Redefining family planning programs

The Population Council's issue paper entitled Reconsidering the Rationale, Scope, and Quality of Family Planning Programs calls on family planning programs to focus only on reducing unwanted fertility by helping people meet their own reproductive goals safely and ethically. Many family planning programs have been wrongly handed the extra responsibility of reducing wanted fertility. They have therefore used inappropriate means (e.g., incentives, quotas, and coercion) to boost contraceptive prevalence. If programs do focus on reducing unwanted fertility, they will foster reductions in overall fertility and population growth as well as improvements in clients' health and well-being. A new framework has emerged from this shift in rationale. It sets the stage for expanding the scope, improving the quality, and assessing the impact of family planning programs in terms of client choice, health, and well-being. A program needs to determine the range and quality of family planning services it provides at the local level. Local program managers, policymakers, and consumer interest groups should establish minimum or achievable standards of service based on the local health care capacity. Program items that should be assessed include choice of methods, information for clients, technical competence, interpersonal relations, mechanisms to encourage continuity of care, and appropriate constellation of services. The Population Council has conducted rapid appraisals of the quality of care of family planning services to help local program managers to evaluate the strengths and weaknesses of their programs. The HARI (Helping Individuals Achieve their Reproductive Intentions) Index measures a program's success in helping clients safely prevent unwanted or unplanned pregnancy. Program managers can conduct a self-assessment that revolves around answering four questions. Family planning services are an important social investment and are essential to development.     

Measurement and evaluation of national family planning programs

RESUMEN: En los últimos quince a?os diez paises han inaugurado programas nacionales de planeamiento familiar: India, Pakistán, Corea del Sur, Taiwan, Turquía, Malasia, Ceilán, Túez, la República Arabe Unida, y Marruecos. Otros paises, incluyendo Tailandia, Hong Kong, Singapur, Kenya, Barbados, Trinidad y los Estados Unidos, apoyan y/o estimulan actividades de planeamiento familiar. En la mayor parte de los casos la razón fundamental del programa ha sido que si la tasa de crecimiento poblacional disminuyera, aumentaría la tasa de crecimiento económico.Las metas de largo alcance, expresadas típicamente en términos de reducir las tasa.de de natalidad o de crecimiento, tienen su ejemplo en el propósito de Pakistán de reducir su tasa de crecimiento a 26 para 1970; el de Corea de reducir su tasa de natalidad a 20 para 1971; y el de India de reducir su tasa de natalidad a 25 para 1973.Los objectivos intermedios, que cubren diversos aspectos del pro grama, incluyen metas específicas para un determinado mes a a?o, considerando personal, la adquisición de anticonceptivos, y el número de usarios por método. Las metas específicas anuales de aceptantes de dispositivos intrauterinos (IUD), para Taiwán, Corea, Túnez, Pakistán e India, son comunes, tanto por la naturaleza del artefacto, como por la facilidad de medición de los que continúan utilizándolos. El programa de evaluación en Taiwán, que trata de medir por diversos medios los efectos inmediatos, mediatos y de largo plazo del programa de planeamiento familiar sirve de modelo. El propósito de la evaiuación de un programa de planeamiento familiar es contribuir a la efectividad y eficiencia del programa, midiendo y analizando su progreso. Las áreas a medir pueden ser clasificadas como- (1) conocimiento acerca de; (2) actitudes hacia; (3) práctica de control de natalidad; y (4) nivel de fecundidad.Un buen sistema de evaluación debería incluir: A. Un buen conjunto de estadísticas de servicio presentadas en formularios estandarizados, en las siguienies formas: 1. Informes nensuales por áreas administrativas, sobre los actuales servicios de planeamiento familiar proporcionados en la actualidad, de carácter permanente o de larga duración (al presente, esterilización y IUD de acuerdo a las siguientes características del receptor: residencia, edad, paridad (número de hijos vivos por sexo), y donde se enteró del programa, si es posible "clase";(probablemente educación de la madre, pero posiblemente ocupación del esposo, ingreso, o equivalente); prácticas anticonceptivas anteriores; intervalo; y deseo de tener más hijos. En un programa grande estos datos pueden obtenerse en base a una muestra. 2. Informes mensuales sobre la distribución de suministros anticonceptivos (condones, píldoras, sustancias efervescentes, etc.), los primeros suministros deben ir acompa?ados de un registro de las características del recipiente, como anteriormente; los suministros subsecuentes se regietrarán sólo en volumen bruto. Esto también se aplicará al ritmo, donde éste método se ense?e a un número considerable de mujeres. 3. Informes regulares sobre las actividades de planeamiento familiar de médicos privados, como una estimación del efecto catalítico del programa del gobierno sobre ci sector privado. 4. Datos generates mensuales, ppr áreas admirtistrativas importantes, sabre: visitas domiciliarias, reuniones, cu?as radiates y televisadas, avisos en los periódicos y personal que trabaja. 5. Para propósitos de seguimiento una entrevi eta de campo cada 6 a 12 meses a cada N mujer de las listas para (1) y (2) arriba, en un total de 300 o 400, para conocer las tasas de continuación y las razones de abandono (ej: desea otro hijo, insatisfecha can ci método, otras). Las mue.stras podrían ser de 300 cada una, con una supuesta experiencia de 6, 12, 18 y 24 meses. B. Un buen conjunto de datos sobre costa (datos sobre cotos actulaes atribuíbles directamente al programa de planeamiento familiar) fraccionados par áreas principales y cinco a seis categorías de costos importantes tales coma: adminietración, personal de campo, publicidad, suministros, etc. C. Un buen conjunto de dates globales sobre la distribución de los suministros comerciales que puedan llegar tan cerca como sea posible del último consumidor, to cual significa probablemente obtener información de los mayoristas. D. Una encuesta de conocimientos, actitudes y prácticas (KAP) para una evaluación general cada dos a?os. Las preguntas básicas (además de las antes mencionadas y estatus marital y étnico cuando sea pertinente) son: actitud hacia e interés por la anticoncepción, número de ni?os por sexo, deseo de tener más hijos, prácticas anticonceptivas, experiencia sobre abortos, tal vez historia de embarazo (especialmente si esta producirá una tasa de fecundidad válida), aprobación del programa gubernamental (para uso politico), y si está actualmente embarazada (la única y mejor pregunta cuya respuesta habla del efecto sobre la tasa de natalidad). Administrativamente, la responsabilidad por la evalucion debe estar cerca al director, se debe tomar provisiones para obtener informes regulares (meneulaes) y especiales dirigidos a preguntar sobre política. El corolario es que el jefe de evaluación debe tener la confianza del director y debe estar al día en cuanto a las decisiones sabre la politics a seguir. Su trabajo consiste en extractar los aspectos principales que funcionan bien y los no operantes. En cuanto a costos, la evaluación debe hacerse sobre no más del 10 par ciento del costa del programa en paises peque?os (de menos de 30 milliones) y sabre no más del 5 per ciento en paises más grandes.Para medir en que forma el programa satisface el criterio final-la magnitud en que cambia la fecundidad-se debe realizar un trabajo más elaborado en el centro (Universidades, Consejos de población, etc.) para desarrollar una forma (a formas) segura de traducir las estadísticas de servicio en práticas y tal vez aún datos sobre suministro comercial en datos sabre tasas de natalidad. Esto incluye, par ejemplo, los esfuerzos para consolidar observaciones coma "cinco a?os-mujer de usa de IUD, a 400 condones equivalen a la prevención de un nacimiento," y esfuerzos como los de Pakistán de calcular tasas coma "a?os de protección de una pareja contra el embarazo."In the belief that a decrease in the rate of population growth will increase economic development, more than ten countries have inaugurated family planning programs in the past fifteen years. To provide a model for measuring the immediate, intermediate, and long-term effects of any such program, the authors use the Taiwan evaluation.The model suggests that a good system of evaluation should include monthly statistics on (1) participants, who are grouped by characteristics; (2) the distribution of supplies, reported at first by the characteristics of recipients, but after by gross volume only; (3) family planning activities of private physicians to measure the catalytic effect on the private sector; (4) new contacts and amount of advertising in mass media; (5) costs broken down by areas and by cost categories; and (6) distribution of commercial supplies. In addition, the program should conduct 300-400 interviews every 6-12 months to learn the rates of continuation and the rates and reasons for discontinuation. Finally, a KAP survey should be conducted every two years.The administration of the evaluation should be close to the director for policy decisions and for the ultimate work of evaluation-the finding of new ways to measure the main goal of change in fertility by the translation of statistics on Services provided and commercial supplies into birth rate data.     

Integrating reproductive health services into family planning programs

A recent Population Council publication, Reproductive Health Approach to Family Planning, discusses integration of reproductive health into family planning programs in a series of edited presentations that Council staff and colleagues gave at a 1994 meeting of the US Agency for International Development (USAID) cooperating agencies. The presentations reflect the Council's view that family planning programs ought to help individuals achieve their own reproductive goals in a healthful manner. The report discusses four areas of reproductive health: reproductive tract infections (RTIs), including sexually transmitted diseases; prevention and treatment of unsafe abortion; pregnancy, labor, and delivery care; and postpartum care. Christopher Elias (Senior Associate, Programs Division) argued that family planning programs ought to provide services that target RTIs, given that these illnesses afflict a significant proportion of reproductive-age women. The family planning community has an ethical responsibility to provide services to women who experience an unwanted pregnancy. They must have access to high-quality postabortion care, including family planning services. Professional midwives are ideally suited to serve as integrated reproductive health workers trained to combat the five major maternal killers: hemorrhage, sepsis, pregnancy-induced hypertension, obstructed labor, and unsafe abortion. This was demonstrated in a highly successful Life-Saving Skills for Midwives program undertaken in Ghana, Nigeria, and Uganda, and soon to start in Vietnam in conjunction with the Council's Safe Motherhood research program. Family planning services should be viewed as part of a comprehensive set of health services needed by postpartum women, which include appropriate contraception, maternal health checks, well-baby care, and information about breastfeeding, infant care, and nutrition. Family planning programs should incorporate breastfeeding counseling into their services. When programs aim to help individuals meet their own reproductive goals in a healthful manner, this implies that services will not increase clients' risk of morbidity.     

The demographic assessment of family planning programs: a bibliographic essay

Over the past 15-20 years a substantial literature has accumulated in the area of determining the effect of family planning programs upon fertility, and a selected bibliography is provided. The development of modern contraceptive techniques coincided with the development of large national programs designed to reduce the fertility of the general population, and literature is presented on each of the several evaluation methods that have been used to examine program-induced changes in 1 or more fertility measures. 2 methods deal with data on individuals - births averted among acceptors and individual matching; the latter compares the fertility experience of acceptors and matched non-acceptors. A different class of methods is aggregated methods. Either areas and areal variables are the focus of the analysis proceeds with measures on general subgroups identified by such factors as residence, age, or marital status. The aggregate methods are multiple regression, program experiemnts, matching of areas, correspondence between program activity and fertility change, decomposition, and simulation. The disparity in methods has conspired with large differences in programs, data sets, and investigator interests to produce serious problems of non-comparability in results.     

Fertility of rural China: effects of local family planning and health programs

The rationing of births in China after the 1979 announcement of the one-child family policy has been held responsible for the rapid decrease in Chinese fertility, whereas other observers have noted that parallel fertility declines occurred with voluntary behavior in other East and Southeast Asian countries. This paper assesses the joint contribution of local family planning and health programs, individual characteristics of women, and the development of their communities, as explanatory variables for Chinese fertility in rural areas of three provinces in 1985. Given the explicit quantitative reproductive goals of the government, an ordered Probit model for cumulative fertility is estimated for women age 15–34 and 35–49.The authors appreciate the comments on and corrections of our paper by John Ermisch and the programming assistance of Paul McGuire. The financial support of the Rockefeller Foundation is acknowledged.     

Meeting health and family planning needs in Latin America and the Caribbean

The operations research and technical assistance (OR/TA) project in The Population Council has concentrated on fertility and infant mortality issues in Latin American and the Caribbean for more than a decade through INOPAL. INOPAL is an acronym for Investigacion Operacional en Planificacion Familiar y Atencion Materno-Infantil para America Latina y el Caribe (Operations Research in Family Planning and Maternal-Child Health in Latin America and the Caribbean). In March 1995, the project entered its third phase, INOPAL III, with the renewal of its contract from the United States Agency for International Development (USAID). To facilitate communication between INOPAL, collaborating agencies, and USAID, INOPAL Director James Foreit moved from Peru to a Council office in Washington, D.C. INOPAL has six objectives: 1) to test the integration of family planning and reproductive health services; 2) to increase access to family planning; 3) to develop strategies to reach special populations; 4) to improve the sustainability of family planning programs; 5) to improve service quality; and 6) to institutionalize operations research capability in the region. INOPAL II conducted 61 subprojects in 12 countries in collaboration with 24 USAID cooperating agencies and other international organizations. The project established new services for postpartum women, adolescents, and rural women; improved program quality and financial sustainability; increased vasectomy promotion and the range of available contraceptives; and developed new modes of service delivery. A key finding of INOPAL II operations research was the importance of increasing cost-effectiveness to ensure program sustainability. INOPAL III will work toward all six objectives, with an emphasis on integrating reproductive health and family planning services. Operations research and technical assistance (OR/TA) subprojects will focus on the prevention and treatment of sexually transmitted diseases, perinatal and postpartum care, and postabortion care.     

How economic development and family planning programs combined to reduce indonesian fertility

This paper examines the contributions of family planning programs, economic development, and women’s status to Indonesian fertility decline from 1982 to 1987. Methodologically we unify seemingly conflicting demographic and economic frameworks into a single “structural” proximate-cause model as well as controlling statistically for the targeted (nonrandom) placement of family planning program inputs. The results are consistent with both frameworks: 75% of the fertility decline resulted from increased contraceptive use, but was induced primarily through economic development and improved education and economic opportunities for females. Even so, the dramatic impact of the changes in demand-side factors (education and economic development) on contraceptive use was possible only because there already existed a highly responsive contraceptive supply delivery system.     

The differential effects and considerations of family planning programs in basic units]

It has been discovered that the grassroots units that did not well in family planning (FP) programs in China were short of funding, while those units that performed poorly had more funds at their disposal. One of the reasons is that communities which did a good job in FP have less violations of the birth policy, and therefore, fewer fines could be collected by the FP unit. But in those grassroots units were the FP policy was not well implemented, there were more cases of births exceeding the birth quota, and more fines could be collected. Such an outcome was penalizing the diligent and rewarding those who did not work hard. This phenomenon was caused by a severe short fall of funding for the FP program. The program budget allocated by the local government was only 1/5 of what was needed, the remaining part was to be provided by fines. The negative consequences of such a practice was damaging to the morale of FP workers. The following suggestions were make for solving the problem. First, the government budget allocation to the FP program should be increased, and part of the budget allocation should be determined by the performance of the FP program. Second, the spending of income from FP fines should be closely monitored to prevent misuse of the fund. Third, fine collection should not be used as means of income generation for the program, and not other agencies should reallocate the funds from fines. Fourth, the government and FP agencies at all administrative levels should pay attention to the management of funds from fines. FP organizations at higher levels should be able to reallocate the funds from fines collected by units with a poor performance to the units with good program performance as an incentive and to supplement their income.     

Educational efforts in the implementation of rural family planning programs in East Pakistan

The pilot family planning studies reported in this paper were conducted in a rural area adjacent to the city of Dacca in East Pakistan. It reports the preliminary findings of action-research in the implementation of educational efforts to reach rural villagers of a developing country.Preliminary analyses of the records identify two significant educational problems: (1) most of the villagers (85-90 percent of the couples) who initially accepted contraceptives do not truly adopt and become continuing users and (2) the continuing users (10-15 percent of the initial users) are generally characterized by large families. (Later data show an even lower percentage of continuing users.)The field activities in the development of various educational approaches to family planning are described. Three separate geographic areas (from 15,000 to 20,000 population) were each approached in a different way, varying in the number and educational qualifications of the workers and in the degree of involvement of village leadership. Preliminary analyses of field records indicate that these variations of approach apparently have little effect on the percentage of the population willing to accept contraceptive supplies.It is the opinion of the writers that more intensive educational efforts are necessary at the village level to develop social support for continuing use of contraception and to gain adoption of contraception by younger married couples primarily for spacing of births.The impact of introduction of the IUCD in populations where condoms and foam tablets have been available for one to two years has also been reported. Preliminary findings indicate that the IUCD encourages adoption by previous non-users and may increase the over-all percentage of contraceptive users.     

A theoretical framework of collective action for the evaluation of family planning programs

Typically, a family planning program seeks to alter individuals' fertility behavior. The very necessity for the existence of a family planning program presumes that individuals' fertility expectations and behavior are not yet consistent with the objectives of the program. Therefore, some individuals may choose not to cooperate. In this article I establish a theoretical framework for the evaluation of family planning programs by synthesizing the literature on the theory of collective action. Because of the characteristics of collective action — indivisibility and externality — noncooperation (free riding) is bound to occur. Faced with the problem of free riding, a good family planning program should ideally apply selective incentives, localize the costs and benefits, and invest in social capital. The relations among these three factors, cooperation, and fertility are also spelled out.An earlier version of this article was presented at the annual meeting of the American Sociological Association, Washington, DC, 11–15 August 1990.     

Tonga: family planning survey

A survey was carried out in 1975 in Tonga to determine how many families are practicing family planning. Public health nurses visited every household except the Niuas and remote islands. 4253 women out of the total of 9307 married women aged 15-44 years were using a contraceptive (45.7%). The percentage of users ranged from 4.5% in Ha'afeva District to 63.6% in the district of Kolonga. 60% of the users practice effective methods such as the pill, Depo-Provera, IUD, or sterilization; 23% use the condom, and 17% rely on withdrawal, calendar ovulation, or rhythm.     

A note on measuring the independent impact of family planning programs on fertility Declines

This note critically evaluates recent cross-national studies that estimate the independent effect of family planning programs on the fertility of the developing world. The evaluation demonstrates that past research is biased to produce overestimates of net program impact. A new estimate is derived to account more completely for the effects of the social context and socioeconomic development on fertility. This estimate indicates that 5 percent of the variation in crude birth rate decline for 89 developing countries is due to family planning programs. This is substantially less than past estimates.     

Communicating population and family planning

This thorough look at the change in the American family 1900-1700 finds that 40% of marriages among women now in their late 20s may end in divorce, that the divorce rate is stabilizing, that between 1-4% of unrelated men and women are living together in informal unions (the figure made difficult to obtain by the difficulty in framing the question), that 15 million adults live alone, and that only 67% of children live with their own once-married parents. About 33% of births are premaritally conceived. The median age for mothers at birth of last child has moved downward from 33 years in the early 1900s to about 30 years. Childbearing has declined from 3.9 children per mother in the early 1900s to 2.5. The period of childbearing has been compressed to about 7 years, between ages 23-30. 10% of remarried women's children are born between marriages. 50% of pregnancies end in abortion. It was found that persons who had completed an educational level, whether it be high school or college, generally had more stable marriages; those who had not completed a level were more likely to get divorced. Despite changes in lifestyle, however, some typical family situations are experienced by most Americans. 2 of 3 marriages will last until death of 1 of the partners and most young women questioned in census surveys expect 2 children.     

Village family planning: the Indonesian model

The goal of the Indonesian National Family Planning Program is to reduce the 1970 birthrate by 50% by the year 2000. Since the late 1960s the government has taken an active role in family planning. The National Family Planning Coordinating Board initially concentrated on offering family planning services through health clinics on Java and Bali, but, as of 1974, family planning has been expanded to 10 provinces in the outer islands. Early in 1975 the family planning program was extended to the village through the establishment of village contraceptive distribution centers and sub-village family planning groups. The experience generated from the initiation, development and evaluation of the village family planning scheme is useful in many aspects which may be adapted in other countries of the region. The guiding concepts of Java and Bali village family planning have been non-standardization, maintaining a link to the clinic in the movement to the village, and focusing 1st on contraceptive resupply. The following conclusions can be drawn on the basis of the Indonesian experience with village family planning: 1) family planning at the clinic level alone is insufficient in the long run; 2) the village must become involved in the process of providing services; 3) the enthusiasm and imaginative response to the movement in the village has exceeded expectations; and 4) rural people are, in fact, future oriented.     

Thailand: family planning program exceeds targets

According to Dr. Somboon Vacharothai, Director General of the Ministry of Public Health, the number of people in Thailand who practiced family planning exceeded last year's target. 664,895 individuals used family planning services; this was 62.2% above the planned target for 1976. It was further predicted that 700,000 persons would be recruited by the family planning program in 1977. The preferred method of birth control was the oral contraceptive; it is the method of 800,000 acceptors. Service outlets have been extended rapidly with 5836 medical centers providing family planning services throughout Thailand. Government allocations for family planning have increased from 0.9 million dollars in 1975 to 2.47 million dollars in 1977.     

Central Mindanao: selling family planning informally

A research study was conducted in Central Mindanao, Philippines, to evaluate the effectiveness of " selling" informally the idea of family planning to potential acceptors. The study, entitled "the Extent of Involvement of Satisfied Acceptors Clubs/Satisfied Users Clubs" was conducted for the regional office of the Commission on Population (Popcom) by the Notre Dame University Socioeconomic Research Center in Cotabato City. Organized by fulltime outreach workers (FTOWs), the clubs are concerned primarily with the promotion of family planning. The first such club in the region was organized in 1979. Currently, the clubs are linked with other development agencies. The study's respondents were 200 continuing users of a family planning method and were members of the clubs in Illigan City and Cotabato City. Respondents were mostly women (191 or 95.5%), in their early 30s (31%), had 4 children on the average, had reached high school, and belonged to low income families. On the average, respondents had been practicing family planning for around 4 years and 7 months. They were aware of or knowledgeable about the condom, oral contraception (OC), IUDs, rhythm, tubal ligation, vasectomy, and withdrawal. Some of them were aware of injection, abstinence, foam, and the diaphragm. The majority of respondents indicated they had tried other family planning methods before changing to the method they were using. The primary reason for method change was the desire to use a more effective method. The respondents became club members either by being recruited or by applying for membership on their own. Motivating clients to practice contraception was the club's primary activity. 133 club members (66.5%) "claimed to have successfully motivated persons/couples to practice family planning." Among the problems encountered by the clubs, the indifference of people toward the family planning program appeared to bethe most serious from the respondents' perspective. Inactivity of some members was cited as the 2nd most serious problem. The study concluded that despite problems the clubs had been "fairly successful" in helping Popcom promote family planning.