The Navrongo experiment, a family planning and health project in northern Ghana, has demonstrated that an appropriately designed, community-based family planning program can produce a change in contraceptive practice that had been considered unattainable in such a setting. Simultaneously, however, evidence suggests that newly introduced family planning services and contraceptive availability can activate tension in gender relations. In this society, where payment of bridewealth signifies a woman's requirement to bear children, there are deeply ingrained expectations about women's reproductive obligations. Physical abuse and reprisals from the extended family pose substantial threats to women; men are anxious that women who practice contraception might be unfaithful. Data from focus-group discussions with men and women are examined in this report and highlight the strains on gender relations resulting from contraceptive use. The measures taken to address this problem and methods of minimizing the risk of adverse social consequences are discussed.
A decade has elapsed since a project was launched in Matlab, Bangladesh to test the hypothesis that contraceptive services can induce and sustain fertility decline in a rural traditional population. The demographic impact of this project has been pronounced, lending support to the view that supply-side policies can succeed even where institutional supports for demand are weak. This paper reviews the relationship between the Bangladesh climate of demand and the Matlab system of supply with the aim of explaining how such effects arise. A sociologically appropriate system of supply can induce fertility change in a society where such change would not spontaneously arise. The study of programs and the "sociology of the supply side" thus deserve the same degree of rigor accorded to research on the "sociology of demand."
In recent years, increased focus on the quality of family planning and other reproductive health services has led to a better understanding of women's reproductive health needs and has drawn attention to program-client interactions as a critical and neglected dimension of program effort. In this article, the relevant methods and experience related to studying client-provider interactions within family planning programs in southern countries are reviewed. The policy relevance of this work is highlighted first by stressing the operational usefulness of examining what happens when people engage with service-delivery systems that offer family planning or reproductive health services. Subsequently, the content areas encompassed by program-client interactions are clarified by identifying manifest and latent dimensions and by distinguishing the variables that define these interactions from variables related to their determinants and consequences. Finally, a critical review of existing methods is presented, with examples of research and a discussion of ethical issues.
The introduction of new contraceptive technologies has great potential for expanding contraceptive 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 Reproduction (HRP) has taken major steps to develop a new approach and to support governments interested in its implementation. After reviewing previous experience with contraceptive introduction, 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.
Small-scale pilot projects have demonstrated that integrated population, health and environment approaches can address the needs and rights of vulnerable communities. However, these and other types of health and development projects have rarely gone on to influence larger policy and programme development. ExpandNet, a network of health professionals working on scaling up, argues this is because projects are often not designed with future sustainability and scaling up in mind. Developing and implementing sustainable interventions that can be applied on a larger scale requires a different mindset and new approaches to small-scale/pilot testing. This paper shows how this new approach is being applied and the initial lessons from its use in the Health of People and Environment in the Lake Victoria Basin Project currently underway in Uganda and Kenya. Specific lessons that are emerging are: 1) ongoing, meaningful stakeholder engagement has significantly shaped the design and implementation, 2) multi-sectoral projects are complex and striving for simplicity in the interventins is challenging, and 3) projects that address a sharply felt need experience substantial pressure for scale up, even before their effectiveness is established. Implicit in this paper is the recommendation that other projects would also benefit from applying a scale-up perspective from the outset.
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