Contraceptive delivery in the developing world.

A strong demand for family planning exists in most developing countries and family size is falling rapidly in many of them. Effective family planning programmes offer a world-wide range of choices (including voluntary sterilisation and abortion) through a variety of distribution channels. Universal access to voluntary family planning can be achieved easily and cheaply by the turn of the century, but only if conservative medical policies are overcome and funding is greatly expanded. The international community faces a genuine choice: if it responds to current opportunities the global population will stabilize at approximately 10 billion or fewer; if it fails, population may grow to 14 billion or more. The difference between these two projections (approximately equal to the present world population of 5.4 billion) may well determine the future of the planet.

PIP: 48% of couples in the developing world use some form of contraception. The global fertility rate has fallen from a total fertility rate (TFR) of 6.1 million in the 1960s to 4.2 million in 1991. Education and employment opportunities for women, income, and urbanization are all positively correlated with smaller families. Effective, low-dose, combined oral contraceptives (OCs) are used by over 60 million women worldwide. The injectable contraceptive, Depo-Provera, is competitive in price with OCs. The new generation of implantable contraceptives, as represented by Norplant, will not gain widespread use until competition drives the price down and the present 6-rod device is simplified or biodegradable implants are developed. Modern IUDs are increasingly acceptable, but only when the woman and her partner are not exposed to the risk of sexually transmitted diseases. Voluntary surgical contraception (VSC) is the commonest single method of fertility regulation in the UK and the US. OC distribution in parts of Francophone Africa has been made contingent on tests that cost the equivalent of approximately 3 months' per capita income. In one Anglophone country, women are subjected to an unnecessary 45-minute physical examination before receiving OCs. Many family planning (FP) programs are still constrained by a close linkage to primary health care services. In Kenya, contraceptive prevalence was held at a low level because administrators had the mistaken notion that African women did not want to plan their families. International agencies should allocate funds using cost per couple year of protection. Much of the bilateral program of governments and the United Nations Population Fund is not very cost effective. The FP component has actually fallen from 2% of all foreign aid in the 1970s to less than 1% in the early 1990s, although the total cost of FP services will need to double by the year 2000.

A review and assessment of non-governmental organization-based STD/AIDS education and prevention projects for marginalized groups.

A review of projects run by non-governmental organizations (NGOs) in primarily developing countries, which have aimed to provide STD/AIDS education and prevention skills to various marginalized groups, reveals that past quantitative and formative research has failed to identify key programmatic factors which lead to more successful project implementation and sustainability. In observations, interviews with field staff, visits to program sites and information drawn from the literature, a variety of methods to reach a wide range of groups such as men who have sex with men, prostitutes, clients of prostitutes, prisoners, street children, migrant workers and refugees are explored. Factors found to facilitate project success include the following: at least one full-time committed staff member; respectful treatment and appropriate motivation of the target group; suitable and sufficient equipment and supplies (particularly condoms); planning ahead for the participation of HIV-positive individuals and ways to meet their needs; focusing on qualitative rather than quantitative evaluation; planning in advance beyond a 9 or 12 month 'model'. Despite some evidence that marginalized groups can be successfully motivated to practise safer sex through prevention education, long-term behaviour change still presents major challenges--even when specific conditions are met.