CORE PACKAGE FINAL REPORT:
Operational Policy Changes
to Reduce Barriers to
Family Planning in Guatemala
POLICY Project
August 2005
This publication was produced for review by the United States Agency
for International Development. It was prepared by the POLICY Project.
Operational Policy Changes
to Reduce Barriers to
Family Planning in Guatemala
POLICY Project
August 2005
The POLICY Project is funded by the U.S. Agency for International Development (USAID) under Contract No.
HRN-C-00-00-00006-00. POLICY is implemented by Futures Group in collaboration with the Centre for
Development and Population Activities (CEDPA) and Research Triangle Institute (RTI). The views expressed in
this report do not necessarily reflect those of USAID or the United States government.
Guatemala Core Package Final Report
ii
Contents
Abstract
iv
Abbreviations
v
I.
Introduction
Family Planning Policy Environment in Guatemala
Barriers to Family Planning
Policy Implications of Barriers
Purpose of POLICY Interventions
1
1
3
3
4
II.
Methodology and Description of Core Package Activities
Engaging Stakeholders
Document Review
Legal and Policy Assessment
Information Dissemination and Project Design
In-depth Interviews
Problem Diagnosis, Policy Analysis, and Identification
of Policy Solutions
Planning for Immediate Policy Action
6
6
6
8
8
8
9
10
III.
Results
12
IV.
Conclusion
Elements of Success
Lessons Learned
Replicable Methodologies
14
14
15
15
References
Guatemala Core Package Final Report
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iii
Abstract
From January 2002–2004, the POLICY Project and key stakeholders undertook an
intensive, systematic policy analysis process that resulted in identifying two priority
regulatory actions critical for reducing barriers to family planning and reproductive
health (FP/RH); both actions were ultimately agreed to by Guatemala’s Minister of
Health, Dr. Julio Molina-Avilés. In January 2004, during his last weeks in office, MolinaAvilés signed a ministerial order that explicitly included the National Reproductive
Health Program (NRHP) among the ministry’s official health programs, effectively
providing the policy and organizational foundation required to assure continuity of
government-sponsored FP/RH service delivery under future administrations. He also
supported modification of an existing government order that would define the NRHP’s
structure and functions and incorporated this and other stakeholder proposals for policy
reform into the transition plan prepared for the incoming administration. The actions
marked the end of a four-year period of support of FP/RH in Guatemala, as some
members of the newly-elected incoming government vowed to reverse gains in FP/RH
programs. Their task will be more difficult now because of the minister’s actions and the
broad political and popular support these actions received.
This report traces the policy analysis process undertaken by stakeholders and POLICY by
describing the context, methodology, sequence of events, major policy challenges, and
the stakeholders involved in its successful outcome.
Guatemala Core Package Final Report
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Abbreviations
AGMM
AGOG
APROFAM
CA
CALIDAD
DHS
FP
IEC
IGSS
MSPAS
NRHP
POA
RH
SEGEPLAN
STI
USAID
Guatemalan Association of Women Physicians
Guatemala Association of Gynecology and Obstetrics
La Asociación Pro-Bienestar de la Familia
Cooperating agency
USAID bilateral project (Proyecto Calidad en Salud)
Demographic and Health Survey
Family planning
Information, education, and communication
Guatemala Social Security Institute
Ministry of Public Health and Social Services
National Reproductive Health Program
Annual operational plan
Reproductive health
General Secretariat of Plan
Sexually transmitted infection
U.S. Agency for International Development
Guatemala Core Package Final Report
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I.
Introduction
Family Planning Policy Environment in Guatemala
The family planning and reproductive health (FP/RH) policy environment in Guatemala
underwent a remarkable transformation from 2000–2004. During years of government
hostility toward FP/RH and effective opposition to expanding services, even the public
mention of the term “reproductive health” was sufficient to unleash publicized
condemnation from organized opponents. Guatemala only signed the 1994 Cairo
Program of Action with numerous reservations (UNFPA, 1994). Nonetheless, in the mid1990s, alliances were formed among civil society groups, legislators, and supportive
government officials urging that greater attention be paid to the FP/RH needs of the
population. Advocates were able to use Guatemala’s 1996 Peace Accord commitments to
health and gender equality as a means to improve the legislative framework for women’s
issues, favorably amending the public health law and enacting a law to dignify women.
Several events coincided that substantially improved the environment. During 1999,
despite the hostile environment and in response to growing concern about FP/RH needs,
the country’s three major public and private sector service provider institutions [the
Ministry of Public Health and Social Services (MSPAS), La Asociación Pro-Bienestar de
la Familia (APROFAM), and the Guatemalan Social Security Institute (IGSS)] embarked
on a study to identify and reduce medical and institutional barriers to FP access (MSPAS
et al., 2000). In early 2000, as these institutions began preparing action plans to respond
to the study findings, a new administration under President Portillo took office. Its
Minister of Health, Dr. Mario Bolaños Duarte, vowed to restore a vastly diminished
national RH program, publicly aligning himself with FP/RH advocates who quickly
rallied around him. Within a year, the provider institutions began implementing
corrective actions to reduce barriers to family planning; the minister inaugurated the
National Reproductive Health Program (NRHP); and in 2001, the Congreso de la
República enacted the Law of Social Development. The law explicitly affirmed the right
of all persons to decide the number and spacing of their children and the right to accurate
information. It also directed the executive branch to formulate a social development
population policy. The policy, which elaborates the principles underlying the Law of
Social Development, was formally adopted in April 2002 by the General Secretariat of
Plan (SEGEPLAN). The minister maintained a public dialogue on the need for FP/RH
services and information until he left office in early 2003. His successor, Dr. Julio
Molina-Avilés, continued these favorable policies and supported the formalization of
efforts to strengthen the NRHP.

Código de Salud de Guatemala, 7 de Noviembre de 1997, Libro II, Título I, Capítulo II, Articulo
41, Salud de la Familia; Ley de Dignificación y Promoción Integral de la Mujer, Decreto 7–99,
Congreso de la República, 9 de Abril de 1999.

“Bienvenida,” Dr. Julio Molina Avilés, Ministro de Salud Pública y Asistencia Social/MSPAS,
Taller para la Discusión y Validación de Resultados, February 19, 2003. In opening the project’s
workshop, Molina-Avilés urged participants to overcome the difficulties they often face at the
operational level in order to identify and institute RH policies that would endure beyond the
months remaining under his administration.
Guatemala Core Package Final Report
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Midway through the Portillo administration, however, many challenges remained.
Despite the favorable government position and more supportive national laws and
policies for FP/RH, the laws and policies had not yet been translated into action through
regulation, internal ministry procedures and guidelines, or other operational policies.
The NRHP had no basis in law or regulations. Responsibility for FP services was located
far down in the ministry’s organizational structure within a large department responsible
for all of the country’s health service programs. Most resources for family planning came
from bilateral funds administered by an implementing unit within MSPAS and thus were
not part of the formal planning, programming, and budgeting process. Family planning
therefore remained a discretionary program—albeit a favored one—rather than state
policy. After years of hostility and neglect surrounding FP/RH, changes were needed in
the national healthcare delivery system to meet the particular needs of a reinvigorated
NRHP. Existing policies in such critical areas as personnel, clinic organization, physical
infrastructure, warehousing, logistics, and transportation on which FP/RH services are
dependent were inappropriate or unresponsive. Yet, as a program not institutionalized
within the healthcare system, it was difficult to justify supporting FP/RH through
operational policy changes or the integration of FP/RH into high-level policies governing
the planning, programming, and resource allocation process when the interests of other
more formally recognized health programs would have to give way.
Given the public sector’s central role in the delivery of FP/RH services, the absence of
more comprehensive and formal policy change raised doubts that corrective actions
undertaken by either government or nongovernment provider institutions to reduce FP
barriers would be sustainable. Although the new administration exercised its authority to
interpret policies and use resources in ways that would favor FP/RH service delivery, the
administration’s actions would have little long-term effect if there were no formal
policies or organizational structure to guarantee continuity in successive governments.
Finally, the presidential election scheduled for the end of 2003 was a constant reminder
that a future administration could shift away from the supportive policy environment.
This possibility underscored the need to emphasize regulatory and policy change to
ensure that access and quality improvements continued beyond the current
administration. In essence, the remaining two years of the Portillo administration offered
a window of opportunity to address the policy vacuum and institutionalize the NRHP.

Operational policies are the rules, regulations, guidelines, operating procedures, and
administrative norms that governments use to translate national laws and policies into programs
and services (Cross, Hardee, and Jewell, 2001). They affect personnel, clinic organization,
financing, materials, supplies, physical infrastructure, transportation, and other support systems
essential to operating the national service delivery system on which FP/RH service delivery is
dependent. These policies may pose barriers to service delivery as a result of misguided design or
implementation of the policy.
Guatemala Core Package Final Report
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Barriers to Family Planning
Within this context, in 2001, the POLICY Project designed a core package to identify and
address policies and practices governing FP service provision that were inappropriate,
unnecessary, or otherwise detrimental to quality, access, and sustainability.
Prior to the core package, information related to policies and practices unsupportive of
Family planning in Guatemala came from USAID-funded studies on institutional and
medical barriers. POLICY had conducted the most recent study in 1999 in collaboration
with USAID, the Population Council, the Guatemalan Association of Women Physicians
(AGMM), the Guatemala Association of Gynecology and Obstetrics (AGOG) and the
three major service provider institutions (MSPAS, APROFAM, and IGSS). This study
provided valuable information on the nature of service delivery policies and practices that
create barriers to FP services. Although referred to as a “medical and institutional barrier”
study, it cited the Shelton, Angle, and Jacobstein definition of “medical barriers” (Shelton
et al., 1992) and focused primarily on policies and practices that have no medical
justification. It reported little improvement over a similar study (MSPAS et al., 1993),
and in view of the negative policy environment that prevailed throughout the 1990s, this
lack of progress is hardly surprising.
Findings of the 1999 study included:







Inappropriate eligibility criteria—such as minimum age, minimum parity, and
spousal consent, as a condition to receiving contraceptives;
Unjustified precautions for method use and misinformation among providers
about side effects of methods;
Cumbersome procedural requirements—including sexually transmitted infection
(STI) tests and/or multiple visits prior to dispensing certain contraceptive types;
Narrow range of methods offered;
Restrictions on personnel—including on types of health personnel permitted to
prescribe contraceptives, including pills and condoms;
Lack of provider skills—absence of refresher training to bring medical personnel
up to date on norms and standards; and
On-site absence of manuals of standards and norms.
Policy Implications of Barriers
Barriers to services are often symptomatic of inappropriate and/or outdated laws and
policies at higher and operational levels of the healthcare delivery system, and can
sometimes stem from the failure to translate a favorable national legal-policy framework
through operational policies. The policy causes of FP barriers in Guatemala were most
clearly related to norms and standards governing service delivery in the field. However,
stakeholders ultimately identified the failure to formalize and institutionalize the NRHP

A similar medical barriers study was conducted in 2003, but the results only became available
after the core package was completed. It is anticipated that others will be conducted by USAID in
the future to facilitate continuous evaluation of the NRHP implementation.
Guatemala Core Package Final Report
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as a fundamental obstacle to meaningful operational policy reforms needed to support a
sustainable reduction in FP/RH barriers.
Prior to the core package, POLICY/Guatemala had provided technical assistance to the
MSPAS, IGSS, and APROFAM to begin identifying policy-related causes of barriers
highlighted in the 1999 study. As a result, in addition to nonpolicy corrective actions such
as in-service training and increased supervisory visits, the institutions had identified some
necessary policy changes, primarily related to service norms and standards, and approved
appropriate corrective actions. For example, the MSPAS began revising its long
outdated FP service norms and standards to provide explicit guidance and recent
information that would eliminate inappropriate eligibility criteria, such as age and spousal
consent; ensure that clients are correctly informed regarding side effects; and reduce
procedural requirements for contraceptive provision. The IGSS distributed its first set of
FP norms and standards as an essential step toward reducing inappropriate practices
among its provider staff, such as imposition of spousal consent and age and parity
criteria. APROFAM modified its service norms and its manual for voluntary outreach
workers to address barriers related to inappropriate eligibility criteria and restrictions on
methods available at the community level. It also began revising its legal-policy and
regulatory framework to ensure that its financial system could support the cost of any
changes.
Although corrective actions are beneficial, medical and institutional barriers studies
generally focus on facilities and service providers and not the myriad higher level
policies, rules, and regulations that govern provider actions and institutional performance.
Therefore, these studies are limited in what they reveal about underlying policy causes of
unjustified service delivery practices. There is usually little probing beyond the
conclusion that existing practices are inappropriate and need to be corrected through
updated clinic manuals, training, and increased supervision.
As a result, there can be a failure to understand the central role of government and public
sector policies, which could severely undermine the long-term impact of corrective
actions. Training, increased supervision, equipment purchases, or even changes in service
norms or client fees will undoubtedly lead to immediate improvements in certain areas;
however, their effect will be short lived without instituting related policy reforms and an
examination of public-sector policies governing areas—such as personnel, facilities, and
logistics—that greatly influence commercial sector and NGO services. Even the range of
corrective actions at the operational level can be significantly limited if other policies are
not changed. For example, policies that govern the allocation of resources and priorities
for human resource development can substantially restrict the content and frequency of
in-service training that might address some of the barriers.
Purpose of POLICY Interventions
POLICY’s core package provided a timely opportunity for stakeholders to gain an indepth understanding of the public sector service delivery system and to identify and

Detailed information about corrective actions being taken by the three institutions is documented,
including reports of progress, and is available from the POLICY Project.
Guatemala Core Package Final Report
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address the underlying policy causes of the barriers to FP services found in the 1999
study. The rationale was that the three major provider institutions were committed to
addressing the barriers and were already working with POLICY/Guatemala to implement
the most effective corrective actions possible. Furthermore, a new administration was
making concerted efforts to strengthen the NRHP. Equally important, there was a
growing recognition among stakeholders that national support for the NRHP would not
translate into significant long-term improvements in services without operational policy
changes.
The package’s specific objectives were to





Analyze the identified barriers and corrective actions and identify other important
service barriers;
Assess the national legal-policy framework for FP/RH to identify laws,
regulations, and policies—and areas of legal-policy vacuum—that contribute to
these barriers;
Identify and rank policy causes of barriers and the policies needed to expand the
range and effectiveness of corrective actions;
Prepare and implement an action plan for achieving policy change; and
Provide information and materials for advocacy.
POLICY implemented the core package activities from January 2002—January 2004,
coinciding with the second half of the supportive Portillo administration.
Guatemala Core Package Final Report
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II.
Methodology and Description of Core Package
Activities
Core package activities consisted of four workshops for stakeholders and various desk
studies, interviews, and other forms of data collection. Toward the end of the project,
during the last few months of the Portillo administration’s tenure, POLICY’s field
support and core package teams participated in several meetings with the minister and
high-level ministry officials, civil society advocacy groups, and supporters in the
legislative branch to ensure that agreed upon activities were on track and would indeed
take place before the pending elections in 2004. Below are descriptions of each individual
activity. Figure 1 presents a flow diagram of the entire process.
Engaging Stakeholders
In January 2002, POLICY launched the core package activities with a multisectoral
stakeholder workshop to introduce the package, seek commitment to and ownership of
the package by stakeholders, and achieve consensus on the methodology to be used.
POLICY staff gave a presentation on the concept of operational policy reform to improve
FP/RH care and described the goal, objectives, and proposed activities of the package.
Participants, who expressed their support and provided valuable input into the
methodology, included representatives from the Presidential Secretariat on Women’s
Affairs; the MSPAS, the lead government agency and primary service provider institution
for FP/RH; the IGSS, the major health service provider institution for public sector
employees; APROFAM, a major service provider and a key advocate for FP/RH for the
past three decades; the bilateral project managed by URC; the Population Council, coauthor of the medical and institutional barriers study; the Guatemala Association of
Women Physicians (AGMM) and the Guatemala Association of Gynecology and
Obstetrics (AGOG) which were collaborating partners in the 1999 study; the Maternal
Neonatal Health Project managed by JHPIEGO; SEGEPLAN; the USAID mission; and
organized advocacy networks including the Red de Mujeres por la Construcción de la
Paz.
Document Review
Following the first workshop, POLICY staff reviewed documents related to FP/RH
access and quality to supplement findings from the 1999 medical and institutional
barriers study. The documents reviewed included research studies on use of FP services;
assessments of different aspects of the public healthcare system, such as its logistics
management and administrative regulations; surveys including the DHS; internal MSPAS
organizational regulations; reports of the bilateral project and other CAs; and progress
reports of corrective actions taken by MSPAS, APROFAM, and IGSS to address the
barriers to FP access/quality. The review helped identify further information necessary to
determine which policies are most directly related to FP/RH barriers. The review also
provided information on the progress of corrective actions undertaken by MSPAS,
APROFAM, and IGSS in response to the 1999 study; other possible barriers; and
ministry regulations and policies that govern service delivery.
Guatemala Core Package Final Report
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Figure 1. Chronology of Activities of Guatemala Core Package


January 2002 Stakeholder Workshop
Seek commitment
Reach consensus on goals, objectives,
and methodology




Document assessment
Legal-policy review


February 2003 Stakeholder Workshop
Diagnose FP service problems
Develop policy solutions
June 2002 Stakeholder Workshop
Present results to date
Develop interview instruments

In-depth interviews
September 2003 Stakeholder Workshop

Select two policies
for action in the
short term, to be
supported through
the core package

Prepare
medium- and
long-term
roadmap for
operational
policy changes

Criteria for selecting priority actions:
importance, multiplier effect, opportunity,
key actors available, political support,
feasibility, core package results, and
timeframe
Information for
advocacy and
civil society
oversight
Plan action for
policy changes
Implementation
plan (January
2004)
Documentation
of results
Follow-up
implementation
and monitoring
Guatemala Core Package Final Report
Final report
7
Legal and Policy Assessment
Between February and April 2002, a local legal consultant updated an earlier assessment
(Schieber et al., 2000, Unpublished.) of national laws and policies related to family
planning. The consultant concluded that, overall, there are few explicit barriers to FP/RH
but there are weaknesses and gaps to address in the legal-policy framework through
legislation that would compel the state to ensure accessible, high-quality services. The
few explicit barriers to FP relate primarily to some conflicting policies surrounding
sterilization and uncertainty regarding the age of legal majority. Since, during the 1999
study, stakeholders did not identify these issues as needing further analysis and the issues
could prove divisive in generalized discussions, they were not included as agenda items
for the core package. The weaknesses and gaps stem primarily from the absence of any
expressed guarantee of access to FP/RH information and services as a state policy or any
other obligation that would compel the state to more actively pursue the provision of
accessible, high-quality services.
The scope of the 2002 assessment was limited to international conventions, legislation,
and other national policies and commitments established since the previous assessment,
such as the social development law and formal ministerial policies and plans that affect
FP/RH. The assessment did not include internal ministry organizational regulations or
lower level operational policies. The consultant reviewed and prepared a detailed
description of the relevant texts and documents and produced an analytical report of the
current policy and legal framework for FP/RH in Guatemala.
Information Dissemination and Project Design
In a June 2002 workshop, POLICY presented and received feedback on findings from the
document review and legal-policy assessment and received input on the interview design
for the data collection phase. Participants, who were familiar with many aspects of laws
and policies related to their own field, felt that the legal-policy assessment report had
increased their knowledge of the status of FP/RH and recommended that it be more
widely disseminated. They concluded that the existing framework provides adequate
legal authority for FP/RH but also acknowledged the need for more explicit assurances of
its long-term survival. Participants also provided input into the data collection phase
(interview phase) of the core package, commenting on draft interview guides prepared by
POLICY staff and agreeing to participate in field testing. Since the participants included
higher-level officials from the MSPAS and IGSS who had not been in the first workshop,
POLICY used the opportunity to give a comprehensive presentation on improving FP/RH
programs through operational policy reform. As a result, more high-level MSPAS
officials participated in subsequent core package activities, reflecting MSPAS’s greater
resolve to invest more resources in the search for root causes of operational barriers.
In-depth Interviews
Between October and December 2002, POLICY staff and a consultant conducted 40 indepth interviews with service providers, managers, and program planners to gain a better
understanding of public sector policies and their impact on those responsible for FP/RH
service delivery.
Guatemala Core Package Final Report
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Questions were grouped into three major areas: (1) planning, programming, resource
allocation, and financing; (2) human resource development, including pre-service and inservice training and supervision; and (3) logistics management and supply issues,
including the climate for collaborating with the private voluntary and commercial sectors.
The majority of interviewees were chosen from various MSPAS divisions at the central
level that are directly and indirectly related to the NRHP—Regulation, Monitoring and
Control, Health Services, Human Resources, Administration and Finance—and different
facility levels (hospital, health center, health post) in three geographic departments. The
interviews were designed to elicit respondents’ views on a wide range and multiple levels
of existing health service policies that were most likely at the root of FP/RH barriers and
relevant to the success of high-level government commitment to FP/RH. Respondents
were specifically asked to comment on the adequacy of these policies for achieving the
expressed goal of the MSPAS to improve the FP/RH program.
Information garnered from the interviews revealed extensive serious, systemic problems
at different levels of the public sector healthcare delivery system and a strong consensus
that the problems were an obstacle to strengthening the NRHP, an essential condition to
reducing FP/RH barriers. POLICY concluded that in the next phase, stakeholders would
need to identify and rank policy-solvable problems and actions most likely to strengthen
the NRHP. The results of the interviews captured the attention of senior ministry
officials, including the minister, and set the course for the rest of the core package.
Problem Diagnosis, Policy Analysis, and Identification of Policy Solutions
In February 2003, POLICY held a workshop to share the results of the interviews and to
enable participants to (1) quickly diagnose and link problems to all levels of their work,
going beyond the operational level; and (2) rank the major problems. Having limited
time, it was a daunting challenge for the POLICY team to organize the large number of
problems. To facilitate the process, POLICY introduced a conceptual framework inspired
by the Evaluation Project’s guide to family planning evaluation (Bertrand et al., 1994)
(subsequently modified and adopted by workshop participants for the duration of the core
package) and produced a document containing the interview results organized according
to the framework’s three subcomponents (see Figure 2).
Figure 2. Analytical Framework Used in Workshop
Political and
Administrative
System
Political support
Resources and budget
Human resource development
Intersectoral and intrasectoral
coordination
Community participation
Organizational
Structure of Health
System
Planning and programming
Human resources policy
Personnel deployment
Guatemala Core Package Final Report
Program
Operations
In-service training
Monitoring and supervision
Information
Logistics
Promotion
Intra-institutional coordination
9
Using this framework, the participants identified 52 major problems and 36 policy
solutions to address them—ranked according to effectiveness in reducing barriers and the
feasibility of implementation.
The participants intended to conduct follow-up
meetings to prepare a detailed action plan for
implementing the policy solutions. However, time
constraints prevented meeting for the next six
months. During that period, POLICY/Guatemala
and stakeholder activities continued to advance
agreed upon FP/RH objectives, which were
consistent with the policy actions.
Planning for Immediate Policy Action
After an unavoidable delay of six months, POLICY reconvened stakeholders at a final
workshop in September 2003. With five months remaining in the Portillo administration,
the workshop’s purpose was to plan immediate actions and prepare a roadmap for
medium- and long-term policy reform. Participants, including the Vice Minister of
Health, the National Health Director, the NRHP Director, other MSPAS representatives,
and representatives from USAID and cooperation agencies (CAs), reviewed results of the
February workshop, assessed progress in implementing policy solutions in the interim
period, and ranked remaining policy challenges needing both immediate and longer term
attention. Based on this analysis, workshop participants pared the list of problems
hindering FP/RH service delivery from the identified 52 down to the following 10:
1. The political base and organizational structure of MSPAS are inadequate for
assuring continuation of the NRHP and FP/RH service delivery in the face of
political change.
2. Reproductive health and family planning are not considered as part of state
policy as there is no explicit RH law.
3. The MSPAS resources are inadequate to ensure high-quality and sufficient
coverage of services.
4. The population does not perceive FP/RH care as a right.
5. The planning process does not respond to the real needs at the operations level
but is instead an automatic exercise to fulfill a formal requirement.
6. Efforts to integrate FP/RH into the annual operational plan (POA) are neither
systematic nor documented.
7. Resource allocation for the ministry division responsible for FP/RH is a function
of a predetermined ceiling and not of realistic programming based on need in the
POA, and is characterized by reductions in estimated budget needs at all levels.
8. There is great need for promoting the program through nonwritten
communications to better reach the population.
9. Data from the information system are not used systematically and consistently
for decisionmaking at different levels.
10. Information is not used adequately in the supervision and monitoring and
evaluation processes.
Guatemala Core Package Final Report
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Participants concluded that the most fundamental obstacle to reducing FP/RH barriers
was the first problem listed above. Based on this conclusion, they proposed two priority
actions that would result in the operational policy reform needed to support FP/RH:


The formal creation of the NRHP through a ministerial order that would include
it among the ministry’s official service programs. This action would effectively
institutionalize the NRHP, helping to sustain the FP/RH effort and enabling an
allocation for family planning and reproductive health in the national budget; and
Amendments to an existing government order, outlining the ministry’s internal
regulations, in order to define and regulate the NRHP’s organizational structure
and functions. This change would obligate the ministry to maintain a certain level
of competency and resources for implementing FP/RH services.
The selection of regulatory action by stakeholders is significant: it constitutes the highest
level of operational policy. Under a general delegation of discretionary authority,
government agencies use regulatory techniques and decisionmaking procedures to
implement laws and more broadly stated policies in the form of systemwide programs.
Thus, in the hierarchy of laws and policies that govern the operations of a health system,
a ministry regulation is situated just below supportive laws and favorable national
policies and is a necessary first step in operational policy reform.
During the workshop, stakeholders also prepared a roadmap to improving the NRHP with
policy changes for addressing all 10 priority problems. The roadmap includes a problem
statement, the proposed policy solution, specific policy activities, timeframe, products,
source of resources, entities responsible, and expected outcome. The minister of health
agreed to incorporate the roadmap into the transition plan for the incoming
administration.
Guatemala Core Package Final Report
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III.
Results
Guatemala’s key stakeholders and the minister signaled that they were not content to
address FP/RH barriers by tackling only those causes most obvious at the operational
level, and they clearly did not believe that favorable FP/RH policies and high-level
commitment in the ministry and administration would be enough. Therefore, stakeholders
identified the highest possible level of operational policies—regulatory change—for
immediate action by the government to ensure a sustainable reduction of barriers to
family planning and reproductive health. POLICY’s Guatemala core package was
directly responsible for assisting them to implement this regulatory change and to offer a
clear direction for continued policy reform.
During the implementation of core package
activities, stakeholders from the public and private
sectors identified numerous systemic problems in
the public sector that would prevent long-term,
sustainable reductions in identified barriers to
family planning and reproductive health. The most
critical problem, they concluded, was the
insufficient political and organizational base to
guarantee continuity of the NRHP and needed
operational policy reform. Based on their diagnosis,
they selected two priority policy actions and then, between September and December
2003, POLICY staff, representatives of civil society advocacy networks, and other
stakeholders met several times with high-level MSPAS officials, including the minister,
to discuss implementing them. POLICY also contracted a local legal consulting firm to
provide technical assistance to the ministry to analyze and draft the required regulatory
mechanisms. As a result of these efforts, the minister agreed to support
1. A new ministerial order (Acuerdo Ministerial) to include the NRHP among the
minister’s official programs, which would need only the minister’s final
approval; and
2. The modification of an existing government order (Acuerdo Gubernativo 115-99)
to define the NRHP’s structure and functions, which would need the president’s
approval.
On January 6, 2004, on his last day in office, the Minister of Health signed Ministerial
Order SP-M-239-2004, which sets forth the ministry’s 18 national health programs,
including the NRHP. As authority for creating these programs, SP-M-239-2004 cites both
the constitution and the health code requirements that the Ministry of Health organize and
oversee health service delivery and cites the minister’s regulatory authority under the law
of internal organizational regulations of the Ministry of Health. The ministerial order was
published in the Diario de Centroamérica (daily Central America newspaper) on February
5, 2004. Article 1 of the order creates the 18 ministry programs—including the NRHP—
to be under the direction of the ministry’s Department of Regulation of Programs of
Health Care for Individuals (“Atención a la Personas) of the General Directorate for
Guatemala Core Package Final Report
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Health Regulation, Oversight and Control. Article 4 of the order furnishes a basis for
formal inclusion of the NRHP in resource allocation decisions within the ministry and
within the framework of the national budget as well as from outside sources. Specifically,
Article 4 provides that each program can manage contributions from government and
nongovernment entities to carry out its mandate and manage its budgetary allocation
within the ministry. This result institutionalizes the NRHP in the ministry’s regulatory
framework; puts RH services on an equal footing with all other ministry service
programs, regardless of changes in government and ideologies; and provides the
organizational and political base needed to negotiate resources for reproductive health
from within and outside government.
Also as part of his departing actions, the Minister of Health incorporated the roadmap of
operational policy changes for addressing priority FP barriers into the transition plan
prepared by the outgoing administration for the incoming administration.
The second action, modifying an existing government order, has not yet occurred but is
now the first proposed action in the roadmap of operational policy reform, which the
minister incorporated into the transition plan for the incoming administration.
Furthermore, now that the NRHP has achieved the status of a ministry program, it is
expected that its needs will be systematically and routinely included in shaping
operational policies, planning, programming and allocating resources.
The support of USAID-financed projects is essential if the MSPAS is to effectively
implement new and revised operational policies that deal with training, supervision, IEC,
and operational research. Resources are already programmed by CAs to improve provider
skills, abilities, and attitudes, and to increase knowledge among program managers and
service providers, and they could be further targeted to help implement the roadmap.
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IV.
Conclusion
Elements of Success
Multiple
elements factored into the successful outcomes of the core
package; the major ones included a high-level government commitment, stakeholder
ownership of the package, the carefully designed interview guides, and the
implementation of the package as a complement to field support activities.
High-level government commitment. The commitment to health sector policy changes
favorable to FP/RH ensured that the final product would contribute measurably to
reducing service barriers. During the package’s implementation, the public sector became
increasingly involved with greater attention paid by senior officials. Minister of Health
Avilés, the vice minister, and the directors of many of the ministry’s top bureaus
participated in examining public sector policies hampering family planning and
reproductive health and in the discussions that led to the adoption of two proposed
priority policy actions.
Stakeholder ownership. Stakeholders from multiple sectors embraced the package as
their own, using it as an opportunity to meet their own objectives. Provider institutions,
MSPAS officials, and civil society groups were already engaged in a number of efforts to
improve family planning and reproductive health and saw the package as a resource for
more informed decisionmaking and advocacy. They helped to develop the package’s
methodologies and were full participants in analyzing policies, exercising judgment about
findings, drawing conclusions, and making final recommendations. The USAID mission
was a constant, supportive, and active presence throughout the entire implementation
process.
Interview design. First, interviews
with managers, planners, and
providers
were
pivotal
to
understanding how Guatemala’s
public sector policies were affecting
the reality of day-to-day FP/RH
services. However, the interviews
were not designed to ask respondents
to link policies to the FP barriers
identified in the 1999 study or to
suggest policy changes for eliminating them. Instead, the interviews were designed to
elicit respondents’ views on a wide range and multiple levels of existing health service
policies, which were most likely at the root of FP/RH barriers and relevant to the success
of high-level government commitment to family planning and reproductive health.
Respondents were specifically asked to comment on the adequacy of these policies for
achieving the expressed goal of the MSPAS to improve the FP/RH program. This
approach also minimized the risk of opening a “Pandora’s box” of complaints about all
the ills of the public health service system.
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The core package as a complement to field support activities. The value of designing the
core package to complement the POLICY field support project cannot be underestimated
and had significant mutual benefits. The effective working relationships among the
POLICY/Guatemala team and both health ministers, senior officials of the three primary
institutional partners, the USAID mission, and advocacy groups were indispensable to
securing the sustained support of stakeholders throughout the two-year period. The core
package agenda was often advanced in POLICY/Guatemala meetings with advocates
from civil society, legislators, and government officials, particularly toward the end of
the project. In turn, the core package furthered POLICY/Guatemala’s objectives by
providing timely resources for vastly expanding the data base and conducting in-depth
policy analysis essential to FP/RH supporters and advocates. It added impetus to
POLICY/Guatemala’s efforts to mobilize stakeholders to assist a supportive government
administration in formalizing Guatemala’s National RH Program rather than leaving it to
the discretion of future administrations.
Other important elements of success included a legal and policy assessment to inform
stakeholders about (1) the source of authority for FP/RH programs, (2) potential threats to
its sustainability, and (3) the link between the national legal-policy framework and
barriers to family planning and reproductive health.
Lessons Learned
The core package demonstrated some important lessons:




Medical and institutional barriers studies are important in understanding providerimposed barriers; however, further policy analysis by stakeholders and a thorough
understanding of how the public sector functions are essential to identify and
understand the policies underlying these barriers and influencing corrective actions at
the service delivery level.
Even in a favorable environment with strong commitment to family planning and
reproductive health, before operational policy barriers at the service delivery level
can be effectively addressed, high-level regulatory action is needed to formalize the
process of change.
High-level government commitment to public policy reform and multisector
stakeholder engagement in policy analysis, problem identification, and recommended
of policy solutions are critical for policy change. Proposed policy changes identified
and ranked in a collaborative and participatory process are far more likely to be
endorsed and implemented by decisionmakers.
There are four important steps for addressing operational barriers through policy
analysis as described in Policy Occasional Paper No. 7, Reforming Operational
Policies: A Pathway to Improving Reproductive Health Programs:
- Understand the public sector;
- Take a collaborative approach;
- Analyze the operational policy barriers; and
- Follow through with recommendations to reduce operational policy barriers.
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Replicable Methodologies
Numerous countries suffer from similar
medical and institutional barriers and
could learn much from Guatemala’s
experience. The core package has
global implications because it used a
number
of
approaches
and
methodologies to influence policy
changes that are applicable elsewhere:



Policy research and analysis—
including an analysis of existing
research—to identify and diagnose
the underlying causes of key operational barriers to FP/RH services;
Policy dialogue in a multisectoral setting to discuss barriers, reach consensus on
contributing policy causes, and formulate recommendations for addressing key
barriers and strengthening corrective actions already in progress through policy
change;
Participation of policy champions and advocates during all stages of the process.
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References
Bertrand, Jane T., R. Magnani, and J. Knowles. 1994. Handbook of Indicators for Family
Planning Program Evaluation. Chapel Hill, North Carolina: EVALUATION Project.
Cross, Harry, K. Hardee, and N. Jewell. 2001. “Reforming Operational Policies: A
Pathway to Improving Reproductive Health Programs.” POLICY Occasional Papers
Series, No. 7. Washington, DC: Futures Group, POLICY Project.
MSPAS, Futures Group/Proyecto OPTIONS, and USAID. 1993. Evaluación de la
Barreras Médicas a los Programas de Planificación Familiar. Washington, DC: Futures
Group, OPTIONS Project.
MSPAS, IGSS, APROFAM, POLICY, AGMM, AGOG, USAID, and Population
Council. 2000. Barreras Médicas e Institucionales para la Prestación de Servicios de
Planificación Familiar en Guatemala.
Schieber, Barbara (with V. Fernández and M. Montenegro). 2000. Marco Político y Legal
para la Salud Reproductiva y la Planificación Familiar en Guatemala: Instrumentos
legales y disposiciones políticas que debemos conocer. Revisión Bibliográfica.
POLICY/Guatemala. Unpublished.
Shelton, J.D., M.A. Angle, and R.A. Jacobstein. 1992. “Medical Barriers to Access to
Family Planning.” Lancet 340 (8831): 1334–1335.
United Nations Population Fund (UNFPA). 1994. Report of the International Conference
on Population and Development, Cairo September 5–13, 1994. Chapter V. Adoption of
the Programme of Action, Section 26.
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