(1973-1979): FAMILY PLANNING MONITORING (FPM) IN PLAN .(1982-1986) FOR THE NEXT FIVE-YEAR FINDINGS AND IMPLICATIONS

DU PLANNING FAMILIAL (SPF) EN AISIE(1973-1979): SURVEILLANCE LE PLAN QUINQUENNAL (1982-1986) OBSERVATIONS ET IMPLICATIOMPOUR

Roger P. Bernard et A. Charffedine

and Prevalence) Trends of (Incidence An Inquiry into the of Protection and Fertility des (Incidences et Pr~douinances) Une Etude des Tendances de Protection et de Fgcondit6

the Bilateral 1980, subsequent to developed in April, Program in Keport of the National Family ONPFP/USAID Evaluation (Phase 2). 1) and in March, 1980 October, 1979 (Phase lI1valuation 1980, , ia suite de Effectu&e en Avril, par une mission Etude de Planning Fanilial du Programme National 1) et en Mars, 1980 Octobre, 1979 (phase Tuniso-Amricaine en (phase 2).

Fertility Research Program, Epidemiology, International |Director of Field Switzerland. for Family Health, Geneva, International Federation and Division de Recherche, Surveillance Epidemiologique, Tunisie. 2Chef de Section de de la Population, , Planning Familial et Office National du RESUME/ ABSTRACT

Cette etude propose un examen approfondi des r6sultats obtenus par 1'ONPFP durant les premieres sept ann~es de son existence (1973 - 1979).

L'approche m~thodologique est, par excellence, celle de l'6pid&aniologie anajXji3,S: la predominance de protection effective (PPE) ainsi que 1'inci­ dence du nouvel apport (INA) de planning familial sont 6tudiges dans le temps (une sequence de sept annes) et dans l'espace (18 ou 15 entit~s g~ographiques: les gouvernorats) pour en d~river le potentiel d'impact selon les mfithodes. De mime, "l'oeil Gpid~miologique" prend sous sa loupe la tendance de ffconditd par age pour en crystalliser un reservoir A grand potentiel pour l'action de PF.

(1) L'6tude des tendances de l'ventail des m~thodes (incidence) au niveau du gouvernorat permet alcrs de proposer une meilleure repartition des mithodes de PF pour augmenter tr~s sensiblement l'impact d~mographique du programme na­ tional durant le prcchain plan quinquennal (1982-1986). Une piriode de transi­ tion de deux ans (1980-1981) est jug~e n~cessaire et suffisante pour l'adapta­ tion a un r~gime d'incidences qui menerait A cette nouvelle repartition. La composition de l'6ventail des m~thodes va subir un enrichissement autant quali­ tatif que quantitatif en introduisant - petit A petit - les injectables et en favorisant une evolution naturelle de la composition de l'6ventail des m~thodes vers les m~thodes a rendement d~mographique plus consequent. L'equilibre du nouvel apport annuel atteint A la fin du plan quinquennal serait alors comne suit: 20% de m~thodes secondaires, 30% de pilules,30% de D.I.U. et d'injectables, et 20% de ligatures des trompes (Fig. 19). Les avortements sociaux 6volueraient sans avoir fix6 des objectifs - t~moignant ainsi de l'efficacitg du programme.

(2) L'6tude des tendances de f~condit6_pa _-e (incidence) a d~montr6 l'existence actuelle d'un tr~s grand reservoir de femmes mariges, dans leur trentaine et quarantaine, A risque glevk de voir Eontinuer leur ffcondit6 bien qu'elles soient, pour la plupart, des grandes multipares dont les risques accrus pour la santg de famille (mare et enfant) sont 9 red~montrer aussi en Tunisie (Etude genre OMS: sant6 familiale). La convergence de ces deux risques reels justifie amplement la "m~dicalisation du PF" en introduisant en prioritg les injectables et les ligatures des trompes comme une prestation de routine dans chacun des 18 gouvernorats. Il n'y.a pas tache plus grande que de garantir la mise en place de ces prestations au niveau regional durant 1980 et 1981 (Fig.23).

i (3) L'tude des tendances de pridominance de protection effective (PPE) a permis de constater un arr-t du progres de Za protection durant l'annie 1979 pour I Tunisie entiare; l'analyse gfographique montre que cela est le rfsultat d'volutions opposges au niveau regional. Trois gouvernorats ont vu leur taux de protection augmenter de plus de 1% des FMAR: , et . Suivent alors quatre gouvernorats avec un accreissement de 0.5-0.9%: , Bgja, Le Kef et Monastir; tandis que les cinq gouvernorats suivants ont subi un accroissement minime (0.03-0.25%): , , , Gabas et . Par le recul de leur niveau de protection g~n~r~e A travers les ann~es par le programme national de PF, les 6 gouveruorats suivants ont r~ussi a neutraliser le peu d'avance enregistrg durant 1979: SfaxV Medenine _ Tunis, , et . A eux seuls, ils groupent 46% des FMAR. Cette observation montre bien que le programme national de PF doit accentuer ses efforts autant dans les grandes villes que dans le rural. Un programme postpartum bien fourni devrait aider a surmonter assez rapidement les creux qui se tranchent actuellement A Tunis et A , parmi d'autres (Fig. 5). La mise en place d'un syst~me de surveillance des soins de maternit6 (SSM) permettra - parmi d'autres considerations - de quantifier l'apport nouveau de PF dans les institutions par rapport au d~nominateur de l'obst~tricien: le nombre d'accouchements. Les maternitds cnt besoin de"leur 6tude apidamioloque",

(4) L'6tude des predominances de protection effective au niveau rgional rdvale une tr~s faible protection pour les gouvernorats de la Tunisie centrale et la Tunisie eL sud (Figs. 2,3 et 4). L'6tude des tendances d'incidence par m~thodes montre par ailleurs que l'apport A travers les ann~es a 6t6 g~ngrale­ ment faible (S~rie des Fig. 9, en annexe). Il est 6vident qu'un apport substan­ tiel dans ces gouvernorats devra se planifier dans le contexte d'un programme de santg rurale a mettre sur pied sans attardement. L'aide bilat~rale a ici une occasion unique puisque les besoins ont ftg identifi's avec une precision fpidimiologique exceptionnelle. Le d~fi est de concevoir et aider a r~aliser en commun un projet combinant les aspects essentiels de la "sante de famille et de reproduction" -- les deux 6lments 6tant inextricablement lids.

(5) Ce n'est que par le truchement d'un d~nominateur commun (les femmes marines en age de reproduction: FMAR) que ce v6ritable tissu d'6tudes 6pida­ miologiquesa vu se tisser en un temps record. La surveillance mensuelle du programme national de planning familial devient assez sophistiquie, puisque

ii l'Office a su se procurer les num~rateurs par mithode et r~gion, ainsi que les d~nominateurs A travers le temps. Uue ire nouvelle s'ouvre donc sur son deuxi~me septennat de travail ardu pour favoriser une p~n~tration iquitable de 1'action du PF A travers la Tunisie toute enti&re. La mise a jour systiatique des profils 6pid~miologiques permettra de mieux saisir la nuance de l'effort n~cessaire pour garantir un progres reel dans chaque gouvernorat. Au moins deux fois par an une revue totale de l'volution du programme de PF au niveau regional devient maintenant la rgalitg op~rationnelle la plus promettante. Le programme est devenu transparent a ses propres points forts et faibles. L'analyse 6pidgmiologique continue sera le meilleur garant pour le progras optimal du programme national puisqu'elle agit comme agent promoteur au niveau regional.

(6) Une des finalit~s de la surveillance 2 idmiologigSu du programme national de planning familial est de determiner ce qui est possible a r~aliser dans le cadre d'un systame grandissant,essentiellement mis en place durant le premier septennat de l'Office. Cette i~trospection quantifige mine A prouver ce que les dirigeants de l'Office avaient commencA a percevoir il y bien des annges: que la m~dicalisation du planning familial -- la responsibi­ lisation du mndecin -- doit n~cessairement intervenir pour mener le programme national a ses potentiels reels. Il faut bien le souligner, l'aspect quantitatif n'est pas un but en soi. C'est la m~dicalisation du programme qui va enfin permettre a la "sant6 familiale" de se d~ployer professionnellement A travers tout le r~seau de la santg publique. De la surveillance du programme de PF A la surveillance des soins de maternitg il n'y a qu'un petit pas de technicit6: le d~nominateur commun (FMAR) est soumis 5 un 6chantillonage biologique: le souci de prevention et curatif se dirige surtout vers les femmes ensceintes qui accouchent et allaitent parmi toute les fermnes mariges en 5ge de reproduc- tion.(FMAR). Le m~decin penche son regard sur ce sous-groupe a haut risque. Une des grandes taches nouvelles de l'Office est donc de soutenir de plus en plus les facult~s de m~decine et le minist&re de santi dans une recherche ardue et par lune surveillance des soins de maternit& -- allant du dab-it de la grossesse jusqu'a la fin de l'allaitement en passant par l'accouchement -­ afin de garantir l'6valuation continue de la santg de famille dont le planning familial n'est qu'un volet - bien que l'un des plus importants. Ainsi, la surveillance du programme de'PF apparalt comme le premier pas vers une surveil­ lance plus large; aussi la surveillance des soins de maternitg apparatt coimme l'extension naturelle d'un processus mis en route par l'Office A travers le pays.

*iii (7) Le caractare mixte, bilingue, de cette mission tuniso-am6ricaine d'6valuation a pos& - une fois de plus, hnlas - le problame de communication et de comprehension mutuelle, en particulier lorsqu'il s'agit de mettre sur papier les observations et recommandations. En outre, ce travail d'analyse et de synch~se se propose d'aller bien au delA d'un rapport A ranger dans la biblioth~que. II s'agit d'aurirunefaonde.penser et de travailler qui genere des solutions tout au long de l'6volution d'un programme dont la phase actuelle n'est que transition. Nous traitons d'un seul elan toute une s~rie de questions dont chacune est en fait une 6tude p'articuli~re dans un contexte complexe dans le temps et dans l'espaze. (1) "Oi avons-nous abouti aujourd'hui?" est traitg par la protection actuelle; (2) "Oue faisons-nous aujourd'hui?" est trait6 par l'apport nouveau de protection; (3) "L'6ventail des m~thodes influe-t-il sur la protection d~mographique ult~rieure?" trouve une reponse par une comparaison de la predomi­ nance de protection et l'incidence des m~thodes A travers le tempt; (4) "A quelle vitesse faut-il d~velopper le "progr~s" des incidences d'apport pour chaque m~thode?" doit trouver une rdponse dans l'6volution du passe pour chaque m6thode dans chaque r~gion, c'est-A-dire dans une 6tude des m~thodesdans le temps et dans l'espace; (5) "Quels sont les groupes prioritaires de population A atteindre dans un programme de PF visant a un impact d~mographique precoce ?" trouve sa r~ponse dans l'6tude des tendances des taux de fdconditg par 2ge: un r~servoir important de femmes a double risque nifaste fut identifi6 (Fig. 23); etc. De r~pondre ce tissu de questions d'une mani~re coh~rente et en se basant sur les faits n'est possible qu'imm~diatement apr~s une telle mission a 6changes de vues et d'informations multiples et en profitant pleinement du privilhge d'acc&s aux donnges fiables et des plus r~centes. D'oa la responsabilit6 accrue de partager tout ce qui semble faire sens lors d'une synthase ipidemiologique. Mais il y a aussi apprentissage-c6ntinu et il importe de donner les 6tapes. Une telle esquisse m~thodologique demande documentation succersive. Il nous a paru que le trait d'union entre membres de la mission mixte et les collagues a diverses sp~cilisations est l'image scientifiSue, le graphique. Un grand soin a 6t6 appliqug l'Alaboration de ces 38 (23+15) graphiques document~s; c'est la vraie structure de ce travail et ayant comme point de depart une "mini banque des donn~es". Ces grapLiques et 10 tableaux en content bien plus que le texte en serait capable

dans une version frangaise ou anglaise. Les perceptions sont plus nuanc~es ' partir d'une exposition permanente et continue des faits et des options esquissies. Par ailleurs, la liste des figures ainsi que celle des tableaux ont 6t6 donng dans les deux langues. iv TABLE OF CONTENTS / SOMMAIRE

Abstract/Rgsum I... Table of Contents/Sommaire v List of Tables/Les Tableaux vi List of Figures/Table des Figures vii Glossary/Glossaire x Considerations/Considerations xi Page

1. Introduction ...... 1 2. Materials and Methods ...... 6. *.00...... 3 3. Findings ...... 5 32 Evolutionof Protection: public vs private ...... 3.2 Prctection Prevalence, by Gouvernorat and Method: Recent Trend. 8 3.3 Evolution of Family Planning Incidence, by Method ...... 19 3.4 Evolution of FP Incidence, by Method and Gouvernorat ...... 23 3.5 Link of Incidence and Prevalence of Tubal Ligation, by Region.. 33 3.6 Evolution of FP Incidence: Monitoring by Cumulative Trend Study'37 3.6.1 January 1980 vs earlier Januaries ...... 37 3.6.2 January, February, March, single and combined ...... 37 3.6.3 First Quarter, First Semester and Entire Year ...... 41 4. Objectives for Five-Year Plan ...... 46 4.1 Incidence of Family Planning Input, Past and Future ...... 46 4.2 Method Mix, Past and Future ...... 53 4.3 National Work Day Performance, Past and Future ...... 55 The "Ligation-to-IUD" ratio, by gouvernorat 5. Demographic Impact ...... 6] 5.1 Rise of Incidence of Couple Years of Protection (CYP) ...... 61 5.2 Prevalence of Contraceptive Non-Protection ...... 62 5.3 Evolution of Marital Fertility ...... 62 5.4 Trend of Age-specific Fertility: ...... 62 Identification of a "reservoir" for FP Acknowledgements ...... 0...... *...... 65

References ...... 66 Appendix: Figures 9-1 through 9-15: FP Incidence Trend, by Method and Region ...... 67-83

v TABLEAUX / LIST OF TABLES page

I. Predominance de Protection Effective (PPE) au dfbut des annies 12 1979 et 1980, par Rgiou. Tendances. Effective Protection Prevalence (EPP) at the Beginning of 1979 and 1980, by Region. Trend. II. Predominance de Protection Effective par Ligatures des Trompes ( 14 PPE/LT) au debut des annges 1979 et 1980, par Region. Tendances. Effective Protection Prevalence by Tubal Ligation (EPP/TL) at the Beginning of 1979 and 1980, by Region. Trend. III. Incidence du Nouvel Apport de PF (INA),par M~thode. 1973-1979. 18 Incidence of New Acceptance of FP (INA), by Method. 1973-1979. IV. Variations du Nouvel Apport de PF, par Mithode. 1975-1979. 19 Variations of New Acceptance of FP, by Method. 1975-1979. V. Tendance de Nouvelle Activit6 de Planning Familial (INTAPF), 26 par Region. 1974-1979. Trend of New Family Planning Activity (IN-FPA), by Region. 1974-1979. VI. Tendance des Ligatures des Trompes (IN/LT), par Rigion. 1974- 30 1979. Trend of Tubal Ligations (IN/TL), by Region. 1974-1979, VII. Analyse des Tendances pour les Mois de Janvier de 1973 a 1980. 36 Incidence de Nouvelle Activitg de Planning Familial (IN-APF), par Mdthode. A complhter. Trend Analysis by Time Fenestration: Eight Consecutive Januaries. 1973-1980. Incidence of New FP Activity (IN-FPA), by Method. VIII. Analyse Cumulative des Tendances (ACT), par M~thode. 1979 et 39 1980, Janvier,F6vrier, et Mars. incidence de Nouvelle Actvit6 de Planning Fanilial (IN-APF), par M~thode. A compldter. Cumulative Trend Analysis (CTA), by Method. 1979 eL 1980, January, F~bruary, and March. Incidence of NewFamily Planning Activity (IN-FPA), by Method.

IX. Analyse Cumulative des Tendances (ACT), par Mfthode. 1973, 1975 42 1977, 1979 (et 1980). Incidence de Nouvelle Activit6 de Planning Familial (IN-APF), par M~thode. A complEter pour 1980 a 3, 6, et 12 mois. Cumulative Trend Analysis (CTA), by Method. 1973, 1975, 1977, 1979 (and 1980). Incidence of New Family Planning Activity (IN-FPA), by Method. To be completed for 1980 at 3, 6, and 12 months. X. Nouvel Apport de PF, par Annge et Mgthode pour Trois P6riodes: 47 Le Pass6 (1974-1979), Le Present (1980-1981) et le Futur (1982­ 1986). Les Objectifs pour le prochain Plan Quinquennal. Incidence of New Family Planning Acceptance (IN-FPA), by Calendar Year and Method for Three Periods: Near Past (1974-1979), Present (1980-1981), and Near Future (1982-1986). The Objectives for the Next Five-Year Plan.

vi TABLE DES FIGURES / LIST OF FIGURES page

Figure 1. Tendance de Pr&dominance de Protection Effective (PPE) dans 7 les Secteurs Public et Privi. A compl~ter en mars 1981. Trend of Effective Protection Prevalence (EPP) for the Public and Private Sector. To be completed in March 1981. Figure 2. Predominance de Protection Effective (PPE), selon M~thode de Planning Familial et Region; au Ier Janvier, 1980. 9 Effective Protection Prevalence (EPP) , by Method and Region for 1st January, 1980. Figure 3. Pr6dominance de Protection Effective (PPE), selon M~thode de 10 PF et Rggion; au ler Janvier, 1979. Effective Protection Prevalence (EPP), by Method and Region for 1st January, 1979. Figure 4. Predominance de Protection Effective (PPE) pour Toutes Mathodes, 11 selon Region; au ler Janvier, 1979. Carte de Tunisie. Effective Protection Prevalence (EPP), for All Methods combined, by Region, for Ist January, 1979. Map of Tunisia. Figure 5. Tendance R~cente de la Predominance de Protection Effective 16 (PPE), selon M~thode de PF et Rggion. L'6volution durant 1979. Recent Trend of Effective Protection Prevalence (EPP), by Method and Region. Evolution during 1979. Figure 6. Tendance R~cente de l'Incidence de Nouvelle Protection, par 20 Mgthode de PF. 1975-1979. Mise- -jour d'une ancienne Figure. Recent Trend of Incidence of New FP Acceptance, by Method. 1975-1979. Updating of original chart of October, 1979. Figure 7. Cumulation de l'Incidence de Nouvelle Protection et des Avorte- 21 ments Sociaux. 1975-1979. Mise-a-jour d'une ancienne Figure. Taux de Fgcondit6 Nuptiale, 1975-1978. Tendance. Cumulation of Incidence of New FP Acceptance and Social Abortion, 1975-1979. Updating of an original chart of October, 1979. Marital Fertility Rate, 1975-1978. Trend Study. Figure 8. Comie Figure 6, mais calcul6 sur la base des 6 premiers mois 22 (ler Semestre), 1975-1979: Analyse predictive des tendances. Ancienne Figure, pr~parde durant la premiare phase d'6valuation. Like Figure 6, but based on the first six months only, 1975­ 1979: Predictive Analysis of Trends.

Figure 9. Tendance des Incidences, y-compris les retraits de DIU et Avorte- 24 ments Sociaux, 1974-1979. A completer en mars, 1981. Tunisie. Trend of Incidences including Removal of IUDs and Social Abor­ tions, 1974-1979. To be completed in March, 1981. All-Tunisia. Figure 9-1 Sousse IN-APF / IN-FPA 1979 168.7/1000 FMAR,MWRA 69 Figure 9-2 Gafsa 1135.4 70 Figure 9-3 Tunis 1134.2 " 71 Figure 9-4 Bizerte " 130.9 72 Figure 9-5 Monastir 121.3 73 Figure 9-6 Nabeul " 117.0 74 Figure 9-7 Le Kef " 115.8 75 Figure 9-8 Sfax 113.9 76 Figure 9 Tunisie 104.6 (24)

vii page Figure 9-9 Baja IN-APF / IN-FPA 1979 96.6/1000 FMAR/MWRA 77 Figure 9-10 Gabes 93.3 " 78 Figure 9-11 Jendouba " 87.3 " 79 Figure 9-12 Kasserine 81.0 80 Figure 9-13 Mahdia 77.3 " 81 Figure 9-14 Medenine " 63.2 82 Figure 9-15 Kairouan 39.0 83 Figure 10. Nouvelle Activitg de Planning Fanilial, selon Rigions; Tendance 27 1974-1979. A complter -en mars, 1981. New Family Planning Activity, by Gouvernorat; Trend 1974-1979. To be updated in March, 1981. Figure 11. Ligature des Trompes, selon R6gions; Tendance 1974-1979. A 31 complhter en mars, 1981. Tubal Ligations, by gouvernorat; Trend of Incidence 1974-1979. To be updated in March, 1981. Figure 12. De l'Incidence des Ligatures des Trompes A la Predominance de 32 Protection Effective due aux Ligatures des Trompes (PPE/TL). Analyse par region pour !a p~ri6de couvrant les annes 1974 A 1979. Point de depart pour fixer les objectifs en tnt que taux; From Incidence of Tubal Ligation to Effective Protection Pre­ valence due to Tubal Ligation (EPP/TL), by gouvernorat for the period 1974-1979. Pragmatic basis upon which to build target rates. Figure 13. De l'Incidence des Ligatures des Trompes a la Predominance de 34 Protection Effective due aux Ligatures des Trompes (PPE/TL). La part revenant aux Ligatures des Trompes parti toutes les mthodes. Analyse par region pour la pdriode couvrant les annes 1974 A 1979. Observation: Effet important de I'I/LT sur la PPE/TM. From Incidence of Tubal Ligation to Effective Protection Pre­ valence due to Tubal Ligation (EPP/TL), by gouvernorat for the period 1974 to 1979. The ligations' share among all methods. Finding': Small incidence share produces great protection share. or: The I/TL greatly affects the EPPIAM (AM=All Methods). Figure 14. Analyse des Tendances pour le seul mois de Janvier. 1973-1980. 38 A mettre a jour en Fvrier, 1981. Trend Analysis of Incidences by Time Fenestration: Eight Con­ secutive Januaries: 1973-1980. To be completed in February, 1981. Figure 15. Analyse des Tendances du mois de Janvier au mois de Fgvrier, 1980. 40 Observation: Revirement de la courbe d'incidence durant Fe'vrier. Trend Analysis from January to February, 1980. Finding. Reversal of Incidences during the month of February. Figure 16. Analyse Cumulative des Tendances (ACT) .pour trois methodes de PF. 44 de 1973 A 1979. Trois revues annuelles (pour 3,6,12 mois). Greffage d'objectifs raisonnables ta'.crisants l'impact d~mographique. Cumulative Trend Analysis (CTA) for Three Methods of FP (Surgical) for the First Seven Years of ONPFP's Operation. Three points in time (3, 6, 12 months). Grafting of reasonable target rates. To be updated in March, 1981. Figure 17. Planification des Incidences pour 1980, bas6e sur les Incidences 45 obtenues pour les annges 1979 et 1977. Annie de r~f~rence: 1977. Target Setting of Incidence Rates of FP Methods for 1980, based on rates obtained in 1979 and 1977. Reference Year is 1977.

viii page

Figure 18. Incidences . PF V~cues et Projeties, par Mgthode, pour Trois 48 Pfriodes: 1. Le Pass6 (1974-1979); 2. Le Present (1980-1981); et le Futur (1982-1986). Les Objectifs pour le Prochain Plan Quinquennal. Taux pour 1000 FMAR. Past and Projected Incidences, by Method, for Three Periods: 1. Past (1974-.1979); 2. Present (1980-1981); and Future (1982­ 1986). The Objectives of the Next Five-Year Plan. Rates per 1000 MWRA. Figure 19. Eventail des Mgthodes pour l'infornation de la Figure 18. 50 De 1974 a 1986. Repartition en Pourcentage. Plan Quinquennal. Method Mix Profile for the Information of Figure 18. From 1974 to 1986. Percent Distribution. Five Year Plan.

Figure 20. Nouvel Apport de PF par "Journ~e Nationale de Travail" pour 52 Trois MNthodes (Pilules, D.I.U. et Lig. des Trompes) pour l'information de la Figure 18. De 1974 A 1986. Nombre de Nou­ velles Acceptantes per "jour". Plan Quinquennal. New Acceptance of FP per All Tunisia National Work Day,- for three Methods (Pills, IUD, and Tubal Ligation) for the Informa­ tion of Figure 18. From 1974 to 1986. Five Year Plan. Figure 21. Incidende de Trois Mgthodes de PF (INA), par region, pour 54 l'Annge 1979. Etude du rapport "Lig.Tr./(Lig.Tr.+ DIU). Incidence of Three FP Methods (INA), by Region for the Year 1979. Study of the ratio "Tub. Lig./(Tub.Lig. + IUD)". Figure 22. Incidence de Protection par DIU et Lig. des Trompes pour l'In- 60 formation de la Figure 18. De 1974 A 1986. Ann&es de Protection de Couple (APC). Plan Quinquennal. Incidence of New Protection by IUD and Tubal Ligation for the Information of Figure 18. From 1974-1986. Couple-Years of Protection (CYP). Five Year Plan. Figure 23. Tendance de Fgcondit6 par Age de 1960/1965 a 1976. Apparition 63 d'un R~servoir de FMAR agnes de 30+ annees qui pourrait tre la population cible pour les m~thodes miodernes de PF. Trend of Age-specific Fertility from 1960/1965 to 1976. Deli­ neation of a great Reservoir of MWRA aged 30+ years which could and should be a. target population for modern methods of family planning.

'FT GLOSSAIRE / GLOSSARY

PF Planning Familial ... FP Family Planning

Surveillance ... Monitoring (Surveillance)

SPF Surveillance du Planning Familial FPM Family Planning Monitoring SSM Surveillance des Soins de Maternit6 MCM Maternity Care Monitoring SSSP Surveillance des Soins de Santd Primaire PHCM Primary Health Care Monitoring SCT Surveillance Cumulative des Tendances CTM Cumulative Trend Monitoring Ddnominateur ... Denominator

FMAR Femmes Marines en Age de Reproduction MWRA Married Women of Reproductive Age (15-49) (15-49)

Incidence (Taux pour 1000 FMAR) ... Incidence (Rate per 1000 MWRA)

INA Incidence du Nouvel Apport de PF INA Incidence of New Acceptance of Family Planning IN-APF Indice de Nouvelle Activit6 de PF IN-APF Index of New Family Planning Activity - La somme de 6 taux = The sum of 6 rates IN/LT Incidence des Ligatures des Trompes IN/LT Incidence of Tubal Ligation IN/AS Indicende des Avortements:Sociaux IN/SA Incidence of Social Abortions IN/INJ Incidence des Injectables (n'lles) IN/INJ Incidence of Injectables (primary) etc etc

Predominance (Taux pour 1000 FMAR) ... Prevalence (Rate per 1000 MWRA)

PPF Predominance de Protection Effective EPP Effective Protection Prevalence PPE/TM PPE par toutes m~thodes EPP/AM EPP ascribed to All Methods PPE/LT PPE par Ligatures des Trompes EPP/TL EPP ascribed to Tubal Ligations PPE/INJ PPE par Injectables EPP/INJ EPP ascribed to Injectables etc etc Tendance Evolution dans le temps Trend Evolution over time

ACT Analyse Cumulative des Tendances CTA Cumulative Trend Analysis TABLE DES CONSIDERATIONS / LIST OF CONSIDERATIONS

page Consideration 1: SPF fonctionne en tant que systame d'alezte pr~coce, 4 PPE a subi une 6volution en courbe de S: stationnaire. Consideration 2: Les deux explications faciles de l'gtat stationnaire: 7 (1) fuite vers le secteur privg (2) diminution du reservoir non-prot~g6 Consideration 3: Baisse rapide de la PPE A Nabeul A la suite de baisse 8 prolong~e de l'inciderce de plusieurs m6thodes Baisse de la PPE de Tunis et de Sfax. R~ponse? PPP. Consideration 4: Tr~s faible PPE en Tunisie central et du sud, 13 Implications programmatiques.

Consideration 5: Arr~t du prog~s de la PPE en 1979. Une dynamique. 15 diff6rentielle est dccelge au niveau regional. Consideration 6: Lig. des trompes r~sistent le mieux A la diminution 17 naturelle de la PPEo Une Ihg~re augmentation entraT­ nerait un accroissement sensible de la PPE. ConsidEration 7: Le d~doublement de l'incidence des Lig. des trompes 19 produirait un 6ventail des m~thodes assez ideal. Considgration 8: Kairouan et Medenine montrent depuis plusieurs annes 28 I'IN-APF le plus bas. Implications. ConsidEration 9: Analyse r~gionale de l'6volution des lig. des trompes, 29 Implications. Consideration 10: Progr6s rdcent de la PPE/LT au niveau r~gional par 33 rapport au niveau national. Implications multiples. Consid6ration 11: Dgveloppement d'objectifs pour les lig. des trompes 37 A partir des Etudes de tendances: Triple profil. ConsidEration 12: La performance durant Janvier (1980....1973): 37 communication au niveau des regions est souhaitable. Considgration 13: Surveillance des 3 et 6 premiers mois demande une 43 - communication sans attardement des results au niveau des regions: pour permettre une adaptation gventuelle. La liaison entre trois mesures de performance.

Consid~ration 14: Promotion de performance r~gionale A travers les ob- 59 jectifs au niveau national: une r~f~rence pour deux groupes sp~cifiques.

Consideration 15: Dgdoublement du nouvel apport annuel de protection 61 d'ici 1986. Effet accru sur la baisse de f~condit6. Considgration 16: Convergence des deux raisons principales pour favoriser 64 un programme de planning familial "m~dicalis6": Exis­ tence d'un grand reservoir de multipares -',risgue glevg de grossesses ult~rieures non-dsirables et i risque glevg pour la sante de la mare et de l'enfant en cas de grossesse. La ligature des trompes est un acte m~dico-chirurgical par excellence ainsi que 'est l'avortwment. D'ofi un engagement medical necessaire autant dans le rural que dans les villes.

xi FAMILY PLANNING MONITORING (FPM) IN TUNISIA (1973-1979): FINDINGS AND IMPLICATIONS FOR THE NEXT FIVE YEAR PLAN (1982-1986)

R.P. Bernard and A. Charffedine

I. INTRODUCTION

Seven years have gone by since the creation of the Office National du Planning Familial et de la Population (ONPFP) in March of 1973. The "Office" has developed a program that may be envied by most countries regarding vision, humanitarian goals, technical execution and the capacity to mnonitor bX both region and method across time.

Despite the non-availability of electronic equipment for data processing, it was possible to establish within a month a historical profile of the evolution of the Tunisia Family Planning Program (TFPP) spanning from the year 1973 through February, i980. This Report is part of the Phase-2 mid-term GOT/USAID evaluation effort of March, 1980 and was developed during April, 1980 in Geneva after many discussions with the coauthor on field trips and in counterpart meetings at the Office in Tunis.

The epidemiological surveillance of FP evolution is the most important source of knowledge for improving the national program -- presently at a turning point. The major goal of this piece of analytical and synthetic work is to derive meaningful options for the (1) continued national penetra­ tion, (2) increased effectiveness, and (3) surveillance documentation.

This analysis comes at a time when options for the next five-year plan (1982-1986) have to be translated into quantified objectives. The payoff of this epidemiological review is to develop one set of options that builds upon the experience of the past 7 years (1973-1979). The next 7 years may be subdivided into a 2-year period of transition (1980-1981) and the actual five-year plan. The overall objective is to double the annual protection conferred by the National Program from 1979 to 1986. This can be achieved by shifting the method mix gradually towards greater demographic impact potential. In 1974, tubal ligations had a share of 20.8% of the primary methods; by 1979 that share had melted to 11.2'; the

-I goal is to carry that share back to 19.0% by the year 1986 and to be maintained at 20% during the subsequent five-year plan. For primary IUD insertions and tubal ligations, the conferred protection incidence would thus pass from 125.5 thousand couple years of protection (CYP) in 1979 to 237.2 CYP in 1986. The gradual introduction of injectables would complement the..rapid increase in annual input of CYP and bring it well above double the rate experienced in 1979. Hence, by the end of the next five-year plan, the Effective Protection Prevalence would have increased sharply and thus have contributed directly to an acceleration in the decrease of national fertility. Indeed, the Crude Birth Rate (CBR) may be well below 29/1000 by 1986 if the goals are to be met from year to year.

The practical outcome of this analysis and forward projection of realistic objectives of increased program efficiency may be surmarized as follows.

The incidence of new IUD and Tubal Ligation acceptors -- expressed as mean workdaXbxE uvernorat (300 workdays and 18 gouvernorats) -- would have to pass from 4.8 to 5.2 for IUDs and from 1.5 to 4.2 for Tubal ligation perdayand_&ouvernorat from 1979 to 1986. It should be kept in mind that in 1974 the corresponding figures were 3.5 and 2.0, respectively; and that already it 1979 the mean work day performance of tubal ligation for Bizerte and B~ja was 3.7, and 3.2, respectively, that is quite close to the 1986 'average goal'. Of course, with increasing "medicalisation" of the family planning program, and the systematic establishment of family planning sections in the many new maternites during the next few years, the targets appear modest. Nevertheless, the setting of objectives cementing the greatest revolution of the twentieth century : the family's right to plan the number and timing of offspring, should be such that it remains feasible. within a context of various other development priorities.

A particular feature of this analysis is to study "regional case histories". In essence, each gouvernorat has its own administrative, sociocultural, and even motivational dynamics and many pilot projects have unfolded in this or that region. Hence, it is of utmost importance to document, by region, the patterns and trends of contraceptive input evolution, so to speak as a first step in the effort to determine which approach, or which elements of various approaches, are generating which results. Clearly, analytical epidemiology will thus set the stage for meaningful family planning penetration at the regional level during the Eighties. In addition, the documentation of the regional case histories may be a rich source for the arab/francophone countries.

- 2 ­ 2. MATERIALS AND METHODS

All source material was provided by the ONPFP. The numerators bXREiarX methods and &ouvernorat spanning from 1973 to Febr0 are readily available at the Division de Recherche. An important series that was carried from 1974 to the present is: Statistiques de Planning Familial • New acceptors , by-method and gouvernorat, are tabulated each subsequent month after actual occurrence. Thus, the the bilateral mission had access to the January and February, 1980 figures towards the end of March, that is before terninating the second-phase evaluation. Immediate "historical/epider.iiological" analysis of this information nrovided essential knowledge on the presently occurring new increase in performance uhat was incorporated in the final briefing session and then developed into a special section of this report.

The denominators were also immediately available. The Married Women of Reproductive Age 15-49 (MWRA) were derived from a special publication of the Office: Projections de la Population Tunisienne par Delegation, Sexe, Age et Annie: 1975 - 1986 ; In order to provide scope and continuity, backprojections were made for the years 1974 and 1973 (rb). In addition, the relevant trend studies provide for adding the 1980 performance in early 1981 in order to initiate participatory thinking by the d6legues, FP staff and medical personnel at the regional level. Clearly, this sharing of information will lead to better performance at the regional and thus national level, since there is no greater motivation than that built upon known previous performance. within and across regions.

The basic unit of measurement of performance, by region and method, is the number of new method-specific acceptors per 1000 MWRA. This applies also to the incidence of social abortions. By adding up all rates of method-specific acceptance'-- inclusive of social abortions -- one can derive a surmmary Index of New Family Planning Activity (IN-FPA). For instance, in 1979 that index was 168.7/1000 MWRA for Sousse against only 39.0/1000 MWRA for Kairouan -- ironically,two adjacent gouvernorats showed an over fourfold difference in primary FP activity; which suggests the need for one gouvernorat helping the neighbor to seriously improve its performance during the years to come.

Annual new program performance (INCIDENCE) by gouvernorat determines,

-3­ cogether with the uethod specific decay rates (lowest for tubal ligation, much higher for all other methods), Effective Protection PREVALENCE (EPP), expressed as rate per 100 MWRA. The Office had available the EPP-Profile

as of Ist January 1979 , and upon request, calculated the updated profile as of Ist January 1980 still during the bilateral evaluation mission in March of 1980. In other words, the truly exceptional situation has arisen, when both (I) Prevalence and (2) Incidence can be studied as (3) Trend in each (4) Gouvernorat for (5) all FP Methods. Actually, the material is so rich in completeness and information, that the analyst is now confronted with the "embarras du choix". Clearly, the present analysis can only be the beginning of the systematic a22 a n fof analytical epidemiologto surveillance data. A ne. methodological window opens into the 1980's, based on conscientious monitoring of new family planning input. Clearly, only electronic data processing and analysis could fully exploit the growing data bank -- an option that has to be deferred - possibly for many years -- due to non-availability of equipraent and software.

Meanwhile, the present analysis will adhere to the basics of analytical epidemiology, giving (1) intervention and (2) effect by (3). place and (4) time a major consideration and deferring more sophisticated inquiry of (5) cause-to­ effect interaction to a time when electronic data processing and software packages are available.

Particular consideration has been given to (I) ranking of performance and protection rates by region, (2) the study of the method-specific trend by region, and (3) a cuuulative trend analysis (CTA) , the latter by studying the "current year's performance in the making" (cumulative time windows). Instant accessibility of this information requires rich pictorial presentation for both central study and regional feedback in order to provide the information needed to steer ahd affect the annual performance at the regional and national levels.

Finally, the findings are the basis upon which the short and mid-range 2bjectives have to be built. While looking backward seven years, realistic objectives are developed for the next seven years. Social abortions are considered as an indicator rather than as a family planning method per se. Hence no targets should be set in a country that has legalized and made available this "last resort method". But differential incidence by gouvernorat raay signify differences in availability/accessibility - a matter of serious concern.

-4 ­ 3. FINDINGS

3.1 Evolution of Protection

As shown in Fig. 1, the level of national protection prevalence generated by the Public Sector Program (bold line) increased with acceleration from 1974 to 1977 (+1.57, +1.79, +2.46 %age points); followed by a dramatic deceleration of build-up, reaching a perfect plateau at the end of 1979 (+2.46, +1.25, + 0.24, +0.04 %age points). This S-curve had its inflection point during 1977. In 1979, the total new input of the ONPFP's public program was just sufficient to maintain the protection prevalence attained at the beginning of that year.

Consideration i: Routine Family Planning Monitoring (FPM) constitutes an early warning system; unless new life is injected into the ONPFP public sector program, the performance of 1980 will not be sufficient to maintain the protection level obtained by previous programmatic inputs. The public sector program would thus cease to directly contribute to a further lowering of -the fertility rate. The S-shaped trend of the Effective Protection Prevalence (EPP) teaches a lesson insofar as the inflection point could have been spotted as an alarm sign already in early 1978, that is two years ago. At that time, the increase of protection prevalence during 1977 had been cut into­ half (1.25/2.46 = 0.508): that first alarm was missed, at least regarding its implications. One year later, in early 1979, a second alarm could have been sounded, since during 1978 the increase of protection prevalence was reduced to one tenth relative to the year 1976 (0.24/ 2.46 = 0.098). Presently, we are at a turning point because no action following the third alarm would mean the start of the decline of the protection prevalence acquired at high cost and with a great apparatus stretching into the 18 regions: the annual increase in protection prevalence during 1979 came to a virtual standstill (0.04/2.46 = 0.016).

The S-shaped trend indicates that the present system of PF intervention has yielded its best returns and that new avenues have to be searched for bringing about a positive inflection point. Per se this observation has no depreca­ tory implications on the program performance of the seventies. Any country has to start within many restrictions and it is only an epidemiological retrospection 'hat can indicate new needs to be met for sustained program performance.

Fig. I also shows that the Private Sector takes an increasing share of the national protection prevalence, reaching almost one quarter at the end of 1978. Nevertheless, it is quite obvious that the desirable "fuite vers le secteur priv" cannot explain the major part of the increase of national

- 5­ Figum,1. TUNISIE ONPFP/USAIO rP Prugr m, E luat0on, Phow-2

Tendance de Pr domlncnce de Proeoct;on Effective (PPE) pour le Sectevr Public (ONPFP Programme) at le Secteur PrIv (-National mains Public). Trend of Effective Protection Prevalence (EPP)for the Public Sector Program (ONPFP) and the Privete Sector ( Notion-A minu, Public Perforrmance). 'naD 25 -- 2

FIARVmRA: 725.300 74C950 773187 798264 824203 851035 878795 907513 National,

158980 180878 Public" 74814 88328 107163 140976 64109 77959 94294 117006 131165 137427 (142189)

2IL25 20 NATION P

0 q' '+U.24 +0.04

+ .25 -30,

0' I..

EL 4 a % NATIONAL 1.7ETANT PRIVI I0 30A0 1001 .57 Iza.

Nvz4 I 5767 8 98 31.I

Zff

10 IT.

1~6 Gr48b W 0 1 JANV1EL, 74 75 76 77 78 79 80 1.981 protection prevalence generated by the public sector program having come to a grinding halt.

Consideration 2: Stagnation of program performance has had two easy explanations: (1) Shift from public to private sector, and (2) gradual exhaustion of the reservoir of eligible couples. Careful study of these two questions leads to the following conclusions: (1) While it is true that -- particularly in urban areas -- new acceptors may recruit themselves more and more into the private sector, and that the sales of orals and condoms have been on the increase, it is as much true that this is virtually restricted to urban centers. Around two thirds of the gouvernorats remain preponderantly rural and the private sector recruitment remains negligible. It is exactly these rural gouvernorats that show the lowest EPP,.often much below 10% of MWRA. Clearly the lion's share of eligible couples (MWRA) has not been reached by neither the public and less the private sector. This leads to the second point. (2) The reservoir of unprotected eligible couples remains very large. On average, absence of EPP for the following gouvernorats in combination is 93% of the eligible couples: Sidi Bouzid, Medenine, Kairouan, Gabes, and Kasserine and they constitute over one quarter of Tunisia's NMWRA. A second quarter of the MWRA with an average of 85% unprotected women at the beginning of 1980 is made up by the following five gouvernorats: Zaghuan, Mahdia, Gafsa, Nabeul, and Sfax. Clearly, the argument of the exhausted reservoir will have to wait for another decade to become worthy of serious consideration, and only so if the annual programmatic input would generate annual increases in EPP of , say, 3-5 %age points -- a practical impossibility.

The experienced trend of the EPP curve in Fig.] conveys one important additional lesson: It should be possible to achieve an increase of two percenztage points annually by the public sector program of ONPFP, a rhythm basically attained during the calendar years 1975 and 1976. This figure should be retained as a feasible target.

-7­ 3.2 Protection Prevalence by Gouvernorat and Method: Its recent trend

Fig. 2 gives the EPP by gouvernorat, and within gouvernorat for tubal ligations(white base) and all other methods (grey top)j for the cutoff date of 1. January, 1980. The connection with Fig. I is given by the All-Tunisia value of 16.19 % EPP.

Three gouvernorats reached EPP values of 25% (Le Kef, Siliana, and Baja) that harbor one-eighth (12.6%) of all MWRA of Tunisia. These three gouver­ norats have also the highest EPP pertaining to tubal ligations (EPP/TL), 18.6% for Siliana, 16.0% for B6ja, and 11.5% for Le Kef. At the other extreme, four gouvernorats had EPP values well below 10% (Sidi Bouzid, Medenine, Kairouan, and Gab~s); they contain over one-fifth (21.1%) of all MWRA of Tunisia, and the EPP/TL values were 1.5% for Sidi Bouzid, 2.1% for Medenine, and 4.4% for Kairouan. The next three gouvernorats (Kasserine, Mahdia, and Zaghuan) showed EPP values between 10.0 and 14.9% with EPP/TL ranging from 2.8% to 8.4%. Together with the lowest prevalence group, they make up one-third (33.2%) of all MWRA of Tunisia. Clearly, they constitute the gouvernorats that will need special programmatic attention by the ONPFP if a growing gap in EPP with many other gouvernorats is to be narrowed.

Because of their population size the three gouvernorats of Tunis, Sfax and Nabeul merit particular attention. Indeed, they contain almost one-third of all MWRA (32.2%): high values of EPP would affect quite dramatically the All-Tunisia protection prevalence. The recorded EPP values are 19.5, 17.3, and 16.9% MIRA, respectively for Tunis, Sfax and Nabeul, the corresponding values of EPP/TL being 7.1, 8.8, and 5.9% MWRA: not particularly high in the overall context. Disquieting is the fact, as noted by comparing the EPP values one year apart in Fig. 3, that all three gouvernorats sustained a reduction of their EPP levels during 1979; for Tunis from 19.9% to 19.5%, for Sfax from 17.4% to 17.3% and for Nabeul from 18.2% to 16.8%. In addition, while the EPP/ TL is more resistant to "caving in", as noted by a concomitant increase of their values (from 6.3 to 7.1% in Tunis and 8.1 to 8.8% in Sfax), Nabeul managed to see its EPP/TL decrease from 6.0 to 5.9%.

Consideration 3: The one-year trend analysis of EPP identified Nabeul as being in serious trouble with a sinking of the prevalence by 1.3%age points. This needs immediate attention.

-8­ Figure 2. PREDOMINANCE DE PROTECTION EFFECTIVE (PPE): Solon M;thode do PFopd Reglon EFFECTIVE PRO'ECTIOl PREVALENCE (EPP): by Method of FP and Region Data: I Jonuory/Jonvier, 1980

Porcentaga Cumulotil des FMAR a trovert la Tunisa / Cuulolive Percent of MWRA acrou Tunisia 0 20 40 GO 80 100

30 .. Tot. M1to--1 TUNISIE 1.1.80 Public -"Tot"m'had" lI0lk.• AutrBat i oda

122. I I" iaue e r 9- ... -4. 21.0 19..

1 .1t-e ' 'ISIE .173 . TUNItE, PP'/EPP:p/EP 16.19 do FMAR 16.19

!a: , .

V 4 ., 1 7.4 11. 70.3 7.31

S.9 H+ ' I

LI. I• •L •.

32 % 4.0S S116 4.37 17.35 , 3.0O 662 ,30 L12 4.17 351 104 491 19 60* LOG 3.9a

C C

SZ O Clas.s de PPE/of EpP: , 25. ,25.0 j <20.0 1-.­ 1S.0 I < 10.0 - r ­ - -. FMA /M W RLA(%total) : 6.. 43.4

-9­ Figure 3. PREDOMINANCE DE PROTECTION EFFECTIVE (PPE): TCUTES METHODES, Ion REGION EFFECTIVE PROTECTION PREVALENCE (EPP): ALL METHODS BY GOUVERNORAT I Jonvier 1979 1 January, 1979

Pourcentop Cumulati' des FMAR a travelsIt Tuniia Cumulolative Percent of MWRA across Tumis;o 0 20 40 60 80 100 II I I 30 "U NiSE -7'IU L ...outes Mithodes .A .trodis TJilEi 1.1.79 PUBLIC Aues Mloe U c.. Lialure doi Trampsi

I- -t-"~ 05.

5- 223._ LF19=

0 :Z0 : L20

17.4 .UN:.I,..(PPE) 17.3"1•""" TUNISIE: Predomnance do Protiction Ei i i , ,TUNISIA: Effective Protection Prvolen i I'-,'-... .-, - •" 13.8 (EPP) • I " 5-U I .

t'.- ,20o~ 10.. ".;,-" ,.- . .. I ... .; : . =-1L 10 10 14'...... ,. V,__ , / 1:' ..: . i t' -- i': 0.5-'i-- Si '..Yr.

3.1 4. 95 .7 2 W ., K l424. .. ..­" i , F ,"

PPrVEPP(%) ,_ oC=o0 -oi : C1,, <,o.0 2 FMAR/MWRA(e 7 4". . < S.7­

- 10 ­ TUNISIE JAN. 1979 Figure4 PREDOMINANCE DE PROTECTION EFFECTIVE (PPE): TOUTES METHODES, selon REGION EFFECTIVE PROTECTION PREVALENCE (EPP): ALL METHODS BY GOUVERNORAT I Janvier 1979 1 January, 1979 Protection tr~s foible / Very low protection rate ou or Ficondite tres forte /Very high fertility rate en 1979 in 1979

......

_.airouan,

.jSidi Bouz dl-*:''*:*'"'-'***""""

. :...... ­

, . :.- ===-======:::. - ::::.1

-M*

"AI 10 % FMAR 5 Gouvernorats

.:w- 14.9% FMAR::.::..TT ,::.-': II3 Gouvernorats- ::::::::::::::::::

S1 519.9 %FMAR 6 0-ouvernorats r_--*- .7 20-24.9 %FMAR 3 Gouvernorats = 25-29.9% FMAR 1 Gouvernorat

Source: Evolution R.cene du Programme National de Planning Familial par A. Chareddine Tableau F. Revue Tunisienne des Etudes de Population. Iee Anne'e, No 1 , 1980. ONPFP, Tunis , Reclassification des taux de protection: rb GE rb 4 80 TABLE I

EFFECTIVE PROTECTION PREVALENCE (EPP) at the Beginning of 1979 and 1980, BY GOUVERNORAT. Ranked by the Difference in Percentage Points. Government of Tunisia FP Program

EPP 1 2MWRA 3 Difference2 Rank Gouvernorat 1979 1980 % Total Cumulative% I Gafsa 12.60 15.10 +2.50 4.17 4.17 2 Sousse 18.59 20.97 +2.38 4.57 8.74 3 Siliana 23.91 25.29 +1.38 2.95 11.69 4 Kasserine 9.64 10.38 +0.74 4.61 16.30 5 Baja 24.12 24.81 +0.69 4.05 20.35 6 Le Kef 25.03 25.62 +0.59 3.83 24.18 7 Monastir 18.13 18.72 +0.59 3.70 27.88 8 Jendouba 18.26 18.51 +0.25 5.52 33.40 9 Kairouan 7.12 7.35 +0.23 6.09 39.49 10 Zaghouan 13.24 13.45 +0.21 3.51 43.00 11 Gab~s 8.51 8.56 +0.05 5.09 48.09 TUNISIE 16.15 16.19 +0.04 100.00 -­ 12 Bizerte 22.49 22.52 +0.03 5.86 53.95 13 Sfax 17.36 17.30 -0.06 8.30 62.25 14 Medenine 6.21 6.06 -0.15 5.96 68.21 15 Tunis 19.88 19.49 -0.39 17.35 85.56 16 Mahdia 13.84 13.43 -0.41 3.94 89.50 17 Nabeul 18.22 16.92 -1.30 6.52 96.02 18 Sidi Bouzid 8.41 4.35 -4.06 3.98 100.00 1EPP: Effective Protection Prevalence by All Methods: Rate per 100 MWRA. 2Difference of EPP from 1979 to 1980 (1st January). Ranked from positive to neg. 3MWRA: Married Women of Reproductive Age (15-49). Source of EPP: ONPFP, A. Charffedine, Tunis, March, 1980.

- 12 ­ Furthermore, from the programmatic point of view it is unacceptable that the two most populous gou­ vernorats that contain over one-forth of all MWRA of Tunisia (25.7%) would see their level of protec­ tion decrease at a time when the program is expected to grow and with over 80% of the MWRA still unprotec­ ted through the public program. Clearly, these two semi-urban progra8s need renewed attention, perhaps with a much more deliberate operation at the materni­ ty centers. Indeed, a meaningful postpartum progrwn should be initiated without delay in all sizable maternites 4n Tunis, Sfax, and Nabeul, to start with. This should be functional latest by autumn of 1980, in order to reverse the trend of decreasing protection prevalence still during this year; Since this will affect one third of all MWRA, the national prevalence rate will be strongly affected by this specific "three gouvernorat action". The medical world must join hands.

Fig. 4 gives the values of Fig. 3 in a geographic overview. One notes that (1) central Tunisia, and (2) south Tunisia are the regions that will need the greatest attention in rural Tunisia. Indeed their recent very low protection prevalence is necessarily linked with a very high fertility rate for over one-fourth of all MWRA of Tunisia.

Consideration 4: Central and South Tunisia need a new family planning program effort that will have to go much beyond the present possibilities. If this were not to occur in the very near future, the presently growing gap in EPP with various northern gouvernorats would grow further with all its adverse implications to peaceful development of the Center and the South. Innovative programs with bilateral/multilateral AID have to be developed Zo cope during the early eighties with this growing problem of strong regional disparity.

Table I classifies the 18 gouvernorats according to their one-year change in Effective Protection Prevalence (EPP). Only 2 gouvernorats increased their EPP by over 2%age points: Gafsa and Sousse (+2.50; +2.38). Siliana was in third place with a gain of +1.38%age points. At the other extreme, six gouvernorats experienced a regression of their EPP: Sidi Eouzid, Nabeul, Mahdia, Tunis, Medenine and Sfax, while Bizerte and Gab6s stood still. Clearly, these eight gouvernorats have to cope with the question: Can we afford stagnation and even regression of the previously acquired protection prevalence; are we indifferent to the birth rate ceasing tc come down or even increase again? Indeed, there is a direct relationship between the increase in protection prevalence & the decline in the birth rate. Zaghouan, Kairouan, and Jendouba showed also very small progression in their EPP (+0.21, +0.23, +0.25%age points).

13 ­ TABLE II EFFECTIVE PROTECTION PREVALENCE BY TUBAL LICATION (EPP/TL): 1979 & 1980 (Beginning of Year), BY COUVERIORAT. ONE-YEAR TREND. Colun A B C D E F C H I HWRA Protected by MWRA Protected Ly Diff(Z) EPP' Percent Total 1978 ubal Ligation 1979 Tubal t 79-78 1980 EPP pertaining to Number Percent Number Percent Tubal Ligation(1980) 1 4 Siliana 25983 4482 17.25 26357 4893 +18.56 +1.31 25.29 73.4 2 Beja 35392 5316 75.02 36061 5766 15.99 +0.97 74.81 64.4 3 3 Le Kef 33617 3574 10.63 34183 3937 11.52 +0.89 25.62 45.0 4 Bizerte 50477 5074 10.05 51819 5876 11.34 +1.29 22.52 50.4 5 Jendouba 47884 5077 10.60 48980 5335 30.89 +0.29 18.51 58.0 6 SousseS 38490 3622 9.41 39952 3819 9.56 +0.15 20.97 45.6 7 Sfax 71135 5780 8.13 73209 6421 8.77 +0.64 17.30 50.7 8 Zaghuan 30013 2274 7.58 30928 2587 8.36 +0.78 13.45 62.2 9 Monastir 31231 2630 8.42 32393 2706 8.35 -0.07 18.72 44.6

TUNISIE 851035 58056 6.82 878795 64274 7.31 +0.49 16.19 45.2

10 Tunis 145280 9196 6.33 153265 10664 7.05 +0.72 19.49 36.2 11 Hahdia 33151 1957 5.90 34410 2242 6.52 +0.62 13.43 48.6 12 Nabeul 54473 3241 5.95 56753 3372 5.94 -0.03 16.92 35.1 13 Kairouan 51590 2151 4.17 53396 2353 4.41 +0.24 7.35 60.0 14 Kasserine 39053 937 2.40 40444 1124 2.78 +0,38 10.38 26.8 15 Nedeniue 51246 1068 2.08 52658 1114 2.12 +0.04 6.06 35.0 16 Cafsa 35492 660 1.86 36629 707 1.93 +0.07 15.10 12.8 17 Cabes 42864 476 1.11 44475 760 1.71 +0.60 8.56 20.0 I8 Sidi Bouzid 39051 541 1.39 40444 598 1.48 +0.09 4.35 34.0

A Married Women of Reproductive Age for 1978 B Number of !WRA Protected by Tubal Ligation in 1978 C Percent of NWRA Protected by Tubal Ligation in 1978 (EPP/TL-1978) D Married Women of Reproductive Age for 1979 E Number of MiaR, Protected by Tubal Ligation in 1979 +F Percent of MWRA Protected by Tubal Ligation in 1979 (EPP/TL-1979) : ranked in descending order G Difference of:EPPiTL 1979 minus EPP/TL 1978 H EPP: Effective Protection Prevalence by All Methcds for 3980 (Beginning of Year) I Percent All Nethod EPP pertaining to Tubal Ligation (F/H)

IEpP/TL is significantly below 5% of All M'RA. - Indentification of a seriously un.eL need. - The six gouvernorats need stronger 1P Programs of Tubal Ligation Services. 2 with full availability EPP/TL ranges from 5.0 - 9.9% of all HWRA. While the trend is on the increase, Lhree of the 7 Gouvernorats, show no progress. They are: Monastir (-0.07 Zage points), Nabeul (-0.03 " ), and Sousse (+0.15 " ). They need to make available the ligation services. 3 EPP/TL ranges from 10.0 -14.9% nf all MWRA. Of the three Gouvernorats, Jcndouba shows the smallest progression (+0.29 Zage points). Ligation 4 services need to be made available more broadly. EPP/TL ranges from 5.0 -19.9% of all MWRA. The two gouvernorats have the highest prevalence of ligated womcn which further increase swiftly. Siliana (+1.31 age points) B'eja (40.97 " )i .Note the virtual 30-fold prevalence of Tubal ligation for Siliana and Beja over Gabes and Sidi Bouzid. GE rb 4 80

- 14 ­ Consideration 5: Only three in eighteen gouvernorats showed a dynamic increase in their EPP (Gafsa, Sousse, and Siliana) pertaining to only 11.7% of all MWRA. A second group of four gouvernorats showed a just acceptable increase in EPP (Kasserine, Baja, Le Kef, and Monascir) pertain­ ing to 16.2% of all MWRA. The remaining 72.1% of all MWRA in Tunisia experienced during 1979 stagnation and often serious regression in their EPP. Nationwide, this profile of EPP by gouvernorat led to a standstill of the buildup of the EPP, which may signify an arrest of the decrease of the birth rate in connection with the public FP program of Tunisia.

The gouvernorats should be oriented on the implications of above findings that are cause for serious concern in both urban (Tunis, Sfax) and rural Tunisia (Sidi Bouzid, to name just one gouvernorat) It must be a priority goal of ONPFP to see the All-Tunisia, public sector generated EPP increase by at least one percentage point annually as was the case between 1974 and 1977 (see Fig. 1). Once that rate of increase is attained in the short term, the goal has to be shifted in successive steps to ).5%-age points (as was the case between 1974 and 1976) and finally to 2.0 %age points (as was the case in 1977). Without this objective, the ONPFP-generated national protection prevalence would attain by the year 2000 a level significantly below that needed to attain the demographic goal formulated in 1967. The most crucial period for securing a smooth build-up of the national protection prevalence is now, at the first arrest of progression. Adequate and realistic measures have to be taken during the year 1980 to secure a new takeoff of the increase of the national EPP. This may have to be one concern of the Conseil Superieur de Population for its 1980 session.

Table II then gives the Effe.tive Protection Prevalence for ligated women at the beginning of both 1979 and 1980; and the latter rate per 100 MWRA is then studied as a proportion of the All-Method protection prevalence for 1. January 1980. For All-Tunisia, 45.2% of the All-Method EPP was due to women who had undergone tubal ligation. But this proportion is as high as 73.4% (Siliana), 64.4% (Baja), 62.2% (Zaghuan), and 60.0% (Kairouan). The lowest TL-shares are noted with 12.8% (Gafsa), 20.0% (Gab~s), 26.8% (Kasserine), Furthermore, while there were six gouvernorats whose All-Method EPP had decreased from 1979 to 1980 (see Table I), there were only 2 noted decreases for EPP/TL. In other words, protection conferred by tubal ligation is more resistant to "prevalence decay" than the other methods. The findings have been charted in Fig. 5 with a reading in 10 points.

- 15 ­ DIFf RENCE rioum Begirnnlng 1he State of the Natlon's protection Prevalence eapreisd as the Figure 5. of the Year 1979 to ilia leginino of tie Year 1980 - A) EPP due to All Methods B) EPP due to Tubal Ligations

These Data reeoronly to.lh* Prevalence Generated by Ihe National FP Program (."PubIIc':ONPFP)

ONPFP/USAID FP Progress Evaluation, Phase-2. T3i EVOLUTION de IoPREDOMINANCE de PROTECTION, SELC.N REGION ET MrTHODES DE PF EVOLUTION CF EPP, BY REGION AND METHOD r ­ ubal Ligation TUNISlE ... All Methods All0 ethod All Methods 0 250 Other Methods lubol Ligation .F2

4..+. 31 $1

1 10.74 .com I AI.

-, _. L•- 0 I_ I I L o j//-' Tunisa .PP, IL :, i '0.25 A I __~~~~tI_ _ __9 3 _ _ _ _ _ - o1'+I6f + I °s"°1 ;.,- i : - : .o 0 ____,_-7L"'")"j ,o Tun:EPPpp ao

C -0A1

0 0 1 a SesItI C I +-00

"3_ Reading; 1. The AII-tmethod Effective Protection Prevalence remained stationary. "

0 (+0.04/100 MWRA). 2. By contrast, the Tubal Ligation Effective Protection Prevalence Z a" 2advanced by 0.5/)DO hMWRA. 3. Ty ' -ection from 1) and 2) , the "All Other than TL Methods" Effective Protection Prevalence regressed. 4. While Gafsa and Souise have increased their EPP, virtuolly none of this progress is due to tubal ligotions. Incorporation of ligotin services in their respective FP proorams would secure a future greater resilience to the ollained EPP. By contrast, S;liono should add also methods other than TL. 5. Manostir should increase Tubal liomrtions. Similar case with Sousse/Golfsa. -3 6. Regression in EPP for both TL and all other methods is noted in Sidi Bouzid, Nobeul, and Medenine. Their entire program strategy needs examination. 7. Tunis and Mohdia show u similar differential pattern in EPP evolution. Were it not for Tubal Ligations, the 'PP)AII Methods) would hove under­ gone even greater regression. S. The EP' of SFow has );een talonoty, wnile FPP(TL) advanced by 0.64/100MWR 9. Bizerte was able to Iold stoionay the All-Method EfI, thanks to a good progression in TL incidence in IM7. A further increase will secure genuine - 4 growth ofthe EPP(AII /Methods) . 10. In Koirouar, and J.endouo, progression cf baoithTL ad all other methods -4.06 was minimal (I/4 ' .) but homogenously distributed in rPP. More Input Is needed for all mei,nds ,,an that achieved in 1979. .­

- 16­ Consideration 6: Tubal ligations emerge as the method of family planning with the greatest resistance to the early decay of its protection prevalence - in both urban and rural areas, north and south, east and west. While the all-method protection prevalence has come to. a standstill during the'year of 1979, the tubal ligation protection prevalence advanced by one half percent from 6.82 at the beginning of 1979 to 7.31 at the beginning of 1980.

Clearly, a relative moderate increase in the incidence of tubal Zigations would secure a very costeffective path to increase the effective protection prevalence across the nation. The deduction is that with increasing "medicalisation" of family planning in Tunisia it should be possible to boost in a relatively short time (some years) the annual increase of EPP. It matters that potential candidates for ligation are indeed getting that service without much ado, swiftly, and profession­ ally.

Fig. 5 shows that such availability was conspicuousZy absent in Gafsa, Sousse, Medenine, Nabeul, Sidi Bouzid, and Monastir. In addition, there was very limited access also in Kairouan, Jendouba, and Kasserine. At all these places, an early review should take place in order to identify and remedy the bottlenecks that presently secure so low incidences of tubal ligations. Possibly the sheer streamlining of such ligation services could dramatically in- )e the protec­ tion prevalence within 1-3 years.

- 17 ­ TABLE III

iNNUAL METHOD SPECIFIC FP INPUT BY "ONPFP" DURING ITS FIRST SEVEN YEARS OF WORK (Annual Frequency, Rate, and Method Cumulation)

A) Number of "New Acceptors" X Change HErHOD :973 1974 1975 1976 1977 1978 1979 1979/1977 Jelly 4237 3683 4426 5100 5727 4672 4736 -17.3 Condom 8407 7432 8678 11385 13125 12304 10442 -20.4 Orals 11194 10795 16310 25987 27567 27017 23608 -12.6 IUD 16790 19084 17307 20630 23879 26273 25756 + 7.9 Tubal Ligation 4964 10757 9896 8269 7937 8832 8141 + 1.9 Social Abortion 6547 12427 16000 20341 21162 20999 19248 - 9.0

B) Women at Risk (Married Women of Reproductive Age: MWRA) MWRA 725500+ 748950 + 773187 798264 '824203 851035 878795 + 6.62 +Serial back-projection,-rb-.

C) Incidence of "New Acceptors", by Method (See Fig. 6) Rate per 1000 fwiP Z Change METHOD 1973 1974 1975 1976 1977 1978 1979 1979/1977 Jelly 5.84 4.92 5.72 6.39 6.95 5.49 5.39 -22.45 Condom 11.59 9.92 11.22 14.26 15.92 14.46 11.88 -25.38 Secondary Methods 17.43 14.84 16.94 20.65 22.87 19.95 17.27 -23.73 Orals 15.43 14.41 21.09 32.56 33.45 31.75 26.86 -19.70 IUD 23.14 25.48 22.38 26.09 28.97" 30.87 29.31 + 1.17 Tubal Ligation 6.84 14.36 12.80 10.36 9.69 10.38 9.26 - 4.44 Social Abortion 9.02 16.59 20.69 25.48 25.68 24.67 21.90 -14.72

D) Incidence of "New Acceptors", including Social Abortions, Decoiposition of Method Cuulation (See Fig. 7) Rate per 1000 MWRA 1973 1974 1975 1976 1977 1978 1979 TOTAL 71.86 85.68 93.90 115.14 120.66 117.62 104.60 -13.31 ..minus Social Abortion62.84 69.09 73.21 89.66 94.98 92.95 82.70 -12.93 ..rdinus Jelly/Condom 45.41 54.25 56.27 69.01 72.11 73.00 65.43 - 9.26 ..minus Orals 29.98 39.84 35.18 36.45 38.66 41.25 38.57 - 0.23 (=IUD/Tub.Ligation) ..minus IUD 6.84 14.36 12.80 10.36 9.69 10.38 9.26 ­ 4.44 (=Tubal Ligation) Source: ONPFP, GOT, Tunis (A) Statistiques de Planning Familial, No 16, annie 1978 No 4, annie 1974 Personal Communication to -rb- for annie 1979 (B) Projection de la Population Tunisienne par D6l6gation, Sexe, Age et Ann6e 1975-1986 +Serial Backprojection to enable 7-year trend study.-rb- Calculations: TU-GE rb 3 80 Illustrations: Figures 6 and 7. GOT/USAID Midterm FP Ser-vices Evaluation, Phase 2

- 18 ­ 3.3 Evolution of FP Incidence, by Method (1973/5 - 1979)

While the previous section gave information on the most recent 1-year evolution of Effective Protection Prevalence by gouvernorat and method, the present section shall treat the last seven years' evolution of incidence of.ne method acceptance for Tunisia as a whole.

The relevant data has been organized in Table III and Figs. 6 and 7. The figures have already been described in the Phase-] mission report, but are now updated for the year 1979. As noted in Fig.8(old Fig.3 of Phase-] report), the "six-month" trend windows were highly predictive of the entire year's performance. Relative to 1978, all methods had undergone a notable decline during 1979 as measured for the first semester (Phase-] evaluation) and now for the entire year. As shown in Figs. 7 and 8, for most methods, the peak year of incidence was 1977. Relative to this year it is then possible to calculate the positive and negative change of incidence of all methods as suggested in Fig. 7 and summarized below (Table IV):

TABLE IV: Change of Incidence of FP from 1975 to 1979 Percent Change of Incidence Rate

METHOD '1977/1975 1979/1977

Jelly +21.5 -22.5 Condom +30.5 -25.4 Orals +58.6 -19.7 IUDs +29.5 + 1.2 Tubal ligation -24.3 - 4.4

Social abortion - --+24.1 -14.7

All Methods +28.5 -13.3

Note a real strength of this program: there is a quite balanced method rnx, including social abortions. However, contrary to desirable and necessary evolution, tubal ligations were on a continued decrease. If the latter curve could be elevated to around twice the present level, an almost ideal method mix would ensue with a progressive gradient as follows: (1) Jelly, (2) Condom, (3) Social Abortions, (4) Tubal ligations, (5) IUDs, and (6) Pills.

Consideration 7: By doubling the incidence of tubal ligations, a virtual ideal method mix could be developed by ONPFP for the people of Tunisia during the early 1980s. - 19 ­ figure 6.

Govennent or Tunisia Family Plr.:-wi-;g Program : 1975 - 1979A,

MOST RECENT THREE-YEAR TREND OF INCIDENCE OF New Family Planning Acceptors, oy Method Unit: Rate per 1000 Married Women of Reproductive Age (MWA)

GOT/USAID Program Evaluation, Phase 1, Sept/Oct 1979-L 40 Source: Numerators: ONFFF; Statlstiques de Plonsi ng Familial; No. 16, Annie 1976, Ju;ttet 1979 Denomsnators: ONPFP; Proeclions do la Fopulation Tunisienne par Dilgalion, janvier 1979 - Surglcal Preventive Methods (IUD/Tub. Ligaton)

33.5

32.6 ...... Orals ...... 31.8 1YUD 01%.9 30 29.0 ' 30­

&. ' .29.1

-~6. 2,1..6.8o

20 2ot7 2

c; 20.7

15.9 o14.3 Co d m14.5

12.8 11.2 0. 4 L1.88 10.1 0 . .7 Tuba ! Lig ation 10 .4

10 - 9.26 10­

5.7 S.39

MWRA: 773,187 798,264 824,203 651,035 6 5

ITU/GE rb 1079 - 1975 1976 1977 1978 1979" *To be completed in early 1980 (Phase-2 of GOT/USAID Program Evaluut;on)A AUpcjoted for 1979 Year: TU/GE rb 4/0: The "first Semester" Trend study was highly predictive fo the "total year" Trend

(Seo Fig. 3 of Pioase-I Roport).

- 20 ­ Government of Tunisio: 197S - 1979A MOST RECENT T11REE-YEAR TREND OF INCIDENCE OF

(A) ACCEPTANCE OF FAMILY PLANNING, BY METHOD (B) FERTILITY ("Mortal"). Unit: Rote per 10J Moried Women of Reproductlve Age (MWRA) 00Figure 7. GOT/USAID Program Evaluation, Phase 1, Sept/Ocl 1979A 300Fiue7 Source: Numerators: ONPFP; Statistiques de Plunn;ng Familial; No. to, Anni'a IY7b. Juille 197V Denominoort: ONPFP; Projections de la Population Tunitienne par D~iigotion, Jonvier 1979

262.3 261.5

-0.3U%2 240.6 Marital Fertility Rata

-3.33,. 0 1976/1975.-8.3%

200 & S

?.

%CHANGE %CHANGE of of Incidence Rote Incidence Rate for each Method for each method 1977 over 1975 |979over 1977 § (.125) 1176 (:1.31

U. 422.6% Social Abortion 100- " 004.03 93- ,59'.90 95.0 .. o

89.7 ,,93.0 -14.7 22.5-24. Illl r 8. 22.5

30. GS.4

+ 3 0 .5 " : ' " ...... ' "' ...... "."." " . ". "

72. +02.2 1 412.2 +20.3 . 1035.4lLgln 3G. o. ., -Wx', -..>-....- .. • " ' • ' > , ., , •.,./ ." '." " 1975 976 177 19819.7" '/ ,, ",, /x "" " ", Fig. Keport). i;(6.. !!ci.hoie-l

. . !s rig ofpi z -ix. ,,<

12J] > 21 Figure 8.

Government of Tunisia Family Planning Froprom: 1975 - 1979 MOST RECENT FCUR-YEAR TREND OF INCIDENCE OF New fom;i)"Planing Acceptors, by Method FirstSemaster Only

nit: Rote per 10.0 Mariied Women of Roproduclive Age (MWRA)

GOT/USAID Program Evaluation, Phase 1, Sepl/Oct 1979

Sofxco Numerators: ONPFP; Statistique. de Planning Familial, received on request, September, 1979. Denomientors: ONPFP; Projections de Ia Population Tunisienne par Delegation, Jonvier 1979. Appndix. Toals. -Surgical Metlrods (IUD/Tubal Ligaton) 20

18.4 ,,,,"',,, Orals 17 ...... 17.1 / ~ ~~16.5 IUD ""', ..

14. LC is 13.7 1 12. . 13.3 Social Abortion

C10.2 .­ 10 10.0. .9.2

I,7.

59 Tubal LUpation I 5.6 5.9 5.7

5

2.8

MWRA- 773,187 798,264 824,203 851,035 878,795 I EU/GE rb1079 0 I I I 1975 1976 1977 1978 1979

- 22 ­ 3.4 Evolution of FP Incidence, by Method and Gouvernorat (1974-1979)

While Fig. 6 provides a national overview of the method specific trend of incidence of new acceptance, it is quite obvious that trend studies have to be made at the regional level if indeed meaningful changes are to be effected to improve the national incidence. This forbidding task was undertaken immediately after phase-2 mid-term evaluation for 15 regional entities of Tunisia. The charts are given in appendix according to the format of Figure 9 (All Tunisia) as Figs. 9-] through 9-15. The following considerations are incorporated:

(1) Give rates by method for the period 1974 to 1979. (2) Provide now for the space to update in one year the current calendar year (1980). (3) Calculate for each year an index of primary FP activity, (IN-FPL , the sum of the rates of the six categories of interven,.ons ( new jelly, new condom, new pill, new IUD, tubal ligation and social abortion ). Display conspicuously this index and classify the 15 figures according to this index attained for the year 1979.

(4) Give the percent change of this index for the last two years. (5) Document the denominator used for each year and in each gouvernorat (MWRA).Provide now the denominator for 1980. (6) Give the rates of incidence, by nethod, adjacent to the curves, in order to be able to derive new combinations of tables for inter-regional and inter-method comparisons with initiative at the regional and central levels.

Of course, the rationale of this exercise is multifold.

(1) Establish the method trend for each region to serve as a case history of "FP program evolution" during the seventies. Each d616gu& should have early access to all 15 case-histories, in order to initiate a creative investigative dialogue among the d~l~gu~s. D6l6gugs should have multiple copies and share the information in workgroups of clinical staff and also among physicians, etc. Performance must come to be based onto a quantified baseline.

(2) For the ONPFP/HQ, the 15 case histories will suggest what kind of directives have highest, intermediate and low priority in each gouvernorat treated as individual entities.

(3) Sooner or later a linkage is to be made between the trend of prevalence of protection (see section 3.2) and the latest-year incidence of method-specific FP input. For instance, in March 1981, the new prevalence profile, by gouvernorat should be studied against the input during the year 1980. This is a must for "guidance by monitoring" of the medical division of ONPFP. - 23 ­ Figure 9. TUNISIE TENDANCE DES INCIDENCES / TREND OF INCIDENCES ONPFP/USAID FP Program Evaluaion, Phase-2. .IANPF: 8,.68 93.90 115.13 120. 6 117.62 104.60 "49.59% 422AI% +4.80% -2.52% -11.07% FMAR/MA: 748950 773157 798264 824203 851035 40- 678795 907513 A compri.,er en mrs 1981

Toux d'accroissement des FMAR (3.26%) tote of incrase o MWRA (3.26%) 32-33 . . ,:,......

3030 ...... ?.. D... .

20- 0.6.

.20 Co nom 1.20

10- .. ,0..

8.43------I

0 I I C.C.39

74 75 76 77 78 79 1980 IANPF: Index d'Activil' Nouvelle en Planning Familial Vert Io :ornrne des 6 faux Z lexclusion du faux des fetroilt do DIU. PFPAI: Primary Family Nlanning Activity Index: Thuis incthsum of ?he six inpui lutes, excluding the rate of IUD removal.

Note: For region-specific "method-specific trend profiles" see Figs. 9-1 to 9-15 in the Appendix (pp. 67-83).

24 ­ (4) The regional case histories should be studied in the crntext of any special program input organised during the seventies, such as in Sfax (PFAD), Jendouba (PFPC), Le Kef (MCH program), Nabeul, Gafsa, etc. Clearly, this should provide the elements of a cause-to-effect reasoning and suggest which elements have been most "productive", and which least. This approach leads to crystallize new options.

(5) The regional case histories constitute also..a teaching series for program responsibles from arab and francophone countries in particular and family planning administrators in general. Similarly, Medical Schools-should use this material.

(6) Last and most important, "living/working with the growing case histories" is the best guarantee that the right local initiatives are explored and taken in order to improve the overall regional FP INPUT performance from year to year. In other words, understanding the "creation of the trend curves " cannot but lead to high motivation to improve the program performance where and when it is weakest. The year-by-year updated trend series should become the basis of the HQ-Regional dialogue.

A _cursory contemplation of the 15 method-specific trend studies gives an overwhelming flow of impressions, thoughts and ideas: quite bewildering! That is one reason why the 15 d6lgu~es have to put their brains to work perhaps in cooperation with their regional peers. Nevertheless, an attempt is made here to bring some order into this exhibit of termpestuous dynamics of performance of FP input in Tunisia. One may add up the six curves and produce thus an Index of New Famil_ Planni Act:ivty21 v (IN-FPA) . Table V gives an overview by gouvernorat and calendar yetr. One notes:

(1) The year of peak activity was mostly 1977 or 1978, except for Nabeul and Kasserine whose peak activity was reached in 1976, and a continuous decline thereafter. Overall then, the quan­ tified program input is declining. (2) In 1979, there was an over fourfold activity of n6w input in Sousse as co:,pared with Kairouan (168.7/39.0). Sousse performed 61.3% above the national average (106.3 per 1000 MWRA); Kairouan, by contrast, 62.7% below. In order to get at a glance a feel for the whole evolution, Figure 10 was constructed. It gives the evolution of FP activity for the five highest (Sousse, Gafsa, Tunis, Bizerte and Monastir) and five lowest (Kairouan, Medenine, Mahdia, Jendouba, and Kasserine) levels attained in 1979 as well as thE All-Tunisia curve. It appears now that for many years Sousse has had the highest activity , Kairouan the lowest. Tunis had the second highest and Medenine the second lowest.

- 25 ­ TABLE V TREND OF NEW FAMILY PLANNING ACTIVITY, BY GOUVERNORAT 5 / TENDANCE DE NOUVELLE ACTIVITE DE PLANNING FAMILIAL, SELON REGION5 Unit: Rate per 1000 MWURA (Sum of 6 methods) Unit4: Taux pour 1000 FMAR (La somme de six mithodes) INDEX OF NEW FlIILY PLANNING ACTIVITY 6 (IN-FPA) 6 A compldted [6-YEAR I CHANGE INDEX DE NOUVELLE ACTIVITE EN PLANNING 7 F&MILIAL (IN-APF) en mars 1982 PERCENT CHANGE I IEAN OVER 6-YR H

4 5 1974 1975 1976 1978/ 1979/ 1980/ A B C 1977D 1978 1979 1980 1977 2978 2979 E F G E/D F/E C/F H F/H Rank I Sousse 96.7 127.0 178.8 166.3 1 163.7 -- -13.5 + 1.4 1__55.0 + 8.8 4 2 Gafsa 74.9 97.1 130.0 140.6 CiD 135.4 i+ 4.7 - 8.0 _ 120.9 +12.0 2 3 Tunis 1;9.5 134.5 157.3 154.2 1 62.0 134.2 + 5.1 -17.2 - 143.6 - 6.5 12 4 Bizerte 108.4 104.6 115.3 224.1 .9 130.9 +13.5 - 7.1 __ 120.7 + 8.5 5 5 Monastir 90.5 86.7 125.3 134.2 § 121.3 + 9.7 -17.6 115.9 + 4.7 6 6 Nabeul 148.9 251.2 153.7 122.9 117.0 -20.0 - 4.8 142.2 3 -17.7 i5 7 Le Kef 120.0 101.2 224.8 125.2 !25.8 +13.5 -18.5 119.9 - 3.4 9 8 Sfax 113.0 125.2 149.9 228.7 113.9 .- 14.3 -1.5 1230.2 -22.5 24 TU-SIE 85.7 93.9 S-- - . . . .-- ...-.-...-. .-.225.2.... C D 227.6 104.6 - 2.6 -22.1 ...... - - -. _ -..-_.106.3 . . - 1.6 Bja 94.3 65.8 116.4 103.7 96.6 -- -16.6 - 6.8 03.5 - 6.7 I 10 Gab~s 65.8 82.5 107.9 12P 121.5 93.3 -13.0 -22.6 98.8 - 5.6 20 11 Jendouba 71.7 54.4 74.4 3 85.8 87.3 -17.3 + 1.7 80.0 + 9.1 3 12 Kasserine 41.7 44.0 C 94.0 90.4 81.0 - 3.8 -10.4 79.3 + 2.1 7 13 Hahdia L1.7 77.6 91.9 89.4 77.3 + 7.5 -19.6 79.0 - 2.3 8 14 Medenine 36.9 41.4 56.6 55.9 63.2 __ +22.9 - 8.0 5.__ +17.5 2 15 Kairouan 45.9 48.2 40.9 43.4 39.0 __ + 6.7 -15.8 4.__ -11.4 13

ISocial Abortions and Tubal Ligations of Sidi Bcuzid have been 2 I Zaghouan included, together with that denominator, in Gafsa. I , in Tunis. 3 " Siliarn 5Descending "in Le Kef. Rank order for IN-FPA of 1979. 5Except for above notes, Sidi Bouzid, Zaghouan, nnd Q'iana could not be considered in this 7 This Index is the sum of 6 rates/lOG00 NRA (Nw breakdown. IU ,. New pill, New jelly. New condom, new tub.lig, The six-year mn of the IN-FPA: Permits ranking a social sb.) of ]' gouvernorats by 6-year overall new activity. Such means may be established in cuts of 2-years , in order to studiy qhifts of activity across broader time segments. C Peak Activity Year / Ann6e d'acrivit6 d.apointe GE rb 4 80 FlO1.,o TUNISIE ONPFP/USAID FP Program Evoluaton, Phoe-2

NOUVELLE ACTIVITE DE PLANNING FAMILIAL NEW FAMILY PLANNING ACTIVITY Slon R~qions ,t pour 6 onneas consiculives by Gouvernorot and ovvr Time Uni;: laux pour 1030 FAR Unt: Rote per 1000 MWRA (Lo iomme do six nthodes)* (Sum or 6 methods) Voir Iobleou V (,lection des extremes et do Io See Table V (selection or "extremes' and A compleler courbe pout la Tunisie ontire) AII-Tunislo c urve) an mis, 1981 200 IN-APF: Index do nourvelle activit do PF *IN-FPA :Ind.' of New Family lonning Activity

*.rU/ IS < ,, "- - .--- -- sc;-'

Li..

A-//6s .... 1. A. ac ."...*.. 117.62

104.6

, -<.. s.. x . ..':..Kassetine ".

77777.3

ccc C3.2

,so., 39.0

74 75 76 77 78 79 1980 (3) As done in Table V (col. H), one can calculate a 6-year mean of IN-FPA (1974-1979), and then study the 1979 variation relative to this 6-year average performance. The greatest relative increases are noted for Medenine (+17.5%) and Gafsa(+12.0%), the greatest declines for Nabeul (-17.7%) and Sfax (-12.5%). All-Tunisia decreased by 1.6%.

Consideration 8: Kairouan is singled out as the gouvernorat in greatest need of improving overall performance, followed by Medenine. While the latter experiences a slow rise in performance, Kairouan is not only the lowest performer but also further regressing in 1979. In both gouvernorats special task forces have to be formed and the various members must be fully aware that they have a record of lowest national input that has to be corrected from within that gouvernorat. Basic needs to improve the annual performance from 1980 onwards have to be identified by these tack forces and their report must receive high priority at both the (1) Ministry of Health and (2) ONPFP. Major cooperation between MOH and ONPFP has to occur electively in such gouvernorats.

It should be noted that there is no obvious relationship between effective protection prevalence and overall activity. Activity includes such actions as social abortion and secondary methods. Hence, it is essential to study the data according to Table V, but substituting the IN-FPA by the 6 component parts leading thus to 6 new tables (and many overview charts). This analytical work should be done at ONPFP/HQ, in the following sequence: (1) tubal ligation, (2) IUD, (3) Pills, (4) Condom, (5) Ge]he , and , of course, (6) induced abortion the latter possiily before the secondary methods. Given the extraordinary position tubal ligation has for rapid build-up of resilient protection prevalence (see Figs. 2,3,4), specific analytical work has been initiated below.

Table VI and Figure 11 surmarize the findings of Trends in Tubal Li&ation. Note the following points:

(1) The year of peak activity in tubal ligation was 1974, overall and in the greatest number of gouvernorats (Bja, Bizerte, Jendouba, Sfax, Mahdia, Medenine, and Gafsa/Sidi Bouzid); the peak was in 1975 for another three gouvernorats (Sousse, Kairouan, and Kasserine); the only peak noted in ]976 was for Nabeul. Most interesting, during the peak year of overall activity in 1977 (120.6/1000 MWRA) there was not a single peak of tubal ligation! In 1978, there were two spastic peaks (Monastir and Le Kef/Siliana). Finally, in 1979 there were two'peaks'(Tunis and Gabes). This pattern of peaks across go!'vernorats translates momentary efforts to increase tubal ligations. Clearly, in 1974, there must have been a tubal ligation drive, with some echoes in ]975. That drive was not sustained; that is not incorporated into the day­ to-day operation. "Flash in the pan" efforts are noted in 1978.

- 28 ­ (2) Fig. 11 and Table VI (col. F) show that in 1979, there was an over 20-fold ligation activity in Baja (26.8/IO00 MA) as com­ pared with Gafsa/Sidi Bouzid (1.3 /IO000WRA). Baja performed 188.2% above the national average (9.3/I00OMNrRA); Gafsa/Sidi Bouzid, 86.0 below. Fig. 11 gives the evolution of tubal ligation incidence for the five highest (Baja, Bizerte, Sousse, Jendouba, and Kef/Siliana) and five lowest (Gafsa/Sidi Bouzid. 4edenine, Gab~s, Kasserine and Tunis/Zaghauan) 6-.Year mean incidence ittained (col. H in Table VI) between 1974 and 1979. At a glance )ne notes that B~ja has had a continued record of high perfornance :hat averages to 29.08 tubal ligations per 1000 MWRA, contrasting ¢ith a continued low performance in Gafsa/Sidi Bouzid that averages !.05 per 1000 MWRA -- a 14-fold difference in average annual :ubal ligation input. The contrast with Medenine (2.98/1000) Ls ninefold, as it is with Gabes (3.02/1000). Fig. 1] also shows )ery grect variation across years for certain gouvernorats. 'or instance, relative to 1975, the Sousse incidence of tubal ligation (37.1/1000 MWRA = 100) was 57.4 in 1976, 27.U in 1977, 14.0 in 1978, and 20.4 in 1979. Kef/Siliana's 1978 peak of 28.9/1000MWRA =100) fell to 42.2 in 1979, a one-year drop to less than half. Table VI shows other such dramnatic decreases. Jendouba's incidence of tubal ligation dropped from 28.0/]000IMRA in 1974 to 8.3/0001WRA in 1978. In Nabeul the incidence dropped from 15.1/1000MLTRA in 1977 to 4.5/1000MWRA in 1979, etc.

Tunis and Bizerte stand out. A crisp increase in incidence of tubal ligation is noted since two years: from 5.2/1000 to 11.5/1000 for Tunis/Zaghouan & from 11.8/1000 to 21.3/1000 in Bizerte. Care should be taken to keep this increase on the increase and to secure an institutionalized work performance of perhaps 25/1000 MWRA, annually, in order to reach the performance level of B6ja in some years. The three (four) gouvernorats house 27.3%(30.8%) of Tunisia's WRA and the demographic impact would be rather important for the all-nation fertility decline.

Consideration9 : Three early actions are suggested by the tren3 steies: 1. Secure a continued growth of the expanding annual incidence rate of tubal ligation in Tunis/Zaghouan and Bizerte; and, of course, secure continued performance of between 25.0 and 30.0/1000 MTTRA in Bgja. Further investments in equipment, training are warranted in both Tunis and Bizerte to secure the breaking of "flash in the pan" tubal ligation performance.

2. Secure through specific training and investements and specific interfacing of maternity centers and ONPFP teams, to boost the ligation rates within 1-3 years to the national average, that is to annually one percent of the MMRA in central and south Tunisia. Then let the curves evolve slowly upars.

3: Sousse, Sfax,_Nabeul and Jendouba must reconquer rates of past performance. This can only be achieved by creating the material conditions and a smooth cooperation between the maternity centers and the regional delegation of ONPFP. If additional training and equipment is warranted, then it should be provided on a priority basis , that is in 1980.

- 29 ­ TABLE VI TENDANCE DES LIGATURES DES TROIPES, SELON REGION TREND OF NEW ACCEPTANCE OF TUBAL LIGATION, BY GOUVERNORAT Unit6: Taux pour 1000 F MAR. Unit: Rate per 1000 MWRA. COHPARAISON DE IENJEU LES LIGATURES EN INCIDENCE et PREDOMINANCE DE PROTECTION JUXTAPOSITION of the LIGATION's SHARE IN INCIDENCE AND PROTECTION PREVALENCE.

INCIDENCE PREVALENCE

Rate/1000 Rate/ I1979 Incid. is I ALL TUB.LIG EPPthat N C I D E N C E OF TUBA L LIGATION 114RA/FOAR PERCENT CHANGE 1000 relative I N C I D E N C E DES LIGAGURES DES to tHE- over TUBAL TROtES 1HPWRA6-Year Hean TIIODS ALL HTm LIGATION 1978/ 1979/ 1980/. 6-YEAI 1979%Change 6-YEAR X ALL %EPP/AM ank Gouvern. 1974 1975 1976 1977 1978 1979 19806 1977 1978 1979 1EAN OVER 6-YR M. MEAN METHODS being TL A B C 2) E F G EI) FIE /F[ -1 F/H Rank I H/I R K Rank I Sousse 25.2 C D 22.3 20.3 4.3 7.6 -53.4 +58.3 17.1: -57.1 23 i55.0 22.43 R45.6 7 2 Gafa I "3 2.8 2.1 1.5 0.3 1.3 -46.7 +62.5 1 2.01 -36.6 9 220.9 1.70 1. 12.8 15 3 Tns.26 8.7 +7.3 +32.3 I 8.7: +32.9 2 243.9 6.06 22 36.2 10 4 Bizerte 17.5 12.9 11.8 19.8 21.3 +67.8 + 7.6 ,.5F18 +14.6 3 220.7 25.39 4 50.4 5 5 Monastir 19.2 12.3 22.2 8.6 4.4 +241.9 -85.0 14.5 -69.7 15 15.9 22.53 7 44.6 9 6 Nabeul 14.4 12.6 15.1 7.2 4.5 -52.3 -37.5 _ 11.7 -61.8 14 142.2 8.28 2 35.1 11 7 Le Kef 13.8 11.5 10.6 14.9 11.9 +93.7 -58.8 15.2 -22.1 7 119.9 12.74 6 45.0 8 C:0 8 Sfax ($-2.3) 23.9 ------22.7 -----­ 26.8 23.9 22.4 -27.3 -28.0 24.83 -23.2 8 230.2 12.39 9 50.7 4

TUNISIE C1l..36) 12.130 10.36- 9.69 10.39 9.26 ___ + 7.22 -20.79 22.2', -26.88 206.3 10.48 45.'z ------. ------9 B,ja CED 26.3 27.7 34.0 24.6 26.8 -27.7 + 8.9 29.08 - 7.8 5 203.5 28.10 1 64.4 1 Gabes 4.8 2.6 1.9 1.2 0.8 -0 -33.3 +750.0 / 3.0 +125.2 1 98.8 3.06 24 20.0 14 It Jendouba 281.4 14.5 14.1 8.3 8.4 -21 + 1.2 15.2F -45.0 11 80.0 29.20 3 58.8 3 12 Kasserine 1.4 C 7.8 6.2 4.4 5.8 -29.0 +31.8 5.63 + 3.0 4 79.3 7.10 11 26.8 Ii 13 Hahdia 10.1 9.9 12.7 9.0 9.9 -29.1 +10.0 11.07 -10.6 6 79.0 24.01 5 48.6 5 14 Medenine 3.8 4.2 2.7 1.1 1.5 -59.3 +36.4 / 2.98 -49.7 12 53.8 5.5413 35.0 13 15 Kairouan 20.8 Q 8.9 5.9 3.7 5.1 -37.3 +37.8 8.77 -41.8 10 44.0 19.93- 2 69.0 2

I Includes numerator and denominator of Sidi Bouzid; 2 Includes numerator and denominator of Zaghuan; Includes numerator and denominator of Siliana 4 Descending Rank order for IN-FPA of 1979 (similar as organization in TABLE V). 6 Sidi Bouzid, Zaghuan and Siliana are absorbed into Gasa, Tunis, and Lo Kef, Should be respectively. completed in March, 1981. 7 See also Figs. 11 and 12. Figure I1. TUNISIE TrNDANCE DES LIGATURES DES TROMPES / TIEND OF TUBAL LIGATIONS O4PFP/USAID FP Program Evoluation, Phoe - 2. Incidence des Ligatures des Trompes Incidence of Tubal Ligation salon R;gions ei pour 6 annect consicutives. by Gouvernorat and over Time

Volr Tableau VI (election des extremes Ct do Io See Table VI (selection of 'extremes" and coulrbe pour toutse la Tunisia) All-Tunisia curve) Unlet: Unit: 40 Taux per 1000 FMAR Rale per 1000 MWRA

A completer en mars 1981

30"

i761

20 3­

144 . min­ 12.P /

740. 75. 76777 7 lS

-...... 74 75 7G 77 78 79 1980

-31 ­ Figu:e 12. From INCIDENCE TO figveNCIDNCETO 1. Fom PREVALENCE.REVLENC. ICIDNCE...... :?...... INCIDENCE PEAEC PREVALENCE

INCIDENCE MOYENNE DES LIGATUIES DES TRCMFES (1974-1979) EFFECTIVE PROTECTION PREVALENCE pertaining to TUBAL LIGATION (EFPITL) MEAN INCIDENCE OF TUBAL LIGATION from 1974-1979 PREDOMINANCE DE PROTECTION EFFECTIVE due oux LIGATURES DESTRChJPES(PPE/LT) a of I.Jan. 1980 ou Ier Jan";er 1980 (Mean)Ratr per 1000 Women (MWRA/FMAi') Percent Women (MWR,/FMAR) 0 10 20 30 0 5 10 15 I I

BEJA I

UIZERTE 2 18.58 . 10.3

.NCSSOUSSE3 .417.72 59.6 JENDCLMA 4 S: 3 ' 10.9

LE KEF(SiI) 51S.27. 11-

SFAX 6 14.83 ! 8.8

MONASTIR 7 1 14.52 7 84 I T NAEUL 8 . 78 105

______.26 -1 2 -11 ------4-20

MANDIAI Ii1

WHIA7 .07 .

KAIP.OLLAN 10 8.77I4.4

TUNiS(Zog)11 8.72 I ¥KASSERINE 12 I I * I .* 12 | NOTE: Asnt 1974 11y o ,aotousi des ;g lure,. t~~~~ct -.r-u s : ;,,,plique on grao.* part;* lo cor-

GAS(S.B3IS 2O rexlion "z;gzog"n(eddenla encr GAE13 .0 15 1.7 4.4 I'incidencec pour ,une p t;ode fix* at Io ­

MEDENINE )914 2I I3I .~ 2 1 peedomdnan:eBefore 1974 thereou debutwert dealso 1980. I;gat;om, whl exloins to o great extent the "j;g-sowo : GAFSA(S.&)15 2 : 14 1,9 cOrrelation b t'een forandencea Fixed I time segment and the prevalence at the beg; n_ of 19E0. GErb4 60

du lom Qu;tF enn. L b obactilve%basedbasesatcliftansurexperienceJ1experlence: :-climb mnlter gradually grodueflement to reach 20/100020/1000 MVRA pour [aof flnthe lostpiofha;n year of the next Fivv-y-- Plan. ....et fovor;ser Its7(42) gouvernorats qul sottowvent ....and favor the 7 (+2) gouvernorrta which ore , . Sl en dessouil' mayenne nationals, below the notional average. :1986 era o O21Olve gu forMatice ratesgC1vait as we astae oofidhrae ofe f the .u...oratS,ver it is1irrea as theto referencere Becauseof thel P ,t national figures cosiertin10 individualogre an ong others gouverfloratS w annual progressfperformancea" of some Incesed"nby decreases in perforrance ther bicaete by dereand17 ence it is suggested that 0 - h lnpa ' b eaj21-­ - e asses~sed be hiep im erf i t ould entire This is particularly It sihol b s ua of sterilisation eneratedof by Tun theNYtisiFP over e methtthatthod at thetend edn ofe 1979, 45.2% ge protection prevalence pertaining to tubal it fits e)xIstence was One year earlisslowy seve yer sevandA 5 Intshatother wurs..... e lgatu ligationslian S(- - J,/16.19 ) and t prdslethe igaiol it not n ote is slowl was inraig 42.2% (6.82/16.15• ). protetioreanc nations 5onditions shretotheeven under adverse . ash jrigation shre Increasing iesaquiredthis evolution preeraableto favor 0-te Incidenceis a . _ ,,,anitu. prevalence of aru=,On ird protection d of antOf'ac .. ligation senS' tive to the ligto alerte verY easshhedof tubal the del~gueS thelloinll0wing the progresslevel will keep the0 gouvernoratS' ahead. to the ,agnitude of the tasks s bBein e 3 . I n es s en c e Li atiof ".r ovq&jefTubal and Prevalence c eof ncidence and Figure 13. n 3.5Lina to construct Figure 12 Table VI then was used te it is possible to calculr rate of tubal ligation given the low attrition compare this for each period, and to the end of that input rate for the 6-year Pre,alence (EPP) for a mean annual Effectivc Protection gouvernorat with mean 12) on the one hand, and on the other, to comparethe the"kll relative Method period (Figure and prevalence of in both incidence shares of tubal ligations observations are made: 13). The following protetion (Figure across the is a quite strong (pictrial) cralenceP u A s uthern (1) There 5 eSmall in (incidence) e1ligation ti ligns incidencei ...c and prev icdne ml nu ofe 12; despite thern enti~is(i.1)the gouvernorat, effestvely le low EPP/TL- of the Figur 12; luisi15 geographic a th rsrvi.e... WRA for year w , the i bottomat rOnless in Gafsa/Sidithan.a 5% of allBouzid, Medenine, sevenTuisenTeisiaped years bwork,ta l Given thatthe reservoir prt dby tubal lgio. -/4 and 1/3 e n. a Karouan.tubal ligation Is between potentiab has reain be iianaen teWnall A the present EPP/TL of to bat ided bit rWPate is much higher than it ought Th s th ( 0 notp ? beena d thprovied e 14011 robligation bl du e servicesto la k have bbebirth ecau se rate medically ta ee ena -depuate duo lack of between sese hasb n-- coordinationtn. ­ uh cooperation snc ase evaluation mission. days insufficientare now probably gone by, second ph during the amplY discussed - 33 ­ (EPP/TL) PREVJALENCE qC ,TblLa-f ME If Y.ETHCD mX(INCIDENCE) faSHAr.r ENCECF .... ECT. MIX(INCIDEPCE) & oAespondfg (much greater) 13.THEWE: TUBAL LIGATION SHARE of .ETHOD EAnCE INCIDENCE FV A(EPP/TL)1,9 to, Percen AI-M, tb Incidence perta n0"' pertarnIfg to TjboI tlgotoon(EPP/TL) 1.Jon.t (EPP/IL) ° M AR) (6-Year Mon) Percent Women Q to Tubol LUgoion - e 10r , Ligoti P , prevalence beng Tub.75 100 0 percent0 of Protectbo¢' s percent of Incde c beon Tub. LI tiof. 10 20 30 1 0 t010 10, 1441 4..0 1 I 28.10 60.0 1019 .3 SfjA 1 114 19.93 6 ..8 K A IRO UAN 2

19.10 0. S 3 -- ---. 48.6 :I .q JEtjDOIAZERTh SI E .T 15.39 2 - B. AS.O . tAIA S A. 4.6 7 ?PAtHLIA 514.01 2 LE KEF 6 12.74 9.6 9 12.53 5 ~s~ SOUJSSE 85. 11.43 . .it 45 I SAX 911.39 I

TUINISIE= 0.81 :I.":: . 2 1025 i351 NAEU1. 10 a18 K 1 7.1 0 13 2 .SSERINE1 13 2 .1 U I S 12 06 ! .7 12 .0 15 .7 YEDENINE 13 5.54 14 2.0 . ABES 14 3.06 14 14 1.9 3.06 rG BE 1 15 12.6C b4 0 I GAFSA 15 1.70 (2) Figure 12 is also important insofar as it contains the information necessary to set objectives for the next five year plan that are to be realistic in the Tunisian context Look at Figure 12. For a mean annual incidence of 11.1 tubal ligations / 1000 MWRA over the last 6 years (+ a certain amoint of ligations earlier) the nation reached an EPP/TL of 7.3 percent MWRA as of the end of 1979. Baja that contains one twentyfifth of All-Tunisia's MWRA had a mean annual input of 29.1 TL/1000 MWRA, generating an EPP/TL of 16.0 percent of all MWRA at the end of 1979. The first author, in discussion with Tunisian colleagues, has picked the half-way figure of 20/1000 MWRA to be reached at the end of the next five-year plan (1986) and to be maintained as feasible incidence of tubal ligations from then onward (halfway between 11.1 and 29.1 20). Of course, this is arbitrary, but it is halfway between the mean annual incidence of All-Tunisia experienced over the last 6 years and the gouvernorat with the highest performance. This would lead to a EPP/TL of between 12.0 and 15.0% MWRA by 1986. The major consideration is a steady build-up of both incidence and preva2ence avoiding the "flash in the pan" peaks of TL incidence. If this can be achieved gradually, then the stage is set to let the "system" grow from within and that its carefully prepared momentum would then carry the EPP/TL from around 15/100 MWRA in 1986 to well over 20/1000 MWRA in 1991, that is at the end of the subsequent five year plan. The corresponding demographic impact would be salient, and there would then be available still two other five­ year plans for achieving the demographic objectives by the year 2001 ( Italy's profile of age-specific fertility rates of 1967". In essence, the four next five-year plans must be planned by ONPFP not so much in terms of births to be averted as in terms of Effective Protection Prevalence to be attained by (1) Tubal Ligations, and (2) All other methods. Of course, the "Prevalence Approach" stimulates regional performance and hence will automatically boost the number of births averted beyond any figure that would be advanced without passing through the "prevalence approach". Doctors will fully understand the Prevalence Approach because the concept is really one of preventive medicine with a given protection prevalence producing health benefits to be shown by MCM!

(3) Figure 13 gives another relationship: The relative share of tubal ligations in the incidence and prelavence rates cf All Methods for 15 Tunisian geographic entities. For All-Tunisia, 10.5% of the "All Method" incidence pertained to tubal ligation; the cor­ relative share in EPP/AM (Effective Protection Prevalence /All Methods) was 45.2 % for tubal ligations. For Baja, the corresponding figures were 28.1% for the incidence and 64.4% for the EPP/AM. At the other extreme, the figures in Gafsa were 1.7% for incidence and 12.8% for the prevalence. As a very approximate interpolation, one may estimate that the relative share of tubal ligations in the incidence of all methods should grow to around 20% by 1986 and that this may bring the relative share of tUbal ligations in the EPP/AM to around 55-60%. What matters is to understand that the future protection prevalence in Tunisia will be mainly due to tubal ligation; leaving around 40% to all other methods.

- 35 ­ TABLE VII TREND ANALYSIS BY TIME FENESTRATION: Eight Consecutive Januaries from 1973 to 1980. All Primary Methods, including Social Abortions. Primary FiLmily Planning Activity Index. Succinct Readtng: (1) 1977 emerges as the peak year. The 1980 performance proceeds at a rate lying between 1975 and 1976. (2) T-iUe Fenestration Methodology enables to study program dynamica conconitant with program occurrence. JANVIER / JANUARY

1973 1974 1975 1976 1977 1978 1979 1980 80/77(Z) 80/79(Z)

FMAR: 725500 748950 773187 798264 824203 851035 878795 907513

D.I.U. Fr. 790 1371 1484 1512 1914 2017 2301 2285 T.H. 1.089 1.831 1.919 1.894 2,322 2.370 2.618 2.518 T.A. 13.067 21.967 23.032 22.729 27.867 28.441 31.420 30.214 +8.42 -3.84

Pilules Fr. 940 757 1071 1900 2345 2359 2111 1807 T.M. 1.296 1.011 1.385 2.380 2.845 2.772 2.402 1.991 T.A 15.548 12.129 16.622 28.562 34.142 33.263 28.826 23.894 -30.87 -17.11

M4th. Sec. Fr. 844 926 870 1205 1666 1332 1339 1281 T.M. 1.163 1.236 1.125 1.510 2.021 1.565 1.524 1.412 T.A. 13.960 14.837 13.500 18.114 24.256 18.782 18.284 16.939 -30.17 -7.36

Lig. Tr. Fr. 227 963 855 774 808 691 864 651 T.H. 0.313 1.286 1.106 0.970 0.980 0.812 0.983 0.717 T.A. 3.755 15.430 13.270 11.635 11.764 9.743 11.798 8.608 -26.83 -27.04

Les Quatre Fr. 2801 4017 4280 5391 6733 6399 6615 6024 Cat~gories T.M. 3.861 5.364 5.536 6.753 8.169 7.519 7.527 6.638 T.A. 46.329 64.362 66.426 81.041 98.029 90.229 90.328 79.655 -18.74 -11.82

Avort. Fr. 411 852 1111 1537 1847 1752 1769 1486 Sociaux T.M. 0.567 1.138 1.437 1.925 2.241 2.059 2.013 1.637 T.A. 6.798 13.651 17.243 23.105 26.891 24.704 24.156 19.649 -26.93 -18.66

Toutes Categories Fr. 3212 4869 5391 6928 8580 8151 S384 7510 T.M. 4.427 6.501 6.972 8.679 10.410 9.578 9.540 8.275 T.A. 53.127 78.013 83.669 104.146 124.921 114.933 114.484 99.304 -20.51 -13.26

Fr.: Friquence/Frequency: T.M.: Taux mensuel/Nonthly Rate. Taux/Rate: pour 1000 FHAR/per 1000 HMRA. T.A.: Taux amnuel, Annual Rate. Toutes Cat~gories: INDEX dACTIVITE NOVELLE DE PF / PRIMARY FP ACTIVITY INDEX. TU-GE rb/ch 4 80 Consideration H: The trend studies of both incidence and prevalence of protection of all methods in general and of tubal ligation in particular led to (1) defining feasible objectives for the future incidence rate of tubal ligations (20_p2er 1000 nRA b 1986), and (2) estimating the relative share of tubal ligations in the incidence of all methods (20% bX 1986) and in accunulated effective protection prevalence of all methods (55-60% by 1986 up from 45% in 1980). This infornation, derived from the national program experience of the seventies will be very helpful to design an overall scheme of objectives from year to year up to 1986. This realistic planning built upon experience has a greater chance of succeeding than any other approach.

3.6 Evolution of All Methods of FP: Monitoring by Cumulative Trend Analysis (CTA)

3.6.] January 1980 versus earlier Januaries

Table VII and Figure 14 gives a trend analysis by time fenestration. Monthly and annual rates have been computed for all methods -- single and combined -­ for eight consecutive Januaries (1973-1980). At a glance one notes that the performance in January 1980 was significantly smaller than one year earlier. All methods, including social abortions were performed at a rate 13.3% smaller than in January 1979 with the greatest decrease in tubal ligations (-27.0%), followed by social abortions (-18.7%) and new pill acceptors (-17.1%). The smallest decrease was noted with IUDs (-3.8%). Figure 14 shows also that even thl "January window" quite nicely portrays the trend as known from trend analyses pertaining to the entire year. In sum, the expectcd reversal had not yet occurred in January of 1980. Figure 14 is ready for charting in February of 1981 the method-specific performance of the year 1980,

Consideration 12: Figure 14 is a typical "early feedback chart" that should reach the d~l~gu~s with some com-mients by both the statistical division and the medical division, for instance. What matters is that the d6Tgugs perceive that the annual performance can be- easured during its7 nonth-ro-month build-up and that hence monitoring can help to "catch up" still during the calendar year. As important., note the concept of MONITORING PLARNING (ME').

3.6.2 January, February & March, single and combined as 1st quarter

At the end of the mission, the figures of February, 1980 became available. A master table has been developed (Table VIII) that enables comparison of perform­ ance for the first three months, single and combined relative to the same pe­ riod one year earlier. Clearly, a sudden change has occurred as the activity

- 37 ­ Figue 14 GOT/USAID FP Program Ealuation, Phsts-2.

TREND ANALYSIS BY TIME FENESTRATION: Eight Consecutive Januories front 1973 to 1980. All Primary Methods Including Social Abortions. Methodology: The rates per 1000 MVIRA have been ,ul!;plied by 12 In order to get the -annual rate"at which each method has "entered' thePublic National FP Program during -he month of January from 1?73 to 1910. The four categories of primary methods have been summarized to malie a comparison with the e,.olution of Socal Abs. Succinct Reading: (I) 1977 ern-rges as the Penk Ynor of Incidence of all methods. 1980 started out at a rote elxerienced between 1975 and 1976. (2) For the month of January, the overall decline in activity was -13.3% in 1980 as compared with January 1979. From 1976 to 1977 the increase was .24.5%. L gend/Key: LE PASSE / PAST LE PRESENT/PRESEI"T LE FUTUR/ ...... Pilules/Orols I I FUTURE ...... Acceleration ..... Deceleration Acorrpl. ter e D.I.U./IUD Fill in .in: Meth.Sec./Sec.Meth. 4 Ca:cgories/4 34.14 Febra )19E...... Lig. Tub./Tubol Ligation ...... Social Abotion 31..2

S30- 30.21 . . 2 7 .8 7 " 2 8 .83 S."

-. 24... 24.1 .. . f~19 ..- 7......

0o - 20- .- " ,,,'2.26",- ­ -- =

...... 1918.28 / 16.09 69 - ......

. " ...... 3 11.76 " 12.13 ...... 11.80

NOTE: Do 1974 a 1980 (Janvier) l'incidence des ligatures des trompes arboisse do 44.2%. Celle baisst continue. From 1974 to 1980, the Incidence of Tubal L;g=tion decreased by 44.2%. This decrease is continuing. 8.

-* Chang.... tan % de Index d'octil ov el..ledoPF: _:,_' %Change in Primary FP Activity Index :

1973 1974 1975 1976 1977 1973 1979 1980 Janvier"/ January TABLE VIII CUMULATIVE TREND ANALYSIS (CTA) OF HETHOD-SPECIFIC FAMILY PLANNING INPUT (This 2980 over 1979: FIRST QUARTER. Table may be completed at the end of April, 1980 and the Latest by right column figures transferred into "2-3" Line of Table mid-May, the findinga of the first quarter 1980 should be II. T in the hands of the regional delegates: to stiulate 2nd JANVIER FEVRIER er MARS Ier TRIHESTRE 1979 1980 80/79-% 1979 1980 80/79-Z 1979 1980 80/79-2 1979 1980 8C/79-% FrAR: 878795 907513 878795 907513 I 1 878798 907513 878798 907513 i D.I.U Fr. 2301 2285 2027 2691 2614 6942 T.M. 2.618 2.518 2.307 2.965 1 2.975 7.899 T.A. 31.420 30.214 -3.84 27.678 35.583 +28.5 135.694 C 3.598 C ) Pilules Fr. 2222 1807 21736 975 2281 6128 T.H. 2.402 1.991 1.975 2.176 2.596 6.973 T.A. 28.826 23.894 -17.11 23.71 26.115 +11.0 i 31.147 _ 27.893 H4th.Sec. Fr. 1339 1281 2124 1279 2525 T.M. 1.524 1.412 3978 1.279 1.409 1.724 4.527 F.A. 18.284 16.939 -7.36 15.348 16.912 + 0.1 20.687 1. 07 C I Lig.Tr. Fr. 864 651 1 801 977 1 2036 2701 T.M.(T) 0.983 0.717 00.911 1.077 r.A. 1.179 3.074 1.798 8.608 -27.04 i 0.937 12.919 +28.1 14.147 12.294 C C Les Quatre Fr. 6615 6024 1 5688 6922 7446 19749 Cat6gories T.H.(T) 7.527 6.638 1 6.473 7.627 I 8.473 22.473 r.A. 90.328 79.655 -11.82 77.670 91.529 +17.8 1101.676 C 89.89 1 C Avort. Fr. 1769 1486 1 1467 1792 Sociaux .M.(T) 2.013 1.637 1849 5085 1.669 1.975 1 2.104 5.786 r.A. 24.158 19.649 -18.67 20.032 23.695 +18.3 25.248 C 23.145 C D Toutes Fr. 8384 7510 2 7155 8714 9295 24834 Cat~gories r.H(T) 9.540 8.275 r.A. 114.486 8.142 9.602 2 20.577 28.259 99.304 -13.26 I 97.702 225.225 +17.9 126.924 !!3:036

Fr. Fr~quence/Frequency. T.H. (T): Taux nensuel (trinestriel)/ Menthly Rate (quarterly). Taux/Rate: pour 1000 FMAR/ per 1000 1HIRA. T.A. : Taux annuel / Annual Rate. Toutes Cat6gories: INDEXd'ACTIVITE NOUVELLE de PF / PRIMARY FP ACTIVITY INDEX tne nesure pas le suivi) - (does not measure tMie tollow-up) TU-GE rb/ch 4 80 ++ Quarter performance. In like manner, the first semester analysis should reach the delegates before September, 1980. F ;ure 15. GOTrUSAID FF Program Evaluation, ?hate-2

Cr4?FP P.O$5;tAM PERF.M/,NCE: Janucry or.d February, 1980 as compoed vlh lycor eorlier(Jon, Febr. 1979). - .. cip.e$ Of Ar.olylicot Epidemiology applied to month-by-month FP Core Monitoring shows a Reversal 0t i (from decrease to increase) for all methods during the month of February, 1980. (Ann al) lnc'dence of New Acceptors for the Month of jonuor;- in 1979 and 1980 (i) LAnn'ual) Incidence of New Acceptors for the Month of February in 1979 and 1980 Percent Change of In-idence in 19E0 over 1979 . Note: so, below.

Q JANUARY QEFEBRUARY ( PERCENT CHANGE OF INCIDENCE RATE (1980/1979, given month)

(Annual) Role per 1000 M\V;LA (Incidence) (Annual) Rate per 1000 MWRA (Incidence) ... Percent Decrease Percent Increase... 30 20 10 0 0 10 20 30 -30 -20 -10 0 +10 20 +30 5 I I I I I ,

Soc. Abortian 4 19.6s 1980 123.0 - 7Jan. Febr.

Tub. Ligntion 861 390 7 2 1292 .(-27.0 Jn 'p.. '11.80 1979 10.94,/ 0 D..U. '1 /3 . 2f 1980 .SS : -3.8 Jan. Febr. 1*21.S 3 4 2 / . . 1979 " '- - " " 7__27.68

pill 23.901 1980 -1.12an + 28.83.-31779

Sec.Mehliods 6.94 1980 16.91 -7.4 b10.1 / 18 r' :'-"'.L 1979 ...... 35

NOTE: While in January 1980 the incidence of all primary methods was still on the decrease, a sudden rise for oil methods was noted in February, 1980. If this new trend were to be confirmed in March, then the National Family Planning Program would have reached an inflection Point in February 1980. By comparirng the %-changes with those derived from the "exercise pojections" In Figure 4, it becomes obvious that the FP Program has considerable potential for rapid Increase in performance. Note also that Social Abortions experienced an Important Increase In February, 1980. decreos, * increase

TUJ-GE rb/ds 4 80 in February 1980 was greater by 17.9% as compared with one year earlier. However, this February was a leap year. Nevertheless, the activity was significantly greater even if 4% are 'subtracted'for the equivalent of one work day. Thig turn around in February could signal that the performance curve has reached beyond a positive inflection point. The figures of March, 1980 will tell. Table VIII is ready for completion for March and the first quater. No doubt, the first quater findings should be fed back to the dil~guis latest by mid- May in order for them to adapt to that outcome quite before the Summer "valley" in the performance curve. Fig. 15 is one way of showing the apparent inflection.

3.6.3 1st Quarter, I Semester, and Entire Year Monitoring

Table IX and Fig. 16 expand the Cumulative Trend Analysis (CTA) of method-specific family planning input with cizcuLative time fenestration points at 3, 6, and 12 month. What matters is to put the latest findings into the context of earlier "windows". In other words, one of the most powerful approaches in monitoring methodology is to "carry time" at the same tine "two-dimensionally": (1) trend study across years for (2) cumulative time windows. Let's study Figure 16, that may be read as follows:

(1) In 1973,the program was expanding quite rapidly as there was a true acceleration on account of various methods (we chose as indicators the "three surgical methods": they are "syste-i­ bound" and hence reflect the capacity of absorption regarding service provision!). The three curves (quarter/semester/year) are stacked positively, that is the annual incidence rates increased each time a next time segment was added. (2) In 1975, this remained true, when passing from the 1st quarter to the Ist semesterfor all three methods. But during the second semester the activity fell dramatically for tubal ligations and also for IUDS, while abortions were still slightly expanding within and across years. (3) In 1977, the program was regressing as there was a true decele­ ration on account of all three methods. The three curves are stacked negatively, that is the annual incidence rates decreased each time a next time segment was added. In addition, it is clear, that the big deceleration occurred during the second semester. Furthernaore, the method that showed the greatest "resistance" or resilience was social abortions. (4) In 1979, the program continued to regress within that year on account of all three surgical methods, social abortions being again least sensitive to seasonal variations. (5) The first seven years of the ONPFP Program performance, treated by analytical epidemiology in a two-dimensional time frame are a very fine base upon which to project feasible objectives and monitor their "coming to be reality" within a given calendar year!

- 41 ­ TABLE IX

CUMULATIVE TREND ANALYSIS (CTA) OF METHOD-SPECIFIC FAMILY PLANNING INPUT 1973-1979: AGAINST WHICH TO MEASURE the ONPFP PROGRAM PERFOM-ANCE OF 1980 AT THREE TIME POINTS (Ist Quarter; Ist Semester; and Entire Year). "Three-Point Monitoring/Feedback". Figures for Years are Rates per 1000 KIRA; Figures in brackets are I Change of R/1000

MWRA 725500 773187 824203 878795 907513

METHOD PERIOD I1973 75/73------..75/73 1975 77/75 ...1277 ~...... 79/77------1979 80/790/7k­ 1980 Feed- I back: Jelly 1-3 1.20 (+15.0) 1.38 (+34.8) 1.86 (-29.6) 1.31 ( . ) l 1-6 3.15 4.1) 3.02 (+26.2) 3.81 (-27.0) 2.78 ( . ) 2 1-12. 5.84 -2.1) 5.72 (+21.5) 6.95 (-22.4) 5.39 ( . 3

Condom 1-3 2.97 (-25.6) 2.21 (+97.7) 4.37 (-26.5) 3.21 ( . )1 1-6 6.54 (-14.7) 5.58 (+64.3) 9.17 (-29.1) 6.50 . ) 2 1-12 11.59 (- 3.2) 11.22 (+30.5) 15.92 (-25.4) 11.88 C . ) 3

Orals 1-3 4.16 (+ 7.0) 4.45(4111.0) 9.39 (-25.8) 6.97 C . ) 1-6 8.59 (+16.4) 10.00 (+83.9) 18.39 (-21.7) 14.40 ( . ) 2 1-12 15.43 (+36.7) 21.09 (+58.6) 33.45 (-19.7) 26.86 C . ) 3

IUD 1-3 4.23 (+36.6) 5.78 (+40.0) 8.09 (- 2.3) 7.90 . ) 1-6 10.93 (+16.5) 12.73 (+29.2) 16.45 (-3.7) 15.84 ( . ) 2 )-12 23.14 (- 3.3) 22.38 (+29.4) 28.97 (+ 1.2) 29.31 C . ) 3

Tubal Ligation 1-3 1.09(+241.3) 3.72 (+12.9) 3.24 (- 5.2) 3.07 . ) 1I 1-6 2.35(+258.3) 8.42 (-30.2) 5.88 (-3.1) 5.70 C . ) 2 1-12 6.84 (+87.1) 12.80 (-24.3) 9.69 C-4.4) 9.26 C . ) 3

Social Abortionl-3 1.68(+163.1) 4.42 (+49.1) 6.59 (-12.1) 5.79 C . ) 1-6 3.85(+164.2) 10.17 (4-30.9) 13.31 (-12.7) 11.62 ( . ) 2 1-12 9.02(+129.4) 20.69 (+24.1) 25.68 (-14.7) 21.90 C . ) 3

ALL METHODS 1-3 15.33 (+43.2) 21.96 (+52.7) 33.54 (-15.7) 28.25 . ) I1 1-6 35.41 (+41.0) 49.92 (+34.2) 67.01 (-15.2) 56.84 ( . ) 2 1-12 71.86 (+30.7) 93.90 (+28.5)120.66 (-13.3)104.60 C . ) 3

Within Year Chane relative to previous reference yea z ('column') fall fall rise 7 3

Between Year Change I relative to previous •2 reference year ('row') rice rise fail ? 3

1980-1st Trimester figures to be computed at the End of April, 1980. Feedback to Gouvernorates should be made during May 1980 to affect Ist Semester. 2 1980-1st Semester figures to be coilputed at the End of July, 1980. Feedback to Gouvernorates should be nade during August 1980 to affect 2nd Semester. 3 1980-Entire Year figures to be computed at the End of January, 1981. Feedback to Gouvernorates should be made during February 1981 to affect first guarter.

Thus , this table is to be filled in three stages and the latest trend to be explained in a short text for feedback: and hence motivation for "Progran steering from within" at the-regional level. Regional Delegates must get a feel for total work. Source of Raw Data: ONPFP, see also Table IIIalculations GE rb 4 80 Illustrations: Figure 16 and 17.

- 42 ­ (6) The tubal ligations have been projected according to previous steps of reasoning (Fig. 12; Cons. 10). What matters is that the quarterly achievement may be inscribed in Fig. 16 latest by May 1980. The 6dlgu~s and the medical profession performing ligations will then know where."they stand" in the nation's 1st quarter over-all performance. Whatever, the outcome, ONPFP must then unleash some "animation professionnelle" to secure an acceleration in the program performance of tubal ligations, which in turn is measurable in August, 1980, as the curve "1-6" should come to lie above the "1-3" curve. In essence, continued monitoring "along a given year" is now possible and according to the outcome in August 1980 for the first six months, the medical division can take programatic steps 1o be implemented for the months September - December of the same year. What matters is that the "minimal target" of an annual rate of 12/1000 MWRA is going to be reached "by the end of that year". It should also be noted that programmatic steps may mean alerting the medical orofession on the facts, and that their cooperation is essential insofar as they must consider tubal ligation as one priority task of dispensing obstetrics/gynaecology and family health care. Truly, the medical division of ONTFP has a most inportant task to orient the Tunisian medical world on what signal contribution it makes to national development by sticking to targets expressed as annual incidence of contraceptive protection by tubal ligation, among others. If this is handled adeptly, then one has to foresee that the modest targets will be surpassed without much ado. This is the "Promotion from within" aspect of CT-Monitoring!

(7) Because "more tubal ligations" may often mean "selecting IUD candidates", the minimal target projection of IUDs has been kept low. Actually, it is being carried backward to a rate 25/1000 MWRA by 1983. What matters is that the minimal target is going to be reached by the end of 1980, that is 28/1000 INJRA. Of course, cumulative trend figures at 3 and 6 months into 1980 can be charted in Figure 16. Similarly, Social abortions can be monitored. Injectables were also inscribed according to agreements reached during the 2nd phase evaluation.

(8) Figure 17 was constructed as an outgrowth of Fig. 16. , but expanding to all six primary methods and showing the annual incidence as occurred in 1977 and 1979 as well as the annual target rates for 1980 (left side). The relative change of method specific performance in 1979 and that to be expected for programied objectives in 1980, as compared with the peak year of 1977, has been calculated (right side). Note that the only important increase is to occur with tubal ligations (+23.8%). Social abortions, by contrast, have no targets, as they are an indicator rather than an objective per se.

Consideration 13: Method-specific trend monitoring with early feedback to the regions for corrective adaptation is practicable at I, 3, 6, and 12 months of a given year. Objectives, realistic in terms of annual rates of incidence to be reached may be "steered" in March, May, & August, respectively. In turn, ONPFP demographic division can translate these rates into actual births averted. The medical profession in turn will understand the concept of E2Ein2_protection prevalence. The three concepts of quantified performance link three ONPFP divisions with the regional efforts.

- 43­ F;gure 16 GOT/USAID FP Program Evaluation , Phase-2. CUMULATIVE TREND ANALYSIS (CTA) For Three Methods of Family Plann;ng (Surgical) During the First Seven Years of ONPFP's Operation(,oseline). Groftin of reasonable TARGET RATES on PAST PERFORMANCE to cover the ne,t Five Year Plan (1982-1936).Exerc; . The three surgical m,-thods studied are: (|I Intrauterine Device (D..U.)..ner acceptors In Addition (4) Injeclables ore also cons~dr~e (2) Tubal Ligation (L.T.) (3) Social Abortion (A.S.) Unsit of Measurement: Rate per 1000 mWRA / Unite do Mesure: Toux pour 1003 FMAR.

Premier Septennot de I'ONPrP (1973-1979) Transition PLAN (1967 - 1986) 40 L 1 77I I5 II I 1923 1977 179175 19SO 1981 1982 1984 19,86

Taux d'incidence annuelle boa sur le premier Tr;mestre (1-3) A completer Toux d'incdence annuelle Eas? our le premier Semestre (I-6) en mars 1981 Taux d'inc;dence annuelle ba,9 sr soute I'onnee (1-12) .35

31,60j 31 .o ":-'

30 291-12o* 2 29 . .. 29 29 2 11...... 5.. .

2,1-6 , :: .- .| : :::...... : . . : : : . : :- ; : .: , . ....2i. ,, ..... i...... - 2S a. 'a , ,23.16 3)DIU, Stabilizatlon a 25/IO O

""20 - u / / 210 . 4-2020 ..... 2 0

""". a 20/1000 a /16.."8 la flndu Plan.

14.8

o. , /u 2) - HA .0 1 10 1 :10

t 1) Decrease of program pcrformonce during second 6 months %43 0 .. S 2)Decrease of prrmperformance from first to secord 98.. ... Trimest, .. ad mare so tc 11e second Semester ...... 2 3) No Tartl cs Scc;al Aborlior, is rat!rer on lndicator 2 . "! : ! : ! of g ,e ol ovai!ubil;:y of FP services...... ::: ::...: :: : :": ::::::::':: : : .:.'- : : ::.'; ' :: of ,, : :..t .; :. :.:...... i.:. .:. I - :: ;.". .:.; 1973 1975 19770r...... 1979... .. 'SO '81 1982 1984 1986 Faurre17 GOTAJSAID FP Pro,m Evaluation, Phase-2. ONPFP FP PROGRAM PERFORMANCE 1977, 1979 -- Upon which 1983 EXERCISE PROJECTIONS are built ('Target Setting from Within.) j Annual Incidence of New Acceptors, by Method ( Rote per 100 'WRA) ( Change In Incidence reoative to that obtained in 1977 ( Percent of 1977 Incidence Rate) Gradient of Efficacy/Effectiveness: Corespond;ng Incidence Rates lead to 4 Projected short term TREND built upon recent post (Exercise) Na;onal Efficacy/Effectienecs PROFILE o INCIDENCE OF "New 0 Acceptors" / INCIDENCE de nouvelles Contraceptrices PERCENT CHANGE OF INCIDENCE RATE relative to that Obtained In 1977(pek Yeor Rote per 1000 MWRA/ Taux pour 1000 F/MAR Percent Decrease /Pourcertoge "+" Pourcenoge "-/Percent Inceoee 0 10 20 30 40 -3o -20 -10 100 o10 2 30 METHOD YEAR

1980 open ended / No target as dependent on FP 197" 21.9 SOCIAL ABORTION 1977 12S..6

11980 12.0 (0) F-l J 1980 eerc46projection" 2. 4 1979 .9.26 i!A 1979 occurre.d 4.4 TUBAL LIGATION 1977 . .?7'- 9.69 i I 1977 occurred (bench mark) 19E,0 -° 12a KEY: Read from Bottom to Top 1979 .29.31 ICL2 IRIMAZY IUD 1977 ...... 19W 127.0 -19.3I2I~~

PUIMARY PILL 1977 , - , -.

1980 ' 11.0 -30.9_ , 1979 S.S.4 777 PRIMARY CONDOM 1977 __439 1980 G.0 1 .7F 1979 :5.39 2 2 - .4 [ 1.7 PRIMARY JELLY/Cr. 1977 . . 6.$S . Efficicy/Efrectiveriess O 19771100 30Gradient

NOTE: Study from Bottom to Top (along the EE-Gradlent) TU-GE r/ch 4 S J 4. OBJECTIVES FOR THE FIVE-YEAR PLAN

In Tunisia, the medical and paramedical manpower is the key to meeting objectives, because of the very nature of the FP Program. "Clinics" play a key role and a spirit of 'medicalisation' of FP is now conquering the three universities, the ministry of health, and, of course, the Office itself. No dc jt, the eighties will experience an important 'integrative expansion' and hence penetration of FP because the medical profession it to cooperate more fully. Meanwhile, the work of the Office pioneered, among other paths, the one leading to know what it will take to achieve planned and feasible progress.

Monitoring led to new thinking. This section nails down feasible ob­ jectives for the next five year plan: Step 1: Define annual incidence ratesbX method from 1980-1986, based on knowledge acquired through monitoring. Step 2: Derive the method mix profile by transforming step I into pro­ portions of actual activity. Step 3: Calculate the annual new protection conferred by this scheme. Focus, for the time being, on the two most efficient methods (new IUD acceptance and tubal ligation). Step 4: Have the Office calculate the births averted according to the "incidence package", past (1973: 1979), present (1980 & 1981), and during the five-year plan (1982 - 1986). Step 5: Calculate the All-Tunisia AveraeLwok daX_performance for the two above methods; and study the shifting "Ii&ation to IUD" ratio.

In essence, set targets in terms of regional achievement as measured regionally and nationally by incidence rates per 1000 MWRA which in turn are transformed by demographers into a parallel scheme of births averted to enter the 5-Year Plan: mee-ing objectives will then take a new meaning! A series of charts and tables has been developed below with two critical cutpoints: (1) from past tc present, and (2) from present to future (5­ year plan). The outcome of this "pragmatic, monitoring-generated planning" is the doubling of the annual input of ncwprotection within 7 years.

4.1 Incidence of FP Input, Past and Future

Table X and Fig. 18 give past and projected incidences of primary accept­ ance. The idea is to reconquer in a reaonable time the level of incidence of tubal ligation of 1974 and then to build very gradually to an incidence level

- 46 ­ TA8LE I

NOUVEL APPORT DE FT. PAR ANNEE ET 1.THODE POUR TROIS rERI'ODEs. Le Froehe Passf, Le rrfsent. et Le Proche rutur. Effectfts. Taux pour 1000 Frrn'oi -i s en Ag, de Reproductimn, Pourcentage global. INCIDENCE OF ACCEPTANCE. NEW BY CALENDAR YEAR AND METHOD FOR ThREE rERIODS: Near Past. Present. Near Future. Nurber of cases, Rate per 1000 H.rried Wonen of Reproductive Age. Percent Total.

v.2-. r- r? t-3 SI'P o 0 0: PERIODE LE 'ASSE LE PRESENT PLAN QUINQUENNAL 0 -"-ERIOD 1982-1986 PAST PRESENT FIVE YEAR PMAN 1982-1986 0 t- X :J4~ : -:Jr- rrt ANNCE / YEAR 197. 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 2986 rt rt 7" o r .- V au Risque (FHAR) 748950 773187 798264 824203 851035 878795 907513 937198 970547 1005084 1040849 1077886 1116242 M1) 0 V -.Lig. Trompeg.Eff. 10757 e"16 8269 7987 8832 8141 0. "j CD :J 10890 14058 15529 17086 18735 20480 22325 2IT,= 24.36 1Xf.0 10.36 9.69 10.38 9.216 12.00 15.00 16.00 17.00 !8.00 M - fTo 20.79 17.48 19.00 20.00 11.55 10.37 11.17 11.20 14.12 16.48 17.02 17.53 27.82 18.45 19.05 :J :r. M M 3 2.4DIU Prim. E(f 19084 173n7 20830 23879 26273 25756 25410 t- rn -t Ta 25.48 25304 25234 25127 26021 26947 27906 26.092. 28.97 Z0.87 29.-1 28.00 27.00 26.00 25.00 25.00 25.00 25.00 pZ -p M..r iTot 36.88 30.5' 29.10 31.02 33.22 35.44 32.94 29 67 27.66 25.77 24.73 24.27 23.81 - 1 "- 3. Niles PilulehEff 10795 16110 25987 27S67 27017 23608 2L503 267242 28146 V) <4 w Tawu 14.41 30152 31226 32337 33.87 2;. ".' 32.55 33.45 31.75 26.86 27.00 28.00 29.00 30.00 30.00 30.00 2-' 0 rt D MD %Tot 20.86 2F.F1 36.31 30.00 35.81 34.16 32.48 31.77 30.77 30.85 30.90 29.70 29.13 28.57 ;J 1 P4 0 4. Injectables Elf - - - ­ - - 908 1875 2912 4020 5204 6467 7814 Ol H-D 0 Tauz - E;

00 :J 5. Condom.Niles Elf, 7432 8678 11385 13125 12304 10442 9983 1126 _T 9.92 11.72 22617 14071 25612 16168 16744 1.26 15.92 18.16 11.88 11.00 ;2.00 13.00 14.00 15.00 fbM 15.00 15.00 r-t -3 ITot 14.36 15.33 15.91 15.09 15.55 14.37 12.94 13.19 ,I: a 13.83 14.43 14.85 14.56 14.28 . t.r 6. Celle.Nlles Elf, 3683 44,26 5100 4426 4674 4736 5445 6560 6794 7036 8327 8623 8930 0 p. 1.• TC-L 4.92 5.72 6.39 6.95 5.49 5.39 6.00 7.00 7.00 7.00 8.00 8.00 8.00 : (ute T ZTot. 7.12 Hi. 7.82 7.13 5.75 5.91 6.51 7.06 7.69 7.65 7.22 Pherr 0 ::3"O-]rt 7.92 7.77 7.62 I- :r" r_.. Toutes 2thodes Elf. 51751 56617 71571 76984 79100 72683 77139 85285 91232 97492 105125 111022 03 (n Tdl- 69.1 72.2 89.7 117206 95.0 92.9 82.7 85.0 91.0 94.0 97.0 101.0 103.0 105.0 :J 0 C) - Cr ZTot 200 100000 200 2oo 0 11- 200 200 200 200 100 100 200 200 Z 1 Avert. Soclaux EtC 12427 16000 20341 21162 20999 J 1928 T 16.59 20.69 25.48 25.68 24.67 21.90 pas do projections rJ M .! pour cet indicateur .2 du Pyst13e national de F

I.-,w 0 03 loutes lith..AS Eff 64178 72617 9112 98146 100099 91931 MS M H. MTaw 83.7 03.9 115.2 120.7 117.6 104.6 -1 _ ___-____TU-CE rb/eh 3 80 0C C 0 C. Lee 7amr sOnt £lluntre ,. Figure, 18. ZLee Po.r'oentooes ent illustra on Figure79. or E *Les Effectife pour can troia '4:;had.7 ont ;t; di q4a par 201 pour obtenir I rapport nouuecvi t oyen p ur t 0 • (D un e r4tode pour jour de tratvail, naoional en r iore d PF. Lea te'ndaneo Ot ;a. enquioaea en Fgure20. 4 L'apport de L nour,olie proterton par, DIU at Lig. des tro-ipea a ;t; eatiii d! raienn do 7.5 mn;ra de protection par couple pour I ligature des tro.pne at de 2.5 annees pour 5 una rouvolZe cnPtroeptrca par D.I.U. L4 reaultat a et; ituntrie Figure22. le tau-! ZobLa co-prer.mt touten lee r,"ohodre nnuvel lee y-Enclu ten avort-enCn nociau, cat lui-niw un index en d'aotiuitenouuZrte mdtc're do PF . Sor arrnyr.e cat Ill-AlF, un indictew. expcripiental. Voi. afaoi TLle V. Figure 18. INCIDENCE VECUE ET PROJETEE /PAST AND PROJECTED INCIDENCES ONPFP/USAID FP Progrm EvoluatIon, Phase-2. LE PASSE LE rRESENT FtAN QUINOUENNAL 82-86 PASTJ PFRESENT FIVE YEAR PLAN 1982-1986 40 PF/FP 69.1 73.2 E9.7 9S.0 92.9 12.7 $ 91 94 101 103 A-. S. 1c,6 -20.7 2!5.5 2S.7 24.7 ]2. IN-FPA 85.7 93.9 115.2 20.7 1i7.6 0

33.5

30- 30, Pilules 30.9 ~. ... .30 29.3 .30 3 ...... _9.0

2 2552s 2692S, ~26 D.1. U.

22 ._ 2S

2.­

11 Ge19 74 70- 77278 9 2• 3, Vg ,.,7... ..-

74. 7 70. .7 10.48 82 8 4 5 8 of 2% of MWRA to undergo tubal ligation at the end of the next five years plan. While this is a modest target (in light of the MWRA increasing by around 3.2% annually: see Fig.9) it is considered perfectly feasible in the context of the performance during the year of the World Population Conference (Bucharest, 1974), and with the recent training of over a score physicians in the techniques of modern fertility care and the placement in each gouvernorat of at least one coelioscope. It is a "ninirmn objective" that will secure an important increase in the annual protection input. However, if the medical profession were to let evolve the surgical methods openendedly,quite higher incidence rates may actually be attained which would contribute to bring the crude birth rate below 30/1000 population by several years earlier than with the present projections.

The rationale is to reverse the method shift of the seventies during which period IUDs expanded impressively somewhat at the cost of tubal ligations. Given that a very great reservoir of women are indeed ready for tubal ligations a certain part of then should be offered ligation services rather than IUDs in the first place. This then explains that the new IUD incidence rates are carried fron 29.3/1000 MWRA in 1979 to reach 25/1000 MWRA in 1983, while tubal ligations are increased from 9.3/1000 MWRA to 17/1000 1WRA. The latter figure is only 2.6 /1000 MWRA higher than the rate attained in 1974 (14.4/1000 MARA).

The incidence of pill acceptance is to be carried slowly to 30/1000 MWTRA, a conservative figure as well in light of the performance reached in 1977 (33.5). The rationale is that a given prt of new pill candidates can be shifted to injectables that will exhibit a much lower decay rate than pills. By 1983, all'systemic'acceptance (pill and injectables) will have surpassed the peak year incidence of 1977 (34 vs 33.5/1000 MWRA).

A very unique aspect of the Tunisian FP program is its equilibrated method mix. Secondary methods have definitely their important place. Hence, condoas and jelly have been projected in light of past attainments during the peak year of 1977 (15.9+6.9=22.8/1000 MWRA). By 1984 they will make up 23/1000 MWRA (15+8) and carried at this level.

Of course, if tubal ligation services become more readily available -­ a key responsibility of the medical establishment -- so would the services of social abortions. It must be fully realized that social abortions are the valve of security of the nation's FP program. Were it not for providing that

- 49 ­ I - '.

o.O oz~ 0, ......

"',Q. ,.2, 2 C , . .i. 00

" 0 z

z

.. . . , . ,\

"0., , • ,: : --" t' o .....

o 0 0 0 0 0

' 4 uojj .lei seoo4Ju, sap

1Expansion of Ligations at "expense" of mult~iparous TUD candidates. 2 Expansion of Injectables " " " " . 3 Expansion of Injectables " Pill " .

- 50 ­ service, the annual crude birth rate would have remained. higher since the beginning of the national FP Program. The study of the trend of method-specific incidence rates in each gouvernorat tells a telling tale which may be explored by ONPFP during the next few years. What matters is to do such an analysis in the context of an existing conflict between the desire to discontinue an unwanted pregnancy and the difficult availability of pregnancy termination (PT) services. By comparing the making available of PT services in Sousse (Fig. 9-1) with many other gouvernorats, one gets the impression that a very great job by the medical profession remains to be done in most gouvernorats to incorporate the surgical methods of tubal ligation and pregnancy termination more fully in their professional activities. On the other hand one is also impressed by the trend of method-specific incidence in Baja (Fig. 9-9). It r.iay be surmised that the profile of both tubal ligations and social abortions have a relationship, and that the important decrease in the incidence of pregnancy termination is at least partially a result of having nade adequately available the services of tubal ligation for a certain number of years. All this to justify the concept that social abortions in Fig. 18 are not to be projected but rather to be watched as a very complex indicator that hides such elements as availability of services of (1) present pregnancy termination and (2) past high efficiency methods of family planning. The careful study of evolutionary abortion profiles will be most productive if carried on at the regional level(see also pp 67 and 68).

Note in Fig. 18 that the sum of all FP methods (excluding abortions) reached 95/1000 MWRA during the peak year of 77 as compared with only 82.7 two years later. The concept underlying Fig. 18 is to reconquer the peak performance in new acceptance by 1983 (97/1000 MIrRA) and then to let it climb very gradually to a target level of 105/1000 MWRA. Furthermore, by adding the activity of social abortion, one obtains the Index of New Familiy Planning Activity (IN-FPA). which reached 120.7 /1000 MWRA in the peak year (1977). It is surmised that by 1986, that is atthe end of .the next five year plan, social abortions may have decreased to around 15/1000 MWRA if the FP-mix is being adhered to, and that the IN-FPA of 1986 might thus reach around 120 / 1000 MTRA. The incidence curve of social abortions in Fig. 18 would develop a second mode during the early eighties (better availability of abortion services in all gouvernorats) with an important "second decline" due to much greater availability of efficient family planning methods in all gouvernorats (the first decline being mainly due to insufficient availability of abortion services in many gouvernorats).

- 51 ­ Lg ... .,..,.*"! Fgue 20. NOUVEL APPORT DE PF PAR JOUR / NEW ACCEPTANCE per WORK DAY OPFP/USAID FP Puognim vaclutlion, Mloss 2. LE PASSE LE PRSENT PLAN CUINCUENNA 1 982-1986 PAST PRES[NT EIVE YEAR PLAN 1982-1986 100 1930

..-"Pllule, 93.0

EII " -u CZ .. 8-4.4 D.1U .

74.4

' 60-

40­ S36.0 % de (D..1.--. Llg. Tr.) E 35.9 3517 clant des Lig. Tf.

uo 20 ; 24.0 - 20­

-

E E zz

0 74 I I 74 I I 79 81 I 868 6 4.2 Method Mix, Past and Future

One may organize the incidence of acceptance of FP methods -- past and projected as realistic objectives -- in a method mix profile. The concept is to show the relative importance of each method by organizing them from least "use-effective" (secondary methods) to the method of highest "use-effectiveness" and hence demographic impact (tubal ligation). Fig. 19 gives the relevant findings.

The dynamics of past and future method mix are apparent.

(1) Keep secondary methods at a similar level (around 1/5th of the entire method mix). (2) Keep pills at a similar level (around 3/10th of the entire method mix). In combination, secondary methods and pills contribute around half to the entire method mix input. (3) Shift part of conventional IUD candidates to. other long term methods of higher demographic impact, that is injectables and tubal ligations. While the incidence of IUD's will slowly.decrease from over 1/3 of the entire method mix share to around 1/4th by 1986, the newly introduced injectables may reach around 1/15th of the entire input and the tubal ligations could pass from around 1/9th in 1979 to 1/5th in 1986, a proportion originally obtained in 1974.

The most important step is to occur in 1980 and 1981 as during that time the relative share of tubal ligations should shift from 11.2% in 1979 to 14.1% in 1980 and to 16.5 in 1981. This means shifting fron 8141 ligations in 1979 to 10890 in 1980 and to 14058 in 1981. The medical division of ONPFP has a major responsibility to involve the medical establishment across the country to secure these "minimal objectives" in the context of the development of an ideal method mix for the national program during the next few years. The task looks less formidable if one considers that the average All-Tunisia work day in tubal ligations (300 annual work days) should evolve from 27.1 in 1979 to 36.3 in 1980, to 46.9 in 1981. Divide this by 18 to obtain the average regional work day: 1.51 in 1979, 2.02 in 1980, and 2.61 in 1981. Clearly, if reduced to the scope of daily work at the regional level, the figures look extremely modest when viewed as an average. It is the medical division's prerogative to look to it that the pace of tubal ligations is productive while not strained. A gouvernorat-by-gouvernorat review is needed to ascertain that ligation services are functional in at least one institution per gouvernorat by September, 1980. By 1982, each gouvernorat should have at least two coelioscopes in working condition and at least two trained physicians. Continuous review!

- 53 ­ Figure 21. INCIDENCE DE TROIS METHODES de PF pour i'Amr't 1979 / INCIDENCE OF THREE FP METHODS for ih Year 1979 CNPFP/SAID FP Program E~aoIjtien, Pls. - 2. Inc;denc do now-elles occepotantes de PILULESL---. Incidence do rowe. acceptooreofcdec new i'-'-'--1 nPILL~e acceplles do 0.1. 1 . . lndence des L;galves des Tro $rpes Fel.. nc;dence of now 1. U.D. acceptors W.a Incidence of Tubal 4 Ligotions ! iZ I CJ= Er.smbl./Toguther -par rang/ranked i 1 . Rotoper 1000 MWRA /TOUx pour 1000 FMAR Taux pour 1000 FMAR /Rot-3 per 1000 MWRA " i;.f. -03 40 20 0 0 20 40 60 i I I I I I

19.6 1 SOUSSE I 6Z4.7.3 ,0.5 29.0 . BIZERTE 2 40. 61.9 34.2 1 268 14.1 BEJA 3, 34.1 .860i 44.1

42.1 . ° KEF/SILIANA 4 37.0 48.9 24.3

23.1 TUNIS/ZAGH! 5 37.4 J 48.9 I ______4,4 23.5 33.11 MONASTIR 6 38.4f 42.8 10.3 I 20. NABEUL 7 34.3 38.9 11.6 Ln 1.

26.85 TUNISIE 29.31 . 138.57 -­ '131

13.21 SFAX 8 26.3 L - 37.6 30.3 39.4__ I KASSERINE 9 24.6T 130.4 19., 9.9 25. 6MAIDIA 10 29.49 -30.3 . . I __.__,__.______._ 32.7 33.41 JENDOUBA 11 18.6[J27.2 3.9 1.3 43.8 GAFSA/SID.8." 12 19.220LS 6.3 G.6 37.81 GABES 13 13. 120.2 33.7

12.A KAIROUAN 14 8.9- 14.0 IS 36.4 3 . 1 p5ar Iartid :ethdorang. 2 MEDENINE is 1. I2.9 11.6

I I I I TU-GE rb,/ch 3 80 Fusion de deux region%pour ccusa d'execut;on dos Iigatures dons Io premiero ri'glon, essentiellemnent. A portar do 1980 Its (3 (o~l) deux r~g;ons serost Iro;los ;mndivdueliment. Fusion of two regions becous of the I;gat;ons having been performed , mainly, In the first region. Starting in 198, the the limes two regions will &troaOted seperately. 4.3 National Work Day Performance, Past and Future NWD-National Work Day The "Ligation-to-IUD" ratio, by gouvernorat

Fig. 20 reviews the national ',ork day perfornance for three methods of FP in the past and projected future. The "IUD-to-Ligation Shift" is displayed.

The future "work profile" is seen to the right. The incidence of pills is highest (112 new acceptors per NWD), followed by new IUD acceptance (93/NWD); and finally tubal ligations (75/NWD) in third position (followed by condom, gel6e, and injectables, in this order, as shown in Fig. 19).

The greatest change is noted in the relationship of primary IUD acceptance and tubal ligations. The relative share of tubal ligations for the two methods com­ bined (tubal ligation and IUD) was 36.1% in 1974 and decreased to 24.0% by 1979. The goal is to reconquer the ratio of 1974 within 2 years (35.7%) and to let it gradually evolve towards 45% which is virtually reached by the end of the next five-year plan.

Given the great importance ascribed to fully understanding the needed shift from primary IUD acceptance to tubal ligation, the 1979 annual yerfornance of incidence of three methods has been given by gouvernorat in Fig. 21. The combined incidence of IUD acceptance and tubal ligation has been ranked in descending order to the right, and the corresponding incidence of new pill acceptance was given to the left. One notes:

(1) Two of the 15 regional study entities have reached in 1979 incidence rates of tubal ligation beyond that expected for the nation as z whole by the end of the next five-year plan (Bdja and Bizerte with 26.8 and 21.2 vs 20/1000 11WRA); As seen in the column to the right in Fig. 21, B~ja has also reached the projected ratio: (tubal ligationZIUD+tubal ligation) with the calculated value of 44.1% (vs 44.4% for Tunisia as a whole by 1986). Bizerte, in turn has reached what is expected nationwide by 1981 (34.2% vs 35.7%). Clearly, much is to be learned by ONPFP from these two regions that could be adapted (not necessarily adopted) to other regions. In essence, it is these two regions that show through their 1979 performance the way to other regions for attaining both performance and method mix needed to double the annual protection input from 1979 to 1986 (see also below Fig. 22). As shown in the trend studies, Baja has already a long standing tradition of "optimal ratio" performance as far back as 1974 (Fig. 9-9), whereas Bizerte is only recently (1978 and 1979) reconquering the optimal ratio attained in 1974 (Fig. 9-4). These two regional case histories merit particular attention for (1) maintaining the perfon.ance and optival ratios, and (2) learning what might be ad3pted to other regions. This is the "learning from within" aspect of Regional FP Monitoring. The 2 gouvernorats house 1/1oth (9.9%) of Tunisia's MWRA. This chart is the "updated" Figure 6 (Ist Semester window) of Phase-I Evaluation Report: it was highly predictive, since rank order and ratios have barely changed.

- 55 ­ (2) Another 7 regional study entities have reach-d in 1979 incidence rates of primary IUD insertion much beyond or similar with the rate expected ior the nation as a whole from 1983 onwards (25.0/1000 MWRA); by contrast, their respective rates of tubal ligation are below the level expected for the nation as a whole by 1980 (12.0/1000 MWRA). As shown in Fig. 21, these seven regional entities are: Sousse, Kef/Siliana, Tunis/Zaghuan, Monastir, Nabeul, Sfax, and Kasserine. Nevertheless, three of these seven regional case histories are very close: Kef/Siliana (11.9/1000), Tunis/Zaghouan (11.5/1000), and Sfax (11.3/1000). By studying the recent trends, one notes that Tunis/Zaghuan is on the expansion (5.2, 8.7, 11.5; Fig. 9-3), whereas Sfax (16.8, 13.9, 11.4; Fig. 9-8) and Kef/Siliana are in regression (14.9, 28.9, 11.9; Fig. 9-7). Clearly, these three regional entities should try during 1980 to gain ground in tubal ligations, preferably at expense of primary IUD insertion. The new FP clinic opened in March 1980 in Tunis should help to boost the metropolitan li­ gation rate beyond the projected national average of 1980. Sfax needs to review the reasons for the decline in tubal ligations since 1977. It is presumed that a good coordination with the new maternitg now functional should lead to a reversal during 1980. Kef/Siliana need also an early review. The dramatic drop in tubal ligations from 1978 to 1979 would indicate serious problems in recent availability of surgical services of contra­ ception. Since very . modern facilities are available in Kef, it is suspected that the flaw lies with recent availability of Manpower. The Medical Division of ONPFP may have to monitor this! It should be noted that taking action now by the three regional entities (Tunis/Zaghuan, Kef/Siliana, and Sfax) will have a tre­ mendous impact on the national average performance since the five gouvernorats house over one third (35.9%) of the nation's MWRA. The four other gouvernorats (Sousse, Monastir, Nabeul and Kasserine) show definitely too low ligation rates (7.6, 4.4, 4.5, and 5.8, respectively). Except for Kasserine, the share of tubal ligations for combined acceptance of IUD and tubal ligation was only around 10%, that is much below half the national average of 1979 (24.0,%, see Figs. 20 and 21). Clearly, these three gouvernorats should more than double their incidence of tubal ligation during 1980 by offering electively tubal ligation to a certain part of primary IUD candidates. For Sousse, the practicality should be no problem since the proved performance in 1975 and 1976 (37.1 and 21.3/1000 MWPA; Fig. 9.1) demonstrates past excellence. Nabeul's dramatic recent decrease (15.1, 7.2, 4.5; Fig. 9-6) needs early review for a feasible reversal still in 1980. Monastir seems to have a problem with manpower: to experience a 6.7-fold drop in the incidence of tubal ligations from 1978 to 1979 would indicate a serious lack in the institutionalization of modern fertility control technology. The situation needs review before July 1980 for immediate remedy. Kasserine, finally, need;-institutionalization of tubal ligation as the past performance was consistently very low (6.2, 4.4, 5.8/1000 MWRA; Fig. 9-12). Optimal coordination with the maternit~s in at least 2 places is needed now. The situation needs review before July 1980. Above four gouvernorats house around 1/5th (19.4%) of all MWRA.

- 56 ­ (3) The remaining six geographical study entities (Mahdia, Jendouba, Gafsa/Sidi Bouzid, Gabes, Kairouan and Medenine; rank order 10 to 15 in Fig. 21) attained in 1979 incidence rates of primary IUD insertion not only much below the national average (29.3/ 1000 MWRA), but also much below expected average figures from 1983 onwards (25/1000 MWRA plateau); their respective rates of tubal ligation in 1979 were also much below the rate expected in 1980 (with Mahdia and Jendouba having the smallest deficit). In other words, these seven gouvernorats -- that comprise over one third (34.8%) of all MWRA - are in need of a most careful review of progra-matic alternatives for the next five-year plan. As shown in Fig. 3 the non-protection rates (complerient of EPP) of the married women of reproductive age in these 7 gouvernorats are alarmingly high on 1.1.1980: 95.6% for Sidi Bouzid, 93.8% for Medenine, 92.6% for Kairouan, 91.4% for Gabes, to name the the four gouvernorats with less than 10% effective protection prevalence as a result of the entire FP effort of the seventies and pertaining to over one fifth (21.1%) of the nation's MWRA. It is these four gouvernorats that hold back to the greatest extent the progression of the national protection prevalence, that is the decline of the nation's fertility. Sidi Bouzid: In 1977, this gouvernorat's crude birth rate was calculated to be 47.0 / 1000 population (source ONPFP), aScompared with 34.8 / 1000 population for the country as a whole. Over half of all births occur in two out of 6 d~l6gations (Sidi Bouzid (1/3) and Maknassy (1/5)) which house the two hospitals of this gouvernorat. ONPFP should consider two integrated family planning programs, one in Sidi Bouzid (to drain for surgical methods also the delegations of Jelma and Benaoune), the other in Maknassi, to drain also Mazzouna and . Jelma's dispensaire communal should also be strengthened in its FP activity. Directives should be inpleriented by Fall, 1980. Medenine: In 1977, Medenine's crude birth rate was calculated to be 44.8 / 1000 population, as conpared with 34.8/1000 population for the nation. Around three quarter of all births occur in the 4 out of 8 most populous d~l~gations (Djerba, Medenine, , and Zarsis, in this order). Furthermore, as noted on a field trip in March 1980, institutional deliveries are increasing rapidly in Zarsis and other places. The lack of obstetricians in Medenine and Zarsis has been the major stumbling block for getting ahead with surgical contraception, both tubal ligation and social abortions, as shown in Fig. 9-14, and this despite excellent surgical facilities that were idle at the CREPF in Medenine. In Tataouine, excellent facilities exist at at a true model community health center and at the h~pital de del6gation. Because the local physician is not trained in tubal ligations, around 150 ligations are tiissed, every year. In 1979, this "input" could have boosted the All-Medenine

- 57 ­ tubal ligation rate from 1.5 per 1000 MWRA to 4.0 per 1000 11WRA ( 58+150 / 52658 =3.95/1000). The much devoted and competent general practitioner makes "version manoeuvres" in difficult obste­ trical cases to save mother and child but is not permitted to join the drive for increasing modern surgical contraception for grand multiparas. This needs early review. Zarsis shows also very great potential for tubal ligations -- presently virtually unexploited. A local physician should be trained for doing ligations at the Zarzig h8pital de circonscription. Only 200 ligations per year would boost the All-Med'nine ligation rate to 8.0/1000 MWRA. With the placement of a coelioscope in Jerba regional hospital on 14. March 1980, one may hope that 2 hundred ligations are going to be performed for MWRA living on that island. This would boost the rate to around 12/1000 MWRA. Finally, with the arrival of an obstetrician in Medenine in April 1980 -- trained in coelioscopy before taking up work at both the maternit and at the CREPF -- another 200 ligations should be easily mastered in a T'ost ideal environment of the regional CREPF. In short, it is the prerogative of the medical division of ONPFP to look to it that the ligation rate of 1.5 /1000 MWRA in 1979 is to reach the expected national average of 1980, that is 12/1000 MWRA, by climbing from 58 ligations in 1979 to 650 in 1980 (As noted in Fig. 9-14, 650/54109 shall generate a rate of 12/1000). But the critical consideration is to achieve this goal at the four places, rather than forcing at one or two places. This "way" may be tried experimentally because of its possible programmatic implications in other low performance gouvernorats. It can be assumed that this four-center approach would show tremendous growth potential. Hence the projected rate of 15/1000 in 1981 could be easily attained.

Kaircuan: In 1977, Kairouan's crude birth rate was calculated to be 42.2 / 1000 population, as compared with 34.8 / 1000 population for the entire nation. Over half of all births occur in the 3 out of 8 delegations: Kairouan (i/5), Boudjla (almost 1/5) and " (1/7). These three delegations possess the regional hospital and two of the four h~pitaux de circonscription. Because of distances, ONPFP should consider to favor a strong three-center integrated family planning program in close cooperacion with the Ministry of Health. Kairouan would also drain and some northern cheikhats of Bou Haila; Bou Haila itself might also drain the area of Nasrallah; whereas Haffouz would also drain El- and a great part of Hajeb El Aioun. Perhaps a workplan could be consideredin cooperation with neighbouring and best performing Sousse to develop an integrated three-center approach. Action plans should be developed before the start of the next Academic Year (Autumn of 1980). Figure 9-15 shows that Kairouan had a good performance of tubal ligations in 1975 (18.2/1000 MWRA), with subsequent deterioration. Chart 6 in the USAID Field Evaluation Report of July 1975 shows an itpressive rise in tubal ligations from 1973 to 1974 to June 1975. At that time a new team of expatriates took over and as noted in Fig. 9-15 the rate dwindled within three years from 18.2 to 3.7 / 1000 MWTRA. The lesson is that the ONPFP FP program cannot continue to depend on the great variations in performance among expatriate physicians. A basic coordination with the Ministry of Health should make it possible to secure continueacceptable FP performance across various doctor teams.

- 58 ­ rate was calculated to be 40.3 In 1977, Gabes's crude birth Gabes: 34.8 / 1000 population for 1000 population, as compared with all births occur in the delegation nation as a whole. 3/10th of the of with 2/10th of of Gabes, followed by the dflfgation one half of all births occur the gouvernorat's births. Hence Because of great distance, tubal in the 2 out of 7 dil~gations. should be conveniently available ligations and social abortions to Kebili also in Kebili. could drain not only in Gabes but births is in third place regarding for the time being. At its all births in this gouvernorat. with around 1/6th of should the family planning coraponent hopital de circonscription of with as well. Similarly, the delegation be stressed a stronger FP compo­ 1/8th of all births should develop around a stationary team should at its centre de P11. In particular, nent daily from and to Gabes. work there, rather than travelling should occur between In Gabes itself, a better coordination maternitg. Clearly, great potential the gouvernorat's CREPF and the ligation rate. It must be stated exists to improve the region's the ligation rate increased frorm progress was noted in 1979 as that to 6.8/1000 MWRA. This 1.0 per 1000 M1NTRA for 1977/1978 an average Gabes in 1980 nay boost the should be held and the work in impetus average of 12.0/1000. to the desirable :inimal national rate move is to create more be it said here: the strategic However, with Kebili as the than one center for surgical contraception Gabes would need to performn logical , long distance candidate. Fig. the rate of 12/1000 MWRA (see 554 ligations in order to reach there were 302 ligations. 9-10: 554/46146=12/1000). In 1979, are meant to have any promoting 14: If realistic national targets Consideration then they must be set in the effect on regional performance, the exstilg system and a broad context of past performance of improvement backed by specific overall objective of national and management, trained manpower additional inputs in terms of equipment,etc. performance (1980-1986) on the This section has built planned on a recent programmatic effort nation's past experience and surgical contraception in all to improve the availability of This lead time is now "aging". gouvernorats (1978 and 1979). Target Setting" Perfor~nance Promotion by National "Regional Monitoring, by region. has a lot to do with F nily Planning must be distinguished: Two cases most recent annual Group 1:Regions whose method-specific nation's targetted next year goal. performance is smaller than the program and make the inputs They need to review the entire average target - their main necessary to meet the nation's of annual performance: this kind reference regarding the new the review of Sidi Bouzid, Medenine, spirit is to be read behind and Gabes. Kairouan, nost recent annual Regions whose method-specific Group 2: targetted next year goal. is greater than the nation's performance their program to must further streanline (managemient!) They rate attained most recently, at least 10% increase in the secure M'RA, a very feasible but for instance from 25 to 27.5/1000 target set "from within". consequential the national approach cannot but lead to surpassing This dual Regional Progress Target Setting means Promoting target. Realistic progress. monitoring stands by to check quarterly if - 59 ­ Figure 22. INCIDENCE *)E PROTECTION PAR DIU et LIG.DES TR.A'JEW PROTECTION BY IUD/TIL. ONrP/USAID FP Program Evoluallon, Phase - 2.

LE PASSE LE rRESENT PLAN QUINQUENNAL 1982-1986 PAST PRESENT FIVE YEAR PLAN 1982-1986 250C 1980 237.2 167.4

Les Deux Methodes Both Method, 200

C U.

u:Z> 105.

' S.

00 0 "LIGATURE DES TROMPE$ 0- 128.4 122 TUBAL LIGATION

Z0 Zu<- 100 z Z z

0 74 7979.8 81 86 5. DEMOGRAPHIC IMPACT

5.1 Rise in Incidence of Couple Years of Protection (CYP)

The slight shift in the future method mix (see Fig. 19) for new acceptors produces a great increase in new annual input of protection due to the much greater "use--effectiveness" of tubal ligations. In our calculations, we have taken a new ligation to protect on average 7.5 years as coimpared with 2.5 years for new ILD acceptance. Table X and Fig. 22 give the pertinent trends.

(1) From 1974 to 1979, the annual protection input through new IUD acceptance passed from 47.7 thousand couples years of protection (CYP) to 64.4 thousand CYP. In parallel, the corresponding figures for tubal ligations were 80.7 thousand and 61.1 thousand CYP, respect­ ively. Together, the incidence of new protection generated a kind of plateau oscillating around 125 thousand CYP, annually. In other words, the annual input did not increase markedly.

(2) From 1980 to 1986, the new protection input by primary IUD insertions can be kept quite constant. According to the rates developed in Fig. 18 and Table X, the number of new CYP would move from 64.4 thousand in 1979 to 69.8 thousand in 1986 - a virtual plateau (Fig. 22). By contrast, grandultiparas and even multiparas can be favored for electing tubal ligations. By carrying the incidence of tubal ligation from 9.3 to 12.0 to 15.0 / MWRA over the next two years, the input of effective protection shifts from 61.1 thousand in 1979 to 81.7 thousand in 1980 and 105.4 thousand CYP in 1981, an impressive gain to be achieved in such a short time. Then, during the five-year plan, the annual input would further increase from 105.4 thousand CYP in 1981 to ]67.4 thousand CYP in 1986, by adding an incre7ment of 1/1000 '4WRA each year and thus moving from 15 to 20 per 1000 WRA (see Fig. 18). In other words, by far the greatest gain in actual demographic protection will be obtained with the tubal ligations, the annual input rising from 61.1 thousand CYP to 167.4 thousand CYP, a 2.7-fold increase within seven years. This will have a marked demLogra­ phic impact and thus accelerate the needed and planned demographic transition. Clearly, the medical division of ONPFP has an added responsibility: to look to it that the minimal incidence rates deve­ loped in Fig. 18 are being met from year to year. (3) Given that injectables, condoms and even jellies are also planned to increase at their individual rates (see Fig. 18) it is a conservative statement to assume that the present differential schedule of new incidences would easil X double the annual input of new protect ion by the end of the next five-year plan.

Consideration 15: By shifting the share of tubal ligation in the method-mix incidence from 1/ 9 to 1/5 within 7 years, the annual input of new protection can be easily doubled. This would have an important demographic impact by the mid-eighties.

- 61 ­ 5.2 Prevalence of Contraceptive Non-Protection

The complement of the Effective Protection Prevalence (EPP) is the prevalence of actual non-protection. Figure 2 thus shows that as of Ist January, 1980 over 90% of all women at risk in Sidi Bouzid (95.6%), Medenine (93.9%), Kairouan (92.6%) and Gabas (91.4%) were practically at risk of getting pregnant. This very high non-protection prevalence is associated with crude birth rates in excess of 40/1000 population. It should be realized that the non-protection prevalence has to sink below 70% of the MWRA for the crude birth rate to sink significantly below 30/1000.

Therefore, a much greater protection input from year to year is now needed in order to cross the 30/1000 CBR in the foreseeable future. As shown in Figures 2,3 and 5, the All-Nation non-protection prevalence pertaining to the ONPFP program remained stationary during 1979, at 83.8 % MWRA. Only the stronger representation of tubal ligat -ns in the method nix can provide the necessary momentum to a badly needed decrease of the nation's prevalence of non-protection.

5.3 Evolution of Marital Fertility

Fig. 7 shows a modest decrease in marital fertility: -8.3% fron 1975 to 1978. As the Effective Protection Prevalence (EPP) has rermined stationary in 1979, it has to be assumed that the marital fertility rate will come to show a slower decline during the early eighties. Only a rapidly increasing EPP can bring about a swifter decrease in the marital fertility rate. The planned slight shift in method mix towards the most efficient methods can secure this cause-to-effect chain to occur during the early eighties.

5.4 Trend of Age-specific Fertility: Identification of a "reservoir" for FP.

Fig. 23 shows in the upper frame age-specific fertility silhouettes for '1962' (a synthetic curve derived from 1960 and 1965 sources) and 1976. Clearly, the greatest decrease of fertility occurred to women below 30 years of age (A). But this 1976 curve is still very far away from the age-specific silhouette targetted for the year 2000 (Italy's silhouette of 1967). In order to stress this "distance", a "halfway fertility silhouette" was drawn, which delineates a great "delay" in fertility reduction that is greatest for women over 30 years(B).

- 62 ­ - 2. Flpure 23: TENDANCE DE F[CONDITI PAR A^GE ONPFP/USAID FP Pc,ram Evaluation, P$aos TREND OF AGE-SPECIFIC rLAIILITY 50% de lar4ductlon do FIconditl par 'ag prole'e half-way' fetility (decline) 1aux do | eondit( par age pour 1976 (dernore s;r;edisponible) Age-specil;r fertility rates lot 1976 (lost available series) 0 i R.ductacn."Decline '1962 ...... 1976 50% du 'ptrcou. iIIIIl Riducin additionnelle micettaire pour attehdro Additional De'cline needed to reach hall the taroetted total decline. 0 La deux.ime nnaiti6 de t~duction do leconditie r'cessairo jusqud6 230O. 400- C Second half of targelted total fertility decline up to the year 2000. /

00- -- In

8. 100

ac hlie/ltolio 1967 z aI IS-19 20-24 25-29 30-3.4 35-39 40-44 4S-49 Age

I 0-1960/65-=1962'

to I I . F . :-to 0 .-, RESERVOIR n0cessitant lamdicolisation du PF

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- 63 ­ As to judge from the lower frame, it may take a rather long time before the women aged 30 and more reach the "halfway fertility" unless this great reservoir is specifically addressed with modern means of fai.iily planning. Note that women below 30 years of age have made great strides in the reduction of fertility. Those below 25 years are actuall "ahead of schedule" since the age-specific reduction in fertility to pass from the '1962' to the '2000' silhouette has reached -71.8% and -48.6%, res­ pectively. This is mainly due to the increase in age of marriage.

The acid test of recent fertility reduction among women aged 30 and more years has to wait for the next series of age-specific fertility rates. Nevertheless, it may be reasonably assumed that with a stagnating overall prot-ction prevalence in 1979 the delay in fertility reduction may be even more apparent with the next series of figures. In other words, Fig. 23 identifies indubitably the reservoir of women who are in greatest need for effective FP protection to reach them at the earliest possible date across the entire nation (B). This reservoir of women has an unusually high proportion of grandmultiparas and multiparas, among whoimany are desirous to terminate their fertility irreversibly if the availability of professional ligation services is known and understood.

Consideration 16: Analysis of the recent trend in age-specific fertility reduction (up to 1976) identified an important unmet need: there exists a very great reservoir of women in their thirties and early forties who should be able to receive modern fertility care services.in order to keep not really wanted pregnancies at a minimum. Among these women an important delay (retard) in the reduction of fertility has been noted and quantified. It should be remembered that age and parity constitute also risk factors to the health of both mother and child. This can be demonstrated in Tunisia during the next few years by analising" routine information collected by Maternity Care Monitoring (MCM) and/or conducting "Family Health" studies. It is ironic that "high age/parity" women should have fallen behind, programmatically so to speak, in the na­ tion's quest for demographic acceleration of development, that is the decrease of excess fertility. A perfect convergence of the two major reasons why the method mix of the eighties will have to give tubal liga­ tions a greater share is noted here:(1) demographic and (2) health (of the mother, the infant, the family, the nation). Joining forces by the medical profession and national planners cannot but accelerate Tunisia's develop­ ment. Tiis, on balance, is the meaning behind 'medicalisation of family planning in Tunisia': a signal step forward.

- 64 ­ REFERENCES

All sources have been identified within the report, particularly (I) in the text of first section, (2) the tables, and (3) the figures. All sources were from within the ONPFP.

- 66 ­ ACKNOWLEDGEMENTS

This post-mission, additional task would not have been tackled had it not been for the insistence of Elisabeth Maguire, Mel Thorne and various colleagues in Tunis, both at the Office National du Planning

Familial et de la Population and at the Ministry of Health.

Monitoring as conceived in this report during April, 1980 is a somewhat new endeavor as it opens a broad avenue to more realistic target setting "from within" for family planning program performance objectives that are feasible and spell progress as measurable at regular intervals at the central and regional levels through monitoring.

The iron had to be beaten while hot, a basic requirement after any useful evaluation mission. The spirit of this work grew during the first and second phase of the ONPFP/USAID Midterm FP Program evaluation in Autumn of 1979, and -- enhanced -- in Spring of 1980. Many useful and stimulating discussions took place between the two co-authors at the Office, in the car in Medenine, etc. Other discussions between us and the heads of various Divisions of ONPFP -- in formal counterpart meetings or dans les couloirs -- brought additionl motivation to give a try at working on the concept of developing soue "formal monitoring methodology".

Both authors thank Mr. Mezri Chekir, Prgsident-Directeur-Gan~ral of

ONPFP, for his continued interest for early development of evaluation methodology emanating from the nation's own experience. The Tunisian data base pays tribute to a tremendous effort of the ONPFP during its first 7 years of existence. Using these data meant learning.

Roger P. Bernard A. Charff(dine 26 April, 1980 J5 May, 1980 Geneva Tunis

- 65 ­ ANNEXE

Les tendances r~gionales des incidences des nouvelles activitds en mati~re de planning familial des annfes soixante-dix constituent une tras riche resource pour fixer des objectifs, par tadthode, pour les annies quatre­ vingt.

A-la base de cette collection des donn~es tras accessible, et techniquement comparable parmi les regions est 1' unitg de mesure: taux pour 1000 ferimes marines en age de reproduction (FMAR). Cette unitd permet d'effectuer toute une s~rie d'6tudes additionnelles a partir des 15 entit~s r~gionales produites dans cette annexe.

Pour donner un exerxple du potentiel de cette collection des tendances des activit~s nouvelles (6 m~thodes x 6 annes x 15 "regions" = 540 taux + 36 taux pour la Tunisie entiare + 16 x 6 taux d'IN-APF == 672 informa­ tions specifiques- auxquelles vont s'ajouter 112 au mois de mars 1981), la classification des quinzr. "regions" a 6tg assortie avec un exercise d'extraction d'infornation d'un aspect du PF: l'accessibilit6 l'avortement social pour l'ann~e 1979. Ce tableau 'in statu nascendi' peut constituer la base de tout un chapitre a part, non traiti dans ce rapport, h~las Dour manque de temps. Ii va de soi que cette collection contient "les faits" pour r~pondre a une s~rie de questions probantes en ce qui concerne la p~n~tration du PF A travers la Tunisie.

Cette collection des taux est une partie int~grale de la banque des donn~es de .'ONPFP.

La premiere colonne du tableau sur la page suivante est l'inventaire de cette annexe.

- 67 ­ ANNEXE / APPENDIX

1) TENDANCE DES INCIDENCES DE PF, par r~gion' 1974-1979 TREND OF INCIDENCES OF FP, by region 1974-1979 2) NOUVELLE ACTIVITE DE PF en 1979, par r6gion et la part occup6e par l'avortement social NEW FAMILY PLANNING ACTIVITY in 1979, by region and the share of social abortion IN-APF Avort.Soc. / Soc. Ab. Rang/Rank IN-FPA Taux/Rate Part/Share Rang/Rank 62.2 3 .36.94 15 Figure 9-1. Sousse 168.72 Figure 9-2. Gafsa 6 135.4 13.7 10.1 10 Figure 9-3. Tunis 6 134.2 38.6 28.8 2 Figure 9-4. Bizerte 130.9 25.8 19.7 4 Figure 9-5. Monastir 121.3 16.3 7.4 14 Figure 9-6. Nabeul 117.0 33.0 28.2 3 Figure 9-7. Le Kef 6 115.8 14.7 9.3 12 Figure 9-8. Sfax 113.9 17.7 15.5 8 Figre 9 TUNISIE 104.6 21.9 20.9 Figure 9-9. B6ji 96.6 18.0 18.6 5 Figure 9-10. Gab s 93.3 7.9 8.5 13 Figure 9-11. Jendouba 87.3 14.3 16.4 7 Figure 9-12. Kasserine 81.0 7.7 9.5 11 Figure 9-13. Mahdia 77.3 13.4 17.3 6 Figure 9-14. Medenine 63.2 2.1 3.3 15 Figure 9-15. Kairouan 39.0 4.9 12.6 9

Les Figures sont class~es par ordre-de rang de l'IN-APF atteint en 1979 The Figures appear in decreasing rank order of the IN-FPA talue of 1979 2 Indice de Nouvelle Activit6 en matiere de Planning Familial, pour 1979 Index of New Famil- Planning Activity achieved in T979 C'est la somme de six taux pour 1000 F1tAR (voir Figures) It is the sum total of the six rates per 1000 MWRA (see Figures) 3 Taux pour 1000 FMAR / Rate per 1000 MWRA 4 Avortement en tant que pourcentage de l'activitg nouvelle en PF Abortion as percent of total new FP activity 5 Rang du pourcentage de l'IN-APF ayant contribu6 par l'avortement social Rank of the share of social abortions in the total IN-FPA. 6 Sidi Bouzid, Zaghouan et Siliana ont contribu6 seulement mais entieremen les actes de lig. des trompes et avortements sociaux - y compris le d~nominateur de FMAR - pour le calcul de l'IN-APF Figures include the tubal ligations and social abortions of Sidi Bouzid, Zaghouan and Siliana, respectively, including the respective denominators

- 68 ­ Figur 9-1. SOUSSE TENDANCE DES INCIDENcrs,' 7REND C'F INCIDENCES ONrP/US,,DON~rPUSAIDFP Fr Prgram, vola14,eo..,.,2 Phate . IANPr 9 .7 127.0 17.8 192.2 166.3 168.7 (Z­

FMAK/1WRA -13,5% 91.4% 33160 34418 35725 37082 38490 39952 on mon 1901 64.7

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-69­ rlig.9-2. GA FSA 1(NDANCE DrS 14CIDCNCIS / Tcrtf, OF INCirrNCCS OINI /USAin rp ,.am [vioutio,, . ,.-2. IANPF: 74.9 97.1 130.0 140.6 147.2 135.4

+4.7% -8.0% rMAR,/MWRA:/ Golic: 31207 32280 33322 1 34390 35492 36679 37803 'S.B.i 29213 30268 31361 , 32493 33666 34881 3614 r

n 0 70- \ 69.1

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74 75 76 77 78 79 1980 to$ FM/'1, JS5;dl uidi,Wiat liqueique, ligaturesai oviom-nis boa,.iouacddot wnon 1976,1977,o1 1978 o."te1t priu on co,,idrillon. Te MWKA of Sidi touidI and iheiow, Iiooni on,Ii,o onitc.of I9/t, 19 '.,ao 19/h were inclIurd In thecalculoion clthe sle.

- 70 ­ 1puw 9-3. TUNIS TENDANCE DES INCIDENCES/ TREND OF INCIDENCES ONPFP!USAID FPProgrmEvalution Phos IANrF: 119.5 134.5 157.3 154.1 162.0 134.2 FMAP/MWRA: 45.1% -17.2% Tunki: 123620 12a71I 134012 139533 145280 151265 (= -)' 157497 Zoph: 26613 27426 28263 2912 30013 311j

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Q I I I JI G|t4B _____e 74 75 76 77 78 79 1980 ' Lii FIVAR do Zophkian ont ele prI en conslderoflor pour Its t1g. lub. arisl que. pout le%Avormen'.en Socloux. 14*. MWRA of Zoghuon were included in 1he denorm.inolo for oho clculaiion of rotes of Social obonijon and Tubal ;aio~ri.

-71 ­ FOUM, 9. B IZERTE TENDANCE DES INCIDENCES / TREND OF INCIDENCES ONPFP/USAID FP Pr.ogrom Evaluation, Phs. - 2. IANPF. 100.4 104.6 115.3 124.1 140.9 130.9 C-_ .D 413.5% -7.1% FMAIVMWRA: 45449 46657 47897 49170 0477 51819 53197

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- 72 ­ Figurog-5. MONA STIR TCNDANCE DES I'CIDENCES / RrD OF INCIDENCES ONPFP/USAID FP Proam Eolu#ion, Ph,,.-2. IANrF: 90.5 6.7 115.3 134.2 147.2 121.3=

FMAR/MWRA: 49.7% -17.6% ( 33599 26987 27990 29031 30111 31231 32393 A comple'tet en MfL 1981 40-4 38.4

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- 73 ­ Fiurt 9-6. NA B EUL TENDANCE DES INCIDENCES / TREND OF INCILENCES ONrFr/USAIo FP Program Evoiuatr:', Phe. 2. IANPF: ,,6.9 151.1 159.4 153.7 12.9 117A =

FMAPV/MWRA: -20.0% -4.C% 46234 48169 50 5 52285 54473 56753 59128

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- 74­ Figure 9.7. LE KEF TENDANCE DES INCIDENCES / TR.ND OF INCID.NCE ONPFr/UqAID FP Program Evolucita, Phate-2 IANPF: 120.0 101.2 114.6 125.2 142.1 115.8 FMAI/MWRA. -13.5% -18.5% LeKefr 31443 31974 32513 33060 33617 34183 34759 'SIiona.24540 24893 25251 25614 2.W33 26357 26736 G4.e

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- 7r, ­ Figure 9-8.SFA X TENDANCE DES INCIDENCES / TREND OF INCIDENCES ONPFP/USAID FP Program Evoluat;on, IPhoe 2. IANPF: 113.0 125.2 149.9 )I0.2 128.7 113.9 C FMAR,/MWRA: -14.3% -I1.5% 63410 65259 67162 69120 71135 -. 73209 753 A complle'r 40-0 % n rr, 1981

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- 76 ­ Flour, 99 BEJA TENDANCE DES INCIDENCES / TREND OF INCIDENCES ONPFP/USAID FP Program Evaluation, Phos, - 2. IANPF: 94.3 85.8 116.4 124.4 103.7 96.6 FMARI 'M\RA: -16.6% -6.8% 32836 33453 34091 34735 35392 36061 A €ccwrliler36743 40 *n mars-­ 1981

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- 77 ­ Ficura -i0. GASES TENDANCE DES INCIDENCES /7REND OF INCIDENCES ONPIP/USAID FP Propirom Evaluotion, ?I-ao- 2. IANPF:65.8 82.5 107.9 121.5 105.7 93.3 FMWMWRAs -13.0% -11.6%

369-8 38375 39816 41312 42864 44475 46146

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- 78 ­ Figure 9- I. JENDO LJBA TENDANCE DES INCIDENCES / TREND CF INCIDENCES ONPFP/USAID FP Program EvouontP'vose-2. IANPF: 71.7 54.4 74.4 103.7 95.8 87.3 (1) -17.3% +1.7%+ 50101

FMAR/MWRA: *A COMer 43740 44741 45765 46813 .7884".. 48980 *n man 1981

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- 79 - ONPFP/USAID FPPoprom Evoluollono Phot, .2. Figure 9-12. KASSERINE TENDANCr DES INCIDENCES/fIREND OF INCIDENCES 90.4 81.0 IANPr 4'.7 44.0 124.8 94.0 -3.8% -10.4% FMAR/MWRA: 39051 40444 41886 33948 35156 36409 37707

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- 80 ­ Figure 9-13. MAKDIA TENDANCE DES INCIDENCES / TREND OF INCIDENCES ONPFP/USAID rP Ptogram Evaluation, Phase - 2. IANPF: 41.7 77.6 91.9 99.4 96.1 77.3 +7.5% -19.6% Z 35717 FMAR/M\VWA: A compl Ir 28562 29645 30770 31938 33151 34410 en mars 1981 40- -16

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-81 ­ Figure 9-14./AIEDENINE TENDANCE DES INCIDENCES / TREND OF INCIDENCES ONPFP/USAID (P Progamn Evolu;on, P6"-2 IANPF: 36.9 41.4 56.6 55.9 68.7 63.2 422.9% -8.0'% FMAR/MWRA: 45965 47232 48534 49871 51246 52658 54109 40

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-82­ Figure -15. KAIROUAN TN.ANCE DES INCIDENCES/TREND OF INCIDENCES 'ONPFP/USAID FPProg,m Evolumion, P.e -2 IANPF: 45.9 48.2 40.9 43.4 46.3 39.0 CjD I FMRMWA 6.7% -15.8% CC FMAR/MWRA:.4.7, 44953 46527 48157 49844 51590 53398 55268 40

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-83­