>e c ~ n c l u s i o ~ s and v i ~ v s c.qr=ssst L z - Lu-s -- p 3 e r 2:~ :hcse 05 :kt 3';=t:,=.s z d - - - - do j o t aeressarLl7 :C:-SC: k s s e sr =.--e iiorld 3& Gzoup. 3.2 :a;sr is a. S, -a i= f o r C L S C - ~ S ~ O ~ ; ? iazse i o rioC :2=3 vi:hout t h e actkors ' per=fssloa.

- ... Topdat iaa and X m n Sesources Di~isian

. Discasaiou ?ager ,Yo. 81-14

- A Survey of 3er4tmeots and Special ?te!ec:s 23 izdia

?re?ared b y : -hid ?ar;qee

and Ja5nscn .

Irapared f g r : a .

Sesearc i ?=ojoe= 571-38, Yarangval ? ~ ~ u l a t i z a and 3ucrl:fon. 2.e ~~~~e or' t.%s r o , ~ i e u ?suer ',a relac? z=e Sazangwal p_qerL=ezt z = s d = s 7i=Z o t h e r IadXan t:~.e:ie;?c=s. I~-3-=-acica ac 3any of :he e.verf=ezrs ar?c ??D jeccs rzviewed here were coi lectsd 5p -=i=iaq =o :kefr s?ozsots i= Ladia, A list cP :hose 2i=0 gzacisualy 'Ici?ed us vL=,i, izl3r-zarisa is z z gage iii. The auchors wcm2d ~I'LB = 3 :ha& :Sen f o r ZkeFr czoper3cizn.

HEALTH. NJTRITION, -hXD F-WILY PL:A%ISG X Survey of Experiments and S p e c i a l P r o j e c t s i n Ind ia

Xbs t r a c t

This paper surveys f o u r t e e n experiments and s p e c i a l p r o j e c t s i n h e a l t h , n u t r i t i o n , and fami ly planning i n India . They f a l l i n t o t h r e e broad categories--research p r o j e c t s , p i l o t p r o j e c t s , and s e r v i c e p r o j e c t s . The paper reviews s e r v i c e s , workers , and t h e popula t ion covered t o d i s t i l l some important lessons:

( a ) I n t e g r a t i o n of s e r v i c e s f o r h e a l t h , n u t r i t i o n , and fami ly planning is t h e most c o s t - e f f e c t i v e , whether p r o j e c t s a r e oluls ipurpsse o r s i n g l e purpose.

(b ) Community p a r t i c i p a t i o n , where s t r e s s e d , l e a d s t o b e t t e r handl ing of community h e a l t h and we l f a re problems, b e t t e r acceptance of h e a l t h c a r e services, and g e n e r a l l y more e q u i t - a b l e d i s t r i b u t i o n of t he b e n e f i t s of s e r v i c e s . But i n a few p r o j e c t s , community l e a d e r s becam2 even b e t t e r o f f , r e s u l t i n g i n more i n e q u a l i t y , not l e s s .

( c ) I n most p r o j e c t s , pa rap ro fe s s iona l s t a f f d e l i v e r e d p r e v e n t i v e and s imple c u r a t i v e s e r v i c e s and d i d promotional work i n t h e v i l l a g e s . Female s t a f f were p r e f e r r e d ; bu t t h e r e is no c l e a r p i c t u r e about t h e p r e f e r r e d background, educa t ion , and exper ience of workers. I n some p r o j e c t s , even i l l i t e r a t e workers performed w e l l w i th t r a i n i n g .

( d ) The more s u c c e s s f u l p r o j e c t s seem t o have developed an e f f e c t i v e supervfsory and t r a i n i n g system.' General ly t h e sma l l e r t h e p r o j e c t , t h e b e t t e r t h e supe rv i s ion and t h e more impress ive t h e r e s u l t s .

- ( e l For coverage, i t is d i f f i c u l t t o adhere t o s e l e c t i o n c r i t e r i a

3 f i xed a t t h e o u t s e t of a p r o j e c t . N u t r i t i o n and h e a l t h - * c r i t e r i a , even ag& c r i t e r i a , cannot be s t r i c t l y followed. ~ L c h

e f l e x i b i l i t y o f t e n l eads t o a s i t u a t i o n of much l e s s c o v e r a g e s f - t h e t a r g e t group than des i red . P r o j e c t s w i t h s u r v e i l l a n c e systems had more success i n reaching t a r g e t groups.

( f ) Cosc f i g u r e s a r e a v a i l a b l e f o r only a few p r o j e c t s . Even when a v a i l a b l e , they do not r e f l e c t t h e resource c o s t , because many i tem (such a s t h e p r o j e c t d i r e c t o r ' s t ime) a r e not i n t h e es t imates . With t h e s e c o n s t r a i n t s and wi th t h e d i f f e r e n t p r i c e s f o r yea r s i n which estimates a r e made, c o s t s vary widely. A t Narangwal t h e annual c o s t per c a p i t a f o r n u t r i t i o n s e r v i c e s =as between S0.80 and $2.00, f o r populat ion s e r v i c e s between S1.16

acd $2.84. Those c o s t s a r e nea r ly l s u r c i n e s h ighe r t k a n :he c o s t of government s e r v i c e s . A t 2oshak t h e c o s t s ? e r c h i l d ?er annum were a l s o h ighe r than i n o t h e r government nutzi : ion 2 r o g r a m . In g e n e r a l , n u t r i t i o n p r o j e c t s c o s t morc per ca?i:a t h a n h e a l t h and f a n i l y ? l ann ing p r o j e c t s . I n some, e s p e c i a l l y those w i t h s t r o n g community p a r t i c i ? a t i o n , par' of t h e c o s t could be recovered.

(g) I n only a few ?ro:ects were some a t t e z p t s nade t o neasu re tSs i 3 p a c t of s e r v i c e s . Re t rospec t ive surveys and be fo re and after surveys were t aken t o rteasure changes i n outcones (heal:S, n u t r i t i o n , o r fami ly p lanniag) . 3 u t t h e s e changes could n o t be ~ t t r i b u t e d t o s e r v i c e s v i c h any degree of conf idence v i t h o u t c o n t r o l groups. Even i n ?rejects wi th c o n t r o l groups, a t t r i b u t i z g c5anges i n outcomes co s e r v i c e s was d i f f i c u l t . Yost p r o j e c t s used ou tpu t v a r i a b l e s (such a s s e r v i c e coverage) t o monitor prog- ~ e s s .

Although the experiments and s p e c i a l ? r o j e c t s o f f e r i n s i g h t s about d i f f e r e n t s t r a t e g i e s of i n t e r v e n t i o n , t h e coverage has been smal l i n r e l a t i o n t o tbe popu la t ion e v e n t u a l l y t o be served. Xoreover, t h e c o s t s of r e p l i c a t i o n appea r t o be high. One b i g p r o b l e n is t h e i n f l e x i b i l i k y cf l a r g e programs and of the Sureaucracy. 'Vhat is needed i n =he experiments and s p e c i a l p r o j e c t s is a b e t t e r system of moni tor ing and evaluat ion--so t h a t s o r e can be l e a r n e d about what they have achieved and about what t h e i n t e r v e n t i o n s have sieant.

The fo l lowing persons and i n s t i t u t i o n s he lped us w i t h informat ion . We acknowledge t h e i r suppor t and coopera t ion .

D r . R.D. Bansal, Government Xedical Col lege , Jammu.

D r . X. Damodaran, Na t iona l I n s t i t u t e of N u t r i t i o n , Hyderabad.

D r . H. Grewal, C h r i s t i a n Medical College and Brown Hernorial Hosp i t a l , Ludhiana .

M r . P.N. Hans, Na t iona l I n s t i t u t e of Heal th and Family Welfare , New Delh i

D r . V.L. Harasimham, Kasturba Xedical College, Manipal. 1

D r . K.X. Yaik, Heal th and Family Welfare T ra in ing Center , Ahmedabad.

D r . S.C. P a l , Nat iona l I n s t i t u t e of Cholera and E n t e r i c Diseases , C a l c u t t a .

D r . P. Rao, Nat iona l I n s t i t u t e of N u t r i t i o n , Hyderabad.

D r . K.S. S a n j i v i , M.A.C. I n s t i t u t e of Comnunity Heal th, Adyar, Xadras.

D r . A . Timmappaya, Kasturba Medical Col lege Hosp i t a l , Xanipal.

D r . M. Carba l lo , World Hea l th Organiza t ion , Geneva.

Pramit Chaudhuri, I n s t i t u t e of Development S tud ie s , Sussex.

Robert Chambers, I n s t i t u t e of Development S t u d i e s , Sussex. L

. Char les Cooper, I n s t i t u t e of Development S tud ie s , Sussex.

-

Emmanuel De Xadt, I n s t i t u t e of Development S tudies , Sussex. - - Michael Lipton, I n s t i t u t e of Development S tud ie s , Sussex.

& - I s a b e l l e ~ o s s e a u , ~ ~ o o d and A g r i c u l t u r a l Organiza t ion , Rome.

D e w

m

D r . David Yorley, I n s t i t u t e of Child Heal th , London.

D r . P h i l i ? Payne, London School of Hygiene and Trop ica l Xedicine.

P r a v i t Sarabanchong, United Nations Chi ldren ' s Fund, New York.

D r . P. Senanayake, I n t e r n a t i o n a l Planned Parenthood Fede ra t ion , London.

D r . Joe Yray, Harvard U n i v e r s i t y , Boston.

HEALTH. WTRITION. AND FAMILY PLANNING

A Survey of Experiments and Spec ia l P r o j e c t s i n Ind ia

Contents

Page No . The S e t t i n g .................................................... Framework of t h e Survey ........................................ C h a r a c t e r i s t i c s of P r o j e c t s ' ....................................

Services ................................................... Categories of Worker ....................................... ........................................ Populat ion Coverage

Main Elenents of t h e P r o j e c t s .................................. .................................... I n t e g r a t i o n of Se rv ices ..................................... Community P a r t i c i p a t i o n

Use of Auxi l ia ry Workers ................................... Supervision and T r a i n i n g ................................... Use of Home vfsits ......................................... Se lec t ion of C l i e n t s .......................................

P r i n c i p a l Findings about Costs and Benef i t s .................... ...... Nethods of Monitoring P r o j e c t s and Analyzing Thei r E f f e c t

Conclusions .................................................... ................................. . Appendix A P r o f i l e of S t u d i e s

................................ Narangwal N u t r i t i o n P r o j e c t I . Narangwal Populat ion P r o j e c t .............................. . ........ Alternat iv-? S t r a t e g i e s i n Family Planning. Bangalore

Mandwa Rural Health Research P ro jec t . Haharashtra ............ .............. In t eg ra t ed Heal th and N u t r i t i o n P ro jec t . Kasa P ro jec t Poshak ............................................. In t eg ra t ed Heal th S e r v i c e P ro jec t . W r a j ...................

C Indo-Dutch P r o j e c t f o r Chi ld Welfare ....................... No-Birth Bonus Scheme. South India ....... ................ . Comprehensive Rural Health P ro jec t Jarnkhed -................ Applied N u t r i t i o n Program. Kerala .......................... .......... Spec ia l Nu t r i t i on Program. Coimbatore. Tamil Nadu Spec ia l N u t r i t i o n Program. Andhra Pradesh .................. Nid-Day Heals Program. Madhya Pradesh ...................*..

Appendix B . L i s t of Add i t iona l S tud ie s and S p e c i a l T ro jec t s .............................

LIST OF TABLES

Page No.

Text - Table 1:

Tab le 2:

Table 3:

Appendix A

Table A. 1:

Table X.2:

Table A.3:

Table X.4:

Table A.5:

Table X.6:

Tab le A.7:

- Table A.8:

Table -4.9:

2 Table x.ZO: *

0

Table X.11:

............ Experiments and S p e c i a l P r o j e c t s

Hain Elements of Zxperiments and S p e c i a l P r o j e c t s ..................................

i teported Cos ts and S e n e f i t s of P r o j e c t s .....

M o r t a l i t y Rates by Experimental Croup and ........... Age Group a t Xarangwal, 1970-73

P r a c t i c e of Family Planning a t Yarangwal by Experimental Group ........................

A c t i v i t i e s of Community Heal th Workers at Nandwa ....................................

Immunization S t a t u s a t Kasa ................. Improvements under t h e I n t e g r a t e d Heal th

S e r v i c e P r o j e c t a t Xiraj .................. S e r v i c e Coverage by t h e Indo-Dutch

P r o j e c t ................................... Crude B i r t h Rate 1969-70 t o 1976-77,

South I n d i a ............................... I

Comparison of P r o j e c t and Yon-Project Areas Jamkhed ...................................

Hean Heights and Yefghts of Cni ldren by Age, Coinbatore ........................

Weight of Chi ldren by Age i n Xonths, Coimbatore ................................

Xean Heights and Weights of Supplemented and Unsupplenented CSi ldren Aged One ... t o F ive by T r i b a l Group, .hdhra I r a d e s h

List of Tables (cont'd)

Page No.

Table A.12: Weight of ?re-School Supplemented and Unsupplenented Children by Tribal Group,

h d h r a Pradesh ........................... 8 6

Table A. 13: Class i f icat ion of Nurritional Status of Children by Program Efficiency, Xadhya Pradesh ............................ 91

EEALTH, XUTRITION, A\D F-MILY PLANNING h Survey of Experiments and S p e c i a l P r o j e c t s I n Ind ia

I n August 1980 t h e Indian C o u x i l of Xed lca l Xesearch (IOiR) and t h e Ind ian

Council of S o c i a l Sc ience Research (ICSSR) publ i shed Heal th f o r A l l : .4n

A l t e r n a t i v e St ra tegy . That document s t a r t e d a nat ionwide deba te on hea l th-

inc luding n u t r i t i o n and fami ly planning-by h i g h l i g h t i n g t h e l i m i t a t i o n s of

h e a l t h p o l i c i e s and programs. It recommended t h a t t h r e e programs should b e

v igorous ly pursued dur ing t h e next two decades t o reach t h e goal of h e a l t h f o r

a l l :

a I n t e g r a t e d community development, i nc lud ing fami ly planning.

Improvements i n n u t r i t i o n , h e a l t h educat ion , ?nd t h e

environment.

Adequate h e a l t h c a r e s e r v i c e s f o r a l l through an a l t e r n a t i v e

h e a l t h c a r e system.

The a l t e r n a t i v e system, a l s o o u t l i n e d i n t h e document, s t r e s s e s primary h e h l t h

c a r e , p reven t ive s e r v i c e s ( i n c l u d i n g s u r v e i l l a n c e ) , materna l and c h i l d h e a l t h

(MCH) s e r v i c e s , and t h e use of community h e a l t h volunteers . I m p l i c i t i n t h i s

a r e fou r p r i n c i p l e s : f i r s t , i n t e g r a t i n g h e a l t h , n u t r i t i o n educat ion , and

. family planning s e r v i c e s ; second, community p a r t i c i p a t i o n i n t%e planning and

d e l i v e r y of h e a l t h c a r e services; t h i r d , a pyramidal system of h e a l t h c a r e ,

v i t h r e f e r r a l s t o t h e upper l a y e r s ; and f o u r t h , t h e use of indigenous

resources and h e a l t h personnel . These p r i n c i p l e s a r e not new, and t h e i r B

use fu lness has been w e l l t e s t e d i n many set t in 'gs . Nonetheless, eva lua t ing t h e

Indian exper iecce with t h e s e p r i n c i p l e s seem u s e f u l , and that is t h e

o b j e c t i v e of t h i s survey.

The S e t t i n g

A t independence i n 1347, t h e governnent system of h e a l t h c a r e h a r d l y reached

t h e r u r a l a r e a s , which were se rved by h e a l t h f a c i l i t i e s admin i s t e red by l o c a l . counc i l s and f o r e i g n mis s iona r i e s . S ince then , a v a s t network of h e a l t h

s e r v i c e s has been b u i l t , o f t e n i n c o r p o r a t i n g and s t r e n g t h e n i n g nongovernment

agencies . I n 1952 ? r i n a r y h e a l t h c e n t e ~ ~ s were c - t : b l i s h e d a s ? a r t of t h e

n a t i o n a l program of community development, and a system o f comprehensive

h e a l t h c a r e was in t roduced. Also i n 1952 t h e o f f i c i a l I n d i a n fami ly p l ann ing

program got under way, f i r s t a s a fami ly p lanning program, l a t e r a s a f a n i l y

we l fa re program.

Today t h e o r g a n i z a t i o n of medical c a r e comprises pr imary h e a l t h

c e n t e r s and subcen te r s , r u r a l d i s t r i c t h o s p i t a l s , and t h e l a r g e t e a c h i n g in-

s t i t u t i o n s and s p e c i a l t y h o s p i t a l s i n c i t i e s ( f i g u r e 1). The h e a l t h sys tem

pyramid, w i th p r i a a r y h e a l t h c e n t e r s and subcen te r s a t t h e base , g i v e s h e a l t h

workers t h e oppor tun i ty t o r e f e r p a t i e n t s t o h igher l e v e l s . A p r i s a q h e a l r h

c o n t e r provfdes c a r e t o 80,000 t o 120,000 people ; a subcen te r t o 10,000. In

L978 I n d i a had 5,407 p i imary h e a l t h c e n t e r s and '37,690 subcen te r s . These

f a c i l i t i e s provide =any s e r v i c e s , i nc lud ing maternal and c S i l d h e a i t h , - n u t r i t i 6 , s a n i t a t i o n , f ami ly planning, h e a l r h educat ion , t h e c o n t r o l of

4 -

- c o m u n i c a b l e d i s e a s e s , and :he c o l l e c t i o n of ep idemiologica l aod o t h e r

8 e . Along o i r h pyramidal h e a l t h c a r e , v e r t i c a l h e a l t h programs v e r e

launched r e g i o n a l l y and n a t i o n a l l y : campaigns a g a i n s t nalarta , t u k r t u l o s i s ,

and smallpox among them. S t a f f v e r e r e c t u i t e d and s e n t to do s p e c i a l vork

v i t h t h e s t a f f of primary h e a l t h cgn te r s . nis arrangement l ed r o o p e r a t i o n a l

and a d n i n i s t r a r i v , d i f f i c u l t i e s : Cadres of s p e c i a l i z e d o r unipur-nse v o r k e r s

pursued t h e t a r g e t s set f o r t h e i r programs but n e g l e c t e d b a s i c h e a l t h

s e r v i c e s . In t h e f ami ly p lanning program, a g g r e s s i v e s e a s u r e s Co p e r s u a d e

Ind ians t o adopt permanent c o n t r a c e p t i v e methods were s t r o n g l y resented-and

t h e bad f e e l i n g s about f ami ly p lanning a f f e c t e d t h e pe r fa rnance of h e a l t h

vorkers . The r e s u l t w a s t h a t s p e c i a l 2rograms slowed t h e davelopment of b a s i c

h e a l t h care .

The o r g a n i z a t i o n and composi t ion of h e a l t h teams c'nanged i n t h e late

1970s. F i r s t , a m u l t i s e c t o r a l approach has i n c r e a s i n g l y been recognized as

needed t o s o l v e che problems of t h e community, and t h e coord ina t ion of var%ous

s e c t o r a c t i v ~ t i e s - - s u c h zs a g r i c u l t u r e , educa t ion , hous ing , and health--has

been encouraged. Second, unipurpose workers have been conver ted t o

d t i p u r p o s e workers, and v e r t i c a l h e a l t h programs have been i n t e g r a t e d w i t 5

I b a s i c h e a l t h care . E i i r d , community p a r t i c i p a t i o n has been encouraged

through t h e r e c r u i t m n t of v i l l a g e and community h e a l t h workers, chosen by t f ie

I v i l l a g e people and i n some i n s t a n c e s p a i d by them.

X c c o r ~ i a g t o r e v i s e d n a r i o n a l h e a l ~ h po l i cy , which is based on r e c m - '

s e n d a t i o n s of t h e S r i v a s t a v a Committee (1975), one community h e a l t h worker -

provides b a s i c 3 e d i c a l s e r v i c e s i n each v i l l a g e . Yore co . sp l i ca tG c a s e s a r e 6

1 r e f e r r e d t o t h e p r i n a r y h e a l t h c e n t e r o r subcenter . S e r v i c e s are: i r i ceg ra t ed , 9

and t h e p a c t a s e &cludes h e a l t h , nutrir 'on, and family 2 lanning . 'Tke i e ~ i s e d

po l i cy a l s o i n c l u d e s p r o v i s i o n f o r d i r e c t i n g s e ~ ~ c e s co groups a t rLsk i n =%e

community: t a r g e t ?opu la t fons served by s p e c i a l programs.

Despi te such c3anges i n t h e o r z a n i z a t i o n and c ~ q o s i t i o n of health

I taams, access t o hea1:S and r e l a t e d s e r v i c e s l eaves aucn :a be des i r ed . !<ore

I : h n 35 ? e r c e n t of the popuiacion does not have easy a c c e s s io h e a l r h s e r - ~ i c s

(Xntia 1980). Although t h e r e a r e many more h o s p i t a l s and medica l profes-

s i o n a l s , p r even t ive and promotive h e a l t h s e r v i c e s have not been s u f f i c i e n t l y

developed t o reach t h e l a r g e r u r a l populat ion. The i n f a n t m o r t a l i t y r a te i s

e r t i m a t e d a t 110 per 1 ,000 l i v e b i r t h s . Of a l l dea ths 30 p e r c e n t a r e d u r i n g

the f i r s t yea r of l i f e , 14.6 percent iri t h e nex t t h ree . P r o t e i n and c a l o r i e

m a l n u t r i i ,n a r e b ig h e a l t h problems, a s a r e i n f e c t i o u s and p a r a s i t i c

d i seases . H a l a r i a and t u b e r c u l o s i s s t i l l a r e major h e a l t h hazards .

The ICXR-ICSSR document had t h i s t o say about t h e h e a l t h c a r e system:

"its b e n e f i t s do not reacS t h e poor o r t h e bulk of t h e r u r a l people. 9s ic is

devoid of a p a r t i c i p a t o r y element , i t has a c t u a l l y i nc reased t!e dependency o f

t h e people. Its c o s t s a r e e x h o r b i t a n t ; and on t h i s b a s i s , t h e coun t ry will

no t be a b l e t o provide good h e a l t h care co a l l i t s c i t i z e n s " (p. 5).

Framework of t.:a Survey

Yany expe r inen t s , s p e c i a l programs, and research p r o j e c t s have a t t empted to

i d e n t i f y problems and determine ways of achiev ing b e t t e r h e a l t h , p a r t i c u l a r l y

i n t he r u r a l a r eas . Some of t h e s e e f f o r t s a r e designed + - test t h e app ropr i - e

a t e n e a s and e f f e c t of a package of s e r v i c e s t h a t is accep tab le t o t h e

people. Others a r e designed t o test one component among many s e r v i c e s .

Outcome da t a a r e needed t o e v a l u a t e a s t r a t e g y s y s t e m a t i c a l l y and t o compare I

i t with o t h e r s ; but t h e s e da t a a r e nob a v a i l a b l e f o r most of t h e s p e c i a l

p r o j e c t s . Even s o , t h e experiments and s p e c i a l p r o j e c t s can be a s s e s s e d to

s e e what l e s s o n s they o f f e r f o r f u t u r e d i r e c t i o n s i n h e a l t h , n u t r i t i o n , and

fami ly planning.

We have chosen f o u r t e e n from a l a r g e ;lui;;+er of f i e l d exper iments and

s p e c i a l p r o j e c t s completed o r under vay i n primary h e a l t h c a r e , n u t r i t i o n , and

fami ly planning. Y2ny of t h e p r o j e c t s provide h e a l t h , n u t r i t i m , and f a s i l y

p lanning s e r v i c e s . S e v e r a l a r d concerzed p r i m a r i l y w i t i n f a n t , c h i l d , and

a a t e r n a l c a r e and wi th x o r S i d i t p , a o r t a l i t y , and growth. Some a r e n u t r i t i o n

o r popu la t ion p r o j e c t s ].inked t o t h e pr imary h e a l t h c a r e system. l e v had

r i g o r o u s r ~ o n i t o r i c g and e v a l u a t i o n . Our s e l e c t i o n was guided by pub l i shed

documents, r e p o r t s , and a r t i c l e s about t h e p r o j e c t s . We focused on r e c e n t

pro jet ts and t h e r e f o r e exc luded o l d e x p e r i a e n t s , e. g., Khanna, even though

they were w e l l documented. We n a t u r a l l y wanted t o i n c l u d e a s many r e c e n t

p r o j e c t s a s p o s s i b l e , b u t v e ended up c o n c e n t r a t i n g on r e s e a r c h , p i l o t , and

service p r o j e c t s o f government and of vo lun ta ry ~ r g a n i z a t i o n s . Appendix A has

p r o f i l e s o u t l i n i n g t h e background, des ign , and e f f e c t of t he exper iments and

s p e c i a l p r o j e c t s . Appendix 3 l ists ot!,er p r o j e c t s i n I n d i a f o r which some

g e n e r a l i n f o m a t i o n is a v a i l a b l e .

C h a r a c t e r i s t i c s of Pro 'ects

The expe r i&zn t s and s p e c i a l p r o j e c t s surveyed i n t h i s paper f a l l i n t o t h r e e

c a t e g o r i e s (see t a a l e I ) : ,

Experimental-cesearch p r o j e c t s t o i d e n t i f y new s t r a t e g i e s , t o

= t e s t new t h e o r i e s of h e a l t h , n u t r i t i o n , and fami ly p l ann ing , and *? - t o compare s e r v i c e c o q o n e n t s and t h e i r achisvements . - - 8 f ? i l o e p r o j e c t s t o t e s t t h e f e a s i 5 i l i t y of a s t r a t e g y and its

. r e p l i c a t i o n .

Se rv i ce -p ro j ec t s t o g rov ide s e r v i c e s i n response t o coumuni27

needs.

Although =he d i f f e r e n c e s Secveeti : : \ t ~ g o r i e s a r e g o t alvays s u b s t a n t i a l , t h e

c l a s s i f i c a t i m is he lpfu l - - for F t shows the focus and the scope, two

Table I: DEi4XE:;TS XYO S P E C U L ? R M C T S -- P r o l e c t -.- -- Ia31eaencia3 Agency Dates %is Sero ices Provided Cove raqc

:k+'ial ?o?\LiaciOn Project . hmjab

f n d i m Council of U e d i c d 1068-70 S u t r ~ : i o n / h e a l t h ca re / R.search/Jo has Sopicins f u l l y ? l a m i n g se rv ices . L'niversicy

Population Cente r L97.5-79 ? r b r y h e a l t h c a r e 3 a ~ a l o r e / C o r e c u n e a t f a d 1 7 plrnning. Eealch S e m i c u

Wur Wrl Grrtch Xeseuch R o j e c t . : laharashtrr

Poundacion f o r 1973- h4aq h e a l t h eare/HCR Research i n l u r r l x r v i c u / L e p r o r y / T B Beal th , Grmc Yadical c o o t r o l . College, B t m b a ~

Xasa Integraced YCE+ Project . ? a h i r a s h t r a

S u p p l a e a u r y feeding, e d u c a t i o d h e a l t h c u e / f d y plaoniag-

P ro jec t Porbk. !?adhya Pradesh

s t a u m d l o u g w . ~ a c / C I I

S e a l t h c ~ e / e d u c a t i o n / s r r p p l a e n t a r y feeding.

.Uraf Knceqracut Yarl th S e r v f c u Project , %barasher,

Bea l th care/ famIly plaruxhg/Leprosy/TB c u e .

I d z ~ O u c c h R o f e c c f o r Child F e l f a r e . Kyderabaa D i s t r i c r Arx~irra R a d a s h

Z e a l t h care/educat ion/ Creeb t s / supp laaen t l ry ~ u t r i t i o a / f a m i l y plan- ains/rural d e v e l o p e n r .

Foundation f o r k r a a r c h i n C-icy Saa lch /Sca t i gavenmenc,

Famfly planning no-birth sarings scheme XCR n d c a -

No-Birch Soaur Scheme. The 'UPAS1 d x p e r h n r ' om t h r u tea e s a t e s ln South Indfa.

h i e d P laa t* r s Aaaocfacioa of South I n d i a

I

Xucr iUon educat ion and strppLments/medical s e n i c a / f d l y ? l m n i n g / Lcproay/TB s e r p i e e r / r u r r l dc r r lop-aa r - X r r t r i d o n e d u c s t i o d ~~~~~~~~q feeding/ prbdocr ioa program/ hea lch cheelu/ i x r m n i u l i o a .

Feeding pragram.

C a p r e h e n r i v e aura l E e d t h P r o j e c t , Jamkbd

Appllad Nt l t r i t loa Program. KuraLr

e * * .. S t a t e g o r e m a e a t

Special Sucr ic ion ?rograrP, T r i S d arm, .udhra l r a d e s h

S t a t e gwerament 1970- Feeding program. 1 6 0 , ~

Sta t* g w e m e n c 1965- P e s d f q p t o g r a .

I1 h c l u d e s caocro l groups. d

I 2 a a a e i i c f a r l e s only . - i 3 Exdudes coacro l groupr. - /4 Yembers i n L977. 4

/ 5 !h f i n u r e s available far ~ n r t i c < N n t a -

d e t e d n a n t s of r e p l i c a b i l i t y . Zxper i zen ta l - r e sea rch p r o j e c t s t e s t t h e

e f f i c a c y of s t r a t e g i e s and a r e no t a e a n t f o r wide r e p l i c a b i l i t y . P i l o t

p r o j e c t s test an approach and a system expected t o be widely r e p l i c a t e d .

Serv ice-pro jec ts respond t o a F e l t need and a r e no t designed o r e v a l u a t e d f o r

r e p l i c a t i o n .

S e r v i c e s -- The experiments and s p e c i a l p r o j e c t s o f f e r s e r v i c e s i n p r i x a r y h e a l t h

c a r e , n u t r i t i o n , and f ami ly planning-and i f not d i r e c t l y r e s p o n s i b l e f o r a l l

s e r v i c e s , they have c l o s e l i n k s w i t h p a r a l l e l s e r v i c e s . I n t h e Applied

X u t r i t i o n Program, t h e s t a f f of t h e primary h e a l t h c e n t e r worked w i t h t h a t o f

t h e n u t r i t i o n program by s e l e c t i n g c l i e n t s and provid ing h e a l t h checks and

i m u n i z a t i o n s f o r c h i l d r e n . T3e No-3irth 3onus Scheme, p r i m a r i l y a n i n c e n t i v e

p l an f o r fami ly p2-anning a c c e p t o r s , vas c l o s e l y a l l i e d wi th the Comprehensf ve

Labor Welfare Program, vh ich provided m t e r n a l and c h i l d h e a l t h s e r v i c e s and

e d u c a t i o n a l s e r v i c e s on t e a e s t a t e s .

The main s e r v i c e s of tSe p r o j e c t s , a l r e a d y sunmarized b r i e f l y i n L

t a b l e 1, can be c l a s s i f i e d i n t h r e e r a y s : ( a ) t h o s e t h a t provide compre-

hens ive s e r v i c e s f o r h e a l t h , n u t r i t i o n , and family planning; ( 5 ) t h o s e t h a t - .* provide an i n t e g r a t e d s e t of s e r v i c e s f o r h e a l t h , n a t r i t i o n , and fami ly plan- - -

*

d a g and i n a d d i t i o n s e engaged 13 r u r a l development; and ( 2 ) t hose gt: h a v e . m

s p e c i f i c n u t r i t i o n o r popu la t ion o b j e c t i v e s and cha t s ay have l i n k s ~ i t h com-

plementary se r -dces .

P r o j e c t s i n t h e f i r s t ca t egory i n c l u d e t h e Yandwa, Y?ra j, Kasa, and

Yarangwal p r o j e c r s and :o a l e s s e r excent tSe e x p e r i a e n t i n family ? l m n i n g 13

3angalore . The :hrust of t h e s e p r o j e c t s has been p reven t ive and ?ronio t ional

work i n maternal and c h i l d h e a l t h and i n n u t r i t i o n , w i th l e s s emphasis on

c u r a t i v e ca re . Se rv i ces have f o r t h e n o s t p a r t been provided by the h e a l t h

workers -a v i l l a g e s . P r o j e c t s i n t h e second ca tegory a r e t h e Comprensive

Rura l Heal th P r o j e c t a t Jamkhed and t h e Indo-Dutch P r o j e c t f o r Child Welfare ,

which sponsor 6 broad range of h e a l t h - r e l a t e d s e r v i c e s and broader development

a c t i v i t i e s . P r o j e c t Poshak i n :-!adhya Pradesh, the 30-9ir th Bonus Scheme i n

South I n d i a , and t h e n u t r i t i o n p r o j e c t s i n Andhra Pradesh, Tamil Yadu, ~Yadhya

Pradesh, and Kerala , b roadly f a l l i n t o t h e t h i r d ca tegory . Each of them has

s p e c i f i c o b j e c t i v e s f o r n u t r i t i o n o r family planning.

Ca tegor i e s of Worker

The manpower s t r u c t u r e i n primary h e a l t h c a r e encompasses many

v i l l a g e h e a l t h workers. The pyramidal h i e r a r c h y c e n t r a l t o t h i s system

inc ludes s e v e r a l l e v e l s of h e a l t h workers, each provid ing suppor t and super -

v i s i o n f o r t hose a t lower l e v e l s . A 1 1 workers a r e t r a i n e d and q u a l i f i e d t o

perform p a r t i c u l a r t a s k s s u i t e d t o t h e i r educat ion and competence. This

s t r u c t u r e is e f f i c i e n t i n t h e use of s c a r c e manpower and ensures easy r e f e r r a l a

of 'compl ica ted cases t o h ighkr l e v e l s . When t h i s system o f r e f e r r a l works,

people i n remote r u r a l a r e a s have acces s t o t h e most s o p h i s t i c a t e d of h e a l t h

s e r v i c e s .

Although no c o n s i s t e n t pat t e r n of r e c r u i t a e n t , t r a i n i n g , and rn

r e s p o n s i b i l i t y is appare,- , many of t h e p r o j e c t s have a ( i e r a r c h i c a l s t r u c t u r e

s i m i l a r t o t h a t f o r primary h e a l t h care. Close communication and s u p e r v i s i o n ,

coupled with ongoing t r a i n i n g have been an i n t e g r a l p a r t of s e v e r a l

p r o j e c t s . ?!any f e a t u r e s o f t h e western s y s t e a of h e a l t h c a r e have been

avoided. Genera l ly , t h e nanpower s t r u c t u r e has avoided a s y s t e s top-heavy

wi th h e a l t h p r o f e s s i o n a l s .

?any of t he ?rejects have been planned and developed by doctors who

have wide exper ience i n rura l h e a l t h c a r e . Phys ic i ans g e n e r a l l y p l a y a

c e n t r a l r o l e by s u p e r v i s i n g and t r a i n i n g p a r a p r o f e s s i o n a l s and by t r e a t i n g

complicated s e d i c a l c a s e s beyond the c a p a b i l i t i e s of p a r a p r o f e s s i o n a l s . TSe

h i e r a r c h i c a l s t r u c t u r e i n t h e Kasa, X l r a j , Yandwa, Jamkhed, Yarangwal, and

Indo-Dutch p r o j e c t s - - e s s e n t i a l l y t h e smal l - sca le projects--has been developed

a long t h e s e l l n e s . X t Jamkhed, f o r example, t h e Xroles have been d i r e c t l y

involved i n des ign ing and a d m i n i s t e r i n g t h e t r a i d n g program f o r v i l l age -based

h e a l t h workers. l / - ?any of t h e small p r o j e c t s have t r a i n i n g cour ses f o r v i l l a g e h e a l t h

u o r k e r s , cour ses t h a t emphasize p r a c t i c a l s k i l l s and p reven t ive and promotive

h e a l t h work r a t h e r than c u r a t i v e s k i l l s . I n Xaharashtra many of t h e p r o j e c t s

sponsored a shore cour se , u s u a l l y l a s t i n g t h r e e t o s i x weeks, t o t r a i n vL l l age

workers i n i d e n t i f y i n g and d iagnos ing i l l n e s s , m a l n u t r i t i o n , and i n f e c t i o u s

d i s e a s e s . The workers were a,lso t r a i n e d i n p r e n a t a l and p o s t n a t a l c a r e , i a

g i v i n g i a m n i z a t i o n s , and i n o t h e r p reven t ive work. 3ecause many p r o j e c t s - emphasize ongofkg t r a i n i n g , t h e workers can bu i ld on t h e knowledge a l r e a d y

' J &

aa ined through p r a c t i c a l t r a i n i n g and f i e l d exper ience . r

b The i 8 e r n e d i a t e s t a f f g e n e r a l l y inc ludes peopie v i t h wider e q e r i - - -

ence and longer t r a i n i a g , such a s a u x i l i a r y nu r se s i d v i v e s , paramedical

1. 3 r s . Yabel le and 3 a j a n i P a n t Xroles worked i n a Xaharashtra h o s p i t a l frcn 1962 t o 19666. r a v i n g subsequent ly gained t h r e e yea r s of c l i a i c a l z :qe r i - rnce and havinq t aken a one-year cour se in p u b l i c h e a l t h abroad, t h e Xroles recarxed t o Ylaharasntra and i n i t i a t e d rhe Jankhed 2 r o j e c t .

workers, and mult ipurpose h e a l t h workers. They provide t h e t e c h n i c a l guid-

ance, suppor t , and encouragement f o r v i l l a g e workers and r e g u l a r l y v i s i t t he

v i l l a g e s t o supe rv i se h e a l t h a c t i v i t i e s . General ly based a t t h e pr imary

h e a l t h c e n t e r o r u n i t , t h e i n t e rmed ia t e workers p a r t i c i p a t e i n c l i n i c a c t i v i -

t i e s v i t h doc to r s , n u r s e s , and o t h e r s t a f f .

The f ind ings from a o s t of t h e small-scale p r o j e c t s sugges t a

r e l a t i v e l y f l a t o r g a n i z a t i o n t h a t f e a t u r e s c l o s e communication between

l e v e l s . A t hndws , f o r example, t h e p r o j e c t is adminis te red by a l o c a l doc to r

who supe rv i se s t h e work cf a u x i l i a r y nu r se midwives and community h e a l t h

workers. Each 2 u x i l i a r y nu r se midwife supe rv i se s t h e work of f i v e community

h e a l t h workers; a d o c t o r v i s i t s t h e h e a l t h subcenters once a week. Th i s

system of supe rv i s ion is both e f f i c i e n t and e f f e c t i v e i n reaching people i n

v i l l a g e s .

Findings from t h e l a r g e s e r v i c e programs, p a r t i c u l a r l y t h e S p e c i a l

N u t r i t i o n Program and t h e Applied N u t r i t i o n Program i n Kera la , h i g h l i g h t

s e v e r a l problems a s s o c i a t e d wi th s t a f f . The worker-to-client r a t i o appea r s t o

be low i n t h e f eed ing s e r v i c e s of t h e S p e c i a l N u t r i t i o n Program. I n urban a

a r e a s , one in spec to r s u p e r v i s e s many c e n t e r s , which s e r v e up t o 10,000

people. According t o many eva lua t ion s t u d i e q , t h i s superv isory system does ' d S

not appear t o be e f f e c t i v e , and t h e o rgan ize r a t each c e n t e r g e n e r a l l y i s not & - *

t r a ined . Xonthly compensation f o r work a t tHh c e n t e r is low, and suppor t f o r - . workers is l imi t ed . I n t h e Applied X u t r i t i o n Program i n Kerala , poor co-

o r d i n a t i o n and l ack of t r a i n i n g have been c i t e d as two of t h e problems r e t a r d -

i n g program development and success .

The r a t i o s of h e a l t h workers t o populat ion vary from p r o j e c t t o

p ro j ec t : f o r many p r o j e c t s no f i g u r e s are a v a i l a b l e . I n t h e Yaharash t ra

p r o j e c t s (Xasa, Jamkhed, Yandwa, and Y i r a j ) , vo lun ta ry h e a l t h workers on

average covered a popu la t ion of 1 ,500 t o 2,000, but t h e v a r i a t i o n around t h e s e

averages was cons ide rab le . The s p e c i a l n u t r i t i o n programs g e n e r a l l y had one

worker and a h e l p e r t o manage one f eed ing c e n t e r t h a t c a t e r e d t o 100 c h i l d r e n

and mothers , o f t e n t o nore . A t t h e supe rv i so ry l e v e l , however, t h e r a t i o s a r e

such s m a l l e r , wi th one i n s p e c t o r s u p e r r i s i n g c e n t e r s s e r v i n g 10,000

b e n e f i c i a r i e s . A t Yarangwal t h e r a t i o of h e a l t h workers t o popu la t ion was

1:1,500 and c o n t a c t w a s c l o s e between fami ly h e a l t h workers and v i l l a g e

f ami l i e s . E a r l y d i a g n o s i s and t r ea tmen t and continuous follow-up by v i l l a g e

workers had a = f o r i n f l u e n c e on t h e achievements the re .

Popu la t ion Coverage

The p o p u l a t i o i :overed depends on the kind of p r o l e c t : i t p robab ly

is l a r g e r f o r a s i n g l e i n t e r v e n t i o n p r o j e c t . The No-airth 3onus Scheme c o v e r s

521 persons ; t h e e-xperimental program of a l t e r n a t i v e s t r a t e g i e s i n f ami ly

p lanning i n f i v e d i s t r i c t s o f Bangalore, a s many a s 1.7 a i l l i o n . But t h e

d e f i c i t Setween t h e popu la t ion t a r g e t e d and the gopu la t ion covered is o f t e n C

g r e a t . m e problem is i n d i s t i n g u i s h i n g the popula t ion a t r i s k and t h e

popula t ion g e n e r a l l y covered. So d i s t i n c t i o n should be drawn betveen p r o j e c t s = ' J i i n which groups a t r i s k a r e i d e n t i f i e d and given p r i o r i t y and p r o j e c t s i n

I .) *

vhich wide popular ion coverag+ is in tended. 30th k h d s of ? ro j e c t can have .* . I

problems of ach iev ing expected coverage of t h e t a r g e t popula t ion . ?reject

c a p a c i t y , r e source and a d m i n i s t r a t i v e l i m i t a t i o n s , and ass5gning ? r i o r i ~ i e s t o

~ o a l s and o b j e c t i v e s a r e some of t h e i a p o r r a n t reasons f o r selecting c a r g e t

groups and i d e n t i f 7 i n g and t r e a t i n g groups a t r i s k .

S e v e r a l f a c t o r s a f f e c t popu l a t i on coverage. P h y s i c a l a c c e s s makes a

b i g d i f f e r e n c e i n r e a c h i n g t h e t a r g e t popula t ion . One s t u d y i n I n d i a h a s

shown t h a t f a r each a d d i t i o n a l h a l f mile between t h e community and t h e h e a l t h

c e n t e r , t h e pe r cen t age of t h e popu l a t i on a t t e n d i n g t h e c e n t e r f a l l s 50

pe r cen t . 1 A s i m t l a r s t u d y h a s shown t h a t 60 pe r cen t of t h e p a t i e n t s came

from w i t h i n a mile of t h e p r imary h e a l t h c e n t e r . - 21 In g e n e r a l , t h e

popu l a t i on covered by t h e exper iments and s p e c i a l p r o j e c t s is sma l l .

The c o s t of s e r v i c e s and t r a n s p o r t a l s o a f f e c t s a c c e s s , as do o t h e r

s o c i o c u l t u r a l de t e rminan t s . Use of s e r v i c e s , one i n d i c a t o r of e f f e c t i v e

a c c e s s , is i n f l u e n c e d by t h e e f f i c i e n c y and q u a l i t y of s e r v i c e s . The

r e l a t i o n s h i p between t h e h e a l t h s t a f f and t h e community, t h e p a t i e n t s '

p e r c e p t i o n s about t h e i r i l l n e s s e s , and t h e oppo r tun i t y c o s t s i n o b t a i n i n g

ca r e - - a l l t h e s e a f f e c t t h e u s e of s e r v i c e s .

The pro jests have had mixed r e s u l t s i n cove r ing t a r g e t popu1aticr.s .

The expe r i ence i n t h e l a r g e s e r v i c e - o r i e n t e d p r o j e c t s ha s n o t been

encouraging. ?kny of t h e n p rov ide a c l i n i c -ba sed , c e n t r a l i z e d sys tem o f

h e a l t h and n u t r i t i o n c a r e t h a t e xc ludes many of t h e t a r g e t popu l a t i on f o r whom

b a c c e s s f s d i f f i c u l t . The p r o j e c t s a r e t r y i n g t o r e ach t h e v u l n e r a b l e groups--

mothers and c h i l d r e n i n low-income famil ies--but because s e r v i c e s are

a v a i l a b l e o n l y a t c l i n i c s , t h e coverage exc ludes people f o r whom t h e p rog rams -

were in tended . - I n t h e Applied N u t r i t i o n Program i n Kerala, 25 perce& of t h e c e n t e r s

d id no t have t h e f u l l corn,-ement of c l i e n t s , and a t t endance r a t e s were 30 t o

40 pe rcen t below t h e number r e g i s t e r e d i n :he program. Although t h e s t u d y

1. World Sank, Hea l th Seccor Po l i cy Paper 1980 Washington, D.C.

2 . I b id .

r e p o r t does no t provide t h e number of in tended c l i e n t s , S igh drop-out r a t o s

and probl~,ms of r each ing t h e t a r g e t group a r e ev iden t . The i n c e n t i v e s o f :he

program f o r food product.i.on v e r e not used a s expected e i t h e r . I n t h e S p e c i a l

Y u t r i t i o n Program among t r i b a l groups i n Xndhra Pradesh, a s u b s t a n t i a l "take-

up r a t e " has been r epor t ed . The mean a t t endance rate was 86 pe rcen t , bu t nany

Yeople from t h e e l i g i b l e groups were not r e c e i v i n g t h e supplenent . I n t h e

YLd-3ay >!eals Program s c h o o l s on average provided food t o 16 pe rcen t = r e :ban

t h e a l l o c a t e d number of c h i l d r e n , and a s i z a b l e number of p a r t i c i p a n t s v e r e

aged 7 t o 11. Xost of t h e s e c h i l d r e n y e r e from t h e t r a d i t i o n a l unde ry r iv i -

leged c a s t e s .

Outreach e f f o r t s have been i n t e g r a l i n 3any of t h e p r o j e c t s , i ac lud -

i n g t h e rdo Narangwal F r o j e c t s . Outreach is be l ieved t o 3e impor tant i n

e f f e c t i v e coverage wi th s e r v i c e s of h e a l t h , n u t r i t i o n , and fami ly p lanning .

The ou t r each of t h e small p r o j e c t s seems t o have inc reased t h e acceptance of

f ami ly ? l a m i n g and t h e coverage of t a r g e t groups. - 1/ I n the Xiraj 2 r o j e c t

t h e ? r o p o r t i o n of family p lanning accep to r s r o s e from 20 percent i n I974 t o 89

2e rcen t i n 1977. The s u b s t a n t i a l i n c r e a s e may, however, 3e i n p a r t a t t r i b u t e d

t o t h e e x t e n s i v e s t e r i l i z a t i o n campaign i n t h e s t a t c . X t Jamkhed che

p e r c e n t q e of e l i g i b l e couples p r a c t i c i n g family planning is s u b s t a n t i a l l y - - higher than i n conprojeqc a reas .

* The sma i l e r t r o j e c t s have been more e f f e c t i v e i n reaching t a r g e t

r m

groups, p r i m a r i l y because of t h e i r c x t c n s i o n work i n t h e v i l l a g e s - 2x tens ion

s e r v i c e s a t t h e co rnun i t7 l e v e l have reduced o r e l imina ted p rob les s of access

1. 73e l a t i o n a l ? m i l 7 Y e l f a r e Program i n I n d i a has, over t h e y e a r s , adopted a new approach f o r r each ing prospec=ive family p lanniag acce?toLd. I n 1963 t he ou t r each system 3 a s t n i z i a t e d rhen c l in ic-based s e r v i c e s failed t o reducz t h e 3 i r z h r a t e t o :arzeted l e v e l s .

- 15 -

and have enabled h e a l t h and fami ly planning workers t o develop a r e l a t i o n s h i p

wi th v i l l a g e cormmtnities. V i l l a g e h e a l t h workers a t Jamkhed make house-to-

house v i s i t s and a r e r e spons ib le f o r t h e c a r e and fol low-up of a l l p r e n a t a l

and p o s t n a t a l ca ses and of a l l fami ly planning acceptors . V i l l age h e a l t h

a i d e s a t X i r a j were based i n t h e v i l l a g e and undertook h e a l t h and n u t r i t i o n

r e s p o n s i b i l i t i e s with r e g u l a r suppor-: and supervis ion from a v i s i t i n g h e a l t h

team. Health workers a t Kasa, by v i s i t i n g households r e g u l a r l y , were a b l e t o

i d e n t i f y emerging problems and t a k e immediate a c t i o n i n response t o needs.

But t h e success of t h e s e sma l l p r o j e c t s aasks the g r e a t e r d i f f i c u l -

t i e s t h a t planners f a c e i n t ransforming them i n t o l a r g e - s c a l e programs, which

r a i s e s ques t ions about r e p l i c a b i l i t y . Many small p r o j e c t s a r e c h a r a c t e r i z e d

by t h e i r f l e x i b i l i t y i n problem-solving and t h e i r a b i l i t y t o change d i r e c -

t ion . I n add i t ion , smaller p r o j e c t s tend t o have well-defined goals and

--l o b j e c t i v e s and a r e achievement-oriented. Large-scale prog'rams o f t e n a r e more

i n f l e x i b l e and adhere t o r i g i d o p e r a t i o n a l procedures, i r r e s p e c t i v e of prob-

lems i d e n t i f i e d . Large bureaucrac ies emphasize procedures more than goa l s and

ob jec t ives . Pyle U980 ) has h igh l igh ted t h i s problem and suggests ' t h a t when

smal l p r o j e c t s a r e expanded, t h e r e is a "misf i t" between t h e s t r u c t u r e of a -

l a r g e r bureaucracy and t h e newly adopted s t r a t e g y . Jie sugges ts t h a t t h e L

s t r a t e g y adopted should be modified s u b s t a n t i a l l y and t h a t t h e i n t e r v e n t i o n I -

* s h e l d be t e s t e d i n t h e bu reauc ra t i c and p o l i t i c a l s e t t i n q .

Xain Elements of t h e P ro jec t s

I n surveying the f o u r t e e n zxperiments and s p e c i a l ?rejects, v e examined t h e

fol lowing main elezuents: i n t e g r a t i o n of s e r v i c e s , community p a r t i c i p a t i o n ,

t he use of a w i l i n g workers , supe rv i s ion and training, the u s e of home v i s i t s ,

and t h e s e l e c c i o a of c l i e n t s (:able 2 ) .

Sarrlc. :nc8ac:lc Ian :a-ni:y ?arcLcl?ac:on L'se 3t u ; ra l larv Larscrs

:. Saraoqrai Yucrtcion ?ro:acc 78s :acn&ad semlc ra (h88lch. 78s a-nicy 8neaq.d :o arcan- Ycr Tanllr h u i t n d a r ~ e r s . :uce-::om zod taml:? ::ac:on and ex.%uCLon or 708diaq =ea:8r acr8acmcr y lacaias) ymwrted t o pragrama. 8 ~ p . ~ a 8 n c r l sroupa.

2. ::aranpal ?op&cion 'Iea CambLnad s.&c8a (tam11y 'I.. 91:ag.d 1n o rpn t z r c lon rna Yam Tapily n u i c a vorcarr. ??0:8cC ;rlaanh#. WHD'S ~ e ~ 1 ~ 8 8 #X~CUC:OII of ~ C O ~ C ~ M . 'amily ? h o n i n g a r c 8 r 8 .

and :-Id ~ 8 ~ 8 ) ;1~0wld8d t o F a p i 3 ? h o m q Dduucora .xper220u1 ~mup..

1.1 -:ad t o so- eaperi- = n u 1 a r 8 u and only p8r:~rl co-airy p8rc:c- :y8c ion.

Y8r CalarroLcy r 8 l f a r 8 -aor'.us A u t l i a r y aura. 1 h r u 'aaT hu l -A v i s i t o r s

?m I 8 8 l ~ i a u c r i c i o n i i 8 a i 1 ~ ylaaolng ;rrw.nUr8 and cuc8c:r. s . t r lu .

3. h a :nt.qrmc.a .%Fa Pra j u t

So 38oorc8d p8r:icLaac:on an17 l o r . ~ c i l i z a c l o s af #.CVlC88.

3. Lado-Cucch P r o j u t t o r N l d ';.liar.

78s .3ucri:ioofbulzh/t.rlly 21-g ? m 8 m c l w and c u n c i m smtrlcea

I t . Sp&l mcric:oo h a g r a , Colmbac or.

b 3 i l d r 8 0 ;r8rtic:p8~8d :n 'I*. i.aa&( :81~8r I C ~ I D ) Z ~ C . i i a c r 2 h c i o a of food. xo (T88c3inq s:rff .oqmqaa :a 18r.uc yarc lc lp~cioo. ;rr8puac:a and : i s c r i h -

'Lon 8 l r m ) - - 2 - - w

5 v ~ a r V l l l m aad :f.i.101

?as O o ~ o i a q crainlnq and IuQ*rVlSi=-

Aqa. k u l - a and aucrlcion lava1 c n c a r i a .

Yes QuCaC aad O U C C O ~

:r.a col:ec:aa.

Yas O o ~ o i a q c n l n l o g and nuparvision.

Yes (90 cosc I i g u n s Tas J u r w c daca rva l l r b l a ) rvailabla.

Salecelom by ~ e o g n p o l c a r u .

Tam CuCpuC data rvr i labla .

Vas 2 n l l a n a 1 7 aad onqolog CCaiUhS md NparrLlioU-

rarsac s-our and gamra l )om- lac loo coraraq*.

!as Jucpuc aad aucc5a8 daca c01:accad

':as ?rallminary and on-going cratoing and ~ p a n t s i o o .

t am iced 8- r i s l c s ~ r a l y mdm d w co c l r and ) h y s i u l XcasSi- b i l lCr-

Age c r l r a r l a l o r childran. U 1 p r r f o . 0 ~ and laccaring w o r n wrr iacludad.

Yes lu BuCprc and ouccau data collaccad.

ias P r a 1 m o . m and o a ~ o i - CraininS .nd Np*rrLlhD.

Iargac t r a p and ganaral ) o p J . E m corataga.

re. ( u ~ t c a d ) Yes OuC-c aad O U C C ~ ~

iaca coilacced. .?*a

Tar C u C ; u C data m la l~ . ?a* R. l lmiaary and ooqolng taainiog .od mp.rrLlloo.

Targac group and g a ~ r s l popllacZca coran8r .

Jot raporcad. Yam (No cosc f lguras Y 8 s Cucmc aad o u c c o r anal labia f daCa cullaccad.

Tas (Us l ead ) ?I. Oucprc aud o u c c o r data.

rn~lrl-rl a d 0 0 - p i ~ m l o l o # and m w l o o .

Yargac gmap and gamra l pow- Lacloo -raga.

38.4 m ( w g n p a l c location: no l a d i r l b l c r l c a r t . f o r p.rc1cfF.acioo.

h a d oa age c r l c a r l a f o r chl1dr.o. F r 8 p a a c and nursing =chars a l lg ib la .

7- Cost f igures noc Yes Ouc)uc and ouceom r r a l h b l a . d a u collaccad

(racrosp.).

e s Suparrl8los aad Cnlnlog I l r lced; s o u uarkara ur uocralned.

%sad ca a- c r l c a r l a f o r chl1dL.n. ?m#MnC and auralog w a a r s a l f e h l a .

1s t h lC8d SuOaNlSion d cralnlng: c a s c k r s d t - CrLhca toad pmara l l r .

%a Yo rmporrad h o u .isles.

LUgiblUcy basad ca school a o r o u c .

Tas Iacrospcccira OUC-

puc and oucco.. d a u a w l a b l e .

I n t e g r a t i o n o f S e r v i c e s

One impor tan t l e s s o n i s t h e e f f i c i e n c y o f i n t e g r a t i n g s e r v i c e s f o r

h e a l t h , n u t r i t i o n , and f a m i l y planning. According t o t h e well-documented

r e s u l t s o f t h e Y'arangwal r e s e a r c h , t h e e f f e c t s of i n t e g r a t e d s e r v i c e s on

growth, morb id i t y , m o r t a l i t y , and f a m i l y p lann ing accep t ance a r e a l l s i g n i f i -

c a n t . The f i n d i n g s s u g g e s t t h a t p r e n a t a l n u t r i t i o n a l c a r e , which i n c l u d e d a

food supplement and i r o n and f o l i c a c i d , were s t r o n g l y a s s o c i a t e d w i t h a

r e d u c t i o n i n t h e p e r i n a t a l m o r t a l i t y r a t e of 40 t o 50 pe r cen t . Te tanus i m u -

n i z a t i o n s f o r p r egnan t women reduced p e r i n a t a l morta l i t : . about 20 p e r c e n t .

Recognizing t h e r e l a t i o n between n a t e r n a l c a r e and Lnfant m o r t a l i t y ,

and t h e s y n e r g i s t i c r e l a t i o n between i n f e c t i o n and m a l n u t r i t i o n , many p r o j e c t s

focused i n t e g r a t e d s e r v i c e s on n o t h e r s and i n f a n t s . The Xandwa p r o j e c t , f o r

1 example, has combined p r e n a t a l and p c s t n a t a l c a r e w i t h n u t r i t i o n and

immunization programs t o a c h i e v e b e t t e r b i r t h we igh t s , avo id n e o n a t a l t e t a n u s ,

and reduce i n f a n t m o r t a l i t y . E l i g i b l e coup l e s a t Jamkhed a r e approached a t a n

a p p r o p r i a t e time t o encourage t h e i r p r a c t i c e o f f ami ly p lann ing . Wonen who

have j u s t d e l i v e r e d and women who have t h r e e t o f o u r c h i l d r e n a r e u s u a l l y I

encouraged t o adopt f a m i l y p lann ing when t h e c h i l d r e n i n t h e f ami ly a r e

r e c e i v i n g con t inued care and fo l l ow up. The b a s i s of t h i s appioach is t h e - .* b e l i e f t h a t e l i g i b l e c o u ~ l e s w i l l n o t adopt fami ly p l ann ing u n t i l tiiey are - c o n f i d e n t t hey v i l l have th&r d e s i r e d number of h e a l t h c h i l d r e n . -

N u t r i t i o n s u r v e i l l a n c e has been impor tan t i n some p r o j e c t s . The Kasa

pr9 ject developed s p e c i f i c c r i t e r f a f o r groups a t r i s k . These groups were

i d e n t i f i e d through r e g u l a r an thropomet r fc measurement of c h i l d r e n and a number

o f r i s k f a c t o r s f o r p r egnan t women. Prev ious h i s t o r y of s t i l l b i r t h , a b a r c i o n .

o r s m l l - f o r - d a t e s b a b i e s and o t h e r c l i n i c a l s i g n s a l e r t e d h e a l t h p e r s o n n e l t o

problems. Concern ha s been exp re s sed about whether t h e feeding-only s t r a t e g y

of t h e p r o j e c t adequa t e ly a d d r e s s e s t h e h e a l t h and n u t r i t i o n a l needs o f t h e

target groups. The I n t e g r a t e d Ch i ld Development Scheme--a l a r g e p i l o t p r o j e c t

c u r r e n t l y underway i n I n d i a is des igned t o meet t h e h e a l t h , s o c i a l , n u t r i -

t i o n a l , and e d u c a t i o n a l needs o f c h i l d r e n i n t h e p r e schoo l age group as w e l l

a s t h o s e of pregnant and n u r s i n g mothers. Segun i n l a te 1975, i t is a mu l t i - 1 f a c e t e d p r o j e c t t o d e a l w i t h t h e many p rob i ens of h e a l t h and n u t r i t i o n among

t h e -vulnerable groups. P r e l i m i n a r y f i n d i n g s from a s t r a t i f i e d random sample

survey of c h i l d r e n under a i x show a major d e c l i n e i n t h e pe r cen t age of

malnourished c h i l d r e n ove r a two-year pe r i od .

Community P a r t i c i s a t i o n -- Communities c a n p a r t i c i p a t e i r r t h e development of a h e a l t h c a r e

system i n many ways an6 a t d i f f e r e n t s t a g e s . These i n c l u d e having t h e com-

munity pay a f e e f o r s e r v i c e s , make s a l a r y payments t o h e a l t h workers , o r

p rov ide n a t e r i a l s and l a b o r f o r c o n s t r u c t i o n ; having t h e community t a k e p a r t

i n t h e p l ann ing and i d e n t i f i c a t i o n of programs t o s o l v e t h e i r h e a l t h needs ; L ~

having t h e Community h e l p i n p r even t i on , promotion, and t h e c o l l e c t i o n of

ep idemio log i ca l o r o t h e r r e l e v a n t d a t a . <

4

The Jamkhed p r o j e c t g o t t h e community t o t a k e part by f i r s t approach-

ing v i l l a g e l e a d e r s w i t h p roposa l s f o r t h e comprehensive h e a l t h c a r e s e r v i c e s 4

and implement ing t h e d e s i r e d s e r v i c e s wcth community coope ra t i on . The p r o j e c t

became i n c r e a s i n g l y s e l f - s u f f i c i e n t : i n 1978 p a t i e n t fees covered t h r e e -

q u a r t e r s o f t h e r e c u r r e n t expenses (Gwatkin and o t h e r s 1980). The communities

donated l a n d , provided m a t e r i a l s , and o f f e r e d t h e i r s e r v i c e s i n s e t t i n g up t h e

community h e a l t h f a c i l i t i e s . The pro:ect a l s o e n l i s t e d l o c a l cornnunit?

j r o u p s , such a s Young F a r n e r s Clubs , t o h e l p c o n d ~ c t a a s s i nmun iza t i on and

n u t r i t i o n programs.

?any of t h e small p r o j e c t s vo rked th rough gram p a n c t a y a t s ( v i l l a g e

commit tees ) and made no a t t e m p t t o bypass t h e v i l l a g e h i e r a r c h y o r t o

c h a l l e n g e s o c i o p o l i t i c a l s t r u c t u r e s . .It Yandwa ?reject o b j e c t i v e s v e r e n o t i n

l i n e w i t h v e s t e d i n t e r e s t s i n t h e v i l l a g e s . Loca l h e a l t h commit tees v e r e

forzied t o o v e r s e e programs and t o assist community h e a l t h v o r k e r s i n , I

p r e v e n t i v e h e a l t h v a r k . The p r o j e c t d i r e c t o r r e p o r t s t h a t t h e e n t h u s i a s m o f

t h o s e commit tees h a s vaned s u b s t a n t i a l l y because t h e ?reject is d i r e c t e d

I toward t h e poo re r s e c t i o n s o f t h e community and n o t s o a p p a r e n t l y S e n e f i c f a l

t o t h e most v o c a l rnernbers o f t h e c o m m n i t p , vho make up t h e ccmmit tees (Antia

1980). 3 u t t h e community s t i l l pays p a r t o f t h e h e a l t h workers ' s a l a r i e s and

?ays f o r medicine.

A t Yarangwal e f f o r t s v e r e a a d e , b e f o r e and a f t e r p r o j e c t s were

l aunched , t o in form communit ies and t o encourage t h e i r p a r t i c i p a t i o n ( T a y l o r C

and o t h e r s fo t thcoming) . Throughout t h e p r o j e c t ' s l i f e , v i l l a g e r s a s s i s t e d in

o r g a n i z i n g and execu t ed a l l major v a c c i n a t i o n p r o j e c t s . V i l l a g e r s p r o v i d e d - -

food and equipment f o r a s p e c i a l day-care c e n t e r and made payments i n kind to '2 - =-domen l o c a l l y r e c r u i t e d t o aanage t h e j rogram. Vi:al s t a t i s t i c s irere i 8

I

' r o l l e c t e d through a v a r i e t y o f s o u r c e s , i n c l u d i n g v i l l a g e r e p o r t s . The com-

a u n i t i e s ~ r o v i d e d b u i l d i n g s f o r u s e as h e a l t h s u b c e n t e r s and f e e d i n g

c e n t e r s . V t l l a g e p a r r i c i p a t i o n v a s r e p o r t e d t o be i n a cco rd vith i h e

o b j e c t i v e s o f t h e p r o j e c t .

Ia the Xasa and YLrz j ? t o j e c z s t5e coa?muni:7 vas n o t i n v o l r e a =a any

a r e a t e x t e n t . About c 3 e s e t r o ? r o j e c z s , ?yle ( L ' ? T ? ) has sugges ted c h a t t5e

p r o j e c t s a r e e f f e c t i v e o n l y a s l o n g a s t h e v o l u n t a r y agency o r s c v e r n n e n t

s u p p o r t s them. Once s u p p o r t i s withdrawn, t h e p r o j e c t cannot s u r v i v e . 3 u t

p r o j e c t s cannot become s e l f - s u p p o r t i n g i n a s h o r t t ime.

The p r o b l e n s o f t h e fndo-Dutch p r o j e c t a r e common t o many o t h e r s .

Bhen i t was begun a s a p i l o t p r o j e c t i n l a t e L969 i n t h e Hyderabad D i s t r i c t of

Xndhra Pradesh , p l a n n e r s e q e c t e d t h a t i n t e r n a t i o n a l donors c o u l d g r a d u a l l y ,

withdraw a s commanity involvement i n c r e a s e d . Communities were s l o w i n r e -

s p o n d i n g , however, and i t is now e x p e c t e d t h e p r o j e c t w i l l c o n t i n u e w i t h t h e

same i n p u t s u a t i l 1985. Of s e v e r a l problems, one is t h e t h e a t which :he

c o m ~ n t t y was a s k e d t o p a r t i c i p a t e . The f i r s t approach was t o p r o v i d e

c l i n i c s , h e a l t h c a r e , and n u t r i t i o n a l supplements w i t h o u t any community i n -

p u t . I n 1973, f o u r y e a r s a f t e r t h e s t a r t of t h e p r o j e c t , p r o j e c t o r g a n i z e r s

asked t h e l o c a l communities t o c o n t r i b u t e toward h e a l t h c a r e s e r v i c e s and t o

pay membership f e e s f o r women's g roups and c h i l d c a r e s e r v i c e s . The s l u g g i s h

r e s p o n s e h a s encouraged p r o j e c t l e a d e r s i n t h e expanded p r o j e c t i n Hyderabad

t o approach t h e community b e f o l e p r o v i d i n g s e r v i c e s .

w The l a r g e - s c a l e s e r v i c e p r o j e c t s ' i n n u t r i t i o n g e n e r a l l y haire n o t b e e n

e f f e c t i v e i n engag ing t h e p a r t i c i p a t i o n ~i t h e community, bu t comnunity

involvement i n t h e n u t r i t i o , p r o j e c t a t Andhra Pradesh was c o n s i d e r a b l e . I n Q L

t h e Appl ied X u t r i t i o n Program, gram panchaya t s p r o v i d e food u t e n s i l s and p a y a * *

ten-rupee a l lowance t o workers . I n t h e aid-day f e e d i n g p r o j e c t i n Xadhya

Pradesh no d i r e c t p a r e n t a l o r conmunity involvement i s r e p o r t e d , a l t h o u g h t h e

community has e x p r e s s e d p o s i t i v e views abou t t h e p r o j e c t .

The e x t e n t t o which t h e p r o j e c t s s t i e a g t h e n e d power s t r u c t u r e s and

i n c r e a s e d i n e q u a l i t i e s i n :he v i l l a g e s is n o t known. When community l e a d e r s

5econe a s s o c i a t e d w i t 5 r h e s e p r o j e c t s , t h e i r p o s i t i o n $3 t 5 e v i l l a g e h i e r a r c h y

is s t r eng thened and i n e q u a l i t i e s may be enhanced f u r t h e r . !!any p r o j e c t s had

t o work wi th v i l l a g e committees t o r e a c h t a r g e t groups. A t Yfndva t h e vi l1:~ge

committees , composed of t h e s o s t ,qocal members of t h e community, lost i n t e r e s t

when tbsy saw they had l i t t l e t o g a i n from promoting t h e p r o j e c t . A t tarnkhed

t h e p r o j e c t d i r e c t o r s were asked t o urge one of t h e i r workers t o vi:hdrav from

l o c a l community e l e c t i o n s , f e a r i n g t h e vo rke r would unsea t t h e incumbent.

Although h e a l t h v o r k e r s a r e encouraged '9 avoid p o l i t i c s , t h e development of

h e a l t h s e r v i c e s i n v a r i a b l y impinses on t h e ?ewer s t r u c t u r e f n v i l l a g e s .

Vse o f A u x i l i a r y Workers

Yany of t h e p r o j e c t s r e l i e d l a r g e l y on p a r a p r o f e s s i o n a l s t a f f t o

d e l i v e r p r e v e n t i v e and s imple c u r a t i v e s e r v i c e s and t o do promotional work I n *

t h e v i l l a g e s . I n t h e Indo-Dutch ? r o f e c c cormunity h e a l t h v o l u n t e e r s p rov ide

b a s i c h e a l t h and n u t r i t i o n a l s e r v i c e s t o t h e community and n o n i t o r changes i n

h e a l t h 2nd growth of c h i l d r e n . I n t h e Jankhed p r o j e c t v i l l a g e h e a l t h v o r k e r s ,

u s u a l l y women t h e community s e l e c t s , a r e impor tan t i n d e l i v e r i n g h e a l t h

services. People i n - ? i l l a@s can i d e n t i f y v i t b t he worker, ~ h o emphas ize ;

?romotiona?- and p r e v e n t i v e h e a l t h work and nakes i r more accep tab le t o t h e - - community. I n t h e Yarangual p r o j e c t fami ly h e a l t h u o r k e r s . # r e a t e d s i z p l e

L

c o n d i t i o n s a n d ~ r o v i d e d h e a l t h c a r e and fo l low-up t o c h i l d z n r e c s i v i n g s

s e r d c e s . h e i r w r k accounts f o r a l a r g e p a r t of :ha p r o : h c O s succes s .

3 a s i c t o p r i m a q h e a l t h care is t h a t v i i i a q e h e a l t h workers ,

ind igecous t o :he a r e a , should 2 r o v i d e h e a l t h , nutri: ion, and r e l a t e d s e r v i c e s

a r t h e ? e r i ? n e r y of t h e heal:h s y s t e a . Yany 7 r o j e c z s ( X i r a j , Kasa, and

Jtmkhed) have used rSe s k i l l s of tradirional d d v i v e s and ? r a c t i t i o n e r s ;

o e j e r s (Indo-autch and Xandwa) have r e c r u i ~ a d xew c a d r e s o f v o r k e r s , 2-ained

and ass igned them t o t h e v i l l a g e s t h e y come from. Vi l l age h e a l t h workers a r e

men or women u s u a l l y a b l e t o -.,ad and w r i t e , chosen by he community (o r with

i t s agreement), and c ra ined t o d e a l w i t h community problems. They are paid i n -

cash o r i n kind by t h e community f o r t h e h e a l t h func t ions they perform f u l l -

t i m e o r part-time. They a r e p a r t of t h e h e a l t h team working a t t h e per iphery .

There is no s i n g l e system of r e c r u i t i n g a p a r t i c u l a r kind of h e a l t h

worker. Some p r o j e c t s have engaged workers who had previous zxper ience i n t h e

government h e a l t h s e r v i c e s ; o t h e r s r e c r u i t e d and t r a i n e d workers w i t h no

experience i n h e a l t h care. The educat ion of workers a l s o va r i ed substan-

t i a l l y , ranging from t e n yea r s of g e n e r a l educat ion and f u r t h e r medica i

t r a i n i n g ( a s a t Narangwal) t o i l l i te ra te (as f o r women chosen a s v i l l a g e

h e a l t h workers i n Handwa and Jamkhed). Few low-level workers i n t h e l a r g e

n u t r i t i o n p r o j e c t s had trairzing i n n u t r i t i o n in t e rven t ion . There w a s c l e a r l y

a preference f o r female s t a f f , p r imar i ly because many s e r v i c e s a r e more

accep tab le i f d e l i v e r e d by a woman. liiddle-aged women wi th c h i l d r e n of t h e i r

own had o f t e n been chosen by t;:e cormnunity t o provide informal h e a l t h s e r v i c e s

before t h e i r recru i tment i n t o t h e p r o j e c t s .

*ny.projects have emphasized t h e r o l e of pa rap ro ie s s iona l s ' i n

provid ing h e a l t h c a r e and have developed s u i t a b l e p r a c t i c a l t r a i n i n g plans.

Shor t t r a i n i n g courses of one t o s i x weeks have been found most s a t i s f a c t o r y

i n prepar ing h e a l t h workers f o r t h e i r r e sppc t ive assignments. T ra in ing is

m c l o s e t o the v i l l a g e s , and p r i o r i t y is g iven t o p r a c t i c a l s k i l l s . Ongoing

t r a i n i n g needs a r e a l s o met by r egu la r i n - se rv ice teaching and d i s c u s s i o n , a

method t h a t has Seen p a r t i c u l a r l y s u c c e s s f u l i n augmenting the worker 's

knowledge and s k i l l s .

The Jadched p r o j e c t h a s enphas i zed t r o -way l e a r n i n g : c a s e

s t u d i e s a r e d i s c u s s e d weekly, based on t h e e x p e r i e n c e of h e a l t h -

v o r k e r s d u r i n g t h e p r e c e d i n g week. TS i s a l e r t s t h e p r o j e c t

d i r e c t o r s and o t h e r p r o f e s s i o n a l s t a f f t o t h e problems and

p e r c e p t i o n s o f t h e comuuni ty , and r e i n f o r c e s t h e h e a l t h workers '

t r a i n i n g by c o n t i n u i a g e d u c a t i o n .

The Kasa p r o j e c t had some problems i n r e c r u i t i n g v i l l a g e h e a l t h

v o r k e r s . Al though f e n a l e workers were p r e f e r r e d , few vomea who

m e t t h e c r i t e r i a were v i l l i n g t o work i n i s o l a t e d a r c a s . About

60 p e r c e n t o f t h e workers r e c r u i t e d were s e n , f o r whom drop-out

r a t e s v e r e h igh because o f t h e i n c r e a s e d demand f o r l a b o r d u r i n g

h a r v e s t p e r i o d s .

The p r e s e r v i c e t r a i n i n g o f f ami ly h e a l t h workers a t > T a r a n p a l

i n i t i a l l y t o o k e i g h t e e n weeks b u t was l a t e r compressed t o s i x

weeks v i t h o u t a n a p p a r e n t l o s s i n t e c h n i c a l s k i l l s . -411 f ami ly

h e a l t h workers a t J a r angwa l had a h igh s c h o o l e d u c a t i o n ,

p r e v i o u s t r a i n i n g a s l a d y h e a l t h v i s i t o r s , and f o l l o w - u p

t r a i n i n g i n h e a l t h .

A t Jamkhed 80 p e r c e n t o f t h e inany v i l l a g e h e a l t h ~ o r k e r s a r e

i l l i t e r a t e . The experience :here s u g g e s t s t h a t i l l i t e r a t e s can 8

p r o v i d e e f f i c i e n t s e r v i c e s and hand l e 90 p e r c e n t o i t h e Eases,

i n c l u d i n g d i a g n o s i s and t r e a t s e n t .

The Yandwa p r o j e c t , $3 an a t t e m p t t o have an i s m e d i a t o e i f e c c on

v i l l a g e h e a l ~ h ? rob lems , I n i t i a l l y used many h e a l t h ? r o f e s -

s i o n a l s , b u t t h i s proved ccmn te rp roduc r ive . S i g h l g t r a i a e a

T e r s o n n e l I n t h e ? t o ject expec ted r a p i d changes and ?ad

d i f f i c u l t y i n a d a p t i n g t o t h e s lower pace o f v i l l a g e l i f e . The

p r o j e c t is now d i r e c t e d by one h e a l t h p r o f e s s i o n a l ; community

h e a l t h v o r k e r s and a c . x i l i a r y n u r s e midvives p r c v i d e p r e v e n t i v e

and c u r a t i v e s e r v i c e s

I n Madhya Pradesh t h e f e e d i n g program i s r u n by t h e o r g a n i z e r s

of each c e n t e r v i t h t h e h e l p and suppo r t of t e ach ing s t a f f and

s t u d e n t s . Because h a l f t h e s c h o o l s do n o t have a cook a s s i g n e d

t o t h e program, s t u d e n t s and t e a c h e r s are r e s p o n s i b l e f o r much

of t h e p r e p a r a t i o n and d i s t r i b u t i o n of food.

Supe rv i s i on and T r a i n i n g

The more s u c c e s s f u l p r o j e c t s s h a r e many c h a r a c t e r i s t i c s i n t h e i r

h e a l t h manpower, i n t h e i r s u p e r v i s o r y system, and i n t h e i r t r a i n i n g pro-

grams. F i r s t , t h ey s e l e c t e d f r o n t - l i n e v o r k e r s from t h e c o m u n i t y . Th i s made

i t p o s s i b l e f o r h e a l t h workers t o v o i c e t h e needs of t h e community and t o p l a y

a c e n t r a l r o l e i n mee t ing t h e h e a l t h needs of t h e t a r g e t popu l a t i on . The

workers cou ld d e l i v e r s imp le c u r a t i v e and p r e v e n t i v e s e r v i c e s and cover d i s - I

0 pe r sed v i l l a g e communities. Second, t h e more s u c c e s s f u l p r o j e c t s were

developed by h e a l t h p r o f e s s i o n a l s f a m i l i a r w i th l o c a l hea luh problems and - - co-mity needs. T h i r d , t hey develop& an e f f e c t i v e s u p e r v i s o r y and t r a i n i n g

system. R e s u l t s i n v a r i a b l y were b e t t e i n s m a l l e r p r o j e c t s v i t h c a r e f u l 3 .. s u p e r v i s i o n : w e have a l r e a d y no ted t h a t two con t inuous t r a i n i n g programs

based on t h e day-to-day expe r i ence s of workers a t Jaskhed and Kasa produced

s i g n i f i c a n t l y b e t t e r r e s u l t s . Four th , t h e b e t t e r p r o j e c t s had workers t a k e

? a r t Fn s e t t i n g a r i o r i z i e s . ' i f t h , those p r o j e c t s collected e p i d e d o l o 3 i c a l

da ta , i d e n t i f i e d community j eeds , and assessed s e r v i c e 9ackages i n i c l a t i o n t o

t a r g e t s f o r h e a l t h , 3 u t r i t i o n , and famil:? planning.

Here a r e a few examples. i n t h e Yarangwal gopula t ion p r o j e c t , fainily

h e a l t h workers o f f e r e d var ious s e r v i c e s t o groups of v i l l a g e s , and t h e

project's inpac t on con t racep t ive use was seasured longf tud ina l l :~ . A t Jamkhed

and :Kasa, workers were d i r e c t l y involved i n s e t t i n g p r i o r i t i e s , i d e n t i f ~ r i n g

c o m u n i t y problems, and d e l i v e r i n g s e r v i c e s t o groups a t r i s k . The r e s u l t s of

:hese p r o j e c t s have Seen sncouraging. 3ut i n tke S p e c i a l N u t r i t i o n 'rogram,

vhich shares few of t h e c h a r a c t e r i s t i c s jus t l i s t e d , t h e n u t r i t i o n organizer

is n e i t h e r properly t r a i n e d nor supervised, and eva1ua:ion repor t s suggest

t h a t workers have Secome despondent.

Use o f Zome Visits - The primary h e a l t h c e n t e r , t h e subcenter , and ex tens ive home v i s i t i n g

a r e bas ic elements of =any of t h e profeccs. A t Narangwal, :Kasa, Jamkhed,

Y i r a j , andwa , and C i e v e l l a in the fndo-Dl~tch p r o j e c t , :he h e a l t h c a r t sgstcm e

has been based on outreach and on i n t e g r a t e d se rv ices . T5ese 2rojec:s have -

developed a system of regu la r house-to-3ouse v i s i t s t o c o l l e c t in f o . p a t i o n and - * e?idemiological da ta , t o fol low up on cases under s u r v e i l l a n c e , a n d 2 0 - - * Ldentlfy and t r e a t f i r t i c u l a r cond i t ions and groups i n x e d of s p e c k l care .

A t Yaranqwal t h i s system =as i s p o r t a a t i n t h e e a r l y tecognizion and c a r e of

i l l n e s s e s and m l n u t t i c i o n . gome v i s i c l n g appears t o be 2Lfectlve both tn

reaching t a r g e t groups and i2 ?rovitiFns s e r v i c e s t o aeet 5 a s i c xeeds.

Pro jecr ?oshak and c3e l a r g e a u c r i t i o n pro2ects had zo outreach

2rogram. :<ochers and c h i l d r e n a t t znaed a c e n t r a l c l i a i c , as in l o s h a ~ , o r a

n u t r i t i o n c e n t e r t o c o l l e c t food o r a t r e n d t h e f e e d i n g progran. The 3 r o j e c t s

d i d n o t p rov ide f o r an i n i t i a l house-to-house r e c r u i t s e n t campaign o f e l i g i b l e i f ami ly members o r f o i t h e fol low-up of drop-outs. P r o j e c t s t a f f were t h u s I unab l e t o i d e n t i f y emerging h e a l t h o r n u t r i t i o n problems o r t o o b t a i n up-to-

d a t e i n fo rma t ion on t h e e f f e c t o f p r o j e c t s on t h e t a r g e t groups. I n a d d i t i o n ,

t!~e f i n d i n g s r e p o r t e d by t h e s e p r o j e c t s sugges t t h a t t a r g e t group cove rage was

not s u b s t a n t i a l and t h e d rop -ou t r a t e s were high. The Yo-Birth Bonus Scheme

i n South I n d i a n e v e r t h e l e s s r e c r u i t e d many e l i g i b l e coup l e s w i thou t hone

v i s i t s . But t h i s was a s i n g l e - p r p o s e p r o j e c t and t h e environment o f t h e I projec: aade r e c r u i t m e n t and fo l l ow-up s imp le r t han i n t h e broader-based

programs.

I nc r ea sed emphasis on o u t r e a c h g e n e r a l l y l e d t o b e t t e r u s e and b e t t e r

coverage f o r t h e pe r cen t age of t h e p o p u l a t i o n a t r i s k . The Xarangwal e x p e r i - I ence shows t h a t t h e g r e a t e r t h e r e l i a n c e on hone v i s i t s , t h e g r e a t e r t h e u s e

I

of s e r v i c e s by low-income groups. Home v i s i t s were wcekly i n v i l l a g e s w i t h I I

s e r v i c e s f o r fami ly p l ann ing and c h i l d c a r e , and c - o n a t a l d e a t h s were reduced

, most f o r low-caste c h i l d r e n . The v i l l a g e s w i t h combined s e r v i c e s f b r f a m i l y

p l ann ing , women's c a r e , and c h i l d c a r e had on ly monthly ou t r each v i s i t s . -4s a

r e s u l t , fewer low-caste f a n i l i e s were reached , and r e d u c t i o n s i n n e o n a t a l

m o r t a l i t y were moderate , most o f which u e r e i n t h e h i g h - c a s t e group.

S e l e c t i o n of C l i e n t s

%ny of t h e h e a l t h and n u t r i t i o n p r o j e c t s , ? a r t i c u l a r l y i n t h e l a r g e

n u t r i t i o n programs, had no c r i t e r i a based on t h e h e a l t h and n u t r i t i o n a l status

of a o t h e r s and c h i l d r e n . Without such c r i t e r i a t h e p r o b l e a , a s i n t h e Appl ied

N u t r i t i o n Progrzn , is t h e f a i l u r e t o r e a c h t h e n e e d i e s t nenbers of t h e

- 28 -

conmunitg--low-income f a m i l i e s . It zia7 3e unacceptable t o l iz i t ?ar:fcipa=fon

by r i u t r i t i o n l e v e l . There is, i n a d d i t i o n , t h e ? r a c t i c a l d i f f i c x l t p of

s c r e e n i n g a l l p a r t i c i p a n t s . A t :Casa, c r i t e r i a vere s e t t o d e t a r n i n e e l f g i b i l -

i t y f o r t h e s p e c i a l n u t r i t i o n supp lenen t ; p o l i t i c a l r epe rcuss ions were roduced

by a c o m ~ ~ ~ n i t y e a u c a t t o n program g i v e n by p a r t - t i n e s o c i a l wor l z r s j a s e d iz

t h e v i l l a g e s . . ina lys is of ? z o j e c t l o shak shows t h a t t h e = i n t a r g e t group--

t h e hutbound t o d d l e r of low-income b a d l i e s - d i d n o t ? a r t k i p a t e t o :he s x t e n t

e q e c t e d p r i m a r i l y because of t i n e and s o c i a l c o n s t r a i n t s . h s e l e c t i o n

process would t o a larse e x t s n t overcome these p r o b l e m .

The main s c r e e n i n g procedure i n nany s m a l l e r p r o j e c t s is =be c h a r t i n g

of eight on t h e "Under 5" ca rd (Xorley x e i g h t c h a r t ) . Children are a l s o

screened f o r s i z p l e a i l m e n t s , such a s f e v e r , d i a r r h e a , and s k i 3 and s y e

cond i t ions . 3ecause f i n d i a g s , t r z a t s e n c s , and i s m u n i t a t i o n s a r e recorded on

t k e c a r d s , ?rejects c a n t r a c k changes i n morbid i ty and growth over t i n e . The

Kasa p r o j e c t vas a b l e t o hold t h e p ropor t ion of members r e c e i v i n g supplemen-

t a r y n u t r i t i o n a l c a r e t o 23 percen t of tSe popula t ion uader f i v e by u s i n g the L

f o l l o u i a g c r i c i e r i a : low 5 i r t 5 weight , weights Selow 65 percent of Earvard

s t a n d a r d s , no weight ~ a i n i n t h r e e consecu t ive s o n t h s , l o s s of 2 e i g h t ia :-JO * -

success ive zigntbs, o r such il1:lesses as s e a s l e s o r gas t roen te r i : i s . A t - Jankhed and %raj t h e s c r e e n i n g is s i d l a r t o t h a t at :Xasa, and ? a r t i c i p a ~ i o n . * . .. i n s p e c i a l 2 r o j e c t a c z i v i t i e s Is r=s t rZczed 3 a i n l y t o t h e vu lne rab le groups.

i n a n y of t h e l a r g e s e r r i c e ? rograns , project p lanne r s u s u a l l y s e t

age c rL=s r i a . I n s e v e r a l s p e c i a l z u t r f t i o n ?rograms, hovever , zany c:hildren

o u t s i d e t h e age s toup x e r e aCsi:=ed. -l.nothez i z p o r t a n c f a c r o r w a s the need,

i d e n t i 5 i e d i n ?os'hak, :o jake "?re- iaplczientat ion v i s i t s =D t h e car?ez popula-

:Lon t 9 establish rapporc" (Gopalias 1975). if s e l e c t i o n and ? a r = f c i ? a c i a n

s e r v i c e s r e l i e d on suzve i l l ance . ProSlcr~s y e r e i d e n t i f i e d by Zaai ly hea1:h

vorkers . T rea t sen t v a s prompt, and growth oas monitored c o n s i s t e a t l y . If

c h i l d r e n missed more than seven consecut ive days of f eed ing , homes were

visited t o f i n d o u t 3hy. This method of s e l e c t i o n and continued follow-up of

cases had a najsr in f luence on t h e growth OF c h i l d r e n i n the n u t r i t i o n c a r e

v i l l a g e s .

P r i n c i p a l Findings about Costs and a e n e f i t s

.Aa evalua t ion of c o s t s and b e n e f i t s is needed t o judge t h e use fu lness and

r e p l i c a b i l i t y of t h e p r o j e c t s . Tab le 3 provides a b r i e f summary of t h e

r epor t ed impact of t h e v:~rious projects-and i f a v a i l a b l e , :he per c a p i t a

c o s t s and annual c o s t of s e rv ices . 3 e Toshak, Xarangwal, and Andhra Pradesh

f i g u r e s a r e probably t h e a o s t r e l i a b l e . For s e v e r a l p r o j e c t s , only rough

approximations of expendi tures are poss ib l e . I n many of t h e smal l p ro jec t s -

Kasa, Tamkhed, Ura j , a d Handwa-such inpu t s a s donated food and l a b o r a r e

not costed. Analysis of c o s t d i f f e r e n c e s ac ross p r o j e c t s has l i t t l e aean ing I

0

because of d i f f e r e n c e s i n s e r v i c e s , h t h e s i z e and type of t a r g e t group, i n

t h e t i m e span of p r o j e c t s , and above a l l i n r o s t accounting, which u s u a l l y is - ** inadequate o r incomplete. I t a l s o i s fmpossllble t o compare c o s t s and b e n e f i t s

* - C

of p r o j e c t s because of fundamental p r o b l e m + aeasur ing b e n e f i t s ( s e e che 8 - .

l a t e r d i scuss ion ) . Some c o s t compar isms neve r the le s s a r e p o s ~ i b l e .

A t Naraagwal t h e annual pe r c a p i t a c o s t of s e r v i c e s was Bs 5-00 Zo

X.S 15-00 (S0.80 t o $2.00) f o r t h e autrL:ion p r o j e c t and s l i g h t l y h ighe r f o r

=he p a r a l l e l zopulac ion 7rojecc. Averase acnual per c sp iza c o s t f o r each

s e r v i c e ranged from 3s 8.70 t o 3s 21.30 (S1.16 t o j2.51; i a t h e population

? ro jecr . T h e eatiinated per c a p i t a c q e z i d i t u r e f o r s e r r i c e s a t g o v e m e n t

Nuc Arm 37 !I V e d i u l &re Area i O :I :luoYad Care U e a 31 1: Coacrol .we. 123 19

'2.l 51 Curtrnc . u e r s of concraceprioo a i z e r 1-3/0 and A-112 p a r s o i se-ce.

P 9 S C C .&ma 9,- --- 3: ?PVS .We. 2s: rLZ Z X C Area -.-

- 4 - - D T D .we. 30: - coac=o1 . m a 3: -

S d L p o z L 52.X 94.X D P T ( a d ~os.) I.SX ST -52 S c e r l l ' 4 . d o ~

ur .areakern LS (1975) 1668 (2977) 5 ' . 32 of a e w e r e l ~ r lnour i r&ed U r m L q n o e d vei&BC b 102 a b v e e q u e r d ~ r ~ v c h for ape.

112 A/ l.il6.3 755.7 zi 3fffereaces 1: ::a81 'rriqnc of 588 - a r a n u l :aildrum a d , 3 r s e = c a r d :oattol. --re :oc

C s l @ f f e m c . 'Gignc I i i f u e n c u wrra srqC:canc Fn c:. : m C e r age S r o u (abowe i2 s o n c b ) 'mo collected at ? u s e SOX ~i u r ~ c e d f w d -hen . coapamd vich =oncrol srouo.

( p u :ooa ll7e 5i~tC1) C a d . 3fCr!l .Lee 26.3 2: .i !per 1000 pop.) - o t +nc. r c a l - 97:

:asas :overed : a t ~ l i e 5 1 . C ~ U ~ ~ R S j0-5= 39. i=

?taccicinq I .?.

Yo. 3 i s c c r ~ l f ~ a c i ~ s Y C Z ~ ~

- 9 7 0 - i i 1 3

t o s t of s catwide

.;onrul cosc .-a1 cosc replication ?er capita ::hou.sanCs :a l l l ions

?r~:ecc (rupees of rupees) of rupees) Peporred Inpacr

%.a. Cmde 3irch Xaces fo r Z rpe r i aeau l and Coacrol Crou?s :or 3 r e e T h e ?eriods.

Experimeacal Control

% d 4 7 Y . r r l r Prow-. YadhTa P n d u h -

:reacneac Area Coacr.'l Are8 1971 1976 1971 1976

1.x.a. 97 39 - 90 child

X o r c a l i z ~ 97 33 - 90 : af e l i g i b l e

coup lu prac- t i c ing P.P. 2-52 50.52 - 10:

L of under 5's -pized < 1: 382 - 15:

n.1. Coveraqe. Smber of pregaaac and l a c u c i n t aochers ia w r e chaa 50: of center= l e s s than r c i p l a c e d ab . r s . i n more c h r ~ 25X of &e cencen d e r of persolu reeklag adnL.sica lc-s ctvn required number. LOX of chm centers do aat !use sui f ic ienc i ac i l i c i e s for aucrlcioo p c o g ~ .

C L i n i d a s s u m a n c shwed tbac r m c o m =laced co eyes. much. cm(lum md ac chm bc&naiag of chm s-7 dlmppured t o a qrcac -lor a f t e r 6 moach..

7 1 &/ 9,970.0 - V8i~bc u of 1- scrnd8rdr La m o o l m n t e d (S) and uwopiemeacad (US) prc-choal children of d i f ferent t r i b a l groups.

55 1 31.48S.3 - C l u s i f - Program Sf l c l eacy .

DdO 61-65 86-95 % and o u r Lov *dim V e 9 Sigh - --

Veighc f o r

a / ?er u p i u cog= x r u n 1 ?oprlarioo (10,331,881) of R-n!rb i n 1971. - ? u u p i u cost x r u n 1 popuiacioa (34.i01.024) of W u r u h c z a in 1971.

c/ Per b ~ . f i c i a q cosc ac nrbhealch ceacer x 6.87 J l l i o o r u n 1 cnlldrea aged 0-6 ln Yadhya Praderh ta :971. - d l ? u ' m u - i c i a q . - e/ k e d m 1977-78 expenditure. - ¶.a- Soc avalhble . - Soc applicable.

Xeasuring b e n e f i t s i s much more d i f f i c u l t than measuring c o s t s .

F i r s t , t h e output ( t h e immediate r e s u l t ) and outcome ( t h e Lcigal r e s u l t ) -

cannot always be c l e a r l y def ined . Second, even when outcome measures can

be de f ined , they cannot always be c l e a r l y a sc r ibed t o t h e use of s e r v i c e s .

Th i rd , g iv ing d o l l a r va lues t o outcomes, which is necessary t o measure

b e n e f i t s i n comparison wi th c o s t s o r wi th b e o e f i t s of o t h e r p r o j e c t s , i s even

nore d i f f i c u l t . Thus cos t -benef i t a n a l y s i s is i n a p p r o p r i a t e f o r eva lua t ing

these p r o j e c t s . But t he e f f e c t i v e n e s s o f t h e p r o j e c t s can be d iscussed by

cons ider ing ou tpu t s and outcomes. Cos t -e f fec t iveness can a l s o be analyzed by

looking a t cost-to-output and cost-to-outcome r a t i o s .

Few of t he s t u d i e s provide comprehensive d a t a on outcomes, bu t many

:lave d a t a on outputs . These d a t a r e l a t e to coverage of t he t a r g e t popula t ions

and the use of services. But even i f formal c o n t r o l s were e s t a b l i s h e d , i t w a s

d i f f i c u l t t o demonstrate t h a t p r o j e c t i n p u t s were r e s p o n s i b l e f o r changes i n

growth, morbid i ty , o r i n f a n t and c h i l d m o r t a l i t y . The Narangwal s t u d i e s -- two of t he few -11-controlled f i e l d r e sea rch p r o j e c t s -- a r e except ions , f o r

I

they s h o ~ e d the s t r o n g r e l a t i o n between hea l th - r e l a t ed changes and p r o j e c t

inpucs. For example, t h e p e r i n a t a l m o r t a l i t y r a t e w a s reduced 40 t o 50 - - percent i n v i l l a g e s wi th n u t r i t i o n s e r v i c e s ; t h i s major d e c l i n e i s . f t r o n g l y

associaced wi th p r e n a t a l c a r e and n u t r i t k n s u p p i a e n t s f o r mothers'

E e At Jamkhed, f i nd ings from t h e t rea tment and c o n t r o l areas'show a

marked d i f f e r e n c e i n i n f a n t and c h i l d s o r t a l i t y r a t e s and i n the percentage of

e l i g i b l e couples p r a c t i c i n g family planning. The change i n the t rend of t hese

r a t e s i s l a r g e f o r a f ive-year per iod , b u t t h e comparabi l i ty of t h e groups i s

not known. Still, i t i s un l ike ly t h a t t h e downward t r e n d s would have Seen a s

rap id v i thout p r o j e c t s e r v i c e s .

Zive p r o j e c t s -- Kasa, Jamkhed, Narangwal, Xraj , and t h e 90-3i r th

onus Scheme -- have an upward t r end i n r a t e s of f ami ly 2 lanninq accep tance

and, where recorded , a d o n w a r d t r e a d i n inr'ant m o r t a i i t y . I n t h e Kasa

p r o j e c t t h e weight o i s e v e r e l y aa lnour i shed c h i l d r e n s u b s t a n t i a l l y iaproved

after one year of supplementary f e e d i n g f o r groups a t r i s k . The a m b e r of

\

s t e r i l i z a t i o n s a l s o v e n t up s u b s t a n t i a l l y ove r a t h r e e y e a r ?e r iod . T3e

Yo-8irth Bonus Scheme shows t h e d o n w a r d t r e n d i n t h e c rude b i r t h r a t e t o

be f a i r l y s u b s t a n t i a l i n p r o j e c t a r eas . Such i n t e r v e n i n g f a c t o r s a s :he

nat ionwide f ami ly planning campaign 3ay have a f f e c t e d the response, bu t t h e

d e c l i n e in t h e b i r t h rate of c o n t r o l s w a s much slower. A t Sa rangva l t h e

proportion of nev f ami ly planninq accep to r s w a s h i g h e s t 13 areas o f f e r i a g

combined s e r v i c e s - i t was 44 pe rcen t f o r t h e group r ece iv ing f ami ly ? l a m i n g ,

= h i l d ca re , and women's s e r v i c e s ; 42 percent f o r t h e group r e c e i v i c g on17

family planning and vomen's s e r v i c e s ; 38 percent f o r t h e group r e c e i v i n g

fami ly planning and c h i l d care ; and 20 percent f o r tile group r e c e i v i n g only

fami ly planning and educat ion.

The l a r g e p u t r i t i o n p r o j e c t s have been eva lua ted u s i n g c r o s s

s e c t i o n a l s t u d i e s some years a f t e r t h e programs Segan. In t h e f eed ing

program i n Yadhya Pradesh schools , C P S undertook a s tydy t o d e t e r a i n e

t h e c2fect. of t h e school n e a l on a u t r i t i o n and school a t tendance . The s tudy

vaa a l s o t o d e t e r p i n e the e x t e n t t o h i c h t h e sc%ool m e a l r ep laces food

normally consumed a t home. . h th ropomet r i c d a t a were c o l l e c t e d ; home d i e t a r 7

inr 'o -~ion w a s c o l l e c t e d throuqn 24-hour r e c a l l ; a t t e n d a n c e r a t e s y e r e

c o l i e c r e d f rom s c n o o i records . No c o n t r o l groups -dere a v a i l a b i e , azia -he

measurernenr w a s 5aaed on a s tudy comparing c h i l d r e n v i t h "aore ~ x p o s u r e ' ' t3

t h e feeding program and those wi th " l e s s exposure." Children i n h i g h e r

program e f f i c i e n c y schools wi th g r e a t e r exposure t o t h e program were corn-

pared wi th c h i l d r e n from lower pzogram e f f i c i e n c y schools with l e s s exposure

t o t h e program. The f ind ings show tha t t h e program had a p o s i t i v e impact on

t h e growth of c h i l d r e n and on m a l n u t r i t i o n i n t h e schoo l s wi th e f f i c i e n t pro-

grams. Schools wi th i n e f f i c i e n t programs had p ropor t iona te ly more upper c l a s s

c h i l d r e n wi th b e t t e r educated pa ren t s and i t may be concluded t h a t socioeco-

nomic f a c t o r s were r e spons ib le f o r t h e h igher a t t endance r a t e s recorded i n low

e f f i c i e n c y schools .

Some of t h e n u t r i t i o n s t s d i e s compared n a t i o n a l , s t a t e , and p r o j e c t

f i g u r e s . General f i n d i n g s i n d i c a t e lower weights f o r p ro jec t c h i l d r e n i n some

of t h e s tud ie s . A comparison of t r i b a l c h i l d r e n i n Andhra Pradesh i n t h e

Spec ia l N u t r i t i o n Program (SNP) shows t h a t supplemented c h i l d r e n were taller

and heav ie r than unsupplemented c h i l d r e n of t h e same t r i b a l group. The

percentage of c h i l d r e n c l a s s i f i e d a s normal, according t o Indian averages ,

was h igher i n the supplemented group i n t h e same t r i b e . Other f i n d i n g s a r e

inconclus ive . - I n t h e experiment on a l t e r n a t i v e s t r a t e g i e s i n family planning

i n Bangalore, e v a l u a t i o n of primary h e a l t h c a r e sugges t s t h a t involvement of -

a voluntary .@ency and t echn ica l competence of s t a f f had s i g n i f i c a n t e f f e c t s 1

C

on family planning. The use of i n c e n t i v e s i n Und had mixed r e s u l t s . The v .

use of s e r v i k s l o r family planning and maternal and c h i l d h e a l t h improved

during t h e s tudy per iod f o r t h ree of t he s t r a t e g i e s adopted, bu t adminis-

t r a t i v e d i f f i c u l t i e s i n procurement and ..l l i n g were encountered throughour:

t h e p ro jec t . There a r e no comprehensive da ta on outcome f o r t h e p r o j e c t .

The o u t p u t d a t 2 f o r a n y of t h e b e t t e r d o c u m e n t e d p r o j e c t s show

t h a t a comprehensive program or' i n t e g r a t e d s e r v i c e s f o r h e a l t h , s u t r i t i o n ,

and fami ly p l a n n i q appears t o be n o r e c o s t - e f f e c t i v e than many o f t h e l a r g e

s i n g l e i n t e r v e n t i o n s .

F r o j e c t r e s e a r c h e r s a t Narangwal c a l c u l a t e d t h e c o s t of s e r v i c e

i n p u t s i n r e l a t i o n t o outcome a e a s u r e s t o o b t a i n c o s t - e f f e c t i v e n e s s r a t i o s

f o r t h e d i f f e r e n t packages of s e r v i c e s : c o s t p e r d e a t h a v e r t e d , p e r day

of i l l n e s s a v e r t e d , p e r a d d i t i o n a l cen t ime te r s of growth a t thirty-six months,

and pe r a d d i t i o n a l percentage-point i n c r e a s e in psychomotor development

s c o r e s t o age th ree . The lowest c o s t f o r a dea th a v e r t e d ( i n 1970 p r i c e s ) was

$7.75 - f o r t h e c o s t of p r e n a t a l c h i l d c a r e pe r p e r i n a t a l dea th a v e r t e d i n

v i l l a g e s wi th n u t r i t i o n care . The c o s t s p e r i n f a n t d e a t h a v e r t e d and pe r

c h i l d dea th a v e r t e d were lowest i n t h e v i l l a g e s w i t h h e a l t h care : $25 and

$31. X u t r i t i o n s e r v i c e s and combined h e a l i h and n u t r i t i o n s e r v i c e s were much

more c o s t l y p e r c h i l d d e a t h ave r t ed .

Combined h e a l t h and n u t r i t i o n s e r v i c e s y e r e n o s t c o s t - e f f e c t i v e

f o r growth. According to the morbid i ty i n d i c a t o r s , h e a l t h c a r e is t h e r

mst c o s t - e f f e c t i v e program a t Yarangwal. The f i n d i a g s suggest t h a t combined

programs, a l though s l i g h t l y s o r e expensivekhSan s i n g l e i n t e r ~ e n t i o n s such '3 &

a s h e a l t h o r n u t r i t i o n have made a f o r n i d a e impacz on growth, m o r r a l i t y , - - • and n o r b i d i t y . t o r t h e 2apu la t ion 2ro j e c t Bt Yaraxqwal, e s t l a a t e s of =he .I

average number of coup les 2 r a c r i c i z q fami ly p l a n n i x Curfnq t h e second

pear of s e r v i c e s show t h e c o s t of s e r f i c e s pe r praczici i ig couple t o have

been lowest (S90.27) i z ~ ~ L l l a g e s v i t h , i n t e g r a t e d s e n i c e s f o r family pianning,

yomen's c a r e , and c h i l d care . The average c o s t oi f ami ly ? l anu in3 s e r v i c e s

per - new a c r e p t e r of a =ode= family j l a n n i n ~ method Curiag t h e sec3nd y e a r

of s e r v i c e s a l s o sxs lowes t ($12.27) i n those v i l l a g e s . The d a t a on o t h e r

p r o j e c t s a r e l i m i t e d . Cos ts were not r e l a t e d t o outcome measures, a l t hough

one o r two p r o j e c t s were a b l e t o determine c o s t o f s e r v i c e s , such a s t h e c o s t

per c h i l d vacc ina ted .

.Mvocates of an i n t e g r a t e d package o f s e r v i c e s a s s e r t t h a t s e p a r a t e

(convent iona l ) s e r v i c e s f o r heal:h, n u t r i t i o n , and fami ly planning could be

rep laced by a n i n t e g r a t e d package of s e r v i c e s with wide coverage of t h e

popula t ion a t a c o s t comparable t o p re sen t h e a l t h expendi ture i n Ind ia .

Methods of Monitoring P r o j e c t s and Analyzing t h e i r E f f e c t

The experiments and s p e c i a l p r o j e c t s o f f e r some ne thodologica l g u i d e l i n e s f o r

measuring p r o j e c t performance. Few p r o j e c t s used formal c o n t r o l s t o t e s t t h e

e f f e c t of i n t e r v e n t i o n s on the experimental o r service group. I n many cases,

output i n d i c a t o r s were used t o measure performance. 1/ Host s t u d i e s had weak - o r i n v a l i d c o n t r o l s , o r measured p r o j e c t f i nd ings ove r t i m e . Without a con-

t r o l group, i t i s d i f f i c u l t t o show d e f i n i t i v e l y t h a t p r o j e c t i n p u t s have been -

r e spons ib l e f o r changes i n hea l th , nutri:$n, o r fami ly planning. Changes

a sc r ibed t o p r o j e c t i n t e r v e n t i o n s may be caused by s e l f - s e l e c c ion , t h e time

of y e a r , aging of t h e s tudy popula t ion , and o t h e r socioeconomic variables.: sg

I n t he Narangwal populat ion p r o j e c t , socioeconomic d i f f e r e n c e s * * -

between c o n t r o l and e x p e r a e n t a l grouFs emerged a f t e r the p r o j e c t s t a r t e d : ? . f o r example, d i f f e r e n c e s i n l i t e r a c y r a t e s , sex r a t i o s , c a s t e d i s t r i b u t f o n ,

v i l l a g e i n f r a s t r u c t u r e , and socioeconomic l e v e l s . Cont ro l c h i l d r e n w e r e also

1. These included coverage and use r a t e s : f o r example, the number of - a n t e n a t a l cases a t t e n d e d , immunizations perf onned , and family p l ann ing acceptors r e c r u i t e d .

heav ie r and s n o r t e r than e x p e r h e n t a l group c'hildren. 13 essence , t h e c o n t r o l

aroup w a s b e t t e r o f f t h a n the u r p e r i n e n t a l groups, b u t m u l t i v a r i a t e a n a l y s e s

of i n d i v i d u a l s v e r s a b l e t o c o r r e c t t h e s e d i f f e r e n c e s . I n P r o j e c t Poshak t h e

c o n t r o l ?base of t h e p r o j e c t l a s t e d ouly a year . L 3 i l e a decreased m o r t a l i t y

r a t e was repor t ed among t r e a c n e n t c h i l d r e n , compared t o a s e sa tched c o n t r o l s

the d i f f e r e n c e v a s n o t s tat is t i c . + , l y s i g n i f i c a n t and t h e r e sras co follow-up

on n i g r a t e d f a m i l i e s from t h e area .

S e l f - s e l e c t i o n poses d i f f i c u l t i e s f o r p r o j e c t des ign and e v a l u a t i o n .

I n some v i l l a g e s t h e people a r e r e c e p t i v e t o innova t ions , such as a proposed

h e a l t h c e n t e r o r n u t r i t i o n p r o j e c t , and thesr! v i l l a g e s may d i f f e r s u b s t a n t i a l -

l y from v i l i a g e s s e l e c t e d as c o n t r o l s . At Jamkhed the p r o j e c t d i r e c t o r s

agreed t o work on ly i n v i l l a g e s where ccmmunity p a r t i c i p a t i o n i n the p r o j e c t

was a c c e p t a b l e t o the people and vhere t h e people were involved i n p lanning

and implementation. The comparat ive a n a l y s i s of f i n d i n g s f o r the c o n t r o l

group and f o r t h e p r o j e c t a r e a i s thus veakened.

I n nany s t u d i e s the sample groups were no t l a r g e enough i o r f i n d i n g s *

t o be s i g n i f i c a n t . I n t h e Xarangwal n u t r i t i o n s tudy , m o r t a l i t y r a t e s d e c l i n e d

5ut say have be- a f f e c t e d by n i a r a t i o n t o and from t h e p r o j e c t a rea . .Uthough

p r o j e c t s t a f f x e r e v i g i l a n t i n t r a c i n g c a s e s , one missed dea th could substan- - t i a l l y change t h e r a t e s . ?or sany of i h e groups, t he numb.r of d e a t h s iras tao . smal l to be s i g n i f i c s l t . A t jarniched d e c l i n e s iz i n f a n t m o r t a l i t y r a t e s were

shocln to b e s u b s t a n t i a l over a five-year ~ r i o d , but t h e sample w a s t oo s m a l l

f o r f i a d i n g s ;o be s i g n i f i c a n t .

The Kasa, Mandwa, and !4.iraj p r o j e c t s used no c o n t r o l s but neasured

p r o j e c t a c t i v i t i e s and r e s u l t s over time. I n the Kasa p r o j e c t , i n f a n t s and

c h i l d r e n were r e g u l a r l y surveyed by t h e use of a weight cha r t . A t any time

during t h e p r o j e c t , workers could e a s i l y determine what c h i l d r e n i n t h e

p r o j e c t a r e a needed s p e c i a l c a r e , how many immunizations had been c a r r i e d

o u t , and what t h e number of a n t e n a t a l ca ses was i n t h e a rea . There was a

before-and-after e v a l u a t i o n of t h e a l t e r n a t i v e s t r a t e g i e s p r o j e c t i n Bangalore

in family planning t o determine i t s e f f e c t s on family planning p r a c t i c e .

But t h e experimental and c o n t r o l groups were not matched, and s e v e r a l imple-

mentation problems made the eva lua t ion of i n p u t s d i f f i c u l t . . I n t h e S p e c i a l

N u t r i t i o n P r o j e c t i n T d l Nadu, f ind ings of a c ross - sec t iona l survey were

compared w i t h state and n a t i o n a l f i g u r e s t o eva lua te t h e e f f e c t of t h e 'nter-

vent ion on t h e s tudy group. Analysis of t h i s kind i s u n s a t i s f a c t o r y because

of t h e many d i f f e r e n c e s i n n u t r i t i o n and i n i n f a n t and c h i l d m o r t a l i t y between

s t a t e s and a r e a s . For example, p ro jec t workers a t Jamkhed found l a r g e d i f -

f e rences between t h e i n f a n t m o r t a l i t y r a t e i n the t o m of Jamkhed and t h a t i n

t h e surrounding r u r a l a r eas . -

Retrospect ive s t u d i e s a r e common i n India , and many serv ice-or ien ted

programs c o l l e c t no b a s e l i n e data . This appears t o be so i n m n y of t h e - - l a rge-sca le i n t e m e n ~ i o n s of t h e government. I n the S p e c i a l X u t r i t i o n Program,

f o r exampl e , f i v e -

r e r e s e n t a t i v e e c e n t e r s were compared i n Coimbatore, .)

Nadu - measuring weight , he igh t , and d i e t a r y in take . The problem of such a

comparative a n a l y s i s is t h a t i t can be misleading f o r p r o j e c t planners. The

d i e t a r y information was co l l ec t ed by r e c a l l , which of t e n is inaccura te .

anthropometr ic da t a were compared wi th t h a t f o r a l l I n d i a and f o r Tamil Nadu.

X second study i n Tamil Nadu recorded anthropometr ic d a t a over s i x son ths .

m e f i n d i n g s r e v e a l f a i r P y s u b s t a n t i a l growth f o r t he s tudy group d u r i a g t h a t

pe r iod , but t h e t h e r t h e i n t e r v e n t i o n brought about t h e s e changes cannot be

dece ra i aed 'vith this :kind of a n a l y s i s .

C o n s t r a i n t s of t i n e , f i n a n c e , and personnel appa ren t ly i n d ~ c e d

axany p r3 j e c t l e a d e r s t o e v a l u a t e o u t p u t s r a t h e r t han outcomes. Such eval -

u a t i o n has recognized s'nortcominqs, b u t g iven the c o n s t r a i n t s and o b j e c t i v e s

of nany p r o j e c t s , s o p h i s t i c a t e d techniques of d a t a c o l l e c t i o n and a n a l y s i s

would be i m p p r o p r i a t e .

Cutput measures were adopted I n most of t h e p r o j e c t s , b u t a few

?ro ;ec ts - ZCasa, Jamkhed , and Nar angwal , f o r exsmpl e , - s e a s u r ed such

outcome i n d i c a t o r s as i n f a n t and c h i l d a o r t a l i t y r a t e s , n u t r i t i o n a l l e v e l s ,

and fami ly p l a n n i ~ q a c c e p t o r s , and f e r t i l i t y l e v e l s . Even so , i t is d i f f i c u l t

t o e s t a b l i s h a d e f i n i t e r e l a t i o n b e t k ~ e n p r o j e c t i n t e r ~ e n t i o n s and changes

observed i n s o r r a l i t y , morb id i ty , grouch, o r f e r t i l i t y . I n the Narangwal

s tudy , r e c a l l by mothers i n s e a s w i n g rno rb id i :~ changes was so d e r a i l e d t h a t

r e s u l t s a r e inconclus ive . Two-thirds of t he v a r i a n c e i n weight of c h i l d r e n - I

could a o t b e expiai%ed, even a f t e r t he l a r g e number of v a r i a b l e s and 2 r o j e c t

i n p u t s were taken i n t o accocnt . - - Cutput s e a s u r e s r e f l e c t changes i n the u.& of s e r v i c e s and i n -

tke' type of = e r r i c e coverage: f o r suampie, the 2 ropor t ion of c h i l d r e n 8 * -

i m ~ ~ b i z e d , :he number of t u b e r c u l o s i s c a s e s under c r e a t x e n t , o r t h e -,umber lr

of d e l i v e r i e s azzeoded 5y heal:h vorkers . The :Kasa, Inao-gutch, and YanCwa

; r o j e c r s are a n o q those t b r use o u t p t s e a s u r e s t3 =valuate ? r o j e c = p e r

Conclusions

The f i n d i n g s from t h e survey of e x p e r b e n t s and s p e c i a l p r o j e c t s a r e no t

conclusive. There a r e s t i l l many gaps i n howledge about t hese p r o j e c t s and

about t h e p o t e n t i a l c o n t r i b u t i o n of p r o j e c t services, p a r t i c u l a r l y t h a t of

primary h e a l t h care . The c o n t r i b u t i o n s of va r ious f a c t o r s t o p r o j e c t accom-

pl ishments , t h e s e r v i c e packages adopted, and the f i n a l e f f e c t s of d i f f e r e n t

i n t e r v e n t i o n s a r e s t i l l not f u l l y understood. The p o t e n t i a l f o r r e p l i c a t i n g

s e r v i c e s on a l a r g e scale a l s o needs t o be assessed w i t h a focus on c o s t ,

i n s t i t u t i o n a l requirements , and problens of implementation. The f a v o r a b l e

r e s u l t s of some of t h e small p r o j e c t s a r e r e l evan t f o r pol icy.

F i r s t , t h e i n t e g r a t i o n of s e r v i c e s f o r h e a l t h , n u t r i t i o n , and family

planning i s important .

Second, a u x i l i a r y h e a l t h workers, and the out reach s e m i c e s they

d e l i v e r , have g r e a t l y increased phys ica l access . The home v i s i t s i n

var ious p r o j e c t s overcame many problems of reaching t h e mosc vul-

nerable groups. I n a d d i t i o n , community p a r t i c i p a t i o n seems t o be -

, important i n planning and implementation. *

But s c a l i n g up smal l experiments and s p e c i a l p r o j e c t s t o l a r g e , e f f e c t i v e

s e r v i c e programs is complex. The popula t ion coverage by such experiments and

p r o j e c t s is small i n comparison wi th e s t a t ewide need f o r s e r v i c e s i n ul - h e a l t h , n u t r i t i o n , and popula t ion - and minute i n comparison wi th t h e needs

oi a l l India. l o r example, t he Xaharashtra p r o j e c t s covered about 400,000

persons, l e s s than 0.8 percent of t h e populat ion of t h e s t a t e .

One n a j o r 7ro'Dlan is t h e i a f l s - x i b i l i t y of l a r g e programs and or'

t h e Sureaucracr . S a a l l p r o j e c t s c a n b e f l e x i b l e -- i n t h e i r syscem or'

nanagenent , i n t h e way they d e l i v e r s e r v i c e s , and i n t h e a b i l i t y t o change

cour se on t h e b a s i s of new f ind ings . What i s aeeded? E x p e r h e n t a t i o n and

r ezea rch on o p e r a t i o c s t o modify i n s t i t u t i o n a l arrangements i n a way t h a t

acconmodaces mciz of :he f l e x i 5 i l i c y t h a t is so b p o r t a n t :o t h e s u c c e s s of

s m a l l e r p r o j e c t s . 70 r example, i ~ o v a t i v e s e a s u r e s could be t r i e d o u t i n

s t a t e v i d e o r d i s t r i c = v i d e s e n i c e s t o demonstrate. t h e i r e f f i c a c y . The

measures t h a t work b e s t (and f i t b e s t ) could then be i n c o q o r a t e d i n che new

program. tihat has complicated t h i s so f a r is t h a t among t h e s u c c e s s f u l

p r o j e c t s no s i n g l t ' d a d of p r o j e c t s t a n d s ou t . D i f f e r e n t k inds of p r o j e c t s

work w e l l i n d i f f e r e n t condi t ions . That means t h a t a nat ionwide b l a n k e t

program would be i n a p p r o p r i a t e i n zany p a r t s of t h e coun t ry and t h a t programs

should be s u f f i c i e n t l y f l e x i b l e t o be s o a i f i e d t o l o c a l c o n d i t i o n s - a

problem which is l i k e l y t o be exacerba ted by t h e i x - l e s i b i l i t y of t h e n a t i o n a l

l e v e l bureaucracy.

X f v r t h e r prohlern-is t h a t t h e r e is no t enough in fo rma t ion on

s m a l l e r p r o j e c t s - because of t he inadequacy of t h e i r systems f o r c s i l e c r b g

-,data and f o r n o n i t o r i a g and eva lua t ing progress . That prec ludes s y s t e m a t i c .a L

a n a l y s i s of vhat p r o j e c z s have achieved and vha t i n t e r r e n c i o n s have uean t - - - m *or t h e 7opula t ion covered by s e r v i c e s . ? a r t of t h e d i f f i c u l t y i s - t h a t t h e - mst r e l i a b l e i a a i c a t o r s o f pxojec t ac-Meveraents - outcgme i n d i c a t o r s of

growth, s o r b i d i t y , and mortali:y - are the rpost df i f icxlrr t o s e a s u r e and

c o l l e c t . So o u r ~ u c d d i c a t o r s (of coverage and use ) a r e often used k s t e a d .

Less r e l i a b l e than ouccome i z d i c a t o r s , they a r e l e s s convincing (and ?oss iS ly

l e s s c o r r e c t ) i n denons t r a t ing how, what, uhere, and f o r ~ h o a s e r v i c e s should

be provided. The complexi t ies i n h e r e n t i n monitoring and eva lua t ing p r o j e c t s

must be sursounted so t h a t i t is p o s s i b l e to ge t e a r l y warnings about what i s

going wrong and t o g e t t h e informat ion needed t o make dec i s ions about program

development and pol icy . The f i r s t s t e p i s t o c o l l e c t good base l ine da ta .

Xlso needed i s b e t t e r f i n a n c i a l and economic ana lys is . Poor i n most of t h e

p r o j e c t s surveyed, t h e cos t ing of s e r v i c e s and b e 2 e f i t s i s p r e c i s e l y what

i s needed t o compare t h e b e n e f i t s and e f f i c i e n c y of d i f f e r e n t packages of

s e r v i c e s -- and t o e s t ima te what r e p l i c a t i o n on a l a r g e s c a l e w i l l c o s t .

Simply mul t ip ly ing p e r c a p i t a c o s t s by populat ion i s not good enough, f o r

t h e r e m-ay b e eccoomies (and diseconomies) of s ca l e .

.QPE,\TDIX A . P r o f i l e or' S tud ies

Experizental-research p ro j ec t s

:Jarangwal Xut r i t i o n Prof e c t

Xarangwal Populat ion Pro jec t

Al te rna t ive S t r a t e g i e s i n ,Family P l a n n i q , 3angalore

Xandwa iiural Xealth h s e a r c h Pro jec t , Yanarashtra

P i l o t p ro jec t s

In tegrated Health and Xu t r i t i on Pro jec t , Xasa

Project . Poshak

Integrated Health Serv ice Pro jec t , Xiraj

Indo-Dutch Project f o r Child Gielfare

No-girth Bonus Scheme, South Ind ia

Service oro i e c t s

Comprehensive Xural Yealth ?:ujcct, Jamkhed

Applied Yut r i t i o n Program, Kerala - *

Specia l Xut r i t ion Program, Coimbato re , Tamil Xadu

Special Xut r i t ion ?rogram, .hdhra Pradesh

ad-Day Yeals Program, Yadhya'?radesh

NABAt'JGWXL NUTRITION PBOJECT

The Narangwal n u t r i t i o n s t u d y was a ma jo r f i e l d r e s e a r c h p r o j e c t d e s i g n e d ( a )

t o examine t h e r e l a t i o n s between i n f e c t i o n and n u t r i t i o n and ( b ) t o a n a l y z e

t h e impact of s e v e r a l s e r v i c e packages on t h e c y c l e of i n f e c t i o n and m a l n u t r i -

t i o n . The s t u d y , begun i n 1966 and completed i n 1974, w a s conducted a t che

Narangwal Rura l H e a l t h Resea rch C e n t e r i n Punjab. X p a r a l l e l study--the

3arangwal p o p u l a t i o n p ro jec t - -was a l s o conducted by t h e r e s e a r c h team.

The n u t r i t i o n s tudy was done i n t e n v i l l a g e s u i c h a t o t a l p o p u l a t i o n

of abou t 10,500 l o c a t e d around two community development b locks i n t h e Ludhiana

D i s t r i c t of Punjab. The I n d i a n Counc i l of Medical Research , t h e World H e a i t h

O r g a n i z a t i o n , t h e N a t i o n a l I n s t i t u t e o f H e a l t h , and t h e Agency f o r I n t e r n a -

t i o n a l Development provided fund ing . The I n d i a n Counc i l o f Xed ica l Z e s e a r c h

and t h e Johns Hopkins U n i v e r s i t y School of Hygiene and P u b l i c Hea l th r a n the

p r o j e c t .

Desi6n and O b j e c t i v e s

The main o b j e c t i v e s of t h e s t u d y w e r e t o d e t e r m i n e ,the e f f e c t

of n u t r i t i o n and med ica l c a r e , a l o n e and i n combinat ion on t h e growth, n o r

b i a i t y , and m o r t a l i tp of c h i l d r e n under t h r e e . The c o s t - e f f e c t i v e n e s s

of t h e s e r v i c e packages was analyzed and t h e p r o j e c t i n c o r p o r a t e d h e a l t h c a r e - and s e r v i c e s t h a t a u x i l i a r y h e a l t h workers quid provide .

I

The 1 ,QOO i n f a n t s and c h i l d r e n i n t h e t a r g e t p o p u l a t i o n and vonen of

reproduct ive-age were d i v i d e d i n t o f o u r groups: a c o n t r o l group p rov ided w i t h

no s e r v i c e s beyond euergency and nLnimal symptomatic t r e a t m e n t and t h r e e

Findings

Growth. N u t r i t i o n c a r e a l o n e o r i n combination wi th h e a l t h c a r e

i ; : ~ e a s e d s i g n i f i c a n t l y t h e weiyht aud he igh t of c h i l d r e n o l d e r than seventeen

months. Elean wc,ghts and he igh t s i n v i l l a g e s with h e a l t h c a r e werr between

t h o s e i n v i l l a g e s wi th n u t r i t i o n c a r e and conerol v i l l a g e s . Treatment c h i l d -

reg were 500-600 grams h e a v i e r and 2-13 r ~ i l l i m e i e r s t a l l e r than o t h e r s a t

t h i r t y - s i x ~ 0 2 t h ~ . Sex and were shown t o have z pronounced independent

and a d d i t i v e e f f e c t on growth. N u t r i t i c i ~ c a r e had a major e f f e c t on p e r i n a t a l

r n q r t a l i t y , reducing i t 40 t o 50 percen t apparen t ly because of the p r o v i s i s n of

supp l< . . . en ta~y food, i r o n , and f o l i c a c i d t o pregnant women.

Morbidity and 5 Ior ta l i ty . Chi ld ren i r ; v i l l a g e s wi th h e a l t h c a r e had

s h o r t e r episodes of i l l n e s s f o r c o n d i t i o n s such a s .-gh, f e v e r , d i a r r h e a and

eye i n f e c t i o n . Combined lrealth and n u t r i t i o n s e r v i c e s produced a s i g n i f i c a n t

r educ t ion i n the d u r a t i o n of eye i n f x t i o n s ( f u r t h e r reduc t ion of one day) .

Bed ica l c a r e v i l l a g e s b.ad a reduced p e r i n a t a l m o r t a l i t y r a t e ( s t i l l b i r t h and 1

t o 7 days) of about 20 percent .

r * a Other f i n d i n g s rnclude the fol lowing:

Keoaatal m o r t a l i t y (0 t o 30 days) was reduced 60 percen t i n -

group8 provided wi th h e a l t h ~ r . k u t r i t i o n c a r e . L

Pos t n e o n a t a l ~ o r t a l i t y ( 1 t o @ months) was reduced 50 percen t i n

* h e a l t h c a r e v i l l a g e s but on ly 7-percent i n n u t r i t i o n c a r e v i l l a g e s .

o H o r t a l i t y o f c h i l d r e n aged 1-3 vas reduced about 40 percen t

i n a l l v i l l a g e s r e c e i v i c g s e r v i c e s .

Cost. N u t r i t i o n c a r e vas t h e s o s t expensive s e r v i c e ($2.CO a y e a r ) ; 7

a e d i c a l c a s e c o s t l e s s zhan h a l f t h a t . The c o s t of d e a t h s a v e r t e d v a r i s d w i t h

t h e age of t h e c h i l d . Cos t -e f fec t iveness a n a l y s i s revealed t h a t t h e c o s t of

"p r ena t a l c h i l d c a r e pe r p e r f n a t a l dea th a w r t e d " was lowes t i n n u t r i t f o n

v i l l a g e s ; t h e c o s t pe r i n f a n t d e a t h av<:" .-' w a s lowest i n h e a l t h c a r e viI. ..i.,es,

a s w a s t h e c o s t p e r c h i l d dea th sv*:rr?d.

Table X.i. X o r t a l i t y Xates by Expe r i zen t a l Group and Age Group a t Sarangwal . 19 70-73

Xeoaatdl ?o s tneona t a l I n f a n t C h i l d P e r i n a t a l m o r t a i i t y m o r t a l i t y m o r t a l i t y m o r t a l i t

b b b c Exp er imen tal S t i i l b i r t h a o r t a l i t y r a t e r a t e rate rate

Group a a r a t e r a t e (0-30 days) (1-12 nos. ) (0-1 yr.) (1- 3 2

Cont ro l 57.4 104.2 77.8 52.2 I28 .O 18.6

Y e d i c d c a r e 44.6 80.8 46.7 23.3 70.0 11 .O

X u t r i t i o n a r e 24.9 60.9 48.3 48 - 3 96.6 11 .O

N u t r i t i o n and h e a l t h c a r e 36.8 63.3 47.4 35.2 81 .O 13 - 3

* L

Source: Eva lua t i on of X u t r i t i o n I n t e r v e n t i o n ?rejects. USAID. Washington, DC . - -

'5 a. Per 1,000 l i v e and s t i l l b i r t h s . .s

b. Per 1,000 live b i r r h s . - c. Per 1,000 p o t u l a t i o n a t a s i v e n age. -

s !m - - The f i a i n g s show t h a t n u t r i t i o n care yas =ore e f f i c i e n t Fn 2roanotfng

pnys ica l g r o n h , heaLth c a r e i n reducing z o r b i d i t y .

- 48 -

X A U i Y G W A L POPULATION PROJECT

The popula t ion p r o j e c t i n Narangwal was a major r e s e a r c h p r o j e c t conducted i n

con junc t ion w i t h t h e N u t r i t i o n Study i n t h e Ludhania D i s t r i c t of Punjab

between 1968 and 1974. It i s , w e b e l i e v e , t h e f i r s t c o n t r o l l e d f i e l d exper i -

ment p r o s p e c t i v e l y t o neasure the combinations of h e a l t h and fami ly planning

s e r v i c e s a g a i n s t f ami ly planning acceptance. The combined n u t r i t i o n and

h e a l t h c a r e v i l l a g e s i n t h e n u t r i t i o n s tudy were a l s o t h e c h i l d c a r e and

family planning group or' v i l l a g e s f o r t h i s s tudy. The I n d i a n Counci l of

h e d i c a l Xesearch, working wi th t h e Johns Hopkins U n i v e r s i t y School of Hygiene

and Publ ic Heal th , was r e s p o n s i b l e f o r t h e p r o j e c t . The U.S. Department of

Hea l th , Educat ion, and Welfare, U.S. Agency f o r I n t e r n a t i o n a l Development, t h e

Ind ian Council of Medical Research, and t h e World Hea l th Organ iza t ion provided

I f undi ng . Design and O b j e c t i v e s

The main o b j e c t i v e s of t h e s tudy were t o neasure t h e e f f e c t s of

I d i f f e r e n t packages of s e r v i c e s on a t t i t u d e s toward family planning and on i t s

I Q , p r a c t i c e - t o show wha't rneasurabl- e f f e c t each s e r v i c e has on p r a c t i c e .

I . The n ine teen e x p e r i n e n t a l v i l l a g e s had a population of about 27,100; one

I group of v i l l a g e s se rved a s a c o n t r o l f o r t h e experiment. Each group of

I exper imental v i l l a g e s v a s provided w i t h a d i f f e r e n s s e r v i c e package. Inforna-

r i o n was c o l l e c t e d by c r o s s - s e c t i o n a l and l o n g i t u d s n a l s t u d i e s . Longi tud ina l

d a t a included v i t a l s t a c i s t i c s , morb id i ty , an th ropomet r ic d a r a , f ami ly planning

p r a c r i c e , and fertility. Socioeconomic s t u d i e s were conducted and cross-

s e c t i o n a l d a t a were c o l l e c r e d on t h e knowledge and p r a c t i c e of family planning

I and on a r r i r u d e s and b e l i e f s abouc c h i l d s u r v i v a l and family planning.

The use and c o s t of hea lch s e r r i c e s were a l s o aeasured .

S e r v i c e s

The d i f f e r e n t jackages o l s e r v i c e s a r e a s fol lows:

o rTED - fami ly planning and fami ly planning educa t i on on ly .

o FPWS -- f a n i l g planning and women's s e r v i c e s .

o FPWSCC - fami ly p lann ing , women's s e r v i c e s , and c h i l d ca re .

o FFCC - fami ly planning- and c h i l d c a r e s e r v i c e s .

o CQhTROL -- no s e r r i c e s .

%onen's s e r v i c e s inc luded p r e n a t a l and p o s t n a t a l c a r e , e a r l y i d e n t i z i c a -

' t i o n of pregnancy, and t rea t s len t o r r e f e r r a l f o r i l l n e s s . Chi ld c a r e s e r v i c e s

inc luded n u t r i t i o n and h f e c t i o u s d i s e a s e c o n t r o l . Family planning s e r v i c e s

inc luded educa t i on , mot ivac i on, and contracept i 've s e r v i c e s ;ri t h fsllow-up.

The aroup of v i l l a g e s r e ce iv ing fami ly planning and s h i l t c a r e

s e r v i c e s (PPCC) was a l s o p a r t of t h e p a r a l l e l n u t r i t i o n p r o j e c t .

Because t h e p r o j e c t ended e a r l i e r than expec ted , f e r t i l i t ? changes

cou ld no t be snoun i n t h e esrperimenzal groups. o r i g i n a l l y t h e p r o j e c t was

t o con t inue u n t i l t h e curves f o r fami ly planning p r a c r i c e had p l a t eau ed i n

rhe e ~ ~ e r i a e h t a l groups. But serz',ces were ended i n one group a f t e r two y e a r s '3 P

and i n ano thpr a f t e r t h r e e yea r s - In a d d i t i o n , t h e s e r v i c e p a c h g e s were no t - i n t r o d u c d a t t h e same tiae. Although the p r o j e c t was designed co show 5 0 t h

an i n c r a s e i n con t zacep t i ve pracc-ices and a s i g n i f i c a n t d e c l i a e i n f e r t i l f i y ,

:he s n o r t du rac ion of the p r o j e c t liPi red evaiua t f o n t o out?uc aea su renen t s .

A t =he end of the ?reject, che curves f o r Family planniag ? r a c t i c e q e r e s t i l l

- 50 -

r i s i n g . S i g n i f i c a n t d i f f e r e n c e s i n f e r t i l i t y i n t h e exper imental groups could

n o t be shown. The main i n d i c a t o r of program p r f o r m a n c e was t h e number of -

people who accep ted f a n i l y planning dur ing t h e program's l i f e , exc lud ing

previous family p lann ing a c c e p t o r s us ing aodern methods of c o n t r a c e p t i o n .

Tab le X.2. P r a c t i c e of Family Planning a t Narangwal, by Experimental Group

(percen tage of e l i g i b l e coup les )

C u r r e n t u s e r s Experimental New Af te r 1 3 / 4 y e a r s u t e r 4 1 / 2 y e a r s

Group Acceptors of s e r v i c e of s e r v i c e

PPWSCC

FPWS

FPCC

FPED

CONTROL

- - Source: Taylor and o t h e r s , forthcoming.

3

Several variables-such a s c a s t e , i x o m e , and land ownershi?-also

l a f luenced f s n i l y planning p r a c t i c e , but t h e i r i n f luence was shovn to be -

l e s s important than previous use of farnily planning o r of hea l th se rv ices .

One s i g n i f i c a n t v a r i a b l e vas the number of c h i l d r e n a couple had lost : -chi ld 1

deaths had a s t rong inf luence on family planning acceptance.

Cosc-effectiveness a n a l y s i s showed t h a t integrated s e m i c e s f o r

h e a l t h , nu t r i e ion , and family p lannins were the s o s t cos t - e f f ec t ive .

.U.F,DIATIVE STIUTZGIZS I N BAYILY PTAWIXG I N 3AYGALORE

3et-deen 1974 and 1979 the Populat ion Center i n Sangalore d id an

experimental s tudy of f i v e " a l t e r n a t i v e " s t r a t e g i e s i n an area covered by the

ongoing India Populat ion Projec t .

Design and Objec t ives

The exper iaent was t o t e s t the appropr ia teness of changes in the

family planning program and to f i n d ways of i sproving the program's e f f i c i e n c y

a d e f fec t iveness . The implementation f o r each s t r a t e g y vas a l so s tud ied t o

provide b e t t e r i deas about t h a t for the e n t i r e program. Each of f i v e s t r a t e g i e s

vas introduced a t s e l ec t ed aroups of ~ r i m a r y heal:h cen te r s i n Sansa lore * -

i n 1976: '5 Involving a voluntary agency i n family v e l f a r e programs a t p r i aa r?

hea l th cen te r s .

AppLging zmnagenent p r inc i ? l e s a t prizmrg h e a l t h c e n t e r s , inc luding

those f o r planning, superv is ion , t r a i n i n g , and coordinat ion.

Improving t h e t e c h n i c a l competence of h e a l t h s e r v i c e p e r s o ~ e l .

En t ru s t i ng r e s p o n s i b i l i t y f o r family we l f a r e t a r g e t s t o nonheal th

depar tments , i .e . , Panchayat chairnan, v i l l a g e accountant and o t h e r

v i l l a g e l e v e l workers.

Using i n c e n t i v e s inWnd a t t h e primary h e a l t h c en t e r s .

The f i v e s t r a t e g i s s v e r e adopted i n t e n primary h e a l t h c e n t e r s i n f i v e d i s t r i c t s ;

f i v e o the r c e n t e r s , one from each d i s t r i c t , v e r e c o n t r o l s . Performance w a s

es t imated from survey d a t a f o r 1968-69 t o 1973-74, and c e n t e r s were ranked

high, medium and low i n performance. As f a r as pos s ib l e , each s t r a t e g y w a s

t e s t e d i n a high and low performance cen te r .

The performance of each primary h e a l t h c e n t e r w a s eva lua ted on t h e

b a s i s of s i x c r i t e r i a :

Number of s t e r i l i z a t i o n s and s t e r i l i z a t i o n equ iva l en t s dur ing t h e

f i n a n c i a l year .

Regis tered p r ena t a l and pos tna t a l c a se s and number of d e l i v e r i e s by

q u a l i f i e d personnel.

Input-output ana lys i s . P

Changes i n average open b i r t h i n t e r v a l .

a Opinions of personnel involved d i r e c t l y o r i n d i r e c t l y i n t h e program,

e Changes i n f e r t i l i t y and a t t i t u d e s mezsured by a l oug i t ud ina l

sample survey. w t

The Populat ion Cente r co l l e c t ed da t a each month and between 1975 and 1978

conducted surveys t o provide informat ion on s t e r i l i z a t i o n and HCH a c t i v i t i e s ,

on t h e knowledge, a t t i t u d e , and p r a c t i c e of family planning (KA?), and f e r t i l i t y

indexes. Used i n eva lua t i cg che a l t e r n a t i v e s t r a t e g i e s were t h e s t e r i l i z a t i o n

squiva lant r a t e , . t h e aaternal-and-child hea i th equiva lent r a t e , t he s t a f f

e f f i c i e n c y index, and the ;(XP measuremer.2. There vere tvo eva lua t ions : one

i n 1974-75, before izplzmentat ion of the a l t e r n a t i v e s t r a t e g i e s , and one from

1977-79, a f t e r izrplementatfon of :he s t r a t e g i e s .

.U though recognizing the d i f f i c u l t i e s i n developing a t rue experi-

ment i n family planning, t he au thors suggest t ha t the s tudy, i n add i t ion to

providing some answers t o ques t ions r a i sed i n the ex-rfnent, has brought t o

l i g h t a n y new i s s u e s and f i e l d problems. The f ind ings suggest t ha t the

involvement of a vo lun ta ry agency i n the adminis t ra t ion of a primary h e a l t h

cen te r w i l l produce S e t t e r r e s u l t s , but t ha t a coordinated program with

government and voluntary agency involvement r e su l t ed ia p rob lem of a l i e n a t i o n

and c o n f l i c t i n r o l e s . Yanagement p r i a c i p l e s d id not have a s i g n i f i c a n t

e f f e c t on family planning but the iiaproved technica i a b i i i t i e s of star'f

rnembers yielded s i g n i f i c a n t r e s u l t s . The pro jec t emphasized family planning

se rv ices rnore than maternal-and-child hea l th (?EX) s e r v i c e s , and t h a t a f f ec t ed

'daving v i l lage- leve l func t iona r i e s r e spons ib le f o r family welfare - - t a r g e t s d id not y i e l d si@:icant r e su l t s - a i t h e r ia family planning p r f o r -

- 3ance or i n XCX se rv ices . - The r o l e f o r such s toups voulc 5e to c r e a t e awareness * or' and demand f o r r 'ani ly fianninq s e r r i c e s . The use of incent ives Fn Iund a t

?r s u l t s . The u s e f o r family planniag and VCB

s e r v i c e s tsproved under t h i s strategy, but there vere =any problems with :he

i ccen t ives , inc luding an adverse e f f e c t on the c r e d i b i l i t y of vorkers . There vas ~ I O economic ana lys i s of the *rarious s r r a t e g i s s .

Y!WWX RUiUL ZALTH RESEARCH PROJECT, MHAEUSHTRX

The Xandwa Rural Hea l th Xesearch P r o Jec t was s t a r t e d i n 1973, when t h e Depart-

sent o f Heal th agreed t o g i v e c o n t r o l of a primary h e a l t h u n i t t o t h e Founda-

t i o n f o r f(ee=;rc? 'a Community Hea l th , which is p a r t of Grant Xedical Col lege

i n Zombay. Xn ongoing exper imental p r o j e c t , Handwa covers 30,000 people i n

twenty-nine v i l l a g e s i n a r u r a l a r e a of the Konkan c o a s t i n Xaharashtra .

OXF3LY prov ides f i n a n c i n g f o r t h e p r o j e c t along wi th o t h e r i n t e r n a t i o n a l donors

and t h e s t a t e government.

Design and S e r v i c e s

From t h e o u t s e t the p r o j e c t has been s t r o n g l y courinitted t o l o c a l

community involvement by forming l o c a l h e a l t h committees t o a s s i s t h e a l t h

workers i n p r e v e n t i v e and promotive h e a l t h work. P a r t i a l payment of t h e

h e a l t h workers' s a l a r i e s and of charges f o r medicines has a l s o been p a r t of

t h e scheme. Handwa provides i n t e g r a t e d h e a l t h s e r v i c e s t o the community and

i s involved i n l e p r o s y and t u b e r c u l o s i s c o n t r o l . The Foundation, which a c t s

a s t h e a d m i n i s t r a t i v e agency, provided s t a f f to run t h e p r o j e c t and t r a i n e d I

C

twenty-six women, chosen by t h e communities, t o under take s imple c u r a t i v e

procedures and p r e v e n t i v e work. .An a u x i l i a r y nurse-sidwif * -?rovides suppor t - *a

f o r f i v e v i l l a g e h e a l t h workers and covers a popula t ion of 5,000. A d o c t o r - v i s i t s e&h o f the s i x subcen te r s once a week t o a d v i s e on & r e d i f f i c u l t

8 .I

I

c a s e s and provide s t a f f suppor t and t r a i n i n g . I n t h e f i r s t s t a g e s of t h e

p r o j e c t , h o s p i t a l f a c i l i t i e s were provided i n response to t h e need communities

expressed.

S e s u l t s

The experience i n the Xandva p r o j e c t has Seen nixed, and s e v e r a l

changes have been izplemented. .U though the p r o j e c t encouraged the pa r t i c ipa -

t i o n of cormrmnities, l o c a l h e a l t h committees have l o s t i n t e r e s t and s t o ~ p e d

funct ioning. These c o m i t t e e s v e r e mainly cons t i tu t ed by t h e vocal v i l l a g e

nembers who c o n t r o l the v-illage and i ts a c t i v i t i e s . The project 's 3a in

emphasis has been on providing s i a p l e c u r a t i v e and prevent ive s e r v i c e s , n o t ,

t he ao re soph i s t i ca t ed s e r ~ i c e s these committees expected. The Fro ject

d i r e c t o r has h ighl ighted two o t h e r problems. F i r s t , the invo lvemat of

h ighly t r a ined profess ional3 i n the e a r l y period r a s counterproduct ive

because rapid change vas not i n keeping v i t h the pace of l i f e i n v i l l a g e s .

Second, coordina t ion between government hea l th s t a f f and the project 's s t a f f

has been l i s i t e d - and i t is bel ieved t h a t t h i s has adverse ly a f f s c t e d t h e

pro j e t .

Even so , t he r e s u l t s reported by the p r o j e c t a r e noteworthy;

Table h.3 ? r e s e n t s some of them. P r o j e c t c o s t s per c a p i t a a r e s s t i s a t e d a t R s

4.50 a yeaz. L

The :Gsa p r o j e c t w a s a p i l o c s tudy i n a n area served 57 a lrirnary hea l th

?. cen te r , and about 125 iniles north of 3om~ay i n V!a rash t r a . T5e ?reject a rea

covered about 5 6 , G O O people, of vhom 88 peroenc a r e t z i b a l . I 3 1974, t h e

3ovenment handed over the c o n t r o l of ;ersonnel, f f a a n c i a l resources , and

l o c a l h e a i z h f a e i l i c i e s t o the I n s t i t u t e of Child 3eal;h in 3cmoay. ~2

comuletion of t h e 7rojec: Fa 1977 the ? r i n a r y h e a l ~ h cen te r ~ U ~ C ~ ~ C U S r eve r t ed

Table A.3. X c c i v i t i e s of Loamunity Heal th Workers a t ?1an,lw~

a Immunization coverage

Smallpox 9C)%

T r i p l e an t i gen (Dm) 70%

B.C.G. 47%

Tetanus toxoid (second dose f o r pregnant women) 60%

Antena ta l Care

R e g i s t r a t i o n of c a s e s

Coverage wi th n u t r i t i o n supplement

Cont ro l of Tubercu los i s

Cases de tec ted by CBU i n 1978-79

Tuberculosis c a s e s

Propor t ion under r e g u l a r t rea tment

Cont ro l of Lep,rosy

Leprosy cases 15 0

-Cases - de tec ted by CW i n 1978-79 4 5 .a ' P ropor t ion under r e g u l a r t reatment 70% - - *

s P w

-

Source: Jou rna l of t h e Assoc ia t ion of Voluntary Agencies for Rural Development, vo l . 23 , no. 1. 1980.

a . Vaccinat ions a r e by a u x i l i a r y nu r se s i d u i v e s , bu t c a s e s a r e i d e n t i f i e d by community h e a l t h vorkers .

to the Departsent of Yealth. Tfie ?reject was paid f o r by t h e government of

, Ind ia , t he government of Y!harashtrs, and C A Z ; i c was administered by t h e

Institute of C M l d Health a t Grant Yedical College, 3ombay.

Objec t ives and Design

The s o d %as t o develop e f f e c t i v e and e f f i c i e n t i a t e g r a t e d h e a l t h

and n u t r i t i o n s e m i c e s f o r r e p l i c a t i o n i n the r u r a l a r e a s of Yaharashtra .

The ob jec t ives included : 2roviding in t eg ra t ed naternal-and-child ca re t o a l l

preschoolers and pregnant and nurs ing mothers i n each v i l l a g e ; providing c a r e

through part-tPae s o c i a l workers and medical and paramedical s t a f f ; encourag- '. i n g community p a r t i c i p a t i o n ; and evalua t ing the c o s t and e f f e c t i v e n e s s of the

p ro jec t .

Targets v e r e set and groups "at r i s k " vere i d e n t i f i e d by such

c r i t e r i a a s b i r t h weight of l e s s than 1.5 kilograms, and no weight gain i n

t h r e e consecutive sonths . S i s i l a r l y c r i t e r i a were set f o r s e l e c t i n g pregnant

women a t r i s k .

The under 5 ( Y ~ r l e p ) weight cha r t ,and a n observat ion cha r t f o r

mothers vere used t o monitor changes. Yo concrol groups were used; e v a l u a t i o n

w a s based on before-and-after=assessments of condi t ions among the t a r g e t ' J i

s o u p s . Surve i l lance was done by sa in t a in ing a long i tud ina l record f o r aach - - c h i l d , and the bu i l t - in e v a l a t i o n system provided up-to-dace i n f o r r a t i o n on

I

. p r o j e c t a c t i v i t i e s .

Se rv i ce s

The ~ h a s e d - i n t r o d u c t i o n of s e r v i c e s avoided over loading t h e h e a l t h

workers and was be l ieved to be nore accep tab le t o t h e community. For example,

t o avoid su sp i c ion and r e s i s t a n c e t h e p r o j e c t i n i t i a t e d i t s i m n i z a t i o n

program seve ra l months a f t e r t h e p r o j e c t s t a r t e d . B i r t h c o n t r o l p r a c t i c e s

were introduced i n a s i m i l a r way and a t an app rop r i a t e t i s e f o r t h e yoman:

a f t e r a b i r t h , f o r women wi th many c h i l d r e n and f o r women more s u s c e p t i b l e t o

pregnancy i.e. one year a f t e r t h e last b i r t h . The p r o j e c t providea c l i n i c -

based s e rv i ce s .

The p r o j e c t had many parc-t ime s o c i a l wor!cers -dho v i s i t e d homes,

r e g i s t e r e d t a r g e t group members, maintained records , provided supplementary

food, arid conducted educa t iona l c l a s s e s . Doctors and multipurpose workers

provided support and superv i s ion . One vo lun ta ry worker covered about 2,000

people.

Findings

Data f o r t h e i(asa p r o j e c t a r e l im i t ed , and p r o j e c t i npu t s were . n o t a ccu ra t e ly costed. Such i tems as d r : a t ed food and labor were no t inc luded

i n t he f i n a n c i a l a n a l y s i s , but rough es t imates show a c o s t per c a p i t a of about - - R s 7.00 a year f o r t h e s e r v i c e s . There were 45 s t e r i l i z a t i o n s ,* 1974-75,

's

1,568 i n 1976-67. &por t s a l s o show, a f t e r e igh teen months of s m p l e n e n t a r y * feed ing , t h a t %2.9 percent o f s eve re ly d n o u r i s h e d ch i l d r en izyroved t h e i r

weight by 10 percen t more than le expected growth. Table X . 1 shows the

b e t t e r coverage by irmnunizations between June 1975 and Xay L976. The s ucce s s

recorded by t h e p r o j e c t m y be r e l a t e d t o f a c t o r s indepecdent of the g r o j e c t

because t he r e a r e no f i g u r e s f o r a c o n t r o l group.

- 5 9 -

Table X.4. Immunizatisn Status a t Xasa

Immzni zat i o n Percentaqe of population i .?unized - -- June 1975 %y 1976

SCG

Smallpox

Triple .bc igeu (second dose)

Sour.ces: Shah P.X. "The Kasa Yodel Integrated Yother-Child Health- Nutrit ion Project" i n Xiternative Approaches t o Health Care, Indian Council of Xedical Research and ~ndia; Council of S o c i a l Science Xesearch, Xeu Delhi 1977.

PROJECT P C S W

I n the e a r l y 1970s supplenentazy feed ing programs i n I n d i a were a t t r a c t i n g

o l d e r preschool child:?n bu t s e r e no: reaching t h e most v a l n e r a b l e groups.

P ro j ec t Poshak was z p i l o t pro:rct i n Madhya Pradesh to meet t h e n u t r i t i o n a l

needs of hu t hound l n f a n t s and todd le rs between 6 aon ths and 36 months. Run

between 1571 and 1975, t h e p r o j e c t was desigzed t o reach preschoole rs nor

ber.efi t ing from t t 2 om-site feed ing . The n u t r i t i o n program was lL.dced t o t h e

h e a l t h c a r e s t r u c t u r e so t h a t t a r g e t groups would a l s o Senefi t from p reven t i ve

and ?tono t i v e h e a l t h s c r v i c e s . Hany agenrAes were Irr~oloe.-r i n t he funding afid management of P r o j e c t

Poshak, but CARE played a. major r o l e i n admin is te r ing and eva lua t i ng i t .

I f the p r o j e c t were s u c c e s s f u l and i f the take-home supplement proved eff c c t i v e

and e f f i c i e n t , tl:' 73de l would become a permanent p a r t of t he s t a t e ' s n u t r i -

t i o n prog ran,:

Design and Ob j e cz ive s

The ? i l o t p r o j e c t , an i n t eg ra t ed h e a l t h ~ n d i i u t r i r i o n p l aa , was

designed :o t e s t and eva lua t e the f e a s i b i l i t y , e f f i c i e n c y , and impac: 6 f a

laGc ..qiplemen;c.az-y feeding program covering a widely d i spe r s ed populat ion. '3 L

Because i t w a s ccnducted it1 backward t r i b a l a r ea s , i t was be l ieved t h a t t k * * E

p r q c t , if s u c c ~ s s f u l i n meeting it: objec-.tives, could be e a s i l y ;:eplica*d

i n bct ter-off s t a t e s . The p ro j ec r was tq func t ion through t h e h e a l t h c a r e

syszem, S G ~ through new s a r v i c e s , so r e ~ l i c a t i c n would ale^ be f e a s i b l e i n

v i e s of che anpower and f i n a n c i a l c o n s t r a i n t s . P i e r e were t h r e e phases:

e ~ l o r a t o r y , e x t e n s i v e , and i a t e n s i v e . The aaia o b j e c t i v e of t he s t udy vas t o

t e s t t he f e a s i b i l i t y o f p rov idk -~g 3 "take-home" r a t i o n i n s t e a d of an on-s i t=

feed ing r a t i o n t o i np rove n u t r i t i o n among p r e schc? l c h i l d r e n . >e e f f e c t of

s e r v i c e s a n t h e e ~ p e r i n ~ z a l Sroup v a s s ea su red l o n g i t u d i a a l l y a g a i n s t a s m a l l

c o n t r o l group; p o p l a t i o n coverzge and t h e ef f e c t i s e n e s s and zfff c i e n c y of

c e r v i c e s v e r e a l s o n e a ~ u r e d .

Se rv i ce s

The T r o j e c t provided, through t he p r i a a r y h e a l t h c e n t e r s and sub-

c e n t e r s , o e d i c a l and S e a l t h c a r e s e t v i c e s w i t h v i l l a g e i m u n i z a t i o n and

deworaing se r - r i ces . Pregnant and l a c t a t i n g mothers r e ce ived educa t i on and

demons t ra t ions on c h i l d car:- .\, tske-home supplementary food z a t i o n Y a s

d i s t r i b u t e d a t t he h e a l t h c a r e c e n s e r , u s u a l l y veek ly . Th is would a l l o w t h e

=other t o p rov ide r e g u l a r amounts o f the supplement t o t h e chi lc i , and t o avo id

d a i l y t r i p s t o t h e f e e d l a g c e n t e r . The p r o j e c t reached 15,000 b e n e f i c i a r i e s

dur ing t h e f o u r yea r s 02 it?. ope ra t i on .

In t h e e x t e n s i v e Thase. of the p r o j e c t the c o s t pe r c h i l d w a s 3s -

114.46 a pear at t h e subcencers an$ 3s 110.06 a g e a r a t pr5zLar-j h e a l t h c e n t e r s . I

T3c c o s t per c h i l d per annun fr l t;l% e x p l o r a t o r y and i n t ens i - r e phases v a s nuc!l

* hiq'ner. The f i g ~ r e s show t h a t t he -take-home r a t i o n s v e r e less expens ive than

on-s i te feed ing . Zy l e (1978) has suggested that " t he t-40 s o s t t aporcan t

f a c t o r s i n d e t e r s i n i n g t h e - ? d u e of the P o s h a ~ concep t , - c o s t arid e f f ec t i 7 r e -

7 3 3 - % e r e n e i t h e r s t r o n g l y ?os?.tivc nor nega t ive . "

l e c ~ r d s o f i n a l t h - r e l a t e d Inpucs were s c a n t y f o r some a r e a s , and i t

;.as i q o s s i b l e t o t r a c e Fz;xlcs and :heir u s e by rarzet 3r3ups . U o r - . g l i t : r

r a t e s f o r :rPat=ent c5;Fldren hen 3at:hed a g d a s t conc ro l s yere xot

s t a t i s t i c a . l l y s i g n i f i c a n t . The e f f e c t of combined s e r v i c e s was a s se s sed i n a

f i n a l weight seasurement of a subsample of 688 exper imental c h i l d r e n conpared

with aged-matched con t ro l s . Di f fe rences were no t s i g n i f i c a n t . Improvements -

i n 'weight s t a t u s ' among c h i l d r e n with second and t h i r d degree m a l n u t r i t i o n

w a s s u b s ~ a n t i a l dur ing t h e i n t e n s i v e phase of t h e p r o j e c t whi le the ex t ens ive

and exp lo r a to ry s t a g e s demonstrated poor achievement i n weight g a i n aaong

these two groups.

x substudy cornpanring take-home and on-s i te feed ing was conducted

dur ing the i n t e n s i v e phase o f t he p r o j e c t . Findlngs from t h a t s t udy showed

p a r t i c i p a t i o n r a t e s t o be much h igher i n t he on-s i te scheme: t hey were 43

percent t o 53 percen t f o r t he take-home r a t i o n , compared with 60 percen t o r

more f o r on-s i t e feeding. The main t a r g e t group, t o d d l e r s and preschool

c h i l d r s n (6 t o 36 months) of l a n d l e s s l abo r ing f a m i l i e s , d id n o t p a r t i c i p a t e

t o t he ex t en t expected. The sma l l landowner c l a s s benef i t ed most. The e f f e c t

of s e rv i ce s i n t h e ex t ens ive phase on t h e c o n t r o l and exper imental g roups , w a s

no t s u b s t a n t i a l l y d i f f e r e n t . Several s p i l l o v e r e f f e c t s were i d e n t i f i e d among

t he experiments' groups, however, including t h e increa,sed use of s e r v i c e s a t

t h e primary h e a l t h c e n t e r , inc reased acceptance of family planning measures, e

and improved a t t i t u d e s of mothers coward h e a l t h and n u t r i t i o n .

* - INTEGRATED HEALTH SERVICE PROJECT, Y I W 'i

C

The Xiraj P n t e g r a e d Health Se rv i ce P ro j ec t was s t a r t e d i n 1973 and f o i n t l y

w gr run by t h e Governwnt of Xaharashtra and t he Miraj Xedical Cente r . me

Department of Hea l th gave the vo lun t a ry agency f u l l r e s p o n s i b i l i t y Eot

admin i s t r a t i on based a t a priiuary h e a l t h c en t e r . U t e r the completion of t he

p ro j ec t i n 1077, respons ib i l . t y :or s e r v i c e a c t i v i t i e s r eve r t ed to t h e p rev ious

admin is t ra t ion . The Vorld Council of Churches, the governnent of Yaharash t ra ,

ar-d Y i r a j Xedical Centre provided funding f o r t h e p r o j e c t .

Design and Objec t ives

The ob jec t ives included the provis ion cf p r i a a r y h e a l t h c a r e s e r v i c e s ,

family planning, and s p e c i a l programs of leprosy and tube rcu los i s con t ro l .

Training was eaphasized, and the p ro jec t t r a ined 173 of the 186 c r a d i t i o n a l

sidwives i n the s r o j e c t a rea . Community p a r t i c i p a t i o n was encouraged, and t h e

community w a s expected t o pay 3 f l a t f e e of Xs. 0.25 f o r any s e d i c a t i o n

received f o r three-day t r e a t x e n t s . Lnvolvement of l o c a l v i l l a g e organiza t ions

vas not s t r e s s e d , a l though the p ro jec t l eade r s worked with the gram panchayats.

Health s e r v i c e s ve re introduced sequen t i a l ly . .As these became pore acceptable ,

and a s the h e a l t h s e n i c e vorkers es tab l i shed a r e l a t i o n s h i p v i t h the community,

family planning se rv ices were introdaced. Populat ion coverage uas about

230,000. The 2 r o j e c t employed a demographer, who processed and analyzed da ta

on the coverage of s e rv ices and on v i t a l s t a t i s t i c s .

.A s h o r t o r i e n t a t i o n course f o r (voluntary) v i l l a g e h e a i t h a i d s w a s

undertaken, ,nd t r a i n i q v i t h emphasis on p r a c t i c a l s k i l l s vas conducted c l o s e

t o the vorler 's v i l l a g e .

1

Services

The h e a l t h workers nade house-to-house c a l l s i n the v i l l a g e s and

c a r r i e d a b a s k m e d i c b e k i t conta in ing vaccines, s e d i c i r e s , c o n t r a c e j t i v e - devices, some audio-visual a i d s , and a de l ive ry k i t . Yathers r e r e taught hov w . to prepare o r a l rehydrat ion f l u i d s f o r the t r e a t z e n t of childhood d iar rhea .

Ilhe hea l th v o r l e r was supervised and given guidance 5y the healch cean, and

i n t e r s e d i a t e vcr!<ers usua l ly v i s i t e d the - r i l l age once a ye&. VF2al s t a t i s t i c s

vere co l lec ted .

Findings

Daca on che e f f e c t of s e r v i c e s , p a r t i c u l a r l y i n r e l a t i o n t o p r o j e c t

c o s t s , a r e approx isa t ions . The per c ap i t a c o s t of the N i r a j p r o j e c t was

es t imated t o be Rs 3.70 A year . Since the p r o j e c t charged f o r medicines , R s

20,000 were recovered, and the p r o j e c t s e t up a revo lv ing fund t o buy medicines.

Th is =ore than doubled t h e a l l o c a t i o n f o r medicines a t the primary h e a l t h

c en t e r .

b e i n d i c a t i o n of e f f e c t i v e n e s s o f t he p r o j e c t i s the i n f a n t morta-

l i t y r a t e , which w a s reduced 65.8 percent i n t h r e e years . The p r o j e c t d i d n o t

have a c o n t r o l group, but i n f a n t mor t a l i t y r a t e s and ou tpu t d a t a a r e a v a i l a b l e

I f o r coverage of s e r v i c e s dur ing t h e t h r ee years . Table X.5 p rov ides p r o j e c t I 1 r e s u l t s and achievements. I

Table A.5. I m p r o v e ~ e n t s under t h e I n t e g r a t e d Heal th Serv ice P r o j e c t a t X i r a j

Xeasure January 1974 January 1977

Crude b i r t h r a t e (per 1,000 popula t ion)

I n f a n t Nor t aB i ty Rate (per 1,000 l i v e b i r t h s )

Percentage of c h i l d r e n under f i v e immunized

Small pox T r i p l e an t i gen Pol io BCG . - -

' i Percentage of E l i g i b l e Couples P r a c t i s i n g Family p la&ing * - Crude S i r t h Rate

Percentage of c lnte-aata l Cases Y.A. Covered

n.a. not a v a i l a b l e Source: Pyle , 9. Voluntary Agency-3ana9ed P t o j e c t s Del iver ing an

I n t e g r a t e d T a c b 9 e of Hea l th , S u t r i t i o n and Popula t ion Serv ices : The Xaharashtra E x n ~ ~ ~ c ~ c e . N e w Delhi 1979.

IYDO-9LTm ?BOJECT FOR CYILD hTLF.LE

-

a e Indo-Dutch 2 r o j e c t f o r CSi ld ' d e l i a r e was a p i l o t p r o j e c t s t a r t e d i n l a t e

1969 i n Xndhra ? radesh . It was designed t o t e s t and develop 5 e t z s r s e t h o d s of

c a r e Eor c h i l d r e n under s i x t e e n , and t o combine t h e s e s e r v i c e s w i t h a r e s e a r c h

and t r a i n i n g component. n e p r o j e c t was t o je a s o d e l f o r r e p l i c a t i o n e l s e -

vhe re i n t he s t a t e . The 2 r o j e c t donors expected t o complete t h e p i l o t p r o j e c t

i n e i g h t y e a r s and then t o withdraw. It w a s in tended t h a t t he p r o j e c t v o u l a

become s o r e s e l f - s u s t a i n i n g w i t h inc reased cornmunit7 p a r t i c i p a t i o n and even tua l -

l y become a community p r o j e c t . It is now expzc ted t h a t donors ill con t i nue

w i t h t he p r o j e c t u n t i l 1985. Four teen v i l l a g e s i n Chevel la Block i n t h e l a n q a

Keddy d i s t r i c t o f .lndhra Pradesh a r e covered by t h e 2 r o j e c t . It w a s developed

through t he c o l l a b o r a t i o n of t h e I a d i a n Government and t h e Xether lands ?oundat ion.

Design and O b j e c t i v e s

The a a i n o b j e c t i v e s a r e t o provide h e a l t h , n u t r i t i o n , and e d u c a t i o n a l

f a c i l i t i e s f o r c h i l d r e n up t o s i x t e e n . I n a d d i t i o n , t h e n u t r i t i o n component *

is l i n k e d wi th incode-aenerat ing a c t i v i t i e s . The p r o j e c t w a s t o encourage

community p a r t i c i p a t i o n and e v e n t u a l l y t o become a community p r o j e c t w i thou t - - donor suppor t . '9

L

- The h e a l t h comoonent ha s chanqed over :he -Bars t o develop t h e a o s t

8 9? a p p r o p r i a t e tj-pe o f s e r v i c e f o r communities. Auxiliar 'y nurse nidwives , each

cover ing a popu l a t i on of 5,CDO i n t h e p r o j e c t a r e a , super-r ise and suppo r t

community h e a l t h v o l m r e e r s (gram swas t ikas ) . A n o b i l e h e a l t h team v i s l c s

v i l l a g e s twice a yeek t o s o n i t o r and s u p e r - ~ i s e rhe work o f au:c i l iar :~ nu r se

z i d u i v e s and t o t m u n i z e d l g i b l e children.

Serv ices

The community 5eal t h vo lun teer covers approximately 200 f a m i l i e s and -

provides b a s i c h e a l t h c a r e to mothers and c h i l d r e n i n the popula t ion . Scab ies ,

worms, and d i a r r h e a s a r e t r e a t e d ; under f i ve s ' s u r v e i l l a n c e i s maintained; pre-

n a t a l and p o s t n a t a l cases a r e supervised and pregnant women a r e r e f e r r e d f o r

s p e c i a l c a r e t o t h e A%. The community h e a l t h vo lun t ee r has a monthly s t i pend

of 2s 50/= and Famil ies a r e expected t o pay 50 pa i s e a month towards her s a l -

a ry . I n e f f e c t many f a m i l i e s do no t pay t h i s sum and ccmmunity involvement i s

no t apparent . Creches and income-generating schemes, such a s prepar ing

ground s q i c e s an3 making up packets o f p ro t e in foods f o r t he n u t r i t i o n p ro j -

e c t , vere a l s o s t a r t e d . Family planning s e r v i c e s a r e a v a i l a b l e f o r i n t e r e s t e d

couples .

Findings

In 1977 the Yat iona l I n s t i t u t e of Rural Development i n Hyderabad

completed a s t udy of t h e p ro jec t ' s inpac t i n t h e Chevel la block. The survey,

conducted p r ima r i l y among female b e n e f i c i a r i e s o f t he program, produced

s i xed r e s u l t s . The immunization program had widespread acceptance i n an a r e a

vhere immunizations had no t p rev ious ly been undertaken. It vas a l s o found

t h a t i n f a n t i n o r t a l i t y r a c e s dropped and t h a t h e a l t h s e r v i c e s were s o r e acces-

s i b l e t o t h e populat ion. 3ut t h e s tudy d id no t f i nd any major change i n - cornuni ty a t t i t u d e s and p r a c t i c e s o r i8 the adopt ion of income-generating

a c t i v i t i e s b e n e f i c i a l to =he f a m i l i e s . The l o c a l women's group ( n a h i l a

sandals) ve r e no t a s e f f e c t i v e a s expected i n invo lv ing and reach ing l o c a l

women d e s p i t e an expendi ture of Xs 96,000 to s t r eng then these women's groups.

Loans t o encourage incone-genera t ing a c t i v i t i e s have not been recovered.

One of the s a j o r omiss ions w a s t h e absence of community iavolvement i n d e t e r -

a i n i n s ~ needs and a p p r o p r i a t e responses . Only i n 1973, frve y e a r s af:er t h e

p ro j ec t ' s i n i t i a t i o n , were t he communities asked t o c o n t r i j u t e t o t h e v a r i o u s

a c t i v i t i e s of t h e p r c j e c t . De t a i l ed survey f i n d i n g s a r e not a v a i l a b l e t o

a s s e s s the e f f e c t of t h e p r o j e c t , 5 u t f i g u r e s on service coverage a r e

shown i n t a b l e A . 6 .

Table X.6. S e n i c e Coverage by t h e Icdo-Dutch P r o j e c t

S t e r i l f z a t i o n s per forned

Xn teoa t a l cases t r e a t e d

1976 ( f i r s t h a l f ) 2,946

I n 1 9 7 1 :he United ? l a n t e r s . issocLation of Southern I n d i a (UP-GI), -&:h t h e - - s&?ort of USXID., in t roduced zone t a ry i a c e n t i 7 e s :o encourage couples zo - a & o t fami ly p lann ins . The i n c e n t i v e vas a d e f e r r e d *gent 20 c o u ~ l e ~ ~ ~ h o * - . - l i x i t e d t h e i r f ami ly s i z e . Ca l led t h e Yo-3itth 3onus Scheme, i t va s s t a r t e d

on t h r e e t e a e s t a t e s i n South I z d i a and ras open t o a l l pernanent f e n a l e

emuioyees between 1 7 and 40 . On :he t e a e s t a t e s , l e g i s l a t i o n requ ixes :?.at

a l l permanent employees be provided with housing, h e a l t h s e r v i c e s ,

and such b e n e f i t s a s pensions and mate rn i ty and c h i l d c a r e b e n e f i t s .

Design and Ob j e c t f ves

The Yo-Birth Bonus Scheme -- pa r t of t he l a r g e r Comprehensive

Labor Vel fa re Scheme -- w a s in tended t o t e s t n o n t r a d i t i o n a l i n c e n t i v e s

t o l i m i t i n g fami ly s i z e . It w a s designed t o overcome some of t h e problems

with more i m e d i a t e i ncen t i ve s i n family planning and t o encourage couples to

adopt fami ly planning by g iv ing t h e n the freedom to choose betweeu d i f f e r e n t

con t r acep t i ve methods.

Each female estate worker of ch i l dbea r ing age who accepted t h e

p lan w a s provided wi th a j o i n t sav ings account i n her name and t h e company

-me. For each month t ha t the woman d i d no t become pregnant , R s 5 were

deposi ted i n t h e acc0ur.t. The account was f rozen u n t i l t h e woman had passed

t h e ch i l dbea r ing per iod , when she could withdraw t h e savings . I n t he i n t e r im ,

i n t e r e s t w a s earned on the depos i t . I f the woman became pregnant , a c e r t a i n

amount w a s f o r f e i t e d o r payments ceased f o r a yea r .

Se rv i ce s

Under t h e l a r g e r wel fa re scheme opera t ing on a l l t h r e e t e a e s t a t e s , - *a

a s a t e r n i t y and c h i l d we1fare:program provided p r e n a t a l and p o s t n a t a l s e r v i c e s ,

immunizations, supplementary & r i t i o n ca r e , and r e c r e a t i o n a l and educa t i ona l - f a c i l i t i e s . Family planning s e r v i c e s were f r e e . I f a couple decided t o be

s t e r i l i z e d , t h e l a r g e cash i n c e n t i v e provided by t h e government would accrue

i n a d d i t i o n t o t h e de f e r r ed i n c e n t i v e o f fe red by t h e bonus scheme. l5-i t h e

f i r s t year of t he p l an , 480 of 792 e l i g i b l e women joined. I n t he second yea r ,

116 e l i g i b l e women en ro l l ed b u t , s i n c e then, t h e r o l l s f o r membership have

d g r a t e d o r d i e d , and a f tv have f o r f e i t e d sernbership. i n 1977 t h e r e v e r e 521

nembers .

Find ings

I n 1975 a sample survey w a s conducted on e igh t een t2a s s t a t e s .

Xore i n f o m a t i o n , ob ta ined from o f f i c i a l r e co rds o f Sirtns and from persona l

obse rva t i ons , has helped i n a s s e s s i n g t h e e f f e c t and sho r t con inys o f the

scheme. There were t h r e e a roups or' e s t a t e s : t h e f 5 r s t coolprised :he t h r e e

t e a e s t a t e s t h a t had t h e Yo B i r t h a o n w Scheme (Type 1); t'ie second, c i n e

e s t a t e s t h a t had on ly t h e Comprehensive Labor Welfare Scheme (Type 11 ) ; t h e

t h i r d , s i x e s t a t s s t h a t had n e i t h e r scheme and t h a t v e r e s e l e c t e d as c o n t r o l s

(Type 111 ) . Crude b i r t h r a t e s , a v a i l a b l e from company r e c o r d s up t o 1977,

were s e l e c t e d zo ensu re more accu racy i n the d a t a a n a l y s i s . Tab le A. 7 p r e s e n t s

t he c rude b i r t h r a t e s f o r t h e t h r e e types o f t e a e s t a t e and f o r o t h e r a r e a s .

The measurements sugges t t h a t t he b i g g e s t e f f e c t was on vonen aged

30 - 39 and on couples vho had t h r e e o r f ou r c h i l d r e n . O f t h e e l i g i b l e women

i n t h e t h r e e e s t a t e s chosen f o r t h e bonus scheme, 82 pe rcen t jo ined dur ing r h e

NO yea r s t h a t e n r o l b e n t w a s open. .Although b i r c h and f e r t i l i t y r a t e s

appeared t o 5e f a i l i n g f a s t e r on those e s t a t e s than on t he o€her t v o groups , a* L

f u r t h e r d a t a and a n a l y s i s would be zncessa rg t o t e s t t h e s i z e and s i g n i f i c a n c e - - *

of t he d e c w e . Fu r the r so r e s e v e r a l a d m i n i s t r a t i v e s h o r t c o m ~ g s w e r o , i d enc i - - v

l i e d i n t he p l an , vh i ch may have con t r ibuced t o a s lower d e c i i n e L2 S i r i h and

fertility r a t e s . P,e e v a l u a t i o n s t u d y does no t p rov ide a f l z a n c i a i a n a l y s i s

of t he p r o j e c t .

Tab le h7. Crude B i r c h Rates, 1969-70 t o 1976-77, South 11-dia.

A l l Tamil N i l g i r i s Type of estate Year a / - I n d i a Xadu d i s t r i c t I I1 I11

a/ July 3 1 - J u n e 30 . -

Source: UPASI Comprehensive Labour Welfare Scheme. Annual Reert 1975 and n I UPASI o f f i c e r eco rds for 1974-75 through 1976-77. F i g u r e s f o r type

111 e s t i m a t e s f o r t h e s e last t h r e e y e a r s are from f o u r o f t h e s i x e s r a t e s i n t h i s c a t e g o r y .

COXPREXEXSIVE RURAL YZALTH PROJECT, J..LSS,ZD

Jamkhed is i n Xhmednagar D i s t r i c t one of t h e poo re s t a r e a s of

Xaharashtra. hihen t h e s emice -o r i en t ed h e a l t h p r o j e c t s t a r t e d i n 1971, i t

covered an arc-a around t h e t o m and used Jamkhed a s a base f o r i i s a c t i v i t i e s .

3opu l a t i on coverage over t h e f i r s t year was about 40,600; 57 19i8 i t was

I I C 0 , O O O . The p r o j e c t l e a d e r s , r ecogniz ing t h e need f o r comprehensive h e a l t h

I s e r v i c e s wi th f u l l e s t community p a r t i c i p a t i o n , approached v i l l a g e l e a d e r s and I i I race ived a n e n t h u s i a s t i c response to t h e i r sugges t i ons f o r a comprehensive set

of h e a l t h and n u t r i t i o n s e n i c e s f o r t h e area .

Funding w a s provided by t h e C h r i s t i a n Xedica l Commission and -~ar i ,ous

s e c u l a r and r e l i g i o u s agenc ies , bu t t h e p r o j e c t has become i a c r e a s i a g l p

s e l f - s u f f i c i e n t . S t u d i e s be fo r e t h e s tart of t h e p r o j e c t showed a high r a t s

of im-ant n o r t a l i t y i n t he area--from 80 ? e r 1 ,000 i n Jamkhed :own t o 150 ? e r

1 ,000 i n t h e more r u r a l a reas .

Ob jec t i ve s and Design

The main p r o j e c t g o a l s inc lude : reducing n o r t a l i t y and n o r b i d i t y

r a t e s ; reducing popu l a t i on growth r a t e s by g r a d u a l l y i ac roduc ing fami ly -

? l ann inG s e n r i c e s ; and ca r i ng f o r t he c h r o d c a l l y ill and c o n t r o l l i n g leprosy L -

and tubefcu los i s . The j r o j e c t is designed t o en su re f u l l pa r t i c i?a : ion by :he

Jr I I

community: t h e p r o j e c t d i r e c t o r s must be assured of l o c a l supporz be fo r e the

v i l l a g e h e a l t h t e a s t a r t s t o work i n a v i l l a g e . The v i l l a g e h e a l t h =earn a l s o

c o i l e c r s d a t a and i d e n t i f i e s t a r g e t groups.

Se rv i ce s

P r o j e c t s e r v i c e s i nc lude ca r e f o r c h i l d r e z under f i v e , s u ~ p l e -

a en t a ry n u t r i t i o n a l c a r e , i m u n i z a t i o n s , family planning and mate rna l c a r e ,

and a prograin t o c o n t r o l l ep ro sy and t ube rcu lo s i s . A c e n t r a l c l i n i c provides

nore s o p h i s t i c a t e d medical c a r e , wi th an o u t p a t i e n t c l i n i c , ope r a t i ng room,

and f a c i l i t i e s f o r t h i r t y p a t i e n t s . Cura t ive s e r v i c e s a r e provided t o respond

t o t he expressed need of t h e community and t o make t he p reven t ive and promo-

t i o n a l a spec t s o f t h e program more acceptable . Fee-for-service payments a r e

nade f o r c u r a t i v e s e r v i c e s , but not f o r p reven t ive measures. Xobile teams

v i s i t t h e v i l l a g e s and, with v i l l a g e hea l t h workers , a r e r e spons ib l e f o r

i d e n t i f y i n g and fol lowing up pregnant women and family planning accep to r s .

The teams and v i l l a g e hea l t h workers a l s o supe rv i s e home b i r t h s , run a supple-

mentary feed ing program, do s u r v e i l l a n c e of c h i l d r e n under f i v e , c o l l e c t v i t a l

s t a t i s t i c s , and provide ba s i c h e a l t h c a r e and educat ion. They r e f e r s e r i o u s

ca se s t o t h e c e n t e r a t Jaakhed c r t he h o s p i t a l a t hhmednagar.

Findings

I * The Jamkhed p r o j e c t has emphasized c o m i t y p a r t i c i p a t i o n and

r e s p o n s i b i l i t y . .As a r e s u l t , 75 percen t of the r e cu r r en t expenses f o r the - - p r o j e c t a r e met by p a t i e n t fees . The gpernment provides 4 percen t of the

L

budget, f o r e i g n donat ions t he r e s t . C a a t i v e s e r v i c e s account f o r 30 percent *

of the budget; p r even t i ve servir -es f o r 60 pe rcen t , and admin i s t r a t i on f o r t he

remaining 10 percen t . The communities have donated land, con t r i bu t e& bu i l d ing

s a t e r i a l s , and provided labor . I n 1979 t h e per c a p i t a c o s t f o r care w a s

e s t i a a t e d a t X s 8.75 a year .

Table X.8 p r e s e n t s t h e f i n d i n g s O F surveys o f t h e t a r g e t p o p u l a t i o n

i n 1 9 7 1 and i n 1976. Note t h e narked d i f f e r e n c e s i n m o r t a l i t y r a t e s and

s e r v i c e coverage between Jamkhed and n o n p r o j e c t a r e z s . F u r t h e r a n a l y s i s o f

t h e d a t a is needed, however, because t h e r e were no s t r i c t c o n t r o l s to a s s e s s

the e f f e c t o f g ro j e c t z e a s u r e s .

Tai~la A . 3 . Comparison of P r o j e c t and N o n p r o j e c t . \ r c a s , Jamkhed --

P r o j e c t a r e a Nocpro jec t a r e a s

P o p u l a t i o n surveyed

P e r c e n t a g e of c h i l d r e n under f i v e i n n u n i zed

I n f a n t a o r t a l i t y per 1,000 l i v e b i r t h s

P e r c e c t a g e of pregnaot women receiving ancz- n a t a l c a r e

Crude b i r t h ' a t e pe r 1,COO ?c - x l a t i o a

?e reencage o f e l i g i b l e coup les p r a c t i c i n g f a d y p lann ing

. 2 . 5

. Source: i2avld ?yle, Vol~.xicary Agency - Vanaged P r o j r c r s Deliveriaq an

I n t e g r a t e d Package of Beal t !~ , N u t r i t i o n and l o p u l a ~ i o a S e r r i c e s : The uanarashti-a Z s p e r i e n c e ? a p e r p r e p r e d f o r .he l o r d Founda t ion Nerd 3ei;u, 1979.

a. 13 i s 7 3 ic vas 93 p e r c e n t . b. e r c c n c a g e 23r a l l -domen. c . Ia 1973 It -Jas 96 ?ercenc.

APPSXED NUTRITION PROGWX , KERALA -- -

Kerala is orie of =he poorest s t a t e s in I nd i i , and vLth Gujarat, Bihar r.nd

Tamfl Nadu I: kis a high incidents of calorie-deficiznt d ie t s . These delicien-

g i r s par t i cu la r ly affc:t the Pulrernble groups-the young, pregnant women, and

lac ta t ing wther.). Xn 1950 tk t FAO, UKXCEF, otkar i n t e r n a t i o r d organizations,

aad tile government of India a ta r t ed 2 program of snpplementaxy feedin.;

fcr :Liltiten, ptegnarrt womc?, &nd nursing mothers. This program vas l a t e r

expanded t o encourage v i l l age food production and t o educate f a d l i e s about

nu t r i t iona l needs and ways of me t i ng those heeds. In 1963 the Government of

India signed sn cegreement v i t h the in ternat ional a g e n c i e ~ t o extend the

program to the 6 . ':-. country.

In 3963-64 the program s ta r ted i n Ke rda and i n I978 i t val operating

i n d g h s y a u e of the state's I44 c o m m i t y develophut blacks. Sevcr>.L agencies

a ~ d goverrnent departments have been involved i n the proJcct. ZIP gc~vernnent

of Iudia, UNICEF, and CARE provj.de su;,pcrt and ass is tance f o r t h e succes8fu.l

implemcatation of the pragram; the c e n ~ r a l gavernme?t's Departmen;sof Community Y

Development has teen rm,m=rsible f o r coordination.

Ob i ~ . c t i vz s and Design -A

The progra:: is mainly educational and i€s inajoz objective is t o P

i ~ p r o v e the nutriticrnal s t a t u s of preschool childfen, c rag mat womzn, a d

nursing mothers. The program hae fowc main components:

o S u t r i t i o n , h e a l t h eauca t i o n , and t r a i n i n g .

o ? roduc r ion of p r o t e c t i v e and ? r o t e i n foods i3

s choo l , home, and ccmmuni t y gardens .

o Demonstration f eeding . o Scneduled h e a l t h c teck-ups and immunizations.

Sach cumponent is des izned t o encourage g r e a t e r p a r t i c i p a t t o n by t h e communi-

t i e s i n o b t a i n i n g n u t r i t i o u s d i e t s . Educat ion arid t r a i n i n g a r e emphasize+ to

c r e a t e no re awareness of n u t r i t i o n a l . needs and t o e -courage d i e t a r y changes

b e n e f i c i a l t o the vu lne r ab l a groups.

? r t 3ram S e r ~ f c e s

X u t r i t i o n d u c a t i o n has been provided a t day-long women's camps:

d:iring 1976-77 about 75,000 women a t t ended i n t he se c a p s . Teaching s e s s i o n s

emphasized hygiene , food p r e se rva t i on , cooking wi thout l a s i c g n u c z i e n t s , and

t he gene ra l importance of n u t r i t i o n . I n a d d i t i o n , d i s c u s s i o n s of similar

t o p i c s v e r e he id I n 30,CW in formal groups du r ing t h a t year .

The p ro j ec t ' s p roduc t ion component: encourages a c t i v i t i e s i n h o r t i -

c u l t u r e , p o u l t r y keeping, 'and f i s h e r i e s : a s w e l l a s ' t h e development of vege-

t a b l e gardens For d a o m t r a t i o n purposes. The feed ing program f o r p r e s c h o o l e r s -

and f o r p r 9 n a n t and l a c t a t i n g voaen of the s t a t e ' s 3,000 r 'eeding c e n t e r s - 6

bene i i z s 3 0 0 , COO ~ e o p l e . - * * E

h r i a g t h e f i r s t s t a g e s of the Trogram, s e r ~ i c e s v e r e provided .

only i n blocks ohe re they cou ld be t i e d to a t r a i n l a g institution. Such

blodcs would s e r a both as a f i e l d - t r a i n i n g a r e a f o r t r a i a e e s and a s a

d e a o n s r i a t i o n a r e a * d t h on-going f i e l d e s r e n s i o n jrograms. L a t e r , a s s e r s o n n e l

vere zraiaed, t h e 2rojcc: va s s t e n d e d :o b locks no t served 'w z r s i n i s g

L5s-4 -.qrJ n- - - - - - - - ..s.

- 76 -

P r i a a r y t e a l t h c e n t e r s work with the program by grov id ing immuniza-

t i o n s , s e l e c t i n g b e n e f i c i a r i e s f o r the feed ing c e n t e r s , aqd performing

medical checks of aa lnour i shed ch i l d r en , and providing immunizations.

Findings

I n 1975 the S t a t e Planning Board, a t the government's r e q u e s t ,

eval.aated t he impact =id achievements of t he Applied N a t r i t i o n Program i n

Kerala. I t conducted a survey i n a random sample of e leven of the seventy-

four community development blocks then i n ex i s t ence . Only blocks t h a t had t h e

program f o r t h r ee o r s o r e yea r s were included. A c o n t r o l group was s e l e c t e d

with cha r a : t e r i s t i c s similar t o t h e s e l e c t e d Applied X u t r i t i o n Program groups.

Schedules of in format ion about t he program, were c o l l e c t e d by observa t ion and

i n household q u e s t i o n r a i r e s , and these were supplemented by o f f i c i a l da t a f-om

s t a t e records .

*re than a q u a r t e r of the c e n t e r s d i d no t have the in tended number

of b e n e f i c i a r i e s . Furthermore, i n ha l f the c e n t e r s the number of pregnant and

l a c t a t i n g women was f a r lower than intended. a n y be l i eve t h a t low-income

f ami l i e s &n t h e community a r e not aware of t he program and4 t h e r e f o r e , a r e no t

se1e:ted a s b e n e f i c i a r i e s . I n t h r ee q u a r t e r s of t he c e n t e r s s t ud i ed , t h e

medical o f f i c e r was no t involved i n the s e l k t i o n of b e n e f i c i a r i e s . F i e l d ,3 P

i n v e s t i g a t i o n s revealed a de f i cC t between r e g i s t r a t i o n and a t t endan ce of 30 t o - *

LO percen t . h - The p i c t u r e f o r home, school , and community garden p r o j e c t s and

production programs was s i m i l a r , and i t was apparent t h a t f a c i l i t i e s were

underused and t h a t m a t e r i a l s e s s e n t i a l f o r inp lementa t ion of t he p l an were

l a ck j . ~g .

The== was not a f u l l ccmplement of s t a f f , and nany ex tens ion

o f f i c e r s involved d id not have formal t r a i n i n g i a the Applied Y u t r i t i o n

Program. According t o the f ind ings of t he evaluat ior , : i s p l e n e n t a t i o n vas

pcor and r e s u l t s v e r e unsa t i s f ac to ry because of the l imi t ed involvement of

governmenr d e p a r t s e n t s and because of the l a c k of i n t e r e s t of panchayats,

l o c a l bodies , and the community. The n u t r i t i o n a l impact of s e r v i c e s on

b a i e f i c i a r i ~ i n t h e feeding program was not reported.

SPECLU, WTRITION PROGUM, COIXBATORE , T M L Y D U

The Government of Ind ia launched the Spec ia l Y u t r i t i o n Zrogran

(SXP) i n 1970 v i t h t h e o b j e c t i v e of providing supplementary a u t r i t i o n to

preschool ch i ld ren , pregnant women, and nursing rnothers of low-income groups

ia urban s l u n s and i n t r i b a l and backward r u r a l a reas . The n a t i o r a l program i s

under t h e Deparunent of S o c i a l Welfare; t h e s t a t e program under the D i r e c t o r

of Soc ia l Ye l f a re , of Tribal Development, o r of a u r a l Development. The

block development o f f i c e r and h i s s t a f f o a r e respons ib le f o r t he day-to-day

func t ioning of the block program.

Food is provided by CAE, the World Food Program, and the s t a t g s . ,* 5

The scheme has s o r e than 6 n i l l i o n b e n e f i c i a r i e s i n the countrp. - - - During 1970-B5, t h e Spec ia l Nu t r i t i on lrogram i n T a i l Yaau r-hed

I - 80,000 c h i l d r e n i n 280 feeding centers . The program vas s t a r t e d i n Coimbatore

i n 1971, and by t h e end of t h a t year 7,000 c h i l d r e n v e r e rece iv ing supplemen-

t a ry n u s r i c i o n c a r e ac e ighteen cen te r s i n the c i t y .

recommended i n t a k e . m e r e v e r e c l i n i c a l s i g n s of c o r n e a l v a s c u l a r f z a t i o n and

3 i t o t e s s p o t s f o r 36 Tercen t of t h e s t udy c h i l d r e n . T3e a n t h r o p o n e t r l c d a t a

c o l l e c t e d w a s compared t o values f o r all I n d i a and f o r Tamil Nadu. The

s t udy d a t a show t h e weights and h e i g h t s of b e n e f i c i a r i e s t o be below those

va lues ar a l l Lges. (Table A. 9 ) .

Table X.9. Hean Heights and Weights of Chi ld ren , by Age, Coimbatore

Group 6-12 months 13-24 months 25-36 months 37-48 son th s

Height ( c en t ime t e r s )

Boys

Presen t s tudy 69.4 78.1 86.7 92.7 Al l I n d i a 73.9 81.6 89.8 96.0 Tamil Hadu n. a. 88.3 . 89.8 93.0

G i r 1 s

Presen t s tudy 68.4 77.3 81.3 86.3 All I n d i a 72.5 80.1 87.2 94.5 Tamil Nadu 3.a. 81.8 82.8 82.5

Weight (ki lograms)

Present s tudy 6.2 8.9 10.9 l l . 8 .Ill I n d i a 6.4 10.1 h . 8 13.5 Tamil Nadu n. a. 9.9 11.6 13.1

G i r l s *

Present s tudy 6.8 8.6 10.4 ll. 9 A l l I n d i a 7.8 9.6 11 -2 12.9 Tamil Nadu n.a. 9.9 52.1 - 12.2

,* L

- ~ou;ce: I nd i an Jou rna l o f N u t r i t i o n and D i e t e t i c s ( 1 g 7 ) 14, 61. 7

I -

Study 2 . Five c e n t e r s r e p r e s e n t a t i v e of t h e eighteen ia Coizba tore I C i t y were s e l e c t e d f o r s t udy . P.0 w e r e p r i ~ a r ? s c h o o l s , tsro v e r e naternal-anc-

-

c h i 1 - - - - ~ ~ ? a l t h c e n t e r s , and one was a nu r se ry s choo l . Xeasurements o f weight

and he igh t were recorded s o n t h l y f o r s i x s o n t h s , and a phys i c i an conducted a

c l i n i c a l su rvey be fo r e and a f t e r t h e s tudy. A comparat ive aualjsis of f i g u r e s

f o r a l l - I n d i a and f o r Tamil !Tadu and f i g u r e s f o r Coirnbacore vas undertaken.

' Je igh t s of c h i l d r e n i n Coiabatore were below t h o s e o f t he o t h e r

g r o u p s . ( t a b l e X.10) .An iaprovement w a s observed i n che c l i n i c a l s i g n s

a t t h e end of t h e s tudy . Grouth t r ends among p r e sen t b e n e f i c i a r i e s was c l o s e

t o t h e v a l u e s f o r T a d Xadu and a l l I n d i a , even though the s t u d y group vas

of lower socioeconomic s t a t u s .

Table X.10. Weight of Ch i l d r en (kg), by Age i n Xonths, Coimbatore

Group 1-12 U-24 25-36 37-48 49-60 61-72 months m n t h s nonths months months months

P r e sen t s t udy 6 . 4 8.9 10.2 12.5 i4 .5 E . 6

A 1 1 I n d i a , 6 . 4 10.1 11.3 15.5 14.8 16.3

Tamil Yadu - 9.9 U.6 13 .1 1 5 . 4 16.5

Xean i n c r e a s e over six son th s 1.2 1.1 0.9 1.3 1.5 1.2

G i r l s

P resen t s t udy 6 . 2 8.4 10. i 11.8 14 . 2 E. 2

. A l l I n d i a 7.8 9.6 U.2 12.9 14.5 16.0

Tamil Xadu - 9.9 2.1 12.2 14.1 15.6

Xean i n c r e a s e over s i x s o n ~ h s 1.1 1.0 0.3 A.e 1 7 - 1. i 1.3

Source: Indian Journal of g u t r l z i o n and 3 i s t e t i c s (1977) 14, '23 --

Fur ther F ind ings i n Coimbatore C i ty . The same s tudy team eva l ca t ed t he

e f f e c t i v e n e s s o f "take-home" and "spot feeding" i n two f u r t h e r s t u d i e s i n

Tamil Nadu. 1/ A c o n t r o l group was s e l ec t ed u i t h t he same socioeconomic

background a s c h i l d r e n i n the program. The f i n d i n g s repor ted show t h a t t he

nean increment i n weight and he igh t ac ross t h e t h r e e groups was d i f f e r e n t : t h e

b igges t weight i nc r ea se s were f o r "spot fed" ch i l d r en . The d i f f e r e n c e was

a l s o s i g n i f i c a n t i n hemoglobin l e v e l s of exper imental groups and t he c o n t r o l

group. C l i n i c a l assessment i nd i ca t ed t h a t t he n u t r i t i o n a l s t a t u s of c h i l d r e n

rece iv ing s u ~ p l e m e n t s w a s b e t t e r . The s tudy f i n d i n g s r e l a t e d t o growth

measurements sugges t s u b s t i t u t i o n ar.d leakage t o non ta rge t fami ly members

among the "take-home" group.

The second s tudy t e s t e d the e f f e c t of n u t r i t i o n educat ion combined

with supplementary feeding a t a s e l ec t ed feed ing cen t e r . Another c en t e r

provided supplements only; a c o n t r o l group had n e i t h e r s e r v i c e s provided.

The n u t r i t i o n knowledge among mothers and c h i l d r e n markedly i nc r ea sed a f t e r

n u t r i t i o n educa t ion , and t he cho ice of n u t r i t i o u s foods improved.

SPECIAL XUTRITION PROGXAM, XNDHRA PWESH

The Spec i a l N u t r i t i o n Program i n Xndhra Pradesh is under t he D i r e c t o r a t e of - - ~ r i s l Welfare; t h e Block Development Of f i c e r s and t h e i r ex tens ion o f f i c e r s -

I

a r e Zespons ib l e f o r the day-to-day superv i s ion of the program. Opersting r . sin=: 1973, t h e program has reached 140,000 b e n e f i c i a r i e s . Food i s provided

by CARE, t h e World Food Program, and t he s t a t e government. Xecipes based on

l o c a l foods were suggested by t h e Na t l o r~a l I n s t i t u t e of N u t r i t i o n and

1/ Ind ian J o u r n a l of N u t r i t i o n and D i e t e t i c s (1977) 14, 193 and 227. -

a r e used a s sluch a s p s s i b l e ia feed ing c h i l d r e n . The o b j e c t i v e s and n a i n

components of t he Spec1 a 1 S u t r i t i o n ?rogram i a Xndhra Pradesh a r o s izn i la r

t o those of t he grogram i n Tamil Nadu.

- ves Design and Object;

The Xa t i ona l I n s t i t u t e of N u t r i t i o n undertook a s t udy t o e v a l u a t e

t h e impact of :he su?plementary feed ing program on :he n u t r i t i o n a l s t a t u s of

a a r t i c i p a n t s ; t o d e t e r a i n e what e f f e c t the supplement had on i n t a k e l e v e l s

and whether i t r ep l aced home foods; and t o e v a l u a t e o p e r a t i o n a l and a d n i n i s t r a -

c i ve bo t t l enecks .

X comparat ive scudy of supplemented and u supp l emen ted groups v a s

under taken, a f t e r matching t h e c o n t r o l group w i t h i h e program group based

on socioeconoasic s t a t u s , canmunicat ion f a c i l i t i e s , e d u c a t i o n a l and medical

f a c i l i t i e s , and o t h e r chara . t e r i s t i c s . F i f t y c o n t r o l v i l l a g e s and f i f t y -one

p r o j e c t v i l l a g e s w e r e chosen i n n i n e community development b locks i n s i x

d i s t r i c t s of cne state. A d i e t a r y s t udy ?was conducted by a d m i n i s t e r i n g

q u e s t i o n n a i r e s , and d a t a were c o l l e c t e d on t h e food consumed t h e 2 r ev ious day.

i le ight and h e i g h t measures were gathered f o r 5 0 t h c l a s s i f i e d i n t o

four grades .

- - The c o s t of :he suppLement per*hild vas ab:-ut 9s . 0.15 a day and ,

0

un i ike those i n o t h e r a r e a s , t h e 7rogram was f m c r i o n i n g f o r a l l y e a r , noc t h e

300 days suggested. Yean a t t endance vas 86 percen t .

The supplemented group had a lcwer p reva lence of d e f i c i e n c i e s

i d e n t i f i e d accord ing t o s i g n s of p ro t e in - ca lo r i e m a l n u t r i t i o n but vitamin-B

de f i c i ency g e n e r a l l y was more-prevalent among supplemented ch i ld ren . The

supplementary d i e t d i d n o t c o n t a i n e x t r a amounts of these v i t amins and t h e

home d i e t a l s o lacked them. The e x t r a c a l o r i e s t h e supplement provided may

have i n some r a y aggravated t h e e x i s t i n g def ic iency .

Supplemented c h i l d r e n were t a l l e r and heav i e r than unsupplemented

ch i l d r en of t he same t r i b a l group ( t a b l e A.11). The percen tage 05 c h i l -

dren c l a s s i f i e d a s normal -- t h a t i s , c h i l d r e n whose body weights were

equa l t o o r g r e a t e r than 90 percent of t he I n d i a n averages -- was g r e a t e r f o r

supplemented c h i l d r e n than f o r unsupplemented c h i l d r e n of the same t r i b a l

group ( t a b l e X.12). & r e c h i l d r e n i n t he unsupplemented groups were s u f f e r i n g

from severe and moderate malnu t r i t ion . Di f fe rences i n the n u t r i t i o n a l s t a t u s

of var ious t r i b e s were a t t r i b u t e d t o d i f f e r e n c e s i n d i e t a r y h a b i t s a t home.

Tab le A.11 . Xean Xeigh ts and 'deights of Supplemented and LJnsupplenented Chi ld ren Aged One t o F ive , by

T r i b a l Group, Xnahra ? radesh

Yean h e i qht Xean weight

T r i b a l group Supplemented Unsupplement~d Supplemented Unsupplemented /

Gond 81.43 79.05 9.62 9.09

; hya dora a/ 91.77 i39.13 U .48 10.88

Kondo Reddi 86.40 84.75 10.78 10.34

J a t a p u 87.58 84.30 11.01 10.10

Savara 88.49 83.45 U. 11 9.56

Y anad i 84.35 83.16 10.02 9.73

Chenchu

/ Average f o r c h i l d r e n aged t ~ o t o f i v e . d

Source: I n d i a n J o u r n a l of Yed i ca l Besearch 63 ,5 Yay 1975

T a b l e X.12. Weight a s Pe rcen tage of ICZR S t a n d a r d s of Supplemented and Unsupplemented Pre-School C h i l d r e n by S e l e c t e d

T r i b a l Group, Andhra Pradesh.

Weight a s Gond J a t a p u Savara pe rcen tage of ICMR Supple- Urrsupple- Supple- Unsupple- Supple- Unsupple- S tandards mented mented mented nented mented s e n t e d

Xore than 90 p e r c e n t

75-90 . p e r c e n t (Grade I )

60-75 pe rcen t (Grade 1 1 )

L e s s than 60 p e r c e n t (Grade 111)

Sc.rrce: I n d i a n J o u r n a l of N e d i c a l Research 63. 6 Hav 1975

The r e s e a r c h e r s s a s g e s t t h a t t h e observed ispravement i n t h e

supplemen ' a 1 c h i l d r e n , a n i n d i c a t i o n of t h e pro,: ; c i O s s u c c e s s , can be

t r a c e d tzi &he snali number of a d m i n i s t r a t i v e and o p e r a t i o o a l p r o b l e ~ s .

I a p o r t a u c i n t h e p r o j e c t ' s s u c c e s s were t h e i n v o l v e ~ = n t of l o c a l peop le ds

h e l p e r s , cke compactness o f v i l l a g e s , and t h e r e g u l a r s u p p l y of m a t e r i a l s

g iven d i r e c t l y t o t h e o r a a n i z e r s cf t h e 2rog:an.

The Xid-Day Y e a l s Program w a s launcned i n Yadhya Pradesh i n 1965 ;s an emergency

r e l i e f measure i n r t s p o n s e t o a drouc,;;t. '&ping later become a r e g u l a r

f e a t u r e of t h e t r i b a l .xchool sys tem i n t h e s t a t e , i t has rvo s a i n o b j e c t i v e s :

improving t h e n u t r i t i o n a l s t a t u s of schoo l c h i l d r e n , and e n c o - s a g i n 3 r e g u l a r

schoo l a t t e n d a n c e z a t e s . The T r i b a l and H a r i j a n Y e l f a r e D e p a r t ~ e n r Pas

r ~ s p o n s i b i l i t y f o r o r g a n i z i n g a12 in?lement ing t h z Trog'ram and f o r 2aying p o r t

charges and c o s t s o f t r a n s p o r t a t f o n , s t c r a g e , d i s t r i b u t i o n and overheads . CARE

a o n i t o r s and e v a l u a t e s t h e program which g e t s s r .? of i t s focd th rough U.S.

food a i d to I n d i a under ? u b l i c Law 480.

LAY q r o v i d e s 85 p e r c e s t of the raw m a t e r i a l s , t h e government o,F

I n d i a 15 p e r c e n t , i n l o c a l groundnvts , g r a i n f l o u r , .?itamins, and a i n e r a l s . - -

Ob jecc ives and Service=

- - The 3Ld-Day Y e a l s Program is in tended o reach t he ol.der c h i l d r e n

E . I

who s t i l l a r e s u b j e c t t o h i g h r a t e s of a a l n u t r i t f o n evezl though they have

passed t h e z o s t vuln ,erable y e a r s , The z f f e c t s o f n a l x u t r i t i o n on l e a r n i n g and

on the development o f c h i l d r e 3 a r e y e l l unders tood. The program l l s o has ?he

o b j e c t i v e of i n c r e a s i n g tile enrol lment and p a r t i c i p a t i o n r a t e s of c h i l d r e n

from d i szdvv l t aged hon.2~. The p r o v i s i o n of d f r c e schoo l meal is an i n c e n t i v e

t o p a r e n t s t o send t h e i r c h i l d t o schoo l and a d e t e r r e n t t o h i g h drop-out

r a t e s .

n e program is admin i s t e red a t t h e l o c a l l e v e l by a n u t r i t i o n

o r g a n i z e r and t h e s c h o o l t e a c h e r s . A d a i l y r a t i o n of food pro7:iding more than

300 c a l o r i e s and 1 4 grams o f p r o t e i n i s d i s t r i b u t e d t o a l l schoo l c h i l d r e n

an a l l s c h o o l aays- and i f p o s s i b l e on nonworking days a s w e l l , but t h i s

depends o n the l o c a l o r g a n i z a t i o n . The t a r g e t e d number of f eed ing days i n t h e

y e a r i s Lao. Xeal th and n u t r i t i o n educa t ion and p r e v e n t i v e h e a l t h c a r e a r e

p a r t of t h i s program. but i t has not been p o s s i b l e t o implement them o r t o

provide the i n p u t s needed.

Eva lua t ion

A t t he r e q u e s t of t h e T r i b a l and H a r i j a n Welfare depar tment , CARE

under took a r e t r o s p e c t i v e s t u d y of the impact of the program on t h e in tended

b e n e f i c i a r i e s . The o b j e c t i v e of the s t u d y was to determine t h e e f f e c t s o f t h e

f r e e s c h o o l seal on n u t r i t i o n a l l e v e l s of program p a r t i c i p a n t s , t o measure i t s

* i s p a c t .;: =c?tool a t t e n d a n c e r a t e s , and t o determine food displacement a t home

and t h e e x t e n t t o which schoo l meals supplement the home d i e t .

F.e s t u d y i s o f primary day s c h o o l s i n twenty-one d i s t r i c t s of

Yadhya p radesh , though meals a r e a l s o provided i n boarding s c h o o l s (Ashrams) 8

and h o s t e l s f o r 5 t u d e r . t ~ . No basg l ine d a t a were a v a i l a b l e f o r t h e program,

and measurement is based on a comparative s t u d y of c h i l d r e n who have "more

exposure " to t h e feed ing program a,d those c h i l d r e n who have " l e s s exposure . "

( A s t r i c t c o n t r o l group was a o t avcl i lable because t h e program ex tends t o a l l

a c c e s s i b l e z r i b d s c h o o l s i n the s t a t e . ) The e f f i c i e n c y o f f e e d i n g 2 rograns

i s a e a s u r e d by t h e f o l l o v i ~ g f o m u l a :

f e e d i n s days schoo l working days I 100

C h i l d r e n vho a t t e n d s c h o o l s u i t h h igh program e f f i c i e n c y and have g r e a t e r

exposure t o t h e program Vera compared w i t h c h i l d r e n who a t t e n d s c h o o l s w i t h

low program e f f i c i e n c y and have l e s s exposure t o t h e program. A t h r e e - s t a g e

randan sampling was under taken: t h e "pay c e n t e r " ( s t o r a g e p o i n t a t b lock

l e v e l ) f o m e d t h e c n i t of sampling a t t h e f i r s t s t a g e ; che s c h o o l s and school-

c h i l d r e n f o m e d t h e second and t h i r d s t a g e s r e s p e c t i v e l y .

Data were o b t a i n e d from a number of sources :

( I ) X d i e t a r y s u r v e y , us ing twenty-four-hour r e c a l l ,

was conducted among t h e s o t h e r s of a subsample

of t h e c h i i d r e n ,

( 2 ) School records provided d a t a on a t t endance , e n r o l l m e n t ,

and f e e d i n g opera t ions . ' b ias tage and dr7;l , r a t e s % e r e

e s ~ i m a t e d from t h e records w i n t a i n e u a t schoo ls .

( 3 ) Xnthropometr ic d a t a ve r+ c o l l e c t e d , 7 e i g h t and h e i g h t

v e r e expressed as i e i g n t - f o r a g e , h e i q h t - f o r a g e ,

v e i g h t - f o r h e i g h ; , and v e i g h t - f o ~ h e i g h t combined - . d t h h e i g h t - f o r a g e . 8 .

( 4 ) I n t i z ~ i e v s of t h e program o r g a n i z e r , schoo l

c h i l d r e n and t h e i r = o t h e r s a l s o provided da ta .

Find ings

Impact on N u t r i t i o s a l S t a t u s . The Hid-Day Meals Program i n c r e a s e d

the growth of school c h i l d r e n . Chi ldren from t h e h igh e f f i c i e n c y s c h o o l s on

average were t a l l e r and h e a v i e r than c h i l d r e n from t h e low e f f i c i e n c y schools .

I n a d d i t i o n , t h e r e was l e s s second and t h i r d degree m a l n u t r i t i o n i n the h igh

e f f i c i e n c y schools , and lower r a t e s of wast ing and s t u n t i n g . S h o r t l i d g e

(1980) s u g g e s t s i n h i s e v a l u a t i o n of the impact of t h e program on n u t r i t i o n a l

s t a t u s e h a t t h e d i f f e r e n c e s be--een high and low e f f i c i e n c y schools i n v e i g h t

and h e i g h t v e r e n o t dramat ic : 1 1

"The s o s t pe rsuas ive evidence of a l i n k between

t h e Xid-day Meals program and h e a l t h s t a t u s was t h e r e g r e s s i o n a n a l y s i s

exp la in ing percen t w e i g h t - f o r h e i g h t a s a f u n c t i o n of s e x , f ami ly type ,

l a n d holding, e d u c a t i o n of mother, e d u c a t i o n of f a t h e r , home c a l o r i c

i n t a k e , months of p a r t i c i p a t i o n i n t h e HDM program and program e f f i c i e n c y

I n this equa t ion , f o u r v a r i a b l e s were found t o s i g n i f i c a n t l y a f f e c t

weight f o r he igh t - family , l and ho ld ing , months of p a r t i c i p a t i o n and

program e f f i c i e n c y . Of t h e s e four t h e 1x0 most important were months of

p a r t i c i p a t i o n i n t h e X I M program and pr0grz.d e f f i c i e n c y . " a I

Although t h e Fmpact of these two v a r i a b l e s w a s p o s i t i v e i t was n o t

s t r i k i n g . The f i g u r e s i n A 1 3 show_ one index of n u t r i t ~ o n a l s t a t u s of c h i l d r e n - from s c h o o l s of d i f f e r e c t program'!efficiency.

1/ S h o r t l i d ~ e 3.. Assessment of t h e Educa t iona l and Heal th Imvacts of t h e - Yid-Day Yeal; Program. USAID, 1980.

T a b i e h.13. C l a s s i f i c a t i o n of N u t r i t i o n S t a t u s of C h i l d r e n by ?roeram Eff i c i encv . Xaahva Pradesn.

Program Zf f i c i e n c y

Veigh t f o r h e i g h t 0 4 0 61 -85 86-95 96 and above ( p e r c e n t a 3 e of s t a n d a r d ) Sow Uedium Bi qn Very hiqn

Source: CARE, Xid-Day X e a l s Program i n Xadhya Pradesh. CARE, I n d i a . 1979.

Impact on School Attendance. The f i n d i n g s on s c h o o l a t t e n d a n c e are

inconc lus ive : because no matc-hing c o n t r o l group is i n t h e s t u d y , i t was

i m p o s s i b l e t o measure d i f f e r e n c e s -

tow-ef f i c iency s c h o o l s had p r o p o r t i o n a t e l y - re upper c l a s s c h i l 3 r e n a

' with b e t t e r educated p a r e n t s than t h e h i g h e f f i c i e n c y s c h o o l s . 3ecause

socioeconomic l e v e l s c a n a f f e c t schoo l a t t e n d a n c e r a t e s , i t c a n be cogcluded - ,a

t h a t t h e h i g h e r a t t e n d a n c e r a t a s of ' those c h i l d r e n i n t h e low e f f l c i e P c y - s c h o o l s is r e l a t e d co socioeconomic h c k g r o u n d , and no t co t h e nid-daf ineal.

I I -

The number of days p r e s e n t a t schoo l was p o s i t i v e l y r e l a t e d r o :he number

of s o u t h s ? r e s e n t i n t h e s c h o o l f e e d i a g ?rogram.

E f f e c t s on D i e t a r y In take . The f i n d i n g s show t h a t 20 p e r c e n t o f the

c h i l d r e n i n t h e program had t h e i r f i r s t meal of t h e day a t school. The

d i f f e r e n c e s i n food i n t a k e between those who took a schoo l meal and t h o s e

who d id n o t were n o t s i g n i f i c a n t . Ch i ld ren who took no school meal had some

" a d d i t i o n a l " food i n t h e home. Findings from the s t u d y sugges t t h a t , i n

s c h o o l s o f h igh program e f f i c i e n c y , t h e midday meal i s a supplement t o t h e

home d i e t . I n s c h o o l s w i t h medium o r low e f f i c i e n c y , a t h i r d of the c a l o r i e s

of t h e mid-day meal s u b s t i t u t e d the home d i e t .

2.e f o l h v i a g :-re :nc lucu a ~elec:.d ambar oL scua ies and s o e c i a l YroqraM under 389 :a :adla. 3 e s e scxa ics .uve k e n :.viewed hrrei:? h e iu8 =J aaca ? ia icac ionr :hey -vm l o t men ~ n c i u d e d i a :.'.a survey.

1376- Sealrh eduucianlsctrool Z.C.3. 3:oci kealch ?cogramsf f i r s t a idlassiscancm i n ?a- :ion81 h u l t t r groqramsl :untivm c.rvLcas.

2. Pupplaencary oucri- ? l l o c :ion Yroqran f o r scnool cni ldren. U c 3 h i w a l 310ck. i- &nd GunELr.

- 7nder f i v e s carmlprm- 57.266 and Y O S C - u c d carmi ?revencLvm and curacrvm servic.s.

1. Y a t e r m l and :Uld 5.nic. 5ea lc3 car.. SCupi '3luic. : fAnuw1 icacs.

1977- ?re- and ~ o a c - u c a l - c r r e / c ? l l d urncar. s e r v i c e ~ l c u n c i v e care/f1:3~ aid.

1972- Co~rehmnsivm a m d i u l l 5.J00 :ani l iea d e n t a l car..

7. & iacesrread appnwch :o ? W r y ! m d ~ h car.. Alchaac c o u u l t y 3m-loQ- r n c 31ock. 38&& 3i rc r lcc . ? d l udra,

-LAPKC scudy group

! h C i o ~ l I ~ t i t u t m o f Cholmn and Ente r lc Di reua .

References

Antis, N.H. 'Dilemma of Heal th Care' i n Voluntary Act ion. Vol. 23, No. 1. July-August 1980. (Monthly J o u r n a l of t h e A s s o c i a t i o n of Voluntary Agencies f o r Xural Development ) .

Xntia , X.H. A l t e r n a t i v e s t o Health Care System (Mandwa) i n A l t e r n a t i v e Approaches t o H e a l t h Care, A Symposium he ld by IC41R and ICSSR, New D e l h i , 1977.

Arole. Y.. R. Arole. A Comprehensive Rura l Heal th P r o j e c t i n Jamkhed ( i n d i a ) i n A l t e r n a t i v e ipproaches t o Meeting ~ a s i c - H e a l t h Care i n Developing Count r i es . Eds. Djukanomic V. and E. .%ch. WHO, Geneva, 1975.

B u t t , H.W. Indo-Dutch P r o j e c t f o r Chi ld Welfare i n A l t e r n a t i v e Approaches To Heal th Care. Ind ian Counci l of Medical Research and Ind ian Counci l of S o c i a l Science Research. Report of a Symposium. 1977.

Care-India. The Kasa Yodel I n t e g r a t e d Mother-Child, Heal th-Nutr i t ion P r o j e c t i n N u t r i t i o n Planning i n t h e Developing World. Proceedings of a Regional Workshop he ld by Care i n I n d i a , Kenya, and colombia 1976.

Care-India. Hid-Day Neals Program i n Madhya Pradesh. A Study of Impact on T r i b a l School Chi ldren. Care I n d i a 1979.

Devadas, R.P., G. Kamalanathan, M. Kandiah, M. Kupputhai. "Studies on S p e c i a l N u t r i t i o n Program (SNP) 11. Growth Study on 1121 Chi ld ren Receiving t h e - supplementat ion i n Coimbatore City." 1ndian J o u r n a l of N u t r i t i o n and D i e t e t i c s (1977) , 14, 193.

Devadas, R . P., G. Kamalanathan, P. See lava thy , M. Kupputhai. S t u d i e s on S p e c i a l N u t r i t i o n Program (SNP) I V . E f f e c t i v e n e s s of a N u t r i t i o n ducat ion Program ~ r n o n ~ t h e B e n e f i c i a r i e s of SNP. Ind ian J o u r n a l of N u t r i t i e n and D i e t e t i c s (1977) 14, 227. ,

G0r-l-das, T. P r o j e c t Poshak. Vol. 1 and 2, Care, New Delhi , 1975. e t a l .

Gopaldas , T . P r o j e c t Poshak - Evalua t ion ~ e c h n i ~ u e s i n N u t r i t i o n P lann ing I n t h e Developing World. Proceedings of Begional Vorkshops h e l d by Care i n I n d i a , Kenya and Colombia 1976. - -

Gwatkin, D.R., J.X. Wilcox, J . D . Wray. Can e a l t h and N u t r i t i o n I n t e r v e n t i o n s Yake a Di f fe rence? Overseas ~ e v e l o p z n t Council 1980.

He tze l . Basic B e l a t h Care i n Developing Countr ies . Oxford U n i v e r s i t y P r e s s . 1979.

IC4IR and ICSSR. Heal th f o r A l l : A n A l t e r n a t i v e S t r a t e g y . Xeport of a Study Group s e t up j o i n t l y by Ind ian Council of S o c i a l Science Sesearch and I n d i a n Counci l of Xedica l Research. New Delhi , 1980.

ICXR E v a l u a t i o n of ':&nary H e a l t h Care Prograns . Proceedings of a Confersnce h e l d a t t h e I n d i a n Counci l of X e d i c a l Xesearch, Yew Delhi . A p r i l 21-23, 198C.

Kielmann X., C. X j e l l o , !4 Kielnann. E v a l u a t i o n of N u t r i t i o n I n t a r v e n t i o n P r o j e c t s . Repor t p r e ? a r e d f o r USXID, Xashington, D.C.

Zankekar, K., Voluntary Zfffort i n Tamily Planning: -1 3 r i e L S i s t o r y . Xbhina-I P u b l i c a t i o n s . Yew D e l h i , 1974.

N i t r a , A. I n d i a ' s Populat ion2 . b p e c t s of Q u a l i t y and C o n t r o l Vols. 1 and 2. Abhinav P u b l i c a t i c n . Xew De lh i 1978.

P y l e , D. From P i l o t P r o j e c t t o O p e r a t i o n a l program - The ?roblems of T r a n s i t i o n a s E m e r i e n c e d i n P r o j e c t ?oshak. H a s s a c h u s e t t s I n s t i t u t e of .-- - d

Technology 1976.

Py le , D. Voluntary Aqency+anaged p r o j e c t s r l e l i v e r i n g a n Zntegra t zd Package of Hea l th , X u t r i t i o n , and P o p u l a t i o n S e r v i c e s . The Xaharash t ra - Exper ience. P repared f o r Ford Foundation. 1979.

Py l e D. Zrom P r o j e c t t o Program; The Study of t h e E c a l i n g Up/I.sple- s e n t a t i o n Process of a Community Leve l I n t e q r a t e d S e a l t h , Y u t r i c i o n , P o ~ u l a t i o n I n t e r v e n t i o n i n Xaharas h t r a , I n d i a . Unpublished 1981.

'Udker , 3.G. The Xo-Birth 3onus Scherne: The Use of Savizlgs Accounts f o r Family Planning Ln South I n d i a i n P o p u l a t i o n and Development Xeview. Harch 1980, Vol. 6.

Lao D.H., K. Satganarayana, e t a l . Eva lua t ion of t h e S p e c i a l N u t r i t i o n Program i n t h e T r i b a l Areas of .bdhra Pradesh, I n d i a n J o u r n a l of X e d i c a l Research 63, 5 Yay 1975.

se;hagirf Xao K., A. .%o, S. Yadav, e t a l . ~ x p e h m e n t a t i o n of A l e e r n a t i v e S t r a t e s i e s Ln Family Planning: An Zvalua t ion . ?opu lac ion Centre . I n d i a ? o p u l a t i o n T r o j e c t , Karantaka. 1979. - -

S e v a n t i Yiiian. Yother and C3i ld Care (Indo-Outch P r o j e c t ) 53 Xonthlp J o u = a l ,!

of AVXRD Voluntary Xccfon. Vol. 23, Yo. 1. 1980. i

- m

Shah, P.3. The 'Usa Yodel I n t e w a t e d Xother-Ckild-Zealth-Yutrition P r o j e c ~ , ¶

Primary Hea l th Care, :(ass, Taluka Dahana, District a a n a Xakarash t ra 13 SLte rxa t i - re .\unroaches :o 9 e a l t h Care , .I Symposium h e l d 5v IC?lR, !lev C e l h i , 1977.

Sharna, X., S .;C. ~ 3 a c u r ~ e d t . " India" i n a a s i c 3 e a l t h Care i n 3eve lop ing Countries. J e t t e l . OxYord University P r e s s . --

S h o r t l i a q e , 3. .Assessment o f ;he Zducat ion and 3ea lch I s p a c t s * ~ f t h e Xc'i-gay Xea i s ?roeram. l e p o r r prepared f o r E S X 1 3 , W a s n i n 3 t ~ n , 3.C. 1980.

S t a t e P lann ing Board Kerala. Applied N u t r i t i o n Program i n Kera la . An E v a l u a t i o n Study S t a r e P lann ing Board. June 1978.

T a y l o r , C.E., e t a l . 1 Narangwal Exper i ence , World Bank 1980. Washington,D.C. (unpub l i shed)

T a y l o r , C., R. Sarma, R. P a r k e r , W. Reinke , R. Faruqee , I n t e g r a t i o n o f Family I-. World aank , Washington, D.C. (unpub l i shed) .

World aank, Hea l th S e c t o r P o l i c y Paper. World Bank 1980. Washington, D.C.

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In f luence on Earnings i n Tvo Zoor Urban Economies". l e b w r y 1981.

91-5 Dean i. Jamison, e t a 1 n14pr?ving Elementary MathemaSics Education -' . - . - * -

i n Yicaragua: An Experiaental. Study of &he Impact of Textbocks . .- _- ' and W i o oa Actrieve~ller"+. - a r c h 1981. . - --- ..

- . - - - - - . - ' 4 . - - h i d i a m q e e , 'Analyzing the h ~ a c e df H e d t h Se rv i ces : Naranpral

and Other Experiences'. F!rch 1981.

81-7 J. B. Knight and 3. 8. Sabot, .Labor Market Discr=nat ion in a Poor Urban Zconomy". March 1981.

81-8 Oey A. Meesook, ' Incer re lac ionships betveen Demographic Fac to r s and Inc- D i s t r ibu t ion : Problcns of Kc~sureaenc , Desc r ip t ion and I n t e ~ r c t a t i o n . ' Apr i l 1981. . . . . .. _

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