FAMILY PLANNING PROGRAM

1. FAMILY PLANNING PROGRAM FAMILY PLANNING DIVISION Ministry of Health & Family Welfare Government of India

2. SITUATION ANALYSIS

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5. 5 DEMOGRAPHIC TRANSITION 1. India is in the middle of demographic transition. 2. Both fertility and mortality are declining, (the pace and magnitude of the decline varies across the States.) 3. Reasons for high growth rate are.: Large size of population in the reproductive age group High fertility due to unmet needs for contraception High intended fertility due to high IMR

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12. 12 Age Composition Population under 15 years (currently 35%) is projected to decline to 23% by 2026 The age group 15-59 years (currently 58%) is projected to increase to 64% by 2026 Elder persons (age 60 and above) 7% of population in 2001 is projected to increase to 12% of population in 2026

13. 13 WHAT IS TFR The total fertility rate is the average number of children a woman would have if she were to pass through her reproductive years bearing children at the same rates as the women now in each age group. It is computed by summing the age specific fertility rates for all ages. It gives a magnitude of completed family size In simple terms TFR denotes the average number of children borne per woman

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18. 18 Achieving the Fertility Goals Help Reduce Child and Maternal Mortality Today there are many high risk births High-risk births lead to high child mortality

19. 19 Reasons for high infant & child mortality Short birth intervals A child born within 1½ yrs. of the previous sibling will have 3 times the chance of dying than after a 3 yr. interval Leads to malnutrition in children, Leads to 50% of child deaths. Unwanted children are more likely to die than wanted ones (ref. UNFPA) and 75% pregnancies are unplanned and 25% are unwanted in our country (NFHS)

20. 20 In Bangladesh MMR is higher for higher order births … There is a lot of information showing how infant and child mortality are affected by risky births. But we don’t have much information on the relationship of risky births to the MMR in developing countries. Hurt, Ronsmans and Thomas did not find much association between parity and MMR in historical cohorts from developed countries. But there is evidence from Matlab in Bangladesh that higher parity is associated with higher MMR. There is a lot of information showing how infant and child mortality are affected by risky births. But we don’t have much information on the relationship of risky births to the MMR in developing countries. Hurt, Ronsmans and Thomas did not find much association between parity and MMR in historical cohorts from developed countries. But there is evidence from Matlab in Bangladesh that higher parity is associated with higher MMR.

21. 21 … and higher for older mothers. Evidence from Matlab also suggests that births to older mothers have higher MMRs. Evidence from Matlab also suggests that births to older mothers have higher MMRs.

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23. 23 Achieving the TFR goal will reduce the percent of high-risk births … High fertility strongly increases a woman’s life time risk of dying from pregnancy related causes. Reductions in TFR reduce the number and proportion of high-risk births

24. 24 Means of reducing TFR 25% increase in breastfeeding duration would reduce TFR by 11%. (ref. UN-ACC/SCN) Accessible and effective family planning services reduce maternal deaths by 35% by simply preventing unintended babies being born ( ref. DFID.) 

25. 25 In a single generation Thai fertility moved from high to low levels  Fertility declined at the same time. In 1960, Thailand was a high fertility country. The fertility rate was 6.4 children per woman, even higher than what exists in Rwanda today. By 1990, however, the fertility rate had declined to 2.3 children, representing a transition from high to low fertility in a single generation. The drop in the fertility rate was one of the key factors helping Thailand emerge as a middle-income economy in a single generation. Fertility declined at the same time. In 1960, Thailand was a high fertility country. The fertility rate was 6.4 children per woman, even higher than what exists in Rwanda today. By 1990, however, the fertility rate had declined to 2.3 children, representing a transition from high to low fertility in a single generation. The drop in the fertility rate was one of the key factors helping Thailand emerge as a middle-income economy in a single generation.

26. 26 In a single generation Thailand emerged as a middle-income country  Thailand is a good example of an “Asian Tiger”. In a single generation, Thailand moved from low income status to a much more prosperous middle-income nation. In 1960, Thailand had a GDP per capita (using constant 2000 US$ to permit comparison over time) of about US$330, just modestly higher than the Rwandan GDP per capita today. By 1990, however, Thai GDP per capita had risen to US$1,430 and Thailand has moved into the ranks of the middle-income countries. In 1970, Thailand spent $11 per person on education and $2 per person on health care. By 2000, these number rose to $88 per person on education and $25.8 per person for health care. In contrast, Rwanda spent $8 per person for health care in 2005, less than what its neighbors spent in 2002 - $118 in Zimbabwe, $20 in Zambia, $19 in Kenya, $18 in Uganda, and $13 in Kenya*. Hasan, M. Aynul, 2001. Role of human capital in economic development: some myths and realities, in ESCAP, Development Planning in a Market Economy, Least Developed Countries Series No. 6 (ST/ESCAP/2174), pp. 3-14. *World Development Indicators 2005 Thailand is a good example of an “Asian Tiger”. In a single generation, Thailand moved from low income status to a much more prosperous middle-income nation. In 1960, Thailand had a GDP per capita (using constant 2000 US$ to permit comparison over time) of about US$330, just modestly higher than the Rwandan GDP per capita today. By 1990, however, Thai GDP per capita had risen to US$1,430 and Thailand has moved into the ranks of the middle-income countries. In 1970, Thailand spent $11 per person on education and $2 per person on health care. By 2000, these number rose to $88 per person on education and $25.8 per person for health care. In contrast, Rwanda spent $8 per person for health care in 2005, less than what its neighbors spent in 2002 - $118 in Zimbabwe, $20 in Zambia, $19 in Kenya, $18 in Uganda, and $13 in Kenya*. Hasan, M. Aynul, 2001. Role of human capital in economic development: some myths and realities, in ESCAP, Development Planning in a Market Economy, Least Developed Countries Series No. 6 (ST/ESCAP/2174), pp. 3-14. *World Development Indicators 2005

27. 27 Declining fertility was a key factor in the Asian economic “miracle” . . . Greater emphasis on the quality of the population rather than sheer numbers More and better educational opportunities More investment in modern agriculture Higher levels of savings and investment with lower dependency ratios Most observers believe that declining fertility was a key contributing factor to the Asian economic “miracle”. Overall, modern economies are dependent on smaller, highly productive labour forces rather than on a large number of unskilled workers. Declining fertility meant that more resources could go to improving the quality of the Asian labour forces. Declining fertility meant that more resources were available for education and in fact educational expenditures per student rose dramatically in the Asian “miracle” countries. Declining fertility also meant more resources were available for agricultural modernization. (Improving education and agricultural modernization are two of the cornerstones of the Rwandan vision.) Declining fertility also meant that the Asian Tigers could generate higher levels of savings and investment to drive the development of the economy. Most observers believe that declining fertility was a key contributing factor to the Asian economic “miracle”. Overall, modern economies are dependent on smaller, highly productive labour forces rather than on a large number of unskilled workers. Declining fertility meant that more resources could go to improving the quality of the Asian labour forces. Declining fertility meant that more resources were available for education and in fact educational expenditures per student rose dramatically in the Asian “miracle” countries. Declining fertility also meant more resources were available for agricultural modernization. (Improving education and agricultural modernization are two of the cornerstones of the Rwandan vision.) Declining fertility also meant that the Asian Tigers could generate higher levels of savings and investment to drive the development of the economy.

28. 28 Benefits of family planning Stabilises population Reduces maternal mortality Reduces infant and child mortality

29. 29 Benefits of family planning Frees scarce and vital resources for equitable distribution among the people Leads to economic upliftment of the people Improves the quality of life Leads to all-round progress of the state and the country as a whole

30. 30 Slower rates of population growth benefit all aspects of development

31. 31 National Population Policy, 2000 IMMEDIATE OBJECTIVE Address the unmet needs of contraception, Reproductive and Child Health care MEDIUM TERM OBJECTIVE Achieve Replacement Level Fertility by 2010 LONG TERM OBJECTIVE Bring about population stabilisation by 2045

32. 32 WHERE WE STAND NPP 2000 and the present scenario: 2010 Population replacement (put back now to 2021) 2045 Population Stabilization (put back now to 2060 (1.53 billion in 2060). EAG states constitute 42% of the population (TFR between 3.4 and 4.3)

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35. 35 Areas of concern in FP (Programmatic weakness) Poor Access to FP services Fixed day regular services unavailable at sub district level 24/7 PHC & FRUs not providing sterilisation services Poor Manpower development at state level No effort to increase manpower for minilap and lap. Underutilization of trained NSV providers Lack of Contraceptive updates at state/district Lack of Concerted BCC strategy for FP Achieve ELA in the last quarter Pressure on the system where quality is a casualty PPP in FP not evident Non accreditation of private providers at state/distr.

36. 36 Declining performance in FP ( 2006-07)

37. 37 Major reasons assigned for falling performance Supreme court’s order of 2005 on qualification norms of doctors performing sterilisation Lack of laparoscopes (40% of sterilisations done are Lap. St.) (both the above does not explain fall in IUDs) Target free approach introduced in 1996-97 Reduced thrust on FP in RCH II

38. 38 Indicators (OVI)

39. FAMILY PLANNING INTERVENTIONS

40. 40 GOI POLICY(Servicing the unmet need) Based on felt needs of the community TARGET FREE Children by choice & not chance Equal emphasis on both limiting and spacing methods ELA :Scientific and statistically significant way being formulated for calculating state wise performance level based on unmet need Population stabilization is a priority area of the GOI

41. 41 MEETING UNMET NEEDS 1 Two third Indians want to use contraception 2 There is no scope for coercion 3 Ensure availability of quality RH services 4 Meet the felt needs of couple 5 Enable couple to achieve their RH goals

42. 42 New Interventions in Family Planning (GOI) Addressing the unmet need in contraception through Assured delivery of family planning services Developing skilled manpower for the same Increasing male participation through intensive promotion of NSV Promotion of IUDs as a short & long term spacing method Promotion of Emergency Contraceptive Pills Ensuring quality care in FP services Promoting Public Private Partnerships Revised compensation scheme Family planning insurance scheme Increasing basket of choices Promoting contraception through increased advocacy

43. 43 Temporary (Spacing) Methods IUD 380 A EC Pills OC Pills CC ( dual purpose condoms)

44. 44 Reduce unmet need in Spacing method (Increasing access and uptake of IUD 380A) A. Augmenting trained service providers in IUD: (Alternative training strategy in IUD in 12 pilot states) 5 Master trainers each trained at NIHFW for all the 12 states All 12 states completed their state level master trainers’ TOT 6 states have gone in for district level training Feedback extremely positive Plan for pilot to be extended to all states has been approved B. Introducing Social Marketing/ Social Franchising in IUD being piloted in 3 states- Rajasthan, Gujarat, Bihar (in final stages)

45. 45 Reduce unmet need in Spacing (advantages of IUD 380 A) 10 years’ duration & not 3 years Can cover reproductive life span in 2 insertions only (25- 45 yrs.) Can potentially replace the sterilization procedures Can be inserted at subcentre level ANM/ MOs could be given refresher training

46. 46 Promotion of EC Pills 2 tabs of 0.75mg or 1 tab of 1.5mg within 72 hrs of intercourse in the following situations: Unprotected intercourse Unplanned intercourse Failed CC (Nirodh- torn) Assault/ rape Levonorgesterol only No side effect One time activity to replace MTP Reduces Maternal Mortality by 10-15%

47. 47 Promotion of Emergency Contraception (Increasing awareness, supply and use of ECPs) 1. Dissemination through Contraceptive Updates for all states 2. Allowing advertisement by private sector – Relaxation of Drugs & Magical Remedies Act on case by case basis allowed by DCGI

48. 48 Reducing unmet need in Terminal method Assuring service provision through Fixed day service round the year Periodic camps Augmenting trained manpower in NSV Minilap Lap. Ster.

49. 49 Male participation(Why No Scalpel Vasectomy- NSV ?) Attain population stabilization in a short period Shifting responsibility of family planning from females to males

50. 50 Why NSV ? 6 Ss:- (advantages) Scalpel less Stitch less Safe Sound Simple Short

51. 51 Increasing male participation (High focus on manpower development) SURGICAL FACULTY TRAINING 7 centres identified Training started in all centres 50 batches/ 200 faculty trained till March 31st DISTRICT TRAINERS’ TRAINING District TOT for providing 1 district trainer per district. 263 district trainers trained till date Punjab, Rajasthan, Haryana, Uttaranchal, HP has been completed Jharkhand, Chhattisgarh, AP, West Bengal to be completed. NSV PROVIDERS’ TRAINING States have put up NSV trainings in their PIPs. Reports are awaited from NIHFW and states

52. 52 Tubectomy (If client chooses it after all options have been explained) Offer minilap because No postgraduate surgeon/ gynaecologist required No anesthetist required normally No pneumoperitoneum (inflating with gas) Less post operative distress If client still demands Laparoscopic Tubectomy Offer services routinely at DH, FRU, CHC, BLOCK PHC (wherever OT is available)

53. 53 Camps in tubectomy Should preferably start by 9 AM As the client is fasting since the previous evening Has travelled long distances to reach the camp site and Is dehydrated Has to have 4 hrs post operative observation before being discharged after being rehydrated

54. 54 Ensuring quality care in FP The manual on Standards in sterilization has been updated, printed & uploaded on the website. The manual on Quality assurance in sterilization has been updated, printed & uploaded on the website. Six Regional Dissemination Workshops on the revised Standards and QA manuals held countrywide in 06-07.

55. 55 Ensuring quality care in FP All states reported to have set up the QACs at state and district levels as per affidavit filed by them in the supreme court Revised extended QAC as per the updated manuals are in place in most of the states. Most states have completed their orientation of the districts for QA

56. 56 Ensuring quality care in FP Reference manual on IUCD for MOs (revised, printed & distributed countrywide). Reference manual on IUCD for Nursing Personnel (revised and printed) Standard Operating Procedures (SOP) (to ensure the quality in camps has been developed for the first time and is in print) Manual on Emergency Contraceptive Pill (revised & is in print)

57. 57 Revision of rates for compensation scheme for Sterilization Rationale for increase low loss of wages compensation low availability of qualified providers poor access to service especially in remote areas opportunity cost was high ( high transportation/ other costs)

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60. 60 Family Planning Insurance Scheme(limit of indemnity) Claims arising out of Sterilization Operation Amount A Death at hospital/ within seven days of discharge Rs. 2,00,000/- B Death due to sterilization (8th – 30th day from the date of discharge ) Rs. 50,000/- C Expenses for treatment of Medical Complications Rs. 25,000/- D Failure of Sterilization Rs. 25,000/- E Doctors/ Facilities covered for litigations up to 4 cases per year including defence cost Rs. 2,00,000/- Dissemination meetings conducted for all state officials Public institutions to display boards on the scheme

61. 61 9. Strengthening contraceptive supply NSV instruments Revised Specifications prepared in 2006 (on website) IPC has cleared procurement of 2500 sets Consignment received and being distributed to states Laparoscopes Revised Specifications prepared in 2006 (on website) States asked to procure as per their requirements from central funds as per approved specifications (can place indents with the TNMSC ) ECP supply Procurement has restarted recently Requirements from states received and being supplied

62. 62 Expanding Contraceptive range (Increasing basket of choices) Centchroman (Saheli), once a week non steroidal pill, (developed by CDRI, Lucknow in 1992 is now approved by RAC for multi centric study for 3½ years, before introducing in NFWP) Protocol approved Multicentric Study started in Oct ’07 at 31 HRRCs 3 medical colleges 3 NGOs (VHAI, PSS, JANANI)

63. 63 Expanding Contraceptive range Injectables Implants Risug Phase 3 clinical trials on Cyclofem, Net-en have been completed and report presented before Secretary (Health & FW) Protocol developed by ICMR/ NIRRH for phase IV trial before inducting into the NFWP Implanon, a sub dermal implant is presently under clinical trial RISUG, a male intravasal occlusive contraceptive indigenously developed, is in Phase 3 clinical trial -.

64. 64 10. Promotion of contraception through intensive advocacy Advocacy kit on contraceptives Expert committee and core committee set up All existing material reviewed and updated New materials developed for NSV, IUD380A, ECP, OCP All prototypes for audio, video and print (leaflets, flip charts, posters) finalised and passed on to the IEC division for production and distribution to the states (Jan, 08) Dissemination of FP capsule through regional workshops (WHO biennium 08-09) Approval obtained Funding awaited

65. 65 Infertility management 10- 15 % of couples are infertile. Medical, ethical and legal issues involved. Guidelines for ART (Assisted Reproductive Technology) has been prepared in 2005. Draft bill on ART is awaiting legislation.

66. 66 Family Planning Components Contraception Conception (infertility management) Quality Assurance Accreditation of facilities Empanelment of providers Compensation Insurance

67. 67 Responsibilities of the states/ districts Increase number of services centres Availability of services Accessibility of services Affordability of services (Upgradaiton of DHs, FRUs, CHCs, PHCs & SCs under NRHM) Accreditation of private providers (PPP)

68. 68 Responsibilities of the states/ districts Regular fixed day services round the year a) DH - on demand (daily/ weekly) b) FRU/CHC - weekly/fortnightly/monthly c) PHC - monthly/ bimonthly - (Tubectomy only if OT available) d) SC - IUD/ ECP (on demand) Tubectomy: Wednesday (optional) Vasectomy: Saturday (optional)

69. 69 Responsibilities of the states/ districts 1. Ensure at least One NSV Surgeon per PHC (ultimate aim) One Tubectomy Surgeon per PHC (ultimate aim) One IUD Provider per SC (ultimate aim) 2. Effect Manpower Rationalization Manpower Planning (based on ELA) Manpower Training Manpower Placement 3. Develop Comprehensive Training Plan for NSV Minilap LTT IUD ECP

70. 70 Action at State/Dist. level Appoint Nodal officer for Family Planning for Planning, Implementing, Monitoring, Supervising & Evaluation) Constitute QAC at state level (10 members) & notify Constitute DQAC at dist. level (9 members) & notify Accredit facilities (Public/Private/NGO) Empanelment of doctors (Public/Private/NGO) Half yearly/Quarterly meetings of State/Dist. QAC (minuted)

71. 71 Action at State/Dist. level Orientation of CMOs on NFPIS (National Family Planning Insurance Scheme) Compensation Scheme (Revised) ELA district wise for limiting & spacing methods (based on dist. Unmet Need) Manpower development (district action plan) NSV (MOs) Minilap/ LTT (MOs) IUD (MOs/ SNs/ LHVs/ ANMs) ECPs (MOs/ SNs/ LHVs/ ANMs/ ASHAs) Contraceptive updates District budget allocation and disbursement Monthly Review of FP performance with CMOs

72. 72 Action at State/Dist. level Display prominently (facility wise) Revised compensation scheme Family planning insurance scheme Service availability (district action plan) Fixed day service calendar NSV Minilap/ LTT IUD Camp calendar for above IEC materials on NSV IUD ECPs Budget may be provided accordingly

73. 73 Action at State/Dist. level Lay down benchmarks (performance indicators) and Rank Districts Reward districts Reward CMOs (state award) Recommend for national recognition

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