_Private Sector Approaches to Effective Family Plannng_ _10_ Cross et al. (1991) examined the relationship between<sup>economic and political factors and</sup> for-profit contraceptive market share among the 27 countries<sup>for which DHS data are available.</sup> Urbanization, secondary school enrollment, and per<sup>capita GDP were all positively correlated with</sup> private sector use, and use of private sector outlets was<sup>generally higher in urban areas than in rural</sup> areas. These results parallel those reported earlier by<sup>Kenney and Lewis (1989). Government family</sup> planning program effort showed a curvilinear relationship<sup>with private sector use with peak private</sup> sector market share at approximately 52.5 on the Laphawm-Mauldin<sup>scale of government effort</sup> (maximum possible score 120); countries below this point<sup>showed a significant positive correlation</sup> between government effort and private sector coverage (r<sup>= .62, p < .01), while countries above</sup> this point showed a significant negative correlation (r<sup>= -.71, p < .05). Furthermore, of 13</sup> countries with time trend data, six showed loss of private<sup>sector market share of greater than 10</sup> percent between the two surveys, which only one country<sup>showed appreciable private sector gain.</sup> Cross et al. conclude that while a favorable political climate<sup>can stimulate the private sector, strong</sup> government programs have the effect of crowding out the<sup>private sector.</sup> The contraceptive market is partially defined by the different<sup>family planning methods</sup> themselves. Prescription norms notwithstanding, _supply methods_<sup>(pills, condoms, and spermicides)</sup> can be sold wherever pharmaceuticals are found, including<sup>pharmacies, dispensaries, and small shops</sup> and vendors' stands. All else being equal, the private commercial<sup>sector should show a comparative</sup> advantage in distributing supply methods. _Temporary clinical_<sup>_methods_(IUD, implant) require some</sup> sort of health facility, more highly trained personnel, minimum<sup>standards of hygiene, and some</sup> degree of privacy for the provider and client. They are also<sup>likely to be subjected to self-imposed</sup> controls from within the medical community (such as requiring<sup>that only physicians can insert IUDs,</sup> despite empirical evidence that well-trained nurses and midwives<sup>can perform the procedure as well</sup> as or better than physicians). _Female sterilization_ depends both<sup>on the existing clinical infrastructure</sup> and on the conditions under which sterilization is performed.<sup>Even when performed on an outpatient</sup> basis, laparoscopy or mini-laparotomy requires at least a surgical<sup>area and minimum conditions of</sup> hygiene. Thus, if all the surgical facilities in a given countrv<sup>are located in public hospitals, women</sup> must of necessity use that sector if they wish to be sterilized;<sup>whereas the existence of a private</sup> clinical infrastructure permits some degree of possible choice<sup>between public and private sectors.</sup> Other factors relating to specific methods can affect the<sup>shape of the market. For</sup> example, where access to sterilization is restricted and women<sup>cannot obtain interval sterilizations</sup> (interval procedures are those which are performed at any<sup>time other than following a pregnancy</sup> termination), those who want to be sterilized will resort to<sup>other avenues, such as paying a physician</sup> to perform the procedure during an often otherwise unnecessary<sup>cesarean section delivery. Provision</sup> of sterilizations will follow usage patterns of hospital delivery;<sup>the greater the proportion of hospital</sup> births attended in the public sector, the smaller the private sector<sup>coverage of female sterilization.</sup> Easing restrictions on sterilization may increase private sector<sup>participation, especially</sup> to the extent that public facilities are oversubscribed. Since an<sup>interval procedure is elective, women</sup> may have difficulty scheduling an operation in a public<sup>facility if the surgical facilities are already</sup> crowded with deliveries and life-threatening conditions.<sup>Private organizations may take advantage</sup> of the demand for interval sterilizations by constructing<sup>or equipping outpatient surgical facilities;</sup> conversely, organizations whicL have access to surgical .<sup>icilities may aggressively promote outpatient</sup> tubal ligations and thus increase demand.

The effects of government norms and ownership of<sup>infrastructure can be seen in</sup> coverage of female sterilization in Latin America. In Brazil and<sup>the Andean region, access to</sup> sterilization has been limited to high repreduotive risk<sup>women, forcing those who do not meet the</sup> requirements to resort to "informal" postpartum sterilization<sup>via cesarean section. In other countries</sup> such as Colombia, Mexico, and Guatemala, sterilization<sup>norms are less restrictive, which in principle</sup>