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155 ations, and in the introduction of community and commercially based distribution programs. Finally, the leadership pattern exercised in El Salvador was neither inspirational nor entrepreneurial, but rather focuses on overcoming potential barriers to the introduction of family planning services in the form of opposition by various sectors of society. Although referred to as political, this pattern does not involve manipulation for partisan gain, but embodies the capacity for analysis of people, organizations, and actions within the political arena. Two conclusions on patterns of leadership may be drawn from this comparative study. First, more than one leadership pattern may be combined effectively in the launching of new programs. fThe skills and orientations of Dr. Cabezas and Alberto Gonzalez, though quite different, complemented and reinforced each other in the formation of the Costa Rican Demographic Association (ADC). Both men were social innovators, one in offering new types of services (vasectomy) and the other in pioneering new forms of distribution (community-based). As seen from the discussion above, both of these strategic alternatives are consistent with the type of entrepreneurial organization that the ADC assumed. A second conclusion is that different leadership pat- terns may be appropriate in different national contexts. The style and methods of innovation of Cabezas and Gonzalez, effective in the relatively permissive and open society of Costa Rica, would have vio- lated the norms and conventions of Salvadoran society, where careful constituency-building by members of the country's elite was more appropriate. It may be noted further that the inspirational, entrepreneurial, and political patterns of leadership have been found effective in the introduction of social innovations through nongovernmental channels. However, it is not clear that these leadership patterns are appro priate for the management of family planning programs in the public sector, or for the longer-term development of public and private institutions. In fact, Lindenberg and Crosby (1981) present some evidence to the contrary: they cite the case of a permanent secretary of health whose success in program implementation is based upon his knowledge of the bureaucratic rules of the game, and on his skili in achieving program objectives within the constraints imposed by those rules. The pattern of leadership demonstrated by him and by other effective public managers may be referred to as bureaucratic--again, not in the pejorative sense, but in the sense of embodying a capacity to analyze complex organizational processes, and to make decisions and take action within these contexts. Unfortunately, there is no evidence that these four leadership patterns have contributed to the development of decision-making capacity at operating levels of an organization; on the contrary, the inspirational and entrepreneurial patterns in particular have tended to reinforce centralized decision making. Much less common in family planning programs is a pattern of leadership that empowers others within the organization to assume increasing responsibility. This leadership pattern, a fifth type which may be called organizational, seeks to encourage creative and adaptive behaviors among workers at
156 all hierarchical levels in an organization. One example of successful Organizational leadership is Dr. Wasito, provincial representative of the Indonesian National Family Coordinating Board in East Java (Korten, 1977). Through effective teamwork with the local governor, Dr. Wasito worked to mobilize the efforts of public employees in all sectors and at all levels in the province. Inspirational and entrepreneurial leadership patterns are normally associated with the entrepreneurial and linkaged structures, while political and bureaucratic patterns are normally associated with ver- tical and integrated structures. In fact, however, a diversity of patterns may be found in any structural context. Unlike the strategy- structure combinations, there do not appear to be leadership patterns that are clearly inappropriate to different structural contexts, TABLE 1 Effectiveness of Leadership Patterns in Task Accomplishment Leadership Pattern Task Inspirational Entrepreneurial Political Bureaucratic Organizational Introducing Social Innovation + + - - 0 Obtaining Sacrifice by Organization Members + 0 - 0 + Operating Routine Clinic Functions - - - + + Stimulating Program Growth and Expansion 0 + 0 0 0 Mobilizing Resources of International Agencies + + 0 0 0 Gaining Support of Key Decision Makers in Society 0/- 0 + ) 0 Implementing Program in Public Bureaucracy - - 0 + 0 Channeling Public Resources into Family Planning 0 0 + + 0 Developing Organizational Capacity - ~ 0 0 + Note: â+" indicates that leader is effective, "-" indicates leader is ineffective, and â0° indicates that leader is neither effective nor ineffective in performing the particular task.
157 though clearly some patterns are more effective in accomplishing cer- tain tasks. Table 1 contains a list of some of the more critical tasks to be performed in the management of family planning programs, and indicates the effectiveness (+) or ineffectiveness (-) of the five leadership patterns in task accomplishment. What becomes obvious from this matrix is that in any national family planning effort, a combina- tion of many patterns is essential for effective performance. More- over, since these will seldom be found within a single organization, the building of the interorganizational networks described earlier is essential. CONCLUSION The aspects of organizational structure discussed in this chapter have been shown to be related to program performance; however, the complexity of the subject and the wide variation in national ex- periences make generalization regarding the nature of the relation- ship difficult. The evidence clearly indicates that no one pattern of organization will fit all situations. Relatively successful pro- grams exist in Latin America based on a private and often decentra- lized approach, while in Asia, successful programs often have a strong base in government systems. It is also possible to cite failures that are characterized by these structural approaches and others. As important as the formal structure is the need for effective implementation within whatever structure is chosen. Effective imple- mentation is in turn greatly influenced by the level of internal con- sistency or congruence among program elements, and of course by the quality of program leadership. The difficulties involved in generalizing about structure and performance in the field of family planning are exacerbated by a lack of empirical evidence. Much of the reasoning in this chapter is based on the experience of programs other than family planning in the pri- vate sector. More systematic empirical observation of ongoing public- sector family planning programs is therefore a priority if strong programs are to be developed on a scientific basis. REFERENCES Agency for International Development (AID) (1984) Report on the Mission Directors' Conference. Unpublished memorandum, Bangkok. Allison, G.T. (1971) Essence of Decision. Boston: Little, Brown. Andrews, K.R. (1980) The Concept of Corporate Strategy. Homewood, Ill.: Irwin. Burns, T., and G.M. Stalker (1961) The Management of Innovation. London: Tavistock Publications. Chandler, A.D. (1962) Strategy and Structure: Chapters in the History of Industrial Enterprise. Cambridge, Mass.: MIT Press. Ickis, J.C. (1979) The politics of family planning promotion in El Salvador. Pp. 53-74 in Montgomery et al., eds., Patterns of Policy. New Brunswick, N.J.: Transaction Books.
158 Ickis, J.C. (1973) El Salvador Country Report. Managua: INCAE. Ickis, J.C. (1978) Strategy and Structure in Rural Development. Unpublished Ph.D. dissertation, Harvard Business School. Ickis, J.C. (1983) Morazan and Izaltenango. Pp. 105-118 in F.F. Korten and D.C. Korten, eds., Casebook for Family Planning Management, 4th ed. Boston: The Pathfinder Fund. Ickis, J.C., and F.A. Leguizamon (1983) PROFAMILIA: management assistance and innovation. In E. Sattar, ed., Management Contributions to Population Programmes: Views from Three Continents. Kuala Lumpur: ICOMP. Ickis, J.C., and M.G. Olave (1979) San Rafael: family planning promotion in a rural Salvadorean village. In Managing Community-Based Population Programmes: Report of the 1978 ICOMP Annual Conference. Kuala Lumpur: ICOMP. Korten, D.C. (1977) Organization and Management of Population Programs in the Post-Bucharest Era. Cambridge, Mass.: Harvard Business School. Korten, D.C. (1980) Community organization and rural development: a learning process approach. Public Administration Review (Sept.-Oct.) :491. Korten, D.C., and F.B. Alfonso, eds. (1982) Bureaucracy and the Poor: Bridging the Gap. West Hardford, Conn.: Kumarian Press. Korten, D.C., and F.F. Korten (1977) Strategy, Leadership, and Context in Family Planning: A Three-Country Comparison. Cambridge, Mass.: Harvard Institute for International Development. Korten, F., D. Korten, D. Stracham, and C. de Benard (1975) Family Planning in Nicaragua: Description of Program Management. Managua: INCAE. Lawrence, P.R., and J.W. Lorsch (1967) Organization and Environment: Managing Differentiation and Integration. Boston: Harvard Business School. Lindenberg, M., and B. Crosby (1981) Managing Development: The Political Dimension. West Hartford, Conn.: Kumarian Press. Lodge, G.C. (1970) Engines of Change. New York: Alfred P. Knopf. Maru, R. (1985) Comments on Structural Issues. Personal communication. Mayo, E. (1946) The Human Problems of an Industrial Civilization. Boston: Harvard Business School. Misra, B.D., A. Ashraf, R. Simmons, and G.B. Simmons (1982) Organization for Change: A System Analysis of Family Planning in Rural India. Michigan Papers on South and Southeast Asia. University of Michigan, Ann Arbor. Paul, S. (1983) The Management of Development Programmes: The Lessons of Success. Cambridge, Mass.: Harvard University. Peters, T.J., and R.H. Waterman, Jr. (1982) In Search of Excellence: Lessons from America's Best-Run Companies. New York: Harper & Row. Phillips, J.F., R. Simmons, G.B. Simmons, and M. Yunus (1984) Transferring health and family planning service innovations to the public sector: an experiment in organization development in Bangladesh. Studies in Family Planning 15 (2) :64.
159 Porter, M. (1980) Competitive Strategy: Techniques for Analyzing Industries and Competitors. New York: Free Press. Rogers, E.M., and F. Shoemaker (1971) Cammunication of Innovations: A Cross-Cultural Approach. New York: Free Press. Selznick, P. (1957) Leadership in Administration: A Sociological Interpretation. Evanston, Ill.: Row, Peterson. Siffin, W. (1976) Two decades of development administration in developing countries. Public Administration Review 36(1) :61-71. Simmons, R., G.B. Simmons, D.B.Misra, and A. Ashraf (1975) Organizing for government intervention in family planning. World Politics 27 (4) :569-596. Taylor, F.W. (1919) The Principles of Scientific Management. New York: Harper & Bros. United Nations (1973) World population plan of action. Pp. 155-167 in The Population Debate: Dimensions and Perspectives. New York: United Nations. U.S. House of Representatives (1976) New Directions in Development Aid. Committee on International Relations. Washington, D.C.: U.S. Government Printing Office.
7 Operational Planning in Population Programs JK Satta INTRODUCTION Both social setting and program effort are known to determine the effectiveness of population programs. Program effort in turn is a result of population policies and strategies, available resources, and effective program operations (Mauldin et al., 1975). However, it is often weak implementation of the program rather than a lack of poli- cies or resources that determines program performance. Operational planning (often referred to as program planning) is needed for effec- tive program implementation and efficient use of resources. It is defined as planning program activities to implement strategies for achieving program goals in the operational environment. It attempts to answer the questions what needs to be done, when, where, by whom, and how? Population programs vary in terms of their policy frame- work, strategies, and local environment. They may or may not have demographic objectives, may involve a single sector or multiple sectors, may be operated as vertical or integrated programs, and may be clinic- or community-based. Therefore, the nature of program tasks and operations will vary, and so, too, will the nature, process, and content of operational planning. Some form of planning must always precede action. Thus, there is no guestion of whether planning is done, but only a question of who does it, how it is done, and the extent to which different patterns of planning affect outcomes. Two general issues arise. First, what is the relative role of âplannersâ and "âimplementors"⢠in operational planning? Planning is perceived here as separate from the act of doing; however, this does not necessarily imply that planners should be different from implementors. An increasing amount of evidence in the literature suggests that such a separation is artificial and gen- erally dysfunctional. Implementors themselves should be responsible for and actively involved in planning, particularly at operating levels. Second, what is the relative importance of the process of planning as opposed to its product, plans, in influencing outcomes? In situations where the environment is uncertain, formal plans may not be useful, but the process of planning may still be beneficial. Both excessive formalism and informalism will reduce the benefits of 161
162 planning and, in extreme situations of misfit, may even make the planning system dysfunctional. Generally, planning activities are carried out at three levels (Anthony, 1965; Anthony and Herzlingar, 1975) of program management (Table 1). At the top management level, policies and strategies are formulated, and resources are allocated to achieve desired goals. The middle management level is usually responsible for the planning of outputs and inputs. Planning at this level therefore includes the allocation of targets for contraceptive acceptance, as well as plan- ning for physical infrastructure, supplies, manpower development, and program support activities such as mass communication. Coordination with activities in the other sectors of the economy is also sought at this level. At the operational level, planning focuses on activities: who will perform what activity, when, and where? It should be noted, however, that the distinction among these levels may not always be clear, and in the extreme case may not exist at all. In the birth planning program of China, for instance, local levels are responsible for achieving "population growth" objectives and developing necessary program activities themselves (Population Reports, 1982). TABLE 1 Planning Tasks at Different Management Levels Level of Management Planning for Planning Tasks Top Outcome Development of strategies Negotiation of goals Allocation of resources Middle Input-output Planning for service delivery Negotiation of targets Logistics support Mass communication Coordination with other development departments Encouragement of community participation Operating Activities Home visits Follow-up Field worker activities Supervision Clinic/health center operations Record keeping
163 This chapter considers planning at the middle and operational management levels. A review of the literature suggests that planning has received much less attention than related areas such as evaluation and management information systems. The available literature can be generally classified in two categories: reviews of programs, which often identify the prevailing weaknesses in operational planning and their consequences; and a few operational research studies, which des- cribe the experience of improving planning systems. Methodologies for prevalence surveys and target setting based upon demographic objec- tives are well established, but more research on activity planning for field workers and for service-delivery systems is needed. The next section reviews the contribution of operational planning to program effectiveness that results from increasing efficiency in the use of resources and matching program services with user needs. The following two sections summarize current practices in activity planning at the operational level and the planning of inputs-outputs at the middle management level, respectively. Operational planning can be improved in several ways, and these are discussed in the next section. The chapter concludes with a discussion of the characteris- tics of operational planning systems for three types of programs-- supply-oriented, strategically managed, and community-centered--and some research issues. OPERATIONAL PLANNING AND PROGRAM EFFECTIVENESS Operational planning systems can contribute to program effectiveness in two major ways--by increasing efficiency in the use of resources and by matching program services with user needs. Efficient Use of Resources Almost all available data indicate that the use of contraception, par- ticularly of spacing methods (e.g., pills, condoms, and IUDs), in- creases considerably when promoted on a face-to-face or door-to-door basis (Schellstede and Liszewski, 1984). Therefore, most programs include home visiting as an important activity of field staff. How- ever, the productivity of field workers varies considerably. The discussion below focuses on how operational planning affects field worker performance; some specific aspects of this discussion, such as home visits and supervision, are addressed in further detail in the next section. In Bangladesh, acceptance rates in nongovernment programs that seem to share an intensive, geographically limited approach frequently reach a contraceptive prevalence of more than 30 percent, a figure far beyond the national average (about 18 percent in 1982) (Schellstede and Liszewski, 1984). One explanation for this discrepancy is the finding that workers in the national program do not visit their fiela areas systematically (UNFPA, 1978). The Family Planning and Health Services Project in Matlab, Bangladesh provided village-based contra-
164 ceptive services by community health workers--a cadre of young, liter- ate married women who used contraceptives and were from respected families in the community. These workers regularly visited the field areas and provided a wide range of contraceptive methods. A high quantity and quality of field work was ensured by a high management effectiveness; a competent, technically trained, disciplined, and fieldoriented supervisory staff; a team of canmunity health workers with a well-articulated task orientation; and a system guided by per- formance rewards and sanctions. On the other hand, reviews of several national programs have iden- tified how weaknesses in operational planning--inadequate skills in planning, misdirected efforts, a gap between expected and actual roles, and a lack of synergy among the program's education and service activities--have contributed to a loss of productivity among field workers. How much flexibility should be given to field staff in planning field visits? In the Indian program, a fixed visit pattern is speci- fied and a tour plan drawn up, specifying the number of houses to be visited and a fixed cycle of visits. The worker is expected to visit the household; talk to concerned women or men; assess the nature of services to be provided, if any; and update necessary records. While simple in principle to implement and supervise, such a large-scale program of home visiting presents many difficulties in implementation. Misra et al. (1982), for instance, found that even after more than 10 years of program operations, only about 10 percent of couples were re- ported to have been visited by the field worker in the study area of the state of Uttar Pradesh in India. Similar experiences have also been reported from elsewhere. Reasons often mentioned for such short- falls include low worker morale, inadequate skills, poor supervision, and insufficient logistics support in terms of transport and supplies of contraceptives and informational material. A review of the Indian program (Population Council, 1982) recommended that the workers at the subcenter and village levels be systematically trained in management techniques; this would enable them to set priorities among their tasks and systematically organize their time so as to maximize their cover- age of the population to be served, especially those segments most in need of information and services. It was also recommended that super- visory procedures be designed to reinforce such training (as discussed further below). Sometimes the activities of field workers may be misdirected, even in relatively successful programs. A review of the Korean program suggests, "within the existing family planning program, discipline, responsibility and emphasis on performance brings results, as it does in other activities. However, the emphasis is sometimes misplaced with a lack of attention to the follow-up and continuation so that the achievements of the field staff do not pay full dividendsâ (Jain et al., 1981:128). (The need for follow-up is discussed further in the next section.) In the absence of systematic planning, a gap also may arise between the expected and actual role of field workers. A Family Health Project in Sri Lanka (World Health Organization, 1978) found that the canvassing of attendance at immunization clinics and the pro
165 motion and follow-up of family planning receive relatively little attention. Rather, the public health midwives' âadvance program," prepared at the beginning of each month, is geared to prenatal and postnatal visiting, and to an exclusively postpartum approach. Al- though the aim of total community coverage is dismissed by most mid- wives as unattainable, in most areas it would be well within their reach. In practice, those families who are within easy reach receive more intensive care than those living farther away. Further, in the absence of operational planning, the synergistic effect of education and service activities may not be realized. Again, in Sri Lanka, the United Nations Fund for Population Activities (UNFPA) needs assessment mission (UNFPA, 198la) recommended that plan- ning of communication activities should be decentralized so as to link education more closely with supervision of services; agencies involved should work out joint programs with coordinated services and educa- tional elements. Thus operational planning can increase the productivity of program resources, including not only field workers, but also clinics, trans- port, and supplies. It helps in systematizing and appropriately di- recting the use of those resources, maximizing program coverage with the given level of resources, and bringing about a synergistic effect among various program activities. Matching Program Services with User Needs Operational planning contributes to program effectiveness not only by promoting more efficient use of resources in providing services, but also by matching these services with user needs. In planning for services, it should be noted that accessibility and availability are the key considerations that influence the use of contraception (Cornelius and Novak, 1983; Hassouna, 1980; Kamnuan Silpa and Chancara Thirong, forthcoming). Using World Fertility Survey data from Korea, Mexico, and Bangladesh, Tsui and colleagues (Tsu, 1980; Tsui et al., 1981) found a positive relationship between objective availability and contraceptive use that remains significant even if the level of community development and women's education, marriage duration, and parity are held constant. In a related study, these investigators also conclude that the perceived availability of con- traceptives is actually much more closely related to contraceptive use than is actual availability (see Chapter 24 in this volume). The type of service-delivery network may differ depending on user needs. Egypt, for instance, is developing health facilities that can provide unified services in urban areas and a community-based distribution system to make services more widely available in rural areas. The participation of workers in operational planning can sometimes identify a crucial constraint to program operations based on user needs. Murthi (1976) reports on an experiment designed to involve staff of the primary health center in planning its activities. The experimenters held a series of staff meetings, with participation by district officials, to identify constraints to the performance of the
166 health center. The lack of a convenient service facility for female Sterilization and some administrative bottlenecks were identified as the factors resulting in low performance. The provision of a service facility and the removal of these bottlenecks are reported to have doubled performance as compared to the corresponding period in the previous year. On the other hand, the tasks involved may be such that it is nec- essary for field workers to plan their own work. PROFAMILIA, Colom bia's private family planning association (Wolf, 1983), has been draw- ing successfully on the efforts of community volunteers to deliver to people's houses the type of services that a clinic-based program is unable to provide. There is considerable flexibility in the ap- proaches of these leaders. As a supervisor remarked (Leguizamon, 1979:17), - « »« it would not make sense if I were to sit at my desk to plan the promoter's work. Although the Veredas where we work, are not unknown to me, I am not as familiar as they are with the best alternative for planning a route of visits nor do I know when it is best to visit a distribution post. Therefore, they, in accordance with the coordinator, prepare and bring the programs to me. I seldom make modifications and if I do it is because I feel that it is really important to change something. However, these modifications are discussed with the promoter. The Program Administration has granted to me sufficient autonomy in making decisions here without the need to send papers to Bogota. Indigenous women leaders, who are the key to the success of any community-based program, have a special role and significance in Latin American communities. Their success may be primarily because they are sensitive to community needs and listen to the rural women, and therefore can gear the program to local needs and provide appropriate supplies. | Thus matching program services with user needs seems to require a combined bottom-up and top-down approach to planning. To illustrate, a review of the program in Malaysia (Jain et al., 1981) describes the effort at formalizing program planning as follows. In the early stages of the program, a separate unit for planning did not exist. A planning unit was established to provide requisite skills in systema- tizing the planning process. Initially, planning was essentially ad hoc, but now it starts both at the local level and at headquarters, with continuing proposals, amendments, and readjustments as needed. The Indonesian program has developed a sophisticated planning system for similar purposes, and is discussed in detail in a later section. Contribution to Program Effectiveness The above review suggests that operational planning can directly con- tribute to increasing program effectiveness. A good planning system can also contribute indirectly to effectiveness by enhancing the
167 utility of monitoring and evaluating programs. However, conceptual and methodological difficulties arise in evaluating the contribution of operational planning, since it affects and is affected, in turn, by many other factors of program management, such as motivation of staff and availability of supplies. Therefore, it is difficult to answer precisely the question of what improved operational planning can contribute to program effectiveness. On the other hand, the success of several programs has been attributed to strong program efforts that include the use of appropriate operational planning systems. The decentralized planning system with emphasis on commu- nity involvement in Indonesia, and programs of voluntary agencies with flexible operations that are sensitive to the needs of the community, are examples. ACTIVITY PLANNING AT THE OPERATIONAL LEVEL At the operational level of management, program activities have to be planned. These activities include home visits and follow-up, the organization and supervision of field work, and clinic or health center operations. The discussion below addresses key issues arising in planning for each of these activities. Home Visits and Follow-Up Planning for home visiting consists of identifying areas to be visited, drawing up a schedule of visit plans, and defining specific activities to be carried out during the visits. Such operational plans are influenced by the type of worker (purely voluntary, part- time, or full-time); specific activities to be carried out (rapport building, information and education, resupply, or others); and the geographical area to be covered (area, terrain, and accessibility). Several problems related to planning for home visits were dis- cussed in the previous section. The major issue is how to make such visits more productive. In addition to the points made earlier, workers need to be selective about who should be visited: couples who have expressed the intention of having additional children need not be visited so frequently; those who are unfavorably inclined may also be visited infrequently, but each visit may be of a longer duration. Workers should also be prepared for their activities. Different couples require different types of services (resupply of pills or condoms, discussion to allay fears of side effects, and so on). Therefore, workers must know the status of each couple with respect to knowledge, desire for more children, attitude, intentions, and practice of family planning (Bhatnagar and Satia, 1976). A lack of accurate data on the status of the couple, together with rigid visit schedules and inadequate skills in planning, will result in unproductive visits and a loss of morale. When the practice of con- traception is low and demand-generation activities require more em phasis as compared to the provision of services, greater flexibility
168 in visit planning is needed. However, as noted above, programs run in the framework of large government bureaucracies may not foster the required managerial decentralization needed to provide such flexibil- ity. In such situations, community volunteers are often effective, and their work program can be organized around community needs. In any case, there are limitations to what a home-visiting program can achieve (Gadalla, 1978). Complementary group and community activities are needed to sustain the results achieved by a home-visiting program. Therefore, several programs, including those of Indonesia and Korea, emphasize the formation of acceptor or mothers' clubs, particularly in areas where contraceptive prevalence is sufficiently high to sustain such groups. As noted earlier, follow-up of acceptors is important to maintain- ing high continuation rates for spacing methods and quality services for acceptors of sterilization. In Korea, for instance, emphasis was placed on recruiting new acceptors by giving acceptor targets, but targets for follow-up or revisit were not set. Consequently, follow- up was neglected, which led in turn to low continuation rates. Wwith- Out adequate continuation maintenance, the program eventually reached a stage where a great deal of activity was producing little progress. Even when there is adequate motivation of field staff, rigid visit schedules may be at variance with needs for follow-up. For instance, an acceptor of sterilization needs to be visited for several days right after acceptance. Therefore, flexibility in work programs, com- bined with a plan for follow-up visits, is needed. The logistics of follow-up become difficult and expensive when a few acceptors are distributed over a large geographical area. The Indonesian progran, with its heavy emphasis on pills, recognized these difficulties; it sequenced its expansion program, covering heavily populated areas in the first instance. Even here, the program concentrated on a few villages at a time, with an intensive approach. The Organization and Supervision of Field Work Programs spend considerable financial resources on maintaining a large number of field workers. Therefore, the efficient and effec- tive utilization of these workers is essential if the program is to succeed. Preparing operational plans for field workers is complicated because of a need to respond to many, somtimes conflicting considera- tions. Administrative considerations often require that a routine fixed program be drawn up that is easy to implement and supervise. On the other hand, field workers are assigned a range of tasks-~home visits, follow-up visits, referral of clients, service camps and cam- paigns, and attendance at acceptorsâ meetings--and the requirements of these tasks may be at variance with a fixed pattern of visits. Finally, community perception of needs may differ from the services provided by the program. Because of such conflicting demands on workers, actual activities may differ considerably from those planned. An additional hurdle in effective operational planning is the range of tasks assigned to field workers itself. Long travel times
169 and cumbersome record-keeping procedures contribute to the overloading of workers. Therefore, workers perform only those activities either perceived as important or emphasized by supervisors. Weak overall management can also make it difficult to institutionalize the syste- matic activity planning of field workers. In their attempts to in- Stitutionalize an activity-planning system in two primary health centers in Rajasthan, India, Giridher and Satia (1984) found several constraints in matching program activities with assessed village needs, including nonavailability of complementary resources, poor worker and organizational skills, a dysfunctional cycle of centrally dictated program operations, and neglect of some potential for accep- tance of IUDs. Thus, a variety of improvements in management will be needed for effective activity-planning systems. Although this problem has not received adequate attention, functional analysis is often recommended for assessing the feasibility of the tasks given to workers, and for identifying the extent of deviations from plans and their causes to remedy deficiencies. In functional analysis, the actual functioning of workers is observed, and the time spent in various activities is noted; corrective actions need to be taken if observed time allocation differs from desired allocation. Alternative work programs can also be systematically evaluated by operational research. In addition, many programs have integrated family planning with maternal and child health and other health services, which requires that workers perform additional tasks. This addition of new tasks, if not properly handled, can cause difficulties. The experimenters in Matlab Thana of Bangladesh (Phillips et al., 1984) comment upon such difficulties: "the addition of IUD insertions to the work regimen in January 1978 required modifications in the work pattern » « « « There was a brief drop in prevalence in three _ blocks.â Subsequently, a tetanus toxoid program was introduced. No apparent disjuncture in the contraceptive prevalence trend occurred despite the complex operational difficulties of developing a cold chain in a rural riverine area where electrification, roads, and other modern communication networks were absent. This successful introduction of tetanus immunization without major disruption to the provision of family planning services was achieved by using the male supervisors as organizers of logistics, so that the new service component did not in- terrupt the regular family planning work regimen of community health workers. . An important ingredient of effective service delivery is technical and administrative support to field personnel by adequate supervision. A field experiment in Athoor Block in India (Pisharoti et al., 1972) suggested that for successful supervision, in a typical fortnight, supervisors might have 2 days for training and 8 days for field visits. They should have sufficient mobility to visit, and these visits should be prescheduled. Moreover, they should keep a simple diary recording the findings of their supervisory visits. In addi- tion, supervisors themselves should be trained, and such training programs should be continuously scheduled.
170 The frequency of supervision is based upon the physical character- istics of the program, such as area and number of workers to be super- vised, geographical terrain, local transportation and communication systems, and job activities of the supervisors. During the program maintenance phase, the activities of supervisors should be routine, generally including provision of supplies, collection of statistics, review of performance, and training of new workers or distributors. During the program expansion phase, supervisors have to be flexible, and their activities may involve training, the establishment of con- tacts with the community, group meetings, and the provision of special follow-up services. Discussion in a later section reports on an Operational research study designed to identify optimal frequency of supervision. Clinic/Health Center Operations In planning for clinic operations, one has to decide what family plan- ning services will be provided, when, and by whom. In the early 1970s, it was not uncommon for clients to have to come to clinics at rather inconvenient hours for simple services such as resupply of pills. Operating hours for clinic services were planned according to the convenience of the clinic staff, rather than that of clients (Korten and Korten, 1977; Korten, 1979). Many clinics set aside spe- cific days for particular services; consequently, for example, mothers coming for maternal and child health services could not avail them selves of family planning services at the same time. Further, clinic activities should be so organized that informa- tion, education, and communication (IE&C) activities are integrated with other services. The flow of clients through clinics is often poorly organized; such lack of direction leads to confusion. Clients sometimes have to wait for a considerable time for services, and such waiting periods can be minimized and utilized for IE&C activities by proper planning. Thus clinics need to have flexibility in their operations, and the provision of services should be matched with needs for such services. When a clinic supports a field program, the head of the clinic has the additional responsibility of planning the activities of field workers and needed support. The monthly staff meeting is the most inm- portant occasion for joint planning. (Pisharoti et al., 1972). For such meetings to be effective, current data on the progress of various activities should be available for monitoring purposes. Workers should be able to participate and discuss their own experiences, and be able to plan out their course of action. Moreover, to make field work productive, an appropriate extension system may have to be developed. Lessons learned in organizing agriculture extension may be useful in this regard. Benor and Harrison (1977) report on their experiences in implementing a "Training and Visit" system. They re- port that the reasons for ineffective extension services include lack of organizational support and control, dilution of efforts by an attempt to do many things at the same time, inadequate coverage and
171 low mobility, inability to adapt to changing conditions, poor train- ing, lack of ties with research, and low status of extension person- nel. They say that for extension service to be effective, there must be a gap between what farmers can achieve and what they do achieve in their fields. ACTIVITY PLANNING AT THE INTERMEDIATE MANAGEMENT LEVEL Tasks at the intermediate management level include providing inputs and ensuring outputs. Middle-level managers need to plan for service delivery, logistics, mass communication, and community participation, among other things. Since separate chapters in this volume are de- voted to these areas, the discussion here will be brief. Service Delivery Service delivery is planned based upon information on existing facil- ities and staff, and on users' perceptions of accessibility and avail- ability of services. Although considerable work has been done on assessing the latter, corresponding research on physically planning for facilities (their location and size, and range of services) has been limited, partly because many service-delivery systems are incre- mentally developed. Often, several services are developed in paral- lel; subsequently, rationalization and consolidation are needed, particularly in urban areas. For instance, the Ministry of Health in Egypt is constructing multipurpose health centers for providing com prehensive services since different services are currently provided at different locations. Logistics At the operational level, supplies to clinics and field workers can be based upon an indent or a replenishment system. Earlier, most programs used indents from the field level to provide supplies; how- ever, given multilevel stocking, this system often resulted in supply failures, with supplies either lacking or in excess of need. Most programs now link supplies to information about their use (National Family Planning Coordinating Board, 1982; UNFPA, 1978, 1979). Typically, at regular intervals, use information is collected from various distribution points/clinics. Rather than wait for indents from clinics, the supply organization takes action to replenish supplies, with the replenishment quantum based upon set norms for stocking various levels. This system reduces the unreliability of indenting procedures and possible lapses inherent in long supply lines. It shifts the responsibility for replenishment of supplies to the organization, limiting the responsibility of the clinic to re- porting on usage and taking action in exceptional circumstances.
172 Mass Communication Mass communication has not been planned very systematically because its role changes as the program evolves. In the beginning, simple slogans are used to create awareness. Then the focus shifts to pro- viding knowledge. Once knowledge is widespread, attitudes need to be influenced. However, the strength of traditional agencies dealing with mass communication lies in developing action-oriented rather than attitude-focused messages (Roberto, 1978b). The use of various mass media can only be as effective and specific as the program's objec- tives and guidelines. Therefore, the problem-definition and diagnosis stages of implementation are important for the effective planning of communication activities. Two steps are necessary: to have data on the client sector of the task environment available through surveys and village studies, and to specify clearly the objectives of each communication instead of generally aiming at increasing contraceptive prevalence. Community Participation Increased community participation in family planning program activ- ities has profound implications for program planning and management. As noted earlier, it is unwise to assume that any one model or program design will be appropriate for all situations (International Planned Parenthood Federation, 1982); therefore, considerable decentralization of program operations is necessary. For example, the policy statement of the Indonesian program (National Family Planning Coordinating Board, 1982:20) states, âGovernment has taken steps to have the com munity participate from the very beginning ... . The initiative taken by the government should be continued, until such time as the Population and Family Planning Program and its problems have become entirely the responsibility of the community itself." However, this approach has its difficulties since many communities are not yet able to initiate, support, and participate fully in development activities, particularly those related to family planning, because of prevailing social and economic conditions and low educational status. As the means used to secure community participation vary, the role of govern- ment must also vary. Suitable entry strategies, sequencing of program expansion, and functional coordination must be planned for effective community participation (Roberto, 1978a). STRENGTHENING OPERATIONAL PLANNING Several programs are making efforts to strengthen operational plan- ning. A review of the practices of operational planning suggests that in general, the following are the most frequently recommended improvements: strengthening data systems and their use, improving target-setting practices, increasing planning competence,â using operational research, and carrying out organizational development effort.
173 Strengthening Data Systems and Their Use Service statistics and acceptor records are the basis for operational planning in the most well-established programs. However, data on pro- gram results at the national or regional levels are sometimes missing, although during the past decade, a large number of contraceptive prev- alence surveys and other fertility/family planning services have been carried out. A timely prevalence survey can help policy makers and program administrators by measuring knowledge, use, and preference for methods of contraception; by identifying women who may need services; by revealing obstacles to the use of services; and by uncovering opportunities to make services available (Population Reports, 1981). Prevalence surveys are especially useful for determining unmet need. Nortman (1982) developed a model of unmet need by using preg- nancy status, pregnancy desires, and contraceptive practice, based on survey data. Need is estimated for 1 year following the survey and is expressed by two units of measurement: one, the percentage of fecund couples requiring contraception during any part of the year (a measure relevant for the number of program clients to be served); the other, couple-years of protection required to prevent an unintended pregnancy (relevant for certain types of supplies, such as pills and condoms) . Prevalence and/or fertility surveys can also be used periodically to assess user perceptions, and less intensive operations research surveys can be used to obtain similar information for more localized areas. (However, in order to provide data appropriate for planning, any survey should be carried out according to accepted scientific survey design and sampling priorities.) In addition, sometimes field workers maintain family or eligible couple registers for their areas. If accurately maintained and suitably analysed, this information is useful for segmenting the client population, exercising selectively in activities, and sequencing program development. However, these records are seldom maintained accurately, for several reasons. Top- level administrators do not ask for a summary of this information; workers and clinics also do not feel they have the requisite flexi- bility to reorient their activities based upon these data. Neverthe- less, for operational planning to be effective, such data should be collected, analyzed, and used, at least by the person collecting and recording the information. With the increasing availability of micro- processor technology, more such data may be used to systematize pro~ gram operations. While quantitative data are useful, qualitative information may yield insights not provided by surveys. Along with researchers, supervisors can collect and use such data. Management information systems should also provide scope for transmission of this type of information. Thus, supplementing routine information systems with surveys, eligible couple data, and qualitative information on program func tioning can help improve operational planning, provided that accepted Standards are applied to all data collection and analysis procedures.
174 Improving Target-Setting Practices For most programs, program planning starts with either five-year or annual national targets for contraceptive acceptors. In countries where demographic objectives are not set, targets may still be set for the expansion of services. These targets can be further trans- lated in terms of needed inputs of personnel and other resources (United Nations, 1984). There are fairly sophisticated methodologies for setting contra- ceptive acceptance targets to achieve specific demographic goals. However, targets so set should also be within the capacity and will- ingness of those responsible for achieving them; otherwise they may adversely affect program operations. Moreover, program planning should be geared toward the specification of activities and tasks, not simply toward stating objectives and targets. Poor specification of program activities in the planning stage provides very little gui- dance for program managers in management planning, monitoring, and evaluation. A review of the Indian family planning program (Population Council, 1982:83) suggested that e e « if state governments could be induced to play a more active role in designing their own family welfare programs, they might make greater efforts to ensure their success. This same principle is probably applicable at all levels; district managers will be more committed to successful implementation of plans that they have had a part in designing, as will the personnel of PHCs and subcenters, and village leaders. Many programs have attempted to make target setting more partici- pative by combining top-down and bottom-up processes. The planning process in Indonesia (National Family Planning Coordinating Board, 1982) can be used to illustrate such attempts. The Indonesian program uses three mechanisms. The first is from top to bottom: each year the head office sets up programming and budgeting guidelines that are sent to the provinces, regencies, and local implementing units. The second mechanism is from bottom to top: after receiving guidelines, the implementing units discuss them and send back their proposed pro- gram of action. Through these processes an agreed-upon plan is determined. The third mechanism is horizontal, with these plans being coordinated with those of other agencies. The whole process is carried out on a specific time schedule. As contraceptive prevalence increases, target-setting systems need to be reoriented. In the early stages, targets are set in terms of recruitment of new acceptors. As prevalence increases, however, tar- gets should be set to encourage continuation rates; this leads to a necessary emphasis on after-care services. To achieve ambitious tar- gets, more women in younger age groups need to be encouraged to prac- tice contraception and child spacing. Finally, for targets to be meaningful for operational planning, resource allocation processes should be linked to the targets set.
175 Resource distribution to the provinces may not be equitable as regards need, and the provinces may often wait for the districts to report critical demands before responding with resources. In most traditional programs, targets are set for recruiting acceptors or for achieving a desired prevalence rate. However, where decentralization in government is extensive and local communities are well organized, outcome targets, or targets for numbers of births, can be passed on to lower levels. In China, under the birth planning system (Population Reports, 1982), the national government assigns each province a numerical target for the natural increase rate, which in turn is divided among the counties in the province's jurisdiction. The county office then negotiates the birth target received into com mune, brigade, and production team targets, and eventually into indi- vidual certificates of permission to become pregnant and have a birth. Negotiations between communes and brigades sometimes require three or four exchanges. Individual couples are then expected to contracept. Thus, desired outcomes themselves are directly translatea into indi- vidual actions. Of course, excessive pressure in such applications of targets may cause problems or restrictions of personal choice among couples whose cooperation is required. Increasing Planning Competence The need to increase competence for planning at various levels has been felt by managers. Many programs have established planning cells that assist in the preparation of future programs and projects based upon an assessment of resources, objectives, and needs and attitudes of users. As noted earlier, the planning function needs to be dele- gated to field levels because each area has its own particular socio- cultural characteristics, and absolute operational policies dictated centrally would be unsuccessful. Implementors themselves need to participate in planning. Thus, field workers and managers at differ- ent levels need to have skills in planning and using appropriate data with necessary expert support. While training programs and management information systems (MISS) are being developed for this purpose, the Organization of planning cells needs to be strengthened so that they can aid in strengthening the planning process. As communities in- creasingly participate in program activities, not only do the skills of workers in assisting the community need to be increased, but also planning skills within the community need to be strengthened. Using Operational Research When several different ways of organizing activities exist, one can identify the best one by experimenting with them. The use of oper- ational research to evaluate different delivery systems has been re- ported widely. Foreit and Foreit (1984) report on their experiment with frequency of supervisory visits, which illustrates how such research can be used for other operational decisions as well. In the
