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Family Welfare Programme in India: Expenditure vs Performance

Since the launch of the reproductive and child health policy regime in 1998-99, there has been a massive rise in government expenditure on family welfare programmes in India. This paper makes a systematic effort to assess the performance of the family welfare programmes vis-à-vis the trends in expenditure. The trends in key performance indicators for India and selected states reveal that progress has been slow and limited in the post-rch policy regime. Child immunisation coverage has decelerated, and the increase in the contraceptive prevalence rate and institutional delivery coverage have stalled. Consequently, the pace of reduction in the total fertility rate and infant mortality rate has slowed. Overall, the progress in key programme indicators is found to be incommensurate with rising expenditure.

SPECIAL ARTICLE

Family Welfare Programme in India: Expenditure vs Performance

P Arokiasamy, Chander Shekhar, K Srinivasan, Srinivas Goli

Since the launch of the reproductive and child health policy regime in 1998-99, there has been a massive rise in government expenditure on family welfare programmes in India. This paper makes a systematic effort to assess the performance of the family welfare programmes vis-à-vis the trends in expenditure. The trends in key performance indicators for India and selected states reveal that progress has been slow and limited in the post-RCH policy regime. Child immunisation coverage has decelerated, and the increase in the contraceptive prevalence rate and institutional delivery coverage have stalled. Consequently, the pace of reduction in the total fertility rate and infant mortality rate has slowed. Overall, the progress in key programme indicators is found to be incommensurate with rising expenditure.

P Arokiasamy (parokiasamy@yahoo.co.in) is with the Department of Development Studies, International Institute for Population Sciences, Mumbai, Chander Shekhar (shekhariips@rediffmail.com) is with the Department of Mathematical Demography & Statistics, International Institute for Population Sciences, Mumbai, K Srinivasan (ksrini_02@yahoo.com) was earlier director, International Institute for Population Sciences, Mumbai, and Srinivas Goli (sirispeaks2u@gmail.com) is a doctoral student at the International Institute for Population Sciences, Mumbai.

T
he family planning programme in India is both unique and first of its kind in the world. Since its historic initiation in 1951, the programme has changed in terms of policy intended and stated approach to actual programme implementation. The programme has evolved in terms of varied approaches from the clinic approach1 mode during 1952-61 to the current reproductive and child health (RCH) approach. The RCH approach was rolled out on an experimental basis in 1995 and formally launched in 1997. This strategic shift in the programme approach resulted from the recommendations at the International Conference on Population and Development (ICPD) in Cairo by the United Nations in 1994 and India was a signatory to the programme of action (POA).

In the aftermath of the ICPD, the existing national programme of family planning/welfare seeking to achieve predetermined demographic goals of low fertility and population stabilisation were considered too centralised and anti-feminist. This modification of the programme in accordance with ICPD recommendations was formally termed as the Target Free Approach (TFA). In this approach, all predetermined targets were removed and it was recommended that all programmes aimed to improve the health of women and children must be implemented as a part of an integrated package of services to meet the reproductive health needs and rights of women (Srinivasan et al 2007).

Since the launch of the RCH programme in India, there have been persistent and often contentious debates among population and health experts over its “successful implementation” in developing countries. Critics have raised doubts as to how these concepts will be operationalised in patriarchal societies like India with male-dominated, hierarchical services delivery systems. Some of the earlier studies that examined the implications of the new approach to family welfare indicators mostly addressed methodological problems (Salunke and Narvekar 1997; Kothari et al 1997; Ghasura et al 1997; Mavalankar 1997; Srinivasan et al 2007). However, there has not been a serious evidence-based comparative assessment of the proportionate rise in expenditure versus the performance of RCH approach under family welfare programme.

In an earlier attempt of reviewing RCH programme in India, we found that since 1997 the expenditure incurred on the RCH programme, both at an aggregate level and on per capita basis, increased substantially compared with pre-RCH regime (Srinivasan et al 2007). This is on an account of the steep rise in planned allocation and possible loans which were liberally made available by the World Bank. Under the broad umbrella of the RCH programme, which includes maternal and childcare services, family

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planning and immunisation programme, the government expenditure has been more than doubled compared with pre-RCH policy regime. Nevertheless, stated disturbingly as a matter of fact, the contraceptive prevalence rate has been practically stalling and the immunisation levels have been either decelerating or on the drag.

In this context, our objective in this paper is to pursue a more comprehensive examination of comparative trends in expenditure on family welfare programme vis-à-vis performance in programme-related indicators for India as a whole. We also conduct state-specific assessments for Tamil Nadu, Maharashtra and Uttar Pradesh which are at different stages of development and health performance. Such continuing assessment is critical in terms of policy review, reorientation and action. We revisit the recent changes in family welfare programme and examine if the quantum increase in family welfare expenditure has been effective in contributing recognisable change in terms of key RCH and family planning performance indicators for India and for the three selected states.

1 Data and Methods

We have used multiple data sources in this study to assess expenditure on family welfare versus family planning and RCH programme performance for India and selected states. States have been selected based on varying stages of progress in key indicators. A composite index of 24 key family welfare performance indicators is used to classify states on the basis of level of development such as low, medium and high. Three states with high (Tamil Nadu), medium (Maharashtra) and slow (Uttar Pradesh) progress in 24 key performance indicators have been selected for the study.

The various sources of data and methods of analysis include: first, at the aggregate level, we have compiled family welfare MCH/transportation/mass education, and (4) services/supplied and other expenditure. Under the programme of training, there are two subsections: basic training schools and research institutes. The third programme includes rural family welfare centres, subcentres, maintenance of urban family welfare centres, urban revamping scheme (health posts), maternal and child health, reproductive and child health project, immunisation strengthening project, procurement of cold chain equipment, sterilisation and IUD inserting, information, education and communication, village health guide scheme, transport, contraceptives, non-scalpel vasectomy, travel of experts/conferences/meetings, sterilisation beds, etc. The fourth programme includes free distribution, social marketing of contraceptives, logistic improvement, Hindustan Latex Limited, school health scheme and other.

For comparability, the expenditure data has been adjusted to account for inflation rates by using wholesale price index (WPI) from 1986-87 to 2005-06 (base year 1982-83). Third, we have used data from three rounds of the National Family Health Survey (NFHS) to estimate 24 key performance indicators by different socio-economic groups for a trend analysis. Fourth, official statistics on family welfare programme performance published in family welfare year books for different years (1986-2006) of MoHFW have been used to assess the performance outcomes based on key demographic indicators – total fertility rate (TFR) and infant mortality rate (IMR).

2 Family Welfare Expenditure in India

The programme implementation cost for family welfare programmes are generally met through (a) budget outlays of the central government, (b) contribution from the respective state governments, and (c) international donors and bilateral support. However, to assess comparable trends in the aggregate expenditure,

expenditure data available from the union Table 1: Budget Estimates, Revised Estimates and Actual Expenditure under Family Welfare Programme in India (1986-87 to 2005-06, Rs in lakh)

budget of Ministry of Finance, Government of

Year At Current Price

At Constant Price

India. The union budget documents provide data

Budget Revised Expenditure Shortfall/ Budget Revised Expenditure Shortfall/ on outlays and actual expenditure on various Estimate Estimate (Actual) Excess Estimate Estimate (Actual) Excess

1986-87 53,000 52,996 52,603 392.63 39,581.8 39,578.8 39,285.6 293.2

budgetary components. Family welfare pro

1987-88 58,486 57,286 57,315 -28.5 40,587.1 39,754.3 39,774.1 -19.8

gramme outlays and actual expenditure data

1988-89 5,99,990 46,490 63,194 -16,704.11 3,89,098.6 30,149.2 40,981.9 -10,832.8

are given under the health and family welfare

1989-90 65,295 63,795 63,522 273.02 39,405.6 38,500.3 38,335.5 164.8

section. Second, scheme-wise expenditure data

1990-91 67,495 78,479 78,219 259.51 36,943.1 42,955.1 42,813.1 142.0

have been compiled from the official statistics

1991-92 74,895 85,652 84,753 899.24 36,041.9 41,218.5 40,785.7 432.7

and data published in family welfare year books 1992-93 10,00,000 1,04,100 1,02,902 1,197.54 4,37,254.0 45,518.1 44,994.5 523.6
(1986-2006) by the Ministry of Health and Family 1993-94 1,27,000 1,27,357 1,39,529 -12,172.39 51,251.0 51,395.1 56,307.3 -4,912.2
Welfare (MoHFW), Government of India. The 1994-95 1,43,000 1,53,800 1,53,412 388 52,056.8 55,988.4 55,847.1 141.2
state-level expenditure data were collected 1995-96 1,58,100 1,50,600 1,51,002 -401.85 53,448.3 50,912.8 51,048.6 -135.9
from the family welfare departments of respec 1996-97 1,53,500 1,54,700 1,56,225 -1,525.13 48,792.1 49,173.6 49,658.3 -484.8
tive state governments for the three selected 1997-98 1,82,935 1,82,935 1,82,215 719.79 55,468.5 55,468.5 55,250.2 218.3
states. For the present study, we have compiled family welfare expenditure data from all the subcomponents into four major schemes. This data allows comparison and correlation of data on 1998-991999-00 2000-012001-022002-03 2,48,935 2,92,000 3,52,000 4,21,000 4,93,000 2,25,300 3,12,000 3,20,000 3,70,000 4,15,000 2,34,275 3,09,975 3,09,011 3,61,394 3,91,663 -8,974.54 2,024.61 10,989.46 8,606.13 23,337 70,639.9 80,418.6 91,239.0 1,05,329.0 1,19,283.8 63,933.0 85,926.7 82,944.5 92,569.4 1,00,411.3 66,479.7 85,369.2 80,096.0 90,416.3 94,764.8 -2,546.7 557.6 2,848.5 2,153.1 5,646.5
family welfare indicators with expenditure data 2003-04 4,93,000 4,70,000 4,40,927 29,073 1,13,099.3 1,07,822.9 1,01,153.2 6,669.6
of identical schemes. The types of schemes listed 2004-05 5,78,000 5,30,000 4,86,209 43,791 1,24,542.1 1,14,199.5 1,04,763.8 9,435.7
in expenditure under family welfare programme 2005-06 6,42,400 6,00,000 5,67,253 32,747 1,32,535.6 1,23,787.9 1,17,031.8 6,756.1

(1) Expenditure in rupees (in lakh) at constant prices (based on WPI 1981-82).

in India include the following: (1) direction and

Source: Expenditure data compiled from the statistics released by the Family Welfare Programme in India, Year Book, administration, (2) training, (3) family welfare/ MoHFW, Government of India, New Delhi.

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SPECIAL ARTICLE

in this paper we use central government budget outlays and actual expenditure because access to comparable and reliable data from other sources is limited and scanty. It is assumed that the contribution from the international bilateral support for family welfare programme in India is not significant. The family welfare expenditure from budget outlays and actual expenditure reported during 1986-87 to 2005-06 for India are presented in Table 1 (p 128). Trends provide evidence that from the pre- to post-RCH periods, at the aggregate level, budget outlays and actual expenditure have increased twofold.

The year 1997 marks a breakthrough point in terms of family welfare budget outlays and expenditures. The steep hike in family welfare expenditure coincides with an introduction of two-stage programmes launched by MoHFW-RCH in 1997 and National Rural Health Mission (NRHM) in 2005. The post-RCH (after 1997-98) stage is in contrast to pre-RCH (before 1997-98) period where shortfalls in budget outlays over expenditure are significant and a regular phenomenon; in contrast, in the post-RCH period, evidence points out a significant excess of budget outlays over expenditure. The RCH regime, therefore, facilitated a historic shift in the central government budget outlays for health and family welfare.

At aggregate level, a scheme-wise assessment of family welfare expenditure indicates that the share of core family welfare expenditure in total expenditure has shown a remarkable increase from pre- to post-RCH period. The average family welfare (F)/total (T)

Figure 1: Ratio of Core Family Welfare Expenditure to the Total Family Welfare Expenditure during Pre- and Post-RCH Policy Regimes, India and Selected States

(1987-88 to 2004-05)

India

0.28 0.29 0.29 0.36 0.32 0.34 0.32 0.40 0.44 0.46 0.24 0.36 0.87 0.89 0.86 0.78 0.79 0.86

1987- 1988- 1989- 1990- 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 200488** 89** 90** 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05

Tamil Nadu

0.28 0.29 0.29 0.36 0.32 0.34 0.32 0.40 0.44 0.46 0.24 0.36 0.87 0.89 0.86 0.78 0.79 0.86

1987- 1988- 1989- 1990- 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 200488** 89** 90** 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05

Maharashtra

1987- 1988- 1989- 1990- 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004-0.78 0.73 0.73 0.72 0.93 0.94 0.95 0.95 0.79 0.71 0.81 0.47 0.70 0.66 0.53 0.63 0.77 0.88

88 89 90 91 92 93 94* 95 96 97 98 99 2000 01 02 03 04 05

* Annual expenditure is calculated as two years moving average, that is the average of the preceding and succeeding years; ** Expenditure data compiled from provisional data on family welfare expenditure.

  • (1) Expenditure in rupees (lakh) calculated at constant prices and based on WPI 1981-82.
  • (2) F/T ratio is computed from expenditure (rupees in lakh) incurred on core family welfare expenditure and total expenditure includes family welfare, MCH, transport, compensation and mass education to that total family welfare expenditure. Source: Expenditure data compiled from statistics released by Family Welfare Programme in India, Year Book (1986-2006), MoHFW, GoI.
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    ratio doubled from 0.34 in 1987-97 to 0.71 in 1998-2005 for India (Figure 1).

    This increase is obvious due to an increase in domestic funds for family welfare programme after the introduction of RCH programme in 1997. The major shift as a result of the integration of family planning and RCH service provision also led to a sizeable increase in expenditure of the core family welfare programme in the post-RCH period. However, state-level assessments for the three selected states show different scenarios. While there has been a drastic drop in core family welfare expenditure for Maharashtra initially and a rise in later stages, Tamil Nadu shows a slower rise in core family welfare expenditure.

    Overall, family welfare expenditure has increased substantially and continues to rise in the departments of core family welfare programmes such as mother and child health (MCH) 1997, mass education, RCH (1997) and NRHM (2005). Comparatively, less increase is seen in other schemes such as administration and training expenditure from pre- to post-RCH period. Evidentially, two out of the three components show fluctuating trends in family welfare expenditure for India and selected states. Whereas Maharashtra showed a sharp declining trend in the expenditure on supply and services component of family welfare, Tamil Nadu rose notably. The scheme-wise expenditure data for Uttar Pradesh is not available.

    Similarly, there is stagnancy in the flow of expenditure for training component of family welfare for India and the two selected states. The expenditure on direction and administration head showed a steep rise until 2003-04 and thereafter a sharp cut

    Table 2: Number and Percentage of Indicators Showing Slower Progress in the Post-RCH Than Pre-RCH Period by Three Selected Category of Indicators, India

    (1992-93 to 2005-06)

    Background Characteristics Marriage Family Maternal and Percentage of Indicators
    and Fertility Planning Child Health Showing Post-RCH
    A(5) B(7) C(12) Progress Lower Than
    Pre-RCH Progress1
    Place of residence
    Urban 3 5 8 66.7
    Rural 2 4 7 54.2
    Caste/tribe
    Scheduled caste 4 3 9 66.7
    Scheduled tribe 0 3 3 25.0
    Others 5 4 9 75.0
    Religion
    Hindu 3 4 8 62.5
    Muslim 2 4 9 62.5
    Others 3 4 9 66.7
    Education
    No education 2 2 8 50.0
    Primary 3 2 9 58.3
    Secondary 2 3 5 41.7
    Higher 0 2 3 20.8
    Wealth index
    Poor 3 3 9 62.5
    Middle 3 4 10 70.8
    Rich 4 5 9 75.0
    India 3 3 8 57.2

    1 Percentage of indicators showing post-RCH progress lower than pre-RCH progress has been calculated in two steps. Step 1 is estimating the number of indicators showing lower progress in 2005-06 than in 1992 under three major schemes (marriage and fertility, family planning, maternal and child health) of family welfare programme. Step 2 is the estimation of the percentage of indicators showing post-RCH progress lower than the pre-RCH progress by using the formula [(A+B+C)/24)*100]. Source: Estimates based on NFHS data 1, 2 and 3.

    0 0Services/supplied and other expenditure Training Direction and administration

    Figure 2: Trends in Family Welfare Expenditure (in lakhs) for Direction and Administration, Service/Supply tribes. However, very little difference is indicated and Training, India, Tamil Nadu, Maharashtra and Uttar Pradesh (1987-2005)

    between Hindu and Muslim religious categories

    India

    50,000 8,000 in terms of percentage of indicators showing

    post-1998 progress lower than pre-1998 period.

    40,000

    6,000

    Third, variations in the performance of family

    Services and Supplies

    Direction and Administration; Training Direction and Administration; Training Direction and Administration; Training

    welfare indicators are significant across various

    30,000

    educational groups. For women in the highest

    4,000

    educational category, only 21% of all indicators

    20,000

    showed deterioration in the rate of progress in

    the post-RCH period as against 58% in case of

    2,000

    10,000

    1987- 1988- 1989- 1990- 1991- 1992- 1993-1994- 1995- 1996- 1997- 1998- 1999-2000- 2001- 2002- 2003-200488** 89** 90** 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05

    women with primary education. Fourth, wealth quintile as a proxy measure of household economic status emerges out to be a key factor in

    determining the progress in RCH indicators.

    Tamil Nadu

    100 40 Households belonging to poorer wealth quin-

    Training Direction and administration Services/supplied and other expenditure

    tiles showed more number of RCH indicators

    with better performance compared with those

    30

    belonging to middle and richer wealth quintile

    20

    in the post-RCH regime. However, in terms of

    MCH indicators, the middle wealth quintile

    households indicated the lowest progress in the

    post-RCH era.

    10

    This assessment points out that for country as a whole, all the marriage and fertility-related

    00

    indicators registered greater progress in the post-RCH era for scheduled tribe. However, for

    Maharashtra

    70 180 all other caste categories the post-RCH progress

    1987-1988-1989-1990-1991-1992-1993-1994-1995-1996-1997-1998-1999-2000-2001- 2002- 2003-2004-88 89 90 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05

    Services/supplied and other expenditure Direction and administration Training 1987-1988-1989-1990-1991-1992-1993-1994-1995-1996-1997-1998-1999-2000-2001- 2002- 2003-2004-88* 89* 90* 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05 * Figures taken from provisional family welfare expenditure data. Expenditure (in rupees lakh) is calculated at constant prices (based on WPI 1981-82). Source: Expenditure data compiled from statistics released by Family Welfare Programme in India, Year Book (1986-2006), MoHFW, GoI.

    160

    120

    80

    40

    00

    down. This drop is comparatively greater for Maharashtra than for India as whole and Tamil Nadu (Figure 2).

    3 Family Welfare Programme Appraisal

    Table 2 (p 129) shows the percentage distribution of selected programme and RCH indicators. At aggregate level, results reveal that the progress in family welfare and RCH indicators has been stagnant in post-RCH than pre-RCH period, despite the added advantage of NRHM implementation. However, evidence points to clear variations in performance in terms of disaggregated trends in socio-economic strata. First, in urban areas, the progress in the post-RCH era was lower than the pre-RCH era in almost 67% indicators. Similarly, in rural area, there was virtually no progress in half of the 24 indicators (54%) in the post-RCH era as compared to pre-RCH era. Second, on a positive note, by caste, the largest improvement in the post-RCH period is shown for scheduled

    is slower than pre-RCH progress. Among house

    holds of all wealth quintiles, marriage and fertility

    indicators showed a slower progress in the post-

    RCH than pre-RCH period. Compared with the

    poor and middle wealth quintile households, the

    declined, indicating a slower rate of progress in

    the post-RCH period. However, the differentials

    in slowdown of progress in performance indi

    cators persist across various socio-economic groups. The percentage of indicators showing the post-RCH progress less than the pre-RCH progress was greater in urban Tamil Nadu followed by urban Uttar Pradesh and rural Maharashtra. All the indicators related to marriage and fertility and maternal and child health showed slowdown in progress in the post- RCH period for urban Tamil Nadu. In all the three states, ruralurban differentials are greater in terms of progress in family planning indicators.

    The scheduled castes in Maharashtra, scheduled tribes in Uttar Pradesh and other castes in Tamil Nadu showed greater slowdown in terms of family planning and RCH performance indicators in the post-RCH as compared to the pre-RCH regime. Both scheduled castes and scheduled tribes of Maharashtra and Uttar Pradesh did not show any difference in terms of progress of maternal and child health indicators in the post-RCH period. In terms of marriage and fertility indicators Maharashtra showed the worst

    richest wealth quintile households registered

    the least progress in the post-RCH period.

    For all the three selected states, the progress in all the indicators under three major heads

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    performance (5/5) in the post-RCH period. In contrast to this Uttar Pradesh showed a continuous progress in terms of marriage and fertility indicators in the post-RCH period.

    The differentials with regard to the slowdown in progress of performance indicators in the post-RCH period persist between Hindus and Muslims among the states except for Tamil Nadu, where for both Hindus and Muslims, half of the indicators registered a slowdown in progress in the post-RCH period. The Hindus and Muslims of Maharashtra showed the highest percentage of indicators having post-RCH progress lower than the pre-RCH period. The number of maternal and child health indicators showing the post-RCH progress lower than the pre-RCH progress is the highest for Hindus (10 out of 12 indicators) and others (11 out of 12 indicators) in Tamil Nadu and for Muslims (11 out of 12 indicators) in Maharashtra. The number of family planning indicators that registered declines in performance in the post-RCH regime is the highest for the Hindus of Maharashtra and Muslims of Uttar Pradesh. Greater deterioration in the post-RCH progress in terms of family planning indicators was observed among Muslims of Uttar Pradesh. Taking into account the post-RCH progress of all the indicators under three major heads, except Tamil Nadu, Muslims in other two states showed less progress in the post-RCH for higher number of indicators (Table 3).

    By educational categories, the post-RCH progress under all the three heads of family welfare and RCH indicators showed less progress among women with higher education in Tamil Nadu, women with primary education in Maharashtra and women with no education in Uttar Pradesh. Only in Tamil Nadu, fewer indicators registered a decline in progress in the post-RCH regime for women with no education as compared to women with higher education. The slowdown in the progress of performance indicators in the post-RCH regime is comparatively lower in Uttar Pradesh for all educational categories.

    The richer wealth quintile households of Tamil Nadu, middle wealth quintile households of Maharashtra and Uttar Pradesh have shown stagnating progress under all the three heads of family welfare and RCH indicators compared to all other wealth quintiles. However, in Maharashtra a substantial proportion of poor and richer wealth quintile households has also shown slower progress in the post-RCH period.

    4 Family Welfare Expenditure versus Key Performace Indicators

    This section examines the linkages between family welfare expenditure and selected RCH and family planning indicators in India. Effort has been made to understand how far the increase in expenditures in post-RCH era has effectively contributed to the improvements in the selected family planning and RCH indicators. Figure 3 (p 132) shows a rapid increase in expenditure in the post-RCH period compared with the pre-RCH period, but the progress in selected indicators fail to indicate a significant improvement. In spite of the fact that the increase in expenditure in post-RCH p eriod was almost three times more than that in pre-RCH period, the percentage point changes in full immunisation, CPR and institutional delivery virtually remained the same as in pre-RCH era.

    An assessment in terms of progress in three selected states reveals that except Maharashtra the family welfare expenditure for Tamil Nadu and Uttar Pradesh has increased twofold. By comparison, in case of full immunisation, the performance has rather decelerated in the post-RCH period for all the three states.

    Table 3: Number and Percentage of Indicators Showing Slower Progress in Post-RCH Than Pre-RCH Period by Three Selected Category of Indicators in Tamil Nadu, Maharashtra and Uttar Pradesh (1992-93 to 2005-06)

    Background Characteristics Tamil Nadu Maharashtra Uttar Pradesh
    Marriage Family Maternal Percentage of Marriage Family Maternal Percentage of Marriage Family Maternal Percentage of
    and Planning and Indicators Showing and Planning and Indicators Showing and Planning and Indicators Showing
    Fertility Child Health Post- RCH Progress Fertility Child Health Post- RCH Progress Fertility Child Health Post- RCH Progress
    Is Less Than Is Less Than Is Less Than
    Pre-RCH Progress Pre-RCH Progress Pre-RCH Progress
    A(5) B(7) C(12) A(5) B(7) C(12) A(5) B(7) C(12)
    Place of residence
    Urban 5 4 12 87.5 2 1 11 58.3 4 5 8 70.8
    Rural 1 0 10 45.8 3 5 9 70.8 1 1 10 50.0
    Caste/tribe
    Scheduled caste 2 1 10 54.2 5 5 10 83.3 0 2 9 45.8
    Scheduled tribe NC 1 NC 14.3 2 3 10 62.5 4 3 9 66.7
    Others 5 3 8 66.7 2 3 8 54.2 2 1 8 45.8
    Religion
    Hindu 1 1 10 50.0 2 5 8 62.5 1 1 8 41.7
    Muslim 1 3 8 50.0 4 3 11 75.0 1 5 7 54.2
    Others 2 2 11 62.5 3 3 6 50.0 2 2 6 41.7
    Education
    No education 1 2 10 54.2 3 1 7 45.8 1 2 8 45.8
    Primary 4 1 9 58.3 3 5 11 79.2 3 2 4 37.5
    Secondary 2 1 11 58.3 3 3 8 58.3 0 1 4 20.8
    Higher 5 4 7 66.7 0 3 5 33.3 2 2 3 31.8
    Wealth index
    Poor 1 1 11 54.2 3 4 10 70.8 2 1 7 41.7
    Middle 1 1 11 54.2 4 5 10 79.2 5 5 8 75.0
    Rich 5 3 11 79.2 1 5 11 70.8 4 4 8 66.7

    Percentage of indicators showing post-RCH progress lower than pre-RCH progress has been calculated in two steps. Step 1 is estimating number of indicators shows lower progress in 2005-06 than 1992 under three major schemes (Marriage and Fertility, Family Planning, Maternal and Child Health) of family welfare programme. Step 1 is estimation of percentage of indicators showing post-RCH progress lower than pre-RCH progress by using formula [(A+B+C)/24)*100]. Source: Estimates based on National Family Health Survey data (NFHS 1, 2 and 3).

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    Figure 3: Trends in Family Welfare Expenditure and Selected Performance Indicators for India and the Three Selected States (1992-2006)

    India Tamil Nadu

    Expenditure* (in 00 lakhs)Family welfare performance indicators 800 600 400 60 50 40 30 20 10CPR (any modern method) Full immunisation Institutional delivery Expenditure*
    Expenditure* (In 00 lakhs)Family welfare performance indicators 4 3 2 100 80 60 40 1992-93 1998-99 2005-06 CPR (any modern method) Full immunisation Institutional delivery Expenditure

    1992-93 1998-99 2005-06

    Uttar Pradesh

    Expenditure* (In 00 lakhs)Family welfare performance indicators 4.4 3.6 2.8 2.0 79 69 59 49 39 1992-93 1998-99 2005-06 Expenditure Institutional delivery Full immunisation CPR (any modern method)
    Expenditure* (in 00 lakhs)Family welfare performance indicators 83 77 71 65 97 77 57 37 17 Full immunisation CPR (any modern method) Expenditure Institutional delivery 1992-93 1998-99 2005-06

    * Expenditures are calculated in rupees (lakh) at constant prices (based on WPI 1981-82). Source: National Family Health Survey – 1, 2 and 3, Indian Report (1992-93, 1998-99, 2005-06).

    However, progress in the institutional delivery coverage was comparatively better for the states except Uttar Pradesh in the post-RCH period. However, a clear slowdown in child immunisation coverage has been observed particularly for Maharashtra and Tamil Nadu. On the whole, the massive increase in family welfare expenditure could not result in a matching or significant impact on either the utilisation of family planning methods, institutional delivery or childhood immunisation coverage for India and the three selected states.

    5 Family Welfare Expenditure vs Outcome Indicators

    In this section, the progress in two vital programme outcome indicators IMR and TFR are assessed vis-à-vis the rise in family welfare expenditure for India and the three selected states. For India, it is evident from Figure 3 that the decline in IMR was virtually absent between 1992-93 and 1998-99, although the family welfare expenditure increased moderately during the same period. In post-1998-99 for India, the expenditure has increased dramatically but the decline in IMR has been stagnant. However, clear differences are seen among the three selected states. In Tamil Nadu, the comparative trends show a gradual decrease in IMR with corresponding increase in expenditure from pre-RCH to post-RCH policy regime. In contrast, for Maharashtra and Uttar Pradesh, the increase in expenditure has not shown much impact on IMR decline. For these two states, IMR had declined faster in pre-RCH period than in post-RCH period.

    Overall, the massive increase in expenditure during 1998-99 has failed to bring commensurate decline level of IMR in the post-RCH policy regime. Especially, since 2002-03, the expenditure trend line and infant mortality rate appeared to be parallel to each other, particularly in Maharashtra and Uttar Pradesh and India as whole.

    Figure 4 (p 133) provides evidence of a steady increase in e xpenditure from 1987-88 till 1998-99 and thereafter a steep i ncrease. Comparatively, TFR which considerably declined till 1997 registered a slowdown in the pace of decline thereafter. After the introduction of RCH approach, TFR did not show any notable d ecline for four consecutive years (1997 to 2001) despite the sharp increase in expenditure. Also, in the subsequent years, the d ecline in TFR was not significant even though family planning expenditure increased sharply and interrupted.

    6 Conclusions

    In this study, a meticulous effort has been made to determine the effect of the massive increase in family welfare expenditure on key family planning, RCH performance and demographic outcome indicators for India as a whole and for three selected states in different stages of health transition. A comparative analysis of evidence during the pre- and post-RCH policy regimes revealed that expenditure on family welfare programme has more than doubled during the post-RCH policy regime. However, some variable patterns are noted in expenditure allocations. First, the

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    SPECIAL ARTICLE

    Figure 4: Trends in Family Welfare Expenditure and IMR during Pre- and Post-RCH Policy Regime, India (1987-88 to 2004-05)

    India Tamil Nadu

    100 6

    5

    80

    4

    IMR

    1987- 1988- 1989- 1990- 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004-88 89 90 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05

    IMR

    1987- 1988- 1989- 1990- 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004-88 89 90 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05

    IMR

    Expenditure* (in 00 lakhs)

    Expenditure* (in 00 lakhs)

    60

    3

    40

    2

    20

    1

    0

    0

    Maharashtra Expenditure* (in 00 lakhs)IMR 5 4 3 2 1 0 80 60 40 20 0 1987- 1988- 1989- 1990- 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004-IMR Uttar Pradesh IMR 140 120 100 80 60 40 20 0 140 120 100 80 60 40 20 0 IMR

    1987- 1988- 1989- 1990- 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004

    88 89 90 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05

    88 89 90 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05

    Figure 5: Trends in Family Welfare Expenditure and TFR during Pre- and Post-RCH Regime (1987-88 to 2004-05)

    India Tamil Nadu

    TFR
    0 1000 800 600 400 200 0 3.5 3 2.5 2 1.5 1 0.5 0 1987- 1988- 1989- 1990- 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004-88 89 90 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05 TFR 4 2 1 0 2 1 0.5 0 1987- 1988- 1989- 1990- 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004-88 89 90 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05 Uttar Pradesh

    3

    4.5 6

    4 5

    2.5

    Expenditure* (in 00 lakhs)Expenditure* (in 00 lakhs)

    3

    1.5

    TFR TFR TFR

    TFR 4 3 2 1 0 TFR 140 120 100 80 60 40 20 0 TFR 1987- 1988- 1989- 1990- 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004-88 89 90 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05

    1987- 1988- 1989- 1990- 1991- 1992- 1993- 1994- 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 200488 89 90 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05

    6

    6

    5

    4

    3

    3

    2

    2

    1

    1

    0

    0

    * Expenditures are calculated in rupees (in lakh) at constant prices (based on WPI 1981-82). Source: Registrar General, India (2006): SRS Bulletin, Office of the Registrar General of India: 1987-2007, Delhi, Vol 40 (1).

    magnitude of proportionate increase in expenditure is not uni-regime for India and the three selected states. Progress in instiform across all the sub-schemes and among the states. Second, tutional delivery coverage was relatively better but slower and while the expenditure on core family welfare programme has in-smaller in magnitude during the post-RCH period. The decelercreased swiftly, expenditure on services and supplies which have ating trend in immunisation coverage in the post-RCH period a direct bearing on key maternal and child health outcome indi-could be attributed to the sharp decline in expenditure on the cators has not kept pace with the overall increase in expenditure supply and services component during the corresponding postfor India and the three selected states. RCH period.

    Trend analysis of key programme performance indicators Stagnant trends are also evident from the trend analysis of revealed that CPR is virtually stagnant in the post-RCH policy two vital programme outcome indicators TFR and IMR. Compared

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    october 22, 2011 vol xlvi no 43

    with the pre-RCH period, the progress in the post-RCH period in these two programme outcome indicators is virtually stalled for India and the three selected states. State comparisons indicated much slower progress in Maharashtra than in Tamil Nadu and Uttar Pradesh. The RCH programme approach did not suggest evidence of significant and anticipated effect on any of the selected programme indicators, particularly in medium and less developed states of Maharashtra and Uttar Pradesh, respectively.

    Beyond this, disaggregated analysis by social and economic background variables revealed a relatively slower progress in key programme indicators for socio-economically advanced population categories, except for educated population category. This is possible for the reason that the potential for improvement among socio-economically advantaged population categories is limited and consequently the programme as expected might have focused on under-served populations in the post-RCH period.

    The systematic comparison of the progress in family welfare expenditure and its corresponding improvement in performance indicators demonstrate that the integration of the RCH approach with family welfare programme in the absence of revised framework of goals (rather than targets) resulted in limited progress in family welfare indicators. It is possible that the proposed integration under the programme is not understood in its spirit and purpose. Compared with the separate welldefined programmes implemented earlier, the RCH approach seems greatly promotion-driven lacking in operational framework with clearly articulated new strategies of programme implementation.

    There appears to be less integration between different programmes that is supposed to be coming into force when they are implemented under one category. It is evidentially clear that in the absence of suitable mechanism to operationalise RCH approach under the integrated banner of family welfare programme, the exponential increase in expenditure alone cannot lead to commensurate a positive impact on key performance and outcome indicators.

    NoteHealth and Family Welfare, Government of India). MoHFW (1986-2006): Family Planning Year Book, IIPS and Micro-International (1993): National Family Ministry of Health and Family Welfare (New Delhi:

    1 The initial approach of family planning pro-Health Survey (NFHS 1), 1992-93, International Government of India).

    gramme adopted by the Government of India was Institute for Population Sciences, Mumbai. – (2001): Audit Report No3 200, Ministry of Health

    a clinic approach. A number of family planning clinics were opened throughout the country and

    – (2000): National Family Health Survey (NFHS 2), Family Welfare, Government of India, New Delhi.it was assumed the there was already a strong de

    1998-99, International Institute for Population – (2005): National Health Accounts 2001-02, National sire to space and limit the family size among the

    Sciences, Mumbai.Health Accounts Cell, Ministry of Health and couples and if contraception services provided, it – (2007): National Family Health Survey (NFHS 3), Family Welfare, Government of India, New Delhi. is sufficient to reduce the birth rate. 2005-06, International Institute for Population Registrar General, India (2006): SRS Bulletin, Office Sciences, Mumbai. of the Registrar General of India: 1987-2007, Delhi, Kothari, D et al (1997): “Vikalp – Managing the Family Vol 40 (1). Planning Programme in the Post-ICPD Era: An Salunke, S and Sharad Narvekar (1997): Target-

    References

    Experiment in Rajasthan, India”, IIHMR Occa-free Approach for Family Welfare: A Rreview of

    Ghasura, N D, Bella C Patel and M E Khan (1997): sional Paper No 2. Experiences in Maharashtra, Government of “Case Study: Implementing Target-free Approach Mavalankar, D V (1997): “Paradigm Shift in India’s Maharashtra. in Gujarat”, National Workshop on “Target-Free Family Welfare Programme: A Review of Target-Srinivasan, K, Chander Shekhar and P Arokiasamy Approach”, Lucknow, 24-25. Free Approach in Family Planning”, unpublished (2007): “Reviewing Reproductive and Child Health

    GoI (1996): Manual on Target-free Approach in Family document, Indian Institute of Management, Programmes in India”, Economic & Political Weekily, Welfare Programme (New Delhi: Ministry of Ahmedabad. Vol 42 (27), 2931-39.

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