This is on an account of the steep rise in planned allocation and possible loans which were liberally made available by the World Bank. Under the broad umbrella of the RCH pro­gramme, which includes maternal and childcare services, family planning and immunization programme, the government expenditure has been more than doubled compared with pre-RCH policy regime. Nevertheless, stated disturbingly as a matter of fact, the contraceptive prevalence rate has been practically stall­ing and fertility levels have been either decelerating or on the drag in Bihar [7].

An assessment of the program’s performance during the first years of TFA (1996-97) is available for four large, traditionally poor performing states, namely Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh [8]. According to data released by the Department of Family Welfare, Government of India, with the exception of Rajasthan (which followed an alternative Vikalp frame work for RCH), the performance of the family planning program during 1996-97, as compared to previous years (1995-96), declined in all these states. During this period, the number of sterilization, IUD acceptors, oral pill users and condom users increased in Rajasthan, but in all other states it recorded the declining trend [9]. One of the consequences of the above factors seems to be that the couple protection rate has been practically fluctuating since 1997 in Bihar. As one keen observer had aptly put, it has been “a saga of great expectations and poor performance” [10].

The overly optimistic demographic goals that have been set in various planned documents have been continuously put off to the extent that such statements now fail to enthuse anyone. The National Population Policy launched in 2000 has the medium term objective to achieve the replacement level fertility and Millennium Development Goals (MDG) 4, 5 & 6 by 2010 [11]. This also envisages states to bring their own policies, giving priority to local issues in coherence with the goals and objectives prescribed in the national policy. Henceforth, several states have brought out their own policies to attain the replacement level fertility and MDGs within a rational time frame and the prevailing socio-economic status of the people. According many of the state achieved the replacement level of the fertility, but the condition is worse in Bihar while budget allocation has been continuously proportionate increased over the period for achieve to made targets and goals.

Such information was available for 30 indicators: 8 on “marriage and fertility”; 10 on “family planning” comprising “contraceptive use” (7) and “unmet need” (3); 12 on “maternity and childcare” comprising “maternity care” (3), “child immunization” (5), “treatment of childhood diseases” (2) and “child feeding practices” (2). Table 1 provides data on these indicators at the state level as available from the NFHS-3 survey to indicate the current situation in Bihar.

Second, we have compiled family welfare expenditure data and couple protection rate data from the statistics released by the Family Welfare Programme in India, Year Books for different years [15]. Third, demographic indicators – total fertility rate (TFR) and infant mortality rate (IMR) for different years (1985 to 2008) used data from Registrar General of India, Sample Registration System [16].

Family Welfare Expenditure in Bihar

Programme cost for family welfare programmes met by the central government, national and international donors; and international bi-lateral support. Figure1 shown that trends of expenditure of family welfare (not adjusted for consumer price index) in Bihar during 1985-86 to 2007-08. From the figure, it is evident that expenditure from pre to post-RCH period is increasing. This is mainly because of the introduction of programmes like RCH in 1997 and NRHM in 2005, which are bringing bulk of central government funds into family welfare programme. As against pre-RCH (before 1997-98) period there is an excess over expenditure in the post-RCH period (after 1997-98).

Fig: 1 Trends of expenditure of family welfare programme in Bihar (1985-86 to 2007-08)

Source: Expenditure data compiled from the statistics released by the Family Welfare Programme in India, Year Book, MoHFW, Government of India

The family welfare expenditure was 31 percent during pre RCH (1985-97) of total expenditure (expenditure of 1985-2008). However, this expenditure increased 69 percent during post RCH (1998-2008) of total expenditure in Bihar.

NFHS surveys: 1, 2 and 3. The annual change in the percentage values observed during 1998-99 and 2005-06 computed from NFHS-2 and 3 data and between 1992-93 and 1998-99 obtained from the NFHS-1 and 2 data are also given. The last column of the table also provides a summary picture whether the post-1998 changes were worse off (slow down in progress) than the pre-1998 changes; “yes” indicating that the pace of change post-1998 is worse off and “no” implying the opposite. It is remarkable to note that in most of the variables, in 17 out of 30, the pace of improvement during 1998-2005 has slower than the pace of improvement during the period 1992-1998. TFR, Median age at first birth, percentage women of less than three birth order and women no want more children one son and one daughter show that the pace of improvement was slower during 1998-2005 than the pace of improvement during the 1992-1998 period. For example take the case of the percentage women of less than three birth order has increased 0.07 annual percentage point in pre 1998 compared 0.03 point in post 1998. In the case of median age at first birth has declined 0.02 annual percentages in 1992-98 rather than 0.01 point annual percentage declined in 1998-2005. Women no want more children one son and one daughter marginal increases in annual percentage point during pre 1998 period compared post 1998 period. Interestingly, we found that total fertility rate annual percentage declined -0.09 point in 1992-1998 while annual percentage increased 0.07 point during 1998-2005.

For example, in the case of at least 3 ANC, 0.18 points increased annual percentage in 1992-1998 and 0.13 points increased in annual percentage in 1998-2005. Similarly, this increased of annual percentage point 0.98 points in 1992-1998 while the annual percentage point was 0.87 in 1998-2005. Moreover, diarrhoea children who received ORS has increased annual percentage point 0.82 in pre 1998 period, while implying an annual percentage point increase of 0.79 points in the post-1998 period. This implies that the treatment of diarrhoea at the health facility has increased 0.6 points in 1992-1998 while 0.51 point increased in 1998-2005. Surprisingly, the increased in the percentage of children breast fed within one hour after birth was annually percentage points 0.65 during 1992-98 and this declined to 0.24 points post-1998 until 2005. Similarly, the percentage of underweight children declined by 1.38 points annually during 1992-98 while 0.23 points annually increased during 1998-2005.

Family Welfare Expenditure versus Outcomes

In this section, the progress in two vital programme outcome indicators IMR, TFR and CPR are accessed vis-à-vis the rise in family welfare expenditure. For In, it is evident from Figure 3 that the decline in TFR was not appreciable in comparison to the heavy increase in expenditure.

between 1991-92 and 1995-96, although the family welfare expenditure increased moderately during the same period. In post-1998-99, the expenditure has increased dramatically, while the decline in IMR has been slowdown. Overall, the massive increase in expenditure during 1998-99 has failed to bring commensurate decline level of IMR in the post-RCH policy regime. Especially since 2004-05, the expenditure trend line and infant mortality rate appeared to be parallel to each other.

Fig: 5 Trends of Family Planning Expenditure and Couple Protection Rate in Bihar

Source: Expenditure and Couple Protection Rate data compiled from the statistics released by the Family Welfare Programme in India, Year Book, MoHFW, Government of India.

IMR has decreased higher in the pre-RCH period in preference post-RCH period. Moreover, over all around 45 percent declined in IMR during 1985 to 2007.The expenditure has increased with fluctuation. Nevertheless, it is visible in that incompatible relation between expenditure together with IMR.

The increase in family planning expenditure did not have any positive impact on Couple Protection Rate (CPR). After 1998-99 CPR has shown little or no improvements in spite of the fact that expenditures increased remarkably in family planning programme (Figure 4). CPR has increased till 1989, thereafter CPR has fluctuated with decline continuously while expenditure has increased after 1989. Interestingly, expenditure has increased 88 percent during 1985 to 2007, but 35 percent negatively declined in 1985 to 2007, while it should be increased with increased expenditure.

Also it evident clear spport of my finding, government supported audit committee report (Audit Report No.3 2001) revealed that sterilizations programme declined or remained static after adopting TFA. According NFHS-3 Report, the percentage of female sterilization accounts for 70

in India, Year Book, MoHFW, Government of India, and selected performance indicators from National Health Survey-1, 2 & 3.

However, progress in the full immunization and CPR (any modern method) and institutional delivery coverage was comparatively better in the post-RCH period. On the whole, the massive increase in family welfare expenditure could not result in a matching or significant impact on at least 3 ANC and institutional delivery.

Fig-7: Trends in Family Welfare Expenditure (in lakhs) and Selected Performance of Indicators for Bihar (1992-93 to 2005-06)

Source: Expenditure data compiled from the statistics released by the Family Welfare Programme in India, Year Book, MoHFW, Government of India, and selected performance indicators from National Health Survey-1, 2 & 3.

Figure 7 reveals that a speedy increase in expenditure in the post-RCH period compared with the pre-RCH period, but the progress in selected indicators like TFR, Breast feeding within one hour and underweight totally fail to indicate a significant improvement. In spite, the increase in expenditure in the post-RCH period was two times more than that in the pre-RCH period.

Surprisingly, accordingly past trend TFR should be decline in post-RCH but it has increased while TFR has declined during pre-RCH. In case of underweight has declined 62 percent to 54 percent in the pre-RCH period, while 54 to 55 increased in post-RCH. Further comparison in case of children diarrhoea taken to the health facility, the performance has accelerated in pre-RCH then Post-RCH. Furthermore, interestingly finding revealed that Breast feeding within one hour has increased in pre-RCH while clear slowdown in post-RCH.

However, progress in the TFR, Breast feeding within one hour and underweight was comparatively better in the post-RCH period. On the whole, the massive increase in family welfare expenditure could not result in a matching or significant impact on TFR,

A similar situation prevails with regard to facilities at the Health Sub-Centre (SC) level, where the state has 9140 Health SCs i.e. an average of one Health SC for a population of 9000 as against the norm of 5000 [17]. Despite the fact that expenditure of family welfare programme has increased from 14920 lakhs in 1985-06 to 133175 lakhs in 2007-08. This sharp increase in budget estimate could be due to the loans on this programme liberally made available from the World Bank to strengthen the additional RCH components. When look at health infrastructure and human resources, we found that all indicators of health infrastructure suffering from shortfall in table 2. For example, maximum shortfall 92 percentage in Laboratory Technician, followed by 88 percent in CHCs, 87 percent in Male Multi-Purpose Worker (MPW) at Sub Centres, 78 percent in Radiographers at CHCs, 74 percent Pharmacist at PHCs & CHCs, and 70 percent in Health Assistant (Female)/ Local Health Visitor (LHV) at PHCs. Doctor at PHCs of shortfall is 4 percent, followed by 13 percent shortfall of MPW (Female) / Auxiliary Nurse Midwife (ANM).

Table-3: Public Health Personnel

Source- (Status of Health in Bihar, 2009), Indian Public Health Standard (IPHS)

When we talk about situation of health personnel according Indian Public Health Standard (IPHS), the situation is worst in Bihar. Table 3 revealed that a large gap between required, sanctioned and existing among medical officer and ANM. Furthermore, gap of 516 positions in medical officers and large gap 17151 in position of ANM.

In this study, a meticulous effort has been made to determine the effect of the massive increase in family welfare expenditure on key family planning, RCH performance and demographic outcome indicators for Bihar in different stages of health transition. A comparative analysis of evidence during the pre- and post-RCH policy regimes revealed that expenditure on family welfare programme has more than doubled during the post-RCH policy regime.

RCH approach under the integrated banner of family welfare programme, the exponential increase in expenditure alone cannot lead to commensurate a positive impact on key performance and outcome indicators.

There is a need to examine in detail how the RCH budget is really spent and why the expected pace of improvements in various RCH indicators are not achieved. This is a matter of serious concern for policymakers and programme administrators. There appears to be no synergy between different programmes that is supposed to come into force when they are implemented under one umbrella. The RCH umbrella seems to be leaking, as indicated by the overall slowdown in key indicators.