Family planning: Private sector, public good?
Nurse Namondwe is standing by the side of the road clutching a precious package. The rickety bus next to her has finally given up and a mechanic is peering gloomily under the chassis.
But it hasn't been a bad day because Hilda Namondwe has managed to get hold of a month's worth of contraceptives for her clinic in the small village of Namasalima in southern Malawi. One way or another she will get back home and this time it will not be empty handed.
Namasalima clinic is one of sixteen health clinics in Malawi run by the Adventist Health Services. It provides everything from ante-natal HIV testing to safe delivery of babies and family planning services - at least that is, when it has the resources to do so.
Each time her rural clinic needs more supplies, Nurse Namondwe or one of her colleagues has to get on a bus to the nearest hospital twenty miles away, and come back with as much as she can carry. The clinic cannot afford its own vehicle. All too often the journey is fruitless. The bus breaks down on the way, or the hospital itself runs out of contraceptives and the nurse is turned away.
"It's demoralising for us", says Nurse Namondwe, "and devastating for the women who have come for help," she adds. "Some travel hours by foot to get to the clinic, desperate to avoid another pregnancy".
"A lot of women here have maybe ten children." she says. "According to our culture, for men, the more children you have the more of a man you are." However, in a country where the average income is less than a dollar a day, supporting yet another child can be a frightening prospect.
The most popular form of contraceptive in Namasalima clinic is an injection that lasts for three months. There is no need for tell-tale pill packaging or surreptitious taking of tablets and no worries about forgetting a dose. The injection is a discreet, reliable form of contraception and is now the most popular form of contraceptive in sub-Saharan Africa, accounting for 41% of all modern contraceptive use.
For other types of modern contraceptives, such as long-acting reversible implants, the women in Namasalima village will have to go to the same hospital twenty miles away where Nurse Namondwe gets her supplies. The journey puts some women off.
Despite its isolation, Namasalima clinic provides injections, oral contraceptives and condoms to four hundred women a month. When supplies run out the women are given advice about the rhythm method – abstinence at the fertile period of a woman's cycle – and asked to come back later. Some don't ever come back. Some come back pregnant. 'Abstinence' is not always a realistic option for women with little negotiating power.
To reduce such supply shortages, the Malawian government has developed a logistics system coordinating data on government-bought contraceptives with those from donors. This has had an impact nationally, but it clearly takes more than good IT to get condoms to Namasalima.
According to the UN's Population Fund only four in ten women in Malawi have access to modern contraceptive methods. That's about the same as the proportion of women that have access to contraception globally.
The cost of failing to supply the contraceptives that women want is enormous. Every year, nearly 50 million women resort to abortion, many under unsafe conditions. An estimated 68,000 women die each year as a result. Millions more suffer infections and other complications, such as infertility.
Governments have set themselves the task of ensuring all women can access family planning by 2015 as part of the Millennium Development Goals.
However as the global number of women of reproductive age increases, the goalposts seem to be moving. Add to this the demand for condoms to prevent HIV, and by any calculation, the need for contraceptives is set to rise. Funding, by contrast, has been stagnant for almost a decade.
This has driven some of the major aid agencies to try new strategies to ensure women can get the contraceptives they need.
Whilst Nurse Namondwe's clinic provides free contraceptives funded by international charity Interact Worldwide, family planning charity Marie Stopes International (MSI), is running a scheme in Malawi where women are asked to pay.
Tony Kerridge, a spokesman for MSI, explains "Our experience is that when a small fee is charged for contraception, those who purchase items are far more likely to use them."
The scheme, called Blue Star Health Care Network, trains existing pharmacists, nurses and doctors to deliver modern contraceptives. Even the surgical options, like implants, have been developed so they can be carried out safely in non-medicalised, low-resource settings.
The trained health workers are then provided with low-cost contraceptives so they can run mini healthcare franchises. The pricing is flexible and according to MSI, in areas of 'extreme poverty' charges for contraception are waived.
The small profit that the franchises make has provided an incentive to reach the previously unreachable.
Teams of clinicians travel by motorbike to rural health centres and set up temporary surgeries, giving rural women the access to some services for the first time.
The scheme has been very successful and is being replicated in seven other countries. For the thousands of women who can pay, partnerships with the private sector have opened up choices that never existed before.
But if free contraception is to be available to the very poorest, including in remote locations like Namasalima, the private sector can only ever be part of the solution. Donor funding and government money must continue to play their role.
The Malawian government talks about "choice, not chance" in family planning. Millions of women around the world still face chance, not choice.
This feature was written between 6 March and 30 April 2010 as part of the Guardian International Development Journalism Competition