REPRODUCTIVE & CHILD HEALTH
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RF_WH_6_PART_2_SUDHA
Community Involvement in Reproductive Health
Findings from a Research Project
Hunsur taluk, Mysore district Karnataka
Dr. Nirmala Murthy
Foundation for Research in Health Systems
355,1E Cross, 6,h block, II Phase, BSK III Stage Bangalore 560 085
Tel/ Fax: 080- 672 3937 Email: frhs@vsnl.com
Community Involvement in Reproductive Health
Findings from a Research Project in Karnataka
Rationale
In April 1996, the government of India (GOI) decided to provide a package of
reproductive health (RH) services through its existing family welfare program and to
introduce decentralized planning approach to decide services’ levels based on
community’s health needs.
These decisions created opportunities for researchers to undertake studies to explore
effective ways to implement these changes and to assess their impact on service
delivery. Decentralized planning approach attracted the most attention because it was to
replace the contraceptive targets and promote community participation in implementing
the RCH program. In this approach, health workers were to estimate reproductive health
needs of people in their areas and prepare their own plans in consultation with
community.
However, several assessments of this approach, undertaken during 1998-2000 had
found that the target pressure on workers had reduced but community participation had
not increased (Murthy). That may be partly because the CNA manual provided little
guidance on how to involve community in decentralized planning and how to sustain
their interest in it. Many studies had shown that health staff was not too keen to involve
community because they feared their interference; community leaders were also not
keen because no fund was devolved to their level with which they could plan.
Foundation for Research in Health Systems (FRHS) decided to undertake a research
project to explore ways of involving community- based organizations like village health
committees in decentralized planning, under the RCH program. FRHS initiated this
project in Hunsur taluk of Mysore district in Karnataka in collaboration with the
department of health and family welfare. The project was funded by the Frontiers Group
of the Population Council, New York, for a period of two years.
Mysore district is situated in the southern most part of Karnataka, about 200 Km from
Bangalore City and has a population of 2.6 millions, divided in 7 blocks. Hunsur is one of
the seven blocks with a population of 250 thousand, 14 primary health centers and 70
sub-centers (64 rural and 6 urban).
The project involved forming health committees at, with representation from all villages
who would:
•
Be a “bridge” between the community and the government health staff
•
Use data to identify local health problems and plan activities accordingly
•
Network with other CBOs and NGO to increase community’s access to health
services
Past experiences of community involvement
In India, there have been three well-known experiences of involving community in
government health programs. These were - Community-Based Distribution (CBD)
project, Community Health Volunteer (CHV) scheme, and Link Worker scheme.
In the CBD project, village health committees selected “Sanyojak” (organizers) to
function as depot holders for contraceptive methods. They received free supply of
contraceptives from the government, which they distributed in villages for a small price.
Though they made only a small profit that was their incentive to work as organizers.
GOI introduced the CHV scheme in 1977 in which village leaders selected health
volunteers from within village. Government provided them training, medicine kits and a
small monthly honorarium. This scheme was discontinued in 1983 when CHVs started
demanding that they be absorbed in the government service.
In the Link Worker scheme, government appointed volunteer couples from among
villagers and paid them a small honorarium to function as contraceptive depot holders
and to promote contraceptive use. This scheme was effective in improving family
planning acceptance as long as government paid the honorarium.
Thus, in all three schemes, community involvement meant one volunteer per village,
selected either by village leaders or by health officers. They received honorarium from
government and in return they performed certain tasks assigned to them. Many of them
considered themselves village level government functionaries.
However, in non-government organizations (NGO) the concept of community
involvement has been somewhat different. Though most NGOs also used community
volunteers and paid them honorarium, they ensured that:
•
Community always selected health volunteers
•
Volunteers received a lot of training and encouragement
•
Volunteers addressed community’s real health needs
This approach to community involvement has been found to be more effective as
compared to government’s approach.
Project Background
Under the India Population Project-IX, the government of Karnataka had announced
formation of Sub-center Health Advisory Committees to support government's health
activities. Each committee was to have 8-10 members, with panchayat leader as its
president and female health workers as its member secretary. Other members included
development functionaries like mukhya sevika, local doctors and prominent women from
community. State Government directed female health workers to constitute these
committees and provided to them Rs.200 / per month to cover the meeting expenses.
But in reality, most workers did not form these committees either because they did not
know or did not want to form them. However, the state government was keen to revisit
the concept of health committees and therefore agreed to participate in the FRHS’s
project.
This project was to demonstrate effectiveness of health committees in terms of
improving RCH program performance. Therefore, in the project designed, Hunsur was
an experimental block and T. Narasipur was a control block. We collected RCH
performance data from both the blocks, before and after the project. Differences in the
“before and after” measurements would indicate the effectiveness of health committees.
Differences in the experimental and control block would isolate the effect of
government’s regular health activities on RCH performance.
Both the blocks are similar in size, are equidistant from Mysore City, and are neither too
backward nor too developed, having about 14 PHCs and 70 subcenters, but Hunsur is
spread out in many small and isolated villages while T. Narsipur is a compact block.
Table 1: Profile of experimental & control blocks
Experimental Block
Control Block
Block Name
Hunsur
T.Narasipur
Population
258,235
286,457
Number of PHC
14
13
Number of Subcentres
70
69
Number of villages
216
132
Both the blocks are well connected to Mysore City by road. Government buses ply on
Hunsur-Mysore road rather frequently though 25 percent of its villages are not
connected to bus route. Government buses ply less frequently on T. Narasipur-Mysore
road, but most of its village? are connected to bus route.
Hunsur is situated on the state highway linking Karnataka to the neighboring state of
Kerala. It is close to the Nagarahole National Park, a major tourist attraction. This block
also has a sizable proportion of Tibetian population. Five out of its 64 rural sub- centers
are tribal- dominated (Jenu Kurubas tribe) who live in small settlements (Haadis) which
are distant and isolated.
Description of the Project
Though the concept of health committee was not new, in this project FRHS tried out a
new combination of committee structure, formation process and role. To decide on this
combination FRHS convened a meeting of health staff from Hunsur block, some women
panchayat leaders and some representatives of local CBOs and NGOs. Participants in
this meeting recommended that:
5
•
Communities should be involved in nominating members to health committees
•
Committees must have both, men and women (preferably 60% women and 40%
men) and must have caste representation
•
Committees must have some funds for their activities to sustain their interest and to
help them raise funds.
FRHS accepted all those recommendations and accordingly decided that:
Committee structure
•
Each member would represent a cluster of 50-60 households in a village
•
Each committee would have at least equal number of men and women
•
Members would select committee president and secretary
•
ANM, Anganworker and gram panchayat members would be co-opted members
Formation process
•
ANM would use village maps to identify clusters of different caste and community
•
From clusters of 50-60 households, ANM would suggest potential candidates for
health committee
•
Formal and informal leaders would approve the list. If they cannot agree with the
proposed list then they would call gram sabha to decide on committee membership
Committee Role
•
Finding and sharing people’s health concerns with government health staff
•
Supplementing government’s efforts in meeting community’s health needs
•
Fostering trust and understanding between community and health staff
•
Creating demand for new health services
6
Project Inputs
•
FRHS would appoint Community Facilitators (CF) to help form health committees,
train committee members in their roles and responsibilities, to monitor their
functioning.
•
Each committee would receive Rs.2000 (one time payment) for meeting its
expenses. FRHS would pay that amount to committee presidents in four installments
and in the presence of committee members.
•
Committee members would decide how to spend that amount. They would also seek
contributions in cash and kind for their activities from panchayat, community
members, and CBOs.
•
FRHS would develop mechanisms to motivate participants and sustain their
involvement
Project Implementation Process
To help implement the project, FRHS appointed seven Community Facilitators, five
females and two males. One facilitator worked in two PHCs. Their function was to help
form health committees, train committee members in their roles and responsibilities, as
well as monitor their functioning. All CFs were local residents with grassroots experience
in development work.
The project implementation process began with a Baseline survey, followed by
committee formation, then their orientation about their roles and responsibilities and
finally providing them certain inputs to facilitate their functioning.
1.
Baseline Survey
FRHS carried out a household survey to estimate baseline values of 15 indicators,
usually used to assess performance of RCH program. In this survey, a random sample
of 1000 women of reproductive ages was selected from 30 villages of the experimental
and control blocks. This survey showed that in Hunsur block contraceptive acceptance
was high but about 1 /3rd women reported suffering from contraceptive side effects. About
one in five women reported suffering from at least one symptom of RTl but less than
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one- third of them had sought treatment. More than half the women had heard about
AIDS but did not know how it occurred or how to prevent it.
With respect to mother care, ANC registration was almost universal but less than one-
third had received full ANC care. Less than half of them delivered babies either at
institutions or at home by ANM (40%). The remaining delivered at home by untrained dai
or relatives, without using the disposable delivery kit. About one- fourth women reported
complications during delivery and nearly half reported serious postpartum complications
such as excess bleeding, lower abdominal pain with fever.
With respect to child-care, child immunization was universal but practice of immediate
breast-feeding was low (31%), only one in five babies were weighed at birth and less
than half the mother knew about giving ORS to children with diarrhea.
Most committees used these data to decide on the type of activities they should
undertake in their villages.
2.
Forming of Committees
Though the process of forming health committees was decided well in advance, there
were a few problems during implementation. In a few committees health workers and
panchayat leaders disagreed with some names on the proposed list. Instead of taking
that decision to gram sabhas where all adult members of village participate, both health
worker and Leader argued that they should be the ones deciding committee
membership. Health worker, because she had to work with the committee. The leader,
because he knew what was good for his people.
Researchers had planned to implement the project in two phases and had randomly
selected half the PHCs (7) to form committees in phase 1. Now, they decided to resolve
the issue of committee formation through experimentation. Of the 7 PHCs in Phase 1,
they assigned 3 PHCs to gram sabha method, 2 PHCs to health worker method and the
remaining 2 PHCs to panchayat method. All three methods had to follow the same
criteria of each member representing 50- 60 household clusters, giving adequate
representation to women and caste/ community groups.
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In the Gram sabha method, gram sabhas were conducted in public places in villages,
typically lasting one to two hours. CFs informed the gram sabha about the project and
the role of committees. People then suggested names from different clusters. But this
process turned out to be time- consuming taking over 3 months and over 80 scheduled
gram sabhas to form 16 committees. Many gram sahbas were often postponed due to
wedding, death or some festival in villages. For each sabha, CF had to be present.
In the health worker method, workers listed the potential members and took those lists
to formal and informal village leaders for approval. Leaders sometimes suggested
changes but usually approved the list. That way, health workers could form nine
committees within one month. They could not form two committees because of malaria
work. This method made no demand on CF's time.
In the panchayat method, CF met the panchayat presidents and explained the project
and the role of health committees. Panchayat presidents then agreed to nominate
members after consulting others and asked CFs to come back later for lists. This method
also took long, about two months to form 11 committees, because panahcyat leaders
were busy or not available whenever CFs visited them.
After 6 months of functioning FRHS evaluated the three methods using three criteria transparency, member profile, and performance (See Appendix 2).
•
Gram sabha method was found to be the most transparent while “panchayat leader”
•
The gram sabha method gave more representation to women and SC/ST than the
method was least.
other two methods. Panchayat leaders nominated fewer women than required but
gave adequate representation to SC/ST population. Health workers gave
proportional representation to all.
•
In terms of activity level, committees formed through the gram sabha performed the
best while health workers’ committees, the least.
This analysis indicated that the gram sahba method was the best, but it was also the
least efficient method and difficult to implement within government set- up. Instead
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researchers decided to judiciously combine the gram sabha and health worker method
for phase-ll committees. In this combination method, health workers identified clusters of
households using their village maps and listed possible members from each cluster.
They then conducted a meeting, inviting panachyat presidents, members, informal
leaders, members of SHGs and other CBOs to finalize the list. Using this method,
workers took about three months to form 28 committees.
FRHS staff was not involved in committee formation in Phase 2, but they attended the
first meeting of all committees to find out whether the selection process had been
followed and membership norms were met.
3.
Orienting Committee Members
After committees were formed, CFs organized orientation meetings for members to
discuss:
•
Their roles and responsibilities
•
Community Needs Assessment approach under the RCH program
•
Problems people faced in getting services at PHC
•
Actions they could take to improve health condition in their villages
PHC medical officers, supervisors and health workers also attended these meetings.
These meetings usually began with researchers explaining that this was a two-year
research project to explore what role health committees could play in meeting
community’s health needs and what support they would need. They clarified that this
was a NGO project and not one of government schemes. The government health staff
had agreed to participate in the project as partners along with the committee members
and the NGO staff. This explanation went a long way in getting across the concept that
this was a three-way partnership.
Next, ANMs informed committee members about Community Needs Assessment and
the data they had collected about community's health needs. Members usually
expressed satisfaction with ANMs data but in some committees they also expressed
doubts that ANMs had really surveyed the entire areas.
10
Next they discussed problems people faced in getting services at PHC. Some
committees discussed issues like whether poor people could afford to give time for
committee work and whether they should be paid for their time. But they usually decided
not to pay the poor because then everybody would claim to be poor. "If poor want to
participate they must find time for it”, they said.
The problems they frequently mentioned were PHC doctors not giving free medicines,
doctors demanding money from poor people, health staff not keeping to the schedule
etc..
These discussions upset the health staff. But most of them explained their constraints in
giving free medicines. Some doctors even promised to stock emergency medicines or
promised better treatment to the poor. During these discussions CFs emphasized that
committee’s role was not to find fault with government health staff and antagonize them
but to work with them to the extent possible to improve people's access to health
services. These interventions ensured that orientation meetings ended cordially though
many began belligerently.
4.
Providing Project Inputs
The project provided five inputs to facilitate committees’ functioning. These were:
1.
Community facilitators
2.
Rs.2000 start-up grant per committee
3.
Identity cards for committee members
4.
Periodic meetings of committee presidents with Block/district health officers
5.
Publication of a monthly newsletter
Community Facilitators (CF) helped to form committees and motivated them to
undertake village level activities. They attended committees’ monthly meetings and all
their activities. Initially they also suggested health activities that committees could
undertake and identified local resources that would be of help to them. For example,
they identified State Resource Center (SRC) to help organize health education camps
for adolescents. SRC’s help improved quality of these camp as well as boosted
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committees’ confidence in undertaking such activities. CFs also helped committees to
keep records of their meetings and accounts of funds they generated. They also
facilitated their interactions with health staff.
Start-up grant of Rs.2000 per committee helped to initiate its activities. Committees
reported how they spent that amount to FRHS, every month. These reports showed that
they had spent that amount judiciously and built on it further through contributions from
community members and community based organizations.
Identity cards were given to committee members to legitimize their role and to boost
their status in the community. Initially doctors had objected to members getting l-cards,
fearing that they might use it to create trouble for them. Therefore, while issuing those
cards, CFs emphasized that l-cards did not entail any privileges and that they would
have to return them if health staff complaint about their misuse. Though there have been
a few instances of members using the l-card to jump the queue at health centers
(unsuccessfully), health staff has no major complaints about misuse of l-card. On the
other hand, members have reported feeling encouraged working in the community and
getting cooperation from health staff even when they went out of Hunsur because of the
l-card.
Presidents meetings at block level give them opportunity to share experiences among
themselves and with district and state-level health officers. These meetings are
organized in a grand style where all invitees sit around a large table. Each one has a
nameplate in front and gets 5-7 minutes to address the gathering. This event is meant to
make them feel important and proud of what they are doing. Health officers listen to
them, make suggestions on what more they can do and promise cooperation. So far, two
such meetings have taken place. Each one has been a success in terms of attendance
and stimulating interest in the project.
Monthly newsletter, Arogya Midita, informs committees about what programs others
are undertaking, highlights innovative programs with photographs. It has published items
like a PHC doctor’s speech on the World Population Day, research findings dealing with
adolescents, hysterectomy, and nutritious recipe by an anaganwadi worker etc. It
facilitates cross learning of ideas. For example when it reported about a well-executed
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eye-camp by a health committee, five others also organized similar camps. The
Newsletter has become a prime mover, motivating committees to organize more and
better programs.
The Project Achievement
In June 2002, the project completed two years. We evaluated its achievements using
two types of indicators - process and outcome. Process indicators included number of
“active” health committees and the types of activities they have undertaken, resources
they mobilized, and quality of their interaction with health staff. Outcome indicators
included increase in health knowledge and access to RCH care (Box 1).
Box 1: List of Process and outcome indicators
Process Indicators
1. % Committees meeting regularly and active in health work
2. % Committees mobilizing local resources for health activities
3. % Committees maintaining transparency in fund management
4. % Committees maintain cohesive and democratic style of functioning
5. % Committees having respectful and supportive relationship with health staff
Outcome Indicators
1. % Pregnant women received full pre-natal care and safe delivery
2. % Couples using contraception and not suffer from side effects
3. % Women following appropriate child care practices
4. % Couples and adolescents participated in village level health activities
5. % Women know about RTI/ STI and sought treatment in case of problem
Achievements on Process Indicators
The process of committee formation actually began in December 2000 and completed
by July 2001. During this period we were able to form 64 committees.
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Activity level of committees
By June 2002, 56 committees have remained active while 8 have either stopped or
never became active. Of the 56 active committees, half meet regularly and carry out
some activity once in two months. In a one-year period, these 56 committees have
carried out 172 programs (Table 2).
The key to activating committees was to get them to successfully implement their first
planned activity. Therefore, researchers urged them to select activities that they were
confident of carrying out. Also, CFs provided any support needed to implement the first
activity. For example, in one case the committee had planned a sub-center clinic but
that was about to be canceled because the ANM was on leave on that day. CF then met
the doctor and requested him to send someone else in her place. The doctor agreed and
the clinic was held.
From then on, committees decided dates for meetings, planned subsequent activities,
reviewed activities, and maintained proceedings and account books. FRHS staff
continued to guide them on types of activities they could undertake, suggesting a
strategy of focusing on hitherto neglected areas like adolescent health, family education
for newly-wed couples, treatment of RTI/ STI etc. Most committees seemed to have
followed that advice.
Committees have so far carried out a total of 172 activities of 18 different types. Those
include health awareness camps, health check- up camps, village cleanliness drives and
so on (See Table 1 below).
For these activities, committee members choose the topic, either on their own or in
consultation with health staff. They employ various participatory methods like games,
songs, skits, quiz to create awareness and to entertain participants. For some programs
like those for pregnant women and newly- wed couples, committee members visit their
homes and invite them in a traditional manner. The most popular of all activities is the
one for adolescents. These have received good responses from adolescents, parents
and teachers.
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Table 2: List of activities carried out by committees as of June 2002
No. of
Name of activity
Sr.
activities
35
1.
Awareness program for adolescent boys and girls
2.
Program on ANC care for pregnant women______________
32
3.
Nutrition awareness for mothers
28
4.
Program on diarrhea control and use of ORS
13
5.
Village cleanliness drive involving school children, health staff &
13
_______
panchayats
6.
Health awareness program for newly- wed couples
11
7.
Program on various government health services
09
8.
First -aid training for committee members / volunteers
05
9.
Free eye check - up camp
05
10.
RTI/ STI awareness camp
04
11.
Getting water tank cleaned in the village
04
12.
Gender sensitization**
03
13.
Anti- malaria drive
03
14.
Prevention, Control and treatment of ARI
02
15.
Free health check- up
02
16.
Celebrated World Health day/ Women’s day
02
17.
Training committee members to weigh newborn
01
18.
RTI/ STI detection & treatment camp
01
Total number of programs
172
Even though there were only three programs specifically on gender sensitization, gender issues were the
focus in all programs on nutrition & pregnancy and those for adolescents and newly- wed couples.
Since these activities are well- attended committees have gained visibility not only
through the Newsletter but also through local newspapers. Health staff has been
supportive especially of committees that invite them and honor them. Some staff
members are more popular than others. By and large they all feel that, if they are friendly
with committee members then members ease their burden in the field.
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Mobilizing resources and transparency in fund management
Members themselves meet expenditure of their monthly meetings. They also generate
resources by contacting other groups in the community like gram panchayat, SHGs,
school development committee, milk cooperative society, and religious establishments,
usually in kind or in service form (Box 2).
Box 2: How KMH Committee organized adolescent awareness program
When KMH committee decided to organize an adolescent awareness program in a local
school, they invited teachers and headmaster of that school to their monthly meeting.
Headmaster and teachers were enthusiastic and agreed to allot one whole dayfor the
program. The committee then asked the CF whom o invite as resource persons. The CF
suggested SRC in Mysore. The Committee president called SRC and confirmed their
availability. Committee members then approached a local religious establishment and
requested them to make food arrangements. They obtained a mike system free of cost and
hired a hall at a nominal charge because this was for a "social cause". This committee
prefers to take help in kind. That way everyone can see how their contribution is being used
and there is no room for suspicion.
Another committee organized a free health check- up camp, inviting doctors from the
taluk hospital, PHC and rotary club. They collected free drugs worth Rs.7000 from local
chemist shops. This half a day camp attracted 340 people.
The start-up grant has
Figure 1: Mobilizing resources
helped committees raise
funds. Of the 64
□ Mobilizing > 60% of
the expenses
committees, 25 generated
■ Mobilizing < 60% of
the expenses
sizable funds, 20 generated
□ Mobilizing none
some, and 19 none (See
Figure 1). So far there has
been no instance of
misappropriation of funds. Some committees have opened accounts in post office to
keep grant amount; some have divided it among themselves and paid interest on that
amount to committee.
16
Out of the 92,500 rupees grant amount from FRHS, committees have spent 69,551
rupees and mobilized a sum of 48,433 rupees to create a saving of 71,382 rupees by the
end of the project period.
Democratic and Cohesive Style of Functioning
From the beginning FRHS has emphasized the need for committees to function in a
cohesive democratic manner. Indicators used to assess the functioning style were
regularity of meetings, attendance at meetings, sharing tasks among members. We
found that the project has not done as well on this indicator. We realized that this was a
rather difficult criterion to meet because members came from different villages so
attendance at any meeting was about 40 percent. Members also belonged to different
social and economic classes. Some were from well off families could spend time for
village work while others working on daily wages had little time for these activities
We observe a
variety of functioning
styles. In some
committees one
person (president or
vice presidents)
would take all
decisions and other
follow. In some others, committees would take decisions but actions were left to one or
two persons. Five committees broke into smaller units while 3-4 committees always
worked jointly so they can do large-scale activities. Some committees fight bitterly during
meetings but then organize excellent programs. When we compared the "very active",
"active" and "non-active" committees on these three indicators we found that even in
"very active" members attendance in meetings was low. They conducting meetings
regularly, mobilized resources, shared tasks equitably.
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Relation with health staff
FRHS paid much attention to the relation between health committees and health staff
realizing that this was the most difficult part of the project. Many committees felt that
because they were doing health work, health staff should do their errands like calling
members, running around for activities etc. Workers resisted such demands because
they had other work and did not want to be seen as working for committees.
Though researchers from
time to time had emphasized
that committees' role was that
of a bridge between community
and health staff and that they
had no power over the staff,
some presidents had managed
to complain about the staff to
district officers who took those
complaints seriously and
reprimanded staff. Such events did affect cooperation between the two but those were
not many because committee members feared that if they complained health staff might
not give whatever services they were giving and committees would lose people’s
support.
Many non-active committees have poor cooperation from the health staff. The health
staff has tried to disrupt committee activities by inciting members not to participate. They
have behaved rudely in meetings and refused to support committee activities because
they fear that if committees become strong they would harass them. The very active
committees have managed to develop friendly relationship with health staff. That has
been one of the factors determining their success.
Achievements on Outcome Indicators
The evaluation indicated that the project had made progress on certain outcome
indicators while on some others there was none. Overall, 42% couples reported knowing
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about health committee and its activities and reported that committees were doing good
work. Since most committees had organized activities for specific groups like pregnant
women, adolescent girls, and newly- wed, it is possible that household that did! not have
them, had not participated or did not know about those activities.
Table 2: Status on outcome indicators
Sr.
Indicator
Baseline
Evaluation
N1=1057
N2=1050
1
% Full ANC (3 visits + IFA tablets>=90 + TT)
28
31
2
% Institutional delivery
32
39
3
% Safe deliveries
40
49
4
% Home delivery used DDK
12
18
5
% Women knew all FP method
14
16
6
% Using FP method
72
75
7
% Reported FP side effects
34
25
8
% Women reported at least one RTI symptom
26
26
9
% Sought treatment for RTI (N1 =271; N2=277)
31
43
10
% Reported immediate BF
32
34
11
% Babies weighed
21
43
12
% Low birth weight babies (<=2500 grams)
48
33
13
% Children fully immunized
96
92
14
% women knew about giving ORS or fluids
47
23
0
42
during diarrhea
15
% couples know about committee activities
Indicators that showed significant increase were institutional and safe deliveries, use of
DDK (since DDK was available now but not during the baseline), women seeking
treatment for RTI/STI and proportion of babies weighed. Sterilization acceptance
increased from 72 to 74 % but use of spacing method perhaps slightly reduced and
women reporting FP side effects declined from 34 to 25 percent.
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However, we were surprised to find decline in ORS awareness from 47 to 23 percent,
even though 175th committees had organized ORS programs. In these programs giving
ORS was promoted only as a primary level treatment. If diarrhea did not subside they
were asked to take the child to the doctor. But a more pertinent reason could be that
committees usually organized ORS programs in Anganwadis, where participants were
mothers of children attending anganwadi and some school children. Therefore, that
message perhaps did not reach as many women as in case of ANC or Adolescent
programs. Here committees made special efforts to ensure all pregnant women/
adolescents participated and did not restrict it to convenient groups, as had happened in
the case of ORS programs.
Implementation Analysis
The idea of creating health committee at the village level was not new. Most government
health programs have them. But they mainly consist of ex-officio members or people
with status in community. The Mahila Swasthya Samiti (MSS) i.e. women's health
groups is one such example. Health workers selected members to MSS based on who
they thought were active. Members attended health education meetings that workers
convened and sometimes helped them in Pulse polio campaign or for recruiting family
planning cases.
The health committee model tried out in this project was different from MSS in at least
three respects: (1) Committee membership was broad -based (2) Members represented
people were not there as ex-officio members. (3) Committees were expected to plan and
implement certain tasks that would improve access and quality of health services in the
community.
But unlike the School Development Committee in Karnataka, they had no financial or
administrative power vis-a-vis the health staff. They only received a grant of Rs.2000 for
start up activities. Beyond that, they had to raise resources for their activities.
This project had three stakeholders - health staff, community leaders and researchers.
What made this project interesting that they all had different expectations and
apprehensions about the role of committees.
20
Health staff wanted committees to undertake activities such as:
•
Making DDK available at a nominal cost
•
Helping the poor to come to health center
•
Motivating people to accept family planning methods
•
Changing attitudes of husbands and mothers-in-law towards RTI/STI etc.
The committee model that they liked was the MSS, where health department decided
activities and members participated.
Health staff was apprehensive about the new model of health committee. Many of them
feared that these health committees, having no health knowledge would try to interfere
and harass them. Their fears were kind of confirmed in initial committee meetings when
they had to face questions like, ‘why do doctors take money?’ 'Where are all the
medicines going?’ ‘Why do you come late?’
Therefore, they strongly opposed the project. They wanted the option of not participating
in it but the DHO ruled that out because “community participation”, he said, “is a
government policy”. So they decided to tolerate the committees for the 2 project period.
Community leaders on the other hand, wanted health committees to function as
watchdog of health system. They wanted them to find out:
•
What the ANMs were doing or not doing?
•
Which PHC doctor takes money for services?
•
Does PHC staff keep to correct timings and behave well with people?
Researchers did not want health committees either to be dominating or be subservient
to health staff. They wanted health committees to play a constructive role of a bridge
between the community and health functionaries by undertaking activities such as:
•
•
Creating health awareness in the community
Encouraging women, especially the poor and socially disadvantaged, to seek health
care
21
•
Mobilizing local resources to increase access and quality of services
•
Educating community about new health challenges such as adolescent health and
HIV/AIDS
Success of committees therefore depended on how well they were able to balance these
three types of expectations. When we analyzed the functioning of the “very active" and
“non-active” committees, we found three features that distinguish them. These were:
•
Ability to manage conflicts with health staff.
•
Capacity to network and manage vested interests
•
Playing the “bridge” role between community and health system
Managing conflicts with health staff
In active committees, usually the relationship between members and health worker was
mutually helpful. For example, in one such committee members asked health worker to
suggest priority health issues that they could work on. When she told them about many
cataract cases in the area, the committee decided to hold an eye camp. Even when
there were friction and workers not cooperating, committees managed to carry on their
work, taking them along to the extent possible.
In non-functioning committees, relationship between health staff and committee
members was usually unfriendly and both were responsible for that. Members continued
to find faults with workers (they were not unjustified) but could not get over that hurdle.
Doctors’ behavior made the most difference. Some doctors, by talking rudely in first
committee meetings, had discouraged committees from functioning. But in active
committees, doctors were friendly and encouraged committee work.
22
Capacity to Network and Manage Vested Interests
Most active committees networked with Continuing Education Centers, Self-help
Groups, local NGOs, Panchayats to carry out their activities. In their programs for
pregnant women, SHG and panchayat members contributed flowers and coconuts to
felicitate the pregnant women or volunteers from Continuing Education Centers got
adolescents together for programs.
One such committee organized a large eye camp where over 300 persons were
examined. In that camp, facilitators of the Continuing Education Centers made the camp
arrangements. Panchayat president supplied food. Transport Owners' Association made
vehicle arrangement to transport 32 cataract patients to hospital and back, free of cost.
One NGO met the cost of publicity and Bankers Association made monetary
contribution.
While this camp was an example of convergence at the grassroots level, some health
staff thought the committee was trying to get political mileage. Some members also felt
hurt in the process of credit sharing. This affected their further work. On the other hand
committees that have been functioning on a less grand scale, have managed to make
steady progress.
Also, committees, where a few members tried to dominate all activities have split in
smaller units. In one such committee when a powerful member unilaterally decided to
cancel a health camp other members were so upset that were not willing to come
together for any more activities. Some other committees broke because powerful
members held all activities in their areas, ignoring claims of other areas.
One positive trend so far is that committees have managed to avoid political attention.
That may be because they work with small funds and they also take care not to offend
political sensitivities in villages. Members belong to different political parties and they
guard against any one party getting mileage out of their collective work.
23
Playing the “Bridge" Role
Initially most health committees wanted to work on controversial issues like medicine
supply at PHC, doctors charging money, staff not available during clinic time etc.
Addressing them would have meant taking on an adversarial role, which committees
were not equipped to do. Fortunately most of them soon realized that this approach
would not work and people would blame them if doctors refused to give whatever little
treatment they were giving. As a result, they agreed to researchers’ suggestion of
focusing on preventive and promotive aspects of health, focusing on problems identified
from the baseline survey.
These activities helped to channel their energies into doing something in collaboration
with health staff. They invited health staff as resource persons and felicitated them in
village gatherings. As a result, health staff had fewer complaints about them. In one staff
meeting they admitted, “if we don’t get scared of their questions and answer them
properly, they can be valuable in our work”.
Many of the non-active committees had not accepted this role, either because their
leaders wanted to control health staff or did not want to collaborate. In one committee
the president was not interested in any constructive work and kept talking about
corruption at the PHC. In another, the doctor was not interested in cooperating with
committees. The doctor often remained absent from duty but resented committee
members commenting on it. Committee president was equally rude and unfriendly. The
relation between doctor and the community was so hostile, the committee had no
chance to play the “bridge” role.
Notwithstanding such negative forces, the final evaluation showed that 88 percent
committees have remained active mainly because CFs encouraged them and provided
help in their activities. The Newsletter was a source of information and inspiration.
Increasingly, committees are receiving support and recognition from local agencies like
Swami Vivekananda Youth Movement, State Resource Center and Vedavathi charitable
trust because they find committee presence helpful in their work.
24
The questions that we need to answer now are, how would these committees be
sustained and what future direction can they take?
Sustaining committees and their activities
To strengthen and sustain these committees would require sustaining their motivation
and building their capacities. In this project, we used public appreciation through
Newsletter and Presidents’ meetings, as mechanisms to sustain their motivation. Where
health staff was non-cooperative but committees were motivated, we tried to link them
with other resource organizations. How can committees be sustained beyond the
project? This question remains to be answered.
What they really need is a mechanism that would sustain their motivation, empower
them vis-a-vis the health system and build their capacity.
The newsletter for example, provides motivation and facilitates exchange of ideas and
learning. Linkages with resource institutions and NGOs provide direct inputs into their
activities, empowering them vis-a-vis the health system. For example, instead of
depending on government doctors they now invite NGO experts for their activities and
the project has a list of such resources, willing to offer services on request. An equally
important input for their sustenance would be a federation like structure of health
committees, supported by local NGO, playing the role as that of the FRHS.
If government recognizes them as a legitimate local institution they can be useful in
implementing various programs like eye camp, DOTS treatment for TB, and water &
sanitation. However, if these committees are not federated or do not have NGO support,
health staff is likely to use them as CHVs, which would surely kill their initiatives. We see
this trend already setting in.
25
Summary and Recommendations
This project rather successfully stimulated community participation in the planning and
implementation of health services in Hunsur taluk of Mysore district. During this 2-year
project, which ended in June 2002, there were 64 health committees, one in each sub
health center of which 56 were active and eight were dormant.
It took some time for health staff and committee members to understand and accept
their respective roles. Health staff resisted the committee idea because they expected
committees to create nuisance forthem. Committees also took some time to realize that
their role was to promote health activities in their areas and not to discipline health staff.
They also knew that the project was not providing funds for their activities except a grant
of Rs.2000 for start-up activities. Beyond that, they would have to raise funds for their
activities and they accepted those conditions for participation in the project.
Health staff on the other hand, had more reservations about the project. They doubted
committees’ capacity to do anything good except harass them. Initially, some tried to
incite committee members not to participate or created hurdles by not cooperating with
them. But as more and more committees started undertaking various health awareness
activities and organizing health services camps and gained visibility through local
newspapers, health staff also changed their view and became active participants in
many places.
These committees are not functioning as people’ watchdog or pressure groups. Nor are
they passively participating in government health programs like the mahila swsthya
samithi. Committee members represent all clusters of houses in the community. They
have a specific role to play that involves deciding which health activities to undertake,
plan them, and generate resources to implement them. They get support from friendly
doctors, health workers and NGO facilitators. Through their support and by networking
with other community-based organizations, they have managed to undertake many
health awareness programs and service camps. Through these activities many are
acquiring visibility and fame.
26
Their next challenge would be to retain their visibility without antagonizing the local
politicians and health bureaucracy especially for those ambitious committees that want
to take-up large-scale programs and generate a lot of funds. Committees can avoid
those dangers if they chose to work on less ambitious but effective programs like
championing the health of neglected groups like the poor, the old, girl children, and
adolescents.
State government officially recognizing health committees, would go a long way in
sustaining them beyond the project period. In that case we would like to sound two
cautionary notes. If government recognizes them then they might start assuming more
powers and start having conflicts with health staff. Or health staff would start treating
them like village health workers, ordering them to undertake various tasks. Neither of
these possibilities would help committees to collaborate with health staff but plan their
activities according to their priorities. To keep playing that role they would continue to
need NGO support of the type the FRHS provided. Therefore creating a federation of
health committees with administrative support from a NGO, might be the answer to their
sustainability and growth.
27
Appendix 1
Selecting the Best Method for Committee Formation: an embedded experiment
Though the process of forming health committees was decided well in advance, in one
or two instances in the beginning of the project, panchayat leaders proposed their own
lists which did not at all match with ANM’s list and both disagreed with some names on
each other’s list. And instead of taking that decision to gram sabhas where all adult
members of village participate, both ANM and Leader argued that they should be the
ones deciding committee membership. ANM because she had to work with the
committee. The leader because he knew what was good for his people.
Researchers therefore decided to resolve this issue through experimentation. Of the 38
sub center they had selected to implement the project in phase-l, they randomly selected
16 where gram sabha would decide members, in 11 sub-centers health worker would
decide, and in remaining 11, panchayat leaders would nominate members, by consulting
community or otherwise.
In the Gram sabha method, gram sabhas were conducted in public places in villages,
typically lasting one to two hours. After learning about the project and about committee’s
role, people suggested names from different clusters. The criteria they used were, ability
to read and write, permanent residents of the village, and would regularly attend
meetings. They also suggested names of women, whose husbands had no objection to
their attending meetings.
But this process was long and laborious. It took over 3 months and over 80 gram sabhas
to form 16 committees. Sabhas were often postponed because of wedding, death or
some festival in villages and for each sabha, community facilitator had to be present.
In the health worker method, workers listed the potential members and took those lists
to formal and informal village leaders for approval. Leaders sometimes suggested
changes but usually approved the list. That way, health workers could form nine
committees within one month. They could not form two committees because of malaria
work. Workers made no demand on community facilitators ’ time.
28
In the panchayat method, community Facilitators met the panchayat presidents and
explained to them the project and the rationale for forming health committees.
Panchayat presidents would agree to nominate members after consulting others and ask
CFs to come back later for lists. Leaders also took long, about two months to form 11
committees, because they were too busy or not available whenever CFs tried to visit
them.
FRHS observed their functioning for about 6 months before selecting the most effective
method by comparing them on three criteria - transparency, member profile, and
functionality. Our observations indicated that:
•
Gram sabha method was most transparent while "panchayat leader method was
least transparent.
In all 16 committees formed through gram sabha method, people knew who was
selected and why? Serious disagreements occurred only in three cases. In one, leader
agreed to do what the people wanted. In another, people agreed to include two of
leader’s men in the committee. In the third, the leader managed to appoint all members
of his choice by not allowing anyone in the sabha to speak. That committee never met
again.
Since health staff workers had consulted informal leaders, all these committees enjoyed
local support.
However, pachayat leaders it seems had not consulted any one while nominating
members. In these villages, researchers often faced questions like why someone was
selected or not selected. They complained about some clusters of houses not
represented while some were over represented. Some panchayat members had
nominated themselves.
29
In terms of members’ profile, the gram sabha method gave more representation to
•
women and SC/ST than the other two methods. Panchayat leaders nominated fewer
women than required but maintained the share of SC/ST population (Table 4).
Member profile by committee type
Profile Indicator
Committee Formation Method
Gram sabha
Health workers
Panchayat leaders
(16 committees)
(9 committees)
(11 committees)
% women members
53%
52%
42%
43%
33%
34%
% SC/ ST members
•
In terms of activity level, committees formed through the gram sabha method
performed the best while health workers’ committees, the worst.
Activity Levels by committee type
Activity Level Criteria
Gram-sabha
Health Worker
Panchayat
method (18)
method (7)
leader method
72
57
73
61
43
36
(11)
% Committees organized at
least 2 programs
% Committees raised
| resources
Even though this analysis indicated that the gram sahba method was the best, it was the
least efficient and impossible to implement without NGO involvement. Therefore FRHS
decided to use a judicious mix of the gram sabha and health worker method for phase-ll
committees. In this method, health workers used village maps to identify clusters of
households. They also listed possible members from each cluster and then conducted a
meeting in each village where she invited panachyat presidents, members, informal
leaders, members of SHGs and other CBOs to finalize the list.
30
<a3YA.'- &
WORLD
HEALTH
ORGANIZATION
SPECIAL PROGRAMME OF RESEARCH, DEVELOPMENT
AND RESEARCH. TRAINING IN HUMAN REPRODUCTION
TASK FORCE ON VACCINES-FOR1 FERTILITY REGULATION
Project Number:
. Project Title:
91904
Phase II clinical trial of a prototype
anti-hCG vaccine
INFORMATION BROCHURE AND CONSENT FORM
.BROCHURE
20.09.1991
NOTICE
YOU ARE CONSIDERING PARTICIPATION
TRIAL OF AN ANTIFERTILITY VACCINE.
IN
A PHASE II CLINICAL
IN ORDER FOR YOU TO REACH A DECISION ON WHETHER OR NOT TO
TAKE PART IN THIS STUDY, IT IS IMPORTANT THAT YOU UNDERSTAND
WHAT THE VACCINE IS,. HOW IT IS BELIEVED TO WORK, AND WHAT IS
INVOLVED FOR THE PARTICIPANTS IN THE TRIAL.
THIS BROCHURE HAS BEEN PREPARED IN ORDER TO PROVIDE YOU WITH
THIS INFORMATION.
IT HAS BEEN WRITTEN IN THE FORM OF
ANSWERS TO QUESTIONS LIKELY TO BE ASKED BY INDIVIDUALS WHO
VOLUNTEER TO BE IN THE STUDY.
PLEASE ' READ THIS BROCHURE CAREFULLY AND ASK ANY ADDITIONAL
QUESTIONS THAT MAY OCCUR TO YOU.
YOU ARE FREE TO ASK
QUESTIONS AT ANY TIME BEFORE AND DURING THE STUDY.
IF YOU DECIA^ TO PARTICIPATE, YOU WILL BE ASKED TO SIGN THE
STATEMENT ON THE LAST PAGE OF THE BROCHURE. THIS STATEMENT
SAYS THAT YOU HAVE BEEN GIVEN SUFFICIENT TIME TO READ THIS
BROCHURE, THAT YOU UNDERSTAND ITS CONTENTS, THAT YOU HAVE
RECEIVED SATISFACTORY ANSWERS TO ANY AND ALL QUESTIONS YOU
’MAY HAVE ASKED, AND THAT YOU ARE PARTICIPATING IN THE TRIAL
OF YOUR OWN FREE WILL.
SHOULD YOU DECIDE TO WITHDRAW FROM THE STUDY, FOR ANY REASON
AND AT ANY TIME, YOU ARE FREE TO DO SO WITHOUT IN ANY WAY
AFFECTING YOUR FURTHER MEDICAL CARE.
Quescion
1. HOW ARE NEV DRUGS AND VACCINES DEVELOPED?
. -
..
' '
.
..................................................
1
2 . WHY ARE CLINICAL TRIALS NECESSARY?...................................................... 1
3'. WHAT ARE CLINICAL TRI-ALS?'
?AR“.:C.r LV3
TJ-”. TRIAL.......................... /.
2
U. WHAT ARE VACCINES AND HOU DO .THEY WORK? ............................................................ '. .
3
5.
WHAT IS AN ANTIFERTILITY VACCINE?. .... ......................................... ....
4
6.
WHAT IS HCG?..................................................................................................................................
4
5
7.
WHAT IS AN ANTI-HCG VACCINE AND HOW DOES IT WORK?.....................................
8.
FOR HOW LONG WOULD THE ANTI-HCG VACCINE REMAIN EFFECTIVE?
.....
6
9.
WHY IS AN ANTI-HCG VACCINE AN ATTRACTIVE BIRTH CONTROL METHOD? ...
6
10.
WHAT IS THE CURRENT STAGE OF DEVELOPMENT OF THE ANTI-HCG VACCINE?.
11.
WHAT ARE THE COALS OF THIS PHASE II CLINICAL TRIAL?................................
12.
WHO IS ELIGIBLE TO PARTICIPATE IN THIS CLINICAL TRIAL?........................... 10
13.
WHAT WILL PARTICIPATION IN THIS CLINICAL TRIAL INVOLVE?
......
10
14.
WHAT ARE THE POTENTIAL RISKS AND PROBLEMS THAT MIGHT BE ENCOUNTERED?
11
15.
WHAT ARE THE BENEFITS OF PARTICIPATION?
16.
WILL PARTICIPANTS BE COMPENSATED?.............................................. .................................. 13
. .
.’.................................... ....
.
17.
WHO HAS ACCESS TO THE CLINICAL TRIAL RECORDS?.......................... ....
18.
WHO SHOULD BE CONTACTED IF QUESTIONS ARISE DURING THE TRIAL? ....
STATEMENT OF INFORMED CONSENT 10 PARTICIPATE IN THE TRIAL
8
.
.'......................... 14
9
12
13
13
''Ptjase II clinical trial information brochure and consent fort.
'
1.
HOU ARE NEW DRUGS AND VACCINES DEVELOPED?
The
often
dollars.
It
stage,
involving
clinical
requiring
can
more
divided
be
ten
than
two
into
and many millions qf
years
parts - the preclinical
major
animal experiments and laboratory tests, followed by the
stage,
volunteers.
drugs .and vaccines is a long and expensive
new
of
development
undertaking
the
in
preparation
human
testing
of
the
preclinical
and
clinical stages of new drug and
involving
Both
new
vaccine development have the following two principal objectives.
is
first , objective
The
does
and
safe
to
produce
not
determine
any
side
that
W
the new preparation is
which
effects
would
make
it
unacceptable for human use.
The
in
is
to
determine
objective
in
that
it
prevents, cures or alleviates illness and disease,
case
of
a
the
new
....
| |
that the new preparation is
second
effective
or,
.
family planning method, provides protection.
against unwanted pregnancy.
2.
WHY ARE CLINICAL TRIALS NECESSARY?
way
experiments
necessary
prove
Therefore, however carefully the preclinical animal
humans.
as
do not always respond to a drug or vaccine in the
animals
Laboratory
same
and
laboratory
tests
are
designed
and
carried out, it is
at some time in the development of all new drugs and vaccines to
how
and effective they are in humans.
safe
clinical
trials
efficacy
studies
and
are.
and
carried
only
These tests are called .
when
all of the safety and
referred
above
have
been
when
the
information
obtained
has
been
the
appropriate
national
regulatory'
which
the 'clinical
trials
are' to be'*
completed
submitted
to,
and
approved
by,
authorities
in
the
country
in
and
out
tests
laboratory
satisfactorily
conducted.
A
'
to
Page 2
’ CHAT ARE CLINICAL TRIALS?
3.
Clinical trials are usually carried out in the following four phases.
- Phase I:
Phase I clinical-fcvlaL.is? the first time the new drug or vaccine is
A
in
tested
The main objective of a Phase I clinical trial is to
humans.
determine
the
therefore,
to
of
the
preparation.
that
the
volunteers
safety
ensure
Great
are
possible risk.
control
for
confirm
that
expected
manner.
are
who
to
is
taken,
the lowest
-.c--
purpose
The
care
exposed
of
woman
a
I ’clinical trial of a new method of birth
Phase
of ' the preparation, and to
to ■ cast "'the > safety
is
or
the-' drug
vaccine
is
"processed"
by
the body in the
Therefore,-these-studies.are dona in healthy volunteers
infertile 'because- they have previously elected to be surgically
sterilized.
their
Phase
I
Since
participation.
trials will receive no direct benefit
they
have
already
been
surgically
they are unlikely to be candidates for the new vaccine once it
sterilized,
becomes
these
in
Volunteers
from
for
available
the''general
public as a method of birth control.
Participation in a Phase I clinical trial serves only to benefit others.
Phage, n;
A
is
Phase
tested
method
of
healthy,
fertile
on
as
clinical trial is the first time the new drug or vaccine
efficacy
birth
information
pregnancy,
II
for
In the case of a new
(effectiveness) in humans.
control, therefore, a Phase II trial is carried out with
volunteers.
The
principal
how
the
new
well
effective
as
objective
preparation
is
is
to
obtain
in ’ preventing
to obtain additional Information on possible side
effects- associated with its- usev.
b .-
'
ajcinrt
Prototype anti-hCG vacci^
Phase II clinical trial information brochure and consent for-,
Page 3
If
the
during
take
in
preparation
of
or
benefit
course
the
part
role
drug
new
will
volunteers
of
as
works
the
Phase
intended,
protective
effect
II
trial
of the new method
It is possible that the volunteers who
the trial.
Phase II clinical trial might be future users of the new
a
it
when
available for general use.
becomes
eventually
The
trial volunteers is, therefore, different;'to
clinical
II
Phase
device
from
that of Phase I trial volunteers.
.
Phase III:
is
Phase
III
healthy,
of
the
and
does not produce any unacceptable side effects,
clinical
trials
are
started.
volunteers
and
are
fertile
a
of
effect
the
future
for
II
Phase III trials also involve
designed
to
generate
additional
number of individuals and over a longer period of time.
larger
The
in Phase III clinical trials will benefit from the protective
participants
that
Phase
the efficacy and safety of the preparation when it is used
on
information
by
trials indicate that the drug or
results
effective
the
If
device
the
new method during the course of the trial.
volunteers
users
of
general
use.
It is possible
who take part in a Phase III clinical trial might be
the new preparation when it eventually becomes available
The
role
of Phase III clinical trial volunteers is,
therefore, similar to that of Phase II trial volunteers.
mse-LY:
IV clinical trials are usually carried out when the new drug or
Phase
vaccine
has
been
licensed
for
general
use.
These
trials
involve
of side effects and efficacy of the preparation when it is used
monitoring
by'the general population.
4.
WHAT ARE VACCINES AND HOW DO THEY WORK?
Healthy
’foreign'
-
that
disease.
people
materials
have
an
- such as
immune
systemthat"’protects thenTagainst
.cteria, viruses and other micro-organisms"
enter or coma into contact with the body and can causa Illness and
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system
When
a
person’s
immune
produces
an
immune
response
the
destroy
protection-
material,
foreign
on.
However,
and
the
and,
of * a
sufficient:- level
the more serious diseases, even death.
.
; Vaccines
immunity
provide
to
-ora- ’
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""
'
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have: been- developedT-invardbr ■to overcome the health tiiks
delay.. -..-. As vaccinecontains
caused
by.
foreign
material
molecules
are
this
which
but
are
not
molecules which mimic the
These
capable of causing disease.
recognized by the immune system which responds by producing
response, which
Immune
of
Sometimes this delayec-aheleadotocHiness , and, in the case of
protection.
an
same time, provide lasting
the
at
is a delay between exp'osur'i^'to''the foreign material
there
production'
provides
foreign material, it
of antibodies and immune cells.
person comes into contact-with the Same material later
the
if
this
detects
consisting
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and immune cells circulate in the body and neutralize or
antibodies
These
?n
'
pre-existing
persists,
protection
sometimes for many years, and which
should
the vaccine recipient come into
contact with--foreign microAorganx_msorT.materials.~at a later date.
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WHAT IS ANTAHTIFE2TILITY VACCIHE?.-.,1r.i uir. -ind hurro-A.ng
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are like any other vaccines, except that they
Ancifertllfty
vaccines
are
designed
to
protect
than
disease.
Antifertility vaccines, therefore', are not directed against
the recipient against unwanted pregnancy rather
foreign
materials but against molecules produced by the body and which are
needed
for
directed
successful
Other
fertilization.
reproduction.
woman's
a
against
eggs,
antifertility
Some antifertility vaccines can be
or
a
man’s
vaccines
to
sperm,
prevent
can be directed against a
hormone, such as hCG, which is needed for pregnancy to occur.
6.
WHAT IS HCG?
for
HCG
stands
first
produced
It
attaches
pregnancy.
This
is
before
human chorionic gonadotrophin.
It is a hormone that
by the egg after it has been fertilized by a sperm and
to, and burrows Into,- the wall of the womb to begin a
process
of
attachment
and
burrowing
Is
known
as
Phase 11 cixnxcax crxax xnxormation orocnure ana consent
’•
Page 5\
implantation.
The main role of HCG is to stimulate the ovary to continue
its ’ production
of
for
Implantation
another hormone, progesterone.
to
be
Progesterone is needed
completed and without it pregnancy
successfully
will not occur.
7.
WHAT IS AN ANTI-HCG VACCINE AND HOW DOES IT WORK?
The
piece,
In
vaccine" to
antl-hCG
the
that
order
qiajxaxial,
it
is
be
used in this trial consists of a small
of hCG which has been manufactured in the laboratory.
peptide,
or
immune ' system
chemically
will
the
see
to
attached
another
peptide
as a foreign
molecule,
diphtheria
toxoid,
and a small amount is injected into the muscle of the buttock in a
thick,
creamy
chemical,
suspension.
called
Also
included
whose
adjuvant,
an
role
is another
in
the-
is
to further stimulate thia
Vaccine
immune response.
After
produces
injection
of
and
antibodies
the
vaccine,
immune
cells
the
recipient’s
immune
system
hgainst hCG that circulate in her
body and protect her, temporarily, from becoming pregnant.
It
is not known exactly how the vaccine works (this is the- subject of
a - number of ways in which the
ongoing
research).
However,
vaccine
might work.
For example, a few days after an egg is fertilized by
a
sperm
and
pre-existing
started
has
ax-cibcdies
there
to
and
divide,
are
it
begins
to . secrete hCG,
The
immune cells produced by an antl-hCG vaccine
could either:
(a)
the
thereby
prevent -its
and/or;
(b)
in
inhibit
•
neutralize
thereby
cells
.
the fertilized egg which produce hCG and
production
and
release
into
the blood, .
.
the hCG after ft has been released into the. blood and ,
prevent
it - reaching '■' the
progesterone production-.
ovary
and
maintaining /
‘
.phase Il elinlcal- crlal; ifi^ormatipn .hrochure and consent fora
the-■ mhchahism, ■"the-':rrtfS\il/4i"'fir ” that
' " Whatever "
the
ovary
the
is
not
Without progesterone, implantation of
co produce progesterone.
stimulated
egg ' cannot' ' be ’.rumple red- and . a normal menstrual period
fertilized
occurs
8.
FOR HOW LONG WOULD THE ANTI-MCG VACCINE REMAIN EFFECTIVE?
Thisl-anti-hCG-va'ccitie-'has taeeriTdbSighed -ride•to pro'duce a long-lasting
or
permanent
trial’
with
antifertility
anti-hCC’.
this
Information from a Phase I clinical
effect.
ode liters shows:- thatvdt. '.iyiikely to provide
against pregnancy fbr-'' at least-three''months'-and-perhaps as'much
protection
six months or more.
This means that at the end of this time the immune
response
produced
theparaccine-will drop and th"e-woman.should again be
able
become - pregnant-.-
as
to
control,
by
.-If
she chooses' toi continue-practising birth
she ■ could--.either:receive.-another Injection of the vaccine which
should' provide
a■..■secondmperiod iof.protection expected to be of similar
duration tp .efte first or select-an .alternative method; of her choice. .
tp, produce, a,, range o.f, ant;l-hCG
Further. - research, is,being .parried
different
durations
select
vaccine
with
vaccines
Individuals
to
a
of
to
efficacy.
suit
would
This
allow
their own needs from a range
offering protection for a few months or for one oiy more years.
9.
WHY IS AN ANTI-HOG VACCINE AN "ATTRACTIVE METHOD OF FAMILY PLANNING?
An
antifertility vaccine is considered to have a number of advantages
over some of the currently available methods of birth controls .
(a)
It
does
not
involve the use of hormonal steroids such as those
contained in blr^h^ontroL pj.als or Injectable contraceptives..
Although
these-' ^teroid
amounts
segment
of
the
significant
health
certain
based
preparations
are
given in very
and find a high level of acceptability in a large
small
high-risk
contraceptlng
problems
groups,.;
population,
they
do
pose
... small proportion of women in
In a slightly larger proportion of
Jhase II clinical crxar inrocaacxon orocnuw *uu
women,
annoying buc noc dangerous side effects
causa
may
they
Page. 7\
such
as irregular menstrual periods or lick of menstruation.
such
menstrual disturbances were seen in the preclinical studies
in
and
baboons
in
the
No
Phase I clinical trial of the anti-hCC
vaccine.
Tha
does not involve the insertion of a foreign object,
vaccina
such as an intrauterine device (IUD), into a woman's uterus.
While
the
IUD
is
women,
in
soma
it increases tha likelihood of pelvic infection
or
heavy
a very good method of birth control for many
menstrual
ho such risk is associated with
bleeding,
the vaccine.
The
vaccine
appears
to
be
effective
more
some
than
other
methods.
In
preclinical studies in baboons, the antifertility efficacy of
the
vaccine
effective
was
to
found
This is more
in excess of 95X.
ba
most barrier methods, rhythm, or withdrawal.
than
It
is
not
yet known what the efficacy of the anti-hCG vaccine will
be
in
fertile
women
•
is
obtain
this
trial
to
information
obtained
at
as
be
least
so
one of the objectives of this Phase II
information.
However,
from
the
far it is likely that the vaccine will
effective
the contraceptive pill in those
as
women who generate ar adequate immune response to the vaccine.
The vaccine would be easy to use.
is
the duration of protection offered by the
possible
that
vaccina
can
adjusted
woman.
During the period of protection provided by the vaccine,
It
the
woman
be
would
not
the
to
have
to
child-bearing
of the
take a pill every day, or use a
barrier
method or withdrawal with’ every
Frequent
visits
although
this
particular
plans
act of intercourse.
to a family planning clinic would not be needed
would
depend
vaccine , selected
detected in cli.*lc*l trials.
on
the
duration of effect of the
and'the nature of~the side effects
''
.....
"-:3
Phase II clinical trial Infortnation brochure and consent form
Page 8
10. ’ WHAT IS THE CURRENT STAGE OF DEVELOPMENT OF THE ANTI-HOG VACCINE?
The
•
hCG vaccine to be-'tested- in this Phase II clinical trial has been
the
for
development
under
15 years.
past
During this time it has been
(ability - to "prevent pregnancy)-in baboons and for
studied
for
efficacy
safety
(lack
of side effects) in several different types of animal and in
women volunteers in a Phase I clinical trial.
--
-•-•.-AT..
-meh,
--
:
.. Animal studiesmentioned
As
at the beginnings of ,;this brochure [see Question 1], the
the animal studies, is two-fold, to-determine the safety of the
of
purpose
vaccine, and-to determine thfr-an&irfertl-lity efficacy-of the vaccine. .
The
injecting
animal
safety -studies- that
mice,
rats,
have
been
carried
out
include
rabbits, and baboons with the complete vaccine and
No sign of any adverse side effects where seen
its
Individual components.
in
these studies even when tho vaccine was given in amounts that were many
the amount to be;given to.women and on a. mbra'.fre'quent' basfs than, is
times
being proposed for■ the. clinlcal.-jtirialseuir. • •;» lu-:
and humans.
apes
in
gonadotrophin
as
CG is a hormone produced only by monkeys,
The animal efficacy studies were carried out, therefore,
which,
baboons
mice, rats and rabbits, do not produce
such
(CG).
Laboratory'* animals;
chorionic,
m
the
like
human, require CG for the fertilized egg to
implant
in the womb and for pregnancy to become established.
earlier
in
with
the
with
a
this
[see Question 9 (c)], female baboons immunized
vaccine
had a pregnancy rate of less than 51 compared
rate
70Z
anti-hCG
pregnancy
immunized
baboons
adequate
to
continued
normally,
of
became
provide
protection.
no
in nonimmunized baboons.
pregnant
when
their
immune
Occassionally,
response was not
Every time this happened, the pregnancy
miscarriages-
occurred, -and
normalJibabies were
Similar results were obtained in other studies in which a different
born..
tyPe —
anti-hCG - vaccine
monkeys.
this
As indicated
brochure
was used to immunize rhesus monkeys and'bonnet
However,-- when marmosets, a smaller monkey, were immunized with
second type of anti-hCG vaccine, tney exhibited a higher-than-average
rate of miscarriages as their immune response to hCG began to decline.
Phase II clinical trial information brochure and consent' fotv
Page 9 <
22-f\
Phase T clinUaV.,g.r.m
Phase
I clinical trial of the antl-hCG anti-fertility vaccine was
out
1986 and 1987 with women who had previously decided to be
The
carried
In
sterilized
before
volunteering
took
part
in
women
to take part in the trial.
A total of 42 - .
and were assigned to five different dose
trial
the
groups.
six
Each
woman
received
weeks
and
provided
anti-hCG
antibody
tests.
In
examinations
twc injections of the vaccine at an interval of
frequent
each
addition,
was
and
and urine samples for measuring
blood
and for conducting a large number of laboratory
levels
volunteer
received
thorough
physical
carefully monitored for side effects throughout the
>-
s tudy.
and
a
women
the
of
few
A
site,
few
had
However
injections.
developed
temporary soreness at the injection
muscle
aches
lasting
of
the
women
none
up
to
48 hours after the
considered these side effects
enough to withdraw from the study and no other significant adverse
serious
effects were seen.
Women
at .levels
These
to
from all of the vaccine dose groups developed antibodies to hCG
that
were
estimated
to provide protection against pregnancy.
levels lasted for at least three months in the low dose group and up
six
months
previously
been
antibody
levels
in the higher dose groups.
sterilized,
actually
it
were
was
not
capable
However, since these women had
possible to determine if these
of
providing protection against'
pregnancy in these individuals.
11.
WHAT ARE THE GOALS OF THIS PHASE II CLINICAL TRIALT
The "principal
antibodies
further
produced
information
objective of this Phase" II trial is to see whether the
by
the vaccine- will prevent-pregnancy.: .In addition.
will, be collected about side effects-.associated.with
' the use of the vaccine.
- 7.
-
,
'
Prototype anci-hCG vaccine
Phase"II clinical trial information brochure and consent form
Page 10
WHO IS ELIGIBLE TO PARTICIPATE IN THIS CLINICAL TRIAL?
12.
women between-Che ages of'18 and 39 who have had at least one
Healthy
pregnancy
All participants-'should have regular menstrua^
eligible.
are
sexual relationship with a man who is
periods,
be
engaged
in
a
capable
of
fathering
a
child, and be using an IUD or barrier methods of
as their sole method of family planning. ■ They: should not be
contraception
nor
breast-feeding,
severe
Women.jwho
in
the
nor
have a history of
to participate will be thoroughly
study-. - . A total-bf~_up. to .250 participants will be
needed for the Phase II trial,
/<% ~.f. •••
-
. ■>
-
WHAT''WILL PARTICIPATION IN THIS CLINICAL TRIAL'INVOLVE?
13.
.
;T.-i. -.or •. ,■«•.<>«
:• ... ■
... ....
Women
be
medications,
choose,
and other conditions which might make them Ineligible
these
for
inclusion
for
certain
taking
allergies.
screened
steady
up-
v . n-
■
choose to partlcipatp..ln:-.thislPhasei,ir ’clinicalitrlal'will
who
interviewed^ and glvan.ia phy'slcaleaxaail'haeion-Including-a. gynecological
examination.
A
carried,
These
out.
Pap
will
smear
be
taken and laboratory tests will be
tests require the provision b'y the-participant of a
urine specimen and the drawing of a blood sample from a vein in the arm.
a women meets all screening criteria, she will be given a diary in
If
which
to record her menstrual cycles, the dates of sexual intercourse, and
changes in her general health.
any
She will come to the clinic once every
month for three months for interviews and the drawing of blood samples.
.She
of
will
then be given three injections of the.vaccine, at intervals
four and six weeks.
Each injection will be given into the buttocks and
will be preceded by a brief physical examination and.a skin (prick) test.
Following
visit
At
each
injection,
all
participants
in
this
trial will need to
clinic, twice each month for a period of approximately 6 months.
the
of
ample taken.
these
visits,,
participants
will be interviewed and a blood
A urine sample will need to be provided on some occasions.
'
prototype antl-hCG vaccv
Phase II clinical trial infarmation brochure and consent fot^
Page 1K
When
a
participant’s
estimated
to
provide protection against pregnancy, she will be advised to
antl-hCC
antibody levels rise above the level
have
her IUD removed (or to stop using condoms).
fall
below
comes
earlier,
the
estimated
all
women
When her antibody levels
efficacy level, or after six months, whichever
will
be
given
the
option • of
recommencing
contraception.
the first year, participants will be monitored at three-monthly
After
intervals
for another year.
This monitoring will involve an interview and
the provision of blood and urine Samples.
participants
All
time
have
the
to withdraw from the study at any
right
for.any reason without in any way affecting their future medical
and
care.
14.
WHAT ARE THE POTENTIAL RISKS AND PROBLEMS THAT MIGHT BE ENCOUNTERED?
There are three types of risks and problems that' must be considered:
Side e£fe.ct:s
soreness
at
experienced
by
some
of
the
trial;
is
likely
that
Temporary
it
(
’
the
injection
women
the
same
site
and
muscle
aches were
part in the Phase I clinical
taking
events
may occur in this Phase II
clinical
trial.
Although no other significant side effects have been seen
in
the
animal
and human studl. ■. carried out with this vaccine so far, ir
is
possible
that a new side effect could become apparent as the number qf
women .receiving
whether
If
such
.the
vaccine
increases..
It is ndt possible to predict.
an event will occur or what type of side effect ft might be.
a number of women develop serious side effects, the physician, in charge.
of the trial may decide to stop it.
Any
woman
who takes part in the trial and who develops a side ef'
will be offered the appropriate treatment xor it.
-------- _______________________________________________ '----- Jr^
.accine
Phase II clinical trial information brochure and consent form
Page 12
/
/
Due 1 to
by
vaccine
recipients
or
the
variations
in
-•
• '
the
immune responses
•
anti-hCG antibodies may persist longer in some
vaccine,
in Others and, in" some cases,the antibodies may
than
Although this has hot-been seen'in the animals 'studies
indefinitely.
in
individual
expected
produced
last
1
. ...r-■
Irreversibility
/
Phase I clinical trial human .studies^ ft-remains a theoretical
the
possibility.
'
-
Failure
It
an
possible
is
against
what
known
occur;.- two
continue
vaccine
may
fail
to protect some women
Although
no
adverse
effects
on fecal
of
antibodies' ■ to .-hCG were seen in animal-studies, it is not
the
effects,
-if
any , : will-be in the human.
options. .'Will
be
available-to the.volunteer. . One will be to
with
pregnancy
the
immune'"-- response.
adequate
development
that
oven though*they had"produced' what was considered to be
pregnancy
the
pregnancy;
the
other
option
a very early stage.
at
terminated
will
If-pregnancies
be
to
have the
Whichever option is chosen,
the women involved will be offered the appropriate care.
If
)
two „or
more
level
calculated
a
above
stopped
and
all
participants
to
participants
be
will
become
pregnant with antibody values
effective,
the Phase II trial will be
'ba advised to recommence using their
previous or an acceptable alternative method of birth control.
WHAT ARK THE BENEFITS OF PARTICIPATION?
15.
Participants
their
inclusion
conditions
not
previously
treatment
date.
were
will
in
the
found
been
receive a very thorough medical screening prior to
Phase
II
trial.
In the Phase I trial, medical
in several prospective trial participants that had
diagnosed.
This allowed them to obtain preventative
for conditions that might have caused serious Illness at a later
Phase II clinical trial information brochure and consent ft.
Page 1\
. &
By
taking
in
part
this
trial, participants may benefit personally
from
the antifertility effects of the vaccine during the efficacy stage of
the
study and will be performing an important role in the development of a
new method of birth control that may benefit women throughout'the world.
WILL PARTICIPANTS BE COMPENSATED?
16.
will be reimbursed for travel expenses, child care, time
Participants
from
lost
and
emr’oyment,
other
trial-related
expenses.
However, no
payments will be -ade.*s an inducement to take part in the trial.
WHO HAS ACCESS TO THE CLINICAL TRIAL RECORDS?
17.
All
trial
are
records
personnel.
kept
When
presented
in
individual
participants.'
be
will
a
strictly
.Ion that will not perm’r. identification of
summarized
retained
for
confidential with access limited to
results of the study are' published, data will be
Information
many
generated
in this Phase II trial
years, so that contact can ba re-established
with volunteers* at a later date.
18.
WHO
SHOULD
BE
CONTACTED
IF
QUESTIONS OR PROBLEMS ARISE DURING THE
TRIAL?
Should
during
you
require
further
details about the trial, either before,
or after the study, you may contact
......................
(tel. no. and
Phase II -clinical trial information brochure and consent form
Page 14
f
y
STATEMENT OF INFORMED CONSENT TO PARTICIPATE IN THE TRIAL
are inviced co parcicipace in a study entitled "Phase II clinical
You
trial
a
of
see' if
pregnancy
side
preparation'
(anti-hCG vaccine)57 iseffective in preventing
in fertile women.
The study will also collect information about
of
effects
in women who volunteer to participate. ' An
vaccine
the
promises
vaccine
anti’-hCG
have' ■ fever - Side "effects,
to
to
be
more
to use", and" to ’h'ef>'a more effective" method of birth'control chan
-convenient
■ iifiiny other current methods’.
j
The purpose of the" study is to
anti’-hCG vaccine".
prototype
new
a
-.?/■
r.
■’ r
.v ir The.
of
procedures
the
study 'are
as
follows.. - All
women
who
interviewed._s:'. ..They..w-ill have a physical examination,
i vodjunteer -..will . be
whicdr ’ includes a pelvic, examination, drawing of. a blood sample from a vein
in the arm, giving a urine sample, and other rotitine medical tests.
■ ..
p
If
-•?.
in
-the . study?.? will—take place over a two-year period.
you, arer eligible
to.;,-partlclpat-pn?;oyou wl-Ll^, be-^giyen a diary tot fill
Participation
•
In this diary ypu-yilkbep asked to gecorflyour menstrual cycles ,, the
-out.
.dates
.you jhaye..-,sexual
will
then
interviewed
clinic
to
and
again
intercourse, and any changes in your health.
the
to
come
have
each
once
You
month for three months to be
blood samples taken and will be asked to
provide urine samples.
brief-physical examination, the vaccine will be injected
---------- Following-~a
into
your • buttocks-.-'™The”’injectib"p’s""(nb'mdre" than three)''’will be 'given at
five weeks and seven weeks.
intervals
of
you
come
will
during
to
During the following 18 months,
the clinic for follow-up visits twice each month
maximum
six months of the efficacy stage and at three-monthly
thereafter.
At these visits you will be Interviewed and a blood
the
Intervals
back
and sometimes a urine sample will be taken.
When
preventing
medical
tests'
pregnancy, ..you
suggest
that
will
advised
be
the
vaccine
is
effective
in
to’ stop using your current
’.’.o^ birth control. f You will be informed when, the tests, suggest that
the
vaccine
is
no
longer
method of contraception.
effective so that you can start using another
i
..
-■
prototype antl-hCG vacci\
'Phase II clinical trial information brochure and consent fora..
Page 15 \
'
and
RT-.y.,
side
effects
of
the
place
soreness
may
occur
soreness,
will
disappear
in
in
where
side -effects
side
new
temporary.
follows.
Some
The
Some women who participated
There are no ocher
anti-hCG vaccine, but there is a possibility
the
effects may appear.
There is a small risk of soreness and
drawn,
but those side effects are minor and
whenever
bruising
of
as
vaccine is Injected.
the
after a short time.
are
earlier study of the vaccine felt muscle aches.
an
known
that
2-2r
'
participation
blood
is
You will be offe-
1 appropriate medical treatment for any side
effects that occur in the course of the study.
may
There
vaccine ' has
the
some differences among women in the length of time the
be
will remain effective.
vaccine
Although there are no known cases in which
indefinitely, there is a very small
effective
remained
possibility that this may happen to you.
is
There
possibility
a
that
the
vaccine may fail to protect some
study
participants
against
pregnancy.
If that happens to you, you may
freely
choose
to
continue
with
the
pregnancy or to have the pregnancy
at
a
very early stage.
terminated
Whatever choice you make, you will be
.offered appropriate care in accordance with local medical practice.
The
receive
the
is
more
of
benefits
benefit
may
this
research are as follows.
Your general health
from the thorough medical examination and monitoring you will
before
and during theFrstudy.
effective
and
The benefit to others in the future
of an alternative method of birth control that may be
development
have fewer side effects than some currently available
methods.
‘
not
of
The
participation
to
alternatives
are
as follows.
You may choose
to participate in the research and continue to use your current method
birth
control
or
use
another
appropriate
method available at your
family planning clinic.
Your
free
to
participation
withdraw
future medical care.
in
this
study is entirely voluntary and you are
at any time and for any reason without prejudicing your
rcocuc>pu ancx-nuo vaccine
Phase 11 clinical trial information brochure and consent fora '
Page 16
All
records
will be kept strictly confidential and no participant in
the study will be identified by name in any published reports.
Participants
lost
from
will be reimbursed for travel expenses, child care, .time
employment,
and
other
trial-related
expenses.
However, no
payments will ba made as an inducement to take part in the trial.
'•-Phase II clinical trial information brochure and consent foru
Page 17%.
z?g
IMPORTAn, i«OTE TO Tire PARTICIPANT
DO
SIGN
NOT
WITH
AND
STUDY,
STATEMENT
THE
BELOW UNTIL YOU HAVE MET FOR THE SECOND TIME
INTERVIEWER, YOU HAVE DISCUSSED ANY QUESTIONS YOU HAVE ABOUT THE
THE
SATISFACTORY
RECEIVED
HAVE
YOU
ANSWERS
TO
ALL
OF / YOUR
QUESTIONS.
I,
have
been
given
adequate
time to read this brochure and feel I understand its contents.
have
had
the
opportunity
ask
to
have
satisfied
with
the
answers
understand
that
my
participation
voluntary
and
reason
and
that
I
I
questions
in
about
the
received to all of my questions.
this
I
research study is completely
have the right to withdraw at any time and for any
that my withdrawal will not affect my rights to future medical
care. .
I hereby consent to participate in this trial.
Signature of participant
Date
Signature of investigator
. Date
Signature of witness
Data
Name of witness
Relationship to study
This
I
study and I am
study
conforms
to the requirements stated in The World Medical
W.H.O. has established the 'Special Programme of Research
Development & Research Training in Human Reproduction ' in
1972 ob^nrtiTo promote international research and develop
ment effort required by developing countries for the successful
implementation of their health strategies in the area of "fertility
i&gilation"•
Three Aspects of Research.
First New & Improved Methods of Fertility Regulation.
Thy? There is an unmistakeable need for new^iethods.
1.
2.
Present methods unacceptable
New methods that are relatively mare safe - taking into
'consideration the health pro file/^developing country
Populations and the ability of health services to help
'those who may have problems.
J.
Methods'that can have a more extended availability. Another »
fact.or is that whenever a ndw method is untouched a new
1
layer of acceptors is added. Given the diversity and
complexity of the socio cultural background in developing
countries^ there is a need and potential demand for ndw
method in developing countries.
Six task forces.
1.
2.
Long Acting Systemic Agents of fertility Regulation.
Post Ovulatory Methods of fertility regulation
3.
1.
Vaccines for fertility regulation
Methods for regulation of male fertility.
5.
6.
Methods for the National regulation of fertility.
Plants for fertility/Regulation.
Methods under development :
Once - a - month Injectabl.es, Anti Fertility Vaccines Vaginal
Rings
Prostaglandins
Anti Progestins
Synthesized new long Acting progestins^ Biodegradable Implement
(Capronor) Progesterone releasing vaginal rings..
The SecRid Major Aspect :
On improving the performance of currently available methods for
fertility regulation :.hich requires a) epidoanological research
on safety andjsfficac.y of the method in the set up of develooipg
countries and b) to understand the behaviour^®*/’social determinated
of fertility Regulation.
1
‘ F
2
"W.H.O. is in a unique position to fulfil this task of
ner?ting t nd providing information on the safety and
efficacy of metho ds A.-a—fehohe al th^a^d, its impartiality
its capability to undertake global ami inter regional studies
plus its traditional strengths in the/area of epidemiological
•7 studies ”.
jrso two *fask forcesof WHO .Special programme are involved and
many research projects have been^conducted on OC's^IUDS,
injectable contraceptives etc..* Some of the Indian Projects
1.
«
Comparative study of the biochemical effects of combined
estrogen/progestogen OCs containing less than 5.0
estrc
Vitamin supplements to women using OCs.
3.
Interactions between OCs and Malaria.
Case control study on the relative risk of ectopic
pregnancti and peiure inflama.tory disease associated with
IUD use.
p«Jvi'CfPhase III comparative evaluation of the contraceptive
effectiveness of NET-EN given every two or three months.
6.
Peturn of fertility following discontinuation of ICs.
7.
Psychosomatic seq-ua&le of femal sterilization.
8.
Studies on sterilisation and abortion.
PSYCHOSOCIAL RESEARCH
INDIAN PROJECTS
Dsycho social factors affecting continuation discontinuation
of IUDS & Pills. Acceptability^)f Male fertility regulating
methods in India (field study L (patterns and perceptions of
menstrual bleeding .
cceptability of methods in a freechoice situation.
HEALTH SYSTEMS RESEARCH
INDIAN PROJECTS
Participation of rural practitioners in the delivery of services.
Introduction of NET-EN in the national family planning programme.
Use of services for the termination of pregnancies
Role of health delivery services on acceptance of family planning.
OBJECTIVE
x-The health system research aims at improving the effective
utilisation of presently available methods of fertility regulation.
This involves studying the use of non physician personnel in ±he
delivery of F.p. services. Studies have been conducted on
f< mily formatin patterns andhealth, & large scale introductory
field trials cTf injectable contraceptives involv fro mo re than
25,000 subjects.
7
III
ASPECT
Promotion of national self reliance for research in Family Pl anning
Developing country scientists play a major role in “fask force* acti
vities,/five Indian scientists presently as members of steering
committers for Research & Development. Indian scientists have
carried out 11J task force projects in the past 14 years - 5$%
of steering committee members came from developing coyntri&s. /
|A global network coordinated clinical trials using common protocols
•1 carefully gtst^nderftiized diagnositic techniques and laboratory
methods, ^he
collaborating centres for Research is ’
presently 25 - lyor which are in developing countries. Three
centres are in India. The Institute of Research in Reproduction
in Bombay, "’he Deptt. of Obstetrics -.nd Gynaecology of the
post graduate Institute of Medical Education & Res_earch in
Chandigarh and the All ‘ndia Institute of Medical Sciences,
New Delhi.
Apart from OCRS more than 120 non designated centres have parti•cipated in the programme's multi centred clinical trials. The
programme h< s so far conducted more than 18omulti-centred
clinical trials involving approximately 1,85/000 subjects in
.150 centres in 55 countries.
Finally collaboration of the programme with the ICMR has beer
outstanding.
Depot - Medroxyprogesterone acetate (DMPA) and Cancer.
Memorandum from a WHO Meeting
(Meeting convened in 1985 to review both published and unpublished
e fi entiological date from human studies onl„ and data available
since 1. 1 nesting were thus examined in
epth).
One subject under review by che WHO’s special Programme of
Research, Development & Research Training in nuuian Reproduction
is whether
of neoplas:
the effect
"risk o i: Neo ilasia".
This conclusion
tn<
he finding of
fcu./MOMrS.
iya»ee®s in animal.toociology studies of progestogen nape
^-<4 <’-c/
AS-n-dl -$-C>r
<X
WHO’s S )ecial rogr;
barked upon the pla .ning of a
.{J,
multinational collabarative case^contr ,1 study to examine the
relationship between steriod sontraceptives and the risk of
select d NeoplasiAnfeA
^n 1981 the programme reviewed all data available on injectable
c onraceptives.
At this meeting it was conclud
th; t kith ..
DMPA users have,
thus far demonstrated no increase in the risk of developing
li any type of cancer,, because of the lac;
trials ;
the long latency period
of well controlled
" sor
c; ncers, it is
important to continue to monitor the possible development of
neoplas is among ;omen who have used DMPA".
:he preli 1 .nary results of the WHO initiated collabarative
study concerning breast and cervical cancers have bee 1 published.
2.
But results of other epidetteological studies on DMPA and cancers
of the breast and cervix initiated in New'Zealand, Costa Rida
and Jamaica are not yet available.
The
0 collaborative study on Neoplasia & Steriod contraceptives
was carried out in IL collaborating centres in 11 countries.
The risk of cancer in L/MPA users was examined using data collected
in three centres in Thailand, one centre in Kenya and one centre
in Texico which were the centres where DMPA use was appreciable.
TP POTT1 RIAL CA’ICT1
experimental data in rhesks monkeys have raised the possibility
that DMPA may inc -ease the risk of endometrial cancer.
Although
neither of the two record linkage-epidemiological studies suggest
an adverse effect of DMPA with respect to endometrial cancer
no meaningful conclusion on this issue can be drown from the
studies
primarily because of the small numbers involved.
On the other hand several studies have demonstrated a negative
association between use of combined oral contraceptives and
endometrial cancer and this protective effect is thought to be
due
progestogen component of oral contraceptives.
RBS'T.TS FROM WTO STUDY .
data on ph cases of endometrial cancer.
A total of 316 controls were matched to individual cases on e
exact year of birth year
of entry into the stud; and centre.
Only one
30 of 316 control had ever used
cases
3
-3
an estimated relative risk in v/onou who hud ever
ised DMPA to o.J.
However this study has accumulated insufficient
assess the risa of endometrial cancer in ^ong term users
or the risk long after initia
exj >sure.
A. total of 10J cases of ovarian canc >r,
From among the 6206
vid
>
.
•
h
l
ise
v>M?A.
’he r ilativ j risk 1 i
:: ised DMPA /as estimated to
•
0.7 ,J.
LIW? CAN CO??
57 cases of primary liver cancer. - Two hundred and ninety controls
were matched.
Seven of the 57 cases and 34 of the 290 controls
had used D?-'OA giving a relative risk in women who had ever used
DMPA as 1.0
Experimental dat;
on beagle .bitches have raised
the possibility that injectable progestogens such as DMPA as
may increase the risk of breast cancer.
Altnough the relevance
of these findings to women in controversial they underline the
need to eva uate breast cancer risit in epidemiological studies.
In one study among 19,o75 women who received DMPA no breast
abnormalities of any type were diagnised.
STUDY
Data available for 42 f cases and 951 controls of whom J9 cases
and 557 controls had ever used DMPA.
The relative risk in women
had ever used DMPA was estim ted to be 1.0
For cervical cancer the adjusted, relative risk in women who had
ever used DMPA is 1.2
To date in the VJHO study only a small number of women who have
used D'-’PA for prologed periods or have had a long interval
since first use. Infor lation on cancer ris : in these women can
only be gained by continuing t .e present study or by initiating
additional^ studies facused on these specific topics.
Since
any effect of DPPA on cancer incidence might not appear until
after a delay of many years further studies .'.ill need to be
Carried out
t„c future.
/s
A
One crucial bias, cases and controls referred from fertility
or family planning clinics were excluded unless uhe visit
leading to hospital referral was the woman's first visit to
the fertility or family pl- ining clinic.
This decision was made
to prevent over representation in the study ef cases that had
used steriod contraceptives,
(why ?)
A CRI'.1I'~>UE O’: "!.T'.O
- AND CONTRACEPTION RESEARCH
I
rge sums are being
raped into research in human reproduction.
"”/ith particulars reference to the needs of developing countri - ".
"hat is tl e net result *.
"11 :in Is >f
der drugs / 1
'
inf
different -.--ye - be it
trSc tives, impl ts, v rinal rings, pellets etc.
L
. le is the
bombalfiHment of hormonal contra
ceptives on worn n, mostly poor, po erless and ill/ter^ e.
has generated a movement aimed at resisting it. No doubt the
'.n,0. which has given these trials the status of "scientific
studies" is embarrassed by some of the criticisms. And an impact
assessment programme was instituted in June 1989 to suggest ways
and means of making the research programme more acceptable to
women .... viDually to be .
One crucial assumption of the W.H.O. team is that their ethical
guidelines with regard to informed consent of those who parti
cipate in the clinical testing are followed correctly. But
there is a lot of ^scepticism about this. In some of the larger
multi centred trials, even a cursory visit to the programme
centre would clearly indicate that the circumstances in which
these products are tested there is neither the time nor the
inclination to give unbaiased information to women, According
to Vimal Balasubramanyam in some hospitals women seeking abortion
were being made to accept the injectable as a pre condition..
Moreover voluntary bodies like the compaign against long-Actig
Hormonal contraceptives have also criticised the new guidelines
on another score while the guidelines now seek a reduction in
intensity and kinds of animal studies which constitutes the
first stage of drug testing for safety & efficacy they have
stressed "large scale surveillance studies on women once the
drug has been Registered and is in widespread use . This is
completely impractical in developing countries", "/omen's
/->
andjhenlth groups have documented-in detail the«<4B^be=be disregarding of medical ethics in various centres which were part
of the
sponsored multicentre clinical trials of NET-EN
an injectable contraceptive. .Perhaps because of all these
criticims the clinical trials which, arr^at Jpr,psen{t conducted
are done on a much smaller scale.^^AccbrdiHg to'Dr. subodh Das
of Safdarjung Hospital, who is at present one of the investi
gators in the phase II clinical trial of a Birth Control vaccine
admitted that the trials are being conducted on a smaller scale
to enable a better surveillance.
,
——————
CcAJi-a.
/A d\
.At-
The Pole of W.H.O. i tilth the withdrawal of private industry
from major investment•in this fieldjihe task of developing new
approaches to fertility regulation'll^being increasingly en
trusted to international research programmes and organisations
and
has led the coordination of these research efforts".
The IfOrty ^rst World Health Assembly (May 1988) approved the
Go ?-sponsorship of the Special pro-gramme of Research Develop
ment ?nd Research Training in Human Reproduction by UNDP, UNfPA
and the WORLD BANK. During 1988-89-80 countries including 54
Developing Countries participated in the programme's activities}
500 research projects in progress at 240 centres including 140
institutions in developing countries.
AREAS OF RESEARCH
Contraceptive Safety
:
I979-WHO collaborative study of Neoplasia & Steroid Contraceptive
initiated in 13 centres in developed and developing countries.
Results of the study
1.
Protective effect of oral contr ceptives a sinst both endo
metrial
ovarian C< ac
Develonina Countries
Oral contraceptive did not appear to increase the risk of liver
incr, se in the risk of breast cancer.
The possible link between the use of long acting injectable progestoge
(DMPA) and cancer of the reproductive organs are currently being >n ly
In collaboration with Family Health International & the Population
Council, '7.H.0 conducting post-marketing surveillance in 8 countires o
a recently introduced long acting subdermal implant. About 8,000
users and the same number of controls will be abserved for fi\ e
years.
W.H.O. started studieson thepossible relations between contraceptive^
and human iitnum^odeficiency Virus (HIV) infection.
'
SOCIAL SCIENCE RESEARCH
projects - designed to provide information on the ways in which
individuals or couples reach decision on family size, child spacing
breast feeding, contraceptive use, sexual behaviour - role of
men in reproductive decision making.
2
-3 CONTRACEPTIVE CHOICE
Research in preparation for, the introduction of two new
injectables and a vaginalhas now been completed.
other new subjects of research are : -
2
to J monthly injectable progestogejjpwith 12 to 15 times
less Steroid than those currently available^.
An improved
anti-progesti^v-- Prostaglandin combination for post-ovulatory
use.a frameless copper releasing I.fc/tD.
Anti-fertility
.va-xa-ae- - a long acting hormonal contraceptive for men.
ANTI FERTILITY VACCINE
The programme has always recognised that a Safe, effective and
reversible birthA-would be a greatly needed addition to the
currently available fertility regulating methods and an
P2tjc><attractive proposition to family planning ■■pge.gr.ess-, a view
that is oh wed by the Indian"7government which puts birth
control Vaccines as a too priority area for National Research.
The programme has now developed.- An almost totally Synthetic
birth control 'l.coynCj
(Synthetic, peptide corresponding to
the C-terminal 109 - 145 amino acid region of the B-sub&uLU-of
HCG conjugated to Diphtheria
toxoid as the carrier and
administered with Muraftey/dipeptide adjuvant in a squalene arlacel vehicle'.
'.fter a full decade of indepth study on its
efficacy and safety in monkeys, this new vaccine has been brought
to the stage of clinical testing, after permission from both
the Australian Dr^u Regulatory Authorities and the Food &
Drug Administration of the United States.
Phase I Clinical trials have started with this vaccine in one
centre in Australia on 3° women.
The programme has supported
the early animal experimentation with vaccine development in
the All.Indig Institute of Medical Sciences. It is most
gratifying to see the progress that Indian Scientists have made
in this field Dr. G. Talwar, is also since 1985 a member of the
programme is’fask Force on Vaccines for Fertility Regulation ".
>1 RREP
May 24 93
TEL:
8=55 No.002 P.02
WH-4-
MhY 2 4 igg?
1
May 22, 1993 - Draft
SEXUAL AND REPRODUCTIVE RIGHTS IN FEMINIST PERSPECTIVE
Chapter Outline for
Population Re-Considered: Health. Empowerment, and Rights.
ed. Lincoln Chen, Adrienne Germaine, and Gita Sen
Sonia Correa and Rosalind Petchesky
Abstract: While the term "reproductive rights" is of recent (and
probably North American) derivation, the ideas about entitlement
it represents and its philosophical underpinnings have a much
older and broader history. This chapter will provide a very
brief summary of that history to ground the contemporary develop
ment of the concept of reproductive rights, but will concentrate
on the current international context. That context is one in
which women's groups are actively seeking recognition of women's
rights as fundamental yet specific components of human rights,
and in which an increasing concern with economic and social
rights challenges the "individualist" connotations of rights
discourse generally. The chapter aims to achieve three main
tasks:
(1) to situate an understanding of "reproductive rights"
within a socially grounded reconception of both reproduction and
rights; (2) to develop a feminist ethical framework for defending
women's agency and (moral/legal) authority as reproductive
decision-makers (bearers of rights)—that is, a gender analysis
of reproductive rights; and (3) to suggest some consequences of
this analytical framework for programs and policies dealing with
population and health.
(Cross-references: Chapters on The Rise
of the Women's Health Movement, Empowerment, A Gender Perspective
on Population Policy, Rethinking the Concept of Reproductive
Health, and Population and Human Rights.)
I.
Introduction
A.
Definitions of Reproductive Rights Growing Out of
National and International Women's Movements in
1970s and 1980s
(cross-reference: Chapter on The Rise of the
Women's Health Movement)
B.
Historical Precedents (brief overview)
1.
Early modern European ideas about "self-owner
ship" and women's rights2
*
2.
19th and early 20th century feminist birth control
movements
May 24 93
TEL:
RREP
8=56 No .002 P.03
2
II.
Framewoxk of Analysis
i
A.
Rethinking the Problem of "Rights"
1.
R. R. as part of indigenous human rights move
ments and worldwide struggles for social justice,
democratization and citizenship
2.
Ethical principles and their meanings as histori
cally constructed and evolving; "rights,"
"entitlements," and "choices"
3.
Traditional notions of reciprocal rights and duties
within authoritarian or hierarchical social forma
tions (Dumont); problem of conflating rights and
duties in social democracies
4.
Western origins and the Lockean paradigm: indi
vidualism, formalism, and the competitive market
model (rights as the product of "choosing" and
bargaining)
5.
Distinction between classical liberal (contractual)
and feminist, socially contextualized approaches
to agency (the problem of "autonomy")
6.
B,
C.
a.
bearers of rights as social beings with gender/
class/cultural identities
b.
from contract to social being and intersectionallty (black feminist and critical race
theory; P. Williams and K. Crenshaw)
Current efforts to redefine rights as relational,
social, and substantive, (integration of rights
and needs); relevance to core ethical principles:
gender equality, diversity, personhood and bodily
integrity
Public-Private Boundaries
1.
Public v. private domains of action and responsibi
lity; ambiguity of distinction; applications to
production and reproduction as both personal and
social
2.
Feminist challenges to the "public"-"private dis
tinction: R. R. and the reordering of gender
divisions of labor, power and resources
The Limits of "Reproduction"
1.
Dangers of reifying women's bodies and traditional
roles:
"difference" v. "equality"
way Z4 y.
o :$< NO . UUZ t- . U4
3
2.
D.
Toward an expanded vision of reproduction: integra
tion on continuum with sexuality, health and well
ness, child care, and production
Rethinking the Dichotomy between "Individual Rights" and
"Public Good"
1.
Reproductive rights as social and individual at the
same time; inevitability of a residual tension,
even in a feminist utopia (example: sex selection]
(R. Petcheeky, Abortion and Woman's Choice):
necessity of anchoring individual rights in social
and political rights
2.
Intersections that refute dichotomization—i.e.,
"individuals" don't make "choices" in a vacuum;
social mediations that construct "the personal"
(economic conditions, cultural norms, family dyna
mics, communal power relations, etc.)
3.
The social rights approach (between individual
rights and public necessity); as enabling (pre)conditions for individuals to exercise agency/make
decisions in socially responsive (cf. responsible)
ways (language from "Women's Declaration" and
alternative "Conceptual Framework" for ICPD)
4.
a.
material (example: child care, transportation
as preconditions for clinic visits)
b.
political: the relevance of empowerment and
democratization (cross-reference chap, on
"Empowerment"); the social and historical
construction of "the public interest" or
"public good": who decides? in what context?
c.
problems with the language of "freely and res
ponsibly" in international population instru
ments:
(1) "corresponding duties" don't
belong to r'ights-bearers; (2) need for poli
tical empowerment to feel "responsible"; and
(3) responsible to whom? who is responsible?
men? (apply to specifics of reproduction)
Problematizing definitions of "choice" and "coer
cion" through a social model of choice (see C-2,
above)
a.
critique of the market model of "choice";
application to "quality of care" framework
May 24 93
TEL:
RREP
III.
8:57 No .002 P.05
b.
examples of de jure and de facto coercion, as
contrasted with agentic decision-making
within constraints ("constrained choices")
(case study: sterilization in Brazil)
c.
the issue of incentives: distinguishing
between coercive and supportive (enabling)
preconditions of responsible reproductive
decisions
d.
why coercion is never appropriate in reproduc
tive matters, from a public health or a
rights standpoint (case study: prosecution
of pregnant drug users)
Ethical Principles Grounding the Concept and Some' Recent
Applications
A.
Equality (v. Liberty)
1.
2.
Between genders
a.
Problems of gender-neutral language in inter
national instruments (e.g., CEDAW - possi
bilities of misinterpretation around issues
like spousal consent); tensions with
particularity of women's situation in
reproduction. Q: What are the justifica
tions and costs of privileging women (i.e.,
do/should men have repro. rights/duties?
b.
Implications for respective responsibilities
of women and men, and for (erasing) differ
ences in power; links between R. R. and
gender justice. Cross reference: Chapter on
Rethinking the Concept of Reproductive Health
c.
Feminist dilemmas: balancing the need for
increased male responsibility (for safer sex,
contraception, child care) and the need for
women's control (over contraceptive methods,
their own bodies, the fate of children)
Among women
a.
Problems of universalizing language that
ignores differences (of class, nationality,
race/ethnicity, religion, sexual orientation,
generation, region)
b.
Problems of unequal power and resources that
exacerbate differences; links between R. R.
and social justice, empowerment, development,
‘
‘rrep
May 24 93
TEL:
8:58 No.002 P.06
and strategies for national and international
economic redistribution
B.
C.
D.
Diversity
1.
Attention to particular issues and priorities of
different groups of women (by race/ethnicity,
class, religion, region, sexual orientation, etc.)
2.
Tensions between universal principles and principle
of respect for local cultures, meanings and values
(counter-examples: genetic mutilation; meanings
of menstrual blood, vaginal bleeding)
3.
Women's intersectional location—as members of
communities, cultures, kin groups, sexual identi
ties, mothers, etc.; challenges to R. R. discourse
and prospects for a pluralistic, multi-cultural
concept of R. R.
Personhood (agency)
1.
Applying a feminist concept of "autonomy" to r. r,:
subjectivity as relational and contextual in
decision-making about reproduction and sexuality
2.
Treating women as ends, not merely means; subjects,
not merely objects - adapting the Kantian impera
tive (counter-examples: policies and programs
that prioritize demographic targets)
3.
Trusting women’s judgments and experience (counter
examples:
clinical practices regarding side
effects of hormonal & long-acting contraceptives)
Bodily Integrity
1.
1975 International Women's Year Declaration and
other international standards; analogous applica
tions (prisoners, torture, medical ethics, etc.)
2.
Specific relevance to gender relations and women's
location as reproducers in the gender division of
labor; women's bodies as reproductive vessels
(counter-examples: impregnation as a tool of
patriarchal, national, or ethnic identity - e.g.,
Bosnia; fertility control as exclusive focus of
population reduction strategies)
3.
Bodily integrity and sexuality; specific relevance
to women's social and cultural location as sexual
signifiers, incidence of male sexual violence, and
power relations between women and men
(case study: the cycle of sexual subordination -
RREP
May 24 93
8 = 59 No .002 P.07
•
j
6
STD risk - HIV risk - female morbidity/mortality )
E.
4.
Bodily integrity and having or not having children:
Is there a right to procreate?
(case study: China's family planning policy)
5.
The right to sexual pleasure and expression: Are
there justifiable limits? How can limits be com
patible with principles of gender equality, social
justice, diversity, personhood and bodily
integrity?
Applications of Principles in Recent International
Women's Documents:
"Women’s Declaration" and Comments
on Conceptual Framework for ICPD; Women's Statement for
International Conference on Human Rights
1.
Cross-reference chaps, on Human Rights, Conventions
and Treaties and Implementation
2.
Emphasize large gap between formal language, adop
tion of rhetoric (even feminist) and practical
enforcement measures by intergovernmental organi
zations, states and private parties
£sH-L-2aJ
Section III, Chapter 14
2.7
Draft: Mav fe, 1993
Beproduc ti ve..AeaUhj__ MCg and Primary ^ali£_Care
By lain
W, Aitken
for
Population Reconsidered: Health, Empowerment and Rights.
Edited by Gita Sen, Adrienne Germaine and Lincoln Chen.
Assumption:
The basic case' for improved, integrated
reproductive health care services has been made in Adrienne,
Sia, and Enin Enin's chapter.
Goal of this chapter:
To develop the concept of a basic reproductive health
services package. This will vary in content and form
according to local needs and health services history, it is
composed of technologies, personnel and organization, its
effectiveness in meeting reproductive health needs depends
upon vertical integration between levels of service/facility;
its efficiency in meeting those needs depends upon horizontal
integration/coordination between different sub-programs.
Context.;.
District health services.
Chapter outline
I
INTRODUCTION
Reiterate the need for an improved, integrated
reproductive health service, and outline the goal and
approach of the chapter.
II
THE NEED FOR REPRODUCTIVE HEALTH SERVICES
2
Review the nature and extent of reproductive health
problems, pointing out the size of the problems where
data exist and the significance of the lack of good
information about certain kinds of problems. This
section would elaborate the situation more than in the
Germaine chapter to emphasize their importance, their
interconnectedness and long term inclinations in the
life cycle.
Health problems to be addressed:
- Maternal morbidity and mortality
- Reproductive tract infections(Tncl.Stds and AIDS)
- Contraception and abortion services
- Infertility
- Anemia and protein-calorie under nutrition
- Rape management
- Cancers of the cervix and breast
(Gender-related violence and mental health problems are
both important, but will not be included in this context
of reproductive and sexual health.)
Ill
PRESENT HEALTH SERVICES AND APPROACHES.
Our health services usually operate in a situation where
"health" is not usually expressed as a priority, when
people require help, they usually have options to choose
from. People will only choose options that they have
some faith in, understand and can rely on.
This section will review the history and current
situation of the main reproductive and sexual health
service programs in different parts of the world,
in
particular it will examine the motive and methods of
previous efforts to develop community level services and
3
those to integrate different health services and their
results.
These have clearly been productive in some
situations, but in many situations, community level
proggrams have failed, and the integration of activities
already suffering from lack of resources or management
has led to a worse situation.
Present health services problems;
a)
Problems of priorities:
- Competition for resources in which child health and/or
family planning usually take precedence
- Lack of awareness of RTls, infertility and anemia
- Almost total lack of services for women's RTIs and
other gynecological problems
- Absence of a life-cycle approach to repro. health
- Lack of clear goals and objectives for reproductive
health services.
b)
Problems of Organisation
- Lack of vertical integration within programs
- Lack of horizontal integration, fragmentation of
different services
c)
Problems of resorces
- Lack of resources
- Human resources spread to thin or given too many
(conflicting) responsibilities.
IV
VERTICAL INTEGRATION:
OF CARE
TECHNOLOGIES, PERSONNEL AND LEVELS
This section is concerned with the trade-offs of
improving access with safety and accountability, and
how to maximize each of them within different levels of
care.
Most,district health service systems consist of a
"typical" three level type of health service structure,
vis:
community level
- health centre level (nurses & auxiliaries)
- district hospital
For each. Qf_the main health problem-areas, identify;
{a) the technologies that are effective in preventing
or "treating" the main problems already identified,
(b) the levels of skills and facilities that are
required,
(c) the vertical linkages - support/supervision,
referrals - required to achieve both enhanced access and
choice as well as safety/accountability.
THE ORGANIZATION OF CARE
This section now addresses the issues of horizontal
integration more specifically.
NB, Distinguish:
a)
Integration: bringing diverse, separate functions
into a new unitary structure.
Coordination : smooth relationships between
separate activities.
b)
Administrative v. service integration.
c)
Integration at role level, agency level, sectoral
level, policy-planning level.
Community level
Issues:
•
Target groups:
men and/or women.
• Control. The selection of the community worker and
her/his relationship to women's groups or other
concerned community groups and to professional
supervisors.
• Concentration versus dispersion of knowledge. Is the
community worker the "possessor" of special knowledge or
the technical expert in knowledge that is shared among
the women in the community?
5
NB the importance of empowerment of women in the
community as opposed to disempowerment consequent upon
"professionalisation" of
community members.
• Division of labor v. integration. Separation of
roles of TBA, CBDC, CHW, store-keeper, etc. v.
multipurpose worker. Number of households it is
possible to effectively cover.
(Importance of time constraints for volunteer
activities, cultural precedents.)
• Coordination/integration of activities of several
community-level workers.
Empirical evidence from programs
2.
Integration of services at health centre level
General: Evidence for benefits for one program by
association or integration with another, e.g.
integration of FP into MCH or MCH into FP.
Issues:
♦ Method of integration: role, intra-agency or inter
agency integration.
• Social reputation of primary service.
• Operational factors
- Number and range of services and the organization
of work time,
- availability for acute care
- availability for maternity care
- preventive care activities, e.g. prenatal &
child health clinics
- outreach activities,
- supervision activities (TBAs, CBDCs, Chws,
etc.)
- continuing education
- Requirements for patient confidentiality
- Numbers/types of health workers available per
population served;
- Specific needs for service overlap at different
service entry points.
I
6
- Efficiency issues in separated or integrated
clinics.
- Community access/convenience issues in separated
or integrated clinics
3.
Management of services at district level
The importance of management in a situation where both
vertical and horizontal integration and/or coordination
of services is essential.
- setting of goals and targets for the district and
™
its health units,
- information systems,
- training, continuing education and supervision,
- personnel management,
- supplies.
- community management/support bodies.
VI
CONCLUSION
- Importance of focus on the health of persons and not
just the treatment of diseases, on a life cycle
approach and not just management of isolated
episodes.
- Integration/coordination of services highly desirable.
- Integration only works when individual programs are
adequately planned, funded and managed.
- Integration can and does work.
- Serious concern for these issues implies application
of more resources than presently available.
TOTAL P.O?
jh-G.
Chen, Zeitlin, Govindaraj Outline
draft May 7, 1993
Financing Reproductive Health Services
Outline
I
Introduction
•
Brief discussion of reproductive health services (cross
reference chapters by Germain, Nowrojee, Pyne and by Aiken).
•
Universal call for additional resources for family planning
and reproductive health. Current recommendations are based
almost exclusively on cost per unit of actual and desired
use of family planning.
•
The current estimates of resource requirements for family
planning and reproductive health services have 2 major
problems:
(1) they are incomplete because they have not explicitly
integrated resources for other reproductive health
services in addition to family planning services;
(2) they are of questionable validity because estimates
are based on crude projections of current costs into
the future. Calculations of current costs vary greatly
depending on attention given to individual components
such as contraceptive mix, research needs and,
especially, service delivery.
(TABLE 1: CURRENT ESTIMATES OF RESOURCE REQUIREMENTS)
The focus has been primarily on HOW MUCH and not on HOW
reproductive health programs should be,financed. The
question of how services are financed will determine whether
allocated resources are used to provide effective, efficient
and equitable services which are sustainable over time.
II
Defining Reproductive Health Services for an Analysis of
Financing
•
Classical focus has been on contraceptive and abortion
services. Use is measured by contraceptive prevalence and
resources required for these services are calculated based
on "unmet need" and on demographic projections, (table 2:
•
Neglected are costs of broader reproductive health services.
Reproductive health services can be variously defined to
include: family planning + safe motherhood + STD/RTIs (men
and women) + nutrition + child health (cross-reference
"UNMET NEED" FROM DHS SURVEYS and COST PROJECTIONS) .
chapter by G,N,H and by I.Aiken).
(TABLE/FIGURE 3: BURDEN OF DISEASE WORLDWIDE AND BY REGION)
III
How Much is Currently Being Spent of Family Planning and
Reproductive Health Services ?
•
This section will apply a broadened definition of
reproductive health services to an analysis of current
expenditures given available data. A comparison will be
made between the narrow definition based on family planning
services and one in which reproductive health services are
included.
•
Estimating total current expenditures on reproductive health
services hindered by:
• joint costs/products: difficulty of separating
expenditures allocated to reproductive health in government
programs from other health services (family planning,
maternal and reproductive health services expenditures in
MCH programs; reproductive' health services from total health
expenditures; vertical programs versus integrated programs)
• Reproductive health needs are. addressed by a variety of
government programs and service providers. Although some
data exists on government programs, there is an absence of
data on private sector and other providers of reproductive
health services.
•
Present available data on government provision and describe
patterns:
national estimates of family planning expenditures
(TABLE 4: GOVERNMENT BUDGETS ON FAMILY PLANNING AS % OF HEALTH, FAMILY
PLANNING AS % OF TOTAL EXPENDITURE, MCH AS % OF HEALTH, STD PROGRAMS)
•
Present data on national and international financing and
describe patterns and trends. Government financing and
international foreign assistance in population/health.
(TABLE 5: FINANCING OF FAMILY PLANNING: % INTERNATIONAL, PRIVATE, GVT) .
(TABLE 6: ODA: FAMILY PLANNING, MCH, STD PROGRAMS AND TOTAL
HEALTH).
•
IV
Explore question of integrated versus vertical programs in a
sample of countries.
Can Resource Requirement Projections for FP and Reproductive
Health Be Improved ?
•
Evaluate validity of cost projections based on current point
estimates. Look at evolution of average costs in countries
with time-series data on expenditures on family planning
services.
How Should Reproductive Health Services Be Financed?
V
This section will present a conceptual framework for
addressing the question of how reproductive health services
should be financed. Micro-level and country-level studies
which have analyzed financing systems and factors
influencing the effectiveness, efficiency and equity of
service delivery will be reviewed (cross-reference Aikin
chapter). Focus on issues of:
•
•
•
Efficiency/effectiveness
• allocation of resources to reproductive health within the
health system, efficiency of financing and administrative
procedures;
• composition and organization of reproductive health
services: integration of services, operational links with
PHC, public/private mix;
Equity
• local control and participation.
• differential control of resources and access to care
between men and women.
Quality
• Economic incentives in provider systems to promote quality
of services. Relationship between quality of services and
demand for services.
Future Needs
VI
•
Data on expenditures for reproductive health services needed
for more accurate projections of resource requirements,
analysis of use and evolution of resources allocated to
reproductive health.
•
Research on economics of reproductive health: factors which
determine demand for reproductive health services (service
as well as community, household and individual
characteristics).
•
Research on financing systems and effectiveness, equity and
quality of service provision (organization and management,
integration of services and programs, operational linkages
with PHC).
•
•
•
•
•
•
•
•
•
•
•
•
Promote spacing & timing. Spacing and number of births being crucial to the reproductive health
of mothers as well as to child survival.
Do follow up and monitoring of people using contraception; and referral if necessary.
Achieve 100% registration in the first trimester, to ensure proper antenatal, natal, and postnatal
care.
Enable trainee ANMs & Dais to perform a sufficient number of normal deliveries in the field.
Delay ligation of umbilical cord till it stops pulsating.
Take care of the newborn.
Ensure that breast feeds start within the first hour after birth, promote feeding of colustrum.
Promote exclusive breast feeding till the baby is 6 months old.
Develop leadership qualities & elicit community participation.
Perform the specific functions that are expected of them at a sub-center.
Perform "Visual Inspection" for down-staging of Cancer Cervix.
Carry out examination for Breast & Oral Cancers.
11. A second village level functionary to take care of the newborn, in addition to the birth attendant
during delivery, should be initiated. Aanganwadi teachers or other health workers who reside in the
village may be selected for this and trained and equipped for neo-natal care as well as the care of the
child up to 2 years of age. They can also assist in other health programs, Health Education, Adolescent
health; and facilitate women's self-help groups. Alternately, the Gram Panchayat could appoint and
support a woman of the village for this purpose as a health functionary.
Genderisation of Family Planning
11. Gender sensitiveindicators as given above, should be incorporated in the programme.
12.
13.
Male Health Workers should be trained to tackle Gender issues and ensure male participation
through individual counseling as well as community education programmes
The Village Health Guide Scheme may be reintroduced with a new name, workers be given a
higher honorarium and the scheme be controlled by the panchayat system. Women volunteers
should be given preference and encouraged to join.
The services of Lady Medical Officers should be made available, if necessary with support from
the private sector. Especially in Northern districts two MO in the PHCs, one at least a Lady MO,,
Should be posted.
15. The working hours of staff at the periphery may be changed to suit community needs.
14.
Other facilities & services:
16’ ‘Personal hygiene especially during menstrual period should be promoted by the distribution of
subsidised mentstrual cloth and supported by awareness programmes to ensure correct usage.
Menstrual cloth is preferrable to pads for reasons of cost, familiarity of use and prevention of build
up of non-degradable waste.
17. Only safe, effective contraceptive choices should be offered.
18. It is important that routine treatment for parasitic infections should be carried out for all children annualb
. In particular for adolescent girls .It is also equally important to ensure treatment of all members in the
household fbr some of the infections.
19. In general the majority of parasitic infections that occur iff ptenancy do not require treatment during pre
However, if severe symptoms, anemia or malabsorption occur, treatment should be initiated during pregr
10
GOVERNMENT OF KARNATAKA
13™ STATE LEVEL STEERING COMMITTEE MEETING
OF THE RCH PROJECT
ON
12 - 10 - 2000
AT
10.30 A.M
Venue: Committee Room No..253, M.S.Building, Bangalore -1.
ST. 17T .'I O/Z/.V II'ELE IRE BOREAL'.
OlRECnitUTE <>E HEALTH EH'SERHCES.
IV I xr- I RAO CIRCLE.
o i Xt'r'M.OixE - 560 009
13th state level steering committee meeting of
THE RCH PROJECT
DATE- 12/10/2000 AT 10.30 A.M.
Agenda I:
Reading & confinning proceedings of the 12,h Stale Level Steering Committee
Meeting held on 10 08 2000.
Agenda 2:
Report on the Action Taken on the decisions ofthe 12,h State Level Steering Committee
meeting held on.10-08-2000
_____________
_____ ____
Action Taken
SI.
Agenda Item
Decision Taken
1
No. 2 (i)
Xo.’2"(H)'~~
No. 2(iii)
No 2(i\)
Commissioner to review the The review was conducted on !
i performance of the Post Partum . 12, 09 2000 and the proceedings i
i issued separately. Heads of Post '
; Centres of ‘A‘ Type.
; Partum Centres of A type have been 1
impressed upon to achieve the inbuilt i
targets and prove effectiveness of;
these institutions in urban areas
‘ Feed back on the study "Factors Preliminary work on the study has j
Affecting Institutional Deliveries been initiated as per the letter;
from
the
Director, {
in Karnataka” from the Director. received
■ Population Centre to be obtained. i Population Centre and as per the ■
j discussions held by its staff with the 1
i Demographer___
Auditing of Primary Centres by The proposal is not cleared by the i
i institute of Charted Accountants - i GDI
as
per
the
Letter 1
No.D.C).No.G.27017/10 98 - RCH I
1 piloting in P1IC. Bidadi
(DC). Dated: 19/09/2000- It has been |
1 intimated that the cost will have to be I
met by the State itself or the audit got I
1______________________________ _donc by the A.G _
; Formation of Health & F\V This will be included in the Agenda j
1 Society in Karnataka - placement 1 of (he 4th Empowered Committee 1
I of the subject for the approval of1 leeting of the RC11 Project, for i
, the Empowered Committee
reconsideration
Placing ol Budget giants of the Released Rs.275 - 1 akhs to the ■
RCH project at the disposal of; Project
Administrator.
KILSDP. I
Project Administrator. K1JSDP for. taking the cumulative release to '■
c:'il works
Rs.375 lakhs
Sanction oi Telephone Io the I Commissioner had discussions with 1
• PHCs of Sub-Project, Bellary
; the Telecom Authorities and a letter ;
has been addressed to the General i
Manager Telephones___
1 Delegation of Powers to Deputy , Orders issued
‘ Commissioner
to
recruit
j Contractual Staff_____ __ ______
Utilization of funds for ''24 hours i Government order issued
j No. 8
' Delivery Services”
i
i Hiring of Vehicles. Payment of Government order issued
i 9 ■ No. 9
i TA DA for under taking tours and
1
; reimbursement
of
local
i transportation charges for visiting
1
i other offices to RCH consultants_
Release of Funds for maintenance | Amount released to Districts
No. 10
’ io
i of Cold Chain and Purchase of
|
Injection Safety (Kerosene)___
Release of Funds for Referral ■ Government Order Issued
No. 11
I 11
I Transport_________________
'___________________________
1
1 Hiring of Vehicles under Sub- ; Rs.12 lakhs released to CEO. Bellary
.. 12 ■ No. 12
i Project. Bellary_______________
i Procurement of Furniture to i Order placed
i 13 j No. 13
1
Consultants
No; M ’
r 14
' Procurement of .Surgical Kits (Kits ' Procurement Plan has been submitted 1
I to KI-ISDP on 23-9-2k
j C to P) for RCH Project
| Procurement of two Ambulances i Action has been initiated by KHSDP
No. 15
; 15
for STibTToject. Bel 1 ary
j procuremeii£
IF.C Activities in Sub - project. 1 During the visit of Commissioner for
16 I No. 16
i Health & FW Services to Bellary. the I
__ J Bellary
: Action plan has been finalized _
Appointment
of
Contractual
Staff
; The subject has to be placed before
No.
17
: 17 ;
Empowered Committee as it involves
under
Sub
project.
Bellary
1
1____ i
creation of posts _
;
r is > No. 18
Procurement of Drugs. Pethidine GOI will supply these items except
and AB Cotton under National ! pethidine directly to the Districts as \ (
Component
per their Letter No. 15012 46 2000- <
RCII(P) dated Sept. 2000. Hence '
i
I_____ 1
procurement is not needed
;
|
7
i No. 7
Agenda 3:
Status report on the RCH project
The financial and physical progress under (he National Component and Bellary
Sub-project are shown in Annexure -II(A&B).
I he status of implementation of the various components of the project is as
follows:
Government Order No.FD-692 TA - 99 Dated: 28 09 1999 regarding the mode of
drawal of funds under the project, by the CEOs of ZP expired on 31 03 2000. Proposal
was submitted to the Government and discussions held with the Secretary (Exp.),I'D .
lor renewing the Government Order till the expiry ol the project.
The following Government Orders have been issued (Copies attached)
I.
2.
3.
Rcferal Transport
I 'tilizalion of funds for "24 hrs’’ delivery sen ices
Hiring of Vehicles, payment of TA & DA for undertaking tours and
reimbursement local transportation charges for visiting other offices to the
RCH Consultants.
Agenda 4:
Utilizing the services of FOGSI members for conducting Safe Motherhood clinics in
the PHCs of Bellary District.
Regular ANC by health staff can be substantially and qualitatively supplemented
by arranging Safe Motherhood Clinics by FOGSI. In this direction, the entire district
can be treated as a unit for operational convenience . Doctors belonging to this body
should conduct AXC and PNC clinics and render health services related to safe
motherhood once in a week or atlcast once in a fortnight on a fixed day al PHC level.
They should perform MTPs during their visits Io PHCs subject Io availability of
equipment. It shall be the responsibility of the MO, PHC. to mobilise clients needing
these services. These S.M. Consultants will be paid 'a> Rs.500- per visit. Transport
allowance at the rate of Rs.200 - per visit is also proposed.
This is proposed to be initiated in Bellary district on a pilot basis. I here are 60
PHCs in this distiict out of which 10 have been identified initially by the FOGSI for
conducting Safe Motherhood Clinics to begin with.
Agenda 5:
Special Financial Envelope
i)
Mobility support to PHCs in Districts of Gttlbarga, Bidar. Bijapttr, Bagalkot,
Raichur and Koppal
Majority of the PHCs in these districts do not have vehicles. Govt, of Lidia desire
.strengthening outreach services by providing mobility support to the PHC personnel as
one of the interventions in the modified annual envelope, which it has approved.
Instead of procuring vehicles for the mobility support and encounter delays and
other attendant disadvantages, it is proposed to hire and place them al (he disposal of
PHCs for about 10 days in a month on rotation. Thus one vehicle can cover 3 PHCs in a
month. Il is proposed to hire about 35 vehicles during remaining 5 months of the current
year to enable 100 PHCs to have mobility support
‘
4
The Dll & FWO will have to prepare the schedule for allotment of the hired
vehicles io the PIICs for ten days hi a month. Each PHC will draw up a plan ol action for
its hmi of 10 days and use the hired vehicles for effective supervision of field work.
holding immunization sessions hi remote-interior inaccessible areas and for fulfilling the
requirements of clients of family planning program.
I'he hiring charges are at the rate of Rs.660<- per day and the amount accordingly
required to be released to (he districts is given below:
Xo. ofPIICs
___District
Gulbarga
_ 31
n’"
Bidar_____
Bijapin
_____ 1£_____
Bagalkot___ _____ 12________
__ 14___ i
Raichur
Koppal
13 _
'i olal
__ 10 0_
ii)
.Xo. of Vehicles :__ Amount required (Rs.)
i 660x30x5x11 -10.89.000 _i
11
I 660x30x5x4 =3,96,000
|
__7___ 1660x30x5x7 = 6.93.000___ 1
I 660x30x5x4 =3.964)00
*
4
___ 5______ ; 660x30x5x5 =4.95.000 __ i
660x30x5x4 =3.96.00(1" 1
___ 4
35
I 34,65,000 _
Dais training
In Karnataka more than 50°o arc domiciliary deliveries, hi the backward districts
this is as much as 77.42° o out of which the share of untrained trained birth attendants is
8.04%.
There are 2.600 untrained birth attendants in the districts of Gulbarga, Bidar,
Bijapur. Bagalkot. Raichur and Koppal and Bellary. It is proposed to provide training to
all these 2600 (L’TB’s) during 2000 - 01. Under (he annual envelope proposal was sent to
strain only 1000 I' I B As. This has been approved by Govt. of India and funds have also
clcased. In addition, all the UTBs will be provided with Dai kit at the end of the
ig. The cost of each kit is Rs. 500
—A
.An amount of Rs.21.00 lakhs is released under this component
Tliis component has been included in the separate State Plan under Women
Health Care submitted for approval of the Cabinet. Under this, it has been proposed to
train all (he 2.600 UTB’s nt the seven :C category districts and also to provide them
Dai kits. .An amount of Rs.24.96 Lakhs has been proposed under this scheme.
iii)
Disposable Delivery Kits:
It is proposed to provide disposable delivery kits to ANMs-AWWs. They will
have to hand oxer them to the "would be delivery mother” for utilization at the tune
delivery so that sepsis and complications arc avoided.
.An amount of Rs. 10.20 Lakhs is released under this component.
,\n amount of Rs.6.40 lakhs is required for 5 months to provide
delivery kits at Rs.20 - for 32.000 kits.
disposable
This component hits also been included in the separate State Plan under Women's
Health Care, submitted lor approval of the Cabinet.. Under this, it has been proposed to
provide 1.14 lakhs kits al a rate of Rs.36 - each.
The total requirement for (he disposable delivery kits works to Rs.41.04 lakhs for
the seven C category districts.
iv)
Adolescent Health Education:
Adolescents constitute a ven’ highly critical segment of the population required
to be covered by RCH services. This segment in the schools will be covered through the
School Health Programme. However to cover those adolescents who drop out from
schools . a mechanism needs to be worked through the Women & Child Development
department using the link of AWWs. It is expected to cover a population of 18.000 in
the above 6 U districts.
A sum of Rs.10 lakhs towards preparation of charts, booklets, handouts and also
contingent expenditure is proposed to be released. -+*
P Ai
v)
,
(o-t-xoC.
u
l-'andly Health Awareness Campaign (P'HAC)
This component has been provided to the Karnataka State AIDS Prevention
Society. An amount of Rs.5 lakhs has been received from the Govt, of India to meet
the expenditure tow ards surgical gloves to the doctors examining RTI'STl clients and
towards distilled water atnpulesfor dissolving penicillin injection.
Agemla 6:
\
Constitution ofState Co-ordination Committee for RCH Training
The Director, State Institute of Health & Family Welfare, in his letter
No.Sil I 54-2000- 01 dated 12 09 2000 had submitted a proposal for the constitution of
the State Co-ordination committee for RCH training. This has been modified as indicated
below for app.roxal of the Government. The NH-IFW, New Delhi, has suggested the need
for such a committee to coordinate . guide and monitor the RCH training programs.
Chairman
Member
Member
Member
Member
Member
Member- Secretary
- Commissioner.'Director. Health & FW Services
- Director of Health & FW Services
- Director. State Institute of Health & Family Welfare
- Project Director (RCH)
Representative- from National Institute of Health &
Family Welfare
a. Divisional Joint Director. Bangalore
b. District Health & FW Officers of Belgaum, Gulbarga,
Mysore and Bangalore Rural districts
- Joint Project Director. RCH
■ i" District Co-ordiiiuiian Committee fi;r
In aecoi<!a!’..'. with the suggestion of the National Institute of Health & Family
Welfare, the Nodal agency for training under then RCH. the Director. State Institute of
Health & Family Welfare.’ in his letter^No. No.SIII 54 '2000 - 01 dated 12 09'2000 had
submitted proposals for the constitution of District Level Co-ordination Committees lor
RCH training. This has been modified and the following constitution is proposed for
approval of Government.
Members
a.
b.
a.
b.
District Health & FW Officer of the District
Principal. DTC
Principal. A.N.M. Training Centre.
District Family Welfare Officer
Assistant Director. Women & Cliik
Department
District RCH Officer
Nj
Development
Supply of \1CII. Antenatal Cheek Up cards to beneficiary under RCH Consultancy
The District Health & FW Officer. Bellary District, in his letter Dated:
15 09 2000 addressed to the Project Director (RCH). has requested funds lor planting of
.Antenatal Cards. MCH cards for the beneficiaries under RCII program as per the type
design suggested by the Secretary, FOGSI.
An amount of Rs.2.00.000 - may kindly be released.
Ag en d a 9:
Follow up action on the evaluation report by the Regional Evaluation Team,
liangalore
The Regional Evaluation Team of GOI , Bangalore, has carried out sample
verification of Family Welfare Acceptors in Bangalore City, Haveri, Mysore and
Chamarajnagar Districts during May and June 2000.Some of the noteworthy findings of
this team, communicated by the Government of India hi their letter D.O. No. Q 11015 14 2000 - Slats. Dated: 17 08.2000 are as follows:
1.
Sterilisation and IUD registers were not updated in Bangalore City district.
Case cards of sterilisation, IUD and other methods were not maintained in the
districts listed.
2.
Sterilisation. IUD, OP and CC registers were updated but not printed hi
Haveri. Mysore and Chamarajanagar districts. Sterilisation, ILT) and other
case catds were not maintained hi Haveri District. IUD Cards were not
maintained in Chamarajnagar and Mysore districts.
3.
i lie team could contact only 178. 121. 55 and 101 cases out of total selected
.uses ol 232 168. 116 and 137 respectively, in the aforesaid districts. The
detailed findings are given in the statement enclosed.
4.
Xo. ofXon Contact cases reported was much higher which is very serious
and needs proper attention.
This for perusal of the Steering Committee
Agenda 10;
Appointment oj Child Health Consultantfor the RCH Project
1 he 3“' l inpowered Committee meeting on RCH held on 27 ()(»•■2000. approved
the proposal to appoint Dr. Mary Chandrakumari Thomas as Child Health Consultant in
the project and to obtain the concurrence of the World Bank for this as her appointment
is on a sole source basis.
As per the letter dated 08 09 2000 from the Project Administrator. K.HSDP,
Bangalore (the procurement agencs for the RCH project). World Bank has no objection
to appoint Dr. Maty Chandrakumari Thomas as Child Health Consultant on a consultancy
fee of Rs. 20.000 - per month.
Dr. Mary Chandrakumari Thomas was asked to report as Child Health Consultant
on 18 09 2000 vide this Directorate's letter Xo. RCH 9'98 - 99 dated: 15.09'2000. She
has been accordingly working in the project since 18-09-2000.
A formal Government Order is needed to ratify her appointment as Child Health
Consultant as done in the case of the other tluec Consultants: M&E'MHIEC.
The Slate Level Steering Committee may therefore ratify the appointment of
Dr.Mary Chandrakumari Thomas as (he Child Health Consultant with effect from
18 09 2000 for a period of one year initially.
<7? J
ProjectDirector(RCH)
&
Member Secretary,
State Level Steering Committee
PROCEEDING OF THE 12,h STATE LEVEL STEERING COMMITTEE MEETING OF
RCH PROJECT HELD ON 10°' AUGUST 2000
IN COMMITTEE ROOM No. 253, M.S. BUILDING, BANGALORE
Sri. A. Sengupta, Principal Secretary to Govt, II & F W Dept. Bangalore, in the Chair
Members /Officers Present
1
2
3
4
5 .
Sri. Sanjay Kaul. Commissioner for H & F W Services, Bangalore________________________
Sri. Ashok Kumar Manoli, Secretary(Expendilure), Finance Dept. Bangalore
Sri G.V. K. Rao, Project Director, IPP - DC, Bangalore
Sri. Anand G. Risbud. Project Administrator, KIISDP, Bangalore________________________
Dr. G.V. Nagaraj, Director (VC), Directorate of Health Services and Project Director (RCH)
Bangalore_____________________________________________________________________
Sri. K. Shankar Rao, Director, Planning Dept., Representing Secretary' to Govt., Planning,
i 6
_____ Institutional Finance and Statistics, Bangalore________________
!• 7
Dr. A Shamanna, Joint Project Director (RCH) (VC) Bangalore
g | Sri. G. Prakasam. Demographer, DH&FWS Bangalore_________________________________
_9_i Sri. N.T. Marulasiddappa, Joint Director (VC), IEC Bangalore
10 Sri. Krishnamurthy Accounts Officer (FW) Bangalore__________________________________
11 Dr. Manjunalh Gowda, DH&FWO, Bellary representing CEO, ZP, Bellaiy
12 Representative of Secretary to Govt., Women & Child Welfare Department Bangalore
13 Representative of Secretary to Govt., Public Works Department Bangalore_________________
14 Under Secretary, IPP -IX and RCH Project Bangalore
15 Consultant IEC
16 Consultant MH
17 Consultant M&E
18 Deputy Director (MCH)__________________________________________________________
Deputy Director (IUD & PPP)
Members who did not attend the meeting
1
Secretary1 to Govt., Education (Primary' & Secondary Education) Department
Director, Medical Education in Karnataka, Bangalore
The Principal Secretary to Government, Health & Family Welfare Dept, commenced the
meeting with a cordial welcome to all the members, officers and invitees .He extended a special
welcome to Sri Ashok Kumar Manoli, Secretary (Expenditure), Finance Department, who was
attending the meeting for the first time.
The agenda items were then taken up for discussion.
2
Agenda 1:
Reading and confirming the proceedings of the lln SLSC meeting held on 801 May 2000
The proceedings of the H11' SLSC meeting held on 8U1 May 2000 were read and
confirmed. On tire suggestion made by tire Chairman it was decided that the SLSC meetings
should be held regularly eveiy month as in the case of the Steering Committees meetings of other
projects like IPP -LX, KHSDP, etc.
Action'. Project Director (RCH)
Agenda 2:
Action Taken Report on the Proceedings ofthe 11°' SLSC Meeting
The Commissioner for H & F W services briefed the Committee on the considerable
progress made in recent months and informed that Government orders have been issued in
accordance with all the decisions of the previous SLSC meeting. The Chairman suggested that
copies of GOs issued should be supplied to all members.
.
The Committee approved the action taken report with the modifications listed below:
(i)
SI. No.2:- Management of Post Partuin Centres of A Category:
The Project Director (RCH), explained that tire PPP is not being implemented as
envisaged, in the teaching and bigger hospitals. The Commissioner at this juncture cited the
example of HS1S Ghosha Hospital, Bangalore. It was pointed that the major impediment in the
programme is the lack of coordination between the different Senior Doctors in the major hospitals.
The Project Director (RCH) pointed out that the approval of GOI is needed before taking
any decision of far-reaching nature and that a thorough discussion with tire concerned Programme
Officers is very essential to diagnose the problems.
The committee thereafter approved the proposal to have the review- meeting of the PPCs
of‘A’ category under the chairmanship of the Commissioner.
Action-. Demographer/ DD (IUD &PPP)
(ii)
Sl.No.3. Study On Factors Affecting Institutional Deliveries In Karnataka:
The Commissioner informed that a feedback would be obtained from lire Director,
Population Centre periodically on the progress of the Study.
Action: Director, Population Centre
(iii)
SI. No. 7. Audit of Primary Health Centres:
12"‘ SLSC agreed for the pilot study to be taken up in the Bidadi PHC by the Institute of
Chartered Accountants and also suggested that the proposed audit should cover both financial and
work aspects of all national Programs. Chairman desires that this should be finalized urgently on a
time bound basis.
A ction: Commissioner/DI IS
(iv)
Si. No.9 Annual Financial Envelope:
The SLSC was infonned that Govcnuncnt of India has given sanction for the revised
financial envelope of Rs.2.09 Crores.
£
It was decided to incur expenditure according to the
sanction by Govt, of India.
Agenda 3:
Action Taken on the Proceedings of the III Empowered Committee meeting held on "
27/06/2000
SI. No. 1, Agenda 2: - Formation of the State Health & FW Society in Karnataka:
Both the Principal Secretary and Commissioner were of the opinion that action needs to be
taken for Lire establishment of a Society in -view of the expected flow of external funds for number
of health programmes and that the subject has to be therefore placed before the next Empowered
Committee Meeting. Meanwliile, all tire factors and arguments advocating the establishment of tire
Society have to be identified and the Chief Secretary impressed about them.
•
.
Action: DHS / RCH Consultant (M & E)
SI.No.2 Agenda 3: - Contractual appointment of Staff nurses to PHCs of ‘C’ category
Districts:
The committee while agreeing to implement the scheme strongly suggested that:
a. Action should be initiated for widespread awareness in the community about the availability of
delivery services during nights at PHCs.
b.
The institutions should remain open at any time during nights to attend to emergency calls for
the delivery services.
c.
Sufficient care needs to be exercised at the time of the recruitment of the contractual staff and
it has to be specified that the staff nurses will be requir ed to stay in headquarters and work
during the nights also in order to bring about substantial increase in the obstetric care.
Action: Project Dir ector (RCH)/RCH Consultant (MH)
51.No. 3, Agenda 4: -Utilizing Services of AVVWs on Part Time Basis in ‘C’ Category
Districts:
The modus operandi of drawing the state RCH funds by the district authorities for
implementing various schemes /programmes like payment of remuneration to AWWs was
deliberated upon at length, eliciting the views of Project Director (IPP-LX), Secretary
(Expenditure) DH&FWO. Bellary and Accounts Officer (FW).
It was decided that the Secretary (Expenditure) would be the appropriate authority to sort
out the issue and a find a smooth solution after formal discussions with Project Director IPP-IX.
Project Director (RCH). CAO cum FA. CAO of IPP- IX, and Accounts Officer (FW). It was
further urged that the meeting to discuss this complicated and key issue should be convened very
urgently.
Action-. Secretary (Expenditure), Finance Department/ Accounts Officer (FW)
SI. No 4, Agenda 5: - Mode of utilizing of Funds Received from UNFPA for Granting Loans
to ANMs for Purchase of Moped:
The Commissioner. H&FW services, proposed that a comprehensive Government Order
indicating the modalities of granting of loans and maintenance of proper accounts could be
issued based on the proceeding of the meeting held in this connection on 8/8/2000. The SLSC
agreed with the modalities worked out at the meeting held on 08/08/2000 and authorized the
issue of a Government Order in this regard.
Action: Under Secretary EPP-LX /Accounts Officer (FW)/Consultant (MH)
Sl.No.7, Agenda 8: - Utilization of the services of FOGSI, Bellary Branch, in Emergency
Obstetric Care:
The Commissioner gave an account of the progress made so far and the discussions with
Dr Kanu.nl Rao. President, FOGSI in this regard. It was also informed to tire conunittee that
FOGSI would claim, tire service charges for the service rendered by its members from the GOI
'directly.
The Project Director (RCH) sought clarification about permitting private doctors into
Government institutions for rendering their services. The committee agreed that there is no bar
on such arrangements, which is in the overall interest of promotion of EsoC and EmOC. The
Conunittee then cleared action for further measures in this regard.
Action: FOGSI ■'Consultant (MH) /DH&FWO. Bellarv
Agenda 4:
Status Report on the RCH Project
The Committee appreciated that alter two years the RCH project expenditure is picking up.
The Project Administrator, KHSDP, and the Secretary (Expenditure) both pointed that
presently most of the expenditure is attributable only to one component namely, civil works.
They desired the programme to become multi-dimensional so that the RCH objectives can be
achieved. Therefore, speed of expenditure should improve in all components of the programme.
The Commissioner. H&FW services, assured the Committee that RCH machinery would
be geared up for accelerating work on all the activities both under National Component and Sub
Project. He also elucidated that once civil works are completed, progress on some other activities
would also as a corollary, follow.
As regards procurement of Drugs, AB Cotton Etc., the KHSDP agreed to expedite the
procurement process according to the requirement already furnished by Project Director (RCH)
Action-. Project Administrator. KHSDP/PD (RCH)
As regards sub-project, Bellary, the Principal Secretary requested the Commissioner
H&FW services, to visit Bellary shortly and draw a plan in consultation with DC, CEO and
DH&FWO. for giving momentum to all the components of the sub-project.
It was also decided that out of the Rs.141 lakhs provided for drugs, Rs.100 lakhs may be
utilized for drugs and (he remaining Rs.41 laklis should be used for minor repairs to furniture,
purchase of linen, upholstery, pillows etc.
The DH&FWO, Bellary was directed to prepare, by the time the Commissioner visits
Bellary:
i.
The List of sites for all categories of Civil works, including alternate sites wherever
required
ii.
A plan for Rs.41 laklis for purchasing linen and for effecting minor repairs and paints
to furnitures, for the PHCs and sub-centres.
iii.
An exhaustive statement for plan/non-plan and salary and non-salary components
under the general budget and link document
Action: CEO. Bellary/ DH&FWO, Bellary
The Secretary (Expenditure) assured the committee the GO facilitating drawal of RCH
funds ( white bills ) would be issued immediately
Agenda5:
Placing of Budget grants under RCH Project at the disposal ofProject Administrator, KHSDP
for the year 2000-01for Civil works.
The Committee agreed for the release of Rs.275 lakhs now available, to the Project
Administrator, KHSDP, for Civil Works and to release the balance requirement as and when
funds are replenished by the GOI
Action-. Accounts Officer (FW)/ RCH Consultant (IEC)
Agenda 6:
Sanction of Telephone to the PHCs of Sub-project, Bellary
The Committee agreed to release a sum of Rs. 10 Lakhs to Bellaty District for installing
telephones in PHCs and enhance the essential communication facility. Hie Principal Secretary
and Commissioner cited the recommendation of The Task Force on Health in this regard.
It was also agreed that meanwhile the Commissioner would have discussions with the
telecom authorities regarding various alternatives; OYT/PCO etc., to facilitate an efficient decision
about the type of telephones to be installed.
Action: Accounts officer (FW)/CEO, Bellary/DH & FWO, Bellary/Consultant (EEC)
Agenda 7:
Delegation ofpowers to Deputy Commissioners to recruit Contractual Staff
The committee decided to empower the Deputy Commissioners to recruit all categories of
contractual staff to be funded by RCH Project, both under the National Component and sub
project, Bellary on the same lines as being done for tire other Health depar tment staff
Action: Under Secretary. IPP - LX & RCH
7
Agenda 8:
Utilization offundsfor "24 hours delivery services”
The Secretary (Expenditure) Finance Department raised tlie need for including the
backward Northern Karnataka Districts also in all the RCH Components .
It was explained that though these funds were released earlier the activity could not be
started because there was no GO for enabling drawal of funds by the District authorities. RCH
Consultant (MH) mentioned that under the special financial envelope, a number of Northern
Karnataka Districts have been included for expanding various RCH services and for strengthening
infrastructure too .
The Committee thereupon agreed for the proposal to release funds to the six districts
shown below for the 24 hours delivery services:
1.
2.
3.
4.
5.
6.
Kolar
Mysore
Mandya
Chatnrajnagar
Dharwad
Bangalore (R)
:
}
}
}
}
:
Rs. 1 lakh
Rs.0.5 Lakhs each
Rs.0.43 lakhs
Action; Under Secretary EPP -IX and RCH/ Consultant MH)
Agenda 9:
Hiring of Vehicles, Payment of TA / D.A for under taking tours and Reimbursement of local
transportation chargesfor visiting other offices to, RCH Consultants:
The committee agreed in principle, for the proposal to hire vehicles for tours by the three
Consultants (IEC,MH,M & E ) subject to the following conditions:
For reaching long- distant district headquarters the Consultants would use
railways, wherever possible.
b)
For nearby districts( Kolar, Tumkur, Mysore and Mandya) they can liire
vehicles from Head Quarters i.e. Bangalore
c)
If a no. of districts are covered in one tour, even if they are nearby, the veliicles
can be hit cd from Head Quarters i.e. Bangalore
d)
The District Health & FW Officers will be authorized to liire the veliicles at tlie
local rates by following local shopping procedures for the Consultants on receipt of
their tour programme.
a)
It was decided that the Consultants would be reimbursed the luring charges by the Project
Director (RCH) as per the approved rales.
Action; Under Secretary IPP -IX and RCH/ Accounts Officer (FW)/ Consultants IEC/MH/M&E
Agenda 10:
Release of funds for maintenance of Cold Cham and purchase oj Injection Safety
(Kerosene oil):
The PD (RCII) clarified that kerosene oil would used for boiling water in the autoclaving
equipment, thereby ensuring sterilized syringes and needless for use in immunization sessions.
Release of funds for CC maintenance and Injection Safety, as per the nonns stipulated by
the Govt, of India to the District Health & FW Officers, was approved by the committee.
Action: Accounts officer (FW)/Under Secretary (IPP-IX&RCH)
Agenda 11:
Release offundsfor Referral Transport:
Il was suggested by (he Principal Secretary that clarification should be obtained from the
GOI about the applicability of tlris to the obstetric services rendered by private institutions.
However; the proposal for operating tire scheme, to start with, in the Govt. Institutions, was
approved by the committee.
Action: a. Project Director (RCII) (for clarification from GOI)
b. For issue of G.O. - Accounts Officer (FW)/ Under Secretary IPP - LX (RCII)
Agenda 12:
Hiring of vehicles tinder sub - project, Bellary
The DHFWO, Bellary, informed that he has already submitted a proposal to the Project
Director (RCH) in this regard.
The committee while agreeing to release Rs. 12 Lakhs simultaneously suggested that tire
proposal of the Dll &.FWO, Bellary should also be examined as to the competitiveness of rates,
before issuing necessary* permission.
Action: Accounts Officer (FW)/DH&FWO, Bcllaiy
Agenda 13:
Procurement of Furniture to Consultants
The Committee delegated the powers for procurement of furniture for Consultants to the
Project Director (RC1I).
The Committee further delegated powers to Project Director (RCH) for all minor
procuremenls/purchases as per the general delegation of powers for a HOD, without having to
seek the approval of the SLSC.
Action'. Accounts Officer (FW)
Agenda 14
Procurement ofSurgical Kits (Kits CtoP) for RCH Project
Dr. A.S. Shamanna, Joint Project Director (PC), explained the contents of these kits and
process of revision of the specifications.
He further informed the committee that the revised
specifications of GO1 have already been handed over to (he KHSDP authorities.
The Committee then requested the Project Administrator ,KHSDP, to expedite the
procurement surgical kits &drugs and place proposals for release of funds .
Action-. Project Administrator, KHSDP
Agenda 15
Procurement of two (2) Ambulance for Sub-Project, Bellary
The committee noted that two ambulances would be given to the two NGOs in.Bellary.
District and that these NGOs have to bear the cost of drivers and POL.
The Committee agreed to the procurement of two ambulances for the Bellaiy Sub-project
at an approximate cost Rs. 10 lakhs and requested the Project Administrator, KHSDP, to take
necessary action for procurement.
Action'. Project Administrator, KHSDP
10
Agenda 16:
I EC Activities in the Sub-Project Hellary
The Committee gave approval in principle for implcnfenting the IliC Action Plan chalked
out by the Joint Director (LEC) and placed at Annexure-3 of (he agenda notes.
The Commissioner briefed the Principal Secretary and the committee that this action plan
is in accordance with the convergent LEC Strategy and that detailed guidelines would be issued.
The DH & FWO, Bellaiy was instructed by the Committee to implement the action plan
effectively and bring behavioral changes in the community. The Principal Secretary, requested the
Commissioner to look into the LEC activities also during his ensuing visit to Bellaiy.
The JD (LEC) has to accompany the Commissioner to ensure action for vigorous
implementation of the LEC activities.
Action-. Joint Director (JECJ/DH & FWO, Bellaiy/ Consultant (IEC)
Agenda 17:
Appointment of Contractual Staff under sub-project, Bellary
The committee while conceding the need for incremental staff for improved services felt
that the remuneration fixed for Staff Nurses should be atleast equal to or more than that for the
Lab. Technicians, in view of their liighcr qualification.
The Project Director (RCH) intervened
and pointed out that the proposed rales are as per the prevailing rates of government. The Project
Director (IPP - IX) suggested that the proposal be approved as placed before the committee and
revise the rates as ;md when changes arc effected by the Govenunent. Tliis suggestion was agreed
to by the conuuiltee and thereafter approval was given for creating these posts on an incremental
basis as proposed in the Sub Project document and to empower the DCs to recruit them .
The Project Administrator, KIISDP, was requested by the Piincipal Secretary to prepare a
suitable cabinet note for modifying the remuneration- structure of all categories of contractual staff
in tunc with the changes in the corresponding pay scales and other relevant aspects like
qualification, and nature of responsibilities.
Action-. Under Secretary 1PP - 1X/RCH, Deputy Director (MCH)ZProject Administrator
(KI-ISDP)
Agenda - 18:
Procurement ofDrugs. Pethidine and AB Cotton under National Component
It was agreed that the KI ISDP could procure AB Cotton and other essential drugs already
listed and approved.
Action: Project Admijustraior, KIISDP
No.RCH/12/98 - 99
Sd/Principal Secretary to Govt.,
Health & FW Department
and
Chairman State Level
Steering Committee
Sri. Sanjay Kaul, Commissioner for H & F W Services, Bangalore
Sri. Ashok Kumar Manoli, Secretaiy(Expenditure), Finance Dept. Bangalore
Sri G.V. K. Rao, Project Director, IPP - IX, Bangalore
Sri. Arvind G. Risbud, Project Administrator, KHSDP, Bangalore
Dr. G.V. Nagaraj, Director (PC), Directorate of Health Services and Project Director (RCH)
Bangalore
6. Sri. K. Shankar Rao, Director, Planning Dept., Representing Secretary to Govt., Planning,
Institutional Finance and Statistics, Bangalore
Dr. A Shamanna, Joint Project Director (RCH) (FC) Bangalore
Sri. G. Prakasam, Demographer, DH&FWS Bangalore
a
tA'/Ls' <r
Sri. N.'f. Marulasiddappa, Joint Director (VC), IEC Bangalore-^
-Sn. Krislinamurthy Accounts Officer (FW) Bangalore
Dr. Matijunath Gowda, DH&FWO, Bcllaiy representing CEO, ZP, Bcllaiy
Representative of Secretary to Govt., Women & Cliild Welfare Department Bangalore
13. Representative of Secretary to Govt., Public Works Department Bangalore
✓Under Secretary,. IPP -LX and RCH Project Bangalore
Consultant IEC
Consultant MH
Consultant M&E'
U(18. Deputy Director (MCH) .
19. Deputy Director (IUD & PPP)
1.
2.
3.
4.
5.
Project Director (RCH)
&
Member Secretary
State Level Steering Committee
PROCEEDINGS OF THE GOVERNMENT OF KARNATAKA
Subject: - Reproductive and Cliild Health Services ProgrammeUtilization of funds for 24 Hours Delivery services at the
PHC’s/CHC’s.
READ :
1. No. FWG(l). RCH/29/99-2000 Dated: 17/07/99 of Project Director (RCH)
2. No. FWG( 1 )/RCH/29/99-2000 Dated: 17/02/2000 of Project Director (RCH)
3. Proceedings of the 12th State Level Steering Committee on RCH held on
1 O'1' August 2000
PREAMBLE:
Attempt is being made to set up 24 Hours delivery services in the PHC’s/ CHC’s in the
districts under the RCH Programme. The arrangements in this scheme is proposed to involve a
mechanism for one doctor to be available on call, atleast one staff nurse being available beyond
normal working hours in the PHC’s and cleaning services being available similarly beyond the
normal working hours i.e. Between 8.00 P.M. in the evening and 7.00 A.M. in the morning.
The Honorarium paid to each of them arc as follows-
;
1. Rs.200-/-per delivery to the doctor who conducts the delivery.
2.
Rs. 100-/-per delivery' to the staff nurse who conducts and/or assists in the
delivery.
3.
Rs.30- - per delivery to the cleaning services personnel.
The above Honorarium will not be admissible to Doctors /staff Nurses on night shift
duly and also restricted upto 50% of deliveries conducted in such institutions or actual
number of deliveries conducted during night hours whichever may be less.
GOI has released Rs.3.43 Lakhs to ensure 24 Hours delivery services available in
health centres.
The State Level Steering Committee on RCH in its 12lh meeting held on 10/8/2000 has
approved the above action plan.
Hence. :iris order.
GOVERNMENT ORDER NO.HFW/7/RCH/2000-01 BANGALORE,
DATED-4.10.2000
In the circumstances explained above and in superssion of the earlier orders
issued by Project Director RCH in tlris regard, the government of Karnataka ’are pleased
Io accord sanction for the release of funds to different districts as detailed below:
SI.N’o. District
Kolar. .
Mysore
Mandya
Chamarajnagar
Dharwad
Bangalore (R )
1
3.
4.
5
6.
Amount.
Rs. 1.00 lakh
Rs. 0.50 laklr.
Rs. 0.50 laklr.
Rs. 0.50 lakh.
Rs. 0.50 lakh
Rs. 0.43 laklr
Rs. 3.43 lakhs.
The CEO’s of the concerned districts are authorised to draw and disburse the
above amounts to different PHC’s/CHC’s through the concerned DH & FWO’s. These funds
shall be utilized for 241-Iours delivery services at the PHC’s /CHC’s in the manner
prescribed in the RCH manual i.c. for payment of Rs 200-/- per delivery to the Doctor,
Rs. 100-/'-per delivery to the staff nurse and Rs 30-/-per delivery to the cleaning services
personnel subject to the condition that:1. The delivery must be between 8.00 P.M. in the evening and 7.00 A.M. in the
morning.
Hie Honorarium is not admissible to Doctors/Staff Nurses on night shift duty and
also restricted upto 50% of deliveries conducted in such institutions .of actual
number of deliveries conducted during night hours whichever may be less.
2.
The above expenditure is debilable to the Head of Account “2211-FW-00103MCH-0-70-RCH Services, National Component
By Order in the Name of the
Governor of Karnataka.
Under Secretary' to Govt.
Health &FW Dept. IPP IX & RCH Project
To:
1.
The Accountant General. Karnataka. Bangalore
2. '1 he Private Secretary to Chief Secretary to Govt, of Karnataka, Vidhana Soudha, Bangalore •
3.
The Principal Secretary to Govt., Health & FW Dept./Planning Dept.
4.
The Commissioner for Health & FW Services, Bangalore
5.
The Additional Secy, to Govt Finance Dept.. Bangalore
6.
The Project Director IPP - LX, Bangalore
7.
The Director for Health & FW Services, Bangalore
8.
The Project Director (RCH), Dll & FWS, Bangalore
9.
The CAO - cum - FA, DH & FWS. Bangalore
10.
The Accounts Officer (FW), SFWB, DH &FWS, Bangalore
11.
The CEO, Zilla panchayat, Kolar/Mysore/Mandya/Chanuajnagar/Dharward/Bangalore
(Rural)
12.
Divisional Joint Director, Bangalore/Mysore/Belgaum Division
13.
Distr ict Health & FW Officers Kolar/Mysorc/Mandya/Chamrajnagar/Dhanvard/Bangalore
(Rural)
14.
Consult (RCH) IECMHM&E/CH
15.
Oflice Com
PROCEEDINGS
OF THE GOVERNMENT
OF KARNATAKA
Subject: Reproductive and Child Health Services Programme Engaging Transport Facility to pregnant women for safe delivery at
Subdistrict and CHC level-
Rcad: Proceedings of the 11th and 12th State Level Steeling Committee oh RCH
held on 8lh May 2000 and 10th August 2000
Preamble:-
As
a
supplement
to
emergency
obstetric
care
under
the
RCH
programme, it is proposed to incur an expenditure upto a sum of Rs 200- per
client for providing transport facilities to pregnant women to have safe deliveries al
FRUs. Ncccssaiy amount is earmarked for tins putposc. This amount is proposed
to be kept at the disposal of Taluk Health Officer of the concerned taluk.
The State Level Steering Committee on RCH in its 11th and 12th meeting
held on 8th May 2000 and 10th August 2000 respectively has approved the
. proposal for operating the scheme in the Government institutions of the districts of
Gulbarga, Bidar, Bijapur, Bagalkote, Raichur and Koppal.
Hence (his order.
Government Order No. HF W/11/RCH/2000-01
Bangalore
Dated 3..SU - 3.x o o In
the circumstances explained above, the Government of Karnataka is ’ pleased
to accord sanction for the release of Rs 10.00 lakhs ( Rupees ten lakhs only ) to
the following districts towards engaging transport facility to pregnant women for
safe deliveiy at subdistrict and CHC level. Approval is also accorded for payment
of Rs 200- per client for tin’s puipose.
SL. NO.
1.
?
3.
4.
5.
6.
District
Amount in Rupees.
Gulbarga
Bidar
Bijapur
Bagalkote
Raichur
Koppal
2.5 lakhs
1.5 lakhs
1.5 lakhs
1.5 lakhs
1.5 lakhs
1.5 lakhs
Total
lOktkhs
This above expenditure is debitable to the Mead of account 2211-F W-00-103MCH-0-70 RCH Services-National Component.
By Order and in the name of Governor of
Karnataka
(Scwngflg^pth-al)
Under Secretary to government Health & FW Dept.
1PP-IX and RCH project.
TO
1. The Accountant General, Karnataka, Bangalore.
2. The Private Secrelaiy to cliief secretary to govt. Of Karnataka, Vidhana soudlia,
Bangalore.
3.
The Principal secrelaiy to Govt., Heallh&FW Dept./planning dept.
4.
The Commissioner for Hcallh& FW Services, Bangalore.
5.
Tito Additional Sccretaiy to Govt., Finance Dept., Bangalore.
6.
The Director of Health & FW Services, Bangalore.
7.
The Project Director ( RCH),IPP - LX, DH & Fvvs, Bangalore.
8.
The cliief accounts ofTicer-Cum -Financial Advisor, D H & FWS, Bangalore.
9.
The Accounts officer (FW), D H &FWS, Bangalore.
10.
The CEO, Districts of Gulbarga, Bidar, Bijapur, Bagalkote, Raichur and
Koppal.
11.
The Divisional Joint Director, Gulbarga and Belgaum Division.
12.
The District Health & FW Officer of Districts of Gulbarga, Bidar, Bijapur,
Bagalkote, Raichur and Koppal.
13.
Consultants lEC/lvRPM&E.
14.
Office copy.
EINANCIAL PROCRESS UNDER RCII - NATIONAL COMPONENT
Item
■
Budget Released ;
1997 to
1999
2000- i
_2ooi__
E:tpcnditure
1 Total
1998- i 19992000199? J .2000 . 20(11 J
(Rs. in Lakhs)
_ Remarks
1
Drugs
15.50
A.B. Cotton
31.13
Civil Works-Major
Minor
0.00
190.00
PHN__________________
185.00
SCOVA__________ _2-VQ9__
SM Consultant
8.00
24 hour Delivery
3.13
Services______________
Transport Charges
5.00 _
CC Maintenance____
26.00
Petliidine injection___ ___ L80____
Immunization Cards __
Eligible Couple
198
Registers
Consultants
__ _ ooo
IEC-ZSS
57.30
1EC- National
0.00
Component____________
Upto June 2000
Govt. Of India is supplying drugs directly.
Hence there is no need tor litis amount
Govt. Of India is supplying drugs directly.
Hence there is no need for tliis amount
i07,20 ~TO7,2O ~ o9 Major Civilworks under pr*»gress_____
~ 86.07
86.07
Works have been completed in progress in
17 districts
r 0
1
____0____
0
Not applicable
_0 J
0
0____ Z_______________________________________1
0
0
1
883.00—
3£62"_
12.99
L 'T00_
1
0.00
7.70
3 20
0
0
__ 0___
0
0
___ 1.20__
2.16
’ 21.14
2.95
0
6.80
Total___________ __
558.92
J 14.62
Kind Materials______
1275.84
3o3 00* _2HL95_
12.99
34.85
2172.09
216.57
0
25.99
0
7.70
3.20
This is not required as there are substinites
Amount spent hilly___________ __________ 1
Amount spent fully
3.36
r 24.09
_______________________________________ J
________________________________________
6.80
26441
________________________________________
n
0___-1284.64 ________________________________________ 1
Anncxure — Il (B)
FINANCIAL PROGRESS UNDER RCH-SUB-PROJECT, BELLARY
Physical
Item
Civil Works
19992000
20002001
20012002
19992000
20002001
20012002
31
49
21
150.00
330.00
216.21
096.21
174
Equipment
64
93
'
51
Furniture
15
Vehicles________
IEC
Training______
NGO Support
Total
Financial
i
1
2
Contractual
Sen-ices________
Drugs___
Operating Cost
50
'
14
4
4
___ oO
?s
_
1
I
37.80
15.00
8 40
|
______
01.20
o
40.00
0
1
30.93
52.50
5.65
2
0_
_o0.00_
10.00
10.00
28.50
10.13
15.05
i_________
i 104.00
91 50
___ q_ _
0
124.02
25.00
93.00
259.52
51.72
? '
10 00
55.00
52 D
11125
5-1.14 T 11 1.1 1
___ q
Consultancy
"i:"
j
rz
!_______
I
_....
7 50
~<00 '
441.19
560
Amount
Reieased’to
implementing
agency__
Expenditure
l’p to
March
2000
lip to
May
200b
100.00
0
62.00
50.00
0
0
0.00
0
0
6
0.00
5 00
3 81
5.00_____ 4,21
0
2 OO+^.OO
____ =9.00
_
5.00
0
___ 50J)0_
O.OO’
0
___ 3.81____
1.21
0
2.00
0
100+126 =
226.00
'13.02
Construction work of 25 sub - centres
started and expected to be completed by
Sept. 2000__________________________
Tenders have been called and evaluation
process_K completed
Furniture will be supplied after the
of (lie bujklings
Training programme1S under progress
Two NGOs have been selected and GO.
releasing Rs/TOO Lakhshas been issued-
0
0
5.00
_0
5.0b
|
478.48 ''”15O4'.75
L ... t J ....
.
(Rs. In LalJts)___ ____
Remarks
1
'75.02'
[ (33.19%)
World Bunk clearance is sought
Balance of funds has to be utilized in the :
successive years __
Budget released
to
engage
8 M j
Consultants- expenditure awaited
It is often forgotten that women also suffer from communicable and other diseases during pregnancy
with attendant morbidity & mortality in the mother and the child. These include malaria, Viral
hepatitis, Tuberculosis, rheumatic heart disease, diabetes, etc.
Parasitic infections like Amebiasis, Giardiasis, Leishmaniasis, Malaria, Nematodes etc.
may adversely affect fertility and/or reproductive capacity in the following ways:
They may produce sufficient debilitation and/or anatomic damage to the genital tract so that conception is
impossible or normal implantation does not occur,
Several reports have suggested that the parasitic infections during pregnancy may be more severe and may b
associated with a higher mortality rate than occurs in a non-pregnant women.
Protozoan parasites may infect and cross the placenta to produce adverse effects on the fetus such as abortioi
fetal infection, still birth, intrauterine growth retardation, and congenital infection.
They interfere with the nutrition of these women and result in a worsening of the already critical nutritional s
with resultant impaired fetal growth. Malnutrition is also associated with immuno- deficiency, and thus the
susceptibility of pregnant women to bacterial and viral infections apd their recognised consequence for the ft
new bom is increased. Infections by nematodes like ancylostomiasis (hookworm) for instance can lead to an<
Malaria in pregnant women is associated with intrauterine growth retardation, spontaneous abortion and stilll
the neonate congenital malaria presents within 48-72hr after delivery.
Trichomoniasis: women who are infected during pregnancy are predisposed to premature rupture of
the placental membranes, premature labour and low-birth weight infants. Also linked to this disease are
cervical cancer, atypical pelvic inflammatory disease and infertility.
Some complications during pregnancy also affect the child, which increases foetal and perinatal death
as well as morbidity like premature birth, low birth weight and infection among children.
Latest studies show that nutritional insults during the first trimester may set a low fetal growth
trajectory and once set, the potential for later catch up in growth orfunctions appears to be limited.
Health and Family Welfare Policy:
In the past, India’s Health and Family Welfare Policy focussed on meeting contraceptive “targets”. The
programmes virtually ignored women who were not of child bearing age (adolescent girls, single
women, women with infertility and post-menopausal women). Even among child- bearing women,
only sexually active women, especially those who had not yet “completed their desired family size”
were targeted for reproductive care interventions. They failed to address the root causes of women’s
poor reproductive health status, and consequently did little to improve their general well being over the
long term.
In the obsession with meeting family planning targets, training and skills development
in clinical diagnosis and rational management of women's health problems have suffered.
The International Conference on Population Development, held in Cairo in 1994, and The Fourth
World Conference on Women, held in Beijing in 1995, emphasized the need to empower women to
access services relating to all aspects of their health. It asserted that improvements in women’s health
needs should be met through the availability of affordable, comprehensive, integrated and holistic care,
within easy geographical reach of women. Reproductive health and primary health care programmes
are expected to address these gaps in health service delivery,
with the
comprehensive health problems
gender equity concerns into their
programmes.
... ,
'
2
Following this the Government of India’s Health and Family Welfare Program changed to a
more comprehensive Reproductive and Child Health (RCH) Programme offering the following:
a. Prevention and management of unwanted pregnancies and family planning services:
Spacing & sterilization.
Providing services for MTP to women who choose this option in order to avoid incidences of unsafe
abortion.
b. safe motherhood (ante natal, natal & post natal) services
Antenatal care and identification and referral of high risk pregnancies to the FRH
Immunization with 2 dozes of Tetanus toxoid
Prevention, detection and treatment of anaemic pregnant women with Iron Folic Acid (IF A) tablets.
Natal Care
Delivery as far as possible, in hospitals, PHCs or subcentres under the supervision of trained qualified
personnel. Assisted by LHVs, ANMs or trained birth attendants. Delivery in hospital ensures newborn
care and therefore can substantially reduce incidence of infant mortality.
Emergency obstetric care services for high-risk labour cases
Postnatal Care - for 42 days after delivery of the placentaAdvice and guidance to the mother about breast-feeding, nutrition, hygiene, care of the newborn and
immunisation.
Referral immediate emergency obstetric care in case of fever foul smelling discharge, bleeding,
abdominal pain, painful breasts, pain while passing urine and abnormal behaviour. '
c.
Diagnosis and treatment of RTI & STI
d.
Child survival - care of new bom
immunization
management of diarrhoeal diseases and ARI
Vitamin A prophylaxis
RCH programmes in the rural areas:
The RCH programmes in the rural areas are implemented through the Primary health care facility
network of Sub-Centres and Primary Health Centres. The Community Health Centres (CHCs) and
Taluka Hospitals are the First Referral Units (FRUs).
The ANMs play the major role in these programmes and are assisted by traditional birth attendants
who also provide antenatal and delivery services. The ICDS programme of Women & Child
Department, through Anganwadi workers are responsible for ensuring access of the health care
services for children up to 6 years of age. The Male Health Workers are supposed to focus on
motivation of males to access family planning and other health care services.
Urban RCH programmes are within the ambit of the City Corporations Of Town Municipalities. In
Bangalore for example the Bangalore Mahanagara Palike has 30 maternity homes, 37 Urban Family
Welfare Centres (UFWCs) and 55 health centres funded by the World Bank under the Indian
Population Project VIII (IPP-VHI). In addition there are 25 dispensaries and some Aurvedic clinics for
general ailments under the BMP.
3
The IPP centres and UFWCs focus on routine out patient RCH activities, with field staff and Honorary
link workers residing in the slums, who motivate mothers to utilize facilities and services for antenatal
care, delivery, family welfare, immunization etc. They act as referral units for the maternity homes
which focus on delivery; medical termination of pregnancy (MTP) and laboratory test in addition to
providing antenatal / postnatal care, family planning non-surgical care for children needing specialists
attention and minor gynecological procedures. All the services at all these facilities are supposed to be
provided free of cost. The IPP VUI programmes are being extended to other urban areas.
Specialized facilities, staffed with trained gender sensitive health care providers of both sexes,
were expected to provide the full range of reproductive health services to both men and
women.
• Sub Centre plan: Unmet needs for Reproductive Services were supposed to be identified &
quantified which, along with demographic data for that area and the previous years
performance, would form the basis for the planning of the programme.
Unmet need is defined on the basis of women’s response to survey questions. The unmet group
includes all fecund women who are married or living in union and thus presumed to be sexually active,
who either do not want any more children or want to postpone their next birth for at least two more
years, but not using any method of contraception.
•
However, at the field level, this paradigm shift has not become a reality, the target based
functioning is still very much in practice and the programme still targets mainly women.
Health indicators:
. It is apparent from the some of the health, developmental and other indicators that the RCH
: programme is not as effective as envisaged. This is true of Karnataka as also of most other states in the
country.
Infant Mortality Rate (IMR)
The IMR is 51.5 according to NFHS-2, and 58 according to SRS 1998.
IMR is 70 for Rural and 25 for Urban areas and varies from 29 in Dakshina Kannada to 79 in Bellary.
The IMR for females is 72, and highest in Dharwad Bellary & Bidar.
The Maternal Mortality Rate (MMR) according to UNESCO is 450. But recent estimates by SRS
(1998) places it at 195 per 100,000 live births.
Crude Birth Rate
The SRS estimate of CBR in 1998 was 22 per 1000 population; 23.1 in rural as against 19.3 in urban
areas. CBR has been fluctuating widely rather in Karnataka and the regional disparity is similar to
other indices.
Family Welfare:The then Maharaja of Mysore created history when he started the first official family
welfare clinics (birth control clinics) in Victoria, Vani Vilas Hospitals at Bangalore and
Krishnarajendra Hospital at Mysore in 1930.
Since then the Family Welfare programme has come a long way. The couple protection rate increased
from 12% in 1971 to 48 % in 1993 and to 57% in 1995-96. This varied from 41% in Raichur to 73% in
Mandya
But the emphasis of the programme is on sterilization (40% in 1993) and not on spacing (9% in 1993)
4-
Another disquieting fact is that over the years the participation of men in family welfare has reduced.
The proportion of vasectomies in the total sterilizations in Karnataka increased from 43% in 1958-59
to 59% in 59-60 and to 95% in 67-68. It was 52% in the emergency year of 1976-77. But this fell to
0.1% in 1993-94, 94-95 & 95-96.
1992-93 figures also showed that fewer men (1.7%) than women (6.8%) adopted spacing methods.
The Second National Family Health Survey, 1998-99, showed that in the preceding 4 years:
The emphasis on sterilization and that too among women was apparent from the 51.5% of married
women being sterilized.
Mothers received antenatal care in 86% of births, though mothers in rural areas were less likely to visit
an allopathic doctor.
Only 51% of live births took place in a health care institution but 70% were attended by doctors and
15% by dais.
Nearly 25% of mothers did not receive even one doze of Tetanus Toxoid.
75% of mothers were given Iron & Folic Acid tablets but it is anybody’s guess as to how many
actually took them.
Immunization for BCG, DPT & Polio was good but for Measles it was only 67.3%.
Nearly 42% of children with diarrhoea were not given Oral Rehydration Therapy of any sort.
In Karnataka:
According to the 1991 census the Gender Ratio is 960 women for 1,000 men. This is worse than in
Kerala, Andhra Pradesh, Orissa and Tamil Nadu. But more disturbing is the fact that it has worsened
between 1981 & 1982.
The Gender Ratio is unfavourable to women in most districts except in Dakshina Kannada & Hassan
Issues of concern in implementation of RCH programs:
Inadequacies in terms of infrastructure and delivery of services:
• The aim of the RCH program to attain 100% institutional deliveries may be a laudable one. But the
inadequate capacity both in terms of numbers and in terms of quality of services has led to a low
proportion of institutional deliveries.
• Shortfalls in staffing requirements, especially lady medical officers and trained birth attendants has
lead to sub-optimal implementation of RCH programs. ANMs too are not always available. Large
vacancies are aggravated by cumbersome recruitment procedures; unauthorized absence and
indiscipline in work force.
• In this context the role of the Traditional Birth Attendants or Dais is very crucial especially
in providing natal services. It was surprising to note therefore, that the Dai training program was
abruptly stopped without ensuring functional alternatives.
• The Disposal Delivery Kit program also has been abandoned without insights into its functioning
or the need for alternate measurements.
• During delivery, while the birth attendant looks after the birth component, the crucial needs of
the newborn is ignored. This can lead to complications like hypothermia, infections etc. This is
one reason for the increased incidence of infant morbidity and mortality.
• The nutrition needs of the child between 6 months to 2 years does-not get the attention it
deserves. ICDS does not adequately cover this age group, leading to high rates of malnutrition
amongst them. This leads to increased incidence of infections, delay in mile-stones and retarded
physical & mental growth.
Inadequate attention to quality:
The quality of care framework developed by Judith Bruce (1990) uses the following indices to assess
the quality of care received by clients:
Accessibility and availability of services; availability of basic facilities and essential supplies, choice
of methods; information to users; technical competence; client-provider interaction; continuity of
services; and appropriate constellation of services, including treatment for sexually transmitted
diseases and MCH care.
In terms of these indices it is seen that the quality of services is poor. Lack of discipline,
accountability and a lack of adequate training and motivation among the health care givers at all levels
are factors which lead to the poor quality. Often even the basic common courtesies are not extended. A
telling evidence is the treatment meted out to the women at tubectomy camps, where numbers score
over the entitlement of the people.
Poor quality of care and client satisfaction in the RCH services is reflected in lower levels of client
satisfaction, a poor image and general distrust of public sector system. This in turn results in weak
commitment among the RCH staff.
• Bed occupancy in PHCs is low as 11.9%; and there is a lack of proper integration of PHCs with
higher level facilities; Many patients go directly to secondary and tertiary level facilities.
Several Indian studies have reported that the rude behaviour of health staff has been a major reason
why women have not liked or used the government health'services and compelled them to go to private
doctors.
.
Government health functionaries usually blame the lack of equipment and supplies for the poor quality
of their services. Ramasundaram (1994) has however observed that even when equipment and
supplies were made available, clients continued to receive poor quality of care. He attributed this to
the attitudes of health workers, who showed little respect for clients, particularly if they were poor,
illiterate or from lower social strata. Some health workers even believed that because the government
provided free services and also gave cash incentives for sterilization operations, the clients had no right
to demand good-quality services.
Corruption - A major barrier to quality care for the poor:
People are not aware of their rights to health care, the facilities that are available and do not value the
services provided because everything is supposedly free. At the same time, several studies have proved
that corruption at many levels ensures that unaccounted charges are collected even from the poorest.
In a study by Jagadish C. Bhatia (1995) on the " Constraints to service quality in Rural Karnataka", all
categories or workers have cited the issue of widespread corruption during the in depth interviews and
focus group discussions. The Auxiliary Nurse Midwives (ANMs) complained that their bills, arrears,
and other claims were inordinately delayed unless they agreed to pay a portion of their claims as
"speed money".
Following are some highlights of the comments made by anLJHV with more than two decades which is
a telling tale of how deep rooted corruption.is in the area of pwblic service delivery:
6
"In the past, although we had much less manpower, logistic support, service prerequisites, housing etc.,
you will be surprised to learn that we used to work well. However overtime the working standards
deteriorated with the gradual erosion in the ethical standards of immediate supervisors and higher
officials, which paved the way to the institutionalization of corruption in the health department. Today,
to be corrupt is no longer considered reprehensible. Drugs and equipment in the health facilities are
misused without any hesitation. The doctors are interested only in private practice and amassing
wealth".
A World Bank initiated study in 1999 confirms free access to quality health care services at the IPP
health centers, but not in the maternity homes being run by BMP. None of the services like MTP,
sterilization, delivery were being provided free of cost and an "informal / unofficial user fee" (= bribe)
was demanded in almost all cases. The desperate condition of the patient and the their families in a
medical emergency is being exploited to the maximum.
A study by the Public Affairs Centre published in May 1998 on "Bangalore Hospitals and the Urban
Poor- A Report Card " revealed that:
• About 89% of the respondents interacting with BMP maternity homes admitted having paid bribes
(speed money) to access better services.
• There are distinct differences in service quality between maternity homes and IPP health centres.
While maternity homes do not score that well on cleanliness and hygiene, IPP health centres do.
Basic medicines that are to be given free are not being given to a large proportion of poor patients
at Maternity homes, while at IPP HCs most people get free medicines.
• The differences in quality of service are also indicative of poor discipline and responsiveness
, among the staff at maternity homes
• The practice of corruption is far more entrenched in maternity .homes than in IPP health centres.
Bribes are being demanded and paid for almost every service being provided at maternity homes.
• The staff are not ready to accept the prevalence of corruption leave alone trying to tackle it.
With the termination of World Bank assistance in the year 2001, the IPP facilities are going to be
integrated with the existing system of the BMP for routine operation and maintenance. The two main
concerns arising out of this are about the state of infrastructure and strong foundation laid by the IPP
health centers under the administrative regime of BMP; and the impact of corruption in terms of its
potential to invade and corrode the IPP facilities.Inadequacies in terms of infrastructure and delivery
of services
Distortions in Primary l(ealth Care:
There is Itick of ibif^ratioh ofthe RCH programme into the general Health System. This emphasis as a
separate vertical program results in ignoring the basic health aspects and diseases not addressed under
the RCH program, including menopausal and other gynecologic problems, cancers etc.
Community participation and ownership of the programme by the community is lacking. This can be
seen by the fact, that even the Sub Centre plans are still made on the basis of the previous year's
"targets". Ahousehold survey and assesses "Unmet Needs" is not being done.
Partners^ps.with, the JiGOs and the private health sector are not adequately explored
Eaek* of Equity:.
Regional inequalities:
7
The poor quality of services is worse in the Northern districts and gets compounded by poor social
structures, poverty and low literacy levels. All this leads to even lower access to whatever services are
available.
Gender inequality
The programme is insensitive to the gender inequality factor and therefore does not address it
adequately.
• When women are not allowed to make choices about their life, they are hardly in a position to
make choices about contraceptive methods, ‘negotiate’ with their partners to use condoms or to
respect their reproductive rights, their feelings and their emotional needs.
• Male Responsibility
The issue of male responsibility in matters of contraption, STD, AIDS; sexual violence, growth of red
light areas, trafficking of women, spread of pornographic literature and blue films, growing market for
aphrodisiacs and male potency drugs, need to be addressed. The role of male sexual behavior, gender
relations, sexual and gender responsibility, role of the ‘Y’ chromosome from the male partner in
determining the gender of the child, etc.
• In the name of empowerment, contraceptive responsibilities have been transferred to the women.
In health programmes and policy planning, it should be ensured that pregnancy is made a matter of
male concern.
Gender sensitive indicators
The indicators used to assess RCH programmes focus on general reproductive health aspects, thus they
are not useful to measure the impacts of the gender sensitive policy on the field level situation. So <
there is a need to develop gender sensitive indicators to specifically measure the integration and
outcome of gender sensitivity at the programme level and subsequent changes at the community level.
Gender sensitive indicators that may be used to assess RCH programmes are:
• Average attendance of men and women at meetings with the community.
• Number/percentage of couples who participate equally in decisions regarding reproductive issues
and sexuality.
• Number of women who negotiate with their partners for the use of condoms.
• Number/percentage of men using condoms.
• Number/percentage of the total pregnant women who report that the present pregnancy was not
planned/unwanted and who are able to take a decision themselves to undergo MTP.
• Number/percentage of men who think that use of family planning method is the wife’s
responsibility.
• Number/percentage of sterilizations that are vasectomies.
Men have to be sensitized to this gender perspective and influenced to assume responsibility for the
consequences of their sexual behaviour and reproductive roles; and share household work and child
■ rearing. They have to actively promote gender equity, girl’s education and women’s empowerment
within their families, communities and work places.
Gender perspective of heaftfrcare providers
The work of health care providers is divided along gender lines and tends to be inequitable fpr fppiale
providers.
3
The ANMs are completely responsible for MCH, family planning and outreach work, while male
health providers focus on prevention and control of infectious diseases. This makes male health care
workers insensitive to reproductive health issues.
ANMs are overburdened; lack logistical and administrative support, travel long distances alone at odd
hours of the day for home visits, risking their own personnel safety and security; and receive abusive
and biased treatment by virtue of working at the bottom rung of a male dominated hierarchy.
Lady Health Visitors do their own work as well as that of the male workers.
Ensure that gender inequalities among male and female health workers are reduced.
Give adequate training and skills to perform their responsibilities in a gender sensitive manner.
Ensure that both men and women are represented in managerial and supervisory roles.
Recommendations
Improvement of infrastructure-StalT:
1. The system of deliveries by Dais should be supported, with enhanced training.
2. Disposable delivery kits should be reintroduced with good quality cost effective components. This
should be available with the expectant mothers.
3.
As far as possible, ANMs should be posted in their home villages. This will solve the problem of
safety and timely attendance.
4.
The present workload of ANMs needs to be rationalized- less paper work and better use of their
expertise and talent.
5.
Mobility of the ANMs should be enhanced and the loan facility to buy a two wheeler may be
made available in districts not covered by IPP IX also. As far as possible the ANM should be
encouraged to drive it herself. Training for this may be given as part of the ANMs Training
Programmes.
6. Village health committees should be established with the ANMs, so that essential programmes are
planned with certain objectives and aims which are specific to local needs, rather than target
oriented vertical programmes. The committee could involve the community and NGOs in
generating demand for RCH services.
7. Improve availability of trained staff by introducing certain government approved, training courses
such as:
a. Trained Nurse Anaesthetist
b. Nurse-Obstetrician Practitioner (2.5 year course for registered nurses)
c. Short-term training in anaesthesia for MBBS doctors (6m to lyr)
d. Midwifery courses for local village girls.
Training of birth attendants:
8. Initial as well as Periodic reorientation training should be obligatory.
9. There should be periodic evaluation of the educational courses for ANMs, Dais and staff nurse
midwives. All training institutions should be periodically inspected to ensure that prescribed
teaching facilities are available.
10.
The existing training programmes should be revised to incorporate enhanced field training
facilities ^nd technical a4td«communication skills to enable them to:
• Understand the£$A «e||i(>dology, assess the "Unmet Needs", and work out a realistic SC plan
based on acjl^l preferences of couples and not try to a^jeive top-down, unrealistic targets.
3
(Jo ct:i J e.-7>:.s-rupto 1-J-;
J->j; f: <jy>i f-c/O In
*I
£ v o I'j~f 1 p*> fi,ry *•”
i* p »<-<*■/•‘vc’ (Perzy^ <r
G-u'.H'tfe
V. fl. CrS'J,
u®.
^y/or^Fr^df
^cZr,
Endocrine Disruption in Children
”> V ZIFOV
Chapter 12_____________________________
AN ANTHROPOLOGICAL
INTERPRETATION OF
ENDOCRINE DISRUPTION
IN CHILDREN
Elizabeth A. Guillette
Bureau of Applied Research in Anthropology
University of Arizona
Tucson, AZ 85721
The first words uttered by parents after the birth of a child reflect their concerns
about normalcy. "Is my child all right?” The reply is based on the gross anatomy
of having five fingers and five toes, or other normal external features. The hidden
internal anatomy and physiological function are unknown. As scientists, we rec
ognize that harmony in external features does not guarantee conformity in
internal functioning. This fact grows in importance as environmental contami
nation becomes increasingly widespread. The possibility of covert effects of
endocrine-disrupting contaminants (EDCs), which may have an immediate or
delayed internal influence on the child’s overall health, have only recently
emerged, although gross teratogenic defects have been associated with such
EDCs as dioxin and certain herbicides (Sherman, 1995). The purpose of this
chapter is to present what is suspected and known about EDCs as obstructing
normal childhood physiology and functioning, and to place this knowledge
within a framework applicable to all types of EDC research.
Introduction
Other sections of this book reflect on the interactions of evolutionary responses
to the environment and how EDC contamination has not allowed sufficient
time for a protective evolutionary response to develop for most vertebrates.
Temporally, evolutionary responses occur very slowly in humans, reflecting a
323
long reproductive cycle between generations. On the other hand, cultural evo
lution has occurred at a more rapid pace. Marked technological change has
occurred in the western culture over the last hundred years and is increasing
rapidly. Developing countries, taking benefit of industrial and agricultural
advances, have experienced marked technological change in a .^natter of
decades. The children of today are a product of this cultural evolution as much
as they are of biological evolution. As with biological evolution, cultural evolu
tion serves as provocation for continuing action and reaction {n future
generations. We act and react according to the preceding changes that have
occurred, both on an individual level and on a global level.
More ancestral vertebrates are not excluded from this process of "moderniza
tion.” Specific aspects of both biological evolution and social organization are
tied to various aspects of human cultural evolution and social change. Foremost
are the pressures from human-induced ecological change and habitat compres
sion. Other diverse factors affecting both animal and human welfare include
pressures from population growth, social, economic, and political influences,
plus access to the basic necessities of life. Correspondingly, we must remember
that an event occurring locally may eventually have a global impact (i.e., the
destruction of rain forests). Evolutionary factors are .also a two-way street,
reflecting the evolutionary interdependence of animal and plant life. Changes in
biodiversity are known to lead to previously innocuous insects becoming devas
tating pests. Zoological and botanical change and/or extinction can easily feed
back into the quality and quantity of human life (Epstein et al., 1997). Thus, the
assessment of the impact of EDCs must be placed in a holistic, global context,
with recognition of the magnitude of events that are capable of shaping the
future for both animal offspring and our own children.
Reproductive Rights
The early unsettling hints that EDCs may be disrupting the many loci in the
endocrine system are increasingly being accepted as reality. In light of the exten
sive scope of findings, both in animals and humans, the time has come to place
endocrine disruption in a broad-based framework in which to evaluate the
future of our children. The foundation of the framework lies in the reformula
tion of basic rights to reflect the need for sustainable existence, including
ongoing reproduction and productivity. Three basic prerogatives, based in terms
of reproductive rights to ensure the health and productivity of future children,
are necessary: (1) the right to a healthy body for pregnancy and parenting, (2)
the right to impregnate or become pregnant when a child is desired, and (3) the
right to have the expectation that one’s children will be able to express these
same reproductive rights without physical or mental liabilities leading to restric
tions (Guillette, 1997). Such rights, as stated, decrease the emphasis on the
traditional soijiobiological paradigm regarding the passage of genes and increase
324
Environmental Endocrine Disrupters
emphasis on a continuation of normal physiological function and intellectual
prowess for all generations. Other chapters present what is known about EDCs
in relation to reproductive processes. I will discuss reproductive rights as they
apply to the children of today, integrated with thoughts on what is needed to
ensure that today’s generation can expect that future generations will have the
same reproductive rights.
The course of the future will reflect the mental status, as well as the physical
status, of today's children beginning with their conception' and continuing
throughout life. The healthy child is defined as bom free of contaminationinduced defects and who has no greater risk of exhibiting pathology later in life,
either in terms of disease or dysfunction, than if never exposed to EDCs, and
who has the same, or greater, ability to reproduce in adulthood as his or her fore
fathers. Implied in this statement is the concept that the child will be mentally,
as well as physically, fit. With pressures to limit family size because of world
population growth and limited resources to care for an excessive number of
children with preventable pathology, it is of paramount importance that all chil
dren fall within this definition of "healthy.”
The Right to a Healthy Pregnancy
Worldwide fertility rates, reflecting the number of births per woman, dropped
for the first time in 1996 (Popline, 1997). Population control advocates assert
that the decrease reflects an increase in the use of contraception, particularly in
developing countries. Other factors are not generally considered. Unfortunately,
there is no systematized record of global infertility, but a few statistics are avail
able. In parts of sub-Saharan Africa—including Kenya, Uganda, Cameroon,
Zaire, and Babon—infertility rates range between 30% and 40% (Leke et al.,
1993). The underlying cause of most of the infertility is unknown. Sexually
transmitted disease accounts for only one-third of the cases. Pathology, such as
low sperm counts and endometriosis, has been identified in another third, con
ditions that have already been correlated with toxic exposures. The cause of
infertility in the remaining third is unknown, which may be reflective of pathol
ogy difficult to diagnosis (Leke et al., 1993). Abnormal ovarian morphology,
including polyovular follicles and polynuclear oocytes, is associated with alliga
tors and mice exposed to a number of EDC contaminants (Iguchi, 1992;
Guillette, 1994; Guillette and Guillette, 1996). An accelerated onset of repro
ductive senescence following prenatal exposure to EDCs occurs in rodents,
although there is no comparable menopausal data for humans (Gray, 1991).The
relatively recent increase in infertility for the sub-Saharan African women
described above suggests that it is due to environmental change. Exposurp levels
in most sub-Saharan human populations, resulting from widespread use of pes
ticides—particularly DDT in coffee, tea, and cocoa plantations common to
these areas—has never been fully determined or documented.
Endocrine Disruption in Children
325
Problems with conception need not result from actual disease Contamina
tion from exposure to microwaves, industrial chemicals, or pesticides are
associated with sexual disturbances. The problems range from decreased libido
to erectile and ejaculatory problems in males (Bancroft,1993). The impact of
toxins on female sexual behavior is unknown (Bancroft, 1993). Many studies
have shown that when mothers are exposed to high levels of EDCs prior to or
with pregnancy, incidence of spontaneous abortion, prematurity, reduced birth
weights, and smaller head circumference increase, depending on the type of con
taminant exposure (Guo et al., 1993; Karmaus and Wolf 1995; Guillette et al.,
1998). Thus, the EDC-related prenatal health status of the child is frequently
assumed to be a reflection of only the maternal exposures and cross-placental
transfer. This may not be totally accurate. Men exposed to pesticides through
farm work in India produced children with a 300% increase in congenital
defects and a 4-fold increase in neonatal de^th'.when compared to controls
(Rupa et al., 1991). However, neither the mother’s exposure nor the history of
grandparents was considered in this research. Children of dioxin-exposed
mothers continue to have significantly elevated dioxin blood levels 25 years
after birth (Schecter and Ryan, 1993). These children, now adult women, are in
a position to pass the same EDCs on to the third generation.
Other factors, resulting from cultural evolution but completely unrelated to
EDC or other toxic waste contamination, serve to further complicate the right
to a healthy pregnancy. The obvious ones of poor diet, alcohol, tobacco, and drug
use, poverty, and lack of prenatal medical care are generally considered when
evaluating the impact of contamination. We must equally consider psychosocial
stressors that impact the outcome of pregnancy. Such stressors may be observ
able. Loud, ambient noise levels at airports and at some industrial facilities have
been correlated with lower birth weights and reduced physical growth during
early childhood (Schell, 1997). Many of these same confounders complicating
human research apply to wildlife and the stresses of noise, poverty in terms of
limited habitat and food supplies, and disrupted social patterns of behavior
resulting from human intervention (Epstein et al., 1997). These various con
founding variables should no,t be allowed to become faults in research design.
Instead, recognition should be given to their absence or presence within the
studied and reference populations, along with the possible role of such factors in
pregnancy outcomes and health of the newborn. Comprehensive recognition of
all factors involved with pregnancy can provide strength to the correlative evi
dence relating EDCs to poor postnatal outcomes.
The Right to a Healthy Body for Parenting
It is beyond the scope of this chapter to detail the suspected health changes in
adults that result from environmental change. An overview of changes in world
health patterns provides basic insight. The increase in various chronic diseases
32S
Environmental Endocrine Disrupters
among younger and younger adults during the last 50 years appears to corre
spond with the introduction and increased presence of EDCs. Cancer is no
longer a disease of the elderly in modern nations. Half of the world's cancers are
now found in developing nations, all of which have been experiencing modern
ization and the accompanying increase in EDCs for the last 30 to 50 years
(Polednak, 1989; World Cancer Research Fund, 1997). Since the introduction
of man-made toxic chemicals, cancers of the reproductive track are now occur
ring early in life, besides having increased 3-fold in incidence fBenedek and
Kiple, 1993).
Research is minimal on the correlation between EDC exposure and adult
infectious disease. We are all aware of the recent outbreaks of both old and
new infectious disease, yet neither pathogen mutations nor increased inci
dence of disease in adults has been investigated in terms of contaminant
exposure. At the same time, correlation between immune system malfunc
tioning and EDCs has been documented (National Research Council, 1993;
Colborn et al., 1996).
Environmental change appears to be influencing the gender of the child to be
patented. Slow, mysterious declines in male births have occurred in various parts
of the world. Suspect factors include exposure to dioxin, pesticides, and high
voltage (Knave et al., 1979; Dimich-Ward et al., 1996; Mocarelli et al., 1996).
Impairments to male-producing fertility are found with both fathers and moth
ers, leading to a hypothesis that the involved toxic agents impact hormone lev
els related to sex determination and/or pregnancy outcomes (Toppari et al.,
1996;Toppari and Skakkebaek, 1997).
The Right to Expect Our Children to Have Healthy Bodies and Pregnancies
Given the suspected insidious and sometimes minute but important alterations
induced by EDCs, the identification of changes in health and factual proof of
such change presents a major dilemma. There is a scarcity of baseline data prior
to the introduction of toxic chemicals on which to base the actual occurrence
of possible EDC-induced aberrations. For example, birth defects are the leading
cause of infant death in Florida, although a birth-defect registry, aimed at track
ing the problem and looking at the causes, was not approved by the state
government until May 1997 (Gainesville Sun, 1997). Florida is a state with a
history of heavy agricultural and residential pesticide use. The rate of defects
prior to the introduction of pesticides will never be accurately known.
Although 34 other states have a similar registry, a national registry is still
lacking. Such problems should not be viewed as deterrents for documenting
changes in health status but used to enlarge the scope of recognizable steps that
must be taken to promote better documentation and recognition of the health
changes found in association with EDC exposure. One step that must be
undertaken rapidly is the procurement of broad-based physical and mental
s
Endocrine Disruption in Children
327
health baseline data on both adults and children living in the few lesser conta
minated areas of the world, for EDC exposure will eventually increase in
amount and complexity with modernization processes.
The process of growth and development during fetal life and childhood are
reflections of health. While the foundations for body growth are laid down
during fetal life, the human infant is compositionally immature at birth. Physi
cal growth is a continuous process. Tissue organization and cellular maturation
continues until adulthood. It has been demonstrated that infants exposed to
high levels of PCBs or herbicides transplacentally are small for gestational age
at birth (Munger et al., 1997). An enigma exists in regards to this question:
Does in utero EDC exposure continue to disrupt postnatal growth? Children
exposed transplacentally to PCBs can be used in this debate. Jacobson and
Jacobson (1990, 1996) found that children with in utero PCB exposure were
small for gestational age and remained small at 4 years of age. The studies on a
prenatally PCB-exposed group of Yu Cheng children read that they may or
may not continue to have continued growth retardation (Gnu et al., 1994; Lai
et al., 1994). Cultural and social factors, some of which were considered as vari
ables in the various studies, can account for some of the differences. In addition,
one must consider the usual outcome of small infants for gestational age. In a
1972 study, occurring prior to the large-scale recognition of EDCs, babies who
were bom small were evaluated at 4 years of age. Of these children, 35%
remained below the third percentile for both length and head circumference,
and only 8% rose above the 50th percentile markers for their age group
(Fitzhardinge and Steven, 1972). These data provide hints that other factors
besides EDC-induced growth disruption may be involved with the continua
tion of the exposed fetus's failure grow to a normative level following birth. At
the same time, it does not refute correlation between EDCs and limited
growth. One must ask if there are any accompanying inborn genetic and/or
physiological alterations due to EDCs that accompany below-average growth.
This appears to be so. Disorders of ectodermal and neurological tissue are
present in children with in utero PCB exposure (Rogan et al., 1998).
One of the most important postnatal maturation processes occurs within
the central nervous system. Rapid neurological development, particularly
learning capabilities, occurs during the first 5 years of life and ends with com
plete rhyelination of the peripheral and spinal cord nerve tracts at adulthood.
Research has documented that children with high levels of transplacental
exposure to PCBs have hypotonia and hyporeflexia at birth, indicating that
the central nervous system (CNS) has been affected prior to birth (Rogan and
Gladen, 1992). Other signs of defective CNS function that exhibit themselves
later in; childhood include slowed motor development, with deficits in gross
and fine eye-hand coordination (Chen and Hsu, 1994; Cherr and Hsu, 1994;
Guillette et al., 1998). The capacity for intellectiial abilities also increases
during these early years (National Research Council, 1993). Findings suggest
that prenatal exposure to PCBs and pesticides tend to affect high cortical
328
Environmental Endocrine Disrupters
•
function rather than the sensory pathway, resulting in a lower IQ (Chen and
Hsu, 1994; Jacobson and Jacobson, 1996). Many of these identified deficits,
including behavioral problems and increased activity levels, persist over time
(Cherr and Hsu, 1994). Both human and animal research are also providing
correlative evidence that prenatal exposure to heavy metals induces varied
mental and psychomotor disturbances, including learning, behavioral, and
memory disorders (Liu and Elsner, 1995). We do not know if the identified
learning/behavioral deficits ever occur with postnatal exposure to an addi
tional compound or if the prenatal deficits are exacerbated by postnatal expo
sure to similar EDCs. These questions are difficult to answer because of the
multiplicity of extraneous factors affecting growth and development in any
child, including genetics, diet, ethnic practices, and cultural opportunities for
mental stimulation and the overt expression of abilities.
Ethnic and regional differences in thought processes do exist and will con
tinue to exist (Polednak, 1989). Such differences must be taken into account
with the mental evaluations of children living in various areas of the world.
American children are presented with many opportunities to recall a series of
numbers (zip codes, social security numbers, and telephone numbers). In
underdeveloped areas, the need to recall a number series is usually absent,
making any test item involving this task difficult for the child to comprehend.
Revision of the method is often necessary, as done with the children of the
Yaqui tribe of Sonora, Mexico, under study for pesticide exposure (Guillette et
al., 1998). Only when asked to repeat vowel sounds in abstract order, can the
child grasp the task, eventually moving into number repetition. Acceptable
childhood play behaviors also vary among cultural groups. Most American
preschoolers are encouraged to engage in standing on one foot, which repre
sents a sense of balance. When this same task was asked of Yaqui preschoolers,
the children either refused to perform the task or managed to stand on one foot
momentarily, usually holding onto an object. Only after questioning the
parents did cross-cultural differences regarding the activity emerge. Children
had been taught that standing on one foot was dangerous and results in injury
(Guillette et al., 1998). Therefore, any claim that low scores on this activity
reflected disruption of a sense of balance would have been invalid. Cross-cul
tural research studies are increasing. Interpretation of findings must always
account for social and cultural factors and their implications in regards to neu
rological and mental performance.
Body functioning also includes the response to disease! The incidence of all
cancers in children up to 14 years old rose 7.6% from 1973 through 1989 (Miller
et al., 1992). The largest increases were for cases of acute lympocytic leukemia
(23.7%), cancers of the brain and nervous system (28.6%), and cancers of the
kidney and renal pelvis (25.9%). During the same time interval, other childhood
cancers decreased (bone and joints, -15%; Hodgkin’s disease, -1.5%; non
Hodgkin's lymphomas, -0.9%).Total cancer incidence for the entire U.S. popula
tion increased approximately 16.1% during this period (Miller et al., 1992).
Endocrine Disruption in Children
329
EDCs have also been correlated with a depressed immune response (Colbom
et al., 1996; see Chap. 7).The number ofT-helper cells is known to be decreased
in mice when exposed to DES prior to birth, raising questions with regard to
humans (Palmlund et al., 1993). One study on the Yu-Cheng children, with in
utero exposure to polychlorinated biphenyls and dibensofurans, demonstrates
altered T-cell function and increased rates of sinopulmonary infection (Luster,
1996). Immune system depression, believed to be induced by PCB-contaminated
food, is at the point where Inuit children have chronic ear infections and fail to
produce antibodies in response to the usual childhood vaccinations (Colbom et
al., 1996). Pesticides appear to create a similar immune system depression. Over
half the families residing in the agricultural regions of Sonora, Mexico, experience
seven or more bouts with infectious disease per year, in addition to autoimmune
ailments of allergies and asthma, compared to incidence of none to two episodes
of infectious disease and no autoimmune symptoms in the reference group. Most
common are upper and lower respiratory infections, with adults similar to chil
dren in disease incidence (Guillette, 1997). The long-term impact of a compro
mised immune system gains greater importance when viewed in terms of social
and environmental change. Already the more common infectious agents show
resistance to new and powerful antibiotics. Looking to the future, will these chil
dren be more susceptible to certain diseases of adulthood, including the sexually
transmitted diseases and such immune disorders as rheumatoid arthritis, for
which there is no known cure?
Evaluating Risk
Risk assessment is usually approached in the context of the probability of a par
ticular compound producing undesirable health outcomes, usually cancer. Risk
is generally determined from the extrapolation of data derived from highly
exposed subpopulation groups and/or data based on the chemical's effect on
rodents, and then applied to adult humans (May 1996). Several problems exist
with this approach. First is the assumption that only the heavily exposed sub
population is at the greatest risk. Little consideration is given to the fact that the
majority of all children are exposed to unknown doses of contaminants, includ
ing heavy metals, carcinogens, and multiple EDCs. For instance, background
levels ofTCDD up to 20 ng/kg have been found in the general population, with
no identifiable specific exposures (Peterson et al., 1993). Adults and children are
also unknowingly exposed through the foods we eat and water that we drink, in
addition to the dust of our environment (National Research Council, 1993).
Opportunities for children to become contaminated are even greater than
parents may suspect. Play leads to direct contact with pesticide residues in yards,
schools, and homes (Calabrese, 1997; Stanek, 1995). Other sources of contami
nation include poorly ventilated classrooms and the arts and crafts supplies at
330
Environmental Endocrine Disrupters
schools (Fields, 1997). In addition to the hidden sources of exposure is the fact
that the child can be absorbing more toxic material than an adult in the same
area. The child inhales and absorbs lead at a level 2 to 3 times that of an adult
due to the child's higher metabolism and higher level of activity (Schell, 1991).
One can assume that other airborne EDCs enter at a comparatively similar
increased rate.
The universality of contamination places all children at some degree of risk,
with the possibility of having cellular disorganization during fetal life and the
later development of endocrine-related dysfunctions. The interrelationships be
tween body size, time of exposure, and amount of exposure are not considered.
This interrelationship is most important for the developing fetus and the young
child (Bern, 1992). "Weak" estrogen, or EDCs that bind to the estrogen receptor,
have a far more potent effect on unborn mice than on adult animals (Bern,
1992). There are also critical developmental periods during which exposure can
induce modifications in cell function and structure (Bern, 1992; Guillette,
1994). Although these studies involve research on nonprimates, the applicabil
ity of findings to human fetal life should not be denied. As described by Bern
(1992), the treatment of mice’with diethylstilbestrol (DES) during the time pe
riod of development of the reproductive tract results in the same vaginal and
uterine cell dysplasias as found in women whose mothers received DES during
the third month of pregnancy. Such specifics are good to know, but the situation
of the world today means that developing embryos are exposed to multiple
specifics, many of which remain unknown.
Risk assessment for children needs to be considered both in terms of interurterine exposure and continuing exposure throughout childhood. It is now
believed that many EDCs are able to pass the placental barrier and enter the
fetus. Fetal blood and breast milk have a high lipophilic content and appear to
absorb lipid soluble EDCs. The transfer of the contaminants to the fetus and
child is well known (Rogan and Gladen, 1990; Ahlborg et al., 1992). Develop
ing countries, which do not have controls on the use and types of chemicals as
strict as those in developed countries,.have a fetal blood and breast milk EDC
concentration that meets or exceeds levels found in the developed world
(Autrup, 1993). In human populations, the average levels of DDT in breast
milk range from 70 to 170 mg/1, with highs of 830 (Wolff, 1983). Assorted pes
ticide residues have been found in such diverse areas as Australia, Uruguay,
Spain, Italy, Mexico, and Guatemala (Thomas and Colbom, 1992).Therefore, it
seems reasonable to assume that all children bom today have experienced in
utero exposure to some form of EDCs and continued exposure if breast feeding
was undertaken. Hopefully, the time will arrive when child risk assessment con
siders the maternal body load of EDCs prior to pregnancy but not based
exclusively on such data. Exclusive use of the toxic equivalency approach may
underestimate the risk of deleterious effect, because of the many independent
mechanisms involved with these effects and the number of factors involved,
including the amount and timing of fetal exposure and possibly the mixture of
Endocrine Disruption in Children
331
transferred compounds. For these same reasons, the evaluation of children must
extend beyond the typical disease incidence approach to include the endpoints
of growth and development, including varied physical maturation process, cog
nitive abilities, neuromuscular performance, and behaviors.
Both the role of Darwinian evolution and, cultural evolution must be incor
porated into any evaluative method of growth and development. Genetic
differences among children and among racial groups are increasingly recog
nized as being meaningful in terms of susceptibility to actual disease. Facemire
(Chap. 3) discusses racial differences in the adipose tissue composition. The
most rapid deposition of total body fat occurs during infancy and reoccurs later
during puberesence, especially for the female (National Research Council,
1993). Questions exist if the rapid deposition of fat serves to protect EDC
target organs of the neonate when exposed to lipophilic contaminants. The
issue becomes paramount with breast feeding, as the intake of varied contami
nants via breast milk can be exceedingly high and involve over 250 chemical
contaminants' (Thomas and Colbom, 1992). The anticipation that rapid fat
deposition protects the infant’s organs from high concentration of dioxins and
feuans in breast milk is included in the 1990 Canadian Environmental Protec
tion Act (Anonymous, 1990). Others claim that the magnitude of the safety
margin cannot be determined, and the available information does not rule out
the possibility that there is no safety margin for the weight-gaining infant
(Ahlborg et al., 1992).
Cultural evolution has created circumstances in which the safety margin is
compromised. Social-economic conditions in particular produce outcomes
similar to the mental deficits identified with EDC exposure. Undemutrition is
known to affect cognitive functioning, including poor scores on IQ tests, de
creased intersensory perception, and increased propensity towards illness
(Cravioto, 1966; Kamphaus, 1993). Nutrition is not the only social economic
variable related to mental and neuromuscular achievement. It has long been
known that poor sanitation, inadequate health care, limited and/or low-quality
educational and recreational facilities, all interact to play a major role in child
hood development (Krogman, 1972). Social-economic inequality is frequently
correlated with environmental inequality, with the poor and minorities residing
in the more highly contaminated areas (Johnson, 1997). The presence of envi
ronmental EDCs may well be the straw that breaks the camel's back, placing
the children of these families at extreme risk.
In summary, actual risk assessment should not be based on single factors.
Assessment is complicated. The child, from conception onward, is exposed
many times to many compounds. The varied mechanisms of action, in conjunc
tion with the varied times of doses and varied time lines of possible adverse
effects, add additional confusion to determining risk, as children are not just
little adults. They have different exposure, metabolism, and physiological
processes. The total problem is compounded by sociocultural factors that
create their own risk factors and possibly multiply those of EDC exposure. In
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Environmental Endocrine Disrupters
addition, childhood risk assessment does not take into account the possibility of
delayed effects that may not be expressed until early adulthood or later (Bern, ■
1992; Guillette et al., 1995).
The Future
The course of the future depends on action taken today. Such action includes
two important segments: that of limiting our exposure to EDCs released into
the environment and that of integrating EDC research to present a valid and
realistic picture of what is actually happening. These two segments apply to all
living species, as the physiological and endocrine parameters, although species
specific, also share a great degree of similarity.
Scientists involved with the study of EDCs tend to use a categorical
approach in their research. Investigation centers on such areas as the impact on
biochemistry (i.e., binding properties), cell responses (i.e., mutations), specific
organs (i.e., ovarian function), or the general population (i.e., risk, disease inci
dence). Such research is important in that it provides new knowledge. At the
same time, the treatment of these factors as separate entities carries overtones
of artificiality, in that research addresses issues that are related causally and con
ceptually but fails to give a total picture. The building blocks that result from
compartmentalized research are seldom erected in total to provide a total view
of what may be occurring with all children. The findings give the impression
that there are pockets of children with intellectual deficits and other separate
pockets with children exhibiting hormonal dysfunction or gross birth deformi
ties or growth retardation. While pockets with extremes do exist, one cannot,
and should not, come to the erroneous conclusion that EDCs are not affecting
all children to some degree. The unification of specific knowledge from tach
category is necessary to prevent a heightened state of environment-induced
vulnerability for parenting and reproducing, especially with our children and
our children's children.
Research involving children must be approached holistically, extending
beyond one specific area of interest or expertise. The range of possible outcomes
and their endpoints are largely unknown, as are appropriate methods to assess
possible probabilities (Weiss, 1998). The broad-based assessment of the normal
play behaviors of 4- and 5-year-old pesticide-exposed Yaqui children showed
that all areas of play behavior, ranging from ball catching to jumping, from
drawing a stick figure to remembering a gift of a balloon, were compromised
(Guillette et al., 1998). Such broad-based investigations, delving into unknowns,
not only point out the scope and multitude of possible environment-induced
deficiencies but also point out a need for more in-depth research in areas not
previously recognized as being affected. The holistic approach calls for an inter
disciplinary approach involving social, medical, and natural scientists working
together without the artificial separation of topical components. Secondly, the
Endocrine Disruption in Children
333
need for more international investigation must be recognized, particularly in
developing countries. Contamination is not just a problem in industrialized and
western nations. Many published reports of birth defects, correlated with mater
nal and paternal EDC exposure, do not receive recognition because they are
usually in lesser-read publications, such as Rupa et al.’s (1991) findings of a
300% increase in congenital defects and a 4-fold increase in neonatal death of
children bom to pesticide-exposed men in India. Such reports—plus verbal
reports by nurses, midwives, agronomists, and others—indicate that children
worldwide are exhibiting syndromes consistent with EDC exposure. For
instance, a South-African midwife asked me for help in explaining "a strange
new disease of newborns” in a particular agricultural area. The symptoms she
described fit the syndrome of hermaphroditism. Many countries are those that
contain sites with maximum and minimal exposure, providing valid reference
groups for research.
;■
Lastly, as research identifies an increasing array of pathological and physiolog
ical changes hypothesized to be associated with EDC exposure, consideration
must be given to the acceptable and nonacceptable trade-offs that accompany
technological advances. Evolution of flora and fauna, including Homo sapiens,
continues to go onward as life continues. Clean air, water, and sufficient food is
needed for all life. Providing these basics involves an integrated plant-based,
animal-based, and human-based political economy. Short-term advantages that
maintain the political economy must be weighed against long-term disadvan
tages, as should short-term disadvantages against long-term advantages.
Similar choices must be made for proposing and selecting intervention for
protecting children. There are no simple answers. Mothers have been advised to
cut away fatty portions of contaminated meat and fish where bioaccumlation is
greatest. The removal of fat is a stopgap at best, for where is such tissue dis
carded? I have observed it being fed to other meat-producing livestock,
including goats and hogs. At other times it ends up in a garbage heap, where it
reenters the earth. Agricultural workers are advised to wash pesticide-contami
nated clothing separate from other articles. Yes, this does decrease skin
absorption of these pesticides by others. But where does the contaminated water
flow? The possibility of its reentering the water system is present, particularly in
rural areas served by shallow wells and drainfields.
Other family-based interventions for decreasing exposure pose similar deci
sion-making problems, balancing economics and health. A mother's decision in
regards to breast or bottle feeding frequently reflects the social and economic
status of the family in society (Frayser, 1985). Only recently have the possible
relationships of decreased maternal breast cancer risk and immunological
advantages for the infant play a strong influencing role on the lay person's deci
sion-making process for infant feeding. The maternal cumulative EDC load is a
new facet to be considered in the decision-making process. With regard to all
EDCs, the estimated intakes for neonates could be exceedingly high, and may
exceed the permissible daily intake (Colbom et al., 1996). One point of view is
334
Environmental Endocrine Disrupters
that breast feeding occurs only for a relatively short period of the life span, with
exposure reduced below the guidelines during the remainder of the life span
(Anonymous, 1990; Ahlborg et al., 1992). Also, the supposition is that with the
rapid deposit of fatty tissue during neonatal life, EDC concentration occurs in
the adipose tissue rather than the target organs (Anonymous, 1990). The ques
tion whether breast feeding should be advocated or not remains a serious
matter for scientists to resolve. There should be concern for the transference of
EDCs, but considerations must also be given to the positive benefits for the
mother and infant
In all instances, the choice that must be made by the individual involves
choosing between short-term and long-term options that will affect their health
and their environment. The question all of us must face is: Should EDC produc
tion and use be restricted? If so, what will be the outcome in terms of global
quality of life and for public health? There are no easy answers to these ques
tions. Advances in knowledge, technology, and policy must provide avenues that
will protect both the environment and the people, now and in the future. Until
adequate means are found to substitute for present technology, we are left with
the question: "Is my child all right?"
References
Ahlborg, U.G., Hanberg, A., and Kenne, K. (1992). Risk assessment of poly
chlorinated biphenyls (PCBs). Nord 26: 1-99.
Anonymous (1990). Polychlorinated dibenzodioxins and polychlorinated
dibenzofurans. Canadian Environ. Protection Act 56.
Autrup, H. (1993). Transplacental transfer of genotoxins and transplacental car
cinogenesis. Environ. Health Perspea 101:33-38.
Bancroft, J. (1993). Impact of environment, stress, occupational and other
hazards on sexuality and sexual behavior. Environ. Health Perspea 101
(Suppl. 2); 101-116.
Benedek, T.C., and Kiple, K.F. (1993). Concepts of cancer. In The Cambridge
World History of Human Disease. (K.E Kiple, ed.). Cambridge University
Press, Cambridge, UK.
Bern, H.A. (1992).The fragile fetus. In Chemically-Induced Alterations in Sexual
and Functional Delopment: The Wildlife-Human Connection. (T. Colbom and
C. Clement, eds.), pp. 9-16. Princeton Scientific Publishing, Princeton.
Calabrese, E., Stanek, EJ., James, R.C., and Roberts, S.M. (1997). Soil inges
tion: A concern for acute toxicity in children. Environ. Health Perspea 105:
1354-1358.
Chen, Y.J., and Hsu, C.C. (1994). Effects of prenatal exposure to PCBs on the
neurological function of children: A neuropsychological and neurophysio
Endocrine Disruption in Children
335
logical study. Develop. Med. Child Neurol. 36:312-320.
Cherr, YJ., and Hsu, C.C. (1994). Effects of prenatal exposure to PCBs on the
neurological function of children: A neuropsychological and neurophysiolog
ical study. Develop. Med. Child Neurol. 36:312-320.
Colbom, T, Dumanoski, D., and Myers, J.P. (1996). Our Stolen Future. Dutton,
New York.
Cravioto, J., DeLicardie, E.R., and H.G. Birch. (1966). Nutrition, growth and
neurointegrative development: An experimental and ecologic study. Pedi
atrics 38:319-372.
Dimich-Ward, H., Hertzman, C.,Teschkl, K., Hershler, R., Marion, S.A., Ostry,
A., and Kelly, S. (1996). Reproductive effects of parental exposure to
chlorophenate wood preservatives in the sawmill industry. Scandinavian J.
Work Environ. Health 22:267-273.
Epstein, P.R., Dobson, A., and Vandermeer/J. (1997). Biodiversity and emerg
ing infectious disease: Integrating health and ecosystem monitoring. In
Biodiversity and Human Health. (F. Grifo and J. Rosenthal, eds.), pp. 60-87.
Island Press, Washington, D.C.
Fields, S. (1997). Exposing ourselves to art. Environ. Health Perspea 105:
284-289.
Fitzhardinge, P.M., and Steven, E.M. (1972). The small-for-date infant: Later
growth patterns. Pediatrics 49: 671-681.
Gainesville Sun (1997). New birth-defect registry. May 27, p. 26.
Gnu, Y.L., Lin, C., Yau, WJ„ Ryan, J.J., and Hsu, C.C. (1994). Musculoskeletal
changes in children prenatally exposed to polychlorinated biphenyls and
related compounds (Yu-Chong children). J. ToxicoL Environ. Health 4:
83-93.
Gray, L.E. (1991). Delayed effects on reproduction following exposure to toxic
chemicals during critical periods of development. In Aging and Environ. Toxi
cology: Biological and Behavioral Perspectives. (R.L. Copper, J. Goldan, andT.
Harbin, eds.), John Hopkins University Press, Baltimore.
Guillette, E.A. (1997). Environmental factors and the health of women. In
Second Meeting of National Leaders in Women's Health in Gainesville, FL.
(S.V. Rosser and L.S. Lieberman, eds.), pp. 81-96. Custom Copies,
Gainesville.
--------- , Meza, M.M., Aquilar, M.G., Soto, A.D., and Garcia, I.E. (1998). An
anthropological approach to the evaluation of preschool children exposed to
pesticides in Mexico. Environ. Health Perspea 106:347-353.
Guillette, L.J., Jr. (1994). Endocrine-disrupting environmental contaminants
and reproduction: Lessons from the study of wildlife. In Women's Health
Today: Perspectives on. Current Research and Clinical Practice. (D.R. Popkin
and L.J. Peddle, eds.), pp. 201-207. Parthenon, New York.
336- Environmental Endocrine Disrupters
--------- , Crain, D.A., Rooney, A.A., and Pickford, D.B. (1995). Organization
versus activation: The role of endocrine-disrupting contaminants (EDCs)
during embryonic development in wildlife. Environ. Health Penpea 103
(Suppl. 7): 157-164.
--------- and Guillette, E.A. (1996). Environmental contaminants and reproduc
tive abnormalities in wildlife: Implications for public health? Toxicol. H
Indust. Health 12:337-350.
Guo, Y.L., Lai, T.J., Ju, S.H., Chen, Y.C, and Hsu, C.C. (1993). Sexual develop
ments and biological findings in Yucheng children. Chemosphere 14:
235-238.
Iguchi, T. (1992). Cellular effects of early exposure to sex hormones and anti
hormones. Internal. Rev. Cytol. 139:1-57.
Jacobson, J.L., and Jacobson, S.W. (1996). Intellectual impairment in children
exposed to polychlorinated biphenyls in utero. New England J. Med. 335:
783-789.
--------- ,--------- , and Humphrey, H.E.B. (1990). Effects of exposure to PCBs
and related compounds on growth and activity of children. Neurotox. Terat.
12:319-326.
Johnson, B.R. (1997). Life and death matters at the end of the millennium. In
Life and Death Matters: Human Rights and the Environment at the End of the
Millennium. (B.R. Johnson, Ed.), pp. 9-22. AltaMira, Walnut Creek.
Kamphaus, R.W. (1993). Clinical Assessment of Children's Intelligence. Allyn and
Bacon, Boston.
Karmaus, W, and Wolf, N. (1995). Reduced birthweight and length in the off
spring of females exposed to PCDFs, PCP, and Lindane. Environ. Health
Perspea 103:1120-1125.
Knave, B., Gamberale, E, Bergstrom, E.E., Birke, E., Iregen, A., KolmodinHedman, B., and Wennberg, A. (1979). A long-term exposure to electric
fields: A cross-sectional epidemiologic investigation of occupationally
exposed workers in high-voltage substations. Scandinavian J. Work &
Environ. Health 5:115-125.
Endocrine Disruption In Children
337
Luster, hji.l. (1996). Immunotoxicology: Clinical consequences. Toxicol. &!
Indust. Health 12: 533-535.
May, M. (1996). Risk assessment: Bridging the gap between prediction and
experimentation. Environ. Health Perspea 104:1150-1151.
Miller, B.A., Reis, L.A.G., Hankey, C.L., Kosary, C.L., and Edwards, B.K. (1992).
Cancer Statistics Review 1973-1989. NIH Pub. No. 92-2789. National Insti
tutes of Health, Bethesda.
Mocarelli, P., Brambilla, P., Gerthous, P.M., Patterson, D.G., and Needham, L.L.
(1996). Change in sex ratio with exposure to dioxin. Lancet 14:348-409.
Munger, R., Isacson, P., Hu, S., Bums, T., Hanson, J., Lynch, C.F., Cherryholmes,
K., Van Dorpe, P., and Hausler, WJ., Jr. (1997). Intrauterine growth retarda
tion in Iowa communities with herbicide-contaminated drinking water
supplies. Environ. Health Perspea 105:308-314.
National Research Council (1993). Pesticides in the Diets of Infants and Chil
dren. National Academy Press, Washington, D.C.
Palmlund, I., Apfel, R., Buitendijk, S., Cabau, A., and Forsberg, J. (1993).
Effects of Diethylstibestrol (DES) medication during pregnancy: Report
from a symposium at the 10th International Congress of ISPOG. J. Psychoso
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Peterson, R.E., Theobald, H.M., and Kimmel, G.L. (1993). Developmental and
reproductive toxicology of dioxins and related compounds: Cross-species
comparisons. Crit. Rev. in Toxicol. 23: 283-335.
Polednak, A.P. (1989). Racial and Ethnic Differences in Disease. Oxford Univer
sity Press, New York.
Popline (1997). Fertility decline reported. World Population News Service
' Popline. Vol. 19: May-June, p. 33.
,
Rogan, W.J., Gladden, B.C., Hung, K.L., Shish, S.L., Taylor, J.S., Wu, Y.C., Yand,
D., Ragan, N.B., and Hsu, C.C. (1988). Congenital poisoning by polycholorinated biphenyls and their contaminants in Taiwan. Science 241: 334-336.
--------- and---------- (1990). Perinatal exposure to polychlorinated biphenyls
(PCBs) and child development at 18 and 24 months. Pediatric Resident 27:
Krogman, W.M. (1972). Child Growth. University of Michigan Press, Ann
Arbor.
97A.
|
--------- and---------- (1992). Neurotoxiclology of PCBs and related compounds.
Lai,TJ, Guo, Y., Yu, M.L., Ko, H.C., and Hsu, CC. (1994). Cognitive develop
ment in Yucheng children. Chemosphere 29: 2405-2411.
Leke, F.J., Oduma, AJ., Basson-Mayagoitis, S., and Grigor, K.M. (1993).
Regional and geographic variation in infertility: Effects of environmental,
cultural and socioeconomic factors. Environ. Health Perspec. 101: 64-73.
Neurotoxicol. 13: 27-35.
Rupa, D.S., Reddy, P.P., and Reddy, O.S. (1991). Reproductive performance in
populations exposed to pesticides in cotton fields in India. Environ. Res. 55:
Liu, G., and Elsner, J. (1995). Review of the multiple chemical exposure factors
which may disturb human behavioral development. Preventive Med. 40:
209-217.
123-128.
Schecter, A., and Ryan, J. (1993). Exposure of female production workers and
their children in Ufa, Russia, to PCDDs/PCdFs/planar PCBs. In 13th Interna
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University of New York, Binghamton, pp. 55-58. State University of New York.
334
Environmental Endocrine Disrupters
that breast feeding occurs only for a relatively short period of the life span, with
exposure reduced below the guidelines during the remainder of the life span
(Anonymous, 1990; Ahlborg et al., 1992). Also, the supposition is that with the
rapid deposit of fatty tissue during neonatal life, EDC concentration occurs in
the adipose tissue rather than the target organs (Anonymous, 1990). The ques
tion whether breast feeding should be advocated or not remains a serious
matter for scientists to resolve. There should be concern for the transference of
EDCs, but considerations must also be given to the positive benefits for the
mother and infant.
In all instances, the choice that must be made by the individual involves
choosing between short-term and long-term options that will affect their health
and their environment. The question all of us must face is: Should EDC produc
tion and use be restricted? If so, what will be the outcome in terms of global
quality of life and for public health? There are no easy answers to these ques
tions. Advances in knowledge, technology, and policy must provide avenues that
will protect both the environment and the people, now and in the future. Until
adequate means are found to substitute for present technology, we are left with
the question: "Is my child all right?"
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Bancroft, J. (1993). Impact of environment, stress, occupational and other
hazards on sexuality and sexual behavior. Environ. Health Perspec. 101
(Suppl. 2): 101-116.
Benedek,T.C, and Kiple, K.E (1993). Concepts of cancer. In The Cambridge
World History of Human Disease. (K.F. Kiple, ed.). Cambridge University
Press, Cambridge, UK.
Bern, H.A. (1992). The fragile fetus. In Chemically-Induced Alterations in Sexual
and Functional Delopment: The Wildlife-Human Connection. (T. Colbom and
C. Clement, eds.), pp. 9-16. Princeton Scientific Publishing, Princeton.
Calabrese, E., Stanek, E.J., James, R.C., and Roberts, S.M. (1997). Soil inges
tion: A concern for acute toxicity in children. Environ. Health Perspec. 105:
1354-1358.
Chen, YJ., and Hsu, C.C. (1994). Effects of prenatal exposure to PCBs on the
neurological function of children: A neuropsychological and neurophysio
Endocrine Disruption in Children
335
logical study. Develop. Med. Child Neurol. 36:312-320.
Cherr, YJ., and Hsu, C.C. (1994). Effects of prenatal exposure to PCBs on the
neurological function of children: A neuropsychological and neurophysiolog
ical study. Develop. Med. Child Neurol. 36:312-320.
Colbom, T, Dumanoski, D., and Myers, J.P. (1996). Our Stolen Future. Dutton,
New York.
Cravioto, J., DeLicardie, E.R., and H.G. Birch. (1966). Nutrition, growth and
neurointegrative development: An experimental and ecologic study. Pedi
atrics 38:319-372.
Dimich-Ward, H., Hertzman, C.,Teschkl, K., Hershler, R., Marion, S.A., Ostry,
A., and Kelly, S. (1996). Reproductive effects of parental exposure to
chlorophenate wood preservatives in the sawmill industry. Scandinavian J.
Work Environ. Health 22: 267-273.
Epstein, P.R., Dobson, A., and Vandermeer, J. (1997). Biodiversity and emerg
ing infectious disease: Integrating health and ecosystem monitoring. In
Biodiversity and Human Health. (E Grifo and J. Rosenthal, eds.), pp. 60-87.
Island Press, Washington, D.C.
Fields, S. (1997). Exposing ourselves to art. Environ. Health Perspec. 105:
284-289.
Fitzhardinge, P.M., and Steven, E.M. (1972). The small-for-date infant: Later
growth patterns. Pediatrics 49:671—681.
Gainesville Sun (1997). New birth-defect registry. May 27, p. 26.
Gnu, Y.L., Lin, C., Yau, W.J., Ryan, J.J., and Hsu, C.C. (1994). Musculoskeletal
changes in children prenatally exposed to polychlorinated biphenyls and
related compounds (Yu-Chong children). J. ToxicoL Environ. Health 4:
83-93.
Gray, L.E. (1991). Delayed effects on reproduction following exposure to toxic
chemicals during critical periods of development. In Aging and Environ. Toxi
cology: Biological and Behavioral Perspectives. (R.L. Copper, J. Goldan, and T.
Harbin, eds.), John Hopkins University Press, Baltimore.
Guillette, E.A. (1997). Environmental factors and the health of women. In
Second Meeting of National Leaders in Women's Health in Gainesville, FL.
(S.V. Rosser and L.S. Lieberman, eds.), pp. 81-96. Custom Copies,
Gainesville.
--------- , Meza, M.M., Aquilar, M.G., Soto, A.D., and Garcia, I.E. (1998). An
anthropological approach to the evaluation of preschool children exposed to
pesticides in Mexico. Environ. Health Perspec. 106:347-353.
Guillette, L.J., Jr. (1994). Endocrine-disrupting environmental contaminants
and reproduction: Lessons from the study of wildlife. In Women's Health
Today: Perspectives on, Current Research and Clinical Practice (D.R. Popkin
and LJ. Peddle, eds.), pp. 201-207. Parthenon, New York.
336
Environmental Endocrine Disrupters
Schell, L.M. (1991). Effects of pollutants on human prenatal and postnatal
growth: Noise, lead, polychlorobiphenyl compounds and toxic wastes. Year
book Phys. AnthropoL 34:157-188.
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tion. Am. J. Phys. Anthropol. 102:67-78.
Sherman, J.D. (1995). Chlorpyrifos (Dursban)-associated birth defects: A pro
posed syndrome, report of four cases, and discussion of the toxicology.
Intematl. J. Oct. Med. & Toxicol. 4: 417-431.
Stanek, J.I., and Calabrese EJ. (1995). Daily estimates of soil ingestion in chil
dren. Environ. Health Perspec. 103: 276-285.
Thomas, K.B., and Colbom,T. (1992). Organochlorine endocrine disruptors in
human tissue. In Chemically-induced Alterations in Sexual and Functional
Development: The Wildlife/Human Connection Vol. XXI. (T. Colbom and C.
Clement, eds.), pp. 365-394. Princeton Scientific Publishing, Princeton.
Toppari, J., Larsen, J.C., Christiansen, P., Giwercman, A., Grandjean, P., Guillette, L.J., Jr., Jegou, B., Jensen, T.K., Jouannet, P., Keiding, N., Leffers, H.,
McLachlan, J.A., Meyer, O.,Muller, J., Rajpert-De Meyts, E., Scheike,T.,
Sharpe, R., Sumpter, J., and Skakkebaek, N.E. (1996). Male reproductive
health and environmental xenoestrogens. Environ. Health Perspec. 104
(Suppl. 4): 741-803.
--------- and Skakkebaek, N.E. (1997). Response to James, W.H. Environ. Health
Perspec. 105:162.
Weiss, B. (1998). A risk assessment perspective on the neurobehavioral toxicity
of endocrine disruptors. Toxicol. & Indust. Health 14: 341-359.
Wolff, M.S. (1983). Occupationally derived chemicals in breast milk. Am. J.
Ind. Med. 4: 259-282.
World Cancer Research Fund (1997). Food, Nutrition and the Prevention of
Cancer: A Global Perspective. American Institute for Cancer Research,
Washington, D.C.
INDEX
leuar /
. p.g< numb.
dut » illusion b on that
- — ubU)
effect on immune system, 186-187
evidence. 130-131
syntbess, 131-132
Androgen receptors
levels, 10
location, 83
Androgenic hormone, function, 136
Anllinonaphthalenesulfonic acid, effect on
thyroid hormone binding, 166-167
Anlmalfs), threat of environmental estro
tion, 62
gens, 251-252
Adrenal cortex of mammals, zones, 32
Animal models
Adrenal cortlcotrophin, function, 32
endocrine disruptors and neoplasia
African clawed frog, thyroid hormone cross
dlchlorodiphenyltrichloroethane, 307
talk, 88
estrogenic pesticides, 307
African walking frog, endocrine disruption,
hormonal carcinogenesis
24
experimental neoplasia, 301
ovarian hormones and neoplasia
Age effect
endocrine-disrupting contaminant-recep
endometrial tumors, 302-303
tor Interactions, 110—111
mammary turnon, 303-304
steroid receptor interactions, 85
pituitary tumors, 304-305
Agglutlnln-secreting rosettes, immunological
prostrate, 306-307
biomarker, 193-200
studies, 302
Agonism!, endocrine-disrupting contami
testicular tumors, 305-306
nant-receptor interaction, 90—91
spontaneous neoplasia of estrogen target
Alkylphenol(s), threat to human and animal
organs, 301
populations, 251-252
Antagonism, endocrine-disrupting contami
Alkylphenolic detergents, endocrine disrup
nant-receptor interaction, 92-93
Anthropology, Interpretation of endocrine
tion, 127
disruption in children, 332-334
Alligator*
effect
<
Antibodies ,
endocrine-disrupting contaminants on
classes, 18’4
hormone excretion and blotransforfunction, 184
Antiestrogenic effects of environmental con
mation, 12-13
polychlorinated biphenyls on endocrine
taminants, role in human abnormalities,
parameters, 9-10
127-128
endocrine disruption by environmental
Antithyroid agents, role In thyroid tumors,
chemicals, 127
171-172
Alligator mississippiensis, effect of cndocrincApoptosis, effect of glucocorticoids, 185-186
disruptingcontaminants on hormone ex
Aquatic food chains, role in bioaccumula
cretion and biotransformation, 12-13
tion, 55
American alligator, effect of polychlorinated
Arochlor effect
biphenyls on enoocrine parameters, 9-10
earthworms, 193
Aminoheterocyclic compounds, effect on io
perinatal exposure, 249
dide transport, 166
Arthropods, effect of sex steroids, 135-136
Amphibian, endocrine disruption, 23
Aryl hydrocarbon receptors, activation, 89
Androgen(s)
Action, See Hormone action
Acylglycerols, biotransfonnations, 67-68
Adipose tissue
differences, 62
storage of endocrine-disrupting contami
nants, 59-66
Adipsln/acylation stimulating protein, func
339
I1^0 p
Vj H _ 6 -
World Bank
Population and Reproductive Health
(Some Documents)
1.
2.
Population And Reproductive Health - Information Brief
India Reproductive And Child Health Project Signals Policy
Change For Family Welfare Program - World Bank provides
largest ever creditfor population project
3. World Bank Group and Population and Reproductive and Child
Health in India
4. Despite Progress, Millions In The Developing World Still
Denied Access To Reproductive Health
Action Programme for People’s Economics and Allied Literacy
A Unit Of
Popular Education and Action Centre
F-93, Katwaria Sarai
New Delhi - 110 016
World Bank
Population and Reproductive Health
(Some Documents)
Population And Reproductive Health - Information Brief
India Reproductive And Child Health Project Signals Policy
Change For Family Welfare Program - World Bank provides
largest ever creditfor population project
3. World Bank Group and Population and Reproductive and Child
Health in India
4. Despite Progress, Millions In The Developing World Still
Denied Access To Reproductive Health
1.
2.
Action Programme for People’s Economics and Allied Literacy
A Unit Of
Popular Education and Action Centre
F-93, Katwaria Sarai
New Delhi - 110 016
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■ttUB "71 III! 11111111 ■IIHIIIIM
Regions: South Asia
The World Bank Group and Population and
Reproductive and Child Health in India
India was among the first developing nations to recognize the threat rapid population
growth poses to national development and to adopt policies to address the problem. Its
Family Welfare Program, launched in 1951, has contributed significantly to improving the
health of mothers and children and to providing family planning services.
Forty-six percent of eligible couples now use some form of contraception, fertility has
declined by about two-fifths, and immunization coverage of children is approaching 80
percent. However, maternal deaths remain high at 437 per 100,000 live births, and the total
fertility rate, while below replacement level in the states of Kerala and Goa, is as high as
four or more children per woman in the poorer northern states of the Hindi-speaking belt.
India's continued high fertility rate, combined with a two-thirds drop in the death rate
and a doubled life expectancy, have resulted in substantial population increases, from 342
million in 1947, to 684 million in 1981, to 931 million people today. Each year, 16 million
people are added to the population and by 2050, India's population is projected to reach 1.5
billion.
Slow progress in the 1980s made it essential for India to devise innovative strategies to
achieve greater dynamism in its Family Welfare Program. In the early 1990s, the
Government of India began a paradigm shift from a system based on contraceptive method
specific and fertility reduction targets and monetary incentives to a broader system of
performance goals and measures designed to encourage a wider range of reproductive and
child health services. The Ministry of Health and Family Welfare developed an action plan
to strengthen the program and made several recommendations consistent with the
reproductive and child health approach.
This approach, which was adopted by the Government of India when it initiated the Child
Survival and Safe Motherhood Program in 1992, is also central to the new vision of
population policy that emerged from the 1994 Cairo International Conference on Population
and Development. Reproductive health refers to a state in which people can reproduce and
regulate their fertility, women go through pregnancy and childbirth safely, the outcome of
pregnancy is successful in terms of maternal and infant survival and well-being, and
couples are able to have sexual relations free of the fear of pregnancy and disease.
In its transition to this approach, India is taking careful account of the links between family
welfare and other health services. More emphasis is now placed on the private and
voluntary sectors as they develop in the increasingly dynamic Indian economy.
World Bank Group assistance to India's efforts in population and reproductive and child
health (RCH) dates back to the earliest days of Bank involvement in the population sector.
Between 1972 and 1986, four population projects totaling about US$188 million were
http://www.worldbank.org/html/extdr/offrep/sas/saspop.htm
10/6/99
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approved. Since then, Bank Group-Government of India collaboration has been stepped up,
with approval of five more population projects and a Child Survival and Safe Motherhood
(CSSM) Project totaling about US$645 million, and preparation of a Reproductive and
Child Health Project for some US$248 million. The objective of each of these projects has
been to strengthen the capacity of the family welfare and health systems to deliver better
quality services more equitably.
The development of this lending program has been based on a number of analytical efforts
and on a continuous dialogue between the Bank Group and the Government of India, which
has allowed the Bank to support India's transition to a reproductive and child health
approach. The Bank has focused an increasing share of its attention on those features of the
Family Welfare Program that constrain it from being more effective, including reorienting
management focus from contraceptive targets to client-responsive quality service. The Bank
Group also continues to emphasize assistance to the national immunization program,
programs in safe motherhood, and the control of acute respiratory infections and diarrheal
disease.
Completed World-Bank Assisted Operations
The First Population Project (1972-80) was financed by an IDA credit of US$21.2
million and a grant from the Swedish International Development Authority. The project
supported the Family Welfare Program in five districts in the state of Karnataka and six
districts in the state of Uttar Pradesh. The project was essentially an experimental
demonstration project intended to test the efficacy of various program activities, and to
develop ways for attaining better performance of the national program.
The project experience indicated ways subsequent World Bank support of the Family
Welfare Program could be improved, and was the foundation for the government's
subsequent accelerated program of family planning and maternal and child health. Also, the
two population centers established under this project have carried out a variety of research.
The Second Population Project (1980-88) was supported by an IDA credit of US$46
million. The project assisted the Family Welfare Program in six districts of eastern Uttar
Pradesh and three districts in the state of Andhra Pradesh. The project was part of a
government effort to obtain external assistance to strengthen the Family Welfare Program in
underprivileged districts of selected states.
The project gave further support for the integration of family planning and mother and child
health care services, emphasized the importance of generating demand for services and, as
in all subsequent projects, stressed the increased use of temporary contraceptive methods
and gave substantial support for the construction of basic health facilities. An estimated
22.7 million women and children benefited from strengthened family welfare services
provided under the project.
The Third Population Project (1984-91) was financed by an IDA credit of US$70
million. It too was implemented in underprivileged districts-six districts of northern
Karnataka and four districts of the state of Kerala.
Project impact was particularly notable in Kerala, where project support helped bring
program implementation in the underprivileged project districts up to the much higher
standard already achieved in the rest of the state. In Kerala project districts, contraceptive
use has increased and, on average, immunization of children has risen from about 28
percent to about 78 percent. Overall, approximately 18 million women and children in the
10 project districts were reached by the project-assisted family welfare program.
The Fourth Population Project (1986-94) was supported by an IDA credit of US$51
million and was implemented in West Bengal. In the four districts where facility
construction was supported by the project, program implementation benefited more than 12
million women and children. The project emphasized maternal and child health. A
http://www.worldbank.org/html/exldr/offrep/sas/saspop.htm
10/6/99
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comparison of fertility, mortality, and infant mortality rates between the pre-project year of
1984 and 1992 indicates substantial progress in these three vital indicators.
During the course of the project, the birth rate in West Bengal declined from 30.4 to 24.6
per 1,000, the death rate from 10.7 to 8.3 per 1,000, and the infant mortality rate from 82 to
64 per 1,000 live births. There was also very good progress in the share of couples using
modern contraception, which improved from 33 to 52 percent. State-wide support for
program management information, communications, and training components had a
positive effect on the implementation and impact of West Bengal's family welfare program
in general.
The Fifth Population Project (1988-96), financed by an IDA credit ofUSS57 million,
supported the National Family Welfare Program in the municipalities of Bombay and
Madras, and was extended to other urban areas in the states of Maharashtra and Tamil
Nadu. The main goal was to improve the service delivery and outreach systems of family
welfare services in urban slums. Innovative features included support for involvement of
non-governmental organizations (NGOs) and private medical practitioners in carrying out
the Family Welfare Program. The project met its service delivery objectives and benefited
some 2.5 million poor women and children in slum areas.
The Child Survival and Safe Motherhood Project (1991-96), financed by an IDA credit of
USS214.5 million, supported the enhancement and expansion of the Maternal and Child
Health (MCH) component of the National Family Welfare Program. It was national in
scope, with emphasis on districts where maternal and infant mortality rates were higher than
the national average.
The project's specific objectives were to enhance child survival, reduce maternal mortality
and morbidity rates, and increase the effectiveness of service delivery by supporting:
o child survival programs including the Universal Immunization Program, diarrhea
control programs, and the control of acute respiratory infections;
o a Safe Motherhood Initiative to improve ante-natal and delivery care for all pregnant
women and to identify high-risk pregnancies; and
o institutional systems development, including improving and expanding training
programs for family welfare workers, education and communication, and
management information.
More than 42 million women and children benefited annually from the services provided.
Ongoing World Bank-Assisted Operations
The Sixth Population Project, approved in 1989, provides assistance through an IDA
credit of USS 124.6 million. The project supports improvements in the efficiency and
effectiveness of the delivery of family welfare services in the rural areas of the states of
Andhra Pradesh, Madhya Pradesh, and Uttar Pradesh. The project has established a wellregarded and systematic program of in-service training and a training culture focused on
improving performance of workers and an increased awareness of how to monitor and
improve the quality and effectiveness of training.
Three state institutes of health and family welfare, 18 regional training centers, 91 district
centers/teams, and 23 field practice demonstration areas have been established and are
conducting regular in-service training; 23 basic auxiliary nurse midwife (ANM) training
schools have also been strengthened. In addition, 1,620 sub-centers with ANM residence
have been constructed, equipment and furniture have been provided to sub-centers, and
primary health centers and delivery kits have been provided to traditional birth attendants.
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o a local capacity enhancement component that would fund district and city sub
projects aimed at meeting specific needs of local priority groups.
The project is expected to be approved in mid-1997, and would be financed with an IDA
credit of about US$248 million.
Research and Analysis
Two major studies, Improving Women's Health in India (1996) and India's Family Welfare
Program: Moving to a Reproductive and Child Health Approach (1995), provide
background for the Bank Group's discussions with the Indian government on further
developing public, voluntary, and private sector capacity to address needs of the Family
Welfare Program and health problems of India's women. The former was published as part
of the Bank's Directions in Development series and the latter was published as part of the
Bank's Development in Practice series.
Both studies build on an earlier study entitled Family Welfare Strategy’ in India: Changing
the Signals (1990). Taken together, these studies provide support for the important steps
the government has taken in moving away from a target-driven, demographic approach
emphasizing female sterilization, toward a client-centered approach that helps people meet
their broader health and family planning goals.
Improving Women's Health in India provides a comprehensive overview both of women's
health issues and the government's programs to improve them. Despite considerable
progress, the report argues that India still has a large, unfinished agenda in the areas of
reproductive and child health. The report emphasizes women's reproductive health and the
factors underlying excess female mortality at early ages, especially in the northern "Hindi
belt" states of Bihar, Rajasthan, Madhya Pradesh, and Uttar Pradesh. These states account
for almost 40 percent of India's population and exhibit well-documented unfavorable
demographic trends compared with the rest of India.
The book also points out the needs of women in rural areas where mortality levels are
substantially higher than in urban areas and access to care is limited. Its focus is on the
measures necessary to address existing policy and implementation constraints and improve
the quality, acceptability, and use of services essential to women's health. Further progress
and more resources are needed.
In 1994, the Cairo Conference formalized agrowing international consensus that improving
reproductive health, including family planning, is essential to human welfare: reducing
unwanted pregnancies safely and providing high-quality health services both satisfies the
needs of individuals and stabilizes the population.
This perspective, strongly supported by the Government of India in its Program of Action in
the India Country Report prepared for the Cairo Conference, led to a major piece of
collaborative analytical work with the World Bank Group entitled India's Family Welfare
Program: Moving to a Reproductive and Child Health Approach. The report identifies the
major constraints on India's Family Welfare Program and recommendsways in which these
constraints might be overcome. In addition, it discusses an "Essential Reproductive Health
Package" designed to provide a cluster of recommended reproductive health services
directed primarily at the needs of actual and potential patients. The Reproductive and Child
Health Project was based partly on this work.
For more information, please contact:
In Washington: Rebeca Robboy: (1-202) 473-0699 e-mail: Rrobboy << worldbank.
In New Delhi: Geetanjali Chopra: (91-11) 461-7241 e-mail: Gchop’rau/ worklbank orc
SEARCH
SITE MAP
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SHOWCASE
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Overall, it is estimated that up to 40 million rural households in the three project states are
benefiting from program improvements achieved with project support.
The Seventh Population Project, which supports the National Family Welfare Program in
the states of Bihar, Gujarat, Haryana, Jammu & Kashmir, and Punjab, through an IDA
credit of USS81.6 million, Was approved in 1990. This project, which also has a special
training focus, is similar to the Sixth Population Project. At least 22 million families in the
rural areas of the project states will ultimately benefit from project-assisted improvements
in the quality and coverage of program services.
Since the project began in 1991, rates of sterilization and use of IUDs, oral pills, and
conventional contraceptives have been steadily rising. Systematic and regular in-service
training for family welfare workers has also been established.
The Eighth Population Project, financed through an IDA credit of USS79 million,
became effective in May 1994. The project supports the improvement of family welfare
services in the slum areas of Bangalore, Calcutta, Delhi, and Hyderabad. Il focuses on the
reduction of fertility as well as maternal and infant mortality rates among people living in
urban slums by improving the outreach of family welfare services, upgrading the quality of
family welfare services, expanding the demand for health services through expanded
information, education and communication activities, and improving the administration and
management of municipal health departments.
The Ninth Population Project, which became effective in September 1994, is being
implemented in three states-Assam, Karnataka, and Rajasthan-and is financed through an
IDA credit of US$88.6 million. The project supports improved access to, demand for, and
quality of family welfare services, particularly among poor, remote, and tribal peoples.
The project aims to:
o strengthen family welfare service delivery, including establishment of first-referral
units;
o improve the quality of family welfare service;
o strengthen demand-generation activities through improved information, education,
and communications planning and activities;
o strengthen program management and implementation capacity; and
o provide funds for innovative schemes to improve service delivery.
Future Operations
Building on a major analysis done collaboratively by the World Bank and Government of
India, and recent Indian program developments, the Indian government is preparing a
Reproductive and Child Health (RCH) Project, which would support the National Family
Welfare Program in improving the health status of women and children, especially the poor
and underserved. An essential package of reproductive and child health services is integral
to the project approach.
The project would include two major components:
o a nation-wide policy reform package, covering monitoring and evaluation,
institutional strengthening, and service delivery; and
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10/6/99
THFWORLD BANK GROUP
News Release No. 97/ 1368 SAS
Contacts: Rebeca Robboy: (202) 473-0699
Durudee Sirichanya: (202) 458-9031
Paul Mitchell: (202) 458-1423
INDIA REPRODUCTIVE AND CHILD HEALTH
PROJECT SIGNALS POLICY CHANGE FOR FAMILY
WELFARE PROGRAM
World Bank provides largest-ever credit for population project
NEW DELHI, May 29, 1997— The World Bank today announced the approval of a USS248.3
million equivalent Interim Trust Fund credit to the Government of India for a Reproductive and
Child Health Project. The project will support the National Family Welfare Program in improving
the health status of women and children and stabilizing population growth.
The credit, which is the largest support undertaken by the Bank or any other development agency
for follow-up to the 1994 International Conference on Population and Development, will be
provided on International Development Association (IDA) terms.
The India Family Welfare Program is the longest established and one of the largest programs in
this field in the world. It was assigned the formidable task of reducing fertility in the world’s
second most populous country. Fertility has declined from 6.0 to 3.4 births per woman, but it is
still short of the replacement fertility goal of 2.1 births per woman. To address this, intensive
evaluation within and outside the country, as well as the Bank’s highly participatory sector work
in 1994, contributed to a policy shift known as the "participatory planning approach."
"The Government of India has taken a bold, imaginative, and innovative step in initiating a shift
in its long-standing program. With the new approach, the program focus will shift from achieving
contraceptive targets to responding sensitively to the health needs of clients, and provide better
quality. gender sensitive information, and services that are more accessible to the poor.
Communities, particularly the rural poor, will participate in identifying their reproductive health
needs and in monitoring service quality," says Indra Pathmanathan, a World Bank Public
Health Specialist and project task manager.
"More specifically," Pathmanathan continues, "the project will serve the contraceptive needs of
the one in three couples who do not want another child but are not using contraception, reduce
the very high levels of death and illness among pregnant women, andfurther reduce the high
levels ofpreventable childhood illness."
The project will assist the Family Welfare
Program in strengthening management
performance by shifting to the participatory
management approach. Implementation of such
policy reform requires fundamental attitudinal
and behavioral change in more than 280,000
managers and workers, as well as in the
community. Recognizing this, the government,
in partnership with the NGO community,
spearheaded an extensive series of consultations
with stale policy makers, NGO and academia,
rural communities, and grassroot providers.
ABOUT INDIA’S FAMILY WELFARE
PROGRAM
With 950 million people, India is the world’s
second most populous nation after China.
India has made remarkable strides in
improving family welfare since the Family
Welfare Program was launched in 1951. In the
intervening period, mortality levels fell by
nearly two-thirds, fertility declined by about
two-fifths, and life expectancy at birth almost
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10/6/99
ncrtb i n
rural communities, and grassroot providers.
These consultations provided guidance on how
to re-direct a massive program without losing its
existing momentum and strengths. This
consultative process will be continued during
project implementation.
n.. rage x ui J
doubled. The Family Welfare Program helped
to bring the country about two-thirds of the
way toward its goal of replacement-level
fertility (2.1 births per woman), with fertility
declining from about 6 to 3.4 births per
woman.
The project will enable the Family Welfare
Program to deliver a package of essential
reproductive and child health services, defined
by the Government of India as: prevention and
management of unwanted fertility; management
of pregnancy and childbirth; reproductive tract
infections; and child survival, including
immunization, diarrheal and acute respiratory
illness, and newborn care.
India has also made inroads in improving
maternal and child health. The country has
established an impressive network of more
than 2,300 community health centers; 21,000
primary health centers; and 131,000 village
level sub-centers to provide primary health
care, including maternal and child health care
and family planning at the grassroots level.
I According to India's Ministry of Health and
Family Welfare (MFHW), more than 40
The project has three major components. The
percent of eligible couples are using
first is a nation-wide policy reform package,
contraception. MFHW's figures also show that
including monitoring and evaluation,
over 60 percent of mothers had received
institutional strengthening, and service delivery. tetanus-toxoid immunizations during their
It will expand existing monitoring systems
most recent pregnancy, over 50 percent of
through regular client polls and technical
mothers had received iron-folate tablets to
assessments of quality. This component also
combat anemia, and over 60 percent of infants
provides training and technical support for more had received at least one immunization.
responsive decentralized activity planning.
I Source: India's Family Welfare Program:
A second component will expand the essential \ Moving To a Reproductive and Child Health
package of reproductive and child health
\ Approach, Directions in Development Series.
services and improve their overall quality,
World Bank.
coverage, and effectiveness. The upgrading of
quality and scope of services will take place through improved clinical and communication
practices and the establishment of referral procedures from the community to the appropriate
facility. This component will also support pilot experimental schemes designed for tribal areas
and urban slums.
A third component focuses on local capacity enhancement. In India’s most disadvantaged districts
and urban slums, the project will provide additional investment for expanding the family health
care infrastructure by financing the construction of health posts, special NGO schemes, and
stipends for voluntary health workers and women’s village health committees.
More specifically, the project will:
• reduce unwanted fertilitypregnancies aamong the 30 million women reported in the 199394 National Family and Health Survey who have ‘unmet contraceptive needs’, namely,
those not using contraceptives, although they wished to space or not have any further births.
• reduce the health risks and burden of disease associated with pregnancy and childbearing
among the 220 million women in the reproductive age group in India, in particular, the
largely poor women in districts that have high concentrations of scheduled tribes and castes.
and poor women in urban slums.
• increase child survival in the 0-4 year age group by increasing program coverage to an
estimated 10 million additional children over the five year period, improve effectiveness of
ongoing interventions, and reduce poor maternal health which is estimated to be associated
with 30 percent of deaths of children under five years of age.
The US$248.3 million equivalent credit will be provided through theon standard IDA terms with a
10 years grace period and 35 yearsto maturity and includes a commitment fee of 0.5 percent and a
service charge of 0.75 percent. IDA is the World Bank’s concessionary lending affiliate. The
Indian Government will contribute US$60.5 million. Total project costs are US$308.8 million
equivalent.
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10/6/99
THF WORLD BANK GROUP
,i*ZT Population and Reproductive Health
-Information Brief
Challenges
The World Bank, its client countries, and other donors
are implementing new approaches in their response to
population and reproductive health issues after the call
by the 1994 Cairo Population Conference (ICPD) to
link population policy more closely to poverty
reduction and human development and to adopt a
reproductive health approach that integrates family
planning, maternal health, and prevention of sexuallytransmitted infections. ICPD seeks to place individual
rights and needs m the forefront of population and
development policies and programs.
Reasons for Investing in Reproductive
Health Projects
•
•
•
Implementing these new approaches poses special
challenges. Population policies and programs need to
be adapted to the diverse demographic, economic and
geographical conditions in countries. Countries with
high rates of population growth require sustained,
coordinated investments in family planning, child
survival, maternal health, girls' education and women's
empowerment.
Experience shows that such investments can have a
significant demographic impact. For a variety of
reasons, including changes in attitudes linked to
increased education and economic opportunities for
women, dissemination of new ideas through the mass
media, and organized efforts to increase access to
modem methods of fertility regulation, fertility rates
have declined to below half their 1960 levels in East
Asia and Latin America, and nearly so in South Asia.
Investments by the Bank and other donors created
enabling conditions for these fertility declines.
•
•
•
•
High-quality, user-oriented health
services offering a range of reproductive
health services and information can
improve individual health and welfare.
Improvements in reproductive health
have multiple benefits : lower fertility.
lower maternal mortality, healthier
children, and better-off families.
Slowing ofpopulation growth is still a
high priority in the poorest countries:
rapid population growth makes it more
difficult to provide education and health
services, create jobs, and preserve the
environment in poor countries.
Integration ofpopulation policy with
social policies, including girls'
education, women's status, and poverty
reduction, is more effective in reducing
high birth rales than policies that focus on
fertility reduction alone.
Empowerment and choice enable
people to make their own choices about
family size by providing them with the
means - family planning information,
education, supplies, access.
Promoting better reproductive health
helps women avoid the risks of too many
births, too closely spaced, or initiated
when the mother is too young or too old
Poor reproductive health undermines
women's potential to contribute to
increased productivity and family welfare.
The poor in all regions continue to experience
unacceptably high fertility, malnutrition, and child and maternal mortality. An estimated 120 million
women who currently wish to space or limit further childbearing are not using contraception. Almost
10% of the total disease burden in the developing world is due to maternal and perinatal conditions.
Among women in the age-group 15- 44, pregnancy-related illness and death impose the greatest
disease burden. While illustrating the high global burden of preventable disease, this statistic masks
considerable regional variation even among poor countries. For example, at similar per capita income
levels, maternal mortality in Yemen is ten times higher than in Vietnam, and almost 30 times higher in
the Ivory Coast than in Sri Lanka.
The Link to Poverty
Improving human development and economic productivity are central to the Bank's efforts to reduce
poverty. Population and reproductive health are linked in various ways to these important agendas.
For example, the growth, age composition and geographic distribution of populations affect and are
affected by progress in reducing poverty and improving living conditions. In poor households, high
mortality and morbidity, along with unwanted fertility, are among the major burdens of poverty.
Reducing them contributes directly and indirectly to poverty reduction.
The linkages between poverty, population and reproductive health are complex. Most of the increase
in global population over the last four decades has occurred in developing countries, and future
increases are projected to occur in the poorest of those countries. Despite the pressures of rapid
population increase, developing countries have made substantial progress in improving living
standards. However, rapid population growth continues to undermine efforts to reduce poverty in
Africa and Asia and poor economic performance combined with a high rate of population increase has
http: www.worldbank.org/html/extdr/hnp/population/infobrief/index.htm
10 (> 99
led to declines in per capita income in several countries.
The World Bank's Role
In keeping with its development objectives, the World Bank is working closely with partners and
client governments to address population issues within a broader context. The Bank's main
comparative advantage in population and reproductive health policy is through dialogue and analytical
work to help borrowers understand how demographic shifts affect the social sectors (health, education.
social security) as well as the environment and agriculture, employment, and basic infrastructure.
Over the past 40 years, Bank population projects have included a combination of strategies. In the
1970s, projects supported infrastructure projects to provide facilities to provide reproductive health
services to clients. At the same time, funds were provided to provide technical assistance and training
for the development of skills to implement family planning programs. During the 1980s, the focus
expanded to cover primary health care and communities, particularly addressing the health of children
and more recently, of women. In the 1990s, operations are increasingly addressing health sector
reform and new health problems, including HIV/AIDS. In addition, reproductive health and family
planning are now being addressed as components of broader health programs. The broader approach is
expected generally to be more cost effective and yield greater results.
The World Bank is working with borrower countries and other donors to implement the agreements on
reproductive health and rights agreed upon at the 1994 International Conference on Population and
Development (ICPD) and the 1995 Fourth World Conference on Women and is working to reduce the
gender gap in education and to ensure that women have equitable access to and control over economic
resources.
World Bank Lending
The Bank is the largest single source of external funding in developing countries for human
development (HD) programs: health, nutrition, population (HNP), education and social protection.
Population and Reproductive health activities constitute a significant portion - just less than one-third of all lending for health, nutrition and population. Most of the World Bank's funding for Population
and Reproductive health programs is provided on highly concessional terms to low-income countries
through the International Development Association (IDA).
Population and Reproductive Health Related Development
Impacts of Bank Operations
Operations
Sector Outcomes
Human Development Impacts
Bank lending supports investments in a variety of initiatives that contribute to positive population and
reproductive health outcomes, as shown in the figure above. These programs contribute directly to
7www.worldbank.org/html/extdr/hnp/population/infobrief/index.htm
10'6,99
outcomes that are important in their own right (the middle column of the figure). They also contribute
indirectly through changes in the enabling environment, for example by influencing desired family
size or by increasing women's capacity to make decisions that affect their reproductive health (as
shown in the right-hand column of the figure). At the policy level, recognizing these broader
development links and ensuring that social programs contribute positively to them is much of what
ICPD meant when it called for population issues to be addressed in a broader human development
context.
In the HNP sector, the Bank has lent USS 3.7 billion over the last twenty-five years to support
population and reproductive health through 192 HNP projects in over SO countries. Although new
commitments have varied from year to year, the trend has been steadily upward. In recent years, Bank
lending has integrated reproductive health projects with its population programs, financing an average
of nearly USS 400 million a year since fiscal 1992 for projects involving population and reproductive
health activities. Many Bank projects include grant assistance from other donors or are designed to
complement the work of other donors in client countries.
Other Bank-funded projects also make significant contributions to Population and Reproductive
health issues. Over the past three fiscal years (1996-1998), die Bank and IDA have committed nearly a
billion dollars in new lending to increase education for girls. Outside of the Human Development
sector, rural development projects provide micro-credit, which contributes to the empowerment of
women and indirectly enables them to exercise greater choice in reproductive decisions. Genderfocused initiatives in a number of sectors have similar effects. For example, the Second Egypt Social
Fund Project has a $354 million enterprise-development component providing loans and technical
assistance through NGOs, with special emphasis on credit for poor women.
Regional Perspective
The Bank's six regional units have all made major commitments to reproductive health and family
planning. During the period covering FY 1992 to FY 1998, South Asia accounts for the largest share
(35 percent) of the $2.7 billion in loans and credits. Latin America and the Caribbean countries have
the second largest share with 20 percent, and Africa is third with 17 percent.
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10'6,99
Commitments for PopulatiowReproductive Health in Lcans/Credits,
Fiscal Years 1992-9S by World Bank Region (Millions of U.S. Dollais)
Fiscal Year
1992
1993
1994
1995
1996
Sub-Saharan
25.2
67.1
96 7
145.8
50 7
1 7
65.0
452.2
Per
cent
17
East‘ Asia
Europe &
Central Asia
Latin America
& Caribbean
Middle Easts
North Africa
South Asia
TOTAL
0.5
46.6
79.3
O'
9.4 |
0
93.5
1.8
114 4
111.8
8.0
26.1
50.6
2.7
355.7
189.0
13
7
2.3
35.6
184 5
54.0
111.8
64.5
98.2
550.9
20
0
79.4
0
46 4
37.5
0
38.0
201.3
8
243.7
318.3
78.6
340.0
133.1
423.7
106.6
448.1
82.7
508.9
131.7
232.0
171.0
425.5
947.4
2696.5
35
100
1997
1998
Total
Effective Action
The Bank's comparative advantage
The World Bank's partners in the population and reproductive health fields - including UNFPA.
WHO, UNAIDS, UNICEF, bilateral donors and NGOs - provide borrowers with most of the technical
expertise as well as significant financial assistance for their programs. These partners look to the Bank
for support in policy dialogue and resource mobilization. Because of the Bank's access to both finance
and planning ministries as well as functional ministries such as health, education, and women's affairs.
it is well positioned to facilitate actions that link investments in different sectors, including health.
education, and gender, to achieve optimum impact. Further, it has the financial capacity to support
investments in these areas and has committed itself to increased support of the social sectors.
In order to sharpen strategic focus and strengthen
Key Population and Reproductive Health
effectiveness, the Bank's staff in population and
Indicators:
reproductive health are working to ensure that these
perspectives are included in key documents during
• The total fertility rate
policy dialogue with client governments in countries
• The maternal mortality ratio
where such a perspective is expected to have a critical
• The prevalence of HIV/AIDS
impact on poverty and human development. A
• An index of the force of population
database of key population and reproductive health
momentum
indicators (see box) will be maintained to identify key
• Urban population growth
issues for possible discussion in World Bank Country
• Growth of the young working-age
Assistance Strategies (CASs) and other key
population
documents. These indicators will help to identify
• Enrollment of girls in secondary school
population and reproductive health issues in countries
slated for CAS review with the aim of directing
increased attention on these issues during discussions with governments.
Strengthening Partnerships
Many Bank Population and Reproductive health projects currently involve a partnership between
governments, international agencies, other donors and non-governmental organizations (NGOs).
Many of these partners have developed specialized skills over the years and Bank collaboration with
these groups is steadily increasing.
• United Nations Population Fund (UNFPA) : UNFPA is the lead international agency in the
population field, with a sh'ong network of field offices that are knowledgeable about local
conditions and issues. The Bank already uses UNFPA's contraceptive procurement facility and
is working to increase collaboration in such areas as training, procurement, strategy
development, and country program management.
• World Health Organization (WHO) : WHO is the lead international agency in health, with
strong links to the scientific community for maternal, reproductive and child health. The Bank
supports WHO's program for training and research in reproductive health, and WHO provides
the Bank with policy guidance and technical support.
• Joint United Nations Programme on AIDS (UNAIDS) : UNAIDS is a global partnership
cosponsored by the World Bank and five other international agencies. Its goal is to provide
policy and technical leadership to countries in their efforts to turn back the epidemic.
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10 6 99
• United Nations Children's Fund (UNICEF) : UNICEF is a partner in a number of Banksupported RH operations, and has recently begun to expand its focus on adolescent
reproductive health. UNICEF's specialized skills in advocacy and health communication are
particularly important for reproductive health initiatives.
• Bilateral Donors : Bilateral donors cofinance P/RH activities in a number of borrower
countries and provide a broad range of technical support to country programs.
• Nongovernmental organizations (NGOs) : NGOs have played a critical role in the
population and reproductive health fields - particularly for developing and testing novel
approaches to problems, in research, advocacy, and service delivery in settings where the
government and for-profit private sectors are particularly weak.
Addressing the multisectoral dimensions of population and reproductive health also requires working
with partners outside the HNP sector. Within the Bank, links to the Education and Social Protection,
as well as Gender, Poverty Reduction and Environment, are being strengthened. Outside the Bank, ties
are being nurtured with more general development groups as well as those with a special focus on
gender, the environment and human rights.
Additional Funding Sources
One of the most effective mechanisms for working with these partners is through grants given under
the Bank's newly established Development Grant Facility (DGF, formerly the Special Grants
Program). In addition to the WHO programs mentioned above, these grants have enabled the Bank to
build the capacity of grass-roots groups in borrower countries that work on issues (female genital
mutilation, for example) which cannot be addressed through the lending program Another initiative
supported by the program, the South-South Partnership in Population and Reproductive Health, is
already helping to bring a range of development partners into collaborative arrangements to assist in
training and interagency coordination.
Making A Difference - Bank Population Programs
INDIA
The India Reproductive and Child Health project is upgrading the quality and scope of reproductive and child
health services. The two central project components include a nationwide policy reform package covering
monitoring and evaluation, institutional strengthening and service delivery, and a local capacity enhancement
component that would fund district and city sub-projects aimed at meeting specific needs of local priority groups.
The project is intended to increase access for particularly disadvantaged groups such as scheduled castes and tribes.
□nd the urban poor.
BANGLADESH
In Bangladesh, a consortium of development partners, including the Bank and the Government of Bangladesh, has
funded a series of health and population projects. The consortium was established during earlier projects and is now
working with the Government in implementing a sector-wide program that will support delivery of an essential
package of reproductive and child health services Priority will be given to the needs of vulnerable groups.
particularly poor women and children, and to addressing Bangladesh's high rates of maternal mortality and
morbidity. The program is also supporting key reforms aimed a making Bangladesh's health system more cost
effective and sustainable.
MOROCCO
The Morocco Social Priorities Program/Basic Health Project is working to increase access to essential curative and
preventive health services in 13 target provinces. Safe motherhood goals arc being attained by increasing
availability to contraceptives, reorganizing prenatal service delivery, training traditional birth attendants, and
establishing a medical evaluation system for obstetrical emergencies.
MALAWI
The Malawi Social Action Fund is a multi sectoral Bank project. It will upgrade and construct community
infrastructure such as schools, health facilities, community water points, rural/urban markets, and granaries to help
women gain better access to health and education facilities and employment opportunities. The project's
promotional activities focus attention on women's priorities and needs and support women's involvement in the
design, implementation and management of subprojects.
The benefits of the projects include:
•
•
•
Increased access to health care, including family planning, at sites where health facilities have been
constructed.
Better access to maternal care at sites with maternity facilities.
Better management of emergency cases as a result of road works, allowing ambulances to reach previously
inaccessible communities.
w. worldbank.org/html/extdr/hnp/population/infobrief/index.htm
10'
•
Increased food purchasing power and improved women's and children's nutrition resulting from higher
earnings.
http?.'www .worldbank.org/html/extdr/hnp/populatioii/infobrief/index.htm
10 6 99
THE WORLD B AN K RESIDENT MISSION IN ROMANIA
l < .■ >
I
DESPITE PROGRESS, MILLIONS IN THE
DEVELOPING WORLD STILL DENIED ACCESS TO
REPRODUCTIVE HEALTH SERVICES
WASHINGTON, February 4, 1999--Around the globe, 120 million poor couples are still denied
access to good reproductive health services and counseling. Lack of access is most serious in subSaharan Africa and in several countries in Asia and the Middle East, where most of the additional 2 3 billion people will be born before global population stabilizes sometime late in the next century,
according to the World Bank.
As experts and policymakers gather in The Hague, Netherlands, next week to review progress since
the 1994 International Conference on Population and Development in Cairo, population growth
remains a persistent problem. Despite the strides many countries have made, unwanted
pregnancies, malnutrition, and high child and maternal death rates are still far too common in the
developing world.
Tragically, one in every 48 women in the developing world dies from pregnancy-related causes each
year, compared to one in 4,000 in developed countries. Reproductive- tract infections are
widespread. The leading cause of death and disability for women in the developing world is poor
maternal health and birth-related problems..
Governments can no longer afford not to invest in population and reproductive health programs—
the most cost effective public health initiatives developing countries can undertake. Because such
investments are inexorably linked to economic growth, the World Bank has been working with
developing countries to implement the landmark agreement signed in Cairo and to integrate its
population and reproductive health activities into its core agendas of poverty reduction and human
development.
"The Cairo conference shifted the focus of population work from demographic targets and control to
an approach that puts people and their human rights first," said Tom Merrick, World Bank Senior
Population Adviser. "This shift parallels the World Bank's own move toward greater emphasis on
social development and on balancing its goals of poverty reduction and human development with
more traditional concerns about public finance and macroeconomics."
The World Bank% the single largest external financier of human development programs in
developing countries% is also working closely with partners and client governments to address
population issues within a broader context. The Bank's main comparative advantage in population
and reproductive health policy is through dialogue and analytical work to help borrowers
understand how demographic shifts affect the social sectors (health, education, social security) as
well as the environment and agriculture, employment, and basic infrastructure.
Following its commitment made at the Cairo conference, World Bank has steadily increased lending
for population and reproductive health activities— over $2 billion in loans since 1994— and
developed a new strategy linking these goals to its core agendas of poverty reduction and human
development. Even more lending has been provided through support for child survival, girls’
education, and the empowerment of women, where the links to population and reproductive health
are indirect. The social sectors now account for a fifth of overall Bank lending.
With access to both finance and planning ministries, as well as to ministries such as health,
education and women's affairs, the Bank is well-positioned to encourage a broader perspective of
population issues and to link investments in various sectors to achieve the best results.
The Bank works with its partners to find the underlying flaws that make health and education
systems unresponsive to the needs of the poor. Constraints like financial disincentives and rigid civil
http: /www.worldbank.org.ro/eng/news_e/despite.htm
service rules—guaranteed employment no matter how poor the performance—undermine efforts to
improve the quality of health and education programs. Improving the performance of health
systems is particularly important for such initiatives as Safe Motherhood, which requires an
effective referral of obstetric emergencies in order to save women's lives.
"For all aspects of population and reproductive health, empowering women is a critical factor,” said
Anne Tinker, Senior World Bank Health Specialist. "This requires careful analysis to identify
synergies across sectors such as health education, and social programs. Coordinated support for
programs in reproductive health, girls' education and access to income-generating opportunities
and employment for women will yield gains in welfare for individuals, families and communities."
MAKING A DIFFERENCE - WORLD BANK POPULATION PROGRAMS
INDIA
The India Reproductive and Child Health project is upgrading the quality and scope of reproductive and child health services. The
two central project components include a nationwide policy reform package covering monitoring and evaluation, institutional
strengthening and service delivery, and a local capacity enhancement component that would fund district and city sub-projects
aimed at meeting specific needs of local priority groups. The project is Intended to increase access for particularly disadvantaged
groups such as scheduled castes and tribes, and the urban poor.
MALAWI
The Malawi Social Action Fund is a multi sectoral Bank project. It will upgrade and construct community infrastructure such as
schools, health facilities, community water points, rural/urban markets, and granaries to help women gain better access to health
and education facilities and employment opportunities. The project's promotional activities focus attention on women's priorities
and needs and support women's involvement in the design, implementation and management of subprojects.
The benefits of the projects include: increased access to health care, including family planning, at sites where health facilities
have been constructed; better access to maternal care at sites with maternity facilities; better management of emergency cases
as a result of road works, allowing ambulances to reach previously inaccessible communities; and increased food purchasing
power and improved women's and children’s nutrition resulting from higher earnings.
[ Up ] [ Next ]
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106.99
Soc. Sa. Med. Vol. 25, No. 4, pp. 357-365, 1987
Printed in Great Britain. AH rights reserved
0277-9536/87 $3.00 + 0.00
Copyright © 1987 Pergamon Journals Ltd
DESTRUCTIVE HEAT AND COOLING PRAYER:
MALAY HUMORALISM IN PREGNANCY,
CHILDBIRTH AND THE POSTPARTUM PERIOD
Carol Laderman
Department of Sociology and Anthropology, Fordham University, Bronx, NY 10458, U.S.A.
Abstract—Malaya, an ancient crossroads of trade, was the recipient of Chinese and Ayurvedic humoral
ideas and, later, those of medieval Islam. These ideas were readily accepted by Malays, since they are
highly congruent with pre-existing notions among aboriginal peoples of Malaya involving a hot-cold
opposition in the material and spiritual universe and its effects upon human health. Islamic Malays have
adapted these aboriginal beliefs to correspond to the Greek-Arabic humoral model in matters concerning
foods, diseases, and medicines. Although Malay theories of disease causation include such concepts as
soul loss and spirit attack, along with ‘naturalistic' ideas such as dietary imbalance and systemic reactions
to foods, all of these theories can either be reinterpreted in humoral terms, or, at least, are congruent with
the basic tenets of Islamic humoral pathology. Behaviors and beliefs regarding human reproduction,
however, while essentially following a humoral pattern, diverge from Islamic, as well as traditional Chinese
and Indian Ayurvedic, humoral theories. Unlike any other major humoral doctrine, Malay reproductive
theory (like that of non-Islamic aboriginal peoples of Malaya) equates coldness with health and fertility
and heat with disease and sterility. These ideas, in turn, are related to beliefs regarding the nature of the
spirit world: the destructiveness of spiritual heat and the efficacy of cooling prayer.
Key words—reproduction, humoral pathology, Southeast Asia, Islam
A systematic theory of pathology defining health as
the balance of opposing elements in the body was
basic to medical thought in three of the world’s great
civilizations: ancient Greece, India and China. The
similarities of humoral thought in these cultures
are due, in part, to early and continuing cross
fertilization, yet each has its own special variation on
this broad theme. In the ancient world, Greek and
Indian humoral traditions travelled from east to west
and back again through Persia [1], In the centuries
following Chinese conversion to Buddhism, particu
larly during the fourth to tenth centuries A.D.,
pilgrim-monks established links between India and
China and brought back Indian medical texts in
Chinese translation [2],
From hundreds of years before the birth of Christ
until modern times, Malaya has been the crossroads
of trade from India and China, exchanging ideas as
well as goods with representatives of these cultures.
Archaeological evidence suggests that Indian ships
visited Malaya as early as the fifth century B.C. By
the second century A.D. there were Indianized king
doms throughout the Malay peninsula [3]. Although
the earliest written records of Chinese trade with
Malay states date from the seventh century A.D. [4],
since they are not reports of first contacts, there is
reason to believe that the association considerably
predates these records.
‘Malaya’ refers to the Malay peninsula, ‘Malaysia’ to the
modern state which comprises the peninsula plus Sabah
and Sarawak on the island of Borneo. ‘Malay’ refers to
the politically dominant ethnic group which professes
Islam, habitually speaks the Malay language, and con
forms to Malay customs (so defined by the constitution
of Malaysia).
When Arabic humoral theory, offshoot of Greek,
reached Malaya along with Islam in the fourteenth
and fifteenth centuries, the circle was complete. Ele
ments of the three great humoral traditions had come
together on the Malay peninsula. Arabic medicine
found a fertile field for the dissemination of its ideas
among a people who had long subscribed to similar
Ayurvedic theories, introduced into Southeast Asia
by early Brahman immigrants [5], and tempered
by long association with representatives of Chinese
culture.
Over the centuries, humoral theory has been
shaped by and integrated into Malay* thought.
Elaborated humoral ideas now extend from such
mundane matters as food and illness to the workings
of the Universe and the nature of its inhabitants, both
seen and unseen. For foreign ideas to take root and
flourish, as humoral theories have done in Malaysia,
there must be a favorable climate, a welcoming
soil. What preconditions might have favored the
acceptance of humoral assumptions in Malaya?
What world-view could incorporate them without
dissonance?
Just as the humoral system brought to the New
World by Spaniards found acceptance among Native
Americans who believed the Universe to be ordered
by a balance of opposites [6], so may such theories
have found points of resemblance in pre-Hindu
Malayan beliefs about sickness and health, particu
larly in regard to reproduction. Since we lack written
records of Malay life and thought in ancient times, we
must turn to ethnographic accounts of aboriginal
peoples of Malaya, the Orang Asli, for clues. This
entails a number of problems, ranging from the
unevenness of coverage in the ethnographic record,
the varying degrees of contact these peoples have had
357
Carol Laderman
358
with the dominant Malays, and the diversity to be
found among the Orang Asli themselves. Tradi
tionally grouped into three broad categories, the
Semang or Negritoes, the Senoi, and the Aboriginal
or Proto-Malays, Orang Asli vary in their accommo
dations to the environment, from foraging, through
shifting agriculture, to sedentary village life. Their
cultural values and social organization are equally
various, and their languages range from forms of
Austroasiatic to Austronesian dialects almost indis
tinguishable from Malay. Yet despite the great di
versity of Orang Asli, there are several broad cultural
themes that connect these aboriginal peoples of
Malaya*.
HUMORALISM AMONG ORANG ASLI
Although they do not employ a humoral classificatory system, hot-cold opposition is dominant in
Orang Asli medical theories. Among the Semelai, a
Proto-Malay people, glowing health is equated with
coolness, tiredness and ill-health with heat, a feeling
which undoubtedly reflects good commonsensical
observation of life in a hot equatorial climate. The
Semelai, however, do not attribute sickness only to
the heat of the day. Sickness can also result from
contact with badi, a hot destructive spiritual force
found in all living things and released upon death, but
concentrated especially in human corpses and jungle
animals. It can also inhere to certain kinds of food,
making them hot and dangerous as well. The basic
Semelai healing ritual consists of reciting cooling
spells and employing cooling rice-paste to rid the
patient of excess heat and bring him back to normal
[7]. Senoi Temiar healers combat the heat of malevo
lent spirits with the cooling power of beneficent
spirits who assist them in magically infusing their
patient’s body with refreshing invisible liquid [8].
Although these beliefs and practices strike a chord
of recognition among students of Malay culture, I
find it significant that healers of these Orang Asli
groups, which were neither part of the Hinduized
Malay kingdoms nor, later, Islamicized, differentiate
their medical practices into those which they say were
borrowed from the Malays and those which they
claim were not influenced by their neighbors. Among
the latter are both the basic ideas I have briefly
mentioned, and the steps taken by a mother and her
attendants during and after childbirth to protect her
health and that of her child.
Semai and Temiar women in labor are asperged
with cold water to keep them cool and healthy, and
to protect them from destructive heat [8, 9]. After a
woman has given birth, however, her body is no
longer normally cool but has temporarily become
abnormally cold and vulnerable. She and her equally
vulnerable child must be kept warm and protected
from chilling. The new baby is given a warm bath [9],
and the mother is massaged with and bathed in
heated water [8], Cold drinking and washing water is
’A further caveat lies in the direction of possible Hindu
influences on Orang Asli cosmology. Benjamin [26] and
Endicott [27] mention that the Temiar and Batek Negrit
oes, respectively, have incorporated Hindu terms and
stories into their mythology.
forbidden to women in the puerperium [8-10]. Sashes
containing warmed leaves or ashes are tied around
their waists, and they lie down near a fire source (a
practice widespread throughout Southeast Asia.
often referred to as ‘mother roasting’, although.
considering the moderate amounts of heat produced.
it might be more accurately termed 'mother warming’
or ‘mother toasting’).
All of this behavior has its direct or close counter
part among practices of contemporary Islamic
Malays, who have incorporated them into an elabor
ated humoral system. Among most Orang Asli, how
ever, they are part of a belief system that makes
general statements about heat and coldness and does
not categorize particular diseases, treatments, medi
cines, or foods according to the hot, cold, wet or dry
properties of their components in the ‘scientific’ and
‘rational’ manner of Greek-Arabic or Ayurvedic
humoralism. A basic hot-cold opposition could set
the stage for acceptance of an exogenous humoral
theory, since such a theory would agree with pre
existing modes of thought. After its acceptance, the
humoral system is shaped by and incorporated into
the medical and cosmological beliefs of the recipient
group. It may elaborate and diffuse through many
domains, yet it remains only one of a number of
multiple overlapping theories within an overarching
world-view.
Rather than merely propose this point as a plau
sible generalization, I will show, through a discussion
of contemporary beliefs and practices during preg
nancy, childbirth and the postpartum period of rural
Malays on the east coast of peninsular Malaysia, the
shape of the Malay humoral system and its place
within the world-view of which it is one component.
THE MALAY HUMORAL SYSTEM
The Malay humoral system, which I have previ
ously described in detail [11, 12], is a dynamic com
plex, incorporating variation as one of its precepts.
People are believed to be different from one another
in their humoral proportions, and each one’s hu
moral relation to the outside world is expected to
change daily and seasonally, and as he passes through
the stages of life. Owing to this expected variation,
broad humoral categories, such as ‘hot, cold, or
neutral’ foods, and the rationales behind such categ
orizations, are shared concepts, but particular items
within these categories differ on an individual basis
without causing disruption of the system.
Among contemporary rural Malays, beliefs, hu
moral and otherwise (with the exception of the five
daily prayers and other religious duties demanded by
Islam), tend to remain quiescent unless some crisis
calls forth action. Childbirth is such a time of stress—
physiological, psychological, and social. Even though
it is viewed as a normal occurrence in every woman’s
life, childbirth’s potential dangers evoke protective
measures to minimize these risks. Ideas and behaviors
surrounding reproduction tend to be highly conser
vative. Malay women who have accepted the precepts
of hospital-based medicine, including wives of doc
tors and women who themselves possess advanced
degrees in biological science, return, during the weeks
360
Carol Laderman
practical-sounding advice as admonitions to preg
nant women to refrain from sleeping during the day
for fear heat might collect in their cheeks and make
them swell, or to sit on the floor instead of a chair for
fear their ankles might swell. Other pantang reflect
belief in sympathetic magic. Mothers are cautioned
that tying cloths around their necks may result in the
umbilical cord looping itself about the baby’s throat.
Fathers are warned that sitting on their house steps
and blocking the entrance may obstruct a wife’s birth
canal. Although some prospective parents obey these
injunctions, others ignore them completely. While the
neighbors may think such people are tempting fate,
their chances of escaping unscathed are considered
good. It is only because pantang are not implicitly
obeyed that satisfying ex post facto explanations are
possible (see [9] for similar observations about the
Semai).
Besides allowing for individual decisions in their
observance, pantang themselves are often both prac
tical and flexible. For example, the husband of a
pregnant woman should not hammer nails into wood
lest his wife have a difficult labor, unless he is a
carpenter. He should not slaughter wild animals,
unless he is a fisherman. The prohibitions of preg
nancy do not restrict a family’s usual economic
activities or interfere seriously with the continuation
of their normal daily life.
The primary sources of danger to the unborn come
from risks to his spiritual and ultimately his bodily
integrity, due to his father’s carelessness or cruelty, or
his mother’s shock or fright; and from contact with
badi, the destructively hot spiritual force previously
mentioned in connection with Orang Asli. To avoid
increasing the risks to his child, a father-to-be should
not engage in wanton destruction. Animals must be
slaughtered cleanly and for good cause. Wood should
not be splintered or cut leaving jagged edges. Animals
and wood possess semangat, the life-force that perme
ates the Universe and dwells in man, beast, plant, fire
and rock (see also [15]). All share a form of life; the
life of a fire is swift and soon burns out; a rock’s life
is slow, long and dreamlike. Slashing and splintering
wood is equivalent to cutting and chopping flesh and
bone. Both can disfigure a growing fetus, since all are
bound up in the actions of the father, its primary
source of life.
A mother should guard against being startled or
disgusted during pregnancy, when her semangat is
particularly vulnerable to shock. Fright can deplete
the life-force, leaving the mother’s body a prey to
spirit attacks and interfering with her baby’s devel
opment. Many minor birth defects and behavioral
anomalies of newborn babies are attributed to pre
natal shock.
A father can avoid afflicting his unborn child with
the destructive force of badi by foregoing hunting
during his wife’s pregnancy. Killing domestic animals
and fish is a necessary part of village life and carries
no risk if done humanely. Chickens belong to the
world of Man, the cultivated, domesticated, familiar
village. Fish, although wild, are essential to the diet,
•The baby in question died in the hospital several hours
after being admitted. The diagnosis was gastroenteritis
and severe dehydration. See [12] for further details.
and fishing is a primary occupation of rural Malays.
Hunting, however, is a non-essential activity that
takes a man away from the protection of his home
and into the jungle, where dangers range from savage
animals to untamed spirits. As frightening as the
hantu of the village and fields might be, jungle spirits
are known to be wilder and more unpredictable.
unused to the ways of men and resentful of their
encroachment. The animals of the jungle are cher
ished by the spirits. Killing the spirits' pets can expose
the hunter and his unborn child to the wrath of their
ghostly friends, and to the malign heat of the animals'
badi which escapes at the time of their death.
The badi of human corpses can be extremely
dangerous to those with a precarious hold on their
semangat. Prospective parents, and sick or delicate
people, may have an unpleasant aftermath to a visit
of condolence. An adult with depleted semangat may
find himself growing weaker, and an unborn child
may be afflicted with badi mayat (the badi of a human
corpse), which manifests itself in the newborn as a
wasting disease. In the one case of badi mayat I
observed, the baby, who was fat and healthy at birth,
refused to eat, took on the appearance of a corpse,
and died within weeks of her birth*. Considering the
severity of badi mayat, if Malays believed in a direct
cause-and-effect relationship, it would be simple com
mon sense for all vulnerable persons to stay away
from the dead. That they do not is ample proof that
they believe in increased probabilities rather than
certainties, and that the peril is remote enough for
many people to test the limits or flirt with danger.
Islamic Malays share the concept of destructive
spiritual heat with the Orang Asli. They have, how
ever, adapted this pre-humoral notion to correspond
with the Greek-Arabic humoral model of the Uni
verse and the Islamic myth of Man’s creation. The
spirits, to a Malay, are not merely hot, they are
lacking in two of the four basic elements of which the
world is made. They were created through the curi
osity of the archangel Gabriel. God entrusted the
Breath of Life into Gabriels hands and ordered him
to place it into Adam’s nostrils so that his still lifeless
body, fashioned of earth and water, might be ani
mated. Gabriel opened his hands before reaching his
destination to see what he was carrying, and the
Breath of Life escaped. Having no body to receive it.
the Breath became hantu, disembodied spirits com
posed only of air and fire. They can bring sickness to
humanity by blowing on their victims’ backs, causing
humoral imbalance.
Rituals performed during the reproductive process
attempt to balance the fire and air of the spirit world
by adding earthy and watery elements to the prospec
tive mother’s body. Such spiritual prophylaxis is most
important during a woman’s first pregnancy, since
she has not yet become adept at her womanly task.
The ceremony of rocking the abdomen (lenggang
perut), performed by a midwife during the seventh
month of a primagravida’s pregnancy, combines
symbols of release and rebirth, such as loosening
slipknots and passing through circles, with humoral
‘balancers’. The mother-to-be is bathed in cold water
into which humorally ‘cold’ lime juice has been
squeezed. Tepung tawar, the neutralizing rice paste
employed in much of Malay magic, is added to the
Destructive heat and cooling prayer
water and painted on the foreheads of both the
midwife and her patient. Its efficacy is owing to its
qualities of earth and water, which neutralize the
spirits’ fire and air. Tepung tawar is made of rice, the
quintessential fruit of the earth for a Malay, which is,
moreover, grown in water. It is ground into flour and
mixed with water to form the most efficient ‘balancer’
of Malay materia magica. Spiritual heat is further
balanced by the midwife’s breath, cooled by the
power of her incantations and blown toward her
patient. The fetus is protected from heat by ‘cooling’
herbs which are strung around its mother’s waist. All
of these measures are expected to help a prospective
mother deliver her baby safely, yet they may not
achieve their goal if she is not in harmony (sesuai')
with the midwife she has chosen.
361
mother, not her birth attendant, has the final say. If
she wants to lie on her side or sit up during labor,
there is nothing to prevent her from doing so. If she
wants to eat or drink, she may. If she does not wish
to wear a sash above her uterus, she may discard it.
She and her family may either neglect some of the
usual magical procedures, or, in the case of difficult
or abnormal deliveries, add to them by calling in
other healers or birth attendants as they see fit. The
behavior of Malays during childbirth, like their be
havior during pregnancy, is neither routinized nor
completely predictable. In common with the behavior
of people in all societies, Malay reproductive behav
ior is based on shared cultural concepts transformed
by individual desires and situational requirements.
This will be demonstrated further in the discussion of
behavioral changes specific to the Malay puerperium,
to follow.
MALAY CHILDBIRTH
The successful outcome of a pregnancy depends
not only upon the harmony of the fetus and its
mother, and the harmony of a mother and her
midwife, but also the harmony of the mother and the
Universe. The midwife assists the patient in achieving
this harmony by advising her, toward the end of
labor, to lie in the direction that corresponds to the
heat of the prevailing wind of the day. All of the
possible positions in this directional system for child
birth cluster around south and west. North is
avoided, since Muslim corpses are buried facing in
that direction, and east is avoided since it is the
opposite of west, the holy direction towards Mecca
which Malays must face when they pray. The value
of harmony, which runs through much of Malay
thought, has been enriched in this directional system
to include both humoral and Islamic ideas.
The midwife employs many other measures to
assist her patient through childbirth, some of which
are specifically humoral, such as rubbing ‘hot’ sub
stances like calcium oxide (lime) paste on her abdo
men to make the womb uncongenial to the baby and
encourage him to leave. Other treatments range from
such ‘naturalistic’ measures as tying a rolled-up
sarong above a laboring woman’s uterus to keep the
fetus from rising, to actions designed to discourage
malevolent spirits, such as placing sharp and spiny
objects beneath the place of birth to catch the hang
ing intestines of birth demons and frighten away the
genies who live in the earth. Danger to the baby can
come, as well, from the afterbirth, considered to be
his own sibling. While it possesses the human qual
ities of earth and water, it lacks the fire and air that
quicken its brother into life. Its human qualities
demand that it be given a decent burial, washed and
placed in its winding sheet and coconut shell coffin by
the midwife. Its lack of humoral balance, however,
makes it the mirror image of the disembodied spirits
and admits it into their company. Postpartum depres
sion is often attributed to the placenta’s envy of its
sibling’s favored lot.
Throughout labor and delivery, although a mid
wife’s advice is treated with the greatest respect by her
patient and the family, there is nothing that compels
the prospective parents to follow her advice. Unlike
the experience of many American women, a Malay
THE POSTPARTUM PERIOD
Malays consider the 40 days following childbirth to
be the most dangerous time for both mother and
baby and, accordingly, take many precautions to
guard against threats to their bodies and souls. It is
during this period that we find the greatest concen
tration of humoral thought and behavior, although,
once again, these humoral conceptions are only one
facet of Malay medical theory.
During pregnancy, a Malay woman usually con
tinues her normal diet and behavior with few
changes, secure in the belief that her physical vitality
and humoral balance will protect her from spirit
incursions and other unusual threats to her health.
After she has given birth, however, she must guard
herself and her baby against danger. The newborn
and his mother are vulnerable to attack from the
spirit world during the postpartum period—he, be
cause his little body is tired after its long journey from
the darkness of the womb to the light of day; she,
because her body is tired from the exertion of giving
birth. The infant’s semangat has a precarious hold on
its new lodging; the mother’s semangat has been
depleted by her labors. When the essential vitality is
depleted, the body’s defenses lose their integrity and
spirits may use the opening to launch an attack.
A baby bom with the umbilical cord looped
around its neck will need to be ritually released from
the dangers inherent in its hazardous entry into the
world. A baby who exhibits the symptoms of prenatal
shock will also require a healer’s care. If he does not
thrive despite the best efforts of his parents and their
medical-magical consultants, a baby’s problems may
be attributed to the lack of harmony between his
personality and his name. The discordance set up by
a ‘wrong’ name may contribute to a child’s vulner
ability. Many Malay children are known by two
names: a school name (the one on their birth
certificate) and a home name, given for reasons of
health [16],
Malays believe that the greatest threat to a new
mother’s health is the danger of postpartum hemor
rhage. They attempt to obviate this possibility by
careful obstetrical procedures during delivery of the
placenta, by the use of massage and heat applications
during the postpartum period, and by avoiding a
362
Carol Laderman
number of foods which they believe can cause di
gestive upsets and uterine hemorrhage during this
time of increased vulnerability.
Although Malay concerns with maternal and in
fant health in the puerperium are often phrased in
humoral or magical terms, we would be naive to
think of them as merely symbolic. The perinatal
period is so severe a challenge to the newborn that in
some cultures a baby is not even given a name until
he has safely passed through its dangers and proved
his continued viability. Pneumonia, cellulitis (spread
ing inflammation of the tissues) and septicemia
(blood-poisoning by fungi passed on from a maternal
vaginal infection during the birth process, or by
bacteria passed on by droplet infection or on the
hands of his caretakers) are common in the newborn.
Although he has acquired some immunity from his
mother, the infant has not yet developed all his own
necessary antibodies, nor have his gamma globulins
been fully synthesized and phagocyte activity reached
a satisfactory level. The blood-brain barrier of the
newborn is ineffective, and he is therefore particularly
susceptible to meningitis. Symptoms of infection in
the newborn do not always follow a recognizable
pattern. Lethargy, poor feeding and respiratory irreg
ularities may be closely followed by vascular collapse,
renal failure and death [17, 18]. To people who
believe in the reality of spirit-inflicted disease, the
rapid snuffing-out of a baby’s life after little warning
may well seem like the work of unseen hands.
A new mother is susceptible to infection from
bacteria she can ordinarily tolerate. Micro-organisms
that normally live in the vagina can become patholo
gic in the puerperium, invading the uterus [18],
Postpartum hemorrhage is, after infection, the major
cause of maternal mortality. It can result from a
number of causes, including hemorrhage from the
placental site, from lacerations incurred in the birth
process, and from retained products of conception. In
humoral terms, the new mother’s lowered vitality and
increased vulnerability are due to her abnormally
‘cold’ condition.
Following the tenets of humoral pathology, the
Malays believe that loss of‘hot’ blood during delivery
precipitates a woman into a ‘cold’ state. This humoral
belief is strengthened by observable physiological
reactions of new mothers. Within the first 24 hr, her
pulse rate drops [18], a clear indication of humoral
‘coldness’. In the case of some new mothers, the signs
of internal ‘coldness’ are dramatic, as illustrated
by the following advice given to American nursing
students:
During this first critical hour of the fourth stage of labor
(immediately after delivery), the mother may experience a
shaking chill. This reaction does not commonly result in an
elevation of body temperature nor is it associated with any
type of infection. The mother should be covered with a
blanket, and, if alert, can at this time be given warm tea to
drink [17],
Malays, like Americans, also apply heat both
internally and externally to a new mother, although
their reasons for doing so are humoral. Many of the
Malay postpartum practices belong to a Southeast
Asia cultural complex, which includes the Orang Asli.
Like their non-Islamic compatriots, Malay mothers
are bathed in warmed water, ‘hot’ substances are
bound around their abdomens, they lie above or
near a fire and avoid drinking cold water and eating
a variety of foods. Unlike Orang Asli food avoid
ances, however, Malay postpartum dietary rules in
corporate a well-developed humoral classifactory sys
tem. Sources of animal protein, including milk and
eggs but excluding fresh fish, are ‘hot’, as are salty,
bitter, or spicy foods, and those high in animal or
vegetable fat. ‘Cold’ foods include juicy or sour fruits
and vegetables, plants that exude viscous matter,
such as okra, astringent plants, such as tea, as well as
vines, creepers and climbers. Some foods, notably
rice and fresh fish, are ‘sederhana’ (neither ’hot’ nor
‘cold’; see [12] for further details). Foods classified
as ‘cold’ are, in general, not eaten until a new mother
has been ritually released from the postpartum
period.
For three days after giving birth, a new mother
receives a thorough massage from her midwife to
increase the speed of her circulating blood and bring
healing heat to all parts of her body. She adds to her
internal heat by taking ‘hot’ herbal medicines, many
of which have symbolic as well as humoral, and
perhaps physiological, value. A typical postpartum
mixture contains herbs whose names have powerful
symbolic connotations: tiger’s milk, grave’s adver
sary, Fatimah’s areca nut slicer, and Ali’s staff, beard
and moustache. Fatimah, the daughter of the
Prophet, and her husband, Ali, are regarded by
Malays as the perfect husband and ideal wife.
Besides attempting to regain normal humoral bal
ance by increasing heat and refraining from eating
humorally cold foods, Malay mothers avoid a num
ber of foods which are not problematic because of
their humoral classification but because they are bisa,
a word usually glossed as ‘toxic’. A number of fish
avoided as bisa have been linked to toxic reactions by
ichthyologists. The incidence and severity of these
reactions depend on the potential victim’s state of
health, the level of toxicity of an individual fish, and
the amount eaten. The variable nature of fish poison
ing supports the concept of bisa. Malays do not think
of bisa foods as toxic, but, rather, as intensifiers of
disharmonies already present within the body. They
are believed to aggravate a pre-existing condition or
bring to light hitherto unsuspected imbalances.
Foods are not considered bisa per se, but only in
context, and even then some people are thought to
have constitutions so strong and balanced that they
can eat them with safety.
Postpartum prescriptions and prohibitions, like the
pantang of childbirth, are not absolute rules, but only
guideposts for behavior. Women who eat bisa foods
and experience stomachache or postpartum hemor
rhage may be criticized as foolish, but they will not
bring down supernatural or human wrath upon
themselves through having broken a taboo. Those
who eat bisa foods and remain healthy may even be
envied and praised for their ‘cast-iron’ stomachs.
Since no one can know in advance one’s sus
ceptibility to foods normally proscribed during the
puerperium, midwives advise women who have given
birth for the first time to try small amounts of a wide
variety of foods, starting with ‘hot’ and ‘neutral’
foods and gradually adding ‘cold’ and bisa foods. If
Destructive heat and cooling prayer
they experience no ill effect during their first post
partum period, they may eat a full diet after each
subsequent delivery.
The way a woman views her own humoral balance,
and her perceived reactions to bisa or ‘cold’ foods
during the vulnerable postpartum period, can explain
much of the variation in adherence to pantang found
among contemporary rural Malays. In an east coast
village considered very traditional by health author
ities, 60% of the 145 women I interviewed did not
follow a restricted diet for the entire 40 days of the
postpartum period. They restricted their diets for
shorter periods of time, added items gradually, or (as
was the case with 21%) ate any foods they chose—
hot, cold, or bisa.
This was no recent phenomenon arising from
modernization, exposure to scientific medicine, or a
growing rebellion of village women against the bonds
of tradition. Women in their sixties and older re
ported the same variation now found among younger
women, and village midwives said that their mothers
and grandmothers, who had been midwives before
them, had given the same advice to their patients.
Clearly, Malay expectations of variable needs and
behavior have a long and honorable history.
DISCUSSION
The conceptual boundary points and guideposts
for behavior that assist Malay parents along the
difficult road that leads from conception to the
postpartum period illuminate the special nature of
the Malay humoral system and the world-view that
shapes and nourishes it. The Malay cosmos is one of
odds and probabilities rather than simple cause-andeffect relationships. Because of this, Malays believe
that the results of any action cannot be anticipated
with complete confidence. Added to this philosophy
is the expectation of individual differences and situ
ational requirements which exert a strong influence
upon the outcome of behavior. Pantang or rules for
behavior frequently have subsidiary clauses which
allow the continuation of normal life under unusual
circumstances. Following these rules is a matter of
individual volition; each person has autonomy of
choice, and each must accept responsibility for the
outcome. Some people interpret and manipulate the
rules, continually testing the boundaries, while oth
ers, wary by nature or rendered cautious by past
experience, obey them to the letter.
At the core of Malay belief is the conviction that
harmony is the basis of health and life itself. If a fetus
is not in harmony with its mother, its chances of
becoming a viable infant are slim. Many things can
disturb its precarious hold on life—a blow, a fall,
massage, heat. If a healer is not in harmony with his
patient, no amount of knowledge or skill will effect
a cure. For the health and happiness of a Malay, even
his name must be harmonious with his personality, or
he may suffer the ill effects of discordance.
Threats to harmony and integrity come from de
pletion of one’s inner forces (semangat), due to
fatigue or fright, and from incursions by outside
forces which, like badi, destroy one’s balance by the
addition of destructive spiritual heat, or, like bisa,
363
aggravate and emphasize any tendencies toward dis
harmony that may already exist within one’s body.
The Malay humoral system, in common with other
portions of Malay belief, is dynamic, situational,
reinforced by empirical observations, and incorpor
ates variation within its model (see [11]). Harmony
and balance, both humoral and otherwise, are
equated with health and happiness, imbalance with
disease and disaster.
Notwithstanding the real economic and social
differences that exist within a Malay village, there is
no rigid class stratification, and villagers conceive of
themselves as equals. This lack of rigidly hierarchical
social relationships, and the expectation of individual
differences, is reflected in their humoral system. As
interpreted by Malays, humoral pathology is far from
the exact ‘science’ of post-Galenic Europe, which
attempted to measure innate qualities of foods by
their precise degree of heat, wetness, etc., and which
believed in the innate human qualities that made
some men serfs and others noble. Humoral qualities,
in the Malay system, are neither precise nor invari
able, but shifting idiosyncratic variations on a basic
theme. For example, although most people classify
taro as a ‘cold’ food, since eating much of it gives
them a ‘cold’ stomachache, those who can tolerate
large amounts of taro often classify it as ‘neutral’. A
well-known Malay proverb expresses this expectation
of individuality within a common core: Rambut sama
hitam, hati berlain-lain (We all have black hair, but
each one’s heart is different). S. Husin Ali believes
that proverbs of this kind “can crystalize the very
essence of Malay folk philosophy and outlook, or
sum up some important experiences of Malay life,
[and] are often used to explain things more clearly, or
sometimes ’taken as simple guides to certain social
behavior” [19].
The Malay humoral system shares the basic pre
cepts of the three great humoral traditions from
which it derives, but the character of Malay society
and the content of their pre-humoral beliefs both
opened the way for acceptance of these traditions and
modified their shape. The composition of the Malay
Universe—earth, air, fire and water—is the compo
sition of the Greek-Arabic Universe, but Malay
insistence on coolness as the optimum condition for
health and growth brings it closer to both Ayurvedic
doctrine and aboriginal belief in this respect than to
Greek medical philosophy, which equated life and
happiness with warmth. The extention of this prefer
ence for coolness to the beginning of life itself sets the
Malay system apart from other humoral systems.
Chinese and Korean women fear sterility, which they
associate with a ‘cold’ womb (e.g. [20]). Malays, on
the other hand, believe conception cannot take place
unless the womb is cooler than usual. A pregnant
woman in India is said to be in a heated condition
[21], and among the Latin American heirs to Galenic
doctrine, her heat is considered to be so intense that
it can cure some people’s ‘cold’ ailments and infect
others with ‘hot’ [22]. As we have seen, this idea is
diametrically opposed to Malay belief. The meta
phorical use of coolness as personal and social good,
and of heat as evil and threatening, extends to many
areas of Malay thought. A rational, calm person is
said to have a cool heart, while a man whose heart
364
Carol Laderman
is hot is bad-tempered and full of hate [23], The
successful rule of a sultan and the blessedness of
prayer are expressed in terms of their ‘coolness’ [24],
and the opposite of beneficent, socially sanctioned
spiritual activity—the work of the sorcerer—is called
the ‘hot science’ (ilmu panas).
Malay valuation of coolness must be considered in
relation to their beliefs about the destructive heat of
the spirit world and its emanations. Unlike the
Chinese, who associate ghosts and the trouble and
pain they bring with the coldness of the Yin world
[25], and the ancient Greeks and their intellectual
heirs, who associate cold with fear and death, and
cold winds with malevolent spirits, Islamic Malays
resemble the non-Islamic Orang Asli in their associ
ation of incursions from the spirit world with heat.
Although Malay theories of disease causation in
clude such concepts as soul loss and spirit attack,
along with ‘naturalistic’ ideas, such as dietary imbal
ance and systemic reactions to foods, all of these
theories can either be reinterpreted in humoral terms,
or, at least, are congruent with the basic tenets of
humoral pathology. These theories of disease causa
tion are far from mutually exclusive and, in fact,
often overlap. A humoral imbalance may precede
soul loss, which in turn invites spirit attack, which
further skews the victim’s internal balance. Because
of this causal interaction, treatments we would classi
fy as medical or humoral blend with those we would
think of as magical, i.e. a massage, meant to soothe
muscles and increase circulation, is preceded by an
incantation to insure effectiveness of the treatment. A
difficult or abnormal labor calls for the proliferation
of all the methods at the midwife’s command. She
combines massage and the application of humorally
‘hot’ substances on the mother’s abdomen with the
censing of amulets, the use of magical oil, and the
opening of windows and doors to evoke the sympa
thetic opening of the womb.
Combining treatments is frequent, since many
problems are perceived as having more than one
cause, but the palpable humoral content decreases as
the condition is perceived as owing more to spiritual
than to material causes. Most of the conditions as
village healer (bomoh) treats are considered ‘usual’,
or biasa. Aside from the obligatory incantation, they
are controlled by the manipulation of diet and by
medical treatments that are often classified as ‘hot’ or
‘cold’. For those conditions which are !uar biasa, or
‘unusual’, involving intangible forces, the humoral
content is limited to such materia magica as tepung
tawar (neutralizing rice paste) which is not ingested
but acts on the spiritual plane to protect the body;
and to the metaphoric use of heat and coolness to
characterize the spirits and the work of the healer.
Conditions which do not respond to treatments for
either usual or unusual ailments are ascribed to the
will of Allah. For these, no material treatment will
suffice, and one must rely for help on the ‘blessed
cooling prayer’.
Acknowledgements—Research on which this article is based
was supported by the Social Science Research Council, the
Danforth Foundation, National Institute of Mental Health
Training Grant 5 F31 MH05 352-03, and by the University
of California International Center for Medical Research
through research grant Al 100541 to the Department
of Epidemiology and International Health, University of
California, San Francisco, from the National Institute
of Allergy and Infectious Diseases, National Institutes of
Health, U.S. Public Health Services. It was done under
the auspices of the Institute for Medical Research of the
Malaysian Ministry of Health.
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2.
Huard P. and Wong M. Chinese Medicine. World
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3.
Winstedt R. O. The Malays: A Cultural History. Rout
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4.
I-Tsing A Record of the Buddhist Religion as Practiced
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Hart D. V. Bisayan Filipino and Malayan Humoral
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6.
Madsen W. Hot and cold in the Universe of San
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7.
Mohd. Hood Salleh. Semelai rituals of curing. Ph D.
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8.
Roseman M. The social structuring of sound: the
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Dentan R. K. Some Senoi Semai dietary restrictions:
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10.
Skeat W. W. and Blagden C. O. Pagan Races of the
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II.
Laderman C. Symbolic and empirical reality: a new
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Ethnol. 8, 468-493, 1981.
12.
Laderman C. Wives and Midwives: Childbirth and
Nutrition in Rural Malaysia. University of California
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13.
Burkill I. H. A Dictionary of the Economic Products of
the Malay Peninsula. Ministry of Agriculture and Coop
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Siegel J. T. The Rope of God. University of California
Press, Berkeley, Calif., 1969.
15.
Endicott K. M. An Analysis of Malay Magic. Clarendon
Press, Oxford, 1970.
16.
Laderman C. Conceptions and preconceptions:
childbirth and nutrition in rural Malaysia. Ph.D.
dissertation, Department of Anthropology, Columbia
University, 1979.
17.
Anderson B., Camacho M. E. and Stark J. The Child
bearing Family. McGraw-Hill, New York, 1974.
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Holvey D. N. and Talbott J. (Eds) The Merck Manual
of Diagnosis and Therapy, 12th edn. Merck, Sharp &
Dohme Research Labs, Rahway, N.J., 1972.
19.
Husin Ali S. Malay Peasant Society and Leadership.
Oxford University Press, Kuala Lumpur, 1975.
20.
Kendall L. Cold wombs in balmy Honolulu: ethno
gynecology among Korean immigrants. Soc. Sci. Med.
25, 367-376, 1987.
21.
Beck B. E. F. Colour and heat in South Indian ritual.
Man 4, 553-572, 1969.
22.
Fabrega H. Jr. Disease and Social Behavior: An Inter
disciplinary Perspective. MIT Press, Cambridge, Mass.,
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23.
Iskander T. Ramus Dewan. Dewan Bahasa dan Pustaka,
Kuala Lumpur, 1970.
1.
Destructive heat and cooling prayer
Zainal-Abidin bin Ahmad. The various significations of 26.
Benjamin G. Temiar religion. Ph.D. dissertation,
the Malay word Sejok. J. Rl Asiat. Soc., Malay Branch
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20, 41-44, 1947.
27.
Endicott K. M. Batek Negrito Religion. Clarendon
25.
Ahern E. M. Sacred and secular medicine in a Taiwan
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Geertz C. The Religion of Java. Free Press, New York,
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et al.). Schenkman, Cambridge, 1978.
24.
REPRODBCTT VE -AND. (!HTT.D HEALTH-ERQGRAMME -~blRTRLGT_S_0RyEY-^—KES'.-IIWICAIORS.. DI STRICTWISE.
SL.
NO
R . Iore(n) Belgaum_Kellaxx_Bid.ar_ifiJtegaluX--J?--K
KEY—INDICATORS.'.
Gul.barga_ Kodagu
Handxa
Rai.chur Tumkur. _
_____ 1.S9.8—RopulatLon—data.
_86_,2.
------- d—rercenr-urnan-------------------- —-;-XL36
14—71
JEercent—Scheduled-Casteleraen.t_Saheduled_Tribe.
.5—Decennial—Eopulation—Growth.
--- ra.te-(-l-981^91)——- --- ——
.2-3;
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19-32
_8-82
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20-71
119..,25_
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6,.52_ ..23,65..
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3.94
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7.80
7.27 .
13-36
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15.96
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—30.
-Reproductlve —and—child—Health—
-MARRIAGE-AGE.
---- -------- y------- j,-.—rjetcui——J-ix-s u-kAina ux-uu-viuu--------
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_________________________________________________________ _________
__ 20-9 __ 30-2_____.9$ —1_____ 3,4___30—9______ 8-5_____ 6-0___ 30-7___ _5-9L
.4-2___ 21,5
____________ 1 ess—than—21tsince_j—Jan y_199 5.)--3,- Fercen t—of—Gi-r-1-s—Mar-1 ed—a t—age147,71
22-0
37-0---- 57,-1---- 27,1 —
55
—
8
_____
54,1---- 6-7,6---- 1-3,6—
12,0—1 ess—than—18tsince—l-=-l-=-l-9 95-)------- --- 4.—Birth—Rate—(-During—1—Jany---- ---- ------------------------------------------------------------------------------------------------ -r--- 1995—16—30—June—19384------ ------------------------------------------------------------------------------------------------- J
-------l^C-ru'de—Bi-rtli—Rate—(-Average-)—------ i-- 20-4—----- 24,0—-- 41,9---- 31,6---- 25,5---- -19,7-----30,1——-34,2---- 20,3--- —29,1—-- 24,1---1
or—higher------- - ----------------------------------------------------------------------------------------------;
---------- order—bi-rths—reported------------ --- 2-3,3—----- 364----- 45,9---- 52,9---- -18,4---- 32,0----53,7---- 18,9---- 26.2---- 52,9
27,4 —i
R-ERT-J-U-T-Y-----------------2-t—Pxereent-ef—third—
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—MvRBiDITY----------------------No•of Css03 Reported
—Malsi-ia—(-3—month s^pr-i-or—to-----survey.)
______ 21
—Tu bercuLosis____________________
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—Leprosy_________________________
2__
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ri
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REPRODUCTI
JO
---- SLt------ KEY-INDICATORS- ------------ B.-lore(U) —Belgauro’
—Beliary—Bj-dar CvMagalur D.K_
Gulbarga
——
- ■ Planning
use *or~ramiiy
— . .....
—----------
1. Percent of-Currently Married
nomen*—
--- -a. Kno.wing any method
b.-Knowing any modern method
c. Knowing—any modern-spacing
„
.
99.1
... 99.1
99.0
99.0
7 9.9
1u. V
40. 4
62.9
61.8
d. Knowing-all—mo-dern-methtyds ——-- 55.8
----65.9
e. ever used any method
6071
f. currently-rrslng any method
"
*• ■ 99T6
99.6
_____
06.0
2674
50.0
48.7
9975“—TOO. 0
9973'—TOO.0
~
63.8 --- 91.7
52T2
2372'
5277~ --- 7577
5076“—
2. Percent of currently married_____________________________________ _________
women currently using
a. reroaie sterilisation
b. male sterilisation
c. I.U.D
d. pills
e. condom
f. any traditional method
Ut"
W
•-
- -
—-
-
4t .b
0.3
5.3
1.7
4,2
U. 7
DO , D
0.6
ITS0.3
07/
0.2
3. Percent of currently, married_____ ■
______________ • .
women having unmet need for
'
. 15.2
5.2
________ a. limiting___________________ •
18.5
24.9
____ b. spacing__________ ___________
33.7
30.1
_________ c. total_____________ __________
46.5
0.2
~~ri’
074
0.0
0.2
46.0
078“
077“_
077“
o. 9“
1.2
" 99 74
99.3
— -- ------------------ 1
—
----------------: — - ------100.0’ ““9976— 100.0
100.0“ “9976 “10070 • ’■
----9574 ~ 83.6 ’ ’ 76.8
76.2
8878
5072“
29 73
40.8
7379““ “ 73.3
47.9
63.1
70.6
71,7
45.4 ’
61.3
.
method
■
-
Kodagu Mandya —
Raichur Turokur
.
■.... — — ——
“ ’9978—
98.7
9978 — * “9877“
92.8
64.2 ‘
70.7 ~2772-—
6774“
4170“’
' ’ 39 72 "
________
59,1
978
5 23
2.0
2.8
41,1
0,6
5,6
1.6
4.1
10.3
37,8
44,7
0,4 ~
0.2
0.3
9.5
0.2
2.5
0.3
3.0
0.0
“ 10.6 ’
i
68,8
42.7
55.2
J
1.0 ___ _o. 9_
~ 0.1
‘i
0.9 __ _0,_8_ _ _ 5_. 2
0.2 ___oci_ ___ 0.2___ j
0.8 ____071_ __ 0.5_
0.0
0.8
0.0
__________ ________________ _______________________________ .
_____
____________
___
___
______________
12.6
8.8
6.8
5,9
9.5
16,4
4.8
16.4
9.2
24,6
34.2
14.4
14.4
16.8 _ 25.8_
21,4
31,7__
21,8
21.7
31.0
48.1
21.3
42.2
43.0 __ 37.2
20.3 __
_3T0_
MATERNAL HEALTH.CARE -
Percent of women who had still/
_______________ JD irrn since i January
a . received antenatal care
- ---------------------
---------- .-------------- ——
—
•______
C3 cheek-UDS. 2TT injections
and IFA tablets)
___________ b. Delivered at health facility
____________ c. delivered at home and attende
d, total safe delivery (b-i-c)
——
_____________ _ _-----------
—=Z1
------------------------
—--------
71.9
82.5
40.1
50.6
29.0___2L2____ §.3_,J____ I5_,.5____ 20.4___ .78,1.. __59.7___ _27.«-6- . 68.4___
48,8___ _ 22 ,.7_ ... 48.-4___
32.9
62.4
76.6 ___ 2.T..9___ _67,7_.
17.0
-------------- - ------ -
90.6
68.7
40.4
52.7
78,1
91.7
47.8
CHILD CARE
1. percent of 0-4 months childre
__
____ £
__________ on exclsive breast feeding
52,9
87.5
31_._3
86_,_2--- _8.r_2__ 3.7.,5.
63.1
2. percent of women who gave
;----------------------------- ------------------- ------ ---colostrum to their children
65,7
40.0
38_.,2
79.5.
-
66.6
--- -5.2.J?
62.0
48.3
63_.6__
------- ---------------- ----- —- ---- —
17., 3 ..
85.1
.35,4
---- —
52,2
19.3
56,7.
50.0
30,2
- - ---------------------------------------------------
---------------------- -------- - 3'-- ----------
^P^n^iT-iVS 3EEWIO1WEC pwiRAWE_l WJJUCT; survey’s^- key indicators, districtwise
SL
-NO.-
KEY—INDICATORS
B. 1 ore_(.ID—Be 1 ga um_BeI Larz__Bi_dai^ Jlagal_ur IDK
Gulbarga
Kodagu
Mandya Raichur Tumkur
------ 3—percent_of—children-age—12=.3.b----- ----- -------------------------- —------------------ ----------- ----- ---__
aa
88
____________ a__ BCG
_____________________________
.________________ tl^xee_ i n ,1 ec t«5. ons o ~F DPT ___
........ ...... .........<2*- d t-bree_ doses_ of po 1. i o_______ _
■
*=> PAmnl +■.£»- (Ta (7 CI 3 DPT. 5>
...------------------ —polio—&—measles.)_______________
'■
96.7___
89.6
90.2___
84.7___
90.6
80.8
75.1
77,5____ _74_._4_
73,1
85.5
76.2
80,3
72.4
-6IL3 __ 57,2
93_. 9__ _ 9JL0
' 94.8__ 95.5
__ 95_.2_ _94.5 '
92,2__ 88,5
52,4
42,1
55.8
32,5
98,8
98,2
97,1
97,1
---
99,0
95,0
96.0
91 .5
---
61,4
50,8
58.0
44,0
98.7
95.8
95.4
90,0
_--------------------------------------- —--- -------------------------------------------------------------------
77_._7___
64.8
83.5
50.3
86.0___ .25,3____ 94,8
88 ,_0__37._2__ . 89:6
J
REERODUCTI-VE-MORBIDITY,a -F
PAHAV'-f AH---------------------------------------------- --------------------------------------------- --------------------------- --------_ . . .... ..........
33.3 ____ 1.8_,_7____ 5.0_,_Q_ ___ 41-6_ —-41,6
22,2
___ 43.7
............................_________' __ ______
__________ _
33.3___
0.0
64.2
40,7
56,3. — 40.6 . - -25.5 . .
.54.7 .
___ 54.8______ 44-0-____ 2.4—4. ___ 66_7____ 56.9 . _ 60.5 . 29.3
25.5
16,3
16.9
__
24-6_
___
38.-6
___
28.9_
10.2
17.8.
___
16-.-217 7
--------- e-—delivery—compl-ictions ---------- ___ 42-,-2___
30 9 ____ 21—8-___ 49—2.___ 41-9-___ 32,7 _ . -23,3 _
__ 24.8 __ 23 ;.3_ __ 36.3 - i4
d, postdel-i-vei y ^omplic-fvtins
- ~
e, codti ecepti-ve side effec-ts
18.9
___ 2Q,1
17.7 ___ 33.5.___ 14-5-___ 13-..7- . _35.-6— __ 15.5— - —9.6_ZZitZbZ -Zcs-sIZ ]
■
1. female—s-teiiliirft-ti-on
44.4 ___ 0.0- _ 11.7___
__________ i—Hr
4_<__ JLU1?
t nn________________________ ____ 0^5___ ___ 16,6-____ 15-^3-___ 33.^3-___ 16.-2- ___ 28.5-33.3 . . _ 13.54____-^4 1 1 £V________ ’ __________________________ ____ 7 t i
___ 33^3-____ 2 CD-0-____ (D-0- ___ 30—0- ____ 8,3 - ___ 0,0 . __ 15,3— - -0.0.___ 0-..0— ___ 0.0____ i
• • - _ _____________ 4,4
ill-,
pills
- - - - — ■
____ 5—4___ ____ 0-04,2— __ l.,2 — 13.4 ___ 2.3___ n
--- 4S-.2--- 2.8 __ 11,0-AWARENESS-OF-WOMEN-ON-RCH"
!
Percent- of women aware of
a. pregnancy ■■ccuuplications
b, Lreatment/practiees to be
followed in diarhoe episodes
c. peuKOiila-symptoms
d. reproductive tract infection
e. sexually transmitted
infection
f. HIV (.AIDA")
'
n*f . 7
VI
t
- — 69,0
00,0
__ KZt_ X_
■ ■
39v4—
82v3~
71.0
28,1
13.4
"24,8‘
89.1
73.7"
47~6—-- 53v8~ - -3174
1J~8"—38v0—-- 25vl——------- 5 7 8_
17.3
24,9
2,0 ■ --------1”7—------ 0t7~ -------- 10t2—-- 1579 - — 0.3
rsro
i 1 .2
3.0
bb. 0
1,4
26.4
0,4
0.2 --- 1278—-- 187424T8
6675—-- 7874 - -- 3070
______ 07--1____ 07.7__ __ a a., a
y1 . f
-- 8571 - - 69,4——84 ; 7 --- 5975--£*ct • •q —- - - ■» C - n - — 10,4
"f Q - A -- QG Q - 51,7
■ 28.0—
2 7 2~ -- 25,4 ■
"
45.9
-- 74 79"~
M
___
au _________________ VISITY BY HEALTH WORKER_______________________________________________ _______________
_____
1. Percent of rural households
visited by ANM/Health worker
29.2
38,4
21,b
18T0"
4372—-- 4879" "13 78
a 7 . -q........ _!
9t5~
173 ---- 4 ; 4
72 74— “48'73
______________
’
87.0
"60.0
18 73
49,3 “ ’
1
____ J,
44.1
4
-"REPRODUCTIVE AND CHILDl'HEALTH'PROGRAMME - DISTRICT_SURVEYS -KEY INDICATORS/ DISTRICTWISE
—1-______ —-------- --------- j
B-lore(U)
KEY INDICATORS
UTILIZATION OF GOVERNMENT
'
'
.
Belgaum
Bellary
Bidar C.MagaIur D-K
aa
■___
,
Kodagu
:
.
Mandya
Raichur Tumkur
...
healjOacility
US
Gulbarga
1. Percent of currently married
1
—----- ----------.._---------women availing Government
______________________________
________________ _
'
,
__ _ _____ Health facility for____________ ’_____ __________________________ ______________.________________ *
_
______ _____ _L _ .____ J
___ a.__ind.uced_aboiition_________________ 0.0_______ ILQ____ 66,6
0,0
50.0____ 25.0___ 0.0
42.8
100.0__ 33,3___ 0.0
____ Ji._ treatment_of____ ;___________ '_____________ i.________________________ _ ________ l_______ _____ _______________________ .___
: •
]
complications following
’ _ ■___________________________
____________________
. ____________ i . induced abortion_______________ *________ *________ *_____ *
*_______ *______ *_
.
.. . *.
___ * _
___ j
__ ____ ii , spontaneous abortion
_________ *______ :__ _________ *_______*___ #____ _ ■
__
*
*'
■*’ .. ---------------*
*
38.3
42.7
54,8
41,6
43.2
32,1
75.5
39,9
61,8 ’ ’ 31.2 ' 57.0
c, antenatal care
ao
■
_____ d. treatment of complications_______________________________ i_______ __ ____________________________ ____________________________ 2
■L______________ during pregnancy
_____________________________
___________
.
<
72.1
42.9
46.4 —30_.9__ _36,_7
32.7
29.5
42.6
25,8
56,0 __ 17_. O'
____
i. Doctor___________________
r.
0,0
4.7
9.0
0.4
___ 1.2_
6.4 ___ 1,2_ __ 1^6
5,3 ____ 6^2_
_______________ ii. hurse/ANH________________
oto"
0.0
0.0
____ 1_<9_____ (L0
OJO
0,0
0.0
0,0
0,0
0,6
... ............iii_.__dl spensrv________________
i______________ Treatment of post delivery______________________________________________________________________________ ______________________ ■
_________________ complications
_______
i. Doctor
■
•
4__ 42.3 .
25,.7
■, 50.4___ 7 ___ 43.7
25,0___ .33,8, .. -.67.5 — 56,8 2 __ 12,21 _47.1
5.3
ii . nurse/ANM
0.0 '
5..7
5.9
13.7 ~ 4.6
0.0
2.6
1 .9
0.0
7.1
|_____________ e. child birth (percentage of____ i___________ _ _____________________________________________ _____ ____
. . __ ____________ ___
_____ __ __ ___ _________ ________ _
_________________ institutional deliveries________________________________________________________ _________
________________________ taken pl ace in Govt._______________
________ inatjLtiitions_}_ ______________
_______ f.
_____ g.
immunisation of children_______ . ■
treatment of children____________
havi ng
_________ i^_ILLarrhneja_____________________
__________ ii. Pneumonia_________________________
h.__ contracepti ve servi ces________
jg.____ _______
_______ i— treatment of side effects/_____
59.2
33. y
88.,6
1 1 54
13.4
64.7
17 ,1
15 7
82 4
44.8
__ 66.1
93.7
___30.2
50 0
___ 93.3
57.3 ___ 62,5
33,8___ ,39.4 . J 73.6
86.5_ __ 7_9—0___ .52,2___ _ 88,2..
92.4
69,2..
96.4_
39,1. —73,9.
57.2 __ 90.8___
30.7 ___ 26,4_ __17—6___ .19,6 .____38-1. ___ 48...8_ __ 16.9-
19.2___
14.2 ___ 28—1____ 18-9___ -25.5- — - 41.6. __ 43...4_ ___ 14.2- - - 25.0 . ... ;
91.8__ 1
«R 5 __ 69,6___ .83.9-___ 86.8- ___ 94.3- ___ 76.2.
_82—9_
_______________ health—problLems—of_______ '_________________
__
___
__
i . female steri1i sati on
___ 35 8__
48 1
51 5
.4 5-5-_____ 52.8__ __ 42.4___ .34.-1— . ...66,6 __ 7.4.4. __ 39,1. .. 55 8
ii. IUD
0.0
100.. 0
50 0
_JL_q_
40.0___ _ #_ _ .80,0 __ 50.0- ____ *. — 66.6
50.0
iii. pills
*
* ____ 0—0_ ___ 0...0___ _ *_ ___ 100,0. ______ *____ ___
IQO.Q.
#
_____ ,j. treatment of RTI Doctor______
11.9
5.8
17 9 ___ 8.8___ 14.5
10.,8__
... 26.7_ __19.8
.7,8
25.2
12.3
Nurse/ANM/LHV
0.0
3..1
____2,6___ _JL._0_____ 2.9 ___ 8-8___ _0-0_____ 0,9 ___ 2.4 . ___ 1.6 . 2.3 _ J
----—
—
—
88 .. —
- ... . -j
_ _ . ..
i
!
REPRODUCTIVE AND CHILD HEALTH PROGRAMME' - DISTRICT SURVEYS "- KEY_INDICATORS, DISTRICTWISE
SL. ---- KEY-INDICATORS-------------- Brlore(R)-Bi japur CrDurga-^Dharwad'Hassan - Kolar
NO.--- --------------- --- !-------- —--- ————
------———
Mysore
Shimoga
U.Kannada
igg 8-Popuia tion-data--1Total—Population—fin—thousands")
' 2. Percent Urban
3. Percent Scheduled Caste
4. Percent Scheduled Tribe
5, Decennial-"Population Growth
rate (1981-91")---------- ---------
'—1673-72"--- 292870--- 218014—350372-7 1569.7 "488,5" 3165.0
1909.7
1’22073 '
18,1
3419 - 17.4 "“ 16 .'. 0
29.7
"" 2615
24.1
-17141- --- 1'918'4"----- 11172----- 23.65" "17142
--- 1975"
18789
17.70
7.54
1135
2 z 95
4.14
14,60"
1.06
3,23
3.00"
" 3.00
0.83
19,8
1312
207"4D"
1978"
17130""~”2’4710 — ”"T476 "
13,0"
1472 ’
.......
---
Rapid Household Survey;
Reproductive and child Healtlf
. .. : .
az._
W
MARR PAGE-AGE
1. Mean age at first Cohabitation
14.8
17.0
for women interviewed
__
16.8
16.5
____ 2. Percent of Boys Married at age______________
2.0
26.9
13.3
less than 21(since 1 Jany 1995)
12,2
3. Percent of Girls Married at age_________________________________
21.5
64.8
less than 18(since 1-1-1995)
30.5
36.5
17.5
16.2"” '
16.6
18.2 “
19.0
9,6
15,7
3.4
’ 6.3
3,3
15.2__
33.5
47.9
16,5
15.0
------ ---------
Birth Rate (During 1 Jany
1995 to 30 June; 1998)
1. Crude Birth Rate (Average)
2. Percent of third or higher
order births reported
f
-
i_
22,9
22,5
22.9
17,5
21.^3.
20.,6 . .
19,6
19,5
1Ac4______ 43,1
34,4
37,4
19_,_7
29,7
23,9
22,9.
.27,2
;
PJ
4_.l
4...0
4.6
3,9.
.3,6.
3,5
17,3
FERTILITY
1
’
1- Mean. Nec of Children ever
,------------- bom-to-women age 40-44
................ INEANT-MORTALITY- -
_
3_iZ
5_._0
ZZ
p.--------- 1——Infant—Deaths—among_____________________________ ___________________ ______________
---- —------- children—born—during—1=1=95____________________ _
---------------to—3-1—12=9-7----------------------------- 4-- 1_____ 22________ U_____ 19
14______12_____ 17_______ 5..
ZZZZZZZZZZZZZZZl
_____
____ 6.__________________
|---- ——----- MORBIDITY____________________________________ ________________ ______________________________ _____’1
:---------- l-^—No-,-of—Cases—Reported
__________ ____ ___________________________________________________________________
------ ----- Ma-l-a-ri-a—(-3—months—prior—to
______________________________________________________________________________
la----------- survey-)-------------------------------- 1-0-------- 108
8----- 67------ 54------ 7------ 11----- 38-------1-------------- 1
-------- :---- T-ubereulos-i-s------ ------=-------------- 1-2------- ;——6__________ g_____ 1-7—_____ 4—-- 18------- 18—
14
- -- 5 - --------- '
1----- -------- Leprosy------------:----- -------- ■ —;----- 0---------- 1--------- 3------ 1------- 1------ 1
- — 0
-1
0 ----- -- ----- -—
5
__6..__ REPRODUCTIVE AND CHILD HEALTH PROGRAMME _-x_ DISTRICT.'.SURVEYS -KEY INDICATORS, DISTRICTWISE
SL------- KEY- INDI CATOR:
JB.lore(RJ_ Bijapur—C..Durga—Dharwad -Hassan—Kolar—Mysore. Shirooga . U.Kannada
NO,____________________
-- ---——Knowledge—and_us.e_of_Family_
--------- Elannin g__
ijfi
---- ..
....
.
--------------- -
.1-, Percent. of_Currently Married
Wcmeni________________
. . _a —Knowing. any meikod
. b.
Knntrtne anv
9 a. 7
9 a..6__
mnd^rji__ metbr.d
_ _______________ :___ iD'Et tliod______________________:______________________
•---------- --------------------------- —
-------If.
ra ’ia
J_ra l£__ JU
1-1
V-) fel ££ it tnrt urit?r»ri
fc» H _______ —
FI:
rHTr.
WTTiD
cj +
t—
tnrJ.rxrJT
e. ever used any method
f. currently using any method
3Q
73 0
ag, a
100.0
__ 1OCL.Q—
9.3,6
11^8
86.9
__ a^-F)__ ____ .23J___ •
oj
61 8
___64,3__ ___ 48-6__
___ 59.9
47.1
___ 0 3—0__
99.6
99,8 ,
99.8 _ 99.6
99". 8
99.8
__ 8Q^8____ 71.8___ 81.7
24.. 7___ ’40.1
a a, a
__ 6.4—4___ .7 6.3___ 58.5
.75.1
___ 57.1__ 61-.2.___
99.8
99,8
1’00,0
100.0
99.6
77.0
30.0
68.3
65.4
99.0
’ 81.9
74.2
69,3
' 85.1
55.3
69.5
66.0
99.6
.
j
2. Percent of currently marriedt—————
.
..
—
....... |
women cuxTenviy us>ahb
__ n~
-56,6
47,6__
___ 4 4—0______ 54-^9____ 55.^___ _72,6___ 52.6__ .61,8
O vj; ____
1
a, female sLeiui 11 sal-ion
____ _____
0.6__
_
_______ H
0 4 ___ 0,3___ —0—1___ -0..4__ _0,.2__ —0,4
v • 9£*
b, male-sterilisation
____ iJL_r VR__ ____ -j_1___
___ l_rG___ — 1,7 . _2,1__ _1.9_
6,1 __
..5,7
c, I, U. D
_______ n
9
___
1-^
1
___
,1,0
0.6.
.
,
0,3,
..
-1,1
____
i_..o
_
_
0,5
___
____
1
—
0
__
U
/
ir
1
d. pills
____ n_i
. 3,7. ..
____ nV > 90
1.8
V . JL___ ____ Q_-4__ ___2,0___ _ 0 -, 3___ —0.7-__ 0.7,.
eC CUIld’OTH
__ n V n#V-___0-^0___ _ 0^0___ _ 0,0__ - 0.1 ____ n
__V .nV_ fi__ ---0.3_____________ _
. .0.0
u. nU__
f; any modern method.
____ nU_/ 11—__ ;___ 0—8_ ___0-6_____ 0,1___ _.0,5__ —0,2_ _ —3.5 ___ 6.4___________
0 1
g. any uth'er" tradi tionai method
3. Percent of'currently married
women naving unmeu neeu xvx
al 1imiting
b. spacing
~
~
c, total
-6,4- ___ 5..7___________
— 4.8. __________ ..
2,810.6________________
9,2
_____ q
_ 4*3z •!*3___ -_ gv5__ - 6,6 —
7 5
—9O : zi9
b_. n
U __
3 , Q___ _ 2-4___ _4_z 2__ _ 3,2__
■ ..V9 t <7a
0,1
7
--- l-l-r2—--- 1-4-HJ-- --- 12-v-l——1-1-4--- -6^5--- -1.3 8-- - 9.9-
■MATERNAIT-HEALTH-CARE-
......
Percent of women who had still/
live
birth since 1 January-1-995
a , TeDeivea anvena Lax caie
z
___ _______
nmm x
Hw hAWfet.s f x
_______________________
______ ___ De-l-i-vered_ at_ health_ -Fj^t 1 i ty_____
--------------q——□ei’i’V&T63—EtX:—Home—cl HU du-ud iuc m
30 '
d. total safe delivery (b+c)
CHILD CARE
__ 1, percent of 0-4 months children
_j____ on exclsive breast feeding______ _
____ 2._ percent of women who gave
____
__ colostrum to their children___ ■
59.5
64,7
________
28.0
60.5
38.9
39.5
i4 i4 -.4-f
___4 4-.
___
3 a___
79.1
50.1
. 7f,4
45T4
5378---- ' 21.4
-
1 A -Q
5'3t8
47 , /
44.8
_ _ .
---- 60T4
60.4
____________ I
__ -_____ _____________ '7-t — n---------- a a—o------------------------------------------------'
t>y.i
bo. 5
78.1
4
41.3 ” 5975’7'
' 62.
-2Q—4__ ___ g__3___ 17.9 __ 10.2__ -20,6
83,0
-65rv3——69~7--- RCl— O_-- 69.7—-
____ 8,0___ ______ _______
--- 86.1-------- ------ ,
_____________ ______ !
--- 63773--- _8 37'3
■4G z b — 45,8
—65t5--------■49
60,0
54,2 -
41.5'^'-40t6
41/8 — 55,6
45,8
45,9
4 7? 3
■ AMME_^_DISTRICT.SURVEYS. . KEY IHDIGATORSDISTRICTWISE
REPRODUCTIVE_AHD CHILD.HEALl
32
SL.
KEY INDICATORS
NO
— — --3 —pCi-CCDt—Of—Clli 1 cli Oil —
.
B-. l.o.r.e_CR? _
....---------- :—REPRODUCTIVE-MORBIDITY------------- ;-----
Percent of—women reported----------________ Oft—R----------a, a dot von coropi i ca ux vu s
____ 4-ft_ a-b. pregnancy-complications
______ nc_ q__ ..
c. delivery compilations
d. post-deli very compiica ti ns
e . "contraceptive side -effects
---- 15-7-- 1. female sterilisation
'll—TUD---------------------------- i-frrs---in; piii-5---------------- :---------- o -u---reproductive traRftrinfection
1'470
—
__ !
Shimoga U.Kannada
-----
...___________ ___gCG______ *_________________________9.8_EU___
------------ c—injo c t-i on s—of—DPT--------------- —_ g 2-.-1____
---c-;—three doses of polio----------- —_g.2-.-l____
ci? '7_ “
■ ------------- e.—cvrapi-e-ue—k, <?
i
_
33^-7
____
polio &—measles)
■
PHx.__ C.,.D.urga_ Dharw5d_H a ssan. _ Kolar. Mysore
———__________
_______
—l.zi—3t>-----------
: ~3_____ 95.8____ 92_ 2___ 99 - 3- __98.2____ 98.5
,8______ 92 .1____ 86.5____ 97—4 - 94.2. ___ 97.6
7 -6-- ,__ 93—5___ 90.9___ -96.1— .95.9 —95.6 .
: .-7______ 91 __2____ 7 9 fi___ 9 6 _7— —95.0-___ 96.6__
98.4 .
95.9
94.4
96.4
97.8
95.2
93.1 —
3^2____ — 88-^4____ 7-4,8___ 92,8 - —90.6-— -92-7—
92.9.
89.9
___
-
----
-
-
-
-
----
-
94.1
•
■
-
-------
5—3------ 1-6—6--- 63-6-----O^O--- 20.0--- 20.0
1.8------ 41-4---- 29.6--- -36—7—37—7----41,1
-0 ------------- 1-5-2---- 1-9^4--- 11.1- 13.1
2.
20.9
4.0------ 25—4—-- 22—9----24-1-- -20,0— 29.7
29.4
69.5
40.1
43.2
42.8—37,9--------17.4 -------15.1
6—8------ 20-2----- 9—2---- 16-.4—-• 20.-1--- 10.7
9-0------ 20v0-----0-0---- 6v6--- 35v0--- 11.1
0-0------- 0-0---- 10?0--- -40-0-- 50.0---- 0.0
6—3------ t2v8---- 11-76---- 13~0
19.6
11.0-
23.0
24.4
22.2
23.0
- 6.1
-8.3-------11.1 -
176------ 75t8--- 39v5--- 93.0—79,9--- 84 ?4
91.8—5073—
14t4------------------
----------
“A'WA'RENESS-OF-WOMEN-oir~RCH------ ’--------
55
Percent of women aware oi____________
7BTT~
a. pregnancy complications
b. treatment/practices to be
6979
foilowed in diarhoe episodes
T3T0
c. peuroonia symptoms
24.1
d. reproductive tract infection
e. sexually transmitted________________
24.7
infection
62.5
f. HIV (AIDA)
-*
________________ VISITY BY HEALTH WORKER_______________
1.
Percent of rural households
visited by ANM/Health worker
-
,972------ 57T4--- "6471---- 55t4--- 5571----5475— 81.8
62; 5---: 471------ 1279---- 27T4---- 11T3--- 11t8--- " 1371--- 5671---- 2872-----------------576
17,9
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|La.’ «yVx.X /■• Women s Sexual & Re
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The International Federation of Obstetrics & Gynaecology (FIGO) as
part of its ongoing efforts
to improve women's health internationally,
initiated a project with the aim of using international human rights to
improve women's reproductive and sexual health through collaboration,
education and advocacy.
Entitled the "Women's
Sexual and
Reproductive Rights Project" (WSSR), it has emphasized the role of the
Ob-Gyn profession in the respect, protection and implementation of
human rights related to women's sexual and reproductive health. India was
one of the six countries selected for the implementation of this project.
As part of the first phase of the project a National Workshop was held
with the aim of:
• Educating the Obs/Gyn profession
about
national /international
women's rights related to sexual and reproductive health.
• Developing a plan for the formulation of a human rights based code of
ethics.
• Identifying priority areas in the country where failures in human rights
impact on women's health and where obstetricians & gynecologists
with collaboration can do something about it.
• Encouraging the development of effective collaboration of Obs/Gyn
professionals with women's health advocacy groups and legal and
legislative representatives to protect, promote and advance sexual
and reproductive rights.
Report of the FIGO WSRR National Workshop 11 th & 12th May 2002
Women’s Sexual & Reproductive R/ghtsI
SAFE ABORTION WORKSHOP
The FIGO-WSRR Project in India was inaugurated with a Safe Abortion Workshop on
II*” May 2002 at The Safdarjung Hospital, New Delhi. A strong turnout of around 225
registrants ensured the success of the Workshop. The Workshop commenced at 9.00 am
with a Live Demonstration of Safe Abortion Techniques including Manual Vacuum
Aspiration. Prominent invitees included Dr.Shirish Sheth, President of FIGO, Dr.Dorothy
Shaw, Chairperson, WSRR Project, Dr. Jagdish
Hospital
Prasad, Superintendent of Safdarjung
and a recipient of India's National Award-The Padmashree, Dr. Usha Saraiya,
President of FOGSI and Dr.Kamini A. Rao, Immediate Past President of FOGSI and Co
ordinator of the FIGO - WSRR project in India.
Dr. Shirish Seth outlined a brief history of FIGO and FOGSI. He also pointed out
that "every woman must have the right to choose pregnancy and safe motherhood". Dr.
Jagdish Prasad proclaimed that gynaecologists and obstetricians play an important role
in the upliftment of women. He stressed the importance of birth control and
implored doctors to adopt an unselfish view in dealing with their patients. Speaking on
the occasion, Dr Usha Saraiya expressed satisfaction in FOGSI having successfully trained
personnel in dealing with abortions. She also lauded the role of this organization in
making inroads into rural areas and promoting safe abortion and safe motherhood. "Be
human when it comes to carrying out abortions. What goes on in any part of a woman's
body also goes on in her mind" she said.
Dr Dorothy Shaw from Canada, highlighted some lamentable facts:
•
In the 10 minutes that it takes for this presentation , about 400 women will
undergo unsafe abortion.
•
There is a high incidence of mortality from unsafe abortions the world over.
• The WHO states that the cost of treating a septic abortion is 2-3 times more
thana normal delivery.
• Awoman dies every minute due to causes related to unsafe pregnancy.
Giving the Indian view point, the co-ordinator of the FIGO- WSRR project and the
pivotal figure behind the meet, Dr Kamini Rao pointed out that:
•
13% of maternal mortality is due to unsafe abortions.
Annually, nearly 15 million abortions take place in India :of these 10 million risk
their lives by approaching quacks.
Report of the FICO WSRR National Workshop 11 th & 12th May 2002
Women's Sexual & Reproductive Rights
Every year 15000-20000 women die from complications of illegal abortions.
•
Highlighting the efforts of FOGSl over the past two years in promoting safe abortion,
Dr. Kamini Rao drew the attention of the audience to the following:
•
Over the past one year nearly 15000 FOGSl members have been sensitized and
trained in the technique of manual vacuum aspiration.
•
FOGSl raises awareness, promotes safe policies and practices and interacts with the
government and NGOs.
"I look forward to your cooperation in fighting unsafe abortion and female
foeticide", she announced.
1
Subsequent speakers
stressed on abortion techniques during the different
trimesters and methods of ensuring safe pregnancy and motherhood.
A cross section of the audience
Report of the FIGO WSRR National Workshop 11 th & 12th May 2002
Women s Sexual & Reproductive Right
PUBLIC FORUM
(3.30- 6.30 pm)
SESSION! : Compere: Dr. Mala Arora
Chairperson: Dr. Ardi Kaptiningsih
Co Chairperson : Mr. Ashish Bose
Women's Empowerment Through Health -Role of FIGO
Women's Empowerment Through Health -RoleofFOGSI
Women's Sexual & Reproductive Rights-A Global Perspective
Dr.Shirish Sheth 5 Mins.
Dr.Usha Saraiya 5Mins.
Dr.DorothyShaw 5 Mins.
The Role of Religion in Empowering Women (lOminseach)
•
•
•
•
•
Shahi Inam Mufti Mukarram of Fatehpuri
Giani Hem Singh, President Namdhari Durbar
Rev. Anil Couto, Arch Bishop of Delhi
Swami Agnivesh Ji
Sadhvi Rithambra ji
Compere : Dr. Hema Divaker
Mr. A.R.Nanda
Co Chairperson : Dr. VK.Behal
SESSION II :
Chairperson :
GROUP DISCUSSION : " Can We Alter the Gender Equation ?"
Moderator : Dr. Kamini A. Rao
Kalpanajain Usha Rai
Mohini Giri
45 mins
Sharada Jain Mr. A.R.Nanda Vinay Aggarwal
Address by the Chief Guest, Madam Sheila Dixit, Hon. Chief Minister of Delhi 15 mins
Multimedia Dance Drama "Flame of Life" by Dr.Neelam Verma
High Tea
Sheila Dixit, Hon. Chief Minister of Delhi releasing
the WSRR booklet along with Dr. Kamini Rao,
Coordinator, WSRR Project, India.
Women's Sexual & Reproductive Rights Project
PUBLIC FORUM
A public forum was organized on the evening of I I th May at the India Habitat
Centre. The forum was held with the aim of generating public awareness on the issue of
Womens Empowerment. Inaugurated by Madam Sheila Dixit, Hon. Chief Minister of
New Delhi, the forum was attended by religious leaders, NGOs,
government
officials, doctors and the lay public who came together to raise a united voice against
female feticide, unsafe motherhood and gender discrimination. Prominent speakers
included Shahi Imam Mufti Mukarram of Fatehpuri, Giani Hem Singh of the Namdhari
Darbar, Rev. Anil Cuoto Bishop of Delhi, Swami Agnivesh and Sadhvi Rithambra. The
star attractions were these religious leaders who pointed out that all religions
respected women and accorded her the highest dignity, but it was the
misinterpretation of the holy scriptures that leads to injustice. Everyone came
jj^ together and as one body condemned the atrocities against women in this country
and the world over and vowed to fight it. The highlight oftheeveningwas an oath "to
refrain from sex determination" administered to all gynecologists present, by Justice
Sujata Manohar of the Supreme Court of India.
“Can We Change The Gender Equation?" was the topic of a Panel Discussion
moderated by Dr.Kamini Rao. Mr. A.R.Nanda Secretary for Health & Family Welfare
GOI, well known women's activist Mohini Giri, media representatives Kalpanajain and
Usha Rai, and the medical profession represented by Dr.ShardaJain, senior obstetrician
& gynecologist and Dr. Vinay Agarwal Chief Secretary of the Indian Medical Association
were the panelists for the discussion.. Interesting debates on issues such as falling sex
ratios, male dominance and superiority and gender discrimination along with
intensive audience participation and interaction formed part of this panel discussion.
Madam Sheila Dixit, Hon. Chief Minister of New Delhi in her address urged the
audience to promote, protect and uphold the sexual and reproductive rights of
women. She stressed that obstetricians and gynecologists as a professional group had
the power and the influence to act as a 'force' not only at the national level but also at
the international level to ensure the implementation of women's rights.
A booklet on the FOGSI-FIGO partnership, aimed at creating an awareness of their
commitment to the promotion of the sexual and reproductive rights of women and
emphasizing FOGSI's stand as an advocacy group rather than a service delivery
organization, was released by the Chief Minister.
The Public Forum has been a firm step forward in bringing about an awareness to
pave the way for the promotion of "safe motherhood as a right" for every woman in
India.
Report of the FIGO WSRR National Workshop 11 th & 12th May 2002
Women’s Sexual & Reproductive R/ghts^ffl
Day 2, 12 May, 2002
CLOSED DOOR MEETING AND GROUP DISCUSSION ON PRIORITY
AREAS OF CONCERN WITH REGARD TO WOMEN S SEXUAL &
REPRODUCTIVE RIGHTS
9.00 am
Registration
9.30 am
Welcome
9.40 am
Inaugural Address
Mr. A. R. Nanda
10.00 am
Women's Sexual & Reproductive Rights Project
Dr. Dorothy Shaw
10.15 am
Tea
10.30 - 1.00 pm
WORKING GROUP DISCUSSIONS
Five priority areas were identified for discussion
Making Abortion Safe and Accessible
2. Anemia Prevention
Adolescent Reproductive and Sexual Health
4.
Preventing HIV/AIDS
5.
Female Feticide Countering the Menace
GROUP-I: Making Abortion Safe and Accessible
• Service Delivery/Certification of Centres
• Training Requirements and Certification
• MTP Act and its implementation
• Advocacy and Sensitization of Stakeholders
• Contraception availability, accessibility and counseling
Report of the FIGO WSRR Nationol Workshop !, ch & , 2th May 2OQ2
Dr. Kamini A. Rao
Women's Sexual & Rep.
GROUP-ll: Anaemia Prevention
• Recognition of Early Signs and Symptoms of Anaemia
• Prophylactic Administration of Iron & Folic acid in Pregnancy
• Nutrition Counseling
• Worm Infestation Treatment
• Adolescent Health Counseling
GROUP-III : Adolescent Reproductive and Sexual Health
• The psychological, emotional and socio-cultural dimensions of adolescent
reproductive health
• Increasing the availability & accessibility of Gender sensitive Teaching and
Curricular material
• Providing appropriate information and services
• Availability of Counseling services with a commitment to the autonomy and
confidentiality of adolescents
• Behavioral patterns that are conducive to good reproductive and sexual health
GROUP-IV: Preventing HIV/AIDS
• Providing information & services on Safe Sexual behavior
• Roleofmenin preventingthetransmissionofHIV/AIDS
• Importanceofempoweringwomeninreducingthespread ofHIV/AIDS
• Introduction of information on HIV/AIDS into the school curriculum
• Improving the accessibility and availability of barrier methods
GROUP - V : Female Feticide Countering the Menace
• Interventions to sensitize doctors, NGOs and the govt, machinery starting from
the Panchayat level on the need to protect the girl child
• Need for education and sensitization of male members of the community
regarding gender bias, female feticide, female infanticide
• Improving awareness regarding the PNDT Act.
• Effective implementation of the PNDT Act.
2.00 3.00 pm
Presentation of Group Reports and Discussion
3.00 4.00 pm
Action Plan
Report of the FIGO WSRR National Workshop 11 th & 12th May 2002
X9
Womens Sexual & Reproductive Rights
The participants were divided into five groups and each group was assigned one of
the above subjects. During group selection care was taken to ensure that, not only did
participants have a personal interest in the subject they were allotted, but also that
participants from different backgrounds formed part of each group. Broad guidelines on
which to base the discussion were given to each group. Two of the members of each
group were designated Chairperson and Rapporteur of the group.
At the end of the two-hour group discussion, group rapporteurs presented the
synopsis of their deliberations in a plenary session. The larger group discussed, debated
and endorsed the issues that are outlined below.
Dr. Usha Saraiya, Dr. Dorothy Shaw and
Dr. Shirish Sheth along with gynecologists
pledging the “Sex Determination Oath”
at the Public Forum.
^^anSe The^Gcmd^er^quatio 0
^'
progress during the Public Forum.
Youth Incentives Fact Sheet - Draft
A Rights-based Approach to Young People's Sexual and Reproductive Health
Introduction
In the last decade of the 20lh century new thoughts emerged concerning the sexual and reproductive
health of young people. The time had come to rethink the approaches used to address young people’s
sexual and reproductive health. Young people are sexual beings and many are sexually active by their
18th birthday. Young people have real sexual and reproductive health needs, as well as rights. Many
programmes designed for young people often ignore these needs and rights.
In many countries the sexual and reproductive health of young people is considered to be a problem, as
well as a taboo subject. The approaches used to address this “problem” are frequently based on a topdown theory. This means that most programmes and policies are developed by adults and frequently view
young people as only recipients of the services offered. Such an approach cannot effectively reach young
people, especially those who are sexually active - they typically have the most needs and are the most at
risk for the negative consequences of sexuality; unintended pregnancy, STIs, and HIV/AIDS.
Young people are often not encouraged to become active participants of the programmes developed to
target them. If services are available they are frequently not designed to be “youth friendly". This
ultimately results in many young people not using sexual and reproductive health services. Young people
do not receive the information and education they need concerning their sexual and reproductive health,
ultimately leaving too many young people in the dark and unprepared.
Young people can be reached effectively if they are perceived as social actors within their own rights.
Young people are capable of speaking and deciding for themselves and should be encouraged to do so.
In 1989, a rights-based approach towards the sexual and reproductive health of young people began to
take shape—an approach based primarily on existing international human rights. For the first time, young
people were recognised, internationally, as sexual beings that have a right to education, information,
youth friendly services and participation. Great strides were made during four United Nations conventions,
International Convention of the Rights of the Child (1989), International Conference on Population and
Development (1994), ICPD +5 (1999), and UN Women’s Conference Beijing +5 (2000). Participating
governments and NGOs recognised the sexual and reproductive rights of young people and produced
signed declarations binding them to respect and promote these rights.
Ago-basod doflnltlon of Young Pooplo (combination of UN and WHO definitions):
All young men and women between 10-24 years old.
Worldwide there are 1.7 billion young people. 85% of them are living in developing countries.
Young people make up 40% of the total population of most developing countries.
Social-based definition of Young People:
Young people are social actors in their own rights. They are a diverse group with great
potential and capability.
The UN Conventions, important outcomes for young people
1989, International Convention of the Rights of the Child
•
•
Young people are human beings and are the subjects of their own human rights.
Young people have the right to express their views and have them taken seriously.
1994, International Conforonco on Population and Dovolopmont (ICPD)
•
•
•
•
The focus changes from family planning and fertility to reproductive health.
Sexual and reproductive health and rights of young people are recognised.
Reproductive health programmes must also meet the needs of young people.
Young people have a right to the information and services necessary to learn about their
sexuality; as well as make informed choices concerning their sexual lives, (source:
Wereldbevolkingsrapport 1995)
1999, ICPD +5 and 2000, Beijing +5
First Youth Forum takes place during ICPD +5
Special attention is paid to the sexual and reproductive rights of young people - how to make
sure that these rights are respected and exercised.
Need for integrated and holistic approach to the sexual and reproductive health of young people
is expressed.
Demand of full participation of young people at all levels of the programmes targeting them policy, development and implementation. (Source:
http://www.unfpa.orq/icpd/round&meetinqs/ny adolescent/reportrtl.htm )
•
•
•
•
Sexual and Reproductive Rights of Young People (source: IPPF Voice)
(Based on recognised international human rights laws)
The right to be yourself - free to make your own decisions, to express yourself, to
enjoy sex, to be safe, to choose to marry (or not to marry) and plan a family.
2.
The right to know - about sex, contraceptives, STIs/HIV, and about your rights.
3.
The right to protect yourself and be protected - from unplanned pregnancies,
STIs/HIV and sexual abuse.
4.
The right to have healthcare - which is confidential, affordable, of good quality and
given with due respect.
5., The right to be involved - in planning programmes with and for youth, attending
meetings/seminars etc. at all levels and trying to influence governments through
appropriate means.
1.
/What is a rights-based approach?
A rights-based approach to the sexual and reproductive health of young people starts from internationally
agreed human rights_as a base. Sexual and reproductive rights are then recognised as their own entity. A
rights-based approach, as developed over the last 12 years, insists on the protection, empowerment, and
equality of all young people, including their sexual lives. It is an approach for young people and not about
young people. A rights-based approach serves the real needs of young people by involving them, which
allows programmes to be more effective and sustainable. A rights-based approach provides the
necessary freedom to meet the sexual and reproductive health needs of young people.
(Source: www.familvcareintl.org/briefinq cards 2000/riqhts.htm)
A rights-based approach:
•
•
•
•
•
•
Is a strategy that recognises young people's rights within an ethical framework.
Is meant to protect these rights, ensuring that young people can enjoy them.
Promotes the sexual and reproductive rights of young people.
Educates and informs young people of the existence and meaning of their rights.
Empowers young people to exercise their rights and advocate for their rights.
Empowers young people to be in control of their own sexual lives and make the decisions that
best fit their own needs.
What does a rights-based approach mean in reality?
How can one ensure that these rights will be respected and enjoyed? What does the outcome of the UN
conventions mean in reality when addressing the sexual and reproductive rights of young people?
There are many challenges associated with a rights-based approach. Some of the largest challenges are
based in culture, religion, economics and politics. However, states that have chosen to recognise the
sexual and reproductive rights of young people within a rights-based approach have accepted a certain
amount of responsibility. Furthermore all other parties directly involved, NGOs and young people, must
also accept certain responsibilities.
2
“While the significance of national and regional particularities and various historical, cultural
and religious backgrounds must be borne in mind, It Is the duty of the States, regardless of
their political, economic and cultural systems, to promote and protect all human rights and
fundamental freedoms." (IPPF Charter on sexual and reproductive rights)
Responsibilities of national governments:
Respect the sexual and reproductive rights and health needs of young people.
Act as a safeguard for the sexual and reproductive rights of young people
•
•
Develop policy that ensures sexual and reproductive rights are known, understood and exercised
•
by all young people.
Make sure that sexual and reproductive rights are understood outside of religious, cultural and
•
political beliefs.
(These responsibilities are especially true for the countries that signed the commitments and plans of
action at the UN conferences mentioned above.)
Responsibilities of organisations that serve young people:
•
•
•
•
•
•
•
Inform and educate young people of their sexual and reproductive health and rights.
Educate communities, leaders and parents about the sexual and reprod. rights of young people.
Advocate for the sexual and reproductive rights of young people, at the international, national
and local level.
Mobilise communities to assist in advocating for the sexual and reproductive rights of young
people.
Develop a working relationship with young people to ensure that their needs are met and that
they are empowered to advocate for themselves.
Develop policy that includes young people at all levels of programme development,
implementation, and evaluation.
Provide sexual and reproductive health services within a “youth friendly" environment.
Responsibilities of young people:
•
•
•
Must respect their own sexual and reproductive health and rights, as well those of others.
Inform and educate other young people about their sexual and reproductive rights.
Become active participants within their communities and advocate for sexual and reproductive
rights and health needs of young people.
Implementing a rights based approach
Implementation of a rights-based approach requires an equal working relationship between the
government, organisations and the young people they serve. The IPPF Youth Committee
developed three goals which should be kept in mind when implementing a rights-based
approach, Youth Manifesto:
1.
Young people must get what they need; access to education and information on
sexuality and the best possible sexual and reproductive services (including
contraceptives).
2.
Young people must take part; involved at all levels of decision making and
development empowering them to become active members of society.
3.
Young people should feel good about their sexualities; taking pleasure and feeling
confident about all relationships, including sexuality.
Examples of programmes Incorporating a rights based approach
Duo to the fact that a rights-based approach Is a relatively new theory, It is challenging to locate
programmes or projects that have Implemented it and evaluated its effectiveness. However, there are
several organisations that have implemented pieces of the theory into their programmes targeting young
people. A rights-based approach has several valuable aspects. They are not always used simultaneously,
yet when used individually each aspect of the theory can have a positive influence on the sexual and
reproductive health and rights of young people.
3
Advocacy -Youth Coalition, International
In February of 1999 a group of young people attending the First International Youth Forum (organised
around ICPD +5) in The Hague, the Netherlands, decided to take their concerns regarding the state of the
sexual and reproductive health and rights of young people one step further. This group of concerned
young people decided to organise the Youth Coalition — an organisation established by young people
working for the sexual and reproductive rights of young people.
•
•
•
The Youth Coalition advocates, at the governmental, NGO, and community level, for the
recognition and respect of the sexual and reproductive rights of young people.
The Youth Coalition encourages youth participation and empowers young people to advocate for
their own sexual and reproductive rights through trainings and workshops.
The Youth Coalition shares the perspective of young people through disseminating information,
knowledge, and sharing policy recommendations with others.
As an international organisation with young members from all parts of the world, The Youth Coalition has
created a global voice for young people to express their concerns and become active in issues regarding
their sexual and reproductive health and rights.
(Source: www.vouthcoalition.org)
Youth friendly services - CEMOPLAF, Ecuador
During the evaluation process of a pilot project implementing sexuality education in high schools, young
people expressed the need for youth friendly services. In 1998, Centro Medico de Orientation y
Planificacion Familiar (CEMOPLAF) a family planning NGO in Ecuador, implemented youth friendly
services based on a participatory model. Active involvement of young people, parents and the community
at large was encouraged—ensuring respect for the clinics and their activities within the communities
where they are located.
•
•
•
•
•
•
Youth participation was encouraged during all stages of programme development,
implementation and evaluation.
Creation of new services to meet the real sexual and reproductive health needs of young people.
Existing services were improved and made more acceptable and accessible for young people, for
example separate waiting rooms.
Opening hours, schedules, and fees were adjusted to meet the needs of the young clients.
Personnel received Intense trainings on how to work with young people and how to serve them-Interpersonal communication and counselling training with an emphasis on confidentiality.
Counselling and education was also integrated into the clinics’ activities.
Information and education is disseminated for young people, teachers, parents and the
community outside of the clinic.
Evaluations of the program, including interviews with young clients, demonstrated that since the
implementation of youth friendly services the demand for services by young people has increased. There
is also a higher return rate of young clients. In addition to the five CEMOPLAF clinics involved in the first
stages of this project, sixteen clinics are expected to implement youth friendly services. CEMOPLAF has
created an environment that allows young people to feel comfortable and exercise their sexual and
reproductive rights. Information and services are easier to attain which encourages young people to make
informed decisions concerning their sexual lives.
(Source: www.advocatesforyouth/
Education for school youth - Malaysia and Vietnam
Malaysia
In 2001 the Federation of Family Planning Associations of Malaysia produced a Module on the
reproductive health of adolescents (RHAM). This comprehensive guide for educations, including youth
poor educators, promotes adoloscont reproductive health using a holistic approach. Tho RHAM uses
seven concepts, nineteen topics and seventy-five activities plus Integration of reproductive rights and
reproductive health to empower young people.
4
RHAM is also based on four objectives: Information, Attitudes and Values, Relationships and
Interpersonal Skills and Responsibility. The active participatory approach used aims to involve
participants to share knowledge and dispel myths.
Vietnam
Also in 2001, the World Population Foundation (WPF) teamed up with the National Institute of
Educational Sciences (NIES) from the Ministry of Education and Training in Vietnam to develop a
comprehensive and holistic curriculum to be used in the re-education schools for children in conflict with
the law (CCWL). Results from a needs assessment told of a need for the students to better understand
their sexuality and how to protect themselves against sexual health problems. As a result, WPF and NIES
with technical assistance from Youth Incentives were able to develop a sexuality education and HIV
prevention programme using a rights-based approach as one of the central development themes.
The development process included defining objectives based on the actual sexual health concerns of the
young school participants. Learning objectives to be included are to increase sexuality knowledge,
communication and negotiation skills and social norms. Knowledge of sexual and reproductive rights was
also integrated with the goal to empower the students to make informed decisions and advocate for their
own rights. The participatory-based programme model encourages active Interaction and allows students
to be involved In their own learning process. The pre-test showed positive results and the extended
module of more than 50 lessons will be implemented and evaluated in the first part of 2003. Young people
have been involved from the beginning of the development process. Their own needs have become a real
part of the programme. The module and the book to be used reflect the thoughts of the young people, as
well as their rights—positive steps towards success.
5
' References
Advocates for Youth. (2002) Programs at a Glance: Improving Youth's Access to Contraception in Latin
America, www.advocatesforvouth.org.
Bernstein, S., Ryan, W., Marshall, A., Sadik, N. (Eds). (1995). Wereldbevolkingsrapport 1995: wegen
voor ontwikkeling: vrouwen, 'empowerment' en reproductieve gezondheid. (Translation from: The State of
World Population 1995: Roads toward development: women, empowerment and reproductive health United Nations Family Planning Association). Stichting Wereld & Bevolking.
CRLP. Implementing adolescent reproductive rights through the Convention on the Rights of the Child.
http://www.crlp.org/pub art adolriqhts.html
Family Care International, www.familvcareintl.org/briefing cards 2000/riqhts.htm
Federation of Family Planning Associations of Malaysia, www.ffpam@po.jaring.mv
International Planned Parenthood Federation. (1996) IPPF Charter on Sexual and Reproductive Rights.
IPPF: London.
International Planned Parenthood Federation (2000) Voice: How the IPPF/Youth Manifesto Can Work for
You. IPPF: London.
IPPF/Youth Manifesto (2000). London: IPPF
Marriott, H., Pollard, F., Kohn, D., Britton, A., Nott, J., Faulkner, K. (Eds). (2001). Eye to Eye. London:
IPPF.
Reproductive Health of Adolscents (RHAM). Federation of Family Planning Associations of Malaysia,
www.ffpam@po.iarinq.my
Schroff, R; Reinders, J., Quynh, N. Q., Thuy, L.T., Nga, B.P. (2002) Systematic Development of a
Curriculum on Sexual Health and AIDS Prevention for Children in Conflict with the Law in Vietnam.
Abstract presented at 2002 International AIDS conference in Barcelona, Spain.
UNFPA (2002) http://www.unfpa.orq/icpd/round&meetinqs/nyadolescents/report1.htm
UNFPA (1998) Report of the Round Table on Adolescent Sexual and Reproductive Health.
http://www.unfpa.org/publicalions.html .
Youth Coalition website, www.vouthcoaltion.org.
Utrecht, August 2002
Prepared by: Annemaire Oomans and Sara Massaut
6
WHAT IS REPRODUCTIVE
HEALTH?
The 1994 Cairo ICPD Conference deFines
Reproductive Health as
"A State of complete physical, mental and social well being and
not merely the absence of disease or infirmity in all matters
relating to reproductive system and its functions and processes"
Reproductive health approach means that:
■
People have ability to reproduce and regulate their fertility,
Women are able to go through pregnancy and child birth safely,
The outcome of pregnancy is successful in terms of maternal
and infant survival and well being and
Couples are able to have sexual relation free of fear of
pregnancy and of contracting diseases.
Fathallah -1988
( i
PACKAGE
Health:
4
4
4
4
• 4
4
♦
♦
♦
4
Family Planning
Safe abortion, Prevention of abortion and
management of consequences of abortion
Safe Motherhood
Prevention and Management of RTI’s and STI's
Child Survival
Health, Sexuality and Gender information,
Education and Counselling
Referral Services
Growth monitoring and Food Supplementation
for Children, Pregnant and Lactating Women
Screening and Management of Cervical and Breast
Cancer
Prevention and Treatment of Infertility
NON-HEALTH
-■
4
4
Reduce Gender Discrimination and Violence
Enhance female literacy
RCH means
REDUCTION OF THE BURDEN OF
CHILD BEARING
Responsibility of RCH
THE CLIENTS :
1.
For each girl — equal access to nutrition,
education and health services;
2.
For each adolescent — access to reproductive
health information and services;
3.
For each woman oF Reproductive age — access
to family planning and appropriate abortion
management;
4.
For each pregnant women — at least three
prenatal contacts by a health care delivery
personnel;
5.
For each High risk pregnant woman with threat
oF complications — access to transport to first
referral;
6
For each woman in labour — assistance by a
trained health care provider;
7
For each new mother — access to postpartum
health care and child spacing services and child
care services;
8
For women at large — including the elderly
women amenities for protection from and
intervention for diseases that are gender specific
and sex related.
9
Youths and Adult Men
CHANGING THE SIGNALS
OLD SIGNALS
NEW SIGNALS
Primary goal
Reach two-child family size
norm
Priority Services
Family planning, especially
female sterilization
While still encouraging smaller families,
help clients meet their own health &
family planning goals
Full range of family planning services
Immunization
Full range of MCH services
Performance
measures
Number of Cases
Quality of care, coverage, measures,
client satisfaction
Management
approach
Top-down, target driven,
male dominated
Decentralized, client needs Gender sensitive
Attitude to client Motivate, persuade
Accountability
To the bureaucracy
Listen, assess needs, inform
To the client and community, health
and family welfare staff
COMPREHENSIVE REPRODUCTIVE HEALTH
SERVICES PACKAGE
Prevention and Management of Unwanted
Pregnancy
4
Service to Promote Safe Motherhood-^
Service to Promote Child Survival-^
&
Nutritional-Services for Vulnerable Groups-^
♦
Prevention and Treatment of RTI's and STI's
□
Prevention and Treatment of gynaecological
Problems
□
Screening and Treatment of Breast Cancer
♦
Reproductive Health Services for Adolescents
♦
Health Sexuality and Gender Information,
Education and counseling — Advocacy
♦
Establishment of Effective Referral Systems — NGO's
and PRl's
♦
Essential RCH Package
THE APPROACH
4-
Package of Services
0
Improve Accessibility — Institution & Outreach
More Responsive to Client Needs
<
Improve Quality of Care
Women Health Services — WHS
4*
Provide Accessible, Complete and Accurate
Information
♦
Training
♦
Involvement of NGOs and Private Sector
♦
Cost Recovery
♦
Social Marketing
♦
Involvement of:
Health Personnel
NGOs
Counsellors
MSS Members
Zilla Panchayat Members
Religious Groups
Mahila Mandal Members
P.M.P's
REPRODUCTIVE HEALTH
People have the ability to reproduce and regulate their fertility
Women are able to go through pregnancy and child birth safely
The outcome of pregnancy is successful in terms of maternal and infant survival
and well being
Couples are able to have sexual relations free of fear of pregnancy
and of contracting diseases.
Fathallah -1988
DEMOGRAPHIC INDICATORS
SI.
NO.
STATE
Popn
(91)
GR
(81-91)
FLR
(91)
SR
(91)
CBR
(94)
CDR
(94)
IMR
(94)
TFR
(92)
AM
(92)
CPR
(95)
1.
Kerala
29.09
1.34
86.17
1036
17.3
6.0
16
1.7
22.1
50.7
2.
Tamil
Nadu
55.85
1.43
51.33
974
19.0
7.9
59
2.2
20.25
54.8
3.
Andhra
Pradesh
66.5
2.17
32.72
972
23.7
8.3
63
2.8
17.8
49.4
Karnataka 44.9
1.92
44.34
960
24.9
8.1
65
2.9
19.4
52.7
INDIA
2.14
39.29
927
- 28.6
9.2
73
3.6
19.5
45.8
4.
846.3
KJ H - 6 .
Registration form
Workshop on
Gender, Sexuality and Reproductive Rights
22 - 24 April, 2006 Visthar, Bangalore
Please fill in the following and mail it to us before the
25th of March.
1. Name ofthe participant
Sex and age
3.
Educational background
4.
Languages known
5.
Postal address, telephone number
and email
7.
Trainings attended
8.
Nature of current work / involvement
Workshop on
GENDER,
SEXUALITY AND
J
REPRODUCTIVE RIGHTS
22-24 April, 2006
7.
Cheque/draft details (registration fee)
y
''Visthar
Signature ofthe participant
Bangalore
Tel: 91 80 28465294/295
Email: visthai-@vsnl.com
Overall objective
Methodology
To enable participants to develop a gender and rights
perspective on issues related to sexuality and
reproduction.
The workshop will follow a participatory approach and
will draw on participants’ experience and knowledge.
The methodology will include case studies, role plays,
audio-visuals, inputs etc. Background readings will be
compiled into a dossier (sent in advance on request) and
handouts issued during the workshop.
Specific objectives
At the end of the workshop, participants will
• Have conceptual clarity on gender, sexuality, sexual
and reproductive health and sexual and reproductive
rights
• Be familiar with social determinants of sexual and
reproductive health and identify gender as one of
these detenninants, affected by and interacting with
other determinants
• Acquire skills to apply gender analysis and a human
rights framework to analyse sexual and reproductive
health policies and programmes
• Be acquainted with strategies to advocate for sexual
and reproductive rights at the community and state/
national levels
Themes / aspects to be covered
•
•
•
•
•
•
•
Introduction to concepts of gender, sexuality, sexual
and reproductive health, human rights, sexual and
reproductive rights
Analysis of the social determinants of sexual and
reproductive health at the household, community,
national and international levels
Introduction to international human rights frame
work and how they have been applied to advance
sexual and reproductive rights
Analysis of policies from a gender and rights
perspective (using a specific state population policy
and/or NRHM as examples)
A gender and rights approach to reproductive health
programmes: What does it mean?
Advocacy and social mobilisation for sexual and
reproductive rights: approaches and strategies
Planning for integrating sexual and reproductive rights
hin the work of participants’ NGOs
Participants
The workshop is designed for women and men invotad
in training and advocacy on issues related to gen®r,
reproductive rights and health. Coordinators, trainers,
policy makers from governmental and non-governmental
organizations, who have already undergone a basic course
in gender, will find the programme particularly useful.
Facilitator
The workshop will be facilitated by Dr. Sundari
Ravindran, Honorary Professor, Achutha Menon Centre
for Health Science Studies, Trivandrum. Sundari has also
served as Gender and Health Specialist at the Department
of Gender, Women and Health and as Technical Officer
of the World Health Organization (WHO). Her major
publications include a training manual on ‘Transforming
Health Systems : Gender and Rights in Reproductive
Health' - Published by WHO, 2001.
•
Course fee and registration
Visthar is subsidizing the board and lodging expenses of
the workshop. Patricipants are expected to pay a nominal
sum of Rs. 1500/-(Rupees one thousandfive hundred
only) as registration fee. Interested candidates are
requested to fill in the enclosed form and mail it to us
before the 25111 of March with a cheque/ draft drawn in
favour ofVisthar. Activists / non-fitnded groups will be
exempted from the registration fee on a ‘first come first
serve’ basis.
Contact: Mercy Kappen
email: visthar@vsnl.com, mercykappen@yalioo.com
vjh-6
GOVERNMENT OF KARNATAKA
STATUS REPORT
&
ACTION PLAN
2000-2001
REPRODUCTIVE AND CHILD HEALTH PROJECT
NATIONAL COMPONENT
ANNUAL FINANCIAL ENVELOPE
OFFICE OF THE PROJECT DIRECTOR (RCH)
DH&FWS, ANANDA RAO CIRCLE, BANGALORE - 560 009
MAY 2000
REVISED ANNUAL PLAN AS APPROVED IN THE INSTATE LEVEL STEERING
COMM inEE ON RCH HELD ON 8-5-2000
PRESENT STATUS AND ACTION PLAN FOR 2000-200 J
BACKGROUND
Ministry of Health and Family Welfare, Government of India in their
communication no. M. 14015/7/97 dated 3rd December, 1997 sanctioned the
launching and implementation of the Reproductive and Child Health (RCH)
programme with effect from 1997-98 to 2001-02 as a part of the centrally
Sponsored programme with a total project outlay o'f Rs. 190 crores for Karnataka
for the project period. This includes the contribution that will be provided from
Government of India directly to the State both in cash and kind.
PROJECT GOALS
The RCH programme intends to integrate a) fertility regulation and b) maternal
and child health with reproductive health services such as screening, diagnosis
and treatment of RTIs and STIs with the aim to reduce infant and maternal
mortality and unwanted fertility thereby eventually contributing to stabilization
of population growth and improve the health status of children.
CATEGORISATION AND COVERAGE OF DISTRICTS
Interventions directed towards improved and added facilities under this
programme are to be covered in a phased manner depending on the
classification of districts on the basis of certain important indicators and
needed inputs. Accordingly districts are grouped under three categories as
below:
"A” category
Districts
D.Kannada
(Udupi)
Kodagu
Mandya
“B" category
Districts
U.Kannada
“C" category
Districts
Gulbarga
Be/gaum,
Chikmagalur,
Dharwad, (Gadag, Haveri)
Hassan,
Mysore, (Chamarajnaqar)
Bangalore(R)
Tumkur
Shimoga
Chitradurga (Davanagere)
Kolar
Bijapur (Bagalkot)
Bidar
Bellary
Raichur (Koppal)
Bangalore (U)
-2-
BELLARY SUB-PROJECT
Bellary sub-projecf has been selected for the district project to fill up the gaps in
the MCH and FP programmes. The cost of the sub-projecf is Rs. 15.05 crore. A
separate status report on this is prepared.
DEMOGRAPHIC GOALS FOR KARNATAKA
Based on an exercise similar to the NPP 2000, the department has set the
following provisional demographic goals which it feels are realistic and
achievable provided appropriate RCH and other sectoral interventions are
made in the next few years.
Year
TFR
CBR
CDR
/MR
CPR
1988**
2000
2005
2011
2016
2031
2.5
2.4
2.1
1.8
1.6
22
21
19
17
14
8.0
8.0
7.5
7.5
7.0
58
53
42
30
30
58
60
64
69
75
+
+
+
+
+
Popn.
(000,sj
50983
52091
55425
59815
63007
69836 #
** SRS estimates/official estimates
+ not fixed
#
level at which it is expected population may stabilize with the right
interventions.
PROGRESS MADE UNDER THE RCH PROGRAMME
The RCH programme in Karnataka has had a slow start. The Government of
Karnataka sanctioned the programme in its order no. HFW FPR 95 dated 1.6.98.
An empowered committee has been set up with the Chief Secretary as
Chairman and this committee has met on two occasions. For overseeing the
implementation of the programme, a Steering Committee with the Principal
Secretary, Health and Family Welfare has also been set up. This Committee has
met on many occasions.
Additional Director(FW) has been designated Project Director. The Joint Director
and other supporting staff assist him. Three consultants have been appointed.
Commissioner Health and Family Welfare Services also guides and monitors the
implementation of the programme.
In brief, the following action has been faken/initiafed.
-3National Component:
1.
The Empowered Committee under the Chair Personship of the Chief
Secretary to Govt., met twice and cleared some important policy
decisions.
2.
The State Level Steering Committee has to far met at least 10 times in
order to give momentum to the implementation of the programme.
3.
Out of five consultants allocated for the State, three consultants namely
for Maternal Health, Evaluation & Monitoring and IEC have been
appointed. They have been in position formore than three months and their
services are being fully utilized.Under the major civil works component,
works are in progress in various stages (Annexure -1).
4.
The eligible couple registers have been printed to the extent of25,000
using the amount of Rs.2.98 lakhs allocated for the purpose.
5.
An amount of Rs.7.72 lakhs for printing of immunization cards has
been utilized. Immunization cards have been districted to all the
£
districts with instructions to ensure that these are in turn handed over
to the beneficiary families.
6.
Under the training component, the progress made so far is as follows :
Awareness Generation : 2921
Composite Groups
:518
7.
Outreach services are being strengthened by involving Anganawadi
Workers working in the Dept., of Women and Child Development.
FINANCIAL PROGRESS UNDER RCH
(Rs.in lakhs)
SI.
Budget released by
No.
Government of India 1998
A) National Component
1.__ Drugs
15.55
31.13
2.__ A.B.Cotton
Civil works
190.00
60.00
PHN
25.00
5.__ SCOVA
S.M.Consultants
8.00
6.
3.43
7.__ 24 Hour Delivery Services
125.00
8.__ PHNs
9,__ Transport charges
5.00
26.00
10. C.C. Maintenance
Pethidine
Injection
1.80
11.
7.72
12. Immunization cards
2.98
13. E.C. Registers
57.37
14. IEC - ZSS
15. IEC National Component
558.98
Sub Total
234.00
B) Sub - Project
792.98
Total
1275.84
C) Kind Materials:
Grand Total
Expenditure
1998-99
12.99
5.00
17.99
2111.95
Expenditure
1999-2000
Cumulative
expenditure
1.20
1.20
13.00
25.99
7.70
3.20
2.95
6.80
34.85
6.82
41.67
2172.69
7.70
3.20
2.95
6.80
47.84
11.82
59.66
5566.48
5626.14
-4NATIONAL COMPONENT
(2000-01)
Apart from the schemes included under the financial envelope, the State of
Karnataka proposes the following schemes to be continued under the National
Component of RCH programme.
I
Civil Works Over the years the position of buildings for different health institutions such as
district hospitals, community health centres and PHCs have improved in most of
the periphery. The position of subcentres has not been improved. Therefore it has
become necessary fofake up repair works for subcentres and PHCs involving
repair of electric supply lines, water supply arrangements, attending leakage of
ceiling and also repairs of floors, doors and windows limiting to the expenditure.
A lumpsum budget of Rs. 10.00 lakhs to every district for such repairs will be made
available. The Dist. Health and FW Offleer/Disi.RCH Officers will identify such
institutions and contact
the Executive Engineers and Zilla Panchayat Division to
get them repaired. No funds will be made available for construction of compound
wall etc.,
Action is being taken to issue a GO in this regard. For this purpose an amount of
Rs. 190.00 lakhs is ear marked during the 2 year project period 2000-2002.
GOI has released budget of Rs.190.00 lakhs, for civil works. Against these 69 civil
works have been commenced.The civil works are being taken up in the PHCs
(preferably MNP PHCs,) for construction of OT/!abour room etc., wherever there is a
greater demand for FP & MCH services and also the availability of land for add on
work. The average estimated cost of these works is Rs.9.00 lakhs. For 69 civil works
Q the total estimated cost is Rs.6.21 Crores. Against these works an amount of Rs.62
lakhs'have been committed and payments are being made. During the remaining
part of the year an additional expenditure of Rs.3.00 crores for this project is
required.
In addition, in respect of 19 district excluding (Bellary). The ZPs have been asked to
take up minor civil works up to Rs. 10.00 lakhs each. Towards these Rs. 1.9 crores is
required. The total net amount required for civil works is as below
The total amount for civil Works proposed is therefore as below
a) Works already committed
Rs.362 lakhs
b) Repair Works
Rs. 190 lakhs
Total
Rs.552 lakhs
Funds already released (-)
Rs, 190 lakhs
Funds required for 2000-01
Rs.362 lakhs
-5-
//.
DRUGS:
The following amount has been released by GO! fordrugs and supplies
Drugs
15.55 Lakhs
A.B cotton
31.13
Pethidine Inj.
01.80
Total
48.48
This amount is being utilized for provision of drug kits to improve the essential
obstetric care in PHCs in category 'C & 'B' districts as well as supply of drug kits for
emergency obstetric care forFRU's.
The total outlay required will be Rs. 108 lakhs. @ Rs.54.00 lakhs per year for
the period 2000-2002.
III
Consultants
a)
State Level Consultants are required for preparation of proposals, monitoring,
evaluation and follow up at state level. If is also felt that the appointment of
consultants will help in carrying out and formulating the activities of RCH
programme effectively. 3 consultants have already been appointed in the field of
Maternal Health, IEC, Monitoring & Evaluation . The balance are being appointed
shortly. To meet the expenditure towards honorarium of consultants including
expenses on their travel, stationery etc., a sum of Rs. 15 lakhs is provided.
b)
It is proposed to identify 2 suitable persons to fill the balance post of child
health consultant and financial consultant.
For this purpose an amount of Rs.25.00 lakhs has been released under SCOVA for
meeting the expenditure of honorarium, TA, Stationery etc.,
IV
Monitoring & Evaluation
’One of the important components of the RCH programme is the implementation
of the CNAA for the Monitoring and Evaluation of the programme. Under this
approach, if is envisaged that the annual plans/targets have to be prepared
starting from the sub-centre level and consolidated in the form of State Plan in
plan no.5. Similarly, the monitoring of the progress of the programme has to be
ddhe ifTthe monthly reports starting again from the sub-centre level in form no.6
which has to be consolidated to the District/State level monthly progress report in
form no.9_
The immediate operationalisation plan of this approach is the transmission of both
form no.4 and form no.9 through NICNET. However, in a phased manner, it is
desirable to computerize the PHC-wise plan/monthly report also. As a first step in
this direction, if is proposed to obtain the progress report PHC-wise for all the 1600
and odd centres in the state which will reflect the progress for the entire year 19992000. These reports will be collected at the State head quarters and by engaging
private agencies, its consolidation and analysis will have to be taken up.
<7^-/
-6-
ln addition to the above activity, the amount earmarked for Monitoring and
Evaluation will also be utilised for printing and distribution of the various registers
and formats prescribed under the MIS for RCH project.
The community needs assessment approach has to be implemented by
using computers and information technology. One computer has already been
purchased for this purpose. For this it will be necessary to engage computer
agencies in the non-governmental sector and staff skilled in computer operations
provision is also required for monthly monitoring meeting of RCH officers at State
Level.
Following is the anticipated annual requirement of CNAA formats.
No.of CNAA forms to be printed
Form No. 1
a)
Form No.2
b)
Form No.3
c)
Form No.4
d)
Form No.6
e)
Form No. 7
f)
Form No.8
a)
Form No. 9
h)
Manual
______ a______
20000
5000
1000
100
225000
50000
10000
1000
12000
In addition it is proposed to take up audit of PHCs. The Chairman Professional
Development Committee of Southern India Regional Council of the Institute of
Chartered Accountants of India in the letter dtd. March 24, 2000 addressed that
the organization has around 5000 chartered accountants in Karnataka of which
nearly 2000 are in practice.
They have expressed to offer their services in the area of auditing primary Health
Centres. During the preliminary discussion it was brought to the notice that such an
audit system is being installed in Andhra Pradesh, and it will also be feasible in
Karnataka also.
An amount of Rs.2000/- for each of the PHC, would be charged for auditing.
During the current year it is proposed to audit 200 PHCs.
@ of Rs.2000/- per each PHC, if would require an amount of Rs.4.00 lakhs towards
this which can be met under monitoring and evaluation sub head of National
Component during 2000-2002.
Towards Monitoring & Evaluation during the current year of the project 2000-01 a sum of Rs. 50.00 lakhs is required.
-7-
V.
IEC through ZSS : An amount of Rs.57.37 lakhs has been released to 14
Districts to take up IEC activities of RCH programme through ZSS. The activities are
being implemented through the district level committees headed by Dy.
Commissioner.
National Component
Abstract 2000-200 J
SI.
No
Interventions
Expenditure
Plan
2000-2001
552.00
Amount released
/ proposed for
re appropriation
190.00
1.
Civil Works
2.
Drugs
54.00
48.48
3.
Consultants
15.00
25.00
(Rs. in lakhs)
Net amount
required
362.00
5.52
10.00
{excess)
4.
Monitoring & Evaluation
50.00
0
50.00
5.
IEC
57.37
57.37
0
728.37
320.85
Total
417.52
(Deduct Rs 10.00
lakhs)
407.52
-8FIN ANCIAL ENVELOPE UNDER RCH
(2000-01)
During the World Bank review meeting in May 1999, with the State Governments,
among other things, one of the decisions was to grant greater flexibility to the
Southern States to meet the specific needs within a fixed financial envelope to
further smoother) the implementation of the RCH programme.
Govt, of India in November 1999 indicated the flexibilities offered and requested
to forward a proposal with details such as districts selected, expected outcome
and funds already received etc.,
The flexibilities offered in this envelope are:
1.
The envelope would be applicable to 20% of the disadvantaged population of
the State and free to set criteria for selection of the districts.
2.
The States will be free to choose the intervention provisioned for round the
clock delivery services at PHCs.
3.
The State will be free to choose the no. and category of contractual
appointment of staff.
CRITERIA FOR SELECTION OF THE DISTRICTS :
The following are considered as criteria for selection of the districts.
o Low levels of Antenatal care
o High Crude Birth Rate
o
High unmet need in Family Planning
®
Low levels of institutional deliveries
o
Low levels of fully immunized children
. The Rapid House Hold Survey reports under RCH for the years 1998 and 1999
are available. Keeping in view the above listed criteria, the districts such as
Gulbarga, Bidar Raichur (Koppal), Bijapur (Bagalkot) are selected for the financial
envelope.
Important findings of Rapid House Hold Survey under RCH of these districts are
listed.
-9-
Important findings of Rapid Household Survey under **RCH project
Districts
SI.
Gulbarga Bidar *Raichur *Bijapur State
Parameter
No
1.
Popl. in lakhs
25.82
12.55 23.09
29.28
44.97
2.
% Girls married less than 18 47.7
67.6
57.1
64.8
35.20
years
3.
CBR
30.1
31.6
29.1
22.9
22.0
4.
Couple Protection Rate
39.2
50.6
45.4
41.9
58.1
5.
Birth order3 & + %
53.7
52.9 52.8
43.1
27.8
6.
Unmet need %
48.1
37.2
42.2
14.0
18.1
7.
% of ANCs who had 360.6
28.0
47.8
57.3
57.6
checkups
8.
Institutional deliveries %
22.7
27.9
32.9
38.9
52.5
9. Exclusive breast feeding % 63.1
86.2
85.8
45.4
67.8
10. Children fully immunized % 25.3
50.3
37.2
53.2
64.9
11. Reproductive morbidity % 29.3
66.7
40.6
31.8
25.7
(pregnancy
complications)
Old Districts before reorganization of the districts.
Rapid House hold survey I and II phase [ 1998, 1999]
Among other things, the following are observed from the findings of the Survey:
The total population of these districts is about 91 lakhs which works out to 18%
of the State population.
b)
The ante-natal care is about 48% as'compared to State average of 75%
(NFHS-II).
c)
The average Crude Birth Rate of these districts works out to 28 per 1000
population whicFTis morelhdhTfFie'Stdte average of 22 (1998 SRSj" '
d)
The averageJnsiitutional deliveries works out to 31% as compared to 52% of the
State average (NFHS-I &II)
e)
The unmet need in Family Planning is about 35% as compared to the State
average of 18% (NFHS -11992-93}
f)
The levels of fully immunized children works out to 42% as compared to the
State average of 60% (NFHS - 2).
a)
Therefore selection of these districts for the financial envelope is justified to
furthering the progress in the implementation of FW/MCH/RCH programmes. These
districts have already been identified by Govt, of India as 'C category districts for
additional inputs under RCH.
-10Further, in general these districts are characterized by:
®
°
LqwFemale Literacy levels
Infrastructure weaknessincluding large number of vacancies of ANMs and
doctors and also lack of mobility support in health facilities.
OBJECTIVES
Having realised that the identified districts are having poor demographic profiles,
the objectives envisaged under the Financial Envelope are the following :
®
•>
•
®
Strengthening outreach services
Provision of round the clock services in PHCs
Ensuring Clean and safe delivery practices
Adolescent health education.
EXPECTED OUTCOMES:
At the end of the Project period of two years (2002) the expected outcomes
would be
1. To increase the present level of ANC care from 48% to atleast 65%
2.
To bring down the crude birth rate from the present average level of 28 to
about 25%
3.
To promote the institutional deliveries from the present average level of 31% to
about 50%.
4.
To increase the coverage in the immunization level from the present average
level of 42% to 62%.
5.
To reduce the gap in unmet needs in family planning from the present average
level of 35% to 25%.
6.
To enhance awareness in improved hygienic practices and behavoural
changes under RCH programme.
INTERVENTIONS:
As seen from the findings of the RCH Survey, those districts are considerably pulling
down the average levels in the demographic profiles of the State.
Keeping in view the objectives and the outcomes, envisaged the following
interventions are proposed.
-III.
STRENGTHENING OF OUTREACH SERVICES :
Large no.of vacancies of ANMs in the above selected districts are posing a
problem in providing effective delivery of outreach services particularly in
delivering ante-natal care, immunization and promotion of spacing methods.
Large no.of health institutions are not able to provide credible preventive care,
family planning services and curative care because of lack of doctors and other
skilled staff. Therefore it is proposed
To hire the contractual services of doctors
To utilize part time services of Anganawadi workers ( of women
& child development dept.)
c)
To provide mobility support for the PHC personnel for increasing
the coverage in outreach services.
a)
b)
Q
a) Doctors at PHCs : Out of the existing 347 PHCs in these districts 63 PHCs are
Govt, of India pattern PHCs in which there are two sanctioned posts of Medical
Officer. In the remaining MNP PHCs there is only one sanctioned post of Medical
Officer. Out of this 284 MNP PHC, if is proposed to select only 100 PHCs (recording
poor immunization coverage and family Planning coverage) from these districts.
Hiring of the contractual services of one additional doctor to each of the 100 PHCs
is proposed. The placement of the doctor will enhance the availability of health
services provided by PHCs, and also improve holding of subcentres clinics and
supervision. The services of the doctors will also help in providing round the clock
services including family planning services in these selected 100 PHCs. For the
current year (for 8 months) the amount required Rs.48.00 lakhs. ( 100 Doctors x
6000 x 8 months). These Doctors will be recruited on the basis of qualifying marks by
the Deputy Commissioners.
&
Anganawadi Workers.-Part time services of Anganawadi Workers will be
utilized to improve the outreach services irrespective of whether the incumbent
in the ANM sub centre is positioned or not. The job responsibilities have been
identified. It is therefore, proposed make to 163 PHCs fully functional round the
clock. For this purpose selected categories 'C districts. 163 PHCs includes 63 GOIP
and 100 MNP.
.
b)
One day joint training'with ANM will be organised. Important monitoring lines will
also be identified to justify the need of her services.
*
An honorarium of Rs.250/- for part time services (about 3 hours in the afternoon) is
proposed.
COST: 6019 AWWsX Rs.2501- pm X8 months = Rs. 120.38 lakhs
-12-
c)
Mobility Support For PHCs : Barring supply of four wheelers to few selected
PHCs under National Programme such as family planning, Malaria, Leprosy, TB
majority of the PHCs do not have vehicles of their own.
There has been no replacement even since long time. Most of the vehicles
supplied earlier have become road unworthy. Therefore there is an urgent need
to support the PHCs for availing the vehicles for improving the mobility of the
doctors and the staff.
Instead of procuring the vehicles which pose many disadvantages, it is proposed
to hire the vehicle preferably four wheelers and placed for the use at PHCs for
about 10 days in a month. Thus about 100 vehicles proposed can cover 300
PHCs in a month which do not have vehicles.
£
COST: 100 VEHICLES X Rs.500/- per day X 30 days X 8 months = Rs. 120.00 lakhs.
Each PHC will draw up a ' plan of itinerary ' for its turn of 10 days and use it for
effective supervision of the field work, holding of Immunization sessions in most
remote/inaccessible areas and also use for family planning client needs.
d)
Transport Charges : A sum of Rs.5.00 lakhs released from Govt, of India,
towards transport charges is being placed with the Taluk Health Officers towards
payment of transportation charges in case of emergency situation.
£
e)
S.M. Consultants : To supplement the regular arrangements in the Health
Institutions, it is proposed to utilize the services of doctors trained in MTP in the
PHCs once a week or afleast once in a fortnight on a fixed day for performing
MTP. These doctors will also provide antenatal care and post natal care to the
patients during their visit. An amount of Rs.500/- per visit is proposed. In addition
to this, it is proposed to utilize the services of Anesthetist for providing Emergency
Obstetric care. Rs. 1000/- per attended case in case of emergency obstetric care is
proposed.
The amount of Rs.8.00 lakhs released from Govt, of India towards this will be
utilized in selected 6 districts.
II
PROVISION OF ROUND THE CLOCK SERVICES AT PHCs :
The staff sanctioned in almost all the PHCs particularly for MCH care is very
minimal. This problem is further compounded with limited hours of govt, timings
from 9 am to 5.00 pm. There is a wide gap of non-availability of services at PHCs
and therefore the services rendered from these PHCs have no credibility at all in
the eyes of the public. Community seems to have lost confidence that some staff
is available in the PHCs during night times. The emergency situation such as
delivery, abortion, acutely ill mother and child has no solution to tide over the
critical hours. Many a times their lives will be at stake.
-13Hiring of doctors at 163 PHCs will fill up the gap to a certain extent as dealt under
strengthening of outreach services.
In addition the services of staff nurse and a cleaning staff is expected to ensure a
very good solution for providing round the clock services especially maternity
services such as institutional deliveries, abortion services etc.,
These staff nurses will be absorbed into the general health system as and when
vacancies are available after the project period.
If is expected that about 28000 deliveries will be taking place during nights in these
districts which are to be attended for providing cleaning services. Each attendant
is proposed to be given an honorarium of Rs.50/- per attended delivery case.
The services of staff nurse and cleaning staff will also be utilized for promotion of
family planning services through PHCs. (63 GOIP, 100 MNP PHCs)
The projected requirement during the current year is as bellow:
Staff Nurse
163 x Rs.3800/- x 8 months = Rs.49.55 lakhs
Cleaning Staff
3500 x Rs.50/- x 8 months = Rs.14.00 lakhs
(per month)
Rs. 63.55 lakhs
GOI has already released Rs. 185 lakhs towards payments of Staff Nurses. The total
contractual services proposed towards outreach services as well as for round the
clock services is as below.
(Rs. in lakhs)
Category
Number
Amount required
Doctors
100
48.00
Anganawadi Workers
6019
120.38
Staff Nurses
163
49.55
Cleaning Staff
3500
14.00
Total
231.93
Against the above amount of Rs. 185 lakhs already received from GOI. which will
be used for this purpose, the balance amount required to be released towards
this will be Rs.46.93 lakhs.
III.
ENSURING CLEAN AND SAFE DELIVERY PRACTICES :
a)
Training of Dais : Since the discontinuance of the Dai Training from 1997, it
has not become possible to upgrade the skills of traditional birth attendants. There
are considerable no.of these personnel in the villages who are to be trained in safe
delivery practices, family planning and child care. Vacancies of large no.of ANMs
in the districts has further aggravated the problem of lack of services. There are
large no. of untrained birth attendants who need immediate training.
-14-
Keeping in view the skills to be learnt under maternity care, it is proposed to bring
these untrained birth attendants wherever there are good no.of deliveries taking
place either in PHCs or CHCs and provide them 'Hands-on' training for a period of
30 days in conducting safe deliveries. An honorarium of Rs. 50/- per day would be
given. In addition one delivery kit is proposed to be given to each Dai after the
completion of the training.
= Rs. 15.00 lakhs
30 days
Rs. 100/= Rs. 1.00 lakh\
candidate
500/- kit
= Rs.5.00 lakhs
Dai kit (one time) x 1000
X
Rs.21.00 lakhs
b) Disposable Delivery Kits : It is estimated that about 30% of the deliveries in these
districts are taking place in ‘unsafe hands’ which will be about 51000 during the
period of 8 months. It is proposed to provide a Disposable Delivery Kit through
ANM/AWWs which will be placed in hands of each ‘would be delivering mother',
so that this can be used at the time of delivery to prevent sepsis and
complications thereafter. Each kit costing about Rs.20/~ will contain a pair of
gloves, one umbilical clip, an antiseptic lotion bottle, one plastic bowl, one towel
and a gauze piece.
Cost: 51000 deliveries x Rs.20/- per kit = Rs. 10.20 lakhs
Cost: 1000 (UTBAs)
TA (One time
Rs.50/- per day
x 1000
X
X
IV)
ADOLESCENT HEALTH EDUCATION :
1/5 of the total population constitute adolescent (10-14 years) in terms of both
boys and girls. This group has not been covered so far in Health care delivery
system except when they fall sick. Further, 50% of this group will drop out from the
schools and hence not available to any type of education / services.
This is a very critical segment of the population who are to be covered by RCH
services. This cohort who will be in the schools will be covered through school
Health Programme. To cover those adolescents who drop out from the schools, a
mechanism will be worked through women & child Development Dept., to link if
with Anganawadi centres for organising orientation sessions at frequent intervals.
It is expected to cover population of about 18000 adolescents in these districts.
To begin with, if is planned to prepare simple educational materials covering
physical development, personal hygiene, population education etc., which will be
distributed through schools and anganawadi centres. It is also planned to hold
sessions to adolescents by teachers who are in schools and out of schools.
Cost: A sum of Rs. 10.00 lakhs towards preparation of charts, booklets, handouts
and also contingent expenditure .
VoH - G -
NATION, CURRENT AFFAIRS
India’s maternal mortality rate drops further
TEENATHACKER
PublishedFeo 2. 2015. 1 01 pm 1ST
UpdatedJan 10. 2016, 8 38 am 1ST
Annual compound rate of decline was highest in Maharashtra, followed by Andhra
Pradesh
Representational photo (Photo: AFP)
New Delhi: India’s maternal mortality rate has further dropped to 167 per one lakh live
births, an indication that India will be able to achieve Millennium Development Goal 5
concerning maternal deaths — a feat that the World Health Organisation had earlier claimed
would remain unmet. While the MMR in 2010-2012 was 178 per one lakh live births it further
dropped to 167 per one lakh live births in 2011-2013.
“At the current annual compound rate of decline of MMR, India will be able to achieve MDG
5. In 1990 Indian's MMR as per the UN agency estimates was 560, the drop this time is
commendable. We are confident to achieve MDG 5 if the progress continues,” said a senior
official in the health ministry.
According to the recent data from the registrar gener.al of india, ministry of home affairs,
Kerala continues to register the lowest MMR at 61 per one lakh live births, followed by
Maharashtra with MMR of 68 per one lakh live births. Significantly, the MMR also continue to
drop in high-burden states like Bihar (208 per one lakh live births) and Uttar Pradesh (285
per one lakh live births).
The annual compound rate of decline was highest in Maharashtra, followed by Andhra
Pradesh and Haryana.
Ironically. Dr Nata Menabde, WHO representative to India, had earlier claimed that India
would miss 2015 MDG. Dr Menabde had said that India would be able to achieve its
unfinished targets only after 2015.
As per the MDG targets, the MMR is to be reduced by three quarters between 1990 to 2015.
India has been observing an average annual decline of 5.5 per cent. “Assuming that the
annual rate of decline of 5.5 per cent observed between 2004-2006 and 2007-2009 will
continue, India’s MMR will decline well below the MDG target," added the source.
DATA
NEW DELHI, December 23, 2014
India to reach replacement levels of fertility by 2020
health
Fertility is falling faster than expected in India, and the country is on track to reach replacement levels of
fertility as soon as 2020, new official data shows.
The 2013 data for the Sample Registration Survey (SRS), conducted by the Registrar General of India, the
country's official source of birth and death data, was released on Monday.
The SRS shows that the Total Fertility Rate - the average number of children that will lie born to a \\ oman
during her lifetime - in eight States has fallen below two children per woman, new official data shows.
Just nine States - all of them in the north and east, except for Gujarat - haven't yet reached replacements
levels of 2.1, below which populations begin to decline. West Bengal now has India’s lowest fertility, with
the southern States, Jammu & Kashmir, Punjab and Himachal Pradesh. Among backward States, Odisha
too has reduced its fertility to 2.1.
"At 2.3, India is now just 0.2 points away from reaching replacement levels. Fertility is declining rapidly,
including among the poor and illiterate. At these rates, India will achieve its demographic transition and
reach replacement levels as early as 2020 or 2022," Dr. P. Arokiasamy, a demographer and Professor at the
International Institute for Population Sciences (UPS), Mumbai, explained to The Hindu
The news on the other key indicator in the SRS - the infant mortality rate (1MR) - is less positive. India’s
IMR lias fallen to 40 deaths per 1,000 live births, and 49 deaths of children under the age of 5 for every
i.ooo live births, but at these rates is unlikely to meet its Millenium Development Goals for 2015. IMR has
fallen faster in rural areas than in urban areas.
Among the metro cities, Chennai has the lowest IMR (16). Among states, Kerala has by far the best 1MR at
12 deaths per 1,000 live births; the next best states, Delhi and Maharashtra, have IMRs that are twice that
of Kerala.
Another worrying trend that continues is the unnaturally higher mortality rates both for infant girls and for
girls under the age of five than for boys, a trend that runs contrary to the global trend.
Keywords: I ndia'sjertility rate
Distance and institutional deliveries in rural
India
India has the highest rate of maternal deaths in the world
Santosh Kumar
. | Emily Dansereau
| Christopher J.L. Murray
First Published: Fri, Apr 19 2013. 01 53 PM 1ST
The current Maternal Mortality Ratio (MMR) in India is 212, whereas the country’s target in this
respect, as per the Millennium Development Goal (MDGs), is 109 by 2015. Photo: Priyanka
Parashar/Mint
Updated: Fri, Apr 19 2013. 0158 I’M 1ST
One-fifth of the 2,87,000 maternal deaths worldwide in 2010 occurred in India (WHO 2012). India is
very likely to miss the Millennium Development Goal (MDG) for maternal mortality. The current
Maternal Mortality Ratio (MMR) in India is 212, whereas the country’s target in this respect, as per
the MDGs, is 109 by 2015.
Institutional deliveries or facility-based births are often promoted for reducing maternal and neo-natal
mortality. Yet, many women in low- and middle-income countries, including India, continue to
deliver babies at home without the presence of a skilled attendant.
About half of all births in India in 2007-2008 occurred at home without skilled attendance (District
Level Household Survey (DLHS-3)). Institutional deliveries in India range from about 35% in
Chhattisgarh to 76% in Madhya Pradesh. Of the 284 districts in nine high-focus states which account
for 62% of maternal deaths in the country, institutional delivery is less than 60% in 170 districts
(Annual Health Survey (AHS) 2011).
Besides reducing maternal and neo-natal mortality, institutional deliveries are also believed to
improve health-seeking behaviour and practices in the period following childbirth. Children born at a
health facility are more likely to be vaccinated and breastfed (Odiit and Amuge 2003). Properly
vaccinated and adequately breastfed children are less likely to be malnourished and have better health.
Additionally, poor childhood health can have an adverse effect on educational attainment as well as
on adult work productivity, and can hence affect adult earnings (Bleakley 2010). Therefore,
institutional delivery can also be thought as an investment in human capital and can play an important
contributory role in the development process of the economy.
Barriers to visiting a health facility
Women face various barriers to visiting a health facility to seek delivery care. These include cost of
care, access to clinics, cultural factors, quality of care, and a lack of health awareness.
To relax the financial barrier, the government of India launched the Janani Suraksha Yojana (JSY) in
2005. JSY is a conditional cash transfer programme that provides a cash incentive to women who give
birth at public health facilities. Rural women receiveRs. 1,400 ($28 approx.) and urban women
receive Rs. 1,000 ($20 approx.) upon delivery at a public health facility. All services provided at the
public health facility are free of charge.
The success of JSY has been mixed so far- the percentage of mothers availing financial assistance
ranges from less than 15% in Jharkhand to about 60% in Orissa (AHS 2011).
Too far to travel
Physical access is an important barrier as longer distances entail higher transportation and opportunity
costs. Distance to health services exerts a dual influence—it is a disincentive to seeking care in the
first place, and also an actual obstacle to reaching care after a decision has been made to seek it
(Thaddeus 1994). The adverse effect of distance is stronger when combined with lack of transport,
poor roads, and poor quality of care.
In a recent study, we attempt to unravel the causal effect of distance to health facilities on institutional
delivery in rural India (Kumar et al. 2013). It is very important to understand the effect of the access
barrier as it greatly depends on contextual factors. For instance, distance may become irrelevant in a
setting with high-quality health facilities and transport infrastructures. Some studies have shown that
households are keen to travel longer distances for high-quality care (Collier et al 2002).
Analysing the distance barrier
Using DLHS-3, a nationally representative household data set, we find that distance to health facility
is a significant barrier and adversely affects the number of institutional deliveries in India. For a I km
increase in the distance to health facility, there is a reduction of about 4% in the chances of opting for
an institutional delivery. At the average distance of 9 km from a Primary Health Centre (PHC), there
is a 64% chance of opting for institutional delivery.
Additionally, the study finds that women who live 5-9 km away from the nearest health facility are
13% less likely to opt for institutional delivery as compared to women that live 0-5 km away from the
nearest health facility. When the distance increases to more than 9 km, the chances of institutional
delivery are reduced by 30% (as compared to a distance of up to 5 km). Based on a thought
experiment conducted as part of the study, we find that if additional facilities are built such that the
maximum distance of a health facility is restricted to 5 km, institutional deliveries will rise
significantly.
We also find that women living in households that own cars or other motorised vehicles are more
likely to deliver in health facilities. Poor road connectivity also deters women from visiting a health
facility for delivery care.
What should be done?
Our findings indicate that in countries such as India, where distances to health facilities are quite large
in rural areas, geographical access to health care is a significant barrier to institutional delivery. An
increase in the density of health facilities and providers in rural areas is likely to greatly help improve
maternal and neo-natal care.A comprehensive cost-effective analysis should be undertaken to
demonstrate that the benefits would outweigh the cost of building new facilities.
In addition, it is important to improve road and transport infrastructure to reduce inequity in access to
health facilities, and thereby, increase institutional deliveries.
Santosh Kumar, PhD, is a lecturer of Global Health Economics at the Institute for Health Metrics and
Evaluation (IHME) at the University of Washington.
Emily Dansereau is a post bachelorfellow at the Institute for Health Metrics and Evaluation, and an
MPH candidate at the University of Washington.
Christopher J.L. Murray, MD, DPhil. is a Professor of Global Health at the University of Washington
and Institute Director of the Institute for Health Metrics and Evaluation (IHME).
of Indict-.
Vfipplp- cf Indict-
...access to reproductive and
sexual health services
^n-te-rnn-l AerdiA. services
tenhces
and Information
CHETNA
For Women Young people Children
E-mail: chetna456@gmail.com Website: www.chetnaindia.org
October 2010
(p> constitute one third of the Indian population. Our reproductive and
sexual health status demands attention at the policy formulation,
programme planning and programme implementation levels.
Our concerns have not been adequately addressed in policymaking and
programme implementation so far.
The National Health Policy 2000, in its operational strategy mentions the following:
nforce the Child Marriage
Restraint Act, 1976, to reduce the
incidence of teenage pregnancies,
nsure adolescents' access to information,
counselling and services, including reproductive
health services that are affordable and accessible,
mphasise a minimum of
three year spacing between
birth of two children.
Effect of these provisions are not reflected in the health statistics of young people in India.
The National Youth Policy 2003 has briefly touched upon the issue of reproductive health of young people.
Reproductive and sexual health is not reflected in the rationale and thrust areas of the policy. The issue of
reproductive and sexual health is not discussed as a key sector of specific youth concerns. The need for access to
reproductive health information and safe sexual behaviour is mentioned in the HIV/AIDS and Sexually Transmitted
Diseases. Also the process of policy formation does not value or encourage young people's participation at
policymaking levels.
The National AIDS Prevention and Control Policy focuses on the age group 15-49 years in the context of
prevention of HIV/AIDS. It does not address sexual and reproductive needs of young people that ideally should
include provisions for ensuring their complete reproductive and sexual health and wellbeing in a comprehensive
manner.
The Government of India (GOI) along with the Department of Youth Affairs and Sports is now aiming to bring out a
National Youth Policy 2010. It is time to join hands and address the reproductive and sexual health concerns of
adolescents and young people (10-18, 19-24) in India's National Youth Policy 2010.
cu
ywyU Are ce.ntr^t
critical for dckieViny
Universal Access to reproductive health (Target 5b)
Looking at our large numbers, our significance as a truly distinct segment with
specific needs cannot be neglected anymore.
Nearly half of the people of the world arc under the age of 25 years. In India Young people between 10-24 vears
will continue to constitute approximately one third of India's population in the coming years. India will have highest
number of young people, which will continue to grow till 2050.
Many among us, especially those who live in rural areas succumb to social pressures that
lead to early marriage and subsequently to early pregnancies and other health
complications.
■ The median age of marriage for women aged 20-49 is 16.7 years
44.5% of all women aged 20-24 many by 18 years
24% marry by 15 years.
wnmln^t
marr‘aSe; eari>er the onset of sexual activity and thereby rising rates of fertility in
h itk c 3 S° lncreases th® rate of unsafe abortions that lead to death of young girls National Family
Health Survey (NFHS III 2006).
7
66
j
■ More than1 in 5 married adolescents have undergone childbirth by age of 17 and half of all women
ave already experienced pregnancy and childbearing by the age of 19 years. About 13% of deaths
among women and girls below 24 years are related to pregnancy and childbirth (NFHS III 2006).
We need access to contraceptives that should be made accessible in a non-threatening,
non-judgmental and friendly environment...
□ Most young people aged 15-24 want fewer children. 4 among 5 young people want 2 or fewer children
(Parasuraman and Kishore 2009). Almost 1 in 4 young women between the age of 15-24 years reported
an unmet need for contraceptives'.
■ The use of contraception to delay the first pregnancy is rare. Just 13% and 9% of young women aged
15-19 and 20-24 respectively practised contraception to delay the first pregnancy1.
□
Use of oral contraceptive and Intra Uterine Device (IUD) is as low as 14% and 5% respectively among
■
A large proportion of young men and women (15-24 years) hesitate to procure contraceptives from
married young women of age 15-25 years'.
health care providers or pharmacies. Even among the married, one quarter of young men and half of
young women reported inhibitions in approaching health care providers or medical shops'.
We need access to sexual health services...
□
Sexually Transmitted Infection is an increasing concern among young people. In India it is estimated
that 2.3 million people are currently living with HIV/AIDS. Youth aged between 15-24 years are the
fastest growing segment in the newly infected population.
We strongly demand access to reproductive and sexual health information through all
different channels in local languages...
■
Only 20% of unmarried women between the age of 15-19 years and 31 % between the age of 20-24
years have ever discussed family planning methods with anybody. (District Level Household Survey -
DLHS 2007-08).
■ Among the age group of 15-24 years only 25% men and 35% women knew that oral pills should be
®
taken daily/weekly. Only 30% young women knew that one condom could be used for only one sexual
act. (The International Institute for Population Sciences- UPS and Population Council 2010)
■ Among unmarried adolescent girls (15-19 Years) 30% and between the age of 20-24 years 43% have
ever heard of RTI/STDs.
■ 91% men and 88% women between the ages of 15-24 years heard of HIV/AIDS. Out of which 45%
men and 28% women had comprehensive knowledge of HIV/AIDS (UPS and Population Council 2010)
■ Less than 50% (37% men and 45% women) knew that women could get pregnant the first time they had
sex.
!1
5eVerAi fatties infantecorrect in/vrmAtim fve-lys tv
Ay
pre.aWWW
fecruw uwtfe.
WMr faring the. ye-iwZ007,
A W 5tAte5 rftfa. country hw-wu( rwirfactiVe. aa<( texunt fantth
^/cAtiw in t(ve.fvrw^t scMolinc) curriwtuw.
'(UPS and Macro International 2007) ’(DPS and Population Council 2010)
;
Call for Action....
Voices of Young People
Considering our concerns and challenges, we seek attention
to our following recommendations in:
The National Youth Policy 2010, National Reproductive and
Child Health programmes of Government
Access to information...
.: age specific life skill based reproductive and sexual health.
. : Design health education strategy and develop health education material in local languages. Disseminate
.eelth information widely through various socially acceptable communication channels. A proper delivery
and monitoring system needs to be established to ensure better outreach and awareness building.
Toll free help lines should be made available particularly to young people residing in the remotest areas.
Professionals who can provide counselling with empathy should be recruited at these centres.
Awareness programmes to increase sensitivity about needs of sexual minorities.
a Parents, teachers and other concerned stakeholders including government officers should be sensitized and
trained on "Sex, Sexuality and Gender Issues”
Access to Services...
□ Youth friendly centres or health clinics should be rebuilt or established in all the communities. The services
should include a comprehensive sexual and reproductive health package to ensure overall health.(Access
to contraceptive, maternal health entitlements, treatment of reproductive and sexually transmitted
infections, safe abortion services)
□ Trained male and female counsellors should be recruited at all schools, Primary Health Centres and
Community Health Centres.
■ All girls and boys must have equal access to the full range of health information and services.
■ Proper monitoring systems should be established to ensure adequate and timely delivery of services.
■ Reproductive and sexual health needs of vulnerable groups should be addressed with sensitivity, i.e. young
people living on the street; institutions; physically and mentally challenged; migrants; survivors of natural
disasters; sex workers and their children, etc.
■ Address special health needs of transgender groups (Males who have sex with males (MSM), bisexual,
lesbian and gays and young people living with HIV/AIDS)
Other recommendations■ Strict action should be taken against early marriage.
■ Registration of births, marriages and deaths should be followed strictly.
■ Strict action should be taken against cases of violence and sexual harassment.
■ Enforcing the fundamental right of education for all adolescents must be a priority
We strongly recommend a convergence among different Ministries and Departments to deliver various health,
nutrition, education and livelihood services to young people. We recommend setting up a mechanism through
which different departments can work together on common goals.
Centre for Health Education, Training and Nutrition Awareness
CHETNA
For Women Young people Children
Supath-ll, B-Block, 3rd Floor, Opp. Vadaj Bus Terminus,
Ashram Road, Vadaj, Ahmedabad-380013
Phone: 91-079-27569100/01,27559976/77 Fax: 91-079-27559978
E-mail: chetna456@gmail.com/chetna456@vsnl.net
Website: www.chetnaindia.org
UH-
p bjectjy£
The basic approach'of the model is to establish Mini
Family Welfare Centres-to promote MCH, Immunisation of
Family Welfare Programme amongst the section of population
resistant to family welfare programme and having high-birth
rates. This will be applicable to town and city upto a
population of 1,00,000 and rural areas.
Preference under
the scheme will be such districts which have been identified •
as low CPF< and high birth rates (Annexuro-I),
2.
The objective of the scheme will be entirely motivational
to create a link between the infrastructure .of Health and
Family Welfare facilities and the community to promot’d .
responsible and healthy motherhood and small family rinx-’.
3.
The salient features of the scheme are :--
3,1
-The Scheme of Mini Family Welfare Centre will be operative
•amongst the population group resistant to Family Welfare
Programme.
For urban areas, it will be limited to slum
and unauthorised areas, in towns with population ranging upto
one likh. In the rural areas, the scheme will be restricted
to areas having low CPR and high birth rote.
3.2
The objective of the scheme will be entirely
motivational to serve as a link between the infrastructure
of Primary Health Centres, Sub-Divisional*Hospitals and
Family Welfare Centres, Voluntary Organisation Hospitals/
Clinics and the community.
3.3
The population to be covered in urban areas will be
25-,ODD divided i.-.to five field units of 5000 each.
In rural ereas, the' population to be served by each
unit will be 15,000 consisting of five field units of
,3'JUO each;. ■
3.4
Structure:- Each Project will consist Mini Family
If.nre
Centre (r-iFWC) with ?. Unit Coordinator as Incharge.
Each
Mini Family Welfare Centre will have five field units.
In each field unit there will be five Sahel’ics to be
selected fr’om Anganwadi workers, Balwadi teachers or any
instructor under othor child survival schemes from the
operative units under these schemes located in the
area of operation of these project. The lady workers from
community can also be appointed as Saheli (ij if above named
workers nre not willing (ii) due to special requirement of
the segment of population to be covered.
Ono of th.o Saheli
worker will be selected as group lender after ascertaining
the le-’dership quality and w-’tching th'ei'r work for about
three, months,
4.
This scheme is both for urbar/ind runl areas. Through
this model, attempt is to reach the gross root levels -nd
crs-te awareness in the community served in a phased manner
step by step from the very beginning of family formation-i.e.
marriage.
In a gradual and step by step method the need for
MCH and family planning is generated as the family develops
keeping a continuous touch with the bride developing into
a young mother.
She is also trained in the art of motherhood
by the grass root level Voluntary Worker known ns ’Saheli’
in this model. This trained mother becomes an agency herself
for passing these traits to the new brides in her family
and those in close proximity. Thus gradually the MCH &
Family Welfare motivation would progress in a chain like
manner and in due course the worker pill have to concentrate
on lesser number of families and contact with trained mother
woulo be of maintenance centre.
The Mini Family Welfare Centre
5.
The Mini Family Welfare Centre will have 5 field units
and each unit will serve a population of 3,000 in rural areas
and □ population of 5,000 in urban areas. The following
conditions have to be fulfilled
) The Mini Family Welfare Centre will .be situated in
the area of population served by it.
Its 5 fields
units will be disbursed around in the area of
operation.
(2) The Mini Family Welfare Centre will be attached for
clinical and referral services to the nearest PHC of
Community Health Centre or Urban Centre in city
area or Voluntary Organisation Hosp ital/Clinic
to be specifically earmarked in this project.
1
(
(3) The Mini Family Welfare Centre will serve as ~
depot for supply of contraceptives like condoms
and oral pills.
<4) The Mini Family Welfare Centre will serve as a unit
for Community uplift by (i) Imparting Health '
Education (ij/) training married young women in
the art of motherhood; (iii) immunisation in '
children and mothers; (iv) motivating the community
specially the target couples to have small family
norm and (v) ensuring proper sanitation and
hygienic conditions.
.
(5) The staff should be employed from the community to
be served specially the grass root, level worker
the Family Female Voluntary Worker 1Saheli1.
-3-
6Fha basic principle involved in the success of
- ij
to create rapport with the newly wed.bride ano follow cac.
couple through their.reproductive phase including first
pregnancy, delivery, post natal care, spacing of pregnancy,
second pregnancy and finally sterilisation. During this
follow up she will bo educated and helped as the need
arises in various phases step by step, ensuring a healthy
marital life, healthy pregnancy period, safe delivery,
healthy and .trained motherhood and- finally ensuring spaced
small, family, This step by stop, approach will provide
complete' FiCH■ cover and Family Planning. This approach uiil
produce well trained mother who can-help other newly weds
in her family and neighbourhood.
Fiet ho oology
In average there.are three to four marriages performed.
□ach marriage session in a village/cover area of an ayer-ge
090 to 1000 population.
( b)
First Stop
To establish rapport with the.Newly Weds and thei’
family and this is done by ‘Saheli1 (Family Female Voluntary
Worker) by ensuring her presence in the marriage'and
creating closeness to the family by presenting a small
gift to. the newly wed. This gift may bo small and consist
of some' g'eneral items of brides use.
In this gift pack
•there should be nothing related to Family Planning, so that
no .sensitivity,is created in the family or with the bride.
This primary rapport with family of newly wed and the bride
herself will open the path for consequent visits.
The worker pays a casual visit to kn6w the welfare
of.the newly.wed and creating personal friendship with
her. This may be done .at a convenient and congenial time.
(dj
Third Step
During the casual visits 'Saheli* (Family Welfare Femnl
Voluntary Worker) may come to know about the conception
occuring in the newly wed. ■ From this, tho visits of the.
worker is goal oriented and purposeful. The worker she Id
start educating the would bo mother regarding the conception
pregnancy, nutrition, for mother and child and few do’s
and dont's in sanitation. During this visit the worker
should congratulate ano encourage the would bo mother
■and take her into confidence. . This is tho best period
when the young mother is most receptive and inquisitive to
loam -.bout motherhood in confidence through a frion...
□)
Fourth Step
The would-be mother is gradually prcparocj'to cornu
to the Primary Health Centre/Hospital with the help of elder
family members specially the mother-in-law. Thus the
routine .-into-natal help is provided and would-be mother
is told about healthy motherhood, protection of self from
tetanus, nutriative value of specific foods to be taken
ano role of sanitr.ation in pregnancy and delivery.
She
is educated for preparing clothese for delivery and the
child" to come. Complete checking is done at the nearest
centre and if she is a risk case, she should be referred to
Community Health Centre, Thus at one side, the would-be
mother is educated for motherhood and at the other side
she is given full ante-natal services and care.
f)
Fifth Step
’Sahcli* (Female Family Voluntary Worker) thus fully
prepares the would-be mother to have safe healthy delivery.
Physically and mentally, she should be motivated for
delivery at home or Community Health Centre or a Hospital
as the case may bs. The Voluntary Worker should as far as
possible attend the delivery for providing psychological
confidence in the mother to bo.
9)
Sixth Step
As the delivery takes place the 'Saheli* should present
another 'Gift Pack' containing articles like Baby So~.p,
Powder, Clean Napkin etc. with a small booklet of Baby Care
and Birth Car
The use of each article is to be fully
explained putting emphasis on baby immunisation, nutrition
and knowledge about oral rehydration along with method for
preparing it. This all should be dona in home surroundings
in presence- of womens' gathering which is a tsual way.
/iftur delivery, by this step continuation of contact is
ensured and knowledge is gained by other mothers, elderly
ladies, and other would be mothers.
h)
Seventh Step
The new mother is now prepared to listen about spacing
methods and be made interested in the use of Nirodh, Copper '
oral pills.. The need of spacing be generated through
knowledge about the healthy development of baby if spacing
is adopted. Also Family Planning is talked but casu?Hiy and
if the need is generated services are provided.
i)
Eighth Step
If the need for second child is shown in a strong manner
the worker should wait and help her through the second
pregnancy.
But usually for the second pregnancy the mother
is fully prepared. Gifts may be repeated for the second
delivery to create a final approach to sterilisation after
second delivery.
-5-
Thus, it is seen that step by step the young lady is
■aepro.achod as peraneed creation and helped and educated
gradually when she is fully receptive.
i\ person is nut
receptive for everything, .every time but she becomes
very- receptive at the time of need and this is the key
of success in above methodology.
Secondly, this scheme ensures creation of trained mother
who can become a natural trainer in future.
Third advantage is that the image of the ’Sahsli’
^Family Female Voluntary Worker) gradually grows and in this
way she is herself sought/or, reducing her work gr.adu • .ly
and also the number of visit-in later period.
Fourthly, it may bo seen that in operation-wise the
scheme may look .ns slow ano cumbersome but practically after
, proper scheduling the' visitslit is not difficult to
follow in a small populstion of 1000 people in urban areas/
600 in rural areas.
j)
Mfkt_crna.l^_Pr^ct_ice__:
All the women who are pregnant in the area of operation
will be supplied with a maternity packet consisting of a.piece
of Lifebouy Soap,.a Blade, Boric Powder, Sterilised Thread,
Cotten, three Tablets of anglesic and tissue paper andchlorine drop for disinfecting the water tc bo used
’ /_sterili~.'at the time of delivery. These items will be packed in a/_
sed pncketdouble cover to avoid perforation and infection. This
in a thickpacket will also contain instructions for its use in Hindi/
plastic
iogicnal Languages/English as may be suitable. The mothers
p.-ck and will be advised to handover this packet to the Dai at- tnu
sealed in time of delivery and suggest to use these items in the
7.
The most important point for the success of, the scheme is:
1. Proper selection of 'SaEieli' (Family Female worker;
which may be easier for a Voluntary Organisation to
do due to their close proximity with the' community’.
2. Gontinued-and proper education of-’Saheli' who is
the key person of tho scheme is very important.
’Saholi*.
,
3. Besides the remuneration admissible the motivational
and other benefits for sterilisation,IUD and Copper *T'
insertion will be according to the rates prescribed
by the '"■-ate Government in addition.
She will also
nave th promote sale of commercial variety of
condemns as psr rates specified.
Arrangemant for training of' 1 S-.nnli1 s, Unit Ciuvuin
will be mac..? -it nearest PHC or Post--Pactum Centro or ?• • h
Contre/Hospital .according to prescribes curriculum.
.y
will also receive field or iont at i> >n is a continuous :■
' ,ss
to ba arranged by the organisation in consultation ui‘j thu
Directorate of family Welfare of State.
8.
.Financial, ...Imp lie n,t ion,
Gift.. f o,r,„the Bride
Th-, gift for the bride costing Rs. '20/- will bo selected
by rho Group Leader preferably in consultation with th'b
bride or other women in the home.
fs. 2/- per head.
Flat or nit y Packet.
Baby,.,Gift__P3,c,kGt_.
1.
2.
3.
4.
5.
1
2 { In two instalments at the time
2 1 of birth and 4 months later.
1
Baby Soap
Napkin
Small Towel
Baby Care Chart Article of mother
choice
••
1
The total cost not to exe <eed Rs. 20/- .
9•
?
Vi) Mini__Family,, W,el_f ar.'j Centre
Unit Coordinator (Full-time Employee;
on salary
-Rs. 1000/- p-.-m.
Conveyance allowance
-.Rs. 50/- p.m.
Postage/Cont ingency
fizULt.
ib, 1.100/- p.,m.
Pur Annum
Rs. 13,200/-
•s i i ) Field Unit
Saholies
-
5
Rs. 100/- p.m. for each
Extra honorarium for
Group Leader
jis_.__ 75/-• jj,jh,_
- Total :-
•
Rs. 575/-- p.m.
Per Annum = Rs. 6900/iii )
/iQ.O.ujil.
’Recurring - Salary of the Staff
Mini Family Welfare Centre fe. 13,200/5 Field Units ® Rs. 6900/- per unit - 34500/-
2 • Baby Pack
J
4000/3
. flat er city Pack
jj
jAdministet ive support cost to
Voluntary Organisation @ Rs. 250/- p.m.
Rs. 30G-_/-
Building Rent = Rs. 250/- p.m. per project - Rs. 3000/-Contingencies = Rs. 2000/\. v)
No n.~ recurring_ expenditure
Furniture and educational aid = Rs. 2000/Trainirig of Unit Coordinator
and Sahelies
= Rs.5000/Sub total
= Rs. 7000/-
Grand Total for tho project = Ps._ 66700/- per annum.
10.
Unit Coordinstor/Group Leader/Sahsli
(a) The Unit Coordinator will coordinate and supervise
the project and keep a regular liason with tho field uni-..
She/He will spa;nt one day each with 5 units and will bo at
. headquarter 'on tha 6th day. She/he will maintain rujrrfs •
apd monitor the whole project, arid undertake correspondence,
. Unit Coordinator will- be a full time employee and
primarily Extension Educators and will be required to .
develop rapport with tho Primary Health Centres, Sub-Divisional Hospitals, Family Welfare Centres and Voluntary '
.Organisations, Hcspitals/Clinics where he will be required
to send tho motivated persons. In case of male Unit Coordinator
he will also try to motivate ths men in his areas for
adopting a small family norm and terminal and spacing -methods
of family planning.
Unit Coordinator will have a degree in Science' or Social'
Science and Biology from'the rc-c.ognised University.
Prsfcrcnco will be given to persons having two .years
experience in health cars/ family planning activities.
(b)
.Group'Leader
Group Leader will primarily be a Saheli but she would
also be-given an additional responsibility to assist the
Sahelies and .act as group leader of tho unit. She will
□stcblis’h rapport with the Primary Health Centre,.
Sub-Livisional Hospital and other Hospitals/Clinics and main
•b-pgic records to be passed over to tho Unit Coordinator.
She will help to develop a programme for motivation of women
.in reproductive age group for a small family norm.
Sho will
extend support to Sahelies by visiting family etc.
-8-
(cj
Sahel!
Th arc will be' one Sahali for
population uf 1 ,6'3.; in
urban area and 600 in ’rural area. The Saheli will opted
from ths Anganwedi worker/oalwadi workers or instructors er
other Child Survival■Scheme fr.m the units located in the
orca of operation of the project. The lady workers .fz-m'
community can also be appointed as Saheli (i) if above
narndc. workers are not willing.
(ii; duo to special r-euirumant of the segment of population to be served. Be&idea,
ths honorarium cf Rs. 100/- p.m. motivational and .their
jun-fits for sterilisation and IUD cases will be
admissible tu the Saholi in .addition in accordance with
the r :tus prescribed by the respective State Governments.
This will be done each month at the level of PHD. in
rural set-up ano at District level in city set-up by
M.O., PHC/CMO respectively in their regular meetings.
Project Manager will present the report regarding the
work of tha Centre under various heads like
1. Referral Cases.
2. MCH Work.
3. Motivation.
4. House Visits.
5. Educational Programme
6. Training Programme
' 7. Area Profile.
12.
'
.
Release of ..Funds
Release of funds will be under the Central Sector
Schemes for grant-in-aid to' Voluntary Organisations. The
amount of Rs. 66700/- for meeting the co.st cf implementation
'of the scheme during one year period will bo paid into
two instalments. The first instalment for the six months
will consist of full non-recurring expenditure and 5b,A of
recurring expenditure. Thu second instalment will be given
whan the project starts operating after comnlatir.n nf
OPR
(31st
Jan.,
1985
"2"
Birth
Rata
(1.00)
Growth
1971-61
Female
literacy
;/)
I FIR
1980
An at
ii: 'rings
fWialos
1961
... • • 7‘.’
"S'."”
23.2
20.2
92
16.0
27.1
9.8
+
16.2
26.6
24.5
10.3
10.9
+
+
14.8
14.5
23.9
+
90
16.5**
15.9
21 .9
13.6
15.1
J9.5
100
16.1
Anantnag 18.0 39.0
iij d.-rmula 12.6 37.6
iii; Jammu
'19.5 37.9
29.7
26.7
36.5
30.2
15.9
10.9
9.6
32.2
72
92
90
63
17.4
7.1
1?, 1
17.4
32.8 27.6
23.3 34.8
24.8 37.2
26.4
19.3
25.7
27.8
71
80
67
16.9
13.7
13.6
5. k ar ala.
38.1 26.8
i•
J am22.9 40.1
19.0
64.5
40
19.1
29.4
53.8
4-
17.8
6. . i^tiya Pr.
i) 3h in d
ii) Flurena
iii; Rc’wa
29.5 37.1
1-6.8 40.2
14.7 44.6
16.5 40.6
25.2
22.2
32.1
23.3
15.5
14.6
10.1
11.4
142
129
132
133*
15.5
14.7
14.8
14.4
19. 8 38.7
i) Barmer
8.8 41.5
ii) Jalore
13.7 41.3
iii) SawaiPladhavpur .14.9 43.3
32.4
11.3.
105
15.7
43.8
35.3
3.7
4.5
102*
104*
16.9
17.3
28.4
8.0
141* .
15.7
8• Uttar Pr ., 17.1 39,6
i) .Rrsti
11.8
iijPlainpur i '10.0
iii; Gunda
12.0
iv) Shahjnh. npur
12.4
25.5
19.9
19.3
23.3
14.4
8.0
18.6
6.6
159
J 7.8**
4+
16.0
' -6.1
15.4
28.2
0.8
+
16.4
1 • A?rfhra ?JL’ 3 2 •0 31 • D
i; Adllabad 20,1 34.3
ii) rlehabubnagar.
20.8 35.3
iii; Fie dak
21.1 33.6
Bihar
17.2 37.8
J Bhcjpur
11.7 36.9
ii) Khagaria 10.6 3>.
iii) Sit oni.irh.i 11,6 35.6
2.
4.
4 Gulbarga
ii; r.aichur
7. 'Ra j .-jsthan
19.8
4-
16,6
16.0
-2-
•1.J, Kama of the
Or-CKinisat ion
2.
.cgistered Address
3.
ikegistraticn No.
isuith Act Statute
uncer which
registered)
Details of Health/Family
'Welfare infrastructure
Hs aIt h/F j. 1 y Wei fare
workers pre iout.] y in
employment.
7,
previous Activities of
the Organisation,
sspecially in relc.t.inn to
Family Welfare.
1
Amount of grant-inrequested it em-uis >,
i) .'■(ocurrinQ
iij Non-recurring
Lu ration of
Project
10.
Project area. - Urban
(i) Name of City & District.
Municipal Uard/Mohalla
where units to be locate.
(ill) Address of I'lFUC/Field Units.
Naino of District/Block
Names of Village to be
covered
Location bf MF'JC/Field Unit
& Address.
13.
14.
Objectives of the Project.
Nome of P.H.C./Hospital/
Dispensary which will
provide.MCH/Immunisation.
Oral Pills and Family
Welfare Services.
I
15.
iSethcdu.l.sgy to bo used
Pur achieving the
stated objectives.
prefer to para5~6 of scheme)
16.
Target to be achieved.
17.
whether the Organisation
is already running any scheme
under Family Welfare programme
with assistance from State Govt./
Govt, of India.
18. (a;
Are ICCS/Balwadi/Creche/
Child survival Schemes
functioning in the area
cf Project?
vb)- Whether the anganwadi worker,
Balwadi worker is participating
in the scheme as S.ihelj/in the
field units.
Please give the
particulars of those participating
with location of Anganwadi/
ialwadi/Creche .
(c)
19.
Number of Sahelis to be associated
not falling under (b, aoove.
Any other relevant information.
Signature
J*
Hl <3 BW<
sfrirrr qrf«n»r nrr?rsr
rqrrhr hth, =rf RfhI-I 10011
GOVERNMENT OF INDIA
A- K. MEHRA
MINISTRY OF HEALTH & FAMILY WELFARE
NIRMAN BHAVAN, NEW DELHI-110011
Joint Director (Area Projects)
r«'e: 3019131
D.O. NO. L19012/2/98-APS
July 9, 1998
Dear Madam,
This has reference to your letter no.793/CMDA/FW(US)/IPP-8/N-l l/96(Pt.II) dated
30.06.98 regarding incurring of some expenditure in connection with extension of IPP-VIII
Project activities to ID additional cities in West Bengal.. As discussed during the wrap-up
meeting held on 08.06.1998, the State may take up preliminary preparatory activities e.g.
training, orientation workshop, contracting of some key personnel, Baseline Survey,
finalization of selection procedures, constitution of various committees, assessment of
additional requirements of equipments and furniture in the health facilities proposed to be
covered, training to existing officers in additional cities in the World Bank procedures and
other related activities. You may utilize the IPP-Vlll funds to meet expenditure on the above
preparatory activities subject to a maximum of Rs. 15 lakhs. Regarding Baseline Survey, it is
suggested that it may be got done in all the additional cities by one agency for which the sole
source agency approval of the World Bank may also please be obtained. A copy of the
questionnaire developed for Baseline Survey and terms of reference for RCH sub-projects are
also enclosed for your ready reference.
With regards,
Yours sincerely,
((a(|K. MEHRA)
Joint Director (Area Projects
To,
Secretary, CMDA & Project
Director, IPP-VIII, Calcutta,
Unnayan Bhavan,
Bidhan Nagar 'G' Block,
3rd Floor,
Calcutta-700 091
Copy to: S'
/Ms. Indira Padmanabhan,
World Bank,
70, Lodhi Estate,
New Delhi-110 003.
&
'•
(. vnivA
NtT/waU
<
TERMS OF REFERENCE FOR ORGANISATIONS UNDERTAKINS RAPID BASE
LJNE
SURVEY
UNDER
THE
SUB-PROTECTS
C-HXJ.D-H^AfcTH-PROU-Eg-T-G .
O (J
d-'P P Vl I.'’
OF
REPRODUCTIVE
nv(.' r c [
AND
C.
( , , '* /(\,
1 OC'l1-*7'
I - Background:
Ministry of Health & Family Welfare, Govt, of India
has obtained a credit from IDA under Reproductive Child
Health
(RCH)
project.
Under
the
project,
various
interventions are being planned to enable clients to make
informed choice, to receive counselling and education for
responsible and healthy sexual behaviour, to access userfriendly services for preventing unwanted pregnancy and
safe abortion, maternity care and child 'survival and,
management of reproductive tract infections (RTIs) and
sexually
transmitted
diseases
(STDs).
Under
the
District/City sub-projects of the RCH project, Bar.oJino
surveys are reguired to be undertaken in each sub-project
area to determine baseline values for certain socio
economic,
demographic
and
Health
t
Family
Welfare
indicators. This necessitates the engaging of Consultant
organisations for undertaking the Baseline surveys in the
specified Districts/Cities where the sub-projects are
proposed to be undertaken.
II.
A concise Statement of Objectives:
To undertake a baseline survey in the Cities/Districts
where the sub-projects are being undertaken under the
RCH project as per the de ta i 1 s/gu ide 1 i nes to be
finalised by the Ministry of Health & Family Welfare
in consultation with the Bank.
To
determine
the
baseline
values
as
per
the
requirements.
To analyse and evaluate the findings of the survey.
V)
Data, Services
Client;
and
to
Facilities
be
provided
by
the
Th^S.taiLe_Qtoy_er.m&rrtrE/Project Authorities will provide
all necessary data, document and information,
other
inputs necessary as agreed to by the y^Gov-ea-nme-nt—erf
Lndi-a and—StatV-Government/-.are-jest—- Authori-ties for
carrying out the assignment by the consultant.
i
Consultants
will
discharge
consultation with client.
their
duties
in
VI • Final output (i.e.. Reports, Documents, etc.) that will
bo required of the Consultant;
The Consultants would deliver the following outputs:Detailed findings of the Survey.
M^nth^y Progress Reports indicating the up-to-date
status and giving details relating to progress,
shortfalls, future work with the time frame, -e-t-e-.
pd~r. - -T—to—the—Govt.—of- Indi a , State—Guver nmel'TCirajid
Project Authorities.
Interim Report of the Baseline Survey undertaken.
Final Report of the survey with an Executive Summary.
Any other relevant Report/Reports
Review Committee.
VII.
Composition
of
Consultancy Work:
a
Review
requested
Committee
to
by
the
monitor
The State Secretary (FW), the Project Director of
respective sub-projects and the Joint Director
(Area
Projects)
from
the
Government
of
India
or
his
representative will constitute the Review Committee which
will review and monitor the work as and when
felt
necessary.
VIII. Cost of Consultancy:
The remuneration for undertaking the Baseline survey
of a sub-project would vary between Rs.2 - 3 lakhs
depending on the sample size.
15
8.
1 lie (Name of Consultant) will be responsible for appropriate insurance coverage In this rermtrl. the (Name of
Consultant) shall maintain workers compensation, etnplovmcni liability insurance for their stall on the assignment. I he
(Name of Consultant) shall also maintain comprehensive general liability insurance, including contractual liability
coverage adequate to cover the indemnity of obligation against all damages, costs, and charges and expenses for injury
to any person or damage to any property arising out of, or in connection w ilh. the services which result from the fault of
the (Name of Consultant) or its slatT. Tire (Name of Consultant) shall provide the (Name ol Client) with certification
thereof upon request.
9.
The (Name of Consultant) shall indemnify and hold harmless the (Name of Client) against any and all claims,
demands, and/or judgements of any nature brought against the (Name of Client) arising out of the services by the
Consultant and it’s stalT under this Agreement. The obligation under this paragraph shall survive the termination of this
Agreement.
10.
The Consultants agree that any manufacturing or construction linn with which they might be associated with
will not be eligible to participate in bidding for any goods or works resulting from or associated with the project of
which this consulting assignment forms a part.
II.
All final plans, drawings, specifications, designs, reports and other documents or software submitted by the
(Name of Consultant) in the performance of the Services shall become and remain the property of the Client. The
Consultants may retain a copy of such documents but shall not use them for purposes unrelated to this Contract without
the prior written approval of the Client.
ll I The Consultant undertakes to carry out tne assignment in accordance with the highest standard of professional
and ethical competence and integrity, having due regard to the nature and purpose of flic assignment, and to ensure that
the staff assigned to perform the services under this Agreement, will conduct themselves in a manner consistent
herewith.
13.
' The (Name of Consultant) shall pay the taxes, duties fee. levies and other impositions levied under the
Applicable law and the Client shall perform such duties in this regard to the deduction of such tax as may be lawfully
imposed.
14.
file (Name of Consultant) also agree diat all knowledge and information not within the public domain which
mav be acquired during the carrying out of this Agreement, shall be. for all time and for all purpose, regarded as strictly
confidential and held in confidence, and shall not be directly or indirectly disclosed to any person whatsoever, except
■ with the (Name of Client) written permission.
i'< J-
■
'' Place: •
1
Dale:
(Signature ol Authorized Representative
on behalf of Consultant)
(Signature & Name of the Clicnl’s Representative)
Attachment: Terms of Reference
m:\sbd\cons\othcr\c-9.doc: November 17. 1997 NR/^-v
IS
The (Name ol Consultant) will be responsible for appropriate insurance covemue In this regnal. Ihe (Name of
“nsu lant) shall maintain workers compensation, employment liability insurance for their stall on the assignment. The
aine of Consultant) shall also maintain comprehensive general liability insurance, including contractual liability
coverage adequate to cover the indemnity of obligation acainst all damages, costs, and charges and expenses for injury
to an) person or damage to any property arising out of, or in connection w ilh. the services which result limn Ihe fault of
t ie (Name of Consultant) or its staff. The (Name of Consultant) shall provide Ihe (Name ol Client) with certification
thereof upon request.
9.
Tlte (Name of Consultant) shall indemnify’ and hold harmless Ihe (Name of Client! against any and all claims,
demands, and'or judgements of any nature brought against the (Name of Client) arising out of the services by (he
Consultant and it's stalT under this Agreement. The obligation under this paragraph shall survive the termination of this
Agreement.
'
'
■
10.
The Consultants agree that any manufacturing or construction firm with which they might be associated with
will not be eligible to participate in bidding for any goods or works resulting from or associated with the project of
which this consulting assignment forms a part.
11.
All final plans, drawings, specifications, designs, reports and other documents or software submitted by the
(Name of Consultant) in the performance of the Sen ices shall become and remain the property of the Client. Tlte
Consultants may retain a copy of such documents but shall not use them for purposes unrelated to this Contract without
the prior written approval of the Client.
I-. I Tlte Consultant undertakes to carry out t/te assignment in accordance with the highest standard of professional
and ethical competence and integrity, having due regard to the nature and purpose of flic assignment, and to ensure that
the staff assigned to perform the services under this Agreement, will conduct themselves in a manner consistent
herewith.
13.
The (Name of Consultant) shall pay the taxes, duties fee. levies and other impositions levied under the
Applicable law and the Client shall perform such duties in this regard to the deduction of such tax as may be lawfully
imposed.
14.
The (Name of Consultant) also agree diat all knowledge and information not within the public domain which
may be acquired during the carrying out of this Agreement, shall be. Tor all lime and for all purpose, regarded as strictly
confidential and held in confidence, and shall not be directly or indirectly disclosed to any person whatsoever, except
• with the (Name of Client) written permission.
' Place: •
Date:
(Signature ol Authoii/ed Representative
on behalf of Consultant)
(Signature i Name of the Client’s Representative)
Attachment: Terms of Reference
m:\sbd\cons\ollier\c-9.doc: November 17. 1997 NRMv
SlJikfit;
(Name of Consultant)
I.
(Nameol A««icmnciit)
Set out below are the terms and conditions under which (Name of Consultant) has agreed to carry out (Name of
tent) the above-mentioned assignment specified in the attached Fenns of Reference.
For administrative purposes (Name of responsible stall el Client) has been assigned Io administer the assignment
and to provide tire (Name of Consultant) with all relevant hr for motion needed to ratty nut the assiimnirnl. I he services
will be required in (Name ofPtojecil for about
daw mouths, dunite the period liom
to
•>
3.
The (Name of Client) may find it necessary to powprue nr cancel the assignment and.or shorten or extend its
duration. However, every effort will be made to give 'ctr. as earl' as possible, notice of any changes. In (he event of
termination, the (Name of Consultant) shall be paid for the ’c-.'ces rendered for carrying out the assignment to the dale
of termination, and the (Name of Consultant) will provide the (Name of Client) with any reports or parts thereof, or atty
other information and documentation gathered under this Agreement prior to the date of termination.
4.
The services to be performed, the estimated time to be spent, and the reports to be submitted will be in
accordance with the attached Terms of l|efcren|;e.
5.
This Agreement, its meaning and interpretation and the relations between the parties shall be governed by the
Laws of Union of India.
6.
This Agreement will become effective upon ccnluination of this letter on behalf of (Name ol Consultant) and
will terminate on. or such other date as mutually agreed between the (Name of Client) and the
(Name of Consultant).
Pavments for the services will not exceed an total amount of Rs
The (Name of Client) will pav (Name of Consultant), within 30 days ol receipt ol invoice as follows:
Amount
copy
of this
letter
and
submission of inception report
Slums Report
report.
acceptable
to
(Name
of
Borrower)
The above remuneration includes all the costs related to carrying out the services, including overhead and any
taxes imposed on the (Name of Consultant).
1
RAPID HOUSEHOLD SURVEY
REPRODUCTIVE AND CHILD HEALTH (RCH)
Confidential
for research
purpose only
WOMAN’S QUESTIONNAIRE
1998-99
NAME OF THE INVESTIGATOR:
SIGNATURE OF THE INVESTIGATOR
SECTION-I
SECTION-II
ANTE-NATAL, NATAL AND POST-NATAL CARE
-----
Q.NO
Q20I
-- ------------- (l()lt 'V'WIKNIIAVINCLASI- pregnancy
IN THE PANT .1 YEARS. I.r. SINCE JANUARY. 1995 )
----------------- QUESTIONS AND FILTERS_______
<?id Y°\'. become pregnant
last (excluding current
pregnancy, if any)?
SKIP TO
CODING CATEGORIES
NO PREGNANCY.............................. 00
9-1 OR BEFORE..............................01
95...................................................... 02
96...................................................... 03
97...................................................... 0-1
98...................................................... 05
-J
►SECTION
III
Q2O2
..what was the outcome of your
last pregnancy?
LIVE BIRTH..................................... 1
•“ STILL BIRTH.................................. 2
INDUCED ABORTION...................... 3
SPONTANEOUS ABORTION............ 4
Q203
If induced abortion, who
performed the abortion?
GOVT. DOCTOR................................ 1
PRIVATE DOCTOR........................... 2
'PRIVATE NURSE.............................. 3
GOVT. NURSE/LHV/ANM............... 4
TRAINED DAI.................................. 5
UNTRAINED DAI..............................6
RELATIVES/FRI ENDS....................7
SELF INDUCED................................ 8
OTH ER_________________________ 9
(SPECIFY)
Q204
At what month of pregnancy did
it happen?
MONTH
Q2O5
Did you have any health problem
'immediately after abortion
(within 6 weeks)?
YES....................................... .............. 1
NO........................................................ 2
02(16 - -If yes, what was the health
problem?
(CIRCLE ALL RESPONSES MENTIONED)
1. EXCESSIVE BLEEDING.......... A
2. HIGH FEVER..............................B
3. FOUL SMELLING
DISCHARGE................................ C
’4. WEAKNESS................................... D
5. BACKACHE, BODYACHE ...... E
6. PAIN IN LOWER
ABDOMEN..................................... F
7. OTHER______________________ G
(SPECIFY)
Q207 , , Did you consult doctor/health
worker for your health problem?
YES...................................................... 1
NO....................................... 2 — - -’v--SECTION
III
Q208
If yes’,
whom did you consult?
-► Q209
-► Q209
-► Q204
|------------ 1
GOVT. HOSPITAL DOCTOR.......... 1
PHC/CHC DOCTOR........................... 2
PRIVATE DOCTOR........................... 3
PRIVATE NURSE............................. 4
GOVT. NURSE/LHV/ANM...............5
DAI...................................................... 6
OTHER_________________________ 7
(SPECIFY)
-► SECTION
III
►SECTION
III
Q.NO
Q2O9 .
Q2I0
Q211
Q2I2
■IQgjjATION FOR WOMEN WITH LIVE BIRTH AND STILL BIRTH
------------ 2yESTIONS^A2ID_FILTERS
*ANMnevcr vTe* Pre9”ant, did
is if you at horne?
weremvo,y "?nChs P^gnant
ere you when ANN first__visited you?
cirsc
How.many times did she
visit you during pregnancy?
Did she advice you for
check-up?
Q2I3 _ J'lhen you were pregnant, did
you go for antenatal checkup?
Q2I4
If yes,
where did you go?
SKIP TO
CODING CATEGORIES
YES.................................................................. 1
. NO..................................................................... 2
NOT APPLICABLE........................................ 1
MONTHS
NO. OF VISITS
|-- 1-- 1
YES...................................................................1
NO..................................................................... 2
DO NOT REMEMBER..................................... 9
YES................................................................... 1
NO..................................................................... 2
How many months pregnant
were you when you first had
antenatal check-up?
MONTHS
|------- 1
Q2I6
■How many times did you go
for ante-natal check-up?
NUMBER OF TIMES
|
Q2I7
(IF 'NO' FOR 213 )
Why did you not go for
’ante-natal check-up?
(CIRCLE ALL RESPONSES
MENTIONED)
-►
Q218
-►
-►
Q224
Q224
1.
LACK OF KNOWLEDGE
OF SERVICES........................................ A
DID NOT FEEL NECESSARY............ B
NOT CUSTOMARY................................... C
FINANCIAL COST................................ D
DISTANTLY LOCATED......................... E
POOR QUALITY SERVICE................. F
HOME VISIT BY HEALTH
STAFF. .................................................... G_.
8. NO TIME TO GO................................... II
9. NOT PERMITTED TO GO.................... I
10. OTHER__ ■_______________________ J
(SPECIFY)
,.2.
3.
4.
5.
S.
7.
YES................................................................... 1
NO..................................................................... 2
DO NOT REMEMBER..................................... 9
Q2IX
Was your weight taken when
’5'ou were pregnant?
Q2I9
YES................................................................... 1
Was your blood pressure
NO..................................................................... 2
■measured when you were
pregnant?
_______ _____ __________ ‘ DO NOT REMEMBER..................................... 9
Q22I
-► Q217
GOVERNMENT HOSPITAL........................... 1
FHC/CHC......................................................... 2
GOVERNMENT DISPENSARY...................... 3
K SUB-CENTRE................................................. 4 •
PRIVATE DOCTOP/PRIV. HOSPITAL..5
OTHER
____ 6
(SPECIFY)
Q2I5
Q220
-- Q213
-> Q2I3
YES................................................................... 1
Were you given Iron and
.NO..................................................................... 2
Folic Acid tablets during
pregnancy?_______
_ ____________ DO NOT REMEMBER..................................... 9
MONTH
|j
If yes, in which month of
pregnancy you started
taking Iron-Folic Acid
L’O NOT REMEMBER..................................... 9 |
tablets?_______________________L
Q.NO
9222
-------------- AND FILTERS
Xc^enydX‘ablets did y™
During pregnancy?
9223
SKIP TO
CODING CATEGORIES
NUMBER
|
|
|
~j
“DO NOT
REMEMBER..................................... 999
How many iFA tablets in a d
you were taking?
HUMBER
Were you given an injection in
the arm during pregnancy to
prevent Tetanus?____________
YES...................................................... 1
NO......................................................... 2
DO NOT REMEMBER.........................9
If yes, how many times did you
take Tetanus injection?
NUMBER
DO NOT REMEMBER.........................9
9224
Q225
-► Q226
-f
Q226
DO NOT REMEMBER......................... 9
9226
At what month of pregnancy did
you have abdominal check-up for
the first time?
MONTHS
9227
How many times did you have
abdominal check-up?
NO. OF TIMES
Q228
Can you tell me about health
problems that some women suffer
from, during pregnancy?
(CIRCLE ALL RESPONSES MENTIONED)
1. SWELLING OF HANDS
AND FEET.................................. A
PALENESS.................................. B
3. WEAKNESS OR
TIREDNESS................................
-.4. DIZZINESS................................ D
5. VISUAL DISTURBANCES ....E
6. BLEEDING.................................. F
7. CONVULSIONS........................... F
8. WEAK OR NO MOVEMENT
OF FOETUS................................ H
9 . ABNORMAL
PRESENTATION .........................I
10 . OTHER_____________________ J
(SPECIFY)
11 . DO NOT KNOW........................... K
During your pregnancy did you
suffer from any of these health
problems?
IT SWELLING OF HANDS
--------AND FEET.................................. A
2. PALENESS.................................. B
3. WEAKNESS OR
TIREDNESS................................ C
-4. DIZZINESS................................ D
5. VISUAL DISTURBANCES ....E
6. BLEEDING.................................. F
7. CONVULSIONS........................... F
8. WEAK OR NO MOVEMENT
OF FOETUS................................ H
9. ABNORMAL
PRESENTATION.........................I
10.OTHER
________ J
(SPECIFY)
11 .NONE............................................ K
-► Q232
If any, did you consult doctor
or any other health worker for
your health problems?--------------------------
YES................................................
1
NO........................................................ 2
->■ Q2 3 2
|----- j
NO CHECK-UP.................................. o'
-► Q228
DO NOT REMEMBER.........................9
9229
9230
2.
Q.NO
---------- - —S^ggllONS AND FILTERS________
CODING CATEGORIES
Q23I
(CIRCLE m'?'" did yOU Consult?
CLE ALL RESPONSES MENTIONED)
1 .
2.
3.
4.
S.
6.
7.
8.
9.
Q232
Were you advised to go to
hospital for delivery?
YES....................................................... 1
NO......................................................... 2
Q233
Where did the delivery take
place?
GOVERNMENT HOSPITAL............... 1
PHC/CHC............................................. 2
'PRIVATE HOSPITAL...................... 3
HOME.................................................... 4
Q234
If home delivery,
the delivery?
DOCTOR............................................... 1
NURSE/ANM........................................ 2
TRAINED DAI................................... 3
UNTRAINED DAI.............................. 4
RELATIVES/FRIENDS.................... 5
NONE.................................................... 6
Q235
Was Disposable Delivery Kit,
used during delivery?
who conducted
YES....................................................... 1
"'NO......................................................... 2
Q237
During delivery, did you
experience any of the following
problems?
YES NO
1 . PREMATURE LABOUR.......... 1
2
2.OBSTRUCTED LABOUR .... 1
2
3.PROLONGED LABOUR
- (MORE THAN 12 HOURS)..1
2
4.BREECH PRESENTATION..!
2
5 . OTH E R_________________ _ 1
2
(SPECIFY)
Q238
During the first week after
delivery did you experience any
of the following health
problems?
Q239
If any, did you consult
doctor/health worker for your
he□ 1Ch problems?_____
Q240
Q24I
whom did you consult?
Q236
YES...................................................... 1
NO......................................................... 2
DO NOT KNOW.............................. •. . 9
Q236 •> ^Was the delivery normal?
If yes,
SKI!’ TO
DOCTOR,GOVT.HOSPITAL ... A
DOCTOR IN PHC/CHC............ B
PRIVATE DOCTOR.................... C
PRIVATE NURSE...................... D
ANM/GOVT . NURSE................. E
TRADTNL. PRACTITIONER..F
DAI............................................... G
GOVT. DISPENSARY............... H
OTHER_________________ I
(SPECIFY)
YES NO
1 . HIGH FEVER...................... 1
2
2. LOWER ABDOMINAL
PAIN......................................1
2
3. FOUL SMELLING
''VAG'INAL DISCHARGE. . . 1 —2~
4. EXCESSIVE BLEEDING..1
2
5. DIZZINESS, SEVERE
HEADACHE........................... 1
2
6. OTHER__________________ 1
2
(SPECIFY)
If NO to
all
-► Q241
YES....................................................... 1
..
MO......................................................... 2
-► Q241___
DOCTOR IN GOVT.HOSPITAL...1
PHC/CHC DOCTOR....................
2
PRIVATE DOCTOR........................... 3
PRIVATE NURSE.............................. 4
ANM/NURSE........................................ 5
TRADITIONAL PRACTITIONER. . 6
OTHER______________________ ____ ?
______________ (SPECIFY)__________
Did ANM visit you within 2 weeks
YES.......................................................
of delivery?
NOT APPLICABLE............................
Q243
■
m
Q.NO
QZ42
™
Q243
J
QUESTIONS AND FILTERS
How many times did she visit you
within six weeks of delivery?
_______ CODING CATEGORIES------------
''
number
SKir TO
|
not visited....... .
Q244
II
II
—
(CHECK Q202 , ASK Q243 AND Q244
ONLY IF IT IS LIVE BIRTHS)
Was the baby weighed immediately
What was the weight o£ the baby?
IMMEDIATELY........................ ' 2
WITHIN 2 DAYS..........
.... 3
°“"s
-► SECTION
III
COZD
DO NOT REMEMBER..........
= ======
-------------------
SECTION-111
•../
'.J?
/
'
■---' ■ ■ ■■■«■—
(IMMUNISATION of CHTinnr
IMMUNIZATION AND CHILD CARE
JANUARY, 1999)
J-LDREN FOR LAST AND LAST BUT ONE LIVING
Q.NO
QUESTIONS AND FILTERS
J4ame of the
Q302
Sex of the child
BOTH
CODING CATEGORIES
LAST HUT ONE
CHILD .
LAST CHILD
Q30I
CHILD;
BORN AFTER
SKIP
TO
(index) child
BOY................................ 1
GIRL..............................2
Q303 ! Month and year of birth
MONTH
[■ - | — |
BOY........................ 1
GIRL...................... 2
- 1— |
MONTH
j
DO NOT KNOW.......... 9 9
DO NOT KNOW..99
YEAR..
YEAR 95,96,97,98
95,96,97,98
ASK Q 3 04 TO 310 FOR THE YOUNGEST CHILD
Q304
When you were pregnant with...
(name), did any one advise you
'on breastfeeding?
YES..........................................................................
1
NO............................................................................... 2
Q305
If yes, who advised you on
breastfeeding?
(CIRCLE ALL RESPONSES
MENTIONED)
1.
2.
3.
4.
5.
6.
7.
8.
Q306
When did you start
breastfeeding your child?
WITHIN 2 HOURS OF BIRTH........................... 1
AFTER 2 HOURS BUT ON THE SAME DAY..2
WITHIN 3 DAYS.................................................... 3
AFTER 3 DAYS...................................................... 4
NEVER....................................................................... 5
Q3O7^ Are you currently breast~feeding the child?
YES............................................................................ 1
NO.............................................................................. 2
Q3O8
0309
Q3I0
How many months did you
breastfeed the child
exclusively?
-►Q306
DOCTOR IN GOVT. HOSPITAL................. A
PHC/CHC DOCTOR.......................................... B
PRIVATE DOCTOR.......................................... C
NURSE/ANM...................................................... D
TRADITIONAL PRACTICE........................... E
DAI..................................................................... F
RELATIVES/FRI ENDS...................................G
OTHER_________ ______________________ II
(SPECIFY)
MONTHS
j
-►Q309
|
|
CONTINUING.................................................... ?.88
At what age of the child, did
you start giving semi-sol id
food?
MONTHS
At what age of the child, did
you start giving solid food?
MONTHS
|- 1-
1
NOT YET STARTED............................................ 9 9
NOT YET STARTED............................................ 99
TTyou know what to do when
Q3U
rhild gets Diarrhoea.
"(CIRCLE ALL RESPONSES
MENTIONED)
told
“I “S 5° ,i>h
>< • worker
th,ld h
“ you
Q3I2
1 . GIVE ORS.........................................................A
2. CONTINUE NORMAL FOOD........................... B
3. CONTINUE BREASTFEEDING...................... C
4. GIVE PLENTY OF FLUIDS.........................D
5. OTHER_________________________________ E
_____ ______________ (SPECIFY) '_______________
1 YES............................................................................ 1
NO.............................................................................. 2
Diarrhoea?.------ --------------------------------------
—
y/
--------
;U.w
QUESTIONS AND FILTERS
CODING CATEGORIES
SKIP
TO
0313
YES.............................................................................1
NO............................................................................... 2
Q3I4
1 did yOU do?
ll responses
MENTIONED)
(CIRCLP
Q3I5
Do you know the danger signs of
Pneumonia ?
Q3I6
If yes, what are they?
(CIRCLE ALL RESPONSES
MENTIONED)
Q3I7
Did any of your child born
since January, 1995 suffer from
cough, cold and difficulty in
breathing in the past two
months?
1 ,
2.
. 3 .
~4.
5.
6.
-►Q315
DID NOTHING..................................................A
HOME REMEDY................................................. B
ORS GIVEN...................................................... C
TREATMENT IN GOVT.HOSPITAL............ D
TREATMENT OF PRIVATE DOCTOR.......... E
OTHER________________
F
(SPECIFY)
YES.............................................................................1
NO............................................................................... 2
-►Q317
1. DIFFICULT BREATHING.............................. A
2. CHEST INDRAWING........................................ B
3. NOT ABLE TO DRINK OR
TAKE A FEED..................................................C
4. EXCESSIVELY DROWSY AND
DIFFICULT TO KEEP AWAKE.................... D
5. PAIN IN CHEST AND
PRODUCTIVE COUGH..................................... E
6. CONDITION GETS WORSE
THAN BEFORE.................................................. F
7. WHEEZING/WHISTLING................................ G
8. RAPID BREATHING........................................H
YES.................................................... '.......................1
NO............................................................................... 2
Q3IX
If yes, what did you do?
(CIRCLE ALL RESPONSES
MENTIONED)
1.
2.
3.
4.
5.
Q3I9
Did ANM advise you about
treatment of Pneumonia?
YES............................................................................... 1
NO.................................................................................. 2
-►Q320
DID NOTHING................................................. A
HOME REMEDY................................................. B
WENT TO GOVERNMENT FACILITY.......... C
WENT TO PRIVATE FACILITY................. D
OTHER_________________________________ E
(SPECIFY)-
FOR BOTH LIVING CHILDREN
LASrCIHLD
last out
YES, SEEN....................
YES, NOT SEEN..........
NO CARD.........................
1
2
3
1
2
3
YES...................................
Was polio vaccine(OPV '0')
NO.....................................
given to the child? (drop in
vD0 NOT KNOW...............
'•the mouth immediately after
birth)
_____ _ _____________________
2
9
2
9
-
Q320
Q321
Q322
Do you have a card where
(Name's) vaccination are
written down? (IF YES. MAY ISEE IT, PLEASE?)_________________
Was BCG vaccination against
Tuberculosis given to Che
>rrhat?is an injection in the
left shoulder that caused a
scar) .___________ ______ _______________
ONE
CHIU)
YES...................................
1
1
NO.....................................
2
2
-►Q324
DO NOT KNOW...............
9
9
-►Q324
W.NO
SKIP
TO
CODING CATEGORIES
QUESTIONS AND FILTERS
I am <11111.
cim.li
Q323
At what age BCG vaccine was
given?
AGE IN MONTHS
At what ages these injections
were given?
FIRST INJECTION
IN MONTHS
□
CHILD IS TOO
YOUNG..............................
NOT AWARE OF ALL
3 DOSES....................
MOTHER TOO BUSY...
CHILD WAS ILL..........
FAMILY PROBLEM ....
VACCINE NOT
x AVAILABLE...............
NO SPECIFIC REASON
OTH E R___________ ____
(SPECIFY)
Q32«
Did ANM/doctor advise you to
get L/Jrl
__ _
____ _____
YES
NO
Q329
Was Polio vaccine (i.e., drops
in the mouth) given to the
YES
NO
DO NOT KNOW
child?_______________ _____ __________
Q330
If yes,
how many Polio doses
UJ |
O
|
“
DO NOT REMEMBER..
If all required injection are
not given, ask why the
remaining were not 9iven?
(RECORD ONE IMPORTANT REASON)
99
00
V3 |
DO NOT REMEMBER..
THIRD INJECTION
NOT GIVEN.................
IN MONTHS
99
00
U °
. DO NOT REMEMBER..
SECOND INJECTION
NOT GIVEN.................
IN MONTHS
Q327
9_____
-►Q328
->Q328
J
NUMBER
2
9
“U
How many DPT injections were
given?
1
2
V) 1
Q326
YES
Was a vaccination against
Diphtheria, Whooping Cough and
NO
"Tetanus given to the child as
s DO NOT KNOW
an injection (DPT)?
l O
Q325
9
99
DO NOT REMEMBER
Q324
99
1
1
2
3
4
5
2
3
4
5
6
~’
6
8
8
1
1
2
9
2
1
2
9
NUMBER
were given?
DO HOT REMEMBER...
9
9
-»Q333
-►Q333
QUESTIONS and FILTERS
CODING CATEGORIES
SKIP
TO
________
Q323
At what age BCG vaccine was
given?
AGE IN MONTHS
[
|
99
DO NOT REMEMBER
Q324
S19
Was a vaccination against
YES
Diphtheria, Whooping Cough and
NO
Tetanus given to the child as
DO NOT KNOW
an injection (DPT)?
s
2
9
2
Q325
How many DPT injections were
given?
NUMBER
□
□
Q326
At what ages these injections
were given?
FIRST INJECTION
IN MONTHS
.
DO NOT REMEMBER..
SECOND INJECTION
NOT GIVEN.................
IN MONTHS
DO NOT REMEMBER..
THIRD INJECTION
NOT GIVEN.................
IN MONTHS
DO NOT REMEMBER..
Q327
Q328
Q329
Q330
If all required injection are
not given, ask why the
remaining were not given?
(RECORD ONE IMPORTANT REASON)
CHILD IS TOO
YOUNG..............................
NOT AWARE OF ALL
3 DOSES....................
MOTHER TOO BUSY...
CHILD WAS ILL..........
FAMILY PROBLEM....
VACCTNE NOT
<
AVAILABLE...............
NO SPECIFIC REASON
OTH E R________________
(SPECIFY)
99
99
00
00
99
99
00
00
99
99
1
■
5
6
8
8
Did ANM/doctor advise you to
qet DPT doses of vaccine?
Was Polio vaccine (i.e., drops
in the mouth) given to the
child?______ ________ ________________
YES
NO
DO NOT KNOW
1
2
9
If yes, how many Polio doses
were given?
NUMBER
------- -----------------------------
~
6
1
DO NOT REMEMBER...
1
2
3
4
5
2
3
YES
NO________ _____________
-►Q328
->-<2328
2
1
2
9
[
[
9
|
-►Q333
->-Q333
|
9
QUESTIONS AND FILTERS
Q33I
At what age Polio doses were
given?
FIRST DOSE
IN MONTHS
DO NOT REMEMBER..
SECOND DOSE
NOT GIVEN.................
IN MONTHS
Q332
Q333
Q334
Q335
If all required doses are not
given, ask why the remaining
doses were not given?
(RECORD ONE IMPORTANT REASON)
Did ANM/doctor advise you to
.get the
doses of Polio
vaccine?
_______________________
At what age injection for
Measles was given?
99
00
99
99
00
00
m
DO NOT REMEMBER..
99
CHILD IS TOO
YOUNG..............................
NOT AWARE OF ALL
3 DOSES....................
MOTHER TOO BUSY...
CHILD WAS ILL..........
^FAMILY PROBLEM....
VACCINE NOT
AVAILABLE...............
NO SPECIFIC REASON
OTHER________________
(SPECIFY)
99
1
3
1
J
5
3
4
5
8
8
YES
1
1
NO
2
2
01
02
03
04
05
06
07
08
09
10
01
02
03
04
05
---- ------ 06
07
08
09
10
11
12
13
12
13
15
16
15
16
YES...................................
NO.....................................
1
1
2
2
-►Q337
9
9
-►Q337
□□
Pl 1
99
99
’
DO NOT KNOW.......
Q336
99
00
DO NOT REMEMBER..
THIRD DOSE
NOT GIVEN..................
IN MONTHS
1. CHILD TOO YOUNG FOR IMMUNIZATION
(IF NO FOR
2. UNAWARE OF NEED FOR IMMUNIZATION
Q321, Q322,
3. PLACE OF IMMUNIZATION UNKNOWN
Q324 AND
4. TIME OF IMMUNIZATION UNKNOWN
Q329)
5. FEAR OF SIDE EFFECTS
■Why (Name)
6. NO FAITH IN IMMUNIZATION
was not:
given any
x 7. PLACE OF IMMUNIZATION TOO FAR TO GO
'a. TIME OF IMMUNIZATION INCONVENIENT
vacci9. ANM ABSENT
nation?
10. VACCINE NOT AVAILABLE
(RECORD ONE
11. MOTHER TOO BUSY
important
12. FAMILY PROBLEM. INCLUDING ILLNESS
reason)
OF MOTHER
13
CHILD ILL NOT BROUGHT
14. CHILD ILL BROUGHT BUT NOT GIVEN
15. LONG WAITING TIME
15. OTHER___________________________________
________________ (SPEIL'IFY)
Was an injection against
Measles given?
SKIP
TO
CODING CATEGORIES
IN MONTHS....................
PO
REMEMBER . . .
-►Q33B
—T----- ■------- O.NO
QUESTIONS
and filters
CODING CATEGORIES
SKIP
TO
LAST Clllt.n
.____
Q337
Q338
Q339
Q34O
Q34I
why was the
Measles
injection
not given
to the
child?
(RECORD ONE
IMPORTANT
REASON)
Did
ANM/doctor
advise you
to give
Measles
vaccine to
your child?
(Ask this
question
only to
those
persons who
reported at
least one
inununi zation)
where from
the last
immu
nisation
was given?
Was a dose
of Vitamin
A liquid
^ever given
to (Name)
to protect
him/her
from night
h 1. indness ■
If yes, how
'many
Vitamin A
doses were
given?_______
QNIC
CHILD
1. CHILD TOO YOUNG FOR IMMUNIZATION
2. UNAWARE OF NEED FOR IMMUNIZATION
3. PLACE OF IMMUNIZATION UNKNOWN
4. TIME OF IMMUNIZATION UNKNOWN
5. FEAR OF SIDE EFFECTS
6. NO FAITH IN IMMUNIZATION
7. PLACE OF IMMUNIZATION TOO FAR TO GO
8. TIME OF IMMUNIZATION INCONVENIENT
9. ANN ABSENT
10. VACCINE NOT AVAILABLE
11. MOTHER TOO BUSY
12. FAMILY PROBLEM, INCLUDING ILLNESS
X
OF MOTHER
13. CHILD ILL NOT BROUGHT
14. CHILD ILL BROUGHT BUT NOT GIVEN
15. LONG WAITING TIME
16. OTHER___________________________________
(SPECIFY)
01
02
03
04
05
06
07
08
09
10
11
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
12
13
14
15
16
YES....................................................................................
1
1
NO......................................................................................
2
2
1. GOVT. HOSPITAL.................................................
1
1
2. PHC/CHC...................................................................
2
2
3. SUB-CENTRE...........................................................
3
3
4.
PRIVATE HOSPITAL.............................................
4
4
5.
PRIVATE DOCTOR.................................................
5
5
6. OTHER___________________________
(SPECIFY)
7 . DO NOT KNOW...................... ~. . . .’.......................
6
6
7 -------- • -
7
YES....................................................................................
DO NOT KNOW................................................................
IN NUMBER.....................................................................
DO NOT REMEMBER......................................................
|
1
1
2
2
-►Q342
9
9
-►Q342
|
9
7
U.NO
QUESTIONS
AND FILTERS
SKIP
TO
CODING CATEGORIES
LAST CHILD
Q342
Q343
Q344
Was I FA
tablets
given to
the (name)
child?
If yes, how
many I FA
tablets
were given?
Is the
child
attending
ICDS
centre?
YES...................................................................................
1
1
NO.....................................................................................
2
2
-►Q344
DO NOT KNOW................................................................
9
9
-►Q344
□
□
x
IN NUMBER....................................................................
9
9
DO NOT REMEMBER......................................................
YES...................................................................................
1
1
NO......................................................................................
2
2
NO ICDS CENTRE.........................................................
3
3
SECTION-IV
CONTRACEPTION
(FOR ALL ELIGIBLE WOMEN)
Q.NO
Q40I
QUESTIONS AND FILTERS
CODING CATEGORIES
Which of the Family Planning
methods are you aware of?
SKIP
TO
YES
NO
FEMALE STERILISATION......................
1
2
2. MALE STERILISATION...........................
1
2
3. COPP.ER-T/LOOP.......................................
1
2
PILL.............................................................
1
2
5. CONDOM/NIRODH.......................................
1
2
6. RHYTHM OR PERIODIC ABSTINENCE.
1
2
1.
4.
7. WITHDRAWAL............................................
1
2
8. OTHER
1
2
(SPECIFY)
Q402
Are you currently pregnant?
YES.......................................................................... 1
'NO............................................................................. 2
Q403
Are you/your husband currently
using any Family Planning method?
x.
YES.......................................................................... 1
NO............................................................................. 2
Q404
Which method you/your husband is
using?
FEMALE STERILISATION................................ 1
MALE STERILISATION..................................... 2
IUD/COPPER-T/LOOP....................................... 3
PILL........................................................................4
CONDOM/NIRODH................................................. 5
RHYTHM/PERIODIC ABSTINENCE................. 6
WITHDRAWAL......................................................... 7
OTHER__________________ _________________ B
(SPECIFY)
/
Q417
Q417
Q4O5
Who mainly motivated you to use
this method?
SELF........................................................................1
HUSBAND................................................................ 2
RELATIVES/FRIENDS....................................... 3
ANM/DOCTOR/HEALTH WORKER...................... 4
^MEDIA..................................................................... 5
OTHER .................................................................. 6
Q4O6
For how long have you been using
this method continuously?
OR
How long ago did you/your husband
undergo sterilization?
MONTHS
j
|- ------- 1
MORE THAN 8 YEARS.i................................ 96
DO NOT REMEMBER............ .. ...................
99
-
STERIIJXATION.askAND TH(,-SK WOiU,':N "’HO/ WHOSE HUSBAND HAD UNDERCONE
NEXT SECTION.*
-^416. 1()R THE USERS OE WITHDRAWAL/RH YTHM METHOD/ANY OTHER METHOD, GO TO
QUESTIONS AND filters
F
CODING CATEGORIES
Q407
husband
GOVERNMENT/MUNICIPAL HOSPITAL....01
PRIMARY HEALTH CENTRE........................... 02
FAMILY PLANNING CAMP..............................03
SUB-CENTRE...................................................... 04
PRIVATE HOSPITAL........................................05
GOVT. DOCTOR..................................................06
PRIVATE DOCTOR............................................. 07
GOVT. NURSE/ANM.......................................... 08
MOBILE CLINIC............................................... 09
CHEMIST.............................................................. 10
DO NOT KNOW.................................................... 11
OTHER________________ _________________ 12
(SPECIFY)
OR
Where did you go for Copper-T
insert ion?
OR
From where did you obtain the
pills usually?
OR
From where did you get
condom/nirodh usually?
Q408
(ONLY FOR COPPER-T USERS)
Who inserted Copper-T?
Q409
(ONLY FOR PILL & CONDOM USER)
PRIVATE DOCTOR............................................... 1
GOVERNMENT DOCTOR................................... . .2
ANM/NURSE........................................................... 3
—PRIVATE NURSE................................................. 4
DO NOT REMEMBER.............................................5
Q4II
When you started using this
method, did doctor/nurse/ANM
inform you about possible health
problems that may occur?
YES.......................................................................... 1
NO............................................................................. 2
x
After you adopted this method,
did any health worker/ANM visit
you for enquiring about your/your
husband's health?____________________
~~DO NOT REMEMBER............................................ 9
YES.......................................................................... 1
NO............................................................................ 2
Q4I2
Have you/your husband had any
health problem with the use of
Chis method?_______;___________ _________
YES.......................................................................... 1
NO............................................................................. 2
Q4I3
If yes, what health problem did
vou/vour husband have?
’(CIRCLE ALL RESPONSES MENTIONED)
1. WEAKNESS/INABILITY TO WORK.......... A
2. BODYACHE/BACKACHE................................ B
3 . CRAMPS........................................................... C
4 . WEIGHT GAIN............................................... D
5. DIZZINESS.................................................... E
6. NAUSEA/VOMITING..................................... F
7. BREAST TENDERNESS................................ G
8. IRREGULAR PERIODS................................ H
9. EXCESSIVE BLEEDING.............................. I
10 .SPOTTING.............................. ’....................... J
11. WHITE DISCHARGE..................................... K
12 . OTHER__________________ _____________ L
(SPECIFY)
’^^P®^7^eafth worker/
YES.......................................................................... 1
NO............................................................................. 2
Q4I4
r-
NO PROBLEM......................................................... 1
NOT REGULARLY AVAILABLE WITH PHC..2
NOT REGULARLY AVAILABLE WITH ANM..3
NOT REGULARLY AVAILABLE WITH
SHOPS/CHEMIST........................................4
OTH E R_______________ ____________________ 5
(SPECIFY)
Have you ever found difficulty in
getting pills/condoms?
Q4I0
SKIP
TO
Q416;
Q416?
questions and filters
------- ■--------- --------- --------------
1)423
Q424
Q425
What was the main reason for
discontinuing use of the method?
(CHECK Q402 , IF WOMAN IS PREGNANT
GO TO Q425)
Are you currently menstruating?
Has ANM/health worker ever
advised you to adopt any family
planning method?
CODING CATEGORIES
SKIP
WANTED CHILD................................................. 01
METHOD FAILED/BECAME PREGNANT.... 02
SUPPLY NOT AVAILABLE.............................. 03
DIFFICULT TO GET METHOD...................... 04
WEAKNESS /INABILITY TO WORK............ 05
BODYACHE/BACKACHE..................................... 06
CRAMPS................................................................ 07
WEIGHT GAIN.................................................... 08
DIZZINESS......................................................... 09
NAUSEA/VOMITING.......................................... 10
BREAST TENDERNESS..................................... 11
IRREGULAR PERIODS..................................... 12
EXCESSIVE BLEEDING...................................13
SPOTTING........................................................... 14
WHITE DISCHARGE ........................................15
LACK OF PLEASURE........................................16
METHOD WAS INCONVENIENT...................... 17
OTHER__________________________________ 18
(SPECIFY)
YES.......................................................................... 1
IM AMENORRHOEA............................................... 2
NEVER MENSTRUATED........................................3
IN MENCPAUSE/HYSTERECTOMY.................... 4
-
YES.......................................................................... 1
NO............................................................................. 2
Q427
Q426
If yes, what method did she/he
advise you to use?
FEMALE STERILIZATION................................ 1
MALE STERILIZATION..................................... 2
IUD/COPPER-T/LOOP........................................3
PILLS..................................................................... 4
CONDOM/NIRODH..................................................5
RHYTHM/PERIODIC ABSTINENCE..................6
WITHDRAWAL......................................................... 7
OF H E R___________________________
0
(SPECIFY)
Q427
Do you intend to use any method
of Family Planning at any time in~
the future?_______ _____________________
YES.......................................................................... 1
NO.......................................... .............. ................... 2
Q428
If yes, which method you would
FEMALE STERILISATION................................ 1
MALE STERILISATION..................................... 2
IUD/COPPER-T/LOOP....................................... 3
PILL........................................................................ 4
CONDOM/NIRODH................................................. 5
RHYTHM/PER IODIC ABSTINENCE................. 6
WITHDRAWAL......................................................... 7
OTHER___________________________________ 8
(SPECIFY)
prefer to use?
Q429
Q43O
Q42i
(CHECK Q402, IF WOMAN IS PREGNANT
GO TO NEXT SECTION)
Would you like to have another
WANT MORE CHILDREN..................................... 1
WANT NO MORE CHILD..................................... 2
NOT DECIDED.......................................................3
UP TO GOD........................................................... 4
How long would you 1 ike to wait
to have another child.
SOON/NOW/LESS THAN 12 MONTHS.......... 96
MORE THAN 12 MONTHS
NOT DECIDED.................................................... 98
Q43
SEC'
V
O.NO
Q43I
QUESTIONS AND FILTERS
CODING CATEGORIES
What is the main reason for
currently not using any method of
family planning?
LACK OF KNOWLEDGE ABOUT FAMILY
PLANNING METHODS................................ 01
AGAINST THE RELIGION.............................. 02
OPPOSED TO FAMILY PLANNING............... 03
HUSBAND OPPOSED.......................................... 04
OTHER FAMILY MEMBERS OPPOSED... .05
NOT LIKE EXISTING METHOD.................... 06
AFRAID OF STERILIZATION...................... 07
CAN NOT WORK AFTER
STERILIZATION....................................... 0B
WORRY ABOUT SIDE EFFECTS.................... 09
COSTS TOO MUCH.............................................10
HEALTH DOES NOT PERMIT......................... 11
HARD/INCONVENIENT TO GET METHOD..12
INCONVENIENT TO USE METHOD............... 13
DIFFICULT TO PREGNANT........................... 14
. OT H E R________ _ _____ __________________ 15
x
(SPECIFY)
SKI
__ TO
^^££inX.ATTAINMENT SURVEY OF HEALTH CENTRE/
!•
Name and Address
MATERNITY HOME
.
2.
How old are you
. j
3.
How many children do you have
: |
4.
Age of last child
;
5.
Why did you visit the hospital
:
1
..................................... .................
II. ANTE NATAL CHECK UP:-
1.
What time did you come to Hospital
2.
What time you received treatment
3.
Are you satisfied with treatment
Q5O8
Was doctor/ANM available when
"vou went there for treatment?
l
YES....................................................................... 1
''NO.......................................................................... 2
YES....................................................................... 1
Did you have to wait long for
Q509
'service? _______ ___ ________________ -NO. .......................................... „.......... ............. 2
Q5I0
Q3II
Q512
Was there privacy where you
were examined?
YES........................................................................1
NO.......................................................................... 2
..CAN NOT SAY.................................................... 3
YES........................................................................ 1
Was the staff at the centre
^NO.......................................................................... 2
f r i gnd ly ?______________ —-------------YES........................................................................ 1
Were medicines available at
NO.............................................•............................ 2
the centre?
—.CAN NOT SAY.................................................... 3
Q513
Did the health staff explain
to you how to take medicines?
Q5I4
old you rind
the centre elective
YES........................................................................ 1
NO.......................................................................... 2
-CAN NOT SAY.................................................... 3
YES........................................................................1
. NO.......................................................................... 2
__________ ^CAN NOT SAY.................... ;............................. 3
Q.NO
QUESTIONS AND FILTERS
Q5I5 _ Xiid you have to pay to the
doctor or staff any money to
get treatment?
Q5I7
(IF SHE DID NOT VISIT CENTRE
DURING LAST THREE MONTHS)
What is the main reason for
not visiting the centre?
NO NEED...........................................................01
NOT CONVENIENTLY LOCATED................. 02
xTIME IS NOT SUITED................................ 03
POOR QUALITY OF SERVICE....................04
HEAVY RUSH..........................................1 . . . 05
NON-AVAILABILITY OF DOCTORS/
HEALTH WORKERS.................................. 06
RARE AVAILABILITY OF
DOCTORS/HEALTH WORKERS................. 07
DOCTORS/HEALTH WORKERS DO NOT
EXAMINE PROPERLY........................... 08
MEDICINE NOT/RARELY GIVEN............... 09
MEDICINES ARE OF BAD QUALITY.... 10
DOCTORS/PARA MEDICAL STAFF
DOES NOT BEHAVE PROPERLY.......... 11
SERVICES ARE CHARGED........................... 12
PREFER PRIVATE DOCTORS...................... 13
OTHER______________ _ ________________ 8 8
(SPECIFY)
Are you satisfied with treatment
4.
Comments
5.
Were you informed regarding
complications
yill, GENERAL INFORMATION
1.
"1.
“y^TtheDoctor/ANM available
^i^F^dly
be attended
3.
t0 take
4.
medicine
__________
Doc“r or
staff to get treatment.
---- —'
NO......................................................................... 2
YES....................................................................... 1
"NO......................................................................... 2
What time did you come to Hospital
SKIP
TO
YES....................................................................... 1
Will you recommend this centre
to your friends/relatives?
T~ What time you received treatment
3.
-
Q516
VII. FOR IUD/OP/CC:-
1.
CODING CATEGORIES
Section
VI
SECTION- VI
_______ AWARENESS ABOUT
Q.NO
Q60I
Q602
Q6O3
RTI, STI AND HIV (AIDS)
---------------- -- QUESTIONS AND FILTERS___________
th- PaSt Chree monChs did you
have burning sensation, pain or
difficulty while urinating?________
CODING CATEGORIES
YES.............................................................1
NO............................................................... 2
During the past three months did you
experience pain in the lower abdomen
or vagina during intercourse?___________
NO............................................................... 2
During the past three months, did you
have any problem of vaginal
discharge?
NO............................................................... 2
YES............................................................. 1
YES............................................................. 1
IF 'NO' TO Q601, Q602 AND Q603 GO TO Q609
Q6O4
(IF 'YES' TO Q603, ASK Q604 TO Q607)
What was the nature of discharge?
1. MUCCID NON FOUL SMELLING,
SMALL IN AMOUNT, PRESENT
ONLY ON CERTAIN DAYS
(NORMAL)......................................... 1
2. THICK CURDY WHITE.................... 2
3. THIN DIRTY WHITE FOUL
SMELLING..........................................3
4. THICK GREY WHITE FOUL
SMELLING......................................... 4
Q605
With vaginal discharge did you get
itching or ulcers on both the sides
in the vaginal area?
ITCHING................................................... 1
ULCERS...................................................... ?
BOTH...........................................................3
NONE...........................................................4
Q6O6
With the discharge, did you have
severe lower abdominal pain?
Q607
Did you have fever with the
discharge?
Q6O8
(IF 'YES' TO ANY OF 601-603)
Have you consulted anyone for
treatment?
IF YES, who?
KIRcZe^LL^ESPONSES MENTIONED)
YES............................................................. 1
NO............................................................... 2
NO............................................................... 2__
1. GOVERNMENT DOCTOR................... A
2. PRIVATE DOCTOR...........................B
3. GOVERNMENT NURSE/ANM/LHV-. . C
-4. MEDICAL SHOP/PHARMACIST/
PRIVATE NURSE............................. D
5. TRADITIONAL PRACTITIONER..E
6. DAI..................................................... F
7. RELATIVE/FRIENDS...................... G
8. SELF-TREATMENT........................... H
9. OTHER____________ ____________ -1
(SPECIFY)
10, NO TREATMENT SOUGHT............ J
Have you heard of an illness called
Q609
—»--
YES............................................................. 1
RTI/STI/HIV (AIDS)?
21
RTI
STI
YES....................1
’1
NO...................... 2
2
HIV
(AIDS)
1
______ 2_
I
If all
NO
STOP
■
Q. NO
CODING CATEGORIES
QfilO
Q61I
Q6I2
Q6I3
From which sources of information or
RTT/c??/'laVe you heard about
RTI/STI/HIV (AIDS)?
(CIRCLE ALL RESPONSES MENTIONED)
How is RTI/
STI/HIV (AIDS) transmitted?
(CIRCLE ALL RESPONSES MENTIONED)
1. HOMOSEXUAL
INTERCOURSE. ..... .A
2. HETEROSEXUAL
INTERCOURSE............ B
3. NEEDLES/BLADES/
SKIN PUNCTURE....4. MOTHER TO CHILD..5. TRANSFUSION OF
INFECTED BLOOD...6. LACK OF PERSONAL
HYGIENE............... i..C
7 . OTHER______________ D
(SPECIFY)
8 . DO NOT KNOW.............E
Do you think that one can get HIV
(AIDS) from someone who has HIV
(AIDS) by:
HOW do you think one can avoid HIV
-^T^LT^I/STI/HIV (AIDS)
curable disease?
-
-
RADIO
TV
NEWS PAPERS
MAGAZINES
SLOGANS/
PAMPHLET/POSTERS
E
E
6. DOCTOR
F
F
7. HEALTH WORKERS
G
G
8. SCHOOL TEACHERS H
H
9. COMMUNITY
MEETINGS
II
10.FRIENDS/
RELATIVES
J
J
11.HUSBAND
K
K
12. OTHER_____________ L
L
(SPECIFY)
1.
2 .
3.
4.
5.
E
F
G
H
I
J
K
L
RTI STI HIV
(AIDS)
(C^RcLe ALL RESPONSES MENTIONED)
Q614
SKIP TC
RTI STI HIV
(AIDS)
AAA
BBS
C
C
C
D
D
D
rs a
A
A
B
B
C
C
D
D
E
E
F
F
G
YES
SHAKING HANDS................. 1
HUGGING................................ 1
KISSING................................ 1
SHARING CLOTHES.............1
SHARING EATING
UTENSILS.............................. 1
6. STEPPING ON URINE/
STOOL..................................... 1
7. MOSQUITO,FLEA OR
BEDBUG BITES.................. 1
NO
2
2
2
2
1.
2.
3.
4.
5.
2
2
2
1. USING CONDOMS DURING
EACH SEXUAL INTERCOURSE ... A
2. SAFE SEX.......................................... B
3. CHECKING BLOOD PRIOR
TO TRANSFUSION........................... C
4. STERILIZING NEEDLES AND
SYRINGES FOR INJECTION ....D
5. AVOIDING PREGNANCY WHEN
HAVING -HIV (AIDS) ................. E
6 . OTHER________________ _ _______ F
(SPECIFY)
7 , DO NOT KNOW................................... G
RTI STI HIV (AIDS)
YES......................... 1
1
NO............................ 2
2
2
DO NOT KNOW... 9
9
9
1
pi?»n^.RAPID HOUSEHOLD survey
Reiroductive and child HEALTH (RCII)
1998-99
NAME OF THE INVESTIGATOR:
Confidential
for research
purpose only
SIGNATURE OF THE INVESTIGATOR
SEClIUX-i
household characteristics
Q..N«.
question AND filter
CODING CATEGORIES
Q103
How many eligible women
are there in your
household?
Q104
Please give the name of
all eligible women.
QI05
What is your religion?
NAME OF ELIGIBLE
WOMEN
5.'
■■ ■
-----
■
HINDU................................................. 1
MUSLIM.............................................. 2
SIKH................................................... 3
CHRISTIAN....................................... 4
BUDDHIST......................................... 5
JAIN................................................... 6
ZOROASTRIAN.................................. 7
NO RELIGIQN. ................................ 8
OTHER_________________________ 9
________ (SPECIFY)_________________
QI06
Do you belong to
Scheduled Caste,
Scheduled Tribe or Other
Backward Classes?
SCHEDULED CASTE.........................1
SCHEDULED TRIBE.........................2
OTHER BACKWARD CLASSES....3
OTHER CASTE.................................. 4
DO NOT KNOW )................................ 9
Q107
What is the main source
of drinking water for
your household?
TAP......................................................1
HANDPUMP......................................... 2
WELL................................................... 3
RIVER................................................. 4
PCMD................................................... 5
OTHER_______________________ 6
(SPECIFY)
—
. _____
;■ /
/QI 08
Type of house
(RECORD BY OBSERVATION)
SEMI-PUCCA....................................... 2
K/VHCIIA.............................................. 1
VITAL EVENTS SINCE JANUARY, 1995 __________
Q109
Was there a birth, among
the usual residents of
this household since
January, 1995? If yes,
how many?
quo
Was there a birth, among
the visitors of this
household since January,
iqqq? Tf ves . how many?
YES, NUMBER............................. |
j
NO.......................................................... 0
YES, NUMBER............................. |
|
NO......................................... .................2
(IF NO FOR Q109 AND QUO GO TO Q112)
Qin
(a)
SI.
NO
1.
(b)
Name of the baby
(c)
Does the
baby belong
to usual
residents?
(d)
Sex
of
the
baby
<e)
Month
of
birth
YES..1
M - 1
NO...2
F - 2
1 1 1 | | ~j LU
(f)
Year of
birth
(g)
Order
of
birth
(h)
Is the
child
alive?
YES. . 1
M -
NO... 2
F - 2
1
1 1 1 | | | LU
I child at the time
ci death(in months,
in days if < 1
month)
(j)
Was the death due
to Tetanus?
YES..1
YES. . 1
Days
NO... 2
NO...2
□K...99
2.
Lf dead, age of the
Months
YES..1
YES..1
DAYS
NO...2
NO...2
MONTHS
DK. . .99
3.
YES. .1
M - 1
NO... 2
F - 2
[ I I LU LU
YES..1
YES. .1
DAYS
NO... 2
NO. . .2
MONTHS
DK...99
1 .
YES..1
M - 1
NO... 2
F - 2
UJ 1 1 1 m
YES..1
DAYS
NO... 2
MONTHS
DK...99
5.
YES..1
M - 1
NO...2
F - 2
LU LU LUI
YES..1
NO...2
YES..1
YES..1
DAYS
NO... 2
NO... 2
MONTH'
DK...99
r
t!
Q.No
QI 12
QI 13
QUESTION AND FILTER
CODING CATEGORIES
Since January 1995, did any woman
(usual residents) of this household
Anh1?^Pre9nanCY or while delivering
a child or within 6 weeks after
termination of pregnancy?
If yes, did the death occur due to
complication of pregnancy or child
birth?
SKIP
TO
YES.................................................................... 1
NO...................................................................... 2
Q114
NUMBER OF DEATHS
YES.................................................................... 1
NO.......................................................................2
NUMBER OF DEATHS
QI 14
Was there any marriage among usual
residents of this household since
January, 1995?
QU5
If yes, who got married? What was
the age of that person at the time
of marriage?
YES.................................................................... 1
NO....................................................................... 2
Q116
1
i
1111111111
— mmujm
Ql 16
Q117.
SI
NO.
1.
During the last 3 months did any
member of this household suffer from
Malaria?
YES.................................................................... 1
NO....................................................................... 2
Q118
If yes, give details
Age (in
completed
years)
Sex
Name of thepatient
Was he/she given
treatment?
YES.........................1
M - 1 ; F - 2
NO........................... 2
2.
M - 1 ;
YES........................ 1
F - 2
NO........................... 2
3.
-YES-^.-................... 1
M - 1 ; F - 2 -
NO........................... 2
4-
YES........................ 1
M - 1 ; F - 2
NO........................... 2
5.
YES........................ 1
M - 1 ; F - 2
NO...........................2
5
7
Q.No
QI 18
QUESTION AND FILTER
CODING CATEGORIES
Is a'iy member of your household
suffering from tb?
SKIP
TO
YES.................................................................... 1
NO...................................................................... 2
Q120
Q119.
If yes, give details
SI
NO.
Name of the
patient
Sex (M/F)
1.
Age (in
completed
years)
M - 1 ; F - 2
Was he/she
given
treatment?
YES......................... 1
NO........................... 2
2.
YES......................... 1
M - 1 ; F - 2
NO........................... 2
3.
YES......................... 1
M - 1 ; F - 2
NO........................... 2
4.
M -
1 ;
YES.........................1
F - 2
NO........................... 2
YES......................... 1
M - 1 ; F - 2
5.
NO........................... 2
Q120
Q121.
SI
NO.
1.
YES..................................................................... 1
NO....................................................................... 2
Is any member of your household
suffering from‘Leprosy?
If yes,
Q122
give details
Name of the
patient
Sex
Age (in
completed
years)
M - 1 ; F - 2
Was he/she
given
treatment?
YES.........................1
NO. . ..................... 2
2.
YES.........................1
M - 1 ; F - 2
NO........................... 2
3.
M - 1 ; F - 2
YES.........................1
NO........................... 2
4 .
YES.........................1
M - 1 ; F - 2
NO........................... 2
5.
YES......................... 1
M - 1 ; F - 2
NO........................... 2
6
Q.No
QUESTION AND FILTER
CODING CATEGORIES
QI22
Is there any unmarried girl in this
household in the age group 15-19?
YES.................................................................... 1
NO...................................................................... 2
Q123
Has ANM/Doctor/Health Worker ever
counselled her about possible health
problems of girls?
ANN.................................................................... 1
DOCTOR............................................................ 2
HEALTH WORKER............................................ 3
NO...................................................................... 4
DO NOT KNOW................................................. 9
Q124
Does the girl suffer from Anaemia
during last 3 months?
YES.................................................................... 1
Q125
If yes, has ANM/Doctor/Health Worker
given Iron and Folic Acid (IFA)
tablets to her?
ANM.......................................................... 1
DOCTOR................................................... 2
HEALTH WORKER.................................. 3
NO............................................................. 4 ~l_
SKIP
TO
Sectn.ll
Scctn.II
DO NOT KNOW....................................... 9 -J
Q126
How many tablets were given to her?
NUMBER
||||
DO NOT REMEMBER........................ 999
Section
II
SECTION 11
( VSI^ONLY IF THE RESPONDENT IS MALE ANU IN THE AGE GROUP OF 20-54)
Q.NO
QUESTIONS AND
FILTERS
Q2 01
Have you heard
of an illness
called
RTI/STI/HIV
(AIDS)?
CODING CATEGORIES
SKIP
TO
RTI STI HIV (AIDS)
YES................................................ 1
1
1
If
all
NO
NO...................................................2
2
2
Q207
Q202
From which
sources of
information or
persons have you
heard about
RTI/STI/HIV
(AIDS)
(CIRCLE ALL
RESPONSES
MENTIONED)
RTI STI HIV (AIDS)
1. RADIO.................................. A
A
A
2. TV......................................... B
B
B
3. NEWS PAPERS................... C
C
C
4. MAGAZINES...........................D
D
D
5. SLOGANS/PAMPHLET/
POSTERS............................. EE
E
6. DOCTOR................................ F
F
F
7. HEALTH WORKERS............... G
G
G
8 . SCHOOL TEACHERS............ H
H
H
9. COMMUNITY MEETING.... I
I
I
10.RELATIVES/FRIENDS....J
J
J
11 . OTHER___ __ _____________ K
K
K
(SPECIFY)
Q203
How is RTI/
STI/HIV (AIDS)
transmitted?
(CIRCLE ALL
RESPONSES
MENTIONED)
RTI STI HIV (AIDS)
1. HOMOSEXUAL
INTERCOURSE................... A
A
A
2. HETEROSEXUAL
INTERCOURSE................... B
B
B
3. NEEDLES/BLADES/
SKIN PUNCTURE............... C
4. MOTHER TO CHILD.......... - . C
D
5. TRANSFUSION OF
INFECTED BLOOD............ D
E
6. LACK OF PERSONAL
HYGIENE............................. C
7. OTHER_________________ _ DE
F
(SPECIFY)
8 . DO NOT KNOW.................... E
F
G
Q204
Do you think
that one can get
HIV (AIDS) from
someone who has
HIV (AIDS) by:
■
YES
NO
1. SHAKING HANDS.................... '................ 1
2
2. HUGGING...................................................... 1
2
3. KISSING......................................................1
2
4 . SHARING CLOTHES.................................. 1
2
5. SHARING EATING UTENSILS............... 1
2
6. 'STEPPING ON URINE/STOOtrr^-r-r . . 1
2
7. MOSQUITO, FLEA OR BEDBUG
BITES.......................................................... 1________ 2_
Q205
How do you think
one can avoid
HIV (AIDS)?
(CIRCLE ALL
RESPONSES
MENTIONED)
1. USING CONDOMS DURING EACH SEXUAL
INTERCOURSE.............................................................A
2. SAFE SEX.................................................................... B
3. CHECKING BLOOD PRIOR
TO TRANSFUSION......................................................c
4. STERILIZING NEEDLES AND
SYRINGES FOR INJECTION.................................. D
5. AVOIDING PREGNANCY WHEN
HAVING HIV (AIDS) ............................................E
S . OTHER________________ _ ____________________ F
(SPECIFY)
7 . DO NOT KNOW............................................................. G
8
Q . NO
QUESTIONS AND
CODING CATEGORIES
______ filters
Q206
Do you think
RTI STI HIV (AIDS)
Rti/sti/iiiv
(AIDS) is a
curable disease?
YE«....................1
Q203
Did you ever had
any of the ,
following
problems?
If yes, have you
ever consulted
any one for
treatment?
Q2 0 9
If yes, whom did
you consult for
treatment?
(CIRCLE ALL
RESPONSES
MENTIONED)
Q210
Have you ever
discussed about
this with your
wife?
Q211
What Family
Planning method
you think that
couples who want
no more children
should adopt?
1
2
99
1
2
9
NO............................................................... ...
DO NO T KNOW...
Q207
SKIP
TO
YES
1. ANY DISCHARGE FROM PENIS /..... 1
2. ANY SORE ON GENITAL OR
ANAL AREA................................................ 1
3. POSITIVE SYPHILIS BLOOD TEST..1
4. DIFFICULTY IN URINATING............... 1
5. PAIN WHILE URINATING...................... 1
6. VERY FREQUENT URINATION............... 1
7. SWELLING OF TESTES OR IN
GROIN AREA (PENIS)........................... 1
NO
2
2
2
2
2
2
If
all
NO
Q211
2
YES....................................................................................... 1
NO.......................................................................................... 2
Q210
1.
2.
3.
4 .
5.
6.
7.
PHC DOCTOR............................................................... A
PRIVATE DOCTOR......................................................B
MALE HEALTH WORKERS.......................................... C
MEDICAL SHOP.......................................................... D
RELATIVES/FRIENDS...............................................E
SELF TREATMENT...................................................... F
OTHER_______________________________________G
(SPECIFY)
YES........................................................................................ 1
NO...........................................................................................2
FEMALE STERILIZATION..................................... 1-i
COPPER-T/LOOP...................................................... 2 4->PILLS......................................................................... 3 —(
Q213
MALE STERILIZATION......................................... 4
CONDOM/NIRODH......................................................5
OTH ER_____________________________________ 6
(SPECIFY)
Q212
When you need
will you use the
__ (name)
method?
YES........................................................................................ 1
NO............ . ............................................................................ 2
NOT APPLICABLE......................................... ................... 3
Q213
Why are you not
preferring male
method?
(CIRCLE ALL
RESPONSES
MENTIONED)
1.
2.
3.
4.
5.
6.
FEAR OF IMPOTENCY.............................................. A
LACK OF SEXUAL PLEASURE................................ B
FEAR OF METHOD FAILURE.................................. C
FEAR OF OPERATION.............................................. D
FEAR OF WEAKNESS................................................. E
OTHER__________________ _ _________________ F
(SPECIFY)
9
STOP
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