Health and Family Planning in Community-Based Distribution Programs

Maria Wawer

• Publisher: Routledge
• Year: 2019
• Topic: Social Sciences
• eBook ISBN:
  9780429725876
• Subtopic: Sociology
• Index: Social Sciences

The authors of this book address the major issues involved in developing and evaluating community-based delivery (CBD) healthcare services administered by nonmedical workers in developing countries. Ranging from a general discussion of integrated community-based programs to the prescription of dose regimens that nonmedical personnel can use in field situations, the contributions cover such topics as nutrition intervention, antihelminthics distribution, oral rehydration therapy, and the efficacy of existing programs designed to train those who administer these services.

Part One
Issues in Integration of Community-Based Distribution Programs

1
The Nature of Community-Based Distribution: Some Field Results and Problems

R. W. Osborn

An objective of this workshop is to examine the health and family planning activities employed in experimental and demonstration field projects in less developed countries. But before proceeding in depth into the complexities of these interventions (program activities), it is important that we have a shared understanding of the type of field structure implied in the phrase, Community-Based Distribution (CBD).

Family planning intervention projects have been previously reviewed by Cuca and Pierce (1977) and a more circumscribed appraisal of community-based and commercial contraceptive distribution has been made available by Foreit, Gorosh, Gillespie, and Merritt (1978). The present statement, based on three major surveys (Cuca and Pierce, 1977; Foreit et al., 1978; Osborn and Reinke, 1981), focuses on CBD projects rather than broader family planning and health projects in less developed countries. Incompleteness of data and rapidity of change make an exhaustive review well-nigh impossible. The goal of these few remarks is to provide an introduction to the setting in which activities — that is, interventions — are delivered.

CBD systems are non-clinical family planning delivery systems. Whereas there was general agreement as to the structure and function of clinic-based services, there is no similar agreement as to the nature of non-clinical family planning systems. CBD systems cannot be easily classified (Foreit et al., 1978; Korten, 1978), as shown by the following examples of so-called CBD systems:

• - Outreach or mini-clinics located in villages or neighborhoods.
• - A village depot managed by a resident.
• - Village provider of services who visits households where he or she lives.
• - Periodic sweeps of households by trained workers from the surrounding area.

There are, however, some shared characteristics among these approaches. As discussed by Foreit, et al. (1978), CBD systems can embrace the following structures:

• - Provision of services in a non-clinical setting;
• - Use of non-health or paramedical personnel to provide services; and
• - Minimal use of screening and recording procedures.

The necessity for these structures became apparent in the early 1970s, when it was clear that traditional clinic-based approaches were reaching only segments of the population in need (Burkhart, 1981). Obstacles to the equitable provision of clinic-based services include lack of funds and shortages and maldistribution of trained health personnel.

Non-clinical delivery systems are designed to minimize costs and remove barriers to use for the rural and urban poor, who compose a high proportion of the population of most of the less developed countries. It is hoped that CBD systems, employing less expensive facilities and workers with lower levels of education, facilitate the extension of outreach among this population.

Behind the decision to establish CBD programs are the assumptions that family planning services are wanted; that minimally educated lay personnel can be trained to deliver them, either door-to-door or from a village-based supply depot; and that the use of contraceptives is constrained by a lack of service capacity.

Receptivity, or pre-existing community demand, will vary, and service capacity may be too limited or too great for that demand, as shown in Figure 1.1:

Figure 1:1. Service Capacity and Demand in CBD Projects SOURCE: Korten, 1978.

Where capacity is limited, village workers can be trained to deliver services. Projects facing a situation illustrated by Ⓐ would need to strengthen outreach or adopt information, education and communication (IE&C) interventions to increase demand. Most Asian and Latin American countries are at point Ⓑ,where demand is greater than services but a strengthened service would quickly meet pre-existing needs. At that point, contraceptive prevalence will cease to increase, and new efforts will be needed to improve both receptivity and service capacity.

The strong emphasis given to the supply-side approach is due in large measure to the efforts of the U. S. Agency for International Development (AID). Although other groups, including the International Planned Parenthood Federation (IPPF), also sponsored CBD programs, it was largely through AID efforts that systematic demonstration and research projects to document and evaluate the CBD approach were undertaken. Under the rubric of Operations Research, different interventions were introduced in delivery systems and results recorded. Among the findings from the 28 projects reviewed in the Community-Based Distribution of Contraceptives Review (Osborn and Reinke, 1981) are the following:

1. A trend toward increased range of contraceptives offered to village residents is seen throughout the 1970s. A broader mix is associated with higher use of contraceptives.
2. Increasingly, health services were added to non-clinical family planning delivery systems. In many countries, health delivery systems are inadequate or non-existent. As family planning delivery systems were developed, there was considerable pressure to add health interventions to these systems.
3. These non-clinical family planning delivery systems are affordable, culturally acceptable and effective in raising contraceptive prevalence to the 30 to 35 percent level.

As non-clinical delivery systems increase the number of contraceptives and health interventions they offer, problems arise concerning both receivers and providers of the service. These include:

1. Limits in the ability or poorly educated villagers to effectively deliver a multiplicity of interventions. When numerous or incompatible tasks are assigned to an individual, some tasks will suffer. Compatible tasks involve similar skills, are directed to similar target groups, and involve similar styles of work (Korten, 1978).
2. Possible side-effects of some interventions in some recipients, necessitating the provision of high-level medical backup to deal with them.
3. Questions about how to select the most appropriate intervention for a given community, and ways of introducing these into the population.
4. Pressures on CBD systems to deliver more and more — now may not be the time for increasing this load.
5. Emphasis has been on distribution of contraceptives or primary health care, but there are frequent calls for an added concentration on the community and community development (Anonymous, 1979; Korten, 1978). As the data from the Shanawan-Egypt project show, mobilizing the community differs significantly from providing health care; and increased acceptance of contraception follows from increased attention to the community, its leaders and major groups.

These are some of the concerns that prompted the design of the present workshop. We anticipate that the papers and discussion over the next three days will answer some of these concerns. But as in all complex human undertakings, we also await the presentation of even more vexing problems throughout these proceedings.

References

Anonymous. "Community Emphasis." People 6 (1979).

Burkhart, M.C. "Issues in Community-Based Distribution of Contraceptives." Pathpapers 8 (1981).

Cuca, R. and C.S. Pierce. Experiments in Family Planning. Baltimore, MD: Johns Hopkins University, 1977.

Foreit, J.R. et al. "Community-Based and Commercial Contraceptive Distribution: An Inventory and Appraisal." Population Reports Series J, (1978).

Huber, S.C. et al. "Contraceptive Distribution: Taking Supplies to Villages and Households." Population Reports Series J., 5 (1975).

Korten, D.C. "Managing Community Based Population Programmes: Insights from the 1978 ICOMP Annual Conference." Kuala Lampur, Malaysia, July 17-19, 1978.

Osborn, R.W. and W. Reinke, eds. Community-Based Distribution of Contraception: Review of Field Experience. Baltimore,MD: The Johns Hopkins University, Population Center, 1981.

Ravenholt, R.T. and D.G. Gillespie, "Striking Results of Household Distribution." People 14 (1977): 4-5.

Trainer, E.S. "Community-Based Integrated Family Planning Programs." Studies in Family Planning 10 (1979).

2
Issues in Integrated Family Planning and Health Programs

Duff G. Gillespie

The organized family planning program is a fairly recent phenomenon in the developing world. Much has happened since India declared the first official population policy in 1952. This paper focuses on one aspect of the evaluation of family planning programs - integration Issues associated with community-based family planning delivery systems, which go beyond the respective countries' existing clinic-based health infrastructure.

One of the most dramatic changes that has occurred in family planning is in the number and types of delivery systems that have evolved. Initially, family planning programs mimicked the delivery systems of the developed world. As a result, family planning services were clinic-based with medical professionals as service providers. The clinic facility and staff primarily provided health services and, in a sense, family planning could be considered as being integrated with health. Free-standing, unipurpose, family planning clinics also existed but, as is the case now, they were not as common as multipurpose clinics and were usually associated with private family planning associations. These clinic-based delivery systems worked fairly well for urban populations. However, with the realization that a clinic-based system could never adequately serve the largely rural population of the developing world, modifications began to be made. Outreach workers traveled into communities to recruit new and follow up old acceptors. Mobile clinics were in fashion for a time, taking the clinic to the people. This metamorphic trend continued and became quite intense and innovative in the 1960s and 1970s. Delivery systems were developed that were no longer tied to a stationary clinic or a physician. The system that evolved has been generally termed community-based distribution.

In most community-based systems, family planning services are provided by specially trained lay persons from the community. Having nonphysicians provide such services as oral contraceptives was unthinkable in most countries a decade ago. Now, there is little exceptional about it (Huber et al., 1975; Foreit et al., 1978; Rosenfield et al., 1980). The first social marketing program was launched in India in 1969. These programs provide subsidized contraceptives through retail outlets; in ten years, 35 social marketing programs have been started throughout the world (Altman and Piotrow, 1980). From tentative efforts with household visitations in the Subcontinent (Osborn, 1974; Population Council, 1964) many programs have developed which systematically canvass households, providing a wide variety of family planning services. Household distribution projects are found in such diverse socioculturel settings as Korea, Mexico, Zaire, Egypt, and Bangladesh. Here again, a delivery system considered radical less than a decade ago is now, if not commonplace, certainly lacking singularity.

Integration

Calls for the Integration of family planning services with other development activities have been long and persistent. Initially, this call was confined to family planning and health, especially maternal and child health (MCH) (Taylor, 1965); now, they encompass a wide variety of socioeconomic actions (Family Planning in the 80's: Challenges and opportunitues, 1981). Two international events did much to strengthen the trend towards integration. The Bucharest Conference produced a Plan of Action that emphasized the interdependence of population and socioeconomic variables. From this consideration, family planning was viewed as something that should be encompassed in a larger, comprehensive development effort (World Population Plan of Action, 1974). Even more influential was the Alma Alta Conference The Alma Alta Declaration clearly states that family planning should be part of a broader primary health program (World Health Organization, 1978). A third meeting in Copenhagen, which concerned women in development issues, was too recent to assess its effect, but its conclusions are clearly akin to Bucharest and Alma Alta, especially the latter (World Conference of the United Nations Decade for Women, 1980). It is difficult to disagree philosophically with the general thrust of these gatherings. They call for some very desirable things: health, peace, equality, and development. Politically and ethically, integration is compelling. But, does it make sense programmatically?

Definition of Integration

There are many definitions of integration, but very few operational definitions. Not infrequently, statements, articles, and plans of action leave the term undefined. The vagaries of defining integration are understandable - it will unavoidably mean different things in different programs. In a sense, integration is defined by what particular programs do in the name of integration. Nevertheless, for discussion purposes, one needs a reference point.

Integration entails the combining of various functions or tasks. Implicitly, integration means that the elements to be integrated are distinct entities which, for whatever reasons, did not previously exist together. Otherwise, of course, there would be no reason to integrate. Any discussion of the pros and cons of integration must explore the reasons why these elements existed separately, for the rationales for their separate state may be more compelling than the rationales for combining them. Also, although this paper focuses on family planning and health, the concept of integration encompasses much more than these two rather broad fields. Indeed, just as important an issue in the present international climate concerns the Integration of various health interventions into a holistic health effort. As a result, this paper will not only deal with the integration of health and family planning, but also discuss combinations of various health interventions.

Two important considerations to keep in mind when discussing integration are the locus of the integrative process and its purpose. Ness makes a useful functional distinction between administrative and service integration.

Administrative integration proposes structural changes and speaks to issues of administrative authority, responsibility, jurisdiction and accountability. Service integration concerns linkages at the point of service delivery and speaks to issues of work flows, referrals and individual contacts. (Ness, 1979, p. 18).

Ness goes on to point out that one can have administrative integration and not service integration, and, somewhat paradoxically, that services can be integrated while the administrative infrastructure is unintegrated, Ness observes that there are temporal and spatial aspects to integration; for example, an immunization campaign can entail other developmental sectors for a short period and be confined to a specific geographic region.

Rationales for Integration

The reasons why organizations and development experts advocate the integration of family planning with other development efforts are often philosophical and lack any empirical basis or logical consistency. An example of faulty reasoning is found in the product of one recent working group that considered the integration of family planning with rural development.

There has been increasing interest on the part of policymakers and administrators in the integration of family planning services with other socio-economic development activities, especially those designed for rural development. This is partly due to a realization of the limitations of unifunctional family planning programs in dealing with the multi-faceted nature of fertility regulation. It is also due to a growing awareness, as exemplified in the World Population Plan of Action, that effective fertility regulation must be accompanied by the improvement of socio-economic conditions for the rural population (UNFPA, 1979, p. 1).

Two points are made above. First, the statement correctly notes that family planning programs typically do not address all the factors that influence fertility. Second, it implies that without an improvement in socioeconomic conditions, fertility regulation will be ineffective. The debate about the relative importance of development versus family planning is a long one (Davis, 1967). It is still not clear what type or what level of socioeconomic development gains must be realized before the demographic transiti...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• List of Tables
• List of Figures
• Preface
• PART ONE ISSUES IN INTEGRATION OF COMMUNITY-BASED DISTRIBUTION PROGRAMS
• PART TWO CONTRACEPTIVE SERVICES IN CBD PROGRAMS
• PART THREE ADAPTING ORAL REHYDRATION THERAPY TO CBD PROGRAMS
• PART FOUR ANTIHELMINTHICS IN CBD PROGRAMS
• PART FIVE NUTRITION ACTIVITIES IN CBD PROGRAMS
• PART SIX IMMUNIZATION IN CBD PROGRAMS
• PART SEVEN OTHER THERAPEUTIC INTERVENTIONS
• PART EIGHT TRAINING ISSUES AND STRATEGIES IN CBD PROGRAMS
• PART NINE EVALUATION AND RESEARCH