Research shows, however, that most people, even those who cannot afford the full costs of contraception, are willing to pay something for family planning services that meet their needs (100). Even when free services are available, some prefer to purchase services because they associate price with quality, because they mistrust the motivation behind the offer of free services, or because of convenience (100, 173 ). Although sometimes small, commercial markets for contraceptives exist in virtually all countries. In some countries contraceptives also are sold by retail outlets at subsidized prices through social marketing programs (see Lesson 2, Access).

The Indonesian national family planning program has demonstrated that, as more people use contraception, the private sector can play a greater role in supplying it. In 1987 the KB Mandiri (self-reliant family planning) program was begun in order to increase the number of contraceptive users who buy their services from private-sector providers. The government's "Blue Circle" campaign has promoted the services of private-sector family planning providers, identified with a blue circle logo, and has supplied them with contraceptives so that users have to pay only for services (65). Within four years after the start of the KB Mandiri program, more than 8,000 "Blue Circle" midwives and physicians were providing family planning services in urban centers throughout the country (142). The percentage of users who receive their services from private sources rose from 12% in 1987 to 22% in 1991. Also, the percentage of contraceptive users who pay some fee for their services rose from 36% to 62%, although often the fee paid is a fraction of the full cost of contraceptive supplies and services (34).

Concerned about the rising cost of paying for family planning, some donor agencies are calling for developing countries to make their programs more self-sustaining. If donor aid declines, however, government subsidies must rise, or more of the responsibility for providing health and family planning services must shift to private health care practitioners and commercial outlets, and consumers must bear more of the cost (130). Such shifts could decrease access to contraceptive information and services and mean poorer services for millions of people. In the quest for sustainability, advises Miguel Trias of Colombia's Profamilia, "the need for substantial donor help for the beginners should not be forgotten" (263).

Some countries where contraceptive use is already widespread may be able to shift more of family planning costs to users without reducing use, but countries where the demand for contraception still is rising rapidly must depend on public support. Even where contraceptive use is widespread, family planning programs, not the commercial marketplace, make it possible for most couples to practice family planning. Even in countries with strong economies, many people lack access to the cash economy and thus cannot purchase family planning services. Women, who are the vast majority of family planning clients, often lack their own financial resources, have restricted access to household money, or have little say in household spending decisions.

For family planning to become more widely available, governments must continue their commitment to provide free or subsidized family planning services for those who need them. Many agree that governments and donors must continue to provide most of the funding for family planning programs in the 1990s (21 , 80, 186, 226, 229, 231, 257, 331).