Ruth Simmons

The study of client-provider interactions: a review of methodological issues.

In recent years, increased focus on the quality of family planning and other reproductive health services has led to a better understanding of womens reproductive health needs and has drawn attention to program-client interactions as a critical and neglected dimension of program effort. In this article, the relevant methods and experience related to studying client-provider interactions within family planning programs in southern countries are reviewed. The policy relevance of this work is highlighted first by stressing the operational usefulness of examining what happens when people engage with service-delivery systems that offer family planning or reproductive health services. Subsequently, the content areas encompassed by program-client interactions are clarified by identifying manifest and latent dimensions and by distinguishing the variables that define these interactions from variables related to their determinants and consequences. Finally, a critical review of existing methods is presented, with examples of research and a discussion of ethical issues.

Beyond supply: the importance of female family planning workers in rural Bangladesh.

Using participant observation data on worker-client exchanges from Bangladesh, this article examines the interface between a government family planning program and the rural women it serves. Case material focuses first on the program function typically identified in the literature: meeting unmet demand for contraception by providing convenient supply. Functions that have been less recognized are then illustrated: (1) the workers role in reducing fear of contraceptive technology; (2) her effort to address religious barriers, child mortality risks, and high fertility preferences; and (3) her role in mobilizing male support. The range of functions performed by the female family planning worker in the cases discussed here demonstrates that her role transcends the boundaries of what is conventionally implied by the concept of supply. She acts as an agent of change whose presence helps to shift reproductive decision-making away from passivity, exposing women long secluded by the tradition of purdah to the modern notion of deliberate choice.

Trends in family size preferences and contraceptive use in Matlab, Bangladesh.

In the nearly ten years of its existence, the Matlab Family Planning and Health Services Project has been characterized by a remarkable rise in contraceptive use and a corresponding decline in fertility. This study examines available evidence on trends in family size preferences in the Matlab area from 1977 to 1984 and their relationship to contraceptive use. Within the Matlab treatment area, the most significant factor behind the increase in contraceptive use has been a sharp rise in the practice of contraception for spacing births. There also appears to have been a more modest increase in the proportion of women wanting no additional children. Family size preferences in the treatment and comparison areas were roughly comparable, suggesting--to the extent that such preferences have changed over time--change may have occurred throughout the Matlab study area. The findings are evaluated in terms of their implications for the current debate on the contribution of family planning programs to fertility decline in developing countries.

Employment in family planning and women's status in Bangladesh.

This study investigates how employment in family planning affects the status of community workers. The focus is on three critical variables: prestige, professional status, and social influence. The data are derived from a focus-group study conducted in 1987-88 in the Maternal and Child Health and Family Planning Project in Matlab, Bangladesh. Focus-group sessions were held with community workers, their husbands, community leaders, and community women. Results show that although community workers initially faced intense hostility in the community, they succeeded in maintaining the prestige that is traditionally accorded to women in their conservative, rural society. Moreover, they established themselves as valued health and family planning professionals in a social context where professional roles for women have been extremely circumscribed. Finally, they gained social influence by performing a range of functions in the community that exceed formally prescribed job responsibilities. The professional and social leadership roles that community workers now assume imply a degree of status that seemed inconceivable a decade ago. That such change could result from a well-designed and appropriately managed family planning project deserves careful attention.

Women's lives in transition: a qualitative analysis of the fertility decline in Bangladesh.

The fertility decline that began in Bangladesh in the late 1980s and continues has prompted diverse theories to explain it. In this qualitative analysis of 21 focus-group sessions with rural women ranging in age from the teens to late 40s and living in the villages of the Matlab area, the womens perceptions of their changing society and of the influence of the family planning program are examined. The womens statements reveal their awareness of the social and economic transition they are undergoing and their interest in family-size limitation, which is bolstered by a strong family planning program. Although the shifts in economic and social circumstances are not large, in conjunction with the strong family planning program they constitute a powerful force for change in attitudes, ideas, and behavior among these women.

Integrating health services into an MCH-FP program: lessons from Matlab Bangladesh.

Since 1977 the International Centre for Diarrhoeal Disease Research, Bangladesh, has conducted a field experiment in family planning and MCH in its Matlab research station. The project began with an emphasis on family planning and MCH services were added in stages. This paper uses time series regression methods to address the question of whether the addition of health services contributed to family planning efficacy in Matlab in a program launched with minimal MCH services. The results show that some MCH interventions increased contraceptive prevalence, some decreased it, and others had no effect. The broader significance of these findings for implementing integrated programs is discussed.

Transferring health and family planning service innovations to the public sector: an experiment in organization development in Bangladesh.

The International Centre for Diarrhoeal Disease Research, Bangladesh, has launched a field experiment in two rural thanas of Bangladesh to test the transferability of its successful health and family planning experiment in Matlab to the Ministry of Health and Population Control service system. This paper reviews the Matlab experiment with particular attention to its organization and identifies elements for transfer. The intervention strategy and operations research design of the new experiment are discussed. The proposed design follows an organization development strategy in which collaborative diagnostic research is used to foster institutional change.

Helping Public Sector Health Systems Innovate: The Strategic Approach to Strengthening Reproductive Health Policies and Programs

Public sector health systems that provide services to poor and marginalized populations in developing countries face great challenges. Change associated with health sector reform and structural adjustment often leaves these already-strained institutions with fewer resources and insufficient capacity to relieve health burdens. The Strategic Approach to Strengthening Reproductive Health Policies and Programs is a methodological innovation developed by the World Health Organization and its partners to help countries identify and prioritize their reproductive health service needs, test appropriate interventions, and scale up successful innovations to a subnational or national level. The participatory, interdisciplinary, and country-owned process can set in motion much-needed change. We describe key features of this approach, provide illustrations from country experiences, and use insights from the diffusion of innovation literature to explain the approachs dissemination and sustainability.

Diffusion of the culture of contraception: program effects on young women in rural Bangladesh.

This article describes a process of diffusion of family planning information, ideas, and technology among an unanticipated audience of young, unmarried women in rural Bangladesh. The data are derived from a focus-group study conducted in 1987-88 in the Maternal Child Health and Family Planning Project in Matlab, Bangladesh. A discussion with a staff member revealed her vivid memory of the arrival of the community-based family planning worker in her village 10 years earlier, before she was married. Based on this research lead, four focus-group sessions were held with newly married young women, and a set of questions about young women were incorporated into the sessions with other community women. The discussions showed that many young, unmarried women learn about family planning from an early age from the community-based family planning worker, from female relatives, peers, and the media. The findings of this exploratory study suggest that greater attention be paid to the contraceptive needs of young women and that continued research be conducted with this population of women.

Worker-client exchanges and contraceptive use in rural Bangladesh.

In this article, longitudinal data from rural Bangladesh are used to assess the impact of household visits from family planning workers on contraceptive use. A panel of women was interviewed in a demographic survey and reinterviewed every 90 days for six successive rounds. Regression methods are used to estimate the effect of these encounters on the odds that a woman will use contraceptives. Statistical controls adjust for the potentially confounding effects of underlying demand for contraception. Findings suggest that both male and female worker-initiated exchanges have an effect, although the impact of outreach is more pronounced if the worker is female. Estimated effects are consistent with the hypothesis that the predominant impact of outreach is to crystallize existing latent demand for contraception. Results also suggest, however, that female worker outreach generates new demand by fostering ideational change.