• TABLE OF CONTENTS
HIDE
 Front Cover
 Front Matter
 Advertising
 List of OR summaries in the...
 Table of Contents
 Access
 Quality of care
 Situation analysis
 Contraceptive options
 Postabortion care
 RTIs, STIs, and HIV/AIDS
 Gender and empowerment
 Youth
 Cost and sustainability
 Institutionalization of OR
 Back Cover














Title: Operations research summaries
CITATION THUMBNAILS PAGE IMAGE ZOOMABLE
Full Citation
STANDARD VIEW MARC VIEW
Permanent Link: http://ufdc.ufl.edu/UF00088805/00001
 Material Information
Title: Operations research summaries operations research and technical assistance : improving family planning and reproductive health services worldwide
Physical Description: 1 portfolio : ill. (some col.) ; 31 cm.
Language: English
Creator: Population Council
Publisher: Population Council
Place of Publication: New York NY (One Dag Hammarskjold Plaza New York 10017)
Publication Date: 1998-
 Subjects
Subject: Birth control clinics -- Developing countries   ( lcsh )
Maternal health services -- Developing countries   ( lcsh )
Infant health services -- Developing countries   ( lcsh )
Genre: non-fiction   ( marcgt )
 Notes
General Note: Title from portfolio.
General Note: "January 1998"--P. 1.
General Note: Loose-leaf for updating. Portfolio consists of 2 p. + 10 pockets, with leaves of text in pockets and text on pocket verso.
 Record Information
Bibliographic ID: UF00088805
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 38926672
lccn - 98161676

Table of Contents
    Front Cover
        Front Cover
    Front Matter
        Front Matter 1
        Front Matter 2
    Advertising
        Advertising
    List of OR summaries in the folder
        Page i
        Page ii
    Table of Contents
        Table of Contents
    Access
        Page 1
        Page 2
        Page 3
        Page 4
        Page 5
        Page 6
        Page 7
        Page 8
        Page 9
        Page 10
    Quality of care
        Page 11
        Page 12
        Page 13
        Page 14
        Page 15
        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
        Page 21
        Page 22
        Page 23
        Page 24
        Page 25
        Page 26
        Page 27
        Page 28
    Situation analysis
        Page 29
        Page 30
        Page 31
        Page 32
        Page 33
        Page 34
        Page 35
        Page 36
        Page 37
        Page 38
    Contraceptive options
        Page 39
        Page 40
        Page 41
        Page 42
        Page 43
        Page 44
        Page 45
        Page 46
        Page 47
        Page 48
        Page 49
        Page 50
        Page 51
        Page 52
        Page 53
        Page 54
    Postabortion care
        Page 55
        Page 56
        Page 57
        Page 58
        Page 59
        Page 60
        Page 61
        Page 62
    RTIs, STIs, and HIV/AIDS
        Page 63
        Page 64
        Page 65
        Page 66
        Page 67
        Page 68
    Gender and empowerment
        Page 69
        Page 70
        Page 71
        Page 72
        Page 73
        Page 74
        Page 75
        Page 76
    Youth
        Page 77
        Page 78
        Page 79
        Page 80
        Page 81
        Page 82
        Page 83
        Page 84
    Cost and sustainability
        Page 85
        Page 86
        Page 87
        Page 88
        Page 89
        Page 90
        Page 91
        Page 92
        Page 93
        Page 94
        Page 95
        Page 96
    Institutionalization of OR
        Page 97
        Page 98
        Page 99
        Page 100
        Page 101
        Page 102
        Page 103
        Page 104
        Page 105
        Page 106
        Page 107
        Page 108
        Page 109
        Page 110
    Back Cover
        Back Cover
Full Text
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d Population Council



April 9, 1998


Dear colleague:

We are pleased to share with you a copy of our new information folder, Operations
Research (OR) Summaries, which contains significant findings of 45 recent studies
carried out by the Population Council's Operations Research and Technical Assistance
(OR/TA) Projects in Africa, Asia and the Near East, and Latin America and the
Caribbean. The information is organized by topic (i.e. maximizing access and quality of
care (MAQ); postabortion care; RTIs, STIs, HIV/AIDS; gender and empowerment;
institutionalization of OR) rather than region in order to promote a synthesis of
experiences.

This OR summaries series, which will also be available in French and Spanish in June, is
being distributed to provide useful information to key policymakers and program
managers for improving reproductive health services around the world. Each summary is
identified by theme and country, and contains study findings and information on
utilization of findings.

We will periodically be sending you new batches of OR summaries to add to your folder
for easy reference. We ask that you share this information with other colleagues who may
find it useful and are enclosing an order form for additional copies. We also ask that, even
if you do not wish to order additional copies, you fill out the organizational data on the
order form to update our database.

We hope that you will find the new OR summaries useful and look forward to your
feedback and suggestions.



Nichol s Goued6, M.S.
Communication Specialist
International Programs Division
ngouede@popcouncil.org


One Dag Hammarskjold Plaza, New York, New York 10017
Telephone. (212) 339-0500 Facsimile: (212) 755-6052 Email. pubinfo@popcouncil.org http://www.popcouncil.org






PUBLICATIONS ORDER FORM
For additional copies of the OR Summaries, please complete the following
form and mail or fax it to the Population Council office nearest you. A list of the
Population Council offices is enclosed. This publication is available in English,
French and Spanish. Please include your subscriber number which is located
next to your name on the mailing label.

QUANTITY LANGUAGE
copies OR Summaries Folder in English
copies OR Summaries Folder in French
Copies OR Summaries Folder in Spanish


Subscriber number:


Title:

Organization:

Mailing address:


Country:


Telephone:


Fax:


Website Address:


ORGANIZATIONAL DATA
Type of organization (please circle one).
1. Governmental
2. Non-governmental
3. Parastatal (Autonomous)


4 UN Agency
5. University
6. Other (Specify:


Type of work done by your organization (circle all that apply).
1. Health Provision 5. Women's Group
2. Research 6. Advocacy
3. Media/IEC 7. Other (Specify:
4. Donor/Foundation


Your areas) of interest (circle all that apply).
1. MAO Access
2. MAQ Quality of Care
3. MAQ Situation Analysis
4. Contraceptive Options
5. Postabortion Care
6. STIs, RTIs and HIV/AIDS
7. Gender & Empowerment
8. Youth
9. Cost and Sustainability
10. Institutionalization of OR


11. Issues in Operations Research Methods
12. IEC/Counseling
13. Sexual Health/ Sex Education
14. Reproductive Health Technology
15. Training
16. Reproductive Rights
17. Program Management
18. Population Policy/Advocacy
19. Maternal and Child Health
20. Other (Specify:


Name:


E-mail:








'. *I i *
I




Pouato Coni Iaioc r
S 6
ma~~'~ I. *SS *-6 .6


List of OR Summaries in the folder


Theme
MAQ/Access
MAO/Access
MAO/Access
MAO/Access


MAO/Quality of Care
MAO/Quality of Care
MAQ/Quality of Care
MAO/Quality of Care
MAO/Quality of Care
MAO/Quality of Care
MAO/Quality of Care
MAO/Quality of Care

MAO/Situation Analysis
MAO/Situation Analysis
MAO/Situation Analysis
MAO/Situation Analysis

Contraceptive Options
Contraceptive Options
Contraceptive Options
Contraceptive Options
Contraceptive Options

Postabortion Care
Postabortion Care
Postabortion Care
Postabortion Care
Postabortion Care


STI-I STIs, RTIs and HIV/AIDS
STI-2 STIs, RTIs and HIV/AIDS


GE-I Gender & Empowerment
GE-2 Gender & Empowerment
GE-3 Gender & Empowerment
Y-I Youth
Y-2 Youth
Y-3 Youth


CS-1 Cost &Sustainability
CS-2 Cost & Sustainability
CS-3 Cost & Sustainability
CS-4 Cost & Sustainability
CS-5 Cost & Sustainability


Institutionalization of OR
Institutionalization of OR
Institutionalization of OR
Institutionalization of OR
Institutionalization of OR
Institutionalization of OR


No.
ACC- I
ACC-2
ACC-3
ACC-4


QOC-I
OOC-2
QOC-3
OOC-4
OOC-5
QOC-6
OOC-7
OOC-8
SA-I
SA-2
SA-3
SA-4

CO-I
CO-2
CO-3
CO-4
CO-5
PAC- I
PAC-2
PAC-3
PAC-4
PAC-5


Country
India
Pakistan
Kenya
Guatemala


Burkina Faso
Kenya
Kenya
Egypt
India
Philippines
Mexico, Guatemala
Honduras
Zanzibar
Senegal
Pakistan
Turkey

Tanzania
India
Indonesia
Philippines
Peru

Kenya
Kenya
Egypt
Guatemala
Mexico

Kenya
Kenya, Uganda,
Botswana

Bangladesh
Egypt
Honduras

Botswana
Ghana
Mexico


Ecuador
Ecuador
Ecuador
Guatemala
Haiti

Senegal
Bangladesh
Indonesia
Philippines
Mexico
Latin America and
the Caribbean


Headline
CBD program uses dairy cooperatives to increase FP access and acceptance
Village-based workers increase women's access to FP
Measuring the impact of community-based distribution programs
Bilingual primary teachers educate indigenous Guatemalan audiences in
reproductive health

Measuring changes in family planning services quality over time
Identifying client and provider perceptions on quality of care
Quality of family planning services shows marked improvement
Continuation of contraceptive and service use: the CSI project experience
Training private medical practitioners improves quality of care
Factors affecting family planning drop-out rates
Increasing the use of reproductive health services
Community volunteers successfully refer women to reproductive health services

Situation analysis data evokes immediate response
Situation analysis of family planning services identifies program gaps
Situation analysis of family welfare centers
Situation analysis of reproductive health care services

Vasectomy: a new reproductive health option for men
Satisfaction with diaphragm high among poor women in Madras city
Creating conditions for a sustainable family planning program
Major technical assistance effort provides timely data on reintroducing DMPA
Identifying gaps in DMPA method counseling

Identifying unmet need for postabortion care
Improving care of postabortion patients in hospitals
Postabortion care counsel husbands as well as patients
Improving postabortion quality of care
Improving postabortion services in the Mexican health system

Strengthening the integration of STI/HIV and MCH/FP services
Integrating STI/HIV services into existing MCH/FP programs


Family planning enhances women's status
Confirming the extent of female genital mutilation (FGM)
Volunteers prove successful at increasing men's knowledge of FP

Strengthening NGOs providing reproductive health services for adolescents
Examining awareness of reproductive health issues among youth
Family life education increases contraceptive knowledge and use by
Mexican youth

Examining cost, quality and safety in laboratory services
Reducing costs and increasing profits in mini-pharmacies
Increasing prices while minimizing client loss
Measuring costs of providing integrated reproductive health services
Productivity and payment of volunteer workers

Dissemination of situation analysis findings increases utilization
Operations research utilized for review of population policy
Increasing utilization of operations research results
Making operations research a part of program management
Institutionalizing OR in the Mexican Social Security Institute for Govemment Workers
Institutionalizing operations research


INS-1
INS-2
INS-3
INS-4
INS-5
INS-6









d Population Council


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^^^^^^^^Managing Editor:i SRaainT~tjffeT nKKiMmaI
^^^^^^Associate Editors: Nicholas Go^iede, Heidi Joiles
^^^^^^^Editorial Coordinators: Sahar Hegazi, Sylvia LlagL^^I1H0
^^^^^^^^^Editorial Consultant: Launa Hess^^^^^^^^^^^^^^
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MEASURING THE IMPACT OF COMMUNITY-
BASED DISTRIBUTION PROGRAMS

CBD programs in Kenya are effective sources of FP information, and many
provide a significant proportion of contraceptive supplies to users,
particularly women using pills. A strong supervisory system is a key
determinant of CBD agent performance.

BACKGROUND
Kenya is one of the leading countries in Africa in developing and implementing
community-based programs as part of the national family planning program.
Virtually every approach to CBD that has been tried somewhere in the world is
represented in Kenya. The Population Council's Africa OR/TA Project undertook
an evaluative study of seven of Kenya's largest CBD programs (four rural and
three urban) to determine the effectiveness, cost-effectiveness and performance
of the different approaches for use in guiding program planning and future
resource allocations. Study methodologies included catchment area
questionnaire surveys; in-depth interviews with CBD agents, supervisors and
managers; and a review of program service statistics. The study also assessed
the degree to which the programs met other reproductive and sexual health
needs, addressed gender concerns, and provided other basic health services.

FINDINGS
* One-half of men and women interviewed in the catchment areas said they
knew of a CBD agent; these
SOURCE OF SUPPLY FOR PILL USERS
proportions were higher for rural KENYA Govt/
programs. Govt/mission
programs. clinics 44%

* Among women who use
contraceptive pills, 44 percent Private/NGO
get their method from an agent. clinics 8%
Among women who use a Pharmacy/
supply method (i.e. a method for shop 1% Friends/
which a source of supply is others 6.
needed), 40 percent obtain
their method from a CBD
agent. Over one-third of male n=209
condom users get their method CBD
from an agent. agent44%
Source: Chege etal., 1997
* Among current
contraceptive users, CBD agents were cited as the method source for 16 percent
and 19 percent of all female and male users respectively.


-APoutoConA-






* Almost 80 percent of CBD clients said the agent discussed methods other
than the one they chose and told them they could change methods if they wanted.

* Overall, the CBD agent was the source of most information about family
planning for 12 percent of women and 11 percent of men interviewed. Among their clients,
however, over half said the agent was their main source of information.

* Three-quarters of the CBD agents interviewed said they would not provide
contraceptives to a young woman who had never been pregnant, but less than one-fifth
said they would not provide contraception to a young male, regardless of whether he had
proven his fertility or not.

* The program with full-time, salaried agents had the highest average number
of clients met per year and the greatest number of users. Other factors which appear to
influence service output per agent include the level of FP demand within the catchment
area and the quality of supervision.

* The four programs with the highest average outputs per CBD agent all require
supervisors to have individual and group contacts with CBD agents on a monthly basis.

* The vast majority of clients said that they are satisfied with the quality of services
CBD agents provide. However, all programs were weak in three areas: 1) discussing
method side effects and how to manage them; 2) maintaining adequate contraceptive
supplies; and 3) the technical competence of CBD agents.

* A female CBD agent's work in her community appears to provide an opportunity for
self-enhancement, and increased autonomy and decision-making power, both within her
own family and in the wider community.

UTILIZATION OF RESULTS
* National level policy makers, program managers, donors, and managers and
staff from several programs have proposed numerous recommendations and made plans
to take actions aimed at strengthening their programs.

* Other countries in the region, like Tanzania, are using the study approach as they
seek ways of improving existing and developing new approaches to CBD programs.


January 1998


Chege, Jane NIeri and lan Askew. 1997. An Assessment of Community-based Family Planning Programmes in Kenya. Nairobi: the
Population Council. January.
For more information or to obtain a copy of the report, please contact the Africa OR/TA Project II, Population Council, PO. Box 17643,
Nairobi, Kenya, Tel: (254)(2)713-480, Fax: (254)(2)713-479, E-mail: ORTA@popcouncil.or.ke.
This project was supported by the Population Council's Africa Operations Research and TechnicalAssistance Project II. The Africa
OR/TA Project II is funded by the U.S. Agency for International Development (USAID), Office of Population, under Contract No.
CCP-3030-C-00-3008-00, Project No 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.


January1998









IND

CBD PROGRAM USES DAIRY

COOPERATIVES TO INCREASE
FP ACCESS AND ACCEPTANCE

A community-based distribution (CBD) program in India's rural Bihar State
provided family planning and maternal and child health (FP/MCH) services
to members of dairy cooperatives at work and in their homes. The program
improved access to services, expanded the choice of available methods,
and increased members' knowledge of family planning and acceptance of
contraception.

BACKGROUND
This study documents the results of the Rural Family Health Project implemented
in Samastipur District by the Bihar State Cooperative Milk Producers Federation
(COMPFED) in collaboration with the Center for Development and Population
Activities (CEDPA). The three-year project tested whether improving the access of
dairy cooperative members to family planning services at the work site and at
home, providing an expanded choice of contraceptive methods, particularly
temporary methods, and providing follow-up care would increase their
knowledge of family planning and acceptance of contraception. The Population
Research Center conducted baseline and endline surveys with 2500 randomly
selected households spread over 40 Dairy Cooperative Societies (DCS) in 63
villages. The study's qualitative component, conducted by the Institute of
Psychological Research and Services, Patna University, focused on the project
implementation process.

FINDINGS
* The survey results
show a substantial increase CURRENT AND EVER USERS OF CONTRACEPTIVES, INDIA
in ever users (10 percentage Percent
points) and a 3.6 point
increase in current users. current
CPR increased from 23 to 27 us
percent. The increase in ever
users was mainly due to
acceptance and later E U
discontinuation of pills.
0 10 20 30 40
0 Although knowledge Baseline Survey Endline Survey
of all contraceptive methods
increased with the CBD Source: Prasadetal., 1995
approach, about half of
eligible women still did not know how to use temporary methods correctly at the
end of the project. Misconceptions about all methods except pills declined.


0" P4aiIICA,.9







* The high unmet need (31 percent) for contraception did not decline. Qualitative data
showed that 52 percent of pregnancies and 23 percent of births in the lifespan of women
aged 15 to 45 years were unwanted.

* Commercial sources for contraceptive methods in the project area are limited. In
many villages, the project's Voluntary Health Worker (VHW) was the only local source for
condoms and pills. Easier access to contraceptives and the availability of a VHW within the
community encouraged some women to adopt family planning even without the
knowledge of their husbands or mothers-in-law.

* Wherever the VHWs were active and contacted the village women regularly, their
acceptance of family planning increased. However, not all VHWs were active, and in many
areas they could not visit homes because of social barriers.

* Opposition from husbands and in-laws, the desire for at least two sons, and lack of trust
of VHWs from a different caste or religion were obstacles to acceptance of contraception.

* Potential VHWs should be provided with realistic information about the nature and
scope of the job. Many were unprepared for the work's challenging nature. They need
regular guidance, an evaluation system that measures quality in terms of providing more
choices, and more detailed information about contraceptives.

* The project had a very positive impact on the life of the VHWs, resulting in
enhanced self-esteem, an improved spousal relationship, and increased independence
both inside and outside the home.

* Cost analysis showed that an investment of US$8,695 was required for every unit of
increase in CPR (in an area covering about 54,000 eligible women). The cost for reaching
a new condom acceptor was US$10 and a new oral pill acceptor, US$15. The cost of one
Couple Year of Protection for female sterilization was between US$8 and $10.

UTILIZATION OF RESULTS
* The COMPFED model is being replicated in Uttar Pradesh under the Innovations in
Family Planning Services Project (IFPS) with modifications based on the lessons learned in
Bihar. Modifications include more comprehensive training for VHWs and outreach activities
to family members, particularly husbands and mothers-in-law.

* The Bihar project has been extended in order to study the dynamics of sustainability
and costs in the model, with the objective of applying the lessons learned to projects
elsewhere in India. In order to make the FP and MCH services more sustainable, Dairy
Cooperative Societies need to contribute toward the cost of maintaining them and assume
responsibility for program management.
Prasad Rudranand, Ram Bachan Ram, M.E. Khan, Bella C. Patel. 1995. Promotion of FP/MCH Care Through Dairy Cooperatives
in Rural Bihar. New Delhi: Population Research Centre (Patna), Institute of Psychological Research and Services (Patna) and the
Population Council.
For further information on this study or to obtain a copy of the final report, please contact the Population Research Centre, Patna
University Patna, Bihar. Tel: 0612-650017. Or the Population Council, 53 Lodhi Estate, New Delhi 110 003, India. Tel: 91-11-461-0913/
461-0914, Fax: 91-11-461-0912.
This project was conducted with support from the Population Council's Asia and Near East Operations Research and TechnicalAssistance
Project. The ANE OR/TA Project is funded by the U.S. Agency for International Development, Office of Population, under Contract No.
DPE-C-00-90-0002-10, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.
January 1998




m -

I M rMlA I S


BILINGUAL PRIMARY TEACHERS
EDUCATE INDIGENOUS GUATEMALAN
AUDIENCES IN REPRODUCTIVE HEALTH

The Guatemalan Association for Sexual Education (AGES) trained bilingual
teachers to conduct reproductive health classes. As a result, contraceptive
use in the participating communities rose by 3 percentage points within six
months of course completion.

BACKGROUND
The Mayan population, 40 percent of the total population in Guatemala, has a
contraceptive prevalence rate of 10 percent, one-fourth of the national figure.
Studies have shown that Mayan men and women are aware of the deleterious
effects of having too many children and having children too closely spaced.
However, they have only limited knowledge of contraception and of contraceptive
sources. One of the main obstacles for providing RH information and services is
the lack of service providers who can speak indigenous languages. Traditionally,
agencies in Guatemala have tried to provide family planning information in
indigenous communities by training volunteers or having an outside agent carry
out activities in the communities. Both systems have failed.

This project, carried out by the Guatemalan Association for Sexual Education
(AGES), with technical assistance from the Population Council's INOPAL Project,
tested using teachers from the National Bilingual Education Program (PRONEBI)
to teach reproductive health courses in indigenous communities. AGES
developed three 10-hour courses. Topics included birth spacing; pregnancy, birth
and gender; and mother and baby care. PRONEBI teachers wishing to
participate in the Reproductive Health Education System had to pass a written
examination based on a list of readings, and attend a 12-hour training course for
each module. Teachers who completed certification assembled groups and
taught courses in their communities. At the end of the course, they were paid 125
quetzales (US $22) for each 10-hour course taught.

FINDINGS
A total of 56 teachers Participant Responses
completed the training After Taking the Course
process and taught at least "Now I am going to plan my family."
one course in an "I learned about the sexual parts and functions of men
indigenous community. and women."
"I learned how our body changes and how a child is
During a seven born and grows."
month period, trained "I learned to improve communication with my partner."
teachers taught a total of "I learned to value my wife and children."
496 courses to 11,171 Source: Cospin etal., 1997
persons.


-emfplfin^ud






* The contraceptive prevalence rate among married women of reproductive age
increased by at least three percentage points after the course (equivalent to a relative
increase of 18 percent in the use of all methods, and of 40 percent in the use of modern
methods).

* A follow-up survey showed that participants liked the course. Communication
between partners on sexuality seems to have been enhanced.

* Sixty-five percent of the participants not in union, and those married but not yet
using methods, said they expected to use a family planning method in the near future.-

* The cost per course was US $56.40, and per student US $2.50.

Implication of Findings
* The Reproductive Health Education System tested was effective in screening out
unmotivated teachers or teachers who do not have the learning skills who do not have the
learning skills needed to participate effectively in the system. In addition, the project
showed that PRONEBI teachers can do much of the studying by themselves, thus greatly
reducing training expenses.

UTILIZATION OF THE RESULTS
* AGES is now in the process of securing funding from different sources to continue
using this educational strategy, not only for family planning purposes, but also for other
topics such as environmental protection, nutrition and women's rights.

* AGES has begun a new project which uses PRONEBI staff to distribute family
planning methods in addition to teaching reproductive health classes.


Cospin, Gloria and Ricardo Vernon. 1997. Reproductive Health Education in Indigenous Areas Through Bilingual Teachers in Guatemala.
Guatemala City: Asociacion Guatemalteca de Educaci6n Sexual y Desarrollo Humano (AGES) and the Population Council. April.
For more information or to receive a copy of this report, please contact Ricardo Vernon, Deputy Director. INOPAL III, Population Council.
Escondida 110, Col. Villa Coyoacan. 04000, Mexico, D.F, Mexico. Tel-52.5-659-8541, Fax: 52-5-554-1226. E-mail.
rvernon@ianeta.apc.org.
This project was supported by the Population Council's INOPAL III Prolect. INOPAL Ill is funded by the U.S. Agency for International
Development 'USAID). Oftice ofPopulation, under Contract No. CCP-C-00-95-00007-00. Project No. 936-3030, Strategies for Improving
Family Planning and Reproductive Health Service Delivery.
January 1998




Oeto Researc
I1411Ik. __M MARI, ES:
A -AISA


.errvonce
of woman interviewed ravine
reported overall satisfaction VBFPW -
with VBFPW services, and Source: Ministry of Population Welfare and
the VBFPW was the source
of contraceptives among 70 percent of contraceptive users.


* Most clients reported being visited repeatedly by the VBFPW, and nearly
three-fourths were visited at least once a month. Forty-five percent of those visited
were current users of contraception, with another 14 percent having agreed to
accept but not yet begun use.


"l P tw i .


SOthers
Population Council, 1996


VILLAGE-BASED WORKERS INCREASE
WOMEN'S ACCESS TO FAMILY PLANNING

Village-based family planning workers in Pakistan have been successful in
improving rural women's access to a range of family planning services.
Planning for expansion of their duties to include more primary health care
responsibilities has begun.

BACKGROUND
An objective of the Government of Pakistan's Eighth Five Year Plan is to expand
access to family planning in rural areas from five to 70 percent by 1998. The
Village-Based Family Planning Worker Scheme of the Ministry of Population
Welfare (MPW) is the centerpiece of these efforts, and by 1997 the scheme is
expected to deploy 12,000 Village-Based Family Planning Workers (VBFPW) to
deliver family planning and health care services at the household level. Begun in
1992, the scheme is being undertaken at a time when the rural population is
showing new signs of readiness to reduce traditionally high levels of
childbearing. This Situation Analysis of the VBFPW Scheme examined how
effectively the scheme was working after two and a half years of
implementation. Data was collected on the activities of 211 VBFPWs through
client and worker interviews, observation of worker visits, and inventory of the
workers' family planning method supplies.

FINDINGS
* The average VBFPW PERCENT ACQUIRING CONTRACEPTIVES
is a woman aged 28 with FROM VILLAGE-BASED FP WORKER, PAKISTAN
three living children. More 100
than half had completed o80 ....------ -
secondary education and 6
nearly half were using some 60
method of family planning. e 40
Most resided in their
assigned villages.
S M e t 9 p PAKISTAN Punjab Sindh Baluchistan N.W.F.R
* More than 90 percent






* Eighty percent of users had been using family planning for less than one year. Pills
and condoms were the most commonly used methods, but there were substantial
numbers of users of IUDs, female sterilization and injectables.
* Thirty-two percent of the clients who did not want more children were not using a
method. However, 36 percent who were using contraception wanted more children,
indicating awareness of birth spacing.
* Nearly 90 percent of VBFPWs had served for more than one year, and about 46
percent had been serving for more than two years. About two-thirds reported that their
social status had improved as a result of becoming a VBFPW.
* Discussion of side effects was the major outcome of 23 percent of visits, while
general and health visits were the primary outcome of 21 percent. Eight percent of visits
resulted in a method being accepted and 7 percent in a referral.
* About 63 percent of VBFPWs had completed registration of all eligible couples in
their villages. However, only about 30 percent kept complete client information in their
registers, and only about 20 percent kept their registers up-to-date. Few developed
monthly work plans.
* Administrative support to VBFPWs from the Provincial Welfare Departments for
supervision, supplies and salaries is variable. Supervisors had visited 59 percent of
workers during the previous two months, though nearly all workers had visited their
training center during the past month. Only 39 percent had received their previous
month's salary.
* Contraceptive stocks were generally low, and 56 percent of VBFPWs had run out of
some contraceptive stocks in the past six months.
* Fewer than half of VBFPWs had any information, education and communication
(IEC) materials, and a worker used IEC materials in only one of the 814 visits observed.

UTILIZATION OF RESULTS
* The Situation Analysys findings on quality of VBFPW interaction with clients, the
range of methods being provided, and client information on methods were the basis for a
national VBFPW seminar in May 1996.
* The findings on the lack of IEC materials for VBFPWs led the MPW, in collaboration
with the Council and UNFPA, to sponsor a strategy workshop to develop a complete set of
IEC materials for the program, for training, reference, and counseling, as well as materials
for clients. A comprehensive plan for preparation of materials and implementation has
been approved.
* Further evaluation of VBFPW training is underway, with the goal of improving
curricula, training of trainers and follow-up.


Ministry of Population Welfare and the Population Council. 1996. Situation Analysis of Village-Based Family Planning Workers.
Islamabad. May.
For further information on this study or to obtain a copy of the final report, please contact: the Population Council, House No.55, Street
No.1, Sector F 6/3, Islamabad, Pakistan. Tel: 9251-277439, 827536, Fax: 9251-821401.
This project was conducted with support from the Population Welfare Department, Ministry of Population Welfare, Overseas Development
Administration (UK), Asian Development Bank and the Population Council. The production of this research summary is supported by Asia
and Near East Operations Research and TechnicalAssistance Project. The ANE OR/TA Project is funded by the U.S. Agency for
International Development, Office of Population, under Contract No. DPE-C-00-90-0002-10, Project No. 936-3030, Strategies for
Improving Family Planning and Reproductive Health Service Delivery.
January 1998
































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COMMUNITY VOLUNTEERS SUCCESSFULLY
REFER WOMEN TO REPRODUCTIVE HEALTH
SERVICES

In Honduras, a simple reproductive health (RH) referral instrument developed
for use by semi-literate community volunteers enabled them to make accurate
referrals for needed preventive health and family planning services.

BACKGROUND
In Honduras, weak reproductive health service delivery is compounded by an
ineffective referral system at the community level. Save the Children (STC) and
the Population Council's INOPAL Project collaborated to design and evaluate a
program to improve reproductive health referrals by semi-literate community
volunteers. Project activities included assisting the Ministry of Health (MOH) in
adding cytology and FP services to health care facilities; and adding pills and
condoms to mini-pharmacies run by community volunteers. To strengthen the
referral system, the project developed a job aid, or checklist, to facilitate
reproductive health counseling and referral. The checklist is a simple matrix in
which the "yes" or "no" responses of individual women to questions on health
status and reproductive intentions are easily entered by the volunteers in
columns and rows.

The project's evaluation methodology included monitoring the number of women
contacted, the number of referrals made and kept, and the effectiveness of
referral. Volunteers filled in the checklist for 12 simulated client contacts. The
appropriateness of their responses were scored as a "hit," i.e. a preventive RH
need existed and a correct referral was made; a "miss," i.e. an RH need existed
but no referral was made; a "correct rejection," i.e. no service was needed and no
referral made; and a "false alarm," i.e. no service was needed but a referral was
made. Half of the simulated clients required referrals and half did not. If volunteer
classification of clients were completely accurate, 50 percent of all clients would be
referred and classified as "hits" and
50 percent would not be referred and
ACCURACY OF VOLUNTEER REFERRALS
classified as "correct rejections. IN HONDURAS REFERRALS
Correct
FINDINGS Rejection 42%
* Approximately 85 percent of all
contacts resulted in appropriate
referral behavior by the volunteer.
Forty-three percent were "hits," or
correct. Another 42 percent were 4 Miss 7%
correct rejections. The 15 percent Correct
Referral 43% False
incorrect response rate was almost Alarm 8%
equally divided between "false
Source: Planells et al., 1997
alarms" and "misses."

.... is'"* S







* Common reasons for false alarms included referring women for pap smears who
did not require them, according to program norms, and advising women who were using
temporary barrier methods such as condoms to go to the health center to switch to
methods such as pills and IUDs which the volunteers felt were more effective. The largest
number of misses occurred when women requiring tetanus vaccination were not referred
to the health center.

* Volunteers contacted 1,184 women in 11 villages in five months. Approximately 60
percent of contacted women were referred for one or more reproductive health services.
Even given the poor record keeping in health centers, it was obvious that large numbers of
referred women visited the center as suggested by the volunteer.

* The findings demonstrate that adequately trained volunteers using a simple job
aid can successfully detect and refer women in need of preventive reproductive health
care services.


UTILIZATION OF RESULTS
* Save The Children plans to extend the use of the instrument, and other non-
governmental organizations have expressed interest in incorporating the job aid in their
own volunteer programs.

* Information on the patterns of misses and false alarms are being used to strengthen
the referral training curriculum.

* The Honduras Ministry of Health is adopting the job aid for use by auxiliary nurses
in all rural health centers.


Planells, Marano, Luis Amendola, Irma Mendoza and Rebecka Lundgren. 1997. Systematic Provision of Reproductive Health Services by
Community and Institutional Personnel. Tugucigalpa: Save the Children and the Population Council. July.
For more information or to receive a copy of the report, please contact Population Council, Residencial Casavola No. 37, Area Bancatlan,
Miraflores, Tegucigalpa, Honduras, Tel/Fax: 504-32-60-21.
This project was supported by the Population Council's INOPAL III Project. INOPAL III is funded by the U.S. Agency for International
Development (USAID), Office of Population, under Contract No. CCP-C-00-95-00007-00, ProjectNo. 936-3030, Strategies for Improving
Family Planning and Reproductive Health Service Delivery.
January 1998










TRAINING PRIVATE MEDICAL
PRACTITIONERS IMPROVES
QUALITY OF CARE

Training private practitioners in family planning methods improved their
technical knowledge and perception of family planning services and resulted in
better quality of care for their clients. Physicians in private practice play an
important part in the government strategy to increase access and improve
the quality of family planning services in northern India.

BACKGROUND
The Indian Medical Association (IMA), with training input from Development
Associates and evaluation support from the Centre for Operations Research and
Training (CORT), launched a project in 1992 to assess the feasibility of involving
private medical practitioners in promoting family planning services, particularly
the provision of oral contraceptive pills (OCP), among their clients. The goal was
to improve physicians' perception of OCP through short training sessions and
increase the percentage of women seeking family planning care from private
practitioners. Approximately 1,300 private physicians were trained in two half day
sessions held during a one week interval and a follow-up half day session one
month later. This impact evaluation study used quantitative and qualitative
approaches to document the experience and assess the management of the
training sessions conducted by the IMA.

FINDINGS
* An increase of 23
PERCENTAGE OF INDIAN DOCTORS RECOMMENDING OCP
percentage points was BEFORE AND ONE YEAR AFTER TRAINING
reported in doctors
recommending the oral
contraceptive pill after they Baseline
received training.

* A mystery client study
among a sample of doctors
showed that trained doctors Endline
more often provided
alternative choices of family
planning methods than 0 20 40 60 80
untrained doctors. Source: Barge etal., 1995

* More clients were satisfied with the quality of service provided and the
amount of time spent with them by the trained doctors. For example, a client who
visited a trained doctor said, "I would recommend this doctor because he
listened to me patiently and explained when the pills should be started, how it
should be taken regularly..."

I MilliW






* Despite the marginal increase in the number of clients actually accepting OCP after
training, the physicians' improved competency and proficiency helped in enhancing the
image of the program and improving the quality of care.


* Significant increases were
also achieved in the perception
of OCP among trained
physicians. For example, the
percentage of doctors viewing
OCP as 'very effective' increased
by 68 percentage points, and
'easy to use' by 60 percentage
points. They also viewed OCP
more favorably than before in the
categories 'unrelated to sex',
'decreases risk of pelvic infection
and cancer' and 'helps in
regulating periods'.


PERCEIVED ADVANTAGES OF OCP BY PRIVATE MEDICAL
PRACTITIONERS AFTER TRAINING IN INDIA


Very effective

Easy to use

Unrelated to sex

Less risk to cancer

Regulates period


100 80 60 40 20 0 20 40 60 80 100

M Baseline = Endline


* Although the physicians' Source: Barge eta., 1995
technical knowledge about OCP
increased significantly as a result of the training, many were still uncertain about critical
information for clients, such as when to take the first pill in a packet and how to make the
transition between packets. Some also retained misinformation about the potential risks of
OCP use and stereotypes about the clients for whom OCP is an appropriate method.

* Most doctors perceived the training to be both practical and of good quality. They
were clearly interested in more information on family planning methods.


UTILIZATION OF RESULTS
* The Indian Medical Association training model has now been replicated and
upscaled in the state of Uttar Pradesh, with modifications based on the results from this
study. Modifications include expansion of training to include additional contraceptive
methods, addressing the issue of counseling, doing more physician follow-up, introducing
marketing and communications strategies to increase the draw of clients, and taking a
more competency-based training approach.

* The IMA training model needs further development, but, given the high demand for
private medical services in Uttar Pradesh and throughout rural India, improving the
competency of private physicians in family planning services is critically important.


Barge, Sandhya, Irfan Khan, Bella C. Patel and M. E. Khan. 1995. Use of Private Practitioners for Promoting Oral Contraceptive Pills in
Gujarat. New Delhi: Centre for Operations Research and Training and the Population Council.
For further information on this study or to obtain a copy of the final report, please contact the Centre for Operations Research and
Training (CORT), 402 Woodland Apartment, Race Course, Baroda 390 007, Gujarat, India. Tel: 91-265-326-453, Fax: 91-265-330-430. Or
the Population Council, 53 Lodhi Estate, New Delhi 110003, India. Tel: 91-11-461-0913/461-0914, Fax: 91-11-461-0912.
This project was conducted with support from the Population Council's Asia and Near East Operations Research and TechnicalAssistance
Project The ANE OR/TA Project is funded by the U.S. Agency for International Development, Office of Population, under Contract No.
DPE-C-00-90-0002-10, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.
January 1998


61
*I

27

30o


6

86
9 9



8 0
0 92











IDENTIFYING CLIENT AND PROVIDER
PERCEPTIONS ON QUALITY OF CARE

Clients and providers largely agree on what constitutes quality of care in
services provided through family planning service delivery points (SDPs) in
Kenya. Clients placed more emphasis than providers, however, on
counseling for side effects, method choice, and FP education.

BACKGROUND
Little research has been carried out to determine how clients and service
providers themselves define quality of care in family planning service delivery.
This study, undertaken in 1994 by the Population Council's Africa OR/TA Project,
explored the perceptions of both clients and providers on quality of care
provided through public and NGO family planning SDPs in Kenya. Study
methodology included focus group discussions, in-depth interviews with clients
and service providers, and "simulated client" visits at nine SDPs in two rural and
two urban locations. Four SDPs belonged to NGOs, and five were public clinics
operated by the Ministry of Health (MOH) or the Nairobi City Council (NCC).

FINDINGS
* Clients and providers agree
that cost and proximity are two of Client Comments on Quality of
the most important factors that Care in Kenya
attract or deter clients from using "The provider checks whether the coil is in
certain services. position. Then urine is sent to the laboratory to
exclude infections. I appreciate this service."
* A noticeable disparity exists "I reported my problems to the provider and
between clients and providers on asked whether or not they could change the
the issues of counseling for side method. They said the method could not be
effects and availability of method changed to injection, but that the provider could
effects and availability of method insert the coil. She maintained that I must have
choice. While viewed by clients as a second child before she can give the
major elements of service quality, injection."
neither are even mentioned by "I asked them to give me the injectable. They
providers. Receiving counseling told me that the pill was okay with me and I
on only one method or a limited couldn't receive the injectable with only two
number of methods was a definite children. I decided to stop and have never
gone back."
source of dissatisfaction for many
women. Source: Ndhlovu, 1995

Both clients and providers identified medical examinations as a central
factor affecting choice, continuation, and satisfaction with FP service delivery.
Types of examinations clients felt were important were: weight taking, blood pressure
checks, and cervical examinations.






* Providers and clients both give weight to provider attitude. Though few clients
stated that they stopped using a clinic because of bad treatment, abuse of the provider
discourages clients from continuing. Some clients reported having been rebuked if they
used their method incorrectly, and lectured disapprovingly for making lifestyle choices of
which providers personally disapproved.

* Both providers and clients recognized confidentiality and privacy as desirable
characteristics of service delivery. Their definition of confidentiality differed, however:
providers perceived it as frankness when examining and counseling, while clients defined
it as keeping secret their contraceptive use.

* A surprising observation was that women did not view a clean health facility
environment as a matter of concern.

* Long waiting time affected all clients surveyed. The ability of SDPs to deliver
services promptly is often compromised by staff shortages and lack of space, but
evidence suggests that providers could do much to minimize client waiting time.

* The personal biases of providers effectively deny young, unmarried men and
women access to public FP services. NGO clinics were perceived as being more willing to
provide them with services.

* Many clients felt that an important aspect of quality of care was the availability of
maternal and child health and laboratory services, supporting a more integrated approach
to providing reproductive health care. Providers also mentioned integration of services as
important.

UTILIZATION OF RESULTS
* Findings that brought out the age and marital restrictions imposed by providers on
FP clients contributed to the MOH incorporating these issues into the Government's policy
documents, including FP service delivery guidelines and the National Implementation Plan.


Ndhlovu, Lewis. 1995. Quality of Care in Family Planning Service Delivery in Kenya: Clients' and Providers' Perspectives, Final Report.
Nairobi: Division of Family Health, Ministry of Health, and the Population Council. November
For more information or to obtain a copy of the report, please contact Lewis Ndhlovu, Africa OR/TA Project II, Population Council,
RO. Box 17643, Nairobi, Kenya, Tel: (254)(2)713-480, Fax: (254)(2)713-479, E-mail: ORTA@popcouncil.or.ke.
This project was supported by the Population Council's Africa Operations Research and TechnicalAssistance Project II. The Africa OR/
TA Project II is funded by the United States Agency of International Development (USAID), Office of Population, under Contract No. CCP-
3030 C-00-3008-00,Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.
January 1998





Operations Research





INCREASING THE USE OF
REPRODUCTIVE HEALTH SERVICES

A series of questions used by providers to screen clients at service delivery
points (SDPs) was effective in increasing awareness and use of family
planning, pap tests, and screening for sexually transmitted infections
(STIs), but less effective in increasing use of other SDP services.

BACKGROUND
Most health systems do not screen patients for an unmet need for family
planning or other reproductive health services. In Guatemala, the Ministry of
Health (MOH) and, in Mexico, the Social Security and Services for State Workers
(ISSSTE), with assistance from the Population Council's INOPAL OR/TA Project,
tested a job aid to help providers detect unmet need for services, provide
comprehensive RH care, and increase the number of users of different services.
The job aid, an algorithm of seven questions, each answered by a simple yes or
no, helps providers segment clients into different categories of unmet need for
services, such as prenatal care or family planning. In Guatemala, the MOH
trained service providers of 55 health centers and posts in the use of the
algorithm, and compared them to 31 health outlets where no training was done.
In Mexico, the staff of one large SDP was trained in the use of the algorithm.
Researchers conducted exit interviews with clients at both sites to assess the
degree to which services had been offered. In addition, service statistics were
collected to observe project impact on service use.

FINDINGS
Guatemala
* The main reasons why women visited the SDP were illness of a child (23
percent), prenatal care (20 percent), immunization of children (18 percent),
personal illness
(15 percent), well baby REASONS FOR ATTENDING HEALTH CENTER
care (10 percent), and IN GUATEMALA
family planning (8 percent). Illness of
child 23%
Immunization
* The job aid appears of child 18n.'
to have been perceived by
providers primarily as a tool Well baby
to promote family planning. Other are 10%
SDPs that used the reason 7% /
algorithm showed a greater
than expected productivity / \ Prenatal
in FP services but not in Own Illness _J_ care 20%
other reproductive health 15% Family
Planning 7%
services such as prenatal Source:ernon etal, 1997
care and postnatal care. I


'e, iii *







* Service providers who had been trained in the use of the job aid provided
information on family planning methods to 36 percent of their clients, compared to
26 percent of women where the staff had not been trained.

* In the last nine months of 1996, SDPs that used the job aid had 124 percent more
new family planning clients than in 1995. SDPs in the control group saw an increase of
21 percent.

Mexico
* In Mexico, before introduction of the job aid, no RH services were offered to more
than five percent of clients, with the exception of the pap test, which was offered to 32
percent of all women of reproductive age. After training, 21 percent of women were offered
screening for sexually transmitted infections; 35 percent were offered FP services; and 66
percent were offered a pap test. On average, training in the use of the job aid helped
increase the number of services provided by 10 percent, compared to the four month
period before the training.


UTILIZATION OF RESULTS
* In Guatemala, the MOH will conduct a larger scale test of the job aid facilities.

* In Mexico, the Mexican Social Security Institute for Government Workers (ISSSTE)
has used this study to further institutionalize the development and implementation of
operations research projects in-house.


Vernon, Ricardo, Emma Ottolenghi, Jorge Sol6rzano, Luis Roberto Santamarina, Juan Jos6 Arroyo, and Clara Luz Barrios. 1997.
Systematic Offering of Family Planning and Reproductive Health Services in Guatemala. Guatemala City: Ministry of Health of Guatemala
and the Population Council. April.
Dominguez del Olmo, Javier, Marco Antonio Olaya, Francisco Javier Gomez Glavenlina and Ricardo Vernon. 1997. Using Operations
Research to Solve Reproductive Health Problems. Mexico City: Instituto de Seguridad y Servicios Sociales para los Trabajadores del
Estado (ISSSTE), National Autonomous University of Mexico (UNAM), and the Population Council. June.
For more information or to receive a copy of this report, please contact Ricardo Vernon, Deputy Director, INOPAL III, Population Council.
Escondida 110, Col. Villa Coyoacan, 04000, Mexico, D.E, Mexico, Tel:52-5-659-8541, Fax: 52-5-554-1226, E-mail:
rvernon@laneta.apc.org.
This project was supported by the Population Council's INOPAL III Project. INOPAL III is funded by the U.S. Agency for International
Development (USAID), Office of Population, under Contract No. CCP-C-00-95-00007-00, Project No. 936-3030, Strategies for Improving
Family Planning and Reproductive Health Service Delivery.
January 1998











FACTORS AFFECTING
FAMILY PLANNING DROP-OUT RATES

Drop-out rates among family planning (FP) acceptors can be reduced by
informing clients about possible side effects and the advantages and
disadvantages of several methods. Local government support for the FP
program and the attitude of husbands toward FP are also important factors.

BACKGROUND
Government statistics indicate that by the early 1990s, around half of family
planning acceptors throughout the Philippines were dropping out of the
government FP program every year. Department of Health (DOH) data for
Bukidnon province, for example, showed a 60 percent drop-out rate. This study
examined the extent of the drop-out problem in Bukidnon, the reasons given by
drop-outs for their decision to stop using FP and the characteristics of drop-outs
as compared to those who continued using FP The study was carried out by the
Research Institute for Mindanao Culture (RIMCU), Xavier University with technical
assistance from the Population Council. The study team interviewed 400 married
women who were family planning acceptors in 1992; held in-depth interviews with
the FP Coordinator, nurses and midwives in the Barangay Health Stations (BHS);
and observed provider-client interactions for one day each in a sample of 18 BHS.

FINDINGS
* About 31 percent of FP
acceptors drop out of the REASONS FOR DROPPING OUT BY METHOD USED
PHILIPPINES
government program within a year Pills Condoms
of adopting a contraceptive 70.80% ---- 7/ 21.4%
method. All IUD acceptors (n=57) 21.4%o
were still using some FP method
at the time of follow-up. DOH clinic---
records on current users, drop- 6.3%
outs and switchers were accurate \ 3.1%
in 73 percent of all cases. 1 9.8% _
n=96 50.0% n=14
* More than half of all drop- L Sideeffects = Personalreasons = Clinic related
outs said they stopped using FP Methodrelated =-3 Husband related
because of side effects. This
response was particularly Source: Sealza, 1995
common among those using pills.
The negative attitude of husbands towards condoms was a major factor why
women stopped using this method.

* Ninety-one percent of FP clients reported to be "satisfied" or "very
satisfied" with their visits to the clinic. Clients who were dissatisfied cited
unavailability of supplies and criticized the work of the local midwife.


In w^^^-^f'Ut






* Most clients were not given a variety of methods to choose from. About 60 percent
received information about only one method, and nine percent never received any
counseling about FR Even so, 98 percent of all respondents said they were given the
freedom to adopt whatever FP method they desired.

* FP trainers were given high ratings with regards to friendliness and their ability to
"clearly explain" how to use the method and its advantages. The trainers seemed less
capable, however, when it came to explaining the method's disadvantages and side
effects. This response was particularly common among those who were using
contraceptive pills.

* Women with less education, lower socio-economic status, no paid employment
during the past year, a greater number of pregnancies, and a less favorable attitude
towards FP were most likely to become drop-outs. Lack of support for FP on the part of
the husband was found to be a more important factor in dropping out than the attitude of
the acceptor herself.

* Drop-out was highest among condom acceptors, followed by pill and IUD acceptors
respectively. Clients who had to return to the clinic each month for a resupply of
contraceptives were more likely to drop out.

* Better quality of care was generally associated with lower levels of dropping out.
Clients who received information on more than one method and some orientation on
possible side effects were less likely to drop out.

* The situation analysis pinpointed several problem areas, including: personnel without
training in IUD insertion; inadequate infrastructure, particularly lack of running water; and
irregular visits by supervisors. Cleanliness and storage facilities were generally adequate.

UTILIZATION OF RESULTS
* FP service providers now utilize FP clinical standards and the manual as a guide for
running day-to-day operations in the clinic.

* During training and supervision, emphasis is now put on the importance of
informing clients about possible side effects and complications, and the advantages and
disadvantages of specific methods.

* The local government units (LGUs) conducted program reviews, which have led to
submission of budget proposals for improving the stock of basic supplies at rural health
units and increased support by some LGUs for the FP program.

* More efforts are being made by the public program to inform men of the
advantages of family planning.

Sealza, Lita. 1995. Factors Affecting the Family Planning Program Drop-Out Rate in Bukidnon, Philippines. Manila: Research Institute for
Mindanao Culture, Xavier University and the Population Council.
For further information on this study or to obtain a copy of the final report, please contact the Population Council, Monteverde
Mansions# 17, 85 Xavier Street, Green Hills, San Juan, Metro Manila, Philippines. Tel: 63-2-722-6886, Fax: 63-2-721-2786.
This project was conducted with support from the Population Council's Asia and Near East Operations Research and Technical Assistance
Project. The ANE OR/TA Project is funded by the U.S. Agency for Interational Development, Office of Population, under Contract No.
DPE-C-00-90-0002-10, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.
January 1998










MEASURING CHANGES IN FAMILY
PLANNING SERVICES QUALITY OVER TIME

A comparison of the results of Situation Analysis (SA) studies carried out in
1992 and 1995 in Burkina Faso shows that rapid expansion of FP services
nationwide resulted in both improvement and decline in selected elements
of program functioning and quality of care. The comparison also provides
information on the possible impact of interventions aimed at improving
identified gaps in the system.

BACKGROUND
In 1992 the Burkina Faso Ministry of Health (MOH) conducted a first Situation
Analysis, which included a census of 53 service delivery points (SDPs) in twelve
regions, or about one-third of the SDPs offering family planning at the time.
Following that study, FP services were rapidly expanded, and by 1995 had been
introduced into 585 SDPs in all 30 provinces. In addition, the MOH and donor
agencies carried out several interventions to improve services at both existing
and new family planning SDPs. Interventions focused mainly on training but also
on equipment, decentralization of services, and information, education and
communication (IEC). In order to evaluate these services and interventions, the
MOH undertook a second Situation Analysis in 1995. This study compares FP
services at the 53 SDPs included in the 1992 Situation Analysis with the sample
of 117 SDPs from the same regions in the 1995 study.

FINDINGS
Functional Capacity
l C CHANGE IN SDPS WITH MINIMUM EQUIPMENT
Indicators BURKINA FASO
* The average amount of 100 percent of SDPs
equipment available at SDPs
did not change over time, but 80
there were changes in 60
supplies of specific items,
such as a decline in sterilizers 40
and specula and an increase
in blood pressure (BP) 20
machines and gloves. 0
Sterilizer* BP machine* 10+gloves* 5+specula
* Most SDPs have 992 n=52 1995 n=111
waiting rooms or toilets, and
no decline occurred in the Source: Milleretal., 1997 p<.01
availability of these items
between 1992 and 1995. The availability of satisfactory examining areas fell
dramatically from 60 percent to 21 percent, mainly due to water shortages and
problems with cleanliness.


,;j~lYII~~;Y~U"'-l~aLi~*i~






* In 1992, 43 percent of 86 providers reported that they had been trained in both
clinical FP and IEC. By 1995, however, only 11 percent of 244 providers in the same
regions had been trained in both subjects. Most of this decrease is due to lower levels of
IEC training, which dropped from 47 to 14 percent.

* Comparison of data shows a decline in availability of IEC materials. In 1992, 28
percent of SDPs had a poster and a brochure, but by 1995 only 18 percent of SDPs were
recorded having these materials.

* In 1992, 57 percent of SDPs reported having had a supervisory visit in the previous
six months, but by 1995, only 25 percent of the SDPs in the same areas reported
supervisory visits.

Quality of Care Indicators
* The percentage of SDPs offering injectables and natural family planning increased;
the availability of condoms and spermicides decreased; and availability of pills remained
constant.

* In 1992, 45 percent of new clients were told of at least one method other than the
method chosen. By 1995 this number had risen to 66 percent.

* Appropriate information exchange seemed to have declined. For example, the
percent of new clients asked about previous FP use declined from 72 percent in 1992 to
only 25 percent in 1995.

UTILIZATION OF RESULTS
* The findings from the results of the 1995 Situation Analysis are being used by the
MOH to design and carry out a range of interventions in training and strengthening of
IEC activities.

* The MOH has also used the findings to identify systems problems in training,
supervision, and logistics associated with the rapid expansion of family planning services.


Miller Kate, Inoussa Kaborb, Nafissatou Diop, etal. 1997. Change in family planning service quality in Burkina Faso, 1992 to 1995. MOH,
Burkina Faso and the Population Council. October
For further information or to obtain a copy of the final report, please contact the Africa OR/TA Project II, Population Council, One Dag
Hammarskjold Plaza, New York, NY 10017. Tel. (212) 339-0500, Fax (212) 755-6052, E-mail: pubinfo@popcouncil.org.
The Situation Analysis studies were supported by the Population Council'sAfrica Operations Research and Technical Assistance Project
II. The Africa OR/TA Project II is funded by funded by U.S. Agency for International Development (USAID), Office of Population, under
Contract No. CCP-3030-C-3008-00, Project No 936-3030, Strategies for Improving Family Planning and Reproductive Health Service
Delivery. The comparison analysis was supported by UNFPA subcontract, project BF/92/P08, "D6centralisation des services de SMI/PF"
January 1998





EY





CONTINUATION OF CONTRACEPTIVE AND

SERVICE USE: THE CSI PROJECT EXPERIENCE

Three-fourths of Clinical Service Improvement (CSI) clients were still using a
method of contraception four to five years after initial contact with CSI.
However, only 17 percent continue to use CSI services after four years. A major
reason for CSI clients switching their source of family planning supply was
ease of access for follow-up services.

BACKGROUND
The Clinical Service Improvement project in Egypt has sought to develop a
clientele of continuous contraceptive users. The client drop-out rate from CSI
services is a cause for management concern, especially if accompanied by a
break in contraceptive use. The Population Council sponsored a study
conducted by the Cairo Demographic Center (CDC) to evaluate the effectiveness
of the CSI project in achieving long term sustained use of contraceptives among
its clients. The study interviewed 2,227 CSI clients about their contraceptive use
since their initial contact with a CSI clinic four or five years ago. More than three-
fourths of the enrolled clients were successfully contacted.

FINDINGS
CUMULATIVE CONTINUATION RATES OF
Lack of method IUD, PILLS AND CONDOMS, EGYPT
continuity Percent
* CSI clients 100
changed FP methods up 80 o
to five times over the past
four to five years; 62 60
percent of clients cited 40
side effects as the reason
for changing methods.
0 ----------------------------
6 12 18 24 30 36 42 48
* Injection and Months since first contact
condom users switched IUD Pills M Condom
more frequently to other
methods and particularly For IUD: n=540, for Pills: n=425, for Condoms: n= 274
to pills. IUD users by
contrast were more Source: Makhlouf and Amin, 1995
stable. The IUD is the
most commonly used method by CSI clients (65 percent).

Lack of continuity for source of method
* Although the entire sample began at a CSI clinic, only 17 percent
continued to use CSI services for four or five years. Twenty-nine percent stopped
using both a contraceptive method and CSI services. Of the 54 percent still using
a contraceptive method but not using CSI services, 22 percent were using a long
acting method and thus did not need to return to CSI.

v xs~r~ii^*r'*T^







* Among CSI clients who changed to another source, the majority shifted to using
pharmacies (45 percent) or private doctors (25 percent). The most common reasons for
changing their source of method were the relative ease of access to the new source for
follow-up services (70 percent),
and the high cost of CSI services HISTORY OF UNINTENDED PREGNANCY AMONG CSI
(12 percent). CLIENTS IN EGYPT

Unintended pregnancies
* The 2,227 women
interviewed for this study 75% Nothing
experienced a total of 1,081 No Yes
50% 50%
pregnancies during the past five
years. Half of these pregnancies
were reported to be unintentional, I Attempted
of which 31 percent occurred Abortion
Abortion
during a temporary period of non-
SDid you have an unintended pregnancy If yes, what did you do?
use, and 19 percent were during the past five years? (n=543 unintended
accidental during contraceptive (n=1081 pregnancies) pregnancies)
use. Clients attempted to Source: MakhloufandAmin, 1995
terminate, either with or without
success, 25 percent of the unintended pregnancies recorded in the study.


UTILIZATION OF RESULTS
* These findings have assisted CSI program managers to examine their clients'
patterns of method use and their reasons for changing services. Program managers are
considering relocating some clinics to make them more accessible to clients and are
exploring the feasibility of using mobile clinics.

* Based on the study recommendations, CSI obtained a grant to update its
Management Information System (MIS). The MIS department is developing a database in
Arabic that includes basic client data at the governorate level.

* Mechanisms for follow-up were improved and outreach activities strengthened as a
consequence of this study. CSI management is currently revising and updating the follow-
up system and information, education and communication strategies.

* A circular has been distributed to all CSI clinics that emphasizes counseling clients
to return to the clinic if they are not satisfied with their contraceptive method, and stressing
the risks involved in temporarily discontinuing the method. CSI physicians monitor this
counseling during their visits to the clinics.


Makhlouf, Hisham, and Saad ZaghloulAmin. 1995. Continuation and Discontinuation of Contraceptive Use by Method and Reasons for
Drop-out in CSI Project. Cairo:-airo Demographic Centre and the Population Council. May.
For further information on this study or to obtain a copy of the final report, please contact the Cairo Demographic Centre (CDC). 78 (4th
St.) El Hadaba El Olya, Mokattam 11571, Cairo, Egypt. Tel. 20.2-347-0674, Fax: 20-2-346-8782. Or the Population Council. 6A Mohamed
Bahie Eddine Barkat Street, lOth Floor, Giza, Egypt. Tel: 20-2.573 -82771570- 1733, Fax: 20-2-570-1804.
This project was conducted with support from tne Population Council s Asia and Near East Operations Research and Technical Assistance
Project The ANE OR, TA Project is funded by the U.S. Agency for International Development. Office of Population, under Contract No.
DPE-C-00-90-0002. 10. Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.
January 1998





R"ooi A0 416




QUALITY OF FAMILY PLANNING SERVICES
SHOWS MARKED IMPROVEMENT

Kenyan program managers have improved family planning services
provided through Ministry of Health (MOH) facilities, as demonstrated by
comparing data collected under Situation Analysis studies in 1989 and 1995.
Room for further improvement remains.

BACKGROUND
By 1993, 27 percent of currently married women in Kenya were using modern FP
methods, an increase of 9 percent since 1989. The Ministry of Health's FP
program is credited with having contributed to the increase. A Situation Analysis
study of family planning services in Kenya carried out in 1989 by the Population
Council provided data on specific areas where services provided through MOH
service delivery points (SDPs) could be improved. The 1995 study sample was
expanded from 99 Ministry of Health SDPs in 1989 to 147 MOH SDPs. The
second study also gathered a broader range of information. Data were collected
through interviews with 562 providers, observations of 958 FP clients, exit
interviews with 927 FP clients (241 new clients, 717 revisit clients), and exit
interviews with 1,738 maternal and child health (MCH) clients.

FINDINGS
The percent of MOH
facilities displaying FP posters IEC ACTIVITIES AT SDPs IN KENYA
increased from 53 to 75 1oo
percent, and the availability of
pamphlets and other IEC
materials increased from 38 to 60
74 percent. Only 9 percent of 40
facilities are currently using
health talks to introduce FP 20
as compared to 17 percent 0_a
in 1989. FP posters Pamphlets/ Health Health talk
displayed* other IEC talk given including FP
available* given
On average, most new 189 n=99 19
clients were told about six <.01 8 n=
methods. Oral contraceptives Source: Ndhlovu etal., 1997
are the method most
frequently mentioned to new clients (86 percent), followed by injectables (83
percent), IUDs (74 percent), and condoms (72 percent). The percentage of
clients hearing about foams/spermicides decreased.

Most facilities tend to have at least four methods available on site: oral
contraceptives, condoms, injectables and the IUD. One-fourth of facilities now
offer tubal ligation, and 11 percent offer vasectomy.






* Between 1989 and 1995, the availability of Depo-Provera at MOH facilities increased
from 80 to 91 percent and NORPLANT implants from 0 to 6 percent.

* One-third of MCH clients reported that they had seen or heard anything about family
planning during the course of their visit. Sixty-six percent of them cited a poster as the
source of FP information provided during visit.

* In 1995, more MOH clients heard about side effects and their management. The
proportion hearing about how to use a method and its advantages stayed relatively
constant.

* About two-thirds of MOH facilities are being supervised in accordance with MOH
policy, i.e. once every three months. Two-thirds of supervisors asked about problems, and
almost half observed several services during one visit.

* The percentage of MOH nurses receiving in-service training increased from about
one-third to 60 percent.

* The proportion of MOH clients who were observed to hear about at least one other
health issue during their FP consultation increased significantly, from 15 to 35 percent.

UTILIZATION OF RESULTS
* The MOH, which is the main provider of FP services in Kenya, has used the 1995
Situation Analysis results in the preparation of two key documents: the MOH Reproductive
Health Strategy and the National Implementation Plan for the Kenyan Family Planning
Program for 1995-2000.

* The MOH is now implementing a follow-on study of the potential for greater
provision of family planning information and services to MCH clients.


Ndhlovu, Lewis, Julie Solo, Robert Miller, Kate Miller, and Achola Ominde. 1997. An Assessment of Clinic-Based Family Planning
Services in Kenya: Results from the 1995 Situation Analysis Study. Nairobi: Division of Family Health, Ministry of Health and the
Population Council. January.
For more information or to obtain a copy of the final report, please contact the Africa OR/TA Project II, Population Council, PO. Box
17643, Nairobi, Kenya. Tel: (254) (2) 713-480; Fax: (254) (2) 713-479; E-mail: ORTA@popcouncil.orke.
This project was supported by the Population Council's Africa Operations Research and Technical Assistance Project II. The Africa OR/
TA Project II is funded by the U.S. Agency for International Development, Office of Population, under Contract No. CCP-3030-C-3008-00,
Project No. 936-3030,Strategies for Improving Family Planning and Reproductive Health Service Delivery.
January 1998















* 3t~b

j. _-
ThS



















S










SITUATION ANALYSIS OF

FAMILY WELFARE CENTERS

The study identified areas in which the Family Welfare program needs
improvement, including staff training, information materials, client
counseling, inventory and supply of contraceptives, and community
outreach. A pilot project for rural areas is addressing many of these issues.

BACKGROUND
Although the current use of family planning (FP) methods in Pakistan has
increased from 12 to 18 percent since 1990, a significant number of couples still
wish to limit their family size, which suggests that the FP service delivery system
needs improvement. Family Welfare Centers (FWCs) are the government's main
FP service delivery outlets and serve the majority of current contraceptive users.
Services offered through FWCs include FP counseling and services, maternal
and child health care, health education, and training of community volunteers. At
the request of the Ministry of Population Welfare, the Population Council carried
out a Situation Analysis of FWCs in 1992, with the objective of providing an
overview of the availability, functioning and quality of their FP services. Research
teams checked contraceptive supplies and equipment, inspected facilities,
observed counseling sessions and interviewed staff and clients at 100 of the
country's 1,288 FWCs.

FINDINGS
* Of the 100 FWCs STATUS OF FAMILY PLANNING SERVICES PROVISION ON THE DAY
included in the study, 72 OF VISIT AT FAMILY WELFARE CENTERS, PAKISTAN
included in the study, 72
provided services to FP Providing FP
Providing FP
clients on the day of the Services 72%
team's visit. Seven
FWCs were closed, had
no service providers
present or had the 2Clos
contraceptives locked Partially
up. Twenty-one had no Closed 5%
clients on the day the
team visited, but staff
were present.
Without FP
Client 21%
* An average of
2.8 FP clients came in n=100 FWCs
on the day of the visit. Source: Cernada etal., 1993
Clinic records for May
1992 indicated an average of 4.6 FP clients per day. Eighty percent of clinics
serve an average of fewer than 150 FP clients per month. In FWCs, the IUD is the
most frequently accepted method, followed closely by oral contraceptive pills,
injectables and condoms.


ri







* Approximately 20 percent of FWCs did not have the following: an examination table,
equipment for sterilizing instruments, blood pressure cuffs, or syringes. Forty percent had
no antiseptic lotion.

* Most FWCs can be reached by public transport and over 90 percent by road.
Three-fourths of clients came on foot, however, and one-half travelled less than 15 minutes.

* Female professional staff were present at 83 FWCs on the day of the visit. Staffing
records indicate that 95 percent of the centers open the day of the visit have Family
Welfare Workers, and over 80 percent have both male and female Family Welfare
Assistants.

* Of the 84 FWCs where information on contraceptive supplies was available, 23
percent lacked some supplies. All had condoms; 77 percent had Copper T380s; 87
percent Lippes Loops; 83 percent had injectables; and 89 percent had pills.

* Signboards identified 85 percent of FWCs. Forty-one percent had informational
pamphlets on FP methods. No clients were given pamphlets to carry away; pamphlet
language was inappropriate in 30 percent of FWCs.

* Nearly all staff said that community outreach was part of their job, but during the
month prior to the study, 65 percent conducted no home visits, 70 percent no community
meetings, and 96 percent no meetings in schools or factories.

* In counseling sessions with potential acceptors, staff mentioned condoms in one-
third of the sessions, pills and IUDs in two-thirds, and tubectomy in two-fifths. Many did not
discuss how a method works, how to use it, or its effectiveness. Contraindications were
infrequently mentioned.

* Staff took a medical history of 68 percent of new clients. Ninety percent of staff said
that high blood pressure was a contraindication to pills and injectables, but checked the
blood pressure of only 20 percent of clients.

UTILIZATION OF RESULTS
* Using the data from the Situation Analysis, a pilot program to provide 12,000 village-
based family planning workers was initiated as part of the government's eighth five year
plan (1993-98). The new program's goal is more FP outreach, particularly in rural areas.


Cernada, George R, Ubaidur Rob, Saifia 1. Ameen, Muhammad Shafiq Ahmad. 1993. A Situation Analysis of Family Welfare Centers in
Pakistan. Islamabad: The Ministry of Population Welfare and the Population Council.
For more information on this study or to obtain a copy of the final report, please contact the Population Council, House No. 55, Street No.
1, Sector F 6/3, Islamabad, Pakistan. Tel: 9251-277439, 827536, Fax: 9251-821401.
This project was conducted with support from the Population Council's Asia and Near East Operations Research and Technical Assistance
Project. The ANE OR/TA Project is funded by the U.S. Agency for International Development, Office of Population, under Contract No.
DPE-C-00-90-0002-10, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery
January 1998







UMMA -E


SITUATION ANALYSIS OF REPRODUCTIVE
HEALTH CARE SERVICES

Although linkages between family planning, postpartum and abortion
services exist, not all of the patients for those services were able to obtain a
contraceptive method at the time of their consultation.

BACKGROUND
The family planning program in Turkey has been providing permanent
contraceptive methods (female tubal ligation and more recently vasectomy) for a
number of years. These services are provided in tertiary care centers in seven
regions. A Situation Analysis study of several reproductive health care services
was conducted through a cooperative effort between the Ministry of Health and
Gazi University, with technical assistance provided by AVSC International and the
Population Council. The aim of the study was to describe the availability,
functioning and quality of family planning (FP) and abortion services, and to
analyze the linkages between family planning and antenatal, postpartum and
abortion services. The study was conducted in 47 facilities, including both
hospitals and MCH/FP centers.

FINDINGS
Counseling and
information exchange AVAILABILITY AND USE OF FAMILY PLANNING
* IEC materials (FP Percent IEC MATERIALS: TURKEY
posters, flip charts or 70
brochures) were present 60
in half of the family 50
planning clinics but they
were seldom used. Only 40
one-fifth of the staff, 30
including providers of 20
sterilization services, 10
have received IEC 1
training. FP Posters Flip Charts FP Brochure Contractive Anatomical
Pumphlet Samples Models
* Only 30 percent Available used
of family planning clients Avaie
received counseling in a Source:Dervisogluetal., 1995
private area. Complete
information on contraceptive methods was not adequately discussed during
counseling.

* Only half of all clients receiving a pelvic examination received an
explanation of the procedure, and more than one-third were not informed
of the findings.


Alk







Method choice
* Of the clients
interviewed, two-thirds
decided during their
pregnancy to use a FP
method postpartum, one-
fifth decided following
delivery, and the rest could
not decide. Only one-tenth
of postpartum patients
received the method before
leaving the hospital.

* The majority of
abortion patients decided to
use a contraceptive method.
Two-thirds received the
method before leaving the
hospital.


ABORTION PATIENTS' INTENTIONS
AND PROVISION OF A FP METHOD: TURKEY


Intention to use
FP Method
(n=224)


Method Provision
(n=197)

Not R

Withd


received 25%


rawal 2%


IUD 41%/


IUD 41%


Condom 12%
NORPLANT2%
Tubal Ligation 8%
Injectable 1%
Source: DerviMoilu etal., 1995


Technical competence
* Only one-tenth of the staff in all services knew that the combined pill could be given
two weeks after delivery if the woman is not breastfeeding, and six months after delivery
if she is breastfeeding. While only one-half of family planning outpatient staff could
report that an IUD can be inserted at any time if the woman is not pregnant, only one-
sixth of the clinic staff indicated that an IUD could be inserted immediately or within 48
hours of delivery.

* Sterile or clean gloves were used during all FP procedures, although in most
cases the providers did not wash their hands. Providers used clean gloves in 30 percent
of the abortion procedures, but no gloves in 16 percent of them. Before most abortion
procedures, the instruments were not sterilized and the providers did not wash
their hands.


UTILIZATION OF RESULTS
* The Turkey Situation Analysis study was used to assist in formulating strategies for
IEC activities in the National IEC Training Strategy. The findings were also used to establish
the rationale for introduction of National FP Clinical Guidelines during a Social Security
Administration workshop, and have been a principal data source for the development of
the government's MCH/FP National Strategic Plan.


January i799


Dervisoglu, Ayse Akin, MehmetAli Biliker MehmetAli Bumin, Cigdem Bumin, Dale Huntington, Barbara Mensch, John Pile, Derman
Boztok. 1995. Turkey Situation Analysis Study of Selected Reproductive Health Care Services, Final Report, Condensed English Version.
Cairo: Ministry of Health (Turkey), the Population Council and AVSE International (Turkey). June.
For further information on this study or to obtain a copy of the final report, please contact AVSC/Turkey Country Office, Abidin Daver
Sokak 7/6-7, Cankaya 06550, Ankara, Turkey. Or the Population Council, 6A Mohamed Bahie Eddine Barakat Street, 10th Floor, Giza,
Egypt. Tel: 20-2-573-8277/570-1733, Fax: 20-2-570-1804.
This project was conducted with support from the Population Council's Asia and Near East Operations Research and TechnicalAssistance
Project. The ANE OR/TA Project is funded by the U.S. Agency for International Development, Office of Population, under Contract No.
DPE-C-00-90-0002-10, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.


1










SITUATION ANALYSIS DATA EVOKES
IMMEDIATE RESPONSE

A Situation Analysis (SA) study of family planning services identified gaps
in equipment and supervision that the MCH/FP unit of the Government of
Zanzibar began working immediately to fill. The government is also using
the results to plan the next phase of the national program, which will
integrate reproductive health, family planning and safe motherhood
services.


BACKGROUND
From the start of its Zanzibar Family Planning Project (ZFPP) in 1985, the
Government of Zanzibar conceived family planning (FP) services as an integral
part of the overall maternal and child health (MCH) care services. From six clinics
in 1985, the program expanded to 104 in 1995. However, the Government of
Zanzibar remains concerned that services are underutilized, with contraceptive
prevalence of modern methods estimated at 6.6 percent by the Tanzania DHS of
1992. In response to this concern, a SA study was conducted by the Government
with technical assistance from the Population Council's Africa OR/TA Project. The
SA objective was to provide comprehensive information on the availability,
functioning, and quality of FP services in order to plan for the needed
improvements and expansion of the program. The study covered 100 out of the
104 family planning service delivery points (SDPs) on the islands of Unguja and
Pemba.

FINDINGS
* FP clients are
highly concentrated in a AVAILABILITY OF METHODS AT SDPs IN
few SDPs: one SDP ZANZIBAR
alone handles one-third Combined I_
of the roughly 75,000 Pill
annual family planning Injectable
visits, and a second SDP Condom- __
receives another fifth of
all visits. The remaining IUD
SDPs average 57 new
acceptors and 340 POP
revisits per year. Spermicide
Family planning visits
0 20 40 60 80 100
account for 12 percent of n=100 Percent of SDPs offering methods
all MCH visits.
Source: Mapunda, 1996


=g 5?'^^^







* Almost all SDPs offer combined oral contraceptives and injectables, but only 55 percent
offer condoms, and fewer than half offer progestin-only pills (POP), IUDs, or spermicides.

* During consultation, pills and injectables were by far the most commonly mentioned
methods; IUDs and condoms were mentioned in about two-thirds of observed interactions
and other methods in fewer than half.

* Over 80 percent of the clinics have clean examination rooms with adequate privacy
and light. Virtually all have access to sterilizing equipment, specula, blood pressure
machines, and stethoscopes. However, more than half have no running water, two-thirds
have no electricity, 60 percent lack thermometers, and almost half are missing a flashlight
or angle poise lamp, gloves, needles, and syringes.

* The majority of family planning providers in Zanzibar are MCH Aides. Two-thirds of
those interviewed had been trained or retrained in FP within the last five years and more
than 80 percent had received a supervisory visit in the previous three months.

* Only 36 percent of new users were asked about their spacing or limiting needs;
one-half were asked about their breastfeeding status.

* Four out of five new users were told how to use a method, but far fewer were given
additional information about advantages, disadvantages, side effects, and what to do if
problems arise.

* Almost one-fourth of providers will not provide a contraceptive method to an
unmarried woman. Between 32 and 56 percent of providers, depending on the method,
require spousal consent for a prescription; and half or more place parity restrictions on all
methods, particularly injectables.

* Four-fifths of all new clients were weighed, had their blood pressure taken, and were
asked their medical history and date of last menstrual period. However, half or fewer had a
breast or pelvic examination or were asked about unusual bleeding, pelvic pain, or discharge.

UTILIZATION OF RESULTS
* Senior MOH officials, MCH/FP coordinators, senior program staff, UNFPA, WHO,
UNICEF, and members of the Family Planning Advisory Committee are using the SA
results to plan the next five-year phase of the ZFPRP which will be a broader-based
reproductive health, family planning, and safe motherhood program.

* The MCH/FP unit has purchased and distributed equipment found missing
during the study. IEC activities have been intensified and planning for refresher and
newcomer courses is underway. Management and supervisory courses for the MCH/FP
supervisors have also been incorporated into the next phase of the program.

Mapunda, Patiens and the Africa OR/TA Project II. 1996. The Zanzibar Family Planning Situation Analysis Study. Nairobi: Ministry of
Health, Tanzania and the Population Council. May.
For more information or to obtain a copy of the report, please contact the Africa OR/TA Project II, Population Council, PO. Box 17643,
Nairobi, Kenya, Tel: (254) (2)713-480, Fax: (254) (2)713-479, E-mail: ORTA@popcouncil.or.ke.
This project was supported by the Population Council's Africa Operations Research and Technical Assistance Project II. The Africa OR/
TA Project II is funded by the U.S. Agency for International Development (USAID), Office of Population, under Contract No. CCP-3030 C-
00-3008-00,Project No 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.
January 1998











SITUATION ANALYSIS OF FAMILY PLANNING
SERVICES IDENTIFIES PROGRAM GAPS

This Situation Analysis (SA) study of clinic-based family planning services
in Senegal identified program gaps in training, supervision, and
equipment which national and regional FP staff have used to develop
program strategies, establish quality of care indicators, and develop
regional workplans.

BACKGROUND
Senegal's National Family Planning Program (PNPF) coordinates nationwide
family planning activities, promotes the integration of family planning with
maternal and child health (FP/MCH) services, and serves as a central channel for
funding and program direction. In 1994 PNPF carried out this SA study of clinic-
based FP services with technical assistance from the Population Council's Africa
OR/TA Project. The study provides descriptive information on the availability,
functioning and quality of FP services provided through the country's 180 service
delivery points (SDPs); identifies program strengths and weaknesses; formulates
recommendations for the USAID-funded Program on Child Survival and Family
Planning; and provides quality of care indicators for the Ministry of Health and
Social Action. Researchers inventoried supplies, equipment, and facilities;
observed provider-client interactions; and interviewed FP and MCH clients and
FP staff.

FINDINGS
* Fifty-three percent of FP clients and 35 percent of MCH clients have at
least four children. More
than one-fourth of FP clients MOST RECENT SUPERVISORY VISIT TO CLINIC SDP
and almost one-fifth of MCH SENEGAL
clients do not want any
Do not know
more children. Last 3 months 2%
Approximately one-third of 38%
the women were No supervision
18%
breastfeeding at the time of
the survey.

p Only 38 percent of
SDPs had been visited by a
4-6 months
supervisor during the three 9%
months prior to the survey;
one-third had not received a 7+months
supervisory visit in seven n=180 33%
months or more, and 18
percent had received no Source: Diop etal, 1994
supervisory visits at all.


P.7T."






* Most SDPs offered a variety of contraceptive methods. More than 80 percent of new
clients obtained their preferred contraceptive method. In most cases, other possible
methods were not discussed. More than 95 percent of clients received a written reminder
of when to return for method resupply.

* Fifty-two percent of SDPs had a record system in place for tracking contraceptive
supplies and ordering. Pills, condoms and spermicides are available at all SDPs. The IUD
and injectables are available at 78 percent and 63 percent of SDPs, respectively. Over 20
percent of SDPs had stockouts of injectables.

* Sixty-two percent of service providers say they have received training in
clinical FP; 26 percent have received training in counseling; 24 percent in IEC; and 13
percent in HIV/AIDS counseling. The majority of family planning providers are midwives
whose formal training has been limited to the management of pills and IUDs.

* Client counseling on method side effects and how to manage them was
inadequate. Provider-imposed non-medical barriers to the provision of contraceptive
methods existed in terms of age, parity, and marital status. Providers asked only 56
percent of new clients about their reproductive intentions.

* Eighty percent of SDPs had FP and MCH posters, but only 40 percent had a visible
sign announcing the availability of FP services.

* At virtually all SDPs, FP services are offered within the context of a wide range of
services. However, FP was discussed in only 36 percent of MCH interactions.

* Concerns about HIV/AIDS were discussed in only 1 percent of new client visits, and
STI history was discussed in only 3 percent.


UTILIZATION OF RESULTS
* PNPF and key donor agencies, notably USAID, have used the SA data to develop a
set of indicators describing the quality of care provided by the program. These indicators
are being used to evaluate progress in strengthening the program.

* Dissemination of study results culminated in development of workplans by regional
FP staff. Many providers felt empowered to establish new procedures and propose
changes that could be managed at the local level and implemented immediately.


Diop, Maribme, Isseu Tourb, Nafissatou Diop, et al. Analyse Situationnelle du systbme de prestation de services de planification familiale
au S6n6gal. 1995. Dakar: National Family Planning Program, Ministry of Health and SocialAction and the Population Council. October
For more information or to receive a copy of this report, please contact Diourati6 Sanogo, Deputy Director Africa OR/TA Project II,
Population Council, Villa Nx4, Stele Mermoz, Route de Pyrotechnie, B.P 21027, Dakar Senegal, Tel: (221) 24-19-93, Fax: (221) 24-19-98,
E-mail: pcdakar@sonatel.senet.net.
This project was supported by the Population Council's Africa Operations Research and Technical Assistance Project II. The Africa OR/
TA Project II is funded by the U.S. Agency for International Development (USAID), Office of Population, under Contract No. CCP-3030-C-
00-3008-00, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.
January 1998


















4 11












0

0

z



0
m


m











CREATING CONDITIONS FOR A

SUSTAINABLE FAMILY PLANNING PROGRAM

Data from this study indicate that most women in Indonesia are obtaining
removal of NORPLANT on time and are willing to pay for removal services.
However, they need to know ahead of time what the cost will be for
contraceptive services, so they can make an informed choice that fits their
financial circumstances.

BACKGROUND
As of March 1995, National Family Planning Coordinating Board (BKKBN) service
statistics indicate that the cumulative number of NORPLANT acceptors in
Indonesia exceeded 2.6 million. BKKBN has developed a client tracking plan and
has initiated an accelerated program to increase the availability of removal
services. In order to obtain information on the extent to which removal of implants
was being completed on time, BKKBN, in collaboration with the Department of
Community Medicine (Medical School, University of Indonesia) and the
Population Council, conducted a study of a representative sample of women who
accepted NORPLANT between April 1987 and March 1991. Twenty teams of
researchers interviewed 2,979 women in 14 provinces, obtaining data on
continuation rates; facilities and providers used for insertion and removals;
complications or side effects experienced; barriers to removal; the role of the
private sector in removals; and the experience of NORPLANT clients during the
past five-year period.

FINDINGS
* At the time of their
NORPLANT acceptance, the NORPLANTe CONTINUATION RATES
INDONESIA
mean age of the women was
100
.28 years. They had an average
of three living children, half of so
them had little or no education,
half of their husbands worked 60
in agriculture or fishing, 90 2
percent lived in rural areas,
and 70 percent worked 20
at home.
O L
1 2 3 4 5 6 7 8
* Ninety percent of Years
acceptors are still using Average for all cohorts, 1987-1991, n= 2978
NORPLANT four years after Source: Fisher etal., 1996
insertion. Approximately two-
thirds continue to use NORPLANT for five years, and 90 percent obtain removal
before six years. Thus, only 8 percent have not yet had NORPLANT removed.
The data strongly suggest that removals are under-reported and that there is not
a large backlog of removal cases, particularly after the sixth year of use.







* Only 16 percent of those who are overdue for a removal use any other form of back-
up contraception.

* About five percent, or 89 women, have used NORPLANT for at least 7 years. Of
those, 67, or 4 percent, are married, younger than 45, and presumably sexually active.

* Continuing users tend to be older, divorced or widowed, have more living children,
accepted NORPLANT to stop (rather than postpone) the next pregnancy, and were less
likely to be informed about the need for a removal after five years of NORPLANT use.

* Two-thirds of removals are performed by nurse midwives. About 28 percent are
performed in private facilities; 23 percent are done in mass camps.

* About 91 percent of all women who have had a removal received the removal
immediately upon request. The remaining 9 percent often had to wait several days and
make two or more requests before obtaining a removal.

* Almost 70 percent of all women said they had not been informed at the time of
NORPLANT insertion that a fee would be charged for removal. Three-fourths of women
who had a removal were charged a removal fee. The majority of them considered the
removal fee "average" and 15 percent considered the fee "expensive".

* Over one-fourth of those who had not yet had a removal cited cost as the major
reason; 12 percent were afraid of the removal process, and 9 percent forgot the date.


UTILIZATION OF RESULTS
* The study was presented at the BKKBN's mid-year pre-programme review in
October 1996 and served as the main planning materials for officials from 27 provinces at
the BKKBN's National Planning Meeting (RAKERNAS) in March 1997.

* The Minister of Population and Chairman of the BKKBN has requested a follow-up
study to examine the characteristics of 8 percent of 2,979 current and former NORPLANT
users interviewed in the survey. The findings will be presented together with the findings of
a qualitative study, complementary to the survey, in 1997.

* The Population Council's ANE OR/TA conducted a follow-up analysis in June-July
1997 to compare the characteristics of women who did and who did not have NORPLANT
removed. Results suggest that priority for follow-up should be given to women in poor
families, those over 40 years of age, those who want to limit births, those who did not go to
school, and those who work outside the home.


Fisher, Andrew, Joedo Prihartono, Yayasan Kusuma Buana, and Jayanti Tuladhar 1996. Indonesia NORPLANT Removal Assessment
Study. Jakarta: National Family Planning Coordinating Board (BKKBN); Department of Community Medicine, Medical School, University
of Indonesia; and Population Council. July.
For further information or to obtain a copy of the final report, please contact Population Council, Tifa Building, Suite 404, JI. Kuningan
BaratNo. 26, Jakarta, Indonesia 12710. Tel: 62-21-520-0094, 520-0494, Fax: 62-21-520-0232.
This project was conducted with support from the Population Council's Asia and Near East Operations Research and Technical
Assistance Project. The ANE OR/TA Project is funded by the U.S. Agency for International Development (USAID), Office of Population,
under Contract No. DPE-C-00-90-0002-10, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health
Service Delivery. USAID support for this project was also provided through the Population's Council's Expanding Contraceptive Choice
Program. Support was also provided by the World Bank.
January 1998











VASECTOMY: A NEW REPRODUCTIVE
HEALTH OPTION FOR MEN

This study found that men in Dar es Salaam reacted positively to the
promotion and introduction of vasectomy services by two Tanzanian NGOs.
The findings contributed to development of a strategic plan to expand a full
range of FP services, with a special emphasis on longterm and permanent
methods, nationwide.

BACKGROUND
Until recently, vasectomy was virtually unknown in Tanzania. The lack of a supply
of and demand for vasectomy services was blamed on negative male attitudes
toward taking responsibility for family planning and the perception that
vasectomy was equivalent to castration. The Population Council's Africa OR/TA
Project studied the extent to which a six-month project by two Tanzanian FP
organizations, Population and Health Services (PHS) and the Tanzania Family
Planning Association (UMATI), was effective in providing knowledge, fostering
favorable attitudes and creating demand for vasectomy in Dar es Salaam. Their pilot
project featured four main interventions: promotion on radio, television and
newspapers; informational posters and leaflets; talks given to men at workplaces;
and training of vasectomy counselors and surgeons at 5 PHS and UMATI clinics. The
OR study comprised a survey of the male population in Dar es Salaam and Situation
Analysis and Mystery Client studies of the quality of counseling and information
services offered at the family planning clinics involved in the vasectomy promotion.

FINDINGS
* The vasectomy promotion COVERAGE AND EFFECTIVENESS OF
activities were successful in VASECTOMY PROMOTION CHANNELS
reaching a majority of men in Dar TANZANIA
es Salaam. Sixty percent of men Heard message but Heard
reported hearing at least one could not name message
message during the promotion "vasectomy" and named
period. But comprehension of theasecomy
message was much lower; only
one-third of men who had heard
the message could recall the term
"vasectomy."
40%
n=435 Did not hear message
* More than half the men
who were exposed to the Source: Eustace etal., 1997
Vasectomy Promotion Project
had at least one positive attitude toward vasectomy. These men rejected the
notion that vasectomy amounts to castration or reduced a man's sexual potential,
disagreed that sterilization was acceptable for women but not for men, and
agreed that vasectomy improves the sexual relations of partners.







* One-fourth of the respondents reported they would consider vasectomy when they
had all the children they wanted. Five percent said they had made special efforts to learn
more about vasectomy.

* One-third of the men who heard a talk about vasectomy during the promotion
period later discussed vasectomy with friends or relatives.

* Few respondents knew where to go for vasectomy services and mystery clients
found it difficult to reach some of the facilities.

* While 95 men sought more information at the five participating clinics and received
counseling about vasectomy during the project, only 11 men actually received a
vasectomy.

* Facilities for providing vasectomy information and counseling were often
inadequate. Only one-half of the service providers in the project clinics had been trained in
counseling for vasectomy; audio and visual privacy during counseling was lacking, and all
concerns of the mystery clients were addressed in less than half of the counseling
sessions.

* More than half of the men interviewed reported an ideal family size of four or fewer
children. More than two-thirds rejected the notions that a large family is prestigious and
that many children are helpful in providing old age security.


UTILIZATION OF RESULTS
* The results of this activity are contributing to the introduction of vasectomy
services in other urban centers of Tanzania.

* Drawing on these findings, PHS has already developed a strategic plan to expand a
full range of family planning services, with a special emphasis on longterm and permanent
methods including vasectomy, to 21 service delivery points nationwide.


Eustace Muhondwa, Naomi Rutenberg and Grace Lusiola. 1997. Effects of the Vasectomy Promotion Project on Knowledge, Attitudes
and Behavior in Dar es Salaam, Tanzania. Nairobi: the Population Council. June.
For more information or to receive a copy of the report, please contact the Africa OR/TA Project II, Population Council, RO. Box 17643,
Nairobi, Kenya, Tel: (254)(2)713-480, Fax: (254)(2)713-479, E-mail: ORTA@popcouncil.orke.
This project was supported by the Population Council's Africa Operations Research and Technical Assistance Project II. The Africa OR/
TA Project II is funded by the U.S. Agency for International Development (USAID), Office of Population, under Contract No. CCP-3030-C-
00-3008-00, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.
January 1998




m





SATISFACTION WITH DIAPHRAGM HIGH
AMONG POOR WOMEN IN MADRAS CITY

Poor women in the city of Madras, India chose the diaphragm and were
satisfied when it was added to the range of contraceptives offered as part of
a comprehensive community outreach program on reproductive health.

BACKGROUND
This feasibility study examined user perspectives regarding the desirability of the
diaphragm as a contraceptive method when included among other methods
distributed without cost through family planning clinics serving lower income,
urban neighborhoods in Madras, India. The project was carried out by the Rural
Women's Social Education Centre, Tamil Nadu with assistance from the
Population Council's ANE OR/TA Project. Information dissemination on
contraceptive options was part of a comprehensive community outreach program
on reproductive health education in the catchment areas of three service delivery
points, two implemented by a non-governmental organization and one by a
women doctor's association. The project's emphasis was on adding the
diaphragm to the present range of contraceptives. The study documented the
profile of 97 diaphragm acceptors and their experiences with the method over the
first month of use.

FINDINGS
* At the time of the baseline
survey, 2,295 non-pregnant women Profile of Diaphragm Acceptors
of reproductive age were living in Women who are breastfeeding
the study area, with a CPR of 66 Women want to space a second birth
percent. Fifty-three percent of the Women who have small children and
women were sterilized, 13 percent prefer to wait before adopting a
were using a temporary permanent method
contraceptive method, and the rest Women whose husbands are working
were not using any method. elsewhere
Following the supply of Women who have sex infrequently, but are
diaphragms, diaphragm acceptors at risk of an unwanted pregnancy
represented about 8 percent of Source: Sundari, 1995
potential users and four percent of
all non-pregnant women of reproductive age in the study area.

* No woman was fitted with a diaphragm bigger than 65mm. All preferred to
use it with spermicide. Virtually all women said they used the diaphragm for every
sexual contact.

* Irrespective of their education level, all acceptors reported that they
thought the method was appropriate and easy to use. Only one person had
difficulty with insertion after returning home and had to be retrained.


-. 4#P~ io .P I U d






* Absence of a bathroom or toilet at home did not pose a problem. Storage and
maintenance of the diaphragm was not problematic.

* The majority of acceptors were young women with one or two children, and most
had never used a contraceptive method before. None of the women with four or more
living children chose to use the diaphragm.

* Practically all women over 40 included in the study are sterilized. Twenty-six women
switched from pills, condoms or the IUD to the diaphragm, either to avoid side effects or to
have more control over method use.

* Twice as many married women in the 15 to 19 age group are diaphragm users (14
percent) when compared to other age groups (7 percent). The data suggest that the
diaphragm has an important role in delaying births, particularly the second birth, among
younger women who are underserved by the methods currently available.

* The key advantages of the method, from the users' perspective, were the absence
of side effects and the possibility of using it only when needed and not on a continuous or
daily basis.

* The investment of time and effort in community outreach and education, and the
high quality of the service delivery were important factors in acceptance and use of the
method. Acceptors mentioned the kindness shown by the doctors, their willingness to
explain diaphragm use in detail, and their patience in insertion training as important
motivating factors.

UTILIZATION OF RESULTS
* Several NGOs are exploring the feasibility of including the diaphragm in their
reproductive health programs. The study suggests that inclusion of the diaphragm among
the methods offered by FP programs in India would meet the needs of a significant portion
of women who are looking for a safe, user-controlled method.

* The Indian Council of Medical Research is testing the acceptability of the diaphragm
in its Human Reproduction Research Centers, when offered along with a wide range of
other contraceptives.

* Additional research is planned on the acceptability and use dynamics of the
diaphragm and other barrier methods in reproductive health programs with a user
perspective.


Sundari, TK. 1995. A Study of User Perspectives on the Diaphragm in an Urban Indian Setting. New Delhi: Rural Women's Social
Education Centre (Madras) and the Population Council. June.
For further information on this study or to obtain a copy of the final report, please contact the Rural Women's Social Education
Centre, Chengalpattu, Tamil Nadu. Or the Population Council, 53 Lodhi Estate, New Delhi 110003, India. Tel: 91-11-461-0913/0914,
Fax: 91-11-461-0912.
This project was conducted with support from the Population Council's Asia and Near East Operations Research and Technical Assistance
Project. The ANE OR/TA Project is funded by the U.S. Agency for Intemational Development, Office of Population, under Contract No.
DPE-C-00-90-0002-10, ProjectNo. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.
January 1998











IDENTIFYING GAPS IN DMPA METHOD

COUNSELING

In Peru, inadequate counseling limits women's use of Depo-Provera (DMPA)
and is a cause for concern even for the clients who continue to use it. The
Ministry of Health is now training providers in counseling, with the goal of
improving provider-client interaction and quality of services.

BACKGROUND
The Ministry of Health (MOH) has made Depo-Provera widely available in both
rural health posts and urban clinics throughout Peru. However, the 1993 DHS
survey noted that DMPA had the highest discontinuation rate at one year (68
percent) of any method offered. To learn more about the factors contributing to
client satisfaction and dissatisfaction with DMPA, the MOH and the Population
Council's INOPAL OR/TA Project conducted a qualitative study of users and
discontinuers in coastal and Andean towns and nearby rural areas. Focus group
discussions and in-depth interviews with 112 users and 38 discontinuers
explored beliefs and knowledge relating to reproductive physiology, the
menstrual cycle, the effects of DMPA, and their experiences with service
providers. The study also included interviews with a small group of providers
concerning their knowledge, attitudes and practices related to prescription
of DMPA.

FINDINGS
Continuers
* Many users receive Quotes from a Client and a Provider
distorted and incomplete "I would like to ask questions, but the nurses
information from service providers are always hurried, and what's more, there are
about reproductive physiology many people and it makes me feel ashamed to
and about how DMPA works. be asking questions and saying my business
Others discount what they are told out loud."
because it is inconsistent with Luisa, 27years old
traditional beliefs. Many women "The women express their concern about
who do not understand the amenorrhea. We tell them it is normal and
information provided are reluctant causes no problem to their health, and they
leave reassured."
to ask for more information, in part leave reassured
because of a lack of privacy. Obstetrician at Hospital de lave, Puno
Providers often respond to Source: Garate etal., 1995
concerns about amenorrhea by
telling their clients that it is "normal" and not to worry about it.

* Approximately half of the continues were less than 30 years old and
all had been pregnant at least once. About 60 percent had some secondary
education.



#, B r =m ;llr '


'i/-. *k.i'L'''-1 -*<'t-i
.i.*-iS^ .j :i.;,';i-







* Traditional beliefs in the benefits of menstruation to a woman's health make even
continues fearful of the common DMPA side effect, amenorrhea. Many continues worry
that when they do not menstruate they are pregnant.

* Users sometimes skipped an injection so that they would menstruate and be
reassured that they were not pregnant.

Discontinuers
* Discontinuers were slightly better educated, younger and had fewer children than
continues.

* Amenorrhea was the most common reason cited for method discontinuation.
Discontinuers feared that amenorrhea meant pregnancy, or believed that it could cause
health problems. Other reasons cited for discontinuation included weight gain, headaches,
and depression.

* Some discontinuers reported that they did not understand the information service
providers gave them; others felt that they did not receive enough information about side
effects. Many discontinuers were still experiencing amenorrhea when interviewed and
feared they were permanently sterile.

Providers
* Providers often possessed erroneous information about DMPA. Many believed that
it caused sterility or was appropriate only for women with three or more children.
Paraprofessional providers were found to share many of their clients' traditional beliefs
about the beneficial health effects of menstruation.


UTILIZATION OF RESULTS
* The MOH has begun an extensive program to improve the quality of services
including the client-provider interaction. The training emphasizes counseling on
side effects.


Gdrate, Maria Rosa, Manuela de la Peia, and Margarita Diaz. 1995. Estudio Cualitativo Sobre Inyectable Depo-Provera en Dos Regiones
del Per&. Lima: The Ministry of Health and the Population Council. May.
For more information or to receive a copy of this report, please contact Maria Rosa Gdrate, In-Country Advisor INOPAL ll, Population
Council, Paseo Padre Constancio Bollar 225, El Olivar de San Isidro, Lima, Peru L-27, Tel: 51-14-42-04-48, Fax: 51-14-40-06-35, E-mail:
postmast@pclima.org.pe.
This project was supported by the Population Council's INOPAL II and III Projects. INOPAL II and III are funded by the U.S. Agency for
International Development (USAID), Office of Population, under DPE--3030-Z--00-9019-00, Project No. 936-3030 (INOPAL II) and Contract
No. CCP-C-00-95-00007-00 (INOPAL II), Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health
Service Delivery
January 1998








3 33


MAJOR TECHNICAL ASSISTANCE
EFFORT PROVIDES TIMELY DATA ON

REINTRODUCING DMPA

The government and other agencies are using the study's timely data on a
pilot program reintroducing DMPA in the Philippines for program
implementation and planning. About one-fourth of DMPA acceptors under
the pilot program are first-time family planning users.

BACKGROUND
When the Department of Health (DOH) initiated the DMPA Reintroduction
Program in April 1994, the method was available in few public health service sites
and was accepted by less than one percent of family planning users. A total of
2,081 health facilities serving a population of about two million people in six
provinces and four cities were selected for inclusion in the program. The
Population Council provided technical assistance for program monitoring,
including data on DMPA stocking, utilization, acceptance rates, and continuation
rates. Five separate reports summarize the pilot program's results to date and
provide qualitative information on service providers, DMPA acceptors, and the
acceptors' male partners.

FINDINGS
* A total of 1,748
trained providers, DMPA CONTINUATION RATES
PHILIPPINES
usually a female PHILIPPINES
midwife, are
providing DMPA 80
services in 66 percent
of all health facilities
in the pilot area.

* A total of 40
102,778 DMPA
injections were
dispensed between
April 1994 and June 3 Months 6 Months 9 Months 12 Months
1995. Forty-eight Duration of DMPA Use
percent of these were
first injections. Most No. of 2nd, 3rd, 4th and 5th reinjections/1,374 acceptors
facilities averaged Source: Patron et al., 1995
between three and
four new acceptors per month.

* The continuation rate per 100 new DMPA acceptors was 78 at three
months, 53 at six months, 43 at nine months and 31 at 12 months (fifth injection).


I







* The number of DMPA vials and syringes in stock per facility ranged from 16 to 112,
suggesting a continuing need for logistics management. As of June 1995, 62 percent of
health facilities had DMPA reminder cards in stock, and 56 percent had DMPA leaflets.

* About 2 percent of married women of reproductive age in the pilot area now use
DMPA compared to the national DMPA use rate of 0.1 percent prior to the reintroduction
program.

* The average DMPA acceptor was 29 years old, had attended high school, and had
three children. Sixty-two percent of acceptors wanted no more children. For 27 percent,
DMPA was the first family planning method they had ever used.

* Nearly 80 percent of male partners were supportive of women's adoption of DMPA.
Twenty-nine percent became less supportive as side effects, particularly irregular bleeding,
were noted, but only 2 percent of women discontinued DMPA because of their partner's
objections.

* Ninety percent of women reported experiencing a side effect. Nausea/headache
was the most common (46 percent), followed by spotting (40 percent) and weight gain (39
percent). One-fifth of them returned to the clinic to consult with the service provider, eight
percent treated themselves and 71 percent did nothing.


UTILIZATION OF RESULTS
* Reports and briefings on the OR results by the DMPA Task Force have been the
principal source of information for DOH on DMPA reintroduction in the Philippines. The
DOH has requested that the Population Council continue technical assistance on this issue
for the next year to ensure continued availability of data on DMPA utilization.

* The UNFPA and DOH have utilized the studies' estimates on expected demand,
based on the number of supply sites, acceptance and continuation rates, in developing
their DMPA procurement plans.


Patron, Maria Carmel, and Marilou Palabrica-Costello. 1995. Experience with the DMPA Injectable Contraceptive: Findings from a Survey
of DMPA Acceptors. Manila: Department of Health and the Population Council. August.
---- 1995. The DMPA Service Provider: Profile, Problems and Prospects. Manila: Department of Health and the Population Council.
August.
---- Knowledge, Attitudes and Practice of the DMPA Injectable Contraceptive: Data from Focus Group Discussions. Manila: Department of
Health and the Population Council. August.
---- DMPA Monitoring Study, Final Report. Manila: Department of Health and the Population Council. August.
Arenas, Myra L. and Marilou Palabrica-Costello. 1995. Experience with the DMPA Injectable Contraceptive: A Comparison between
Continuing-Users and Drop-Outs. Manila: Department of Health and the Population Council. August.
For more information on these studies or to receive a copy of the final reports, please contact the Population Council, Monteverde
Mansions, Unit 2A3, 85 Xavier Street, Greenhills, San Juan, Metro Manila, Philippines. Tel: 63-2-784-475, Fax: 63-2-721-2786.
This project was conducted with support from the Population Council's Asia and Near East Operations Research and Technical Assistance
Project. The ANE OR/TA Project is funded by the U.S. Agency for International Development, Office of Population, under Contract No.
DPE-C-00-90-0002-10, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.
January 1998





am M_ Opel_ raItfions Research




IMPROVING CARE OF POSTABORTION
PATIENTS IN HOSPITALS

This study of the treatment of incomplete abortion patients in Kenya
obtained baseline information for planning the integration of treatment of
abortion complications and family planning services in Kenyan hospitals.
The findings were used to design three different models for improving
postabortion care.

BACKGROUND
The Population Council's Africa OR/TA Project and the Robert H. Ebert Program
on Critical Issues in Reproductive Health and Population are working in close
collaboration with IPAS, the Kenyan Ministry of Health, and the Family Planning
Association of Kenya (FPAK) to test alternative models for providing improved
postabortion care in Kenya. Evidence suggests that Kenya has a high rate of
repeat abortion. Although FP services are available in the public institutions
where management of incomplete abortion takes place, these two services are
largely segregated from each other. This study examined emergency treatment
services for postabortion patients; postabortion FP counseling and services; and
the links between emergency abortion treatment services and comprehensive
reproductive health care in 18 Kenyan hospitals.

FINDINGS
Annual caseloads for the treatment of incomplete abortion at the 18
hospitals, drawn from 1993 records, ranged from a low of 113 to a high of 1,101,
with an average of 482 cases per hospital. Provider estimates of their caseloads
were much higher than their records showed. Since records were often only
partially completed, poorly
organized and not centralized, ARE INCOMPLETE ABORTION PATIENTS
e n f t r ROUTINELY GIVEN FP INFORMATION?
the numbers from the records KENYA
were most likely an undercount
of the true figures.
No 91%
Eighty-six percent of the
service providers interviewed
thought that their patients
should always be given family
planning information while still
in the hospital. However, 91 Don't
percent said that incomplete
abortion patients are not n=57
routinely given family planning Source: Solo etal., 1995
information or offered services.




M ILy^^







* Almost two-thirds of the postabortion care providers suggested that FP counseling
be done on the ward. As for the provision of methods, 64 percent indicated that the
methods should be provided at the FP clinic, since the clinic already has a system in place
to provide for follow-up of FP clients.

* Of the 75 providers interviewed, 95 percent indicated that the current postabortion
services could be improved. Areas cited for improvement include increasing supply of
antibiotics, gloves, disinfectant, specula, and MVA equipment; improving the blood bank;
adding staff; and giving prompt attention to patients.

* Treatment of uncomplicated incomplete abortions through manual vacuum
aspiration (MVA), rather than sharp curettage (also known as D&C), was used at 11 of the
18 hospitals. The most common reason cited for not using MVA was the lack of equipment
or expendable supplies, such as disinfectant.

* A number of providers had negative or judgmental attitudes toward incomplete
abortion patients.

* Family planning services are offered in all 18 hospitals visited. On average, each
hospital saw 86 new FP clients and 546 revisiting clients each month. Hospitals generally
have 7 to 8 FP methods available and in stock.

* Although the hospitals are set up to provide family planning services, minimal
linkages were found between the treatment of incomplete abortion patients and family
planning information and services. Few postabortion patients actually receive FP services.

* More than two-thirds of family planning providers interviewed felt that FP
counseling should be offered to postabortion patients on the ward.


UTILIZATION OF RESULTS
* The study results are being used to plan for the introduction of three hospital-based
interventions that will enable development of a direct link between postabortion
treatment and family planning counseling with the goal of improving the quality of both
postabortion treatment and family planning services. The three interventions are: a)
providing family planning on the gynaecological ward by ward nurses; b) providing family
planning at the MCH/FP clinic; or c) providing family planning on the gynaecological ward
by the MCH/FP staff.


Solo, Julie, Esther Muia, and Khama Rogo. 1995. Testing Alternative Approaches to Providing Integrated Treatment of Abortion
Complications and Family Planning in Kenya: Findings from Phase I. Nairobi: the Population Council and the Centre for the Study of
Adolescence. August.
For more information or to receive a copy of the report, please contact Julie Solo, Africa OR/TA Project II, Population Council,
RO. Box 17643, Nairobi, Kenya, Tel: (254)(2)713-480, Fax: (254)(2)713-479, E-mail: ORTA@popcouncil.orke.
This project was supported by the Population Council's Africa Operations Research and Technical Assistance Project II. The Africa OR/
TA Project II is funded by the U.S. Agency for International Development (USAID), Office of Population, under Contract No. CCP-3030 C-
00-3008-00, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery. Additional support
was provided by the Swedish International DevelopmentAuthority through its funding of the Population Council's Robert H. Ebert
Program on Critical Issues in Reproductive Health.
January 1998











POSTABORTION CARE: COUNSEL

HUSBANDS AS WELL AS PATIENTS

Postabortion patients and their families in Egypt have major concerns about the
women's future fertility. Joint counseling sessions for husbands and wives
could help remove apprehensions and inform couples of the woman's almost
immediate return to fertility and the need to use a contraceptive method.

BACKGROUND
This study, conducted by the Population Council, investigated the concerns of
postaboration patients in Egypt in order to improve the counseling these women
receive. The study's objectives were three-fold: decrease the risk of mortality and
morbidity associated with incomplete abortions, increase postabortion patients'
use of family planning, and use the information gathered in the production of
counseling materials and in development of culturally sensitive survey
questioning techniques on abortion in Egypt. The research team conducted in-
depth interviews with 31 women hospitalized following an abortion and focus
group discussions with family planning clients.

FINDINGS
* In this sample, the
average postabortion patient is Concerns of Postabortion
between 25 and 35 years old, Patients In Egypt
with three children. The majority "To get back to her normal condition, a woman
do not work outside the home needs a proper diet and a place to relax and rest.
and have minimal formal But how can I get that? Where I come from
education. (a rural area) women have to work hard...
education.
"Having an abortion affects the women's fertility.
She has to stay for a long time until she gets
* About one-third of the n
pregnant again...
patients have never used
"This is the first time for me to have an abortion,
contraception. Only 16 percent but thank God, we do not want any more
were currently using a family children. I really did not want to have this
planning method at the time pregnancy..."
of conceiving the pregnancy "I feel severe pain with every move I make... This
they had just lost. About has been the most painful experience I have ever
one-third of pregnancies were had."
planned. "Many women go through a lot of psychological
pain, especially if the husband is not appreciative
* The women and their of the situation...Many husbands think that
women induce the abortion."
families have major concerns
about the women's future fertility. Source:Huntingtonetal., 1995
They are preoccupied by the
causes of the abortion and the actions they can take to reestablish 'bodily order'.


LALP1111






* Many women expressed apprehensions about contraceptive use following abortion,
fearing that it could inhibit restoration of reproductive health. On the other hand, they
stated that it is important to avoid another pregnancy in the near future.
* Almost all postabortion patients are accompanied to the hospital by one or more
family members. Husbands often accompany patients on admission or come to the
hospital at discharge.
* Women arrived at the hospital for postabortion treatment in a state of heightened
anxiety due to physical pain and discomfort, and substantial hemorrhaging. All patients
interviewed were alarmed about the implications of the bleeding on their recovery and
future health.
* Multiple economic pressures and family obligations prohibit many women from
enjoying a full recuperation period. Recovery is further hindered by fear of the social and
family stigma attached to failing to carry a fetus to term.
* Spousal support can be a vital factor in the emotional as well as physical healing of
the patient. Most patients readily support the idea of counseling for their husbands about
care during recovery and return to fertility.

RECOMMENDATIONS
* The husband should be advised about the trauma experienced by his wife and the
importance of a recuperation period. A male physician could be the most appropriate
counselor for spouses. Such sessions should take place before the woman leaves the
hospital.
* Joint counseling sessions where husband and wife receive information about the
woman's ability to conceive and carry to full term another pregnancy could help remove
any apprehensions about their ability to achieve their desired family size.
* Postabortion women should receive clear and careful explanations about how the
postabortion period is different from the postpartum period, in particular stressing the
almost immediate return to fertility and the need for a contraceptive method.


UTILIZATION OF RESULTS
* A program is now being developed to institutionalize postabortion medical services
in Egypt over the next three to five years by creating linkages between the consortium of
medical universities training students in MVA clinical procedures and public and private
family planning services.
* The findings of this study support and update the current research on the
procedures and contents for counseling postabortion women and their husbands
in Egypt.
* Study results are being used in developing counseling curricula and thus will be
used in implementing the strategy for improving postabortion care in Egypt.

Huntington, Dale, Laila Nawar and Dalia Abdel Hady. 1995. Exploratory Study of Psycho-social Stress Associated with Abortion in Egypt.
Cario: the Population Council. September.
For further information on this study or to obtain a copy of the final report, please contact the Population Council, 6A Giza St., PO Box
115, Dokki, Cairo-12211, Egypt. Tel: 5738277, Fax: 5701804.
This project was conducted with support from the Population Council's Asia and Near East Operations Research and Technical
Assistance (ANE OR/TA) project. The ANE OR, TA project is landed by the U S. Agency for International Development, Office of
Population, under Contract No. DPE-C-00-90-0002-10, Prolect No. 936-3030. Strategies for Improving Family Planning and Reproductive
Health Service Delivery
January 1998




















































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IDENTIFYING UNMET NEED FOR
POSTABORTION CARE

A diagnostic study of the services currently provided to women attending
hospitals for the treatment of complications due to spontaneous or induced
abortions shows a largely unmet need for more comprehensive services
and scope for improvement in the quality of care provided.

BACKGROUND
Hospital-based studies in Nairobi have shown that unsafely induced abortion
accounts for as much as 35 percent of pregnancy-related mortality and at least
50 percent of hospitals' gynecological admissions. In collaboration with IPAS, the
Kenyan Ministry of Health (MOH), and the Family Planning Association of Kenya
(FPAK), the Population Council's Africa OR/TA Project is testing three different
models linking emergency treatment of incomplete abortion and FP services in
six MOH hospitals. Study methodology includes collecting pre-intervention data;
carrying out an intervention consisting of training, facility upgrades, and
reorganization of services; and collecting post-intervention data. Researchers
interviewed 481 patients and 140 staff at six public hospitals in Kenya to establish
an understanding of the current treatment of women admitted for postabortion
complications.

FINDINGS
* Only one-fifth of all
SOnly one-fifth of all WOMEN'S REPORTING OF PAIN
patients received pain EXPERIENCED DURING PROCEDURE, KENYA
medication before or during
the procedure. Of the women Pain
medication
who were awake during the used
procedure, almost all reported Pain was
experiencing pain. Two-thirds experienced
indicated that the pain was Amtof pain
extreme
"extreme." extreme
Amt of pain
moderate
The staff perceived their
patients to be mainly young, Amtinimal
unmarried girls trying to delay 0 0 40 60 80
their first full-term pregnancy. D c D MVA
Patient interviews revealed,
however, that over 60 percent For MVA: n=285-303; for D&C n=114-176.
were aged 20-29 years and 71 Source:Acholla etal., 1997
percent were married.

Although, as an outpatient procedure, manual vacuum aspiration (MVA)
requires less time to administer than dilation and curettage (D&C), patients
attending hospitals which use MVA tended to wait longer for treatment than those
attending hospitals using D&C.


-US






* Infection prevention was found to be less than satisfactory, due both to a lack of
supplies and incorrect practices by staff.

* Almost half the providers described their relations with the patients as "poor," one-
third felt they were "good," and 15 percent said "it depends," as they often differentiate
between women attending for spontaneous and induced abortions.

* Less than one-fifth of patients were given any information about the treatment
procedure, their general health status, or their return to fertility.

* At five hospitals, only 7 percent of patients reported receiving any FP information,
but virtually all said they would have liked to receive such information. Only 22 percent
decided to begin using contraception at the five hospitals, and of these, only 3 percent
received their method before discharge. At the sixth hospital, staff had already begun to
implement a comprehensive postabortion care service and 98 percent of patients received
family planning counseling.


UTILIZATION OF RESULTS
* The results from this baseline survey were used during a two-day joint planning
workshop for implementation of the comprehensive postabortion care models to be tested
at each hospital.

* Training in MVA and FP counseling for postabortion patients completed at the six
hospitals incorporated study results, including provider-suggested ways in which pain
could be reduced, the need to separate personal biases from their treatment practices,
and the need to provide counseling to women before, during and after the procedure.

* To address providers' negative attitudes toward patients with complications from
induced abortion, a forum was set up for staff dialogue, supplies were improved and pay
was increased. Providers were trained, at their request, in practices regarding infection
prevention in the handling of MVA equipment.

* Hospitals that had been treating patients in main or shared theaters, which
caused long waiting times for treatment, have created rooms on the gynecological ward to
treat incomplete abortion patients.


Acholla, Ominde, Margaret Makumi, Deborah Billings, and Julie Solo. 1997. Postabortion Care Services in Kenya: Baseline Findings from
an Operations Research Study. Nairobi: the Kenyan Ministry of Health (MOH),the Family Planning Association of Kenya (FPAK), IPAS, and
the Population Council. March.
For more information or to obtain a copy of the final report, please contact the Africa OR/TA Project II, Population Council, PO. Box
17643, Nairobi, Kenya. Tel: (254) (2) 713-480; Fax: (254) (2) 713-479; E-mail: ORTA@popcouncil.orke.
This project was supported by the Population Council's Africa Operations Research and TechnicalAssistance (OR/TA) Project II. The
Africa OR/TA Project II is funded by the U.S. Agency for International Development (USAID), Office of Population, under Contract No.
CCP-3030-C-00-3008-05, Project No. 936-3030. Strategies for Improving Family Planning and Reproductive Health Service Delivery
January 1998











IMPROVING POSTABORTION
QUALITY OF CARE

The Guatemalan Social Security System (IGSS) offers integrated
postabortion care. However, the quality of services was hampered by limited
patient counseling and limited contraceptive availability. Study results led to
improved information for clients and increased availability of contraceptive
methods.

BACKGROUND
Presently, only a few health care systems in Latin America have integrated family
planning services into their provision of postabortion care. One place where
integration has taken place is a large Social Security Institute (IGSS) hospital in
Guatemala City which treats 150 postabortion women every month. With
assistance from the Population Council's INOPAL OR/TA Project, IGSS
conducted a study to examine the quality of postabortion care provided,
including: 1) client-provider interaction, 2) information given to the client, 3)
contraceptive availability, and 4) provider's ability to diagnose infections at the
time of admission, as diagnosis of infection is a contraindication for insertion of
an IUD immediately postabortion. The study sample was 304 postabortion
women, diagnosed at admission as not infected. They were asked at discharge
to return for a check-up and an interview within three to five days. To facilitate
their return, they were offered 50 quetzales (about US$8.00), to defray visit costs.
Returning women who participated in the study were interviewed about their
experience in-hospital and were examined for evidence of infection. Non-users of
family planning were offered information and contraception.

FINDINGS
* Approximately 91 percent
of women reported being "well- CLIENT'S RATING OF POSTABORTION CARE
IN GUATEMALA
treated" during the postabortion
Bad
experience; about 8 percent Mixed 1%
said treatment was "mixed," 8
and 1 percent rated it "bad."
The most common reason for
dissatisfaction was the length
of waiting time in the emergency
room before admission. Most
women experiencing long waits
were being kept under
observation by providers, a fact treated 91%
that may not have been Source: Orellana et al., 1996
adequately explained to them.


PopIa I







* Postabortion treatment at the hospital consisted of dilation and curettage (D&C)
followed by hospitalization. Contraceptives available in-hospital were limited, before the
study, to the IUD and minilaparotomy. Women desiring other methods could only receive
them if they returned for a check-up, routinely scheduled for three to six weeks after
hospital discharge.

* About 88 percent of the 304 sampled women received in-hospital family planning
information, and 25 percent received an IUD. The remaining 149 who were given
information did not receive a contraceptive method, although 124 stated they would have
preferred to receive a method predischarge. About 82 percent of non-users accepted a
method at the follow-up visit, mainly DMPA. No women were sterilized.

* Two-thirds of the 304 women returned. Under normal circumstances only about 25
percent of postabortion women return for a check-up. As intended, the payment produced
a much higher return rate than usually encountered among postabortion women. About 68
percent of those returning were ages 20 to 35, 20 percent were over 35, and 12 percent
less than 20.

* Only a few women knew the symptoms of postabortion complications or how soon
fertility returned following an abortion.

* At the check-up, 15 percent had a pelvic infection, including 5 of 51 IUD users (10
percent) and 25 of 149 non-family planning users (17 percent). The small difference in
infections encountered suggests that infection status usually cannot be detected or
predicted by IGSS personnel at the time of admission.

Implications of Findings
* It may be worth considering delaying insertion for, or providing antibiotics to,
women receiving IUDs.

* Since few women return for postabortion visits, strategies for increasing the return
for postabortion checkups should become a national priority.

UTILIZATION OF RESULTS
* As a result of the study, IGSS increased in-hospital contraceptive availability
to include hormonal and barrier methods, and published patient information materials.


Orellana, Maria Lobos, Gustavo Gutierrez, Carlo Bonatto, and Emma Ottolenghi. 1996. Calidad de Servicios Dirigidos alas Mujeres Que
Cursaron con Aborto: Hospital Gineco-Obstetricia IGSS. Guatemala City: Hospital Gineco-Obstetricia IGSS and the Population Council.
For more information or to obtain a copy of the report, please contact Jim Foreit, Director INOPAL III, Population Council, 4201
ConnecticutAve, NW, Suite 408, Washington, DC 20008, USA, Tel: (202)237-6455, Fax: (202)237-6458, E-mail: inopal@pcdc.org.
This project was supported by the Population Council's INOPAL III Project. INOPAL III is funded by the U.S. Agency for International
Development (USAID), Office of Population, under Contract No. CCP-C-00-95-00007-00, Project No. 936-3030, Strategies for Improving
Family Planning and Reproductive Health Service Delivery. Technical and financial assistance was provided to IGSS by the Population
Council's Program Development Fund.
January 1998





SM I S -r, ME XICO





IMPROVING POSTABORTION SERVICES
IN THE MEXICAN HEALTH SYSTEM

A study seeking to humanize the postabortion procedure in Mexico,
provided information about the fear, pain, and waiting times endured by
women seeking treatment for incomplete abortion, and demonstrated the
high health system costs of the procedure. Procedures, counseling and
quality of care have been improved.

BACKGROUND
An estimated four million abortions take place annually in Latin America, and
complications from the procedure are among the region's primary causes of
maternal morbidity and mortality. The Dr. Aurelio Valdivieso General Hospital in
Oaxaca, in conjunction with the Population Council's INOPAL OR/TA Project and
IPAS, carried out a study to assess the quality of postabortion services provided
through the hospital and train health providers in the use of safer medical
techniques and better FP counseling and services. Researchers interviewed and
examined the medical records of 132 postabortion patients and interviewed
service providers. The study developed a profile of the women who come to the
hospital with incomplete or complicated abortions, and provides information on
the quality of care provided.

FINDINGS
The average cost per
postabortion case at the DISTRIBUTION OF COST FOR POSTABORTION CARE
IN MEXICO
hospital is $192. The major IN MEXICO
costs are related to the Hospital
practice of hospitalizing Stay 63%
women after postabortion
treatment.

a One-third of the women
are illiterate or semi-literate.
Roughly 80 percent depend
economically on their male Supplies &
Medications 30%
partners. For one-fourth, this Staff
was a first pregnancy; for one- Costs 7%
third, it was at least their fifth Source: Barahona etal., 1996
pregnancy. Seventeen percent
reported having a previous
abortion. One-third did not want this pregnancy, and 19 percent said they were
using a contraceptive method when the pregnancy occurred.

E Sixty-five percent of patients spent six hours or more waiting for
emergency treatment.


," vi






* Forty-five percent of the women felt "very fearful" upon arrival at the hospital. The
most common fears mentioned included the operation and anesthesia (48 percent),
bleeding (27 percent), pain (22 percent), and death (18 percent). Seventy percent of the
women reported feeling even more afraid after the receiving physician examined them.

* In spite of the fact that 58 percent of the women reported feeling great pain, none of
them were given an analgesic prior to entering the operating room. After the procedure, 40
percent reported pain, and about 28 percent received some form of pain medication.

* Prior to treatment, one-third of the women were not informed of their diagnosis, 12
percent were not aware of the type of treatment planned, and only 13 percent were asked
if they had any questions. The main reasons they did not ask questions were: 1) it did not
occur to them; 2) they were afraid to bother the physician; or 3) they were too
embarrassed.

* More than three-fourths received no information in the recovery room about the
state of their health. Approximately 96 percent received no information about post-
treatment medication, warning signs of possible complications, or what to do in case of
an emergency.

* Fifty-eight percent of women did not receive any family planning information. Of the
42 percent who did receive information, 70 percent accepted a method, but nearly half of
acceptors did not receive their preferred method.

UTILIZATION OF RESULTS
* Project staff used the study results to help design an intervention to improve quality
of care. A follow-up study is planned.

* Hospital staff participated in the development of strategies to improve service
delivery. Strategies included: adopting standardized protocols for postabortion treatment
and routine provision of family planning counseling and methods; staff training in manual
vacuum aspiration (MVA) and provider-patient relations; development of a series of IEC
pamphlets on complications for patients; and development of a series of posters for
providers on interpersonal relations.


Barahona, Vilma, Beatriz Casas, Francisca Ramirez, Felipe Perez Sainoz, Aurelio Validivesio, Jose David Ortiz Mariscal, Andrea Saldala,
Cecila Garcia Barrios, Ana Langer Glas. 1996. Estimating Cost of Postabortion in General HospitalAurelio Valdivieso, Oaxaca. Mexico
City: Aurelio Valdivieso General Hospital, IPAS and the Population Council. September
For further information or to receive a copy of this study, please contact Carlos Brambila, Program Associate, INOPAL III, Population
Council. Escondida 110, Col. Villa Coyoacan, 04000, Mexico, D.F, Mexico, Tel:52-5-659-8541, Fax: 52-5-554-1226, E-mail:
cbrambila@laneta.apc.org.
This project was supported by the Population Council's INOPAL III Project. INOPAL III is funded by the U.S. Agency for International
Development (USAID), Office of Population, under Contract No. CCP-C-00-95-00007-00, Project No. 936-3030, Strategies for Improving
Family Planning and Reproductive Health Service Delivery
January 1998










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STRENGTHENING THE INTEGRATION OF
STI/HIV AND MCH/FP SERVICES

A case study that assessed the addition of STI/HIV services into the existing
MCH/FP activities of an NGO program in Mombasa, Kenya led to a better
understanding of how to offer an integrated reproductive health care
service and to significant improvements in the quality of care provided.

BACKGROUND
Data from the National Sentinel Surveillance system show that the prevalence of
HIV infection among women attending antenatal services in Mombasa rose from
10 percent in 1990 to 16 percent in 1993. The Mkomani Clinic Society (MCS), a
non-governmental organization (NGO) based in Mombasa, Kenya, supported
two primary health care SDPs with on-site laboratories, and a community
outreach program with 30 full-time Community Service Workers (CSWs). With
technical assistance from Pathfinder International, in 1992 MCS began to
integrate STI screening and treatment services and HIV education into routine
MCH/FP service delivery activities, and MCS developed a model for providing
integrated services. The Population Council's Africa OR/TA Project undertook a
case study to document how the model functions so that lessons could be
passed on to others interested in providing STI case management and HIV
education and screening within an MCH/FP setting. The study also highlighted
areas in which the quality and efficacy of the model can be strengthened.

FINDINGS
* Most MCS staff have
not attended any formal The Mkomani Clinic Society
training courses on STI and Integration Model
HIV/AIDS management, but Routinely carry out a risk assissement for STI/HIV/
MCS has organized in-house AIDS among all clients visiting the SDPs for FRP
training sessions for all staff. antenatal and child welfare services;
Although many staff Provide information on STI/HIV to all clients;
understood the key concepts Inform the public about STIs and HIV/AIDS and the
of providing an integrated availability of services;
service, most did not fully Protect health personnel and MCH-FP clients from
implement such key elements infection;
as risk assessment and Test all ANC clients for syphilis;
screening when providing Diagnose and treat common STIs within the MCH/
services to MCH/FP clients. FP unit;
Identify and refer all clients with symptoms and
S There were no formal signs of HIV infection, or those requesting HIV
testing;
guidelines, protocols or
Carry out contact tracing, and risk assessment,
service manuals to assist staff screening, diagnosis and treatment for the contacts.
in implementing the
t Source: Twahir et al., 1996
integrated activities.


I d.Pop o







* Both SDPs have an adequate supply of basic equipment and other requirements for
providing STI and HIV/AIDS services in addition to MCH/FP services. The only deficiency
is waste disposal facilities.

* The physical infrastructure at both SDPs does not facilitate client flow between
services, group IEC activities, or provide for adequate client privacy.

* IEC materials on STIs and HIV/AIDS for use in the SDPs and in their community-
based activities are lacking.

* Staff need further training to clarify the differences between STI risk assessment and
the syndromic approach to diagnosis and treatment of STIs.

* Contacting sex partners with STIs continues to be a major problem.

* Cost analysis undertaken concurrently with the case study found that it costs the
MCS US$ 8.20 to provide an STI service, yet the client pays US$ 4-5. It is difficult to raise
user fees beyond this, so the difference has to be raised from other sources like donors
and charitable fundraising activities.

UTILIZATION OF RESULTS
* A service provider instruction manual for STI case management has been
developed and introduced. The manual has been used for monitoring and supervising the
quality of services.

* Changes have been made in the physical layout of the clinics to reduce
overcrowding in the waiting areas and enhance clients' privacy during consultations.

* The information gained from the case study and cost analysis has encouraged MCS
to re-examine its cost-recovery and funding mechanisms to look for ways of becoming
more financially sustainable.


Twahir, Amina, Baker Ndugga Maggwa and lan Askew. 1996. Integration of STI and HIV/AIDS services with MCH/FP services: A case
study of the Mkomani Clinic Society in Mombasa, Kenya. Nairobi: Mkomani Clinic Society and the Population Council. April.
For more information or to receive a copy of the final report, please contact the Africa OR/TA Project II, Population Council, PO. Box
17643, Nairobi, Kenya. Tel: (254) (2) 713-480; Fax: (254) (2) 713-479, E-mail: ORTA@popcouncil.orke.
This study was supported by the Population Council's Africa Operations Research and TechnicalAssistance Project II. The Africa OR/TA
Project II is funded by the U.S. Agency for International Development (USAID), Office of Population, under Contract No. CCP-3030-C-00-
3008-00, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery
January 1998





Oeto Research




INTEGRATING STI/HIV SERVICES INTO
EXISTING MCH/FP PROGRAMS

STI and HIV/AIDS management services can be integrated successfully into
existing MCH/FP programs in East and Southern Africa. A prototype model
common across different types of service delivery programs appears to be
emerging.

BACKGROUND
The presence of certain STIs increases the risk of the sexual transmission of HIV.
Thus, controlling STIs can significantly reduce the incidence of HIV. Almost all
women in the East and Southern African regions attend MCH/FP clinics regularly,
and recent surveys have shown that the prevalence levels of many STIs,
including HIV, can be high for women seeking FP and antenatal services, despite
the fact that they are frequently asymptomatic. MCH/FP services are provided by
medically trained staff with many of the same skills needed for managing STIs.
Consequently, several MCH/FP programs have started looking for ways to
integrate STI management strategies, such as STI screening, treatment and
education, into their routine services. The Population Council's Africa OR/TA
Project undertook case studies of four such programs: one national (Botswana);
one municipal (Nakuru, Kenya); one NGO (Mombasa, Kenya); and one church-
based (Busoga, Uganda). The model includes: case detection and treatment,
HIV/AIDS management, detection and treatment of syphilis, and information and
education materials.

FINDINGS A Prototype Model for Integrated Services
* Risk assessment 1. Case detection and treatment of asymptomatic
women
and clinical history taking .wm
and clinical htory ting Assess risk; take clinical history; perform general exam;
are essential for detecting perform pelvic exam; categorize any signs or symptoms
STI cases among mainly into general syndrome, and provide curative treatment;
asymptomatic MCH/FP encourage contact tracing.
clients, but neither are 2. HIV/AIDS management
being performed Refer clients with signs and symptoms to nearest
consistently or according specialist site; refer clients who request testing; provide
o giine IEC on prevention of HIV transmission and signs/
symptoms of infection to all clients.
3. Detection and treatment of maternal syphilis
* The syndromic Screen all antenatal clients on first visit through referral or
approach has been on-site test; encourage contact tracing.
adopted for detecting 4. Information and education to prevent new infection
STIs because of its and improve health-seeking behavior
applicability at most MCH/ Raise awareness of signs and symptoms of infection;
FP clinics, where educate on safer sexual practices; promote condom use;
laboratory testing is not give health talks; make print materials available in waiting
room and during consultations; give talks within the SDP
possible, but this catchment area; advertise availability of services.
approach has not always Source: Maggwaetal., 1997
been correctly applied.


O~ ~Ip Rr~ m,4',,







* Clients' awareness of symptoms and signs associated with STIs, their ability to
identify and describe them, and the providers' capacity to understand clients' descriptions
need to be improved for the syndromic approach to work effectively.

* The syndromic approach is intended to simplify treatment of STIs by requiring a
small range of drugs that can treat several types of infection. The supply of these drugs at
clinics and their purchase by clients are major problems in all but the strongest programs.

* The procedure followed for contact tracing (i.e. asking the woman to notify her
partner and to visit the clinic) was found to be universally weak, thus increasing the
woman's risk of reinfection.

* The model developed is appropriate for MCH/FP service delivery points with limited
or no access to laboratory facilities. The integrated service is offered as a package of
services in a single visit, primarily to new family planning clients and to antenatal clients.

* MCH/FP clients suspected to have HIV, or who have asked for a test, are referred to
specialist clinics for testing and counseling.

* All programs have mandatory syphilis screening for antenatal clients. Because this
normally requires the client to return at a later date for the result, and it requires payment,
few women have the test and fewer return for the result.

* Condom promotion is expected to be an integral component of all information
exchanges with clients but is undertaken to differing extents by each program. For
example, the Uganda study found that only 25 percent of new FP clients were asked about
condom use, and in the Kenya study, less than 7 percent of MCH/FP clients were informed
about the role of condoms in reducing the rate of STI and HIV transmission.



UTILIZATION OF RESULTS
* Results were used to guide development of OR studies on integration in other
African countries, including Kenya, Zimbabwe, Ghana and Burkina Faso.


January 1998


Maggwa, Baker Ndugga and lan Askew. 1997. Integrating STIIHIV Management Strategies into Existing MCH/FP Programs: Lessons from
Case Studies in East and Southern Africa. Nairobi: the Population Council. June.
For more information or to receive a copy of the report, please contact the Africa OR/TA Project II, Population Council, PO. Box 17643,
Nairobi, Kenya. Tel: (254) (2) 713-480; Fax: (254) (2) 713-479, E-mail: ORTA@popcouncil.orke.
This study was supported by the Population Council's Africa Operations Research and TechnicalAssistance Project II. The Africa OR/TA
Project II is funded by funded by U.S. Agency forlnternational Development (USAID), Office of Population, under contract No. CCP-3030
C-00-3008-00, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.


January 1998









rCBBF r N~




f ,
,,_ ~~~ ...















































Ti
U

SI











VOLUNTEERS PROVE SUCCESSFUL AT
INCREASING MEN'S KNOWLEDGE OF FP

This project demonstrated that male involvement in reproductive health in
rural Honduras can be increased through a fairly simple, low cost strategy
adapted from successful, on-going agricultural extension strategies.

BACKGROUND
In rural Honduras, men believe they should play a major role in reproductive
decision making, but have limited family planning knowledge. CARE, Honduras,
with technical assistance from the Population Council's INOPAL Project, tested
two strategies to increase male knowledge and involvement in family planning
and reproductive health in rural Honduras. Both were based on CARE's experience
with agricultural improvement projects. In the first strategy, CARE trained paid
agricultural extensionists to provide reproductive health education in ongoing
meetings with farmers and cooperative members using a manual which includes
participatory activities and questions to stimulate reflection and discussion.

The second strategy, based on the Farm Management Plan utilized in Latin
America by CARE to assist farmers to conduct strategic planning, designed an
interactive family management booklet to help rural couples assess the
resources and needs of their families and work together to develop a vision of
their long term goals and how to achieve them. While filling out the booklet,
which was designed for use by semi-literate individuals, couples reflect on the
size of their family and the timing of their children. Both interventions included
involvement by community volunteers. Most were small farmers and
entrepreneurs who had successfully adopted farm management interventions or
established small businesses who became actively involved in disseminating
reproductive health education to other community members.

FINDINGS
* Among non-pregnant women,
S ng -rent e i WOMEN WHO USED REPRODUCTIVE HEALTH
the percentage of current users of family SERVICES FOLLOWING VOLUNTEERS' SUPPORT
planning increased from 51 percent to
58 percent. The percentage who 60Prc
requested having a pap smear 50 Before
50 After|
increased from 30 percent to 43 percent.
40
The percentage of women who 30
reported having spoken to their partners 20
about family planning in the last fifteen
days increased from 36 percent to 50 10
percent. The percentage who had spoken Family Planning Pap Smear
with their partners about STDs or HIV Source: Lundgrenet a., 1996
increased from 42 percent to 54 percent.


'I,








* Paid agricultural extensionists had
serious reservations about providing
reproductive health education, even after
training. The focus group results
demonstrated that community members
were much more open to reproductive
health education than were the
extensionists.

* Baseline survey data showed that
only some of the men reached by this
project had more than a sixth grade
education. Their mean age was 37 years,
and all were small land holders.


Why is family planning important?


Extensionists
"Improve the level
of life."
"Food security."

"We can't keep
thinking in terms
of a sick family."


Community Members
"To live better and
educate our children."
"To feed the
children better"
"To protect the health of
mothers and children."


Source: Lundgren etal, 1996


* Men were enthusiastic about receiving reproductive health information. They would
like the extensionists to dedicate more time to reproductive health during their meetings
and would like to participate in training exclusively dedicated to the topic.

* Community volunteers were enthusiastic about the program and did not require
extra training. Many said it was the most valuable community activity they had participated
in and asked for additional programs in reproductive health and sexuality.

* In general, both volunteers and community members felt capable of providing
reproductive health education themselves, and did not feel it was necessary to involve the
extensionists. The time constraints imposed by the extensionist's regular duties did not
leave much time for the new activity.

* Simple interactive materials were culturally acceptable and were more popular than
the more elaborate program of focus groups and meetings run by extensionists.


UTILIZATION OF RESULTS
* Preliminary results led the Government of the Netherlands to provide funds to
continue the project through July 1998 in the original project area.

* CARE is using the materials developed under the project in its programs in Peru
and Bolivia.

U- CARE is developing a strategy to scale up the intervention in the new five year
extension of their agricultural extension project.

* The Man to Man model for reproductive health is being replicated by an agricultural
extension NGO in Mindanao, Philippines.

Lundgren, Rebecka and Dolores Valmana. 1996. Strategies to Involve Men in Reproductive Health Care: From Farm Management to
Family Management. Tegucigalpa: PACO/CARE Honduras and the Population Council. December.
For further information or to obtain a copy of the final report, please contact Population Council, Residencial Casavola No. 37, Area
Bancatlan, Miraflores, Tegucigalpa, Honduras, Tel/Fax: 504-32-60-21.
This project was supported by the Population Council's INOPAL Ill Project. INOPAL III is funded by the U.S. Agency for International
Development (USAID), Office of Population, under Contract No. CCP-C-00-95-00007-00, Project No. 936-3030, Strategies for Improving
Family Planning and Reproductive Health Service Delivery.
January 1998






Mm




CONFIRMING THE EXTENT OF FEMALE
GENITAL MUTILATION (FGM)

Female genital mutilation (FGM) is an embedded cultural practice in Egypt,
where 93 percent of women in this study were found to have some form of
FGM. Study findings suggest that increased efforts to inform women and their
families of the problems associated with FGM, especially cases of severe
health complications or mortality, are needed to help discourage the practice.

BACKGROUND
The 1995 Egyptian Demographic and Health Survey (EDHS) was the first
nationally representative survey to measure female genital mutilation (FGM),
which is performed mainly on pre-adolescent girls and involves the partial or total
excision of external parts of the genital tract (labia minora, labia major and
clitoris). The study data indicated an FGM prevalence of 97 percent among
Egyptian women of reproductive age. FGM is considered to mark a girl's
passage to womanhood or her preparation for marriage. Negative health
implications of the practice include death from hemorrhage, infection or tetanus;
infertility; incontinence; and complications during pregnancy and childbirth. The
Egyptian Fertility Care Society (EFCS), with support from Macro International and
the Population Council's ANE OR/TA Project, carried out a clinic-based study to
investigate the types of FGM practices in Egypt as well as the accuracy of the
EDHS self-reporting. A total of 1,339 women selected at the out-patient services
of 11 clinics providing gynecological or family planning services participated in
the study. The women were interviewed using the FGM module from the 1995
EDHS. A specially-trained OB/GYN physician then conducted a physical
examination to collect data on the prevalence and type of FGM.

FINDINGS
Self-reporting of FGM
and the examination findings COMPARISON OF WOMEN'S SELF REPORTED
cn tch re inati ii FGM STATUS AND RESULTS OF PHYSICAL EXAMINATIONS
concurred in approximately 94
percent of cases. In all, 93
Report: No FGM
percent of the women were Exa Yes FGM I
found to have some type Rora x Report: Yes FGM
of FGM. 9 Exam: No FGM 5%
of FGM.
Report of Exam
agree no FGM 2%
Approximately 60
percent of the women
examined were found to have
partial or total removal of both Source:HassanetaL, 1996
the clitoris and labia minora;
17 percent had their clitoris removed; 7 percent had the labia minora excised;
9 percent had the tissue of the labia major excised; and 7 percent showed no
evidence of FGM.


14,, Pouatio Couni








* The women included in the study are predominantly from lower socio-economic
segments of Egyptian society as women from higher classes are less likely to utilize public
health services for their health care.

* Sixty-six percent of the women interviewed are below age 35, 95 percent are Muslim, all
have been married, 64 percent were married below age 20, 35 percent have four or more
children, 44 percent have no formal education, and 55 percent live in rural areas.

* The likelihood for a woman to have some type of FGM decreases if her husband or
either of her parents, particularly her mother, have a higher education.

* Partial or total excision of only the clitoris was more prevalent among women
between 15 and 24 years of age.

* Eighty percent of all women in this study think that FGM should continue.
Meanwhile, 94 percent of women with FGM intend to do the operation on their daughters
as opposed to 64 percent with no FGM. Almost 40 percent of women with daughters cited
custom as the main reason for this practice.

* Among women who do not intend to practice FGM on a daughter, 59 percent said
the practice was unacceptable and 40 percent feared complications.

* Fourteen percent of women stated that FGM should be stopped. Of those, 43
percent view it as a bad custom, 42 percent fear the risk of complications, and 22 percent
confirmed it prevents satisfaction with marital relations. Almost 80 percent of them
emphasized educating parents on the hazards of the operation and 25 percent suggested
banning the operation as a possible means of abolishing the practice.

* Sixty-five percent of mothers had the procedure performed by a traditional midwife,
as opposed to only 31 percent of daughters. A physician performed the operation on 10
percent of mothers and 37 percent of daughters.


UTILIZATION OF RESULTS
* The study's findings have been incorporated in the final report of the 1995 Egyptian
Demographic and Health Survey.

* The findings are contributing to the scientific understanding of the practice of female
genital mutilation in Egypt.

* The national NGO task force on FGM is using the findings to develop a media
advocacy plan and develop key public messages. This plan aims at suggesting and
implementing tools that strengthen political support, educate media professionals about
FGM hazards, and create a network of media professionals interested in covering the
issue. The task force is also developing future research priorities.

Hassan, E.O., N.EI Nahal, M. El Husseinie, F Gamil, F El Zanaty, A. Way, D. Huntington and L. Nawar. Clinic-based Investigation of the
Typology and Self-reporting of FGM in Egypt, Final Report. 1996. Cairo: Egyptian Fertility Care Society, the Population Council, and
Macro International. November
For further information on this study or to obtain a copy of the final report, please contact the Egyptian Fertility Care Society (EFCS), 2A
Mahrouki St., Monadesen, Cairo, Egypt. Tel 20-2-347-0674, Fax: 20-2-346-8782. Or the Population Council, 6A Giza Street, PO. Box 115,
Dokki, 12211 Egypt. Tel: 20-2-573-8277/570-1733, Fax: 20-2-570-1804.
This project was conducted with support from the Population Council's Asia and Near East Operations Research and Technical
Assistance Project. The ANE OR/TA Project is funded by the U.S. Agency for International Development, Office of Population, under
Contract No. DPE-C-00-90-0002-10, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service
Delivery. Funding was also provided through Macro International's Demographic and Health Survey.
January 1998











FAMILY PLANNING ENHANCES

WOMEN'S STATUS

Family planning programs can act as a stimulus for the spread of new ideas,
information, beliefs, behaviors and even technology beyond their intended
audiences. In this case, the unintended audience was young, unmarried women.

BACKGROUND
This study by the Department of Population Planning and International Health at
the University of Michigan looked at the effects of family planning on women's
status in Bangladesh. Data was collected from 36 focus groups in Matlab,
Bangladesh, where the Family Planning and Health Services Project had been
underway for ten years. The study resulted in two separate papers, one dealing
with the effect of family planning fieldworkers on the knowledge and attitudes of
young, unmarried women towards fertility and family planning; and the second
reflecting on the relative importance of demand-side and supply-side factors in
the fertility decline in Bangladesh.

FINDINGS
Program effects on young
women Shamiran's Story
* The Matlab family SHAMIRAN was so excited that she came out of
planning program inadvertently the room and went to her aunt, saying,"We have
reached girls and unmarried seen what Mukti's Ma said to you and gave you.
We know the story." The aunt said: "Well, since you
young women, introducing the came to know already, listen; those medicines are
culture of contraception as a for controlling childbirth. If you do not want any
part of their normal process of more children, then you can have those. When you
socialization, will want another child, then stop using those
medicines and you can have the baby. You should
not discuss these with anybody. When you will be
* During a time when married off, Mukti's Ma ... or I will tell you OK? No
family planning information more questioning. Go."
was not widely available to Shamiran was amazed at her discovery. She went
young girls, the home visits of to Bani and explained everything. Bani said: "You
family planning workers should not say all those things. I feel shy." But
stimulated a growing Shamiran and Bani continued to discuss the topic
aware of the npt and several times. Shamiran said: "I think Mukti's Ma is
doing a good job. I will have those medicines when
meaning of family planning I will be married off." Bani said: "How dare you talk
among the daughters of the like that before marriage?" But Shamiran replied: "I
workers' clients, think you should also think about these medicines,
because you are going to get married soon."
* Family planning workers Then Shamiran went to school and discussed
provided a new role model for everything with the other young girls of the village.
young women and served as Source: simmonsetal., 1994
an example of female mobility,
employment, modern dress and reproductive decision making.


wry "I








* Young girls discussed the family planning worker's activities with their friends before
and after marriage. These discussions provided an important mechanism for the diffusion
of knowledge about sexuality and contraception.

Qualitative analysis of the decline in fertility
* The decline in fertility has multiple determinants. While the presence of a strong
family planning program is a major contributing factor, many social and economic aspects
of these women's lives are being transformed. Together these changes explain the interest
in family limitation and spacing.

* Women perceive that the cost of living is increasing generally, and they are
concerned about the rising cost of providing for their children's needs, especially beyond
the basic necessities of food and clothing. Their interest in "investing" in educating their
children, both boys and girls, is increasing.

* An important social factor in fertility decline is women's changing position in society.
The authoritarian role of parents and in-laws is weakening, conjugal bonds are stronger,
and young women are gaining a new degree of influence. The freedom to delay the onset
of childbearing is a central element in this change.

* Women often view the Matlab family planning worker as a trusted friend they can
rely on to help them overcome fear of contraceptive methods and mediate disputes about
family planning with relatives.

* Women are aware of the many social and economic changes going on around them
and are conscious and deliberate actors in the fertility transition. Program agents and the
media help them to escape pre-established cultural scripts.

UTILIZATION OF RESULTS
* The papers produced by this study are contributing to a better understanding of the
mechanisms behind fertility transition and successful family planning programs. The first
paper from this study, "Diffusion of the Culture of Contraception: Program Effects on Young
Women in Rural Bangladesh," was published in Studies in Family Planning (January/
February 1995).

* The second paper, "Women's Lives in Transition: A Qualitative Analysis of the
Fertility Decline in Bangladesh," was presented at the annual meeting of the Population
Association of America. In this manner, the study's message--the importance of family
planning workers in the diffusion of information about family planning and models of small
families--was disseminated to a large audience of academics and program managers.

* Both papers have been incorporated in the research utilization process in
Bangladesh sponsored by the Ministry of Health and Family Welfare.

Simmons, Ruth, and Rezina Mita. 1995. Women's Status and Family Planning in Bangladesh: An Analysis of Focus Group Data. Dhaka:
University of Michigan and the Population Council.
For further information on this study or to obtain a copy of the final report, please contact the Population Council, House CES(B) 21,
Road 118, Gulshan Dhaka, Bangladesh. Tel: 880-2-883-127/881-227, Fax: 880-2-883-127.
This project was conducted with support from the Population Council's Asia and Near East Operations Research and TechnicalAssistance
Project The ANE OR/TA Project is funded by the U.S. Agency for International Development, Office of Population, under Contract No.
DPE-C-00-90-0002-10, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.
January 1998













14 d,

qmzl



,?v, :2 *A
tie











0

7r











EXAMINING AWARENESS OF REPRODUCTIVE
HEALTH ISSUES AMONG YOUTH

This descriptive study identified several areas where attitudes and social
norms of Ghana's youth may be substantial barriers to their reproductive
health (RH). They are eager for discussion of RH issues and assistance with
their RH concerns.

BACKGROUND
In preparation for planning a large project on sexual health for youth in the Volta
Region, the Planned Parenthood Association of Ghana (PPAG) collaborated with
the Population Council's Africa OR/TA Project on development of an instrument
to elicit detailed descriptions of knowledge, behavior, and attitudes of Ghanaian
youth on a wide array of reproductive health issues. Both as a pretest of this
instrument and as a means of collecting baseline information for other new youth
center activities, PPAG interviewed 250 youth aged 12-24 in each of three
regional capital towns where new youth centers are planned. The stratified
random samples contained in-school youth, out-of-school "organized" youth in
apprenticeship programs, and youth selected from an "unorganized," out-of-
school population.

FINDINGS
* Concerns: Economic
concerns about the lack of PERCENTAGE OF GHANAIAN YOUTH WHO TOLERATE
jobs and high clothing prices THE BEATING OF WIVES AND GIRLFRIENDS BY GENDER
jobs and high clothing prices
were paramount, especially 100 percent who report beating is tolerable
for males. Although the lack
of recreational facilities is one Male Female
basis of the youth center 80
initiative, this issue was of
least concern to the 60
respondents.

S Sexism and Violence 40
Towards Women:
Respondents scored 20
relatively high on a sexism
scale. No significant
differences were found by o
religion, age, or education. Wife beating Girlfriend beating
Seventy-two percent agree For wife: n=744 For girlfriend: n=737
that there are "circumstances Source: Gloveretal., 1997
in which a husband can beat
his wife." There are no differences between male and female responses
on this issue.







* Sexual Intercourse: More than half of the respondents claim to have had sexual
intercourse, with a noticeable difference by age group. Less than 10 percent of youth aged
12 to15, about 40 percent of those aged 16 to17, and almost 75 percent aged 18 and over
claim to have ever had sex. More females than males claim to have had sex in the 18 and
over group. Almost all report their first sex partner was a boyfriend or girlfriend, playmate
or classmate. They usually report a consensual first sexual encounter. Among those who
have ever had sex, 69 percent of females and 35 percent of males report having only one
partner in the last month. More males reported having either no partner, or two or more
partners.

* Pregnancy: Only 18 percent of the sample correctly indicate when, during the
monthly cycle, pregnancy is most likely to occur. More than three-fourths say that there is
nothing good about a teenage pregnancy. Thirty-four percent of never-married females
who have ever had sexual intercourse indicate they have experienced a pregnancy; 91
percent of these say they did not want to be pregnant at the time; 89 percent of them had
or attempted an abortion.

* Contraceptives: Almost all claim knowledge of ways to avoid pregnancy. Methods
mentioned most frequently are full abstinence, condoms, and oral contraceptives. Virtually
all youth claim to have "heard of condoms," but less than half mention each specific step
of correct condom use. Sixty-one percent disagree that "it is OK for a young man to carry
condoms in his pocket", and 74 percent disagree that "it is OK for a young woman to carry
condoms in her purse."

* STI/HIV/AIDS: Virtually all know of diseases one can get through sexual
intercourse. Ninety-seven percent mention HIV/AIDS; 81 percent mention syphilis. Among
respondents who have ever had sexual intercourse, 43 percent of males and 28 percent of
females claim to have done something to avoid getting an STI in the last sexual encounter;
93 percent of these used a condom. Almost all indicate that AIDS is transmitted during
sexual intercourse; only 11 percent incorrectly indicate that casual contact or insect bites
are a source of HIV.

UTILIZATION OF RESULTS
* Findings from this survey were used to improve the instrument that will be used in
the larger Volta Region Project in 1997.

* PPAG is using the findings to strengthen its strategies for several youth education
programs. For example, based on the concerns expressed by youth, PPAG began to
explore ways to incorporate more economic-related activities, such as job and
apprenticeship counseling, into their youth center programs.


Glover, Kofi, Angela Bannerman, Robert Miller, et al. 1997. Adapting reproductive health strategies to adolescent needs: Findings from
three Ghanaian towns. Accra: Planned ParenthoodAssociation of Ghana and the Population Council, October.
For more information or to receive a copy of this report, please contact the Africa OR/TA Project II, Population Council, One Dag
Hammarskj6ld Plaza, New York, NY, 10017. Tel: (212) 339-0500; Fax:(212) 755-6052; E-Mail: pubinfo@popcouncil.org.
This project was supported by the Population Council's Africa Operations Research and Technical Assistance Project (OR/TA) Project II.
The Africa OR/TA Project II is funded by the U.S. Agency for International Development (USAID), Office of Population, under Contract No.
CCP-3030-C-3008-00, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery.
January 1998











FAMILY LIFE EDUCATION INCREASES

CONTRACEPTIVE KNOWLEDGE

AND USE BY MEXICAN YOUTH

In Mexico, an operations research project developed a family life education
course that increased adolescents' reproductive health and family planning
knowledge. The course was incorporated into the public school curriculum
and also became the most widely used course in Mexican private schools.
Replication has been successful in other Latin American countries, notably
Peru and Bolivia.

BACKGROUND
While fertility has declined among older women in Latin America, unwanted
fertility remains high among adolescents. Survey data indicates that in most
countries in the region, between 50 and 60 percent of unmarried women have
had sexual intercourse by age 20, but have low levels of contraceptive use.
Unmarried women with children suffer negative social and economic
consequences from unintentional childbearing. In response to the problems of
adolescent fertility in Mexico, the Population Council's INOPAL Project provided
assistance to the Instituto Mexicano de Investigacion de Familia y Poblaci6n
(IMIFAP) and the Secretariat of Public Education (SEP) to conduct two studies in
secondary schools in Mexico City that tested the impact and acceptability of a
reproductive health and sex education course called "Planeando Tu Vida"
(Planning Your Life). Course contents included reproductive anatomy and
physiology, sexuality, contraception and sexually transmitted infections. In the
first study, students in two schools were randomly assigned to treatment and
control groups. The experimental group studied the Planning Your Life course.
The control group received no formal sex education in school. The second study
replicated the first in 88 schools and gathered parent and teacher opinions about
the course.
WHAT WOULD YOU RECOMMEND TO DO ABOUT
FINDINGS THE ADOLESCENCE AND DEVELOPMENT COURSE?
100
* Parents, teachers, and
students were overwhelmingly Teachers
in favor of including the course Parents
in the national secondary 60 Students
school curriculum.
40
* The cost of the course
was modest. It was estimated 20
that the cost of offering the 0 2
course throughout Mexico Extend to Continue Eliminate from
would be as low as US $1.36 all schools testing it program
per student. Dk/Da not included
Source: Pick ere Weiss et al., 1992student.
Source: Pick de Weiss et al., 1992


E









* Students receiving the Planning Your Life course had more contraceptive
knowledge than students who did not. The course increased the proportion of students
who could name at least one contraceptive method from 40 to 80 percent, and produced a
positive change in the experimental groups' attitude toward contraceptive use.

* Experimental group students who took the course were no more likely to become
sexually active than controls who did not take the course. However, sexually active
experimental group students were more likely to use contraceptives than sexually active
controls.


UTILIZATION OF RESULTS
* The Ministry of Education contracted IMIFAP to adapt the Planning Your Life course
for inclusion into existing primary and secondary school curricula. About 50 percent of the
original contents were included in the national secondary school curriculum. The State of
Coahuila added the course in its entirety to the curriculum. Planning Your Life was also
widely adopted in private secondary schools; over 300 had adopted the course by 1994. A
video based on the course was produced and shown repeatedly on Mexican TV.

* The McArthur Foundation supported a training of trainers from institutions in
seven Latin American countries (Peru, Bolivia, Honduras, Uruguay, Chile, Colombia and
Mexico). Funding from the Packard Foundation and the Bergstrom Fund has allowed
IMIFAP to provide in-country training where the replication of the curricula has been
especially successful (Peru and Bolivia), as well as in other countries where the course is
being replicated (the Dominican Republic, Nicaragua, Guatemala and El Salvador).


Pick de Weiss, Susan, J.C. Hernandez, M. Alvarez and R. Vernon. 1992. An Operational Test to Institutionalize Family Life Education in
Secondary Schools in Mexico. Mexico, D.F: Institute Mexicano de Investigaci6n en Familia y Poblacion (IMIFAP) and the Population
Council. November.
For more information or to receive a copy of this study, please contact Ricardo Vernon, Deputy Director INOPAL Ill, Population Council.
Escondida 110, Col. Villa Coyoacan, 04000, Mexico, D.F, Mexico, Tel:52-5-659-8541, Fax: 52-5-554-1226, E-mail:
rvernon@laneta.apc.org.
This project was supported by the Population Council's INOPAL IlI Project. INOPAL III is funded by the U.S. Agency for International
Development (USAID), Office of Population, under Contract No. CCP-C-00-95-00007-00, Project No. 936-3030, Strategies for Improving
Family Planning and Reproductive Health Service Delivery.
January 1998










STRENGTHENING NGOs PROVIDING
REPRODUCTIVE HEALTH SERVICES FOR
ADOLESCENTS

The Government of Botswana is encouraging NGOs to play an active role in
providing reproductive health services to adolescents. The program
summarized here led to creation of an NGO network and the strengthening
of the members' management and research capabilities to work with
Botswana youth.

BACKGROUND
As part of an overall effort by the Government of Botswana to enhance the role of
the non-governmental sector in health and social service provision, the
Population Council's Africa OR/TA Project has supported the development and
strengthening of a formal network of eleven NGOs which address the
reproductive health needs of adolescents. This effort had a two-pronged
strategy: the Botswana National Productivity Centre (BNPC), a local parastatal
management training and consulting organization, assisted the NGOs to identify
and address organizational and managerial issues; while the Health Research
Unit (HRU) of the Ministry of Health provided training and technical assistance to
the NGOs in how to use operations research (OR) to improve the delivery of
reproductive health services.

FINDINGS
* To meet a need
identified during the OR studies implemented by the
project's Kick-off Youth Empowerment Project (YEP) Network
Workshop, the Botswana BOTSWANA
Council of NGOs Assessing the Coverage and Adequacy of Services
(BOCONGO) created a Provided by AMMB to Care Givers of HIV/AIDS
database linked to a Positive Youth
Geographic Information Effectiveness of Peer Education Training Programs in
System (GIS) with Gaborone
information on most Accessibility, Availability and Use of Condoms among
Botswana NGOs and Youth
maps showing the locale Utilization of Information, Education and
and activities of the Youth Communication Materials (IEC) on HIV/AIDS by
Education Project NGOs Adolescents with Disabilities
and registered members Source: Montsietal., 1997
of BOCONGO.

N At the two training workshops on operations research led by HRU, eight
NGOs collaborated in development of four small-scale OR studies to diagnose or
evaluate their service delivery problems.


-EDpillon








* At a series of retreats facilitated by BNPC staff, the NGOs identified factors that had
the potential to promote or retard organizational performance. These retreats formed the
basis for a tailored program of technical assistance to each organization and for design of
management training workshops which covered strategic planning, change management,
and time management.


UTILIZATION OF RESULTS
* The Botswana Red Cross Society is using OR study recommendations to address
factors which have limited the availability, suitability, and accessibility of IEC materials on
HIV/AIDS for youth with disabilities.

* The Botswana Family Welfare Association, based on recommendations to
strengthen its teen peer education training program, developed a refresher course for peer
educators. The NGO is also using its new research skills to evaluate and re-introduce a
Family Life Education training program for primary school teachers.

* The findings of a study on condom use and safe sex among youth led the
Botswana Scouts Association to begin work on the development of a scout's curriculum
on reproductive health education for youth.

* As a result of the study by the Association of Medical Missions for Botswana
(AMMB) on home care for youth with HIV/AIDS, an existing but outstanding proposal to
introduce a hospice in one of the AMMB sites was reviewed and approved. The AMMB
also approved recommendations to streamline activities and strengthen its home care
program.

* Collaboration on workshop and OR activities, and development of the GIS
network has facilitated collaboration, networking, and information exchange among NGOs,
the government and donor agencies.


Montsi, Mercy and Naomi Rutenberg. 1997. The Youth Empowerment Project: Strengthening NGOs Management and Service Delivery
Capabilities in Botswana. Nairobi: the Population Council. June.
For more information or to obtain a copy of the report, please contact the Africa OR/TA Project II, Population Council, PO. Box 17643,
Nairobi, Kenya. Tel: (254) (2) 713-480; Fax: (254) (2) 713-479; E-mail: ORTA@popcouncil.or.ke.
This project was supported by the Population Council's Africa Operations Research and TechnicalAssistance (OR/TA) Project II. The
Africa OR/TA Project II is funded by the U.S. Agency for International Development (USAID), Office of Population, under Contract No.
CCP-3030-C-00-3008-00, Project No. 936-3030, Strategies for Improving Family Planning and Reproductive Health Service Delivery
January 1998












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PRODUCTIVITY AND PAYMENT OF

VOLUNTEER WORKERS

This study found little relationship between productivity and payment for
health service referrals by traditional birth attendants ("matrones") in Haiti.
Expansion of the matrone training and referral program does not provide for
payment for these volunteer workers.

BACKGROUND
The Comite de Bienfaisance de Pignon (CBP) provides health services, including
perinatal services using traditional birth attendants ("matrones"), to a population
of 150,000 in five rural communities in Haiti, where 90 percent of women deliver
at home. Matrones usually help with births and are also a source of perinatal
care. To increase use of health services, CBP trained ten matrones in one
community in perinatal care, birthing, referral of high risk pregnancies,
breastfeeding, and family planning and paid them 600 Gourds (US$40) per
month to refer women for perinatal and postpartum family planning services to
health centers. The perinatal service was successful, but upon deciding to
expand the program into two additional communities, limited funds forced re-
examination of the payment policy. With the goal of examining the relationship
between productivity and payment of these traditionally volunteer workers, CBP
with technical assistance from the Population Council's INOPAL Project, carried
out two studies. The first study examined the impact of reducing matrone
payment by 50 percent in the original project community. The second study was
conducted in two new villages and compared the productivity of paid and unpaid
matrones. The new groups of matrones received training, and each community
received a health post. In one new community, the matrones received a US$20
per month stipend, in the other, the matrones received no stipend.

FINDINGS
Decreasing the Stipend
cre g t S NUMBER OF REFERRALS MADE BY PAID
* The pay cut did not AND UNPAID MATRONES IN HAITI
lower matrone referral output Number of referrals made
compared to the pre-pay cut
period.
30
f Combined mean
referrals by matrones equaled 20
20.2 per month, with great
variability. Referrals by
individual matrones for both
periods ranged from one every
five months to more than twelve 0
Paid Matrones Unpaid Matrones
per month.
Source: Bouchard, 1997


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* No reliable difference was found between the total number of pre- and postnatal
visits to CBP services during the months when matrones received a full payment and when
that payment was reduced.

Comparing Paid and Unpaid Matrones
* There was no reliable difference in total prenatal visits per month between the two
communities.

* Matrones who were paid US$20 per month made more referrals (30.9 vs. 23.8) than
unpaid matrones, but the difference in the number of referrals did not translate into a
higher total number of health center visits in the community with paid workers. In both
communities, worker referrals resulted in an average 53 visits per month.

* The marginal cost per referral in the experimental commune was estimated at
US$28.57.

Implications of Findings
* In rural Haiti other factors, such as access to professional and para-professional
health care providers and health centers, may be more important to program success than
the extent to which matrones are paid.

* Payment affects matrones' activities. However, matrone productivity does not
appear to be strongly related to the level of payment. This lack of relationship between
payment and productivity may result in part from the fact that the population covered by a
matrone in rural Haiti is limited, and thus greater effort cannot result in proportionally
greater output.

* Non-professional payment should be linked to performance. Initial payments should
be relatively low, and should increase with productivity.

UTILIZATION OF RESULTS
* CBP has eliminated matrone payments in all communes, but the organization
continues to train traditional birth attendants and integrate them into perinatal activities.


Bouchard, Glen. 1997. Model Postpartum Program for Rural Populations in Haiti. Port au Prince: Comit6 de Bienfaisance de Pignon and
the Population Council.
For more information or to receive a copy of the report, please contact Jim Foreit, Director INOPAL Ill, Population Council, 4201
ConnecticutAve, NW, Suite 408, Washington, DC 20008, USA, Tel: (202)237-6455, Fax: (202)237-6458, E-mail: inopal@pcdc.org.
This project was supported with funding from the Population Council's INOPAL III Project. INOPAL III is funded by the U.S. Agency for
International Development (USAID), Office of Population, under contract No. CCP-C-00-95-00007-00, Project No. 936-3030, Strategies
for Improving Family Planning and Reproductive Health Service Delivery and Cooperative Agreement No. 521-0189-00-4019-00.
January 1998







A1 -




REDUCING COSTS AND INCREASING

PROFITS IN MINI-PHARMACIES

This study identifies a number of factors, including inventory, location, and
staffing costs, which affect the profitability of mini-pharmacies operating in
CEMOPLAF's service delivery points (SDPs) in Ecuador. Mini-pharmacy
managers are using study results to increase profitability and reduce costs.


BACKGROUND
As part of sustainability activities, 16 CEMOPLAF clinics opened mini-pharmacies
("Botiquines") to sell medications at slightly less than commercial pharmacy
prices, but at a price higher than product cost. Local managers make all
decisions related to mini-pharmacies, including their location, product line, and
selection of wholesaler. Although they are open to the general public, the majority
of clients are CEMOPLAF patients, because the pharmacies are located inside
the SDP CEMOPLAF, with assistance from the Population Council's INOPAL
Project and Family Health International (FHI), conducted a study of 13 mini-
pharmacies to identify factors contributing to their profit or loss. All 13 had been
operating a minimum of one year. Cost and income data were examined for the
first six months of 1995.


FINDINGS


Overstock
* Overstock was the
managerial factor that
most affected variation in
profits (losses). Supplies
that were sold generated
a profit of 24.7 percent
versus their costs. The
cost of supplies plus
overhead versus income
from sales suggests mini-
pharmacies more or less
break even (0.6 percent
profit). When the cost of
overstock is included in
the calculation, however,
the mini-pharmacy results


PROFIT/LOSS MARGIN BY COSTS INCLUDED IN ECUADOR
Profit/loss as percent of cost
30%


20%


10%

0.6%


0%


Supplies


Source: Pinto etal., 1995


in a loss of close to 4 percent.


* Mini-pharmacies mainly stocked items prescribed to clients using
CEMOPLAF services. Eleven of the thirteen mini-pharmacies were
overstocked on at least one item, and the value of overstock ranged from
between US$9 and US$174.


Supplies & Supplies, Overhead
Overhead & Overstock


- --- ~ I


r








* Levels of excess inventory ranged from less than one month supply to several years
at current sales levels.

* If overstock were eliminated, the current monthly loss would be reduced by 21
percent. Reducing inventory below three-month levels would further decrease losses.

* The maximum amount of monthly overstock that a clinic may have on hand and still
break even is US$4 worth of overstock. Every additional dollar in inventory over the US$4
cut off point increases monthly loss by 23 percent.

Profitability
* Average monthly sales in all 13 mini-pharmacies during the study period were
US$18,560. Average monthly costs were estimated at US$19,525, resulting in an average
monthly loss of US$965, or almost 5 percent. Only three mini-pharmacies made profits
(between 2.5 and 2.6 percent per month). Losses in the remaining mini-pharmacies
ranged from less than 1 percent to over 27 percent.

* Fixed costs averaged 20 percent of income. Only mini-pharmacies where fixed
costs were less than 20 percent of income were profitable. Salaries were the largest fixed
cost element, accounting for over 64 percent of total fixed costs.


UTILIZATION OF RESULTS
* Based on study results, some clinics are working to increase their profitability by
reducing mini-pharmacy staff, and all clinics began reducing inventory.

* Managers are attempting to improve income generation by adding higher profit
product lines on a trial basis and selling them at current market prices.


Pinto, Ernesto, John Bratt, Carlos Rivas, Fanny Simbatia, Ana Ilbay, Maria Rosa Garate, and James Foreit. 1995. Investigation Operativa:
Generacion de Costos e Ingresos en Mini Farmacias. Quito: CEMOPLAF, Family Health International and the Population Council. June.
For more information or to receive a copy of the report, please contact Krishna Roy, Program Manager, INOPAL III, Population Council,
4201 ConnecticutAve, NW Suite 408, Washington, DC 200008, USA, Tel: (202)237-6455, Fax: (202)237-6458, E-mail: inopal@pcdc.org.
This project was supported by the Population Council's INOPAL Ill Project. INOPAL III is funded by the U.S. Agency for International
Development (USAID), Office of Population, under Contract No. CCP-C-00-95-00007-00, Project No. 936-3030, Strategies for Improving
Family Planning and Reproductive Health Service Delivery. This study was conducted under the Ecuador Buy-In, Contract No. CCP-3030-
0-00-5008-00.
January 1998











INCREASING PRICES WHILE MINIMIZING
CLIENT LOSS

A study of the effect of price on demand for services (elasticity of demand)
in Ecuador suggests that many family planning/reproductive health (FP/RH)
organizations in Latin America have been setting the prices of their services
unnecessarily low. Results suggest that price increases of 50 percent will
only result in a 7 percent client loss.

BACKGROUND
NGO reproductive health providers in Latin America face reductions in donor
funding. The Centro Medico de Orientacion y Planificacion Familiar (CEMOPLAF)
in collaboration with the Population Council's INOPAL Project, The Futures Group
International (POLICY Project), and Family Health International, launched a price
elasticity of demand (PED) study that tested a simple low cost survey
methodology to measure consumer willingness-to-pay (WTP) for FP/RH services.
The study also determined the price elasticity of demand for CEMOPLAF's
services; and helped the organization understand how it might recover costs and
increase financial sustainability while minimizing the loss of poor clients. Most
clients who could not afford CEMOPLAF's prices would have to rely on Ministry
of Health services. In the first stage, the study interviewed 5,000 clients to
determine their ability to pay for services and their willingness to pay a
hypothetical increase for a given service. The study then measured client reaction
to three levels of price increases at three groups of service delivery points
(SDPs), and compared this data with that of the survey.

FINDINGS
* At the time of the survey,
the average price that PREDICTED PRICE-REVENUE RELATIONSHIP
CEMOPLAF charged for an OB/ FOR OB/GYN CONSULTATIONS IN ECUADOR
CEMOPLAF charged for an OB/
GYN consultation was about 25000
US$4 (Sucres 9,114). The price OUT OF SAMPLE-
range for a consultation among 20000
all SDPs was between $2
and $10. 15000
a 10000
* The predicted price- 1 0cc
revenue relationship for OB/ 5ooo
GYN services shows that
raising prices within the Sucre .__
5,000 to 10,000 range (US $2- 20000 40000 60000 80000 100000
10), will yield higher revenues Average current price= S. 9,114 Price
because the price increment
will offset any corresponding Source:Brattetal., 1997
decline in utilization.


p ei i.e I









* Over 80 percent of the survey respondents expressed a willingness to pay prices
that were, on average, 50 percent higher than current service prices. Over half were willing
to accept prices that were double what they were currently paying. These acceptance
rates are consistent across the different services offered at the SDPs.

* The study found that a CEMOPLAF clinic that charges $4 for an OB/GYN
consultation could raise prices to the revenue maximizing $10, thus increasing revenues
by 85 percent, but would lose over a quarter of its clients as a result. Raising prices and
increasing revenue by 40 percent, however, leads to a loss of only 7 percent of users.

Implications of Findings
* At the extremes, a program can set prices either to maximize revenue or minimize
client loss. Between these two extremes, however, are a multitude of other prices, each
associated with a different degree of client loss and revenue increase. Using information
from price-revenue and price-utilization relationships, program managers can compare
revenue increments and client losses associated with each pricing option available to them
and make pricing decisions that balance the multiple objectives of their organization.

UTILIZATION OF RESULTS
* The project continues to investigate whether client responses to survey questions
administered prior to the increase reliably predict the price elasticity of demand (PED) for
FP/RH services.

* CEMOPLAF is convoking a meeting of SDP managers to discuss project results
and set price increases.

* APROFE, Ecuador's largest NGO service provider, will replicate the study in its SDPs.


Bratt, John, Jim Foreit, and Dan Kress. 1997. Price Elasticity of Demand for Reproductive Health Care in Ecuador Quito: CEMOPLAF,
Family Health International, The Futures Group International, and the Population Council.
For more information or to receive a copy of the report, please contact Jim Foreit, Director INOPAL III, Population Council, 4201
ConnecticutAve, NW, Suite 408, Washington, DC 20008, USA, Tel: (202)237-6455, Fax: (202)237-6458, E-mail: inopal@pcdc.org.
This project was supported by the Population Council's INOPAL III Project. INOPAL II Is funded by the U.S. Agency for International
Development (USAID), Office of Population, under Contract No. CCP-C-00-95-00007-00, Project No. 936-3030, Strategies for Improving
Family Planning and Reproductive Health Service Delivery and The Futures Group International Policy Project, funded under USAID
Cooperative Agreement No. CCP-3078-C-00-5023-00. Additional funding was provided under Family Health International's Contraceptive
Technology and Family Planning Research Program, Cooperative Agreement No. CCP-3079-A-00-5022-00.
January 1998











MEASURING COSTS OF PROVIDING
INTEGRATED REPRODUCTIVE HEALTH
SERVICES

This study in the Guatemala Ministry of Health demonstrates that the cost of
providing integrated reproductive health services can be greatly reduced
when more than one needed service is provided during the same visit. A job
aid helps providers determine what services the client needs.

BACKGROUND
The Guatemala Ministry of Health's service delivery points (SDPs) provide family
planning, perinatal care, well child services, and vaccinations; and promote
breastfeeding. Currently, most women receive only one service when they visit an
SDP, even though they may actually require more than one. This study tested a
methodology for increasing the number of preventive reproductive health care
services provided per visit in Ministry of Health (MOH) facilities in two
Guatemalan departments (Quezaltenango and San Marcos). The goal of this cost
analysis study was to measure the marginal costs of providing additional
services required by women attending health posts and health centers of the
Ministry of Health of Guatemala. The MOH carried out the study with assistance
from the Population Council's INOPAL Project. The intervention is a job aid, used
by the provider while interviewing the client, which prompts the provider to ask
questions that elicit information on the need for other services.

FINDINGS
N As expected, the
program cost of providing ESTIMATED TOTAL COST OF SERVICES PROVIDED
SEPARATELY VERSUS COMBINED IN HAITI
more than one service per Cost in US$
client visit is considerably 40
less than the costs of
$32.8
providing the services
singly, at different visits.
For example, if provided $21.5
separately, postnatal and 20 $19
family planning services -
cost US$32.60. If$4
provided together, they 10
cost US$19. Similarly, the
cost of providing well
child services and 0 -
vaccinations separately Seperate Combined Seperate Combined
cost US$21.50, while Source: Brambila etal, 1997
integrating the services
costs US$14.




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