IIntroduction

PROFAMILIA, a private non-profit institution established in 1965 by Dr Fernando Tamayo to promote and safeguard the human right to family planning, became the first International Planned Parenthood Federation (IPPF) affiliate in Latin America to perform vasectomies when it started the voluntary male surgical contraceptive programme in 1970. By the time the organization started to offer female surgical services in 1973, the male programme had attained 1,064 surgical procedures.

But, soon after, a decrease in the number of vasectomies and an accelerated and sustained increase in tubal occlusions was observed. Men-oriented population activities took a back seat until 1985 when PROFAMILIA opened its male clinics in Bogota and Medellin. Currently, PROFAMILIA has five male clinics; however, activities and services for men are also performed at the other 35 female clinics around the country.

According to Dr Maria Isabel Plata, PROFAMILIA's executive director, the reasons for introducing an innovative programme involving men in population activities are threefold. One, the outstanding performance of PROPATER's male programme in Sao Paulo, Brazil was an encouragement. Two, providing family planning and reproductive health services for both men and women is an important step towards programme sustainability. Three, in Colombia there are no other specialized services available for men, and even fewer services offering low-cost surgical contraception. PROFAMILIA's male clinics filled this gap and this is part of their success.

The medical specializations include urology, male family planning, infecundity, sexology, and treatment and control for sexually transmitted diseases (STDs). The surgical services are vasectomy and out-patient urological procedures as well as low-cost social-oriented aesthetic and reconstructive surgery.

The male clinics also have laboratory facilities available for their own clients as well as for outside clients referred by the female clinics and youth centres. With these facilities, the clients are able to obtain quick and low-cost lab tests.

By integrating other services into the sphere of FP and reproductive health services (including non-related uro-genital services), PROFAMILIA's male clinics can attract a larger number of clients than it would otherwise get. This also allows the clinics to be more financially viable.

Specific Needs and Men's Expectations

The programme offers services to male clients in a private environment, since "... the man may feel intimidated in the presence of a large number of women attending our regular family planning clinics, where he is afraid of expressing his concerns or has the feeling that he will not get any attention, or be given sufficient information or the desired individualized medical attention." (Trias, 1994)

One of the major difficulties facing men with respect to access to services and information on sexual and reproductive health is the time factor. The male clinics seek to avoid, as much as possible, obstacles related to time by going directly to firms, factories and institutions to provide information and education services as well as extending clinic hours to allow male workers access to consultations or surgeries at their own convenience.

To meet information needs and ensure integrated services, the clinics offer counselling to all their clients. In general, men are found to seek more information about FP and reproductive health services such as the procedures, side-effects and costs, particularly, for vasectomies. Above all, men seek to clarify doubts on the vasectomy procedure as they are afraid of impotence and loss of sexual desire.

It is reasonable to expect men to require or seek clinical or counselling attention from other men since they would not feel comfortable expressing their needs or problems in sexual and reproductive matters to a woman health providers. At PROFAMILIA's male clinics, trained men and women health providers work to satisfy the needs of clients. According to Vernon, Ojeda and Vega (1992), in an operational research testing two models of vasectomy service at PROFAMILIA, the male clients expressed no difficulties or inconveniences receiving counselling from a woman.

By providing men not only with information and education on the issue but also the means to use temporary or permanent contraception through low-cost and low-risk vasectomy, men become involved in sharing responsibility for family planning and reproductive health in the context of their relationships and families.

While contraception services and information/education are available as part of the male clinic activities through person-to-person consultations or community group work, male participation is encouraged in decisions pertaining to family sex and reproductive health issues. Topics such as STDs, contraception, HIV infection and violence against woman are routinely brought up by the providers and discussed with the clients.
 

Clear and explicit information-education materials were developed on medical issues such as contraception, STDs, urological and sexual problems, and they enable PROFAMILIA not only to obtain better programmatic outcomes but a higher satisfaction from clients for the services received.

The innovation of having male clinics and providing services for men made it possible for the organization to reach out to even more couples. In many cases, it takes away the need to deal with a couple separately. Men attending clinics for contraception share and discuss information they have received with their wives or partners, thus achieving the programme's goal to seek a shared decision-making process and participation.

Family planning and reproductive health programmes involving men have provided good opportunities for working with women as well. For almost fifteen years, PROFAMILIA achieved outstanding results with its women-oriented programmes; however, the importance of other quality-of-service characteristics such as privacy, space, work with couples, and the importance of individual counselling may have diminished as a result.

Resources for Innovation

At present male-oriented activities at the Bogota and Medellin clinics are being carried out in physical facilities exclusively for men. These activities share facilities with female clinics in other cities. The reason for sharing facilities is, of course, to take advantage of existing physical, administrative and human resource infrastructure to reduce programme overhead and other costs.

Clinics offering services within an exclusively-male context have medical staff (urologists, sexologists, physicians), counsellors, auxilliary nurses and administrative personnel devoting time to work for these clients. In contrast, in clinics providing services for male and female clients, the clinic personnel perform duties for both sets of clients and clinic hours may or may not be shared.
 

Management Processes Involved

The experience gained in testing two male clinic models (sharing services with female clinics) has allowed PROFAMILIA to plan and expand the range of cost-cutting actions especially with respect to financial and human resources. At present, there are only two exclusively-men clinics (Bogota and Medellin) in operation, and those located in other cities share services with female clinic facilities.

To reconcile the objective of providing services for men and the physical, financial and human resources available, PROFAMILIA has adopted the principle of "integration with independence". That is, developing programmes with the best allocation of resources, which entails sharing administrative staff (managers, secretaries and auxilliary personnel) and infrastructure, while maintaining the identity of each individual programme whether it is designed for men, women or youth.

It has been established that when clinic directors (male and female) play an important role in trying to satisfy male needs and not just offer vasectomy services, clients acknowledge these efforts by requesting for more vasectomies. Thus, offering integrated services to male clients within a "female context" (that is, in female clinics) is feasible and has been reflected in profits for the programmes. This is not to say that exclusive milieus such as male clinics do not reach higher statistical accomplishments as, in fact, they do, but given the scarce financial resources, the strategy of mixing milieus or sharing resources is found to be feasible. The imperative here is the leadership role played by the director (either urologists or gynaecologists).

Moreover, having available staff exclusively devoted to serve male clients brings forth better programmatic outcomes and quality of services, no matter who provide these services. This statement was confirmed by the operational research carried out by PROFAMILIA in 1989 (Vernon, et al, 1992).

A key element in the quality of services and the satisfaction of clients is the role played by counsellors, even above that of physicians and other members of the team. The role of the counsellor is not only to inform, but encourage clients to express their fears and doubts, and they also serve as a link between the clients, services, and providers involved in the programme.

Given the demand for quality by male clients, coordination and monitoring actions aim at establishing needs and expectations from the clients, either through small questionnaires, direct talks or claims, and suggestion boxes, feedback to team members are processed in such manner that each client is likely to leave satisfied.

In order to maintain high standards of information and to raise greater motivation in their work, staff in direct contact with the clients require continual updating and advisory processes. Since their work entails making a differences to the lives of men, women and families with respect to their fertility choices, counsellors and other team members should recognize the extent and importance of their work.

At the beginning of the male clinic programme, printed information-education materials were based on those used for women clients. However, later experience points to the need to design and distribute printed materials and audio-visuals that focus on the characteristics, perceptions and expectations of men, even taking into account cultural diversity of regions where potential clients live.

Programme Personnel Requirements

Considering the fact that family planning work has been present since the 1950s, activities and services in FP and reproductive health oriented toward men are thus relatively new, having only been present in the last ten years. PROFAMILIA itself, as a pioneer in Latin America, has over thirty years of experience. Thus, the overall experience gained in the last three decades has, for the organization, made the job of establishing requirements for the implementation, operation and expansion of male-oriented work in this area an easier task.

As mentioned earlier, it is essential to have motivated staff who understand the extent and importance of their duties and have enough knowledge about sexual and reproductive health issues as well as beliefs, habits, needs and expectations of those served. In particular, they should have a supportive attitude towards the benefits of male participation in family planning and reproductive health issues.

While it is true that individual staff carrying out counselling, information, and education tasks are not required to be experts in medical-surgical issues, it is important that they have basic knowledge in male reproductive health topics. Possessing good inter-personal and group communication skills is also important because of the need to inform - clearly, factually and in a friendly manner - the clients of methods, procedures, side effects, and so on.

Male clinics offering services in a mixed context and sharing administrative personnel with programmes for women and young adults are a challenge for managers as the ability to promote and expedite team work while keeping the independence and identity of each programme, is a must. Managers and supervisors must struggle-together with their teams-to find strategies to reach different population segments and satisfy the demands and needs of both male and female clients.

Experience of Clients and the Community

A common proverb,"a satisfied tourist bring with it more tourists", could well be applicable to male clients at PROFAMILIA's male clinics. The continuing growth of the programme, both in clinical services as well as in the number of vasectomies, is clear evidence of the satisfaction and quality of services as perceived by the clients.

While it is true that those men attending the clinics for the first time show an apprehensive attitude, they usually express their gratitude and acknowledgement for the attention received by the time they leave the clinic. Almost 97 percent of total clients have indicated that they are willing to recommend the clinic services to friends and relatives, thus becoming effective promoters of the programme.

In a research study conducted in 1989 among vasectomy acceptors, almost 100 percent of interviewees qualified the attention received from staff personnel (receptionist, counsellor, physician and nurse) as good or very good. More than 95 percent of them thought that clinic facilities were comfortable, pleasant and clean. Service hours seemed to be adequate, since approximately 76 percent of users state that schedules were convenient and another 13 percent reported not having problems in attending clinic hours scheduled. Less than 7 percent considered services to be expensive or very expensive.

In general, it could be stated that men requiring sexual and reproductive health services and having the chance to attend specialized programmes or clinics, experienced a favourable change in their perception of reproductive health, of their relationships with their partners, and of their values and responsibilities towards self-care. While it is true that men attending services do not reveal this fact in public, they share, in confidence, their experience with other friends or relatives. By doing this they not only promote the clinic's services but also bring the issue of FP and reproductive health up as a relevant topic of conversation among men.

Some Lessons
Although male clinic programmes are at present expanding, and its demographic or health impact has not yet reach the levels and impact of women-oriented programmes, both medical services and educational activities have prompted a transformation process on men's role in FP, and sexual and reproductive health matters. Mass media communications and educational information have popularized discussions among men about their perceptions towards risky sexual behaviour, their responsibility towards family planning and some wrong beliefs supporting the traditional "Latin machismo".

With respect to vasectomy, it was found that, sometimes, the wife or partner may be opposed to this procedure in part because of fears of reduced sexual desire on the part of the man, and also the suspicion that the "welcomed" sterility may make the man have affairs. Despite the above, it is true that suggesting to women who visit FP clinics to return accompanied by their husbands or partners to discuss jointly the impact of sterilization (both vasectomy and tubal ligation) is an excellent opportunity to "capture" male clients. This is the most likely "sacrifice" in the immediate post-partum period of women when the habit of blaming men is remarkable (Trias, 1986).

Most women welcome male clinics and men-targeted programmes. This is a phenomenon observed among women with higher than average levels of education. Education and information processes on STDs and HIV/AIDS have made women aware that risky behaviours by their husbands or partners also place them also at risk. This is why so many women support and promote male programmes since the benefits are mutual.

Receptiveness to and support by the overall community for male programmes are evident and positive, except for small fundamentalist groups, especially Catholics, who have always been opposed not only to this type of male programmes but to everything related to family planning.

Nowadays, Colombian men and women are demanding sexual and reproductive health services from the government. It has been recognized that the government, through the health sector, should provide the means for those who wish to have access to information and services. PROFAMILIA's male-oriented population activities through its innovative "male clinic" programme, are raising social consciousness of rights and responsibilities in sexual and reproductive health issues. This can be regarded as pressure being put on the health system to promote, and make easier to exercise, the human rights in this field.

Cadavalia, C, 1992. Vivencias de un programa de planificacion familiar (ponencia). Simposio Latinoamericano de planificaci¢n Familiar, Mexico, December 1992.

Guevara, J, 1995. Nuevo enfoque de programas masculinos. Informe de Taller. Bogota: PROFAMILIA, April 1995.

Gutierrez, A, 1995. The male clinic of PROFAMILIA. Present, past and future of an innovative program. Bogota: PROFAMILIA.

Patino E, Adviser-Counsellor, Male Clinic, 1996. Personal Communication.

Plata, M I, PROFAMILIA Executive Director, 1996 . Personal Communication.

PROFAMILIA, 1995 Manual de funciones del personal de la Cl¡nica para el Hombre. October, 1995.

Trias, M, 1994. Lecciones aprendidas en la Cl¡nica para el Hombre (ponencia). Presented at the AVSC Workshop at the International Conference in Population and Development, Cairo, September 1994.

__________, 1996. "Vasectomy. What more can be done to make it available and acceptable in Latin America?" (ponencia). Singapore, October 1986.

Vernon, R, G Ojeda, and A Vega, 1992. Ofrecer la vasectomia de manera mas aceptable para los hombres. In Rev. Planificacion, Poblacion y Desarrollo. PROFAMILIA, Vol. 8 No. 19, June 1992.