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 each setting.