On-line version ISSN 1680-5348
Print version ISSN 1020-4989
Rev Panam Salud Publica vol.29 n.5 Washington May. 2011
ORIGINAL RESEARCH INVESTIGACIÓN ORIGINAL
Stakeholder perceptions of a total market approach to family planning in Nicaragua
Percepciones de grupos interesados sobre la aplicación de un enfoque de mercado total a la planificación familiar en Nicaragua
Jennifer Kidwell Drake; Henry Espinoza; Chutima Suraratdecha; Yann Lacayo; Bonnie M. Keith; Janet G. Vail
PATH, Seattle, Washington, United States of America. Send correspondence to: Jennifer Kid-well Drake, firstname.lastname@example.org
OBJECTIVE: To assess private-sector stakeholders' and donors' perceptions of a total market approach (TMA) to family planning in Nicaragua in the context of decreased funding; to build evidence for potential strategies and mechanisms for TMA implementation (including publicprivate partnerships (PPPs)); and to identify information gaps and future priorities for related research and advocacy.
METHODS: A descriptive exploratory study was conducted in various locations in Nicaragua from March to April 2010. A total of 24 key private-sector stakeholders and donors were interviewed and their responses analyzed using two questionnaires and a stakeholder analysis tool (PolicyMakerTM software).
RESULTS: All survey participants supported a TMA, and publicprivate collaboration, in family planning in Nicaragua. Based on the survey responses, opportunities for further developing PPPs for family planning include building on and expanding existing governmental frameworks, such as Nicaragua's current coordination mechanism for contraceptive security. Obstacles include the lack of ongoing government engagement with the commercial (for-profit) sector and confusion about regulations for its involvement in family planning. Strategies for strengthening existing PPPs include establishing a coordination mechanism specifically for the commercial sector and collecting and disseminating evidence supporting publicprivate collaboration in family planning.
CONCLUSIONS: There was no formal or absolute opposition to a TMA or PPPs in family planning in Nicaragua among a group of diverse nongovernmental stakeholders and donors. This type of study can help identify strategies to mobilize existing and potential advocates in achieving articulated policy goals, including diversification of funding sources for family planning to achieve contraceptive security.
Key words: Family planning services; health policy; public-private sector partnerships; Nicaragua.
OBJETIVO: Evaluar las percepciones de los grupos interesados y de los donantes del sector privado sobre la aplicación de un enfoque de mercado total a la planificación familiar en Nicaragua en el contexto de una reducción del financiamiento; establecer datos científicos que avalen posibles estrategias y mecanismos para ejecutar este tipo de enfoque (lo que incluye alianzas entre los sectores público y privado); y determinar las brechas de información y las prioridades futuras en la investigación y la promoción de este enfoque.
MÉTODOS: Entre marzo y abril del 2010 se llevó a cabo un estudio exploratorio descriptivo en varios lugares de Nicaragua. Se entrevistaron 24 personas de varios grupos interesados y de donantes clave del sector privado y se analizaron sus respuestas mediante dos cuestionarios y una herramienta de análisis específica (programa informático PolicyMakerTM).
RESULTADOS: Todos los encuestados respaldaron la aplicación de un enfoque de mercado total y la colaboración entre los sectores público y privado respecto de la planificación familiar en Nicaragua. Según las respuestas obtenidas en la encuesta, las oportunidades para desarrollar alianzas adicionales entre los dos sectores respecto de la planificación familiar incluyen mejorar y ampliar los marcos gubernamentales existentes, como el actual mecanismo de coordinación de Nicaragua para la seguridad anticonceptiva. Los obstáculos son la falta de colaboración actual del gobierno con el sector comercial (con fines de lucro) y la confusión acerca de la reglamentación para participar en la planificación familiar. Las estrategias para fortalecer las alianzas existentes entre los sectores público y privado comprenden el establecimiento de un mecanismo de coordinación específico para el sector comercial, y la recolección y difusión de datos que avalen la colaboración entre los dos sectores respecto de la planificación familiar.
CONCLUSIONES: En la evaluación de varios grupos interesados y de donantes del sector no gubernamental no se encontró ninguna oposición formal o absoluta a un enfoque de mercado total o a la conformación de alianzas entre los sectores público y privado respecto de la planificación familiar en Nicaragua. Este tipo de estudio puede ayudar a identificar estrategias que motiven a los promotores de la causa actuales y potenciales a alcanzar las metas políticas enunciadas, lo que incluye la diversificación de las fuentes de financiamiento para la planificación familiar a fin de alcanzar la seguridad anticonceptiva.
Palabras clave: Servicios de planificación familiar; política de salud; asociación entre el sector público-privado; Nicaragua.
Global family planning programs were strongly influenced by the "health for all" movement of the 1970s. As a result, many national programs have supplied free contraception to all segments of their populations. The public sector is still the primary provider of family planning in many countries, especially low-income countries in sub-Saharan Africa and Asia (13). In other regions, especially Latin America, and in many middle-income countries elsewhere in the world, that scenario is changing rapidly as donors phase out their support for family planning and governments find that the needs of their entire populations cannot be met solely through public-sector programs (49).
A total market approach (TMA) (also known as a whole market approach) can ease the burden on public entities by enabling coordination with private entities (social marketing groups, nongovernmental organizations (NGOs), and commercial organizations) so that each sector can target different segments of the population. In many places, consumers already choose family planning services best suited to their needs and ability and/or willingness to pay; health sectors can respond to client behavior and allocate their resources in a more sustainable and equitable way through the use of a TMA. Within the realm of reproductive health, a TMA can help achieve contraceptive security, defined as a situation in which people are able to choose, obtain, and use high-quality contraceptives and condoms whenever they want them (10, 11).
A successful TMA requires public private collaboration, a national policy environment conducive to private-sector involvement, and public-sector commitment to effective, equitable programming. This might include involving the private sector in centralized and coordinated planning, decision-making, and resource allocations; creating incentives to attract private-sector participation; and eliminating political and regulatory barriers to private-sector participation. Within the context of family planning, this means that rather than acting as the sole provider of contraception, governments should assume the dual role of serving some consumers directly through the public sector while simultaneously investing in and advocating for engagement by other sectors (12).1
Despite the existence of various frameworks for this type of collaboration, communication and coordination between the public and nonpublic health sectors is rare in practice. In some cases the government does not acknowledge the existence of the private sector or consider its impact when prioritizing public family planning interventions. An analysis of family planning in Cambodia, Nigeria, Uganda, and Zambia found that despite the fact that a relatively significant proportion of the population in those countries uses private-sector services, open government acknowledgment of the private sector's role in family planning tends to be limited (12). Governments often lack basic information about the size of the private sector's consumer base, the range of reproductive health needs and preferences that each sector serves, and the ability or willingness of different consumer groups to pay for family planning (11, 14).
Nicaragua is currently facing significant challenges to contraceptive security because the dominant donors of contraceptive suppliesthe United States Agency for International Development (USAID) and the United Nations Population Fund (UNFPA)plan to end their family planning support in 2012. According to demographic survey data, 70% of women in Nicaragua were using modern contraception in 2007 (15). The government is the main provider of family planning services, with two-thirds of users receiving modern contraceptive methods free of charge from the public sector.2 Approximately 28% of Nicaraguans access their contraceptive methods through the private sector, which includes NGOs; social marketing groups; and commercial (for-profit) providers such as private hospitals, clinics, and pharmacies. A smaller number of people (currently 4%) access family planning services through the provider network of the Nicaraguan Social Security Institute (Instituto Nicaragüense de Seguridad Social, INSS). The adolescent fertility rate in Nicaragua is the highest in Latin America, and unmet need, while relatively low at 11%, remains a concern, especially for adolescents and low-income women (15).
There is strong, documented political support for family planning in Nicaragua, including such policies as the National Development Plan (2005), the National Health Plan (20042015), and the National Strategy for Sexual and Reproductive Health (2008) (16). Various steps have been taken by government leaders in collaboration with diverse stakeholders to prepare for the elimination of funding from USAID and UNFPA. For example, the provision of family planning services through the INSS in both public and private health facilities is being expanded and strengthened (16). In addition, the nongovernmental Pan American Social Marketing Organization (PASMO) is currently working with the Nicaraguan government to increase the use of socially marketed intrauterine devices (IUDs) in public and NGO health facilities. The Nicaraguan government has also worked with UNFPA and the USAID DELIVER project to establish a contraceptive security strategy. A committee on contraceptive security (Disponibilidad Asegurada de Insumos Anticonceptivos, or DAIA Committee) was formed in 2003 and is now in its second phase of strategic planning. Objectives of the Committee's 20092011 strategic plan include increasing access to family planning services and ensuring the availability of funding for contraceptives in both public and private institutions. Long-standing members of the Committee include representatives from the Nicaraguan Ministry of Health (MINSA); the INSS; PASMO; Profamilia (the national affiliate of the International Planned Parenthood Federation); UNFPA; and USAID and its DELIVER project. A 2007 study of the Committee by the USAID Health Policy Initiative (HPI) found that some members felt that membership should include a wider range of stakeholders (including officials from additional government agencies and more representatives from pharmaceutical distributors, donors, and other NGOs) (17).
Social security providers, NGOs, pharmacies, and private clinics present diverse opportunities for increasing contraceptive security through private-sector provision during the current period of transition in family planning funding in Nicaragua. Government engagement with the private sector, however, remains a challenge. The Seattle-based NGO PATH is working on a multiyear project with MINSA and other key stakeholders to identify and clearly define these opportunities and challenges and to develop concrete program actionsincluding strengthening and diversifying publicprivate stakeholder engagementto advance contraceptive security. The authors of the current study aimed to assess private-sector stakeholders' and donors' perceptions of a total market approach to family planning in Nicaragua and current and potential mechanisms for TMA implementation (including PPPs), and to identify information gaps as well as priorities for future research and advocacy. This article sheds light on the results of the assessment, with a focus on PPPs.
MATERIALS AND METHODS
This study received exempt review status from PATH's Research Ethics Committee, under Category 2 of the criterion specified in the United States Code of Federal Regulations 45 CFR 46.101 (i.e., the survey/interview procedures qualified as not enabling information obtained to be linked directly to human subjects, and not reasonably placing the subjects at risk). The study team utilized PolicyMaker version 4 (Polimap, Brookline, MA, USA), a software program that 1) systematically analyzes key players' positions of support and opposition with regard to a specific policy and what they perceive as policy-related opportunities or obstacles, and 2) assists in designing strategies for managing the politics of policy reform (18). The team also examined and compared communication within family planning service provider and policy-maker networks in Nicaragua.
Two questionnaires were used to collect information from the survey participants. Questionnaire 1 was a semi-structured survey designed to identify individuals and organizations influential in policy-making, financing, and the provision of technical resources for family planning in Nicaragua. Survey participants were selected according to specific criteria (described below), provided with a list of organizations considered influential in family planning in Nicaragua (identified through a literature review and informational meetings), and asked to provide information on the types and frequency of their interaction with each organization on the study team's list of stakeholders, as well as any organizations that were not on the list. The list included stakeholders beyond the range of those selected to participate in the survey (e.g., several government agencies on the stakeholder list were not part of the study sample). Questionnaire 2 was a structured survey on respondents' perceptions of 1) Nicaragua's national family planning program, and 2) a hypothetical TMA. The survey questions covered the current family planning program, policies, and strategies; access, quality, and sustainability of the family planning program; factors that facilitate or hinder the success of public- and private-sector family planning; challenges and perceived benefits of a TMA; roles, responsibilities, and capacity of the public sector in establishing coordination mechanisms and implementing a TMA; and potential interventions to enhance access to and the quality and sustainability of family planning services.
The study sample included representatives of organizations that participated in Nicaragua's family planning market and/or family planning policy development (including NGOs with previous or current work relevant to family planning). Because the study team's government partners had expressed a desire to focus on the private sector, no national or local public-sector stakeholders (other than donors) were included. The government partners had also requested that NGOs, medium-size distributors of family planning products, social marketing groups, and small pharmacies be included in the survey, given the limited knowledge about these types of stakeholders. Large distributors and wholesalers were excluded from the study due to their limited previous involvement in initiatives focused on improvements or changes to service delivery. Interviews were conducted during March and April of 2010 by two Nicaraguan consultants specially trained by the study team in administration of the questionnaires and various interview methodologies. Interviews were conducted in the interviewees' native language, which was generally Spanish.
Frequency and contingency tables were generated in Excel version 5.0 (Microsoft, Redmond, WA, USA) and SPSS® version XI (SPSS, Chicago, IL, USA) using data from both questionnaires. Principal policy goals developed by the study team prior to the interviews were added to the PolicyMaker database to define the policy content to be analyzed (Table 1). Upon completion of the interviews, based on previous knowledge as well as questionnaire responses and interview notes, the study team and consultant interviewers compiled and entered information about each survey respondent, including their level of power (amount of influence on whether defined policies are adopted or implemented), which was classified as "low," "medium," or "high"; position (level of support or opposition); and perceived opportunities and obstacles to achieving the stated policy goals. A player with a high level of power generally has substantial but not complete influence over a policy outcome while a player with a low level of power is relatively powerless but still has potential influence (18). Level of power was informed by survey participants' responses to Questionnaire 1 about key stakeholders in family planning. Level of support or opposition ("position") was based at least in part on survey participants' responses to Questionnaire 2 regarding challenges and key benefits of a TMA. Potential strategies for achieving the policy goals by working with the key players were identified based on study team analysis and discussion. Analysis of the data, which were entered into the PolicyMaker database in English, was an iterative process, with the study team reviewing and updating the information as the research discussions progressed.
The study team conducted interviews with 24 individuals from five categories of stakeholders: private commercial providers (4 representatives); academic researchers (2 representatives); donor/ technical agencies (7 representatives); NGO providers (8 representatives), and private distributors (3 representatives). To maintain confidentiality, survey respondent data are presented by category (e.g., "Donor/technical agency #1," "Private commercial provider #2") rather than individual or organization name, and at least two representatives were interviewed for each category.
Responses to Questionnaire 1 identified important stakeholders in family planning programming in Nicaragua (Figure 1). All of the stakeholders mentioned most frequently were included in the study team's initial list of stakeholder organizations. Other key stakeholders (not on the study team's list) emerged in data collection but were mentioned less frequently. These included religious and media groups. Not surprisingly, the results of Questionnaire 1 underscored the importance of government as the most prominent stakeholder, with MINSA identified most frequently as being in a position to "make decisions or bring about changes in family planning service provision." Respondents also reported frequent interaction with government at the departmental level, where health care is provided and managed by 17 local health systems (Sistemas Locales de Atencion Integral en Salud, SILAIS) (one for each department or region).
The most frequently cited stakeholder overall was UNFPA, identified as a "financer of family planning" (58% of respondents); "directly influencing decision-makers on family planning" (46% of respondents); and "supporting, reinforcing, and strengthening recommendations on family planning" (42% of respondents).
Three NGOs3 emerged in the responses as decision-makers or influential actors more frequently than expected, given that they were not yet DAIA Committee members: IXCHEN, an NGO providing women with affordable education, health, and legal services; the Luisa Amanda Espinoza Association of Nicaraguan Women (Asociacíon de Mujeres Nicaragüenses "Luisa Amanda Espinoza," AMNLAE), a participatory women's human rights group; and Puntos de Encuentro ("Meeting Points"), an NGO that uses communication for social change. Two NGO DAIA Committee members were especially prominent in survey participants' responses: PASMO (identified as an organization with which they "coordinated and collaborated") and Profamilia (identified as an organization from which they "sought technical support"). Profamilia was also the second-most cited organization (after MINSA) deemed able to "make decisions or bring about changes in family planning."
Power and position
The policy content used for the Policy-Maker analysis is presented in Table 1. The study team collectively inferred the 24 survey participants' power and position relative to the stated policy content. Most donor/technical agencies and two NGO providers were characterized as having high power, and all high-power organizations were classified as highly supportive. Eleven other respondents (including all commercial providers) were classified as highly supportive of the policy content but having a lower level of power. Only one respondent (a technical agency) was classified as having a neutral position.
Only one respondent felt that PPPs would not create equitable and sustainable access to family planning (Figure 2). All respondents agreed (and most agreed strongly) that a TMA would improve access to and the quality and sustainability of family planning programs among low-income populations in Nicaragua.
Opportunities and obstacles
Opportunities and obstacles to achieving the stated policy goals were identified through analysis of responses to Questionnaire 2. The opportunity articulated most clearly by survey respondents was maintaining the contraceptive security coordination mechanism comprising relevant stakeholders (i.e., the DAIA Committee). Many responses emphasized the need to expand the scope of the Committee to include perspectives from a broader range of private-sector groups. More specifically, several survey participants mentioned the need for all sectors (public, NGO, commercial) to identify their targeted market segments or populations of responsibility and coordinate more effectively (Figure 2). This need was emphasized by representatives of academic and research organizations, NGO providers, private commercial providers, and donor/technical agencies.
In addition, academic researchers and NGO providers emphasized that media and advocacy groups could be mobilized to support a TMA. Along with private commercial providers, they also stressed that engagement with the private sector could be linked with the current overarching paradigm for MINSA, known as the Conceptual Model of Family and Community Health (Marco Conceptual del Modelo de Salud Familiar y Comunitario, MOSAFC). The MOSAFC conceptual framework calls for an integrated system of health care to reach the entire population. Ideally, service providers (both public and private) would be organized into networks to provide care to specific populations of responsibility, as determined by Nicaragua's General Law on Health (No. 423).Another opportunity identified in the analysiscited by representatives from all five stakeholder survey groups as widely recognized by key players in Nicaragua, including governmentwas diversification of product and service provision (to improve access) and of family planning financing mechanisms (to mitigate the effects of funding withdrawal by traditional donors).
Survey participants also cited many obstacles to achieving family planning policy goals. Most respondents, including at least one from each of the five stakeholder categories, said the government did not usually engage with and has no links with the commercial sector. NGO providers, commercial providers, and private distributors were not aware of any laws or regulations that enabled private-sector participation and saw their absence as an obstacle. Academic researchers, on the other hand, were aware of these regulations. Respondents from a range of stakeholder categories felt that neither a TMA nor engagement with the commercial sector was consistent with the national health policy.
The PolicyMaker tool includes a set of suggested strategies for capturing opportunities and addressing obstacles, based in part on identifying and leveraging the positions and levels of power of specific stakeholders. The study team selected and adapted three of these strategies (listed below in bold) to achieve the stated family planning policy goals (Table 1):
1. Link policy change or connect supporters of policy change with established and widely accepted policy frameworks. Specifically, link the principles of private-sector engagement and the TMA to the MOSAFC framework to help build a case for government engagement with the private sector.
2. Provide tools and evidence to supporters, including technical and political information. The PolicyMaker analysis identified several organizations in Nicaraguaparticularly private commercial providers, some NGOs, and academic research groupsas being highly supportive of stated policy goals (Table 1) but having a low level of power. Providing those organizations with tools and evidence, including information and awareness regarding regulations and legislation on private-sector participation, might help increase their ability to credibly engage with government stakeholders.
3. Create a new organization, coalition, or partnership of existing organizations. Given the clearly articulated need for coordination with the private sector, especially the commercial sector, another potential strategy will be to create a coalition or working group of private, for-profit groups that can link with government, particularly the DAIA Committee. This strategy will include defining the role of commercial stakeholders in family planning as well as their contribution to national family planning goals; defining commercial markets, client populations, and obstacles; supporting commercial stakeholders' procurement channels; and helping to facilitate links between the private sector and government at the SILAIS level.
The current study provided evidence that there is no formal or absolute opposition to the concept of PPPs in family planning from the perspective of diverse family planning organizations. It also helped the study team focus on strategies to 1) mobilize potentially powerful advocates to achieve the articulated policy goals, and 2) increase the power of stakeholders who are already supportive.
Private-sector participation in family planning. The current membership of the DAIA Committee in Nicaragua does not include any commercial sector providers or distributors, and there is no other mechanism or organization through which these groups convene. Initiating a coordination mechanism organized around their shared interests may be a first step in addressing their isolation by providing a means for government to reach out to the commercial sector, and increasing their power as a group. The survey results highlighting the importance of engagement with MINSA at the SILAIS level suggest the possibility of beginning coordination work on the scale of one or two departments before tackling this challenge at a national level.
The fact that the DAIA Committee already includes NGO stakeholders provides a platform on which to build stronger engagement with the private sector, including commercial entities. Prominent NGOs such as Profamilia and PASMO, who have close ties with the government and are perceived as powerful in family planning, may also be key allies in helping to make these connections. INSS is another potential link, having been described as a "natural bridge" between the public and private sectors (16).
This research has helped to create a more complete picture of private NGO providers. Shortly after the results of the analysis were shared with the DAIA Committee, the three NGOs that had emerged as influential stakeholders in the survey results were invited to join the group. Visual representations of family planning stakeholders as represented in Figure 1 may also give MINSA and other key actors a broader view of potential networks and alliances.
Equitable access to family planning services and products. This research helped highlight the MOSAFC policy as an important mechanism for furthering the use of PPPs and a TMA in family planning. As noted by survey participants, the MOSAFC specifically states that different sectors should work together to reach different populations. Organizations who already have an awareness and understanding of this framework and how it relates to PPPs can be important allies in helping to make those links for other stakeholders, including those in government, who may be initially resistant to the idea of working with the commercial sector or segmenting the market. For example, they may play a key role in supporting the DAIA Committee, in coordination with a potential commercial-sector working group, to map different types of providers to their populations of responsibility. Achieving this policy goal will also require addressing the perception that enabling the private sector to serve targeted population segments is incompatible with the government's mandate to ensure health for all of its citizens.
The reality is that nonpoor populations tend to benefit disproportionately from free and subsidized services, so shifting users with an ability to pay to the private sector has the potential to free up scarce public-sector resources for vulnerable populations (19). This approach may help to address the current disparity in fertility and contraceptive prevalence in Nicaragua, where the poorest women average 4.5 children apiece, and less than two-thirds use modern contraceptives, while the wealthiest women average less than 2 children apiece and nearly three-fourths use modern contraceptives (15). In fact, global work within the DELIVER project has established a direct correlation between the public sector's success in reaching the poor, improved equity in contraceptive use, and higher overall contraceptive prevalence (11). Given the overall disparity in unmet need for family planning between the poor and nonpoor throughout Latin America (20), and the widespread withdrawal of donor support, these findings should be carefully considered in regional policy-making.
Government stewardship of the total family planning market. The current research helped clarify that regulations and legislation regarding the role of the private sector in family planning do exist in Nicaragua, and pointed to specific opportunities to work with stakeholders who are familiar with these policies and encourage them to disseminate relevant information to those who are not. For example, based on the current analysis, many NGO stakeholders recognize a role for government as a steward of the private sector (Figure 2) and would likely welcome government leadership and coordination. Since the public sector was not included in the current analysis, it is not known whether government stakeholders are aware of this perception. In any case, use of the PolicyMaker software enabled the study team to illustrate and convey the support of the private sector for this goal in an innovative way.
Diversification for family planning financial sustainability. Based on the current analysis, stakeholders recognize the limitations of government financing for family planning. This is a promising first step, as no specific efforts will be required to convince them of the need to diversify funding sources. On the other hand, no relevant opportunities, obstacles, or strategies emerged from the data in terms of how to approach developing a specific financial resource plan that includes private-sector participation. It may be that the other policy goals will serve as better starting points and additional opportunities may emerge as coordination and collaboration between sectors is strengthened. One priority that did not emerge from this analysis but has been mentioned elsewhere is involving the Ministry of Economy on the DAIA Committee to help safeguard expenditures for contraceptives in the national budgeting process (16); however, that Ministry's specific position on PPPs for family planning is not known at this time, nor was it explicit in these analyses.
This analysis has several limitations. First, data entry and analysis in Policy-Maker is open-ended and subjective, increasing the likelihood that the strategies developed might be flawed due to the potential biases and misperceptions of those participating in data entry. Conducting direct interviews with representatives of the stakeholder organizations versus simply applying the stakeholder analysis tool should have helped to reduce the likelihood of this type of skewed data. An additional limitation is that the information collected through interviews presents only a "snapshot" perspective; survey respondents' power and position can shift over time, creating new opportunities and obstacles that may require revised strategies. To mitigate the effect of this limitation the study team must remain engaged with a diverse group of stakeholders as the work moves forward. To date, the authors of the current study have not had the opportunity to formally assess the impact of their analysis and whether it was effective in helping to achieve the objectives of strengthening and diversifying private-sector stakeholder engagement for contraceptive security. A final study limitation is the fact that the authors focused on the perspectives of private-sector organizations and donors, limiting their capacity to assess the larger network of family planning stakeholders in Nicaragua.
Overall, the methodology used in this analysis proved to be an effective means of formally engaging with a range of stakeholders at the outset of a policy assessment process. The PolicyMaker program was particularly helpful in analyzing and subsequently describing a policy environment in terms of specific stakeholder categories. For example, it requires users to state their assumptions about different stakeholders vis-à-vis specific policy positions in an explicit and systematic way. The authors of the current study are not aware of a similar step-by-step approach to stakeholder analysis. The use of PolicyMaker helped the researchers develop specific approaches to engaging key stakeholder groups, as has been documented elsewhere (2123).
The PATH stakeholder analysis of private-sector stakeholders' and donors' perceptions of a family planning TMA in Nicaragua was part of an overall effort to help strengthen and diversify engagement between public and private sectors in this area of public health and thus create potential financing alternatives to achieve national contraceptive security. Specifically, the authors aimed to identify 1) mechanisms for TMA implementation, 2) relationships and perceptions among private-sector stakeholders, and 3) strategies to guide and strengthen PPPs in family planning in Nicaragua. The study results indicated strong stakeholder support for the TMA concept in general and PPPs in particular, but limited current engagement between the public and private sectors. The authors were able to identify specific strategies for advancing PPPs and the TMA concept, including promoting the participation of the private sector in family planning through a commercial-sector working group and expansion of DAIA Committee membership. It was challenging to identify more specific strategies at this level of analysis, including developing shared financial resource plans between sectors, mapping different sectors of providers to their perceived populations of responsibility, and/or shifting users with an ability to pay to the private sector. These challenges are at the forefront for MINSA, the DAIA Committee, and other family planning stakeholders in Nicaragua and are also relevant to other countries in Latin America. The authors hope that their approach to increasing communication and strengthening partnership among the various sectors involved in family planning will enable movement on these critical next steps and provide a model starting point for other countries.
Acknowledgments. This research and related work in Nicaragua and Vietnam were funded by a grant from The Fred H. Bixby Foundation. The authors wish to express thanks to the colleagues, research partners, and survey participants who contributed to the study in Nicaragua.
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Manuscript received on 1 October 2010.
Revised version accepted for publication on 8 February 2011.
1. This latter function has also been described as stewardship ("setting and enforcing the rules and incentives that define the environment and guide the behaviors of health-system players" (13)).
2. Quesada N. Nicaragua: contraceptive market segmentation analysis and georeference tools used to identify gaps in FP services. Presentation to the Ministry of Health of Nicaragua, August 13, 2009. Arlington, VA: U.S Agency for International Development | DELIVER.
3. These three NGOs were included on the study team's initial stakeholder list for Questionnaire 1.