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RHO archives : Topics : Family Planning Program Issues

Key Issues

This section provides brief summaries of some of the major issues in delivering high-quality, cost-effective family planning services in low-resource settings. Click article references to read abstracts in the bibliography.

Be sure to use the Glossary if you are unfamiliar with any of the terms on this page.

Increasing access to family planning

Access to contraceptive supplies and services affects the likelihood that people adopt a method, continue using it, or switch methods when they are dissatisfied (Ali 2001; Ketende et al. 2003; Ross et al. 2002; Steele and Geel 1999; Steele et al. 1999; Stephenson and Tsui 2002; Thang and Anh 2002). In some settings, access may even be more important than a couple's reproductive intentions in determining contraceptive use. Some researchers have speculated that increasing access to family planning actually influences couples' intentions, that is, it prompts them to feel a need for family planning (Magniani et al. 1999; Shelton et al. 1999).

Access to family planning services touches on many issues; barriers can be geographic, economic, administrative, cognitive, or psychosocial in nature (Bertrand et al. 1995). In Lesotho, for example, obstacles to contraceptive use included inconvenient clinic hours, long distances and high transportation costs, lack of privacy, contraceptive shortages, and restrictions imposed by providers on who can use certain methods (Tuoane et al. 2004).

To overcome geographic and economic barriers, family planning programs have experimented with a variety of outreach efforts, ranging from mobile clinics to social marketing of subsidized commodities at retail outlets (Debpuur et al. 2002). One of the best-tested approaches is training volunteer or paid community-based distribution (CBD) workers to make home visits. Research has found that CBD programs overcome social as well as geographic barriers to access, that they can safely deliver oral contraceptives (OCs) and injectables, that they fill unmet need for contraception, and that they reduce discontinuation (Best et al. 1999; Green et al. 2002; Hossain and Phillips 1996; Katz et al. 1998; Philips et al. 1999; Sultan et al. 2002). However, a shift away from community-based to facility-based services in Bangladesh compromised neither access to nor use of family planning services (Routh et al. 2001).

Cognitive and psychosocial accessibility refer to whether clients know where to seek services and whether psychological or social factors discourage them from doing so. In Nepal, for example, uneducated people refuse to seek services because providers treat them so poorly (Schuler et al. 1985). In addition to provider training, a common solution to these barriers involves multimedia communication campaigns to publicize family planning facilities and to change community attitudes so that seeking family planning services is not stigmatized (see section on Information, education, and communication activities below). Another approach is to screen all health care clients for unmet need for family planning and offer contraceptive services to those in need during the same visit (Vernon and Foreit 1999).

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Overcoming medical barriers

In recent years, attention has focused on administrative barriers to family planning, that is, unnecessary rules and regulations that burden clients and narrow their contraceptive choices. One type of administrative barrier, so-called medical barriers, have a medical rationale even though they are scientifically unjustified (Bertrand et al. 1995; Shelton et al. 1992; Stanback et al. 1997). They include:

  • Outdated contraindications that remain part of a program's official guidelines or providers' informal screening routine, for example, refusing to supply oral contraceptives to women with varicose veins or tuberculosis.
  • Eligibility requirements that needlessly limit the use of certain methods based on a woman's age, parity, or lack of spousal consent.
  • Demands for additional procedures that may benefit women's overall health but are unnecessary for safe and effective contraceptive use, for example, requiring women to undergo a pelvic examination before receiving oral contraceptives (Brown and Morgan 1998).
  • Scheduling hurdles that force women to make extra visits, such as requiring women to return during their menses to get a method, limiting the number of OC cycles distributed at one time, and scheduling frequent check-ups for new IUD users (Bossyns et al. 2002).
  • Requiring certain provider qualifications to deliver a method, for example, restricting IUD insertions to physicians when nurses can be trained to perform the task.
  • Provider biases for or against specific methods (Katz et al. 2002).
  • Regulatory mechanisms that prevent certain contraceptive methods from being approved or that hinder their advertising.

Global investigations into medical barriers in the early 1990s found that there was a lack of consensus on medical eligibility requirements as well as delays in acting on new research findings (Cottingham and Mehta 1993; Hardee et al. 1995). As a result, practices varied widely between individual providers. To help overcome these problems and eliminate medical barriers, international experts have codified medical eligibility requirements for contraception (see RHO's Contraceptive Methods section, particularly the WHO Eligibility Criteria page). In addition, they have developed job aids for providers, such as checklists to rule out pregnancy among family planning clients (Mendez et al. 2004; Stanback et al. 1999; www.reproline.jhu.edu/english/6read/6multi/pg/ca1.htm). Some critics worry, however, that the drive to eliminate medical barriers is decreasing the quality of care by removing safeguards to contraceptive use and by eliminating procedures with broad health benefits, such as pelvic exams. Even with changes in official guidelines, unnecessary medical barriers have persisted in many countries because they are rooted in providers' personal beliefs and cultural values (Miller et al. 1998; Speizer et al. 2000; Stanback and Twum-bah 2001).

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Guidelines and indicators

Program guidelines include service policies and standards that specify the services offered, provider qualifications, and acceptable levels of performance, as well as clinical protocols and management procedures that give detailed instructions for performing tasks like inserting an IUD or ordering contraceptive supplies (Kols and Sherman 1998). Well-designed guidelines improve the consistency of service delivery and support functions, reduce barriers to access, guide training and supervision, and establish the criteria by which individual and program performance are judged. No single set of guidelines is appropriate for all family planning programs because guidelines must reflect the social context and service setting as well as the latest scientific evidence. All stakeholders, including providers and clients, should participate in developing or revising a program's guidelines to make sure that they reflect the practical realities of service delivery (Ippolito et al. 1995; Lea and Knauff 1998).

To have an effect on the quality of care, guidelines must be accepted by providers and applied to everyday practices. This only happens when guidelines are feasible and easily understood, when they are broadly disseminated throughout the organization, and when they are reinforced by training materials, service manuals, job aids, client materials, supervision criteria, and monitoring systems (Hardee et al. 1998).

Selecting evaluation indicators that match program guidelines and priorities is especially important, since staff members are sensitive to how their performance is judged. For example, one indicator commonly used to evaluate family planning programs, couple-years of protection (CYP), is biased toward clinical programs and long-term methods (Fort 1996) and emphasizes the quantity of services over their quality (Shelton 1991). Focusing on CYP discourages managers from launching community-based services to reach under-served communities and discourages providers from offering short-term methods. In contrast, the novel HARI (Helping individuals Achieve their Reproductive Intentions) index encourages family planning programs to take a broader reproductive health approach by measuring the percentage of women who achieve their individual reproductive intentions without suffering any severe reproductive health problem (Jain 2001; Ravindran and Mishra 2001).

Indicators can measure four different aspects of performance (Bertrand et al. 1994):

  • Input indicators ask whether resources, such as personnel, equipment, and supplies, are sufficient and whether they are delivered on time.
  • Process indicators investigate how well program activities, such as training and counseling, are carried out.
  • Output indicators check whether expected changes in access to services, quality of care, and service utilization occur.
  • Outcome indicators examine whether expected changes in contraceptive use and fertility levels occur throughout the population.

Each type of indicator can be designed to focus on quantity, quality, or cost (Bessinger and Bertrand 2001). Managers interested in devising a monitoring and evaluation program that reinforces program priorities can consult various instruction manuals (Bertrand et al. 1994; Bertrand et al. 1996; Horstmann et al. 2002; Sullivan and Bertrand 2000) and reference materials (RHAG 2002; UNESCAP 2003).

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Infection prevention

Infection prevention measures protect clients, providers, and cleaning staff from the transmission of infectious diseases, which is especially important given the current epidemic of bloodborne viral diseases, including hepatitis B, hepatitis C, and HIV/AIDS (Tietjen 1997). These and other infections can be transmitted by contact with blood and body fluids and generally can be spread before symptoms are present. It also is essential to prevent infections following the provision of surgical contraceptive methods, such as the IUD or tubal ligation. Family planning providers need to follow strict infection control procedures with all clients, treating each one as if she or he is potentially infected. Care should be taken to decontaminate, sterilize, and disinfect instruments and other equipment; wash hands before and after every patient contact, use gloves and other protective clothing when appropriate; follow injection procedures; and dispose of waste safely (AVSC 2000; Huezo and Carignan 1997; Tietjen et al. 2003). Successful infection prevention programs also call for the commitment and active involvement of administrators, clinic managers, and supervisors in setting standards, mentoring and monitoring workers, and reinforcing safety efforts (Tietjen et al. 2003).

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Logistics and contraceptive security

There is growing concern about shortages of contraceptives and other reproductive health supplies in the developing world (Marie Stopes International 2002; Tarmann 2001). Rising interest in family planning and growing numbers of people of reproductive age are boosting demand for contraceptives, but supplies are limited by insufficient and poorly coordinated donor funding as well as inadequate logistics capacity in developing countries (Marie Stopes International 2002). Thus ensuring contraceptive security calls for action at the national and international levels (Finkle 2003); Pandit and Bornbusch 2003).

At the country or program level, a sound logistics system ensures the smooth distribution of contraceptive commodities and other supplies so that each service delivery point has sufficient stock to meet clients' needs (FPLM 2000; Setty-Venugopal et al. 2002). In addition to preventing stockouts, a well-run logistics system assures that all supplies are in good condition and controls costs by eliminating overstocks, spoilage, pilferage, and other kinds of waste. As family planning programs become more self-reliant, purchasing supplies themselves rather than relying on donated products, they must strengthen quality assurance mechanisms to make sure that commodities are safe and effective (PATH 1997).

Logistics managers must forecast demand for commodities; decide what and how much to purchase; properly store commodities to control their exposure to extreme temperatures, humidity, sunlight, ozone, chemicals, and insects; ensure the quality of supplies by tracking expiration dates, making routine inspections, and testing samples; and distribute commodities as needed to each service delivery point. A variety of logistics guides and manuals offer practical advice on how to accomplish these tasks; they include essential formulas, worksheets, and sample forms (Binzen 1992; Binzen 2000; CDC and JSI 1993; UNFPA 1999; Wolff et al. 1991). Recommended systems include logistic management information systems (LMIS) that track the amount of stock on hand and consumption rates at each facility; FEFO (first-to-expire, first-out) inventory management systems that distribute commodities in the order of their expiration; and maximum/minimum inventory control systems that express inventory levels as the number of months supply. To be sustainable, however, a LMIS must be tailored to fit the country and program setting, and it must allow for continuing adaptation (Chandani and Breton 2001).

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Interpersonal communication and counseling

Counseling is central to family planning services, and improvements in client-provider interaction may lead to higher rates of contraceptive adoption, effective use, and continuation (Abdel-Tawab and Roter 2002; Canto de Cetinha et al. 2001; Lei et al. 1996; Luck et al. 2000) and thus reduce abortion rates (Xinh et al. 2004). Ideally, the counseling process should be client-centered. That means treating all clients with respect, regardless of their age, marital status, ethnic affiliation, or socioeconomic group; maintaining confidentiality; and personalizing the content of each session to fit the client's individual situation (PATH 1999; Schuler and Hossain 1998; Worsley 2001). This may require training, along with job aids and supervision, to clarify providers' values, overcome their biases, and strengthen their interpersonal communication skills. Other approaches, such as client and community education, accreditation systems, and self-assessment also can help improve client-provider communication (Heerey et al. 2003).

Good counseling also supports informed choice by clients (AVSC 1998; EngenderHealth 2003; Kim et al. 2003b; Kim et al. 1998; Upadhyay 2001). It is the provider's job to supply accurate, complete technical information that is relevant to the client's situation and that covers negatives, such as side effects, as well as positives. Research suggests that the amount of time spent with a client is less important than how sharply the information exchange focuses on the clients situation (Leon et al. 2001). Thus providers should discuss a client's childbearing intentions, sexual relationships, partners, and STI risk-taking behaviors as well as technical information. Given complete and balanced information, clients have proven able to make good choices: they are not swayed by provider biases (Baveja et al. 2000), and they can more accurately assess their own STI risks than physicians (Lazcana et al. 2000). Once a client selects a method, providers have to instruct clients how to use the method safely and effectively. Thus a complete family planning session should cover:

  • Information on side effects and complications.
  • Advantages and disadvantages of the methods from the client's point of view.
  • Method effectiveness.
  • Proper method use once a method has been selected.
  • What to do if the method fails or is not used properly.
  • The availability of emergency contraception.
  • STI and HIV prevention.
  • Information on scheduled return visits, resupply, and unscheduled visits if there are problems (Murphy and Steele 2000).

To ensure that providers cover all essential information during consultations and lead clients through a systematic decision-making process, family planning professionals have developed systematic approaches to counseling. These include the balanced counseling strategy (Lon et al. 2003) and the GATHER mnemonic (Greet clients, Ask clients about themselves, Tell clients about their choices, Help clients choose, Explain what to do, and Return for follow-up) (Rinehart et al. 1998). Family planning is just one of many issues covered by the REDI approach (Rapport-building, Exploration, Decision-making, and Implementing the decision), which provides a framework for integrated sexual and reproductive counseling (EngenderHealth 2003).

Training can strengthen providers technical knowledge and interpersonal communication skills, both of which are essential to good counseling. It can also help providers clarify their values and overcome biases. But training alone is not enough to improve providers performance on the job. Programs also should address the other factors that influence providers ability to counsel clients. These include guidelines and accreditation programs that set job expectations; supervision, accreditation, and self-assessment systems that give providers feedback on their performance; job aids that reinforce knowledge and skills; rewards and recognition that motivate providers to excel; and a supportive work environment that offers adequate time and space for counseling (Heerey et al. 2003; Rudy et al. 2003).

Finally, family planning programs can improve the quality of client-provider interaction by broadening their focus to include clients as well as providers. They need to recognize the importance of the clients role in counseling, work to understand community and client perspectives on family planning decision-making, and launch client and community interventions that encourage clients to play an active role in consultations (Heerey et al. 2003; Kim et al. 2003a; Kim et al. 1999; Rudy et al. 2003).

The following six principles promote a positive interaction between the client and provider and sum up many of the key issues in family planning counseling (Murphy and Steele 2000). They apply to all staff who come in contact with the client, not just providers.

  • Treat clients with friendliness and respect.
  • Create a two-way interaction with clients by listening attentively and encouraging clients to ask questions and express concerns.
  • Use information provided by the client to tailor the counseling session to the individual client's health and personal needs.
  • Provide the method the client wants as long as there is no medical reason against it.
  • Avoid giving clients too much information since that leads to confusion and forgetfulness.
  • Help the client understand and remember key information by using audiovisual materials, repeating key instructions, and checking comprehension.

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Supporting correct and continuing contraceptive use

As contraceptive prevalence rises, it becomes increasingly important for family planning programs to shift their emphasis away from adopting a method to supporting correct and continuing contraceptive use. Many couples stop using contraception within a few months or a year after adopting a method even though they do not want another child (Ali and Cleland 1999; Khan et al. 2003b). Others keep using a method, but they do so incorrectly or inconsistently (Rosenberg et al. 1995). Their actions place both groups at risk of an unwanted pregnancy and in some countries raise the total fertility rate substantially (Blanc et al. 2002).

While women give many reasons for dropping a contraceptive method, side effects and health concerns are foremost among those who do not want another child (Bhat and Halli 1998; Henry-Lee 2001; Huezo and Malhotra 1993). How women interpret and respond to side effects depends in part on local beliefs about reproduction and the meaning of physical symptoms (Henry 2001; Hodgins 1999) and in part on the quality of counseling they receive. Studies have found that counseling clients about possible side effects before they begin a method lowers discontinuation rates (Cotton et al. 1992; Canto de Cetina et al. 2001; Lei et al. 1996). Service provision also affects continuation in another way: women are less likely to discontinue contraception when they receive the method they want (Huezo and Malhotra 1993; Pariani et al. 1991).

As for misuse of contraceptive methods, lack of knowledge is a crucial factor. Many women do not fully understand how to use their method. Nor do they realize that using a method incorrectly or inconsistently puts them at risk of pregnancy and may aggravate side effects (Khan et al. 2003a; Rosenberg et al. 1995; Saha et al. 2004). Correct use is especially challenging for pill users, who must know when to start a new cycle, what order to take the pills in, and what to do if they skip one, two, or more pills (Oakley 1994).

To encourage contraceptive continuation and prevent misuse of methods, family planning programs should:

Acting on these recommendations requires changing the way that providers counsel family planning clients (see section on Interpersonal communication and counseling above).

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Information, education, and communication (IEC) activities

Information, education, and communication (IEC) activities directed to potential clients are able to change individual attitudes and social norms about family planning, to increase knowledge of contraception, to promote discussion of family planning issues with family and friends, to publicize service sites and providers, to encourage people to adopt contraception, and to create demand for high-quality care (Babalola et al. 2001; Gupta et al. 2003; Kane et al. 1998; Rogers et al. 1999; Sharan and Valente 2002; Storey et al. 1999; Westoff and Bankole 1999). These effects explain why exposure to mass media messages about family planning is associated with contraceptive use (Kabir and Islam 2000; Parr 2002). In addition, IEC activities may be directed to policy makers (to advocate for more accessible and better family planning services) and to providers (to strengthen their skills and change their attitudes toward clients) (WHO 1994; WHO 1997).

Programs routinely develop client education materials and provider job aids, such as posters, leaflets, and flip charts, to speed the flow of accurate and complete information to clients. An innovative program in Pakistan even distributes audiocassettes to substitute for traditional contraceptive counseling (Collumbien and Douthwaite 2003). Care must be taken, however, to ensure that the pictures and text in these materials effectively communicate the intended message (Mbananga and Becker 2002). Community mobilization activities, including group talks, peer counseling, and live dramas, also have proven their ability to disseminate information, shape attitudes, and change behaviors (Babalola et al. 2001; Brieger et al. 2001).

Family planning programs recently have capitalized on the global telecommunication revolution to develop multimedia campaigns that employ radio and television (Villanueva 2001), although conservatives may oppose the use of the public airways for this purpose (Ellertson et al. 2002). Research has found that the impact of multimedia campaigns is greater when they are designed systematically and to commercial standards (Piotrow et al. 1997) and when they employ multiple, reinforcing communication channels (Jato et al. 1999). Entertainment formats, such as soap operas and popular songs, have proven effective in attracting huge audiences and modeling desired attitudes and behaviors (JHU/CCP 1997). However, the impact of a media campaign may be short-lived unless IEC activities continue (Kincaid 1996).

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Training and performance improvement

When workers lack knowledge or skills, they need training. A continuing program of in-service training is critical for family planning providers to strengthen existing skills and teach new knowledge and skills (Kortman 1994). Studies show that carefully designed training programs not only improve the performance of family planing providers and managers but also have a favorable effect on outcomes, such as client knowledge, compliance with return visits, and contraceptive use (Halawa et al. 1995; Jain et al. 1999; Kim et al. 1992).

Effective training shares certain characteristics. The content, timing, and trainees are carefully selected based on the results of a needs assessment (Wolff et al. 1991; Mariani and Klaus). It is competency-based, that is, trainees must demonstrate their ability to perform key job skills and tasks before they are certified (Sullivan 1995). Models and simulations are used to accelerate the learning process so that, for example, trainees practice IUD insertions on anatomical models (Limpaphayom et al. 1997). Trainees receive continuing feedback and support after they return to work (Best 1998; PRIME II and JHPIEGO 2002), and they have the opportunity to practice newly learned skills (Valadez et al. 1997).

Conventional training courses require trainees to attend workshops at off-site training centers, but other approaches to training may be more effective, less disruptive, and less expensive. In whole-site training, all of a facility's staff trains together, as a service delivery team, so they can support one another; training also takes place at the facility (Bradley et al. 1998; Baraister et al. 2000). On-the-job training pairs trainees with experienced co-workers, who can tailor their advice to the setting. Effective on-the-job training is highly structured and utilizes specially developed materials and specially selected instructors (Sullivan and Smith 1996). Distance education delivers a standardized curriculum to scattered and isolated health workers via print materials, audio tapes, radio and television broadcasts, computer software, or electronic conferencing (Long and Kiplinger 1999; Storey et al. 1998). As technology becomes more widely available, interactive computer-based training is becoming a cost-efficient option (Knebel 2000).

Although managers may assume that training is the answer when faced with a performance problem, that is not always the case. The Performance Improvement approach, which applies industrial experience to reproductive health care, first analyzes the performance problem to identify its root causes (Caiola and Sullivan 2000; Lande 2003). Often, these are not lack of knowledge or skills, but rather inadequate equipment and supplies, limited supervisory support, or inappropriate incentives. Research into providers' perspectives on their jobs also has the potential to shed new light on performance issues (Shelton 2001). For example, interviews with female health workers in Pakistan found that gender inequities in the broader society also permeate the health care system and prevent them from doing a good job (Mumtaz et al. 2003).

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Supervision

Effective supervision is critical to the performance of family planning programs (Simmons 1987). Supervisors assess performance, identify weaknesses, and give feedback; provide technical support and training in clinical activities; motivate staff; manage conflict; and advise on management practices (Benavente and Madden 1993; Wolff et al. 1991). Despite its importance, however, supervision is frequently one of the weakest elements of family planning and reproductive health programs. Studies in Africa, Asia, and Latin America have found that supervisors do not visit service delivery sites as often as they are supposed to and do not remain long enough at a facility to provide needed guidance (Ahmed et al. 1994; Ashraf et al. 1996; Combary et al. 1999; Kim et al. 2000; Valadez et al. 1990). Supervisors frequently lack the time and transportation needed to visit scattered clinics, and they also lack the training, job manuals, and assessment tools needed to carry out their duties effectively.

To strengthen supervision without increasing its costs, health programs have tested a number of alternative strategies. Giving supervisors a simple checklist or brief technical training has improved their performance as well as the performance of the providers they oversee (Combary et al. 1999; Loevinsohn et al. 1995). Group meetings with providers have proven to be effective substitutes for one-on-one supervision sessions; they allow supervisors to reach more providers and spend more time on training (Jacobson et al. 1987; Vernon et al. 1994). The most radical and cost-efficient alternative is to substitute self-assessment for supervision. In this approach, providers use checklists and other materials to rate their own performance and to decide which of their skills and behaviors need to be strengthened (Vernon et al. 1994; Kim et al. 2000).

Some innovative programs are asking supervisors to move beyond the traditional role of outside inspector and instead to collaborate with the facility's staff. This approach asks supervisors to coach and motivate workers, facilitate staff efforts to solve problems, and advocate for needed training and supplies (Lammerink 1994). Sometimes outside supervisors share these responsibilities with staff teams (Ben Salem and Beattie 1996; Benavente and Madden 1993). Supportive supervision builds on these innovations to create a system in which a combination of officially designated supervisors, other staff, peers, and health providers themselves use a variety of supervision methods to monitor providers’ performance continuously (Marquez and Kean 2002).

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Quality improvement strategies

Over the past decade, international family planning programs have shifted priorities to focus on the quality of the services they offer rather than the number of contraceptives distributed (WHO 2002). Research suggests that quality of care may contribute to both contraceptive adoption and continuation rate (Hanifi and Bhuiya 2001; Henry-Lee 2001; Koenig et al. 2003; RamaRao et al. 2003; Sanogo et al. 2003; Tuoane et al. 2003). Bruce's (1990) landmark paper on the quality of care defined six elements essential to good family planning services: method choice, information giving, providers' technical competence, interpersonal relations between providers and clients, follow-up and continuity mechanisms, and an appropriate constellation of services. In defining quality services, however, clients often have different priorities than providers (Hardee et al. 2001). For example, they frequently place a higher value on respect, privacy, and waiting time than on technical competencies (Aldana et al. 2001).

To achieve good quality in each of these areas, many programs have strengthened their monitoring systems and developed formal certification systems in which outside inspectors periodically visit every facility (read about Egypt's certification system in the program examples). Some programs have invested heavily in quality, but improving care does not necessarily require additional resources. Programs can make major improvements by reorganizing work processes to use available resourcesincluding soap and water, IEC materials, and staff timemore efficiently (Haberland et al. 1998; Setty 2004).

Another strategy is continuous quality improvement, an approach using industrial principles and tools in which staff members try to exceed accepted standards of care by constantly refining processes. Various family planning organizations have developed structured quality improvement (QI) processes, all of which share a common approach: groups of staff members work together to identify problems and opportunities for improvement, collect data on the root causes of a problem, and design and implement a practical solution to the problem  (Buxbaum et al. 1993; Cross et al. 2002; DiPrete Brown et al. 1993; Hardee and Gould 1993; Lynam et al. 1992; Thorne et al. 1993). Applying QI processes requires specialized training and tools (Quality Assurance Project 2001). Some QI models are designed to work nationwide (Franco 1995); others focus on providing simple tools to front-line workers (Dwyer and Jezowski 1995). No matter what the approach, the goal is to institutionalize the process so that quality improvement because a routine and sustainable part of the program (DiPrete Brown 1995).

QI programs in every region of the world have succeeded in raising the quality of family planning and reproductive health services and in increasing productivity, but results may come slowly and the programs demand a significant amount of staff time and energy (Kols and Sherman 1998). QI programs also generally build morale, heighten providers' awareness of client needs, improve staff relationships, and encourage staff members to tackle problems instead of ignoring them. Experience has shown the importance of keeping tools and measurement systems simple, involving people at every level of the system (Bradley et al. 2002; Stinson et al. 2000), making changes worthwhile for providers, and fostering a client orientation (Family Planning Service Expansion and Technical Support Project 2000). More attention, however, must be paid to scaling up successful innovations from pilot tests to large public-sector programs (Simmons et al. 2002).

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Integrated services

Integrated services have taken many different forms depending on pre-existing service delivery systems, political will, and available resources (Lush et al. 1999). In some areas, family planning services are offered through a department or clinic that is part of a general purpose health facility. Here integration may mean increased coordination between departments, so that providers screen and refer patients for other services available onsite (Vernon and Foreit 1999). For vertical family planning programs, integration usually means adding services that are directly relevant to existing clientele, for example, addressing STIs or domestic violence. Such programs have been more successful when they have applied existing expertise to new problems—for example, advocating STI prevention in counseling sessions—than when they have added totally new activities—for example, clinical services to treat STIs (Shelton 1999). (For further discussion of the challenges and benefits of integrating STI services with family planning, see RHOs Reproductive Tract Infections section.) Integration also may mean adding family planning services to other health programs, for example, incorporating family planning into voluntary counseling and testing (VCT) for HIV (FHI 2004; USAID 2003). Integration may even occur outside the clinic setting, for example, in communication, advocacy, and social marketing efforts (Shelton and Fuchs 2004). No matter what the approach, it is important to integrate goals, policies, management, budgeting, and funding as well as the actual delivery of services (Berer 2003).

Data on the effectiveness and cost of integrated services are mixed (Briggs et al. 2002; Lush et al. 1999; WHO 1999). Two reviews concluded that integrating STI prevention activities benefited family planning clients but had little effect on STI morbidity (Dehne et al. 2000; O'Reilly et al. 1999), while a third review decided that integrated services have the potential to reduce transmission of HIV/AIDS (Askew and Berer 2003). Although studies in Ghana and Morocco found that integrated services encouraged contraceptive use (Fullerton et al. 2003; Hotchkiss et al. 1999), vertically organized programs in West Africa generated more demand for family planning than integrated facilities and were more cost-effective (Mancini et al. 2003; Stewart et al. 1999).

Family planning associations in Latin America and the Caribbean have succeeded in transforming attitudes, both internal and external, toward their mission and in expanding the range of services offered (Helzner 2002). In some countries, however, attempts to integrate services have foundered because of limited administrative support; inadequate training, equipment, drugs, and space; unresolved conflicts between family planning and STI guidelines; and the inability to overcome existing hierarchies and lines of authority (Lush 2002; Maharaj 2004; Mayhew 2000; Mayhew et al. 2000). Making the decision to integrate services should come only after a careful assessment of its potential benefits and problems (Mitchell 1994), including a consideration of how well matched the clientele and service delivery requirements are (Fleischman Foreit et al. 2002; Shelton and Fuchs 2004). Family planning programs integrating new activities must prevent staff from being overburdened and distracted or the quality and effectiveness of family planning services will suffer (Hardee and Yount 1995).

For more information on integrating family planning services and STI/HIV prevention, see RHO's Special Focus: Dual Protection and HIV/AIDS.

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Financial management and sustainability

Governments and outside donors heavily subsidize family planning services offered by the public sector and even some services offered by the private sector. Demand for services continues to grow while funding does not, however, creating a serious gap in resources (Lande and Geller 1991). Integrating other reproductive health services into family planning programs will only exacerbate the problem. This makes it increasingly important for family planning programs to use scarce resources efficiently and to achieve financial sustainability—while also maintaining good quality of care (Yeboah 2002).

Accomplishing these aims requires sound financial management (Wolff et al. 1991). Family planning managers need basic financial management skills to ensure that their program's resources are used responsibly and appropriately (Wolff et al. 1991). They should base decisions about staffing patterns, service mix, service practices, procurement, and other aspects of service delivery on thorough cost and revenue analyses (Donaldson et al. 1993; Janowitz et al. 2000).

Programs have tested a wide variety of strategies to increase their financial sustainability (Janowitz et al. 1999). Common strategies include:

  • Charging fees: User fees can generate funds needed to increase the quality of services or expand coverage (Barnett 1998), but fees may reduce demand for services and access to services by poor people—especially women (Bratt et al. 2002; Ciszewski and Harvey 1995; Janowitz 1996; Nanda 2002). Fee collection systems also can be difficult to administer, especially if they include some system of means testing to protect the poor (Musau 1999; Schuler et al. 2002).
  • Subsidizing family planning with profits from other services: Cross-subsidization uses profits from services that clients are willing to pay for, such as lab tests, to cover the cost of family planning services (Wolff et al. 1991). Programs also may use profits from clinics located in prosperous communities to subsidize clinics in poor neighborhoods.
  • Encouraging people to use private-sector services: Given appropriate incentives (such as convenience or higher-quality services), some clients may be willing and able to switch from public- to private-sector family planning services (Finger 1998). This frees up government resources to serve the poor (Fleischman Foreit 2002). This strategy is more likely to succeed in countries where contraceptive prevalence and national income are high and the private sector is well developed (Hanson et al. 2001).
  • Cutting costs: Managers can use existing resources more efficiently by offering fewer or lower-cost contraceptive methods; switching to less expensive service delivery strategies (Barberis and Harvey 1997; Levin et al. 1999); ensuring that staff, equipment, and facilities are fully utilized (Hubacher et al. 1999; Janowitz et al. 2002; Mitchell et al. 1999); eliminating unnecessary and wasteful medical barriers (Bratt et al. 1998); and integrating vertical family planning and health programs.

Selecting and implementing one of these strategies is not easy. In Bangladesh, for example, changes in service delivery designed to cut costs may reduce field workers productivity and poor womens access to contraceptives (Arends-Kuenning 2002). No matter what strategy is implemented, managers must work to overcome clients suspicions and entrenched habits (Schuler et al. 2001; Schuler et al. 2002).

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Policy making

The policy environment—which includes political support, formal population and health policies, laws, and regulations—shapes access to and the quality of family planning and reproductive health care. Policy makes its influence felt in a host of ways: it determines what services the public health system offers, where, and at what price; it regulates (and taxes) contraceptives and contraceptive advertising; it sets restrictions on providers and determines eligibility requirements for clients; and it allocates funding and other resources (Bertrand et al. 1994; CRLP 2000). Indeed, national population and family planing policies help explain the variation in the timing and extent of fertility declines in developing countries over the latter half of the twentieth century (Lush et al. 2000).

Over the course of the twentieth century, family planning policies evolved in response to shifting rationales—from demographic to public health to human rights—and in response to global challenges (Seltzer 2002). In recent years, the provision of family planning services has been deeply affected by two fundamental policy changes: health sector reforms to improve efficiency and cost-effectiveness and the ICPDs move toward a reproductive health approach focused on individual needs (Ashford 2001; Finkle and McIntosh 2002). Health sector reforms such as decentralization, innovative financing, streamlined operational policies, and increased private-sector participation have the potential to increase the efficiency, equity, and quality of family planning services. However, some worry that health sector reforms may divert attention away from reproductive health needs (Hardee and Smith 2000; Langer et al. 2000) or conflict with reproductive health policy (Lubben et al. 2002). There is greater consensus on the benefits of the ICPDs Programme of Action, but translating its hundreds of recommendations into national policy and law is proceeding slowly, and implementing and enforcing the policy changes poses an enormous challenge (CRLP 2000; Hardee et al. 1999). Part of the problem is the fundamental tension between human rights and public health agendas (Jacobson 2000).

Case studies of population, family planning, and reproductive health policy making in developing countries around the world suggest that the process of making and implementing policies is as important to the success of family planning programs as the content of those policies (Hoodfar and Assadpour 2000; Population Reference Bureau 2001; Tantchou and Wilson 2000; Visaria et al. 1999). Critical elements include high-level political commitment, broad-based coalitions to spread policy risks, and a stable institutional home and funding for family planning (Jain et al. 1998; Lee et al. 1998).

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Advocacy

The commitment of national leaders, favorable policies and laws, adequate financing, and popular support are essential to ensuring broad access to good-quality family planning and reproductive health services (Upadhyay and Robey 1999). Advocacy uses persuasive communication to gather that support. Carefully planned activities—including public awareness campaigns, direct lobbying of legislators and policy makers, and working with the press—can spur public discussion and raise the profile of an issue, secure political commitment and legal changes, and even encourage changes in personal behavior and social norms. Because of the controversial nature of family planning, advocacy has always been essential. Its importance has grown, however, first as proponents of family planning began advocating for dramatic shifts in national policies and programs in response to the ICPD Programme of Action (Ketting 1996) and more recently as political support and funding for reproductive health has declined (Gillespie 2004).

Many resources are available to help family planning and reproductive health programs become effective advocates for family planning. Manuals outline a step-by-step advocacy process, beginning with the definition of objectives and identification of stakeholders, including supporters, opposition forces, and key decision makers (CEDPA 1999; Ianey 1999; IPPF 2001; JHU/CCP 1999; Sharma; Van Kampen). Next, advocates build a broad base of support through networking and coalition building, and then they develop an effective strategy to get the message out. Monitoring and evaluation is essential to heighten the impact of ongoing advocacy efforts.

Content is as important as process to successful advocacy. Urgent and appealing messages that demand action—and present objective evidence to justify those demands—rest at the heart of effective campaigns. Both print (Singh et al. 2003; Upadhyay and Robey 1999) and online resources (www.PLANetWIRE.org, www.populationaction.org, www.policyproject.com, www.crlp.org) are available to help advocates craft effective messages and make the case for family planning. General information of this kind, however, must be supplemented with details of the local situation.

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