TABLE OF CONTENTS
1.	Introduction
2.	Contraception in the Context of NPP-2000
	• Keeping Women's Needs at the Centre
	• Alternative Paths to Demographic Transition
	• Brief Record of Performance in Family Planning
	• Importance of Holistic Approaches
3.	The Concept of Unmet Needs - Extent and Trends
	• How to Address Unmet Need in Backward States?
	• Should the Current Definition of Unmet Need for Contraception of Expanded?
4.	Strengthening Existing Set up
	• Need to Step up the use of Current Methods
	• Logistical Issues-Drug Procurement and Supply
	• Importance of Ensuring Quality
	• Age Specific Unmet Need
	• Urban-Rural Difference
	• Impact of Standard of Living
	• Prevention and Management of Unwanted Pregnancy
5.	Expanding the basket for Choice and Access
	• Method Mix and Informed Choice
	• Contraceptive Safety
	• Counseling and Follow-up
	• Male Participation and Responsibility
	• Increased Choices for Contraception
	• Extending the Channels for Distribution for Better Access
	• Information, Education and Communication (IEC)
6.	Linking to New Opportunities
	• Emergency Contraception Facilities
	• The Right to Information
	• Minimum Needs Program Implementation
	• Health Insurance
	• Putting Health on people's Agenda
	• Building Accountability using Panchayat Institutions
	• Tackling Teenage Motherhood
7.	Summary of Recommendations

The National Commission on Population, Government of India constituted four Working Groups vide Order No. N.11011/25/2000-NCP dated 4.10.2000. The first working group on "Strategies to address unmet needs " was broken into four subgroups. This is the final report of the subgroup on "Strategies to address unmet needs for contraception"

Sri R Srinivasan formerly Union Health Secretary and member of the Commission was the Chair and Mrs Meenakshi Datta Ghosh, Joint Secretary, Department of Family Welfare acted as convenor.

2. Contraception in the Context of NPP 2000.

2.1 National Population Policy 2000 sets out a framework for integrated service delivery of reproductive health services at various levels within which the demand for contraceptive products and services would be met as fully as possible with due sensitivity to economic realities and the cultural context.

The immediate policy objective in NPP is -

The intermediate objective in NPP is -

2.2 Clearly the emphasis is on convergence of effort across sectors in order to satisfy needs for contraceptive products and services. Steps for meeting unmet need for contraception would be a critical component of such convergence. While unmet need has been an evolving concept for family planning programs it can only complement ongoing programs that provide service and information to current users and cannot be a substitute for them. Unmet needs are conceptually identified as a separate category within family planning services in order to focus on such married women whose attitudes resemble those of contraceptive users but whose practices do not. Reasons why they do not practice may be due to fertility related or method related reasons or due to opposition from husband or family or inability of the programme. Removal of such impediments to wider adoption will it is expected increase contraceptive use and lead to faster fertility control.

2.3 Interventions to meet unmet need should not be viewed as an isolated vertical program component within the RCH program. Instead they should be seen an integral part of delivery of basic reproductive and child health services -so far largely provided in the public sector. These should be embedded into the country's public health infrastructure and associated nutrition and child development and schooling infrastructures. Only by creating such synergy between various activities all addressed mainly to women and children can our efforts become optimal and cost effective .It would also be an approach consistent with the NPP goals being realized through people's informed voluntary participation within a democratic framework. Contraception would then be seen not as an end in itself but as a tool to achieve these larger aims. This perspective on contraception in NPP 2000 should inform the examination of the issue of meeting unmet need.

2.4 It would appear that in one sense we have a broad choice between two historical paths to success in achieving population stabilization goals - and indeed we have to combine elements of both. First there is the East Asian path to demographic transition - through State led public action for social development securing large behaviour changes in favour of low fertility low mortality with low social breakdown. Of course the extent to which such behaviour changes were voluntary would depend on the content of democratic freedoms in each country. Second there is the post modern Western path which has also completed the transition but within a far reaching social security system. This model has also enabled low fertility and low mortality but has been accompanied in many cases with substantial social costs in high teen age pregnancy, high divorce and out of wedlock children. What is common to both paths is the sustained positive role of the State in political commitment, a caring approach and sustained long term allocation of resources to social development. This has facilitated both public action and evolution of partnerships. This has provided greater choices among contraceptive services, and encouraged multiple channels of delivery for more information about services and how to access them. Clearly our choice must lie closer to the former path but moderated by our democratic constitutional and social cultural context. Unmet needs must therefore be attended to keeping in mind our pluralistic society and regional diversities and dynamic changes in new methods of contraception.

2.5 In our view this would call for a three fold approach - within which interventions could be identified at various levels for better implementation of family welfare services, of which unmet need forms a part-

Brief Record of Performance in Family Planning

2.6 What has been the record so far in rendering family planning services ? What lessons are relevant to meeting unmet needs for the latter is only a complement to the main programme ? It is difficult to establish any direct co-relation between contraceptive prevalence, levels of public expenditure and crude birth rates. There are many intermediate factors within and outside the demographic and health sectors that influence such relationships. Wherever social development had been a sustained concern and become a politically salient issue there has been improvement in the easy availability, wider choice, more channels for distribution and increased contraceptive prevalence. On many fronts there has been progress but not though not always cost effectively. Costs in the shape of expenditure per eligible couple provided with family welfare services or cost per sterilization equivalent has been steadily increasing partly due to poor ability to coordinate creation of collective and public assets such as MNP and greater convergence with anti poverty programs and which could have been helpful to better contraceptive use. In spite of uniform norms for funding, there is wide variation between States often due to budgetary constraints in weaker States in a period of widespread compression of budgets. The cent per cent assistance from the Centre for the major part of family planning services still leaves a substantial burden on the States. During the past five decades the total fertility rate in India has come down from 5+ to 3 - that is about two children less than say, 25 years ago - and we seem set on a path of irreversible decline. There has been growing awareness of the need for family size limitation but not always in practice of contraception thus creating unmet needs. What is worrying is the degree of inter - state differences in States under which the better off states have brought down TFR by one full point during the last 15 years whereas the lagging states have done only just half as much. This has made a material difference considering that the latter account for dose to 44% of the current population and 55% of the projected increase of population by 2010. Even at low levels of expenditure birth rates can come down by sound policies and purposeful use of funds and prudent attention to management issues. States differ in resource endowments, population size, age distribution, budgetary constraints, health infrastructure and above all in political will and administrative performance. And yet it is essential that all lagging States reach a minimum threshold in all these aspects within a short period if NPP goals are to be met.

2.7 What accounts for differential performance ? Many positive and negative factors are at work especially in the lagging States. More attention to child centred programs -nutrition, infant mortality and immunization to children- MCH - and guidance to mothers for reproductive understanding and greater empowerment women - women's education. On the other side these States are faced with poor logistics, information and access to contraceptives for women who wish to avoid unwanted fertility (delivery of service issues) and they also suffer drag from effect of the population momentum that is bound to play itself out only over the next few decade(momentum effect). However the key issue is how to induce greater ownership and generate innovation at the State level and reduce centralized uniformity in design programming and direction which partly arises from cent per cent funding. Central funds do not catalyze the State effort adequately in plugging gaps, in existing public health infrastructure. And its potential remains unrealized. For instance, success at subcenter level depends on a sound referral link at PHC and CHC which is weak. There is waste in duplicating referral structures earmarked for RCH services. Thus subcenters (funded fully from the Centre) can not be developed beyond a point or optimized standing alone unless accompanied by general improvement at PHC/CHC levels (both borne on the State budgets). The well known imbalance between ANM and MPW strength at SCs and the lack of doctors and anesthetists to handle complicated cases at PHCs are examples of this disconnect. Closer linkages and flexible funding between structures that exist but are weak will significantly optimize resource use It will also bring on more community response to programs delivered better.

2.8 There is a clear geographical skewing adversely to North and Central Indian States which account proportionately for a larger share of incremental population. In the near term, the concentration in these States must lie in improving general health and family planning arrangements and so service unmet needs. But they have also to confront factors such as early marriage and early child bearing and deep rooted son preference and other obstacles to empowering women. A combined success in all these factors will alone complete the transition to low fertility; this will need calibrated Central support over a long period. Otherwise the country will face the danger of differences getting polarized. It is a reasonable assumption that in these States millions of women have more children than they want because they are ignorant of, or lack access to, or fear higher risks and side effects from methods of fertility regulation i.e. they have in each case an unmet need for family planning, and services should reach them soon to avoid grave national consequences. It is this context that gives unmet needs its strategic importance.

2.9 The key lessons of experience in better performing states are improved availability of contraceptives and better information and counseling and better logistics to increase access to contraception. Even though sterilization still dominates the field, spacing methods are also better organized and delivered. A more caring approach, better training and supervision, and logistical optimization of the primary health care level make it possible to improve quality. There is greater flexibility and devolution in functioning and more decentralized oversight of programmes improved. There is greater convergence in the cluster of programmes concerning infant survival, better nutrition, more imaginative and holistic tackling of women's health issues, including girl's education, gender equity and safe motherhood issues.

2.10 Taking into account the analysis made above any strategy to meet unmet needs must

3. The Concept of Unmet Needs, its Extent and Trends

3.1 Under the current definition, unmet need represents the gap between women's reproductive intentions and their contraceptive behaviour as indicated through answers to questions administered to them in well designed surveys. If measured effectively potential demand for family planning services and the likely impact on fertility if the identified demand is met effectively. It also attempts to give reasons why having become aware of contraceptive availability some women do not accept it or, having accepted the need, some others do not proceed to use contraception. Such reasons may be related to fertility problems or to method related problems or due to opposition from husband and family or due to lack of information and access. Some studies show that unmet need is a function of her background such as income level, degree of autonomy in functioning etc; on her child bearing experiences, her level of education and exposure, and also program factors. Hence it must be realized that program efficiency can be useful but not sufficient. It must be added that unmet need for contraception will ultimately take its place in a hierarchy of competing unmet needs. The definition has evolved over time and in some countries been extended to cover beyond married women. Unmet need does not reflect just women who want contraceptives -a supply need -but also those women who require motivation to want what they are presumed to need. In the developing world as a whole, barring China unmet need has been assessed at 20%. Strictly speaking this may be an understatement as it supposes that all women using any contraception -effective or not and appropriate or not -have their contraceptive needs met, which may not be the case. Some may be using ineffective methods, or use a method incorrectly or use methods unsafe for them. All of them too have an unmet need.

3.2 Unmet needs for contraception assessed during NFHS I (1992-93) and NFHS II [1998-99] for the country as a whole separately for spacing and for limiting have been shown in table I below.

3.3 The total "demand" for family planning is visualized as the sum of the "met need" and the "unmet need" and the rate of contraceptive prevalence (CPR) is used as the surrogate for measuring satisfied demand. An "unmet need" for family planning is gauged with reference to those sexually active women who do not seek a pregnancy, either right away, in the near medium term, or ever, but who do not use any method of contraception, and nor does the partner use any method of contraception. Translated in absolute numbers, based on the current population of 1027 million, present unmet need in India totals about 40 million married women. If all women who say that they want to space or limit births were to use family planning, the contraceptive prevalence rate of currently married would increase from 48% to 64%, and this in turn may, despite the population momentum acting as a drag, begin to impact the total fertility rate.

3.4 States in Indian demographic transition can be divided into three categories. In category-I States with deficient socio demographic indicators, when a change occurs merely in attitudes following the first stage of high fertility it may not be translated into contraceptive use. During this stage, more couples want to control their fertility, and their unmet need rises because attitudes change faster than program capacity to satisfy that demand. Only when as a result of improved programs contraceptive use begins to rise as well, fertility starts to decline. Category-II States refer to those where such fertility decline has set in, and indeed in some cases reached replacement levels. In category-III States, total fertility rate declines steadily through increasing contraceptive use and the lower fertility stage is on the anvil but this stage of more contraceptive use and low fertility has to be followed by a third stage viz., change in behaviour. During this phase reproductive behaviour continues to change and, as information and services respond to people's changing attitudes, contraceptive use rises more rapidly, while unmet need declines.

3.5 As stated already when unmet needs are met effectively CPR tends to go up. Increasing the CPR would require that both spacing and limiting unmet needs are met, which now has come down respectively at 8.3% for spacing and 7.5% for limiting for the country as a whole.

It would be inaccurate to judge the national family welfare program as having fulfilled its role, simply because the percent of women with unmet need has decreased (NFHS-II). For unmet needs arise for several reasons such as fertility related reasons or method related reasons or opposition from husbands or family etc. Not all of them may in a given context be met by the successful program. The key question is whether the program has attracted more people to contraceptive use and whether it has motivated couples to have fewer children that is a decrease in TFR and CBR. The level of unmet need in a country is not static but always in a flux, presenting a ii moving target "' which rises as more women seek to limit their fertility, and falls as more women begin to use contraception.

3.6 Amongst the major States unmet need is the highest in Bihar and UP. These two States will critically determine overall TFR outcome for the country. Unmet need is roughly 25% in each State even according to NFHS II lower estimates but against a backdrop with only 50% of demand for family planning satisfied. The unmet need for limiting is 7.5% at the national level but nearly twice this 13.4% in UP and 11.9% in Bihar. Spacing methods are predominantly the forte of the private sector but terminal methods including IUDs are largely contributed by the public sector most so in States with poor infrastructure with limited private and NGO activity. These States have also the largest concentration of below poverty line population. On the other hand MP and Rajsthan though similar in many respects have an unmet need at 16 to 17% but are a bit better off total demand satisfied seems higher at 70 to 75%. What should be the strategy by which unmet needs of these States can be mopped up in the short run ? Would they need more innovations and new programs for spacing and reversible methods set up as campaigns outside the health system or should the States concentrate on direct improvement to the existing system ? It would be wise to adopt a middle course anchored first on improving and using the existing system without excluding innovations consequent on proved technologies. For backward States steady improvement of the public health system must remain a vital priority.

3.7 How different has been the growth of demand for limiting and spacing needs ? Despite the focussed policy shift since 1996 and substantial increase in knowledge of spacing methods - spacing has had limited thrust. Even though awareness about pills is assessed at about 80% and condoms and IUDs at over 70% total contraceptive use for spacing method over last five years stands at only 7% of acceptors, with a one percent rise per year. On the other hand female sterilization increased by 6% during this period and now accounts for 36% of acceptors. Modern Spacing Method acceptance has been reported at NFHS II - 6.8% & NFHS I - 5.5% and Traditional Methods acceptance at NFHS II - 5% & NFHS I - 4.3%, assuming all of it for spacing. On the contrary the unmet need for spacing methods has declined by almost 3%. There seems to be no clear explanation except that women in general seem to have placed more faith in terminal methods. Is there some message of preference implicit in these data since even among those who wish to use contraceptives in the future a good two thirds want to go for sterilization and express satisfaction with the method.

3.8 The significance of these factors needs to be carefully analyzed. It may even be due to a feeling that high CPR levels achieved through aggressive promotion of modern spacing methods will somehow lead to significant and rapid lowering of TFR. There are international examples to show that high usage of modern spacing methods can coexist with high TFR of 3 or 4+ in many countries. Examples are Morocco CPR 32.5 and TFR 4.04- and Zimbabwe CPR 39.7 and TFR 4 plus. Even within India Punjab has CPR as high as 66% almost half of it by reversible methods and yet it lags far behind Kerala with CPR only at 40 %.,and that too mostly by terminal methods. All this goes to prove that high CPRs need not necessarily lead to low TFR. Of course it is also true that even if the percentage of unmet need is less than earlier, the absolute number of women is bound to be much larger. This estimate needs to be finalized by the Ministry soon and compared with the earlier survey to comprehend the dynamics better and disseminate it widely State wise.

How to Address Unmet Need in Backward States ?

3.9 Unmet needs in backward States -in either eventuality -can be met successfully only if services are known effective accessible and safe and remain consistently good in quality. What this implies is as below is much greater attention should be paid to six related areas

3.10 There is striking diversity among states with regard to their unmet need for family planning, varying from 7% in Punjab to 36% This emphasizes again the need for State specific strategies, indeed for unique district specific interventions, locally designed and executed with full participation of panchayats and other civil society organs acting on subsidiarity as the guiding principle.

3.11 Although broad national strategies must continue to be evolved, there is a crying need to evolve appropriate state specific strategies to meet the unmet need in each state. Further, each state needs to evolve region specific, district specific, and block/panchayat level strategies in order to reach out to household levels. This will be a multi faceted effort calling for sustained political will and public education if the experience of the Southern States is any guide. Among the Group III States, for improved performance, spacing methods must be urgently stepped up. How it should be done in each State will depend on local leadership and social imagination and levels of corruption free administration and additional resources alone can not bring forth results. The divide between the North and the South has further increased. This has been recognized as a spur to action in the State Population Policy documents of UP, Rajasthan and MP which already provide a framework for concerted action. The major northern States enumerated above need to be treated as critical to NPP goals and assisted through special central help for filling gaps in staffing and logistical aspects of infrastructure. Greater responsibility to ISM&H and private doctors on contract will provide some relief. Mandatory rural posting must become a precondition for doctors wishing PG admission. ANM still remains overloaded with work her jurisdiction is too large and in the absence of a well supervised work routine neglects remote parts in her area. Not only additional ANMs are needed but the Centre should seriously consider at least funding cent-percent the cost of MPWs in 133 selected districts at demographic risk where the TFR is more than 3.5. NCP has already taken steps to and Innovative strategies have to be found out its own way by each State. Such initiative should cover all aspects of social development programs and departments and sectors impinging on family welfare, not forgetting the robust implementation of MNP in view of its relevance to unmet needs. Unmet needs should not however in this process be allowed to become a furtively introduced target during a period when replacing Community need assessment is yet to stabilise itself on the ground. All these steps will help develop and accelerate demand generation for both spacing and limiting methods of contraception.

Should the current definition of Unmet Need for contraception of expanded?

3.12 The National Family Health Survey (NFHS II) - 1998-99 places unmet need for contraception as 16 per cent in "currently married women (ages 15-49) who say that they either "do not want any more children or they want to wait two or more years before having another child, but are not using contraception". This unmet need is stated to be 25 per cent of present total demand for family planning i.e the sum of the met and unmet need. Even within the current definition, if all currently married women who say they want to space or limit their births but are not contracepting are assisted to realize this demand, then TFR may go down by one birth, which would help attainment of TFR goal of 2.1.At this stage is there a case for expanding the definition of unmet need to include new categories beyond married women ? Would it affect current performance by diverting attention from more urgent coverage of the present unmet categories. The group agree that unmet is a fluid concept and periodic changes in definition would have to be made. There was, however, the danger that any change in definition at this stage will divert attention from immediate tasks on which undivided attention must be focused, especially in the lagging States.

3.13 There was a view canvassed within the subgroup that redefining and broadening the concept of unmet need in order to further expand its ambit at this stage may hold potential for confusing programme managers and delay results as was witnessed in the RCH programme the nomenclature was changed from Target free to Community needs approach. The unmet need as identified under the current definition presents a substantial challenge in some North Indian States accounting for half the population. When the backlog itself is immense and contains the more difficult to reach, it may not be necessary or wise to expand the ambit. In particular, there are dangers in creating a new "general adolescent" category to cover both married and unmarried adolescents who are perceived and treated within different behaviour norms within our social context. The adolescent problem per se requires sex education within a value framework and sensitive understanding of sexuality and its balanced advocacy in the median and our concern with married adolescents of a group of married women is well founded.

On the other hand it was argued that following the paradigm shift, our approach should be premised on inclusion of more categories rather than exclusion. The sub group would opt for caution in accepting a more inclusive definition of unmet need. For the present this may remain as a direction for the future and may not be pursued till the pressing tasks in backward States are not dealt with till the end of the decade. It is in those States the coverage within the existing definition itself leaves much to be desired -the better should not become the enemy of the good.

3.14 On a balance of convenience therefore the group would recommend a two part strategy - concentrating on the present definition say till 2005 to reach near term goals in the lagging States. Any broad based definition must get endorsed through a series of participatory processes, involving diverse stakeholders including policy-makers, researchers, NGOs and the community.

4. Strengthening Existing Setup

Need to step up the use of current methods

4.1 A number of reversible and a few irreversible methods are currently available but it is disheartening that between the two rounds of NFHS the use of currently available best spacing method IUDs has gone down in the country. Condom performance has improved slightly, and pills are only beginning to pick up in view of its delayed introduction in the country. On the whole the spacing programs have not realized their potential in spite of much energy invested in them and not been growing fast enough. This may be one key contributing factor for failure to meet unmet needs The outlay over the last three years ending 1999-2000 has registered a significant jump but condom use has not been significantly larger over the last three years.

4.2 The reasons for low acceptance of IUDs need to be found out particularly because IUD may be in more tune with our needs if the side effects are attended to. There are communities which distinctly prefer IUDs for religious or personal reasons. This matter should be looked into by the Ministry and appropriate action taken. Further, it also possible that given the current levels of high IMR in some lagging States/Districts IUDs may be a rational choice which minimizes risk for possible acceptors of limiting by sterilization.

4.3 Despite the focussed policy shift in recent years and substantial increase in level of knowledge of spacing methods - pills now 80% known and condoms and IUDs 71 % modern spacing methods have had a slow increase in the last five years. They are presently used only by 7 % of acceptors registering only 1% rise in last five years. Even traditional methods seem to have done as well. The use of condoms has only increased slightly, in spite of the HIV/AIDS becoming a reality ,and yet condom still accounts for only 3% of users ,registering an increase of only 0.7% between NFHS I and NFHS II. Barring Tamil Nadu and AP the position is disquieting elsewhere. On the other hand, there is great potential for rejuvenating the relatively cost effective Postpartum program which now accounts for 1.4 million acceptors and constitutes one fifth of the country's terminal method cases and 8.5% of IUD insertions. There is much scope for expanding the programme as part of revitalisation of health infrastructure.

But there is the pending task that innovative ways still need to be found to deliver condoms to couples at risk of unwanted pregnancy and infection through sexual contact. Social Marketing can play an important role here, if set to standards and guidelines and as far as possible supplemented by the Community Based Distribution (CBD) approach. Pills acceptance can further improve using the same route, but the question should be asked whether from the vast infrastructure already existing from the Ministry down we are getting value for money in regard to spacing method dissemination.

4.4 Sterilization has been and may continue to be the main stay of the National Family Welfare as it has been since its inception. A key reason may be that this method is by now well understood by the masses as a certain method to prevent unwanted pregnancy and adopted to an extent through peer transmission of relevant facts. Being a method requiring only one time intervention, it is suitable to our country specific needs and failure rates are within limits. Between the two NFHS, in spite of no target approach, the acceptance of sterilization has gone up- from 30.7% to 36.1 %. In spite of the se facts there continues to exist an unmet need for sterilisations in the country. The reason must lie in the inability to provide quality and convenient and diligently followed up services in public hospitals, and more so in camps. This can be remedied immediately without any coercion if only fuller use is made of health infrastructure on a planned and supervised manner. Quality services and availability of different methods of sterilization such as laproscopy and mini-lap for women and non-scalpel vasectomy for men, (all procedures under local anesthesia) will go along way in better acceptance by the users and as safe procedures for the providers.

4.5 A detailed analysis must be done of the extraordinary success in the last decade in Andhra Pradesh which has achieved a contraceptive prevalence rate of 59.6%, mainly with limiting method of 58.9%. In the process, the average age of women at sterilization has come down to only 23.6 years. AP also has the distinction of greatly improving its Vasectomy performance in the recent years. Census 2001 results have revealed lowest population growth in this State. Detailed analysis is awaited. How far can it be replicated in the lagging States as a strategy using both modern IT for monitoring and evaluation can be decided only after such case study.

4.6 The group noted that - in spite of a target free approach for some years now there has been no significant pickup in reversible methods. This calls for field checks and State level analysis, in particular about the decline in IUD acceptance. At the same time sterilisation continues to be preferred even if not by the desirable lower age groups quality service must be the focus. Similarly, the post partum approach seems to have reasonable success and should be further stepped up.

Among the States the dramatic decline in fertility in AP in the ten years ending 2001 needs to be understood better.

Logistical Issues - Drug Procurement and Supply

4.7 The models of drug procurement and distribution introduced in the State of Tamil Nadu through the creation of the Tamil Nadu Medical Supplies Corporation and later by the National Capital Territory of Delhi have demonstrated that accessibility to medicines, both at rural and urban levels can be markedly improved by means of pooled procurement of a selected list of essential drugs and an efficient system of distribution. It is suggested that this model should be tried out in other States in respect of contraceptive products. The system would disconnect the purchase and quality determination process (to be handled centrally) from the transport warehousing and distribution tasks to be done on contract or by units. It allows for close and just in time delivery avoiding inventory costs through a computerised control and monitoring system. Its key is reporting and management by exception approach with genuine devolution of powers. This begins with a careful selection of a list of essential preferably generic drugs whose purchase and quality tests will be done centrally to avail of scale economies but the drugs themselves would be distributed by the pharmaceuticals or a private sector agency direct to the primary health care level. Based on experience it is important to build into the system mechanisms which would ensure that every larger health facility could monitor the provisioning of services and supplies in the next lower facility, in a hierarchical manner. This will ensure both a sense of ownership, as well as accountability. The drugs would, in this system, be obtained at prices about thirty percent less and be available at the primary health level since more drugs could be procured with the help of the same budget. Panchayat authorities have the funds and basic machinery for purchasing those drugs directly and that if drugs are needed outside the list of essential drugs these could be obtained for special purposes up to 10% of the budget for medicines. In Tamil Nadu model, a separate autonomous agency has been set up for this purpose. In Delhi, the programme is implemented by the Government and an NGO working in partnership. It is also possible to envisage that this total programme, after the selection of drugs needed have been listed could be implemented by a private agency.

4.8 There has been long standing difficulties in meeting the shortage of doctors in rural PHCs. Many methods have been employed by states with mixed success. Compulsory rural postings have been failures for political economy reasons. Rotational postings have not worked due to weak political will. Doctors themselves feel their genuine difficulties are not understood and solved through transparent negotiations. Contract service arrangements with private doctors have been tried. Responsibility for running remote PHCs have been offered and accepted by private business and NGOs. Rural medical experience has been made a condition for PG admissions. None of these can become the unique solutions and circumstances will vary from state to state. Clearly all these steps will have to continue as part of the solution as long as the quality of life in rural and urban areas do not converge more, as in Kerala and Tamil Nadu. In the mean-time, accountable contractual arrangements with private doctors should be tried out more. Some of the less than fully qualified doctors, who fill-up the vacant space from the shortage of public sector doctors, must be upgraded in skill and competence in basic medical care. The sub-group would endorse that all these steps should continue.

4.9 However, the indigenous system of medicine and homeopathy have begun to get focused attention. They are largely in the private domain. Even then the number of facilities and staff under government is increasing and should be utilized as an additional channel to meet the shortage. There are 22612 dispensaries in ISM&H run by govt./local bodies in the country. There are 99000 institutionally qualified doctors from these systems, many of whom have exposure to ancient and modern medical subjects, including understanding of the basics of anatomy and physiology. Besides there are 211000 non institutionally qualified practitioners with experience. In most cases they have no direct involvement in rendering family planning information or services. They could be trained in the basics especially on counseling for promoting a small family norm. Their involvement will extend the workforce and increase coverage and if otherwise professionally good his voice will influence decisions of household and community opinion leaders in some States. In some States, institutionally qualified ISM doctors have been allowed under by local State permitted areas to practice modern medicine. Such graduates with some training can be utilized in RCH program for meeting unmet needs. Use of Pippalayadi Yoga as a non-hormonal contraceptive is already under study at JIPMER and AIIMS. In the circumstances the services of ISM&H doctors can be utilized to fill gaps where allopathic doctors are not available; some conventional ISM medicines can be used for RCH and one could even incorporate into the mainstream some Ayurvedic drugs after due operational research. The sub-group would commend this approach.

Importance of Ensuring Quality

4.10 Ensuring Quality requires action in several dimensions. Minimum assurance of professional outcomes and minimum standards in level of service must be maintained at all times. Training arrangements are required for providers in contraception, particularly those that involve follow up for which records are to be prescribed as proof of acting in the best interests of the patient. Priority has to be given to closer supervision in remote areas of both lagging States and to those remote pockets in better performing States. These are challenging enough to make quality of care as the central issue in success in determining if demand exists and if it does so whether it is met.

Several guidelines are required that have to start with setting criteria and protocols and changing minimum standards where none exist or changes are required. Guidelines for fair standards are necessary for accountability under different contraceptive methods and must be given appropriate publicity among users and providers.

4.11 The continued prevalence of high levels of induced abortions (an estimated 6.7 million per annum) is another strong evidence that millions of women want to control their fertility but have not used either any form of effective contraception. Several studies in India have shown that abortion remains a common way for women to control their fertility and avert potential births. While increasing usage of family planning methods in the country, efforts would also have to be stepped up to make abortions safe in the country. This platform must get sensitively debated and information fully and discreetly made available and without coercion, in order to increase acceptance of contraception in the country. It must be remembered that even with a 70% CPR, there would be need for abortions as method or use failure is likely to continue as seen in developed countries. Therefore, the group will point out that the need for an around attention to quality in different methods and point out that creating safe back-up abortion facilities will help meet part of unmet needs.

Age Specific Unmet Need

4.12 It may be noted from NFHS II that 27.1% of the unmet need in 1998-99 amongst married women in the age group15-19 years, almost all of it being for spacing methods. If this unmet need is addressed and fulfilled, this will accelerate population stabilization; record reductions in maternal and infant mortality; and reduce morbidity in women and children. Condoms and pills have an important role to play but more importantly needed for this segment is the provision of sex education and counseling about the place of sexuality and reproduction and about contraceptive method choice, understanding the relative costs and risks of pregnancy and spacing contraception and information about how to access methods of choice taking into account risks and consequences in each case.

4.13 The next important category are women in the age group 20-24 years, who represent 24% of the unmet need. For this segment, the unmet need may be assumed as 75% for spacing methods, and a 25% emerging need for terminal methods. In other words, this age group must be provided with choices in respect of all reversible methods such as condoms, pills, injectables, IUDs & usage of traditional methods. Also using focus groups mahila mandals etc they should create peer pressure for small family so that they may encounter better family based pressures for more children.

The above two categories can also be linked to women with no children (14% unmet need in all categories) and with women one living child (23% in all categories).

The next category representing 19% of the unmet need covers women in the age group 25- 29 years, with equal percentages of need for spacing and limiting. It is possible that women in the last two categories may have completed their families, but may not yet be ready to decide on the terminal method. They may possibly be in need of a long acting reversible method such as IUDs and injectables.

Regarding "unmarried adolescents" they should be addressed with great care. Depending on where they live life styles adopted and levels of schooling some of them may have an unmet need for contraception, which they are first unable to voice and, if expressed, unable to procure because of social pressures, timely and quality counseling in the nature of value education is their first need so that they better understand the relationship between sexuality and reproduction in the context of nature of social norms and values regarding premarital sex habits. The need to avoid social disruption is an important factor to be kept in mind.

As regards adolescents who are not yet sexually active they need to be informed about reproductive health, contraception, safe motherhood and infant care as part of sex education and family life as they (both boys and girls) stand at the thresh hold of marriage and get prepared for responsible parenthood. About to be married adolescents and youth could be a separate target for information, education and counseling at the time of registration of marriage.

Urban-Rural Differences

4.14 The unmet need for family planning is only marginally higher in rural areas (16.7%, NFHS- II; 8.9% for spacing and 7.8% for terminal) in comparison to the unmet need in urban areas (13.4%, of which 6.7% is for spacing and another 6.7% for terminal). It is difficult to believe that promotion of family planning has been more successful in rural areas. For, in view of the lower satisfaction of demand for family planning in rural areas (44.7%) as compared to urban areas (58.2%), one anticipated a higher unmet need in rural areas. Reasons are not clear and may be looked into.

Within rural areas the remote and inaccessible areas stand apart where every indicator is more adverse. Only through the reach of routine administration, of which PHC infrastructure is a part can they be reached within Governmental channels. Most inaccessible areas have also large SC/ST concentrations with multiple deprivations. To meet unmet needs in those areas we may need patient path-breaking NGO activity using self help groups -may not add to numbers but will be an earnest of commitment and should be fully supported.

4.15 There is another neglected dimension namely the unmet need in the urban areas, particularly in the increasing number of urban slums, would have to be met. By the end of the next decade the slum population will be rising at the rate of 5- 6 % while large cities will grow at 4% and the total urban population will grow at 3% and the country population at 2 % %. The estimated annual rate of growth of slum population will be double that of urban population and more than double that of India as a whole. While general awareness may be high there would be much greater need for access to spacing and supply chains for pills and condoms and case specific counseling. The urban public health infra-structure needs to be designed with modalities for health posts and volunteers and community based distribution for contraception as part general health effort. This approach has worked very well, inter alia, in the Parivar Sewa Sanstha [PSS] implemented CBD projects in different parts of the country which has been used to reach a population with limited access to services by accessing household levels within the community. In all its variations, community based distribution programs are based on the method that takes products and information to where of people live, rather than requiring people to visit clinics or can other locations for these services. In the process community members become family planning workers to door-to-door education and counseling, in favour of spacing methods PSS Sitapur programme has shown a growth of 17.21 % in three years from 34.91% to 52.12%. Only socially marketed projects were made available at a price to the people in these poor urban slum areas.

Impact of Standard of Living

4.16 The group noted that as standards of living rose the demand for services will undergo change and programs should be nimble enough to meet them. A purely marketing segmentation approach by social class may prove inappropriate to the complex nature of the problem.

As the standards of living rise, women in different social and economic segments tend to exhibit dissimilar needs for contraception. Those at the top with good education and in employment develop more dimensions beyond reproductive realm. They generally take extra effort to ensure that their goals for a small family or for limiting births to levels considered sustainable by the couple have a high priority. Even in this category there is unmet need of 12 .8%; largely for spacing but it is backed by met need of 61 %. Women in the middle classes have an unmet need of 15.6%; and a met need of 48.4% and are driven by both supply and demand factors to adopt contraception. Finally, women with a lower standard of living and lower level of education have an unmet need of 17.9%, and met need of 39.5%.

If we are to achieve the medium term objectives of NPP 2000, it would be foolhardy to wait till economic development percolates all the way down. Andhra Pradesh, Tamil Nadu, West Bengal and Gujarat provide examples where, despite low literacy levels, and a modest growth of per capita income, contraceptive usage has been high and growing. This may have more to do with easy availability of contraceptives and relentless peer pressure apart from improvements in service delivery and its h-tech monitoring. It may be stressed that for each of the categories there has to be effective provision of information and demand induced quality service perceived as value for money. Strategies must be evolved also to meet the needs of the population below the poverty line. This is a difficult area because one has to constantly dispel tendencies towards wasteful subsidies in some cases combined with under funding in others and general beliefs about lower quality. These problems. have been met with in for instance the restructured anti poverty programmes and public distribution system (PDS) too. However free services and products must continue to be made available to them and group or community based distribution has an important role to play. For the low income and middle income groups, social marketing can make available a range of subsidized products and services, followed by sales in the open market at commercial rates.

There was a view that on the basis of this analysis full fledged market segmentation exercises should be done to create client profiles and attributes. Doubts were expressed whether such a course would not commodify further what was still a care- based service. It was also questionable if such a purely value-neutral market strategy can at all succeed in a sphere where we are seeking to influence behaviour in most personal realms of which the product can but be a part. But the fact cannot of course be denied that different segments have their own priorities and program should be nimble enough to make changes.

Prevention and Management of Unwanted pregnancy

Table 4 -Method wise performance during last four years

4.17 From table 4 it is clear that the program in India currently relies heavily on female sterilization which is by far the most dominant method. We have had a sea change in our approach to sterilization whose abuse at an earlier was rightly seen an affront to the dignity of women and their human rights. When balance was restored with the paradigm shift there is evidence of sterilization being accepted by most women. The issue was about its timing it in the individual case either by age or order of birth There is a danger now of an opposite swing even though the alternative of spacing has yet to command any significant following as mentioned already. However, a balanced view would be to give no overriding emphasis to female sterilization but recognize its huge acceptability among women and at the same time create a menu of choices including vasectomy, and reversible contraceptive methods for women. Spacing methods, however, require complementary attention by providers for placing before users harms and benefits attached to each method without imposing his own values. Some spacing methods may also require greater accountability for outcomes and to ensure quality service would include proper follow up.

4.18 The group noted the importance of balance between attention to Limiting and spacing methods noting that the latter may demand more commitment of time and effort by providers to make for real life choices.

5. Expanding the Basket for Choice and Access

5.1 The group will recommend that - With differing needs and preferences among users and a cafeteria of services being available it is important that public information is fully given on the new method and also about the precautions before the launch to minimize controversies based sometimes on misinformation. It is equally necessary to ensure that the choices in contraception remain informed choices in letter and spirit.

5.2 Contraceptive needs and preferences of users differ and change over time; therefore, a broad selection of reversible and irreversible methods should be available through public health system, social marketing programs, community based outlets and commercial outlets through which condoms and oral contraceptives could be provided. Permanent methods though should be available with the assurance of qualified medical backup at call -at primary health centres, community health centres and hospitals in the public health system, as well as through private practitioners and NGOs participating in partnerships. The addition of injectables, progestin-only pills (for women who are breast feeding), barrier methods, and spermicides should be done after due safety and efficacy testing subject to its initial release in the field being carefully monitored and escorted. The threat of HIV/AIDS and the demand from women's groups for barrier methods make a strong case for including these methods in the basket of contraceptive services. Research shows that each new method added attracts new users, improves contraceptive continuation and, thereby increases contraceptive prevalence. However, in view of past controversies over new contraceptives, which were often spearheaded by women's groups themselves, it will be wise to issue a public information sheet prior to introduction about the tests conducted with results of tests or safety, efficacy, acceptability and costs and subsidies so that misinformation may be less and an informed debate may take place without getting mired into tangential controversies. With a real cafeteria of services, informed choice must form an important element of the programme. Service providers should explain pros and cons of each method and the relative risks involved. This will help users make decisions for selecting contraceptive methods that are most appropriate for them after receiving information on harms and benefits and contraindications of contraceptive methods offered to them. Information should also be provided on what users can expect from service providers with regard to advice, support, supply, treatment, referral, and related services in case of need. It is most essential that there is no attempt to impose the value of the provider while guiding the user.

5.3 The group will recommend that - special training programs must be organized to inculcate contraceptive safety skills at levels especially for ANM, so that they can help in making informed choices.

5.4 The aim of the program is to provide people with the means to achieve their reproductive goals in a healthful manner. Contraceptive safety is an essential requirement to ensure that contraceptive products as well as services are delivered safely. At the very least, those reproductive health problems that are directly related to provision of contraceptive services must be addressed. For example, infections should not be caused or exacerbated by the provision of contraceptive methods. Ensuring service quality and safety is specially important for all surgical procedures. Special care must be taken for inserting intrauterine devices (IUDs), particularly in areas where reproductive tract infections (RTls) and sexually transmitted infections (STIs) are widely prevalent. All health workers including frontline workers such as auxiliary nurse midwives (ANMs) should be trained to provide informed choice of methods, counseling and follow-up care. If the ANM is expected to insert IUDs at the sub-centre (as is the case in several states), then health sub-centres must be provided with equipment to enable her to effectively perform this procedure. Special training programmes must be organized to ensure that she can develop the skills for inserting IUDs safely.

5.5 A woman needs to be screened so that she is found to be free of contraindications, and therefore an appropriate candidate for the IUD insertion, which again, must be inserted under aseptic conditions to prevent infection. Follow-up of acceptors must be regular and continuous as these women are at greater risk of infection. It is known that RTIs can be exacerbated by the presence of IUDs. IUDs can lead to increased menstrual bleeding, the increase being greater for women with anaemia, thus aggravating this condition. For ensuring safety, therefore, the programme must focus greater attention on all clinical procedures, especially on aseptic techniques, and on screening clients for contraindications and pre-existing health problems.

5.6 The group will recommend that - well thought out supportive counseling and follow-up services should be essential elements to ensure of a quality care, particularly for reversible method.

5.7 After the users have made their choice of the method, counseling should concentrate mainly on the services and caution which they should receive for proper use of the method. Follow-up services are especially important in the initial period for providing advice and managing side effects. Users should have access to service providers if they receive method-related problems, and should have the freedom to switch methods for which supportive counseling should be provided. It is necessary to plan convenient follow-up contacts with users and encourage them to approach providers at any time opportunity for continuing counseling and education and for discussing related reproductive health issues not dealt with earlier. These visits also provide an opportunity to discuss alternative choices if the user is not satisfied with the current method. Developing effective outreach should be a high program priority if counseling and follow-up services are to be provided, especially in remote areas that are difficult to access.

5.8 The group will recommend that - special efforts should be made to encourage men to take responsibility for family planning in the context of the importance of having their support for the program in a male dominated society.

5.9 Vasectomy is a simpler and safer procedure yet it is rarely used and often not acceptable to the wives. Health providers should be pro-active to propagate and reintroduce the no- scalpel vasectomy (NSV), into the program. The successful experience with NSV in the north-east where it has been tried should be upscaled and anxieties regarding vasectomy allayed through counseling and education. Already condoms are being promoted as a method to provide dual protection against both pregnancy and infection. For those at risk of STIs, condoms should be advised even if the client or partner has been sterilized or is using another family planning method such as the IUD or oral contraceptives. Gender inequalities also favour men in most communities in India and sexual and reproductive health decisions are made by men. Research on sexuality and spread of infection has highlighted the inadequacy of strategies that target only women since they are usually subordinate to men, and cannot effectively negotiate changes in sexual behaviour. Research on sexual negotiation has underscored the need for involving men bringing about changes in sexual behaviour. For such change, sexual negotiation and spousal communication must be encouraged which can also be a tool to prevent unwanted pregnancy and STIs.

5.10 The unmet need for contraceptives falls squarely in the arena of family planning and therefore in the concurrent list. Both the Centre and the States can legislate in this area, but implementation is in the hands of the State Governments many of whom have been forced into expenditure compression after the reforms. Even though it is claimed economic reforms themselves are non - discriminatory, they are bound to affect States differently because of State specific characteristics in level of development and patterns of public expenditure. Economic and social development depend heavily upon efficiency in resource use, which in turn is determined by the overall policy environment and the quality of governance. Good governance will be needed for reasons beyond unmet needs.

5.11 As regards cost effective strategies at the State level we are at present having a wealth of data on population and fertility issues of India from KAP studies, Census and related output data from NSS and NCAER besides two National Family Health surveys, and a plethora of service statistics. All of them point to gross inadequacies on both demand and supply side in infra-structure, equipment and supplies, shortage of health care providers but in broad aggregates. More of these should relate to specific policy dilemmas faced by State Governments. We recommend that - rigorous operational studies be done in the States in great need to determine unit costs for help in reallocation of resources. Such unit costs can help set up benchmark standards for services providing a basis of comparison to judge proposals received for private partnerships and social marketing strategies know whether they are cost effective and better value than public programs serving the same purpose.

5.12 NEW IUDs Choice in contraceptives will be real only if full information of two or more contraceptive methods are made available.. The absence of a basket of choices has led to stress on sterilization's Of course product differentiation is crucial when competing choices are offered but there is also need for informed acceptance by eligible couples after information about its safety efficacy and of relative risks .For instance, new variety of IUDs such as CuT380A is commended as it offers protection for 10 years as compared to 3 years with currently used Cut 200B, Both products are important and will address different types of users. Such introduction must be preceded by counseling and the new users escorted with medical monitoring of health status. recorded by locally situated voluntary agency for a prescribed initial period before we can be assured of acceptance. .Mere proof of safety and efficacy according to the minimum provisions of law followed by aggressive promotional effort will not be adequate for long term acceptance.

5.13 INJECTABLES - Injectable contraceptives providing long acting protection have been available in the country commercially for some years now. The group noted that Population Council is doing operations research to introduce the three -month injectable contraceptives, DMPA, to private physicians serving an urban population in India to demonstrate the feasibility of providing DMPA to private sector users at subsidized prices in a manner that promotes informed choice, adheres to good technical quality, and supports sustained use by satisfied users. The group also noted Parivar Seva Sanstha has for several years now used injectables with excellent acceptance by women and DKT, Bombay another NGO has also been working on similar lines. injectables can be made available under the social marketing programme subject to guidelines for social marketing reported to be under consideration in the Ministry.

5.14 The group recommends that - for all new contraceptives such escort system may be made suitably into an additional requirement for protection of user by drug controller. And other spacing products such as Gynae-Fix (said to offer a protection for 18-20 years) may also be tried out in the country if and when found safe and efficacious under the law nominated as If accepted CuT 380A can over a period reduce the need for sterlisations the promise of long acting contracepties raises ethical questions. A balanced view has to be taken on a case by case analysis, keeping both individual autonomy to decide family size and the social imperative of stabilizing population level.

5.15 The Group was convinced that if the choice in contraceptives was increased there will be need for more channels and it is useful to try trying out social marketing for focussed distribution of subsidized contraceptives. It will be particularly relevant to the States in greatest need, as was seen in the success of Janani an NGO in Bihar. The past record on the whole has neither been inspiring in advocacy nor successful in outcomes. Social marketing as an addition to public systems and pure commercial channels should be developed after careful guidelines are laid down to make it -

5.16 The Group could not discuss the matter further in depth as details of the proposed strategy could not be made available by the Ministry. The group will recommend therefore - that while the social marketing is desirable in principle full public debate should take place on the finalized draft strategy before it is implemented even though it may have been prepared consulting stake holders. The group will also suggest that as far as possible all efforts should be made to support the emergence of local organs of civil society and similar motivated groups to cover specific regions or neglected social segments and prevent organised marketing firms using social marketing as a second string to the bow. The group will also point out that social marketing and the strengthening of the existing health systems approach require different IEC back up- and may entail different expenditure patterns, the one geared to large sums for mass media, and the other more to local structures and community based low cost communication.

Information, Education & Communication (IEC)

5.17 Within the existing health delivery system, IEC must be viewed as an integral strategic partner. It has to be integrated within the training and functioning of all health providers. Mass media campaigns can create an enabling environment, on which inter personal communication can clinch the desired change. The challenge is to make the massive army of health workers within the health sector effective as primary communicators and support a functional minimum package of services for daily ailments, the major communicable diseases and RCH. Unmet need would be easiest tackled if that reduces maternal risks at child birth - an approach which individuals and communities would offer practical support to implement. Mass media has a critical role to play but the most effective communication will often be from person to person be the most telling communication of all.

Health risks of fertility are greatest for the mother when she is too young, too old, having births too close or too many. The distribution of births by birth order according to NFHS is 29 per cent of all births -first order, of which births to married adolescents are contributing almost half; 26 percent second order; 18 per cent third order and 28 percent or more than 1 in 4 births are of birth order four and above. The strategy of avoiding the four toos -too early, too late, too close, too many for the health and well being of the mother and the child -has remained an effective approach (and communication tool) in many countries.

5.18 The group will recommend -

Presently more than four fifths of all births in India fall in the following category - they are occurring either too early (19 percent of births to married adolescents), too close (28 per cent within 24 months; 13 per cent within 18 months), too many (28 per cent four plus; 46 percent 3 plus) and too late (7 percent after 35, but a significant number of high order births in the early thirties, also late twenties). A four toos campagned would be worth while.

The group will also recommend that- sex education should be provided to adoloscents within a positive values framework and provided in a manner that is not provocative or Population and AIDS Prevention Education including sex education as appropriate to age, must be made compulsory for the young. NCERT and all other training materials need to be urgently reviewed.

5.19 In this connection the group noted excellent examples of practical strategies that will greatly increase acceptability of contraception. In Gandhigram the sterilization ward was virtually a "mother's home" because an excellent doctor, aseptic operation arrangements and aftercare in a non hospital like setting with local food and permission to feed a family attendant and accompanying little children alongside; Or at Jamkhed aseptic conditions for surgical interventions, camping facilities and a strong volunteer force of women workers increase acceptability; in Orissa enterprising PHC doctors have stretched POL by encouraging local bullock carts and providing chara -follow up visits -which increases the mobility of the ANMs.

6. Linking to New Opportunities

Emergency Contraception Facility:

6.1 The sub group noted that as recommended by the National Consortium on Emergency Contraception the use of the "morning after" pill in the country is being tested by the ICMR through operations research projects with the collaboration of 12 medical colleges in different parts of the country. The results are awaited. Parivar sewa Sansthan too has brought out its own morning after pill, called No Preg, and has sought a no objection from the Drug Controller of India for social marketing of this pill. It was also noted that Use of IUDs can also be used as an emergency contraception. During 2000, the Population Council completed a media campaign on Emergency contraception a manual on emergency contraception has been widely disseminated to users, service providers, and policy makers in India, and has now been adapted for use in Bangladesh. Efforts are continuing to make abortions safe in the country. The subgroup was informed that following a recent National Conference several recommendations intended to make early abortions safe and accessible are being reviewed. Including an amendment devolving powers of approval of the premises and the provider for carrying out medical termination of pregnancy to the district level, instead of the earlier state level.

The Right to Information

6.2 No intervention at the grass-roots is perceived as sustainable unless the community develops a stake in both the process and in the final outcome. On May 1, 2000, the State Assembly enacted a law that gave the people the right to information in all spheres of governance. This simple but powerful mechanism of transparency had revealed undeniable proof of corruption through the social audit held in the gram sabha held in the presence of the Zilla Parishad - a rare synergy among PR institutions. The group noted that a Central Bill on the Right to Information has also been tabled in Parliament which will ensure that there would be stiff penalties for non - compliance by bureaucracy and exemption clauses must be extremely restricted and unambiguous and suo moto display and dissemination of information must be mandated by the Act, to enable transparent governance.

6.3 The relevance of this for quality and accountability in delivery of service for family welfare and for unmet need for contraceptives in particular, cannot be ignored. What can be done is to map the location, address and title of every health facility -public, private, allopathic, homeopathic, and the Indian Systems of Medicine. These can be made available free of cost for distribution through the voluntary sector, community groups civil society organs and public outlets like post offices. The precise facility provided for citizens -be it information, education, and counselling, or routine vaccination and services for contraception, or pre-natal and post natal check ups care and delivery points should be unambiguously indicated. Attendance of staff at public sector health institutions, such as Doctors and ANMs can also be verified by the community. There should also available on demand a listing of the supplies received / purchased / stocked in the public health facilities at regular intervals. The community will develop a stake in pre-empting stock - outs. This may become a precursor to levying user fees, to facilitate local purchasing ability. Finally, there should be information on the availability of emergency health products such as oral dehydration salts for infant diarrhea, contraceptives, simple medication like paracetamols, antiseptic creams, anti -nausea remedies and so on.

6.4 The unmet needs of a community are best appreciated in the context of their social conditions. Indeed there are hierarchies of unmet needs in several spheres and contraception may not rank high in communities starved of basic needs. The importance of the minimum needs programme as a support to family planning is obvious in this context. Access to basic needs and amenities include both individual and social consumption such as food, drinking water, housing, education, employment, transport, communication. Increasingly, the all encompassing nation state coupled with the individual and group competition for scarce resources determines the situation. Political forces play a dominant role in shaping health services, and determining the health status of a community. The critical gap between availability and accessibility of health services has been instrumental in excluding a large proportion of the rural population in India -the marginal communities especially the low caste and the tribal groups -from leading a normal healthy life. Meeting the unmet need for contraceptives, and indeed for all other basic needs and amenities involves a struggle for democratization, just and fair social relations, gender equity.

6.5 About two fifths of India's GDP is said to originate from the informal sector and over 85 per cent of families depend on this sector for their livelihood. Nevertheless a large number of workers from the informal sector, in both rural and urban areas are illiterate, poor, living in unhygienic conditions and susceptible to innumerable infectious and chronic diseases. They also need timely and effective family planning services. Among them unwanted pregnancy is bound to exist, apart from a general desire for spacing in what way if at all can insurance help ? In the first place there are the costs of hospitalisation for maternity, which are usually not covered as a risk. There could also need for induced or natural abortions or complications arising out of the practice of contraception methods. There could also be innovative insurance against death during operation or against failure and birth of a child after sterilisation.

6.6 Insurance sector has been liberalised. And foreign investors are partnering Indian companies for general insurance Private voluntary health insurance will become more important in both funding and provision of health care including RCH services. The metro and urban demand for health insurance will be more attractive for commercial reason. Most of it would also be covered for hospitalisation expenses. Insurers should be required by the regulator to innovate new products to cover problems connected with fertility control and maternity. Health insurance may not also cover small town and rural remote communities or broad health care including outpatient maternity and child health needs. The number of exclusions, levels of premia and difficulties in rapid settlement of claim will present problem. In far flung communities it may be appropriate to adopt community risk assessment. But insurance cover in respect of RCH services, especially maternity services is urgent and relevant. Sensible and constructive regulations of general Insurance Industry will help develop community based new insurance products appropriate to different areas.

6.7 A majority of poor households, especially the rural ones, reside in backward, hilly and remote regions where neither government facilities nor private medical practitioners are available. They depend on poor quality services provided by unqualified practitioners and faith healers. Wherever accessibility is not a problem, the primary health centres may not be providing quality services. Developing and marketing of unique and affordable health insurance package for low income people would be a challenge especially if individuals are rated for risk. Instead community risk assessment should form the basis for a selected number of common illnesses. But it must include out patient treatment and also maternity. The group noted efforts in the voluntary sector Since 1992, SEWA has introduced a unique integrated insurance plan for their petty members mainly engaged in petty occupations. By paying just Rs. 65/- as premium, a poor woman gets coverage for health and maternity benefits, life coverage and asset insurance. There appears to be a strong preference for SEWA type of health insurance scheme that beneficiaries is not only affordable but also accessible in terms of easy settlement of claims and other related administrative procedures. The range of services for which coverage is sought include hospitalization, maternal and outpatient facilities. If transportation could be included, there would be many more takers. How far will it provide a model for community rated community based cover for ordinary illnesses and maternity remains to be seen. regulator can require of companies to create products for specific segments. They should also be asked to devise schemes that panchayats can run with the backing of re-insurance by larger insurance companies and can be used for identifying targeted groups for subsidizing primia. In terms of management of a health insurance scheme, there is a marked preference for some version of community financing. Management of health insurance by panchayats may also be feasible with a scheme where the disbursement of services will take place from a public sector hospital with monetary contribution from the beneficiaries.

Putting Health on People's Agenda

6.8 The group will point out to the rising movement for putting people's hands in many countries as a source of much innovation.. The group will suggest that such examples in India may be studied for encouraging local initiatives.

6.9 For instance it would like to cite the case of the work of Kashtakari Sanghatna, an organization of tribal working people in Thane district, in getting local women trained as health workers and getting Government to nominate them all of them as hamlet level volunteers, to receive medicines from public health supplies, and a small honorarium for distribution during the monsoon season in spite of resistance from village level vested interests and inertia from public health system. From mid - 1999, a WHO supported project for "empowerment of the rural poor for better health", was conducted in 6 talukas in different parts of the country. The idea is to make local health functionaries accountable to the village people. A health calendar containing certain key health messages has been published. Teams moved from hamlet to hamlet displaying exhibitions on health issues. ANMs and other functionaries informed the people their monthly work schedule for each village, so that their absence could be noted by members of the village health committee. Another aspect of this unique grass roots initiative was to generate awareness about medical malpractice like the unnecessary use of injections and saline infusions and accountability of public health services and to draw attention upon the basic rationality of private medical care. The community took on the responsibility of re-educating doctors on rational care. An "Arogya Padayatra" or Health March saw people led by health activists visit and argue with private doctors, even demand to examine their degree, put up posters in their clinics demanding a commitment that they will not charge in excess of the rates [as indicated] for a given service.

Question of public importance could then be raised meaningfully -such as, why does the hospital not have in its stocks all the medicines required? Why do certain staffs demand money for services? Why do staffs behave badly with patients coming from hilly displaced populations, tribals, and the very poor? Why are immunizations not regularly given? Why does the ANM from the PHC and even from the SC not visit large numbers of hamlets? The PHC doctor is asked to display her full schedule of visits, and to ensure that the ANM regularly visits all hamlets.

The lesson clearly is unless the village community is involved in the process of supervision and functioning of the whole primary health care system to make it accountable to the users, there will be no real accountability. Any other intervention will remain tinkering at the margins.

6.10 In this connection the group considers that Panchayats can play a key role in many ways to reduce unmet needs. Panchayats have been increasing control over the primary health care system. But this position has been uneven in results on the ground. Health providers and administrators by and large have given a guarded welcome. Panchayati Raj institutions themselves have not managed to play their new role with clear understanding of health priorities and delivery systems. Panchayats represent a power structure after all and can be hierarchical tending to marginalize its own women members as well as those in the community. Introducing norms and transparency in panchayat control over health staff, and giving them the responsibility of ensuring delivery of health care at village level, would be critical for making the relationship mutually supportive and non-exploitation. Hence a graded set of tasks of importance to specific aspects of family welfare could be assigned. A series of feasible supervisory and record keeping task can entrusted. This will gradually help Panchayats to ensure accountability.

6.11 Take for instance the issue of maternal mortality. The group would suggest the following tasks be entrusted to Panchayats -

Second it can actively register pregnancies and monitor the provision of maternal health care by the primary health care system. Panchayat members may monitor entitlements in the card issued to each pregnant women.

Third it can review maternal deaths occurring in the area, ascertain whether deceased woman received the card and essential services.

Fourth they can add a column on whether the pregnancy was unwanted or mistimed.

Fifth it can help the health system to better supervise the performance of its field personnel.

Sixth it can act as a tool for health communication.

Seventh Service providers can also use the card as a clinical record of the woman's health status through the maternal period especially important if the woman is referred to another level of care. Lastly, the card guides decision-making on place of delivery and referral.

6.12 NGOs or community groups can help the panchayats by popularizing the card, reviewing its utilization and by carrying out verbal autopsies of maternal deaths occurring in the area. The card and incremental orientation-training activities may be funded either through government or external agencies. Another option is for the panchayat to nominally price the card for cost recovery (it costs about Rs. 2.50 to print a card with transparent polythene cover).

For reviewing maternal deaths, selected residents of the panchayat or a local partner NGO may be trained to carry out simple verbal autopsy. Review of maternal deaths by the panchayat will include information on whether the pregnancy was (possibly) unwanted or mistimed, the extent to which the deceased women received routine and emergency maternal health care, and the social and economic circumstances that contributed to her death.

Tackling Teenage Motherhood -

6.13 Child Marriage is a common phenomenon in several states of north India. It is followed by a formal "gauna" ceremony a few months to years after puberty, whereupon the couple begins to cohabit. As a consequence, most girls become sexually active around mid- adolescence and go through pregnancy and childbirth while still teenagers. Child marriage and sexual initiation violate human rights, since they occur without the free and full consent of the child or adolescent. A lack of political will and practical difficulties (for example in establishing that marriage and not merely engagement has occurred) have prevented the effective enforcement of the Child Marriage Restraint Act. Thus adolescent sexual activity is the norm for most girls, largely within marriage. Most girls (and their husbands) are either unaware of the consequences of teenage pregnancy, or lack access to information or services for contraception. Apart from being a health hazard and personal burden, teenage pregnancy is a manifestation of the lack of reproductive choice among adolescent girls. In addition to legislative a targeted public health approach can be considered taking sequential steps to delay "gauna" among those who have been married, delay pregnancy (to beyond adolescence) among those who have started cohabiting, and provide priority maternal care to those who have nevertheless become pregnant while still teenagers.

Suggesting later marriage and family size at two through spacing and ending fertility at thirty.

1. Interventions to meet unmet need should not be viewed as an isolated vertical program component within the RCH program. Instead they should be seen an integral part of delivery of basic reproductive and child health services and embedded into the country's public health and associated nutrition and child development and schooling infrastructures. Only such synergy can make our efforts optimal and cost-effective. Contraception would then be seen not as an end in itself but as a tool to achieve larger aims. This perspective on contraception in NPP 2000 should inform the examination of the issue of meeting unmet need.

First, strengthen existing strategies and sharpen the focus of existing public health infrastructure, for in the near term it will have to bear the brunt of the effort.

Second, expand the basket of choices and improve easy availability of wider choice through more channels for distribution

Last, link family planning services to new opportunities arising from decentralisation and economic reforms and minimum needs and link feasible program goals with panchayats to ensure accountability.

3. The following areas of intervention need attention -

# strengthen and maximise use of public health infrastructure and expand arrangements for counselling, and organisation of supplies and services with greater flexibility and responsiveness.

# improve penetration into rural areas, urban slums, among vulnerable groups, and cover all areas of unmet need, with better quality and follow-up.

# additional Central funds and monitoring attention must flow into the five lagging States to bring them upto NPP national targets

# expand private - NGO - community -public partnerships, as feasible carefully ensuring that accountability is clearly established.

# expand the current basket of contraceptives to include lower dose OCPs, and other long acting spacing products after appropriate field testing / clinical/acceptability trials and escort them to acceptance.

# promote appropriate social market channels subject to guidelines and apply feasible segmentation techniques for better distribution.

# redesign IEC aspects, including face to face counselling and followup.

# link with new opportunities arising from economic reform and decentralisation.

4. High CPRs need not necessarily lead to low TFR. Even if the percentage of unmet need is less than earlier, the absolute number of women will be much larger. This estimate needs to be finalized by the Ministry State wise.

5. A view prevails that the definition of unmet needs should be broadened and that modern segmentation of market techniques should be applied to promote methods aggressively. The question is whether this is an opportune time for doing so.

The group would see the balance of convenience to lie in working along the present definition till near term goals in the lagging States are met. Any broad based definition must get debated more widely in a series of participatory processes, involving diverse stakeholders including policy- makers, researchers, NGOs and the community.

Similarly new contraceptives must be added to the programme by including proven technologies but arrangements should exist side by side for informed choice follow up and counseling.

6. ISM &H practitioners could be trained in the basics especially on counselling for promoting a small family norm Their involvement will extend the workforce and increase coverage and if otherwise professionally good his voice will influence decisions of household and community opinion leaders.

7. There is need for due attention to quality in all methods and in creating safe back-up abortion facilities to help meet part of unmet needs. To meet unmet needs in remote areas and urban slums of past neglect we may need patient path-breaking NGO activity using self help groups and community based distribution which should be fully supported. As standards of living rise the demand for services will undergo change and programs should be nimble enough to meet them. A purely marketing segmentation approach by social class may be inappropriate to the complex nature of the problem.

8. With differing needs and preferences among users and a cafeteria of services being available it is important that public information is fully available on new methods and also about the precautions before the launch to minimize controversies based sometimes on misinformation. It is equally necessary to ensure that the choices in contraception remain informed choices in letter and spirit.

9. The group will also recommend that -

# special training programs must be organized to inculcate contraceptive safety skills at all levels especially for ANM so that they can help in making informed choices.

# well thought out supportive counseling and follow-up services should be essential elements to ensure quality care, particularly for reversible method

# special efforts should be made to encourage men to take responsibility for family planning in the context of the importance of having their support for the program in a male dominated society.

# For new contraceptives an user escort system of giving information and support may be made into an additional requirement for protection of user Products such as Gynae-Fix (said to offer a protection for 18-20 years) ad ut 380A (offering protection for ten year) may be tried out in the country if and when found safe and efficacious under the law as if accepted they can over a period reduce the need for sterilisations.

# Sex education should be provided to adolescents within a positive values framework and provided in a manner that is not provocative or Population and AIDS Prevention Education including sex education as appropriate to age, must be made compulsory for the young.

10. The Group welcomes the intention of Government to develop a new strategy for social marketing but could not discuss the matter further in depth as details of the proposed strategy could not be made available by the Ministry. The group will recommend that there should be full public debate on the finalised draft strategy before it is implemented. The group will also suggest that social marketing strategy should support the emergence of local organs of civil society and similar motivated groups to cover specific regions or neglected social segments and prevent organised marketing firms using social marketing as a second string to the bow.

11. The group recommends that for all new contraceptives an escort system may be made suitably for protection of users. Other spacing products such as Gynae-Fix (said to offer a protection for 18-20 years) may also be tried out in the country if and when found safe and efficacious under the law. as such long acting contraceptives can reduce the need for sterlisations.

12. Unique and affordable health insurance package for low income people would be a challenge. Community risk assessment should form the basis for a selected number of common illnesses. The cover must include out patient treatment and also maternity. The regulator has a key role in ensuring this.

13. There is a rising movement for the right to information and putting people's hands in many countries. Both could be a source of much innovation and should be encouraged. Panchayats can be a positive factor in ensuring local accountabilty. The case for such a role in maternal marketing is set out.