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Completed
World-Bank Assisted Operations
The
First Population Project
(1972-80) was financed by an IDA credit of US$21.2 million and a grant from the
Swedish International Development Authority. The project supported the Family
Welfare Program in five districts in the state of Karnataka and six districts in
the state of Uttar Pradesh. The project was essentially an experimental
demonstration project intended to test the efficacy of various program
activities, and to develop ways for attaining better performance of the national
program.
The project experience indicated ways
subsequent World Bank support of the Family Welfare Program could be improved,
and was the foundation for the government's subsequent accelerated program of
family planning and maternal and child health. Also, the two population centers
established under this project have carried out a variety of research.
The
Second Population Project
(1980-88) was supported by an IDA credit of US$46 million. The project assisted
the Family Welfare Program in six districts of eastern Uttar Pradesh and three
districts in the state of Andhra Pradesh. The project was part of a government
effort to obtain external assistance to strengthen the Family Welfare Program in
underprivileged districts of selected states.
The project gave further support for
the integration of family planning and mother and child health care services,
emphasized the importance of generating demand for services and, as in all
subsequent projects, stressed the increased use of temporary contraceptive
methods and gave substantial support for the construction of basic health
facilities. An estimated 22.7 million women and children benefited from
strengthened family welfare services provided under the project.
The
Third Population Project
(1984-91) was financed by an IDA credit of US$70 million. It too was implemented
in underprivileged districts-six districts of northern Karnataka and four
districts of the state of Kerala.
Project impact was particularly
notable in Kerala, where project support helped bring program implementation in
the underprivileged project districts up to the much higher standard already
achieved in the rest of the state. In Kerala project districts, contraceptive
use has increased and, on average, immunization of children has risen from about
28 percent to about 78 percent. Overall, approximately 18 million women and
children in the 10 project districts were reached by the project-assisted family
welfare program.
The
Fourth Population Project
(1986-94) was supported by an IDA credit of US$51 million and was implemented in
West Bengal
. In the four districts where facility construction was supported by the
project, program implementation benefited more than 12 million women and
children. The project emphasized maternal and child health. A comparison of
fertility, mortality, and infant mortality rates between the pre-project year of
1984 and 1992 indicates substantial progress in these three vital indicators.
During the course of the project, the
birth rate in
West Bengal
declined from 30.4 to 24.6 per 1,000, the death rate from 10.7 to 8.3 per
1,000, and the infant mortality rate from 82 to 64 per 1,000 live births. There
was also very good progress in the share of couples using modern contraception,
which improved from 33 to 52 percent. State-wide support for program management
information, communications, and training components had a positive effect on
the implementation and impact of
West Bengal
's family welfare program in general.
The
Fifth Population Project
(1988-96), financed by an IDA credit of US$57 million, supported the National
Family Welfare Program in the municipalities of
Bombay
and
Madras
, and was extended to other urban areas in the states of
Maharashtra
and Tamil Nadu. The main goal was to improve the service delivery and outreach
systems of family welfare services in urban slums. Innovative features included
support for involvement of non-governmental organizations (NGOs) and private
medical practitioners in carrying out the Family Welfare Program. The project
met its service delivery objectives and benefited some 2.5 million poor women
and children in slum areas.
The Child Survival and Safe Motherhood
Project (1991-96), financed by an IDA credit of US$214.5 million, supported the
enhancement and expansion of the Maternal and Child Health (MCH) component of
the National Family Welfare Program. It was national in scope, with emphasis on
districts where maternal and infant mortality rates were higher than the
national average.
The project's specific objectives were
to enhance child survival, reduce maternal mortality and morbidity rates, and
increase the effectiveness of service delivery by supporting:
- child
survival programs including the Universal Immunization Program, diarrhea
control programs, and the control of acute respiratory infections;
- a
Safe Motherhood Initiative to improve ante-natal and delivery care for all
pregnant women and to identify high-risk pregnancies; and
- institutional
systems development, including improving and expanding training programs
for family welfare workers, education and communication, and management
information.
More
than 42 million women and children benefited annually from the services
provided.
The Fifth (
Bombay
and
Madras
) Population Project will support the Government's goal of improving the
availability and quality of family welfare services to poor urban families. In
order to achieve this goal the project comprises several components; a service
delivery expansion component comprising the construction, furnishing, equipping
and staffing of new health posts (HP), and the rehabilitation/extension of
existing facilities to create new HPs; and a training component to improve the
quality of service provided by family welfare workers in both cities. To improve
management of the family welfare program; a central coordinating office in the
Bombay Public Health Department and three family health bureaux are to be
created; and, in Tamil Nadu by strengthening the State and Madras city family
welfare bureaux. A final component is to increase the involvement of private
voluntary organizations and private medical practitioners in the family welfare
program.
Ongoing World Bank-Assisted
Operations
The
Sixth Population Project,
approved in 1989, provides assistance through an IDA credit of US$124.6 million.
The project supports improvements in the efficiency and effectiveness of the
delivery of family welfare services in the rural areas of the states of Andhra
Pradesh, Madhya Pradesh, and Uttar Pradesh. The project has established a
well-regarded and systematic program of in-service training and a training
culture focused on improving performance of workers and an increased awareness
of how to monitor and improve the quality and effectiveness of training.
Three state institutes of health and
family welfare, 18 regional training centers, 91 district centers/teams, and 23
field practice demonstration areas have been established and are conducting
regular in-service training; 23 basic auxiliary nurse midwife (ANM) training
schools have also been strengthened. In addition, 1,620 sub-centers with ANM
residence have been constructed, equipment and furniture have been provided to
sub-centers, and primary health centers and delivery kits have been provided to
traditional birth attendants.
Overall, it is estimated that up to 40
million rural households in the three project states are benefiting from program
improvements achieved with project support.
The
Seventh Population Project,
which supports the National Family Welfare Program in the states of Bihar,
Gujarat, Haryana, Jammu & Kashmir, and
Punjab
, through an IDA credit of US$81.6 million, was approved in 1990. This project,
which also has a special training focus, is similar to the Sixth Population
Project. At least 22 million families in the rural areas of the project states
will ultimately benefit from project-assisted improvements in the quality and
coverage of program services.
Since the project began in 1991, rates
of sterilization and use of IUDs, oral pills, and conventional contraceptives
have been steadily rising. Systematic and regular in-service training for family
welfare workers has also been established.
The
Eighth Population Project,
financed through an IDA credit of US$79 million, became effective in March 1992.
The project supports the improvement of family welfare services in the slum
areas of
Bangalore
,
Calcutta
,
Delhi
, and
Hyderabad
. It focuses on the reduction of fertility as well as maternal and infant
mortality rates among people living in urban slums by improving the outreach of
family welfare services, upgrading the quality of family welfare services,
expanding the demand for health services through expanded information, education
and communication activities, and improving the administration and management of
municipal health departments.
The
Ninth Population Project,
which became effective in September 1994, is being implemented in three states-
Assam
, Karnataka, and Rajasthan-and is financed through an IDA credit of US$88.6
million. The project supports improved access to, demand for, and quality of
family welfare services, particularly among poor, remote, and tribal peoples.
The project aims to:
- strengthen
family welfare service delivery, including establishment of first-referral
units;
- improve
the quality of family welfare service;
- strengthen
demand-generation activities through improved information, education, and
communications planning and activities;
- strengthen
program management and implementation capacity; and
- provide
funds for innovative schemes to improve service delivery.
Future
Operations
Building
on a major analysis done
collaboratively by the World Bank and Government of
India
, and recent
India
n program developments, the
India
n government is preparing a Reproductive
and Child Health (RCH) Project,
which would support the National Family Welfare Program in improving the health
status of women and children, especially the poor and underserved. An essential
package of reproductive and child health services is integral to the project
approach.
The project would include two major
components:
- a
nation-wide policy reform package, covering monitoring and evaluation,
institutional strengthening, and service delivery; and
- a
local capacity enhancement component that would fund district and city
sub-projects aimed at meeting specific needs of local priority groups.
The
project is expected to be approved in mid-1997, and would be financed with an
IDA credit of about US$248 million.
Research
and Analysis
Two major studies, Improving Women's Health in
India
(1996) and
India
's Family Welfare Program: Moving to a Reproductive and Child Health Approach
(1995), provide background for the Bank Group's discussions with the
India
n government on further developing public, voluntary, and private sector
capacity to address needs of the Family Welfare Program and health problems of
India
's women. The former was published as part of the Bank's Directions in
Development series and the latter was published as part of the Bank's
Development in Practice series.
Both
studies build on an earlier study entitled Family Welfare Strategy in
India
: Changing the Signals (1990). Taken together, these studies provide support
for the important steps the government has taken in moving away from a
target-driven, demographic approach emphasizing female sterilization, toward a
client-centered approach that helps people meet their broader health and family
planning goals.
Improving
Women's Health in
India
provides a comprehensive overview both of women's health issues and the
government's programs to improve them. Despite considerable progress, the report
argues that
India
still has a large, unfinished agenda in the areas of reproductive and child
health. The report emphasizes women's reproductive health and the factors
underlying excess female mortality at early ages, especially in the northern
"Hindi belt" states of
Bihar
, Rajasthan, Madhya Pradesh, and Uttar Pradesh. These states account for almost
40 percent of
India
's population and exhibit well-documented unfavorable demographic trends
compared with the rest of
India
.
The
book also points out the needs of women in rural areas where mortality levels
are substantially higher than in urban areas and access to care is limited. Its
focus is on the measures necessary to address existing policy and implementation
constraints and improve the quality, acceptability, and use of services
essential to women's health. Further progress and more resources are needed.
In
1994, the Cairo Conference formalized a growing international consensus that
improving reproductive health, including family planning, is essential to human
welfare: reducing unwanted pregnancies safely and providing high-quality health
services both satisfies the needs of individuals and stabilizes the population.
This
perspective, strongly supported by the Government of
India
in its Program of Action in the
India
Country Report prepared for the Cairo Conference, led to a major piece of
collaborative analytical work with the World Bank Group entitled
India
's Family Welfare Program: Moving to a Reproductive and Child Health Approach.
The report identifies the major constraints on
India
's Family Welfare Program and recommends ways in which these constraints might
be overcome. In addition, it discusses an "Essential Reproductive Health
Package" designed to provide a cluster of recommended reproductive health
services directed primarily at the needs of actual and potential patients. The
Reproductive and Child Health Project was based partly on this work.
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