The family planning programme in India is both unique

Transcription

1 Family Welfare Programme in : Expenditure vs Performance P Arokiasamy, Chander Shekhar, K Srinivasan, Srinivas Goli Since the launch of the reproductive and child health policy regime in , there has been a massive rise in government expenditure on family welfare programmes in. This paper makes a systematic effort to assess the performance of the family welfare programmes vis-à-vis the trends in expenditure. The trends in key performance indicators for and selected states reveal that progress has been slow and limited in the post-rch policy regime. Child immunisation coverage has decelerated, and the increase in the contraceptive prevalence rate and institutional delivery coverage have stalled. Consequently, the pace of reduction in the total fertility rate and infant mortality rate has slowed. Overall, the progress in key programme indicators is found to be incommensurate with rising expenditure. P Arokiasamy (parokiasamy@yahoo.co.in) is with the Department of Development Studies, International Institute for Population Sciences, Mumbai, Chander Shekhar (shekhariips@rediffmail.com) is with the Department of Mathematical Demography & Statistics, International Institute for Population Sciences, Mumbai, K Srinivasan (ksrini_@yahoo.com) was earlier director, International Institute for Population Sciences, Mumbai, and Srinivas Goli (sirispeaksu@gmail.com) is a doctoral student at the International Institute for Population Sciences, Mumbai. The family planning programme in is both unique and first of its kind in the world. Since its historic initiation in 9, the programme has changed in terms of policy intended and stated approach to actual programme implementation. The programme has evolved in terms of varied approaches from the clinic approach mode during 9- to the current reproductive and child health (RCH) approach. The RCH approach was rolled out on an experimental basis in 99 and formally launched in 997. This strategic shift in the programme approach resulted from the recommendations at the International Conference on Population and Development (ICPD) in Cairo by the United Nations in 99 and was a signatory to the programme of action (POA). In the aftermath of the ICPD, the existing national programme of family planning/welfare seeking to achieve predetermined demographic goals of low fertility and population stabilisation were considered too centralised and anti-feminist. This modification of the programme in accordance with ICPD recommendations was formally termed as the Target Free Approach (TFA). In this approach, all predetermined targets were removed and it was recommended that all programmes aimed to improve the health of women and children must be implemented as a part of an integrated package of services to meet the reproductive health needs and rights of women (Srinivasan et al 7). Since the launch of the RCH programme in, there have been persistent and often contentious debates among population and health experts over its successful implementation in developing countries. Critics have raised doubts as to how these concepts will be operationalised in patriarchal societies like with male-dominated, hierarchical services delivery systems. Some of the earlier studies that examined the implications of the new approach to family welfare indicators mostly addressed methodological problems (Salunke and Narvekar 997; Kothari et al 997; Ghasura et al 997; Mavalankar 997; Srinivasan et al 7). However, there has not been a serious evidence-based comparative assessment of the proportionate rise in expenditure versus the performance of RCH approach under family welfare programme. In an earlier attempt of reviewing RCH programme in, we found that since 997 the expenditure incurred on the RCH programme, both at an aggregate level and on per capita basis, increased substantially compared with pre-rch regime (Srinivasan et al 7). This is on an account of the steep rise in planned allocation and possible loans which were liberally made available by the World Bank. Under the broad umbrella of the RCH programme, which includes maternal and childcare services, family Economic & Political Weekly EPW october, vol xlvi no 7

2 planning and immunisation programme, the government expenditure has been more than doubled compared with pre-rch policy regime. Nevertheless, stated disturbingly as a matter of fact, the contraceptive prevalence rate has been practically stalling and the immunisation levels have been either decelerating or on the drag. In this context, our objective in this paper is to pursue a more comprehensive examination of comparative trends in expenditure on family welfare programme vis-à-vis performance in programme-related indicators for as a whole. We also conduct state-specific assessments for, and Uttar Pradesh which are at different stages of development and health performance. Such continuing assessment is critical in terms of policy review, reorientation and action. We revisit the recent changes in family welfare programme and examine if the quantum increase in family welfare expenditure has been effective in contributing recognisable change in terms of key RCH and family planning performance indicators for and for the three selected states. Data and Methods We have used multiple data sources in this study to assess expenditure on family welfare versus family planning and RCH programme performance for and selected states. States have been selected based on varying stages of progress in key indicators. A composite index of key family welfare performance indicators is used to classify states on the basis of level of development such as low, medium and high. Three states with high (), medium () and slow (Uttar Pradesh) progress in key performance indicators have been selected for the study. The various sources of data and methods of analysis include: first, at the aggregate level, we have compiled family welfare expenditure data available from the union budget of Ministry of Finance, Government of. The union budget documents provide data on outlays and actual expenditure on various budgetary components. Family welfare programme outlays and actual expenditure data are given under the health and family welfare section. Second, scheme-wise expenditure data have been compiled from the official statistics and data published in family welfare year books (98-) by the Ministry of Health and Family Welfare (MoHFW), Government of. The state-level expenditure data were collected from the family welfare departments of respective state governments for the three selected states. For the present study, we have compiled family welfare expenditure data from all the subcomponents into four major schemes. This data allows comparison and correlation of data on family welfare indicators with expenditure data of identical schemes. The types of schemes listed in expenditure under family welfare programme in include the following: () direction and administration, () training, () family welfare/ 8 MCH/transportation/mass education, and () services/supplied and other expenditure. Under the programme of training, there are two subsections: basic training schools and research institutes. The third programme includes rural family welfare centres, subcentres, maintenance of urban family welfare centres, urban revamping scheme (health posts), maternal and child health, reproductive and child health project, immunisation strengthening project, procurement of cold chain equipment, sterilisation and IUD inserting, information, education and communication, village health guide scheme, transport, contraceptives, non-scalpel vasectomy, travel of experts/conferences/meetings, sterilisation beds, etc. The fourth programme includes free distribution, social marketing of contraceptives, logistic improvement, Hindustan Latex Limited, school health scheme and other. For comparability, the expenditure data has been adjusted to account for inflation rates by using wholesale price index (WPI) from to - (base year 98-8). Third, we have used data from three rounds of the National Family Health Survey (NFHS) to estimate key performance indicators by different socio-economic groups for a trend analysis. Fourth, official statistics on family welfare programme performance published in family welfare year books for different years (98-) of MoHFW have been used to assess the performance outcomes based on key demographic indicators total fertility rate () and infant mortality rate (). Family Welfare Expenditure in The programme implementation cost for family welfare programmes are generally met through (a) budget outlays of the central government, (b) contribution from the respective state governments, and (c) international donors and bilateral support. However, to assess comparable trends in the aggregate expenditure, Table : Budget Estimates, Revised Estimates and Actual Expenditure under Family Welfare Programme in (98-87 to -, Rs in lakh) Year At Current Price At Constant Price Budget Revised Expenditure Shortfall/ Budget Revised Expenditure Shortfall/ Estimate Estimate (Actual) Excess Estimate Estimate (Actual) Excess 98-87,,99, 9. 9,8.8 9,78.8 9, ,8 7,8 7, -8.,87. 9,7. 9, ,99,99,9,9 -,7.,89,98.,9.,98.9 -, ,9,79, 7. 9,. 8,. 8, ,9 78,79 78,9 9.,9.,9., ,89 8, 8,7 899.,.9,8., ,,,,,,9,97.,7,.,8., ,7,,7,7,9,9 -,7.9,.,9.,7. -, ,,,,8,, 88,.8,988., ,8,,,,, -.8,8.,9.8, ,,,,7,, -,. 8,79. 9,7. 9, ,8,9,8,9,8, 79.79,8.,8., ,8,9,,,,7-8,97. 7,9.9,9.,79.7 -, ,9,,,,9,97,. 8,8. 8,9.7 8, ,,,,,9,,989. 9,9. 8,9. 8,9.,88. -,,,7,,,9 8,.,,9. 9,9. 9,.,. -,9,,,,9,,7,9,8.8,,. 9,7.8,. -,9,,7,,,97 9,7,,99.,7,8.9,,.,9. -,78,,,,8,9,79,,.,,99.,,7.8 9,.7 -,,,,,7,,77,,.,,787.9,7,.8,7. () Expenditure in rupees (in lakh) at constant prices (based on WPI 98-8). Source: Expenditure data compiled from the statistics released by the Family Welfare Programme in, Year Book, MoHFW, Government of, New Delhi. october, vol xlvi no EPW Economic & Political Weekly

3 in this paper we use central government budget outlays and actual expenditure because access to comparable and reliable data from other sources is limited and scanty. It is assumed that the contribution from the international bilateral support for family welfare programme in is not significant. The family welfare expenditure from budget outlays and actual expenditure reported during to - for are presented in Table (p 8). Trends provide evidence that from the pre- to post-rch periods, at the aggregate level, budget outlays and actual expenditure have increased twofold. The year 997 marks a breakthrough point in terms of family welfare budget outlays and expenditures. The steep hike in family welfare expenditure coincides with an introduction of two-stage programmes launched by MoHFW-RCH in 997 and National Rural Health Mission (NRHM) in. The post-rch (after ) stage is in contrast to pre-rch (before ) period where shortfalls in budget outlays over expenditure are signi ficant and a regular phenomenon; in contrast, in the post- RCH period, evidence points out a significant excess of budget outlays over expenditure. The RCH regime, therefore, facilitated a historic shift in the central government budget outlays for health and family welfare. At aggregate level, a scheme-wise assessment of family welfare expenditure indicates that the share of core family welfare expenditure in total expenditure has shown a remarkable increase from pre- to post-rch period. The average family welfare (F)/total (T) Figure : Ratio of Core Family Welfare Expenditure to the Total Family Welfare Expenditure during Pre- and Post-RCH Policy Regimes, and Selected States ( to -) ** 89** 9** ** 89** 9** * * Annual expenditure is calculated as two years moving average, that is the average of the preceding and succeeding years; ** Expenditure data compiled from provisional data on family welfare expenditure. () Expenditure in rupees (lakh) calculated at constant prices and based on WPI () F/T ratio is computed from expenditure (rupees in lakh) incurred on core family welfare expenditure and total expenditure includes family welfare, MCH, transport, compensation and mass education to that total family welfare expenditure. Source: Expenditure data compiled from statistics released by Family Welfare Programme in, Year Book (98-), MoHFW, GoI SPECIAL ARTICLE ratio doubled from. in to.7 in 998- for (Figure ). This increase is obvious due to an increase in domestic funds for family welfare programme after the introduction of RCH programme in 997. The major shift as a result of the integration of family planning and RCH service provision also led to a sizeable increase in expenditure of the core family welfare programme in the post-rch period. However, state-level assessments for the three selected states show different scenarios. While there has been a drastic drop in core family welfare expenditure for initially and a rise in later stages, shows a slower rise in core family welfare expenditure. Overall, family welfare expenditure has increased substantially and continues to rise in the departments of core family welfare programmes such as mother and child health (MCH) 997, mass education, RCH (997) and NRHM (). Comparatively, less increase is seen in other schemes such as administration and training expenditure from pre- to post-rch period. Evidentially, two out of the three components show fluctuating trends in family welfare expenditure for and selected states. Whereas showed a sharp declining trend in the expenditure on supply and services component of family welfare, rose notably. The scheme-wise expenditure data for Uttar Pradesh is not available. Similarly, there is stagnancy in the flow of expenditure for training component of family welfare for and the two selected states. The expenditure on direction and administration head showed a steep rise until - and thereafter a sharp cut Table : Number and Percentage of Indicators Showing Slower Progress in the Post-RCH Than Pre-RCH Period by Three Selected Category of Indicators, (99-9 to -) Background Characteristics Marriage Family Maternal and Percentage of Indicators and Fertility Planning Child Health Showing Post-RCH A() B(7) C() Progress Lower Than Pre-RCH Progress Place of residence Urban 8.7 Rural 7. Caste/tribe Scheduled caste 9.7 Scheduled tribe. Others 9 7. Religion Hindu 8. Muslim 9. Others 9.7 Education No education 8. Primary 9 8. Secondary.7 Higher.8 Wealth index Poor 9. Middle 7.8 Rich Percentage of indicators showing post-rch progress lower than pre-rch progress has been calculated in two steps. Step is estimating the number of indicators showing lower progress in - than in 99 under three major schemes (marriage and fertility, family planning, maternal and child health) of family welfare programme. Step is the estimation of the percentage of indicators showing post-rch progress lower than the pre-rch progress by using the formula [(A+B+C)/)*]. Source: Estimates based on NFHS data, and. Economic & Political Weekly EPW october, vol xlvi no 9

4 Figure : Trends in Family Welfare Expenditure (in lakhs) for Direction and Administration, Service/Supply and Training,,, and Uttar Pradesh (987-), 8, Services and Supplies Services and Supplies Services and Supplies down. This drop is comparatively greater for than for as whole and (Figure ). Family Welfare Programme Appraisal Table (p 9) shows the percentage distribution of selected programme and RCH indicators. At aggregate level, results reveal that the progress in family welfare and RCH indicators has been stagnant in post-rch than pre-rch period, despite the added advantage of NRHM implementation. However, evidence points to clear variations in performance in terms of disaggregated trends in socio-economic strata. First, in urban areas, the progress in the post-rch era was lower than the pre-rch era in almost 7% indicators. Similarly, in rural area, there was virtually no progress in half of the indicators (%) in the post-rch era as compared to pre-rch era. Second, on a positive note, by caste, the largest improvement in the post-rch period is shown for scheduled,,,, 8 7 Services/supplied and other expenditure Direction and administration Training ** 89** 9** Services/supplied and other expenditure Direction and administration Services/supplied and other expenditure Training Training Direction and administration * 89* 9* * Figures taken from provisional family welfare expenditure data. Expenditure (in rupees lakh) is calculated at constant prices (based on WPI 98-8). Source: Expenditure data compiled from statistics released by Family Welfare Programme in, Year Book (98-), MoHFW, GoI.,,, 8 8 Direction and Administration; Training Direction and Administration; Training Direction and Administration; Training tribes. However, very little difference is indicated between Hindu and Muslim religious categories in terms of percentage of indicators showing post-998 progress lower than pre-998 period. Third, variations in the performance of family welfare indicators are significant across various educational groups. For women in the highest educational category, only % of all indicators showed deterioration in the rate of progress in the post-rch period as against 8% in case of women with primary education. Fourth, wealth quintile as a proxy measure of household economic status emerges out to be a key factor in determining the progress in RCH indicators. Households belonging to poorer wealth quintiles showed more number of RCH indicators with better performance compared with those belonging to middle and richer wealth quintile in the post-rch regime. However, in terms of MCH indicators, the middle wealth quintile households indicated the lowest progress in the post-rch era. This assessment points out that for country as a whole, all the marriage and fertility-related indicators registered greater progress in the post-rch era for scheduled tribe. However, for all other caste categories the post-rch progress is slower than pre-rch progress. Among households of all wealth quintiles, marriage and fertility indicators showed a slower progress in the post- RCH than pre-rch period. Compared with the poor and middle wealth quintile households, the richest wealth quintile households registered the least progress in the post-rch period. For all the three selected states, the progress in all the indicators under three major heads declined, indicating a slower rate of progress in the post-rch period. However, the differentials in slowdown of progress in performance indicators persist across various socio-economic groups. The percentage of indicators showing the post-rch progress less than the pre-rch progress was greater in urban Tamil Nadu followed by urban Uttar Pradesh and rural. All the indicators related to marriage and fertility and maternal and child health showed slowdown in progress in the post- RCH period for urban. In all the three states, ruralurban differentials are greater in terms of progress in family planning indicators. The scheduled castes in, scheduled tribes in Uttar Pradesh and other castes in showed greater slowdown in terms of family planning and RCH performance indicators in the post-rch as compared to the pre-rch regime. Both scheduled castes and scheduled tribes of and Uttar Pradesh did not show any difference in terms of progress of maternal and child health indicators in the post-rch period. In terms of marriage and fertility indicators showed the worst october, vol xlvi no EPW Economic & Political Weekly

5 performance (/) in the post-rch period. In contrast to this Uttar Pradesh showed a continuous progress in terms of marriage and fertility indicators in the post-rch period. The differentials with regard to the slowdown in progress of performance indicators in the post-rch period persist between Hindus and Muslims among the states except for, where for both Hindus and Muslims, half of the indicators registered a slowdown in progress in the post-rch period. The Hindus and Muslims of showed the highest percentage of indicators having post-rch progress lower than the pre-rch period. The number of maternal and child health indicators showing the post-rch progress lower than the pre-rch progress is the highest for Hindus ( out of indicators) and others ( out of indicators) in and for Muslims ( out of indicators) in. The number of family planning indicators that registered declines in performance in the post- RCH regime is the highest for the Hindus of and Muslims of Uttar Pradesh. Greater deterioration in the post-rch progress in terms of family planning indicators was observed among Muslims of Uttar Pradesh. Taking into account the post- RCH progress of all the indicators under three major heads, except, Muslims in other two states showed less progress in the post-rch for higher number of indicators (Table ). By educational categories, the post-rch progress under all the three heads of family welfare and RCH indicators showed less progress among women with higher education in, women with primary education in and women with no education in Uttar Pradesh. Only in, fewer indicators registered a decline in progress in the post-rch regime for women with no education as compared to women with higher SPECIAL ARTICLE education. The slowdown in the progress of performance indicators in the post-rch regime is comparatively lower in Uttar Pradesh for all educational categories. The richer wealth quintile households of, middle wealth quintile households of and Uttar Pradesh have shown stagnating progress under all the three heads of family welfare and RCH indicators compared to all other wealth quintiles. However, in a substantial proportion of poor and richer wealth quintile households has also shown slower progress in the post-rch period. Family Welfare Expenditure versus Key Performace Indicators This section examines the linkages between family welfare expenditure and selected RCH and family planning indicators in. Effort has been made to understand how far the increase in expenditures in post-rch era has effectively contributed to the improvements in the selected family planning and RCH indicators. Figure (p ) shows a rapid increase in expenditure in the post- RCH period compared with the pre-rch period, but the progress in selected indicators fail to indicate a significant improvement. In spite of the fact that the increase in expenditure in post-rch p eriod was almost three times more than that in pre-rch period, the percentage point changes in full immunisation, CPR and institutional delivery virtually remained the same as in pre-rch era. An assessment in terms of progress in three selected states reveals that except the family welfare expenditure for and Uttar Pradesh has increased twofold. By comparison, in case of full immunisation, the performance has rather decelerated in the post-rch period for all the three states. Table : Number and Percentage of Indicators Showing Slower Progress in Post-RCH Than Pre-RCH Period by Three Selected Category of Indicators in, and Uttar Pradesh (99-9 to -) Background Characteristics Uttar Pradesh Marriage Family Maternal Percentage of Marriage Family Maternal Percentage of Marriage Family Maternal Percentage of and Planning and Indicators Showing and Planning and Indicators Showing and Planning and Indicators Showing Fertility Child Health Post- RCH Progress Fertility Child Health Post- RCH Progress Fertility Child Health Post- RCH Progress Is Less Than Is Less Than Is Less Than Pre-RCH Progress Pre-RCH Progress Pre-RCH Progress A() B(7) C() A() B(7) C() A() B(7) C() Place of residence Urban Rural Caste/tribe Scheduled caste Scheduled tribe NC NC Others Religion Hindu Muslim Others...7 Education No education Primary Secondary Higher Wealth index Poor Middle Rich Percentage of indicators showing post-rch progress lower than pre-rch progress has been calculated in two steps. Step is estimating number of indicators shows lower progress in - than 99 under three major schemes (Marriage and Fertility, Family Planning, Maternal and Child Health) of family welfare programme. Step is estimation of percentage of indicators showing post-rch progress lower than pre-rch progress by using formula [(A+B+C)/)*]. Source: Estimates based on National Family Health Survey data (NFHS, and ). Economic & Political Weekly EPW october, vol xlvi no

6 Figure : Trends in Family Welfare Expenditure and Selected Performance Indicators for and the Three Selected States (99-), Expenditure* (in lakhs) 8 CPR (any modern method) Full immunisation Expenditure* Institutional delivery Family welfare performance indicators Expenditure* (In lakhs) Expenditure Institutional delivery CPR (any modern method) Full immunisation 8 Family welfare performance indicators Full immunisation 89 Uttar Pradesh 97 Expenditure* (In lakhs)..8 CPR (any modern method) Expenditure Institutional delivery Family welfare performance indicators Expenditure* (in lakhs) Institutional delivery Expenditure CPR (any modern method) Full immunisation Family welfare performance indicators * Expenditures are calculated in rupees (lakh) at constant prices (based on WPI 98-8). Source: National Family Health Survey, and, n Report (99-9, , -) However, progress in the institutional delivery coverage was comparatively better for the states except Uttar Pradesh in the post-rch period. However, a clear slowdown in child immunisation coverage has been observed particularly for and. On the whole, the massive increase in family welfare expenditure could not result in a matching or significant impact on either the utilisation of family planning methods, institutional delivery or childhood immunisation coverage for and the three selected states. Family Welfare Expenditure vs Outcome Indicators In this section, the progress in two vital programme outcome indicators and are assessed vis-à-vis the rise in family welfare expenditure for and the three selected states. For, it is evident from Figure that the decline in was virtually absent between 99-9 and , although the family welfare expenditure increased moderately during the same period. In post for, the expenditure has increased dramatically but the decline in has been stagnant. However, clear differences are seen among the three selected states. In, the comparative trends show a gradual decrease in with corresponding increase in expenditure from pre-rch to post-rch policy regime. In contrast, for and Uttar Pradesh, the increase in expenditure has not shown much impact on decline. For these two states, had declined faster in pre-rch period than in post-rch period. Overall, the massive increase in expenditure during has failed to bring commensurate decline level of in the post- RCH policy regime. Especially, since -, the expenditure trend line and infant mortality rate appeared to be parallel to each other, particularly in and Uttar Pradesh and as whole. Figure (p ) provides evidence of a steady increase in e xpenditure from till and thereafter a steep i ncrease. Comparatively, which considerably declined till 997 registered a slowdown in the pace of decline thereafter. After the introduction of RCH approach, did not show any notable d ecline for four consecutive years (997 to ) despite the sharp increase in expenditure. Also, in the subsequent years, the d ecline in was not significant even though family planning expenditure increased sharply and interrupted. Conclusions In this study, a meticulous effort has been made to determine the effect of the massive increase in family welfare expenditure on key family planning, RCH performance and demographic outcome indicators for as a whole and for three selected states in different stages of health transition. A comparative analysis of evidence during the pre- and post-rch policy regimes revealed that expenditure on family welfare programme has more than doubled during the post-rch policy regime. However, some variable patterns are noted in expenditure allocations. First, the october, vol xlvi no EPW Economic & Political Weekly

7 Figure : Trends in Family Welfare Expenditure and during Pre- and Post-RCH Policy Regime, ( to -) Expenditure* (in lakhs) 8 8 Expenditure* (in lakhs) SPECIAL ARTICLE Uttar Pradesh Expenditure* (in lakhs) Expenditure* (in lakhs) Figure : Trends in Family Welfare Expenditure and during Pre- and Post-RCH Regime ( to -) Expenditure* (in lakhs) Expenditure* (in lakhs) Uttar Pradesh... Expenditure* (in lakhs) Expenditure* (in lakhs) * Expenditures are calculated in rupees (in lakh) at constant prices (based on WPI 98-8). Source: Registrar General, (): SRS Bulletin, Office of the Registrar General of : 987-7, Delhi, Vol (). magnitude of proportionate increase in expenditure is not uniform across all the sub-schemes and among the states. Second, while the expenditure on core family welfare programme has increased swiftly, expenditure on services and supplies which have a direct bearing on key maternal and child health outcome indicators has not kept pace with the overall increase in expenditure for and the three selected states. Trend analysis of key programme performance indicators revealed that CPR is virtually stagnant in the post-rch policy regime for and the three selected states. Progress in institutional delivery coverage was relatively better but slower and smaller in magnitude during the post-rch period. The decelerating trend in immunisation coverage in the post-rch period could be attributed to the sharp decline in expenditure on the supply and services component during the corresponding post- RCH period. Stagnant trends are also evident from the trend analysis of two vital programme outcome indicators and. Compared Economic & Political Weekly EPW october, vol xlvi no

8 with the pre-rch period, the progress in the post-rch period in these two programme outcome indicators is virtually stalled for and the three selected states. State comparisons indicated much slower progress in than in and Uttar Pradesh. The RCH programme approach did not suggest evidence of significant and anticipated effect on any of the selected programme indicators, particularly in medium and less developed states of and Uttar Pradesh, respectively. Beyond this, disaggregated analysis by social and economic background variables revealed a relatively slower progress in key programme indicators for socio-economically advanced population categories, except for educated population category. This is possible for the reason that the potential for improvement among socio-economically advantaged population categories is limited and consequently the programme as expected might have focused on under-served populations in the post-rch period. The systematic comparison of the progress in family welfare expenditure and its corresponding improvement in performance indicators demonstrate that the integration of the RCH approach with family welfare programme in the absence of revised framework of goals (rather than targets) resulted in limited progress in family welfare indicators. It is possible that the proposed integration under the programme is not understood in its spirit and purpose. Compared with the separate welldefined programmes implemented earlier, the RCH approach seems greatly promotion-driven lacking in operational framework with clearly articulated new strategies of programme implementation. There appears to be less integration between different programmes that is supposed to be coming into force when they are implemented under one category. It is evidentially clear that in the absence of suitable mechanism to operationalise RCH approach under the integrated banner of family welfare programme, the exponential increase in expenditure alone cannot lead to commensurate a positive impact on key performance and outcome indicators. Note The initial approach of family planning programme adopted by the Government of was a clinic approach. A number of family planning clinics were opened throughout the country and it was assumed the there was already a strong desire to space and limit the family size among the couples and if contraception services provided, it is sufficient to reduce the birth rate. References Ghasura, N D, Bella C Patel and M E Khan (997): Case Study: Implementing Target-free Approach in Gujarat, National Workshop on Target-Free Approach, Lucknow, -. GoI (99): Manual on Target-free Approach in Family Welfare Programme (New Delhi: Ministry of Health and Family Welfare, Government of ). IIPS and Micro-International (99): National Family Health Survey (NFHS ), 99-9, International Institute for Population Sciences, Mumbai. (): National Family Health Survey (NFHS ), , International Institute for Population Sciences, Mumbai. (7): National Family Health Survey (NFHS ), -, International Institute for Population Sciences, Mumbai. Kothari, D et al (997): Vikalp Managing the Family Planning Programme in the Post-ICPD Era: An Experiment in Rajasthan,, IIHMR Occasional Paper No. Mavalankar, D V (997): Paradigm Shift in s Family Welfare Programme: A Review of Target- Free Approach in Family Planning, unpublished document, n Institute of Management, Ahmedabad. MoHFW (98-): Family Planning Year Book, Ministry of Health and Family Welfare (New Delhi: Government of ). (): Audit Report No, Ministry of Health Family Welfare, Government of, New Delhi. (): National Health Accounts -, National Health Accounts Cell, Ministry of Health and Family Welfare, Government of, New Delhi. Registrar General, (): SRS Bulletin, Office of the Registrar General of : 987-7, Delhi, Vol (). Salunke, S and Sharad Narvekar (997): Targetfree Approach for Family Welfare: A Rreview of Experiences in, Government of. Srinivasan, K, Chander Shekhar and P Arokiasamy (7): Reviewing Reproductive and Child Health Programmes in, Economic & Political Weekily, Vol (7), 9-9. october, vol xlvi no EPW Economic & Political Weekly