Simmons article

Document Sample
Simmons article Powered By Docstoc
					                             The Strategic Approach to
                             Contraceptive Introduction
        Ruth Simmons, Peter Hall, Juan Díaz, Margarita Díaz, Peter Fajans, and Jay Satia

               The introduction of new contraceptive technologies has great potential for expanding contracep-
               tive choice, but in practice, benefits have not always materialized as new methods have been added
               to public-sector programs. In response to lessons from the past, the UNDP/UNFPA/WHO/ World
               Bank Special Programme of Research, Development, and Research Training in Human Repro-
               duction (HRP) has taken major steps to develop a new approach and to support governments
               interested in its implementation. After reviewing previous experience with contraceptive intro-
               duction, the article outlines the strategic approach and discusses lessons from eight countries.
               This new approach shifts attention from promotion of a particular technology to an emphasis on
               the method mix, the capacity to provide services with quality of care, reproductive choice, and
               users’ perspectives and needs. It also suggests that technology choice should be undertaken through
               a participatory process that begins with an assessment of the need for contraceptive introduction
               and is followed by research and policy and program development. Initial results from Bolivia,
               Brazil, Burkina Faso, Chile, Myanmar, South Africa, Vietnam, and Zambia confirm the value of
               the new approach. (STUDIES IN FAMILY PLANNING 1997; 28, 2: 79–94)

Over the past several decades, new methods of contra-             rations entered the market, and subdermal implants
ception have made essential contributions to couples’             were introduced beginning in 1983. Without doubt,
well-being by allowing them to avoid unwanted preg-               health and social problems resulting from unwanted
nancy and abortions and by permitting improvements                fertility could be alleviated if the contraceptive technolo-
in the timing of childbirth. The oral contraceptive, which        gies that now exist were more broadly available, acces-
became widely available in the 1960s, was the first of            sible, and affordable to a wider range of people than
the modern reversible methods, followed by the intrau-            those who currently benefit from them. Introduction of
terine device (IUD). Shortly thereafter, injectable prepa-        new technologies has long been seen as one important
                                                                  way of expanding contraceptive use and addressing
                                                                  unmet need. More recently, introduction of new meth-
                                                                  ods has also been regarded as a means of improving
Ruth Simmons is Professor, Department of Health Behavior          quality of care by making available a wider choice of
and Health Education, University of Michigan School of            contraceptives.
Public Health, 1420 Washington Heights, Ann Arbor, MI                  Although the introduction of new contraceptive
48109–2029. Peter Hall is Chief and Peter Fajans is               technologies into service systems has great potential,
Scientist, Technical Introduction and Transfer, HRP, WHO.         three decades of experience have also shown that in
Juan Díaz is Medical Advisor for Latin America and the            practice, the benefits of technology have not always
Caribbean, Population Council. Margarita Díaz is Director,        materialized. Close examination of contraceptive intro-
Department of Education, Training and Communication,              duction in the public sector of Southern countries sug-
CEMICAMP, Brazil. Jay Satia is Executive Director,                gests that the availability of new contraceptives alone
ICOMP. John Skibiak, Associate, Population Council, has           will not expand use or broaden choice unless the exist-
contributed substantially to this article, has provided           ing constraints faced by programs in delivering ad-
technical assistance to three of the assessments, and has         equate services are addressed (Simmons, 1971; Soni,
played an important role in the development and evolution of      1984; Ward et al., 1990; Simmons et al., 1994; Lubis et
the strategic approach.                                           al., 1994; Snow and Chen, 1991). Even when users are

Studies in Family Planning                                                                  Volume 28   Number 2     June 1997   79
satisfied with methods, a program’s inability to attend      from simplistic and mechanical assumptions to much
to the technical requirements of a method, for example,      broader understandings. Widespread introduction of
the necessity to remove Norplant® implants after five        the IUD in the 1960s, especially in India, proceeded on
years of use, is problematic (Hull, 1996). The issues to     the notion that the provision of new contraceptive tech-
be considered in policy choices related to technology in-    nology on a large scale was a routine matter. The de-
troduction are complex. Above all, they require greater      vice itself was widely considered to offer the solution
systematic attention to the social and institutional con-    to India’s population problem. The importance of the
text of method choice and broader input from relevant        social impact of method use and of the new service-
stakeholders than they have received so far.                 delivery requirements involved in providing the IUD
     In response to these lessons from the past, the         with an appropriate level of quality were ignored (Soni,
UNDP/UNFPA/WHO/World Bank 1 Special Pro-                     1984), as was the need for early evaluation (Simmons,
gramme of Research, Development, and Research Train-         1971). As a consequence, the Indian program was un-
ing in Human Reproduction (HRP) has taken major              able to ensure appropriate levels of technical compe-
steps to reframe its strategy for contraceptive introduc-    tence and counseling; it did not provide adequate lo-
tion and to support governments interested in imple-         gistics and supplies; and it did not support women as
menting new approaches. This process of redefinition         they experienced the physical and social consequences
was initiated at a strategic planning meeting in Decem-      of IUD use. After an initially favorable response to the
ber 1991, organized by the Task Force on Research on         method, the IUD soon became discredited, depriving
the Introduction and Transfer of Technologies for Fer-       Indian women of the benefits that could have been pro-
tility Regulation within HRP. Experts from the World         vided if introduction had proceeded more cautiously and
Health Organization and other institutions revised the       with greater attention to both the social and institutional
existing concept of introduction to avoid focusing on        contexts of method use.
single technologies, to advocate instead an examination
of what can be learned about services and users that         Bridging Clinical Testing and Introduction with
will better inform the decisionmaking process for selec-     Applied Research
tion of methods (Spicehandler and Simmons, 1994). This
new model, referred to as “the strategic approach to con-    The Indian IUD experience shaped subsequent ap-
traceptive introduction,” also suggests that new tech-       proaches to contraceptive introduction in public-sector
nologies must be introduced within a quality-of-care         settings. Research on experience with and acceptabil-
and reproductive-health framework and must incorpo-          ity of new methods within routine service-delivery set-
rate the perspectives of a broad range of stakeholders,      tings served as a bridge between clinical testing and
including those of users, providers, managers, policy-       broad introduction of the methods. This approach con-
makers, and women’s health advocates.2                       sisted initially of two components: introductory or field
     Since the end of 1993, WHO has been providing           trials and acceptability studies. In the late 1980s and
support to public-sector programs in Bolivia, Brazil,        early 1990s, several projects with a focus on service-
Burkina Faso, Chile, Myanmar, South Africa, Vietnam,         delivery research were added.
and Zambia, in order to implement this strategic ap-              Introductory trials are organized after the safety and
proach. Experience has confirmed that this new way of        effectiveness of methods have been established, at least
proceeding can be a means of enhancing the capacity          provisionally, through a series of clinical trials con-
to provide quality services. This article provides an        ducted to examine methods under rigorously controlled
overview of the strategic approach and presents lessons      conditions, according to clinic-based research protocols.
from the implementation experience in eight countries.       Introductory trials continue to examine safety and ef-
Although many illustrations in this paper refer pre-         fectiveness, but their focus shifts to introducing program
dominantly to the introduction of contraceptive meth-        providers to the requirements of the new method and to
ods, the strategy addresses fertility-regulation technolo-   examining patterns of, and reasons for, discontinuation.
gies broadly defined to include menstrual regulation         Acceptability studies document the user’s perspective
and abortion.                                                on the new method and typically are conducted through
                                                             individual or group interviews with users or potential
                                                             users. Service-delivery research is undertaken to study
Previous Approaches                                          the organizational and operational adaptations neces-
                                                             sary to ensure quality of care if and when delivery of
Approaches to contraceptive introduction have evolved        new methods is scaled up for routine provision in na-
considerably over the past three decades, progressing        tional programs.

80   Studies in Family Planning
     Such a bridging approach has characterized the           existence of these problems at the time of scaled-up in-
Norplant introduction undertaken by the Population            troduction demonstrated that earlier detection of these
Council (Beattie and Brown, 1994). Clinical and intro-        potential weaknesses would have been important. The
ductory trials were organized in more than a dozen            second study examined the implications of adding
countries, including Chile, the Dominican Republic, and       Cyclofem to the Indonesian national family planning
Indonesia. Acceptability studies were undertaken in           program while focusing both on quality of care and
Colombia (Vollmer, 1985), the Dominican Republic,             quality in management of the delivery system (Sim-
Egypt, Indonesia, and Thailand (PIACT, 1987), and ser-        mons et al., 1994; Lubis et al., 1994). The major conclu-
vice-delivery research was initiated in the late 1980s and    sions from that study are reviewed here because dis-
early 1990s in Colombia, Indonesia, and Peru (Ward et         cussion of that research provided the impetus for the
al., 1988 and 1990; Simmons and Ward, 1991). Family           formulation of the new strategy for introduction.
Health International also conducted Norplant introduc-             The study showed that although Cyclofem’s intro-
tory trials in several countries, including Bangladesh,       duction into six trial clinics had broadened women’s
Nepal, Pakistan, the Philippines, Senegal, and Singa-         choice to some extent, conditions of routine service de-
pore, as well as acceptability studies in Bangladesh,         livery included a range of weaknesses likely to coun-
Nepal, Haiti, and Nigeria, among others (Kane et al.,         teract the potential contribution of this new method
1990; Grubb et al., 1995).                                    to the national program (Simmons et al., 1994). Evi-
     WHO followed a similar approach in its introduction      dence from observation of nontrial service settings
of a monthly injectable, Cyclofem™. Introductory trials       showed that the availability of two injectable formu-
were initially undertaken in five countries (Indonesia, Ja-   lations—DMPA (depot medroxyprogesterone acetate)
maica, Mexico, Thailand, and Tunisia), and subsequently       and NET-EN (norethisterone enanthate)—in the Indo-
in Brazil, Chile, Colombia, and Peru (Hall, 1994). Ser-       nesian program did not broaden women’s choices. Pro-
vice-delivery research was conducted in Indonesia.            viders did not emphasize the difference between the
     The main objective of Norplant and Cyclofem in-          two injectables to prospective clients, and routinely
troductory trials was to provide data for national regu-      substituted NET-EN for DMPA when stock depletion
latory approvals, develop national training capabilities,     or logistic bottlenecks occurred. Typically, women were
and offer first-hand experience to leading health-care        not informed of this substitution. Providers’ under-
providers. Systematic feedback from service providers         standing of the differences in the hormonal preparations
and users was channeled into the preparation of tech-         or the management of side effects was poor, and rein-
nical and counseling guidelines and training activities       jection time frames (three months for DMPA and, ini-
(Spicehandler, 1989). Findings from service-delivery          tially, two months for NET-EN) were not followed rig-
studies underlined the importance of identifying man-         orously. The record-keeping system made provision for
agement and program parameters required to integrate          injectables, but did not allow for differentiation between
new methods into service-delivery systems.                    the two types, and the logistics system did not ensure
                                                              the availability of needles appropriate for each formu-
Evidence from Research in Indonesia                           lation. These findings raised doubts about the wisdom
These applied introductory research efforts produced          of adding yet another injectable to this service-delivery
the knowledge that induced WHO to question this ap-           setting.
proach and to undertake a strategic shift in introduc-             Policy commitment to making major changes in
tion initiatives. Two service-delivery studies in Indo-       counseling, information giving, record keeping, logis-
nesia were most influential in this transition. One of        tics, and training would have been required for Cyclo-
these, the Population Council-supported Norplant study        fem introduction to expand contraceptive options. Com-
(Ward et al., 1990), was conducted at the time of the         mitment to such major operational change, however,
transition from field studies to large-scale expansion        was unlikely in light of the government’s interest in cost
within the national program. It demonstrated that the         reduction. Thus, although introduction of Cyclofem in
national program was inadequately prepared at that            the context of an introductory trial, with its associated
time to provide Norplant with appropriate quality of          special training, monitoring, and supply inputs, was
care. For example, method choice was not guaranteed,          beneficial for women enrolled in the study, the poten-
removal on demand was not routinely available, side-          tial addition of this method to routine service settings
effect counseling was minimal or absent, and the pace         would have been problematic.
of training in removal was inadequate. While some of               The service-delivery study on Cyclofem introduc-
these quality-of-care and operational inadequacies were       tion in Indonesia raised a central question that had not
subsequently remedied (Beattie and Brown, 1994), the          been routinely considered in advance of an introduc-

                                                                                     Volume 28   Number 2   June 1997   81
tory trial: Is it appropriate to introduce the method? The   refers to the characteristics of contraceptive methods,
decision to proceed with the Cyclofem introduction in        including their safety, efficacy, administration, side
Indonesia had been based largely on biomedical crite-        effects, reversibility, and duration. Here, the basic ques-
ria; Cyclofem was viewed as an improvement over other        tions identified by Bruce (1990: 63) as the defining ele-
injectables because it generally causes fewer disruptions    ments of method choice should be raised:
in women’s vaginal bleeding patterns. Findings from
                                                                 Which methods are offered to serve significant
the service-delivery study, however, revealed that the
                                                                 subgroups as defined by age, gender, contra-
intrinsic characteristics of new methods, by themselves,
                                                                 ceptive intention, lactation status, health pro-
do not enhance women’s choices.
                                                                 file, and—where cost of the method is a factor—
     The December 1991 planning meeting at WHO con-
                                                                 income groups? To what degree will these
cluded, therefore, that although the prevailing approach
                                                                 methods meet current or emerging need (for ex-
to contraceptive introduction constituted a clear ad-
                                                                 ample, adolescents)? Are there satisfactory
vance over earlier patterns, the overall paradigm re-
                                                                 choices for those men and women who wish to
mained flawed. It had been technology driven and had
                                                                 space, those who wish to limit, those who can-
relied on decontextualized assumptions about method
                                                                 not tolerate hormonal contraceptives, and so
introduction. The addition of technology, ipso facto, had
been assumed to increase reproductive choice, and the
relationship between technology and choice had been               Characteristics of methods provided within a ser-
considered largely in a social and institutional vacuum.     vice-delivery system, as well as attributes of those with
Attention to the social context of method choice had         potential for introduction, should be considered. This
been limited, the fit of the new method into the range       emphasis shifts attention from an exclusive focus on
of existing methods within a country remained unex-          methods considered for introduction to the character-
plored, and questions about the capability of service-       istics of the actual or potential method mix. When in-
delivery systems to provide quality of care in the pro-      troduction activities are focused on increasing variabil-
cess of introduction and beyond was only beginning           ity in the characteristics of available methods, repro-
to be examined. Moreover, concerns for the perspec-          ductive choice is enhanced.
tives of users, as well as service capability, had been
viewed as essential only with regard to facilitating the
                                                             Users’ Perspectives and Needs
process of introduction, not as a set of questions to be
raised prior to the decision to introduce a method.          Technology must be appropriate to the reproductive
                                                             health needs of potential users and to the sociocultural
                                                             context into which they are introduced. Reproductive
The Strategic Approach                                       health needs and people’s perspectives on technology
                                                             and on the service-delivery system should be consid-
The 1991 WHO meeting led to the development of a             ered when decisions are made about which contraceptives
new approach that views contraceptive introduction not       to offer. Attention to women and men in various stages of
as a narrow operational issue, but places it in the con-     the life cycle is essential. In the framework described
text of overall program strategy. This strategic approach    in the figure, users’ perspectives and needs are placed
shifts attention from promotion of a particular technol-     at the apex of the triangle to reflect the preeminence
ogy to an emphasis on quality of care, reproductive          they deserve. The user–technology interface suggests
choice, and users’ perspectives and needs. It recognizes     such questions as these: Do users find that the advan-
the implications of technology introduction for changes      tages of a particular method outweigh its disadvan-
in program management systems. When policy choice            tages? Do they have specific health-related concerns or
and research are guided by a systems framework that          fears about the method? Do they experience side effects,
allows for the integration of technologies, programmatic     and if they do, what is their significance within the cul-
capabilities, and the social context of method use, out-     tural and social context of the women’s lives? Are pres-
comes are likely to serve users’ needs. Figure 1 repre-      sures brought to bear by partners, family members, or
sents the user/technology/service system that serves         others in the community to use or reject specific meth-
as a foundation for the strategic approach.                  ods for personal, political, religious, or cultural reasons?
                                                             In populations where the incidence of reproductive tract
                                                             infections (RTIs) is high, consideration of IUD services
                                                             should be linked to the capacity for RTI diagnosis and
The technology point in the triangle within the figure       management; where the threat of HIV/AIDS is high,

82   Studies in Family Planning
Figure 1   Systems framework guiding the strategic approach to contraceptive introduction

                                                  • Reproductive health needs and rights
                                                  • Users' perspectives
                                                  • Medical profile
                                                  • Sociocultural and gender influences




                                      Service                                    Technology
                                      • Policies, program structure              • Method-mix
                                      • Personnel, facilities, management          characteristics
                                      • Availability and accessibility           • Efficacy
                                      • Quality of care                          • Side effects
                                                                                 • Administration
                                                                                 • Reversibility
                                                                                 • Duration


the need for dual protection must be a priority. Where              vices offered in distant clinics in cultures where wom-
maternal mortality from illegal abortion is high, con-              en’s limited status restricts their mobility.
sideration of methods and services must focus on how
such deaths can be avoided.                                         Program/Service Capacity
     The user–service interface, in turn, suggests the fol-         Policy choice related to technology introduction must
lowing questions: Do users find the health center eas-              also be guided by the capabilities of service-delivery
ily accessible in terms of distance and travel cost? Are            systems. Central questions are: Does the service-deliv-
waiting times acceptable? Are users’ rights to adequate             ery system have the necessary managerial capacity in
levels of information and their voluntarism in contra-              terms of human resource development, planning, logis-
ceptive use and method choice respected? Are people                 tics, and monitoring? Does it have the technical capac-
treated respectfully by staff? Are women with incom-                ity to provide new methods with appropriate levels
plete abortions provided with adequate care? Are con-               of quality of care? Do existing policies support volun-
traceptive methods affordable? Where clinic-based ser-              tarism in contraceptive use and method choice? Does
vices are widely used and service providers are trusted             this capacity exist in both the public and the private
by the local people, introduction of new methods is                 sector? Is it feasible to provide the method within a
likely to have important payoffs. Where the opposite is             large network of clinics or health posts or should it be
true, addition of new technology may have no effect or              restricted to special settings? Are the costs of new
may possibly increase social distance, distrust, and sus-           methods affordable within the limitations of existing
picion. When women’s power to negotiate contracep-                  resources? Are some methods too expensive to war-
tive use is limited, methods requiring male cooperation             rant introduction?
or consent are of limited value; so are contraceptive ser-               Where service-delivery systems do not have the capac-

                                                                                              Volume 28   Number 2   June 1997   83
ity to provide methods with appropriate levels of qual-     vices focused on the method mix, the extent of cover-
ity of care, addition of new methods may not be warrant-    age, and the capability of the service-delivery system
ed. In such circumstances, focusing on building the ca-     to provide quality services, to assure voluntarism, and
pacity to increase availability, management support,        to respond to the needs and perspectives of actual or
and quality of service in provision of the methods that     potential users. A systematic assessment with input
are already within a program may be more important.         from a broad range of stakeholders conducted prior to
     In the figure, the user/technology/service triangle    making decisions about introduction constitutes a ma-
is embedded in a circle that draws attention to the broad   jor departure from previous approaches.
social, economic, environmental, and political context           The central purpose of these assessments is to an-
within which relationships occur. Users’ perspectives       swer the following three questions: (1) Does a need ex-
and needs are anchored within a social structure and a      ist for the improved provision of existing methods? (2)
set of gender relations. Religious and cultural norms,      Is there a need to remove methods from a service-de-
as well as the power relations between men and wom-         livery setting in cases where the safety or efficacy of
en, shape views about contraceptive methods and af-         these methods has not been systematically established
fect the legitimacy of formally organized efforts to ad-    or in cases where they have been replaced by improved
dress reproductive health needs. Economic conditions        formulations or devices? (3) Does a need exist for the
and political ideologies, in turn, determine the resource   introduction of new contraceptive methods, and if so,
pool available to address health needs and to build in-     for what level of service delivery are they appropriate?
stitutional capacities for organizing provision of con-     These questions shift attention from considering exclu-
traceptive methods with attention to quality of care.       sively methods that are new to a program to a concern
                                                            for the improved provision of currently available meth-
A Participatory Process                                     ods or to the potential removal of methods from a ser-
                                                            vice system. Thus, within this context, the very concept
The strategic approach to contraceptive introduction        of introduction assumes a broadened meaning.
involves a change in the process of policy choice, em-           The assessment is not envisaged as an extensive
phasizing country ownership, broad-based participa-         analysis or as a baseline research study. Assessment re-
tion, and transparency of decisionmaking. Although in-      ports make recommendations for policy and research
ternational agencies make essential contributions to        with regard to the strategic questions of contraceptive
facilitate and support the strategic approach, the pro-     introduction and related policy, programmatic, or op-
cess must be led and implemented by key decision-           erational issues. The strategic assessment is a first step
makers from all relevant sectors of the country. More-      in a larger process, as well as a valuable tool in its own
over, broad-based participation implies expansion from      right. The data-collection component of these assess-
a relatively narrow group of decisionmakers toward in-      ments comprises: existing secondary data; a number
clusion of other stakeholders from governmental and         of key informant interviews with policymakers, pro-
nongovernmental institutions representing multidis-         gram managers, service providers, community people
ciplinary perspectives. Transparency in decisionmaking      (including young people), users, and women’s health
necessitates a commitment to an open process and wide-      advocates; as well as selective observations of service-
spread dissemination of information. Such a particip-       delivery practices. Prior to field observations, the inter-
atory process increases the likelihood that contracep-      disciplinary team summarizes secondary data and
tive introduction abides by ethical principles and          available literature in a background document to en-
enhances reproductive choice.                               sure that the assessment addresses areas where informa-
     A participatory process and a systems framework        tion is lacking.
guide the following three stages of work within the stra-        Overall, the extent of primary data collection in these
tegic approach: assessment, research, and use of re-        assessments is limited. However, the methodology em-
search for policy and planning. Each of these phases also   phasizes evaluation of existing field conditions through
corresponds to a funding category within which WHO          qualitative interviews and observations of service con-
has supported these activities with increasing involve-     ditions in major regions of a country. Although the main
ment from other agencies. The three stages of work are      emphasis has been on an examination of public-sector
described below.                                            services, assessments have also included some attention
                                                            to the private sector, in particular in those settings where
                                                            government services are limited and the private sector
Stage I: Strategic Assessment of Need
                                                            is the sole provider in large parts of the country.
Stage I is an assessment of national family planning ser-        Assessments are government led, involving rel-

84   Studies in Family Planning
evant national decisionmakers in all aspects of the pro-     ration with the public-sector program. WHO and its
cess including in the development of instruments, site       collaborating institutions have provided technical as-
selection, conduct of field visits, analysis of findings     sistance for this research.
and recommendations, preparation of the assessment
report, and the dissemination of results. The team also      Stage III : Use of Research for Policy and Planning
includes women’s health advocates, local researchers,
and representatives from national NGOs. Technical            The primary objective of Stage III is the use of research
support has been provided by WHO and by the agen-            results for policy and program development. Past ex-
cies that have collaborated in the development and           perience has shown that the application of lessons
implementation of the strategic approach. Following          learned is not assured by good assessments and re-
the strategic assessment, a national workshop is orga-       search findings alone but must be carefully fostered.
nized at which key findings are presented. The work-         Although attention to the use of assessment and re-
shop provides a critical forum for ensuring the ongo-        search findings is an ongoing process, the third stage
ing involvement and input of local, national, and            of the strategic approach focuses on initiatives intended
international institutions.                                  to ensure that Stage I and Stage II are heeded as service
    Whereas the core strategic questions related to con-     innovations are introduced and method introduction
traceptive introduction provide the guiding framework,       expands.
the flexibility of the Stage I methodology allows other           Moving from Stage II to Stage III involves a review
reproductive health issues to be included, reflecting the    of the three strategic questions related to contracep-
country’s interests and needs.                               tive introduction. In examining the bigger picture,
                                                             policymakers must then determine how to scale up the
Stage II: Research                                           quality of services elsewhere and decide which service-
                                                             delivery points are most appropriate. Additional changes
Assessments of the need for contraceptive introduction       and adaptations required for scaling up from a pilot
may lead to a variety of policy changes, to research ini-    phase to regional or national implementation may re-
tiatives related to contraceptive introduction, and to im-   quire testing and refinement. If a new method is to be
provements in quality of care. Among policymakers and        incorporated on a larger scale, plans for gradual expan-
other relevant stakeholders, they also produce greater       sion must be made in order to retain the emphasis on
awareness of the relationship between contraceptive          quality of care as the process unfolds. The central focus
technology, quality of care, and reproductive health.        of these efforts must remain the overall improvement
      Stage II entails the design and implementation of      of quality of care and the provision of contraceptive op-
applied research focused on country priorities as es-        tions, not the physical availability of a particular meth-
tablished by the strategic assessment. This stage may        od. If contraceptive expansion is recommended, a stra-
entail research on the improved provision of methods         tegic plan is required for developing and upgrading
already offered within a service-delivery setting, or on     training curricula and courses; information, education,
the introduction of a new method or methods, with            and communication materials; infrastructure; logistics;
attention to the technical, operational, and managerial      and supply systems.
changes required to ensure that these methods are pro-            Specific activities undertaken at this stage vary and
vided with an adequate level of quality. Service-de-         must arise out of country and program needs. They may
livery settings are studied in order to evaluate what        entail additional research for scaling up from demon-
adaptations are needed when innovations are intro-           stration or pilot projects to a larger number of program
duced on a broader scale. Such research has included         sites, technical assistance, dissemination of results, and
as main components demonstration or pilot projects           continued evaluation. In order to ensure that innova-
and user-perspective and service-delivery research           tions from research are sustainable, Stage III activities
within public-sector settings. Both quantitative and         must continue to address questions related to costs, the
qualitative methods are used; because of the need for        longer-term availability of funding, and other activities
in-depth understanding of program functioning, how-          initiated during Stage II.
ever, qualitative methods are particularly important.             Continuation of the participatory and community-
To guarantee research relevance and policy use, the          oriented approaches that guided the earlier phases of the
broadly participatory process initiated during the stra-     strategic approach are essential. Program managers, in
tegic assessment is continued. Research is undertaken        particular, must be part of the process of sharing results,
either by researchers from government institutions or        because ultimately they will implement the recommen-
it is conducted by local research institutions in collabo-   dations that arise from research. An important element

                                                                                     Volume 28   Number 2   June 1997   85
of Stage III is, therefore, the organization of workshops     Table 1 Implementation of the strategic approach to
and the promotion of dialogue to ensure that the impli-       contraceptive introduction, by country, according to stage in
cations of findings are fully understood and that consen-     the process, 1993–97
sus is reached. In addition, results from these initiatives                                                      Stage II
                                                                             Stage I               Dissemination (Research Stage III
should be disseminated through professional or policy         Country        (Assessment)          workshop      underway) (Initiated)
seminars and publication of papers and newsletters.           Brazil         November 1993         February 1994            
                                                              South Africa   July 1994             September 1994           —
                                                              Vietnam        November 1994         February 1995            —
                                                              Zambia         March 1995            May 1995                 —
Experience with Implementation                                Bolivia        November 1995         September 1996           —
                                                              Chile          July 1996             August 1996      —        —
                                                              Myanmar        September 1996        January 1997     —        —
The strategic approach to contraceptive introduction is
                                                              Burkina Faso   October 1996          December 1996    —        —
currently being implemented in eight countries: Bolivia
                                                              — = Not yet underway or initiated.
(Camacho et al., 1996); Brazil (Formiga et al., 1994); Bur-
kina Faso (CRESAR, 1997); Chile (Ministerio de Salud,
1997); Myanmar (Government of Myanmar, 1997);
South Africa (Reproductive Health Task Force et al.,          tween steps varies depending on the circumstances of
1994); Vietnam (Hieu et al., 1995); and Zambia (WHO,          the countries involved. Because most of the implemen-
1995). Choice of countries for this exercise has de-          tation experience to date covers the assessment stage
pended upon country interest in pursuing this approach        and the development of subsequent research, the les-
and a request directed to WHO to support the process.         sons discussed below refer primarily to these first
The potential contribution of the exercise in light of the    phases of the strategic approach.
particular historical moment at which a country or pro-
gram finds itself, or the extent of previous work, has        Validating the Method-mix Focus
also been important. For example, in South Africa, the
exercise was supported in large measure because the           Experience has validated the importance of analyzing
country was in a major transition where such input            the need for introducing a contraceptive within the con-
would be of particular value. In Myanmar, the exercise        text of methods currently available in a particular set-
was especially relevant because contraceptive services        ting. In Brazil, the assessment led to the conclusion that
are extremely limited, but the government is planning         introduction of new methods should await improve-
major program expansion. Zambia, by contrast, faced           ments in the provision of currently approved methods
implementation of significant bilateral funding support       of family planning (Formiga et al., 1994). Significant de-
for its family planning program, a situation where a          mand for family-size limitation in Brazil is reflected in
strategic assessment could provide critical guidance to       the widespread use of oral contraceptives and tubal li-
the program-development process. Vietnam was con-             gation. However, the current provision of these meth-
cerned about its skewed method mix and wished to ex-          ods does not reflect a commitment to quality of care or
pand contraceptive options. The choice of countries has       to reproductive choice. The incorrect use of oral contra-
also been guided by desire for a wide geographic spread       ceptives is widespread (Pinotti et al., 1990; Costa et al.,
and diversity in social and economic development, in          1990) and, in large measure, is linked to inadequate pro-
program settings, in contraceptive prevalence, and in         vision of information to clients who obtain the method
methods currently available.                                  through pharmacies. The ambiguous legal status of tu-
     As Table 1 indicates, the process of implementation      bal ligation, physicians’ financial exploitation of wom-
extends over several years, which is, in part, a reflec-      en’s demand for this method, and the frequent insis-
tion of the exigencies involved in working on systems im-     tence upon sterilization as a prerequisite for employ-
provements using participatory approaches. Length of          ment have made women vulnerable. By contrast, IUDs,
implementation has also depended on WHO procedures            condoms and other barrier methods, lactational amen-
related to ethical and scientific reviews and the funding     orrhea, and periodic abstinence—all of which are ap-
process. As experience with the strategic approach ac-        proved for public-sector services within the existing
cumulates, implementation time may decrease. The table        policy context—are little used. Therefore, instead of in-
indicates the countries in which Stage I assessments          troducing additional methods, attention to improving
have been held and the dates for the dissemination            access, quality of care, and provision of all approved
workshop that precedes the initiation of research activi-     methods is required in Brazil.
ties. In general, Stage II research projects are designed          The other country assessments also revealed that
to last for as long as two years. The length of time be-      reproductive choice is limited because of major method-

86   Studies in Family Planning
mix imbalances and serious shortcomings in all dimen-         introduction research and policy change focus on im-
sions of quality of care. In Vietnam, providers tend to       proving quality in the provision of all methods. Thus,
emphasize use of the IUD and discourage use of the pill,      broadened attention to the method mix and the local
which is considered too difficult for rural women to re-      program context enhances the potential for increasing
member to take regularly and potentially dangerous.           reproductive choice.
In South Africa, most users, particularly black South              Although the experience of implementation of Stage
Africans, are essentially limited to injectables. Access      II research is still limited, emphasis on the method mix
to IUDs, sterilization, and barrier methods is greatly        has characterized all projects and is producing impor-
constrained. In Bolivia, by contrast, use of periodic ab-     tant results. In Brazil, the Stage II project organized in
stinence is widespread, yet women and providers lack          one municipality has drawn attention to the contracep-
accurate information about how to identify the fertile        tive needs of populations that were previously ignored
period. Unplanned pregnancies and a high rate of clan-        by the service system, namely, adolescents and men.
destine abortion are the results. In Zambia, where use        With limited municipal resources, a referral center for
of modern methods is low, the pill accounts for almost        family planning was created in which vasectomy, atten-
half of contraceptive use among married women of re-          tion to adolescent needs, and distribution of condoms are
productive age, while about one-fifth use condoms and         all provided. Moreover, increased availability of and ac-
tubal ligation. According to the assessment, these meth-      cess to gynecological services and improvement in the
ods were little used because of limitations in the service-   collection of pap smears became possible for the total
delivery system, client and provider misinformation,          municipal service system (Diaz et al., 1997).
and weaknesses in the management-support system.
     In some settings, method cost is a major factor con-
                                                              Removing Methods from Distribution
straining contraceptive options, a condition that is rare-
ly solved by introducing new methods. Cost issues             In all countries where an assessment has been com-
manifest themselves both at the program and the indi-         pleted, removal of methods from general distribution
vidual level. For example, in Bolivia, where clients must     has been identified as important, especially with regard
pay for public-sector contraceptive services and sup-         to hormonal methods, particularly oral contraceptives.
plies, the IUD is selected often as the cheapest method,      Oral contraceptives containing 50 milligrams of estro-
rather than as the preferred method (Camacho et al.,          gen were found to be used routinely in Brazil, Bolivia,
1996). Moreover, many service settings do not even stock      South Africa, Vietnam, and Zambia. WHO has recently
condoms or oral contraceptives because of limited fi-         recommended that the use of oral contraceptives con-
nances. Cost constraints reinforce providers’ belief that     taining more than 35 milligrams of ethinyl estradiol be
the cheapest method is the best for all women. Fre-           strongly discouraged. Triphasic preparations were en-
quently, as a consequence, women’s only option of a           countered in Brazil, South Africa, and Zambia, and re-
modern method is the IUD. In such settings, the broad-        moval of these from the public sector was suggested,
ening of choice among theoretically available methods         because service providers were unable to explain what
or the introduction of new ones through Stage II research     they were or to ensure that they were taken correctly.
can only succeed if cost issues are appropriately ad-              In Zambia, confusion prevailed about the numer-
dressed. In the private sector, cost is less problematic.     ous brands of oral contraceptives available in the pub-
     In Bolivia, South Africa, Vietnam, and Zambia, as-       lic sector. Neither providers nor clients understood the
sessments have recommended that introduction of meth-         differences among the formulations and brands. In Bra-
ods that were previously unavailable or not officially        zil, pills and injectables were produced by local com-
available can serve as a useful vehicle for increasing        panies in which quality control was inadequate. In both
quality of care in the provision of all methods. Stage        Brazil and Bolivia, the assessment team expressed con-
II research in South Africa and Zambia is particularly in-    cern about high-dose injectables available in the com-
structive in that it focuses on the addition of methods       mercial market. In Vietnam, the use of quinacrine for
that have previously been neglected in introduction ef-       sterilization, the safety of which has not been estab-
forts—emergency contraception and barrier methods.            lished through internationally accepted scientific pro-
The South African project focuses on barrier methods,         cedures, created a major concern (Pies et al., 1994; Berer,
including both male and female condoms, and on emer-          1995). The assessment team endorsed the Ministry of
gency contraception as backup. In Zambia, emergency           Health’s decision to halt this method’s introduction.
contraception and barrier methods are introduced in                Many developing countries do not have strong drug
conjunction with the reintroduction of Depo-provera.          regulatory mechanisms and, therefore, have limited in-
Characteristically, assessments have recommended that         fluence over methods available from the private sector.

                                                                                      Volume 28   Number 2   June 1997   87
When methods are deemed no longer appropriate for               care improvements in the delivery of all methods through
distribution, ministries of health are in a position to with-   a Stage II research project in two provinces.
draw these methods from supply. However, when meth-                  The important point of comparison with previous
ods are commercially available or available by means of         introductory studies is the deliberate attempt to use
highly decentralized systems where commodity pur-               method introduction as an entry point for general qual-
chases are made locally, method removal is difficult to         ity-of-care improvements. In Vietnam, training has em-
accomplish. In such settings, introduction of a new             phasized counseling and the provision of balanced and
method into the public sector can encourage withdrawal          technically accurate information on all available con-
of inappropriate formulations from the commercial sec-          traceptives. Moreover, all staff providing family plan-
tor. For example, in Brazil and Bolivia, where high-dose        ning services—including community-based workers
once-a-month injectables are widely available through           and volunteers—are being trained, not just a small sub-
the commercial sector, public introduction of low-dose          set of people addressing the special needs for a Depo-
injectables has the potential to encourage a general shift      provera protocol. Stage II projects under way in Bolivia,
to these formulations. Similarly, in Myanmar, commer-           South Africa, and Zambia will also introduce additional
cial provision of a monthly injectable, which has a com-        methods of family planning. While the specifics of these
plex treatment regimen and low efficacy, argues for the         projects vary considerably, they all function within a
public-sector introduction of newer products.                   broad quality-of-care paradigm that emphasizes volun-
                                                                tarism and choice, technical quality of care, counseling,
                                                                and information-giving in all methods.
Linking Introduction to Quality of Care
Implementation of the strategic approach has demon-
                                                                Managerial, Structural, and Philosophical Barriers
strated in several countries the value of linking the in-
troduction of contraceptive methods to quality-of-care          All of the assessments conducted so far have revealed
improvements. A concern for quality of care and the             major structural, managerial, and philosophical barriers
need to improve the provision of currently approved             to quality of care in services for reproductive health in
methods led to the conclusion in Brazil that the intro-         general and family planning in particular. As noted,
duction of additional methods had low priority. In Viet-        these weaknesses have been so significant in several set-
nam, the emphasis on quality of care produced a gov-            tings that the assessments concluded that introduction
ernment decision to reconsider the widespread intro-            of additional methods was unwarranted. Where assess-
duction of Norplant. Extensive field observations and           ments have recommended introduction of new methods,
analysis carried out during the strategic assessment led        this has been done through a carefully phased and re-
to the conclusion that the Vietnamese program (with             search-based process intended to encourage the devel-
its target-driven, promotional approach and its weak-           opment of the appropriate managerial capacity and to
nesses in technical quality of care and counseling) did         engender a humanistic philosophy of care.
not have the capacity to provide this method in a man-               Results from Stage II projects reinforce the impor-
ner that would increase contraceptive choice. Decisions         tance of giving attention to management support sys-
concerning future introduction have been delayed pen-           tems and the philosophy of care. In Brazil, the Stage II
ding a retrospective analysis of earlier limited introduc-      project succeeded in reorganizing the service systems
tory trials of Norplant.                                        substantially to increase both access and quality of
     A similarly motivated, though less dramatic, shift         care. However, critical leadership and supervisory im-
occurred regarding the introduction of Depo-provera             petus for this change relied heavily on the institutional
in Vietnam. Prior to the strategic assessment, the gov-         support provided by CEMICAMP. The challenge of in-
ernment and several major donors were interested in a           stitutionalizing such management capacity within the
quick, wide-scale introduction of Depo-provera through-         public sector remains unaddressed. In Vietnam, ini-
out the national program. However, previous limited             tial project results show that change in training alone
experience with provision of Depo-provera showed                has a limited and short-lived impact unless extensive
high drop-out rates and lack of attention to counseling.        supervision is provided. Without related changes in
In light of these and other observed weaknesses in qual-        management and in the general philosophy of care-
ity of care, the assessment recommended that an incre-          giving, providers quickly revert to old patterns of be-
mental and research-based approach to injectable intro-         havior. These results re-emphasize a point made ear-
duction was needed. The introduction of Depo-provera            lier with regard to the introduction of injectable con-
is currently being supported within the context of vol-         traceptives in Bangladesh, that “[s]ystematic changes
untarism, broad method choice, and general quality-of-          are needed that address critical structural and opera-

88   Studies in Family Planning
tional barriers to improving quality of care” if new          framing introduction issues within a larger context will
contraceptive technologies are to make a contribution         be accrued when multiple actors and institutions are
(Phillips et al., 1989: 243). These issues remain major       able to use assessment findings.
challenges in the organization of Stage II research and
in the subsequent use of research findings for program        The Participatory, Field-oriented Process
and policy development.
                                                              The power of a participatory process in assessments,
                                                              policy development, and research has been demon-
Social and Institutional Contexts
                                                              strated unmistakably in the implementation experience.
The significance of anchoring the strategic approach in       The strategic approach emphasizes country ownership
social and institutional contexts of contraceptive use is     of the three-stage process of introduction. With one ex-
well illustrated by several of the findings from strate-      ception, assessments that have been conducted were led
gic assessments and subsequent research. Race, eth-           by senior ministry-of-health officials. In one case, the
nicity, class, religion, and sex are central forces that      process was directed by a member of a research insti-
shape not only social attitudes and norms about con-          tution. Sustained governmental and nongovernmental
traception but also policies and programs and the power       participation in all stages of the fieldwork was accom-
relations within which they are implemented.                  plished in all assessments. WHO and its collaborating
     In South Africa, the influence of a racially moti-       institutions provided extensive technical support and
vated and often coercive family planning program              facilitated the process, but were not in charge of orga-
during the apartheid regime translated into an empha-         nizing and leading the process. The development of as-
sis on the provision of injectables to black women, ne-       sessment instruments, the conduct of visits to the field,
glecting entirely their need for meaningful options and       the analysis and interpretation of collected data, as well
informed choice. The racially based political and ad-         as the organization of workshops and subsequent re-
ministrative organization of the country produced             search, were a team effort. A variety of governmental
highly differential access to services, leaving black         and nongovernmental institutions participated in work-
women in rural areas with few options. In Bolivia, dif-       shops both prior to and after the assessment. Stage II
ferences in ethnicity and class background between            research is undertaken by a government or involves a
providers and clients explain low usage of services in        government agency in collaboration with national re-
the public sector, while the strong influence of the          search institutions.
Catholic Church and political ideologies have limited              Involving senior government officials in the con-
government involvement with family planning. Tra-             duct of clinic observations and interviews with commu-
ditional beliefs have impeded the use of modern ser-          nity members or providers at service-delivery points at
vices and specific methods. All assessments under-            all levels is of significant value, especially when such
taken so far have provided ample evidence of the effect       visits go beyond the ceremonial encounters typical of
of gender imbalances on contraceptive choice. View-           official field visits. Government authorities rarely have
ing contraceptive introduction within a broader insti-        the opportunity of seeing the realities of program imple-
tutional context also raises the question of whether          mentation at the local level. They are even less likely to
method introduction enhances reproductive choice or           converse with ordinary people in their homes, or to par-
subjects people to coercive institutions of the state.        ticipate in discussion groups with community leaders
Such ethical issues are particularly relevant in cases        in a frank exchange about the conditions of service de-
where provider-dependent, long-acting methods are             livery. In addition, they seldom have the opportunity
considered.                                                   to conduct a strategic analysis of policy choices regard-
     Stage II research projects have been designed with       ing contraceptive introduction, using a systems frame-
a concern for the larger institutional context. In Bolivia,   work focused on quality of care.
Stage II research will institute a process of dialogues            Expanding participation in the strategic process to
between community representatives and service pro-            other stakeholders, especially those typically not in-
viders and managers to reduce the social distance be-         cluded at this level of decisionmaking, has proved to
tween the two groups and to enhance opportunities for         be both feasible and valuable. Collaboration of repre-
adapting services to local needs. The proposed train-         sentatives from nongovernmental organizations and
ing program will devote attention to gender dynamics.         women’s health advocates was secured for all Stage I
However, a single research project is limited in the ex-      assessments. In some settings, such participation was
tent to which it can respond to general social needs and      easily accomplished. Because close collaboration be-
address institutional constraints. The full benefits of       tween the Women’s Health Secretariat, NGOs, and wom-

                                                                                     Volume 28   Number 2   June 1997   89
en’s health advocates existed prior to the initiation of     searchers with community and district-based provid-
the three-stage process in Bolivia, soliciting participa-    ers, women’s health groups, and young people is both
tion and establishing constructive working relationships     informative and provocative. These alliances are not
was easy. In Zambia, team members were chosen from           necessarily natural ones, nor is working across such con-
a group of individuals representing more than a dozen        stituencies in a collegial manner effortless.
organizations, including Planned Parenthood Associa-
tion of Zambia and the Young Women’s Christian Assoc-        The Importance of Flexibility
iation. Although some of the representatives were from
women’s organizations, women were also represented           The strategic approach suggests a logical process that
through legal, health, and development organizations.        may follow a number of paths. Flexibility is essential
     Addressing women’s concerns is more difficult when      in assuring its participatory nature. Broad-based par-
few or even no nongovernmental organizations exist           ticipation of a range of stakeholders leads to adapta-
that represent women’s interests. In Vietnam, the Viet-      tions that reflect both national priorities and local con-
nam Women’s Union (VWU) was a partner in the ass-            cerns. Several countries broadened their approach to an
essment. Although it is a governmental organization,         assessment of reproductive health services, while main-
the Union does not necessarily represent the same point      taining an emphasis on contraception. In South Africa,
of view as the Ministry of Health or the National Com-       doing so implied attention to sexually transmitted dis-
mittee on Population and Family Planning. The partici-       eases (STDs), reproductive-system cancer screening, in-
pation of the VWU in the strategic process served to         fertility, and abortion. In Bolivia, obstetric care was in-
legitimize the perspectives of the organization and in-      cluded, and in Brazil, attention to the diagnosis and
clude women’s voices, to encourage a client-oriented         early treatment of cervical cancer was added to the as-
approach to services, and to strengthen the ability of       sessment. In all countries, the contraceptive introduc-
the VWU to influence governmental health policy. In          tion strategy has allowed significant input for identify-
Myanmar, participation of the Myanmar Maternal and           ing and addressing broader reproductive health needs.
Child Welfare Association, an NGO working closely            In Zambia, recommendations for policy and program
with the government, has provided women from that            changes from the strategic assessment were adopted as
organization the opportunity to become aware of how          part of the national reproductive health agenda.
their village-level membership could play a more ac-              Implementation has shown that the strategic ap-
tive role in promoting birth-spacing services in rural ar-   proach produces a more complex set of outcomes than
eas. The assessment gave them a chance to learn not          originally had been anticipated and that these can oc-
only from discussions with their own members during          cur earlier than expected. Policy, programmatic, or op-
field visits, but also from interviews with nonmem-          erational outcomes can result from Stage I assessments
bers—that is, with villagers and local providers. Par-       immediately, rather than later from Stage II research.
ticipants gained new insights into what their organiza-      An example is the Vietnamese government’s decision
tion was and was not accomplishing at the village level.     to change its plans for widespread introduction of Nor-
     In Brazil, where controversy existed between fam-       plant in favor of a more cautious process. The govern-
ily planning providers and women’s health groups in          ment and international agencies accepted the Stage I as-
the past, collaboration in the assessment and extensive      sessment as the national strategy for contraceptive
participation of women’s health groups in the subse-         introduction. As a result, several donor agencies wish-
quent workshop provided an opportunity for some rap-         ing to introduce injectables have decided to wait until
prochement of divergent perspectives, as well as for         results from the introductory research in two provinces
continued expression of diverse points of view. A            are available.
unique result of the Stage II research project in Brazil          Similarly, useful research findings were expected
was the creation of a community-based women’s orga-          to emerge at the completion of research. Experience
nization that has supported the action research project      has shown that dissemination and replication of such
organized within a municipality. In preparation for the      findings can occur earlier. Findings from the Stage II
third phase of work, the project organizers are placing      research project in the municipality of Santa Barbara
considerable value on the contribution of such groups        d’Oeste in Brazil have been shared with other munici-
in assuring replication of lessons from research.            palities and with state and federal officials midway
     The three principles of country ownership, partici-     through the project. In Vietnam, the Stage II project
pation of all stakeholders, and an open, transparent pro-    produced a large workshop nine months after pro-
cess are essential to the three-stage process. Bringing      ject initiation that shared preliminary results with
together policymakers, program managers, and re-             agencies supporting reproductive health activities. The

90   Studies in Family Planning
Figure 2    Anticipated outcomes of the strategic approach to contraceptive introduction

                      Stage I                                          Stage II                                     Stage III
  Assessment and consensus building                                   Research                                 Use of research
 Assessment of the need for the introduc-            Research focused on improving quality         Use of research results for policy and
 tion of fertility-regulation methods within         of care in the provision of all methods       program development
 a reproductive health framework,                    within a reproductive health framework        • Scaling up of improvements in
 focused on the user–service technology              • Improved provision of currently                provision of existing methods
 interface                                               existing methods                          • Scaling up of contraceptive
 Strategic questions addressed:                      • Phased introduction of new methods             introduction, if warranted
 • Should any methods be removed                     Research approaches                           • Identification of additional research
     from the existing service system?                                                                needs
                                                     • Pilot and demonstration projects
 • Are there methods that are inappro-               • Service-delivery research                           Dissemination projects
     priately or inadequately provided that
                                                     • Research on users’ perspectives             • Publication of results
     would benefit from reintroduction?
                                                     • Organization development                    • Workshops and dialogue with key
 • Does a need exist for new methods of              • Action research
     fertility regulation?                                                                            stakeholders

                          Policy/program change                                                  Other results
      •    Adoption of the strategy for introduction of fertility-      • New strategic questions raised
           regulation methods                                           • Identification of key reproductive health issues and need for
      •    Operational changes                                            research
      •    Improved provision of existing methods                       • Addition of new components of reproductive health services
      •    Introduction of new methods with attention to quality of     • Greater understanding of user/technology/service interface
           care                                                         • Legitimization of the role of key stakeholders in policymaking
      •    Removal of unsafe or outdated methods                        • Greater coordination or collaboration with and between

                                                Quality of care, improved access and availability

closely interactive process of assessment, research,                      questions of what project to undertake and what meth-
and policy and program development is illustrated in                      od(s) to focus on are critical. Unless a number of research-
Figure 2.                                                                 ers and funding agencies are willing to pursue the broad
                                                                          research agenda suggested in Stage I assessments, intro-
                                                                          ductory research must be chosen to ensure that projects
Issues and Concerns                                                       most critical for policy and program development are un-
Although those who have participated in, or seen the                           A second issue arises from the flexibility of the stra-
results of, the strategic approach have been persuaded                    tegic approach that allows broadening of the assessment
of its underlying value, the following four issues require                to include other areas of reproductive health. Although
attention as this approach becomes more widely imple-                     the rationale for such an expanded scope of work can
mented: (1) selection of research for Stage II ; (2) conse-               be extremely persuasive, such broadening must be pur-
quences of flexibility; (3) implications of undertaking                   sued with caution, to make sure that attention to stra-
the relatively lengthy process required to implement the                  tegic introduction questions is not compromised. More-
strategic approach; and (4) assurance of sustainability.                  over, doing justice to several of the elements of repro-
     First, the transition from assessment to research in-                ductive health within the context of a single assessment
volves critical choices related to the selection of Stage                 is not easy. Use of sequential assessments may be an
II projects. Stage I assessments typically conclude with                  appropriate approach for some settings. For example,
a range of recommendations about what type of intro-                      the Vietnamese government decided to pursue a sec-
ductory research is desirable. Only one project has been                  ond strategic assessment, this time addressing abortion
funded in each country from the range of research sug-                    and menstrual regulation, rather than focusing on con-
gestions contained in the assessment report. Therefore,                   traceptive services. Although these issues were identi-

                                                                                                     Volume 28    Number 2     June 1997     91
fied in the contraceptive method-mix assessment, they       deprived for a long time, are finally coming within
have such central significance for reproductive health      reach.
in Vietnam that three years later an additional assess-          A final concern is the sustainability of the strategic
ment is scheduled to take place. The overall framework      approach. Whereas the emphasis on country ownership,
and process remain the same, but the topic and strate-      participation, and capacity building certainly has the po-
gic questions change.                                       tential for contributing to an enduring process, the issue
     Third, the amount of time required to implement        of sustainability remains problematic. As Stage II re-
technology introduction using a participatory approach      search and Stage III activities unfold, the salience of this
focused on quality of care is considerable. Senior gov-     issue is likely to increase. Many of the changes proposed
ernment officials, representatives of women’s groups,       through the application of the strategic approach require
and other participants in the process are limited in the    strengthening the management infrastructure of pub-
amount of time they can dedicate to such a process. A       lic-sector programs as well as reorienting the overall phi-
related limitation concerns continuity and stability in     losophy and ethics of care. Such institutional change is
government. Implementation of the strategic approach        not easily attained or maintained when results from pi-
requires an ongoing rational process of policy choice       lot projects are transferred to larger settings. Outside
and program development. Where ministries and po-           support from institutions with credibility and technical
litical process are unstable, the strategic approach may    skills is essential to ensure that the process is transpar-
not succeed fully, but the approach still has value, and    ent and inclusive. Such support should continue as the
the process may not need to extend over several years.      strategic approach is more widely implemented.
In fact, the flexibility of the approach allows it to be
adapted to the constraints inherent in such situations.
Finally, because many countries are still dependent         Conclusion
upon donor agencies for supply of contraceptive com-
modities, multilateral partners such as UNFPA and rel-      The strategic approach to contraceptive introduction
evant bilateral donors must be involved from the out-       represents an important shift in perspective. It empha-
set of the strategic process. However, because assess-      sizes quality of care and a reproductive-health focus as
ments are country-owned exercises, it is essential that     central elements in the process of improving provision
donor agencies support the process but do not influ-        of existing methods and adding new technology into
ence it unduly. Such collaboration has been achieved        the service system. In contrast to previous practice, it
in many of the countries where assessments have been        encourages a participatory approach that values respon-
conducted. In some of them, UNFPA and certain bi-           siveness to a country’s needs and collaboration among
lateral agencies have provided financial support for        governments, women’s health groups, community
the assessment and continuing support for the Stage         groups, nongovernmental providers, researchers, inter-
II research activities.                                     national donors, and technical assistance agencies.
     The underlying logic and philosophy of the strate-     Implementation to date indicates that, in general, ser-
gic approach argue that method introduction should          vice-delivery settings are not well equipped to intro-
only proceed where a system’s ability to provide ser-       duce new methods widely with adequate quality of care
vices of high quality exists or can be generated. Such      without significant change and adaptation in manage-
strengthening of quality, however, takes time. Does this    ment and the philosophy of care. Improved provision
emphasis on the quality of care deprive women and           of existing methods has been shown to be just as im-
men of the benefits of new technology for too long? As      portant as—at times more important than—the intro-
Bruce suggests “[T]he ill-prepared introduction of a        duction of new ones. The strategic approach produces
technology does not constitute the expansion of choice”     not only longer-term benefits with regard to improved
(Bruce, 1990: 98). Taking the time necessary to move to-    quality of care and method choice but also has imme-
ward greater quality of care when introducing a method,     diate policy, programmatic, and operational results that
therefore, is a worthwhile investment. Moreover, given      can transcend the narrow confines of existing contra-
the emphasis of the strategic approach on method mix,       ceptive services to extend broader benefits in reproduc-
the results that are achieved, although they require time   tive health. Although it should not be viewed as a pana-
and effort, have an impact on all available methods, not    cea providing instant relief from the many institutional
merely on a newly introduced technology. The poten-         problems that afflict public-sector programs, the stra-
tial exists for ensuring that the benefits of currently     tegic approach is a participatory policy-development
available technology, of which women may have been          process of relevance for all countries.

92   Studies in Family Planning
Notes                                                                    Kane, Thomas T., Gaston Farr, and Barbara Janowitz. 1990. “Initial
                                                                            acceptability of contraceptive implants in four developing coun-
1   United Nations Development Program/United Nations Popu-                 tries.” International Family Planning Perspectives 16,2: 49–54.
    lation Fund/World Health Organization/World Bank.                    Lubis, Firman, Peter Fajans, and Ruth Simmons. 1994. “Maintaining
2   Formulation and implementation of the strategic approach has            technical quality of care in the introduction of Cyclofem™ in a
    involved extensive collaboration between WHO and the follow-            national family planning program—Findings from Indonesia.”
    ing institutions: the Center for Maternal and Child Health Re-          Contraception 49,5: 527–40.
    search (CEMICAMP), a nongovernmental organization linked to          Ministerio de Salud de Chile et al. 1997. “Assessment of reproduc-
    the University of Campinas, Brazil; the University of Michigan;         tive health and family planning services in Santiago, Chile.” Un-
    the Population Council; and the International Council on Man-           published.
    agement of Population Programmes (ICOMP). These institutions         Ministry of Health, Republic of Zambia and WHO’s Task Force on
    have provided major support to WHO through their participa-
                                                                            Research on the Introduction and Transfer of Technologies for
    tion in consultations and planning meetings of the Scientific Re-       Fertility Regulation. 1995. An Assessment of the Need for Contra-
    view Committee on Technology, Introduction and Transfer,                ceptive Introduction in Zambia. Geneva: World Health Organiza-
    HRP, and through their role in the design and implementation
                                                                            tion. WHO/HRP/ITT/95.4.
    of the various stages involved in the new approach.
                                                                         Phillips, James F., Mian Bazle Hossain, A.A. Zahidul Huque, and
                                                                             Jalaluddin Akbar. 1989. “A case study of contraceptive introduc-
                                                                             tion: Domiciliary Depot-Medroxy Progesterone Acetate services
                                                                             in rural Bangladesh.” In Demographic and Programmatic Conse-
                                                                             quences of Contraceptive Innovations. Eds. S.J. Segal, Amy O. Tsui,
References                                                                   and S.M. Rogers. New York: Plenum Press.
                                                                         PIACT. 1987. “Use of focus group discussion research: Looking at
Beattie, Karen J. and George F. Brown. 1994. “Expanding contracep-          the acceptability of NORPLANT® implants in four countries to
    tive choice: Norplant.” In Contraceptive Research and Development       improve product introduction efforts.” New York: Population
    1984–1994. Van Look P.F.A. and G. Pérez-Palacios. Delhi: Ox-            Council. Unpublished.
    ford University Press.
                                                                         Pies, Cheri, Malcolm Potts, and Bethany Young. 1994. “Quinacrine
Berer, Marge. 1995. “The Quinacrine controversy continues.” Repro-           pellets: An examination of nonsurgical sterilization.” International
    ductive Health Matters 6, 142–144.                                       Family Planning Perspectives 20,4: 137–141.
Bruce, Judith. 1990. “Fundamental elements of the quality of care: A     Pinotti, J., A. Díaz, M. Díaz, E. Hardy, and Anibal Faúndes. 1990. “A
    simple framework.” Studies in Family Planning 21,2: 61–91.               identificação de use de anticoncepcionais orais pela população
Camacho, Hubner V. et al. 1996. Diagnóstico Cualitativo de la Atención       feminina do Estado de São Paulo.” Revista de Ginecologia e
   en Salud Reproductiva en Bolivia. Geneva: World Health Organi-            Obstetrícia 2: 110–116.
   zation. WHO/HRP/ITT/96.1 .                                            Reproductive Health Task Force, South African Ministry of Health
Cellule de Recherche en Santé de la Reproduction (CRESAR). 1997.            et al. 1994. “Assessment of reproductive health services in South
    “Evaluation des besoins en santé de la reproduction au Burkina          Africa focusing on family planning.” Report submitted to the
    Faso: Enquête qualitative.” CRESAR. Forthcoming.                        World Health Organization, Geneva.
Costa, Sarah, Ignez Martin, Sylvia Freitas, and C. Pinto. 1990. “Fam-    Simmons, George B. 1971. “The Indian Investment in Family Plan-
   ily planning among low income women in Rio de Janeiro: 1984–             ning.” An Occasional Paper of the Population Council. New York:
   85.” International Family Planning Perspectives 16,1: 16–22.             Population Council.
Díaz, Margarita et al. 1997. “Expanding contraceptive choice: Find-      Simmons, Ruth and S. Ward. 1991. “Service delivery systems and
    ings from an action research project in Brazil.” Unpublished.           quality of care in the implementation of NORPLANT® in Peru.”
Formiga, José Noble et al. 1994. An Assessment of the Need for Contra-      Report submitted to the Population Council, New York.
   ceptive Introduction in Brazil. Geneva: World Health Organiza-        Simmons, Ruth, Peter Fajans, and Firman Lubis. 1994. “Contracep-
   tion. WHO/HRP/ITT/94.2.                                                  tive introduction and choice: The role of Cyclofem™ in Indone-
Grubb, Gary S., Deborah Moore, and N. Gustav Anderson. 1995. “Pre-          sia.” Contraception 49,5: 509–526.
   introductory clinical trials of Norplant® implants: A comparison      Snow, Rachel and Lincoln Chen. 1991. “Towards an Appropriate
   of seventeen countries’ experience.” Contraception 52,5: 287–296.        Contraceptive Method Mix: Policy Analyses of Three Asian
Hall, Peter E. 1994. “The Introduction of Cyclofem™ into National           Countries.” Working Paper Series. No. 5. Cambridge, MA: Harvard
    Family Planning Programmes: Experience from Studies in In-              Center for Population and Development Studies.
    donesia, Jamaica, Mexico, Thailand and Tunisia.” Contraception       Soni, V. 1984. “The development and current organization of the fam-
    49: 489–507.                                                             ily planning programme.” In India’s Demography: Essays on the
Hieu, Do Trong et al. 1995. An Assessment of the Need for Contracep-         Contemporary Population. Eds. T. Dyson and N. Crook. New Delhi:
   tive Introduction in Viet Nam. Geneva: World Health Organiza-             South Asian Publishers.
   tion. WHO/HRP/ITT 95.3.                                               Spicehandler, Joanne. 1989. “NORPLANT® introduction: A manage-
Hull, Terence H. 1996. The Dilemma of Norplant Removals in East Nusa         ment perspective.” In Demographic and Programmatic Consequences
   Tenggara, Indonesia. Report to the Annual Research Meeting,               of Contraceptive Innovations. Eds. S.J. Segal, Amy O. Tsui, and S.M.
   Mataram, Lombok, 1–3 May.                                                 Rogers. New York: Plenum Publishing Corporation.

                                                                                                      Volume 28     Number 2     June 1997    93
Spicehandler, Joanne and Ruth Simmons. 1994. Contraceptive Intro-         succeeded without the support from policymakers and pro-
    duction Reconsidered: A Review and Conceptual Framework. Geneva:      gram managers, participants from nongovernmental orga-
    World Health Organization. WHO/HRP/ITT/94.1.                          nizations, women’s organizations, research institutions, and
                                                                          international agencies. In particular, we wish to acknowl-
Union of Myanmar. 1997. “An assessment of the contraceptive meth-
                                                                          edge the important contribution of national members of the
   od mix in Myanmar.” Unpublished.
                                                                          assessment teams: For Bolivia: Virginia Camacho Hubner,
Vollmer, L. 1985. “Women’s perspectives on the NORPLANT® con-             Alberto de la Gálvez Murillo, Marcos Paz Balliván, Rosario
    traceptive implants: Colombia.” New York: Population Coun-            André, Ximena Machicao Barbery, and María Dolores
    cil. Unpublished.                                                     Castro; for Brazil: José Nobre Formiga Filho, Simone Grillo
Ward, Sheila, Ruth Simmons, and George Simmons. 1988. “Service            Diniz, and Sara Sorrentino; for Burkina Faso: J. Kabore, B.
   delivery systems and quality of care in the implementation of          Bone, A. Nougtara, A. Pare, M. Rouamba, Y. Sanda, O.
   NORPLANT® in Colombia.” Report submitted to the Population             Sankara, I. Sanou, C. Saouadogo, R. Saouadogo, G. Sorgo,
   Council, New York.                                                     G. Traore, and Y. Yacouba; for Chile: C. Alvares G., V. Baez
Ward, Sheila et al. 1990. “Service delivery systems and quality of care   Pollier, C. Bravo Romero, René Castro, B. Fernandez R.,
   in the implementation of NORPLANT® in Indonesia.” Report               Pablo Lavin, M. Tijeros M., J. de Valle, C. Videla, and S.
   submitted to the Population Council, New York.                         Vivanco Z.; for Myanmar: Thein Swe, Thein Thein Htay,
                                                                          Nilar Tin, Khin Thet Wai, Khin Myint Wai, Saw Isaic, Nu
                                                                          Aye Khin, Khin Win Kyu, Katherine Ba Thike, Tin Tin Cho,
Acknowledgments                                                           Myint Zaw, and Khin Ohmar San; for South Africa: Helen
                                                                          Rees, Nelly Manzini, Nontaka Gumede, Lulu Mabena, and
This article was written under the auspices of the Strategic              James McIntyre; for Vietnam: Do Trong Hieu, Pham Thuy
Component for Technology Introduction and Transfer, UNDP/                 Nga, Nguyen Kim Tong, Vu Quy Nhân, Nguyen Thi Thom,
UNFPA/WHO/World Bank, Special Programme of Research,                      Do Thi Thanh Nhân, and Doan Kim Thang; and for Zam-
Development, and Research Training in Human Reproduc-                     bia: the late John Mbomena, N. Mulikita, J. Puta, H. Kaluwe,
tion, World Health Organization. Many people have contrib-                J. Kamwanga, R. Mulumo, J. Muunyu, C. Mutungwa, D.
uted to the development and implementation of the strate-                 Chimfwembe, R. Likwa, E. Ndalama, and M. Luhanga.
gic approach. Joanne Spicehandler, Assistant Task Force                      We also wish to express our gratitude to the many service
Manager between 1989 and 1993, played a central role by                   providers, community leaders and local women and men who
initiating the transition to the new paradigm and by pro-                 shared their experience and point of view with the assess-
viding continued support. Jane Cottingham’s insight and                   ment and research teams. Technical assistance to the assess-
advice on how to ensure the integration of women’s per-                   ments was provided by the authors of this paper and by John
spectives have been invaluable. Members of the Steering                   Skibiak, Anibal Faúndes, Luis Bahamondes, Christopher
Committee—in particular, Karen Beattie, Sandra Kabir,                     Elias, Andrew McNee, Davy Chikamata, Maria Yolanda
Firman Lubis, and Rushikesh Maru—have provided inspi-                     Makuch, Elizabeth Cravey, Anne Young, and Kus Hardjanti.
ration, wisdom, and technical expertise to the process.                   Martha Brady and Ayo Ajayi of the Population Council also
Implementation of the strategic approach could not have                   made significant contributions.

94   Studies in Family Planning

Shared By: