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Final report of an operations research project: "A Study to Increase the Availability and Price of Oral Contraceptives in Three Program Settings", Contract CI90.59A.
[Unpublished] 1991 Oct 10. , 32,  p. (PER-19; USAID Contract No. DPE-3030-Z-00-9019-00)In an effort to reach more clients while increasing self-sufficiency, a group of private and public agencies in Peru collaborated in 2 operations research (OR) studies. This OR project, which cost US $62,040, was affected by the action of the newly elected government which ended price controls and subsidies in August 1990 and resulted in changes in the spending habits of most Peruvian families. Sales of all oral contraceptives (OCs) fell from an average of 141,400 to 73,400 cycles/month, and sales of Microgynon in pharmacies fell from 76,400 to 38,000 cycles/month. The first OR study tested the use of community-based distributors (CBDs), Ministry of Health (MOH) facilities, and private midwives as contraceptive social marketing (CSM) outlets by adding the OC Microgynon (sold at pharmacy prices) to CBD programs and raising the price of the donated OC, Lo-Femenal, over time. Specific objectives were to determine 1) if total CBD sales increased with the method mix, 2) whether CBD from homes of small businesses was more effective, 3) if the new distribution of Microgynon would increase sales of the OC as a whole, and 4) the impact of Lo-Feminal price increases on sales and user characteristics. The study was carried out in 44 experimental and 44 control groups in Lima and 20 experimental and 21 control groups in Ica. Baseline data were obtained for December 1989-April 1990, and monthly sales were monitored during the 12 months from May 1990 to April 1991. Data were also obtained from surveys of dropouts and new Microgynon acceptors. It was found that the August 1990 price increase effectively destroyed the significant market penetration exhibited by Microgynon in the first 4 months of the study. Adding an affordable CSM brand to CBD programs will, however, increase sales and self-sufficiency, although the sale of donated OCs for around $0.30/cycle will reduce sales of the new brand by 20-40%. It was also found that most clients who dropped out because of side effects were less likely to be contracepting than those who dropped out because of cost, indicating a need for improved distributor counseling. The second study tested the price elasticity of demand for OCs in CBD programs by measuring the demand for Microgynon. Specific objectives were to determine 1) the level of Microgynon sales in MOH facilities, 2) the level of sales by nurse-midwives, 3) the number of Microgynon users who formerly used Lo-femenal from the MOH, and 4) the number of Microgynon users in MOH and nurse-midwife facilities who formerly obtained the OC from pharmacies. A demonstration project was carried out in the rural departments of Ayacucho and Huancavelica, the poorest areas of Peru. 4 MOH hospitals in 4 cities and 17 nurse-midwives participated. The hope was that the CSM products would mitigate the effect of stock-outs in the hospitals. It was found that no Microgynon was sold because of a reluctance to recommend it and other unfavorable study conditions (the necessity for separate accounting, the lack of stock-outs, the reluctance of the midwives to sell a contraceptive, and the decline in client purchasing power). Cost recovery in the MOH would be better served by charging a modest amount for donated contraceptives.
In: Earth summit. Conversations with architects of an ecologically sustainable future, by Steve Lerner. Bolinas, California, Commonweal, 1991. 229-36.A senior associate with the World Resources Institute believes that it is more worthwhile to strengthen the UN Environment Program than to create a new international environmental organization. Another possibility would be to convert the UN Trusteeship Council's purpose from administering UN territories to dealing with environmental issues. The Council has an equal number of developing countries and developed countries and no country has veto power. She also favors ad hoc groups dealing with very specific issues, e.g., International Panel on Climate Change. We need an international debt management authority which purchases outstanding debt at real market prices to finance policies and programs that alleviate poverty and protect the environmental issues should lie with 1 organization. She dismisses suggestions that the Group of Seven industrialized nations serve as a group to propose international initiatives because developing countries would not accept the G-7 process plus the G-7 countries do not even agree on environmental issues. Citizens push US politicians to address environmental issues rather than the politicians leading on environmental issues. Some members of the US Congress have taken the initiative, however, including Senators Gore and Mikulski from Tennessee and Maryland, respectively. The President must have a vision for a transition to sustainable development, which he does not. In the 1973-74 oil crisis, industry took it upon itself to become more energy efficient and still had real growth in the gross national product, illustrating that the costs required to become more sustainable are not as great as many people claim. Sustainable agriculture would reduce the demand for fossil fuels, on which fertilizers and pesticides are based. It would require making institutional changes. USAID should change dramatically the system it uses to distribute foreign aid money and to dedicate considerably more money to the environment and development.
In: To cure all hunger. Food policy and food security in Sudan, edited by Simon Maxwell. London, England, Intermediate Technology Publications, 1991. 191-206.Targeting on grounds of equity, cost, or minimizing interference fails to consider whether targeting is politically possible. In the case of the USAID-sponsored famine-relief and emergency food aid operation in Darfur, western Sudan, in 1985, the expressed intention of target this relief was not fulfilled. The target group received inadequate amounts of relief grain owing to the lack of targeting by area councils within Darfur, and the lack of targeting within area councils. After severe rainfall failures in 1982, 1983 and 1984, large numbers of people in western Sudan faced severe food shortage, abnormal migrations, and increased risk of destitution. USAID, the principal donor for relief operations to western Sudan in 1984-85, approved 82,000 metric tons (mt) of relief grain for western Sudan in September 1984, and then a further 250,000 mt in late 1984 and early 1985. The target population for the first 41,000 mt of relief sorghum was the neediest one-fourth later, the neediest one-third. A USAID document provided estimates of people and the way the area councils conceived sheltering throngs of the target group. There was 153,141 seriously affected in Kutum area council, 102,907 in Mellit, and 507,348 in Geneina representing around 25% of Darfur's population, the size of the target group envisaged for the first 41,000 mt of relief grain. USAID made concessions to the Darfur regional government allowing South Darfur a higher proportion of early allocations than need dictated. Save the Children Fund experienced serious difficulties with the local contractor to distribute food from area-council level. Aid agencies and donors need to consider how targeting is to be accomplished and how to confront influential local players with interests contrary to such targeting. Allocations of relief grain could be made on the assumption that targeting will be only partially achieved; and through alternative forms of relief.
LINKS. HEALTH AND DEVELOPMENT REPORT. 1991 Fall; 8(3):11-2.The authors respond to Tony Dajer's critique of their study concerning the trend in Nicaraguan infant mortality and its possible explanations. It is pointed out that the sharp decline in Nicaragua's infant mortality in the mid-1970s is an intriguing phenomenon, since it began to occur at a time of economic slump, civil disturbance, and under a government that gave low priority to the social sector. It is contended that a number of factors (among them the Managua earthquake) prompted the government to shift its allocation of resources from hospital-based health care in the capital city to ambulatory health care throughout the country. After the revolution, the Sandinista government continued this process. Dajer's characterization of USAID-funded clinics as "notoriously ineffective" is rejected; arguing that although operating under overt political guidelines, these projects are well-advised by experts. Dajer's question as to the importance of health care within the Sandinista government is considered. It is maintained that the revolution was not fought in order to reduce infant mortality, and that health was not the primary concern of the Government of National Reconstruction. It was the international solidarity movement, not the Sandinista government, which focused so intently on infant mortality, hoping to find good news to report. The issue of health care had the added advantage of being politically noncontroversial. It is also maintained that since the mid-70s, the country's health policy has remained stable, despite the radical changes in government because the international arena helps determine national health policy.
Ann Arbor, Michigan, University Microfilms International, 1991. vii, 266 p. (Order No. 9116069)The effectiveness of official development assistance in responding to health problems in recipient countries may be examined in terms of 1) the results of specific aid-supported projects, 2) the degree to which the activities have contributed to recipients' institutional capacity, and 3) the impact of aid on national policy and the broader development process. A review of the literature indicates a number of conceptual and practical constraints to assessing health aid effectiveness. Numerous health projects have been evaluated and issues of sustainability have been studied, but relatively little is known about the systemic effects of health aid. The experience of Nigeria is analyzed between the mid-1970s and the late 1980s. In the 1970s, Nigeria's income rose substantially from oil revenues, and a national program was undertaken to increase the provision of basic health services. The program did not achieve its immediate objectives, and health sector problems were exacerbated by the decline of national income during the 1980s. Since 1987, a progressive national primary healthcare policy has been in place. Aid has been given to Nigeria in comparatively small amounts per capita. Among the major donors, WHO, UNICEF, and, most recently, the World Bank, have assisted the development of general health services, while USAID, UNFPA, and the Ford Foundation have aided the health sector with the principal objective of promoting family planning. 3 projects are examined as case studies. They are: a model of family health clinics for maternal and child care; a largescale research project for health and family planning services; and a national immunization program. The effectiveness of each was constrained initially by limited coordination among donors and by the lack of a supportive policy framework. The 1st 2 of these projects developed service delivery models that have been reflected in the national health strategy. The immunization program has reached nationwide coverage, although with uncertain systemic impact. Overall, aid is seen as having made a marginal but significant contribution to health development in Nigeria,a primarily through the demonstration of new service delivery approaches and the improvement of management capacity. (author's)
Arlington, Virginia, DUAL and Associates, Population Technical Assistance Project [POPTECH], 1991 Dec 5. vii, 41,  p. (Report No. 91-127-127; USAID Contract No. DPE-3024-Z-00-8078-00; PIO/T No. 623-0004-00-3-10002)In 1975, International Planned Parenthood Federation (IPPF) founded the Centre for African Family Studies (CAFS) in nairobi, Kenya to train family planning program personnel in service delivery management skills and technologies. A USAID funded 4 year CAFS Project Grant, scheduled to end in June 1993, consisted of training courses with incountry follow up to make sure courses were applicable to the changing situation of family planning programs in Africa. CAFS was to become totally self sufficient by June 1993. It planned to recover direct training costs from participants. CAFS experienced considerable difficulties in organization and management (a new director and loss of IPPF funding), during the project. The evaluation team found the training courses to be of high quality. Further former participants wished to continue receiving CAFS services and would recommended CAFS courses to colleagues. New financial procedures and addition of experienced financial staff had set CAFS on its way to financial self sufficiency, but these changes would not bring about self sufficiency by June 1993. Further CAFS restructured management and its organizational structure thereby moving it towards decentralization of authority and decision making. Even though CAFS was the only African regional institution providing training services for family planning personnel, it could lose its competitive edge since it had problems in providing francophone courses, inadequate incountry follow up visits, and insufficient research and evaluation skills in developing training programs. CAFS needed to address these obstacles. The team highlighted the need for CAFS to no longer depend on individual staff to maintain high quality courses so courses would not suffer from staff turnover. In conclusion, the team recommended that USAID continue to support CAFS.
Maternal anthropometry for prediction of pregnancy outcomes: memorandum from a USAID/WHO/PAHO/MotherCare meeting.
BULLETIN OF THE WORLD HEALTH ORGANIZATION. 1991; 69(5):523-32.The memorandum is an abbreviated version of a prepared report on maternal anthropometry which summarizes the general recommendations of a consensus of 50 experts on field applications and priority research issues in developing countries. Consensus was reached at a meeting on Maternal Anthropometry for Prediction of Pregnancy Outcomes held in Washington, D.C. in April 1990. 15 general recommendations are identified for field applications and research priorities. Specific recommendations differentiating field applications from research priorities are provided for prepregnancy weight, weight gain in pregnancy, height, arm circumference, and weight for height and body mass index. For example, the discussion of arm circumference indicates that it is useful as an indicator of maternal nutritional status in nonpregnant women because of its correlation with maternal weight or weight for height. During pregnancy, it is useful as a screen for risk of low birth weight (LBW) and late fetal and infant mortality. Maternal arm circumference has been found to be stable during pregnancy in developing countries and is independent of gestational age. Field applications involve the use 1) to assess the nutritional status of pregnant and nonpregnant women, 2) to screen women at risk of poor maternal stores postpartum because it reflects maternal fat and lean tissue stores, for instance, 3) to screen women and refer to facilities for a more thorough assessment of nutritional risk, and 4) to assess the extent of undernutrition in an area, particularly for surveillance. Community level workers, especially birth attendants (TBA's) should be trained and have access to arm circumference tapes. The technology is simple enough also for use by women in the home. Cutoff points for assessing biological risk are fairly consistent across developing country populations, and range between 21-23.5 cm. Routine monitoring during pregnancy is not necessary because the changes are too small to detect. Where prepregnancy weight is unavailable and weight is monitored, arm circumference may serve as a proxy for prepregnancy weight. All women of childbearing age should be measured. Research priorities are to explore the functional significance with women of difference body compositions (fat versus lean upper arm), the relationship to pregnancy related outcomes, arm changes relative to stages throughout the reproductive period and to weight changes, different instruments such as color-coded tapes or 1 tape for arm measurement and uterine height, combinations of different measurements, the relationship with prepregnancy weight, and the development of arm circumference in weight gain charts as a proxy for prepregnancy weight.
Arlington, Virginia, Management Sciences for Health, Technologies for Primary Health Care [PRITECH], 1991.  p. (USAID Contract No. DPE-5969-Z-00-7064-00)Representatives from several nongovernmental organizations visited Uganda in February-March 1991 to help the Control of Diarrheal Disease (CCD) program bolster its ability to advance case management, training, and supervision of health care professionals. Specifically, the team focussed its activities on determining a strategy to create a national level diarrhea training unit (DTU) centered around case management for medical officers, interns and residents, medical students, and nurses. Similarly, it participated in developing a strategy for training traditional healers in diarrhea case management and for inservice training for health inspectors (preventive health workers). The team presented a generic model for a training/support system to the DTU faculty and CDD program manager. The model centered on what needs to be done to ensure that the local clinic health worker manages diarrhea cases properly and instructs mothers effectively to manage diarrhea. Further, in addition to comprehensive case management, content included interpersonal communication at all levels supplemented by supervision and training skills. It encouraged a participatory approach for training. In addition, it strongly encouraged the DTU faculty and CDD program staff to follow up on training activities such as supporting trainees and reinforcing skills learned in the training course. The team met with relevant government, university, and donor representatives to learn more about existing or proposed CDD activities. Further, the CDD program asked team members to assist informally in the surveyor training session for the WHO/CDD Health Facilities Survey. The team also spoke to WHO/CDD staff about its plans and future activities. WHO/CDD was concerned that training in interpersonal skills not weaken the quality of training in diarrhea case management.
Washington, D.C., Population Crisis Committee, 1991. 52 p.Noting that US population assistance programs have suffered from ideological controversies and increasing bureaucratization, this publication outlines the actions needed to reinvigorate and redirect US population assistance programs, including the Agency for International Development (AIDS), the largest financial assistance provider and condom supplier to developing countries. The extent of family planning during the 1990s will have a definite impact on the years to come, since this decade represents the last opportunity to prevent the doubling of the world's population before it stabilizes during the 21st century. An example of the ideological controversies, the Reagan administration, prompted by anti-abortion groups, withdrew support from the UNFPA and the International Planned Parenthood Federation (IPPF). The publication makes recommendations at 3 levels -- for the President and Congress, for AID, and for the Office of Population. Recommendations for the President and Congress include: reasserting White House leadership on world population issues; increasing population assistance to $1.2 billion by the year 2000; resuming funding to the UNFPA and IPPF; and eliminating statutory restrictions relating to abortion. Concerning AID, the publication urges: broadening its birth control approach to include injectable contraceptives, safe abortion services, and adolescent and female education programs; increasing contraceptive distribution; improving quality of services; etc. Recommendation for the Office of Population include: taking responsibility for providing technical support to AID's country level population programs; coordinating the activities of private institutions and AID activities; and stressing long-term institution building needs of family planning programs.
FRONT LINES. 1991 Nov; 16.Indonesia's success in reaching World Health Organization (WHO) universal immunization coverage standards is described as the result of a strong national program with timely, targeted donor support. USAID/Indonesia's Expanded Program for Immunization (EPI) and other USAID bilateral cooperation helped the government of Indonesia in its goal to immunize children against diphtheria, pertussis, tetanus, polio, tuberculosis, and measles by age 1. The initial project was to identify target areas and deliver vaccines against the diseases, strengthen the national immunization organization and infrastructure, and develop the Ministry of Health's capacity to conduct studies and development activities. This EPI project spanned the period 1979-90, and set the stage for continued expansion of Indonesia's immunization program to comply with the full international schedule and range of immunizations of 3 DPT, 3 polio, 1 BCG, and 1 measles inoculation. The number of immunization sites has increased from 55 to include over 5,000 health centers in all provinces, with additional services provided by visiting vaccinators and nurses in most of the 215,000 community-supported integrated health posts. While other contributory factors were at play, program success is at least partially responsible for the 1990 infant mortality rate of 58/1,000 live births compared to 72/1,000 in 1985. Strong national leadership, dedicated health workers and volunteers, and cooperation and funding from UNICEF, the World Bank, Rotary International, and WHO also played crucially positive roles in improving immunization practice in Indonesia.
PEOPLE. 1991; 18(4):33.Never before has the World Bank (WB) spent more money than the United States Agency for International Development (USAID) on population and family planning programs (FP). The WB's budget calls for US$340 million dollars for FP compared to USAID which has budgeted US$322 million, some of which may not be allocated. The 1991 WB figure is double the 1990 of US$169 million which was an increase of 40% over the 1989 figure. Total international FP in 1989 was US$757 million including WB and USAID. In the last 25 years the US has Contributed over US$4 billion to FP. Japan contributes about 8% (they announced they will increase their spending on FP by 1.8% for 1991). Norway, Sweden, the Netherlands, Canada, Germany, and the United Kingdom each provide about 4-6% of the total. However, FP accounts for only 1.3% of all total official development assistance. In 1991 the WB has 13 new programs and loans which will be given to Nigeria and Rwanda for the 1st time. The United Nations Population Fund (UNFPA) estimates that a total of US$4.5 billion is needed by 2000 just for FP, with developing countries contributing the same amount. The US house of Representatives recently voted to increase spending with US$300 million for FP in addition to USAID's budget bringing the total up to US$400 million for 1992. Estimates suggest the US should increase spending to $600 million in 1992 and US$1.2 billion by 2000.
USAID HIGHLIGHTS. 1991 Fall; 8(3):1-4.This article considers the epidemic proportion of AIDS in developing countries, and discusses the U.S. Agency for International Development's (USAID) reworked and intensified strategy for HIV infection and AIDS prevention and control over the next 5 years. Developing and launching over 650 HIV and AIDS activities in 74 developing countries since 1986, USAID is the world's largest supporter of anti-AIDS programs. Over $91 million in bilateral assistance for HIV and AIDS prevention and control have been committed. USAID has also been the largest supporter of the World Health Organization's Global Program on AIDS since 1986. Interventions have included training peer educators, working to change the norms of sex behavior, and condom promotion. Recognizing that the developing world will increasingly account for an ever larger share of the world's HIV-infected population, USAID announced an intensified program of estimated investment increasing to approximately $400 million over a 5-year period. Strategy include funding for long-term, intensive interventions in 10-15 priority countries, emphasizing the treatment of other sexually transmitted diseases which facilitate the spread of HIV, making AIDS-related policy dialogue an explicit component of the Agency's AIDS program, and augmenting funding to community-based programs aimed at reducing high-risk sexual behaviors. The effect of AIDS upon child survival, adult mortality, urban populations, and socioeconomic development in developing countries is discussed. Program examples are also presented.
Evaluation of Matching Grant II to International Planned Parenthood Federation / Western Hemisphere Region (IPPF/WHR) (1987-1992).
Arlington, Virginia, DUAL and Associates, Population Technical Assistance Project [POPTECH], 1991 Jul 26. xii, 48,  p. (Report No. 90-078-116; USAID Contract No. DPE-3043-G-SS-7062-00)This is a mid-term review of a matching grant given to the International Planned Parenthood Federation/Western Hemisphere Region (IPPF/WHR) by USAID's Office of Population for 1987-1991. The grant covers projects in Brazil, Colombia, Mexico and 9 smaller countries, and 4 regional activities, commodities, technical assistance, management information systems (MIS), and evaluation support. The goal of the grant was to reach new acceptors with quality services, to exert leadership of public sector providers, and to improve internal management. The goals in the 3 large nations are to focus on pockets of need or inadequate service or method mix. The goals of attracting 2.8 million new acceptors, improving services, making detailed plans and keeping strict financial reports have been met. The most serious problem was the lack of a regional evaluation of goal evaluation, the real cost of contraception, and impediments to contraceptive use. There were also difficulties in forwarding funds at the beginning of the FPA's year, and in sending in agency workplans on time. Better communication structures could probably remedy this. It is recommended that the matching grant be renewed in 1992.
[Unpublished] 1991.  p.Jose G. Rimon, II, Project Director for the Johns Hopkins University Population Communication Services (JHU/PCS) Center for Communication Programs, visited Finland to attend a NORPLANT planning meeting. Meeting discussion focused upon issues involved in expanding NORPLANT programs from pre-introductory trials to broader national programs. Financing and maintaining quality of care were issues of central importance for the meeting. Participants included representative from NORPLANT development organizations, the U.S. Agency for International Development, the World Bank, and other donor agencies. Mr. Rimon was specifically invited to make a presentation on the role of information, education, and communication (IEC) on NORPLANT with a focus upon future IEC activities. The presentation included discussion of the need to develop a strategic position for NORPLANT among potential customers and within the service provide community, the feasibility of global strategies positioning in the context of country-specific variations, the need to identify market niches, the need for managing the image of NORPLANT, and the need to study IEC implications in terms of supply-side IEC, content/style harmonization, materials volume, and language and quality control. Participants collectively agreed to develop an informal group to address these issues, concentrating upon universal issues potentially addressed on a global scale. A meeting on strategic positioning is scheduled for August 19-20, 1991.
EARTHWATCH. 1991; (41):15.The National Audubon Society began a population program in 1979, set up a 5-year plan of public education, advocacy and coalition-building in 1985, and joined a broad-based coalition of the Sierra Club, the National Wildlife Federation, the Population Crisis Committee and the Planned Parenthood Federation of America in 1990. The 1985 impetus resulted in production of teaching materials and staging of focus groups across the U.S. The 1990 coalition has directed funds to the USAID Office of Population. Another project is the International Environment/Population Network, which organizes letter-writing, media programs and town meetings for ordinary citizens to press for sustainable development. Many of the Audubon's 510 local chapters have partnerships with similar groups in other countries, as do 8 wildlife sanctuaries have links to sanctuaries abroad. An example is the Indus River in Pakistan visited by the manager of Audubon's Platte River Sanctuary in Nebraska. The 2 rivers share the problem of reduced flow and vegetation overgrowth as a result of engineering projects upstream.
Study cites unmet world demand for contraceptives..House panel votes to increase Pop Aid funding, rescind program restrictions.
WASHINGTON MEMO. 1991 May 20; (8):1-2.In addition to increasing overseas family planning aid, the House Foreign Affairs Committee has voted to reverse restrictive policies begun during the Reagan administration. This decision comes after the publication of a UNFPA annual report entitled "The State of World Population," which indicates that the world's population could double to 10.2 billion with 60 years. Despite the Bush administration's opposition to earmarking funds for specific programs within the Agency for International Development (AID), the committee allocated funds specifically for population programs. For population assistance, it reserved $300 million for 1992 and $350 for 1993, up from $250 million the previous year. The committee also made available $100 million for family planning under the Development Fund for Africa, doubling the amount from the previous year. Besides increased funding, the committee also voted to renew funding to UNFPA and to reverse the "Mexico City" policy. In 1985, the Reagan administration ended all aid to UNFPA because the organization contributed money to China's family planning program. The administration viewed this as condoning coercive abortion practices. The Mexico City policy, named after the host city of the 1984 International Conference on Population, banned any US aid to family planning organizations in developing countries which provided abortion-related services or information, even if these programs were being funded without US money. Although just beginning to prepare its reauthorization bill, the Foreign Relations Committee in the Senate also appears ready to increase its support of population activities, including the reversal of the 2 policies. But critics of UNFPA and defenders of the Mexico City policy have threatened with a presidential veto if the measures are eventually adopted.