Elements of Family Planning Success

This bulletin shares findings from recent assessments of national effort on family planning, maternal and neonatal health and HIV/AIDS. Highlights from this issue include: Composite Indices to monitor national program efforts are now available for family planning, maternal and neonatal health, and AIDS. Composite national indicators have commonly been used for international comparisons in many social and economic fields (e.g., Human Development Index, economic indices). A solid research foundation is necessary to enhance the credibility and long-term utility of national composite indices. The Family Planning Effort Index has been successfully used for three decades, and five global rounds of data collection have shown gradual improvement over time. A Maternal and Neonatal Program Effort Index has been developed and was used in 49 countries in 1999. An AIDS Program Effort Index aims to measure political commitment and program effort in HIV/AIDS and is likely to play an important role in monitoring global and national efforts to expand the response against AIDS. (excerpt)

Evaluation findings from a particular setting need to be generalized into policy implications if they are to find widespread use. Skilled attendance at delivery is widely regarded as one of the most important intervention strategies for safe motherhood in low-resource settings, particularly in Africa, but implementations of such strategies are often not rigorously evaluated or interpreted into future policy. Initiative for Maternal Mortality Programme Assessment (Immpact) has applied a package of research-based monitoring and evaluation tools to assess the Family Care International Skilled Care Initiative in Ouargaye District, Burkina Faso. This evaluation research aimed to generate reliable, evidence-based policies for accelerating safe motherhood programmes in Burkina Faso and elsewhere in Africa. Five policy priorities were identified as representing real chances of improving the safety of motherhood: (1) enhancing national coverage of delivery by professionally skilled attendants; (2) to provide a network of 24-h basic emergency obstetric care within 5 km; (3) to have an effective referral system, equipped and resourced to undertake a reasonable number of Caesarean sections; (4) to promote community mobilization activities as a lever to increasing delivery care utilization; and (5) to implement strategies to remove financial barriers to delivery care. To meet Millennium Development Goal five by 2015, both supply and demand side constraints on the provision of quality maternity care have to be addressed, which in turn need greater political commitment and funding. (author's)

This detailed report presents the major findings of the 2006-07 Swaziland Demographic and Health Survey (2006-07 SDHS). The 2006-07 SDHS is the first survey of its kind to be undertaken in Swaziland. It was a nationwide survey aimed at generating estimates at the country level, regional level, and for urban and rural areas. The survey was commissioned by the Ministry of Health and Social Welfare and implemented by the Central Statistical Office. Fieldwork was carried out between July 2006 and March 2007. The primary objective of the 2006-07 SDHS was to collect up-to-date information for policymakers, planners, researchers, and programme managers that would provide guidance in the planning, implementation, monitoring and evaluation of population and health programmes in Swaziland. Specifically, the 2006-07 SDHS collected information on fertility levels, marriage, sexual activity, fertility preferences, awareness and use of family planning methods, breastfeeding practices, nutritional status of women and young children, childhood and maternal mortality, care and protection of youth, and awareness and behaviour regarding HIV/AIDS and other sexually transmitted infections (STIs). In addition, it collected information on malaria, the use of mosquito nets, and the prevalence of HIV in the population age two years and above. (excerpt)

Alternative strategies to increase access to reproductive health services among internally displaced populations are urgently needed. In eastern Burma, continuing conflict and lack of functioning health systems render the emphasis on facility-based delivery with skilled attendants unfeasible. Along the Thailand-Burma border, local organisations have implemented an innovative pilot, the Mobile Obstetric Maternal Health Workers (MOM) Project, establishing a three-tiered collaborative network of community-based reproductive health workers. Health workers from local organisations received practical training in basic emergency obstetric care plus blood transfusion, antenatal care and family planning at a central facility. After returning to their target communities inside Burma, these first-tier maternal health workers trained a second tier of local health workers and a third tier of traditional birth attendants (TBAs) to provide a limited subset of these interventions, depending on their level of training. In this ongoing project, close communication between health workers and TBAs promotes acceptance and coverage of maternity services throughout the community. We describe the rationale, design and implementation of the project and a parallel monitoring plan for evaluation of the project. This innovative obstetric health care delivery strategy may serve as a model for the delivery of other essential health services in this population and for increasing access to care in other conflict settings. (author's)

This detailed report presents the major findings of the 2006-07 Swaziland Demographic and Health Survey (2006-07 SDHS). The 2006-07 SDHS is the first survey of its kind to be undertaken in Swaziland. It was a nationwide survey aimed at generating estimates at the country level, regional level, and for urban and rural areas. The survey was commissioned by the Ministry of Health and Social Welfare and implemented by the Central Statistical Office. Fieldwork was carried out between July 2006 and March 2007. The primary objective of the 2006-07 SDHS was to collect up-to-date information for policymakers, planners, researchers, and programme managers that would provide guidance in the planning, implementation, monitoring and evaluation of population and health programmes in Swaziland. Specifically, the 2006-07 SDHS collected information on fertility levels, marriage, sexual activity, fertility preferences, awareness and use of family planning methods, breastfeeding practices, nutritional status of women and young children, childhood and maternal mortality, care and protection of youth, and awareness and behaviour regarding HIV/AIDS and other sexually transmitted infections (STIs). In addition, it collected information on malaria, the use of mosquito nets, and the prevalence of HIV in the population age two years and above.

The objective was to assess whether there were improvements in client perceptions of the quality of care received at clinics that were part of the Sewa (Nepali for "care") franchise network; an increase in reproductive health visits occurred at the Sewa clinics The Commercial Market Strategies project implemented a pilot network of private-sector nurses and paramedics in Nepal. Network activities began in April 2001. Franchisees were given basic reproductive health training for seven days. In addition, a two-day training was given on services marketing, which included the use of interpersonal techniques to develop trust and loyalty among clients. Sewa clinics were supported by a referral mechanism and were supplied subsidized family planning products. External-marketing activities, such as mass media promotions, began only two weeks prior to the second-round survey, because of political unrest and associated delays in implementation. Two rounds of surveys were conducted with clients who exited franchise clinics. The first-round exit survey was conducted in March 2001. The second round was conducted in February and March 2002. Logistic regression analysis was used to assess changes in clients' perceptions of the quality of care they received. Clients' perceptions of the quality of services improved after the intervention. The proportion of women who visited for reproductive health reasons was also higher in the second round. The latter suggests that a larger number of reproductive health clients visited clinics in round two. Better-educated women were more likely to make a reproductive health visit in round two as well. The greater likelihood of educated women making a reproductive health visit at round two was explained by an improvement in their perception of service quality. In round two, because of the delay in the implementation of external marketing activities, most clients were not aware that the provider was a member of the Sewa network. Those clients who were aware, however, were significantlymore likely to make a reproductive health visit. The Sewa franchise has made progress in increasing the availability, perceived quality, and use of reproductive health services. These improvements appear to be related to provider training on building relationships with clients. Clients' limited awareness of the Sewa franchise brand name, however, suggests that providers have not received the full benefits of belonging to a franchise. A stronger marketing effort that increases client volume is likely to lead to the strengthening of the Sewa franchise. (author's)

The in vitro activities of artemisinin, dihydroartemisinin (the biologically active metabolite of artemisinin derivatives), chloroquine and pyronaridine were assessed in 32 isolates of Plasmodium falciparum from Abobo in the northern of Abidjan district (Cote d'Ivoire) using a test based on the standard microtechnique recommended by the World Health Organization (WHO). The parasites densities were ranged between 8,000 and 540,000 rings/microl of blood. The geometric means 50% inhibitory concentration (GMIC50) values for chloroquine, pyronaridine and artemisinin were 145.5 nM (95% confidence interval (CI) = 65-226 nM), 17.69 nM (95% CI = 9.1-26.3 nM) and 5.72 nM (95% CI = 2.3-9.1 nM), respectively. Dihydroartemisinin was the most potent drug against chloroquine-sensitive and chloroquine-resistant isolates with a geometric mean of 2.72 nM. There was no correlation between the parasite densities and the responses to chloroquine (r/2 = 0.01, p less than 0.5), pyronaridine (r/2 = 0.13, p less than 0.05), artemisinin (r/2 = 0.13, p less than 0.05) and dihydroartemisinin (r/2 = 0.07, p less than 0.1). (author's)

Many governments have implemented conditional cash transfer (CCT) programmes with the goal of improving options for poor families through interventions in health, nutrition, and education. Families enrolled in CCT programmes receive cash in exchange for complying with certain conditions: preventive health requirements and nutrition supplementation, education, and monitoring designed to improve health outcomes and promote positive behaviour change. Our aim was to disaggregate the effects of cash transfer from those of other programme components. In an intervention that began in 1998 in Mexico, low-income communities (n=506) were randomly assigned to be enrolled in a CCT programme (Oportunidades, formerly Progresa) immediately or 18 months later. In 2003, children (n=2449) aged 24-68 months who had been enrolled in the programme their entire lives were assessed for a wide variety of outcomes. We used linear and logistic regression to determine the effect size for each outcome that is associated witha doubling of cash transfers while controlling for a wide range of covariates, including measures of household socioeconomic status. A doubling of cash transfers was associated with higher height-for-age Z score (beta 0.20, 95% CI 0.09-0.30; p less than 0.0001), lower prevalence of stunting (-0.10, -0.16 to -0.05; p less than 0.0001), lower body-mass index for age percentile (-2.85, -5.54 to -0.15; p=0.04), and lower prevalence of being overweight (-0.08, -0.13 to -0.03; p=0.001). A doubling of cash transfers was also associated with children doing better on a scale of motor development, three scales of cognitive development, and with receptive language. Our results suggest that the cash transfer component of Oportunidades is associated with better outcomes in child health, growth, and development. (author's)

The 2003 urban NGO Service Delivery Program (NSDP) evaluation survey assessed the urban component of the NSDP program in terms of delivering an Essential Service Package (ESP) of primary health care interventions to under-served urban populations of Bangladesh. The survey's main objective was to collect information about knowledge, awareness, and use of services related to family planning and maternal and child health provided through the NSDP project and its alternatives. Part of a continuing evaluation that began with a 1998 baseline survey and a 2001 midproject impact evaluation, the 2003 survey was conducted by Mitra and Associates with technical assistance from the MEASURE Evaluation project at the University of North Carolina at Chapel Hill. Data were collected from 5,691 women in urban areas served by the NSDP and from 4,201 women in non-NSDP urban areas. (excerpt)

The 2003 Rural NGO Service Delivery Program (NSDP) Evaluation Survey in Bangladesh provides data to evaluate the rural component of the NSDP, a four-year health and population project funded by the U.S. Agency for International Development (USAID). It provides information on the use of Essential Service Package (ESP) components for 7,507 women in NSDP project areas and 4,372 women in non-NSDP areas, including utilization of services at the NSDP network of facilities (static and satellite clinics, and depotholders) and alternative providers, knowledge of health promotion behaviors, awareness of NSDP services, and the quality of treatment at NSDP clinics. The survey, part of a continuing evaluation that began with a baseline survey in 1998 followed by a mid-project evaluation survey in 2001, was conducted by Associates for Community and Population Research (ACPR), a Dhaka-based research firm, with technical assistance from the MEASURE Evaluation project at the University of North Carolina at Chapel Hill. To assess changes in behaviors and outcomes, an effort was made to utilize the same clusters as the 2001 survey. However, substantial changes in the project catchment population occurred between 2001 and 2003 (including the departure of BRAC and expansion into new areas), complicating straightforward comparison of indicators across the two surveys. Accordingly, a separate chapter focuses on a sample of common clusters (ie those appearing in the 2001 and 2003 samples). (excerpt)

Project HOPE has been implementing a five-year Jinotega Child Survival Project (JCSP) since 2002, aimed at improving the health status of children under five and women of reproductive age in the Department of Jinotega, Nicaragua. The focus has been on rural populations, including those working on coffee plantations. The main partners in implementation are the Ministry of Health (MOH) at the Departmental level (SILAIS), Health Centers/Posts, and private sector coffee growers. Specific program health interventions and level of effort include the following: maternal and newborn care (30%), nutrition/micronutrient deficiencies (13%), breastfeeding promotion (10%), control of diarrheal disease (15%), pneumonia case management (10%), immunization (7%), child spacing (10%), and HIV/AIDS/STIs (5%). The proposed interventions focused on the MOH's PROCOSAN initiative, which is a program based on community growth monitoring. This initiative incorporates IMCI; community-based family planning, Life Saving Skills training, Birth Planning for health facility staff and community volunteers, and strengthening the Health systems and quality of care. The project focus was to strengthen the SILAIS and all health units within the department. The target population was identified as the entire population of Jinotega, totaling 62,451 children under five and 67,461 women of reproductive age living in approximately 750 villages (129,912 total beneficiaries). All MOH health facility staff have been involved in institutional strengthening activities, but the CSP selected 80 priority communities where the project would provide more direct support to community based activities on a monthly basis. (excerpt)

The DELIVER project carried out by JSI in Honduras benefited in particular the Ministry of Health (MOH) and the Honduran Family Planning Association (ASHONPLAFA). DELIVER's main accomplishments were the development of local capacity to plan procurement that uses logistics information from family planning activities, the development of software for managing inventories and logistics management information for the MOH, and the formation and consolidation of the Contraceptive Security Committee and the contraceptive security (CS) national strategy, which involved a variety of national stakeholders and was ratified by the MOH. DELIVER also helped ASHONPLAFA strengthen its logistical process in the areas of storage and distribution as well as in the use of PipeLine software to produce its contraceptive procurement tables and strengthen the procurement process. Among other things, the most important achievement is the recognition and application of the CS national strategy, which is demonstrated by the routine functioning of the inter-institutional CS Committee, and the purchase of contraceptives with national funds, thus fulfilling the agreement reached with the U.S. Agency for International Development/Tegucigalpa to gradually increase funding from the national treasury to meet contraceptive needs. A foundation has been laid to incorporate other institutions into the CS process in the future by including them on the CS Committee. (author's)

During 1982-1992, the Maternal and Child Health Family Planning (MCH-FP) Extension Project (Rural) of International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), in partnership with the Ministry of Health and Family Welfare (MoHFW) of the Government of Bangladesh (GoB), implemented a series of interventions in Sirajganj Sadar subdistrict of Sirajganj district. These interventions were aimed at improving the planning mechanisms and for reviewing the problem-solving processes to build an effective monitoring system of the interventions at the local level of the overall system of the MOHFW, GoB. The interventions included development and testing of innovative solutions in service-delivery, provision of door-step injectables, and strengthening of the management information system (MIS). The impact of an in-built monitoring system on the overall performance was assessed during the period from June 1995 to December 1996, after the withdrawal of the interventions in 1992. The results of the assessment showed that Family Welfare Assistants (FWAs) increased household-visits within the last two months, and there was a higher use of service-delivery points even after the withdrawal of the interventions. The results of the cluster surveys, conducted in 1996, showed that the selected indicators of health and family-planning services were higher than those reported by the Bangladesh Demographic and Health Survey (BDHS) 1996-1997. During June 1995-December, 1996, the contraceptive prevalence rate (CPR) increased by 13 percentage points (i.e. from 40% to 53%). Compared to the national CPR (49%), this increase was statistically significant (p less than 0.05). The in-built monitoring systems, including effective MIS, accompanied by rapid assessments and review of performance by the programme managers, have potentials to improve family planning performance in low-performing areas. (author's)

This guide is designed to help family planning champions-including civil society and NGOs, international and donor organizations, and interested government officials-and other stakeholders promote the inclusion of family planning issues and programs into Poverty Reduction Strategy Papers (PRSPs). Countries prepare PRSPs to qualify for loans and debt relief from the World Bank and International Monetary Fund (IMF). As a condition of receiving assistance, the PRSPs must outline the macroeconomic and social policies countries will adopt to alleviate poverty and, ultimately, accelerate progress toward meeting the Millennium Development Goals (MDGs). From the perspective of family planning advocates, the PRSPs can demonstrate the government's commitment to devise, fund, and implement family planning initiatives. From the perspective of governments and PRSP planners, satisfying unmet need for family planning is an innovative approach for reducing poverty that can help countries more easily achieve a range of socioeconomic goals. (excerpt)

The focus of the activities of ICDDR,B in Chakaria has been to facilitate local initiatives for the improvement of health of the inhabitants in general, children, women, and poor in particular. Thus, the activities of the project have been participatory with emphasis on empowering the people by raising awareness about health, inducing positive preventive behavior through health education, and providing technical assistance to any health initiatives taken by the village-based indigenous self-help organizations. Some major initiatives taken by the villagers included assessment of health needs, defining actions for health, implementing them, and monitoring their implementation and outputs. Among the health-related activities, identification of volunteers for health education, mobilizing local resources for the establishment of village health posts and their management, introduction of a pre-paid family health card, and establishment of health cooperatives have bee the major ones. (excerpt)

From a representative sample of men and women in the COMPASS Project target areas, the survey teams collected information on the respondent's background, contraception use, pregnancy status and history, antenatal care, breastfeeding activities, childhood illnesses, use of mosquito nets, childhood vaccinations, home-based disease prevention practices, and educational status of children living in the household. The objective of this report is to present a second set of estimated values for a set of indicators used by COMPASS and USAID/Nigeria for monitoring program performance. Data from the baseline surveys will be compared to the midline survey results to set program targets, as well as to measure changes in indicators resulting from the COMPASS Project's interventions. Part I describes survey objectives and methods, and provides background information about the sample. Part II presents results from the household survey; Part III presents results from the health facility survey; and Part IV presents results from the headmaster and teacher surveys within primary schools located in project LGAs in the States of Kano, Lagos, and Nasarawa. Appendix A lists USAID and COMPASS estimated indicator values and definitions. Appendix B lists the LGAs where the COMPASS Project is working. Appendices C-F are the survey instruments, and Appendix G lists the data collectors and supervisors who implemented the midline surveys. (excerpt)

This guide is organized into three parts. The first part provides an overview of the guide, including its organization, development and purpose. The second part consists of technical information, including a brief process by which integrated PHE program managers can develop an M&E plan, types of evaluations, a list of generic monitoring and evaluation terminology, and the major data sources from which the indicators in this guide are drawn. This section also includes guidance on the importance of assessing data quality. The section on data sources should serve as a reference point for implementation of the indicators. The third part contains the indicators themselves, which are divided by technical area: population, health, environment, and indicators of integration, and value-added. Each indicator description contains the definition, disaggregates (if appropriate), a time frame, data sources and collection considerations, as well as strengths and weaknesses. Programs should define and measure indicators in the same way. This allows for comparison across countries and programs. The use of comparable measures can also provide international programs with valuable measures of the same indicator in different populations and habitats, enabling triangulation of findings and regional or local differences to be addressed. (excerpt)

The Implementing AIDS Prevention and Care Project (IMPACT) in Mexico provided technical assistance to build the capacity of Mexican institutions and organizations to develop and implement HIV/AIDS prevention activities. This included behavior change communication (BCC) initiatives, developing national sexually transmitted infection (STI) guidelines, improving STI services, enhancing STI/HIV/AIDS prevention and care, developing NGO capacity to implement activities, strengthening monitoring and evaluation (M&E) capabilities, and conducting applied research. As part of this effort, IMPACT collaborated with the National AIDS Program (Centro Nacional para la Prevencion y Control de VIH/SIDA/ITS or CENSIDA), the National Public Health Institute (Instituto Nacional de Salud Publica or INSP) and other key stakeholders to train health personnel, conduct workshops, and respond to the HIV/AIDS epidemic in Mexico. Project activities focused on reaching high priority populations at greatest risk for acquiring and transmitting HIV. These populations included commercial sex workers (CSWs), men who have sex with men (MSM), injection drug users (IDUs), youth, mobile populations, and persons living with HIV/AIDS (PLHA). The activities included a behavior change communication (BCC) and prevention project implemented by INSP targeting mobile populations in Mexico and the countries of Central America. Also, a formative study was done in collaboration with Colectivo Sol, a local research organization, among youth MSM ages 15 to 24 to serve as a guide for developing HIV prevention interventions. (excerpt)

If India is to reach the Millennium Development Goals to reduce child mortality, eradicate hunger, and promote gender equality, innovative policy solutions are urgently needed as economic growth and overall poverty reduction alone will not be enough. This paper evaluates an attempt in Andhra Pradesh to improve the outreach, quality and accountability of educational, health and Early Childhood Development services by involving parents closely in their monitoring and management. Participatory Education Committees and Mothers' Committees were established in the context of a growing consensus in national and international policy circles that decentralization and community participation are critical for improved coverage, responsiveness and quality of public services. (author's)

There are currently a large number of indicators being collected and used in the health system. Some of these are based on surveys carried out in selected public health facilities such as the annual antenatal HIV prevalence survey. Others are based on community surveys such as the 5 yearly demographic and household survey which assists in the estimation of infant mortality rates. Other indicators are based on research such as the measurement of client satisfaction at hospitals. A large number of indicators are also calculated from the collection of routine data at facility level. Out of all of these facility-based indicators, ten of the most important have been selected for more in depth discussion in this document. This is done in an attempt to assist managers at all levels of the health system, from facility managers to programme managers at the national Department of Health, to use these indicators as a management tool to improve planning, implementation and monitoring of health services. (excerpt)