Describe the evaluation of family planning services.

Evaluation of Family Planning Services

• The levels of evaluation — input (funds, staff, supplies, facilities); process (services delivered, counselling given, workers trained); output (acceptors, couple protection); outcome (contraceptive prevalence, unmet need); and impact (fertility rate, birth rate, maternal and infant mortality)
• The indicators in common use:
• The couple protection rate — the percentage of eligible couples effectively protected by an approved method
• Its defects are instructive and should be given — it counts sterilisations cumulatively, so it rises automatically year on year even if no new service is provided; it gives NO information about method choice or quality; and it counts a couple as "protected" whether or not they wished to be
• The contraceptive prevalence rate — the percentage of women of reproductive age, married or in union, currently using a method, which is measured by survey rather than by service records and is therefore less open to reporting inflation
• The method mix — the distribution of users across methods, which is diagnostic in itself, since a mix dominated by sterilisation shows that spacing services are failing
• Unmet need — the proportion of women who wish to space or limit births but are not using contraception
• This IS the most honest single indicator, because it is defined by the woman’S own stated intention rather than by a programme target, and therefore cannot be improved by persuading people to accept something they do not want
• Other measures — the discontinuation rate, which reveals quality of counselling and follow-up; the failure rate; the pearl index, expressing failures per 100 woman-years of use; and couple-years of protection
• The discontinuation rate deserves emphasis, since programmes rarely report it — a high number of acceptors with a high discontinuation rate represents effort wasted and, worse, women left unprotected while believing themselves covered
• The impact indicators — crude birth rate, total fertility rate, net reproduction rate and the decadal growth rate
• A caution about attributing impact — fertility falls for many reasons besides the programme, including education, income, urbanisation and child survival; so a falling birth rate cannot simply be credited to the family planning programme, and an honest evaluation acknowledges this
• The historical lesson about indicators is the substance of this answer:
• When India used method-specific targets, workers pursued the target rather than the client
• The observable consequences were — sterilisation of people already unlikely to have more children, which achieves nothing demographically; neglect of spacing methods, which met no target; poor counselling and follow-up, since only the acceptance was counted; falsification of records; and coercion and misinformation
• The general principle, which extends far beyond family planning — what IS measured IS what gets done, and an indicator that is easy to count will displace one that is hard to count, however much more important the second is
• Sterilisations are easy to count; a good counselling conversation is not — and that asymmetry alone explains much of the programme’s history
• The modern approach follows from this — target-free, with community needs assessment; evaluation by unmet need, method mix and continuation rather than by acceptor numbers; quality of care assessed by client satisfaction, informed choice and follow-up; and independent survey data (NFHS) rather than programme self-reporting
• The BRUCE framework of quality of care is worth naming, with its elements of choice of methods, information given to clients, technical competence, interpersonal relations, follow-UP and continuity, and an appropriate constellation of services
• The conclusion — a family planning programme should be judged by whether people are able to have the number of children they want, when they want them; and unmet need is the indicator that asks precisely that question
• What is measured is what gets done, and an easy indicator displaces a hard one however much more important the second is
• Unmet need cannot be improved by persuasion, since it is defined by the woman own stated intention
• Couple protection rate rises by itself, counting sterilisations cumulatively whatever else the programme does
• Contraceptive prevalence comes from surveys, and is therefore less open to inflation than service records
• Report discontinuation, which programmes rarely do, since acceptors who stop leave women unprotected while believing otherwise
• Targets caused sterilisation of the already infertile, which achieved nothing demographically but met the number
• Fertility falls for many reasons besides the programme, so a falling birth rate cannot simply be credited to it
• The Bruce framework names quality elements — choice, information, competence, relations, follow-up and services
• Evaluate at input, process, output, outcome and impact, since a programme may succeed at one level and fail at another
• Pearl index expresses failures per hundred woman-years, which allows methods to be compared on a common basis
• Use independent survey data rather than programme self-reporting, which has an obvious interest in the answer
• Judge by whether people have the children they want, when they want them, which is what the programme is actually for
• A good counselling conversation cannot be counted, which is precisely why it gets displaced by things that can