1
Enabling the Expansion & 
Sustainability of Integrated 
RCH/Infectious Diseases Outreach 
Services in Ranchi, Jharkhand 
Final Evaluation
CEDPA/India
 Krishi Gramin Vikas Kendra
July 2003
2
This project was conducted with support from the Office of Population and Reproductive Health, Bureau for 
Global Health, US AGENCY FOR INTERNATIONAL DEVELOPMENT under the terms of Cooperative
Agreement No. HRN-A-00-98-00009-00.
1400 16th Street, NW, Suite 100
Washington, DC 20036 USA
Ph: 202-667-1142 Fax: 202-332-4496
cmail@cedpa.org • www.cedpa.org
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CONTENTS
#
List of Tables and Figures
Acknowledgements
Chapter 1: Background 4-8
1.1 About the Project
1.2 Sampling Procedure
1.3 Data Processing
1.4 Limitations of the Study
Chapter 2: Project Implementation Process 9-19
2.1 Reactivated Sub-Centres 
2.2 Recruitment of the Project Staff
2.3 Skill Upgradation and Capacity Building
2.4 Service Delivery Package
2.5 Information, Education and Communication (IEC)
2.6 Networking and Logistics Management
2.7 Supervision and Monitoring
2.8 Management Information System
2.9 Social Marketing
2.10 Sustainability/ Cost Recovery 
2.11 Consortium of Industries for Prevention of HIV/AIDS
2.12 Base-line Survey
2.13 Feasibility Study
Chapter 3: Reproductive Health and Family Planning Services 20-29
3.1 Awareness and Utilization of Services
3.2 Performance Indicators
3.3 Ante-Natal Care 
3.4 Natal Care
3.5 Child Immunization
3.6 Management of Diarrhoea
3.7 Knowledge of Family Planning Methods
3.8 Current Use of Family Planning Methods
3.9 Reproductive Health Problems
3.10 Exposure to Information, Education and Communication 
(IEC) Activities
4
Chapter 4: Cost Recovery 30-32
4.1 Cost Recovered by the Sub-centres
4.2 Cost Recovered by the Rural Hospitals
Chapter 5: Summary and Conclusion 33-35 
Annex
5
LIST OF TABLES AND FIGURES
#
Table 2.1 Base-line survey results 18
Table 3.1 A comparison of base-line and end-line project related
indicators
22
Table 3.2 Percentage of children (12-23 months) who received complete 
immunization
23
Table 3.3 Prevalence of diarrhea and ORS distribution 24
Table 3.4 Percent distribution of eligible couples by use of any modern 
method of contraception
26
Table 3.5 Self-reported symptoms of RTIs/STIs among respondents by 
source of treatment sought by them 
27
Table 4.1 Analysis of expenditure incurred and income per patient at 
KGVK rural hospitals
31
Table 4.2 Cost recovery analysis of rural hospitals 32
Fig. 3.1 Age-wise distribution of respondents 20
Fig. 3.2 Utilization of services during last three months by place of 
availing
21
Fig. 3.3 Knowledge of family planning methods 25
Fig. 4.1 Cost recovered by sub-centres 30
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ACKNOWLEDGEMENTS
In collaboration with the CEDPA, Krishi Gramin Vikas Kendra, a non-government organisation, 
has implemented a project titled “Enabling the expansion and sustainability of integrated 
RCH/infectious diseases outreach services through skill upgradation, capacity building, and 
women's empowerment in Ranchi, Jharkhand.”
In order to assess the impact of the project, the Indian Institute of Health Management Research 
(IIHMR), Jaipur was entrusted with the responsibility of carrying out a evaluation study of the 
same. The study was carried out to record the experiences of the strategies, and interventions, 
and to evaluate the achievement of the objectives thus far. We are grateful to CEDPA, New 
Delhi for providing us the opportunity to carry it out. During the process, we received co￾operation from the officials of CEDPA. We are grateful to Ms. Marta Levitt Dayal, Country 
Director and Dr. Bulbul Sood, Programme Management Specialist for their inputs and co￾operation.
The team also remembers and acknowledges the support and cooperation received from the 
KGVK staff during the fieldwork.
At the Indian Institute of Health Management Research (IIHMR), we are extremely grateful to 
Dr. S.D. Gupta, Dr. Barun KanjiLal, Dr. L.P. Singh, Dr. Santosh Gandhi and Prof. A. L. Shah for 
their guidance and support. Timely help and support from the Computer staff is gratefully 
acknowledged.
Project Team
7
 Chapter 1
BACKGROUND
1.1 About the Project
Under the USAID-funded ENABLE project, CEDPA supported Krishi Gramin Vikas Kendra 
(KGVK), a non-governmental voluntary organisation, to implement the project "Enabling the 
expansion and sustainability of integrated RCH/ infectious diseases outreach services through 
skill upgradation, capacity building and women's empowerment in Ranchi, Jharkhand.” The
project focuses on piloting a community-based sustainability plan through a number of
innovative measures. It covered two blocks, namely Ormanjhi and Angara in the Ranchi district. 
The project aimed to provide integrated, quality, and sustainable reproductive and child health 
(RCH)/ infectious disease services in Ormanjhi and Angara blocks and the surrounding
community of Usha Martin dispensary in Ranchi by upgrading providers' skills, capacity
building and women's empowerment and initiating HIV/AIDS activities through a consortium of 
industries in Jharkhand. The project was implemented for a period of one year, starting from 
February 2002.
The objectives of the project included the following:
i. To increase the use of integrated RCH/infectious disease services by expanding the provision 
of quality, gender-sensitive, sustainable outreach service delivery.
ii. Expanding outreach services through the sub-centres from approximately 25,000 populations 
in 19 villages to 50,000 population in 40 villages of Ormanji and Angara blocks.
iii. Introducing outreach services in 20 surrounding villages of the Usha Martin Ranchi
dispensary covering 20,000 population.
iv. To continue providing quality RCH and infectious disease services to surrounding 30,000 
population through the two KGVK rural hospitals in Ormanji and Angara blocks.
v. To reach 35 per cent CPR for modern contraceptive methods in the original 19 villages and 5 
percentage points above the baseline for the additional 21 villages in Ormanji and Angara 
blocks through expanded informed choice and improved quality of care and counseling.
vi. To expand choice by increasing the types of effective family planning methods by
introducing injectables, NSV, Minilap, LAM, and SDM and introduce social marketing of 
pills, condoms and injectables.
vii. 75 per cent of pregnant women are to receive basic antenatal care (3 ANC checkups, 2 TT 
injections and 100 IFA tablets) in the existing 19 villages and 10 percentage points from the 
baseline in the 21 additional villages in Ormanji and Angara blocks.
8
viii. 40 per cent of deliveries are to be attended by trained/skilled persons in the original 19 
villages and increase by 10 percentage points above the baseline in additional 21 villages in 
Ormanji and Angara blocks.
ix. To upgrade the skills of service providers through the provision of technical updates on
contraceptives and infectious diseases and competency-based training on counseling,
infection prevention, IUCD insertion/removal, provision of spacing methods including 
injectables, Minilap and NSV, STD diagnosis and treatment training of trainers, and
HIV/AIDS prevention, counseling and testing.
x. To forge alliances with the State Government, Panchayati Raj institutions, NGOs and the 
corporate sector by making it a mode l private-public partnership project.
xi. To increase the financial sustainability (cost recovery) of the rural hospitals from 50% to 
65% and for the sub-centres from 15% to 35% through increased community contribution, 
management and ownership, introduction of social marketing and piloting a women's
empowerment model of integrating RCH/infectious disease prevention into women's Self￾Help Groups.
The outcome of the project would be measured on the following selected indicators:
· Thirteen sub-centres were to be made operational providing a full range of FP/RCH and
infectious disease services.
· 70 per cent of eligible couples / families were to be visited by a health worker (HW) and or 
village volunteer within the last 3 months.
· 35 per cent CPR for modern contraceptive methods were to be achieved in the original 19 
villages and 5 percentage points above the baseline for the additional 21 villages.
· A wide range of modern contraceptive methods was to be made available including
injectables, OCPs, condoms, IUDs, NSV, minilap, LAM and SDM).
· OCPs, condoms, or ORS were not to go out of stock in the last three months.
· 40 per cent of deliveries were to be attended by a trained/ skilled person in the original 19 
villages and 10 percentage points increase above baseline in the additional 21 villages. 
· 75 per cent of pregnant women were to receive basic antenatal care (3 check-ups, 2 TT, and 
provision of 100 IFA tablets) in the existing 19 villages and 50 per cent in the additional 21 
villages.
· 80 per cent of children of 0-5 years of age were to be fully immunized in the existing 19 
villages and 10 percentage point increase in the additional 21 villages.
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· 75 per cent cases of childhood were to be diarrhea treated with ORS in the existing areas and 
10 percentage points increase in additional 21 villages.
· 65 percent cost was to be recovered in the rural hospitals and 35 per cent in the sub-centres.
The Indian Institute of Health Management Research (IIHMR), Jaipur was assigned to undertake 
end-of-project evaluation to assess the achievements of the project objectives during the
reference period. Specifically, the end-line-evaluation would explore whether better access to 
RCH services had an impact on the utilisation of reproductive health services that included
antenatal care, natal care, postnatal care, family planning services, etc., and cost effectiveness of 
health facilities i.e. sub-centres and rural hospitals. The evaluation was carried out with the 
following specific objectives:
· To review the interventions undertaken during the reference period of the project
· To assess the achievements with regard to the expected results of the project
· To document bottlenecks and success stories of the project
· To recommend corrective measures based on the findings of the evaluation
The End-line evaluation included household survey of eligible women, visit to health facilities, 
interviews with the medical officers, health care providers, opinion leaders, in-depth discussion 
with the project staff and public sector representatives, and focussed group discussions with the 
community. Exit interviews were conducted with the clients in the health facilities. In addition, 
discussions were held with the staff of primary health centre and members of Jharkhand AIDS 
Prevention Consortium (JAPC).
Various instruments, developed by IIHMR and reviewed by CEDPA, were used for evaluation. 
The instruments used were: Schedule for eligible women; Schedule for health workers; Schedule 
for medical officers; Schedule for exit interviews of the beneficiaries; Schedule for village health 
committee members; Checklists for focus group discussions; Checklists for discussions with
Consortium members and Data Sheet for sub-centres and rural hospitals
1.2 Sampling Procedure
Selection of Proportionate Sampling Units (PSU)
The evaluation was carried out in two sets of villages (original/old and additional/new). 
Proportionate to Size (PPS) framework of sampling for selection of villages. There were a total 
of 43 villages (27 new and 16 old). The proportion of new and old villages was 65 and 35 per 
cent respectively. The household survey was conducted in 20 villages including original/old and 
additional/new. A total of 1027 eligible women were interviewed. 
The following steps were taken:
a. To select the villages to be used in the survey, a list of all villages (for each set original 
and additional) with the respective population in the project area was collected.
10
b. A three column table was created, where
Column 1 : Serial number of village
Column 2: Population of each village
Column 3: Cumulative population of each village
c. Sampling interval 
Cumulative total population / number of villages required
A random number, which was equal to or less than the sampling interval, was selected for 
selecting the first village. After selecting the first village whose cumulative population 
exceeds this random number, the next village was selected by adding the sampling interval 
to the first selected village whose cumulative population just exceeds. The process was 
continued until reaching the desired number of villages (13 for new and 7 for old set of 
villages).
Selection of Eligible Women
i) Number of households (HHs) was estimated by asking the health worker/ community
leader of the selected PSU.
ii) The total number of HHs was divided by the desired sample size. (i.e. 50.) to compute the 
sampling interval. The first household was selected randomly using a random numbers.
iii) After selecting the first HH, the next HH was selecting by adding the sampling interval to 
the first HH selected. The process was continued till completion of the desired number of 
eligible women in a PSU.
Besides household survey of eligible women, 43 exit interviews with beneficiaries at the health 
facility, interviews with health workers, in-depth discussions with the project staff and public 
sector representatives, were conducted. All the health facilities funded under the project were 
visited. The project proposal and the results of baseline survey were collected from KGVK and 
used for making comparisons with the outcome of the evaluation.
To make sure that the respondents feel free to give full and correct information without any 
hesitation, female investigators were employed. After selecting the field investigators for the 
proposed study, they were oriented to the project, its methodology, interviewing techniques and 
recording of findings. The investigators were given practical training through the mock filling-up 
of schedules. The evaluation team from IIHMR stayed in the field area and went along with the 
investigators throughout the duration of the fieldwork to ensure the quality of the data collected. 
The field investigators were supervised closely in the field itself. The IIHMR team also did spot 
checking of about 10 per cent of the schedules. 
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1.3 Data Processing
All the information collected from the field was brought to the IIHMR for processing. All the 
schedules were edited once again to check for discrepancies and errors that might have been 
overlooked in the field.
The data entry operation was undertaken in consultation with the staff at the Computer Cell of 
the IIHMR. Checks were introduced at various places to ensure correct entry of the information. 
After data entry, 5 per cent schedules were checked for the quality of data entry. The information 
was processed using Fox Pro and Epi-info version 6 programs.
1.4 Limitations of the Study
· Baseline of the project was a census and the end-line evaluation was based on a sample 
survey. Therefore, the results of the end-line evaluation need to be compared with
caution.
· The duration of the intervention project was too short to make an assessment of change in 
outcomes and some of the key indicators.
 
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Chapter 2
PROJECT IMPLEMENTATION PROCESS
The key tasks in the implementation of the project included development and reactivation of 
the infrastructure, recruitment of the staff and building their capacity in providing reproductive 
health services, developing a monitoring and supervision system and establishing a
management information system, developing a package of services and mechanisms for service 
delivery, creating demand through information, education and communication and social
mobilization activities, and improving access through outreach and social marketing.
2.1 Reactivated Sub-Centres
One of the key objectives of the project was to expand outreach of the reproductive health
services. The project successfully expanded activities from 19 villages covering a population of 
16,124, to 40 villages with a population of 42,391, which meant an increase in coverage by more 
than two and a half times. While six sub-centres were functional before the project, the project 
succeeded in revitalizing seven more sub-centres and made them fully functional. All the
subentries were well equipped with material and equipment. To enhance the access, information 
about the timings of the centre, the day of the doctor’s visit, the name of the health worker, and 
names of the members of the swasthya samiti were displayed at each sub-centre.
Community participation was notable in renovation of the sub-centres. The health workers on 
their own renovated the centres. The material cost was provided by KGVK. Even one of the sub￾centres, was constructed by the health worker himself. This has set a good example of workers' 
commitment and initiative in the project area, which is a critical ingredient in enhancing
community involvement.
2.2 Recruitment of the Project Staff
Availability of health workers at the subcentres is crucial for improving access and availability of 
health services. Each sub-centre under the project had a health worker who was in-station 24 
hours. The health workers recruited for the additional sub-centres of the project were local
residents of the area and had received the six-month training of community health workers 
conducted by KGVK earlier. 
Recruitment of local persons has helped in reactivating the existing health centres and has made 
a significant change in the availability of a health worker at the health facility and provision of 
services all the day and night. It was evidently clear that the local persons had higher
acceptability in the community thus creating greater chances of community involvement in
health-related activities. A medical consultant was hired as a project coor dinator.
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2.3 Skill Upgradation and Capacity Building
The project emphasized improved quality of reproductive health services. In order to achieve its 
goals, a vigorous competency development of all categories of the staff undertaken to upgrade 
technical and interpersonal skills through on-the-job training. The training programmes
conducted under the project were:
Training Imparted under the Project
Name of training Duration of training Objectives
CTU training January 3-5, 2002 To provide the latest knowledge to the doctors 
and other nurses working in the KGVK
Sustainability 
workshop
February 27-28, 2002
and 
May 2, 2002
To develop a common understanding of
sustainability and skills analyzing service and
financial data for decision-making
Injectables 
contraceptives 
training
April 15, 2002 To update the doctors and nurses on injection 
technique 
Infection 
prevention 
training
April 17-18, 2002 To train the KGVK staff on infection prevention 
practices
IUCD training April 29-30, 2002 To make the medical and paramedical staff
competent in IUCD insertion and infection
prevention
RCH Training April 30 - May 4, 
2002
To make the health workers able to understand 
RCH package, components and its importance
Standard Days
Method
May 1, 2002 To update the doctors and health workers about 
the method
MIS training February 7-8, 2002
February 25-26, 2002
June 25-26, 2002
To train the doctors and the health workers in
filling up the daily Diaries and in preparing
monthly reports
TBA training July 16-17, 2002 
October 17-19, 2002
November 25-27, 
2002
December 12-14, 2002
To use the local human resources available for 
best practices in safe motherhood and child
survival 
Self-help group
training
October 23-25, 2002 To orient the SHG members in the RCH and their 
role in promoting health
Social marketing
training
October 29-30, 2002 To make the health workers able to understand 
the concept of social marketing
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The training of medical officers has yielded desired dividends in terms of increased perception 
and awareness of roles and responsibilities, enhancement of requisite skills and commitment to 
the project. 
The medical officers and health workers perceived training as very useful and strengthened their 
capacity to performance the tasks effectively. They felt that the CEDPA supported training
provided them an opportunity to translate information into action that influenced individual
behavior and improved community health. 
These training programmes clarified their concepts, removed their doubts, resolved their 
misconceptions, imparted new knowledge on IUCD and injectables, and finally increased their 
self-esteem.
Health Workers' Knowledge of Family Planning 
The health workers were asked about the natural family planning methods. They explained that LAM is 
postpartum breast-feeding and is successful to some extent if the woman is:
· breast feeding exclusively, 
· amenorrhoeic
· less than six-months post-partum
They were told about Standard Days Method - a fertility awareness-based method that is appropriate for 
women with regular menstrual cycles of between 26 and 32 days long. To prevent pregnancy, the couple 
should avoid unprotected intercourse during the 12-day fertile window. To monitor the cycle length, cycle 
beads and wall clocks were used. Each bead represented a day of the cycle. About one-half of the health 
workers narrated all the steps one by one while the remaining were able to tell all the steps but not step by 
step or in the proper order. All the health workers knew about the use of the condom.
On being asked about the knowledge of OCP When can a woman start using OCP? a majority of the 
health workers knew that it should be started in the first five days of her menstrual cycle whereas the rest 
said that it should be started in the first day of the menstrual cycle. What should a woman do if she misses 
one pill? All the workers gave the correct response: “She should take the forgotten pill as soon she 
remembers.” What should a woman do if she misses two pills? A majority of the workers could respond 
correctly: “She should take two pills the next two days, then continue taking one pill everyday and use 
condoms for seven days.” The rest did not mention the use of condom in addition to oral pills. What should 
be told to a woman having common side effects of pills? A majority of the workers correctly said: “Do not 
worry, these symptoms will not harm you and will disappear in 2-3 months.” Some said that they would tell 
the client to stop the pills and consult the doctor. The rest of them did not respond to this question during 
the interview.
The health workers were asked about the major problems that they faced in rendering services. A majority 
of them spontaneously responded that they did not have any problem in rendering services. About one￾half of the health workers reported that they had problems mainly in dealing with the Swasthaya
committee members. They said that the members did not cooperate with them, especially in conducting 
meetings and finalizing the dates of meetings. Besides, they were reluctant to attend the meetings (bahut 
bulaane par aate hein). 
15
The training also enabled them to develop their technical and communication skills. The
evaluation revealed that all the medical officers knew and practiced GATHER steps while
counselling the client. Similarly the health workers felt more competent and comfortable in
counselling the clients (bolne mein hitchkichahat kum hoti hai, niyamanusar bata sakte hein).
The medical officers were also asked about the use and technical aspects of various
contraceptives (condoms, OCPs– their starting and side effects, IUDs, and injectables) and the 
results revealed that they had correct and complete knowledge about the same. Besides the 
modern methods of family planning, the health workers also talked about natural methods,
namely lactational amenorrhoea method (LAM) and Standard Days Method (SDM). However, 
health workers’ knowledge about advantages, disadvantages and side effects of each family 
planning method needs to be updated regularly. 
The service providers were found to have the requisite knowledge about the preparation of the 
bleach solution, use of the puncture resistant sharp disposal container, and handling hospital 
waste disposal with respect to infection prevention and control.
Training in management information system (MIS) played a major role. It was imparted to the 
health workers to conduct the baseline survey in a better way and to utilize the information 
effectively for further activities in their respective area. Family cards and daily diaries were 
also shown to the health workers, explaining how 
they should fill them. The involvement of the 
health workers in conducting baseline survey
helped the workers to assess the situation on their 
own resulting in high degree of perceptibility and 
ownership. 
One spinoff effect of training was that the
medical officers felt that it has enhanced their 
training competence as trainer. Soon after their 
training, they were able to provide good quality 
training to the staff at different levels. The
medical officers organized TBA training
programmes in KGVK. One of the doctors was 
also invited as a resource person to train TBAs by Swa-Shakti Project, Patna.
2.4 Service Delivery Package
Another important objective of the project was to develop an integrated package of reproductive 
health services and provide it through the health facilities (rural hospitals and sub-centres) under 
KGVK. The rural hospitals in Angara and Ormanjhi were well-equipped and provide d a
comprehensive range of health care that included the following: Outpatient consultation;
Inpatient care; Emergency services; ANC/NC/PNC; Family planning; Social marketing of RCH 
products (pills, condoms, ORS, DDKs, IFA, etc.); Child health services; General medicines; 
Swathaya Samiti (Health Committies)
Each sub-centre had a Swasthaya
Committee whose aims were close
monitoring by the community (33%) and
educating and motivating the community
about health-related issues (33%). Though 
initiatives were undertaken, concrete
achievements in this direction were yet to be 
seen. More efforts are needed to
communicate the broader as well as specific 
objectives to the health workers to “make the 
community feel their ownership which results 
in sustainability”.
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Pathology services; Surgery; Organization of camps; Infertility treatment; Referral services; 
Follow-up services; and Support to KGVK sub-centres.
While rural hospitals were equipped to provide a wide range of clinical and reproductive he alth 
services, a service package for each sub-centre was developed that included: provision of 
antenatal care (checkup, TT immunization, IFA); delivery by trained personnel; postnatal care 
with referrals; family planning counseling, including newly married and postpartum women, and 
provision of a full array of contraceptive methods; social marketing of RCH products (pills, 
condoms, ORS, DDKs, IFA, cycle-beads, clocks, disposable syringes, etc.); immunization
services for children aged 0-5 years; treatment of diarrhea; general medicines; referral services; 
follow-up services; and laboratory services (linked with the rural hospitals).
2.5 Information, Education and Communication (IEC)
The IEC activities mainly included school health camps and health talks, which were held at 
various sub-centres. The main objective of these activities was to sensitize the community about 
reproductive and child health (RCH) related issues, including RTIs/STIs/HIV/AIDS. Other than 
health talks and camps, street plays were also performed in some of the villages and centres. 
Each health centre displayed posters and pamphlets related to ANC, diarrhea, anaemia, safe 
delivery, malaria, TB and HIV/AIDS to make the community aware. A list of essential drugs was 
also displayed at some of the centres. The IEC activities and interventions undertaken facilitated 
the people to understand the messages related to RCH.
2.6 Networking and Logistics Management
 
It was envisaged that the project would create strong linkages with the government, locally 
elected leaders, and local service providers to facilitate sustainability aspects. The KGVK
strengthened its linkages with the public sector to provide services to the community. The 
KGVK procured vaccines from the primary health centres in the block. 
A Swasthya Samiti (Health Committee) was set up to assist the health workers in creating a 
demand for services and social marketing. Each Samiti had 11 members including Traditional 
Birth Attendants, Angan Wadi worker, helper at Anganwadi Centre, and Auxiliary Nurse Mid￾wife. Under the Swasthaya Samiti, a Nigrani Samiti was established to keep an eye on the centre 
and its functioning. Guidelines were also developed for the health committee members
prescribing monthly meetings (fortnightly meetings in case of epidemics), documentation of the 
proceedings, the presence of at least one member from each village covered by the centre, 
women representation, etc. 
17
2.7 Supervision and Monitoring
A system of supervision was established under the project. The doctors visited the health
centres weekly. During the visit, the doctors accomplished their tasks by helping the health 
workers to develop task-related competencies and the capability to face problems effectively. 
Besides, the health workers also used to come to their respective rural hospital, which were 
Rukka hospital in Ormanjhi block and Narain Soso hospital in Angara block) for weekly
meetings, which gave the doctors another opportunity to know their performance and progress 
made during the week. Sometimes home visits were made. The doctors tried to know the 
perceptions of the community by talking to the Swasthaya Samiti members and the community. 
These meetings were utilized in various ways, for example, to deposit the amount of social 
marketing and to share/discuss the progress made and problems faced. The doctors provided 
possible options as solution to their problems and the health workers decided for them. It is 
worth mentioning that it was compulsory to attend the meetings. If anyone was not able to 
come to the respective hospital, s/he was supposed to inform the hospital in advance. The risk 
involved was that s/he would be considered absent throughout the week. Besides, the chief 
medical officer made surprise visits.
During their weekly visits to the sub-centres, the doctors monitored the centre's as well as the 
workers' activities. Monitoring was done through a system of collecting information about 
quantitative and qualitative performance. 
An effective tool for supervision and monitoring used was the development of activity plans by 
using three columns: activity, to be conducted/ performed by whom, and when (with date). 
Though there is no empirical evidence for this observation, however, they reflected during
interaction with them that this tool has really empowered them.
2.8 Management Information System
There was a centre-based and a field-based management information system. CEDPA had
developed an elaborate MIS format including "family card" and "daily diary", which were used 
by the project staff for field visits. Field workers were provided with printed books of “pariwar 
card” and “daily diary” which provided information on clients and visits to them. 
Various formats were developed for centre-based information system and used to maintain 
information on income and expenditure, services delivery, stock of medicines, procurement of 
equipment and medicines. The centre-based MIS included:
· OPD register (doctor’s visit and daily OPD)
· ANC register
· Immunization register
· Social marketing register
· Swasthaya Samiti register
· PNC register
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· Stock
o Medicines
o Accounts (of money to be collected from those who have yet not paid)
· Accounts (of money deposited in the hospital)
On a monthly basis, the doctors collected and compiled the data obtained from the weekly 
reports from the sub-centres and developed a monthly report of the progress made. The quality 
of record keeping at the health-centres was emphasized.
19
2.9 Social Marketing
To improve demand for family planning in the project area, the health workers introduced the 
sale of condoms (Deluxe Nirodh and Mithun), oral pills (Mala-D and Apsara), disposable 
delivery kit (DDK), disposable syringes, ORS packets, IFA tablets etc through social
marketing. This was in addition to the government supplies. To promote Standard Days
Method (SDM), cycle beads and clocks were also made available. Depo-Provera could also be 
obtained only in consultation with the doctor. 
2.10 Sustainability/Cost Recovery
One of the most important components of this project was the sustainability through enabling the 
community to take active part in the management of the local services. The KGVK had already 
initiated the process of sustainability in their overall health services area. Revenue was
generated/ recovered mainly by charging fees for medical consultation, pathology testing, X￾rays, deliveries, and surgery. The following charges were decided for various services:
S No. Rural Hospital Sub-centre
Services Charges (Rs.) Services Charges
1 Outdoor consultancy/ 
registration
10.00 Outdoor consultancy/ 
registration
10.00
2 Indoor (Observation + stay) 25.00 NA
3 Emergency services 25.00 NA
4 Hydrocele operation 300.00 NA
5 Tubectomy 0.00 NA
6 Vasectomy 0.00 NA
7 IUD insertion 0.00 NA
Investigations
8 Blood- Hb%, TLC, DLC ESR 20.00
9 Blood- PS for malaria, type of 
anaemia
20.00
10 Blood- BT/CT 20.00
11 Blood- Grouping Rh. & Cross 
matching
20.00
12 Urine-Routine (Sugar and 
Albumin) and microscopic
20.00
The pathology services were available at the 
hospital only. The health workers collected the 
blood/ urine/ sputum samples at the sub-centre and 
sent them to the respective hospital.
13 Urine– Bile salts and bile 
pigment
20.00
14 Stool- Parasites (Ova and 
Cyst) and Occult Blood
20.00
15 Stool- Hanging drop (V 
Cholera)
20.00
16 Sputum-AFB 0.00
17 Blood-VDRL 30.00
18 Pregnancy test 50.00
19 Social marketing of 
contraceptives
Selling of contraceptives
20
Deluxe Nirodh Rs. 4.40/packet Deluxe Nirodh Rs. 4.40/packet
Mithun Rs. 5.00/ packet Mithun Rs. 5.00/ packet
Mala-D Rs. 2.00/ 
cycle
Mala-D Rs. 2.00/ cycle
Apsara Rs. 3.20/ 
cycle
Apsara Rs. 3.20/ cycle
20 Cycle Beads for SDM Rs. 45.00 Cycle Beads for SDM Rs. 45.00
21 Depo-Provera Rs. 30.00/inj. Depo-Provera Rs. 30.00/inj.
22 DDK Rs. 15.00/ pc. DDK Rs. 15.00/ pc.
23 Distribution of ORS packets 1.50 for small
10.00 for big
Distribution of ORS 
packets
1.50 for small
10.00 for big
24 IFA tablets 1.00 / tablet IFA tablets 1.00 / tablet
25 Disposable syringes Rs. 5.00/piece Disposable syringes Rs. 5.00/piece
26 Health card (family card) 30.00 Health card (family card) 30.00
A family card system was established by the KGVK. If a family was registered through this card 
(costing rupees 30/-) at the centre, it could avail itself of the health facility (health centre and 
rural hospital) on a concession basis for a three -month period. Again, they might renew the card 
by paying the same amount of Rs. 30/-.
The Swasthaya Samiti had a provision to have 50 per cent of the registration fee, which comes to 
five rupees. Similarly, the family card charges (Rupees 30/-) would go to the Samiti. The purpose 
was to strengthen the Samiti financially so that the committee could spend money on activities 
related to health like maintenance of the sub-centres, arrangement of meetings/talks,
transportation arrangements, etc.
2.11 Consortium of Industries and NGOs for the Prevention of HIV/AIDS in
Jharkhand
First meeting of the Jharkhand AIDS Prevention Consortium (JAPC) was held in Ranchi, in
August 2002, Approximately 40 participants from industry, NGOs and Government participated 
in the first meeting in which resolution to establish a consortium was passed. Mission of 
consortium has been to work together to maximize all available resources and empower people 
in order to reach out to all members of the society to make Jharkhand AIDS-free.
The purpose of this consortium is to bring together committed individuals, communities and
organizations to achieve the common goal of preventing HIV/AIDS by sharing expertise, 
experience, assets and best practices in order to achieve following objectives:
· To increase availability of counseling and testing services;
· To increase the geographical and population coverage of HIV/AIDS prevention activities;
· To mobilize communities throughout Jharkhand for the prevention of HIV/AIDS;
· To promote proper use of and increase access to condoms;
· To build capacity of non-governmental organizations, industries, opinion leaders, health 
care providers for the replication of best practices in the prevention of HIV/AIDS;
21
· To conduct research, collect and disseminate information on HIV/AIDS in Jharkhand;
· To advocate for the implementation of effective HIV/AIDS prevention strategies and for 
programme changes outlined in the National AIDS Control Organisation HIV/AIDS
policy; and
· To share and develop Information Education and Communication material that contains a 
jointly agreed set of technical messages and is appropriate to local cultures, values and 
languages and is disseminated as per local need.
Since its formation in August 2002, JAPC has had several governing body meetings in which, 
besides finalising the name of the consortium, it was decided to have four Regional Co￾ordination Centres (RCC). JAPC has been very active since its formation and has initiated
membership drive and opened a bank account; it is planning to issue a newsletter. State AIDS 
Control Society (SACS) too have been actively involved in the consortium and the Director of 
SACS is the President of the JAPC. 
The IEC materials developed by the RCCs at Bokaro, Jamshedpur and Ranchi have been
collected centrally for redesigning, printing and further actions. The RCCs are making all efforts 
to recruit as many members as possible in the society. 
Under the auspices of JAPC, KABP survey on Male Reproductive and Sexual Health including 
HIV/AIDS was conducted in the three cities of Ranchi, Bokaro and Jamshedpur with the help of 
three RCGs and ORG-MARG with technical assistance provided by CEDPA. Questions were 
also asked on services desired by truckers and helpers and their willingness to pay for the 
services if Male Clinics were initiated at these sites. Based on the finding plan is to pilot Male 
clinics at three sites in Jharkhand.
 2.12 Baseline Survey
The KGVK project staff and the health workers carried out a baseline survey to establish the 
baseline indicators on which the progress was measured. The baseline covered two blocks 40 
villages in the Ormanjhi and Angara blocks and 20 villages surrounding Usha Martin Groups of
Industries in Namkum block of Ranchi district. The survey covered the population of both the 
original/old and additional/new sub-centres. The major purpose of baseline survey was to assess 
the situation of key reproductive health indicators and establish benchmarks for various
indicators aimed at strengthening reproductive health services. The survey was conducted during 
March – April 2002. It included information about family members, contraceptive users, women 
who had delivered in the last 12 months, antenatal, natal and postnatal care services received, 
and immunization status of children. 
The key finding of the baseline survey was that 45.1 percent eligible couples were using
modern contraceptive methods in the project area. Among the contraceptive methods, female 
sterilization was the dominant method (38.0 percent). More than half (54.4%) of the pregnant 
women received antenatal care. It was lower in the newly expanded area of the project. The 
average coverage with two doses of TT was fairly high, i.e. 75 percent. However, the coverage 
22
with TT2 was much higher in the old existing project villages. Nearly half the pregnant women 
(46.3 percent) had received iron folic acid tablets. The survey further revealed that 47.5 percent 
children (12-23 months) had received full immunization in the project area. The baseline status 
of various reproductive health indicators is shown in Table 2.1. 
Table 2.1: Base-line Survey Results
Indicators Old Sub-centres New Sub-centres
Anga Orma Comb Anga Orma Comb
Combined
Total population 5,524 10,600 16,124 1,799 8,275 26,267 42,391
Eligible couples 1,010 1,736 2,746 3,184 1,536 4,722 7,468
Contraceptive Prevalence Rate 
(CPR) – any method
36.9 50.1 45.2 49.1 42.7 47.0 46.4
CPR (modern methods only) 36.5 50.0 44.9 48.1 39.3 45.2 45.1
Family planning method users
Condoms 2.4 4.5 3.7 2.5 1.6 2.2 2.8
Oral pills 1.8 4.5 3.0 4.3 1.9 3.5 3.3
IUDs 0.4 0.4 0.4 1.3 1.4 1.3 1.9
Sterilization (Total) 31.9 41.0 37.7 40.0 34.5 38.2 38.0
Vasectomy 0.6 0.5 0.5 0.9 0.3 0.7 0.7
Tubectomy 31.4 40.5 37.1 39.0 34.2 37.4 37.3
Natural 0.4 0.4 0.4 1.0 3.3 1.8 1.3
Women who had delivered a child 
during the last 12 months
12.4 17.3 15.5 14.9 17.1 15.6 15.6
Received ANC
3 Check-ups 49.6 79.0 70.3 48.2 39.9 45.2 54.4
2 TT 84.8 87.7 86.8 75.8 55.9 68.7 75.3
100 IFA 36.8 75.3 64.0 38.1 32.7 36.2 46.3
Delivery by trained personnel 26.4 82.7 66.1 64.2 36.1 54.2 58.5
Children (12 -23 months) Fully
immunized
23.5 60.4 51.0 54.7 19.3 45.5 47.5
2.13 Feasibility Study
A feasibility study was conducted by TNS MODE Private Limited at the request of KGVK with 
technical support from CEDPA. The purpose was to explore the current health expenditure of the 
households, source of utilization of health services and willingness of household to pay for 
specific services. Data were collected on desired services and health products, community
willingness to pay for medicines and services, preferred brands, and hours of services desired. 
Besides collecting information from 405 families, ANMs, TBAs, KGVK workers, private health 
service providers, chemists and members of village health committee were interviewed. A cost 
pricing analysis on the existing services and RCH products was also conducted.
Salient findings were that knowledge of KGVK health facility in the community was good, but 
there was tremendous scope to involve the health committee. Majority of families had shown 
willingness to have comprehensive health insurance for both OPD services with investigations 
and indoor services for the entire family. Families were also willing to pay for the package of 
23
ANC along with delivery services if they were at reasonable and affordable cost. Non￾availability of doctors at KGVK hospitals round the clock was a deterrent for not delivering at 
these facilities. One of the recommendations was also to develop a referral network with private 
health service providers. 
Based on the recommendations, KGVK has developed linkages with Saren Laboratory in Ranchi 
for conducting various investigations, which were earlier not done in their laboratory. Samples 
are collected at the hospitals and health centres, sent to the laboratory and clients collect the 
report from the collection sites. This has resulted in client satisfaction along with increased
revenue for KGVK. Based on feasibility study, KGVK has also introduced package of ANC, 
deliver and PNC services, which again is proving successful. 
24
Chapter 3
REPRODUCTIVE HEALTH AND FAMILY PLANNING SERVICES
In this section, the findings of the end-line evaluation (eligible women survey) are presented on 
accessibility and availability of services; utilization of services; antenatal, natal and postnatal 
care; family planning practices; reproductive tract infection; sexually transmitted infections; 
HIV/AIDS, etc. The findings are presented separately for additional (new) and the original (old) 
villages and the combined analysis of both areas.
The eligible women were the key respondents. The evaluation covered 1027 eligible women. 
Figure 3.1 shows the age-wise distribution of the respondents. 
Fig 3.1: Age-wise distribution of respondents
26.4
23.1
16.9
8.2
2.4
13.5
21.7
22.5
13.8
3.5
12.6
10.3
22.8
2.2
up to 19
20-24
25-29
30-34
35-39
40-44
>44
Type of village
Age in years
Old
New
3.1 Awareness and Utilization of Services
The project was already functional in the old set of villages and quickly established itself in the 
newly added villages. The IEC activities, a major component in the project, had evidently
influenced awareness and knowledge of the households. A huge majority of women, 79 percent, 
were aware of the project and the activities. Most of them had learned about it from the relatives 
and friends, in addition to the project staff. However, knowledge about the services varied. A 
majority of them (77%) knew the project health worker and 79 per cent could identify the project 
health worker either by his/her name or her husband’s name or the place where s/he resided. 
About one-half of them (48%) had met the project staff at the sub-centre, while 40 per cent met 
them during their home visit. 
The utilization of services had significantly increased. However, the type of services utilized 
varied. Of the women who visited the centre, as many as 92 percent had utilized the services, 
with nearly one-half availing of general health and immunization services. The remaining
women did not visit the centre intentionally as they had no need. The centre was situated close to 
their residence and they usually visited the centre when their schedule permitted, sometimes to 
have a casual conversation with the service provider. Similarly, during the home visit and/or 
Anganwadi centre, etc. in the village other than the sub-centre, 84 per cent had utilized the 
25
services, with 48 per cent availing of immunization, followed by general health services, such as 
providing medicines (42%). Services rendered at home included treating injuries from accidents, 
treating high fever (emergency), providing IFA (ANC), and collecting blood sample (laboratory). 
Fig. 3.2 shows the service utilisation.
Fig 3.2: Utilisation of services during last three months by place of availing
51
4.5
4.5
4.5
48.1
17
5.9
8.1
3
39.5
13.4
5.7
5.1
3.2
1.3
1.3
42.2
5.2
5.9
4.4
2.2
1.5
0 10 20 30 40 50 60
General health services
 Immunization services
 Natal care
PNC services
 Family Planning counselling
 Family Planning services
ANC services
Emergency services
Laboratory services
ORS distribution 
Others
Services
from health worker
from centre
3.2 Performance Indicators
The project had identified key project related performance indicators to be achieved by the end 
of the project. The end-line evaluation considered the baseline survey findings to assess the 
performance and achievement of objectives. Table 3.1 below provides comparison of baseline 
indicators related to ante-natal and natal care of women who had delivered child during the last 
12 months and immunization status of children aged 12-23 months with the end of project 
indicators.
26
Table 3.1: A comparison of baseline and end-line project-related indicators
New Sub￾centres
Old Sub￾centres
Total
Base End-line Base End￾line
Base End￾line
Women who had delivered a child during the last 12
months
15.6 14.9 15.5 17.9 15.6 16.0
Received ANC
Check-ups 45.2 65.3 70.3 63.6 54.4 64.6
2 TT 68.7 72.4 86.8 78.8 75.3 75.0
100 IFA 36.2 56.1 64.0 59.1 46.3 57.3
Delivery by trained personnel 54.2 43.8 66.1 50.0 58.5 46.3
Fully immunized Children (12-23 months) 45.5 77.7 51.0 81.4 47.5 78.8
3.3. Antenatal Care
Among the eligible women, 164 (16%) delivered a child during the project period. Overall 64.6 
percent of them availed of antenatal care as against 54.4 percent at the beginning of the project, 
with a clear increase of 10 percentage points. However, in the base-line survey in the original 
(old) villages it was 70.3 percent, and in the new villages, it was found to be 45 percent. Thus, in 
the new villages the change was 20 percentage points.
Similarly, the performance regarding TT2 immunisation was maintained at a high level as was 
reported in the baseline survey. The end-line survey reported a coverage of 75 percent with TT2, 
which was much higher than reported in RCH surveys in the state. The project has maintained a 
high performance despite increase in the population and number of villages under the project. 
Coverage with iron folic acid tablets as prophylaxis against anaemia also showed about 10
percent point increase at the end of the project. As many as 67 percent received iron folic acid 
tablets during pregnancy against 46 percent at the beginning of the project. However, the
differentials between the old and new villages existed.
It is worth recording that the proportion of deliveries conducted by the trained personnel was 
reduced from 58.5 percent to 46.3 percent, a reduction of about 12 percent points. However, the 
absolute number delivered by trained personnel has shown a significant increase. The proportion 
mainly declined due to increased denominator due to expansion of population under the project. 
 
27
3.4 Natal Care
The proportion of institutional deliveries was low. More than three-fourths of the deliveries had 
been conducted at home. Of these, one-third (32%) had been conducted by trained persons. 
About 30 per cent women reported that Disposable Delivery Kit was used during the delivery. 
The result shows that the use of DDK was higher in the new set of villages.
According to the NFHS-II, nearly 81 per cent of deliveries took place at home in Ranchi 
district; three-fourths of them were performed by untrained persons. 
3.5 Child Immunization
The vaccination of children against six serious but preventable diseases (tuberculosis, diphtheria, 
pertusis, tetanus, poliomyelitis, and measles) has been the cornerstone of the child health care. 
Immunization was the key component of the reproductive health services in the project. 
For the purpose of immunization coverage evaluation, the age group 12-23 months was
considered. The project registered a spectacular performance. In all, 78.5 percent children were 
fully immunized (BCG, DPT 3 doses, OPV 3 doses and measles) against the desired output of 80 
percent. The immunization status of children was better in the old set of villages than in the new 
ones (Table 3.2). 
Table 3.2: Percentage of Children (12-23 Months) Who Received Complete Immunization
New Old Overall
Age 
Desired 
Output (%) Sample
size
Fully 
Immunized
Sample
size
Fully 
Immunized
Sample
size
Fully 
Immunized
12-23 months 80 103 77.7 43 81.4 146 78.8 
12-60 months 80 488 81.8 239 82.4 727 82.0
3.6 Management of Diarrhea
All the mothers having children under five years were asked whether their children had suffered 
from diarrhoea during the reference period and during two weeks prior to the survey. The
operational definition given for diarrhoea was “one or more loose watery stool in large amount 
within 24 hours1
”. About 13 percent women reported episodes of diarrhea among their children 
during15 days preceding the date of data collection. However, the use of ORS was low. Only 
one-third of the women reported the use of ORS during diarrhea. Of those who used ORS, about 
70 percent obtained it from the sub-centre or the project health workers. Keeping in view the 
general trends in use of ORS in the region, its use the project area was fairly satisfactory.
 
1
 Singh et.al. ((2002) End line Evaluation of Ninth India Population Project: Rasjathn. Indian Institute of Health Management 
Research (IIHMR), Jaipur
28
Table 3.3: Prevalence of diarrhea and ORS distribution 
Diarrhea and Use of ORS Total 
Percentage of children suffered from diarrhea during last 15 days (n=896) 12.8
Percentage of children given ORS (n=115) 32.2 
3.7 Knowledge of Family Planning Methods
Knowledge of contraceptive methods was nearly universal in the project area, with 98 per cent of 
currently married women knowing at least one method of contraception in both old and new 
areas. Female sterilization was the most widely known method of contraception, followed by 
male sterilization. The oral pill was the most widely known spacing method (83 per cent), 
followed by IUD (69 per cent) and condoms (63 percent) as shown in Figure 3.3. 
It was a major effort in the project to raise the knowledge of women regarding contraceptives, 
especially the spacing methods. The project has made serious efforts to raise the awareness 
regarding spacing methods and making them available.
 
64
73.4
82.2 84.3
67.5
72.4
83 83.7
92.4
93.5
19 21.4
28.4
26
21
21.4
2.7 1.4
0
10
20
30
40
50
60
70
80
90
100
Percentage
Condom Oral pill IUD Vasectomy Tubectomy Injectables Standard
Days
Method*
LAM Others
(withdrawal,
desi dawai)
Method
Fig 3.3: Knowledge on Family Planning methods
New Old
29
3.8 Current Use of Family Planning Methods
Raising the contraceptive prevalence rate (CPR) was an important objective of the project. It 
aimed to reach 35 per cent CPR for modern contraceptive methods in the original 19 villages and 
5 percentage points above the baseline for the additional 21 villages through expanded informed 
choice and improved quality of care and counseling. The current contraceptive use was defined 
as contraceptive use during the 30 days preceding the date of data collection. 
The Project has achieved an increase in CPR by 6.5 percentage points within the project period. 
In additional set of villages it was found to be 5.3 percentage points while in original villages, it 
was 8.7 for modern methods only. The data show that current CPR for any method was 44.5 with 
an increase of 9.7 points.
In the project area, as is the case of Jharkhand and other states, voluntary sterilization dominated 
the contraceptive method-mix. 34.3 percent of currently married women were sterilized, and
female sterilization accounted for 83.6 per cent of the total current contraceptive prevalence. 
Only 6 percent of the currently married women used spacing methods (Table 3.5). By chance, no 
standard days method user was found during the survey. During the focus group discussions, it 
was found that a few women use the method.
Table 3.4: Percent distribution of eligible couples by use of any modern method of 
contraception
 
Family Planning Method Contraceptive use as per IIHMR Survey 2003
At the time of initiation of the project 
(before 10 months)
At the time of Evaluation
New Old Total New Old Total
Condom 0.7 0.8 0.8 1.5 2.4 1.8 
Oral Pill 1.4 1.3 1.4 2.9 4.1 3.3 
IUD 0.4 0.8 0.6 0.9 1.3 1.1 
Vasectomy 0.4 0.3 0.4 0.4 0.3 0.4 
Tubectomy 32.1 29.8 31.1 34.6 33.6 34.3 
Injectables 0 0.3 0.1 0.0 0.3 0.1 
Total number of users 231 123 354 266 155 421
Total Eligible Couple 658 369 1027 658 369 1027
CPR (Modern method 
only)
35.1 33.3 34.5 40.4 42.0 41.0
30
Quality of Care for Family Planning Services
During the reference period, most of the oral pill users (65%) were screened or checked before 
using the pills. As many as 35 percent of the OCP users received follow up services and 10 
percent of them were helped by the project staff. 
Among the women who opted for sterilization, 55 percent underwent screening/ check-up and 
received follow up (FUP) services. For follow up services, the project staff helped 19 percent 
women.
3.9 Reproductive Health Problems
About three-fourths of the women had heard about RTIs (andruni / parda/ gupt rog). More than 
half of the women (56%) had received such information from their friends and relatives. About 
one-third of the women knew that it is caused due to lack of personal hygiene. Most of them did 
not know or had misconceptions about the cause. More than 70 per cent women knew about the 
symptoms. An overwhelming major ity of women (>90%) knew about boils, ulcer, itching,
burning sensation during urination and white discharge. A majority of the women (75%) knew 
that RTIs were curable. 
The results revealed that as many as 39 percent respondents had heard about sexually transmitted 
infections (Yaun sankramit rog). The symptoms identified were: burning sensation during
urination (90%), white discharge (87%), itching (86%), and boils (85%). Most of the women 
(63%) knew that treatment is available and STIs are curable.
Although the spread of HIV/AIDS was a major concern of the agency, nearly 7 out of 10 women 
in the area had not heard of AIDS, compared with 85 percent for Jharkhand as a whole. Among 
women who had heard of AIDS, 67 percent received information about the disease from
television and 37 percent from friends and relatives. About 35 percent of the women did not 
know any mode of HIV/AIDS transmission. About 7-14 percent women believed in some myths 
about its mode of transmission. Among women who had heard of AIDS, 38 percent did not know 
of any way to avoid infection. Among the women who had heard about the same, 37 percent had 
the impression that treatment of HIV/AIDS was possible or AIDS was curable.
The prevalence of reproductive health problems among the women was estimated from the 
women’s self-reported experience with each of the problems. However, since information on 
reproductive health problems was based on self-reports rather than clinical tests or examinations, 
the results should be interpreted with caution. 
Among RTI symptoms, white discharge (6%) was most common. Other symptoms, such as 
genital ulcer/ boils, micturation, itching, and lower abdominal pain were reported by 3-4 percent 
women. As many as 33-69 per cent of the women who had suffered from any symptom had 
sought treatment. Most of the women approached a government or a private doctor.
31
Table 3.5: Self-reported symptoms of RTIs/STIs among respondents and by source of 
treatment sought by them
Total (n=741)* 
Symptoms % 
Suffered
% Sought
treatment
Sources
Project staff Govt. Doctor Pvt. Doctor Others
White discharge 6.3 57.4 3.7 14.8 40.7 40.7
Micturation 3.8 35.7 0 40.0 40.0 20.0
Itching in genital area 3.0 45.4 20.0 20.0 30.0 30.0
Genital ulcer/boils 3.5 46.1 16.7 16.7 25.0 41.7
Lower abdominal pain 3.5 34.6 0 11.1 66.7 22.2
Abnormal discharge from
penis
0.8 50.0 0 66.7 33.3 0
Intercourse related pain 1.1 37.5 0 33.3 66.7 0
*Those who have heard of RTI 
3.10 Exposure to Information, Education and Communication (IEC) Activities
All the women who responded to the end line survey were asked about their exposure to IEC 
activities conducted under the project. The results revealed that as many as 39 per cent of women 
were aware of such activities. Of these, 91 percent wome n had attended group meetings in their 
village/ area. The contents of the discussions in the meetings were family planning (51 percent), 
followed by immunization (30 percent). 
More than one-half of the women reported that Self-Help Groups (SHGs) were formed in their 
villages and that they were members of these groups. However, the SHGs were not formed under 
the project. The project staff did utilize the opportunity for participating in the monthly meetings 
of SHGs. About 42 per cent women observed that the project brought some improvement in their 
area. 
32
Health Committee Members/ Opinion Leaders
A total of 20 members including the Swasthaya Samiti members and the Anaganwadi 
workers were interviewed. An overwhelming majority of them (90%) were men in the age 
bracket of 20-30 years (70%), and Hindus (95%) belonging to other backward castes or 
scheduled castes / tribes. Their main occupation was agriculture. The main health
problems in the area were malaria and diarrhoea. Most of them reported that they were 
consulted about the project.
These members or leaders knew about the services available at the centre, such as 
distribution of general medicines (dawa dete hein); immunization (65%); safe motherhood 
(55%); family planning (55%); health education (35%); doctor’s visits, services related to 
child health; counselling; and selling of ORS. When asked how they had come to know 
about them, the responses were: from the health worker, in community meetings, at the 
centre, during the doctor’s visits, and from AWWs. They were also asked whether the 
community was actively participating in the intervention. About 50 per cent of them 
reported in the affirmative. The positive responses were supported by some details, e.g. 
the community members attended meetings, they extended information to others and 
provided/ arranged transportation. The negative responses included restricted availability 
of medicines (since the worker was not allowed to prescribe drugs excepting paracetamol, 
etc.); shortage of health service providers, lack of trust in the providers, etc. When asked 
whether the samiti meetings were useful, the members said that they were useful for new 
knowledge and information, performance evaluation, better coordination, understanding of 
both client and provider perspectives. To make the health samiti more effective, they 
suggested the following measures: creating awareness, availability of medicines at the 
centre, increasing the number of staff, regular visits of the doctor with a longer stay (at the 
time of the doctor’s visit, women used to be in the field), etc. Besides, they played an active 
role by supervising the centre activities, sharing information with others, motivating the 
couples, problem solving, etc. Most of them perceived the project as a successful
intervention for various reasons, for example, they did not have to go outside, doctor’s 
availability, cost effectiveness (yahan das mein hota hai dusri jagah pachas lagenge), 
immunization of children, facility available at the doorstep, and referral. Again when they 
were asked how these benefits would be sustained with not so intensive involvement of the 
KGVK, they observed that the community people had good intentions to sustain but were 
not able to identify the measures for it.
33
Medical Officers' Perspectives
When asked the medical officers about their satisfaction with the project’s achievements,
their response was in the affirmative. They justified their response mentioning regular 
visits of the doctors to the centres and the hospitals, training inputs from CEDPA, 
increased ANC and immunization coverage.
Enabling the expansion and sustainability of integrated RCH/infectious diseases outreach 
services through skill upgradation, capacity building, and women's empowerment in 
Ranchi, Jharkhand.”
They also made the following suggestions: 
ÿ The project staff should be imparted management training.
ÿ More efforts on the part of the project staff towards social marketing were needed.
ÿ Performance based honorarium to the health workers should be introduced.
ÿ The project staff should make more efforts to ensure the involvement of the 
Swasthaya Samiti and the community.
34
Chapter 4
COST RECOVERY 
Sustainability of the project activities and services was an important consideration. It envisaged 
cost recovery as a key approach, in addition to other issues such as capacity development,
community ownership and continued support from the existing health system. The project aimed 
at 65 percent cost recovery in the rural hospitals and 35 percent in the sub-centres. The health 
services were available by paying nominal/ subsidized user charges
To increase the motivation level of the health workers, some performance-based reward criteria 
were introduced. Therefore, for most of the services and contraceptive social marketing, the 
worker had a share in the income. To sustain the activities, part of registration fee went to the 
swasthaya samiti. The norms were prescribed for the share of the health workers and cost 
transfer to the samiti.
4.1 Cost Recovered by the Sub-Centres
The cost recovery analysis was done only for 12 sub-centres. The expenditures incurred by a 
sub-centre included only the variable cost i.e. consumables, and human resources i.e. health
workers' salary.
Cost recovery was measured as a ratio of expenditure to income. The overall cost recovery, 
being 31.3 percent, was close to the targeted 35 percent. Five sub-centres (Baridih, Gagari, 
Mayapur, Masu and Gandhigram) recovered the cost even more than 40 percent. The other two 
sub-centres closely reached the targe t. However, there were some sub-centres that could not 
perform well (Fig. 4.1). 
Cost recovered by Sub-centres
43.4
28.1
31.7
11.2 9.9
46.9
21.6
52.6
61.6
15.6
50.7
32.7
0
10
20
30
40
50
60
70
 Baridih
Bartoli
Tundahali
Similia
Turup, hesal
Gagari
Hindibelli
Mayapur
Gandhigram
Hundru
Masu
Salhan
Sub-centres
Cost recovery ratio
 Baridih
Bartoli
Tundahali
Similia
Turup, hesal
Gagari
Hindibelli
Mayapur
Gandhigram
Hundru
Masu
Salhan
Fig: 4.1
35
A comparative analysis of the original and the new sub-centres revealed that the new sub-centre 
were able to recover 35.9 per cent cost whereas the original sub-centres could recover only 9.9 
percent cost. 
A comparison between the cost recovery of the sub-centres of two blocks was made. The results 
revealed that the centres of Ormanjhi block did better (36.7 percent) than the Angara block (27.6 
percent).
The average per patient cost recovery was 31.0 percent. However, further analysis revealed a 
wide variation among the sub-centres. The cost recovery was as high as 61.7 percent at 
Gandhigram and as low as 15.6 percent at Hundru. 
4.2 Cost Recovered by the Rural Hospitals
The cost analysis was done for each hospital taking into consideration the cost of transportation, 
equipment, consumables, human resources, training and documentation. 
The rural hospitals could not recover the cost as targeted (65 percent). On an average the cost 
recovery was 47.6 percent, thus leaving a gap of 17.4 percent points. The cost recovery was 50.4 
percent in Narayan Soso hospital and 45.3 percent in Rukka hospital.
However, if the cost of human resources is taken out from the analysis, the cost recovery as high 
as 97.1 percent in Narayan Soso hospital and 89.1 percent in Rukka hospital. Thus, by and large, 
the hospitals have been able to recover the cost as per the objective of 65 percent. 
Per patient expenditure was Rs 244.1 in the rural hospitals. The analysis shows that Rs. 116.2/-
was recovered against the recoverable cost of Rs. 158.7 per patient. The cost recovery per patient 
was better at Narayan Soso hospital than Rukka hospital.
Table 4.1: Analysis of expenditure incurred and income per patient at KGVK rural 
hospitals (April 2002-January 2003)
Total number
of OPD
registered 
cases
Expenses 
incurred per
patient (Rs.)
Desired Outcome
(Amount @ 65% of per 
patient expenses in
rupees)
Actual Outcome (Income 
per patient in rupees)
Rukka Hospital 2529 332.40 216.06 150.60
Cost recovery ratio 69.7
N Soso Hospital 3713 183.90 119.55 92.8
Cost recovery ratio 77.6
Total 6242 244.1 158.7 116.2
Cost recovery ratio 73.2
36
Table 4.2: Cost recovery analysis of rural hospitals (April 2002-January 2003)
Ormanjhi (Rukka Hospital) Angara (Narayan Soso) Total
Expenses Income Expenses Income Expenses Income
Transport 110,000.00 Registration 
OPD
16,370.0 Transport 110,000.00 Registration 
OPD
16,320.0 Transport 220,000.00
Equipment 99,670.00 Registration 
IPD
21,622.0 Equipment 99,670.00 Registration 
IPD
5,252.0 Equipment 199,340.00
Consumables 92,612.62 General 
Ward
5,375.0 Consumables 27,027.22 Operation 7,750.0 Consumables 119,639.84
Human 
resource (MO/ 
doctors)
213,450.00 Drugs and 
Medicines
82,736.1 Human resource 
(MO/ doctors)
188,270.00 Drugs and 
Medicines
117,594.0 Human 
resource (MO/ 
doctors)
401,720.00
Human 
resource 
(paramedical 
and other 
staff)
200,040.00 Diagnostic 
tests
28,384.0 Human resource 
(paramedical 
and other staff)
139,990.00 Diagnostic 
tests
54,805.0 Human 
resource 
(paramedical 
and other 
staff)
340,030.00
Overheads 117,604.76 Social 
Marketing
3,573.5 Overheads 110,554.00 Social 
Marketing 
and 
Others
68,160.0 Overheads 228,158.76
Training 5,800.00 Training 1,44,000.0 Training 5,800.00 Training 70,000.0 Training 11,600.00
Others 78,810.0
Documentatio
n
1586.00 Documentation 1586.00 Documentatio
n
3,172.00
Total 840763.38 236,870.6 Total 682,897.22 Total 274,484.00 Total 1,523,660.60 7,25,354.6
Cost recovery 
ratio
45.3 Cost recovery 
ratio
50.4 Cost recovery 
ratio
47.6
Cost Recovery 
Excluding 
Human 
Resource Cost
89.1 97.1 92.8
37
Chapter 5
SUMMARY AND CONCLUSION
The project “Enabling the expansion and sustainability of integrated RCH/infectious diseases 
outreach services through skill upgradation, capacity building and women’s empowerment” was 
implemented by the Krishi Gramin Vikas Kendra (KGVK) with the support of CEDPA for a 
period of one year in Ranchi District of Jharkhand State. The project mainly aimed to provide 
integrated quality and sustainable reproductive and child health services along with other health 
services to the population residing in the project area. The project envisaged expansion of 
services to about 50,000 population. It also envisaged reactivation of additional seven sub￾centres and their strengthening with equipment and human resource. The Indian Institute of 
Health Management Research was assigned to undertake an end-line evaluation project to assess 
whether the project had achieved the objectives for which the KGVK was supported.
The KGVK has a strong presence and has already been working in the area, providing health 
services to a population of about 16,000 through six sub-centres. The end-line project evaluation 
has revealed that the project was successful in expanding the outreach and coverage of the 
integrated reproductive health services as per the objectives laid down. Seven additional sub￾centres were activated and equipped with necessary furniture, equipment, medicine and
manpower in the early stages of the project. The non-functional sub-centres were made
functional.
The project also made an unique experiment in training and recruiting local health workers to 
manage sub-centres and provide health services. The presence of health workers and
strengthening of the sub-centres brought an incredible change in the access and availability of 
integrated reproductive health services in the area. The health workers were involved in carrying 
out the base-line survey, which not only enabled them to understand the health situation and 
status of utilization of services, but also enhanced their motivation and ownership to achieve the 
given objectives. A series of efforts were made to build the capacity and the skills of health 
workers to provide quality services. The impact of training was evident, as there was an
increased role perception and skills to perform the required tasks.
The project has successfully maintained a consistently high contraceptive prevalence rate
through promotion and counseling for various methods of contraception, especially spacing
methods. Expansion of services and availability of health workers has facilitated improved
access and availability of contraception methods.
The impact of the project was visible on reproductive health services, especially antenatal care, 
that included regular check ups during pregnancy, two doses of tetanus toxoid, and the
distribution of iron folic acid tablets. The project has successfully achieved its objectives by
providing these services to more than 75% of the pregnant women in the project area.
The impact of the project on immunization services was significant. About 80 per cent of the 
children in 12-23 months of age group had received complete immunization. Similarly, the 
coverage with Vitamin-A was also high. 
38
The most important issue that the project has addressed is that of sustainability. It has shown that 
the people were willing to pay for good quality services and the cost recovery was possible and 
could be a plausible alternative of financing the healthcare.
Cost recovery mechanism was developed at the rural hospitals and sub-centres. It was heartening 
to note that the cost recovery from the users of the services was initiated. About one half of the 
sub-centres were successful in cost recovery almost up to 35 per cent as per the objectives. 
Similarly, at the rural hospital, the cost recovery was about 48 per cent and it would increase to 
above 93 per cent if the salary of the health workers and medical doc tors were excluded. In 
addition to cost recovery, involvement of the community and sustained motivation of the staff is 
crucial. The project was successful on both the accounts. This is evident especially in the case of 
the repair and construction of the sub-centres and their maintenance. The project has
demonstrated that non-governmental organizations can play a significant role in expanding the 
outreach and improve the access and availability of the services. 
Lastly, a word of caution. The period of one year is too short to demonstrate success of
alternative approaches and sustainability of health services. Much more time would be needed to 
demonstrate the success of cost recovery mechanism and continued participation of the
community in service delivery at the village level. The real test would be in scaling up the 
experiment. 
The Major Strengths of the Project
· The project was conceived and initiated by an experienced team;
· The project staff (health workers) belonged to the area of operation and initially trained by 
KGVK itself;
· Training inputs came from CEDPA; and 
· The organization was able to create awareness of the project and its activities in the area.
The Major Impediments of the Project
· Lack of staff at supervisory level other than the medical doctors; 
· More focus on the main village where the centre was located; and
· Lack of leadership and management skills among the staff.
The fact that six sub-centres have been reactivated and are being used is an achievement. Seven 
new centers were established, thereby doubling the services available. In general, it can be 
concluded that there has been an increase in the utilization of the facilities during the project.
Suggestions and Recommendations
ÿ It is suggested that the training programmes may be conducted to develop leadership and 
management skills of the medical officers and the other key officials of KGVK. One of 
the responsibilities of the medical officers is to manage the rural hospital. The medical 
39
officers are trained in technical aspects but not on the management issues. An orientation 
of the management may enhance the hospitals' efficiency and effectiveness.
ÿ There is a further scope for active involvement of the Swasthaya Samiti members in the 
activities conducted by the KGVK, for example, as depot holders to the hamlets,
organising IEC activities, etc, so that their own notion of sub-centres may change from 
place of treatment of illness and drug distribution to the place where other services 
reproductive health and family planning servic es are available. Efforts must be made at 
changing this mindset of the members of the samiti. 
ÿ Monthly meetings conducted under SHGs may be utilized effectively. It was observed 
that the SHG members conduct monthly meetings regularly but linkages with the project 
were weak. The project staff may utilize this opportunity for health related activities such 
as health talks, CSM, etc. 
ÿ The health workers may increase their visits to the area, especially to the hamlets. Most 
of the activities of the health worker were centred on the health centre and therefore, 
women living in the hamlets were less aware of the services provided by the health
worker. 
ÿ Besides providing services, quality of care needs to be focused on completeness of 
antenatal care, regularity of contraceptive (spacing methods) users, RTI/STI treatment, 
follow up services, etc.
ÿ It is suggested that the health workers may devote their time in managing the information 
by keeping registers, daily diaries and pariwar cards. The same can be made more 
effective by keeping uniformity in records at each centre and also by apprising the health 
workers of its purpose.
40
ANNEX
PROJECT RELATED INDICATORS AND ACHIEVEMENTS
PRI# 1: Thirteen sub-centres operational and providing a full range of FP/RCH and 
infectious disease services
Original/ old 
(n=369)
Additional /New 
(n=658)
Combined 
(n=1027)
Number sub-centres operational 
during the EOP survey
6 7 13 (objective 
achieved)
% Women aware of the project 84.3 76.6 79.5
% Women aware of health services 
provided by the centres
75.1 66.7 69.7
Family planning 49.9 45.3 46.9
Safe motherhood 67.5 62.5 64.3
Child health 56.6 48.8 51.6
Infectious diseases 0 0.3 0.2
PRI# 2: 70% of eligible couples/ families visited by a health worker and or village 
volunteer within the last 3 months
Original/ Old 
(n=369)
Additional /New 
(n=658)
Combined 
(n=1027)
DO* AO** DO* AO** DO* AO**
% Women visited by HW at home 
during the last 3 months 
70.0 14.9 70.0 16.1 70.0 15.7
% Women visited the sub-centre 
during the last 3 months
70.0 16.5 70.0 16.7 70.0 16.6
PRI# 3: 35% CPR for modern contraceptive methods in the original 19 villages and 
5 percentage points above the baseline for the additional 21 villages
Original/ old 
(n=2,746)
Additional /New 
(n=4,722)
Combined (n=7,468)
Base-line census CPR (modern 
methods only)
44.9 45.2 45.1
Current CPR Original/ old 
(n=369)
Additional /New 
(n=658)
Combined (n=1027)
DO AO DO AO DO AO
Modern methods only 35.0 42.0 45.2+5=50.2 40.4 45.1+5=50.1 41.0
Any method 35.0 44.2 45.2+5=50.2 44.7 45.1+5=50.1 44.5
*DO=desired outcome; **AO=actual outcome
41
PRI# 4: A wide range of modern contraceptive methods available including 
injectables, OCPs, condoms, IUDs, NSV, minilap, LAM and SDM
Method-wise Current CPR (Combined)
CPR before 10 months in the project area Current CPR in the project area
Original/ 
old 
(n=2,746)
Additional 
/New 
(n=4,722)
Combined 
(n=7,468)
Original/ 
old 
(n=369)
Addition
al /New 
(n=658)
Combine
d 
(n=1027)
Condoms (CPR) 3.7 2.2 2.8 2.4 1.5 1.8 
Oral pills (CPR) 3.0 3.5 3.3 4.1 2.9 3.3
IUDs (CPR) 0.4 1.3 1.9 1.3 0.9 1.1
Tubectomy (CPR) 37.1 37.4 37.3 33.6 34.6 34.3
Vasectomy (CPR) 0.5 0.7 0.7 0.3 0.4 0.4
Injectables (CPR) 0.0 0.0 0.0 0.0 0.0 0.1
Natural methods (CPR) 0.4 1.8 1.3 2.1 4.2 3.5
PRI # 5: No stockout of OCPs, condoms, or ORS in last three months
The evaluation showed that each sub-centre had an adequate and regular supply of OCPs, 
CCs and ORS packets. The doctors also carried the same with them during their visit. 
PRI #6: 75% of pregnant women received basic antenatal care (3 check-ups, 2 TTs, 
and provision of 100 IFA tablets) in the existing 19 villages and 50 % in 
additional 21 villages
Original/ old Additional /New Combined
Desired 
Outcome
Actual 
Outcome
Desired 
Outcome
Actual 
Outcome
Desired 
Outcome
Actual 
Outcome
Per cent women who had 
delivered their child 
during the reference 
period 
17.9 (66) 14.9 (98) 16.0 (164)
Per cent women who had 
delivered their child and 
received any ANC 
services during the 
reference period 
75.0 87.9 50.0 83.7 50.0 85.4
Per cent women who had 
delivered their child and 
received complete 
(#checkup, 2 TT, 100 
IFA) ANC services during 
the project period 
75.0 4.5 50.0 6.1 50.0 5.5
Check-up 75.0 63.6 50.0 65.3 50.0 64.6
Project staff contribution 
(source)
23.3 42.2 34.9
>2 TTs 75.0 83.3 50.0 80.6 50.0 81.7
Project staff contribution 
(source)
21.8 31.6 27.6
42
>89 IFA consumed 75.0 10.6 50.0 19.4 50.0 15.8
Project staff contribution 
(source)
20.5 20.5 28.7
PRI #7: 40% of deliveries attended by a trained/ skilled person in the original 19 
villages and 10 percentage point increase above baseline in additional 21 
villages
Original/ old Additional /New Combined
Desired 
Outcome
Actual 
Outcome
Desired 
Outcome
Actual 
Outcome
Desired 
Outcome
Actual 
Outcome
Per cent women who had 
delivered their child 
during the project period 
17.9 (66) 14.9 (98) 16.0 (164)
Per cent women who had 
delivered their child with 
the help of a trained/ 
skilled attendant 
40.0 50.0 54.2+10=6
4.2
43.9 40.0 46.3
PRI #8: 80% of children aged 0-5 years fully immunized in the existing 19 villages 
and 10 percentage point increase in the additional 21 villages 
Old (n=239) New (n= 488) Combined (n=727)
DO AO DO AO DO AO
Percent of children aged 
12-60 months fully 
immunized (excluding 
Vit. A)
80.0 82.4 45.5+10=
55.5
81.8 80.0 82.0
Achieved Achieved Achieved
Percent of children aged 
12-60 months fully 
immunized (including Vit. 
A)
80.0 77.4 45.5+10=
55.5
74.0 80.0 75.1
PRI #9: 75% of cases of childhood diarrhea treated with ORS in the existing areas 
and 10 percentage point increase in the additional 21 villages 
Old New Combined 
Number of children aged 
0-5 years
n = 309 n = 587 n = 896
Percent children who had 
an episode of diarrhea 
during the last 15 days 
prior to EOP survey
14.9 (46) 11.7 (69) 12.8 (115)
DO AO DO AO DO AO
Percent children who had 
episode of diarrhea during 
the last 15 days prior to 
EOP survey and treated 
with ORS
75.0 34.8 75.0 30.4 75.0 32.2
Project staff contribution 37.5 14.3 24.3
43
PRI #10: 65% cost recovery in the 2 rural hospitals and 35% in the 13 sub-centres 
Rural Hospitals Sub-centres (considering 12 sub-centres 
only)
% total cost recovered 47.6 31.3
Cost recovered per 
patient
73.2 31.0
PRI #11: Consortium of industries for the prevention of HIV/AIDS established, plan 
of action developed and activities initiated 
The consortium is active and presently working on:
ÿ IEC material
ÿ Resource mobilization
ÿ Publicity
ÿ Social marketing