Organizing for Effective Family Planning Programs (1987)

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

176 state community-based distribution program in North East Brazil, the Supervisor is almost the only link between program headquarters and the distribution posts. During her visit to a post, she is supposed to deliver contraceptives and other supplies, collect service statis- tics records, discuss the problems of the post, and visit local physicians and political leaders. If time permits, she should give family planning talks and make home visits. Before January 1981, supervisors made monthly visits to all posts in their regions. Monthly supervision guarantees supplies, but as the program expands, the cost of the manpower and travel involved in the supervision also increases. Therefore, the cost-effectiveness of reducing the fre- quency of supervision from monthly to quarterly was evaluated in a closely conducted field experiment. The results demonstrated substan- tial potential savings in supervisors' salaries and travel at no cost to program performance (new acceptors, revisits, and turnover of dis- tributors). Carrying Out Organizational Development Broadly speaking, in this approach, units are encouraged to identify desired changes, and to prepare and implement operational plans for these changes. Unfortunately, there have been very few examples of organizational development in the population field. Bergthold (1974) describes the process work done with the Nicaraguan program as follows: A short while later, the director asked us to provide consulting help in the staff review of the program description. This we agreed to do; not as technical experts providing recommendations on how to improve the program but as process consultants helping to determine priority problems, seeking solutions to these problems, and planning action steps required to implement these solutions. The design we suggested for the staff review was a highly participative series of five meetings patterned after Beckhard's “confrontation meetings". These five meetings, held one morning every week for five weeks were set up as follows: Week 1: A clarification of the present situation including a review of the program description and other evaluation documents. Week 2: Description by each of the six department heads and the Director of the major problems of the organisation and clarifi- fication of these problems. Week 3: Determination of priority problems to be worked on by the group. Week 4: Development of plans for solving priority problems. Week 5: Continued planning and assignment of responsibilities for implementing these plans.

177 These meetings were very lively and there developed a very high level of participation of all department heads and an increased willingness to confront problems directly. The development of the level of trust required to conduct problem-solving meetings of this kind was largely due to the example of the Director who demonstrated with his own behavior his desire to confront and solve problems. The final outcome of these meetings was a rewritten operating manual in which the entire top staff took part and which clearly set out for the first time all of the operating procedures and norms, and defined roles, responsibilities, and goals for every department. Significantly, an operating manual had been in the process of development for nearly two years without ever being completed, and one manual prepared by an expert consultant had been rejected six months earlier. We have begun to see some very concrete results of the problem solving meetings held in the Ministry of Health. Perhaps most Significantly, the key staff have decided upon a common goal toward which each department will attempt to contribute and against which it will measure its own progress. This goal was to increase the number of active users served by the program, an Operating objective which had been emphasised in our seminar with top managers. Measured against this goal, many of the program's norms and procedures were clearly incongruent, so the department heads completely revised the norms to contribute more clearly to the attainment of this goal. DESIGNING SYSTEMS OF OPERATIONAL PLANNING A system of operational planning should delineate the following: who will be responsible for planning at what level, what will be the de- gree of formalism in planning, how planning at various levels will be related, and how corrective actions and replanning will be done when actual implementation deviates from the plans. For operational plan- ning to be effective, however, a conducive organizational climate should exist in which staff have good morale and commitment to the task, at least minimal physical facilities are available, and suffi- cient cooperative spirit is there for team work. Thus, operational planning depends on other elements in the organizational system responsible for delivering family planning services. Considerations in Design Systems of operational planning must be congruent with overall program functioning. Considerations involved in designing such systems are as follows: @ Nature of task. A well-defined routine task (such as resupply of pills) can be formally planned in detail, whereas for

178 for innovative tasks only minimal necessary guidance should be provided. @ Organizational structure. In centrally organized large bu- reaucracies, a top-down approach is used, and guidelines and directions flow from the top. A small voluntary program, on the other hand, is likely to be the least formal and most participative. @ Program environment. In a relatively supportive, homogen- eous, and certain environment, a uniform package of activities may be implemented for which manuals and fixea plans can be drawn up. In a heterogeneous uncertain environment, on the other hand, a great deal of initiative is required from the field staff. Thus, in a varied and complex environment, organizational structure must be decentralized to facilitate more responsive planning operation. @e Systems of reward. If rewards are directly linked to results, only a minimal amount of operational planning is needed. For instance, in commercial distribution systems, the distributor gets monetary incentives. Therefore, in such programs only resupply logistics and communication activities need to be planned. @ Availability of information. The availability of information will dictate how much advanced planning is possible. If more is known about the client, the field visit can be better plan- ned; it is difficult to plan visits in advance when there is no information available on the area to be visited. In the early stages of the program, administrators were concerned with ineffective services, and many examples of the failure of oper- ational planning were documented. These included inappropriate clinic hours, lack of supplies, and inadequately coordinated inputs and ac- tivities. Therefore, an effort was made to develop effective planning systems. However, as services improved and working systems became routinized, attention shifted to demand-creation activities, in which flexibility, experimentation, and willingness to work closely with program beneficiaries to learn about and respond to their local needs are required (World Bank, 1983). Thus, the “process of planning" can become more important than a "plan." This is so, Ackoff (1984:195) says, "because the principal benefit of planning is not derived from consuming its products, plans, but from participating in the planning process. In planning, process is the most important product. There- fore, effective development planning cannot be done for some by others. The others must do it for themselves, but they can be helped by professional planners."

179 Three Modes The above considerations imply that each program must strive to develop its own appropriate degree of formalism and planning system. Broadly, however, three types of programs can be located on this continuum--supply-oriented, strategically managed, and _ community- centered. Table 2 compares the features of planning systems for these three types of programs. TABLE 2 Operational Planning in Three Modes of Programs Type of Program Characteristics of Operational Supply- Strategically Community- Planning Oriented Managed Centered Emphasis of On providing On creating demand: Variable with Planning services and providing the community Activities matching services Who Does the Specialized Implementors of Communities, with Planning planning programs, with assistance from cells special assistance program personnel Setting of Set at Negotiated among Holistic goals Goals national level levels emphasized Program Uniform Varying with Determined by Operations packages local conditions communities Degree of High Medium Low Formalism Focus on High, Medium, Low, Plan manuals used as guidelines flexible Planning Low Medium, High Process used as learning Focus Centralized Decentralized in Decentralized Top-down some respects, centralized in others Top- down/bot tone up Within community

180 In supply-oriented programs, program administrators are concerned with the provision of services; demand is assumed to exist. The major objectives in operational planning for effective services are appro- priate clinic hours, provision of supplies, adherence to home visits and tour schedules, and adequate coordination of inputs and activi- ties. A “blueprint” approach is appropriate. The success of the pro- gram depends upon the extent to which accessible, efficient, quality contraceptive services can be provided in view of existing demand. In strategically managed programs, program administrators are con- cerned with both creating demand and supplying services. As noted above, demand-creation activities such as IE&C and _ incentives/ disincentives require flexibility, experimentaion, and willingness to work closely with program beneficiaries to learn about and respond to local needs. The planning process becomes the vehicle of learning for the organization, and the program staff actively participates in planning. Operational planning concentrates not only on inputs and activities, but also on outputs. In community-centered programs, the population program is seen as integral with developmental activities and as born out of comnunity needs. Here program operations must be very flexible, and the program staff should have the capability to become “people-centered." The community itself, therefore, is the center and participates actively in operational planning. Further complexity in operational planning results when a national program incorporates a mix of the above three systems at the same time ‘ among different regions, or when the system changes from one type to another. In other words, even within a country, systems of opera- tional planning may vary among regions and over time. This review therefore suggests a research agenda in operational planning. First, actual practices and processes used in planning should be adequately documented. Second, operational research should be used increasingly to develop improved planning systems. Finally, more research is needed on how operational planning should change with program strategies. REFERENCES Ackoff, R.L. (1984) On the nature of development and planning. In D.C. Korten and R. Klauss, eds., People Centered Development. West Hartford, Conn.: Kumarian Press. Anthony, R.N. (1965) Planning and Control Systems--A Framework for Analysis. Unpublished manuscript, Graduate School of Business Administration, Harvard University. Anthony, R.N., and R.E. Herzlingar (1975) Management Control in Non-Profit Organizations. Homewood, Ill.: Irwin. Benor, D., and J.Q. Harrison (1977) Agricultural Extension: The Training and Visit System. Washington, D.C.: World Bank.

181 Bergthold, G. (1974) Client-Centered Systems Approach to Management Improvement in the Family Planning Programs of Central America. Paper presented at the Second Inter-University Workshop on Management Issues in the Organization and Delivery of Family Planning Services, University of North Carolina. Bhatnagar, S.C., and J.K. Satia (1976) Using KAP data for family planning programme management. The Journal of Family Welfare XXIII (1) :54-65. Cornelius, R.M., and J.A. Novak (1983) Contraceptive availability and use in five developing countries. Studies in Family Planning 14(12) :302-317. Foreit, J.R., and K.G. Foreit (1984) Quarterly versus monthly supervision of CBD family planning programs: an experimental study in northeast Brazil. Studies in Family Planning 15 (3) 3112-120. Gadalla, S.M. (1978) Is There Hope? Fertility and Family Planning in a Rural Egyptian Community. Cairo, Egypt: American University in Cairo Press. Chapel Hill, N.C.: Carolina Population Center. Giridhar, G., and J.K. Satia (1984) An Experiment in Planning for Service Delivery at the Primary Health Center. Unpublished manuscript, Indian Institute of Management, Ahmedabad. Hassouna, M.T. (1980) Assessment of family planning service delivery in Egypt. Studies in Family Planning 11(5) :162. International Planned Parenthood Federation (1982) Community Participation in Family Planning: Issues and Examples. Working Paper, International Planned Parenthood Federation, London. Jain, S.C., K. Kanagaratnam, and J.E. Paul, eds. (1981) Country Case Studies--Bangladesh, Egypt, Indonesia, Kenya, Korea, Malaysia, Thailand. Unpublished manuscript, School of Public Health and the Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina. Kamnuan Silpa, P., and Chancare Thirong (forthcoming) Accessibility and availability of family planning in Thailand. In J. Ross and R.McNamara, eds., Survey Analysis for the Guidance of Family Planning Programme. Liege: Ordina Press. Korten, F., and D.C. Korten (1977) Case Book for Family Planning Management--Motivating Effective Clinic Performance. Boston: Pathfinder Fund. Korten, D.C. (1979) New issues, new options: a management perspec- tive on population and family planning. Studies in Family Plan- ning 10(1) :3-14. Leguizamon, F. (1979) Integration of Family Planning with Rural Development in Colombia. Case Study, International Committee on Population Program Management, Kuala Lumpur, Malaysia. Mauldin, W.P., and B. Berelson (1975) Conditions of fertility decline in developing countries: 1965-75. Studies in Family Planning 9 (5) :90-147. Misra, D.B., A. Ashraf, R.S. Simmons, and G.B. Simmons (1982) Organization for Change--A Systems Analysis of Family Planning in Rural India. New Delhi: Family Planning Foundation.

182 Murthi, M.N. (1976) Participative style of management in a family planning program. Studies in Family Planning 7 (2) :58-62. National Family Planning Coordinating Board (1982) Basic Information on Population and Family Planning Program. Unpublished manu- script, Bureau of Population Data, Jakarta. Nortman, D.L. (1982) Measuring the unmet need for contraception to space and limit births. International Family Planning Perspectives 8 (4) :125-134. Phillips, J.F., R. Simmons, J. Chakraborty, and A.I. Chowdhury (1984) Integrating health services into an MCH-FP program: lessons from Matlab, Bangladesh. Studies in Family Planning 15(4) :153-16l. Pisharoti, K.A., K.V. Ranganathan, S. Sethu, and P.R. Dutt (1972) The Athoor Experience: Implications for a State Wide Family Planning Program. Unpublished manuscript, The Gandhigram Institute of Rural Health and Family Planning and Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina. Population Council (1982) India's Population Policies and Programs. Regional Office for South and East Asia, Bangkok. Population Reports (1981) Contraceptive prevalence surveys: a new source of family planning data. Population Reports, Series M, No. 5. Baltimore, Md.: The Johns Hopkins University Press. Population Reports (1982) Population and birth planning in the People's Republic of China. Population Reports, Series J, No. 25. Baltimore, Md.: The Johns Hopkins University Press. Roberto, E.L. (1978a) Managing Community Mobilization for Population Objectives. Report of the 1978 ICOMP Annual Conference, Malaysia. Roberto, E.L. (1978b) Managing the Application of Commercial Distribution and Communication Capabilities in Population Programs: Case Study. Asian Institute of Management, Manila. Schellstede, W.P., and R.L. Liszewski (1984) Social marketing of contraceptives in Bangladesh. Studies in Family Planning 15(1) 339-39. Tsu, V.D. (1980) Underutilization of health centers in rural Mexico: a qualitative approach to evaluation and planning. Studies in Family Planning 11(4) :145-154. Tsui, A.D., D.P. Mogan, J.P. Teachman, and C. Welti Chanes (1981) Community availability of contraceptives and family limitation. Demography 18:615. United Nations (1984) Report of the Preparatory Committee for the International Conference on Population 1984. E/1984/28 March, 1984. Recommendation No. 26 and 27. United Nations, New York. UNFPA (1978) Report of Mission on Need Assessment for Population Assistance. Report No. 6, Bangladesh. United Nations, New York. UNFPA (1979) Report of Mission on Need Assessment for Population Assistance. Report No. 15, Kenya. United Nations, New York. UNFPA (1981) Report of Mission on Need Assessment for Population Assistance. Report No. 36, Sri Lanka. United Nations, New York. UNFPA (1982) Report of Mission on Need Assessment for Population Assistance. Report No. 47, Republic of Korea. United Nations, New York.

183 Wolf, D. (1983) Overcoming circumstances. International Family Planning Perspectives 9(1) :2-8. World Bank (1983) World Development Report 1983. New York: Oxford University Press. World Health Organization (1978) Terminal Report on Family Health Project. Unpublished manuscript, World Health Organization, Geneva.

8 The Integration of Family Planning With Health and Development Ruth Simmons and James E Phillips INTRODUCTION For some, integration is the "golden word"1l of the population field, identifying the solution for pressing problems of service delivery and program implementation. To others it symbolizes the pursuit of organ- izational domain and professional interest by population specialists, international donors, national governments, and service agencies. To still others, integration is neither solution nor explanation, but a set of questions to which there are varying answers, many of which are still uncertain. The importance of integration as a determinant of family planning program effectiveness has been much debated. Nevertheless, more than three decades after initiation of the first official family planning program, the overarching questions behind the debate are still of in- terest: Is there a need for specialized population activities? If so, how much priority do they deserve and where within the government machinery should responsibility for population reside? Should family planning activities be organized into a free-standing, autonomous pro- gram, or should they be incorporated into the existing infrastructures of public health? To what extent should population components be part of development planning and merged with specific development sectors? In the pre-Bucharest years, attention focused on the integration of family planning with health, and considerable programmatic initia- tive was directed at implementing specialized projects designed to demonstrate or assess the value of integration, especially of family planning and maternal and child health (MCH). The Taylor-Berelson proposal and projects focused on the integration of family planning with postpartum programs (Taylor and Berelson, 1968; Castadot et al., 1975), the Narangwal experiment in India, and the Danfa Project in Ghana sought to test the efficacy of various health and family plan- ning service packages as compared with family planning services pro- vided in isolation (Taylor et al., 1983; University of Ghana Medical School, 1979). National governments that made a commitment to family planning generally either placed these efforts within the framework of the public health sector (India, Thailand, South Korea) or estab- lished autonomous agencies, generally under a high-level interminis- terial board (Indonesia, Pakistan, Philippines). 185

186 In the post-Bucharest decade, attention shifted toward the inte- gration of family planning with development. The intention of one of the major groups of nations at the conference had been to divert at- tention from population to issues of the New International Economic Order (Finkle and Crane, 1975). The result was not the end of popula- tion activities, but a flourish of programmatic efforts in subsequent years directed at incorporating population components with the devel- opment sector. Examples are the addition of a population and develop- ment section to the Population Division of the United Nations; the Population and Development Program (PDP) in Egypt; and the so-called multisectoral strategies, which add family planning to women's pro- grams, social welfare, and the like. Recently, the debate over integration has lost some of its inten- sity, not because the efficacy or appropriateness of various ap- proaches has been scientifically demonstrated, but because the key issues have, in some measure, been historically and politically re- solved. Consensus has been reached in many nations and international Organizations that specialized population activities are legitimate, but that these must be tied to the health and development sectors (UNFPA, 1978:2, 1981; Brown, 1984; ESCAP, 1982; WHO, 1978). # The legacy of Bucharest has contributed much toward ideological and political resolution of the debate. The World Population Plan of Action encouraged the integration of family planning with health and "other services designed to raise the quality of family life," and recommended that "countries give priority to development programs -.« e » with decisive impact upon demographic trends" (Mauldin et al., 1974:385). The idea of integration has acquired broad ideological and political appeal, symbolizing for many the positive values associated with desired outcomes of programmatic action: health and welfare for all. Within this broad consensus there is much scope for divergent views and practice, but the extremes of the original controversy have been contained: both global challenges to population activities and excessively narrow approaches to family planning have lost credibil- ity. Even the fairly radical shift of the official U.S. position on population evident at the 1984 International Conference on Population does not imply a rejection of family planning (Finkle and Crane, 1985). In the 1980s, family planning is in many nations an estab- lished set of public-sector activities, with an established location-- wherever it may be--and a variety of linkages to other sectors of government. Policy reversal and structural change have not been pre- empted. The current reorganization in Egypt, as well as changes in Bangladesh, Jamaica, Malaysia, and the Philippines, attests to the fact that the question of integration can be reopened. Moreover, for nations currently without public-sector family planning activities, especially several nations in Africa, questions of organizational structure are yet to be resolved. Nonetheless, elsewhere established Organizational patterns are beginning to gather momentum, rendering the question of where family planning/population activities belong more an issue of history than of current concern. While political and ideological resolution of central issues has reduced excitement

187 over the debate, basic questions concerning the degree, type, or phasing of integration that contribute most effectively and effi- ciently to policy planning and implementation remain largely un- answered. The next section below provides a conceptual overview of integra- tion, first tracing its theoretical foundations, and then presenting some definitions. The chapter then turns to a review of the evidence on critical issues of integration. In doing so, it distinguishes be-~ tween evidence derived from experimental projects and findings from research on public-sector programs. Finally, the chapter reviews the literature on the political economy of integration and presents conclusions. CONCEPTUAL OVERVIEW Theoretical Foundations Arguments in support of integration are based on a set of propositions pertaining either to the conditions under which there is demand for fertility limitation, or to the organizational requirements of supply- ing needed services effectively and efficiently. Demand-side argu- ments maintain that "the integration of human behavior demands an integrated approach to changing that behavior" (Ness, 1977a:35). The assumption is that the interactive and often synergistic relationships among fertility, mortality, morbidity, and socioeconomic status trans- late into a compelling organizational logic for integrated program matic approaches (Taylor et al., 1976; Johnston and Meyer, 1977). Reference is made to the deleterious health consequences of high fer- tility for mothers and children; to the child survival hypothesis, which maintains that demand for fertility limitation depends on the assurance that children will survive; and to the widely documented finding that social and economic development motivates low fertility. (See Winikoff, 1978, for a critical perspective on the implications of biological interrelationships for policy.) It is also argued that integrated approaches increase worker motivation (Johnston and Meyer, 1977), that clients prefer holistic approaches (Taylor et al., 1983); and that family planning is acceptable only if introduced in the con- text of other, especially health, services. Supply-side arguments in favor of integration rest on the notion that the medical nature of modern contraception requires the involvement of qualified health per- sonnel. It is also argued that the need for efficient use of existing health infrastructures and outreach personnel in health or other development sectors provides a compelling organizational rationale for integrated programs. (See Finkle and Crane, 1976, for more de- tailed discussion of these arguments.) Etzioni and Ness place the issue of integration within the frame- work of sociological theory.2 Etzioni (1979:543) argues that, given the nature of social systems as integrated units, the basic concept of the integration of population and development is sound. “One cannot prudently proceed with family planning or other population programs

188 without taking into account the linkages which the impacted sector has with other societal sectors." However, since societies vary in their actual degree of integration at any given point in time, it may be possible to attain “substantial progress on any one front without simultaneous progress on the others." Thus, concern with the linkages among various sectors of society may lead to policies that either emphasize a broad spectrum of specialized areas, including population, Or focus more specifically on one or the other. Etzioni rejects the notion of applying the policy of integration mechanically in all cir- cumstances. Moreover, acceptance of integration as a broad policy stance does not, in Etzioni's view (1979:559), imply a commitment to any parti- cular form of "institutional embodiment." He argues that organiza- tional analyses show independent institutionalization to be extremely common. . . . Activities left completely uninstitu- tionalized, or on a low level of institutionalization, tend to be weak in the sense of being poorly legitimated, vulnerable, and low in budget, labor force, and managerial attention. Unless a program must "hide" because of a lack of social and political legitimacy, Etzioni hypothesizes, separate institutional embodiment serves progress. The interrelationships among demographic and socio- economic variables are considered insufficient justification for decisions that one particular type of institutional instrumentality is always appropriate for population policies and programs (see also Simmons et al., 1983). Ness places the issue of integration into the context of theories of social evolution that have focused extensively on two key concepts: differentiation/specialization and integration. Social progress has often been associated with the development of specialization, which “permits the development of high levels of skill and the concentration of skills on limited targets or activities, thus leading to higher levels of human performance" (Ness, 1979:18). However, specialization must also be accompanied by integration, and an appropriate balance must be maintained between the two. (This argument has also been made in the organizational literature; see, e.g., Lawrence and Lorsch, 1969.) “Excessive integration", Ness argues, would reduce “capacities for action" (p. 18). Thus Etzioni and Ness affirm the need for both integration and specialization, and argue that there is no theoretical basis for expecting one single best approach to apply to all circum stances. Population is not the only field where integration has been an issue, but this experience has remained largely ignored in the popula- tion debate (Ness, 1984). Integration has been extensively considered in the context of rural development and in the human service organiza- tion field in the United States. The enthusiasm for integration in these areas parallels that of the population field, even though em- pirical evidence for the superiority of integrated over functionally specific approaches is equally weak and contradictory in all three fields (Montgomery, 1981; Morris and Lescohier, 1978; U.S. Department of Health, Education, and Welfare, n.d.).

189 Siffin (1979:9) argues that the administrative problems associated with the implementation of rural development programs are generally complex. It is difficult to deal with "the general problems of making things work." Implementing integrated rural development involves more than just ordinary problems; it places extraordinary demands upon the implementing agencies. The feasibility of integrated rural develop- ment depends upon organizational and administrative factors. The issue is “workability,” and administratively integrated rural develop- ment is not easily workable. Siffin in no way implies a rejection of the content of broad intersectoral approaches. The content of inte- gration is important, but attaining it does not necessarily require that implementation be administratively integrated. Issues of integration have also recently been debated in the U.S. social services field. In the 1970s, integration of the pluralistic and diverse human services field was suggested as a solution to what was considered excessive fragmentation of services. On the other hand, Redburn (1977) argued that a link between administrative inte- gration and improved service delivery tends to be assumed rather than empirically demonstrated, and various evaluation efforts have re- mained inconclusive. In a review of integration schemes in the U.S. social welfare field, Morris and Lescohier (1978:28) suggest that possibly the multiple provider, pluralistic system with many relatively small units may meet the innumerable wants and needs of a large and diverse population much more satisfactorily than a large hegemony of tightly controlled coordinated subunits. Definitions The organizational literature makes a distinction between integration and coordination. Integration tends to be defined as “that action which brings previously separated and independent functions and organ- izations (or personnel, or resources, or clientele) into a new, uni- tary structure” (Morris and Lescohier, 1978:23). Coordination, on the other hand, is used "to describe various efforts to alter or smooth the relationships of continuing, independent elements such as organi- zations, staffs, and resources" (Morris and Lescohier, 1978:23). The population literature has imbued the word "integration" with a wide range of meanings encompassing both integration and coordin- ation as defined above. Integration has been used in reference to the dynamic interaction between health and population variables; the incorporation of demographic factors into development planning; the implementation of family planning activities by multiple sectors; the creation of interministerial committees or boards for purposes of overseeing the program; the addition of family planning functions to agricultural, social work, or health personnel; the merger of pre- viously independent family planning agencies into the public health services; the addition of health components to a vertical family planning program; and the combined delivery of family planning, health, family, or related services. It is not clear that knowledge

190 is advanced by debates over what is and what is not properly labeled integration (for a contrasting view, see Files, 1982; Jain and Files, 1984). It seems more fruitful to acknowledge the wide variety of em pirical referents for which the term has been used with an equally broad definition, and then to distinguish among different types, levels, or degrees of integration (ESCAP, n.d., 1977, 1981, 1982). In work conducted primarily under the aegis of ESCAP, Ness draws on a set of concepts originally developed in connection with the U.S. Human Service Integration projects of the 1970s (ESCAP, 1977:18; Ness, 1977a:34). He adopts a broad definition of integration as a "multi- dimensional variable in which the underlying idea is the linkage of specialized tasks." Such linkages, he argues, can be accomplished by a variety of structural arrangements. This definition is broad enough to include essentially all programmatic activities under the umbrella of integration. By its breadth, one might argue, this definition loses explanatory power; however, given the historical evolution of the integration debate, it is productive to reflect the ideological consensus over integration in a comprehensive definition. This pre- empts fruitless polarization over the pros and cons of integration per se, and allows analysis to shift toward dimensions of variance in degrees and types of integration. Ness identifies the following partially overlapping Gimensions of variance: (1) actual versus prescribed integration, (2) administra- tive versus service integration, (3) levels of integration, (4) sub- stantive networks across which integration occurs, and (5) routine versus sporadic integration. l. The distinction between actual and prescribed integration refers to the frequently observed phenomenon that plans, policy state- ments, government orders, or job descriptions may prescribe that specialized functions be performed by a single service provider or administrator; actual behavior may or may not coincide with these prescriptions. 3 2. Administrative integration refers to "the creation of an um brella organization that has administrative control over a large array of specialized services." Service integration, on the other hand, de- notes “the linking together of specialized services at the point of service delivery." It has been argued that service integration helps "to provide more effective service, but that administrative integra- tion raises costs, does not necessarily improve service delivery and sometimes obstructs the provision of better services" (UNFPA, 1978:2; Ness, 1979). | 3. Integration may furthermore be attained at different levels within the organization. Ness distinguishes among integration at the level of roles, agency, sector, and the nation (Ness, 1979:18). Integration at the role level refers to the addition of family plan- ning functions to personnel in other sectoral programs, such as health workers or agricultural agents. In some contexts, this is also re- ferred to as functional integration (see, e.g., Minkler et al., 1982). When roles are linked across several agencies through joint activities of family planning and health personnel, agency-level integration occurs; when such linkages tie together different sectors of the

191 economy, sectoral integration is involved. Linkages through policy and planning mechanisms at the national level constitute the highest level of integration. 4. Interactive linkages may be established with a wide range of sectoral activities. The health sector is the most frequently uti- lized substantive network, but more recently, linkages with develop- ment, social welfare, and industrial sectors have also_ been attempted. 5. Integrative linkages may furthermore vary over time. In many instances, routine or regular linkages are established; in others, such as specialized family planning campaigns, linkages are temporary. To these five dimensions of variance among forms of integration, the scope of integration might be added. Proposals for integrated packages of MCH and family planning vary according to the number of MCH services that are added to family planning or vice versa (Phillips et al., 1984). It is essential to identify the particular dimensions of integra- tion, and to indicate how these relate to other independent variables and to family planning program performance. The underlying assumption in much of the debate has been that "extending the scope of family planning programs enhances the capacity of programs to reduce fer- tility” (Ness, 1977a:35). In its extreme and most simplistic version, this argument has amounted to a unicausal theory stating that integra- tion determines performance. However, as is apparent from many other contributions to this volume, performance is the product of multiple, interacting forces, among which the different dimensions of integra- tion may represent an important, but certainly not the only, influ- ence. Moreover, it should not be assumed that the dimensions of integration all work in the same direction. In fact, it has been argued that, while service integration enhances performance, adminis- trative integration does not (Ness, 1979:21). INTEGRATION AND EXPERIMENTAL PROJECTS: TESTING THE ACCEPTABILITY OF SERVICE PACKAGES We now focus on the question of whether potential users of family planning respond better to integrated service packages than to categorical ones. This question is examined from the point of view of client acceptability (the demand side) alone, leaving aside for the moment the complex set of administrative, political, managerial, and economic issues associated with the organization and delivery of such services (the supply side). One way of accomplishing this is to examine experimental projects where the ceteris paribus assumption of high-quality services is a reasonable one. Experimental projects approach questions of integration in a variety of ways; a basic difference is between projects that consti- tute in some sense a test of the client acceptability hypothesis and those whose design does not allow for an assessment of the effect of various service packages on the client population. The discussion here concentrates on the former. (For a review of integrated experi-

192 mental projects, see Cuca and Pierce, 1977; JOICFP, 1982, as cited by Ness, 1984; IDRC, as reviewed by Ness, 1983; Williamson, 1979.) The focus is exclusively on experiments with differentiated treatment cells or timing of service interventions within the special project; experiments that consist only of a treatment cell and the government program as comparison are excluded. Given the variation in implemen- tation capability of government programs and experimental projects, supply side factors are not held constant, therefore making it diffi- cult to draw conclusions about demand. The Evidence from Experimental Projects The Narangwal Project This project is one of the more frequently cited field experiments that permits systematic research of the integration issue. It was implemented between mid-1969 and mid-1974 in the Punjab in northern India. Project villages were provided with one of four combinations of health, family planning, and nutrition services, one of which con- sisted of contraceptive services and education only (Taylor et al., 1983; Farugee, 1982). The Narangwal project posed this question: "Will the practice of family planning improve if services for family planning are integrated with those for health?" (Taylor et al., 1983:33). The authors of the study argue that the project provides factual evidence in support of the growing consensus for integration. Their analysis shows that effectiveness (as measured by acceptor, continuing user, ever-user, and use-effectiveness rates) had increased at the end of the project in all four treatment areas. It had increased least of all in the family planning only area, but this result poses difficulties of in- terpretation since treatment in this area was initiated 33 months after the experiment began. When adjustments for differences in duration are made in ever-user and continuing user rates, the family planning only and family planning and child-care treatment areas re- veal higher rates than the other two areas. The authors conclude that these differences are unimportant. They attribute the higher rates to the "more aggressive promotion of the less effective con- traceptive methods in a situation where there was no health care input” (p. 71). Nevertheless, analysis of the effective user figure shows that after 27 months the proportion of effective users was as high, if not higher, than in any of the integrated cells. The differences in duration of the various areas and the failure to build these differences systematically into the analysis (Phillips et al., 1984) make the published Narangwal results an invalid test for the hypothesis that integrated services are more effective. What the data show most clearly, perhaps, is that these four service pack- ages, when implemented, produced results irrespective of whether they were integrated or categorical in nature (see also Mosley, 1985). A final point is that the populations of all four treatment areas were small, ranging from 4,614 to 5,877 in population size.

193 The Matlab Family Planning and Health Services Project (FPHSP) This project conducted by the International Centre for Diarrhoeal Disease Research, is a field experiment in family planning and MCH. It addresses the question of whether the addition of health services contributes to family planning effectiveness in a project launched with minimal MCH services (Phillips et al., 1984; Rahman et al., 1980; Bhatia et al., 1980), consisting of clinic-based treatment of minor Maternal and child illnesses. Over a period of 5 1/2 years, the following MCH services were added in a population of 80,000: tetanus vaccination for pregnant women, oral rehydration therapy (ORT), tetanus vaccination for all women, measles vaccination, antenatal care, and training of traditional birth attendants. Results showed that the major increases in contraceptive preva- lence occurred prior to the addition of incremental MCH services. No apparent disjuncture in the contraceptive prevalence trend occurred with the introduction of tetanus vaccination; the subsequent addition of ORT, however, produced a decline. Thereafter, prevalence remained constant for 2 years. The disjuncture at the time of ORT introduction was attributable to organizational factors: attention was temporarily diverted from family planning because of the complex health education and community organization activities associated with the ORT effort. (Such imbalances have been noted elsewhere as a problem of integrated services; see Waiwer, 1985.) Later in the project, prevalence in- creased, but these increases were observed in all blocks, not only in those receiving special MCH services. A regression analysis showed that oral rehydration detracted from prevalence, child care in the family welfare center contributed to prevalence, and other MCH inter- ventions had no significant effect (Phillips et al., 1984). The success of the Matlab FPHSP was thus attributable to compre- hensive family planning and limited MCH. These results indicate a slight shift in the parameters of the integration hypothesis. The issue is not exclusive family planning versus family planning inte- grated with health, but minimal MCH built into a comprehensive family planning service package from the outset, with other MCH elements added subsequently. The dominant emphasis of the FPHSP has always been family planning with referral for contraceptive side-effects and child care, as well as a user-oriented environment supportive of Client concerns, including health as an essential component. The incremental addition of other MCH services, however, did not contri- bute to contraceptive use. This finding has been confirmed by a recent update of the analysis (see DeGraff et al., 1986). Based on the Matlab experience, then, one can conclude that clients respond well to family planning services with referral links for side-effects and basic child care services, introduced with a strong user orientation. Fertility and mortality trends are also encouraging (Phillips et al., 1982; Chowdhury et al., 1984).

194 The Matlab Community Distribution Program (CDP) Project It is interesting to contrast the results of the Matlab FPHSP with its predecessor, a community-based pill and condom distribution program, implemented in Matlab thana between 1975 and 1977 (Rahman et al., 1980). While the initial impact of service delivery on prevalence was pronounced, contraceptive use subsequently plummeted, and the pro- ject was abandoned. Comparison of these two projects raises issues of interest from the perspective of integration. The CDP project consis- ted of a household distribution scheme for pills and condoms through the use of local, traditional birth attendants, who received minimal training and supervision. Clients who were interested received pills and condoms with little or no education or follow-up; no other ser- vices were provided. Did the Matlab CDP project fail because of its categorical nature, or because of the nature of the family planning services and the char- acteristics of the management system? Implicit in the organization of the subsequent, successful FPHSP project are several answers to this question. First, the CDP project failed because of its exclusive focus on pills and condoms and its lack of educational activities. To be effective, at least under the socioeconomic and cultural condi- tions of rural Bangladesh, projects must provide comprehensive family planning services, and recognize that education is essential. Second, the CDP project failed because of its lack of referral for side effects and basic child care services. Finally, the CDP project failed because of an inadequate management and service-delivery infra- structure. Changes in the type of service providef had to be made, and new systems of supervision, management control, and information to be developed. The success or failure of programs is thus tied not only to the question of whether or not services are integrated, but to the scope of family planning and to questions of program organiza- tion and management as well. These issues will be discussed further below. The Danfa Project This project in Ghana is of interest since it implemented various service packages in a sociocultural context that is generally be- lieved to make the introduction of family planning in any form ex- tremely difficult. The project region in Danfa district was divided into four areas, ranging in population size from 13,142 to 18,873, each receiving a different service package: in Area I, primary health care, family planning and health education, and contraceptive services were provided; in Area II, primary health care was omitted from this package; Area III received contraceptive services only; and Area IV, where only minimal health services were available through the govern- ment program, served as a control (University of Ghana Medical School, 1979; Ampofo et al., 1976; Blumenfeld, 1983). Over the five-year period from 1972 to 1977, ever use of contra- ception increased most in Area I, where family planning was delivered

195 as part of comprehensive health care; second-most in Area II, the family planning and health education, and contraceptive services area; and relatively little in Area III, the family planning only area.4 The control area experienced almost no change. The experience in Area III (the contraceptive services only package) confirms the finding from the CDP project in Matlab that it is not effective to provide family planning services without attention to education. Results for Area II show that ever-use rates can increase considerably when con- traceptive services are combined with family planning and health edu- cacion; this service package is quite similar to the family planning and education package provided under the Narangwal experiment. How- ever, integration with comprehensive health services proved clearly most effective. Lessor.s About Service Mixes The experimental projects reviewed here are perhaps the _ best- documented pilot projects with some built-in test that allows for com parative assessment of integrated versus categorical approaches. They suggest some tentative conclusions about the relative effectiveness of different service mixes and provide some insight on the service inte- gration hypothesis. Comparison shows that integration can be viewed as a continuum of service packages, from a minimal package of family planning services at one extreme to comprehensive family planning, MCH, and primary health care services at the other. In between these extremes are a range of service models that first broaden the range of contraceptive services, and subsequently the range of MCH and pri- mary health care components. The various service mixes provided through the experimental projects discussed here can be arrayed on this continuum (Table 1). It is possible to draw some conclusions about the effectiveness of various service mixes. At one extreme of the continuum, Package 1, limited contraceptive services without educational efforts, does not work and is also problematic from an ethical perspective. Pro- viding inadequate education and follow-up and leaving women without medical attention (especially where inadequate education and follow-up increase side-effects) runs counter to the human service mandate from which programs derive much of their legitimacy. On the other end of the continuum, Packages 5 and 6, which provide comprehensive family planning and comprehensive primary health care, may not be necessary for purposes of family planning effectiveness; this is suggested by both Narangwal and the second Matlab project. Distinctions among service mixes in the middle of the continuum are less readily apparent. Matlab's second project would lead one to believe that child care services in conjunction with a program of comprehensive family planning services and education are essential. However, it must be recognized that Matlab did not test the effective- ness of a service package providing comprehensive family planning ser- vices and education only. Narangwal provides evidence, in spite of the authors’ contrary interpretation, that family planning services

196 J O d d T e a b u e s e N III eazy ezyued T Peary (7 aseyd) (z aseyd) III eeay qadi ejyuegd dSHdd QeT3eW dSHdd QeT3eW eyuegd Teabue sen qeT3eW ddo SaTawexg A s u e u b e a i d xST I-yubtYy uot zeoNnps IOJ 9 1 8 5 pue ‘ T e r l 1 9 a j a 1 pue [er1azjoy Bbutuuetd A t t w e z pue d n - M o O T T O g uot 3eZTUuNUMIT uo sATSUdsYysIduUOD spoyu jouw os p u e ’ a 1 8 5 T e O T u T { T S jo AzozeT aque AAYFpTqzow zo A Q T T q e T y e a e 4a7e9 $ 3 9 7 N O S OMQ 10 S S S U T T T PItTYyoO pue spoy jeu Aqeq [124 auo uo stseydue pue Teu1zajeuU eTdtytnw Jo ‘AzaaTtTap U T A Sd9OTAIAS JO Quseu{e3a73 uot zeONpa uoT3ANQTIIASTp quay jedur peseq-abeTT ta peseq-otut{o yuITeeH prloyesnoy Spoy au SAT A d a 5 e 1 4UOD + + + + + O M 10 3uU0 zgO uOoT{ANGTAASTP G aebeyoeg y a b e x o e g € e b e y o e d Z a b e y o e g [I a b e x o e g p l o y e s n o y a b e y o e g s O T A I a S JO s3zUaqQUoD azep yyreeaq Azeuyt1zg HOW HOW uot zeonpg” (uUOTQeONpS Atuo buyuueltd a A t T s u a y s a r d u o y pue S A T S U S A Z U T pue p e q t u y ] pue uUITe2eH pue pue aoTAjzas) Attwegq p a q y w y T butuuetTq ATrwegZ B u r u u e t g A t r w e q b u y u u e t q A t t w e q Bbuyuuetgq Attwegq b u t u u e t q A t t w e g 2[ a b e y o e d s a T s u s y a z d u o g a a T s u a y a r d w o y g 2p a b e y o e g a A T S u a y a l r d u o g a a T s u s y s I d u o g | 79 a b e y o e g 2G a b e x y o e g :¢ a b e y o e g :Z a b e x y o e g w n n u t q U o D u o T z e I b s q U L e u L T A T A V L