equivalents to CYP as outcome measures for reproductive health services other than family planning? A Reproductive Health Indicators Working Group, with subcommittees on safe pregnancy, breastfeeding, maternal nutrition, safe abortion, and HIV and sexually transmitted diseases, is at work under the auspices of the EVALUATION Project funded by the Agency for International Development, but it is unlikely to propose one or even a small set of measures comparable to CYP for family planning. Jain and Bruce (1994) have proposed an indicator that takes into account reproductive intentions, rather than just contraceptive use, as an outcome of a successful program, but this would still leave some goals of comprehensive reproductive health services uncovered.
Family planning programs have multiple goals, making it hard to measure effectiveness or efficiency with one ratio. But as Mark Montgomery pointed out, this situation is hardly unique to family planning; health economists have developed methods for looking at cost functions when there are joint outputs (for example, teaching and patient care as joint outputs of hospitals).
THE POLITICAL SETTING FOR DECISIONS ON FAMILY PLANNING
The relationship between donors and recipient governments is a complicated one. Both have goals other than maximizing the outputs of the family planning program, and they face different constraints and incentives. Although donors may designate aid for particular projects or sectors, this may have little effect on overall sectoral allocations, since the domestic resources freed by the provision of external aid to one sector may be invested in another. The incremental effect of aid allocations to a sector (such as family planning) on the total availability of public funds (local and foreign) for the sector depends on such factors as the percentage of aid in the government's budget and the effectiveness of aid conditions (Pack and Pack, 1993).
The history of donor-recipient negotiations over health sector reforms is instructive. Michael Reich argued that governments often act as agents of private interests, including service providers, and as agencies that seek to retain power. Governments find it difficult to withdraw subsidized services, because people become accustomed to the benefits and can exert influence to sustain the services. Political and organizational analysis is therefore required to improve the feasibility of any effort to reduce subsidies or target popular services. Reich criticized the vague use of the term political will, for example in the 1993 World Development Report (World Bank, 1993), as being too close to a tautology: since the evidence that a government had the political will to do something is often just the fact that it did it, political will of course appears to be an essential precursor to all change (Reich, 1994a). Reich called for more analytical attention to the role of particular politically effective groups—political leaders, civil servants, health care providers, and consumers—in policy choice and implementation.
