Focus 1996 July - September

Focus 1996 July - September



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Volume X No. 3
July-September, 1996
ROLE- OF NON-GOVERNMENT
ORGANISATIONS IN ACCELERATING
THE PACE OF DECLINE IN INFANT
MORTALITY AND FERTILITY
The two-day National Seminar on
"Role of Non-Government
Organisations in Accelerating the Pace
. of Decline in Infant Mortality and
Fertility", organised by the Population
Foundation of India (PFI) in
collaboration with the International
Development Research Centre (IRDC),
,Canada on 29th July, 1996, discussed
issues and trends in Infant Mortality
and the important role NGOs could
play in this regard. The major stress
Was on strengthening NGOs financially,
technically and professionally so that
ql.!ality health care services could be
provided to infants and mother in
remote areas where fertility and infant
mortality levels are high and help in
reducing these rates. A brief report of
the two-day National Seminar:
In his welcome address, Dr. K.
Srinivasan, the Executive Director of
PFI, said that the findings of PFr projects
in reducing infant mortality in remote
areas of UP, MP and Orissa had been
encouraging and this seminar would
provide NGOs an opportunity to share
their experiences in evolving specific
guidelines and programme of action
useful for both governmental and non-
governmental organisati.ons in future.
"NGOs with their commitment to
human welfare, flexibility of operation
and efficient utilisation of available
resources, through their innovative
methods, could effectively implement
programmes to serve the unreached
and underserved".
The PFr Chairman, Dr. Bharat Ram,
while inaugurating the Seminar said
tha t infant mortali ty had been
universally considered not only as a
sensitive indicator of health status of
the society, but also as a level of its
socio-economic development. "It
symbolises the educational status of
women, the care given to infants when
they are most vulnerable to sickness
and diseases and the extent of out-reach
of health care services and their
utilisation by the pop,ulation".
Though there had been a significqnt
decline in infant mortality rate (IMR) in
the country - from 139 infant death per
1,000 live birth in 1972 to almost half, 69
at present - wide differences in IMR
existed in different regions. The PFI, Dr.
Bharat Ram said, had realised the
importance of NGOs in reducing IMR
and narrowing of the wide disparities
in some of the states.
Dr. Bharat Ram suggested that
"High Infant Mortality region" should
be given priority by organising
programmes,
of community
mobilisation,
health education,
providing basic minimal health care
and arranging services at the village
level, hilly and tribal areas. Citing
experiences of the three action research
projects of Phulbani district in Orissa,
Damoh district in Madhya Pradesh and
Tehri Garhwal district in Uttar Pradesh
funded by PFI, he said that these projects
implemented by NGOs could lower
down the IMR significantly in these
regions. He hoped that the two-day
deliberations would ~o beyond
highlighting success, failures, ider~.tify
problem areas, underlying factors and
feasible solutions.

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NATIONAL SEMINAR
Dr. Anwar Islam, Senior
Programme Officer, IRDC, Canada, in
his address called upon NGOs in the
country to collectively explore the
"unexplored and be imaginative and
innovative while taking up challenges
for creating' a human, just, eqUitable
and sustainable society".
,~", :.,p..'" ::!
. '.~"- .~~'~L:·"."·]G.i\\11!!j(
~ i:!" '·:i:'J~~UU
~... ;::;1;
Speaking to the NGO's
representatives he said," you are the
vanguards of social justice. It is your
duty to make knowledge universally
available, accessible and be a catalyst to
change for a better society".Referring to
NGO's role in development, he saId
that in Canada they had the courage to
challenge the government: on many.
issues relating to sound policy but such
situation had not yet happened in India.
Inaugural Session (left to right) : Dr. Wazim Zaman, Dr. Anwar Islam, Dr. Bharat Ram
(Chairman), Dr. K. Srinivasan and Dr. Jon E. Rohde
Critically evaluating "the factors
underlying reduction in IMR,Dr. JonE. .
Dr. Almas Ali, Senior Consultant growing numbers and competition
Rohde, Representative, UNICEF, said'-: Voluntary Health Association of India, among them, the NGOs have to take on
that it had almost reached a plateau and: ; in his paper explained the importance additional activities beyond their
further reduction would be, difficult·- of understanding and assessing the traditional areas of involvement. It is
unless NGO community looked into .' determinants which governed the implied that "NGOs should develop
the underlying factors with openness --.variations in infant mortality rates. The new allies within the system and form
and adopt innovations that could bring determinants are different for the neo- coalitions to broaden the base of
about. the desired change in this. natal mortality and post-neonatal poU tical, economic and 'social
Apprehensive about solely relying on mortality rates. Generally the neo-natal participation".
technological inputs for lowering IMR
he said that the problem could be
tackled only by women, if they could
find solidarity at community level and
evolveappropriate solutions that would'
deal with the proximate determinants
of Infant Mortality and' Fertility at the'
community level. Dr. Rohde advocated
for having a broader. perspecUve' on
utilisation of resources and asked that
both NGOs and comm~ititybe formally
involved to check the misu~~of 'funds.
~[h'-
mortality constitutes about 50 percent
of infant mortality. Thus, in order to
reduce IMR in areas where it is high,
efforts to reduce the neo-natal mortality
are to be undertaken.
Dr. Ali stated that the services and
.support of NGOs active in the field
should be utilised and intermeshed
with the governmenta~1efforts in an
integrated manner. He added that
NGOs are indispensable allies in the
delivery of primary health care, not
Presenting a paper on "Potential
Role of the NGOs in the Programmes of
Reduction in Infant and Child
Mortality", Prof. E. Eswara Reddy from
the Council for Social Development,
Hyderabad, chose to identify
deficiencies in awareness, action and
management as reasons for gaps in /
various development programmes. He
said every voluntary organisation
irrespective of its agenda of activities
should accept child care and family
Dr. B.' N. Tandon, Director, only because they can supplement planning work as an essential
P. SinghaniaResearchInstitute for Liver, government resources and efforts but component of their activities.
Renal and Digestive Disease, Delhi,'
while analysing the impact of ICDSon
reduction ofIMR said that it had helped
in redUcing IMR through selected
interventions such as by promoting
ante-natal care, post-natal care,
immunisation, and nutritiorialstatus of
both mother and child. He said if
government agencies and public
institutions
were involved
systematically in the implementation of
programme,it would yield better results.
also as there is much to learn from their
experiences, expertise and innovative
ventures.
According to a paper on "NGOs
Efforts to Prevent Maternal and Infant
Mortality in India", written by Dr. Saroj
Pachauri, Regional Director, the
Population Council, India, presented
byDr. SaumyaRao, NGOsare emerging
as an increasing visible force in the
health scene in India. Due to their
In her talk on "Family Planning in
'the context of Child Survival", the
Advisor
(Health), Planning
Commission,Ms. Prema Ramachandran,
said that though the last two decades
witnessed a substantial fall in post-
neonatal mortality component of Infant
Mortality Rate, a similar decline in
still-birth rates and neonatal mortality
rate had not occurred.

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NATIONAL SEMINAR
Coyaji, while summing up the second
session urged the participants not to get
into the controversy of Government's
Vs Non-Government's role in reducing
IMR but consider NGOs as a junior
partner to governmental efforts to solve
the problem. She emphasised on
improving the care of mothers that
would take care of perinatal mortality
reduction and provide greater care to
the girl child. Dr. Coyaji said that
sufficient stress should be put on NGOs
at grassroot level, as she felt 'mahila
mandals', 'youth clubs' and 'farmers
clubs' could play an important role in
health care programmes.
The presentation of three case
tudies conducted by NGOs in the
"High Infant Mortality Region" in MP,
UP and Orissa formed the basis of third
session. Mr. Neeraj Chatterjee of
'Damoh, predominantly a rural district
of MP which had high infant mortality
of 189 per thousand in 1981; through
innovative strategy and interventions,
it was possible to lower the IMR to 36
as compared to control villages with
IMR of 124 per thousand in 1995. He
said one of the factors that affected
reduction in IMR was sound strategy
adopted in programme implementation
which had ensured active co-operation
of block Sarpach, gram-panchayats and
community members. Elevating the
status of trained 'dais' by giving them
incentives such as certificates, uniform
etc. had also helped in getting their full
y support and reducing IMR, he added.
_. - --In
her presentation -on 'PhUlnar
Project in Tehri Garhwal of UP, Dr.
(Mrs.) Mawizuala said though all the
lives of pregnant women in the project,
area were saved after they had been
given anti-natal checkups and full dose
of Tet-Toxid injections, the full impact
of 'Phulna' programme was difficult to
assess because declines in IMR would
be noticeable only after a year or two
after the programme implementation.
She suggested that declines in IMR
would not automatically result in
reduced fertility rates unless suitable
methods for family planning were also
readily available.
Mr. Albert Joseph of 'Jagruti', while
presenting 'Tikabali Project' said that" ,',help in the,co,ntinuation of the project
wellplannedinterventionstrategycould
,activiti~. iIi tIle project area after the
increase referral cases that might have 'completion 'of the project. Referring to
led to the lowering down of IMR to 64 his ~xperiences, of these projects he said
per thousand as reported by 'Tikabali' further sUPP9rt in terms of providing
PHC recently. It had also been able to regular' supply of contraceptives to
sensitise ANMs who took active interest alread,y motivated ladies would be able
in the health of mothers and provided . to' reduce fertility. Emphasising the
them with not onlyTT injection but also important role of NGOs and GOs in
sincerely followed them up. One of the training lady health workers, he said
important findings of the project, he that if any further training was required
said, was that an NGO could work in for,sc;>meof them, they would be able to
liaison with Government and also' tCJ,keilp such training themselves and
ensure sustainability
after the ',uJti~,ately would be able to contribute
"as completion of project. An effective
15eWemployed health workers and
networking among ICDS personnel, j1hi's'would'helpto sustain the projects.
PHCstaffincludingANMsandmothers
,:J.,r.airing of self sustaining health
could be established.
In this background of experiences
being expressed by NGOs in their
w,prl>krs in rural areas should be high·
,of}, f~ ag~nda of NGO activities.
Mr. J. c. Pant Secretary, Ministry
papers, Dr. Sunil Mishra, Senior ~,9f.):i~alth, who chaired the session,
Consultant, PFI, provided a conceptual ; p~~~ilt,edhis views on the governments
framework for all the three projects !:i~~ti!l~~ve,in r~cent months t~ reduce
which was supported by PFI and IDRC, ~Pf'\\.Qt,:mortahty and recogrused the
Canada. He said that high IMR, low "~io,~~Jir;\\;kp.gebetween TFR and IMR. In
socio-economic development, more .".I11.~:'Opinion some kind of specific'
reliance on TBAs and dis-inclination to ,:\\hl~h:~ntions to promote mothers health
make use of the available health service , 'have'fo be worked out because he felt
by the community were some of the that even in state like Kerala where IMR
factors common to all the project areas. ''is'oFdy 13,·the neo-natal mortality among
Accordingly, the registration of all the children dying within one year is 75
pregnant women, screening and pel; c'erii·of infant deaths and still-birth
identification of high risk cases and ,rates are: quite high. Even if children
training of TBAs become the main focus 1:>eingboth are taken care of, theIMR in
of all the three projects. However, Dr. Ketala may 'Still be lower than what it
Mishra said that region-specific
is now. Therefore, the determinants of
packages of services had to be developed neo-natal mortality seems to be almost
for each project.
similar in Worst states as well as good
Mr. K. S. Natarajan, Joint Director,
PFI, while presenting data on baseline
survey carried out on the above
mentioned three projects, pointed out
that some contradictions existed
between the estimates of IMR based on
census data and on the baseline survey
on infant mortality, fertility and child
morality in the project areas. Therefore
he stressed on the need for an
states. Mr" Pant suggested, "the care of
, the n'eW-bornand care of women has to
be, addressed as a national campaign
and as an impo,rtant health intervention".
He ,said problems are rather severe in
some states. "We have to deal with the
Jarger issues of the high IMR in
the States of UP; NiP, Orissa,
Rajasthan, Bihar, Assam and even in
Tamil-Nadti~. -
independent final evaluatjon of these
Keeping high Il\\1R in mind, Mr.
projects so that assessment could be Pant Said that there was need not only
made on the impact interventions in of tremendous amount of sensitive
reducing IMR in the regions.
interventions by official workers at
Dr. B.K. Anand, Emeri tus Professor
AIIMS, who ,h~ired the session, drew
attention to those factors which could
places where the problems are severe
but also recognised an increasing ,role
of Traditi6nal Birth Att~nda.nt (T8A) in

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NATIONAL SEMINAR _~~~
__ .
tackling IMR. Ip.spite of a realisation
that TBAs are an asset to th~ communi ty
and lakhs of them are being trained
regularly, the number of birth attended
by a trained TBA still remains very low.
Speaking about experiences of UP
in reducing'IMR, Mr. Lov Verma,
Secretary Family, Welfare, Government
of UP, said that the 'target-free approach'
recently introduced should be called
'self target regime' which implied that
targets were set by the health workers
themselves or a more appropriate
terminology should be 'community
based need assessment'. This approach,
he said would hopefully remove
pressure of over reporting right from
commissioner down to the ANM.
Another strategy' adopted is the
'pregnancy based approach' that
identified 15 activities ANM has to
perform right from early registration of
pregnancies, regular pre-natal checkups
and help in delivery to identify high
risk cases and provide post-natal
checkups.
Referring to Mr. Pant's stress on
logistics, Mr. Verma said that the
government had both short and long
term master plan to strengthen the
logistical system in UP. However, he
said more surveillance and all round
efforts were required to decentralise the
system.
Dr. 1. N. Balaji, Chief of Planning,
UNICEF, while sharing the experiences
with CSSM programmes pointed out
that recent evaluation of CSSM
programme carried out by different
NGOs in differed states had come out
with interesting results on the extent of
coverage of the immunisation of
children. But the results of such
evaluation differed from those of
government figures. He said there had
been considerable a",:areness generated
about the care to be given to the 'would-
be mothers' and .also specific'
programmes for reduction of IMR and
'maternal mortality rate. He also
highlighted the improvements in the
CSSM programme over the earlier MCH
programme, particularly, the care for
girls in different age groups.
Mr. 1. K. Das of Population
Research Centre, Patna presented a
statistical analysis of trends and
determinants of IMR in Bihar and said
that as ante-natal and delivery care
were the important proximate
determinants of lMR; pregnant women
should be prOVided with essential
medical care during pregnancy. He also
suggested the need for eligible couple
to be motivated to have children with
an interval of four years.
. Dr. M. M. Gandotra, Additional
Director, Population Research Centre,
Baroda, while presenting the trends of
IMR in Gujarat said that a Significant
decline was observed only after 1987
due to intensive programme inputs in
the state and since then there had been
steady decline in infant and neo-natal
mortality. According to him, mother's
age, shorter birth interval, mothers
education and socio-economic status,
housing conditions and calorie intake
are the major determinants of lMR.
Referring to Karnataka's experience
of IMR, Mr. V. S. Badri, Population
Research Centre, Bangalore, said it
showed a decline after 1991 and the
possible determinants of high mortality
were mothers resorting to unskilled
attention at the time of delivery in
remote villages where no heal th facilities
were available to them. He suggested
that NGOs might be encouraged to
promote community participation in
health care through a system of health
guides and also take up income
generating activities by involving
panchayats, mahila mandals and youth
clubs.
Dr. S. Irudaya Rajan, Associate
Fellow at Centre for Development
Studies, Trivandrum, said that the
decline in the neo-natal, post-natal and
infant mortality in Kerala was mainly
due to the fact that about 90 percent of
births are occurring in hospitals and
other health institutions where timely
medical care was available to the mother
and the child. He said other factors that
had impact on IMR reduction were
mother's education and the availability'
of general health services within a short
distance and easily accessible. He
pointed out that the still-birth rate in
Kerala significantl y higher than in other
states and it is possible that a number of
early infant deaths are classified as
still-births in hospitals.
Dr. B. B. Hota, PRC, Bhubaneswar,
said that inspite of an overall decline of
IMR in India, IMR in Orissa' had
remained at a very high level and
showed slow decline. Considering the
state as most vulnerable for high
clustering of deaths in infancy, Dr. Hota
stressed the need for effective health
services in terms of accessibility and
utilisation.

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NATIONAL SEMINAR
In his presertation of IMR in UP,
Dr. P. Misra said that the decline had
been slower and :1 wide gap existed
between rural and ur'oan areas. He drew
attention to the poor utilisation ofMCH
care and most oJ the deliveries were not
getting any skilled attention. He felt the
need to strengthen ~he IEC activities to
draw more people into the programme.
Several background papers based
on NFHS data formed the basis of Sixth
session chaired by Dr. K. Srinivasan,
Executive Director, PFI. According to
Dr. G. Rama Rao, IIPS, Bombay, the
IMR declines sharpl y with the increasing
education of m.others, ranging from a
high of 86 p~r 1,000 live births for
illiterate mothers to a low of 35 per
1,000 live births for women with at least
high school education. Dr. Rao said that
risk of neo-natal deaths in women who
studied till high school and above
reduced by 58 percent as compared to
_.•/
mothers who wp-re illiterate. It was also
important that women avoid early
(below 20) and later (over 30) child
bearing as ~he ::isk of neo-natal as well
as post-natlll deaths were high in these
age groups.
Dr. N. P. Das, while discussing the
differential impact of the programme
factors vis-a-vis socio-economic
variables in reducing infant mortality,
said that mere inputs were not adequate,
but their effective reach had an impact'
on IMR reduction. He was of the opinion
that socio~onomic development had a
greater potential than the programme
-, - -factors, to influence all the-proximate
.determinants affecting infant mortality.
He stressed the need to give priority to
mother and child nutrition,
environmental sanitation in IEC and
training programme.
Pointing out the great regional
variation in terms of demographic
indicators in Karnataka, Dr. P. H.
Rayappa, said that out of 20 districts of
the state, the growth rate of five districts
had been quite high. The NFHS data
has not able to provide an assessment
On the quality of delivery system, that
has a great impact on the IMR reduction.
He also dr'ew attention to the decline in
quality ofh,=alth services in recent years
because of ANMs being overburdened
and suggested that attention should be
paid to involve NGOs for better quality
services.
Dr. Sanjay Kumar of PFI, while
presenting
the socio-economic
differentials and correlates of child
mortality based on NFHS data, found
significant differentials in child
mortality across the states. He said that
parent's education, role of mass media
and sanitation facilities had a significaHt
impact on the child mortality level. He
suggested that NGOs should work as a
catalyst between service providers and
service users and they could also work
as co-ordinating agencies for various
government services to enhance the
socio-economic,
health
and
demographic conditions of the people.
Dr. Y. N. Mathur of UNICEF, in a
session on experiences of the
International Organisation in health
sector said that NGOs need to have
positive attitude and clean image both
with people around and service
providers. They also need to have good
professional support and networking in
the delivery system. Dr. Mathur
emphasised that NGO must play a
catalytic role and strongly felt that they
must have clear cut exit policies by
which he meant that NGOs must
energise the community and decide
when to quit from those areas after
providing the kind of impetus that was
needed
for
sustainability.
"Sustainabili ty ,
transparency,
accountability and financial stability
are must for NGQs so that they are not
donor driven or driven by other
agencies", Dr. Mathur added.
On the role of USAID in reducing
IMR, Ms. Rajni Ved said her agency had
supported many NGOs and expansion
plan for serving underserved areas and
prOVided necessary infrastructure for
improvement of services. She said
importance had been given to
institutional strengthening of NGOs
and also support to other development
agencies. She strongly recommended
that NGOs should be encouraged for
sustainability by helping them set up
corpus funds. "As donors one should be
thinking about making NGOs
sustain.able so that they can carryon
doing better than what.they are doing,"
she added.
Ms.
Christina
Bierring,
International Programme Officer,
UNFPA informed that its programmes
had considered women's status and
access to reproductive health and family
planning services as major factors
influencing IMR and fertility. She said
NGOs were critical to support and
reinforce government action to
effectively implement the post-Cairo
policies and programmes. The real issue
she said was, "how can NGO
experiences be absorbed as good
practices by the government health
infrastructure to make innovative
programmes sustainable."
Dr. Orapin Singhadej informed that
WHO follows the concept of safe
motherhood and new-born care coupled
with family planning, women's equity,
greater emphasis on trained midwives
to provide quality care to mother and
infant. But she regretted having no
linkage with NGOs as all WHO's health
activities had been implemented
through government agencies.
Summing up the session Dr. Anwar
Islam said that three key areas where
NGOs could playa critical role were:
one of a catalyst for community
mobilisation of serving as a linkage
between the community and the service
providers; and as an advocacy group
for integrating the health needs and
services. He cautioned that the donors
and government should not view NGO's
role as a one-way street but to take the
responsibility of how to empower them
and fulfrl their infrastructural needs so
that in the long run they become
sustainable themselves.
Chairing the concluding session,
Mr. B.C. Verghese, Journalist and
Research Professor, CPR, Delhi, hoped
that from Dr. K. Srinivasan's summation
of the two-days' deliberation and
recommendations from them will be of
tremendous val ue in shaping the policies
and programmes to reduce IMR and
Fertility in the country.
Recommendations on page 10

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INSIGHT
INFANT MORTALITY DECLINES THROUGH AREA
SPECIFIC INTERVENTIONS
The three action research
projects of PFI show that by
Attendants (TBAs) who could act
as the main link between the project
cases, conducting safe deliveries,
post-natal care, care of the infants,
concentrating on the filtered
and the local population.
base of high risk pregnant • Provision of services to the
reproductive health and fertility
regulation.
women, infant mortality can be
brought down significantly
identified pregnant women, new • Regular follow-up of the pregnant
mothers, infants, young children
women, particularly those in the
and the ~1igh risk case, and fulfil
high risk category and monitoring
from 20 to 40 per cent within a
their nutritional needs through
of the ante-natal health of women
period of three to five years.
nutritional education on balanced
and infant care.
The studies on "Accelerating the
Pace of Decline of Infant Mortality and
Fertility," jointly commissioned by the
Population Foundation ofIndia and the
International Development Research •
Centre, Canada, in three high infant
mortality regions of Orissa (Tikabali),
-Uttar Pradesh Uaunpur) and MCI;dhya
Pradesh (Damoh), have shown a
significant decline in infant mortality. •
This could be achieved by evolving
intervention strategies that were
compatible with the social, cultural and
demographic situation in the respective
region, focusing attention on high risk
pregnant women and immunisation of
children.
diet, obtaining nutrients from the
locally available cheap foods,
supplementary nutrition, wherever
pOSSible etc.
Provision of necessary maternal
and child health care at the village
level either through the trained
TBAs or by organising visits of the
health staff.
Development of Information,
Education and Communication
(IEC) material based on local beliefs
and practices. The notable aspect
of the IEC package was that the
local talent and folk media were
used to educate and mobilise
people's support.
• Ensuring service support by the
health functionaries by organising
field visits, immunisation camps
and arranging referral services for
those in the high risk category. , --
• Nutrition education and arranging
nutritional supplements for the
p~egnant women, new mothers,
infants and young children,
wherever feasible.
• Organising IEC - activities with
particular emphasis on individual
counselling.
The three projects had I11any
common elements; however, area
specific intervention strategies. had to
These three project are infact a
follow-up of the first phase study,
"Infant Mortality in Relation to
Fertility," jointly funded by PFI and
IDRC, Canada, which identified many
risk factors related to maternal health,
infant care, poor nutrition and poor
sanitary environment. The study also
pointed out poor outreach of the health
services, which had created a sense of
aisEmchantment among people towards
using such services.
Based on these principal findings,
the second phase or the 'Intervention
Phase' was launched in three 'High
Infant Mortality' regions of the country;
Tikabali· (1992) fully funded by the
• Efforts are being made to mobilise
community support by establishing
rapport with community leaders
through meetings, discussion etc.;
involving senior women, pregnant
women and new mothers in the
programme; forming small groups
of adolescents and youths for
discussion on social issues.
• Maintenance of liaison with the
local health functionaries for
arranging necessary services that
community needs and demands.
OPERATIONAL STEPS
The operational
steps in
be evolved to ensure compatibility with
the social, cultural and demographic
situation in Tikabali, Jaunpur and
Damoh blocks. They were all
implemented
on a common
methodology by non-governmental
organisations working in these areas.
I
THE TIKABALI PROJECT
Tikabali block of Phulbani district
in Orissa, si tuated in semi -mountainous
terrain with a population of 44,000 of
which majoriiy are scheduled tribes
and scheduled castes, presents a dismal
picture of heal th care services. The
block has only one PHC that invariably
remains short of staff and other health
Foundation; and Jaunpur and Damoh
(1994) jointly supported by PFI and
IORC, Canada.
implementing the programme were:
• Baseline survey to identify and
register all the pregnant women.
facilities. The mother and child care
was poorest in the district. Spread over
11 Gram Panchayats, Tikabali no doubt
had the highest Infant Mortality Rate of
MAIN INTERVENTIONS
• Screening of pregnant women and 164 as against 122 in Orissa and 91 in
enlisting high risk cases based on a India. Although agriculture is the main
The common key interventions of
predetermined check list.
occupation, people get poor yield
these projects were :
because of lack of proper irrigation. The
•
Identification and training of the
village level Traditional Birth
•
Village wise ~nlistment of the TBAs
and their training in ante-natal
care, identification of high risk
result is, acute poverty and low
nutritional level that leads to high infant
mortality and fertility. Portable water

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INSIGHT
supply is another perennial problem
for the people who also have to walk
iong distances in the absence of adequate
transport and communication facilities.
The project was funded by PFI and
implemented by 'Jagruti'-an NGO
working in Phulbani district. The
Government of Orissa full y co-operated
in the project work. Coordination
committees were formed at the district,
block and the village level in which the
project people, the health staff and the
community leaders at the respective
levels participated. This enabled in joint
formulation of the plans of operation,
co-ordination at all the levels and also
in supervision and monitoring of the
activities by the local leaders. The
'system, however, functioned smoothly
in some villages but was not so
successful in other areas due to various
reasons.
Joint training programmes for the
field level health functionaries and the
project staff were organised at the block
and village level. The health
functionaries thus could understand
the project philosophy and also had an
orientation in the methodology of work.
Besides, they could also co-ordinate
and plan jointly for the programme
operations. On the other hand, it also
provided an opportunity to the project
people to empathise with work situation
and conditions in which the health staff
functioned.
As mentioned earlier, the nutrition
}status of the population in general and
that of the women in particular was
poor.-The-pregnant
women, new
mothers and the young children suffered
from malnutrition giving rise to many
ailments besides. lowering the body
resistance to infections. The earlier study'
in Phase - I, had identified the low
nutritional status of the women and
children as one of the important factors
for infant mortality. As such, nutrition
became an important component of the
programme. Towards this goal,
nutrition education was prOVided to
the population in general and the senior
women, pregnant women, and new
mothers in particular, using a variety of
communication media and channels.
Efforts were made to encourage
people to make kitchen garden as a
means of getting nutritious food from
.
.
. Month~'I:c' f!fiCxup of :l/gh risk pregnant woman in Damoh (MP) ,.
home grown vegetables. Tapioca
cultivation was introduced in different
villages to provide for minimum calorie
req~irements
during the lean
agricultural seasons. In addition,
mushroom cultivation was also imtiated
in the area. This had a dual purpose;
one to make the nutri tious food available
to the family and for commercial
marketing for supplementary income.
The basic idea being that with
supplementary income, people may be
able to afford nutritious food from the··
~arkets. While kitchen gardening
picked up, the Tapioca and mushroom
cultivation had mixed success.
Mushroom cultivation in particular had
a limited success as there were no
.organised marketing facilities.
In order to develop a need based
and
culturally
compatible
communication strategy, efforts were
made to make use of the local beliefs
and practices
in producing
communication material. For this, local
talent was used.' A few of the street
plays produced by the local artists were
immensely popular.
Balwaadis were started in the
villages where Aanganwadis were not
functioning. The project staff identified
and,trained local volunteers to take up
the Job. The families, which wanted to
partic:ipate in the experiment had to
contribute a small amount per month.
Though initially, there were objections
against charging money since
Aanganwadis provided these services
free,. the Balwaadis in 12 villages
contmued to function with support
from the local population.
In Tikabali the Khond tribe lUts ~.
system of youth dormitories called
'Dhangara Ghar' where the young
members of the tribe from the village or
a group of villages live. Although, the
boys and girls live in separate
dormitories, they frequent! y meet, dance
and play together. Therefore, education
of the adolescents in reproductive heal th,
sexuall y transmitted diseases, hazards
of early marriage and teenage
pregnancies, multiple pregnancies with
shorter.int.er-birth interval, etc, assumed
importance. Small groups Ofadolescent
girls, including tribal and non-tribals
were organised and their group
meetings were held, where such topics
were discussed. Likewise, the groups of
male youth were also organised where,
in addition to the topics related to
responsible parenthood, social evils like
alcoholism, drug abuse, etc. were also
discuSSC!d.The education of the young
boys and girls was assigned considerable
importance under the project.
THE JAUNPUR PROJECT
This project was funded by PFI and
IDRe and implemented by the NGO

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.Traditional birth attendents participating in a
Jaunpur (Tehri Garhwal, u.P.)
"Phulna, Landour
Hospital".
Community
Jaunpur block of district TeJ:ri
Garhwal, a sub-Himalayan range m
North Uttar Pradesh, has all the
trappings of a rugged m~untain, rough
terrain, small scattered Villages, lack of
transport, communication facilities,
supply of drinking water,. e.tc, ~or a
. population of about 50,000 hvmg m 251
revenue villages of Jaunpur, the
outreach of the health services is poor.
With} only one PHC at the block
headquarters Thatur which covers a
small percentage of population, Land0l;1r
Community Hospital serves as the mam
referral centre.
Although agriculture and a~mal
husbandry are the main occupatiOns,
land alone does not sustain the families
more than three or four months in a
year. This compels the male population
to migrate to plains in search of work.
They work as casual contract labourers,
road construction workers, resin tappers
or as domestic help in cities.
Distances in the hilly regions often
deter the health functionaries from
making .field visi ts, thereby dep!iving
the local population of modern health
services. The need, therefore, was felt to
develop local functionaries who could
act as a link between the heal th staff, the
. project and the community. The TBAs
were such social
functionaries whose
presence
was
normally required at
the time of parturition
in most of the
households. In view of
the utility of TBAs in
rendering necessary
MCH care, they were identified,
registered and given training und.er t~e
project. They were ~mp~rted sk,~ls. m
conducting safe dehveLles, provIdmg
proper maternal and child healt~ care,
identifing high risk maternal and mfant
cases, prOViding education on proper
nutrition to the pregnant women, new
mothers and the young children. The
TBAs were also trained in identifying
the high risk or complex cases and refer
them to the health centres.
It is noteworthy, that formed:}' the
TBAs were only invited at the time of
delivery. However, after the training
they became a sort of health guides to
the local population and consultants on
the matters related to the ante-natal,
post-natal and infant care. The TBA
training was organised at the sub-eentre
level by involving the local h~alth
functionary. They were prOVided
disposable safe delivery kits, a blue
coloured saree and a small bag to carry
things. This gave them the status of a
health functionary who could be
consulted any time during the pregnancy
and after delivery .
Because of the difficult terrain,
mobility and coverage of the project in
villages became a difficult task .. To
overcome this situation, a networkmg.
with the local NGOs was arranged. In
this connection, those NGOs who had
expertise, wer~ made to organise
training programmes for the women,
TBAs and the community leaders.
The proje~t in the Jaunpur. block
was carried out under the auspices of
the Landour Community Hospital
which also provided back up medical
services to the cases from the nearby
villages. In order to organise survey
and registration of the preg~ant women,
transportation of cases With complex
nature to the hospital and to ensure
regular follow up of the hig~ risk cases,
mobile van was used. ThiS not only
facilitated mobility of the project staff
but also helped in prOViding necessary
services at the village level.

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INSIGHT
Selected sub-eentres in the block
were used for training of the TBAs as
well as for organising programmes for
the senior women of the community,
pregnant women, new mothers and the
community leaders. Bal Melas (Baby
shows/Fairs) and Mothers' meets were
also organised at the sub-eentre level.
Since difficult topography made regular
interactions with the health staff
difficult, such occasions provided an
opportunity for health education, health
check-ups, immunisation and also for
organising small group meetings with
the community leaders.
TIlE DAMOR PROJECT
This project was funded by PH and
. RC and implemented by 'Grameen
Navjagruti Yojana' -Damoh, MP.
Unlike the above two project areas,
Damoh block in MP has the highest
density of population which is about
14,000liVing in 267 villages. Agriculture
being the main occupation, the
population remains poor and illiterate.
Since the reach of the health services is
inadequate, people still place greater
faith on the traditional beliefs and
practices pertaining to MCH care.
As in the case ofJaunpur block, the
TBAs in Damoh were trained and given
blue sarees, kit bags and also safe
delivery kits. This helped in their greater
acceptability and accessibility in the
households where they were treated as
some sort of an expert on matters
related to maternal health and child
care.
In Damoh, a mobile van proved
extremely useful in carrying a lady
doctor and nursing staff who prOVided
health check up ~o the village people,
monitor pregnant women 'and
transported high risk cases to the nearest
health centre. The van regularly made
visits at particular time and at fixed
points, where the village people used to
collect. This arrangement helped to'
carry out monthly check ups of the high
risk pregnant women and also enhanced
the mobility of the staff in proViding
necessary services at the village level.
'The 'Grameen Navjagruti Yojana',
under whose auspices the Damoh
project is being carried out, had a well
equipped' audio-video proQuction
studio. This faCility had helped in
producing video films based on the
local situation and using local talents.
Likewise, audio cassettes were also
produced
for small group
communication. These proved helpful
in inculcating proper attitudes as they
were based on the perceived health
problems of the people and the
audiences could identify themselves
with the situation.
Two or even three years period is
too short a span to measure impact of a
programme on the demographic rates
or to assess the processes of changes in
the traditional practices. The analysis of
the project records of the pregnant
women in all the three blocks, however,
shows that there has been a significant
decline in the incidence of infant
mortality, which is much higher than
the normal trends of decline observed
over the years. This shows that the
earlier assumption of "concentrating
on the filtered base of high of high risk
pregnant women could significantly
bring down the infant mortality in a
region", was by and large correct.
However, it would require scientifically
planned special studies to conclusively
prove the assumption, accurately
estimate the extent of decline and to
establish a cause and effect relationship
between the decline and the intervention
strategies as adopted under the project.
On the other hand, the trends and
directions of change under these projects
can be assessed with the help of indirect
process indicators such as significant
increase in the number of safe deliveries
and live births among the high risk
pregnant women under all the three
projects; a tremendous increase, in
demands of MCH services even after
completion of the project more than a
year ago; and a greater and persistent
demand for the services of the trained
TBAs who are being accepted as some
sort of a health functionary in the
villages. _
Like previous years, the World and the role community could play in
Population Day on July 11, 1996· reproductive health of women and
began with a commitment to control the HIV/AIDS control. Viewed by the millions
galloping population. Commemorating the across the continent on CNN and 003, the
day, programs on population reminde~ us . one-hour programme highlighted the
of the devastating effect the rapidly growing importance of direct involvement of community
popUlation has on the lives of people all in dealing with ever increasing population and
over the world. The central theme of this problems arising out of it. Those who
year as chosen by the United Nations is, participated in the program were, Dr. K.
"Community Responsibility: Reproductive
Health and HIV/AIDS,"
Srinivasan, Dr. Wasim Zaman, Dr. Saroj
Pachauri, Dr. Meara Shiva, Dr. S.P. Khanna
On this day the PopUlation Foundation and Mrs. Rami Chhabra.
of India took the initiative to organize
activities and discussions on population
related issues. One of the most important
being the round table discussion for
DOQrn'ir<:han on population scene today
The Executive Director of PFI, Dr. K.
.:lrinivasan also presented a paper on "Role
of Corporate Sector in the improvement of
rural health and family welfare programme :
J\\ suggested model for the districts of
Ghaziabad in UP and Kota in Rajasthan"
in a Seminar on Population Moderation and
Corporate Sector, organisedJor the World
Population Day ~vent by the Federation of
Indian Chambers of Commerce on July 10,
1996. On the same day he presented a
paper on "India's Urbanisation and, Health
Conditions: Some Observations," in a half-
day seminar on PopUlation, Health and
Urban Affairs jointly organised by the
Ministry of Urban Affairs and Employment
Department of Urban Development and
. UNFPA at Vigyan Shawan, New Delhi.
The President of India, Dr. Shankar
Dayal Sharma released a five-rupee
commemorative coin on the occasion of
World Population Day.
-

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STATE FILE
PLIGHT OF WOMEN PRADHANS
The good news is that there are one-
third women pradhans in Rajasthan
today but the bad news is that they are
not, being allowed to exercise their
rights indepen<;lently.In a majority of
cases their menfolk are virtuall y defacto
functionaries and have direct control
over panchayat matters.
Realising the problem - that many
elected members did not know their
rights, which they 'secured' under the
73rd Amendment to the constitution,
the Government had launched Rs. 2.5
crore training programme for them. But
for women representatives, who
In Rajasthan many elected women observed purdha such exercise was an
pradhan with little or no education find up-hill task. In the first place, many
themselves helpless victims in the hands refused to attend the training camps as
of gram sewaks who do not allow them they had to come alone to district
to function efficiently. 'In fact women headquarters. In'many cases, they were
representatives have no access to not allowed by their husbands to attend
accounts and other documents and they the training as it included male
have to take help of male members of - members. Many who could participate
their families. A classic case is that of felt that men dominated the training
Kanku Bai, a vegetable vendor and an programme while w.omen did not get
illiterate sarpanch of Badkochra gram the attention they needed.
Panchayat in Jawaja Panchayat Samiti
in Rajsamimd district, w.howas told by
the gram sewak that her main job was
to bring family planning cases. In many
.caseseachwoman member was assigned
the task of 'bringing' a certain number
of family planning cases. Not being
aware of their real work and rights
But exposure to such meeting and
programmes changed the approach and
life style of many of the women
representatives. They were prOVided
with attractive shoulder bags and plenty
of literature to learn the basics of
Panchayat Raj at these camps.
these women suffer in the hands of
Shri BhairoSinghShekhawat,Chief
Minister of Rajasthan, who had
suggested many amendments in the
present Panchayat Raj Act to increase
the role of women representatives, feels
that at present the women are still
feeling their way around. He is of the
view that by the next panchayatelections
alone, will they be more aware and
assertive. 5hri Shekhawat concedes that
women understand the problems of the
villages better than many men because
by nature they are more honest and
sincere and do not tolerate corrupt
practices.
LOST POST FOR V
HAVING THIRD KID
Three elected village level
representatives including a woman
in Rajasthan lost their posts .for
having more than two children
under the newly enacted Panchayati
Raj law by the State Government.
Thenew law restricts the village
level representatives, panches and
sarpanches, from having a third
child (PTI).
Recognising the increasing role and
requirements of NGOs in accelerating the
pace of decline in infant mortality and
fertility, the national seminar recommends:
NGO" at State level to coordinate the
activities of 'Lead NGO'. To provide
financial, professional and management
support to the member NGOs.
The strengthening of NGO Sector in
health care by providing financial,
technical and training support through
government and international
5. 'To promote NGOs participatio'n
in 'High Infant Mortality Region' th,ough
programmes of community mobilisation,
healt.t1education and healthcare services.
organisations.
To provide training and IEC ~upport ~o
Th~ need of networking among NGO~
. NGOs to facilitate health caril activities.
to" share' informatldnand innovative . 7. , Th~ need for honouring and rewarding
:" iaeas~'th~rinterdependence on each :;, . " . NGOs'working for wom~.n'~aus~;. their
'ii: :.r .otllet~lO'·.exchang~
~xl?erLen.9..~s~,~ ,', . ' r.~proguctive rights,.gendW;equity etc.; in
, resources, research' and observation
" remote areas to ensurE{soeialrecognition
fo 'ImprOVe tlieir 'efficiency 'arid
, for their work.
,'. ' ,
effectivity.
•.
NGOs to adopt a four tier system to :
3.· The need of pooling and utilization of
the expertise of NGOs working in the
same area but for different
programmes.
train traditional birth attendants; assist
and supervise these trained TBAs through
a network of field level community health
workers; provide back up support with
medical and para-medical personnel to
The establishment of 'Lead NGO' for
remote villages and build a strong referral
coordination of activities between the
system, to deal with complicated cases
NGOs at each District and a 'Mother
for timely medical attention.
9. NGOs to take lead role to educate
women about the importance of mother-
child nutrition and monitor the nutrition
services provided to expectant mothers
by the government.
10. NGOs should work in close
cOllaborationwith panchayats to ensure
greater 'community participation.
11. NGOs to work as a 'watchdog' to
ensure gender equity, to protect
women's reproductive rights, eradicate
female infanticides and feoticides.
,.
1._
12. NGOs should avoid political linkages
in their activities and work for the
welfare of the people.
13. NGOs to develop a data base
for sharing experiences and
achievements for mutual benefits.
14. NGOs to play a role in
elevating the status of 'dais' by
providing them incentives like dress,
more income and renaming them as
'sakhi' or any name closer to this,

2 Pages 11-20

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2.1 Page 11

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STATE FIlE
PROPOSED BILL TO MAKE SMALL
FAt"\\t11LY A A1UST FOR CIVIC POLLS
The Delhi Government is bringing
in a Billwhich, once enacted, will debar
from the municipal elections all those who
have more than two children or violate the
norm after the bill is passed.
This was announced by Health and
Education Minister Harsh Vardhan. He,
however, clarified that 'certain safe-guards"
would ~ included in the proposed Bill.
"As a safeguard, this legislation will
providethat birth, within a reasonabie period
from the enforcementof the Act, an additional
child shall not be a disqualification".
"If a person already has more than two
children on the date of enforcement of the
Act, he will not be disqualified. A further
safeguard will be provided to· those who
happen to have twin.....within a period of 10
months from the date of commencement of
the Act. This will also not be a
disqualification:' he said.
The resolution, to be moved by
Harsh Vardhan, will also request the Union
Government to provide for similar
amendment to the Constitution, applicable
to all state Assemblies, state Councils, Lok
Sabha and Rajaya Sabha.
The minister said he was quite hopeful
that public representatives would agree to
these measures and would accept them in
the right perspective.
This would set a healthy example for
the public to follow the concept of a small
, family, he added.
-he role of family planning in the
T development of the country has
been repeatedly emphasised by the
policy planners, politicians and experts
alike. Even today the number of women
who die each year during pregnancy
and childbirth inIndia is quite alarming.
The situation is far worse in rural areas
for want of proper medical
infrastructure and care. It has now been
recognised that only properly trained
midwives or 'Dais' can mitigate the
problem.
Dr. (Mrs.) Prakashwati Bhatnagar,
a graduate from Christian Medical
College, Ludhiana, and the recipient of
the Viceroy's Platinum Medal, has been
tirelessly working in training traditional
birth attendants since 1936. Her
experiences are result oriented. She has
rel~ntlessly made efforts to reduce
maternal and child mortality while
promoting positive health and family
welfare.
"The main focus of my training
method has been on utilising the local
resources and trainees. This was the
reason 1 could train 'dais' without the
financial help from agencies of health,"
says the lady doctor.
She has written a book "Training
Traditional Birth Attendants" based on
her methodology and experience gained
during her long years in the field. This
book is of great use to trainers of
traditional birth attendants at> well as
.paramedical workers and medical
officers looking after health care services
through community health centres,
primary health centres and district
hospitals. The technique and training
suggested in the book are economical
and traditional, but, scientific.
The emphasis which Dr. Bhatnagar
has placed· on dais is remarkable. The
Institution of dais is a part of India's
tradition and this needs to be
progressive, improved· and widely
utili sed in the interest of the mother and .
child.
The distinguished services of Dr.
Bhatnagar was recognised by the
Government of Rajasthan and she was
given the best social worker award in
1989. Earlier she got the Medical, Health
& Family Welfare Services Award in
1983. She has been associated with a
number of other organisations engaged
in social welfare and community
development. (HT)
MINISTER WANTS CONDOM ADS BACK AT PRIME TIME
r-
Health and Family Welfare Minister
Salim Shervani has challenged
Even the new Information and
Broadcasting Minister, Mr. CM. Ibrahim,
lot of aid fram countries like the US, UK,
Germany, Canada and Sweden to fight
-- Doordarshan's "morality" standards that did not dare revoke Ms. Swaraj's decision, popula tion and AIDS. A part of the budget,
were imposed by the BJP government.
that had forced condom-makers to take say Rs. 20-30 crare, can be used for
He wants the ban on the telecast of
cond~m advertisements and family
planrung campaigns during prime time to
be revoked and plans to take up the
matter with the Information and
Broadcasting Ministry.
their commercials off Doordarshan. They
continue- to maintain a distance from
Doordarshan as they are not interested in
the advertisements of their products after
11 pm.
"But we have to show such things on
advertisements," Mr. Shervani said.
'We are not going to be at the mercy
of Doordar:shan anymore. Wearenotgoing
to beg for time slo ts. We will buy them wi th
this money," Mr. Shervani said, adding,
"at present, there is a tendency in
''We have taken a strong view of the
~an. We will have to change it,
Mr. Shervani told The Asian Age.
prime time. The message has to go to t~e
whole nation," Mr. Shervani said, while
agreeing tha tAIDS was affecting more and
more youngsters and condom was the only
government departments to look for free'
advertiseqtents in television, in which case,
Doordarsbangives them a slot like 6.30 am
or 7 am when very few wa tch television."
The ban came into force when BJP's
Information and Broadcasting Minister
Ms. Sushma Swaraj ruled that such
commercials should not be viewed by the
-:ri:drcn and sbould be telecast only after
11 pm.
effective weapon against it.
The health minister even plans to go
a step ahead by pumping in for money for
a "meaningful advertisement" for
population and AIDS control. "We get a
The minister said that he would call
a meeting of senior health ministry officials
to work Qut the details of the budget for
advertisement of population and AIDS
control measure.

2.2 Page 12

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PFI NEWS IN BRIEF
FAMILY
lVELFARE
PROJECT
LAUNCHED
A Rupees 6.8 million
famil y welfare programme
of the Population Foundation of
India (PH) and the Federation of
Indian Chambers of Commerce
and Industry (FICCI) was
launched at Ghaziabad in Uttar
Pradesh on July 12, 1996. The
project aims to bring down the
infant mortali ty and fertili ty ra tei
improve reproductive health,
increase the contraceptive use;
and female literacy in three years
time in the entire district of
Ghaziabad.
The project commenced with
two day orientation camps for
Gram Panchayat Pradhans with
a view to provide them intensive
training on health of mother and
child, services available etc. and
how they could hel p to mobilise
local resources and ensure
community participation. The
training of 'dais', community
health volunteers, auxiliary nurse
and midwives would ensure
quality health service to people.
A core team set up by FICCI
would co-ordinate and monitor
the health activities through a
series of packages developed by
PFI. This team will maintain
liaison with government,
industry, panchayat and other
involved agencies.
Editorial Direction &
Guidance:
DR. K. SRINIVASAN
Editor:
UMA YADAV
Dr. M. S. Swaminathan (left), Chairman, Advisory Council of PFI, releasing a book,
'Population Policy and Reproductive Health; edited by Dr. K. Srinivasan (extreme
right) on 15th July, 199B,.New Delhi. In the middle is Dr. Banoo J. Coyaji.
Dr. K. Srinivasan, Executive
Director, PFI visi ted Dhaka, Bangladesh
to participate in a seminar on 'Health
Care Reform : User-Provider-Policy
Maker Dialogue - A Regional
Perspective' organised by International
Centre for Dairrhoeal Disease Research,
4-5 August, 1996. He presented a paper
on "Role of NGOs in the Child Survival
Programme and some issues on
Evaluation".
He was also the panelist for the
session on "Private Sector Service
Delivery' of the state level seminar on
'Perform Survey - 1995', organised by
the State Innovations in Famil y Planning
Services Project Agency under the
auspices of USAID, 10th September,
1996, Lucknow.
'"
SHARE
WITH US
FOCUS has a new look now.
We have introduced new columns
for exchange of information and
innovative ,ideas in the filed of
reproductive health and family
welfare. We invite from our
readers research findings,
success stories and articles
along with photographs on
population, environment and
development. We would be
happy to have feedback from
our readers so as to make
FOCUS a forum for exchange
of information and knowledge..
Published by the POFUU.TION FOUNDATION OF INDIA, 8-28, Qutab Institutionai Area, New Delhi-110016. Tel. : 6867080. 6867081
uy Designed and Prjn~",d Rerroductions India. 198/19, Sapna Apartments. Ramesh Market, East of Kailash. New Delhi-110065. Phone: 6233269