1
USAID/INDIA
STRATEGIC OBJECTIVE CLOSE OUT REPORT
1. Basic Information 
SO Name: Reduced Fertility and Improved Reproductive Health in 
North India
SO Number: 2
SO Period: FY 1994-2002
Geographic Area (Code): India (386)
Total Cost of SO:
DA $136,470,000
CSH $ 31,816,000
Total $168,286,000
2. Principle Implementing Partners:
Bilateral Projects: 
1. Department of Economic Affairs, Ministry of Finance, Government of India, New Delhi
2. SIFPSA, Lucknow, Uttar Pradesh
3. ICICI Limited, Mumbai, Maharashtra
Field Support:
CEDPA, JHU, POPTECH, AVSC, CARE, CONRAD, BUCEN, POPULATION COUNCIL, 
FUTURES GROUP, INTRA-HEALTH, JHPEIGO, POPULATION REFERENCE BUREAU
3. Background to SO 2:
Achieving worldwide reproductive health (RH) goals depends largely upon achieving reproductive 
health goals in India as it accounts for one-sixth of the world's population. Within India, there are 
important differences between northern and southern states. The northern states, with more than 
40% of India’s population, are growing at a substantially higher rate and have poorer reproductive 
health conditions than the rest of the country. Therefore, improvement in the reproductive health
status of the northern states is crucial in helping to meet India's population and reproductive 
health goals. Keeping this in view, this SO was initiated in 1992 to directly address reproductive 
health and fertility in northern states of India, with the majority of its activities focused in the state 
of Uttar Pradesh (UP) - a state home to over 166 million people that would be the sixth largest 
country in the world were it an independent nation. Two bilateral projects that made direct 
contribution towards the achievement of SO2 goals were:
· The Innovations in Family Planning Services (IFPS) project that focused its activities 
primarily on UP, and 
· The Program for the Advancement of Commercial Technology/Child and Reproductive 
Health (PACT/CRH) project complemented the efforts of IFPS by addressing
Reproductive and Child Health (RCH) issues in urban areas of north Indian states.
3.1 Intermediate Results (IR):
In order to assess objectively the progress of this SO, the SO had three intermediate results (IR):
· IR 1 - Increased quality of family planning services
· IR 2 - Improved use of family planning services
· IR 3 - Increased use of RH services.
2
The progress of IR 1 was measured through the number of IFPS-trained public sector providers 
performing to standards as defined by standardized (IFPS and Government of UP) protocols in 
the 28 districts of UP (referred as PERFORM districts). 
The progress of IR 2 was measured through contraceptive prevalence rate (CPR) for the 28 
PERFORM districts of UP.
And the progress of IR 3 was measured by two indicators:
· Indicator 1: Percentage of deliveries attended by a trained provider, in 28 PERFORM 
districts of UP; and
· Indicator 2: Percentage of pregnant women receiving two doses of tetanus toxoid during 
their last pregnancy.
In addition to the above IRs, the SO level objective was measured by the Total Fertility Rate 
(TFR). The SO level indicator (total fertility rate) pertained to the entire state of UP, however, all 
other IRs were measured in the 28 PERFORM districts of UP. These (28 PERFORM) districts 
represent half of UP (over 88 million people per 2001 census) which received more focused 
attention under the IFPS project. Various sources of data were used for tracking the indicators,
including USAID funded annual household surveys in the project area, Government of India’s 
(GOI) Sample Registration System (SRS), National Family Health Survey (NFHS)-2 1998-99,
implementing agency’s training data verified by independent provider surveys, and retail audit 
data carried out by market research organizations. The NFHS-1 (1992-93), SRS data, the 
PERFORM Survey (1995), retail audit data and project training data provided the baseline values 
for the different indicators.
3.2 Activities/Projects under the SO:
3.2.1 The Innovations in Family Planning Services (IFPS) project:
IFPS was designed as a ten year project with a funding of $325 million over its Life of Project 
(LOP), which was matched by a $400 million host country contribution (HCC) from the 
Government of India (GOI). Out of the total LOP funding, $225 million was available for bilateral 
assistance and $100 million was kept aside for providing technical assistance. Although the 
project was signed in late 1992, it was not until 1994 that the key implementing agency, the State 
Innovations in Family Planning Services Project Agency (SIFPSA), was formed and project 
activities got underway. As mentioned earlier, the geographic focus of this project has been the 
state of UP. Most activities of IFPS project are centered primarily in 28 districts of UP (referred 
as PERFORM districts) which represent half of the total population of the state. Additional 
activities, including contraceptive marketing; information, education and communication (IEC) 
efforts; and contraceptive logistics management were implemented statewide. 
The basic goal of the project was to reduce fertility by substantially increasing contraceptive use 
in UP through public, private and marketing channels. Based on the mid-term assessment, in 
1998 a new reproductive health focus was added to the project alongwith new interventions 
designed to improve the health of women and children. Key interventions were added include 
training traditional birth attendants on safe delivery practices, increasing coverage of maternal 
iron-folic acid (IFA) and increasing tetanus toxoid (TT) immunization for pregnant women. A mid￾term project assessment also determined that the project was on track in meeting most of its 
objectives and recommended that the project be extended to 2004 to compensate for the start-up 
delays. After a series of consultations, the project was amended in 2001 to:
a) Extend the life of the project period to 2004;
b) Expand the scope of the project to include HIV/AIDS prevention and control activities in 
addition to the ongoing project interventions in family planning, reproductive health and child 
survival interventions;
3
c) Scale up the IFPS project to the entire state of UP, and continue supporting activities in 
Uttaranchal (a new state carved out of UP) which were initiated prior to the formulation of the 
new state; and
d) Extend the geographical coverage of the IFPS project by including the newly created state of 
Jharkhand (27 million people). 
3.2.1a IFPS adopted a unique bilateral funding mechanism:
A major element distinguishing IFPS from most other USAID-financed activities is the nature of its 
funding. Bilateral activities conducted under IFPS were funded through a mechanism known as 
performance based disbursement (PBD). In this funding mechanism, a set of targeted results 
were agreed upon between USAID and SIFPSA. Thereafter, a dollar value was attached to the 
activities that would produce those results. The benchmarks were then incorporated into project 
implementation based on an agreement with the GOI. When the results were achieved and 
verified, payments of the benchmark’s value were made to the GOI, which passed on the funds to 
SIFPSA as payment for the activities that resulted in the achievements outlined in the benchmark. 
The targets for achievement were set at an achievable yet ambitious level to emphasize the focus 
on achieving results.
3.2.1b Technical Assistance provided to the IFPS project:
Early, timely and sustained technical assistance (TA) was critical to the project. A key element of 
the IFPS project was the provision of technical assistance through the USAID/Washington field 
support mechanisms. The Mission had engaged organizations such as Engender Health, 
Futures Group International, CEDPA, IntraHealth International, Futures Group, Johns Hopkins 
University (JHU), Population Council, JHPIEGO, BUCEN, ORC Macro and Population Reference 
Bureau to provide technical assistance. Technical assistance was focused on developing quality 
competency-based training in the public and private sector, monitoring of provider skills back in 
the work setting, institutional strengthening, supporting private sector development, expanding 
commercial markets, logistics improvement, management information systems development and 
information, education and communications support for the project. 
3.2.1c Key Public Sector approaches supported under the IFPS project and some related 
outputs/accomplishments were:
· Up-gradation of public health facilities: All (over 500) primary and secondary health care 
facilities in the project areas (i.e., PERFORM districts) were assessed and strengthened to 
make them ready and safe to provide quality RH services, including the full range of GOI 
supplied family planning services. Of these, 84% (452) facilities were certified as performing 
to standard for RH quality servi ces. Also, the project was able to institutionalize an initiative
called the Quality Improvement circles, to improve and sustain the quality of strengthened 
sites.
· Enhancement of clinical and counseling skills of providers: The project has made 
significant contribution in enhancing clinical and counseling skills of public and private sector 
health providers. Over 8,000 providers have been trained in clinical skills and of these 6,000 
were ascertained as performing to standards. In addition, close to 9,500 service providers in 
infection prevention, 6,700 medical and para-medical staff in family planning counseling 
skills, 7,600 trained birth attendants (TBA) on home-based life saving skills and clean 
deliveries, and 8,500 practitioners of indian systems of Medicine on family planning skills
have been trained under this project.
· Micro-planning – Districts Action Plans (DAP): IFPS successfully developed, piloted and 
replicated decentralized health improvement plans at the district level (an administrative unit 
4
with an average population of 2.5 million). By the end of 2003, District Action Plans covered 
38 districts of UP, home to more than 94 million people. The rationale for district planning 
was to encourage bottom-up planning, taking into account local needs and resources. 
District planning ensured the devolution of administrative and financial authority to the 
districts, with continued technical assistance from SIFPSA to streamline service delivery 
systems. The district planning exercise also created District Innovations in Family Planning 
Services Agencies (DIFPSA) and Project Management Units (PMU) to provide operational 
linkage between SIFPSA, the districts, and the public and private sectors.
DAPs have served as a model for UP and India. The IFPS DAP guidelines have been sent to 
every state in the country along with the instruction to use them when formulating district￾specific plans as part of state activities in conjunction with the national RCH-II program, $8.7 
billion five-year initiative of the GOI. This decision of the GOI to implement DAPs in all 
districts of India has resulted in USAID’s investments in a single state affecting health 
programming throughout the entire country. 
· Integrated services through RCH camps: RCH camps, which are popular as Parivar 
Swasthya Sewa Divas (Family Health Days) organized at Community Health Centres (CHC)
and Primary Health Centres (PHC), provide an opportunity to integrate the efforts of providers 
and increase access to reproductive health services. Each camp included a gynecological
check-up, child examination and immunization, family planning counseling and services and 
provision for transportation to clients who utilized sterilization services. Though sterilization 
camps have been part of the family planning program for many years, these RCH camps 
were different in that IFPS was able to:
· Provide an array of maternal and child health (MCH) and family planning services under 
one roof;
· Provide assured services as per a pre-determined calendar; and
· Combine benefits of rural outreach and high quality services.
The organization of camps involved detailed planning relating to publicity, manpower 
deployment, camp arrangements, and post-camp services including transportation, 
availability of consumables and medical equipment. Each camp was scheduled in advance 
and publicized. In rural areas, attractive jingles on audio cassettes were played. Since most 
of these camps were in remote rural areas, the availability of a team of surgeons, anesthetist
and female gynecologist were ensured from the district level. Enhanced budget for 
maintenance and fuel for vehicles was provided so that an adequate number of vehicles 
could be deployed to transport doctors to RCH camp sites and sterilization clients to their 
homes. District health officials monitored these camps regularly contributing significantly to 
their success. SIFPSA has funded 47,889 camps over a six-year period from 1998. On an 
average, 100 clients attended each camp and more than half of these accessed integrated 
MCH services. 
· Campaigns to provide TT and Iron Folic Acid (IFA) to pregnant women: Special drives 
(once in six months) were undertaken to identify and enroll all pregnant women for RH 
services, particularly for TT immunization and IFA supplementation. As a result of these 
drives, the TT and IFA coverage among pregnant women increased significantly. The 
maternal TT coverage in UP has increased from 41% in 1998 to 63% in 2003, and the IFA 
coverage has increased from 20% to 34% during this period.
· Policy, leadership, and advocacy efforts undertaken under the IFPS project: To achieve 
change in UP, a comprehensive program for family planning and reproductive health was 
needed. With technical assistance from the IFPS project, the Government of UP (GOUP) 
adopted a holistic population policy, and extended its physical presence into each IFPS 
district. The IFPS project also provided Technical Assistance for the development of state 
population policy for Jharkhand, integrated population and health policy for Uttaranchal 
5
(India’s first and only integrated state policy), and essential medicines policies for Uttaranchal 
and Jharkhand.
3.2.1d Key Private Sector Approaches supported under the IFPS project and some related 
outputs/accomplishments were:
· Expand access through private networks: A community-based distribution (CBD) 
approach was developed, tested and replicated through dairy cooperatives, Non￾Governmental Organizations (NGO) and employment sector to cover more than 13 million 
people in the project areas of UP. More than 70 CBD projects through a network of 
approximately 7,500 CBD workers were engaged to provide RH/FP services in IFPS project 
districts of UP. Data from the 2003 population-based survey shows that the Contraceptive 
Prevalence Rate (CPR) in CBD areas was significantly higher than in non-CBD areas. 
Contraceptive Prevalence Rate (CPR) in areas where community-based distribution (CBD) 
projects were in place was 30%, significantly more than other non-CBD project areas which 
was 22%. In addition to CBD, other networks—Integrated Child Development Services and 
Nehru Yuvak Kendra were also utilized to strengthen RH/FP community outreach activities.
· Community Midwife (CMW) initiative: To extend the reach of trained midwives, a pilot 
project was initiated in four districts of UP to train community-based midwives. Candidates 
for the 18 month training course were selected from rural communities. The curriculum 
developed for this initiative has been adopted by the GOUP as a resource for all auxiliary 
nurse midwife (ANM) training in the state. GOUP and USAID are exploring ways to scale-up 
this activity. 
ß Enhance demand for services through information, education and communication 
campaign: A communication strategy for health and family planning in Uttar Pradesh was 
developed and released by SIFPSA in 1995. As part of this overall strategy, the “Aao Batien 
Karien” or “Come Let’s Talk” logo and message were developed and produced. “Aao Batien 
Karien” served as the unifying theme for selected FP/RH IEC activities and materials. It was 
prominently featured in a multimedia campaign promoting discussion of spacing methods 
among and between family members and providers and is widely used by NGO outreach 
workers in their home visits. In addition, 18,500 NGO workers and ANMs in IFPS districts 
were trained in the use of these IEC materials. In addition to the “Aao Batien Karien” 
campaign, several other statewide multimedia campaigns on priority FP/reproductive/child 
health themes had been conducted, some of these used private sector advertising and media 
production agencies. Also, under the project, statewide IEC efforts were undertaken to 
promote reproductive/child health camps, non-scalpel vasectomy, and safe motherhood. The 
project also provided IEC support to the districts for purposes such as measles vaccination 
and promotion of Intra Uterine Contraceptive Device (IUCD) use. FP/RH messages were 
placed on the panels of 300 state buses and on the walls of village sub centers in 15 districts. 
In smaller villages in 24 districts, 6,800 folk performances were given to carry (RCH) 
messages to rural audiences in an entertaining way. Mobile fairs were also used to promote 
awareness and immunization services in villages in 18 districts, with an average of 2,013 
immunizations per district during the functions. Numerous staff members from SIFPSA and 
other Indian organizations received training in communication planning and IEC at 
international workshop venues.
ß Social marketing of pills & condoms: The original IFPS project did not envision SIFPSA 
as the conduit for bidding and awarding contraceptive social marketing contracts. However, 
an agreement was reached between the GOI and USAID in 1998 that allowed SIFPSA to 
function as the contracting entity in social marketing. SIFPSA launched the first 
contraceptive social marketing pilot project (with Hindustan Latex Limited (HLL), a para-statal 
distributor and manufacturer). In the interim, USAID’s global support mechanism funded 
social marketing projects in western U.P. from 1994 to 1998. These efforts were directed at 
6
areas within minimal access to contraceptives, primarily focused on reaching 60% of the 112 
million rural people residing in mid-sized villages. As a result of these initiatives, a good 
increase in the availability of oral contraceptives and condoms was recorded. Availability of 
both pills and condoms in villages of UP increased from 19% in 2000 to 45% in 2003. 
3.2.2 The Program for the Advancement of Commercial Technology/Child and
Reproductive Health (PACT/CRH) project: 
PACT/CRH is a twelve-year $29.8 million collaborative project with the ICICI Bank, which is one 
of the largest financial institutions in India. The goal of this project is to increase the use of RCH, 
and HIV/AIDS related products and services through the private sector. The project objectives 
are to: a) introduce and commercialize new RCH and HIV/AIDS technologies; and 2) improve 
quality and use of private sector, primarily commercial sector RCH and HIV/AIDS products and 
services.
3.2.2a The Goli Ke Hamjoli (GkH) or Friends of the Pill Campaign:
This campaign was initiated in November 1998 to improve the reproductive health of women in 
eight north Indian states. The oral contraceptive (OC) pill was identified because the affordable, 
high quality products were already widely available in the market, yet their use remained very low. 
The GkH strategy utilized an integrated communication and marketing approach to promote the 
entire category of low dose estrogen OCs to consumers and health providers, while encouraging 
industry partners to promote their own brand. The communication campaign used a multi￾pronged approach of advertising, public relations, and interpersonal communication to create 
demand, dispel myths and misconceptions and encourage correct use of OCs. Improving 
provider knowledge and attitudes, and encouraging industry partners to expand distribution, 
helped increase consumer access to the product. The GkH campaign focused on the urban 
areas of eight Hindi speaking states of Northern India which has over 40% of India’s population, 
with poor health indicator and high need for modern methods of spacing. After five years, results 
of this initiative are very encouraging. Tracking surveys show increases in positive attitudes 
towards OC’s and in the target audience group, use of OCs increased from 4% to 11%. 
Knowledge and attitudes amongst providers have also improved. As result of this initiative, sales 
of all OC’s have increased by 48% in volume over the five years of the campaign in urban ares of 
north India, while non-campaign areas have been stagnant. In terms of value the market grew by 
over 110% thereby encouraging OC marketers to make greater investments in this category. In 
addition, for the first time in decades, new OC brands were launched during this period of market 
expansion. GKH has clearly demonstrated the power of the private sector in India in meeting 
social goals while expanding the market.
4. Impact:
The overall performance of the SO was more than satisfactory. Data from different independent 
sources show that this SO was able to meet/exceed all SO and IR level indicators. 
SO level: The objective of the IFPS (which has been implemented under SO2 and continued 
under SO14 of current strategy) project was to decrease the TFR in UP to 4.2 by 2002 and to 4.0 
by 2004, which meant the project aimed to decrease the TFR by 1 child in 10 years (1993-2002). 
Per the Sample Registration System (SRS) data of GOI, the TFR in UP has declined from 5.2 in 
1993 to 4.2 in 2002. A decade prior to the initiation of the project, between 1983 and 1992, the 
TFR in UP declined by only 0.6 child, nearly half a child less than what has been achieved during 
the project period. Thus, the project appears to be on track to reach its life of project goal of 4.0
by 2004. TheTFR data from SRS for 2004 is likely to be available in 2006.
IR level: As mentioned in section 1.1, this SO had three IRs that were measured through four 
indicators. 
7
IR 1 Increased quality of family planning services was measured through the number of IFPS￾trained public sector providers performing to standards as defined by standardized (IFPS and 
Government of UP) protocols in the 28 PERFORM districts of UP (Indicator1). The project 
planned to create a pool of 4343 trained providers performing to standards (PTS). Against this 
target, the project was able to train more than 8,000 public sector providers; of these nearly 6,000
were ascertained as PTS. 
IR 2 Improved use of family planning services was measured through CPR for PERFORM 
districts of UP (Indicator 1). The CPR defined as the use of modern methods of contraception, 
has increased from 20.9% in 1995 Source: (PERFORM 1995) to 27.6% in 2003 Source: (USAID 
Annual Survey) in the project area. The objective of the project was to increase the CPR to 26% 
by 2003 in the project area. Therefore, the expected level of CPR has exceeded the planned
level. A comparison of the project areas and non-project areas of UP shows that the project 
areas have done significantly better than the non-project areas. The CPR in project areas has 
gone up from 18.4% in 1992 to 27.3% in 2003, nearly 9 percentage points. However, during this 
period, the CPR of non-project areas has increased by around 5 percentage points, from 17.2% 
to 22.4%.
IR 3 Increased use of RH services were measured through two indicators - Indicator 2.3.1: 
Percentage of deliveries attended by a trained provider in PERFORM districts of UP; and, 
Indicator 2.3.2: Percentage of pregnant women receiving two doses of tetanus toxoid.
· Indicator 1: Percentage of deliveries attended by a trained provider, in PERFORM 
districts of UP - The percentage of deliveries attended by trained providers in the project 
area has increased from 32.8% in 1998 to 48.8% in 2003, an increase of twelve 
percentage points in a span of six and a half years. The objective of the project was to 
increase the percentage of deliveries attended by trained providers in the project districts 
to 37% by 2002. The training of TBAs was the key intervention supported under the 
project for increasing the percentage of deliveries attended by trained providers as the 
proportion of institutional deliveries was extremely low (about 15%). In addition, the 
project has embarked on a community midwives program. The follow-on IFPS project
has discontinued its support for TBA training as available data indicates that deliveries 
attended by TBA have no or little impact of the maternal mortality.
· Indicator 2: Percentage of pregnant women receiving two doses of tetanus toxoid - The 
original objective was to increase the TT coverage in the project districts from 1993 level 
of 37.4% to 47% by 2001. During this period, the TT coverage in the project area 
increased to 61.8%, 15 percentage points more than what was expected. Keeping this in 
view, a highly optimistic target of 70% was set for the year 2002. The project failed to 
achieve this revised target as the 2003 TT coverage rate was 62.5%. 
5. Changes in the Results Framework during the life of the SO:
Per the results framework that was established in 1996, “Reduced Fertility in North India” was the 
SO level statement. It had one IR stated as “Increased contraceptive use and Improved 
reproductive health in target areas.” Subsequently, in 1998, the SO framework was broadened to
emphasize RH and quality of services. The SO level statement was changed to “Reduced 
Fertility and Improved Reproductive Health in North India.” The old IR (increased contraceptive 
use and improved reproductive health) was broken into two IRs i.e., increased use family 
planning services and increased use of RH services and a new IR on quality of care i.e., 
increased quality of family planning services) was added. Moreover, the planned/target values 
for most of the indicators were adjusted based on past performance.
8
6. Prospects for sustainability and threats:
In 2004, a new government came to power in India that pledged significant increases in health 
budgets. The new government also started paying increased attention to health care in rural 
areas as well as fertility issues in high fertility parts of the country. Additionally, the central 
government followed an open, transparent and highly consultative process to develop its five￾year, (2005-2010) $8.7 billion RCH II program and each Indian state were encouraged to develop 
state-specific Program Implementation Plan (PIP). SIFPSA, the implementing agency for IFPS 
project, took the lead in developing the RCH II PIP for U.P. State and was able to include most of 
the innovative components of IFPS project in this PIP. Therefore, most IFPS innovative activities
are likely to be funded by the GOI’s RCH II program. In addition, GOI has also provided
resources to SIFPSA to expand decentralized-planning activities to the non-IFPS districts of UP. 
Additionally, GOI is considering SIFPSA to be the implementing agency for the RCH II program in 
UP. If RCH II is implemented through SIFPSA, SIFPSA will have to undergo a dramatic evolution 
and expansion as its mandate and its activities grow. Keeping these factors in view, the new 
technical assistance contract (signed under IFPS-II, the IFPS follow-on project) proposes to help 
with this evolution process. In short, most of the successful components of the IFPS project are
likely to be expanded and extended through GOI’s RCH II resources. In addition, USAID is 
planning to provide technical assistance at the national level, in support of the RCH II program. 
This offers the potential for nationwide impacts with relatively small investments. However, 
USAID must remain aware of the tendency for India to resort to incentives and disincentives for 
adoption of family planning methods, which may be problematic due to USAID’s legislative 
requirements. 
7. Evaluations, Assessments and Lessons Learned:
Key lessons learned over the course of the IFPS project are: 
· An intermediary is necessary. An intermediary organization (like SIFPSA) is needed to 
manage implementation of the wide variety of initiatives that were carried out under IFPS, 
particularly when dealing with the large number of diverse actors that make up the private 
sector. In a federal structure like India, transfer of funds for specific activity from the central
government to state government seemed to work much better when an intermediary is 
involved, as opposed to working directly through the state treasury or central government. 
The intermediary ensures that program resources are available for the intended purpose and 
do not get diverted for other priorities, as is common with funds routed through the state 
treasury in select states. Unlike some other bilateral programs, IFPS has never encountered 
any significant problem related to funds flow from GOI to SIFPSA. Additionally, an 
intermediary is useful for undertaking large-scale private sector contracts since the 
government (both central & state) lack the capacity to undertake large competitive contracts 
because of cumbersome procedures that are often not transparent as well as a lack of trust 
to provide substantial amounts of funds to the private sector. This model of creating an 
intermediary has been adopted by other state governments to implement various 
developmental projects.
· The society (intermediary) model can achieve significant results. Under SIFPSA, results 
have been achieved, greater NGO involvement fostered, new approaches instituted (DAPs, 
RCH camps, TT campaign, contraceptive rural marketing, and CBD networks), and 
monitoring systems established that can track progress. There has been a significant 
increase in contraceptive use in IFPS districts as compared with non-IFPS districts: IFPS 
districts have increased at 0.9 percentage points annually compared to the state average of 
0.6 percentage points. 
· Building capacity of the states to access GOI and donor assistance necessary. 
Management capacity, especially in the areas of planning and budgeting, is weak in most 
North Indian states, including UP. Consequently, states are not able to access resources 
9
from other programs (such as GOI’s Empowered Action Group and RCH, and the World 
Bank funded Health Systems Development Project). Developing capacity to access these 
resources will expand the pool of available resources. Due focus on this area could lead to 
optimal synergies between various projects. 
· Competition among states useful. Initially, UP did not show much interest in developing a 
population policy for the state. However, USAID assistance to several other states in the 
country drew the attention of UP policymakers who essentially did not want to be perceived 
as being left behind. As a result, USAID supported a comprehensive population policy for 
UP, providing an opportunity to place family planning and population issues on the table in 
the state. 
· Closer engagement with state government is key. Broad program oversight is provided to 
the IFPS project through a committee structure in which the GOUP is represented. However, 
the GOUP has never taken full ownership of the IFPS project. As a result, while a majority of 
IFPS assistance has gone to public sector interventions, GOUP staff view SIFPSA as a 
parallel structure. Another example is the fact that SIFPSA—not GOUP—has scaled up 
numerous innovations. Cases in point include multiple year support for RCH camps, provider 
training, TT campaigns, CBD projects, upgradation of sites, etc., when these costs could 
have been gradually assumed by the GOUP and the RCH project. 
· The focus on results has proved beneficial. Through the performance-based funding 
mechanism, the project has focused on results instead of inputs. Such a focus has been 
beneficial for three reasons. First, other donor programs often measure their success in 
terms of the percentage of allocations that have been expended. In contrast, the success of 
the IFPS project has been measured in terms of people-level impacts, which have been 
substantial in the areas in which it has worked. Second, the results focus has allowed for 
organizational flexibility to make management and implementation changes as required. In 
contrast, centrally-sponsored schemes often specify with exacting detail the number and 
salary of personnel managing activities and implementation arrangements. Such 
specifications may not be appropriate for every situation, yet are difficult to change or waive. 
IFPS’s focus on results has allowed implementers to determine the right mix and nature of 
interventions, as long as results are achieved. Third, the focus on results has provided 
leverage for ensuring implementation. Project implementers have found it useful to state that 
payments for activities can only be made if results are achieved. 
· The focus on results is not a panacea. Despite the beneficial aspects of a focus on 
results, the system is not perfect. Without careful attention to benchmark design—the most 
tangible manifestation of the results-based focus—it is possible that the quality of 
interventions can be subordinated to numbers of a given result that make up the benchmark. 
Short term pursuit of numbers at the expense of quality may be detrimental to long term 
project goals.
· Decentralization with accountability works. Initial trends within the project districts 
indicate that the original six DAP districts performed better than non-DAP project and non￾project districts. Therefore, the DAP approach was scaled up to cover 38 districts throughout 
UP. PMUs in each district have proven vital to the success of the DAP approach. With the 
inevitable and frequent changes in the technical and administrative leadership at the district 
level (Chief Medical Officer and District Magistrate), it is important to have a stable group of 
personnel in the districts to ensure that population and reproductive health issues remain on 
the agenda. The IFPS DAP guidelines have been sent to every state in the country along 
with the instruction to use them when formulating district-specific plans as part of state 
activities in conjunction with the national RCH II program. This decision of the GOI to 
implement DAPs in all districts of India has resulted in USAID’s investments in a single state 
affecting health programming throughout the entire country. 
10
· Innovations can be tested on a scale that is replicable. In the IFPS project, several 
innovations have been tested and replicated successfully to cover vast project areas. 
Examples include the DAP approach, RCH camps, the TT campaign, social marketing 
activities, and CBD approaches using NGOs, dairy cooperatives and the employer sector.
· Improved supply alone is necessary but not sufficient for results. IFPS provided 
substantial inputs for strengthening clinical and counseling skills of service providers and 
upgrading service delivery sites. These interventions are not having the desired impact 
because actual service provision has not increased dramatically. Demand creation has been 
identified as the missing link to increased service provision in both the public and private 
sector. 
· Rural marketing efforts have improved access. One of the major criticisms of the social 
marketing programs around the world has been that they focus on urban and easier to reach 
populations. To ensure that the social marketing efforts were directed at areas within minimal 
access to contraceptives, SIFPSA designed a social marketing effort that focused on 
reaching 60% of the 112 million rural people residing in mid-sized villages. SIFPSA has 
demonstrated that through concerted efforts the availability of pills and condoms can be 
significantly improved in rural UP. However, in order to improve utilization, the expansion of 
distribution needs to be coupled with strong demand creation efforts, which has been a gap. 
Thus until recently, the full potential of the social marketing effort has not been tapped fully. 
Further, the contraceptive social marketing component and GkH communication effort have 
shown the power of the market to reach to a larger audience within a short period of time to 
achieve public health goals. 
· Behavior change efforts are critical for significant impact. Behavior change efforts have 
been limited in both scope and intensity in IFPS. Adequate emphasis was not provided on 
promoting trained providers and upgraded sites. Further, method-specific misconceptions 
were not addressed adequately. 
· The CBD approach has worked. NGO and other community-based distribution projects 
have yielded good results in terms of increasing CPR, child immunization rates and maternal 
health indices. 
· CBD training in itself empowers women. Through IFPS, over 15,000 female community 
based distribution workers have been trained. On site visits and in success stories that have 
been reported, the IFPS implementation team has heard how as a result of their position in 
the village, they have become empowered agents for change on a broad agenda. At least 12 
women who were CBD workers have gone on to be elected as village pradhans after their 
association with the project activities. 
· Opportunities for stronger linkages between HIV/AIDS, family planning and child 
survival not fully tapped. Since 2002, efforts have been made to further strengthen RH 
components and better integrate key child survival and HIV/AIDS interventions into the IFPS 
project. For example, the social marketing efforts have been expanded to include Oral 
Rehydration Salts, IFA and safe delivery kits. However, efforts to link HIV/AIDS prevention, 
family planning and social marketing were not that successful. 
· Key research is essential to program expansion. The project could have benefited from a 
systematic tracking of client perspectives and an enhanced understanding of factors leading 
to utilization of services. This would have helped in orienting the strategic focus of the project 
to the client rather than the provider. Furthermore, assessments of interventions 
effectiveness and impact have not been undertaken to the extent necessary, and where 
these have been undertaken the findings have been utilized selectively.
11
· Diversity needs to be adequately recognized. UP is the most populous state of India with 
over 166 million people. Only five other countries in the world have larger populations. UP 
represents four broad socio-cultural regions and a rich cultural, religious, social and economic 
diversity. Though to a large extent the UP population policy recognizes this diversity, it 
posed a challenge to the IFPS program response, particularly with regard to client 
segmentation.
· Technical Assistance is crucial for success. The role of TA in enhancing public sector 
readiness was clearly demonstrated through quality improvements in skills of trained 
providers, infection prevention practices, supportive supervision and facilities improvement in 
IFPS-funded districts. GOUP and neighboring states are taking advantage of resources 
developed under the IFPS project and learning from these experiences to enhance the 
quality of their services.
· Dissemination is important. The documentation and dissemination of program efforts has 
been limited largely due to issues of control and openness of the implementing partner during 
a substantial part of the IFPS project. This has led to considerable misconceptions about 
IFPS both within India and USAID/W. Wider dissemination would have resulted in building 
greater ownership of the efforts and support for the project. 
These lessons and others have been taken into consideration during the design of the proposed 
activities (IFPS-II, the follow-on IFPS project) to improve the RCH situation in UP, Uttaranchal 
and Jharkhand. 
12
APPENDICES
Appendix 1
(A list of evaluations and special studies conducted during the life of the SO, including 
Annual Reports)
1. National Family health Survey (Uttar Pradesh), 1992-93;
2. Family Planning Programs in Uttar Pradesh: Issues for Strategy Development, 1994;
3. 1995 PERFORM Survey in Uttar Pradesh;
4. Uttar Pradesh: Male Reproductive Health Survey, 1995-1996;
5. IFPS Project management Review, 1996;
6. IFPS Mid-term Assessment, 1997;
7. Annual Indicator Surveys, 1998, 1999, 2000, 2001, 2003;
8. IFPS Project Aide Memoire, 2001 and, 2002;
9. IFPS Project Impact Analysis, 2001;
10. IFPS Lessons Learned, 2002;
11. Alternative Projections for Contraceptive Use, and Intentions to Use a Method : An analysis 
for the Project Areas of the IFPS, 2003; and
12. Assessment of the Innovations in Family Planning Services Project, 2003
Appendix 2
(A list of instrument close out reports prepared for contracts, grants, and cooperative 
agreements)
Close-out reports are maintained by Regional Contracting Office, USAID/India. For any 
information, please contact Mr. Marcus Johnson, Regional Contracting Officer at e-mail:
mjohnson@usaid.gov
Appendix 3
(Names and contact point of individuals who were directly involved in various phases of 
the SO (planning, achieving, and assessing and learning), and who would be good
sources of additional information)
1. Linda Morse (USAID)
2. John Rogosch(USAID)
3. Bill Goldman (USAID)
4. Jerry Tarter (USAID)
5. Jinny Sewell (USAID)
6. Kris Loken (USAID)
7. Jim Bever (USAID)
8. Randy Kolstad (USAID)
9. Sheena Chhabra (USAID)
10. Samaresh Sengupta (USAID)
11. Anjana Singh (USAID)
12. Meenakshi (USAID)
13. Jyoti Shankar Tewari (USAID)
14. Robert Clay (USAID)
15. G. Narayana (Futures Group)
16. Rita Leavell (Futures Group)
17. Uma Pillai (Government of India)
18. Aradhana Johri (Government of India)
19. J. S. Deepak (Government of India)
20. Kalpana Awasthi (Government of India)
If you wish to contact any of the above individuals or if you would like any additional information 
about this SO please contact Mr. Jyoti Tewari at Tel# 2419-8428 or e-mail: jtewari@usaid.gov.