Please note: This archive was last updated in 2005.

RHO archives : Topics : Family Planning Program Issues

Overview

Family planning programs and modern contraceptives enable millions of couples and individuals throughout the world to plan the number and spacing of their children—or to avoid pregnancy altogether. Today almost 60 percent of couples use some form of contraception and more than 50 percent use modern methods—well on the way to the 70 percent use that demographers call the "fully contracepting society."

Advances in the design and delivery of family planning services have contributed to the growing use of contraception. Health managers have analyzed their own experience, borrowed techniques from the business world, and conducted operations research to improve the quality and efficiency of family planning services in low-resource settings. However, they face the challenge of achieving multiple, sometimes conflicting objectives with strictly limited resources. On the one hand, family planning programs must try to meet the needs of each individual client by consistently offering high-quality care. On the other hand, programs strive to reach as many people as possible, ideally making services financially and geographically accessible to the entire population, including the poor and those who live in distant areas. This section reviews some of the issues that arise as family planning managers seek to simultaneously increase access, improve quality, and minimize costs.

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Changing priorities

The 1994 International Conference on Population and Development (ICPD) transformed the agenda for international family planning. The consensus forged in Cairo emphasized individual human rights over national development and population goals, redefined family planning as one element of comprehensive reproductive health care services, viewed health within a broader social context, and acknowledged the importance of equity and empowerment for women. Since the Cairo meeting, family planning programs have set new goals, including:

  • offering client-centered care,
  • improving the quality of care,
  • integrating family planning with other reproductive health services,
  • addressing social problems that affect women's health, such as domestic violence (see RHO's Gender and Sexual Health section); and
  • meeting the needs of special groups (see RHO sections on the reproductive health of adolescents, men, and refugees).

Ten years after the Cairo meeting, the United Nations Population Fund (UNFPA) (www.unfpa.org/swp/2004/pdf/en_swp04.pdf) and a global meeting of reproductive health professionals (www.countdown2015.org/) reviewed the progress made toward achieving the goals laid out in the Programme of Action. Support for the ICPD’s approach to reproductive health and rights has grown. Family planning programs around the world have worked to improve the quality of services and extend their reach, integrate family planning with other reproductive health services, and focus on meeting the needs of individual clients. Both reviews concluded, however, that serious challenges remain. Governments and donors have not lived up to their financial commitments to support the reform effort. As a result, shortfalls of contraceptive supplies pose a growing problem, and many people still have limited access to services. Broad political support is also lacking in some countries, especially regarding sensitive issues such as adolescent sexuality and abortion. Finally, implementation has lagged behind policy—translating the goals of the Cairo meeting into working programs has proved difficult, especially given shortages of skilled staff, institutional constraints, and difficulties in coordination.

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Increasing access to family planning

Family planning programs have developed innovative approaches to delivering services so that women and men who are interested in using contraception can readily find a source of information, assistance adopting a method, continuing support for contraceptive use, and a source of resupply. Strategies to increase access to family planning services include building additional clinics in under-served areas, taking services to people via mobile clinics and community-based distribution workers, selling contraceptives at a subsidized price in pharmacies and other retail outlets, and training private-sector providers.

However, true access requires more than conveniently located services. Potential family planning clients may face a variety of barriers. For example, the cost of transportation, services, and supplies may be unaffordable; they may not know where to seek services; or they may fear side effects too much to act. In some settings, conditions at the service delivery point discourage clients from seeking services; family planning clients have complained about limited hours, long waits, rude treatment by clinic staff, and unreliable supplies of contraceptives. Unnecessary medical barriers, such as outdated contraindications or parity requirements, also may prevent clients from receiving the contraceptive method they prefer.

Still other obstacles to family planning are rooted in the cultural and social context. Fear of disapproval by family and neighbors discourages some potential clients, and individual providers and entire programs may deny services to unmarried adolescents for cultural reasons (see RHO's Adolescent Reproductive Health section). The low status of women often poses a barrier: although more than two-thirds of family planning users worldwide are women, in many societies women lack the power to make independent decisions about using contraceptives or seeking services (see RHO's Gender and Sexual Health section).

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Improving the quality of care

Providers' performance is central to the quality of services offered by family planning programs. Their technical knowledge and skills ensure clients' safety as they screen clients for contraindications and perform clinical procedures; their interpersonal communication skills help clients make an informed choice of methods. However, providers do not operate independently. They rely on a wide array of management systems for essential supplies, equipment, and support. Therefore, efforts to improve the quality of care offered to family planning clients must go beyond the provider and encompass the following management systems.

  • Logistics systems deliver contraceptive commodities and other supplies when and where they are needed and ensure that they are in good condition. For clients, this means a full range of contraceptive supplies are available when they seek services.
  • Records systems deliver medical records to providers so they have access to clients' medical history and can ensure continuity of care.
  • Training systems teach providers and other staff members new skills and strengthen existing skills. Training ensures that providers' knowledge is complete and accurate and that their practices are safe and up-to-date.
  • Information, education, and communication (IEC) systems expedite the flow of information to clients by producing job aids, educational materials, mass media campaigns, and community mobilization activities.
  • Supervision systems assess the performance of staff members and identify areas that need attention.
  • Monitoring and accreditation systems enable managers and inspectors to determine which providers and facilities meet minimum standards of care.
  • Management information systems (MIS) collect accurate and reliable information about service delivery so that managers can make decisions based on data rather than intuition and assumptions.
  • Referral systems give clients access to services that are beyond the capability of local facilities, for example, tubal ligation or domestic violence counseling.
  • Financial management systems help managers make cost-effective decisions about staffing patterns, service delivery strategies, contraceptive mix, service practices, and procurement.

Program guidelines, including service policies, service standards, clinical protocols, and management procedures, shape the everyday operation of all of these management systems and determine the quality of care offered at family planning facilities. Reviewing and revising program guidelines to reflect the latest scientific evidence and the best management practices is a fundamental step in improving the quality of care. To upgrade management systems and service delivery, some family planning programs also have turned to the team problem-solving approaches associated with continuous quality improvement.

Other issues affecting the quality of care are beyond the control of program managers. In many areas, for example, unreliable and insufficient supplies of contraceptives reduce access to family planning and undermine clients’ right to choose a method. Given the worldwide shortfall in condoms and other reproductive health commodities, improving local logistics systems may not be enough to solve the problem.

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Promoting informed choice

Helping clients make and implement an informed decision is the goal of family planning counseling sessions. New clients must choose the most appropriate contraceptive method from a range of options, while continuing clients must decide whether to continue using their current method, switch methods, or stop using family planning altogether when they experience side effects or their circumstances and reproductive intentions change. The concept of informed choice has two elements: first, clients have the right to make their own decisions, and, second, clients need expert information and advice in order to choose wisely.

Informed choice places heavy demands on providers' interpersonal communication skills. Providers must explain the options available to clients and help them weigh the advantages and disadvantages without making decisions for them. Ideally providers help family planning clients feel well informed, reassured, and comfortable with their decisions, so that clients are able to use their method correctly, cope with side effects or other setbacks, and change methods as needed, and as a result, enjoy greater success using contraception.

However, the process of informed choice is not confined to counseling sessions. Before they see a provider, most clients have already gathered information about family planning from other sources, including relatives, friends, radio and television broadcasts, posters, and clinic brochures. Indeed, many clients have already decided on a method before they arrive at a clinic. Family planning IEC activities can contribute to informed choice by stimulating discussion of the benefits of family planning, by disseminating accurate information about contraceptive methods to the general public, by encouraging partners to discuss their reproductive intentions, and by supplying job aids and educational materials to supplement providers' explanations.

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Integrating family planning with other health services

There is a strong political consensus in favor of integrated reproductive health services, although evidence on its impact is mixed. Integrated services offer definite benefits to clients, who can receive multiple services during a single visit to a facility. After screening clients for a broad range of needs, providers in integrated facilities can encourage clients to receive other services, for example, advising family planning clients about STI services or offering contraception to women seeking postnatal care. Integrated services also have the potential to be more efficient and effective: sharing facilities and personnel minimizes duplication in administration and service delivery, makes greater use of existing infrastructure and personnel, and simplifies logistics.

Critics are concerned, however, that integration overburdens fragile delivery systems, reduces the effort devoted to family planning, and erodes the quality of care. Integrating services exacerbates existing problems and creates new demands on every aspect of service delivery, including supplies and logistics, records systems, staff training, and supervision. Adding STI services to a family planning program, for example, requires more training for providers and supervisors, stocking additional drugs, and providing new laboratory services. (For detailed consideration of integrating family planning and STI services, see RHO's Reproductive Tract Infections section.) Providers also may pay less attention to family planning when they become responsible for a host of new activities.

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