This summary report presents the lessons learned during the two-part qualitative case study on the efficacy of the Prevention Marketing Initiative (PMI) in its implementation of an HIV prevention program. About 179 community participants were included in the PMI program, which discussed topics ranging from organizing initial planning committees to financially sustaining federal demonstration programs. One of the successes observed was the development of rapport with schools and churches; however, during the course of its implementation, the program realized the necessity of 1) approaching the program as an ongoing process; 2) going beyond studying the target population through formative research; 3) changing the role of a community coalition as the project matures; 4) reexamining the composition of coalition in the light of the target audience; 5) advocating the project as a community resource that promotes collaboration; 6) attending the needs of coalition members; and 7) using the media in the campaign. Likewise, several lessons were also learned in the areas of youth involvement, intervention development, program implementation, and maintenance of PMI activities.

Targeted projects conducted by nongovernmental organizations (NGO) and other local groups form the core of the AIDS Control and Prevention (AIDSCAP) Project\'s comprehensive HIV/AIDS prevention programs in 17 countries. Each of the 465 subprojects is based upon a detailed subagreement outlining the project\'s objectives, each organization\'s responsibilities in meeting the objectives, the products to be delivered by the implementing agency, and the indicators for measuring whether the objectives have been met. AIDSCAP country and regional staff work closely with each implementing agency to review and strengthen every subagreement. AIDSCAP\'s rapid project development method, field tested in Tanzania and Honduras in 1995, accelerated the process by bringing together in one place staff from implementing agencies and AIDSCAP country and regional offices. In so doing, AIDSCAP and its partners were able to write, review, and complete most of the subagreements for each country program in just 2 weeks. The experiences in Tanzania and Honduras are described.

Niger\'s Quality Assurance Project has improved the delivery of primary health care services and facilitated the implementation of decentralization. In the Tahoua region, a multidisciplinary Quality Improvement Team has addressed the problem of child malnutrition by arranging for children to be assessed and treated in the same day by a team of providers. As a result of this intervention, child dropout rates at the health center dropped from 40% to 20%, the nutritional rehabilitation rate rose from 7% to 34%, average counseling time increased from one to five minutes, and the average waiting time was reduced from four hours to 40 minutes. Collaboration between the Tahoua departmental and district health services and the Quality Assurance Project has strengthened the analytical skills and action-oriented decision-making capabilities of district-level staff. On the basis of the Tahoua region\'s successful experience, the Government of Niger is considering the integration of quality assurance measures into broader health sector reform.

This supplement to \"The Family Planning Manager\" presents a case scenario and three discussion questions to amplify the process of clinic decentralization. In this hypothetical situation, the Ministry of Health has announced plans to decentralize management functions, including finances--a step that will require family planning clinics to charge for services and use the fees collected to support clinic operations. It is stressed that, before such a change, the central level must clarify exactly what responsibility, authority, and accountability will be transferred. Unless adequate training and technical support are provided to field staff, services can be disrupted and their quality compromised. Training programs can focus on areas such as preparing demographic projections for a catchment area, setting performance standards, developing procedures for collecting fees and handling cash, reporting income and expenses, analyzing and projecting service costs, preparing budgets, and introducing and managing income-generating projects.

This case study examines the conditions of families and individuals who resettled in Ghana. These Ghanaians (about 7000) had migrated to Liberia in search of a better life many years before, but they left Liberia because of Liberia\'s civil war. Many of these involuntary migrants were in fact Ghanaian \"returnees.\" Many of the migrants who returned were from the fishing village of Senya Beraku. This study includes a brief summary of findings from an evaluation of the Senya Beraku Cooperative Society, a nongovernmental credit organization providing loans to returnee families. Funding was available for loans to 120 families. Repayment rates showed that 80% of women and 60% of men repaid their loans. Refugee board members were accurate in predicting the success of repayment. 95% of loans were repaid by persons predicted to repay, and 40% of loans were repaid among persons considered unlikely to repay. The 75 members of the Cooperative were not considered representative of the 6500 returnee population. There were 7 defaulters and 12 nondefaulters among the interviewed population of Cooperative members. Findings indicate that the timing of loans was a critical issue for investment. Many loans were small and given at the beginning of the dry season when there was little economic activity. Most respondents had little or no formal education, but this appeared to be unrelated to loan performance. Readjustment was a function of many factors, including, for instance, family connections, degree of financial success abroad, and prevailing attitudes toward returnees. Defaulters more frequently reported negative social exchanges on their return. Most returnees were considered failures and suffered from a loss of status due to the forced return from Monrovia. 10 out of 19 experienced the loss of all their property and one or more close relatives. The 9 remaining lost some property and some relatives. More defaulters \"struggled with self-pity and a sense of paralysis.\" All respondents who were members of indigenous African churches were defaulters. A secure belief in God strengthened coping skills. Nondefaulters had more self-confidence in dealing with their situations. Many experienced guilt for a variety of reasons. It is suggested that strategies for reintegration must be long term and supportive of returnees needs.

This case study in Indonesia examined some assumptions about the outcome of family planning services. Safe Motherhood programs were flawed, because of the misplaced emphasis on family planning as a strategy to reduce maternal mortality. Family planning programs reduce the exposure to the risks of child-bearing, but they do not reduce the actual risks. Reproductive health should not be linked so tightly to demographic concerns and family planning. That cost saving occurs from family planning is insufficient to justify inattention to the needs of high quality obstetric care. Family planning should be viewed as just one component of a larger, comprehensive set of measures designed to assure the health of women at all stages in the life cycle: as citizens and workers, as mothers, and as adolescents. Interventions must begin before childbearing and include growth in economic, educational, and health opportunities. The aim of reducing maternal mortality by 50% by the year 2000 was included in Indonesia\'s five-year development plan: Repelita V. The example of Indonesia was important, because of its achievements in reducing poverty and increasing the standard of living of the population, and because of its large population size. Estimated maternal mortality in Indonesia was 450/100,000 live births in 1989, up from 390/100,000 in 1982. There was evidence from other studies that maternal mortality has increased. Criticism has been directed to the misplaced emphasis on family planning and the top-down delivery of professional services for ignoring local health-enhancing practices and the role of families, fathers, and communities as health providers. The realized cost effectiveness of family planning is an abstraction. Fertility has declined with an increase in family planning from 5.6 children to 3.0 children in 1990, but, for example, Bali has both high levels of contraception use and high maternal mortality. Integrated programs and the high risk approach have not been particularly successful.

A case study examines the Nigerian effort to finance their communication industry. The study revealed that except during the period 1981-85, planned public investment in the communication sector has been moderately high at a level of 6.1% of aggregate ex ante expenditure. For the period 1960-80, actual communications expenditure as a ratio of actual total expenditure was lower at an average of 4.5%. Total sector performance measured by the degree of resistance to plan distortions was lower for the communication sector relative to aggregate performance through the 24-period beginning in 1962, except during the 2nd development plan period between 1970-74. The trend in domestic public financing appears to have been dictated by 2 factors: The philosophy of economic planning and the fluctuations in economic fortunes. The oil book of the mid-1970s prompted the largest planned allocation of 9% during the period 1975-80, although realized expenditure fell slightly below to a level of 7.2%. These observed trends show clearly a lack of any strong commitment by the Nigerian government for communication services to meet the needs of a significantly portion of the population, especially those in the rural areas. This situation is not likely to change soon due to the country\'s presently poor economy and the overemphasis by the government on market forces.

Panchdona, about 40 kilometers northwest of Dhaka, the capital city of Bangladesh, has 1 of the highest contraceptive prevalence rates--59.83% against the national rate of 29.7%--and the lowest worm infection rate--52% against the national rate of about 90%. These distinctions were achieved in less than 7 years and are attributed to the community-based Integrated Family Planning, Nutrition and Parasite Control approach adopted on an experimental basis by the Government of Bangladesh from 1980 to 1987. Panchdona is 1 of 4 project areas selected to test the effectiveness of the integrated approach. This paper attempts to describe the measures and activities undertaken by the project to bring about the changes in Panchdona. The Integrated Project was conceived in terms of community participation. It selected as partners for integration with family planning such supporting subjects as parasite control and nutrition which are more concrete and more in tune with people\'s daily life as well as requiring less funding and technology. Some of strategies for the implementation of the project include: 1) implementation of project activities within the potential of an existing family planning organization, 2) enlistment of volunteers for motivational work, 3) creation of organizational mechanisms for involvement of community leaders in project implementation, 4) formation of mothers\' clubs, and 5) providing a vigorous information/education/communication thrust.

The family planning program of the Republic of Korea has been quite successful, yet it has not been able to extend its services to all couples of childbearing age. There still exists a group of couples who want no more children and yet are not currently using any contraceptive method. The word pong-eem which literally means being neglected, i.e. untouched by the family planning program, was coined to describe this group. National surveys have shown that the proportion of women of reproductive age in this group is significant. The study on which this article is based focuses on the psychosocial characteristics of the group to provide policy makers, family planning administrators and workers with the specific information they need in order to reduce its size. Among the factors affecting the family planning decisions of couples is demographic pressure. However, there was no statistically significant relationship between demographic pressure and family planning status. With regard to the couples\' knowledge about contraception, the higher the respondents\' level of knowledge was, the lower was their proportion in the pong-eem group. In both the urban and rural areas, the proportion of women in the pong-eem group was higher among those who disapproved of the Government\'s population policies. The proportion of women in the pong-eem group was much higher among those who were least motivated to limit family size. The lower the level of social support for family planning, the higher was the proportion of women in the pong-eem group in both the urban and rural areas. Among the psychosocial characteristics, social support for family planning was the most closely related to the family planning status of couples no matter what measure of social support was used.

The central question to be addressed when discussing the adequacy and relevance of pharmaceutical action in a country, or in the world generally, is what are the objectives of such pharmaceutical action. The central and overwhelmingly preeminent objective is to restore the health of suffering and sick people. There is consensus among practitioners worldwide that health services in 3rd World countries have followed an urban-centered, hospital-based pattern. The consumption has, therefore, followed a similar pattern. In 1979, the urban hospitals of Thailand, both public and private, accounted for 30% of the total drug consumption, or an estimated US$85 million. The urban population within reach was less than 15% of the total population. The primary health care (PHC) policies adopted at Alma Ata resulted in the establishment of a special PHC unit in 1981 and a number of pharmaceutical studies were undertaken at the time. In 1982, the urban hospitals\' share of drug consumption had slightly decreased. Overconsumption of unnecessary products by urban elites leaves the poor majority underserved and bearing very high levels of morbidity for which no treatment is accessible, despite the availability of drugs in the country as a whole. During 1969-81, there has been a 10-fold increase of the pharmaceutical market.