Final evaluation : private sector family planning project -- Indonesia : project no. 497-0355

The project achieved most but not all of its targets. It reached targets for contraceptive prevalence rate, acceptors utilizing the private sector, rural acceptors fully or partially paying for FP through the private sector, commercial sales of contraceptives by couple years of protection, and midwives (at nearly double the target number) and pharmacists trained in FP. The social marketing of Blue Circle (BC) contraceptives was very successful; BC has high brand awareness and sales expanded quickly. The National FP Coordination Board"s (BKKBN) community-based distribution (CBD) component, which was concentrated in the eight most populous provinces, was also very successful. A total of 286,608 fieldworkers, volunteers, and community leaders were trained, and each province developed a distribution system to provide commercial contraceptives to rural communities. On the down side, the use of LTMs by both men and women increased only marginally from 35% in 1989 to 36.5% in 1994. This was due to a decline both in the use of IUDs and, since 1989, in the annual number of voluntary sterilization (VS) procedures. Causes of the decline in VS include prohibition of VS by the government due to opposition by Islamic leaders, competition from non-operative FP procedures such as IUDs and implants, and BKKBN"s vigorous promotion of implants. Another project shortfall occurred when doctor training was terminated in 1993; many general practitioners were not interested in it and few provided FP services in their practices. There are several issues for sustainability. (1) In the private sector component, recent Ministry of Health policies constrain the provision of FP services by midwives, and there is need to strengthen the Indonesian Midwives Association"s provincial and district headquarters, where most midwife training is conducted. (2) Sustainability of social marketing depends on affordable, accessible, and quality products; quality providers; and effective promotion. The Indonesia program had all these until 4/95, when BC advertising ended as scheduled. (3) CBD sustainability faces three problems: the fragile and not especially profitable private sector contraceptive distribution system in rural areas; midwives" need for continuing refresher training in persuasion skills and small business management; and the greater economic incentive afforded CBD workers for promoting short-term methods rather than LTMs. In terms of management, it is not clear who will take over the important function of coordinating the growing number of Cooperative Agreements when the Project Support Group staff leaves in 12/95. Finally, without additional staff it may be difficult for BKKBN to continue increasing contraceptive prevalence while working to fulfill its new mandates to improve family welfare and relieve poverty. BKKBN will also face an accelerated demand for the removal of contraceptive implants as it continues to vigorously promote this method; there will be a need for rapidly increasing numbers of midwives and doctors to be trained in proper removal techniques. The following lessons were learned. (1) Midwives, rather than doctors, are the most important providers of FP services through the private sector, and their role is likely to increase in the future. In fact, except for VS, doctors have a limited role in the private sector. Similarly, pharmacists have almost no role in FP; assistant pharmacists, however, play an important role, especially for sales of condoms. (2) A large majority of both urban and rural couples are willing to pay some or all costs of their FP needs, provided products are of high quality, affordable, accessible, and provided by well trained persons. (3) BKKBN has an unusual capacity to train large numbers of people throughout the country. (4) Without mass media promotion, private sector sales would not have grown from 12% to 28% of all contraceptive purchases in just 7 years. (5) Major pharmaceutical companies are willing to make significant price cuts for socially significant causes as long as there is a profit potential. (6) A successful VS program requires strong government support and adequate publicity. Facilities, equipment, and trained staff are not enough.