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RHO archives : Topics : Family Planning Program Issues

Annotated Bibliography

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Financial management and sustainability

Arends-Kuenning, M. Reconsidering the doorstep-delivery system in the Bangladesh family planning program. Studies in Family Planning 33(1):87-102 (March 2002).
Based on an analysis of longitudinal data from the Maternal and Child Health-Family Planning Extension Project, the author questions two recommendations made to increase the cost-effectiveness of family planning services in Bangladesh. The first recommendation is to encourage women to switch from nonclinical to clinical methods. Womens preferences for temporary nonclinical methods are reasonable, however, given the context of high child mortality, high infection risks, and limited availability of clinical services. The second recommendation is for field workers to focus on motivating nonusers to adopt a method rather than on resupplying continuing users. Data show, however, that resupply visits will have the larger impact on contraceptive prevalence. Results also suggest that field workers will be most effective if they target their visits to women who are uneducated or live in poor areas.

Barberis, M. and Harvey, P.D. Costs of family planning programmes in fourteen developing countries by method of service delivery. Journal of Biosocial Science 29:219-233 (1997).
This article analyzes the cost-effectiveness of different modes of service delivery in 14 countries, based on cost per couple-year of protection (CYP) in 1991 and 1992. Sterilization services had the lowest cost per CYP (US$1.85), followed by social marketing programs (US$2.14), and clinic-based services other than sterilization (US$6.10). The highest costs were for community-based distribution projects (US$9.93) and clinic-based services with a community-based distribution component (US$14.00). While no single mode of service delivery is appropriate for all settings, the authors conclude that social marketing shows special promise as a cost-effective way to reach large numbers of people.

Barnett, B. Do client fees help or hurt? Network 18(2):6-11 (1998). Available at: www.fhi.org/en/fp/fppubs/network/v18-2/nt1822.html.
While charging for services may limit access to contraception, the revenues generated by fees may lead to improvements in quality of care and increases in financial sustainability for individual programs. Program managers must consider the impact of pricing systems both on client demand and on clinic resources. Before establishing a fee system, managers need to measure the unit costs of the services offered, decide whether and how to subsidize services for clients who cannot afford to pay, and give plenty of warning to clients. One approach that preserves access to family planning is cross-subsidization, in which charges for health services such as lab tests are used to subsidize family planning services.

Bratt, J.H. et al. The impact of price changes on demand for family planning and reproductive health services in Ecuador. Health Policy and Planning 17(3):281-287 (2002).
This study measured the impact of price increases on (1) the utilization and revenues of family planning clinics in Ecuador and (2) access to services by poor clients. The authors compared price increases of different amounts at different clinics for IUD insertions, IUD revisits, gynecology visits, and prenatal visits. Their findings suggest that demand for the IUD and prenatal services was inelastic, so that price increases would boost clinic revenue without greatly reducing utilization. In addition, there was no consistent association between higher prices and loss of low-income clients.

Bratt, J.H. et al. Three strategies to promote sustainability of CEMOPLAF clinics in Ecuador. Studies in Family Planning 29(1):58-68 (1998).
Separate studies were conducted to analyze the impact of three strategies to increase the sustainability of a private organization operating 20 reproductive health clinics in Ecuador. Reducing the number of follow-up visits for IUD users during the first year from four to one liberated provider time for gynecological consultations and saved money for IUD users with little impact on quality of care. A survey of clients found that CEMOPLAF fees are low relative to clients' income and could be increased, although measures should be taken to protect truly need clients. A cost projection determined that ultrasound machines would be a profitable investment of scarce resources at only 3 of 19 potential sites. The authors conclude that, individually, none of the interventions would make a large impact on CEMOPLAF's cost-recovery ratio, but together they could improve the agency's financial situation.

Ciszewski, R.L. and Harvey, P.D. Contraceptive price changes: the impact on sales in Bangladesh. International Family Planning Perspectives 21:150-154 (1995).
This article examines the impact of price changes in the price of condoms and pills sold by a social marketing program in Bangladesh. Retailers, wholesalers, and consumers resisted a steep price increase, and condom sales dropped by 29 percent and pill sales by 12 percent. When sales had not returned to previous levels two years later, prices were lowered and sales increased, reaching and then exceeding earlier levels. The authors conclude that large increases in contraceptive prices dampen demand.

Donaldson, D. et al. (eds). Using cost and revenue analysis tools. The Family Planning Manager 2(1)(1993). Available in English at: http://erc.msh.org/mainpage.cfm?file=2.1.1.htm&module=finance&language=English, in French at: http://erc.msh.org/readroom/francais/coreisfr.htm, and in Spanish at: http://erc.msh.org/mainpage.cfm?file=core.htm&module=toolkit&language=spanish.
Conducting cost and revenue analyses helps managers understand how staffing patterns, service mix, service practices, and procurement affect resource use. Results of these analyses can prompt managers to consider different ways of delivering services to reduce costs and/or increase revenues. Managers can use the results to decide whether to change service practices, add new services or facilities, or use some services to subsidize others. Three spreadsheet tools are presented: Cost-Analysis Methodology for Clinic-Based Family Planning Methods, Cost and Revenue Analysis Tool (CORE), and A Supply-Demand Model of Health Care Financing.

Finger, W.R. Commercial sector can improve access. Network 18(2) (1998). Available at: www.fhi.org/en/fp/fppubs/network/v18-2/nt1825.html.
Public resources can be focused more effectively on low-income clients if people who are able to pay shift to the commercial sector. This requires convincing consumers that private-sector services are affordable and have advantages over public services (for example, convenience, easier access, greater confidentiality, and better quality). Free public services, lack of information and training, and legal restrictions have slowed down the expansion of the commercial sector into family planning, but some donor agencies and government health ministries are helping train private-sector providers in family planning, including pharmacists, midwives, and private physicians. Social marketing has successfully involved the private sector in contraceptive distribution.

Fleischman Foreit, K.G. Source of maternal and child health care as an indicator of ability to pay for family planning. International Family Planning Perspectives 28(3):167-169 (September 2002). Available at: www.guttmacher.org/pubs/journals/2816702.html.
Using data from the Demographic and Health Survey from eight developing countries, this research note estimates how many women can afford to purchase contraceptives from the private sector, thus reducing the burden on government family planning funding and allowing governments to target their subsidies to needier clients. The percentage of female contraceptive users who receive private maternal and child health care (used as a proxy to estimate who has the economic resources and information needed to purchase contraceptives from the commercial sector) ranged from 5 percent in Peru and Zimbabwe to 22 percent in Colombia. A further analysis calculated the impact if all pill users in Indonesia, the Philippines, and Zimbabwe who had children aged five and younger and who paid for private maternal and child health care purchased their pills from commercial sources. The private sectors share of the oral contraceptive market would increase by 22 to 26 percent, while the governments financial burden would decline by 3 to 7 percent.

Hanson, K. et al. Ends versus means: what is the role of markets in expanding access to contraceptives? Health Policy and Planning 16(2):125-136 (2001).
This economic analysis examines the trade-offs between public- and private-sector supply of contraceptives. Where the private sector is the only source of contraceptives, market failures may keep contraceptive coverage lower than socially desirable. Providing free or subsidized contraceptives, however, may inhibit the development of the commercial sector. Evidence is mixed on the extent to which price influences the demand for contraceptives. The authors conclude that strategies must be tailored to the local context, and a market assessment should be an important part of the decision-making process. Four key variables are: contraceptive prevalence rates (market-based strategies are more appropriate where contraceptive use is high), HIV prevalence (the ready supply of condoms to high-risk groups must take priority over all else where HIV prevalence is high), income level of country (market-based strategies are more appropriate in middle-income than poor countries), and size and geographic spread of private-sector development (care must be taken not to undercut a well-established private sector with subsidized goods).

Hubacher, D. et al. Increasing efficiency to meet future demand: family planning services provided by the Mexican Ministry of Health. International Family Planning Perspectives 25(3):119-124, 138 (1999). Available at: www.guttmacher.org/pubs/journals/2511999.html.
By correcting inefficiencies in the delivery of family planning services, the Mexican Ministry of Health potentially could meet rising demand for services without expanding current programs. Increasing the length of the providers workday (currently less than six and one-half hours) and the proportion of time providers spend with clients (37 percent for nurses and 47 percent for doctors) would increase efficiency as would dispensing more contraceptives at each visit. For example, doubling the number of pill cycles distributed during a visit reduces the cost per couple-year of protection from US$27 to US$19. Implementing all three suggestions would reduce the overall cost per couple-year of protection from the 1995 level of US$29 to US$22 by 2010.

Janowitz, B. et al. Excess capacity and the cost of adding services at family planning clinics in Zimbabwe. International Family Planning Perspectives 28(2):58-66 (2002). Available at: www.guttmacher.org/pubs/journals/2805802.html.
This study used mini-situation analyses and time-motion studies to determine the impact of adding a new service (syndromic management of reproductive tract infections) on provider time and service costs. Following retraining, the median length of visits for new acceptors increased from 20 to 27 minutes and more clients were offered syndromic management services. Despite these additional demands on their time, providers spent less than 40 percent of their time with clients after retraining and had substantial amounts of unoccupied time in the early morning and late afternoon. The authors conclude that family planning clinics in the developing world can provide additional services at little extra cost if providers simply spend more time with clients. However, providers may require incentives to increase their workload.

Janowitz, B. et al. Community-based distribution in Tanzania: costs and impacts of alternative strategies to improve worker performance. International Family Planning Perspectives 26(4):158-160, 193-195 (2000). Available at: www.guttmacher.org/pubs/journals/2615800.html.
This article compares costs and worker performance at three community-based distribution programs in Tanzania. Compensation, supervision, and training costs vary widely between the three programs, and all three contribute to the cost per visit. The program that paid CBD agents the most ($398) had the highest cost per agent ($701), but also had the highest number of visits per agent (425). Because of high training and supervision costs, the program that paid agents the least ($33) still had high costs per agent ($558), and its agents made the fewest visits (105). The third program had by far the lowest total cost per agent ($155) because compensation, supervision, and training costs all were low, and its agents made an intermediate number of visits (132). The authors conclude that increasing the pay of CBD agents actually reduces the cost per visit, because it increases the number of visits they make and spreads the costs of training and supervision over more visits. Spending less on training or supervision, however, may reduce costs without reducing the number of visits.

Janowitz, B. et al. Issues in the Financing of Family Planning Services in Sub-Saharan Africa. Research Triangle Park, NC: Family Health International (1999). Available at: www.fhi.org/en/ReproductiveHealth/Publications/booksReports/fpfinancing/index.htm.
This extensive report analyzes all available information, both published and unpublished, on financing family planning services in sub-Saharan Africa. It is addressed to policy makers and program managers and identifies gaps in the information needed to facilitate policy and program change. To calculate the shortfall in funding, the report presents information on the current and projected needs for family planning services, the estimated cost of meeting those needs, and current government and donor expenditures. The authors then closely examine the potential of three different strategies in the African context: (1) charging fees so that users pay a greater share of service costs, in combination with a system of means-testing to protect the poor; (2) encouraging the growth of the commercial sector, including for-profit providers, retailers, social marketing, managed care, and employer-based family planning programs; and (3) reducing the cost of family planning services by mobilizing underutilized capacity, eliminating unnecessary medical barriers, and integrating family planning and other reproductive health services that are currently offered by separate vertical programs.

Janowitz, B. What do we really know about the impact of price changes on contraceptive use? International Family Planning Perspectives 22(1):38-40 (1996).
Charging user fees for family planning services is controversial, since fees may reduce access to services among poor women and lead to declines in contraceptive prevalence. This article reviews econometric modeling and experimental studies on the impact of price changes on demand for family planning services. The author concludes that various methodological problems undermine the validity of all of the studies, so that the potential of user fees remains unclear. Well-designed experimental studies are needed to assess all of clients potential responses to price increases: paying the higher prices, switching to a lower-cost method or provider, and discontinuing family planning.

Lande, R.E. and Geller, J.S. Paying for family planning. Population Reports Series J, Number 39. Baltimore, Maryland: Johns Hopkins University Population Information Program (November 1991).
As demand for family planning continues to grow, paying for services is becoming a greater challenge. While governments and donors may pay more, new approaches are looking toward users, employers, and insurers to bear a greater share of the burden. Potential approaches include removing constraints on retail sales, training and promoting private providers, expanding social marketing programs that sell subsidized contraceptives through retail outlets, charging small fees for improved government services, setting up workplace family planning services with employer support, including family planning in health insurance coverage, cross-subsidizing family planning for the poor, and increasing efficiency in service delivery.

Levin, A. et al. Cost-effectiveness of family planning and maternal health service delivery strategies in rural Bangladesh. International Journal of Health Planning and Management 14:219-233 (1999).
This article assesses two alternative service delivery strategies that were designed to improve the effectiveness and efficiency of service delivery in rural Bangladesh. While delivering services at a centrally located neighborhood spot reduced travel time for providers, the approach was less cost-effective compared with home delivery of services because clients attendance was low. Increasing the frequency of outreach clinics and adding immunization to the services offered generally did prove more cost-effective than static clinics, probably because of increased demand for services.

Mitchell, M.D. et al. Costing of reproductive health services. International Family Planning Perspectives 25 (Suppl.):S17-S21, S29 (1999). Available at: www.guttmacher.org/pubs/journals/25s1799.html.
Cost data were collected from the Zimbabwe National Family Planning Council (ZNFPC) and MEXFAM and disaggregated to calculate the cost of individual services. Costs were consistently lower at ZNFPC, largely due to the use of specially trained nurse-midwives rather than doctors to provide most family planning and reproductive health care. Because labor accounts for most of the cost of reproductive health services, adding clients does not necessarily reduce the cost per client. However, staff, equipment, and facilities at most health and family planning programs operate below capacity. In this situation, the cost of adding clients or services is low. The authors conclude that the simple methodology they propose can help managers understand the financial and programmatic implications of alternative service delivery strategies.

Musau, S. (ed). Charging fees for family planning services. Family Planning Manager 1(3):1-12 (1992). Available online in English at: http://erc.msh.org/mainpage.cfm?file=2.1.3.htm&module=finance&language=English, in French at: http://erc.msh.org/readroom/francais/fees.htm, and in Spanish at http://erc.msh.org/readroom/espanol/fees.htm.
This article examines the pros and cons of charging fees for family planning services. Before deciding to charge such fees, managers must consider the objective for the fees, whether clients are willing and able to pay for services, client perceptions of the quality of services offered, policy and regulatory restrictions on a fee-for-service program, the cost of the services offered, and the cost of implementing a user fee system. The article offers advice on how to overcome staff and client resistance to introducing fees, and provides practical tips on deciding what kind of fee to introduce, determining how much to charge, developing a system of controls for fee collection, and developing a system of exemptions and waivers.

Nanda, P. Gender dimensions of user fees: implications for women’s utilization of health care. Reproductive Health Matters 10(20):127-134 (2002).
This gender-based analysis of user fees for health services reviews recent literature from Africa. Evidence suggests that utilization of women’s health care services drops when user fees are introduced. Evidence also questions whether the small amount of revenue generated by user fees enhances the quality of health services, given the administrative costs of the system, although fees may have a positive impact if they are retained at the local level. Women are less able than men to pay for health care, and systems to exempt women, especially the poor, from user fees typically are inconsistently applied and poorly executed. The author recommends that user fees not be implemented on a broader scale until there is evidence, including gender-disaggregated data, that such fees improve resources without reducing utilization or hurting poor women.

Schuler, S.R. et al. Paying for reproductive health services in Bangladesh: intersections between cost, quality, and culture. Health Policy and Planning 17(3):273-280 (2002).
Using data from 500 in-depth, semi-structured interviews, this article examines clients response to a shift by NGOs in their service delivery strategy in Bangladesh. Clients are required to travel further and pay more for services, but higher quality services are offered. The goal is to increase access while maximizing cost recovery. Findings suggest that attitudes related to charging and paying for services are as important as an appropriate pricing structure in achieving these objectives. Gender, class, and ideas about entitlements, the role of government, the status of NGOs, and obligations among people all affect the ability and willingness of people to pay for health services. The poor may expect the government to provide free services and drugs, consider themselves unfairly exploited when charged even nominal sums by NGOs, and equate free cost with service quality.

Schuler, S.R. et al. Reconciling cost recovery with health equity concerns in a context of gender inequality and poverty: findings from a new family health initiative in Bangladesh. International Family Planning Perspectives 28(4):196-204 (2002). Available at: www.guttmacher.org/pubs/journals/2819602.html.
A new model of service delivery in Bangladesh has expanded the range and quality of women’s health services, but the emphasis on cost recovery means higher costs for clients. This study gathered qualitative information on the response to the new model through individual interviews with clients, husbands, community members, and service providers; group interviews; and observations at clinics. Economic constraints limit access to health services and shape the health-seeking strategies of the poor. The new service model has created problems for poor women by undermining the informal system of credit they used to rely upon. While fee waivers for the poor are part of official policy, staff do not provide them openly and systematically out of concern that it will discourage other clients from paying. The authors conclude that a transparent system for providing credit and fee exemptions based on need would help NGOS in Bangladesh and elsewhere maintain access to services while maximizing cost recovery.

Schuler, S.R. et al. The persistence of a service delivery culture: findings from a qualitative study in Bangladesh. International Family Planning Perspectives 27(4):194-200 (2001). Available at: www.guttmacher.org/pubs/journals/2719401.html.
A combination of interviews and observations were used to investigate how clients, communities, and program staff were adapting to a shift from door-to-door contraceptive distribution in Bangladesh to clinic-based delivery of a broader package of health services. While client and community reactions are generally favorable, indicating a willingness to adapt, the old family planning service delivery culture persists and creates obstacles to change. These include clients expectations of discounted or free services and compensation for adopting clinical methods; suspicion of clinical methods and providers motives for offering them; and holding providers who supply a method responsible for treating subsequent health problems and side effects free of charge.

Smith, E. Evaluations suggest better ways to use resources: economic analysis of programs can improve productivity and quality of care. Network 21(3):21-25 (2002). Available at: www.fhi.org/en/fp/fppubs/network/v21-3/nt2133.html.
Economic analysis of program can help managers identify revenue-producing services that can subsidize other activities, evaluate clients ability to pay for services, discover whether certain services or products are draining resources, determine if clinics in different regions should charge different prices, and evaluate staff productivity. Economic analyses conducted in El Salvador, Ecuador, Jamaica, and Tanzania illustrate the contributions this approach can make to family planning program management.

Wolff, J.A. et al., eds. "Making your Program Sustainable." In: The Family Planning Manager's Handbook: Basic Skills and Tools for Managing Family Planning Programs. West Hartford, Connecticut: Kumarian Press (1991). Available in English at: http://erc.msh.org/fpmh_english/chp10/index.html, in French at: http://erc.msh.org/fpmh_french/chp10/index.html, and in Spanish at: http://erc.msh.org/fpmh_spanish/chp10/index.html.
The three keys to organizational sustainability are a stable organization, creating demand for services, and achieving greater control over resources. Programs can develop organizational stability by articulating a clear mission, developing strong leadership, recruiting and rewarding excellent staff, strengthening management systems, and being responsive to changing environments and client needs. Increasing demand calls for understanding client needs and how to meet them, providing high-quality services, and marketing family planning services effectively. Programs can achieve greater control over resources by broadening the resource based, finding ways to reduce costs, gathering information on program costs, planning and monitoring expenditures, and basing decisions on actual program results. Cross-subsidies (between services, between clinics, and between clients) also can contribute to sustainability.

Wolff, J.A. et al., eds. "Managing your Finances." In: The Family Planning Manager's Handbook: Basic Skills and Tools for Managing Family Planning Programs. West Hartford, Connecticut: Kumarian Press (1991). Available in English at: http://erc.msh.org/fpmh_english/chp9/index.html, in French at: http://erc.msh.org/fpmh_french/chp9/index.html, and in Spanish at: http://erc.msh.org/fpmh_spanish/chp9/index.html.
Family planning managers must have basic financial management skills so that they can ensure their program's resources are used responsibly and appropriately. The financial management cycle consists of providing services, receiving cash, paying for expenses, and reporting to donors and other outside sources of the use of funds provided. This chapter provides practical advice on how to prepare a budget for the work plan, project revenues and monitor cash flow, control and manage funds, compare program results with budget projections, determine and compare the cost of services, meet institutional reporting requirements, and understand and use financial reports for decision making.

Yeboah, D.A. Strategies adopted by Caribbean family planning associations to address declining international funding. International Family Planning Perspectives 28(2):122-125 (2002). Available at: http://www.guttmacher.org/pubs/journals/2812202.html.
In recent years, Caribbean family planning associations (FPAs) have lost international funding because their need has been rated as lower than other regions of the world. To understand how the FPAs are adapting to this loss of funding, the authors sent a questionnaire to five countries. They found that Caribbean FPAs have adopted many new strategies to deal with the loss of funding, including strict financial management and restructuring to increase efficiency, business development and purchase of their buildings to improve sustainability, expansion of services and revision of fee structures to increase revenues, use of volunteers to reduce costs, and membership and fundraising drives to provide additional revenue.

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Policy making

Ashford, L.S. New population policies: advancing womens health and rights. Population Bulletin 56(1) (March 2001). Available at: www.prb.org/Template.cfm?Section=PRB&template=/ContentManagement/ContentDisplay.cfm&ContentID=3697.
This article reviews the evolution of national population policies, particularly following the historic 1994 Cairo conference. It describes the new focus on improving reproductive health and women's rights and how governments have tried to incorporate this new approach in their policies and programs. The Bulletin also looks at possible new directions for population policies.

Bertrand, J.T. Et al. Indicators to measure the policy environment. In Handbook of Indicators for Family Planning Evaluation, Chapter 2, pp. 25-44. Chapel Hill, North Carolina: EVALUATION Project (December 1994). Available in English, French, and Spanish at: www.cpc.unc.edu/measure/publications/manuals/handbook/handbook.html. This chapter provides a conceptual framework for evaluating the policy environment of family planning programs, based on the standard input-process-output-outcomes model. Five indicators are proposed to assess the process of policy planning and policy development that modifies the policy environment over time. Eleven indicators are proposed to assess the outputs of this process, including measures of political support, national policy, and operational policy. The handbook sets out the operational definition, data requirements, data sources, and purpose of each indicator.

Center for Reproductive Law and Policy. Reproductive Rights 2000: Moving Forward. New York (CRLP) (June 2000). Available in English and Spanish at: www.crlp.org/pub_bo_rr2k.html.
To ensure that international declarations on womens reproductive rights are meaningful, women must work toward the adoption and enforcement of national laws and policies reflecting their principles. This book examines legal and policy developments since the Cairo and Beijing conferences in eight areas: population, reproductive health, and family planning; contraception; abortion; HIV/AIDS and other sexually transmissible infections; harmful traditional practices affecting reproductive health; rape and other sexual violence; marriage and family law; and reproductive rights of adolescents. Each chapter also includes recommendations for further government action.

Finkle, J.L. and McIntosh, C.A. United Nations population conferences: shaping the policy agenda for the twenty-first century. Studies in Family Planning 33(1):11-23 (March 2002).
This article reviews the population conferences sponsored by the UN, beginning in Rome in 1954, and shows how their priorities have shifted from scientific to political considerations. At the same time, participants have changed. First, independent experts were replaced by national delegations selected by and representing their governments. More recently, nongovernmental organizations representing civil society have begun to play an active role at the conferences. Because of the broader range of participants, the population field has grown in scope and complexity and is in danger of losing its focus. Increasingly, population issues are linked with broader questions of poverty, the environment, human rights, economic development, globalization and the like. The authors suggest that smaller regional or thematic meetings may be a good way to rationalize the conference process in the years to come.

Hardee, K. and Smith, J. Implementing reproductive health services in an era of health sector reform. The POLICY Project Occasional Paper 4 (March 2000). Available at: www.policyproject.com/pubs/occasional/op-04.pdf.
This paper reviews the impact on reproductive health care of various health sector reform initiatives, including decentralization, integration, essential services packages, streamlining operational policies, cost recovery, and encouraging private sector participation. There is too little evidence as yet to determine whether health sector reform will promote efficient, effective, and equitable reproductive health care delivery or whether it will lead to neglect of reproductive health in favor of more pressing health issues. Reform process must be monitored and evaluated, especially their impact on issues of equity and access.

Hardee, K. et al. Reproductive health policies and programs in eight countries: progress since Cairo. International Family Planning Perspectives 25 (Suppl.):S1-S9 (1999). Available at: www.agi-usa.org/pubs/journals/25s0299.html.
To examine progress in implementing the ICPD Program of Action, stakeholders were interviewed in Bangladesh, India, Nepal, Jordan, Ghana, Senegal, Jamaica, and Peru. While all of the countries have begun formulating policies to reflect the new emphasis on reproductive health care, program implementation has only just begun. Moving from policy to programs faces several challenges, including disseminating the message of Cairo to a wider base of stakeholders, planning for the complexity of integrated services, increasing human and financial resources, improving the quality of care, and viewing Cairo as a long-term process. The authors conclude that setting priorities and phasing in interventions are the key to progress.

Hoodfar, H. and Assadpour, S. The politics of population policy in the Islamic Republic of Iran. Studies in Family Planning 31(1):19-34 (2000).
This case study examines the different phases of population policy in Iran, especially after the 1979 revolution, based on informal interviews with officials, medical personnel, family planning clients, and religious leaders. It focuses on the formal and informal strategies adopted by political experts, the media, religious authorities, and the government to bring about a reversal in policy toward family planning in what seemed to be an unfavorable environment.

Jacobson, J.L. Transforming family planning programmes: toward a framework for advancing the reproductive rights agenda. Reproductive Health Matters 8(15): 21-32 (2000).
New approaches to family planning and reproductive health call for the application of human rights as well as public health principles, but these are not easily reconciled. The reproductive rights agenda focuses on the process as well as the outcome of program activities; addresses the gender dynamics of sex, which are rooted in cultural and social norms; addresses sexual coercion and infection as well as unwanted pregnancy; and seeks to instill a sense of entitlement among clients and a rights-based ethos among programs. Obstacles to change include: social, economic, and political conditions, such as poverty, that undermine rights and entitlement; weak support for the rights agenda at the national level; continuing program focus on reduced fertility; vague definitions of key concepts; rapid health care reforms; and limited capacity in the womens movement at the local level.

Jain, A. et al. Do Population Policies Matter? Fertility and Politics in Egypt, India, Kenya, and Mexico. New York: Population Council (1998).
The four case studies in this book illustrate how and why the formulation, implementation, and effectiveness of population policies vary over time, within, and between countries. The book concludes that population policies must go beyond family planning programs, following the ICPD Programme of Action. The authors recommend the involvement of non-health sectors to reduce gender and other disparities; the involvement of health as well as family planning departments in the delivery of reproductive health services; making the improvement of individual well-being the sole objective of fertility-reduction and population policies; and increasing public advocacy for change.

Langer, A. et al. Health sector reform and reproductive health in Latin America and the Caribbean: strengthening the links. Bulletin of the World Health Organization 78(5): 667-676 (2000). Available at: www.who.int/docstore/bulletin/pdf/2000/issue5/bu0560.pdf.
In many countries of Latin America and the Caribbean, the health sector is being reformed to increase its effectiveness and efficiency while simultaneously being asked to adopt the ICPD model of broad-based reproductive health care. This article examines how common approaches to health sector reform (decentralization of management, changes in financing to increase sustainability, and increasing the role of the private sector) have helped or hindered efforts to improve reproductive health care. Despite the rhetoric, actual change has so far been limited. However, the authors warn that if health reforms are driven exclusively by financial and political considerations, the quality of reproductive health care may suffer. They recommend specific strategies to improve reproductive health in a health reform environment.

Lee, K. et al. Family planning policies and programmes in eight low-income countries: a comparative policy analysis. Social Science & Medicine 47(7):949-959 (1998).
In order to understand why some countries adopt effective family planning policies and programs while others do not, four pairs of low-income countries were analyzed: Bangladesh and Pakistan, Zimbabwe and Zambia, Thailand and the Philippines, and Tunisia and Algeria. Each pair differed in the strength of their family planning programs but was matched socioeconomically and culturally. Policy analyses of all eight countries found three factors that promoted strong population policies and family planning programs: the formation of broad-based coalitions among policy elites in support of family planning, the spread of policy risk beyond a single individual or group, and stability of the institutional home and funding for family planning programs. The study suggests that the process of making and implementing national family planning policies is as important as the content of those policies to the success of family planning programs.

Lubben, M. et al. Reproductive health and health sector reform in developing countries: establishing a framework for dialogue. Bulletin of the World Health Organization 80(8):667-674 (2002). Available at: www.who.int/docstore/bulletin/pdf/2002/bul-8-E-2002/bu1060.pdf.
Lack of dialogue between the areas of reproductive health and health sector reform has led to disjointed policymaking in developing countries. Different participants, with different priorities and ideologies, operating in different policy environments have contributed to the divide. The authors propose a framework that encourages a productive dialogue between the two areas. The first step is to identify stakeholders in both policy areas and develop collaborative links between them. The next step is to introduce a common understanding around relevant policy contexts. Then the key participants must agree on a common purpose. The final step is to identify causal links between policy content in reproductive health and health sector change as a basis for evidence-based policy making.

Lush, L. et al. Politics and fertility: a new approach to population policy analysis. Population Research and Policy Review 19: 1-28 (2000).
Demographic and policy change over a 30-year period was analyzed in four pairs of developing countries: Algeria and Tunisia, Bangladesh and Pakistan, Zambia and Zimbabwe, and the Philippines and Thailand. In the first three pairs of countries, evidence suggests that state policies and programs explain much of the difference in the timing and extent of fertility declines, while cultural contrasts are more important in the final pair. Policies and programs were more successful in countries that identified a coherent rationale for reducing population growth and in which strong and financially secure coalitions of policy elites shared the political risks associated with population policies.

Pachauri, S., ed. Implementing a Reproductive Health Agenda in India: The Beginning. New Delhi: Population Council, South & East Asia Regional Office (1999). (Introductory essay and order form available online at www.popcouncil.org/reprohealthagenda/implementingreprohealth.html.
Following the ICPD Program of Action, the Indian Ministry of Health and Family Welfare made a fundamental shift in policy, moving from method-specific contraceptive targets to providing client-centered, good quality, reproductive health services. The first eight chapters in this book examine how this policy change came about, its implementation, and the impact on program performance and field operations. The next four chapters discuss whether the changed policy environment is helping reach neglected population groups, including young people and men. The final seven chapters discuss the challenges of addressing specific reproductive health problems, including HIV/AIDS, reproductive tract infections, abortion, safe motherhood, and sexuality.

Population Council. What Can Be Done to Foster Multisectoral Population Policies: Summary Report of a Seminar. New York: Population Council (1998). Available at: www.popcouncil.org/multisectoral/multisectoral.html.
Speakers at a 1997 conference strongly endorsed a multisectoral approach to population policy that goes beyond family planning services to engage other sectors, such as education and employment, and that focuses on individual welfare, human rights, gender equity, and broad-based socioeconomic equity. They discussed how to move policy thinkers to realize that many factors over and above family planning availability are at issue, what institutional barriers exist, and the relative roles of donors, ministries, coordinating processes, and constituents.

Population Reference Bureau. Reproductive Health in Policy & Practice: Case Studies from Brazil, India, Morocco, and Uganda. Washington, DC : Population Reference Bureau (2001). Available at: www.prb.org/Template.cfm?Section=PRB&template=/ContentManagement/ContentDisplay.cfm&ContentID=5934.
To assess how the ICPD Program of Action is being implemented in diverse settings, researchers in Brazil, India, Morocco, and Uganda investigated changes in reproductive health policies and services, as well as in the political and social environment in which initiatives are carried out. Not surprisingly, progress on reproductive health and women's status is uneven across and within countries, and none of the countries have addressed all of the Cairo goals. However, the studies reveal major changes in the political, social, and economic environment in which reproductive health goals are pursued. In all of the countries studied, there is greater openness in political decision-making, growth in NGO activity, increasing visibility and influence of the womens rights movement, increasing decentralization of authority from national to local governments and some major reforms in the way that health systems operate. At the service level, attempts have been made to improve the quality of services, to increase the integration of family planning and other health services, and to expand services to under-served groups.

Seltzer, J.R. The Origins and Evolution of Family Planning Programs in Developing Countries. Santa Monica, CA: RAND (2002). Available at: www.rand.org/publications/MR/MR1276.
This book discusses the three public policy objectives that have underpinned family planning programs—the demographic, public health, and human rights rationales—and the criticisms associated with each. The author reviews the research evidence to assess the validity of each criticism and describes how programs have evolved in response to them. Important lessons for guiding policy can be drawn from the criticisms and controversies surrounding international family planning programs. Programs must continue to evolve in response to valid criticisms, and they must adapt to new global challenges, such as the enormous cohort of adolescents moving into its childbearing years. Adapting the health care rationale to current global conditions requires new organizational and financing arrangements and a reconfiguration of services. Continuing support of womens groups and health advocates is important, since their criticisms have contributed to improvements in policy and program design; research is also important.

Tantchou, J. and Wilson, E. Post-Cairo reproductive health policies and programs: a study of five Francophone African countries. POLICY Occasional Papers No. 6. Washington, DC : The POLICY Project (August 2000). Available in English at: www.policyproject.com/pubs/occasional/op-06.pdf, and in French at: www.policyproject.com/pubs/occasional/op-06fr.pdf.
This summary examines reproductive health policy in Benin, Burkina Faso, Cameroon, Cote dIvoire, and Mali following the ICPD and 1996 Ouagadougou Forum. While all five countries have adopted the ICPD definition of reproductive health, they are still in the process of developing comprehensive policies and program implementation lags behind. Shared challenges include: garnering broad support for reproductive health; coordinating reproductive health and population policies and programs; systematically determining reproductive health priorities; encouraging NGO involvement; and using resources more efficiently and effectively.

Visaria, L. et al. From family planning to reproductive health: challenges facing India. International Family Planning Perspectives 25 (Suppl.): S44-S49 (1999). Available at: www.guttmacher.org/pubs/journals/25s4499.html.
In the 1990s the government of India rejected demographic goals for its family planning program in favor of addressing more comprehensive reproductive and child health needs. This article analyzes the reasons behind this dramatic change in policy, its reception in India, and challenges in implementing it. The authors conclude that the success of the new approach depends on convincing stakeholders, both providers and clients, of its importance.

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Advocacy

Center for Development and Population Activities (CEDPA). Advocacy: Building Skills for NGO Leaders. CEDPA Training Manual Series vol. IX. Washington, DC : CEDPA (1999). Available at: www.cedpa.org/publications/pdf/advocacy.htm.
This manual, which is available in English, French, and Spanish, provides the basis for a three-day workshop to build the capacity of NGO leaders to advocate effectively for reproductive health issues. It is written for experienced trainers and utilizes participatory methodologies. The six sessions teach: how the advocacy process contributes to policy change; how to select advocacy issues, set policy-focused objectives, and identify sources of support and opposition; how to identify audiences and analyze their interests; how to develop compelling messages and deliver them to policy makers; how to use networking and coalition-building as a tool for effective advocacy; and how to develop an advocacy implementation plan.

Gillespie DG. Whatever happened to family planning and, for that matter, reproductive health? International Family Planning Perspectives. 2004;30(1):34-38. Available at: www.agi-usa.org/pubs/journals/3003404.html.
This commentary urges advocates to revisit the Cairo Programme of Action and reconsider their messages in order to reverse the current trend towards declining political support and funding for reproductive health and family planning. New messages are needed that focus on problems policy makers consider important and that present a clear course of action. Best bets are averting mother-to-child HIV transmission, reducing abortion, and expanding access to family planning services for the poor.

Ianey, M.L. et al. An introduction to advocacy: the what and why of advocacy. BOND Guidance Notes (1999). Available at: www.bond.org.uk/advocacy/guidwhatandwhy.html.
BOND, a British network of NGOs engaged in international development and development education, originally compiled this material for a training course on advocacy. This series of guidance notes discusses how developing country NGOs can advocate to change polices that affect the lives of disadvantaged people and how NGOs in the developed world can support them. Each note outlines essential steps in the advocacy process, offers practical tips, and lists lessons learned. One note also discusses how to monitor and evaluate advocacy programs and suggests appropriate indicators.

International Planned Parenthood Federation (IPPF). Advocacy Guide for Sexual and Reproductive Health and Rights. London: IPPF (2001). Available at: www.ippf.org/pubs/advocacyguide/index.htm.
This user-friendly guidebook offers clear and practical advice on how to advocate for sexual and reproductive health, including family planning, no matter how large or small an organizations resources and ambitions may be. It discusses how to: establish goals, objectives and activities; expand your base of support through networking and coalition-building; frame issues and shape messages for target audiences; reach the general public; work with the media; use the Internet; develop print materials, conduct public education; lobby policy makers; hold conferences to educate colleagues; and deal with the opposition.

Johns Hopkins University Center for Communication Programs (JHU/CCP). "A" Frame for Advocacy. Baltimore: JHU/CCP (1999). Available at: www.jhuccp.org/pr/advocacy/.
This pamphlet summarizes a six-step process for public policy advocacy to guide interested programs and personnel. Accompanying each step (analysis, strategy, mobilization, action, evaluation, and continuity) is a list of specific activities that need to be accomplished.

Ketting, E., ed. Advocacy for reproductive health. Planned Parenthood Challenges 1(1996).
In the mid 1990s, IPPF placed a new priority on advocacy to explain, promote, and defend the ICPD Programme of Action. This special issue of Planned Parenthood Challenges highlights the efforts of IPPF and its member family planning associations to generate public awareness and advocate for change around the world. Articles describe regional efforts as well as specific country programs advocating change in Palestine, safeguarding individual rights in China, combating opposition in the Philippines, speaking out for youth in Kenya, raising the issue of unsafe abortion in Mauritius, and working with the media in Peru.

Sharma, R.R. An Introduction to Advocacy: Training Guide. Washington, DC : Support for Analysis and Research in Africa (SARA) Project, Academy for Educational Development, (no date). Available in English at: www.dec.org/pdf_docs/PNABZ919.pdf, and in French at: www.dec.org/pdf_docs/PNACB277.pdf.
This training guide was prompted by the recognition that systematic and iterative advocacy is as important to policy and program change as identifying problems and finding solutions. The guide is designed to inform a diverse audience about advocacy and its methods, give them the basic skills and confidence they need to proceed, and increase the use of available data to inform the advocacy process. Ten training modules cover the meaning of advocacy, identifying policy issues, selecting an advocacy objective, researching audiences, developing and delivering messages, understanding the decision-making process, building alliances, making effective presentations, fundraising, and improving advocacy. It is illustrated with case studies in reproductive health from Africa.

Singh S et al. Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care. New York: Alan Guttmacher Institute and UNFPA; 2003. Available at: www.guttmacher.org/pubs/addingitup.html.
This report makes the case for increased funding for sexual and reproductive health services, including family planning, in developing countries. It takes a broader approach to measuring the costs, benefits, and return on investment of these services by analyzing how sexual and reproductive health services contribute to economic growth, societal and gender equity, and democratic governance as well as health. The authors argue that policy makers need a fuller accounting of these broad benefits as well as more complete information about costs in order to appreciate the substantial returns on sexual and reproductive health investments.

Upadhyay, U. and Robey, B. Why family planning matters. Population Reports, Series J, Number 49 (July 1999). Available in English, French, and Spanish at: www.infoforhealth.com/pr/online.shtml#j)
Advocacy is essential if family planning programs are to receive the leadership commitment and financial resources they need to meet rising demand for family planning. This report summarizes key evidence in support of family planning and family planning programs for use in advocacy campaigns. Family planning programs offer numerous benefits; they meet demand for family planning, saves womens and childrens lives, offers women choices, encourages safer sex, reaches out to youth, involves men, protects the environment, and aids development.

Van Kampen, J. Dealing with Advocacy: A Practical Guide. Hanover, Germany: RHI ComNet, EC/UNFPA Initiative for Reproductive Health in Asia (no date). Available at: www.asia-initiative.org/pdfs/advocacy_guide.pdf.
This brief guide explains the importance of advocacy for reproductive health and provides an overview of the advocacy process. It is an excellent introduction to the field.

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Financial management and sustainability

Arends-Kuenning, M. Reconsidering the doorstep-delivery system in the Bangladesh family planning program. Studies in Family Planning 33(1):87-102 (March 2002).
Based on an analysis of longitudinal data from the Maternal and Child Health-Family Planning Extension Project, the author questions two recommendations made to increase the cost-effectiveness of family planning services in Bangladesh. The first recommendation is to encourage women to switch from nonclinical to clinical methods. Womens preferences for temporary nonclinical methods are reasonable, however, given the context of high child mortality, high infection risks, and limited availability of clinical services. The second recommendation is for field workers to focus on motivating nonusers to adopt a method rather than on resupplying continuing users. Data show, however, that resupply visits will have the larger impact on contraceptive prevalence. Results also suggest that field workers will be most effective if they target their visits to women who are uneducated or live in poor areas.

Barberis, M. and Harvey, P.D. Costs of family planning programmes in fourteen developing countries by method of service delivery. Journal of Biosocial Science 29:219-233 (1997).
This article analyzes the cost-effectiveness of different modes of service delivery in 14 countries, based on cost per couple-year of protection (CYP) in 1991 and 1992. Sterilization services had the lowest cost per CYP (US$1.85), followed by social marketing programs (US$2.14), and clinic-based services other than sterilization (US$6.10). The highest costs were for community-based distribution projects (US$9.93) and clinic-based services with a community-based distribution component (US$14.00). While no single mode of service delivery is appropriate for all settings, the authors conclude that social marketing shows special promise as a cost-effective way to reach large numbers of people.

Barnett, B. Do client fees help or hurt? Network 18(2):6-11 (1998). Available at: www.fhi.org/en/fp/fppubs/network/v18-2/nt1822.html.
While charging for services may limit access to contraception, the revenues generated by fees may lead to improvements in quality of care and increases in financial sustainability for individual programs. Program managers must consider the impact of pricing systems both on client demand and on clinic resources. Before establishing a fee system, managers need to measure the unit costs of the services offered, decide whether and how to subsidize services for clients who cannot afford to pay, and give plenty of warning to clients. One approach that preserves access to family planning is cross-subsidization, in which charges for health services such as lab tests are used to subsidize family planning services.

Bratt, J.H. et al. The impact of price changes on demand for family planning and reproductive health services in Ecuador. Health Policy and Planning 17(3):281-287 (2002).
This study measured the impact of price increases on (1) the utilization and revenues of family planning clinics in Ecuador and (2) access to services by poor clients. The authors compared price increases of different amounts at different clinics for IUD insertions, IUD revisits, gynecology visits, and prenatal visits. Their findings suggest that demand for the IUD and prenatal services was inelastic, so that price increases would boost clinic revenue without greatly reducing utilization. In addition, there was no consistent association between higher prices and loss of low-income clients.

Bratt, J.H. et al. Three strategies to promote sustainability of CEMOPLAF clinics in Ecuador. Studies in Family Planning 29(1):58-68 (1998).
Separate studies were conducted to analyze the impact of three strategies to increase the sustainability of a private organization operating 20 reproductive health clinics in Ecuador. Reducing the number of follow-up visits for IUD users during the first year from four to one liberated provider time for gynecological consultations and saved money for IUD users with little impact on quality of care. A survey of clients found that CEMOPLAF fees are low relative to clients' income and could be increased, although measures should be taken to protect truly need clients. A cost projection determined that ultrasound machines would be a profitable investment of scarce resources at only 3 of 19 potential sites. The authors conclude that, individually, none of the interventions would make a large impact on CEMOPLAF's cost-recovery ratio, but together they could improve the agency's financial situation.

Ciszewski, R.L. and Harvey, P.D. Contraceptive price changes: the impact on sales in Bangladesh. International Family Planning Perspectives 21:150-154 (1995).
This article examines the impact of price changes in the price of condoms and pills sold by a social marketing program in Bangladesh. Retailers, wholesalers, and consumers resisted a steep price increase, and condom sales dropped by 29 percent and pill sales by 12 percent. When sales had not returned to previous levels two years later, prices were lowered and sales increased, reaching and then exceeding earlier levels. The authors conclude that large increases in contraceptive prices dampen demand.

Donaldson, D. et al. (eds). Using cost and revenue analysis tools. The Family Planning Manager 2(1)(1993). Available in English at: http://erc.msh.org/mainpage.cfm?file=2.1.1.htm&module=finance&language=English, in French at: http://erc.msh.org/readroom/francais/coreisfr.htm, and in Spanish at: http://erc.msh.org/mainpage.cfm?file=core.htm&module=toolkit&language=spanish.
Conducting cost and revenue analyses helps managers understand how staffing patterns, service mix, service practices, and procurement affect resource use. Results of these analyses can prompt managers to consider different ways of delivering services to reduce costs and/or increase revenues. Managers can use the results to decide whether to change service practices, add new services or facilities, or use some services to subsidize others. Three spreadsheet tools are presented: Cost-Analysis Methodology for Clinic-Based Family Planning Methods, Cost and Revenue Analysis Tool (CORE), and A Supply-Demand Model of Health Care Financing.

Finger, W.R. Commercial sector can improve access. Network 18(2) (1998). Available at: www.fhi.org/en/fp/fppubs/network/v18-2/nt1825.html.
Public resources can be focused more effectively on low-income clients if people who are able to pay shift to the commercial sector. This requires convincing consumers that private-sector services are affordable and have advantages over public services (for example, convenience, easier access, greater confidentiality, and better quality). Free public services, lack of information and training, and legal restrictions have slowed down the expansion of the commercial sector into family planning, but some donor agencies and government health ministries are helping train private-sector providers in family planning, including pharmacists, midwives, and private physicians. Social marketing has successfully involved the private sector in contraceptive distribution.

Fleischman Foreit, K.G. Source of maternal and child health care as an indicator of ability to pay for family planning. International Family Planning Perspectives 28(3):167-169 (September 2002). Available at: www.guttmacher.org/pubs/journals/2816702.html.
Using data from the Demographic and Health Survey from eight developing countries, this research note estimates how many women can afford to purchase contraceptives from the private sector, thus reducing the burden on government family planning funding and allowing governments to target their subsidies to needier clients. The percentage of female contraceptive users who receive private maternal and child health care (used as a proxy to estimate who has the economic resources and information needed to purchase contraceptives from the commercial sector) ranged from 5 percent in Peru and Zimbabwe to 22 percent in Colombia. A further analysis calculated the impact if all pill users in Indonesia, the Philippines, and Zimbabwe who had children aged five and younger and who paid for private maternal and child health care purchased their pills from commercial sources. The private sectors share of the oral contraceptive market would increase by 22 to 26 percent, while the governments financial burden would decline by 3 to 7 percent.

Hanson, K. et al. Ends versus means: what is the role of markets in expanding access to contraceptives? Health Policy and Planning 16(2):125-136 (2001).
This economic analysis examines the trade-offs between public- and private-sector supply of contraceptives. Where the private sector is the only source of contraceptives, market failures may keep contraceptive coverage lower than socially desirable. Providing free or subsidized contraceptives, however, may inhibit the development of the commercial sector. Evidence is mixed on the extent to which price influences the demand for contraceptives. The authors conclude that strategies must be tailored to the local context, and a market assessment should be an important part of the decision-making process. Four key variables are: contraceptive prevalence rates (market-based strategies are more appropriate where contraceptive use is high), HIV prevalence (the ready supply of condoms to high-risk groups must take priority over all else where HIV prevalence is high), income level of country (market-based strategies are more appropriate in middle-income than poor countries), and size and geographic spread of private-sector development (care must be taken not to undercut a well-established private sector with subsidized goods).

Hubacher, D. et al. Increasing efficiency to meet future demand: family planning services provided by the Mexican Ministry of Health. International Family Planning Perspectives 25(3):119-124, 138 (1999). Available at: www.guttmacher.org/pubs/journals/2511999.html.
By correcting inefficiencies in the delivery of family planning services, the Mexican Ministry of Health potentially could meet rising demand for services without expanding current programs. Increasing the length of the providers workday (currently less than six and one-half hours) and the proportion of time providers spend with clients (37 percent for nurses and 47 percent for doctors) would increase efficiency as would dispensing more contraceptives at each visit. For example, doubling the number of pill cycles distributed during a visit reduces the cost per couple-year of protection from US$27 to US$19. Implementing all three suggestions would reduce the overall cost per couple-year of protection from the 1995 level of US$29 to US$22 by 2010.

Janowitz, B. et al. Excess capacity and the cost of adding services at family planning clinics in Zimbabwe. International Family Planning Perspectives 28(2):58-66 (2002). Available at: www.guttmacher.org/pubs/journals/2805802.html.
This study used mini-situation analyses and time-motion studies to determine the impact of adding a new service (syndromic management of reproductive tract infections) on provider time and service costs. Following retraining, the median length of visits for new acceptors increased from 20 to 27 minutes and more clients were offered syndromic management services. Despite these additional demands on their time, providers spent less than 40 percent of their time with clients after retraining and had substantial amounts of unoccupied time in the early morning and late afternoon. The authors conclude that family planning clinics in the developing world can provide additional services at little extra cost if providers simply spend more time with clients. However, providers may require incentives to increase their workload.

Janowitz, B. et al. Community-based distribution in Tanzania: costs and impacts of alternative strategies to improve worker performance. International Family Planning Perspectives 26(4):158-160, 193-195 (2000). Available at: www.guttmacher.org/pubs/journals/2615800.html.
This article compares costs and worker performance at three community-based distribution programs in Tanzania. Compensation, supervision, and training costs vary widely between the three programs, and all three contribute to the cost per visit. The program that paid CBD agents the most ($398) had the highest cost per agent ($701), but also had the highest number of visits per agent (425). Because of high training and supervision costs, the program that paid agents the least ($33) still had high costs per agent ($558), and its agents made the fewest visits (105). The third program had by far the lowest total cost per agent ($155) because compensation, supervision, and training costs all were low, and its agents made an intermediate number of visits (132). The authors conclude that increasing the pay of CBD agents actually reduces the cost per visit, because it increases the number of visits they make and spreads the costs of training and supervision over more visits. Spending less on training or supervision, however, may reduce costs without reducing the number of visits.

Janowitz, B. et al. Issues in the Financing of Family Planning Services in Sub-Saharan Africa. Research Triangle Park, NC: Family Health International (1999). Available at: www.fhi.org/en/ReproductiveHealth/Publications/booksReports/fpfinancing/index.htm.
This extensive report analyzes all available information, both published and unpublished, on financing family planning services in sub-Saharan Africa. It is addressed to policy makers and program managers and identifies gaps in the information needed to facilitate policy and program change. To calculate the shortfall in funding, the report presents information on the current and projected needs for family planning services, the estimated cost of meeting those needs, and current government and donor expenditures. The authors then closely examine the potential of three different strategies in the African context: (1) charging fees so that users pay a greater share of service costs, in combination with a system of means-testing to protect the poor; (2) encouraging the growth of the commercial sector, including for-profit providers, retailers, social marketing, managed care, and employer-based family planning programs; and (3) reducing the cost of family planning services by mobilizing underutilized capacity, eliminating unnecessary medical barriers, and integrating family planning and other reproductive health services that are currently offered by separate vertical programs.

Janowitz, B. What do we really know about the impact of price changes on contraceptive use? International Family Planning Perspectives 22(1):38-40 (1996).
Charging user fees for family planning services is controversial, since fees may reduce access to services among poor women and lead to declines in contraceptive prevalence. This article reviews econometric modeling and experimental studies on the impact of price changes on demand for family planning services. The author concludes that various methodological problems undermine the validity of all of the studies, so that the potential of user fees remains unclear. Well-designed experimental studies are needed to assess all of clients potential responses to price increases: paying the higher prices, switching to a lower-cost method or provider, and discontinuing family planning.

Lande, R.E. and Geller, J.S. Paying for family planning. Population Reports Series J, Number 39. Baltimore, Maryland: Johns Hopkins University Population Information Program (November 1991).
As demand for family planning continues to grow, paying for services is becoming a greater challenge. While governments and donors may pay more, new approaches are looking toward users, employers, and insurers to bear a greater share of the burden. Potential approaches include removing constraints on retail sales, training and promoting private providers, expanding social marketing programs that sell subsidized contraceptives through retail outlets, charging small fees for improved government services, setting up workplace family planning services with employer support, including family planning in health insurance coverage, cross-subsidizing family planning for the poor, and increasing efficiency in service delivery.

Levin, A. et al. Cost-effectiveness of family planning and maternal health service delivery strategies in rural Bangladesh. International Journal of Health Planning and Management 14:219-233 (1999).
This article assesses two alternative service delivery strategies that were designed to improve the effectiveness and efficiency of service delivery in rural Bangladesh. While delivering services at a centrally located neighborhood spot reduced travel time for providers, the approach was less cost-effective compared with home delivery of services because clients attendance was low. Increasing the frequency of outreach clinics and adding immunization to the services offered generally did prove more cost-effective than static clinics, probably because of increased demand for services.

Mitchell, M.D. et al. Costing of reproductive health services. International Family Planning Perspectives 25 (Suppl.):S17-S21, S29 (1999). Available at: www.guttmacher.org/pubs/journals/25s1799.html.
Cost data were collected from the Zimbabwe National Family Planning Council (ZNFPC) and MEXFAM and disaggregated to calculate the cost of individual services. Costs were consistently lower at ZNFPC, largely due to the use of specially trained nurse-midwives rather than doctors to provide most family planning and reproductive health care. Because labor accounts for most of the cost of reproductive health services, adding clients does not necessarily reduce the cost per client. However, staff, equipment, and facilities at most health and family planning programs operate below capacity. In this situation, the cost of adding clients or services is low. The authors conclude that the simple methodology they propose can help managers understand the financial and programmatic implications of alternative service delivery strategies.

Musau, S. (ed). Charging fees for family planning services. Family Planning Manager 1(3):1-12 (1992). Available online in English at: http://erc.msh.org/mainpage.cfm?file=2.1.3.htm&module=finance&language=English, in French at: http://erc.msh.org/readroom/francais/fees.htm, and in Spanish at http://erc.msh.org/readroom/espanol/fees.htm.
This article examines the pros and cons of charging fees for family planning services. Before deciding to charge such fees, managers must consider the objective for the fees, whether clients are willing and able to pay for services, client perceptions of the quality of services offered, policy and regulatory restrictions on a fee-for-service program, the cost of the services offered, and the cost of implementing a user fee system. The article offers advice on how to overcome staff and client resistance to introducing fees, and provides practical tips on deciding what kind of fee to introduce, determining how much to charge, developing a system of controls for fee collection, and developing a system of exemptions and waivers.

Nanda, P. Gender dimensions of user fees: implications for women’s utilization of health care. Reproductive Health Matters 10(20):127-134 (2002).
This gender-based analysis of user fees for health services reviews recent literature from Africa. Evidence suggests that utilization of women’s health care services drops when user fees are introduced. Evidence also questions whether the small amount of revenue generated by user fees enhances the quality of health services, given the administrative costs of the system, although fees may have a positive impact if they are retained at the local level. Women are less able than men to pay for health care, and systems to exempt women, especially the poor, from user fees typically are inconsistently applied and poorly executed. The author recommends that user fees not be implemented on a broader scale until there is evidence, including gender-disaggregated data, that such fees improve resources without reducing utilization or hurting poor women.

Schuler, S.R. et al. Paying for reproductive health services in Bangladesh: intersections between cost, quality, and culture. Health Policy and Planning 17(3):273-280 (2002).
Using data from 500 in-depth, semi-structured interviews, this article examines clients response to a shift by NGOs in their service delivery strategy in Bangladesh. Clients are required to travel further and pay more for services, but higher quality services are offered. The goal is to increase access while maximizing cost recovery. Findings suggest that attitudes related to charging and paying for services are as important as an appropriate pricing structure in achieving these objectives. Gender, class, and ideas about entitlements, the role of government, the status of NGOs, and obligations among people all affect the ability and willingness of people to pay for health services. The poor may expect the government to provide free services and drugs, consider themselves unfairly exploited when charged even nominal sums by NGOs, and equate free cost with service quality.

Schuler, S.R. et al. Reconciling cost recovery with health equity concerns in a context of gender inequality and poverty: findings from a new family health initiative in Bangladesh. International Family Planning Perspectives 28(4):196-204 (2002). Available at: www.guttmacher.org/pubs/journals/2819602.html.
A new model of service delivery in Bangladesh has expanded the range and quality of women’s health services, but the emphasis on cost recovery means higher costs for clients. This study gathered qualitative information on the response to the new model through individual interviews with clients, husbands, community members, and service providers; group interviews; and observations at clinics. Economic constraints limit access to health services and shape the health-seeking strategies of the poor. The new service model has created problems for poor women by undermining the informal system of credit they used to rely upon. While fee waivers for the poor are part of official policy, staff do not provide them openly and systematically out of concern that it will discourage other clients from paying. The authors conclude that a transparent system for providing credit and fee exemptions based on need would help NGOS in Bangladesh and elsewhere maintain access to services while maximizing cost recovery.

Schuler, S.R. et al. The persistence of a service delivery culture: findings from a qualitative study in Bangladesh. International Family Planning Perspectives 27(4):194-200 (2001). Available at: www.guttmacher.org/pubs/journals/2719401.html.
A combination of interviews and observations were used to investigate how clients, communities, and program staff were adapting to a shift from door-to-door contraceptive distribution in Bangladesh to clinic-based delivery of a broader package of health services. While client and community reactions are generally favorable, indicating a willingness to adapt, the old family planning service delivery culture persists and creates obstacles to change. These include clients expectations of discounted or free services and compensation for adopting clinical methods; suspicion of clinical methods and providers motives for offering them; and holding providers who supply a method responsible for treating subsequent health problems and side effects free of charge.

Smith, E. Evaluations suggest better ways to use resources: economic analysis of programs can improve productivity and quality of care. Network 21(3):21-25 (2002). Available at: www.fhi.org/en/fp/fppubs/network/v21-3/nt2133.html.
Economic analysis of program can help managers identify revenue-producing services that can subsidize other activities, evaluate clients ability to pay for services, discover whether certain services or products are draining resources, determine if clinics in different regions should charge different prices, and evaluate staff productivity. Economic analyses conducted in El Salvador, Ecuador, Jamaica, and Tanzania illustrate the contributions this approach can make to family planning program management.

Wolff, J.A. et al., eds. "Making your Program Sustainable." In: The Family Planning Manager's Handbook: Basic Skills and Tools for Managing Family Planning Programs. West Hartford, Connecticut: Kumarian Press (1991). Available in English at: http://erc.msh.org/fpmh_english/chp10/index.html, in French at: http://erc.msh.org/fpmh_french/chp10/index.html, and in Spanish at: http://erc.msh.org/fpmh_spanish/chp10/index.html.
The three keys to organizational sustainability are a stable organization, creating demand for services, and achieving greater control over resources. Programs can develop organizational stability by articulating a clear mission, developing strong leadership, recruiting and rewarding excellent staff, strengthening management systems, and being responsive to changing environments and client needs. Increasing demand calls for understanding client needs and how to meet them, providing high-quality services, and marketing family planning services effectively. Programs can achieve greater control over resources by broadening the resource based, finding ways to reduce costs, gathering information on program costs, planning and monitoring expenditures, and basing decisions on actual program results. Cross-subsidies (between services, between clinics, and between clients) also can contribute to sustainability.

Wolff, J.A. et al., eds. "Managing your Finances." In: The Family Planning Manager's Handbook: Basic Skills and Tools for Managing Family Planning Programs. West Hartford, Connecticut: Kumarian Press (1991). Available in English at: http://erc.msh.org/fpmh_english/chp9/index.html, in French at: http://erc.msh.org/fpmh_french/chp9/index.html, and in Spanish at: http://erc.msh.org/fpmh_spanish/chp9/index.html.
Family planning managers must have basic financial management skills so that they can ensure their program's resources are used responsibly and appropriately. The financial management cycle consists of providing services, receiving cash, paying for expenses, and reporting to donors and other outside sources of the use of funds provided. This chapter provides practical advice on how to prepare a budget for the work plan, project revenues and monitor cash flow, control and manage funds, compare program results with budget projections, determine and compare the cost of services, meet institutional reporting requirements, and understand and use financial reports for decision making.

Yeboah, D.A. Strategies adopted by Caribbean family planning associations to address declining international funding. International Family Planning Perspectives 28(2):122-125 (2002). Available at: http://www.guttmacher.org/pubs/journals/2812202.html.
In recent years, Caribbean family planning associations (FPAs) have lost international funding because their need has been rated as lower than other regions of the world. To understand how the FPAs are adapting to this loss of funding, the authors sent a questionnaire to five countries. They found that Caribbean FPAs have adopted many new strategies to deal with the loss of funding, including strict financial management and restructuring to increase efficiency, business development and purchase of their buildings to improve sustainability, expansion of services and revision of fee structures to increase revenues, use of volunteers to reduce costs, and membership and fundraising drives to provide additional revenue.

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