Introduction

As population programmes make the transition to comprehensive reproductive health programmes in the late 1990s, one of the most prominent items on its agenda is the issue of men.  Conventional population programmes, for more than four decades, have largely been designed and implemented with a gender bias - towards women.  These programmes, most of which provide family planning and maternal child health (FP-MCH) services for women and mothers through their existing health care outlets, inevitably overlook or neglect the role of men in fertility decision-making, contraceptive use, as well as their reproductive health needs.  This bias should be shaken off.

A revolution-of-sorts has quietly been taking place: men and their influence on women's contraceptive use and continuation; men and their role in prevention of sexually transmitted diseases (STDs) including HIV/AIDS; men and their attitudes towards family planning and male contraceptive methods; and so on.  This recognition points the way towards a population/reproductive health (P/RH) programme agenda that must include men to be effective and sustainable over the long run.

The 1994 UN International Conference on Population and Development (ICPD) effectively raised - and essentially legitimized the profile of "men" on the global population. and reproductive health agenda.  In Chapter IV of the ICPD Programme of Action, it says that "...in most societies, men exercise preponderant power in nearly every sphere of life, ranging from personal decisions regarding the size of families to the policy and programme decisions taken at all levels of government" (pp 28), and therefore, men are key to bringing about gender equality.

Putting men on the agenda is not at all in contradiction to the promotion of women's equality or empowerment, one of the basic tenets of the ICPD-POA.  Rather, it is to bring men to the forefront in an area where they were traditionally neglected but exactly where they should participate more actively - shared decision making in responsible sexual and reproductive health and rights.

 A more egalitarian approach to shared household responsibilities - with increased duties for men in "nurturing" activities such as child care, socialization, family health, education, etc - is needed for healthy social change (Mundigo, 1995).  However, programme managers should be mindful that enhancing men's involvement in P/RH activities should not in any way, unwittingly or otherwise, increase the level of male dominance in areas that have come to be perceived as women's "territories" (e.g., contraceptive choice and use) (Helzner, 1996).

Narrowing the Gap

Since the 1950s and 1960s, the amount of research and writings on population programmes and their impact on women's fertility and choices have been enormous, but one would be hard pressed to find many surveys and articles on men (Hulton & Falkingham, 1996).  Men seemed to have become what Potts (1992) called the "forgotten 50 percent of family planning".  Indeed, Mason and Taj (1987) found that not only was there "a general paucity of studies focusing on differences between men and women's reproductive goals.. [but].. men are rarely interviewed in fertility surveys of any kind" (pp 620).  It was only in 1987 when the DHS (Demographic Health Surveys) programme started filling in this vacuum with a male survey, its first, in Burundi.  Now, male surveys are regularly undertaken in countries participating in the programme (DHS, 1996).

Understanding the differences in reproductive goals between men and women may explain why many women in developing countries, though expressing the desire for fewer number of children, do not use contraceptives.  The "unmet need" syndrome.  A cursory gender analysis may reveal that although the woman would like to use contraceptives, her subservient position in the household may cause her to adhere to the wishes of her husband or male partner or other senior members of the household.  Bongaarts and Bruce (1995) bring our attention to the existence of a "cost" that is associated with practising contraception, a cost that refers to intangible factors such as health, psychological and social considerations.  This disputes the traditional explanation for unmet need which is the lack of access to contraceptives and services.

Thus, men's role or participation in reproductive health has generally been typified by their conspicuous absence (Ferdinand, 1996), although their pervasive influence, as husbands, partners, fathers, uncles or brothers, is clear.  Strategies for men-targeted initiatives should be directed towards engaging men in more active ways in family planning and reproductive health to increase their responsibility and commitment.  Many such initiatives, particularly in Africa, acknowledge this fact by using IEC approaches, via a variety of mass media, to "enlighten" men or the benefits of family planning and responsible reproductive be haviour (Kim et al, 1996; IPPF, 1992).

The following are just five of perhaps many justifications for increasing male involvement in P/RH programmes.  One, men should, and need to, be involved in P/RH activities, not only to fulfill the women's reproductive health needs but their own.  Two the traditional neglect of men with respect to their reproductive goals and behaviours since the advent of the family planning movement in the 1950s.  Three, the low level of male involvement or contraceptive prevalence could thus be attributed to the lack of available services (and male methods) in most current programmer rather than a lack of desire to be involved.  Four, the spread of AIDS since the 1980s has made condoms (still the premier modern male contraceptive method) the most effective tool, besides abstinence and fidelity, in HIV/AIDS prevention strategies.  The issue of multiple sexual partners in the context of unsafe sex should be addressed.  Five, the need to address the emerging sexuality of youths, particularly the role of young men in the context of responsible sexual behaviour and the prevention of STDs and unwanted pregnancies.

Obstacles to Men's Involvement

The rhetoric for involving men in P/RH programmes has become strong and forceful, but providing, integrating or expanding reproductive health services to men in current programmes may not be easy.  Certain realities need to be considered.  Obstacles to men's involvement are many, both tangible and intangible; six of these are given below.

Socio-cultural environment.  Studies have found that men tend to be more steadfast in holding on to traditional roles and values systems than women (Helzner, 1996).  Men's roles as fathers and husbands tend - and continue - to emulate traditional values of a patriarchial system (Mundigo, 1995) such as being economic providers and decision-makers within the family.  Hence, in many cultures, men may perceive the practice of discussing and sharing decision-making on family size and contraceptive use with their wives or partners as a personal loss of control (IPPF, 1992).  They may also regard having many children as security for old age.  They may live in conservative communities that frown upon restricting or reducing family size or letting women decide on fertility and reproduction.

Men's attitudes and beliefs.  Besides traditional beliefs such as women's God-given and society-sanctioned roles in bearing and nurturing children, fear appears to play a big part in many of men's attitudes towards family planning and reproductive health.  Fears such as loss of power in a relationship; sexual virility/ pleasure/potency; their women's fidelity; ridicule by other men or the community; and so on can be obstacles to men willingly taking greater responsibility in family planning and reproductive health (UNFPA, 1995).  Men's indifference or aversion to reproductive responsibility is not something that can be overcome quickly.  One reason why many men-targeted initiatives focus on educational and awareness-raising activities is to gradually change some of these beliefs and attitudes to make men more aware of their personal responsibility and to be more women-supportive.

Male bias in policymaking.  Many high-level decision- and policy-makers, predominantly men, may not have, as yet, committed to initiating or institutionalizing male involvement in their programmes.  It may be cultural perceptions or it may be a resource availability decision.  However, a display or indication of interest in this area can serve as a motivating force, in many instances, towards changes in attitudes and practices of lower level programme personnel (UNFPA, 1995).

Policy-related obstacles. There may be policies or regulations that hinder greater usage of male contraceptive methods such as condoms or vasectomies, for example.  These could be high import taxes on condoms or restrictions on advertising, sales or distribution of condoms (UNFPA, 1995).  Vasectomies are simple, quick and effective but are among the least known and least used of family planning methods (Johns Hopkins University, 1992).  Strict eligibility criteria may exist for those men who wish to undergo vasectomies.  Why is this so?  Employment policies, in most developing countries, are not likely to be supportive of men who may wish to take a greater share of domestic and child-rearing duties, thus foregoing the opportunity to correct a gender imbalance in the household.

Lack of programmes.  Quite a number of presumptions exist with respect to men's perceptions, values and attitudes on sexual and reproductive matters.  Presumptions such as disinterest in family planning; lack of concern for their wife's or female partner's contraceptive choice and use; unwillingness to use contraceptives themselves; and so on.  However, studies have indicated men's low contraceptive prevalence or involvement in reproductive health is not due to presumptions such as above, but to the lack of P/RH programmes (Hulton and Falkingham, 1996; IPPF, 1992) and the perception that these services are generally not men-friendly.

Provider bias. As FP-MCH programmes are very much women oriented, and have been so for four decades, service providers are not likely to be trained or sensitized to men's reproductive needs or goals.  In fact, these providers are likely to stereotype that men are not interested in taking responsibility for family planning.  Even in an environment where services to men, particularly young men, were integrated into the clinic with special hours one evening a week, as indicated by one such project in the United Kingdom, the providers (all female in the beginning) were not adequately  prepared to deal with their male clients (Seex, 1996).  Although many studies have shown that men are not as uninvolved or disinterested in family planning as commonly assumed (IPPF, 1992; UNFPA, 1995; Hulton and Falkingham, 1996), it will take some time for providers and service outlets to cater to male clients adequately, and as a matter of course.

Lack of relevant information.  Forty years of women-oriented FP-MCH programmes have left a scant legacy of information on men's knowledge, attitudes and practices (YAP) with respect to their reproductive health goals, sexual behaviour, fatherhood, etc.  Improved research methodologies such as participatory research and rapid rural appraisals have only lately been applied to the health sector (De Koning and Martin, 1996), thereby opening up an avenue for involving men in research.  The interest in men as partners and fathers has only very recently been manifested in some social research on families and fatherhood, and disparate programme initiatives in various countries (Bruce et al, 1995).  Although this discrepancy is recognized, and more studies are now being conducted, it will take some time before an adequate body of work surfaces.

Strategic Planning and Programme Management

As Mundigo (1995) says, "..the availability of information on the extent to which male involvement in reproductive decisions remains a fairly uncharted territory, yet a crucial one from a policy standpoint." (pp 20).  To mainstream men-targeted initiatives into P/RH programmes, more information on men vis-a-vis their knowledge and involvement in fertility and reproductive matters is vital as inputs into the policy making process.  The ICPD-POA spells out that, "It is essential to improve communication between men and women on issues of sexuality and reproductive health, and the understanding of their joint responsibilities, so that men and women are equal partners in public and private life" (pp 22).  "Men" has become an imperative for P/RH programmes or, in management jargon, a "strategic issue" (MSH, 1995).

Experiences from a variety of men-targeted initiatives have begun to provide some useful lessons from a policy formulation and strategic planning standpoint.  Brazil's PROPATER, perhaps the earliest men-targeted P/RH initiative, has been providing vasectomies, urology services, and treatment for various sexual dysfunction and infertility problems at its male clinic since 1981.  PROFAMILIA in Colombia (chapter 4) started a chain of male clinics in 1985, with the aim of making them self-reliant.  The Zimbabwe National Family Planning Council undertook its first male motivation campaign in 1988, followed by a second campaign (chapter 6).  And there are other examples.  These field experiences indicate that the planning and management of men-targeted programmes should take account of the following five areas.

1. Integrated approach.  It is important that men-targeted interventions are included as an integral part of programme goals and strategies (UNFPA, 1995; IPPF, 1992).  For purposes of resource planning and provision of services, these interventions should not be regarded or planned as separate projects.  Integrating these interventions within existing programme parameters is also a cost-efficient measure.  In some cultures or environments, reaching out to men like community and religious leaders, husbands, fathers, etc, can also be a way to reach out to more women as well (Hulton & Falkingham, 1996).

2. Research and evaluation.  As interest in men as a "strategic issue" has only just began, more KAP research on men's motivational and behavioural patterns vis-a-vis reproduction, fertility, gender perceptions, and their roles as partners and fathers is needed.  For example, research findings indicate that men are attracted to five main factors: (1) positive role models, (2) economic interests, (3) personal testimonials of other men, (4) good self image, and (5) humour (UNFPA, 1995).

Findings such as this enable programme managers to plan appropriate programme interventions, utilize alternative service delivery outlets, or design innovative outreach approaches.  There should also be research on youth and their reproductive needs, behaviour and attitudes, particularly young men who generally have greater sexual freedom than young women (MSH, 1995).  As men-targeted interventions are still fairly new, evaluation is crucial in monitoring and documenting outcomes and impact.

 3. Spouses/Partners as one unit.  It is well established that women are more likely to use - and continue use of - contraceptives if they have the support of their husbands or male partners (IPPF, 1992).  As the notion of shared decision-making, or interspousal communication, is being promoted, policy-makers, programme managers and service providers should see couples as one reproductive unit.  Only when men have better understanding and are better informed of reproductive responsibility can they be effective partners with the women in this area (Hulton and Falkingham, 1996).  In an age when disease prevention is a major concern, the participation of men in reproductive health issues is crucial in terms of protecting both men and women.

4.  Target groups and segmentation.  It would be a mistake to categorize men as one homogenous group.  Service delivery and IEC strategies have to differentiate between various possible male target groups to allow different approaches to be customized.  Common differentiation denominators are: age, geographic location, behaviour, beliefs, information sources, and socioeconomic groups.  For example, STDs and HIV are now most widely spread among young people, so one programme strategy may be to target young men under 25 years of age.  Social marketing programmes have used modern marketing and audience research techniques to reach target groups more effectively.

5.  Costs. One of the major concerns arising out of the ICPD is the costs implicit in funding the kind of comprehensive reproductive health programmes envisioned by the POA.  It was estimated that US$17.5 billion per annum would be needed by the year 2000 (UNFPA, 1994).  While men-targeted interventions may add to the costs of operating programmes, many initiatives have found small changes within existing infrastructure such as clinic hours, facilities, decoration in waiting areas, etc, to be affordable and practical (UNFPA, 1995).  Services to men can be implemented or integrated in a various of ways such as static (or stand-alone) and mobile clinics for primary health care, or FP-MCH or man-only, special STD clinics, military hospitals, and so on.

What have emerged are a variety of managerial issues that P/RH programme managers should be aware of (Diagram l):

• Creating and sustaining organizational commitment to providing services for men as part of an reproductive health agenda.
• Building or creating structures and institutions within which men-oriented interventions can be embodied.
• Enhancing gender sensitivity within programme institutions and personnel.
• Developing appropriate programme strategies and structures for youth, especially young men.
• Strengthening IEC interventions to be sensitive, appropriate and relevant to men's perceptions and needs.
• Re-focusing or expanding training curriculum to account for men-targeted interventions, including service provision, counselling and information-giving.

Many programmes have adopted innovative approaches to integrate men-targeted initiatives since the mid-1980s.  "The future direction for programmes in terms of effectiveness, impact and sustainability lies in making clinics, community-based services and private sector services acceptable and appropriate to both women and men...... (IPPF, 1992, pp 17).  The quiet revolution-of sorts is really a wave of the future.  This issue of Innovations highlights three innovative approaches to enhancing male participation in population and reproductive health programmes.

1   Research.
The first approach is the use of action research by the YPP project (chapter two) in Java, Indonesia to raise the awareness and participation of men with respect to their reproductive responsibility.  In the process, it was also to enhance the women farmers' knowledge of reproductive health and to empower them to exercise their reproductive rights.

Formative research that included a two-month anthropological study was conducted by the PSPI (chapter three) in the Philippines to better understand men's perception and needs before programme implementation.

2.   Service Delivery.
The second approach is reaching out to men through service delivery.  PROFAMILIA in Colombia (chapter four) first opened a male clinic in 1985, and now have five such clinics although services and activities for men are also performed by its female clinics around the country.  By providing such services in a "exclusively men only" environment, these clinics were successful enough to become financially self-reliant in a short space of time.  PROFAMILIA also reach out to men by taking its IEC services to firms, factories, etc.

The PSPI uses a variety of service delivery mechanisms to involve men.  In addition to static clinics, the PSPI used mobile teams to deliver services to distant locations.  The use of marketing research and especially tailored communications strategies to reach the working class men, its primary male target, was effective in meeting the reproductive health needs of men.  Similarly, the PPAG (chapter five) created Daddies Club as an effective tool to deliver IEC services and reproductive health counselling to its target groups of men.  A contributory factor to its effectiveness is the motivation that it gives to the members.

3.   Social Marketing.
The third approach is reaching men through social marketing.  DKT International, Inc., a US-based non-profit social marketing organization with programmes in more than 35 countries, presents the experience of three of its affiliates in Pakistan, Philippines and Vietnam (chapter seven).  Social marketing, an approach that makes use of commercial marketing techniques to produce, market and distribute public health products and services, has found much success in the family planning environment.  This approach has the potential for attitude and behaviour modifications on the part of men with respect to their reproductive responsibility.

Similarly, the ZNFPC (chapter six) used an effective multi-media communications strategy to motivate men to increase their involvement in family planning and contraceptive use.  Beyond the conventional mass media, the ZNFPC used the popularity of football matches (capitalizing on the notion of male virility) to reach men.  What is distinct about its campaigns was the careful evaluation after each phase to gauge the effectiveness of the interventions.

Bongaarts, John and Judith Bruce, 1995.  "The Causes of Unmet Need for Contraception and the Social Content of Services".  In Studies in Family Planning, Volume 26 Number 2, March/April 1995, pp 57-75.

Bruce, Judith, Cynthia Lloyd, Ann Leonard, Patrice Engle and Niev Duffy, 1995.  Families in Focus.  New York: The Population Council.

De Koning, Korrie and Marion Martin (eds.), 1996, Participatory Research in Health.  Issues and Experiences.  London: Zed Books Ltd and Johannesburg: NPPHCN.

DHS, 1996 Newsletter, Volume 8, Number 1, 1996.

Ferdinand, Dinys L, 1996.  "Another Side of Quality".  In Reproductive Health Matters (RHM), Number 7, May 1996, pp 144-45.

Helzner, Judith F, 1996.  "Men's Involvement in Family Planning".  In RHM, ibid, pp 146-54

Hulton, Louise and Jane Falkingham, 1996.  "Male Contraceptive Knowledge and Practice: What do we know?".  In RHM, ibid, pp 90-100.

ICOMP, 1996.  Managing Quality Reproductive Health Programmes: After Cairo and Beyond.  Brochure for 14th ICOMP international seminar held in Addis Ababa, Ethiopia, December 2-7, 1996.

IPPF, 1992.  Male Participation in Family Planning.  A Review of Programme Approaches in the Africa Region.  Edited by Kirstan Hawkins.  London: International Planned Parenthood Federation.

Johns Hopkins University, 1992.  "Vasectomy: New Opportunities".  In Population Reports, Series D, Number 5, March 1992.

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Kim, Young Mi, Caroline Marangwanda and Adrienne Kols, 1996.  Involving Men in Family Planning: The Zimbabwe Male Motivation and Family Planning Method Expansion Project, 1993-1994.  IEC Field Re. port Number 3. Baltimore, MD: Johns Hopkins School of Public Health, Center for Communication Programs.

Management Sciences for Health (MSH), 1994.  "Cairo and Beyond: Addressing the Critical Management Challenges".  In The Family Plan. ning Manager, Volume Ill, Number 4, July/August/September 1994.

---,1995.  "Working Solutions Worldwide".  In The Family Planning Manager, Volume IV, Number 1, January/February 1995.

Mason, Karen O and Anju M Taj, 1987.  "Differences between women's and men's reproductive goals in developing countries." In Population and Development Review, Volume 13, Number 4, December 1987, pp 61 1 638.

Mundigo, Axel I , 1995.  Men's Roles, Sexuality, and Reproductive Health.  The John D and Catherine T MacArthur Foundation International Lecture Series on Population Issues.  In Sao Paulo, Brazil, July 31, 1995.

Potts, M, 1992.  Quoted in "Getting Men More Involved".  In Network, Volume 13, Number 2, August, 1992.

Population Reference Bureau (PRB), 1994.  Family Planning Programs: Diverse Solutions for a Global Challenge Information Packet.  Washington, DC:PRB

Seex, John, 1996.  "Making Space for Young Men in Family Planning Clinics".  In RHM, op cit, pp 111-114.

United Nations Population Fund (UNFPA), 1995.  Male Involvement in Reproductive Health, Including Family Planning and Sexual Health.  Technical Report Number 28.  New York: UNFPA.

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