We wanted to see how access to care can be expanded and service quality can be improved when one uses a participatory approach to program development. We showed that major changes become possible if you work in a participatory manner, listen to local people, diagnose what the problems are, provide training and identify where there are opportunities for mobilizing local resources to take action. In time leaders from other municipalities expressed interest in replication and the project succeeded in expanding innovations to three other areas.

Bureaucratic systems are not set up to be what we refer to as human service organizations. They were established to collect revenue and maintain law and order and they used a law and order approach in providing family planning services.

If we succeed in learning more about how to expand program innovations from pilot projects so that they have broader program impact, this should be very relevant for public health initiatives in Michigan and elsewhere in the US.

Fear of failure is the fuel of achievement. If you weren't afraid to fail, you probably wouldn't be highly motivated to work at the level that most of us have to work at to do well.

I have been working with the World Health Organization since 1989 in an effort to redefine approaches to contraceptive introduction. This has given me the opportunity to insist that strategies for research and policy development must simultaneously address people's needs, the capacity of programs to provide good quality of care, and the range of technological options available.

If instead policy makers and program managers participate in an interdisciplinary assessment team, make informal visits to local families and have in-depth conversations with local providers and health authorities, the real needs and complex challenges of organizing good reproductive health services become apparent.The first country that implemented this participatory program of assessment, research and policy development was Brazil. I was one of the outsiders who provided support to the initiative.

A longer time perspective is needed because we face a daunting task both in an intellectual and practical sense.