From home to clinic and family planning to family health: client and community responses to health sector reforms in Bangladesh.

International Family Planning Perspectives Bangladesh is one of many countries struggling to implement the expanded approach to family planning agreed to at the International Conference on Population and Development (ICPD)1 in the context of broader health sector reforms.2 The ICPD Programme of Action mandated, among other things, the integration of family planning with broader reproductive health services, an emphasis on client-centered approaches rather than on demographic targets, and improvements in the quality and range of services provided. The government’s Health and Population Sector Strategy, introduced in 1997, reflects many of the ICPD goals as part of a broader program of reforms to improve efficiency and expand access. The strategy proposes to integrate the previously bifurcated family planning and health sectors to provide family planning and reproductive health services as part of an “essential services package” to which everyone, including the most economically disadvantaged, would have access. The strategy explicitly emphasizes client choice over the achievement of method targets. It also mandates improvements in quality of care and, in a departure from the top-down population programs of the past, calls for ongoing stakeholder involvement in program design and monitoring.3 The government program charged with implementing the revised strategy—first as part of the Health and Population Sector Programme and then the Health, Nutrition and Population Sector Programme (HNPSP)—is supported by the World Bank and a consortium of international donors. In 1999, the program began the process of establishing community clinics throughout the country. These clinics created a network of primary level community“owned” health facilities (for which community groups are expected to contribute land and resources for maintenance, and provide some degree of oversight) to deliver the essential services package in conjunction with higher-level services. (This process has been slow and, many feel, poorly coordinated.) The health and family planning workers who previously made home visits are being gradually redeployed and based in these facilities. They are being instructed to no longer visit each client, but instead focus outreach on potential clients who may have difficulty obtaining services. In 1997, ahead of but aligned with this government program, a group of nongovernmental organizations (NGOs) began implementing the clinic-based essential services package model as part of a seven-year bilateral health and family planning program funded by the U.S. Agency for International Development (USAID). These NGOs officially discontinued door-to-door contraceptive distribution and started offering a wider range of services through fixed and satellite clinics. Village-level depots were established in rural areas to resupply contraceptives. To improve sustainability, USAID began to channel its support through a smaller number of NGOs and to expand the use of service charges. The NGOs also introduced a variety of measures to improve quality of services and responsiveness to client needs, such as upgrades in the technical capability of staff, training of staff, improved monitoring and management practices, and expanded facilities and services. With regard to family planning, the NGOs also sought to expand the range of methods available to couples and increase the use of long-term clinical methods.4 The changes these NGOs introduced are both pioneering and bold. The conditions that fostered a population crisis mentality in Bangladesh have not fully abated,* and the NGOs are experimenting with previously untested service delivery strategies that some believed, if taken to scale, might seriously jeopardize Bangladesh’s impressive gains in population stabilization over the past 30 years. Previous policies focused more narrowly on family planning and sought to minimize the direct and indirect costs of contraceptive use by bringing information and methods to women’s homes, at no user cost or for nominal fees. Domiciliary service provision is widely credited as a key factor in the success of these policies,5 and the prospect of discontinuing it to provide family planning in the context of other reproductive and family health services has provoked concerns in various policy circles. Some analysts predicted detrimental effects on contraceptive prevalence and fertility rates, and even on women’s status.6 Thus, the new NGO service delivery approaches test the strength and nature of the demand for family planning, as well as the feasibility of sustaining contraceptive use while integrating family planning with broader reproductive health services. The NGO initiative also tests the extent to which clients, families and communities, as well as providers, can overcome the entrenched attitudes and practices that developed under the previous, demographically driven, vertical family planning program.7 The government of Bangladesh has an important opFrom Home to Clinic and from Family Planning to Family Health: Client and Community Responses to Health Sector Reforms in Bangladesh