Programme objectives:

i)

Within the overall umbrella of reducing infant, child and maternal mortality, the specific objectives of RCH I were as follows:

(a)

Improve management performance by nationwide implementation of policy change referred to as the "participatory planning approach,"' and institutional strengthening for timely, coordinated utilization of project resources;

(b)

Improve quality, coverage and effectiveness of existing FW services;

(c)

Progressively expand the scope and content of existing FW services to include more elements of a defined package of essential reproductive and child health (RCH) services;

(d)

In selected disadvantaged districts and cities, increase access by strengthening FW infrastructure while improving its quality.

Programme performance:

I

Overall achievements

RCH I Project is a complex project covering a wide gamut of reproductive and child health services whose impact is influenced by a wide variety of operational, systemic, governance, socio-economic, cultural issues both intrinsic and extrinsic to the sector. Impact in terms of outcomes like maternal mortality, fertility also can't dramatically change over life of a medium-term project such as RCH I, therefore, the project has rightly laid emphasis on process indicators for measuring the improvement attributable to it.

Although baseline for the project is available in terms of Rapid Household Surveys carried out during 1998-99 covering the entire country, similar endline surveys are available only for 294 districts carried out during 2002-03. Although the two surveys are not true representative of baseline and endline, however, their proximity to these time-points as well as the fact of slow start-up of the program enable us to use them for measuring the achievement of the program. A comparison of key indicators based on results of 274 matched districts is shown in Annexure I . As endline survey was made two years prior to actual completion of the project, therefore further improvement and correction of negative trends is not ruled out.

Maternal Health : Percentage of women receiving any ANC rose by about 12 % to reach 77.2%. Proportion of women delivering at home declined by 6.9 %, whereas that in institutions rose by 12.9% to reach 46.9 %. Surprisingly, delivery in government institutions declined by 5.5 % to 18.5 %. Most surprisingly, it is the women in the better placed states which have deserted the government institutions the most ( decline in % delivering in government institutions for Andhra Pradesh, Kerala, Karnataka, Maharashtra and Tamil Nadu are 9.8 %, 28.9 %, 10.2 %, 9.1 % and 15.3 % respectively). It may be due to the fact that rising aspirations of service quality may not have been matched by the public facilities. There has been a very modest increase in home deliveries being attended by trained persons (1.3 %), whereas safe delivery i.e. assisted by health professional rose by 7.9 % to reach 47.5 %. The proportion of women with 1 post-partum visit instead of improving declined marginally (1.4 %) to 12.7 %, again an effect of declining home visits.

Family Planning : Comparison of the two indicate contraceptive prevalence increasing by 3.3 % to 52.0 %, while that due to spacing method rose by 3.3% to 10.7 %, while that for permanent methods remained more or less same. While the CPR rise is welcome, lack of rise in permanent method CPR and likely rise in traditional methods CPR are causes of concern as is slowing down of improvement in CPR, which(as per NFHS data) rose by 10 % points between 1992-93 to 1998-99. It may be largely due to the fact that programmatic attention to family planning declined during the period both in terms of management attention and inputs. It is significant that operational definition of RCH as CSSM + RTI/STI + adolescent reproductive health left out family planning. Overall unmet need for contraception declined by 3.6 % to 15.9 %.

Child Health: The child health component aimed at bringing down sharply the infant mortality by addressing neonatal care apart from consolidating the immunization and protection against diarrhea and ARIs. Infant mortality came down from 71(SRS 1997) to 63(SRS 2002), but not to the extent expected. The NNMR is also showing a declining trend, but its ratio to IMR stays put at ~ 65 %, reflecting probably better coverage of programs, but not the extent of services or quality.

The immunization performance is a cause of worry. As per RHS data, full immunization coverage declined 52.0 in 1998-99 to 44.6 % in 2002-03. Disaggregated data show decline of 7.1 % in coverage with 3 doses of DPT and 9.1 % in that of polio. This has to be viewed against the fact that an initiative for improvement of immunization program ran along side the supporting polio eradication activities which aimed at increasing full immunization coverage by 5 %. Probably deteriorating outreach is a cause as may be low profile of routine immunization. The proportion of women visited by any health worker during 3 months prior to survey has declined by 9.6 % to 10.1 % during this period.

Polio incidence has come down from come down from 1931 in 1998 to 136 in 2004. From being spread allover India , it has been localized to some pockets in Bihar and UP, although eradication target slipped by. A variety of factors including socio-cultural belief, health system weaknesses and overdose of polio IEC may have been responsible for this.

The awareness of diarrhea management and ARI danger signs have also gone down slightly (2.3 % and 4.8 % respectively) reflecting lack of emphasis. Lack of due attention may again have been the cause.

Sub - Projects : The RHS surveys have showed that institutional and safe deliveries increased in large majority of 9 projects for which matched data is available. However, full immunization coverage has decline in 8 out of 9 sub-projects, in 5 sharply. The performance in FP and home visit was found to be mixed. Because of likely data problems, evaluators have employed pooling of data and on that basis have reported that 4 sub-projects reached state average, whereas remaining lagged in one area or another. Sub-projects in Mehboobnagar and Murshidabad could not close the gap between them and the state average in any area.

The Statewise status of the key indicators is given at Annexure II .

It is worth mentioning that one of the key goals of the RCH I was to reduce the disparities in RCH between the regions, socio-economic groups, etc. However, comparison of RHS data for EAG states for both the rounds of surveys (Bihar, Chhatisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh, Uttaranchal) indicate no reduction in disparities in RCH status.

Cost and expenditure

The total expenditure incurred under the programme (1997-98 - 2003-04) was Rs.5288.99 crores. The external support was Rs.4138.82 crores while the domestic budgetary support was to the extent of Rs.1150.17 crores. The external support was provided by the World Bank (Rs.1933.63 crores); European Commission (Rs.531.64 crores); DFID (Rs.919.08 crores); Kfw (Rs.208.64 crores) and UNICEF (Rs. 545.83 crores). Out of the total expenditure of Rs.5288.99 crores a sum of Rs.5073.63 crores was provided to the States as cash and kind support under the programme while the balance amount of Rs.215.36 crores was used as Central support for the programme and included expenditure on activities such as NGO, training, surveys, etc.

A statement showing Statewise support extended under the programme is at Annexure III and a statement showing break up of the expenditure activitywise is at Annexure IV .