P.D. Agarwal Memorial Lecture by Saroj Pachauri Year 1997

Dr. D . A .
H e n d e r s o n L i b r a r y
J a i . p u r
~~- - - - ~- - - - - - ~~~
IIHMR
HBglonul Director, South and East i\5iu
Population Coullcil
Ne.. "J rJ dhi, !Illiliu
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P. D. Agarwal Memorial Lecture - 1997
REPRODUCTIVE HEALTH IN
INDIA: CONCEPTUAL ISSUES AND
IMPLEMENTATION CHALLENGES
Saroj Pachauri
Regional Director, South and East Asia
Population Council
NewDelhi, India
Indian Institute of Health Management Research
Jaipur, India
I I
~:::. ;. . . . ----------. "
REPRODUCTIVE HEALTH IN INDIA:
CONCEPTUAL I SSUES
AND IMPLEMENTATION CHALLENGES
Saroj Pachauri *
BACKGROUND
At the International ConferenceonPopulation and Development (ICPD)inCairoin
September 1994, the world community effectivelywrote anewagenda for national
actionandinternational cooperationforpopulationanddevelopmentforthenexttwenty
years. Thisnewapproach isfirmlybasedontheright todevelopment andonequality
between womenand men. TheProgramme ofActionproposedat Cairo sets out very
clearly the development framework within which population policies should be
formulated inkeepingwithuniversally agreedprinciples ofhuman rights (UN, 1994).
AtCairo, thenations ofthe worldagreedthat thefocusshouldbeonindividual needs
instead ofdemographic targets andthat governments shouldgivespecial attention to
theeducationofgirls; thehealth ofwomen;thesurvival ofinfants andyoungchildren;
and ingeneral, the empowerment ofwomen. At the sametime, they shouldprovide
comprehensive reproductive health services to enable couples to achieve their
reproductive goalsbydetermining freelyandresponsibly the number and spacingof
their children. TheCairoconsensusimpliesthat ifgovernments ensurethat this basic
package of social policies and reproductive health services is in place, they will
simultaneously make strides toward greater social equity and reduce high rates of
population growth.
National priorities forimplementation areamatter foreachcountrytodetermine, and
countries have the primary responsibility for the implementation of the ICPD
Programme of Action. Within countries, implementation is the responsibility of all
groupsinsociety-government at all levels, parliamentarians, theprivate sector,non-
governmental organizations, the corporatesector, the academic community, and the
media.
* Regional Director for South and East Asia, Population Council, NewDelhi, INDIA
1
P. D. Agarwal Memorial Lecture-1997
Animportant principlefor actionisthefreedomofchoiceofeachindividual. Thiswas
first enunciated ageneration ago, and it remains vitallyimportant today. TheICPD
consensusstrengthened thisprincipleandgaveitpractical expression. Oneofthemost
important achievements oftheCairoconsensus, infact, wasestablishing theplaceof
familyplanning programmes inthewider context ofreproductivehealth. Cairo'snew
approach has far-reaching implications for policies, programmes, services, and
contraceptivetechnology.Thereisaparadigmshiftwhichimpliesachangeinthinking
and behaving, away fromademographic orientation, whichhas been in placeover
threedecades. OperationalisingthisparadigmshiftinIndia, therefore, presents amajor
challenge.
Empowerment of Women
Women'sgroupswereparticularly central inshapingthedebatethroughout thethree-
year ICPDplanning effort, and at Cairo, agreement onthe central roleofwomenin
development became sonon-controversial that it was not evenan issueat the ICPD
Conference.
The Programme of Action articulated at the Cairo Conference delineated certain
important principles which must formthe basis for designing and implementing
national programmes. It isimportant tokeepthese principles infocus:
Population and Development
Thefundamental relationship betweenpopulationanddevelopment issummarized in
the articulation oftheprogramme's underlying principles:
"The right to development is a universal and inalienable right and an integral
part of fundamental human rights, and the human person is the central subject
of deoelopment."
"Human beings are at the centre of concern for sustainable development ... They
have the right toan adequate standard of living for themselves and their families,
including adequate food, clothing, housing, water and sanitation.
"The main objective is to fully integrate population concerns into development
strategies with the goal of meeting the needs and improving the quality of lifefor
all people and topromote socialjustice and toeradicate poverty through sustained
economic growth in the context of sustainable deuelopment."
2
"The main objectives include achieving equality and equity based onharmonious
partnership between men and women and enabling women to realize their full
potential; ensuring women's... full involvement in policy and decision-making
processes at all stages and in all aspects...; and ensuring that all women, as well
as men, are provided with the education necessary for them to meet their basic
human needs and to exercise their human rights. This extends to economic
equality (access to jobs, equal pay and credit); health equality (right to
reproductive and sexual health); political and legal equality; and social equality."
"Special efforts should be made to emphasize men's shared responsibility and
promote their active involvement in responsible parenthood, sexual and
reproductive behaviour, including family planning;pre-natal, maternal and child
health; prevention of sexually transmitted diseases, including HIV; prevention
of unwanted and high-risk pregnancies; shared control and distribution offamily
income, children's education, health and nutrition; and recognition and
promotion of the equal value of children of both sexes. Male responsibilities in
family life must be included in the education of children from the earliest ages.
Special emphasis should beplaced on theprevention of violence against women
and children."
Family Planning
"Assist couples and individuals toachieve their reproductive goals and give them
the full opportunity to exercise the right to have children by choice."
"Improve the quality offamily planning programmes, and uphold the principle
of voluntary and informed choice."
Preventing the Spread of Sexually Transmitted Diseases and
HIVand Addressing the AIDS Pandemic
"Prevent and reduce the spread of reproductive tract infections and other sexually
transmitted diseases (STDs), including HIV / AIDS, and provide treatment for
STDs and other complications, such as infertility, with special attention to
increasing the ability of girls and women toprotect themselves."
3
l.
P. D. Agarwal Memorial Lecture- 1997
"Provideuniversal accesstoaffordable, preventive serviceswith respect tosexually
transmitted diseases, including HN /AIDS, through the primary health care
system."
"All sexual and reproductive health programmes, including family planning
facilities, especially at the primary health care level, should:
*
prevent, detect, and wherever possible, diagnose and treat, sexually
transmitted diseases and other reproductive tract infections;
*
promote, supply and distribute high-quality condoms and provide drugs
for the treatment of sexually transmitted diseases;
make sexual education, information, and counselling onresponsiblesexual
behaviour, including voluntary abstinence, and effective prevention of
sexually transmitted diseases and HN an integral component of all
reproductive and sexual health services, especially for adolescents;
mobilize all parts of society in response to the HN /AIDS pandemic,
including launching education campaigns that raise awareness and
emphasize behavioural change."
Health, Morbidity and Mortality
"Countries should strive to reduce their infant and under-5 mortality rates by
one-third, or to50 and 70per 1,000 live births, respectively, whichever is less, by
the year 2000, with appropriate adaptation to the particular situation of each
country."
"By 2005, countries with intermediate mortality levels should aim to achieve an
infant mortality rate below50 deaths per 1,000 and an under-5 mortality rate
below 60deaths per 1,000 births."
By2015, all countries should aim to achieve an infant mortality rate below35
per 1000 live births and an under-5 mortality rate below45per 1000. Countries
that achieve these levels earlier should strive to lower them further. "
Countries should strive to effect significant reductions in maternal mortality
by theyear 2015;areduction in maternal mortality by one-half of the 1990 levels
4
by the year 2000 and a further one-half by 2,015. The realization of these goals
will have different implications for countries with different 1990 levels of maternal
mortality. "
"However, all countries should reduce maternal morbidity and mortality tolevels
where they no longer constitute apublic health problem. Disparities in maternal
mortality within countries and between geographical regions, and socio-economic
and ethnic groups should be narrowed."
"In no case should abortion be promoted as a method of family planning. All
governments and relevant inter-governmental and non-governmental
organizations are urged to strengthen their commitment to women's health, to
deal with the health impact of unsafe abortion
1
as a major public health concern,
and to reduce recourse to abortion, through expanded and improved family-
planning services. Prevention of unwanted pregnancies must always be given
the highest priority and every attempt should be made to eliminate the need for
abortion. "
Reproductive Health and Reproductive Rights
Theproponents ofthe reproductivehealth frameworkbelievethat reproductivehealth
isinextricably linked tothe subject ofreproductive rights, whichinturn islinkedto
women'sstatus and empowerment.
Reproductive rights embrace certain human rights recognized in national and
international legal and human rights documents, including:
*
the basic right of all couples and individuals todecide freely and responsibly the
number and spacing of their children, and to have the information, education
and means to do so;
*
the right to attain the highest standard of sexual and reproductive health;
the right to make decisions concerning reproduction free of discrimination,
coercion and violence.
*
1.
"Unsafe abortion isdefinedasaprocedure forterminating anunwanted pregnancy either bypersons
lacking the necessary skills, or inan environment lacking the minimal medical standards, or both
[based onWorldHealth Organisation. The Prevention and Management of Unsafe Abortion, Report
of aTechnical Working Group, Geneva, April 1992(WHO/MSM/92.5)]."
5
PD. Agarwal Memorial Lecture-1997
Promoting the Health and Well-being of Adolescents
Youngpeoplearehumankind's future. Their full participation andintegration insociety
requires that theybeenabledtomanage their sexual andreproductive livesresponsibly
andinaninformed way, through education and servicesthat meet their development
needs. Todate, theneeds andrights ofadolescentsinthis areahavebeenlargelyignored
byexisting programmes, as bysocietyat large.
"Protect and promote the rights of adolescents tosexual and reproductive health
information and services, and reduce the number of adolescent pregnancies. "
"Ensure that girls and women have continuing, full and equal access tonecessary
health and nutrition information and services as they mature and throughout
their life span."
"Eliminate discrimination against young pregnant women."
FROM RHETORIC TO REALITY
The ICPD process brought the international community together around oneof the
mostpressingproblemsofourtimeandenabledbothdevelopedanddevelopingcountries
toreach consensus onawidevariety ofissues. Thechallengenowistotransformthis
consensus into action. It is, indeed, heartening that Indiahas taken aleadtobeginthe
process oftranslating these conceptsintoitsnational programme. Thefirst major step
that the Government took was removing contraceptive targets. AsofApril 1996, the
country has been"target free"!Removal ofcontraceptive targets was aprerequisite for
moving the ICPD process forward -- for focussing onquality and not numbers -- to
implement areproductive health approach. However,inorder totranslate reproductive
rhetoric into reality, twoimportant issues must beaddressed. First, aparadigm shift
is essential. And, second, packages of goodquality services must be designed and
implemented toaddress reproductive health needs ofpeople.
Shift from Demographic Goals to Individual Needs
Ashift inparadigm implies achangeinthefocus fromapopulation control approach
ofreducing numbers todevelopingprogrammes designed toaddress the reproductive
health needs ofpeople. Implementing reproductive health serviceswithin thenational
6
programme in India will require an ideological shift. A change in the culture of the
programme fromonethat has focusedinthepast onachievingtargets, toonethat now
aims at providing arange of quality services, isessential (Pachauri, 1995;Pachauri,
1996).
This agenda recognizes the need to change the programme's thrust on achieving
demographicobjectivesofsocietal fertility reductiontoanexplicitconcernforassisting
clientstomeet their personal reproductive goals. Attheaggregate level, it means that
insteadofremaining responsibleforreducingtherateofpopulationgrowth,reproductive
health programmes wouldbecomeresponsible for reducing theburden of unplanned
and unwanted child-bearing and related morbidity and mortality. For achieving
demographicgoalsofreducingtherateof populationgrowthat themacro-level,broader
social and economic policies are needed (J ain &Bruce, 1994). Policies to promote
women'seducation and empowerment arespeciallyneeded.
If reproductive health programmes are to bedesigned to address clients' needs, an
important implication fortheir implementation isensuring that thequality ofservices
isimprovedfromtheperspectiveoftheclient. Several studiesinIndiahavehighlighted
the widesocial and cultural gap that exists between the providers and the users of
services. In order tobridge this gap, more attention should befocusedonthe users'
perspective within the overall framework of the servicedelivery system. There is a
needtospeciallyfocusonwomen, sincetheyconstitute themajor client grouporusers
ofthese programmes and alsohavethegreatest problemof access, bothphysical and
social, tohealth services (Pachauri, 1994).
Women~Burden of Reproductive Health
AccordingtotheWorldBank, about one-thirdofthetotal diseaseburdeninadeveloping
country onwomen, 15to 44years of age, is linked to health problems related to
pregnancy, childbirth, abortion, human immuno-deficiency virus (HIV), and
reproductive tract infections (RTIs). Among diseases for which cost-effective
interventions exist, reproductivehealthproblemsaccountformostofthediseaseburden
inwomenofthis agegroup(WorldBank, 1993).
7
There are substantial data to show that Indian women bear a high burden of
reproductive ill health (Banget al, 1989;Bang&Bang, 1991;Pachauri andGittlesohn,
J . 1994; J ejeebhoy and Rama Rao, 1992). Studies show that the heavy load of
reproductive morbidity among Indian women is an outcome of their poverty,
powerlessness, lowsocial status, malnutrition, infection,highfertility,andlackofaccess
tohealth care. Thus, socio-economicandbiologicaldeterminants operatesynergistically
throughout thelivesofpoorwomentoundermine their health, resulting inhighlevels
ofmorbidityandmortality. Thereis, therefore, anurgent needtodesignandimplement
services to address women's reproductive health needs. Women-centred, gender-
sensitive services must beorganized andimplemented (Pachauri, 1995a).
P. D. Agarwal Memorial Lecture-Lini?
Gender inequalities favour men in most societies in India and other developing
countries, and sexual andreproductive health decisionsaremadebymen. Therefore,
there is agrowing realization that unless men are reached, programme efforts will
have limited impact. While focussing onwomen and addressing their reproductive
health needs, special efforts shouldbemadetoencouragementotake responsibility
forfamilyplanning andreproductivehealth (Pachauri, 1995a).Research onsexuality,
especiallyinthefieldofHIV/AIDS, has highlighted theinadequacy of strategies that
target only women. Because of their gender-power equation, women are specially
vulnerable but unable tonegotiate changes in sexual behaviour. Research onsexual
negotiation has dramatically underscored theneedforinvolvingmeninprogrammes
that aimat bringing about changesinsexual behaviour fortheprevention ofinfection.
However, suchbehavioural changeisrelevant not onlyfor theprevention ofinfection
but also for addressing other reproductive health problems. Therefore, men's
involvement and participation isessential.
Men's Roles and Responsibilities
Sexual and Reproductive Health
Mostgovernment programmes havegenerallyignoredthefactthat reproductiontakes
placethrough sexual relations, whichareconditionedbybroader gender relations. A
reviewof conventional demographic and family planning literature illustrates that
thepopulation fieldhas neglectedissues related tosexuality, sexual decision-making,
8
andgender roles and relationships, andfocusedlargelyonoutcomes, suchasfertility
decline, unwanted pregnancy, andmorerecently, infection.
Clearly, social constructions ofsexuality andgender relations impact onreproductive
health. But, because they are generally considered to be politically and culturally
sensitive, theseissues havebeenneglected. Howlongcanweskirt aroundtheseissues
when men, women and especially young peopleare being increasingly exposedto
unwanted pregnancy andinfectionwithHIVandSTDs, duetolackofinformation and
services?Aproposed approach istoplacesexuality andgender relations at thecentre
of reproductive health programmes; to empower womento ensure that their health
needs are addressed; and toencouragemaleparticipation byensuring that mentake
responsibility for family planning, family support, and child-rearing (Germain et al,
1994).
ORGANISING REPRODUCTIVE AND CHILD HEALTH SERVICES
IN INDIA: IMPLEMENTATION CHALLENGES
Designing and Implementing Reproductive Health Services
Althoughthere isahighburden ofreproductivemorbidity, cost-effectiveinterventions
are also becoming increasingly available. The challenge is to developcost-effective
packagesofgoodquality servicestoaddresstheneedsofspecificclientgroupsinvarious
settings and tomake these available and accessibletoall, especiallytothe poor and
thedisadvantaged.
But, isthis feasiblefor resource-poor settings? Providingcomprehensivereproductive
health services toall isadesirable goal, but becausethere isconsiderablevariability
intheorganizational capacityofprogrammes inthedifferent regionsandstates ofthe
country, the extent towhich aprogramme might expand without compromisingthe
quality and effectiveness of existing services must beseriously considered. There is
clearly aneed to prioritize and to developaphased approach with an incremental
addition of health interventions that require greater skills and resources (Pachauri,
1995a).
TheMinistry of Health and FamilyWelfareisplanning toimplement aReproductive
andChildHealth Programme. Anessential packageofservicesisproposedfornation-
9
*
couples are abletohave sexual relations freeof the fear of pregnancy and of
contracting disease(Fathallah, 1988).
wideimplementation. In India, shifting tothe reproductivehealth approach implies
changing the implementation signals sent to 250,000family welfare staff. Client
satisfaction wouldbecometheprogramme's primary goal,withdemographicimpact a
secondary, though important concern. Broadening the existingpackageof servicesis
necessary, and improving the quality of services becomes the top priority. A quiet
revolutionisnecessary inthewaytheprogrammeisplanned andmanaged (Measham
&Heaver, 1995).
Promoting Reproductive Health: Addressing Clients' Needs
Areproductivehealth approachmeans that:
*
*
peoplehavethe abilitytoreproduceandregulate their fertility;
womenareabletogothrough pregnancy andchildbirth safely;
theoutcomeofpregnancyissuccessful interms ofmaternal andinfant survival
andwell being; and
*
Thus, thereproductive health approachextends beyondthenarrowconfinesoffamily
planning toencompass all aspects ofhuman sexuality andreproductivehealth needs
duringthevarious stages ofthe lifecycle.Programmes must, therefore, beredesigned
to address diverse needs at different stages of the lifecycle. Reproductive health
programmes areconcernedwithaset ofspecifichealth problems, identifiableclusters
ofclient groups, and distinctive goalsandstrategies.
Criteria for Designing a Package of Services
Thefollowingcriteriawereusedforprioritizingwhichhealth servicesshouldbeincluded
intheessential package:
1. levelsoffertility andmortality;
2. diseaseburden;
3. cost-effectivenessofavailablehealth interventions; and
4. thecapacity ofthehealth systemtodeliver health services.
10
Rationale for Reproductive Health Services Package
But, whyapackage of services?Therationale for suggesting apackage approach isto
enableprogramme planners to:
1. examine the cost, financing and sustainability implications of implementing
these services;
2. assess the feasibility and management implications for organizing various
combinations ofservicesat differentlevelsofthehealth servicesystemindiverse
settings; and
3. determine howto integrate reproductive health services within programmes
that arecurrently inplace.
Three oints deserve emphasis asthis programme isdesigned andimplemented.
*
First, most oftheservicesincludedintheessential packagearealreadyincluded
intheHealth andFamilyWelfareProgrammeinIndia, but areoftennotprovided
for want ofresources, adequate training, andother reasons.
*
Second, childsurvival interventions arealsoincluded. Whilesomereproductive
health interventions benefitbothwomenandchildren, others, suchastreatment
ofdiarrhoeal diseaseinchildren, donot. Nevertheless, sincewomenandchildren
formadyad, services for bothareincluded.
*
Athird important point isthat the services included inthe essential package
areamongthemost cost-effective.And, although someelements ofthe package
are, necessarily, morecost-effectivethan others, improvements inhealth depend
onmaking thewholeset availablebecausetheseservicesareinextricably linked
andtheir effectiveness dependsonensuring that theyareeffectivelyintegrated.
11
bD
~
AnEssential Reproductive Health Services Package
I - < < l >
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Prevention andmanagement ofunwanted pregnancy
tlJ
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Services topromotesafemotherhood
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Services topromotechildsurvival . . . . ,0
ac t >
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~~ Reproductive health servicesfor adolescents
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Prevention and treatment of reproductive tract
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infections and sexually transmitted infections
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Consequently, no priorities are set for interventions within the essential package. If
sufficient resources arenot availabletoprovidethewholepackage, itissuggested that
thewholepackagebeintroducedinphases rather than attempt tostrengthen individual
services on apiecemeal basis. Although adding newservices and improving quality
aremajor challenges, theydonotrequire aquantumincreaseinresources intheIndian
context. It is increasing coverageby fillingcurrent gaps in staff and infrastructure
that requires very substantial additional resources (Measham&Heaver, 1995).
Fortheeffectiveimplementation oftheessential packageofreproductivehealth services,
these issues must beaddressed: first, thegaps inexistingfacilities must befilledand
services expanded to areas that are not served; second, where reproductive health
servicesareprovidedtheymust beadequately financedtoensure acceptablequality of
\
care. TheWorldBank estimates that only17per cent incremental costsareassociated
with the provision of additional services for moving the present family welfare
programme to a reproductive health approach. If the entire costs are borne by the
public sector, an additional amount of 8.9per cent ofrecurrent costsper year inreal
terms wouldbeneeded for the programme until theyear 2000. Thesecostswouldbe
minimized if somereproductive health servicesareprovidedbyNGOsandtheprivate
sector also(WorldBank, 1995).
12
Organizing Integrated Services
Sincemenandwomenhavemultiple reproductive health needs, animportant guiding
principle should beto design services to address these multiple needs. Therefore, an
important challenge istoprovideintegrated servicestotheuser. However, integration
isabuzzwordthat has revisited thepopulation andhealth fieldsfor decades. Andyet,
many, if not most health services areprovidedthrough vertical programmes. Services
forfamilyplanning, child survival, andAlDSandSTDsareparticular examples. There
is, however, a growing realization that horizontal integration of services must be
achieved if reproductive and sexual health and rights aretobeuniversally realized.
There must beaconvergence of services at the users' level -- particularly sincethe
. sameserviceproviders deliver servicesat theperipheral level.Atpresent, theseservices
areadministered through multiple vertical programmes that originate fromdifferent
government departments andarefundedbymultipledonors, eachwithitsownagenda.
Such a multiplicity and fragmentation of services can bewasteful and' inefficient.
(Pachauri, 1996a).
It would be counterproductive to have reproductive health as yet another vertical
programme. In fact, the reproductive health approach provides an opportunity for
integrating many of the programmes that arecurrently inplaceand others that are
planned. InIndia, for example, thegovernment has implemented thefamilyplanning
programme for thepast four decades. Thechildsurvival programme has beeninplace
since the 1980s. Services for promoting safemotherhood have been initiated more
recently through the Child Survival and Safe Motherhood (CSSM) Programme. A
programme for the prevention ofAlDS andSTDsisalsoamorerecent initiative. The
challenge isto strengthen all these servicesbyexpanding their reach and improving'
their quality and by effectively integrating additional reproductive health services
within these ongoingprogrammes.
Contextualizing Reproductive Health Services in Diverse Settings
Major issues must beresolvedinthelocal context inorder todetermine whichservices
sh?uld bemade available at what level ofthe health system. Afirst step istoassess
therationale for recommending particular servicesinrelation totheir importance and
relevanceforspecificcontexts. Eachoftheservicesrecommendedintheessential health
13
services package incorporates anumber of health interventions. Many of these are
frequently not inplacebut must beincorporatedtoensuretheeffectiveimplementation
of services. It is important to determine which interventions within each service
component canbeimplemented at various levelsofthecare, giventhestaff skills and
organizational capacities at these levelsof theprimary health system. Clearly, while
someinterventions canbeimplemented at the peripheral levels, others that require
moresophisticated professional skillsandfacilitiescanonlybeimplemented at higher
levelsofthehealth servicesystem.
Inthe caseof India, I have prepared amatrix todelineate interventions that canbe
implemented at the community, sub-centre, primary health centre and community
health centre district/sub-district hospital levels(AnnexureI). Asystems approach is
taken withtheassumption that thefacilitiesat eachlevel canbecoordinatedandthat
referral systems can be established to refer cases that require more sophisticated
services fromperipheral tohigher level facilities that are better equipped and have
trained staff with better skills and capacities. It is suggested that this matrix bere-
formatted to design specificpackages of reproductive health services for particular
settings within India.
Monitoring and Evaluating Reproductive Health Services
Sincemethod-specific contraceptive targets havebeenusedinthepast formonitoring
and evaluating the programme, an important issue confronting the policyplanners
and serviceproviders ishowtheprogramme shouldbemonitored and evaluated now
that targets have been removed. Theimpact of the family planning programme in
India has sofar been measured primarily in terms of its contribution to increasing
contraceptiveprevalenceandtodecreasingfertility. Sincetheseindicators donotreflect
programme quality or the impact of programmes onreducing reproductive health
morbidityandmortality, theyarenot adequateformeasuring theimpact ofreproductive
health programmes. Thesecriteria for programme successor failuremust, therefore,
bemodified.Indicators formeasuring thequalityofhealth servicesfromtheperspective
oftheclient are, therefore, urgently needed(Pachauri, 1995a).
14
. .
Addressing Policy and Programme Relevant Research Needs
Afact that isfrequently not appreciated when designingcomprehensive, goodquality
reproductive health services isthat agreat deal ofpath-breaking research isneeded
as afirst step. Information isneeded onthe levelsand determinants of reproductive
morbidity andmortality indifferent populationgroups. Researchisneededtoenhance
our understanding ofthecontextinwhichhealth problemsarise; howwomenandmen
definetheir health problems; andhowtheychoosetheir health careoptions. Research
is also needed toassess the feasibility, cost, and effectiveness of interventions when
implemented within thehealth caredeliverysystemindiversefieldconditions.
At present, not onlyis research onreproductive health limited, but most available
data are fromhospitals or clinic settings, and these research results cannot be
generalized. Population-based studies are urgently needed to rectify the frequently
misleading results obtained fromhospital and clinic-based studies. Weneed multi-
disciplinary research, combining bio-medical and social sciencemethods to provide
epidemiological information onprevalenceandriskfactors, aswell ascontextual data
and information on the perceptions of women and men about reproductive health
problems aswell as anunderstanding oftheir health-seeking behaviours.
Thefollowingaresomeexamplesofpriorityresearch questions that must beaddressed
inorder tomoveforward onareproductive health agenda:
*
Howshouldthequality ofservicesbeimproved?
Howshouldreproductive rights beaddressed?
What services must beput inplacetomakemotherhood safeandprovidesafe
abortion?
*
*
*
Howcanprogrammes bedesignedtoexpand contraceptive choiceandprovide
informed choice?
*
What programme strategies areneededtoimprovecontraceptive safety?
What strategies areneededtoaddress problems of adolescents andyouthwho
represent our future, but whoseneedshavethus far beenneglected?
Howshould men be included as partners, and howshould their roles and
responsibilities infamilies beenhanced?
*
*
15
*
Howcanissues ofprogramme costsand sustainability beaddressed?
Inall work, there shouldbeanexplicitefforttoinvolvepolicyplanners, serviceproviders
(government andNGOs),researchers andothers, sothat researchisdesignedtoaddress
priority needs andthe research results arecontinually disseminated andshared with
users ofresearch sothat suchresearch canbeeffectivelyusedforprogramme planning
andimplementation.
Developing Partnerships with NGDs and the People
TheGovernment istobecongratulated ontherapid strides taken at thepolicylevel to
promote the reproductive health approach. It is, however, useful to learn frompast
experience. The Government's pioneering and far-sighted policies in the past have
frequently been"poorlyimplemented, resulting inagrowingdisenchantment withthe
public system. Whilethere will bedifferentials inprogramme success inacountry of
this scaleand diversity, the Government shouldrecognizeits limitations andmakea
concerted effort to work in partnership with a range of institutions, including
educational and research institutions, the corporate sector, NGOs, panchayats, and
most importantly with the people, to achieveits ambitious goals. There should bea
strong focus on decentralizing and devolving power to the people so that their
participation is sought inall effortstoimprovetheir quality oflife(Pachauri. 1996b).
Undertaking Advocacy to Make the Paradigm Shift
Reproductivehealth terminologyisnowpart ofthe rhetoric ofmany constituencies as
there has been agrowingdiscourseinrecent years onissues related topopulation and
reproductive health, and morerecently onsexual health. Today,reproductive health
rhetoric isbeingusedbymany. However,there aremajor information gapsat all levels,
ranging fromalack of understanding of"theideologyand the ethos embodiedinthe
reproductivehealth concepttoquestionsaboutwhat short-termandlong-termstrategies
are needed at the policyand programme levels to implement services. This lack of
information presents amajor deterrent tomaking aparadigmshift andimplementing
reproductive health programmes.
There isatremendous needfor strong advocacyeffortstochangerigidmind sets - to
change ways of conceptualizing the population problemand developingstrategies to
address this complexproblem. Toachievethis objective, an important priority is to
16
involveandempower arangeofdifferent constituencies, suchasNGOs, educationists,
activists, feminists, researchers, and government functionaries at all levels. The
objectiveshould be to catalyze a process of networking with a growing number of
organizations and individuals sothat theideologyandtheethos embodiedinthenew
concept areeffectivelyinternalized andprogrammes responsivetopeople'sneeds are
designedwith the activeinvolvement andparticipation ofall (Pachauri, 1995a).
The implications for changing paradigms are enormous because in promoting a
reproductivehealth approach, weareseekingtobringaboutinstitutional changewithin
rigid, bureaucratic, hierarchial government systems. Before newconcepts can be
internalized, existing ones must first be'unlearned'. Multiple stake-holders must be
informed and empoweredbeforeanyprocessof changecanbeeffected. All concerned
constituencies, -ofpolicy-makers, researchers, grassroots organizations, privatesector,
and others - must work in partnership to promote reproductive health policiesand
programmes.
Reproductive Health and Sustainable Development
Consensus onthe ICPD Programme of Actionprovides the foundation for practical
progress toward anumber ofinterrelated sustainable development objectives, which
are set out inthe Programme ofAction. Implementation ofthe Programme ofAction
requires that:
*
population agencies movebeyondfamilyplanning as their main (if not their
only) programme mechanism, and collaboratemuch morecloselywithhealth
and development agencies;
development sectors integrate population-related and human rights concerns
into their policiesandprogrammes; and
*
*
communities and their governments cometoterms with imbalances inpower
and opportunities between menandwomen, and controversial and eventaboo
issues, such assexuality andunwanted pregnancies.
Toaddress such concerns and to achievethe overall objectivesof the Programme of
Action, wemust foster participatory processesthat giveleadership andresponsibility
not solelytothegovernment, but alsotoNGOsandtothepeople.
17
REFERENCES
Bang, RA, Bang, AT., Baitule, M., Chaudhury, Y., Sarmukaddam, S., and Tale, O. 1989. High Prevalence of
Gynecological Diseases in Rural Indian Women. Lancet 1(8629):85-88.
Bang, RA and Bang, A 1991. Why Women Hide Them: Rural Women's Viewpoints on Reproductive Tract
Infections. Manushi 69:27-30.
Fathalla, M. 1988. Research Needs in Human Reproduction. In: E. Diczfalusy, P.D. Griffin, and J . Kharlna
(eds. ), Research in Human Reproduction. Biennial Report (1986-87), Geneva: World Health Organisation.
Germain, A, Nowrojee, S., and Pyne, H.H. 1994. Setting aNewAgenda: Sexual and Reproductive Health and
Rights. In: Sen, G., Germain, A, and Chen, L.C. (eds.). Population Policies Reconsidered: Health, Empowerment
and Rights. pp-27-46. Harvard Series onPopulation and International Health, Harvard University Press, Boston,
USA
J ain, A, and Bruce, J . 1994. A Reproductive Health Approach to the Objectives and Assessment of Family
Planning Programs. In: Sen, G., Germain, A, and Chen, L.C. (eds.). Population Policies Reconsidered: Health,
Empowerment and Rights. pp-27-46. Harvard Series onPopulation and International Health, Harvard University
Press, Boston, USA
J ejeebhoy, S.J ., and Rao, S.R 1992. Unsafe Motherhood: A Review of Reproductive Health in India. Paper
presented at the Workshop onHealth and Development inIndia, National Council ofApplied Economic Research
and Harvard University Centre for Population and Development Studies, NewDelhi, J anuary 2-4, 1992.
Measham, AR, and Heaver, RA 1995. India's Family Welfare Program: Moving to aReproductive and Child
Health Approach. Directions in Development. The World Bank, Washington, D.C.
Pachauri, S. and Gittlesohn, J . 1994. Summary of Research Studies and Implications for Health Policy and
Programmes. In: J . Gittlesohn, M.E. Bentley, P.J . Pelto, M. Nag, S. Pachauri, AD. Harrison, and L.T. Landman
(eds.). Listening to Women Talk about their Health Issues and Evidence from India. The Ford Foundation and
Har-Anand Publications, New Delhi, India.
Pachauri, S. 1994. Women's Reproductive Health in India: Research Needs and Priorities. In J . Gittlesohn,
M.E. Bentley, P.J . Pelto, M. Nag, S. Pachauri, AD. Harrison, and L.T. Landman (eds.). Listening to Women Talk
about their Health Issues and Evidence from India. The Ford Foundation and Har-Anand Publications, New
Delhi, India.
Pachauri, S. 1995. Relationship between AIDS and Family Planning Programmes: A rationale for developing
integrated reproductive health services. Health Transition. Review, Supplement to No.4, 321-347.
Pachauri, S. 1995a. Defining a Reproductive Health Package for India: A Proposed Framework. South and East
Asia Regional Working Paper No.4, New Delhi, India.
Pachauri, S. 1996. A Shift fromFamily Planning to Reproductive Health: New Challenges. In:Srinivasan, K
(ed.). Population Policy and Reproductive Health. Population Foundation of India. Hindustan Publishing
Corporation (India), New Delhi, India.
Pachauri, S. 1996a. Programmatic Considerations for Prioritizing Reproductive Health Programs. Paper presented
at the Expert Consultation on Operationalizing Reproductive Health, UNFPA, NewYork, April 16, 1996.
Pachauri, S. 1996b. Interface between Research, Action and Policy-Making Interventions. Paper presented at
Seminar on Reproductive Health Organized by UNICEF, Luxor, Egypt, September 30- October 3, 1996.
United Nations. 1994. Report of the International Conference on Population and Development, (Cairo, 5-13
September 1994). AlCONF.171113.
World Bank, 1993. Investing in Health. World Development Report, NewYork: Oxford University Press.
WorldBank, 1995. India Family Welfare Program: Toward aReproductive and Child Health Approach. Population
and Human Resources Operations Division, South Asia Country Department. (Bhutan, India, Nepal).
18
ANNEXURE-I
FRAMEWORK FOR ESSENTIAL REPRODUCTIVE
HEALTH SERVICES PACKAGE
Table 1 : Services for the Prevention and Management of Unwanted Pregnancy
at Different Levels of the Health Service System
Community
Level
Sub-centre
Level
Primary Health
Centre Level
Community Health Centre
District/Sub-district
Hospital Level
Sexuality and gender
information, education
and counselling
Community
mobilization and
education for
adolescents, youth,
men and women
Community-based
distribution of
contraceptives
Social marketing of
contraceptives
Establishment of
effectivereferral
systems
and counselling
Expansion of
contraceptive choice
Provision of oral
contraceptives and
condoms
Insertion ofIUDs after
screening for
contraindications
Counselling,
management and
referral for side-effects,
method-related
problems, and change
of method where
indicated
Motivation and referral
for sterilization
Counselling and
referral for medical
termination of
pregnancy
Establishment of
effectivereferral
systems
Management of
referred cases and
feedback toreferral
source
and counselling
Expansion of
Provision of oral
contraceptives and
condoms
Insertion of IUDs after
screening for
contraindica tions
Conducting vasectomy
procedures
Performing first
trimester medical
termination of
pregnancy (upto 10
weeks)
Counselling and
management of cases
referred for side-
effects, method-related
ofmethod where
indicated
Motivation and referral
for sterilization
Counselling and
referral for second
trimester pregnancy
termination
Establishment of
effectivereferral
systems
Management of
referred cases and
feedback toreferral
source
and counselling
Expansion of
Provision of oral
contraceptives and
condoms
Insertion of IUDs after
screening for
contraindications
Conducting vasectomy
procedures
Provision offirst and
secondtrimester
medical termination of
pregnancy
Counselling and
management of cases
referred for side-
effects, method-related
of method where
indicated
Establishment of
effectivereferral
systems
Management of
referred cases and
feedback to referral
source
Note: Health interventions that are not apart ofthe present programme in India arehighlighted.
21
Table 2A:Antenatal Services at Different Levelsof theHealth Service System
Community
Level
Sub-centre
Level
Primary Health
Centre Level
DistrictlSub-district
Hospital Level
Counselling and
education for
breastfeeding,
nutrition, family
planning, rest,
exercise, etc.
Detection and referral
of cases with
complicated
pregnancies
Immunization for
tetanus prevention
Birth planning
Counselling and
education for
breastfeeding,
nutrition, family
planning, rest,
exercise, etc.
Immunisation for
tetanus prevention
Treatment of malaria
Birth planning
Provision of antenatal
services at clinics and
through outreach (at
least 4visits)
for complications, e.g.,
hypertension,
preecclemphxia,
eccalmpsia, severe
anemia, malaria,
tuberculosis, diabetes,
antepartum
hoemorrhage and
cephalopelvic
disproportion
ofwomenwith RTIs
and STIs
Counselling and
education for
breastfeeding,
nutrition, family
planning, rest,
exercise, etc.
Immunization for
tetanus prevention
ofcases with
complicated
pregnancies
Birth planning
Treatment of
tuberculosis
services at clinicsand
through outreach (at
least 4visits)
Detection &
management of
complications, e.g.,
hypertension,
preecclemphxia,
malaria, tuberculosis
and diabetes
Referral for hospital
delivery incases with
complications
Routine testing for
syphilis
Diagnosis and
treatment of selected
RTIs and STIs, and
referral for others
Management of
referred cases and
feedback toreferral
source
Counselling and
education for breast-
feeding, nutrition,
family planning, rest,
exercise, etc.
Immunization for
tetanus prevention
Birth planning
services at clinics(at
least 4visits)
Management of cases
with complications
Treatment of
tuberculosis
Routine testing for
syphilis
Diagnosis and
treatment ofRTIs and
STIs
Management of
referred cases and
feedback toreferral
source
Note: Health interventions that arenot apart ofthe present programme inIndia arehighlighted.
22
Table 2B: Delivery Services at Different Levels of the Health Service System
Community Sub-centre Primary Health Community Health Centre
Level Level Centre Level DistricUSub-district
Hospital Level
Detection of pregnancy Detection ofpregnancy Detection of Provision of
complications and complications and complications and institutional delivery
referral for hospital referral for hospital referral for hospital services
delivery delivery delivery
Treatment of
Clean home deliveries Clean home deliveries Clean home deliveries pregnancy
with delivery kits with delivery kits
Supervision ofhome
complications
Recognition of danger Recognition of danger deliveries byANMs Management of
signals (rupture of signals (rupture of
Treatment ofinfection
obstetrical emergencies
membranes of more membranes of more
Routine prophylaxis for
than 12hours than 12hours Routine prophylaxis for
duration, prolapse of duration, prolapse of gonococcal infection in
gonococcal infection in
the cord, hoemorrhage) the cord, hoemorrhage) the newborn
the newborn
and referral and referral
Arrangement of
Arrangement of
Routine prophylaxis for Supervision ofhome transport for referral
transport for
gonococcal infection in deliveries byANMs
obstetrical emergencies
the newborn
Management of
Management of
referred cases and
Arrangement of gonococcal infection in feedback to referral
referred cases and
feedback toreferral
transport for referral the newborn source
source
Arrangement of
transport for referral
Note :Health interventions that are not apart ofthe present programme in India are highlighted.
23
Table2C:Postpartum Services at Different Levels of the Health Service System
Community Sub-centre Primary Health CommunityHealthCentre
Level Level Centre Level DistricUSub-district
Hospital Level
Provision of postnatal Provision of postnatal Provision of postnatal Provision of postnatal
carethrough four carethrough four carethrough four post- carethrough four
postpartum visits (less postpartum visits (less partum visits (less postpartum visits (less
than 24hours, 7-10 than 24hours, 7-10 than 24hours, 7-10 than 24hours, 7-10
days, 3-4weeks and 5- days, 3-4weeks and 5- days, 3-4weeks and 5- days, 3-4weeks and 5-
6weeks) 6weeks) 6weeks) 6weeks)
Provision of Provision of Provision of Provision of breast-
breastfeeding support breastfeeding support breastfeeding support feeding support
Provision of family Provision offamily Provision of family Provision offamily
planning, counselling planning, counselling planning, counselling planning, counselling
and services and services and services and services
Provision of nutrition Provision of nutrition Provision of nutrition Provision of nutrition
education and education and education and education and
supplements supplements supplements supplements
Management of mild Treatment ofpuerperal Management ofwomen Treatment of puerperal
and moderate asphyxia seepsis referred with scepsis
ofthenewborn complications
Management of mild Manual removal of
Management of and moderate asphyxia Treatment ofpuerperal retained placenta
neonatal hypothermia ofthe newborn scepsis
Resuscitation for
Outreach carewithin Management of Resuscitation for asphyxia ofthe
24hours of delivery by neonatal hypothermia asphyxia ofthe newborn
sub-centre or PHe staff newborn
Treatment for some Management of
Management oflow and referral for other Management of neonatal hypothermia
birth weight (2000- complications neonatal hypothermia
Management of
2500gms) infants by
feeding, temperature
Referral for referred cases and
control and infection
complications feedbackto referral
prevention measures
source
Management of
referred cases and
for complications
feedback toreferral
source
Note: Health interventions that arenot apart ofthe present programme inIndia arehighlighted.
24
Table 3:Child Health Services at Different Levels of the Health Service System
Community
Level
Sub-centre
Level
Primary Health
Centre Level
DistricUSub-district
Hospital Level
Health education for
breastfeeding,
nutrition,
immunization, etc.
Provision of
immunization
Supplementation of
Vitamin A
Treatment of diarrhoea
without dehydration
Treatment of some
upper respiratory
infections
Treatment of mild and
moderate asphyxia and
lowbirth weight
infants (2000-2500
gms)
Provision of routine
prophylaxis for
gonococcal infection
Referral of infants with
complications
breastfeeding,
nutrition,
immunization, etc.
Provision of
immunization
Supplementation of
Vitamin A
with mild/moderate
dehydration
Provision offirst aid
for injuries, etc.
Treatment of some
upper respiratory
infections
Treatment of mild and
moderate asphyxia and
management oflow
birth weight infants
(2000-2500gms)
prophylaxis for
Referral ofinfants with
complications
breastfeeding,
nutrition,
immunization, etc.
Provision of
immunization
Supplementation of
Vitamin A
Treatment of acute
respiratory infections
for injuries, etc.
Management of
referred cases
Referral ofinfants with
complications
Treatment of asphyxia
and management of
lowbirth weight
infants (2000-2500
gms.)
prophylaxis for
Management of
referred cases and
feedback toreferral
source
breastfeeding,
nutrition,
immunization, etc.
Provision of
immunization
Supplementation of
Vitamin A
Treatment of acute
respiratory infections
Treatment of infection
for injuries, etc.
Treatment ofinfants
referred with lowbirth
weight, asphyxia,
infections, severe
dehydration, acute
respiratory infections,
etc.
prophylaxis for
Management of
referred cases and
feedback toreferral
source
Note: Health interventions that arenot apart ofthe present programme in India arehighlighted.
25
Table 4: Services for the Prevention and Treatment of RTls and STls at Different
Levels of the Health Service System
Community
Level
Sub-centre
Level
Primary Health
Centre Level
District/Sub-district
Hospital Level
and counselling for
adolescents, youth,
men and women
Community-based
condomdistribution
Social marketing of
condoms
gonococcal infections of
the newborn
Sexuality and gender Sexuality and gender Sexuality and gender
information, education information, education information, education
and counselling for and counselling for and counselling for
adolscents, youth, men adolescents, youth, adolescents, youth,
andwomen men andwomen men andwomen
Provision of condoms Provision ofcondoms Provision ofcondoms
Pilot testing ofthe Pilot testing ofthe Laboratory diagnosis
syndromic approach syndromic approach and treatment
Referral ofwomenwith Diagnosis and Pilot testing ofthe
vaginal discharge, treatment of some syndromic approach
lower abdominal pain infections and referral
and genital ulcers, and of others
Partner notification
men with urethral
and treatment
discharge, genital
Partner notification,
Routine syphilis
ulcers, and swelling in
treatment and referral
testing in antenatal
the scrotumor groin
Routine syphilis women
Partner notification
testing in antenatal
and referral
women
Routine prophylaxis for the newborn
Management of
the newborn
the newborn
referred cases and
Management of feedback toreferral
referred cases and source
feedback toreferral
source
Note: Health interventions that arenot apart of the present programme in India arehighlighted.
26
IIHMR RESEARCH PUBLICATIONS
BOOKS Price
(Including Postage)
First Decade of Research at IIHMR (198595) us$7/ Rs. 200.00
OCCASIONALPAPERS
Devendra Kothari (1991) Growing Population in
Rajasthan: Some Emerging Issues (No.1) (Revised
version under print)
us$5/ Rs. 100.00
Devendra Kothari et al. (1997)Vikalp :Managing the
Family Planning Programme in the PostICPD
Era: AnExperiment in Rajasthan, India (No.2)
us$5/ Rs. 100.00
WORKINGPAPERS
Lakhwinder P. Singh and S. D. Gupta (1997) Health
Seeking Behaviour and Healthcare Services in
Rajasthan, India: A Tribal Community's
Perspective (No.1)
Prashanta Pathak andK. K. Gaur (1997)AComposite
Index-based Approach for Analysis of the Health
System in the Indian Context (No.2)
US$3/ Rs. 50.00
US$3/ Rs. 50.00
POLICYBRIEFS
Devendra Kothari et al. (1997)Operationalising the
Concept of Unmet Need for Family Planning
Services: A Case Study (No.1)
Dhirendra Kumar andRahul Bhawsar (1997)Quality
of Care . Infrastructure, Human Resources and
Services Utilisation: Findings from Concurrent
Evaluation of Reproductive and Child Health in
Rajasthan, India (No.2)
\ ._ , '0:. . '":t" ~~ . ~~:. . r . (:
Late Shri 'Po b. A.garwal
1.1.1920-17.9.1982
Late Shri Prabhu Dayal Agarwal was born on 1st
J anuary, 1920,inBari Nangal, ahamlet inthedesert
district of Churu in Rajasthan. From humble
beginnings, herosebydint of sheer hard work and
single minded devotion to become an eminent
entrepreneur, settinguptheTCI groupofenterprises.
Withtime, hegrewinbothstature andkindness, and
becamealegendinhis lifetime.
With his strong commitment to the virtues of hard
work, truth and goodness, hewontheloveandtrust
of all those who came into contact with him. His
fairmindedness, magnanimity and altruism, as also
hisdetermination andrareconfidencewereproverbial. Aself-mademan, hecontinued
to work hard all through his life, and became a synonymfor success. In work, he
represented ablendofenergyandambition.
Hehas beenagreat sourceofinspiration tohis sons, employeesandpeers. Themany
growingTCI and Bhoruka enterprises owetheir stature primarily tohis progressive
outlookandhis abilitytothink big.

P.D. Agarwal Memorial Lecture by Saroj Pachauri Year 1997

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