At this time, private research efforts to discover new contraceptives are threatened. Drug companies, particularly in the US, have reduced their interest in contraceptive development due to concern over the rising cost of product liability insurance, the cost of lawsuits in defense of liability claims, and the fear of extremely high awards by juries in product liability cases. The current form of private-public collaboration, now threatened by the liability crisis, works under a few simple principles of agreement. Private industry agrees to supply its patented chemical compounds for assessment as contraceptive agents, to be willing to enter into negotiations with public sector organizations to develop the contraceptive drugs if initial tests warrant it, and to release compounds to another company if the patent-holder declines to proceed with contraceptive development. The public-sector program agrees to fund the studies, keep the industry informed, and maintain confidentiality. When the technology is discovered by the public sector and is of potential interest to private industry, the collaboration involves other issues. The public agency agrees to supply manufacturing know-how and all biological and clinical information, to license under applicable patents, and to permit cross reference to regulatory agency filings. Private industry agrees to use its best efforts to bring the product to market, to manufacture the product at reduced cost for public sector use, or to provide know-how for others to do so. It also agrees to assume product liability and to grant the public sector agency licenses to any patented improvement in its product. Contraceptive research both within and outside the US is feeling the effects of the US litigious atmosphere. Companies from abroad now wish to steer clear of contraceptive research, even though these companies would be prepared to meet the requirements of the Food and Drug Administration. Contraceptives, considered to be high risk targets for lawsuits, are receiving little of the research budgets of pharmaceutical companies. Opposition anti-abortion forces also has had an effect. When the Population Council received new drug approval for the Copper-T-200, it was the 1st time the FDA had issued approval to a noncommercial sponsor. This unprecedented event established a new phase in the cooperative efforts between industry and the nonprofit sector to develop contraceptive products. It showed that given adequate funding, nonprofit agencies can carry out full product development, including the initial regulatory agency clearances.
Private initiatives in developing countries have been successful in increasing women's desire for family planning by enabling them to earn more income. These approaches have incorporated a woman-to-woman strategy in which women train others not only in how to earn an income from producing and marketing products, but also in the skills needed to establish and manage their own organizations. Private voluntary organizations play an especially crucial role in training project managers. The Center for Development and Population Activities, for example, has held 19 Women in Management workshops and channels funds and technical assistance for projects in health, family planning, nutrition, and income generation. Women who move from managerial to policymaking positions are most able to help other women raise their political, social, and economic status.
Private medical practitioners, including physicians, midwives, traditional practitioners, and pharmacists, are important sources of services and information about contraceptive methods. In many developing countries, private practitioners anticipated government policy and were the 1st to provide family planning services. They are the principal source of information and services for the middle and upper classes. Many people have more trust in private practitioners than government institutions. From the viewpoint of national investment, it is sometimes more cost effective to use existing private outlets than to create a new infrastructure of government family planning clinics. In several countries, private doctors have contracted with the government to insert IUDs and provide sterilizations. The role of private practitioners in the provision of family planning services can be developed much further, however. Restrictive laws can be eliminated or modified. The philosophy that private physicians complement but do not compete with government services should be promoted. Fuller use of the skills and resources of private health care providers is especially important in developing countries where there is an unmet need for contraception.
Application of commercial marketing techniques has not only increased awareness, acceptability, and use of modern contraceptives in developing countries, but also overcome logistic problems in service delivery. The ability of contraceptive social marketing to reach large numbers and to treat contraceptives as common consumer products has helped to diminish social and religious constraints associated with family planning. Each contraceptive social marketing program is built around a theme tailored to meet specific cultural, social, and management requirements. The primary target populations are those who cannot afford regular commercial products and those who are not adequately reached by government programs. In countries such as Sri Lanka and Jamaica, profit is not a primary sales objective and retail prices are highly subsidized to make products affordable to low-income people. In contrast, the Colombian and Thai programs use contraceptive social marketing to help offset the operating costs of rural community-based programs and seek profits. The most impressive contraceptive social marketing sales performances have been recorded in Bangladesh, Colombia, Egypt, and Jamaica. The main reason contraceptive social marketing is more cost-efficient than other modes of contraceptive distribution is that the cost of product delivery is assumed by the commercial system. Although there has been some interest in making these programs self-sufficient financially, this step has tended to undermine the purpose of serving lower income groups.
Thailand's pilot Community-based Incentives Program in the northeast illustrates the high level of contraceptive prevalence that can be achieved when entire communities profit from economic incentives. This particular community incentives program began in 1983 with funding from the Special Projects Fund of the Population Crisis Committee under the auspices of Thailand's largest nongovernmental organization, the Population and Community Development Association (PDA). PDA, with its long and impressive record as a grassroots family planning service network, had almost a decade of experience in creating demand for family planning by offering income generating incentives to individuals. Through the community incentives program, PDA used the grant from abroad to establish loan funds of about $2000 in each of 6 villages. The loan funds grew in size as the overall contraceptive prevalence rate in the villages increased. Loans between $80 and $200 were made available to villagers for income-generating activities, mostly to buy fertilizer, rent tractors, or hire workers for planting and harvesting the local crops. Elected villagers administered the funds and reviewed loan applications with assistance from PDA. By the end of 2 years, loans totaling $72,000 had been granted in the 6 villages, and 75% of all village households had received at least 1 loan. Repayment was nearly 100% on schedule with no defaults. The 6 loan funds are still operating in 1986 but without outside assistance. Contraceptive practice increased from 46% to 75% of all married women aged 15-44 in the 6 villages between 1983-85. In a comparative study of 3 villages in which no loan fund operated, contraceptive prevalence increased from 51% to only 57%. In the Thai experience, the private PDA appears to have several advantages over the central government in implementing a community incentives approach: because PDA works closely with community members, it is able to determine community needs, involve the community in decisionmaking, and create the foundation for community self-management; it is able to provide close supervision to assure that performance is rewarded; and it may be perceived as a more credible source of rewards than a government that is removed from the people. Community incentives programs work because family planning and economic development reinforce each other to increase per capita income.
