National health services and family planning: Thailand, a case study.

The family planning program of Thailand was organized, planned, and implemented by means of the rural health and hospital services of the Ministry of Public Health. Without this integration, the program would not have been allowed by the government. The Thai health system was reasonably well-established, the use of its personnel lessened cost and duplication of efforts, and the resulting integration was successful. The program operated very quietly between 1968 and 1970. No public information was allowed. There were no full-time family planning workers, and no goals and incentives were offered. Only in 1970 when the government announced a national population policy were the restrictions on public information removed. In the development of the program, more than 7600 employees of the Ministry of Public Health received the 1-week training program. After training, family planning clinics were opened in the provincial hospitals and in those rural health centers staffed with a physician. Initially, the auxiliary midwives were expected only to motivate and provide information to those in their areas, referring interested couples to the centers and hospitals for the IUDs, oral contraceptives, and sterilization programs that were available. However, after the successful completion of a pilot study in 1970, the midwives were permitted to prescribe the oral contraceptive. A postpartum program which attempted to motivate women in the use of family planning 2-4 days following delivery revealed that with proper motivation efforts a majority of women will accept family planning services postpartum. A special evaluation section was developed within the Ministry to assess the progress of the program. Many problems continue to require attention, such as the need for high level government support shown by a budget increase and the development of effective supervision for staff within the health system.     

Community-based approach to refugee relief: experiences from Thailand

The Community Based Emergency Relief Services (CBERS) of Thailand pioneered a new approach to solving the problem of assisting Cambodian refugees. In 1980 following the influx of more than 150,000 Cambodians into Thailand CBERS proposed family planning to address the potential infant and maternal health threat posed by hazardous conditions within the refugee camps. Based on a survey CBERS launched a voluntary family planning and maternal and child health care program which offered oral contraceptives (OCs), IUDs, and injectables through existing health units, mobile service vans, and community-based distributors. Approximately 1500 Khmer leaders were trained in family planning and mass media techniques passed the information to the general population. Movies were shown and desensitization techniques were used. Each acceptor was counseled about choice and method as well as use of contraceptives and appropriate health education; sessions were held in groups of 30 women. A total of 8236 women chose to practice family planning during the campaign with 95% of all acceptors choosing the injectable contraceptive. Following service delivery a community-based family planning program was initiated to provide followup services. Other services provided by CBERS include sanitation services, vector control, and waste disposal as well as agriculture and skills development programs to train the refugees. By the end of 1981 over 12,000 people received specialized training. These programs have heightened the refugees' self esteem and they are well prepared to begin their return to Cambodia.     

Incentives and disincentives in the Indian family welfare program

The Indian family welfare program has offered financial incentives since the early 1960s to both family planning motivators and acceptors of sterilization and the IUD. This article reviews the available evidence regarding the impact of incentives on the quality and quantity of family planning services in India. Administrative concerns related to the implementation of incentive programs are discussed, and the current debate on disincentives, as well as the brief period when disincentives were used, is summarized. The studies reviewed, though few in number and varying in quality and methodology, indicate that incentives to acceptors help to increase the level of contraceptive acceptance, especially when they are part of a well designed strategy of service delivery and client motivation. Incentives do not appear to have an adverse effect on quality of services and acceptors, and they do not seem to influence method choice. Disincentives, if they are used, should not impinge on fundamental individual rights of either the parents or the child.     

Community participation in national family planning programs: some organizational issues

Increasing the involvement of communities in implementing national family planning programs has been advocated as a means of increasing the acceptability, availability, and sustainability of services provided. This article reviews the nature and extent of community participation in the national programs of Bangladesh, China, the Republic of Korea, the Philippines, and Thailand by analyzing the structures and processes through which participation is organized. Across all five countries a similar pattern of participation has emerged in which a community-based delivery system is supported by the involvement of community leaders in activities that promote family planning. Active participation in planning and management functions is, however, virtually nonexistent. This limited form of participation is attributed to the bureaucratic organization of national family planning programs that seek to implement policies with explicit demographic goals. Given these goals and organizational structures, however, the pattern of organizing participation observed is probably the most appropriate. Consequently, policymakers should be wary of expecting greater involvement by community members in program implementation activities or in contributing resources unless consideration is given to reorienting the goals and organizing programs that meet needs that are directly relevant to families and communities.     

Incentives to promote family planning

ObjectiveOver the past 60 years, population control has become an increasingly urgent issue worldwide as a growing population strains already limited resources. The use of financial incentives to promote family planning is an innovative approach that has potential to make a contribution to efforts to better manage population growth. This report reviews eight studies that examined the effect of incentives on family planning.MethodPublished studies that tested the impact of incentives to promote some aspect of family planning and included an appropriate control or comparison condition were reviewed.ResultsIncentives have been used to promote attendance at contraceptive education sessions, adoption and continuation of contraceptive methods, sterilization, and to limit family size. All but one of the eight studies reviewed reported positive outcomes, but weaknesses in study design and execution limit the strength of the conclusions that can be drawn.ConclusionReview of this literature suggests that family planning behaviors, like other behaviors, are sensitive to incentives. Given the tremendous need for efficacious interventions in global efforts to manage population growth, further research on this topic using more rigorous experimental methods is warranted.     

East Asia Review, 1973. 9. Thailand

Developments in the field of population and family planning during 1973 in Thailand are reviewed. Thailand's National Family Planning Program experienced a 10% decline in acceptors. There were 18% fewer pill acceptors in 1973 than in 1972. IUD insertions increased slightly and the number of female sterilizations rose considerably. It has been difficult to maintain the program's momentum. However, in the last quarter of the year there was an increase in the number of new acceptors. In 1973, the United Nations Fund for Population Activities (UNFPA) supported the first nationwide public information and communications program. It also assisted in expanding the sterilization project and in accelerating the development of the 4-province maternal and child health and family planning service project. Preliminary plans were made for increasing the number of contraceptive methods provided by the national program. The Thai program assumed an active role in the International Committee for Applied Research in Population and the Inter-Governmental Coordinating Committee. The Planned Parenthood Association of Thailand expanded its activities, primarily in the area of public information and communications. A pilot project to train nurse-midwives to conduct gynecological examinations and insert IUDs was begun. A new 7-story building for the Family Health Division was completed in early 1973 with the support of the Royal Danish Government and was occupied in April. Motorcycles provided by the UNFPA for use by government midwives began to arrive during the year. Over 1500 of a total of 3600 expected by mid-1974 are already in the field. This equipment is expected to increase dramatically the mobility of midwives throughout the country.     

RCH in the context of women's health

India's current reproductive and child health (RCH) program is based upon the principles of the 1994 International Conference on Population and Development (ICPD), with the goal of making contraceptive and terminal methods available to couples who wish to limit their family size. As a signatory to the ICPD, the government of India reoriented its family welfare program so that it no longer focuses upon contraceptive targets and incentives. Decentralized planning and monitoring at the local level, the promotion of community involvement, and increased intersectoral coordination are central elements of the program, with client satisfaction as its main goal and demographic impact only secondary. The new integrated package of RCH was launched countrywide in October 1997 to provide integrated family welfare and health services for women and children, with the goal of improving the quality, coverage, effectiveness, and access to the services. Issues overlooked in the RCH and the role of voluntary organizations are discussed.     

The indigenous midwife in Asia--supporter or opponent of family planning?

A traditional birth attendant, also known as an indigenous midwife, is the main provider in many developing countries of obstetric services. Due to this unique position, the traditional birth attendant has been considered as possibly the ideal person to deliver family planning services in her local community. This consideration has influenced program policy in many countries and consequently there is information available to aid in the determination of whether to involve traditional birth attendants and, if so, how to best use them. There have been 2 opposing views in response to the involvement of traditional birth attendants. 1 view regards them as potential innovators. She is seen as ideally placed both physically and socially to act as a representative of the family planning program to her patients. The traditional birth attendant is the acknowledged and often prestigous expert on obstetrics matters, including at times traditional methods of birth control. The alternative view is less hopeful for rather than identifying the traditional birth attendant as an innovator it regards her as a firm opponent of innovation, a determined conventionalist. Pro gram experience in India, Pakistan, Indonesia and East Java and experime ntal studies in the Philippines, Malaysia, and Thailand along with anthr opological inquiries generally support the skeptical view but none of the findings imply that the traditional birth attendant should be ignored by the family planning programs. In the intermediate positions of many actual programs, the wisest plan seems to be to ensure that the potential contribution of the traditional birth attendant is neither overlooked nor exaggerated.     

Family planning programme and management tools

India's family planning program is not improving. The performance in 1973-1974 was about 1/3 of the 1972-1973 performance. It is the opinion of some experts that the family planning program is not being managed well and that greater success can be realized if the standard management tools, with appropriate modifications, are utilized. Management is the process of planning, organizing, directing, coordinating, and controlling people, materials, machines and money in order to realize the optimum achievement of the program objectives. The family planning program should be reviewed as a system. Decisions made in the various sub-systems of the family planning system should be made in such a way that the various sub-systems act in a coordinated manner to achieve the overall program objective. The approach of the current family planning program is trial and error. In order to make the family planning workers more committed and motivated, the program should be planned at the micro level on the basis of 2 management principles -- participation and decentralization. Various management principles may be used to plan a family planning system. The principles of marketing can be effectively utilized. Evaluation should be a built-in process of the program. An effective Management Information and Evaluation System (MIES) should be devised because such a system furnishes relevant data in a useful form to the right person at the right time, for use in policy decision.     

Family planning and adoption promotion: new proposals,long-standing issues

This paper sheds lights on long-standing issues and new proposals on family planning and adoption promotion. The spate of bills promoting adoption in Title X family planning clinics and federally funded health centers by opponents of family planning programs raise a significant concern in the family planning community. This concern gave rise to questions on the nature of adoption counseling that should be offered to pregnant women in government-funded programs and the extent to which family planning programs should assume the duties of adoption agencies. Budgetary constraints also raise a serious question on the degree to which family planning funds should be rechanneled to serve this purpose. One more immediate issue, however, is the fact that two of the proposed strategies deny women facing pregnancy crisis the right to informed decision on their options by preventing family planning providers to discuss on abortion. Other measures set include the revival of the abortion "gag rule" previously imposed by the Reagan and Bush administrations and promoting a program of direct federal subsidy to organizations which provide counseling to women provided that these organizations shall provide full information on pregnancy options.     

Family planning education as an integral part of day care services in Korea

The Integrated Day Care Program (IDCP) in Korea provices family planning classes as an integral part of comprehensive day care services for low-income families. The program was initiated by CARE in 1973, with support from the Korean government, and has received important inputs from national family planning agencies. A review of the first two years' accomplishments shows that mothers participating in the IDCP knew more about, were more favorable toward, and were more likely to practice family planning than mothers using day care centers that were not a part of the program. Findings also demonstrate the potential for program expansion: the substantial numbers of friends and relatives brought by mothers to the classes, and the number of IDCP and non-IDCP mothers indicating a willingness to use family planning clinic services in the day care setting.     

The dilemma of family planning in a North Indian State.

An empirical study of the family planning program and its clients in the rural areas of Allahabad Division of Uttar Pradesh in India was undertaken in 1971-1972. While family planning acceptance in this region is low, interviews with villagers and family planning staff suggest that organizational shortcomings of the program may help to explain the low level of acceptance. The reported level of contact between the program field staff and the village population was unexpectedly low. The paper discusses a number of administrative problems within the family planning organization, especially at the level of the primary health center. It is concluded that in designing family planning programs, efforts should be made to minimize organizational requirements.     

Family planning in the People's Republic of China

China's goal is to reduce the current growth rate of 2 to 1% per annum by the year 2000. To do so all methods of family limitation are encouraged, such as raising the age of marriage, distribution of contraception, and induced abortion. The paramedical barefoot doctors have helped the spread of family planning by their ability to prescribe pills and insert IUDs. Sterilizations are performed, and there are monitary incentives for vasectomy of 20% of the mans monthly salary. Abortion is permitted during the first 3 months of gestation. The optimum age of marriage is considered 30 for men and 22 for women, and is promoted by propoganda means. The program began in the late 1950s and has been administered through the Ministries of Health, Propaganda, Culture, Commerce and the China Medical Association.     

Education in family planning in Indonesia

Indonesia's family planning program has raised contraceptive prevalence from 3% in 1970, the year the program was established, to 58% in 1984. One of the keys to the success of this program has been education, brought directly to the community by community leaders, field workers, and program officers in public health centers, hospitals, and the private sector. The information, education, and communication campaign around the varius contraceptive methods has required large numbers of trained personnel. Family planning workers receive training in the health service centers in a variety of basic, functional, and specific subjects and are informed about the most recent advances in fertility management. In addition, full family planning training is provided to medical students at Udayana University, which produces 100 doctors/year. By 1984, a total of 32,753 personnel had been trained. It is estimated that within another 5 years, there will be 50,000 trained family planning workers. Most of those trained are field workers who recruit family planning acceptors in rural areas. Some family planning methods are introduced directly to the villagers, a practice that creates an information chain for surrounding communities and facilitates the work of field personnel.     

A cost-benefit analysis of the Mexican Social Security Administration's family planning program

A cost-benefit analysis of the family planning program of the Mexican Social Security System (IMSS) was undertaken to test the hypothesis that IMSS's family planning services yield a net savings to IMSS by reducing the load on its maternal and infant care service. The cost data are believed to be of exceptionally high quality because they were empirically ascertained by a retrospective and prospective survey of unit time and personnel costs per specified detailed type of service in 37 IMSS hospitals and 16 clinics in 13 of Mexico's 32 states. Based on the average cost per case, the analysis disclosed that for every peso (constant 1983 currency) that IMSS spent on family planning services to its urban population during 1972-1984 inclusive, the agency saved nine pesos. The article concludes by raising the speculative question as to the proportion of the births averted by the IMSS family planning program that would have been averted in the absence of IMSS's family planning services.     

Contraceptive Use,Birth Spacing,and Autonomy: An Analysis of the Oportunidades Program in Rural Mexico

Oportunidades, a conditional cash‐transfer program instituted in Mexico in 1997, provides cash incentives to mothers to invest in the health and education of family members. Drawing from data gathered by Mexico's National Institute of Public Health, this study assesses the effect of the program on contraceptive use and birth spacing among titulares (female household heads) living in rural areas during the experimental period, 1998–2000, and during 2000–03, after incorporation of the control group. In 2000, titulares were more likely to use modern contraceptives than were women in the control group, although by 2003 all beneficiaries had the same probability of use. Change in autonomy was not a mediator, although baseline autonomy modified the program's influence on contraceptive use. Cox proportional hazard models produced estimates that birth spacing was similar between the beneficiaries and controls. Inconsistent findings may be the result of the way contraceptive use was defined in this study. Findings from this study may be useful for helping program planners better understand the role of conditional cash transfers in modifying family planning and fertility among poor rural women in Latin America.     

Florida doctors seeing Medicaid patients show broad interest in federal incentives for adopting electronic health records

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 aims to expand the use of electronic health records by offering financial incentives to physicians to fully adopt and implement them. We surveyed Florida physicians who deliver care to Medicaid participants to identify their interest in participating in the incentive program. More than 60 percent of all respondents expressed interest in applying for the incentives; of those already using electronic health record systems, 86 percent intend to apply for funding. This relatively high proportion of physicians creates the potential to reach the overall policy goals of the law. Among those not planning to seek incentives, common barriers--especially among nonusers of electronic health records--were "costs involved" (69 percent), "need more information about incentive program" (42 percent), and uncertainty about what system to purchase (42 percent). We suggest that these findings hold implications for the Regional Extension Centers working to help physicians achieve the federal meaningful-use criteria that are a condition of receiving the incentives. In particular, the centers should focus on providing physicians with information about costs of electronic health record systems.     

A five-year plan for population research and family planning services. 3. Family planning services

A tentative family planning program plan for 1971-1975 is presented. The estimated need for family planning services by 1975 is projected to be 6.6 million individuals, classified as poor and medically indigent. The author states that more research is needed to project a similar need for higher income groups who have trouble controlling the number and timing of their children. With better research family planning services could help meet their needs too. The plan projects greater expansion of services to non-metropolitan areas to overcome a maldistribution of present programs. It is estimated that 90% of those in need can now be served by existing services, while new delivery agencies would need to be created to serve the remaining need. Manpower development of this plan calls for an expansion in the use and role of paraprofessional personnel. The utilization of operational research, planning and evaluation is needed for objective data, to help programmers determine shape and scope of required program, and to improve its efficiency and effectiveness. To do this a 3 phase 5 year plan is presented. As program services expand the role information, education and communication plays is critical. Development of these functions will help in reaching program goals. Projected estimates by 1975 of direct costs of provision of family planning services will be between 360 and 395 million dollars.     

Extending Medicaid coverage for family planning services: Alabama's first four years

OBJECTIVES: This study examines whether Alabama's Medicaid family planning demonstration program reaches a different segment of the population than the health department-based Title X family planning program, whether service use rates differ across clients using care within and outside of the Title X provider system, and whether additional risk assessment and care coordination services provided by health department personnel increase the likelihood that family planning clients return for follow-up visits over time. METHODS: Administrative data from four years of operation of the program were used to examine characteristics of the clientele, differences in services used across provider types included in the program, and the impact of risk assessments and care coordination on return visit rates. RESULTS: The number of family planning service users increased dramatically over the four-year period, but were more similar demographically to Title X clients than to Medicaid maternity clients. Growth was greatest among clients of non-Title X providers. Newly covered services, including risk assessments and care coordination, were available mostly to Title X clients, and these services were associated with a greater likelihood that clients returned for care in subsequent years. CONCLUSION: Expanded provider networks can increase the number of low income women using family planning services while risk assessment and care coordination can improve the effectiveness of these services. However, enhanced services may not be equally available across provider systems. Additional outreach efforts are needed to reach women eligible for publicly supported family planning services who are not currently using these services.