Fertility incentives and disincentives

Some 40 countries use some form of incentives and disincentives in support of population policies, about half with the aim of reducing fertility and half with the aim of increasing it. These schemes range from limitations on tax and family allowances or maternity benefits after a given family size has been reached to payments to acceptors of fertility control methods. Some schemes aim to eliminate or reduce the cost and inconvenience people may face in achieving their fertility preferences, whereas others contain an element of deterrence. It is difficult to isolate and measure the impact of incentives on fertility from the effects of other factors such as family planning service availability or modernization. Studies in pronatalist countries suggest that incentive schemes produce short-term fertility increases without a change in average family size. Monetary incentives must be constantly increased to keep pace with inflation, placing a heavy burden on government budgets. Administrative capacity to operate the scheme is critical in terms of both manpower and efficient systems for record keeping, monitoring, and close supervision to prevent abuse. There is also considerable debate on the moral and ethical implications of incentives and disincentives as policy tools. Incentives offered for the acceptance of a particular fertility control method potentially contravene the principle of voluntary and informed consent. In addition, the relative value of the reward is greater for those in the lower income groups. The discriminatory nature of certain types of incentives and disincentives is illustrated by measures introduced in Singapore that give highest priority in school enrollment to the children of highly educated mothers with 2-3 children. This ruling is expected to further intensify the controversy surrounding incentive and disincentive schemes.     

Costs, payments, and incentives in family planning programs: a review for developing countries

Anxieties about financing health and family planning programs have grown in recent years, leading to discussions of cost-recovery measures that would raise charges to the consumer. Yet some governments wish to lower cost to encourage contraceptive use, and a few use incentives and disincentives. Data from numerous developing countries are presented on contraceptive cost topics: charges for contraceptive supplies and services, in both public and private sectors, and conversely, payments made to clients and providers to offset costs and to increase contraceptive use. The data show great diversity, and much inconsistency within countries, indicating that the structures of charges, payments, and incentives in many programs could be improved. Ethical considerations are discussed, and guidelines are suggested for developing effective financial policies.     

From clinical recommendations to mandatory practice. The introduction of regulatory practice guidelines in the French healthcare system

In an effort to control ambulatory care costs, regulatory practice guidelines (références médicales opposables or RMOs) were introduced by law in France in 1993. RMOs are short sentences, negatively formulated ("it is inappropriate to..."), covering medical and surgical topics, diagnosis, and treatment. Since their introduction, physicians who do not comply with RMOs can be fined. The fine is determined by a weighted combination of indices of harm, cost, and the number of violations. The impact of the RMO policy on physician practice has been questioned, but so far few evaluations had been performed. At the end of 1997, only 121 physicians had been fined (0.1% of French private physicians). The difficulty of controlling physicians, the large number of RMOs, and the lack of a relevant information system limit the credibility of this policy. The simultaneous development of a clinical guideline program to improve the quality of care and of a program to control medical practice can lead to a misunderstanding among clinicians and health policy makers. Financial incentives or disincentives could be used to change physician behavior, in addition to other measures such as education and organizational changes, if they are simple, well explained, and do not raise any ethical conflict. But these measures are dependent on the structure and financing of the healthcare system and on the socioeconomic and cultural context. More research is needed to assess the impact of interventions using financial incentives and disincentives on physician behavior.     

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.     

Some medical impressions of a second China visit

A team of 20 International Planned Parenthood Federation (IPPF) members from 18 countries, including 6 doctors and professionals of varying backgrounds, paid an official visit to the People's Republic of China in October, 1977. The team obtained a broad overview of family planning and health services which is compared to the author's observations made on a more recent rrip in 1979. Organized family planning progaganda began in China in 1956. By 1977 the 2-child family was the accepted norm. Family planning is regarded as an integral part of socioeconomic development and a requirement of social reconstruction and the general way of life. The leadership acknowledged a population of at least 950 million in 1979. The populace was exhorted to reduce the rate of population growth to 10/1000 by the end of 1979, to 5/1000 by 1985, and to zero by 2000. Various incentives, including housing, education and health facilities, and money, and disincentives, including tax on parents of more than 2 children, are being used to encourage a 1-child family norm. In 1979 family planning workers were more prepared to admit to problems and failures of contraceptive methods. There are still only 3-4 different oral contraceptives, 2-3 types of IUD, and condoms, available. A long-acting combination pill with norgestrel 12 mg and quinestrol was being tested in 1979. The most popular pill is the megestrol 1, 0 mg and ethinyloestradiol. .035 mg.     

Expanding the availability and improving delivery of natural family planning services and fertility awareness education: providers' perspectives

Despite the recognized benefits for clients and programs of providing natural family planning (NFP) services, few family planning programs offer NFP and few provide fertility awareness education. Furthermore, many non-governmental organizations (NGOs) that provide only NFP actually reach a very small percentage of the potential NFP users in the areas they serve. This paper discusses the results of interviews with selected family planning providers that were conducted to explore reasons why NFP and fertility awareness education are not offered in their programs, and with NFP providers to get their opinions on how to improve service delivery. The interviews were structured around some of the lessons learned from the successful incorporation of the lactational amenorrhea method (LAM) into several multimethod family planning programs. There is agreement that the need for NFP services is far from being met and that most clients lack the information and skills they could learn through fertility awareness education. The providers interviewed also acknowledged that offering these services would improve the quality of reproductive health services in general. Presented here are some ideas about why these services are not offered, as well as suggestions for integrating NFP and fertility awareness education into existing family planning programs.     

Is permanent contraception acceptable in sub-Saharan Africa?

Some authors contend that the low use of family planning in sub-Saharan Africa is due to a low demand for fertility regulation among African men and women. The present authors' experience in Africa has been that it is not the demand for family planning services, but the way services are delivered that accounts for low numbers of acceptors in Africa. The specific case of Kenya is mentioned, where improvements in the quality of sterilization services and increases in the number of institutions that can provide minilaparotomy under local anesthesia have led to an increase in the acceptance of sterilization. The authors maintain that the demand for all family planning methods does exist, and it is up to the donor agencies and family planning service providers to try to meet that demand by providing services that are efficient to providers while oriented to the clients' needs. In the case of voluntary surgical contraception, that means providing minilaparotomy under local anesthesia.     

Health care reform and family planning services

With the reforms expected for US health care, the question remains as to the impact on family planning services. Although the focus is on health care finance reform, the mix of patients seen, the incentives for decision making, and the interactions between health care providers will change. Definition of key concepts is provided for universal access, managed competition, and managed care. The position of the obstetrician/gynecologist (Ob/Gyn) does not fit well within the scheme for managed health care, because Ob/Gyns are both primary care providers and specialists in women's health care. Most managed health care systems presently consider Ob/Gyn to be a specialty. Public family planning clinics, which have a client constituency of primarily uninsured women, may have to compete with traditional private sector providers. "Ambulatory health care providers" have developed a reputation for high quality, cost effective preventive health care services; this record should place providers with a range of services in a successful position. Family planning providers in a managed competition system will be at a disadvantage. 3 scenarios possible under managed competition are identified as the best case, out of the mainstream, and most likely. The best case is when primary reproductive health care services, contraception, sexually transmitted disease screening and management, and preventive services are all obtained directly from reproductive health care providers. Under managed care, this means allowing for an additional entry gatekeeper to specialized services. The benefits are to clients who prefer seeing reproductive health care providers first; reproductive services would be separated from medical services. The out of the mainstream scenario would place contraceptive services and other preventive services as outside the mandated benefits. The government would still provide Title X type programs for the indigent. The most likely scenario is one where primary care providers offer contraceptive services, and some family planning providers would expand their services to include nonreproductive health care. Abortion services are presently out of the health care mainstream, and efforts will need to be made to identify impact on reproductive and family planning practices and to advocate for specific provisions in health care reform.     

Family planning and sexual health organizations: management lessons for health system reform

Advocates of health system reform are calling for, among other things, decentralized, autonomous managerial and financial control, use of contracting and incentives, and a greater reliance on market mechanisms in the delivery of health services. The family planning and sexual health (FP&SH) sector already has experience of these. In this paper, we set forth three typical means of service provision within the FP&SH sector since the mid-1900s: independent not-for-profit providers, vertical government programmes and social marketing programmes. In each case, we present the context within which the service delivery mechanism evolved, the management techniques that characterize it and the lessons learned in FP&SH that are applicable to the wider debate about improving health sector management. We conclude that the FP&SH sector can provide both positive and negative lessons in the areas of autonomous management, use of incentives to providers and acceptors, balancing of centralization against decentralization, and employing private sector marketing and distribution techniques for delivering health services. This experience has not been adequately acknowledged in the debates about how to improve the quality and quantity of health services for the poor in developing countries. Health sector reform advocates and FP&SH advocates should collaborate within countries and regions to apply these management lessons.     

Reproductive technologies and the private sector -- implications for women's health

Many scientific and medical techniques exist to intervene and alter the natural process of pregnancy and childbirth. Examples include contraceptive techniques such as the contraceptive pill and IUDs, instrumental and caesarian deliveries, amniocentesis and ultrasound, in-vitro fertilization, test tube babies, and artificial wombs. These services are provided by governments and private medicare institutions. Little, however, is known about private sector involvement in this area except that the number of private facilities is increasing in both urban and rural areas of India, and that private facilities include clinics, nursing homes, diagnostic centers, and corporate hospitals for both inpatient and outpatient care. With practitioners enjoying wide latitude to recommend and carry out tests and services, unlimited profit-making potential exists. Nursing homes focus primarily upon pregnancy, childbirth, and family planning. 40% of nursing homes and corporate hospitals in Hyderabad had ultrasound testing facilities, while amniocentesis is conducted widely in private clinics and hospitals around the country. 84% of private gynecologists in Bombay conduct sex determination tests which often lead to the abortion of female fetuses. 73% of nursing homes in Delhi had an ultrasound machine, with 80% of facilities using the machines for sex determination testing. Concerns over the cost of raising and marrying off daughters lures clients to test the sex of fetuses and not carry females to term. Hospitals and clinics also capitalize upon the social stigma of marital infertility by promoting the treatment of infertility and in-vitro fertilization. Moreover, responding to government incentives to provide comprehensive family planning services, many private clinics and nursing homes claim to offer services even when they do not. Private nursing homes and clinics offer services to maximize profit. As public spending for programs continues to be slashed and the role of private institutions increases, more attention needs to be given to monitoring the quality of services.     

Declines in the age and family size of family planning program acceptors: international trends

Social changes are encouraging couples to inititate contraception at younger ages, practice spacing, and in general reduce fertility. The personal characteristics of acceptors in the family planning programs of 23 developing countries were accumulated with concentration on the age and number of children by contraceptive method. The findings indicate that the ages and family sizes of acceptors decline with little relation to available family planning programs or contraceptive method. Contraceptive methods must fit the needs of younger couples; therefore, services for sterilization must still be maintained while new services are added which take into account age distributions of married women and age-specific acceptance rates.     

Family planning funding through four federal-state programs, FY 1997.

CONTEXT: The maternal and child health (MCH) and the social services block grants have long played an important role in the provision of family planning services in the United States. The extent to which states have incorporated family planning services into the newer federally funded, but state-controlled, programs--Temporary Aid to Needy Families (TANF) and the State Children's Health Insurance Program (CHIP)--has yet to be identified. METHODS: The health and social services agencies in all U.S. states, the District of Columbia and five federal jurisdictions were queried regarding their family planning expenditures and activities through the MCH and social services block grants and the TANF program in FY 1997. In addition, the states' CHIP plans were analyzed following their approval by the federal government. Because of differences in methodology, these findings cannot be compared with those of previous attempts to determine public expenditures for contraceptive services and supplies. RESULTS: In FY 1997, 42 states, the District of Columbia and two federal jurisdictions spent $41 million on family planning through the MCH program. Fifteen states reported spending $27 million through the social services block grant. Most of these jurisdictions indicated that they provide direct patient care services, most frequently contraceptive services and supplies. Indirect services--most often population-based efforts such as outreach and public education--were reported to have been provided more often through the MCH program than through the social services program. MCH block grant funds were more likely to go to local health departments, while social services block grant funds were more likely to be channeled through Planned Parenthood affiliates. Four states reported family planning activities funded under TANF in FY 1997, the first year of the program's operation. Virtually all state plans for the implementation of the CHIP program appear to include coverage of family planning services and supplies for the adolescents covered under the program, even when not specifically required to do so by federal law. CONCLUSIONS: Joining two existing--but frequently overlooked--block grants, two new, largely state-controlled programs are poised to become important sources of support for publicly funded family planning services. Now more than ever, supporters of family planning services need to look beyond the traditional sources of support--Title X and Medicaid--as well as beyond the federal level to the states, where important program decisions are increasingly being made.     

Managed care and the prevention of unintended pregnancy.

Managed care organizations (MCOs) hold the potential to help address the significant public health issue of unintended pregnancy. Managed care's delivery of women's primary care and family planning services is reviewed. Some MCOs provide better coverage of contraceptive options as well as better confidentiality protections, but not enough is being done in partnering with existing family planning providers and in educating providers about the need to provide family planning counseling, particularly for adolescents. Performance indicators should be developed to create incentives for health plans to assess their success in reducing unintended pregnancy within their enrolled populations.     

Vanguard family planning acceptors in Senegal

This study examines contraceptive use among clients at the three clinics providing family planning services in Dakar, Senegal in early 1983. Most clients first became interested in family planning following the birth of a child, and most are interested in spacing future pregnancies, although one-third state that they want no more children. The clinic itself was found to be an important determinant of the type of contraceptive used, with only the government-operated clinic providing a balance between IUDs, oral contraceptives, and barrier methods. Nearly half of the clients interviewed said that a lack of knowledge about contraception is the reason for the low contraceptive prevalence rates among Senegalese women; another frequently cited reason was the opposition of the husband. Most clients reported the broadcast media to be the best means of providing family planning information to potential acceptors.     

The quality of family planning services in the United States: findings from a literature review

CONTEXT: Family planning services are frequently used and important services for American women, yet little is known about their quality. Service quality has important implications for women's reproductive health. If women do not receive adequate information and tools, and learn appropriate skills, from their providers, they may be hampered in their efforts to control their fertility. METHODS: A variety of strategies, including database, journal and Internet searches, were used to identify published and unpublished U.S. studies on family planning service quality that came out between 1985 and 2005. Studies were categorized by their focus, and key points of their methodologies and findings were assessed. RESULTS: Twenty-nine studies were identified, most of which were based on client surveys. Most conceptualized quality as a multidimensional construct, but a uniform definition of quality is lacking, and the domains studied have not been consistent. The available studies focus on four areas: assessments of quality, its correlates, its consequences for client behavior and attitudes, and clients' values and preferences regarding services. Relations between clients and service facility staff have typically been rated favorably, but communication, patient-centeredness and efficiency have been rated more poorly. Service quality varies by characteristics of the facility, provider, client and visit. Research on the consequences of service quality for clients' contraceptive behavior or risk of unintended pregnancy has been very limited and yielded mixed results. CONCLUSIONS: Studies that assess service quality need stronger designs and greater consistency in measures used so that results are comparable.     

Cultural feasibility assessment of tuberculosis prevention among persons of Haitian origin in South Florida

A cultural feasibility study was conducted among persons of Haitian origin in South Florida to identify factors which might influence utilization of screening and treatment services for latent tuberculosis infection in this population. Five focus group interviews conducted among men and women explored cultural beliefs and practices related to TB, barriers and incentives to screening, and approaches to increasing treatment adherence. Key findings include the influence of social stigma and fears related to confidentiality of medical status as disincentives to screening. Cultural sensitivity to being labeled as a high risk group for these infections also emerged as a critical variable. Community-based approaches to health education for this population are described. Study recommendations include the planning of programs based on a service delivery model that stresses respect and personal attention to clients, improved interpersonal skills of health center staff, and coordination of services between private doctors and public health agencies.     

Women's experiences with family planning

India's family planning programs target rural women because they do not have political power. Interviews with those in Maharashtra show their lack of choice and low access to resources and their need for safe contraception. In 2 rural villages, for every dead child, a woman bears, on average, 2 more children. When a child dies, villagers first suspect the mother of having performed voodoo or witchcraft. Other suspected women are deserted women, widows, and menstruating women. Health and family planning services are not based on people's perceptions of body, anatomy, illness, and cure. People are not informed about interventions, particularly contraception. Women are not comfortable with contraceptives, and when physician ignore genuine symptoms and sequelae, it reinforces women's suspicions about contraceptives. Sterilizations performed in camps result in more side effects than individually performed sterilizations. During 1975-1977, women were kidnapped and sterilized under very unhygienic conditions. Common complaints after sterilization are menstrual disturbances and lower back pain. Many private physicians treat these complaints by performing hysterectomy. Women rarely are involved in the decision-making process determining whether or not they should undergo sterilization. They are often given false promises, if they accept sterilization. Indian women have little choice in contraceptives. The low biodegradability of condoms poses a disposal problem. Health workers often dispose of IUDs, pills, and condoms which they claim have been accepted. Auxiliary nurse midwives are pressured to meet family planning targets, so they harass women to accept contraception. Village women do not trust them. Health workers often steal cases from each other. Many complain that minorities are responsible for the population explosion, but the minority's family size is basically the same as that of the majority. Low access to general health services and harassment to fulfill family planning quotas create an undesirable climate to introduce injectables and implants into the family planning program.     

A study of costs and behavioral outcomes of menstrual regulation services in Bangladesh

This paper reports the results of a program evaluation of menstrual regulation (MR) services provided by the Bangladesh Women's Health Coalition, a nongovernmental organization formed in response to a concern about the availability of quality MR services to Bangladeshi women. The program emphasizes individual counseling which stresses informed choice in reproductive health care. The evaluation examines the cost of this process as a function of behavioral outcomes which include the percentage of clients who are post-MR contraceptive acceptors and the percentage which return for follow-up care and consultation 2 weeks after the procedure. The average cost per post MR contracepting client is $3.75; the average cost per returning client is $5.68, figures which appear to be well within the range of costs reported by family planning programs in developing countries.     

Gender, sexuality and communication issues that constitute barriers to the use of natural family planning and other fertility awareness-based methods

Fertility awareness-based methods of family planning are rarely offered through reproductive health services in Latin America, despite evidence that many women use them. Providers state that clients do not want these methods, but provider-bias is evident. Providers overestimate the difficulty of learning and using fertility awareness-based methods, and they underestimate their efficacy. Both providers and clients have difficulty dealing with sexuality (which is central to fertility awareness-based methods). Many providers lack gender sensitivity, 'worsening' the unequal relationship between providers and clients. Experience has shown that when fertility awareness-based methods are well provided, they can have a positive effect on sexuality, self-understanding, and equality in the couple's relationship.     

A comparative study of characteristics of adolescent and adult family planning acceptors in Lagos

A comparative study of adolescent and adult new acceptors of family planning at a family health clinic of a primary care project in Lagos over an eleven-year period, showed only 0.8#pc of acceptors to be adolescents ( 9 years. It found a statistically significant smaller proportion old adolescents than adults without education, but a greater proportion of adolescents with at least secondary school education. Significantly fewer adolescents were in polygamous unions and in professional occupations. The gravidity, parity, and number of children alive was expectedly lower among the adolescent acceptors.

More adolescent acceptors had previously practised abstinence as a means of contraception. The two most common methods accepted from the clinic by both groups was the IUD and the pill, and none of the adolescents contemplated stopping childbearing. The implications of the findings for family planning services for adolescents are discussed.