People Show the Way :: PFI Publication :: KNOWLEDGE MANAGEMENT CENTRE PORTAL, POPULATION FOUNDATION OF INDIA

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Preface

The Family Planning Foundation of India is happy to present in the

tollowing pages some gl~mpses of the NGO effort for family planning in

India. This compendium of successful experiments consists of projects

whIch have been selected for the innovative and creative elements in their

work. The projects depict varied backgrounds. in terms of their locations,

the people who are the targets of the programmes, the programmes them-

selves. as also the approaches, methods and processes that have gone

into making them successful. The attempt has not been to select the

"best programmes"; rather, these symbolise the basic spirit of innovation

and experimentation with which the NGOs try to function in family planning.

Each project while being local or region specific in varying degrees of

success, is a response to the needs of the people. The innovations or the

creative elements may be at the level of a method or an approach in the

programme content or nature of manpower involved or in the way they

relate to government or perhaps a combination of several of these elements

The attempt may be in the nature of a corrective or a gap-filling exercise.

Sometimes, it is an attempt at systemic change.

These experiments show in various ways that people matter in all

development effort. especially in family planning. It is hoped that these

reports provide some meaningful insights for the International Population

Conference, particularly when matters relating to non-governmental and

voluntary action groups are discussed as part of the overall emerging

9 loba I strategy.

The NGOs in India enjoy great independence and therefore have

shown tested and forward -looking fleXibility for experimenting with new

ideas and demonstrating their value for the larger policy and programme

needs.

It is in this spirit that these reports have been presented. These

were il: the first instance prepared by the project directors themselves or

other:;, co'nected with the project and edited by the Foundation. Ti"e

authors Of these reports deserve our thanks for their cooperation Vj",.'

wou:d like to thank the Government of India, particularly Mr. C. R

VJio'/anathan, Secretary, Health and Mr. R. P. Kapoor Additional Secretary

and CommiSSIoner (FW)for Inviting the Foundation to undertake this work

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· for the International Population Conference. We also gratefully acknow-

ledge the help of the office of the Registrar General of India. particularly

Dr. B. K. Roy. Deputy Registrar General (Maps) for the invaluable assis-

tance rendered in the preparation of the maps.

It is our hope that the compendium would prove useful not only

for the International Population Conference but to the larger audience

who are involved in population in India and elsewhere.

The Family Planning programme has very soon to move away from

a preponderant technological base to a <;ulturally sensitive approach.

This transition is indeed a real challenge and a time of opportunity for the

NGOs. There is no future for family planning effort in the coming decades

without the avant-garde role of the NGOs at whose heart are the people

themselves; people. who are both the creators of the will for determined

action as well as beneficiaries of that action. It is therefore appropriate

at this time to recall what the Prime Minister of India. Mrs. Indira Gandhi.

has said: "Family planning must be a people's movement. of the people.

by the people and for the people".

August. 1984

New Delhi. India

J. C. Kavoori

Executive Director

Family Planning Foundatior

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UPASI: Leading the Way for

Organised Labour

Background:

The low mountain ranges hugging the Western coastline of the Indian

peninsula provide a picturesque setting as they traverse the states of

Karnataka. Tamil Nadu and Kerala. Here. the hill slopes are perennially

green as the miles stretch out in emerald strings of tea. coffee, rubber or

cardamom groves. Nature's rich bounty to this area has had dividends

for the people: for the management of these valuable crops being grown

in commercia~ plantations is labour intensive.

Further, whether corporate or family owned the plantation estate -

if it employs more than 30 workers - is governed by compulsory. compre-

hensive labour welfare legislation. Since 1951, the Plantation Labour

Act ensures all the usua1 workers' benefits of minimum wages. maternity

benefits. provident fund etc. It also ensures all basic amenities such as

housing, water supply. medical care for the workers and their dependents.

and with 56 percent of the labour force female (80 percent within the re-

productive age group) creches for their children. The medical and welfare

facilities are statutorily laid down depending on the size of the estate and

the number of the workers. which normally ranges between 30 to 150 on

an average. with a few large estates E'mployingaround 500.

High Birth-,.t •• on PI.nt.tion.

But despite the salutory conditions of service this seemingly idyllic

scene had its shadows. As late as 1~71. birth rates were as high as 40

per 1.000 population on these plantations and infant deaths took a toll

of one child of every eight born; although. the women workers suffered

from the burdens of frequent pregnancies and their consequences. birth

control measureswere practised by less than one in ten couples. Despite

extra cash incentives offered by employers to workers who accepted a

permanent method cf family planning. there were few takers.

Surveys showed the workers' primary concern was for their health.

But with three-Quartersof the population illiterate misconceived fears about

the methods of contraception and their effect on the individual's health

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coupled with Justified fears about child-loss were major deterrents to a

wider practice of family planning.

It was against this backdrop - and in response to the national con-

cern about the population issue - that the United Planters Association of

South India (UPASI) - the apex body of the plantation industry which is a

forum for the promotion of the industry's interests and a voluntary associa-

. tion of practically all estates - undertook to launch a pilot Comprehensive

Labour Welfare Scheme. It aimed to test whether a more concerned.

conscious canvassing of family planning acceptance within the frame of

an integrated welfare programme would bring better success. A decade

later. that tentative involvement seeded with external funding has become

a fIrm commitment of the industry itself. And today UPASl's name com-

mands the same respect in Indian health and population circles as it does

In the commercial world of tea. coffee. rubber and cardamom markets.

Objective. :

UPASl's Comprehensive Labour Welfare Scheme was launched with

two main objectives:

1. To promote the acceptance of the small family as a felt need of

the individual family.

2. To improve the quality of life of the workers by maximising the

use of existing facilities provided under the Plantation Labour Act.

Strategy Adopted:

To translate the objectives of the CLWS into rea~ity a multi-pronged

strategy was followed - one that infiltrated the workers' lives from angles

as diverse as craft training. leisure planning. hygiene. social education.

nutritional support. care and training of the young. besides family planning.

Amongst these diverse activities the greatest accent was laid upon the work

for mater nal and child health including family welfare. nutritional support

to the children. health education and environmental hygiene.

However. though the above broad thrust remained consistent over

the years. the implementation of the CLWS scheme was not so much

predesigned as it evolved from experience as the experiment proceeded.

To begin with. in 1971 the CLWS was introduced in the Nilgiri district of

Tamil Nadu State in three estates with a total population of 5.532. USA/D

prOVided the funds for the project and there was an additional compo-

nent - an imaginative deferred incentive for those planning their families

called the No Baby Birth Bonus Scheme (NBBS). Under the NBBS the

equivalent of a day's wages were deposited in a savings account for each

year that a working woman or a worker's wife continued to practise family

planning - the accumulated amount to be released at the end of her re-

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ARABIAN

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Based upon Survey of India map with the permission of the Swveyor General of India

The territorial waters of India extend into the sea to a distance of twelve nautical

miles measured from the appropriate base line.

United 'Planters' Association of South India Comprehensive

Labour Welfare Scheme,

Medical Advisor: Dr. V Rahamathul/ah

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productive life as an alternative form of old-age security. However. later

in 1975 this scheme was discontinued. largely because of financial and

administrative reasons: as for one thing. wages had increased rather rapidly.

and for another. the results though positive were not dramatically superior

to other estateswhere the CLWS was being implemented in isolation.

Expen.ion of the CLWS

Within a year of starting the CLWS had been substantially expanded

as in 1972 Government of India provided UPASI with a grant to extend

the scheme to 6 planting districts - 2 each in Karnataka. Tamil Nadu and

Kerala. altogether having a population of over 0.6 million. But although

manpower and facilities - a 7 person team of medical. paramedical and

communication personnel. audio-visual equipment and a vehicle - were

provided. the logistics of serving dispersed clusters of population in far-

flung estates posed difficulties. Eventual/y. each district was divided into

several zones and a specific target estate selected in each. on the basis of

management support available. and it was decided to first consolidate the

work in each selected estate before proceeding to others. Through this

pattern of implementation the population covered in 1972 reached 81.491.

increasing by 1976 to 1.28.164 - when the programme ran into temporary

difficulties as government support was terminated because the work was

not seen to measure up to earlier expectations. However. by this time

UPASI had become sufficientfy committed to continue the scheme with

its own funds.

Between '72-'76 the CLWS developed on two different fines. In

one format the CLWS staff and the estate management worked in close

collaboration. in the other they wcrked independently. Not surprisingly.

the functioning of the CLWS staff in isolation led to a spate of problems.

such as demands for concessions and incentives by workers. which did not

occur where management support to the welfare activity was visibly inte-

grated. In fact where it was integrated the health and welfare scheme

compelled the management policy-makers to recognise it as a vital factor

contributing to the shape of overall policies.

But in the wake of the government withdrawal of. funds. UPASI

reviewed the experience gained through two thirds of the seventies' decade.

This review led to certain modifications aimed at making the programme

more cost-effective and penetrating in its reach. Several critical changes

followed: it was decided that the individual plantation interested in im-

proving its health and welfare programme would have to pay for the services

rendered in this direction by UPASI: Further UPASrs role from now on

would be merely advisory. The estateswere given a choice of hiring fulltime

resident staff for the work. sharing the same with several estates or simply

continuing the health and welfare tasks with their exi~ting personnel further

strengthened through the advisory services to plan. monitor. train and

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Il.....-..-

evaluate their efforts in the field. Simultaneously, tne apprq,acnto health

And welfare was also radically altered: from a curative servi¢e to one that

focussed strongly on promotion of health and prevention of dIseaseand the

medical manpower and services reorganrsedto suit this ~oncept. As

health care services were moved to the periphery where th~ people lived

and the measure of their success became contingent to charging age-old

practices the importance of involving the workers therrjselves in the

scheme suddenly became clear.

Operational Details and Innovations:

The Link Worker concept that emerged at this stage -j proved to be

the major breakthrough for UPASrs CLWS scheme which Py 1982. had

covered a population of 0.2 million and now continues to e>tpandsteadily

each year. Cost-effectiveness was a critical criteria for the approach to

sell itself to individual estates. Studies undertaken at this juncture showed

that the previous style of operation using an outside team to periodically

visit estates required heavy investment in mobility. while the question of

accommodation for their stay posed a constant problem. As pertinent

was the fact that the frequency of contact required to build a real rapport

was not possible in these circumstances. especially as the community had

its own reservation towards outsiders' suggestions. Thus, though im-

provements in use of services and in family planning acceptance had taken

place on estates following the CLWS pattern these results were not quite

commensurate with the efforts and inputs.

The Link Worker Concept

Analysing the performance and the problems UPASrs management

hit upon the novel idea of enthusing and training sorrie of the workers

to assume social responsibility in the spirit of community service and self-

help. It was postulated that the Link Workers - as such workers were to

be designated- should not be paid. For this would not only increase the

expense but more fundamentally effect their image for they might then be

viewed as an extended arm of the management instead of being seen as

true representativesof the community. Through joint consultations of the

entire community, alongside the management. individuals were identified

who were known to be of a helpful nature and with a zest to improve

their community's lot. Each individual was assigned twenty households

around his or her residence. Sixty percent of the chosen workers had to

be women. Their work was clearly defined to:

Act as an important conduit of information - carrying into the

community messages of change and details of services and

facilities available and bringing back to the management a feed-

back on health welfare problems and service bottlenecks.

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Ufldertake health education on prevention of disease.

Initiate community action for better health.

·~G•o• lp Sessions"

The work is done in 'a most informal manner. Other than a monthly

meeting for all Link Workers - where a specific health topic is discussed

with the aid of visual materials and pamphlets, as also other information

on services and plans of the management provided - the Link Workers

perform mostly through their "gossip sessions" with neighbours. Their

name provides an apt description of their role - they form a vital connection

between the workers and the management. acting as two way relayers of

information; the age-old village grapevine system transformed into a

dynamic development model as they pick up all vital information on births,

deaths, illnesses and like problems and push across needed nuggets of

knowledge in the normal everyday course of life; the dual role strengthen-

ing their ability as mobilisers of change.

The force of person-to-person contact and the oral tradition of

communication put to informed, structured use - has created a cost-free

powerful grassroot network that works. Largely because there is minimal

burden of formal activity placed on the Link Worker's shoulders while there

is a meticulous back-up of service to their information relay and contact.

Further, the entire medical. paramedical workforce as also the creche

workers and other allied workers have been reoriented to a holistic approach

to health and the middle management with which the workers deal made

equally supportive through education and training.

Documentation:

A streamlined documentation system has played an important part

in keeping precise tab on each plantation's situation and providing a birds-

eye view of conditions so that prompt remedial actions and proper plann-

ing of priorities can take place. Every family has an individual file with

each member given a card. Colour coding and numbering help the pro-

cess of identification and pinpointing of disease outbreak, as also providing

a ready frame for epidemiological studies. The comprehensive monthly

collection of information on the community's health profile alongside the

utilisation staff and expenditure patterns of the estate's health and welfare

services, which is yearly collated and provided to estates. is an effectivE:

tool for the management to gain 'perspective on problems and plan on-

coming priorities.

Other Anic/es

The Link Workers have been further backed with expertise from a

number of outside agencies that have helped to popularise simple but

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extremely relevant technologies - such as smokeless chulas. compost

pits. soakage pits and the creation of kitchen gardens. A scientific look

at existing feeding programmes for children led to a more balanced and

economic diet that could than be increased in frequency. while vegetable

and fruit gardens planted near creches by the community have helped to

supplement it further. The male Link Workers have provided the main

leadership for bettu environmental hygiene and sanitation - leading to

building and use of more latrines. drains and garbage dumps. The women

Link Workers have had the aid of innovative ideas such as the launching

of Mothers' Clubs - which bring women together and provide an entry

point for nutrition and ather health education work. The Mothers' Club

which have become exceeding popular had a fame start initially - but as a

chit fund was launched in which every member pooled a sum of money

that was won by rotation by one member at a time the membership

spiralled and is now a regular forum where a number of activities are being

undertaken.

At the other end. managerial level workshops - prov.iding precise

documented facts on a particular problem and its solutions have helped

to move the planning and allocation of limited funds into the most useful

directions. An example is that of water supply. After a study on one

estate pinpointed that 80 percent of morbidity and 40 percent of drug

cost on the estate related to water-linked disease which within a year after

the introduction of a mechanical chlorinator. came down to a level of 22

percent morbidity and 12 percent drug cost most of the estates have

begun a phased programme to improve water supplies.

Impact:

A decade of work. half of it having the Link Worker as a pivot. has

brought fairly dramatic results. There have been substantial improvements

on many fronts. not the least of these the realisation of the population

goals. The change wrought on this front can be gauged from the fact that

cradle children in the creches and enrolment in the first class of the primary

school has reduced on the estates even as the utilisation of these services

by the workers has greatly accelerated - from a mere 10 percent in 73 to

75 percent in '82.

Because of the excellent documentation system adopted in this

project and its ongoing monitoring and evaluation considerable facts and

figures are aViilable. They reveal that birth rates have plummeted from a

level of 40 per 1.000 population in 1971 to 22.7 by 1982. More than three

quarters of all live births are now occurring to women below the age of 30

and the contraception rate by starilisation has spiralled from a mere 9.4

percent in 1971 to 46.9 percent in 1982 with three quarters of the acceptors

coming in after 3 or less children. Alongside the Infant Mortality Rate has

tumbled from 120 per 1.000 births to 50 per 1.000.

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These achievements have been possible on the backbone of a caring

health service programme that has coordinated efficient medical care with a

working la'l-intelligence network that could not only link the community

to needed relief but had enough know-how to help in creating conditions

for basic well-being. To quote one illustration - in 1973 the status of

ante-natal care on the estates was a single check at 28 weeks of pregnancy,

if and when the woman reported before proceeding on maternity leave.

Only 27 percent of pregnant women did so. Concerted effort in subse-

quent years brought the figure upto 70 percent of pregnant women coming

in from the 5th month onwards but coverage during the last six weeks -

when the woman went on leave - continued to be poor. With the intro-

duction of the Link Workers who undertook responsibility to ensure attend-

ance at ante-natal clinics 98 percent of pregnant women are now examined

from the third month onwards and tetanus toxide and iron supplementa-

tion during the last month assured.

Institutional deliveries have gone up from 42 percent in '73 to 76

percent in '82. The better maternal care is reflected in better child health:

average birthweights have increased from 2.2 kilos to 2.7 kilos and pre-

mature deliveries which once caused more than half the infant deaths now

contribute less than a quarter. Also, infant deaths by diarrhoea, once a

major killer. now account for less than ten percent mortality. .Child

care has undergone a revolution from being a mere mother substitute pro-

gramme to one aiming at total development of the child. Today 30,000

children are monitored regutarly for weight, immunisation for all child

diseases including measles is a normal routine, demanded and got by the

mothers. The impact of the child care programme emerges from a com-

parison of '76 and '82 medical care figures: outpatient attendance of

children dropped from 60 percent to 26 percent and inpatient bed occu-

pancy in the pediatric ward came down from 90 percent to less than ten

percent over the six years.

Several research studies undertaken in this project area are substan-

tiating its philosophy that the expenditure on health and welfare is not a

consumption budget but an investment on human resource development

that is in the self-interest of the industry. A double blind study of 240

women workers to understand the effect of anaemia on plucking per-

formance in the tea industry, has shown that iron supplementation at a cost

of 1 paise per day brought an increase of 52 percent in plucking capacity.

Another study highlights th'at post-childbirth. there is longer absenteeism

and an erratic performance over a whole year, while yet another study has

observed that frequent absenteeism from work for health and family reasons

reduces the performance of women in the age-group 20-30 though their

plucking ability is at peak at these ages. Altogether, it has been noted

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that the health and welfare work done on the Comprehensive Labour

Welfare Scheme pattern has brought about fairly remurkable chJnges in the

health .status of the workers and their dependenls -. a sen~e of well- being

and a feeling of being cared for that has alongside brought a heartening

change of attitude towards family planning.

Policy Implications:

The UPASI experiment has conclusively proved its basic hypothesis:

that family planning is best canvassed within an integrated. caring health

and welfare programme. and that careful husbanding of existing facilities

and resources can bring substantial improvements in the quality of life of

the workers. Moreover. it has developed and demonstrated a methodology

by which this approach is also cost-effective and therefore replicable on a

very wide scale. UPAS/'s CLW Scheme has shown that existing funds

and facilities can be far better utilised with proper management and medical

coordination and the involvement of the people themselves. In an organis-

ed setting the task is not difficult also.

The Link Worker concept evolved at UPASI now stands a key. tested

innovation proving that workers can be readily persuaded to assume social

responsibility and through this element rapid changes in living standards

can take place within an existing economic frame. Mediating between

the management and the community the Link Worker - given tile spur of

due recognition and nothing else - can help to pinpoint health and welfare

problems, assist in the implementation of services and act as an animator

towards community action. To the hardheaded commercial world the

UPASI Scheme proves that such health and welfare programmes Zlre not a

mere exercise in charity. but rather an investment that increases worker

productivity besides reducing wasteful medical expenditure in the long

term. Over and above is the bonus of contributing towards the achieve·

ment of national population goals, It is a model that is being steadily taken

up by the plantation industry, but could be adopted by organised industry

anywhere.

Based on material provided by Dr. V. Rahamathullah

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The Vadu Rural Health Project:

Proving Existing Facilities can

be Further Energised

Background:

Even in the best monsoon season Sirur Tehsil of Pune District

Maharashtra, receives only enough rainfall to be labelled a chronic Drought-

Prone Area. As ineffectual as the scanty rainfall and the meagre crop it

engenders were the health services available to the population of Sirur

and neighbouring Haveli Tehsils till just a decade ago.

High birth rates. high infant and maternal mortality rates and an

above-normal incidence of anaemia, malnutrition and preventible diseases

- all the usual scars of underdeveloped areas - characterised Sirur and

Haveli, although they were a mere 30-50 kilom&tres from the modern Pune

City with its excellent range of medical facilities.

The King Edward Memorial (KEM) Hospital. a Trust-run University

teaching-institution in Pune, which for the past six decades has provided

quality medical care to Pune and its surrounding areas, observed these

problems in the hinterland - despite the fact that villagers in fair numbers

flocked to use its services in emergencies. Obviously, the distance was

a major factor for any regular and lasting relationship. Determined to

change the situation, the hospital authorities decided to set up a rural

health centre. they chose Vadu Budruk in Sirur and aimed to cover, in the

first instance, a population of 30,000 spread over 19 villages. Thus began

the Vadu Rural Health Project.

Ready CooperatIon With KEM Hospital

The villagers readily donated land and labour, their basic goodwill

bolstered by the reputation of the KEM Hospital. So that there' would be

no delay in launching the project the Village Panchayat actually moved

out of its offices and handed over a school-room for the school-health

programme to house the health centre, However, despite the enormous

cooperation, there were some initial difficulties also - mainly stemming

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from the community's differing perceptions of its needs. While the doctors

envisaged the centre as a hub for preventive and health promotion work in

the villages. the people were anxious for curative measures at their door-

step. Therefore. the project started with a conscious compromise: it

concentrated on providing curative services as an entry point for the accep-

tance of a package of comprehensive health care and family planning

services.

Five years later. however, with ever-in~reasing demands for curative

medicine, an over-crowded out-patient department and a high turnover

of trained personnel it was clear that the focus would have to be sharpened

and the needed health transformation would only come in the wake of

wider community participation. Accordingly, in 1977 the project was

reformulated to its present design: the KEM Hospital moved to collaborate

with the State Government of M aharashtra and the Pune district authori-

ties-the Zilla Parishad, to develop a programme by which village-level

workers could be trained and involved in the community's health care and

the local health functionaries made more responsive. The work was to

become one of the forerunners that gave shape to what is now a national

strategy: the Village Health Guide Scheme.

Objectives:

The Vadu Rural Health Project was launched with

objectives to be achieved in a phased manner:

three main

1. The establishment of a system of a delivery of comprehensive

health care in rural areas with community participation.

2. The assessment of its replicability.

3. Total development of the area in collaboration with other

agencies.

To achieve the first phase objective a set of short-term objectives were

outlined: The success of the project was seen to be hinged on necessary

~ttitudinal changes in the community. wherein with the help of local

workers real health needs would be translated into felt needs. Therefore,

a network of Community Health Guides (CHGs) were to be selected and

trained to act as catalysts in the community for health work. They were to

particularly work with "high risk" groups, collect data on vital events and

carry out health educatiOn, with special reference to sanitation, nutrition.

chronic morbidity and handicaps, besides family planning motivation. A

system of continuous built-in evaluation with various health and related

indices was to be developed through their feedback and the referral links

established.

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Strategy Adopted:

The Vadu Rural Health Project works with the health system as it

exists - good. bad or indifferent. Its basic underlying philosophy is that

a partnership between the people and the health services can energise a

great unexploited resource: the innate capacity of the people for self.-

health, which can have particular significance to the welfare of the most

vulnerable groups - the women and children .• Another important premise

is that family planning acceptance improves substantially alongside thE:

provision of better health-care services. Concommitant research studiAS

have been initiated in the area under the separate Khosla Research Project

investigating fertility and population dynamics to test this hypothesi~.

The constant endeavour of the project from its outset to this date.

has been to move the health system and the people to a closer interaction.

The project was launched at a massive meeting attended by hundreds of

villagers, besides key state and district officials and the leaders of the area

Here. the villagers were asked to identify suitable individuals to be trained

as CHGs - the main criteria for their selection being their acceptability

to the community and prior record of welfare service and community in-

volvement. 45 persons - 23 men and 22 women. - so selected under-

went a three week training - on data collection. health education. sanitation.

preventive health issues - at the Vadu Budruk centre. Finally. 20 male

and 19 female workers were retained from amongst them. so that each

village in the project area had one male and one female worker. Signi·

ficantly, they were not given any kits or medicines for the first six months:

instead. their progress was intensely followed by the project personne:

and as some skills were mastered, new techniques were introduced to

strengthen their capabilities.

ViI/age Workers: The Vital First Link

Ranging in age from 20-50 years the village level workers. mainly

from socially a'nd economically backward classes. proved ideal for the

collection and dissemination of information. As members of the com-

munity they could draw out essential facts over a shared cup of tea and

similarly convince fellow villagers on steps crucial for their personal welfare.

Further, the CHGs began to provide leadership in a number of vlilage chores

such as regular disinfection and chlorination of wells. the construction of

soakage and compost pits, latrines, smokeless chulas. biogas plants

the raising of kitchen gardens. They were specially involved in MCH

work and identifying high-risk pregnant women and children. Thev hejpL~d

to identify and ensure regular medical therapy to cases of communlcab;e

diseases like TB. Leprosy and could even take slides for fever cases. render

first aid in emergencies and provide symptomatic treatment for routrne

ailments prior to referral. They held stocks to directly provIde p:'ls ami

condoms to users, while they motivated and referred those w8nnng the<

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IUD or sterilisation to the Rural Health Centre - but in all cases they

followed up the acceptors in their homes for any problems that might occur.

Altogether, they became the critical first link in the chain of the referral

system that now moves through the Vadu Rural Health Centre with its

outpatient facility to the KEM Hospital in Pune.

Monthly meetings, where the villagers, the CHGs and the project

personnel got together to discuss common problems and possible solutions

were useful forums which provided· essential feedback to the project. As

importantly, these meetings introduced the villagers to the experience of

articulating their needs and consciously striving for their satisfaction -- a

vital step in the process of moving the community to assuming full res-

ponsibility for its health care and ultimately, total development.

But even with defined goals being systematically met, the Vadu pro-

ject is learning that the path is not easy and can have unexpected pitfalls.

The community being a hetrogeneous group with often conflicting interests

and values poses a challenge for continuing participation and smooth

functioning of a programme that aims to bring up its most oppressed

sections. In one effort to meet this challenge, the project expanded its

strategy of community involvement to the formation of Village Health

Committees and specific-interest groups, such, as women's groups, youth

groups, farmers clubs, persuading each to take a primary interest in health

care so that a broader canvas of support could be created. What has

emerged from this experience is that community involvement is far more

readily forthcoming in such programmes if they haw: a distinct economic

component.

Operational Details and Innovations:

Graphically, the project's service structure can be represented by an

inverted pyramid: at the base are the village workers; the Vadu Rural Health

Centre comprises the middle level and the KEM hospital the apex. The

Medical Officer at the Vadu Centre is supported by two Health Assistants

and a complement of 6 male and 6 female paramedical multipurpose

workers who together oversee and assist the 38 grassroot workers to carry

out the major taskload, while carefully providing the needed medical cover.

The specialist services of the KEM Hospital, available if needed, further

provide a reassurance of the highest standards. The entire system works

through a coordinated team approach and therefore special reorientation

and training has been given at all levels to equip the personnel to playa

mutually supportive and enhancing role. A management information

system closely monitors activities towards this end. However, though

considerable success has been achieved constant vigil and mid-course

corrections are needed to ensure that the reconceptualisation of the health

service infrastructure into a people-supported and people-operated venture,

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which was the raison d' :.:~re fu t~~Vaau Rural Health Project becomes

a replicable reality,

But several factors are noted as having contributed to the degree of

success reached so far: first and foremost amongst these is the correct

selection of the CHGs from amongst persons truly motivated to be of service

to the community. (It is noteworthy that with just one exception the entire

set of village workers initially chosen and trained continue to be in the

field today). Secondly. the regular training and retraining of all levels of

staff so that they can implement in practical terms and with updated skills

and knowledge. the philosophy and concept of primary health care. To

this may be added the constant communication and rapport maintained

between the project and the field area through monthly village meetings.

the carefully worked out logistics of supervision and referral systems. further

strengthened by the connecting role played to bring about cooperation

and coordination with institutions essential to other sectors of the village

life.

Socio-Economic Development Efforts

For not only has the project helped to create special interest groups

in the village as part of its community involvement efforts, but it has also

assisted in setting into motion schemes that pertain to the socio-economic

development of the area and the formation of Pragati Panchayats (Village

Leadership Groups for Progress).

Since 1981 a separate non-profit making company known as the

United Socio-Economic Development and Research Programme (UNDARP)

has been functioning in the area helping the people to think through their

socio-economic requirements and draw up feasible schemes that can

engineer the required changes by availing of existing resources - from

subsidies. bank loans, foreign agencies and area development inputs. By.

on the one hand, linking thE" community with benefits existing but often

lying dormant in the system and on the other. by bringing it Simple tools

that can effectively tackle some of its urgent problems -- such as presterilised

delivery packs, oral rehydration therapy and nutrional support through

locally cultivated foodstuffs on the health front and simple technology

regarding sanitation. animal husbandry upgradation, irrigation techniques

and gobar gas plants on other fronts - the Vadu Rural Health Project has

functioned on two levels of mobilisation and empowerment.

Impact:

The results have amply vindicated KEM's decision to move closer

into the people's lives. The project has been closely monitored through

the several research studies and a series of surveys-a Benchmark establish-

ed in 1977, resurveys in '79 and '82 which are now being yearly updated-

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that provide precise documentation. It reveals excellent headway in two

critical indicators of health improvement: a near halving of the Crude Death

Rate from 13.1 per 1,000 population in '77 to 7.8 in '82 and a decline of

more than a third in infant mortality which tumbled from 107 in '78 to 68

by '82.

Antenatal registration is near total (98 percent) with tetanus toxoid

immunisation given to nearly 84 percent of pregnant women. Besides,

though institutional deliveries are mounting more slowly, the wide use of

the presterilised delivery packs by the trained CHGs has been a major factor

in the very low maternal morbidity and mortality. The identification and

follow-up care of "high-risk" mothers and children in special clinics has

eliminated a number of problems and immunisation of children has reached

high levels (86 percent for OPT -- 61 percent for BCG, though polio is less

satisfactory because of problems in the coldchain arrangements). Malaria

and diarrhoeal diseases that had plagued this area have plummeted in

incidence while TB and Leprosy control work has moved apace.

Family Planning Improves Substantially

The better health profile has paid off with a mounting acceptance

of family planning. In just four years, acceptance of a terminal method

has spiralled fou"rfold - from 64 sterilisations in '78 to 250 in '82. Al-

together, today nearly 38 percent of the eligible couples in the area are

effectively protected by one method or another - a figure that is well above

the national average and compares favourably with the Maharashtra average,

which leads the nation. The critical role played by the people themselves

in all this is the most heartening feature.

In sum, in a short span of time the Vadu Rural Health Project has not

only developed and demonstrated a workable design for the delivery of

comprehensive health care in rural areas through community participation,

but it has rapdlv moved through to its subsequent phases. Since 1981

it has p;coceeded to test still more precisely and over a larger area - the two

adjacent Primary Health Centres of Kendur and Bhawara in Sirur Tehsil

covenng 59 villages and a total population of 1,25,000 - the validily of

the Vcdu Budruk model's replicability. This time KEM is working with the

district's heJlth hierarchy placed under its technical control. Since '81,

the third phase of the Vadu experiment itself has been ongoing, as UNDARP

has joined hands in the area to bring about its total development: in pur-

suance of the phlosophy that health care can neither be the sole res-

ponsibility of health personnel nor is to be achieved in isclation. The

economic life in and around Vadu has had a considerable fillip through the

introduction of a number of schemes: such as for biogas, gobar gas, lift

irrigation, animal upgradation etc., besides the introduction of a technical

wing for vocatmal training of rural youths at the high school and the crea-

tIOn of a c2dre of village level workers to assist the villagers in self-help and

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self-employment programmes. These are opening entirely new vistas

for the villagers.

Now Vadu Rural Health Project is moving to accomplish more than

its initial outlined objectives: a blueprint of a District Health Plan covering

the whole of Pune District basedon the Vadu experiencehas been developed.

Proposed to be implemented by KEM through the existing health infra-

structure of the district. it has already the approval of the District authorities

and IS presently with the State and Central governments for technical

scrutiny. clearance and funding. Its very formulation represents a major

stride in the involvement of the non-governmental sector in a spirit of

partnership with government efforts for the health care of the people.

Policy Implications:

Though implemented as a mere micro-project in 19 villages the Vadu

experiment's influence has been both far-reaching and of a substantive

kind. Its experience, amongst several others in the country that had

individually moved to explore the rolt: of the people themselves in under-

taking responsibility fcr community well-being and family planning pro-

motion, led to the recognition of this concept by the government resulting

in the Village Health Guide Scheme. Vadu's team~approachwith its health

staff and the particular emphasis to practical problem-solving job-oriented

training has been adopted throughout the State, as has been the concept of

monthly meetings for the continuing education of functionaries. The

State government has also introduced in its health care programmes some

of the innovations tested at Vadu. such as. the presterilise'ddelivery packs

for home deliveries, oral rehydration remedies and the focus on the "high-

risk" category of mothers and children. A rationalisation of referral systems

and several other streamlining measures based on the lessons learnt at

Vadu are now under consideration of State and District authorities. Most

exciting of all is the fact that the stage for the implementation of a

district-wide innovative health '.'vorkwith voluntary participation has been

set. The willingness of the district authorities to share their power in this

field is no ordinary triumph. And if successfully carried through could

open a new chapter for health and family planning work in India

3 Pages 21-30

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The FPAI Malur Rural Project:

Extracting "Another" Gold

from Karnataka

Background:

The Kolar district in Karnataka state is famous primarily for its gold

fields. But away from the mining areas, one of the DistriGt's " talukas

(blocks) Malur. - a population of 1.43,000 in 344 villages spread over 647

kilometres - is mainly agricultural; sericulture and tile manufacture pro-

vide the only other employment.

Although Malur town, the taluka headquarter. is a mere 50 kilometres

from Bangalore. the state capital and India's fastest growing metropolis.

literacy I~vels across Malur taluka are low - a bare 27 percent average

that descends to 16 percent for female literacy. Till about a decade ago.

the primitive level of economic and social development tied-in with the

gaps in both the availability and utilisation of health services. Alongside.

the people's attitude to family planning was a mixture of cynicism and

lethargy: they saw it as a government programme removed from their

personal interests and equated family planning with a sterilisation drive.

It was to alter the prevailing depressing conditions of places like

Malur that the Government of India, in 1973, launched the India Popula-

tion Project I (in collaboration with the International Development Associa-

tion and Swedish International Development Authority) in certain selected

districts of Uttar Pradesh and Karnataka. Kolar was one of the selected

districts. Moreover, IPP 1 set up a Population Centre at Bangalore to

help it develop and test new ideas to vitalise family planning services. As

a part of its effort the Population Centre devised five strategies for field

experimentation in ten selected Primary Health Centre:;: of these one

aimed t6 involve a voluntary agency to take charge of the PHC's FP and

MCH work.

FPAI Invited to M.lu,.

Family Planning Association of India (FPAI), an organisation with a

proven track-record of work in the field, was invited to take up this challenge

at the Malur Primary Health Centre which serVedthe entire taluka. It was a

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PROJECT AREA

(Malur Taluk )

o BOUNDARY, STA,T[jU.T

DISTRICT.

fAUJt<

.. _._._.-

.• _._._._._

I<Il",OMETRr.S

8aHd Upon Sur~ at India maP with tt'le permission of the Surveyor General r:I Indio.

The territorial weT :8r5 of India extend into the sea to a distanco of twolve

nautteli miles me. !lsured 'rom the 8PPI'opriate base line.

The FPAI Malur Rural Project

Project Director : Dr. K. Rams RIJ()

3.3 Page 23

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signal honour to a voluntary organisation. For not only did the government

extend an invitation to participate in the area: it further backed its offer by

an assurance -- the first time ever to a voluntary group - to hand over

technical and administrative control of the FP and MCH staff at the PHC for

the two years of the project experiment. After a quick survey of the area -

the percentage of couples effectively protected by contraception in Malur

was less than 13 percent in 75-76, a figure which was bslow the state

average, while Karnataka state remained below the national average -

FPAI picked up the gauntlet. It was agreed that while the Government of

Karnataka and IPP would turn over to FPAI the total budget it would have

normaliy spent on FP and MCH work in this PHC area, the FPAI could add

some inputs from its own resources to test its innovations -- chiefly, for

the support of its personnel and for educational purposes. The neigh-

bouring PHC of Kamasamudram in the same district which had registered

a slightly better family planning performance during the past first six years,

would provide the control area for comparison. The experiment was

scheduled to begin in 1976, but eventually that year was treated as a pre-

paratory period and actual work commenced from April 77 through to

March 79. At the end of the agreed two year experiment period the adminis-

trative control of the staff reverted back to the government. But FPAl's

involvement at Malur, now intertwined into the people's lives, continues -

at the behest of both the people of Malur and the State Government.

Objectives:

1. To create great/ar awareness among the villagers, through educa-

tion, on the importance and relevance of family planning and

MCH to the individual, the community and the nation.

2. To stimulate community participation for health, particularly

family planning and MCH and development activities, as a

spontaneous people's movement.

3. To increase the acceptance of family planning and MCH services.

Strategy Adopted:

From April 77 the Government of Karnataka placed the services of

the Malur Primary Health Centre FP and MCH staff - one Lady Medical

Officer, six Lady Health Visitors, 29 Auxilliary Nurse Midwives and one

Computer in charge of statistical compilations - under the technical and

administrative charge of FPAI. The voluntary organisation was to handle

not only day to day administration, supervision, planning. and reorganisa-

tion of work patterns but was even authorised to take disciplinary action,

if necessary. In addition, all government circulars and other information

about health programme activity at the PHC were routinely sent on to

FPAI to enable it to functionally coordinate with other health a<;tivities.

Further, the government 5et up a Project Implementation Committee having

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on it representatives of the Population Centre, the Directorate of Health

Services and the FPAI, which would deal with all broad policy matters of

the project and assure total cooperation from other fronts within the para-

metres of government rules and regulations.

At the same time FPAI appointed its own Project Director - a senior

retired medical man familiar with the area and stationed him in Malur

with a small secretariat. It also made some departures from the govern-

ment staffing patterns and brought in an experienced educator from one

of its branches as a Project Coordinator and further enlisted five Community

Welfare Workers in lieu of the Family Planning Health Assistants that formed

the official health hierarchy. These CWWs were positioned across the

taluka, each covering a population of about 25,000.

B,olldening the Horizon

Through this remodelled infrastructure FPAI aimed to both broaden

the horizon of FP and MCH work and to bring it closer to the doorsteps of

the people. The three key strategies it chose to achieve its objectives were;

1. A demo.nstration of the interlinkages between health and other

development activities such as promotion of literacy, education

and income generating skills, as also the creation of village

amenities and assets that could better family and community

existence.

2. The formation and training of small village groups around self-

determined activities that could nurture a sense of self-reliance

and motivate the groups to act as change agents within their

family and community.

3. A streamlining of services for family planning and MCH and a

reorientation of staff personnel to encourage their delivery within

the community setting.

Towards this end, it adopted two main thrusts: a near-total educa-

tional coverage of the popUlation and the systematic building of a close

rapport with the community. Communication activities, therefore, formed

an important part of the project work. Through face-to-face contact

group discussions, exhibitions, film and slideshows the project worked

itself into the lives of the people. The communication effort ranged over a

wide spectrum of topics - keeping the family planning and MCH agenda

as a subtle integral part - but concentrating on capturing the community's

interest and attempting to generate a desire for collective actio,l.

FPAI volunteers and staff visited the villages frequently and built

intimate contacts with local leaders, teachers, members of village cQunoils,

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private medical practitioners and those involved in existing village group

aGtivities- anyone and everyone who could be a potential change agent.

Every possible occasion was used - in joy and in sorrow the project per-

sonnel were a part of the people's lives and wherever a chance arose suit-

able information and education was a part of the exchange. An invitation

to a weddirw. for example. provided the opportunitv to present to the young

coup'le a set of publicationsp'roviding valuable information on health. family

planning and nutrition.

The efforts were three pronged-: At the community levtJ intensive

work in information education and communication together with training

of persons in skill development; active encouragement for the formation of

village groups committed to self-reliance and linking their need-based deve-

lopment activities to family planning and MCH promotion. At the staff

level reorientation and training to ensure better delivery of services and a

greater enthusiasm for the work through periodic reviews and experience-

sharing. And thirdly. a catalytical role at the other agencies level which

served to· bring into the area various voluntary and government agencies

to work for the development of Malur. while care was taken to coordinate

these efforts with the ongoing FP and MCH activities.

Operational Details and Innovations:

As organised mass involvement was the major ingredient of the

project strategy. considerable time and effort was spent in providing the

impetus and training to local village groups of different categories - youths.

women. farmers. community leaders - to gain initiative. confidence and

management knowhow for organising and executing activities that would

lead to their overall betterment. A focus on family planning MCH and

primary health care was woven into this vision. so that birth control and child

spacing as a way of life were seen as inseparable from the developmental,

effort. The training also focussed on getting the community groups to actually

assist iry organising MCH clinics sessions and immunisation programmes.

identify those needing special care and counselling for both family planning

and MCH services. help in motivating and follow-up work. besides under-

taking the direct distribution of conventional contraceptives. The training

of untrained dais (traditional birth attendants) to ensure more hygienic

deliveries and have a better understanding of FP and MCH was another

important undertaking which created yet another cadre of influential

supporters and-through the designing of a special kit-equipped them with

the necessary tools. Side by side with the training efforts within the

community went -reorientation training of the Malur PHC FP and MCH

staff to appreciate the importance of this community mobilisation to the

succeiS of their work and to perceive their role in a wider perspective. so

that they were enthused and involved in the village activities.

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Educlltions' Efforts

Population education programmes for students. teachers and out-of-

school youths were a continuing feature. Schools and voluntary groups

were encouraged to hold debates and essay-writing competitions. More

fundamentally. the project assisted the community groups to start and run

adult education classes. nursery schools. libraries and reading rooms and in

numerous ways to work towards an environment that exerted a pull for

education. In the field of health. Well-Baby shows - initially funded

by FPAI but v.ery soon turned into village-sponsored events - health

education talks. cultural programmes and cleanliness drives created the

backdrop which lead to "shramdaan" -labour donation - by voluntary

groups to effect improvements in water supply. sanitation and the creation

of various needed facilities in the village.

At the one end. the project latched on to the regular festivities in

village life: organising film shows. cultural programmes and meetings that

celebrated the occasion but also took up purposeful themes; on the other.

it created village events by organising simple traditional ceremonies to

felicitate women family-planning-acceptors who were accorded the title

of "Kalyan Matas": welfare minded mothers. Similarly. newly-wedded

couples were individually contacted. felicitated and alongside provided

family planning information.

Othllr Activities

At a more basic level. the project provided trammg skills for pro-

ductive work encouraging the voluntary groups to organise small scale

industries and cooperative societies. Providing the initial seed-money it

launched 22 youth clubs and 8 women's clubs in income generating acti-

vities. such as. the hiring out of agricultural implements. preparation of

condiments and spices etc. The net income earned was then ploughed

back to finance developmental activities. including the organisation of

MCH clinics and IUD insertion camps. The movement steadily snow-

balled.

Since Karnataka is the country's major producer of raw silk and Ma/ur

lies in an area where sericulture has good potential, women in many

villages were trained and helped to launch silkworm rearing and the

making of bamboo baskets for this purpose. In one village. where

family planning acceptance achieved 90 percent coverage and the

women's club was particularly active. international funding was secured to

launch an advanced sericulture programme with a silk-reeling machine:

an example for others to aspire towards.

Tree plantation programmes and the growing of vegetables. provided

another thrust. Alongside extensive extension work to help the community

3.7 Page 27

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to acquire better agricultural knowledge. and access to implements, improved

seeds. fertilisers. better technologies and finances. was undertaken.

Yet another important service performed. by the volumary groups.

with the guidance of the project personnel. was in helping deserving

vill3gers secure benefits from existing government schemes: equally. to

ensure that development inputs reached the villages.

Altogether. an intricate network of supportive and self-reliant groups

was spawned: in the first year by the intensive activity of the project staff

which organised more than 450 educational events of different types over

the course of the year. but throughout working to release the lever of the

people's innate energy. Later. as the clubs got going they seized the

initiative and the number of such events increased spectacularly and with

it a step-up of MCH and FP promoting activities. While initial funding to

mobilise the community was invested by FPAI. a very conscious effort was

made from the very beginning to solicit the community's own contribution

and to make the activities self financing. as far as possible. This stand also

provided a litmus test to the real acceptance of the project by the community.

Impact:

The awakening and energlslng of the population of Malur was a

prime objective of this rural health project. The extent to which this has

been achieved can be ga'uged from the fact that through the community's

efforts (linking in with government resourceswherever available) an areathat

had no preprimary schools in 76 has by 1983, 125 nurseriescatering to over

6.000 children; 175 adult education classes have made more than 3.500

personi literate and a high school has been started. Through the efforts

of youth volunteers school enrolment has reached 97 percent of all children.

including 96 pErcent for girls and attendance at schools is phenomenal

at over 90 percent in most schools.

The project had aimed at stimulating active grassroot volunteers:

in a short span it has at hand 357 trained dais who have substantially

improved child-delivery practices in the area and become an important

link for the PHC MCH and FP staff. It has developed 450 community

leaders and more than 5.000 active workers in 201 youth, women and

special interest clubs which have been instrumental in orgaising 49

Fair Price shops. 3 cooperative societies in which 81 clubs are involved

while another 58 women's clubs have organised o;her income generating

activities. There is a Dairy Development Project and three skill training

centres in the area. An unending roster of events - free labour donation

for the creation of various village assets. tree plantations. road repairs.

sanitation, training of community volunteers. of youth. of women, basic

health care training for women. nutrition demonstrations. baby shows,

family planning educational .ctivities ". pulsuatingly· punctuate the

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calendar. From 1980 an annual plan of activities was projected. Each

year since. the activities have far exceeded the set target. The community,

poor as it is. has mobilised over RS. 220.000 (s 20.000) so far. to finance

these activities - contributing 80 per::::entof the share to FPAI's 20 percent

input. And leaders of the community finding potential through this work

are moving on, in substantial numbers, to take their places on village

councils. including a few on the Taluka's Development Board.

Family Planning Acceptance Increases

The spin-off to family planning and MCH work has been very tangi-

ble. Within two years the project had 139 condom depots run by volunteers

and with a regular clientele of over 1.670 acceptors: a development that has

helped the PHC to exceed its annual targets for this method, not only during

the experimental period but in each of the subsequent four years, recording

an annual achievement of about 200 percent. The 69 percent acceptance

among the 750 married women members of clubs has been a trend setter.

Altogether. active community participation has contributed 30 percent of

new acceptors each year. Significantly, Malur was able to maintain a high

level of performance even during the late seventies when the family plann-

ing programme was in difficulties across the nation. This resulted in Malur

PHC, which prior to the project was a below average area within Karnataka

with a less than 13 percent coverage of eligible couples, to zoom to a 50

percent effective protection of all couples - nearly double the state average

and equally. well beyond the national average.

Similarly, the MCH programmes of the PHC have achieved out-

standing success: immunisation cover has become nearly 100 percent as

club volunteers have organised regular clinic sessions on a planned schedule

and helped PHC staff with compiled lists of women and children needing

help. In the last three years 41 training programmes in basic health care

for over 2,600 women activated 1.162 women and children to seek MCH

services and 512 women to adopt family planning. Deliveries through the

trained dais have risen in '83 to 36 percent of all deliveries in Maim, as

opposed to 1.5 percent in 76, and the dais' role in MCH activities has been

considered noteworthy.

During the experimental period the impact of the FPAI strategy was

formally evaluated by IPP which checked the Malur PHC performance

against the neighbouring control PHC. The family planning performance

measured in a Sterilisation Equivalent Rate that also took into considera-

tion a certain value for IUD, pill and abortion acceptors observed the diffe-

rence between the two PHCs to be statistically significant; the same was

the case with MCH activities The better performance of Malur was clearly

attributed to the "strategy effect". Of the total of 10 PHCs -- which had

carried out field experimentation of the different strategies suggested by

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the Population Centre - finally, only Malur emerged as having produced

statistically significant positive results in hoth FP and MCH.

The motivation of nearly one-third of the taluka's total population in

the age group 18-25 in village-betterment activities, that have also exposed

them to population concerns has already had direct results in a per-

ceptible increase in tbe age of marriage of both boys and girls. The under-

standing and involvement of youths in FP motivation work can be further

considered as one of the most outstanding contributions of the project.

which will pay still richer dividends in the years ahead.

Policy Implications:

The Malur project has developed and demonstrated a methodology

for reaching the stage of widespread community-action, which is the final

test of "community involvement" in support of family planning work. It

has shown that the process has three distinct stages: initially involvement

hl!ls to be coaxed and stimulated through strenuous. imaginative and patient

external efforts attempting to build local partnerships. In the second stage,

the external agency. having identified the official and natural leaders in the

community. must assist them to articulate their felt needs and come to-

gether for action - this is the community participation stage and it is vital

that at this juncture. the community is helped to perceive the linkages bet-

ween family planning and their development needs so that the issue emerges

as a felt need. In the final stage, as groups become better organised they

must receive training to develop latent skills and further be helped to mobi-

liae resources. plan, implement and manage their activities with minimal

outside assistance. When this stage of community action is reached

- at which Malur is presently,-self-help can be increasingly generated to

meet local needs. although a sustained presence of the external agency is

needed to consolidate.

What Malur has also demonstrated is tnat the process can be quick-

ened - when development measures go hand in hand, with family plann-

ing and population programmes reinforcing each other. The strategy for

community action for overall betterment not only guarantees a greater

demand for family planning - providing this aspect has been consciously

built into the work - but also leads to more cost-effective ways of meeting

the demand. Voluntary organisations with a grassroot outreach. that

are prepared to work on a partnership basis with government prograrnmes.

provide an effective instrument to establish quick rapport with the com-

munity and build its strengths. Therefore, such agencies are needed to

be intermediaries and catalysts so that the vast energy of the people can be

galvanised arid equally, the government staff motivated to give its best.

Malur is an example of a model that is replicable and cost effective. Many

more Malurs can happen when there. is a conscious policy to bring in the

people to help themselves.

Based on material provided by FPAI

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Working Women's Forum:

Experiment in Leadership

Training that Blazes a Trial

Background:

The metropolis of Madras with a population of 4.2 million is India's

fourth largest city. Expanding in phenomenal leaps and bounds - it

grew by 63 percent in the sixties and by nearly 35 pucent in the seventies

- the city's amenities have not been able to keep pace with the spiralling

demands. Today, what was once a garden city has more than 1.500 slums

pocking its face. It is estimated that ne'arly a million or in other words,

one in four persons residing in Madras is a slum-dweller.

lifE. for the women folk in these slum areas - as in all deprived

communities - holds a still harsher edge.. It is they who bear the greater

brunt of the family's poverty as they struggle for survival amidst the conges-

tion, dirt and violence of their environment more often than not unaided or

simply bypassed by the official programmes for the poor. Despite the

high degree of femele literacy in Madras - about three in five women are

literate - the women slum-dwellers of the city remain the worse-off segment.

In repent years, as consciousness on the more vulnerable and de-

prived condition of women has increased, efforts to address women's

special needs have resulted in the formation of a number of women's

organisations, (at least in the urban areas) that are significantly different

from the earlier elite welfare-oriented groups. The new genre of women's

organisations attempt to develop a mass-base that can help women to

unite and fight for a better deal for themselves. Madras has one such

organisation that is, in fact among the pioneers of the new mould.

The concept of this organisation's unique format and role evolved

from the frustration of several women political party workers familiar with

the slums, from where they mobilised women for political rallies and forums.

They noted the women's low economic and social position and the utter

lack of benefits from government programmes - a plight often com-

pounded by confrontation with a system which ignored the civic needs

of a population that was either encroaching on or simply overcrowding

4 Pages 31-40

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4.1 Page 31

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WORKING WOMEN'S FORUM AREA MAP. -MADRAS.

_ 50 " 3

150

• 100 "10 =' 1000

*• 1SO • 3 = 450

200 "14 : 2800

•• ~OO x 8 0 4000

Total No ot

members

8 400

Experiment in leadership Training for Family Welfare

Project Director: Ms. Jaya Arunachalam

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the existing facilities. It was against this backdrop that a longtime political

worker - Jaya Arunachalam - decided to quit the political arena and to

work towards a nonpolitical alternative that would attempt to give the nearly

half million slum-dwelling women of Madras a platform from which to

battle for their rights. Thus in April 1978. was established the Working

Women's Forum.

The Working Women's Forum consist~ of small neighbourhood

groups of 20-25 women coming together and electing a group leader

from amongst themselves. The group leader automatically becomes a

member of the Working Women's Forum's Governing Board - which

meets regularly to take all decisions so that there is direct participatory

management of the activiti~s of the organisation by its members. Arrang-

ing access to credit has been the chief instrument with which the WWF

struck its roots. The main objective of the organisation, at the time of its

formation, was to organise women involved in productive roles into a mass

movement through which they realised their potential and overcame their

oppressive situations: both at home, by husbands; and outside, by money

lenders and employers. WWFs first efforts therefore were to help women

engaged in petty trade, cottage and household industries to acquire easier

credit and more remunerative prices. But it soon moved on to help women

tackle a number of other social problems. Beginning with an initial member-

ship of 800 the organisation rapidly grew to 6,000 within two years.

G'IIU'OOt Support fo, Fllmily Plllnning

It was at this stage that the Family Planning Foundation, as an NGO

promoting and funding innovative programmes with replicable value,

interacted with WWF and jointly developed a project that would strengthen

the organisation to take up health and family planning concerns. leading

to a model that could hopefully persuade other similiar women's organisa-

tions to ackn0wledge their potential for a primary role in the family

planning cause. The basic hypothesis was that elite groups cannot consti-

tute the leadership for mass movements, more particularly so in as intimate

an area of life as fertility-control. wherein the compulsions influencing

behavioural patterns can be completely different between the classes.

Active support from within the groups to be reached therefore alone can

help to understand the problems and breakdown the psychology of resis-

tance. Therefore. particularly the need to dev610pleadership for this issue

from within mass based women's organisations, enabling them to under-

stand and espouse it as an integral instrument of women's uplift and

emanicipation.

Meanwhile, WWF had observed in the course of its own work that

despite the pivotal role played by the women within the household economy.

their health and nutritional status was often so poor that it was affecting

productivity. Further, that the frequent cycles of pregnancy and lacta-

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tion, as also miscarriages and abortions, could be distinctly seen as contri-

buting to the women's disturbing plight. while the health of the children

was also being badly affected by the deprivation within large families.

These concerns merged to shape the Experiment in Leadership Training -

a three year action-demonstration project to develop "Grassroot Worker-

Leaders", undertaken with a budget of Rs. 300,000 ($27,250). About a

quarter of this was earmarked for training and documentation and the rest

provided a modest compensation to the women worker~, mostly for the

time they had to spend away from their regular employment.

The experiment has become noteworthy; not only for the results it

has achieved but even more so for the methodology it has developed-

which enables the v\\WF to now forge further ahead to take up this work

throughout the slums of Madras, with a government grant supporting this

bigger phase.

Objectives:

The Project objectives were outlined at two levels:

I. 1. In its broader perspective. the project aimed to provide a model

for the development of leadership among women that were

sensitive to primary health care and family planning as focal

concerns of social and economic development action, so as to

generate a spontaneous mass movement for family planning as

an important personal right of the woman.

2. To build the expertise for the training of such cadres of women

workers; alongside. to create a base of competent women

workers who could be entrusted with other social programmatic

work, as also set into motion a further multiplier effect within

the geographical area of the experiment.

II.

The specific short term objectives were:

1. To develop an effective training programme. that would build a

cadre of 60 women workers to be community leaders for family

welfare motivation and conscientisation on women's status

issues. as also the link between the 6.000 members of WWF

and existing health and family planninQ facilities in the area

resulting in complete and satisfactory coverage of al/ WWF

members for family welfare purposes.

2. To develop simple low cost visual communication materials, as

also to col/ect basic data and document the entire experiment.

Strategy Adopted:

Building on the WWFs established network and known capacity to

exert pressure on other institutional services to render their d-.Jeto the poor

4.4 Page 34

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women. the project sought to help these women further organise and

activise themselves. This time to seek better linkages with existing health

and family planning services in the c)ty. while learning to handle as much

promotive and preventive work as could be managed at their own level.

However, the family planning component was not to be an isolated one. nor

indeed centred only in a health and nutrition framework. but within an

overall integrated perspective of women's personal rights and searcA for

bt.tterment. Therefore, the attempt was to cr6at€ a better understanding

ot the interlinkages in the woman's condition, alongside imparting practical

information and the skills to address some of the. needs relating to the

health and family welfare aspects as a stepping stone towards total

development.

As the purpose of the experiment was to seed the impulse for trans-

formation of attitudes, most particularly towards family planning, within

the sections needing these changes most. "worker-leaders" were to be

selected from amongst the ranks of the members of the WWF and streng-

thened to take up the challenge amongst their peers. As. at the time. the

WWF had 6,000 members it was decided to select 60 such "worker-

leaders" - who could each be assigned the care of 100 families over the

three year project period. At this point of time, WWF consisted of 110

neighbourhood groups. Therefore, one "worker-leader" was to be selected

from two adjoining groups thus accounting for 55 "worker leaders" with

the other five taken from the groups. which because of their size or distance

could not be conveniently amalgamated. These workers were to be

closely helped by three supervisors and a programme coordinator corres-

ponding to existing levels in the WWF organisation on its credit and other

social programmes front.

Training

The Working Women's Forum's strong grassroot base and intimate

knowledge of the local problems needed. initially. to be supplemented by

the requisite expertise to handle a new field of work. The training of thes.e

workers plus supervisors was seen as a most critical input for the success of

the programme. The project design therefore incorporated a strong

continuing involvement over the three years for the Gandhigram Rural

Health and Family Welfare Institute. situated 400 miles away from Madras

but within an easy overnight train journey's reach. (The GRHFW's own

pioneering work in Athoor Block has been documented elsewhere in this

report). Gandhigram undertook to assist WWF with the initial training.

periodic review and refresher training work through senior staff personnel

assigned to this task. However, in order that Gandhigram sharpened its

own perspective on the potential of ordinary illiterate women to be catalytic

change agents for primary health care and family planning - as opposed to

the paramedical workers mostly used in their own experiment - the

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Gandhigram training team visited the Comprehensive Rural Health Project

at Jamkhed (which has also been described elsewhere in this report) and

exchanged experiences with the Aroles before taking up the development

of the training curriculum and work pattern. Local experts from Madras,

besides FPF. also assisted VWVF from time to time

The training programme provided for a six week intensive involve-

ment at the very outset. This was to be broken into three slots of two

weeks each and the "worker-leaders" to be trained in groups of fifteen.

The training was planned to provide a base line course in the first fortnight.

the attempt being to provide basic sensitisation on health. family planning.

family life and awareness issues. alongside encouraging communication,

counselling and information gathering skills. In the second slot the

workers were to carry out a census of the 100 families allotted to each to

build baseline data and understand the problems confronting them and in

the third slot to develop an appropriate action plan based on these needs.

A mechanism of quarterly review and guidance meetings. plus refresher

training at the end of each year. with Gandhigram staff was further designed

to supplement WWFs ongoing supervision and monitoring.

Operational Details and Innovations:

The project was formally launched on 2nd October 1980 - the anni-

versary of Mahatma Gandhi's birthday - at a ceremonial function in which

several leading figures from Madras participated in addition to state health

officials.

Prior to this WWF had already selected the 60 "worker leaders" and

3 supervisors - the Programme Coordinator, a post graduate from Gandhi-

gram was identified and placed later. The "worker-leaders" were selected

by a process of consensus. They were all lay persons residing within the

community they were to serve. The other criteria observed in their selec-

tion, besides the key one of Acceptability to the community wer~ that the

woman should be (or have been) married; have a minimum educational

qualification of sixth standard; an aptitude for social work and health care;

the ability to relate and communicate with others and be in an age level

between 25-35, though the upper limit was relaxed for otherwise Qualified

candidates.

The "worker-leaders" were not necessarily from amongst the group

leaders. In fact, two third were from ordinary members chosen because

they had demonstrated leadership qualities in the other credit and social

programmes already organised by the WWF or were considered more

knowledgeable and caring on health and family planning issues. They

were to work from their homes and workplaces and within the homes

and workplaces of those they were to serve. But as these women came

from the poorest sections for whom time taken out from livelihood activities

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would affect the income on which the family depended. they would be

compensated by an honorarium of Rs. 75 (57) per month and a dally stipend

of Rs. 10/- or (about S1) paid during the fulltime training and days of

review meetings. The three supervisors also residing in the ccmmunity

were given Rs. 180/ - as there was need for greater time from them.

In tho overall orgcJnlsational structure Mrs. Jaya Arunachalam.

President VV'vVF bore the ultimate responsibility of the family planning

project. Under her, \\/\\'25 the Programme Coordinator, whose role was to

supervise all workers .. clarify their doubts and problems. conduct monthly

review meetings and mamtain all records. reports. charts and maps. The

Coordinator was further expected to make four field visits a week each day

with four "worker-leaders". and conduct area meetings, specially on nutri-

tion demonstration. The three supervisors' task was to take an account of

work from the women workers. solving their problems. guiding. training

Clnd checking them; visiting two workers area per day they were to assist in

collecting and compiling records and reports and further motivate eligible

couples found to be resisting family planning.

The initial training was organised at a central point in Madras. It

was strongly practical in its orientation and participatory in its approach.

Information was given through the extensive use of visual aids and through

role-playing and other techniques that stimulated the women unused to

straight lectures. Besides, it included a number of field visits that acquainted

the women with resource places with which they were to build links.

The survey conducted as a part of this training process identified the dimen-

sions of the task. The total number of families eventually taken up were

6,131 with a total population of 29.002 of which 14.320 were women and

14,674 men. The total number of eligible couples amongst these was

5.019 and children under-five numbered 2,267. Of these, at the time of

the survey only 937 children had been vaccinated against small pox. 260

against OPT and 660 given polio drQPs; 420 women had registered them-

selves for antenatal care and a mere 78 had received tetanus cover protec-

tion. Of the eligible couples 1,133 or a little over 40 percent were found

to have accepted a permanent method - 876 women have undergone

sterilisations. while in the case of 257 their husbands had been vasectomised.

Only 47 women were on spacing methods: 20 using the IUD and 27 oral

contraceptives. The women worked an average of 17 hours and their

average earnings varied from Rs. 3 - 5 (thirty to fifty cents) so that even

after the men's earnings were pooled. (though frequently these were

squandered on alcohol, cigarettes and cinema) the families remained below

the poverty line.

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WtI"ker-Leaders Maktl Headway

Initially. the "worker-leaders" taced considerable difficulties -

even hostility as they tried to elicit information. But as. undaunted by

general indifference and the male taunts. they embarked on the work - in

the first instance. organising nutrition demonstrations. that helped to show

how to maxi mise the family's nutritional requirements with cheap low

90st food items tastily prepared. lectures on hygiene and occasional visits

by paramedical personnel and later through steadily building contacts with

the hospitals and clinics in the area helped the women and their families

to get better attention for their health problems - the attitude of the

community changed. As the workers contacts increased. they organised

regular immunisation camps for the children and antenatal and postnatal

check-ups for the women almost at their doorstep and began escorting

them for deliveries and other needs to the hospitals. Building connections

with the health services they secured fret MCH materials such as iron

tablets. Vitamin A solution. conventional contraceptives and even the

further supplies of oral contraceptives after the women had been checked

by the doctor initially. If a woman was hospitalised - whether it was for

a delivery. sterilisation or some other emergency. the workers often under-

took to cook and care for her family.

Thus. though the initial response to family planning was a Iittle more

difficult to establish than for other health needs - the reasons varying

from a lack of conviction on the needs for limiting' births to the practical

problems associated with taking a step in this direction - the patient and

persistent persuasion of the workers. backed by their ability to link the

community with a range of services and additionally to provide physical

assistance in the household at a time of need proved a t::ritical input. Their

relentless effort which not only provided the necessary information. but

equally the pragmatic assistance as and when needed did much to boost

the moral and emotional confidence of the target families. Further. the

image of the worker-leaders as women who had personally known and

evaluated the benefits of family planning -- most of the "worker-leaders"

were either family planning acceptors or became so within a short exposure

to the issue-also 'helped in evoking a positive community response. Of

as much value was the fact of this project functioning within the context

of the Forum's economic programme. which was providing a need-based

service in terms of credit and other ammenities. This added to the credi-

bility of the thrust for family planning. for linked with the economic and

general development effort - in the mind of the recepients of the services

and not in any programmatic way - the primary health care and family

planning work acquired a holistic and multidimensional image that its

official implementation had never given it.

The "worker-leaders" dedicated effort was constantly supplemented

and supported through the supervisors and the monthly meeting at the

4.8 Page 38

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WWF office brought the range of WWF infrastructure behind their efforts

at problem-solving. thus adding to their ability and confidence to work on

whole heartedly. Problems did crop up - from inertia and lack of support

at some hospitals and clinics to hostility from some paramedical workers

who refused to part with the eligible couples registration numbers or to

acknowledge the "worker-leaders" role in motivation of family planning

cases preferring to take the credit and incentives themselves. However.

these were relatively minor irritants that the women steadily overcame -

through their own vocal articulation of grievances at the appropriate level

and when they got individually stuck. through the WWF's organisationaJ

clout and influence.

Impact:

The solid provision of servicesfor maternal and child health and family

welfare made through the efforts of the WWF in three short years has been

nothing less than remarkable. In the case of child immunisation which

formed one priority. the project reports 2.601 children vaccinated against

small-pox as against 937 noted in the initial survey. 3.231 protected against

OPT as opposed to 260 at the outset; 2.930 vaccinated with BeG and

3,464 given regular Vitamin A supplements against none before the experi-

ment; polio drops provided to 2.872 as against 610 prior to the project.

Health and nutrition education through nearly 2.000 group meetings

and well over 1.000 nutrition demonstrations. besides the constant personal

contact obviously made headway: an internal evaluation made at the end

of the project by WWF investigators showed that acute malnutrition in the

form of kwashiorkor and marasmus was observed in only 16 cases as

against 118 noted in the initial survey. The number of women suffering

from anaemia had reduced from 30 to 12 and in the case of children from

28 to 14. The incidence of scabies was substantially lower - from 140

cases to 43.

Antenatal registration and referral for check up had spiralled from

420 to 1.397 while the protection of pregnant women with tetanus toxide

had increased to 1.121 from a mere 78. Nearly 200 women had been

helped to terminat€ their pregnancies. Further. the phenomenal success

with family planning efforts can be realised from the following figures:

2.273 women underwent a tubectomy. 120 men were vasectomised, 251

women received an IUD and another 191 accepted oral contraceptives.

In terms of the original 6,131 families expected to be covered these

performances would be considered ·straggering. However, while the

quantum of work accomplished is very considerable and verifiable from

hospital and service records, the extent to which it can be correlated to the

original target group needs more careful assessment than is presently

available. The "worker-leaders" enthusiasm for their tasks was not always

4.9 Page 39

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matched by their ability to document all the details. Difficulties also came

up as families moved from their listed place of residence to other areas and

the workers took on newcomers to complete their workload of 100 families.

The original concept of covering all the WWF members was not fully trans-

lated in the field. where the tendencv became to take up 100 families in the

neighbourhood that were easily accessible. The extent to which the

original group changed would. therefore have to be documented carefully

before the percentage coverage and consequent change of attitudes can be

correctly assessed. But whatever the outcome, it does not in any way

lessen the very demonstrateable success of the WWF in canvassing and

creating a momentum towards health 'and family planning within the most

deprived segments of society living in the worst urban settings.

A survey made by WWF among 30 of its 60 "worker-leaders" selected

at random documents that in the general opinion of these workers igno-

rance was the major problem of the women slum dwellers. According to

them, most of the women were not aware of the availability nor of the im-

portance of the immunisation, antenatal. postnatal and delivery services.

Many erroneously believed that immunisation made children ill; similarly,

ignorance and misconceptions about family planning methods made many

women believe that it was "against God" and/or would affect the health

of the acceptor. The educationaI effort. particularly as group meetings

were reinforced on ·the one-to-one level by one of their own kind and had

the backing of an organisation that they knew to be helpful and protective

to their interests, changed these ideas. The practical help rendered by the

"worker-leaders" to actualise needs. was able to eventually persuade them

to join in not only using, but demanding these services.

Further evidence of the substantive impact of the three year project

is the fact that even before it ended a Government grant had already become

available to the WWF to use its cadre of workers to extend the activities

on similar lines through its now much further expanded network of

members and across all the slum areas of Madras.

Policy Impli"cations:

This project has proved that women's organisations, particularly

those with a mass base, are a most critical ally for the health ard family

welfare cause. What is clearly evident from this experiment is that poverty

need not be a barrier to realising the importance of the health and family

planning measuresand that further, the poor, barely literate slum dwelling

women themselves can be the most dyn3mic agents for this work. Igno-

rance of facilities and their importance - despite the proximity of services

can exist in deprived communities and prove a major impediment to their

greater use. Communication through one of their own kind - plus the

concern, care and courtesy of the workers who were of a similar background

and therefore more sensitive and understanding of problems and needs -

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broke the barriers of ignorance and resistance fast. This experiment has

also demonstrated that a credible economic development programme can

provide a most positive base for further social action, including family

planning. It is a most cost-effective model that can be replicated in other

city slums or rural areas wherever a women's network exists.

5 Pages 41-50

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The Varanasi Community Based

Distribution Project: Moving

Social Marketing Along

the Ganges

Background:

The Ganges basin is one of the most thickly populated regions in the

world. The state of Uttar Pradesh which spans a considerable part of its

fertile alluvial plains holds 110 million-nearly one sixth of India's total popu-

lation and remains one of its least developed regions. Of the 56 districts

that comprise Uttar Pradesh. Varana~i District - a 5.100 square kilometre

area around the ancient temple city of Varanasi that is amongst the most

revered spots on the sacred'Ganges - is one of the most populous.

With a near 30 percent growth over the last decade. population

density in this region has reached almost double the Uttar Pradeshaverage.

thus further impacting upon the physical quality of life. A survey of the

area conducted in 1980 revealed the per capita annual income of a family

to be Rs. 650 ($59); half the men were literate but less than one-sixth

of the women; the birth rate ranged around 35 per 1.000 population and

the death' rate at 14 per 1.000. with infant mortality as high as 122 per

1.000 live births.

Low Contraceptive practice-

Effective contraceptive practice - low enough in Uttar Pradesh at a

13 percent coverage of couples against the national average of 23.6.in

1979-80 - was 8.5 percent. The need to supplement the official family

planning effort with more imaginative support was obvious. More parti-

cularly. as in recent years a number of studies have highlighted the exis-

tence of considerable "unmet demand" in rural areas resulting more from

logistical problems of transport and supplies than traditional resistance to

family planning: observations which are further coroborrated by the in-

creasing number of pregnancy terminations in such areas.

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lOCATION

OF VARANASI

C B 0 PROJE"CT

Varanasi CaD Project

Project Coordinator: Dr. N. S. N. Rao

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Could the growing international experience with community based

distribution of contraceptives - which in several countries has demons-

trated rapid increases to the 30-35 percent acceptance level - be tried

out for its relevance in the Indian context? It was with this question in

mind that the Family Planning Association of India, a leading voluntary

organisation. approached the Department of PreveFltiveand Social Medicine

of Banaras Hindu University (Dept. of PSM, BHU) to assist in carrying out

Q programme that would develop a feasible scheme for reaching previously

ignored groups.

The Varanasi Community Based Distribution Project was developed

after considerable preliminary work by the two concerned organisations.

It synthesised the University's insights and experiences in delivering health

care and that of FPAI in delivering family planning services. By this com-

bined effort the Project set out to create a network within the community,

consisting of local lay persons with a little education who could be trained

to help with basic health care needs. so that common ailments which

accounted for much of the area's health problems and infant and child

deaths could be eliminated and alongside, couples needing contraception

could be assisted on a continuous basis.

The Project commenced in 1979 in one selected block of the district.

Since then. it has expanded .to cover 1,242 villages with a popUlation of

over 1.1 million spread over 1.465 square kilometres and 8 of the District's

22 administrative blocks, that is roughly one third the total Varanasi District.

Its experience stands out as a beacon of hope.

Objectives:

In broad terms. the Varanasi Community Based Distribution Project

aimed at developing a model for integrated family planning and primary

health care services which are strongly supported by women's and rural

development activities.

To achieve this goal it set out the following specific objectives:

1. To evolve. within the existing medico-legal constraints, a self-

supporting and locally-relevant contraceptive distribution system

which would, by deploying the services of trained local men and

women in the delivery of contraceptives, raise contraceptive usage.

2. Towards this end. to carry out information, education, com-

munication and training activities; further, to set up distribution

centres from where regular supplies would be made available of

oral and conventional contraceptives as also primary health

care materials; establish a referral system for IUDs and sterilisa-

tion.

3. To organise specific women's development and rural developmenf

activities as supportive programmes.

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4. To scientifically assess the usage and side effects of oral contra-

ception in the Indian rural context through research conducted

by post graduate medical students of Benares Hindu University.

Strategy Adopted:

The effort of the Varanasi Community Based Distribution Project is

to create an affordable, effective and culturally-acceptable delivery of family

plannin] services that will augment the official approach. The backbone

of its strategy for organising such an alternative are local. literate lay persons

carefully selected and trained to hold stocks and dispense certain contra-

ceptives and health care products from their vantage point within the

community.

The health component is an integral part of the strategy. For. a

basic premise on which the project is based is the existence of unmet needs

for basic health and family planning services in the area that need to be

serviced --- and can be - by selected local volunteers (Samyojaks) trained for

the purpose. Its fundamental belief is that contraceptive services integrated

with primary health caie services can increase the acceptability of both.

Therefore, the training programmes of the project cover the two aspects

and deal with health management and the preparation of health care items.

While. at its formulation stage the Project had envisaged a social

marketing approach for both contraceptives and the line of health commo-

dities - which tackle the area's most pervasive health problems of diarrhoea,

skin and eye infections - ultimately this was not adopted for the contra-

ceptive items. The government requirement at the time of the project;

initiation - that oral pill dispensation could only be against medical pres-

cription -' disallowed the Samyojaks from freely dispensing the pill.

Further. it was felt the extreme poverty of the area could hamper continued

use, if contraceptives WEre charged for. Therefore, only the health items are

allowed to bring in a small remuneraton for the work done by the volunteers.

But nevertheless. the Samyojaks motivate couples for family planning,

screen potential pill users, distribute pill resupplies .. condoms and foam

tablets. arrange referrals for other methods and follow-up all acceptors. For

IU Os and sterilisations. camp services in selected villages in cooperation

with the referral centres are arranged periodically. This is in addition to

their normal availability at the various hospitals in the area.

The organisation of activities to promote rural development and

women's development are seen as important complementary work to the

project's health and family planning distribution arrangements, as they

are criticai to the greater involvement of the community. However, self-

sufficiency is the principle here. Activities for women's development

include training-cum-production centres which are managed by community

level committees with trainees paying a nominal fee towards the cost of

the trainer (usually a woman from the community) and maintenance of

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equipment. The financial support extended to cover the gap in imple-

menting these activities is recovered when the trainees start earning an

income from their work. With regard to rural development. the project

mostly assists village communities to get the nec.essaryhelp in the form of

loans or subsidies from Government departments. Rural Development Banks

or other non-governmental agencies willing to initiate self-generating

activity. These efforts. though still limited in scale. are calculated to bring

the community closer to the Project's work.

Operational Details and Innovations:

In 1979. the project commenced in one block with a view to refine

the training and operational procedures before expanding. The six-month

pilot study provided feedback for determining the project logistics. pre-

paring education materials and finalising the recording and reporting

systems. The experience was utilised in two more blocks the same year;

then in the second year extended to another four blocks; and with one more

block added i"nthe third year reaches eight blocks presently.

Close cooperation and coordination between the FPAI and the

Department of PSM. BHU has enabled joint implementation of the project

to proceed smoothly and in fact. enriched by the mutual interaction. The

project is guided by a committee set up at Varanasi that is presided over

by the Head of Department of PSM. BHU who is also the honorary Project

Director and includes.· besides the President and Project Development

Director of FPAI, the Deputy-Registrar and heads of other concerned de-

partments of the University. plus the district level government health and

family welfare officials. FPAI HQ closely monitors and guides the decision

of the local committee. if necessary. For actual implementation there is a

Project Coordinator and a field staff of six Project Assistants. eight super-

visors and 52 field assistants supported. by a small office secretariat. The

six Project Assistants take care of separate components of the programme

- namely Field Operations. Training and Education Evaluation and

Statistics. Women's Development, Management and Supplies and Medical

Support; they periodically visit the field to ensure coordination and hold

responsibility for the important activity in two blocks. Below them the

eight supervisors have the programme responsibility and supervision of the

6-7 Field Assistants who operate in each block. Each Field Assistant

has responsibility for about 20.000 population and lives within the com-

munity overseeing the work of about 16 Samyojaks. each of whom serves

approximately 1.275 persons.

Selection of Menpower

Two streams of manpower have merged in the project implementa-

tion: the regular paid project staff and the volunteer force which operates

at the village level. The right selection of both was considered crucial

5.6 Page 46

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and the steps taken to ensure it have been interesting innovations in them-

selves. Following an overwhelming response to the advertisements for

project personnel posts - over 4.000 applicants for the less than 70 posi-

tions - each appliant was mailed a booklet providing details of the pro-

ject. plus general information on population and health matters on which

a written test would be conducted. The appiicants were also asked to

conduct a village survey using a proforma developed by the project and

encouraged to send back a list of questions based on the booklet for possible

use in the selection. While this process helped to sift out candidates

of better capability. it was also subsequently found that an estimated

100.000 persons had read the information booklets. The selection

methodology therefore became a major educational aid for the community

in general. Finally. candiates who had scored well in the written tests

were called for personal interviews. The different categories of staff

selected were trained through special sessions and practical on-the-job-

training by the Department of PSM.

The recruitment of the Kalyan Kendra Samyojaks or depot holdtrs.

the real kingpins of the CSD system was by a different procedure. As

thesE were to be "of the people. for the people" it was essential that the

community should actively assist in their selection process. Small group

meetings WHe therefore held in project villages and members of the com-

munity helped the Project staff to identify Samyojaks on the basis of three

criteria:

1. their known interest to serve fellow villagers'

2. their general acceptability to the community; and

3. assured income from other sources.

The selection threw up persons from different walks of life which was felt

to be helpful as volunteers following different vocations couid enhance

the possibility of recruiting larger number of acceptors. These volunteers

were given short intensive training of three half-day sessions through

lectures supported by audio-visual materials that covered general popula-

tion and family planning issues. and particularly emphasised motivational

techniques. screening of potential pill users and the management of pill

side effects. basic health care. nutrition and information on follow-up and

referral services in the area. Subsequently. periodic on-the-job training

through brief refresher courses helped to sharpen skills. update knowledge

and interchange their experience.

Ktllyan Ktlndra Stlmyojaks (Organizers of Welfare Centre.)

The Samyojaks were identified and trained in phases as the project

expanded - by 1980 around 200 were already functioning and their num-

ber increased to 865 by the end of 1983. In all only 23 persons once

selected and trained have abandoned their responsibility so far. \\!vhil-e the

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Samyojaks form a varied group the substantial involvement of the regls~

tered medical practitioners of the area in this work - one third of the

Samyojaks (289) are in this category - is an important feature. The parti-

cular care taken to carry along the medical practitioners in recognition of

the fact that they are r~spected leaders of the community has added to the

extensive cooperation and support received by the project and prevented

negative currents against lay involvement in distribution of oral contracep-

tion and other health materials. Other major categories amongst the

. Samyojaks are farmers (170). community health guides (145); govern-

ment workers (63), petty shopkeeper.s (63) : and thG rest teachers. graduate

students and general community volunteers.

Health Products Plus Contraceptives

The Samyojaks are provided with a number of health care items

that are prepared and packed in the project office under the supervision of

a pharmacist as per the directions of the Department of PSM. These in-

clude oral rehydration. sulphur and boric powder, chlorine and iron tablet~,

first aid kits, disposable delivery kits and nutritional supplements. Special

arrangements for contraceptives normally not available in free supply -

through IPPF - have provided coloured condoms, and catchy packaged

oral contraceptives (the latter though identical to the government supplies

are repackaged onder the names of Sona: Gold and Mamta: Affection

plus foam tablets, which are unavailable with the government prcgramme.

A villager requiring any of these items - other than the pill - is

promptly served by the Samyojak. Women opting for the pill are screened

by the Samyojak against a checklist and given the contraceptives only

after a subsequent examination by a physician has confirmed this p;'elimi-

nary screening. Regular clinical sessions organised in the project villages

according to a set schedule - through the services of registered medical

practitioners involved with the project - ensure no delays. While the

major thrust is on the non-clinical methods, the comprehensive education

of the community on family planning provides information on the spectrum

of methods. lEe activities are carried out at both individual and group levels

and form a major activity. Those preferring a clinical method such as IUD

or sterilisation are then referred to the Hospital and the rural and urban

centres run by the Department of PSM, the Government District Hospital

and another nearby hospital run by a voluntary agency. Periodic IUD

and sterifisation camps are also arranged in the villages with the help of

lady gynaecotogists.

Simple documentation and rigorous supervision procedures ensure

that quality and quantity go together in the project activities. The Samyo-

jaks maintain an "acceptor card" and a "stock and supply record" which

are regularly checked by the Field Assistants and the physicians during

their programmed visits. The basic information of demographic data, distri-

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bution of supplies and management of side-effects, if any, is available on

these cards; Field Assistants also make home visits to get first hand accounts

and keep tab of the demand and supply situation. They compile the infor-

mation with the Samyojaks on a village-wise basis which in turn is check-

ed by the Supervisors and above in the hierarchy. The close follcw-up

prevents bottlenecks and ensures. an early detection and follow-up on

dropouts. A fortnightly meeting of the senior proJect staff to assess and

solve field difficulties and a monthly meeting of the field assistants to review

performance and chalk out special thrusts keeps the activities moving with

a direction. The Project Committee meets and gives guidance on a quarterly

basis.

Impact~

In the short span of four years the results achieved by the Varanasi

CBD project have been nothing short of dramatic. Over 37.000 new

effective acceptors ot family planning - a figure arrived at by calculating

72 condom/foam tablet items and 13 pill cycles per user, while sterilisa-

tion forms a single unit - were added in the area. This is a ten-fold swell

from 1980. Between the government and the CBD programme the cumu-

lative couple protection has now reached 30.2 percent. With regard to

the three methods for which the CBD takes primary responsibility, it

provided 72 percent of the new condom users, 96 percent of the oral pill

users and 100 percent of the foam tablet users. In all, the annual contribu-

tion to these spacing methods during the period 1980-83 was 9.436

equivalent usersof family planning, as against an average of 2,779 brought

in by the government Primary Health Centre staff. Even for IUDs and

sterilisations - for which the CBD only provides the referral - the CBD

project's contribution has mounted each year and accounted for an average

of 21 percent of the total performance. Together, these figures account

for an annual recruitment of 6.3 percent of the Project area's 187,800

couples.

The conventional contraceptives have had a steady offtake-

condom use registering 2,200 regular acceptors in 1980 moved onto a level

of 6,000 users in the following year; foam tablets b~ginning with 127 users

in 1981 have added each year to account for 576 women on this method

in 1983 Oral contraception did not have as steady a path. An initial

high recruitment of 2,388 in 1980 tapered down- to less than 2,000 the

next year, but has climbed steadily since. A reassuring aspect is the

high level of continuation of use: 67 percent for condom users, 73 percent

for foam tablet users and 43 percent for oral contraception. Altogether.

persons sustaining with a method have increased from 3,519 in 1980 to

19,368 in 1983. The constant efforts of the project personnel to under-

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stand reasons for discontinuation of one method and to· persuade accord-

ingly for a more suitable choice have helped 4.778 persons or 36.6 percent

of potential dropouts to merely switch - reducing the numbers in real

terms of those who have "given up" from 13,043 to 8.265. with the

figure including a large percentage of those who have migrated else where

or actually wished to have a ch.ld at this point. The method shifts also

indicate certain trends that are useful to note - people moved from one

temporary method to another. bearing out that when a couple is convinced

on the need for family planning. they will experiment with more acceptable

methods rather than abandon contraception altogether. Further, about a

third of the dropouts from temporary methods actually went in for sterilisa-

tion: pointing out that couples who have completed their desired family

size tend to opt for a short-term remedy while they make up their mind

for an irrevocable decision.

At the same time the Project has also changed the normal sterilisa-

tion bias of the family planning programme. By 1983 sterilisation accounted

for only 23 percent of total performance in the project area as compared to

78 percent in the national picture.

Samyojaks Prove a Success

Evaluation studies done by the University have shown that the

Samyojaks ability to handle the non-clinical contraceptive needs of the

community increased significantly with the training. irrespective of their

own educational. caste or economic status. Their accuracy in screening

oral pill userswas found to be particularly noteworthy - physicians backing

their decision to the extent of 85 percent according to cne study and 97.0

percent to another. The Samyojaks were also able to manage. at their level,

nearly 70 percent of the side-effects. They were most effective in recruiting

people of their own caste and occupation and it was noted in general. that

the longer the Samyojak's experience the better the number of continuing

acceptors. Amongst the Samyojaks. the medical practitioners showed a

higher continuation of oral pill users. community health volunteers

scored better in maintaining continuing condom users,and graduate students

brought in the highest number of acceptors but rated pporer on contra-

ceptive knowledge. Oral pill use was found to be highest in nuclear

families and the average age of the pill user was 27.5 years with an average

of 3.1 children-side-effects in the first few months led to maximum drop-

out but if the initial difficulties were overcome continuation was observed

to be steady. Serving an approximate 217 couples. each Samyojak re-

cruited an average of 22 new acceptors in 1980 which later in 1983-

because of the greater number of Samyojaks working - dropped to an

average of 14.3 new acceptors; however. at the same time. the threefold

increase in the average number of those to be continuously serviced by a

method testifies to a steady maintenance of quality alongside quantity.

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Role in Heelth Care

In terms of health care commodities the Samyoiaks have distributed

over a hundred thousand packets to serve different needs since 1980 -

the average number of packets sold by a Samyojak for a marginal profit

accelerating from 24 in 1980 to 110 in 1983. This reflects a small general

improvement in health practices in the area. Amongst the ten items catered

to through this effort the increase in the number of disposable delivery kits

from a mere 203 in 1980 to 1440 in 1983 is one heartwarming sign of a

movement. slow as it may be. towards adoption of preventive practices.

Educating the families on health needs is a continuous activity of the pro-

ject and therefore alongside the health care products is always -3 pamphlet-

that not only explains its contents and use but shows how the item can be

made. as also what else can be done in the absence of such materials.

Over and above. the project has directly organised training courses

that have taught some 3.740 families to prepare simple home remedies

and nearly 1.800 are now reported to be making their own nutritional

supplement and oral rehydration packs.

Through the supportive activities nearly 800 women have been

trained in tailoring embroidery and spinning leading to regular earning for

400 amongst them. Another 200 persons. have been helped to start a

range of small craft industries. Altogether. an area that seemed backward

and hopeless in its outlook prior to the systematic intervention. supervision

and training has shown a surprising capacity to absorb progressive ideas

and move with the times to change some basic characteristic') of its profile.

Policy Implications:

The Varanasi CBO project has been a pioneering exercise that has

amply demonstrated the relevance of CBO concepts to the most backward

parts of India. It has proved that such an approach can be a most useful

adjunct to the ongoing family planning programme; adding quantum leaps

in acceptance within a relatively short time-frame. The mechanism of

establishing a large number of service points within easy reach of those

needing to use family planning and basic health care services enables

intensive propogation of motivational messages and services toa manage-

able population. It also enormously expands outreach in generally inaccessi-

ble rural areas - through ways that are at the same time affordable for

poor communities.

Several specific lessons can be drawn from the experiment. The

success with the lay Samyojaks not only in terms of their performance. but

equally their continuity in the project with the very minimal material returns

available to them - znd particularly the excellent work in the contracep-

tion service field for which no return was available - reinforces the view

that ordinary community members can bep6rsuaded to respond with

6 Pages 51-60

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6.1 Page 51

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commitment to their peers' needs and kept involved on a long-term basis

Theeoncomitant increase in the use of both contraceptive and health care

products points to a positive relationship between the two and the support

that family planning can-and must - receive through th.is aspect.

More than anything else the project has highlighted that there can

be ready acceptance --- and regular servicing - of spacing methods, the

spread of which is so vital to the future of India s family planning effort If

it is to have a demographic impact. A.lso, the st€ady sustamed in-

crease of condom users - and indeed a sizable switch to 'condoms

by couples dissatisfied with the pill and the foam tablet - indicates greater

male involvement in family planning is possible through the personalised

doorstep delivery of the eso approach. At a time when India neEds

desperately to reach the younger couples and motivate males to shoulder

equal responsibility in contraception, the Varanasi eso projeCt of FPA.I and

SHU PSM has brought a fresh spring of hop€ on the scene It has the

potential of swelling and sweeping on -- like the mighty Ganges by the

side of which it has emerged.

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The Comprehensive Rural Health

Project Jamkhed: An. Individual

Commitment that Became a

Community's Triumph

Background:

The ancient Ellora cave-temples near Aurangabad in Ahmednagar

District. Maharashtra - towering tiers of sculptures hand-tooled out of

solid rock - stand as magnificient testimony of the power of indomitable

human will and vision. No such spectacular landmark distinguishes the

dusty wilderness of the taJuka of Jamkhed, one hundred and twenty miles

south in the same district. Yet its name has also begun to echo - albeit

in a different way - the same powerful message of the triumph of the

human spirit against odds.

Chronic drought poor communications, dusty rough roads, rampant

poverty and ill iteracy are the main features of the profile of this southern

tip of Ahmednagar District though its northern half is a highly prosperous,

sugar cane-growing area. Scant in natural resources, Jamkhed and its

neighbouring taluka of Kharjat -- two of the four talukas officially classified

as backward in this district - appear additionally bypassed by planned

development. Nontheless, in the past decade a health revolution has

swept through these remote villages, bringing hope to a people long

traumatised by disease and death. High birth, death and infant mortality

rates have tumbled to unexpectedly low levels - those normally associated

with more developed conditions.

Theie developments have occurred without the aid of expensive

equipment, costly drugs or many highly trained medical persons. as a result

of the Comprehensive Rural Health Project begun in this area in 1970 by

just two doctors filled with idealistic zeal. The project grew out of their

youthful dream to shape change in the land of their birth: Ahmednagar

District is where Rajnikant Arole was born and brought up ; his wife Mabel

worked alongside him here at a mission hospital in the years after their

graduation. The earlier work - "curative, prescriptive and cJinica'" -

left the Aroles feeling that they were themselves ill-equipped to accom-

plish what they sought; and so. they left to join the John Hopkins Medical

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IOONDARIES

STATE

DISTRICT

TAHSIL

LOCACATION OF COMPREHENSIVE

HEALTH PROJECT

JAMKHED AND KARJAT

6.4 Page 54

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School in the United States to specialise in Public Health. The Compre-

hensive Rural Health Project design and strategy was a part of Mabel

Arole's post-doctoral research presentation. but conceived for another

backward part of Maharashtra.

However. when the Aro/es returned to India their investigations

revealed that public cooperation - which they' considered to be the most

fundamental aspect of their concept - was not forthcoming at the original

site. At the same time. as word spread of their interest. offers came from

other areas. including Jamkhed. The Aroles personally visited the various

places. Jamkhed earned their allegiance - because it was backward

and as importantlv. its local leadership and community was one in voicing

a need for better health care and guaranteeing its own full cooperation

and participation in the work.

As proof of earnestness. the village council renovated a disused

three-room veterinary dispensary and gave it over to the doctors. A gift

cf land to site the hospital followed. And so in September 1970 the

Aroles - M Os from the USA - began work in a former cowshed

with a paraffin lamp for light and a rough wooden table as an examination-

cum-operation table. This was the Project headquarters from where the

two doctors and the skeleton paramedical staff proposed to reach out to a

tE'n mile radius.

To start with 8 villages were taken up. expanding by 1972 to cover a

population of 40.000 scattered over 30 villages; by 1980 coverage had

extended to 70 villages. Today. its services extend to the entire popula-

tion of the two talukas of Jamkhed and Karjhat approximately 200.000

persons in 175 villages. The concepts developed at Jamkhed have be-

come guiding principles in national health and family planning strategies.

the most significant among these being the recognition of the role even

illiterate women can - and must - play in the health and family planning

revolution.

ObJectives:

The broad aim of the Comprehensive Rural Health Project was to

develop a health care system suited to the specific needs and resources

of the area. mobilising the people's active participation and creating a

sense of independence and self-sufficiency in the villagers.

The specific goals it proposed to attain were:

a reduction in the birth rate from 40 to 32 live births per 1.000

population;

a halving of the infant mortality rate;

a substantial reduction in maternal morbidity and mortality

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,----,------------- fJ

-----

,-~ 74

--- --------------- ---

LOCA TION OF VADU RURAL

HEALTH PROJECT

-.a! i

BOUNDARIES

STATE

DISTRICT

TAHSIL

110 KMS.

I .l.

I'HI .•

... •••.•n• o AT ,,,' 00 ••.• "'O'Ol''"Cu ".h' ""~I ," •• ,0,1'8'

,..

-" .. "-"", ...,,.

6.6 Page 56

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control of chronic diseasessuch as leprosy and tuberculosis and

prevention of blindness to the extent possible; .

the provision of adequate curative cure alongside preventive work.

Strategy Adopted:

In order to develop a suitable programme the first task the Arcles

undertook was a study of the records of the primary health centre. the rural

hospital statistics and government census data, supplementing this with

sample surveys. Their findings revealed a simple, repetitive pattern of

preventible diseasesgiving rise to a stark situation of considerable morbidity

and mortality, especially amongst women and children under five,

Common aliments were diarrhoea, fevers, malnutrition, anaemia and

the various childhood diseases, with measles causing a high degree of

mortality. A survey of 1.550 households in 4 villages showed infant

mortality to range from 80 per 1,000 live births in the main taluka village

of Jamkhed to 120 in the more remote ones; similarly, child mortality

ranged from 70 to 116 per 1,000 population. Less than one half percent

expectant mothers had any help from a trained worker. Family Planning

had been adopted by less than one percent of eligible couples and high

birth rates with closely spaced child births were a major cause of maternal

depletion. The high prevailing incidence of tuberculosis. leprosy and other

chronic communicable diseases was impacting on the people's social

and economic condition, while acute poverty sharpened the edge of all

difficulties.

Esteblishing Confidence

Against this backdrop the logical ultimate aim was to establish a

sound preventive health care programme to tackle the otcurrence of these

problems. at the root. But the Aroles realised that this would take time to

ground. Further, they felt the villagers could be persuaded along the

preventive path only if the doctors who preached it enjoyed their faith and

confidence as healers. Therefore. they considered it essential that the

villagers did not mistake them for failure$ from the city seeking a iiving -

as could easily happen if they began with health education, which might

seem like begging the issue to the cruelly-afflicted local population. Think-

ing things over, the Aroles picked on two strategies to provide the Com-

prehensive Health Programme with a solid base:

The first was to very deliberately, project an image of their competence

through a display of their curative skills at every opportunity, particularlv

taking on what seemed dramatic surgical operations but which they assess-

ed could be easily handled even with the simple aids available to them.

An early instance that brought fame to Raj Arole - the surgeon in this

husband-wife team - was the case of a man brought with his Intestines

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spilling out from a bull goring, who was stitched whole again by the light

of the paraffin lamp.

At this early juncture, the Aroles often worked a twenty-hour shift

to cater to the nearly 300 indoor cases and an OPO averaging 165 daily.

In between they also made a weekly visit to the 8 project villages to back

up the paramedical staff positioned there. whom they hoped to build to

greater responsibility. But throughout. the Arcles remairred acutely con-

scious that the route to change lay not in the ever increasing use of super·

skilled healing capacities, but in the extent to which they could stem this

flow to their door - so that the hospital became a real referral. available

in need but its success gauged more by the numbers that did not need

to come to it.

Community Involvement

The second very deliberate decision was to operate in only those

villages where the community as a whole welcomed them and 8ave a place

and assistance to the nurse they wished to have at the outpost. Adhering

to this philosophy meant changes in their original concept of a ten milt

radius around Jamkhed. Fer. in the first instance, the villages that valued

their link were not in Jamkhed's immediate periphery, but much further

up in the hills where access to existing government-run health facilities

was most difficult. But as people's participation was the sine qua non of

the CHRP. everything else was secondary. A third major decision was to

play an active role in the development activities of the area, in view of the

tact that the poverty of the region lay at the root of most maladies.

Operational Details and Innovations:

When the Aroles began work in Jamkhed the total staff with them

was 2 nurse supervisors. one trained in anaesthesia and TB control and

the other in public health and family planning; 3 nurse-midwives, 3 auxiliary

nurSE midwives. 5 male para medical workers, 1 accountant and 4 mainte-

nance wcrkers. The total budget wa~ Rs. 0.25 million (roughly $22.725) -

about half already raised by donations and government grants, but

the other half to be generate.d from patients' fees against services

rendered.

From its inception thE. project set up a special Advisory Committee

consisting of representatives from all segments of the local population,

such as Harijans. women. political parties and minority communities.

Shortly after the project began a local farmer had donated it 7 acres of land,

The Advisory Committee played a vital role in the designing and building

of the Centre. raising local resources to contribute materials and in the

supervision of the construction. It also guided the project's policy-making

and determined the plan of action, setting out the priorities.

6.8 Page 58

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PI.n of Wo,k

In terms of health care it was decided that simple symptomatic

health care :;hould be available in the villages at all tmes. This would

particularly emphasise on the care of pregnant and nursing mothds. child-

births and on the preschool children for nutrition. immunisation and the

treatment of simple illnesses. Health and family planning education with

contraceptive supplies would also be made available at the local level.

but sterilisation facilities arranged for at the base hospital. In addition.

the project would work to control the incidEnce of chrcnic diseases like

T8 and leprosy and also help the physically handicapped through identify-

ing such cases. ensuring their regular treatment and rehabilitation at the

village level. It would endeavour to prevent blindness through appro-

priate nutrition education and vitamin supplements. treatment of eye

infections and injuries including arrangements at the base hospital for

cataract surgeries. The hospital would undertake to provide facilities for

all follcw-up and emergencies.

The major thrust on the developmental Jront would be to help alle-

viate seasonal unemployment and create income supplementation activities

through linking the villagers with small scale industries. poultry raising.

fibre. making and other such income generating activities. Non-formal

educ.ation particularly for women. small children and school dropouts or

those elsewise left out of the school syst6m would constitute another

supportive programme to the health and income-raising work. Upgrada-

tion and better health care of livestock and the creation of alternate energy

sources were priorities that were added over time.

Initially. hope was placed on nurses as suitable intermediaries and

change agents. Problems arose at the very outset. as it became obvious

that the nurses were not happy at living alone in remote villages. To solve

this. the enterprising doctors resorted to unconventional steps - such as.

finding suitable grooms for the nurses from amongst the male leprcsy

workers be;ng trained for placement at individual villages because of the

very high leprosy incidence. and positioned pairs. It helped. The resident

nurses organised antenatal clinics. immunisation and family planning work

to a consid~rabl6 extent and curative services made good headway. But

their continuing inability to carry the community fully on preventive steps

and to establish a real rapport remained a worry.

Pl'Ojer;t's Mlljor Breakthrough

It was the villagers themselves who provided the solution - and

with it the real breakthrough for the project. What about a middle-aged

talkative woman from the village itself they asked? One such woman

was identified - from a backward community. Her only qualifications

were her personal experience in childbearing and rearing, her power to

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communicate to the villagers in their own language and the faith the

villagers reposed in her. After a short one week's training on basic hygiene.

antenatal care. nutrition and family planning, the village health worker

(VHW) as she was designated. took her place in the project -- the Aroles

gently guiding and strengthening her wIth each weekly visit they made to

the village. Within six months the illiterate VHW /;lad been able to accom-

plish far more than thE nurse had done ov€r a year: she had been called in

to deliver 90 percent of the births in the area ~nd had hrcught in 80 percent

of the wome:l with large f2milies for tubectomies, besides substantially

extending the MCH activities. As similarily selected women took their

place in the other villages, maternal deaths from tetanus, whooping cough,

polio and diphtheria disnppeared from the villages, diarrhoea and malnutri-

tion was reduced -- through the simple techniques taught and implemented

by the conscientious village women able to communicate with their

own kind.

Meanwhile, the grave drought that struck Maharashtra in 1972

provided the project with another major turning point. Sharing and serv-

ing in the community's suffering drew the project personnel closer to the

community. Moreover. because donors were available for relief work.

particularly for drinking water arrangements, the p~oject was able to ame-

liorate camditions in 21 villages, often tying-up Food-for-Work programmes

with well-digging and deepening operations. The need for supplementary

feeding of children, pregnant and nursing mothers and TB patients that

w"s brought into focus during this situation also led to a project scheme

for agricultural support by purchasing and loaning tractors and other tools

for the cultivation of fallow land as long as fifty percent of the produce

went to support the village nutrition programme. A new dimension was

added to the health work. showing even more clearly and convincingly

the need for an integrated approach so that health needs could emerge

from their marginalised perception in a community struggling for sheer

survival.

Three Tier System

By 1974, the CRHP had arrived at a clear cut idea of its methodology

which has been steadily implementer' over the past decade. A three tier

system d health delivery evolved: the first tier consist5 of the village h~alth

worker resident in the village; the s€;cond tier is formed by a mobile health

team residing at the centre (or one of the four subcentres later set up at

selected villages) and visiting the villages by rotation once weekly/fort-

night/y; the third tier is formed by the cer.tre at Jamkhed - a 30 bedded

hospitnl with X-rav, laboratory and operating facilities -- and the four

subcentres which have some facilities for diagnostic. inpatient and emer-

gE.ncy care. The hei1lth programmes are supported by a skein of develop-

ment activities that include agriculture extension, water supplv provision.

employment generation. mother and child care etc.

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The VHW is the, pivot: she is not merely the last but the most critical

link of the health delivery system. Paid only an honorarium of Rs. 50 (less

than S5) per month by the project and allowed to charge five paisa (or less

than half a cent) for each medicine item fhe suppliEis to the community it

IS her commitment Gnd conc&rn - recharged continually by the respect

earned from the village in the r.nocess - that makes her a dymmic change-

agEnt. Selected by the village she is given ~n initial vV2ekiong trainIng

a:lO tht-.n continues a biwH kly contact \\fI/ith the Cf:;ntrE. This ongcing

two-way com~uni('ation bAtweeG instructors and the groups of VHWs is

the major tool that reinforces her information base. breaks down village:

superstitions and through practical observation and discussion of problems

adds to her compEtenCE..

Back in thE: village the VHW must cater to all irrespective of caste or

class. She treats an average of 15-20 persons dailv and conducts the

creche. weighing of children. non-formal education and nutrition pro-

grammes i~ the village. getting assistancE. from members of Farmers' Clubs

and Women's Clubs which have ccme up in the villages. Some. of the

members also help the usually illitErate women with record keeping.

Through personal visits to households she systematically covers the emire

village weekly - - and thus has her finger on the pulse of need in eV€rY home.

The mobile team brings in a nurse, a paramedical workH and a doctor

or social worker to the village on a regular basis. Essentially, they back up

the VHW's activities, add to the curative, consultative work that can be

done on the spot. the nurse particularly conducting clinics for mothers and

small children and the paramedical workers examining the communicable

disE.ase patients

The third tier meets all medical and surgical emergencies and pro-

vides the referral reassurance that enables the others to function with

supreme confidence. Its other major role is as the training-hub: not only

for the VHWs, but equally for all other members of the project staff. so that

thBre is consistency and coordination in their approach to health care and

devE lopment work.

Side by side, two important village networks have emerged through

the CRHP efforts in the field: Young Farmers' Clubs and Mahila Mandals

or Women's Clubs which have become vital instruments for the regenera-

tion of the area, alongside being major supporters of the health work.

With social workers from the project providing the stimuli, the village

young men - particularly from the poorest sections - have been brought

together and persuaded to undertake activities that benefit the entire com-

munity. Through rural employment and Food-for-Work

programmes

these groups have been helped to plan and execute schemesthat develop

fallow village lands, water resources, roads, and through afforestation or

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allied developmental work create other durable assets. Similarly, the

Women's Clubs have become a forum that have enabled women to take a

more prominent place in village society. They have contributed to a four-

fold increase in functional literacy and through linking individual women

and cooperatives with bank loans and training ensured new avenues of

opportunities. The women's groups are particularly active in the village

nutrition, health and hygiene work. The Young Farmers' Clubs voluntarily

jointly cultivate fallow land and turn over half its harvest for the nutritional

programme for children. Both groups help in surveys, carrying out sanita-

tion and nutrition work. organising clinics and health camps, and gene-

rally motivating the community to cooperate to the fullest.

Impact:

Beginning in 1970, the Comprehensive Rural Health Project Jamkhed

had, by the close of the decade, so outstandingly achieved its original

objectives that, in 1979, the international community acclaimed the Aroles

with the Magsaysay Award for their health and population work.

A survey undertaken by the Project in 1981 documented the extent

of change over the decade - it is way beyond the outlined objectives. The

birth rate had fallen from 40 per 1,000 to 23 and the infant mortality had

tumbled to 41 ; the crude death rate was 8.5 per 1,000 against the national

average of 14.98. Of the children in the project villages 98 percent were

immunised, as against 38 percent in control villages in the same taluka;

the incidence of malnutrition amongst children was down to 6 percent as

compared to 31 percent elsewhere in the area and this too, largely

accounted by children of migrant labourers; antenatal care coverage was

also 98 percent - compared to 2 percent in control villages. Family

planning had been adopted by 55 percent of all eligible couples. Amongst

those with large families acceptance of a terminal method peaked to 96

percent, while three quarters of all families with more than two children

were found to be contracepting.

Another detailed household-to-household

survey carried out in

1983 covering ('l population of over 20,000 in 20 villages has shown the

birth rate now to be 26 per 1,000 - with some villages showing 21 and

the IMR down to 18 per 1,000 live births. In villages with strong Farmers'

and Women's clubs contraceptive prevalence is as high as 74 percent -

with 2/3 having accepted a permanent method. In 4 villages an active

campaign to delay the first child has been taken up by the Farmers' Clubs.

Services Rendered

Over the severities decade the project had offered curative services

to 77,810 patients -- nearly 47,000 from the project area but over 30,000

from the adjoining areas had been attracted to seek its services. Of those

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within the project area more than three quarters had been handled by the

VHWs. another 14 percent by the mobile team and only 8 percent by the

last tier - a considerable fulfillment of the Aroles' mission of phasing out

their own neE.d to the system. In the case of under-five children the

figures were even more dramatic - 84 percent had been attended by the

VHWs. 5 percent by the mobile team and just 1 percent at the health centres.

Further, the hospital figures for the first half of 1983 - with the project

catering to all 175 villages of the two blocks from this year and handed

over the entire leprosy programme by the government - make a fascinating

comparison with those of the first six months when the Aroles arrived in

Jamkhed: the daily OPO was actually down to 41 from 165 and thosE

hospitalised numbered only 900 - a mere tripling. though the canvas of

the project has expanded more than twenty-fold! In these six months the

cadre of 156 trained VHWs treated nearly 20.000 minor illnesses. apart

from their continuous work on the immunisation. ante and post-natal care

and family planning fronts.

In 1983 the health programme spent approximately S 150.000 -

but three quarters of it came from the patients themselves. another one-

fifth was provided by government grants and bank interest accruing from

project funds and only 5 percent was raiSEd from donors. local or foreign.

The goal of self sufficiency for the health work had therefore been largely

met within a decade. However, the project now also administers a

substantive socio-economic development and training programme for

which the budget is twice that 0; the health programme. This still has

to be raised.

Collective Action for Development

On the development front the project has progressed into a move-

ment: the last count of 79 active Young Farmers Club and 76 Mahila

Mandals is a dynamic ever-growing figure, as more and more people

realise the strength of collective action. A major programme of aRimal

husbandry-upgrading livestock and ensuring better management practices

- is now underway with 81 village veterinary workers trained through the

project offering village level services on the pattern of the VHWs. Agri-

culture extension work has brought new improved seeds and totally new

crops - such as fruits. veoetables and watermelon - where only coarse

cereals and oilseeds had grown. Afforestation activities have already led

to 700.000 trees being raised across the block with another 500,000

saplings undertaken for the current year. Much of this has become possi-

ble because of the land contouring. bund making and irrigation arrange-

ments undertaken through the food-for-work programmes and the technical

assistance provided by the proJect. A cooperative formed of 40 landless

labourers has now begun experimenting with sprinkler irrigation techniques

that have wide possibilities for this region.

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The women's groups - gaining greater strength as the declining

morbidity and mortality amongst women and small children has freed

VHWs for more intensified efforts on non-health issues - are now bonding

further into cooperatives. Through these operations a number of Mahila

Mandais have undertaken successful business ventures. such as the collec-

tion and sale of neem seeds and the wholesale purchase. cleaning and

sale of tamarind. Spurred by their successes they are venturing into

other areas.

Jllmkhed Provides Proof

Jamkhed has amply demonstrated that a steady transformation of a

deprived area can occur without very substantial investments - by un-

lockin'g the resources that exist in the system and the will of the people-· that

further. when this happens the population problems are simultaneouslv

tackled. Within the general acceptance of family planning witnessed at

Jamkhed. of particular interest is CHRP's experience with oral contracep-

tion. More than 2.000 women chose the pill from amongst the cafeteria of

methods the workers suggested. Interestingly. both the illiterate worker

and the illiterate user expressed lea~t difficulty with this method. A study

of 980 women across 20 villagr-s shows that most women experienced a

feelin~ of well-being rather than side-effects. which were minimal. whilE.

daily pill-takinp posed no special difficulty to the ritua!-steeped women.

Young women unable to assert their viewpoint within the family set up

are said to have found it a particularly convenient method to adopt

surreptitiously in connivance with the VHW.

Policy Implications:

There are several reassuring lessons that have emerged. loud and clear.

from the J amkhed experience. Most notably. that the integrated health

and development path to family planning does not have to be remetfully

abandoned as too expensive or too long to be pursued on any scale. The

CHRP started with the people's needs as they saw them. However. it

consclQuslV integrated the family welfare programme as a primary focus

within the general health and development work. particularly concentrat-

ing on child survival as an issue and linking the family planning education

with this need. It has shown that as rapport with the community develop-

ed. so did family planning acceptance - with the people seeking advice

and services from those they trusted and making a natural selection of thb

most modern and efficacious methods. because they had been helped to

understand and choose what suited them best.

Further. CHRP has conclusively established that this rapport is best

built by those that are from within the community. [,nd since family plann-

ing is a more fundamental concern of the women. women workers in the

community better accelerate family planning awareness within a general

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health movement. Perhaps Jamkhed's most outstanding contribution

has been in r::-roving the extraordinary capacity of the ordinary village

woman to be a catalyst of change, given a chance and systematic suoport

to play this role However, as its experience shows SL;ch workers need to

be carefully selected -- comrritment and a caring attitude beinQ more

crucial than educational or technical competence which can be built teirly

quickly given the will to learn. But the workers cannot function in isoia-

tion. They also need to be given backing: by 8nergising organisations

within the community on the one hand and by ensuring that the pro-

fessional health staff with which they deal is suitably reoriented to recognise

and respect the strength the village-worker brings to their work. The im-

portance and role of the women's status issues - which build women's

self-esteem and bring her a wider awareness - in changing the traditional

attitudes and resistance to family planning is another fundamental princI-

ple the Jamkhed experience has highlighted to the national view.

Official Recognition

Official recognition of the excellent work done in the area has been

considerable. Since 1980 the demand to replicate the work on a wider

scale ha~ mounted The Aro/es have had to progressively accept greater

responsibility in extending their own work and in ccoperating with the

government to improve its delivery of health services in the vicinity.

The Jamkhed experience provided one key input into the thinking

that led the Government of India to launch on a national scheme of training

one community member for every unit of thousand population to under

take health and family planning work -- and further, to issue guidelines

that the worker should preferably be a woman, even if uneducated. The

Government of Maharashtra has asked the CHRP to train all the 3,000

Village Health Guides to be placed in thtj entire Ahmednagar district whish

is presently being done with some of .~Jamkhed's eadlest VH\\Ns playing a

leading role in the training. The CH RfJ [,as been further requested to

design a training that wourd

sUitable for the Female Health Workers

who will have to supervise the work of the Village Heaith GUides, so that

the team-spirit evidenced in Jamkhed can be further recleMad. In line

with this, the District's training-teams and Health Officers dre also under-

going reorientation to develop more supportive attitudes throughout the

health hierarchy, Meanwhite, national deve/ooment strategies are re

cognising the connection between the improv0ment of women's status

and familv planning acceptance.

While the Jamkhed CHRP is definitely the product of charismatic

leadership - the rare blend of dedication, democratic, functioning and

professional competence with which the Aroles translated their perscnal

vision into a larger reality - the experiment and its successful outcome

has generated a methodology for a viable model that others can take up

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with confidence. The Arole factor cannot be cloned. But Jamkhed

today provides the inspiration for unknown Aroles acrcss the country to

emerge in their own areas and follow on this track of dEmystification of

medicine and partn€rship with the people. Bt.::causeexciting proof exists

such sharing of knowledge-power adds to. not diminishes. the stature cf

the doctor.

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The Athoor Experience: A Pioneer

in the Partnership Approach

Background:

The district of Madurai in the Southern State of Tamil Nadu is famous

for its Meenakshi temple and also for Gandhigram - an unique complex of

rural institutions. the foundation-stone of which was laid by Mahatma

Gandhi himself and which have since endeavoured to work for translating

his message of "people's uplift" in living terms. Despite this. by the time

of the 1961 census Athoor block. where Gandhigram is situated. had

totally lost its fresh countryside look. A population of 1,00.605 (of whom

40 percent was below 15) packed an area of 91.2 square miles. making for

a population density that was over thrice the national average and nearly

75 percent more than the Tamil Nadu state average.

The occupation aI structure remained largely agri-.;ulturai - besides a

large settlement of handloom weavers in the main Chinnalpatty town-

and with the primitive infrastructural facilities available. was dependent on

the vagaries of the elements for sheer survival Consequently eighty-

percent of the families were in extreme poverty - earning less than Rs. 600

a year. Forty percent of the households did not have a literate adult. With

the birth rate at 40 per 1.000 - despite a survey undertaken in 1959 re-

vealing the majority of the adults to be favourably inclined towards family

planning - the population continued its upward spiral. at a pace that could

only add to difficulties.

Pilot Health Project

At the time. the Gandhigram Institute of Rural Health and Family

Welfare Trust working in collaboration with the Government of India. -the

Tamil Nadu State Government. the Indian Council of Medical Research and

the Ford Foundation was engaged in evolving a pattern of integrated rural

health services through action-research in Athoor block that could be

duplicated in other parts of the country. This exercise led to a closer

appreciation of the population question. This Pilot Health Project was

therefore. in 1962. extended to include a family planning component and

a study made to develop a methodology to better motivate and then deliver

services for family planning.

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,..t .rr'"l·...-. '\\.....j

IOUNDAllU

STATl/UT

O<orne<

SRI

LANKA

The Athoor Family Planning Project

Project Director : Dr. T. S. Soundram

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The Athoor experience. built up during a decade of fieldwork following

this. was to provide a pioneering example of voluntary and governmental

sector cooperation which has been an ever-increasing feature of the Indian

family planning programme; it was also to contribute towards the shaping

of subsequent strategies and to create an t1nduring proof that the family

planning concept once planted in the community's life takes firm roots that

cannot be shaken.

Objectives:

The goal of the project was to reduce the birth rate from 40 per 1.000

population to 25 per 1.000 within a span of ten years. In operational terms.

the project aimed to create for, at least. 80 percent of the couples, the three

basic conditions it hypothesised as necessary for accelerating family planning

acceptance:

1. Group acceptance: so that the individual was backed by the

support of peers in regarding family planning as a desirable

behaviour pattern.

2. Informed knowledge base that provided an understanding of the

importance of family planning to personal and community wel-

fare; and equally, ensured full information on the various contra-

ceptive methods to enable rational selection.

3. Free availability and real access to contraceptIve methods and

supplies.

Strategy AdoPted:

Gandhigram staffs existing intimate knowledge of the area was

further sharpened by the novel device adopted by some of the senior-

most project personnel before the programme was actually launched: for

a while they worked as ordinarv family planning fieldworkers. maintaining

a daily record of their observations and activities. The insights from this

personalised experience brought depth to the information marshalled

through a Baseline Survey and the working of the Pilot Health Project. It

deepened the conviction that the route to family planning lay through

a "social change" approach - the general socio-economic development

programme of the block being more critically linked with the educational

activities and the basic health services. of which maternal and child services

and family planning would be a most important part.

Towards this end the project methodology emphasised:

involvement of all influential local leaders for creating a congenial

atmosphere for the small family norm by. on the one hand. helping

to shape a programme acceptable to the people and. on the other,

generating group pressure for its wider acceptance.

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the systematic involvement of the entire Community Develop-

ment staff, alongside the regular health staff of the primary health

centres not only to ensure a wider dissemination of the message

but as importantly, to underline the inseparability of the socio-

economic, health and family planning issues.

the use of a combination of interpersonal and mass media

approaches to education and motivation.

Further. it aimed to develop detailed information of each village area

through a map of the village showing household positions, plus a list of

the eligible couples classified according to their needs leading to separate

targets for the motivation of different categories. On the service side. it

was proposed to intensify maternal and child health services and make

family planning services more easily available by organising village-level

depots for condoms and pills. plus a regular system for delivery of IUD

and sterilisation services nearer to the people and with a rigorous follow-

up procedure.

But though the field trial-run undertaken under the Pilot Health

Project had helped to concretise the strategy and redefine the detailed job

functions of different functionaries towards more efficient and family

planning supportive performance, this was not placed in a rigid frame. The

full-scale fieldwork was carried out as a piece of action-research: a conti-

nuous research on methodology. followed by periodic evaluation and refine-

ment built into the programme.

Operational Details and Innovations:

As the success of the family planning efforts was seen to be hinged

on the extent of coordination this programme had with other health and

socia economic development efforts. the need to ensure overall coopera-

tion and coordination was realised to be paramount. A Block Level Action

Committee comprising the key medical. development and education offi-

cials besides local elected leaders, women representatives of vol untary

organisations and a representative of the Gandhigram Institute was there-

fore set up to steer the project - develop plans, ensure the coordination of

different sectors. including the voluntary; review progress and bring about

on-course corrections.

The administrative control of the government Primary Health Centre

catering to Athoor was not handed over to Gandhigram but it enjoyed

technical control on its staff. The PHC's family planning staff was how-

ever under both the administrative and technical control of Gandhigram.

This complement of staff was, to begin with, exactly the same as was

supposed to be provided elsewhere in the country, with this difference:

Gandhigram ensured they were all in position and screened the recruit-

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ment to secure persons with a rural background and social work aptitude

Further.they were required to stay in one of the villages. falling in their work-

beat which was also redesigned geographically to coincide coverage of a

single area by related services in family planning. health and development.

A similar regrouping for supervisioh purposes and a c1earcut line of res-

ponsibility - with Gandhigram project personnel fulfilling the district

level function - completed the structural rearrangements.

. Changes in Work Pattern

Some basic changes were also made in the work pattern. The

national norms at the outset of the Athoor experience provided for only

one auxillary-nurse-midwife for 10.000 population. Recognising the im-

possibility of properly covering such a sizable population by a single worker.

Gandhigram assigned this paramedical full responsibility for only half the

population. categorising this as an "intensive area" and the other half, as an

"extensive area" to be attended only for MCH emergencies. After satura-

tion the intensive area was to be interchanged with the extensive. Later in

1965. Gandhigram was also able to secure paramedical staff in a ratio of 1

for 5.000 population. which only became the national norm more than a

decade afterwards.

A similar phased demarcation of duties to enable sustained family

planning education work in one village before proceeding to the next.

followed by a systematic pattern for the delivery of the services that retained

built contact was also made. Certain periods were set aside for intensive

efforts amongst particularly resistant and backward groups. Thus. Family

Planning education workers assigned a 20.000 population by official plann-

ing were taught to break up their eventual responsibility into more manage-

able units of 1.500-2.000 to be covered at one stretch. develop a close

contact with the community through more trequent visits. informal chats.

groups sessions that could encourage a more lasting relationship. They

were also taught to zero in on those couples who would provide a greater

demographic impact on adopting family planning - such as. younger

couples with two or three children and the newly-married for promoting

spacing.

Villages were classified according to their acceptance of contracep-

tion. High resistance villages were not immediately tackled so as .to avoid

frustration both among workers and the community. On the other hand.

villages which were more amenable were taken up for intensive educa-

tional activities as the aim was to hand over responsibility of the pro-

gramme to the people. First the involvement of the community was

ensured through its influential leaders - identified by sample surveys

seeking the people's preferences and perceptions in this regard. Those

that popular opinion placed its faith in were not necessarily the only known

village influentials: they emerged from every sector of village life - the

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traditional medical practitioners. the local midwives. mothers. educated

youths and satisfied users of contraceptive methods. At the next step

small groups. based on common interests or relationships were mobilised

and involved in discussions and so on. till the worke.rs and the couples

arrived at a one-to-one contact.

Training of the workers, of the community leaders and of the support-

ing staff from the health and development departments was a key. creative

activity of the programme. Gandhigram's long experience in community

work helped in providing the Initial gUidel;nes for developing community

organisations in a systematic manner. mainly through two techniques:

helping them address felt needs and imaginative. educational sessions

using audio-visual aids. But with the training of the workers being largely

field-based and task-oriented, concentrating on practical problem-solving

which helped in the achievement of objectives even as it was carried out.

it became as much an exercise in learning for the trainers. The training

and the action were a constant interactive cycle.

An important element of the training was the fecognition of existence

of felt needs of the community of higher priority over family planning which

had to be met. or at least attempted to be met before headway could be

made in enlisting people's support for famil,! planning. Therefore. workers

of other development departments had to be constantly involved with the

meetings of the village leaders and planning for solving many other genuine

difficulties of the people was an integral part. of the effort at three levels:

the quarterly meetings of the Block Level Action Committee. monthly

meetings of the PHC and Community Development Block and the constant

informal flow and interaction at the village level.

An importar.t innovation triggered through this effort to satisfy felt

needs - which became one of the most important ehannels for-communica-

tion. group action and decision - was the formation of mothers' clubs

in every village who were to oversee the creches and nursery schools

opened for the small children. Through frequent educational sessions -

and the mechanism of providing admission on a priority basis to children

of family planni'ng acceptors - these women's groups became a powerful

force for propagating MCH and family planning.

At the same time every effort was made to make family planning

materials and services most easily available to those motivated to use them.

The workers identified suitable persons within each village to hold stocks

of condoms. While teachers and the traditional birth attendants "took the

lead. the women's group conveners. small shopkeepers and persons like

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barbers and tailors also volunteered and proved most effective depot-

holders. The organisation of the work-schedule of the woman doctor at

the PHC in a pattern that brought about a fixed day visit to each sub-

centre when IUD insertions could be done was another addition. Making

workers function not on a 9 A.M. to 5 P.M. schedule. but often in the late

evenings i/1harmony with the rythm of village life was another crucial change.

Last. but by no means least. mention must be made of the role of the

Kasturba Hospital at Gandhigram - a 100 bedded hospital with operation

facilities. An open-sided bamboo and that chroofed shed was added in the

hospital compound as the family planning ward. Here. the woman accept-

ing sterilisation was permitted to bring her children and such family

members as wished to attend on her. Patients - moved out here a day

after the operation - and families slept on straw-mats on the floor, while

their babies swung from cloth hammocks tied to the bamboo rafters -

exactly as they did in their huts back home. With the diet money available

from the government for each acceptor the simple rice and "rasam" that

was the daily food of the villagers could stretch to feed many more. Instead

of the hospital setting being an intimidating barrier to family planning

acceptance the sterilisation ward earned the nickname of "ammaveedu" -

mother's home. because it paralleled for the harassed overworked woman

the care and hospitality she only associated with going to her parental

home. Sterilisation lost its fear and hospitalisation became a needed

holiday!

Impact:

The Athoor action experiment came to an end in 1973. Evaluation

of the programme was very systematically done and a number of studies

were conducted on various aspects. The increase in knowledge about

family planning was found to be phenomenal - 90 percent of men and

65 percent of women were well informed and the community leaders were

observed to have played a vital role in addition to the workers. The accep-

tance of contraceptive methods was much higher in Athoor than in the

five neighbouring blocks - 34.5 percent or more than a third of all eligible

couples were already found to nave accepted one or another method of

contraception by mid-71. The acceptance of sterilisation was a third

to a double that of the five neighbouring blocks. while IUD acceptance

was more by 50 to 94 percent.

The birth rate targeted to reach 25 was close enough at 27.4 in 1974

and eventually dropped to 23.7 by 1980. The total fertility rate declined

from 4.7 in '64 to 3.5 in 74. Proof of much greater efforts at spacing of

children came from the fact that birth intervals increased steadily over

the decade to be ten months more by 74, with the increase being most

pronounced in the caseof women having a third or higher parity birth. Later,

some decline in contraceptive practice took place after the action pro-

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gramme had closed; however it eventually recovered and even as of March

'81 Athoor's performance was higher than the Tamil Nadu state average.

Further. a recent study at the Kasturba Hospital of sterilisation cases

over the last half of the seventies decade reveals the average age of the

women opting for sterilisation to be 28 years. that of the wife of a male

acceptor to be 33 years and the average number of living children to be

3.5 - pointing to the steadily increasing acceptance of terminal method3

at younger age levels. particularly by the women. A full decade after

the conscious thrust ended the effect of the work done by Gandhigram can

be seen from these figures to be an internalised part of many lives.

Policy Implications:

The Athoor experiment's relevance and importance ·Iies in the

methodologies that it developed to engineer certain conditions: to create

widespread community participation and a congenial environment; to

bring about a convergence of intersectoral interests in ways that family

planning could benefit: and. more innovative ways of working and

training of the family planning personnel. Through these it demonstrated

that a wide surge for family planning acceptance does not have to walt

upon the improvement of the socio-economic condition - even though

this must be pursued as a most desirable objective and one which further

contributes to reduction in fertility. What it showed was that a com-

passionate caring concern and an attempt to bring some physical change

in the lifestyle. alongside education and information on family planning. is

enough to make the community concertedly move towards a smaller family-

size that can contribute to the achievement of their other aspirations for

themselves. Many of the Athoor project's concepts and methodologies

have since been incorporated in national thinking.

To what extent Athoor is replicable on a wide scale is the key ques-

tion that remains. While the basic methodologies to be followed have

been fairly precisely enumerated. can the corresponding commitment of

the workers - that was the other half of the Athoor experiment's success

- be regeneratedon a sufficient scale throughout the government mechan-

ism and over long sustained periods of time? In recent years the Govern-

ment of Tamil Nadu has moved to assessthe feasibility of the Athoor model

across the entire district of Madurai and Gandhigram has been associated

with this work. retraining the staff and advising on implementation. The

eighties will test how wide the ripple can grow.

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Oral Contraceptives CBO Haora

Project: Rural Women

take to the Pill

Background:

The steel spider-web spanning the Hooghly River provides a picture-

sque landmark to Calcutta, India's biggest city with a population of over

9 million. The famous Haora* Bridge is also a significant punctuation

point to the megapolis' way of life: across the river Ci:dcutta's so-called

sister-city of Haora attracts only three quarter million people and rapidly

melts into the green paddy fields and ponds that make the rural areas of

West Bengal look like a picture postcard. The greater majority of Haora

district's three million population lives in its rural hinterland.

Haora's predominantly rural nature and its easy access from Calcutta

combined to attract a group of Calcutta residents to set up the Humanity

Association of Howrah, a philanthropic organisation devoted to the social

development of this area. One of its founder members and secretary was

Dr. Biral Mullick, a medical man who had spent long years promoting

family planning within and around Calcutta and wished to develop a major

family planning thrust in the rural areas. The Humanity Association's

family welfare programme particularly proposed to examine how oral

contraceptives - which had made such a powerful contribution to the

birth control movement in the West and subsequently in many other

countries-could be brought to the poor rural women.

It was decided that In the first instance the work undertaken would

not be an action project but a scientific study that would develop a feasible

model for wider replicability. It was felt that there was need to ascertain

the feasibility of the community based distribution concept. identify the

shortcomings and strengths in the processes involved and then build

a programme that could spread a real service. This was way back in the

late sixties - long before the pill's official acceptance in the Indian familY

planning programme, which was in 1977.

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BOUNO ••.•Ut:S

INTERNATlON"'L.

ST .•.TE' • .

i:»5TJtICT ..•.

u.,.,"S-:;:::;;~-;;';-~·;.r ...:.~•~-;-;~;-s;,.n)'o,. o( 80'.0

.w., ...• ""t., II,.. n••t.,.,.jt~"IDt ••g•.t.r. of Indio •• Iend inlo t"" ,,,. 100 Oi.tone. of

"Out/eat

""Glllred

fro •••• 100. ?ooropr ••,I. ~o ••

G•••••.. GI :"'dl"~ .

Oral Contraceptives CBD Haora Project

Project Director: Dr. Biral Mullick

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Initially funded by an US based NGO the Humanity Association

undertook a pilot study in a selected representative area. This eventually

progressed to a district-wide distribution programme with support from

another US based organisation. Despite a rather chequered history over

a decade.. the programme overcame its considerable setbacks to persevere

and evolve a successful methodology that now makes it responsible for the

distribution of over 200.000 pill cycles being provided by the Government

of India. Besides. its experience has provided a wealth of scientific data.

-recording both the pitfalls and the modalities of success in establishing a

community based distribution system for oral contraceptives that holds

important lessons. It was a look at voluntary initiatives of this kind which

eventually led the authorities to reappraise pill distribution procedures.

The resulting recent liberalisation hopefully will step-up the usage of a

modern efficient method in India - which till the eighties had not reached

more than 100.000 women from amongst an estimated 65 million couples

needing to space their families.

Objectiv •• :

The broad objective of the oral contraceptive programme in Haora

was to design a community based distribution system that could effectively

bring oral contraception as a method option to women in the rural areas.

Towards this ultimate end. a number of scientific studies were conducted.

beginning with a pilot study phase that had for its specific aims three

aspects:

1. to find out the acceptability of oral contraceptives in different

socio-economic. religious and demographic groups.

2. to accurately assessthe efficiency and side effects of oral contra-

ceptives for rural women.

3 to determine the extent and cause of spontaneous dropouts

from the project.

Strategy Adopted:

In its overview the strategy has been one of building blocks-

carefully studying. analysing and providing service as and when possible.

to the extent possible. It has been an open-ended approach. flexible and

innovative. learning at each stage and moving from phase to phase. in-

corporating corrections and innovations. using the scientific tools of careful

documentation. constant monitoring and evaluation to chart a course that

others could follow.

The pilot study took for its universe three distinct clinic areas -

urban. slum and rural - each having a population coverage of 10.000 and

a minimum of 1,500 eligible couples as a target group. At each of these

clinics two doctors - one male and one female - plus four trained social

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workers knowledgeable about family planning carried out the study under

the direct supervision of the Chairman and Secretary of the Humanities

Association of Howrah. They had besides the assistance of a Health

educator and a statistical unit that maintained. processed and analysed

the data. Community participation in the work was achieved through

two Voluntary Advisory Committees of nine local men and women res-

pectively. who· guided the staff and motivated 'the eligible couples to

consider this method.

Field workers visited each household in batches of two - one male

and one female to ensure communication access - and collected baseline

information on both socio-economic and demographic facts during the

course of the visit attempting to persuade the eligible women to come and

try the oral contraceptives at the clinic. A systematic but simple procedure

of numbering the contact-cum-follow up cards made for each household

helped to keep meticulous track. If the women did not respond after three

consecutive visits to her home her card was transferred to the Dead

section; if she was found to be pregnant it moved under that head. but if

she did arrive at the clinic an Oral Contraceptive Record Card was issued

to her in duplicate. This was filled suitably by the doctor after the check

up; if she was to receive a supply of contraceptives it was placed in "Follow-

up Box". The acceptor was asked to return earlier to the clinic if she had a

problem; otherwise. the following momh. If she missed out. the worker

who had her dates noted in a diary contacted her at home. There was a

monthly collation of the information on the basis of which future action

was decided in cooperation with the advisory committees.

Pill distribution in this programme ceased in September 1972 because

the stocks which had been received from abroad came to an end. But the

results of the pilot study alld of the several field surveys and follow up

studies of acceptors undertaken subsequently showed most encouraging

results. Of the 4.221 women contacted in the three areas. two out of

five women in the urban area. about one in three in the slum area and one

in four in the rural area had accepted oral contraception - together totally

1.700 on the active list at the time supplies ceased. While literate women

had higher acceptance rates in the urban and slum areas. illiteracy was

found to be no bar in the rural areas, where though illiterates made up only

130 percent of those contacted. their share was over 70 percent amongst

the acceptors. Further. no religious differences could be noted in the rural

areas where continuation rates were also the highest Of the over 1.500

pill users who could later be identified and followed some 643 were

motivated enough to continue on the method by purchasing the pills from

local chemists while more than 97 percent of those not using it blamed

non-availability for the reason.

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Encouraged by these findings the Humanities Association pursued

a search for funds that could continue the work and in July 1977 finally

embarked on an action programme to distribute oral contraceptives

throughout Hoara District. this time with support from another international

NGO. In this phase the clearly defined objective was to distribute oral

contraceptives to as many eligible couples as possible through local depots

situated conveniently near the target populations and using local people

focal participation and to undertake screening and distribution. The

< strategy was shaped to maximise to work towards self-sufficiency on the

distribution costs. This programme has had enormous ups and downs

but pragmatic modifications based on timely evaluations ultimately hJve

steered it to a highly successful profile.

Operational Details and Innovations:

In July 1977 a detailed plan of operations was drawn up. The

three million population of the district was divided into units of 10-12,000

and a local depot set up within their vicinity to service the 1.500 - 1,600

eligible couples that were the target groups. The depot was provided by

the community and staffed by a local volunteer. preferably a female with

at least 8 year~ schooling who was given a short training and mor,itored

through supervisors - to maintain records on the pattern of the pilot study.

Based on the earlier experience the depot holder was required to bring in

300 pill acceptors within 18 months ;:Jnd establish a prevalence rate of

15 percent users.

The depot holder received fifty paisa (roughlv five US cents) from

the project funds for each couple reglstra11·)n card filled In and again another

fifty paisa for recruiting an acceptor and was allowed to charge twenty five

paisa per couple as a fee from the acceptor. However. this time the depot

holder was trained to examine the woman for contra-indications against

a checklist and only in the event of problems to refer her to a doctor. But

oniy one cycle of pills was given at a time to minimise problems, ensure

effective record - maintenance and regular use. Dropouts were investi-

gated at home. but users came for their supplies to the depots which were

opened at fixed hours. The original project design had earmarked one

supervisor for 10 depots, but in the interest of economy eventua!ly one

supervisor was allotted for 20 depots.

Within a year and half near!v 200 depots were functioninD and

40.000 women had been registered. At this stag," a change was made in

the mode of payments in order to move nearer the goal of s8if-SLfF:c erlCY·

Payment for registration was stopped, the service fee upped tc, fi ftv [1.1';'::

and half of this required to be returned to the project tuwards is (:'stnbl1

tion costs. The decision brought S8ri:JUS repe~cussjons or rather reve(j;~"r::

flaws in the work done so far - which till then, i-Jad seemed a rraSSi ,e

community movement.

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By June 1970, 311,834 eligible couples had been registered at 210

depots across the district. A scrutiny of the records showed 88 percent

to be satisfactory. Of 145,203 couples whose records had a satisfactory

audit check nearly 24 percent were found to have accepted oral contra-

ceptives. But the prevalence rate which had begun at 27.6 percent had

a year later dropped to 15 percent - the expected target - but unfortunately

had not stabilisedat that level as expected. In the wake of the seNice

charge changes made towards the end of 1978 which came on the heels

of the devastating loods which occured in the area at this time, prevalence

rates further plummeted and reached one percent by June 1979. The

number of users per depot dropped from an average of 143 to 27. Beides

the natural catastrophe which had disrupted the whole area, it also seemed

obvious that there had been both over-reporting of acceptors (at the earlier

stage when money was being given for each recruit) and of discontinuers

(when half the service charge was required to be deposited).

Careful analysis of the depots according to a number of performance

criteria was able to distinguish the depots into 'good', 'paying' and 'non-

paying'. What emerged from this critical evaluation was the importance

of ensuring some revenue in return for supplies from the beginning so that

no false reporting could occur. Further, that no incentives should be

given for recruiting new acceptors as this agair. could lead to inflated re-

.turns. Rather, it was realised remuneration of depot holders should be

based on their service charge, for which only a minimum should be set

and more could be taken according to the client's capacity to pay. How-

ever, to provide income to the workers during the start-up period, a fixed

payment would need to be given for contacting and registering all eligible

couples in the cachement area but with a regular sample check of their

registers at fixed intervals to ensure their correctness.

Another major finding of this analysis was that the 'good' depots

were in the majority associated with a medical Institution whether govern-

ment or a private clinic. The project moved to swiftly close all 'non-

paying' depots and within a short period had re-established itself on the

new lines of work. Following the review, a systematic effort was also

made to involve more medical practitioners. The Indian Rural Medical

Association was founded in 1980 and in collaboration with the West Bengal

branch of the Indian Red Cross, a training programme on population educa-

tion and family welfare was conducted with most fruitful results. It

brought in the Involvement of some 2,566 doctors - allopaths, homeo-

paths, and those from indigenous systems. A still more recent innovation

has been to form and associate women's groups linking programmes for

vocational training, adult education and general mother and child services

to the oral contraception distribution work.

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Impact:

. ... - ,.. , I

While of the 210 local depots originally started a little over a third

had to be discontinued. two-thirds have not only continued to function

but there has been a steady progressive rise in acceptance and continuation

of new acceptors through these every depots. This is now within a format

which because it takes a certain monetary return. has tightly controlled

the accuracy of ftled returns. Since the corrective measures were insti-

tuted in September 1979 pill distribution figures began to first average

6.588 in the last quarter of that year. then doubled to a monthly average of

12.112 in 1980 and have finally moved onto an average of 18.032 over

1983. This performance has been through the original concept of lay

workers. But following the involvement of several thousand medical

practitioners the programme got a sti/l greater fillip: pill distribution

through the members of the Indian Rural Medical Association starting

with a little over 5.800 cycles in January 1980 had already doubled to

to over 10.000 by the end of that year and averaged 30.913 cycles over

1983. This last measure is considered to be a very substantial break-

through that offers an exciting potential. The creation of an association

of their own tor rural practising physicians with appropriate training

programmes and newsletters that keep the physicians updated with

developments has provided a mechanism for the involvement of rural

physicians anywhere. Within West Bengal 50me 1500 local depots have

now been created. The most recent development of women's groups.

while yet under tria/. is already indicative of another natural pathway.

Policy Implications:

Despite the trials and tribulations faced by the Haora CBD project

for a number of reasons it has triumphed to show that the oral contracep-

tive IS an acceptable contraceptive even in largely illiterate. poor. rural

settings and that further religion is no barrier to its acceptance. particularly

in rural areas. It has shown that once an effort has been made to syste-

matically motivate women to accept the pill. satisfactory continuation rates

can be obtained as long as supplies are maintained and there is some

medIcal backup to deal with complaints. It highlights that community

involvement in community based distribution programmes can have a

significant impact in motivating and keeping users. but that a tie-up with

the medical practitioners brings quantum leaps in building confidence.

What emerges clearly from this project's experience is that rural medical

practitioners represent an untapped source of cooperation for the family

planning programme and that this is particularly needed for the oral contra-

ceptive method. Distribution of oral contraceptives through indigenous

practitioners has particeJlar potential fer rapid achievement of financi2/

selfsufficiency through a social marketing approach. and is. therefore an

area that needs to be further explored.

9 Pages 81-90

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9.1 Page 81

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Edited by Rami Chhabra, Programme Director Communications,

Family Planning Foundation, New Delhi.