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Concern about rapid growth in demand for reproductive health services in developing countries has created interest in productivity and costs of existing programmes. Staff costs usually constitute the largest share of total service costs, meriting special effort to ensure that they are measured accurately. Several techniques have been used in the literature to analyze staff activity, but these techniques have not been validated. This paper reports on a study conducted in three Ecuadoran clinics. The study uses an observational time-motion (TM) technique as a benchmark, and compares results from three other techniques to those obtained using TM. None of the alternative techniques produces estimates that agreed with TM estimates; deviations from TM are particularly large for non-contact time, defined as clinician activities carried out when clients are not present. Implications of these findings for productivity and cost studies are discussed, and possible avenues for future research are proposed.

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The continuing trend of donor attention and resources away from Latin America threatens the sustainability of nongovernmental family planning organizations in that region. Managers can improve sustainability through cost control, cost recovery, and income generation. The Population Council's INOPAL II and INOPAL III projects and Family Health International assisted CEMOPLAF, an Ecuadoran private voluntary organization, in carrying out operations research in each of these areas. Studies included cost-savings analysis from altering IUD revisit norms (cost control), an ability-to-pay study that showed potential gains from increased prices for reproductive health services (cost recovery), and a feasibility study to estimate income from ultrasound services (income generation). Results indicate that any one intervention will probably have a limited impact, and that managers likely will need to undertake several initiatives simultaneously to make significant progress toward sustainability.

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This report presents the results of an operations research project to increase male involvement in family planning in Peru. Two community-based distribution (CBD) programs, PROFAMILIA of Lima and CENPROF of Trujillo, Peru, recruited male contraceptive distributors and compared their performance to that of female distributors recruited at the same time. Both programs found it harder to recruit men than women as distributors. Program supervisors, who were women, were less comfortable with men than with other women, even though there were no differences in distributor compliance with program norms. Male distributors were more likely to serve male clients and sell male methods (condoms), while female distributors were more likely to serve female clients and sell female methods (pills). Men sold as much or more total couple-years of protection than did women, and they recruited as many or more new acceptors. Gender was found to exert an impact on method mix independent of other distributor characteristics, such as age, education, marital status, and number of living children. The study suggests that family planning programs can influence method mix and client characteristics by recruiting men as CBD distributors.

PIP: The findings of an operations research (OR) project designed to compare the effectiveness of male vs. female contraceptive distributors in Peru are reported. The OR project was conducted by 2 private, nonprofit family planning agencies that have community-based distribution (CBD) programs: PROFAMILIA in Lima and CENPROF in Trujillo. The OR project sought to test 3 hypotheses: 1) male distributors would sell more condoms and female distributors would sell more oral contraceptives; 2) male distributors would serve more male clients and female distributors would serve more female clients; and 3) male distributors would sell less contraceptive protection than female distributors. Between 1987 and January 1988, the 2 agencies recruited new male and female distributors to serve in the project. Both agencies had a more difficult time recruiting male than female distributors. PROFAMILIA recruited 38 men and 171 women, while CENPROF recruited 52 men and 94 women. All but one of the supervisors in both agencies were female. The supervisors generally regarded the male distributors with skepticism, but the study found no significant difference in the reporting compliance of male and female distributors. The project confirmed hypotheses 1 and 2. In both agencies men sold twice as many condoms as did women, and women sold more oral contraceptives; and male distributors were more likely to serve men, while female distributors were more likely to serve women. The 3rd hypothesis, however, was unsupported. Men sold as much or more contraceptive protection than did women and recruited as many or more new acceptors. It is concluded that men can be effective CBD distributors, and that CBD programs can influence method and client mix by recruiting more men as distributors.

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Operations research is the study of factors that can be controlled by program administrators. Among such factors is the frequency of performing program activities. The present experiment, conducted in Lima, Peru during 1985-86, tested the impact of holding family planning post sessions once per month, twice per month, and weekly. Frequency was shown to have a major impact on program outputs, costs, and cost-effectiveness. Depending on the indicator, sessions held twice per month produced between 1.5 and 2.1 times the output of those conducted once per month. Weekly sessions produced between 1.3 and 1.6 times the output of those held twice per month. At an output level of nearly 11,200 visits per year, twice-per-month sessions were estimated to be 7-38 percent more cost-effective, depending on the indicator, than once-per-month sessions, and 6-28 percent more cost-effective than weekly sessions.

PIP: Operations research is the study of factors that can be controlled by program administrators. One of these factors is the frequency of performing program activities. The operational variable is the frequency of having clinical sessions in medical back-up posts in a community-based distribution (CBD) program in Lima, Peru. The study covered 42 posts in urban marginal areas of Lima. 3 performing frequencies were compared: 1) once a month; 2) twice a month; and 3) weekly. A randomized block design was used. The study lasted 12 months--from August, 1985-July, 1986. 3 output indicators were chosen: 1) effectiveness; 2) efficiency; and 3) cost-effectiveness. Outputs include program acceptors, total visits, IUD insertions, sessions and family planning (FP) visits. The once-per-month posts finished 98% of scheduled sessions while the twice-a-month and weekly sessions finished 97% and 96%, respectively. Mean duration of the clinic sessions held by the monthly and twice-monthly posts was 2.9 hours (s.d.=.84 and .73, respectively). Mean duration for the weekly group was 2.8 hours (s.d.=.67). About 73% of the FP talks scheduled for the monthly post were really accomplished compared to 66% for the twice-monthly and weekly groups. The 42 posts held 1136 clinic sessions during the year and had 11,196 visits, including 5371 FP visits. 1705 women accepted a FP method at the posts. 77% were IUD takers; 15% chose pills; and 8% accepted barrier methods. There were 4768 IUD visits. There were 414 pill visits and 18% barrier method visits. About 89% of all FP visits were IUD-related. 87% of all IUD insertions were referred by CBD workers and 5% by supervisors. There were 2954 total visits in monthly posts; 3501 in twice-monthly; and 5641 in weekly posts. Output went up linearly with session frequency, but in lesser proportion than the rise in the number of sessions held. Differences are statistically significant for all outputs. Twice-a-month posts had 1.5-2.1 times the output of once-a-month posts; weekly posts had about 1.3-1.6 times the output as twice-a-month posts, depending on the variable chosen. With output level of nearly 11,200 visits per year, twice-a-month sessions were estimated to be 7-38% more cost-effective than once-a-month sessions; 6-28% more cost-effective than weekly sessions.

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The cost-effectiveness of reducing the frequency of routine supervision from monthly to quarterly was evaluated in a closely controlled field experiment conducted in a community-based distribution program in Piaui State in northeast Brazil. The results demonstrated substantial potential savings in supervisors' salaries and travel at no cost to program performance (new acceptors, revisits, distributor turnover). A possible reason for this finding was that most supervisory visits were primarily concerned with collecting inventory and service statistics, which probably contributed little to post performance. It was suggested that the number of supervisors and the frequency of supervision should be linked to productive rather than routine supervisory activities.

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PIP: In 1976 326 students, 149 men and 177 women, were asked to fill a questionnaire in 2 U.S. campuses to analyze interpersonal factors related to contraceptive practices. 86% of students were white, belonged to the middle class, and were of average age 19.6. The questionnaire carried questions related to demographic problems, personality, and sex behavior. Of 326 students, 113 were virgin, and 213 sexually active. Sexual activity tended to increase with age, with a notable acceleration between 16-25 for women, and 14-18 for men. About half of the participants stated not to have used contraception at their first sexual experience; for the others the methods used were coitus interruptus, or condom. In case of a lasting relationship the method used the first time was later changed for a more reliable one. Major predictors of contraceptive method were the frequency of sexual relations, the method used the first time, age, and knowledge of the physiology of reproduction. 77% of couples who lived together used the pill. Results showed that use of a reliable contraceptive method depended much more on the type of relationship, than on personality or characteristics of the individual.^ieng

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