(introduction...)

Beyond the general willingness and ability to unearth and respond to existing demand - whatever the form - are there specific structures, activities, or approaches essential for program success? In 1964, Bernard Berelson, a major figure in the population movement, proposed a set of requirements that have been expanded over time into the 30 items that give the family planning program effort score previously mentioned. The 30 items - shown grouped into sets in Table 3 in accordance with factor analysis results - are widely recognized as indicators of serious organizational effort.

The first two sets of items are central and essential. First, adequate program effort means providing access to a variety of contraceptive methods - pills, condoms, IUDs, sterilization - to meet the varying needs and preferences of couples. To provide such access, a good logistical system is needed. In addition - as the second set of items indicates - effective contraceptive provision requires managing the front-line providers: They have to be trained, made to focus on their assigned tasks, motivated to keep essential records on their clients, and properly supervised in their duties. A good management system that accomplishes these things will also periodically assess progress and use evaluation results to improve operations.

Table 3 - Family Planning Program Effort Items

SOURCES: Descriptions abridged from Mauldin and Lapham (1985, pp. 8-10). See Bulatao (1996) for grouping of items.

³These could include the health ministry, if it is not the primary service provider; the prime minister's office or its equivalent; and a host of other ministries in the areas of social security, planning and development, finance, interior, education, environment, youth and sports, transport, defense, women's affairs, mass media and information, foreign affairs, rural development, urban affairs, religious affairs, and social affairs.

The third set of items has to do with mobilization of government resources to support family planning. Six items reflect this: the adoption of a national population policy; supportive public statements from political leaders; the rank accorded to the program leadership within the government bureaucracy; the involvement of other ministries besides the service delivery agency itself; the involvement of the civil bureaucracy at regional, provincial, and local levels; and the provision of incentives or disincentives to family planning clients or staff. This set of items is somewhat problematic; official support is essential in obtaining program resources but can easily shade into official pressure. In fact, the last item, the provision of incentives, needs to be carefully handled so as not to lead to undue influence on potential clients (Isaacs, 1995).

More consistently important than mobilization is program activity to reach the population with appropriate messages (the fourth set of items), especially through mass media, advertising, and commercial sales. The last two sets of items reflect delivery-system alternatives chosen in some but not other cases: clinic-based or largely "medical" alternatives, such as postpartum programs and abortion, and outreach systems, often with a strong volunteer component, such as community-based distribution, private agencies, and home visitation.

Rather than strict program requirements, a number of these items are alternatives that may be more or less important in particular settings. Few programs receive high scores across all these areas, and even some quite successful programs do little in some areas. In Bangladesh, for instance, where an extensive review of experience concludes that program-promoted changes in acceptability and availability of contraception have been much more responsible for fertility decline than any changes in preferred family size, a few of the items just discussed were identified as critical (Cleland et al., 1994, pp. 97, 122):

· an organizational culture of excellence, stressing dedication to realistic goals and "insulating the workforce from dysfunctional social pressures"

· frequent contact with clients by outreach workers with basic technical skills and strong supervision

· reliable supply of multiple methods and available follow-up and ancillary services.

The essential elements of organizational effort may vary not only by setting but also by stage of development of the program. Table 4 indicates the stages a program goes through, drawing on several schemes suggested by researchers (Bulatao, 1993; Vriesendorp et al., 1989; Keller et al., 1989; Townsend, 1991; Bernhart, 1991).

Table 4 Stages in Program Development

SOURCE: World Bank (1993).

The evidence that program actions in each of these areas contribute to success is varied and complex (and not without occasional contradictions). Some evidence will be briefly reviewed, covering the provision of access to methods and satisfaction of other client needs, management issues, promotion through the media, delivery systems, and political and financial support.