Family planning and population programs in Colombia : 1965 to 1997

The central role of family planning (FP) programs in increasing contraceptive use to 72% over this period is widely acknowledged. Demographic, economic, social, and cultural factors contributing to the momentum for change included the accelerated decline in mortality, with corresponding increases in life expectancy and the rate of population growth; (2) accelerated urbanization; (3) the modernization of the Colombian economy, including improved education of both women and men; and (4) the special nature of the relationship between Colombian Catholics and their church. Enabling factors included the commitment of key Colombian institutions in designing and improving programs; the training of nearly 4,000 Colombian research and service delivery professionals; the level and flexibility of external financial and technical assistance provided by USAID, other donors, and cooperating agencies; the technological revolution in contraception; and the positive attitudes of Colombian women toward modern contraception. Although a formal FP policy was lacking, there was a consensus among key officials and institutions that the population problem required action. Population policy development that did occur was subtle and pragmatic, and provided the necessary environment for private FP service delivery. Since the mid-1960s, PROFAMILIA has dominated the FP field in Colombia, not only by developing FP services through its institutional infrastructure, but also by creating a FP consciousness in the minds of Colombians. Key elements in PROFAMILIA"s successful management included: (1) its strong, consistent mission and the role of its leadership; (2) its translation of this mission into performance through effective program strategies; (3) its method of managing and measuring performance; and (4) the people and relationships associated with the institution. The combined strength of these elements has made PROFAMILIA a model of an effective nonprofit organization in the field of FP and reproductive health. The evolution of PROFAMILIA"s service program is replete with innovative strategies that have been useful not only in Colombia, but also in other countries. The service delivery strategies began from a clinic base, expanded over time into rural and then urban community-based distribution (CBD), incorporated radio and other means to promote services, added a contraceptive social marketing (CSM) component, and established mobile units. After more than two decades of providing services, and with contraceptive use becoming ever more prevalent, PROFAMILIA converted its CBD and CSM programs into a community marketing program. Other service delivery strategies have focused on the special needs of males and adolescents. PROFAMILIA was innovative in changing the roles of service providers: CBD promoters distributed pills, and nurses inserted IUDs. In moving toward financial sustainability, PROFAMILIA adopted a multifaceted approach, beginning with charging fees for services. PROFAMILIA developed a good system for tracking the "real" costs of services by method, clinic, and program or delivery strategy, emphasizing efficiency and cost reduction. It expanded into a broader range of reproductive health services that were provided for a profit and that served to cross-subsidize FP. Finally, in the new era of health reform under Law 100, PROFAMILIA has initiated numerous contracts for FP and health services with social security and health insurance companies. PROFAMILIA is the deserving beneficiary of an endowment fund that moves it a step closer to sustainability and provides a welcome cushion for special program needs. Besides PROFAMILIA, other institutional actors played important parts in the story of FP in Colombia. Teaching hospitals played a critical role in the early days, and may play an increasingly larger role in the future. With few exceptions over the years, the Ministry of Health (MOH) through its Maternal Child Health (MCH) Division has provided services to roughly one- quarter of the population of contraceptive users. Pharmacies, the pharmaceutical industry in Colombia, and private physicians have contributed to ensuring an adequate supply of contraceptives and services. Over this 30-year history, the examples of useful collaboration between the public and private sectors have been numerous. (Author abstract, modified)