NGOs, social marketing programs, and private providers already have a major role in family planning in many countries, especially in Latin America and Africa, where government programs are new or weak. There is little association on a cross-national basis between the share of a country's health care expenditures financed privately and the proportion of contraceptives supplied privately, Bulatao noted. The portion of private-sector provision varies across methods as well as over time and among countries. Pills are commonly purchased from private-sector or commercial providers, whereas sterilizations tend to be provided by the public sector in Asia.
Private-sector providers may have advantages over public organizations in both efficiency and responsiveness to client's needs, making possible some accommodation to concerns for cost reduction and greater quality of care. Bulatao noted three broad ways in which private-sector provision of services makes sense: (1) in getting family planning started, (2) in providing services for which small or nonpublic organizations have a comparative advantage, and (3) when there are constraints on public-sector budgets or staff size. Public- and private-sector providers can coexist for years, specializing in different services to different populations. As private-sector provision of services increases in many countries, the role of the public sector could be strengthened in regulation, quality assurance, management of remaining subsidies, and provision of public information.
Even in countries like Thailand, where there is a pervasive and heavily subsidized public-sector program, commercial outlets are important sources of contraceptive supplies and services, especially for users who value convenience and choice. The potential, and even the existence, of the commercial sector is often ignored by decision makers in the public sector. Bulatao (1993: 68), for example, documented a joint effort of a state government and an NGO to expand availability of contraceptive pills in Piaui state in northeast Brazil; the main effect of the subsidized program appeared to have been to lure away the existing customers of pharmacies, most of which ceased marketing contraceptives.
MEASURING COSTS AGAINST OUTCOMES
Just as a full range of costs needs to be considered for strategic decisions about resource allocation, so must a full range of program objectives. Dispensing pills, with no information and advice, through pharmacies might appear to be cost-effective if judged by a simple calculation of cost per couple-year (CYP) but ineffective in a calculation that includes quality standards for the process or informed choice as an outcome measure. Demedicalization of services may often be worthwhile, but some valued outcomes could suffer. There was general dissatisfaction with CYP, at least as a sole criterion for cost-effectiveness, but some such indicators are needed to make comparisons across very different types of service and contraceptive methods. Such simple measures have their uses, and one question that has emerged from the 1994 Cairo conference is what are the
