|The Value of Family Planning Programs in Developing Countries (RAND, 1998, 98 p.)|
|Chapter Three - THE RECORD OF FAMILY PLANNING|
|The Basics of Program Success|
Consider first some of the evidence that a program that responds to client needs increases contraceptive use:
· Improved access to services helps clients. Access can vary greatly: Some countries may have only one service point for 15,000 women; in others, every community may have at least one such facility. Such variation in proximity to services, according to a review of 16 studies that differ widely in methodology, does affect contraceptive use, even controlling for other factors (Tsui and Ochoa, 1989; Angeles et al., 1996). Expanding access when contraceptive use is still limited is especially important (Phillips et al., 1994).
· Facilities or field-workers must, of course, have contraceptive supplies available. This is often an obstacle in newer programs, such as several in sub-Saharan Africa that suffer from supply shortages and inadequate logistical planning (UNFPA, 1990). Providing not only reliable supplies but also a wider range of appropriate methods increases use. In the Philippines, for instance, providing an additional method through clinics raises prevalence by 5 percentage points (Samara et al., 1996, p. 48). Increasing method choice need not be costly; data from Bangladesh suggest that adding reversible methods to a program that relies heavily on sterilization need not raise the cost per birth prevented (Simmons et al., 1991).
· Measures that promote continued use are also helpful. Improved counseling and better client information, for instance, lead to better method choices, fewer complaints about side effects, less-frequent discontinuation (W H O, 1980), fewer method failures, and less need for abortion. But the possible choices still have drawbacks that discourage some women, although others persevere despite them. Focus-group researchers quote one woman in Karachi as saying: "There is pain in these methods, but at least there is no danger that the woman will conceive" (Snow et al., n.d.). Research to improve contraceptive methods and develop new ones is still critical and requires continued public-sector funding (Harrison and Rosenfield, 1996).
· Whether ancillary services should also be provided is a complicated issue involving difficult trade-offs. Clients have other needs and demands besides contraception, and a program that can address these may be more effective and may also make critical contributions in such related areas as the attempt to contain the human immunodeficiency virus (HIV) and the acquired immun-odeficiency syndrome (AIDS).4 Some added services, including pregnancy tests, Pap smears, and screening for sexually transmitted diseases, are sufficiently integral to providing contraception that their role in a clinical program is clear. Other services range farther afield, from emergency obstetric services to income-generating activities for women and female education. Certainly desirable themselves, such activities may also promote lower fertility preferences, and combining them with family planning may have synergistic effects. Recognizing such arguments, the 1994 International Conference on Population and Development in Cairo supported the idea of family planning as one among various reproductive health interventions, all to be pursued together. However, ancillary interventions increase program costs, in some cases (as with emergency obstetric services) by quite substantial amounts, and additional financing is seldom easily available. Family planning program staff are not necessarily the proper people to provide ancillary services. Integrating such staff into larger health organizations risks submerging concerns about family planning, which seldom receive adequate attention within health ministries (Finkle and Ness, 1985). For these reasons, the debate about "vertical" (stand-alone) family planning programs versus integrated programs run as part of health ministries has continued unresolved for decades. A series of careful quasi-experiments in Bangladesh concludes that
minimal health provision indeed may indirectly benefit contraceptive acceptance. However, the addition of a broader range of health skills and supplies made no further impact on the success of family planning. Rather there was evidence of a drop in contraceptive use as the attention and energies of workers were diverted. ... Integration must be justified on grounds other than enhanced family planning effectiveness (Cleland et al., 1994, p. 146).
4Attempts at integrating services for sexually transmitted infections (STIs) with family planning, as in Mombasa, Kenya (Twahir et al., 1996), and eastern Uganda (Mukaire et al., 1997), suggest that there are advantages for family planning programs in offering more services, but also difficulties posed by the increased responsibilities. Serious questions also remain about the accuracy of STI diagnoses and the cost-effectiveness of integrated services (Maggwa and Askew, 1997).
The issue of what services to combine with family planning therefore remains to be approached in each case as a matter of values and objectives, but with full awareness of the practical consequences.5
5See Tsui, Wasserheit, and Haaga (1997, pp. 158-163) for a further discussion of the issues from the perspective of reproductive health services - a discussion that does not, however, appear to come to a clear conclusion.