Integrating Family Planning with Health Services Does It Help? SWP515 Rashid Faruqee .vv.- llwllAMa uLJVLLUPMENT WASHINGTON. D.C. 2O4aI WORLD BANK STAFF WORKING PAPERS Number 515 FILE CP WORLD BANK STAFF WORKING PAPERS Number 515 Integrating Family Planning with Health Services Does It Help? Rashid Faruqee Development Research Department The World Bank Washington, D.C., U.S.A. Copyright © 1982 The International Bank for Reconstruction and Development / THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America This is a working document published informally by The World Bank. To present the results of research with the least possible delay, the typescript has not been prepared in accordance with the procedures appropriate to formal printed texts, and The World Bank accepts no responsibility for errors. The publication is supplied at a token charge to defray part of the cost of manufacture and distribution. 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Library of Congress Cataloging in Publication Data Faruqee, Rashid, 1938- Integrating family planning with health services--does it help? (World Bank staff working paper ; no. 515) Bibliography: p. 1. Maternal haealth services--India--Narangwal. 2. Child health services--India--Narangwal. 3. Birth control clinics--India--Narangwil. I. Title. II. Series. RG965.I42N373 1982 362010o425 82-8405 ISBN 0-8213-0003-2 (pbk.) AACR2 ABSTRACT Narangwal is more than the name of a village In Punjab, India. It has become associated with one of the best known and well documented field experiments in health care and family planning anywhere in the world. In that experiment, groups of villages were provided with combinations of services for health, family planning, and nutrition between 1968 and 1974. The households in each group were then followed through extensive data gathering. The World Bank has been collaborating with Johns Hopkins University in analyzing this rich set of data to study policy questions relating to systems for the delivery of services. Two monographs on the findings of this research--one dealing with population, one with nutrition--are forthcoming. One important question addressed in the population monograph is whether the integration of health and family planning services helps in attaLning family planning and health objectives. This paper focuses on the findings on this question. The findings show that integration was more effective in recruiting family planning acceptors than was the provision of family planning alone. They also show that integration was more cost effective than separate services and more equitable in distributing family planning services to all socioeconomic groups. Integration also produced better contraceptive protection. These results were not obtained by sacrificing health benefits. The findings show that health benefits were also impressive--in effectiveness, in effi- ciency, and in equLty. The life of the experiment was too short to produce a perceptible fertility decline, yet the results generally suggest that integration can help in reducing fertility, too. CONTENTS Page no. Introduction ..................................... . 1 Description of Services and Variables ........al .... 2 Use of Family Planning .. . ................ .. .. 7 Effecttveness . ......... .......... .................. . 7 Efficiency .................................... 20 Equity ........................................ 23 Use of Health Services .......................... 25 Effectiveness . ..... ......... . 25 Efficiency.................. ....29 Equity ............................................... 34 Decline in Fertility ........................ . .... . 36 Effectiveness . . ......... ...... . 36 Efficiency . . .. .... . 39 Equity ............................................... 40 Conclusion ..... 41 References ........................................ 42 LIST OF TABLES Page no. Table 1 Summary of Service Inputs 5 Table 2 Preproject Use of Modern (Permanent and Temporary) and Traditional Methods among Experimental Groups 9 Table 3 Percentage Distribution of Current Users of Family Planning, by Method 16 Table 4 Multiple Regression Results: Effects of the Volume of Service Contacts in 1969-1973 and other Variables on Use or Nonuse of Family Planning at Any Time During the Project 1969-73 19 Table 5 Mean Number of Services and Associated Regression Coefficients from the Regression Analysis in Table 4 21 Table 6 Preproject Use (modern, temporary, and permanent methods) Project Use Rates, Project Recruits from Nonusers among Sociodemographic Groups 24 Table 7 Effects of Children's Services on Mortality Rates, by Age, Caste and Experimental Group, 1970-73 27 Table 8 Effects of Children's Services on Morbidity Levels, 1970-73 30 Table 9 Comparative Efficiency of Narangwal Services 32 Table 10 Percentage of Women Who had a Live Birth, by Practice of Family Planning in the Preceding Year and by Experimental Group 38 Table 11 Mean Number of Service Contacts and Percentage Decline in Fertility 40 LIST OF FIGURES Page no. Figure 1 Experimental Design for the Narangwal Population and Nutrition Projects 3 Figure 2 Percent Currently Married Women Age 13-19 Who Were Acceptors of Modern Family Planning Methods at Specified Periods in Time by Experimental Group 10 Figure 3 Cumulative Rates of Project Acceptors in Experimental Groups 12 Figure 4 Percent Currently Married Women Aged 15-49 Who were Practicing Family Planning by Experimental Group 13 Figure 5 Trends in Contraceptive Practice Rates in Experimental Groups 14 Figure 6 Percent Currently Married Women Age 15-49 Who were "Effective-Users" of Family Planning at Specified Points in Time by Experimental Group 17 INTEGRATING FAMILY PLANNING WITH HEALTH SERVICES: DOES IT HELP? Whether family planning and health services should be integrated to increase the effectiveness of family planning services is no longer a subject of debate. Most countries and international agencies favor integration because of the efficiency of using health personnel for family planning. But it still is important to ask, does integration increase the impact of services? The question can be addressed by studying the experience of a controlled experi- ment at Narangwal in the Indian state of Punjab. The Department of Interna- tional Health of Johns Hopkins IJniversity conducted a field experiment there between 1968 and 1974. In that experiment, different groups of villages were provided with different combinations of services for health, nutrition, and family planning. The experiment had two parts. The population study examined the outcome of integrating health services with those for family planning. The nutrition study considered the interaction between malnutrition and infec- tions in children under three years of age. Timothy King gave the valuable comments on an earlier draft of this paper, which is drawn from Carl Taylor, Rashid Faruqee, Robert Parker, William Reinke and R.S.S. Sarma, Benefits of Integrating Family Planning and Health Services: the Narangwal Experience (Washington, D.C.: World Bank, forth- coming). That source contains the details of the experimental design, services, and findings. - 2 - In the population study, five experimental groups of villages were matched as closely as possible for comparability. Each group of villages received a different service package: 10 Family planning, women's services, and child care services (FPWSCC) 2. Family planning and women's services (FPWS)o 3. Family planning and child care services (FPCC). 4. Family planning and family planning education services (FPED)0 5. Control group (CONT-P). In the nutrition study, which covered all children under three, each of four groups of villages received a different service package: 10 Child care services: nutritional supplementation, and health care (NUTHC)o 2. Nutritional supplementation (NUT)0 3. Health care (HC)0 4. Control group (CONT-N) The NUTHC experimental group was the FPCC group of the population study (see figure 1). Description of Services and Variables As services developed in the course of the experiment, care was taken to ensure that the intensity of services in each experimental group was roughly the same0 The project services are summarized in table 10 Never static, the services continued to evolve, so that activities would become more relevant and realistic0 Services did not start at the same time in all experimental groups; this complicated the analysis, as will be noted later0 Figure 1 EXPERIMENTAL DESIGN FOR THE NARANGWAL POPULATION AND NUTRITION PROJECTS t … - - - - - - _ HC I CONT-N Child Health Care ' Nutrition Project Control I (Health Care only) (No services) 2 Villages 2 Villages FPEd i FPCC (NUTHC) NUT Family Planning Family Planning IChild Nutrition Care Educatio and Child Care I Education I , I ,(Health Care and (Nutrition only) I Nutrition) X 4 Villages 3 Villages 1 3 Villages FPWS FPWSCC Family Planning Family Planning & and Women's Services Women's Services & Child Care 4 Villages 4 Villages CONT-P Population Project Control (No Services) 4 Villages __ Population Nutrition Project Project - 4 - The project services can be described as follows: o Women's illness care, which included visits or contacts related to women's illnesses usually initiated by ill women or their families and most often occurring in the village clinic. o Women's other care, which included contacts initiated by project health workers through routine home visits to women for fertility surveillance, health education, family planning motivation, and preventive care. o Children' illness care, which included visits or contacts for curative purposes to children of women in the study villages, usually at family initiative and in the village clinic. o Children's other care, which included routine contacts initiated by project health workers for prevention and surveillance (but including early diagnosis and treatment in the home) for children of women in the study villages. o Family planning services and follow-up, which included contacts with both women and men involving the provision of modern family planning methods or the follow-up of users. o Family planning motivation, which included contacts by male family planning workers with husbands of women in the study villages (these contacts involved general rapport generating activities, health related advice, specific family planning and population education, and motivation to use contraceptives)0 The first two categories constituted women's services (WS), the second two children's services (CC), and the third two family planning (FP) and family planning education (ED). Table 1: SUMMARY OF SERVICE INPUTS Kind of service Description of service FAMILY PLANNING Education and motivation Intense educational efforts were provided in FPED villages; education was well integrated with health care delivery in FPWSCC and FPWS villages, and less adequately integrated in FPCC villages. Contraceptive services Condoms, pills, IUDs, injectable Depo- provera, vasectomies, and tubectomies were provided under similar conditions in all experimental groups. Follow-up The same method-specific patterns of follow-up were established for all groups. WOMEN'S SERVICES Monitoring fertility and Routine in FPWSCC, FPWS, and FPCC villages; early diagnosis of pregnancy carried out in simplified fonn in FPED villages. Prenatal and postnatal care Well-developed pattern in FPWSCC and FPWS and supervision of deliveries villages; modified prenatal care provided in done by dais (indigenous mid- FPCC to protect the child. wives) CHILD CARE Periodic health surveillance Weekly monitoring of morbidity status in and education to three years FPCC villages, much less frequent (about every two months) home visiting in FPWSCC villages. Periodic measurement of Routine ranged from every month for weight and height infants to every three months at three years of age for FPWSCC and FPCC villages. Immunization Routine smallpox, OPT, BCG, polio, and measles in FPWSCC and FPCC villages. Nutrition supplementation Selective provision of supplements to mal- and education nourished or faltering children, and education of mothers of all children in FPWSCC and FPCC villages. Diagnosis, treatment, and Early care emphasized in FPWSCC and FPCC referral of illness villages. Note: All services in the health care villages were provided by family health workers, who were auxiliary nurse-midwives with two years' hospital training beyond high school plus an intensive six to eight weeks re- training period in the project. They were supervised on weekly visits by a doctor and by a public health nurse or lady health visitor. Family planning educators were the peripheral workers in the FPED villages. They were village teachers whose training and supervision paralleled the level and intensity of the family health workers. - 6 - A large number of input-output-outcome variables were measured in the many surveys and studies during the project. Detailed data on services were collected to provide a basis for using quantitative measures of services as independent variables in input-output-outcome analysis and for detailed studies of cost-effectiveness. To identify the background factors that lnfluenced project results, many variables were measured. The variables can be categorized as follows: i) demographic; ii) socioeconomic; iii) attitudes and beliefs; iv) family planning knowledge and practice; v) fertility and mortality; and vi) morbidity and growth of children. In evaluating the benefits of integration, three outcomes of the ex- periment were examined: the use of family planning, selected indicators of health, and the decline in fertility0 Three criteria were used to assess the value of services: effectiveness, efficiency, and equity0 Effectiveness was judged by looking at the outcome: for example, whether integrated health and family planning services increased the use of family planning without sacri- ficing health benefits0 I/ Efficiency cost-effectiveness was judged by re- lating outcome to input, equity by examining the dtstribution of services among socioeconomic groups. The results of the Narangwal experience are summed up in the follow- ing table0 1/ Outcome and output can be defined in many ways0 Reduced Infant mortality or fertility are the ultimate outcomes of project services, but there are also such lntermedLate variables as the number and duration of service contacts0 .Similarly, input can be measured in many ways0 Here It is defined as the time of the personnel and the cost of services0 Note that no attempt is made to distinguish the quality of output on the basis of whether services are provided separately or in combination with others0 Nor is the quality of a unit of output distinguished on the basis of who uses it0 - 7- Criteria for Family planning Health Fertility evaluation use improvement decline Effectiveness Yes Yes Yes Efficiency Yes Yes ? Equity Yes Yes ? I turn now to the results. Use of Family Planning The experience of many developed countries shows that with socioeconomic development, there is a decline in fertility because of the greater use of family planning. This does not mean that a fertility decline is possible only through socioeconomic development. Recent experience in China, Sri Lanka, and in the Indian state of Kerala shows that a country can achieve a substantial fertility decline by intervening with family planning programs, even without reaching higher income levels. But socioeconomic development alone will not increase the use of family planning programs. It is therefore important for policymakers to know what kinds of services and what approaches to the delivery of services will increase the use of family planning. Effectiveness The effectiveness of integrated services in increasing the use of family planning was looked at in four ways. The first was to observe changes in the use of both modern and traditional methods during the project (the ever-use rate). This would not exactly capture how much of the change was contributed by the project, which only provided modern methods. So, the second was to observe only the increases in the use of modern methods (the new- acceptor rate of modern method). Acceptance rates do not capture the continuation of use. Therefore, the third was to observe changes in the - 8 - proportion of women contracepting (the continuing-use rate) at a given point of time. The fourth was to observe changes in the methods of contraception (the effective-use rate). - Acceptors of project contraception fall into three categories: those who had used modern contraceptives, those who had used traditional methods of contraception, and those who had not used contraception. The distinctions are important because they show how great an effect the project had. For example, the biggest shift in use was from nonuse before the project to the use of modern methods under the project; the smallest, from prior use of modern methods to the use of modern methods under the project0 The second was merely a shift in the source of supply, but it may also have been a shift to more effective methods0 A comparison of preproject use of permanent, temporary, and tradi- tional methods of family planning is shown for the four experimental groups in table 20 Considering both modern and indigenous methods, the ever-use rates were similar in the villages where family planning services were offered (49.4 percent of eligible women, that is, married women in the age group 15-49) and in those where no family planning services were offered (52 percent of eligible women)0 The ever-use rates in the four experimental groups ranged from 46.4 to 51.2 percent, but the differences were not significant0 The overall preproject use of modern methods was 17.6 percent of eligible women but varied greatly among the four groups: the ever-use rate of modern methods was 26.0 percent in the FPED group, 19.1 percent in the FPWS group, 1801 percent in the control group, 1109 percent in the FPCC group, and 11.7 percent in the FPWSCC group0 Modern contraceptives accounted for about half the prior contraception in the FPED group and more thAn a third in the FPWS group and control groups0 In the FPWSCC and FPCC groups, modern - 9 - contraception was used by only a fourth of those who had practiced family planning, and the use of traditional methods was correspondingly greater. Thus, if the prior use of family planning is considered with its mix of contraceptives, the biggest impact is expected in the FPWSCC and FPCC groups, followed by the FPWS group. The least is expected from the FPED group. Table 2: PREPROJECT USE OF MODERN (PERMANENT AND TEMPORARY) AND TRAD[TIONAL METHODS AMONG EXPERIMENTAL GROUPS FPWSCC FPWS FPCC FPED Method villages villages villages villages Permanent 1.0 5.1 2.8 7.3 Modern-temporary 10.7 14.0 9.2 18.6 Traditional 39.1 29.9 34.5 25.1 None 49.2 51.0 53.6 48.8 Total 100.0 100.0 100.0 100.0 In Narangwal villages during the project, the acceptance (ever-use) rates of modern family planning methods rose to between 51 and 54 percent of eligible women (see figure 2). Those in FPCC and FPED villages rose to 45 and 37 percent. These increases relate to all acceptors. A better indicator of the effect of the project is the new-acceptor rate--for those who used modern methods for the first time as a result of project activities. Cumulative new acceptor rates in FPWSCC, FPWS, FPCC, and FPED villages respectively were 45 percent, 42 percent, 39 percent and 22 percent by the end of the project (see figure 3). In comparing these rates, one has to bear in mind that services started at different times in the - 10 - Figure 2 PERCENT CURRENTLY MARRIED WOMEN AGE 15-49 WHO WERE ACCEPTORS OF MODERN FAMILY PLANNING METHODS AT SPECIFIED POINTS IN TIME BY EXPERIMENTAL GROUP 60 |FPWSC 50 0D~ o Fwsc 10 _ 0 40 J | | 00000000 1 I I _ I t 30 969 1 970 1 97 1 19721973 1974FPCC 40~~~~~~~~~~~~~~~ 0~~~~~~~~~ 10 OoooooOOoOOoO ~ ~ ~ ~ ~ ~ ~ ~ ~ 10 M = March i = June S = September o December World Bank-23899 - 11 - different service groups; FPED services, for example, started nearly two and a half years later than FPWSCC services. These rates are useful, however, to indicate the trend of project acceptance rate and they somewhat modify the picture in figure 2. Cumulative project acceptor rates show that although the overall acceptor rates were higher in FPWS villages than in FPWSCC villages, the present acceptor rates were higher in the FPWSCC villages. In addition, the gap between the curves for FPCC and FPED villages, which widened during the project period in figure 2, remained essentially the same in figure 3. The much greater source-substitution by prior users in FPWS and FPED villages accounts for the differences between figure 2 and figure 3. Figure 3 more accurately portrays the project results. 1/ Figure 3 shows that acceptance curves in all the four groups of villages are roughly parallel, implying that the project succeeded in getting couples to start contraception more or less at the same rate in all the experimental groups. More important, however, is a comparison of trends in continuing-use rates, measured by the proportion of eligible women practicing contraception at a given time. Ftgure 4 presents the fluctuating continuing- use rates in the four experimental groups. A trend line (constructed by fitting quadratic equations to smooth the curves) shows a somewhat different picture (see figure 5). The smoothed curves show that in all the experimental groups except FPCC, the practice rates were still rising. However, the rate of rise in FPED villages was considerably slower. In FPCC villages, even a decline in the practice rate seemed to have started. One possible reason for the observed trend in FPCC villages is that there may be a lag period between 1/ These results at Narangwal are comparable with the achievements in family planning by other experiments and special projects in India. - 12 - Figure 3 CUMULATNVE RATES OF PROJECT ACCEPTORS 0N EXPERDMENTAL GROUPS 60 50 - FPWSCC 00 F PWS 40 -7 0 0r BPC0 w w~~~~~~ 30 o 0~~~~~o L) 0/~~~0 20~~~~~ 0~~~~~~0 19917017 92 9317 M = March J = June S =September D = December World Bank-23900 - 13 - Figure 4 PERCENT CURRENTLY MARRIED WOMEN AGE 15-49 WHO WERE PRACTICING FAMILY PLANNING BY EXPERIMENTAL GROUP 60 50s 40 / FPWS 0 FPWSCC WU 30 F PCC w a.~~~~~~~~~~. 20 Z # / / / a 10 / 0 I A ----ii tii t Ii M J S D M J S D M J S D M J S D M J S D M 1969 1970 1971 1972 1973 1974 M = March J = June S = September D = December WVorld Bank-23901 - 14 - Figure 5 TRENDS IN CONTRACEPTIVE PRACTfCE RATES IN EXPEROlMENTAL GROUPS (Smooth Curve Obtained by Fitting Quadrate) Equations to Continuing - Us' Ratt) 60 50 40 FPWS 0 0 z O I- O Ooo° FPWSCC rr 30 0 z Z 0 g ~~~~~~~~~~~~~~~~~~FPCC w 20 10~~~~~~~~~~~ 20 0 I I I I I I l I I I I ,1I1 I 1 1 M J S D M J S D M J S D M J S D M J S D M 1969 1970 1971 1972 1973 1974 M = March J = June S = September D = December World Bank-23902 - 15 - the use of services and a rise in family planning (because it would take time for the reduced infant and child mortality to have an effect on desired family size). The demographic impact of family planning depends on what kinds of contraceptives are used. 1/ Obviously, the use of condoms or pills cannot be as effective as sterilization. So, further adjustments in contraceptive prac- tice rates are needed. The mix of contraceptives differed greatly for the four experimental groups and changed from beginning to the end (see table 3). Toward the end of the project (1974) almost half those practicing contracep- tion in FPED group were still only using condoms. At the other extreme, more than 40 percent of those practicing contraception at the end of the project in FPCC group were sterilized. The expectations for demographic impact thus are reduced for the FPED group and increased for the FPCC group. The continuing- use rates were adjusted for effectiveness of the methods to give effective-use rates (see figure 6). In general, the integration of family planning and health services helped in the movement from less effective methods to more effective methods. To be considered next is the effect of the various health services on the practice of family planning. This is best done by reviewing results among the different categories of prior practice of family planning. Because prior nonusers of family planning started with the zero practice rates, they showed the greatest increases in family planning practices. Children's other services tripled the use of modern methods by prior users of traditional 1/ The relative effectiveness of various methods (measured by the pregnancy rate of noncontracepting women) was measured as follows: condom, 34 per- cent; oral pills, 28 percent; tubectomy, 97 percent. - 16 - Table 3: PERCENTAGE DISTRIBUTION OF CURRENT USERS OF FAMILY PLANNING, BY METHOD Method FPWSCC FPWS FPCC FPED 1970 1974 1970 1974 1970 1974 1970 1974 Condom 18.0 34.8 20.6 28.7 OoO 30.7 5.5 47.7 Pill 3.8 5.5 1.9 09 000 4o7 00 04 IUD 18.8 8.2 13.5 25.1 OoO 3.3 18.2 7.0 Injectable Depo-provera 308 29.9 27.7 200 00 19.8 1.8 19.4 Vasectomy 9.8 6.7 25.2 13.7 58.6 23.6 32.7 12.8 Tubectomy 18.8 14.9 110 1106 41.4 17.9 41.8 12.9 Total 100 100 100 100 100 100 100 100 methods0 1/ No significant effect was observed among prior users of modern methods0 Similar but less dramatic effects were observed for women's other services0 Children's illness care more than doubled family planning practice rates among prior nonusers. Effects less dramatic but still significant were observed for both children's and women's illness care for other categories of use0 In contrast with other care, illness care for both women and children produced a significant increase in the practice of family planning by prior users of modern methods0 Because these other services were more project- initiated than patient-initiated, the results indicate that services have the potential of being targeted on those who have never used family planning or who have used only traditional methods0 People with prior experience of family planning tended to respond spontaneously to the availability of family planning and health services; therefore, project initiative seemed to be less important for them, and illness care had the greater impact0 1/ See page 4 for a description of illness services and other services0 - 17 - Figure 6 PERCENT CURRENTLY MARRIED WOMEN AGE 15-49 WHO WERE "EFFECTIVE-USERS" OF FAMILY PLANNING AT SPECIFIED POINTS IN TIME BY EXPERIMENTAL GROUP 60 so _ 50_ 40 - cn > 30 L FPWS I- LU we FPWSCC 20 F P Ed 10 - - 0 * a i I I I I I I I I M J S D M J SD0 M J S D M J S D M J S D M 1969 1970 1971 1972 1973 1974 M = March J = June S = September D = December World Bank-23903 - 18 - The project-initiated other services for surveillance and prevention had much more universal coverage and showed less of a direct concurrent rela- tion with the use of family planning than did illness services. The only apparent association was that new recruits to family planning late in the pro- ject seem to have received (somewhat) more children's other services during the period of successful recruitment to family planning. A converse rela- tion--early acceptance of family planning leading to greater use of health services--was not demonstrated. A regression model was used to assess the net effect of services on contraceptive practice. Table 4 presents the results0 The coefficients in the regression equation are small because service inputs are expressed as individual contacts0 The coefficients can be interpreted as approximate in- creases in the percentage of contraceptive users in the population given an increased input of one unit (contact or visit) of service per woman0 In this context, one contact with women's other services is seen to have almost nine times the effect of one contact with children's other services; a visit for women's illness services is about twice as effective as a visit for child's illness services0 But when the effect of services is examined in relation to the mean number of services received, the picture is somewhat different (table 5). If the coefficient for each service variable is multiplied by the mean number of service contacts, the effect of children's other services in the project is shown to be as strong as women's illness services, but still not as strong as women's other services0 Women's other services were assocLated with a 14.4 percent increase in the probability of accepting family planning, compared - 19 - Table 4: MULTIPLE REGRESSION RESULTS: EFFECTS OF THE VOLUME OF SERVICE CONTACTS IN 1969-1973 AND OTHER VARIABLES ON USE OR NONUSE OF FAMILY PLANNING AT ANY TIME DURING THE PROJECT 1969-73 (DICHOTOMOUS DEPENDENT VARIABLE) Regression Level of Independent variable coefficient t-value significance Education of husband .0337 2.1 <.05 Occupation of husband: Labor .0082 0.2 n.s. Farming .0543 1.3 n.s. Other * * * Religion-caste: Jat-Sikh -.0800 1.8 n.s. Ramdasia and other low castes -.0474 1.1 n.s. Other * * * Living children and wife's age: <3 and <35 .1810 3.4 *.001 <3 and >35 * * * >3 and <35 .2568 4.4 <.001 >3 and >35 .0885 1.7 n.s. Number of children dead -.0234 1.6 n.s. Awareness of modern contraception -.0296 0.6 n.s. Prior use of contraception .0704 3.5 <.001 Belief about child mortality .0112 0.7 n.s. Talk with husband .0671 2.4 <.02 Attitude toward family planning: Approval .0799 2.1 <.05 Uncertain * * * Disapproval .0307 0.8 n.s. Service contacts: Women's illness .0026 5.0 <.001 (1969-1973) Women's other .0071 5.8 <.001 Children's illness .0012 2.7 <.01 Children's other .0008 4.8 <.001 Male motivation -.0025 0.9 n.s. R2 , 0.24 * Suppressed category; effect included in constant term (-0.0373). n.s. = not significant (p >.05) - 20 - Table 5: MEAN NUMBER OF SERVICES AND ASSOCIATED REGRESSION COEFFICIENTS FROM THE REGRESSION ANALYSIS IN TABLE 4 Mean number (B) x (X)* Beta Service variable of contacts (X) Coefficients (B) x 100 coefficients (X) Women's illness 1801 oO026 4.7 0.1472 Women's other 20.3 oO071 14.4 0.1729 Children's illness 21.6 oO012 2.6 0.0866 Children's other 60.3 o0008 4.2 0.0973 *?~ Estimated percentage increase in likelihood of family planning acceptance with average services use. - 21 - with an increase of somewhat less than 5 percent associated with women's illness and children's other services. In this case the relative importance of the variables in explaining differences in contraceptive use is about the same as the ranking of the "t" values (table 4) and the beta coefficients, normalized coefficients that take into account differences in standard deviations of the variables (see also table 5). Di ;'tn: Combined and integrated services for health and family planning were more effective in getting women to practice family planrilig than were services for family planning alone. But integrated services (FPWSCC) were less effective than one of the two combined services (FPWS). Of the health services, women's services were more effective than children's services in getting women to practice family planning. That may explain why the services in FPWS villages were more effective than those in FPWSCC villages. Efficiency Integrated health and family planning services at Narangwal were efficient because, by combining various activities in a single visit, economies were significant in both time and money. In addition, because the combinations made sense in the village home, there appeared to be more rapport and greater changes in behavior. By the last year of the project (1974) the input of family planning workers and family planning educators averaged six to eight hours of direct service time a week. For family planning activities the weekly distribution of time was 37 minutes in FPWSCC villages; 57 minutes in FPCC villages; 83 minutes in FPWS villages; and 249 minutes in FPED villages. The time taken to maintain friendly relations and rapport took 113 minutes in FPED villages, - 22 - compared with 43-49 minutes by family health workers in the other experimental villages. Further evidence on the relative increase in efficiency is provided by the time per average service contact in 1973-74, which was shortest where integration was greatest: 4.4 minutes in FPWSCC villages; 5.7 minutes in FPWS villages and FPCC villages; 14.3 minutes in FPED villages. When time per family planning contact was estimated separately, the averages were found to be about 4 minutes in FPWSCC villages, 8 minutes in FPWS villages, 19 minutes in FPCC villages, and 16 minutes in FPED villages. What was the relative cost-effectiveness of different service packages? The cost per new family planning acceptor was $12.27 in FPWSCC villages, twice that amount in FPWS villages, three times that amount in FPCC and FPED villages. The cost per couple-year family planning was $1027 in FPWSCC villages, 1.7 times that amount in FPWS villages, 2.5 times that amount in FPCC villages, and three times that amount in FPED villages0 The cost per family planning contact was $051 in FPWSCC villages, $077 in FPWS villages, $1.45 in FPED villages, and $1.92 in FPCC villages0 The cost in FPWSCC villages approached the 1968-69 cost per family planning contact in the government's primary health centers ($033). One explanation for the FPCC contacts being least efficient is that family planning services in these villages were started several years after child care services had been well established, thus requiring a big readjustment in the work patterns of family health workers0 It appears that child care services will be always somewhat more difficult to Integrate with family planning services than with women's services0 But when family planning was combined with both women's and children's services, family health workers made much more efficient use of their work time. - 23 - Equity There were significant differences in preproject rates of ever-use of modern contraceptives among religion-caste groups, among education groups, among occupation groups, among age groups, and among family-size groups (table 6). The general pattern was that people of higher caste, higher education, higher occupation, and larger family size groups had greater rates of contraceptive use. The group aged 25-34 had the highest rate, the group under twenty-five the lowest. The differences in rates of contraceptive use during the project became less significant than the differences in preproject use. The exception was the age of wife: there was a reversal of the difference between the youngest (under twenty-five) and the oldest (over thirty-five). The reversal, which was demographically more advantageous, was so great that the age difference became even more significant than the preproject difference. Couples recruited by the project were from three prior-use categories: users of traditional methods, users of modern methods, and nonusers. There were no socioeconomic differences in acceptors recruited from preproject users of traditional methods and of modern methods. More important than eliminating differences in the recruitment of prior users was narrowing differences among new recruits. The sociodemographic characteristics of new recruits were distinctly different from those of preproject users: the low-caste group had a recruitment rate greater than did the high-caste group. Differences by the occuipation of the husband, highly significant for preproject users, were eliminated. Education of husband maintained the same pattern of distribution as that for preproject users, with higher education being associated with - 24 - Table 6: PREPROJECT USE (MODERN, TEMPORARY, AND PERMANENT METHODS), PROJECT USE RATES, PROJECT RECRUITS FROM NONUSERS AMONG SOCIODEMOGRAPHIC GROUPS Preproject users of modern, temporary, and Percentage Sociodemographic permanent method Project users recruited by project group (percent) (percent) from nonusers Religion-Caste: Jat-Sikh 20.6 45.8 32.4 Sch-Sikh 12.9 47.0 38.9 Others 18 4 X2 = 21.88 47.5 x2= 049 35.6 x2= 5001 (2) (2) (2) p =