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India started its family planning (FP) programme in 1952, becoming the first government-sponsored programme in the world. The programme evolved gradually moving from awareness and information activities initially, to clinical services, and later on to a time-bound target-oriented programme from 1966 onwards (Gupta, Sinha & Bardhan, 1992). The FP programme, along with Maternal and Child Health (MCH) services, is called Family Welfare in India. This programme is sponsored by the Department of Family Welfare in the Ministry of Health and Family Welfare at the central. At the state level, it is managed by the Department of Health and Family Welfare. At the central and state levels, there are various divisions within the Department of Health and Family Welfare that look after various programmes. But at the district level and below, the same infrastructure provides both family welfare and health services. Generally, the primary health centre (PHC, one for 30,000 population) and sub-health centre (one for 5,000 population) provide the information, education and communication (IEC) services as well as spacing methods of family planning. Sterilisation operations are done at some PHCs, community health centres (CHCs, 1 for 100,000 population), at district hospitals or at specially arranged camps in the PHC or in selected villages. The PHC also provides MCH services, immunisation and services for control of communicable diseases.

Under the target-oriented planning and monitoring system introduced in 1966, the central government gave to each state method-specific contraceptive acceptor targets, which were based on calculations to achieve replacement fertility level by a certain year. These targets were then distributed to the districts by the state governments, and the district administrator or health officers passed them on to the PHC. In turn, each paramedic working under the PHC was given a target of new acceptors for each method. In most states the targets for family planning were also given to non-health staff, such as staff of revenue, education and rural development. The district administrator and the state level technocrats and bureaucrats reviewed performance of health care organisation, at each level, based on the achievement of the targets.

Over the years, the contraceptive prevalence rate (CPR) has increased from about 10 percent in the early 1970s to around 45 percent in the mid-1990s. The total fertlity rate (TFR) has declined from 6 in 1950s to 3.3 in 1997, and is likely to continue on its downward trend. The birth rate declined from about 42 in the early 1960s to 27 in 1997 (World Bank, 1995; Registrat General of India, 1998).

Inspite of these successes of increasing CPR and declining birth rate, there has been criticism of the Indian family planning programme within and outside the country (Conly & Camp, 1992), for its highly centralised, inflexible, target-oriented monitoring which both limited choice for couples in selecting FP methods and did not ensure quality. The target-oriented monitoring also encouraged some degree of inflation of the results reported in terms of clients served, as well as created a feeling of alienation in the community toward the programme. The workers and the staff also felt pressured for non-achievement of targets. The programme neglected several systemic problems, such as lack of proper infrastructure, poor logistics and supplies, weak supervision and training (Mavalankar, 1998).

The major impetus for change seems to have come from three sources. First, during the late 1980s and early 1990s, some research studies, evaluations and assessments indicated various problems faced by the family planning programme as mentioned above. Second, the program performance reached a plateau as the pace of increasing contraceptive prevalence and decreasing birth rate slowed down inspite of increasing efforts. Third, over the years, several women's groups, women activists and NGOs had also criticised the target-oriented FP programme as being insensitive to women's needs (Visaria et al., 1998).

This situation led to rethinking about the strategy and the programme at several levels within and outside the government. The Government of India set up two committees Ñ one headed by the Chief Minister of the state of Kerala and another headed by an agricultural expert and bureaucrat to review the population policy and the family welfare programme. The latter committee, which gave its report in May 1994, recommended moving away from target-oriented approach (The Futures Group International, 1998).

In 1994, the Government of India participated in the International Conference on Population and Development (ICPD) held in Cairo and presented a country paper which considered family planning in the broader context of health and development (Government of India, 1994). The ICPD Programme of Action (POA) emphasised quality of care, voluntary choice in family planning and action to help couples meet their reproductive goals. It talked about reproductive health (RH) in the context of reproductive rights, thus moving away from demographic, macro level goals to a client focus as endorsed by ICPD-POA, 1994.

In 1994-95, the World Bank reviewed the family welfare sector in India in collaboration with the Government of India and a report was published in May 1995. The report focussed on how the programme can carry out the commitment given at the ICPD to implement a client-centred approach that responds more effectively to the RH and FP needs of women and men in India. The overall recommendation of the report was "reorient the family welfare programme, as quickly as possible, to a reproductive and child health approach that meets individual health needs and provides high quality services". One of the key policy recommendation of the report was "eliminate method-specific contraceptive targets and incentives. Replace them with working with universities broad reproductive and child health goals and measures. Increase emphasis on male contraceptive methods and broaden the contraceptive method mix". The report also recommended increasing the budget for reproductive and child health to meet critical gaps and enhance service quality (World Bank, 1995).

The Government of India started doing away with using specific, quantitative targets for monitoring the programme in the early 1990s. ICPD provided a final push in this direction. Meanwhile, some states had already initiated steps to experiment with alternate strategies for the FP programme. For instance, in the state of Tamil Nadu in the early 1990s, one district collector had removed targets from non-health functionaries and involved ANMs (auxiliary nurse midwife) in target setting. Beginning in 1992, the state of Rajasthan also started experimenting with alternate ways to plan and monitor the FP programme. Following the recommendation of its expert committee and consensus at ICPD, in April 1995, the Government asked each state to identify one or two districts and make them target-free for family welfare. Two states, Kerala and Tamil Nadu, where fertility had declined to near replacement level, opted to make the whole state free of targets. Other states experimented with removing targets in one or two districts as per central guidelines. Targets for condoms were discarded from April 1995 onwards for all states. After one year of piloting this approach, the Government decided to make the family welfare programme in the whole country, target-free, from April 1996. Several state administrators and family welfare directors were concerned that in the absence of targets the programme performance in terms of number of acceptors recruited for sterilisation would decline and suggested a slower process of removing targets (Murthy N. 1999).

A group formed by the Government to come up with alternatives to using targets for monitoring the family welfare programme, suggested selecting good points of previous efforts for monitoring under a target-free approach (Murthy N., 1999). A national meeting in March 1996 also discussed alternative, target-free strategies for the family welfare programme (Satia and Subramaniam, 1996). Based on various inputs such as the aforementioned, the Government produced the "Manual on Target-free Approach in Family Welfare" and widely distributed to the states to facilitate this change from target-oriented programme monitoring to target-free approach (Government of India, 1996).

The basic idea behind the TFA was that the central government would no longer give method specific contraceptive targets. The states should develop their own system of performance planning and performance monitoring based on assessment of the community needs. A decentralised participatory planning process was to be adopted by the grassroots level workers to arrive at the needs of the community. These needs had to be aggregated at the PHC and then at the district level to form the action plans. The TFA manual gave various formats for this process. Such planning was to be backed up by reporting various data for monitoring of work done. For improving supervision and detecting quality problems, the TFA manual provided supervisors' checklists. Supervisors were to observe the work of the subordinate, interview the clients and check the records to fill up the supervisory forms. It was hoped that such a process would help improve quality of service.

Target-free approach was communicated in the Health Department through regular meetings and written communications of the Health Department. It was also discussed and explained during the regular meetings of Secretaries and Directors of family welfare at central level. In 1996, the states were asked to conduct a two-day workshop for state officers and similar workshops at district and sub-district levels for orienting the whole family welfare infrastructure to the new approach. Unfortunately there was confusion regarding the approach because the central level left the methodology regarding how to calculate the work load at sub-centre level and how to set expected level of achievement to the discretion of the states. Even at the formulation stage, there seemed to be differential understanding among senior programme managers about the spirit, purpose and the mode of implementation of this approach which was reflected in the manual. For instance, the manual used various terminology such as "felt need of population", "area requirement", "unmet needs", "service needs", "expected needs" and "norms". It was also not clear as to which feature of the approach were critical: "target-free" or "decentralised participatory planning" (Government of India, 1996; the Futures Group International, 1998:88).

Thus, there was no concise understanding of this complex and novel concept nor concrete ways to operationalise the new approach. At the lower level Ñ district and below Ñ a similar reorientation was done but gave somewhat clearer instructions regarding calculation of workload by the workers and supervisors.

The field staff generally found the formats for planning, supervision and reporting suggested in the TFA manual too complicated and removed from what really was happening on the ground. Consequently, they were not used systematically. In the absence of proper understanding of the programme, its purpose and approaches, the target-free approach in many states was interpreted as, the "work free approach". Many activities, such as FP extension work, IEC work, sterilisation camps, etc., which were performed under the family welfare programme, possibly under the pressure of targets, stopped in several states after targets were dropped. Some workers thought that as there was no pressure of targets they did not need to put in even the usual effort. Even though the target-free manual had suggested a series of indicators for performance measurement and quality assessment, no systematic effort was made in many states to collect data on these indicators and use them for monitoring and improving the programmes. Some states, such as Maharashtra and Rajasthan, did try to focus on unmet needs, access and quality of care. Field observations in two districts of Gujarat showed that the TFA became an exercise to prepare sub-centre, PHC and district action plans without understanding the purpose and meaning of the whole exercise. The following table summarises the actions taken under TFA by some states.

Table 1 Key Target-Free Actions

State Key	Features of TFA Implemented
Karnataka	At each sub-centre the workers estimated clients' needs through survey of 100 couples for 15 health interventions. The workers felt involved in setting the targets
Andra Pradesh	Workers listed all the married women with 2-3 children and guessed how many were likely to accept sterilisation. These guess-estimates were discussed and revised if found low at PHC level to form the targets. The state government set targets and revised them upwards three times in 1996-7.
Rajasthan	Workers were asked to find out the unmet need by surveying the couples and then told to convert a fixed percentage of the unmet need to sterilisation cases.
Uttar Pradesh	Workers were asked to set FP targets equal to an average of the last three years. Uttar Pradesh reintroduced the targets following the decline in performance after the first year.
Tamil Nadu	Workers were given a formula to calculate the target based on number of second and higher order births.

(Modified from Murthy N., 1999; the Futures Group International, 1998)

Because of the lack of pressure following removal of targets and the lack of close monitoring in some states (especially in central and north India), the number of sterilisations performed dropped somewhat in the year 1996-97, the first year of implementation of the TFA. This was especially true for Uttar Pradesh and Bihar where sterilisation performance went down substantially between 1995-96 and 1996-97. In several states, there was a gradual decline Ñ a continuation of the previous trend beginning before the TFA for certain states. Only in one or two states, there was a marginal increase in sterilisation acceptance. The decline worried the programme managers at the state and central levels, and some states informally or formally reintroduced the targets at state or district level.

During 1997-98, each state had developed its own way of managing the family welfare programme. As indicated above, many states introduced informal, formal targets or surrogates for targets such as expected level of achievement, etc. The birth rates have continued to decline at almost the same rate as before, after the adoption of the TFA (see Table 2) and the performance in most states improved as compared to the first year of the TFA (1996-97). The reasons for this could be 1) the locally developed strategies (and possibly some pressure exerted) and 2) the fact that the workers, supervisors and PHC medical officers realised that target-free did not really mean no work. Hence, the stoppage of activities which took place in the previous year did not take place again.

In many states, instead of central determination of targets on population, the PHC and workers were asked to calculate their expected level of achievement based on a formula given by the state government (as happened in Gujarat and Tamil Nadu) or based on unmet needs determined by survey of eligible couples (as happened in Rajasthan and Gujarat during second year). In effect, in many states, the target-setting exercise was decentralised to the periphery, which was a positive move, but in only one or two states consultation with clients was undertaken as the basis for estimating the unmet need for family planning. In other states, when the peripheral workers came up with lower need than expected by the higher level managers the targets were increased.

The other component of the TFA, which was focussed on improving quality of care and generating community participation, did not systematically take place in many states, partly because there was no emphasis on these activities in the manual and at any of the other communications including workshops and meetings. Secondly, no additional resources were allocated for such activities. Thirdly, the health system had not emphasised community participation or quality issues in the past and hence lacked adequate skills on how to do them. There is no evidence to suggest that the quality of service or community participation improved in the programme. The state of Rajasthan seems to be an exception, as some innovative community participation activities and IEC efforts did take place.

Given the initial confusion over the TFA and the lack of an alternative system of monitoring, there was some rethinking about the approach and a new approach called "Community Needs Assessment Approach" (CNAA) was developed by the central government (Government of India, 1998). The new manual on CNAA removed many of the supervising and reporting formats given in the TFA manual and tried to simplify the approach. The new approach also did not emphasise or allocate any additional money for quality improvement or community participation. The emphasis of this approach was setting local level targets in a decentralised and participatory manner through assessment of community needs.

The Government of India, with assistance from donors, established two systems of evaluation: 1) the National Family Health Survey (NFHS), which is equivalent to Demographic and Health Surveys (DHS), and 2) the "quality of service and Client Satisfaction Rapid Surveys" or district level surveys for reproductive and child health (RCH), which are being conducted in each district every alternate year. The first round of NFHS was carried out in 1992-93 before the TFA and the second round is brnmeneing carried out in 1998-99 in all states of India through Population Research Centres. Pilot projects, operations research projects and other research studies conducted by various national and international organisations also assisted in the implementation of the TFA, assessment of the impact, improvement of quality and integration of RH in PHCs.² These projects are providing valuable insights on the ground level realities of changing the family welfare system.

One of the expectations from the TFA was the increased use of spacing methods. To date, there is no evidence to suggest that the TFA has led to increased use of spacing methods. The data on spacing method use will only become available through the second round of NFHS and special studies carried out in certain project areas.

There has been some indication that a process of change has begun as a result of this paradigm shift in the form of the TFA. This new approach has compelled the states to think of how to manage and monitor the programme in the absence of targets from the central government. This has spawned several innovative approaches in programme management on small as well as large scale, which itself is a positive change. Some states such as Kerala, Rajasthan and Tamil Nadu, have demonstrated the ability to manage their programmes successfully without central level targets.

At the field level, including district, PHCs and sub-centres, the pressure for targets has reduced and generally the workers seem to feel positive about the approach. Some small studies carried out in Tamil Nadu, Rajasthan and Maharashtra indicate a positive attitude and perception of the workers towards this approach (Visarias, 1998; the Futures Group International, 1998). For example, an ANM from Uttar Pradesh said, "the target-free approach has made our work much easier. We can give our time for other services also" (referring to MCH). Another ANM from Uttar Pradesh said, "earlier the villagers refused to talk to us. Now they themselves ask for FP methods (Khan and Townsend, 1999). Experience in Gujarat also indicates that PHC medical officers and workers have by and large welcomed this change.

According to some reports, performance in MCH related indicators such as ante-natal care, delivery care, and immunisation, may have improved due to lack of pressure on FP target achievement under the TFA (Murthy, 1999, Visaria, 1999). Some workers also reported that with the decreased pressure on family planning, they are able to concentrate more on other MCH activities. No clear data is available to assess how much improvement has taken place or what proportion of it can be ascribed to the TFA. Preliminary results from the NFHS in Gujarat state indicate that FP acceptance has increased in the last few years but there is no major improvement in MCH indicators (International Institute of Population Studies, 1993; International Institute of Population Studies, 1999). National evaluation of routine immunisation has recently shown that there has been slight decline of coverage over the last few year (Government of India, 1999).

Many administrators in India are very committed to containing population growth. As such, the reaction among the state level officers is quite mixed. There are some senior officers who still strongly believe in targets, and, given the confusion related to target setting generated by the TFA, continued to give state level and district level targets (TFA Workshop, 1998).

In tandem with the paradigm shift in FP programme in the form of the TFA, the MCH programme along with the FP programme, is being given a new shape in the form of the RCH programme, which is in line with the suggestions made at ICPD and the World Bank sector review in India to reorient FP programmes to RH approach. In October 1997, with the help of the World Bank and other donors, the Government of India launched a five-year programme with an expected expenditure of about 50 billion rupees (US$1.25 billion) to provide RCH throughout the country.

The key features of the strategy of the government's RCH programme are community participation in planning, client-centred approach, upgrading of facilities and improved training, emphasis on good quality care, absence of contraceptive targets and incentives, making services gender sensitive and multi-sectoral approach in implementing and monitoring services. The programme aims to reorient programme planning from top-down to bottom-up. It focusses on quality of care to produce client satisfaction leading to improved use of services. The key components of the programme are child survival and safe motherhood, FP, women's health including RTI, STD/HIV, and adolescent education. The programme espouses a life-cycle approach (Government of India, undated).

The expectation is that this programme will provide the resources needed to reorient the FP programme from a target-oriented approach to client oriented approach and help improve the scope and quality of services. Thus it complements and takes further the changes envisaged under the policy shift of the TFA. The implementation of the RCH programme has started but is progressing somewhat slowly as it continues to evolve, and it is too early to assess its impact. When the RCH programme is fully implemented, it is hoped that the paradigm shift envisaged under TFA in the family welfare programme will be fully realised.

The whole strategy and process of moving away from method-specific, centrally determined contraceptive target toward decentralised, participatory planning in India is an interesting learning experience to various stakeholders (national and state governments, NGOs and researchers) involved. The lessons that emerged from this experience will help strengthen the programme in future.

The change involved in moving away from centrally determined demographic targets is momentous. For three decades, the targets have been the driving force for the programme. A large number of administrators have been habituated to ensure accountability of the staff through targets. The service providers more than 200,000 Ñ have seen targets as a way to assess their own performance and target-chasing has become habitual.

There could have been two ways to bring about such a large and complex change: 1) build consensus on the need and direction of change and then proceed to institute a policy; and 2) institute a policy change rapidly as a precursor to behavioural change. The Government of India chose the latter route. The process of change, however, is only likely to be rapid if the implementation efforts for this policy change match its complexity. The implementation efforts, however, were inadequate, and, consequently, it will be a long time before the change becomes fully institutionalised and its benefits are visible on a large scale.

What is needed? First, it is necessary to enhance implementation efforts. Such a massive change as the TFA, which in some sense is a Cultural Revolution in the family welfare programme of a continental country like India, needs very dynamic and pro-active leadership and responsive health system at central as well as state government levels. The experience of the TFA showed that in states where such leadership was available, for example, in Rajasthan and Tamil Nadu, the programme at least did not falter in terms of performance and at times actually showed improved performance and quality of service. In the states where such pro-active leadership was lacking or the health system was not responsive, performance declined. Some of the problems of the TFA seem to emerge from limits of capacity at central and state levels to plan for and manage large changes in a huge programme systematically. Even though the Indian health system has a large number of field functionaries, the system is incredibly lean at the top level. Given this situation, the limited number of top people are over-stretched at managing such a large change. The key lesson is to enhance the managerial capacities at central and state levels in order to manage such a large change. It would have been even better to set up a temporary task force or a group which would go from state to state convincing state level managers and helping them manage change over a period of 3-5 years. The RCH project will be providing support to the central and state level to bridge this gap.

Second, the pace of learning and change needs to be accelerated. Additional resources need to be provided to implement the change process and problem-solving mechanisms should be set up as an integral part of this process. Such additional resources will be available from the RCH and other donor-supported state health systems projects.

Third, the scope of change and communications on it could be simplified. Also, greater communication effort is needed to achieve conceptual clarity and consensus on the new approach among the large number of administrators. For service providers, detailed step-by-step guidelines will be needed. At middle management, improved supervisory skills are needed, and at grassroots level, better technical and interpersonal skills are needed.

Fourth, the focus on quality of care is still inadequate. One of the key criticisms of the target-based FP approach was that it led to poor quality services, which alienated the community and frustrated the workers. Thus improving quality was one of the implicit as well as explicit objectives of this change. Although removal of targets eliminates one of the key barriers to improving quality of care, the reasons for poor quality of service are many and targets may just be one of them. The lesson from this experience is that to improve quality, programmes need to undertake many changes, and unless the whole constellation of causes of poor quality is addressed, removing targets alone may not increase the quality of service. Complementing implementation of target-free approach by including support for improving quality of services, the RCH programme may lead to better quality of care. But to ensure quality improvement, it should become a central focus of the top management at the state and central level. They should convey to the whole organisation, through words and actions, that quality is their top priority. Only then will lower level functionaries provide quality services.

In conclusion, after ICPD in 1994, India's policy relating to FP programme experienced a paradigm shift and moved substantially forward with major changes in the way the programme was planned and monitored. Central government has moved away from target-oriented, centralised monitoring of the FP programme. It has initiated implementation of a more comprehensive RCH programme.

The experience to-date highlights the implementation difficulties of such a paradigm shift in a large country like India. The pace and direction of change as implemented shows a high degree of variability. For a rapid transition, implementation efforts need to be substantially enhanced through strengthening management resources for bringing about the change, accelerating the pace of learning, simplifying strategy and communication and providing more resources for improving quality of care. Much also remains to be done to increase community participation, especially women's participation.

Nevertheless, this policy change has begun the process where administrators and technocrats at various levels and service providers have begun to think of what they should do and how to meet client needs. The service providers have generally welcomed such a change and feel less pressured, and the performance of other services such as MCH may have begun to improve.

The success of this great effort to reform the family welfare programme will highly depend on the kind of leadership that will be available at the central and state level and the perseverance of the key managers in ensuring that the original vision is not lost over time. Effective partnership with donors, NGOs and researchers will be essential to carrying on the paradigm shift that has started in the Indian family welfare programme.

¹The author is assistant professor with the Public Systems Group, Indian Institute of Management, Ahmedabad.
²Examples of such projects are: RH project in Sanand Taluka of Ahmedabad district run by Indian Institute of Management, Ahmedabad, project in Parner block of Ahmad Nagar district run by Foundation for Research in Health Systems, both funded by the Ford Foundation; Projects in Agara and Sitapur districts of Uttar Pradesh run by Population Council; Vikapa Project in Rajasthan run by Indian Institute of Health Management Research.

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