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close this bookThe Value of Family Planning Programs in Developing Countries (RAND, 1998, 98 p.)
close this folderChapter Three - THE RECORD OF FAMILY PLANNING
close this folderThe Basics of Program Success
View the document(introduction...)
View the documentResponding to Client Needs
View the documentManaging Effectively
View the documentPromoting Family Planning
View the documentSelecting a Delivery System
View the documentMobilizing Support


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



Method access

Pills access

Proportion with easy access to pills or injectables

Condom access

Proportion with easy access to condoms, diaphragms, or spermicides

IUD access

Proportion with easy access to IUDs

Female sterilization

Availability of female sterilization and proportion with easy access

Male sterilization

Availability of male sterilization and proportion with easy access


How frequently stocks of supplies and equipment are adequate


Training programs

Adequacy of staff training programs

Tasks execution

How well all staff categories carry out assigned tasks


Whether client records are kept, summarized, and fed back to clinics

Managers use evaluation

Extent of use by program managers of evaluation and research results to improve program


Whether program-related demographic and operations research are conducted and whether staff or other institutions exist for this purpose


Adequacy of supervision at all levels


Government policy

Whether government officially supports family planning and population control

Public statements

Whether high officials publicly state support for family planning

Rank of leader

Rank in the bureaucracy of the family planning leadership

Other ministries

Involvement in population activities of ministries and government agencies without primary responsibility for service delivery

Civil bureaucracy used

Use of civil bureaucracy (including central, provincial, district, and county administrators) to ensure program directives are carried out


Whether incentives and disincentives are provided to clients or staff


Advertising restrictions

Freedom from restriction of contraceptive advertising in mass media

Social marketing

Extent of coverage by subsidized commercial contraceptive sales

Media coverage

Frequency and coverage of mass media messages

Medical approaches

Abortion access

Proportion with easy access to abortion under good conditions

Postpartum programs

Extent of coverage by postpartum programs

In-country budget

Proportion of family planning budget provided from country sources

Missionary approaches

Community distribution

Extent of coverage by community-based contraceptive distribution programs

Private agencies

Involvement of private-sector agencies and groups

Home visitors

Extent of coverage by family planning workers who visit women's homes


Administrative structure

Adequacy of national, provincial, and county administrative structure and staff

Age-at-marriage policy

How high the minimum legal marriage age for women is and how strongly it is enforced

Import laws

Whether laws facilitate contraceptive imports or local manufacture

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

Initial Level of Family Planning Effort

Dominant Concern

Client Focus

Main Source of Support

Extensiveness of Program Functioning

Very weak (0-24)


Highly motivated couples

Donors and voluntary organizations

Very few sites

Weak (25-54)


Couples with unmet demand


Limited coverage

Moderate (55-79)


Broad populations


Extensive coverage

Strong (80+)


Least accessible populations


Increasingly selective coverage

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.