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Indian Journal of Community Medicine

Vol. 25, No. 4 (2000-10 - 2000-12)

Editorial

Implementation of strategies of National Population policy (NPP) - 2000

Sunder Lal Prof. & Head Deptt. of SPM Pt. BDS PGIMS, Rohtak

India's runaway population growth is attributable to large size of the population in the reproductive age group because of high Total Fertility Rate (TFR) in the past. High fertility due to unmet needs of contraception and high wanted fertility due to high infant mortality rate (IMR) are other important factors besides half of the girls getting married below the age of 18. Around 33% of births occur at interval of less than 24 months, which also results in high IMR. On 11th May 2000, India crossed the 1 billion mark. At last, the NPP has been formulated by the Govt. after a period of 50 long years since it launched the National Family Planning Programme in the country. This is an important milestone in achieving the stable population. The establishment of National Commission on Population, National Technical Committee on Child Health and Technology Mission will further boost the realization of NPP goals. The national population policy, 2000 (NPP 2000) affirms the commitment of govt. towards voluntary and informed choice and consent of citizens while availing of reproductive and child health care services and continuation of target free approach in administering family planning services. The NPP 2000 provides a policy frame work for advancing goals and prioritizing strategies during the next decade.

The immediate concern of NPP 2000 is to address the unmet needs for contraception, health care infrastructure, health personnel and to provide integrated services delivery for basic reproductive and child health care. The medium term objective is to bring TFR to replacement levels by 2010. The long term objective is to achieve a stable population by 2045, at a level consistent with the requirements of sustainable economic growth, social development and environmental protection. In pursuance of these objectives, the following National Socio-Demographic goals to be achieved in each case by 2010 are formulated.

  1. Address the unmet needs for basic reproductive and child health services, supplies and infrastructure.
  2. Make school education upto age 14 free and compulsory and reduce drop-outs at primary and secondary school levels to below 20 percent for boys and girls.
  3. Reduce infant mortality rate to below 30 per 1000 live births.
  4. Reduce maternal mortality ratio to below 100 per 1,00,000 live births.
  5. Promote delayed marriage for girls, not earlier than age 18 and preferably after 20 years of age.
  6. Achieve 80 percent institutional deliveries and 100 percent deliveries by trained persons.
  7. Achieve universal access to information/counselling, services for fertility (abortions) regulation and contraception with a wide basket of choices.
  8. Achieve 100 percent registration of birth, death, marriage and pregnancy.
  9. Contain the spread of Acquired Immuno Deficiency Syndrome (AIDS) and promote greater integration between the management of reproductive tract infections (RTIs), sexually transmitted infections (STIs) and the National AIDS control programme.
  10. Prevent and control communicable diseases.
  11. Integrate Indian System of Medicine (ISM) in the provision of reproductive and child health services and in reaching out to households.
  12. Promote vigorously the small family norm to achieve replacement levels of TFR.
  13. Bring about convergence in implementation of related social sector programmes so that family welfare becomes a people centered programme.

The NPP document has identified 12 strategies themes:

Decentralized planning and programme implementation, covergence of service delivery at village level, empowerment of women for improved health and nutrition and child health and survival, meeting the unmet needs for family welfare services, under-served population groups, diverse health care providers, collaboration with the commitments from non govt. organizations and private sector, mainstreaming of Indian system of medicine and homeopathy (ISMH), contraceptive technology and research on reproductive and child health, providing for older population and information, education and communication.

NPP has evolved an action plan to operationalize these strategies. The bold and conscious decision to begin action at community level is most appreciable and laudable indeed. NPP deserves credit to advocate area specific plan of action rather than a uniform plan of action. Special support and extra resources to poor performing states is most wise and welcome step. The action plan indicates utilization of self help groups at the village level to plan, organize and provide basic services for reproductive and child health combined with on going integrated child development services (ICDS). Thus the policy directives lean heavily on the element of community participation and Panchayati Raj Institutions (PRI). Policy envisages formation of village level committees of the panchayats (headed by an elected women panchayat member) who will think, plan and act locally and support nationally. These committees may identify area specific needs for reproductive health services and prepare need based, demand driven, socio-demographic plan at the village level. Besides panchayat members, two trained birth attendants and anganwadi workers should be member of this self help group. These self help groups are to be trained and motivated to become the primary contact at household levels and take responsibility to provide package of services, through an institution of local point. Once every fortnight these accepters groups will meet and provide at one place, six different services for:

  1. Registration of births, deaths, marriage and pregnancy.
  2. weighing of children under five years and recording of weight on standard growth charts.
  3. counselling and advocacy for contraception, plus free supply of contraceptives.
  4. preventive care, with availability of basic medicines for common ailments.
  5. nutrition supplements
  6. advocacy and encouragement for the continued enrolment of children in school upto age 14. One health staff, appointed by the panchayat will be suitably trained to provide guidance to self-help group. Revolving fund will be provided to these groups for income generation.

The role and appropriate use of "self help group" as envisaged by NPP seems to be unrealistic. Their specific role should be advocacy and informants in their neighbourhood at household level. They could help in:

  1. Identification and reporting of pregnant women, births, deaths and marriages and diseases to anganwadi workers.
  2. To audit the services, births, deaths and morbidities at village level.
  3. Organize meeting of women groups in their area once in a fortnight for information and education and motivation to utilize the available services.
  4. To become depot holders for ORS, contraceptives, disposable delivery kits, chloroquin tablets, chlorine tablets/bleaching powder and iron and folic acid tablets.
  5. To provide enrolment of children in school.
  6. To organize feeding programmes for young children and mothers and to identify beneficiaries for services.

One self help group should be constituted for 1000 population or for one anganwadi area covered by an anganwadi worker. Composition of group should have a membership from all section of community; preference should go to economically weaker sections and below poverty line. It is proposed that clustering of package of services to be provided at village level through anganwadi centre "which will become the pivot of basic health care activities, contraceptive counselling and supply, nutrition education and supplementation as well as pre-school activities." The anganwadi centers can also function as depots for ORS/basic medicines and contraceptives.

The endeavour of NPP is to decentralize planning and programme implementation through village panchayati raj institution (PRI), however, the PRI have not been delegated administrative and financial powers, by many states as stipulated, under 73rd and 74th constitutional amendments. In some states elections for PRI are long overdue. The other critical question is preparedness of PRI to take these responsibilities. The onus of decentralization and delegation of power lies with the respective state governments, they must break their inertia and empower village panchayats with a sense of urgency in order to implement the plan of action. Secondly, the village panchayats should be oriented and supported adequately to implement the NPP, with built in system of monitoring. As of today village panchayats have seldom expressed/voiced their concern for population growth or demographic charter. Their prime concern have been other issues like water and irrigation, pavement of streets, village school, ponds, electricity and roads. Health and family welfare issues are last and least priority with village panchayats. Although 33% of elected panchayat seats are held by the women, the elected women panches, sarpanches and chairpersons occupy a back seat and their husbands continue to play their roles in different fora, women are just figure heads and silent spectators. It will take sometime before the elected women can assert themselves and play their effective and active role in village development. Aggressive efforts are needed to empower and organize women groups in the villages so that they become self reliant and play their effective roles. Many of the organized women groups at village level are dormant, financial and material support being negligible, these groups seldom meet or organize any worthwhile activity leave alone the responsibility of identification of unmet needs of reproductive and child health, their planning and managing at local level. The onerous task to organize and activize these women groups should be entrusted to village panchayats and village health workers should play a lead role. Experience of organizing mahila swasthya sangh leaves much to be desired. Funds should be given directly to women groups rather than to health agencies. Initiative should come from women group themselves. Convergence of services delivery at village level is an uphill task but nevertheless, not an impossible one. It has been rightly emphasized that efforts at population stabilization will be effective only if we direct an integrated package of essential services at village and household levels. We have created a huge village based infrastructure of nearly half a million (580621) network of anganwadi centers under ICDS (which cover around 75% of community development blocks in rural areas) as also universal primary health care infrastructure of 136000 subcentres, 25000 primary health centers and 2500 community health centers to reach village and household levels. India has also effectively demonstrated its capacity to reach over 95% of households of the country through pulse-polio immunization campaigns; however, inadequacies in the existing health infrastructure have led to an unmet needs of 30% for contraception services. At present the coverage and quality of RCH services tends to be poor though the subcentres are well equipped but continue to function in poor physical structure. Supportive supervision by health supervisors including Medical Officers, almost non-existent and the health workers are left to themselves to perform the jobs/tasks. Thus, on the job training which leads to improvement of work performance is negligible and consequently the quality and utilization of services being poor. But for outreach session of immunization the work schedule is not fixed, though the CSSM programme advocated maternal and child health sessions along with immunization but it never took off. Delivery services, neonatal care and postnatal care tend to be minimal by health workers (female) and quality of antenatal care leaves much to be desired. Though the district training teams continue to provide perfunctory integrated skill training to workers under RCH programme, their impact is too little. This needs to be reviewed very seriously for further improvement. As the NPP envisages to strengthen the subcentres, PHCs and CHCs for building an appropriate referral system, it has been observed that all these institutions function much below their installed capacity. The urgent and essential task, therefore, is to make these institutions function well and use the available infrastructure in most efficient manner by improving management system. Referral support is the weakest area; it needs to be developed through suitable reforms in health sector. This huge infrastructure has not utilized or has utilized minimally the vast resource of infrastructure of people, panchayati raj institutions, voluntary organizations and non-governmental organizations. We have a culture to work in isolation; working together has not been learnt or seldom practised. At the village level several institutions are available (education, health, development and ICDS etc.) but they tend to work in isolation, convergence and co-ordination amongst these institutions have been attempted half heartedly. PRI is a right forum to bring about convergence and that should be its pivotal role, since health and education programmes have been decentralized to village panchayats. Anganwadi is a village based institution supported by village panchayat and anganwadi workers are residents of that village chosen by village panchayats. Convergence of services and synergies are likely to be achieved and infact have been achieved in various situations between health and ICDS systems for reproductive and child health. The ICDS services are essentially women based and focus on women in reproductive age group as also other women and adolescent girls. The key services of reproductive and child health can be delivered in an integrated manner through the institution of anganwadi, with essential support mechanism of health worker female. Strong formal linkages should be established between ICDS programme and the health system. The female health workers should work with and work through the system of anganwadi workers. Work schedule of female health workers and the supervisors should be dovetailed with work schedule of anganwadi workers, with an objective to support the system of ICDS and not to overload the anganwadi workers. The experience of locating subcentre and anganwadi at one place, joint work schedule, home visits, sector level meetings, continuing education, sharing of information and monthly progress report, outreach session of immunization and antenatal contacts, weighing of children and MSS meetings have paid rich dividends in terms of work output as also improving quality and coverage of services. Besides physical co-ordination, it is more of mind and heart and mutual understanding. The integration and co-ordination mechanism should not only be confined to the level of anganwadi and village but it should prevail amongst supervisors and managers and leaders at the level of sector, block and district.

In ICDS over the last 25 years the system of co-ordination has been built up and institutionalized, but all is not well with this co-ordination system. This needs to be strengthened further for improving integrated service delivery in the context of NPP. ICDS is a goldmine, health sector should own it and support it whole heartedly to derive the benefit of integrated service delivery and enhance its reach to women and children. Linking universities and medical colleges to the system of ICDS, reviving of central technical committee on ICDS and universalization of ICDS can go a long way to enrich the monitoring continuing education and motivation of work force to realize the objective of NPP. It is encouraging to note that NPP explicitly states that meaningful decentralisation can only result if the convergence of national family welfare programme with the ICDS programme is strengthened. The ICDS programme needs to be more focused, modified with priorities redefined; to rationalize the work load of anganwadi workers. Priorities should be for infants and second year of life. A serious thought should be given to critical component of supplementary feeding which absorbs 60-70% budget and time of ICDS, could it be more selectively targeted to below poverty line families and handed over to self help groups in the village or done away completely and time thus saved can be invested on building more fruitful activities such as education and contacting women in their homes to enhance care of under two children. Since covergence of several related activities at service delivery level of RCH, in particular the ICDS programme, is critical for extending outreach and increasing access to services. It is, therefore, most imperative for village panchayat to promote this co-ordination and exercise effective supervision through village committee or self help groups. Anganwadi workers, traditional birth attendants and health workers should become a village health team along with self help groups. To have increased access and coverage we must establish more anganwadi centers and subcentres on the basis of current population (Census 2001).

Similarly, the present day RCH programme should have a balanced focus on health worker (female) and anganwadi workers. At the moment there is least involvement of anganwadi worker. The current scenario being lop-sided and is quite discouraging as it persues the inservice training for health workers female and health supervisors and leaves a vast pool of anganwadi workers and their supervisors as also male workers. Initial training and in-service training of anganwadi workers and health workers should be looked into seriously to build a system of team training and team functioning. A team will only function together if they are trained to do so. Teams training is something to be talked over as a ritual rather than to actually practice it effectively in the system of health care delivery.

Since there is vast network of 1,36,000 subcentres accessible to village population but the health workers female and male are non resident and seldom conduct the deliveries and seldom give postnatal care and neonatal care. A strong policy/decision is vital in this area. Should we recruit locally resident health workers or else should we promote anganwadi workers as heath workers female to man the subcentres after requisite training? The PRI can be more assertive to raise this demand and recruit local workers from their own village.

The NPP document proposes to expand the ICDS programme to include children between 6-9 years of age, with an idea to promote universal elementary education, particularly for girls, is a wishful thinking. In reality this ask appears to be a herculean one and heavy burden and shift of focus to old age group rather than younger age group children. Certainly the anganwadi workers should play strong role of advocacy of universal elementary education. It is a matter of great pride that ICDS programme has initiated organized programme of adolescent girls in symbolic 507 blocks, hopefully it gets expanded to increase coverage. A sound programme through school health services for adolescent boys and girls by health department can go a long way to realize the NPP programme goals of building awareness and preparing young adolescent for responsible parenthood. Vocationalization of education in rural areas can enhance enrolment and retention of girls in schools and can delay the marriage and build self esteem to generate income at household level. Though it is envisaged in the education policy but it has not been implemented.

Meeting the unmet needs for RCH and Family Welfare services in urban slum population is much more difficult than rural areas because of absence of organized health infrastructure. Nagarpalikas should organize these services but they are ineffective because of lack of resources. Networking of service delivery system in urban slums consisting of voluntary, public, private and non governmental health organizations, identified by a common logo, for delivery of RCH services is a positive approach by NPP. The modalities of such a networking are to be worked out. This networking must ensure location of service delivery within the slum area itself. Mobile clinics can be partial answer to the problem but developing essential static services and RCH programme in urban slum is the answer. Existing infrastructure/resources can be pooled and unified under the command of single authority for better accountability. Developing RCH insurance scheme can be another model for urban slums. Medical colleges can be involved to take responsibility of a nearby accessible urban slum area as its field practice area for delivery of RCH services with some essential support of mobility and inputs of infrastructure.

NPP document has rightly emphasized to modify the under/post-graduate medical, nursing and paramedical professional course syllabi and curricula in consultation with Medical Council of India, the Council of ISMH and the Indian Nursing Council, in order to reflect the concepts and implementation strategies of the RCH programme and NPP. This will also apply to all in-service training and educational curricula. This should get implemented sooner than later as an urgent national issue. In the first instance the faculties of medical colleges must be oriented towards NPP, which in fact is substantial revised health policy. Once the faculty gets the right kind of orientation they can lay adequate emphasis on priority areas and urgent RCH needs of our population. The attitudes and motivation of teaching faculties can bring a model of need based professional and paraprofessional education and training. The department of Community Medicine can take a lead role of co-ordination for organization of orientation training of faculty members as also building NPP contents into their own curriculum. Similarly, the discipline of Community Medicine can enhance the content and quality of their research contribution relevant to the RCH priority needs as identified by the NPP document. The results of such operational researches can be fed back to the local health system for improving the content and quality of RCH services. District training teams and State Health and Family Welfare Training Institutions look forward to the active support of Community Medicine department to improve in-service training programme. Let us support them well in this endeavour, through development of in-service training modules and guides.

Continuous interaction and linkages between training institutions/ departments with the service delivery system are not only essential but is an over-riding priority to have a need based and meaningful training of undergraduate and postgraduate in general and to the discipline of Community Medicine in particular. The task of rapid surveys in RCH can be entrusted to Community Medicine department because of availability of experienced consultants and researchers.

References:

  1. Government of India. National Population Policy 2000. Deptt. of Family Welfare, Ministry of Health and Family Welfare. Nirman Bhawan: New Delhi, 2000.
  2. Government of India. Reproductive and Child Health News letter. Vol. 1 No. 1 April 2000. Deptt. of Family Welfare Ministry of Health & Family Welfare. The Hindustan Times, New Delhi; Oct 2, 2000: p 15.
  3. Lal S: Poverty in Plenty (Editorial). Indian Journal of Community Medicine, 1998; 23(2): 47-9.
  4. Lal S: Integration of RCH with Primary Health Care and ICDS Programme (Editorial). Indian Journal of Community Medicine, 1998; 23(4): 139-41.
  5. Lal S: Innovative approaches in the persuits of teaching, training and research in Community Medicine (Editorial). Indian Journal of Community Medicine, 1999; 24(1): 3-8.
  6. Lal S: Let people "operate" and Government Co-operate in health development programmes (Editorial). Indian Journal of Community Medicine, 1999; 24(3):95-9.
  7. Roy TK, Pandey R, Ram F: Reproductive health problems and care in India. Some observations from the National Family Health Survey and the Rapid Household Survey - Paper for regional consultation meeting for the North Zone on Research priorities in RCH and nutrition - Nov 1999 - organized jointly by ICMR & UNICEF, New Delhi.
  8. Lal S: Research priorities in reproductive and child health (Editorial). Indian Journal of Community Medicine, 2000; 25(2): 51-6.
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