Advancing Sexual and Reproductive Health and Rights
 
International Family Planning Perspectives
Volume 27, Number 3, September 2001

The Family Planning Program Effort Index: 1999 Cycle

By John Ross and John Stover

Context: Indices of effort by large-scale family planning programs have been measured periodically since 1972. These scores are intended to capture program effort or strength, independent of outputs such as contraceptive use or fertility change.

Methods: Questionnaires were sent to expert observers who provided judgments on the details of program effort for 89 developing countries. The responses for each country were converted to scores for 30 program features, which were then grouped into four components of program effort. An overall program effort index was calculated as the sum of all 30 feature scores.

Results: The average program effort index was higher in 1999 (54% of the maximum possible score) than in 1994 (48% of maximum). Countries with low scores in 1972 improved considerably more than those with initially high scores; by 1999, the gap between these two groups was small. On average, strong and weak programs differed sharply in their score profiles; strong countries outscored weak ones in every feature category. All countries, regardless of their average score, were selective in the program features they emphasized, but weak programs were more erratic in their selectivity. The strongest programs have stabilized at about 80% of the maximum score. Prevalence of contraceptive use continued to be highest for countries possessing both favorable social settings and strong programs.

Conclusions: Many developing countries have expanded their reproductive health programs in accordance with recommendations issued by the 1994 International Conference on Population and Development. The improved program effort index and scores for 1999 suggest that countries have been able to do so without seriously weakening their family planning efforts.

International Family Planning Perspectives, 2001, 27(3):119-129

The Family Planning Program Effort Index was begun around 1970, when many developing countries had established large-scale programs to reduce fertility or to extend contraceptive services and information for other reasons. Some of these programs existed in name only, while others were fully operational, covering a large proportion of the population in their respective countries.

In response to a growing belief that standard measures were needed to quantify the nature and strength of these efforts, Robert Lapham and W. Parker Mauldin1 assembled data on the programs and used a simple scale to rate them; they then created a set of indices to describe the types of program efforts and monitor change over time. Using data from a variety of countries, they were able to correlate these program inputs with outcomes such as contraceptive use and fertility change. Other researchers also used the indices for extensive analyses of program inputs and outcomes.2

Around 1980, Lapham and Mauldin developed the precursor of the current questionnaire. They identified a wide variety of program characteristics and included approximately 125 items in the questionnaire. In 1982, they sent the questionnaire to recipients in 93 countries,* whose responses were coded and combined to create a final set of 30 scores. The conversion rules for score creation and all other aspects of the methodology have since remained consistent, to maintain the accuracy of time trends. The 30 scores were further organized into four groups or components: policy and stage-setting activities; service and service-related activities; evaluation and recordkeeping; and availability of fertility control methods. Lapham and Mauldin published the results,3 relating the scores to contraceptive prevalence and fertility. Three more cycles of the questionnaire were conducted in 1989, 1994 and 1999, so that estimates are now available from five cycles over a 27-year period.

The index measures 30 features of program effort, each of which is meant to capture inputs independent of outputs such as contraceptive use or fertility change. This permits an examination of the relationship between effort and outcomes, while taking into account the levels and the 30 types of effort. The scores are also useful for diagnosing program weaknesses and detecting improvement over time. Two countries, Vietnam4 and Egypt,5 have adapted the scores to gauge provincial differences in effort and to provide suggestions for administrative changes.

Earlier reports have summarized the extensive historical literature on this index since 1974;6 here we discuss only research that has appeared in the last 5-8 years. The scores have been used extensively to examine how program effort interacts with socioeconomic setting to increase contraceptive use and lower fertility. The vast majority of that work has been cross-sectional and has examined how much fertility decline has been due to effective family planning programs and to favorable socioeconomic conditions. However, the accumulation of score cycles over the decades has made it possible to do time-series analyses,7 which have found an appreciable program effect on fertility after controls for numerous social and economic factors were introduced. These studies also reviewed much of the technical literature regarding such calculations.8 Several methods have been employed repeatedly over the years.9

It has been argued that fertility change has been driven by shifts in desired family size rather than by the efforts of family planning programs.10 However an exploration of program effects upon fertility found that much of the disagreement concerning program effects disappeared when countries' scores were weighted by their respective population sizes (in which case the higher scores for some large countries raised the means).11 Furthermore, some program effects that had seemed modest and had not been expected to improve further after 1982 actually improved substantially, from an average score of 29% of the maximum to a score of 54%.

In recent years, program effort strength has continued to increase beyond the levels observed in earlier analyses,12 especially in countries where modernization has lagged. As a result, many analysts have shifted their attention away from confirming the existence of a program effect and toward examining the ways in which programs make their contributions and how those can be enhanced.

Also notable are the numerous documents that were published as part of the six-year EVALUATION Project. This body of work examined much of the research literature concerning program evaluation and made innovative use of the program effort index and scores; it included a major review of findings on how selected family planning programs have worked,13 an inquiry into methods used by programs to increase contraceptive use14 and a review of what programs do to reduce fertility rates.15

In another study, researchers used international data to create two scales, based partly upon the program effort scores, to estimate for most developing countries the sustainability of national family planning programs and of the fertility transition.16A wall chart containing tabular data for monitoring national family planning programs was also published in collaboration with the Population Reference Bureau; it displayed selected effort scores, along with numbers of facilities and personnel, ratios of staff to population, service types and per capita funding levels.17

In this article, we present the most recent data on family planning program effort, collected during 1999 from 374 informants in 89 countries. We examine regional patterns in program effort, contrast the stronger programs with the weaker ones and present time trends in various measures of program effort. Finally, we briefly analyze how levels of socioeconomic development and program effort are interrelated.

METHODOLOGY

In the 1999 assessment, the detailed questionnaire, printed in English, French, Spanish and Russian, was sent as in previous cycles to four types of expert respondents:

•government officials directly involved in the implementation of the program;

•donor personnel close to the program in agencies such as the United Nations Population Fund (UNFPA), the World Bank, the U.S. Agency for International Development (USAID) and various nongovernmental organizations, including some International Planned Parenthood Federation affiliates;

•citizens in the various countries who were familiar with the program but were not involved in policy or management; and

•foreigners who were closely familiar with the program.

The respondents did not know what items produced which of the 30 scores, nor did they know the weights involved in converting items to scores.

All questionnaire responses were entered into a computer, and a complex set of programming statements automatically converted the items to the 30 scores. Within each country, scores were averaged across all respondents after highly improbable outliers had been eliminated. The total program effort score is simply the sum of the 30 individual scores, as in the previous cycles. Subscores were also computed for the four program components mentioned earlier (policy, services, evaluation and fertility control method availability). The appendix gives a brief description of each score and groups them under the four component categories.

Each of the 30 scores ranges from zero to four, giving a maximum of 120 for the total effort index. The four components vary in the number of scores they encompass: eight for policy, 13 for services, four for evaluation and six for method availability; the maximum scores for these components are therefore 32, 52, 12 and 24, respectively. For ease of comparison, we give most results as a percentage of the maximum possible score (for example, a policy score of 25 becomes 25/32, or 78%.

A variable for level of social setting (i.e., social and economic development) is also included. As in earlier analyses,18 the social setting categories are based on an index composed of seven items: the proportion of adults who are literate; the primary and secondary school enrollment ratio as a percentage of those aged 5-19; life expectancy at birth; the infant mortality rate; the proportion of the male labor force that is doing nonagricultural work; the gross national product per capita; and the proportion of the population living in an urban setting.

We ranked countries on each item and calculated the index as the sum of the item ranks divided by seven; each country was then assigned to the high, upper middle, lower middle or low social setting category, according to quartiles. We also assigned countries to high, upper middle, lower middle or low program effort quartiles, using the average of their total program effort scores for 1994 and 1999.

RESULTS

Survey Responses

Eight months after the mailing of the questionnaire, 374 replies had been received from respondents regarding 89 countries, with a range of one to 12 per country and an average of 4.2 per country. The overall response rate was 49% from 758 names (more than were sought in the previous cycles). The final number of replies for the 1999 cycle was similar to that for previous years (359-433 respondents in about 95 countries).

Regional Patterns

Scores for all 89 countries in 1999 are presented in Table 1, which shows the program effort index (i.e., the total score) as well as the four component scores. Each score is cited as a percentage of the maximum; a score of zero signifies no effort and a score of 100 represents full effort. The total scores range from a low of 29 (for Venezuela) to a high of 86 (for China); the average program effort score for all countries in 1999 is 54. China, Indonesia, Taiwan, Vietnam, Thailand and Mexico, all of which are recognized for the strength of their family planning programs, have total scores of 75 or higher. These six countries, as well as others at the upper end of the range, generally score well on all four components.

At the lower end of the range, seven countries have total scores of 35 or less: Sudan, Congo, Gabon, Uruguay, Costa Rica, Argentina and Venezuela. Countries with low scores have varying program characteristics. Sudan, Congo and Gabon simply have extremely weak programs. Costa Rica has only a modest program, yet contraceptive prevalence is high and fertility is low, due to the favorable social setting and to contraceptive use outside of the program proper. Governments in Uruguay, Argentina and Venezuela have not implemented a formal outreach program to support contraceptive use.

Average scores for each region are shown by component in Figure 1 . The widest variation in scores clearly occurs in contraceptive method availability. Regions differ by only 15-20 points in the areas of policy, services and evaluation, but more than 50 points separate the region that is lowest in method availability (Francophone Africa) from the region that is highest (East Asia). Most regions now have positive policies in place, as well as programs containing important elements of service delivery and evaluation. However, the implementation of these programs, as represented by the availability of contraceptive methods, sharply differentiates the high-effort countries from the low-effort ones. A relatively full choice of methods is available to those living in most East Asian countries, whereas many programs in Sub-Saharan Africa provide more limited options and reach only certain segments of the population.

Latin America has the lowest regional scores for policy, services and evaluation. The low scores are probably due to a number of factors. Latin American countries originally developed family planning programs to improve maternal and child health, and never adopted the demographic rationale common to many countries in other regions. In addition, the private sector plays a much larger role in many Latin American countries than in other regions: Argentina, Uruguay and Venezuela all score quite poorly because of their lack of emphasis on public-sector programs to provide services, and their low scores pull down the regional average.

North Africa and the Middle East received the highest score for evaluation. It is not entirely clear why this is the case, but all respondents in the region except those for Yemen felt that these programs were strong in evaluation and recordkeeping.

Stronger and Weaker Programs

In previous rounds, programs were classified into four broad categories of effort based on the total score:

Program effort Total score % of maximum
Strong >=80 >=67
Moderate 55-79 46-66
Weak 25-54 21-45
Very weak/none 0-24 0-20

According to this classification, in the 1999 survey, 13 countries had a strong program, 53 had a moderate program and 23 had a weak program. No programs were classified as "very weak or none" in 1999.

Although these categories are somewhat arbitrary, they do separate programs into very different types. Figure 2 shows the average scores on all 30 features for the stronger programs (the 66 programs in the strong and moderate categories) and the weaker programs (the 23 programs classified as weak). The features within each component are arranged in descending order by the scores of the stronger countries. The stronger countries had higher average scores for every one of the 30 categories. Furthermore, the gap between the stronger and weaker countries is fairly consistent, with only a few exceptions (marriage age policy and abortion availability). As a group, the weaker countries need to improve in essentially all program features.

The weaker programs exert effort less evenly across the 30 feature categories than the stronger programs do. This is confirmed by the standard deviations across the scores (not shown), which are considerably greater for the weaker programs than for the stronger programs. However, even stronger programs vary in their relative emphasis of program features. It is possible that the conversion rules governing the questionnaire items and feature scores may contribute to this observed variability in both the weaker and the stronger programs.

Although weaker and stronger program profiles differ in the magnitude of their total scores and the variability of their individual feature scores, they are similar in the relative emphasis that they place on features within each of the four components (Figure 2). For instance, in the policy and stage-setting activities component, most countries in both groups score highest on items related to policies in place, lower on leadership levels and budget support, and most poorly on policies regarding age at marriage.

The services and service-related activities component also shows a similar pattern in both groups: a continuum from highly rated activities, such as completion of assigned tasks and training, to poorly rated ones, such as involvement of the civil bureaucracy, community-based distribution, home-visiting workers and the use of incentives and disincentives. Within the method availability component, both stronger and weaker programs judge condoms, pills and IUDs to be more available than sterilization and abortion, and male sterilization is clearly the least available method. The one exception is availability of abortion services, which scores higher relative to other methods in the weaker countries than in the stronger countries.

Time Trends

The average program effort index for all countries rose from 48 to 54 between 1994 and 1999, continuing a trend toward improvement observed in each of the previous cycles (Table 2). This 12% rise is substantial, about twice that observed from 1989 to 1994, but much less than the 55% jump that occurred between 1982 and 1989.

Although the global program-effort index has continued to improve, the scores of some countries, especially those with strong programs, have reached a plateau or even declined. Furthermore, when countries' scores are weighted by their respective populations, the improvement since 1972 is less dramatic. For instance, the rise in the unweighted average score from 20 in 1972 to 54 in 1999 corresponds to a much smaller increase in the population-weighted average, from 52 to 68 (not shown).

Temporal trends in the distribution of countries and population by program effort level appear in Table 3. When program effort was first assessed in 1972, many countries had no programs or policies at all. Of the 108 countries listed in Table 2, 42 received scores of zero in 1972. Overall, effort level in more than 60 countries was classified as very weak or none (Table 3). As more countries have worked over the years to institute and improve policies and programs, effort levels have improved dramatically. By 1999, no countries were classified as having a very weak or no program, and only 23 were considered weak; the majority of countries were classified as showing moderate program effort. There has been very little change over the years in the number of countries classified as having strong programs.

Temporal trends based on the total populations rather than on the number of countries present a more positive picture (Table 3). The strong category has remained the largest in every cycle because of China, and has continued to grow over time. While only 36% of the population lived in countries with strong programs in 1972, this percentage increased to 62% by 1982 and to 68% by 1999.

We established cohorts of countries according to their effort level in 1972 and followed them through time (Figure 3). The average program effort index for the strong cohort declined slightly in 1982 but has remained fairly consistent since then. The average total score for the moderate cohort increased slightly, from 53 in 1972 to 62 in 1999. The greatest change is seen in the weak and very weak or no effort cohorts, whose scores rose dramatically and had nearly converged with those of the stronger cohorts by 1999.

Regions differ in the degree of their improvement across program components. East Asia had the highest scores in the past, but in 1999 experienced a decline in all categories except method availability (not shown). The declines are mainly due to small decreases in China's scores and large decreases in those for the Republic of Korea, especially in the services component.§ South and Southeast Asia has shown steady improvement: By 1999, this region matched or exceeded East Asia in policies and services, but still lagged behind in method availability. Considerable improvement has occurred in North Africa and the Middle East for all four components. In Sub-Saharan Africa, there has been significantly less growth in method availability compared with the other three components: Although many of the policies, structures and programs are in place, implementation is still weak. Latin America showed improvement from 1972 to 1982, but its component scores have been more or less stable since then. In all regions, the average component scores conceal important differences among individual countries.

Program Effort by Social Setting

Researchers have used the Family Planning Program Effort Index since the 1970s to examine the effects of social and economic development and family planning effort on fertility decline and contraceptive use. Studies have generally found that program effort and social setting both play important, and roughly equal, roles in fertility decline. Figure 4 uses the 1999 scores to show how these two characteristics are associated with contraceptive use. Categories for social setting effort appear in the left-hand column, while those for strength of program are shown across the top row. (The cell value for each country is contraceptive prevalence as of 1999.)

The row and column averages indicate that contraceptive use is positively associated with both social setting and program effort. The average prevalence of contraceptive use is 65% among countries in the high quartile for social setting; prevalence declines to 53%, 36% and 16% as social setting declines to the upper middle, lower middle and low quartiles, respectively. A similar pattern is seen for program effort: Prevalence falls off from 60% in high-effort countries to 28­29% for the lower-middle and low-effort countries. The gradient is sharper and occurs over a greater range for social setting than for program effort, suggesting that the former exerts a more fundamental influence. The highest prevalence (73%) is found in the upper left-hand corner of the figure, where both social setting and program effort strength are high.

The findings of the cross-tabulation analysis in Figure 4 are supported by an ordinary least-squares multiple regression of social setting and family planning effort on prevalence, which confirms that both determinants have significant effects.** Thus, the 1999 results are consistent with the conclusions of other studies that family planning program effort, as measured by the program effort index, makes an important contribution to contraceptive practice independent of social setting.19

DISCUSSION

Use of Expert Respondents

The use of expert respondents to provide information has both advantages and disadvantages; one of the latter is the potential for bias. National respondents might exaggerate the strengths of a program; international respondents might be influenced by their knowledge of contraceptive prevalence and fertility trends, and give lower ratings to those programs that they perceive have performed worse.

The methodology contains a number of features designed to decrease respondent bias. Some items are factual rather than judgmental. Consulting four different types of respondents avoids overreliance on any single perspective on program effort. The questionnaire does not directly solicit a score for each of the 30 features; instead, it contains a large number of detailed closed-ended questions, which are later coded and combined to yield each score. Thus, the respondent does not provide the score directly, and does not know how each score is calculated. The mean of the respondents' scores is used because it is generally thought to be the most stable measure; however, when the standard deviation among responses is unusually high, the original questionnaires are examined in detail and improbable outlying scores are removed.

The small number of expert respondents per country, the unknown extent of variance among respondents, and changes in the respondent pool over time are also limitations of the survey methodology. The results would be more robust if, to reduce respondent variance, the same respondents could rate several countries, but that would be feasible for only a small number of respondents. Time trends would also be more precise if the same persons rated each country across cycles. However, considerable turnover of expert respondents is inevitable, especially over a span of five or more years.

Validity and Reliability

Tests of validity require a "gold standard" against which to compare an instrument's results. The program effort index has no single standard, as it encompasses several program features for which objective measures are unavailable, such as the adequacy of training and supervision, restrictions on contraceptive advertising, and strength of community-based distribution systems. The questionnaire, as used from 1982 through 1999, contains items of this type, as well as fairly objective measures for items like the formal policy of the government or the administrative level held by the program director, but checks on those cannot be done independently for many countries all at once.

A number of studies have assessed the validity and reliability of the program effort scores. One conducted in Kenya and Bangladesh compared scores obtained using the standard questionnaire and methodology with those obtained from direct measurement.20 Direct measurement activities included sampling print media and radio programs to assess the extent of mass media coverage and interviewing ministry representatives to assess the degree of multiministry involvement in the program. In both countries, the scores based on direct measurement were quite similar to those obtained using the questionnaire. The great amount of labor and time required to perform direct measurement of all 30 scores rules out the latter as a feasible alternative to an expert respondent-based methodology, especially for a large-scale data collection effort involving almost 100 countries. Attention therefore returned to the methodology of the standard questionnaire, to which informed respondents in each country can reply within a limited time span.

A second exercise to obtain a separate estimate for each feature score was conducted among the 89 participating countries in the 1999 cycle.21 The standard questionnaire was followed by a final section asking for a simple rating of each of the 30 features on a scale from one (very weak effort) to 10 (very strong effort). These directly solicited scores were generally in close agreement with the scores that had been calculated using the standard methodology; discrepancies in the scores were greatest where the wording of the questions differed significantly between the two methodologies.

Another important analysis applied factor analysis methods to the 30 feature scores obtained in the 1982­1994 cycles, thereby identifying six components that were predictive of strong family planning programs.22 The fact that these components remained relatively consistent across cycles argues in favor of the questionnaire's reliability.

The Family Planning Program Effort Index was developed from the concept of program effort or strength as input, which implies that a vigorous program should be placed at a high administrative level, should be supported by a firm government policy position, should have adequately trained and supervised staff, should make frequent and effective use of mass media, should undergo regular evaluation, should stimulate the private sector and should provide services to a large proportion of the rural and urban population. It is not possible to demonstrate the validity of this concept in a definitive fashion, nor can we conduct a test-retest reliability exercise in each cycle for such a large undertaking. However, the detailed patterns and trends over time make sense and correlate reasonably to outcome measures, for both individual countries and regions.

Future Directions

The program effort index has continued to rise in most developing countries during the last five years, but still leaves considerable room for further improvement. As of 1999, the average country score is only 54% of maximum; even the strongest programs have never risen much above 80% of maximum. Based on these results, one might ask how much further progress can reasonably be expected. If we use the 80% attained by the strongest programs as the standard rather than 100%, the average index of 54 in 1999 actually represents a more substantial two-thirds of maximum achievement.

The 1999 scores confirm earlier findings that family planning program effort makes an important contribution to contraceptive practice independent of social setting. Although many developing countries have improved their efforts remarkably over the past 25 years, they still differ significantly in the component for method availability. Progress has been least in the actual provision of contraceptive methods to the mass of the population. That appears to be more difficult than the development of policy positions or the implementation of training and supervision protocols; clearly, it is still a major task facing many family planning programs.

The upward movement in the program effort index since the International Conference on Population and Development held in Cairo in 1994 could not have been confidently predicted. Countries attending the conference had been urged to broaden their reproductive health programs to focus on issues other than contraception, and there was a possibility that this expansion might occur at the expense of their current programs. In addition, many countries had experienced fertility declines that might have tempted them to relax their policies and programs.

Some expectations of downward movement have been realized. Since 1994, the Republic of Korea's overall score dropped substantially. Taiwan has revised its antinatalist policy, and China's lower score in 1999 may reflect the liberalization of some aspects of its aggressive program. Singapore and Malaysia have weakened their policies, and in 1996 India revolutionized its target system by essentially canceling method-specific worker quotas. These changes may be too recent to have affected 1999 scores appreciably. However, the increase in the average 1999 index and scores suggests that countries have been able to expand programs to include other aspects of reproductive health without seriously weakening their family planning efforts.

While the present study serves as an important resource for family planning monitoring and analysis, it does not collect information on some of the key topics that emerged during and after the Cairo conference. The current questionnaire is already extensive, and the expertise of its respondents somewhat narrow. It would be cumbersome to expand the questionnaire into a multipurpose instrument and assemble different sets of respondents for different sections, so other sources of information are critical.

The Cairo mandates are being monitored internationally based on donor funding, which has been disappointingly low,23 and on conditions within the countries themselves. Some researchers are collecting time-trend information on the unmet need for and the intention to practice contraception;24 estimates of maternal mortality are also being refined.25 Three other activities related to Cairo priorities are underway. Levels and types of maternal and neonatal health program efforts are being measured in 49 countries, including China and India.26 HIV and AIDS program efforts in some 43 countries are also being evaluated.27 A five-part policy survey has been implemented in several countries to obtain a "policy environment score," which will measure strength at the policy level for family planning, safe motherhood, safe abortion, adolescent health, and HIV and AIDS.28 Over the next two years, more complete information regarding funding, family planning issues and specific elements of reproductive health should help to clarify the state of post-Cairo achievements.

APPENDIX

Policy and Stage-Setting Activities

(1) Government's official policy or position concerning fertility family planning and rates of population growth. Existence and type of official policy to reduce the population growth rate, support family planning activities for reasons other than demographic ones, allow private-sector family planning activities in the absence of government-sponsored activity, or, on the other hand, to discourage family planning services.

(2) Favorable statements by leaders. Whether the head of the government speaks publicly and favorably about family planning at least once or twice a year, and whether other officials also do so.

(3) Level of family planning program leadership. Level of the post (i.e., the person appointed) to direct the national government family planning program, and whether or not the program director reports to the highest level of government.

(4) Age-at-marriage policy. Minimum legal age at marriage for females of at least 18 years (higher scores for minimum legal ages of 19 years and 20 years or more), and the extent of effort to enforce any changes in the law since 1960 regarding legal age at marriage for females. (A score for the latter item is allowed only if the new legal minimum is at least 18 years.)

(5) Import laws and legal regulations regarding contraceptives. Extent to which import laws and legal regulations facilitate the importation of contraceptive supplies that are not manufactured locally, or the extent to which contraceptives are manufactured within the country.

(6) Advertising of contraceptives in the mass media is allowed. Whether the advertising of contraceptives in the mass media is allowed with no restrictions, whether there are weak restrictions, whether there are social restrictions, or whether there are strong restrictions.

(7) Other ministries or government agencies involved. Aside from the ministry or government agency that has primary responsibility for delivering family planning supplies and services, the extent to which other ministries and governmental agencies assist with family planning or other population activities. This involvement or assistance may be provided through the public sector or through private-sector family planning programs or population activities, and is classified as follows: assistance with the delivery of family planning supplies and services; assistance in the form of services particular to that ministry; assistance with family planning information and education in concrete ways; membership on a council for family planning that meets at least twice annually; moral support and small miscellaneous assistance; and no assistance.

(8) In-country budget for program. Percentage of the total family planning and population budget available from in-country sources. The top score is given if in-country sources provide 85% or more of the budget; no score is given if these sources provide less than 50% of the budget.

Service and Service-Related Activities

(9) Involvement of private-sector agencies and groups. Extent to which private-sector agencies and groups (including family planning associations) assist with family planning or other population activities. Involvement or assistance with family planning and population activities may include: delivery of family planning supplies and services; training; family planning information and education; membership in an interagency family planning group that meets at least twice annually; moral support; and other assistance.

(10) Civil bureaucracy used. Use of the civil bureaucracy of the government to ensure that program directives are carried out, and the extent to which the senior government administrators at the following levels assume responsibility for the success of the program: central government level; provincial or state level; district, governorate, regency or other levels; and county levels.

(11) Community-based distribution (CBD). Proportion of the country covered by public or private CBD programs for the distribution of contraceptives in areas not easily served by clinics or other service points. The essential feature of CBD is that contraceptive supplies are available upon request within the village, local community or local residence neighborhood. CBD programs are assumed to be primarily rural; however, a partial extra score is allowed for urban CBD programs.

(12) Social marketing. Proportion of the country covered by a social marketing program (i.e., subsidized contraceptive sales in the commercial sector). The essential feature of social marketing is that contraceptives are subsidized and sold at low cost, through channels easily available to rural or urban residents, such as in local shops, pharmacies or specially created local sales outlets. Some forms of social marketing are called commercial retail sales programs. Social marketing programs are assumed to be primarily urban programs; however, an extra score is allowed for rural programs.

(13) Postpartum programs. The extent of coverage of new mothers by postpartum programs, which may be hospital-based or field-based. (Most are field-based.) For hospital-based programs, the score is constructed from the proportion of deliveries in hospitals and maternity centers where the new mothers are provided family planning information and education services (by trained female workers), and the proportion of all deliveries in the country that take place in hospitals and maternity centers (often a small proportion). For field-based postpartum programs, the score is constructed from the proportion of women who deliver at home and are offered family planning information and education services by trained fieldworkers.

(14) Home-visiting workers. The proportion of the population covered by a group of workers whose primary task is to visit women in their homes (at least in rural areas) to talk about family planning and child care. The population covered by each fieldworker is taken into account; the score for the proportion of the country covered by fieldworkers is deflated if the average population covered by each home-visiting worker is more than 15,000.

(15) Administrative structure. Whether there is adequate administrative structure and staff at the national, provincial and county levels. "Adequate" means that the administrative structure is sufficient to ensure that plans developed for each level are carried out, is capable of recognizing and solving problems that cause low performance, and is able and willing to use existing resources or to call upon higher administrative levels to obtain resources needed to carry out plans for the delivery of family planning supplies and services.

(16) Training programs. Whether there is an adequate training program for each category of staff in the family planning program: administrative staff, physicians, nurses, paraprofessionals, village-level distributors, fieldworkers and motivators, staff in other ministries and organizations, and others. "Adequate" means that the training provides personnel with the knowledge, information and skills necessary to carry out their jobs effectively, and that facilities exist to carry out the training. The score is determined by the quality of the training program for each category of staff: very good; moderately good; mediocre or poor; or nonexistent.

(17) Personnel carry out assigned tasks. The extent to which each category of family planning program staff carries out assigned tasks: administrative staff; physicians; nurses; paraprofessionals; village-level distributors; fieldworkers and motivators; staff in other ministries and organizations; and others. The ratings for task implementation are: very well; moderately well; and poorly.

(18) Logistics and transport. The extent to which the logistics and transportation systems are sufficient to keep stocks of contraceptive supplies and related equipment available at all service points at all times, at the following levels: central; provincial; and county. The score is based on the availability of supplies and equipment: all or almost all of the time; about half to three-quarters of the time; sometimes; or seldom or never.

(19) Supervision. Whether there is an adequate system of supervision at all levels. "Adequate" means that: supervisors exist at all levels of program operations in sufficient numbers to make possible supervisory visits at least once a month at service delivery levels (and quarterly at higher administrative levels); supervisors do in fact make such supervisory visits to the work sites of the persons supervised; during these supervisory visits, encouragement, advice and support are provided to supervised workers, in addition to any necessary checking of operations and records that assist in the evaluation of worker performance; and supervisors follow through on providing and obtaining supplies and services identified as needed during their visits (or at least make serious attempts to obtain these needed supplies and services).

(20) Mass media for information, education and communications. The frequency of mass media messages that provide family planning information, including where family planning services are available and how much of the country is covered by various types of mass media: newspapers, magazines, radio, television, mobile information, education and communication units (films, etc.), billboards and other outdoor media (buses, etc.), traditional types (puppet shows, folk dances, local theater, etc.), and other types. The frequency classifications include: at least once a month; sometimes (about once every 3­6 months); infrequently (about once a year or less often); and never.

(21) Incentives and disincentives. The use of monetary or other incentives for the adoption of family planning. Incentives may be provided to clients, recruiters, service personnel (including CBD workers) or communities. Disincentives may refer to individuals or to communities, and include regulations and constraints designed to encourage family planning or small family size.

Evaluation and Recordkeeping

(22) Recordkeeping. Whether there are recordkeeping systems for family planning clients at the clinic level, a system for the collection and periodic reporting of summary statistics at regional and national levels (e.g., numbers of acceptors, quantity of supplies distributed, numbers of workers), and feedback from regional or national units to each reporting unit. The scoring takes into account both the existence and the quality of recordkeeping systems. "Feedback" refers to the reporting back to lower-level units on a regular basis, with progress measured against some standard, such as acceptance or prevalence targets or trends.

(23) Evaluation. Whether any of the following exist (partial score given for each): regular estimation of prevalence levels and trends (annually or quarterly), using program statistics and estimated continuation rates; measurement every 2­4 years of family planning prevalence levels and trends, using data collection methods that are independent of program statistics (such as contraceptive prevalence studies); implementation of operations research studies designed to help program management understand the program, its problems and potential improvements; professional staff in an evaluation unit who prepare technically correct periodic reports on the program, what it has achieved, etc.; professional staff who interpret and summarize, for program management, national and regional population data collected through censuses, vital registration systems and surveys (these staff may be directly associated with the program or with other institutions); good coordination and working relationships, and timely sharing of information, between the evaluation unit and other units in family planning programs. A partial score is also given for the existence of universities or research institutes in the country that carry out demographic research, family planning research or population research of other kinds.

(24) Management use of evaluation findings. The extent to which program managers (decision-makers) use the research and evaluation findings to improve the program in ways suggested by those findings.

Method Availability and Accessibility

(25) Male sterilization. Whether medically adequate voluntary sterilization services for males are legally and openly available, and the percentage of the population that has ready and easy access to such services.

(26) Female sterilization. Whether medically adequate voluntary sterilization services for females are legally and openly available, and the percentage of the population that has ready and easy access to such services.

(27) Pills and injectables. The percentage of couples of reproductive age who have ready and easy access to pills through programs other than CBD and social marketing programs. "Ready and easy access" means that the recipient spends no more than an average of two hours per month to obtain contraceptive supplies and services. Easy access also implies that the cost of contraceptive supplies is not burdensome; to meet this criterion, a one-month supply of contraceptives should cost less than 1% of a month's wages. (If the availability of injectables is higher than that of pills, data on injectables are used to score this item.)

(28) Condoms and spermicides. The percentage of couples of reproductive age who have ready and easy access to condoms through programs other than CBD and social marketing programs. "Ready and easy access" is defined as in item 27. (If the availability of other conventional contraceptives is greater than that of condoms, data on those other methods are used to score this item.)

(29) IUDs. The percentage of couples of reproductive age who have ready and easy access to IUDs through programs other than CBD and social marketing programs. "Ready and easy access" is defined as in item 27.

(30) Abortion and menstrual regulation. The proportion of the population that has ready and easy access to abortion services, whether or not abortions are legal, or to menstrual regulation services; however, excluded from the scoring is the availability of abortions carried out only under poor conditions.

References

1. Lapham RJ and Mauldin WP, National family planning programs: review and evaluation, Studies in Family Planning, 1972, 3(3):29-52.

2. Freedman R and Berelson B, The record of family planning programs, Studies in Family Planning, 1976, 7(1):1-40; and Mauldin WP and Berelson B, Conditions of fertility decline in developing countries, 1965-75, Studies in Family Planning, 1978, 9(5):84-148.

3. Lapham RJ and Mauldin WP, Family planning program effort and birthrate decline in developing countries, International Family Planning Perspectives, 1984, 10(4):109-118; and Lapham RJ and Mauldin WP, Contraceptive prevalence: the influence of organized family planning programs, Studies in Family Planning, 1985, 16(3):117-137.

4. San PB et al., Measuring family planning program effort at the provincial level: a Vietnam application, International Family Planning Perspectives, 1999, 25(1):4-9.

5. Khalifa M, Suliman ED and Ross JA, Family Planning Program Effort in Egypt's Governorates, Cairo: POLICY Project, The Futures Group International, May 1999.

6. Mauldin WP and Ross JA, Family planning programs: efforts and results, 1982-89, Studies in Family Planning, 1991, 22(6):350-367; and Ross JA and Mauldin WP, Family planning programs: efforts and results, 1972-94, Studies in Family Planning, 1996, 27(3):137-147.

7. Tsui AO, Population policies and programs and the Asian economic miracle, paper presented at the annual meeting of the Population Association of America, Washington, DC, March 27-29, 1997; and Tsui AO, Population programs and fertility: the family planning record, revised paper presented at the Conference on the Global Fertility Transition, Bellagio, Italy, May 18-22, 1998.

8. Ahlburg D and Diamond I, Evaluating the impact of family planning programs, in: Ahlburg D, Kelley A and Mason K, eds., The Impact of Population Growth on Well-Being in Developing Countries, Berlin: Springer, 1996, pp. 299-336; Schultz TP, Sources of fertility decline in modern economic growth: is aggregate evidence on the demographic transition credible? in: Rosenzweig MR and Stark O, eds., Handbook of Population and Family Economics, Amsterdam: North Holland Publishing, 1993; and Schultz TP, Human capital, family planning and their effects on population growth, American Economic Association Papers and Proceedings, 1994, 84(2):255-260.

9. Ross JA and Mauldin WP, Measuring the strength of family planning programs, paper prepared for the IUSSP/EVALUATION Seminar on Methods for the Evaluation of Family Planning Program Impact, Jaco, Costa Rica, May 14-16, 1997; and Ross JA and Lloyd CB, Methods for measuring the fertility impact of family planning programmes: the experience of the last decade, in: Phillips JF and Ross JA, Family Planning Programmes and Fertility, Oxford, UK: Clarendon Press, 1992, pp. 28-55.

10. Pritchett LH, Desired fertility and the impact of population policies, Population and Development Review, 1994, 20(1):1-55.

11. Bongaarts J, The role of family planning programmes in contemporary fertility transitions, in: Jones GW et al., eds., The Continuing Demographic Transition, Oxford, UK: Clarendon Press, 1997, pp. 422-444.

12. Pritchett LH, 1994, op. cit. (see reference 10); and Bongaarts J, 1997, op. cit. (see reference 11).

13. Samara R, Buckner B and Tsui AO, Understanding How Family Planning Programs Work: Findings from Five Years of Evaluation Research, Chapel Hill, NC, USA: Carolina Population Center, The EVALUATION Project, 1996.

14. Guilkey D, The impact of family planning programs on contraceptive use: a review of the literature, Chapel Hill, NC, USA: Carolina Population Center, The EVALUATION Project, 1998.

15. Hermalin A and Khadr Z, The impact of family planning programs on fertility: a selective assessment of the evidence, Chapel Hill, NC, USA: Carolina Population Center, The EVALUATION Project, 1996.

16. Knight RJ and Tsui AO, Family Planning Sustainability at the Outcome and Program Levels, Chapel Hill, NC, USA: The EVALUATION Project, Carolina Population Center; and Honolulu, HI: East-West Center, 1997.

17. Population Reference Bureau (PRB), Monitoring Family Planning Programs, 1996, wall chart issued by PRB and the EVALUATION Project, Washington, DC: PRB, 1996.

18. Mauldin WP and Berelson B, 1978, op. cit. (see reference 2).

19. Freedman R and Berelson B, 1976, op. cit. (see reference 2); Tsui AO, 1997, op. cit. (see reference 7); Bongaarts J, 1997, op. cit. (see reference 11); Guilkey D, 1998, op. cit. (see reference 14); Hermalin A and Khadr Z, 1996, op. cit. (see reference 15); Angeles G et al., A meta-analysis of the impact of family planning programs on fertility preferences, contraceptive method choice, and fertility, MEASURE Evaluation Working Paper WP0130, Chapel Hill, NC, USA: Carolina Population Center, 2001; and Tsui AO, Population programs and fertility: the family planning record, revision of paper presented at the Conference on the Global Fertility Transition, Bellagio, Italy, May 18-22, 1998.

20. Mauldin WP et al., Direct and judgmental measures of family planning program inputs, Studies in Family Planning, 1995, 26(5):287-295.

21. Ross JA and Cooper-Arnold K, Comparison of long- and short-form questionnaires to collect judgments on family planning effort, Glastonbury, CT, USA: The Futures Group International, 2000. (Accessible as a MEASURE Evaluation Working Paper at http://www.cpc.
unc.edu/projects/measure/publications/workingpapers/wp0128.pdf.)

22. Bulatao RA, Evolving dimensions of family planning effort from 1982 to 1994, unpublished paper, Glastonbury, CT, USA: The Futures Group International, 1996.

23. Vlassoff M, Exterkate M and Eelens F, Global resource flows for population activities: post-ICPD experience, paper presented at the 1998 annual meeting of the Population Association of America, Chicago, IL, USA, Apr. 2-4, 1998; and Ross JA and Bulatao RA, Contraceptive projections and the donor gap, Washington DC: The Futures Group International. (Also issued as a background document for the seminar Meeting the Reproductive Health Challenge: Securing Contraceptives, and Condoms for HIV/AIDS Prevention, Istanbul, May 3-5, 2001.)

24. Casterline JB and Sinding SW, Unmet need for family planning and implications for population policy, Population and Development Review, 2000, 26(4):691-723; and Ross J and Heaton L, Intended contraceptive use among women without an unmet need, International Family Planning Perspectives, 1997, 23(4):148-154.

25. AbouZahr C, and Wardlaw T, Maternal mortality in 1995; estimates developed by WHO and UNICEF, New York: UNICEF, 2000; Hill K, AbouZahr C and Wardlaw T, Estimates of maternal mortality for 1995, Bulletin of the World Health Organization, 2001, 79(2):182-193; Shiffman J, Can poor countries surmount high maternal mortality? Studies in Family Planning, 2000, 31(4):274-289; and WHO and UNICEF, Revised 1990 estimates of maternal mortality: a new approach by WHO and UNICEF, 1996, available at http://www.unicef.org/reseval/matr/htm.

26. The Futures Group International, The Maternal and Neonatal Program Effort Index (MNPI): Manual, Glastonbury, CT, USA: The Futures Group International, 1999.

27. Stover J, Rehnstrom J and Schwartlander B, Measuring the level of effort in the national and international response to HIV/AIDS: the AIDS program effort index (API), paper presented at the 13th International AIDS Conference, Durban, South Africa, July 9-13, 1999.

28. The Futures Group International, The Policy Environment Score (PES): Manual, Glastonbury, CT, USA: The Futures Group International, 1997.

RÉSUMÉ

Contexte: L'effort des programmes de planning familial à grande échelle est mesuré régulièrement depuis 1972. Ces mesures visent à quantifier l'effort ou la force de ces programmes, indépendamment de leurs résultats (pratique contraceptive, variations de la fécondité, etc.)

Méthodes: Des questionnaires adressés à des observateurs experts ont permis d'obtenir leur évaluation détaillée de l'effort des programmes d'une centaine de pays en voie de développement. Les réponses relatives à chaque pays ont été converties en 30 cotes de fonction, en- suite groupées en quatre composants d'effort de programme. La somme des 30 cotes de fonction a été calculée pour produire l'indice d'effort global des programmes.

Résultats: L'indice d'effort moyen de 1999 s'est révélé supérieur (54% de la cote maximale possible) à celui de 1994 (48%). Les pays dont la cote était initialement faible ont enregistré une amélioration nettement supérieure à celle de leurs homologues à cote élevée en 1972. En 1999, l'écart entre les deux groupes était faible. En moyenne, les programmes forts et faibles différaient largement dans leur profil de cote, les pays forts l'emportant sur les plus faibles dans chaque catégorie de fonction. Tous les pays, indépendamment de leur cote moyenne, faisaient preuve d'une approche sélective des fonctions qu'ils accentuaient, mais les programmes plus faibles révélaient une plus grande inconstance dans leur sélectivité. Les programmes les plus forts se sont stabilisés à 80% environ de la cote maximale. La prévalence de la pratique contraceptive reste supérieure dans les pays présentant, à la fois, un cadre social favorable et des programmes forts.

Conclusions: De nombreux pays en voie de développement ont renforcé leurs programmes d'hygiène de la reproduction conformément aux recommandations de la Conférence internationale de 1994 sur la population et le développement. L'amélioration de l'indice et des cotes d'effort de 1999 semble indiquer la réussite de ce renforcement sans affaiblissement marqué de l'effort de planning familial.

John Ross is senior fellow and John Stover is vice president at The Futures Group International, Glastonbury, CT, USA. The authors wish to acknowledge support for the research presented in this article from the U.S. Agency for International Development through the MEASURE Evaluation Project (HRN-A-00-97-0018-00). For assistance with data management, the authors thank Katharine Cooper-Arnold, Amy Willard, Erin Croughwell and Kate Abel.


*Of 630 questionnaires sent in 1982, 427 were returned.

An exception is that in the 1999 cycle, the budget item was reduced to a single question that asked for the respondent's estimate of the proportions of program funding from donor and local sources, respectively. Prior to 1999, the estimates came from a complex table asking for funding amounts in highly detailed categories.

Technically, India should have shifted from the strong to the moderate category in 1999, but since its score decreased only slightly, from 68 to 65, we have left it in the strong category for this analysis.

§Since this region comprises only 4-6 countries, its averages are more sensitive to individual country changes than is true for other regions.

**The regression equation with standardized coefficients is P=-24.45+(0.65xSES)+(0.38xFPE), where P is the contraceptive prevalence in the most recent year available, SES is the social and economic setting (as measured by the average rank in the seven component indexes) and FPE is the average of the 1994 and 1999 family planning effort scores expressed as a percentage of maximum. There are 79 observations. The adjusted R-squared is .73. All coefficients are significant, with t-scores of -4.2, 11.7 and 6.3, respectively.