PSI is leading the effort in Guinea to overcome the effects of generations of pronatalist policies and practices through a successful, comprehensive family planning/HIV prevention program. The Family Planning Options Project (FAMPOP), financed primarily by USAID, involves private sector social marketing, integration of family planning services into public sector "Bamako Initiative" primary health care clinics, and policy and institution building. The program is an integrated endeavor addressing both the immediate need for increased contraceptive use as well as the equally critical longer term need for an effective family planning infrastructure and policy environment. FAMPOP aims to achieve sustainability as a partnership between the private sector and the public sector, uniting such diverse groups as the Government of Guinea, religious leaders, merchants and youth in both the struggle against AIDS and the adoption of child-spacing practices.

Some of the world's highest infant and maternal mortality rates, combined with a poor human resource base and obsolete physical, legal, commercial and public health infrastructure, greeted PSI in 1990 as it launched a pilot condom social marketing project with private funds. The Government of Guinea had recognized these overwhelming deficiencies and became committed to the Bamako Initiative principles of decentralized primary health care and cost recovery. As a result, the government eagerly embraced PSI's proposal to create a partnership between the government, PSI and AGBEF, an indigenous family planning NGO and IPPF affiliate, to make a variety of modern contraceptive methods acceptable, available and affordable to Guineans.

A February 1996 external evaluation of the USAID-financed project, commenting on the success of "so effective a partnership", noted that "PSI provided the engine which, combined with the AGBEF bridge between private and public sectors and the Ministry of Health commitment to family planning in a decentralized integrated health system, made FAMPOP possible."

FAMPOP was conceived as having three separate but mutually reinforcing components, with information, education and motivational behavior change communications activities forming an integral part of all three:

• Social Marketing: private sector social marketing of contraceptives—first condoms and later pills and injectables—for both family planning and STD/AIDS prevention in all major regional and prefectural towns and sub-prefectural towns and villages of the country.

• Public Sector Integration: integration of family planning into Bamako Initiative, public sector, primary health care service centers in two of Guinea's four regions: Upper Guinea and Forest Guinea, and the capital city of Conakry.

• Family Planning Support Activities: enhancement of the climate for family planning and contraception through various educational, institution-building, legal, and policy initiatives specifically designed to complement and fill in the gaps in the ongoing efforts of the government, UNFPA and others.

Before PSI arrived in Guinea, fewer than 200,000 condoms per year were distributed nationwide, and the contraceptive prevalence rate was less than 2%. In 1995, FAMPOP social marketed over 2.8 million condoms—14 times the 1990 level. When coupled with the public sector integration program, total FAMPOP CYPs exceeded 46,000—equivalent to approximately 2.8% contraceptive prevalence due solely to the project, and representing over 60% of total country contraceptive prevalence.

Social Marketing
The social marketing program for condoms (PRUDENCE plus) has matured to a nearly cash only, demand driven, private sector delivery system. Condoms flow through a network of more than 3,500 retail outlets including official pharmacies, kiosks, bars, nightclubs, and hotels. The marketing mix was expanded in late 1995 to include oral contraceptives (PLANYL) and injectables (Depo Provera). PSI Guinea sales staff operate out of Conakry and three regional offices to assist with the arduous process of maintaining linkages between retail outlets and effective wholesalers and distributors in a nascent economy.

Well over 500,000 people have been informed about family planning issues and AIDS prevention through a combination of mass media advertising (TV; national and rural radio) and interpersonal communications (theater, events, seminars). These efforts as well as heavy point-of-purchase and trade promotions, have resulted in 80% brand awareness of PRUDENCE plus.

PSI has also actively cultivated the support of Islamic religious leaders through a series of seminars. Not only have the leaders removed barriers to cultural acceptance of family planning and AIDS prevention, they have used their positions actively to educate their congregations.

The social marketing program targets men and women of reproductive age as well as those at high risk of contracting HIV. All social marketing contraceptives are priced to allow a full year of protection for less than 1% of per-capita GNP. For example, PRUDENCE plus condoms are priced at 50 Guinean francs per two-pack (2.5 U.S. cents a piece), making high quality condoms accessible to the majority of Guineans.

Public Sector Integration
PSI has worked with the Maternal Child Health and Family Planning unit of the Guinean Ministry of Health and AGBEF to develop and implement the national plan for integrating family planning services and products into the budding network of primary health care centers spreading across Guinea through UNICEF, World Bank and other donor support. Following Bamako Initiative principles of decentralized management and cost recovery, these health centers have become the only health facilities accessible to the majority of Guineans. The Public Sector integration program enables health centers to deliver five types of contraceptives, including IUD insertions and removals at some facilities, with consultation and products available to rural people, for about $2.40 per person per year. At the end of 1995, FAMPOP had integrated family planning and STD/AIDS prevention into 93 health centers and 13 hospital maternities in the two regions of the project area. These facilities have each received a starter kit comprised of contraceptives, family-planning related medical instruments, a moped for rural media campaigns, and a $25 per month operating subsidy limited to two years. In addition, over 500 health professionals (MDs, midwives, nurses, supervisors, health agents) have been trained intensively in contraceptive technology, STD/AIDS prevention, communications techniques, management of family planning services, supervision, monitoring and reporting. PSI organizes and carries out a regular program of supervisory visits and retraining activities in order to assure continued high quality of care.

Intensive communications outreach in the form of rural radio listeners clubs and family planning volunteer groups as well as local theater, seminars and special events contributed to a 70% increase in family planning contacts during 1995 as well as a 55% increase in new family planning acceptors served by integrated health centers. Behavior change communications outreach activities are conceived and implemented by a team of 15 AGBEF health promoters stationed throughout the project area and supervised by PSI/Guinea communications staff.

A community-based distribution (CBD) pilot project was started during 1995 in conjunction with several of the more advanced health centers. Fifty community-based agents organize awareness meetings, sell condoms and spermicides, and refer consumers to health centers for other methods. At these rates of increase, many of the initial health centers are already in a position to cover all family planning services delivery costs through family planning fees, showing that the Public Sector Integration Program promises to be both effective and sustainable.

Family Planning Support Activities
FAMPOP was designed to address key policy and institutional constraints in addition to delivering family planning services. Several discrete activities have demonstrated considerable progress. For example, PSI collaborated with the government and UNFPA to help produce a well-articulated Population Policy, representing a broad consensus of decision makers and various population groups and officially sanctioning family planning programs for the first time in the country's history. PSI funded and worked with AGBEF to produce a Family Code, recommending legislation addressing such topics as child spacing, responsible parenthood, women's rights, marriage age and other key social concerns. Working with JHPIEGO, a series of institution-building programs have been undertaken to introduce reproductive health curricula into the University of Conakry Faculty of Medicine and four national health schools. PSI coordinated and co-financed the efforts of the Ministry of Plan, UNFPA, and Macro/IRD to produce Guinea's first Demographic and Health Survey as the project's baseline data.

FAMPOP also financed a series of informational seminars held nationwide by the National AIDS Control Program aimed at key decision makers and high risk target groups such as commercial sex workers, hotel and bar owners, transport workers and medical professionals. These and other activities have produced the context in which a country in the emerging state of family planning program development can provide meaningful and sustainable family planning services to its population.

Management for a Sustainable Partnership
PSI Guinea's 50 local employees have benefited from extensive training, involving travel to other countries, and are widely recognized as forming the most effective family planning delivery organization in the country. Efforts are under way to incorporate the project as a local NGO, which, in partnership with PSI, will be capable of continuing the supervision of the public sector integration program as well as assisting the private sector to implement the social marketing program as the Guinean economy matures.

More than $11 million has been invested in the four and-a-half year old program, the first such investment in Guinea's population programs. According to the February 1996 external evaluation, "when trying to jumpstart an ambitious program in a difficult environment, an excessive preoccupation with sustainability can often be a deterrent to progress in the near term. With a project as large and complex as FAMPOP, it is important not to short change the up front investment needed to get things really rolling. Otherwise it might not develop to a point that makes it worth sustaining."

The ambitious goal of the FAMPOP partnership is to reverse the effects of history and establish a stable population growth rate while heading off the escalating AIDS epidemic. Given the time constraints, lack of complementary family planning infrastructure, and the socio-economic context, it is remarkable that so much progress has been made at any cost. This is due to the good faith efforts and commitment on the part of all of the Family Planning Options Project partners.

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