|Strengthening the Fabric of Society: Population. Capacity Building for Sustainable Development (UNDP - UNFPA, 1996, 53 p.)|
|6. How Can Services Best Be Delivered?|
Many countries, developed and developing alike, have a mix of services. In some countries - Mexico and Colombia, for instance - private family planning organizations pioneered nation-wide programmes built up from community-based delivery systems. In others, such as Indonesia and Thailand, high level political support and adequate funding enabled both countries to launch effective, national programmes with sizeable government involvement in a relatively short period of time.
Over the past three decades, government-sponsored maternal and child health care (MCH) and family planning efforts have evolved away from vertical, self-contained programmes. A number of countries are in the process of broadening their services to include all aspects of reproductive health care. More efforts are being made to link family planning with primary health care networks.
A consensus has emerged within the national and international communities that involvement of the health sector in population programmes is important for the following reasons: as a vehicle for the involvement of women in decision-making and in the provision of maternal and child health care and family planning services; to upgrade the technical and communication skills of midlevel female health workers and community-based workers; to ensure training, supervision and medical backup to non-medical delivery systems; to provide those medical services which cannot be delivered by family planning programmes alone; and to promote family planning.
Four types of service delivery for reproductive health and family planning services have evolved in both public and private programmes. Elements of all of these are generally used:
1. Clinic-based services offer a wide range of family planning services, including examinations by qualified doctors and the provision of information and appropriate contraceptives. In most cases these services are based around an established government supported or NGO clinic. Normally, family planning acceptors must come to the facility in order to get access to services, but some countries (eg. Thailand, Tunisia) provide mobile clinics which service remote villages. In addition, some countries offer services on a regular basis in places of work, such as factories and offices.
2. Community-based delivery provides contraceptives to persons not easily served by established clinics or other service units. Community-based delivery programmes provide simple family planning services at the local level and may also assist with the supply of oral rehydration salts and oversee infant and child vaccinations.
3. Social marketing programmes provide contraceptives at very low prices (often below market price) by subsidizing the cost. Normally, services are easily available to urban residents through the use of work places, barber and beauty shops, pharmacies, local food stores, nonprofit family planning associations, or specially created local sales outlets.
4. Regular commercial distribution through direct sales to family planning acceptors. Usually commercial distribution is done through private sector retailers (pharmacies, drugstores, grocery stores), or private medical providers (physicians, hospitals, clinics, midwives and traditional healers).
Despite the trend towards integrated services, the debate around which kinds of services should be combined continues among national and international policy-makers. The ideal solution will involve some combination of approaches that would contain elements of clinic-based, community-based, social marketing and the commercial sector, based on local conditions and needs. Involving local communities - particularly women's groups - in their design, implementation and assessment is crucial.
Building essential capacities in population and reproductive health requires three levels of activities:
1. national action;
2. international cooperation; and
3. partnerships with NGOs and the private sector
During the past few decades, considerable experience has been gained on how government policies and programmes can be designed and implemented to address population concerns, enhance people's choices, and contribute to broad social progress. Experience has shown that countries where the leadership is strongly committed to human resource development, gender equality and to meeting the reproductive health needs of the population, including family planning, have been able to mobilize sustained commitment at all levels to make population programmes successful. There is a growing recognition that population policies and programmes, to be sustainable, need to involve the intended beneficiaries in their design and implementation.
For national programmes to be successful, the following elements are usually present:
1. Governments back up stated policies with high level political commitment and ensure that population issues are not left out of policy- and decision-making. They do this using a variety of mechanisms, commonly forming population policy units within planning ministries or ministries of health and welfare.
2. Governments formulate national strategies and programmes that address population and development problems as integral parts of their sectoral and overall development planning process. Normally, such strategies involve the active participation of local governmental authorities, NGOs, the private sector and local communities.
3. Governments, in collaboration with NGOs, and assisted where possible by the international donor community, make the necessary plans and take the actions required to measure, assess, monitor and evaluate progress towards the goals set forth in their "population action plans".
4. Building up the capacity and self-reliance of countries to undertake successful population action programmes in order to further national development objectives and to improve the quality of life for all citizens remains a fundamental goal of national policies.
Within this context, the following actions should be taken:
- Formulate human resource development programmes in a manner that explicitly addresses the needs of population programmes, giving special consideration to the training and employment of women at all levels;
- Formulate systematic manpower plans to ensure the efficient deployment of trained personnel to manage population programmes. In general, this means the training of midwives, doctors and nurses in the provision of family planning services. But it also implies that planning and health ministries have trained personnel capable of managing large-scale programmes;
- Rationalize salary scales to ensure the retention and advancement of managerial and technical personnel involved in population programmes; and
- Maintain data bases of national experts and institutions of excellence in order to bolster national competence in formulating and implementing population policies and programmes.
In addition, governments need to calculate carefully the costs of their population programmes. It has been estimated by the United Nations that, on average, it costs about $13 per year to provide basic reproductive health and family planning services to developing world couples. Modest as this seems, many countries fail to take adequate account of costs and their programmes suffer as a result.
International cooperation in the area of population is a relatively recent phenomenon, one that has undergone profound changes over the last two decades. The following developments are worth noting:
- Although the number of donors has increased, financial resources for population have remained at about the same level for over a decade;
- The profile of the donor community has been shaped by the growing presence of NGOs and private sector organizations;
- Numerous experiences of successful cooperation among developing countries have dispelled the stereotyped view of donors being exclusively from the developed world; and
- Donor partnerships have become more prevalent in a variety of configurations, so that it is no longer unusual to find governments and multilateral organizations working closely with national and international NGOs, and the private sector.
The maturing process continues to go on within international agencies which cooperate on population issues. But a number of shortcomings remain to be addressed. For instance, the expanding number of development partners forces both recipients and donors to choose among a multitude of competing development priorities - a task which recipient governments in particular find hard to carry out. Lack of effective coordination mechanisms has been found to result in unnecessary duplication of efforts and lack of programme consistency. Re-establishing and adhering to national priorities requires a new clarification of, and commitment to, reciprocal responsibilities among development partners.
The following elements are usually present in successful programmes:
1. By forming broad-based, integrated development committees charged with coordinating international support - containing representatives from all key ministries - governments can ensure that national development plans take specific account of the intended role of international cooperation in their population programmes, particularly with respect to capacity building and transfer of technology.
2. Recipient governments often set up national coordination mechanisms for channeling international cooperation in population, and to better clarify the responsibilities assigned to various cooperation partners, including intergovernmental organizations and international NGOs. Careful coordination of donor aid and national investments in population results in more effective programmes and ultimately in the delivery of better reproductive health and family planning services.
3. There is a strong consensus on the need to mobilize significant additional financial resources both from the international community and within developing countries to strengthen the capacity of governments to carry out national population programmes. It has been suggested that donor governments should endeavor to allocate at least four per cent of their total development assistance to population (the current average is around 1.34 per cent). In lieu of this, governments find it useful to adopt funding targets for population programmes, securing contributions - both domestic and from the donor community - commensurate with the scope and scale of activities required to meet stated population goals.
A. Local, national and international NGOs
Non-governmental organizations are actively involved in the provision of programme and project services in virtually every area of socio-economic development, including the population sector. Many of them - eg. the International Planned Parenthood Federation - have a long history of involvement in population related activities, particularly family planning. Formal and informal organizations and networks, as well as grassroots movements, merit greater recognition at local, national and international levels as valid and valuable partners for development initiatives in the population sector.
The following actions are considered useful when trying to strengthen the institutional capacities of NGOs:
1. Governments and intergovernmental organizations can help each other identify useful NGO partners. NGOs can be useful vehicles for testing new approaches in service delivery or in disseminating information and contraceptive commodities. Successful NGOs may offer more comprehensive and better quality services than government programmes. Some governments, such as Thailand's, find it useful to develop appropriate mechanisms and frameworks aimed at encouraging, enhancing and facilitating the important contribution that NGOs can make at the local and national levels in addressing population and development concerns.
2. Adequate financial and technical resources as well as data and information necessary for the effective participation of NGOs in the research, design, implementation and evaluation of population and development policies and programmes are made available to NGOs by governments and intergovernmental organizations.
3. Governments and intergovernmental organizations have created an enabling environment which assures that NGOs and their international networks are able to strengthen their capacity and expertise through appropriate training and outreach activities, thus playing a greater partnership role at local, national and international levels.
4. At the same time, NGOs and their networks find it useful to strengthen their interaction with the diverse communities they represent by educating their constituencies, mobilizing public opinion, and actively contributing to the national and international debate on population and development issues, including their complex interrelationships.
B. The private sector
The private, profit-oriented sector plays an increasingly important role in the social and economic development of countries. One aspect of its role is its involvement in the production and delivery of commodities and services relevant to population programmes. In a growing number of countries, the private sector has, or is developing, the financial, managerial and technological capacity to carry out a greater variety of population activities in a comprehensive and effective manner. However, the effectiveness of the private sector is dependent upon respective governments eliminating barriers which hinder or restrict its operation.
For the private sector to be effective, the following elements are usually present:
1. Governments and international organizations have intensified their dialogue with the private, for-profit sector in matters pertaining to population and sustainable development in order to strengthen its contribution to programmatic action in this area, including the production and delivery of selected commodities and services in a socially responsible and cost-effective manner.
2. Governments have eliminated barriers, such as export and import restrictions, which hinder or impede the private sector's ability to operate effectively. This applies particularly to the production, distribution and marketing of family planning commodities.
3. Non-profit and profit-oriented entities and their networks identify mechanisms whereby they can have constructive dialogue and exchange ideas and experiences in the population and development fields with a view to improving existing programming and sharing innovative approaches.
4. The private sector considers how it might better assist non-profit NGOs to play a wider role in society through the enhancement or creation of suitable mechanisms to channel financial and other appropriate support to NGOs and community organizations. The private sector, in collaboration with NGOs, can launch effective partnerships for sustainable development, especially in those areas of a country where both have effective operations.