Stages of program development. Despite different settings, most family planning programs pass through similar phases. As programs have developed, successful leaders have adjusted their strategies in similar fashion to respond to changing circumstances (35 , 84 , 201).

At the beginning, when contraceptive prevalence is low, programs seek legitimacy for family planning. As they develop, they first concentrate on rapidly expanding access to meet the latent demand. Then they turn to reaching more of the rural areas and hard-to-reach groups. Then they improve the quality of services, try to become more efficient, and work to assure continued financing.

Recent reviews have defined similarly the stages of growth of family planning programs. The Family Planning Services Division of the Office of Population, USAID, has identified five stages classified by prevalence of modern contraceptive methods, based on a scheme developed by John Stover (35 ). These five stages are: Emergent, where prevalence of modern contraceptive use is below 8% of married women of reproductive age; Launch, where modern method prevalence is 8% to 15%; Growth, at 16% to 34%; Consolidation, at 35% to 49%; and Mature, where at least 50% of couples use modern contraceptive methods.

Currently, most countries with family planning programs in the "emergent" stage are in Africa. Services are limited, and contraceptives are little used except by the small group who are urban and educated. Many African countries are now reaching the "launch" stage, however, where popular interest in family planning is rising, and family planning programs make more headway. Countries in the "growth" stage, such as Bangladesh, Kenya, and Morocco, have reached most educated and urban couples and are extending services to meet growing demand. In recent years an increasing number of countries, including many in North Africa, Latin America, and the Caribbean, have reached the last two stages in the USAID scheme; they focus on maintaining widespread service delivery while improving the quality of services and becoming less dependent on external donors (35 ).

Another classification scheme, by Alan Keller and colleagues at the United Nations Population Fund (UNFPA), identifies four stages (84). In the first stage, where prevalence is below 20%, the top priority is to legitimize family planning. In the second stage, where prevalence is 20% to 35%, programs rapidly expand services, often using community-based distribution and social marketing, and make services more acceptable and accessible. In the third stage, where prevalence is 36% to 50%, programs extend services to remote areas, improve quality—by providing more choice of methods, for example—and serve other groups as well as married couples. In the fourth stage, where prevalence exceeds 50%, programs have met much, although not all, of the need for family planning, and their mission is chiefly to improve quality and assure continued funding.

Indonesia offers an example of how experienced leaders can strategically shift emphasis over time to anticipate the changing climate for family planning services. Indonesia's family planning program has seen three phases in its development: expansion, maintenance, and institutionalization. In the first phase the program emphasized strong promotion and provision of family planning, at times making the strategic decision to extend the reach of services rather than to improve quality, so that no one would be denied family planning services for lack of resources. As contraceptive prevalence rose, the program entered the maintenance phase. The focus shifted to expanding the range of available services. Now, in the third phase, contraceptive prevalence has reached 50%, and the program believes that communities and individuals should play a greater role in obtaining and paying for family planning (65).

In no country, developing or developed, is the family planning program self-sufficient in the sense that the commercial marketplace meets all of the demand for family planning (60). Even in countries with "mature" programs, where the commercial sector serves many people, many others cannot afford to pay the full costs of contraception, and the public sector continues to play an important role. In most developing countries, providing family planning is seen as a valuable service that government should provide or subsidize (see Lesson 10 Financial Resources).