supported by the large multilat-
eral and bilateral donor agencies, notably, the apex UN body for family planning,
the UNFPA, in much the same way as the global ideological consensus among
governments and donors had done in previous decades with regard to population
policies that targeted poor women in developing countries as fertility agents. At
the International Conference on Population and Development (ICPD) of 1994
held in Cairo, the Government of India added its voice to that of its own national
civil society advocates as well as international women’s organisations and wom-
en’s health advocates to endorse the shifting of the Indian Family Planning Pro-
gramme into a Reproductive and Child Health Programme, which was one of the
first in the world to be so recast.
The ‘paradigm shift’ was indeed overdue. Doubts had been surfacing even within
government circles for quite some time about the efficacy of the Family Planning
Programme in its centralised target-driven form, given that birth rates were prov-
ing slow to decline in most of the states. Starting from the late 1970s, these doubts
gained momentum through the 1980s and were most candidly expressed in the
Eighth Plan related documents of the early 1990s and capped by the 1991 Cen-
sus. The writing on the wall was that the Family Planning Programme had to be
reoriented. The inefficient, manipulative, ineffective, and insensitive nature of pro-
gramme implementation, the blindness of its national demographic goal orienta-
tion to individuals’ reproductive aspirations, and the alienation felt by women and,
indeed, whole communities, were among the problems that were acknowledged.
One of the first steps that the Government of India took, following Cairo, was to
abolish centrally stipulated targets for the national Family Planning Programme.
In its place, under the new policy, communities would themselves determine their
own priorities and set targets accordingly, in consultation with the local health
personnel of the Primary Health Centre of which the Auxiliary Nurse Midwife
(ANM) — the key functionary on the ground of the centrally administered Family
Planning Programme — would play an important part. This decentralised plan-
ning process named Community Needs Assessment would focus primarily on
contraception (preventing and managing unwanted pregnancy) and the welfare
of mothers and children (antenatal, delivery, and postpartum maternal care and
care of newborns and infants). It would also aspire to go beyond to the manage-
ment of sexually transmitted infections and reproductive tract infections, that is,
reproductive health services. The whole would be coordinated and monitored at
PFI had already been looking at the 1990s as a
decade of efforts to strategise for population
stabilisation. At a national seminar organised by
the Foundation in 1992, the consensus was that
for the vast majority of the poor in the
country, the message of the small family norm
was still an obscure one as they saw it as in no
way connected to their own future well-being
the district level, with efficient referral mechanisms and improved quality of care.
The focus would be on ensuring responsiveness of the system to the needs of
women.
If, in an earlier era, the state of Kerala, with its unique historical and social constel-
lation of factors making for an enviable demographic profile, eluded replication in
other states of the country, now another southern state, Tamil Nadu, seemed to
offer a different kind of hope. An exploratory study sponsored by PFI suggested
that fertility decline did not have to necessarily await the gestalt of favourable cor-
relates of social development such as high female literacy, high per capita income,
low infant mortality, etc. to bring about a decline in birth rates. A coming together
of alternative fostering factors — political, social, administrative, and organisational
strengths, jointly making for better quality maternal and child health services and
better governance, generally — could also act to bring about fertility decline.
PFI had already been looking at the 1990s as a decade of efforts to strategise for
population stabilisation. At a national seminar—Seminar on Family Planning in the
Nineties: Search for New Approaches — organised by the Foundation in 1992, the
consensus was that for the vast majority of the poor in the country, the message of
the small family norm was still an obscure one as they saw it as in no way connect-
ed to their own future well-being. Even if family planning was a desirable national
policy goal, it was no alternative to healthcare services. Other aspects of social
development that had to proceed apace were the care of adolescent girls before
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Safe, healthy and happy motherhood - when will it be ensured for all women?
marriage, promotion of female literacy, employment of women in the health and
education sectors, and empowerment of women in general. It was within such a
holistic perspective of population, with sustainable development and environment
at its centre, that family planning would have an integral role to play.
In its new Action Plan for the decade, the Foundation had identified its principal
challenge as one of focusing on how to bring up to speed the 90 most backward
districts in the country, identified by the government on the basis of Census data.
All of these districts were located in the five major North Indian states of Bihar,
Odisha, MP, UP, and Rajasthan. The premise was that, ‘if this could be achieved,
most of the battle for sustainable development would have been won.’ The
Foundation also decided that as a general funding policy, higher priority would
henceforth be accorded to action-demonstration projects designed for socially
and economically backward target populations in rural and tribal areas and urban
slums, and there would be greater encouragement for projects engaging women
as active participants. Further, the approach to population stabilisation would be
one of embracing diversity, rather than follow a unilinear thinking. In other words,
projects would henceforth be geared to experimenting with a whole range of new
approaches: whether quality of care, or employment orientation, or promotion of
literacy, or maternal and child health services, or spacing methods. It was hoped
that some strategies would emerge from these as models for influencing popula-
tion dynamics.
In accordance with this policy, district level and block level experimental projects
were initiated in the five North Indian states. There were also slum-based projects
in the three major metropolises of Bombay (renamed Mumbai in 1995), Delhi
and Hyderabad. In addition, there were targeted interventions to address high-risk
mothers as a follow-up to the PFI-IDRC study to try and bring about declines in
infant mortality. A few projects were also initiated for industrial workers in the or-
ganised sector in collaboration with industrial houses in the states of UP, Himachal
Pradesh (HP), Odisha, and Rajasthan.
Mr Tata and Dr Bharat Ram renewed their efforts to get leaders of business and
industry to lend support in larger numbers to the non-governmental sector’s
partnership with the government to meet the challenges of both stabilising the
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numbers and improving the quality of the population. As pointed out by the two
leading voices of the fraternity, how much longer could captains of industry ignore
the desperate state of maternal health and vulnerability of newborns and infants
among the population groups from which industry recruited its workers. If not in
the name of philanthropy, at least in its own economic interests, industry needed
to get involved. ‘Industry and business must ponder over this grim reality’, urged
Mr Tata. “As we move nearer the one billion population mark, our options are clos-
ing. Our giant plans of expansion, modernisation, competitive exports, global ex-
cellence and the rest will unavoidably be hindered or considerably slowed down”.
And Dr Bharat Ram endorsed: “An important segment of the National Family
Planning Programme is related to the role of the organised sector in promoting
family planning. This sector includes private industry, large public undertakings
employing a workforce exceeding 30 million. If we take account
of the families which depend on industrial workers, or the general
population living in the area where industries are established, or
from where the workforce is drawn, this figure would be consid-
erably larger. Studies made by experts and institutions have pro-
vided evidence that a rupee spent on family planning services
for the workers generally translates itself into five rupees in terms
of reduced absenteeism, increased productivity, reduced burden
on health care and generally improved environment in the work-
place. Thus, these programmes are cost effective too.”
In 1995, UNFPA and PFI jointly initiated a series of three con-
secutive workshops on the broad theme of Where To From Cai-
ro? At these forums, the Foundation sought to wrestle with the
themes relating to reproductive health raised by the Cairo Con-
ference. The outcome was the policy decision reached by the
Board to support the steps taken by the Government of India to
It (PFI) urged the government
to increase allocation of
resources for population
stabilisation for a greater focus
on health and education, greater
effort in the northern states, and
a greater involvement of NGOs
and the corporate sector
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reject the target-oriented approach of the national Family Planning Programme
and shift the programme’s goal away from demographic parameters to variables
concerning reproductive health and development. Here, the Foundation’s prefer-
ence was to interpret ‘a programme centering on reproductive health’ as implying
the following elements: (i) minimum essential antenatal care; (ii) skilled care at
the time of delivery; (iii) postnatal care; (iv) immunisations; and (v) provisions of
limiting/spacing methods of contraception to the women or their spouses. All of
these were, admittedly, still within the realm of contraception, maternal health, and
child survival and not inclusive of the additional dimensions of reproductive health
spotlighted by the ICPD Programme of Action that was adopted in Cairo, most
notable of which were gender sensitive approaches to health and sexuality.
The shared silence with regard to sexuality among adolescents and adults, wheth-
er in health or disease, and the similar silence with regard to women’s reproductive
health outside of pregnancy, lactation, or the postpartum period of mothers, was
too stubborn a product of consensual cultural norms and dominant patriarchal au-
thority structures for a renamed national Family Planning Programme or its think
tank partner to confront. Given that the health system was not even performing
the minimal role of maternal health care and infant survival, and there was the ad-
ditional challenge of having to deal with a family planning programme that would
henceforth have no targets driving the system, one may argue that PFI’s limited
reading of the ‘paradigm shift’ was a fair position to take. It was also one that re-
mained true to the core philosophy of PFI.
In 1997, the Indian Family Planning Programme was formally renamed the Repro-
ductive and Child Health Programme. Its primary focus would henceforth be to
enhance the well-being of individuals and their families, rather than simply reduce
population growth by controlling fertility. Family planning, voluntary and based on
informed choice, would be an integral component of the new approach as a tool
to enable men and women to achieve their personal reproductive health goals.
What really worried programme managers about the policy shift was whether the
proclaimed ‘target-free’ nature of the new programme might completely derail
the fertility reduction gains made hitherto by the outgoing unilinear family plan-
ning approach. This was a fear shared by many in the demography and family
planning fields, including the Board of PFI. In 1997, at PFI’s inaugural J.R.D. Tata
Award ceremony for the best performing states and districts in the field of repro-
ductive health, the Chairman of the Board, Dr Bharat Ram cautioned, “We are
moving away from the mere demographic goal of reducing population growth
rates, and concentrating on improving the quality of life. But there is an inherent
danger that the immediate task of promotion of family planning and extension of
adequate services may get lost against the vast canvas (of reproductive health)
however desirable it may be…” Acknowledging the huge growth in favour of con-
traceptive use in the country, as evident from the large extent of articulated unmet
needs even in the northern states, he stressed, “…therefore, we must concentrate
on provision of good contraceptive services, counselling and creation of the im-
portance of limiting family size. This focus should not be lost sight of in the large
context of reproductive health”.
The enthusiasm for PFI’s Action Plan for the decade (referred to earlier) formu-
lated in the 1990s stayed in place. Its task would be to implement action-demon-
stration projects addressing community needs assessment. In economically and
socially backward districts and urban slums this would be done in collaboration
with local NGOs, and among workers in the organised sector, it would be in col-
laboration with industrial houses. But, accompanying the Action Plan now was a
renewed vigour that PFI put into advocacy on the need for government to keep
its eye firmly fixed on the family planning ball. It urged the government to increase
allocation of resources for population stabilisation for a greater focus on health
and education, greater effort in the northern states, and a greater involvement
of NGOs and the corporate sector. Another important advocacy issue was for
the government to continue with the freeze on the number of seats in the Lok
Sabha at the prevailing level (that was fixed on the basis of the 1971 Census and
scheduled to be lifted in the year 2000 upon achieving population stabilisation).
PFI argued that since the population had not yet stabilised, those states that were
moving ahead in fertility reduction ought not to be penalised; in fact, retaining
the freeze would act as a force to motivate the laggard states to do better. PFI
also re-launched its seminars for parliamentarians as a means of building political
commitment across party lines for population programmes. It produced a film
called People, Population and Leaders as an additional instrument to reach out
to elected representatives. An important component of these zealous advocacy
efforts was to build consensus among these elected representatives to support
the freeze on Lok Sabha seats. The global tide of opinion and particularly wom-
en’s voices, within the country and also internationally, may have swept away the
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nation’s coercive population policy and brought in the women-oriented concept
of reproductive health but, national political opinion with the power to prevail on
the day-to-day functioning of the government’s Family Planning Programme was
still lagging far behind. As Dr Bharat Ram noted in his address to the PFI Board in
1998, “Most of our elected representatives still think of population policy in terms
of family planning targets and sterilisation using coercive means. This is apparent
from private members’ bills introduced in the last session of Parliament”.
Continuing in its efforts towards population stabilisation, PFI in 1998 launched a
new annual publication titled State of India’s Population, with an accompanying
PFI now saw its own role as one of ensuring
‘the success of family planning and health
goals’ by facilitating panchayat members’
access to the ‘necessary knowledge relating
to family planning, population and
environment, nutrition, maternal and child
health, and communicable diseases’
chart on Population, Reproductive Health and Human Development that pre-
sented three indices: the Human Development Index, the Gender Related Health
Index, and the Reproductive Health Index (most of the latter two still related to
fertility). PFI’s support continued for policy-oriented studies looking at factors
responsible for population stabilisation that could yield ideas for new policy ini-
tiatives.
On the ground, the agenda that PFI identified for itself was to work out the prac-
tical aspects of experimenting with the actual design and implementation of the
community needs assessment approach that was meant to be the bedrock of the
new RCH policy, that is, the new family planning ‘targets’ would now be voluntarily
decided upon through a dialogue between local communities and health service
providers to assess the needs of the community. Here, PFI chose to work with
its NGO partners in training the newly empowered Panchayati Raj Institutions
(PRIs) in the country. In 1993, the Government of India had, through a Consti-
tutional Amendment — the 73rd Amendment — devolved power to grassroots
elected bodies to take decisions on issues relating to local development process-
es. Elected councils of panchayat members from the district to the village levels
were given the power to plan and implement programmes for health and social
and economic development of their respective areas. Naturally, many of these re-
sponsibilities related to family planning and health. PFI now saw its own role as one
of ensuring ‘the success of family planning and health goals’ by facilitating pancha-
yat members’ access to the ‘necessary knowledge relating to family planning, pop-
ulation and environment, nutrition, maternal and child health, and communicable
diseases’, as well as the skills required — leadership and motivation — to discharge
their responsibilities to their constituencies. A significant element in the Constitu-
tional Amendment was the stipulation that 30 per cent of PRI members had to
be women. PFI accordingly resolved to focus especially on these elected women
leaders. This initiative of working with PRIs would be in addition to the ongoing
work in backward areas, urban slums, and tribal and rural communities where PFI’s
grants were already supporting integrated projects on health, family planning, and
employment oriented schemes based on community needs assessment.
With funding from UNICEF, the backing of the government of the state of Hary-
ana, and in partnership with seven implementing agencies, PFI piloted the PRI
initiative in 19 districts in the state among all the three tiers of village panchayat,
block panchayat samiti, and district zilla parishad, and it included all the elected
members. The strategy was subsequently extended to seven districts in six states.
The outcome was a grant from the Ministry of Health and Family Welfare in 1998
to set up a Training Resource Development Centre (TRDC) in Delhi that would
train personnel working in NGOs in Delhi on RCH related activities, so that they
might in turn train elected representatives in the PRIs to exercise leadership in
RCH implementation. This initiative snowballed into the creation of Regional
Training and Resource Development Centres (RTRDCs) across the country in
collaboration with local NGOs with pre-existing infrastructure for training, whose
personnel then went on to train smaller NGOs in their areas on RCH issues.
Over the last years of the 1990s and into the 2000s, PFI continued to brainstorm
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internally on the best strategies for sharpening its focus on the five major North In-
The government, in 2003, largely as a result of PFI’s advocacy efforts, passed the
dian states. It also organised seminars on Population, Health and Social Develop-
91st Constitutional Amendment Bill, freezing seats in the Lok Sabha until 2026.
ment in the concerned states. These state level seminars brought together state
By that date, the population was expected to reach replacement level across the
government officials, politicians, academecians, NGOs, and media representa-
country, with the only exceptions of, perhaps, UP and Bihar. PFI now proceed-
tives, to discuss the challenges to population stabilisation faced by the concerned
ed to align its future directions and activities with the National Population Policy
state, prepare diagnostics of the prevailing population situation, and draw up ac-
2000. It would continue to work to empower PRIs, network with the government
tion agendas in collaboration with the government with the objective of speeding
and NGOs, work with states to implement their population policies, continue to
up the process of population stabilisation. The efforts bore fruit, first in UP and
develop a population database for the country, and continue advocacy efforts
then in MP followed by Uttaranchal and Jharkhand (by then separated from UP
among diverse audiences on the role of population in sustainable development
and MP, respectively), resulting in the establishment of committees charged with
and the environment. It now recruited the use of community radio and satel-
the task of drawing up population policies with clearly defined short- and long-
lite television in its work of empowering PRIs through distance education pro-
term objectives and specific programmes of action to meet them.
grammes designed for hard-to-reach districts in different states. A new action
In February 2000, the Government of India announced its National Population
Policy (NPP 2000). The immediate objective of the policy was to address the
issues of unmet need for contraception, health infrastructure and health person-
nel, and integrated service delivery for basic reproductive and child healthcare.
The medium-term objective was to bring fertility rates to replacement level by
2010 and achieve a stable population — or zero growth — by 2015. The policy
announcement was followed by the setting up of a National Commission on Pop-
ulation presided over by the Prime Minister. Along with senior members of the
Cabinet, Chief Ministers of all the states, leaders of major political parties, Mem-
bers of Parliament, academicians and NGO representatives, and four members
of the PFI Governing Board, including the Executive Director and two members
of its Advisory Council, were also invited to be part of the Commission. The Ac-
tion Plan prepared by the Commission proposed the creation of a Rs 100 crore
Population Stabilisation Fund, and an Empowered Action Group (EAG) to tackle
research-demonstration project — Total Integrated Programme of Reproduc-
tive Health, Child Health and Family Planning Services (TIP) — was launched
in collaboration with local NGOs in one district each of the five northern states.
The objective was to accelerate the pace of decline in infant mortality, maternal
mortality, and unwanted pregnancies and to create model districts that would act
as templates for the state governments and for NGOs seeking to collaborate in
the implementation of the RCH Programme as part of their own activities. It also
continued with its various publications as part of its advocacy efforts. These con-
sisted of the quarterly magazine, Focus, the publication of the annual J.R.D. Tata
Memorial Oration, and the annual handbook, State of India’s Population, with its
accompanying chart on Population, Reproductive Health and Human Develop-
ment. The newest publication commemorating the launch of the new millennium
was a scholarly book titled Population Development Nexus in India: Challenges
for the New Millennium.
the problem of persistent high population growth rates in the laggard northern
states.
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04
Widening the Scope of
Engagement: Reproductive
Health, Adolescent Health,
and HIV/AIDS
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An active ‘Hum Kuch Bhi Kar Sakte Hain’ discussion group, part of Main Kuch Bhi Kar Sakti Hoon outreach, Nawada, Bihar
Widening the Scope of Engagement:
Reproductive Health, Adolescent Health,
and HIV/AIDS
T
he decade or so from the end of the 1990s was once again years of grey as far as family planning was concerned. The
hesitant move away from a totally target-driven programme towards a limited RCH approach that was still chasing
the elusive horizontal integration of maternal and child health services could tip either way. The new thinking about
communities assessing their own needs within the framework of their elected local bodies — PRIs — was yet to find
its feet. The shift to a population stabilisation policy approach had been announced and was unravelling itself, but it
still needed to be fully and resoundingly won on the political front. Activist civil society groups, notably health NGOs
and advocates of women’s rights, were using the lens of gender rights to scrutinise policies and programmes that
impacted negatively on poor women, and the debates around these issues were occupying increasingly contested
public space. A growing volume of field-based research by doctors and social scientists was pointing to reproductive
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health problems and needs of poor women that had never before figured in any
thinking on women’s health. Further, the still uncomfortable shadowy presence of
the country’s HIV/AIDS epidemic and questions of how it might affect the popu-
lation over the long term were all up in the air.
It was a space that offered opportunities to PFI to once again innovate at the mar-
gins, and it responded by dramatically widening the scope of its engagement in the
population question. The new move, starting 2002, sought to incorporate a fuller
appreciation of the complex concept of reproductive and sexual health and rights.
Admittedly, it was a concept that was yet to be fully unpackaged for its practical
programme implications, and PFI possibly saw it as an opportune moment to sim-
ply raise awareness of the components, within both the government and the NGO
space, in the hope that it might lead on to the thoughtful absorption of some of
these components into the RCH policy. These were the elements of gender equal-
ity and rights, increased male responsibility, a life-cycle approach to reproductive
health, the sexual health and rights of women and men, and adolescent health and
development including their sexual health and rights. All of these were missing
from the prevailing RCH programmatic structure.
Also, the new global HIV/AIDS epidemic,which was driven primarily by heterosexu-
al transmission in the Indian cultural context, had its links with reproductive and child
health and with family planning. On the larger ‘population’ stage, India had already
marked a dubious presence in this epidemic as one of the world’s largest theatres
of infection, and international worries were rife about the extent of its prevalence
and its repercussions and potential to destabilise several aspects of the country’s
social and economic planning. But, in programmatic terms, HIV/AIDS had been
compartmentalised into a vertical programme under the umbrella of the Ministry of
Health and Family Welfare. And there it occupied a stigmatised corner. The many
fundamental cross-cutting issues of gender inequality and power that underlay both
family planning and HIV/AIDS were kept strictly apart, and any scope for osmosis
between the two policy spheres seemed decidedly remote.
It was by now a known fact that consistent condom use by men — inside and out-
side of marriage — was one of the surest ways to prevent HIV transmission. Con-
doms were also less problematic than IUDs, technically, where its deployment in
the Family Planning Programme was concerned. Among women, their low status
may have been preventing them from accessing information and services relating
to spacing technologies such as IUDs; by contrast, men enjoyed greater power in
sexual relations, but promoting actual condom use — as against mere distribution of
condoms — had never been an effective part of the Family Planning Programme.
As far as policy and programme interest in women was concerned, it began and
ended with their fertility and the survival of their infants and children. For protection
on the former front, sterilisation seemed to be doing the job, if only women could be
motivated to go in for it in greater numbers, particularly in the large northern states.
Although the RCH programme paid lip service to treating Sexually Transmitted
Infections (STI), there was little interest in or awareness of how to address this issue.
Given that both reproductive and sexual health were governed by the same skewed
gender regimes, women and young people and especially adolescent girls — who
were adversely placed in the prevailing gender and age hierarchy, besides their being
left illiterate and prematurely married off — were the most vulnerable. Both women
One of the first new
programmes was an advocacy
initiative relating to youth and
their vulnerability and rights
and young people were powerless to access information about sexual health even
if it was available. Young people lacked knowledge of, and access to, condoms and
to non-judgemental sexual health services and counselling. If infected with HIV, all
these groups were powerless to gain access to Anti-Retroviral Therapy (ART).
All of this meant that an evolving approach to the issue of population stabilisation
would have to go beyond the provision of just maternal health and child surviv-
al services integrated with family planning services. It would have to place family
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planning within the broader context of reproductive health and comprehensive
primary health care. It would need to design gender sensitive health services for
women throughout their life cycle, but particularly during their reproductive years,
and services that were acceptable and accessible and that observed high standards
of quality of care and confidentiality. It would need to bring men back into the
arena in gender sensitive roles, in adopting safe sexual behaviour, and in sharing
responsibility for contraception. It would also need to empower women, men, and
young people with knowledge about their bodies and sexuality and equip young
people with lifeskills to be able to exercise control over their own lives.
Lacking any policy mandate, but equally unconstrained by policy closures, PFI was
in a position to open its windows and doors a little wider. It now figured that it
needed to strategically reposition itself to organise interventions within the context
of the changing global scenario relating to advocacy, policy dialogue, research, and
piloting of new approaches. It chose to adopt advocacy as its main instrument for
the coming period and networked with a combination of familiar donors and new
NGO partners to organise seminars among government and important stake-
holders in the larger population on the multiple issues sketched out above.
One of the first new programmes was an advocacy initiative relating to youth and their
vulnerability and rights. The 2001 Census had highlighted the significance of youth in
the country’s demographic profile, which showed that they accounted for over a third
of the population. PFI took on the role of the National Secretariat of a network called
the Alliance for Young People: Towards a Healthy Future. The objective was to bring
together policymakers, NGOs, PRIs, health practitioners, media, people working with
youth, and young people themselves to formulate effective policies and programmes
concerning the future of youth in the country. In collaboration with another Delhi-based
NGO — Centre for Health and Social Justice — PFI organised 16 state-level con-
sultations across 13 states of the country, which culminated in 2004 in a national level
consultation on youth issues. The advocacy strategy was framed within the population
stabilisation framework. The consultations sought to demonstrate how issues such as
early age at marriage, high unmet need for contraception, adolescent maternal health,
vulnerability to HIV/AIDS, absence of information on STI and HIV/AIDS, and sexu-
ality education in schools and through youth groups, interacted with each other. It also
demonstrated how these, in turn, interacted with the prevailing poverty, low educational
levels, restricted career opportunities, migration, and associated social determinants to
impact negatively on young people. The objective of the advocacy was to influence
state health and youth policies to put into place informational resources and practi-
cal support systems, so that adolescents could be led towards more gender sensitive
mindsets and adopt safer behaviours and, in general, develop into healthy adults. With
support from the Packard Foundation, PFI followed this up with intensive advocacy in
the states of Bihar and Jharkhand, the two EAG states in which the Packard Founda-
tion focused its grants. The intervention led to PFI providing technical assistance to the
governments of the two states in formulating their youth policies.
The findings of the 2001 Census marked a significant moment in the country’s de-
velopment trajectory in many respects, and it offered plenty of fresh issues to fire the
Foundation’s imagination for engaging in advocacy on population issues. One of the
foremost was the issue of sex-selective abortions and the resulting declining sex ratio in
the country. The Census highlighted, as never before, the severe discrimination against
girls and women in the country. It is a discrimination that comes into play even before
birth in the form of sex-selection, continues into infancy and childhood in the neglect of
girl babies and children, and into adolescence and adulthood in the form of malnutrition
and, ultimately, results in maternal mortality. What was alarming, as brought out by the
Census, was that this discrimination seemed to be deepening. Between 1991 and 2001,
the sex ratio declined 18 points from 945 to 927, and 14 states emerged as the worst
offenders with child sex ratios below 900.
As mentioned earlier, the National Population Policy 2000 had identified the eight
North Indian states with their stubborn fertility, maternal mortality and morbidity, and
infant mortality rates as Empowered Action Group (EAG) states for focused pro-
gramme measures. In these EAG states, 327 districts were now defined as socially
and demographically backward, and PFI was already focusing on these districts in its
population stabilisation advocacy efforts. To these eight states, PFI now added the
14 states that exhibited excessively low child sex ratios and proceeded to raise aware-
ness of the problem of pre-birth elimination of females in the 122 districts across
these states that showed up with the worst child sex ratios. In collaboration with Plan
International India, PFI now launched a series of policy advocacy workshops around
the country on the theme of Missing Girls. The workshops addressed the issues of
gender discrimination, scope and content of the Pre-Natal Diagnostic Techniques
(PNDT) Act, and the need to evolve gender sensitive programme strategies. In the
14 concerned states, workshops were held at the state and district levels where, along
with local NGOs, PFI engaged with government officials, legislators, corporate enti-
ties, and members of industrial associations, academicians, NGOs and PRIs.
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The Missing Girls campaign brought back into the spot-
light the insidious Two-Child Norm that had temporarily
faded out of public attention. This was a blatantly dis-
criminatory measure against women’s fertility in the pub-
lic domain that was still in existence in multiple ways in
many states of the country even after the Emergency
and long after the Centre had announced the removal of
targets and incentives and disincentives from the Family
Planning Programme. The fact was that the targets had
been called off by only the Centre. Several states had re-
tained their family planning targets, incentives and disin-
centives, and given that health is a state subject the Cen-
tre had preferred to not overly influence the states lest
it be interpreted as an infringement on state autonomy.
In collaboration with Plan International India, PFI
launched a series of policy advocacy workshops
around the country on the theme of Missing
Girls. The workshops addressed the issues of
gender discrimination, scope and content of the
Pre-Natal Diagnostic Techniques (PNDT) Act,
and the need to evolve gender sensitive
programme strategies
A look at the Family Planning Programme during the
Emergency of 1975–1976 is required to understand its lat-
er repercussions on policy. The Emergency had brought
in the norm that families with more than two children would not be eligible to qual-
ify for over 20 centrally sponsored government welfare schemes meant for tar-
geted disadvantaged groups. In many states, the norm was also used to withhold
salary increments or job promotions, access to bank loans and educational aid, and
multiple other measures. Even after the revoking of the Emergency, these norms
had sunk into the crevices of the state level administrations and had remained
there by and large unquestioned.
In the wake of the 1991 Census, this norm of eligibility was sought to be sanctioned
within the electoral process. Purportedly inspired by the Chinese one-child policy and
meant to make role models of elected representatives, the Karunakaran Committee
proposed the norm as a pre-qualification for nomination of candidates aspiring to all
elected bodies, from the Parliament down to the PRIs. A Constitutional Amendment
to this effect was even introduced in the Rajya Sabha in 1992, but the Bill could not
gain a broad consensus in the Lok Sabha. The 1990s, as mentioned earlier, was a peri-
od of growing activism by women’s groups, and there were many demands from them
for the withdrawal of the Bill. There must have been, also, the overshadowing effect
of the ICPD Programme of Action with its global rejection of coercive population
control programmes, of which the Government of India was a signatory.
Although the Bill did not get political traction in the national Parliament, the issue
continued to rear its head every now and again. It went on to be implemented in
some states for local body elections (PRIs and urban local bodies), and, from time to
time other states seriously debated its desirability. The idea that political actors should
present themselves as role models for the small family norm was one that enjoyed
support in several quarters, including the Supreme Court and the Board of PFI. By the
early 2000s, when PFI was conducting its advocacy campaign against the practice of
female foeticide, findings from the field were beginning to suggest that women po-
litical aspirants from the more socially and economically disadvantaged social groups
were being effectively kept out of PRI bodies by rivals, since such women were also
more likely to have not benefited from access to contraceptive and health services
and, therefore, more likely to have more than two children. More worrying was the
growing evidence that the whole host of less visible but equally pernicious micro ‘wel-
fare’ spaces at the state level into which the Two-Child Norm had comfortably settled
itself following the Emergency, were further fuelling the already intensifying practice of
female foeticide and female discrimination in general. Therefore, PFI now integrated
the Two-Child Norm into its Missing Girls advocacy campaigns at the state level.
Through its flurry of advocacy efforts directed at parliamentarians and state legisla-
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tors, it tried to stave off more states — beyond the original six — from adopting the
Two-Child Norm as a pre-qualification for their local body elections.
Simultaneously, it sought to integrate the gender rights issue into the ‘population ques-
tion’ in its awareness raising efforts directed towards elected representatives and other
stakeholders at the state level. The advocacy campaign explained how the root of the
problem of population growth in the country lay not in women’s fertility per se, but in
women’s disadvantaged position that denied them control over their fertility, access to
education, food and nutrition, healthcare, and employment and other productive op-
portunities. That the rate of population growth was in fact declining was evident in the
successive censuses since 1981. But, the rate of decline was necessarily slow because
of the higher percentage of the population in the reproductive age group. There was
Health and Family Welfare and UNFPA, PFI launched three strategic advocacy
interventions to promote a favourable environment for the implementation of the
NPP 2000 and Country Programme 6 (a UNFPA initiative). The first workshop on
Policy Advocacy was a national consultation called ICPD+10: NGO Perspectives.
The objective was to assess achievements, identify challenges, constraints, and op-
portunities, formulate lessons learnt from implementing the ICPD Programme of
Action, and suggest corrective strategies for the next 10 years. The second was a
more issue-focused workshop on advocacy measures for building an environment
of support for Quality of Care, something that was emerging as a critical pro-
gramme issue. The third workshop focused on ways to involve and build the capac-
ity of NGOs in promoting issue-based advocacy initiatives through small grants.
The root of the problem of population growth in the country lay not
in women’s fertility per se, but in women’s disadvantaged
position that denied them control over their fertility, access to
education, food and nutrition, healthcare, and employment
and other productive opportunities
also clear evidence that women across the country wished to have fewer children.
But, they had little power to change the situation of early marriage, early and closely
spaced pregnancies, pressure to have sons, lack of access to contraception, lack of
involvement of men in contraception, and persistently high infant mortality rates.
The findings of the 2001 Census, coming close on the heels of the NPP 2000 and
the initial policy changes set off by the ICPD Programme of Action, spurred other
PFI-led advocacy initiatives as well. In 2004, in collaboration with the Ministry of
Other consultations followed that served to carry the above agenda forward. A na-
tional consultation was held on the theme of Laws, Policies and Rights in the Context
of Reproductive Health, where, among other issues, the Two-Child Norm, the MTP
Act, and the PNDT Act were discussed. An exercise in Perspective Building on ICPD
and NPP 2000 was launched thereafter with support from the Packard Foundation.
The objective was to build the perspective of key stakeholders — the judiciary, media,
bureaucrats, elected representatives, corporate houses, NGOs — towards influencing
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Releasing key documents on Community Action for Health
policies and programmes, both at the national level and in the two EAG states of Bi-
har and Jharkhand. This initiative entailed organising seminars, developing reference
materials, and identifying partner organisations and key resource persons to engage
with the stakeholders on issues relating to population and development. The issues
covered safe abortion, contraceptive choice, maternal mortality and safe motherhood,
reproductive and child health. PFI also conducted seminars on the theme of reproduc-
tive health and rights at the Lal Bahadur Shastri National Academy of Adminitration in
Mussourie for entrants into the Indian Administrative and Allied Services to sensitise
young bureaucrats who were on the brink of going on to implement diverse govern-
ment policies and programmes.
Advocacy, thus, remained the most visible of PFI’s activities during the first decade
of 2000. Simultaneously, the previously established agendas continued, particularly
of working with state governments to formulate population policies based on a diag-
nosis of the state situation. In Odisha, PFI organised a conference on Population and
Development for the state government; the outcome was an offer of technical as-
sistance to the state to formulate a population policy. In states where PFI had earlier
held conferences on population stabilisation and where some responses had resulted
in the form of state level policy initiatives, it now followed up the momentum with
district level conferences. These were primarily in the worst performing districts and
accompanied by a presentation of district-level diagnostics, with a view to formulate
focused action agendas closer to the grassroots. Local NGOs were engaged in these
exercises, as also bureaucrats, legislators, PRI representatives, doctors and members
of medical associations, academicians, corporate houses, and representatives of UN
and other international donor agencies. In Bihar, for instance, the state level confer-
ence on Population and Development was followed up with a similar conference in
the district of Kishanganj, the second-most notoriously backward district in the coun-
try. Together, these efforts resulted in the establishment of a standing Task Force for
the state to follow up on the recommendations generated, and a special PFI advisor
came to be appointed for the states of Bihar and Jharkhand. The government of
Chhattisgarh, where PFI had already held a state level conference on Population
Stabilisation, Health and Social Development, now followed up with a request to
help draft an integrated health and population policy for the state.
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Frontline health worker with the beneficiary at a health camp in Tamil Nadu
In 2003, the Government of India sanctioned an ambitious project that gave PFI a
key role in actually implementing Phase Two of the RCH Programme in Bihar and
Chhattisgarh. As the Regional Resource Centre for these two states, it was expect-
ed to bring about closer linkages between the respective state governments and
NGOs at the district and state levels, provide technical assistance to the NGOs,
that is, build their capabilities for implementation of the RCH Programme, and
thereby bring about an enhancement in the quality of services, provide coordina-
tion support to both NGOs and government for implementing and monitoring
the programme, and generally provide inputs to the government to enable policy
modifications.
The fact remained, however, that outside of the problematic EAG states, there
were other states that had done better on the population front and had even suc-
ceeded in achieving replacement levels. As part of this line of thinking, PFI initiated
a study on the causes of fertility decline in Andhra Pradesh, yet another southern
state. A national conference on Population, Health and Social Development: Ex-
periences from Southern States followed soon thereafter in 2007, with the objec-
tive of gleaning a clearer perspective on the demographic and health transition
process in the four southern states and for extracting lessons for the northern
states. The key lesson that emerged was that focusing on fertility reduction alone
did not necessarily lead to improvement in the health status of women and chil-
dren; the quality of healthcare and of maternal care in particular was critical to
population stabilisation.
In addition to all of the above described advocacy initiatives, grantmaking by PFI
continued, as in years gone by, towards support of NGO-led field-level projects,
for which the preference was for projects located in the slow moving EAG states.
Efforts also continued towards capacity building of small NGOs through the
RTRDCs. PFI’s collaboration on projects run by industrial groups/associations also
continued. The expression of a new interest by corporate groups in undertaking
Corporate Social Responsibility (CSR) projects led to PFI’s setting up of a special
cell within PFI to provide guidelines to corporate houses interested in initiating
programmes on issues of RCH and for proposal development, capacity building,
strategic planning, and monitoring mechanisms.
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It would be in order to include here a brief mention of an initiative that was a first
— and last — for PFI. This was an HIV/AIDS Care and Support implementation
project in the six high prevalence states of Tamil Nadu, Andhra Pradesh, Karnataka,
Maharashtra, Manipur, and Nagaland and, specifically, in those districts that had
the highest prevalence of the infection. This was a grant that PFI received in 2003-
2004 from the Global Fund to Fight AIDS, Tuberculosis and Malaria to implement
a five-year project for the Care and Support of People Living With HIV. PFI won
the grant as the lead NGO of a five-member NGO consortium (of which one of
the members was the Indian Network for People Living with HIV/AIDS). The only
other recipient agency in the country for a similar grant was the Government of In-
dia. The project involved rolling out ART in 50 tertiary institutions and 138 district
hospitals. This required setting up treatment-counselling centres, positive living
centres, district level networks, and comprehensive care and support services. It
also included taking responsibility for treatment adherence, nutrition, psychosocial
support, palliative care, and building the capacity of all the components of the proj-
ect to provide care and support.
The project certainly bridged PFI’s traditional agenda with another important re-
lated issue. It gave the Foundation an opportunity to address the survival needs of
some of the most stigmatised sections of the country’s population. It strengthened
PFI’s identity as a desirable partner for the government. Additionally, it brought
about a quantum leap in PFI’s financial base — the grant amounted to Rs 90 crores
over five years — and PFI increased its staff size exponentially. But, the specif-
ic nature of the project was too far removed from the core competencies of the
Foundation to advance the thrust of the organisation. Further, there was little poli-
cy congruence between the national RCH Programme, to which PFI was aligned,
and the HIV/AIDS Programme that functioned as a separate vertical programme.
When at the final stages of the HIV/AIDS project, unresolvable conflicts devel-
oped between one of the constituent NGOs and the donor agency, it seemed to
be a signal to PFI to gracefully conclude its practical engagement in an area where
it had worked to establish its importance through its advocacy efforts and also with
a programme that it had steered to the best of its ability. It had also successfully
cut its teeth on a new mode of international funding, where it had to learn how to
bring together and lead a consortium of collaborating agencies. It was a skill that
would stand it in good stead in a sphere of work soon to follow, namely, the Health
of the Urban Poor.
In 2005-2006, a new policy shift presented PFI with the opportunity to work with
the government to recast the RCH Programme itself, albeit in a totally unprece-
dented direction. The Government of India created a new policy instrument, the
National Rural Health Mission (NRHM). The objective of the NRHM was to im-
prove health service delivery in the rural and tribal areas of the eight EAG states,
and also the eight northeastern states, and the states of Himachal Pradesh and
Jammu and Kashmir, by bringing all disparately working health services under a
single umbrella and providing universal access to affordable, equitable, and quality
health care in ways that were both accountable and responsive to people’s needs,
particularly of the most marginalised groups. The RCH programme, whose key
objectives were to bring down maternal and child deaths and bring about pop-
ulation stabilisation and gender and demographic balance, now came to be sub-
sumed under it.
PFI won the Global Fund to Fight AIDS,
Tuberculosis and Malaria grant as the lead NGO
of a five-member NGO consortium. The only
other recipient agency in the country for a similar
grant was the Government of India. The project
involved rolling out anti-retroviral therapy in 50
tertiary institutions and 138 district hospitals
The NRHM came into existence on the basis of the realisation, from the accu-
mulating evidence of the Census 2001, the National Family Health Surveys, and
the Sample Registration System, that despite overall declines in population growth
rates, there was a serious stumbling block to the population stabilisation project in
the form of stubbornly high rates of maternal mortality and morbidity, infant and
child mortality, and under-five malnutrition. Adding to this was the fact that the
bulk of the maternal mortality and morbidity, and infant deaths were occurring in
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the EAG states. Also, a substantial proportion of these maternal deaths were oc-
curring among malnourished married adolescent girls in the age group 15–19 years.
Owing to their age and nutritional status, these adolescents suffered the highest
incidence of complications during pregnancy, birth, and the postpartum period,
which resulted in pregnancy loss, stillbirths, and the births of low birthweight and
highly vulnerable infants. The neglect in these states of the public health system
with regard to financial allocations and ensuring reach, quality, effectiveness, and
affordability for those who most needed it had, over the decades, left the health
services severely compromised. The result was the alienation and exclusion of the
vast masses of the poor, particularly the women and children in their midst, from
essential life-saving services.
The bulk of impact of any future work relating to population stabilisation, therefore,
district and state level need-based plans. It was also imperative to build capacity
at all levels — district, state, and Centre — to ensure improved programme imple-
mentation, especially the strengthening of financial management systems and of
monitoring and evaluation capabilities. The intended nodal NRHM agencies at
the state level to steer the whole process were State Health Systems Resource
Centres (SHSRC) or State Health Societies, as the case might be (and District
Health Societies wherever possible).
The enactment of the 73rd Amendment that democratised decision-making at the
panchayat level had thrown the ball into the court at the district and village levels,
and it expected communities to simply run with it. The NRHM now offered a con-
crete framework for this process to work within the context of the health services.
Village Health, Sanitation and Nutrition Committees (VHSNCs) at the village
At the request of the Ministry, PFI took on the role of
Secretariat of the AGCA. Its brief was to act as an interface between
the government and NGO leaders, provide technical assistance to
the agencies directly engaged in the communitisation process itself
and engage in advocacy with the governments of the states
had to accept the primacy of the health services, and it had to happen at the level
of states. To strengthen state-run health services, it was imperative to build state
level ownership of policies and programmes. States would have to be involved
from the outset in the development of programmes, and these programmes need-
ed to be decentralised right down to the district level through the development of
level and Rogi Kalyan Samitis (RKSs) at the health facility levels of the Primary
Health Centre, Community Health Centre, and District Hospital would be the
new instruments. They would consist of representatives of PRIs and civil society
organisations, such as self-help groups, and also include local communities in the
planning and monitoring of the health programmes meant for them. The planning
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would take into cognisance the issues of need, coverage, access, quality, effective-
ness, behaviour and presence of healthcare personnel at service points, negligence,
and possible denial of care. The monitoring process was intended to cover out-
reach services, public health facilities, as well as the referral system. The essential
objective of this policy instrument was to design services that were appropriate to
the needs of the users as also accountable to them for the quality of performance.
Both elements had never before been even remotely considered in the design of
services meant for disadvantaged social groups. There was also a provision under
the NRHM for monitoring bodies at the village level and health facility level to
have access to ‘untied funds’; these funds were for them to proactively use as they
saw fit to make small improvements in the prevailing health related infrastructural
conditions at their respective levels. The NRHM also earmarked five per cent of its
budget for the continuous evaluation of the efficacy of this mechanism.
To give shape to and guide the implementation of the community participation
process and public accountability component, the NRHM created a statutory Ad-
visory Group for Community Action (AGCA). The Advisory Group consisted
of NGO leaders who had proven records of service to communities in remote
areas and whose contributions included developing low-cost and effective models
of healthcare that called for community mobilisation. The brief of these NGO
leaders, acting in their individual capacity, was to assist the Ministry of Health and
Family Welfare in thinking through ways of strengthening the capacity of commu-
nities to participate in monitoring their own health needs in dialogue with public
providers. At the request of the Ministry, PFI took on the role of the Secretariat
of the AGCA. Its brief was to act as an interface between the government and
NGO leaders, provide technical assistance to the agencies directly engaged in
the communitisation process itself (the community level agencies, collaborating
NGOs, as also the state level NRHM agencies), and engage in advocacy with
the governments of the states, for which this was going to be a whole new level of
engagement.
The challenge before PFI/AGCA was that this component of Community Based
Monitoring could not conceivably be made to happen by diktat from the Centre. It
had to happen on the ground in collaboration with the health services in the states.
The advocacy, therefore, was required to be done at the state and district levels. It
also required PFI/AGCA to engage in a complex process of learning by doing on
how to operationalise the process of community participation in each state and its
districts. This necessitated their finding and building partnerships with locally active
NGOs/community-based organisations/self-help groups on the ground, getting
the involvement of PRI representatives, and setting up, training, and initiating the
working of the designated citizens’ committees through which communities would
become aware of their entitlements and begin to participate in shaping their own
health environments. A significant part of the preparatory learning also entailed
understanding how to adapt to the successful public system micro-level NGO
models of community-based health interventions that had been evolved to re-
spond to the needs of remote unserved rural and tribal areas.
The window offered by the NRHM for the public system to learn from the NGO
sector about how to bring about community participation and possibly to ab-
sorb some of these NGO innovations seemed unprecedented. The new aper-
tures created by the policy shift already had major donors in the health sector,
such as USAID and the Bill and Melinda Gates Foundation, which were explor-
ing solutions that could be scaled up for wider impact. ‘Sure Start’ (an initiative
funded by the Gates Foundation and implemented by PATH in UP and Ma-
harashtra) and ‘Vistaar’ (funded by USAID and implemented by Intrahealth in
UP and Jharkhand) were examples of such efforts at scaling up. Also, since the
early years of the new millennium, the international policy environment had begun
heating up — yet again — on population issues. The UN Millennium Development
Goals (MDGs) of 2000 kept up steady pressure on member countries to meet by
the year 2015, time-bound and quantified targets for addressing extreme poverty
in its many dimensions (hunger, disease, lack of adequate shelter and exclusion),
while promoting gender equality, education and environmental sustainability. Goal
numbers 4 and 5 of the MDGs is related to infants and children, and mothers. They
specified under-five mortality, maternal mortality ratio, proportion of births attend-
ed by skilled health personnel, immunisation of infants and children, and univer-
sal reproductive health coverage (unmet need for family planning, contraceptive
prevalence rate, antenatal care coverage and adolescent birth rate). International
pressure was thus mounting on the Government of India to demonstrate large-
scale impact of its policies.
Supported by the MacArthur Foundation, PFI launched on an intensive
period of learning the skills of scaling up management (SUM). One of MacArthur
Foundation’s American grantees — a private consulting firm Management Sys-
tems International (MSI) — had prodigious expertise in the area of scaling up with
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governments and corporate structures, besides NGOs, in over 40 countries. They
now came to India to spearhead the process, using their ‘three-step, ten-task’ Scal-
ing Up Management Framework. Until recent years, the need for methodologies
(and frameworks) for scaling up micro-level NGO innovations into public systems
had never really received serious analytical consideration, either by policymakers,
donors, or researchers. The simple assumption was that any worthwhile innova-
tion would, as a natural process, go on to be adopted by larger systems. But the
evidence building up was that governments and non-governmental organisations
stayed within their own circumscribed worlds.
Among the preconditions in the SUM Framework were a receptive policy climate;
knowledge and capacity to manage the change on the part of both originating
and implementing organisations evidence gathering, including evaluation of
what works where and why, costs, and cost-effectiveness; political buy-in; and ev-
idence-based advocacy. An important additional precondition was the presence of
an intermediary agency that would bring together the originating and implement-
ing agency and help to steer the scaling-up process. PFI, as a national-level NGO
based in Delhi, with the reputation of an advocacy agency that was familiar with
government processes and that enjoyed a good rapport with the NGO sector,
seemed the ideal intermediary in the making. With the right support, its role could
be to support design and implementation; identify and address gaps in motivation,
skills, and resources (technical, managerial, documentation, organisational devel-
opment); carry out monitoring and evaluation; and conduct advocacy.
PFI’s work in the first phase consisted of learning the above SUM skills, while work-
ing with MSI and then going on to work with some of its own promising grantees
in the second phase with technical assistance from MSI. The MacArthur Foun-
dation, dedicated to supporting solutions in the area of maternal and adolescent
health, was already supporting some of the most innovative Indian NGOs working
in these fields, which had evolved interventions that had been documented and
tested, with their replicability demonstrated under controlled conditions and sub-
mitted for international scientific scrutiny. Admittedly, scaling up all of these tightly
packaged innovations could not be expected to be an easy or simple exercise, their
technical components were supported by process-intensive and horizontally inte-
grated structures, with the intangible elements of community trust and values of
dignity and respect and gender sensitivity at their core. Led by dedicated figures,
who tended to be uncompromisingly purist in their strategies, the innovations pre-
sented difficulties in adapting them to large-scale applications with the inevitable
dilution — and distortions — that it implied. Nevertheless, it was a challenge well
worth taking on.
PFI and MSI worked with several promising models that met the scaleability as-
sessment criteria and provided need-based support in systematically planning and
scaling them. These included: Home-Based Neo-Natal Care (Society for Educa-
tion, Action and Research in Health [SEARCH], Maharashtra), Increasing Age
of First Conception/Child Spacing (the Institute of Health Management, Pachod
[IHMP], Maharashtra), Community-Based Health Insurance (Self Employed
Women’s Association [SEWA], Gujarat), NGO Management of Public Primary
Health Care (Karuna Trust [KT], Karnataka), Training of District Medical Officers
in Emergency Obstetric Care (The Federation of Obstetric and Gynaecological
Societies of India [FOGSI]), Improving Maternal Health through Improving De-
centralised Governance (Community Healthcare Management Initiative [CHMI],
West Bengal), and Community Based Planning and Monitoring (Advisory Group
for Community Action [AGCA]). In addition, PFI went on to develop a Mono-
graph on Adolescent Reproductive and Sexual Health Programmes in India and
another one on Community Action for Health: Experiences, Learnings and Chal-
lenges.
The scaling-up framework identifies seven key challenges to scaling up to a large
system, The first is building the capabilities and skills of the adapting institution.
Another is sustainability, which is the ability to persist despite frequent changes
in officials, angularities of individual personalities, etc. Building coalitions through
different approaches, resources and incentives comes third. A fourth is a commit-
ment to advocacy/engagement over a long time frame and advocacy at several
implementing levels and across many stakeholders. A commitment to conver-
gence of different technical competencies, mandates and agendas, hierarchies of
knowledge and skills, and power politics is yet another. A sixth key challenge is
working out the sticky issues of who owns and controls the process. And, finally,
there is the implementation process itself, which entails adapting the model to di-
verse institutional and social settings, maintaining quality of services at scale, and
equity, that is, reaching poor marginalised groups and rural areas.
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The framework is clear on the importance of clarity with relation to all of the above
One of the most significant lessons that PFI learnt from the experience was that
challenges for the success of an intervention. Is the intervention to be a pilot, a
among the key bottlenecks in rapid and effective scaling up of innovations into the
demonstration, a capacity-building project, or a campaign? Is scaling up integrated
Indian public healthcare system, is the lack of a scaling-up strategy, poor knowledge
into the design of the pilot project itself? Has the model been refined and simpli-
management, and little attention to technology transfer and capacity building. The
fied to the extent possible? Has financing been built in for all three steps of prepa-
fundamental principle of scaling up is that it is a systematic process that requires
ration and planning, legitimation and advocacy, and implementation? Are funders
multiple skills and close partnerships between multiple actors and institutions from
being taken into confidence on what is involved at every stage? Has legitimation
civil society and government.
and constituency building begun early? Has a sound monitoring and evaluation
plan been instituted? Has the ownership of the scaling-up process been clarified?
Is there willingness for a long-term commitment?
....
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05
Recasting Institutional
Identity, Renegotiating
the Population Question:
Women’s Empowerment
and Rights
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Discussion using Main Kuch Bhi Kar Sakti Hoon BCC materials, Bhopal, Madhya Pradesh
Recasting Institutional Identity,
Renegotiating the Population Question:
Women’s Empowerment and Rights
A
s PFI stood poised, just a decade short of the half-century mark of its existence, it seemed that while a foreseeable
future of positive contours in the national and international policy landscape lay ahead, holding out both possibilities
and constraints, there were also crucial unfinished agendas from the past that had not yet been frontally addressed and
resolved in an effective way.
The country, at the time of Independence, had begun its project of national reconstruction, while, at the same time,
trying to craft a holistic policy approach to enhance the quality of life of the Indian population. This had quickly shifted
to a unilinear agenda of population control with grave repercussions that took the country decades to shake off. The
harshness of the sterilisation policy had gradually yielded to a concern for maternal health as a more sustainable route to
fertility control. Finally, the wheel seemed to be coming full circle with the policy move to strengthen the health services
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as a whole in the most disadvan-
taged regions of the country and
make the government account-
able to the most disadvantaged
sections of the population.
However, in the country’s over 60-
year long journey of engagement
with the population issue, women
as agents in their own right, that
The year 2010 marked the formal beginning of the ongoing
phase in PFI’s institutional evolution and growth. It started
off with the Foundation making a conscious shift towards a
stronger rights-based, people-centric, gender sensitive, and
sustainable approach to development
is, their right to autonomy and to
well-being, free from the crushing
weight of patriarchal cultural and
social norms, had simply fallen
through the cracks. The overshad-
owing effect of the Family Plan-
ning Programme ideology had rendered them into little more than troubling statis-
tics: their fertility requiring manipulation in the service of national and international
demographic objectives, their fallopian tubes destined for assembly-line sterilisation
at the hands of uncaring health services, their maternal lives needing to be saved
from death as they themselves strived to fulfil patriarchal family-completion goals.
Some of the building blocks for this phase had begun to be assembled during the
immediately preceding years. A broad commitment to reproductive and sexual
health and rights of women and adolescents and to improving the quality of ma-
ternal and child health care as an integral component of population stabilisation
was one. Vigorous advocacy as the principal strategy to advance this agenda was
The year 2010 marked the formal beginning of the ongoing phase in PFI’s insti-
tutional evolution and growth. It started off with the Foundation making a con-
scious shift towards a stronger rights-based, people-centric, gender sensitive, and
another. Further, with the new role of the Foundation as an officially designated
bridge between civil society and the government, a beginning had been made in
integrating civil society into health policies and programmes.
sustainable approach to development. With this shift, PFI proceeded to recast its
identity as a national level think tank in the field of population, health, and develop-
ment, one whose central goal was a commitment to women’s empowerment with-
in a rights framework. With this as the lens through which to concentrate its work
and programmes for maximum synergy and impact, PFI launched on an exercise
of sharpening its vision and focus, crafting a strategic plan that would be regularly
subjected to internal scrutiny and review, identifying priority areas for the next phase
of its work. The tools would be a combination of research and advocacy on the
interlinked issues of family planning, social determinants of health, gender equality,
and women’s empowerment. And the objective would be to create an enabling
environment for policy debate and for catalysing the reformulation of policies and
programmes within a women’s empowerment and human rights framework.
With the start of the new phase, the framework of population stabilization came to
be redefined and more sharply etched. Reproductive and Child Health and Ado-
lescent Reproductive and Sexual Health would from now on be seen as the rights of
women and adolescents and marginalised groups in rural and urban areas to have
access to reproductive and sexual health care that consists of quality maternal and
child health services and family planning services within an enabling environment
marked by safety, full information and the right to choice.
The experimentation and learning from the Scaling Up Management (SUM)
Framework, with the exciting possibilities that it offered for large scale impact of
micro-level innovations, resulted in two outcomes. These outcomes related to the
Foundation’s positioning within the national scene and its own organisational vision.
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The Foundation launched on a major dissemination programme that took the
SUM Framework well beyond the NGO domain. Starting in 2010, and with the
grant from MacArthur Foundation still facilitating its work, the PFI offered train-
ing programmes across the country. It responded to requests from organisations
ranging from national institutions like the Planning Commission to international
agencies like the World Bank, offering a series of workshops to share the SUM
Framework with a wide spectrum of receptive organisations to facilitate skills
for them to enhance the effectiveness and reach of their work. In this manner, it
reached across to the wider development community, including educational and
social work institutions and health policy research organisations such as the Tata In-
stitute of Social Sciences, the Public Health Foundation of India, the Public Health
Resource Network; donor agencies such as the UNDP, DFID, UNICEF, and the
World Bank; and senior professionals in government agencies such as the Planning
Commission and the National Innovation Mission. Recognition was growing that
the SUM Framework was relevant across all fields of development activity and not
just for health. SUM was a potent tool to bring creative ideas from the periphery
into the mainstream. In 2010, with support from the Planning Commission, PFI
organised a National Conference on Scaling Up to share experiences from health
and other sectors and to develop the vision and strategy for scaling up social sector
programmes in the country.
It also went on to absorb the SUM Framework tools into its own organisational struc-
ture as a guiding principle for its future agenda and grant-making activities. Hitherto,
PFI’s strategy had been one of trying to mostly remain within the confines of the role
of an outsider partner to the government. It had stayed close to the parameters of
government policies and programmes without overly involving itself in actual imple-
mentation. This strategy now changed to working with the government as potential
implementer along with a range of partners — NGOs, other private and public in-
dividuals and agencies with complementary skills, and donors. This entailed various
stages: from the inception of an idea to working out feasible innovations/structures
and testing them, developing the associated skills for their application, and bringing
the whole to the public system for implementation.
In tandem with the above change, PFI fine-tuned its style of engagement to one
of proactive negotiation and collaboration with the government, accompanied by
evidence-based advocacy that was grounded in research. With the central, state, and
local government institutions, this took the form of technical assistance for effective
policy formulation, planning, and implementation. With the mass media — both print
and electronic — it was with a view to keep public debate well informed through
reportage and analysis as well as to bring about large-scale behavioural change over
time. With communities and intermediary agencies — elected local bodies, self-
help groups, NGOs — it was for mobilising people’s participation at the grassroots
to increase the efficacy and accountability of the public health services. And, in the
international sphere — with multilateral and bilateral agencies, philanthropies, and
pressure groups in the field of family planning — it was to help reorient funding pri-
orities in favour of family planning as an instrument to promote women’s health and
well-being, rather than as a technological fix to deal with global demographic and en-
vironmental sustainability concerns. Advocacy was accompanied by the production
of imaginatively designed infographs and other printed materials that succinctly and
strategically conveyed findings/information/messages to diverse audiences.
The sharpening of thematic priorities, strategies, approaches and activities was set
off and shaped by two carefully planned organisational interventions. One was a
programme of organisational transformation. The other consisted of developing a
strategic work plan.
The objective of the organisational transformation exercise that began in 2011 was to
transform the work culture of an organisation that was nearly half a century old to be
able to develop its capability to meet the challenges of working within the redefined
goals and recast focus. It was also to build its capability to continuously renegotiate
its strategies and gain leverage within a national and international environment of
rapidly changing policy and political landscapes and shrinking financial resources.
The assumption was that this retooling would put PFI on the road to becoming a
critical voice — nationally and internationally — in the population and sustainable
development debate.
This transformation, steered by a private management consulting firm and support-
ed by one of PFI’s long-term donor partners — the Packard Foundation — entailed
several internal changes, notably, ‘bringing in clarity in roles and responsibilities, effi-
cient functional unit structures, focused and streamlined information flow, and better
and sharp attention to coordination and team work’. In other words, it meant getting
the entire staff to understand and internalise the core vision and purpose of the or-
ganisation; bringing all the departments and programmes together in alignment with
this vision and, therefore, with each other; and creating clear lines of authority and
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The (strategic) plan identified
six key priority areas: delaying
age at marriage; promoting
spacing between births;
improving quality of care of
family planning and
reproductive health
programmes; preventing sex
selection; and promoting
non-coercive practices,
programmes and policies
accountability and building leadership capabilities across the organisation. The first
phase of this transformation was concluded in 2012, followed by a second phase that
was consolidated in 2014. It was recognised that this needed to be an ongoing process.
The strategic planning exercise that happened coterminously with the organisational
transformation was carried out with the objective of preparing a guide for the strat-
egies and activities over the five-year period, 2011–2016. The plan identified six key
priority areas: delaying age at marriage; promoting spacing between births; improving
quality of care of family planning and reproductive health programmes; preventing
sex selection; and promoting non-coercive practices, programmes and policies. All of
these had been identified and recognised from time to time, over the years, by study
findings and policy statements, but no cogent interconnected pathways had been
conceived or put in place to address them in definitive ways. By repositioning family
planning and recasting maternal and child health policies and programmes within a
women’s empowerment and human rights framework in national development, PFI
intended to achieve long-term outcomes for these clearly identified and vitally inter-
related priority areas and thus returned to its original core agenda — this time with the
objective of completing it.
Henceforth PFI research, capacity building, advocacy and scaling-up strategies
would all be directed towards achieving the proposed long-term outcomes. In
2013, PFI revisited the strategic plan with a view to reflect, review, and revise, its
vision, mission, and goals and to consolidate the key thematic areas, strategic pri-
orities, and critical strategies. The review exercise also afforded an opportunity to
reinforce the internalisation of the rights perspective within the organisation. The
revised five-year strategic plan (2016–2020) — with the original six priority areas
intact — currently guides PFI’s activities.
Repositioning Family Planning: PFI made ‘Repositioning Family Planning’ an
important thematic area for its work early in this phase. It took the stance that
the time had come to move away from the long-held view of family planning as
a means to control population growth rates in poor countries and redefine the
family planning approach as a means of reaching quality birth control information
and services to all women and men — and adolescents — in developing countries.
This would enable people to voluntarily, with full knowledge, and as an exercise of
conscious choice decide whether to have children, when to have them, and how
many to have in the course of their reproductive lives. Seen thus, family planning-
becomes a means of achieving women’s health and well-being as well as family
well-being and a means where birth control becomes a reproductive right. Such a
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PFI conducted a thorough analysis of the available
evidence from India and across the world on
effective interventions among disadvantaged
communities relating to delaying age at marriage,
delaying age at first pregnancy, promoting spacing
between births, and improving the quality of
family planning services
But what did this really mean in concrete terms at the
level of operation of the family planning programme it-
self? Were women who were accessing the public health
system given full information about various birth control
options and guided in making the right choice for them-
selves? Were adolescents receiving information about
and access to contraceptives? PFI conducted a thorough
analysis of the available evidence from India and across the
world on effective interventions among disadvantaged
communities relating to delaying age at marriage, delaying
age at first pregnancy, promoting spacing between births,
and improving the quality of family planning services. It
resulted in a report: Repositioning Family Planning: A Re-
view of Evidence on Effective Interventions.
view of reproductive rights also aligns with the rights of adolescents — including
unmarried adolescents — to have access to contraception as a means to both pre-
vent conception and afford protection from sexually transmitted infections. Sim-
ilarly, reproductive rights align with child rights, that is, the right of children to be
born wanted to mothers who are fully able to give them a good start for achieving
their full potential and extending their capabilities.
The background to the ‘Repositioning of Family Planning’ agenda lay in a multilat-
eral initiative, dating back to the early years of 2000, to increase political commit-
ment and funding for family planning services in sub-Saharan Africa. At a summit
on Family Planning held in London nearly ten years later in 2012, a broad global
consensus for this approach was brought together across multiple stakeholders:
national governments, the donor community and civil society. India was represent-
ed at this consensus.
Within India itself, the Indian National Population Policy 2000 had already reaf-
firmed the government’s commitment to keeping the family planning component
of the RCH Programme based on voluntary and informed choice and to address-
ing the unmet need for spacing and limiting births. Following this, in 2010, at a Na-
tional Consultation on the Repositioning of Family Planning held by the Ministry of
Health and Family Welfare, the stated government position on family planning was
to place it within the population stabilisation framework and highlight the centrality
of improving maternal and child health as a means of reducing fertility.
All assessments seemed to point to the picture, in India,
of an unreformed national Family Planning Programme, whose dark underbelly was
still sustained by the engine of sterilisation and quantitative targets. This situation
persisted, notwithstanding the Government of India’s 1997 policy announcement of
a ‘target-free’ programme, the subsequent change in nomenclature to Reproductive
and Child Health (RCH) Programme, and the rhetoric of the reproductive health
movement. Nor had the most recent policy goals as outlined by the National Popu-
lation Policy 2000 been mainstreamed into the programme. Health personnel were
neither sufficiently aware of, nor skilled, in dealing with non-terminal spacing meth-
ods. Nor indeed was there any clarity about how communities — women, men, mar-
ried adolescent couples — may be reached and made to feel comfortable with infor-
mation regarding spacing, given the huge cultural pressure on young married women
to quickly follow up their marriage with their first pregnancy. The effectiveness of
the ‘community needs assessment’ approach that was meant to replace quantified
targets for contraception acceptance showed poor outcomes. It seemed that pol-
icy and programme priorities continued to highlight the importance of maternal
and child health services, but the overwhelming focus was on preventing maternal
deaths rather than promoting family planning for delaying and spacing pregnancies.
Even preventing maternal deaths was being translated into a new set of quantitative
targets: that of demonstrating increasing numbers of institutional births, rather than
improving the quality of the services themselves.
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PFI argued that population stabilisation had already been reached in nine
states in the country. However, low fertility was yet to result in improved ma-
ternal health, because the situation of early marriage and childbearing and
closely spaced births remained unchanged. Also, while steep reductions in
fertility had indeed been achieved in several states, for example, in Andhra
Pradesh, they had been at a huge cost to women’s health, given the absence
of quality health services and the undue reliance on sterilisation camps. While
in the earlier era the high sterilisation figures were due to coercive targets,
there was no evidence that the removal of targets had resulted in correspond-
ing improvements in quality of care. In such states, therefore, as PFI argued,
‘repositioning family planning as a health and development issue’ could contrib-
ute to designing programmes that addressed women’s other reproductive health
needs alongside fertility control.
The other associated question was that of ‘population momentum’ and its role in
contributing to continuing population growth in the country despite overall de-
clines. PFI argued that the root cause of population momentum was the persisting
situation of early marriage and early childbearing, which resulted in nearly 50 per
cent of the population being in the reproductive age group. Delaying age at first
pregnancy and spacing subsequent births to between two to four years were key
to reducing the population momentum. Despite all this, the only method that the
Family Planning Programme offered to women was sterilisation; and average age
at sterilisation could be as low as 22 years.
The time seemed ripe, therefore, for yet another paradigm shift. One that respect-
ed and upheld women’s rights in the provision of family planning services: the right
to be informed about the range of contraceptive alternatives available; their pros
and cons at different stages in the life cycle; what side effects to expect; and what
services to access in the event of such side effects. This called for greater commit-
ment of financial and personnel resources to family planning in the national agenda
and to widening the basket of contraceptive choices. But above all, it called for
placing women and their right to well-being at the centre of family planning and
bringing men into the picture to take their rightful roles as responsible partners.
Armed with the evidence and understanding of the issue, and pithily designed
pictograms, PFI proceeded to engage with parliamentarians, policymakers, pro-
gramme planners, civil society, and other stakeholders to build the political will re-
quired for greater investment in family planning. PFI’s focused advocacy efforts in
the wake of the tragic maternal deaths in Barwani in 2010 and sterilisation deaths
in Bilaspur in 2014 also added strength to its push for improving quality of care and
building capacity of service providers (see Appendix: Case Study Two for details).
Following on its investigation of the tragedies, PFI, as part of its advocacy directed
to the government, also carried out a review of the pattern of government expen-
diture on family planning. The review showed that a mere 1.87 per cent of expen-
diture was being directed to spacing methods, with the rest going into sterilisation.
Even within this overwhelming focus on female sterilisation, 97 per cent of total
expenditure was going into monetary compensations — incentives — to acceptors
and to medical personnel rather than into ensuring quality health services and care
for the women accessing them.
Spurred by its findings, PFI went on to explore how best to frame its argument
for the sterilisation policy to be shifted to a genuine family planning approach that
offered a wider basket of choices. The result was an analysis, again in concise in-
PFI argued that the root cause of population
momentum was the persisting situation of early
marriage and early childbearing, which resulted
in nearly 50 per cent of the population being in
the reproductive age group. Delaying age at first
pregnancy and spacing subsequent births to
between two to four years were key to reducing
the population momentum
fographs form, that presented the range of contraceptive choices that are offered
to women in other Asian countries, in contrast to India’s unilinear focus on sterilisa-
tion. The document opened up a whole set of policy possibilities. Notable among
them are injectables, along with contraceptive education, informed consent, and
high-quality service back-up, as a first step towards the true notion of a basket. This
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ASHA’s discuss village health Action Plan, Jharkhand
is still a work in progress.
PFI’s strategic advocacy efforts around the sterilisation linked health services issue
yielded much fruit. The Government of Madhya Pradesh agreed to the develop-
ment of a one-year plan for Barwani district to implement the recommendations
contained in the PFI/AGCA investigative report on the maternal deaths. A com-
mittee that comprised state NRHM officials and AGCA members was constitut-
ed to review and monitor the implementation of the action plan submitted to the
MP High Court. The state government also requested PFI to provide technical
assistance in the training of health officials in Quality of Care.
In 2012, its Note on Repositioning Family Planning was integrated into the Gov-
ernment of India’s Twelfth Five-Year Plan. Further, in the government’s Economic
Survey of 2014–2015, there was acknowledgement for the first time of the need to
revisit incentives for family planning, particularly for sterilisation and, therefore, the
need for repositioning family planning priorities. The Survey drew extensively on
PFI’s reports on Barwani and Bilaspur for its evidence base. The Ministry of Health
and Family Welfare felt impelled to send directives to the concerned state govern-
ments to improve service providers’ capabilities for family planning services, and
it announced an expanded basket of contraceptive choices. The PFI’s wide and
nuanced engagement with the media on this occasion also helped in increasing
informed coverage of family planning issues. In place of sensational condemna-
tions of the concerned governments, on the one hand, and wholesale rejection of
family planning, on the other, news reports highlighted the vital agenda of the right
of women to have access to birth control methods of their choice, including sterili-
sation if they so desired, their right to space their births, their right to safe abortion,
and their right to safe and quality health services that included the information and
support required to make their choices.
Currently, PFI is working with the governments of both Uttar Pradesh and Bihar
along with its other civil society partners, who are also engaged in these states, to
review and revise their respective state population policies. In Uttar Pradesh, it has
been also working at the district level and has been providing technical support
to district authorities to examine the local functioning of the Family Planning Pro-
gramme with a view to identify ways to improve the services. In Bihar, backed by
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government support, PFI began with conducting dissemination activities among
journalists from the print and electronic media relating to health and development
issues, with a view to bringing about improvement in the quality of reporting on
these subjects. Also, when PFI was implementing its project of scaling up the
Community Action for Health (CAH) process in the state, it had integrated family
planning as a thematic area for monitoring in the project area. The success of the
experiment led to the scaling up of this component in CAH at the national level.
Main Kuch Bhi Kar Sakti Hoon: While working to reorient government policies
and programmes in favour of women’s rights was a significant area for intervention,
PFI recognized that it was equally important to change deeply rooted mindsets
and behaviours in the wider society that inevitably also find their way back into
healthcare and related services. The six priority areas — early marriage, early and
repeated pregnancies, sex selection, domestic and gender violence, and gender
inequality — that PFI identified for itself all reflected widespread negative social
practices in the country, with some of them taking particularly acute forms in the
two large North Indian states of Bihar and Madhya Pradesh. The challenge right
from the start was how to address the task of changing these culturally ingrained
attitudes and mindsets that underlie these practices and that sustain them. To set
off any process of change required communication strategies with clear focus and
informed content.
PFI’s investigations toward its report on Repositioning Family Planning had yielded
some clues for strategic action from the several field-based interventions. Chang-
ing mindsets regarding delaying early age at marriage appeared to be among the
more intractable of the problems. Keeping girls in school was clearly one of the
most promising strategies to delay marriage. Broad-based life-skills education that
included ‘empowerment’ education, side by side with education about sexuality
and reproduction, was another. Skill building was a third. The evidence also showed
that it was essential to simultaneously work with gatekeepers in the community to
raise awareness and to use media campaigns to raise the visibility of these issues
in the community at large. Promoting spacing between births worked best when a
combination of three strategies were simultaneously employed: working intensively
with women and their husbands; working with the community to build community
support, and this worked best when men’s support was also mobilised; and building
health worker capacity to provide the appropriate services.
The promise of mass communication — through the use of radio, including com-
munity radio, television (TV) and documentary films — to convey the message of
the small family norm had always been an important area of involvement for PFI
alongside its main agenda of supporting research and engaging in policy advocacy.
But, the engagement with these media tools hitherto had been small in scale in
both conceptualisation and production, with negligible emphasis on follow-up or
impact assessment. Given PFI’s new commitment to building a strong evidence
base for every intervention, scaling up every initiative, and continuously monitoring
and evaluating the efficacy of its projects, it now looked at mass media with new
eyes.
How can the available media and digital technologies, which were daily trans-
forming both mass and interpersonal communications, be used to bring about
an enduring shift in gender norms, perceptions, and behaviours? And how can
health-seeking behaviours and the uptake of non-terminal family planning services
be improved in favour of women’s health? The high television penetration even
in rural areas and the universal popularity of commercial soap operas suggested
that packaging education in an entertaining way and using drama based on real
life situations to create ‘edutainment’ on gender and population issues might be a
promising option. Using adaptations of the TV serial on radio could further am-
plify the communication strategy. In a developing country with one of the larg-
est mobile phone using populations in the world, mobile friendly serial clips and
Interactive Voice Response System (IVRS) technology offered the potential to
receive questions and feedback on content and impact along with instant enter-
tainment. Where youth were educated and had access to the internet and social
media, such as YouTube, Facebook, and Twitter, these could all be experimented
with to extend the reach of the messages. Finally, at the ground level, access to
some or all of these technologies could be supported, where possible, by facilitated
face-to-face interactions in the form of viewers clubs and discussion groups. The
TV serial, Main Kuch Bhi Kar Sakti Hoon, that PFI launched in 2014 thus embod-
ied a ‘360 degree’ approach to behaviour change communication: multiple, dis-
tinct, yet complementary channels of communication working together to create a
whole that is greater than the sum of its individual parts.
Backed by assurance of seed funding from the Board and expression of interest-
by the UK Government’s Department for International Development (DFID)
in part-funding such an intervention, as also Doordarshan’s offer (Government
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of India’s TV channel) of free air time to assist in scaling up, PFI’s explorations
towards the serial began in January 2013. Seminal insights from the theory and
practice of educational entertainment helped frame the creative brief for the film
team. Insights from formative research (specially commissioned field research) in
Bihar, MP, and Odisha, which were among the EAG states and were also the key
states of DFID-supported programming, yielded real life stories. From these sto-
ries, the realistic could be combined with the aspirational in conceptualising the
main characters in order to make them credible and relatable to both rural and
urban audiences and especially to the youth. Behaviour change communication
strategies were tested in MP and Bihar in order to refine the outreach strategy and
The teleserial’s reach had been wide. Women
and youth, the target audiences, had watched
the serial in large numbers. Knowledge levels
had risen on the issues covered. Above all,
Main Kuch Bhi Kar Sakti Hoon had entertained,
and people were ready for more
approach. The serial title and one episode each for TV and radio were pre-tested
for audience reactions. A baseline survey of prevailing perceptions and attitudes
relating to women’s health, gender relations, and family planning was conducted.
An endline survey was undertaken in the same districts to assess impact.
At the end of Season One consisting of 52 episodes, qualitative and quantitative
impact assessments were carried out in MP and Bihar, the two states that together
account for 15 per cent of the country’s population. These states also have high
fertility rates and unmet need for family planning. They are also prime candidates
in relation to the urgent need to raise the age at marriage and at first childbirth as
well as levels of knowledge and access to family planning services. What came
across was a story of resounding success. The teleserial’s reach had been wide
(despite the fact that both the states have an 80 per cent penetration of both
Direct-to-Home and cable networks that broadcast popular commercial serials).
Women and youth — the target audiences — had watched the serial in large num-
bers. Knowledge levels had risen on the issues covered. Above all, Main Kuch Bhi
Kar Sakti Hoon had entertained, and people were ready for more (see Appendix:
Case Study of MKBKSH for details).
The encouraging public response has taken the serial into Season Two consisting
of 78 episodes, this time funded by the Bill and Melinda Gates Foundation. The
launch took place in April 2015. This season focuses on youth related issues, and
it engages with men in interesting ways, since male viewership was found to be a
missing element in the previous season. It deals with the priority areas of sexual and
reproductive health, alcoholism, de-addiction, violent behaviours, mental health,
and non-communicable diseases.
Most importantly, Doordarshan, encouraged by the positive response, has extend-
ed its broadcast of Season One to 15 of its regional channels across the country,
translating and dubbing it into regional languages as appropriate. The Ministry
of Health and Family Welfare has sought the collaboration of PFI in its recent-
ly launched national health programme for adolescents — the Rashtriya Kishor
Swasthya Karyakram (RKSK) — in the form of Season Two episodes. The MoHFW
is currently using the teleserial to create community acceptance for the RKSK pro-
gramme and is culling out select issue-based episodes for use in the training of
peer educators. These episodes will be also used by the peer educators in the
sessions that they will be conducting with young people at the community level.
The RKSK peer leaders — the animators of the programme — have already been
renamed ‘Saathiya’, the name given to the youth peer leaders in PFI’s Season Two
episodes. A Season Three of Main Kuch Bhi Kar Sakti Hoon is already on the cards.
Community Action for Health: One of the invisible areas of work that PFI engag-
es in is that of steering the Community Action for Health (CAH) process in the ru-
ral and tribal districts of EAG states. This is in its ongoing role as Secretariat of the
Advisory Group on Community Action (AGCA) since 2005. Between 2007 and
2009, the AGCA had guided the implementation of a pilot project to implement
the process (then called Community Based Monitoring and Planning [CBMP]).
The pilot was undertaken in nine states (Assam, Chhattisgarh, Jharkhand, Karna-
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One of the invisible areas of work that PFI engages in
is that of steering the Community Action for Health
(CAH) process in the rural and tribal districts of the
Empowered Action Group (EAG) states
taka, MP, Maharashtra, Odisha, Rajasthan, and Tamil Nadu), covering 36 districts
and 1,620 villages. Following the pilot, the MoHFW decided to go ahead with the
programme and made the necessary grants to states wishing to implement it upon
obtaining ministry approval for their Project Implementation Plans (PIPs). It also
gave grants to the AGCA/PFI Secretariat for guiding the states through the entire
process. (See Appendix: Case Study of AGCA for details).
As part of its preparation for its role of steering the CAH process, PFI under-
took to implement the scaling up of the process in the state of Bihar. Between
2012 and 2014, a period of two and a half years, it carried out the implementa-
tion in five districts of the state, across 300 villages consisting of 50 panchayats
and 10 blocks. It worked closely with two state level institutions that it had assist-
ed the state government in setting up: the State Health Society and a District
Health Society in each of the five districts. It was PFI’s experience that in bringing
together trained resources from multiple levels in a mutually supportive way, it was
possible for community action to make huge improvements in maternal health as
evidenced in antenatal check-ups and detection of high-risk pregnancies. It also
significantly raised awareness on health and healthcare entitlements at the grass-
roots level in the form of a heightened sense of community ownership over the un-
tied grants placed by government for use by community level bodies in the CAH
process. When the funding for the project came to an end in 2014, PFI was able
to successfully exit the project area after having institutionalised the village level
community participation component within the Accredited Social Health Activist
(ASHA) system, that is, a trained community health worker in every village. The
model that it developed is currently operating in 100 villages in two districts of
Bihar, where PFI is currently involved in other ongoing projects.
The role of the PFI/AGCA Secretariat begins with advocacy with the states on
the concept of ‘communitisation’ itself. This is followed by technical assistance to
the governments in framing their respective PIPs. Once having got the states to
come on board, PFI goes on to advocate with the state governments for setting
up and strengthening State Health Systems Resource Centres (SHSRCs) whose
work is to plan, coordinate, and support the creation of the grassroots community
participatory institutions that form the bedrock of the communitisation process, that
is, the Village Health, Sanitation and Nutrition Committees (VHSNCs) and the
Rogi Kalyan Samitis (RKSs). The PFI/AGCA Secretariat then assists the SHSRCs
by way of training the officials manning it and handholding them as they grow into
the CAH process. A crucial part of the process guided by PFI is encouraging and
facilitating the participation of the front line workers (Anganwadi Worker [AWW]
and Auxiliary Nurse Midwife [ANM]) and the PRI representatives in the citizens’
committees. This is done by raising their awareness for health service accountability;
training them in the skills required in negotiating this unfamiliar participatory pro-
cess, such as holding regular meetings after due notice, recording minutes of these
meetings, and ways of following up on problems and ventilating grievances; and,
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generally, guiding their growth and empowerment. It is an iterative process that re-
quires connecting and reconnecting the grassroots bodies, the state and district lev-
el bodies, and national bodies with each other. At the grassroots level, PFI/AGCA
Secretariat inevitably looks to those NGOs, community-based organisations, and
self-help groups that are active locally for collaboration in the work of activating
the citizens’ committees and help in providing on-the-ground training to the PRI
representatives, who must eventually carry this process forward as part of their local
governance responsibilities.
PFI’s agenda as described above is indeed pathbreaking. Against the historical
background of the neglect meted out to public health over more than a century,
the NRHM has created a framework for a whole new engagement for the states,
given that health is a state subject. This is a notable step towards bolstering the
spirit of federalism and building capacity within the health sector to rise to the
requirements of the public health situation in the country, besides inducing willing-
ness on the part of the system to be held accountable to its users. It is neither easy
nor simple for the health services to be responsive, or for citizens’ committees to
act on their entitlements; both sets of responsibilities as well as the required dia-
loguing skills need to be learnt, practised, and fine-tuned. This experience is bound
to be different in different states, depending on the governance effectiveness of
different states, the extent to which communities are able to organise themselves
and form committees that actually work, the extent to which PRI institutions have
the capabilities and enlightenment, and local level intermediary groups, such as
self-help groups, community-based organisations, and non-governmental organi-
sations, are present and active to help bridge the initial gap between policy intent
and policy realisation.
As of 2015, following intense advocacy efforts by the PFI/AGCA Secretariat for
inclusion by states of the CAH component in their annual National Health Mission
(NHM) PIPs, 25 states across the country have ‘bought into’ the idea. In actual fact,
however, the process is in operation only in pockets in a few districts of each state.
The picture that emerges as of now is of a landscape that is still in a state of flux,
sparsely populated with the community action component, where the concept of
the primacy of the community in the eyes of the health services, is still alien in the
eyes of the system. In the case of the Barwani maternal deaths referred to earlier,
local communities that had been through the pilot process of communitisation and
had been made aware of their entitlements had protested to the state authorities
about the callousness of the state’s health services. The authorities, however, chose
to treat their protests as a law and order problem rather than as a factor relating to
the responsibility of the health system to be answerable to the people. States still
tend to view the whole community action component with suspicion. Niggardli-
ness in allocation of resources for this aspect of social engineering means that the
finances required for seeking out locally relevant solutions and innovations and for
training communities in the processes of enquiry, audit, and negotiation are simply
not there. The semi-autonomous SHSRCs that could provide leadership are only
just coming into existence. They are as yet very new to the concept and modalities
of community involvement and the rights of users to demand accountability from
state powered health facilities. Further, a lot of investment is required for the build-
ing of their capabilities.
The wished-for active participation by local stakeholders on the ground — represen-
tatives of village and block level Panchayati Raj Institutions, the Rogi Kalyan Samitis,
or even just the village community health worker (ASHA) — continues to be elusive.
Among the sustainability issues is the question of how to strengthen the PRIs to take
primary responsibility for steering the committees at the village and facility levels. Pres-
ently, NGOs are still playing the major role of intermediaries, which serves to delay the
coming of age of the PRIs besides alienating them. At the moment, as far as village lev-
el responsibility is concerned, the ASHAs seem to be the most logical choice as stake-
holders. The ASHA is uniformly present across the NRHM states, and it is an institution
that was brought into existence to serve the NRHM objectives. The ASHA belongs to
the village and is also part of the health services structure and is meant to act as a bridge
between the two. But is the ASHA, a one-size-fits-all answer? Or might there be other
locally relevant solutions in different states for process ownership at the community lev-
el, given the diverse socio-cultural-political landscapes that prevail in different states?
This is one question that PFI is currently exploring with a view to documenting and
demonstrating the effectiveness of alternative approaches for strengthening the CAH
process and ensuring its sustainability. Grappling with ways of strengthening the Rogi
Kalyan Samitis is yet another challenge that it is geared to taking on.
Preparing training materials for participants at all levels of the CAH process —
including PRIs, VHSNCs, and RKSs — is one of the many tasks that the PFI has been
addressing. Another task is working with NGOs, self-help groups, and other local col-
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Orientation of VHSNC members, Tamil Nadu
lectivities/civil society partners who actually do the training of the elected bodies or
CAH committees at the ground level. During its scaling-up work in Bihar, the PFI had
developed two films — one on health entitlements and the other on the key processes
of the Community Based Monitoring and Planning process (CBMP) — to support the
programme. It has also since developed several manuals to guide the implementing
organisations and health managers in rolling out the community action processes at
state, district, and block levels: Guidelines for Programme Managers, a User Manual
on Community Action for Health, and a Trainers’ Manual for Village Health Sanitation
and Nutrition Committees. The AGCA/PFI team, along with the National Health
Systems Resource Centre (NHSRC), has also helped the Ministry of Panchayati Raj in
developing a Handbook on Health for gram panchayat representatives.
Also, while the CAH process has been playing out differently in different states,
one near universal feature across states has been the shortage of funds for the
community level bodies, that is, theVHSNCs and RKSs, to take timely action in the
interests of their own health. Inordinate delays in communities accessing the untied
funds that are their entitlement are probably the weakest link in the chain. This
points to the need for advocacy for increased political and financial support. An-
other weak link is the paucity of prompt grievance redressal mechanisms available
to the community level bodies. In the absence of this, powerlessness can quickly set
in, thus jeopardising the sustainability of the whole process.
PFI is paying special attention to the high focus (EAG) states in this regard. It is
building leadership to strengthen and scale up CAH, providing technical support to
state governments in reviewing the implementation of processes and formulation
of the CAH component in their PIPs, increasing the availability of both orienta-
tion materials and facilitators at state and district levels to train key actors on CAH,
and increasing the visibility and understanding on health entitlements through the
mass media. Two comprehensive monographs have been published as markers of
the journey of PFI as a learning organisation: Monograph on Community Action
for Health, which pulls together national and international experiences on CAH,
and Monograph on Grievance Redressal, which documents field experiences in the
country of models/processes for grievance redressal in the country and lessons that
might be drawn from them.
Health of the Urban Poor: In 2013, a reorganisation brought the NRHM and a
newly created National Urban Health Mission (NUHM) under the umbrella of
the National Health Mission (NHM). Until this reorganisation, there had been no
attempt at a nationwide vision for urban health. An urban arm of the RCH Pro-
gramme existed that was meant to address the goals of the Family Planning Pro-
gramme in urban areas, but there was no horizontal integration between this pro-
gramme and the tasks related to public health that city municipal structures were
expected to address. Nor indeed did a streamlined system of urban municipalities,
with specified preventive, curative, and promotive health duties, exist across the
country’s cities, unlike in the rural areas where a uniform system of Primary Health
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Centres, Community Health Centres, and District Hospitals prevailed. Apart
from the three original Presidency towns of colonial India — Bombay, Calcutta,
and Madras — with their well-defined municipal corporations, in all other ‘urban
agglomerations’ — including the capital city, Delhi — a situation prevailed where
multiple agencies were responsible for individual components relating to health,
with no coordinating authority charged with bringing them all together under a
unified vision or structure. The National Urban Health Mission was meant to create
a national vision and structure to guide urban growth and assist in setting up an
The unique contribution of PFI was to help
shape a policy focus on urban health and,
within that, a dedicated focus on the health
of the urban poor. The Health of the Urban
Poor programme (HUP) was conceived as
a technical assistance programme to try out
systemic approaches to urban health
challenges in as holistic a way as possible
accompanying health apparatus for implementation in India’s cities.
The 2011 Census underlined the urgency of addressing this situation of unplanned
and haphazard urbanisation, particularly given the rapidly growing size of the coun-
try’s urban population (accounting for 31.16 per cent of the country’s population)
whose growth rate was even higher than that of the rural population. The concom-
itantly growing proportion of the poor living in slums (17.4 per cent of the urban
population) and their concentration in ever-shrinking land areas have meant an
intense problem of density and overcrowding. This is exacerbated by the extreme
shortage of basic health related services available to the slum-dwelling population
— safe water, drains, toilet facilities — making for a situation of acute vulnerability,
particularly for infants and children and pregnant and postpartum women. Despite
the relatively thicker presence of health providers in cities, primary health care fa-
cilities that the poor are actually able to access fall so woefully short that they have
to resort to unregulated private providers, who indulge in haphazard prescription
of drugs, especially antibiotics. The tip of the vulnerability iceberg is that maternal
and under-five mortality rates in slums rival the situation in rural areas. Close to 50
per cent of under-five children are malnourished and underweight. Almost 60 per
cent of poor children miss total immunisation before completing one year of age.
All this signals a serious situation.
The unique contribution of PFI was to help shape a policy focus on urban health
and, within that, a dedicated focus on the health of the urban poor. The Health of
the Urban Poor Programme (HUP) was conceived as a technical assistance pro-
gramme to try out systemic approaches to urban health challenges in as holistic a
way as possible. It was envisaged that the provision of quality technical assistance
to the Government of India, states, and cities for effective implementation of the
NUHM would primarily involve a three-pronged approach. This would entail: ex-
panding partnerships in urban health including engaging the commercial sector in
Public Private Partnership (PPP) activities; promoting the convergence of differ-
ent Government of India urban health and development efforts; and strengthen-
ing urban planning initiatives by the government through evidence-based city-lev-
el demonstration and learning efforts.
To do this, PFI formed a consortium of organisations with complementary
strengths, in which each took responsibility for different regions/cities and func-
tions, so that their combined experience and expertise could provide the required
technical assistance. Once again, the learnings acquired through exposure to the
Scaling Up Management Framework came in for application. The sustainability of
the development models evolved in the process of implementation remained a
concern from the start; it was sought to be secured through capacity building and
hands-on skill development at the national, state, and city levels.
The programme was initiated in the eight EAG states (Bihar, Chhattisgarh,
Jharkhand, MP, Odisha, Rajasthan, Uttarakhand, and UP) and five cities (Agra in
UP, Bhubaneswar in Odisha, Jaipur in Rajasthan, and Pune in Maharashtra). It has
since been scaled up to 18 cities in the EAG states and two metropolises — Kolk-
ata and Bengaluru. Convergence is one of the key underlying principles. The pro-
gramme brought together the horizontal integration of five departments in each
state: Health and Family Welfare, Women and Child Development, Housing and
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Urban Development, Public Health Engineering, and Urban Local Bodies. Under
PFI’s leadership, the consortium gives technical assistance in the areas of health
systems strengthening; evidence-based planning; convergence; public private
partnerships; promotion of water supply, sanitation, and hygiene; and strengthen-
ing of the management information system to address the health needs of the
urban poor.
(iii) A community engagement component embodied in Mahila Arogya Samitis
(MAS) (the urban equivalent of the Village Health, Sanitation and Nutrition
Committees), that is, voluntary citizens’ organisations linking the community
and the city’s administration services in order to demand for and monitor ser-
vices/rights, increase community ownership and sustainability, and facilitate
community-based monitoring;
Through its city demonstration component, the HUP programe developed, tested
and demonstrated strategies and approaches for urban health and created evi-
dence and scope for scale up and replication to other cities. The model that it put
together out of this exercise consisted of five approaches calculated to provide
‘easy and equitable access to health care, facilitated by community involvement,
guided by a systematic plan, coordinated by local authorities, and monitored reg-
ularly’. These approaches were:
(i) The development of a comprehensive decentralised health plan for every
city and mapping the prevailing health situation, infrastructure, facilities and
the prevailing gaps;
(ii) Creation of a single convergent Urban Health and Nutrition Day service
providing maternal, newborn, child health, and nutrition services to every
slum once a month at the Anganwadi Centre, and linking water, sanitation,
and hygiene to this;
(iv) City and Ward Coordination Committees (the equivalent of the facility level
committees in the rural areas) to facilitate convergence and coordination ac-
tivities between various departments, between the government and private
sector, with representation from the local slum communities, and with the
task of improving access to quality healthcare services; and
(v) Health Management Information Systems to monitor the programme, cre-
ate a database on maternal and child health and information related to water,
sanitation, and hygiene to be analysed on a monthly basis to track progress
of the programme.
The USAID funding for the HUP project came to an end as of October 2015.
....
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06
Overview and Options
for the Future
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A Frontline Worker interacting with the beneficiaries
Overview and Options for the Future
W
hen one looks at the institutional history of the Population Foundation of India over the last 45 years, what comes
across is the steady course that it has maintained. It has engaged in and supported research focused on policy is-
sues. It has encouraged NGOs, through grants, to enter the population field and take on field level action research
that might yield practical insights for enriching policy. And, it has engaged in advocacy activities — earlier called
‘promotional’ activities — to disseminate findings from investigative studies and to highlight the changing contours
of and responses to the population problem in the country. In this last area of involvement, it has related to various
constituents, such as government, parliamentarians and state level elected representatives, the scholarly community,
the general public and the international community,
During the first twenty-odd years of this course, PFI was one among several actors trying to find its feet in the
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population field in the country. At the time, in India, the field of demography was
still coming into its own. Although the country had a few leading demographers,
the discourse on population was dominated by Western scholars and heated in-
ternational concern and debate over the nature and dimensions of ‘runaway’ pop-
ulation growth in the developing world and its implications for the world’s future.
The Foundation worked closely with the
community of demographers within the country as
it cautiously navigated its own research progress.
The towering figure of Mr J.R.D. Tata gave PFI the
necessary visibility and legitimacy, particularly in
relation to the Government of India. This gradually
resulted in its institutionalisation, with a secure
financial base as preparation for its onward journey
The Foundation worked closely with the community of demographers within the
country as it cautiously navigated its own research progress. It also supported the
growing number of biomedical researchers in the country as they worked towards
evolving contraceptive solutions — culturally appropriate, easy to use, and afford-
able — suited to Indian conditions. The towering figure of Mr J.R.D. Tata gave PFI
the necessary visibility and legitimacy, particularly in relation to the Government of
India. This gradually resulted in its institutionalisation, with a secure financial base
as preparation for its onward journey.
The ‘steady state’ phase of the following twenty years or so was a period of moving
from an overwhelming worry and urgency about speeding up ‘population control’
to building on a somewhat more nuanced picture of what was emerging as wide
regional variations in population growth rates. This is not to say that the central
political concern with curbing population growth rates was put away entirely. But
successive demographic studies and census results offered some comforting as-
surance of achieving ‘population stabilisation’ in the foreseeable future, and parlia-
ment even debated possible future scenarios when states’ electoral representation
in the Lok Sabha might need to be altered in keeping with reduced population
sizes. The consensus now was that what needed to be addressed were the still high
maternal and infant mortality rates. Attention shifted to focusing on the states with
the worst demographic and social indicators (now classified under the new rubric
of EAG states).
In the meanwhile, a new global population development discourse — Reproduc-
tive Health — linked with the burgeoning global women’s health movement and
the unprecedented ramifications of the global HIV/AIDS pandemic, had emerged
to replace the single-minded obsession with population control in poor countries.
Within the country, discontent with the Family Planning Programme was already
high, both outside the government and in policy circles, for its corrosively insen-
sitive and target-driven character and continuing failure to lower fertility levels in
the EAG states. The Government of India’s response was to recast the national
Family Planning Programme into a Reproductive and Child Health Programme. In
the policy interregnum that followed, the formal withdrawal of sterilisation targets
and its replacement with little else by way of identifiable performance markers,
PFI identified spaces for innovation, much in the way that it had done when the
Emergency-led family planning excesses had shaken the ground under its feet in
an earlier era. Reproductive health, adolescent sexual health and gender rights that
were elements of the new conceptual framework became themes for advocacy.
Networking with advocacy NGOs around these themes, while simultaneously en-
gaging with parliamentarians and governments at the Centre and the states on the
political fallouts from the still powerful subterranean impulses towards population
control, became the new strategy for PFI’s re-energised identity as an advocacy
organisation.
Additionally, openness to mounting and leading NGO consortiums to engage in
large-scale intervention programmes in hitherto untested areas gave a new spurt
to PFI’s finances and numerical strength. An openness to learning new skills, nota-
bly the Scaling Up Management Framework, in response to glimmerings of a new
policy climate offered possibilities for experimenting with new areas for engage-
ment and for promoting greater dialogue between government and civil society,
which formed an important aspect of PFI’s mandate. On the whole, this period
was marked by assured financial security owing to both PFI’s own abundant re-
sources and the readiness of large global donors to fund policies, projects, and
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programmes that aimed to address family planning within a framework of maternal
and child health. International funding was also ready to flow to NGOs amenable
to engaging in open-ended strategies to cope with the HIV/AIDS epidemic.
The ongoing phase began for PFI with a commitment to two strong and chal-
lenging shifts in its identity and work orientation. One was a shift to a rights-based,
people-centric, gender sensitive, and sustainable approach to development, with
women’s empowerment and rights at its centre, an approach around which all the
work of the Foundation would henceforth cohere. The other was a shift to working
with both the central government and the state governments on the nitty gritty
of policy implementation as a way of infusing greater depth into PFI’s role as a
national think tank in the field of population health development. It helped that
the new population policy climate was a favourable one. Its principal feature was
its orientation towards enhancing the quality of life of the poor and disadvantaged
in both rural and urban areas, especially women and children, through reaching
public health services to them. Enhancing the quality and accountability of these
services through civil society participation was an important component of this
policy. It also showed a relatively greater openness, more than ever before, to new
ideas and approaches coming from civil society for achieving the above objectives.
What continued from earlier was policy concentration on the EAG states, whose
high fertility rates were persistently eluding the national mission of population sta-
bilisation.
PFI seized the opportunity to be at the forefront of responding to the unprec-
edented stimulus offered by the new policy climate. It had already worked with
proficient technical partners, supported by generous and flexible donor grants, in
learning how to apply the specialised skills needed for assessing the scaleability of
micro-level NGO innovations. In concert with the new national resource organisa-
tions created within the NRHM framework, it had helped to successfully scale up
and advocate for the integration of some of these models — notably the ASHA
— within the NRHM. It had also worked with other promising models relating to
maternal and child care and young people’s sexual and reproductive health as well
as delivery systems for primary healthcare using the mechanism of public private
partnerships to successfully scale them up both within their home states and across
states. These initiatives are still snowballing.
Now, as Secretariat of the Advisory Group on Community Action (AGCA), PFI
began the work of technical assistance for scaling up, of the rural Community
Based Monitoring process across 25 states of the country. This was a model that
the Foundation had itself initially developed and refined in the state of Bihar. The
ongoing learnings from that AGCA/PFI intervention became valuable for leap-
frogging to the challenge of conceptualising and rolling out a new National Urban
Health Mission (NUHM), and a Health for the Urban Poor (HUP) intervention
programme that cohered around the key concept of vulnerability. Throughout
this exercise, PFI played a key role in focusing national policy attention on fram-
ing urban health and sanitation issues to address the acute vulnerability of the
slum-dwelling poor. At the state level, it extended technical assistance to several
states and cities in the EAG category (eight states and five cities) in implement-
ing the multidimensional HUP programme that it had designed and piloted. It
went on to scale up this programme to 18 EAG cities and two metropolitan
(non-EAG) cities. Bridging both rural and urban populations and national level
policy initiatives and ground level implementation processes is PFI’s transmedia
initiative, Main Kuch Bhi Kar Sakti Hoon. This ‘edutainment’ initiative has begun
the long-term process of changing deeply ingrained cultural perceptions and be-
haviours relating to gender inequalities, gender-based violence, age at marriage,
family planning and reproductive choice, women’s autonomy, etc.
The baptism in the Scaling Up Management Framework proved to be a defin-
ing point for PFI. At least some of the features that have come to characterise
the Foundation’s organisational ethos in its ongoing phase may be traced to the
lessons learnt. Evidence of this is seen primarily in the streamlining of strategic
themes and priority areas of a strong central focus positioned within a five-year
strategic plan. Concomitantly, there has been a tightening of the style of or-
ganisational management in order to increase horizontal integration, efficien-
cy, and impact in relation to its central thrust area. Iterative thinking and action
between ground level realities in the states and the big national policy picture
is another core feature of its functioning. Another integral feature is the use of
evidence-based advocacy, along with maintaining transparency, and a collab-
orative approach when dialoguing with the government at the Centre and the
states as well as with civil society partners in the interests of moving the common
population, health and development agenda forward.
Specific instances of impact are also evident. PFI’s strong emphasis on preparatory
and ongoing research and testing, and process documentation of pilots/interven-
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tions, with an eye to the quality of evidence being generated, is one such instance.
Another is the commitment to both internal assessment and external evaluation of
its interventions to assess impact. Even in its grant-making role, PFI has integrated
the scaling-up approach into the process itself; it extends support to those NGO
grantees whose models have shown some potential for scaling up, and it has also
intensified its own role in the monitoring and evaluation of its grants.
The manner in which the PFI takes forward its programme agendas reflects simi-
lar considerations. The SUM Framework acted as a tool for the visioning and pro-
gramming exercises that went into developing the Foundation’s five-year strategy
for Repositioning Family Planning within a rights-based framework. It gave PFI the
try’s population — a logic that goes beyond population stabilisation defined in terms of
numbers alone — the Population Foundation of India has today set itself on a poten-
tially revolutionary path. It is a path that could take it significantly forward in terms of
impact. There is every indication to assume that this could happen, but, it is also a path
that is pregnant with the possibility of failure. PFI is thus poised rather as a start-up that
holds a tiger by its tail as it enters a brave new world.
To do all that it wants to do, PFI needs access to flexible funds. It is precisely at this junc-
ture that it is facing major internal and external resource constraints. On the one hand,
its own previously secure in-house resources have shrunk with the drastic reduction in
what used to be its rental income. Combined with this is the steady vacating of the field
To do all that it wants to do, the PFI needs
access to flexible funds. It is precisely at this
juncture that it is facing major internal and
external resource constraints
self-confidence to play a leadership role in steering the formulation of the NUHM
and undertake and execute the HUP programme. Last but not least, the impact is
evident in its launching of an evolving 360-degree transmedia initiative that knits to-
gether all of PFI’s programme and priority concerns around the single central theme
of women’s rights and empowerment, with the objective of triggering behaviour
change, and change in the fundamental ways in which Indian society views women
and men.
In following the logic elaborated above of engaging with the quality of life of the coun-
of population and reproductive health by bilateral agencies like the DFID and small in-
ternational donors like the Packard Foundation and the MacArthur Foundation, which
had hitherto been significant and strategic partners for PFI, particularly in its more inno-
vative explorations. The flexibility of these grants and their donors’ policy of investing in
institutions and individuals and facilitating processes for intellectual growth — much in
the manner that the Ford Foundation had done for PFI in its infancy years — had en-
abled PFI to experiment with new ideas and areas of intervention as well as introspect
and put itself through organisational transformation exercises. This has changed.
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The architecture of the international donor scene today is one where large donors
dominate, and the relationship between donor and recipient is an instrumental one,
where desirability of the latter is assessed in terms of its ability to deliver large-scale
quantifiable impact. As the large bilateral agencies and philanthropies look to in-
vest huge sums, they are also looking for recipient agencies that have the near-cor-
poratised financial and human resources management capabilities to absorb these
sums and to convincingly promise quick and massive impact.
The search for impact has led PFI to align itself with the government. What then
of the Foundation’s identity as an organisation that straddles all three worlds of
government, small NGOs, and private industry, where it is comfortable working
with all, but protects its autonomy to be able to step back quietly to the margins
when called for, so as to innovate in new directions? This is a dilemma that is likely
to stay with PFI for a while.
on ways of maintaining its financial viability and autonomy to be able to con-
tinue to shape its own destiny. The crucial importance of remaining econom-
ically self-sufficient and with an agenda of its own that will keep it immune to
the fallouts from the rise and fall of governments, can hardly be overempha-
sised. Working closely with the government as an implementing agency may
not always remain a reliable option. This was witnessed in an earlier era of PFI’s
own history by the Ford Foundation, which had helped to implement the Indian
Family Planning Programme, but found itself having to retreat when the pro-
gramme began to acquire coercive overtones prior to the Emergency. Not too
soon thereafter, the same fate overtook the fledgling PFI when it aligned itself
too closely with the government’s family planning goals and programmes, only
to undergo a temporary loss of direction when the Emergency’s family planning
excesses came to light.
At the moment, PFI is embracing its funding
constraints and challenges in the interests of keeping
intact and undiluted its newly sharpened and cohesive
programme focus and proactive advocacy approach
At the moment, PFI is embracing its funding constraints and challenges in the
interests of keeping intact and undiluted its newly sharpened and cohesive pro-
gramme focus and proactive advocacy approach. It is putting itself through a
series of exercises to keep its organisational transformation going and to build
the resilience and agility that it needs to see itself through possible hard days
ahead without losing that focus. At the same time, it is doing some hard thinking
What is creditworthy is that, notwithstanding this changing dynamic of internal and
external constraints, PFI is currently witnessing a phase of unprecedented activity
on several new initiatives. These initiatives certainly allow PFI to stretch several
muscle groups and assess where its comparative strengths may lie for planning for
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its immediate and medium-term future. They also have the value of enhancing its
appeal as an interesting and desirable agency to engage with.
Questions may be raised among some quarters about why PFI has strayed so far
from its original moorings as a grant-making agency that at best permits an addi-
tional portfolio for advocacy to one that now implements programmes in partner-
ship with the government and runs TV soap operas? There may be others who
view the new repositioning of family planning in its activities as a regressive return
to a discredited programme that was believed to have been buried long ago. Par-
ticularly, PFI’s endorsement of injectables as part of a wider basket of contraceptive
choices may tend to be interpreted as a betrayal of the reproductive health agenda
as a whole and of women’s real health interests.
The fact is that all of PFI’s current ongoing initiatives are knitted into each other in
terms of programme objectives. They draw lessons and insights from each other,
build transferable skills, and together form part of its overarching goal of sexual
and reproductive rights for women and adolescents, and women’s empowerment.
The repositioning of family planning is not a return to the old discredited Family
Planning Programme, but a return to a grossly neglected and unfinished agenda
that is vital to poor women’s rights. It is an impassioned plea for the overhaul of the
blinkered sterilisation, incentive-driven, and camp-based family planning service
that is still operative in far too many parts of the country. At present, this service
is the only ‘choice’ available to women at the bottom of the pyramid. What ‘repo-
sitioning of family planning’ is calling for is a service that is housed in an enabling
and respectful environment of hygienic, safe, and well-provisioned health services.
This enabling environment should be one where women, adolescents, and men
can work out the contraceptive choices that are best suited to them at wherever
they are in their life cycle. Wishing away the existence of the huge family planning
apparatus by simply shifting the focus to maternal and child health under the new
name of Reproductive and Child Health (RCH), neither raised the quality of ma-
ternal health services nor removed the sterilisation camps, as the recent Barwani
and Bilaspur tragedies showed. The nuanced and evidence-packed advocacy by
PFI following these two tragedies highlighted as never before that ‘moving on’
without first dealing with the demons already in the closet, merely creates ever
newer agendas without resolving the old ones.
Similarly, the work on the teleserial, Main Kuch Bhi Kar Sakti Hoon and in Communi-
The repositioning of family planning is a
return to a grossly neglected and unfinished
agenda that is vital to poor women’s rights. It
is an impassioned plea for the overhaul of the
blinkered sterilisation, incentive-driven, and
camp-based family planning service that is
still operative in many parts of the country
ty Action for Health (CAH) are both conscious attempts to establish complemen-
tary linkages between impersonal policies and programmes that come from afar and
disadvantaged people’s own abilities to participate in these programmes as informed
agents. For far too long have disadvantaged populations, particularly the most disad-
vantaged within them, that is, women and children, been at the receiving end of rousing
slogans and paternalistic programmes carried out in their name. Rarely have they had
the opportunity to be taken into confidence about the measures taken in their name,
their entitlements in relation to these measures, and be assisted with the training in the
skills required to take maximum advantage of these measures. Both the teleserial and
the CAH institutional mechanisms are modes of empowerment. One works through
information/knowledge delivered in the form of entertainment. The other is a learn-
ing-by-doing engagement with actual health issues at the level of the community and
relevant health facility. Admittedly, both are complex. CAH is also uncertain, besides
being pregnant with the possibility of failure, if it is not sustained over a length of time.
What then are the options ahead for PFI? These may be phrased in both general and
specific terms. In terms of broad strategy, the question may be posed as a set of con-
tinuing challenges before any organisation.
One is the challenge of how to balance its own imperative of augmenting its fi-
nancial base with the need to retain a relatively autonomous and flexible style of
functioning.
A second relates to the justifiable desire to influence social policies and be an
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agent of large-scale impact, which requires aligning itself ever closer to the State.
The challenge here is how to balance this impulse with the equally important im-
perative of retaining the independence to voice critical views. The latter in turn
involves sustaining alliances with and amplifying the voices of those at the opposite
end of the spectrum: ordinary people and communities on the social margins.
Yet another challenge calls for balancing the predilection among donors within
the prevailing complex funding scene that looks to support big and fast-moving
projects/programme ideas with the impulse of small NGO groups on the ground
to be experimental, creative, and determinedly small in the scale of their work, for
which they look to PFI for trusted and supportive partnership.
Finally, the laudable urge to pursue a dynamic programme strategy that will begin
to shift the terms of social and cultural discourse away from their hitherto unques-
tioned moorings, needs to be tempered with the political sagacity to run only as
fast as the prevailing orthodoxies permit, if PFI is to sustain its own political lever-
age and viability.
In terms of specificities, this institutional history suggests a few options for PFI’s
short and medium term future. All have to do with building knowledge and skills,
the only long term bulwark against instability and uncertainty. Given below is a list
of options, which is not in any order of importance, and which is followed by an
elaboration on each:
Rebuild PFI’s corpus;
Complete the unfinished agenda of developing PFI as a centre for scaling up;
Continue the task of investing in capacity building among state-based second
level government personnel to enhance their effectiveness in implementing the
communitisation process in both rural and urban programmes and their supportive
roles that are essential for the maturation of citizens’ organisations;
Strengthen PFI’s focus on research and publications to build a body of knowledge
relating to rural and urban development processes in the health sector;
Extend the scope and life of the teleserial by adding urban related themes and
introducing the serial into rural and urban government/municipal schools;
Stay abreast of scientific developments relating to contraceptive technologies;
Hone and further deepen PFI’s skills as an advocacy centre;
Intensify the ongoing work of building population health development awareness
and competence among elected representatives at all levels, but most of all with
PRI representatives;
Reorganise and upgrade PFI’s documentation centre and archival skills;
Continue the engagement with urban health issues;
Continue grant-making to the select group of trusted NGO partners that the
Foundation has been nurturing.
Building a corpus: The problem that PFI faces today is somewhat reminiscent of
the challenge faced by its founding fathers in the initial years following the creation
of the organisation. The founders assumed (and hoped) that private industrialists
would be munificent in their support for the then still unfamiliar idea of family plan-
ning, but were also willing to accept whatever came along. A glance through the
earliest Annual Reports shows meticulous listing of the tiny amounts donated by
individual industries. Today, it might be worthwhile for PFI to go back to encourag-
ing individual giving and combine it with casting a wide net to bring in both large
and new smaller national and international donors who are able to subscribe to the
values underlying PFI’s priority areas. The shift in focus towards health and women’s
issues may make it easier for individuals and businesses to relate to them, particu-
larly when they are shown as extending to educational interventions through the
formal school system, which is another sector that now attracts huge private and
philanthropic organisations as well as volunteering efforts by a wide cross-section
of urban middle class professionals. Violence against women, rape, alcoholism and
other forms of substance abuse, non-communicable diseases — themes which are
dealt with through the teleserial — may individually evoke supportive responses.
This is more likely to be so if they are shown as linked to ongoing educational work
of sensitising and empowering schoolgoing adolescent girls and boys — the coun-
try’s demographic dividend — and building leadership skills among them for future
participation in community-based citizens’ organisations, which are nurseries that
will help them grow into responsible citizens in a democracy.
Centre of Excellence in Scaling Up — An Unfinished Agenda: The objective
of the MacArthur Foundation grants that began in 2005 was to facilitate PFI to
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develop itself into a centre that would offer training and services in scaling up.
However, this objective did not materialise. Changes in staffing, partly because of
the closure of the HIV/AIDS Care and Support project, and staff turnover in gen-
eral, left PFI depleted of many of the personnel who had been trained as part of the
original MSI-PFI collaboration phase. Also, opportunities for extending into new
areas of work afforded by policy developments, such as scaling up the communi-
tisation component of the NRHM, initiating technical assistance for piloting and
scaling up the HUP programme and bringing the NUHM into existence, initiating
and scaling up new programme areas like the transmedia initiative, and reposition-
ing family planning, further deflected attention away from the original objective of
maturing into a dedicated centre for scaling up.
The need for, and challenge of, creating such a centre still exists, given that re-
source organisations providing such support are by and large non-existent within
the country. PFI made a beginning when, in collaboration with the MSI, it conduct-
ed an introductory workshop with key stakeholders in the government, NGOs,
academic institutions, and international donor organisations working in the country.
But, for the institutionalisation of the SUM skills to happen, such that scaling-up
components are routinely integrated into the design and implementation plan of
new pilots, particularly in the health sector which has historically been the victim
of neglect, much more investment of financial, intellectual, and management re-
sources is required.
The creation of a centre of excellence is probably best done in a collaborative
relationship between PFI and one of the publicly funded Indian Institutes of Man-
agement. This could be a lean and technically proficient team that is regularly
available for training and providing hands-on technical assistance to NGOs, state
governments, educational/research/public health institutions in planning and de-
signing intervention projects. For a start, explorations could begin with the Indi-
an Institute of Management, Lucknow, and the Indian Institute of Management,
Bengaluru, that are mandated to focus on enhancing management skills in the
NGO sector and the public sector, respectively. Other than small NGO based
projects, this could be offered as a consultancy service and charged to the client;
the monies earned could be used to defray the salaries of the centre’s personnel
and the rest funnelled into PFI’s corpus. If the centre is unable to become self-suf-
ficient within a specified time frame, it could be disbanded.
Strengthen Technical Skills at The State and Sub-State Level: PFI’s move
towards integrating the population question with the task of improving public
health services and their accountability raises the significant issue of how to build
the prestige, quality, and capabilities of all the components involved: the health
services, the resource agencies meant to provide programme support; and the citi-
zens’ organisations meant to participate in keeping the services accountable. All of
this needs to happen at the state and sub-state levels, which are the only enduring
loci for the communitisation processes. PFI is already trying to work with some
of these institutions: state governments, State Health Systems Resource Centres,
State Health Societies, and District Health Societies (where they exist). It is training
middle-level state officials in the SUM Framework skills, building capacity to pre-
pare PIPs for both NRHM and NUHM components, and building a commitment
among officials to strengthen the communitisation component and improve the
quality of health services. Training and retraining these categories of personnel that
form the backbone of the long-term changes set in motion is crucial, and the pro-
cess of keeping it as an ongoing intervention — including who the trainers should
be — needs to be thoughtfully envisioned.
Course structures need to be drafted to suit the needs of each batch of trainees
as the communitisation process matures. By weaving course structures around
the challenges and problems faced by these officials in the course of their own
work and relating pedagogy to real-life situations and issues, much as is done in
management training, course structures can be made to come alive and bring
meaning to the programmes that these officials handle in the course of their
daily work. For far too long has the importance of leadership coaching, executive
coaching, skill development, and personal growth been emphasised only in relation
to those engaged in profit generation. The second-level echelons of government
officials and health professionals who work along the last mile need coaching and
skill building too, since their work impinges on the lives of multitudes of ordinary
people. Industries in the particular state could be coaxed to contribute to a state
corpus to support such skill development, reviving Mr J.R.D. Tata’s dream of PFI’s
partnering with private industry for the common social project of improving the
quality of life of the population. It may be worthwhile to try persuade philanthro-
pies, particularly national philanthropies, to also contribute to the cause of such
training programmes.
This in itself could become a theme for a time-bound grant programme that brings
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together pedagogy professionals with an interest in health related development
issues that are grounded in a regional understanding of cultural, social, political,
and historical circumstances. Small working groups could be created, one for each
state, or fluid structures, rather like colloquia, to design frameworks for carrying out
such trainings.
Strengthen the Focus on Research and Publications: With its deepening en-
gagement with the community mobilisation component of the NRHM and with
strengthening the capacities of states to address the issues of their urban popu-
lations, PFI has entered a very challenging arena. ‘Village communities’ that work
unitedly in their enlightened collective self-interest simply do not exist in most
parts of rural India. Rather, villages tend to be battle zones, driven apart by rival
communities that are organised around caste, a social reality that is regularly fu-
elled and sustained by the way in which political/electoral processes operate. As
long as PFI played the role of a national think tank that did demographic research,
related to the central government and the big policy picture, and concerned itself
with the states only in terms of organising seminars and conferences, the problem
of its having to negotiate ground level social and political realities in order bring
about change simply did not arise. The logic of the population stabilisation phase
as articulated by PFI today has propelled it — and rightly so — into integrating the
population question with the public health question. Since health is a state subject,
it is the states and their districts, blocks, and villages that become the inevitable
arenas for investigation and action.
PFI already accords importance to research as a source of generating high-quality
evidence for its advocacy activities. Research on issues/puzzles generated by PFI’s
programmes should ideally incorporate both applied and conceptual dimensions.
One of the huge questions, for instance, raised by the ‘communitisation’ compo-
nent in development programmes is: what is a ‘community’ in rural India today,
outside of the homogenous caste clusters? Questions relating to the concept of
‘community’ were raised even by researchers examining the community develop-
ment programme of the 1950s, which was predicated on the assumption of the
harmonious idyllic village republics idealised by Gandhi. It has been common for
all development programmes since to unquestioningly build this assumption into
their planning. It is time to interrogate this concept and tease out the contradic-
tions and nuances under different regional, social and political contexts. How can
villages reconcile conflicting community interests and power equations, both social
and political, for expedient practical gains relating to health? How can PRIs, which
are more often than not configured on the basis of caste equations, rally around
issues relating to health that affect all sections of the village society? What could
be different forms of mobilisation under conditions of caste homogeneity and het-
erogeneity?
The communitisation component of the NRHM attempts to build a consumer
movement among users of the public health services. One of the research chal-
lenges that PFI is already grappling with — and which the third in the series of the
MacArthur Foundation’s flexible grants has been making possible — is to identify
the diversity of social-institutional possibilities that might exist in the different states
for anchoring the community monitoring process. The challenge of what might be
the most appropriate grievance redressal mechanisms for individual states is yet
another puzzle that PFI is currently engaged in unravelling. A third and urgent
research question is how to envision and work towards the building up of PRIs to
play their rightful role in the Village Health, Sanitation and Nutrition Committees
and Rogi Kalyan Samitis, keeping in mind that they are not free of the influence
of electoral caste-based politics. The potentialities and constraints here may be
expected to be different in different states, and therein lies the creative challenge.
Communitisation is a long-term process and must be given a long time horizon
in which to come into its own. Impatience and shortcuts based on expediency of
whatever variety will simply not take it forward.
PFI’s presence in, and familiarity with, states across the country can be leveraged
to mount imaginative comparative research programmes that pursue sets of ques-
tions that are planned for crystallisation through working papers and publications.
These time-bound researches can also usefully feed into the designing of practical
tools/processes for implementing these programmes as they mature. In the same
way that, in an earlier era, PFI brought into the intellectual discourse the diversity
of state and regional demographic profiles and trends this phase offers the oppor-
tunity to highlight the interaction of social, cultural, and political diversities within
and across states, and how this influences participatory processes related to health,
sanitation, and nutrition, in both rural and urban manifestations. Useful publications
could emerge from these research efforts.
Extend the Scope and Life of the Teleserial: The foregoing discussion dealt with
the invisible aspects of PFI’s work. The teleserial Main Kuch Bhi Kar Sakti Hoon
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The challenge of what might be the most
appropriate grievance redressal mechanisms
for individual states is yet another puzzle that
PFI is currently engaged in unravelling
constitutes the most visible aspect. The potential of the serial as an instrument of
awareness raising can go far beyond the television and radio broadcasts, YouTube
and DVD resources, and social media. The episodes of the serial could usefully
be taken into schools in villages, towns, and cities of the EAG states to begin with
and serve as focal points for generating discussion on gender roles and gender
inequalities. Government/municipal schools could be the starting point. One of
the findings of the evaluation of Season One was that men and frontline workers
had slipped through the cracks and were not impacted by its message. All govern-
ment and non-governmental intervention programmes concerning contraception,
family planning, and building support for community level accountability mecha-
nisms, share the common finding of missing men or men who ensure that women
are kept out or made into proxies for themselves. Until and unless the manner in
which boys are brought up is questioned and changed, men will not be available
for such teleserial viewings or participation in health related programmes alongside
women, and things will not change so easily for women. Changing adolescent
gender norms is also vital, and schools are the most logical institutional locations
for this effort, particularly since son preference ensures that every boy is sent to
school irrespective of his academic performance.
Teachers will have to be trained, and their counselling skills built around discussion
questions framed around themes and clusters of episodes of the serial. Alongside,
‘empowerment education’ modules need to be built for both girls and boys. Front
workers can be usefully drawn into these school programmes, forming a link be-
tween the school and the home. This engagement of frontline workers could be
brought about by including them along with teachers in the training sessions and
linking students with them so that the children grow into thinking on and participat-
ing in health and gender issues in multiple ways.
The teleserial, through its many seasons and sets of issues addressed, offers a
hugely valuable opportunity to anchor such questions in place of vague didactic
styles of the textbook variety for conveying ‘civic’ messages and lessons. This is a
task that is grossly overdue and carries with it the promise of long-term outcomes.
Its huge magnitude ought not to be seen as daunting, for it can be done jointly us-
ing the government’s Rashtriya Kishor Swasthya Karyakram (RKSK) and the edu-
cational department umbrellas. PFI’s learnings from the horizontal linkages forged
in the NUHM and HUP may come in useful here.
Such an initiative — ‘health in education, and education in health’ — could extend
the life of the teleserial considerably. Community-based researches into the im-
pact of health education have shown that schoolgoing children are the best carriers
of knowledge regarding health issues back into the home. Future seasons of the
serial may also wish to address issues relating to the citizens’ committees, PRIs, and
issues of women’s participation in public processes by using the medium of en-
tertainment carrying social messages. Using a combination of industry donations
under corporate social responsibility, government funds, individual giving, crowd-
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funding, and bringing in social entrepreneurs, PFI could use the teleserial initiative
to build up a corpus of finances, skills, and even enthusiastic professionals taking
time off from corporate sector careers to help set off and sustain this huge inter-
vention project in the form of a social movement. In the process it could exploit the
particular institutional strengths of individual states.
Monitor International Developments in Biomedical Research: The 1970s saw
the start of an intensification of research into newer generations of contraceptive
technologies (following on the IUDs and oral pills) by international biomedical
groups. Many of these researches have since been steadily coming into fruition
in the form of technologies ready to go into trials or purchasable in the market.
It is important to track these developments, the related scientific literature, and
generally stay abreast of scientific facts relating to trials and efficacy as well as the
movement of these technologies across national boundaries through the medium
of joint international research programmes, donor aid, or market mechanisms. This
is an additional anchoring role in the population field that PFI is best suited to do,
The teleserial, through its many seasons and
sets of issues addressed, offers a hugely
valuable opportunity to anchor such
questions in place of vague didactic styles
of the textbook variety for conveying ‘civic’
messages and lessons. This is a task that is
grossly overdue
given its national and international leverage.
Deepen Advocacy Skills: PFI has already done a commendable job of putting
out graphic presentations of some of its key contributions, for example, SUM
Framework, Repositioning Family Planning, and Pattern of Contraceptive Use
across countries. It might pay rich dividends to build the skills of a small and nimble
core advocacy group within the Foundation that could service all of its projects.
Such a group could monitor international donor and policy developments, Indian
philanthropy trends, biomedical advances in contraceptive technology, national
population and health policies, performance of health and family planning services
at the level of individual states, trends in school health education, etc. Monthly
briefs could be prepared by the group for both internal circulation and for strategic
placement in the media and for lobbying with elected representatives.
The current phase has already witnessed an intensification of engagement with
the media, both print and electronic. This has related to ongoing debates on issues
to do with family planning, population, quality of care, budgetary allocations, child
marriage, women’s agency, new contraceptive technologies, etc. It has also taken
the form of regular editorials in mainline dailies, press statements, and analysis of
specific issues/occasions such as the Union Health Budget, World Population Day,
and Census results. When mass tragedies have occurred — such as sterilisation
camp deaths or mass maternal deaths — where PFI has played a proactive inves-
tigative role, it has taken the form of presentation of key findings from fact-finding
reports relating to the mass tragedies and their policy implications. These initiatives
by PFI have helped to disseminate evidence and analysis in a form that is friendly
for use by journalists, with a view to enabling professional and balanced coverage
of news that could potentially be needlessly sensationalised and politicised.
Regular infusion into the proposed core advocacy group of new skills in writing,
collating, and presenting information could be an asset to PFI in moving issues
and debates forward in prompt and cogent ways. The ability to stay centred and
nuanced through balanced analysis and expression is a strength at all times, but
particularly so when the public arena is rife with volatile and strident cultural and
political overtones.
Work with Parliamentarians, State Legislators, and Municipal Councillors:
PFI has a long tradition of working to raise the understanding of population and
development issues among parliamentarians. This continues even now in the
form of tracking questions raised in Parliament, and providing assistance to parlia-
mentarians for participation in debates. With PFI’s deepening engagement in the
states, it would do well to explore ways of extending this assistance to the state and
municipality levels and use relevant data and insights to educate them. Document-
ing the process could be an invaluable source of insights and lessons. This would
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begin to have spin offs for the support of health programmes and policies and also
Urbanisation is one of the fields of the future, and PFI would do well to see how to
offer learnings for the training of PRI representatives on how they could highlight
remain positioned within it.
their issues for consideration at the state level.
Grantmaking: Reference has already been made to strengthening PFI’s research
Archival Skills: The steady collection and organisation of data for the states,
focus. The Foundation has over the years nurtured a small group of trusted NGO
districts, and sub-districts would require upgrading archival skills to handle this
associates who have benefited from its grants. Remaining invested in the ongoing
important data source and make it available to researchers and policymakers.
work of these associates is a good strategy through regular disbursal of grants,
Continue the Engagement with Urban Health Issues: PFI’s
experience of engaging with the HUP programme is too valuable to lose.
albeit small, is a good strategy. This also leaves the door open for possibly drawing
these associates into experimental studies/approaches that PFI may wish to take
up in the future.
....
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01
Case Study
Main Kuch Bhi Kar Sakti Hoon:
Shifting Deeply Rooted
Gender Norms Using a
Transmedia Initiative
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Main Kuch Bhi Kar
Sakti Hoon:
Shifting Deeply
Rooted Gender
Norms Using a
Transmedia Initiative
104
An Institutional History of the Population Foundation of India, 1970–2015
he ongoing TV serial, Main Kuch Bhi Kar
T
Sakti Hoon (I, A Woman, Can Achieve
Anything), is admittedly the most visible
of the Population Foundation of India’s
(PFI) current interventions, and the ful-
crum of the transmedia initiative that is
the subject of this case study. It is the
flagship intervention project of PFI and
was launched in early 2014. In the last
year and a half or so of its existence, the
serial has become almost synonymous with the larger paradigm shift in PFI’s mission
since 2010. This shift places women’s health and rights at the heart of PFI’s work and
identifies women’s empowerment as the key instrument for achieving the nation’s de-
velopmental goal of nurturing a healthy, happy, and productive population. Family
planning is recognised as a key component in strategies to achieve this goal.
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The serial’s objective is an ambitious one: to change the way people think about
the fundamental questions of what it is to be a woman or man in Indian society. It
illustrates how the prevailing skewed gender norms, roles, and relations operate
to cause negative health outcomes for girls and women. It also decisively demon-
strates how such problems/issues can be resolved. It does all this through the
dramatic portrayal of realistic situations and characters and credible and powerful
positive role models of both women and men. Thus, the serial seeks not only to
raise awareness among women, youth, and communities at large about these vital
gender issues, but also to create an enabling environment for action by individuals,
families, communities, and health providers to set off the process of changing the
way those norms work.
What is it about this particular project that makes it a point of departure for PFI’s
long-term identity as a national advocacy organisation ? How was it conceived,
planned, and implemented? And what is its potential for making a sustainable dent
in the way ordinary people think about gender issues? These are the questions that
this case study seeks to address.
The birth of the idea: PFI has a long tradition of producing short one-off docu-
mentary films on topics of public interest relating to population issues. From the
Foundation’s early beginnings, the goal of this activity was defined as one of ‘mo-
tivating’ people to adopt family planning methods. Generally commissioned by
the Ministry of Health and Family Welfare, these films tended to be designed to
either commemorate population related annual ‘events’ (such as World Population
Day) or highlight new government policies in the population-health sector. Thus,
Pag Pag Aagey (Moving Forward One Step at a Time), supported by the Pack-
ard Foundation, sought to inform people about their entitlements to improved
public health services under reforms set in motion by the National Rural Health
Mission (NRHM). Another film, Haule Haule (Slowly, Slowly), supported by the
MacArthur Foundation, focused on the importance of women’s health by paying
attention to the age at marriage and birth spacing.
Haule Haule was particularly well received. It gained popularity as a teaching and
training tool in capacity building of field level village and health functionaries and
communities and was dubbed into four regional languages as well as in English
for wider dissemination across India and the neighbouring countries. Analysis of
the content showed that it touched a chord in the viewing audiences. A young
woman undergoes a second premature pregnancy in keeping with her husband’s
wishes, because their first child was a girl. She suffers foetal loss because of her
weak state of health and barely survives the ordeal herself. What redeemed the
content — and this suggested a promising point of departure — was that it also
showed how the problem might be resolved. Juxtaposed against the given dismal
cultural scenario is the young female protagonist — the husband’s younger sister
— who refuses to submit to an underaged marriage and face the same fate as her
sister-in-law. She is shown winning the support of her prospective educated groom
and together they are able to bring their conservative families around.
Haule Haule was particularly well received. It
gained popularity as a teaching and training
tool in capacity building of field level village and
health functionaries and communities and was
dubbed into four regional languages as well as in
English for wider dissemination across India and
the neighbouring countries
The challenge that PFI set for itself when making the teleserial, Main Kuch Bhi
Kar Sakti Hoon, was not only to raise awareness about the social determinants of
health and family planning, but also to monitor the direction of change in thinking
among the public and the government health and family planning personnel when
exposed to such audio-visual messages. What did it take to shift deeply rooted
cultural norms?
The commonest reasons for the failure of the Indian Family Planning Programme
to curb the still high birth rates in many regions of the country are twofold. One is
the near total reliance on female sterilisation and invisibility of non-terminal spac-
ing methods. The other is the near universal practice in different culture regions of
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the country to marry off girls in adolescence, followed by family and social pressure
on them to conceive soon after. Son bias is at play throughout. It makes for un-
dernourished young mothers to start with, and it results in births remaining closely
spaced until the desired number of sons have been born and have survived. The
consequence is low birthweight babies and maternal depletion as well as pregnan-
cy loss and maternal deaths, with abortion frequently becoming the only contra-
ceptive method of choice to ensure sex selection. By the time young women and
men are ready for the government’s family planning agenda, sterilisation is the only
option offered to them.
How can the available media and digital technologies, which are daily transforming
both mass and interpersonal communications, be used to bring about an enduring
change in the gender norms, perceptions and behaviours responsible for the above
scenario? How can health-seeking behaviours and uptake of non-terminal family plan-
ning services improve in favour of women’s health? The high television penetration
even in rural areas and the universal popularity of commercial soap operas suggested
that packaging education in an entertaining way and using drama based on real situ-
ations to create ‘edutainment’ on gender and population issues might be a promising
option. Using adaptations of the serial on radio could amplify the communication strat-
egy. In a developing country with one of the largest mobile phone using populations
in the world, mobile friendly serial clips and interactive voice response system (IVRS)
technology offered the potential to receive questions and feedback on content and
impact, along with instant entertainment. Where youth were educated and had access
to the internet, YouTube, Facebook, and Twitter, these could all be experimented with
to extend the reach of the messages. Finally, at the ground level, access to some or all
of these technologies could be supported, where possible, by NGO facilitated face-
to-face interactions in the form of viewers’ clubs and discussion groups.
The implementation: Primary among the key elements that came together to feed
into the conceptualisation, planning, and implementation of the project, was PFI’s ef-
fectiveness in being able to convene a significant group of collaborators with diverse
skills to engage with its embryonic ideas for this project. The backing of assured seed
funding from PFI’s Board and expression of interest by the UK Government’s De-
partment for International Development (DFID) in part-funding such an intervention
received a further boost from Doordarshan’s offer (the Government of India’s TV
channel) of free air time to assist in scaling up. All these together helped the project
think big from the start.
Real heroes being facilitated at an event in collaboration with Dainik Jagran in Patna, Bihar
In January 2013, PFI brought together the first of a set of concentric circles of pro-
fessionals from the social sciences, mass media, theatre, policy analysis, and related
fields for a brainstorming on six focus areas that it believed ought to be the kernel
of the TV series. These were: delaying age at marriage; delaying first births of
married adolescents; promoting spacing between births; improving quality of care
of family planning and reproductive health programmes; preventing sex selection;
and promoting non-coercive practices, programmes, and policies. These were the
same six key priority areas identified by PFI’s strategic planning exercise for the
five-year period 2011–2016, extendable until 2020.
A key early input were seminal insights from the theory and practice of enter-
tainment education (EE) by leading academic researchers in this field, notably,
Dr Arvind Singhal, Professor and Director, Social Justice Initiative, Department
of Communications, University of Texas. These perspectives helped frame the
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creative brief for the film team, which was led by theatre director Feroz Abbas
Khan who brought to the TV series a strong theatre background and scripting skills
that specialised in dramatising real-life stories. Drawing on international research
evidence from successful experiments, notably in Central and South American
countries and in South Africa, that had used soap operas to trigger major social
changes in the health, family planning, and education sectors, the creative brief
argued for the importance of real-life stories and for combining the realistic with
the aspirational in conceptualising the main characters in order to make them cred-
ible and relatable to both urban and rural audiences, and especially the youth. EE
research also pointed to the value of using the ‘positive deviance’ approach, that is,
identifying positive behaviours and practices in a community, so that they might be
amplified as a norm for all in the community to adopt. When this approach is used
to model the behaviours of the key actors, audiences are given the opportunity to
look to characters for clear clues on how they might act to change their own lives.
The opportunity to pilot a sustainable project that would go to scale in a planned
manner (two principles that underlie PFI’s ongoing policy) came in July 2013, with
a DFID grant to PFI for a project called Promoting Planned Families. This made
possible the planning for Season One of the serial: the first 52 episodes that would
address the six core areas that formed the initial brief for this intervention. The
grant required that the episodes be grounded in the social situation and needs
prevailing in the states of Bihar, Madhya Pradesh, and Odisha, the key mandated
states for DFID supported programming. This was a geographical concentration
that was in keeping with PFI’s own pre-existing commitment of work in the relative-
ly less well-performing states on maternal and child health and fertility indicators
(EAG states). Following the grant from DFID, PFI was able to leverage funding
from the UNFPA to adapt the serial to the radio and for an IVRS designed to
obtain viewer feedback.
During the 12 months leading up to the launch of the serial on Doordarshan Na-
tional in March 2014 and the launch of the radio series on All India Radio in May
2014, formative field-based research was designed and carried out to inform the
content, message, and production. About 90 positive deviance stories focusing
on the quality of care, birth spacing, counselling, and contraceptive choices were
collected from the contiguous culture region of Bihar, Madhya Pradesh, Rajasthan,
Delhi, and Haryana to feed into the creative brief being prepared for the film team.
Simultaneously, research findings on the drivers and barriers to family planning
were reviewed and distilled to inform the questions being posed in the serial. Be-
haviour change communication strategies were tested in the Madhya Pradesh and
Bihar contexts in order to refine the outreach strategy and approach. Both, the
proposed title of the TV series and one episode each for the TV and radio, were
pre-tested for respondents’ reactions.
A baseline survey of prevailing perceptions and attitudes relating to women’s
health, gender relations, and family planning was conducted in five districts each
of Bihar and Madhya Pradesh, where the transmedia intervention, along with out-
reach activities done in concert with locally active NGOs, was to be intensively
deployed. These were also the districts where an endline survey was conducted at
the end of Season One to assess impact.
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From March to October 2014, the 52 episodes of Season One were broadcast in
the Hindi language across India on Doordarshan National and Doordarshan-Bihar,
on Saturdays and Sundays from 7–7.30 p.m. From May to December 2014, the
broadcast was extended to Doordarshan India (serving audiences in West Asia,
the Far East, Canada, and Europe), also in the Hindi language.
Over this same period, the radio adaptation of the serial, also in Hindi, was broad-
cast nationally on the Government of India’s All India Radio, across a total of 239
stations (216 FM primary and 23 FM Rainbow stations). In the states of Uttar
Pradesh, Bihar, and Madhya Pradesh — or, rather, in their ‘media-dark’ sub-regions
— narrowcasting of the radio adaptation in the local languages was simultaneously
undertaken over six community radio stations. This was managed by Graam Vaani
— a social technology company based at the Indian Institute of Technology, Delhi
(IIT-D), working on reversing the flow of information by using simple technologies
and the social context to design tools that can impact rural communities in over
As Season One drew to a close, there was a
sense that the serial seemed to have been a
significant success. Doordarshan on its part
had already evinced interest in broadcasting
the serial in the original Hindi over its regional
kendras across Northern India and in translating
and dubbing it into regional languages for its
kendras across Southern and Eastern India
15 states of the country. Graam Vaani also works in other developing countries
in the Asian and Sub-Saharan region. In Jharkhand, Bihar, Madhya Pradesh, and
Uttar Pradesh, a few state level private mobile radio platforms run by another or-
ganisation partnering with PFI, aired the series in the local languages and also ran
discussions on the issues that the initiative raised.
Co-terminus with telecasting of the serial and radio broadcasts was the operation
of a dedicated national IVRS for viewers to simply call in and share their experi-
ences and thoughts on the serial and the issues that it raised, ask questions and
receive advice, answer weekly quiz questions related to the show, or simply listen
to interesting bytes from celebrities and title songs.
In addition to all of the above interventions, five districts in each of the states of
Madhya Pradesh and Bihar were selected for an even more intensive outreach
strategy. In these two regions, PFI partnered with local NGOs under whose aegis
community activities based on the serial were launched. These were in the form of
viewers’ clubs consisting of women and youth groups called Sneha Clubs, where
groups of people gathered to watch the serial and engage in discussions about
the issues that it raised and organise Hum Kuch Bhi Kar Sakte Hain (We Can Do
Anything) events. Master trainers from these NGO partners were identified and
trained in using the specially prepared communication materials like games, comic
books, and illustrations to help facilitate discussion about the issues that the show
raised. The master trainers in turn were charged with training the group leaders of
the viewers’ clubs in the use of these materials for facilitating discussions in groups.
In this manner, the TV serial adopted a ‘360-degree’ approach to behaviour change
communication. In other words, starting from the mass media TV and radio serials
that provide entertainment and knowledge, accompanied by engagement through
mobile phones and IVRS that deliver information and advice, and provide a plat-
form for sharing, the process of communication gets reinforced within face-to-face
groups where facilitators and frontline workers engage in one-on-one discussions;
people also have the chance to engage in discussions within group situations. Thus
multiple, distinct, yet complementary channels of communication work together to
create a whole that is greater than the sum of its individual parts. As people start to
hear the same message from multiple sources, knowledge is increased and shared,
attitudes can be changed, and social norms start to transform.
The impact: As Season One drew to a close, there was a sense that the serial
seemed to have been a significant success. Doordarshan on its part had already
evinced interest in broadcasting the serial in the original Hindi over its regional ken-
dras (stations) across Northern India and in translating and dubbing it into regional
languages for its kendras across Southern and Eastern India.
Season Two with an even larger stable of 78 episodes was in the offing, with fund-
ing commitments and the original production teams still in place. Clearly, the proj-
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Coming in for particular
appreciation was the
serial’s demonstration of
knotty issues being resolved
over the space of just a few
episodes
Behind the scene: Feroz Abbas Khan on set with the cast of Main Kuch Bhi Kar Sakti Hoon
ect was achieving scale, as originally planned. Three issues,
however, needed clarity.
What had been the relevance of Season One’s stories, characters, and messaging
to the audiences? What were the key likes and dislikes? What did audiences want
more of and why? And what were the gross negatives that they had perceived in
the stories, characters, and messages? This would indicate which aspects needed
changing, strengthening, and altering in future programming and suggest how the
storyline for Season Two of the series might be developed.
Who were the people actually watching and following up on the serial? Which
among the target groups were falling through the cracks? What themes emerged
unambiguously as the key relevant themes for Season Two?
To answer the above questions, PFI attempted to assess the impact of Season
One in both qualitative and quantitative terms. Both of the assessments were car-
ried out as in the baseline survey in Madhya Pradesh and Bihar. These two states
together account for 15 per cent of the country’s population, have high fertility
rates, and high rates of unmet need for family planning. In this region, more than
any other, there is an urgent need to raise the age at marriage and at first birth as
well as levels of knowledge and access to family planning services.
Qualitative assessment: Over the period August to December 2014, a qual-
itative Rapid Assessment was commissioned to see how the serial had actually
fared among its target audiences. It focused on young adults, married couples, and
frontline health workers in the intensive outreach districts of the states of Mad-
hya Pradesh and Bihar. It used a combination of methods: in-depth interviews with
frontline workers, focus group discussions with currently married female and male
viewers of the serial, and in-depth telephone interviews with viewers who could
be accessed through the IVRS callers’ database. What came across was a story of
resounding success.
Viewers were quick to perceive the positives that the serial offered. High on the
list was the character of Dr Sneha, seen as a dedicated professional woman, confi-
dent and powerful, even as she came across as compassionate, a loving and caring
daughter, and unhesitatingly identifying herself with the village of her birth. Older
women were able to see her as a role model for their daughters, and young wom-
en felt inspired by the model of modernity and independence that she project-
ed. Viewers were able to see the stark contrast between this portrayal of a strong
woman versus women in commercial soap operas where they are rarely seen as
economically independent or as trained professionals and where the focus is on
manipulative and regressive daughter-in-law/mother-in-law bickering.
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Launch of Main Kuch Bhi Kar Sakti Hoon Seaon 1
Equally positive was the perception of the story line as realistic and authentic, faithful-
ly portraying problematic and familiar situations of gender and age asymmetry in the
family. Viewers also welcomed the focus on rural India and its transformation under
the impact of modernising influences. Coming in for particular appreciation was the
serial’s demonstration of knotty issues being resolved over the space of just a few
episodes. Both these features were seen as being so different from those commercial
serials that focused exclusively on city folk leading trivia-consuming lives and whose
problems are shown to go on endlessly without ever reaching a point of resolution.
Above all, women viewers appreciated that the serial, while offering entertainment
and good stories, also provided food for thought. A number of them felt that the
serial had made them aware of a great many things relating to vital aspects of their
lives. These related to self-care during pregnancy and the postnatal period and the
importance of feeding colostrum to the newborn. They also learnt that family plan-
ning was more than just sterilisation and that other contraceptive methods could be
considered for different needs. The importance of women finding a common voice
to question and deal with the widespread domestic violence was another issue. And
so on. These were issues that they either had been largely ignorant of or had never
before been stimulated to think about in clear and constructive ways.
Perceived negatives were fewer but constructive. They pertained to both program-
matic and time slot issues. People expressed the desire to see more positive roles that
focused on men, including showing men in supportive roles in relation to women.
The timing of the programme, too, came in for dissatisfaction. It was the common
view that 7 p.m. was far too early, with men not back from work and, therefore, their
missing out on viewing the serial. Nor was it a good time for women, for it was their
time slot for finishing off cooking and other household chores before the family set-
tled down to its leisure time in the late evening. Viewers also felt that the serial could
have gained from better publicity efforts. Despite the promotional events launched
by PFI, significant sections of the population had remained unaware of it. Viewers
contrasted this with the relentless advertising that one witnesses for commercial se-
rials.
Notably, those who seemed to be missing out on watching the serial because of lack
of knowledge about it were the frontline workers — ANMs, AWWs and ASHAs —
precisely those health-related staff who are a significant target audience for the
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serial. These village level health workers can be expected to be the first port of call
for rural communities. They were also visualised from the start as possible candi-
dates for training as animators of the community level focus group discussions with
adolescents and young couples and at community events based on issues raised
by the serial. All these frontline workers are also significant members of the Village
Health, Sanitation and Nutrition Committees wherever these had been brought
into existence under the Community Action for Health intervention process. The
assessment exercise showed that the serial, during Season One, had not been very
successful in empowering them with knowledge and certainly not to the extent that
it had set out to do.
Quantitative assessment: In terms of sheer numbers, the serial’s performance
during Season One was impressive. An estimated 58 million viewers had watched
Season One of the TV serial (as measured by the Indian Readership Survey [IRS]
and Television Audience Measurement [TAM]), and it had been ranked between
the third and fifth most popular programmes in its time slot of 7 p.m. on Saturdays
and Sundays.
The serial had also generated 625,000 calls through the IVRS from across the coun-
try, made by 150,000 callers, a majority of whom were women and youth (the serial’s
primary target audience), a clear endorsement that PFI had reached out to the right
demographic group via this initiative.
An endline evaluation conducted in February–March 2015 in seven districts of
Bihar and nine districts of Madhya Pradesh, exactly one year after the baseline survey
had been undertaken, covered married and unmarried men and women, mothers-
in-law, and frontline workers. It showed that 36 per cent of TV owning households
had watched the serial, 42 per cent in Bihar and 34 per cent in Madhya Pradesh; this
despite the fact that both of these states have a high penetration (80 per cent on
average) of both Direct-to-Home (DTH) and cable networks that broadcast pop-
ular commercial serials. As with the IVRS callers above, a sizeable proportion (40
per cent) who had watched the show were youth (in the age group 15–24 years).
Half the married women who watched the show were in the age group 18–24 years.
The series had also reached 72 per cent households who owned radios, with 82 per
cent in Madhya Pradesh and 42 per cent in Bihar. The six community radio stations
in Madhya Pradesh, Bihar, and Uttar Pradesh had reached out to 570,000 listeners
and had received 31,244 calls from people to engage with the serial.
The survey showed that across the board, exposure to the serial had progressive-
ly increased viewers’ knowledge on the issues of legal age at marriage, the risks
posed by early marriage to the lives of the mother and child, the desirability of
women having their first child between the ages of 21 and 25, the need for spacing
pregnancies, awareness of the different methods of family planning, and the desir-
ability and benefits of family planning. The number of people who felt that women
had the right to make their own reproductive choices and decisions, that domestic
violence was unacceptable, that boys were in no way better than girls, and that
there was no justification for gender discrimination, had also increased. In fact, the
highest recall of any character in the serial was that of Dr Sneha, who was seen as a
lovable, admirable, and aspirational character, and this was followed by Buaji, who
was seen as familiar and endearing.
What came across in the final assessment of the impact of the serial was that, on
the whole, viewers saw the serial as representing realistic situations and relatable
characters and problems. They had learnt a great deal from it. But most important-
ly, they had enjoyed watching it. Over 94 per cent of viewers said that they would
like to watch the programme again.
In terms of the impact on current and potential sponsors, too, the results have
been encouraging. After the run of Season One on its national and interna-
tional channels, Doordarshan has extended the broadcast of the Season One
series to 16 of its regional channels. The telecast is already completed on twelve
Regional Kendras (Bhopal, Lucknow, Jaipur, Ahmedabad, Bhubaneswar, Maha-
rashtra, Chennai, Thiruvananthapuram, Benguluru, Srinagar, Patna and Northeast)
and two are underway (Guwahati and Jalandhar). It is noteworthy that the negative
feedback during the Rapid Assessment Survey regarding the inconvenient early
evening timings of the broadcast on these channels was taken into account; in fact,
a variety of time slots are being experimented with. Viewers across the country,
both men and women, can expect to have the chance to watch the series at a more
convenient hour. Technological mechanisms for outreach have been easier to put
in place; the IVRS call-back system is in place, and social media outreach has been
stepped up. But community level support systems are not in place at this scale.
The encouraging response to Season One took Main Kuch Bhi Kar Sakti Hoon
into its second season, with funding from the Bill and Melinda Gates Foundation.
This season consisted of 79 episodes and was launched on 4 April 2015. Probably
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Farkhan Akhtar, Founder of MARD, launching ‘Main Kuch Bhi Kar Sakti Hoon’ Season 2
in response to the positive finding that nearly half the viewers of Season One were
youth and over half the callers on the IVRS were also youth, Season Two focused
on youth related issues. Dr Sneha continued to be the main protagonist and here
played the lead role as doctor-cum-youth counsellor on health and reproduction
issues. Again, possibly in response to the negative feedback regarding the ‘miss-
ing men’ among the viewers of Season One and the paucity of positive male role
models, Season Two also engaged with men in interesting ways in its dealing with
the priority areas of sexual and reproductive health, alcoholism, de-addiction, do-
mestic and gender-based violence, mental health, and non-communicable diseas-
es. It had on board the popular Bollywood star Farhan Akhtar as the serial’s anchor
and narrator, who introduced and explained the twists and turns of every issue
being addressed. Farhan also represented his NGO, MARD (Men Against Rape
and Discrimination), which was an official collaborator with PFI for the season.
Other members of the Bollywood fraternity have also lent their support for PFI’s
transmedia initiative. Brand ambassadors for Season One included Sharmila
Tagore and Soha Ali Khan, who gave away the Main Kuch Bhi Kar Sakti Hoon
awards meant to honour those community-based women and men who had ac-
tually challenged gender norms in the serial’s target regions. They offered yet new
stories of ‘positive deviance’ and thus vindicated some of the serial’s messages.
Season Two was aired on Saturdays and Sundays, but, in deference to public feed-
back, the timings were pushed forward to 7.30 in the evening. The season was also
aired an adaptation for radio on All India Radio (the same 239 stations as in Season
One) and the six community radio stations that had narrowcasted Season One.
The IVRS response from the public has been extraordinary — more than 12 Lakh
calls from 136,432 callers (till November, 2016).
The telecast of Season Two on regional Doordarshan Kendras is completed on
four regional Kendras (Ahmedabad, Bhopal, Srinagar and Northeast) and two are
underway (Jaipur and Lucknow). The dubbing in regional languages is in process
in seven Kendras ( Guwahati, Jalandhar, Bhubaneshwar, Chennai, Thiruvantapur-
am, Benguluru and Sahyadri).
These widening concentric circles of association, collaboration and outreach, with
youth at their centre, have given a new fillip to PFI’s attempt to harness social me-
dia to promote the objectives of the transmedia project and, indeed, to complete
its 360-degree linkages. Since March/April 2015, viewer engagement with the se-
rial’s issues grew significantly on Facebook and Twitter, while YouTube has become
a growing resource for those wishing to access past and ongoing episodes. Partly
this could be a function of the collaboration — which includes joint social media
campaigns and co-production of issue-based songs — with Farhan Akhtar’s NGO,
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MARD, during Season Two.
The year 2015 also saw PFI achieve a more intensive engagement at the commu-
nity level through the agency of local NGOs/community-based organisations in
the selected intensive engagement districts of Madhya Pradesh and Bihar. The
process of facilitating this engagement — the preparation and dissemination of
communication materials such as comic books, puzzles and facilitator manuals, has
gained momentum. To date, 429 Sneha Clubs (viewers’ clubs) have come into
existence, and the identification of the award-winning women ‘heroes’ — the wom-
en emerging as leaders in challenging gender norms referred to earlier — is often
through the agency of these clubs.
The Ministry of Health and Family Welfare (MoHFW) and UNFPA collaborated
with PFI to rebrand their Peer Educator programme for adolescents under the Na-
tional Health Mission’s Rashtriya Kishor Swasthya Karyakram (RKSK). The peer
educators were renamed ‘Saathiya’, which means a trusted friend. The concept
was then launched across India through the MKBKSH series in the last 26 epi-
sodes. The scripts were rewritten to incorporate the key messages identified by the
RKSK programme and extensive field visits by the MKBKSH creative team. The
voices from the youth across India have been included in the scripts. Additionally,
MKBKSH created the visual branding — providing the name and the logo, both
of which have been adapted by the Ministry. Through a creative storyline and en-
dearing characters shaped by positive deviance research, the series established the
need for Saathiya and demonstrated the process of change that can be triggered
by them. It showcased the selection and training process in an easy to understand
and entertaining format. Kishor Ka Shor –an innovative and informative quiz show
where adolescents find answers to the issues that concern them, was introduced
in the series. Additionally, PFI collaborated with the MoHFW and UNFPA to
develop a comprehensive Saathiya resource kit which consists set of eight films
developed from the 26 MKBKSH – Saathiya episodes including messages from
Farhan Akhtar to the youth on being a Saathiya. The set of eight films have been
translated into 13 Indian languages to reach the peer educators across the country.
The Saathiya diary also developed in line with the episodes have been included
in the kit among other materials developed by UNFPA and UNICEF. These are
being utilised as training modules for peer educators across India as well as con-
ducting community level meetings and intercations. The Saathiya resource kit was
launched in February 2017 nationally followed by roll out across states during the
year.
In December 2017, when Doordarshan decided to reteleast the serial Season One
onwards reinforced the popularity and demand for the importance of the series as
a key influencer to change behaviours on issues of women’s health and agencies.
As per Doordarshan, it was the most watched series in India with a viewership of
400 million and counting. Efforts continue unabated to extend the reach of the
teleserial and radio adaptation; the Main Kuch Bhi Kar Sakti Hoon team remains
alert to new and unexpected developments that might push the frontiers of this
transmedia initiative. And Season Three — which will take on themes relating to
preventive and promotive health — is already on the cards.
....
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02
Case Study
Bilaspur and Barwani Tragedies:
Evidence-Based Advocacy
for Strengthening Public Health
Services and Widening
Reproductive Choice
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Robbed of Choice
and Dignity:
Indian Women
Dead after Mass
Sterilisation
Situational Assessment of Sterilisation
Camps in Bilaspur District, Chhattisgarh
Report by a Multi-organisational Team
November, 2014
118
An Institutional History of the Population Foundation of India, 1970–2015
Bilaspur and
Barwani Tragedies:
Evidence-Based
Advocacy for
Strengthening
Public Health Services
and Widening
Reproductive Choice
or decades after the launching of the
F
national Family Planning Programme in
the 1960s, ‘motivating people’ to go in for
‘planned families’ (defined as a husband,
wife, and two children preferably one of
each gender — hum do, hamare do) was
seen as the main role for the government’s
advocacy partners in the family planning
arena. The premise was that large families
were an inevitable outcome of ignorance,
born largely out of rural residence, origins
or poverty. Cultural issues like son preference, rampant anaemia among adolescents
and young women, early marriage, premature childbearing, and the implications of
these for women’s health and family size played a weak role in the thinking, as did the
appropriateness and quality of family planning services on offer under the programme.
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In the initial years after Independence — the decade of the 1950s — the devel-
opment policy, in keeping with the broadly Gandhian approach to social change,
had been one of promoting holistic ‘community development’ that focused on
the predominantly rural population. Social education with a view to raising age
at marriage, health education, immunisation, and environmental sanitation, with
their long-term implications for family health, were the cornerstones of India’s
first public health policy. Where family planning was concerned, policy was large-
ly guided by the Gandhian aversion to artificial methods. By the late 1950s, impa-
tience with the slowness of this approach to development had gained momen-
tum. The rising temperature of the global debate on the exploding population
situation in the developing countries found its echo in India in the alarm bells set
off by the results of the 1961 Census.
The outcome was the opening of a new era of policy focus on technology-driven
contraceptive devices. The public health system became the site for promoting
condoms and ever newer generations of oral contraceptive pills and IUDs along
with vasectomy and female sterilisation. Spacing methods, however, came with
several complicating features. Their single common feature was the long-drawn
nature of putting into place the support structures required to sustain them. Im-
plementing IUDs required continuing public education and the creation of qual-
ity medical skills and follow-up structures to handle the associated problematic
side effects among users. Condoms and oral pills required ensuring their steady
supply and promoting their consistent use.
All this was sought to be circumvented by a push in favour of vasectomy and
female sterilisation. The sense of urgency about coming up with politically de-
sirable quick and demonstrable impact on population growth figures resulted in
a predominantly ‘camp’ approach to administering the irreversible methods to
large and concentrated populations of men and women. By the 1970s, the use of
these methods through the centrally administered Family Planning Programme
was additionally bolstered by the policy of setting targets for health personnel
and offering monetary incentives to ‘acceptors’. The Emergency years of 1975–
77 witnessed the intensification of the camps and coercive targets in the form of
enforced mass female sterilisations and vasectomies.
The large-scale vasectomy drives in particular resulted in disastrous political
fallouts. It was not long before women and their bodies were identified as the
most pliable solution to the problem of controlling population growth. Given
the skewed nature of gender relations and the still simmering outrage against
the vasectomy era, this paternalistic focus on women’s fertility had tacit and
widespread social approval. The policy now focused on ‘motivating’ women with
suitable monetary incentives to go in for sterilisation after their second or at
best third child. The public health system across the country — however thin
the spread and poor the quality — and its personnel — suitably driven by targets
— became the most convenient location and mechanism to implement the cen-
trally administered, vertical, and numbers-driven national programme for family
planning.
The success of the policy can be seen from the fact that sterilisation has made a
dent on population growth figures across large regions of the country. Regions
lagging behind are those where the public health system is too feebly present,
too thinly provisioned, and with too poorly trained doctors and paramedical staff
to carry out this central agenda. In these regions, the family planning policy has
tended to rely predominantly on the ‘camp’ approach, where qualified doctors,
motivated by monetary incentives based on the numbers sterilised, carry out
mass sterilisation procedures on women brought in from distant villages, with no
responsibility for the patients’ well-being either before or after the procedures.
Chhattisgarh, a state with a majority tribal population, is one such region.
Bilaspur Sterilisation Deaths:
The episode: On 8 and 10 November 2014, at four camps conducted in Bilaspur
district of Chhattisgarh under the aegis of the state public health system, 137
women underwent laparoscopic tubectomy. Of this number, 16 women died and
scores of others went into a near death condition. The overwhelming majority of
women attending the camp were very young mothers, many with small infants
following two or three previous births. They had been almost universally ‘moti-
vated’ by their respective ANMs and Mitanins (the Chhattisgarh version of the
community health worker or ASHA) to get themselves sterilised and had been
promised a monetary compensation each of Rs 600. Admittedly, none of the
women had actually been coerced into the decision. All were ready to stop hav-
ing children, and sterilisation was the only modern contraceptive method known
and available to them.
What was it about the quality of the family planning services at those camps that
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caused the tragedy? Bilaspur was not the first such instance of mass sterilisation
deaths in camps. Other states with similar economic and social indicators (no-
tably Madhya Pradesh, Rajasthan, Bihar) had had similar camp scandals. Was it
only to do with the camp approach per se? Or was it an inseparable hazard of the
public health system itself?
Just as daily deaths and irrevocable disability due to unrelenting urban air pol-
lution, poverty, malnutrition, and overcrowding go unnoticed until a Bhopal-like
disaster focuses public and government attention on such issues, so too with
the silent mortality and chronic morbidity that often follow sterilisations or IUD
insertions. The conditions under which family planning services are delivered to
unsuspecting poor women tend to be routinely appalling — unhygienic environ-
ments, unprofessional medical conduct, and total absence of follow-up — and
attract the spotlight only when large numbers of victims get tragically and dra-
matically concentrated within space and time.
The official story put out by the govern-
ment was that it was a case of adverse
drug reactions. But all the empirical
evidence examined by the investigating
team pointed to septicaemia
For PFI, the Bilaspur camp tragedy was yet one more piece of evidence that the
country’s family planning agenda was still an unfinished one. If women’s well-be-
ing mattered, rather than their mere numbers as sterilised bodies, the Family
Planning Programme needed to be revisited. Family planning needed to be re-
positioned within a women’s rights framework. It was a women’s right to have
access to a range of both spacing and terminal methods of contraception, infor-
mation about the merits and demerits of each method, assistance in exercising
the best choice for themselves, and quality service back-up in relation to both
method administration and side effects. What happened in Bilaspur showed
that the Family Planning Programme offered women no choice other than ster-
ilisation. And, irrespective of all policy pronouncements, women continued to
be ‘robbed of choice and dignity’ by an uncaring public health system that was
grossly violative of their basic human rights.
The evidence: Using its convening skills, PFI quickly brought together a
multi-organisational fact-finding team consisting of doctors, family planning pro-
fessionals, and women’s health advocates to investigate and collect evidence. It
also garnered the support of senior officials in the Ministry of Health and Family
Welfare at the Centre for its investigation. They in turn elicited the backing of
the Chhattisgarh state health and district administrative officials and local medi-
cal staff. PFI intended to carry out a transparent, meticulous, and science-based
enquiry that would constructively use the government’s own quality guidelines
as the framework for examining the case, and it was vital that the government
agencies be on board.
Mercifully, the camp deaths had stopped at 16. The panicking local administra-
tion had swung into swift action soon after the deaths came to light and had
brought every one of the sterilised women along with their close family members
from their homes to specialty hospitals at the district headquarters for observa-
tion and treatment. But, there was no getting away from the fact that what had
happened was symptomatic of a much deeper malaise afflicting the entire Fam-
ily Planning Programme, not only in the state of Chhattisgarh, but also possibly
across the country. All the policy rhetoric about reproductive health following
the International Conference on Population and Development (ICPD) had not
gone below the tip of the iceberg: the unreformed historical baggage of a Family
Planning Programme based solely on targets and compensation-driven num-
bers of sterilised women still remained. It was time to go beyond ‘death control’
and ‘birth control’ statistics and, instead, focus on a woman’s right to lead a safe,
healthy, and dignified life on the basis of her own informed choice.
The investigators spoke to all the actors involved: families of the deceased; hos-
pitalised survivors and their families; staff of the state primary, community, and
district health centres, and the private and district level hospitals, where the sur-
viving women had been admitted; the peripheral health workers involved like the
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ANMs and Mitanins; and state and district level senior health and administrative
personnel. Indeed, all but the offending doctor, who was already in jail. The evi-
dence that they unearthed is as follows.
Of the 137 procedures, 83 had been carried out in the space of just one and a
half hours at one camp. The remaining 54 procedures had been similarly speedily
executed at three other camps. At each camp, the same gloves, injection nee-
dle, syringe, and suture needle, and only one laparoscope had been used for all
the cases. The operating room — itself in a state of long disuse — had been in
an unfumigated state. The interaction between the health system and acceptor
women had been perfunctory. There had been minimal screening before the
procedure, and no information or counselling was given about what they were
about to undergo. Nor were they offered the choice of or information about
alternative spacing methods. In the operating theatre, a ward boy had been in
charge, positioning the women on the operating table to be sterilised in assem-
bly-line fashion, and then carrying them back to mattresses on the floor follow-
ing the procedure (since there were no beds in what was essentially an unused
facility). Immediately after the procedures had been completed, the officiating
doctor had signed the requisite papers and left. Neither doctor nor nurse had
checked the sterilised women or offered any information or counselling about
the procedure that they had undergone or about self-care. Barely 30 minutes
to an hour after it was all over, the women had been given their compensation
amounts and sent home with their motivators. Even the drugs meant to be taken
post-procedure had been given to them by the motivator ANM/Mitanin only
after they had reached home.
The outcome of the procedures was the almost immediate onset of rampant
septicaemia across the board. When women in large numbers started arriving
at the public health facilities with multiple symptoms of septicaemia, and the
first 16 deaths and near-deaths of scores of others surfaced, the government
administration took the action of fetching all the rest of the women from their
homes and admitting them into good quality hospitals in Bilaspur. This was a
move that saved their lives, but left open the question of their convalescence,
full recovery, and possible lingering long-standing morbidities, including repro-
ductive morbidities. At the time that the PFI team concluded its investigation, 63
of the women were still in intensive care, and only 58 had been discharged from
hospital. The official story put out by the government was that it was a case of
adverse drug reactions. But all the empirical evidence examined by the investi-
gating team pointed to septicaemia.
Indeed, the unambiguous evidence was that on all quality parameters, the camp
procedures had violated the government’s own quality guidelines. These per-
tained to choice of method, dignity and comfort, privacy and confidentiality,
safety of procedure, follow-up, referral services, and space for feedback. Among
the proximate factors causing the epidemic of septicaemia was that the camp had
been organised in a non-functional health facility, which compromised the basic
standards of cleanliness and care during and after the procedure. According to
the guidelines, the 83 procedures in the first camp alone required three teams
of medical staff in the operating room, each team consisting of one surgeon,
one theatre assistant, and one nurse. The after-care of the patients required the
local health centre to have two doctors (including one lady doctor), four staff
nurses, one ANM, and two attendants. Instead, the only personnel actually pres-
ent had been one surgeon, one theatre assistant, two nurses, and one ward boy,
of whom only the surgeon was a trained professional. The surgeon’s apparent
competence had not prevented him from performing the maximum number of
procedures in the minimum amount of time, backed by untrained support staff
and unhygienic operating theatre conditions. He had used the same unsterilised
equipment throughout, violating the requirement that not only the gloves, injec-
tion needle etc., but also the laparoscope needed to be changed after every 30
patients. Clearly, the surgeon was motivated solely by his entitlement to be paid
according to the number of procedures completed.
The investigation further revealed that the public health centres in the district
were too poorly staffed and provisioned to carry out sterilisations at all. Nor were
they at all fit to administer spacing methods, with their abysmal stocks of pills,
condoms and IUDs and poor professional skills. This dismal state of affairs left
no real choice for women of the region who wished to limit their families. On
their part, the peripheral level staff had the tyranny of annual sterilisation targets
hanging over their heads, accompanied by the fear that their salaries and incre-
ments would be withheld if they failed to come up with the requisite numbers.
And that was not all. Inefficiency in the release of funds from the state headquar-
ters for achieving the sterilisation targets further meant that all the targets had
to be met within the last four months of the financial year. Given that the entire
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district had only three surgeons trained in laparoscopic sterilisation, it was little
wonder that hurriedly put-together sterilisation camps, such as the ones under
investigation, had become the norm.
The advocacy: The above picture accurately described the conditions pre-
vailing on the ground. However, since PFI was looking to mount an objective,
constructive, and comprehensive advocacy strategy, it deemed it important to
place the particular situation in Chhattisgarh against the macro-situation prevail-
ing across the country. To this end, it commissioned a detailed study of national
13 per cent had been spent on other family planning related activities like staff
expenses, transportation, equipment, etc.
That the gargantuan appetite of the sterilisation programme with its misplaced
emphasis on monetary inducements has tended to take away from resources
(‘untied grants’ in official parlance) that could alternatively have gone into main-
tenance and improvements in the quality of services of the Primary Health Cen-
tres can be seen from the fact that the amount spent as compensation for female
sterilisation in 2013–2014 (Rs 324.49 crores) was 2.5 times the untied grants (Rs
Although the district had not gone beyond the pilot phase and
Community Monitoring had been discontinued by the Madhya
Pradesh government, the local communities there had become
mobilised and aware of their rights and entitlements
expenditures on sterilisation and on family planning as a whole, to see where
these expenditures stood in relation to the expenditure on the primary health
care system itself. The picture that emerged is as follows:
In 2013–2014, the total national expenditure on family planning had been to the
order of Rs 396.97 crores. Of this, Rs 338.91 crores or 85 per cent had been spent
on female sterilisation alone. Of the amount that had gone into sterilisation, al-
most 96 per cent (Rs 324.49 crores) had been dedicated to compensation dis-
bursements. Less than five per cent (Rs 14.42 crores) had been spent on camps.
In contrast to the sterilisation expenditure, barely 1.45 per cent of the family plan-
ning budget (Rs 5.76 crores) had been spent on spacing methods. The remaining
129.38 crores) given to the primary health system. The pattern of family planning
expenditures in the state of Chhattisgarh in 2013–2014 more or less faithfully
mirrored the above national priorities.
Thus, what happened in Bilaspur, while totally unfortunate, could theoretical-
ly also have happened anywhere else. In fact, in another district of the country
Barwani, like Bilaspur, a predominantly tribal region in the neighbouring state
of Madhya Pradesh, that also figures in this case study, albeit for different rea-
sons, sterilisations were co-terminously taking place in camps similar to Bilaspur.
There, too, sterilisation targets ran into tens of thousands. Individual local gy-
naecologists were setting records of carrying out 200 to 360 procedures in the
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course of single-day camps. In Barwani, however, it was mass maternal deaths
that came to corner the spotlight.
The challenge before PFI was to frame a convincing advocacy strategy that fruit-
fully combined the empirical evidence from Bilaspur and the expenditure analysis
of the national Family Planning Programme. The objective was to advocate that
the Government of India needed to move away from quality-compromised and
responsibility-compromised family planning services, the most notorious variant of
which were the ‘camps’. Instead, what was required was a shift towards better-pro-
visioned and more quality-controlled services. These services needed to be run
round the year at institutional public health facilities equipped to offer women both
sterilisation and spacing methods on fixed days of the month.
methods of contraception, an exercise that led to the inclusion of injectables in the
basket of choices. This was a technology that had hitherto been kept at bay by
protesting women’s health activists, who were still unwilling to accept the latest sci-
entific evidence in favour of injectables as one more spacing choice. The activists
preferred, instead, to sidestep the issue of family planning altogether, rather than
re-examine options for poor women trapped in a sterilisation dominated policy.
The Ministry of Health and Family Welfare constituted a committee of Secretaries
of Health of all the states to review and monitor, on a three-monthly basis, the
situation prevailing in all the states pertaining to the Family Planning Programme,
quality of care, expanding contraceptive choices for women and related issues.
The PFI-led multi-organisational team submitted its report to the Prime Minis-
Barwani Maternal Deaths
ter of the country. Rather than adopt an adversarial posture relating to the flawed
national family planning policy or a politically essentialist position relating to the
state government in question, PFI used the damning evidence generated by its
investigation to advocate that the government at the Centre and in the states
permanently abandon the ‘camp’ mode of female sterilisation, driven as it was by
targets and insidious compensations, and in its place strengthen the public health
system and expand reproductive choice for women.
The episode: Conceptually, apart from being a woman’s right, family planning is
an important complementary strategy to support maternal health programmes
in bringing about an overall reduction in maternal mortality and morbidity. How-
ever, as evident from the foregoing case of the Bilaspur tragedy, the target-driven
sterilisation-based Family Planning Programme is not only being implemented in
blatant disregard for quality norms, it is also taking away valuable resources from
the primary health care system under whose aegis maternal health programmes
The immediate outcomes of this constructive advocacy approach were swift.
(among other services) are meant to reach needy women.
The Ministry of Health and Family Welfare sent out ten
key recommendations to all the states. These included,
among other things, the abolition — finally — of targets
and camp-based sterilisations; stipulation of a fixed day
at every Primary Health Centre for carrying out family
planning related surgeries and activities; the institution of
high quality clinical training in family planning techniques
for medical personnel at all levels of the public health
system, including laparoscopic and mini-laparoscopic
surgeries; training in and enforcement and oversight at all
Above all, the Bilaspur advocacy effort
paved the way for a new national level as-
sessment of available spacing methods of
contraception, an exercise that led to the in-
levels of the government’s quality guidelines; and regular
review and improvement of the guidelines themselves.
clusion of injectables in the basket of choices
Above all, the Bilaspur advocacy effort paved the way
for a new national level assessment of available spacing
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The tragedy of 26 maternal deaths in a single district hospital in Barwani district
of Madhya Pradesh — a predominantly tribal area — within the space of a few
months in 2010, illustrates just how badly the public health services serve the
needs of women in their most vulnerable reproductive role. Again, as in Bilas-
pur, Barwani was not a unique occurrence, but symptomatic of a national prob-
lem: the callousness and ill treatment meted out by the public health services
to women in pregnancy and labour. What brought on the spotlight in this case
were the mass community protests against the mass deaths, mounted under the
leadership of a local Adivasi organisation, the Jagrit Adivasi Dalit Sangathan.
The tragedy was promptly investigated by both the state government’s health
services and by civil society groups.
For PFI, the mass deaths scandal posed both opportunities and challeng-
es. On the one hand, as symptomatic of the abysmal quality of public health
care that afflicts the nation as a whole, the maternal deaths could become a
spur for advocacy in the direction of appropriate corrective mechanisms,
with potential to cascade across the states. On the other hand, Barwani dis-
trict had been part of the nine-state pilot phase (2007–2009) of the Com-
munity Monitoring process set in motion by the NRHM. This was part of the
government’s broad agenda of making the health services in rural areas more
accountable (this is addressed in another case study focused on the Commu-
nity Action for Health initiative). Although the district had not gone beyond
the pilot phase and Community Monitoring had been discontinued by the
Madhya Pradesh government, the local communities there had become mobil-
ised and aware of their rights and entitlements. Yet, the mass maternal deaths
had occurred.
In its role as Secretariat of the Advisory Group on Community Action — the
empowered civil society body set up by the MoHFW to guide the nationwide
process of Community Monitoring — PFI had an additional reason to undertake
the investigation. It could provide clues to identifying the obstacles to the imple-
mentation of the NRHM reforms. A further disturbing signal was that when the
mass protests erupted in the wake of the deaths — and particularly the death of
one woman, Vyapari Bai, who became the rallying symbolic figure when she died
40 hours after being admitted into the District Hospital — the state government
had simply retreated into a ‘law and order mode’ and slapped legal cases against
200 of the protestors under the Indian Penal Code. This had resulted in a com-
Mothers and their newborns in a Verandah: Community Health Centre in Pati, Barwani, Madhya Pradesh
plete breakdown of dialogue between the service providers and the community.
The evidence: In keeping with its inclusive and collaborative approach, PFI in-
vestigative team of four AGCA members and three PFI staff also had on board
key state government representatives: the Deputy Director of the state’s ASHA
programme and the District Facilitator for Maternal Health. In March 2011, the
team visited and physically reviewed the situation at Barwani at four levels: the
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community (village), the Primary Health Centre (PHC) (choosing one out of
the three PHCs), the Community Health Centre, and the District Hospital.
Throughout the investigation, the team consciously kept to the given mandate
of the AGCA. These were:
(i) Accountability and responsiveness: What precisely were the issues that
had contributed to the fuelling of the mass protests? What were gover-
nance oversights? And what were the prevailing state of accountability and
transparency processes and mechanisms concerning health services in the
district?
(ii) Referral mechanisms: What were the processes through which women
reached the District Hospital, the final referral point? Could the women
have been managed at a lower but legitimate centre?
(iii) Quality of care of services: What was the nature of the services provided
at both the District Hospital and the lower centres of obstetric care? What
was the nature of the patient-provider relationship and the management of
adverse outcomes?
At the village level, the situation was that in the wake of the pilot project on Com-
munity Based Monitoring, the Jagrit Adivasi Dalit Sangathan (the local NGO that
went on to lead the protests) had taken the initiative to form village health commit-
tees. These committees had been monitoring and holding regular dialogues for
improved antenatal services, immunisation, anganwadi services, and distribution
of below poverty line (Antyodaya) cards. Grievances relating to the poor quality
of services had repeatedly been submitted to the District Collector and Chief
Medical Officer, and there was a paper trail to establish this. But, these grievanc-
es had never been addressed. Very specifically, the main grievances were about
issues of antenatal care. This component of care was limited to occasional distri-
bution of folic acid tablets and administration of tetanus toxoid injections; testing
of haemoglobin levels and blood pressure, urine examinations, and abdominal
examinations, were conspicuous by their omission. Nor did the ANMs stay at
the sub-centres as required.
As a result of the persistent attempts of the village level health committees in
sustaining a dialogue with the ANMs, some improvement had come about in
child immunisation and the distribution of Antyodaya cards. But little else had
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The doctors did mainly private practice, and the
ANM whom the team met, admitted that she
was able to conduct only normal deliveries. The
health centre itself was housed in a dilapidated
and dirty building, its open verandah serving
as the OPD and in-patient ward as well as the
registration counter and pharmacy
changed. Home deliveries still took place in the villages. Only in cases where
there were problems during labour did the ASHA immediately refer the woman
to the PHC or Community Health Centre. A jeep for this purpose — the Janani
Express — existed and could be called for; but the jeep had no arrangement for
a woman in labour. There was no provision for the patient to lie down or space
for accommodating a stretcher. And, for women living in villages in the interior
to get to the main road for the jeep, it meant having to be carried in cloth slings
over long distances.
At the PHC level, the investigating team found that there were no haemoglo-
binometers at all, this in a tribal region where sickle cell anaemia is known to be
rampant, and pregnant women, particularly, tend to suffer from severe anaemia.
When the ANM present at the PHC was asked to take the blood pressure of an
investigating team member, she clearly did not know how to do it. As regards
the Medical Officer, the team could not meet him, as he reportedly only deigned
to visit the PHC once a month to collect his salary. The labour room had no
evidence of its ever having been used — even the bed’s plastic cover had not
been removed — and, upon probing, the team found that the ANM admitted
that since she did not wish to be responsible for any untoward happening, she
preferred not to conduct any deliveries at all! Rather, she simply sent on every
woman in labour to the Community Health Centre. No ward or laboratory facil-
ities were evident at the PHC.
At the Community Health Centre, the team found the data on home deliveries
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An Institutional History of the Population Foundation of India, 1970–2015
to be totally haphazard and unreliable. What data existed in the so-called Health
Management Information System (HMIS) records showed that on average, in
that year, there had been around 300 deliveries a month. Of these, roughly one-
third were noted as home deliveries, one-third as institutional deliveries from the
three constituent PHCs put together, and one-third as deliveries at the Com-
munity Health Centre. The majority of the home deliveries were recorded as
having been conducted by ‘skilled birth attendants’ (a requirement stipulated by
the Janani Suraksha Yojana, a maternal health care scheme introduced by the
NRHM that stipulates that all births should be institutional or, at best, delivered
by a ‘skilled birth attendant’). However, none of those questioned — either local
health staff or block level officials responsible for signing the records — quite
knew what exactly a skilled birth attendant was; the figures had simply been in-
flated to conform to the Janani Suraksha Yojana requirement. The deliveries
supposedly occurring at the PHCs, too, were suspect. The team found some
other records that showed that a large proportion of women had actually deliv-
ered ‘on the way’, yet on the HMIS they were shown as having had institutional
deliveries. Clearly, the Rs 1,400 that every woman was entitled to receive on
arriving at an institution for her delivery might have been misappropriated.
Despite being designated a Comprehensive Emergency Obstetrics and New-
born Care Centre, the Community Health Centre did not seem to have ei-
ther qualified personnel or the necessary infrastructure for maternal care. Two
non-specialist doctors and three ANMs were all that it had by way of medical
personnel. The doctors did mainly private practice, and the ANM whom the
team met, admitted that she was able to conduct only normal deliveries. The la-
bour room had only one delivery table, and therefore, deliveries when there were
more women were conducted on the floor. The Community Health Centre’s
bathroom — the only one that the maternal cases could use — was dirty and had
no provision for use for bathing by women soon after delivery. The health centre
itself was housed in a dilapidated and dirty building, its open verandah serving as
the OPD and in-patient ward as well as the registration counter and pharmacy.
Seeing the women who had come to deliver lying on the floor, the investigating
team enquired as to why there were no beds. They learnt that one of the doctors,
who runs a hospital in his home, had taken away all the beds. The laboratory had
two technicians who did not know how to conduct any tests related to pregnancy
care, including haemoglobin, urine albumin, etc.,and, therefore, did not conduct
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any such tests. The operation theatre did not conform to any quality standards,
yet it was being regularly used to conduct laparoscopic tubectomies. The x-ray
machine appeared dusty and in a state of disuse, which was also evident from
next higher level by maternal health services staff reluctant to assume responsibility.
Once the women, after going through the series of delays, finally arrived at the
District Hospital, their care was further delayed by their being routinely sent off for
The investigating team found that one of the major
problems that doctors at the District Hospital were
having to cope with was an overload of patients,
much of which was due to their referral from the
PHCs and the Community Health Centre
the fact that the room was not even equipped with any electrical connections.
The Community Health Centre also had an unused baby warmer, which none
of the staff knew what it was for or its mode of use. Stacks of weighing scales,
suction apparatus, blood pressure machines, and cervical collars all stood around,
layered with dust.
The Barwani district female hospital sitting at the apex of the above-described
dysfunctional medical system at the PHC and Community Health Centre levels,
appeared to be the only institution actually operating in some respects. Even there,
it was overburdened with patients. It was in this hospital that the 29 maternal deaths
had occurred.
The investigating team found that one of the major problems that doctors at the
District Hospital had to cope with was an overload of patients, much of which was
due to their referral from the PHCs and the Community Health Centre (as de-
scribed earlier). Families were bringing in their pregnant women for delivery with-
out any delay to the lower level centres. Yet, they were being referred on to the
needless ultrasound investigations. It was this total abdication of responsibility and
deliberate prevarication that were endangering the lives of the unsuspecting wom-
en. It was this that had resulted in the avoidable loss of the 29 lives in 2010. It was not
that the women who had normal deliveries at the lower level Community Health
Centre were particularly safe; the prevailing unhygienic conditions there posed their
own set of dangers.
A second major cause for the maternal deaths at the District Hospital had been the
extremely fragile condition of several of the referred cases. Severe levels of anae-
mia among women arriving in a state of labour — levels so seriously low that the
anaesthetist found it impossible to administer anaesthesia if required — acted as a
tipping point. Severe eclampsia was yet another major cause of the maternal deaths.
Both of these avoidable causes could have been averted had these women received
appropriate antenatal care at the village sub-centre, PHC, or Community Health
Centre levels earlier in their pregnancy. A third problem faced by the District Hos-
pital was the severe and prolonged shortages in the stocks of essential medicines.
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Exacerbating the above set of problems was the fact that the district-level doc-
tors were often away at sterilisation camps, where they performed hundreds of
procedures a day (much as described earlier in the case of Bilaspur). One doctor
whom the team met with at her home stated that she had been away on camp
duty doing hundreds of sterilisations, which had left her too tired to attend to her
duties at the District Hospital.
The advocacy: PFI was clearly cut out for the advocacy challenge in its capacity
as the AGCA Secretariat. The already terrible state of the quality of maternal
care services and absence of their monitoring was being exacerbated by the way
in which the health staff at the levels below the district perceived the institutional
The already terrible state of the quality of
maternal care services and absence of their
monitoring was being exacerbated by the way
in which the health staff at the levels below
the district perceived the institutional birth
requirement of the Janani Suraksha Yojana
birth requirement of the Janani Suraksha Yojana. The result was overcrowding at
the District Hospital. This resulted in the hospital falling short of the personnel
and infrastructure required to respond to the demand. The Janani Suraksha Yo-
jana had been been put into place without any accompanying measures for the
improvement or upgradation of infrastructure, including the staff’s technical and
behavioural skills and work ethic. Clearly, the narrow preoccupation with one set
of inputs was resulting into an unfavourable set of outcomes. Either way, women
continued to be the losers.
The advocacy approach became one of arguing for the government at the Cen-
tre and in the states to view the maternal health problem as a proxy for the public
health care problem and to start putting into place immediate measures for the
strengthening of the public health system. Isolated inputs meant to tinker with
maternal care alone could clearly have unintended and untoward consequenc-
es. Further, tribal regions with their already difficult physical access conditions
for users of the health facilities and the chronic shortage of qualified personnel
required greater sensitivity to the way health services were organised so as to
make them more enabling. The investigative team’s report listed several specific
recommendations for the states.
Simultaneously, in its role as AGCA Secretariat, PFI filed a Public Interest Lit-
igation (PIL) with the Madhya Pradesh High Court on behalf of the affected
communities. Using the team’s report as its evidence base, the PIL urged the
state government to act constructively in response to the deaths at Barwani.
The High Court acted speedily and ruled that the state government implements
the AGCA recommendations without further delay. It also resolved the cases
that had been filed by the government against the 200-odd protesting Adivasi
women.
The AGCA’s legal action was at best an emergency measure. What was required
was a sustainable mechanism for grievance redressal and oversight. Further, giv-
en that every health service had perforce to be demanded and monitored, no
top-down reforms would have lasting impact unless accompanied by user scru-
tiny. Under the Community Monitoring reforms initiated in 2006–2007 by the
NRHM, Rogi Kalyan Samitis (RKSs) were mandated to be set up at the level
of the Community Health Centre. The RKS is meant to consist of communi-
ty representatives (including elected PRI representatives) and act for patient
welfare and citizen rights. It is vested with a budget that it can use to ensure
maintenance and improvement of infrastructure and services at the lower levels
of public health care. In the absence of the adoption of the NRHM in its entirety
by Government of MP, the Adivasi protests had at least focused the spotlight
on the problem. But, the activists had been arrested and threatened with severe
legal action for their pains. Clearly, there was still a long way to go, and public
mechanisms needed to be legitimised and strengthened before the government
services would begin to see themselves as accountable.
PFI, again in its role as Secretariat of the AGCA, has been keeping up advocacy
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attempts to push the EAG states (such as with the governments of Madhya
Pradesh and Chhattisgarh) to take more action in the matter of public health re-
form. One of the tentative outcomes is a greater sensitivity on the part of these
state governments to their respective tribal situations. In Barwani itself, following
the PFI/AGCA intervention, doctors were posted in remote areas, female wards
established in the District Hospitals, and a neonatal intensive care unit set up to
enable improved access.
The AGCA also meets with senior officials of the Ministry of Health and Family
Welfare once in every three months to share report cards from the regions and
thereby, keeps up a dialogue between the Centre and the states. At the level of
the individual EAG states, Common Review Missions, of which PFI as AGCA
Secretariat is a part, attempt to keep community issues within the sight of the
governments. Through the Common Review Missions, PFI stresses the impor-
tance of governments seeing the maternal health problem as a health system
problem. It also works on formulating guidelines and creating training manuals
for State Health Systems Resource Centres to build capabilities within the health
system and for building the competence of PRIs and communities on the ground
to become more aware of their rights and to hold the health system more ac-
countable.
....
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03
Case Study
The PFI-led Advisory Group on
Community Action (AGCA)
Fashioning a Responsive Public
Health System
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The PFI-led
Advisory Group on
Community Action
(AGCA)
Fashioning a
Responsive Public
Health System
lthough the priorities for health policy are
A
laid down by the Ministry of Health and
Family Welfare at the Centre, within the
federal Indian system, health is a state
subject. Therefore, the actual imple-
mentation of policies and programmes
takes place at the level of the states. How
much political will, funds, technical ex-
pertise, and social responsiveness states
infuse into their public health systems
determines whether these systems are well provisioned and functional round the year,
and staffed by qualified and responsive professional teams with support systems in a
state of constant use.
Village Health Mapping exercise in Gaya, Bihar
As recently as 2010 and 2014, the Barwani and Bilaspur maternal and sterilisation
related deaths, respectively (see Case Study Two), highlighted the long-overdue
reform of the public health system at its locus of operation, that is, the states. Exces-
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sive importance accorded to centrally privileged ‘national’ programmes — in this
instance, the national Family Planning Programme — while continuing with a cyn-
ical neglect of the decentralised system meant to anchor and actually deliver the
programmes, has been resulting in too many distortions. These make news only
when they take on the proportions of a tragedy. But on the flip side, major episodes
of system failure offer renewed advocacy opportunities for an agency like PFI to
intensify its ongoing dialogue for policy change with the government at the Centre
and in the concerned states.
PFI was already rolling up its sleeves to work at the state level from as far back as
2005, when it took on the role of being the Secretariat for the Advisory Group on
Community Action (AGCA), a body empowered by the Government of India
to partner with the National Rural Health Mission (NRHM) constituted in that
year. The NRHM was set up as a larger umbrella under which to nest the national
Reproductive and Child Health (RCH) Programme, which, in turn, had succeeded
the national Family Planning Programme. The NRHM came into being with the
core agenda of addressing the stubborn challenge of still high fertility rates in the
big northern states. To these were added other smaller poorly performing northern
states. Together, they formed the EAG group of states for focused policy attention
on social, economic, and demographic indicators that were placing obstacles in the
path towards achieving population stabilisation.
The NRHM also carried with it the underlying hope of strengthening state level
health systems to enable them to more effectively address the health needs of the
people as a whole, particularly disadvantaged groups — especially women — in
disadvantaged rural and tribal regions. Thus, while the key programme objectives
were to bring down maternal and child deaths and thus make for population stabil-
isation and gender and demographic balance, its mission objective was to improve
health service delivery. It hoped to achieve this by bringing all disparately working
health services under a single umbrella and providing universal access to afford-
able, equitable and quality healthcare, in ways that were both accountable and
responsive to people’s needs, particularly of the most marginalised groups. The
NRHM, on both of the above counts, was in broad alignment with the objectives
of PFI, making the partnership between the two a natural one.
At the heart of the NRHM policy for transforming the way health services are
delivered at the grassroots is an intensive three-pronged accountability frame-
work. This consists of (i) routine internal monitoring, (ii) external surveys, and (iii)
community-based monitoring (which later came to be termed ‘Community Ac-
tion for Health’[CAH]). The last-mentioned element of the framework places the
‘community’ firmly in the driver’s seat, giving it the mandate to undertake inclusive
need-based planning and monitoring of the health services for ensuring account-
ability. The premise is that community participation can lead to better health out-
comes both by empowering communities through raising awareness of their rights
and entitlements in relation to the health system and by strengthening the health
services through dialogue and joint solution seeking by users and providers.
For 18 months between 2007 and 2009,
a pilot project in community-based
monitoring was led by the PFI/AGCA
Secretariat in collaboration with large
and small NGOs in nine states
Piloting the Community-Based Monitoring and Planning (CBMP) Process:
The AGCA was brought into existence by a government statute to provide guid-
ance to and oversight of this ‘communitisation’ aspect of the NRHM implemen-
tation. Leaders of health NGOs from across the country with successful records
of evolving micro-level health interventions at the grassroots and mobilising com-
munity involvement were invited by the Ministry of Health and Family Welfare
to come on board in their individual capacity to assist in thinking through ways of
strengthening the capacity of communities to participate in monitoring their own
health needs in dialogue with providers. While NGO leadership and engagement
were seen as critical to triggering off the process of community mobilisation, the
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long-term implementation of Community-Based Monitoring and Planning was
expected to take the form of a three-way partnership between healthcare pro-
viders and managers of the government health system, village communities, and
elected representatives in Panchayati Raj Institutions (PRIs) at the village, block,
district, and state levels (the village panchayats, panchayat samitis, zilla parishads,
and state legislatures, respectively) .
For PFI, as a national level NGO with a history of engagement with the govern-
ment in policy dialogue on population and health issues, the role of Secretariat was
to act as an interface between the government and the NGO leadership of the
AGCA and NGO networks on the ground across the states. For the states, this
was going to be a whole new and unprecedented level of engagement in demon-
strating public accountability. For the proposed citizens’ committees, this was a
first-time learning in democratic self-governance at the grassroots in relation to
health and in how to relate to government health service institutions directly as
users deserving of accountability. PFI had its role cut out for it. It had to ceaselessly
advocate with the state governments to take on and shoulder this responsibility in
a sustained manner by extending policy, administrative, and financial support to
both the state level coordinating institutions and the citizens’ committees. It had to
work to set up the citizens’ committees, provides technical assistance to all of these
agencies directly engaged in the CAH process and strengthen their capabilities
for their new roles.
Providing PFI with the intellectual bulwark for this role was its recent extensive
exposure to and training in the theory and practice of scaling up NGO-led par-
ticipatory health innovations for implementation by government-led systems. The
MacArthur Foundation in India, with its programme focus on maternal and ado-
lescent health, had supported intensive studies of NGO models of innovation in
the health sector in Mexico, India, and Nigeria. The objective was to explore their
potential for scaling up into countrywide programmes. The Indian component of
the engagement had been housed at PFI. Involving work with eight of the MacAr-
thur Foundation’s Indian grantees and followed up by work with a selection of PFI’s
grantees, the Indian scaling-up exercises had been the most intensive and fruitful
in terms of lessons learnt. It had led to PFI being designated the ‘intermediary’
organisation for future scaling-up activities in this sector.
The NRHM had brought into existence a National Health Systems Resource
Centre (NHSRC) in Delhi to provide broad policy directions for, offer technical
assistance to, and oversee the implementation of the NRHM. The Community
Processes wing of the NHSRC was expected to oversee the community participa-
tion component of the new health system reforms. The AGCA, as an autonomous
body, was mandated to work closely with the Ministry of Health and Family Welfare
and the NHSRC Community Processes wing in a consultative capacity. As states
‘bought into’ the NRHM process, State Health Systems Resource Centres or State
Health Societies — and also District Health Societies wherever possible — in the
individual states were expected to be set up by the respective state governments.
The role of these state resource centres/societies was to adapt the principles and
framework of community participation to the conditions prevailing in the particular
states and mentor the sub-state community participation processes. The national
and state-level health systems resource centres were created as ‘Societies’, that is,
semi-autonomous agencies of the government, with different service rules and,
therefore, relatively unencumbered by the bureaucratic strangleholds that afflicted
regular government departments. They were empowered with flexibility to raise
and use funds as required and hire qualified professionals on contract to meet
mission-oriented goals. This tried and tested model had worked successfully in
other user-oriented sectors in the country, such as that for drinking water. For the
historically neglected, financially starved, and bureaucratised and politicised pub-
lic health system, autonomous state level structures offered the hope of possibly
injecting a new dynamism into the system, including moving it in the direction of
accountability to its users.
The expectation was that the AGCA, with the assistance of the above-described
institutions, would guide the process of bringing together a combination of large
and small NGOs, community-based organisations (CBOs), and self-help groups
(SHGs) to address the initial task of knitting together the communities and their
PRI representatives with the public health facilities. This would entail creating
community awareness about the NRHM entitlements and about the roles and
responsibilities of service providers. Also involved was the training of members
of the Village Health, Sanitation and Nutrition Committees (VHSNCs), the PRIs
as well as of facility level bodies — the Rogi Kalyan Samitis (RKSs) — in their as
community representatives. These roles and responsibilities included: undertaking
community and facility level enquiries in order to monitor the health services and
plan for their better utilisation; organising Jan Samvads/Sunwais (public hearings/
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Dr Monica Rana, State Programme Officer, Delhi State Health Mission with MAS Members in Sanjay Gandhi Slum, Chanakyapuri, Delhi
dialogues) to highlight gaps and find solutions; and following up on all of the above
through action and planning to address issues emerging from these enquiries and
dialogues. The assumption was that this mediating action by NGOs would help
shift the locus of power gradually from the Health Department to the people and
their elected representatives.
The actors at the base of the pyramid were at the village and facility level. In the vil-
lage the institution of Accredited Social Health Activist (ASHA) — a new category
of ‘community health worker’ created by the NRHM and one of the foundation
stones for community participation — was to be the link between the health system
and the village community. The ASHA was a woman belonging to the village, who
also enjoyed legitimacy in the eyes of the health system. The collective body in
the village was the VHSNC, which brought together the interlinked components
of health, child and female nutrition, potable water, and disposal of liquid and solid
wastes. Its membership comprised the ASHA, the Anganwadi Worker (AWW),
representatives from among elected members of the village panchayat, locally
active women and men volunteering to be on the committee, and other relevant
persons, such as the handpump mechanic. At the Primary Health Centre (PHC)
and Community Health Centre levels, the collective body was the RKS or Patient
Welfare Committee, also called Hospital Management Society. And at the district
and state levels, Planning and Monitoring Committees (PMCs), consisting of rep-
resentatives of providers and PRIs and key health officials, were meant to deal with
issues relating to the quality of services at the relevant facilities. A key empowering
element placed by the CAH process in the hands of each of these bodies were ‘un-
tied funds’, ranging from Rs 100,000 to Rs 500,000, and meant to be used for any
village or facility-level purpose deemed by them to be most urgent or important in
the interests of public health.
The AGCA proposed a phased programme of implementation. For 18 months be-
tween 2007 and 2009, a pilot project in community-based monitoring was led by the
PFI/AGCA Secretariat in collaboration with large and small NGOs in nine states
(Assam, Chhattisgarh, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Odi-
sha, Rajasthan, and Tamil Nadu) covering 36 districts and 1,620 villages in all (three
blocks in each district, three PHCs in each block, five villages in each PHC). The
evaluation of the pilot project revealed that a great deal had been accomplished in
the course of the single cycle of monitoring that had been completed. Training ma-
terials had been prepared, village committees formed, report cards drawn up, and
Jan Samvads/Jan Sunwais held. Importantly, optimism had been generated — most
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notably, among the most vulnerable and marginalised groups — about the potential
of engaging in such a direct monitoring of the health system and demanding ac-
countability from services that had never before been responsive to people’s needs.
In substantive terms, the pilot’s impact had been a mixed one. In several
instances at the village level, the political complexities in mobilising gram sabhas
had been bypassed when constituting the VHSNCs, and these were formed on
the basis of small meetings instead. Women were coming to the village commit-
tees in large numbers, but they lacked the empowerment to take decisions on what
should be done, while the real decision-makers — men — rarely attended. On the
whole, some knowledge and enthusiasm about community entitlements and rights
had been generated. There were even instances where community involvement
had helped frontline workers like the ASHA to overcome service delivery con-
In the Rogi Kalyan Samitis and the Planning and Monitoring Committees formed
at the level of facilities, two major sets of stakeholders were still absent from the
process: PRI representatives and health officials. The general view among the for-
mer was that the committees were NGO committees, rather than those owned
by local stakeholders. The report cards, meant for providing feedback, had been
enthusiastically received and made some headway. But, their format proved to be
too complex, often confounding many of the NGO facilitators themselves; this
was found to be the problem at every level. At the Jan Samvads/Sunwais where
the report cards were shared and people’s grievances about the health services
publicly aired, the health officials tended to recoil from this firstever confronta-
tion with users’ views, for they viewed all criticism as a threat to their power and
preferred to avoid participation altogether. On this platform alone, the whole
process threatened to break down. In those states where NGOs were visibly and
The pilot’s impact had been a mixed one. Women were
coming to the village committees in large numbers, but they
lacked the empowerment to take decisions on what should be
done, while the real decision makers — men — rarely attended.
On the whole, some knowledge and enthusiasm about
community entitlements and rights had been generated
straints. But, further progress would require training and retraining of the citizens’
committees in the skills of participatory engagement and a much more fundamen-
tal and prolonged negotiation with ground-level socio-cultural, political, and social
realities to ensure genuine participation by women and to draw in participation by
men and PRI representatives.
thickly present, the Jan Samvads/Sunwais were relatively more successful. But, in
states where the very notion of civil society having a voice was an alien one, the Jan
Samvads/Sunwais proved to be non-starters.
The evaluation thus highlighted both the resistance to be expected from en-
trenched power equations all round and the need for much greater training among
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communities and service providers in the art of constructive dialogue, so as to
minimise adversarial and conflictual encounters that only sharpened battlelines
between users and providers/managers. It also raised questions about the indef-
inite involvement of NGOs — with their complex and intense styles of engage-
ment and their already heightened sense of social responsibility — in what was
essentially meant to be a government-run programme that by its very nature was
imperfect. What was required when scaling up the model were extremely simpli-
fied, streamlined, and cost-effective processes and institutions and protocols — in-
cluding tools of enquiry — that allowed for key issues to be addressed in a phased
manner in keeping with the gradual development of skills and participatory abili-
ty among ground level actors and institutions. Also, prolonged NGO leadership
could possibly delay the process of confidence building among ordinary people
in the community, including the emergence of organic leaders from within local
communities and PRIs. At the same time, NGOs had a valuable contribution to
make. Conditions were not uniform across the states, and lessons from community
action models from various social sectors in different states and their applicability
for the health sector showed a very wide array of possibilities for capacity building
and action on the ground, including panchayats, women panchayat representa-
tives, self-help groups, social audits, and NGOs.
From ‘Community Based Monitoring and Planning’ to ‘Community Action
for Health’ and Countrywide Scaling Up: Following the pilot phase, the po-
tentially destabilising nomenclature of community-based ‘monitoring’ gave way to
community ‘action’. The controversial Jan Sunwais — social audit mechanisms that
could simultaneously generate huge confidence among the community and acute
aversion and rejection on the part of the health system — were abandoned by
many of the states. Given the political will behind the NRHM, its scaling up across
the states in the country was an almost inevitable development, and currently, 25
states/union territories have undertaken to implement the NRHM reforms, with
community action as one of the components.
The AGCA’s brief is to remain closely involved in this process and guide it, and
that of the PFI/Secretariat is to provide technical assistance to the states. This
includes: building capacities of state level institutions — resource centres/health
societies — and strengthening and scaling up implementation; adapting guide-
lines, tools, and protocols; supporting states in initiating and strengthening
accountability mechanisms, such as grievance redressal, public display of health
As preparation for its expanded role, PFI
had already tried its hand at implementation
in the state of Bihar, where it took on the
role of lead implementing agency in
collaboration with NGO partners
service guarantees, and citizens’ health right charters; undertaking periodic reviews
of activities, sharing key lessons and challenges; and providing inputs in the for-
mulation of the community action component of the individual states’ National
Health Mission (NHM) Programme Implementation Plans (PIPs). In its capacity
as the AGCA Secretariat, PFI participates — along with AGCA members, disci-
pline-based specialists, and the Ministry of Health and Family Welfare (MoHFW)
— in the annual Common Review Missions that critically evaluate the programme’s
functioning in every state. Feedback from these review missions and from voices
on the ground are regularly brought to quarterly meetings held at the MoHFW,
where AGCA members and PFI Secretariat meet with MoHFW officials to assess
the state of play and discuss problematic issues.
As preparation for its expanded role, PFI had already tried its hand at implemen-
tation in the state of Bihar, where it took on the role of lead implementing agency
in collaboration with NGO partners over a two and a half year period, using the
same distribution of blocks, PHCs, and villages as in the pilot phase and working
closely with two institutions that it assisted the state government in setting up —
the State Health Society and the District Health Societies. Between 2012 and 2014,
it carried out the implementation in five districts of the state, across 300 villages
consisting of 50 panchayats and 10 blocks. Its experience was a positive one. It was
able to demonstrate a model where, through bringing together trained resources
from multiple levels in a mutually supportive way, it was possible for community
action to make huge improvements in maternal health, as evidenced in antena-
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tal check-ups and detection of high-risk pregnancies, and significantly also raise
awareness on health and healthcare entitlements at the grassroots level, in the form
of a heightened sense of community ownership over the untied grants placed by
government for the use of community level bodies in the CAH process. When the
funding for the project came to an end in 2014, PFI was able to successfully exit the
project area, after having institutionalised the village-level community participation
component in the ASHA system. The model that it developed — which was well
received by the MoHFW — is operating in 100 villages in two districts of Bihar
where PFI is currently involved in other ongoing projects.
Close to a decade after the idea was launched, however, the picture is of a land-
scape still in a state of flux, sparsely populated with the community action com-
ponent, where the concept of the primacy of the community in the eyes of the
health services is still an alien one. States still tend to view the whole community
action component with suspicion. Niggardliness in the allocation of resources for
this aspect of social engineering means that the finances required for seeking out
locally relevant solutions and innovations and for training the community in the
processes of enquiry, audit, and negotiation are simply not there. The semi-auton-
omous State Health Resource Centres, which must provide the leadership, are only
just coming into existence and are as yet very new to the concept and modalities
of community involvement and the rights of users to demand accountability of
state-powered health facilities. They require a lot of investment in the building of
their capabilities.
Thus, state level ownership of the process is a major sustainability issue that needs
to be shored up. As of 2015, following intense advocacy efforts by the PFI/AGCA
Secretariat for inclusion of the CAH component in their respective annual Nation-
al Health Mission (NHM) Project Implementation Plans (PIP), 25 states across
the country have ‘bought into’ the idea. In actual fact, however, the process is in
operation only in pockets of a few districts of each state. Even if states have bought
in, sustained advocacy is required with the respective governments for the setting
up of State Health System Resource Centres (SHSRCs) — or State Health So-
cieties (SHSs) as the case might be. These state level bodies and their teams for
community processes need to be strengthened through training programmes that
effectively impart an understanding of both the big picture and the day-to-day
skills required to participate in and steer the complex CAH process. These are
the bodies that are critical to the sustainability of the CAH process at the state
and district levels, for it is they who must take ownership for the process, demand
allocation of resources to support implementation, and give support to the com-
munity level structures. Enriching the skill sets of government officials belonging
to the NRHM system at the Centre and in the states by training them in the SUM
Framework is a task that PFI has been engaged in. By 2012 alone, it had trained
more than 250 of these personnel in the SUM Framework, given how critical their
sense of involvement and skill upgradation is to the long-term sustainability of the
communitisation component. This is particularly relevant against the backdrop of
the routinely high turnover of bureaucrats at the senior level, the uncertainty of
support from state level legislators, and the potentially politically volatile nature
of the community participation component, given the rank indifference and cal-
lousness with which citizens have been treated over the decades by the public
health system. State level financial and administrative will is essential also for provi-
sioning and upgrading health services infrastructure and human resources, since all
responsibility for accountability cannot be placed at the doorstep of communities.
At the bottom of the pyramid, the wished-for active participation by local stake-
holders on the ground — representatives of village and block level Panchayati Raj
Institutions, ordinary villagers, or even just the village ASHAs — continues to be
elusive. This absence of ownership and participation by local communities also
serves to give rise to a sense of unease about the sustainability of the concept of
community participation. It needs a lot of working on, and to PFI’s credit, it has
been steadily chipping away at the problem.
Using the financial and time flexibility afforded by the MacArthur Foundation’s
third scaling-up grant, PFI is currently exploring the possibility of alternative lo-
cally relevant solutions for process ownership under the diverse socio-cultural
conditions prevailing in different states. In its implementation work in Bihar, PFI
had identified the ASHA as the most appropriate village level institution to vest
ownership of the community participatory process, pending the gradual coming of
age of the VHSNCs. One way out of the impasse is to focus on the ASHA’s skill
building, strengthen her role as a village level fulcrum, and link her strongly with the
AWW and the ANM, while simultaneously upgrading the provisioning, skills, and
responsiveness at the level of the PHC. As the mutual strengthening of this most
fundamental set of building blocks proceeds, the skills of the VHSNCs and the
village panchayat can be gradually built to take on the investigation and monitor-
ing component, with the ASHA, AWW, and ANM acting as local resource per-
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sons. With the gradual building up of skills from the bottom-up, community action
at the level of the Community Health Centre and District Hospital, with their Rogi
Kalyan Samitis, can become a reality. Component after component needs to be
fine-tuned to the conditions prevailing in the sub-regions of each state, with the
community level custodians of the participatory process changing according to
the cultural genius of that particular state or district. Training, retraining, and men-
toring are probably the most required resources. These are long-term processes,
which need investment of time and money and require continuous evaluation and
assessment.
Political will on the part of the states to commit finances for such long-term
gains is essential. Equally salutary is political presence — of elected represen-
tatives — at Jan Samvads/Sunwais in those states/districts where these public
hearings are still held, given how the cynical politicisation of the health services
centres; inadequate water supply for use by patients; non-availability of doc-
tors round the clock at the health centres at all levels and the tendency of these
personnel to simply collect their salaries regularly and do little else; inordinate
delays in reaching honorariums to the ASHAs; irregularity in making medi-
cines available to them; illegal charging of patients for medicines and even for
deliveries; and expecting patients to buy their medicines from private shops
even when these medicines are available at the health centre. Trust needs to
be built up in the health system that the CAH process is not meant to be one
of confrontation, but one of collaboration to improve the situation all round.
Thus, poorly provisioned infrastructure affects health workers in their duties
just as much as it affects users, and, in the same way, poorly understood duties
or low levels of skills compromise health worker’s efficacy in their own eyes as
much as they compromise the quality of services offered or denied by them in
the eyes of users.
Political will on the part of the states to commit finances for such
long-term gains is essential. Equally salutary is political
presence — of elected representatives — at Jan Samvads/Sunwais
in those states/districts where these public hearings are still held
has been one of the factors historically making for the poor quality of service
delivery. Citizens need to be listened to and backed by powerful local leaders
when they air their grievances about what seem to be the most stubborn prob-
lems relating to the quality of services that have cropped up regularly at the
Jan Samvads/Sunwais. These range from gross neglect of cleanliness at health
In some states, such as Maharashtra, with stronger traditions of grassroots com-
munity involvement in public affairs and active NGOs, there is ground level
thinking afoot about how to strengthen and expand the community action pro-
cess by exploring the potential for implementing such community involvement
in other services such as the ICDS, PDS, and water supply. The thinking is
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the community leads to hesitation on the part of local
leaders to make their voices heard. There is simply no
escape from strengthening understanding, awareness,
and skills at the level of communities. The continuing
A very important missing link is an institutional
grievance redressal mechanism, without which
community action could lose credibility and
eventually run out of steam
indefinite involvement of nodal NGOs or groups of
NGOs as implementing agencies means that, as of
now, the programme is being implemented in just a
few areas across these 25 states, adding to the picture
of unsustainability. The challenge of how to build skills
and promote involvement of PRI representatives in the
CAH process remains unresolved. At the same time,
working with NGOs — small, committed, open to being
skilled — is inescapable. Innovations must necessarily
come from NGOs working on the ground and at the
along the lines of establishing a broad and comprehensive participatory forum
at the block level, a possible ‘Federation of Monitoring Committees’, which
could positively impact on the CAH process in relation to health services.
margins of power. NGOs also fill gaps that the govern-
ment is not interested in addressing. The returns on training NGOs would prob-
ably be higher than working with warring political groups.
At the present moment, community action as a social process still seems some-
what patchy and without a clear and sustainable future. A very important missing
link is an institutional grievance redressal mechanism, without which community
action could lose credibility and eventually run out of steam. Interminable delays
in reaching the allocated untied funds to the respective committees leave them
disempowered to act on even small infrastructural shortcomings. The routine
government practice of releasing funds only during September to November of
each year has been found to be a constraint on the timely utilisation of funds. PFI
is — at the time of writing — in the process of finalising a monograph that exam-
ines the features of currently prevailing grievance redressal mechanisms across
sectors and states — Tamil Nadu, Maharashtra, Andhra Pradesh and Telenga-
na, Odisha and Madhya Pradesh — as a possible source of clues to the kind of
mechanism that might be appropriate to the health services in the CAH process.
Some clear strategies on how to deal with this bottleneck might be expected in
the months to come. While NGOs on the ground have a huge role to play in
bridging the gap between communities and the government, the flip side is that
under the 73rd Amendment, PRIs are expected to play this role of an organic
bridge that is nested in the community. The status of NGOs as outsiders to
It is a matter of general consensus that the public health apparatus in the country,
whether preventive or curative, has seriously failed the mass of the people, in general,
and, in particular, those social groups that need it the most and has put them at the
mercy of expensive and variable private medical facilities. The complex set of causes
bringing this about, historically and politically, could bear with considerable elabora-
tion. Suffice to say here is that the consistent devaluation of public health by the State
historically and the absence of political will have led to weak policy structures and
even weaker implementation. The most obvious symptoms of the chronic and
deep-rooted malaise that afflicts the system are: poor funding, provisioning, and or-
ganisation in general; low quality of skills all round; total absence of oversight; and
excessive bureaucratisation and politicisation leading to a debilitating callousness
towards users.
PFI’s active thinking on possible grievance redressal mechanisms is to be welcomed.
On the one hand, the CAH process is evidence that there is a seriousness of purpose
and that communities can actually expect some changes to start occurring in the way
that services are being delivered. These are probably the most representative of em-
powerment and rights. But in the absence of any prior training of either communities
or health officials on how these dialogues might be conducted or prior preparation
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of both parties around the issues proposed to be discussed and how to take them
towards minimising any damage due to insensitive reporting.
forward in a constructive manner, the positions taken tend to lead very often to the
complete breakdown of this process altogether. Rather than using it as a tool, as
originally conceived, these ‘dialogues’ only too often become a forum for only high-
lighting the denial of services.
In conclusion, it might do to reiterate that it is crucial to see how to increase par-
ticipation at the community level of both women and men; how to simplify tools
of enquiry and address key issues in a phased manner in keeping with the partici-
patory ability of those engaged in the process; how to get the PRI representatives
While media reports often support the process by covering them in their reports,
involved at all levels; and how to overcome the distrust and distance on the part of
their tendency to sometimes sensationalise stories of health system malfunctioning
the health officials. It is impossible to overstress the importance of training, across
only exacerbates the breakdown of communication between the people and the
the board — not only of community members and representatives of PRIs, but also
system. PFI’s intervention in the state of Bihar at the start of the institutionalisation
of NGOs and health officials — in how to participate in the process of dialogues, so
of the CAH process and sensitising Hindi language journalists — both print and
that the process remains one of collaboration and not confrontation.
electronic — on the nuances of the issues involved has perhaps gone some way
....
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16 Pages 151-160 |
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04
Case Study
Health of the Urban Poor:
Pioneering a Convergent
Approach to Delivering
Health Services to
Vulnerable Populations
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Health of the
Urban Poor:
Pioneering a
Convergent Approach
to Delivering Health
Services to Vulnerable
Populations
he Health of the Urban Poor (HUP)
T
programe, which PFI pioneered through
the first five years of its introduction
(2009–2015), is a unique instance of
how the Foundation built on the lessons
learnt from the Scaling Up Management
(SUM) Framework to envision, pilot,
and scale up an integrated intervention
programme of the Government of India,
focused on improving preventive and
promotive public health services for the
urban slum-dwelling populations living in the EAG states.
Collecting drinking water from an unsafe hard pump
In the implementation of this programme, supported by the USAID and creatively
leveraging a scaling-up grant from the MacArthur Foundation, PFI led a consortium of
seven technical and implementation partners to assist the central and the concerned
state governments in designing and implementing this first-ever government urban
health programme, led by an NGO that seeks to address the acute health vulnerability
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of poor urban communities. The focus of the HUP pro-
gramme was on improving the delivery and utilisation of
maternal, child health, and nutrition services and promot-
ing water supply and sanitation and hygiene services to
The focus of the HUP programme was on
poor communities in the eight high focus states of Bihar,
Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Ra-
jasthan, Uttar Pradesh and Uttaranchal and the five cities
of Agra, Bhubaneshwar, Delhi, Jaipur and Pune.
Until this programme came into existence, there had
been no attempt by the government to roll out a nation-
improving the delivery and utilisation of
maternal, child health, and nutrition
services and promoting water supply,
sanitation and hygiene services to poor
communities in the eight high focus states
wide framework for urban public health that also had a
provision for drawing communities into the process (as
had been done for the National Rural Health Mission
[NRHM]). In the rural areas of the country, right from the
time following Independence, there has at least been a
uniform system of Primary Health Centres, Community Health Centres, and Dis-
trict Hospitals, notwithstanding the poor quality of these services, which the mech-
anisms under the NRHM have been trying to redress since 2005. However, outside
the three original Presidency towns of pre-Independence India — Bombay, Calcut-
ta, and Madras — and a few other metropolises like Bangalore and Ahmedabad,
which had come of age in this regard with their well-defined municipal corporations,
no streamlined system of urban municipalities with specified preventive, curative,
and promotive health duties has existed in the country’s cities and towns. In all ‘ur-
ban agglomerations’ — including the capital city, Delhi — the situation is one where
multiple government departments/agencies are responsible for individual compo-
nents relating to health, and there is no coordinating authority that is charged with
bringing them all together under a unified vision or structure. The only dedicated
institutional health services available to urban populations are: the Family Welfare
Centres in the bigger towns and cities run by the central government (the urban
arm of the Reproductive and Child Health [RCH] Programme); District Hospitals
in district headquarters that are run by the state governments; and clinics run by
local bodies (municipalities) in towns and cities. In the EAG states, these last-men-
tioned municipal clinics are a rapidly dying breed, given the precarious resources of
the municipalities and their policy of not recruiting new personnel and, therefore,
The urban health scenario, therefore, is one of over-congestion in the meagre ter-
tiary curative facilities. This has resulted in the dense presence of a growing private
curative sector with varying levels of efficacy. For the very poor, accessibility and
affordability act as major constraints to public and private facilities, respectively,
leaving them with no option but to resort to unregulated small private providers.
The concomitant delayed and uninformed care-seeking and haphazard treatment
regimens that these engender often results in hospitalisation. The unaffordably high
out-of-pocket expenditures on healthcare, thus, push the poor even further into
indebtedness and impoverishment. The prevailing weak and dysfunctional public
systems of outreach do not help in any way either. The combined effect of all of the
above, along with high slum population densities, unsafe water, absence of drain-
age leading to a proliferation of liquid and solid wastes, and the general abysmal
sanitation in slum clusters, which is largely responsible for frequent diarrhoeal, respi-
ratory, and other illnesses, make for outcomes that are particularly grim for women
and children. As highlighted by the 2011 Census, maternal and under-five mortality
rates among slum-dwellers rival the situation in rural areas. Close to 50 per cent of
under-five children are malnourished and underweight. Almost 60 per cent of poor
children miss total immunisation before completing one year of age. If the NRHM is
seeking to redress the acute vulnerability of poor women and children in rural areas,
their poor counterparts in urban areas do not seem to fare much better.
the phasing out of this cadre of doctors.
The vulnerability of the urban poor, which has been neglected so far, is only poised
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Given the situation of unplanned and haphazard
urbanisation in the country, the proportion of the poor
living in slums (17.4 per cent of the total urban population)
can only be expected to grow concomitantly with their
concentration in ever-shrinking land areas
to worsen further. The country’s urban population is rapidly growing in size. Ac-
cording to the Census of 2011, it now counts for 31.16 per cent of the country’s
population, which makes its growth rate higher than the growth rate of the rural
population. Given the situation of unplanned and haphazard urbanisation in the
country, the proportion of the poor living in slums (17.4 per cent of the total urban
population) can only be expected to grow concomitantly with their concentration
in ever-shrinking land areas.
The USAID in India had long been interested in bringing urban health back onto
the development agenda. Between 2002 and 2005, it had conducted some pilot
studies under the umbrella of an Environmental Health project where it explored
the urban health situation, needs, and options. In 2004–2005, the Government of
India set up a National Urban Health Task Force, which came up with a framework
for a National Urban Health Mission (NUHM) in 2006–2007 as a counterpart
to the NRHM. In the situation prevailing at the time, different Government of
India departments were responsible for different urban health and development
efforts, with no convergence of vision, funding, or governance. The capabilities for
planning, designing, and implementing comprehensive urban health initiatives that
would effectively deal with the issue of the urban poor were weak at both national
and state levels. In the EAG states, these capabilities were particularly lacking and
in need of an infusion of technical assistance. Evidence-based city level demon-
stration and learning efforts were sorely called for.
This seemed an opportune moment for a new programme that would:
(i) Aim to bring more focused policy attention towards the health of the urban
poor. National, state, and city governments, with appropriate technical assis-
tance, could make for an effective roll out of the NUHM in the making. In
the interim, work could get underway on putting together the urban health
components within the NRHM;
(ii) Expand partnerships across the urban health sector that include the private
sector through Public Private Partnership (PPP) activities and forge linkages
with other USAID-supported partners, donors, and development partners
involved in urban health activities in India;
(iii) Promote the convergence of different Government of India urban health
and development efforts; and
(iv) Strengthen the evidence-based rigour of city level demonstration and learn-
ing efforts in order to improve programme learning.
The USAID/India Country Development Cooperation Strategy put out a global
‘Request for Proposals’ under its sub-goal of strengthening Indian systems in pri-
ority sectors. In response to this, PFI brought together a consortium of seven po-
tential partner organisations to submit a proposal for the USAID’s India’s Health of
the Urban Poor project. It believed that the proposed partnership contained within
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it the combined experience and expertise to bring into play the complementary
strengths and ability to take responsibility for various regions/cities and functions
required to provide the technical assistance called for by the project.
The grant award came through in 2009. PFI’s track record of working with multiple
partners at various levels — communities, NGOs, research institutions, and govern-
ments — as Secretariat of the AGCA under the NRHM and as a centre for scaling
up non-governmental innovations for adaptation into large public programmes
commended it as also its experience of combining research with advocacy skills.
Initial stages: The process of obtaining the final sanction from the Department of
Economic Affairs, Government of India, for the USAID grant to PFI delayed the
starting date of the five-year programme by well over a year. However, the waiting
PFI took responsibility for overall project
implementation and grant management. It
also took additional responsibility for
technical support to the states of Odisha,
Uttar Pradesh, and Madhya Pradesh, and for
the cities of Bhubaneswar, Delhi, and Agra
period was usefully spent in ideation towards developing a systemic approach to
addressing the health needs of the rapidly increasing urban population, particularly
focusing on the urban poor. This approach was nested within a framework of ad-
vocacy and technical assistance to the Government of India for crafting a national
urban health policy. The task undertaken by PFI consortium of evidence genera-
tion for the initial advocacy so strengthened the appeal of the programme for the
government that it spun off several gains. Not least of this was the final approval
in 2010 from the Department of Economic Affairs for the Health of the Urban
Poor (HUP) programme, an approval that was eventually endorsed by the Union
cabinet of ministers in 2013 for a National Urban Health Mission.
The progress made even prior to the final approval consisted of: disaggregating
and analysing the urban data in the National Family Health Survey (NFHS) data
sets to highlight the disparities between the poor and non-poor; developing project
strategies and the work plan; setting up a national programme management unit
for the project; and initiating the recruitment process. An important component
was initiating technical assistance to the central and state governments, primarily
to convince policymakers at both the Centre and the EAG states of the urgency of
extending the reach of urban health services to all manner of poor urban residents
and not just those in the ‘listed’ clusters. This meant taking cognisance of the tran-
sitory/migratory nature of a large section of poor urban dwellers and their often
resultant ‘illegal’ status that puts them outside the pale of health services. All this
progress enabled the project to come up to speed as soon as the formal sanction
was in and simultaneously move ahead along several parallel lines.
Implementation: Although working relationships between the partners had been
forged even prior to the formal launch of the HUP programme, the fully-fledged
working of the eight state teams (with their project personnel housed in local offic-
es in the respective states — each team taking both solo and cross-cutting respon-
sibilities) could begin only after the final sanction in 2010. PFI took responsibility
for the overall project implementation and grant management. It also took addi-
tional responsibility for technical support to the states of Odisha, Uttar Pradesh,
and Madhya Pradesh, and for the cities of Bhubaneswar, Delhi, and Agra, making
it one of the implementing partners on the ground. The other implementing part-
ners were:
(i) The International Institute of Health Management Research (IIHMR) (Jai-
pur), responsible for programme implementation in the states of Rajasthan
and Chhattisgarh;
(ii) Plan India (New Delhi) responsible for programme implementation in the
states of Jharkhand, Bihar, and Uttaranchal and in the city of Pune;
(iii) Care India (New Delhi) responsible for implementation in Uttar Pradesh;
(iv) The Bhoruka Charitable Trust (Jaipur) responsible for implementation in Jai-
pur city.
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The technical partners were:
(v) The International Institute for Population Sciences (IIPS, Mumbai), respon-
sible for research and data management and developing the tools for the
baseline and endline studies;
(vi) The Micro Insurance Academy (MIA, New Delhi), responsible for develop-
ing community insurance models and scaling them up for implementation
across the eight states; and
(vii) The Centre for Development and Population Activities (CEDPA, New Del-
hi), responsible for leading the process for developing need-based national
and state level healthcare practice guidelines and training packages with a
focus on: maternal and child health (MCH) issues; leading advocacy efforts
and events to build consensus and advance public policy in urban planning
with specific reference to MCH; providing technical assistance for main-
streaming gender issues; supporting evaluation, secondary analysis, and doc-
umentation; and providing support through NGO partners already working
with CEDPA.
Following the sanction of final approval for the project, the teams now continued with
the tasks of evidence generation. These consisted primarily of preparing state and
city profiles. The latter involved carrying out city baseline surveys and vulnerability
assessment; listing and mapping of slum clusters; listing of households within each
cluster; collecting ward-wise information on slums, health facilities, and health-related
programmes in their vicinity, and on NGOs/community-based organisations working
in these areas. On the basis of this evidence, the teams prepared city profiles of the
burden of disease; reviewed the governance structures; and visualised the strategies
for collaborative and convergent planning to increase access of the poor to services in
Jaipur, Pune, and Bhubaneswar. A key principle was to devise innovative and inclusive
ways of reaching health services to those living outside discernible ‘slum settlements’,
such as footpath dwellers, rickshaw pullers, coolies in markets and railway stations,
street vendors, and the rest of the urban ‘unlisted’ homeless.
Refinement and finalisation of the proposed NUHM strategies moved in tandem
with progress on the HUP project. PFI sought to straddle both tasks: of incorporat-
ing the approaches and lessons of different urban health models into the proposed
NUHM, and providing technical assistance for the review and strengthening of the
protocols and guidelines related to the NUHM. In 2010, a drafting committee had
come into existence to begin the task of drafting the policy framework for a National
Urban Health Mission. PFI now proceeded to assist the drafting team. One of the
first tasks was to re-analyse the evidence from the NFHS surveys and slum surveys
that presented bland urban data on the assumption that urban populations in general
were better off than their rural counterparts. Given its focus, which was to demon-
strate that the urban poor required a dedicated policy focus, PFI now sought to mine
the NFHS data to generate knowledge about the poor health conditions of the urban
population, in general, and of the poor among them, in particular. Two PFI consultants
with public health specialisation were placed within the Ministry of Health and Family
Welfare (MoHFW) to work closely with the skeletal ministry staff allocated to the
task of drafting the NUHM policy approach. By culling out the health status differ-
entials between the urban poor and non-poor, the PFI team was able to highlight the
acute vulnerability of the urban poor and their similarity with — and often even worse
than — the vulnerability levels prevailing among the rural poor. They further carried
out a comparison of health indicators of the urban poor from the NFHS II and III to
show that there had been no improvement in this regard over the preceding five-year
period (1998/1999 to 2005/2006). As part of initial state level advocacy a re-analysis
of NFHS III data was carried out for each of the eight EAG states and fact sheets
brought out to highlight the glaring disparities between the poor and the non-poor.
Simultaneously, the MoHFW officials were taken to the individual EAG states, so
that they could understand the dimensions of the problem in each state and what
precisely was each state’s unique situation and requirements. Senior MoHFW officials
were also taken on study visits to major metropolitan cities of the country to absorb
lessons from the best practices adopted by them. PFI team conducted a comparative
study of these practices and offered the evidence to the Ministry officials. At the
request of the MoHFW, PFI also conducted an examination of other developing
countries, including Brazil, Kenya, Turkey and Indonesia, to understand the mecha-
nisms developed by them to handle their respective urbanisation processes. It further
made a comparative analysis of health indicators prevailing in India and in the G-20
countries, which showed up the comparatively poor health status of the Indian urban
population.
In the field, PFI-HUP began demonstration programmes in the slums in Agra and
Delhi. In these, the convergence between various authorities — for water, sanitation,
nutrition, ICDS, health, RCH, slum development, among others. — was forged and
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Counseling session by Mahila Arogya Samiti member
the results documented for each city context. These provided the required evi-
dence for further advocacy activities with the Centre and states on urban health
issues. In collaboration with the International Institute of Health Management Re-
search (Jaipur), one of the partners in the consortium, five preliminary research
studies were carried out in the slums of Delhi on various aspects of health service
availability and healthcare seeking. These covered: the cost of healthcare seeking;
access and availability of healthcare services; social determinants of health; treat-
ment-seeking behaviour; and male involvement in reproductive and child health.
At the suggestion of the MoHWF, PFI-HUP also took up two thematic studies
to assist the NUHM policy in the making. One sought to understand the nature
and magnitude of the disease burden in urban areas; the other tried to identify
promising PPP models to help widen the reach of health services to the poor. The
studies were done by PFI in partnership with two other members of the consor-
tium, CEDPA and MIA, and discussions and meetings around these two themes
were organised at the level of several of the individual states.
The strategic dissemination in the public domain of the insights emerging from
all this documentary and field evidence proceeded apace. It took multiple forms:
dedicated space on PFI website for the HUP programme; presentations at na-
tional and international conferences; workshops/seminars/discussions organised in
Delhi and in the individual EAG states in partnership with a spectrum of research/
non-governmental/governmental/international agencies on the multiple issues re-
lating to urban health conditions and the state of the urban poor in the country and
issues raised by the ongoing learnings of the HUP programme; and articles in the
print media, including in PFI’s own periodic journal Popfocus, for moving the policy
process and debate forward.
From 2010–2013, PFI-led team held three decisive consultations. These were part
of the effort of building an informed consensus, a commitment, and visioning skills
within the Government of India and the governments of the EAG states for the
proposed policy focus on the health of the urban poor and for the final thrust to-
wards the firming up of the NUHM framework. At the national level, a consultation
was organised in collaboration with the multiple central ministries hitherto dealing
with urban issues, that is, Housing and Urban Poverty Alleviation, Women and
Child Development, Urban Development, and Human Resource Development.
An important collaborator in this consultation was the MoHFW, which, as of then,
was responsible solely for the urban RCH Programme. Crucially, under this, RCH,
maternal and child health were not seen as part of urban health conditions and
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the living environment, particularly among the urban poor. This consultation also
drew in the officials of the Jawaharlal Nehru National Urban Renewal Mission (a
programme with the goal of creating economically productive, efficient, equitable,
and responsive cities), Secretaries of the Urban Development and Health Depart-
ments of the different states, over 60 Municipal Commissioners of urban local
bodies, and 15 Mission Directors from various State Health Societies and State
Health System Resource Centres under the NRHM umbrella, as well as other city
health officials. The consultation’s objective was to bring about a commitment to
convergence among national level programmes, refine the strategies of the pro-
posed NUHM, and infuse new energy into defining a policy focus on the health
needs of the urban poor at the national, state, and city levels. This was the only na-
tional level consultation. The venues for the others that followed were in the states,
where responsibility for the actual implementation would need to rest.
The second consultation brought together the Mission Directors and Nodal Of-
ficers — already assisting the NRHM implementation — of State Health Systems
Resource Centres of the EAG states. Led by the NHSRC and with technical in-
puts from the PFI-HUP team, these officials were walked through the whole vision
of the HUP programme and its place within the overarching national urban health
policy that was at the time undergoing its final drafting stages.
This was followed by two regional workshops, one in Mumbai (with officials from 13
states) and the other in Kolkata (with officials from 15 states), at both of which the
theme was to share learnings from innovative ways of tackling urban health issues,
drawn from selected cities in the country, and deliberate on potential innovations
to address urban health priorities. NUHM officials from the national level, including
State Mission Directors, and State Nodal Officers from the state level, and city
level officers from the City Programme Management Units participated in these.
The meetings were accompanied by field visits that provided exposure to good
practices.
Through the medium of these three consultations, the core themes of the Health
for the Urban Poor programe within the framework of the NUHM were presented,
and training in the visioning of and approaches to associated planning, designing,
and implementation tasks and skills were imparted to more than 300 senior gov-
ernment officials. In carrying out these critical exercises in evidence-based advo-
cacy, PFI was immensely supported by the flexibility for exploration and learning
A Mahila Aarogya Samiti member working with the community
afforded by the second scaling-up grant that it had received from the MacArthur
Foundation.
PFI had costed the whole NUHM programme for the first five-year period and
had placed it before the Planning Commission. From there the proposal travelled
to the Cabinet. It took all of two years for it to go from MoHFW to the Empowered
Finance Committee, then to the Planning Commission, and finally to the Cabinet.
Six months after it had reached its destination — in May 2013 — the Cabinet allo-
cated Rs 22,000 crores for urban health. The health of the poor, disadvantaged ur-
ban populations in the EAG states, which had hitherto been a small component of
the NRHM, now took the first step of coming into its own as a legitimate area for
policy intervention within the NUHM. In 2013, the Government of India created
a new National Health Mission (NHM) as an umbrella under which were brought
together the previously established NRHM and the newly set up NUHM, all of
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During the period of germination of
the policy idea and piloting of
development strategies by PFI and
its partners, three Health Secretaries
and three Joint Secretaries for Health
at the Centre had moved through the
position of Mission Director
which were put under the MoHFW. PFI came to be prominently represented in
the Technical Resource Group constituted by the NUHM, particularly the sub-
groups related to Community Processes and Convergences, Reaching Vulnerable
Populations, and Institutional Arrangements.
During the period of germination of the policy idea and piloting of development
strategies by PFI and its partners, three Health Secretaries and three Joint Secre-
taries for Health at the Centre had moved through the position of Mission Direc-
tor. This drove home the hard reality that responsibility and ownership for public
health had necessarily to be housed in the states, and among the second line of
leadership there. Investment in the skills and enthusiasm of this stratum of officials
had the potential to sustain the agenda, irrespective of changes at the top eche-
lons of bureaucracy.
Using its learnings from its experience of steering the NRHM communitisation
process as AGCA Secretariat, which, in turn, had been a learning in the appli-
cation of the SUM Framework, PFI had steadily worked through the years of
PFI-HUP with this second line of leadership. These were the officials in the State
Health Systems Resource Centres and State Health Societies. From 2013, a Nodal
Officer for urban health for each state along with a Joint Director for urban health
joined this leadership, dedicated to the HUP process.
The three major consultations — referred to earlier — were closely followed up by
similar state level consultations and activity in each of the eight states. Simulta-
neously, PFI-HUP worked intensively to extend technical assistance to both the
MoHFW and the state governments for strengthening urban health programmes
in the form of contextualised inputs. These inputs were in the nature of drawing
up and reviewing state project implementation plans (PIPs) and capacity building
in the NUHM and HUP, that is, training and orienting government officials at the
Centre and in the individual states.
There were the inevitable lags involved in the institutionalisation of a new policy
vision. It did not help that the process had been dogged by delays during those
five years — delays in obtaining the Government of India’s approval for the HUP
programme and consequent uncertainty on the part of the states with the con-
comitant flagging of enthusiasm for the programme. The first two years of the
NUHM coincided with the last two years of the HUP programme. During this
period, less than half the Twelfth Five-Year Plan allocation of Rs 5,000 crore was
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PFI now proposed a model for urban health
that comprised five principal approaches that
together work towards the long-term goal of
developing a responsive, functional, and
sustainable urban health system that provided
need-based, affordable, and accessible quality
healthcare and improved sanitation and
hygiene to the urban poor
disbursed to the NUHM. And barely 15 per cent of the disbursed amount was
actually spent. All these factors caused inevitable unevenness in the EAG states’
operationalisation of the HUP programme.
Nevertheless, by 2015, drawing from its experience of conducting interventions
under the city-demonstration programmes, the HUP had made sufficient prog-
ress in consolidating urban health approaches. It now proposed a model for urban
health, which comprised five principal approaches that together would work to-
wards the long-term goal of developing a responsive, functional, and sustainable
urban health system that provided need-based, affordable, and accessible quality
healthcare and improved sanitation and hygiene to the urban poor.
(i) City Health Plan (CHP): This consists of the development of a compre-
hensive, decentralised health plan based on mapping the prevailing health
situation, infrastructure and facilities and the gaps therein. The plan details
the activities required to improve health related services and suggests com-
munity and system-level processes. Crafted with the involvement of the
different concerned government departments, the plan chalks out the facil-
ities, the current and future role of various stakeholders, as well as capacity
enhancement plans along with budgets;
(ii) Urban Health and Nutrition Day (UHND): This creates a single conver-
gent Urban Health and Nutrition Day service to provide maternal, newborn,
child health and nutrition services to cover every slum once a month at the
Anganwadi Centre. Services relating to water, sanitation, and hygiene are also
linked to this;
(iii) Mahila Arogya Samitis (MAS): This is a community engagement compo-
nent (the urban equivalent of the VHSNCs), that is, citizens’ voluntary organ-
isations led by women, which links the community and the city’s administration
services to demand for services/rights, increase community ownership and
sustainability, and facilitate community-based monitoring. The setting up of
these samitis has proven to be far more successful than the village commit-
tees in the rural areas;
(iv) City and Ward Coordination Committees (CWCC): This committee is
meant to facilitate convergence and coordination activities between various
departments (Health, ICDS, and Urban Development) and between the
government and private sector, as also improve access to quality healthcare
services. Expected to meet once in a month, it has representation from the lo-
cal slum communities and is a close equivalent of the rural Rogi Kalyan Sami-
tis. The complexity of the challenges involved here has been one of the great
learnings of the HUP;
(v) Health Management Information Systems (HMIS): These systems
monitor the programme, creating a database on maternal and child health,
and water, sanitation and hygiene related information. The data is to be anal-
ysed on a monthly basis to track progress of the programme.
The elements of systematic planning, coordination by local authorities, regular mon-
itoring and community involvement are, thus, all integral to the model.
The PFI-HUP programme also developed a range of resource materials and custom-
ised them to individual state contexts to facilitate the NUHM and the HUP compo-
nent within it. These were in the form of operational guidelines for the Mahila Arogya
Samitis and urban ASHAs and operational guidelines for city level outreach services
and for tools assessing the performance of NGOs implementing urban health re-
lated projects. It also trained state level trainers on the NUHM/HUP programme.
The HUP kept up a steady output of documents and publications arising out of its
work. Among the explorations that it conducted were those that looked for ways to
assist in the involvement of private sector actors in implementing components of
the NUHM/HUP. These pertained particularly to water, sanitation and hygiene, and
their relationship with health under the varying contexts of conduciveness prevail-
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ing in the different states (for example, model Anganwadi Centres or model urban
health posts). Explorations also went into identifying and building capacity among
intermediary agencies to oversee the onward march of the HUP programme. This
was much in the way that PFI had itself been built and strengthened as an intermedi-
ary for scaling up management (SUM) activities in the country.
Between 2013 and 2015, the last two years of the HUP programme, the model was
scaled up to 18 cities in the EAG states and the two metropolises of Bangalore and
Kolkata. The USAID funding for the HUP programme came to an end in October
2015. The next steps which relate to long-term funding, are awaited.
PFI continues to give support to the NUHM programme, using the learnings ac-
quired in the implementation of the HUP programme. In the meanwhile, several
states — such as Maharashtra and Odisha — have requested PFI’s continued sup-
port for their HUP activities under the NUHM. The next phase of the HUP pro-
gramme is to be funded by the Asian Development Bank, which is keen to ensure
that there is a provision for the technical assistance required to put into place the
guidelines and structures that have been developed so far.
....
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B - 28, Qutab Institutional Area,
New Delhi - 110016