A major outcome of the 1994 International Conference on Population and Development (ICPD) is the expansion of population programmes to include reproductive health services and strategies to raise the status of women (United Nations, 1994). Grassroots women's organizations influenced the recommendations as well as the strategies for their implementation. In the pre-planning stages within countries and during the Conference itself, the Women's Caucus, representing more than 400 organizations from 62 countries, stressed the important role that women's empowerment plays in promoting acceptance and use of reproductive health services (Ashford, 1995). They argued that women who are empowered, that is, who have control over their lives and have skills in seeking information and using resources, are more likely to make their own reproductive decisions.

The inclusion of empowerment activities in population programmes opened the door for grassroots development organizations to become more active participants in service delivery. Among the donor community, increased emphasis is now placed on implementing reproductive health programmes through community-based development organizations. Within countries, Governments recognize the positive role that grassroots organizations play in serving the needs of hard-to-reach poor communities.

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* The authors of this paper are Linda Lacey, Carolina Population Center, University of North Carolina at Chapel Hill , CB# 8120, University Square East, Chapel Hill, NC 27516-3997, United States, and Delia Carba, Office of Population Studies, University of San Carlos, Cebu, Philippines. They would like to acknowledge with gratitude the assistance of Ms. Meera Viswanathan on some of the earlier analysis and that of the Wilhelm Flieger, Director, and staff of the Office of Population Studies for their assistance in the research, as well as the United States Agency for International Development for funding the study.

Nonetheless, even though population programmes have expanded to include reproductive health and women's empowerment, family planning will continue to be a key programme component. Family planning protects the health of women and families, and enables women, in particular, to balance their reproductive and productive roles in society. Community-based development organizations engaged in health care delivery provide new opportunities to increase access to family planning programmes. They have years of experience fostering empowerment processes among the poor, women, minority groups and other hard-to-reach populations. In addition, grassroots organizations are more flexible than government programmes and can adapt projects and programmes more quickly to respond to changes and demands in the environment. Because they depend on their membership for support, they are more accountable to the needs of their clients. Most have strong political linkages within communities and, in some cases, with regional and national networks. Political networks enable them to act as pressure groups to advocate services for the poor. Community-based groups also mobilize substantial resources from within poor communities and convert them into goods and services for their clients. Last of all, non-governmental organizations (NGOs) have long histories of promoting innovative service delivery approaches, including the types of cross-sectoral linkages that are needed to increase access to family planning services among diverse populations (Curtin, 1994; Esman, 1991; Paul, 1988).

While there are numerous advantages in working with grassroots development organizations, a number of constraints face those wishing to involve community-based development organizations in family planning programmes. Firstly, many organizations have limited staff and do not operate on a full-time basis, which has implications for the availability of services. Secondly, most lack the technical skills to design, manage and evaluate population programmes. Since they operate in one or a few locales, replication of high quality services would require one to work at building the capacities of numerous small organizations, which could increase management and evaluation costs considerably. More importantly, little is known about the priorities placed on family planning among organizations that provide multiple social services to communities.

To promote the involvement of grassroots organizations in family planning, research is needed to distinguish the characteristics of community-based organizations that have the greatest potential to provide effective and sustained services. Studies are also needed on ways to evaluate the impact of empowerment activities on the decision to select and use reproductive health services including family planning. A comparable assessment of the effectiveness of alternative private and public sector actors will help policy makers choose an appropriate mix of providers for funding, especially in the context of limited resources.

The purpose of this paper is to explore the role of grassroots organizations in expanding family planning information and services. Volunteer health and family planning associations are compared with two types of grassroots organizations -- religious and development institutions. The development organizations in the study provide a range of social and financial services and counseling to improve the lives of the urban poor. While religious organizations are concerned mostly about the physical and spiritual health of their participants, many are also engaged in empowerment activities, that is, they help the poor gain access to social and economic resources and information to improve their lives. For all three types of organizations, we explore how family planning began within the organizations, the intended population for services and information, the types and volume of services and commodities provided to clients, cost recovery activities, and future intentions to expand family planning services.

This qualitative study is limited to a census of 33 non-profit organizations that provide clinical and non-clinical family planning services in Metropolitan Cebu, the Philippines. The findings provide insights on the types of community-based organizations that are engaged in family planning activities. The results also show the roles that these organizations play in family planning counseling and service delivery. The paper begins with a discussion of the study location. Next, the provision of family planning services among volunteer organizations is examined.

Based on the 1990 census, the Philippines has a population of 60.7 million people and of this number, 49 per cent reside in urban areas. The Philippines Demographic and Health Survey of 1993 reports a total fertility rate (TFR) of 4.09 among women in the reproductive age group. Among currently married women, contraceptive prevalence is 40 per cent, with 25 per cent using modern methods. Among the 15 per cent using traditional methods, natural family planning accounts for 7.3 per cent of use (PDHS, 1994).

National family planning efforts began in the Philippines in 1968 with the establishment of the Office of Maternal and Child Health in the Department of Health. By 1970, the Population Commission was established as a coordinating body to promote government and private sector efforts to reduce fertility as a means of fostering national welfare. Currently, about 60 per cent of modern contraceptive users receive services from the public sector. Government services are offered through various outlets such as Rural Health Units, Barangay (village) Health Stations, hospitals, social hygiene clinics, city health centres and mobile outreach services.

NGOs have always played significant roles in family planning service delivery. Prior to government involvement, non-profit organizations were early advocates of family planning. Private volunteer family planning organizations pioneered the use of voluntary surgical contraception, initiated adolescent fertility management projects that focused on sex education (USAID, 1992) and led the way in the rapid expansion of clinical services, operating more than 14 per cent of family planning clinics (United Nations, 1991).

The Government of the Philippines continues to rely on the help of non-profit organizations in meeting the demand for family planning services. The Government and select industries have contracts with private volunteer organizations to deliver services. The Philippine Demographic and Health Survey (1994) shows that non-profit organizations are significant sources of supply for the IUD, providing 28 per cent of the total. Volunteer organizations also meet about 14 per cent of the demand for pills and about 14.5 per cent of the need for condoms. Further, non-profit organizations performed 7.5 per cent of the female sterilizations in the country (PDHS, 1994:50).

Metropolitan Cebu is located in the Province of Cebu which has 48 municipalities and five cities. Three of the cities and six of the municipalities comprise "Metro Cebu". Based on the 1990 Census of Population and Housing, Metro Cebu has a population of 1,252,339 (NSO, 1990). Cebu is experiencing high levels of urban growth as a result of new employment opportunities in the city's emerging industries. Both men and women are taking advantage of employment opportunities in the city. About 71.3 per cent of the men and 48 per cent of the women are in the labour force.

Cebu is located in the Central Visayas region of the country. Within this region, about 46.1 per cent of currently married women are current users of family planning, with 28.8 per cent using modern methods and 17.3 per cent relying on traditional methods (PDHS, 1994). Of the 17.3 per cent using traditional methods, 8.8 per cent use natural family planning.

As in most other areas of the country, the Government is the primary provider of modern family planning services and supplies in Metro Cebu. Family planning users can obtain public services and supplies from more than 170 government health centres and stations in the metropolitan area. Within the private sector, family planning services and supplies can be received from 253 pharmacies, 55 employer-based companies, 50 obstetric/gynaecological and family physicians and 33 non-profit organizations including religious organizations.

Volunteer organizations complement government services and the commercial sector by providing low-cost services and supplies for poor families and individuals in acceptable, familiar settings. Religious organizations provide a range of natural family planning methods for couples concerned about the religious implications of artificial birth control. Development organizations engaged in income-generating activities provide information, services and supplies to the hard-core urban poor. Health and family planning agencies integrate their services with those of the Government and industries to fill gaps in service delivery.

This study is based on a census of private volunteer organizations in Cebu that provide clinical and non-clinical family planning services and supplies. Interviews were conducted with 33 non-profit organizations in 1994. Agencies were identified through a number of different sources. Initial lists of organizations were obtained from the regional office of the Population Commission in Cebu, a government organization that is responsible for coordinating population activities within the province. Additional lists were obtained from other government organizations and from private associations including the Department of Health -- Integrated Provincial Health Office, the Department of Labor and Employment Population Program Office, Cebu Medical Society and USAID (United States Agency for International Development/Manila). Staff of the Office of Population Studies, University of San Carlos, visited each institution and selected organization to ensure that they provide family planning services.

Managers were interviewed who are in charge of the organizations or clinics. Respondents included directors, senior coordinators, doctors or nurses. As mentioned previously, questions were focused on the types of services provided, the rationale for offering family planning, the types of family planning services offered, the volume of services and the target clientele, cost-recovery efforts, ability to monitor and evaluate programme performance, and future intentions to expand services.

As mentioned previously, we compared volunteer health and family planning associations with two types of grassroots organizations -- religious and development institutions. Religious organizations were included because they influence reproductive decisions in most developing countries, including the Philippines. For many couples, religious institutions influence the decision to practise contraception, the selection of method, and the duration of use. Organizations offering natural family planning as well as modern methods are also included in the study. Also as mentioned previously, of the 46 per cent users of family planning, close to 9 per cent within the region rely on natural family planning methods. It is possible that couples who begin with natural family planning may later switch to modern methods.

We begin with a discussion of the overall mission of the organizations, the types of social services provided and the intended clients for those services. While all three types of organizations provide family planning, the missions of the agencies address different community needs. All of the grassroots development organizations included in the survey focus on empowering poor urban communities through income-generating activities, education programmes and the provision of social services. Among the organizations, five offer primarily income-generation and job skills; three provide services for children and young adults including day care, nutrition programmes, leadership training and recreation programmes; two agencies address the legal and welfare needs of workers; one promotes environmental protection and agro-industries, and one organization protects the rights of battered women by giving them legal assistance and employment training skills.

Religious organizations combine spiritual goals with those of empowering poor members of their church, or the community. Six agencies are community centres and offer multiple social services including nutrition programmes, health, day care, income-generating activities, housing and financial resources in emergency situations. Two are branch offices of international organizations and provide educational programmes and other social services including housing and emergency relief for poor families. Two are mission hospitals and offer primarily health care services. Three of the organizations are churches or missions and provide multiple social services for their members including health care, financial assistance, supplementary feeding programmes and counseling on effective parenthood.

Health and family planning organizations consist of two community health centres, three nursing and physician agencies, one research institution, and two private family planning associations. One of the private family planning associations exclusively provides natural family planning while the other one offers a full range of traditional and modern methods. All of the organizations focus primarily on meeting the health and reproductive needs of their clients. The community health centres and one of the nursing programmes also provide income-generation activities and training for their beneficiaries.

All of the organizations in the study provide family planning and some aspect of primary health care. However, health and family planning organizations and, to a lesser extent, development organizations, offer the broadest mix of health services, especially those which are used primarily by women in their reproductive years -- well-baby services, and pre-natal and maternal health care (see table 1).

As indicated in table 1, the organizations vary in the number of years they have been in operation. Half of the health and family planning organizations and a third of the religious organizations have been located in the communities for more than 20 years. Most development agencies are fairly new to the communities. Most were established during the mid-1980s. Only one development organization has a long history within the city. It began more than 40 years ago as a labour union to meet the needs of workers and their families.

Background characteristics	Developmenta	Religious	Health/family planning	All non-profits
Social services
Legal services	25.0	0.0	0.0	9.1
Income generation/financial aid	83.3	23.1	37.5	48.5
Education/training	50.0	53.8	25.0	45.5
Housing	8.3	23.1	0.0	12.1
Catechism/religious training	0.0	23.1	0.0	9.1
Health care offered
Well-baby care	50.0	23.1	87.5	48.5
Pre-natal/maternal	50.0	23.1	87.5	48.5
Curative care	33.3	61.5	75.0	54.5
Family planning	100.0	100.0	100.0	100.0
Nutrition/feeding	75.0	69.2	37.5	63.6
Medical/dental	33.3	76.9	75.0	60.6
Sanitation	25.0	0.0	25.0	15.2
Reflexology/spiritual healing	0.0	0.0	12.5	3.0
Year established
Before 1976	8.3	30.8	50.0	27.3
1976-1989	83.4	61.5	37.5	63.6
1990 to present	8.3	0.0	12.5	6.1
Do not know	0.0	7.7	0.0	3.0
No. of people (all programmes)
No record	50.0	38.5	75.0	51.5
1-100	0.0	7.7	0.0	3.0
101-500	16.7	38.5	12.5	24.2
501-1000	16.7	15.4	0.0	12.1
1001-1500	8.3	0.0	0.0	3.0
2000+	8.3	0.0	12.5	6.1
Hours per week all services are offered
1-15	0.0	15.4	37.5	15.2
16-30	0.0	23.1	12.5	12.1
30+	83.3	23.1	37.5	48.5
Not given	16.7	38.4	12.5	24.2
Number of non-profits	12	13	8	33

Many of the organizations did not keep records on the number of participants in their programmes. Among those with record-keeping systems, it was observed that health and family planning organizations have the largest number of beneficiaries, with some organizations serving more than 7,000 people. Among those development and religious agencies that kept records, it was found that development organizations serve the needs of an average of 824 people while most religious organizations assist an average of 441 families. We suspect that the number of participants in the religious and development organizations is higher than recorded, since many also meet the needs of non-participants from the community as well as people living elsewhere who request emergency assistance.

Availability of services is measured in terms of hours during a week when all programmes and projects are available to participants. It was found that most development agencies operate on a full-time basis. Over three-fourths provide services at least 30 or more hours per week. More than half of the religious organizations provide services 25 or more hours per week, although some operate on a part-time basis. Of the health and family planning agencies, over half provide services more than 30 hours per week (see table 1).

In this section, select attributes of organizations are examined to distinguish those that demonstrate the greatest ability to provide services and information for the urban poor. The following are explored: (a) the rationale for offering family planning services and/or information; (b) length of experience in the provision of services; (c) availability of services and supplies, including location of services; (d) the volume of services and supplies, and (e) intentions to expand family planning services.

Reasons for starting family planning services varied among the organizations. Among development organizations, relieving problems associated with urban poverty and improving the quality of life of the poor were given as the primary reasons for introducing family planning services. While religious organizations were also concerned about the problems of the poor, several also spoke of improving the health of mothers and children and promoting responsible parenthood. Several religious organizations also mentioned that they provided services to prevent the use of artificial methods by offering alternatives to their clients. Traditional health and family planning organizations began offering services primarily to control population growth and improve the health of families. Several mentioned the importance of implementing the country's population policy.

Differences observed among the agencies on the rationale for offering family planning are reflected in the type of clients they wish to serve. Development and religious organizations are interested in empowering poor communities, while health and family planning organizations wish to provide services to all citizens requiring their services, including the urban poor.

Experience in the provision of family planning also varied among the organizations (see table 2). Health and family planning organizations have offered family planning methods the longest. About half began offering services prior to 1976. In all cases, family planning was introduced when the organizations were first established. Most religious and developmental organizations introduced family planning services between 1976 and 1989, after the Government introduced population programmes. A high percentage of religious organizations established family planning services about the same time when other social services were introduced to the communities. Among grassroots organizations, close to 25 per cent added family planning after other programme components were in place. As mentioned previously, family planning was introduced as one of many resources to help the poor improve their lives.

Organizations varied in the type of family planning information and services provided, as indicated in table 2. Among development organizations, all provide population information and the promotion of family life counseling and 10 of the 12 organizations offer a full range of natural family planning methods. Three agencies offer both traditional and modern contraceptives, including condoms and, to a lesser extent, oral contraceptive pills. The agencies include a national labour union (1,009 new and continuing users of condoms, and 359 new and continuing users of oral pills in 1993), and a social service organization engaged in income-generation and vocational training programmes (428 new and continuing users of condoms and 1,420 new and continuing users of the pill in 1993).

Nine of the twelve development organizations provide services through community out-reach programmes where motivators play a key role in providing family planning information and services. While several organizations have staff motivators, half of them train and use the services of volunteer motivators who provide information and services on a part-time basis. The number of volunteers ranged from 3 to 800. It was observed that the development organization which provided services to the largest volume of clients relied on part-time doctors and nurses, 30 full-time staff motivators and 100 volunteer motivators. That organization is a labour union that was established in 1953. It began offering family planning in 1972 as a way to reduce poverty among its workers. It provides health and employment-related services for union members in more than 200 companies in Cebu. About 1,680 members and their dependents receive a variety of social, economic and legal services each month. A mobile clinic, community-based distributors and volunteer motivators bring health services including family planning to its members and their dependents.

Services provided	Developmental	Religious	Health/family planning	All non-profits
Year established family planning services
Before 1976	8.3	23.1	50.0	24.2
1976-1989	58.3	61.5	37.5	57.6
1990 to present	33.4	15.4	12.5	18.2
Rationale for offering family planning
Socio-economic reasons	49.9	53.8	37.5	48.5
To promote family planning	41.6	23.1	62.5	39.4
Against artificial methods	8.3	23.1	0.0	12.1
Type of intended client
Poor	75.0	61.5	50.0	63.6
Middle income	0.0	0.0	25.0	6.1
Everyone	25.0	38.5	25.0	30.3
Counseling
IEC	100.0	100.0	87.5	93.9
Family life counseling	100.0	100.0	87.5	93.9
Natural family planning methods
Rhythm	83.3	76.9	100.0	84.8
Billings method	83.3	76.9	75.0	78.8
Basal temperature method	83.3	76.9	87.5	81.8
Symptom thermal method	83.3	76.9	87.5	81.8
Lactational amenorrhea	83.3	76.9	75.0	78.8
Modern family planning methods
Condoms	33.3	7.7	62.5	30.3
Spermicide	0.0	7.7	25.0	9.1
Pills	8.3	7.7	62.5	21.2
Injectable	0.0	0.0	25.0	6.1
IUD	0.0	0.0	50.0	12.1
Female sterilization	0.0	0.0	25.0	6.1
Male sterilization	0.0	7.7	25.0	9.1
Location of services
Own clinic	0.0	30.8	12.5	15.2
Community-based distributors	66.7	15.4	12.5	33.3
Combination	33.3	53.8	75.0	51.5
Hours per week devoted exclusively to family planning services and programmes
As need arises	25.0	7.7	0.0	12.1
1-15 hours	41.7	61.5	37.5	48.5
16-30 hours	8.3	0.0	0.0	3.0
Over 30 hours	25.0	7.7	50.0	24.2
Number of non-profits	12	13	8	33

All the religious organizations studied offer population information including counseling on the promotion of family life. Ten of the thirteen organizations offer a full range of natural family planning methods. Only one local mission offers both natural and modern methods, including condoms, spermicides, pills and vasectomy. The mission began offering natural family planning methods when it was established in 1965. In 1980, it began offering modern contraceptives such as spermicides. The mission's reasons for providing family planning include concerns about the health of mothers, and the inability of poor parents to feed and educate large numbers of children.

About half of the religious organizations provide services through a combination of clinics and community-based distribution programmes while one-third provide services exclusively through their clinics. Many rely on a few part-time staff members, usually a nurse, social worker or motivator, while others use a combination of staff members including part-time doctors, nurses, community-based out-reach workers, motivators and volunteers. The volunteers include doctors as well as community out-reach workers. One organization relies on the help of five doctors who are church members; another uses teacher volunteers. Through parent-teacher association meetings, teachers inform parents about natural family planning.

A key attribute of health and family planning organizations is their ability to offer clients the broadest possible mix of methods including permanent contraception. Seven of the eight organizations offer at least three natural methods, and six offer several clinical and non-clinical modern methods including pills, condoms, injectables, IUDs, and male and female sterilization. Among those agencies that do not offer long-term and permanent methods, referrals are made to other health care providers. Most health and family planning organizations use a combination of clinics and community distribution programmes to provide services. The organizations rely on the part-time help of doctors while nurses and midwives play key roles as counselors and providers of non-clinical services. Community-based distributors are used to bring information and non-clinical services to residents.

In the study, the availability of services was found to vary greatly among the organizations. Health and family planning organizations were devoting more time during a given week to the provision of services than the other organizations. Half were providing services more than 30 hours per week. Most of the religious organizations have small staffs consisting of part-time workers and volunteers. As a result, hours are limited when social services including health and family planning are available. Most religious organizations offer family planning 1-15 hours per week. Development organizations that provide only natural family planning were found to have limited hours when family planning services are offered. However, development agencies that provide both traditional and modern methods have longer operating hours, i.e. 15-40 hours per week.

Many of the religious and development organizations do not keep client records on family planning services. Because of this, it is difficult to compare the volume of clients among the organizations. The limited data available show differences among the organizations. Based on comparisons of median distributions, development organizations had the highest median for natural family planning and condoms. The median number of natural family planning users in the year prior to the survey was 101 compared to 61 for religious organizations and 80 for health and family planning clinics and agencies. The median number of condoms for development organizations was 100 compared to 32 for health and family planning and zero for religious organizations. Health and family planning organizations had the highest volume of clients for other modern methods including oral contraceptive pills, the IUD and injections (see table 3). The median for contraceptive pills was 728 compared to 364 for development organizations. For the IUD, the median was 442 for health and family planning agencies. The higher volume of clients was expected since health and family planning organizations have record-keeping systems in place and have longer hours when services and supplies are available.

Are grassroots organizations interested in expanding family planning services in the near future? To answer this question, we asked whether or not the organizations planned to increase services within the next year. Plans to expand family planning services varied by type of organization. Among health and family planning agencies, over two-thirds planned to expand services within a year. Most expressed interest in broadening the geographic area for services. Several also planned to increase cost-recovery efforts. Among development agencies, close to half were interested in expanding services. Many had introduced new activities and wished to provide family planning for their new participants. One organization, the labour union, wished to train its staff in IUD insertions. Those with plans to increase services included two youth programmes, a labour organization, and two organizations that promote income-generating activities among their participants.

Methods	Development non-profit organizations			Religious organizations			Health/family planning organizations
	Median	Highest volume	No.	Median	Highest volume	No.	Median	Highest volume	No.
Natural family planning	101	800	4	61	155	3	80	478	4
Condoms	100	1,103	3	-	-	-	32	5,726	3
Spermicide	-	-	-	-	-	-	201	201	1
Pills	364	364	1	-	-	-	728	3,568	4
Injections	-	-	-	-	-	-	34	34	1
IUD	-	-	-	-	-	-	442	1,793	4
Female sterilization	-	-	-	-	-	-	8	8	1
Male sterilization	-	-	-	-	-	-	-	-	-

About two-thirds of the religious organizations were not interested in expanding services. Most were concerned about meeting the immediate needs of children and poor families. For example, an international religious organization felt that the needs of "street children" were more urgent than family planning activities. The third that were interested in expanding services wished to promote family life education or expand natural family planning efforts. One organization was interested in improving data collection efforts to monitor the number of new and continuing acceptors.

To expand family planning programmes, organizations must mobilize resources from a variety of different sources. We examined funding sources of the organizations to gain insights on whether or not they could finance programme expansion. We discovered that all three types of organizations were mobilizing support for family planning services from a combination of sources. Health and family planning organizations rely on client fees, the Government, and local and international donors. Among the sources, client fees are a key source of support. Development agencies also mobilize support from a number of different sources including client fees, government supplies and a range of international organizations. However, most rely on the Government and client fees. Among religious organizations, few clients pay for services. Local and international religious institutions provide financial support for services.

It is difficult to say which types of organizations can mobilize and sustain financial support for programme expansion. Organizations that primarily meet the needs of the poor cannot rely on client fees (which are usually based on a sliding fee schedule) to recover full costs of services and counseling. Costs of operation must be subsidized by the Government, the donor community or other fund-raising efforts. Unfortunately, these are not reliable sources of long-term support: economic and political change within countries can reduce government support for services, and support from the international donor community can be influenced by changes in the world economy, or in the policies of major donors.

Those organizations that have years of experience mobilizing broad-based support are more likely to raise resources to expand services. Among the grassroots organizations, the labour union has the longest history of mobilizing different sources of support. It relies on support from union members, the Government and local and international donors. The Philippines Family Planning Association also has a long record of obtaining wide-spread support. It generates revenues from contracted services with private industries and the Government, receives financial and technical support from the International Planned Parenthood Federation (IPPF) and collects fees from clients who represent a broad range of income levels.

The 1994 ICPD generated new actors in the delivery of population programmes including grassroots organizations involved in reproductive health and empowerment activities. The purpose of this paper was to explore the role of grassroots organizations in expanding family planning services. Compared were development agencies and religious organizations involved in health, including family planning services, with traditional health and family planning agencies. The study was based on a census of 33 volunteer organizations in Metropolitan Cebu.

It was discovered that organizations engaged in empowerment and family planning services are highly diverse. Labour unions, income generation and vocational-training organizations, environmental institutions, youth centres, and local and international religious organizations mobilize resources to help individuals and families to improve their lives. For these organizations, family planning is viewed as one of many resources to help the poor to gain control over their productive and reproductive lives.

It was also observed that development and religious organizations cannot compete in service delivery with traditional health and family planning associations. Private family planning associations that offer both natural and modern family planning methods demonstrated the highest capacity to provide modern contraceptives. They have years of experience in providing and adapting family planning services and information to meet the needs of diverse populations including couples, women in their reproductive years, teens and men. They have also played major roles in expanding programmes by introducing innovative, alternative service-delivery models. Because of the large number of women involved in managing or serving as community-based distributors, private associations have played a major role in empowering women. Over the years, women at the community, provincial and national levels have developed skills in advocacy, participatory planning, negotiation and community development. The limited data available suggest that development and religious organizations complement existing public and private sector services by providing information and family planning methods for urban populations that would otherwise be difficult to reach. In a country where religion influences the decision to use contraception, religious organizations play a role in counseling and providing natural family planning methods to families concerned about the religious implications of fertility regulation.

Development organizations cannot compete with the volume and method mix offered by health and family planning agencies. A key contribution of these organizations is their ability to link the urban poor with providers that offer effective long-term methods of birth control.

What types of grassroots organizations have the greatest capacity to expand family planning services? With the limited data available, we cannot answer that question. We did observe that grassroots organizations that promote economic development and survival skills among the poor had the largest number of contraceptive users. Key attributes of these organizations include the following; they: (a) promote income-generation activities as part of services for the poor, (b) have a large number of beneficiaries, (c) operate on a full-time basis, (d) have skills in mobilizing financial and human resources from within and outside the communities, and (e) have established networks among public and private health providers within the health care delivery system. Unfortunately, no information was obtained on the quality of family planning counseling and services provided by development organizations. Further studies are needed that will measure the quality of care and the cost-effectiveness of involving grassroots organizations in information, education and communication (IEC) efforts, counseling and service delivery.

The study raises questions about the indirect impact of participation in grassroots organization on contraceptive use. It is possible that development organizations that conduct empowerment activities increase the participants' ability to take advantage of family planning services outside of the agency. Schuler and Hashemi (1994) observed that communities having access to a Grameen Bank, a credit programme that promotes self-help among its lenders, had higher levels of contraceptive use than communities where such a programme does not exist. Although the Grameen Bank does not offer family planning services, it helps women to earn cash outside the home, creates women's solidary groups to increase self-esteem, and raises awareness about existing resources, including family planning within the community. Through involvement with the empowerment processes of the Bank, women can take advantage of family planning services as a resource to raise their standard of living.

The study presented is descriptive and is limited to an

analysis of volunteer organizations that offer health care services, including family planning, in Metropolitan Cebu. While it gives some insights on the types of grassroots organizations that are engaged in empowerment activities and family planning, it provides no information on the relationship between empowerment processes and the decision to seek family planning. Further research is needed that addresses the following two questions. To what extent does participation in empowerment activities influence the desire to use contraception? What types of interventions are used by grassroots organizations to influence their members to use modern contraceptives?

Empowerment can be viewed from the perspective of individuals, groups and/or communities. At the individual level, it can be defined as a series of steps by which individuals gain access to critical resources which can be used to bring about improvements in their lives. Zimmerman (1995) introduced the concept of psychological empowerment which focuses on perceptions of personal control, a pro-active approach to life, and a critical understanding of the socio-political environment. From the group or community level, it can be viewed as a social action process in which individuals work together in an organized fashion to improve their lives collectively. Organizational or community empowerment fosters networks between community organizations and agencies that help to promote and maintain the quality of life (Zimmerman, 1995; Stein, 1994).

Measures of empowerment are slowly being defined and are difficult to measure. Research by Hashemi and Schuler (1993) on contraceptive use among women involved in credit programmes in Bangladesh suggest several indicators of individual empowerment. Indicators include the ability to make use of existing resources, vision of the future, status and decision-making power within the household, and participation in non-family groups such as grassroots organizations. Many of these indicators can be linked to the decision to use contraceptives. The ability to make use of existing resources could include family planning and reproductive health services. A vision of the future could include a vision of one's ideal family size. Decision-making power withing the household can include joint decisions on the use of contraceptives.

Further research is needed that explores ways to develop and test measurements of the relationship between empowerment and reproductive health including family planning. Since empowerment processes produce incremental change in behaviour over time, longitudinal studies are needed that assess participants of development programmes as well as institutions engaged in empowerment activities in order to more fully understand the potential roles of community organizations in promoting family planning.

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For further information on this material please contact: loftus.unescap@un.org