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Family Planning

 Overview/Lessons Learned | Contraceptive Methods | Key Issues
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Program Examples

The programs below illustrate how family planning and reproductive health programs have responded to changing demands for services.

Submit your own Program Example.

  • Bangladesh: Multi-angle approach to improving the quality of family planning services through planning, supervision, training, and referral services.
  • China: The introduction of interpersonal communication and counseling skills into a family planning training program.
  • South Africa: Review of national policies and practices related to contraceptive service delivery in consideration of WHO Medical Eligibility Criteria for Contraceptive Use.
  • Zambia: A national development plan focused on ensuring that all couples and individuals can exercise the right to freely and responsibly determine the number and spacing of their children.



With a population almost half that of the United States in an area less than 2% the size, Bangladesh relies heavily on family planning services to enable men and women to limit family size. Yet use of clinical contraceptives has been declining, in part because the quality of services is often inadequate.

As part of a Bangladeshi government initiative to address these problems, AVSC International implemented a project from July 1995 to March 1997 in five thanas, or counties, in Sylhet and Jhenaidah districts. Its goal was to improve the quality of family planning services and the variety of contraceptive methods available by strengthening four components of the family planning system: planning at the local (thana) level, supervision, training, and referral services.

Approaching Quality Improvement
To get started, meetings were held with key health and family planning officials at the local, district, and national levels to orient them to local planning issues. Then AVSC engaged over 200 providers, supervisors, and support staff at all three levels in COPE (Client-Oriented Provider-Efficient), AVSC's self-assessment technique used to identify and solve problems in service-delivery settings. (For a description of COPE, see

Through COPE exercises, staff identified several factors hindering service quality.

  • Routine examinations were not being performed due to lack of laboratory facilities.
  • Sterilization services were offered in few locations and at limited times, owing to staff vacancies and insufficient numbers of staff trained in the procedures.
  • Norplant implant services were not available at all in the thanas.
  • Clients had limited access to information about clinic services, schedules, and service charges.
  • There was no regularly scheduled pre- and post-natal counseling, no counseling arranged for male clients, and often no separate room available for counseling.
  • Provider supervision and training were insufficient, as was providers' knowledge about sexually transmitted diseases and infection prevention procedures.
  • Linkages between services were also lacking.

Strategies Implemented
To solve these problems, local staff developed and implemented action plans which were reviewed monthly.

Training courses were attended by 183 service providers. Refresher courses were given on all contraceptive methods, counseling, and infection prevention, with comprehensive training given in sterilization, Norplant implants, and injectable contraception. Through facilitative supervision workshops, the supervisors learned new approaches to supporting providers in improving quality.

Providers who participated in the COPE exercises and trainings indicated overwhelmingly that they were becoming more aware of and responsive to clients' needs and rights. They also paid greater attention to counseling, client screening, and infection prevention procedures, reporting that the clinics had become cleaner than before. And client referrals and coordination between sites increased substantially.

In addition, supervisors found that after participating in the workshops, they were better able to identify staff training needs, and their supervisory style became less directive and more helpful. They also gained a better understanding of what was expected of them, and since supervision became easier to perform, they provided it more systematically.

During the project period, there were no dramatic changes in the mix of contraceptive methods used. However, more clients started using clinical contraceptive services than before. Just as important, client exit interviews indicated high levels of satisfaction with the services received during the project period. Almost all clients said that the problem that had brought them to the clinic had been resolved, and all said they felt comfortable discussing the problem with the provider. The clients also believed that they had been treated well by the provider, and said they would recommend the services to friends and relatives.

Of those clients who had also received services within the past year, many noted such improvements in the clinics as the addition of partitions for client privacy, a much-needed fan, greater cleanliness, and better lighting.

Due to the project's success, the interagency evaluation team has recommended extending it for another three years. Ultimately, it is expected that these improvements in quality will result in more individuals and couples requesting clinical contraceptive services.

Adapted from Landovitz, K., Increasing access to contraception , AVSC News 35(4) 1997.

For more information contact Karen Landovitz, AVSC International; 440 Ninth Avenue; New York, New York 10001 USA; phone (212) 561-8000; fax (212) 779-9489; e-mail:
[email protected]

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Studies on communication efforts have shown that mass media and educational tools such as brochures and posters are useful for transmitting information to large numbers of people, but that their influence on behavior change can be limited. Interpersonal communications and counseling provide the needed catalyst and personalized attention to needs and concerns that make a major contribution to behavior change. This country example describes the introduction of interpersonal communications and counseling (IPC/C) skills into a family planning training program for the first time.

One of the strategies the Chinese Government has chosen to improve the quality of its family planning program is to strengthen services in the rural areas, where 70 percent (PRB 1998 World Population Data Sheet) of the population -- about 870 million people -- live. In the early 1990s, the government decided to upgrade the skills and knowledge of family planning workers at the township/village level through its five-year Counseling Training Project. The Counseling Training Project was launched in 20 of China's 30 provinces and served as a pilot project for a larger program. This project addressed key aspects of quality of care in China's national family planning program -- in particular the quality of information and counseling given to clients, and interpersonal relations between service providers and clients.

As a first step, national project staff learned about local realities by conducting knowledge, attitudes, and practice (KAP) surveys with villagers and family planning workers at the grassroots level. The information from this study was used to develop training programs and materials, and was used as baseline data for project evaluation. A "pyramid" training program was designed in which a small group of core trainers from the provincial and prefecture training stations received training, who then trained a larger group of master trainers from their province. The master trainers then trained an even larger number of staff at the county and township levels, who in turn trained village level workers. Ultimately, over 80,000 rural family planning providers were trained.

Trainers acquired skills in interpersonal communication/counseling, adult learning principles, participatory training methods (such as group discussion and skill practice), and development of training materials based on the needs of the audience. Later, trainers learned interpersonal communication/counseling training skills specifically tailored to rural Chinese situations and counseling skills related to help clients select appropriate family planning methods and prevent STD/ HIV.

Post-workshop evaluations showed that family planning workers understood the concept of informed choice and that counseling is important in a family planning program to achieve client satisfaction and effective use of methods. Family planning workers also liked the participatory learning techniques used in the trainings and reported that they learned far more than they had previously through the usual lectures. Feedback also showed that family planning managers and local government officials who had been trained in IPC/C or oriented to the goals of the project were more likely to support the local workers in their efforts to improve the quality of services for clients.

A PATH report, Face to Face: Training Family Planning Counselors in China (1995) provides additional information about this program.

For more information, please contact:
Margaret Britton, PATH, 4 Nickerson Street; Seattle, Washington 98109 USA; phone (206) 285-3500; fax (206) 285-6619; e-mail: [email protected].

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South Africa

The WHO eligibility criteria are intended to be adapted by country programs to reflect the diversity of settings in which contraceptives are provided. Many local factors affect how the guidelines can best be adapted. For example,

  • the level of clinical knowledge and experience of various types of providers in the program
  • the type of service delivery system through which contraceptives are provided
  • local policies regarding contraceptive service provisionthe family planning needs and perspectives of clients
  • resources available at various levels of service delivery
  • the types of contraceptive products registered for use and or available in the country
  • the prevalence of STD or other chronic diseases (such as current liver disease, breast cancer, heart diseases) that limit use of certain contraceptive methods.

South Africa is one of the first countries to undertake a systematic review of the WHO Medical Eligibility Criteria for Contraceptive Use and make recommendations for adapting the criteria for local use in their service delivery guidelines. The review and adaptation process has been coordinated by the South Africa Directorate of Maternal, Child and Women's Health and has involved representatives from numerous women's groups, medical experts, as well as researchers and reproductive health program personnel. Although the adaptation effort is still ongoing, the process has resulted in recommendations for changes in service delivery, training, and research.

The Directorate began its national policy review by asking for feedback from the field. Provincial health departments held workshops involving local stakeholders to review current policies and practices in light of the WHO recommendations. Based on these workshops, local groups developed a list of critical policy questions and identified areas where current practices differed from the WHO recommendations. The same stakeholders will review the revised national family planning policy plan once it has been drafted.

Using locally generated information, The Directorate's Task Force convened to review national policies and practices related to contraceptive service delivery. The group carried out a method by method review and also considered broader issues, such as the need for quality counseling and the individual client's right to choose a method.

In addition to making method specific recommendations the Task Force identified areas for further research as well as a number of technical questions that need to be addressed. For example, the Task Force recommended South Africa-specific reviews of the following issues:

  • the relationship between hormonal contraceptive use and bone density,
  • the acceptability of the diaphragm,
  • the effect of repeated use of emergency contraception,
  • the recommended dose of emergency contraception among women using liver enzyme inducing agents,
  • the feasibility of introducing decentralized female sterilization services, and
  • the relative advantages of triphasic, monophasic, and third generation oral contraceptive products.

During the initial review, the task force recognized but did not attempt to address the program implications of their recommendations. Transforming the group's recommendations into actionthrough changes in policy, training and IEC efforts will be considered as the next step in the adaptation process.

For more information contact Ms. Meena Cabral, Family Planning and Population Unit, World Health Organization, 20 Avenue Appia; CH 1211 Geneva 27; Switzerland; phone (41 22) 791-3360; fax (41 22) 791-4189; e-mail: [email protected]

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The Government of the Republic of Zambia adopted a National Population Policy in 1989 as part of its fourth National Development Plan. This policy recognized the effects of rapid population growth on Zambia's socio-economic development and the need to incorporate population concerns into the national development and planning process.

The main objective is to ensure that all couples and individuals can exercise the basic right to decide freely and responsibly the number and spacing of their children and have the information, education, and means to do so. Other specific objectives include slowing the nation's high population growth rate, enhancing the health and welfare of all, and preventing premature death and illness, especially among high-risk groups of mothers and children.

To help the national and district levels in the planning and implementation of the family planning component of their reproductive health programs, a policy framework was developed. The first section of the document describes the framework for family planning supported by the Ministry of Health. The second section, "Strategies for Providing Family Planning within Reproductive Health" addresses the challenges of providing family planning within the context of the broader context of reproductive health as defined at the International Conference on Population and Development in 1994 (ICPD). It looks at the status of various aspects of reproductive health in Zambia, especially family planningand proposes specific strategies for improving access to and quality of family planning care. For example, the importance of addressing the reproductive health needs of couples throughout their reproductive lives is emphasized. The third section, "Family Planning Methods," contains a technical description of all family planning methods available in Zambia and includes guidelines for service provision based on the revised WHO medical eligibility criteria. Some specific recommendations include:

  • ensuring that providers are trained in all available modern methods,
  • making barrier methods, particularly condoms and spermicides, available through a range of channels,
  • making COCs available through community-based providers who will use checklists based on the eligibility criteria,
  • making family planning methods available to women seeking postabortion care.

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Copyright 1997-2000, PATH.

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