28.2 simmons article

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 addedto public-sector programs. In response to lessons from the past, the UNDP/UNFPA/WHO/ WorldBank 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 governmentsinterested 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 onthe method mix, the capacity to provide services with quality of care, reproductive choice, andusers’ perspectives and needs. It also suggests that technology choice should be undertaken througha participatory process that begins with an assessment of the need for contraceptive introductionand 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 ofthe 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 importantway of expanding contraceptive use and addressingunmet 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 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 al., 1994; Snow and Chen, 1991). Even when users are 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, 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 single technologies, to advocate instead an examinationof 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 The Indian IUD experience shaped subsequent ap- new model, referred to as “the strategic approach to con- proaches to contraceptive introduction in public-sector traceptive introduction,” also suggests that new tech- settings. Research on experience with and acceptabil- nologies must be introduced within a quality-of-care ity of new methods within routine service-delivery set- and reproductive-health framework and must incorpo- tings served as a bridge between clinical testing and rate the perspectives of a broad range of stakeholders, broad introduction of the methods. This approach con- including those of users, providers, managers, policy- sisted initially of two components: introductory or field trials and acceptability studies. In the late 1980s and Since the end of 1993, WHO has been providing early 1990s, several projects with a focus on service- support to public-sector programs in Bolivia, Brazil, Burkina Faso, Chile, Myanmar, South Africa, Vietnam, Introductory trials are organized after the safety and and Zambia, in order to implement this strategic ap- effectiveness of methods have been established, at least proach. Experience has confirmed that this new way of provisionally, through a series of clinical trials con- proceeding can be a means of enhancing the capacity ducted to examine methods under rigorously controlled to provide quality services. This article provides an conditions, according to clinic-based research protocols.
overview of the strategic approach and presents lessons Introductory trials continue to examine safety and ef- from the implementation experience in eight countries.
fectiveness, but their focus shifts to introducing program Although many illustrations in this paper refer pre- providers to the requirements of the new method and to dominantly to the introduction of contraceptive meth- examining patterns of, and reasons for, discontinuation.
ods, the strategy addresses fertility-regulation technolo- Acceptability studies document the user’s perspective gies broadly defined to include menstrual regulation on the new method and typically are conducted through individual or group interviews with users or potentialusers. 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 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 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 ensurethe 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- 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 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- 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 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- file, and—where cost of the method is a factor— The December 1991 planning meeting at WHO con- 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 therelationship 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- tives of users, as well as service capability, had beenviewed as essential only with regard to facilitating the Users’ Perspectives and Needs
process of introduction, not as a set of questions to beraised prior to the decision to introduce a method.
Technology must be appropriate to the reproductivehealth needs of potential users and to the socioculturalcontext into which they are introduced. Reproductive The Strategic Approach
health needs and people’s perspectives on technologyand 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 tractinfections (RTIs) is high, consideration of IUD services Technology
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, Systems framework guiding the strategic approach to contraceptive introduction • Reproductive health needs and rights• Users' perspectives• Medical profile• Sociocultural and gender influences Technology
• 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 howsuch 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 or consent are of limited value; so are contraceptive ser- Where service-delivery systems do not have the capac- 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 concernfor 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- sure that the assessment addresses areas where informa- A participatory process and a systems framework 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 services, assessments have also included some attentionto the private sector, in particular in those settings wheregovernment 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- 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 and recommendations, preparation of the assessmentreport, 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 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, 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- 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 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- 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 of Stage III is, therefore, the organization of workshops 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- sus is reached. In addition, results from these initiatives Dissemination (Research Stage III
should be disseminated through professional or policy (Assessment)
workshop
underway) (Initiated)
seminars and publication of papers and newsletters.
Experience with Implementation
The strategic approach to contraceptive introduction is 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 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, theexercise 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 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- 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- 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.
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.
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 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- 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 challenges in the organization of Stage II research andin the subsequent use of research findings for program The Participatory, Field-oriented Process
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 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 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, 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- 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 fromwomen’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 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 Anticipated outcomes of the strategic approach to contraceptive introduction Stage III
Assessment and consensus building
Research
Use of research
tion of fertility-regulation methods within Dissemination projects
Policy/program change
Other results
Adoption of the strategy for introduction of fertility- • Identification of key reproductive health issues and need for • Addition of new components of reproductive health services Introduction of new methods with attention to quality of • Greater understanding of user/technology/service interface • Legitimization of the role of key stakeholders in policymaking • 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- ers and funding agencies are willing to pursue the broadresearch 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-dertaken.
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- fied in the contraceptive method-mix assessment, they deprived for a long time, are finally coming within have such central significance for reproductive health 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- 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 beadapted 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- 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.
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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, NuAye Khin, Khin Win Kyu, Katherine Ba Thike, Tin Tin Cho, Acknowledgments
Myint Zaw, and Khin Ohmar San; for South Africa: HelenRees, 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

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