For information, contact:
In the U.S.: Sandra Waldman 212/339-0525
In India: Anjali Nayyar (91)(11) 464-2901/2
Implementing a Reproductive Health Agenda in India:
An Assessment of the New Policy
NEW DELHI (June 12, 1999)ÛThe Ministry of Health and Family Welfare of the Indian government launched a new reproductive and child health programme in October 1997, setting in motion a paradigm shift in the provision of reproductive health services in the countryÛfrom a focus on achieving method-specific contraceptive targets to providing client-centered quality services.
How has this new policy been implemented? What progress has been made? What are the obstacles and challenges? A new Population Council book, Implementing A Reproductive Health Agenda in India: The Beginning, answers these and many other questions in a 600-page volume edited by Saroj Pachauri, MD, Ph.D., DPH, with contributions by over two dozen scholars and practitioners who have been engaged with these issues in their respective fields of work. The book, which was published in India, provides a glimpse of the processes under way to implement the reproductive health agenda.
The authors analyze the fertility transition in India; trace what happened when method-specific targets were removed from the family planning programme; describe the design of new methodologies, indicators, and processes for monitoring and evaluating decentralized programmes; and detail the financial and human resource needs for implementing the new agenda. The book also assesses programmes that address reproductive health problems such as maternal mortality, unsafe abortion, HIV/AIDS, and reproductive tract infections, and tackles the challenge of reaching neglected population groups such as adolescents and men. Gender and sexuality are cross-cutting themes.
Dr. Pachauri, Regional Director of the Population Council for South and East Asia, describes the challenge this way: "The rhetoric must be translated into reality. The shift in paradigm has mind-boggling implications because it calls for a change from a top-down, male-dominated, bureaucratic, target-driven programme to client-friendly, gender-sensitive services that respond to peopleÌs needs." But the greatest challenge of all, Dr. Pachauri saysÛof changing policy by the largest democracy in the worldÛhas been overcome. "India is now on the threshold of change as it operationalizes the new agenda that it has embraced. There is now no turning back."
Shifting to a reproductive health approach in India means designing a cost-effective package of good quality services that can be made available and accessible to all, especially the poor, says Dr. Pachauri. Planners need to expand interventions without compromising the quality and effectiveness of existing services. Essential services must be integrated horizontally within the existing health care system, a daunting task since the capacity of the delivery system varies widely among regions, states, and even within states.
The package of essential reproductive and child health services to be implemented nationwide over a five-to ten-year period includes services for the prevention and management of unwanted pregnancy; promotion of safe motherhood and child survival; nutritional services for vulnerable groups; services for the prevention and management of reproductive tract infections and sexually transmitted infections; and, reproductive health services for adolescents.
Sudden Removal of Targets Shook the System
When method-specific targets were removed nationwide, their sudden and abrupt removal was a dramatic change that shook the system, Dr. Pachauri reports. Critics of the move to abandon targets still question why this action was taken; they point to a decline in programme performance in the first year as proof that the decision was ill-advised. Researchers M.E. Khan and John W. Townsend examined the programmeÌs status 18 months later; they found that in the first year the target-free approach had been implemented unevenly and confirmed a decline in programme performance. However, they also report that this trend has since been reversed. Birth rates show a continued decline, even in states with persistent high fertility. They found no evidence of reduction in contraceptive prevalence; in fact, the results suggest a modest improvement in the quality of services, with a broader choice of contraceptive methods. In the state of Tamil Nadu, Leela Visaria and Pravin Visaria found a significant increase over the last 7-8 years in immunization services, antenatal visits by health workers, and mothersÌ meetings at the village level. In addition, workers there enjoyed a better status as health care providers than they did when they provided only family planning services.
Nirmala Murthy examines the issue of decentralized planning and monitoring and concludes that it has brought about several qualitative changes. Almost all states have begun to report on improvements in prenatal care and to focus their attention on providing safe delivery services. The acceptance of reversible methods by younger couples has increased, and health workers are better able to identify contraceptive side effects. However, services for emergency obstetric care, safe abortion, and treatment of reproductive tract infections and infertility are still not in place.
K. B. Pathak, F. Ram, and Ravi K. Verma describe the new indicators for assessing access to services and quality of care, including rapid household surveys conducted by independent agencies to assess clientsÌ health-seeking behaviours and satisfaction. This is a marked departure and improvement, the authors conclude, from the earlier top-down system.
Other researchers detail the rising importance of NGOs in forging partnerships with the government and the growing private sector, in defining and articulating reproductive health needs, and in monitoring services. Swapna Mukhopadhyay and Jyotsna Sivaramayya explore the potential for using the panchayat as an instrument at the community level for womenÃŒs empowerment and sustaining interest in reproductive health issues over the long term. Panchayats are elected bodies that serve as organs of governance at the village level to promote the process of democratic decentralization. Currently, one-third of the seats in panchayats are reserved for women.
Services Lacking for Adolescent Girls
Several chapters focus on reaching neglected population groups, particularly adolescent girls. "Health services for adolescent girls have special significance in India where there is a strong son preference and where adolescent pregnancy is the norm," Dr. Pachauri says. Sagri Singh examines the policy environment in the country and discusses recent policies and programmes that aim to address the multiple needs of adolescents and youth. She says that, while the ICPD provided a platform, a space, and a vocabulary for a discourse on the needs of adolescents, "there remains a paucity of information on how to address these needs." Her key messages are that the government and NGOs must form true partnerships to move the agenda forward and that youth must be brought in as equal partners in the process. Masuma Mamdani discusses the work of NGOs with adolescents in rural, urban, and tribal communities. She examines the prevailing gender norms that impede access to health and education for adolescent girls and underscores the importance of designing appropriate services for this target group. As past programmes focused mainly on birth control, many reproductive health problems were not addressed.
Mamdani also examines NGO models that address the problem of diagnosing and treating reproductive tract infections in women. The author also discusses the possibility of upscaling these NGO innovations and the tremendous challenges this poses in terms of management of symptomatic and asymptomatic infections in men and women.
Dr. Pachauri raises the question of why even after 40 years of implementing a maternal and child health programme, maternal mortality rates continue to remain high. Dileep Mavalankar reviews the status of the safe motherhood programme and finds that this programme received low priority at the policy and implementation levels. He concludes that there is a lack of co-ordination between inputs, processes, and outputs and that the absence of monitoring systems makes it more difficult to assess impact.
Unsafe induced abortion is the single greatest cause of maternal mortality, and also the most easily preventable. About 12 percent of maternal deaths are due to abortion. M.E. Khan and co-authors review the status of abortion services in the public sector in four states. They find that there is a wide gulf between demand and availability of safe abortion services and that many issues pertaining to access, quality, and cost of services need to be addressed.
In patriarchal societies like India, gender inequalities favour men and sexual and reproductive health decisions are made by them. "Therefore, menÃŒs involvement as responsible partners is essential," says Dr. Pachauri. MenÃŒs roles in reproductive and sexual health is analysed by Saraswati Raju, who draws on the experiences of NGOs in addressing the reproductive health problems of men. She concludes that NGOs are undertaking a variety of innovative and creative programmes, but an examination of government policy shows little recognition of the need to work with men, even as India makes the paradigm shift.
India is now thought to have more HIV-positive persons than any other country in the world but denial of the problem has impeded action. In her chapter, Radhika Ramasubban draws attention to the serious gulf between rhetoric and reality. She makes a case for bridging the gap between womenÃŒs powerlessness and the uncharted terrain of menÃŒs sexual behaviours; between AIDS control measures and primary health care strategies; and, between health policy formulation and its implementation.
Response to HIV/AIDS Pandemic
Geeta SethiÃŒs chapter chronicles the Government of IndiaÃŒs response to the HIV/AIDS pandemic. Due to lack of political will and poor implementation, the country lost precious time; the national programme has gained some momentum only in the last couple of years. The author also draws attention to the shared concerns between reproductive health and AIDS-control programmes.
NGO programmes that focus on controlling HIV/AIDS by empowering women are studied by Ravi Verma, Asha Bhende, and Purnima Mane. They discuss the experiences of NGOs that are integrating these services within broader reproductive health programmes. The authors conclude that sensitive issues related to sexuality and sexual behaviours are beginning to be addressed, and that there is a growing recognition of the need to empower all women.
According to Dr. Pachauri, the reluctance to address issues related to gender and sexuality has limited the effectiveness of programmes designed to improve womenÃŒs health, promote family planning, and prevent HIV and other sexually transmitted infections. Sexuality is inextricably linked to reproductive health. Pert Pelto reports on research to study the sexual experiences of several sub-categories of men and women, including married women, women with multiple sexual partners, unmarried men, and menÃŒs first sexual experiences, sexual behaviours of adolescents, and sex with relatives. The author argues that if effective interventions are to designed, more sophisticated research will be needed to understand sexual negotiation strategies between spouses; issues related to domestic violence and sexual coercion; and sexual practices of men who have sex with men.
Lack of information about the reproductive health agenda presents a major deterrent to implementing the new policy, Dr. Pachauri reports. It is essential to build coalitions and alliances to prepare common ground, she says. Local partnerships need to be developed. The media can be a powerful tool for disseminating information. Initiatives should involve not only the government and NGOs, but also such experts as obstetricians and gynaecologists, other physicians, paramedical staff, researchers and trainers. Demographers, Dr. Pachauri says, are natural allies of all these groups in promoting the reproductive health and rights agenda.
The Population Council is an international, nonprofit, nongovernmental institution that seeks to improve the wellbeing and reproductive health of current and future generations around the world and to help achieve a humane, equitable, and sustainable balance between people and resources. The Council conducts biomedical, social science, and public health research and helps build research capacities in developing countries. Established in 1952, the Council is governed by an international board of trustees. Its New York headquarters supports a global network of regional and country offices.
The Population CouncilÃŒs South and East Asia office, based in New Delhi, carries out programmes in ten countries. Work in India focuses on population policy, reproductive health, and gender, family, and development. Staff in the New Delhi office have been engaged with the process of policy change from its inception, as a research advisor to the government, and they continue to play a pivotal role in advancing the new national population policy agenda, including research, monitoring, and evaluation activities.
RSS