Targets versus Extension Education: the Family

Planning Programme in Uttar Pradesh, India

ROBERT E. ELDER, JR.
INTRODUCTION

Governments in developing countries, face the difficult task of bringing about needed social
change in a relatively short time. Those governments which claim to be democratic are faced
with the additional problem of bringing about such change in a manner consistent with the
country's proclaimed values. In these societies, tensions have frequently resulted because administrative programmes contained demands that a quantifiable amount of change should take
place within a specified period, as well as requiring information on the reasons for change to be
given to the population.
This paper utilizes data from the family planning programme in Uttar Pradesh, India, in
order to describe negative results which can occur when the time-bound target-oriented aspect
is allowed to take precedence over the extension-education aspect of an administrative programme.^
BACKGROUND

Population was increasing at the rate of approximately two per cent per year, swallowing up a
major portion of economic gains when the Indian government early in 1963 initiated a programme
of extension education in the area of family planning.^ Uttar Pradesh introduced its own extension education programme in family planning late in 1965.^ Programme results on an all-India
basis were slow in materializing and Uttar Pradesh, being one of the least developed Indian
states, lagged far behind most others in early efforts.*
During 1964 and 1965, several new concepts were introduced into the programme's methodology in the hope of boosting achievement. In April 1964, the central government inaugurated
an intensive sterilization scheme. Ten rupees were to be paid to any person willing to undergo
vasectomy, five rupees to the surgeon performing the operation, and two rupees to anyone, other
^ The data presented in the paper which follows result from a multi-phase study of the Uttar Pradesh Family
Planning Programme conducted between January 1968 and July 1969. In the course of the study, questionnaires
were administered to 114 block extension educators, 100 health assistants and 56 block development officers.
A mail questionnaire was sent to all 54 district family planning officers in the state with a 60 per cent response.
In-depth interviews were held with 25 health assistants, 18 block extension educators, and eight district family
planning officers. As a check on the validity of statements made by the family planning and development staff,
three additional studies were conducted including an assessment of the demographic characteristics of 1,606
vasectomy cases from seven districts in Uttar Pradesh; a one-district, 22 village survey of villagers' attitudes toward
the programme; and a survey of the attitudes of 42 members of the legislative assembly from 28 districts in Uttar
Pradesh. The samples were intentionally overlapped in order to include attitudes from as many of Uttar Pradesh's
54 districts as possible and ultimately every district was included in some phase of this study. For further information in regard to data collection including the questionnaires as they were administered, see Robert E. Elder,
Development Administration in a North Indian State, (unpublished Ph.D. dissertation. Duke University, 1971X
Appendices I-VIII, pp. 355-439. Hereafter this will be cited as Elder op. cit.
^ Government of India, Department of Family Planning Directive No./40/63FP, Family Planning Programme Reorganization. (New Delhi, 4 October 1963).
^ Uttar Pradesh, Department of Family Planning Directive No. FP/4057/E12/65 from S. L. Talvar to all District
Medical Officers of Health, Integration of Family Planning Services with the National Malaria Eradication Programme
under the Maintenance Phase (Lucknow, 30 August 1965), p. 1.
* It ranked sixteenth of 17 in number of urban family planning centres, and eleventh of 14 in percentage of target
achievement and had more family planning centres functioning without doctors than all but two other Indian
states. Department of Economics, University of Lucknow, Demography and Development Digest Vol I No 1
(Lucknow, 1967), pp. 145, 150.
,
. ,
.

249

250

ROBERT E. ELDfiR, JR.

than a family planning worker, who motivated the case to come for the operation.^ In 1965,
following the approval of the Lippes loop as a safe and effective method of female contraception
by the Indian Council of Medical Research, the Centre approved and requested the States to
institute a similar scheme with slightly smaller incentives for the intra-uterine contraceptive
device.^
Closely connected with the creation of these two programmes was the introduction of the
'target' concept. Beginning in 1965, each State was given and encouraged to achieve a target
based on its population of couples eligible for family planning. States with the best achievements
received awards and publicity, thus encouraging a spirit of healthy competition.
In 1966, one additional achievement technique, the 'drive' or 'family planning fortnight'
was introduced. These were two-week periods in which the staffs of various departments as well
as family planning personnel were given targets and encouraged to make special efforts to achieve
them. Beginning in 1966, the number of declared fortnights national, state, and local, were
increased each year, until in 1968, from August until January, with the exception of two two-week
periods in October and November, the family planning programme in Uttar Pradesh was occupied
in one continual drive. ^
The introduction of these new methods risked pushing family planning workers in the
direction of a quantity-oriented approach to family planning, but also raised a number of additional problems. What would be the effect of multi-agency fortnights on relationships between
different categories of block level workers and on family planning staff morale ? Would it be
possible for revenue and development workers who were totally untrained in family planning,
to bring properly motivated, demographically valid cases to family planning camps ? The incentive of ten rupees represented a large sum of money for an Indian peasant, approximately five
times his daily wage. Would this be extension education, or bribery? Would a high-pressure
programme encourage voluntary change or engender negative feelings on the part of the target
population ? Finally, in a programme the future support of which would depend on a popularly
elected legislature, how would negative popular reactions to the programme affect legislative
attitudes of support for family planning ? The remainder of this paper has been devoted to exploring the issues raised above and reporting negative ramifications of the programme methodology
outlined above.
ADMINISTRATIVE METHODOLOGY AND THE FAMILY PLANNING WORKER

According to the Raina Report, extension educators were to be the key to family planning
extension education in the block. What was the effect of targets, drives and incentives on the way
^ Uttar Pradesh, Department of Family Planning Directives No. FP/l 104/XVI 1-49/64, Intensification of Sterilization under the Family Planning Scheme (Lueknow, 18 April 1964), p. 1. The incentive fee to be given to the ease
being motivated was increased shortly after the implementation of the programme from ten to 15 rupees.
^ Uttar Pradesh, Department of Family Planning Directive No. nil, Intra-uterine Contraceptive Device Crash
Programme, from i 5-/7-65 (Lueknow, June 1965), p. 1.
^ Information in regard to the continuous-drive situation became known to this author because of relationships
established with different training centres throughout the State. Training centres were unable to procure sufficient
trainees from the field because of the reluctance of superior officers to release them for training during the drive
periods.
^ The Raina Report refers to B. L. Raina, Family Planning Programme Report for 1962-63 (New Delhi: Government Press, April 1963). In consultation with the block medical officer and f"emale surgeon the extension educator
was required to plan and organize extension services in collaboration with other block staff, foster and maintain
co-operative and productive relationships with both formal and informal leaders in the block, organize meetings
of the block health staff once a month, conduct in-service training, arrange lUCD and vasectomy camps which
included overseeing preparatory and follow-up services given by other categories of family planning workers, and
supply and distribute contraceptives at the block level. In carrying out these activities he was required to tour at
least 25 days in each month, attend meetings held once a month by the district family planning officer and block
development officer, and hold fortnightly meetings with the maternal child health and family planning staffs. See
also in this regard Uttar Pradesh, Health Ministry, 'Revised Roles and Functions ofthe Family Planning Personnel
at the Primary Health Centre Level' (Lueknow, mimeographed, 11 pp., 2 March 1965), pp. 4-5.

TARGETS VS EXTENSION EDUCATION

251

in which they perceived and attempted to implement their role? In the spring of 1968, a survey
was conducted involving 114 block extension educators in which an attempt was made to answer
this question.^ To summarize briefly, the study discovered that although family planning workers
were receiving training in extension education techniques, once they went into the field they
quickly perceived that it was the number of cases rather than their quality that was most important
to their superior officers. The 114 respondents, when asked whether their superior officers were
more interested in extension education techniques than the fulfilment of targets gave the answers
presented in Table 1.
TABLE

Number
97
106
107
106
104

1. Block extension educators' composite assessment of superior officers'"

commitment to qualitative vs. quantitative programme
Officer

Quantitative

Block Medical Officer

District Family Planning Officer
Block Development Officer
Sub-Divisional Magistrates
TASOS*
* Total average superior

58%
74%
84%
93%
77%

Qualitative
42%
26%
16%
7%
23%

Significance
Not signif.
001
001
001
001

officer score.

Source: Elder op. cit., 'Block Extension Educator Administered Questionnaire', p. 189.

Superior officers were tending to punish subordinates who proved unable to fulfil their
quotas on a regular basis. The method most frequently utilized was dismissal or the threat of
dismissal. ^
Dismissal, however, was not the only method utilized to punish the worker. His pay could
be stopped, his touring allowance (expense account) might be cut off, or he might receive a
warning that if his record did not improve he would be dismissed. ^^
That insecurity of tenure and role ambiguity contributed to lowered morale on the part of
family planning workers was indicated by the low job satisfaction scores given them by their
superior officers presented in Table 2 below.
TABLE

2. Job dissatisfaction of block extension educators as viewed by district

family planning officers and block development officers

Number

Officer

34
56

District Family Planning Officer

Block Development Worker

Block extension.educator
Satisfied
Not satisfied
16%
25%

84%
75%

Significance
001
001

Source: Elder op. cit., 'Mailed District Family Planning Officer Questionnaire and Administered Block Development Officer Questionnaire,' pp. 357, 409.
' For a brief explanation of the manner in which various parts of this study were carried out see footnote 1.
' The author was unable to ascertain the exact number of dismissals each year, but a fairly accurate estimate was
possible. 34 district family planning officers who responded to a written mailed questionnaire involving their job
activities reported that 96 health assistants and 30 extension educators had been dismissed in their districts during
1967-68. There were 510 blocks represented in the 34 districts. This would appear to indicate a termination level
of one worker for every four blocks. As approximately one block extension educator and two health assistants
were posted in each of these blocks during 1967-68, the dismissal rate for this sample would be one in twelve, or
approximately nine per cent. Elder op. cit., 'Family Planning Officer Mailed Questionnaire', p. 356.
^' Block extension educators from 105 blocks in 39 districts reported 100 warnings, 30 dismissals, and six pay
stoppages during the same period. 70 per cent of all block extension educator respondents reported cutback in
touring allowance requests, while 30 per cent had received no touring allowance at all. Although the nine per cent

252

ROBERT E. ELDER, JR.

Block extension education reflected a dissatisfaction rate still higher than the estimates of
their superiors. Only two out of 18 interviewees were satisfied with their job. Most seemed aware
that their performance was less than satisfactory, but generally attributed job difficulties to factors
beyond their control: low status, lack of power, and the constant threat of dismissal. A block
extension educator from Allahabad District accurately reflected the feelings of block extension
educators interviewed when he said:
'My morale is very much down. There is no reward even if I do the best work. As the job is
only temporary, the threat of dismissal always hangs over my mind. Because of this, I have to
give more time to flattery and acting as a yes-man to the oflicers and less time to my actual work.
Otherwise, these people may report against me and I'll be turned out the next day. Here we are
getting more than Rs. 300 if we can get even 200; with self respect and security of job, we would
resign this next
RELATIONSHIPS BETWEEN DIFFERENT CATEGORIES OF WORKERS AND MULTIAGENCY FORTNIGHT CONCEPT

An increasingly large part ofthe family planning workers' inability to procure cases was due to the
fact that multi-agency fortnights forced them to compete for targets with members of other
agencies. Each ofthe stafl's with whom the family planning workers were being forced to compete
possessed suflicient power to command favours and/or obedience from villagers. The block
development staff controlled seeds, fertilizers, and the granting of loans. Members of the health
staff, such as the sanitary engineer, administered food adulteration statutes and thus had considerable control over the merchant castes, and revenue workers dealt with tax collection and
land redistribution. Even basic health workers brought medicines to the villages and so possessed
some power.
All these categories of workers had been of some assistance to family planning workers in
making contacts with villagers prior to the institution of multi-agency family planning fortnights. ^^
However, at the point where they became involved in the family planning programme they
also became subject to targets and the threat of dismissal. ^""^
In competition with more powerful revenue and development staffs, family planning workers
were not able to compete on an equal basis. Table 3 indicates comparative achievement statistics
for family planning, revenue and planning staffs in seven districts of Uttar Pradesh during a tenmonth period in 1968-1969.
When revenue and development workers were forced to achieve targets, co-operation with
family planning workers virtually ceased and competition became intense. Two examples given
by family planning worker interviewees show the sort of competitive situation which existed.
'Case I: Taken at the Camp
A., a health assistant from Jaunpur District, had worked two days in Kyothali Village
preparing two cases for a family planning vasectomy camp which was to be held near the block
dismissal rate reported by block extension educators was comparable to that given by the district family planning
officers, it is easy to see that the overall discipline rate was considerably higher. Elder, op. cit.. Part 3, 'Block Extension Educators Administered Questionnaire', p. 369.
'^ Block Extension Educator, Allahabad District, Oral Communication, January 1969.
^^ It should be added that relationships between family planning workers and workers of other agencies were
never excellent. Family planning has never been a popular programme, and whoever has been associated with it
has suffered in terms of popularity at the village level to some degree.
** The National Herald on 23 June 1968 contained an article stating that 300 lekhpals had been suspended for
failing to motivate their required number of cases. On 16 October 1968, the Hindu paper, Tarun Bharat carried an
article which declared that village level workers were not receiving their wages because they had not brought cases
for vasectomy. See The National Herald, 23 June 1968, p. 4. See also Tarun Bharat, 16 October 1968, p. 3.

TARGETS VS EXTENSION EDUCATION

253

health centre. When the two men arrived at the camp the next day, A. came forward smiling to
offer ''namasthe'' (hello, greetings). Before he could greet them, B., a lekhpal (revenue worker)
came up to them and offered them both 30 rupees in cash and the allotment of two bighas of
land if they would undergo vasectomy under his name.'^
Case II: At the Time of Motivation
C , a health assistant from Mathura District, motivated two cases for vasectomy. The village
level worker of this village was present at the time and, taking them aside, quickly explained that
C. would give them little, but that he could give them three times the amount of fertilizer they
had requested if they would go with him for vasectomy. The two villagers readily agreed.'^^
Because there was no officer in the block with sufficient interest in the cause of the family
planning workers to intercede on their behalf, the lot of the health assistants and block extension
educators was made extremely difficult. ^^
TABLE

3. Vasectomy cases brought by family planning., revenue and planning

staffs in first ten months of 1968-69

Divisions

Planning

Revenue

Family
planning

Others

Total

34(2/)
*500(34%)
518(35%)
414(28%)
157(28%)
111(20%)
*192(35o) 92(17%)
168(32%)
152(2900)
115(22^) 88(17O
405(51%)
109(14%)
277 (35/)
0(0%)
1,270(27%)
3,061 (65%)
347(17%)
26 (Po)
979 (40%)
683 (28%)
494 (20"0) 318(13%)
608 (32%)
448 (24%)
514(27%) 335 (18%)
4,001 (32%)
5,082(41%)
2,439 (20 ) 893(7%)
* This figure includes cases brought by both Health and Famil>' Planning Staff.

Lucknow Division A
Meerut Division A
Lucknow Division B
Lucknow Division C
Agra Division A
Nainital Division A
Meerut Division B

1,466
552
523
791

4,704
2,474
1,905
12,415

Source: These figures were collected from statistics available at seven district planning bureaus
visited during the month of December 1968.
TWO STUDIES OF CASE QUALITY
SINGH PRAI STUDY, 1 9 6 6

As was indicated by the responses of block extension educators in Table 1 above, family planning
workers felt that the predominant interest of their superior officers was that they should achieve
as large a portion of their target each month as possible, that quality might be sacrificed to achieve
this target, and that rewards would go to those workers who achieved their targets while nonachievement would bring the threat of punishment.
The result, according to extension educator interviewees and newspaper coverage of the
programme, was that the cases that were brought were having little impact on efforts to lower the
birth rate. They included people over age, unmarried people, people from polyandrous households, individuals who were sick, or too young, as well as a large number of untouchables.'^
'* Health Assistant Jaunpur District, Oral Communication, November 1969,
'* Health Assistant Mathura District, Oral Communication, October 1968.
" At the block level control over family planning workers was divided between the block medical officer and
the block development officer, neither of whom were members of the family planning department,
'^ Newspaper articies tend to lend some credence to interviewers' conclusions. From December 1967 to January
1969, The Pioneer and The National Herald earned 17 separate articles in regard to improper cases of vasectomy.
See in this regard. The Pioneer, 'Vasectomy on Mendicants', 2 December 1967, p, 3; 'Vasectomy Leads to Dacoity',
24 December 1967, p. 7; 'Vasectomy Scandal: Congressman's Protest', 28 March 1968, p, 6; 'Stricter Control Over'

254

ROBERT E. ELDER, JR.

Although research in this area has been extremely limited, such studies as have been carried
out tend to support these findings. Prior to January 1969, only two studies on vasectomy had
been undertaken in Uttar Pradesh.
One of these carried out by the State Family Planning Department in 1965, indicated that at
least 30 per cent of all cases operated on for vasectomy were over age. A more intensive study
undertaken early in 1966 analysed 1,000 persons motivated for vasectomy in the Barabanki
District. Investigators looked at records at the primary health clinics where the operations had
been carried out and questioned each patient on his age, marital status, and number of children,
living and deceased. The essence of the findings are presented in Tables 4 and 5 blow.
TABLE

4. Age of vasectomy respondents as recorded and

verified

Age
Below 30 years
30-39
40-44
45-49
50 and above

Official records
1%
23%
29%
33%
14%

On the spot verification

3%
17%
14%
17%
49%

Source: Ranbir Singh, 'A Study of Sterilization Cases in a District of Uttar

Pradesh', Research Section, Rural Health Division, Planning Research
Action Institute (Lucknow: 1966, unpublished, mimeographed, 20 pp.), p. 13.
TABLE

5. Types of persons vasectomized

Types
Having wives 45 or older
Unmarried
Widower or separated
With wives below 45 years of age
(1) Having one or no child
(2) Having two female children
(3) Having two children excluding (2) above with the
youngest child not exceeding five years
Total

Per cent
35-5
60
21 0
1-7
04
24
670

Source: Ranbir Singh, 'A Study of Sterilization Cases', p. 15.

As is evident from these tables, substantial discrepancies existed between the ages recorded
in ofiicial records and the actual ages as verified by this investigation team. 67 per cent of the
cases examined did not meet government requirements for a valid vasectomy.
ELDER STUDY,

1968

In December 1968, the author attempted to discover whether variations in the quality of cases
brought by different agencies might be a major factor contributing to the rising number of
Vasectomy', 3 July 1967, p. 3; 'Seventy-two Year Old Man Undergoes Vasectomy', 3 May 1968, p. 7; 'Forced
Vasectomy on Unmarried Man', 24 May 1968, p. 6; 'Unmarried Man Sterilized', 23 May 1968, p. 6; 'Forcible
Vasectomy on Seventy-Year Old Man', 23 August 1968, p. 2; 'Vasectomy Done on Bachelor', 10 September 1968,
p. 6; 'Poverty Drives Young Man to Undergo Vasectomy', 22 September 1968, p. 6. See also in this regard The
National Herald, 'Family Planning Drive in Basti', 24 March 1968, p. 4; 'One Dies After Vasectomy', 7 September
1968, p. 7; 'Family Planning: Complaints of Villagers', 11 September 1968, p. 3; 'A Bachelor's Complaint', 14
October 1968, p. 7; 'Vasectomy Done on Bachelor', 14 October 1968, p. 7; 'Small Family or No Family', October
1968, p. 6.

255

TARGETS VS EXTENSION EDUCATION

demographically valueless vasectomies. It was reasonable to suspect that this might be the case,
given that 73 per cent of the patients were being brought in by block and revenue workers who
had neither interest nor training in family planning extension education. The study analysed
data from 1,606 vasectomy cases from nine districts in Uttar Pradesh. Their distribution by agency
in terms of husbands aged over 45 years, wives aged 38 or over, and families having five or more
children are presented in Tables 6-8 below.
TABLE

6. Percentage of husbands 45 years of age or over, brought in for

vasectomy by different agencies
Husbands over 45

District
Aligarh
Almorah
Barabanki
Hardoi
Lucknow
Meerut
Muzzafarnagar
Nainital
Sitapur
Base
Mean Percentage

Percentage of total

Total by
district

Family
planning

167
191
204
118
291
142
274
172
47

Revenue

Planning

Health

Other

20%
31%

47%
46/o

43//
41%

26//
27/o
37%
9%
13%
35/o
25//

43//

35/o

44/o

38/o
46%
28/o
33/o

80/o
0%
55/o
60/o
9o
I3/o
10%
20 0

35%

17%

33%

0
0
13/
0
0
0
27%
0
0

28/o

39%

33/o

31%

4%

22/o
43/o

23%
49%

11%

1606

Source: Information for Table 6 was procured from a selected sample of vasectomy patients
from the districts mentioned above, 10 December 1968 - 14 January 1969.
TABLE

District
Aligarh
Almorah
Barabanki
Hardoi
Lucknow
Meerut
Muzzagarnagar
Nainital
Sitapur
Base
Mean Percentage

7. Husbands with wives aged 38 or over, by agency

Total by
district

Family
planning

165
185
198
118
292
147
272
157
47

16%
23%
26%
22%

20/o
17%
23/o
21%
0%

Revenue

Planning

Health

Other

46%
54/o

69%
20%

60%
20//

24%

73/o

52/o
49/o
37/o
52/o

17%
49%
46%

52%
50/o

0
25%
33/o
67/o
2'o

31%
50%

11%
41%

44 0

40%

30/o

46%
28%
18%
0%

0%
37/o

20%

67/o

O^^o

38%

20%

1581
19%

Source: Information for Table 7 was obtained from a selected sample of vasectomy patients
from the districts mentioned above, 10 December 1968 - 4 January 1969.

As was indicated in Tables 6 and 7 above, revenue staff workers were bringing in larger
proportions of demographically marginal patients than did workers from the planning, health,
and family planning departments. The quality of patients brought by family planning department
personnel varied considerably between districts. However, in only one district did the number of
women aged over 38 and men aged over 45 brought in by family planning workers exceed 35 per
" L Z. Husain, Mean Age at Marriage and Natality, Demographic Research Centre Department of Economics,
University of Lucknow (Lucknow: 1968), p. 13. Miss Husain places the mean age at marriage of males and females
in Uttar Pradesh at 18-76 and 14-40 respectively. A man aged 45 has had on the average, 20 years of married life

256

ROBERT E. ELDER, JR.

As regards proportions of patients, who did not meet vasectomy criteria, results were almost
as discouraging as the Singh Study cited above. Table 8 presented below indicates that 62 per
cent of the men in the sample tested had wives aged 38 or over, five or more children, or both.^
It might be argued that for a relatively recent programme involving the type of social change
required, the family planning programme was making substantial progress. Elderly people, or
those who had large families, were making some demographic contribution to the programme.
In addition, a nucleus of family planning acceptors was being created in each village which would
make vasectomy appear less and less anti-social for those who still remained to be motivated.
If this was the government's intention, then the present policy may in some cases have been
successful.
TABLE

8. Number of men in the sample with wives aged 38, or over five or
more children, or both

District
Aligarh
Almorah
Barabanki
Hardoi
Lueknow
Meerut
Muzzafarnagar
Nainital
Sitapur

Number of Number of
Total
number of
men with
casesf
cases'* wife 38 or over

Five or
more
children

Number
with
both

92
60
98
45
128
51
81
28
21

84
87
47
51
128
61
121
78
67

129

165
185
198
118
292
147
111
157
47

163
205
203
107
301
147
261
170
47

no
122
75
201
11
151
96
28

1,581
1,604
* Total number of cases in which data on wives were available.
t Total number of cases in which data on number of children were available.
Source: Information for Table 8 was obtained from a selected sample of vasectomy cases
from the districts mentioned above, 10 December 1968 to 14 January 1969.

Yet the government was making frequent pronouncements about the number of births
prevented by vasectomies performed each year. Until the autumn of 1968, it had made no effort
to collect the age breakdown of patients undergoing vasectomy and may have been misleading
itself as to the number of births it was in fact preventing. ^^ Furthermore, the distortions which
occurred daily as a result of the pressure to achieve targets were having as great a negative as
and a woman aged 38 approximately 24 years. 45 and 38 years and over were selected as cut-off ages for males and
females respectively, not only because it was reasonable to assume that a man or woman will have achieved most
of his or her family by this time, but also because of the distortion of agefiguresdiscussed in the early PRAI study.
Age is very diflficult to ascertain at the village level and in a programme where popular acceptance is not equal to
the targets which must be achieved it is likely that age distortion continued to occur at approximately the same
frequency as was ascertained in the PRAI study. District Family Planning Officers interviewed, with one exception,
gave estimates of invalidity ranging from 50 per cent to 75 per cent and agreed that statistics given in case cards
and vasectomy registers were, generally speaking, understated. For this reason the relatively high percentage of
marginal cases which appeared in this sample gave some cause for alarm. If all case ages were increased by only
five years, between 40 and 45 per cent of the cases in the sample selected would be invalid on the basis of age alone.
^ Although it is fairly easy to understand why the bringing in of wives over age is no positive contribution to a
lowering of the birth rate, the category of five or more children presented in Table 8 deserves explanation. Since
the programme is attempting to limit families to two or three children, vasectomizing family heads who have had
five or more children is very much like shutting the barn door after the horse is already out. When they are in their
middle thirties the number of births prevented may become inappreciable.
2^ The author discovered that no effort was made to break down case statistics by age when they were forwarded
to the State office, until the autumn of 1968 in interviews with district family planning officers in December 1968.
It should be kept in mind that if information received by the State offices was distorted to the extent portrayed in
the Barabanki study, the government, even when in possession of age statistics, may have been misleading itself,
if it accepted them at face value.

TARGETS VS EXTENSION EDUCATION

257

positive effect on popular attitudes toward the programme. Rather than create a nucleus of
support for family planning practices in each village, it was just as likely that programme policies
were creating reservoirs of distrust.
VILLAGER ATTITUDES TOWARD FAMILY PLANNING

An indication of possible negative effects which the programme had on the Uttar Pradesh populace was found in the responses and attitudes of a sample of villagers and their popularly elected
representatives.
TABLE

9. Programme organization and implementation as perceived by villagers'

multiple response
Base 335

Affirmative
responses

The workers rarely visit the villages, no systematic education programme is

conducted.
Workers only talk of loop or vasectomy; they do not talk of anything else
Workers are scolded by people wherever they go. People even chase them out
of the village. They do this because they talk only of vasectomy.
People are only forced to become acceptors but the follow-up of the case
after vasectomy does not happen.
Workers come and collect data about family members. People get scared.
The wrong type of people are forced to take vasectomy simply to inflate the
numbers.
People are given allurements and false promises are made. Sugar, blankets,
and even land are promised, but these promises are not often kept.
Pradhans (village leaders) are used to put pressure on prospective acceptors.
Workers come and make night halts, properly educate people, do not force
people to accept exhibitions, cinema shows are organized. Sometimes,
meetings are also organized by them.
We have had little contact with the programme or its personnel and could
not give an answer in regard to programme organization or implementation.

Per
cent

81
55

24-2

2-4

9
49

2-7
146

2-7

30
4

90
1-2

31

9-3

103

307

164

Source: Elder, op. cit., 'Village Level Questionnaire,' p. 415.

TABLE

10. Whether the programme organizationneeds any revision

Base 335

Frequency

Per
cent

It should be continued to run as it is

It needs revisions and changes
Do not know

43
132
160

12-8
39-4
47-8

Source: Elder, op. cit.. Question 11, 'Village Level Questionnaire,' p. 415.

Village respondents were asked three questions in regard to the attitudes which they held
toward family planning workers and the programme as it was currently being administered:
the manner in which the family planning programme was organized (Table 9), whether they
thought changes were necessary (Table 10), and the changes they would suggest, if given the
opportunity (Table 11).
The responses of villagers to the programme which had been instituted tend to be consistent
with the hypothesis generated by the data presented earlier in the paper. A situation had been
created in which villagers remained essentially uninformed about the immediate benefits and

258

ROBERT E. ELDER, JR.

long-range goals of family planning, and yet were periodically confronted with the negative
results of a target-oriented, time-bound programme which left a number of acceptors dissatisfied.
At best, their reactions were to suggest that changes must take place before the programme
would gain acceptance. Moreover, a substantial percentage of the sample studied (49 per cent)
who were willing to make suggestions in regard to the programme, would have abolished it
altogether.
TABLE

11. Suggested modifications of programme made by respondents who

felt that modifications should take place - multiple response
Base 132

More emphasis on education, efforts to be more concentrated on females more frequent visits by workers - efforts and demonstration of recanalization of vasectomy.
Vasectomy operation should be performed only on eligible couples.
More emphasis should be on mass publicity and group meetings.
There should be extensive follow-up of acceptors.
More efforts should be on making female acceptors for IUCD, tubectomy,
etc. - as they can effectively prevent pregnancies more than men. Muslims
should also be asked to accept family planning.
Treatment of sterile couples.
There should be efforts to popularize simple methods. Associated problems
such as sepsis, bleeding, etc. should be minimized by providing medicines.
Workers should not manipulate or make false promises or force acceptance.
Promises should be fulfilled.
Workers and government officials should accept family planning first.
Legislation in support of the programme should also be passed.
Lands should be given as incentive for vasectomy. Programme should be run
through acceptors. Marriage age should be raised to 28 for males and 22
for females.
Family planning should be eliminated altogether. It is against religion.
Vasectomy leads only to impotence and causes both physical and moral
deterioration.

Frequency

Percent

14
12
11
10

106
91
8-3
7-6

8
7

61
5-3

10

7-6

3-8

23

3-0

64

48-5

Source: Elder, op. cit., 'Village Level Questionnaire,' p. 415.

A ttitudes of Elected Representatives

In a democratic context popular dissatisfaction will be mirrored in the attitudes of elected officials,
and, in a democratic state, administrators operate and implement programmes only at the discretion of popularly elected officials. The section which follows presents results of an examination
of the attitudes of a selected sample of Uttar Pradesh legislators in an effort to ascertain the
extent to which such a reaction had already occurred.^^
One area of legislator opinion which was examined concerned the manner in which the
programme was being implemented and whether or not they felt that their constituents were
favourably inclined toward it. Respondents were asked to estimate what percentage of the
patients in their district brought in for family planning were demographically invalid and what
percentage they thought were brought in by non-extension education as opposed to extension
education techniques. Respondents' answers are presented in Tables 12 and 13.
Although it is likely that the percentages given by legislators in Tables 12 and 13 were
exaggerated, the actual percentage of invalid cases brought in produced the high negative
response. This is indicative of the fact that legislators, like the villagers and subordinate level
workers, felt that education had been sacrificed to target achievement and that because the
2^ See footnote 1, also see Elder, op. cit., pp. 434-438.

TARGETS VS EXTENSION EDUCATION

TABLE

259

12. How many of the cases being brought in for vasectomy and loop
in your constituency are valid?

Responses invalid
90% and over
70-89%
50-69%
25-50%
0-25%

Frequency

Per

cent
28
3
4
5
2

67
7
10
12
5

Source: Elder, op. cit., 'M.L.A. Questionnaire,' p. 438.

TABLE

13. What percentage of the cases being brought in from your constituency
have been produced by non-extension education techniques ?

Responses non-educational
90% and above
70-89%
50-69%
25-50%
0-25%
No answer

Frequency

Per
cent

29
7
3
0
2
1

69
17
7
0
5
2

Source: Elder, op. cit., 'M.L.A. Questionnaire', p. 438.

pressure to achieve was particularly strong, many people who could make little or no contribution
to the programme's goals and objectives were included.
When questioned on the opinions of their constituents concerning family planning, the
pattern remained essentially negative. Responses are presented in Table 14.
14. What percentage of your constituency would you say is favourable to
the family planning programme as it is currently being administered ?

TABLE

Unfavourable

Frequency

Per
cent

90% and above

70-80%
50-69%
25-49%
0-25%

34
6
2
0
0

81
14
5
0
0

Source: Elder, op. cit., 'M.L.A. Questionnaire,' p. 438.

It is evident from responses presented in Tables 12 to 14 that legislators had concluded that
the programme was not achieving its intended goals. Given these attitudes, it was not surprising
that their support for new measures in this field was less than enthusiastic. Tables 15 and 16
below indicate respectively the priority given to family planning vis a vis other areas of development by Uttar Pradesh legislators and the degree to which they would be willing to continue
financial support for the existing programme.

26o

ROBERT E. ELDER, JR.

Responses presented above indicated that a significant majority of Uttar Pradesh legislators
in mid-1969 felt that the programme as administered was neither popular nor effective. On the
basis of these feelings, they were unwilling to grant additional funds for the present programmes.
53 per cent of the sample studied suggested that funds be cut. In terms of development, family
planning was clearly at the bottom of their lists.
Unless a popular base of support for the programme is created, the central government
will have to support it indefinitely. Such a consensus will be difficult to create without the help of
elected representatives, the majority of whom in 1969 were hostile to the programme. They felt
TABLE

15. Rank the five activities listed belo w in terms of their

importance to India's development*

Activities

Frequency

Agriculture
181
Education
147
Rural industries
127
Rural health
110
Family planningf
71
* First ranks in priority were given five points, last ranks one and totals
for 42 respondents added for each development area in order to obtain
figures presented above.
t The Government of India had given family planning number two
priority in the Fourth Five Year Plan, In light of this, the fact that family
planning was given such a low priority by Uttar Pradesh legislators is
especially significant.
Source: Elder, op. eit., 'M,L,A. Questionnaire,' p, 438,
TABLE

16, Should allocations in regard to family planning be raised or lowered

or remain the same ?
Responses

Frequency

Per
cent

Should receive less

8
19
Raised without qualification
5
12
Raised if properly utilized
6
14
Remain the same*
9
21
Stopped completely
14
33
* This could be seen as a negative statement because at this time most of the money for the
financing of family planning programmes is being given to the State by the Centre,
Source: Elder, op. eit., 'M,L.A. Questionnaire,' p, 434,

that family planning was already being given far greater priority than it deserved. It is likely
that a major reason for both popular and legislative hostility towards the programme was caused
by the distortions which had occurred as a result of the changes in programme methodology
begun in 1965.
POSTSCRIPT

Since the research on this paper was completed (July 1969) two major changes - a large-camp
approach and greatly increased incentive fees (from ten to 80 rupees) for vasectomy - have been
made in the family planning programme. These changes, which were first introduced in 1971
in the Gorakhpur Division, are more of emphasis than of policy.

TARGETS VS EXTENSION EDUCATION

26I

The large-camp, large-incentive approach assembles as many as 100 doctors in mobile

camps located in a single administrative division. The programme is administratively similar to
that of the multi-agency fortnight concept. As usual, members of all agencies of the government
are encouraged to bring cases to the camps. The local family planning staff is again in charge of
follow-up, but is given no special targets. Most importantly, the primary health centre doctors
(the local doctors) are not allowed to participate, except where absolutely necessary.
The theory behind this approach is that when large numbers of people from a given area
accept family planning, the programme will be more easily popularized. This appears to be true,
for the programme thus far has had great success in terms of the number of cases being brought.
66,000 vasectomies were performed in the Gorakhpur Division Pilot Project Camp during one
month in 1971 and, for the first time, Uttar Pradesh came close to meeting its targets. Additional
camps have been held since then with equal success.
The large-camp approach has seemingly solved the problem of target achievement, but what
of the problems of case quality ? Case quality figures at the Gorakhpur camp have not yet been
released, but it is reasonable to assume that a fairly high percentage of invalid cases will be found.
The sole criteria for acceptance were that the patient should state that he was married, had two
children, and was not more than 44 years old. With the high (80 rupee) incentive fee (representing
two to three months' earnings to the average Indian) and the difficulty of determining age in a
culture where men often look old, it is likely that invalid cases could slip by. In addition, nonindigenous overworked camp staffs, concerned with making the programme a success, might be
expected to be even less careful than local units.
Another disturbing factor concerns the quality and quantity of case follow-up. Because of
poor family planning staff attitudes and an overemphasis on quantity, follow-up was inadequate
under the old system. Yet now, with the local staff being by-passed, and the number of cases to be
followed up rapidly increasing, will family planning workers be any more eager to follow up
cases they have not even brought in themselves ? Sepsis in even a small number of cases may further
harden villagers' attitudes toward family planning.
Further, the emphasis of the large incentive fee approach represents a rejection of the extension education approach. Extension educators' morale, which was already low, may have
deteriorated further as less use was made of extension education techniques. Apparently, a
quantity-oriented approach continues to take precedence over a quality-oriented extension
education approach in the family planning programme of Uttar Pradesh.^^
^^ Oral communication with Professors George and Ruth Simmons, Population Planning Staff, University of
Michigan. Mr and Mrs Simmons did an intensive study in 1971 of family planning in the Allahabad Division in
co-operation with the Department of Sociology and Demography, Indian Institute of Technology, Kanpur.
It would also be appropriate at this time to express appreciation to Eric Brown, my student assistant, for providing
editorial assistance during the second of three drafts of this paper, produced in the spring of 1973.