The Family Planning Program Effort Index: 1999 Cycle

Publication date: 1999

119 fertility change. Other researchers also used the indices for extensive analyses of program inputs and outcomes.2 Around 1980, Lapham and Mauldin de- veloped the precursor of the current ques- tionnaire. They identified a wide variety of program characteristics and included approximately 125 items in the question- naire. In 1982, they sent the questionnaire to recipients in 93 countries,* whose re- sponses were coded and combined to cre- ate a final set of 30 scores. The conversion rules for score creation and all other as- pects of the methodology have since re- mained consistent, to maintain the accu- racy of time trends.† The 30 scores were further organized into four groups or com- ponents: policy and stage-setting activi- ties; service and service-related activities; evaluation and recordkeeping; and avail- ability of fertility control methods. Lapham and Mauldin published the re- sults,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 pro- John Ross is senior fellow and John Stover is vice presi- dent 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 Eval- uation 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. The Family Planning Program Effort Index: 1999 Cycle By John Ross and John Stover The Family Planning Program EffortIndex 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 popu- lation in their respective countries. In response to a growing belief that standard measures were needed to quan- tify the nature and strength of these ef- forts, 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 va- riety of countries, they were able to cor- relate these program inputs with out- comes such as contraceptive use and gram effort, each of which is meant to cap- ture inputs independent of outputs such as contraceptive use or fertility change. This permits an examination of the rela- tionship between effort and outcomes, while taking into account the levels and the 30 types of effort. The scores are also useful for diagnosing program weak- nesses and detecting improvement over time. Two countries, Vietnam4 and Egypt,5 have adapted the scores to gauge provin- cial differences in effort and to provide suggestions for administrative changes. Earlier reports have summarized the ex- tensive 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 ex- amine how program effort interacts with socioeconomic setting to increase contra- ceptive use and lower fertility. The vast majority of that work has been cross-sec- tional and has examined how much fer- tility decline has been due to effective fam- ily 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 ap- preciable program effect on fertility after controls for numerous social and eco- nomic factors were introduced. These studies also reviewed much of the tech- nical literature regarding such calcula- tions.8 Several methods have been em- ployed repeatedly over the years.9 It has been argued that fertility change has been driven by shifts in desired fam- ily size rather than by the efforts of fami- ly planning programs.10 However an ex- ploration of program effects upon fertility found that much of the disagreement con- cerning program effects disappeared when countries’ scores were weighted by their respective population sizes (in which case the higher scores for some large coun- Volume 27, Number 3, September 2001 Context: Indices of effort by large-scale family planning programs have been measured peri- odically since 1972. These scores are intended to capture program effort or strength, indepen- dent of outputs such as contraceptive use or fertility change. Methods: Questionnaires were sent to expert observers who provided judgments on the de- tails of program effort for 89 developing countries. The responses for each country were con- verted to scores for 30 program features, which were then grouped into four components of pro- gram 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 consider- ably 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 av- erage 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 max- imum 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 Popula- tion 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 *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 re- spondent’s estimate of the proportions of program fund- ing from donor and local sources, respectively. Prior to 1999, the estimates came from a complex table asking for funding amounts in highly detailed categories. 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 fami- ly planning programs have worked,13 an inquiry into methods used by programs to increase contraceptive use14 and a re- view of what programs do to reduce fer- tility rates.15 In another study, researchers used in- ternational 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.16 A wall chart containing tabular data for tries raised the means).11 Furthermore, some program effects that had seemed modest and had not been expected to im- prove 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 lev- els observed in earlier analyses,12 espe- cially in countries where modernization has lagged. As a result, many analysts have shifted their attention away from confirming the existence of a program ef- fect and toward examining the ways in which programs make their contributions and how those can be enhanced. Also notable are the numerous docu- ments that were published as part of the monitoring national family planning pro- grams 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 re- cent data on family planning program ef- fort, collected during 1999 from 374 in- formants in 89 countries. We examine regional patterns in program effort, con- trast the stronger programs with the weaker ones and present time trends in various measures of program effort. Fi- nally, we briefly analyze how levels of so- cioeconomic development and program effort are interrelated. 120 International Family Planning Perspectives The Family Planning Program Effort Index: 1999 Cycle Region/country Total Policy Services Eval- Method uation availability Grand average 54 55 51 57 55 East Asia 64 60 57 64 86 China 86 89 87 70 88 Korea, Rep. of 55 45 39 63 97 Mongolia 38 31 35 26 58 Taiwan 79 74 67 96 100 South/Southeast Asia 60 62 58 60 63 Bangladesh 74 70 75 72 81 Cambodia 46 56 45 50 32 Hong Kong 57 63 41 32 100 India 65 72 58 60 72 Indonesia 82 84 86 81 72 Laos 39 51 41 36 18 Malaysia 69 72 61 86 72 Myanmar 37 34 38 59 27 Nepal 57 61 56 67 49 Pakistan 57 59 57 52 57 Philippines 57 56 50 66 67 Singapore 44 41 44 29 54 Sri Lanka 69 67 71 49 76 Thailand 75 61 72 95 89 Vietnam 76 82 74 66 79 North Africa and Middle East 58 61 54 66 61 Algeria 64 81 55 65 60 Egypt 57 63 58 60 46 Iran 71 70 62 68 94 Jordan 47 47 45 53 48 Lebanon 60 49 63 74 61 Morocco 57 57 51 76 61 Oman 53 41 45 59 81 Syria 66 52 74 88 56 Tunisia 71 80 71 88 52 Turkey 59 71 44 61 76 Yemen 37 56 27 33 36 Anglophone Africa 54 57 53 59 47 Ethiopia 44 48 49 43 28 Ghana 63 68 61 72 58 Kenya 62 55 64 63 67 Lesotho 62 62 58 77 61 Malawi 50 57 58 53 23 Mauritius 71 67 67 91 75 Mozambique 43 49 37 52 40 Namibia 54 66 30 63 84 Nigeria 45 47 49 38 38 South Africa 54 62 45 46 65 Sudan 35 41 40 39 12 Tanzania 55 64 65 46 27 Uganda 54 62 57 60 34 Zambia 50 42 57 62 39 Zimbabwe 61 61 63 79 49 Region/country Total Policy Services Eval- Method uation availability Francophone Africa 49 55 52 57 29 Benin 45 46 48 54 30 Burkina Faso 54 58 59 60 33 Cameroon 44 53 52 54 10 Central African Rep 50 66 57 50 13 Chad 43 67 44 52 4 Congo 35 56 26 29 27 Côte d'Ivoire 50 56 52 71 27 Gabon 35 27 37 40 40 Guinea 60 61 64 63 48 Madagascar 42 44 48 44 26 Mali 58 55 70 73 31 Mauritania 37 35 39 55 25 Niger 47 59 50 61 16 Rwanda 62 77 60 66 44 Senegal 55 58 54 64 46 Togo 63 64 67 75 45 Latin America and the Caribbean 50 48 44 51 65 Argentina 30 33 21 36 40 Bolivia 49 46 44 45 64 Brazil 59 50 46 59 100 Chile 61 50 56 60 86 Colombia 64 44 66 78 80 Costa Rica 32 38 21 19 57 Dominican Republic 50 43 52 44 58 Ecuador 46 47 43 47 50 El Salvador 46 49 45 41 46 Guatemala 37 35 32 35 51 Guyana 46 42 44 56 51 Haiti 51 59 50 39 51 Honduras 44 43 41 40 52 Jamaica 62 71 59 63 58 Mexico 75 79 62 84 90 Nicaragua 49 35 53 60 55 Panama 49 61 34 60 61 Paraguay 56 56 43 59 81 Peru 59 65 42 60 85 Puerto Rico 62 49 53 66 97 Trinidad & Tobago 59 55 59 62 63 Uruguay 34 22 30 54 47 Venezuela 29 32 12 13 71 Central Asian Republics 52 51 48 53 60 Kazakhstan 42 36 42 38 51 Kyrgyzstan 49 45 43 54 64 Tajikistan 54 58 48 68 55 Turkmenistan 59 49 59 65 68 Uzbekistan 55 69 48 41 60 Table 1. Family planning program effort scores as percentage of maximum possible score, by component, according to region and country, 1999 121Volume 27, Number 3, September 2001 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 cate- gory, according to quartiles. We also as- signed countries to high, upper middle, lower middle or low program effort quar- tiles, using the average of their total pro- gram effort scores for 1994 and 1999. Results Survey Responses Eight months after the mailing of the ques- tionnaire, 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 Methodology In the 1999 assessment, the detailed ques- tionnaire, printed in English, French, Spanish and Russian, was sent as in pre- vious cycles to four types of expert re- spondents: •government officials directly involved in the implementation of the program; •donor personnel close to the program in agencies such as the United Nations Pop- ulation Fund (UNFPA), the World Bank, the U.S. Agency for International Devel- opment (USAID) and various non- governmental 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 con- verting items to scores. All questionnaire responses were en- tered into a computer, and a complex set of programming statements automatical- ly converted the items to the 30 scores. Within each country, scores were averaged across all respondents after highly im- probable 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 compo- nents 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 en- compass: 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 so- cial setting categories are based on an index composed of seven items: the pro- portion of adults who are literate; the pri- mary and secondary school enrollment ratio as a percentage of those aged 5–19; life expectancy at birth; the infant mor- tality rate; the proportion of the male labor 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 pre- sented in Table 1, which shows the pro- gram effort index (i.e., the total score) as well as the four component scores. Each score is cited as a percentage of the max- imum; 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 coun- tries in 1999 is 54. China, Indonesia, Tai- wan, Vietnam, Thailand and Mexico, all of which are recognized for the strength of their family planning programs, have 0 10 20 30 40 50 60 70 80 90 100 East Asia South/Southeast Asia North Africa and Middle East Anglophone Africa Francophone Africa Latin America and Caribbean Central Asian Republics % Figure 1. Family planning program effort scores as percentage of maximum possible score, by component, according to region, 1999 Policy Services Evaluation Method availability Rica, Argentina and Venezuela. Countries with low scores have varying program char- acteristics. Sudan, Congo and Gabon sim- ply have extremely weak programs. Costa Rica has only a modest program, yet contracep- tive prevalence is high and fertility is low, due to the favorable social setting and to contra- ceptive use outside of the program proper. Governments in Urug- uay, Argentina and Venezuela have not im- plemented a formal out- reach program to sup- port contraceptive use. Average scores for each region are shown by component in Figure 1 (page 121). The widest variation in scores clear- ly occurs in contracep- tive 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 posi- tive policies in place, as well as programs con- taining important ele- ments of service delivery and evaluation. Howev- er, the implementation of these programs, as rep- resented by the avail- ability of contraceptive methods, sharply differ- entiates 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 num- ber of factors. Latin American countries total scores of 75 or higher. These six coun- tries, 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 originally developed family planning pro- grams to improve maternal and child health, and never adopted the demo- graphic rationale common to many coun- tries in other regions. In addition, the pri- vate 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 re- ceived 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 clas- sified into four broad categories of effort based on the total score: Program effort Total % of score 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 clas- sified 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 av- erage 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 classi- fied as weak). The features within each component are arranged in descending order by the scores of the stronger coun- tries. The stronger countries had higher av- erage scores for every one of the 30 cate- gories. Furthermore, the gap between the stronger and weaker countries is fairly con- sistent, with only a few exceptions (mar- riage 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 pro- grams than for the stronger programs. However, even stronger programs vary in their relative emphasis of program fea- 122 International Family Planning Perspectives The Family Planning Program Effort Index: 1999 Cycle 0 1 2 3 4 Male sterilization Abortion/men. reg. Female sterilization IUD Pills/injectables Condoms Availability � Evaluation Management use Recordkeeping Evaluation � Incentives Home visits Community-based dist. Civil bureaucracy Social marketing Supervision Postpartum programs Media Logistics Private involvement Admin. structure Training programs Carry out tasks Services � Age at marriage Budget Leadership Advertising Govt. policy Statements Multiple ministries Import laws� � Policy Score Figure 2. Mean family planning program effort score, by area and item, according to strength of program Stronger Weaker Index item 123Volume 27, Number 3, September 2001 features within each of the four compo- nents (Figure 2). For instance, in the pol- icy and stage-setting activities component, most countries in both groups score high- est on items related to policies in place, lower on leadership levels and budget support, and most poorly on policies re- garding age at marriage. The services and service-related activi- ties component also shows a similar pat- tures. 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 pro- gram 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 tern 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 distribu- tion, home-visiting workers and the use of incentives and disincentives. Within the method availability component, both stronger and weaker programs judge con- doms, pills and IUDs to be more available Region/country 1972 1982 1989 1994 1999 Overall average 20 29 45 48 54 East Asia 49 58 76 68 64 China 83 84 87 92 86 Korea, PDR 0 50 54 63 u Korea, Rep. of 80 79 81 71 55 Mongolia 0 0 u 38 38 Taiwan 80 79 81 78 79 South/Southeast Asia 33 45 50 54 60 Afghanistan 10 11 36 u u Bangladesh 10 57 72 69 74 Bhutan 0 u 22 36 u Cambodia 0 0 9 26 46 Fiji u 50 u u u Hong Kong 77 69 u 61 57 India 63 66 72 68 65 Indonesia 47 75 80 83 82 Laos 0 0 8 28 39 Malaysia 60 51 66 54 69 Myanmar 0 4 12 27 37 Nepal 20 37 59 51 57 Pakistan 27 40 48 48 57 Papua New Guinea 0 26 26 28 u Philippines 53 56 49 60 57 Singapore 87 79 63 63 44 Sri Lanka 40 67 80 69 69 Thailand 37 61 80 75 75 Vietnam 67 53 68 67 76 North Africa/Middle East 12 19 41 43 58 Algeria 10 25 46 44 64 Cyprus u 25 u u u Egypt 27 40 66 59 57 Iran 47 11 57 61 71 Iraq 0 3 1 38 u Jordan 0 16 31 40 47 Kuwait 0 5 u 23 u Lebanon 0 33 49 33 60 Morocco 13 35 57 63 57 Oman u 1 5 45 53 Saudi Arabia 0 1 u 5 u Syria 0 11 44 48 66 Tunisia 40 59 69 82 71 Turkey 20 29 46 54 59 United Arab Emirates u 1 33 14 u Yemen 0 10 28 30 37 Anglophone Africa 8 20 37 46 54 Angola 0 u 39 24 u Botswana u 27 75 66 u Ethiopia 0 6 32 38 44 Gambia u 26 u u u Ghana 10 18 52 53 63 Guinea-Bissau u 14 28 36 u Kenya 20 28 58 56 62 Lesotho 0 14 45 43 62 Liberia 10 22 3 u u Malawi 0 6 16 44 50 Mauritius 67 68 69 74 71 Mozambique 0 16 27 33 43 Namibia u u 11 43 54 Nigeria 7 13 43 42 45 Region/country 1972 1982 1989 1994 1999 Anglophone Africa (cont.) Sierra Leone 0 16 35 47 u Somalia 0 10 1 u u South Africa u u 62 56 54 Sudan 10 8 20 29 35 Tanzania 10 22 42 48 55 Uganda 0 17 12 44 54 Zambia 0 16 49 41 50 Zimbabwe 10 27 56 68 61 Francophone Africa 1 10 36 40 49 Benin 10 11 28 38 45 Burkina Faso 0 4 45 u 54 Cameroon 0 8 34 49 44 Central African Rep. 0 10 42 40 50 Chad 0 7 20 27 43 Congo 0 15 36 28 35 Côte d'Ivoire 0 6 55 38 50 Gabon u u u u 35 Guinea 0 5 40 50 60 Madagascar 0 9 40 33 42 Mali 0 11 38 45 58 Mauritania 0 4 21 32 37 Niger 0 5 38 46 47 Rwanda 0 23 43 u 62 Senegal 0 23 44 51 55 Togo 0 14 30 u 63 Zaire 10 13 28 u u Latin America and the Caribbean 30 39 51 50 50 Argentina u u 21 21 30 Bolivia 0 8 23 49 49 Brazil 0 43 32 43 59 Chile 53 44 58 55 61 Colombia 53 71 62 66 64 Costa Rica 70 33 16 46 32 Cuba 50 52 65 54 u Dominican Republic 47 55 54 67 50 Ecuador 20 35 58 53 46 El Salvador 43 63 68 58 46 Guatemala 30 28 53 58 37 Guyana 0 26 55 26 46 Haiti 10 36 42 38 51 Honduras 23 25 63 51 44 Jamaica 77 56 66 65 62 Mexico 13 66 77 74 75 Nicaragua 0 20 u 53 49 Panama 63 51 52 56 49 Paraguay 10 8 36 35 56 Peru 0 22 51 59 59 Puerto Rico u u u 53 62 Trinidad & Tobago 50 47 66 50 59 Uruguay u u 42 39 34 Venezuela 23 31 54 38 29 Central Asian Republics na na na 39 52 Kazakhstan u u u 34 42 Kyrgyzstan u u u 36 49 Tajikistan u u u u 54 Turkmenistan u u u 33 59 Uzbekistan u u u 54 55 Table 2. Program effort scores as a percentage of the maximum, by country and region, according to year of survey Note: A “0” entry means that the score when rounded equaled zero. u=unavailable, because the country was omitted that year. na=not applicable, because averages could not be computed. Entries lack- ing data can affect the regional averages in each year. 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 im- proved dramatically. By 1999, no countries were classified as having a very weak or no pro- gram, and only 23 were considered weak; the majority of countries were classified as show- ing moderate program effort. There has been very little change over the years in the number of countries clas- sified as having strong programs. Temporal trends based on the total pop- ulations rather than on the number of countries present a more positive picture (Table 3). The strong category has re- mained the largest in every cycle because of China, and has continued to grow over time. While only 36% of the population 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 im- provement observed in each of the previ- ous cycles (Table 2, page 123). This 12% rise is substantial, about twice that ob- served 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 coun- tries’ scores are weighted by their respec- tive 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-weight- ed average, from 52 to 68 (not shown). Temporal trends in the distribution of countries and population by program ef- fort level appear in Table 3. When pro- gram effort was first assessed in 1972, many countries had no programs or poli- cies at all. Of the 108 countries listed in Table 2, 42 received scores of zero in 1972. 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 ac- cording to their effort level in 1972 and fol- lowed 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 co- horts, whose scores rose dramatically and had nearly converged with those of the stronger cohorts by 1999. Regions differ in the degree of their im- provement 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 com- ponent.† South and Southeast Asia has shown steady improvement: By 1999, this region matched or exceeded East Asia in policies and services, but still lagged be- 124 International Family Planning Perspectives The Family Planning Program Effort Index: 1999 Cycle Table 3. Number of countries, total population of countries and percentage distribution of population, all by program effort level, according to year Program effort level 1972 1982 1989 1994 1999 No. of countries Very weak/none 61 40 12 1 0 Weak 9 24 28 34 23 Moderate 11 14 31 34 53 Strong 9 10 14 14 13 Population (in millions) Very weak/none 695 450 137 18 0 Weak 186 502 507 663 259 Moderate 838 295 629 724 1,132 Strong 961 2,067 2,260 2,748 3,018 % distribution of population Very weak/none 26 14 4 <1 0 Weak 7 15 14 16 6 Moderate 31 9 18 17 26 Strong 36 62 64 66 68 Total 100 100 100 100 100 *Technically, India should have shifted from the strong to the moderate category in 1999, but since its score de- creased 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 av- erages are more sensitive to individual country changes than is true for other regions. Figure 3. Family planning program effort score as a percentage of the maximum, by year, according to effort rating in 1972 100 90 80 70 60 50 40 30 20 10 0 1972 1982 1989 1994 1999 % Strong Moderate Weak Very weak/none 1972 effort rating 125Volume 27, Number 3, September 2001 program effort and social setting both play important, and roughly equal, roles in fer- tility decline. Figure 4 uses the 1999 scores to show how these two characteristics are associated with contraceptive use. Cate- gories 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 contra- ceptive prevalence as of 1999.) The row and column averages indicate that contraceptive use is positively asso- ciated with both social setting and pro- gram 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 mid- dle, lower middle and low quartiles, re- spectively. A similar pattern is seen for program effort: Prevalence falls off from 60% in high-effort countries to 28–29% for the lower-middle and low-effort countries. hind 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 Plan- ning Program Effort Index since the 1970s to examine the effects of social and eco- nomic development and family planning effort on fertility decline and contracep- tive use. Studies have generally found that 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.* Figure 4. Contraceptive prevalence, by family planning effort category, according to social setting Social setting Program effort Average High Upper middle Lower middle Low prevalence Country % Country % Country % Country % Total 60 45 28 29 41 High Average prev. 73 Average prev. 67 na na Average prev. 49 65 Hong Kong 86 Brazil 77 United Arab Emirates 28 Rep. of Korea 77 Panama 58 Kuwait 35 Jamaica 66 Singapore 65 Kazakhstan 59 Colombia 72 Trinidad & Tobago 53 Costa Rica 75 Cuba 69 Uzbekistan 68 Mauritius 75 Puerto Rico 78 Mexico 65 Upper middle Average prev. 62 Average prev. 57 Average prev. 54 Average prev. 38 53 Syria 40 Nicaragua 60 Kyrgyzstan 60 Iraq 18 Iran 73 El Salvador 60 Jordan 53 Mongolia 57 Sri Lanka 66 South Africa 53 Paraguay 51 Thailand 72 Algeria 47 Honduras 50 Tunisia 60 Turkey 64 Oman 24 Egypt 55 Namibia 29 Philippines 46 Ecuador 57 Dominican Republic 64 Peru 64 Lower middle Average prev. 57 Average prev. 23 Average prev. 25 Average prev. 36 36 Morocco 59 Senegal 13 Côte d'Ivoire 11 Papua New Guinea 26 Zimbabwe 48 Lesotho 23 Nigeria 15 Congo 8 Botswana 33 Pakistan 18 Zambia 26 Myanmar 33 India 41 Ghana 20 Cameroon 19 Gabon 75 Vietnam 75 Kenya 39 Guatemala 31 Mauritania Indonesia 57 Bolivia 48 China 83 Low Average prev. 31 Average prev. 14 Average prev. 13 Average prev. 13 16 Rwanda 21 Tanzania 18 Ethiopia 4 Sudan 10 Togo 24 Mali 7 Benin 16 Laos 25 Bangladesh 49 Nepal 29 Haiti 18 Yemen 21 Guinea 2 Central African Rep. 15 Chad 4 Niger 8 Cambodia 13 Malawi 22 Bhutan 8 Uganda 15 Madagascar 19 Burkina Faso 8 Mozambique 6 *The regression equation with standardized coefficients is P=–24.45+(0.65xSES)+(0.38xFPE), where P is the con- traceptive 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. equacy of training and supervision, re- strictions on contraceptive advertising, and strength of community-based distri- bution systems. The questionnaire, as used from 1982 through 1999, contains items of this type, as well as fairly objec- tive measures for items like the formal pol- icy of the government or the administra- tive level held by the program director, but checks on those cannot be done indepen- dently for many countries all at once. A number of studies have assessed the validity and reliability of the program ef- fort scores. One conducted in Kenya and Bangladesh compared scores obtained using the standard questionnaire and methodology with those obtained from di- rect 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 de- gree of multiministry involvement in the program. In both countries, the scores based on direct measurement were quite similar to those obtained using the ques- tionnaire. The great amount of labor and time required to perform direct measure- ment of all 30 scores rules out the latter as a feasible alternative to an expert respon- dent-based methodology, especially for a large-scale data collection effort involv- ing almost 100 countries. Attention there- fore returned to the methodology of the standard questionnaire, to which in- formed respondents in each country can reply within a limited time span. A second exercise to obtain a separate estimate for each feature score was con- ducted among the 89 participating coun- tries in the 1999 cycle.21 The standard questionnaire was followed by a final sec- tion 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 gen- erally in close agreement with the scores that had been calculated using the stan- dard methodology; discrepancies in the scores were greatest where the wording of the questions differed significantly be- tween the two methodologies. Another important analysis applied fac- tor analysis methods to the 30 feature scores obtained in the 1982–1994 cycles, thereby identifying six components that were predictive of strong family planning programs.22 The fact that these compo- nents remained relatively consistent across cycles argues in favor of the question- naire’s reliability. The Family Planning Program Effort Index was developed from the concept of Thus, the 1999 results are consistent with the conclusions of other studies that fam- ily planning program effort, as measured by the program effort index, makes an im- portant contribution to contraceptive prac- tice independent of social setting.19 Discussion Use of Expert Respondents The use of expert respondents to provide information has both advantages and dis- advantages; one of the latter is the poten- tial for bias. National respondents might exaggerate the strengths of a program; in- ternational respondents might be influ- enced by their knowledge of contracep- tive 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 ef- fort. The questionnaire does not directly solicit a score for each of the 30 features; instead, it contains a large number of de- tailed closed-ended questions, which are later coded and combined to yield each score. Thus, the respondent does not pro- vide 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 de- viation among responses is unusually high, the original questionnaires are ex- amined in detail and improbable outlying scores are removed. The small number of expert respon- dents 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 re- duce respondent variance, the same re- spondents 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 sever- al program features for which objective measures are unavailable, such as the ad- 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 govern- ment policy position, should have ade- quately trained and supervised staff, should make frequent and effective use of mass media, should undergo regular eval- uation, should stimulate the private sec- tor and should provide services to a large proportion of the rural and urban popu- lation. It is not possible to demonstrate the validity of this concept in a definitive fash- ion, nor can we conduct a test-retest reli- ability exercise in each cycle for such a large undertaking. However, the detailed patterns and trends over time make sense and correlate reasonably to outcome mea- sures, for both individual countries and regions. Future Directions The program effort index has continued to rise in most developing countries dur- ing the last five years, but still leaves con- siderable 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 av- erage index of 54 in 1999 actually repre- sents a more substantial two-thirds of maximum achievement. The 1999 scores confirm earlier findings that family planning program effort makes an important contribution to con- traceptive practice independent of social setting. Although many developing coun- tries have improved their efforts remark- ably over the past 25 years, they still dif- fer significantly in the component for method availability. Progress has been least in the actual provision of contracep- tive methods to the mass of the popula- tion. That appears to be more difficult than the development of policy positions or the implementation of training and supervi- sion protocols; clearly, it is still a major task facing many family planning programs. The upward movement in the program effort index since the International Con- ference on Population and Development held in Cairo in 1994 could not have been confidently predicted. Countries attend- ing the conference had been urged to broaden their reproductive health pro- grams to focus on issues other than con- traception, and there was a possibility that this expansion might occur at the expense 126 International Family Planning Perspectives The Family Planning Program Effort Index: 1999 Cycle 127Volume 27, Number 3, September 2001 Appendix Policy and Stage-Setting Activities (1) Government’s official policy or position concern- ing fertility family planning and rates of population growth. Existence and type of official policy to re- duce the population growth rate, support family planning activities for reasons other than demo- graphic ones, allow private-sector family planning activities in the absence of government-sponsored activity, or, on the other hand, to discourage fam- ily 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 pro- gram, 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 lat- ter item is allowed only if the new legal minimum is at least 18 years.) (5) Import laws and legal regulations regarding con- traceptives. Extent to which import laws and legal regulations facilitate the importation of contra- ceptive supplies that are not manufactured locally, or the extent to which contraceptives are manu- factured 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 fam- ily planning supplies and services, the extent to which other ministries and governmental agen- cies assist with family planning or other popula- tion activities. This involvement or assistance may be provided through the public sector or through private-sector family planning programs or pop- ulation activities, and is classified as follows: as- sistance with the delivery of family planning sup- plies 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 fam- ily 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 edu- cation; membership in an interagency family plan- ning group that meets at least twice annually; 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 move- ment have been realized. Since 1994, the Republic of Korea’s overall score dropped substantially. Taiwan has revised its anti- natalist policy, and China’s lower score in 1999 may reflect the liberalization of some aspects of its aggressive program. Singa- pore 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 affect- ed 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 se- riously weakening their family planning efforts. While the present study serves as an im- portant resource for family planning mon- itoring and analysis, it does not collect in- formation on some of the key topics that emerged during and after the Cairo con- ference. The current questionnaire is al- ready extensive, and the expertise of its re- spondents somewhat narrow. It would be cumbersome to expand the questionnaire into a multipurpose instrument and as- semble different sets of respondents for different sections, so other sources of in- formation are critical. The Cairo mandates are being moni- tored internationally based on donor funding, which has been disappointing- ly 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 ma- ternal mortality are also being refined.25 Three other activities related to Cairo pri- orities are underway. Levels and types of maternal and neonatal health program ef- forts 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 pol- icy survey has been implemented in sev- eral countries to obtain a “policy envi- ronment score,” which will measure strength at the policy level for family plan- ning, safe motherhood, safe abortion, ado- lescent health, and HIV and AIDS.28 Over the next two years, more complete infor- mation regarding funding, family plan- ning issues and specific elements of re- productive health should help to clarify the state of post-Cairo achievements. moral support; and other assistance. (10) Civil bureaucracy used. Use of the civil bu- reaucracy of the government to ensure that pro- gram 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, re- gency or other levels; and county levels. (11) Community-based distribution (CBD). Propor- tion of the country covered by public or private CBD programs for the distribution of contracep- tives 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 resi- dence 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 cov- ered by a social marketing program (i.e., subsi- dized contraceptive sales in the commercial sec- tor). 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 as- sumed to be primarily urban programs; howev- er, 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 de- liveries in hospitals and maternity centers where the new mothers are provided family planning in- formation and education services (by trained fe- male workers), and the proportion of all deliver- ies in the country that take place in hospitals and maternity centers (often a small proportion). For field-based postpartum programs, the score is con- structed from the proportion of women who de- liver at home and are offered family planning in- formation 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 fieldwork- ers is deflated if the average population covered by each home-visiting worker is more than 15,000. (15) Administrative structure. Whether there is ad- equate administrative structure and staff at the national, provincial and county levels. “Ade- quate” 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 de- livery of family planning supplies and services. (16) Training programs. Whether there is an ade- quate training program for each category of staff in the family planning program: administrative staff, physicians, nurses, paraprofessionals, vil- lage-level distributors, fieldworkers and motiva- tors, staff in other ministries and organizations, and others. “Adequate” means that the training provides personnel with the knowledge, infor- mation and skills necessary to carry out their jobs effectively, and that facilities exist to carry out the (23) Evaluation. Whether any of the following exist (partial score given for each): regular estimation of prevalence levels and trends (annually or quar- terly), using program statistics and estimated con- tinuation rates; measurement every 2–4 years of family planning prevalence levels and trends, using data collection methods that are indepen- dent of program statistics (such as contraceptive prevalence studies); implementation of operations research studies designed to help program man- agement understand the program, its problems and potential improvements; professional staff in an evaluation unit who prepare technically cor- rect 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 pro- gram or with other institutions); good coordina- tion and working relationships, and timely shar- ing of information, between the evaluation unit and other units in family planning programs. A partial score is also given for the existence of uni- versities 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 ex- tent to which program managers (decision-mak- ers) 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 legal- ly and openly available, and the percentage of the population that has ready and easy access to such services. (26) Female sterilization. Whether medically ade- quate voluntary sterilization services for females are legally and openly available, and the per- centage 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 ac- cess to pills through programs other than CBD and social marketing programs. “Ready and easy ac- cess” 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 in- jectables 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 contra- ceptives is greater than that of condoms, data on those other methods are used to score this item.) (29) IUDs. The percentage of couples of repro- ductive age who have ready and easy access to IUDs through programs other than CBD and so- cial marketing programs. “Ready and easy access” is defined as in item 27. (30) Abortion and menstrual regulation. The pro- portion of the population that has ready and easy access to abortion services, whether or not abor- tions are legal, or to menstrual regulation services; however, excluded from the scoring is the avail- ability of abortions carried out only under poor conditions. 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 pro- gram staff carries out assigned tasks: adminis- trative staff; physicians; nurses; paraprofession- als; village-level distributors; fieldworkers and motivators; staff in other ministries and organi- zations; and others. The ratings for task imple- mentation 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 re- lated equipment available at all service points at all times, at the following levels: central; provin- cial; and county. The score is based on the avail- ability 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 sys- tem of supervision at all levels. “Adequate” means that: supervisors exist at all levels of program op- erations in sufficient numbers to make possible supervisory visits at least once a month at service delivery levels (and quarterly at higher adminis- trative levels); supervisors do in fact make such supervisory visits to the work sites of the persons supervised; during these supervisory visits, en- couragement, advice and support are provided to supervised workers, in addition to any neces- sary checking of operations and records that as- sist in the evaluation of worker performance; and supervisors follow through on providing and ob- taining supplies and services identified as need- ed during their visits (or at least make serious at- tempts to obtain these needed supplies and services). (20) Mass media for information, education and com- munications. The frequency of mass media mes- sages 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 clas- sifications include: at least once a month; some- times (about once every 3–6 months); infrequently (about once a year or less often); and never. (21) Incentives and disincentives. The use of mone- tary or other incentives for the adoption of fami- ly 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 reg- ulations and constraints designed to encourage family planning or small family size. Evaluation and Recordkeeping (22) Recordkeeping. Whether there are recordkeep- ing systems for family planning clients at the clin- ic level, a system for the collection and periodic re- porting of summary statistics at regional and national levels (e.g., numbers of acceptors, quan- tity 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 recordkeep- ing 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. References 1. Lapham RJ and Mauldin WP, National family plan- ning programs: review and evaluation, Studies in Fami- ly Planning, 1972, 3(3):29–52. 2. Freedman R and Berelson B, The record of family plan- ning 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 Fam- ily Planning, 1978, 9(5):84–148. 3. Lapham RJ and Mauldin WP, Family planning pro- gram effort and birthrate decline in developing countries, International Family Planning Perspectives, 1984, 10(4):109–118; and Lapham RJ and Mauldin WP, Con- traceptive prevalence: the influence of organized fami- ly planning programs, Studies in Family Planning, 1985, 16(3):117–137. 4. San PB et al., Measuring family planning program ef- fort at the provincial level: a Vietnam application, Inter- national 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 Pro- ject, 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, Fam- ily planning programs: efforts and results, 1972–94, Stud- ies 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, Wash- ington, DC, March 27–29, 1997; and Tsui AO, Population programs and fertility: the family planning record, re- vised 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 mod- ern economic growth: is aggregate evidence on the de- mographic transition credible? in: Rosenzweig MR and Stark O, eds., Handbook of Population and Family Econom- ics, Amsterdam: North Holland Publishing, 1993; and Schultz TP, Human capital, family planning and their ef- fects on population growth, American Economic Associa- tion 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 Eval- uation of Family Planning Program Impact, Jaco, Costa Rica, May 14–16, 1997; and Ross JA and Lloyd CB, Meth- ods 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 Fertili- ty, Oxford, UK: Clarendon Press, 1992, pp. 28–55. 10. Pritchett LH, Desired fertility and the impact of pop- ulation 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 Bon- gaarts 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 128 International Family Planning Perspectives The Family Planning Program Effort Index: 1999 Cycle 129Volume 27, Number 3, September 2001 available at 26. The Futures Group International, The Maternal and Neonatal Program Effort Index (MNPI): Manual, Glaston- bury, CT, USA: The Futures Group International, 1999. 27. Stover J, Rehnstrom J and Schwartlander B, Mea- suring the level of effort in the national and internation- al 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 Envi- ronment Score (PES): Manual, Glastonbury, CT, USA: The Futures Group International, 1997. Resumen Contexto: Desde 1972, se han estado desarro- llando periódicamente los índices de rendimiento de los programas de planificación familiar en gran escala. Estas puntuaciones tienen por fi- nalidad identificar el trabajo y la solidez de los programas, en forma independiente a resulta- dos tales como el nivel de uso de anticoncepti- vos o el cambio de la fecundidad. Métodos: Se enviaron cuestionarios a obser- vadores expertos quienes formularon juicios sobre los detalles del trabajo del programa que se realiza en aproximadamente 100 países en desarrollo. Estas respuestas correspondientes a cada país se convirtieron en 30 puntuacio- nes del programa, las cuales fueron luego cla- sificadas en cuatro grupos de componentes que representaban el trabajo del programa. Se cal- culó un índice general sobre el trabajo del pro- grama, lo cual presentó la suma de las 30 pun- tuaciones de las características. Resultados: El promedio del índice de trabajo del programa fue más elevado en 1999 (54% de la posible puntuación máxima) que en 1994 (48% del máximo). Los países que al princi- pio presentaron puntuaciones bajas mejora- ron considerablemente más que aquellos que al inicio registraron puntuaciones elevadas; en 1999, la brecha entre los dos grupos era pe- queña. En el promedio, los programas sólidos y débiles presentaron una gran disparidad de los perfiles de las puntuaciones; los países más sólidos lograron una puntuación promedio mayor que los más débiles con respecto a cada una de las categorías de las características. Todos los países, fuere cual fuere su puntua- ción promedio, fueron selectivos con respecto a las características que destacaron en sus pro- gramas, aunque los programas más débiles re- sultaron ser más erráticos con respecto a esta selectividad de énfasis. Los programas más só- lidos se han estabilizado en una puntuación de aproximadamente el 80% de la puntuación máxima. La más elevada prevalencia del uso de anticonceptivos continuó registrándose en aquellos países que disponen de un entorno so- cial favorable y de programas más sólidos. Hill, NC, USA: Carolina Population Center, The EVAL- UATION Project, 1998. 15. Hermalin A and Khadr Z, The impact of family plan- ning 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 Sustainabil- ity 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 Fam- ily 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 ref- erence 2). 19. Freedman R and Berelson B, 1976, op. cit. (see refer- ence 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 pref- erences, contraceptive method choice, and fertility, MEA- SURE 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 Plan- ning, 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 Fu- tures Group International, 2000. (Accessible as a MEA- SURE Evaluation Working Paper at http://www.cpc. pers/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 Pop- ulation 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 Fu- tures Group International. (Also issued as a background document for the seminar Meeting the Reproductive Health Challenge: Securing Contraceptives, and Con- doms for HIV/AIDS Prevention, Istanbul, May 3–5, 2001.) 24. Casterline JB and Sinding SW, Unmet need for fam- ily planning and implications for population policy, Pop- ulation 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 Plan- ning 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 mortali- ty? 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, Conclusiones: Muchos países en desarrollo han ampliado sus programas de salud repro- ductiva, conforme a las recomendaciones ema- nadas de la Conferencia Internacional sobre Población y Desarrollo de 1994. Los mejores en el índice de trabajo y las puntuaciones de los programas sugieren que los países han po- dido hacerlo sin debilitar seriamente los es- fuerzos que realizan en el campo de la planifi- cación familiar. Résumé Contexte: L’effort des programmes de plan- ning familial à grande échelle est mesuré ré- gulièrement depuis 1972. Ces mesures visent à quantifier l’effort ou la force de ces pro- grammes, indépendamment de leurs résultats (pratique contraceptive, variations de la fé- condité, 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 développe- ment. 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 fonc- tion a été calculée pour produire l’indice d’ef- fort global des programmes. Résultats: L’indice d’effort moyen de 1999 s’est révélé supérieur (54% de la cote maxi- male possible) à celui de 1994 (48%). Les pays dont la cote était initialement faible ont enre- gistré 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 pro- fil 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 sé- lective 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 préva- lence de la pratique contraceptive reste sup- érieure 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 inter- nationale de 1994 sur la population et le dé- veloppement. L’amélioration de l’indice et des cotes d’effort de 1999 semble indiquer la ré- ussite de ce renforcement sans affaiblissement marqué de l’effort de planning familial.

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