November 2, 2011

Evaluation Report
of
UNFPA India Country Programme-7

2011

Evaluation conducted for

UNFPA Country Office, India
 Evaluation Team

A.R. Nanda
Independent Consultant
Former Secretary, Ministry or Health and Family Welfare, and
Former Census Commissioner India

Firoza Mehrotra
Independent Consultant
Former Special Consultant, Planning Commission, Government of India, and
Former Director and Secretary, Women and Child Development Department, Government of
Haryana

Ravi Verma
Regional Director, Asia Regional Office,
International Center for Research on Women

Priya Nanda
Portfolio Director, Reproductive Health and Rights, Asia Regional Office, International Center
for Research on Women

Rekha Masilamani - Team Leader

Independent Consultant
Former Country Representative, Pathfinder International
 Contents
Executive Summary ............................................................................................................................................. 1

Part A: Introductory .......................................................................................................................................... 15

Section I: Introduction ................................................................................................................................... 15
Section II: Evaluation Scope, Purpose, Objectives, Key Questions................................................................ 18
Part B: Assessment of Programme Components ............................................................................................. 23
Section III: Reproductive Health Component including Gender; HIV/AIDS; and RH in disaster response .... 23
3.3.1 Output 1: Enhanced access and utilization of high quality RH services by vulnerable
communities ............................................................................................................................... 25
Technical Assistance & capacity building ………………………………………………………………………..26
Quality assurance …………………………………………………………………………………………………………..31
Communitization ……………………………………………………………………………………………………………33
Gender based violence …………………………………………………………………………………………………..35
Advocacy ………………………………………………………………………………………………………………………..36
3.3.2 Output 2: Promoting safe sex behaviours among vulnerable population groups: Sex-workers
and women ................................................................................................................................. 38
3.3.3 Output 3: Mainstreaming of RH and gender issues in recovery and rehabilitation responses for
natural disasters and environmental challenges ........................................................................ 42
Section IV: Adolescents and Youth ................................................................................................................ 49
Section V: Sex Selection................................................................................................................................. 62
Section VI: Population and Development Strategy ....................................................................................... 76
Part C: Geography & Partnerships ................................................................................................................... 94
Section VII: Programme Geography .............................................................................................................. 94
Section VIII: Partnership Strategies ............................................................................................................... 97
Section IX: Operational Modalities .............................................................................................................. 103
Part D: Conclusion........................................................................................................................................... 111
Part E: Annexes ............................................................................................................................................... 115
Annex 1 - RESULTS & RESOURCE FRAMEWORK FOR INDIA (2008-2012) ................................................... 115
Annex 2 - Terms of Reference for the Evaluation Team ............................................................................. 124
Annex 3 – Relative roles of evaluation consultants .................................................................................... 126
Annex 4 - List of Documents Reviewed ....................................................................................................... 127
Annex 5 – List of visits made & persons met............................................................................................... 136
Annex 6 – Agenda of Gender Consultation Workshop and presentation on UNFPA’s gender work.......... 140
Annex 7 - List of Protocols, Tools, Guidelines and Manuals produced during CP 7 .................................... 150
Annex 8 - Methodology of Composite Ranking of the States on Seven Indicators ..................................... 152
 Acknowledgements

This evaluation was made possible because so many people so generously shared with the
evaluation team background, information, insights, problem priorities, expectations, projections,
and their vision of what could be expected in the near and medium term future:

UNFPA staff:
Dr. Marc Derveeuw, Representative, a.i.
Ms. Ena Singh, Assistant Representative
Mr. Venkatesh Srinivasan, Assistant Representative
Mr. Sanjay Kumar, National Programme Officer (M&E)
Senior staff of UNFPA both in the Country Office and in the States

Key counterparts in:

The Central and State Governments
The National Health Systems Resource Centre
UNICEF, UN Women and the World Bank
DFID and USAID
Civil society partners of UNFPA

To all of them the evaluation team extends its grateful thanks.

Special thanks to Sanjay Kumar, National Programme Officer (M&E) for immense help with
coordination of the evaluation, critical review, and for making available the many inputs needed;
to Leela Jose, thanks for her efficient support with travel and other logistics.; and to Hemant
Bajaj for assistance with the formatting of this report.

To Ruchika Kumar and the team at the International Center for Research on Women, the team is
grateful for providing it with a home and hospitality on the many days on which it needed to
meet and work together.
List of Abbreviations
AA Appropriate Authority
ACC Apex Coordination Committee
AEP Adolescence Education Programme
AGCA Advisory Group on Community Action
AHD Adolescent Health and Development Project
AIDS Acquired Immune Deficiency Syndrome
ANM Auxiliary Nurse Midwife
APRO Asia Pacific Regional Office (UNFPA)
ARSH Adolescent Reproductive and Sexual Health
ASHA Accredited Social Health Activists
ATI Apex Training Institute
AWP Annual Work Plans
AWW Anganwadi Worker
BEmOC Basic Emergency Obstetric Care
CBOs Community Based Organizations
CBSE Central Board of Secondary Education
CEDPA Centre for Development and Population Activities
CEmOC Comprehensive Emergency Obstetric Care
CHC Community Health Centre
CHSJ Center for Health and Social Justice
COBSE Council of Boards of Secondary Education
CP Country Programme
CPAP Country Programme Action Plan
CSR Child Sex Ratio
DFID Department for International Development
DLHS District Level Household Survey
DP Development Partners
DPIP District Project Implementation Plan
DWCD Department of Women and Child Development
EAG Empowered Action Group
EmOC Emergency Obstetric Care
FP Family Planning
FRU First Referral Unit
FSW Female Sex Worker
GBV Gender Based Violence
GMTF Gender Master Trainer Facilitators
GOB Government of Bihar
GOI Government of India
GOMP Government of Madhya Pradesh
GOM Government of Maharashtra
HIV/AIDS Human Immuno Deficiency Virus/Acquired Immune Deficiency Syndrome
HMIS Health Management Information System
ICPD PoA International Conference on Population and Development Programme of Action
IHMP Institute of Health Management Pachod
IIHMR Indian Institute of Health Management Research
IIPS International Institute of Population Studies
IMA Indian Medical Association
ISEC Institute for Social and Economic Change
JRM Joint Review Mission
JSY Janani Suraksha Yojana
KISS Kalinga Institute of Social Sciences
KVS Kendriya Vidyalaya Sangathan
LSE Life Skills Education
M&E Monitoring and Evaluation
MDG Millennium Development Goals
MISP Minimum Initial Service Package
MO Medical Officer
MOD Ministry of Defence
MOHFW Ministry of Health and Family Welfare
MHRD Ministry of Human Resource Development
MOPR Ministry of Panchayati Raj
MOSJE Ministry of Social Justice and Empowerment
MOYAS Ministry of Youth Affairs and Sports
MP Madhya Pradesh
MPVHA Madhya Pradesh Voluntary Health Association
MTP Medical Termination of Pregnancy
MWCD Ministry of Women and Child Development
NACO National AIDS Control Organization
NACP National AIDS Control Programme
NCERT National Council of Educational Research and Training
NCF National Curriculum Framework
NDMA National Disaster Management Authority
NFHS National Family Health Survey
NGO Non Governmental Organization
NHRC National Human Rights Commission
NHSRC National Health Systems Resource Centre
NIDM National Institute of Disaster Management
NIHFW National Institute of Health and Family Welfare
NIOS National Institute of Open Schools
NPEP National Population Education Programme
NRHM National Rural Health Mission
NSS National Service Scheme
NSV No Scalpel Vasectomy
NVS Navodaya Vidyalaya Samiti
NYKS Nehru Yuvak Kendra Sangathan
ORGI Office of the Registrar General, India
OVHA Orissa Voluntary Health Association
PCPNDT Pre-Conception and Pre-Natal Diagnostic Techniques
PDVA Prevention of Domestic Violence Act
PFI Population Foundation of India
PHC Primary Health Centre
PHI Public Health Institute
PIL Public Interest Litigation
PIP Project Implementation Plan
PNDT Pre-natal Diagnostic Technique
PPP Public Private Partnership
PRI Panchayati Raj Institutions
PWC Price Waterhouse Cooper
QA Quality Assurance
RCH Reproductive and Child Health
RGNIYD Rajiv Gandhi National Institute of Youth Development
RH Reproductive Health
RKS Rogi Kalyan Samiti
RRE Red Ribbon Express
RSACS Rajasthan State AIDS Control Society
RTI/STI Reproductive Tract Infections/Sexually Transmitted Infections
SCERT State Council of Educational Research and Training
SRB Sex Ratio at Birth
SRH Sexual and Reproductive Health
SWAp Sector Wide Approach
TA Technical Assistance
TCG Thematic Core Group
THP The Hunger Project
TSU Technical Support Unit
UNDAF United Nations Development Assistance Framework
UNDMT United Nations Disaster Management Team
UNESCO United Nations Educational, Scientific and Cultural Organization
UNFPA United Nation Population Fund
UNICEF United Nations Children‟s Fund
UP Uttar Pradesh
USG Ultra Sonography
VHSC Village Health and Sanitation Committee
WHO World Health Organization
WPC Women Power Connect
YFHS Youth Friendly Health Services
 Executive Summary

Executive Summary

Part A: Introductory

Section I: Introduction
UNFPA‟s Country Programme 7 (CP-7) defines the goals, outcomes and strategies that the
Government of India (GOI) and UNFPA will jointly use to reach national goals in health and
population, the Programme of Action of the International Conference on Population and
Development (ICPD) and the Millennium Development Goals (MDGs)

The National Rural Health Mission (NRHM), launched in 2005, focuses on 18 Indian states with
weak health infrastructure and poor health outcomes. The Reproductive and Child Health Project
(RCH) II is incorporated into NRHM. Large financial resources have been devoted by the GOI to
RCH, to improve access to quality health services, particularly for the poor and marginalized and
to achieve reduced maternal and infant death and total fertility. Development assistance forms a
mere 8% of the resources provided for RCH-II. However, government values the flexible
technical assistance (TA) and programme implementation support of development assistance
partners– particularly assistance that demonstrates how implementation can be made stronger
and more effective at the state and district level in geographic areas that are lagging behind.

Responding to the great regional imbalances in India and the over 300 million that live in
poverty despite India‟s middle income status, development partners have focused assistance on
districts and states where development lags behind.

UNFPA has provided sector wide support to the RCH-II project by pooling 28% of its CP 7
budget with funds of the GOI and other donors – UNFPA‟s contribution works out to 0.48% of
all funds dedicated to RCH-II. UNFPA also provides technical support for the programme. In
the states of Maharashtra, Madhya Pradesh (MP), Rajasthan, Orissa and Bihar, where it has a
presence, UNFPA provides policy and programme support to the state governments. In these
states it also supports the implementation of a variety of pilots to assess their feasibility for
replication and scale-up.

Overall, UNFPA development assistance to India is meant to achieve reduced regional

disparities, social inclusion, gender equity, increased participation of women in local
government, reduced gender based violence and discrimination against the girl child, a
successful demographic transition with attention to emerging demographic issues, reduced
maternal mortality and reduced transmission of the human immune-deficiency virus (HIV).

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 Executive Summary

CP 7 has three broad components:

1. Reproductive health (RH): Where the outcomes desired are a reduction in maternal
mortality, reduction in unmet need for contraception, reduction in adolescent fertility, and
reduction in adult HIV prevalence.

2. Gender: This component seeks to mainstream gender in UNFPA‟s RH programmes;

advocate and act against gender based violence (GBV) and empower women. Moreover it
seeks to reduce sex selection. The outcome desired is a reduced skew in the child sex ratio.

3. Population and Development Strategy (PDS): This component seeks to foster systematic
use of data on population dynamics and trends to guide increased investments in
decentralized development planning.

Section II: Evaluation Scope, Purpose, Objectives, Key Questions

UNFPA commissioned this evaluation to elicit achievements made in each of the programme
components, understand effectiveness of mainstreaming cross-cutting themes such as gender and
advocacy in programming, and examine lessons learned for incorporation into CP 8. The
evaluation involved a desk review of key documents, field visits, and meetings with UNFPA
staff, government and non government counterparts at both national and state levels,
development assistance partners and other UN agencies. A special consultative meeting on
gender was also held in Delhi with UNFPA staff. The evaluation was not designed to include
meetings with a representative cross section of final beneficiaries. Data has been gathered from
meetings with these stakeholders. The evaluation has looked at inputs, processes and outputs that
are visible at this time (CP-7 ends only in 2012). Data from surveys which will provide values of
performance indicators as of the end of CP-7 are awaited. However, intermediate values of two
indicators have been extracted from other sources. The evaluation team has assessed how
UNFPA‟s work serves needs in the country, fills gaps in RCH- II programme implementation,
and what potential the various initiatives have for scale-up and sustainability. Challenges the
programmes have encountered are also discussed, and suggestions made for strengthening. The
report explains the challenges to measuring performance against the indicators given in the
Results and Resource Framework of CP-7. The evaluation has been conducted in accordance
with UNFPA evaluation guidelines- including ethical guidelines.

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 Executive Summary

Part B: Programme Assessment – Findings, conclusions &

recommendations
The evaluation report has looked at the many initiatives that make up CP 7- reproductive health
including gender based violence and HIV/AIDS, adolescent sexual and reproductive health, sex
selection, and population and development strategy. Though adolescent reproductive and sexual
health is a part of the reproductive health component, because of the scope of this initiative, this
report has discussed it in a separate section. The report also addresses issues of program
geography, partnership strategies, and operational modalities.

Section III: Reproductive health component – excluding adolescents

CP-7 shares 4 indicators with RCH-II and the National AIDS Control Program (NACP) III:
reduce total fertility rate, infant mortality rate, maternal mortality ratio, and adult HIV
prevalence. UNFPA‟s 5 states are home to 42% of India‟s poor and four of them are amongst the
6 most backward states of the country. This ensures that UNFPA‟s work addresses those who
are most vulnerable.

UNFPA‟s significant contributions towards achieving RCH II and NACP III goals are
characterized by TA and capacity building support, quality assurance programmes,
communitization of NRHM, gender mainstreaming efforts including efforts to reduce gender
based violence, RH related advocacy, and promotion of safe sex behaviours among most
vulnerable populations- female sex-workers and women. In addition, CP-7 envisioned
mainstreaming RH and gender issues in recovery and rehabilitation responses for natural
disasters and environmental challenges.

In CP-7, UNFPA has provided wide ranging TA and capacity building support to the National
and State governments and has produced technical guidelines, operational manuals, protocols
and tools that incorporate evidence based public health innovations that have not yet become
standard clinical practice in India.

The QA initiatives that UNFPA has carried out in Rajasthan and Maharashtra are its most
significant contribution. It is showing results in terms of improvement in the quality of facilities
and services at the primary health care level. Both the Maharashtra and Rajasthan governments
have begun to see quality as an essential element of the national programme and are committed
to taking the effort forward with their own resources. A holistic model of QA would enable
UNFPA to weave together all its priorities in RH- quality, adolescents, gender, gender based
violence, and community needs assessment and engagement- into one coherent framework and
programme.

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 Executive Summary

Recommendations
Widen and deepen the quality assurance model to include gender sensitivity of providers,
detection of gender based violence, convergence of HIV with RH, sensitivity to adolescents,
and community needs assessment and engagement.

Advocate at both the national and state levels to scale up QA programmes and for the
addition of quality indicators in the HMIS.

UNFPA commissioned Price Waterhouse Cooper (PWC) to carry out a study and recommend
robust processes for managing Public Private Partnership (PPP) so that access to family
planning services can be improved. PWC has recommended that the government use a third
party to procure services from the private sector. The PWC recommendations need to be
reviewed and implemented.

Recommendation
Advocate with government, fund and evaluate pilots of the PWC recommended PPP
management model so that private sector participation in FP service delivery is promoted.

Interventions to address Gender Based Violence (GBV) have been undertaken in a health
facility and also in the community. There is need to see if the programme has resulted in change
in practices related to detection of violence and provision of support for survivors of violence.
The synthesis of Indian evidence on the health and social consequences of marital violence1
commissioned by UNFPA could prove to be a strong advocacy tool for building sustained
responses from within the health care system to gender based violence.

Recommendations
Before the formulation of CP 8, UNFPA should carry out an evaluation of the gender work
that it has done in support of the NRHM programme, and prepare a document that records
the approaches it has used, the inputs it has provided, whether these have really been
institutionalized and whether they have changed the gender sensitivity of the system. Have
the gender aspects built into the PIPs been implemented? This evaluation, combined with
documenting the gender work of UNFPA post NRHM, could be a good starting point for a
fresh attempt to orienting government personnel and other stakeholders including civil
society, to the pressing need to incorporate gender sensitivity into health services.

UNFPA should continue to work to enhance the capacities of Panchayati Raj Institutions2
(PRI) members through organizations like PRIA and The Hunger Project and ensure that
there are measurable indicators to assess the role of PRIs and their members in community
based monitoring of key issues related to sex-selection, child marriage and maternal and
child health.

In community settings in Rajasthan and Bihar, NGOs funded by UNFPA are working with
elected local government leaders and women leaders, to motivate them to address violence

1
Jejeebhoy et al (2010); “Health and social consequences of marital violence: A synthesis of Indian evidence”;
UNFPA/Population Council
2
Panchayati Raj Institutions are structures of the system of local self government that has been in place in India since the early
1990s, but is not yet quite fully functional.
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 Executive Summary

against women. Given the increasing importance of and devolution of powers to PRIs and the
increased number of elected women representatives, it is important that PRIs take greater
responsibility for community based monitoring of key issues of gender based violence and also
on maternal and child health.

UNFPA‟s advocacy work has chiefly focused upon advocating (successfully) with other
development partners for the national government to drop the age and parity clauses that
excluded young mothers below the age of 18, and those with more than 2 children, from being
eligible for the Janani Suraksha Yojana (JSY) scheme3. This advocacy effort was sustained
through CP-7 to ensure that these clauses were not revived.

CP-7 had identified the need to revitalize the stagnant family planning program in India by
working for improved conceptualization of strategies to service contraceptive needs of the
community and to provide TA to ensure systemic planning for delivering quality family planning
services. However, there have been a few issues on family planning that need stronger and more
sustained advocacy. The most important of these is the need to reposition family planning as a
tool for achieving good health and reduced mortality for mothers and infants, empowerment of
girls and women through delayed marriages and spacing between births, family well being and
poverty alleviation.

Recommendation
Build strong advocacy strategy to reposition family planning, UNFPA should undertake a
planned program of advocacy for repositioning family planning within the ICPD framework
of informed choice and quality care with a much broader range of services rather than merely
endorsing the overwhelming use of sterilization methods that some of the state governments
seem to currently place emphasis on.

TA provided by UNFPA in the area of human immunodeficiency virus/acquired immune

deficiency syndrome (HIV/AIDS) in Rajasthan, has been seen by the state authorities as
comprehensive, material, problem solving, and supporting effective implementation of the AIDS
programme. However the strategies to promote safe sex-behaviours among female sex-workers
and women need careful review to ensure that these strategies do not stigmatize community
based sex-workers. UNFPA has not yet comprehensively addressed the issue of RH and
HIV/AIDS convergence as planned in CP-7. This is a niche that no agency has yet sought to fill.

Recommendation
Begin to work on providing TA to the National AIDS Control Organization and its
intervention programmes for other vulnerable groups on how to converge RH with
HIV/AIDS interventions.

3
A nationally sponsored scheme that offers financial incentives to encourage institutional delivery

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 Executive Summary

The UNFPA country office has played a small but critical role in mainstreaming RH and
gender issues within recovery and rehabilitation responses for natural disasters and
environmental changes. The main thrust of the work is to engage with agencies such as the
National Institute of Disaster Management (NIDM) and its Apex Training Institutes (ATIs) and
provide technical support to integrate a minimum initial service package (MISP) for RH in
disaster in the professional development course for managers of disaster relief programmes.

Recommendation
Map vulnerabilities due to environmental challenges within its 5 states, identify geographic
locations with recurring or constant environmental challenges, where continuing work could
be done to mitigate effects on the RH of vulnerable segments of society and advocate with
others to work to mitigate these conditions.

Section IV: Adolescent Reproductive and Sexual Health (ARSH)

Outcome 4 of CP-7‟s RH component is “Adolescents and youth empowered with knowledge and
life skills for improved reproductive and sexual health (in school and out-of-school).” Indicators
relate to the integration of life skills education (LSE) into school education through curricular
and co-curricular approaches; training of teachers in the life skills approach; increased accurate
knowledge of HIV/AIDS, and increased application of life skills imparted to them. A third
component of the programme for adolescents and youth is “Institutionalization of Adolescent
and Youth Friendly Health Services”.

A variety of strategic interventions have been worked on.

Life skills education for adolescents in school: Material has been developed that meets the
criteria of UNESCO‟s International Guidelines for Sexuality Education. Formal feedback on the
material and on the quality of nodal teachers training has rated those at 4 at the high end of a 5
point scale. Extensive coverage has been achieved of schools affiliated to the boards of
secondary school education at the national level. Scores for knowledge and attitude change
brought about by the training show modest gains, somewhat higher in knowledge than in
attitude. Preliminary findings of a study to see if adolescents exposed to the programme have
acquired life skills, show modest programme effects. Though the ultimate goal of UNFPA‟s
programme is to deliver adolescent LSE in the curricular format in schools, most programmes so
far have been in the co-curricular format. Only three organizations have so far opted for the
curricular approach. With the exception of Rajasthan, the programme has not yet been rolled out
in the schools governed by the state boards of education in which the large majority of the
neediest students study. If the benefits of the programme are to reach the large majority of Indian
adolescents in school, it will have to be rolled out in the state board schools. In Rajasthan
UNFPA is working with all the seven universities that provide pre-service teacher training to
incorporate LSE in the teacher training curriculum. This will make LSE sustainable.

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 Executive Summary

Recommendations:
Scale up the adolescence education programme (AEP) in schools affiliated to state boards of
education

Make LSE more sustainable through pre-service teachers‟ training programs

Initiatives for adolescents who are out-of-school: Six different approaches were to be used to
reach adolescents out-of-school with reproductive and sexual health knowledge. Only three of
these activities have so far been undertaken, of which the most significant is the Teen Club
programme of the Nehru Yuva Kendra Sangathan (NYKS). UNFPA has also funded 3 village
level ARSH programmes in MP and one in Bihar to change RH behaviour, and improve demand
for and delivery of RH services to the villages. There have been some positive outcomes of these
programmes.

An assessment of the 4000 Teen Clubs set up across the country under the UNFPA programme,
showed that although the activity was primarily meant to reach out-of-school adolescents, 89%
of Teen Club members were attending school. UNFPA has now decided to re-strategize the Teen
Club initiative and from 2011 to implement it in only the 5 UNFPA priority states so as to avoid
spreading the programme too thinly over the entire country, and also to develop alternative
models.

Given that 65% of India‟s 240 million adolescents aged 15 and above are not in school, reaching
adolescents in out-of-school contexts has priority. Given the enormous number of adolescents to
be reached, financial investment by government will be required, and advocacy to encourage this
investment is essential. A programme that has to reach out-of-school adolescents to scale must
have clear and limited objectives, have clear and pragmatically defined content in a brief capsule
which can be delivered in a very short period in community settings. From out of its excellent
life skills module for schools UNFPA could create a capsule which will focus on young people‟s
need to make healthy and responsible sexual and reproductive choices as they grow into
marriage and adulthood. Both the community based models in MP and in Bihar, funded by
UNFPA to change adolescent reproductive behaviour, offer proven alternatives to the Teen Club
approach. UNFPA must invest in finding effective ways of reaching them by developing realistic
content and methodology and testing alternative delivery mechanisms.

Recommendation:
Prioritize the development and evaluation of practical approaches for reaching out-of-school
youth, and advocate with government to invest financial resources in reaching out-of-school
adolescents.

Institutionalizing Adolescent Friendly Health Services (AFHS): NRHM provides for the
provision of adolescent friendly health services through primary health facilities. UNFPA
provided the Government of Maharashtra with TA to set up such clinics in selected districts. An
evaluation of the programme revealed that the access and quality of services through these
clinics were quite limited and the intervention did not have much success.

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 Executive Summary

Recommendation:
A stronger approach and demonstration pilot will offer concrete alternatives to many states of
India, most of whom are struggling with understanding the purpose and modalities of the
concept of YFHS and with how to implement it.

Section V: Sex Selection

The desired output for the overall gender component of CP-7 is the child sex ratio (CSR), which
at baseline (2001 census) was 927 per 1000 males. This was to be improved by at least five
points as measured by the 2011 census. The desired output for the sex selection programme is –
to address through advocacy and action the skewed sex ratio at birth (SRB). Two indicators have
been selected:

(i) Sex ratio at birth in the worst affected districts improved- for which the baseline was to
be determined and a ten percentage point improvement was sought by end-line

(ii) The gender gap in under 5 mortality rate reduced at the national level. The baseline was
6.8 per 100 births in 2005 and this was to be brought down to below 5 in 2012

The CSR at the national level in the 2011 census is 914. It has deteriorated by 13 points
compared to the 2001 value of 927. There has been similar deterioration in the states of
Maharashtra, MP and Rajasthan4. CP-7 has 2 more years to go and it seems unlikely that the
targets set for reduction of CSR or SRB will be met within this timeframe. In the five UNFPA
states too, the SRB has deteriorated since 20015. The evaluation team finds that the national level
indicators that UNFPA chose to measure success were grossly unrealistic and overly ambitious.
Other intermediate measures of outputs and processes which would enable measurement of
UNFPA‟s contribution to achieving CSR or SRB should have been used.

CP-7 interventions sought to strengthen implementation of the Pre-Conception and Pre-natal

Diagnostics (PCPNDT) Act at the national and state level; mainstream the work in sex selection
by integrating sex selection issues into ongoing programmes of various ministries; create through
advocacy, an environment that would discourage, disapprove and act against sex selection;
strengthen capacity of civil society to address this issue; and build a strong evidence base for
advocacy by supporting research initiatives. The programme has experienced significant success.

Efforts to strengthen implementation of the PCPNDT Act through training and orientation of
the judiciary; mobilization of medical professionals; mobilization of civil society to activate and
participate in statutory bodies responsible for Act implementation, and to monitor ultra-
sonography (USG) clinics; have resulted in better case preparation, expeditious disposal of cases,
improved functioning of statutory boards, higher rates of registration of USG clinics, and better
compliance with the Act. Where only community awareness work was undertaken, compliance
with the Act has not improved6.

4
Rajasthan decline from 909 to 883; MP decline from 932 to 912; Maharashtra decline from 913 to 883; Orissa 953 to 934.
5
Some of the worst off states, where UNFPA has contributed through workshops with medical communities, judiciary and
religious leaders, have seen an improvement in the CSR as in Punjab, Haryana and Himachal Pradesh.
6
Interviews with key civil society organization stakeholders in Haryana
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 Executive Summary

Community level work through networks of NGOs has brought about higher awareness of the
issue of sex selection and awareness of the PCPNDT Act to the grass roots level and other
specific positive outcomes. The work has challenges in that grass roots communicators need
value clarification on abortion per se, the intersect between legal abortion and sex selective
abortion, and on reproductive rights, so that their messaging to women and communities is clear,
and their community level work does not end up stigmatizing legal abortion.

Recommendation:
Community based work to change mindsets may not be the best use of UNFPA‟s resources.
However, the learning from the community level work should be documented and
disseminated as a resource for others working on these issues, and to advocate for more
community work to change social norms.

The media has been a key partner in advocacy initiatives. The many media initiatives are
interesting and innovative, but the evaluation team did not perceive the existence of an overall
synergistic strategy for communication and advocacy for the issue of sex selection.

Recommendation:
Lay out a more forward looking and comprehensive communication strategy in the area of
sex selection. Evidence based advocacy to shape public opinion must be a central objective
of communication.

Several publications have been developed by UNFPA as the evidence base, and as tools for
understanding and advocating on the issue of sex selection. There is a need for current and
representative data on attitudes of men and women towards son preference and sex selection and
on how social norms change or resist change.

Recommendation:
Continue to build the evidence base for advocacy and action through new research in the area
of son preference and sex selection.

The findings of Census 2011 show that work against sex selection is urgently and widely needed
in India. The need of the hour is advocacy at the national level, to build equal value for daughters
compared to sons. If UNFPA wishes to have national impact through its work on sex selection, it
may need to consider playing the role of a catalyst for advocacy, using its position and influence
to draw and hold together a strong group of influential, independent and resourceful partners at
both the national and state levels, who will work together to advocate for allocation of resources
and action on the issue of sex selection. Discussions with development partners including other
UN agencies bear out the idea that in order to build partnerships and buy-in, it is important to
reposition the work within a wider lens of discrimination.

Recommendation:
Catalyze action and partnerships by bringing together a wide variety of agencies, to
contribute to rapid change in a coherent manner, using a wider frame of gender
discrimination.

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 Executive Summary

Government commitment to Act implementation at both national and state levels remains weak.

Recommendation:
Advocate for scale up and strengthening of Act implementation: work closely with the
governments of Maharashtra and MP, civil society, legal and medical professional agencies
to advocate at the national and state levels for greater government commitment to the issue of
sex selection, and for more rigorous Act implementation.

Section VI: Population and Development Strategy

The overall outcome for the Population and Development Strategy (PDS) component of CP-7 is
that capacity be built to integrate population dynamics into national policies and programmes.
Two outcomes are desired, the first is that development plans at the national and sub national
level build upon the findings of studies on emerging population issues, and the second is that
plans and policies are linked to population and development realities, through use of
disaggregated data in planning and monitoring.

The most significant programme inputs to achieve CP-7 objectives included capacity building for
decentralized planning through the joint GOI-UN Convergence Programme; TA for
strengthening the health management information system and the civil registration system for
vital statistics; TA for the Census of 2011; support for developing the Bihar Population Policy;
and the commissioning of policy studies on the emerging issue of aging.

Decentralized district planning: To facilitate the development of integrated district

development plans through convergent action of various government departments and schemes
at the district level, UNFPA organized capacity building training for both senior officials
engaged in planning and programme management, and for statistical and planning officers. Both
participant feedback and the request from the state governments for repeat workshops to be
organized at the state level are evidence of relevance and effectiveness. UNFPA needs to review
the content and methods of these training programs to include inputs on the cross cutting
development issues of gender, rights and equity. The evaluation team finds that 20 out of 35
districts have prepared the integrated district plans using participatory and consultative
processes, and the quality of the plans has improved. The monitoring of programmes has become
more focused and systematic, and the plans are made on the basis of data, facts and evidence.

Recommendations:
Continue to give priority to broadening the vision and perspectives of development planners
to understand population and development linkages. The relationship of the key issues of
gender, equity, and empowerment to development, must continue to receive priority in the
India country programme. For sustained in-service capacity building of senior administrators,
and programme and policy leaders, population and development courses should be integrated
into the induction, orientation and training courses that are regularly conducted for
government officials. Side by side, to widen the pool of population and development
professionals in the country, UNFPA should support the development of
Masters/Diploma/Certificate programme on population and development at appropriate
educational institutions.

10
 Executive Summary

Continue to support decentralized and convergent district level development planning.

Other important contributions towards district planning are the development of a sub-national
estimation methodology for tracking developmental indicators and district level population
projections for eight selected states of India (2006 - 2016). The exercises of district level
projections and sub-national estimation are likely to have positive impact on decentralized
planning and programme monitoring UNFPA has worked strategically and systematically to help
the districts to define the denominators that form the basis of the planning exercise.

The Health Management Information System (HMIS) is an essential input for monitoring the
RCH-II programme. UNFPA supported the training of functionaries at the sub-district levels in
Bihar and Maharashtra. The evaluation team finds that the HMIS does not include strong data
quality checks and data triangulation. It does not measure any elements of quality of care, nor
does it gather data disaggregated by markers of social disadvantage. These are necessary for
assessing whether programmes are reaching the vulnerable with quality services. UNFPA should
advocate for the inclusion of such data in HMIS.

There is a need for improvement in the use of vital registration data. Since coverage levels of the
civil registration system are not high, there is a need to show how the most reliable estimates can
be made from even imperfect levels of coverage. This would be an important contribution that
UNFPA could make.

Technical Assistance and Support for the conduct of Census, 2011: UNFPA supported the
Office of Registrar General of India (ORGI) in four specific areas: (a) digital mapping of census
blocks in capital cities, (b) census training and publicity, (c) gender aspects of the census and (d)
data dissemination. A „Census Training and Resource Centre‟ has been proposed to be set up
and UNFPA has commissioned a study to develop a road-map for the establishment of the
Census Training and Resource Centre which is expected to be used for south-south collaborative
activities.

Emerging Population Issues: Several emerging issues identified by CP-7 require study and
analysis for advocacy. Progress so far has been made on the issue of aging. UNFPA
commissioned eight secondary studies covering a range of issues relating to the elderly that have
been peer reviewed and are to be published and disseminated to a wide audience of stakeholders
including government. Three large scale primary studies have been initiated to study additional
areas so that policy and programme advocacy can be better supported.

Recommendations:
Use the results of Census 2011, to point emerging demographic trends and issues. Launch a
concerted and continuing advocacy effort at many levels and for many audiences, to shape
public opinion, create an environment, and generate pressure for government to respond with
appropriate policies and programmes.

11
 Executive Summary

Census data should be further analyzed and built upon to deepen the understanding of
emerging population issues like the youth bulge and the demographic dividend, migration
and urbanization, population and environment, abortion and sex selection, and post-
reproductive morbidities. These have not been substantially taken up during CP-7, and need
to be taken up in CP-8.

In summary, the PDS work accomplished under CP-7 is varied, significant and relevant. The
evaluation team found that considering the importance of PDS in the context of the global
mandate of UNFPA, the expansive scope of this thematic area and the present and future needs
of the country, the human and financial resources provided to this component of the UNFPA
programme need enhancing so that it is better able to (a) engage in policy advocacy, (b) provide
capacity building inputs on population-development dynamics, (c) ensure gender mainstreaming
in population programs, and (c) establish essential linkages with resource persons and
institutions that are inter-disciplinary. The evaluation team found that the budget allocation for
PDS thematic area is quite low. During 2009 and 2010, it varied between 6% and 8% of the total
funding for those years.

Recommendation:
Strengthen the PDS thematic area group in UNFPA to enable it to more fully and effectively
address the scope and complexity of this critical component of UNFPA‟s portfolio.

12
 Executive Summary

Part C: Geography & Partnerships

Section VII: Programme Geography

The evaluation team has reviewed the appropriateness of the selection of states where UNFPA
works. Criteria used are the ranking of states on key development indicators in the areas of
population and health, absolute numbers of the poor, and potential for work on emerging issues.
The evaluation team is of the view that UNFPA should remain in the states where it presently is.
Discussions with officials in the GOI reveal they too are of the opinion that UNFPA should
remain in the states where it currently is- these states are amongst the most under developed of
India‟s states, and require UNFPA support.

Recommendation:
The evaluation team recommends that in CP-8 UNFPA continue to maintain offices in the 5
states where it is currently present.

UNFPA plays a mix of three meaningful roles: policy advocacy, TA, and programme
implementation support. Given these, UNFPA‟s current mix of national and state presence is
well considered. However, to play the policy advocacy role effectively, especially on emerging
issues, UNFPA may sometimes need to work in states other than the 5 in which it has regular
programmes. It should be able to pursue work on key issues at the state level, even if that work
falls outside the 5 states where it is pursuing state level programmes.

Recommendation:
UNFPA should retain the flexibility it currently has to pursue policy, advocacy or selective
work in some themes, particularly in emerging issues, outside of its 5 states. Such
programmes could be managed out of Delhi or one of the five state offices depending on
proximity, and technical skills of the staff in the state offices.

Section VIII: Partnership Strategies

The evaluation report discusses the partnerships that UNFPA has in-country with the
government, other development partners in India, a range of academic, research and civil society
organizations, and other UN agencies in India. Civil society organizations play a variety of roles
in UNFPA‟s programmes, contributing to research, providing TA and building capacity on
behalf of UNFPA, implementing programmes and pilots for scale-up- particularly projects that
are community based, and furthering UNFPA‟s advocacy agenda by mobilizing civil society.

Harmonization and synergy between UN agencies in India is a concern of the UN. Efforts to
harmonize at the national level are exerted by the UNDAF. However, at the state level, given
that each UN agency follows different norms related to the delegation of authority and power to
their state representatives, some UN agencies do not feel that they are able to adequately
represent the agenda of their agencies.

13
 Executive Summary

Recommendation:
In the interest of ensuring that UNFPA‟s interest and agenda is represented at par with those
of other UN agencies, it is recommended that the UNFPA state representatives be given the
same degree of flexibility and decentralized authority as representatives of other agencies
have.

Section IX: Operational Modalities

The evaluation reports examines the three main modalities by which UNFPA operates in India:
SWAp, annual work plans, and direct execution.

Recommendation:
Among several issues including staffing, processing of annual work plans, and improving
accountability for mainstreaming gender into UNFPA‟s work, the most significant
recommendation is related to the SWAp:Only if the Ministry of Health and Family Welfare
(MOHFW), conscious of the limited resources of UNFPA, feels that a monetary contribution
from UNFPA to the pool will help to underline a robust partnership between the two, then
UNFPA should continue to contribute to the SWAp, albeit with a lesser contribution, as it is
not the financial resources of UNFPA per se that matter to MOHFW.

14
 Part A: Introductory (Section I: Introduction)

Part A: Introductory

Section I: Introduction
UNFPA’s Country Programme 7 (CP-7) is a five-year framework defining mutual cooperation
between the Government of India (GOI) and UNFPA covering the period 2008-2012. The CP
was designed based on the Programme of Action of the International Conference on Population
and Development (ICPD PoA) and the needs of the country as reflected in the national XIth Plan
document. It was prepared in close consultation with the government and other stakeholders, and
defines the goals, outcomes and strategies that the government and UNFPA have jointly
subscribed to within agreed financial parameters. After CP-7 was approved by the GOI, the
United Nations Development Assistance Framework (UNDAF), and UNFPA‟s Strategic Plan
(2008-2013), were approved. UNFPA India reworked the results framework of CP-7 to achieve
alignment with both UNDAF and the Strategic Plan. CP-7 has been detailed in the Country
Program Action Plan (CPAP).

The national health policy and programme environment in India has seen much change in the
period between CP-6 and CP-7. The National Rural Health Mission (NRHM), launched in 2005,
incorporated within itself the Reproductive and Child Health-II (RCH-II) project. NRHM
focuses on 18 Indian states with weak health infrastructure and poor health outcomes. Large
financial resources have been devoted to improving access to quality health services, particularly
for the poor and marginalized. Donor assistance forms an insignificant proportion of resources
that government has provided for NRHM. In this new environment, government values flexible
technical assistance and programme implementation support that demonstrates how
implementation can be made stronger and more effective at the state and district level,
particularly in geographic areas that are lagging behind.

Recognizing that inspite of India‟s middle income status, great disparities in regional
development remain, and that over 300 million Indians still live in poverty, donors have shifted
focus from the national to the state level, choosing to work in states that are lagging behind. The
Department for International Development (DFID) of the United Kingdom has decided to focus
all its funding on the three states of Madhya Pradesh (MP), Bihar and Orissa, with only policy
interventions at the national level. The United States Agency for International Development
(USAID) focuses on state level interventions in its programmatic priority areas, while continuing
to provide policy and NRHM programme review inputs to the central government. UNFPA uses
its presence at the national level, to support the implementation of national programs, advocate
for issues and provide policy inputs. In addition, UNFPA uses it presence in 5 states to provide
policy and programme guidance to the state governments in areas that are UNFPA programme
priorities. It also funds and supports the implementation of pilots to assess their feasibility for
replication and scale-up.

All multilateral and bilateral development assistance partners are members of the Development
Partners Forum, where, along with the Ministry of Health and Family Welfare (MOHFW), they
reach coordinated development assistance decisions based upon their individual strengths and
mandates, and where they jointly review progress of the Reproductive and Child Health Project-
15
 Part A: Introductory (Section I: Introduction)

II (RCH-II). The assistance provided by UNFPA and other UN agencies is guided by the
UNDAF strategic framework.

Towards the end of 2010, the MOHFW sought the cooperation of its development partners in
strengthening implementation of all health programmes in 265 districts across the country.
These districts were identified as requiring “high focus” for development. Partners were allotted
districts in their respective focus states, with the request that they be responsible for assisting
government to coordinate all health programming in the districts. UNFPA was allotted 13
districts in 4 of its 5 states. Partners are fine tuning district strategies and plans, in consultation
with state governments. Government would like partners to assist in programme implementation
so that RCH objectives in the districts are met.

Funds and implementation modalities of CP-7

Midway through CP- 6 UNFPA agreed to pool its resources with those of the GOI for its SWAp
(sector wide approach) programme for RCH. Other donors who contributed to the pool were
DFID, and the World Bank. In CP-7 UNFPA pooled 28% of its resources to the pool. Together
the 3 donors contributed 8% to the pool, with 92% coming from government. UNFPA‟s
contribution to the pool was 6% of donor contributed funds, or 0.48% of the total pool.
Following this decision, UNFPA‟s development assistance to India changed from a project mode
with direct execution to providing stronger policy and technical support at the national and state
levels for RCH-II. UNFPA as a member of the Development Partners Forum, and as a pooling
partner of the GOI, participated in key program formulation and review activities including the
Joint Review Missions (JRM) of NRHM. This role transformation continued to be firmed up in
CP-7 where, in addition to policy advocacy and need-based technical assistance, UNFPA used
the un-pooled portion of its CP budget to provide implementation support in areas where new
approaches needed to be proven or the government was experiencing implementation difficulties.

Programme objectives

UNFPA assistance was focused on addressing challenges in states that were lagging behind in
development indicators- Bihar, MP, Rajasthan and Orissa, and also in Maharashtra, though it is
not considered one of the laggard states. This assistance was to achieve:

reduced regional disparities;

social inclusion- particularly of the scheduled castes and tribes, and within them of women
and girls;
gender equity, increased participation of women in local government, a reduction of gender
based violence including discrimination against the girl child;
a successful demographic transition including reducing fertility in high fertility states,
reducing high adolescent fertility, meeting unmet need for contraception, optimizing the
opportunity of the demographic dividend by addressing the health and development needs of
youth, and managing the issue of aging;
reduced maternal mortality;
Controlling the spread of human immunodeficiency virus (HIV) transmission with an
emphasis on building capacity to scale up preventive interventions in the general and
vulnerable population
16
 Part A: Introductory (Section I: Introduction)

Programme components

CP 7 has three broad components:

1. Reproductive Health (RH)

The key outcome sought in this component is to improve the RH of the population, particularly
of vulnerable and unreached groups such as scheduled castes and tribes and within them
particularly women and girls. The measures of improved RH status are:

reduction in maternal mortality

reduced unmet need for contraception
reduced adolescent fertility and
reduced adult HIV prevalence

Four subcomponent strategies are proposed to be used to address the vulnerable: first, enhance
access and utilization of high quality RH services; second, promote safe sex behaviour; third,
empower in and out of school adolescent and youth with life skills education (LSE); and fourth,
mainstream RH and gender issues into recovery and rehabilitation response to natural disaster
and environmental challenges.

2. Gender

This component focuses on mainstreaming gender in UNFPA‟s RH programs, advocates and

acts to prevent gender based violence and to empower women. In CP-7, gender based violence
and gender in general were mainstreamed into RH. The gender component focused on the area of
sex selection. The measure of success in this component is a reduced skew in the female child
sex ratio.

3. Population and Development Strategy (PDS)

The component seeks to ensure systematic use of population dynamics to guide increased
investments in gender equality, youth development, RH and HIV/AIDS for improved quality of
life, sustainable development and poverty reduction. Key strategies used are enhancing the
capacity of programme managers to use disaggregated data for integrated district planning,
monitoring and policy dialogue; making data on key issues such as aging, urbanization,
migration, abortion, maternal mortality and sex selection available when policy and programmes
are made; assessing performance through data and evidence; broadening the vision of
administrators on the linkages between population and development; strengthening the capacity
of the Office of the Registrar General, India (ORGI) and Census Commissioner for conduct of
the 2011 Census; and putting in place south south cooperation mechanisms to support knowledge
transfer for understanding of population and development issues.

Annex 1 is the Results & Resource Framework taken from the CP-7 document. It provides
details of outcome and output indicators for each of the three key components of CP 7.

17
 Part A: Introductory (Section II: Evaluation, Scope, Purpose, Objectives, Key Questions)

Section II: Evaluation Scope, Purpose, Objectives, Key Questions

UNFPA has commissioned this evaluation of CP-7. As a parallel exercise it has also
commissioned a Population Needs Assessment. The findings of both these studies will be used
to draw up a strategy for the next programme cycle-2013 to 2017.

2.1 The main aim of this evaluation is to elicit achievements made in each of the thematic areas
as well as to understand effectiveness of mainstreaming cross-cutting themes such as gender
and advocacy in programming. In addition, the evaluation from the perspective of the next
cycle of the India programme is meant to be lesson-learning and forward looking. The scope
of the evaluation therefore is to examine:

2.1.1 The financial, policy and technical assistance provided by UNFPA through the CP, in
each of its thematic and cross-cutting areas of work in terms of:

i. Whether interventions are aligned with the current and future needs of the country and
with the larger CP / UNDAF results and strategic framework;

ii. The extent to which UNFPA‟s support has added value to national and state
government programmes and priorities;

iii. The extent to which gender has been mainstreamed in UNFPA‟s work, and the extent
to which this has been accepted and adopted in Government or civil society actions.

iv. Whether adequate attention has been devoted to building capacities of Government
and other partners, and the extent to which this has been achieved

2.1.2 Whether the geographic focus and spread of the programme is appropriate;

2.1.3 Whether partnership strategies have been appropriate;

2.1.4 The extent to which internal UN coordination has avoided duplication or built synergies

2.1.5 Whether the operational modalities of implementing the programme (SWAp pooling,
annual work plans (AWPs) with partners, and direct execution) have been utilized
effectively;

2.1.6 Whether UNFPA presence has been effectively used in policy advocacy, gap
identification, programme design and implementation, and responding to the needs of
state governments.

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 Part A: Introductory (Section II: Evaluation, Scope, Purpose, Objectives, Key Questions)

2.2 Methodology of Evaluation

This evaluation was conducted between February 2, and April 30, 2011. The Terms of Reference
for the Evaluation Team are at Annex 2. The evaluation was conducted by a team of four
consultants.

The evaluation process commenced with a meeting at UNFPA on February 2, 2011. At the
meeting, senior management of UNFPA gave the consultants an overview of the concept of the
evaluation, went over the steps in the process to be followed, reviewed key elements of
UNFPA‟s Evaluation Guidelines, and reviewed the relative roles of the consultants in the
evaluation team. The relative role of the consultants is specified in Annex 3. The Advisor, Asia
and Pacific Regional Office (APRO) participated in the meeting by conference call to provide
guidance to the consultants on the UNFPA‟s minimum requirements for a quality evaluation.
Towards the end of the meeting, the consultants worked out a preliminary/draft schedule for the
evaluation. The consultants developed an inception report laying out the methods that would be
followed for the evaluation, and a list of areas to be investigated during evaluation visits and
interviews. The inception report and timeline were provided to UNFPA on February 22, 2011.
Comments received from both the Country Office and APRO were incorporated into the work
done by the evaluation team.

In these initial discussions that the evaluation team had with UNFPA it was agreed that the
evaluation would look at 4 of the 6 evaluation criteria- relevance, effectiveness, sustainability
and management. Impact could not be evaluated at this mid way stage of CP-7 because
according to the CP-7 Results Framework, impact indicators will be measured by large national
surveys only in 2012-2013. A study to establish efficiency would need to compare cost of inputs
with value of outputs, and compare the resultant ratios with those of other similar programmes.
Such an analysis would need more data than was available for CP-7 and was not possible within
an evaluation such as this one.

The steps in data collection were:

Desk review of key documents (Annex 4 provides a list of documents reviewed by the team)

Meetings with concerned UNFPA staff and some project counterparts both in Delhi and in
the states where UNFPA is present and has programmes. Between February and March, 2011
team members made visits to four of the five states where UNFPA has programmes and
offices. The team was unable to visit Orissa, but the UNFPA Programme Coordinator in
Orissa came to Delhi to meet and brief the evaluation team, as did one of the key
implementing partners of UNFPA. Ms. Priya Nanda also visited sites in Haryana and Delhi
where interventions to prevent sex selection were being implemented. Visits to the states
began with a comprehensive and detailed briefing by UNFPA‟s state team led by the State
Programme Coordinator. The members of the evaluation team then met key counterparts in
both government and non- governmental partner agencies to gain their perspectives about
UNFPA‟s role, achievements, and responsiveness to the requirements of states. The
expectations and suggestions of counterparts related to UNFPA‟s work in the present and
future were also discussed. On return to Delhi from the states, members of the team
continued to meet more UNFPA staff and government and non-governmental counterparts to
gather data and share impressions gained from the visits to the states. The evaluation team
19
 Part A: Introductory (Section II: Evaluation, Scope, Purpose, Objectives, Key Questions)

met donors - both those who had joined the RCH pooling arrangement, and those who had
not. Annex 5 is a list of the persons met by the evaluation team.

On April 21, 2011the evaluation team facilitated a gender consultation meeting for all state
and country office staff, to understand how gender was being mainstreamed into CP- 7, and
what direction the staff felt their work in gender mainstreaming should take in the future.
Annex 6 is the agenda of this consultation and a presentation made by UNFPA staff outlining
UNFPA‟s work in gender over the years.

Throughout the evaluation, members of the evaluation team coordinated closely with each
other, to reach a common understanding and analysis of issues, of how to provide a unified
picture of CP-7 achievements and issues.

The team obtained and analyzed data on the annual work plans of the country office and the
state offices, and the distribution of funds between SWAp, technical assistance, and projects
implemented by the range of partners.

The largest possible range of stakeholders had the opportunity to provide information on
their involvement in CP 7, project their achievements, their concerns and further needs.

2.3 Ethical considerations

The evaluation team was brought together after ensuring that there were no conflicts of interest.
All those who were interviewed by the evaluation team were assured of confidentiality. Where
interviews were recorded for future reference, consent was obtained. Individuals interviewed
were informed that their specific consent would be taken before anything that they said was
quoted directly. Sensitive information gathered has been collated and generalized- it has not been
used as a specific example or as a direct quote. The evaluation team has taken care to ensure that
all information that is not in the public domain is kept confidential.

2.4 The structure of the evaluation report

Part A of this report contains Sections I and II which broadly describe the programme being
evaluated, and the aims and methods of the evaluation.

Part B contains an assessment of the components of CP-7. This part contains Sections III to
VI on programme components- RH including HIV/AIDS and RH in disaster response,
adolescent reproductive and sexual health (ARSH), sex selection, and population and
development. Each of these sections can more or less be read alone. They contain
background, the results desired, findings, analysis, conclusions and recommendations. These
sections discuss the purposes and broad approaches of programme components,
substantiating and illustrating the discussion with specific examples. The sections assess and
comment on the achievements of these programmes. Conclusions and recommendations
related to a particular section are provided at the end of the section.

20
 Part A: Introductory (Section II: Evaluation, Scope, Purpose, Objectives, Key Questions)

Part C is made up of Sections VII to IX. Sections VII and VIII address the issues of
geography and partnerships, including partnerships within the UN system. Section IX
discusses the modalities of financial, administrative and human resources management in
CP-7.

Part D is conclusions, and

Part E is made up of annexes that contain supporting information that has been used in
writing the report. All annexes are referenced in the text of the report.

2.5 Challenges and limitations

The UNFPA programme is spread over 5 states of India, has many different small and large
elements and components, and is complex. Mostly, UNFPA state programme coordinators in
consultation with senior management and concerned programme officers, shape the projects that
they are implementing based on features negotiated with the host government. Therefore,
projects even on the same theme, for example on quality assurance, could differ from state to
state, with different emphases and components. Studying and commenting upon such a wide
ranging, complex programme in a coherent manner within a span of 35 days has been a huge
challenge, and this is an evaluation of the programme as a whole. It is not a detailed evaluation
of its component parts.

Several factors make it difficult to measure performance of CP-7 against the indicators specified
in the Results and Resources Framework at Annex 1. In the two programme areas of improved
access to RH services for the vulnerable, and safe sex behaviour of vulnerable groups, the
indicators are national level impact indicators that measure the overall performance of the RCH-
II and National AIDS Control Programme (NACP) III. They do not measure UNFPA‟s
contributions to these programmes. To this extent, the appropriateness of these indicators as
measures of UNFPA programme performance is in question. It would have been advisable to
select indicators that more directly reflect the outputs and outcomes of the inputs provided and
processes used by UNFPA in the geographies where it operates. The MOHFW will be measuring
achievements against the indicators of RCH-II and NACP-III in 2012-2013, using large
household surveys such as the District Level Health Survey IV, and the National Family Health
Survey IV. The Ministry is now planning these surveys. When the RCH-II and CP-7 results
frameworks were developed, no periodic/intermediate benchmarks or proxy indicators were set
up that could be used to measure progress toward achievement of desired results. The evaluation
team found that UNICEF‟s Coverage Evaluation Survey (2009) and the District Level
Household and Facility Survey-3, provide the value of two of the indicators and these interim
value have been added to the data on programme performance in Annex 1.

When the large surveys are done in 2012, attribution of results to UNFPA will be difficult.
Achievements against these indicators would depend on the pace and effectiveness of RCH-II
programme implementation by Government. Given the design of the RCH-II implementation
mechanisms, donors contributing to the programme have little control over the pace of
programme implementation.

21
 Part A: Introductory (Section II: Evaluation, Scope, Purpose, Objectives, Key Questions)

Two components of CP-7, ARSH and PDS, have outputs or outcomes that can be directly related
to UNFPA inputs and processes in the geographies where the programmes operate. Also,
projects and programmes that are being directly supported by UNFPA in the 5 states do have
input, process and output indicators specified. Some of these programmes are half way through
their implementation period, others are just beginning. These projects will be evaluated towards
the end of CP-7. At that time more complete performance data will be available.

The evaluation team relied largely on document review and discussions with UNFPA staff to
understand the programme and its achievements. Meetings were held with key government
counterparts, both at the national and the state level. Key staff of almost all NGOs engaged in
implementing UNFPA supported projects, were met. Data gathered from government and NGO
counterparts related to their overall understanding of program priorities, achievements and
challenges. They were rarely able to share data related to outcomes. The methodology of the
evaluation did not include meetings with a representative cross section of beneficiaries. The team
did meet some beneficiaries during visits to the field, but data gathered from them could best be
described as anecdotal.

This evaluation has looked at inputs, processes and such programme outputs as are evident as of
now (programmes will be completed only in 2012). This information, as well as data gathered
from stakeholders have been used to analyze and assess how UNFPA‟s work serves needs in the
country, and fills gaps in RCH-II programme implementation. It also helped to assess the
potential of programmes for scale-up and sustainability. The evaluation discusses the challenges
that the programmes has encountered, and makes suggestions for programme strengthening.

2.6 Key stakeholder involvement

The concept of the evaluation and the scope of work for the evaluation team were approved by
the GOI. Besides this, the involvement of stakeholders in the evaluation has been mostly in the
capacity of interviewees. While several categories of stakeholders have been met and their inputs
taken, the evaluation was not designed such that the team could meet a representative cross
section of final beneficiaries of programs at the community level, or providers who have been
trained in the various UNFPA capacity building programmes. The scope of work of the
evaluation did not suggest that this was necessary.

Once the evaluation findings are available, a series of consultative meetings are to be held at
which the findings of the evaluation and a suggested strategy for CP-8 are to be shared with all
key stakeholders including the government, development assistance partners, UN agencies, and
other partners.

2.7 Gender considerations in the evaluation

The evaluation team was gender balanced; it ensured that it talked to key informants of both
sexes to obtain a balanced view of programme perceptions; as the team studied the programme it
attempted to observe the extent to which they were engendered. A special gender consultation
was organized with UNFPA staff to understand fully the gender perspectives that underlay the
programme and the extent to which UNFPA staff were aware of how programmes could be
engendered.

22
 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

Part B: Assessment of Programme Components

Section III: Reproductive Health Component including Gender;

HIV/AIDS; and RH in disaster response

3.1 Background

CP- 7 of UNFPA is in consonance with the GOI‟s RCH-II programme. RCH-II commenced
from 1st April, 2005 within the overall umbrella of the NRHM (2005-2012). The main objective
of RCH-II is to bring about a change in three critical health indicators: total fertility rate, infant
mortality rate and maternal mortality ratio, for “realizing the outcomes envisioned in the
Millennium Development Goals, the National Population Policy 2000, and the Tenth Plan
Document, the National Health Policy 2002 and Vision 2020 India7”. RCH-II adopted the sector
wide approach (SWAp) which aimed to extend programme reach beyond reproductive and child
health to the entire family welfare sector and emphasized the need for decentralization based on
state and district level planning. The RCH-II strategy also envisaged pooled financing by
development partners to “simplify and rationalize the process of accessing external assistance”8.

A key component of CP-7 is the wide ranging RH component which includes adolescent sexual
and RH, HIV/AIDS, and RH in disaster. The RH component aims to achieve the following
outcomes:

3.2 Results Desired

Improved RH of the population, particularly of vulnerable and unreached groups such as

scheduled castes and tribes and within them particularly women and girls, is to be assessed
through the following indicators9 at the national level:

Reduction in maternal mortality ratio from 301 per 100,000 live births in 2001-03 to less than
100 in 2012
Reduction in unmet need for contraception: 80% of unmet need to be met.
Reduction in adolescent fertility rate from 16.8% to 12% by 2012.
Reduction in adult HIV prevalence from the 2005 level of 0.36

HIV related outcomes have been included within the overall RH portfolio because the
regional/global division of labour matrix among UN agencies designates UNFPA as the lead
agency for the prevention of HIV transmission in sex workers10. Aspects of child health are
excluded from CP-7 because that is UNICEF‟s area of focus.

7
Government of India, National Rural Health Mission; Reproductive and Child Health- Phase-II; 2006-2012;
www.mohfw.nic.in/nrhm.htm
8
ibid
9
Government of India and UNFPA: Country Programme Action Plan 2008-2012 for the programme of cooperation between the
Government of India and The United Nations Population Fund (UNFPA)
10
UNAIDS (2006): “The Framework for Supporting Country Level Action Against in the Asia Pacific Region” visit:
http://www.unfpa.org/hiv/iatt
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

The outcome indicators in CP-7 are congruent with national goals but as emphasized in CP-7, the
responsibility for implementing the RCH-II programme rests with the Government. The
achievement of outcomes depends on the pace of RCH II programme implementation - over
which UNFPA and other development partners have little or no control.

Compared to other components of CP-7, the RH component - both TA and non-TA has received
a fairly substantial proportion of financial resources and adequate priority11 .

Activities and interventions that received financial, technical and policy support sought to
achieve the following RH outputs:

Output 1: Enhanced access and utilization of high quality RH services by vulnerable

communities. This output also included gender mainstreaming through enhanced response to
issues of gender based violence (GBV)

Output 2: Safe sex behaviours among vulnerable population groups (sex-workers and women)

Output 3: Empowerment of adolescents and youth with knowledge and life skills for improved
reproductive and sexual health ((in-school and out of school)12 and

Output 4: Mainstreaming of RH and gender issues in recovery and rehabilitation responses for
natural disasters and environmental challenges

The specific indicators against each of these outputs are listed in the Results and Resource
Framework for India (2008-2012) included in the CP-7 document. Intermediate values of three
indicators are available - the percentage of deliveries attended by a skilled birth attendant13 has
increased substantially (in 2009) to 76.2% 14 from 48.8% at baseline (2005-06), against the target
of 80%. The percentage of first referral units that are functional has increased from 30% at
baseline to 52% in 200915 against a target of 100%. The number of districts that have established
Quality Assurance Groups is 1616 in 2010 against a target of 20. However, for the large majority
of indicators in the RH component, no progress data is available since data from the large scale
household survey is still awaited.

The RH programme under CP-7 comprises a wide range of activities and interventions
undertaken both at the country and the state level. Every activity has nuances and adds value to
the total programme. Details of activities can be found in the annual work-plans, state and
country annual reports and other documents listed in Annex 4. The following sections do not
describe each and every activity undertaken by the country and state offices. Rather the section
seeks to trace broad and significant patterns emerging out of the many activities and
interventions undertaken, and presents an analysis of these activities keeping in mind the criteria

11
Of the total $ 65 million, $12.6 million went into SWAp, $10.28 million was budgeted for the RH component,
$3.8 million each for the ARSH and sex-selection whereas PDS received $2.55 million.
12
Output 3 has been addressed separately under Adolescent Reproductive and Sexual Health programme.
13
Skilled births attendant include Doctor, ANM / Nurse / LHV
14
UNICEF Coverage Evaluation Survey 2009
15
District Level Health Survey 3, 2007-2008
16
UNFPA Progress reports
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

of their relevance, effectiveness and sustainability. Some specific activities or intervention are
referred to when they typify or are illustrative of the patterns being discussed.

3.3 Strategic Interventions: Findings and Analysis

3.3.1 Output 1: Enhanced access and utilization of high quality RH services by vulnerable
communities

From senior programme managers at UNFPA, and from a review of state and district project
implementation plans (PIPs), it is seen that the definition of vulnerable population is drawn from
the XIth Five Year Plan document which lays special emphasis on the health of marginalized
groups like adolescent girls, women of all ages, children below the age of three, older persons,
disabled, and primitive tribal groups17. The Plan also views gender as a cross-cutting theme
across all planned schemes.

UNFPA‟s RH interventions are located within the high focus or empowered action group (EAG)
states18 (Maharashtra is an exception) that are home to 42% of India‟s poor. The MOHFW has
further identified 265 high focus districts in India that need special attention because they have
weak public health indicators and poor health infrastructure. In October 2010, GOI allotted 13 of
these high focus districts to UNFPA. These districts are located in 4 of UNFPA‟s 5 states -
Orissa, MP, Rajasthan and Bihar. Thus a major section of the population that benefits from CP-7
programmes is poor, marginalized and vulnerable.

Working directly with the national and state governments and other key civil society partner
organizations, CP-7 supported the following broad sets of interventions/activities to achieve
enhanced access to and utilization of high quality RH services by vulnerable communities:

i. Technical Assistance (TA) and capacity building for RH programmes

ii. Quality Assurance
iii. Communitization19
iv. Programmes to reduce vulnerability to GBV and
v. Advocacy for RH

UNFPA‟s CP-7 program has envisaged mainstreaming gender in all RH activities. In the
following sections, as and when appropriate, we will comment on gender mainstreaming within
the RH programmes.

17
Government of India; XIth Five Year Plan-2007-12; Volume II-social Sector; paragraph 3.1.7; pp. 55-56
18
Government of India, National Rural Health Mission; Reproductive and Child Health- Phase-II; 2006-2012;
www.mohfw.nic.in/nrhm.htm
19
“Communitization” is a word coined in RCH II/NRHM, which is shorthand for the process of community mobilization to build
awareness, generate demand for services, prepare village plans, and use these plans to monitor service delivery and hold
government accountable.
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

3.3.1.1 TA and Capacity Building for RH Programmes

a. Provision of consultants to government: Both at the national and state levels TA for RH
largely comprise the provision of human resources or consultants to national and state
governments. In a recent incident in Barwani district of MP, when a series of maternal deaths
occurred in a public hospital, the first fact finding report was prepared by the UNFPA
programme official seconded to the government. The report became the basis on which the
state government took action. A detailed discussion on consultants provided under CP-7, and
the pros and cons of these arrangements is presented in Section IX: Operational Modalities.

b. Continuing support to state governments from UNFPA state offices: During the field
visits and discussions of the evaluation team with government officials at the national and
state level, it became abundantly clear that UNFPA state programme coordinators and
programme officers are regularly called upon to participate in and provide inputs at various
state level technical and core group meetings and consultations such as on maternal health
and family planning. It is not an exaggeration to say that in many states, UNFPA and its
officials are seen as an extension of Government and are relied upon to represent the state on
technical matters. UNFPA also helped the MOHFW to systematically assess all state PIPs.

c. Reviews, assessments, guidelines and manuals, tools: TA on RH has been provided on

wide ranging issues both at the national and the state levels. At the national level as per
programme needs articulated by government counterparts, UNFPA staff provided support to
NRHM. Assessments and evaluations of various key national and state reproductive and
sexual health programmes were undertaken. Joint Review Missions (JRMs) were facilitated
by preparing tools and a manual on „what to do while in the field, JRM reports were prepared
and mid-term reviews of RCH-II programmes participated in. Based on needs identified
through these assessments, reviews and evaluations, UNFPA either took the lead on or
played a critical role in producing a variety of technical guidelines, operational manuals,
protocols and tools:

Trainer‟s handbooks, training guides and work - books for basic emergency obstetric care
(BEmOC), pregnancy care and management of common obstetric complications, and
practices of safe delivery and immediate newborn care.

Guidelines on maternal health, skilled birth attendance, safe abortion, and (with WHO)
the management of reproductive tract and sexually transmitted infections (RTI/STI)

Operations manual for the district quality assurance programmes for RH services

Guidelines and material have been appreciated by the Ministry of Health & Family Welfare.
They take into consideration the realities of resource poor health care settings and facilities,
and offer pragmatic alternatives to protocols designed for non-resource poor settings.
Protocols incorporate evidence based public health innovations that have not yet become
standard clinical practice in India- magnesium sulphate for eclampsia, the use of uterotonics
and active management of the third stage of labour for prevention of post partum
haemorrhage, and kangaroo care to prevent hypothermia in newborns.

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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

In keeping with its mandate to prevent the consequences of unsafe abortion, UNFPA
contributed to the development of national guidelines for comprehensive abortion care and
advocated for the adoption of the guidelines.

A list of all protocols, tools, guidelines, manuals and training modules produced during the
CP-7 cycle is in Annex 7. Some of the tools and guidelines prepared prior to CP-7 continue
to remain useful for current national programmes - for example contraceptive updates, the
series of books for ASHAs, and the handbook on infertility management.

d. Operationalization of First Referral Units (FRUs): UNFPA consultants in the maternal

health division of the MOHFW supported the operationalization of FRUs and 24 hour
primary health centers (PHCs). The evaluation team views this TA as relevant and timely
since it was provided in response to the recommendations of the JRM. The DLHS 3 of 2007-
2008 shows that the percentage of FRUs made operational had increased from 30% at
baseline (2005-2006) to 52% against the end-line target of 100%.

e. Capacity building for maternal and new-born care: A series of need based training
programmes were undertaken to build capacity in key areas of RH such as EmOC, pregnancy
care and management. Obstetricians and gynaecologists in medical colleges and at the
district level were trained on evidence based delivery and new-born care practices. These
programmes have been appreciated by both practitioners and the state governments. No pre
and post test assessments have been conducted for these programmes. During its visits to the
field, the evaluation team made attempts to assess if the training provided by UNFPA is
being put into practice, but it was not possible to assess this effectively given the short time
frame available to the team. However, reports from some beneficiaries that the team met in
the field (auxiliary nurse midwives and Medical Officers), suggest that they were
appreciative of the various trainings that they attended.

f. Capacity building for family planning

Contraceptive Updates: In 2009, UNFPA funded the Indian Medical Association (IMA) to
provide its members contraceptive updates. Approximately 4000 doctors received the
updates. UNFPA prepared and distributed the instructional material on CD to the concerned
IMA branches, and organized expert master trainers to train six to eight members of the IMA
in each of the five states as trainers. These trainers in turn trained other members of the IMA.
There is no data available on the outcomes of these training programmes.

No scalpel vasectomy: Family planning in India has long been equated with female
sterilization. While no-scalpel vasectomy offers a much more convenient alternative, it is a
method for men. It is not a method that has been popular, though the technology has been
around for close to two decades and was initially introduced and promoted in India with
UNFPA support. UNFPA has supported efforts being made by the governments of Bihar and
of Rajasthan to improve the provision of no-scalpel vasectomy (NSV) services. In Rajasthan,
the government wishes to offer NSV services through special once-a-week clinics at all
district hospitals and in selected FRUs. UNFPA is supporting the branding of these clinics,
and is developing prototype communication material to promote the clinics and generate
demand for NSV. This work is almost done and the Government will then use the prototypes
to produce materials in the volumes that it needs. In Bihar there is a shortage of doctors who
are trained to perform non-scalpel vasectomy. The government would like to undertake the
27
 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

training of providers in all districts, by first training 1 trainer in each district. Commencing
2010, UNFPA helped the Government of Bihar in this effort by training 6 doctors as trainers.
Of these, 4 have been designated to serve as trainers in 4 districts. The doctors will begin
training others in the district in training camps. Currently, UNFPA is providing funds for
demand side activities to generate sufficient case load for training the doctors in these 4
districts.

The work on NSV is particularly relevant since it helps to fill a significant gap in family
planning services. Most stakeholders that the evaluation team spoke to perceived that this TA
would contribute to increasing acceptance of NSV in the states.

Post partum contraception: Training on post partum and post abortion family planning was
provided to professors from medical colleges and senior block and district programme
managers of NRHM.

The demand for post partum and post abortion family planning, as for NSV, has always been
sluggish. The needs, benefits and methods are poorly understood by the general public.
Significant and consistent effort is required to motivate larger acceptance. Mere focus on
provision of services is not going to result in greater acceptance of this method.

g. Enhancing access to FP/RH services: Government has recently begun to see public private
partnership (PPP) as a potentially viable alternative for improving the availability of services
within government RH program structures. UNFPA commissioned Price Waterhouse Cooper
to carry out a study and recommend robust processes for managing PPP so that access to
family planning services can be improved. PWC has recommended that the government use
a third party to procure services from the private sector. For instance, an agency would be
contracted by government and provided funds to make private sector services available as
required by the public sector (for instance for holding sterilization camps, offering IUD
services and so on). Under this arrangement, the contracted third party agency would be
responsible for supervising the delivery of private sector services, ensuring the quality of the
services, and making payments to the providers from funds provided by government.
UNFPA staff informed the evaluation team that UNFPA is now negotiating with government
to pilot the suggested arrangement in one or two UNFPA states, and has offered to support
these pilots with start up funds. This is an important initiative and needs to be pursued. If
successful, it would show the way for how government can use the private sector to extend
access to services in other fields of health care as well.

Even before the PWC study, states like Bihar had already initiated action on expanding
access to family planning services by accreditation of private providers so that they could be
listed as part of a network of providers of essential RCH services. However, the state is
facing difficulties with internal systems that do not allow for timely payment of subsidies to
the accredited private providers. This problem is symptomatic of a wider systemic problem-
weak procurement and contracting systems for services and goods. Technical assistance
inputs are needed to solve these problems and such assistance would have wider benefits
across the health system, including in the procurement of drugs, consumables, and small &
large equipment. UNFPA‟s recent efforts to expose legislators in Bihar to the Tamil Nadu
Medical Supplies Corporation, and the PWC proposal to develop a third party agency to
procure and manage private sector services for the public sector, are both well considered.
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

h. Formulation of project implementation plans (PIPs): In order to facilitate the

decentralized planning that is so central to RCH-II, both UNFPA country and state offices
provided TA for the formulation of state and district PIPs and helped prepare the district
health action plans which were then collated into state PIPs. Through this process UNFPA
has been able to influence state and national RCH strategy and programmes. A review of the
PIPs of Maharashtra and Rajasthan show that these states have incorporated QA into their
PIPs. At the national level too, the revised operating manual for operationalizing and
monitoring the immunization component of RCH-II provides guidance on the need to
undertake QA interventions. The evaluation team observed that NRHM program managers at
both district and block levels need training and capacity development in areas such as
programme management, financial and human resource management, to be able to contribute
fully to PIP formulations and the effective implementation of PIPs.

i. Capacity building for assessment and evaluation of health programmes: To strengthen

national capacity to conduct regular assessments, evaluations and research studies for
national health programmes, towards the end of CP- 6 UNFPA supported the National
Institute of Health and Family Welfare (NIHFW) to conduct a series of training programmes
on research and evaluation for the faculty of medical colleges and government research
institutions. In CP-7, the Center for Health and Social Justice (CHSJ) - an Indian NGO- and
the University of Washington were supported to conduct similar programmes for the NGO
sector.

The idea of building institutional capacities on research and evaluation among both public
sector health institutions and networks of NGOs has the potential to provide long term
support to national and state programmes, provided the training programmes become
institutionalized and thus sustainable. In the absence of any formal pre-post evaluation of
these training programmes it is difficult to assess how effective the programmes were.
Discussions of the evaluation team with various participants from both government and the
NGO sector suggest that these training programmes were perceived as highly relevant and
were appreciated by all the key stakeholders. As regards the future use of research capacity
built, the evaluation team found that because NIHFW is funded by the national government
as a training and capacity building institution for national health programmes, it is in a
position to sustain this programme, and will also be able to mainstream this training into its
regular calendar of training. However in the two years since NIHFW was supported for this
activity, it has not included this training in its regular calendar of programmes. There is no
evidence that NIHFW is committed to running these programmes on a long term basis. In the
case of CHSJ it is clear that it will not be able to continue this programme on its own without
funding. UNFPA should advocate with the government to develop a clear strategy for
utilizing the public sector and NGO capacity that has been enhanced by UNFPA training.
For instance government could routinely involve these institutions in carrying out such rapid
assessments as are needed to monitor the quality of RH services. UNFPA should also plan to
advocate for much greater engagement of NGOs/CBOs, public sector institutions, and other
credible and independent research organizations/institutions, in providing feedback on
maternal health and RH interventions implemented within the NRHM framework. Such
organizations should also be involved in monitoring the extent to which evidence based
practice is being used in public health institutions.

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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

j. Capacity building to mainstream gender into RH: Important inputs on gender have been
the checklist for assessing PIPs from the gender perspective, and the gender tool kit which is
a guide that helps providers and programme managers to make services gender sensitive. In
CP-7, an important capacity building input given by UNFPA to providers has been training
in gender sensitivity. Providers need to go beyond the bio-medical symptoms of a client, to a
holistic understanding which will enable more effective care and treatment. In addition to
training on clinical issues, providers need gender and other inputs which will help them to
achieve greater appreciation of social and cultural aspects.

One of the learnings discussed at the Gender Consultation workshop held with UNFPA staff
in April, 2011 was that providers are not receptive to stand-alone gender sensitivity training.
An alternative training approach is recommended - when technical training is designed and
provided, no matter on what subject, training methodology and content must ensure that
trainees are made aware of all gender and social issues that are related to the subject and that
skills are developed in delivering holistic and gender sensitive care.

Over the years, UNFPA has done a great deal of work on gender. The fundamental belief
underlying this body of work has been that women need to be treated more equally and with
more dignity than they have been treated in the past. Therefore in a way, the term “gender
sensitivity” has become synonymous with „sensitivity to the special needs of women”. This
definition needs re-examination. In recent years there has been growing recognition of the
existence and plight of sexual minorities in society. “Gender sensitivity” and gender
mainstreaming now need to aim for equitable treatment for all genders, according to their
differing needs.

In the CP-7 document, the work that will be undertaken on gender is quite clearly articulated.
However, from the evaluations team‟s visit to the state offices, and from the Gender
Consultation Workshop held with all UNFPA country and state office staff in mid April,
2011 the evaluation team perceived that not all staff has a clear and sufficient understanding
of the issue of gender and of how it should be integrated and mainstreamed into its work.
Even those working in RH were not always clear about what the gender component of their
work is and of how gender is being mainstreamed into RH. At times, personal conviction
seemed to be lacking. Without clear shared understanding of the value of including gender in
all that is done, and of how it is to be done, programme managers will miss opportunities for
mainstreaming, and may not even be able to ensure appropriate attention to gender issues
when programmes are being implemented. Concern for and inclusion of gender is the
hallmark of quality services.

In Section X of this report - Operational Modalities- the evaluation team has discussed
organizational arrangements which could be made to ensure that all programme staff,
whether in the country or state offices, understand the issue of gender from the same
perspective and know what each member of the staff needs to do to take UNFPA‟s important
gender agenda forward.

Overall, stakeholders at both the national and the state levels said that they found the TA and
capacity building provided by UNFPA relevant and valuable. All the key stakeholders
reiterated and underscored this, and singled out UNFPA TA for appreciation. TA has been
particularly relevant and effective in the content areas of maternal health and EmOC, and in
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

the preparation and development of district PIPs. Government partners have felt that family
planning related TA has, by and large, been relevant to current programme needs and has
ensured the development of knowledge and skills of practitioners. Both at the national and
the state levels there is a continuing need for TA in family planning and RH, and
governments see a continuing need for UNFPA TA in these areas.

While government and other stakeholders have appreciated UNFPA TA, it was evident
during field visits made by the evaluation team and during its discussions with community
level functionaries such as ASHAs, auxiliary nurse midwives (ANMs) and Village Health
and Sanitation Committee (VHSC) members, that there are several socio-economic barriers
that prevent women from poor communities from seeking proper health care. They said that
while the monetary incentives for institutional delivery drew poor women into the facilities at
the time of delivery, it did not really ensure change in mother and child health practices.
Women from poor communities do not seek regular antenatal or post natal check-ups. They
are unable to give up daily wages for a visit to the clinic. They continue as before, doing
what they think is appropriate within their circumstances. The evaluation team is of the view
that UNFPA‟s TA to the state governments and NRHM could have added more value by
building the capacity of government and other structures to address the specific needs of
marginalized populations and the socio-economic & socio-cultural barriers to their utilizing
services.

3.3.1.2 Quality Assurance

Among the major intervention programs supported by CP-7, Quality Assurance (QA) is one that
has responded to a much felt gap in quality of maternal health and family planning services.
Pointing to this need the M & E framework of RCH-II says that quality assurance should be an
integral part of service delivery. QA pilot projects in Karnataka and Maharashtra were
implemented in CP-6, and in CP-7 were scaled-up in clusters of districts in Rajasthan and
Maharashtra. It is expected that by 2012, the end of the CP-7 cycle, the UNFPA initiated QA
approach would be scaled up to 20 districts of both states with funds from the respective state
governments. As of today, 16 districts have been covered20.

The QA programme in Rajasthan typifies UNFPA‟s approach to quality. The programme

attempts to both assess and improve the quality of maternal health and family planning service
delivery in the primary health system- at sub-centers, and at primary and community health
centers (PHCs and CHCs). A set of tested checklists are used to assess quality of facilities. The
program includes a series of capacity building programmes at various levels. The key
implementing partner is PRAYAS, a local NGO which has a long standing presence in
Rajasthan. The Government of Rajasthan provides overall guidance and also plays an oversight
role. To ensure commitment at senior levels in the health system, the state government has
appointed nodal QA officers. The district QA team is responsible for reviewing the quality of
facilities and includes senior district officials. Periodic programme reviews are a way of
monitoring the programme and also enable corrections and improvement. The state government
sees the QA interventions in Rajasthan as successful and has made budgetary provision in the
state PIP for 2011-2012 for implementing QA programmes in 50 blocks of 19 high focus

20
See Annex 1 for intermediate results against the indicator “Number o f districts having QA groups established.
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

districts. The eventual plan is to scale up to all blocks of the high focus districts, and then to
scale up to all districts in the state.

In Maharashtra, the major implementing partner for QA is the Public Health Institute (PHI),
Nagpur- a Government of Maharashtra (GOM) institution. The structure and approaches of the
QA project in Maharashtra are similar to those described for Rajasthan. The only difference is
that while in Rajasthan the project is confined to only four blocks in the selected districts, in
Maharashtra the QA project has been implemented in all blocks of the 12 districts. The GOM has
committed to scale up the programme by adding another 6 districts, taking the district total to 18
by 2012. PHI has completed all the training and capacity building required to implement this
programme, and has included faculty of medical colleges and health programme managers in
these training programmes. These participants from medical colleges are expected to become
programme resource persons and trainers when the programme is up-scaled to other districts.

The QA programme is showing results in terms of improvement in the quality of facilities and
services at the primary care level. Between October 2009 and July 2010, the 6 districts where
implementation began in phase 1 of the project, have had a total of 3 rounds of quality
assessments. The assessment shows that there has been impressive improvement in quality in
these facilities. In the first round only 22.5% of CHCs, 4.5% of PHCs and 0.01% of sub centers
qualified to be rated as category A facilities. At the end of round three, 67.5% of CHCs, 51.5%
of PHCs and 64% of sub-centers were graded as category A facilities. The system of assessment
of facilities has been understood and internalized by the staff of primary care facilities in the
intervention areas. TA provided by UNFPA on QA, is relevant as it fits in well within the RCH-
II M & E framework. It has effectively achieved the desired outputs. Programme processes have
attempted to use capacity building approaches which will enable the effort to continue, and be
replicated in more districts. As evidenced by the PIPs of Maharashtra and Rajasthan for the years
2010-2011, where quality assurance activities have been built into the programme plans of the
states, the government has begun to see quality as an essential element of the national
programme and is committed to taking the effort forward with its own resources. Even the GOI
revised operating manual for preparation of state PIPs points out that QA must be an essential
component of RCH II and immunization programmes.

A challenge to scale-up is going to be to ensure that the government allocates adequate resources
and manpower to quality assurance programmes. UNFPA will need to work closely with the
state governments to ensure that appropriate financial and human resource provisions are made
in the PIPs. In fact, if the work of QA is to be scaled up in many more states, UNFPA needs to
take advantage of the current interest of the government in quality assurance, and to leverage
greater resource allocation at the national level for QA work in many more states. The second
challenge is that if quality is to become an essential aspect of service delivery, the health
management information system (HMIS) should report data against a few well chosen quality
indicators, and the performance of the system against these indicators should be routinely
reviewed and monitored. At present the HMIS does not include any indicators of quality.

There is a pressing need to improve the quality of services and care in India. This is a niche that
UNFPA could fill and the work that it has done in Rajasthan and Maharashtra is a credible
starting point. The value and relevance of the work of Quality Assurance could be increased by
developing and implementing a more robust and comprehensive model of quality assurance than
is presently being used. At the facility level, the model should aim for holistic quality of care
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

incorporating detection of gender based violence and support for survivors, gender sensitivity of
providers, sensitivity to the special needs of adolescents and youth, and the provision of services
based on community needs assessment. The present QA approach needs to be aligned with the
overall quality of care framework in which community needs assessment and monitoring is an
essential component. There is a clear need to bring together the experiences of both clinical and
community programmes and rebuild the capacity of the health service delivery system to plan
from the grass roots level, using community based eligible couple registers/health registers and
building much greater and intensive interface between NGOs, communities, and government
officials to bring in community monitoring of quality. In the current programme the linkages
with the community are less than adequate. Such a holistic model of QA would enable UNFPA
to weave together all its priorities in RH, quality, adolescents, gender, gender based violence,
and communitization, into one coherent framework and programme.

At the present time, in Maharashtra, UNFPA is supporting a massive sensitization programme to

train members of women‟s self help groups to enable them to demand need- based and quality
health and RH services. However this work is not being done in the same districts where the QA
programme is being implemented. In Rajasthan too, the Jan Mangal Couples, who were
originally meant to be a community based distribution for contraception, are now being used to
mobilize communities to demand quality services, but the work of community involvement in
quality needs to be much more closely linked to the QA programme.

3.3.1.3 Communitization of NRHM

The work in Maharashtra and Rajasthan, to enable communities to demand need based and
quality services, is an example of communitization.

Within the framework of NRHM, the communitization activities have in recent years, received
major attention from government and development partners alike. The work of the Advisory
Group on Community Action (AGCA) set up by the GOI is particularly relevant in this regard as
it helped to develop strategies, methodologies and tools for community monitoring of NRHM.
CP-7 too has responded with major efforts to pilot and scale-up communitization activities.

In MP and Orissa, communitization activities have aimed at strengthening the capacity of

community based structures such as VHSCs, and Rogi Kalyan Samitis21 (RKS) to carry out
decentralized planning, monitor the quality of maternal health services, and conduct social audits
of maternal and neonatal deaths.

In MP, as part of the communitization process, the State Government, UNFPA and the MP
Voluntary Health Association (MPVHA) jointly took up activities such as capacity building of
VHSC members; establishment and functioning of village information centers; orientation of
health care providers; issue based campaigns; community based monitoring and working with
health care services; experience sharing meetings and workshops; and public dialogue sessions
(Jan Sanwad). The MP Government has made district programme managers (DPMs) and block
programme managers (BPM) of NRHM accountable for communitization processes and
activities.

21
Patient welfare committees formed at larger government health facilities
33
 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

NRHM sees communitization as a means of strengthening the demand for RH services. In

Orissa, working with Orissa Voluntary Health Association (OVHA) and My Heart, UNFPA
worked in 50 villages each of 4 blocks of 2 districts, and supported training and orientation
workshops for VHSC members and a community campaign on communitization. It helped to
prepare village health plans. 50% of the villages prepared village health plans but though these
plans were handed over to the state NRHM authorities, they were not incorporated into the
district and state level plans. In Orissa the main objective of UNFPA‟s communitization program
was to develop process details for operationalizing the VHSC. The programme developed
process details, resource material and training material. These were used and adapted by the
Health Department for operationalizing VHSCs through the whole state.

Most stakeholders including NRHM officials, NGO partners and community members, found the
communitization related activities highly relevant. The activities brought partners together on a
common platform, helped build capacity on issues of community mobilization, and raised
awareness on maternal health issues. The programme succeeded in developing village health
plans and also in laying out processes for forming and activating non-existent or dormant
VHSCs. However, it was not able to get the decentralized district planning process to take
cognizance of and build upon the village planning process. Nor are the village plans being used
to deliver and monitor health services. This is largely because currently ASHAs who are
members of the VHSCs and can be important instrument to help prepare and monitor village
health plans are incentivized only for the work that they do to mobilize women for institutional
delivery, and to mobilize attendance at monthly village health and nutrition days. Our
discussions with VHSC members and ASHAs clearly revealed this. The meagre resource of Rs.
10,000 allocated to VHSCs are spent largely in meeting the logistical and other infrastructural
costs of sub-centers including rents and medicines required at the time of the child delivery as
part of JSY. During the field visits of the evaluation team, it was evident that ASHAs and
resources allocated to VHSCs are focused largely on meeting JSY objectives and not on other
aspects of village health planning and service delivery at the community level. VHSCs need a lot
of handholding to enable them to prepare tangible plans. It appears that while the village health
plans developed pay attention to maternal health and family planning issues, they do not
adequately deal with other aspects of village health and sanitation that are the responsibilities of
the Gram Sabha22.

The whole process of village planning and monitoring requires serious resources of time, and
technical support. It is the impression of UNFPA staff that government does not have either the
commitment or the resources to really make village health plans robust and to scale up these
processes throughout states. This perception combined with other priorities has led to the work
on communitization being placed on the back burner.

Communitization is an important component of NRHM programmes. The extremely relevant and

significant activities supported by UNFPA to help implement the communitization process have
to become part of a larger scheme where community empowerment and quality of services are
integral and complementary components. UNFPA should support the evaluation of various
communitization programmes - including but not limited to those supported by UNFPA- to
assess their potential for providing sustainable, community led mechanisms that will hold
government accountable for delivery of high quality health services. These communitization

22
The Gram Sabha is the general body of the village
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

models need to be studied to assess how best to strengthen VHSCs to prepare decentralized
village health plans and how they can serve as a tool for monitoring service delivery - in a cost
effective manner.

3.3.1.4 Interventions to address Gender Based Violence (GBV)

a. UNFPA has brought out a synthesis of Indian evidence on the health and social consequences
of marital violence23 . This document could prove to be a strong advocacy tool for building
sustained responses from within the health care system to gender based violence.

b. GBV in hospital and health institution settings: In CP-6 UNFPA worked on detecting
GBV in hospital and institutional settings in Rajasthan and Maharashtra. UNFPA has filled a
much felt gap in health services by developing and testing screening tools to detect domestic
violence cases in hospital settings. These tools allow tracking and follow up of cases of
gender based violence.

In CP-7 this work was implemented in one New Delhi Municipal Corporation hospital in
Delhi. Staff of the hospital including doctors, nurses and paramedics was trained to look for
signs of violence when a woman comes for services, and to refer survivors to a counsellor.
The tools for this programme need to be peer reviewed and validated before national
advocacy can be undertaken to use them at scale. There is no information available on
programme outcomes- on whether this training has had any impact on providers and whether
they are now detecting and dealing with cases of gender based violence.

c. GBV in community settings: In Rajasthan and Bihar, UNFPA worked with PRIA and The
Hunger Project respectively to sensitize members of Panchayati Raj Institutions (PRI) about
the need to address violence against women including on the issues of dowry, sex-selection
and child marriage. Pre-election voter‟s campaigns in Rajasthan, and the work with women
elected representatives in Bihar, have helped to generate wide discussion and visibility of
these issues. In Rajasthan, work started in 2009. 10,000 women PRI candidate took an oath
to fight violence against women. There has been no evaluation of this programme and there
is no evidence of any other measurable outcomes of effectiveness of this intervention.
Neither of the programmes have any indicators to measure whether PRIs are doing anything
to prevent sex selection, child marriage or other manifestations of gender based violence. In
Bihar, the intervention began in 2010 and the first report of progress is awaited.

Given the increasing importance of and devolution of powers to PRIs, and the increased
number of elected women representatives, it is important that PRIs take greater responsibility
for community based monitoring of key issues of gender based violence such as sex selection
and child marriage, and also on maternal and child health.. UNFPA should continue to work
with PRIA and THP to enhance the capacities of PRI members and ensure that there are
measurable indicators to assess the role of PRIs and their members in community based
monitoring of these key issues. If PRIs become responsible for taking cognizance of and
acting against gender based violence, it would also help to challenge inequitable gender
norms within community settings and ensure that women survivors receive community

23
Jejeebhoy et al (2010); “Health and social consequences of marital violence: A synthesis of Indian evidence”;
UNFPA/Population Council
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

support. Community partners can also help to advocate with State Governments for setting
up monitoring cells and for allocating resources to implement the Act.

d. Operationalizing the Prevention of Domestic Violence Act: In MP, jointly with Action
Aid Association, UNFPA has worked on the operationalization of the Prevention of
Domestic Violence Act (PWDA), 2005, in two districts. Due to the strong advocacy effort of
this programme, a monitoring cell has been established in the District Collector‟s Office to
monitor the implementation of the Act. Training and awareness materials have been prepared
to raise awareness and also to train auxiliary nurse midwives and ASHAs.

e. Programme for men and boys in Maharashtra: UNFPA is supporting CHSJ to implement
a programme to engage with men and boys in 125 villages of 2 districts of rural Maharashtra,
promote gender equality, reduce violence against women and achieve positive RH outcomes.
WHO conducted a meta-analysis of programmes for men and boys24 that seek to reduce
violence against women and concluded that there is no evidence to show that such stand
alone programmes for men and boys eventually reduce violence. Programmes such as that
undertaken by CHSJ therefore need to be rigorously evaluated for impact on reducing
violence against women. Started in April 2010, the programme has an evaluation plan, and a
baseline study has been conducted. Groups of men and boys have been formed in the 125
programme villages. Both the study and its evaluation are important because they have the
potential for generating evidence on the extent to which such programmes help to
mainstream gender in RH and in the achievement of UNFPA‟s overall advocacy and
programme goals of promoting gender equality and positive RH outcomes. Both the
intervention design and the evaluation design need to be constructed in a manner that will
generate evidence that will withstand scrutiny.

Most stakeholders perceived the UNFPA initiatives to institutionalize GBV in health care setting
as something of a pilot that should be scaled up if found effective. These initiatives were seen as
relevant, although it is difficult to assess the effectiveness as the programme as outcome data is
not being collected.

3.3.1.5 RH Advocacy

UNFPA‟s advocacy work has been low key and has chiefly focused upon:

a. Advocacy against the 2 child norm: Towards the end of CP-6, UNFPA, jointly with other
development partners, led a particularly successful advocacy effort with the national
government to drop the age and parity clauses that excluded young mothers below the age of
18, and those with more than 2 children, from being eligible for the Janani Suraksha Yojana
(JSY) scheme25 . The advocacy efforts were sustained through CP- 7 to ensure that these
clauses were not revived.

b. UNFPA advocated for adding a second auxiliary nurse midwife to the PHC so that the
primary health care delivery system to rural communities could be strengthened. There is
24
Barker G, Ricardo C, Nascimento M, 2007, Engaging men and boys in changing gender inequity in health. Evidence from
programme interventions. Geneva, WHO

25
A scheme that offers financial incentives to encourage institutional delivery
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

also a need for male health workers in the primary health outreach service delivery system.
When there is increased focus on male involvement in health, men in the community need
counselling and education as much as women do. On issues such as family planning,
RTI/STI, safe sexual behaviour, and violence against women, male voices at the community
level are needed to advocate for change. The lack of men in the primary health outreach
system is a debilitating gap and as long as the gap persists, women health workers will
continue to target women, burdening them alone with the responsibility for change. The GOI
is in the process of hiring nearly 53,000 male health workers in 235 high focus districts.
Currently, job description of male health workers is limited to vertical disease control work.
Their role needs re-definition. UNFPA should play a TA role in helping to define the role of
this category of health worker and in preparing it through orientation and training to play its
role productively.

c. Revitalizing Family Planning: CP-7 very accurately identified the need to revitalize the
stagnant family planning program in India. The Country Program document expressed the
need for improved conceptualization of strategies to service contraceptive needs of the
community and to provide TA to ensure systemic planning for delivering quality family
planning services. UNFPA intended to analyze past programme performance, unmet need
and expected levels of achievements, and availability and deployment of skilled providers to
provide an expanded package of contraceptive choices. It also planned to build capacities in
the FP divisions at the national level and in selected states to routinely collect, analyze and
utilize programme data for sound planning leading to improved performance. The work that
UNFPA actually accomplished in the area of family planning has already been discussed in
the paragraphs on TA and capacity building on page 18 of this report.

Advocacy issues in family planning: There have been a few issues on family planning
that need sustained and strong advocacy.

Repositioning family planning: Perhaps the most important of these is the need to
reposition family planning in India. There is a need to change service delivery and
demand generation approaches from those that push sterilization for reasons of
population control to those that recognize that men and women will benefit from deciding
early in life when they want to begin child bearing, how much space they want between
children, and how many children they want. Such family planning needs to be the
centerpiece of a primary health and national development strategy that seeks to ensure
good health and reduced mortality for mothers and infants, empowerment of women,
family well being, and poverty alleviation. However, family planning has not yet been
viewed from this perspective by policy makers and programmers. Strong advocacy is
needed to build such perspectives at all levels of the health system. Given the youth bulge
in demographic trends, and a growing body of evidence that shows the positive impact
that delaying and spacing child bearing has on maternal health and infant mortality, it is
clear that a family planning focus on youth, rather than on those who have attained their
desired family size, will pay greater dividends in both improving maternal and child
health and in stabilizing population growth. This evidence makes it necessary to
“reposition family planning”. Recently, UNFPA has begun to support two adolescent
family planning interventions in Bihar and MP promoting change in social norms that
pressure young people into early child- bearing, and promoting the use of contraception
for delaying the first child and spacing subsequent children. The results of these
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

programmes will need to be carefully measured and disseminated to ensure that the
programmes can be used to support an advocacy agenda for repositioning family
planning.

Advocating against the emphasis on single method family planning programmes: The
government health system is anxious about the high unmet need for contraception. There
is a growing demand for contraception including for non clinical spacing methods, IUD,
and sterilization. The health system has fallen behind on delivery. The response of
programme managers is to focus on the numbers sterilized. Reminiscent of the days when
the family planning programme was target driven, administrative attention and resources
are now being focused on the number of men and women sterilized. As a result, the
attention of the primary health system is diverted from routine provision of quality RCH
and family planning services, to just conducting sterilization camps. The adverse effects
of this approach are well known. The desire of the state health systems to provide family
planning services is laudable. The problem is with the single method approach that they
are choosing. It is imperative that UNFPA uses a farsighted, comprehensive and
constructive advocacy programme to bring balance into the system. There is a need to
gather, analyze and present national and international data that shows that it is possible to
achieve high contraceptive coverage and consequent maternal and child health objectives
through provision of services that deliver a basket of choices suitable for all age groups
and parities. Advocacy on this potentially sensitive issue is needed urgently.

3.3.2 Output 2: Promoting safe sex behaviours among vulnerable population groups: Sex-
workers and women

In accordance with the regional division of labour matrix among UN agencies, UNFPA is
designated to play the lead role in the area of HIV prevention among sex-workers and their
clients. Two specific indicators defined both by NACP III and by the United Nations General
Assembly Special Session to review HIV/AIDS guide the activities under this HIV output:

Percentage of female sex workers (FSWs) reached by targeted interventions –to increase
from 45% in 2005 to 80% by 2012; and

Percentage of female sex workers reporting use of condoms with their most recent client-
no specific values have been assigned by the NACP III for this indicator.

Review of UNFPA‟s HIV portfolio in India, field visits and discussions with programme
personnel suggest that in CP-7, UNFPA has not been confined to the sex-worker and client
themes, but has played a much wider role in HIV prevention. The following interventions were
undertaken during CP-7:

TA for HIV;

Interventions among female sex-workers in Rajasthan, and MP, to promote female

condoms and safe sex behaviors and

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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

Development of learning sites for the transfer of targeted interventions to community

based organizations in Rajasthan;

In addition, UNFPA has tried to integrate content on HIV into its life skills programmes for
youth. Jointly with UNICEF, UNFPA is a global lead agency responsible for working on the
theme of preventing HIV among out of school youth.

3.3.2.1 TA for HIV

Within the framework of the NACP III, UNFPA has provided TA on a wide range of issues and
activities to the National AIDS Control Organization (NACO), and in particular to the Rajasthan
State AIDS Control Society (RSACS). Some of the areas of TA that were provided by the
technical staff both at the country and the state offices include:

Capacity strengthening of RSACS to up-scale targeted interventions. This included the

establishment of a Technical Support Unit (TSU); facilitation of the Mid Term Review of
NACP-III in Rajasthan, and support during the observance of World AIDS Day/Week.

Concurrent evaluation of the Red Ribbon Express26 ;

Joint review of the Gates Foundation funded Avahan programmes in Maharashtra in

order to assess how AVAHAN funded target HIV prevention interventions for risk
groups can be cost-effectively transferred to the state government

Preparation of a user‟s manual on best practices by Community Based Organizations

(CBOs) on FSWs

In 2005, UNFPA invested in the study on convergence between the service delivery
approaches of HIV/AIDS and of RCH27 . It intended to provide TA to convert the key
themes of this policy document into action. In the CP-7 document, convergence was
rightly viewed from two angles: (a) integrating RH services into HIV AIDS services
being provided to vulnerable groups such as sex workers, and (b) integrating HIV/AIDS
services into RH service packages for the general population. Pilots were intended to
demonstrate both approaches. UNFPA is currently funding two FSW projects in MP and
Rajasthan. Neither has been used to demonstrate integration of RH into HIV services for
vulnerable groups.

Of the many TA activities in HIV, the support provided in Rajasthan is significant. UNFPA has
played a critical role in developing the action plan for HIV prevention in the state of Rajasthan,
and has also facilitated the establishment of a Technical Support Unit (TSU) in RSACS to
provide on-going technical expertise in the area of HIV prevention, through the placement of
consultants and a team of professionals. Currently UNFPA is supporting 3 state level programme

26
The Red Ribbon Express is national campaign focusing on mainstreaming the issue of HIV through a railway train and is the
world‟s largest mass mobilization campaign on HIV/AIDS. A one year long journey of the trained covered over 27,000 kms
and touched 180 district / halt stations along with outreach activities at the halting stations.
27
Convergence Between The National AIDS Control Programme (NACP) And The Department Of Health And Family Welfare
(DOHFW), Dr. Rajani Ved, February 2005
39
 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

officers to help run the TSU and has hired two field staff. The Technical Support Unit (TSU) of
RSACS is providing technical support to the State of Rajasthan to achieve maximum coverage
and sustain quality of the implementation in HIV/AIDS prevention, care and treatment
programmes. The TSU provides technical expertise to RSACS in the areas of evidence based
strategic planning & management; targeted interventions for core & bridge populations; capacity
building of civil societies & service providers; information education &
communication/behaviour change communication; advocacy & enabling environment; public-
private partnerships (PPP) & mainstreaming; and condom promotion.

The TSU team is a high calibre, technically competent team with solid previous experience of
working on issues of HIV prevention. According to the RSACS chief, the UNFPA run TSU is
the „eyes and ears of RSACS‟.

According to RSACS, some valuable contributions of the TSU include playing a „problem
solving‟ role between NGOs and the community; providing support during planning phase and in
strengthening the surveillance system. The TSU has also played a technical oversight role in
supervising some UNFPA supported female sex-worker projects in Rajasthan.

Clearly the TSU has effectively played its routine role and ensured stronger implementation of
NACP-III targeted interventions. Programme data has been systematically organized and is used
for planning purposes. This important experience could inform and help refine the HMIS for
HIV at the national level.

However, the evaluation team finds that UNFPA missed the opportunity presented by the NACP-
III to work to bring about convergence between RH and HIV. Guidance on how this can be
achieved is available from two studies, one commissioned by USAID in 200428 , and one by
UNFPA in 200529. Neither UNFPA nor others have as yet taken up the challenge of showing the
way to convergence. As funding for HIV programmes shrink and NACP-IV begins to be
designed, consideration of convergence is timely. NACO has expressed the need for TA in this
area. Any work done in this area would be hugely innovative and would need to be carefully
designed and documented. Maharashtra offers the ideal setting for this work which should be
done in collaboration with the state government. Mumbai and Pune have large populations of
brothel based sex workers and would be ideal locations for piloting sex worker interventions that
integrate RH into HIV services. Similarly, a rural district could be used to demonstrate
integration of HIV into RH. Maharashtra has a critical mass of expertise in both government and
the NGO sector in HIV AIDS programming, and two of the largest donor programmes in HIV,
funded by USAID and the Gates Foundation. UNFPA could draw all these partners into
designing and implementing a significant programme that would be truly relevant and
pioneering.

3.3.2.2 Interventions among female sex-workers to promote female condoms and safe sex
behaviour in Rajasthan and MP.

28
An Exploration of Scope for Convergence of Services between National AIDS Control Programme (NACP) and Reproductive
and Child Health (RCH) Programme, Policy Project, the Futures Group International, New Delhi, June 2004
29
Convergence Between The National AIDS Control Programme (NACP) And The Department Of Health And Family Welfare
(DOHFW), Dr. Rajani Ved, February 2005
40
 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

UNFPA has supported a couple of interventions to promote safe sex-behaviours among FSWs in
Rajasthan and MP. Population Services International (PSI) implements the intervention in
Rajasthan, promoting and testing the efficacy of female condoms among FSWs. In MP, Jeevan
Jyoti Health Service Society, works in two districts to mobilize and build the capacity of FSWs
to implement community led targeted interventions for HIV prevention. Jeevan Jyoti has set up
drop-in-centers, distributes condoms and communication materials; and offers peer counselling
and STI treatment services. Though both projects appear to be one-off and disconnected, since
they address the same population, they are likely to have the potential to offer learning that
would be useful for other sex worker interventions. It is not immediately clear how the State
AIDS Control Societies propose to sustain these two activities and mainstream the uptake of
female condoms and other prevention services provided by these projects when UNFPA support
is withdrawn.

In the MP FSW project, some recent attempts have been made to extend RH services to FSWs.
These include weekly clinics for FSWs to diagnose and treat RH problems and offer counselling
services. However, it is our considered view that the FSW projects in MP and Rajasthan can
even now be used to design and evaluate approaches to integrating SRH into HIV programs for
sex worker..

3.3.2.3 Developing learning sites for the transference of targeted interventions to

community based organizations in Rajasthan

With technical support from Ashodaya, an Indian NGO that runs a targeted intervention (TI) for
FSWs in Rajasthan, UNFPA has implemented a mentorship programme under which a series of
training programmes sought to build the capacity of sex workers to manage their own TI. The
aim is to transfer the TI to the community. While no detailed work plan has as yet been
submitted to the state office, Ashodaya plans to hold a series of workshops and training
programmes for a few identified community based organizations of FSWs and hopes to handhold
them till they are able to run their own TI programmes. As a part of this effort, a visioning
workshop was also held for RSACS officials. There is certainly a need to evaluate this
programme to assess the feasibility of the model and then to work out a sustainable way of
ensuring capacity building of community based organizations (CBOs) formed by sex workers
and other target groups.

Transferring the management of TI programmes to the community for which they are meant
appears to offer a sustainable and stigma free solution to the provision of prevention and care
services. The evaluation team recognizes that NACP- III strategy includes a major objective of
building the capacity of CBO‟s to implement TIs, and that this is the basis for supporting the
ASHODYA intervention. However, it is also important to recognize that, the concept is fraught
with challenges. In situations where sex-work is home-based and hidden- as is the case with a
large majority of sex-workers- or where women covertly sell sex as a means of supplementing
income, and do not define themselves as sex-workers - as in the Bedia and Nat tribes in
Rajasthan-it is problematic to create artificial “community based” structures to take over and
manage targeted interventions meant for them. Such a move would destroy the cover that the
women so carefully create for themselves. Once the cover is destroyed, social stigma cannot be
avoided. In the case of communities such as the Bedias and Nats, entire communities run the
risk of being stigmatized.

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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

This programme is just beginning. FSWs and NGO staff have just made one exposure visit to
Mysore to study similar programmes, and it will be interesting to observe the results of this
programme. If the ASHODYA model works, UNFPA should promote it to NACO for
replication. S Long term sustainability of programs such as Ashodaya would depend a lot on the
availability of funds to NACO to run these interventions.

In our discussion with NACO we learned that it is glad of UNFPA‟s support, particularly now as
funds from the Global Fund for HIV/AIDS for India are shrinking, and the Gates Foundation is
withdrawing support to the NACP. NACO views UNFPA positively for its technical strength in
the areas of RH, population and youth. However the support NACO expects from UNFPA is not
in the area of sex-work as there are several players (despite shrinking funds). Rather, NACO
expects UNFPA to contribute to the issues of convergence and evaluation- as with the evaluation
of the Red Ribbon Express.

In deciding on the role that UNFPA should play in HIV/AIDS, there is a need to balance several
factors: that UNFPA‟s core competence is in population and development, in RH. family
planning, and youth; and that though its core competence is not in HIV, yet its global mandate
for HIV programmes gives it the role of being the lead player on sex work. UNFPA‟s overall
strategy to address HIV prevention needs to be carefully defined within these factors as well as
with in-country expectations of it. Evaluation and convergence are certainly two key areas where
UNFPA should play a role.

3.3.3 Output 3: Mainstreaming of RH and gender issues in recovery and rehabilitation

responses for natural disasters and environmental challenges

The UNFPA country office has played a small but critical role in mainstreaming RH and gender
issues within recovery and rehabilitation responses for natural disasters and environmental
changes. It is understood that this has been done in keeping with the UNDAF commitment and
also in line with UNFPA HQ role in natural disaster.
The CP 7 programme in India has largely focused on advocacy efforts to mainstream gender and
RH into responses to natural disaster. This has been done working closely with the National
Disaster Management Authority (NDMA), the Indian network of NGOs called SPHERE which
works on issues of disaster management, and the Joint UN Disaster Management Technical
Group (UNDMT),

Worldwide, UNFPA provides “Dignity Kits” as an immediate relief item to women and girls
during a disaster and in the post disaster phase. “The dignity kits in India contain clothing for
adolescent girls and women and other items like sanitary napkins and panties that promote
maintenance of menstrual hygiene and provide basic dignity”30.

UNFPA CP-7 also provides training to NGOs/CBOs to enable them to provide psychosocial
counselling to the community.

Members of the UNDMT team agreed with the evaluation team that in India, the scale of disaster
is too large, and the Government‟s own system of response is well developed. Although the

30
UNFPA; Brochure on Dignity Kit
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

evaluation team recognizes that UNFPA support in disaster relief has been vital in leveraging the
larger pool of resources available within the government, there is very little that an agency like
UNFPA can meaningfully do to actually provide direct relief.

Though there is lot of visibility of the dignity kits, it has received mixed reactions in terms of its
uniform suitability across hugely diverse Indian cultural settings. UNFPA team members in the
states have commented on the fact that some of the materials kept in the dignity kit- for example
Salwar Kurta31 which is used largely in the north India-, were not suitable for women in the
North East or in places like Leh. Also, they pointed out that ensuring timely and regular supply
of a sufficient number of dignity kits to meet the large scale of disaster in India presented a major
logistical challenge. Perhaps the dignity kit is not the best use of UNFPA‟s technical role and
resources. Government could be assisted to source it from elsewhere if needed.

In Maharashtra UNFPA provided technical support to integrate a minimum initial service

package for RH in disaster in the professional development course for middle level managers.
UNFPA has recently signed a memorandum of understanding with National Institute of Disaster
Management (NIDM) to mainstream the gender and RH related training programmes in NIDM
and the Apex Training Institutes (ATIs). This is a welcome move in the right direction and needs
to be pursued to provide TA and assess its impact in the delivery of services.

At the present time, the only material available on how to incorporate RH and Gender issues into
disaster response is in the form of power point presentations. Considerations of sustainability
require that this content is included into all training programmes on disaster management and
response so that the content is mainstreamed and institutionalized.

Apart from large disasters, there are smaller, more localized environmental challenges - for
instance desertification and other forms of land degradation, floods and regular droughts - that go
unnoticed since they are not large in magnitude. Yet these local environmental challenges impact
men and women differentially. More often than not it is the women who bear the brunt of these
challenges. Very often men go out in search of jobs and money and women are left behind with
little or no support. A niche role for UNFPA could be within its 5 states to identify locations with
recurring or constant environmental challenges, where continuing work could be done to
mitigate the effects of challenges on the RH of vulnerable segments of society. For these areas,
UNFPA could play a role in mapping RH and gender vulnerabilities, disseminate this
information to governmental and non-governmental agencies, and advocate for them to work to
mitigate these conditions.

3.4 Conclusions and recommendations

Some significant achievements of the RH program have been:

Success at ensuring that Janani Suraksha Yojana entitlements are not limited to only women
with two children or less.

Development of a wide range of knowledge products for TA- guidelines, tools, protocols,
and manuals including those on incorporating gender perspectives

31
Outer garments used by women in the northern India.
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

State ownership of the QA pilots in Maharashtra and Rajasthan, resulting from successful
intermediate scale- up of the QA model, to district clusters in Maharashtra and Rajasthan.
These two state government have now bought into the program and will invest their own
funds for further scale up

Major efforts in communitization in MP and Orissa

Development and testing of tools for use within medical facilities to screen for gender based
violence so that survivors can be followed up and supported

An impressive TSU in RSACS offering comprehensive and much appreciated support to the
State‟s HIV programme

MOU with the NIDM for integration of RH/gender issues in training programs on disaster
response

3.4.1 TA and Capacity Building

Guidelines, manuals, protocols tools developed: The guidelines, protocols and training
modules developed and used under the CP-7 and in previous cycles need to be disseminated and
used widely, and integrated into regular pre-service, in-service and refresher training
programmes for practitioners at all levels.

Suggested Action: UNFPA should evolve an advocacy strategy to review and promote both the
training materials and the learning from various capacity building activities.

Public Private Partnership for Improved Access to RH Services: Public private partnership
does offer a means of expanding the service delivery network for family planning and RH
services provided the government has reliable systems for accrediting, using, and paying for
services provided by the private sector to the poor and marginalized.

Recommendation: Advocate with government, fund and evaluate pilots of the PWC
recommended PPP management model.

3.4.2 Quality Assurance

Improving the quality of services in the health system is a pressing area of need and requires
consistent, high level attention and there are few agencies working systematically and
comprehensively on this area. UNFPA has chosen to fill this niche. Advocacy for more NRHM
resources to be dedicated to QA in the PIPs of the 5 UNFPA states would be a good starting
point. UNFPA advocacy for inclusion of its QA model into these five states could be done in
collaboration with the governments of Maharashtra and Rajasthan, who have tried out, and are
themselves investing in scaling up the model. Simultaneously, through continued work in
Maharashtra and Rajasthan, the QA model can be made more robust through the inclusion of
some other key quality measures such as whether the facilities detect, track and follow-up cases

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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

of gender based violence; how gender sensitive and youth sensitive the systems and staff are;
how HIV has been converged with RH; whether the facility uses community needs assessment
data to tailor its services; and to what extent the community is involved in monitoring service
delivery. A holistic quality of care strategy should help to bring both clinical and community
components together to complement and build accountability on service delivery system on one
hand and the community based structures like ASHA and VHSCs on the other. UNFPA should
try and facilitate the process through evidence building, advocacy, networking and capacity
building.

Recommendations:

Advocate at the national level for greater resource allocation from NRHM/RCH for QA in
the 5 UNFPA states, for establishing QA cells at the state level and QA teams in districts,
and for financial resources for QA to be set aside in the PIPs.

Widen the quality assurance model to include gender sensitivity of providers, detection of
gender based violence, convergence of HIV with RH, sensitivity to adolescents, and
community needs assessment and engagement.

Suggested Actions:

Advocate for and fund wider use of technical guidelines, tools and protocols developed.

Assess the current QA process for gender sensitivity- to what extent are tools currently
measuring gender sensitivity, and have quality assurance activities actually led to gender
sensitivity.

As a part of its quality agenda, UNFPA could advocate for independent, objective feedback to
NRHM of program performance and quality, from agencies that have the capacity to conduct
quality assessments and evaluations, and provide actionable feedback. Funds would need to be
set aside in the NRHM budget for this role, evaluation agencies identified, and their capacities
honed. Similarly, there is a need for continuous feedback to the health system on evidence based
practices. This is an important aspect of using data for RH and development. Partnerships could
be established with academic and research agencies to gather and provide this evidence to the
health programme.

3.4.3 Communitization

Major efforts have been made in MP and Orissa. The capacity of VHSCs and RKSs has been
strengthened for decentralized planning, monitoring the quality of RH service delivery, and
social audit of maternal death. Public dialogue has been encouraged and village health plans
made. Process details for operationalizing VHSCs have been documented. This is important
work. However, over the rest of CP-7 this work should be brought to its logical conclusion.
Plans should be subsumed into district and state PIPs, and be used to deliver or monitor services.

Communitization is not an end in itself. It should lead to community empowerment, to

demanding for and receiving quality services.

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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

There is a need to develop a strong model for successful communitization. A first step could be a
study of various approaches that have been used to date, to identify what processes result in
strong and comprehensive decentralized planning, and in holding government accountable for
delivering to plan.

Suggested Action:
Evaluate various communitization programmes and models to assess how best to strengthen
VHSCs to prepare decentralized village health plans and how they can serve as a tool for
monitoring service delivery.

3.4.4 Gender in RH

Gender based violence: Addressing gender based violence or violence against women within
health care settings has been a major contribution of UNFPA. This work needs to be
strengthened and strategized in a manner that results in institutionalization and scale up. Valid
and reliable tools, widely disseminated and widely adopted, are a way of taking pilot
interventions to scale, not directly through an investment of one‟s own resources, but through the
resources of those who begin to use the tools in their own programs.

Suggested Action:
Carry out intensive policy advocacy with organizations like IMA and FOGSI to review and
vet the screening tools that are to be used in health care settings to detect gender based
violence. After review and evaluation, UNFPA should disseminate he tools widely for use.

UNFPA currently works with three powerful civil society groups on issues of gender based
violence and sex selection- The Hunger Project, Women Power Connect, and PRIA. All UNFPA
advocacy efforts in the area of gender based violence should include the strong voices of these
partners. The current programs with PRIA and THP do not have any indicators to assess if PRIs
are doing anything to prevent sex-selection or child marriage or to ensure that poor pregnant
women seek appropriate maternal and child health care. UNFPA should continue to work with
partners such as PRIA and THP to enhance the capacities of PRI members and ensure that there
are measurable indicators to assess the role of PRIs and their members in community based
monitoring of these issues.

Recommendations:
UNFPA should continue to work to enhance the capacities of Panchayati Raj Institutions32
(PRI) members through organizations like PRIA and The Hunger Project and ensure that
there are measurable indicators to assess the role of PRIs and their members in community
based monitoring of key issues related to sex-selection, child marriage and maternal and
child health.

32
Panchayati Raj Institutions are structures of the system of local self government that has been in place in India since the early
1990s, but is not yet quite fully functional.
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

Involvement of men and boys: Gender strategy within RH should necessarily bring both men
and boys and women and girls programmes together. Stand alone programmes like the one with
boys in Maharashtra should be avoided.

Recommendations:

Before the formulation of CP- 8, UNFPA should carry out an evaluation of the gender work
that it has done in support of the NRHM Programme, and prepare a document that records
the approaches it has used, the inputs it has provided, whether these have really been
institutionalized and whether they have changed the gender sensitivity of the system. Have
the gender aspects built into the PIPs been implemented? This evaluation, combined with
documenting the gender work of UNFPA post NRHM, could be a good starting point for a
fresh attempt to orienting government personnel and other stakeholders including civil
society, to the pressing need to incorporate gender sensitivity into health services.

Suggested Actions:

Stand alone gender programmes like the one working with men and boys in Maharashtra,
need review to assess the extent to which they are helping to achieve UNFPA‟s overall
advocacy and programmatic goals- promoting gender equality and positive RH outcomes.
UNFPA should have an institutional strategy to work with both men and women across all
Programmes rather than working with men alone or women alone.

3.4.5 Advocacy

A priority area for UNFPA advocacy is the achievement of a shift in perspective from the
emphasis on sterilization to that of serving the unmet need of those who also wish to delay and
space child bearing. Given the youth bulge in India, a family planning focus on youth, rather
than only on those who have attained their desired family size, is what will pay dividends in
stabilizing population growth and also in achieving maternal health and infant mortality goals.
There is a need to “reposition family planning” so that it is seen not as a population controller,
but as a guardian of maternal and child health, of environment, of quality of life, and of family
well being, and as an empowerer of women. Viewed from this perspective, family planning
needs to be the centerpiece of a primary health and national development strategy. Family
planning is not yet being viewed from this perspective by policy makers and programmers.
Strong advocacy is needed to build these perspectives at all levels.

Recommendation: Build strong advocacy strategy to reposition family planning. UNFPA should
undertake a planned program of advocacy for repositioning family planning within the ICPD
framework of informed choice and quality care with a much broader range of services rather than
merely endorsing the overwhelming use of sterilization methods that some of the state
governments seem to currently place emphasis on.

3.4.6 HIV: Promoting Safe Sex Behaviour

In HIV programming in India, the field of targeted intervention for vulnerable populations is
crowded with players who bring significant experience and large resources to the issue. UNFPA
is the designated lead UN agency for working with sex workers for prevention and mitigation of
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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

the effects of HIV on sex workers. However, the NACO does not expect UNFPA to play this
role in India. There is one particular niche in HIV that UNFPA could meaningfully choose to
fill- that of convergence of RH and HIV. Convergence has two aspects- (a) convergence of RH
services into HIV prevention and services programs for high risk groups, and (b) convergence of
HIV with RH services for the general population. UNFPA could develop its female sex worker
projects in Rajasthan and MP, into pilots to demonstrate how RH can be integrated into targeted
HIV interventions for female sex worker populations. Similar efforts could also be made within
targeted interventions being implemented by other agencies, for other vulnerable populations.
Simultaneously UNFPA should support pilots to demonstrate how HIV prevention and services
can be incorporated into RH services for the general population- one or more of Maharashtra‟s
districts where HIV and STI prevalence in the general population is greater than 1% would be
ideal for such pilots. Once proven these models can be advocated for and scaled up through
NACO‟s targeted intervention programmes, and through RCH-II.

Recommendations:
Begin to work on providing TA to NACO and its intervention programs for other vulnerable
groups on how to converge RH with RTI/STI/HIV interventions.

Suggested Actions:
For the remainder of CP- 7, develop the two FSW programs in Rajasthan and MP into pilots
to demonstrate how RH can be integrated into HIV prevention programmes for vulnerable
populations.

Work in one high prevalence district of Maharashtra to demonstrate how RTI/STI/HIV

interventions can be integrated into RH services for the general population.

3.4.7 Mainstreaming RH and Gender into Disaster Response

UNFPA plays a small but critical role in the UNDMT. It has succeeded in signing an MOU with
the National Institute of Disaster Management under which, it will contribute essential training
content on how RH and gender need to be accounted for in response to disaster. Given the scale
of disaster in India, and the very limited role that external agencies can play in a disaster
situation in India, this strategic approach to engendering disaster response is well thought out,
and should receive continued emphasis. Over the years, training inputs may be required, training
material may need refreshing, and the training of civil society organizations that pitch in to help
in national emergencies, may be appropriate roles for UNFPA to play. Given the logistics
challenges of making the dignity kit available to all who need it in an emergency, it is advised
that UNFPA discontinue the supply of dignity kits. It is also recommended that in all its 5 states,
UNFPA map areas of chronic environmental challenge, the RH vulnerabilities present there, and
advocate with Government and NGOs to respond appropriately. UNFPA may itself wish to take
on a pilot project in one or two states.

Recommendations:

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 Part B: Assessment of Programme Components (Section III: RH including Gender, HIV/AIDS & RH in Disaster)

Mapping vulnerabilities due to environmental challenges: UNFPA could within its 5 states,
identify geographic locations with recurring or constant environmental challenges, where
continuing work could be done to mitigate the effects of challenges on the RH of vulnerable
segments of society and advocate with others to work to mitigate these conditions.

Suggested Action:
UNFPA should pursue the mainstreaming of gender and RH related training into disaster
management programmes run by the NIDM and it‟s Apex Training Institutes (ATIs).

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 Part B: Assessment of Programme Components (Section IV: Adolescents and Youth)

Section IV: Adolescents and Youth

4.1. Background

UNFPA has since 2003 worked on the issues of young people in and out of school through
partnerships with the Ministry of Human Resource Development (MOHRD) and the Ministry of
Youth Affairs and Sports (MOYAS).The National Population Education Project (NPEP) was
initiated as a UNFPA-Government partnership in 1980, with „Family Life Education‟ as a focus,
and in 1986, under the National Policy on Education, was recognized in all states as a thrust area
in school education. Post ICPD, adolescent reproductive and sexual health (ARSH) was
identified as an important focus area under the NPEP. After 2005, in the wake of controversy
around sex education, and in tune with the recognition of „Adolescent Education‟ in the school
curriculum by the National Curriculum Framework (2005), the ARSH Programme was
restructured as the Adolescent Education Programme (AEP) in school settings. As a continuation
of these years of involvement that CP-7 envisaged empowering adolescents and youth both in
and out-of-school with knowledge and life skills for better reproductive and sexual health.
The “Adolescent Health and Development” (AHD) project was designed in line with the focus of
the National Youth Policy for out-of-school adolescents this segment.

4.2. Results Desired

Adolescents and youth are a part of the RH component of the CP. Output 4 of the RH component
is: “Adolescents and youth empowered with knowledge and life skills for improved reproductive
and sexual health (in school and out-of-school).” The indicators for this output are:

% of youth 15-24 with accurate knowledge of HIV/AIDS who recall 3 modes of

transmission, 2 modes of prevention and who reject major misconceptions about HIV
transmission- this is to be measured by NACO‟s BSS at the end of NACP III though no end
line value has been specified.

Application of life skills by adolescent boys and girls- for which no base line is available and
the end line value is 40% of boys and girls in intervention will demonstrate life skills.
Measurement of achievements is to be through the administration of skill application tests.

Integration of LSE in school curricula and extracurricular activities- LSE gaps have been
identified by a baseline mapping exercise. At end line, LSE should be included in school
curricula and extra-curricular activities.

The number of teachers trained to impart knowledge and skills through LSE- no baseline or
end-line values have been specified. However, for the purpose of monitoring and measuring
teacher training, UNFPA has established a goal of training at least one teacher for every 150
secondary school students.

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 Part B: Assessment of Programme Components (Section IV: Adolescents and Youth)

4.3. Strategic Interventions: Findings and Analysis

CP- 7 pledged to continue supporting interventions and provide technical assistance to reach
adolescents and youth through a range of partners with emphasis on “increasing access to
knowledge and providing opportunities for acquiring life skills for both in-school and out-of-
school adolescents”. The two main national supports were to be the MOHRD for
adolescents/youth in school, and MOYAS for out-of-school youth. A third component of the
programme for adolescents and youth is “Institutionalization of Adolescent and Youth Friendly
Health Services”.

4.3.1. Programmes for adolescents in school

The Adolescence Education Program (AEP) aims to empower young people with accurate, age
appropriate and culturally relevant information, promote healthy attitudes and develop skills to
enable them to respond to real life situations effectively.

The conceptual framework guiding programme design and implementation has been updated in
2010, to recognize adolescents as a positive resource and focus on the transformational potential
of education in a rights framework. The guiding principles of the program recommend that AEP
should be participatory, process-oriented and non-judgmental, and that it should not be
prescriptive, stigmatizing or fear inducing. AE should enable adolescents to understand and
negotiate existing and constantly changing lived realities.

The updated training/resource materials address various topics of concern to adolescents

including gender discrimination, sexuality, and HIV AIDS

The revised conceptual framework and the updated training and resource materials is a big step
forward from the „abstinence only‟ curricula that was the forced reality of AEP immediately after
the turbulent political controversy that arose in 2005 around sex education in schools. As a
result of consistent advocacy efforts by multiple stakeholders including civil society, academic
and research institutions, UN agencies, educationists, and certain government departments and
officials, program related resource materials were revised and updated. The National Council for
Educational Research and Training (NCERT) revised the adolescent education curriculum to
make it more comprehensive and responsive to the concerns of young people.

The training and resource materials currently used in the program are the outcome of a series of
consultative workshops in which professionals from all concerned constituencies, including
adolescents and teachers, contributed. In 2010, the revised resource materials were pre-tested
with master trainers and teachers. Quantitative and qualitative feedbacks were taken on five
criteria including content, understanding, transaction, learner participation, relevance and
usefulness. The average score across the 5 criteria was „4‟ on a scale of 1 through 5 with 1 being
„unsatisfactory‟ and 5 being „excellent.‟

It is recognized that outcomes in terms of prevention of teenage pregnancy, RTIs/STIs and HIV
are important for programs working to improve sexual health of young people. These issues have
been addressed in the curriculum. Although, it may seem that there is less emphasis on these
specific risk behaviours, the contours of the curriculum are determined by the reality that
substantive proportions of unmarried adolescents in India are not sexually active either by choice
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 Part B: Assessment of Programme Components (Section IV: Adolescents and Youth)

or due to social norms disapproving of premarital sex. Findings from the nationally
representative youth survey conducted by Population Council and International Institute of
Population Sciences in 2006-07 show that in the age group of 15-24, 12% unmarried males and
3% unmarried females reported pre-marital sex. In order to respond to young people‟s concerns,
the curriculum focuses on important non-health attributes that have a strong influence on health
outcomes, for example the agency of young people, gender norms in the local context etc. The
updated training and resource materials fulfill the 18 criteria cited as key characteristics of
effective sexuality education programs as provided in UNESCO‟s International Guidance on
Sexuality Education of 2009.

4.3.1.1. Programmes using co-curricular approaches

a. The co-curricular approach: works through the three national school systems - Central
Board of Secondary Education (CBSE), Navodaya Vidyalaya Samiti (NVS) and Kendriya
Vidyalaya Sangathan (KVS). The program works on a cascade training approach that has
created a pool of master trainers who orient nodal teachers who are entrusted with the
responsibility of transacting life skills based education (16 hours module) to secondary
school students through interactive methodologies. Nodal teachers are provided guidelines
and materials to facilitate the transaction process. Advocacy sessions are organized with
principals of participating schools and sensitization sessions are held with parents. By end
2010, at least two nodal teachers from 3500 CBSE schools, all the 919 KV schools, and all
the 583 NVS schools have received orientation on adolescent education issues

For better impact and quality, the programme has been consolidated in 5 UNFPA priority
states (rather than 32 States), to achieve the goal of one trained teacher for every 150
secondary school students.

The programme conducts an annual assessment of the quality of the nodal teacher‟s training.
The assessments for the years 2008 and 2009 used 4 indicators: how completely was the
content covered, have life skills been integrated, did trainees participate actively, and did the
participants feel confident that they would be able to deliver the curriculum in a class room
setting. On a scale of 1-5 where 1 is unsatisfactory and 5 is excellent, the average score
across all the four indicators was 4, i.e., very good. These scores are statistically significant.
Change in knowledge is higher than change in attitude which is understandable since
attitudes are harder to change through training. Similar results are visible from the
assessment of teacher training programs and sensitization programs held for principals.

A concurrent evaluation of the co-curricular component of AEP was conducted across 200
schools in 5 different states of the country in end 2010 and early 2011. Recognizing the fact
that there is a lack of good instruments for assessing life skills, a consortium of experts from
relevant disciplines was created to develop the assessment tools. The core group developed
the draft tool kit that was validated by a larger group of experts and finalized after field test.
Both quantitative and qualitative tools were used to assess adolescents‟ knowledge, attitudes
and abilities to apply life skills in the context of their health and well being. The data from
the evaluation are still being analyzed but preliminary findings using an experimental and
control design show modest programme effects. Findings show that 56% of the adolescents
who have been exposed to the programme knew the correct definition of menstruation
compared to 14% who have not been exposed to the programme. In comparison to 62% of
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 Part B: Assessment of Programme Components (Section IV: Adolescents and Youth)

adolescents who did not have programme exposure, 70% who were exposed to the
programme knew that green leafy vegetables should be included in the diet of anemia
patients. Ninety percent of adolescents exposed to the programme had correct knowledge of
minimum legal age at marriage in comparison to 81% who did not have programme
exposure. Sixty seven percent of adolescents exposed to the programme knew that male
condoms can prevent both HIV transmission and pregnancy compared to 58% who were not
exposed to the programme. Similarly on attitudes to gender and response to sexual
harassment, students exposed to the program had marginally higher scores than did students
who were not exposed to the program.

b. Orissa: In the Kalinga Institute of Social Sciences (KISS) in Orissa, a different approach to
life skills and adolescent education is being followed. Inputs are provided in both co-
curricular and curricular formats and age appropriate content is provided in all classes
starting from primary school. Institutional capacities are being enhanced for broadening the
research base for AE and LSE (LSE). KISS has 12000 tribal students who are the direct
beneficiaries of this program. The efforts of KISS in Orissa aim to upscale the intervention
through ashram schools33 where tribal students from vulnerable areas will be benefitted.
Effective linkage of KISS to NCERT and the State Council for Educational Research and
Training have not so far been established.

c. Bihar: In 2010, UNFPA began to work with SCERT, Department of Human Resource
Development, Government of Bihar, to reach out to young people in about 1000 secondary
schools across 9 districts with information and skills for improved health and well-being.
CEDPA is the lead technical agency appointed by UNFPA for providing technical assistance
to SCERT, and for ensuring that the ability to address adolescent concerns is institutionalized
in the government school system. CEDPA has created a pool of 100 master trainers. Two
hundred teachers have been oriented to the program. This is the first pilot that uses the co-
curricular approach in state government schools and will help to take the program to scale in
Bihar. It is noteworthy that the costs of the project are being shared between the Government
of Bihar and UNFPA, laying the ground for sustainability of the effort.

4.3.1.2. Curricular Approach

a. The curricular approach: The National Curriculum Framework (NCF)34, 2005 clearly
outlines that rather than a stand-alone program the AEP should become an integral part of
school education. At the present time, UNFPA‟s work at the national level with MOHRD
is largely co-curricular. The goal remains to mainstream adolescent education into the
curriculum. NCERT has undertaken a content analysis exercise which shows that
textbooks in different parts of the country have integrated adolescent education issues
into various scholastic subjects. Efforts are underway for more comprehensive inclusion
of adolescent concerns into the curriculum. The Council of Boards for School Education
(COBSE) is involved in advocacy efforts with relevant stakeholders in selected state
education boards in India, to integrate life skills into the curriculum.

33
Ashram schools are residential schools for tribal boys and girls
34
A policy document to guide school education across the country
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 Part B: Assessment of Programme Components (Section IV: Adolescents and Youth)

b. National Institute of Open Schools (NIOS): Curricular interventions also include

ongoing UNFPA support for integration of life skills in the secondary curriculum of
NIOS that enrolls approximately 400,000 learners each year. NIOS provides those who
cannot enroll in regular secondary and senior secondary schools with the opportunity to
learn on their own, attend contact classes to seek clarifications on items that they do not
understand, and take qualifying examinations. Learning materials in NIOS must facilitate
self learning and are popularly known as „teachers in print.‟ NIOS officials have bought
into the idea that life skills enhancement is a worthy initiative that would go a long way
in improving the overall quality of their learning materials. In 2009, NIOS took an
informed decision to undertake an innovative pilot to integrate life skills in selected
lessons and subjects in its secondary curriculum.

In order to maximize the reach of the integrated lessons, the most popular subjects of
Home Science, Social Science, Science, and Languages (Hindi and English) were
identified for integration. Life skills woven into the curriculum include empathy,
communication skills, and recognition that a large population could also be viewed as
India‟s most important asset and Life skills were woven into all the 15 model lessons
without compromising the subject content. Consistent efforts were made to enhance
capacities of subject coordinators, lesson writers and tutors (who provide clarifications to
open learners). Several rounds of sensitization workshops were organized and this
initiative will be further strengthened in the coming years. As yet, the integrated lessons
have only been in limited circulation, but the feedback from all stakeholders has been
very positive.

c. Rajasthan: In 2005, life skills focused adolescent education was introduced as a separate
subject in the senior secondary curriculum across approximately 4500 government
schools in the state of Rajasthan and the subject is now institutionalized within the
government schools. The state government has bought into the programme completely
but has not yet thought about investing its own resources into continuing the programme
once UNFPA financial support for the programme ends. Sustaining the programme with
Government‟s own resources is critical.

d. Life skills integration into pre-service teacher training: Recognizing the importance
of integrating life skills and adolescent concerns in the pre-service teacher training
curricula, UNFPA‟s Rajasthan state office has launched an ambitious project in
partnership with all the seven universities in Rajasthan that provide pre-service teacher
training. The curricula are under revision and it is expected that by 2013, teacher trainees
will be trained in the integrated curriculum. This activity is very important to ensure long
term effectiveness and sustainability of school based programmes.

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 Part B: Assessment of Programme Components (Section IV: Adolescents and Youth)

4.3.1.3. Health Services for in-school adolescents

Given the gradually improving school continuation rates through middle and senior school in
India; there is an enhanced focus on providing youth friendly health services in school settings.
Mental health and counselling is being rightfully recognized as a vital component of school
health services. However, there is very limited information on the feasibility of providing
counselling services in school settings in India.

In order to address this gap, the services of a professional agency, Sangath were hired in 2009-
2010 to build capacities of existing nurses in the Jawahar Navodaya schools35 from two regions
in the country- Chandigarh and Pune- to provide first level youth friendly counselling services.
In the pilot phase, 32 staff nurses in the Chandigarh region and 26 staff nurses in the Pune region
were trained and approximately half of them received continuous telephonic supervision.

An assessment after one round of orientation and refresher training showed that 98% of the staff
nurses agreed that the training was useful and 98% felt that it would help them in their work.
Based on these findings, the 10 day orientation program followed by a three day refresher
training programme and constant telephonic supervision have been extended to all the 5 UNFPA
priority states. In these states, 4 orientation training programmes have been completed and 96
nurses have been trained from 4 of 5 regions. Although the importance of providing counselling
services is well understood, more efforts need to be made to popularize these services and
improve their uptake. At present, a trained staff nurse sees only one case per month. A
qualitative assessment of the pilot phase conducted in 2010, shows that several systemic barriers
need to be addressed so that improved counselling services can be provided and accessed by
students in school settings.

4.3.2. Programmes for adolescents who are out-of-school

As envisaged in CP-7, these programmes were to focus on developing new structures or utilizing
the potential of existing structures to reach rural out-of-school youth with adolescent
reproductive and sexual health knowledge. A national level program with the Nehru Yuva
Kendra Sangathan (NYKS) was to organize most rural youth into Teen Clubs. The Ministry of
Youth Affairs was to be the key nodal ministry for reaching out-of- school youth. The Country
Plan also included exploring opportunities for partnership with the National Service Scheme
(NSS) and the Rajiv Gandhi National Institute of Youth Development (RGNIYD). The potential
of the rural IT kiosks to reach youth was also to be explored. In Orissa, village based Balika
Mandals (girls groups) were to be formed and linked to anganwadi centres. In Rajasthan they
were to be reached through post literacy schemes.

4.3.2.1. Nehru Yuva Kendra Sangathan (NYKS) Teen Clubs

Starting in 2006, approximately one hundred thousand adolescent girls and boys were enrolled
through 4000 teen clubs in 64 districts across 31 states. The enormous geographical spread of the
initiative led to difficulty in monitoring and getting a good understanding of the quality of

35
Jawahar Navodaya Vidyalayas are residential government schools in rural areas that are mandated to have a para-medical staff
available on the campus round the clock
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 Part B: Assessment of Programme Components (Section IV: Adolescents and Youth)

program implementation. Hence, an independent assessment was conducted by UNFPA‟s

country office in the first quarter of 2010.

The assessment covered 120 teen clubs in 5 representative geographical regions of the country.
It was found that though the programme was meant to serve out-of-school youth, only 11% of
members were out of school youth. The rest were all in school. On an average, there were 122
male teen club members for every 100 female members. While lower participation rates of girls
is understandable given the social norms that restrict participation of girls in activities outside
school and home, work is needed to improve the enrolment and active participation of girls in
these fora.

The 2010 assessment measured the knowledge of Teen Club members on some key adolescent
RH issues. Unfortunately since no baseline was done for the teen club program in 2007, changes
brought about by the program cannot be compared with what prevailed before the programme
started. Findings of the National Youth Survey conducted by the Population Council of India
and the International Institute of Population Sciences in 2006-2007, and of the National family
Health Survey of 2005-2006 were examined. One measure that is not identical but is reasonably
similar and could be compared is in the National Family Health Survey and is related to
knowledge of HIV prevention. 52% of young people in the age group 15-24 reported that
HIV/AIDS can be prevented by using condoms and limiting sexual intercourse to one uninfected
partner. In the Teen Club Assessment, 80% of Teen Club members were aware that the major
modes of HIV transmission were infected blood, unprotected sexual intercourse, and multiple
sexual partners.

UNFPA has now decided to re-strategize the Teen Club initiative and from 2010 to implement it
in only the 5 UNFPA priority states so as to avoid spreading the programme too thinly over the
entire country.

UNFPA is now attempting to design alternative models to reach unmarried adolescents who are
out of school. The objective remains to provide them with focused experiential learning on
reproductive and sexual health issues in a gender-sensitive manner; information on education and
skills building for better employability; and to improve access to youth friendly and gender
sensitive services in the public and private sectors.

4.3.2.2. The Rajiv Gandhi National Institute for Youth Development (RGNIYD)

RHNIYD is being supported by UNFPA for its Masters Programme in Life Skills Development
to create and nurture a pool of well-trained human resources equipped to respond to adolescent
concerns. The programme commenced in 2008 when the first batch of 9 students was enrolled.
The batch graduated in 2010, and 6 students have been placed. The second batch enrolled in
2010 has 33 students. A faculty of 6 are involved in teaching, extension work, and research.

At RGNIYD, the UNFPA Country Office also supports a community radio program that is being
run by young people enabling them to articulate their concerns and also to find ways of
addressing some of them. This initiative also builds awareness on various issues related to the
health and well-being of young people. Officials in the Ministry of Youth Affairs informed the
evaluation team that government considers this community radio programme a great success, and

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 Part B: Assessment of Programme Components (Section IV: Adolescents and Youth)

would like such programmes to be replicated in other states. However the ability of the
community radio program to reach and involve out-of-school youth has not yet been assessed.

4.3.2.3. The Samarthan programme in Sehore, MP

Since July 2008, Samarthan has implemented a pilot intervention in 205 villages in Sehore
district of MP, to enhance life skills of young people. Each village has 3 groups, of adolescent
boys, adolescent girls, and newly married couples. There are 615 youth groups in the 205
villages. Capacity building activities have been conducted for different groups and a trained
cadre of 205 girls and 205 boys has been created to facilitate orientation of other youth groups in
the villages on RH issues and concerns. The groups also take collective action to improve both
demand and utilization of RH services. Youth groups help to monitor the availability/delivery of
primary RH services to the poor and the marginalized in the village. As a result of consistent
efforts of the youth groups, 213 out of the 245 anganwadi centers36 have begun to function
regularly. VHSCs have been formed in all the 205 villages and 95% of gram panchayats 37 have
started discussing reproductive and sexual health issues. Better menstrual hygiene practices, and
higher demand for family planning consequent to counselling of all newly married couples, are
reported. However, evidence from the field reveals that there is a need for UNFPA to do
effective policy advocacy with government for recognition of the model and its scale–up.

4.3.2.4. Interventions for adolescent girls in Rajasthan

In four blocks of each of four districts in Rajasthan, support is being provided to an initiative that
reaches approximately 20,000 out-of- school adolescent girls with the objective of empowering
them with knowledge and life skills for improved reproductive and sexual health and to delay the
age of marriage. Adolescent girls‟ clubs have been established in these blocks and a village level
animator holds weekly sessions to build awareness. The girls are connected to formal or non-
formal education. The learning from this programme has fed into the development of the
SABALA (empowered woman) programme that has been approved by the national government
for implementation in selected districts across the country. The resource material developed
under the UNFPA supported programme has been nationally disseminated to all the states where
the SABALA programme is now being implemented.

4.3.2.5. Interventions for newlywed couples including married adolescents in Bihar and
MP

RH and family planning interventions with these groups to change social norms of early
childbearing, and to increase the adoption of contraception to delay first child and space
subsequent children are underway in Bihar. A similar activity has also begun in MP.

All these programmes are approaches to reaching out-of-school youth with RH information and
education and methods and results need to be watched carefully. Given that 65% of India‟s 240
million adolescents aged 15 and above are not in school, reaching adolescents in out-of-school
contexts is vital. The evaluation team finds that there are three challenges to reaching out-of-
school adolescent with effective health and development programmes. The first is to design

36
Government sponsored pre-school education and nutrition centers
37
Village self government councils
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 Part B: Assessment of Programme Components (Section IV: Adolescents and Youth)

essential content in a manner that can be delivered completely and with consistency in
community settings. The second is finding appropriate delivery systems that can achieve
effective contact with out-of-school adolescents and youth. The third is to find delivery systems
that can reach scale. Given the enormous number of adolescents to be reached, financial
investment by government will be required, and advocacy to encourage this investment is
essential. The use of voluntary peer educators poses challenges too. Training, retraining,
motivating, supervising, and managing a field force of peer educators so that the programming
that is desired is effectively implemented is even more challenging than managing a paid work
force because volunteers are hard to hold accountable. The life skills approach which desires to
build skills and linkages for livelihood and careers is extremely ambitious. It involves much
more than delivering specific RH information in a short capsule. There is no evidence that life
skills programs have been successfully delivered by peer educators. A programme that has to
reach out-of-school adolescents to scale must have clear and limited objectives, clearly and
pragmatically defined content in a brief capsule which can be delivered in a very short period.
UNFPA‟s excellent life skills module for schools contain material that can be refocused for
adolescents out of school, enabling them to make healthy and responsible sexual and
reproductive choices as they grow into marriage and adulthood. Such a programme can be
delivered as a one-time intensive capsule by NGO training teams visiting communities. The
value and impact of this model has been demonstrated by Pathfinder International‟s Prachar
Project in Bihar. If India‟s millions of out-of-school adolescents are to be reached several
alternatives will have to be developed and tested.

4.3.3. Institutionalizing Adolescent Friendly Health Services

NRHM provides for the provision of adolescent friendly health services through the primary
health facilities. Based on this, the government of Maharashtra has made provision in its PIP for
opening adolescent friendly health clinics in its facilities. By the end of 2009, the government of
Maharashtra initiated 73 adolescent friendly health clinics in 33 districts and a few municipal
corporations. These clinics have been branded and named Maitri (friendship) clinics in
consultation with experts and adolescents.

UNFPA support to this endeavour included conducting workshops to build the perspective of
providers in the facilities where the adolescent clinics were located; orienting them on an
implementation guide; and holding workshops for district officials of related departments such as
the National Service Scheme, NYKS, Department of Youth Affairs and Sports, and Department
of Education). Counselors appointed by GOM at all district hospitals, were trained on ARSH
issues. GOM was supported in building the capacity of Mother NGOs and Field NGOs of the
RCH project, to mobilize attendance at the clinics and to refer adolescents to them.

The GOM requested UNFPA to undertake an evaluation of the functioning of the Maitri clinics
and to assess service environment, status of training of service providers and availability of
information to adolescents with regard to ARSH services. The study revealed that around 61% of
facilities had one medical officer (either a male or female) trained for provision of ARSH
services; only 8% of the facilities had both medical officers trained. Only 30% of facilities had a
trained paramedical staff for provision of ARSH services. Communication material on ARSH
was available in only around 22% facilities. All but 4% of clinics had an appropriate waiting area
with sitting arrangement. 75% facilities had a clean examination table. Contraceptive availability
at the clinics was low, although most hospitals where clinics were functioning had sufficient
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 Part B: Assessment of Programme Components (Section IV: Adolescents and Youth)

quantities of contraceptives and these were made available to adolescents as and when required.
In the one year between 1st April 2010 and 31st March, 2011, 53137 adolescents (40% male and
60% female) accessed the services provided by 73 clinics. The scope of services included
counselling for contraceptive choices, handling concerns related to menstruation and gender-
based violence, improving life skills, providing antenatal services, and treatment of RTIs/STIs.
Thus, the access and quality of services were quite limited and the intervention did not have
much success.

The GOM has requested UNFPA to help it to devise a feasible alternative to the present NRHM
concept of youth friendly services/clinics. Re-examination of the concept of youth friendly
services as laid out in NRHM and RCH-II is definitely required. This is an important NRHM
activity and a well thought out concept and demonstration pilot will offer concrete alternatives to
many states of India, most of whom are struggling with understanding the purpose and
modalities of the concept of YFS and with how to implement it.

4.3.4. Programmes/Projects not taken off

a. Support to the MOYAS to undertake conduct of an adolescent survey for reliable data
on adolescents: After the detailed survey on adolescents/youth undertaken by IIPS and the
Population Council, UNFPA did not pursue this matter.

b. Harnessing IT Kiosks in rural areas: UNFPA was to explore the possibilities for piggy
backing on existing IT networks to reach rural youth with an essential package of life skills
focused reproductive and sexual health information. Meetings have been held with ITC,
IL&FS and state governments in this regard. Progress needs to be made in both in preparing
the soft ware modules to be hosted on the IT networks, and on getting permission to use the
IT kiosks for this purpose. During the rest of CP-7, UNFPA will focus on preparing the
standardized curriculum in soft ware.

c. Balika Mandals in Orissa: A collaborative effort with the Department of Women and Child
in Orissa was to pilot Balika Mandals in two districts of Navrangpur and Khurda. UNFPA
developed prototype materials for training trainers/facilitators, field tested them and shared
them with government but there has as yet been no comeback on this activity.

d. Post-literacy centers in Rajasthan: As GOI has revised the strategy for engagement of
these literacy centers, this activity has not been pursued.

e. National Service Scheme: The collaboration with National Service Scheme for engaging
college students to reach out to rural out-of-school adolescents has not taken off so far in CP-
7. UNFPA is discussing a broad based intervention with the Institute of Health Management
at Pachod in Maharashtra. Discussions are ongoing on how students from colleges that are
based in urban locations can reach out to adolescents in disadvantaged urban areas located
close to the colleges.

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 Part B: Assessment of Programme Components (Section IV: Adolescents and Youth)

4.4. Conclusions

A significant achievement of the adolescent health program in CP-7 has been the development of
a sound conceptual framework, with curricular and co-curricular training and resource material
for use within the school system. UNFPA‟s use of the LSE approach, wide consultation, and
concern for quality, successfully overcame the challenges posed by the controversy that arose in
2005 around sexuality education. Government and other stakeholders acknowledge UNFPA‟s
important contribution to the field of AE through the development of material that adapted
international technical guidance to the country‟s cultural values, while successfully addressing
the core concerns of young people in a gender, empowerment and rights perspective.

Except in Rajasthan, the co-curricular in–school programme has been initiated in schools
controlled by the central government. These are the schools for the more privileged sections of
Indian society, and form only a small proportion of the Indian school system. Only work through
the state government run schools can reach the less privileged young people, and also reach
scale. Advocacy efforts are being made for curricular integration in selected state education
boards through COBSE. These are relevant initiatives, and have to be sustained through
advocacy and technical assistance to NCERT, COBSE, SCERT and selected state governments.

Recommendation:
UNFPA should stay with the initiatives it has taken through NCERT to introduce school
based LSE initiatives. This work should now be scaled up to state board schools. The
advocacy work already begun with COBSE needs to be hastened. UNFPA must advocate
with the Government of Rajasthan to make budgetary allocation for this programme from the
regular budget of the department of education, else the programme will die out when UNFPA
funds cease. The successful work done with the 4500 Rajasthan State Board schools should
be used to strengthen advocacy with other states for introduction of LSE into school
programmes.

The quality of nodal teacher‟s training programme as assessed during 2008-2010 has been found
to be better at changing knowledge than in forming attitudes. Preliminary findings from a
concurrent evaluation just completed show modest programme effects of LSE on the knowledge
of students.

The approach being used at Kalinga Institute of Social Sciences, of drawing up a LSE
programme that reaches children with age appropriate inputs from primary school onwards,
rather than just in high school, is interesting, has potential and is challenging. This experiment
needs to be watched closely and its quality and uniformity carefully guided and assessed.

Suggested Action::
UNFPA needs to link KISS with NCERT which is working on developing the LSE
curriculum. The two organizations are using different LSE approaches and a linkage between
them would result in mutual learning, and the provision of technical backstopping from
NCERT to KISS, and a continuing review of the KISS model by NCERT. KISS is influential
in Orissa, and linking NCERT with it will also further the processes of taking LSE
approaches into the schools affiliated to the Orissa State Board of Education.

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 Part B: Assessment of Programme Components (Section IV: Adolescents and Youth)

Feedback from the NIOS‟ limited use of UNFPA‟s material as integrated into the NIOS
curriculum in home science, social sciences, science and languages, is positive. NIOS is now
working towards integration of life skills across all 150 lessons in science, social studies, and
languages.

Pre-service teachers‟ training, as has been initiated in Rajasthan, and is a relevant, effective and
sustainable approach to giving teaches the skills that they need to work with adolescents on life
skills, maximizing the chances of making future work in schools, whether co-curricular or
curricular, successful.

Recommendation:
Pre-service teachers‟ training programs would make school based programs more cost
effective and sustainable. The pre-service teacher training program beginning in Rajasthan
needs careful guidance and management so that it demonstrates the way forward for pre-
service training in other states.

To reach out-of-school adolescents is of the highest priority for adolescent programs The
independent assessment of Teen Clubs conducted in 2010, shows that the Teen Clubs model has
not been effective in reaching out-of-school adolescents. The evaluation team concludes that the
real challenge of the out-of-school programme is content and delivery system. What is needed is
an essential package of RH inputs that can be provided in a time and cost efficient manner to the
millions of adolescents who are out of school in rural and urban areas. Reaching so many
adolescents in community settings requires investment and advocacy with government is
essential so that the necessary financial commitments are made. Apart from the variants of the
Teen Club model that UNFPA is now beginning to develop and test, other alternative approaches
should also be developed. The pilot in Sehore district in M.P. being implemented by Samarthan
is comprehensive in approach (adolescent boys and girls and the newly married group) and
content (RH issues and has shown some positive health outcomes. The newly funded
community based adolescent and youth family planning program approaches in Bihar and MP
also offer alternative models that should be carefully evaluated for potential for scale-up. The
Rajasthan model for out-of-school adolescent girls clubs has been a collaborative effort of the
Rajasthan Government and UNFPA, and its programme learnings have been helpful in approval
of a recent GOI „SABLA‟ strategy now under operation in selected districts of a number of
states.

Recommendations:
UNFPA must invest in finding effective ways of reaching adolescents who are out of school
by developing realistic content and methodology and testing alternative delivery
mechanisms. In addition to the variants of the Teen Clubs that are being developed and
tested by UNFPA to reach out-of-school adolescents, UNFPA should carefully examine other
models that have been tried and tested, before it lays out its strategy for out-of- school
adolescents for CP-8. UNFPA needs to advocate with government to invest financial
resources for reaching out-of-school adolescents.

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 Part B: Assessment of Programme Components (Section IV: Adolescents and Youth)

Stand-alone adolescent friendly health service clinics have not demonstrated much success in the
government health systems since they were introduced in the late 1990s under the RCH-II
Programme. Even the national strategy for adolescent health under the current RCH-II has not
been able to suggest ways of making this system work. In Maharashtra, where UNFPA‟s has
provided sustained and substantial support to Government for setting up the Maitri clinics, the
evaluation reveals very limited success in terms of access to and quality of services. Adolescent
health clinics are an important RCH-II activity. A well thought out concept and demonstration
pilot undertaken in collaboration with the State Government will offer concrete alternatives to
many states of India, most of whom are struggling with understanding the purpose and
modalities of the concept of YFS and with how to implement it.

Recommendation:
UNFPA should help the government of Maharashtra to develop a feasible alternative to the
present RCH-II concept of youth friendly services/clinics (YFS) within the primary health
care system.

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 Part B: Assessment of Programme Components (Section V: Sex Selection)

Section V: Sex Selection

5.1 Background

The gender component of UNFPA‟s CP-7 addresses mainstreaming of gender in RH, and sex
selection. The desired outcome for the gender component is to prevent gender based violence
and empower women. The outcome indicator is the child sex ratio. Activities and interventions
for strengthening the capacity of the health system to address gender based violence have already
been discussed in Section III of this report, and Section VII discusses gender as a cross cutting
theme across CP-7. This section is devoted to UNFPA‟s work on the issue of sex selection.

The 2001 census results revealed that the child sex ratio had continued to decline in most states
of the country. Committed to gender equality, and to correcting demographic and health
imbalances, UNFPA began to work on the issue of sex selection. In 2001 UNFPA launched a
campaign around “Missing Girls” to stimulate a wide response. A widely disseminated booklet
on “Missing Girls” presented census data in a manner that made it easy to understand and absorb
the facts.

A national stakeholder group meeting was convened by the MOHFW around 2001. After 2003,
the convening role for this group went to civil society organizations like the Population
Foundation of India (PFI) and Plan International. The group remained active for a few years and
then petered out. When UNFPA began its program in a big way in CP-6 and 7, it took on the
immense challenge of supporting the implementation of the PCPNDT Act and advocating
against sex selection alone, with no partners to share the needed work and scale to achieve
success

In 2002-2003 at the request of the MOHFW, UNFPA trained state and district appropriate
authorities (AAs) to build capacity for implementing the Pre Natal Diagnostic Technique
(PNDT) Act.

Between 2004-2005, UNFPA‟s sixth CP-6 made concerted efforts to reach out and create
awareness of the sex selection issue amongst a wide variety of new audiences including faith
leaders, the medical community, media, civil society, parliamentarians, celebrities, artists,
corporate houses, advertisers and youth. The idea was to create a domino effect by reaching out
to as many people as possible. Emerging evidence revealed that at that time, sex selection was
not behaviour of the rural poor but an emerging urban middle class trend. However, UNFPA still
needed to decide upon a systematic strategy for addressing sex selection.

The 2005-2006 period was characterized by evidence based advocacy, a desire to set strategic
priorities and to scale up programmes. In 2006, UNFPA commissioned an extensive study that
was conducted by the Center for Youth Development Activities (CYDA). The study observed
that UNFPA‟s efforts to campaign against sex selection and to encourage better Act enforcement
had been sporadic. While there was awareness that sex selection was not legal, the PCPNDT Act
was weakly enforced and its detailed knowledge was limited even amongst the medical
community. Even where efforts were successful they were largely due to visionary individuals
and were not enough to achieve the intensity and spread that could effect change on a large scale.
The study also noted that the effectiveness of advocacy interventions “were directly proportional

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 Part B: Assessment of Programme Components (Section V: Sex Selection)

to the volume or intensity” of awareness creation. The recommendations arising from the study
were that UNFPA should work to strengthen Act implementation, and address the medical
community, the judiciary, and civil society. It suggested that advocacy efforts instead of using a
broad cast approach, be restricted to young people. Thus over the last few years of CP-6
UNFPA‟s efforts focused on building awareness of the issue at all levels in society. UNFPA
proceeded to shape its programme of work in sex selection along these lines.

5.2 Results Desired

The desired output for the overall gender component is the child sex ratio (CSR), which at
baseline (2001 census) was 927 per 1000 males. This was to be improved by at least five points
as measured by the 2011 census. The desired output for the sex selection programme is – to
address through advocacy and action the skewed sex ratio at birth (SRB). Two indicators have
been selected:

a. Sex ratio at birth in the worst affected districts improved- for which the baseline was to
be determined and a ten percentage point improvement was sought by end-line

b. The gender gap in under 5 mortality rate reduced at the national level. The baseline was
6.8 per 100 births in 2005 and this was to be brought down to below 5 in 2012

The CSR at the national level in the 2011 census is 914. It has deteriorated by 13 points
compared to the 2001 value of 927. There has been similar deterioration in the states of
Maharashtra, MP and Rajasthan38 . CP-7 has 2 more years to go and it seems unlikely that the
targets set for reduction of CSR or SRB will be met within this timeframe. In the five UNFPA
states, the SRB too has deteriorated since 200139 . If UNPFA‟s work in sex selection is to be
judged by the CSR and the SRB, then it has not succeeded. However, we believe that the
national level indicators that UNFPA chose to measure success were grossly unrealistic and
overly ambitious given the short, five year timeframe of CP-7, the long timeframes needed to
make any significant change in long standing and deeply ingrained son preference in India, and
the very limited resources that UNFPA has brought to bear on the issue. Even in its priority
states UNFPA did not work with all stakeholder groups and in all districts. Also, its efforts
needed to be complemented by the state‟s efforts at Act implementation- which were uneven.
While UNFPA could facilitate, advocate and build capacity, implementing the Act goes beyond
the mandate of the UN.

On-the- ground assessment suggests that the programme has experienced significant success, but
that the right measures of this success are intermediate measures of outputs and processes that
will over the long term, help to achieve impact (increase in CSR or SRB). Such measures could
be: the formation and effective functioning of statutory bodies charged with implementing the
Act; the engagement of civil society partners in the watchdog role; the registration of ultra-
sonography (USG) facilities and effective oversight of their functioning; the trends in cases
registered and tried; the proportion of convictions, and so on. UNFPA programme staff also
acknowledges the need to develop indicators other than CSR and SRB to capture successes on

38
Rajasthan decline from 909 to 883; MP decline from 932 to 912; Maharashtra decline from 913 to 883; Orissa 953 to 934.
39
Some of the worse off states, where UNFPA has contributed through workshops with medical communities, judiciary and
religious leaders, have seen an improvement in the CSR as in Punjab, Haryana and Himachal Pradesh.
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 Part B: Assessment of Programme Components (Section V: Sex Selection)

the ground – not just to attribute it to UNFPA‟s work but to enable recognition of the
contribution of others-such as the larger civil society actors that have worked with UNFPA to
change attitudes and perceptions of people against sex selection.

5.3 Strategic Interventions- Findings and Analysis

Having successfully achieved magnification of the discourse and broad awareness of the Act
during CP-6, CP-7 interventions were centered on:

a. Strengthened implementation of the PCPNDT Act at the national and state level;
b. Creating through advocacy, an environment that would discourage, disapprove and act
against sex selection
c. Strengthened capacity for community based action on sex selection
d. Supporting research initiatives to build a strong evidence base for advocacy and
e. Mainstreaming the work in sex selection by integrating sex selection issues into ongoing
programmes of various ministries;

5.3.1 Strengthened implementation of the PCPNDT Act at the national and state levels

A 2010 study commissioned by UNFPA in collaboration with the National Human Rights
Commission (NHRC)40 reinforced the need for a prioritized plan of action to enhance the
effectiveness of existing implementation structures and systems, and for pushing for reform in
current practices of implementing authorities.

5.3.1.1 Collaboration with MOHFW

To strengthen the implementation of the Act, UNFPA works to ensure that statutory bodies
charged with implementation of the Act have full membership, function effectively, and that
their capacity to implement the Act is built. At the national level UNFPA has supported the
establishment of a PCPNDT monitoring cell in the MOHFW.

In collaboration with the MOHFW and state governments, UNFPA has developed a PNDT
complaint reporting software to encourage reporting of complaints. The innovation assists the
AA at the district level to receive reports from anyone who is interested in the cause, to weed out
malicious complaints, and to use relevant information for better act implementation. The soft
ware also makes the AA accountable for taking action on complaints received41. In 2010, the
software was launched on the web. Data is not yet available on the extent of use of this site.
However, counterparts in the Rajasthan government shared with the evaluation team their sense

40
Implementation of the PCPNDT Act in India, perspectives and challenges, Public Health Foundation of India, 2010,
unpublished
41
The software, housed on a state government‟s website, will function as an online complaint facility, where anyone can register
a complaint (or report their suspicion) related to sex selection/improper functioning of an ultrasound centre, hospital etc. The
complaint, once reported, will be immediately sent to the concerned district and state level appropriate authorities (mandated
under the PCPNDT law to take cognizance and act on it) to ensure prompt action and maintain the accountability of
appropriate authorities. A copy of the complaint will also be sent to senior administrators in the state The website will become
operational for public after the completion of data security audit by National Informatics Centre (Annual report 2010) 61400.
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 Part B: Assessment of Programme Components (Section V: Sex Selection)

of pride at having launched the site. After Rajasthan adopted the complaints website, three other
states have requested TA for launching similar sites.

5.3.1.2 Intervention with the legal system and the judiciary

Work with the judiciary in Orissa, MP, Maharashtra and Rajasthan, is noteworthy. Judicial
colloquia and a judicial academy are being supported to build awareness and a nuanced
understanding at all levels of the judiciary, of the social and medical issues around sex selection.
The object is to ensure that priority is given to cases registered, leniency discouraged, and
punishment commensurate with the offence is dispensed. The Maharashtra State Legal Services
Authority (MSLSA) in collaboration with the State Health Systems Research Center, and the
State Appropriate Authority, has trained members of the judiciary in all 33 districts of the state
on the Act. The Orissa State Legal Services Authority has achieved a similar feat in Orissa. In
Maharashtra, the first conviction ever, happened in 2010 when a judge who attended a
colloquium went back and reopened a case that he had heard in the past. The judicial academy in
Maharashtra has prepared a compilation of case law which will become an important reference
for other lawyers and judges. The Academy has also included the issue of sex selection and the
PCPNDT Act in all its in-service and induction training programmes. The colloquia have
resulted in violators not being given bail during judicial proceedings and in the reopening of one
case under a full bench.

In Rajasthan, capacity building of legal professionals on the PCPNDT Act and other gender-
related legislation was initiated through a partnership between the National Law University
Jodhpur and the Department of Medical, Health and Family Welfare. Under this initiative, 30
young lawyers were trained over a period of two years.

The National Law University of India (NLUI) in MP has been involved in training lawyers and
judicial members. It has created a pool of 50 young lawyers from 50 districts and equipped them
with knowledge of the PCPNDT Act. These young lawyers will be placed with the district AAs
to provide support in case filing and notification. The 2011 work plan in MP includes
sensitization of the district and state bar councils, and capacity building of district prosecutors.
Training of lawyers and public prosecutors builds awareness of how to prepare and present a
strong case so as to minimize the chances of the case being set aside for lack of strong case
documentation. Other desired outcomes are to increase case notification and expedite judgments.

The mechanism for sustainability is embedded in the design of this work. Training is done
through existing professional bodies whose mandate it is to train and develop legal professionals
and the judiciary. In MP and Maharashtra, it is now being proposed that the curriculum for law
schools be re-examined to ensure that students get adequate exposure to the laws that relate to
issues such as sex selection, and domestic violence. Most of UNFPA‟s work on capacity building
of lawyers and judiciary is seeded with an understanding that these opportunities will also lead to
sustainability. Clearly institutionalizing gender and sex selection curriculum in law training is a
step in that direction.

Capacity building of appropriate authorities, legal experts and of the judiciary has improved
compliance with the Act.

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 Part B: Assessment of Programme Components (Section V: Sex Selection)

The evidence is found in higher registration of ultra sound facilities, maintenance and timely
submission of records and forms stipulated under the Act, and more complete information in the
forms than was available before these interventions were undertaken. This is true in states like
Rajasthan, Maharashtra and MP where UNFPA interventions have included direct work with the
legal system and the judiciary. In Indore district, compliance by facilities has increased from
63% to 83% as a result of monitoring visits. In Haryana where direct work on Act enforcement
was not done, but civil society partners were supported to do community awareness work,
compliance with the Act has not improved42.

5.3.1.3 Act compliance, value clarification and advocacy with the medical community

UNFPA has rightly considered the medical community as the provider of services for sex
selection. This community as a whole could play a critical role in ensuring ethical practices
within the fraternity: educating them about the Act and ensuring compliance with the law;
sensitizing them to the problem of sex selection; dissuading clients; and influencing mindset
change in the larger community. In partnership with the professional medical associations
including those of radiologists, and through the “Doctors for Daughters” initiative at the national
level, doctors have been sensitized and have made professional resolutions to work against sex
selection. In the last few years there have been state and district workshops with the IMA with
the intent of creating a cadre of peer monitors and ambassadors who would be change agents
within their community. Actions have included direct mailers to doctors to stop sex selection and
to take action against violators. Previous work with the IMA at the national and state level
included making of resolutions and taking of oaths to act against violators. Outside of the IMA
the work with the medical community has spanned the Indian Association of Preventive and
Social Medicine (IAPSM), the Indian Radiological and Imaging Association (IRIA), the
Federation of Obstetricians and Gynaecologists of India (FOGSI), Surgeons performing non
scalpel vasectomy, and the faculty and students of medical and nursing schools. The WHO India
Office has prepared modules on the issue of sex selection from the rights and gender
perspectives, for inclusion in undergraduate and postgraduate courses in medical colleges. The
modules have been prepared after consultation with selected obstetricians and gynecologists and
radiologists in 2009-10. A network of academic, research and community based activists were
involved in the Campaign against Pre-Birth Elimination of Females (CAPF).

A tool-kit for doctors43 has been prepared to help them understand what the law says, and also to
clarify values and change attitudes. The tool kit includes Frequently Asked Questions, a sample
checklist to monitor compliance of ultra-sonography clinics (first used in Indore, see box), and
briefs on the law for the medical community. The value clarification content in the kit has been
prepared based on questions that some doctors ask, and responses that other doctors have given
to knotty questions related to sex selection. Doctors who have undergone the first round of
training are meant to identify others in the medical community who will enhance the reach of
this initiative. A self learning CD on the Act is being developed as a training tool for doctors.

The nursing curriculum is being revised by the Maharashtra Nursing Council to include these
issues in the basic training of nurses. Similarly UNFPA supported the capacity building of

42
Interviews with key CSO stakeholders, Haryana
43
A toolkit to guide practitioners – Gender sensitivity and community responsiveness in healthcare, UNFPA, 2010, to be
published
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 Part B: Assessment of Programme Components (Section V: Sex Selection)

professors of medical colleges on sex selection and has proposed to the Maharashtra University
of Health Sciences, that these issues be included as part of the curriculum for under graduate and
post graduate courses.

In Maharashtra, UNFPA provided support for training of nursing tutors on the issue of sex
selection and the Act.

5.3.1.4 Strengthened role of civil society organizations in ensuring Act implementation

UNFPA has built capacity of state partners, to activate the implementation structures constituted
by the Act. In MP for example 114 civil society members of district advisory boards were
reoriented with updated knowledge and skills to review the functioning of the boards and their
contribution to the implementation of the Act. Similar action has been taken in other states as
well. In Orissa, a series of sensitization, orientation and capacity building processes were
initiated involving key stakeholders such as the Indian Medical Association, NGOs, CBOs,
health functionaries, and senior members of the judiciary. UNFPA supported the PC PNDT cell,
and facilitated a mapping exercise of USG clinics. This map was later used to monitor the USG
clinics. Civil society organizations are also oriented to monitor ultra sound clinics and ensure
that they comply with the law44.

In Maharashtra, UNFPA supported the training of 127 Mother NGOs and Field NGOs appointed
under NRHM for effective implementation of the PCPNDT Act.

Where civil society partners serve on district advisory boards and monitor clinics, the AAs more
responsively implement the Act45. Functioning of the state and district supervisory boards and
AAs has improved, with more regular meetings, at which transactions are more focused on the
issue of Act implementation46.

UNFPA is also supporting capacity building of elected representatives from urban areas of
Maharashtra for advocacy and action on sex selection in collaboration with the All India Institute
of Local self Government.

44
This stems from evidence that low sex ratios at birth are directly proportional to availability of USG facilities (Gokhale
Institute Study, Pune).
45
Interviews with key stakeholder at the National PCPNDT Cell, MOHFW
46
Interviews with state programme coordinators and AWPs
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 Part B: Assessment of Programme Components (Section V: Sex Selection)

The Indore ‘Model’

An interesting pilot intervention is underway in CP 7 where a triangulated, multi layered approach is

being executed in Indore district, which had a CSR of 908 in 2001. It is a three pronged approach
with strategies that are mutually reinforcing: 1.Work directly with the Appropriate Authority, Indore
to implement the Act; 2.Build capacity of NGOs to play an advocacy role and monitor USG clinics to
ensure compliance; 3.Simultaneously create awareness among key stakeholders on the issue.

MPVHA is the main partner. It has built the capacity of NGOS to advocate for vigilance and
monitoring of ultra-sonography clinics. These NGOs have become members of the district advisory
board. The capacity building of the district AA has also ensured regular meetings and better
monitoring of USG centers. MPVHA has regular update meetings with key stakeholder from the
medical community (IMA, IRRIA), members of the bar association, media, faith leaders and CSOs
that further the agenda for larger awareness creation. As a result of fairly concentrated efforts there is
now stricter action of the district AA against non compliant clinics or non registered clinics. Within a
few years there is a belief that the pilot is self sustaining and moving forward, the role of MPVHA
would be to monitor, review all training/advocacy material, and document the process.

MPVHA has converted these efforts to a checklist that offers a very good, comprehensive tool to
conduct monitoring of clinics. About 15 members visit 5-7 clinics a month (2 hours per clinic). They
revisit the same clinics a month later to see if concerns raised in the previous visit were addressed and
if the clinic remains compliant. This is voluntary work where travel is reimbursed. The volunteers are
social workers, doctors, legal experts and NGO members. In the last 3 years they have done 147
visits and 151 follow-up visits and been able both improve registration and compliance. Over 63
show-cause notices, 4 court cases, several suspensions of clinics and doctors and Rs 1,30,000
collected in penalties, are some of the indicators of successful Act implementation. The checklist
developed by MPVHA has been incorporated into the orientation tool-kit that UNFPA has prepared
for medical practitioners.

A more thorough evaluation would be needed to obtain a full picture of changes that have occurred as
a result of this intervention.

5.3.2 Strengthening the capacity for community based action on sex selection

In CP-6, UNFPA supported the work of 5 large national NGOs on the issue of Sex Selection and
had positive results. In CP-7, it decided that there was a need to increase the spread of this work
by drawing many more NGOs into it. UNFPA therefore sought a national agency with a large
network and demonstrated commitment to the issue. Women Power Connect (WPC) was such an
agency. It was brought into UNFPA‟s programme to involve its network of civil society member
organizations in fostering community level advocacy and action on the issue of sex selection.
The approach used by the network is to build the capacity of its members to undertake advocacy
and action at the community level, using a common strategy and vision for community
perspective building. The original vision included the formation of state resource groups and a
national coordination mechanism that would find new opportunities for expanding this work and
making it sustainable.

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 Part B: Assessment of Programme Components (Section V: Sex Selection)

WPC has brought into its fold 31 NGOs across 11 states 47. Through each of these NGOs,
grassroots level civil society organizations have been trained and their capacity built to make
communities act against sex selection. These civil society organizations mobilize influential
women- anganwadi workers, auxiliary nurse midwives, teachers-self help groups, and
panchayats- to create awareness of the adverse effects of sex selection. Community mobilization
is done through sensitization, awareness generation, capacity building workshops and creation of
communication materials. Resource groups formed within the community comprise those who
show an interest in becoming change agents. The role of WPC is to ensure consistency and
quality through capacity building workshops, to develop communication materials with the right
messaging, and to screen and approve all material being used by civil society organizations for
appropriateness and quality. Beyond this WPC has also formed state resource groups in 5 states.

The work with the WPC has brought a higher awareness of the issue of sex selection and
awareness of the PCPNDT Act to the grass roots level. Specific positive outcomes reported by
participating NGOs are that many members of the WPC network have become members of
Districts AAs or District Advisory Committees. Two NGOs have joined State Supervisory
Boards. Advocacy meetings have been held in 6 of the 11 states, bringing Government, CSOs,
and media onto one platform. In Uttarakhand this has led to the reconstitution of the once
defunct State Advisory Board, with the concerned implementing partner as its member. In many
communities, the celebration of the birth of a girl child is now announced through celebratory
ceremonies such as kanya lohri, thali bajao, and badhai patra48 which were once reserved for
male children. This is considered by grassroots workers associated with WPC as a sign that
communities are beginning to value the girl child.

While these are shifts in the right direction, field visits in Delhi and Haryana reveal some
problem areas. It is very important to build perspectives of grass roots partners and
communicators at all levels on the issue of sex selection so that they see sex selection within the
larger rubric of discrimination. Though WPC has built the perspectives of project coordinators,
these perspectives have not been appropriately transmitted down to grass roots workers and
volunteers. UNFPA‟s messaging on the issues of abortion and sex selection is clear and
congruent, however, a nuanced understanding, and the ability to communicate these messages to
the grass roots has not yet been developed in participating NGO‟s and their communicators. The
use of the cascade approach to communication training may be resulting in loss of clarity of the
messages around sex selection and abortion. Moreover, some partners do not fully appreciate the
fine line between pregnancy tracking for more effective prenatal care and birth registration and
that done for monitoring sex selection. Based on findings from the field visits, the evaluator
offers a note of caution - over emphasis on monitoring sex selection in pregnancies can easily
create a more repressive environment with clandestine practices and unsafe or risky abortions.
In order to communicate effectively on the issue, grass roots communicators need to understand
the difference between legal and safe abortion, and sex selective abortion, so that their
messaging to women and communities is clear, and their community level work does not end up
stigmatizing legal abortion.

UNFPA chose to work with WPC because of its extensive reach, its capability and experience of
lobbying with parliamentarians, and its commitment to working on sex selection as one of its

47
Bihar, Gujarat, Uttarkhand, Maharashtra, Orissa, Uttar Pradesh, Delhi, Haryana, Rajasthan, Punjab, Himachal Pradesh
48
Celebratory family ceremonies traditionally performed at the birth of a boy.
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 Part B: Assessment of Programme Components (Section V: Sex Selection)

four priority issues. If WPC‟s skills in community level advocacy and communication were built,
it would add a new dimension to its capability and role. The hope was that in each state there
would be one key partner or platform for advocacy. The issue of sex selection demanded
operation on a large scale. Notwithstanding the immense support that UNFPA has provided to
WPC, especially in systematizing the selection criteria of the partners, training the NGO
coordinators, and setting up their monitoring and process documentation systems, the overall
success of WPC‟s work is uneven. A recent evaluation of the WPC program notes that their
skills in lobbying and leveraging with state networks and state level policy advocacy have not
been effectively and uniformly applied to the work against sex selection in all states. Advocacy
has been successful only where there has been a critical mass of partners working on the issue.
Overall only about 50 % of the partners have performed moderately well. This is because
capacity building for work at the community level requires intense and repeated training for
value clarification, and adequate staff time and resources for capacity building and monitoring.
The evaluation report notes that these have not been available consistently across all states.

5.3.3 Research initiatives to build a strong evidence base for advocacy

Several key publications have been developed by UNFPA that include FAQs on the PCPNDT
Act for doctors, the public and implementing bodies. Findings from the very recent and
comprehensive analysis of the implementation of the Act by NHRC through Public Health
Foundation of India can be considered as a very useful resource and advocacy tool on
strengthening the implementation of the Act. The Trends in Sex Ratio at Birth and Estimates of
Girls Missing at Birth in India is a very useful brief to understand the various data sources and
how to read the trends over time. This brief is also very important for researchers, media, district
programme staff and policy makers alike to understand how to read the census data and its trends
and the differences between various types of data sources.
Other resources developed include:

Trends in Child Sex Ratio at District Level: Maps from 2011 Census results 2011
unpublished

A review of “Special Financial Incentive Schemes For The Girl Child In India” by T.V.
Sekher of the International Institute for Population Sciences, Mumbai, 2011, unpublished

A Review Of Literature And Annotated Bibliography On Declining Child Sex Ratio (0-6)
In India, Udaya S. Mishra and T. R. Dilip, Centre for Development Studies, 2009

Reflections On The Campaign Against Sex Selection And Exploring Ways Forward, a
study report, Josantony Joseph, Centre for Youth Development and Activities (CYDA),
2007

Estimation of Missing Girls at Birth and Juvenile Ages in India, Prof. P. M. Kulkarni,
Centre for the study of Regional Development, School of Social Sciences, Jawahar Lal
Nehru University, Delhi, 2007

A research study is in progress which scans the laws of the nations to identify those which may
explicitly or implicitly be promoting son preference.

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 Part B: Assessment of Programme Components (Section V: Sex Selection)

While research and documentation over the last decade is compelling and transformative, more
research on social norms and attitudinal change is needed.

There is a critical need to strengthen evidence through systematic evaluation of UNFPA‟s own
programmes. There are very few interventions currently underway that address the issue of sex
selection as systematically as UNFPA is doing in some of its states- for instance the Indore
model and the WPC project. There is much to be learned from sharing the experience of WPC‟s
31 NGO partners who have engaged in a common task and sought common outcomes, but have
used their own approaches. What was the diversity of approaches and experiences? What has
been the relative effectiveness of these approaches? Which are more sustainable? How can the
approaches be strengthened?

There is a dearth of current and representative data on attitudes of men and women towards son
preference and sex selection. There is much to be learnt from attitudinal studies for the questions
around how social norms change or what makes certain norms resistant to change.

5.3.4 Support advocacy initiatives to create an environment that would discourage,

disapprove and act against sex selection

Several audiences have been reached. Popular media such as song and artwork, posters, films,
advertisements and news articles have lent their voice to the issue of sex selection.

UNFPA‟s media partner, Population First has designed advocacy and promotional messaging for
a young audience, and UNFPA‟s own calendars and posters communicate for the issue.
The media has been the key partner in advocacy initiatives:

a. In partnership with Population First, UNFPA has instituted the Ladli Media Awards for
gender sensitivity. It is expected that these awards will influence media to break gender
stereotypes in its treatment of women. From 2011, Population First will take ownership of
this initiative and work towards long term sustainability of the awards through corporate
sponsorships.

b. BBC radio serial, Life Gulmohur Style, in partnership with MacArthur and Packard on a
range of issues including this one

c. In the Sapno Ko Chale Chune initiative in partnership with Jagran Pehel, the corporate
social responsibility unit of Dainik Jagran (a national Hindi newspaper), young women
from college interned with the Dainik Jagran newspaper in Bihar and were mentored by the
district bureau chiefs of the newspaper. The programme seems to have had unprecedented
success in a short time period.After the initial two years of UNFPA support, Jagran Pehel
\took ownership of the programme and has obtained support from new actors including the
Department of Women and Child Development. This is an example of a multi stakeholder
initiative successfully creating its own momentum beyond the support provided by
UNFPA. Such successful models need to be made visible and promoted to different and
newer constituencies. A note of caution: there is a need to monitor to ensure that after
ownership of the programme changes hands, the original agenda and messaging related to
fighting discrimination against the girl child, continues.
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 Part B: Assessment of Programme Components (Section V: Sex Selection)

d. At the level of the states, there has been extensive media coverage on the issue of sex
selection. Journalists have been trained and have then profiled the issue of sex selection in
the English, Hindi and regional language press.

While each of these media initiatives is interesting and innovative, the evaluation team did not
perceive the existence of an overall synergistic strategy for communication and advocacy for the
issue of sex selection.

5.3.5 Integrating the prevention of sex selection into on-going programmes/activities of

various ministries

5.3.5.1 Ministry of Women and Child Development (MOWCD), Ministry of Youth

Affairs and Sports (MOYAS), Ministry of Panchayati Raj (MOPR) and Ministry
of Defence (MOD)

There have been joint activities undertaken with the Ministry of Women and Child Development
(MOWCD), but they have been opportunistic rather than part of an overall plan made with the
Ministry. MOWCD and UNFPA have held joint briefing meetings with the MOYAS, the
Ministry of Panchayati Raj, and the Ministry of Defence in 2008. Sensitization workshops on the
issue of sex selection have been conducted for members of the National Cadet Corps(NCC) at
the state level, and the NCC is now taking this work forward as part of its regular programming,
with its own resources. Over the next CP, should UNFPA desire to enlarge the treatment of the
theme of sex selection to that of discrimination against the girl child, planned collaboration with
MOWCD would be needed.

5.4 Conclusions and recommendations

The need of the hour is advocacy to build equal value for daughters compared to sons. This work
is needed with immediacy and at scale. The findings of Census 2011 provide fresh impetus for
urgently, systematically, and comprehensively taking this advocacy agenda to the national level
so that it covers all States. UNFPA‟s own resources are not large enough to bring about rapid and
extensive change. If UNFPA wishes to have national impact through its work on sex selection, it
may need to consider playing the role of a catalyst for advocacy, using its position and influence
to draw and hold together a strong group of influential, independent and resourceful partners at
both the national and state levels, who will work together to advocate for quick, high level
attention and resources to the issue of sex selection.

UNFPA‟s own experience has been that it is difficult to get a coalition organized around the
issue of sex selection per se. Given the challenges and divisiveness on the issue of sex selection
in the past, it is important to reposition the work within a wider lens of discrimination to build
partnerships and buy in. Discussions with donors as well as with other UN Agencies reveal that
while everyone is concerned about the issue of sex selection, they have not been able to
articulate what they can do about it and how. They would like to seek a balance- working on sex
selection within the broader framework of women‟s rights in RH and violence against women.
They lean towards sets of interventions that would have dual outcomes. Sex selection is part of
the broader agenda of violence and discrimination against women. Difficult as it may be, allies
are needed in this work, and must be found. If UNFPA does not find allies who can speak
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 Part B: Assessment of Programme Components (Section V: Sex Selection)

strongly with one voice and work together to attain scale, there is no way any significant change
can be brought about. Common perspectives will need to be built on the issue, and clarity
reached on how the messaging on the PCPNDT Act and the Medical Termination of Pregnancy
Act can be provided without compromising either. The timing is right and the need is felt by
others who may have chosen adversarial positions earlier. The new Inter-agency Statement on
Preventing Gender Biased Sex Selection of which UNFPA is a partner, is testimony to the fact
that there is renewed interest in the positioning of this issue and this opportunity must be realized
at the national level49.

Recommendation
Catalyze action and partnerships: UNFPA should act as a catalyst and bring together a
wide variety of agencies, to contribute to rapid change in a coherent manner, each playing a
role that fits its interests and capacity, using a wider frame of gender discrimination. The
opportunity should be used to reframe and renew relationships with key partners within and
outside of the UN system, to reach out to new potential partners including corporate houses
and national foundations that are showing an interest in investing in social causes, and to
build common ground on this divisive issue.

UNFPA has a clear role in advocating with the Government for greater commitment on
monitoring the PCPNDT Act. Broadening the lens and understanding other aspects of
discrimination does not imply that successful efforts on strengthening Act implementation
should not continue. There is clear success in the area of Act Implementation that needs to be
scaled up especially through more committed efforts from the Government.

Recommendation
Advocate for scale up and strengthening of Act implementation: UNFPA could work closely
with the governments of Maharashtra and MP to advocate at the national and state levels for
greater government commitment to the issue of sex selection, and for more rigorous Act
implementation. State Governments and government agencies across the country need to
adopt sex selection as their own agenda. UNFPA should urge agencies such as the
Maharashtra State Legal Services Authority and the MP Voluntary Health Association to
share with other states their experiences and the positive results that they have seen from the
work that they are doing to stimulate thought and action for strengthening Act
implementation.

However, UNFPPA also needs to keep sight of the future. Technology changes fast and it is not
unlikely that it will soon be possible to determine the sex of the foetus with home based
techniques. It will then become harder and harder to get results from Act implementation.
Working within the wider frame of discrimination would allow UNFPA to keep pace with these
emerging trends so that its work does not merely shadow the growth of technology but in fact
addresses the root causes of the problem while curtailing the demand and supply for existing and
newer technology. Analysis of the different policies that address daughter discrimination
triangulated with sex ratio at birth and other data on girl‟s education, health and RH to
understand nuanced patterns of son preference and daughter discrimination is critical. Such an
analysis can influence work with media as well as community advocacy through grassroots and

49
Preventing gender-biased sex selection -an interagency statement, Office of the High Commissioner for Human Rights
(OHCHR) , UNFPA, UNICEF, UN Women and WHO, 2011
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 Part B: Assessment of Programme Components (Section V: Sex Selection)

civil society actors. Choosing to focus on just sex selection at this point has the risk of missing
critical pathways of discrimination that may, in the long run, affect sex ratio at birth. It also
confines the work to Act implementation and advocacy around the issue of sex selection alone.
Emerging data and research show that son preference, gender inequality, and patriarchal
practices such as dowry co-exist with improved outcomes of delayed age of marriage and higher
school education for girls. It is important to delve deeper and understand what factors are
sustaining the ideology of son preference even in a rapidly changing social milieu where women
are taking on iconic positions and roles in sports, media and governance. The role of men and
masculinity thus need more attention in the work on sex selection.

Recommendation:
Research such as the ongoing study on son preferring laws, is a step in the right direction and
more needs to be done. New research could be commissioned to understand attitudes in the
area of son preference and sex selection building the evidence base.

Changing social mindsets through advocacy and communication programmes is the ultimate
ideal and long term goal of programming. To be successful, such communication needs to use of
a broader frame of discrimination against daughters. UNFPA‟s current advocacy strategies and
community work do not make explicit the causes of daughter discrimination and son preference-
cultural beliefs, dowry, practices of inheritance- which result in pre birth elimination of girls,
There is an absence of a well planned and clearly articulated communication strategy with the
central objective of shaping public opinion and changing mindsets so that girls are allowed to be
born. This is a gap that needs filling.

Recommendation:
UNFPA needs to lay out a more forward looking communication strategy in the area of sex
selection with clearly defined objectives, audience segments, segment specific messages,
media plans and budgets, integration of available research in development of messages, and
an embedded evaluation plan. Evidence based advocacy to shape public opinion must be a
central objective of communication.

Community level work through networks of NGOs has brought about higher awareness of the
issue of sex selection and awareness of the PCPNDT Act to the grass roots level and other
specific positive outcomes. The work has challenges in that grass roots communicators need
value clarification on abortion per se, the intersect between legal abortion and sex selective
abortion, and on reproductive rights, so that their messaging to women and communities is clear,
and their community level work does not end up stigmatizing legal abortion.

Recommendation:
Community based work to change mindsets may not be the best use of UNFPA‟s resources.
However, the learning from the community level work should be documented and disseminated
as a resource for others working on these issues, and to advocate for more community work to
change social norms.

The findings of Census 2011 show that work against sex selection is urgently and widely needed
in India. UNFPA has done pioneering work in this important area. The work on sex selection has
not been easy and has generated some controversy. In all its work, UNFPA has maintained a
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 Part B: Assessment of Programme Components (Section V: Sex Selection)

careful balance between disapproving sex selection and strengthening implementation of the
PCPNDT Act, while not stigmatizing legal abortion carried out under the medical termination of
pregnancy Act (1970) which helped cut down maternal death from unsafe abortion. Some civil
society organizations felt that UNFPA was not doing enough about sex selection, and others felt
that UNFPA was endangering hard won maternal health gains from the passage of the Medical
Termination of Pregnancy Act (1970). For these reasons, UNFPA has found it difficult to build
coalitions of influential partners for this programme and has had to work virtually alone. Despite
this, UNFPA has significant achievements to its credit in the area of sex selection.

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 Part B: Assessment of Programme Components (Section VI: Population & Development Strategy)

Section VI: Population and Development Strategy

6.1. Background

The strategic plan of UNFPA 2008-2013, aimed to accelerate progress and national ownership of
the ICPD Programme of Action (ICPD PoA) and drew up the following broad framework for its
work in the area of Population and Development:

a. UNFPA will use its expertise in population data collection and analysis, and contribute to the
Millennium Development Goals by supporting countries to incorporate population dynamics
and its inter-linkages with gender equality, SRH and HIV/ AIDS into public policies, poverty
alleviation strategy and expenditure frameworks.

b. Given the sheer size of the youth population, the Fund will also advocate for strategic
investments in young people‟s health and development by highlighting potential benefits in
terms of building human capital, capitalizing on the demographic dividend and breaking the
inter- generational cycle of poverty.

c. UNFPA will continue technical and financial support- including advocacy and mobilization
of resources- for the collection, analysis, utilization and dissemination of gender-
disaggregated data.

d. One hundred and eleven countries will be supported to implement their national censuses as
the foundation for development planning in the coming decades.

The directions proposed gel well in the Indian context, especially when the country‟s
development is still to reach the millions of underprivileged and there is still a long way to go for
realization of the Millennium Development Goals (MDGs). The demographic transition along
with the present level of social and economic development has presented India with several
opportunities and newer developmental challenges. CP 7 therefore designed its Population and
Development strategy keeping in view the ICPD-PoA and the present and future needs of the
country as reflected in the 11th five year plan.

6.2. Results Desired

The overall outcome for the Population and Development Component of CP-7 is that capacity be
built to integrate population dynamics into national policies and programmes. The Results and
Resources Framework states two outcome indicators:

a. Results of studies on emerging population issues reflected in national/sub-national

development plans

b. Plans and policies are linked to population and development realities, through use of
disaggregated data in planning and monitoring

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 Part B: Assessment of Programme Components (Section VI: Population & Development Strategy)

The output desired is social development planning that takes into consideration demographic
transitions. Four revised indicators have been mentioned:

a. Number of UNDAF districts using disaggregated development data in planning and

monitoring programmes

b. Research and policy studies undertaken and disseminated for policy dialogue

c. Data made available on emerging and priority demographic issues

d. Number of activities undertaken for building the capacity of the Census Organization to
undertake the 2011 Census.

6.3. Strategic Interventions: Findings and Analysis

6.3.1. Joint GOI- UN Convergence Programme

UNDAF 2008-2012 articulated the vision, strategy and collective action of the UN system in
India as “promoting social, economic, and political inclusion for the most disadvantaged,
especially women and girls”, and set priorities and outcomes that were congruent with the 10th
and 11th five year plans. UNDAF outcome 3 is about convergence among various departments
and agencies at the district level to catalyze efforts to achieve the 11th plan targets related to the
MDGs.

The GOI and UN agencies, jointly formulated the GOI-UN Convergence Programme to be
implemented in 35 backward districts of the 7 UNDAF states. The objective of the programme
was to facilitate the development of integrated district development plans through convergent
action of various government departments and schemes at the district level. The Planning
Commission at the national level, and planning departments at the state levels, were involved.
Within the UN, UNICEF, UNDP and UNFPA came together to form a “thematic cluster” and
work together with synergy on this programme. The objectives of the Convergence Programme
were to:

Improve participatory planning through the District Planning Committees

Enable better understanding of budgets and resource flows at the district level
Help address bottlenecks in implementation of flagship programmes and
Support the strengthening of physical and financial monitoring systems for measurement of
programme outcomes

A manual for preparation of district integrated plans has been developed by the Planning
Commission. The manual summarizes district planning as the process of preparing an integrated
plan for the local government taking into account the natural, human and financial resources
available and covering sectoral activities and schemes assigned to the district level and below
and those implemented through local governments in a state.

For the purpose of operationalization, the manual listed the following sequential steps:

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 Part B: Assessment of Programme Components (Section VI: Population & Development Strategy)

Preparation of district, block and panchayat level vision documents

Preparation of participatory plans involving Gram Sabha and from Village Panchayats to
District Panchayats.
Preparation of plans by Urban Local Bodies
Consolidation of plans prepared by local bodies by District Planning Committees.

It lays emphasis on the preparation of a vision document for 10-15 years based on participatory
assessment in 12 sectors of development.

Subsequent to the vision planning exercise, annual plans and Five Year Plans with quantitative
targets and goals pertaining to the 12 sectors of development were proposed.

The division of work among the UN agencies was as follows: UNICEF and UNDP provided
district facilitation support in the rollout and monitoring of the district integrated plans and
strengthened capacity of human resources and institutions. UNDP in addition included change
management principles and development of District Human Development Reports, as other
priority areas of intervention. UNFPA support entailed enhancing the skills of officers at the
district and state level in use of data for evidence-based planning and for monitoring
development programmes.

With regard to the operational modalities of the Convergence Programme, UNDP supported the
establishment of a Programme Management Unit (PMU) which provided technical support to the
Planning Commission for the rollout of the Convergence Programme as well for other
governance related activities of UNDP. The three participating UN agencies, along with the
PMU, are expected to put together a joint annual work plan that is vetted both by the Planning
Commission and the UN Resident Coordinator‟s Office.

While reviewing and discussing the rollout of annual work plans, the evaluation team found that
when one partner was not able to ensure synchronized initiation and progress of interdependent
activities, it hampered the work of the others and caused delays in overall execution of the
project. Inspite of these issues being discussed in coordination meetings, individual agencies
continued to move ahead according to their own plans, adversely affecting other activities that
were interdependent or complementary.

6.3.1.1. UNFPA’s contributions in the Convergence Programme

UNFPA developed sensitization and capacity building programmes for senior government
officers and district statistical officers on the use of data for planning and monitoring
development programmes. It also helped in developing a guide/manual for tracking
development indicators at the sub-national level. Brief details of each of the areas are discussed
below:

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6.3.1.1.1. Training programme for senior officers

This was a two day sensitization programme for senior officials who are departmental heads, and
district administrators engaged in planning and programme management.

India‟s Eleventh Plan document sets out goals (many of which correspond with the MDGs), to be
achieved by the end of the plan period (2007-12). The achievement of these goals requires proper
planning and monitoring of programmes at the state, district and local levels. For this purpose,
senior officers, departmental heads and district administrators need to know what data is
available, how they can be used, and the challenges in their use. These capacity building
workshops aimed to apprise participants about the importance of data and its utilization in
planning and monitoring. Specifically, the programme dealt with data requirements, the different
sources of data, their merits and demerits and how data are to be used and interpreted.

Four programmes were conducted between September and December 2009 and nearly 80
officials participated. Participants comprised senior state officials from the Planning
Departments, District Collectors, Additional District Collectors and UN national and state
officers. The programmes were conducted by the Institute for Social and Economic Change
(ISEC), Bangalore, in its campus. Renowned experts, in-house faculty, and retired senior
bureaucrats were invited to be the resource persons. A range of topics were covered- education,
poverty, income, demography, health, gender budgeting, and the need for planning, monitoring
and evaluation of development programmes. The sessions were participatory and there was
discussion on survey-based and programme generated data systems. Further, there were panel
discussions around monitoring and evaluation and of how, in the absence of denominators in
reports, numerator based data could be used to make inferences about performance. The need for
improving the routine government data-base was emphasized, and most of the experts were of
the view that once programme managers start using routine data for monitoring the data-system
is bound to improve.

Analysis of participants‟ feedback provided during the evaluation session at the end of the
training programme indicates that most participants found the content and structure of the
programme useful. They said that senior experts had enabled them to understand both the uses
and limitations of available data. The administrators admitted that before the training
programme, they had been unaware of the extent of limitations of data. Participants rated the
sessions on need for planning, demography, health, poverty and income as “excellent”. They said
that they would be interested in refresher courses on district income and poverty and requested
that similar programmes be conducted at the state level so that officers in the states could also
benefit from these inputs.

This activity is well aligned with the global mandate and national objectives of the UN and is
relevant to the needs of the country. Positive participant feedback and the request for repeat
courses and refreshers confirm this. A shortcoming of the programmes was that while concepts
and techniques around data collection and use for planning and monitoring were being
emphasized, an important opportunity was missed of orienting senior administrators on the cross
cutting issues of gender, rights and equity which are an important part of the ICPD PoA and also
of national policies and strategies related to population and development.

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6.3.1.1.2. Training programme for district planning and statistical officers:

The objective of this five-day programme is to enhance the capacity of district programme
managers/statistical officers in use of data for planning and monitoring and to enable them to
have a broad, holistic understanding of population and development and of their inter-linkages.
The International Institute for Population Sciences (IIPS), Mumbai is the implementing agency
and 21 training programmes are planned- three programmes of five days each, in each state.
Nearly 400 district statistical officers and UN district teams located at the districts are expected
to be imparted hands-on-training

For the purpose of rolling out the training programmes, local partner agencies have been
identified and assessed in Rajasthan, Orissa, MP, Chhattisgarh and Bihar. In UP an agency is yet
to be identified. An agreement signed with these agencies by IIPS specifies that they will
undertake the training of government functionaries and staff of other UN agencies engaged in the
Convergence Programme, and that IIPS will strengthen the capacity of their faculty members to
do this work. This approach will succeed not just in training state level officials but will also
build sustainable capacity within the states to scale up the training programs to all the districts of
the states.

The training modules were developed in the first quarter of 2010 for a six-day programme, but
after pre-test in Rajasthan was modified and reorganized as a five-day programme. Programme
content included a range of topics- sources of demographic data, merits and limitations of data,
interpolation and extrapolation, population projections, education, poverty, water and sanitation,
results-based management, and monitoring of development programmes. It emphasized the use
of data and the development of practical skills in data analysis. However, the module did not
cover the inter relationship between population dynamics and development, nor did it deal with
the relationship of gender, rights and empowerment (as laid out in the ICPD PoA to development
issues.

To date, 12 training programmes have been conducted in the five states of MP, Chhattisgarh,
Rajasthan, Orissa and Jharkhand. In MP, Chhattisgarh and Orissa all scheduled programs have
been completed. Nearly, 280 participants from different state/district development departments
as well as UN recruited district officers have participated in the training programmes. The feed-
back received from participants, has been encouraging. They appreciated very much the hands-
on practice that they were given in analyzing data from their own districts and states on the
computer. A few of the participants expressed the opinion that teaching life-tables is not relevant.
However they appreciated the content on interpolation and extrapolation, population projections,
education, results based management, and monitoring of development programmes.

IIPS organized an expert group meeting to review participant feedback and to fine-tune, and
make the module more practical and district specific through the use of district level
administrative data sets wherever feasible. The committee concluded that it was essential to
expose participants to the basics of life-tables and of software for working out district estimates.
It was felt that for teaching indirect estimation of fertility through the reverse-survival method,
teaching of life-table is essential. Hence, despite participants‟ feedback, the training content on
life-tables has been retained.

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The training programmes in Rajasthan, Jharkhand, Bihar and UP will all be conducted and
completed in 2011.

These programmes are made most relevant by reason of their timing- when India‟s XIIth five
year plan is under formulation, States with committed leadership have ensured that the
programmes become replicable and sustainable. Jharkhand and Chhattisgarh on the contrary
have not yet identified state-level agencies to conduct the programmes and sustain them in the
future. A letter from the State Planning Board of Chhattisgarh to UNFPA explains that it will
compensate for its inability to find a local training agency by nominating more officers for the
training programmes so that they in turn can take the training forward in the future.

As regards the immediate impact of the training programme, the evaluation team finds that
districts have started working on district plans. Minutes of the review meetings at state planning
departments reveal that 20 of the 35 districts started preparing the integrated district plans within
the stipulated time-frame. The quality of the plans has improved. The planning process has
included consultations with the community, panchayati raj members at the village panchayat
level, and with government development departments. Common elements of the programming
have been discussed and additional budgetary provisions made for better synergy at the service
delivery level (e.g. convergence between Health and Nutrition at the anganwadi level on village
health days, immunization services at schools and anganwadi centers along with co-operation
from the Accredited Social Health Activists). Earlier the “district plan” was merely a set of plans
from individual departments, with no effort at convergence. In the process, district management
has become pro-active in those districts where the District Collector (administrative leader of the
district) is taking the lead. The monitoring of programmes has become more focused and
systematic, and the plans are made on the basis of data, facts and evidence. Of late, it has been
reported that a few districts are venturing into new areas such as afforestation, climate change,
dry land farming and so on. There is now scope for further improvement of district plans and for
use of data in developing these plans.

MP and Chhattisgarh have requested refresher training. Before refresher training is imparted, a
need assessment exercise is underway with participants. Based on feedback received, the
refresher programme would be developed and rolled out in these two states. This activity will be
initiated by UNFPA‟s MP Office during the current year and the local agency that conducted the
initial rounds of training will carry out the refresher training as well.

One of the observations of the evaluation team is that skills within the government system for
development planning are scarce. This reflects the situation in the country where the pool of
development planners is small because there are few academic institutions that offer courses in
development planning. Staff of government planning departments is not trained professionals in
population and development. Also, staff turnover is high. For these reasons, despite the valuable
training devised by UNFPA, one-time training is not going to be sufficient. Repeated rounds of
training and continuous hand holding in the form on on-the-job training will be needed.

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6.3.1.1.3. Sub-National estimation methodology for tracking developmental indicators

In India, the district is the administrative unit for planning of development programmes.
Programme managers need to be able to measure the performance of the district on key
development indicators, study intra-district variations, and decide upon how to devise and
allocate development inputs. However, lack of data at the sub-national level and for small areas,
has impeded planning, monitoring and accountability of development programmes at the district
level. Also there is little expertise in estimation methodologies for sub-national and small area
data, which is generally based on indirect estimation techniques. Building capacity and expertise
in small area statistics, is a high priority task for India given the nation‟s focus on district level
planning and accountability for development.

A two-day workshop of experts on Methodologies for Sub-National Estimation was held at

ISEC, Bangalore, and culminated in field based-studies in districts with both good and not-so-
good data sets. Two districts in each of the two states of Karnataka and Rajasthan were visited by
a team of experts. Data on different development indicators were collected, analyzed, tested for
reliability and validated. A manual of amenable indicators was then prepared and vetted by an
expert group. The draft manual was pre-tested in Orissa with statistical officers from the health
department. Participants‟ feedback has been addressed and the manual finalized.
This manual is useful because it allows the quality of data to be examined before it is used for
planning. The manual not only facilitates planning, it enables district officers to track amenable
MDG outcome indicators related to demography, health and education, and district level process
indicators of national flagship programs.

6.3.1.1.4. District-Level Population Projections in Eight Selected States of India (2006 -

16)

Population Projections in the country are made by an expert group constituted by the Registrar
General, India. Following the 2001 census, the expert group undertook a population projection
exercise at the national and state levels. Realizing the importance of district-data in decentralized
planning, UNFPA undertook a projection exercise for the UNDAF states and Maharashtra. The
report of this exercise provides age and sex disaggregated district data on the basis of which
district planners can develop realistic plans and also calculate the value of development
indicators. The published report has been shared with all the UNDAF states and is being taught
and used in the capacity building programme for district statistical officers. The MOHFW has
reviewed the report and requested UNFPA to share a soft copy of the report which it is now
using for planning purposes. The publication has been hosted on the website of the Ministry
(http://nrhm-mis.nic.in/PublicPeriodicReports.aspx). In addition, MOHFW has written to
UNFPA requesting it to undertake a similar exercise for all the states/districts in the country after
the release of 2011 census data.

The exercises of district level projections and sub-national estimation are likely to have positive
impact on decentralized planning and programme monitoring UNFPA has worked strategically
and systematically to help the districts to define the denominators that form the basis of the
planning exercise.

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6.3.2. Essential data for health programme planning and monitoring- Health Management
Information Systems and Vital Registration Systems

6.3.2.1. HMIS

The MOHFW in collaboration with the National Health Systems Resource Centre (NHSRC) has
developed manuals and a web-based portal for operationalizing the Health Management
Information Systems (HMIS). While NHSRC introduced the HMIS system at the state and
district levels, it was difficult for them to train functionaries at the sub-district levels. Hence,
states were requested to prepare their plans of action for capacity building of functionaries at the
sub-district level and below. Given that UNFPA had presence in Bihar and Maharashtra; the
states requested UNFPA to help to operationalize these plans. UNFPA engaged the Indian
Institute of Health Management Research (IIHMR) and the International Institute of Population
Sciences (IIPS) to carry out this work in Bihar and Maharashtra respectively. In Bihar, UNFPA
support was extended to build capacity of all staff members at the level of the district and below,
while in Maharashtra it was confined to the capacity building only of mid-level managers.
Training modules that complemented NHSRC modules were developed, pre-tested and
introduced in both the states in collaboration with the state units of NHSRC and the respective
state governments and the state units of NHSRC. These modules can continue to be used as and
when required to train additional staff in the future.

The training programmes in both Bihar and Maharashtra have been completed. In Bihar, besides
HMIS training, UNFPA is also helping mid-level managers to analyze the quality of data and to
use the data for monitoring and feedback. In Maharashtra the module focused more on the
monitoring aspects of the programme. Discussions of the evaluation team with state governments
and other agencies including NHSRC and Ministry of Health have revealed that HMIS reports in
Bihar are now being prepared on time and the quality of data reported has improved, though in
many districts, there is still scope for improvement. Supervisory staff that has been trained has
started moving into the field to conduct review meetings. It appears that the states of Bihar and
Maharashtra are seeing HMIS improvements as a result of the UNFPA capacity building inputs.

The evaluation team finds that the quality of training in HMIS has not been evaluated in depth
and would be necessary before advocacy for replication and scale-up. Besides, the HMIS does
not include strong data quality checks, and data triangulation, it does not measure any elements
of quality of care, nor does in gather data disaggregated by markers of social disadvantage.
Without these, it was not possible to train district and sub-district managers and supervisors and
front line workers to analyze programme performance from the point of view of whether
vulnerable sections of the population had access to services or were utilizing them.

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6.3.2.2. The Civil Registration System and Vital Statistics

The civil registration system in India is implemented under a central law, namely, the Birth and
Death Registration Act, with the overall supervision of and guidance from the Registrar-General,
India (RGI). If the system functions well it provides vital statistics for small areas which can be
the key data set for decentralized development and programme planning. In India the system has
not yet taken firm root and system effectiveness, coverage and data reliability vary greatly across
the country.

UNFPA undertook an important study of the civil registration system and vital statistics in the
state of Rajasthan. The study provided estimates of the degree of coverage of the system, and the
community‟s awareness about and perception of the system. Lapses and deficiencies in the
system were identified and the need for sustained building of public awareness was highlighted
and shared with government counterparts. A consultant provided and placed by UNFPA within
the Planning Department of the Government of Rajasthan has been continuously reviewing vital
registration system data and providing regular feedback to the state government. The state
government has accepted a few short-term recommendations from the study and will be
implementing them in the XII Five-Year Plan cycle.

The study in Rajasthan could have benefited from consultation with and guidance from RGI and
other stakeholders such as UNICEF.

Since UNFPA is engaged in building national capacity to gather and use data for decentralized
development planning, the provision of TA for improving the utility of vital registration data and
showing how the most reliable estimates can be made from data even though coverage levels are
not high, would be an important contribution that UNFPA could make.

6.3.3. Technical Assistance and Support for the conduct of Census, 2011

The Census operations in India are carried out in two phases. The 2011 census included house-
listing and housing census in the first phase, and population enumeration in the second. The
United Nations (UN) agencies of UNICEF, UNIFEM, UNDP and UNFPA in India have been
supporting the Office of Registrar General of India (ORGI) in four specific areas:

a. digital mapping of census blocks in capital cities,

b. census training and publicity,
c. gender aspects of the census and
d. data dissemination.

A joint UN-ORGI five-year work-plan was drawn up in 2008 wherein both the programmatic
role to be played by each UN agency and the financial support to be provided by them to the
census were well defined.

In the first phase of the census, UNFPA and UNICEF supported the digital mapping exercise,
and in the second phase, UNFPA and UNICEF supported training and publicity activities for
gender mainstreaming. Presently, UNFPA is supporting streamlining historical data series
through e-archiving going back to 1931 at least, and data warehousing for the 2001 and 2011
censuses. This will enable disseminations of census data with historical comparison and context.
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A study is also being undertaken to develop a road-map for establishment of Census Training
and Resource Centre.

„Digital mapping‟ of all wards in 33 capital cities barring a few in the Kolkata Municipal
Corporation was accomplished in 2010. The RGI and his staff informed the evaluation team that
these digital maps were useful in carving out enumeration blocks and ensured better coverage
during enumeration.

Enumerators were trained for effective conduct of the census. Training of enumerators was done
using a cascade approach. Ninety national trainers trained. 725 master trainer facilitators who in
turn trained 54,000 master trainers who then trained 2.7 million enumerators all over India on the
population enumeration schedule.

Though gender had been a prominent cross-cutting priority in the 2001 census, it had enumerated
several villages/districts that had reported very few women, very low female literacy, and no
female workers. Data related to female count, marital status, female headed households, female
disability and female work-participation had continued to suffer from under count or under
reporting. To ensure better data on these aspects in the 2011 census, it was decided that
enumerator training would include a gender module that sensitized all 2.7 million enumerators in
the country on the need to exercise care to ensure that data gathered on the above mentioned
female issues was accurate, and on how such data should be collected.

The gender module was developed for all levels from national trainer to enumerator. The training
guides integrate the seven categories of gender-specific issues through well laid out session-
plans. To facilitate the sessions, appropriate teaching aids in the form of an e-module, role-plays,
quizzes, flyers and data-posters were developed. A two-sided flyer in A4 size containing gender-
data on one side and gender mainstreaming matrix on the other for 260 critical districts was
printed by India Census office in local languages for all the 2.7 million enumerators across the
country. The flyer was used as training material in the training programs.

Special training was given to the enumerators in “gender critical” rural and urban areas. Gender
critical urban and rural areas were identified on the basis of three criteria emerging from the
2001 Census- overall sex ratio, female literacy, and female work participation. These three
indicators reflect the status of women and additionally enable analysis at the lowest
disaggregated level, i.e. the village. Thus, rural districts that scored low in the 2001 census in sex
ratio (less than 900); female literacy (less than 30%) or female work participation (less than
20%) were identified. For urban areas - cities and towns- different cut-offs were used. Using this
methodology, 260 out of 593 districts and urban areas across the country, were identified as
gender critical.

Enumerator training in these 260 districts was considered the key to ensuring completeness and
accuracy of data concerning women and girls. For these districts, a pool of 260 specially trained
gender master trainer facilitators (GMTFs) were put in place, and they trained the 1.2 million
enumerators of these districts in the gender module. This was done to make sure that in the
gender critical districts, the training of enumerators on gender issues did not suffer any dilution
through the cascade training approach.
For reinforcing gender elements in the 260 gender critical districts, bi-lingual gender-data posters
in A2 size (English and Hindi) were printed by UNFPA for use during training programmes and
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as publicity material at training venues and government offices in the districts. During training of
enumerators, the GMTFs discussed the district situation in 2001 census in terms of the indicators
shown in the poster, and later emphasized the importance of completeness of data concerning
women & girls. This was done through a 45 minute training capsule that focused on ensuring
inclusion, better netting of different categories of women, and appropriate information on births
of girls, female headed households, etc.

UNFPA worked closely with UNICEF and UN Women in the census project. A national alliance
of NGOs was supported by UNICEF through a cost-sharing mechanism with UNFPA, for
developing training outlines, session plans, teaching aids, and e-modules and for imparting
training to the trainers, thus complementing the efforts of the Census Organization. Further,
gender aspects were mainstreamed into training and publicity activities. A note on the processes
of how gender is to be mainstreamed was put together by the gender working group led by
UNFPA. The gender note is hosted on the website of Census India and can be accessed through
the link:
http://www.censusindia.gov.in/2011census/training/docs/Gender_mainstreaming_in_Census_20
11.pdf

For undertaking publicity activities, reputed advertising agencies were hired by UNDP and
UNICEF for the first and second phases respectively. Communication strategy and media
planning, designing and preparing publicity materials and creatives were all undertaken. Web -
based publicity was used for the first time in Census 2011. Apart from generating awareness
about the census, the publicity agenda focused on communicating specific gender messages and
included women‟s work, as one of its major themes.

Dissemination of census data

The dissemination of census data has been planned wherein IT based solutions like „Census Info
India‟ that is both CD and web-based, user-friendly software to run Primary Census Abstract
(PCA), establishment of in-house data ware-housing and mining system, and e-archiving of
earlier census data are on the anvil. Dissemination of the provisional results of the 2011 Census
has just been initiated and UNICEF has provided the Census Info platform for disseminating
data. These efforts are likely to result in expeditious and smooth dissemination of census data
much earlier than in past censuses.

A „Census Training and Resource Centre‟ has been proposed to be set up and UNFPA has
commissioned a study to develop a road-map for the establishment of the Census Training and
Resource Centre which is expected to be used for south-south collaborative activities.

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6.3.4. Bihar Population and Development Policy formulation

UNFPA was requested by the Bihar Government to facilitate the process of developing a
population and development policy and to help in its formulation. UNFPA developed a road-
map of the formulation process which was ratified by the government. To take the initiative
forward, sectoral reviews in the following areas were initiated:

a. Demographic trends and future scenario for attaining replacement level fertility;
b. Health, mortality and morbidity patterns and burden of diseases in Bihar
c. Education status, current gaps and future requirements;
d. Employment scenario and livelihood options;
e. Development options for Bihar; and
f. Status of women in Bihar

All the sectoral reviews have been finalized after seeking feedback from government and civil
society organizations in a one-day consultative workshop. The government is presently
reviewing the papers and after once it concurs, the next steps in the policy formulation process
will be initiated. The evaluation team finds that studies are yet to analyze the inter-sectoral
linkages within a rights-based and gender sensitive framework.

6.3.5. Emerging Population Issues

UNFPA expects that emerging changes in the age and sex structure of the population in India,
particularly the growing numbers of the elderly, combined with the migration of youth and
families, will pose newer demographic and developmental challenges related to the life situation
and care of the elderly. Therefore UNFPA has identified population aging as a priority area in its
work in PDS. CP-7 proposed to pursue three dimensions of work in this emerging issue: (i) build
a general knowledge base in the country through special research and programmatic studies, (ii)
work with the government on policy and programme issues which will enhance the economic
and social integration of the elderly to the mainstream of society, and (iii) build capacity of
national institutions for more effective implementation of the government programme.

6.3.5.1. Build a knowledge base in the country through special research and
programmatic studies

The knowledge base in regard to the elderly in terms of their demographic, social and economic
conditions, health needs and their living arrangements particularly of single and widowed
women is weak. Further, there have been few or no studies that have documented the awareness
and use of entitlements by the elderly. Hence UNFPA commissioned eight secondary studies
covering a range of elderly issues from demographic, socioeconomic and health aspects to
government policies and programmes. These studies were conducted in partnership with the
Institute of Social and Economic Change (ISEC) – Bangalore and the Institute of Economic
Growth (IEG) – Delhi. The eight studies were on:

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a. Demography of the Indian elderly

b. Elderly workforce in India: labour market participation, wage differentials and their
contribution to household income
c. Elderly health in India: dimensions, differentials and changes overtime
d. Family structure, living arrangements and the social dimensions of the elderly
e. Critical gaps in the implementation of integrated programme for older persons
f. Critical review of the national policy on aging
g. Synthesis of policies for the aged, of select Asian countries, and a study of the relevance
of these policies in the Indian context
h. Studies on aging in India: A review

By the first quarter of 2011, these eight studies have been completed and peer-reviewed. They
are to be published in a series of discussion papers, and are to be shared and disseminated to a
wider audience of stakeholders and partners across the country including government.

In the second stage of the research, based on gaps identified by the secondary studies, three large
scale primary studies have been initiated to fill the gaps because they would have bearing on the
development of policies and programmes. The primary studies are being conducted by partner
institutions and will examine (i) family composition, family dynamics and living arrangement of
elderly persons across different socio-economic settings; (ii) health status of the elderly; and (iii)
economic status of elderly, social protection and safety nets in the context of aging in India.
These primary studies are being carried out in seven states of India with a relatively high
proportion of elderly populations. Field data collection started in March, 2011 and is expected to
be completed by August 2011.

A set of comprehensive primary study instruments have been prepared by the partner institutes in
consultation with a technical advisory committee formed of senior researchers from within the
institutes, experts in the field of population aging, and UNFPA.

The evaluation team finds that the process of developing the questionnaires and manuals was
very systematic.

6.3.5.2. Work with the government on policy and programme issues to enhance
integration of the elderly into the mainstream; and (iii) build capacity of national
institutions for more effective implementation of the government programme:

UNFPA approached the Ministry of Social Justice and Empowerment (MOSJE), the nodal
ministry concerned with the care of elderly in India. UNFPA proposed to support the Ministry by
providing policy analysis, identifying programmatic gaps, and helping the Ministry to streamline
its strategies for economic and social integration of the elderly into the mainstream of society.
UNFPA also proposed to build the capacity of apex institution such as the National Institute of
Social Defence; facilitate the formation of networks of NGOs and build their capacity to
undertake national pilot interventions for the elderly. The MOSJE‟s involvement has been
restricted to engagement with UNFPA on a case-to-case basis and UNFPA could not therefore
move ahead systematically with a comprehensive plan for this field of work. Consequently,
UNFPA‟s work in the field of aging is at the moment restricted to research and programmatic
studies.

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6.3.6. Supporting Professional Associations working in the field of Population and

Development

In CP-7, UNFPA has provided technical and financial support to various professional bodies and
associations for organizing workshops and conferences, The support provided professionals the
opportunity to present recent research in the field of population and development, and promoted
discussion and dialogue among scholars. These professional bodies and associations include
Indian Association for the Study of Population (IASP), Indian Association for Social Sciences
and Health (IASSH), Asian Population Association (APA), Centre for Gerontological Studies
(CGS) and Indian National Science Academy (INSA). In addition, UNFPA provided IASP with
one time financial assistance to revive its journal “Demography India‟.

6.3.7. Other research and programme studies

UNFPA has from time to time undertaken other research and programme studies during CP-7
These studies include an assessment of Janani Suraksha Yojna50 (JSY), home-based pregnancy
testing kits for MOHFW; and evaluation of the Red Ribbon Express for NACO; the prevalence
of obstetric fistula; assessments of the adolescent education programme, and of the functioning
of Teen Clubs; and trend analysis of sex ratio at birth based on data from census, and assessing
impact of incentives on SRB.

The CPAP of CP-7 envisioned studies on important emerging population issues such as the
„youth bulge and the demographic dividend‟, migration and urbanization, population and
environment, and post reproductive morbidity. Some papers on these issues have been presented
at national and international conferences. However, more systematic and rigorous studies for
policy advocacy are yet to be taken up.

6.4. Conclusions and recommendations

The interventions to improve decentralized and convergent development planning at the

district level through use of data particularly those related to population dynamics, are fully
aligned with the global mandate of the UN and relevant to the needs of the country. Activities
were planned in a systematic way and interventions were rolled out through the UN- GOI
Convergence Programme. Inspite of lack of synchronized action between the partners, UNFPA
made efforts to take forward the intervention in discussion with other UN partners.

Recommendation:
Continue to support decentralized and convergent district level development planning and
add depth to the training content used so far by emphasizing how to gather, analyze, interpret
and use data for the formulation of policies and programmes that address and safeguard the
fundamental principles of rights, equity, and gender.

UNFPA‟s training programs for senior administrators and planners/statistical officers at the
state and district level on the use of data for planning and monitoring is a good first step in this
capacity building process. Both participant feedback and the requests from the state governments

50
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for repeat workshops to be organized at the state level are evidence of relevance and
effectiveness.

Suggested Actions:
Since repeated rounds of training for capacity building will be needed in the foreseeable
future, and since such training needs to be scaled-up, it is important to build institutional
capacity in the states to design and conduct such programs. This would make the capacity
building sustainable and cost effective. To enable all this, the state governments would need
to allocate resources in their budgets for conducting these programmes on a continuing basis.

For sustained in-service capacity building of senior administrators, and programme and
policy leaders, population and development courses should be integrated into the induction,
orientation and training courses that are regularly conducted for government officials.

There is a shortage of professionals trained in population and development studies particularly

with a gender sensitive and rights based perspective. While in-service training approaches used
by UNFPA are a valuable input for filling the gap, it may be worthwhile to support pre- service
education to enlarge the pool of trained personnel in this field in India.

Suggested Action:
UNFPA should support the development of Masters/Diploma/Certificate programme on
population and development at appropriate educational institutions.

The strengthening of the capacity of administrators by broadening their vision on population

and development inter-linkages as envisaged in CP is an important strategic initiative. This
initiative is yet to take off. This intervention is very crucial to PDS in India along with
sensitization and training on data use. It is a highly effective and sustainable tool of policy
advocacy around the ICPD PoA and for the implementation of the National Population Policy.

Recommendation:
Broadening the vision and perspectives of development planners to understand population
and development linkages, and the relationship of the key issues of gender, equity, and
empowerment to development, must continue to receive priority in the India CP.

The district population projection exercise was highly appreciated by all stakeholders.
UNFPA has worked strategically and systematically to help the districts to define the
denominators that form the basis of the planning exercise. That government put the projections
on its website and is using it for planning purposes speaks for the relevance, effectiveness and
quality of the work. The exercises of district level projections and sub-national estimation are
likely to have positive impact on decentralized planning and programme monitoring.

Suggested Action:
UNFPA should advocate for sustained use of the projections.

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Capacity building support provided for HMIS in Maharashtra and Bihar has begun to show
results. However, the evaluation team finds that the quality of training in HMIS has not yet been
evaluated in-depth. It is necessary to do so before carrying out advocacy with state governments
for replication and scale up. One challenge with the HMIS is that it does not gather data
disaggregated by sex and other markers of disadvantaged social status. It does not permit
triangulation of data, and it does not have strong, in-built data quality checks. Nor does it report
on any elements of quality of care. This makes it difficult to measure access to quality services
for vulnerable sections of the population. Without such data from the HMIS district and sub-
district managers, supervisors and front line workers will not be able to track health programme
implementation on these critical aspects. Given the importance of vital statistics from the civil
registration system for decentralized development planning, TA for both strengthening the
system, and in how to use and make estimates from data when coverage rates are imperfect, are
important contributions that UNFPA could make in India.

Suggested Actions:
Proactively advocate with government for the inclusion of markers of disadvantaged social
status in the HMIS.

Provide TA inputs for strengthening both vital statistics from the civil registration system and
HMIS data.

The evaluation team concludes that the support given by UN agencies (with UNFPA as the lead)
for conduct of Census 2011 has been timely and extremely valuable. The unique role and niche
of UNFPA in engendering the census has been well recognized. Moreover, the effective
leadership provided by UNFPA on this joint initiative has been appreciated by its UN sister
agencies and Government/ORGI. This joint programming approach is a model that could be
replicated for joint UN programming in other areas of work. Most of the products developed by
UN agencies are available on the census website. Furthermore UNFPA staff has reported to the
evaluation team that the Ministry of Rural Development has sought technical support of the UN
for the planning and execution of the Below Poverty Line Census to be conducted from July
2011, and that the UN agencies are supporting the conduct of a pilot for this Census.

With regard to the population policy work in Bihar, well-written sectoral papers have been
prepared. However inter sectoral linkages are yet to be analyzed within a rights based and gender
sensitive framework.

Suggested Action:
In formulating the Bihar Population & Development policy, care needs to be taken to ensure
that the resultant programme is rights-based and gender-sensitive. An advisory group of
eminent population and development and gender professionals may be set up by UNFPA to
advise on policy strategisation.

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Reviewing the work done so far in the field of aging, the evaluation team finds that UNFPA has
approached this emerging issue very systematically, starting with a comprehensive research
agenda to establish a strong knowledge base that will serve as an effective tool for advocacy to
address policy and programmatic gaps related to the elderly. It is disappointing that despite the
best efforts of UNFPA, the MOSJE is not actively engaged. If UNFPA wishes to make headway
on this emerging issue it will need to advocate to find alternative routes and mechanisms to get
civil society organizations and the government to be engaged in the issue of aging, so that the
elderly are included in the national development agenda.

Suggested Action:
Begin advocacy for the issues of the elderly by disseminating the aging studies
commissioned by UNFPA to important civil society organizations and government. In
partnership with these organizations, work out collaborative and persistent policy advocacy
approaches.

As the results of Census 2011 become available, there will be more data on several emerging
issues including the youth bulge, the demographic dividend, aging, sex selection, migration, and
urbanization. Development planning will need to be contextualized in the light of these
developing trends. The need for advocacy to ensure contextualized planning will become even
more apparent than it was in 2008 when CP-7 was formulated. The present advocacy approaches
of UNFPA hinge on training and capacity building of senior managers in government. The
evaluation team is of the view that higher level advocacy is needed such as the wide
dissemination of a series of policy papers with a matching set of articles and reports designed to
inform the public and generate a discussion on what needs to be done. A concerted and
continuing advocacy; effort at many levels and for many audiences, including parliamentarians,
legislators, youth, the university system, policy think-tanks, the media, and the general public
would help to shape public opinion, create an environment, and generate pressure for
government action in these areas.

Recommendation:
Further analyze and use the results of Census 2011, launch a concerted and continuing
advocacy; effort at many levels and for many audiences, to shape public opinion, create an
environment, and generate pressure for government to develop policies and programs in the
context of emerging demographic trends and issues. To enable this, preliminary research and
studies on emerging population issues like the youth bulge and the demographic dividend,
migration and urbanization, population and environment, abortion and sex selection, and
post-reproductive morbidities which have not been substantially taken up during CP-7, need
to be taken up in CP-8.

In summary, the PDS work accomplished under CP-7 is varied, significant and relevant.
Considering the importance of PDS in the context of the global mandate of UNFPA, the
expansive scope of this thematic area, the policy advocacy agenda, and the present and future
needs of the country, there is a need to strengthen UNFPA‟s human and financial resource
allocation to this thematic area so that it acquires the capacity to engage in policy advocacy,
provide capacity building inputs on population-development dynamics, ensure gender
mainstreaming in UNFPA‟s programs, and establish essential linkages with resource persons and
institutions that are inter-disciplinary. The evaluation team found that the budget allocation for

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PDS thematic area is quite low. During 2009 and 2010, it varied between 6 and 8% of the total
funding for those years.

Recommendation:
Strengthen the PDS thematic area group in UNFPA to enable it to more fully and effectively
address the scope and complexity of this critical component of UNFPA‟s portfolio.

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Part C: Geography & Partnerships

Section VII: Programme Geography

The evaluation team has been asked to consider whether the geographic focus and spread of
UNFPA‟s programme is appropriate. In answering this question we considered the history
behind UNFPA‟s present location, the areas in India that need the greatest development inputs in
the sector of health and population, the views of the GOI on where it believes UNFPA could play
a significant role, the cost of maintaining state offices, as well as the intangible costs of exiting
present locations and entering new ones.

In 1991, when CP-4 began, it was agreed that UNFPA would develop a state presence to support
programme implementation in areas where development indicators were behind expectations.
To cover such areas UNFPA set up offices in Kerala, Maharashtra, Gujarat, Rajasthan and
Orissa. At this time Kerala was chosen not because its development indicators lagged behind the
norm but because it had certain unique health issues and pockets of underdevelopment, like
Mallapuram. It also offered the opportunity to roll out the comprehensive ICPD agenda in
middle and well performing regions. Gujarat, despite an overall positive development picture,
had some extremely backward districts and areas within it. In CP-6, Government requested
UNFPA to develop a state presence in Bihar where considerable improvement was needed in RH
and development indicators. UNFPA withdrew from Kerala and Gujarat, and entered Bihar.
Even after it withdrew from Gujarat, UNFPA continued its engagement there by providing inputs
to address issues related to sex selection, adolescent reproductive and sexual health and other
needed interventions. This assistance was coordinated by the UNFPA office in New Delhi.

At the present time, UNFPA works in 5 states- Maharashtra, MP, Orissa, Rajasthan and Bihar.
Last year, in continuation of its policy of guiding development partners to focus their assistance
on less developed areas, the GOI allocated 265 districts requiring high focus for development, to
various development partners. UNFPA was allotted 13 such districts within four of the five states
where it is present.

There is questioning within UNFPA on whether or not it should continue in all the five states
where it currently operates, and if changes are to be made, what those changes should be. Where
UNFPA should be located depends very much on where the Government feels UNFPA‟s
presence would provide the greatest value and support to the national program in line with
UNFPA‟s own priorities.

In essence, UNFPA plays a mix of three meaningful roles: policy advocacy, technical assistance,
and programme implementation support. Given these, UNFPA‟s current mix of national and
state presence is well considered. UNFPA‟s presence at the national level is required for
effective policy advocacy. Its strong technical resources at both national and state levels allow
for sustained interaction and provision of competent technical assistance at both national and
state levels. UNFPA‟s field presence in selected states enables it to support and prove innovative
pilot approaches, and to demonstrate effective programme implementation techniques. When
such work is carefully chosen and executed, with outcomes evaluated and processes documented,
it lends weight and credibility to UNFPA‟s policy change and advocacy agenda. In every state
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that the evaluation team visited, state government representatives said that local presence of
UNFPA in their state was most helpful as it allowed UNFPA to be completely familiar with state
context and scenario and to quickly respond to the technical assistance needs of the state based
on a thorough understanding of the context.

The evaluation team discussed with the GOI the issue of which states UNFPA should work in.
The GOI is of the view that it should remain in the states where it currently is. It agrees that the
states that UNFPA is currently in, are amongst the most under developed of India‟s states, and
require UNFPA support.

Annex 8, compares the 28 states of India on 7 key development, health and population
parameters- female literacy rate, child sex ratio, infant mortality rate, total fertility rate,
contraceptive prevalence, unmet need for family planning and percentage of population living
below the poverty line. Between them the 5 UNFPA states are home to 33 percent of India‟s
population and 42% of India‟s poorest. In Annex.8 a composite indicator combining all 7 of
these indicators has been used to rank the states, and the findings are that Orissa, MP, Bihar and
Rajasthan are amongst the top 6 most underdeveloped states in the country. They are all high
fertility states (TFR over 3.1 when the national average is 2.1), with high infant mortality. In
these states, achievement of national and MDG goals related to population and maternal health
lag behind the national average. These four states fall into the special category of states which,
for development purposes, are monitored by an Empowered Action Group (EAG) set up by
government. Amongst the poorest states in the country, they continue to offer a very appropriate
setting for work in UNFPA‟s areas of core competence- RH including family planning, and
attention to youth. All these states need inputs to create demand for health and family planning
services. Social norms still promote early marriage, and early and too frequent child bearing-
contributing to exacerbating maternal and infant mortality and causing poor maternal and child
health.

Maharashtra is an enigmatic mix of developing and underdeveloped. TFR has fallen below 2.1.
The age at marriage remains low. The sex ratio has worsened since Census 2001. Maharashtra
ranks 16 out of India‟s 28 states, and it ranks 5th amongst the states with the most adverse child
sex ratios. It is a huge state with 10% of India‟s population and an equal proportion of India‟s
poor. The state has its own extensive areas of backwardness in Vidharbha and Marathwada,
which compare with the most backward districts of MP, Bihar and Uttar Pradesh. If district
disaggregated data were examined, there would be very large absolute numbers of people with
poor health and population indicators. Next only to Tamil Nadu, Maharashtra is hugely urban,
with 42% urban population and high levels of employment related migration from other states. It
is a state where health service delivery systems are better organized, and where the state is ready
and wanting to work on emerging issues such as aging, urban health and a more comprehensive
primary health approach to women‟s health – one that addresses issues beyond a woman‟s
reproductive years. Maharashtra has impressive experience in working on HIV prevention and
control, and with its more developed health infrastructure, is exactly the right state in which to
work on programmes that address quality of care; maternal health, family planning and age
appropriate services for young people; and convergence of HIV and RH. It could be a very
valuable proving ground for approaches that will be more widely needed in the future by states
such as MP, Rajasthan and Bihar, once they have moved to the next rung in the ladder of social
and human development.

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There are advantages to staying on in the five states of Bihar, MP, Rajasthan, Orissa and
Maharashtra. Four of these five states are UNDAF states. Effective relationships, trust and
credibility have been built with the state governments. Entering a new state would require large
initial investments of both time and money before results are visible. No clear advantages are
apparent from such a move. Even if UNFPA decides not to work on emerging issues in CP-8,
there is little reason to leave Maharashtra. The Marathwada and Vidarbha regions of eastern
Maharashtra are in every way as backward as MP and Bihar. Approaches relevant for Bihar and
MP are equally relevant in these two regions of Maharashtra. Even in the matter of sex selection,
these five states offer ample opportunity for meaningful policy advocacy, TA and programme
implementation support. The data from Census 2011 shows that the sex selection contagion is no
longer a concentrated epidemic; it is slowly attaining the proportions of a more generalized
epidemic touching states that once seemed unaffected.

Regarding whether UNFPA should spread out more extensively in India, the evaluation team
feels that no purpose would be served by spreading out too thin. India is a huge country. Five
states are a significant presence. Each additional state office costs a significant amount annually
to staff and operate, not including programme resources. Even if UNFPA were to have more
funds than it has at present, it might be well advised to allot more to each of the current 5 states
than to add another.

Recommendations:
In CP-8 UNFPA should continue to maintain offices in the 5 states where it is currently
present.

UNFPA should retain the flexibility to pursue policy, advocacy or selective work in some
themes, particularly in emerging issues, outside of these 5 states. Such programmes could be
managed out of Delhi or one of the five state offices depending on proximity, and technical
skills of the staff in the state offices.

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Section VIII: Partnership Strategies

8.1. Government

UNFPA‟s primary partner has been the government both at the national and the state levels.
The partnership has many dimensions and is largely with the ministries and departments of
Health and Family Welfare, Education, Youth Affairs and Sports, and Women and Child.

The nature of the partnership that UNFPA, indeed all donors, have with the GOI has changed
significantly over the last decade. Donor assistance in the area of health now forms an
insignificant proportion of resources that the government has provided for its flag ship
programmes, including RCH-II (within NRHM) and NACP-III. Except for five bilateral donors
including DFID, the European Union and USAID, most bilateral donors have been informed that
they should provide their assistance to NGOs or the UN, instead of to the government. In this
new environment, government values flexible technical assistance and programme
implementation support that demonstrates how implementation can be made stronger and more
effective at the state and district level, particularly in those that are lagging behind. Late last year
the government allocated such districts to its various development partners, and sought their
assistance in helping these districts to catch up with others on key national programme
indicators..

As discussed in the introduction to this report, donors whose support the GOI continues to accept
have shifted focus from the national to the state level, choosing to work in states that are lagging
behind. UNFPA uses its presence at the national level, to support the implementation of national
programs, advocate for issues and provide policy inputs. In addition, UNFPA uses it presence in
5 states to provide policy and programme guidance to the state governments in areas that are
UNFPA programme priorities. The assistance provided by UNFPA and other UN agencies is
guided by the UNDAF strategic framework.

The primary and most significant partnership that UNFPA has with government during CP-7 is
the co-financing of the RCH-II programme through the SWAp mechanism. Over the life of CP-
7, UNFPA will contribute 28% of its budget to this programme. UNFPA‟s focus in the SWAp
was to be on issues related to evidence based programming, quality of care, gender issues, and
community orientation. UNFPA found that this partnership with the central government enabled
it to participate in and contribute appropriately to the design, review, monitoring and assessment
of RCH-II. UNFPA also provides funds for implementation of specific programmes by various
departments and agencies of state governments -for instance the implementation of the school
based adolescent life skills programme and the incorporation of the LSE programme into the
B.Ed. curriculum in teacher training colleges through the Department of Education in Rajasthan.
In the states, it also funds and supports the implementation of pilots to assess their feasibility for
replication and scale-up.

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8.2. Multilateral and Bilateral Donors

The Development Partners Forum at the national level brings together all bilateral and
multilateral donors that provide development assistance to the RCH-II programme, and the
government. Members of the forum include DFID, and the World Bank who along with UNFPA
have contributed to the GOI‟s SWAp and are called “pooling partners”. Other members such as
UNICEF, USAID, and the European Union, who did not join the SWAp are called “non-pooling
partners”. All partners discuss progress of the RCH-II programme, share information on each
others‟ programmes, and discuss issues of common interest. In the event of a request for
assistance from the Ministry, the nature of assistance that each can provide is discussed and
decided upon. Members from the Development Partners Forum pool their resource to contribute
to Joint Review Missions, assessments, and the development of technical guidelines and tools
needed by the government. All partners have found that this forum is a good platform for
coordination, strategic planning, and programme review.

At the state level too there are Development Partner Forums that play a similar role to that
played at the national level.

Of the bilateral partners, DFID has the greatest geographic overlap with UNFPA as it has
programmes in Bihar, MP and Orissa. UNFPA too works in these states, and should seek a
strategic partnership with DFID in common areas of interest- which would be policy dialogue on
gender issues such as women‟s sexual and RH and rights rather than sex selection alone,
reduction in total fertility rate, and family planning for young women. UNFPA‟s programmatic
emphasis on family planning, maternal health and HIV AIDS is shared by USAID. The
Development Partners Forum enables discussion for coordinated action.

8.3. Non-governmental organizations:

UNFPA has worked with academic, research and professional bodies, and with civil society
organizations that play a variety of roles in the programme:

8.3.1. Research and academic agencies conduct studies, carry out assessments, and develop
tools that become the basis for advocacy on key issues, for programme design, review
and evaluation or for providing technical support or building the capacity of other
UNFPA partners including state government organizations.

8.3.2. Professional bodies such as the Indian Medical Association (IMA) or the national and
state federations of obstetricians and gynaecologists (FOGSI and its state chapters), or the
Maharashtra State Legal Services Authority, set standards, provide and promote
protocols, and carry out professional capacity building and orientation for, and advocacy
with their members. For instance IMA educated doctors on the sex selection issue. The
Maharashtra Judicial Academy has done critical work in educating and sensitizing the
judiciary on the issue of sex selection.

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8.3.3. Civil society organizations/NGOs: play three roles

a. Implement pilot interventions: Several civil society organizations are engaged in

implementing innovative pilot projects to demonstrate new concepts. Once the projects
prove the concept, the effort is to take the intervention to scale through the government.
Jan Mangal is a model that has been adopted by government and has been taken to scale
with government resources. The QA project too has now been taken over by government.
Most of these projects are community based, addressing issues that require community
outreach and mobilization. Several of these interventions are community based, and the
civil society partnership is necessitated because the government own human resources
and communication chain does not effectively reach communities with health education
and primary health services.

b. Provide technical support to government programmes: Agencies such as CEDPA,

PRAYAS, IIPS and IIHMR have provided technical and capacity building support for
UNFPA programmes with government, such as HMIS strengthening in Bihar and
Rajasthan.

c. Advocate on issues: Agencies like PRIA, THP, MPVHA have played an important role
in strengthening the implementation of the PCPNDT Act, by monitoring the registration
and compliance of ultra sound clinics with the Act, and by mobilizing civil society
organizations to pay their legitimate role in making statutory boards and bodies.

UNFPA‟s relationship with NGOs too has changed over the years. Before CP-7, UNFPA worked
to gain the acceptance by government of civil society organizations/NGOs. In CP-7, the
engagement with NGOs shifted to associating with them and having them play the variety of
roles discussed above. In the past few years, there have been developments that are adverse to
NGOs. Government has begun to use them as contractors, but there are few funds that enable
NGOs to work on innovations, or to pursue other issues and priorities of significance to civil
society. Donor funding for NGOs is drying up, and the few large international donors such as the
Gates Foundation, fund very large programmes that are implemented by consortia of a few very
large NGOs, mostly international NGOs. Unless support for civil society organizations is
ensured, there will be a withering away of a small, vital set of players in the development sector.
There has been a slow but steady growth of Indian donors that could be a source of support to
Indian NGOs. However, it is at the moment unclear what the priorities of these donors are, and
of whether they could be interested in funding reproductive health and family planning.

8.4. South south partnerships envisioned in CP-7

South south collaboration has happened on the issue of sex ratio decline, where UNFPA offices
in China, Vietnam, Nepal, and the Caucuses came together to work with UNFPA‟s Asia
Regional Office and Head Quarters. India, Nigeria, Bhutan, Sudan and Afghanistan have had
exchange visits designed to share Indian experience and expertise on Census operations. Work
on south south collaboration to enable other Asian countries to learn from India‟s expertise in
census operations has not yet begun but is expected to begin shortly as soon as the Census
Training Center is set by in Delhi.

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8.5. Partnerships within the UN system- harmony, synergy and avoidance of duplication

A mid-term review of the UNDAF for the period 2008-2012 which was conducted recently by
Rohini Nayyar and Ananya Ghosh Dastidar, has provided a very detailed analysis on the
effectiveness and harmonization of UN Agencies at both the national and state level. This
evaluation report of CP-7, does not therefore reinvestigating all issues in depth. It only offers a
brief summary of the issues.

Harmonization at the national level

The development of the UNDAF was the first step in the harmonization of the work of the many
UN agencies in India. Bi-monthly meetings of the UN Country Team (UNCT), comprising
heads of agencies helps in harmonization. The UNCT shares information and encourages
collaboration and joint programming between the agencies.

The process of harmonization is taken forward by selected member organizations who work on
similar development issues, coming together to form Thematic Clusters. There are eleven
thematic clusters, and UNFPA is a member of 5 thematic clusters: (a) the Joint UN Technical
Assistance Group or JUNTA which works on HIV/AIDS; (b) Empowerment of Women and
Gender Based Violence; (c) Health; (d) Convergence, and (e) the UN Disaster Management
Team (UNDMT). The record of effectiveness of each of these thematic clusters is mixed. Some
clusters have done better than others at harmonization and synergy of operations. Members of
each cluster are meant to share information and resources, and explore ideas that can lead to
effective capacity mapping and resource pooling for addressing their common agendas. The best
example of this is the Gender Cluster. Each cluster prepares work plans annually, putting
together information on those activities of each agency that contribute to the achievement of
outputs related to the theme. A monitoring and evaluation matrix sets out indicators, baselines
and targets with which to track progress that each agency is making towards achievement of
UNDAF results related to the theme. Members of each cluster have the opportunity to work
together to think about how to integrate cross-cutting issues such as gender, decentralization,
capacity development, human rights based approaches, disaster risk reduction, results based
management, and social inclusion into the work of their theme.

The joint program on the Census of UNFPA, UNICEF and UN Women was a success and details
have been discussed in Section VI of this report, relating to PDS. Also in the same section, the
work done by UNDP, UNICEF and UNFPA to improve district planning, including problems of
harmonization have been discussed.

The evaluation team learned from conversations with some members of the Thematic Clusters,
that the barriers to team work are the usual: distrust, a strongly developed sense of territoriality,
and fears of loss of territory and of watering down of one‟s own agenda.

Till 2007, UN agencies typically operated individually, with territories and budgets clearly
demarcated. They developed their own work plans, independent of each other. Each agency
independently pursued its policy, advocacy and programme agenda with host country
governments. The thematic clusters formed in or after 2008, are still nascent. t is going to take a
while for cluster members to be comfortable operating in clusters to build harmony and synergy
between themselves.
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At the state level

Attempts have been made to locate all UN agencies operating in a given state under one roof.
This move has succeeded in Bihar, MP and Orissa, where UN agencies are co-located. This
certainly makes it easier to build effective interpersonal relationships, share information and
collaborate. Even when offices are not co-located, individuals who reach across their agencies to
colleagues in other agencies, and develop effective communication with each other, are able to
work together as in Maharashtra where UNFPA and UNICEF talk to each other regularly about
their work and potential for doing some things together- such as the jointly hosted workshops on
adolescents for the State Government.

In MP, the Department of Health has issued a circular identifying for each major thematic area of
RCH/NRHM which UN agency will play the lead role and which will play a supporting role.
This has helped to avoid duplication. In Orissa, a maternal and neo-natal health group,
comprising UN agencies, bilateral donors, international NGOs working in the state, and the State
Government, meet to share knowledge and learning from programmes. This has resulted in a
harmonized response to the programme needs of the state.

At the state level, given that each UN agency follows different norms related to the delegation of
authority and power to their state representatives, some UN agencies do not feel that they are
able to adequately represent the agenda of their agencies. To ensure that UNFPA‟s agenda
receives equal attention as that of other UN agencies in the states it is suggested that the UNFPA
state representative be give the same degree of delegated authority as the state representatives of
other UN agencies are.

It is understood that the United Nations Country Tea (UNCT) has decided that in the coming
years, attempts will be made by UN agencies that work at the state level to work together in a
few selected districts so that jointly they can cover more than they do separately and can multiply
their impact. To be successful, interagency teams will need to be properly oriented and briefed,
and systems for working together with coherence will need to be worked out.

8.6. Conclusions and recommendations

In the changing aid environment, UNFPA‟s continued relevance and its ability to effectively play
an advocacy role for innovation in RH/FP, and to guard the ICPD agenda of gender, will depend
on its ability to maintain to collaborate with all its partners- national and state governments, other
development assistance partners, civil society organizations, and other UN agencies. Its
credibility with government can be maintained by continuing to deliver responsive TA at both
the national and state levels, demonstrating effective programme implementation particularly in
laggard districts and states, and strengthening government‟s capacity to scale up successful
pilots. A strong state presence will help the advocacy agenda as states operate in a fairly
decentralized manner on health issues- including in implementation of nationally sponsored
schemes such as RCH-II and NRHM. Developing strong collaborative relations with key
development assistance partners such as USAID and DFID on issues of common interest such as
gender discrimination, women‟s empowerment, and family planning, will strengthen its
advocacy voice. Strengthening NGO capacity for effective programme implementation and
assisting them to find alternative and accessible sources of funding for NGOs will keep alive

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civil society participation and voice in innovation and advocacy for critical issues. Specific
recommendations for some of these issues are:

Recommendations:
To ensure that UNFP‟s interest and agenda is represented at par with those of other UN
agencies, it is recommended that the UNFPA state representatives be given the same degree
of flexibility and decentralized authority as representatives of other agencies are.

Suggested Actions:
Since the pilot projects being implemented by NGOs are investments with eventual scale-up
in mind, they need to be designed with sustainability kept in mind from the start, provision
for evaluation, and technical support to ensure strong implementation and success. UNFPA
staff at the national and state levels is continuously focused on providing support and
assistance to government counterparts. However, because the lean UNFPA staff teams in the
states are over-stretched, civil society organizations do not get the same inputs. Also,
concurrent evaluation and documentation of such programmes is essential. Currently, these
are areas of weakness in NGO programming.

The issue of sustainability of programmes designed for scale-up through government needs
to be considered and built into the projects from the project design stage itself. Realistic
project timeframe should allow for: (a) demonstration of results, (b) fine tuning of
methodologies for scale-up and replication, and (c) an additional, concluding period during
which UNFPA should assist the implementing partner to budget for project activities within
its own departmental budget, and provide support so that departmental staff learn exactly
what needs to be done to implement, monitor and continuously review and strengthen the
programme so that it remains as effective as possible. In this model, it is crucial that
departmental staff is completely involved in key stages of project design, roll out and review,
so that they acquire the skills to manage these programmes when UNFPA withdraws.

UNFPA should explore and map emerging Indian sources of funding for social sector
programming, from high net worth individuals, corporate and foundations; ascertain the
geographic as well as subject areas for which funding is available, and how funding can be
accessed. Advocacy with these funders for investment in reproductive health and family
planning is needed, so that these emerging resources can be directed towards NGO to work
for the RH/FP priorities of the country.

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Section IX: Operational Modalities

During CP-7, UNFPA basically uses the following 3 kinds of modalities in the course of their
work:

9.1. Contribution to the Government’s SWAp (sector wide approach programme) of

RCH-II Programme using the Annual Work Plan (AWP) or project modality.

After a detailed analysis of the pros and cons, UNFPA took a considered decision in the middle
of CP-7 to participate in GOI‟s RCH-II programme by contributing to the government‟s pool of
resources. The RCH–II programme is presently funded by GOI to the extent of 92%, and by 3
donors to the extent of 8%. Of the donor pool, DFID contributes 52%, the World Bank 42% and
UNFPA 6%. However, from April 2010, DFID is no longer a pooling partner. Though miniscule
in the larger context of RCH, UNFPA‟s contribution of US$ 18 million, to SWAp amounts to 28
% of CP-7 funds. It appears that the decision to be part of the pool partners was a wise decision
at the time it was taken and has stood UNFPA in good stead. UNFPA has been able to influence
the design of the entire RCH programme including the RCH monitoring and evaluation strategy,
while ensuring that gender and quality of clinical services were properly integrated. UNFPA was
also able to input into the design of the Joint Review Missions. UNFPA support, especially
technical and conceptual, has been well appreciated by the MOHFW. The question that now
needs to be addressed is, should this arrangement continue in CP-8? Is it value for money and the
best use of UNFPA‟s resources? One of the big questions for CP-8 is – „to continue or not to
continue contributing to the RCH SWAp‟. The situation has no doubt changed since 2005 when
UNFPA joined the RCH SWAp by contributing financially as well as technically to the pool. In
the initial days of SWAp, there was a differentiation between „pooling‟ partners who contributed
to the pool and „non-pooling‟ partners (like UNICEF and USAID) who contributed only with
technical assistance. Pooling partners had greater access and opportunities to influence
programmatic matters. Now however there is a „Development Partner‟s Forum‟ where all
development partners have more or less equal standing. So, in today‟s context, being a pooling
partner does not matter much. Discontinuing financial support to SWAp will also mean more
resources for UNFPA to programme in states and at the central level.

9.2. The Annual Work Plan (AWP) or project modality (other than for SWAp):

These can further be categorized as under:

a. AWPs with central ministries like Ministry of Youth Affairs and Ministry of Human
Resource Development.
b. AWPs with national and state level institutions like IIPS, ICMR
c. AWPs with NGOs and research organizations.

The process for finalizing AWPs has been streamlined in mid 2010 and has become more
inclusive and robust. Three Thematic Core Groups (TCGs) have been formed for PDS, RH
(including ARSH, HIV, disaster preparedness and Gender in RH) and Sex Selection. Staff of the
country office and state offices has been spread out in these groups in such a way that each TCG
gets the benefit of the perspectives of staff who are experts in other areas as well, and views from
both the national and field levels. Funds for implementation are either released as advances or

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reimbursements, depending on the partner‟s individual assessment and the kind of work
involved. The funds release process has also recently been further streamlined to make releases
quicker. Electronic transfer of funds to implementing partners has also been introduced. These
recent developments have helped to make the operational modalities more efficient. However, it
is felt that there is still room for speedier and more streamlined approvals, especially of ongoing
AWPs. It was also felt that when projects are conceived of at the country office, there is need for
substantive and consistent involvement of the state offices, especially because they are expected
to follow up and monitor AWPs in their states. There have been instances when AWPs have
been approved / extended and the state officers were unaware of the same.

9.3. Direct execution modality

a. UNFPA is also providing TA through its own country and state office staff. The TA being
provided by UNFPA has been appreciated across the board – both by the centre and in the
states where UNFPA has a presence. The state governments have also been quite satisfied
with the responsiveness of UNFPA to their requests for things like quick reviews,
assessments, workshops etc.

b. It responds to emerging issues and requests from Planning Commission, MOHFW,

MWCD, state governments etc. for quick assessments, evaluations, studies, workshops,
consultations etc.

c. In addition, UNFPA is at present, providing technical assistance by placing 67 consultants

in national and state government departments- 13 persons in MOHFW, 5 in MOHRD and
49 persons in the 4 states of Bihar, Orissa, Rajasthan and MP. However, there are two
sides to this coin. On the one hand there is definitely some value added by placing these
persons in government set ups as they often do provide valuable technical inputs. On the
other hand the cost of providing this technical assistance of 67 persons is quite high at US$
1.3 million per annum, compared to their comparative advantage – often these persons are
used for routine government work and to fill gaps in staffing.

9.4. Conclusions and recommendations

9.4.1. The SWAp modality

The decision of UNFPA to join RCH II as a pooling partner when it was initiated, in the middle
of CP-7, was a wise decision at that time. Today the Development Partners Forum facilitates
more or less equal access to all development partners, irrespective of their pooling or non-
pooling status. Mindful that MOHFW is the nodal ministry for UNFPA, robust partnership with
them is key. There appears to be a question mark on the very existence / continuation of this
sector wide programme in its current pooling modality. While the RCH programme will
definitely continue even after RCH-II, it may not be in the shape of a sector wide pooling
programme. There are indications that the MOHFW, GOI may fund the RCH programme
completely from its own funds.

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Recommendation:
UNFPA should continue to provide technical assistance to the RCH programme. In the event
that RCH continues as a SWAp, involving pooling of funds, it is recommended that only if
MOHFW, conscious of the limited resources of UNFPA, feels that a monetary contribution
from UNFPA to the pool will help to underline solidarity and a robust partnership between
the two, then UNFPA should continue to contribute to the SWAp, albeit with a lesser
contribution, as it is not the financial resources of UNFPA per se that matter to MOHFW.

9.4.2. Processing Projects/Annual Work Plans

The process for finalizing AWPs has been streamlined in mid 2010 and has become more
inclusive and robust. There is however still room for even more improvement.

Suggested Actions for new AWPs

Presently a project proposal goes to the TCG twice in the 1st year and then once every year.
Besides the TCG, the UNFPA Representative also looks at the proposal at each of these
stages and gives the final approval. In the first year, a proposal first goes to TCG and
UNFPA Representative as a Concept Note and secondly as an AWP for that particular year.
This process often takes quite long and sometimes reopens issues that have already been
decided upon. In order to ensure transparency, harmony, consistency and early clearances, it
is recommended that there should be guidelines/check-lists about what aspects will be
looked at/examined at each of these stages. At the concept stage itself, the proposal should
be checked for consistency with UNFPA strategies and views and experiences from other
states should also be invited.

In the first year, instead of an AWP, there should be a project proposal outlining activities,
outputs, outcomes and budgets for the entire project period – such an AWP should in fact be
called a „Project Proposal‟. The process for new AWPs should be started 5 to 6 months prior
to the start of the project.

Suggested Actions for Thematic Core Groups

The setting up of Thematic Core Groups for P&DS, RH and sex selection has been a
welcome step and a good effort to get other perspectives into the formulation process.
However, the TCG should work more as a team, doing peer review in a constructive way.
This has not always been the case.

The membership of the TCGs should be rotational so that all field staff get an opportunity
and exposure as well as contribute. It would be even better if the TCG could be expanded to
include as „ad hoc members‟ state programme staff that have experience in the subject/aspect
under consideration. This could be done via email or teleconference.

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Suggested Action for on-going AWPs:

Since ongoing AWPs have already been thoroughly examined and approved for a particular
period at the time of the first approval, every subsequent year they should be „approved in
routine‟ (without opening up the AWP afresh) unless there has been any substantial change
in the circumstances or the performance of the implementing partner (I.P.) has not been
satisfactory. By „approved in routine‟ is meant that the head of the TCG (either the Deputy
Representative or the Assistant Representative) should decide if the AWP needs to go to the
TCG or not. If there is a substantial change in the circumstances of the IP, or performance
has not been satisfactory, only then should the AWP go the TCG. Or else after clearance by
the head of the TCG (DR or AR), final approval of the UNFPA Representative should be
obtained. These approvals should be given latest by the first week of January every year.
Since 80 to 85 % of AWPs are continuing/ongoing AWPs, this will affect a large number of
AWPs.

Suggested Action for the Apex Coordination Committee (ACC)

ACC chaired by the Secretary, MOHFW should meet by mid-December positively of the
previous year so that progress can be reviewed and the Annual Plan of Operations for the
coming year can be approved, leading to timely final approval of AWPs and release of funds
to I.P.s. Delay in these processes results in a much shorter duration for actual implementation
of project activities, slippages in achievements, low utilization of resources etc.

Suggested Actions for release of funds for AWPs and programme review:
Presently funds are being released on a quarterly basis, using the FACE form. Electronic
transfer of funds is also being encouraged. Inspite of all this, funds releases are delayed and
programme delivery is affected. On a case to case basis, UNFPA could consider releasing
funds six monthly or for 6 months at a time for the first 3 quarters, instead of quarterly as at
present. Programme review should however be undertaken at least quarterly. Country office
staff should be encouraged to undertake field monitoring visits to states more regularly.

UNFPA HQ/APRO communicates budgets for the next year around October/November, so
budgets can be entered into ATLAS in Nov/Dec. As soon as the ACC approves the program
of action (POA) and AWPs (especially continuing AWPs) get clearance, funds can be
released to IPs in January itself. This will hopefully help streamline the flow of funds.

9.4.3. Direct Execution modality

Considering the fact that policy advocacy and technical assistance are likely to be the key planks
of CP-8, which should also look at emerging issues, it is essential that UNFPA has a team of
highly competent professionals for each of their core areas, who will support each other and
ensure continuity in the event of staff attrition. UNFPA presently provides a total of 67
consultants to the central and to 4 state governments. While governments do appreciate this
assistance which often has proved useful, it is still debatable whether this is the best use of
UNFPA resources.

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Suggested Action for delegation to State Coordinators:

Presently State Coordinators have powers to approve proposals/expenditure up to US$ 5,000
at a time. In view of the present costs in India, the short time frame within which requests
from state governments need to be responded to, and considering the competency and level
of the State Coordinators, this delegation could be increased to US$ 10,000 at a time. This
will help state offices to respond in a time bound way to requests that fall within their
mandate, which otherwise other agencies like UNICEF take over. The decentralization with
regard to the categories and kinds of things covered by this delegation also needs to be
reviewed, for instance, small printing and procurement jobs to be in tune with other
development partners.

Suggested Actions for Human Resources in the Country and State Offices:
It is suggested that a detailed needs assessment of the number, competencies & skill mix of
the staff required, based on the content of CP-8 be conducted. Once this kind of profiling of
staff is done, the existing staff can be re-skilled or appropriate staff can be put in place, as
required.
A team building exercise of all UNFPA country and state office staff (both professional and
other) is highly recommended well before the start of CP -8.

Especially in state offices, recourse should be taken to hiring UN volunteers and/or short
term consultants. The establishment of a comprehensive roster of consultants for national and
state levels needs to be constantly updated, in order to facilitate this.

The question/dilemma which has engaged the attention of staff and management has been,
should UNFPA staff themselves provide the T.A. or should consultants be hired for the same.
Considering the technical competencies of a lot of the UNFPA staff and their reputation and
value, it would be a pity not to use their skills and competencies. However care must be
taken to see that they do not over stretch themselves, as often happens at present. Perhaps the
answer lies in striking the correct balance between the two.

There appears to be need for more sharing and learning amongst staff. It is suggested that a
full staff meeting be held at least once in 6 months, where not only is progress monitored but
where at least 50% of the time is spent on substantive issues, providing a platform for
learning and sharing. Outside experts/ regional office could also be invited from time to time
as necessary.

Suggested Actions for Technical Assistance to Government through consultants:

Considering the present stage of development of the health sector in India, where health
infrastructure is fairly well either in place or being provided for, the need of the hour seems
to be adequate and appropriate human resources. Under these circumstances, it is essential
for MOHFW to be adequately staffed with the appropriate skills and competencies. In order
to facilitate this being done in a harmonized and planned manner, it is suggested that
MOHFW commissions a competent independent agency to conduct an “organizational
structure and staffing needs assessment”. Such a study will enable Government to determine
what human resource gaps it would like supported by various development partners. This
could also result in harmonization of contributions from all development partners who
support this kind of TA. UNFPA should simultaneously get the development partners
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together to jointly advocate for such an exercise. This will facilitate the identification of the
number and profile of the staff required as well as the sources of the financial resources
(government, which development partner etc) required for them. All this should be done well
before the start of CP-8. Accordingly, in CP-8, UNFPA should support staff only according
to this assessment. In order to bring in consistency in the recruitment process, all positions
supported by development partners could be recruited by National Health Systems Resource
Centre (NHSRC). Competencies and technical knowledge of these consultants should be
upgraded from time to time by NHSRC in collaboration with other development partners. For
this, a „training needs assessment‟ should initially be carried out.

In addition, Government may wish to obtain assistance with the task of building within
government systems, the capacity to access, procure and utilize both Indian and international
technical assistance. In doing this, the initial challenge is to get government to recognize that
there will always be needs for TA, and that government must itself provide in its annual
work-plans and budgets for the procurement of such technical assistance. Once this
realization occurs, government departments may need capacity building in how to recognize
and clearly define technical assistance requirements, how to scan for and identify appropriate
and capable sources of technical assistance, how to lay down procedures and processes for
procurement and payment of technical assistance, and how to monitor and evaluate the
quality and effectiveness of TA received, so that services being paid for are actually
delivered.

Capacity building in procuring and using technical assistance is a cross cutting requirement
across all departments of Government, and should be addressed by UNFPA in partnership
with other UN agencies, multilateral and bi-lateral donors.

9.4.4. Accountability for programme congruence with UNFPA’s gender objectives and
approaches

Since gender is a crucial cross cutting issue and needs to be mainstreamed in all the work that
UNFPA does across thematic areas, it is suggested that a three pronged operational modality be
adopted.

Suggested Action:
Firstly all programme staff should be held responsible and accountable for ensuring that their
programmes meet UNFPA‟ gender objectives and are in consonance with the organization‟s
gender strategies and approaches. Secondly there should be a full time gender
adviser/programme specialist who is exclusively responsible for providing timely insights,
direction and guidance on the issue of how to ensure that UNFPA programmes address
gender in the most relevant and effective ways. This individual would not be accountable
for UNFPA programmes achieving results in the gender area. Rather she/he would be
responsible for ensuring that the UNFPA team in country has a shared understanding on
what gender means. of how it should be addressed in UNFPA‟s programme, and for ensuring
that there is a coherent gender strategy in place and effective gender tools available to
support programme managers in ensuring that their programme attain gender objectives. The
third prong is to have six monthly or annual gender workshops for all UNFPA country and
state office programme staff to share and learn from each other, and strategize together. This

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could be clubbed with the six monthly full staff meetings. This is being suggested since
gender is a cross cutting issue that needs reinforcement from time to time.

9.4.5. The Organizational Development Group:

The country office has set up such a Group recently with a view to suggest how efficiency and
impact can be improved and systemic issues addressed. The group is also supposed to look at
internal processes and organizational environment.

Suggested Action:
This Group should be activated to see how recommendations of the evaluation as well as
other issues can be operationalized.

9.4.6. Programme Component Managers

The CPAP 2008-2012 provides for Programme Component Managers (MOHFW, MOHRD,
MOYAS, NACO, RGI and State DHFW) for each component. They are expected to coordinate
and synergize interventions related to the component as well as monitor and review progress.
Unfortunately, this has not worked as expected.

Suggested Actions:
Efforts should be made to make these arrangements function well and effectively, or to
identify suitable alternatives as leadership and ownership of government is a key factor for
success.

9.4.7. Monitoring & Evaluation

The CPAP also provides for two main instruments for monitoring and evaluation – the CPAP
Planning and Tracking Tool and the CPAP monitoring and evaluation calendar. AWPs are being
monitored by UNFPA.

Suggested Actions:
These tools have been developed and should be used more effectively for programme review.

Select, orient and use a team of two or three consultants to monitor and provide technical
assistance across states, to all projects that address the same theme- such as quality
assurance, or sex selection, or community mobilization for monitoring quality of services.
Orient consultants in the programme objectives, indicators, and strategic approaches, and in
how cross-cutting issues such as gender, advocacy and capacity building need to be
addressed within the theme.

Organize cross-site learning between similar programmes in different locations, not just for
implementing partners but also for government counterparts to ensure that pilots remain in
government‟s field of attention, ensuring interest and ultimate buy in to successful concepts.

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The three modalities used to operationalise CP-7 described above have proved to be by and large
appropriate, relevant and sustainable. Some recommendations have been given to make them
more effective and efficient which will hopefully contribute to better delivery and even greater
impact of UNFPA‟s resources and efforts in CP-8.

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Part D: Conclusion

UNFPA‟s CP-7 was designed to help India reach the MDGs, and other national health and
population goals articulated in the XIth Plan, using approaches true to the ICPD PoA. India‟s
new found middle income status, has changed its development assistance needs, from financial
to technical support, particularly that which demonstrates how stronger programme
implementation and innovative models can help India‟s backward states and districts catch up
with development in the rest of the country. UNFPA ‟s CP-7 works towards these goals through
contributing approximately a quarter of its funds to sector wide support, and using the rest for a
programme of technical assistance and direct project implementation to help India‟s backward
states catch up. Four out of the 5 states where UNFPA works are amongst the six most backward
states of the country, and it has now begun to strengthen programming in 13 of India‟s 265 most
backward “high focus” districts.

CP-7 has tried to be true to the UNDAF agenda of serving the most vulnerable. The 5 states
where it works are where 42% of India‟s 300 million people living below the poverty line.
Besides this, the various components of the program seek to serve the most vulnerable- women,
adolescents and sex workers.

RH: UNFPA coordinates with other development partners and the GOI to provide technical
support to performance improvement processes such as review, monitoring and evaluation of key
national programs in health- the NRHM, RCH-II, and NACP-III. Based on the findings of these
reviews, technical support is provided to strengthen capacity of the service delivery system, and
to improve the quality of services provided. These inputs include the standardization of clinical
practices, as well as the introduction of newer practices in a variety of areas of RH. This is done
through the development of protocols, tools and guidelines and through training and capacity
building.

Four key areas of RH programming have received particular attention from UNFPA
programmes- quality assurance, communitization, gender based violence, and gender sensitivity.
All four are areas where health systems have noticeable gaps and where there is a need for the
types of pilots and demonstration models that UNFPA is working on, to generate solutions
capable of scale-up.

An area of need that was identified as important when CP-7 was designed was revitalization of
the family planning programme. While work done in this area has been reported in the report,
more is needed, especially advocacy and assistance to support the government to reposition
family planning, particularly to address the issues of delaying and spacing, and family planning
for youth. In the area of convergence of RH and HIV, work has not yet commenced.

UNFPA has been appreciated by both the national and the state governments for its
responsiveness to the government. However, government programmes are supply driven and in
the urgency of attending to government‟s needs for TA and assistance, UNFPA programming
has not paid adequate attention to the demand side of health issues- improving health seeking
behaviour, demand generation, and increasing utilization of services, whether for family
planning, or for other RH services, particularly of the most vulnerable. Currently, health
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management information systems do not capture service delivery data by category of population,
making it impossible to assess whether services are actually reaching those most in need.
Advocacy is needed to correct this situation.

There is also a need to build more holistic approaches by weaving together the many strands of
work in the RH component of CP-7. The work in quality assurance offers the opportunity to
integrate almost all the present work in RH- adolescent services, community involvement,
gender sensitivity, gender based violence, and a repositioned family planning service.

ARSH: The policy, technical and financial assistance provided by UNFPA through the
interventions in CP-7 in the thematic area of “Adolescents and youth” & ARSH has been found
to be relevant to and aligned with the current and future needs of India, as well as with the larger
CP results and strategic framework. UNFPA support has certainly added value to the national
and selected state government programmes and priorities. The extent of the value addition has
been substantial in most of the key interventions of in-school LSE programme, but less in respect
of out-of-school adolescent health and development programme and much less in the health
services programme, as discussed and analysed earlier. UNFPA has devoted adequate attention
to building capacities of the master trainers and facilitators in the few elite schools as well as
NIOS, but more attention is needed to be paid, as it rolls out to more and more schools and more
teachers, particularly in the states. Gender has been mainstreamed in the adolescent education
programme, in the LSE curriculum, and it appears to have been accepted and adopted in
Government and civil society action, as analyzed under the relevant interventions earlier. The
UNFPA presence has definitely been used effectively in policy advocacy, gap identification,
program design and implementation and responding to the needs of some state governments as
discussed earlier. The recommendations made above suggest areas for strengthening and future
directions.

Sex Selection: UNFPA‟s programme has been successful in identifying a major gap in the area
of sex selection- strengthened Act implementation, and through its work in Maharashtra,
Rajasthan, Madhya Pradesh and Orissa, has shown how integrated interventions that address key
segments- government, the legal profession, the medical profession, and civil society, result in
stronger implementation of the law. Sustainability of work has been ensured in the design of
programmes- implementing agencies such as the judicial academies, and law and medical
universities have been capacitated and are incorporating interventions into their regular
programmes of work. The work of changing mindsets is the longer term change that is needed if
sex selection is to be eliminated. In this area, UNFPA‟s strategies have been less successful,
inspite of its work at the community level though a wide network of civil society organizations.
The scale of this work in a country like India is vast and UNFPA‟s resources alone cannot make
a dent. If UNFPA wishes to have long term impact in this programmatic area, it will need to craft
and successfully implement a strategy for bringing many more influential players and resources
into this work.

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PDS: PDS within the framework of the ICPD PoA and National Population Policy remains as
valid and relevant today as it was during the earlier UNFPA CPs.post ICPD. Policy and strategy
advocacy, as well as support for accelerated implementation of core programmes of population
and development (including family planning with quality of care, gender equity, equality and
women‟s empowerment) within a rights-based and gender sensitive approach remains the niche
and unique selling proposition of UNFPA in India. This over all role and function of UNFPA has
been perceived by government and most of the UN system as well as by other development
partners. There is a feeling that the effectiveness of this role has been diluted over the last few
years. Indeed this is also the assessment of the evaluation team- as discussed in the evaluation of
thematic areas in Section II of this report,

Renewed priority to and repositioning of family planning programmes has to be seen in the
above context. Policy advocacy and programme implementation support from UNFPA has to be
strategic, sustained and synergistic. It has to carve out a leadership role among the development
partners and spur the government and civil society players to action. The synergistic framework
of policy and programme implementation will have to be internalized by all stakeholders within
the ICPD PoA, National Population Policy, and NRHM. The same is encapsulated below:

a. Contraception/family planning with a need based, client centered approach and quality of
care indicators for priority monitoring

b. Planning and monitoring of family planning programme at the community (village/block)

level, rather than targeted from above on purely demographic considerations

c. Family planning programme to be organically positioned within “comprehensive RH

care” (for details see section III of this report on the RH component of the programme)

d. RH care (with family planning as a priority) to be positioned and administered within

“comprehensive primary health care” being strengthened under the NRHM

e. The organically planned and administered programme to be positioned within appropriate

social development approach with reproductive and sexual rights, gender equity and
inclusiveness as cross-cutting in all programmes.

UNFPA needs to more proactively support the incorporation of population dynamics and its
inter-linkages with gender equality, sexual and RH into public policies, poverty alleviation
strategies and expenditure frameworks of government at central and state levels. This support
may involve documentation of existing evidence, policy advocacy, and capacity building of
administrators at various levels.

More proactive advocacy is needed for strategic investments in young people‟s health and
development by highlighting potential benefits in terms of

a. Building human capital

b. Capitalizing on demographic dividend and
c. Breaking the inter-generational cycle of poverty

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The PDS work accomplished under CP-7 is varied, significant and relevant. Considering the
importance of PDS in the context of the global mandate of UNFPA, the expansive scope of this
thematic area, the policy advocacy agenda, and the present and future needs of the country, there
is a need to strengthen UNFPA‟s human and financial resource allocation to this thematic area so
that it acquires the capacity to engage in policy advocacy, provide capacity building inputs on
population-development dynamics, ensure gender mainstreaming in UNFPA‟s programs, and
establish essential linkages with resource persons and institutions that are inter-disciplinary. The
evaluation team found that the budget allocation for PDS thematic area is quite low. During 2009
and 2010, it varied between 6 and 8% of the total funding for those years.

These initial years of CP-7 have been characterized by the commencement of very relevant
programming designed for sustainability and scale-up. However more time is needed to
strengthen these models, assess the extent of change that is being brought about by them,
document processes, and assist government to scale up those models that are delivering results.
Evaluation to assess outcomes needs strengthening. For instance in the area of gender based
violence, and developing gender sensitivity in the health system, innovative things have been
done, but no data is being collected to see if change is actually happening. The remaining years
of CP-7 could be devoted to this, and the work continued in CP-8 to see real results,
institutionalization and scale-up.

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Part E: Annexes

Annex 1 - RESULTS & RESOURCE FRAMEWORK FOR INDIA (2008-2012)

Results Indicators Baseline Target Progress Means of Assumptions and

(year) (year) (Latest Verification Risks
available
year)
CPAP Outcome Reduced maternal mortality ratio 301 (01-03) <100 (2012) 212 SRS Reports UNFPA is part of
(2007-09) the National RCH
Reproductive II SWAp and
Health Reduced unmet need for 12.8 (05-06) 80% of need Large scale NFHS helps government
Improved contraception met HH survey National HH at the national,
reproductive for latest Surveys state and below
health of the year is levels. The
population awaited responsibilities of
implementation
Reduced adolescence fertility rate 16.8% 12% --- do ---- NFHS rests with the
National HH government and
Surveys the pace of
implementation
Reduced adult HIV Prevalence 0.36 (05-06) No value --- do ---- NACP III can have a
stated in Repots and bearing in
NACP – III. NFHS Survey achieving the
indicators. The
indicators
proposed are in
sync with the
national goals.

115
 Results Indicators Baseline Target Progress Means of Assumptions and
(year) (year) (Latest Verification Risks
available
year)
CP Outputs 1 Modern contraceptive prevalence 48.5% (05-06) 59% (2012) --- do ---- National level
Enhanced access rate among currently married large HH
and utilization of women aged 15-49 years surveys
high quality
reproductive Percentage of deliveries by SBAs 48.8% (05-06) 80% (2012) 76.2 (2009) Coverage
health services increased Evaluation
by vulnerable Survey, 2009,
communities UNICEF

Percent of FRUs functional as per <30% (2006) 100%(2012) 52.0 District level
national guidelines Household &
Facility
Survey-
(DLHS – 3)

Percentage of districts having <50% (2006) 100% (2012) -- NRHM Service

operational plans for FRUs and 24 statistics/
hr services facility
surveys
Number of districts having AQ 7 (2006-07) 20 (2012) 16 (2010) UNFPA
groups established Progress
reports
Number of institutional Nil 1 state -- Services
mechanisms responding to GBV
(eg. GBV protocols being adopted
by states in responding to GBV as
an health issue)

116
 Results Indicators Baseline Target Progress Means of Assumptions and
(year) (year) (Latest Verification Risks
available
year)
CP Output 2 Percentage of female sex workers 45% (2005) 80% (2012) Next round CMIS Reports UNFPA will be
Safe Sex reached out by Targeted of BSS of NACO supporting setting
Behaviour Interventions Value yet to be No end-line awaited up of TSU in one
promoted published from goal specified BSS Reports state and will
amongst Percentage of female sex workers the latest round in NACP-III of HRG monitor its work
vulnerable reporting use of condoms with of BSS to achieve the
population their most recent client national goals
groups (UNGASS(C(6) specified in the
(sex workers and NACP-III.
women) Source of
verification
depends on
frequency of BSS
studies
undertaken by
NACO and other
development
partners.

117
 Results Indicators Baseline Target Progress Means of Assumptions and
(year) (year) (Latest Verification Risks
available
year)
CP Output 3 Percentage of youth (15-24 years) Boys: 36.1% No end-line Next round of BSS/NFHS Responsiveness
with accurate knowledge of (2005-06) goal specified BSS/NFHS Reports of MoYAS,
Adolescents and HIV/AIDS (who recall 3 modes of in NACP-III Reports MHRD and their
youth transmission, 2 modes of Girls: 19.9% awaited implementing
empowered with prevention and who reject major (2005-06) partners in
knowledge and misconceptions about HIV undertaking
life skills for transmission (UNGASS (G) 10) Comprehensive planning
improved or as an alternative using the same definition: activities.
reproductive and definition, NFHS-III can be used Refer NFHS-3
sexual health (in as well. India Report, Capacity of
school and out- page nos. 325- MoYAS
of-school) 328) improves.

Application of Like Skills by Not available 40% of --- Skill

adolescent boys and girls adolescent application test
boys and girls to be
demonstrate administered
life skills in in select
intervention intervention
sites sites

Integration of life skills education LSE gaps Inclusion of --- Mapping

in school curricula and extra- identified by LSE in Exercise
curricular activities mapping school Reports
exercise curricula and
extra-
curricular
activities

118
 Results Indicators Baseline Target Progress Means of Assumptions and
(year) (year) (Latest Verification Risks
available
year)
CP Output 4: Percentage recovery and Not applicable As and when --- Recovery and
Reproductive rehabilitation plans prepared prepared rehabilitation
Health and reflecting RH and Gender plan
Gender issues perspectives documents
mainstreamed in
recovery and
rehabilitation
response to
natural disaster
and
environmental
challenges

119
 Results Indicators Baseline Target Progress Means of Assumptions and
(year) (year) (Latest Verification Risks
available
year)
CPAP Child Sex Ratio 927 females Improved by 914 females Census 2011
Outcome- per 1,000 at least five per 1,000 and SRS
Gender males (2001 points males (2011 Annual
Census) Census) Reports/Large-
To prevent Scale Surveys
gender based
violence and
empower women

CP Output 1 Sex ratio at birth in worst affected To be Improved by --- Special studies No change in
districts improved determined at least 10 to be current practices
Skewed Sex points undertaken or of doctors
Ratio at birth if available
addressed thru AHS
through
advocacy and
action

Gender gap in under 5 mortality 6.8 (2005) <5 (2012) 9 (2008, SRS and Overall change in
rate reduced at national level SRS) Census Indian society of
the value of the
girl child

120
 Results Indicators Baseline Target Progress Means of Assumptions and
(year) (year) (Latest Verification Risks
available
year)
CPAP Policy actions initiated in one or 0 1 (2009) 7 Secondary Activity
Outcome- two emerging areas 2(2010) studies on Reports and
Population and Aging / 7 project report
Development sectoral
papers for
Build Capacity to Bihar
integrate Population
population &
dynamics into Development
national policies policy
and programmes initiated

Plans and policies reflect 0 DPIPs/ 35 District District

population and development Monitoring PIPs Service
linkages by utilization of reports in Statistics and
disaggregated data for planning intervention DPIPs in
and in monitoring sites located UNFPA states
in states of
UNFPA
presence

121
 Results Indicators Baseline Target Progress Means of Assumptions and
(year) (year) (Latest Verification Risks
available
year)
CP Output 1 X no. of districts adopting and NA 5 districts 35 Districts District Commitment of
using disaggregated data for (2010) Service Collectors to the
Social planning, monitoring and policy Statistics value and use of
development dialogues data at the district
planning is level
supported with
special emphasis
on demographic
transition Information made available on Policy One Report for Workshop and
perspectives policy issues of concern for policy Research on a dissemination JSY, Missing Policy
dialogue and advocacy thematic area workshop Girls and Reports/ Briefs
will be covered each year PTC
each year from assessment
2009 onwards undertaken

Data available on emerging and Will be Surveys Primary Survey

priority issues and programme identified and include PDS studies on Reports and
performance assessed large-scale issues Aging funding
national initiated, agreements
surveys of Analysis of and
AHS, NFHS Census 2011 expenditure
etc. will be data on CSR statements
supported initiated

122
Results Indicators Baseline Target Progress Means of Assumptions and
(year) (year) (Latest Verification Risks
available
year)
X no. of Institutions started Nil 2 ISEC and Agreement,
imparting training on population IIPS + Reports and
and development Regional Work-plan
institute (1 agreement
each in
Rajasthan,
MP and
Orissa)
imparted
training

Pre-census gender mainstreaming Planned and Activity Work-plan and

activities supported for 2011 supported completed agreements
census upon request pre-census and
enumeration documentation
of media
activities

X no. of institutions supported in TBD Just

S-S collaboration initiated, eg.
Census
Resource
and Training
Centre
(CR&TC)

123
 Annex 2 - Terms of Reference for the Evaluation Team

Evaluation of CP-7
The main aim of CP-7 evaluation is to elicit achievements made in each of the thematic areas
as well as to understand effectiveness of mainstreaming cross-cutting themes such as gender
and advocacy in programming. In addition, the evaluation from the perspective of next cycle
of the India Country Programme should be lesson-learning and forward looking. The scope of
the evaluation therefore, is to provide answers and solutions to the following:

1. Examine the financial, policy and technical assistance provided by UNFPA though the
Country Programme, in each of its thematic and cross-cutting areas of work in terms of:
a. Whether interventions are aligned with the current and futuristic needs of the
country; and with the larger CPAP / UNDAF results and strategic framework;
b. Extent to which UNFPA‟s support has added value to national and state
government programmes and priorities;
c. Extent to which gender has been mainstreamed in UNFPA‟s work, and the extent
to which this has been accepted and adopted in Government or civil society
actions.
d. Whether adequate attention has been devoted to building capacities of
Government and other partners, and the extent to which this has been achieved
2. Whether the geographic focus and spread of the programme is appropriate;
3. Whether partnership strategies have been appropriate;
4. Extent to which internal UN coordination has avoided duplication or built synergies
5. Whether the operational modalities of implementing the programme (SWAp pooling,
AWPs with partners, and direct execution) have been utilized effectively;
6. Whether UNFPA presence has been effectively used in policy advocacy, gap
identification, programme design and implementation, and responding to the needs of
state governments.

The evaluation will be conducted by a team of 3 – 4 Consultants under the guidance of a

Team Leader.

The Terms of Reference for the Evaluation Team is to undertake thorough investigation of
the scope of evaluation as outlined above. The exercise will entail a review of the available
documents; interactions with UNFPA staff members and key stakeholders; and undertaking
field visits to validate and ratify the achievements. More specifically, the processes will
include the following:

Desk-review – see illustrative list of documents in Table-1

Discussions with UNFPA staff – management, state office and national programme
staff
Discussions with key stakeholders – see illustrative list in Table-1
Undertake field visits – see illustrative list in Table-1
Debriefing of key findings with UNFPA
Drafting of Evaluation Report and presentation to stakeholders and finalization of
Evaluation Report
Participate in stakeholders consultations for prioritizing intervention and preparation
of strategy paper for UNFPA next cycle of country programme

124
Tenure
The tenure of this assignment will be around 30-35 working days during the period February
to April 2011.

Table – 1: Illustrative list of documents for review and field visit plan for
Evaluation Team

1. Thematic areas of UNFPA Work

 Country Programme 7
 SWAp including district facilitations
 RH supplementary activities to SWAp including gender in RH
 HIV
 Adolescent Reproductive and Sexual Health (ARSH)
 Sex Selection
 Population and Development
 Operations
o Internal processes – Financial management, HR etc.
o AWP Management

2. Illustrative list of key documents for review

 Minutes of GOI Programme Review meetings and reports
 JRM / CRM / MTR reports of GOI
 Country Office Annual Report (C OAR)
 MTR Report
 UNFPA Staff Meeting proceedings, especially meeting held at Bhopal
 UNFPA India Website
 Documents available through E-Archive –UNFPA India
o Summary report of Technical Assistance in each thematic area of work
o Project related key documents
o One pager note per AWP
o AWP Quarterly reports
o Available evaluation reports
3. Field Visits to generate new evidences and validate achievements
 Visit to few states on sample basis
 Undertaking field visit to understand specific project sites
 Interactions with key Government officials
 Interaction with Implementing partners and other development partners
4. Discussions with key stakeholders
 Secretary, Health and Family Welfare, MOYAS, MOHRD
 Additional and Joint Secretaries, MOHFW, MOYAS, MORD
 Director General, NACO
 Registrar General and Census Commissioner on UN Support
 UNRC‟s office, UNDP and UNICEF in regard to PDS-Convergence and
Census support
 State Secretaries from relevant ministries in a few states having UNFPA
offices
 Development Partners, NGO partners and IPs

125
 Annex 3 – Relative roles of evaluation consultants

Responsibilities and Roles of Evaluation Team Members

1. A. R. Nanda: Studied the adolescent reproductive and sexual health program, and the
work done under the population and development strategy theme

2. Firoza Mehrotra: Studied operational modalities and related issues

3. Ravi Verma: Studied the reproductive health program including gender based violence,
integration of gender into emergency response, and HIV/AIDS, but excluding adolescent
reproductive health

4. Priya Nanda: Studied sex selection,

5. Rekha Masilamani: Served as the team leader and studied geographic focus,
partnerships, synergy within the UN system, and cross cutting issues of gender and policy
advocacy

126
 Annex 4 - List of Documents Reviewed

1. Country Programme – 7 (2008 – 2012)

1.1 Country Programme Document for India (2008 – 2012)
1.2 Country Programme Action Plan (2008 – 2012)
1.3 End of CP6 Programme Evaluation
1.4 Mid Term Review Report of UNFPA 7th Country Programme (2010)
1.5 Country Office Annual Report (COAR) – 2008, 2009, 2010
1.6 List of Annual Work Plans (AWPs) – 2008, 2009, 2010, 2011
1.7 Minutes of the Apex Coordination Committee meetings, Briefing Note and
Presentations – 2008, 2009, 2010
1.8 Documents shared with GOI for the upcoming Apex Coordination Committee
meeting to be held in Feb, 2011
1.9 Annual Progress Reports (UNFPA State Offices) – 2008, 2009, 2010
1.10 Report of the Team UNFPA Meeting, April 12 – 14, 2010 at Bhopal

2. United Nations Development Assistance Framework (UNDAF, 2008 – 2012)

2.1 UNDAF Document (2008 – 2012)
2.2 UNDAF Cluster Joint Programming Plan – 2009, 2010
2.3 UNDAF Mid Term Review (2010)

3. Thematic Area: Population and Development

3.1 Population and Development Strategy for UNFPA

UN Convergence Programme: Use of Data for Planning and Monitoring Development

Programmes
3.2 District Level Population Projections in Eight Selected State of India : 2006 - 2016
3.3 Resource Materials for Sensitization of Senior Officers in Use of Data for Planning
and Monitoring
3.4 Module for Training District Officers in Use of Data for Planning and Monitoring
Development Programmes
3.5 Manual for Estimating Development Indicators at Sub-national Level
3.6 Progress Report on Convergence Programme

Census
3.7 MoU between UN agencies and ORGI
3.8 Annual Work Plans (AWPs)-2009, 2010
3.9 District Gender Data Prototype
3.10 Process Note on Engendering Census activities
3.11 Presentation on Joint UN Support to Census, 2011

Aging
3.12 Aging Concept Note
3.13 Building knowledge base on Aging in India
a. Discussion Papers on the basis of secondary data
3.14 Presentations on Aging
a. Living Arrangements of Elderly in India-Trends and Differentials
b. Spatial Analysis of Aging in India-Programmatic Implications

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Bihar Population and Development Policy
3.15 Bihar Population and Development Policy - Concept Note
3.16 Discussion Papers on Sectoral Reviews

Support to HMIS under NRHM-National and State

3.17 Analysis Framework of Critical indicators from HMIS
3.18 HMIS Training Modules for ANMs/LHVs

Articles/Reports/Presentations
3.19 Population Research and MDGs in India in Population, Gender and Health in
India(ed) K.S. James et.al.
3.20 Concurrent Assessment of JSY in Selected States
3.21 Demographic Dividend in Southern States of India
3.22 Tracking Implementation of Health Programmes at Sub-national Levels through
HMIS Data
3.23 A Study of Vital Registration System in Rajasthan – Report and Presentation

PDS
3.24 2011 Census kits and communication material received from Census
Commissioner.
3.25 Manuals on Health Management Information Systems published by Government of
India Vol. 1-2, January, 2011.

4. Thematic Area: Reproductive Health (including Gender and Disaster

Management)
A. Reproductive Health Services

Swap based RCH2 Programme (Support for planning, participation and substantive
inputs in the Aide Memoires)
4.1 Process Note on Transition from Project Mode under CP6 to a SWAp Environment
4.2 Participation in a SWAp based RCH II Programme : Initial Experiences of UNFPA,
INDIA
4.3 Process Manual for 1st Joint Review Mission of RCH2
4.4 Aid Memoires (I – VII) and Mid Term Reviews
4.5 Reports for Common Review Missions of NRHM

District Planning (Facilitating Decentralised Planning)

4.6 District Health Action Plan Manual

Maternal Health (Capacity Building & Quality of Care):

Skilled Birth Attendant
4.7 Guidelines for Antenatal Care and Skilled Attendance at Birth by ANMs/LHVs/SNs
4.8 Guidelines for Operationalizing SBA Training in RCH II
4.9 Skilled Birth Attendance (SBA) - Trainers Guide for Conducting Trainers of
Auxiliary Nurse Midwives Lady Health Visitor & Staff Nurses
4.10 Skilled Birth Attendance (SBA) – A Handbook for Auxiliary Nurse Midwives Lady
Health Visitor & Staff Nurses
4.11 Guidelines for Accreditation of Private Health Facilities for Providing SBA
Training – Reference Manual for Programme Managers on Accreditation Process

128
Basic EmOC/EmOC
4.12 Trainers Handbook for Training of Medical Officers in Pregnancy Care and
Management of Common Obstetric Complications
4.13 Trainers Guide for Training of Medical Officers in Pregnancy Care and
Management of Common Obstetric Complications
4.14 Workbook for Training of Medical Officers in Pregnancy Care and Management of
Common Obstetric Complications
4.15 Recommendations of consultation for of Medical colleges faculty and District
Hospitals staff on delivery and new born care Practices in Rajasthan
4.16 Checklist for labour room in Orissa

Safe Abortion
4.17 Comprehensive Abortion Care Guidelines

Family Planning (Access and Quality of Care):

Standards & guidelines
4.18 Sterilization Standards ( male and female)
4.19 Guidelines for Quality Assurance Committees
4.20 Standard Operating Procedures for Sterilization in Camps
4.21 Emergency Contraceptive Pills, IUDs
4.22 Post Partum Family Planning: A Manual for Service Providers
4.23 Contraceptive updates( Reading material and Guide for facilitators)

Adolescent Reproductive and Sexual Health (ARSH) -Strategy formulation and

programme development
4.24 Assessment of Adolescent Reproductive and Sexual Health (ARSH) -Gujarat

Capacity Building for Rapid Assessment of Health Interventions:

Medical Colleges ( Through NIHFW)
4.25 RAHI Phase II (2008-09) NGOs (Through Centre for health and Social Justice)
4.26 Phase 1 ( 2009)
4.27 Phase 2 (2010-2011)
An edited book compiling the articles from the trainees.

Quality of Care in RCH

4.28 District Quality Assurance Programme for RH Services – An Operational Manual
4.29 Assessment of QA programme in Gujarat State

RTIs/STIs/HIV
4.30 Guidelines for prevention and management of RTIs/STIs in RCH2
4.31 Note on convergence between RCH2 and NACP-III

ASHAs
4.32 Book Number 1 – 4 for ASHAs
4.33 Guidelines for Supportive Supervision of ASHAs
4.34 Communication Kit for ASHAs-FP

Support for Mother NGO Scheme

4.35 Training of Trainers Manual for MNGOs
4.36 Rapid Assessment of MNGO Scheme

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B. Gender in RCH 2
Gender Mainstreaming in RCH – II
4.37 Report on Mainstreaming Gender in RCH Training
4.38 Mainstreaming Gender within India‟s RCH 2 programme ( National PIP)
4.39 Mainstreaming Gender in RCH 2 programme – Guidelines for States
4.40 Note on Enhancing women‟s role in addressing global humanitarian and health
crisis J
4.41 Gender Sensitivity and community responsiveness in healthcare: Toolkit to guide
practitioner
4.42 Gender Ready Reckoner (Gender Kunji)
4.43 Strategy Paper on Men as Supportive Partners in RCH : Moving from Intent to
Action

Gender Based Violence

4.44 Health and social consequences of martial violence : a synthesis of evidence from
India – 2010 - A Report and power point presentation
4.45 Study on assessing various models of family counseling centres (FCCs) addressing
Gender Based Violence (GBV) – Rajasthan
4.46 Family Counseling Centers in Madhya Pradesh -An Assessment
4.47 Concept Note for Protocols to Detect Gender Based Violence in Health Settings
4.48 GBV- Possibilities for interventions by Ministry of Health and Family Welfare,
health service providers to facilitate implementation of Domestic Violence Act -
Sept 2005
4.49 Information kit for Health Service Providers on Violence Against Women
(Information booklet for medical officers, Facilitator‟s Guide and Poster)
4.50 Report of the National Workshop on Violence Against Women: Health Sector
Perspective (Resolution adopted at the National Workshop)

Working with Community and PRI

4.51 Strengthening Gender Responses of Panchayats in Rajasthan – PRIA- Annual
Report 2010
4.52 Awareness building on gender discrimination with a focus on RR and RH and
Gender Justice – Hunger Project- Annual Report 2010
4.53 A note on the process of Jan Samvad to be held in Chhoti-Sadri block of Chittorgarh
District on 30.09.03
4.54 Jan Samvad -Public Dialogue with Women On Gender and Health Management –
Chittorgarh, Rajasthan - September 03

C. Disaster Management and Humanitarian Response

4.55 Standard Operating Procedures for Responding to Natural Disasters issued by
Ministry of Home Affairs in 2010.
4.56 NDMA Guidelines on Psycho social counseling
4.57 Brochure on Dignity Kit
4.58 Presentations:
a. AIUCK Second Workshop, Kobe, 2007
b. First World Congress on Disaster management, Hyderabad, 2008
c. Regional training of Trainers on MISP for RH in Crisis Setting, Bangkok,
2010

130
5. Sex Selection
Annual Reports
5.1 Annual Project Report – 2006-07
5.2 Annual Report: Advocacy – 2007
5.3 Annual Report: Advocacy – 2008
5.4 Annual Report: Sex Selection – 2009

Advocacy
5.5 Strategy Note on Sex Selection - 2007
5.6 Briefing Note on Sex Selection in India – 2007
5.7 A Guidance Note on Sex Selection and Abortion in India - March 07
5.8 Sex Selection Advocacy - An Action Framework - A Brief Report – 2005
5.9 Note on Sex Selection in India for Key Players – 2005
5.10 Presentation on -
a. Advocacy strategy to address Sex Selection – September 2007
b. Locating Pre-natal sex selection in reality – November 2005
c. Issues of sex selection made at Regional planning meeting – February 2007
d. Programme Priorities for Sex Selection in CP7
e. Sex Selection Advocacy Initiatives- Involving new Partners - An action framework
5.11 Complexities & Challenges in Addressing Sex Selection in India: Key Points from
brainstorming discussion – September 2010
5.12 Background presentation - Brainstorming Discussion on complexities & challenges
in addressing SS in India - Sep 2010
5.13 Note on Gender and Sex Selection Intervention Framework (2010-2014)–April
2010
5.14 Sex Selection Programming & Advocacy - Summary of Planned and Ongoing
Initiatives (2008-09)
5.15 Follow-up to State Review meeting-Action points on sex selection-Mumbai-May
2009
5.16 Sex selection Reflections on strategies, interventions and use of terminology -
Session Note for State Review Meeting – 2009
5.17 Addressing sex selection - Strategy and Interventions for 2009
5.18 Sex Selection Programming & Advocacy: Summary of Initiatives and Interventions
from 2002 and planned - ongoing initiatives for 2008 – 09
5.19 Field visit of the Director, APD, Mr. Sultan Aziz to Punjab in understanding
initiatives undertaken to address sex selection. 22 - 23 February, 2007
5.20 To understand the initiatives taken by Dy. Commissioner Nawanshahr on the issue
of SS-Nawanshahr and Chandigarh - Feb 2007

Assessment and Research Reports

5.21 Reflections on the campaign against sex selection and exploring ways forward –
Recommended strategies for UNFPA
5.22 Assessment of the efforts to address sex selection – looking back-looking forward
report- presentation of key findings
5.23 Report -Reflections on the campaign against sex selection & exploring ways
forward- Looking back looking forward – CYDA – Fe 2007
5.24 IMAGES AND ICONS: Harnessing the Power of Mass Media to Promote Gender
Equality and Reduce Practices of Sex Selection-BBC study
5.25 Special Financial Incentive Schemes for Girl Child In India: A Review of Selected
Schemes

131
Global / Regional
5.26 Interagency statement Preventing Sex Selection Statement – November 2010
5.27 Presentation on Communicating around Prenatal Sex Selection
5.28 Technical Consultation on Sex Selection - Workshop Overview and Way Forward -
October 2008

Working with Medical Fraternity

5.29 Note on IMA Strategy for Addressing Pre-Natal Sex Selection - 2008
5.30 Annual Conference of Indian Association of Preventive and Social Medicine,
Gujarat Chapter, 25-26 November 2005, Baroda: To make a presentation on sex
selection and build linkages with IAPSM for the PSM network and faculty to
actively address the issue in their day-to-day work
5.31 Regional Workshop towards development of State and District Action Plans,
Dehradun - March-2008: To facilitate the Northern region workshop consisting of
the IMA members from Punjab, Haryana, Chandigarh, Uttranchal, Delhi, Himachal
Pradesh
5.32 Regional Workshop towards development of state/district action plans, Kolkata -
March 2008
5.33 Sensitization workshop for Medical Colleges faculty of UP on prevention of female
foeticide - March 2007
5.34 Mission Report & Presentation: To participate and present on sex selection at the
14th Annual Conference of IAPSM (Gujarat Chapter) organized by Kesar SAL
Medical College and Research Institute, Ahmedabad - December 2006
5.35 Presentation made on sex selection to IMA - Sept „06

Media and Population Culture

5.36 Presentation made at Madhya Pradesh media workshop on abortion Vs sex selection
- June 08
5.37 Song „BALLO‟ by Punjabi singer, Rabbi Shergill focusing on the girl child
5.38 Song „Sun Zara‟ by Suneeta Rao focusing on the girl child
5.39 Journalist Training Workshop, Bhubaneswar December 2005
5.40 Presentation on sex selection and the State of World Population Report 2005 at a
Journalists‟ workshop - „Media and the Millennium Development Goals‟- Orchha
Madhya Pradesh-September 2005

Political Advocacy
5.41 Notes for parliamentarians/legislators on issue of Sex Selection – 2008
5.42 Note on Sex Selection and Two Child Norm - for Parliamentarians

Partnering with Judiciary

5.43 Presentation:
a. Judicial Colloquium on PCPNDT Act: Ahmedabad – April 2007.ppt
b. Judicial Colloquium on PCPNDT Act: Himachal – January 2009.ppt NLUI work in
c. Judicial Colloquium on PCPNDT Act: Mumbai – December 2007.ppt states
d. Judicial colloquium on PCPNDT Act: Orissa – February 2010.ppt
5.44 Himachal Pradesh state level Judicial Colloquim on PCPNDT Act, Jan 2009 -
Mission Report
5.45 Orissa State Level Judicial Colloquium on PCPNDT Act, Feb 2010-Mission Report

132
5.46 Maharashtra State Level Judicial Colloquium on PCPNDT Act - Dec 2007: To
participate and present at the Judicial Colloquium on 9 December, 2007 and
facilitate work with judiciary and Maharashtra State Legal Services Authority
(MSLSA) -Mission Report

Faith Based Organisation

5.47 Presentation on sex selection during the Art of Living Workshop- September ‟09

Support to Civil Society / NGOs

5.48 WPC Annual Report 2009,2010
5.49 Presentation made on the issues of sex selection to Women Power Connect

Collaborating with the Government

5.50 Note on Sex Selection & women's empowerment for Planning Commission-Sept 05
5.51 Locating prenatal sex selection in reality: Presentation made to MWCD
convergence meeting – June 2007
5.52 Presentation made to Planning commission on issue of sex selection
5.53 Note on strengthening implementation of PC & PNDT Act - Possibilities for
Appropriate Authorities
5.54 Note on Integrating the Issue of Sex Selection in the Work of MOHFW
5.55 UNFPA support to Maharashtra in CP7 - January 2008: To hold discussions with
the Department of Health and potential implementing partners for finalizing
UNFPA support to Maharashtra in CP7 and specifically in 2008-Mission Report
5.56 Presentation on sex selection issues made to Punjab Governor, Feb 2007
5.57 Gender empowerment -sex selection -EC seminar 19.3.07
5.58 Presentation made on sex selection issues to LBSNAA - May 06
5.59 Sex Selection LBSNAA EMS 8 May 2006
5.60 Presentation on sex selection issues for NCC training programme - Mar 2008
5.61 Understanding gender and health issues: Their implications for girls and women :
Presentation made to Bharat Scouts and Guide

Gender-Population Dynamics
5.62 Visit to: Mumbai, Maharashtra Dhanashri & Sathyanarayana : Finalization of
contents and session-plans for census training-enumerators and trainers
5.63 Note on Steps for Ensuring Gender Responsive Census – key points
5.64 Note on Gender Mainstreaming in Census of India-2011
5.65 Sex Ratio at Birth in India and selected states.ppt
5.66 Booklet on Trends in Sex Ratio at Birth and Estimates of Girls Missing at Birth in
India
5.67 Booklet on Missing Girls: Mapping the Adverse Child Sex Ratio in India
5.68 State-wise maps depicting the decline in child sex ratio
5.69 Frequently Asked Questions on Sex Selection – demystifying the legislation
5.70 Declining Child Sex Ratio (0-6 years) in India _ A Review of Literature and
Annotated Bibliography
5.71 PCPNDT Act - Answers to Frequently Asked Questions A Handbook for
Implementing bodies
5.72 PCPNDT Act - Answers to Frequently Asked Questions A Handbook for the Public
5.73 PCPNDT Act - Answers to Frequently Asked Questions A Handbook for Medical
Professionals

133
 5.74 Why do daughters go missing-Frequently asked questions on pre-natal sex selection
in India
5.75 Trends in sex ratio at birth and estimates of girls missing at birth in India
5.76 Doctors‟ Dilemmas-Questions doctors face in communicating about pre-natal sex
selection
5.77 IMPLEMENTATION OF THE PCPNDT ACT IN INDIA : Perspectives and
Challenges
5.78 CYDA report

Thematic Area: Adolescent Reproductive and Sexual Health (ARSH)

Annual Reports
5.79 Technical Assistance - Annual Work Plan – 2011
5.80 Overview of work in ARSH portfolio in 2010
5.81 Annual Plan of Operation – 2010
5.82 Annual Report – 2009

Reaching Out to Adolescents in India: Lessons Learnt and Way Forward

5.83 Strategy Note for Reaching Young People in Out of School Settings
5.84 Strategy Note for Reaching Young People in Institutional Settings: Envisioning the
Future of Adolescence Education Program (AEP)51: 2010 and Beyond
5.85 Presentations on:
a. Addressing Youth Realities in UNFPA India Country Program 7
b. Adolescence Education Program in India: Lessons Learnt
c. Evolution of Adolescence Education Program in India: Lessons Learnt and
Way Forward

Documents related to Monitoring and Evaluation of ARSH Programs

5.86 Evaluation Report of Functioning of Teen Clubs under Nehru Yuvak Kendra
Sangathan
5.87 Presentations on Assessment of Nodal Teachers Training Programs Implemented
Under the Adolescence Education Program in 2008
5.88 Instruments of AEP Assessment 2010-11
a. AEP School Monitoring format
b. FGD Guide for Students, including the pictures to initiate discussion among
students on the program, especially to seek their opinions on gender issues
c. In-depth Interview Guide for Principals
d. In-Depth Interview Guide for Teachers
e. Questionnaire for Students
f. Questionnaire for Teachers

Concept Notes and Training Materials

5.89 Background Note on National Seminar on Life Skills Focused Adolescence
Education, 2009
5.90 Adolescence Education Programme : Scheme of Content across different Stages of
Schooling
5.91 Conceptual Framework :Adolescence Education Program, 2010

51
Please note that the Adolescence Education Program is implemented in partnership with the Ministry of Human Resource
Development for in-school adolescents

134
Co-curricular format
5.92 Adolescence Education Program: Training and Resource Materials
5.93 Presentation on Rationale for Materials Development

Curricular format
5.94 Concept Note: Integrating Life Skills in Secondary Curriculum of National Institute
of Open Schooling(NIOS)
5.95 Presentation on Life Skills Integration: Concept, Rationale, and Characteristics of
Effective Programming in the context of NIOS
5.96 Presentation on Life Skills Evaluation in the Sample Lessons of Secondary
Curriculum of NIOS
5.97 Documents on adolescent health and life skills development prepared by Kalinga
Institute of Social Sciences in Oidya and English

6 Communications
A. Gender & Sex Selection
Laadli Media Awards: Population First, with the support of UNFPA launched the
UNFPA Laadli Media Awards for gender sensitivity and Laadli UNFPA National
Creative Excellence Awards in 2007-08. Since then, every year, the Awards felicitate
gender sensitivity in Journalism and Advertising – both print and electronic.

PCPNDT Online Reporting: The online reporting site allows people to report PCPNDT
Act violations online. The website was launched in Rajasthan in July 2010, and until
January 2011, over 60 reports had been registered online. The software enables
Appropriate Authorities and health officials at the state and district levels to follow-up
and report-back online on the action taken.
6.76 Link to the website for online reporting of PCPNDT Act violations
6.77 PCPNDT Online Reporting Site Users Manual

Self-learning CD to know more abour PCPNDT Act: The CD asks the user a series of
multiple answer questions in an interesting manner – making learning about the Act
interesting & participatory. On successful completion of the test, the CD automatically
generates a certificate that can be printed. The CD is being reviewed before being finalized.

Sapno Ko Chali Chooney

In early 2009, UNFPA India partnered with Jagran Pehel to launch Sapno Ko Chali
Chooney in 21 colleges across the state of Bihar. Designed as a mentorship and
empowerment programme, this initiative facilitated interactions of college girls, with
journalists, women‟s empowerment groups, and with each other. In 2011, the government
and other organizations have come forward to fund the replication of the project in the
rest of the state.

B. UNFPA Organisational Development

6.78 Bhopal Planning Meeting Agenda
6.79 Bhopal Programme Planning Meeting Visuals
6.80 Power of Positioning - First discussion on UNFPA positioning

C. Other work
6.81 RH Communication Development in Bhutan
6.82 Development Sector Photography Workshops

135
 Annex 5 – List of visits made & persons met
S. No. Name & Designation Organization
NEW DELHI
1. K. Chandramouli, Secretary, Health and Family Welfare MOHFW
2. Aradhan Johri, Addl. Secretary NACO
3. Anuradha Gupta, Jt. Secretary, (RCH) MOHFW
4. P. K. Pradhan, Addl. Secy & Mission Director, (NRHM) MOHFW
5. Suresh K. Mohammed, Director (RCH &DC) MOHFW
6. Madhu Bala, Addl. DG (Statistics) MOHFW
7. Pravin Srivastava, DDG, (Stat) MOHFW
8. T. Sundararaman, Executive Director NHSRC
9. S. Kunthia, Jt. Secretary MOHRD
10 Sailesh, Jt. Secretary MOYAS
11. Indu Patnaik MLP Div, Planning Commission
12. Karin Hulshof, Representative UNICEF
13. Anne F. Stenhammer, Regional Director UN-WOMEN
14. Kerry Pelzman, Director (PHN) USAID
15. Vikram Rajan, Sr. Health Specialist The World Bank
16. Billy Stewart, Sr. Health Specialist DFID
17. Saroj Yadav, Reader NCERT
18. Abhijit Das, Director CHSJ
19. P. M. Kulkarni, Prof. JNU
20. K. S. James, Prof. & Head (PRC) ISEC
21. Moneer Alam, Prof. IEC
22. Ladu Singh, Prof. IIPS
23. Prasanta Kumar Routray, CEO KISS
24. Sushanta Kumar Panda, Project Manager KISS
25. Irfat Hamid, Consultant MOHFW
26. Suraj Kumar, Head (Governance) UN-WOMEN
27. Ruchi Pant, Prog. Analyst UNDP
28. Marc Dervwwuw, Representative a.i. UNFPA
29. Ena Singh, Asst. Representative UNFPA
30. Venkatesh Srinivasan, Asst. Representative UNFPA
31. Yogesh Bhatt, Operations Manager UNFPA
32. Dinesh Agarwal, NPO (RH) UNFPA
33. Dhanashri Brahme, NPO (Sex Selection) UNFPA
34. Rajat Ray, NPO (Advocacy) UNFPA
35. Jaya Jaya NPO (ARSH) UNFPA
36. Geeta Narayan NPO (ARSH) UNFPA
37. K. M. Sathyanarayana NPO (PDS) UNFPA
38. Sanjay Kumar NPO (M&E) UNFPA
39. Sachi Grover, NPO (DM) UNFPA
40. Pinky Sharma, Consultant (Gender) UNFPA
41. Azza Omer, JPO UNFPA
42. Nalini Srivastava, NPA UNFPA
43. Sushil Choudhary, NPA UNFPA
44. Hemand Dwedi, SPC, Orissa UNFPA
45. Savita, Programme Manager WPC

136
 BIHAR

1. Sanjay Kumar, Secretary Health Cum Executive Director State Health Society, Bihar
2. Ajay Kumar Sahi, State Family Planning Nodal Officer State Health Society, Bihar
3. Arvind Kumar, State Data Analyst State Health Society, Bihar
4. Yameen Mazumder, Chief Field Office, Bihar UNICEF
5. Shailesh Kumar Singh, State Programme Officer UNDP
6. Hasan Waris, Director SCERT
7. Jaydeep Kar, State Programme Coordinator CEFPA
8. Jaiwanti P. Dhaulata, Senior Consultant ANSWERs
9. Thomas Jenifer Malardizhi, Project Officer ANSWERs
10 Sujeet Kumar Verma, Prog. Associate THP
11. Shahina Perween, Prog. Associate THP
12. Shyama Prasad Chatterjee, Associate State Coordinator IIHMR
13. Aftab Rahamani, Zonal Officer IIHMR
14. Karuna Shanar, Zonal Officer IIHMR
15. Ram Kishore Prasad Singh, General Secretary Gramin Evam Nagar Vikas
Parishad
16. Anju Sinha, Prog Coordinator Gramin Evam Nagar Vikas
Parishad
17. Yogendra Kumar Gautam, Secretary Jan Jagran Sansthan
18. Uday Singh, Project Coordinator Jan Jagran Sansthan
19. Swapan Dey, Prog Director Nirdesh
20. Madhu Singh, Block Coordinator Nirdesh
21. Nielsh Deshpande, State Prog. Coordinator UNFPA
22. Vibhuvendra Singh Raghuyamshi, State Prog Officer UNFPA

MAHARASHTRA

1. Shomita Biswas, Member Secretary Maharashtra State Commission

for Women
2. Shanar Padhal, Dy. Secretary Maharashtra State Commission
for Women
3. Jayant Bantiya, Addl. Chief Secretary Public Health Dept, Govt. of
Maharashtra
4. Archana Patil, Jt. Director Health Services
5. Gorakhnat Chindhe, Jt. Director Health Services
6. Prabir Das, Coordinator PDC, Public Health Institution
7. Shalini Phansalkar Joshi, Jt. Director Maharasthra Judicial Academy
8. Prakash Doke, Executive Director SHSRC
9. Vikas Kharge, Mission Director, NRHM
10 Satish Pawar, Jt. Director NRHM
11. Uddhav Gavande, Addle. Director State Family Welfare Bureau
12. Ashok Chitale, State, QA Officer State Family Welfare Bureau
13. Shambhu Sista, Executive Trustee Population First
14. A.L. Sharad, Programme Director Population First
15. D. K. Mangal, Statr Prog. Coordinator UNFPA
16. Anuja Gulati, SPO UNFPA

137
 RAJASTHAN
1. B. N. Sharma, Principal Secretary, Health Govt. of Rajasthan
2. D. B. Gupta, Principal Secretary, Planning Govt. of Rajasthan
3. Moti Lal Jain, Director, RCH Directorate of Medical Services,
Govt. of Rajasthan
4. Pradeep Kumar Sarda, Project Director RSACS,
5. Hardayal Singh, In-charge PCPNDT Cell
6. Ritesh Tewari, Legal Advisor PCPNDT Cell
7. Vaidehi Agnihotri, Consultant, VHSC NRHM
8. S. D. Gupta, Director IHMR
9. Narendra Gupta, Secretary PRAYAS
10 Mudit Mathur, Asst. Project Coordinator PRAYAS
11. Pradeep Kachawa, Asst. Project Cooridnator PRAYAS
12. Kishan Tyagi, State Coordinator PRIYA
13. Ahmad Tahreem, Programme Officer PRIYA
14. Jaidev Balakrishnan, Dy. Regional Director Population Services International
15. Swati Saxena, R.M. Communication Population Services International
16. Sharad Bharava, R.M., A&F Population Services International
17. K. Jimreeves RSACS
18. Pavan Kumar Shetty, Team Leader, TSU RSACS
19. Reshma Azmi RSACS
20. Suraj Mal Raiger, Director Economic & Statistics, Govt. of
Rajasthan
21. Manoj Kumar Raut, Demographer Economic & Statistics, Govt. of
Rajasthan
22. Sanejeev Bhanawat, Prof. University of Rajasthan
23. Shubhra Singh, Director – Cenusus and Jt. Secretary, GOI Census Dept
24. Kanchan Mathur, Prof. IDS
25. Nutan Jain, Asst. Prof. IHMR
26. Sarita Singh, Commissioner Women Empowerment
27. Rita Arora, Head, Dept of Education University of Rajasthan
28. Bhaskar A Sawant, Commissioner, Secondary Education Life Skill Education Shiksha
& Project Director Sankul
29. Umakant Ojha, Principal IASE, Bikaner
30. G. C. Mouriya, Dy. Director & Nodal Officer – LSE Trg. Dept. of Education
Cell
31. Anita Shekhawat, Asst. Project Officer Dept. of Education
32. Samuel Mawunganidze, State Chief UNICEF
33. Madhu Vijayvergia, District RCH Officer Dept. of Health, Ajmer
34. Pabhakar, MO Saradhana PHC, Ajmer
35. Salukshana Sharma, QA Coordinator PRAYAS, Ajmer
36. Kapil Mali, QA Coordinator PRAYAS, Ajmer
37. Sunil Thomas Jacob, State Prog. Coordinator UNFPA
38. Manita Jangid, State Prog. Officer UNFPA

138
 MADHYA PRADESH
1. Yogesh Kumar, Executive Director Samarthan
2. Harish Verma Samarthan
3. Tapan Mohanty, Project Director National Law University
4. Swati Singh, Project Coordinator National Law University
5. Palak Tiwari, Project Coordinator Vanya
6. Swati Kaithwas Actionaid Association
7. Jayant Lakra Actionaid Association
8. Kamar Fatima Actionaid Association
9. Meera Singh Actionaid Association
10 P. Biswas IIFM
11. Gangan Gupta, Health Specialist UNICEF
12. Rajan Dubey, Sr. Prog. Officer UNOPS
13. Priti Dave Sen, Team Leader, MP-TAST
14. Dyoti Benawri, State Prog, Officer IPAS
15. Sandeep Kumar, Prog. Officer PATH
16. Amit Anand, State Prog. Officer UNDP
17. Dorothy Rodrigues, OIC WFP
18. Sayeed Fareeduuddin, Operations Manager JICA
19. Pratibha Sharma, State Prog. Officer PFI
20. Ajay Khare, Dy. Director, Directorate of Health Services
21. Manohar Agnani, Mission Director NRHM
22. Anand Shukla, Addl. Collector Indore
23. Satish Joshi, Nodal Officer, PC&PNDT Act Govt. of Madhya Pradesh
24. Mukesh Kumar Sinha, Executive Director, MP-VHAI
25. Ramesh Nagrath, Member, IMA, Indore
26. Amit Babre, Div. Family Planning Consultant NRHM, Indore Div.
27. Abhijeet Pathak, Div. Maternal Health Consultant NRHM, Indore Div.
28. Ishrat Ali, Religious Leader (Shahar Kai) Indore
29. Manoij Joshi, Project Coordinator MP-VHAI
30. Sudesh Jain, Religious Leader Jain Muni, Indore
31. Sudhir Gokhale, Ex-Mmeber District Advisory Committee,
PC&PNDT Act, Indore
32. P. Y. Pandey, Member Monitoring Team, PC&PNDT
Act, Indore
33. P. K. Bajaj, Member Monitoring Team, PC&PNDT
Act, Indore
34. Sudhanshu Sekhar MP-VHAI, Maheshwar
35. B. S. Kaney, BMO Maheshwar, Khargone
36. Rahul Jain, DPM RCH/NRHM, Khargone
37. Shalini Kapoor, Project Coordinator MP-VHAI, Indore
38. P. R. Deo, State Prog. Coordinator UNFPA
39. Tej Ram Jat, State Prog. Officer UNFPA

139
 Annex 6 – Agenda of Gender Consultation Workshop and
presentation on UNFPA’s gender work

AGENDA FOR UNFPA’S GENDER CONSULTATION

21st April 2011

Objectives: To brainstorm and debate on what and how to, to integrate gender better into
CP-8, based on an assessment on how gender has been mainstreamed into UNFPA‟s work so
far.

Participants: 1. All UNFPA Delhi and State offices programme staff

2. All members of the Evaluation team

Session Time Session Speaker/Facilitator

1. 09:30-09:40 Introduction and background Rekha Masilamani

2. 09:40-10:15 Overview of how UNFPA perceives Ena Singh

„gender‟ and key achievements

3. 10:15-10:45 Plenary session: Ena Singh

Q.1: Any comments or additions to what
was presented?

4. 10:45-11:00 TEA BREAK

5. 11:00-12:00 Group Work in 4 Groups to discuss theme- A.R. Nanda and

(25 mins for wise Rekha Masilamani
group work; Q 2: What is the most important gender
5 mins for thing you did?
each group to Group 1: RH/HIV/Disaster
present and Group 2: ARSH
15 mins for Group 3: Population data and dynamics
discussions) Group 4: Population Policies &
Reproductive Rights

6. 12:00-13:45 Group Work in 4 Groups to discuss theme- Ravi Varma and

(40 mins for wise Priya Nanda
group work, Q 3: What challenges did you face in
10 mins for trying to mainstream gender in your
each of the 4 work?
groups to -How did you overcome them?
present and -Are there any other ways to handle
25 mins for these challenges in the future?
discussions) Group 1: ARSH
Group 2: Population data and dynamics
Group 3: Population Policies & RR
Group 4: RH/HIV/Disaster

140
Session Time Session Speaker/Facilitator

7. 13:45-14:30 LUNCH

8. 14:30-16:00 Group Work in 4 Groups to discuss theme- Firoza Mehrotra and

(45 mins for wise Rekha Masilamani
group work, Q.4: What is the most important
10 mins for gender work that is needed to
each of the 4 further integrate it in UNFPA’s
groups to RH/HIV/Disaster, ARSH,
present and Population data and dynamics and
35 mins for Population Policies/RR work?
discussions) Group 1: Population data and dynamics
Group 2: ARSH Population Policies & RR
Group 3: RH/HIV/Disaster
Group 4: ARSH

9. 16:00-16:15 TEA BREAK

10. 16:15 –16:45 Session 8 continued -do-

12. 16:45-17:15 How and where should the responsibility Rekha and Firoza
for implementation/mainstreaming gender
be located

13. 17:15-17:30 Summing up and Vote of Thanks Marc and Rekha

141
142
 UNFPA response to emerging concerns

Pre-ICPD
consultations in
India
UNFPA Response

Quality of care Global ICPD

deliberations
A woman’s (client’s)
perspective

Swaminathan Men to share the burden

Committee of FP
recommendations
And why only FP, why not
other RH services

TIME WHAT
PERIOD

CP 3  Recanalization and standards for sterilization  Jan mangal (through to present)

(1988-  Counseling Training Project  Introduction of NSV
1992)

CP 4  Research on alternatives to targets  9 elements quality Framework – incl

(1993-  Pre ICPD Consultations Women’s participation in management
1997)  Gender training for health staff – HP – 1  Protocols – RTI, Infertility, camps
workshop  Working Women’s Forum
 Move away from Targets  Haryana Women’s Empowerment Project (till
 SEARCH conference – Redefining population CP6) 
issues

CP 5  Population Policy in 5-6 states and formulation  Gender Policy in Gujarat

(1998- of NPP  Shift from population education to LSE for
2002)  How to address gender Adolescents
 QOC in IPDs – based on 9 elements framework  Study on injectables
 Gender training for health staff – Sirmour  Gender training of health service provider in
workshop+ follow up IPDs-manuals; 2day training; 1 day integrated
 Support to Gender Issues Project in RCH 1 Training
 Gender Training for staff – 2 programmes  CNA approach promoted
 LBSNAA-Briefings on Population Policies & RR  FCCs in hospitals / Police station/NGOs-Help
 Strategy for male involvement in RH desks in Orissa
 SEWA project on RH  GBV incorporated in gender training of
 Participatory village workplans based on CNA health worker
 GBV part of “Support to Gender Issues”
Project
 Kerala IPD – GBV intervention + studies
 Sex ratio work begins

143
TIME WHAT Contd…
PERIOD

CP 6  IPD5 intense focus – 2outputs GBV + Community , FCC  Instructions to states from MOHFW for RCH II training
continued  Gender in ASHA training; SBA training for ANMs; contraceptive
(2003-  Women’s groups to demand quality services–IPDs – Output 5 updates
2007)  LBSNAA – Briefing on gender sensitive Population policies  Study on female condom use
 Population Policies – 2 child /SSA connect (  ARSH services – piloting + testing + study
 QOC through Panchayats pilot in Bawal/Haryana  Guidelines for states in how to integrate gender in PIPs
 Jan Samwad  Gender included in some state PIPs eg. GBV in Kerala
 In RCH 2 –gender defined for government  In RCH District Planning Manual – included gender & community
 GBV in NHFS – 3  JRMs – gender examined
 Facilitator’s guide for integration in all health training and  GBV incorporated in gender training of health workers (includes
Gender Kunji circulated by Ministry ASHAs, SBA etc.)
 Gender training for health administrators & health staff @  Health & gender issues in SIRD Training – PRIs + faculty
LBSNAA  Balika Mandalis - Orissa
 SIHFW Faculty training @ NIHFW  “How to” address GBV in health sector–NCW & CHETNA Manual
 Gender training of ministry officials (2)  Workshop & Resolution on GBV as health issue – NCW + MOHFW
 NIHFW-Revision of training modules  ICRW status paper on violence against women in India
 Study on Prolapse, FGM, Fistula  Gender in youth policy deliberations

CP 7  Community – PRIs and SHGs; complementary aspect of QA  Dignity kits in emergency situations
(2008- project  Gender consultant in MOHFW
 PIPs checklist, Gender Toolkit for how to; Mid Term of RCH  Operationalizing DV Act in 2 districts in MP
2012)
 Bihar Population, Development Policy – chapter on women’s  BBC series Radio Drama– Life Gulmohar Style
empowerment  Sapno ko chali Choone in Bihar Colleges
 ARSH Services  Male Involvement for women’s empowerment
 Programming on Female Condoms  VHSCs work in Orissa & MP
 Empowering female sex workers – CBOs  QA projects – Rajasthan + Maharashtra
 Gender & Health integrated in SHG – Rajasthan & Maharashtra  Women PRIs– Bihar - Hunger Project
 FCCs leverage into RCH II (minimally)  Voter Awareness Campaign -Rajasthan
 Population Council paper on Physical & RH consequences of  PRIs to address MH, DV & SS –Rajasthan
GBV  Capacity building for integrating RH + gender in disaster
 NDMC experiment on “how to” address GBV in a tertiary management
setting
 PRIs & community to address GBV-Hunger, PRIA

144
Time Period 1 Policy

CP 4  Research on alternatives to targets

(1993-1997)  Pre – ICPD Consultations
 Move away from Targets
 SEARCH conference – Redefining population issues

CP 5  Population Policies in 5-6 states & formulation of NPP

(1998-2002)  Shift from population education to LSE for Adolescents
 Gender policy in Gujarat
 LBSNAA – Briefings on Population Policies & Reproductive Rights
 Participatory village workplans based on CNA

CP 6  Population Policies – 2 child; NHRC Colloquium; NCW; PRI study,

(2003-2007) Population Myths, Question Answer/Briefing kit
 LBSNAA – Briefing on gender sensitive Population policies
 Gender in Youth policy deliberations

CP 7  Bihar Population + Development Policy – chapter on women’s

(2008-2012) empowerment
 Dipstick joint study on out of pocket expenses in Orissa

Time Period 2 Comprehensive & Quality RH Services

CP 3  Recanalization and standards for sterilization

(1988-1992)  Introduction of NSV
 Counseling Training Project
 Jan mangal (through to present)

CP 4  9 element Q Framework – included women’s participation in management

(1993-1997)  Gender training for health staff – ANM/MOs – Himachal – 1 workshop in Mandi
 Protocols for RTI , infertility, ARSH, FP camps

CP 5  Study on injectables
(1998-2002)  QOC in IPDs – based on 9 elements framework
 QA pilots
 Strategy for male involvement
 Gender training for health staff in Sirmour/HP
 Gender training of health service provider in IPDs-manuals; 2day
training; 1 day integrated in RCH 1 Training
 CNA approach promoted, saturation trg –Sidhi, chitt

145
Time Period 2 Comprehensive & Quality RH Services Contd..

CP 6  Gender Training of Health Staff

(2003-2007) ₋ LBSNAA for health administrators
₋ Gender training of Ministry Officials (2)
₋ NIHFW – Revision of training modules
₋ SIHFW Faculty training @ NIHFW
₋ Instructions to states from MOHFW for RCH II training
₋ Facilitators guide for how to integrate in all health training & Gender Kunji - how to
provide client-centered services
₋ Gender in ASHA training; SBA training for ANMs; integration in nursing cirricula,
contraceptive updates
 QOC through Panchayats -pilot in Bawal, Haryana
 Study on female condom use
 Study on Prolapse, FGM, Fistula
 ARSH services – piloting + testing + study

CP 7  Gender training of service providers and Programme Managers- Raj, Orissa

(2008-2012)  ARSH Services
 Programming on Female Condoms
 Empowering female sex workers – CBOs
 Dignity kits in emergency situations
 Capacity building for integrating RH + Gender in disaster management
 NGOs working on disaster oriented on RH and gender
 MISP training - Maharastra
 Conceptualization & integration of ‘gender and equity cell’ within HFW

Time 3 Mainstreaming in RH Planning

Period

CP 6  In RCH II – defined gender for government programmes – more female

(2003- workers, demedicalization, cost for women; GBV; Gender training; security of
2007) women workers
 Guidelines for states on how to integrate gender in PIPs
 In some state PIPs – included gender – eg. GBV in Kerala
 Checklist for assessing PIPs at national level– used by most states for
formulating PIP
 Allocation for labour rooms, provision of toilet – as a result of gender
checklists
 Appreciation of gender elements by program mangers
 In RCH District Planning Manual – included gender & community
 Vishakha guidelines incorporated state PIP -MP
 JRMs – gender examined

CP 7  Gender examined in RCH II Mid Term Assessment

(2008-  Gender Tool Kit – “How to” for service providers
2012)  Gender consultant in MOHFW
 Gender and equity plan in Orissa PIP
 Appointment of female FP counsellor – MP, Bihar
 Yashodas appointed FP counsellor
 Tools and protocols for labour rooms, prescription audit, MCH coordinators of
30 districts oriented on assuring women’s rights in receiving care - Orissa

146
 Time Period 4 GBV - Policy, Research, Training & Health Sector Pilots

CP 5  FCCs in hospitals / Police station/NGOs-Help desks in Orissa – police

(1998- training on addressing GBV
2002)  GBV incorporated in gender training of health worker
 GBV part of “Support to Gender Issues” Project
 Kerala IPD – GBV intervention + studies

CP 6  IPD output 6 – GBV as a health issue – FCCs continued

(2003-2007)  “How to” address GBV in health sector–NCW & CHETNA Manual
 Workshop & Resolution on GBV as health issue – NCW + MOHFW
 ICRW status paper on violence against women in India
 GBV module in NFHS 3
 GBV incorporated in gender training of health workers (includes ASHAs,
SBA etc.)

CP 7  FCCs leverage into RCH II (minimally), GBV protocols, counselling trg ; to

(2008-2012) start counselling centres– mahila aayog
 PRIs & to address GBV – Hunger, PRIA
 Operationalizing DV Act in 2 districts in MP
 Population Council paper on Physical & RH consequences of GBV
 NDMC experiment on “how to” address GBV in a tertiary setting

Time Period 5 Women’s Empowerment

CP 4 (1993-1997)  Working Women’s Forum

 Haryana Women’s Empowerment Project (till CP6)

CP 5 (1998-2002)  SEWA project on RH

 Support to Gender Issues – SGI Project (Includes GBV,
Sex Selection, ARSH)

CP 7 (2008-2012)  BBC series Radio drama – Life Gulmohar Style

 Sapno ko chali Choone in Bihar Colleges
 Male Involvement for improved RH & gender equality –
Maharashtra
 Gender cells in gujarat and raj
 Trg of mngos and fngos on gender – Mhs and Orissa

147
Time 6 Community Demand for Quality
Period

CP 6  Gathering of women panchayat members – rajasthan

(2003-  Joint training AWW, ANMs and PRIs -Rajasthan
2007)  QOC Project with Panchayats – Bawal/ Haryana (module developed)
 Jan Samwads – Women’s testimonies on QOC & RR – Raj SCW
 Women’s groups to demand quality services–IPDs – Output 5
 Health & gender issues in SIRD Training – PRIs + Faculty – MOPR Project – MP,
Maharashtra, Rajasthan
 Balika Mandalis – Adolescent girls empowerment project – Orissa
 Kila – PRI training

CP 7  VHSCs work in Orissa & MP

(2008-  Community level action for QA projects – Rajasthan + Maharashtra
2012)  Women PRIs oriented to address RH & gender – Hunger Project, Bihar
Pre Election Voter Awareness Campaign – gender as an election agenda –
Rajasthan – PRIA
 PRIs to address MH, DV & SS – PRIA – Rajasthan
 Gender & Health integrated in SHG and Sathin-Sanjeevani Training modules –
MAVIM , Maharashtra and Rajasthan

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TIME Period WHAT

CP 3  Recanalization and standards for sterilization  Jan mangal (through to present)

(1988-  Counseling Training Project  Introduction of NSV
1992)

CP 4  Research on alternatives to targets  9 elements quality Framework – incl Women’s

(1993-  Pre ICPD Consultations participation in management
1997)  Gender training for health staff – HP – 1  Protocols – RTI, Infertility, camps
workshop  Working Women’s Forum
 Move away from Targets  Haryana Women’s Empowerment Project (till CP6)
 SEARCH conference – Redefining population
issues

CP 5  Population Policy in 5-6 states and formulation of  Gender Policy in Gujarat

(1998- NPP  Shift from population education to LSE for Adolescents
2002)  How to address gender  Study on injectables
 QOC in IPDs – based on 9 elements framework  Gender training of health service provider in IPDs-
 Gender training for health staff – Sirmour manuals; 2day training; 1 day integrated in RCH 1
workshop+ follow up Training
 Support to Gender Issues Project  CNA approach promoted
 Gender Training for staff – 2 programmes  FCCs in hospitals / Police station/NGOs-Help desks in
 LBSNAA-Briefings on Population Policies & RR Orissa
 Strategy for male involvement in RH  GBV incorporated in gender training of health worker
 SEWA project on RH  GBV part of “Support to Gender Issues” Project
 Participatory village workplans based on CNA  Kerala IPD – GBV intervention + studies
 Sex ratio work begins

CP 6  IPD5 intense focus – 2outputs GBV + Community ,  Instructions to states from MOHFW for RCH II training
(2003- FCC continued  Gender in ASHA training; SBA training for ANMs;
2007)  Women’s groups to demand quality services–IPDs contraceptive updates
– Output 5  Study on female condom use
 LBSNAA – Briefing on gender sensitive Population  ARSH services – piloting + testing + study
policies  Guidelines for states in how to integrate gender in PIPs
 Population Policies – 2 child /SSA connect (  Gender included in some state PIPs eg. GBV in Kerala
 QOC through Panchayats pilot in Bawal/Haryana  In RCH District Planning Manual – included gender &
 Jan Samwad community
 In RCH 2 –gender defined for government  JRMs – gender examined
 GBV in NHFS – 3  GBV incorporated in gender training of health workers
 Facilitator’s guide for integration in all health (includes ASHAs, SBA etc.)
training and Gender Kunji circulated by Ministry  Health & gender issues in SIRD Training – PRIs + faculty
 Gender training for health administrators & health  Balika Mandalis - Orissa
staff @ LBSNAA  “How to” address GBV in health sector–NCW & CHETNA
 SIHFW Faculty training @ NIHFW Manual
 Gender training of ministry officials (2)  Workshop & Resolution on GBV as health issue – NCW +
 NIHFW-Revision of training modules MOHFW
 Study on Prolapse, FGM, Fistula  ICRW status paper on violence against women in India
 Gender in youth policy deliberations

CP 7  Community – PRIs and SHGs; complementary  Dignity kits in emergency situations

(2008- aspect of QA project  Gender consultant in MOHFW
2012)  PIPs checklist, Gender Toolkit for how to; Mid  Operationalizing DV Act in 2 districts in MP
Term of RCH  BBC series Radio Drama– Life Gulmohar Style
 Bihar Population, Development Policy – chapter  Sapno ko chali Choone in Bihar Colleges
on women’s empowerment  Male Involvement for women’s empowerment
 ARSH Services  VHSCs work in Orissa & MP
 Programming on Female Condoms  QA projects – Rajasthan + Maharashtra
 Empowering female sex workers – CBOs  Women PRIs– Bihar - Hunger Project
 Gender & Health integrated in SHG – Rajasthan &  Voter Awareness Campaign -Rajasthan
Maharashtra  PRIs to address MH, DV & SS –Rajasthan
 FCCs leverage into RCH II (minimally)  Capacity building for integrating RH + gender in disaster
 Population Council paper on Physical & RH management
consequences of GBV
 NDMC experiment on “how to” address GBV in a
tertiary setting
 PRIs & community to address GBV-Hunger, PRIA 149
 Annex 7 - List of Protocols, Tools, Guidelines and Manuals produced during CP 7

Reproductive Health
Maternal Health, capacity building and quality of care
1. Guidelines for antenatal care and skilled attendance at birth by ANMs/LHVs/SNs, April
2010
2. Guidelines for operationalizing SBA training in RCH II, 2008
3. Skilled birth attendance (SBA)- trainers‟ guide for conducting training of auxiliary nurse
midwives, lady health visitors and staff nurses, 2010
4. Skilled birth attendance (SBA)- a handbook for auxiliary nurse midwives, lady health
visitors and staff nurses, 2010
5. Guidelines for accreditation of private health facilities for providing SBA training-
reference manual for programme managers on accreditation process, 2009
6. Trainer‟s handbook for training of medical officers in pregnancy care and management of
common obstetric complications, 2009
7. Trainer‟s guide for training of medical officers in pregnancy care, management of
common obstetric complications, 2009
8. Workbook for training of medical officers in pregnancy care and management of common
obstetric complications, 2009
9. Recommendations of consultation for medical college faculty and district hospital staff on
delivery and new born care practices in Rajasthan
10. Checklist for labour room in Orissa, 2010
11. Assessment of training of medical officers in Emergency Obstetric Care including
caesarean under NRHM / RCH – II, 2010

Family Planning
12. Sterilization standards (male and female), 2006
13. Guidelines for quality assurance committees, 2006
14. Standard operating procedures for sterilization in camps, 2008
15. Guidelines for administration of emergency contraceptive pills and IUDs, 2008
16. Post partum family planning: a manual for service providers
17. Contraceptive updates (Reference manual for Doctors & Facilitators Guide), 2005
18. Defining Processes to Administer Public Private Partnership framework for Family
Planning Services at State Level, 2010

Adolescent Reproductive and Sexual health- strategy formulation and program

development
1. Assessment of adolescent reproductive and sexual health (ARSH) – Gujarat, 2008
2. Assessment of adolescent reproductive and sexual health services- Maharashtra, 2010

Quality of Care in RCH

1. District quality assurance programme for RH services- an operational manual, 2006
2. Assessment of QA programme in Gujarat State, 2009

RTI/STI/HIV
1. Guidelines for prevention and management of RTIs/STIs in RCH 2, 2007

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ASHAs
1. Reading Material for ASHA: Book No. 1, 2005
2. Reading Material for ASHA: Book No. 2 – Maternal & Child Health, 2006
3. Reading Material for ASHA: Book No. 3 – Family Planning, RTI/STIs & HIV/AIDS and
ARSH, 2006
4. Reading Material for ASHA: Book No. 4– National Health Programmes, AYUSH &
Management of Minor Ailments, 2006
5. Monthly Village Health Nutrition Day – Guidelines for AWWs/ ASHAs/ ANMs/ PRIs,
2007
6. Guidelines for supportive supervision of ASHAs, 2007
7. Communication kit for ASHAs- FP, 2010

Support for Mother NGO Scheme

1. Training of trainers manual for NMGOs, 2005
2. Rapid assessment of MNGO scheme, 2007

Advocacy
1. Gender tool kit, 2010
2. Notes for parliamentarians/legislators on issue of sex selection, 2008
3. Presentation to IAPPD on sex selection- trends, patterns, implications, 2008
4. Judicial colloquium on PCPNDT Act: Himachal Pradesh, 2009
5. Judicial colloquium on PCPNDT Act: Orissa, 2010

Collaborating with Govt

1. Sex selection LBSNAA EMS, 2006
2. Understanding gender and health issues, their implications for girls and women-
presentation made to Bharat Scouts and Guides, 2006
3. NHRC full commission briefing on sex ratio at birth, 2010
4. Population dynamics, gender issues and sex selection, 2010

HIV/AIDS
1. Zone-wise Reports on Impact assessment of Red Ribbon Express - a pre and post survey,
2010 - 2011
2. Fact Sheet of west, south, east and central and north zones, 2010 - 2011
3. Presentation on mapping sex workers among Bedia community in MP, 2011

Assessment research reports

1. Reflections on the campaign against sex selection and exploring ways forward- strategies
recommended by UNFPA, 2007
2. Special financial incentive schemes for girl child in India- a review of selected schemes,
2011

Population and Development

1. District level population projections in eight selected states of India: 2006-2016, 2009
2. Process note on engendering Census activities, 2010
3. Analysis framework of critical indicators from HMIS, 2010
4. Concurrent assessment of JSY in selected states, 2009
5. Tracking implementation of health programmes at sub-national levels through HMIS
data, Presentation made during IASP conference at Bhubaneshwar, 2010
6. A study of vital registration system in Rajasthan- report and presentation, 2010

151
 Annex 8 - Methodology of Composite Ranking of the States on Seven Indicators

A composite rank of the states in India was computed based on the following seven indicators

1. Female literacy rate, 2011

2. Child sex ratio (0 – 6 age population), 2011
3. Infant mortality rate, 2009
4. Total Fertility Rate, 2008
5. Use of modern methods of family planning, 2005-06
6. Unmet need for family planning, 2005-06
7. Percent of population below poverty line, 2004-05

The data source for the above indicators numbers 1 and 2 is Provisional Population Total of
2011 Census; indicators 3 and 4 are from Sample Registration System; number 4 and 5
are from National Family Health Survey – 3; and indictor number 7 is from Planning
Commission.

To obtain a composite rank of each of the 28 states, firstly ranking was done on individual
indicators and secondly, the ranks for each state were added to get the sum total of all
ranks on seven indicators. For each indicator, states were ranked in such a way as to get
the highest rank for the best performing state on that particular indicator. For example,
Kerala gets highest rank of 28 on female literacy rate, while Goa gets the highest rank of
28 in terms of having the lowest infant mortality rate. Thus, the highest composite
ranking score of a given state could be 196 (28 states x 7 indicators) and minimum could
be 7. After getting the composite states, state with minimum composite ranks may be
termed as backward and with highest composite ranks may be termed as most advanced.

The table below presents the share of each state in total and below poverty line population
along with composite ranks on seven indicators.

152
Percentage share of states in total and below poverty line population of India and ranking on
seven indicators
SL States Total Percenta Percent Number Percenta Composit
No Population ge of of of ge share e rank
(000), 2011 India's populatio persons of states based on
populati n below below to seven
on poverty poverty India's indicator
line, line total s
2004-05 (000) below
poverty
line
populati
on
1 Jharkhand 32,966 2.72 40.3 13285 3.99 64
2 Orissa 1,947 3.47 46.4 19464 5.85 66
3 Madhya Pradesh 2,598 6.00 38.3 27805 8.35 66
4 Uttar Pradesh 199,581 16.49 32.8 65463 19.67 71
5 Bihar 103,805 8.58 41.4 42975 12.91 73
6 Rajasthan 68,621 5.67 22.1 15165 4.56 77
7 Meghalaya 2,964 0.24 18.5 548 0.16 81
8 Assam 31,169 2.58 19.7 6140 1.85 85
9 Goa 1,458 0.12 13.8 201 0.06 90
10 Gujarat 60,384 4.99 16.8 10144 3.05 91
11 Chhattisgarh 25,540 2.11 40.9 10446 3.14 93
12 Karnataka 61,131 5.05 25.0 15283 4.59 97
13 Andhra Pradesh 84,666 7.00 15.8 13377 4.02 98
14 Jammu & 12,549 1.04 5.4 678 0.20 100
Kashmir
15 Arunachal 1,383 0.11 17.6 243 0.07 105
Pradesh
16 Maharashtra 112,373 9.29 30.7 34499 10.37 106
17 Nagaland 1,981 0.16 19.0 376 0.11 107
18 Manipur 2,722 0.22 17.3 471 0.14 107
19 Tamil Nadu 72,139 5.96 22.5 16231 4.88 112
20 Haryana 25,353 2.09 14.0 3549 1.07 114
21 Uttarakhand 10,117 0.84 39.6 4006 1.20 119
22 Sikkim 608 0.05 20.1 122 0.04 122
23 West Bengal 91,348 7.55 24.7 22563 6.78 122
24 Kerala 33,388 2.76 15 5008 1.50 125
25 Tripura 3,671 0.30 18.9 694 0.21 130
26 Punjab 27,704 2.29 8.4 2327 0.70 133
27 Mizoram 1,091 0.09 12.6 137 0.04 135
28 Himachal 6,857 0.57 10.0 686 0.21 153
Pradesh
India 1,210,193 -- 27.5 332803 -- --

153