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WORLD BANK TECHNICAL PAPER NUMBER 297 g ,t I1I;

Key Indicators for Family Planning Projects

Rodolfo A. Bulatao

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WORLD BANK TECHNICAL PAPER NUMBER 297


Rodolfo A. Bulatao

The World BankWashington, D.C.

Copyright © 1995The International Bank for Reconstructionand Development/THE WORLD BANK1818 H Street, N.W.Washington, D.C. 20433, U.S.A.

All rights reservedManufactured in the United States of AmericaFirst printing September 1995

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ISSN: 0253-7494

Rodolfo A. Bulatao is Senior Demographer in the Human Development Department of the WorldBank.

Library of Congress Cataloging-in-Publication Data

Bulatao, Rodolfo A., 1944-.Key indicators for family planning projects / Rodolfo A. Bulatao.

p. cm. - (World Bank technical paper, ISSN 0253-7494; no.297)

Includes bibliographical references.ISBN 0-8213-3372-01. Birth control-Evaluation-Methodology. 2. Evaluation research

(Social action programs). I. Title. II. Series.HQ763.5.B85 1995363.9'6-dc2O 95-35189

CIP

Contents

Foreword . .................................................. v

Abstract . .................................................. vii

Functions of indicators .......................................... 1

Criteria for indicators .......................................... 5

A basic model, with indicators ..................................... 6

Demographic outcomes ......................................... 7Total fertility rate ........................................ 8Infant mortality rate ....................................... 8High-risk births ......................................... 8

Behavioral outcomes ........................................... 9Contraceptive prevalence rate ................................. 9

Program outputs .............................................. 10Proximity of services ...................................... 10Dropout ratio ........................................... 12

Capacity and process ........................................... 12Management information score ................................ 13Couple-years of protection (CYP) provided per worker ................. 15

Program inputs . .............................................. 16Approval of family planning ................................. 16Female secondary education ratio .............................. 17

Applying the indicators ......................................... 17Units of observation ...................................... 19Data collection .......................................... 19Analysis and interpretation .................................. 21

Conclusion . ................................................ 23

Appendix A. Current data available on key indicators for developing economies andterritories ............................................. 24

Appendix B. Demographic and Health Surveys, 1985-94 .................... 29

References . ................................................ 31

Tables

1 Target setting or evaluation provisions in 42 World Bank population projects .... .. 32 Indicators from one family planning project ........................... 43 Demographic outcome indicators .................................. 84 Behavioral outcome indicators ................................... 95 Program output indicators ...................................... 116 Capacity and process indicators .................................. 137 Program input indicators . ...................................... 178 Key indicator summary . ...................................... 18

Figures

1 A basic model for family planning, with key indicators .................... 7

Boxes

i Indicator policy . ........................................... 22 Can a management information system do the work of a survey? .............. 203 Was the project responsible? .................................... 22

iv

Foreword

To assess the impact of development projects, one needs clearly defined indicators thatcan be linked to incremental progress and to achieving ultimate objectives. This paper listsmany indicators and suggests a small set that can be used for these purposes in the area offamily planning. Related indicators in other areas of reproductive health are being provided ina companion paper.

The impact of family planning is a topic that has been practically in continuousdispute for several decades. Although significant progress has been made helping developingcountries complete the transition to lower fertility, much debate continues on the impact offamily planning programs. Increasingly also there has been recognition that family planningimpact should be looked at from the client's point of view, and that the quality of services andhow they actually work should be central concerns. Thus the impact debate has broadened anddeepened, and traditional demographic indicators by themselves are no longer sufficient.

Instead of a comprehensive review of the many evaluation strategies, this paperattempts to suggest a small, economical set of indicators that could apply to many projectswith family planning components, but that still incorporates data from varied sources andreflects numerous features of projects-from inputs and structure up to long-term behavioraloutcomes.

A set of indicators will not resolve the long-running issues regarding family planningimpact. But systematic use of indicators could eventually provide a clearer and moreconsistent picture of how family planning programs are succeeding in, or failing to, improveindividual lives.

David de FerrantiDirectorPopulation, Health and Nutrition Department

v

Abstract

Ihis paper lists numerous indicators that could be used to monitor and evaluate familyplanning and suggests ten potentially useful for most projects. These ten cover all aspects of afamily planning program: program inputs, program capacity and process, program outputs,behavioral outcomes among clients, and long-term demographic outcomes. For a specificproject, these ten (or any selection made from the indicators here) need to be supplementedwith indicators for other reproductive health services, which will be covered in a subsequentnote.

As input indicators, the paper suggests (1) popular approval of family planning, asurvey-based measure that should be collected from both men and women to indicate theacceptability of contraception, and (2) the female secondary enrolment ratio, perhaps the chiefsocioeconomic determinant of demand for contraception.

To represent program capacity and process, two indicators are proposed: (3) amanagement information score, as a strategic measure of the organization's institutionalcapital, and (4) couple-years of protection provided per worker, as a measure of programefficiency.

Program outputs are mainly access to services and their quality, representedrespectively by (5) proximity of services, or the proportion of married women of reproductiveage with services within their rural village or urban neighborhood or no more than onekilometer away, and (6) the dropout ratio, a measure of method discontinuation that should besensitive to the type of services clients receive.

The immediate behavioral outcome of a program should be contraceptive use, whichis represented by (7) the contraceptive prevalence rate, the proportion of couples in unionusing contraception.

Demographic outcomes of a program are covered by (8) the total fertility rate, (9) theinfant mortality rate, and (10) the proportion of high-risk births among all births, a morepractical measure than the maternal mortality rate.

Many alternatives to each of these ten indicators are listed and briefly evaluatedagainst proposed criteria for useful indicators.

Most of the recommended indicators can be obtained from periodic householdsurveys. Some require a management information system or government statistics. Asummary table provides definitions, data sources, and some notes on each key indicator, andan appendix provides data on the majority of these for at least a few countries.

vii


1. This note describes indicators that can be used for World Bank projects involvingfamily planning. Other reproductive health services besides family planning are covered in acompanion note. Bank policy requires the use of indicators in projects but does not imposeuniformity: indicators should reflect the particular objectives of each project (Box 1).Accordingly we list below a range of possible indicators, though to provide guidance we dofocus on and try to provide some understanding of key indicators that could be broadly useful.

2. Given the substantial investments in family planning, evaluating programs has been aconsiderable concern, and indicators have accordingly proliferated. Adding to thisproliferation is the increasing recognition that family planning should be looked at from theclient's point of view, and that services cannot be summed up solely by their demographicimpact. A regularly updated statistical compendium (Ross, Mauldin, and Miller 1993) nowcontains 30 long tables of cross-national data. A recent handbook of indicators-to be referredto extensively below-lists eight main dimensions of family planning programs and underthem 103 indicators in all, some labeled as "illustrative" of still other indicators (Bertrand,Magnani, and Knowles 1994). Bank family planning projects, nevertheless, have tended to beeconomical, if not parsimonious, with indicators. Once one gets past disbursement profiles,many Staff Appraisal Reports-36 percent in an earlier review (Baldwin 1992: 11)-haveincluded no specific indicators.

3. To help remedy this we provide not only long indicator lists but also a suggestedminimal set of ten key indicators. Used consistently across projects, even a few indicatorscould contribute significantly to learning from experience. A few indicators are usuallysufficient to give an overall picture of substantive progress, though a fuller set is more usefulfor diagnosis and strategy development. A small set does need balance and requires carefulselection. We therefore set the stage by discussing what functions indicators serve and whatcriteria should be used to select the most appropriate. Then a simple model will be proposed,the indicators discussed in the context of the model, and their application within projectscovered. For those willing to skip the background and qualifications, Table 8 (page 18)provides a quick summary of the key indicators, and Tables 3-7 provide the longer indicatorlists.

Functions of indicators

4. Indicators may be used to track, monitor, evaluate, compare, and prepare projects.

* Tracking. Indicators show whether the components envisioned for a project areactually put in place. For example, a project may require the production of acertain number of local-language provider handbooks on contraceptive counseling.Two simple indicators are the amount disbursed for handbook production and thenumber of copies produced.

* Monitoring. Indicators show whether project components are having expectedshort-term effects, allowing reformulation if needed. Whereas tracking verifies thepresence of inputs, monitoring attends to their immediate impact. If a project

KEY INDICATORS FOR FAmiLY PLANNING PROJECrS 2

includes management training, for example, monitoring indicators might bewhether trainees are assigned appropriate responsibilities and how they perform.

* Evaluation. Indicators show whether projects affect beneficiaries. Evaluation is along-term process rather than a day-to-day management requirement. It may takeplace at a key point during a project or after a project is completed. Typicalindicators are contraceptive prevalence and total fertility.

* Comparison. When similar indicators can be obtained for different projects,comparisons are possible that often provide more insight than individual casestudies and suggest ways to design other projects. Programs involving smallcontraceptive providers, for example, may be compared through such an indicatoras couple-years of protection (CYPs), allowing experience to accumulate aboutwhat design works best.

* Preparation. As a standardized snapshot of the state of the sector and its needand capacity to change, indicators provide an understanding of the setting for afamily planning project, facilitating formulation or revision of organizationalstrategy. For example, the levels of such indicators as the maternal mortality rateand the quality of contraceptive counseling may determine what policies, type ofproject, or specific interventions may be most appropriate, or at least suggest tothe project design team what other data should be examined.

5. Indicators collected for tracking or monitoring are meant to improve a project'sperformance. Indicators collected for comparison or preparation are meant to improve theperformance of a subsequent project or of projects in general. Indicators collected forevaluation may improve the performance of the current project, by clarifying its goal andkeeping it focused, but their chief utility is often for subsequent projects, to enable them tolearn from the current one. These distinctions parallel other common distinctions amongindicators of input, process, output, and outcome: what is tracked is usually input, what ismonitored is usually process or output, what is evaluated and compared may be output but isusually outcome. Input, process, and output indicators are sometimes grouped together as"progress" indicators, in contrast to outcome indicators, which may be said to represent"development impact."

Box 1. Indicator policy

Bank policies require, for each project, "quantification of project objectives, and selection ofa minimum core of quantitative and qualitative indicators for monitoring progress towardsthese objectives" (OD 10.70 117, September 1989). These indicators should be developed,as part of a monitoring and evaluation plan, no later than project appraisal (14), and thequantitative measures should be included consistently in tabular form in all supervisionreports (OD 13.05 Annex D4 16, March 1989). No specific indicators are mandated.Indicators should be "project-specific and should be decided upon in consultation withproject managers" (OD 10.70 117).

KEY INDICATORS FOR FAMiLY PLANING PROJECrS 3

Table 1. Target setting or evaluation provisions in 42 World Bank population projectsFunction Target setting or evaluation provision No. of projects

Tracking Government to form or announce population policy 5Government obligated to do key surveys 14

Monitoring Functioning health delivery system to be created 9Management information system (MIS) to be improved 6Institutional capacity for operational research to be upgraded 9Demographic data to be improved 4

Evaluation Specified target total fertility rate 21Bank-evaluated demographic targets and acceptor requirements 20Targets for acceptors, by method 8Midterm or other project evaluation exercise 8

Source: Adapted from Baldwin (1992:11).

6. These distinctions may be further illustrated from Baldwin's review of targets andindicators in Bank population projects. He classified all projects under 11 categories withregard to their targeting and evaluation provisions. Leaving out the category of "nodemographic or family planning targets," these may be reclassified under the functions ofindicators (Table 1). The tracking indicators in this table involve concrete actions or events.In contrast, the monitoring indicators go beyond actions and require some judgment ofimproved functioning. The evaluation indicators involve not the service providers but thebeneficiaries and whether their behavior has changed or their welfare improved.

7. We focus here mainly on monitoring and evaluation, on the questions of how well aproject is proceeding and what impact it is having. Of the other functions, tracking is essentialbut highly specific to each project, depending on the particular interventions a project funds.Table 2, taken from one Bank project, illustrates the specificity of tracking indicators, as wellas how tracking, monitoring, and evaluation indicators interrelate. It also illustrates how anyminimal set of indicators needs to be supplemented to reflect project particulars.

8. Two additional uses of indicators require comment. Indicators may be used in settinggoals or targets and in generating support for a project. These functions may be consideredsecondary or derived; an indicator is useful for these purposes only if it is already useful, orperceived as useful, for monitoring and evaluation.

9. Using an indicator as an organizational goal or target helps crystallize priorities andmotivate staff. Properly handled, targets are a useful management tool. However, they need tobe carefully specified and linked with strong injunctions about appropriate values that must berespected and means that may be employed, so that competing goals and values are not put atrisk. A single-minded focus on a simple target of any kind (for example, on improvingefficiency or on satisfying consumers) can be energizing, but it can also have a corrosiveeffect on organizational behavior, leading to inappropriate shortcuts and the violation of othervalues. A single-minded emphasis on a lower fertility target, for example, may appear tosanction violations of human rights and mistreatment of clients. The underlying problem-thatany indicator or any set of indicators is necessarily selective-is common to all uses ofindicators and will therefore come up again below.

KEY INDICATORS FOR FAMILY PLANNING PRoJECTS 4

Table 2. Indicators from one family planning project

Evaluation

Tracking indicators Monitoring indicators indicatorsCom- (from organization records and int(rviews (from operahons research andfield 6rom DHS-tponent with staffl observauion) surveys)

Expan- * Import of appropriate commodities * Adequacy of contraceptive supplies atsion of * Import, distribution, and proper use and local levelthe maintenance of laparotomy kits * Adequacy of counseling about newmethod * Systematic handling of contraceptive methods, at health house, health center, (Quantitativemix logistics hospital (for sterilization), and mobile goals will be set

* Completion of each stage of training team levels after first DHS-* Constitution and operation of 8 mobile * Client satisfaction with counseling type survey.teams in 3 provinces * Client satisfaction with treatment at Outcomes are to* Official approval for GPs to perform facilities and by health staff be evaluated inminilaps and insert Norplant * Increases in adoption of new methods comparison to

and in overall couple-years of protection trends in* Improvements in use-effectiveness of comparablespecific methods, especiaUy the piU developing

Institu- * Appointment of skilled staff at central * Proper supervision of district offices countries,tional and provincial levels * Collection and interpretation of useful extent possible ondevel- * Completion of each stage of training management information the marginalopment * Procurement, use, and maintenance of * Accurate reporting on acceptors and impact of the

vehicles and planned equipment consumption and useful feedback to pro- project itself.)* Institution of appropriate procedures and viders and field supervisorscontrols for provincial offices * Quick responses to organizational * Increased

chaUenges and management focus on public access toproblem areas contraception and* Strong staff morale reduced travel

Infor- * Production of educational and training * Increase in public acceptance and times to sourcesmation/ materials on new contraceptives discussion of family planning of supplyeduca- * Production of advertising and pro- * Increase in public knowledge about howtion/ motional materials to use contraceptive methods effectively * Increase incommu- * Development of plans for IEC cam- * Increase in knowledge and positive contraceptivenication paigns attitudes among particular groups targeted prevalence ratecam- * Completion of and publication of reports by campaigns, such as adolescentspaigns on 5 seminars or workshops * Reduction in

* Completion of and reports on 4 small total fertility rateIEC evaluation studies

* Reduction inEvalu- * Constitution and operation of advisory * Development of strategic plan from unsafe abortionsation Evaluation Committee DHS-type data and in matemaland re- * Completion of report on Human * Revisions in provider practices, clinic mortality andsearch Reproduction Center procedures, targeting, and other practices morbidity

* Completion of and reports on 2 DHS- as a result of evaluation findingstype surveys * Increased program efficiency and * Reduction in* Completion of and reports on 10 pieces effectiveness rate of populationof operations research, including experi- growthment on mobile teams* Management discussions of evaluationresults and their program implications

Source: Adapted from World Bank (1993:67).

KEY INDICATORS POR FAMILY PLAmNNG PROjECrS 5

10. Indicators are also commonly used to publicize a project's successes, as a means ofgenerating external support for it or for the agencies connected with it. Generating public andpolitical support is critical for family planning programs (World Bank 1993:56-57). However,the use of indicators for celebrating success is somewhat at odds with their other uses. Fillingthe other functions requires that indicators be as objective as possible, but generating supportmay require glossing over less favorable indicators.

Criteria for indicators

11. Useful indicators for our purposes should be

* precisely defined, program-specific, and sensitive* unidirectionally linked to program success* easy to measure reliably* summary in capturing multiple dimensions simultaneously* balanced as a set, fairly reflecting different aspects of a program.

12. Precise definition is an obvious criterion. An example of imprecision might be theconcept of leadership: leadership may be the key to family planning program success, but ithas to have a specific operational definition to become a useful indicator. This does not implythat all indicators must be objective; subjective measures-judgments, attitudes, ratings-canbe useful if well defined.

13. An indicator is program-specific if it reflects the impact of the particular programonly rather than being influenced by external factors. Extreme specificity is not necessarilyuseful, however. Programs are open systems and need the capacity to adapt to changingcircumstances, and the adequacy of their reactions needs to be reflected in indicators.Outcome indicators in family planning tend to have some mix of specificity and openness. Forexample, contraceptive prevalence reflects some effect of a family planning program but alsoreflects the impact of various socioeconomic factors, as well as the effects of parallelprograms. For some purposes, the raw indicator is useful, to indicate whether the program isdealing appropriately with challenges. For other purposes, the indicator must be subjected tocomplex analysis to isolate program effects.

14. An indicator is sensitive when small changes in program effectiveness are reflected invariations in its values. Sensitivity is a matter of degree and often implies quantification. Anexample of an insensitive indicator is whether or not the government officially supports familyplanning; this changes rarely, though when it does it can mark a milestone. A more sensitiveindicator might be some measure of continuing government interest, such as the frequency ofofficial statements supporting family planning.

15. It is convenient for indicators to be unidirectional, with a high (or a low) valuereflecting program success and the reverse reflecting failure. It is even more convenient if themeaning of high and low values is readily comprehensible. An example of an indicator ofunclear directionality is unmet need (or "blocked fertility preferences," to use a more accurateterm). Neither high nor low unmet need clearly reflects success: a low value may indicateadequate services, but it may also indicate inadequate educational efforts.

KEY INDICATORS POR FAMILY PLANNING PROJECTS 6

16. Indicators must also be easy to measure, and the measures must be valid and reliable.Management information systems and household surveys are the most common but not theonly ways to obtain indicator data. Management information tends to be routinely collectedbut less reliable; survey information requires special effort and organization but providesmore representative data on the population and is more reliable.

17. Because we seek a minimal indicator set, we favor summary indicators that suggestwhether several parts of a program are all working properly rather than reflecting only somenarrow part of it. Indicators can be summary in two ways: by reflecting a strategic aspect or amajor effect of a process that can stand for the entire process or by being composites ofseveral separate measures. A strategic indicator has the potential disadvantage that a focusedintervention might change the indicator value without affecting other dimensions of theprocess, but a composite indicator has the offsetting disadvantages of requiring more data andbeing difficult to interpret, often involving arbitrary weighting of disparate elements. Theworth of a summary indicator may be illustrated by the potential benefits of having a singlemeasure of service quality, which, if it were developed, would undoubtedly be used muchmore than separate measures of such quality dimensions as method availability, adequacy ofcounseling, technical competence, etc.

18. Balance in a set of indicators requires even-handed coverage of different programgoals and proportionate attention to key program processes. Imbalance is often easy toidentify, even in a large set of indicators: the 103 proposed by Bertrand, Magnani, andKnowles (1994) for example, lack any relating to reproductive health outcomes or to programcosts, though these are promised for later editions of their handbook. Balance is more critical,and often more difficult to achieve, the smaller the set of indicators. A small set cannot affordto overlook important goals or processes. This may mean relaxing some of the precedingcriteria at points: not all aspects of programs are well-researched, and some weak indicatorsmay have to be provisionally accepted.

19. These criteria are meant to identify indicators that are more useful for monitoring andevaluation. Indicators that do not meet the criteria may still be useful in comparisons and inproject preparation and strategy development. Indicators that are less summary but moredetailed, or that are not unidirectional, may actually provide critical information for planning.For example, levels of blocked preferences (or unmet need) across groups may be useful forsuggesting the types of activities a program should stress, the audiences it should try to reach,and the areas where it should concentrate its efforts.

A basic model, with indicators

20. Figure 1 provides a model for a program, its antecedents and consequences, as well assome indicators (in parentheses). A program requires certain inputs (first box), processes themthrough its organizational structures (second box), and produces some definable outputs (thirdbox). The outputs for social programs such as family planning programs are often meant tochange client behavior in some fashion (fourth box), giving rise to societal changes, in thiscase mainly demographic (fifth box).

21. Note that inputs as used here refers broadly not only to resources provided under aproject but also to other resources external to the program itself on which its operation

KEY INDICATORS POR FAMILY PLANNiN PRoJECrS 7

depends. Project inputs, because they vary project to project, are not specifically representedbut, as discussed earlier, have to tracked. Nonproject inputs are represented to try toencourage those most involved with a project to take a broad view of the context in which itoperates. Focusing narrowly only on project elements and overlooking changes in theadequacy of such other essential inputs as popular support for a program and general interestin smaller families and child spacing can lead to biased judgments and poor decisions.

Figure 1. A basic model for family planning, with key indicators

PROGRAM _ Popular interest and support Social development 1INPUI I (Approval offamily planning) (Female secondary enrolnent ratio)

CAPACrrY i Institutional capital Program efficiency(Couple-years of protection provided

AND PROCESS (Management infornation score) per orker)per worker)l

PROGRAM [ Service access Quality of careOUTPUTrs (Proximity of services) (Dropout ratio)

BEHAVIORAL Fertility regulationOUTCOMES (Contraceptive prevalence rate)

4

DEMOGRAPHIC Fertility Child health Matemal healthOUrCOMES (Totalfertility rate) (Infant mortality rate) (High-risk births)

22. Since a major task of a program is to generate interest in smaller families, the arrowsbetween program inputs and program capacity and process go in both directions. Besidesgenerating interest, a program should provide services, the availability and quality of whichare represented as program outputs. In combination with popular demand, these services leadto the use of fertility regulation, which brings down fertility and improves health. Lowerfertility and better health are among aspects of social development, which is also a criticalinput for a program because it increases demand for services.

23. This simple model is easier to operationalize, with fewer indicators, than morecomplex models (cf. Bertrand, Magnani, and Knowles 1994:16). Various dimensions ofprograms are combined or collapsed. For example, political support, often considered acritical program input, is instead one aspect of institutional capital. The indicators listed willeach be discussed in turn, starting with the outcome indicators at the bottom.

Demographic outcomes

24. The demographic outcomes represent the operational goals of a family planningprogram: reducing fertility and improving health. A third common goal, guaranteeingreproductive rights, is more of a service objective than a demographic outcome and is better

KEY INDICATORS POR FAmay PLAMNG PROjECTS 8

represented by indicators in the program output box, to be considered later. Table 3 contraststhe recommended demographic outcome indicators with various possible alternative measures(a number drawn, sometimes with modifications, from Bertrand, Magnani, and Knowles[1994], which can be consulted for more details).

Table 3. Demographic outcome indicators

Key Total fertility rate Infant mortality rate High-risk birthsindicator:

Alternative Crude birth rate Under-five mortality rate Maternal mortality ratemeasures: Age-specific fertility Expectancy of life at Maternal mortality ratio

rates birth Maternal morbidity rates:Parity-specific fertility Mean birth weight vaginal bleeding,

rates Mean length of birth anemiaMean length of birth intervals Perinatal mortality rate

intervals Mean birth weightPopulation growth rate Unsafe abortion rateRate of natural increase Unwanted total fertility

rate

25. Total fertility rate. Total fertility-the number of children a woman would have ifshe replicated the childbearing experience of all cohorts in a given period-is a well-defined,standard demographic measure, with values now ranging in developing countries from aboveseven to around two. As a period index, it can be measured almost contemporaneously and issensitive to program efforts, though it also responds to factors external to programs. It ismore specific than such possible alternatives as the crude birth rate, which depends on the agestructure, or the population growth rate, which also depends on mortality and migration. It isa summary measure, in contrast to age-specific or parity-specific fertility rates. Except at veryhigh and low fertility levels, reduction in total fertility can be fairly seen as an important,operational program objective.

26. Infant mortality rate. Infant mortality, the number of deaths among infants underage one per thousand births, is similarly a well-defined demographic measure affected bycontraception, as well as by nonprogram factors. The evidence that infant mortality can bereduced through greater contraceptive use is substantial (National Research Council 1989);some evidence also exists for reduction in under-five mortality, an alternative measure. Otheralternative measures are mean birth weight and mean birth interval length, but infant mortalityis much more commnonly used and more readily measured.

27. High-risk births. Family planning programs have an important effect on maternalhealth, but reliable measures of this are difficult to obtain. Rather than a direct measure, wepropose an indirect, survey-based indicator: the percentage of births in a given period that (a)involve women under age 18 or over age 34, (b) follow an interbirth interval shorter than 24months, or (c) are fourth or higher-order births. Early childbearing, on one hand, carriesgreater risk for such conditions as obstructed labor, whereas having multiple births, on theother hand, carries greater risk for such complications as uterine prolapse (Liskin 1989).Across developing countries, high-risk births described by these criteria may range from 75 to45 percent of all births (Govindasamy and others 1993:25). This range suggests how much the

KEY INDICATORS POR FAmiLY PLANNING PROJECrS 9

demographic risk can be reduced; many obstetric risks are unrelated to these demographiccharacteristics but are neither easily assessed nor directly affected by family planning.

28. The obvious alternative measure is the maternal mortality rate, but maternal deaths aresufficiently rare and rates difficult to assess from retrospective surveys to make this measureimpractical, except in the long run. (From the broader perspective of reproductive health,however, the maternal mortality rate is nevertheless essential, as is argued in a companionpaper on other reproductive health indicators.) The maternal mortality ratio is no better, andhas the added disadvantage of being insensitive to the use of family planning. Maternalmorbidity measures, especially relating to vaginal bleeding and anemia, may eventually beuseful; at present self-reports of morbidity are still being tested. Two proxies for maternalrisk, the perinatal mortality rate and mean birth weight (an indicator of maternal nutrition),have the advantage of not representing events as rare as maternal mortality, but overlap tosome extent with infant mortality, which is already in the indicator set. The unsafe abortionrate is a particularly important indicator because of its strong relationship to maternalmortality and morbidity but cannot be accurately determined because unsafe abortions areoften illegal.

Behavioral outcomes

29. The distinction between demographic and behavioral outcomes is somewhat arbitrary;the contraceptive prevalence rate could also be considered a demographic parameter.However, as contraceptive use causally precedes and is the main mechanism through whichthe preceding demographic outcomes are produced, we discuss it separately.

Table 4. Behavioral outcome indicators

Key indicator: Contraceptive prevalence rate

Alternative Prevalence of modern methods Number of usersmeasures: Contraceptive method mix Number of acceptors in a given year

Share of users supplied by various Number of visits to service deliverysources points

Use-failure rates Total abortion rateCouple-years of protection Mean female age at marriageBirths averted Median duration of full breastfeeding

30. Contraceptive prevalence rate. The contraceptive prevalence rate is the percentageof married women of reproductive age using (or whose partner is using) contraception. Itranges from around 5 to around 80 percent across developing countries. This indicator iscertainly sensitive to program activities. Should the indicator be tied tightly to theseactivities-say, by counting only program-supplied contraceptive users? We do not favor this,for two reasons: (a) projects should be planned to enhance the totality of contraceptiveservices in an area, rather than to strengthen only the official program; and (b) familyplanning programs provide not only contraceptives but also public education, and theireducational messages should reach and influence many not directly supplied.

31. Some of the alternatives to the contraceptive prevalence rate listed in Table 4 are lessalternatives than supplementary measures, usually available from the same data sources, which

KEY INDICATORS FOR FAmiLY PLANNING PROJECTS 10

provide additional useful information for program strategy. Among these are the prevalence ofmodem methods and the actual number of contraceptive users. The entire method mix is ofcourse similarly useful, as is information on public and private shares in contraceptive supply.Less easily available but also a useful supplement are use-failure rates by method, whichindicate the adequacy of existing contraceptive practices. Other alternatives to thecontraceptive prevalence rate are based on service records: numbers of visits, acceptors,couple-years of protection (calculated from contraceptive distribution data), and births averted.These data allow continuous monitoring of service provision and need to be regularlycollected and reported, but are less useful for evaluation because they are more subject toreporting bias. Finally there are alternative measures relating to other means of fertilityregulation or other proximate determinants of fertility, especially abortion, marriage, andbreastfeeding. These are not as central to a program as contraception, though a comprehensiveprogram does not ignore them.

Program outputs

32. Together, two program outputs in Figure I-access to services and quality of care-could serve as an operationalization of the reproductive rights a program seeks to guarantee.However, providing access to quality care may have little effect unless couples are alsoproperly informed, so that the guarantee may also be assumed to have an educationalcomponent. This component, labeled popular interest and support, is both an output and aninput and will be considered later. In contrast to outcome measures, measures of access andquality (Table 5) are more recently developed and less standard. Hardly any have been usedsufficiently in the past to provide reliable baselines.

33. Proximity of services. Access can be measured directly by distance to fixed facilitiesor travel time to them. Closer services seem to lead, with certain exceptions, to greatercontraceptive use (World Bank 1993:40). We recommend as an indicator the proximity ofservices, defined as the percentage of married women of reproductive age with a communitydistributor or family planning field worker in their rural village or urban neighborhood orwith a fixed service point not more than one kilometer away. The percentage with suchproximate services ranges from under 20 percent to over 90 percent in rural areas in tencountries and is usually 10 to 20 percentage points higher in urban areas. (hese roughestimates are based on data in Wilkinson, Njogu, and Abderrahim [1993].)

34. Table 5 shows many alternatives to the recommended indicator. To replace self-reported distances and travel times to service points, some researchers have proposed suchobjective measures as number of service points within a particular radius (Bertrand, Magnani,and Knowles 1994:105). At the national level, this can be reduced to the number of servicepoints per unit of area or per married woman of reproductive age. However, if this measureis derived not from careful mapping of service points but from ministry records on facilitiesand providers, it may not be reliable. Another alternative is an accessibility scale combiningnumber of sites, travel time, days open, and outreach. This scale, derived from Demographicand Health Survey service availability data, shows some coherence in factor analysis andhelps predict contraceptive use in low-prevalence countries (Phillips and Zimmerman 1993).

35. Additional barriers to access besides distance are reflected in other alternativemeasures in Table 5 proposed by Bertrand, Magnani, and Knowles (1994:103-109). Access

KEY IIDICATORS FOR FAMILY PLANING PRQjECrS 1

may be limited by program policies that restrict certain contraceptive methods, prohibit theprovision of contraceptives to such groups as the unmarried, or regulate the conditions ofprovision. Or access may be limited because of the price of contraceptives-though the priceis typically low or zero in national programs-or because of psychosocial barriers, such aspopular concerns about contraceptive side-effects. Indicators relating to these other barrierscould be useful in program planning but are not sufficiently developed for universal use.

Table 5. Program output indicatorsKey Proximity of services Dropout ratioindicator:Alternative Median distance or travel time to Method discontinuation ratesmeasures: nearest service point User satisfaction

Percentage of villages or city Client willingness to recommendneighborhoods with a service point service to a friend

Service point density: number within a Client reports on service adequacyfixed distance or travel time, or per Variety of contraceptives available atareal unit service point

Accessibility scale (number of sites, Percentage of counseling sessions fortravel time, days open, outreach) new acceptors at which all methods

Service points per married woman of are discussedreproductive age Percentage of clients informed of

Mean time required per month to timing and sources for resupply orobtain contraceptive services and revisitsupplies Percentage of client visits during which

Percentage who know a contraceptive provider demonstrates skill at clinicalsource procedures

Extent of policy restrictions on Percentage of clients reportingcontraceptive choice sufficient time with provider

Percentage who do not use due to Percentage of clients who perceivepsychosocial barriers service point hours and days as

Price of one month's contraceptive convenientsupply as a percentage of monthly Quality of care index (methodwage availability, provider unbiased,

Percentage of population with ready provider nonrestrictive, informationand easy access to specific methods provided, provider trained,

cleanliness, privacy, health andreproductive services)

36. One final alternative measure is the percentage of the population with "ready andeasy" access to specific methods. This is determined through expert judgments, where accessis defined by a user requiring no more than two hours a month on average and spending nomore than 1 percent of wages to obtain contraceptive supplies and services (Ross, Mauldin,and Miller 1993:79-82). One drawback of this measure is that it is only availablesporadically, perhaps once a decade, when an effort is launched to mobilize experts to providecross-national ratings. The focus on specific methods in this measure is useful, but instead ofmaking this a criterion in measuring access, we consider it a part of service quality, which wediscuss next.

KEY INDICATORS POR FAmiLY PLANNMG PROJECrS 12

37. Dropout ratio. What services are of acceptable quality varies from place to place, andeven from institution to institution, so that a standard indicator for quality is difficult todevise. We propose a new measure for quality of care based not on program characteristicsbut on user reactions to services: the frequency with which users discontinue contraception, asmeasured by the dropout ratio.

38. To explain the ratio, it helps to begin with the discontinuation rate, the rate at whichusers discontinue a given method of contraception. This rate can be assessed at a specificpoint in time, say a year after adoption, or represented as a continuous hazard function (seeUnited Nations 1991; Kreager 1977). Rates are relatively difficult to determine, requiring theobservation of appropriate cohorts over time. A simpler alternative, developed in the courseof a review of family planning programs (World Bank 1993:42-43), is the discontinuationratio, which relates the number discontinuing in a given period to all users at the midpoint ofthe period. From the discontinuation ratio, the dropout ratio can be obtained by excludingfrom the numerator all those discontinuers who (a) adopt an alternative method, (b)intentionally discontinue in order to have a child, or (c) discontinue because they are nolonger exposed to the risk of conception. The dropout ratio represents, therefore, theproportion who stop using contraception because of fear of side-effects, spouse opposition,unavailability or cost of supplies, inconvenience, or similar reasons that often can beaddressed with accessible services and good counseling.

39. An alternative to assessing quality from user behavior is to assess it from userattitudes. User satisfaction, or the percentage of program clients who express satisfaction withthe services they receive, has been measured in "situation analyses" of family planningprograms in close to two dozen countries, through exit interviews or in more general clientsurveys. The surveys may also ask whether the client would recommend the service to afriend, as well as asking about specific forms of information and assistance the client may ormay not have received. The evidence to date on these measures, unfortunately, isdiscouraging: they are unreliable and not predictive and cannot be recommended at present.

40. Another alternative is to directly evaluate provider behavior and clinic operation.Possible measures for this purpose are listed in Table 5; a more detailed list of 42 criteria forquality care has also been proposed (Bertrand, Magnani, and Knowles 1994:209-214). Onesummary index covering several of these dimensions is listed as the last alternative in Table 5and has appeared in a case study for Peru (Mensch, Jain, and Arends-Kuenning 1994).

Capacity and process

41. The line between program outputs and the program itself-its structure andfunctioning, or its capacity and processes-is not sharp; some of the alternative quality of careindicators, for example, might be considered to reflect program structure or process. Thedistinction we will try to maintain is that the program itself involves underlying organizationalcapacity and internal functioning, whereas program outputs involve the interface at whichthese organizational resources are brought to bear to affect clients.

42. Two aspects of a program are assumed to be central: its institutional capital and itsefficiency (Table 6). Institutional capital covers the resources, tangible and intangible, that aninstitution has available to carry out its mission. It includes such things as adequate facilities

KEY INDICATORS FOR FAMLY PLANNING PROJECrS 13

and equipment, effective logistics, clear and sensible decisionmaking procedures, trained anddedicated staff, the needed research and evaluation capacity, and essential political support.Efficiency refers to the way this capital is utilized.

Table 6. Capacity and process indicatorsKey Management information score Couple-years ofindicator: protection provided

per workerAlternative Internal organization score Users or visits permeasures Family planning program effort score worker

Access to current information on program progress Cost per user orComposite indicator for commodities and logistics couple-year of

(information and forecasting; procurement, warehousing, protectionand distribution; staffing; policy, organization, and donor Wastage incoordination) contraceptive

(Examples of other measures for specific organizational pipelineareas'.-) Frequency ofFrequency of statements by leaders in support of family contraceptive

planning stock-outsRestrictions on contraceptive advertising in the mass media Commercial sectorPublic sector funding of family planning as a percentage of share of contra-

GDP ceptive useRatings of managerial performancePercentage of staff positions competently filledPercentage of providers trained and assessed as competentPercentage of service points properly stocked with

contraceptivesPercentage of target audience recalling program messagesPercentage of target audience reporting liking messagesDissemination of research and evaluation results

s'he areas covered, for which additional measures are available or could be devised, are degree of policycommitment to family planning; absence of policy restrictions on fertility regulation; supportiveness of corzrlateinstitutions; favorability of the program's public image; adequacy of facilities, vehicles, and equipment;management capacity and leadership; staff motivation and morale; training and supervision adequacy; reliability ofcontraceptive logistics; effectiveness of information-education-communication activities; and quality of research andevaluation.

43. Management information score. Institutional capital is a broad concept coveringmany dimensions of an organization. The closest available summary measure-practically theonly such measure in the literature-is the family planning program effort score, a scoreassigned to each developing country in 1982 and 1989 (and in 1972 in a simpler form) usingkey informants to rate country programs on 30 separate dimensions (Mauldin and Ross 1991).This score is conceptualized as covering "effort" or productive activity rather than capital orresources, but it does include relevant organizational dimensions.

44. An improvement on this measure would focus only on these organizationaldimensions. Nine of the 30 items relate specifically to internal organization, covering (a)

KEY INDICATORS FOR FAMILY PLANNING PROJECTS 14

administrative structure, (b) in-country budget, (c) supervision, (d) training programs, (e) staffperforming assignments, (f) logistics and transport, (g) record keeping, (h) evaluation, and (i)managers using evaluation. A factor analysis of 1982 scores shows that these nine itemscohere strongly among themselves and represent the most important dimension runningthrough all 30 items (Bulatao 1986). This set excludes items on access to variouscontraceptive methods, which we are treating separately under program outputs. It alsoexcludes items having to do with policy support and information-education-communicationactivities. We assume that these factors work mainly as determinants of either internalorganization or the client interface (represented by quality of care measures), and thattherefore their incorporation in the index is not essential.

45. Since this internal organization score is available only at wide and somewhat uncertainintervals and cannot be collected to represent a particular project at a particular time, werecommend as an approximation an indicator focusing on management information, which wetake to be a key to the nine items listed above. Management information appears in severalforms in this list: evaluation and record keeping are about managing information, and suchareas as logistics, training, and budgeting depend on reliable management information. Theavailability of management information seems therefore to capture a central aspect ofinstitutional capital.

46. The management information score is referred to by Bertrand, Magnani, and Knowlesas a score of "access to current information on key areas of program functioning," coveringsuch areas as facilities and equipment, personnel, commodities and logistics, finance, andservice statistics. Specifically, we define the score as the number, from 0 to 18, of thefollowing items of information-each of which must be complete and no more than a yearold-available at the central program office:

(1) number and location of all service delivery points(2) services provided at each service delivery point(3) equipment and vehicle inventory, specifying location and condition(4) number of staff by current assignment(5) number of staff with each type of assignment by training(6) number and location of vacant positions(7) scheduled number of supervisory visits to service delivery points(8) quantity of each program commodity procured(9) quantity of each commodity disbursed from central stores

(10) authorized inventory levels for each commodity at each service delivery point(11) number of stockouts at service delivery points(12) funds budgeted by major budget line item(13) expenditures by major budget line item by district(14) number of family planning service visits by facility(15) number of new acceptors by method and by facility(16) quantities of each commodity disbursed to clients by service delivery point(17) list of scheduled training courses and numbers of trainees by type(18) quantities of media materials produced by type.

This score implies that information of each type contributes to a more effective program. Butall this information does not have to be present for the score to be calculated. Most programs

KEY INDICATORS FOR FAMILY PLANNING PROJECTS 15

will be lacking at least some types of information, but even if a program lacked every one ofthese types, it could still be assigned a score, namely zero.

47. This is a new score that is not in general use. Bertrand, Magnani, and Knowles notethat it indexes the availability of information, not its utility or actual application in planning.Some possible alternatives have similar limitations and fall short in other ways as well. Theseinclude another information index focusing on program progress rather than functioning and acomposite logistics index (Bertrand, Magnani, and Knowles 1994:57, 76-77). Both of theseseem somewhat narrower in focus than the management information score. Many othermeasures are available for specific areas of program capacity and process. Table 6 listsexamples, slightly modified from Bertrand, Magnani, and Knowles (1994:24-99). None ofthese appears broad enough or strategic enough to stand for the whole set.

48. Especially in the case of institutional capital, our choice of a single summary indicatorprovides only a minimal measure meant to be broadly applicable across projects. Sinceprojects build institutional capital in different ways, each should include more specificindicators. For example, a project that includes the construction of training facilities shouldattempt to measure any increase in the proportion of staff trained and any consequences oftheir training on treatment of clients. Or a project meant largely to change the direction ofofficial population policy should provide specific indicators for this.

49. Couple-years of protection (CYP) provided per worker. Program efficiency isusually represented by cost-effectiveness estimates. These require intensive special studies toobtain (see Janowitz and Bratt 1994) and pertain only to particular parts of a program,especially the service-delivery end. Management, research, and other central costs are usuallyignored. Repeated measurements are too difficult to obtain and are therefore seldom available.Because of these limitations, cost-effectiveness estimates are impractical as a regular tool inmonitoring and evaluation, though special studies in this area are nevertheless essential for thefield generally. We recommend instead for broader use a simpler indicator: the couple-yearsof protection provided in a given year per full-time paid program worker. This indicator hasnot been previously used, as far as we know, and therefore requires some definition here.

50. Couple-years of protection is an estimate of the contraceptive coverage provided by aprogram from the quantities of contraceptives distributed. For contraceptive pills, 13 cyclesare needed to provide a year of coverage, but 15 cycles are assumed to equal one CYP, toallow for wastage. Similarly, for other methods, one CYP is provided by 150 condoms, 150vaginal foaming tablets, 4 doses of Depoprovera, 6 doses of Noristerat, or 12 doses ofCyclofem. One Cu-T 380-A IUD provides 3.8 CYPs, a Norplant implant 3.5 CYPs, andsterilization 10 CYPs (Bertrand, Magnani, and Knowles 1994:149). All full-time paid workersenter the denominator of the ratio, including central staff involved in such areas asadministration, information-education-communication, and research but excluding volunteers.If service delivery staff have other duties besides family planning, only their time properlyallocated to family planning should be counted. This should be determined on the basis ofofficial duties, or the time actually paid for out of family planning accounts. To use insteadactual time spent would improperly inflate the ratio if, for example, workers ignored theirfamily planning duties. Data on couple-years of protection and workers should be availablefrom a reasonable management information system. (Cross-national data on workers compiledfrom government reports are in Ross, Mauldin, and Miller [1993:Tables 15, 281.) If such data

KEY INDICATORS FOR FAMnLY PLANNING PROJECrS 16

are unavailable or unreliable, one might assign a poor score by default. This indicator mayexhibit discontinuities when a program is restructured, for example, when new classes ofworkers are added.

51. The alternative of replacing couple-years of protection in the ratio with users mightprovide a more reliable numerator but would make less use of contraceptive distribution data,the regular collection of which should be encouraged. Users are already reflected in anotherindicator, the contraceptive prevalence rate. The alternative of using client visits instead isless reflective of a program's actual accomplishments. Various refinements to the denominatorof the ratio are possible, such as weighting workers by level of expertise or by actual salaries.The latter alternative moves the ratio in the direction of a cost-effectiveness measure. Suchrefinements could eventually be useful but are too demanding of data at present.

52. Possible alternatives to the recommended indicator include measures limited to theefficiency of program logistics: pipeline wastage and commodity stock-outs. Another potentialalternative is the commercial sector share of contraceptive users, which could reflect thedegree to which services are able to pay for themselves. This measure does have drawbacks inrepresenting efficiency, however, because it ignores quality issues in commercial provision ofcontraceptives, does not factor in possible public subsidies for social marketing, and does notdirectly address the efficiency of the system to deliver public services.

Program inputs

53. Program inputs refer to factors in a program's environment that affect its operation,especially popular approval and the level of social development. Two other factors, fundingfor a program and its political support, are not covered here. Funding and budgetary issueswill presumably be investigated carefully in any donor-supported effort. A single additionalmeasure would not be especially useful. Political support, we have argued, should be includedin a program's institutional capital. Treating it under that heading is convenient becausepolitical support itself is not easily observable and a sensitive measure for general use is notreadily devised. However, key political events should certainly be covered in project tracking.

54. Inputs specifically provided by a project fall under this heading, but, as earlier noted,cannot be captured by a generic indicator. Each project has to develop appropriate indicatorsfor tracking the particular inputs it is meant to provide.

55. Both aspects of inputs that we do cover (Table 7) could also be seen as belongingunder other headings. Popular approval is not only an input necessary for a program'soperation but also one of the key outputs for information-education-communication activitiesto generate. Social development is both an input and a long-term outcome of a program.

56. Approval of family planning. Approval of family planning is the percentage ofsurvey respondents of both sexes who say, in response to a direct question, that they approveof the use of birth control to prevent pregnancy or approve of family planning information inthe mass media. The first question is standard in Demographic and Health Surveys for low-contraceptive-prevalence countries. Percentages approving across surveys run roughly from 15to 95 percent. Because approval reaches very high levels as prevalence rises, the question isnot used for high-prevalence countries. For these countries, we use instead responses to the

KEY INDICATORS FOR FAMILY PLANiNO PRoIEcrs 17

second question, whether the respondent approves of family planning information in the massmedia. For countries with recent surveys including both questions, percentages approving onthe two questions are quite similar.

Table 7. Program input indicators

Key Approval of family planning Female secondary enrolment ratioindicator.Alternative Approval of media coverage of family Mean ideal family sizemeasures: planning Female primary enrolment ratio

Mean ideal family size Female literacyPercentage wanting additional children Infant mortality ratePercentage of previous births unwanted Per capita GNPWanted total fertility rate Female labor force participationBlocked preferences (or unmet need) Status of women

for contraception to limit or to space Percentage of population in urban areasbirths

57. The major alternative to this indicator is a measure of family-size preferences, whichpresumably affect reproductive intentions and therefore popular interest in family planning.Given the level of blocked preferences (i.e., unmet need) in some countries, we argue that thepsychosocial barriers to contraceptive use are at least as significant as desired family sizes andtherefore emphasize an indicator that reflects these normative barriers. Nevertheless family-size preferences are also of interest and should be obtained where possible.

58. Female secondary education ratio. Female education, specifically to the secondarylevel, is the dimension of social development that has the most effect not only oncontraceptive use and fertility but also on infant and child mortality. The ratio is the numberof women enrolled at the secondary level over the number of women in the relevant agegroup, which varies slightly across countries. For various reasons, this gross ratio sometimesexceeds 100. This ratio is a measure of program potential: a higher ratio should permit aprogram to be stronger; a lower ratio should signal a program with considerable obstacles toovercome. Although female enrolment is not under the direct control of a family planningprogram, including it helps fill out a picture of the program environment and is likely totemper too harsh or too lenient an assessment.

59. One alternative to this ratio is ideal family size, a more direct measure of thereceptiveness to contraception produced by social development. Other alternatives aremeasures of other dimensions of social development, such as infant mortality and femaleemployment. These other indicators are important, but none as much as female education.

Applying the indicators

60. Table 8 summarizes the key indicators, giving definitions and data sources. Weconsider how to apply these indicators, discussing (a) the units to which they can apply; (b)the data collection required; and (c) analysis, interpretations, and possible actions that mayresult.

KEY INDICATORS FOR FAMILY PLANNiNG PROJECTS 18

Table 8. Key indicator summaryIndicator Definition Data source Notes1. Total number of children born to a woman who lives demographic or direct and indirectfertility rate through her childbearing years and bears chil- family planning measures avail-(TFR) dren at each age in accordance with prevailing knowledge-atti- able, usually for a

age-specific fertility rates in the specified period tudes-practices multiyear period(KAP) survey before the surveyor census

2. Infant number of infants who die before reaching one demographic direct and indirectmortality rate year of age, per thousand live births in a given survey, census, measures may dis-(IMR) year or registration agree, requiring

reconciliation3. High-risk percentage of births in a given period that (a) demographic estimates demogra-births involve women under age 18 or over age 34, (b) survey phic risk, not

follow an interbirth interval of less than 24 actual obstetricmonths, or (c) are fourth or higher-order risk

4. Contracep- percentage of married women of reproductive demographic or modem methodstive preva- age using (or whose partner is using) contracep- KAP survey also worth distin-lence rate tion guishing(CPR)5. Proximity percentage of married women of reproductive demographic more refined mea-of services age with a community distributor or family survey and sures may eventu-

planning field worker in the rural village or accompanying ally be availableurban neighborhood or with a fixed service service avail-point not more than one kilometer away ability module

6. Dropout ratio to current users of those who discontinue fertility history new measure toratio contraception and do not (a) adopt an alternative from demo- reflect impact of

method, (b) intentionally discontinue to have a graphic survey quality of carechild, or (c) discontinue because they are nolonger exposed to the risk of conception

7. Manage- management information items available at cen- program plan- new measure;ment infor- tral program office in the areas of facilities and ning and as- supplement withmation score equipment, personnel, commodities and logis- sessment docu- measures for areas

tics, finance, and service statistics ments, inter- where projectviews with builds institutionalmanagers capital

8. Couple- annual couple-years of protection, calculated program statis- new measure, dis-years of pro- from contraceptive distribution statistics, per tics continuous whentection (CYP) full-time paid program worker or equivalent, projects are re-provided per including workers ranging from front-line to structuredworker administrative9. Approval average of female and male percentages approv- demographic family-size prefer-of family ing use of methods to avoid pregnancy or family and KAP sur- ences may also beplanning planning information in the mass media veys relevant10. Female gross ratio of number of females enrolled in sec- annual school age group variessecondary ondary school to all females in the relevant age statistics and by country; mayenrolment group census or exceed 100ratio projected age-

sex structure

KEY INDICATORS POR FAmiLY PLANNING PROJECTS 19

61. Units of observation. These indicators should apply not only to projects that attemptto institute or improve a national family planning program but also to projects for regional orprovincial programs. They should apply whether or not these projects have a private-sectorcomponent, though some indicators would require definitions that take private services intoaccount.

62. The more comprehensive a project and the more program areas it covers, the moreapplicable should be the entire indicator set. For a narrow project, such as one that deals onlywith information-education-communication capacity (perhaps in the context of improvinghealth promotion generally), some measures, such as proximity of services and themanagement information score, will not be relevant.

63. Where family planning is provided as part of broader reproductive health services, theindicators should apply on the family planning side and be complemented by reproductivehealth indicators discussed in a companion paper. This leads inevitably to an increase in thenumber of indicators, but it is unrealistic to expect that the services a project supports canexpand without parallel expansion in monitoring and evaluation.

64. The indicator set was not designed for evaluating local family planning activities,within a single community or in one or a few health facilities. Although some indicatorsmight apply, for this purpose the data sources tend to be more limited, and quicker feedbackis generally expected. Facility monitoring, therefore, depends mainly on indicators drawnfrom a management information system and can seldom deal with long-term outcomes.Another complication is that, at the facility level, extraneous influences have a large potentialfor overwhelming project impacts. Ideally facility evaluations should be designed asexperiments, to control for such influences. The lists in Tables 3-7 may suggest particularmeasures that could be useful.

65. Data collection. Collecting data on all the indicators in Tables 3-7 would require avariety of approaches, such as a routine reporting system, household surveys, facility andbeneficiary studies, reviews of management records, observational studies, audits and coststudies, etc. The key indicators, however, rely mostly, though not exclusively, on householdsurveys, which provide the most valid and reliable data on outputs and outcomes. Householdsurveys are a type of beneficiary assessment, focusing not on the narrow range of peoplecurrently served by any specific facility but on the general population of past, present, andpotential clients. In contrast to management information systems, they provide more represen-tative and more detailed data (Box 2). The methodology for national household fertilitysurveys has also been refined over two decades through major cross-national survey pro-grams-the World Fertility Surveys, the Contraceptive Prevalence Surveys, and the Demo-graphic and Health Surveys-which have added considerably to their utility.

66. An important alternative to a household survey, particularly for outcome measures, isa household registration system. A vital registration system that covers the entire populationwould be a major undertaking in most developing-country settings and is unlikely to be cost-effective from the standpoint of a specific project. A more feasible alternative may be alimited registration system that relies on health staff to track vital events within a community,Such a system could be an important extension to a management information system thatmight otherwise only report staff activities and client contacts, as well as being an important

KEY INDICATORS POR FANiY PLANNNG PROjECrS 20

element in outreach. A registration system should work better in more cohesive communities,as opposed to heterogeneous urban settings, but will have the drawback of being limited to thecatchment areas of existing health facilities. The types of data that can be collected are alsotypically more limited than what surveys, with trained and more detached interviewers, cancover.

Box 2. Can a management information system do the work of a survey?

Given the cost of national household surveys and, in many cases, the need for externaltechnical assistance, agencies may prefer to rely instead on a management informationsystem for assessing progress. Such a system can provide regular data even for small areas,but the validity and precision of the data are often unsatisfactory.

One thing a management information system might try to track is contraceptive use. Numberof contraceptive acceptors might be counted, or number of contraceptives distributed mightbe converted to some estimate of contraceptive protection. Even careful use of such data,however, can lead to poor estimates of progress. A thorough review of management datafrom all major agencies in Ghana in 1988, for instance, provided an estimate of growth incontraceptive prevalence of 1.5 points over nine years. But a Demographic and HealthSurvey conducted almost simultaneously estimated the gain to be more than twice as much,at 3.4 points.

There are many reasons to be skeptical of management information. New acceptors aredifficult to define and may or may not include couples switching methods, discontinuing andreadopting a method, or switching providers or facilities. Couples relying on nonsupplymethods (such as rhythm or the lactational amenorrhea method) and couples dropping out(perhaps to switch to commercial contraceptive providers) are seldom accounted for. As forcontraceptives distributed, how many are actually used is always uncertain. All thesestatistics are also subject to reporting bias, given the need for program staff to demonstratesome achievement.

Management information must be relied upon for routine monitoring but also needs to besupplemented regularly with a carefully designed household sample survey. A good surveycan provide the added benefit of detailed data about contraceptive users and nonusers, theirsocioeconomic backgrounds, fertility histories and preferences, and experiences withservice-all of which can be useful not only in evaluating the impact of a specific project orintervention but also in designing promotional activities and reforming services to betterserve current and potential beneficiaries.

67. To obtain data on the key indicators, household surveys should be scheduled at criticalpoints in a project and complemented by other specific data collection efforts. A baselinedemographic survey is useful. This could come before or shortly after a project starts andmay be covered by the project itself or may be an independent activity, possibly funded bysome other donor. (Appendix B lists the countries with Demographic and Health Surveysunder the USAID-sponsored program coordinated by Macro International. This list is notmeant to be comprehensive. Other similar surveys may be available in various countries.)

KEY INDICATORS FOR FAMILY PLANNNG PROjECTS 21

Given the delays that usually take place around the start of a project and the lags beforeinterventions have some impact, some delays in establishing a baseline need not be serious.

68. Between the baseline and a follow-up survey, an interval of three to six years isgenerally appropriate. Few indicators change quickly enough to justify a shorter interval.Additional surveys besides those needed to generate indicators might also be important, suchas more frequent and less elaborate KAP surveys or market research studies to refinecommunication strategies and messages. Toward the end of a project, another samplehousehold survey might be useful if enough time has elapsed since the previous one.

69. To ensure that surveys do not become the only data source, two key indicators havebeen included that rely on other data. One indicator, the couple-years of protection providedper worker, requires statistics generated continuously at all service points. Where a reportingsystem is not in place, we suggested above that a low score be assigned by default, indicatingan inefficient system. Where reports are available but unreliable, comparisons with surveyresults may also be useful to permit adjustments. The indicator also depends on estimates ofnumbers of workers. This should be regularly updated, relying on actual field visits, either byimmediate supervisors who then file reports or by teams from the central office or provincialoffices.

70. Another indicator, the management information score, is based on the availability ofdifferent types of information at the central office. This might be determined in various ways,such as from official reports or from actual observation. Perhaps the most reliable approachwould be to assess availability as part of a management audit or a situation analysis. Whateverthe approach, this indicator should be updated at least annually.

71. Analysis and interpretation. Although data on these indicators may appear to provideobvious answers about progress, they will still require some analysis and interpretation. Oneobvious step to take is to compare indicators with levels and trends in other countries; tofacilitate this, Appendix A provides what current data are available across countries.

72. For all the outcome indicators, the central analytical question is attribution: what didthe specific project contribute, once you control for secular trends and the effects of othersocietal developments (Box 3)? In some cases, such as for total fertility and infant mortality,analysis can be guided by substantial previous research (e.g., Hermalin 1979 for techniques;Cleland and others 1994 for an illustration); in other cases, previous theoretical and empiricalwork is thinner. For contraceptive prevalence, such research is gradually accumulating but hasnot so far led to as clear an understanding of determinants. For high-risk births, previouswork has dealt with individual components rather than with the entire indicator; separateanalysis has been done, for example, on early childbearing and on birth spacing.

73. For the output and process indicators, the analytical issues are more qualitative. Thefirst issue in each case is whether the indicator is fair: does it in fact reflect the specifics ofthe case, or are there special circumstances that require qualifying the indicator? Proximity ofservices, for instance, may require special interpretation where communities are heavilydependent on mobile services. A second issue is whether the specific inputs provided in aproject in fact contributed to any improvement in the indicators. Analysis of this sort wouldbe considerably aided by careful tracking of project inputs and by the collection of data on the

KEY INDiCATORS POR FAmiLY PLANNING PROJECTS 22

Box 3. Was the project responsible?

To be able to attribute improvement in the outcome indicators to a specific project would beparticularly gratifying, but it is also particularly difficult. Some researchers find fault withpractically all the evidence that family planning programs ever affect fertility (Pritchett1994). Establishing this link for a specific project requires overcoming substantial conceptualand methodological, and possibly ideological, obstacles. Nevertheless there are four simplesteps that facilitate establishing such a link.

First, confirm the intermediate links in the chain of causality. With tracking information onspecific project inputs and with process indicators from management data, it may be possibleto verify portions of the sequence of events necesssary to change outcome indicators. Forinstance, one could verify that new clinics set up under a project are operating, are staffedwith trained personnel, have been adequately publicized, and have had rising attendance, inorder to begin to make the case that the project has affected outcomes.

Second, ensure that good beneficiary data are available. Measure not only the outcomesthemselves but also related variables that permit the assessment of indicator accuracy, theanalysis of differentials and trends, and the investigation of causation. Good measures cancome from the previously recommended pre and post household surveys, which shouldprovide extensive information on fertility and family planning for representative samples.

Third, search for alternative explanations for changes in outcomes and obtain data that mightexclude them. This step is critical from a scientific perspective but is especially challenging.The ideal way to accomplish it is through an experiment, with random assignment totreatment and control groups that effectively excludes alternative explanations. Experimentsor quasi-experiments may be possible where a project covers only particular regions, orwhere a large project can include small experimental components. But experiments are oftenimpractical because of the need to assign treatment and control groups randomly and protectthem from contamination.

This is the reason why extensive survey data are desirable, because, when experimentscannot be run, surveys make it possible to investigate alternative explanations statistically.This is also one reason why female education is among our key indicators: because it isperhaps the most important alternative explanation for improvements in any of the outcomeindicators. Another possible alternative explanation is the contribution of some other project.Except where projects are separated geographically, their effects are likely to be intertwined,separable if at all only with precise data about each project's actual inputs and their timing.Still another alternative explanation is secular change in such factors as female employmentand mass media exposure. Such changes may be fortuitous and unpredictable, and the datato separate out their influence may therefore have to be collected post hoc. Thesecomplications dictate the need for the next step.

Fourth, allow for independent expert researchers to investigate the outcomes and their causestoward the end of a project or as part of the preparation for the next project. If it isimportant enough to link a project to outcomes, these steps will be useful, though they willnot guarantee that links can be successfully drawn.

KEY INDICATORS IPOR FAMILY PLANNIG PROJECTS 23

specific aspects of institutional capital being built up by a project (Table 6). For example,appropriate tracking of information-education-communication activities might be used to helpestablish whether a project contributed to popular approval of family planning.

74. Deciding whether the levels of the indicators are satisfactory-and then decidingwhether project inputs contributed to process and output indicators and whether the project asa whole contributed to outcome indicators-lead to the question of what to do next with aproject. For this question, more data beyond that provided by the ten key indicators may beneeded and should be collected as part of the planned surveys and other organizational studiesthat produce these indicators.

Conclusion

75. A variety of indicators have been listed, and ten key ones identified, for possible usein monitoring and evaluating World Bank project with family planning components. Theseindicators cover program inputs, program capacity and process, program outputs, andbehavioral and demographic outcomes. They do not include measures of other reproductivehealth services, which are covered in a companion note. Measurement of the indicators isfairly straightforward, requiring demographic surveys and organizational statistics and studies.

76. Of the criteria initially set for indicators, the last-the need for balance-is worthrevisiting as it applies to this set of ten indicators. The set may be considered balanced incertain ways, such as in evenly covering a program from antecedents to consequences, frominputs to long-term outcomes. It also draws on different sources of data to present a multifac-eted picture of a program. Balance is achieved partly by compromise; some indicators dodouble-duty. For example, popular approval of family planning serves as both an input and anoutput, and as an output reflects information-education-communication activities, which arenot otherwise addressed. As another example, output and input indicators combined may betaken to represent one program goal, the guarantee of reproductive rights.

77. If there is one area that is not adequately represented (particularly for monitoringrather than evaluation purposes), it is the area of institutional capital. We argued thatsupplementary indicators will be needed to cover the specific components in any particularproject. An adequate indicator scheme would track specific components, monitor theirparticular impacts, and look at the broader consequences of project activities as represented bythe ten key indicators.

KEY INDICATORS POR FAMILY PLANNINw PROIECrS 24

Appendix A. Current data available on key indicators for developing economies and territories

Key indicators Added data

Contra- I nternalTotal| Infant| | cepotve ApproVa Female organi- Program

fertility mortality High-risk prevalence Prox-mity offamily secondary zaton effortEconomy or territory rate rot births rate of srvices plarrdng enrolm score score

Afghanistan 6.9 162 5 18.5 41.8

Albania 2.9 32 73

Algeria 4.3 55 47.0 53 24.0 54.3Angola 6.6 124 21.8 47.2

Antigua and Barbuda 1.7 20 53.0Argentina 2.8 29 78 10.6 25.3

Armenia 2.8 21Azerbaijan 2.7 32

Bahamas, The 2.1 25 62.0Bahrain 3.7 21 53.0 84

Bangladesh 4.0 91 39.9 72.4 11 20.3 84.1

Barbados 1.8 10 55.0Belarus 1.9 15Belize 4.5 41 47.0

Benin 6.2 110 9 17.9 36.6

Bhutan 5.9 129 2 11.2 25.9

Bolivia 4.7 82 63.1 30.0 79.9 31 11.8 27.8Bosnia-Hercegovina 1.6 19

Botswana 4.7 35 53.5 33.0 91.9 39 28.1 84.5Brazil 2.8 57 55.7 66.0 h 87.2 45 2.3 38.1

Brunei 3.1 7

Bulgaria 1.5 16 76

Burkina Faso 6.9 132 37.2 7.7 64.7 5 21.0 54.2Burundi 6.8 106 58.6 8.7 94.2 3 18.8 48.4

Cambodia 4.5 116 8.6 11.0Cameroon 5.8 61 68.1 16.0 48.8 21 12.2 41.1

Cape Verde 4.3 40 17

Central African Rep. 5.8 105 6 21.2 50.3

Chad 5.9 122 3 7.2 23.5Chile 2.7 17 78 29.1 68.9

China (excluding Taiwan) 2.0 31 83.4 38 29.3 100.9Colombia 2.7 21 45.8 66.0 93.9 95.6 53 24.8 69.0

Comoros 6.7 89 15Congo, People's Rep. of the 6.6 114 17.2 43.4Costa Rica 3.1 14 75.0 42 22.2 68.1

Cte d'lvoire 6.6 91 3.0 12 5.2 19.5

Croatia 1.7 12Cuba 1.7 10 70.0 94 28.4 78.0

Cyprus 2.4 11 89

Czech Rep. 1.9 10 68.9Djibouti 5.8 115 13

Dominica 2.5 18 50.0Dominican Rep. 3.0 41 50.1 56.4 68.8 93.7 57 16.6 60.9

KEY INDICATORS FOR FAmILY PLANNING PROJECrS 25


Key indfcators Added data

Contra- InternalTotal Infant cephive Approval Female organ!- Program

ferllity mortality High-risk prevalence Proximiy offamily secondary zarion effortEconomy or territory rate rate births rate of services planning enrolment score score

Ecuador 3.5 45 61.3 53.0 89.5 91.2 118 20.1 70.9Egypt, Arab Rep. of 3.8 57 61.0 46.0 87.5 71 24.0 78.2

El Salvador 3.8 40 57.7 53.3 74.8 26 26.2 78.8

Equatorial Guinea 5.5 117

Eritrea 5.8 135Estonia 1.8 13Ethiopia 7.5 122 4.3 12 14.8 38.4

Micronesia, Fed. States of 4.8 36

Fiji 3.0 23 53Gabon 5.9 94 0.0 0.0

Gambia, The 6.5 132 12.0 10

Gaza Strip 7.2 45Georgia 2.2 19Ghana 6.1 81 59.1 12.9 75.9 30 20.6 60.5

Greece 1.4 8 94

Grenada 2.9 29 54.0Guatemala 5.1 62 64.9 23.2 b 16 24.4 59.8Guinea 6.5 133 5 17.4 47.5

Guinea-Bissau 6.0 140 4 13.0 34.2

Guyana 2.6 48 31.0 65 24.4 70.0

Haiti 4.7 93 11.0 77.3 19 15.8 48.7

Honduras 4.9 49 46.7 35 27.6 72.6

Hong Kong 1.4 6 81.0 75

Hungary 1.8 15 73.0 77

India 3.7 79 43.0 31 23.4 84.3

Indonesia 2.9 66 47.8 49.7 43 31.9 93.4

Iran, Islamic Rep. of 5.5 65 65.0 44 20.6 66.1

Iraq 5.7 58 14.0 37 0.1 1.1

Israel 2.7 9 86Jamaica 2.7 14 67.0 64 26.1 79.7

Jordan 5.2 28 77.1 b 40.0 84.4 78 15.2 37.4

Kazakhstan 2.7 31

Kenya 5.4 66 47.1 32.7 48.2 89.4 19 23.0 68.1

Kiribati 3.8 60Korea, Dem. People's Rep. of 2.4 24 26.7 62.6

Korea, Rep. of 1.8 13 79.0 85 34.3 95.7

Kuwait 3.7 14 35.0 87 0.0 0.0

Kyrgyz Rep. 3.7 37

Lao People's Dem. Rep. 6.7 97 22 3.8 9.2

Latvia 1.8 17

Lebanon 3.1 34 23.7 59.6Lesotho 4.8 46 23.2 31 21.9 54.1

Liberia 6.2 142 65.4 6.4 37.6 0.0 4.0

KEY INDICATORS POR FAMILY PLANNING PRoIECTs 26


Key inifcators Added data

Cont ra- I nImernalTotal Infant cepduve Approval Female organi- Program

ferdtlay mortality High-risk prevalene Proxiry offarnly secondary zadon effortEconomy or territory rate rate births rate of services planning enrolment score score

Libya 6.4 68 0.0 0.0Lithuania 2.0 16

Macao 2.1 8

Macedonia, Fmr. Yug. Rep. of 2.2 29

Madagascar 6.1 93 50.6 d 17.3 19.3 4 80.2 18 20.6 48.3

Malawi 6.7 134 51.1 13.0 10.0 93.8 3 7.4 19.7

Malaysia 3.5 14 48.0 59 29.5 76.0

Maldives 6.0 55

Mali 7.1 130 71.9 4.7 4 19.8 45.2

Malta 2.1 9 77

Mauritania 6.8 117 3.0 10 12.2 24.9

Mauritius 2.0 18 75.0 53 25.6 81.2

Mexico 3.2 35 63.5 53.0 53 29.5 89.5

Moldova 2.3 23

Mongolia 4.6 60 96

Montserrat 2.4 28

Morocco 3.8 57 64.2 41.5 93.2 30 25.2 66.1

Mozambique 6.5 162 4 13.2 32.8

Myanmar 4.2 72 23 3.5 11.9

Namibia 5.4 57 54.0 28.9 72.9 4.7 13.0

Nepal 5.5 99 23.0 17 23.0 69.7

Netherlands Antilles 2.1 12

Nicaragua 4.4 56 48.7 100 0.0 0.0

Niger 7.4 123 49.4 4.0 64.3 4 9.5 46.1

Nigeria 5.9 84 67.7 6.0 14.3 56.1 16 17.7 51.5

Oman 7.2 20 8.6 40 4.9 6.6

Pakistan 5.6 95 54.9 f 12.0 61.6 12 19.4 57.2

Panama 2.9 21 61.0 63 24.7 62.4

Papua New Guinea 4.9 54 10 10.3 31.4

Paraguay 4.6 36 61.2 48.0 91.1 30 21.8 46.2

Peru 3.3 52 56.4 5 59.0 94.1 60 17.4 57.7

Philippines 4.1 40 62.4 40.0 30.5 86.0 75 18.8 58.1

Poland 1.9 14 83

Portugal 1.5 9 54

Qatar 4.0 26 32.0 91

Romania 1.5 23 57.0 92

Russian Federation 1.7 20Rwanda 6.2 117 38.6 21.0 92.5 6 23.0 51.4

Sao Tomd and Principe 5.0 65

Saudi Arabia 6.4 28 39 0.0 0.0

Senegal 5.9 68 47.4 7.4 55.1 11 21.8 52.4

Seychelles 2.7 16

Sierra Leone 6.5 143 11.6 41.6

KEY INDICATORS FOR FAmiLY PLANNING PROJECrS 27


Key indicators Added data

Contra- IntenalTotal Infant ceptive Approval Female organi- Program

fertility mortality High-risk prevalence Proximiry offamily secondary zatlon effortEconomy or territory rate rate births rate of services planning enrolment score score

Singapore 1.8 5 74.0 71 28.8 75.6

Slovak Rep. 2.0 13 74.0

Slovenia 1.5 8

Solomon Islands 5.8 44

Somalia 6.8 132 7 0.0 1.0

South Africa 4.1 53 50.0 31.2 71.7

Sri Lanka 2.5 18 47.1 62.0 88.7 76 30.0 92.7

St. Kitts and Nevis 2.6 34

St. Lucia 3.2 19 47.0

St. Vincent 2.5 20 58.0

Sudan 6.1 99 72.4 9.0 50.5 17 9.7 24.2

Suriname 2.8 37

Swaziland 6.6 108 20.0 49

Syrian Arab Rep. 6.2 36 20.0 45 24.7 53.0

Taiwan, China 1.8 6 78.0 32.2 94.0

Tajikistan 5.1 49Tanzania, United Rep. of 6.3 92 58.5 9.5 84.4 4 15.5 49.3Thailand 2.2 26 44.8 66.0 28 33.9 93.0

Togo 6.5 85 63.1 12.0 68.9 10 11.7 35.3

Tonga 3.6 21

Trinidad and Tobago 2.8 15 52.2 53.0 94.0 84 22.5 83.6

Tunisia 3.8 48 62.1 50.0 90.9 89.6 39 27.4 81.7

Turkey 2.9 54 63.0 39 17.8 53.9

Turkmenistan 4.2 54

Uganda 7.1 122 71.1 5.0 70.5 63 12.8 39.5

Ukraine 1.8 18

United Arab Emirates 4.5 20 69 1.0 14.2

Uruguay 2.3 20 19.9 50.6

Uzbekisan 4.1 42Vanuatu 5.3 45

Venezuela 3.6 33 62 25.5 61.8

Viet Nam 3.7 36 53.0 40 18.6 79.9

West Bank 5.8 40Western Samoa 4.5 25

Yemen, Rep. of 7.6 106 7.0 30.2 4 11.6 33.8

Yugoslavia, Fmr. Soc. FR of 2.1 28 79

Zaire 6.2 91 8.0 16 17.3 34.0

Zambia 6.5 107 62.6 15.2 80.9 14 19.3 59.1

Zimbabwe 4.6 47 61.2 43.0 79.6 42 29.5 66.7

SummaryMinimum 1.4 5 37.2 3.0 10.0 30.2 2 0.0 0.0

Median 3.7 41 58.6 46.9 59.2 84.4 38 20.4 52.2

Maximum 7.6 162 77.1 83.4 93.9 95.6 118 34.3 100.9

KEY INDICATORS POR FAMILY PLANNING PRoECTrs 28

Definaions, sources, and notes:No data are currently available on the dropout ratio and the management information score. For couple-years of protection per

worker, numerator data have to be obtained by program; some denominator data are in Ross and others (1993:Tables IS and28). The last two columns provide alternative indicators. Blank cells indicate no data.

Total fertility rate (children per woman) and infant mortality rate (per thousand): World Bank estimates for 1992.High risk births (percent of births): percentage of births in the last ten years that (i) involve women under age 18 or over 34, (ii)

follow an interbirth interval shorter than 24 months, or (iii) are fourth or higher-order births, from Demographic and HealthSurveys, 1985-90 (Govindasamy and others 1993:25 and DHS country reports). Deviations from this definition are footnoted, asfollows.a Covers births in the last five years and excludes fourth, fifth, and sixth births.b Covers births in the last five years.c Covers births in the last five years. Estimate is substantially lower than the 70.6 percent reported in the preceding

Demographic and Health Survey in 1989.d Covers birth in the last five years; excludes fourth, fifth, and sixth births; and does not apply age criterion.e Covers birth in the last five years; excludes fourth and fifth births; and does not apply age criterion.f Covers births in the last six years and excludes fourth and fifth births.g Covers births in the last five years; excludes fourth, fifth, and sixth births; and excludes second and third (but not first)

births to women under 18. First births to women 18 and over were counted as high-risk in the country report but areexcluded here.

Contraceptive prevalence rate (percent of married women 15-49): last reported estimate for 1985 or later, from World Bank filesand U.N. (1994).h For married women 15-44.i Excludes Tigrai, Asseb, Ogaden, parts of Gondar and Wello, and nomadic population.j For married women aged 15-39.k For all sexually active women 15-44.1 For married women under age 50.m North Sudan.

Proximity of services (percent of married women of reproductive age): percentage of women with a community-based distributor inthe community or with a family planning facility less than one kilometer away; if the union of these two conditions cannot bedetermined, the higher of the two figures is used, as indicated in the following footnotes (Wilkinson and others 1993 and DHScountry reports).n Average of rural and urban percentages, using population weights from U.N. (1992:82-97).o Percent living within one kilometer of a supply point. Separtely, 67.8 percent of all women in union are reported as being

served by a health promoter or community worker.p Percent living within one kilometer of a supply point. Separately, 12.8 percent of currently married women are reported as

being served by a community worker.q The reference facilities are health establishments offering family planning services.r Percent served by a family planning outreach program (a health worker, a mobile clinic, or a market outlet). Separately, 9.6

percent of currently married women are estimated to live within one mile of a facility.Approval of family planning (percent approving): estimates from the latest Demographic and Health Survey (Appendix B),

averaging female and male percentages where available, or reporting whichever sex has data.Female secondary enrolment ratio: latest estimate of the gross enrolment ratio for 1985 or later, from World Bank files.Internal organizaion score (sum of nine ratings): this score for 1989 is derived from program effort ratings (see Mauldin and Ross

1991).Program effort score (sum of 30 ratings): this score for 1989 subsumes the internal organization score (see Mauldin and Ross 1991).

KEY INDICATORS FOR FAmiLY PLANNNG PROJECTS 29

Appendix B. Demographic and Health Surveys, 1985-94

Cozany Year Respondents Collaborating instituions

Bangladesh 1993/94 10,000 ever-married women Mitra & Associates; NIPORT15-493,000 husbands

Bolivia 1989 7,923 women 15-49 Instituto Nacional de EstadisticaBolivia 1993/94 10,000 women 15-49 Instituto Nacional de Estadistica

Botswana 1988 4,368 women 15-49 Central Statistics Office, Ministry of Finance andDevelopment Planning; Family Health Division, Ministry ofHealth

Brazil 1986 5,892 women 15-44 Sociedade Civil Bem-Estar Familiar no Brasil

Brazil (Northeast) 1991 6,222 women 15-44 Sociedade Civil Bem-Estar Familiar no Brasil1,266 husbands

Burkina Faso 1992/93 6,354 women 15-49 Institut National de la Statistique et de la Ddmographie1,845 men 18+

Burundi 1987 3,970 women 15-49 Departement de la Population, Ministere de l'Int6rieur542 husbands

Cameroon 1991 3,871 women 15-49 Direction Nationale du Deuxi6me Recensement Gen6ral de814 husbands la Population et de l'Habitat

Central African Rep. 1994/95 6,000 women 15-49 Division des Statistiques D6mographiques et Sociales2,000 men 15-59

Colombia 1986 5,329 women 15-49 Corp. Cen. Reg. del Pbblaci6n, Min. de SaludColombia 1990 8,489 women 15-49 PROFAMILIA, Asociaci6n Pro-Bienestar de la Familia

Colombiana

Cote d'Ivoire 1994 7,000 women 15-49 Institut National de la Statistique2,500 men 15-59

Dominican Rep.' 1986 7,649 women 15-49 Consejo Nacional de Poblaci6n y Familia

Dominican Rep. 1991 7,320 women 15-49 Instituto de Estudios de Poblaci6n y Desarollo(PROFAMILIA); Officina Nacional de Planificaci6n

Ecuador 1987 4,713 women 15-49 Centro de Estudios de Poblaci6n y Paternidad Responsable;Instituto Nacional de Investigaciones Nutricionales y MedicoSociales

Egypt 1988/89 8,911 ever-married women 15-49 National Pbpulation Council

Egypt 1992 9,864 ever-married women National Population Council2,466 husbands 15-49

El Salvador 1985 5,207 women 15-49 Asociaci6n Demografica Salvodoreiia

Ghana 1988 4,488 women 15-49 Ghana Statistical Service943 husbands

Ghana 1993 4,562 women 15-49 Ghana Statistical Service1,302 men 15-59

Guatemala 1987 5,160 women 15-44 Instituto de Nutrici6n de Centro Am6rica y Panania

Haiti 1994 5,000 women 15-49 Institut Haitien de l'Enfance1,600 men 15-59

Indonesia 1987 11,884 ever-married women Central Bureau of Statistics; National Family Planning15-49 Coordinating Board

Indonesia 1991 22,909 ever-married women Central Bureau of Statistics; National Family Planning15-49 Coordinating Board; Ministry of Health

Indonesia 1994 28,000 ever-married women Central Bureau of Statistics; National Family Planning15-49 Coordinating Board; Ministry of Health

Jordan 1990 6,461 ever-married women 15-49 Department of Statistics; Ministry of HealthKenya 1989 7,150 women 15-49 National Council for Population and Development

1,153 husbands

KEY INDICATORS FOR FAMILY PLANNNG PROJECTS 30

Appendix B. Demographic and Healtb Surveys, 1985-94

Country Year Respondents Collaboraning Institutons

Kenya 1993 7,540 women 15-49 National Council for Population and Development; Central2,336 men 20-54 Bureau of Statistics, Office of the Vice President and

Ministry of Planning and National DevelopmentLiberia 1986 5,239 women 15-49 Bureau of Statistics, Ministry of Planning and Economic

Affairs

Madagascar 1992 6,260 women 15-49 Centre National de Recherches our i'Environnement;Ministare do la Reserche Appliqu6e au D6veloppement

Malawi 1992 4,849 women 15-49 National Statistical Office1,151 men 20-54

Mali 1987 3,200 women 15-49 Centre d'Etudes et de Recherches sur la Population pour Ic970 men 20-55 D6veloppement, Institut du Sahel

Mexico 1987 9,310 women 15-49 Direcci6n General de Planificaci6n Familiar, Subsecretarfade Servicios de Salud, Sccretarfa de Salud

Morocco 1987 5,982 ever-married women 15-49 Ministere do la Sante Publique

Morocco 1992 9,256 women 15-49 Service des Etudes at de l'laformation Sanitaire, Secretariat1,366 men 20+ Gendral-DPSI, Miniatre de la Sant6 Publique

Namibia 1992 5,421 women 15-49 Ministry of Health and Social Services

Nepal (KAP-gap)b 1987 1,623 currently married women New Era15-49

Niger 1992 6,503 women 15-49 Direction de la Statbtique et des Comptes Nationaux,1,570 husbands Direction Generale du Plan; Ministcre des Finances et du

Plan

Nigeria, Ondo State 1986/87 4,213 women 15-49 Ministry of Health, Ondo State

Nigeria 1990 8,781 women 15-49 Federal Office of StatisticsPakistan 1990/91 6,611 ever-married women National Institute of Population Studies

1,354 husbands 15-49

Pa-guay 1990 5,827 women 15-49 Centro Paraguayo de Estudios de Poblaci6n

Peru' 1986 4,999 women 15-49 Instituto Nacional destadlistica ea InformaticaPeru 1991/92 15,882 women 15-49 Instituto Nacional de Estadfsticaa Informatica; Asociaci6n

Benefica PRISMA

Philippinese 1993 15,029 women 15-49 National Statistics Office

Rwanda 1992 6,551 women 15-49 Office National de la Population598 husbands

Senegal 1986 4,415 women 15-49 Ministere de l'Economie et des Finances

Senegal 1992/93 6,310 women 15-49 Direction do la Pr6vision at de la Statistique, Division des1,436 men 20+ Statistiques D6mographiques; Ministere do l'Economic, des

Finances at du PlanSri Lanka 1987 5,865 ever-married women 15-49 Department of Census and Statistics, Ministry of Plan

ImplementationSudan 1989/90 5,860 ever-married women 15-49 Department of Statistics, Ministry of Economic and National

Planning

Tanzania 1991/92 9,238 women 15-49 Bureau of Statistics, Planning Commission2,114 men 15-60

Tanzania 1994 4,500 women 15-49 Bureau of Statistics, Planning Commission2,250 men 15-59

Thailand 1987 6,775 ever-married women 15-49 Institute of Population Studies, Chulalongkorn University

Togo 1988 3,360 women 15-49 Unite do Recherche D6mographique, Direction de laStatistique; Direction G6ncrale de la Sante

Trinidad and Tobago 1987 3,806 women 15-49 Family Planning Association of Trinidad and TobagoTunisia 1988 4,184 ever-married women 15-49 Direction de la Population, Office National de la Famille at

de la Population, Mini,tcre do la Sante Publique

KEY INDICATORS lniR FAmWLY PLANNING PROJECTS 31

Appendix B. Demographic and Health Surveys, 1985-94Cowury Year Respondents Collaborating msfitaions

Turkey 1993 7,500 ever-married women <50 General Directorate of MCH/FP, Ministry of HealthUganda 1988/89 4,730 women 15-49 Ministry of Health; Ministry of Planning and Economic

Development; Maklrere Universityyameab 1991/92 5,687 ever-married women 15-49 Central Statistical Organization; Pan Arab Project for Child

DevelopmentZambia 1992 7,060 women 15-49 University of Zambia; Central Statistical OfficeZimbabwe 1988/89 4,201 women 15-49 Central Statistical Office, Ministry of Finance, Economic,

Planning and DevelopmentZimbabwe 1994 6,000 women 15-49 Central Statistical Office, Ministry of Finance, Economic,

1,500 men 15-59 Planning and Development

Source: Demographic and Health Surveys, 1994, Newsletter 6(2).a A related experimental survey with a smaller sample was also conducted.b The core DHS questionnaire was not used.c A Safe Motherhood Survey was also conducted in 1993 with 8,481 women 15-49 who reported a pregnany outcome.

References

Baldwin, George. 1992. Targets and indicators in World Bank population projects. PolicyResearch Working Paper No. 1048. Washington, D.C.: World Bank.

Bertrand, Jane T., Robert J. Magnani, and James C. Knowles. [1994]. Handbook of Indica-tors for Family Planning Program Evaluation. Chapel Hill, N.C.: The Evaluation Project,Carolina Population Center, University of North Carolina at Chapel Hill.

Bulatao, Rodolfo A. 1986. Dimensions of family planning effort. Unpublished paper. TheWorld Bank, Washington, D.C.

Cleland, John, James F. Phillips, Sajeda Amin, and G. M. Kamal. 1994. The Determinants ofReproductive Change in Bangladesh. Washington, D.C.: World Bank.

Govindasamy, Pavalavalli, M. Kathryn Stewart, Shea 0. Rutstein, J. Ties Boerma, and A.Elisabeth Sommerfelt. 1993. High-risk births and maternity care. Demographic andHealth Surveys Comparative Studies No. 8. Columbia, Md.: Macro International Inc.

Hermalin, Albert I. 1979. The Methodology of Measuring the Impact of Family PlanningProgrammes on Fertility. Manual IX. New York: United Nations.

Janowitz, Barbara, and John H. Bratt. 1994. Methods for Costing Family Planning Services.New York and Research Triangle Park: United Nations Population Fund and FamilyHealth International.

Kreager, Philip. 1977. Family Planning Drop-Outs Reconsidered. London: InternationalPlanned Parenthood Federation.

Liskin, Laurie. 1989. Prevalence of maternal morbidity in developing countries. Pp. 15-35 inWorld Health Organization, Measuring Reproductive Morbidity. Report of a TechnicalWorking Group, Geneva, 30 August-i September 1989. Geneva.

Mauldin, W. Parker, and John A. Ross. 1991. Family planning programs: Efforts and results,1982-89. Studies in Family Planning 22(6):350-367.

Mensch, Barbara, Anrudh Jain, and Mary Arends-Kuenning. 1994. Assessing the impact offamily planning services on contraceptive use in Peru: A case study linking situationanalysis data to the DHS. Paper presented at the 1994 Annual Meeting of the PopulationAssociation of America, Miami, 4-7 May.

KEY INDICATORS FOR FAMILY PLANNIG PRojEcrs 32

National Research Council. 1989. Contraception and Reproduction: Health Consequences forWomen and Children in the Developing World. Washington, D.C.: National AcademyPress.

Phillips, James F., and Emily Zimmerman. 1993. Assessing the demographic role of familyplanning programs with DHS accessibility data from six developing countries. Paperpresented at the 1993 Annual Meeting of the Population Association of America, Cincin-nati, 1-3 April.

Pritchett, Lant H. 1994. Desired fertility and the impact of population policies. Populationand Development Review 20:1-55.

Ross, John A., W. Parker Mauldin, and Vincent C. Miller. 1993. Family Planning andPopulation: A Compendium of International Statistics. New York: The PopulationCouncil.

United Nations. 1991. Measuring the Dynamics of Contraceptive Use. New YorkUnited Nations. 1992. World Urbanization Prospects. New York.United Nations. 1994. World Contraceptive Use 1994 (Wallchart). New York.Wilkinson, Marilyn I., Wamucii Njogu, and Noureddine Abderrahim. 1993. The availability

of family planning and maternal and child health services. Demographic and HealthSurveys Comparative Studies No. 7. Columbia, Md.: Macro International Inc.

World Bank. 1993. Effective Family Planning Prograns. Washington, D.C.World Bank. 1993. Staff Appraisal Report: Islamic Republic of Iran Primary Health Care and

Family Planning Project. Washington, D.C.

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