Program Strategies and Approaches
Though neither socioeconomic development nor cultural and
institutional factors determine program success, sensitivity to such factors
does seem to be a hallmark of successful programs. Where they have succeeded -
and at least some successes have been recorded in every region of the developing
world - programs have built on existing demand for contraception and have
experimented to develop ways to address socioeconomic and cultural obstacles.
In East Asia, existing demand was exploited in pilot projects
that demonstrated widespread desire for contraception, such as the large-scale
Taichung project in Taiwan and the Jakarta pilot project in Indonesia. Close
attention to the demand was evident in recurrent surveys in Taiwan to learn
about attitudes toward family planning. Political support was a benefit of such
demonstrations, although support also developed for different reasons, not
always within the control of programs. Delivery systems for family planning
eventually became massive and well organized in each country but not before
extensive experimentation with various means of delivery. Thailand tested
optimal delivery systems in the Potharam project; Korea experimented with urban
programs in Sundong Gu and rural programs in Koyang. Eventually, "Mothers'
Clubs" became an important element of the Korean program, used in rural areas to
mobilize support for smaller families and to motivate women to adopt family
planning while assisting with such concerns as income generation (Cho et al.,
1982, pp. 129-131). An existing institutional capacity to mobilize peasants was
also critical in Indonesia, where an aggressive program drew on a local
government structure strengthened after the 1965 coup attempt (McNicoll, 1983,
p. 86) and worked intensively with community groups.
Facing even stronger demand in Latin America coupled with
barriers to government involvement, programs evolved in a different way. Demand
for contraception was initially met by physicians; by commercial sales; and,
increasingly, by private voluntary organizations, such as Profamilia in
Colombia. Discovering substantial latent demand (Tamayo, 1989), Profamilia
began with urban clinics and expanded after a few years into community-based
rural services and also began offering sterilization. The government tolerated
the provision of services, probably recognizing the widespread demand for them.
Demonstration of this demand was critical in the eventual institution of
government services, which eclipsed private services in Mexico. In Colombia,
private services continue to be more important; in Brazil, the private
organization Sociedade Bem-Estar Familiar no Brasil (BEMFAM) remains a
major provider, partly as a contractor to state governments. Experimentation
with delivery options has often involved the private sector. With large
nationally coordinated programs coming late to the region, contraceptive growth
has been slower in Latin America than in East Asia.
South Asia illustrates both initial obliviousness to demand and
eventual responsiveness to it. The early spread of contraception was retarded by
programs that were heavily bureaucratic and largely administered from the top,
especially in Pakistan, where little attempt was made to gauge client demand,
and little attention was paid to the needs of front-line staff. The Indian
program is harder to characterize because of its diversity and some degree of
control by individual states. In general, however, the Indian program also
failed to capitalize on all the existing and potential demand for contraception
and focused narrowly on sterilization. Targets were set high in the hierarchy,
and officials at the top were largely out of touch with village life (Freedman,
1990, p. 39).
In contrast, the program in Sri Lanka, the only one in the
region that showed some early success, was much more sensitive to client needs.
The Sri Lanka program provided a wide range of methods, including such temporary
methods as pills and IUDs, and used community-based distributors in rural areas.
The Indian program, on the other hand, focused initially on the IUD and later
largely on sterilization, avoiding community distribution of other methods, and
experimented instead (to a much greater extent than in Sri Lanka) with
incentives and controls on age at marriage, measures with theoretical appeal but
limited practical attraction to individuals. The Indian program had more
striking political support and better advertising, but the Sri Lankan program
delivered the contraceptives. Much more similar to the Sri Lankan approach was
the program in Bangladesh as it evolved after 1975. Assuming the existence of
latent demand, it focused on mitigating the costs to individuals, both practical
and psychic, of using contraception. Frequent contact by trained and caring
workers with clients was emphasized, often in the clients' own homes to overcome
cultural restrictions on women's mobility. As with earlier programs in East
Asia, substantial experimentation with delivery alternatives has gone on in the
Matlab area and through the succeeding Extension project (Cleland et al., 1994),
with coordinated funding from many international donors.
In the sub-Saharan countries that have made the most progress in
reducing fertility - Botswana, Zimbabwe, and Kenya - programs address existing
demand for child spacing by providing temporary methods, mainly the pill.
Delivery systems have been quite different, however. Botswana, with presumably
stronger demand in a relatively more developed setting with a public health
system that covers the country fairly extensively, has relied largely on health
posts and health centers to provide contraceptives. Zimbabwe placed primary
emphasis on community-based distribution to reach out to the rural population.
Kenya has also emphasized outreach but has relied to a much greater extent than
Zimbabwe on private voluntary organizations to complement public services.
The key to a successful program therefore appears to lie less in
a favorable environment than in what the program does with the material it has.
No socioeconomic setting, however impoverished, appears devoid of some demand
for controlling fertility; even in the most favorable environments, some groups
will have unmet need for contraception. Government programs, properly run and
complemented where appropriate with private efforts, do appear capable of
identifying and satisfying demand, although encouragement and substantial
support from international donors has been virtually continual in these cases.
Demand for controlling fertility can be fragile and variable; given that family
planning is often a sensitive topic, initial approaches need to be tailored to