When we conducted focus group interviews in the first municipality in Brazil before initiating the pilot project, a woman commented: Getting an appointment in the public sector municipal health services is like "winning the lottery." I would like to make it possible for many women and men in Latin America to win the lottery and receive the type of reproductive health services they so urgently need.

Governments have a legitimate concern with slowing population growth. But often this has been attempted with little concern for the individuals most affected.

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.

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.

We are trying to discover where this approach could have the greatest possibility of large-scale impact. We have to choose wisely and see where there is greatest interest and need.

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.

Nobody had counseled women to expect the changes in bleeding patterns which are typically associated with IUD use, and they received no support from the health clinics with their problems. Because in traditional Hindu culture menstruation is associated with a variety of social taboos, prolonged menstrual bleeding produced conflicts within families.