From Hot Spots to Holy Places: Group sales of health products contribute to women’s empowerment and better health in Mali

Togo Kadiatou Malle, president of Muso Yiriwa Ton in Mali, is now an ardent proponent of condoms and contraceptives.

This was originally published on the Knowledge4Health Blog on July 1, 2019.

The first five times the sales manager of Keneya Jemu Kan came looking for Madame Togo Kadiatou Mallé to talk about her women’s association selling condoms and other health products, she ran away and hid, so terrified was she of the prospect of having to work with condoms. 

But the sales manager’s persistence paid off. Eventually, they talked, and Madame Togo has become such an enthusiastic condom promoter, she is known as Mama Condom. She laughs about her fear of condoms. 

Madame Togo is president of Muso Yiriwa Ton (MYT), which means “women-empowering group” in the Bambara language, a women’s association based in the very poor Sabalibougou neighbourhood of Bamako, Mali. Her association – as well as other women’s associations – are a major reason for the success of Keneya Jemu Kan (“Communication Around Health”), or KJK, a project funded by the U.S. Agency for International Development and led by the Johns Hopkins Center for Communication Programs that seeks to reduce maternal, infant, and child mortality in Mali. Palladium leads the social marketing component of KJK.

MYT has more than 400 members, and roughly half of them sell the KJK’s male and female condoms, as well as Aquatabs (water purification tablets), Orasel Zinc (zinc tablets and oral rehydration solution to treat diarrhoea), and CycleBeads (a natural family planning method). MYT members sell an average of 107 cartons of Protector Plus condoms per month. That’s 64,200 condoms. The partnership helps to enhance economic prospects of its members. 

“It has become a source of life for many families,” said Madame Togo. “And it is improving health of the areas where they sell, in Commune 5 and beyond.”

In Brazil, condoms become popular by emphasizing fun, not responsibility

DKT promoted its Prudence brand of condoms in the São Paulo Carnival of 2019, as they do every year.

This was originally published by Knowedge4Health Blog on March 11, 2019.

SÃO PAULO, Brazil — In 1991, a non-profit social marketing organization set out to make condoms accessible and affordable in Brazil at a time when condoms were hard to find and expensive and the number of Brazilians infected with HIV was climbing. In the process, DKT Brazil made its brand Prudence the number one condom in the very competitive Brazilian market, and also helped enhance contraceptive security. 

The result is that condoms have become normalized in Brazil – more used and less stigmatized – and that has helped limit the spread of HIV.

In 1990, the World Bank estimated that Brazil would have 1.2 million people living with HIV by 2000. However, that never happened: By 2000, there were fewer than 500,000 infections. After peaking in 1996, according to UNAIDS, AIDS-related deaths have remained fairly stable. Brazil is now considered an HIV success story. Condoms – distributed both by the public and private sectors – played an important role in that success.

Prudencehas become the most popular condom in Brazil by taking a very different approach to the positioning and marketing. While most commercial condom distributors marketed their products for responsibility and protection, DKT eroticized its condom messaging, celebrated sexuality and used humorous vernacular, with no medical jargon. Its advertising was daring and provocative: The PrudenceYouTube page demonstrates that.

Faith groups do more to promote "healthy timing and spacing of pregnancies"

The Reverend Cannon Kabana and his wife Damalie Kabanda talk to their congregation about the benefits of family planning at St. Mark's Church in Uganda. More religious institutions are promoting the "healthy timing and spacing of pregnancies to their members. Photo: Mona Bormet, Christian Connections for International Health.

This was originally published on Oct. 31, 2018 on Global Health TV.

The role of religious organizations in promoting and advocating for voluntary modern methods of family planning – once met with skepticism or derision — is gradually gaining more acceptance both in the religious and secular worlds. However, the faith-based community still does not get significant funding for family planning (or global development more broadly) despite a growing consensus that faith-based organizations (FBOs) are vital and trusted development partners at the community level. 

“When family planning is positioned primarily as a major public health contributor to improved maternal, child, and family health, the trend has clearly been for growing support for family planning in most religious communities,” said Ray Martin, who was executive director of Christian Connections for International Health(CCIH), a membership network of faith and secular organizations that promote global health and wholeness from a Christian perspective (full disclosure: I am a board member of CCIH). “When family planning was seen as a tool for old-style versions of population control, it was harder to marshal Christian support.” 

Trump's expansion of Global Gag Rule sows chaos in global health

One of Donald Trump’s first acts as U.S. president was the re-imposition of the Global Gag Rule (GGR), also called the Mexico City Policy, a policy that denies healthy options to women and girls, not just safe abortion and contraception but potentially all areas of global health. 

Trump changed its name to “Protecting Life in Global Health Assistance,” but most global health advocates call it the Global Gag Rule because it silences health providers from providing comprehensive reproductive health options to women and girls.

The global gag rule is a failed, outdated and deadly policy,” writes Serra Sippel, the president of the Center for Health and Gender Equity (CHANGE), in the comprehensive new report Prescribing Chaos in Global Health: The Global Gag Rule from 1984 to 2018.

“Throughout this report, CHANGE seeks to document the breadth of the GGR’s impacts on civil society and health systems. For example, CHANGE provides evidence that the GGR under President George W. Bush had consequences outside family planning programs, and that it adversely impacted a wider range of health services provided by foreign NGOs. Some of these impacts were mitigated when President Barack Obama rescinded the policy, but the harmful effects have been shown to linger, particularly as each iteration has become more oppressive, culminating now with the Trump GGR.” 

The policy is having exactly the effect the Trump Administration intended it to have – women are losing health services, programs are being down-sized or closed and advocacy work disrupted. Because of poor communication and miscommunication coming from the U.S. government and prime partners, the CHANGE report says, many organizations are over-interpreting the policy, and going further than they really need to go, out of fear of losing funding and alienating an important donor (the U.S. government).

Global contraceptive use rising but more progress needed to reach target

A DKT Nigeria counselor talks to a group of women in a low-income neighborhood of Lagos, Nigeria about their contraceptive options. Photo: David J. Olson

This was originally published on Global Health TV on January 30, 2018.

By July 2017, more than 309 million women and girls were using modern contraception in 69 focus countries identified by Family Planning 2020 (FP2020), a movement created in 2012 by four core partners, 38.8 million more than in 2012.

This information came out in FP2020’s annual report “The Way Ahead, 2016-2017,” released in December. It reported that use of modern contraception in these 69 countries from July 2016-July 2017 prevented 84 million unintended pregnancies, 26 million unsafe abortions and 125,000 maternal deaths. This is all great news.

It came with some less-than-great news. FP 2020 has set the goal of reaching 120 million new users in the eight years between 2012 and 2020 – or 15 million every year. By that measure, we should have reached 75 million new users by mid-2017, and 38.8 million is only 52% of that.

Clearly, we have a lot more work to do to reach the 120 million target.

For global health, 2017 was a year of progress, near triumphs and threats

A trained community health workers in Bangalore, India takes photos of an oral lesion with a mobile phone during an oral cancer screening. Cancer is growing everywhere in the world. Photo: Biocon Foundation, Courtesy of Photoshare.

This was originally published on Global Health TV on Jan. 2, 2018.

In looking back over my last 12 blog posts here at Global Health TV, it is clear that 2017 was a year of progress, near triumphs and threats to global health.

In September, I reported that great progress has been made against diseases and health conditions that kill us (like respiratory infections, diarrhea, neonatal preterm deaths and communicable diseases like AIDS and malaria) while new threats had emerged  that are generally less fatal — things like obesity and mental illness.

In particular, we have made progress against communicable diseases but now face a rising tide of non-communicable diseases (NCDs) like cancer, diabetes, hypertension and cardiovascular diseases, as I wrote at the beginning of 2017.  Cancer is growing almost everywhere in the world. For example, cervical cancer causes over 500,000 new cases every year, even though vaccination, early screening and treatment of precancerous lesions can prevent most cases.

How to promote contraceptives to teens in Latin America? Don't be boring

DKT Health Counselor Victor Tapia Orijel (center, white shirt) and a group of high school students who attended his sex talk in the Iztacalco neighborhood of Mexico City. Photo: David J. Olson

This was originally published on the Huffington Post on August 1, 2017.

MEXICO CITY, Mexico — Health Counselor Victor Tapia Orijel starts his presentation almost like a stand-up comedian, humorously citing different situations in the reproductive life of a teenager, from first sexual relations to different contraceptive methods.

• “If you get horny in school or your best friend’s house, you need to carry condoms.”
•  “If you make a booty call, it’s obvious you need condoms."
• “If you drink a lot and then have a one-night stand and don’t remember if you used a condom or not, you should get emergency contraception and condoms.”

His audience was a roomful of 65 high school students in the Iztacalco delegation of Mexico City. They were entertained and educated at the same time.

“Most of these young people learned about sex from their friends,” said Orijel. “It is difficult for them to talk about sex with their family. The women are the least likely to talk to their families, due to the burden of machismo that we live with in Mexico.”

That lack of information is prevalent throughout Latin America and the Caribbean: Almost three-quarters of pregnancies among adolescents aged 15-19 in the region are unplanned, according to the Guttmacher Institute, and about half of those end in abortion. Among all women 15-19 who need contraceptives, 36% of them are not using a modern method. In Central America, 46% of sexually active adolescents who want to avoid pregnancy are not using modern contraceptives.

Promoting contraceptives to adolescents in Mexico? Make the campaigns fun

Monserrat, Ariantne and Isis and their children visit a
RED DKT clinic in the Iztapalapa borough of Mexico
City to find a contraceptive to space the birth of their
next child. Photo: David J. Olson

This was originally published on Global Health TV on March 21, 2017.

MEXICO CITY, Mexico — I met the three young women at a reproductive health clinic in Iztapalapa, the most populous and fastest-growing borough of Mexico City, with a population of 1.8 million on the eastern side of the capital city.

Ariatne and Isis, both 20 years old, each have one child. Monserrat was their aunt, but didn’t look much older. She had three children. All of them were looking for a way to space the birth of their next child. One of them wanted to wait five years; another, ten years.

All of them had chosen intrauterine devices (IUDs) as their contraceptive, one of them told me, “because they are comfortable and secure.”

Although unplanned pregnancy is a big problem in Mexico (and the rest of Latin America), good sexual and reproductive healthcare is hard to come by in Mexico, especially for adolescents, according to a recent study.

Almost three-quarters of pregnancies among adolescents aged 15-19 in the region are unplanned, according to the Guttmacher Institute, and about half of those end in abortion. Among all women 15-19 who need contraceptives, 36% of them are not using a modern method. The unmet need is highest in Central America, where 46% of sexually active adolescents who want to avoid pregnancy are not using modern contraceptives.

DKT México, a non-governmental organization that uses social marketing to prevent HIV and promote contraception in Latin America and the Caribbean, has learned some lessons about how to promote contraception to young people after success in promoting condom use but failing to do the same with contraceptives after they took a more traditional approach.

"Game-Changing" Contraceptive Approved for Self-Injection in Nigeria

A DKT Nigeria community health worker gives Sayana Press injectable contraceptive to a woman in the Makoko slum of Lagos, Nigeria. Photo by David Olson.

This was originally published on K4Health Blog on Jan. 4, 2017.

The Nigerian government has approved Sayana Press injectable contraceptive for self-injection by users, a change which advocates hope will improve access to the product. The United Kingdom has already approved self-injection. Other countries are considering doing the same.

Sayana Press is the three-month progestin-only injectable contraceptive that combines the drug and needle in a Uniject™ injection system. It is small, light, easy-to-use, and requires minimal training, making it ideal for rural settings and community-based distribution efforts and, increasingly, for women to administer themselves.

Since it was introduced in 2014, Sayana Press has been hailed as a “game-changer,” because of its ease of use and ability to be administered by lesser-skilled health professionals and now, even users themselves. This video shows how Sayana Press works.

A long, hard road to reversing the stagnation of family planning in Nigeria

DKT Bee Lydia, a community health worker, gives Iya Lekan a Sayana Press injectable contraceptive at her house. She has five children and does not want any more, at least for now.

This was originally published on Global Health TV on September 27, 2016.

LAGOS, Nigeria — Lydia, a community health worker for DKT Nigeria, steps carefully as she navigates the grimy streets of Makoko, one of the worst slums of Lagos. She is trying to avoid mud or something worse. The sanitation is abysmal. But Lydia is on a mission — to bring contraception to some of the most disadvantaged women in Nigeria.

This day, she calls on Iya Lekan. Although neither Iya, 36 years old, or her husband have regular work or specific sources of income, they have five children to look after.

“I don’t know how many times I have given birth,” she says in Yoruba, the local language here. “I’m tired.”

Iya told Lydia she was ready to start practicing family planning. Lydia presented various options, and Iya chose a three-month injectable called Sayana Press. Lydia immediately gave her the injection in her upper thigh.

Some people think Sayana Press could be a game-changer. It’s a new version of the well-known Depo-Provera injectable contraceptive, but contains 30% less of the active ingredient and can be administered by lesser-skilled health workers. The United Kingdom has already approved it for self-injection.

Last month, I spent an afternoon with Lydia, a member of the DKT Bees, a group of community health workers (CHWs) who focus on family planning in some of the grittiest parts of Lagos. DKT calls their CHWs “bees” because they are like the hard-working insects that go from flower to flower spreading pollen. But instead of pollen, DKT Bees go house to house counseling, educating and dispensing contraceptives.

The road to greater contraceptive use in Nigeria has not been smooth. It’s shocking that the percentage of married women using modern contraception in Nigeria is only 9.8 percent (Nigeria Demographic & Health Survey 2013). That figure is lower than all countries in West Africa except Gambia, Guinea and Mauritania, according to the 2016 World Population Data Sheet, and has has hardly changed in the last ten years. Nigeria has a population of 187 million, making it the seventh largest country on earth. If current trends continue, it will be tied for third, with the United States, in 2050.

Already a contraceptive success story in West Africa, Ghana seeks to do better

DKT Ghana midwife advising on family planning at a community gathering in Mpraeso, in the Eastern region of Ghana.

This was originally published in the Huffington Post on September 26, 2016.

ACCRA, Ghana — Although West and Central Africa is an underachieving region in terms of family planning compared to the rest of the continent, Ghana is the family planning star within that region: It has a higher rate of contraceptive use than all the other 24 countries except the island nations of Cape Verde, and São Tomé and Príncipe. 

However, Ghana - with 29 percent of married women using modern contraception, is still much lower than Eastern Africa (37 percent) and Southern Africa (59 percent), according to the 2016 World Population Data Sheet. The fertility rate has barely changed since 1998 and more than 1 in 3 pregnancies are unplanned.

Last month, I visited Ghana to see how the country is faring in terms of of its commitment to family planning. Until recently, Ghana had one of the fastest growing economies on the continent. That fact and the peaceful transfer of power in 2008 were recognized by President Barack Obama in 2009 when he made Ghana the first stop of his first visit to Africa as president. Recently, however, the economy has stagnated.

World Contraception Day on Sept. 26 provides a good opportunity to reflect on the current situation in Ghana and how matters can be improved to enable every Ghanaian woman who wants contraception to have access. The government has set an ambitious goal of reaching 50 percent of married women with modern contraception methods by 2020.

"Millions Saved" shows that global health programs can achieve success

This was originally published at Global Health TV on May 24, 2016.

If you are reading this article, you probably already believe in global health, and its ability to improve the quality of life and save lives. Every month we tell some of these stories here at Global Health TV.

But some people do not believe that global health programs work or, perhaps, are just indifferent to that fact. The Kaiser Family Foundation recently released a survey of the U.S. general public that showed that the visibility of U.S. global health effort are declining – only 36% have heard a lot or some about U.S. efforts in the past year, down from 57% in 2010.

That’s why books like “Millions Saved: New Cases of Proven Success in Global Health,” written by Amanda Glassman, Miriam Temin and a team at the Center for Global Development, are so important. They provide us with specific examples of global health success that they culled from more than 300 examples of rigorous impact evaluations, and explain why there were successful.

“Around the world, people are benefitting from a global health revolution,” wrote Glassman and Rachel Silverman, both of the CGD, in a blog of the British Medical Journal (BMJ). “More infants are surviving their first months of life; more children are growing and thriving; and more adults are living longer and healthier lives. This amazing worldwide transformation begs several questions: What, specifically, are we doing right? What are the policies and programs driving the global health revolution from the ground up? Or put more simply, what works in global health, and how do we know?”

In West Africa, progress on family planning but millions not treated for HIV

Women gather for the launch of the national family planning campaign in a low-income neighborhood of Bamako, Mali in April.

This was originally published on Global Health TV on April 26, 2016.

BAMAKO, Mali — Last year, there were several reports of how West Africa, after decades of seriously lagging behind the rest of the world (and Africa) in family planning, was finally starting to embrace it. IntraHealth International covered this topic extensively on its Vital blog, and I wrote about my own views of family planning in Mali here at Global Health TV.

Senegal, in particular, emerged as a family planning leader in West Africa and provided hope for the rest of the region. The three main reasons for Senegal’s success were strong political will, better coordination and collaboration and innovative approaches, according to Babacar Gueye, IntraHealth country director in Senegal.

New programs here in Mali, like Keneya Jemu Kan (USAID Communications et Promotion de la Santé, in the Bambara language), are making a major push to increase health indicators beyond the anemic progress of the past three decades. For example, the percentage of married women using any modern method of family planning in Mali has only increased from 1.3% in 1987 to 9.9% in 2013, and Keneya Jemu Kan is working to bend that rate upwards. (Full disclosure: I work as a consultant for Keneya Jemu Kan).

But a disturbing new report from Médecins Sans Frontières (MSF), or Doctors Without Borders, claims that similar progress is not being made in HIV/AIDS. On the contrary, MSF claims that millions of people in West and Central Africa are being left out of the global HIV response despite globally agreed goals to curb HIV by 2020, and is calling on the international community to develop and implement an urgent plan to scale up antiretroviral treatment for countries where critical medicines reach fewer than one-third of the population in need.

Brazil struggles to contain damage of mosquito that transmits Zika virus

Dr. Sylvia Lordello of Saúde Criança speaks to a group of parents about Zika.

This was originally published by Global Health TV on March 31, 2016.

RIO DE JANEIRO, Brazil — A group of about 20 poor parents (mostly women) from the slums gathered this month in the offices of Saúde Criança (“child health” in Portuguese), a social enterprise that works with impoverished children and their families in a holistic way. After a meditation, they got down to the main point of the meeting — the Zika virus and how to avoid it.

These poor young mothers are prime candidates for Zika. Aedes aegypti, the mosquito that transmits Zika, will suck anyone’s blood — rich or poor. But they thrive in the densely populated favelas of Rio and other Brazilian cities where few people have screened windows and where even mosquito repellant may be a luxury. Many people have water cisterns on their roofs, usually not covered, which makes an ideal breeding ground for Aedes aegypti.

Dr. Sylvia Lordello, a medical doctor on staff at Saúde Criança, told the parents that prevention starts at home and reviewed a series of steps that could be taken to make their homes less hospitable to mosquitoes, such as covering their cisterns and not leaving water in the plates under house plants.

“If the whole country fights Zika, the mosquito cannot win,” Dr. Lordello told the parents. “Zika is not stronger than the country.”

Amid a flurry of high-tech approaches, some find merit in low-tech techniques

DKT street theater provides family planning information in Bihar.

This was originally published on Humanosphere blog on March 7, 2016.

Because of the meteoric rise of the internet and cell phones in many developing countries, many global health programs have been rushing to embrace these technologies as efficient ways of reaching large numbers of people with information on such issues as family planning, HIV prevention and maternal and child health.

This is happening in countries like India, Tanzania, South Africa, and Ethiopia, where technologies like the internet, mobile phones, social media and geographic positioning systems are bringing health delivery into the 21^st century.

But some programs are eschewing high tech and sticking with low tech as the best way to bring vital health information to their low-income consumers, at least for now.

Faith community steps up its commitment to family planning

Twelve faith leaders read a statement of support for family planning from a larger group of faith leaders attending the International Conference on Family Planning in Indonesia in January 2016.

This was originally published on Global Health TV on Feb. 23, 2016.

NUSA DUA, BALI, Indonesia — To some, it may have been an incongruous image — twelve faith leaders, representing all the major religions of the world, standing on the stage at the closing ceremony of the International Conference on Family Planning (ICFP) here. After all, everyone knows that most religious leaders are against family planning, right?

That was never true, and now it’s becoming even less true. The twelve leaders represented 85 religious leaders and representatives of faith-based organizations (FBOs) who came to Bali from 26 different countries to discuss best practices and scaling up services to help families achieve what they like to call “the healthy timing and spacing of births” during a two-day Faith Pre-Conference.

It might surprise some to know that this support is not just for natural family planning, but extends to all forms of modern contraception with the single exception of sterilization, which is not approved by all types of Islam. All other modern methods are acceptable to all the religions represented at ICFP — Buddhist, Christian, Confucian, Hindu, Jewish and Muslim.

In Indonesia, spicy IUD TV ads try to boost long-acting, reversible contraception

This was originally published on the Maternal Health Task Force Blog on Jan. 21, 2016.

“How does it feel after you get an Andalan IUD?” a woman says in the opening line of a ground-breaking new TV spot (above) in Indonesia promoting intrauterine devices to married women. “Now we can do it anytime. For sure, my husband is more content and obedient now,” she says with a mischievous smile.

A second spot targeting married men poses the same question about how it feels after their wives got an IUD. “Now, every day, I just want to return home quickly,” he says with a broad grin. This deals with a widespread myth held by Indonesian men that IUDs dampen sexual pleasure.

Such ads used to be unheard of in Indonesia, where family planning is normally promoted from a population control and public health perspective. Sex is never mentioned. In a country that values discretion, these commercials link IUDs with sexual pleasure and other benefits of using a long term, reversible method.

The biggest global health stories of 2015, and one untold story

A billboard warning about Ebola in Bamako, Mali.

This was originally published on Global Health TV on December 17, 2015

There seemed to be a lot of good global health news in 2015, especially when compared to 2014, when Ebola was ravaging West Africa and scaring the rest of the world. In the last 12 months, Ebola has mostly passed, progress was made against malaria and AIDS and the climate deal in Paris raised hopes that less climate change could improve global health.  Here are what I consider some of the top global health stories of the year, not necessarily in order of priority:

Ebola on the Decline: A year ago, Ebola was raging. As of Dec. 16, there have been 11,315 deaths and 28,640 cases of Ebola. But Ebola has not disappeared entirely. It re-emerged in Liberia after having earlier been declared Ebola-free. Dr. David Nabarro, the UN special envoy on Ebola, said that he expects transmission in Guinea to finish before the end of 2015 and in Liberia in early 2016. Here’s an update on Ebola in an interview with Dr. Nabarro.

The social marketing legacy of Phil Harvey

This originally appeared on the Huffington Post on December 15, 2015.

From 1992 to 2001, I did some of the most important – and fun – work of my life: I managed social marketing programs for the nonprofit PSI in Zambia, Bangladesh and Paraguay. Social marketing is a technique that uses the tools of social marketing to achieve a social outcome – in PSI’s case, that outcome is improved health. The programs I worked on were HIV prevention, family planning and child health but social marketing can also be applied to other disciplines as well.

I owe that singular experience to Phil Harvey, who founded PSI in 1970 to promote family planning through the social marketing mechanism. In 1989, he founded DKT International, another social marketing organization more tightly focused on reproductive health mainly in very large countries (in order to have cost-effective impact at greater scale). Harvey has also served, and continues to serve, for many years on the board of directors of Marie Stopes International, another organization that uses social marketing.

Phil Harvey is introduced as “a visionary, pioneer and titan in the world of social marketing” in this new video interview. Harvey describes his early work in India, the roots of social marketing, his creation of two social marketing organizations, his legal battle with the State of New York over reproductive health issues (that went all the way to the U.S. Supreme Court) and the impact of social marketing.

Social marketing contributes 20% of all contraception in developing countries (excluding China)

A DKT Indonesia midwife counsels a client in her clinic in Jember, East Java. In 2014, this network of nearly 5,000 midwife clinics helped DKT Indonesia become the Number 1 contraceptive social marketing program in the world.

This was originally published on the Huffington Post on December 1, 2015.

If there was still any doubt about social marketing’s ability to make a major contribution to family planning and HIV prevention, those doubts were dispelled in 2014, when 84 social marketing programs in 62 countries delivered 69 million couple years of protection (CYPs), according to the 2014 Contraceptive Social Marketing Statistics just published by DKT International. DKT says these 69 million CYPs represent an estimated 20% of all women using modern contraception in the developing world, excluding China. (A “couple year of protection” is the amount of contraception needed to protect one couple for one year).

“These are remarkable numbers and a testament to the many organizations and individuals who strive to make a wide range of health products and services available to women around the world,” said Chris Purdy, president and CEO of DKT International.

The report provides details of these 84 contraceptive social marketing programs, all of which are helping provide modern contraception and reduce unmet need for family planning among women and families in their countries, largely through the private sector.