**_Regina_** _McNan_ **_-.- a et_** _al._

_2_ supported by evidence from other parts of the worle where organized programs do make a contribution to contraceptive prevalence, over and above the influence of education, urbanization and other socioeconomic variables (Mauldin and Berelson, 1978; Lapham and Mauldin, 1985) and by evidence from Zimbabwe, Kenya, and Zaire, among others (Ross, 1990). Although the sub-Saharan efforts have been for the most part relatively small-scale, and were launched with resources not easily duplicated, they demonstrate the possibility of an unequivocal positive response.

Contraceptive prevalence levels (modern methods) barely reached one percent in Rwanda in the early 1980s, and did not reach five percent in Ghana or the Sudan (Ross et al., 1988).2 Family planning program efforts were weak or very weak, according to the Lapham and Mauldin (1985) measurements of family planning program efforts ir 1982. Lapnam and Mauldin define three major components of program effort: policies, resources and stage-setting activities; service and service-related activities; and record keeping and evaluation. These three make possible the fourth component, availability and accessibility of supplies and services. Scores on individual components, based on a 30-item scale, are summed for the total program effort. Out of a possible program effort total of 120, Ghana scored 21.3, Rwanda 27.6, and the Sudan 9.0. Table I shows the Lapham and Mauldin country scores and their percentages of maximum possible scores. For comparison with countries at similar development levels according to World Bank ranking (World Bank, 1990, Table 1), Niger and Kenya are shown with Rwanda, Benin and Lesotho with Ghana, and Mauritania and Senegal with the Sudan. These juxtapositions do not reveal any association of development level with program effort.

Rwanda's 52 percent of the possible maximum score for policy and stage setting is notable, yet the availability of services and supplies is scarcely better than that of the Sudan which is much weaker with respect to policy. The situation in Ghana is similar to Rwanda; a score for policy which is relatively good compared with other sub-Saharan countries, and barely perceptible service delivery (as of 1982).3 Family planning programs in these settings, especially new programs, need time to build scale and momentum before fertility change is a useful indicator, but from the outset service statistics and qualitative investigations of service organization and community attitudes are essential tools to reveal program processes and outcomes. These have been used extensively for the evaluation of the Rwanda, Ghana and Sudan projects, supplemented by contraceptive prevalence estimates where community surveys were feasible. In the early program stages, when acceptability of modern methods of contraception and service management skills are still untested, qualitative measures of program continuity and institution building to enlarge capability, such as those cited by McIntosh for programs in India (1989), are also pertinent. The Indian programs

> 2 Modern methods as defined in this paper include oral contraceptives, injectable progestogen, implants, spermicides, condom, 1UD, diaphragm, and male and female sterilization.

'A global assessment of family planning programs in 1989 indicates substantial change in seven years in Ghana and Rwanda. Ghana has reached the 'Moderate<sup>T</sup> category; Rwanda is still Weak, but is giver. 43 percent of the possible maximum score in 1989, compared with 23 percent in 1982. Ghana's percentage of maximum possible total effort score increased from 18 percent to 52 percent. The Sudan, while remaining in the Very Weak or None category. increased from 8 percent to 20 percent in percentage of total maximum score for program effort (Ross et al., 1992).