Selecting a Delivery System

The major distinctions among delivery systems are between clinic-based delivery, community-based distribution (or outreach systems more generally), and commercial distribution. An overlapping distinction may also be made between public and private distribution, although private systems may involve some degree of public subsidy. These different systems are often complementary:

· Clinics are needed for such methods as sterilization and to provide backup for outreach workers and referral, when needed, for clients' medical problems. Proximity to clinics increases contraceptive use, as noted earlier, up to the point at which clinics and other facilities are easily accessible to everyone.

· Community-based distribution involves bringing contraceptives to women in their own communities, rather than requiring them to travel to clinics. Such efforts are especially needed where clinics are too sparse and too expensive to build and maintain. They often depend on local residents with a few weeks' training, who receive no fixed salary but may have various incentives. Their effectiveness at increasing contraceptive use has been demonstrated in many countries, including Egypt, Mexico, the Democratic Republic of Congo, and Bangladesh (Gallen and Rinehart, 1986; Bertrand, 1991). However, at higher levels of contraceptive prevalence in Brazil and the Eastern Caribbean, community-based distribution had minimal effect. With the large workforce they require, the costs of community-based distribution can be a concern. These costs can vary from US$5 to US$150 per user per year (Huber and Harvey, 1989). For each setting in which outreach is needed, the most cost-effective way to provide outreach needs to be considered.

· Distributing partly subsidized contraceptives through commercial channels, aided by catchy advertising, has become known as contraceptive social marketing. This provides an alternative source of supply, especially for condoms and pills, that can be more congenial for some users and therefore can expand contraceptive use. To the extent these are new users or switch from government programs, the considerably lower cost of social marketing saves public funds; however, users may also switch from purely commercial outlets.

· Private voluntary organizations operate a range of distribution systems, some involving clinics and others concentrating on outreach. Volunteer programs have been critical in introducing family planning in various settings and are still useful for reaching specific target groups, such as adolescents, and for providing some competition and some savings to government programs.

· Additional delivery systems of many types often coexist with these. Private physicians and midwives often provide some contraceptive services on their own, although they would often benefit from specific training in family planning. Health insurance or other employer-supported programs may cover contraceptive services. Commercial outlets may be better or worse at supplying contraceptives. Since expanding service outlets and generally making family planning more available lead to increased contraceptive use, the multiplication of such distribution systems can be useful, and public programs should be designed to complement rather than to discourage them.⁶

⁶See World Bank (1993a, pp. 68-69) for an example of how commercial services can be disrupted by a public program.