Implenting family planning in a Ministry of Health: organizational barriers at the state and district levels

1. Family planning occupied a subordinate position in the medical and health bureaucracy almost two decades after its introduction. Senior Ministry officials accorded low priority to formal program objectives, while the State Family Planning Officer, the highest state official concerned solely with the family planning program, suffered from a relatively subordinate position in the Directorate and a lack of authority and support. Within the medical profession, family planning was held in low esteem, and the medical and health bureaucracies did not have a mechanism for selecting personnel on the basis of interest and commitment. 2. Organizational adjustment to family planning in the Ministry of Health was a slow and painful process, absorbing the energy and attention of Ministry officials for almost a decade. The repeated reorganizations of the district setup revolving around the division of labor between medical, health, and family planning acitvities and between the rural and urban program, led to months of almost total inertia and detracted substantially from the supervisory capacity of the officials involved. 3. Decision making and guidance suffered from the quick turnover of the Secretary, the most powerful administrator in the Ministry. In Uttar Pradesh Secretaries stayed barely long enough to begin to understand the complex organizational setup of the program. 4. Multiple and often conflicting lines of authority characterized the relationships between the higher and lower echelons within the Ministry. This was accentuated when the District Family Planning Officer was placed under the administrative control of the District Magistrate. While intended to "energize" family planning through the association of the most prestigious and powerful district official with the program, this organizational arrangement resulted in conflicting instructions to the staffs of the primary health centers. 5. The organizational behavior of the Ministry of Health was shaped by the interplay of the various "professional cultures" of its key actors. The generalist administrators' short time horizon and eagerness to produce quantitative results clashed with the specialists' emphasis upon long-term goals and technical constraints; the politician's defense of the interest of his constituents clashed with the administrator's desire to defend his autonomy. The calculus of political survival made support for family planning goals a costly burden that few politicians have been willing to shoulder. As the party system does not reward the advocacy of family planning, ministers emphasize those programs within their ministry or those decisions within their discretion that correspond to the demands of their constituents.     

Community-based integrated family planning programs.

Since 1976, the Japanese Organization for International Cooperation in Family Planning has operated a series of pilot projects in several Asian countries in which family planning fieldworkers are given the added taks of controlling soil-transmitted intestinal parasite (hookworm) and providing associated nutrition education, as a means of increasing their credibility, contributing to more favorable attitudes toward family planning. Given that family planning is a new and formal program being introduced into a community, the Integrated Program has 4 stages: 1) Strategic planning. The earlier people at all levels are brought into the project processes, the higher the chances of positive commitment. A tripartate steering committee is thus formed, involving influential people from government, private, and expert sectors, with primary policy-making responsibility and responsibility for project design, implementation and assessment, and with links to funding sources. 2) Project design and development. Local leadership is identified and involved in discussions, and additional project staff, other personnel, and community groups are drawn in, a process called "bottom-up planning." Community leaders, properly motivated and trained, are best for organizing in the community, with project staff providing technical and logistical support. Plans are often modified, and identifying community leaders can be time consuming, but they are essential to program success. 3) Implementation. At this stage project staff has 2 functions: promotion and delivery of services and helping the community to take over the program at its maintenance stage. Where potentially cooperative local groups are not functioning, project staff must form them. 4) Assessment. While rates of family planning acceptance and continuation and declines in parasite infestation are indicators of success or failure, more important is people's attitude as shown by participation and assumption of responsibility. In addition to conventional measurements, 4 kinds of evidence also needed are positive reaction of the community; increased government recognition or support; increased cooperation and activity among government and private organizations on information, education, and communication; observable change in the community. The final, maintenance stage, when the program has become institutionalized and self sustaining within the community, has not yet been reached by any of the pilot proejcts.     

Measuring the Extent of Gerontological Home Care Staff Participation in Agency Policy Making and Planning

A survey study of the work experience and views of administrative and direct service program staff (N=91) in both small scale and large scale Older Americans Act-funded home care programs in New York City sheds light on thc extent to which various categories of personnel in the field of community home care have opportunities to participate in a range of agency policy making and planning functions. Findings reveal that home care staff in small scale programs were more directly involved in both client-centered and program-centered policy planning activities. In particular, these workers felt they were significantly more active in: 1) changing service plans; 2) discussing changes that nced to be made in how the agency operates; 3) planning new services and programs at the agency; and 4) helping to train or orient new workers in the program. A strong negative correlation between level of organizational complexity and worker participation rates was discovered. Additional data suggest that all staff, regardless of their status or work responsibility, would like to be granted more of a voice in planning decisions. Those who participate least in such activities were most adamant over being given a greater role in this aspect of program life. Heightened levels of job satisfaction were also associated with greater measures of worker involvcment in organizational decision-making. Study findings are seen to have implications for the design of more equitable decision-making mechanisms in gerontological home care specifically and human service programs generally.     

Measuring the extent of gerontological home care staff participation in agency policy making and planning.

A survey study of the work experience and views of administrative and direct service program staff (N = 91) in both small scale and large scale Older Americans Act-funded home care programs in New York City sheds light on the extent to which various categories of personnel in the field of community home care have opportunities to participate in a range of agency policy making and planning functions. Findings reveal that home care staff in small scale programs were more directly involved in both client-centered and program-centered policy/making activities. In particular, these workers felt they were significantly more active in: changing service plans; discussing changes that need to be made in how the agency operates; planning new services and programs at the agency; and helping to train or orient new workers in the program. A strong negative correlation between level of organizational complexity and worker participation rates was discovered. Additional data suggest that all staff, regardless of their status or work responsibility, would like to be granted more of a voice in planning decision. Those who participate least in such activities were most adamant over being given a greater role in this aspect of program life. Heightened levels of job satisfaction were also associated with greater measures of worker involvement in organizational decision-making. Study findings are seen to have implications for the design of more equitable decision-making mechanisms in gerontological home care specifically and human service programs generally.     

Influences on family planning acceptance: an analysis of background and program factors in Malaysia.

Which factors have the greater influence on family planning performance: fixed background variables such as racial composition, urbanization, and mortality, which are affected by level of development, or program inputs such as assignment of personnel and location of clinics, which are subject to manipulation by administrators? An analysis of differences in family planning acceptance among 70 districts of Malaysia shows that two main program-manipulable variables--level of personnel deployment and accessibility of clinics--have the largest direct effect upon acceptance levels. Variations in background factors explain a smaller proportion.     

People and money matter: investment lessons from the Ontario Heart Health Program, Canada

Resource allocation is a critical issue for public health decision-makers. Yet little is known about the level and type of resources needed to build capacity to plan and implement comprehensive programs. This paper examines the relationships between investments and changes in organizational capacity and program implementation in the first phase (1998-2003) of the Ontario Heart Health Program (OHHP)--a province-wide, comprehensive public health program that involved 40 community partnerships. The study represents a subset of findings from a provincial evaluation. Investments, organizational capacity of public health units and implementation of heart health activities were measured longitudinally. Investment information was gathered annually from the provincial government, local public health units and community partners using standard reports, and was available from 1998 to 2002. Organizational capacity and program implementation were measured using a written survey, completed by all health units at five measurement times from 1994 to 2002. Combining provincial and local sources, the average total investment by year five was $1.66 per capita. Organizational capacity of public health units and implementation of heart health activities increased both before and during the first 2 years of the OHHP, and then plateaued at a modest level for capacity and a low level for implementation after that. Amount of funding was positively associated with organizational capacity, yet this association was overpowered by the negative influence of turnover of a key staff position. Regression analysis indicated that staff turnover explained 23% of local variability in organizational capacity. Findings reinforce the need for adequate investment and retention of key staff positions in complex partnership programs. Better accounting of public health investments, including monetary and in-kind investments, is needed to inform decisions about the amount and duration of public health investments that will lead to effective program implementation.     

The family planning programme: in need of a positive image

The notion of family planning in India is generally connoted exclusively with contraception. The emphasis upon sterilization also causes people to equate family planning with sterilization. Even abroad, people confuse the notions of family planning and contraception. The government in India replaced the term family planning with family welfare, but now these two terms have also become freely interchangeable in their use despite the intent for family welfare to cover a wider range of activity than merely family planning/contraception. The birth rate, infant mortality rate, and fertility rate have declined over the decades in India, but not fast enough in most areas of the country. In Kerala and Tamil Nadu, however, where crude birth rates have fallen below replacement level and continue to decline, the average family at any level is convinced of the advantages of the small family. The national family planning program must project this positive image of creating and rearing a healthy family, and dispel its negative image as a program which simply pushes for the acceptance of contraception. After all, contraception is only a part of planning one's family. The author stresses the need to call contraceptives what they are, contraceptives, and not family planning methods or devices. The terms family planning and family welfare should be reserved exclusively for the larger and positive concept of planning one's family, in which contraception, the reduction of infant mortality, literacy, and higher age at marriage are all important components.     

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.     

Multidisciplinary learning in family planning clinics

This study aimed to evaluate the acceptability of joint learning between clinical and nonclinical members of family planning teams. A multidisciplinary workshop was facilitated by nonexpert facilitators comprising representatives from all disciplines who had received specific training. The workshop included sessions in which clinical and nonclinical staff learned separately and together. The program was evaluated using a questionnaire documenting participants' experience of learning in multidisciplinary teams, a pre- and post-workshop self-assessment of knowledge, a self-assessment of the predicted and actual effect of the workshop on clinical practice, and telephone interviews with the facilitators. Overall, results show that peer-facilitated multidisciplinary learning for clinical and nonclinical staff together is an acceptable form of staff training for family planning teams. Most participants felt comfortable in their learning groups and few reported feeling constrained by inter- or intradisciplinary hierarchies. In conclusion, the exclusion of nonclinical staff from interdisciplinary learning programs represents a missed opportunity for the exchange of ideas between family planning clinic teams.     

Self-sustaining clinics: innovation or retreat?

Can voluntary, nonprofit family planning clinics continue to provide high-quality reproductive health care to low-income women and to teenagers at no cost or low cost in face of ever diminishing federal support? And if the clinics must change to accommodate to a different economic and political climate than the one in which the national family planning program originated and developed, in what directions will they move? These issues were explored at sessions of the 110th annual meeting of the American Public Health Association and the 11th annual meeting of the National Family Planning and Reproductive Health Association. A number of examples from various states of the self-sustaining mode of delivery of family planning services are described in this paper. In a Colorado agency, only 2 types of staff are employed, specialists (such as clinicians, nurse practitioners or physician assistants) and generalists. There are no counselors, or lab technicians, or educators, and fewer employees are needed as everyone can do everything from working the cash register to cleaning the waiting room. There is no billing procedure as the cost for services are explained when the appointment is made, and the woman is told to bring cash or a credit card with her. Another agency in Pennsylvania began its path toward self-sufficiency by obtaining a commitment for greater self-sufficiency from its Board and staff, by careful cash management and investment, by improved productivity cost containment, adequate fees, and improved fee collection, and a vigorous program to raise private funds. An agency in Wisconsin was able to streamline its administration and services by examining the traditional mode, which requires a highly specialized staff, in terms of the needs of the current population rather than that of the 1960s for which the paradigm was created. The efficiency model was introduced in most of the agency's clinics, allowing for a significantly reduced staff. A great many other measures are described as a means of implementing self-sustaining family planning services.     

Implementing QA programs in managed care health plans: factors contributing to success

PURPOSE: The purpose of this paper is to identify the factors that contribute to the success or failure of quality assurance programs implemented by Israeli managed care health plans. DESIGN/METHODOLOGY/APPROACH: An in-depth study of seven quality assurance programs was conducted, comparing successful with unsuccessful ones using the comparative "case study" method. Employing a semi-structured questionnaire, 42 program directors and professionals in the field were interviewed. FINDINGS: A number of factors associated with the programs' success emerged. Those external to the program included: ongoing management support, resource allocation, information system support and perceived financial benefit for the organization. Internal factors included: leadership, perceived problem's importance, laying the groundwork in the field, involving field staff in planning and implementation and staff motivation. ORIGINALITY/VALUE: The study provides insights into ways to encourage the implementation of successful quality assurance programs in the special organizational context of managed care health plans. As the implementation relies heavily on data, one important precondition is the development of computerized information systems to facilitate ongoing data collection. It is also necessary from the planning stage to take into account organizational factors that affect success.     

Developing services for substance-abusing HIV-positive youth with mental health disorders

Models of program development have primarily focused on the internal organizational processes needed to plan, implement, and evaluate new service programs. However, creating an external demand for new programs by policy makers, administrative bureaucracies, public health officials, and funders is critical to establishing new programs. A series of deaths of seropositive youth and an absence of local service settings with staff trained to address the needs of youth living with HIV provided the impetus for Larkin Street Youth Center. In particular, the agency had to overcome stigma associated with having both substance use and mental health disorders to establish service programs to recruit and mobilize staff within the agency and the local community and to establish a comprehensive housing program for symptomatic HIV-infected adolescents. This article examines how a residential assisted care facility for HIV-seropositive adolescents was established using organizational strategic planning processes, problem solving, and social marketing frameworks.     

中国24个县的基层预防接种人员对乙型病毒性肝炎相关知识和态度的调查分析

目的了解基层预防接种人员对乙型病毒性肝炎（乙肝）相关的知识和态度,为开展基层预防接种人员培训提供参考。方法采取分层多阶段抽样方法,将全国（未包括香港、澳门特别行政区和台湾地区）分为东、中、西部地区3层,在各层抽取8个县;在每个县随机抽取县医院或妇幼保健院、10个乡级医院。从医院抽取负责人（预防接种的管理者）和预防接种人员,对上述人员进行预防乙肝相关知识和态度调查。结果预防接种人员对乙肝病毒的感染途径和预防乙肝的措施回答正确率分别为71．93％和58．61％。对各种疾病的认识中,认为乙肝的危害性要低于获得性免疫缺陷综合征、严重急性呼吸综合征、脊髓灰质炎和甲型H1N1流行性感冒。所有预防接种人员认为乙肝疫苗（Hepatitis B Vaccine,HepB）应及时接种,〉95％的预防接种人员认为HepB安全有效。结论随着对预防接种人员培训的开展,对HepB的接受程度较好,但对乙肝相关知识掌握较差,应加大对预防接种人员乙肝知识的培训力度,提高知晓率。     

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.     

The television, school, and family project. V. The impact of curriculum delivery format on program acceptance

Social psychological interventions have been successful in preventing drug and tobacco use in adolescents, but target audience involvement has not been well documented. Examination of program acceptance is necessary to avoid ambiguity when interpreting findings within and across studies. This report presents results from a program acceptance study of a seventh-grade smoking/drug-use prevention and cessation field trial. The research design is an assessment of two experimentally manipulated variations in program delivery on the program acceptance of all provider and target groups involved. Experimental manipulations included classroom and mass broadcast television demonstrations of social resistance skills against pressures to smoke and use drugs. Three aspects of target audience program acceptance were assessed: participation, satisfaction, and perceived program efficacy. Respondents included the target audience (seventh-grade students and parents), instructors, classroom observers, and school administrative staff. Strong main effects of television delivery on student and parent participation were observed. The findings suggest the usefulness of student homework assignment to view television segments with parents at home as a strategy to achieve family involvement in school-based programs. Both television and classroom delivery separately demonstrated significant positive effects on overall program acceptance with moderate interactive effects on perceived program efficacy. While classroom teacher/observers and school administrators reported strong preferences for the experimental (social resistance) classroom curriculum, acceptance of experimental and comparison (information-based) curricula by the student/parent target audience was equivalent.     

The construction of community participation: village family planning groups and the Indonesian state

Indonesia's family planning program has been one of the most effective in the developing world in promoting contraceptive use and contributing to fertility transition. In evaluating why the program has worked, analysts have given much credit to a network of village family planning groups that developed from the 1970s to the 1990s and that blanketed the archipelago. These groups, composed primarily of female volunteers, made contraception available to women in even the most remote parts of the country, and acted as agents of family planning motivation. They have been labeled by the Indonesian state family planning agency as an example of effective community participation on a national scale. In this paper, I investigate this claim and find it to be simplistic. I provide extensive evidence that the creation of this network was orchestrated by the Indonesian state. On the other hand, I show that these groups are not fully state entities, as they have several characteristics that mark them as socially embedded institutions. They are best labeled as unusual state-society hybrids. In my investigation I draw on one of the newest paradigms in the discipline of political science--the state-society approach--to uncover the odd nature of this family planning network. More deeply, I argue that the state-society approach ought to be adopted in family planning analysis on a comprehensive basis. The traditional organizational and social-demographic approaches that have dominated the field offer only limited understanding of the nature of family planning programs in developing countries. The state-society approach is ideally suited to identifying how family planning programs are institutions of a political nature, embedded in states and societies, and transformed by and transformative of each.     

Attitudes of urban Sudanese men toward family planning

Using data from the Male Attitude Survey of 1985, this paper shows that Sudanese men play a major role in family planning decision-making. Attitudes regarding family planning issues are presented for 1,500 men aged 18 years and over, living in urban areas of Khartoum, the capital of Sudan. The decision not to practice family planning is found to be male-dominated, and husbands are responsible for providing contraceptives when family planning is practiced. Widespread misconceptions about vasectomy, along with a very low acceptance rate, exist among the men in the sample. It is concluded that the involvement of men in family planning programs will give these programs a better chance of success in the future.     

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.     

Transforming family planning services in the Latin American and Caribbean region

The 1994 International Conference on Population and Development held in Cairo has generated widespread commitment to changing family planning programs from categorical and medically focused service organizations to reproductive health initiatives that embrace a wide range of social and human services. This article uses qualitative data analysis to review the experience of nine family planning association projects in the Latin American and Caribbean region that have made a successful organizational transition from services focused on family planning to a gender-based and sexual health approach. A conceptual framework is proposed, including factors external to the organization. Factors that can promote a pilot intervention's becoming fully institutionalized include: the need for commitment from high-level staff and members of the board of directors, the creation of partnerships with other agencies, and an emphasis on monitoring and evaluation. Lessons from this experience and their potential relevance to other settings are reviewed and discussed.     

我国卫生监督体系人员流动情况分析

  目的  了解全国卫生计生监督机构人员稳定情况及流动特征。  方法  利用国家卫生计生监督信息报告系统,抽提2012 — 2014年卫生计生监督机构人员的人口学资料、所属机构等信息,采用分组描述分析不同人口学特征及不同类别卫生计生监督机构人员流动情况,并探讨相关的人员流动原因。  结果  2012 — 2014年全国卫生计生监督机构人员年均流出率（4.43 %）高于年均流入率（2.59 %）。从年龄结构看,35～45岁的中青年员工年均流出率（3.60 %）高于年均流入率（1.69 %）。从教育程度看,本科及以上的人员年均流入率较高（3.79 %）,中专、中技及技校学历年均流出率较高（6.05 %）。人员所属机构级别方面,县级机构人员年均流入率（2.63 %）略低于省级机构（2.73 %）,但其年均流出率（4.68 %）高于省级（3.73 %）和市级机构（3.57 %）。  结论  近年来全国卫生计生监督机构人员总体流出大于流入,其中35～45岁的中青年群体以及县级卫生监督机构人员稳定性较差,流入人员教育水平均较高。