During the 1990s national governments and nongovernmental organizations broadened the scope of family planning programs in developing countries, largely by attempting to include reproductive health services. Earlier family planning programs focused on increasing contraceptive use and lowering fertility. In order for these programs to expand and offer reproductive health services, the programmatic goal needs to be redefined as “helping individuals achieve their reproductive intentions in a healthful manner,” says Anrudh Jain, senior director of policy and regional programs in the Population Council’s International Programs Division. Moreover, criteria used to assess program success should be altered to reflect the broadened agenda, which will improve the ability of these expanded programs to incorporate reproductive health services.

“Program managers respond to the way they are evaluated,” explains Jain. “If they are evaluated on how much their programs increase contraceptive use, they will attempt to increase contraceptive use. Right now there is a dissonance between the stated intention to incorporate reproductive health services and evaluation methods. To ensure success, consistency is required among three dimensions of the program—objective, design, and the criteria used to assess its success or failure,” says Jain. He recently tested an index designed to bring program assessment into line with program goals and design.

In 1994, Jain and Judith Bruce proposed an index they dubbed HARI, an acronym for Helping Individuals Achieve their Reproductive Intentions, to measure the success or failure of family planning programs with a reproductive health orientation. Bruce is the director of the Gender, Family, and Development program within the Council’s International Programs Division. HARI measures two program components: whether women achieve their reproductive intentions and whether they avoid severe reproductive health problems (including reproductive health problems requiring hospitalization). Jain applied the HARI index to data gathered from a panel survey conducted in Peru.

Unlike other indexes for evaluating family planning programs, HARI takes into account the rights and well-being of individuals. Consider the example of two women with different reproductive intentions. The first woman wants to have a child within two years; the second woman does not. Older indexes will find a program to be successful if both of these women adopt a contraceptive method or experience decreased fertility. HARI will find a program to be successful if the first woman achieves a pregnancy within two years and if the second woman avoids becoming pregnant in that time.

Jain analyzed data collected from 1,093 married Peruvian women from two locations who were interviewed for both the 1991–92 Demographic and Health Survey (DHS) and a 1994 follow-up survey. The initial survey collected information about the women’s reproductive intentions; the second collected information about their fertility and contraceptive use, and about hospitalizations or visits to health facilities since the first survey.

About 19 percent of women in the sample had at least one live birth between the two surveys. Typically, family planning programs have focused on reducing this “failure rate.” Nearly half of these births, however, were wanted. When Jain considered only unwanted births, the failure rate dropped to 10 percent. But HARI goes beyond simply documenting unwanted births; it also takes into account mistimed births (ones that occurred at least three months earlier than desired) and mistimed and unwanted pregnancies with outcomes other than live births (such as stillbirths, miscarriages, and induced abortions). Inclusion of these pregnancies doubles the program failure rate from 10 to 20 percent. Finally, HARI includes women who experience regret at having undergone sterilization, those with potential infertility problems, and women who have serious reproductive health problems related to pregnancy or contraception. Including these women increased the program failure rate to nearly 28 percent.

"Reducing wanted fertility is beyond the scope of family planning programs," says Jain. "And since the mid-1990s, interest in improving reproductive health has grown dramatically. It makes sense for programs to use an assessment index that reflects the objectives they are attempting to reach." By looking at whether women achieve their reproductive intentions and whether they avoid associated severe reproductive health problems, HARI increases the likelihood that both of these program components will receive appropriate attention from service providers, program managers, and researchers.

Each element in a program—objective, design, and assessment criteria—is responsive to changes in other elements. If HARI were adopted as an evaluation index, for example, the focus of information, education, and communication with clients would shift from motivating individuals to have small families to offering them accurate information about how and where to obtain contraceptive services and supplies, about safety issues associated with the use of contraceptives, and about where to obtain treatment for sexually transmitted infections and infertility. Such a shift in focus might result in a decreasing need for induced abortions and in fewer sterilization procedures that women later regret.

Source
Jain, Anrudh. 2001. “Implications for evaluating the impact of family planning programs with a reproductive health orientation,” Studies in Family Planning 32(3): 220–229. (PDF)

Outside funding
United States Agency for International Development